OBSTETRIC PROBLEMS A MANUAL

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Title: OBSTETRIC PROBLEMS
A MANUAL
extracted text: ■ 1

OBSTETRIC PROBLEMS

A MANUAL
by:

Dr. F. Driessen, gynaecologist
Queen Elizabeth Central Hospital,
Blantyre, Malawi

H1UW GOVEBNMtHI

A MINISTRY OF HEALTH
APPROVED PUBLICATION

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TABLE OF CONTENTS
Acknowledgements

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Introduction

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Part I
Abnormal Pregnancy
Pelvic assessment
Screening for cephalopelvic disproportion
Breech presentation in pregnancy
Transverse lie in pregnancy
Pregnancy following caesarean section (s)
Estimation of the gestational age
Large for dates
Twin pregnancy
Small for dates
Intrauterine growth retardation
Postmaturity
Premature rupture of membranes
Chorioamnionitis
Pregnancy following habitual abortions ...
Intrauterine death
Antepartum haemorrhage
.
Fits in or immediately after pregnancy:
first aid - causes - first assessment
Hypertensive diseases in pregnancy:
eclampsia - preeclampsia - hypertension
Anaemia in pregnancy and labour

Part II
Abnormal Labour
The labourgraph
The prolonged latent phase
The prolonged active phase: the protracted active phase
- secondary arrest - the oedematous cervix
The prolonged second stage (vertex presentations)
Short notes on breech delivery
Face presentation
Brow presentation
Compound presentation
Shoulder presentation
Twin delivery
Cord presentation and prolapse

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31 The conduct of a trial of scar
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32 Obstructed labour
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33 Fetal distress during labour
34 Primary postpartum haemorrhage
35 Resuscitation of patients with severe
bloodloss
36 Retained placenta without postpartum
haemorrhage ...............

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Part IV
The Abnormal Puerperium
Puerperal infections
Secondary postpartum haemorrhage
Complications following obstructed labour
Puerperal psychosis

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Part III
Obstetric Procedures and Operations
External cephalic version
...........................................
Catheterisation
Artificial rupture of membranes with
a high head
The examination under anaesthesia
for antepartum haemorrhage
........................
Vacuum extraction
Symphysiotomy
Shoulder dystocia
Caesarean section
Repair of a ruptured uterus
Subtotal hysterectomy
Repair of acute bladder injury
.......................................
Destructive operations: craniotomy destructive operations for transverse lie - operations
for hydrocephalus - the stuck breech
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Theatre procedures for postpartum haemorrhage
Repair of a third degree tear
Postpartum prolapse of the cervix
Postpartum tubal ligation

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Part VI
Appendices
The use of oxytocin (= pitocin)
Drugs used in eclampsia, preeclampsia and
hypertension in pregnancy
Care of the vacuum extractor
Equipment needed for symphysiotomy
Equipment needed for destructive operations
Equipment needed for the examination under
anaesthesia for antepartum haemorrhage
Equipment needed for the examination under
anaesthesia for postpartum haemorrhage
Equipment needed for the repair of a third degree
tear
Equipment and drugs for the resuscitation of the
newborn
Equipment needed for postpartum tubal ligation ..
Further reading

Index

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Neonatal Problems
Resuscitation of the newborn with a low Apgar score ...
Presention of meconium aspiration
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ACKNOWLEDGEMENTS

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Although this is a book by one author, it is not the work of just one
person. It is based on. a style of practising obstetrics which was
established in Malawi by others, well before I arrived in the country. I
had a lot to learn from colleagues and midwives and this learning
process continued throughout my stay. As the ideas for this manual
developed and its writing progressed, all the gynaecologists in Malawi
gave active support to this project, with their encouragement, ideas,
draft chapters and helpful criticisms. Particularly, without the work
put in by Dr. J. D. Chiphangwi and Dr. M. E. Keller this book would
have been much less a reflection of obstetric practices in Malawi, and
much more prone to error and omission. But I should also like to give
special thanks to Dr. E. Ndovi for the extra clinical burden he
shouldered while I scribbled.
Other important help I received from Dr. A. C. Borgstein,
Dr. Y. E. Ratsma, Dr. M. Cheesebrough and Miss M. van Leeuwen.
Mrs. A. M. Rijcken drew the illustrations for Chapters 1, 42 and 46.
Jo, my wife, not only encouraged me, but also typed and retyped the
manuscript, tidied up the English and chopped excessive Dutchuncleisms.

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Finally, the printing of this manual has been made possible thanks to
a generous grant from the Netherlands Government.

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Blantyre. April, 1985.

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INTRODUCTION

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WHAT IS THIS BOOK AND WHO IS IT FOR?

This book is a manual of obstetrics, that is, it tells you what to do in
difficult obstetric situations and how to do it. Because it is a manual,
it gives you only minimal background information. Therefore, if you
want to know more about, say, the causes or pathophysiology of a
condition, you must refer to the books listed under “Further
Reading”.

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This manual has been written for those in Malawi who deal with
obstetric problems at the hospital level: state registered nurse
midwives, clinical officers and doctors. It assumes that you have had
basic training in obstetrics and some practical experience of
obstetric problems as well. It is definitely not a book for beginners.

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HOW TO USE THIS BOOK

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This book is intended for use on the job, there is no point in keeping
it at home. Hopefully, your hospital will have more than one copy, so
try to keep one in the places where you are likely to meet obstetric
problems: the antenatal clinic, the labour ward and the theatre.

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The book is intended to help you when you are facing difficult
obstetric situations - it is typically a book to look things up in.
However, before you can look things up in it, you need to know what
it contains. Begin by having a look at the Table of Contents: this
gives you some idea not only of what is in the book but also about
how the material has been organised. The next step is to look at
some of the chapters to see what they contain and how they have
been arranged.

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A difficulty you are bound to meet soon is that different aspects of a
problem are dealt with in different chapters. For example, breech
presentation in pregnancy is discussed in Chapter 3, the indications
for caesarean section during labour in breech presentation in
Chapter 24 and the technique of caesarean section for a breech in
Chapter 44. There are ways round this problem - the text contains
many cross references to other chapters but if they do not help, you
can use the index.

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A second difficulty you will meet is that the manual generally
indicates only one plan of management for each problem. This plan
of management may differ from what you were taught or believe to
be right. Of course, when writing this manual, I was aware that
certain problems can be solved in more than one way. However, in
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most cases I did not state the alternatives because this might easily
lead to confusion. Generally when a choice had to be made, I chose a
plan of management which had already become “routine” in the
Queen Elizabeth Central Hospital or the Kamuzu Central Hospital.
This should mean that these “routines” have already proved their
value and that many members of staff are already familiar with
them.

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A third, closely related, difficulty is that a plan of management may
not suit every single patient with a particular problem. It is quite
impossible in a manual of this size - if ever - to cover every single
situation that might arise. This does mean that you should use the
manual intelligently and not follow it blindly: it is a guide, not a
gospel!
WHO IS RESPONSIBLE FOR WHAT?
When there is a patient with a difficult obstetric problem, more
than one member of staff is often involved. The manual indicates, in
many situations, who is responsible for what. However, on this point
there is a difficulty that different members of staff with the same
rank have often had very different training and experience in
obstetrics.
This problem is smallest with state registered nurse midwives. They
have, at least, had the same basic training. However, after their
basic training considerable differences in interest and experience
can develop which results in one SRN being a much better
“obstetrician” than another.
The problem is more complicated with clinical officers and doctors.
Some clinical officers, particularly those who started as medical
assistants, did not receive any basic training in obstetrics. Some of
them were taught a little obstetrics at a later stage and often they
were taught how to do a caesarean section. The fact that they can do
this operation is, of course, a tremendous help. However, they are
usually less good than the SRN at assessing obstetric problems and
may have to take her advice about when a caesarean section is
necessary.

doctors at district or mission hospitals. They should be able to assess
an obstetric problem and do the necessary operations. However,
they may wish to listen carefully to what the SRN has to say about a
problem as she has often had longer experience.

Doctors receive obstetric training during their basic medical course
but the amount and quality of their training varies and is sometimes
less than that of an SRN. Moreover, most doctors were trained in
the temperate zones of the world where some of Malawi’s problems
do not occur. Doctors who go to work in the district or mission
hospitals need further training in obstetrics first in order to be able
to assess patients with obstetric problems as they occur here and to
be able to do the necessary operations.
Therefore, the indications in the manual as to who is responsible for
what, are guidelines only which may have to be modified, depending
on the skill and experience present in your local obstetric team.

Clinical officers trained at the School for Health Sciences (or, as it
was previously called, the Medical Auxilliary Training School)
received basic training in obstetrics but less than an SRN. Without
further training they can do no more than she. A few clinical
officers received both basic and advanced training in obstetrics. The
advanced training was sometimes in a more or less formal
programme at one of the central hospitals, others were trained by
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Part I

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Abnormal Pregnancy
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Chapter 1

PELVIC ASSESSMENT
INTRODUCTION
Clinical pelvic assessment can be done in late pregnancy or during
labour. It is uncomfortable for the patient and should only be done
when necessary. It is a must for patients with one of the following
conditions:
- breech presentation after 36 weeks

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Figure 1.1
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- one previous caesarean section

Sagittal section through the pelvis
a : true conjugate
b : diagonal conjugate

- prolonged labour
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In other patients weigh the advantage of information gained against
the disadvantage of patient discomfort.

TECHNIQUE

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Do a vaginal examination and check the following:

1. PELVIC BRIM
Starting from behind the symphysis pubis feel how far you can
follow the pelvic brim:
- Normal: one-half to two-thirds of the brim can be felt

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- Abnormal: more than two-thirds can be felt

2. DIAGONAL AND TRUE CONJUGATES
In the midline try to tip the sacral promontory with your fingers in a
nearly horizontal direction. The common mistake is to feel too low
down in the pelvis for the promontory.

If you can reach the promontory, measure the diagonal conjugate
[see Figures 1 - 3]. With experience you will know how long the
diagonal conjugate is when your fingers can only just tip the
promontory and, of course, when you cannot reach the promontory,
the diagonal conjugate is even longer!

Figure 1.2

Measuring the diagonal conjugate: step I

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From the diagonal conjugate you can estimate the true conjugate:
this is the pelvic diameter the fetal head must pass. It is 1.5 - 2 cm
shorter than the diagonal conjugate.
Normal: diagonal conjugate = 12 cm or more (most people cannot
reach the promontory in a normal pelvis!)
true conjugate = 10.5 cm or more

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Figure 1.3

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Measuring the diagonal conjugate: step II

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3. SACRUM
Feel the shape of the sacrum:
- Normal: smoothly hollow
- Abnormal: straight or with a sharp hook

4. ISCHIAL SPINES
Feel for the ischial spines:
- Normal: The spines stick out only slightly into the pelvic cavity.
5. PELVIC OUTLET
Feel how many fingers fit comfortably under the subpubic arch.
See how many knuckles you can put between the ischial
tuberosities:
- Normal: a little more than two fingers fit the subpubic arch and
four knuckles fit between the ischial tuberosities.

DIFFICULTIES
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Even with experience it is easy to miss the following abnormalities:
a) THE ASYMMETRICAL PELVIS
With this abnormality the right and left sides of the pelvis are
not equal. Differences between the sides are easily missed
because a right-handed person can examine the right side of the
pelvis much better than the left.

An X-ray pelvimetry should not be done instead of a clinical
assessment : it is expensive (±K10.00) and it does not provide any
information about the transverse diameters.

Always do a clinical pelvic assessment first: if this is clearly
abnormal, you have all the information you need. However, if you
think that the pelvis is normal on clinical examination or if you are
uncertain of your findings, an x-ray pelvimetry can be helpful. You
may then find that the true conjugate is shorter or that the sacrum
is less well curved than you thought on clinical examination.
CLASSIFICATION AND SIGNIFICANCE
OF PELVIC ABNORMALITIES
A very rough classification of the findings on pelvic assessment is as
follows:
1. The severely contracted pelvis
This means that the vaginal delivery of a normal size baby
will probably be impossible.
This kind of pelvis is not often seen.
The more common examples of the severely contracted pelvis
are:
- a pelvis with a true conjugate of less than 8.5 cm
- a pelvis with severe asymmetry.

2.

The borderline pelvis
This means that the pelvis is not normal in all respects but
that vaginal delivery of a normal size baby may still be
possible. This includes pelves with one or more of the
following features:
- true conjugate between 8.5 and 10.5 cm.
- pelvic brim which can be followed for more than
two-thirds of its length.
- a sacrum which is either straight or markedly hooked
- ischial spines which stick out markedly into the pelvic
cavity.
- a too narrow pelvic outlet.
Breech delivery of a term baby or a trial of scar should not be
attempted with a borderline pelvis.

3.

The apparently normal pelvis
On clinical examination and possibly x-ray pelvimetry the
pelvis appears normal in all respects. Vaginal delivery of a
normal size baby is expected to be successful.

b) THE PELVIS WHICH IS CONTRACTED
IN THE TRANSVERSE DIAMETERS
Clinical examination of the transverse diameters of the pelvis is
difficult and abnormalities are therefore easily missed.

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c) THE SHORT DIAGONAL CONJUGATE
This can be missed if the patient cannot relax and the muscles of
the perineum remain tight.

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Even the best pelvimetry does not measure the mobility in the pelvic
joints. If there is a lot of stretch in the pelvic joints, a large baby can
still pass a small pelvis. This factor is unpredictable.

X-RAY PELVIMETRY

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A good lateral pelvimetry provides a precise measurement of the
true conjugate and a good view of the shape of the sacrum. In order
to provide correct information the film must be a true lateral view
(heads of femur projected on top of each other!)

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Chapter 2

Chapter 3

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SCREENING FOR CEPHALOPELVIC
DISPROPORTION

BREECH PRESENTATION IN PREGNANCY

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INTRODUCTION

VARIETIES OF BREECH PRESENTATION
It is impossible to recognise all patients with cephalopelvic
disproportion before labour but some patients are at a much higher
risk for this condition than others. High risk patients should be
recognised during pregnancy in the antenatal clinic.

- Complete or flexed breech:
- Incomplete breech
:
- Frank or extended breech :
:
- Footling breech

both knees flexed, hips flexed
one knee flexed, the other ex
tended, hips flexed
both knees extended, hips flexed
knees flexed and hips partly de
flexed

HIGH RISK PATIENTS
Nulliparae with: - a height of less than 150 cm.
- a deformity of spine or leg.
- a large baby (estimated weight
more than 3500 gm).
Multiparae with a history of:
- caesarean section
- symphysiotomy
- vacuum extraction
- prolonged or difficult labour
- repeated fresh stillbirths or
neonatal death at term
- a large baby in this pregnancy
(estimated weight more than 3500 gm).

MANAGEMENT
• Book for hospital delivery; if necessary admit between 36 and
38 weeks.
• Do a pelvic assessment at 36 weeks : if the pelvis is severely
contracted, consider the possibility of an elective caesarean
section or a section in early labour.

CAUSES

1.

Increased mobility of the fetus
- prematurity
- polyhydramnios

2.

Reduced mobility of the fetus
- multiple pregnancy
- oligohydramnios

3.

Contracted pelvis

4.

Abnormal shape of the uterine cavity
- placenta praevia
- congenital abnormalities (bicornuate uterus etc.)
- fibroids

5.

Abnormal shape of the fetus
- extended legs
- hydrocephalus
- anencephalus
DIAGNOSIS

LOW RISK PATIENTS
Low risk patients come into two groups:
1. Those who will deliver in hospital anyway: for them no
further screening is required.
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Those who will deliver in a health centre or even smaller
unit: for them pelvic assessment by an experienced person
can be considered. Patients with a borderline or worse pelvis
would then have to be referred to hospital.

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The head (hard, round, ballottable) is not felt above the pelvic brim
but in the fundus.
Misdiagnosis
1. Breech diagnosed as a cephalic presentation because of:
- a tight abdominal wall
- extended legs
- a head hidden under the lower ribs
- oligo- or polyhydramnios
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Cephalic presentation diagnosed as breech because of:
- a head deeply engaged in the pelvis
- small parts lying along the side of the head

TRANSVERSE LIE IN PREGNANCY

MANAGEMENT

CAUSES

Chapter 4

Before 32 weeks
• Await spontaneous version to cephalic presentation (the baby
is still so mobile that external version is pointless)

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After 32 weeks
• Attempt external cephalic version* unless there is a contra
indication.
The contraindications are:
- a uterine scar (caesarean section, myomectomy)
- multiple pregnancy
- antepartum haemorrhage
- hypertension or preeclampsia
• If the external version succeeds, check after one or two weeks
whether the presentation is still cephalic.
• If the external version fails, try again after one or two weeks.
It is usually best to give up after two failed attempts.

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Increased mobility of the fetus
- prematurity
- lax abdominal wall
- polyhydramnios

Poor “fit” of head in the pelvis
- placenta praevia
- cephalopelvic disproportion
- pelvic tumour (fibroid, ovarian tumour)
Reduced mobility of the fetus
- multiple pregnancy •
- congenital uterine abnormality (arcuate uterus, etc)
- abdominal pregnancy
RISKS

After 36 weeks
• Attempt external cephalic version unless there is a contraindi
cation [see above]. It is less likely to succeed than earlier in the
pregnancy but may still be possible.
If, after 36 weeks the breech presentation persists:
• Arrange for clinical officer, doctor or gynaecologist to see the
patient.
• Arrange for the patient to deliver in hospital; admit her
between 36 and 38 weeks if she lives far away.
• Assess the pelvis and the size of the baby.
• Decide on the route of delivery:
- Caesarean section for:
- a scar of a previous caesarean section
- a large baby.
- a borderline or worse pelvis
- Vaginal delivery only if:
- baby normal size (estimated weight less than 3500 gm).
- pelvis normal
A decision to allow vaginal delivery is always provisional.
Change your mind if:
- the baby grows a lot bigger in the last weeks of pregnancy.
- labour does not progress satisfactorily [see Chapter 24].

- Premature rupture of membranes
- Labour with a transverse lie
- the risks attached to the condition which caused
the transverse lie
DIAGNOSIS

The signs are:
- the “transverse” shape of the uterus
- the head in one flank, the breech in the other
- the pelvic brim is empty
MANAGEMENT

After 32 weeks

• Attempt a gentle external cephalic version unless there is a
contraindication. The contraindications are:
- uterine scar (caesarean section, myomectomy)
- antepartum haemorrhage
- multiple pregnancy
- hypertension
- premature rupture of membranes

* For technique of external cephalic version see Chapter 37

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• If the version succeeds, check after one to two weeks that the
presentation is still cephalic.
• If the version fails, try again one or two weeks later

After 36 weeks
Midwives should refer the patient to the clinical officer or doctor.
• Consider first the possibility of prematurity: estimate the
gestational age as accurately as possible [see chapter 6].
If the gestational age is less than 36 weeks, review the patient
in one or two weeks.
• Consider the possibility of twins: carefully re-examine the
abdomen and if necessary ask for an abdominal x-ray. If twins
are found, manage as such [see chapter 8].
• Consider the possibility of an abdominal pregnancy. The clues
are:
- the baby’s position is unusual: too high in the abdomen or
too far into the flank.
- no Braxton Hicks contractions can be felt over the
gestational sac.
- on bimanual (vaginal-abdominal) palpation the empty
uterus is felt as separate from the gestational sac.
If an abdominal pregnancy is found or strongly suspected, refer
the patient to a gynaecologist.

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If the above conditions have been ruled out, observation in
hospital becomes necessary.
• Admit the patient into the antenatal ward.
• Gently attempt external cephalic version unless this is
contraindicated and repeat this if necessary on the following
days.

After a few days you will realise that you are dealing with one of
two situations:
- a “fixed” transverse lie, that is, you always find the baby in the
same position and external version is not possible.
- an “unstable” lie, that is, the baby’s position keeps changing
and external version has no permanent success.

- a pelvic tumour.
- a congenital abnormality of the uterus.
Whatever the cause, vaginal delivery is impossible:
arrange for a caesarean section in early labour or an elective
operation at 38 weeks.
An “unstable” lie can be caused by:
- unrecognised prematurity.
- lax abdominal wall.
- polyhydramnios or at least an excessive amount of liquor.
- placenta praevia.
- cephalopelvic disproportion.
- a pelvic tumour.

Consider the possibility of placenta praevia. Other clues pointing
to this diagnosis are:
- any degree of antepartum haemorrhage.
- a high head after external version which cannot be brought
into contact with the symphysis pubis.

If placenta praevia seems possible, do an examination under
anaesthesia at ± 38 weeks [see chapter 40]
• If placenta praevia seems unlikely, consider the possibilities of
a pelvic tumour or severe cephalopelvic disproportion and do a
gentle vaginal examination and pelvic assessment.
If either diagnosis is made, arrange for caesarean section in
early labour or electively at 38 weeks.
In the remaining cases (and these are the majority!) a lax
abdominal wall, an excessive amount of liquor or unrecognised
prematurity are likely causes and they are often present in
combination.
Vaginal delivery may be possible but:
• palpate the abdomen daily and do external version whenever
necessary.
• instruct the patient to report at the first sign of labour.
Further management depends on the findings at the onset of
labour [also see chapter 28].

A “fixed” transverse lie can be caused by:
- placenta praevia.
- severe cephalopelvic disproportion.
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Chapter 5

PREGNANCY FOLLOWING CAESAREAN
SECTION (S)
RISKS

- Rupture of the uterus:
- usually during labour.
- sometimes before labour (with a classical scar, inverted
T incision).
- Repeat cephalopelvic disproportion and obstructed labour.

MANAGEMENT
IN EARLY AND MID PREGNANCY
• Encourage the patient to start antenatal clinic at ± four
months.
• Check the haemoglobin and correct anaemia.
• Assess and record the fundal height accurately : this may help
later to establish when the pregnancy is term.
• Arrange for review by gynaecologist, doctor or clinical officer
at about 36 weeks.

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AT 36 WEEKS
Patients with two or more previous caesarean sections:
• Estimate the gestational age.
• Admit into hospital unless the patient lives nearby and has
transport easily available, in which case admission can be
postponed until 37 - 38 weeks.
• Arrange for caesarean section to be done either electively or in
very early labour [see below]

Patients with only one previous caesarean section:
• Make an assessment:
• find out why the caesarean section was done
• estimate the gestational age
• check the presentation and size of the baby
• assess the pelvis clinically and by x-ray if necessary
[see Chapter 1]
• Make a decision:
Trial of scar is only allowed with:*
- a cephalic presentation
- a normal size baby
- an apparently normal pelvis
_________ - a normal lower segment scar
* For the conduct of a trial of scar see chapter 31.

Caesarean section is indicated for:
- breech presentation or transverse lie
(if persisting to term)
- borderline pelvis
- a large baby (estimated weight 3,500 gm or more)
- a classical scar or inverted T incision

THE PLACE OF ELECTIVE CAESAREAN SECTION
(Elective caesarean section is the operation before the onset of
labour)
Elective caesarean section is a must if the patient is known to have a
classical scar or an inverted T incision. It is best done between 36
and 38 weeks.
Elective caesarean section is desirable in all patients in whom a
repeat operation is indicated, provided the gestational age is
reasonably certain. It is then best done around 38 weeks.

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However, if you have reason to believe that the patient does not
want the operation, it may be better not to book her for an elective
caesarean section. Such patients often give themselves a “trial of
scar” at home and only come to hospital when labour has become
obstructed!
It is better, although not ideal, to admit such a patient at 36 weeks,
say that she will be allowed a short trial of scar and then do a caesa
rean section in early labour. Careful observation in the ward will
still be necessary because these patients tend to retire to a quiet
spot as soon as labour starts to make sure that they do not miss their
“trial”.

THE PLACE OF TUBAL LIGATION
Some patients will want to be sterilised at the time of a repeat
caesarean section. Discuss this during the antenatal visits.
Tubal ligation can be done provided:
- both she and her husband agree to the operation and give
written permission.
- they both understand that ligated tubes cannot be reopened
- they are both aware of the existence of other forms of
contraception
The chance that tubal ligation will be necessary on medical grounds
(extensive adhesions, weak scar) increases with the number of
previous operations.

Tubal ligation is usually done with the fourth operation.

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Chapter 6

THE SIZE OF THE UTERUS

ESTIMATION OF THE GESTATIONAL AGE

With certain precautions the size of the uterus provides a reasonable
estimate of the gestational age.

INTRODUCTION
The gestational age, that is the length of time a patient has been
pregnant, can be estimated from:
- the history:
- the date of the last menstrual period (LMP)
- the number of months counted by the patient
- the size of the uterus past and present

THE DATE OF THE LAST MENSTRUAL PERIOD
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Counting the number of weeks from the LMP often produces an
accurate estimate of the gestational age. There are, however, a
number of possible sources of error:
- the date of the LMP is correct but ovulation was delayed.
Normally a woman ovulates about 14 days after the onset of
the LMP but ovulation can take place much later; weeks or
even months. Ovulation can be delayed in any woman at any
time but it happens more often if:
- she has irregular menstrual cycles
- she used “the pill” up to her last period
- she was still breastfeeding when she became pregnant
If ovulation was delayed, the gestational age is, of course,
shorter than one would think from the date of the LMP.

- the date of the LMP is incorrect.
Common mistakes are:
- the patient tells you the date of the first period she
missed instead of the last one she had
- she mistook a small bleed in early pregnancy for a period.
In either case her gestational age is longer than the (wrong)
date that the LMP suggests.

- sometimes a woman does not know the date of her LMP but
tries to hide her ignorance by making one up.

Best estimates are obtained by:
- bimanual (vaginal-abdominal) palpation before 16 weeks
- abdominal palpation between 20 - 28 weeks)

Possible sources of error are:
- Before 20 weeks
Abdominal palpation alone can lead to bad misjudgements
of the size of the uterus because, due to differences in pelvic
shape and size some uteri sit much higher in the abdomen
than others.
— Between 20 and 28 weeks
- the size of the uterus can be misjudged because of an
umbilicus placed too low or too high on the abdomen
- the size of the uterus does not correspond with the
gestational age in the case of:
- twins
- polyhydramnios
- fibroids

- After 28 weeks
In the last weeks of pregnancy the size of the uterus is very
dependent on the size of the fetus. Some fetus grow much
faster than others at this stage and therefore there are, at
each gestational age, large differences in the size of the
fetus and the uterus. This makes the size of the uterus after
28 weeks a less good indicator of the gestational age than
earlier in pregnancy.
If, therefore, you have to estimate the gestational age in
late pregnancy, do not just look at the uterine size of the
day, but look also at the fundal heights recorded on the
antenatal card earlier in the pregnancy.

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THE NUMBER OF MONTHS COUNTED BY THE PATIENTS

■:

Many patients count the months accurately. Ask them whether
they counted “moon” months (miyezi ya kumwamba) or calender
months (miyezi ya chizungu). A “moon” month lasts 28 days or four
weeks. So at 40 weeks, pregnancy has lasted ten “moon” months.

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Chapter 7

Chapter 8

LARGE FOR DATES

TWIN PREGNANCY

DEFINITION
The uterus is large for dates if the fundal height is three or more
weeks larger than appropriate for the gestational age.

RISKS

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DIFFERENTIAL DIAGNOSIS
Wrong dates [See Chapter 6]
Overestimation of fundal height
This mistake is easily made if the umbilicus is below the
middle of the abdomen.

Twins
The diagnosis should be suspected if three or four large poles
are felt.
The diagnosis becomes certain if: - two heads are palpated
„ , . ,
- x-ray confirms
Polyhydramnios
This is diagnosed on the following grounds:
- the uterus is tense
- a fluid thrill can be demonstrated
- one or more fetus are present but are very difficult to
feel
- the fetal heart is difficult or impossible to hear with the
fetoscope
Large singleton fetus
Only two large poles are present but the shoulders may
impress as a third pole. Confirmation by x-ray is necessary.

Hydatidiform mole
A pregnancy with a hydatidiform mole does not go beyond 24
weeks gestation.
It should be suspected if:
- the gestation is less than 24 weeks
- fetal parts are not palpable after 20 weeks
- fetal heart sounds are not heard by ultrasound (doptone
or sonicaid) after 14 weeks
- no fetus is seen on a, good quality, x-ray
The diagnosis becomes certain when molar vesicles are
passed per vaginam.

16

In pregnancy
- anaemia
- preeclampsia
- polyhydramnios
- antepartum haemorrhage
- premature labour
In labour
- premature rupture of the membranes
- poor uterine action
- malpresentations or cord prolapse
- postpartum haemorrhage

DIAGNOSIS

Suspect twin pregnancy when:
- the uterus is large for dates
- three poles can be palpated inside the uterus
- the head seems small for the size of the uterus,
particularly if there are many parts as well
Confirm the diagnosis:
- by x-ray
- by definitely feeling two heads
Differential diagnosis
Confusion can be caused by:
- large singleton fetus
- wrong dates
- polyhydramnios
- fibroids

MANAGEMENT
PRINCIPLES
• Prevent or treat the complications occurring during preg
nancy

• Do everything possible to ensure delivery in hospital

17

T
IN PRACTICE
• Explain to the patient that she is carrying twins

• Discuss with her in detail the need to deliver in hospital:
- explain that twins are often born prematurely
- explain that twin deliveries are often difficult
- check where she lives and find out whether she needs to
be admitted at about 34 weeks in order to await delivery
in hospital
• See her frequently in the antenatal clinic

•i';

• Check the haemoglobin and correct anaemia
• Other reasons for hospital admission are:
- the development of complications [see under Risks]
- for rest if she can no longer cope at home
- for the prevention of premature labour.
The value of rest in hospital for this reason is debatable.
However it should be considered in:
- a nullipara with a tense or irritable uterus
- a multipara with a history of premature labour

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Chapter 9

SMALL FOR DATES
DEFINITION
The size of the uterus is three weeks or more smaller than
appropriate for the gestational age.

DIFFERENTIAL

3

DIAGNOSIS

A gestation shorter than estimated, due to wrong dates or
delayed ovulation, should be suspected if:
- the uterus was already small for dates in early pregnancy.

i

- the uterus grows regularly from antenatal visit to
antenatal visit.

3

- the amount of liquor round the baby is normal.
Intrauterine growth retardation should be suspected if:
- the size of the uterus was normal in early pregnancy but
stopped growing after 26 - 28 weeks.
- the amount of liquor round the baby is reduced.

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Chapter 10

INTRAUTERINE GROWTH RETARDATION
DEFINITION
The growth of the fetus is reduced and results in the birth of a small
for gestational age baby.
CAUSES

- Hypertension/preeclampsia
- Smoking
- Placental insufficiency of unknown origin.
- Intrauterine infections, for example rubella
- Congenital abnormalities
- Gross maternal malnutrition
- Unknown

•

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MANAGEMENT

When uterine growth retardation is suspected:
• admit the patient into hospital for rest and observation
• check for a possible cause
• check fundal height, fetal size and amount of liquor round the
baby at weekly intervals
• ask the mother about the fetal movements regularly
• check the fetal heart rate frequently

This is a difficult decision to make. Get help from a gynaecologist if
at all possible.

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The diagnosis is often difficult.
Intrauterine growth retardation can be incorrectly suspected if:
- the estimate of the gestation is wrong [see also: Chapter 9]
- the size of the uterus was overestimated in early
pregnancy, thereby producing the false impression that the
uterus is not growing on later occasions.

!

Intrauterine growth retardation is often missed because:
- the patient does not know her dates
- the patient started antenatal clinic late in pregnancy
- the doctor or midwife did not think of it
- the diagnosis is difficult and is often missed by even the
best people under the best circumstances.

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DIAGNOSIS

The typical findings are:
- the uterus grows normally up to 26 - 28 weeks
- after 26 - 28 weeks its growth slows down or stops
- the amount of liquor is reduced
■

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If the diagnosis of intrauterine growth retardation seems certain,
that is, there is little or no growth in the course of two to four weeks,
consider amniocentesis for the assessment of fetal maturity and
induction of labour. Caesarean section may be necessary.

Intrauterine growth retardation must be carefully looked for in:
- patients with a history of stillbirths, premature deliveries
or small babies
- patients with hypertension or preeclampsia
- heavy smokers

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Chapter 11

POSTMATURITY

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DEFINITION
A pregnancy is considered to be postmature when it has lasted 42
weeks or more.

CAUSE
Unknown

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other risk factor present
If any of the following risk factors is present:
- nullipara over 30 years
- multipara over 40 years
- bad obstetric history
- hypertension or preeclampsia
- reduced amount of liquor round the fetus
- markedly reduced fetal movements
• ask the clinical officer or doctor to see the patient
• admit the patient into hospital
• induce labour by artificial rupture of membranes and pitocin
• if induction is impossible or fails, do a caesarean section

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RISKS

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- Intrauterine death
- Fetal distress
- Cephalopelvic disproportion (due to
larger, harder and less mouldable head)

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DIAGNOSIS
Begin by checking that the expected date of delivery was calculated
correctly.
There are three criteria for the diagnosis of true postmaturity:
- the date of the last menstrual period must be certain
- there is no history of conditions known to be associated with
delayed ovulation:
- irregular menstrual cycles
- use of the “pill” up to the last menstrual period
- breastfeeding
- the patient attended antenatal clinic before 28 weeks and the
fundal height was always appropriate for dates

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MANAGEMENT

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Doubtful postmaturity (uncertain dates, etc.)
• Reassure the patient
• Await spontaneous labour

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True postmaturity :
no other risk factors
The management is debatable. Some induce labour with pitocin (but
without artificial rupture of membranes). Repeated attempts at
induction may have to be made. Others advise the patient to rest, if
necessary in hospital, but await spontaneous labour.

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• in patients with one previous caesarean section who were
due for a trial of scar, wait for spontaneous labour for 24
hours, if this does not happen, do a caesarean section
• in all other patients with previous caesarean section (s) do a
caesarean section as soon as possible

Chapter 12

PREMATURE RUPTURE OF MEMBRANES
DEFINITION
The rupture of membranes is said to be premature if it occurs before
the onset of uterine contractions.

CAUSES

- Usually unknown
- Cervicitis?
- Cervical incompetence?

RISKS
At any gestation, chorioamnionitis resulting in:
- maternal sepsis and death
- fetal or neonatal sepsis and death

Before 37 weeks
• admit into antenatal ward or any other area where prolonged
careful observation is possible
• ask the clinical officer or doctor to see the patient
• check the temperature four hourly
• inspect the liquor daily
• check that the patient keeps the vulva and perineum clean
• induce labour with pitocin at 37 weeks
• if signs of chorioamnionitis develop (temperature 37.5C° or
more, purulent or offensive liquor), inform the most senior
person available [also see chapter 13]

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SUSPECTED PREMATURE RUPTURE OF MEMBRANES
• admit into antenatal ward
• ask the Clinical Officer or doctor to see the patient
check temperature four hourly
• inspect the vulva daily for liquor. Do not rely only on what
the patient tells you
• if diagnosis is not confirmed, discharge home after two or
three days

III.

AREAS OF DEBATE

Before 37 weeks, premature labour and its complications

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DIAGNOSIS
• History
Loss of fluid from the vagina
• Inspection : Loss of liquor from the vagina after coughing
• Differentiate from: - spontaneous loss of urine
- vaginal discharge
• When in doubt : • repeat inspection later
• do a fern test [see note(*)l

I.

MANAGEMENT
DIAGNOSIS CERTAIN
After 37 weeks
• observe in labour ward for signs of labour
• check temperature four hourly
• do a vaginal examination to rule out cord prolapse
• provide a clean perineal pad or cloth
• induce labour with pitocin if labour does not begin
spontaneously within 12 to 24 hours

Fern test
Put a drop of fluid from the vagina on a clean microscope slide and let it dry.
Examine under the microscope.
If the fluid is liquor, a rather spectacular pattern of “ferns” is seen.
If you have not done this test before, try it out with some liquor collected during
delivery.

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The use of Antibiotics
The discussion centres on the following questions:
- are antibiotics effective in preventing infection?
- if they are used, which antibiotic, at which gestation and
for how long?
The Use of Corticosteriods
The purpose is to accelerate the ripening of the fetal lungs.
The questions concern:
- are corticosteriods necessary?
(lung ripening is probably faster in the presence of
ruptured membranes)
- do corticosteroids increase the risk of infection?
- are there potentially harmful effects on the baby?
If you use them, give:
- dexamethasone 4 mg 8 hourly for 2 days or
- bethamethasone 12 mg i.m. daily for 2 days

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Chapter 13

Chapter 14

CHORIOAMNIONITIS

PREGNANCY FOLLOWING HABITUAL
ABORTIONS

DEFINITION
Chorioamnionitis is infection of the membranes, amniotic fluid and
fetus.

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CAUSES
It occurs as a complication of:
- premature rupture of membranes
— prolonged labour
Frequent and/or unsterile vaginal examinations can be an added factor

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RISKS
Maternal - septicaemia/septic shock
- clotting defect (disseminated
intravascular coagulation)
- death
- septicaemia
Fetal
- death

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DIAGNOSIS
The diagnosis should be strongly suspected if, in the presence of
ruptured membranes:
- the patient develops fever (37.5 C° or more)
- the liquor becomes purulent or offensive
- the uterus becomes tender on palpation
- the fetal heart rises above 160 beats per minute
- the fetal heart beat disappears

DEFINITIONS

Abortion
: the expulsion of pregnancy before 28 weeks
Early abortions
: before 14 weeks
Late abortions
: after 14 weeks
Habitual abortions : three early, or two late abortions in succes
sion
CAUSES
EARLY ABORTIONS
- Usually no detectable cause

LATE ABORTIONS
General Maternal Illness:
- syphilis
- hypertension
- diabetes
- other
Uterine causes:
- cervical incompetence
- congenital abnormalities of the corpus uteri (bicornuate
uterus etc)
- fibroids
Unexplained

MANAGEMENT
• Inform the most senior person available: this is an emergency
• Start treatment whenever the diagnosis is suspected
• Give chloroquin, if you like, but do not wait to see if this brings
down the temperature
• Give high doses of broad spectrum antibiotics by injection, e.g.:
- chloramphenicol 1 gm i.v. stat., followed by 0.5 gm i.v. 6 hourly
x-penicillin 5 mega i.v. stat., followed by 2 mega i.v. 6 hourly
- Reasonable alternatives are:
- ampicillin i.v.
- x-penicillin + streptomycin
or + kanamycin
or + gentamycin
• Deliver. Induce or accelerate labour with pitocin; do a caesarean
section if necessary.

HISTORY
• Check that the history is indeed that of habitual abortions:
• Did each of the last three pregnancies (two with late
abortions) end in an abortion? (Abortions are not
habitual if there were normal pregnancies in between)
• If the patient had very early abortions, was there any
proof that she was pregnant? (With a very irregular
menstrual cycle a patient may think that she is pregnant
when, in fact, she is not)
• For each abortion ask: which was the first symptom: bleeding,
loss of liquor or contractions?
• Ask about possible causes [see above]

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ASSESSMENT

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EXAMINATION
• Check the blood pressure
• Look for signs of general illness
• Do a vaginal examination:
• Compare the size of the uterus with her dates
• Is the cervix closed?
• Is there any other abnormality?

LABORATORY
Always
When possible

:
:

haemoglobin, urine for albumen and sugar
VDRL, bloodgroup, rhesus factor, blood urea,
blood sugar, glucose tolerance test

Do a pregnancy test if the diagnosis of pregnancy is in doubt or if
fetal death is suspected.
MANAGEMENT
Midwives should refer the patient to the clinical or medical officer
as early in pregnancy as possible.
The management depends on the suspected cause of the abortions.

SYPHILIS
If the VDRL test is positive, treat the patient and her husband with
procain penicillin 3 ml daily for 10 days.
If the VDRL test is not available, consider giving a course of
treatment anyway.

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HYPERTENSION
If the blood pressure is very high (diastolic pressure 110 mm Hg or
more), start blood pressure lowering drugs [see Chapter 18]
If the blood pressure is not so high, anti-hypertensive drugs can be
considered but it is better to get an opinion from a gynaecologist
first.

DIABETES
Refer to gynaecologist and medical specialist immediately.
CERVICAL INCOMPETENCE
Suspect this if:
- the previous abortions were late abortions and started with
loss of liquor before the patient felt contractions
- in the present pregnancy the cervix effaces and dilates
without contractions.
• Refer the patient to a gynaecologist for the insertion of a
cervical stitch:

28

— between 14 and 16 weeks in “cold cases
- immediately if the cervix is already dilating

Before referring the patient
• check the fetal heart with a sonicaid if possible
• rule out other causes of habitual abortion
The final decision to put in the stitch is made by the gynaecologist.
He/she will do the operation and is responsible for the immediate
aftercare. The patient usually goes home after three or four days.
However, you may well have to look after the patient during the
remaining part of her pregnancy.

After the insertion of the stitch:
• make sure the patient knows that she has a stitch
• explain to her that if signs of abortion or labour develop, the
stitch must be removed immediately
• discourage sexual intercourse, discuss this with the husband if
necessary
• review her in the antenatal clinic every two weeks and do a
vaginal examination to check that the stitch is still in situ
• remove the stitch in hospital at 38 weeks

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Problems and complications
- failure to prevent abortion
- lower abdominal pain and discomfort
- vaginal discharge
- cervical lacerations if the stitch is removed too late
- cervical dystocia during labour due to scarring
HABITUAL ABORTIONS OF UNKNOWN CAUSE
This is the largest group of patients.
• Reassure the patient : the prognosis is reasonably good
(about 70% go to term)
• Review her in the antenatal clinic every two to four weeks
• Do a vaginal examination at each visit to check the state of
the cervix up to ±24 weeks
• If all is well at 28 weeks, refer her back to the general
antenatal clinic

PROBLEM PATIENTS
These are patients in whom management along the lines indicated
above, has failed in one or more pregnancies.
If the patient has aborted recently, refer her to a gynaecologist
about six weeks after the abortion and before she is again pregnant.

If she is pregnant now, refer her to a gynaecologist straight away.
29

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Chapter 15

INTRAUTERINE DEATH
DEFINITION

Death of the fetus in utero occurring after 20 weeks gestation

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CAUSES

- syphilis
- high fever or other acute maternal illness
- severe anaemia
- hypertension and preeclampsia
- placental insufficiency of unknown origin
- diabetes
- rhesus incompatibility
- postmaturity
- abruptio placentae
- fetal abnormalities
- unknown causes (50% of all cases)
RISK
Clotting defect due to diffuse intravascular coagulation if the
patient remains undelivered after four weeks

ASSESSMENT
Your assessment should answer the following questions:
- is the patient pregnant?
- is the fetus dead and if so, for how long?
- what is the cause of fetal death?
- is the pregnancy inside the uterus? '
- is there a clotting defect?

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HISTORY
The patient presents with the complaint that the fetal movements
stopped or did not begin when she expected them. Alternatively the
midwife in the antenatal clinic may have noted the absence of fetal
heart sounds and the stationary or decreasing fundal height.
Check:
- when did the fetal movements stop?
- what is the gestation?
- what was the outcome of earlier pregnancies?
- has the patient been ill recently?
30

EXAMINATION
- Check the blood pressure
- Check for anaemia, fever or other maternal illness
- Check the fundal height and fetal size and compare these with
the gestation and antenatal record
- Check the fetal heart sounds with a sonicaid if possible
- Ask someone else to confirm that they are negative or
re-examine the patient on a later occasion (it is possible to
miss a positive fetal heart at the first attempt)
- Do a vaginal and bimanual examination:
- check the state of the cervix
- is the fetus inside the uterus?

LABORATORY
Always : haemoglobin, urine for protein and sugar
When possible : VDRL, blood group and rhesus factor, blood urea
and glucose.

Contrary to common belief : a pregnancy test is not usually
helpful:
- when positive, it proves that the patient is pregnant but not
that the fetus is alive.
- when negative, it does not rule out pregnancy nor does it prove
that the fetus is dead.

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Three or four weeks after fetal death: clotting time. This is done
by collecting a few ml of blood in a dry, clean glass tube. Normally
the blood will clot within five minutes. If it takes longer or if the clot
dissolves again, a clotting defect is present.

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X-RAY
Unnecessary as a routine.
A good quality film may be useful if the presence of a fetus is in
doubt. It may then also confirm the diagnosis of fetal death
(Spalding’s sign, etc.)

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DIFFERENTIAL DIAGNOSIS
The patient is pregnant but the diagnosis is:
- intact uterine pregnancy, possibly of shorter duration
- hydatidiform mole
- polyhydramnios
- multiple gestation with small fetus
- abdominal pregnancy

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The patient is not pregnant but suffers from:
- ascites
- an ovarian tumour
- uterine fibroids
- false pregnancy

MANAGEMENT

ANTEPARTUM HAEMORRHAGE
DEFINITION
Antepartum haemorrhage is bleeding from the genital tract after 28
weeks gestation and before the birth of the baby

BACKGROUND
Spontaneous labour occurs within three weeks of fetal death in 90%
of patients. Induction of labour with pitocin often fails if it is tried
too soon. This can be a bitter disappointment for the patient.
Induction with prostaglandins is more effective but has also more
side-effects.

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Prostaglandins are expensive and not always available. After three
weeks, termination of pregnancy becomes necessary in order to
prevent the possible clotting defect.

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IN PRACTICE
• Explain to the patient that the baby is probably dead
Within three weeks of fetal death:
• await spontaneous labour
• allow the patient to stay at home unless she lives far from the
hospital
• review her weekly in the antenatal clinic
• give her as much moral support as possible
After three weeks
• ask the clinical officer or doctor to see the patient
• admit the patient into hospital
• check the clotting time
• induce with pitocin. Try the regular schedule first unless the
gynaecologist decides otherwise
If induction fails, inform the gynaecologist and ask whether a
higher dose of pitocin or prostaglandins can be used
• if induction of labour is contra-indicated, do a caesarean section
about four weeks after fetal death
In case of a clotting defect (rare):
• seek the help of a gynaecologist
• have fresh blood (less than 24 hours old) available for
transfusion
• induce labour

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Chapter 16

CAUSES

OBSTETRIC
- placenta praevia
- abruptio placentae
- placental edge bleeding
- ruptured uterus
- unexplained (often called “heavy show”)
GYNAECOLOGICAL
- carcinoma of the cervix
- cervical polyp
- cervical erosion
- Trichomonas vaginitis
- vaginal warts
- vaginal varicosity

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INITIAL ASSESSMENT

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This is usually done by the midwife
- when did the bleeding begin?
• Ask
- how much blood have you lost?
- did you have bleeding earlier in this pregnancy?
- how many months pregnant are you?
- are you in labour?

•1

• Check

- colour of tongue and conjunctivae
- pulse and blood pressure
- operation scars on the abdomen?
- uterus: - contracting, - hypertonic, - tender?
- fundal height
- fetal lie, presentation and descent (with an empty
bladder)
- fetal heart
- the present amount of bleeding

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NO VAGINAL EXAMINATION AT THIS STAGE!
EMERGENCIES
These are patients who present with one or more of the following:
- severe bleeding (estimated loss 100 ml or more)
- shock, anaemia or both
- labour
Non-emergencies
These are patients who have none of the above signs.

■

INITIAL MANAGEMENT

This is also usually done by the midwife
Emergencies
• Admit the patient into the labourward
• Put up an i.v. drip with a large (size 18) needle or cannula
• Take blood for grouping, x-matching and haemoglobin
• Inform the clinical officer or doctor

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Non-emergencies
• Admit the patient into hospital
• Take blood for grouping, x-matching and haemoglobin
• Arrange for the clinical officer or doctor to see the patient
within 24 hours

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ASSESSMENT BY CLINICAL OFFICER OR DOCTOR

2. Can I rule out placenta praevia
YES only if the head or breech is deeply engaged in
the pelvis
NO in all other situations
• Only after placenta praevia has been DEFINITEL Yruled out,
do a gentle vaginal examination in the labour ward. Do a
speculum examination when necessary
• If placenta praevia cannot be ruled out, do an examination
under anaesthesia [see Chapter 40. For what to do if general
anaesthesia is not available, see also Chapter 40]
After a digital and speculum examination has been done either in
the labour ward or under anaesthesia in theatre, patients can be
classified into three groups:
I. Placenta praevia
II. Bleeding from the uterus not due to placenta praevia
Within this group of patients there are three subgroups:
A. Patients with severe abruptio placentae.
This diagnosis should be suspected if there are, alone or in
combination, the following signs:
- no fetal heart
- tender and/or hypertonic uterus
- a clotting defect [for the diagnosis of clotting defects
see Chapter 15]
B. Patients with a uterine scar. In them a uterine rupture must
be suspected
C. Patients with no further clues as to the cause of bleeding

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Before you can plan the patient’s management you need to make a provisional - diagnosis of the cause of bleeding. This is not easy :
always get the help of the most experienced person available!

III. Bleeding from a gynaecological cause.
Serious bleeding from gynaecological causes is uncommon but
does occur with carcinoma of the cervix or a ruptured varicosity
in the vagina

I

EMERGENCIES
• See the patient (no management by telephone!)
• Check the history and examination
• Ask yourself two questions:
1. Has the uterus ruptured?
- a ruptured uterus due to obstructed labour should
be diagnosed at this point
- scar ruptures are a different matter because they
may occur during pregnancy or early labour. You
may not be able to diagnose them until you do a
laparotomy

NON-EMERGENCIES
For the assessment of patients with a minor antepartum hae
morrhage observation in hospital is always necessary. How long this
observation should continue depends on your findings.
• When you see a patient, check the history and the findings of
earlier examinations
• Re-examine her with an empty bladder
• Do you suspect placenta praevia?
YES if you find the following:
- a high head or breech
- a head or breech overlapping the symphysis pubis by
more than two fingerwidths

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- transverse or oblique lie of the baby
NO if the head or breech is in easy contact with the
symphysis and does not significantly overlap it

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Patients with suspected placenta praevia’.
• keep the patient in hospital
• explain to her the reason
• correct any anaemia
• avoid speculum or vaginal examination
• do an examination under anaesthesia between 36 and 38
weeks or earlier if recurrent heavier bleeding makes this
necessary
• try to keep a pint of blood x-matched at all times

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Patients in whom placenta praevia is not suspected:
• do a gentle speculum examination. You may find:
- bleeding from a gynaecological cause [see further under
“Treatment and Delivery”]
- bleeding from inside the cervical canal, the cause of
bleeding within the uterus remains unknown.
• Continue to observe the patient in hospital:
- If there has been no further bleeding for at least three
days, she can be discharged home but with strict
instructions to return immediately if the bleeding recurs
• Instruct the patient that coitus should be avoided throughout
the present pregnancy.
• If the bleeding continues, she must stay in hospital.
Examination under anaesthesia must to be done between 36
and 38 weeks.
• The bleeding has stopped. The cause of bleeding remains
unknown. Discharge the patient home if there is no further
bleeding for three days.
TREATMENT AND DELIVERY
This is the responsibility of the clinical officer or doctor.

PLACENTA PRAEVIA
For most patients caesarean section is best. The technique of
caesarean section for placenta praevia is discussed in Chapter 44.
In a few uncommon situations consider vaginal delivery.
1. The cervix is fully dilated.
Usually the mother is badly shocked, the baby is dead and
the placenta is partially prolapsed through the cervix.
You can remove the placenta and deliver the baby. This will
cause less bleeding than caesarean section.
36
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2.

The cervix is not fully dilated but the placenta covers only a
small part of the internal os.
Much depends on where the placenta is:
- if it is anterior and the lie of the baby is longitudinal,
rupture the membranes. Often the presenting part
comes down and the bleeding stops
- if the placenta is posterior, rupturing the membranes
only works if the baby is very small
If the membranes have been ruptured, stimulate the
contractions with pitocin and supervise labour carefully

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Regardless of the route of delivery, make sure the patient gets
enough i.v. fluids and is transfused adequately.

BLEEDING FROM THE UTERUS NOT DUE TO PLACENTA
PRAEVIA
A.

Severe abruptio placentae
The management is as follows:
Resuscitate
• maintain a good i.v. drip through a widebore needle or
cannula
• infuse enough saline, sodium lactate solution and fresh
blood to keep the systolic bloodpressure near 100 mm Hg.
Usually two or three pints of blood are needed but
sometimes (much) more. Stored blood is less useful
because it does not help to correct the clotting defect but
is always more useful than no blood at all.
• avoid dextran solutions (haemacel etc.) which can make
the clotting defect worse
Stop pain if this is severe
• give pethidine 25 - 50 mg by slow intravenous injection.
Repeat if necessary
Intramuscular injections in a shocked patient have an
unpredictable effect and should be avoided

Deliver
• rupture the membranes
• stimulate the contractions with pitocin if necessary,
labour is usually fast
• avoid caesarean section if at all possible. Remember the
saying of older obstetricians
“If with abruptio placentae caesarean section is
possible, it is not necessary, but when it is necessary,
it is not possible.”
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• however, consider caesarean section if:
- the patient seems to be bleeding to death before
having had a chance to deliver. Caesarean
section is then a desperate step and may
sometimes save the mother’s life
- the baby is term and still alive but with signs of
severe fetal distress. Rule out a clotting defect
before starting the operation
- there is a transverse lie of a term baby in which
case vaginal delivery is impossible.
Note that with caesarean section the uterus will look
bruised (the “Couvelaire uterus”) but that it contracts
normally. Do not do a hysterectomy! Occasionally, however,
the uterus does not contract even after very concentrated
pitocin infusion. Hysterectomy is then necessary.

I

After delivery by whatever route:
• give ergometrine 0.5 mg i.v. and put pitocin 10 - 40 units
per litre into the drip. Usually the bleeding stops but if
there was a clotting defect, a steady trickle may continue
for some hours
• monitor kidney function
• insert an indwelling catheter immediately after delivery
• record the urine output, blood loss and fluid intake very
carefully. If kidney failure does develop, fluid overload is a
very real danger

B.

C.

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GYNAECOLOGICAL CAUSES OF BLEEDING

Carcinoma of the cervix
• If the patient is in labour, do a classical caesarean section. If
the tumour seems still operable, refer her to a gynaecologist
one or two weeks after the operation.
• If the patient is not in labour, refer her to a gynaecologist
forthwith.

Cervical polyps
These never cause any serious problem during pregnancy or
delivery.
Atempts at removing them during pregnancy may cause serious
bleeding, so leave them alone until after delivery.
If there is any suspicion of malignancy, refer to gynaecologist
forthwith
Cervical erosion
This never causes problems during pregnancy or delivery. They
do not require treatment. A pap smear can be done to rule out
malignancy.

Trichomonas vaginitis
This sometimes causes a bloodstained discharge.
• Treat with metronidazole tablets total 2 gm stat. (2 gm
usually = 10 tablets but check the dosage)

Patients with a uterine scar
If there is bleeding from the uterus, it is impossible to rule
out a scar rupture
• do a caesarean section unless the cervix is fully dilated
and delivery seems easy
• If the baby is delivered vaginally, examine the uterine
scar very carefully afterwards

Vaginal warts
These sometimes cause a bloodstained discharge. They often
disappear spontaneously after delivery. Attempts at removal
during pregnancy may cause serious bleeding. If there are still
some remaining six weeks after delivery, these can be removed
by cautery.
Never, at any time, apply podophyllin

Other patients with bleeding from the uterus
The management of these patients is as follows:
• Allow vaginal delivery unless there is a contraindication
(transverse lie, CPD, etc.)
• rupture the membranes
• stimulate the contractions with pitocin
• supervise labour very carefully
• if the bleeding continues, do a caesarean section
• make sure the patient is resuscitated adequately

Vaginal varicosity
This sometimes bleeds quite severely. A fine catgut figure of
eight stitch made with a roundbodied needle will control the
bleeding. Vaginal delivery can be allowed.

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Chapter 17

FITS IN OR IMMEDIATELY
AFTER PREGNANCY
CAUSES - FIRST AID - FIRST ASSESSMENT
4

POSSIBLE CAUSES OF FITS
- eclampsia
- cerebral malaria
- meningitis
- epilepsy
- uncommon conditions, for example:
- hypoglycaemia
- intracerebral haemorrhage
- brain abcess or tumour
- unexplained.

FIRST AID
Clear the airway
- clean mouth and throat
- suck away secretions
- insert an airway or padded tongue spatula

Stop the convulsions*
- inject slowly (5 - 10 minutes) intravenously “lytic cocktail”:
pethidine 50 mg + chlorpromazine (= Largactil) 25 mg +
diazepam (= Valium) 10 mg
or
magnesium sulphate 20 ml of a 20% solution.
■

FIRST ASSESSMENT
Do not automatically assume that a patient with fits suffers from
eclampsia but look carefully for other possible causes: missing
cerebral malaria or meningitis is a disaster!
History
Remember to question the relative, friend or midwife, who brought the
patient.

■

11
- Did she have fever?
- Did she complain about headache, blurred vision or
stomach pain?
- Is she known to have epilepsy?
- What is known of her obstetric history?
- Is she in labour?
Examination
- check the vital signs : pulse, blood pressure, temperature,
breathing,
- look for oedema, pallor, jaundice.
- examine for stiffness of the neck.
- check the knee reflexes.
- examine the abdomen.
- do a vaginal examination.

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Investigations
Always do
- urine for protein
- haemoglobin
- thick film for malaria
When indicated, check:
- cerebrospinal fluid (lumbar puncture) for protein, sugar, cells
and gramstain
- urine: full report
- bloodsugar, blood urea.
Points to remember
- eclampsia is uncommon before 26 weeks of pregnancy and
after two days postpartum.
- meningitis in a pregnant patient may produce very little neck
stiffness; when in doubt, do a lumbar puncture.
- “routine” treatment of malaria is not the same as the
intensive treatment of cerebral malaria.
- unexplained fits are treated as if the patient had eclampsia.

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Ask: - How many fits did the patient have before admission?
- What treatment did she receive?
- Has she been ill recently?

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‘See also Appendix B.

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Chapter 18

HYPERTENSIVE DISEASES IN PREGNANCY
(ECLAMPSIA, PREECLAMPSIA, HYPERTENSION)
M

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INTRODUCTION
Definition of raised blood pressure in pregnancy

In a pregnant woman the blood pressure is considered to be raised if:
- the blood pressure is 130/90 mm Hg or more
- the systolic blood pressure has increased by 30 mm Hg or more
- the diastolic blood pressure has increased by 15 mm Hg or
more

We will discuss the following conditions associated with a raised
blood pressure in pregnancy:
- eclampsia
- severe preeclampsia (= imminent eclampsia)
- mild to moderate preeclampsia or hypertension
- severe hypertension without imminent eclampsia
- hypertension postpartum

ECLAMPSIA
DEFINITION

Eclampsia is the condition of convulsions in a pregnant woman with
a raised blood pressure. Other causes of convulsions, such as, for
example, cerebral malaria, meningitis, brain abcess, are excluded
[also see Chapter 17]

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DANGERS
Maternal death
The common causes of maternal death in eclampsia are:
— aspiration of vomit
— kidney failure
- intracerebral haemorrhage
- failure of more than one organ, for example,
heart + liver + kidney
Death of the baby
- intrauterine death due to placental failure
or
- neonatal death due to asphyxia or prematurity

42

MANAGEMENT

BEFORE TREATING A PATIENT FOR ECLAMPSIA MAKE
ABSOLUTELY SURE THAT SHE DOES NOT SUFFER FROM
CEREBRAL MALARIA OR MENINGITIS [see Chapter 17]
Eclamptic fits can begin before, during or after delivery. The
medical management is the same in each case but if the patient is
still undelivered, she should be delivered as soon as possible. Take
the following steps:

1.

2.

KEEP THE AIRWAY CLEAR
• nurse the patient on her side
• clean the mouth, nose and throat regularly of secretions
• insert an airway or padded tongue spatula

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CONTROL THE CONVULSIONS
There are two methods*
Heavy sedation (lytic cocktail)
Start with a slow (5 - 10 minutes) i.v. injection of pethidine
50 mg + chlorpromazine (Largactil) 25 mg + diazepam
(Valium) 10 mg
Continue with an i.v. drip, each litre to contain: pethidine
100 mg + chlorpromazine 50 mg + diazepam 20 - 40 mg. Run
the drip so that the patient is deeply sedated, that is: asleep
most of the time but responding to questions when you wake
her up.
If an i.v. drip is not possible (problems with the veins or in
case of fluid overload), give by i.m. injection every 4-6
hours: pethidine 50 mg + chlorpromazine 25 mg + diazepam
10 - 20 mg.

Magnesium sulphate
First dose : magnesium sulphate 4 gm (20 ml of 20% solution)
by slow i.v. injection.
Repeat doses can be given every four hours but first check
that:
- the urine output is at least 100 ml per 4 hours
- the knee reflexes are present
- the respiratory rate is at least 16 per minute
*More information about the lytic cocktail, magnesium sulphate and possible
alternatives are found in appendix B.

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If not, the next dose should be postponed.
Repeat doses can be: magnesium sulphate 20 ml of a 20% solution
by slow injection
or
magnesium sulphate 8 ml of a 50%
solution by deep i.m. injection.

1

b) Eclampsia in the active phase of labour
Allow vaginal delivery only if:
- labour is progressing quickly (on the alert line or to the
left of it)
- no contraindications to vaginal delivery exist
Avoid difficult deliveries. If there is delay, do caesarean
section without hesitation

3.

c) Eclampsia during the second stage of labour
• Delivery by the quickest and easiest route
• Avoid difficult vaginal operative deliveries

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CONTROL THE BLOOD PRESSURE
• Record the blood pressure hourly
• Start hydralazine if the diastolic pressure is 100 mm Hg or
more on two readings. Give 10 - 20 mg i.m. and continue
to check the blood pressure hourly. Repeat the same dose
as soon as the diastolic pressure is again 110 mm Hg or
more.

N.B. AVOID Ergometrine in the third stage, give pitocin 5 U i.m.
instead

6.
4.

CONTROL THE FLUID BALANCE
• Insert an indwelling catheter with an open drainage
system
• Record the urine output four hourly
• Record the fluid intake
• Diuretics:
- before delivery : none
- after delivery : frusemide (lasix) 40 mg by any route
if urine output is less than 200 ml per
four hours (1200 ml/24 hours)

5.
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DELIVER THE BABY
Patients with eclampsia must be delivered as soon as
possible, even if the baby is still (very) premature. The
method of delivery depends on the circumstances.
a) Eclampsia before labour or in the latent phase
Induction of labour only if:
- the cervix is very ripe
- the baby is normal or small size
- the pelvis is adequate
- no other contra-indications for vaginal delivery exist
To induce labour, rupture the membranes and put up
pitocin.
Caesarean section should be done if the patient is
unsuitable for induction or if induction is not followed by
active labour within four hours.

44

MANAGEMENT AFTER DELIVERY
In patients who had fits before or during labour, fits can
recur after delivery. Careful observation and continued
treatment are necessary for at least 48 hours after delivery.
Keep the patient in the labour ward or another intensive
care area. If the patient fits after delivery, continue
treatment until at least 48 hours after the last fit.
Pay special attention to the fluid balance. After delivery,
oedema fluid tends to “flood” the bloodstream while the
kidneys are slow to excrete the excess fluid. This may cause a
rise in blood pressure. Encourage a good urine output by the
use of frusemide as indicated in 4 above.
If all is well after 48 hours, stop sedation, remove the
catheter and send the patient to the ward. Continue four
hourly blood pressure checks for a few days.

7.

PROBLEMS AND COMPLICATIONS
Continuing fits in spite of heavy sedation or
adequate doses of magnesium sulphate
Check first that:
- the diagnosis of eclampsia is correct
- the blood pressure is adequately controlled
- the patient is not in pain (caesarean section wound)
Try another sedative, for example, paraldehyde 10 ml i.m.
or
Combine magnesium sulphate with the lytic cocktail
Anuria or severe oliguria
(Urine output less than 500 ml per 24 hours)

45

As soon as this is suspected:
• limit the fluid intake to 500 ml per 24 hours
4- an amount equalling the urine output
• give frusemide 200 mg i.v. stat.
• if no improvement within 24 - 48 hours, refer to medical
specialist without delay

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The blood pressure stays high for more than 48 hours
after delivery
With some eclamptic ^patients the blood pressure becomes normal
within a few days after delivery, with others, this takes a few weeks
but with a few it stays permanently high. The latter may need long
term antihypertensive treatment.
In the first week postpartum manage as follows:
• accept without treatment blood pressures up to 160/110
mm Hg
• if, 48 hours postpartum the blood pressure is still very high,
start a standard antihypertensive regimen like you would
use for a non-pregnant patient, for example:
- bendrofluazide 5 mg od + reserpin 0.2 mg bd
or
- bendrofluazide 5 mg od + methyldopa 0.25 gm qid
Continue this for about four weeks and leave the patient
without treatment for two weeks. Then check the blood pressure: if
it is still high, long-term treatment is required.

SEVERE PREECLAMPSIA (IMMINENT ECLAMPSIA)

■

DEFINITION
Severe preeclampsia is the condition in which a pregnant
woman with high blood pressure has symptoms or signs indicating
that she may get eclamptic fits at any moment.
The symptoms are:
- severe headache
- upper abdominal pain
- vomiting
- eye symptoms (blurred vision, spots before the
eyes)
The signs are: - rapidly increasing blood pressure, often but not
always, reaching values of 160/110 mm Hg or more
- proteinuria of ++ or more
- oliguria

46

DANGERS
Maternal:

- development of eclamptic fits

For the baby: - intrauterine death
- neonatal death due to asphyxia or prematurity
DIAGNOSIS
This can be easily missed if:
- the blood pressure earlier in pregnancy is not
known and the present blood pressure is not very
high
- the patient presents with symptoms but you forget
to check the blood pressure

MANAGEMENT

J

Once the diagnosis of severe preeclampsia has been made,
manage as for eclampsia. For details see the section on eclampsia.

MILD TO MODERATE PREECLAMPSIA OR HYPERTENSION
DEFINITION
- The blood pressure is raised but is below 160/110 mm Hg
- Protein in the urine is 1 + or less
- There are no symptoms of (imminent) eclampsia

Often a distinction is made between preeclampsia and hypertension.
We discuss mild to moderate preeclampsia and hypertension
together because:
- in many patients the distinction cannot be made
- the management is the same
RISKS
— Progression to severe preeclampsia or eclampsia
- Damage to the placenta, resulting in:
- premature labour
- intrauterine death
- small for dates baby
- abruptio placentae

ASSESSMENT
• Check the obstetric history: small babies, prematures, still
births or abruptio placentae
• Check for symptoms of severe preeclampsia
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• Check that the size of the present pregnancy is appropriate for
dates
• Test the urine for protein

MANAGEMENT

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In pregnancy
As an outpatient
This is only suitable for patients with a good obstetric history
and no complications during this pregnancy.
• Encourage the patient to rest at home
• Prescribe sodium phenobarbitone (= phenobarb.) 30 - 60
mg tds.
• Advise salt restriction in the diet if there is marked
oedema
• See the patient every two weeks up to 32 weeks and weekly
thereafter
• At each visit: • check the blood pressure
• test the urine for protein
• weigh the patient
• check for oedema
• ask about symptoms of severe pre
eclampsia
• assess the fetal growth
• Book the patient for delivery in hospital
As an inpatient
Indications for admission into hospital during pregnancy are:
- symptoms or signs of severe preeclampsia
- a diastolic blood pressure of 100 mm Hg or more
- a bad obstetric history
- evidence of poor fetal growth
- gestation of 40 weeks or more

Observations in hospital:
• check the blood pressure at least once a day
• test the urine for protein at least once a week
• weigh the patient weekly
• palpate the abdomen once a week to assess the fetal growth:
- fundal height
- fetal size
- amount of liquor round the baby
• ask the mother about the fetal movements regularly
• if complications develop, inform the gynaecologist or the
most senior person available

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Treatment in hospital
• encourage the patient to rest
• prescribe phenobarb. 30 - 60 mg tds
• do not prescribe antihypertensive drugs or diuretics: they
do not improve the outcome of either the mother or the
baby*
• consider induction of labour if the gestation is more than 41
weeks (certain dates!) or earlier if:
- there is a history of stillbirths born before term
- there is no fetal growth in the course of two or four
weeks
- severe preeclampsia develops

Delivery
• Give good pain relief during the first stage of labour
• Watch for signs or symptoms of severe preeclampsia
• Avoid prolonged labour, shorten the second stage by vacuum
extraction
• Do not give ergometrine during the third stage
After delivery
• Observe for symptoms or signs of severe preeclampsia
• Continue mild sedation for 48 hours.

SEVERE HYPERTENSION
WITHOUT IMMINENT ECLAMPSIA
DEFINITION
The blood pressure is 160/110 mm Hg or more but does not rise
rapidly, there is not proteinuria and there are no symptoms of severe
preeclampsia like headache.

RISKS
These are: - the risks of severe hypertension outside pregnancy:
- stroke
- heartfailure
- kidney failure
- severe preeclampsia “on top of’ hypertension
- the complications of damage to the placenta

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*There is a (rare) exception to this rule. In patients where a history of repeated
stillbirths suggests that the hypertension causes poor development of the placenta,
treatment with methyldopa can be considered. It should be started early in
pregnancy and the patient should be on bedrest in hospital as well. This treatment
is expensive and a heavy burden on the patient. It should only take place under the
supervision of a gynaecologist.

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The outcome of pregnancy in patients with severe hypertension
is often poor.

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MANAGEMENT
This is along the lines indicated for mild to moderate
preeclampsia and hypertension [see previous pages] with one
important difference:
• in the interest of the mother do prescribe antihypertensive
drugs
• Continue these until after delivery.
Best is : methyldopa 250 - 500 mg qid.
A good alternative is a betablocker
A poor alternative, but better than nothing at all, is reserpin.
Further:
• Deliver the baby as soon as it seems mature enough for
survival
• Only prescribe magnesium sulphate or heavy sedation if
severe preeclampsia develops
• Get the opinion of a gynaecologist if at all possible
HYPERTENSION POSTPARTUM

DEFINITION
The blood pressure is raised within 48 hours after delivery

OCCURRENCE
It occurs:
- obviously in patients who had hypertension or preeclampsia
before delivery
- suddenly in patients who always had a normal blood pressure
(in some of these it is perhaps provoked by ergometrine)
RISK
- Progression to severe preeclampsia and eclampsia

MANAGEMENT
Within 48 hours after delivery
If there are signs or symptoms of severe preeclampsia [see
page 46], treat as for eclampsia (lytic cocktail etc)
In uncomplicated cases:
• prescribe a mild sedative, for example:
- phenobarb. 100 - 200 mg stat., followed by 30 - 60 mg tds
for two days
or
- diazepam 10 mg stat., followed by 5 mg tds for two
days
• do not use antihypertensives unless the blood pressure is
160/110 mm Hg or more, in which case the patient should be
treated as for severe preeclampsia.
After 48 hours
The risk of eclampsia is now quite small even if the blood
pressure is still high.
If the blood pressure is less than 160/110 mm Hg:
• no further treatment at present
• allow the patient home
• recheck the blood pressure six weeks after delivery
If the blood pressure is 160/110 mm Hg or more:
• start antihypertensive treatment as for a non-pregnant
patient, for example:
- reserpin 0.2 mg bd + bendrofluazide 5 mg od
- methyldopa 150 - 500 mg qid + bendrofluazide 5 mg od
• When the blood pressure is at an acceptable level, allow the
patient home
• Continue treatment for about four weeks and then stop
• Recheck the blood pressure two weeks later: if the blood
pressure is then still raised, permanent antihypertensive
treatment must be considered.

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DIAGNOSIS
The raised blood pressure is usually noted during the routine
checks after delivery

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If the blood pressure was normal during the routine checks, but
the patient complains about headache or epigastric pain, it should
be rechecked.

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Chapter 19
SEVERE ANAEMIA
DEFINITION

Haemoglobin less than 6 gm %.
CAUSES

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Common causes are:
- poor red cell production due to low dietary intake of:
- iron
- folate
- protein
- excessive loss of blood or nutrients due to:
- frequent childbearing and breastfeeding
- hookworm
- malaria

Less common causes are:
- poor red cell production due to bone marrow disease
- blood loss not due to hookworm:
- recurrent nose bleeds
- antepartum haemorrhage
- other causes of bleeding in the gastrointestinal tract
- haemolysis not due to malaria
RISKS

For the mother:
- heart failure
- cerebral anoxia
- death

For the fetus:
- prematurity
- intrauterine death

DIAGNOSIS AND ASSESSMENT

The diagnosis of severe anaemia is usually obvious. However, both
the clinical impression of pallor and the laboratory test for
haemoglobin are subject to error and can be wide off the mark.
When they disagree, a repeat examination is necessary.

The cause (s) of anaemia often go undetected due to our limited
laboratory facilities.

Severe anaemia is dangerous to mother and baby.

52

This danger is acute if:
- heart failure is present:
- pulse rate of 120/minute or more
- respirations 24/minute or more
- shortness of breath in rest
- there are cerebral signs:
- mental confusion
- coma
- the haemoglobin level is still dropping due to:
- haemolysis (jaundice!)
- bleeding
- fever
- there is extra work for the heart:
- fever
- during labour
- immediately postpartum
MANAGEMENT
DURING PREGNANCY OR PUERPERIUM
Without signs of acute danger:
• admit into hospital
• take blood specimens for:
- haemoglobin (full blood count if possible)
- malarial parasites
- grouping and x-match
• transfuse two units of packed cells slowly (about 4 hours per
unit) give frusemide 40 mg per os or per injection at the start
of each unit
check the vital signs hourly during transfusion
• give a full chloroquin tablet course (4-2-2-2)
• start malaria prophylaxis:
- chloroquin 2 tablets weekly or
- pyrimethamine (=Daraprim) 1 tablet weekly
• start folic acid 5 mg daily
• give levamisole (=Ketrax) 3 tablets stat.
• repeat the haemoglobin about 48 hours after transfusion and
weekly thereafter
With signs of acute danger:
• admit into labour ward or another high risk area
• inform the most senior person available (gynaecologist, doctor
or clinical officer)
• nurse in half sitting position
• start treatment indicated above

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• transfuse urgently
• supervise the patient closely for a number of days:
after an initial improvement she can deteriorate again if
haemolysis or blood loss continue

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DURING LABOUR
• Manage as a patient in acute danger [see above]
• Shorten the second stage by vacuum extraction
• Give ergometrine 0.25 mg i.v. and deliver the placenta by
controlled cord traction
• Keep the patient in the labour ward for at least 24 hours after
delivery for close observation

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Part II

I.J
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Abnormal Labour

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54

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Chapter 20

i

THE LABOURGRAPH
Read this chapter with a real labourgraph in front of you.
BACKGROUND
During the first stage of labour the cervix effaces and dilates. If one
plots the cervical dilatation in a graph, the progress of labour can be
seen at a glance. Figure 20.1 shows the progress of an ideal labour. In
the first part of the first stage the cervix dilates only slowly; this is
called the latent phase. The latent phase ends when the cervix has
become fully effaced and is 3 cm dilated. Between 3 cm and full
dilatation the cervix dilates faster; this is called the active phase of
labour.

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Both the latent and active phases of labour can be prolonged. The
labourgraph helps us to recognise this quickly, before serious trouble
has developed. A prolonged active phase in particular is often the first
warning of cephalopelvic disproportion.
The Malawi labourgraph spans 22 hours. The first eight hours on the
chart are reserved for recordings during the latent phase. How
recordings are made when the latent phase lasts longer than eight
hours is discussed later in this chapter. The remaining part of the
chart is for recordings made during the active phase. In it four lines
have been drawn:
- A is the alert line. If the cervical dilation follows this line, the
cervix dilates 1 cm per hour; this is the slowest rate of dilatation
in the active phase which is still normal.
- M and P are the action lines for multiparae and primigravidae
respectively. Action to correct a delay in the active phase should
have been taken before these lines have been reached [see
Chapter 22]
- The broken vertical line indicates the expected time of delivery
[see Chapter 22]
RECORDING ON THE LABOURGRAPH
CERVICAL DILATATION
On admission
If the cervix is still less than 3 cm dilated, the dilatation is recorded
at time 0 with an x. Write date and clocktime underneath [see Figure
20.2]. If the cervix is 3 cm or more dilated, the dilatation is recorded
on the alert line in the active phase [see Figures 20.3 and 20.4].
56

-

Later recordings
1. In the latent phase when the patient is examined again
four hours after admission, there are two possibilities:
- the cervical dilatation is still less than 3 cm. The dilatation
is then recorded at time 4 hours [see Figure 20.2).
- the cervix is 3 or more cm dilated. This dilatation is also
recorded at time 4 hours, but the curve is then
“transferred to the alert line” [see Figures 20.5 and 20.6].
If the latent phase is prolonged, the cervical dilatation will
still be less than 3 cm after eight hours. It can still be
recorded at the appropriate times on the chart, but when
the active phase is reached eventually, a new chart must be
started [see Figure 20.6].

2.

In the active phase. The cervical dilatation is plotted at
the appropriate times [See Figure 20.3].
If the cervix dilates normally the curve is on or to the left of
the alert line. If the curve is on the right of the alert line,
the active phase is becoming prolonged.

How often should vaginal examinations be done?

- Once labour is established vaginal examination is done four
hourly in a nullipara and three hourly in a multipara
— It should also be done at expected time of delivery
It should be done earlier if:
- the membranes rupture
- the patient wants to push
- the cervix was 7 cm or more dilated at the last
examination
- signs of fetal distress develop.

DESCENT OF THE HEAD
The baby’s head is, on examination, divided into five horizontal,
equal parts and as labour progresses the number of parts (fifths)
remaining above the brim is assessed and recorded on the labour
graph with a dot ” or an “o” [see Figures 20.2 - 20.6]. The number
of fifths still above the brim should be determined by abdominal pal
pation or better still by bimanual palpation at the time of a vaginal
examination. The number of fingers that can be placed between the
anterior shoulder and the symphysis indicates the number of fifths
above the brim. Vaginal examination alone can be very misleading:
due to moulding and caput formation the fetal scalp may be seen at
the outlet while the largest part of the head is still above the brim.
57

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CONTRACTIONS
The duration of the contractions is recorded as follows:
more than
less than
20 - 40
40 seconds
20 seconds
seconds

ADDITIONAL NOTES
Short comments can be written on the labourgraph. Longer
notes should be written on a separate sheet of paper.

The number of contractions per ten minutes is recorded as follows:
__ 1/10 minutes

□

■■ 3/10 minutes

■

cervical
dilatation

5/10 minutes
descent.

‘i

FETAL HEART RATE
The fetal heart rate is counted between the contractions, preferably
with the patient lying on her side. If she lies on her back the supine
hypotensive syndrome can cause slowing of the fetal heart.
The normal heart rate between contractions is 120 - 160 beats per
minute. Changes during the contractions are best ignored. They are
difficult to assess with the fetoscope and their significance is open to
question.
time

MEMBRANES AND LIQUOR
The following symbols are used:
I = membranes intact
C = clear liquor draining
M = meconium stained liquor draining
R = membranes ruptured but no liquor draining at present
If the membranes rupture during labour, this should be recorded at
the appropriate time [see Figure 20.5].
The following abbreviations are used:
SRM = spontaneous rupture of membranes
ARM = artificial rupture of membranes

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MOULDING
This is graded as follows:
0 = bones normally separated
+ = bones touching-but not overlapping
++ = bones overlapping but easily separated
+-h- = bones overlapping and cannot be separated
MATERNAL CONDITION
Pulse rate, blood pressure and temperature are recorded in their
appropriate columns.
58

•

ro

LATCNT

PHASE

ACTIVE

Figure 20.1
The curves of cerival dilatation and
descent during a normal labour (not
plotted on a labourgraph)

PHASE

c

5
(C-J
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Jfrzn

A
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Figure 20.2
Labourgraph of a patient admitted in the latent phase at 02.00 on
7.10.84. Four hours later she was still in the latent phase.

59

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10

UtTENT

■

3

<

ACTIVE

PHASE

r

PHASE

c

c

R

R

1 r:z‘

1

111

jk.

Ob'lff

rr

ACTIVE

PHASE

*

ili
TIME
taHUb

PHASE

ACTIVE

5T *

Figure 20.3
Labourgraph of a patient admitted at 06.15 on 10.10.84 with the
cervix 100% effaced and 3 cm dilated. Good progress after four
hours.

INTENT

PHASE

n

D
S

_$

TIME
InlUaln

I-ATF-XT

74

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HMff

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Figure 20.5
Labourgraph of a patient admitted at 14.15 on 9.9.84 with 2 cm
dilatation. Four hours later the cervix was 5 cm dilated.

•<7

PHASE

LATEWT |

>4

IK All

FIRST CHART
ACTIVE

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l-in-F.

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SECOND CHART
ACTIVI

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TIME
laitiAta

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.11
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Figure 20.4
Labourgraph of a patient admitted at 09.30 on 3.7.84 at 7 cm
dilatation.

Figure 20.6
Labourgraph of a patient admitted at 03.45 on 2.9.84 who
developed a prolonged latent phase. After 18 hours she was at last
in the active phase.

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61

Chapter 21

THE PROLONGED LATENT PHASE
DEFINITION

The latent phase is prolonged if a patient who was admitted “in
labour”, has not reached the active phase after eight hours. This
covers two different situations: false labour and the truly prolonged
latent phase.

Ambulation
This is only possible during the daytime or in the early evening
and the patient should not be too tired.

Induction of labour
• Rupture the membranes and start pitocin drip.

This must be done if there are other problems, for example
hypertension. It can be done in other patients, but particularly in
nulliparae it sometimes fails and then caesarean section becomes
necessary. For nulliparae conservative management is usually best.

FALSE LABOUR
DIAGNOSIS
In the nullipara the cervix remains long and closed or just admits a
fingertip. In the multipara the cervix can be one or two centimeters
dilated but it is not effaced. The membranes are still intact.

I
II b

MANAGEMENT
Explain to the patient that she is not yet in labour.
If she wishes, she can go home.
If she insists that she feels painful contractions:
- put her in a quiet area, preferably outside the labour ward
- sedate her with pethidine 100 mg i.m.
After a good sleep she may now be in labour or the contractions
will have stopped altogether
- do not use diazepam, largactil or sodium amytal for sedation.
These make the patient drowsy but do not stop the pain: this
can be very unpleasant!
- do not keep the patient in the labour ward more or less
indefinitely : this is very depressing for her!

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THE TRULY PROLONGED LATENT PHASE

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MANAGEMENT
There are three possibilities

I

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Sedation
- put the patient in a quiet spot
- sedate her with pethidine 100 mg i.m.
Sometimes this must be repeated.
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DIAGNOSIS
Either the cervix is 100% effaced but stays stationary at about 2 cm
or it effaces and dilates very slowly.

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Chapter 22

THE PROLONGED ACTIVE PHASE OF LABOUR
INTRODUCTION
In this chapter only labours with a vertex presentation are
considered. A prolonged active phase may present in different
forms:
The protracted active phase
The cervix dilates too slowly right from the beginning of the active
phase [Figure 22.1].

Secondary arrest
The cervix first dilates more or less normally but then stops dilating
altogether. The dilatation is usually 6 cm or more by the time
secondary arrest develops [Figure 22.2].
Secondary arrest is often complicated by oedema of the cervix

II
I

Cervical dystocia
The cervix is abnormal due to scarring or congenital abnor
mality. It does not dilate in spite of excellent contractions. This is a
rare condition.

■

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THE PROTRACTED ACTIVE PHASE

DIAGNOSIS
Diagnose a protracted active phase as soon as the curve of the
cervical dilatation drifts to the right of the alert line.

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Sometimes it is difficult to distinguish between a prolonged latent
phase and a protracted active phase, because:
- different examiners do not always agree when exactly the
cervix is 3 cm dilated
- in some women the increased rate of cervical dilatation which
is typical of the active phase starts a little later than at 3 cm.

CAUSES
Cephalopelvic disproportion with poor uterine contractions
secondary to it.

Poor uterine contractions alone, sometimes as a result of fear or
exhaustion (for example due to prolonged latent phase). Often the
reason for the poor contractions remains uncertain.
64

■■

■

DANGERS
- obstructed labour and its complications
- intrauterine infection
- eclampsia
- fetal distress
- unnecessary suffering of the mother.

ASSESSMENT (by senior midwife, clinical officer or doctor)
• review her pregnancy (antenatal card!) and labour up to now
• do a complete examination including a vaginal examination
and pelvic assessment
• Look for:
- a mechanical cause of the delay
— other problems which make prolonged labour, regardless
of its cause, undesirable.

Mechanical causes
1. Gross cephalopelvic disproportion
This is diagnosed on the grounds:
- a severely contracted pelvis in combination with a normal
size or large baby
or
- a high head (4/5 or 5/5 above the brim) with severe
moulding; consider a small fontanel in the centre of the
pelvis (maximal flexion!) and a large caput as additional
unfavourable features.
2.

Malpresentation not previously recognized. Examples are:
- brow presentation
- shoulder presentation
- face presentation

3.

Soft tissue obstruction. For example;
- a scarred cervix
- vaginal stenosis
- pelvic tumour

Other problems making further prolongation undesirable
For example:
- previous caesarean section scar
- stillbirth or neonatal death with last delivery
- nullipara older than 30 years
- multipara older than 40 years
- severe preeclampsia or hypertension
- fetal distress

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- intrauterine infection
- an active phase which has already lasted more than 12 hours

MANAGEMENT (by senior midwife, clinical officer or doctor)
The treatment of the protracted active phase should start as soon as
it is diagnosed and certainly not later than when the action line is
reached.
There are two options:
- immediate caesarean section
- trial of conservative treatment

Immediate caesarean section
This is indicated if:
- vaginal delivery is impossible or unlikely (gross cephalopelvic
disproportion etc.)
- further prolongation of labour is undesirable.
Note that the finding of a borderline pelvis alone is not an indication
for immediate section.
Trial of conservative treatment
This consists of:
• artificial rupture of membranes
• pethidine 100 mg i.m.
• rehydration with dextrose 5% in water if necessary
• in nulliparae pitocin drip starting at 5 units per liter and 10
drops per minute [see also Appendix A] No pitocin for
multiparae.
• check frequently:
- contractions
- descent
- fetal heart
- blood pressure
• repeat the vaginal examination after three and six hours
unless it is indicated earlier (signs of the second stage, fetal
distress)
• be prepared for an operative vaginal delivery:
- vacuum extraction
- symphysiotomy
• accept defeat and do a caesarean section, if:
- after six hours the patient is not delivered
- earlier if fetal distress or signs of severe disproportion
develop.

j

SECONDARY ARREST

DIAGNOSIS
Diagnose secondary arrest if after 6 cm dilatation there is no further
dilation for two hours. Look at the examples in Figures 22.1 - 22.5.

Note that:
- if the cervix began by dilating very fast, secondary arrest must
sometimes be diagnosed before the alert line is reached [Figure
22.3]
- if the patient is admitted during labour, she may have been in
secondary arrest for hours before admission [Figure 22.4]
- the diagnosis of secondary arrest may be delayed, because
midwives disagree about the state of cervical dilatation [Figure
22.51.
CAUSES
The main cause is the high presenting part. In normal labour the
presenting part descends during the latter part of the active phase
and stretches the cervix to full dilatation. If the presenting part
stays high, this mechanical stretching of the cervix does not take
place.
The reasons for the high presenting part can be:
- cephalopelvic disproportion
- malpresentation
- poor contractions
- a still intact bag of membranes.

DANGERS
As long as the membranes are still intact, there is little danger
except that labour may become unnecessarily prolonged and that
the contractions will gradually become weaker.
After rupture of the membranes the danger is obstructed labour and
rupture of the uterus. In a multipara these complications may
develop very rapidly.

MANAGEMENT (by senior midwife, clinical officer or doctor)
• Rule out gross cephalopelvic disproportion or malpresentation
needing immediate caesarean section
• Rupture the membranes, if these are still intact. Observe the
necessary precautions [see Chapter 39]
• If the cervix is soft and 8-9 cm, ask the patient to push during
a contraction.
In some patients this is all that is needed: the head comes down and

66

67

the baby is either bom spontaneously or delivered by an easy
vacuum extraction.

If it is too early for the patient to push or pushing does not bring the
head down within two or three contractions and you do still believe
that vaginal delivery is possible:

- with a primigravida
• put up pitocin for 2 - 4 hours
• Sedate with pethidine 100 mg i.m.
• if this does not achieve delivery, do a caesarean section

1

10

I
V

X
(cm)

s

I *

L:

- with a multipara
• wait for one hour
• if she is still undelivered, ask her to push during two
contractions
• if this still does not bring down the head, do an
immediate caesarean section.

IMPORTANT DON’TS
• no pitocin for a multipara
• no vacuum extraction if the head is still 3/5 or more above the
brim.

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r.

D

Figure 22.2
Secondary arrest in a multipara.
Note that the vertical line (expected time of delivery) has not
been reached yet.

10

5:R

1
(cm)

r.

D

S
LATENT

I

IM HSR

ACTIVE

I II \SE

JI

N

*

LATENT

PHASE

M

ACTIVE

zzz

2
10

zz

C

R

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(«m)

r

LI

•JC-Q

>-

D

'Ll

■'1
b'

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Figure 22.3
Secondary arrest in a multipara.
Note that the diagnosis is made before the cervicograph reached
the “alert” line.

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Figure 22.1
Protracted active phase. Treatment was delayed: it should have
started at time 12 hours.

■
■:

L
68

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69

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1

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F

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10 p
i.ATrxr

’ itiwt

ACTIVE

’

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<<•1

r

f

D

S

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r -

- -

d

if

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Figure 22.4
Secondary arrest in a multipara who had been in labour at home.
Rupture of the uterus three hours after admission!

■

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THE 0EDEMAT0US CERVIX
DIAGNOSIS
The cervix is 6 cm or more delated but instead of being thin feels
thick and swollen.
CAUSES
- secondary arrest
- obstructed labour
- pushing before the cervix was fully dilated

MANAGEMENT
• ask the patient to push during a few contractions
• if the head comes down, massage the cervix, try to push it
gently over the head and deliver the baby
• if this is not possible, do an immediate caesarean section
• do not waste hours in the hope that the oedema will go away
again: it will not!

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11

C

5 ■

Ll:
Figure 22.5
Secondary arrest in a multipara. “Bouncing” cervicograph. The
dilatation of the poorly applied cervix is assessed differently by
three different midwives.

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Chapter 23

THE PROLONGED SECOND STAGE
(VERTEX PRESENTATIONS)
DEFINITIONS

The second stage begins when the cervix is fully dilated and the
membranes have ruptured; it ends with the delivery of the baby.
■v

The second stage is prolonged'.
- in a nullipara after thirty minutes
- in a multipara after twenty minutes
CAUSES

■

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- Unfavourable relation between head and pelvis
- cephalopelvic disproportion
- occipitoposterior position
- Soft tissue obstruction
- tight perineum
- vaginal septum or stricture
- Poor uterine contractions
- Poor maternal effort
- Combinations of the above factors
RISKS
- Fetal distress
- Progression to obstructed labour
ASSESSMENT
Before you do anything, quickly assess the situation.
HISTORY
• What is the parity?
• Were there any problems with previous deliveries?
• How was the progress during the first stage of labour?
• How long has she now been in the second stage?

■

EXAMINATION
General condition
• Vital signs
• Dehydration?
• Mental state: can she co-operate?
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Abdominal examination
• Contractions
• Size of the fetus
• Presentation
• Descent
• Overlap
• Bladder
• Fetal heart

1
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Vaginal examination
• Dilatation and state of the remaining rim of the cervix,
(oedema, tightness?)
• Membranes
• Position of sutures and fontanels
• Moulding and caput
• Descent by bimanual palpation:
- between the contractions
- during a contraction together with maximal maternal
effort
• Pelvic assessment
During your examination make sure you rule out silly mistakes:
- cervix not dilated
- membranes still intact
Do not miss signs of obstructed labour (see Chapter 321. If these
are present be prepared for a difficult operative delivery.

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MANAGEMENT

■J

Prompt delivery is necessary to prevent fetal distress or obstructed
labour.

J

DO NOT WAIT

The following outline is meant to help you make a decision about
the method of delivery. This decision is easy if the head is very high
or very low but between these extremes decisions can be difficult.
Within this grey zone practical experience is a great help.
VACUUM EXTRACTION
1. Routine (by midwife in the labour ward)
- head 0/5 above the brim with or without moulding
- head 1/5 above the brim without moulding or with only
slight moulding or caput

2.

Trial of vacuum extraction (by clinical officer or doctor,
preferably in theatre)
73

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Chapter 25

Normal size baby (2500 - 3500 gm)
• Caesarean section for:
- a previous caesarean section
- a pelvis which is borderline or worse
- a footling breech
- delay in the first or second stage of labour
• Vaginal delivery
- only if everything is normal

FACE PRESENTATION
VARIETIES

- Mento-anterior

Small baby (less than 1500 gm)
Unless your nursery facilities are excellent, the chances of
survival for the baby are poor regardless of which route it is
delivered
• Caesarean section
- only for a previous caesarean section (to prevent scar
rupture)
• Vaginal delivery
- in all other cases

N.B. BE CAREFUL NOT TO MISTAKE TWO LITTLE TWINS FOR
ONE LARGE BREECH.

I
NOTE:
A slighly different way of approaching this problem is the Andros score.

4

Points

o

.•
■

1

F■

1

1

2

Parity

Primigravida

Multipara

Gestational age

39 weeks or more

38 weeks

Estimated fetal
weight

over 3600 gm

3200-3590 gm

<3200 gm

Previous delivery
of a breech weighing
more than 2500gm

none

one

two or more

37 weeks

A total score of less than 3 indicates that delivery should be by caesarean section

- Mento-transverse

- Mento-posterior

DIAGNOSIS
Face presentation is usually first diagnosed on vaginal examination
during labour.
You will feel:
- eyes
- mouth
with
gums
nose
- chin

RISKS

- Obstructed labour
- Fetal distress
- Neonatal breathing problems due to the caput succedaneum on
the face

MANAGEMENT
During the first stage of labour
• Rule out anencephaly
• Assess the pelvis and the size of the baby
• Assess progress with the labourgraph
• Only allow vaginal delivery if this will be easy:
- unremarkable obstetric history
- normal progress during the active phase
(graph of cervical dilatation on or on the left of
the alert line)
- small or normal size baby
- normal pelvis
- mento-anterior or transverse position
• Do caesarean section for:
- history of previous caesarean section
- delay in the active phase of labour as soon as this is
noted (there is not a place for acceleration of labour)
- big baby
- borderline or worse pelvis
- mento-posterior position

During the second state of labour
• Observe carefully : progress should be fast
• Make a generous episiotomy
• If not delivered within about 15 minutes, do caesarean section
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Chapter 26

Chapter 27

BROW PRESENTATION

COMPOUND PRESENTATION

DIAGNOSIS

DEFINITION

Brow presentation is diagnosed on vaginal examination
during labour.
You will feel:
- the anterior fontanel
- the supra-orbital ridges
- the base of the nose

RISK
Obstructed labour. Vaginal delivery
of a normal size baby is impossible.

MANAGEMENT
Caesarean section as soon as the diagnosis has been made
unless the baby is very small

The head presents together with one or more limbs

VARIETIES
- Head + hand (elbow cannot be felt)
- Head + arm (elbow can be felt)
- Head 4- foot
- Head + more than one limb

DIAGNOSIS
By vaginal examination during labour

MANAGEMENT
Head + hand
• Await spontaneous vaginal delivery. (The presence of a hand
only beside the head does not affect the outcome of labour)
Head +arm
• Try to push the arm behind the head. This should be easy.
Difficult or prolonged manipulation can cause cord prolapse
• If the arm cannot be pushed back, do caesarean section unless
the baby is very small.

Head + foot
• Try to push the foot behind the head
• If this is not easy, do caesarean section unless the baby is very
small
Head + more than one limb
• Caesarean section is usually best

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Chapter 28

Chapter 29

SHOULDER PRESENTATION

TWIN DELIVERY

DIAGNOSIS

RISKS

On abdominal palpation:
- the “transverse” shape of the uterus
- the head not above the brim but in the iliac fossa or in the
flank.
A shoulder presentation is often missed on abdominal palpation
during labour.

■

-

On vaginal examination:
The diagnosis is obvious if the arm has prolapsed. It is difficult
when:
- the shoulder only presents.
This is recognised by identifying the ribs, axilla and clavicle.
- the elbow presents.
This is recognised by identifying the hand.
RISKS
- Obstructed labour

- Cord prolapse

MANAGEMENT
Spontaneous vaginal delivery
• Only if the baby is very small and not viable (less than 30
weeks)
Caesarean section
• If the baby is alive and more than 30 weeks size
• If the baby is dead and spontaneous vaginal delivery or a
destructive operation is impossible. [For the technique of
caesarean section for shoulder presentation (transverse lie)
see Chapter 44]
Destructive operation
• This can be done if:
- the baby is dead and not too big and
- the cervix is 7 cm or more dilated and
- the neck and trunk can be reached easily
[For the technique of destructive operations see Chapter 48]

IMPORTANT DON'T
Do not do internal version. This is only permitted for a second
twin with intact membranes.

80

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- Labour before term
- Premature rupture of membranes
- Poor uterine activity resulting in:
- prolonged first stage
- prolonged second stage
- postpartum haemorrhage
- Malpresentation usually of the second twin

I

f
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MANAGEMENT

During the first stage of labour and the delivery of the first twin:
- as with singleton pregnancy.

DELIVERY OF THE SECOND TWIN
Two aims: - to deliver the second twin within 30 minutes of the
first
- to recognise and deal with malpresentation
promptly
In practice
• Check the lie of the second twin by abdominal palpation soon
after delivery of the first baby
• If it is transverse or oblique, turn it to a longitudinal lie
(breech is perfectly acceptable)
• Do a vaginal examination:
- identify the presenting part before the membranes
rupture
- if this is difficult because the presenting part is high, put
on a clean glove and feel with four fingers or even the
whole hand
Further maijagement depends on your findings:
1. Cephalic or breech presentation
• Rupture the membranes [for the necessary precautions see
Chapter 39]
• Await spontaneous delivery
• Stimulate the contractions with pitocin if necessary
2.

Shoulder presentation or arm prolapse
• Keep the membranes intact
81

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• Prepare for operative delivery in theatre under general
anaesthesia
• Do internal podalic version and breech extraction (this is
the only situation in which this operation is done)
• If you are not familiar with the technique of the internal
version, do caesarean section
• If the membranes rupture before you can do internal
version, do caesarean section

3.

Cord or compound presentation
• If the baby is small, rupture the membranes and hope for a
quick vaginal delivery
• If the baby is a good size, do either internal podalic version
and breech extraction or caesarean section

THIRD STAGE OF LABOUR
• Be prepared for postpartum haemorrhage
• Give ergometrine 0.5 mg i.v. after delivery of the second twin
• Deliver the placenta by controlled cord traction.
IMPORTANT DON'TS
• If on vaginal examination you are unable to feel the presenting
part, do not wait for it to come down: if the membranes
rupture spontaneously and the shoulder presents or the arm
prolapses, you are in serious trouble.
• If you feel a large rim of cervix after the delivery of the first
twin, do not wait for the cervix to become fully dilated again.
Continue with the delivery of the second twin: the cervix will
move out of the way as soon as the presenting part comes
down.
Beware, however, of a constriction ring: this is a narrowing in
the cervix or lower segment due to spasm. It feels very
different from the loose rim of cervix due to a high presenting
part. A constriction ring may disappear under deep anaesthe
sia but often caesarean section is necessary.

Chapter 30

CORD PRESENTATION AND PROLAPSE
DEFINITION AND DIAGNOSIS
The umbilical cord is felt on vaginal examination.
Cord presentation: the membranes are still intact
Cord prolapse
: the membranes have ruptured
CAUSES

- Prematurity
- Malpresentation:
- flexed breech
- footling breech
- shoulder presentation
- Cephalopelvic disproportion
- Low implantation of the placenta
- Very long umbilical cord
- Polyhydramnios

MANAGEMENT
CORD PRESENTATION
Immediate caesarean section unless the baby is dead or too small to
survive1.
CORD PROLAPSE
Live baby
• Caesarean section for most patients
. Spontaneous vaginal delivery only if the baby is too small to
survive1

• Vaginal delivery assisted by vacuum extraction only if:
- patient is a multipara
- the cervix is fully dilated
- the vertex presents
- the baby is normal or small size
- the pelvis is normal
‘The baby s chances of survival depend very largely on your nursery facilities:
Y*
excellent facil»t>es the chances are close to zero below 30 weeks,
doubtful between 30 and 34 weeks and reasonable thereafter.

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Chapter 31

If immediate delivery is not possible, try to prevent compression and
drying of the cord:
• place the patient in the knee-chest position or in the
semiprone position with pillows under the hip
• push the head up with two fingers in the vagina*
• if the cord is outside the vagina, wrap it in a warm, saline
soaked gauze swab

THE CONDUCT OF A TRIAL OF SCAR*
This is the responsibility of a clinical officer or doctor!

THE FIRST STAGE OF LABOUR

These manoeuvres are not terribly effective and should never
be allowed to interfere with the preparations for a speedy
operative delivery!

■

Reassess fetal size, presentation and pelvis and evaluate the
progress of labour carefully with the labourgraph.

Caesarean section during the first stage of labour is indicated with:
- malpresentation (breech, face, brow, cord) or suspected
cephalopelvic disproportion on first examination
- a curve of cervical dilatation running on the right of the alert
line
- fetal distress
- signs of (impending) rupture of the uterus {vaginal bleeding,
tender scar between contractions, hypertonic uterus, shock)
- ruptured membranes for 24 or more hours without contrac
tions after 36 weeks gestation.

■

Dead baby
Await spontaneous vaginal delivery unless this is impossible for
other reasons (gross cephalopelvic disproportion etc.).

-

■

N.B. NO PITOCIN IN PATIENTS WITH PREVIOUS CAESAREAN
SECTION SCARS.
■

THE SECOND STAGE OF LABOUR

i

This should not last more than 20 minutes.
• When the vertex is 2/5 or below, do a vacuum extraction
• If the vertex is 3/5 or above after 30 minutes do a caesarean
section.

1!

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*An alternative method of preventing cord compression is to fill the bladder with 500
- 1000 ml of saline through a Foley catheter.

84

THIRD AND FOURTH STAGES OF LABOUR
• Delivery of the placenta in the usual manner
• Explore the lower segment with the finger after delivery of the
placenta
• Observe for at least two hours in the labour ward for signs of
bleeding and shock (vital signs).

*For the indications of a trial of scar see Chapter 5.

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Chapter 32

OBSTRUCTED LABOUR*
BACKGROUND

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In order to understand the condition called “obstructed labour
one must know what happens when a patient labours with a
mechanical barrier in the birthcanal.
The first stage of labour is often prolonged but can be normal or
even short. The membranes rupture and the liquor gradually drains
away. Sooner or later, but often before the cervix has become fully
dilated, the uterine contractions begin to force the fetus from the
corpus into the lower segment from where there is no escape
because of the obstruction. The lower segment becomes over
stretched and the uterus moulds tightly round the fetus. Because of
the excessive pressure on the placenta and umbilical cord the fetus
becomes distressed and eventually dies.
In the nullipara a stalemate develops which persists for hours or
even days. Cervix, vagina, bladder and rectum trapped between the
fetal head and the pelvic bones become necrotic and later slough.
After a few days the fetus, softened by maceration and decay, is
delivered. If the mother does not die of infection or bleeding, she will
be left with a bladder fistula as well as extensive scarring in the
vagina.
In the multipara the uterine contractions do not give up but
continue their battle until the uterus ruptures.
It is debatable at which point along the course of events one
begins to call labour “obstructed”. However, a diagnosis of
obstructed labour must be made if:
— the overstretched lower segment can be recognised clinically.
— there is damage to the lower genital tract as a result of
pressure.
Rupture of the uterus, although the ultimate outcome of obstructed
labour in the multipara, is usually discussed as a separate condition.
CAUSES
Common causes of obstruction are:
- cephalopelvic disproportion
- brow presentation
- shoulder presentation or arm prolapse
*An excellent description of the clinical picture of obstructed labour is to be found in
Lawson and Stewart’s “Obstetrics and Gynaecology in the Tropics , Chapter 11.
Highly recommended reading.

86

Less common causes of obstruction are:
- other malpresentations
- after coming head in breech presentation
- hydrocephalus
- other fetal abnormalities
- locked twins
- pelvic tumour
- stenosis of cervix or vagina
- tight perineum

CLINICAL PICTURE
HISTORY
Patients managed with the labourgraph
There are three possibilities:
- the active phase was protracted
- the onset of the active phase was normal but secondary
arrest developed later
- progress was fast through the active phase, but labour
becomes acutely obstructed in the second stage
Of course in the patient with an active phase or secondary phase
arrest, action should have been taken long before labour became
obstructed. Common problems are, however:
- lack of transport to move a patient from a clinic to a larger
hospital
- shortage of staff resulting in inadequate supervision during
labour or delay in treatment once the problem developed
- failure of staff to appreciate the danger of secondary arrest

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Patients admitted late in labour from home
Most of these laboured at home for a very long time and tried all
kinds of home remedies. Sometimes, as with the patients in
hospital, labour was short and became suddenly obstructed.
EXAMINATION
General condition
Physical and mental exhaustion are nearly always present
Other features are often:
- dehydration due to prolonged labour without drinking, in
hot weather
- fever due to intrauterine infection
- (pre) eclampsia as a result of excessive pain and stress
Shock usually indicates rupture of the uterus but can be due to
sepsis
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Abdominal examination
- Frequent and too strong uterine contractions which drive the
patient into a state of panic
or
a uterus which has gone into tetanic contraction and sits
tightly moulded round the fetus
- Bandl’s ring. This is the narrowing between the half empty
uterine corpus and the overstretched lower segment. The
shape of the uterus resembles that of a peanut shell.
In extreme cases the corpus is completely empty, having
delivered the fetus and placenta into the lower segment
- a bladder distended by urine and oedema
- bowels distended with gas

I

Vaginal examination
You will often find:
- oedema of the vulva and cervix
- stinking meconium
- the cause of obstruction:
- a severely moulded head stuck in the pelvis
- a prolapsed arm or shoulder presentation

2.

1.

On catheterisation
— concentrated urine
- urine mixed with blood or even stinking meconium

DIAGNOSIS

2.

The diagnosis is certain:
- if Bandl’s ring is present
- if gross bladder injury (fistula or necrosis) is present

"J!

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The diagnosis should be suspected, when during a protracted
active phase, secondary arrest or a prolonged second stage:
- fetal distress develops
- the cervix does not dilate in spite of good contractions
- moulding and caput increase without descent
- the mother becomes restless and anxious

1

4 I

DIFFERENTIAL DIAGNOSIS
1.

Rupture of the uterus
Rupture of the uterus is common in the multipara, rare in the
nullipara.
The diagnosis is obvious if the fetus is outside the uterus

88

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The prolonged latent phase
If the patient and her supporters firmly believe that she is in
strong labour, severe maternal distress with dehydration may
develop during the latent phase. If she was made to push as well,
the vulva and cervix can be oedematous.
In this condition, the cervix is not or only slightly dilated, the
membranes are intact and Bandl’s ring is absent.
An explanation of the state of affairs, fluids and pain relief are
all that is needed.

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MANAGEMENT

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The diagnosis should be suspected if:
- pallor and shock are present
- the urine is grossly bloodstained
- there is gross bleeding from the vagina
A rupture is impossible to diagnose before delivery if the fetus is
still in the uterus and tamponades the bleeding

3.

Resuscitation
• Put up an i.v. drip with a large (No. 18) needle or cannula
• If she is mainly dehydrated and exhausted give dextrose 5%
one or two litres in about six hours
• If she is shocked, run in saline or sodium lactate as fast as
possible

Antibiotics
Most patients will need antibiotics. For example:
- x-penicillin 5 mega i.v. stat., continue 2 mega i.v. six hourly
plus
- streptomycin 1 gm i.m. stat., continue 1 gm i.m. daily
or
- chloramphenicol 1 mg i.v. stat., followed by 0.5 gm i.v. six
hourly
Delivery
If rupture of the uterus is certain or seems likely, do a
laparotomy.
If the uterus seems intact but the baby is dead’.
Cephalic presentation:
- cervix 7 cm or more dilated + descent 2/5 or below:
craniotomy
- all other situations:
caesarean section

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Transverse lie
- cervix 7 cm or more dilated + neck or trunk easy to reach:
destructive operation
- all other situations:
caesarean section
If the uterus seems intact and the baby is alive
Vertex presentation
- cervix fully dilated + descent 0/5
: vacuum extraction
+ descent 1/5-2/5
: symphysiotomy
+ 3/5 or above
: caesarean section

- cervix not fully dilated

: caesarean section

Other cephalic presentations

: caesarean section

Transverse lie

: caesarean section

For the details of operations for obstructed labour refer to
Part III of the Manual.
For the complications which can follow obstructed labour during the
puerperium see Chapter 55
For the repair of the ruptured uterus see Chapter 45

Chapter 33

FETAL DISTRESS DURING LABOUR
DEFINITION

I

In fetal distress the oxygen supply to the baby in the uterus is
poor and as a result the baby is born with an Apgar score [Chapter
57] after one minute of 7 or less.
CAUSES

Poor oxygen or blood supply to the uterus
in: - the supine hypotensive syndrome
- gross anaemia
- heart or lung disease of the mother
Poor quality placenta
in: - hypertension
- (pre)eclampsia
- other conditions

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Early separation of the placenta
in: - placenta praevia
- abruptio placentae

Labour-related problems
in: - obstructed labour
- delay in the active phase or second stage
regardless of the cause
- overstimulation with pitocin
- cord prolapse
- other cord problems: true knots etc

1
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Sick baby, who cannot stand the stress of normal labour
because of: - congenital abnormality
- intrauterine infection (e.g. syphilis)
- growth retardation
- other conditions
Sometimes no reason for fetal distress is found.

■

SIGNS

Abnormal fetal heart rate
Fetal distress should be suspected, if between the contractions, the
fetal heart rate is less than 120/minute or more than 160/minute.

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• continue to suspect fetal distress if:
- the fetal heart rate stays abnormal or
the liquor contains meconium.
- if when the membranes rupture, the liquor is
found to contain meconium
• check the fetal heart rate
• do a vaginal examination to check for cord
prolapse
• continue to suspect fetal distress even if the fetal
heart rate is normal

Unfortunately an abnormal fetal heart rate is also often found when
there is no fetal distress. For example:
- the fetal heart may be slow at the end of the active phase or
during the normal second stage due to compression of the head
- the fetal heart can be faster than 160/minute if the mother has
fever.
Sometimes the fetal heart rate is abnormal without an obvious
reason.

Meconium in the liquor
Meconium in the liquor can be a sign of fetal distress. Unfortunately
it is also often seen where no fetal distress exists. Thick, pea-soup like meconium is probably more significant than light meconium
staining.

MANAGEMENT
The treatment of fetal distress is delivery of the baby as soon as
possible, if necessary by caesarean section. However, caesarean
section carries risks for the mother and these should be considered,
particularly as the diagnosis of fetal distress is often merely
suspected, not certain.

ASSESSMENT
The signs of fetal distress may present:
- in patients with a known obstetric problem (e.g. obstruct
ed labour, eclampsia or abruptio placentae). In these patients
the fetal distress must be assessed together with their other
problem
- unexpectedly in what seemed to be normal labour. In that
case:
- if the fetal heart rate is suddenly found to be abnormal
• consider the possibility of:
- cord prolapse
- onset of the second stage
- supine hypotensive syndrome
- other causes
• do a vaginal examination immediately. If you find:
- cord prolapse, manage the patient as such [see
Chapter 30]
- full dilatation, deliver the patient
- in other patients:
• rupture the membranes in order to examine the liquor
• ask the patient to lie on her side
• reduce or stop pitocin if this is being given
• recheck the fetal heart with the patient on her side after
five minutes
• stop suspecting fetal distress if:
- the fetal heart is now normal and
- the liquor is clear

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Caesarean section is indicated if:
1. there is also a maternal indication, for example, obstructed
labour.
2. the baby is near term and the mother is a “poor obstetric
risk”, for example, in the case of:
- a primigravida of 30 years or older
- a bad obstetric history
- hypertension or diabetes in this pregnancy
3. the baby is near term, the signs of fetal distress are severe
and delivery cannot be expected soon.
Vaginal delivery is indicated if:
1. the baby is unlikely to survive the neonatal period, for
example due to:
- severe immaturity (gestation less than 30 - 32 weeks)
- a major congenital abnormality
2. the baby is near term but the signs of fetal distress are mild
and labour is progressing quickly. In this case:
• supervise labour carefully
• encourage the mother to lie on her side
• shorten the second stage by a vacuum extraction
There are patients who do not fit these guidelines. Do not
hesitate to get the opinion of the most experienced person available.

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ft:;’

SB-

IMPORTANT DON'T
The following forms of “treatment” for fetal distress are no longer
regarded as effective:
93

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- intravenous injection of dextrose 50%
- the use of a fast running dextrose 5% drip
- the administration of oxygen through a nasal catheter.*

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Chapter 34

PRIMARY POSTPARTUM HAEMORRHAGE
DEFINITION
Primary postpartum haemorrhage is bleeding from the genital tract
which exceeds 300 ml and which occurs within 24 hours after
delivery.
CAUSES

THE PLACENTAL BED
This is the most common site of bleeding. The bleeding does not stop
because the uterus does not contract well. Frequent causes of a
poorly contracted uterus are:
- fiddling with the uterus during the third stage
- a retained or incompletely delivered placenta
- high parity
- prolonged labour
- twin delivery
- polyhydramnios
- anaesthesia
- full bladder
LACERATIONS
Common causes of bleeding are:
- vulval tears (near urethra and clitoris)
- vaginal tears
- perineal tears
Less common causes of bleeding are:
- cervical tears
- rupture of the uterus
- inversion of the uterus (very rare!)
CLOTTING DEFECTS
These make bleeding from any site worse. They are rare after
normal delivery but are seen more often after:
- abruptio placentae
- infected labour
♦In the past maternal acidosis was considered to be an important cause of fetal
distress. A moderate degree of maternal acidosis is now regarded as normal during
labour. An intravenous injection of 50% dextrose can be followed by hyperinsulinism
and hypoglycaemia in the baby. A fast dextrose 5% drip caused hyponatraemia in
mother and baby which can be harmful to both.
Very little of the oxygen administered through a nasal catheter reaches the ternal
blood stream and virtually none gets to the baby. Oxygen given through anaesthetic
mask is effective and should be given before the induction of anaesthesia.

94

MANAGEMENT

ft.

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site
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FOR EVERYBODY
SHOUT FOR HELP
- You need to be at least two to deal with any postpartum
haemorrhage.
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MAKE THE UTERUS CONTRACT AND EMPTY IT
- rub up a contraction
- give ergometrine 0.5 mg i.v.
- deliver the placenta by controlled cord traction (one try
only) or if the placenta is already out, expel the clots
- keep the uterus well contracted
- check that placenta and membranes are complete
- keep the bladder empty

REPAIR TEARS OF VULVA, VAGINA OR PERINEUM

AL WA YS GO AND SEE THE PATIENT

1.

FOR MIDWIVES
ALWAYS INFORM THE CLINICAL OFFICER OR DOCTOR IF:
- the bloodloss is 500ml or more
- placenta and membranes cannot be delivered or are incomplete
- a tear cannot be sutured in the labour ward
- the patient was not delivered in your labour ward but came in
from outside after delivery
IF BLEEDING CONTINUES AND THE MEDICAL OR CLINICAL
OFFICER CANNOT COME, you may:
- put pitocin 10 - 40 units per litre into the i.v. drip
- repeat ergometrine i.v.
- try to remove the placenta manually after giving diazepam
10 mg i.v.
- compress the uterus bimanually between a fist in the vagina
and a hand on the abdomen behind the uterus.

J

IMPORTANT DONTS
- never leave the patient alone until the bleeding has been
controlled and her general condition is good
- never put a pack into the vagina

General condition
- Is she pale, sweating, restless or unconscious?
- Feel the pulse; check pulse rate and blood pressure, but
later, not now.

2.

How much blood has she lost so far?

3.

Is she still bleeding?

RESUSCITATE THE PATIENT
- put up an i.v. drip with saline and run it fast
- take blood for haemoglobin and x-matching
- measure the bloodloss
- check pulse and blood pressure
- keep accurate records

•-

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ON ARRIVAL QUICKLY ASSESS THE PATIENT

4.

-

If no

Ifyes
- Is the uterus well con
tracted?
- Is the placenta out and
complete?
- Are there lacerations
of the vulva, vagina or
perineum?

- Is the uterus well contract
ed and the fundus below
the umbilicus?

What has been done so far?
- How much i.v. fluids were given?
- Which drugs were given?
- Was blood for x-matching taken?
- Has blood for transfusion been organised

STOP THE BLEEDING
If the uterus is empty but poorly contracted:
- rub up a contraction and express the clots
- repeat ergometrine 0.5 mg i.v. or i.m.
- put pitocin 10 - 40 units per litre into the i.v. drip, if necessary
- catheterise the bladder

If the placenta is wholly or partly retained:
- rub up a contraction
- put pitocin 10 — 40 units per litre into the i.v. drip (avoid, if
possible, giving more ergometrine: this makes the manual
removal of the placenta more difficult)
- arrange for immediate manual removal of the placenta [for the
technical detail, see Chapter 49]

FOR CLINICAL OFFICERS AND DOCTORS
The midwives will call you for patients with severe or
complicated forms of postpartum haemorrhage. You should:

If bleeding continues in spite of an empty and well
contracted uterus and without vulval, vaginal or perineal
tears:
- Check if the blood from the vagina is clotting. When in doubt,
check the clotting time [see Chapter 15]

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If the blood is clotting
- examine in theatre
under anaesthesia
[see Chapter 49]

If the blood is not clotting
- arrange for two pints of fresh
blood
- continue pitocin in the i.v.
drip
- catheterise the bladder
- keep a very careful intake/
output chart
- examine under anaesthesia
only when a cervical or ute
rine tear is suspected

ALWAYS INFORM THE MOST SENIOR PERSON AVAILABLE, if:
- the blood loss is more than 1,000 ml
- the patient does not respond to resuscitation
- there is a clotting defect
- the placenta cannot be removed
- laparotomy or hysterectomy is required

IMPORTANT DON'TS
- never treat postpartum haemorrhage by telephone
- do not postpone manual removal of the placenta or an
examination under anaesthesia
- do not pack the vagina.

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RESUSCITATE THE PATIENT IF SHE IS IN SHOCK
- organise a good i.v. drip with a large needle or cannula
DON'T LOSE TIME: do a cutdown if necessary

- Start by running in saline or sodium lactate solution very fast.
[Further, refer to Chapter 35]
UNUSUAL BUT DESPERATE SITUATIONS

1.

I

Continued bleeding from an empty uterus
If the uterus does not contract after large doses of
ergometrine and pitocin, hysterectomy becomes necessary.
While the preparations for this are being made, the uterus
should be compressed between a fist in the vagina and a hand
on the abdomen behind the uterus.
If a clotting defect causes the continued bleeding, transfuse
fresh blood and hope that the bleeding will stop.

2.

3.

Morbidly adherent placenta
If the bleeding is heavy, perform immediate hysterectomy. If
the bleeding can be temporarely controlled with pitocin and
you are nervous about the hysterectomy, givevhigh doses of
antibiotics and refer to a gynaecologist immediately.

1

Injuries to the uterus
These can be: - a rupture, - a perforation, - a cervical tear
extending into the lower segment. Do a laporotomy and
assess the damage. Repair may be possible, otherwise
perform hysterectomy.
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Chapter 35

RESUSCITATION OF PATIENTS WITH SEVERE
BLOODLOSS
INTRODUCTION

-

THE RESPONSE OF THE BODY TO BLOODLOSS
The immediate reaction of the heart and bloodvessels
In order to maintain the blood pressure during severe bloodloss, the
heart beats faster and the bloodvessels contract.

-:v

-

After a moderate loss the blood pressure stays stable but after 1,000
- 1,500 ml has been lost it drops suddenly to a systolic pressure of
around 50 mm Hg. This level is the body’s “last ditch stand”. If
bleeding continues and no intravenous fluids are given, there will be
a second sudden drop of the blood pressure to zero and the patient
dies [see Figure 35.1J.
Systolic
blood
pressure
(mm Hg)

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- the kidneys conserve water and salt and secrete very
concentrated urine only
- the patient feels thirsty and drinks more than usual
The haemoglobin. Immediately after a large bloodloss the
haemoglobin concentration of the patient’s blood is still the
same as before because red cells and fluid were lost together.
In the next few days the fluid, which restores the bloodvolume
back to normal, dilutes the blood and the haemoglobin
concentration falls: the patient becomes anaemic. The bone
marrow will replace the lost red cells but does so only slowly.
Thus it takes a few weeks for the haemoglobin concentration
to return to normal.

PATIENTS WHO TOLERATE BLOOD LOSS POORLY
Without resuscitation an acute blood loss of about 2.5 litres will
kill most patients. However, many patients die after a much smaller
loss. Examples of those who tolerate blood loss poorly are:
- small women
: they start off with a small
blood volume
- eclamptics
: their blood volume is small in
spite of fluid retention and
oedema
- anaemic patients
: the heart is doing extra work
already and they have fewer
red cells to lose
- patients with heart disease : the heart cannot do the ne
cessary extra work

MANAGEMENT

1000

Figure: 35.1

2000

I
3000 ml Blood loss

The response of the blood pressure to blood loss without resuscitation.

The renewal of blood

The bloodvolume. After a large bloodloss, the following
factors help the return of blood volume to normal:
- fluids (water and salts) move from the tissues into the
bloodstream

PRINCIPLES
The principles of treatment are simple:
- stop the bleeding
- replace the blood lost by fluids

Restoring the blood volume to normal is more important than the
replacement of red cells: here quantity comes before quality! The
reason is that an adequate blood volume is necessary to maintain
the blood pressure.
Without blood pressure there is no circulation to take the few
remaining red cells round to do their work.

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WHAT TO GIVE

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Donor blood
This resembles more than anything else the blood that was
lost. It is often life-saving but does have the following
problems:
- it is never available immediately and may not be
available at all
- it can cause fatal transfusion reactions
- it can transmit serious infections: syphilis, hepatitis B.
malaria, others
- it can cause serious septicaemia if it has not been stored
properly
Intravenous fluids
• a) Normal saline or sodium lactate solution
These are effective in maintaining the bloodvolume, blood
pressure and circulation. They are easy to run in fast, are
cheap and are generally available. The main problem is
that they do not stay in the bloodvessels but tend to
“escape” into the tissues. Therefore a much greater
volume of these fluids must be given than the volume of
blood lost but as a first aid they are fine.

b) Dextran solution (haemacel, etc.)
The advantage of dextran solution over saline and sodium
lactate is that it stays in the bloodvessels and even
attracts fluid from the tissues. There are, however, the
following problems:
- it is sticky, like syrup and therefore not easy to run in
fast
- it interferes with blood clotting and should not be
used in patients with a clotting defect
- it upsets the grouping and x-matching tests in the
laboratory
- it is expensive and therefore not always available

c) Dextrose 5% in water
This has the problem that it is lost from the bloodvessels
even faster than saline or sodium lactate. It should only be
used if nothing better is available.
IN PRACTICE
• Put up a reliable drip with a large (No. 18) needle or cannula.
If you do not succeed within 10 to 15 minutes, find somebody

102

more experienced (for example, an anaesthetist) or do a cut
down
• Stabilize the drip in an arm with a good splint.

DO NOT LOSE TIME

• Take blood samples for grouping and x-matching
• Run in one litre of normal saline (or sodium lactate) in about 15
minutes
• Judge the effect:
- if the blood pressure is now about 100mm Hg systolic,
run in a second liter more slowly
- if the blood pressure is still low, run in a second litre of
saline fast and start a blood transfusion as soon as
possible
• If blood is not available for transfusion, continue to run in
saline: three, four or as many litres as are needed
• If available, give a unit (500 ml) of dextran solution after the
second litre of saline; a second unit can be given after the third
litre of saline; try not to give more than two units of dextran
solution.

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Never start the resuscitation with dextran, give saline first!
• Monitor frequently:
- the blood loss (it is usually more than you think)
- pulse and blood pressure
- the urine output
- the fluids which are being given
• Supervise extra carefully patients with a systolic blood
pressure of ± 50 mm Hg. They may look quite well but
sometimes quite a small extra loss is enough to kill them [see
Introduction, this chapter]
• Aim for:
- systolic blood pressure of 100 mm Hg
- a pulse rate below 100 beats per minute
- a urine output of at least 100 ml per four hours
IMPORTANT DON'T
• Do not postpone the operation which is necessary to stop the
bleeding until the general condition has improved. Resuscitate
the patient and stop the bleeding at the same time. If you raise
the blood pressure without stopping the bleeding, the patient
loses her last red cells.

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Chapter 36

RETAINED PLACENTA
WITHOUT POSTPARTUM HAEMORRHAGE
DEFINITION
The placenta is retained within the uterine cavity for more than one
hour after delivery. There is no significant bleeding.
CAUSES
- A placenta which is abnormally adherent to the uterine wall

- AplacentaVhkh has separated but has become trapped in the
lower segment due to a spasm of the cervix. The usual cause of
such a spasm is either ergometrine or pitocin. The uterine body
is well contracted and sits on top of the lower segment.
- The placenta does not separate for an unknown reason.
RISK
Partial separation of the placenta with heavy bleeding at a later
stage.

MANAGEMENT
• Stop trying to deliver the placenta by controlled cord traction
etc.
• Do not give pitocin as long as there is no bleeding (danger .
partial separation of the placenta)
• Arrange for an immediate manual removal of the placenta in
theatre
• x-match a pint of blood
• Be prepared for a difficult manual removal.

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Part III

Obstetric Procedures
and Operations

Chapter 37

4

EXTERNAL CEPHALIC VERSION

• After the version check the fetal heart. This is often slow or
irregular but should recover within 5-10 minutes with the
patient lying on her side. In the rare event that it does not
recover, turn the baby back to its original position or consider
a caesarean section

INDICATIONS

Breech presentation or transverse lie alter 32 weeks
CONTRAINDICATIONS

- Uterine scar (caesarean section or myomectomy)
- Antepartum haemorrhage
- Twins
- Hypertension
- Premature rupture of membranes

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CAUSES OF FAILED VERSION

- Tight abdominal wall
- Frank breech
- Breech deep in the pelvis
- Oligohydramnios
- Multiple pregnancy
- Congenital abnormality of the uterus
- Congenital abnormality of the fetus
- Short cord

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DANGERS

- Placental separation
- Premature rupture of membranes
- Onset of premature labour
- Knots in the cord

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PRECAUTIONS

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Only do easy versions
Accept failure easily
Do not use so much force that it hurts the patient
Do not use anaesthesia

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TECHNIQUE

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Explain to the patient what you are going to do
Check that the bladder is empty
Listen to the fetal heart
Ask the patient to bend her knees a little
Stand on the side of the patient where the baby’s back is
With two hands lift the breech from the pelvis and stabilise it,
with one hand in the iliac fossa on your side
• Try, with the other hand, to push the head of the baby into the
direction of the pelvis. If the uterus contracts, wait until
the contraction is over

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Chapter 38

Chapter 39

CATHETERISATION

ARTIFICIAL RUPTURE OF MEMBRANES
WITH A HIGH HEAD

Before you operate on a patient with obstructed labour you should
empty her bladder by putting in a catheter. This can be difficult but
with the following method you will nearly always succeed.
- use a medium size (FG 16 or 18) plain catheter, preferably a
new one

Never use a metal catheter
- put the catheter into the urethra until it will go no further
- now put two fingers in the vagina between the head and the
symphysis, one finger on either side of the urethra
- with your other hand push the catheter in further and guide
it into the bladder with the two fingers in the vagina.
Sometimes you will have to push the head up a bit.
- when the urine is draining, gently put your hand flat on the
abdomen and squeeze the urine out of the bladder.
Do not be surprised if some bladder remains. The bladder wall
is often very swollen and oedematous and remains palpable
after all urine has been drained.

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If catheterisation of the bladder by this method fails (which should
be rare), empty the bladder by suprapubic aspiration
- use a large needle and a 20 or 50 ml syringe.
- clean the abdominal skin.
- put the needle in at a point where you feel the bladder swelling
best. This is often fairly high (5 or 6 cm) above the symphysis.
Make sure, however, not to mistake a ballooned lower segment
for the bladder.

When the fetal head is still high, it is tempting to postpone artificial
rupture of the membranes in the hope that the head will come down
later. This is dangerous because if the membranes rupture
spontaneously, cord prolapse may remain unnoticed for some time.
With precautions immediate artificial rupture of membranes is safer.
With a high head there can be two situations: the head is in contact
with the brim or it is not.

THE HEAD IS IN CONTACT WITH THE BRIM
After ruling out possible contraindications, the midwife should
rupture the membranes.
The contraindications are:
- a head not in contact with the brim
- cord presentation
- severe cephalopelvic disproportion
- malpresentation (breech, face, brow, shoulder)

With a breech or face presentation artificial rupture of membranes
is postponed until full dilatation is reached.
For the other contraindications inform the clinical officer or doctor.
Method of rupturing the membranes

• Make sure the bladder is empty
• Doublecheck for contraindications
• Ask someone else to push the head into the brim by putting a
hand either on the fundus or directly onto the head (this is
often easier outside a contraction).
• Rupture the membranes with kocher.
• Keep the fingers in the vagina and let the liquor run out slowly
• Check for cord prolapse
• Check the fetal heart
• If the cord does prolapse, which is rare with the above
precautions, put the patient in knee elbow position, inform the
clinical officer or doctor and prepare for caesarean section.

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Once the patient is in the active phase of labour it is usually best to
rupture the membranes.

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THE HEAD IS NOT IN CONTACT WITH THE BRIM
The clinical officer or doctor should see the patient.
• Rule out a full bladder as cause of the high head.
• Check for other possible causes:
- severe cephalopelvic disproportion
- constriction ring in the lower segment
- pelvic tumour
- low lying placenta which does not reach the internal os
- polyhydramnios
- premature baby
- twins
• For cephalopelvic disproportion or a pelvic tumour, do
caesarean section.
• For a constriction ring:
• rupture the membranes with precautions preferably in
theatre and prepared for caesarean section.
• give pethidine 50 mg i.v. and 50 mg i.m.
• do caesarean section if head is still high after one to two
hours
• For the other situations, rupture the membranes with
precautions, preferably in theatre and prepared for caesarean
section:
• if the head comes down, await vaginal delivery
• if the cord or arm prolapses, do caesarean section.

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THE EXAMINATION UNDER ANAESTHESIA
FOR ANTEPARTUM HAEMORRHAGE
PREPARATIONS:
• always do this procedure in theatre:
- i.v. drip with large needle or cannula
- at least one pint of blood x-matched
- general anaesthesia and intubation {not pethidine and
diazepam*)
- caesarean section trolley ready with sutures etc.
- nurse scrubbed and gowned and whenever possible also
an assistant
- lithotomy position, vulval toilet, catheterisation.

TECHNIQUE:
• gently insert two Sims’s specula; do not use a bivalve speculum
• check where the bleeding comes from:
- a local lesion in the vagina or on the outside of the cervix
or
- inside the uterus
• do a very gentle digital examination and note:
- the effacement and/or dilatation of the cervix.
- the presence of clots, placenta or membranes inside the
cervical os or inside the lower segment.
- the presenting part.
- the presence or absence of the umbilical cord
• assess the pelvis if vaginal delivery is considered
• rupture the membranes if vaginal delivery seems possible.
Observe the bleeding : only if this becomes minimal, can the
patient be returned to the labour ward for stimulation with
pitocin and vaginal delivery.
*NOTE: If general anaesthesia is not available and you are forced to use local
infiltration anaesthesia in combination with intravenous diazepam and pethidine, the
following policy is probably best:
• Apart from the general anaesthesia make the same preparations as indicated
above
• Palpate the abdomen:
- if you suspect placenta praevia as the cause of bleeding, do a caesarean
section straight away without doing a speculum or digital examination
first
- if you do not suspect placenta praevia:
• infiltrate the abdomen wall with local anaesthetic
• gently insert the Sims’ specula
• if the bleeding is coming from the uterus and you cannot see the membranes do
a caesarean section
• if you do see the membranes, do a gentle examination with the finger and act
according to your findings.

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Chapter 40

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Chapter 41

VACUUM EXTRACTION

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INTRODUCTION
The vacuum extractor is a traction instrument used as an
alternative to the obstetric forceps. It adheres to the fetal scalp by
suction. The suction cup improves its grip on the scalp by raising an
artificial caput: the chignon.
The vacuum extractor has the following advantages over obstetric
forceps:
- the vacuum cup does not take up room in the often limited
space in the birth canal
- the vacuum extractor brings about “autorotation” of the fetal
head at the level of the pelvis where this is best, rather than
where the person using forceps chooses to rotate the fetal head
- when applied over the posterior fontanel it helps to flex the
head and makes the rotation easier
- general anaesthesia is not required and the mother shares in
the delivery and helps to push
- episiotomy is not always necessary.

INDICATIONS
- delay in the second stage
- fetal distress
- some cases of cord prolapse
- elective, to avoid maternal effort because of:
- previous caesarean section scar
- a prolonged first stage
- any degree of preeclampsia or hypertension
- severe anaemia
- heart disease
- respiratory problems (asthma, pneumonia etc.)

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CONTRAINDICATIONS
- severe cephalopelvic disproportion
- malpresentation : breech, brow, face
- prematurity
- macerated stillbirth

CRITERIA FOR USE OF THE VACUUM EXTRACTOR
- the vertex must be presenting
- the descent of the head must be exactly known

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112

- the position of the occiput must be exactly known
- the cervix must be more than 8 cm dilated
- contractions must be present
- the bladder must be empty.

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ROUTINE VACUUM EXTRACTION
This is done by the midwife in the labour ward:
- the head is 0/5 above the brim with or without moulding
- the head is 1/5 above the brim with only slight caput or
moulding

TRIAL OF VACUUM EXTRACTION
This is done by the clinical officer, doctor or specialist preferably in
theatre:
- the head is 1/5 above the brim but with severe moulding and
caput
- the head is 2/5 or more above the brim.
If the vacuum extraction fails, symphysiotomy or caesarean section
must be possible at short notice.

PREPARATION
•
•
•
•

•
•
•
•
•

•

explain the procedure to the patient
make sure the instrument is in working order
trolley for delivery and suturing ready
check the resuscitaire for the baby, mucus extractor on the
delivery trolley
put the patient in lithotomy position
catheterise the bladder if necessary
clean the vulva and perineum
repeat the vaginal examination : dilatation, position of the
occiput, descent (bimanual palpation!)
infiltrate the perineum with local anaesthetic in case
episiotomy is required
with a nullipara, if the contractions are weak, put up a pitocin
drip

ACTUAL PROCEDURE
Application of the cup
• note the time of application of the vacuum cup
• use the No. 5 medium size cup for most cases
• insert the cup sideways and place the cup over the posterior
fontanel as much as possible
• check that there is no tissue between the cup and the head
113

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3
s?

• ask an assistant to create vacuum with the pump
• check again that no maternal tissue is caught between the
head and cup
• increase the negative pressure in steps of 0.2 kg per cm2 at a
time until a negative pressure of 0.8 kg per cm2 is reached.
Wait one minute after each increase. The whole procedure
should take about five minutes to ensure an adequate chignon.

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- scalp necrosis, caused by the cup coming off
or pulling too long
- cephalhaematoma
Maternal complications:
- tears of cervix or vagina if these were caught
between cup and head.

Traction
• put the thumb of the left hand on the cup and the index finger
on the head. In this way you will be able to feel if the head
follows the cup
• pull only during the contractions
• make sure you pull at a right angle with the cup and the head.
This prevents the cup from slipping off
• observe the rule of three pulls (three contractions really):
- the first pull should dislodge the head
- the second brings it down to the perineum
- the third delivers the head
• make an episiotomy when the head distends the perineum
• stop if two pulls fail to bring down the head
• never pull for more than 20 minutes

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Causes of the cup coming off
- more disproportion than you thought
- instrument leaking (check)
— traction in the wrong direction
— poorly formed chignon because there was already a caput or
because the baby is dead
• stop when the cup has come off twice

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Notes
• record:
- findings on abdominal and vaginal examination
- indication for the procedure
- time of application, size of cup, number of pulls,
episiotomy
- time of delivery, condition of baby

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COMPLICATIONS
There should be none if you stick to the rules.
Possible fetal complications:

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— brain damage if the disproportion was severe

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Chapter 42

-

SYMPHYSIOTOMY

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DEFINITION
Symphysiotomy is the division of the symphysis pubis in order to
enlarge the pelvic diameters during delivery.

INDICATIONS
Symphysiotomy is indicated for moderate cephalopelvic disproportion which has resulted in one of the following problems:

1
Bl

1.

OBSTRUCTED LABOUR WITH A LIVE BABY
If the baby’s head is deeply jammed into the pelvis and the
caput is visible in the vulva, symphysiotomy is life-saving for
the mother and therefore a “must”! The alternative,
caesarean section, will be disastrous because of tears in the
lower segment, bleeding and sepsis.

117

3.

DIFFICULT VACUUM EXTRACTION
Sometimes vacuum extraction succeeds but only with
difficulty after prolonged traction and at the expense of
brain damage to the baby.
Symphysiotomy will make the delivery much easier and
helps to avoid injury to the baby.

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PROLONGED SECOND STAGE
If the criteria for symphysiotomy are met [see below] and
vacuum extraction alone is unlikely to succeed, immediate
symphysiotomy is better than trying a vacuum extraction
first.

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PREPARATION

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FAILED TRIAL OF VACUUM EXTRACTION
Symphysiotomy can be done when a trial of vacuum
extraction has failed by a small margin.
It will not work, of course, if the cephalopelvic disproportion
is gross and the indication for vacuum extraction was wrong
in the first place.

4.

If the head is too high, symphysiotomy will fail because of severe
disproportion, if it is too low, a simple vacuum extraction will be
sufficient.

CONTRAINDICATIONS
- Severe cephalopelvic disproportion
- Malpresentation: breech, brow, face, transverse lie
- Dead fetus (craniotomy is preferable)

2.

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CRITERIA
- Live baby
- Cervix 8 cm or more dilated
- No overlap (the head should not bulge above the symphysis)
- The head is not more than 2/5 and not less than 1/5 palpable
above the symphysis

Ideally you need three helpers; two to hold the legs and one to keep
the i.v. drip going, catch the baby, resuscitate it, etc.
• Explain the procedure to the patient
• Give antibiotics as for caesarean section
• Check that:
- the vacuum extractor is in working order
- the delivery trolley is ready
- the resuscitaire for the baby has been prepared.
• If the contractions are weak and the patient is a nullipara,
start a pitocin drip
• Put the patient in lithotomy position.
Two helpers, who do not do anything else, support the legs; the
thighs should be abducted at an angle of 80°.
This position should be carefully maintained or the strain on
the sacroiliac joints becomes too great; lithotomy poles are
unsuitable.
• Disinfect the skin over the lower abdomen, symphysis and
vulva; use iodine over the symphysis
• Infiltrate the skin and subcutis over the symphysis and the
fibrocartilage with 1 or 2% lignocain; also infiltrate the
perineum for the episiotomy
• Insert a plain catheter and leave this in
• Apply the cup of the vacuum extractor in the usual manner
• Pull once gently on the vacuum extractor (sometimes delivery
is easier than expected and symphysiotomy is not necessary)

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- Previous caesarean section
- Maternal deformity (spine, leg)

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THE ACTUAL PROCEDURE

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• Insert one finger between the fetal head and the symphysis,
this automatically pushes the catheter and urethra out of the
midline (if you use two fingers, the catheter will tend to stay
in the midline)
• Using a scalpel (ideally with a fixed handle) make a vertical
stab incision over the symphysis midway between its upper
and lower border
• Keeping exactly to the midline, push the knife through the
fibrocartilage [see Figure 42.1] until your finger in the vagina
feels its point. If this is difficult, you are not in the midline;
retreat and try again
• Guided by the finger in the vagina, the knife cuts the lower
half of the fibrocartilage and the fibres of the arcuate
ligament; stop there!
• Turn the knife 180° and cut the upper part of the
fibrocartilage; the joint should now separate and one finger
should fit the gap. If this is not the case, the division is
incomplete and you must cut a few more fibres

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Figure 42.1 The anatomy of the
symphysis pubis
1. arcuate ligament
2. fibrocartilage of symphysis pubis
3. urethra
4. vagina

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AFTERCARE
• Keep the patient in bed for about three days, there is no need
to strap the legs together
• After three days allow the patient to mobilise at the pace she
finds comfortable; almost all patients walk well within ten
days
• Leave the catheter in:
- for two or three days if the operation was uncomplicated
and the urine is clear
- for one to three weeks if the urine is blood stained or if
pressure necrosis due to obstructed labour is suspected
• Prescribe antibiotics as you would for caesarean section
• Give a simple analgesic like aspirin for a few days
PROBLEMS AND COMPLICATIONS

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• Deliver the head and the rest of the baby “away” from the
symphysis to avoid more strain on the urethra
• After delivery of the placenta, check the cervix and vagina for
tears
• Repair the skin incision over the symphysis, the episiotomy
and whatever tears there are (usually none, fortunately!)
• Replace the plain catheter by a Foley’s with an open drainage
system
• Put the legs flat

ill

3

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DELIVERY
• Make a large episiotomy
• Pull on the vacuum extractor during a contraction; when the
head descends, you will often feel the last fibres of the
symphysis snap
118

FAILURE
If you stick strictly to the criteria, failure should be rare. If it
happens, caesarean section is the only alternative
BLEEDING
This stops after delivery of the baby. Before delivery it can be
controlled by firm pressure

OSTEITIS PUBIS
This infection of the symphysis pubis is serious and may cripple the
patient for life. However, it should not occur if reasonable aseptic
precautions are taken
INJURY TO BLADDER OR URETHRA
Fistulae can result from faulty technique but are more commonly
due to the obstructed labour which necessitated the symphysiotomy
in the first place.

Incontinence of urine without a fistula is due to avulsion of the
119

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urethra from the pubic bones. It is rare but serious as it is
apparently difficult to treat.
PELVIC INSTABILITY
This is remarkably uncommon. Most patients walk well soon after
the operation and have little or no pain. It is, of course, important to
avoid too much abduction of the thighs during the procedure. If this
does occur, a situation comparable to a fractured pelvis results with
extensive soft tissue damage as well. So beware!!

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DIAGNOSIS
The head is born but the neck and shoulders fail to appear
CAUSES
Large baby due to:
- diabetes
- postmaturity

Baby:
- asphyxia and death
- damage to the brachial plexus
- fractures of arm, clavicle or neck

11.

MANAGEMENT
The trunk must be delivered within five to seven minutes of the
head
• Shout for help
• Put the patient in lithotomy position. This usually has to be
improvised:
- place her with the buttocks on the edge of the bed
- flex the hips as much as possible and ask her to hold her
own legs
• Make a large episiotomy
• Move the head in a downward direction and apply steady
traction
• Ask an assistant to apply firm pressure just above the
symphysis pubis to push the shoulders into the brim
• If necessary add fundal pressure
If these manoeuvres fail to deliver the shoulders:
• Give pethidine 50 mg. i.v.
• Put a hand behind the head in the vagina and try to rotate the
trunk by pushing against the posterior shoulder. Assist this
manoeuvre by suprapubic pressure in the opposite direction

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SHOULDER DYSTOCIA

RISKS
Maternal:
- lacerations of the vagina
- third degree perineal tear
- rupture of the uterus (as a result of excessive pressure on the
abdomen)

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Chapter 43

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• After the shoulders have been rotated into a different position
try downward traction and suprapubic pressure again
If this does not work:
• Bring down the posterior arm.
Delivery of the anterior shoulder now is usually easy, but if
necessary the trunk can be rotated to make the anterior arm
posterior: delivery is then no further problem.

Chapter 44

CAESAREAN SECTION
FOR CLINICAL OFFICERS AND DOCTORS
INTRODUCTION
This chapter is for those of you who have done some caesarean
sections already and who are, therefore, familiar with the technique
of the uncomplicated operation.

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PREPARATION
ANTIBIOTICS
Caesarean section during labour
Clean cases
Before operation:
- x-penicillin 5 mega i.v. stat. 4- streptomycin 1 gm i.m. stat.
After operation:
- x-penicillin 2 mega i.v. or i.m., 6 and 12 hours after
operation

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Infected cases (temperature 38C° or more, offensive liquor or
ruptured membranes of more than 12 hours)
Before operation
- x-penicillin 5 mega i.v. stat. + streptomycin 1 gm i.m. stat.
or
- chloramphenicol 1 gm i.v. stat
After operation:
- x-penicillin 2 mega i.v. or i.m. 6 hourly + streptomycin 1 gm
i.m. daily for seven days
or
- chloramphenicol 0.5 gm i.v. or p.o. six hourly for seven days.

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Elective caesarean section
No antibiotics!
BLOOD
• Check the haemoglobin
• x-match one pint of blood if possible

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CATHETERISATION AND VAGINAL EXAMINATION
The doctor or clinical officer who will do the operation should
catheterise the bladder in theatre.
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If the patient is in labour do a vaginal examination at the same time
in order not to miss unexpected progress and the possibility of a
vaginal delivery.

TILT THE PATIENT TO THE LEFT
Tilt the patient approximately 15° to the left by placing a pillow or
rolled up towel under the right buttock
ANAESTHESIA

•
•
•
•
•

after a few minutes incise the skin and subcutis
inject another 10 - 20 ml under the fascia
after a few minutes incise fascia, muscles and peritoneum
put a few ml of anaesthetic under the peritoneum of the uterus
deflect the bladder peritoneum, incise the uterus and deliver the
baby
• as soon as the baby is out, inject 50 mg of pethidine i.v., this may
have to be repeated once or twice.
• complete the operation

GENERAL ANAESTHESIA

This is only safe if given by a trained anaesthetist who intubates the
patient.
Never assume that the stomach will be empty because the patient
has not taken food for a long time. Emptying of the stomach slows
down during labour.
Aspiration of stomach contents will cause a most violent pneumonia
which will probably kill your patient.

SPINAL ANAESTHESIA
This is a good technique provided:
- you know the technique and its complications in detail
- you put up an i.v. drip and run in 1 - 2 litres of fluid fast
- you tilt the patient to the left Isee above!
- you observe the contraindications
- severe antepartum haemorrhage
- severe anaemia
- severe hypertension or preeclampsia
- serious heart disease

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LOCAL INFILTRATION ANAESTHESIA
Safe for mother and baby.

a

Disadvantages are:
- uncomfortable for the mother
- unsuitable if extensive dissection is required (old scars)
- unsuitable for infected cases because packs cannot be placed
by the side of the uterus and thorough cleaning of the
abdominal cavity is difficult

4

t

Technique
• give diazepam 10 - 20 mg i.v. stat.
• prepare a ,/2%» solution of lignocaine
• inject 10 - 20 ml under the skin in the line of the incision
124

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INCISION OF THE UTERUS
There are four acceptable ways of making an incision in the uterus:
- a transverse incision in the lower segment
- a vertical incision in the lower segment
- a transverse incision in the upper segment
- a vertical incision in the upper segment
The techniques of making and closing these incisions are described
here, the indications follow later in this chapter.
A fifth method of incising the uterus, the inverted T incision, is not
described, as, with forethought, it can always be avoided. It heals
poorly and should not be used.

TRANSVERSE INCISION IN THE LOWER SEGMENT
1. Opening of the uterus
• Cut the peritoneum over the lower segment transversely
and mobilise the peritoneum and bladder well down
• Identify the midline of the uterus (it may have rotated to the
right or the left)
• Incise the lower segment transversely with the scalpel over a
short distance
• Enlarge the opening to the right and the left with scissors
(this is safer than stretching the incision with your fingers
which does not allow you good control over where the lower
segment will tear)
2.

Repair of the incision
• Identify the lower edge of the incision by placing GreenArmytage forceps
• Start at a point where the lower edge is easy to see
• When you have placed the first clamp, lift it and a further
stretch of the edge will come into view
• Place another clamp and continue like this until you have
identified the lower edge over its whole length.
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A common mistake is to pick up a fold of the posterior wall of
the uterus. If you use the above method, that mistake is
almost impossible to make.
• Now repair the uterus with two layers of continuous chromic
catgut No. 1 or No. 2

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Vertical tears
These are often located in the corners and run downward behind
the bladder. Very often there is heavy bleeding as well.
In order to repair these you must be able to see.
• If you are alone with a scrubnurse, ask for an extra assistant
• Identify the edges of the incision and the tear as described
above
• Mobilise the bladder further downward if necessary
• Divide the round ligament if necessary : this often makes the
lower end of the tear much easier to see
• In the area of the tear use interrupted sutures : these are
easier to unpick if you catch the bladder or ureter by mistake
• After repairing the tear check that the ureter has not been
caught in a stitch
• Remember that all bleeding can always, at least, temporarily,
be controlled by pressure with a hot pack

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Difficulties
Heavy bleeding
Bleeding from the edges can be controlled by Green-Armytage
clamps until the incision has been sutured.
A (partly) torn branch of a uterine vessel in one of the corners is
sometimes easier clamped with an ordinary artery forceps. It
may also need to be ligated separately.
Continued bleeding after the incision has been sutured in two
layers needs extra figure-of-eight stitches. Do not pull these too
tight or they will cut through and more bleeding will result.
Continued oozing is best controlled with a hot pack.

THE VERTICAL INCISION IN THE LOWER SEGMENT
(DE LEE INCISION)
1.

Opening of the uterus
• Incise the peritoneum transversely high on the lower segment
• Mobilise the peritoneum and bladder well down
• Identify the midline of the uterus

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• Incise the lower segment vertically with the scalpel
• Enlarge the incision with the scalpel or scissors : often the
upper segment has to be entered

2.

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Repair of the incision
• Suture the incision with two layers of continuous chromic
catgut No. 1 or No. 2
• Make sure that you include the uterine fascia in the second
layer or it will continue to bleed
• Repair the peritoneum and pull it high up so that the top end
of the incision is covered
• If the upper segment was incised over a long distance, do
tubal ligation

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TRANSVERSE INCISION OF THE UPPER SEGMENT
1.

2.

Opening of the uterus
• Check that the uterus is wide enough for an adequate incision
• Incise the peritoneum over the lower part of the upper
segment transversely with the scalpel
• Mobilise the peritoneum away from the incision with scissors
• Incise the uterus transversely in the midline
• Enlarge the incision to the right and left by stretching it with
your fingers (it is usually too thick to be cut with scissors)
• Deliver the baby by breech extraction

*

Repair of the incision
• Suture the incision in two layers with continuous chromic
catgut No. 1 or No. 2
• Do not catch the full thickness of the uterine wall in the first
layer : it is often too thick
• Repair the peritoneum over the incision, preferably with a
locking stitch

THE VERTICAL
SEGMENT

(CLASSICAL)

INCISION IN THE UPPER

This is a poor incision and should only be used as a last resort.
It has two dangers:
- it may rupture before labour in a future pregnancy
- infection can spread directly from the uterine into the
peritoneal cavity
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2.

Opening of the uterus
• Identify the midline of the uterus
• Incise the uterus vertically with the scalpel
• Enlarge the incision by stretching it with the fingers
• Deliver the baby by breech extraction
Repair of the incision
• Repair the uterus in three layers with a continuous chromic
catgut No. 1 or No. 2 suture; each layer should catch about
one third of the thickness of the uterine wall; the last layer
should be a locking stitch.
• always tie the tubes

CAESAREAN SECTION FOR SPECIFIC INDICATIONS

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REPEAT CAESAREAN SECTION
Entry into the abdomen
This can be difficult but the following method is safe:
• Excise the skin scar
• Lift the fascia with two dissecting forceps as close to the
umbilicus as possible and incise fascia, muscles and perito
neum to open the abdomen
• If entry into the abdomen at this site proves difficult, do not
muddle on
• Extend the skin incision higher up the abdomen, round the
umbilicus if necessary, and try again; by going higher it is
always possible to find an area free of adhesions
• After the abdomen has been entered, lift the abdominal wall
on two fingers and incise the layers one by one: fascia, muscle,
peritoneum; in this way the bladder is easily recognised when
it appears at the lower end of the incision
Separation of the adhesions
After a previous operation there can be dense adhesions between the
uterus and abdomen wall
• Open the parietal peritoneum as far as possible
• Lift the parietal peritoneum with two dissecting or artery
forceps to stretch the adhesions
• Cut the adhesions close to the ul erus with curved scissors,
keep the points of the scissors directed at the uterus
• If a plane of loose connective tissue is found, do the further
separation with a finger or a swab; fibrous bands must be cut
• Stay close to the uterus to avoid the bladder
• If dissection of the adhesions proves difficult, give up and
make an upper segment incision

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Mobilisation of the bladder
After a previous operation the bladder is stuck to the lower segment
and cannot be mobilised with the finger or a swab
• Incise the peritoneum on the uterus transversely about 2 cm
above the bladder
• Lift the lower edge with two dissecting or artery forceps to
stretch the adhesions between the bladder and the uterus
• Cut the adhesions close to the uterus with curved scissors
keeping the points of the scissors directed at the uterus
• If this proves difficult, give up and make an incision higher in
the uterus
The uterine incision
Usually a transverse incision in the lower segment is possible and
with an elective caesarean section this should provide no further
difficulty. If the section is done during labour, you may find the head
tightly stuck under the old scar in the uterus. If you then make your
incision just above the scar, the old scar will probably rupture
during delivery of the head of the baby. It is safer to make a
V-shaped transverse incision with the point of the V lying across the
middle of the scar. This is thus divided and the tension removed. If
any tearing occurs, it will be near the midline where it is relatively
easy to see and repair
OBSTRUCTED LABOUR WITH A CEPHALIC PRESENTATION

• Enter the abdomen just under the umbilicus in order to avoid
the bladder
• If catheterisation before the operation was impossible, empty
the bladder now with a needle and syringe; a lot of its swelling
will be oedema and this, of course, does not go away
• Mobilise the bladder of the lower segment in the usual manner
• If someone is going to push up the head from below through
the vagina, let them start now before the uterus is opened; if
you postpone this until after the uterus has been opened, the
shoulder will prolapse into the incision making delivery more
difficult
• Make a transverse incision in the lower segment.
Choose the level of the incision carefully:
- if it is too high, delivery of the baby will be difficult
- if it is too low you may enter the vagina
• Take time to deliver the baby.
• between the contractions work two to four fingers
between the uterine wall and the head until they are
under it

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• lift the head from the pelvis by flexing your fingers
• try to avoid “levering” the head out with your whole
hand because this often causes vertical, downward tears
in the lower segment
• After delivery of the baby and placenta, repair the uterus
• Clean the abdomen very carefully, if the liquor was purulent or
offensive smelling, wash the pelvis with warm saline
BREECH PRESENTATION
There should be no difficulty. Make sure, however, that you deliver
the baby through the incision with exactly the same manoeuvres
that you would use for a vaginal delivery. Failure to do so may cause
extensive tearing of the lower segment.

<I

TRANSVERSE LIE
The choice of the incision in the uterus is what matters here.
You will meet the following situations
- Labour obstructed
Most of the baby is in the overdistended lower segment. Simple
delivery through a transverse lower segment incision will
cause extensive tears. Therefore:
- if the baby is dead
• make a transverse incision in the lower segment
• decapitate or eviscerate the baby
• now deliver it whichever way is convenient
- if the baby is alive
• make a vertical incision in the lower segment
• extend the incision into the upper segment until you
have enough room to deliver the baby safely

- The patient is in early labour but the lower segment is
poorly developed. Most of the baby is in the upper
segment
• make a transverse incision in the upper segment
• deliver the baby by breech extraction

CONSTRICTION RING
Sometimes the cause of obstruction is a constriction ring either in
the lower segment or between the lower and upper segment.
If the baby is entirely above it, make a transverse incision above the
constriction. If the constriction is round the baby’s neck, make a
vertical incision across the constriction.

OTHER PROCEDURES DURING CAESAREAN SECTION
FIBROIDS
Leave these alone. Removal will cause heavy bleeding. If necessary,
they can be removed three months later by a second operation.

OVARIAN CYSTS/TUMOURS
These should be removed. Ovarian cystectomy is possible but if
bleeding is a problem, salpingo-oophorectomy may be quicker and
safer.
ADHESIONS
Adhesions should be separated sufficiently to gain good access to the
uterus. However, there is no point in removing adhesions round the
adnexa. This often causes troublesome oozing and the adhesions will
invariably form again.

BLADDER INJURY
See Chapter 47

TUBAL LIGATION
See Chapter 52

PLACENTA PRAEVIA
Usually the normal transverse incision in the lower segment is
possible. If the lower segment is too small for an adequate incision
or if it is very vascular, make a transverse incision in the lower part

POSTOPERATIVE ORDERS
Routine are:
- intravenous fluids: one to three litres over the first 24 hours,
depending on the patient’s condition
- pain relief : pethidine 50 - 100 mg six hourly for two days;
after that a simple analgesic like aspirin
- antibiotics : as outlined under PREPARATION
: open drainage only when indicated (blood
- catheter
stained urine, bladder repair, obstructed labour)
observations: vital signs, fundus, vaginal bleeding

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- The patient is in early labour, the lower segment is well
developed and the membranes are still intact
• make a transverse incision in the lower segment
• deliver the baby by breech extraction

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of the upper segment. If this is also very vascular, make a classical
incision.

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Chapter 45

ANAESTHESIA

REPAIR OF A RUPTURED UTERUS

If the patient’s condition is poor, local infiltration anaesthesia [see
Chapter 44] is safest.

INTRODUCTION : REPAIR OR HYSTERECTOMY?
In the course of an operation for ruptured uterus you will have to
decide what to do; repair the rupture or do hysterectomy. The
following hints are meant to help you make the right decision.
If you have very little or no experience of hysterectomy, repair of the
uterus is nearly always best. Hysterectomy will take longer and can
cause more bleeding. Only do a hysterectomy when extensive
tearing of the uterus makes a repair impossible.
If you do have some hysterectomy experience, your decision can
depend on the situation.

If general anaesthesia is used, endotracheal intubation is essential.
Do not use spinal anaesthesia for patients with a ruptured uterus.

Factors in favour of a repair are:
- rupture not too large
- edges clean and easy to see
- little or no infection present.

The set of instruments used for caesarean section will do, provided
you add some large curved clamps or artery forceps.

Factors in favour of hysterectomy are:
- extensive or multiple tears of the uterus
- edges which are necrotic or not easy to reach for suturing
(some posterior ruptures, ruptures extending down into the
vagina)
- gross infection of the uterus
This chapter describes repair of the uterus, hysterectomy is dealt
with in the next chapter.

PREPARATION
Rescuscitate the patient
• Put up i.v. drip with large bore needle (No. 18) or cannula
• Give 1-2 litres of saline or sodium lactate before starting the
operation
• x-match 2 pints of blood
Antibiotics
• Give, for example:
- x-penicillin 5 mega i.v. stat. + streptomycin 1 gm i.m.
stat
or
- chloramphenicol 1 gm i.v. stat.

• Catheterise the bladder

STAFF AND INSTRUMENTS
Needed are:
- you, the surgeon
- a scrubnurse
- if at all possible, a second scrubbed assistant
- a “runner”
- an anaesthetist

TECHNIQUE

• Open the abdomen through a midline incision
• Remove fetus and placenta:
- this is easy if they are free in the abdomen
- if the fetus is in the broad ligament, open the broad
ligament: this is often most easily done by dividing the
round ligament over it
- if the fetus is still inside the uterus (with a posterior
rupture for example) you may have to make the
transverse incision in the lower segment, as for caesa
rean section, in order to deliver the baby
• Suck away most of the blood and liquor
• Lift the uterus from the abdomen and assess the damage
• Identify the edges of the tear along its whole length
• Make sure to separate the bladder well away from the edge*
• Divide the round ligament if this makes the tear easier to see
• Trim obviously dead tissue away. Do not trim too much as this
makes the repair more difficult and causes bleeding
• Repair the tear in one layer with a continuous chromic 1 or 2
suture. A vertical tear going down to the cervix can be
repaired from below upwards but sometimes the other way
round is easier: traction on the suture helps to bring the lower
end of the tear into view. Carefully identify the edges before
*For repair of bladder injury See Chapter 47.

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putting in the stitches in order not to include the ureter
If there is oozing from the broad ligament, put in a drain. This
can be brought out either through the tear into the vagina or preferably extraperitoneally — through the abdominal wall
Repair the peritoneum over the uterus
Tie the Fallopian tubes
Clean the abdomen and wash it with warm saline
Close the abdominal wall in layers; use deep tension sutures if
you expect peritonitis

POSTOPERATIVE ORDERS

• I.v. fluids and blood depending on the patient’s condition
• continue antibiotics, for example:
- x-penicillin 2 mega i.v. six hourly + streptomycin 1 gm daily
for seven or 10 days
or
- chloramphenicol 0.5 gm i.v. six hourly for seven or 10 days
• Pethidine 50 - 100 mg i.m. six hourly for two days
• Remove the drain after one or two days
• Open bladder drainage for 10 - 14 days if the bladder was
damaged
• Nasogastric tube if the bowels are distended or peritonitis is
expected.

Chapter 46

SUBTOTAL HYSTERECTOMY
INDICATIONS
There are two situations in which even the inexperienced surgeon
must attempt hysterectomy if somebody more senior is not
available:
- a ruptured uterus with tearing so extensive that repair is
impossible
- postpartum haemorrhage not responding to treatment [see
chapters 34, 49, and 561.

PREPARATION
Resuscitate the patient
• Put up an i.v. drip with a large bore (No. 18) needle or cannula
• Give 1-2 litres of saline or sodium lactate before starting the
operation
• x-match 2 pints of blood

Antibiotics
• Give, for example:
- x-penicillin 5 mega i.v. stat. + streptomycin 1 gm i.m.
stat.
or
- chloramphenicol 1 gm i.v. stat.

Catheterise the bladder
ANAESTHESIA
If the patient’s condition is poor, local infiltration anaesthesia [see
chapter 441.
If general anaesthesia is used, endotracheal intubation is essential.
Do not use spinal anaesthesia.

Needed are:

STAFF AND INSTRUMENTS

- you, the surgeon
- a scrubnurse
- a scrubbed second assistant (essential!)
- a “runner”
- an anaesthetist
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135

The set of instruments used for caesarean section will do, but you
must add large curved artery forceps or kochers, at least 12! A
self-retaining abdominal retractor is a great help.

GENERAL POINTS OF TECHNIQUE

•I

Subtotal hysterectomy, which leaves the cervix and perhaps part
of the lower segment in place, is easier to perform than total
hysterectomy. It causes less bleeding and there is almost no danger
to the ureters. Subtotal hysterectomy is still possible when a uterine
rupture extends down into the cervix and vagina. In that case the
tear in the cervix and vagina is repaired after the body of the uterus
has been removed.

1

Removing the adnexa (adnex = tube + ovary) is often easier than
leaving them in place. The reason is that the pedicle of the
infundibulopelvic ligament is usually smaller and easier to handle
than the pedicle of the cut Fallopian tube and ovarian ligament.

11

Traction on the uterus throughout the procedure is the key to
success in hysterectomy. Traction makes it easier to identify the
structures that have to be divided and it helps to keep bladder and
ureters out of the way.

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• Insert a self-retaining abdominal retractor if this is available
• Lift the uterus from the abdomen
• Maintain traction on the uterus with one hand or put in a
traction suture
• Identify the following structures:
- the corpus uteri
- the round ligaments
- tube and ovary on both sides
- the infundibulopelvic ligaments on both sides
- the avascular area in each broad ligament
- the lower segment
- the bladder
- the rectum
[see figure 46.1]

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The anatomy. Make sure to identify the important structures and
landmarks before you start removing the uterus. With a ruptured
uterus the anatomy can be difficult to recognise and this does not
become any easier if you start cutting without knowing exactly
what you are doing.

5

Control of bleeding. For the control of bleeding concentrate on:
- the ovarian vessels either in the pedicle of the infundibulo
pelvic ligament or in the stump of the cut tube and ovarian
ligaments.
- the uterine vessels
- the stump of the cervix or lower segment.

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There can be some bleeding from other small vessels but this
does not usually cause problems.

TECHNIQUE IN DETAIL

(AS FOR RUPTURED UTERUS)

• Open the abdomen
• Remove fetus and placenta [see chapter 45]
• Clean away most of the blood and liquor

136

Figure 46.1 The uterus seen from behind prior to hysterectomy
1. uterine corpus
6. uterine vessels
2. Fallopian tube
7. rectum
3. ovary
8. sacro-uterine ligament
4. round ligament
9. avascular area in broad ligament
5. ovarian vessels
Note that the uterus is being pulled over to the left and that the right adnexa are
being lifted in order to show the anatomy clearly

137

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• Identify the rupture and clamp obvious bleeding points
• Pull the uterus to the left and divide the right round ligament
between clamps about 2 cm from the uterus; this step opens
the anterior peritoneal leaf of the broad ligament
• Enlarge the opening in the anterior leaf of the broad ligament
with scissors in a downward direction towards the bladder
• Lift the right adnexa with one hand and push a finger of the
other hand from behind through avascular area in the broad
ligament; this step helps to define the infundibulopelvic
ligament
• Clamp the infundibulopelvic ligament with two artery forceps
and cut it
Alternatively, if you wish to leave the adnexa in place, clamp
and divide the tube and ovarian ligament near the uterus. If
the tube and ovarian ligament are very thick and vascular, the
clamping and cutting may have to be done in two steps
• Suture ligate the pedicles of the round ligament and
infundibulopelvic ligament (or the cut tube and ovarian
ligament)
• Repeat the same procedure on the left side
• Now pull the uterus well up in the midline and cut the
peritoneum between the uterus and bladder; extend the
incision laterally to meet the incisions in the anterior leaves of
the broad ligaments
• Push the bladder off the lower segment with your finger or a
swab on a holder; two or three centimeters is enough, pushing
it down further can cause bleeding;
if the rupture is in the anterior lower segment, you have to put
its edge on stretch with Green-Armytage forceps before you
can separate off the bladder
• Now expose the posterior lower segment by pulling the uterus
forward over the symphysis pubis
• Divide the peritoneum over the posterior lower segment at
about the same level as this was done anteriorly
• Extend the incision laterally to join the openings in the broad
ligaments
• Push the lower flap of the peritoneum off the lower segment
with a swab on a holder or if this is difficult, cut it loose with
scissors
• Now review the situation:
on either side of the uterus you should see a bundle of loose
138

connective tissue which holds the uterine vessels; you may
have to strip down the peritoneum of the broad ligaments a
little further to see them more clearly
• Pull the uterus to the left and clamp the uterine vessels on the
right with strong curved kocher or artery forceps just above
the level where the bladder is still attached to the lower
segment; make sure the points of the clamp are very close to
the uterus (there is no harm in including a little uterine wall!)
• Place a second clamp inside the first and cut the uterine
vessels in between
• Sutureligate the pedicle
• Repeat this procedure on the left
• Now amputate the uterus through the lower segment just
above the level of the cut uterine vessels; have artery forceps
ready to pick up the cut edge of the lower segment before it
disappears in the depth of the pelvis
• Clamp obvious bleeders
• If there is a downward tear in the cervix, repair this now after
making sure that bladder and ureters are well out of the way
• Now suture the anterior wall of the lower segment to the
posterior wall with figure-of-8 stitches; make sure you
include the angles on the left and right as these tend to bleed;
leave the centre open for drainage
At this stage the pelvis should be more or less dry.
• Look for remaining bleeding points and ligate these
• If there is a lot of oozing from one of the broad ligaments, place
a rubber drain in that area and bring it out either through the
cervix into the vagina or (preferably extra-peritoneally)
through the abdominal wall
• Close the pelvic peritoneum with a continuous suture; start on
the left at the pedicle of the infundibulopelvic ligament and
suture the anterior edge of the peritoneum to the posterior
edge and place all vascular pedicles under the peritoneum
• Wash the abdomen with warm saline and close it.

POSTOPERATIVE ORDERS
• i.v. fluids and blood depending on the patient’s condition
• Continue antibiotics, for example:
- x-penicillin 2 mega i.v. six hourly + streptomycin 1 gm
daily for seven or 10 days

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or
- chloramphenicol 0.5 gm. i.v. six hourly for seven or 10
days
Pethidine 50 - 100 mg i.m. six hourly for two days
Remove the drain after one or two days
Open bladder drainage for 10 - 14 days if the bladder was
damaged
Nasogastric tube if the bowels are distended or peritonitis is
expected.

Chapter 4 7

REPAIR OF ACUTE BLADDER INJURY
Immediate repair of the bladder is necessary if:
- the bladder has been damaged accidentally during a caesarean
section
- during a rupture of the uterus the bladder was torn as well.
With a ruptured uterus, complete closure of the opening in the
bladder may prove impossible, if there is a lot of pressure necrosis or
if the tear extends far down into the urethra.

The bladder wall near the injury is usually stuck to the lower
uterine segment and needs to be mobilised before the opening can be
closed.
TECHNIQUE
• Put both the bladder wall and the lower segment on stretch
with the help of artery or Allis’ forceps or Babcock clamps
• Clear the operation field of blood
• Separate the bladder off the lower segment with a swab on a
holder or by cutting with scissors
• The bladder wall round the opening needs to be freed over 1-2
cm
• Close the opening in the bladder with two layers of continuous
2/0 chromic catgut:
- the first layer includes the bladder mucosa and the
bladder muscle
- the second layer inverts the first one
• After the operation has been completed insert an indwelling
catheter and maintain open drainage for 10 to 14 days.

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Chapter 48

DESTRUCTIVE OPERATIONS
GENERAL

You should try not to do a caesarean section for obstructed labour, if
the baby is already dead. Often a destructive operation is easier and
safer, because it carries less risk of bleeding and infection and also
because it leaves no uterine scar. However, for a destructive
operation to be safe, three points should always be observed:
- the indication must be correct
- you should follow the correct operative technique
- you should be able to do an immediate laparotomy when you
discover a rupture of the uterus during the operation.
The following sections explain how destructive operations should be
done.

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You should do craniotomy if:
- the fetus is dead
- the head presents
- 2/5 or less of the head is above the brim (if the head is higher,
caesarean section is usually safer!)
- the cervix is fully dilated
- the uterus is not ruptured

INDICATION

PREPARATION

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Anaesthesia
General anaesthesia with intubation is best. Do not use general
anaesthesia without sia without intubation. If general anaesthesia is
not possible, use spinal anaesthesia or local infiltration anaesthesia
of the perineum and vulva.

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(The destructive operation for cephalic presentations)

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• put up an i.v. drip with dextrose 5% in water
• give high doses of antibiotics, e.g.
x-penicillin 5 mega i.v. stat, with streptomycin 1 gm i.m. stat
or
chloramphenicol 1 gm i.v. stat
• give painrelief, e.g.
pethidine 50 mg slowly i.v.
• take bloodsamples for haemoglobin and x-matching
• shave for a vaginal operation and laparotomy

CRANIOTOMY

In the labour ward

1

Staff
Needed are:
- you,the surgeon
- one anaesthetist
- one scrubnurse
- one “runner”

If local infiltration anaesthesia is used, sedate the patient with:
- pethidine 25 - 50 mg i.v. slowly (N.B. Check what she was
given in the labour ward)
- diazepam 10 - 20 mg i.v. slowly.
Technique
• Put the patient in lithotomy position
• Clean and drape the vulva and perineum
• If local anaesthesia is used, infiltrate the perinuem with '/a or
1% lignocaine
• Catheterise the bladder with a rubber or plastic catheter Isee
Chapter 381
• Put one or two Sims specula into the vagina so that you can see
the head well. Ask an assistant to hold the specula
• With the knife make a cross-shaped incision through the skin
of the head right down to the bone
• With a finger feel for a gap (a suture line or a fontanel)
between the bones
• Push a closed pair of scissors between the bones
• Now open and close the scissors a few times while turning
them round (the brain should now be coming out from the
hole)
• Put a finger through the hole in the skull and check that all
brain compartments have been broken up
• Put 3 or 4 strong volsellum forceps or kochers (even better are
Willet’s forceps) on the skin or the skin and the bone
• Pull on these forceps and try to turn the posterior fontanel
under the symphysis

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In theatre (Do not do a craniotomy anywhere else!)
• check the preparations done in the labour ward
• check the i.v. drip
• check the instruments on the trolley
• check that everything is ready for laparotomy

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• If sharp edges of bone come sticking out, protect the vagina
with your fingers or remove the offending bone
• Make a large episiotomy
• Deliver the head

After delivery of the head, sometimes delivery of the shoulders is
still difficult. In that case:
• Put a hand behind the baby in the vagina and turn the
shoulders through 90° or even 180°. Try delivering the
shoulders again.
If the shoulders cannot be delivered by turning them, you
must bring down the arms one by one.
• Put a hand behind the fetus in the vagina and feel for the
posterior shoulder and arm. Pull the arm down gently (the arm
can break, but you should not damage the cervix or vagina).
• After delivering the first arm turn the fetus 180° and deliver
the second arm in the same way. Further delivery should now
be easy.
After delivery of the fetus:
• remove the placenta manually
• Give ergometrine 0.5 mg i.v. stat.
• After removal of the placenta feel immediately for tears of the
uterus or lower segment
• Inspect the cervix, vagina and vulva carefully for tears
• Repair the episiotomy and tears
• insert an indwelling catheter for open bladder drainage
• If the uterus is not well contracted, put pitocin 10 - 40
units per 1,000 ml in the i.v. drip.

vagina are more difficult than craniotomy. However caesarean
section also has its dangers and should - where possible - be avoided.
The operations that can be done are the following:

Decapitation : The fetus’ neck is divided and the body and head
are then delivered separately
Evisceration : The fetus’ chest and/or abdomen are opened and
all internal organs are removed. The trunk
collapses and delivery by either internal version or
decapitation becomes much easier.

Caesarean section in combination with destruction : A
transverse incision is made in the lower uterine segment.
Decapitation or evisceration is done through the uterine incision.
IMPORTANT DON'TS
Never attempt internal version without doing evisceration first. The
risk of rupturing the uterus is enormous. Cutting off the prolapsed
arm does not make version any safer!
Do not attempt decapitation or evisceration through the vagina if
the fetus is still high in the birthcanal. It is dangerous because you
will not be able to protect the vaginal wall and cervix adequately
during the operation.

At caesarean section do not attempt to deliver the fetus intact
because this will cause severe tearing of the lower segment.
Do not make a classical or inverted T incision in the uterus for a
dead fetus.

POSTOPERATIVE ORDERS
• continue the i.v. drip slowly for about 24 hours
• continue with antibiotics in high doses, for example:
— x-penicillin 2 mega six hourly and streptomycin 1 gm i.m.
daily for seven days
or
- chloramphenicol 500 mg six hourly for seven days
• open bladder drainage for 14 days

DESTRUCTIVE OPERATIONS FOR TRANSVERSE LIE

CRITERIA FOR DECAPITATION OR EVISCERATION BY THE

VAGINAL ROUTE

- rhe fetus is dead
- the lie is transverse
- the cervix is 8 cm or more dilated
- the uterus is not ruptured

You can only decide which operation you are going to perform after
you have examined the patient under anaesthesia.

Obstructed labour with a transverse lie and a dead baby is a difficult
problem. Destructive operations for transverse lie through the

Preparation
The preparation of the patient in the labour ward is exactly as for
patients undergoing craniotomy. In theatre the preparations are
also the same

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GENERAL

Anaesthesia
See the section on craniotomy. Good anaesthesia is even more
important than with craniotomy because the operation is done
higher in the birthcanal.
Technique
• put the patient in lithotomy position
• clean and drape the vulva
• catheterise the bladder
Now with the patient under anaesthesia examine her again. Put one
followingb6 Vagma and support the fundus with the other. Note the
- cervical dilatation: If it is less than 8 cm, caesarean section
is probably safer
- the lower uterine segment : explore it as far as you can
without using force. If you find it ruptured,
do a laparotomy now
- the exact position of the fetus : which arm has prolapsed?
where are the head and the neck?^
where are the chest, abdomen and back?
Now decide:
- if the neck and the body are both still high in the birthcanal
do a caesarean section
- if the neck can be reached easily, attempt decapitation
if the neck is difficult to reach but the body is well down
attempt evisceration

Decapitation
a) Using the decapitation saw (this is very well described in
Lawson and Stewart’s Obstetrics and Gynaecology in the
tropics)
• hook the end of the saw in the thimble
• put the thimble on the best finger of your best hand and try
to bring it round the neck
This is often difficult because there is little room between
he neck, the head and the chest. Sometimes it is easier to
put the saw over the neck and under the arm
. when the saw is in position, protect the vagina with specula
• apply firm traction and saw through the neck
• pull on the arm : usually this delivers the body
• put a hand in the vagina and turn the head so that the neck
points downwards
’ PUt
°r tW0 volseIlum forceps on the neck and deliver the
head like the aftercoming head of a breech

146

• if the head was delivered first, deliver the body by pulling
on the other arm. Don’t do a version, the cut neck might
damage the uterus.
b) Using scissors
• hook one or two fingers round the neck and pull it down
• protect the vaginal wall with a speculum held by an
assistant
• carefully cut the neck with a pair of strong scissors
• further delivery will be as described above.
Evisceration
• your assistant should pull on the prolapsed arm
• protect the vaginal wall with one or two specula
• with a knife or a pair of strong scissors make a large
opening in the abdomen and/or chest
• put one or two fingers into the opening and remove all
internal organs. Make sure you remove the liver, the heart
and the lungs. Sometimes the diaphragm has to be
perforated with scissors.

• Now reassess the situation:
• sometimes the breech can be brought down easily by
hooking a few fingers behind the fetus pelvis; further
delivery is then no problem
• sometimes a foot or a leg can be felt easily and this can be
brought down. The operation is then completed by a very
gentle version and breech extraction
• if the breech cannot be delivered easily, the neck can be
brought down for decapitation by pulling on the arm
• in the unlikely event that all this fails, don’t hesitate to do
a caesarean section.
After delivery of the fetus see the section or craniotomy

POSTOPERATIVE ORDERS
See the section on craniotomy. Obstructed labour with a transverse
lie usually does not cause pressure necrosis of the vagina and
bladder. Open bladder drainage for a few days is sufficient.

HYDROCEPHALUS

DIAGNOSIS
On abdominal palpation
The head is large in proportion to the fetal body
147

On vaginal examination
With a cephalic presentation the wide sutures and fontanels are felt.
If the patient presents with a stuck breech, bimanual palpation will
reveal the large size of the fetal head.
x-ray
An abdominal x-ray may confirm the diagnosis but beware with
breech presentations: on the x-ray the head may seem much bigger
than it actually is (this is due to the way it is projected onto the film)
'■

Cephalic presentation
If progress in the first stage is good, prepare for vaginal delivery.
• When the cervix is about 7 cm dilated, insert a good size needle
(lumbar puncture needle, for example) or plastic cannula into
the head through a suture and drain the cerebrospinal fluid.
The head will collapse and delivery becomes easy
• Do not wait for full dilatation (the large head will stay high
and full dilatation may never come)
• If, during the first stage of labour, progress is poor, do
caesarean section. At caesarean section drain the cere
brospinal fluid from the head with a needle before you deliver
it. If you do do not do that, there can be nasty tears of the
lower segment.

Breech presentation
If progress is good, wait until the trunk has been delivered up to the
neck. Insert a needle through and then under the skin of the neck
into the head and drain the cerebrospinal fluid. Delivery then
becomes easy.

IMPORTANT DON'T
• Do not pull the head with great force through an incompletely
dilated cervix: this can cause cervical tears which extend into
the lower segment.

RISK
Obstructed labour with rupture of the uterus

MANAGEMENT

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MANAGEMENT
• For management of the hydrocephalic head see previous
section
• In other cases sedate the patient with pethidine 50 mg i.v. + 50
mg i.m.
• Wait for about an hour, preferably with the patient in
lithotomy position and the baby’s body hanging down;
often the head is delivered spontaneously after ij; has had time
to mould.
If this fails, craniotomy is necessary. This is best done in theatre
under general anaesthesia but it can be done in the labour ward.
• Retract the anterior vaginal wall with a Sims’ speculum and
expose the posterior aspect of the neck
• With scissors cut a small opening in the skin of the neck
• Make a tunnel under the skin and push the scissors into the
head
• Open and close the scissors a few times in different directions
to break up the brain compartments
• Pull gently on the neck and while the brain gradually escapes,
the head is delivered.

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CAUSES
- cephalopelvic disproportion
- incompletely dilated cervix
- hydrocephalus

J

If progress in the first or second stage is poor, do a caesarean section
but drain the cerebrospinal fluid from the head before delivering it
through the uterine incision.

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IMPORTANT DON'TS
- Do not try to force a too large head through the pelvis
- Do not use pitocin

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THE STUCK BREECH
DIAGNOSIS
The usual manoeuvres to deliver the head (Smellie - Veit, supra
pubic pressure) have failed and the baby is dead.

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INSPECTION OF THE CERVIX, VAGINA AND VULVA
• Have a good light source
• Insert two Sims’ specula and ask a helper to hold these
• Grab the anterior lip of the cervix with two spongeholders
Do not use volsella or any other toothed instrument
• Move the spongeholders round the cervix (they leapfrog) and
inspect each part of the cervix in turn : only tears which bleed
severely need suturing
• Inspect the vaginal wall by moving the Sims’ specula. Remove
one speculum altogether if necessary
• Finally inspect the vulva, paying particular attention to the
area next to the urethra and clitoris

Chapter 49

THEATRE PROCEDURES FOR POSTPARTUM
HAEMORRHAGE
(EXAMINATION UNDER ANAESTHESIA,
MANUAL REMOVAL OF THE PLACENTA,
REPAIR OF A CERVICAL TEAR)

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PREPARATION
• Always do these things in theatre:
- Check that there is a good i.v. drip
- Replace pitocin by plain saline
- Check that blood is being x-matched
• Use general anaesthesia with intubation
or
diazepam 10 - 20 mg i.v. + pethidine 25 - 50 mg i.v. slowly
• Lithotomy position, clean the vulva, catheterise
ALWAYS EXAMINE THE WHOLE BIRTH CANAL FROM THE
FUNDUS DOWN TO THE CLITORIS
EXPLORATION OF THE UTERUS - MANUAL REMOVAL
OF THE PLACENTA
• Separate the labia with the fingers of the left hand
• Keeping the fingers together insert the whole right hand into
the vagina
• Shift the left hand to the abdomen to support the fundus
• Insert the whole right hand or as many fingers as will go in,
into the uterus
• If the placenta is still there, gently separate it from the uterus
with the fingers, it may have to be removed piecemeal
• Deliver the placenta by pulling the cord with the left hand
• Check the uterine cavity : anterior and posterior wall, tubal
angles, the lower segment
• Remove remaining bits of placenta, membranes and decidua.
Realise that the placental bed always remains somewhat
irregular
• Give ergometrine 0.5 mg i.v. and remove your hand from the
uterus only when it begins to contract; if it does not contract
well, put pitocin 10 - 40 units per litre into the i.v. drip

NEVER TAKE ANY KIND OF CURETTE OR OVUM FORCEPS TO
A POSTPARTUM UTERUS'

REPAIR OF A CERVICAL TEAR

• Have a good light source
• Expose the cervix with two Sims’ specula and ask a helper to
hold these
• Put a spongeholder on either side of the tear
• Repair the tear with interrupted catgut sutures on a
round-bodied needle from above downwards. At times it is
easier to suture the other way round : from below upwards.
After the first suture has been inserted the spongeholders are
removed and the suture is used for traction
DISASTERS

1.

Continued bleeding from an empty uterus
• Compress the uterus between a fist in the vagina and a hand
on the abdomen and behind the uterus
• What is the problem : does the uterus not contract?
or
is there a clotting defect?
- If the uterus does not contract in spite of large* doses of
ergometrine and pitocin, hysterectomy is necessary
- If there is a clotting defect, the bleeding may stop after
the transfusion of fresh blood

2.

Part of the placenta cannot be removed
• Immediate hysterectomy is best. Temporary control of
bleeding may be possible with ergometrine and pitocin

*For example: pitocin 80 units per litre in a fast running i.v. drip tfhd repeated
of ergometrine 0.5 mg i.v. When available prostaglandins cap'al^o-berried.

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• If only a small piece of placenta is remaining, a second
attempt at removal can be made a few days later. In the
meanwhile the patient should be very carefully watched for
bleeding and be given large doses of antibiotics

3.

Injury to the uterus
This can be a rupture discovered only after delivery, a cervical
tear extending into the lower segment or a perforation made
during attempts at removing the placenta.
In each case laparotomy must be done to assess the damage. Be
prepared for a hysterectomy

Chapter 50

REPAIR OF A THIRD DEGREE
PERINEAL TEAR
DIAGNOSIS*
Place a finger in the anus and lift this slightly. It is then easy to see
whether the anal sphincter is torn. A large second degree perineal
tear with a partially torn anal sphincter is treated as a third degree
tear.
RISK

Incontinence for faeces and flatus if the anal sphincter is not
repaired properly.
OPERATION
PREPARATION
Good light and exposure are essential.

The operation is best done in theatre under general anaesthesia. If
you have to use local infiltration anaesthesia, sedate the patient
with pethidine 50 mg i.v. stat, just before starting the procedure.
You need an assistant.

TECHNIQUE
• Place Allis’ forceps on the vulval skin on either side of the
wound
• Ask your assistant to keep these apart and so expose the
wound
• Identify the tear in the bowel mucosa and anal skin and repair
this with 2/0 chromic catgut interrupted sutures so that the
knots lie in the rectum
• After the bowel and anal skin have been repaired, identify the
end of the torn anal sphincter and grasp these with Allis
forceps. One end is usually easy to see, the other will have
retracted into its “canal” and needs to be retrieved
• Repair the anal sphincter with two or three 2/0 chromic
catgut sutures

•Sometimes an old third degree perineal tear, resultant from a previous delivery is
seen. These old tears can be repaired 6-8 week after delivery.

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• Repair the vaginal wall with interrupted 2/0 catgut sutures
(there are often multiple tears and a tidy repair can be
difficult)
• Repair the perineal (levator) muscles carefully with 0 or 1
chromic catgut sutures
• Repair the perineal skin

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POSTPARTUM PROLAPSE OF THE CERVIX

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DIAGNOSIS

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This is obvious if you think of it!
The cervix looks horribly swollen and bruised and may be covered in
dirt. The mother’s general condition is usually good.

POST OPERATIVE ORDERS

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Chapter 51

• Keep the patient in hospital for 8-10 days
• Prescribe liquid paraffin one to two tablespoons daily to keep
the stools soft for a week
• The value of antibiotics is debatable
• Explain to the patient and write on the discharge certificate
that:
- she should deliver in hospital*next time
- episiotomy is necessary with the next delivery to prevent
recurrence of the third degree tear

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It is possible to confuse postpartum prolapse of the cervix with an
inversion of the uterus. However, when the uterus is inverted, the
patient is shocked and the fundus can not be felt above the
symphysis pubis.

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MANAGEMENT

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This can be done by the midwife:
• Sedate the patient with diazepam 10 mg i.v.
• clean the cervix
• cover the cervix with a wet towel or a gauze pack and squeeze
it gently between two hands: this reduces the swelling
• after a few minutes gently push the cervix back into the
vagina
• keep the patient in bed for a few days
• prescribe a broad spectrum antibiotic, for example:
Bactrim II twice daily for seven days

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Chapter 52

POSTPARTUM TUBAL LIGATION
INDICATIONS
Medical
- Conditions which can result in a weak uterine scar:
- repair of a ruptured uterus
- classical caesarean section
- repeat caesarean section (depending on the findings
during operation)
— other conditions which make a future pregnancy undesirable,
for example a serious heart condition or severe hypertension.

Voluntary
The patient and her husband have completed their family and prefer
sterilisation to other forms of contraception.
COUNSELLING
During pregnancy
Tubal ligation must be discussed with the patient and her husband
if tubal ligation is likely to be necessary on medical grounds, for
example with a fourth repeat caesarean section.
It can be discussed if the patient asks about it or if you have reason
to believe that she might be interested, for example, if she has a
large family already.

If you take the initiative, do not pressurise the patient but mention
tubal ligation as a possibility only. Drop the subject if she is
obviously not interested.

Permission
Obtain written permission from husband and wife. If the patient has
no husband, make sure her family supports her decision. Tubal
ligation without prior permission is only allowed on medical grounds
during an emergency, for example with an operation for ruptured
uterus. Such cases should remain exceptions!
CONTRAINDICATIONS
After a vaginal delivery, tubal ligation is contra-indicated if:
- any sign of endometritis is present
- labour was complicated by a serious postpartum hae
morrhage
- the patient changes her mind.

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ANAESTHESIA
Postpartum tubal ligation can be done under general, spinal or local
anaesthesia.

PREPARATION
• Shave the area where the incision will be made
• Catheterisation is not necessary as a routine: a small amount of
urine in the bladder helps to bring the uterine fundus into the
area of the umbilicus
• Prep and drape the abdomen as usual

•
•
•

TECHNIQUE
Make a 2 - 5 cm long transverse incision in the skin under the
umbilicus
Retract the skin with two toothed retractors or Allis’ forceps
Lift the fascia with two Allis’ forceps and make a transverse
incision through the fascia and peritoneum about 2-5 cm long
Clamp any bleeders

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During labour
This is a bad time to discuss such an emotion-laden subject. Only
discuss it if you have medical reasons for suggesting a tubal ligation.

•

Points to be discussed
- tubal ligation is irreversible
- alternative forms of contraception
- the operation itself:
- it is done within 1 — 4 days after delivery
- anaesthesia is required (discuss which anaesthesia will
be used!)
- the type of skin incision that will be made
- the number of days in hospital after the operation

Next comes the difficult part which is to identify a Fallopian tube
and bring it out through this small incision.
• With a blunt retractor pull the opening in the abdominal wall to
the area where you expect to find the right adnexa
• Put a finger behind the uterus and then slide it to the right until
you are behind the adnexa. The ovary is posterior to the fallopian
tube and the fallopian tube is posterior to the round ligament
• Rotate with your finger the adnexa forward and pick up the
Fallopian tube with an artery forceps

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You may find that it is easier to use a swab on a holder instead of
your finger. If you cannot find the tube by either method, do not
hesitate to make your incision larger!
Ligation of the tube by Pomeroy’s method:
• Identify a nicely mobile part of the tube (usually this is found
at the junction of the isthmus with the ampulla) and lift this
with an artery forceps
• Pass a chromic 0 suture on a needle through the mesosalpinx
about 2 cm away from the tube; be careful not to puncture a
bloodvessel
• Tie the suture round the tube on both sides of the artery
forceps and about 1-2 cm away from it [see Figure 52.1].
• Remove a small segment of tube with scissors; make sure to
leave the remaining stumps ’A - 1 cm long.
• Repeat the same procedures on the left
• Close the abdomen in layers:
- fascia and skin together with continuous chromic 0
- the skin with a few interrupted of sutures catgut or
mersilene (silk).
POSTOPERATIVE ORDERS

• Full diet, no i.v. drip!
• Pain relief:
- a mild analgesic, for example: aspirin II 3-4 x/day for 5
days
- pethidine 100 mg i.m. if necessary the first evening
• Antibiotics: their value is debatable
• Discharge home, if all is well, after one or two days
• Review (and remove the sutures if necessary) after one week

Figure 52.1. Pomeroy's method of tubal ligation.
A. A loop of Fallopian tube is being lifted with an artery forceps and has been ligated
with a chromic 0 suture.
B. A small segment of tube has been removed.

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Part IV

The Abnormal Puerperium

Chapter 53

- generalised peritonitis
- septicaemia: the infection attacked a vein in the pelvis (a
branch of the ovarian or uterine veins) and infected emboli are
discharged into the circulation.
- abcesses:
- in the pelvis as:
- tubo-ovarian abcess
- broad ligament abcess
- abcess in the pouch of Douglas
- in the subphrenic spaces
- in multiple places in the abdomen:
- in the paracolic gutters
- between small bowel loops

PUERPERAL INFECTIONS
DEFINITIONS
Fever postpartum : A temperature of 37.5 C° (under the arm) or
more on any two days within 14 days after
delivery
Puerperal sepsis : Infection of the genital tract following
delivery.

CAUSES OF FEVER POST PARTUM

PUERPERAL SEPSIS
Micro-organisms
Many different micro-organisms can cause puerperal sepsis. They
can be classified as follows:
- sexually transmitted organisms : gonococci, chlamydia
These organisms are present in the cervix before delivery
- large bowel bacteria
There are many different kinds of large bowel bacteria.
Important examples are : Escherichia coli and Bacteroides
fragilis. These bacteria are carried from the perineum into the
birthcanal for example by a vaginal examination.
- other bacteria
For example . staphylococci, beta-haemolytic streptococci etc.
Factors which encourage puerperal sepsis
These include:
- poor hygiene or poor aseptic technique during delivery
- manipulations high in the birthcanal
- the presence of dead tissue in the birthcanal after delivery, for
example retained products or sloughing vaginal wall following
obstructed labour.

Forms
Depending on how the infection has spread puerperal sepsis can
present as:
- endometritis
- salpingo-oophoritis
- parametritis (= pelvic cellulitis) : the infection has spread
through the wall of the uterus into the broad ligament

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160

CAUSES OF FEVER OTHER THAN PUERPERAL SEPSIS
Urinary tract infection
- Wound infection (episiotomy, abdominal wound)
- Chest infections : pneumonia or lung abcess (due to aspiration
during anaesthesia)
- Mastitis
- Deep vein thrombosis
- Medical conditions: malaria, typhoid, meningitis etc.

ASSESSMENT
Take a history and examine the whole patient for possible causes of
fever. Include a rectovaginal examination if the cause of fever is not
immediately obvious.
After your clinical assessment you will find one of the following
situations:
1. The cause of fever is (reasonably) certain
For example : endometritis or urinary tract infection
• Treat the patient according to your diagnosis

2.

No cause of fever is found
If the patient is not very ill:
• send blood for haemoglobin, white blood count and malarial
parasites
• Prescribe a full chloroquin course
• review the patient daily : look for localising signs or signs of
improvement
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If the patient is very ill:
• send blood for haemoglobin, white blood count and malarial
parasites
• send urine for microscopy and culture if possible
(take specimen by suprapubic aspiration or catheter)
• do, if possible, one or more blood cultures*
• order a chest x-ray
• prescribe a full chloroquin course
• start a broad spectrum antibiotic after the cultures have
been taken
• review the patient daily, look for “hidden” causes of fever
[see below)
“Hidden” causes of fever
1. The “hidden” abcess
• Suspect an abcess when the patient has been ill with fever for
more than one week
• Look for:
- a subphrenic abcess. Useful signs are:
- poor air entry over the lower lobe of the lung on the
affected side
- tenderness on palpation between the lower ribs
- a raised hemidiaphragm on the chest x-ray
- a pelvic abcess. Sometimes it takes a while before an
abcess in the pelvis becomes palpable: repeated recto
vaginal examinations every 3-4 days are necessary!
- (multiple) abcesses in the abdomen. Abcesses between
the bowel loops are often difficult to find. Continuing
abdominal distension is often the only sign apart from
fever.
2.

Septicaemia
In the beginning (spiking) fever and chills are the only sign.
Signs of endometritis or infection elsewhere in the pelvis are
usually minimal or absent.
After a while signs of “metastatic” infection may appear, for
example: pneumonia or lung abcess; liver involvement
(jaundice!).
Often after days or weeks an abcess develops at the site of the
infected vein in the broad ligament.

* The value of the high vaginal swab, although it is often done, is very limited. It is
difficult to exclude contamination with material from the lower vagina and many of
the organisms causing puerperal sepsis do not grow in our laboratories (for example,
gonococci, chlamydia, B. fragilis)

162

Generalised peritonitis and/or multiple abcesses in the
abdomen following caesarean section or ruptured uterus
This diagnosis is often made too late.
Suspect generalised peritonitis if, in the presence of fever:
- three or four days after the operation the
abdomen is still distended
- the abdomen remains tender:
- sometimes all over
- sometimes only in the flanks where
most of the pus collects
Additional signs can be:
- vomiting
- poor bowel sounds
- diarrhoea
The diagnosis is certain and laparotomy urgently needed if these
signs persist for more than a week after the original operation.

3.

MANAGEMENT OF PUERPERAL SEPSIS
THE USE OF ANTIBIOTICS
General rules
• Use broad spectrum antibiotics (reason, you do not know
which organisms you are dealing with)
• Give high doses (reason: many of the bacteria are not very
sensitive to antibiotics)
• If the infection develops in a patient who had prophylactic
antibiotics with a caesarean section, do not use the same
antibiotics to treat the infection (reason: the infection is
probably due to a bacteria resistent to your prophylactic
antibiotics)
• If infection develops in a patient who is already on antibiotics,
change the antibiotics unless they were started only one or
two days ago.
• Do not in general change antibiotics too soon: they need at
least three or four days to do their work
Choice of antibiotic
Patient not very ill. Useful regimens are:
- ampicillin 500 mg per os or per injection six hourly
- x-penicillin 2 mega i.m. or i.v. six hourly + streptomycin 1 gm
i.m. daily
- bactrim 2 tablets bd
- tetracyclin 500 mg per os six hourly
All these regimens must be given for at least five days,
preferably seven
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Note that:
- ampicillin or x-penicillin/streptomycin are not effective
against chlamydia
- none of these regimens is effective against B. fragilis
Patients severely ill. Often more than one micro-organism is
involved. B. fragilis is frequently one of the micro-organisms. B.
fragilis only responds to: chloramphenicol, metronidazole or
clindamycin.
Useful regimens are:
- ampicillin 500 mg by any route six hourly + metronidazole
400 mg eight hourly
- x-penicillin 2 mega i.v. six hourly + chloramphenicol 500 mg
i.v. six hourly
These regimens must be given for at least one week.
Follow-up
• Review the patient daily
• If she does not improve, consider:
- is the original diagnosis correct?
- is there an abcess anywhere?
- is she on the right antibiotic?
• Do not change the antibiotics until you have answered the
first two questions.

Generalised peritonitis
• Treat on suspicion alone
• Antibiotics
• i.v. fluids
• Pethidine 50 - 100 mg i.m. six hourly
• Nasogastric tube
If no marked improvement after 24 hours, laparotomy. This is a
major procedure. Refer to gynaecologist or surgeon if possible. Do
not postpone.

Septicaemia
• Antibiotics
• Consider adding: heparin 5,000 - 10,000 units i.v. six hourly
for 10 days
• Refer to gynaecologist if possible
Abcesses
• Posterior colpotomy for abcesses in the pouch of Douglas*
• Laparotomy for abcesses elsewhere in the abdomen.
• Refer to gynaecologist if possible.

MANAGEMENT OF THE VARIOUS FORMS
OF PUERPERAL SEPSIS
Endometritis

After vaginal delivery
• mild : - ergometrine tablets I tds for five days
- simple analgesic
• severe: - same + antibiotics

After caesarean section
• antibiotics in all cases
Salpingo-oophoritis or parametritis

• antibiotics
• pain relief: simple analgesic, pethidine 50 - 100 mg six hourly
if necessary

*The effect of a posterior colpotomy on the patient’s feeling of well-being should be
dramatic and manifest within one or two days. If the temperature remains high and
she is still ill after two to three days, do a laparotomy to drain the remaining
abdominal abcesses.

164
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Chapter 54

SECONDARY POSTPARTUM HAEMORRHAGE
DEFINITION
Bleeding from the genital tract in excess of normal lochial loss after
the first 24 hours postpartum and until the end of the puerperium.
CAUSES

h

Sloughing of dead tissues
• remove the slough
• pack the bleeding area tightly for 24 - 48 hours
• if packing does not not stop the bleeding, hysterectomy or
ligation of the internal iliac arteries may be necessary.

Breakdown of the uterine wound after caesarean section or
ruptured uterus
• do laparotomy
• resuture the wound or do hysterectomy

- Retained products (membranes, placenta)
- Endometritis
- Sloughing of dead tissue (cervix, vagina, bladder, rectum)
following obstructed labour
- Breakdown of the uterine wound after caesarean section or
ruptured uterus

RISK

- Repeated attacks of (very) heavy bleeding
- maternal death, particularly if it happens far from hospital
MANAGEMENT
• Admit into hospital as an emergency
• Check the haemoglobin
• x-match a pint of blood
• Give ergometrine 0.5 mg i.m. or i.v.
• Put up an i.v. drip
• Add 10 - 40 units of pitocin per litre to the drip, if necessary
• Start broad spectrum antibiotics in high doses by injection.
For example:
— x-penicillin 2 mega i.v. 6 hourly + streptomycin 1 gm i.m.
daily
or
- chloramphenicol 0.5 gm i.v. 6 hourly
• Do an examination under anaesthesia as soon as possible.
Do not postpone thisl
• Treat according to your findings:

I

I

Retained products or endometritis
• finger curettage
• avoid the use of a curette if possible; if it has to be used, it
should be large and blunt.

166

1

167

• Remove sloughs in theatre if necessary
• Discharge the patient home when all dead tissue has sloughed
and the vagina is clean

Chapter 55

COMPLICATIONS FOLLOWING OBSTRUCTED
LABOUR

I
$

1

After four months and not earlier, refer the patient to a
gynaecologist for repair of the fistula.
Before referral check that:
- the patient’s general condition is good
- the haemoglobin is 11 gm% or more
- the vagina and vulva are clean
- urinary tract infection and bilharzia have been treated

The main complications following obstructed labour are:
- puerperal sepsis Isee Chapter 53]
- secondary post partum haemorrhage Isee Chapter 54]
- urinary or rectal fistulae
- nerve injuries

RECTAL FISTULAE

URINARY FISTULAE

I

a

3
9
I
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I

II

I
«

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CAUSES
The most common cause is pressure necrosis during labour. A less
common cause is the placing of sutures through the rectum by
mistake during the repair of an episiotomy or perineal tear

CAUSES
The common cause is pressure necrosis of bladder and/or urethra
during delivery
Less common causes are:
- injury to bladder or urethra during:
- caesarean section
- the operation for ruptured uterus
- symphysiotomy
- injury to the ureter during:
- caesarean section
- the operation for ruptured uterus

MANAGEMENT
• Treat infection with antibiotics
• Clean the vagina with sitbaths or vaginal douches
• Remove sloughs if necessary
• Refer to gynaecologist for repair about four months after
delivery

NERVE INJURIES

DIAGNOSIS
The diagnosis is usually obvious: the patient is continuously wet.
Confusion is possible with:
- severe stress incontinence, in which the urine flows from
the urethra
- retention and overflow, in which the (over) full bladder is
easily demonstrated
MANAGEMENT
• Continue open bladder drainage for about three weeks to
promote healing of the vagina. This is easy if the fistula is
small. With a large fistula it can be difficult to keep the
catheter in the bladder. Try with a finger in the vagina to
guide the catheter into the bladder and inflate the balloon
enough to keep it there. If this does not work, remove the
catheter and allow the urine to drain through the fistula
• Treat infection with antibiotics
• Prescribe sitbaths once or twice a day (vaginal douches are
even better)

168

PRESENTATION
:
Common
Less common :

- dropfoot on one or both sides
- weakness of the hip muscles
- weakness of the quadriceps muscle

CAUSES
The most probable cause is pressure during labour

n

DIAGNOSIS
• Look for signs of nerve injury in every patient who has had
obstructed labour
• Check that she can move her toes, ankles, knees and hips in all
directions

Nerve injuries are very easily missed if the patient is completely
bed-ridden for a few weeks (due to puerperal sepsis for example). If
they are missed, contractures develop very quickly.
169

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MANAGEMENT

Principles
• Await spontaneous healing of the nerves. This usually does
occur, but may take a long time (months)
• Prevent contractures from developing during the time the
muscles are paralysed
In Practice
• Keep the weight of bed sheets and blankets off the legs by
using a bed cradle
• Move the affected joints through their full range of movement
a few times each day (encourage a relative to help with this)
• For a dropfoot a backslab during the night can be useful
• Encourage the patient to walk

pit

Chapter 56

PUERPERAL PSYCHOSIS
CAUSES
The cause of puerperal psychosis is not known but at an increased
risk for puerperal psychosis are patients with:
- a history of (puerperal) psychosis
- a family history of psychosis
- obstetric problems, for example:
- difficult operative delivery
- stillbirth or neonatal death
- premature or sick baby

I
•:si'

1

DANGERS
There is great danger of:
- suicide
- murder : - her own child
- other children

3

1
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•J

CLINICAL PICTURE
The onset is usually 3-5 days after delivery.

::

Warning symptoms and signs
The patient may complain of headache, tiredness, or not sleeping
well. She may further complain that she has no breastmilk or that
she is afraid of harming the baby.

S

You may notice that she is restless and anxious and that she
behaves strangely with the baby.
Psychotic stage
Her mental state is unpredictable and changes very rapidly: one
moment she is acutely psychotic, the next moment she will appear
almost normal.

i

During the psychotic phase she will appear to be out of contact with
her surroundings. She looks puzzled and very frightened.
■

She can be very violent and dangerous. She may have wrong ideas,
delusions and hallucinations.

i

1

3

170

171

DIFFERENTIAL DIAGNOSIS
“Toxic states” due to:
- puerperal sepsis
- anaemia
- malaria
- meningitis
- typhoid etc.
are often confused with puerperal psychosis. They disappear as soon
as their physical cause is cured.

A
A
A

MANAGEMENT
• Protect - the patient
- her baby
- other babies

■I

• Make sure someone is with her all the time. Ask the relatives
to help.
• Do not leave her alone!
• Look very carefully for physical illness (puerperal sepsis etc.)
and treat this
• Start chlorpromazine (5= Largactil) 50 mg per os or by injection
three times a day; continue for three weeks, then gradually
reduce the dose, continue with 50 mg once a day at night for
about 6 months
• Allow her to breastfeed and look after the baby but supervise
her carefully
• If she is not markedly better after two weeks, transfer her to
Zomba Mental Hospital.

172

Part V

Neonatal Problems

1

MANAGEMENT

Chapter 5 7

PRINCIPLES
• Keep the baby warm
• Make the baby breathe
• Support the heart action if necessary

RESUSCITATION OF THE NEWBORN
WITH A LOW APGAR SCORE
ASSESSMENT OF THE BABY’S CONDITION AT BIRTH

IN PRACTICE
Preparation before the birth of the baby
• Check the resuscitaire and equipment [see Appendix J J

We use the Apgar score at one and five minutes after birth:

Sign

Score

0

1

Heart beat

absent

below 100/minute

over 100/minute

Respiratory effort

absent

weak/irregular

good/crying

Colour

pale or blue

body pink,
extremities blue

completely pink

Muscle tone

flaccid

some flexion of
arms or legs

well flexed

Reflex irritability
(response to suction
catheter in the nose)

absent

grimace

cough or sneeze

Interpretation:

Normal ■
Low

After birth
• Cut the cord between two clamps
• Put the baby on the warm resuscitaire
• Dry it with a towel and throw this away
• Wrap it in a dry second towel
• Shout for help

2

!

score 7-10
score beiow 7

M.

CAUSES OF A LOW APGAR SCORE ONE MINUTE AFTER BIRTH

- Fetal distress [see Chapter 33 for the causes of fetal distress!
- Brain injury due to a difficult delivery
- Severe congenital malformations (heart, lungs, brain)
- Heavy sedation
CAUSES OF A LOW APGAR SCORE FIVE MINUTES
AFTER BIRTH OR LATER
- As above
- Inadequate ventilation of the lungs due to:
- obstructed airway (meconium, mucus, blood)
- reflex apnea due to excessive suctioning
(this causes a spasm of the vocal cords
making it impossible for the baby to breathe)
- inadequate artificial respiration
- respiratory distress due to prematurity of the lungs
- Inadequate heart action (heart rate below 60/minute) due to
oxygen lack

174

■

Pt
Pt
Pt

Clear the airway
• Suck mouth, throat and nostrils with a mucus extractor
• Do not suction too deep (4-5 cm) or too long (15 seconds) as
either may cause spasm of the vocal cords
• If thick meconium or mucus is present, use the laryngoscope to
see the back of the throat and possibly the vocal cords while
you are suctioning
• Do not take too long. Be quick.
Artificial respiration
1. With mask and bag
• Place the face mask firmly over mouth and nose
• Pull the lower jaw forward
• Hold the head in midposition between flexion and
extension (if you hyperextend it as you would with an
adult, the airway becomes obstructed)
• Squeeze the bag between thumb and forefinger about 30
times/minutes
• Attach the oxygen line to the connection on the bag and
set the oxygen flow at 4 litres/minute
• Continue artificial respiration until the baby breathes
spontaneously

2.

Mouth to mouth ventilation
This can be done when mask and bag are not available
• Put your mouth over nose and mouth of the baby
• Draw the lower jaw forward and keep the head in
midposition
• Blow about 30 times/minute
• Look at the baby’s chest to see whether it expands
• Do not blow too hard: breathe out as you normally would
175

• and then use the air left in your chest for blowing into
the baby

3.

Through an endotracheal tube
If the Apgar score is 1 - 3 and you are experienced at
intubation, intubate the baby with an endotracheal tube and
ventilate through it. If you are not experienced, it is better to
use mask and bag.

Antidotes
If the mother had large amounts of pethidine or morphine, give:
- nalorphine 0.5 mg i.m.
or
- naloxone 0.02 mg i.m.

External cardiac massage
This is necessary when the heart rate is below 60/minute.
You need a helper.
• Place the tips of index and middle finger over the middle third
of the sternum
• Depress the sternum 1 - I'A cm at a rate of 120 times/minute

Successful resuscitation
• Label the baby
• Take it to the nursery in warm towel
• Keep it warm, preferably in a warm incubator, and give
oxygen 2 litres/minute through a small tube in the nose
• Give vitamin K 1 mg
• Start a nasogastric drip through an FG 6 or 8 feeding tube
with 0.5% sodium bicarbonate in 10% glucose solution; give 60
ml/kg in 24 hours. [See Appendix JI
• After 24 hours start normal feeds

Chapter 58

PREVENTION OF MECONIUM ASPIRATION
INTRODUCTION
If the liquor contains meconium, the baby may aspirate this during
its first gasps. The result is a nasty aspiration pneumonia which
often proves fatal.

PREVENTION

• have a mucus extractor ready at the beside
• clean and suck out mouth and nostrils as soon as the baby’s
head is out and before you deliver the trunk
• when the whole baby has been delivered, look in the mouth
and the throat with a laryngoscope. Do this on the delivery bed
if possible, before clamping the cord. Suck away any mucus
and meconium that you can see
• only after the airway has been cleared completely, stimulate
the baby to breathe or ventilate it with mask and balloon.

Failed resuscitation
If the baby is not breathing spontaneously after 20 minutes,
there is severe brain damage. Stop resuscitation.

IMPORTANT DONTS
• Do not suction mouth and throat for more than 15 seconds at a
time
• Avoid suctioning too often
• Do not inject vitamin K before the baby is breathing well
(ventilate first, inject later)
• Do not give injections into the umbilical vein unless you have
had special training to do so
• Do not use nikethamide or other stimulants
• Do not bathe the baby (it is unnecessary and does cool it)

176

177

Appendix A

THE USE OF OXYTOCIN (= PITOCIN)

Part VI

Appendices

GENERAL
Pitocin is one of the trade names of oxytocin. Other trade names are:
Piton-S and Syntocinon. Although it would be more correct to speak
of oxytocin, most people in Malawi have become used to the term
pitocin and this name will be used here.
Pitocin is used to stimulate the uterine contractions. Unfortunately,
it is very difficult to predict how much will be needed and it is very
easy to give too much. The dangers of too much pitocin are:
- an increase of the resting tone of the uterus between the
contractions which may cause fetal distress
- excessively strong uterine contractions which, in the multi
para, may rupture the uterus.
Pitocin should therefore always be started in a small dose. If
necessary small amounts can gradually be added.

INDUCTION OF LABOUR
Induction of labour means that the contractions are stimulated
either when the patient is not in labour at all or when she is still in
the latent phase. This is different from the acceleration of labour
[see below].

Indications for induction
- premature rupture of membranes (this is the most common
indication)
- intrauterine death [see Chapter 15.]
- other (preeclampsia, hypertension, pdstmaturity etc.)

Contraindications
- uterine scar
- cephalopelvic disproportion or other impediments to vaginal
delivery

!

Authorisation
A senior midwife can order the induction of labour for premature
rupture of membranes in nulliparae and in parae I - V.
Inductions for other indications and inductions in parae VI or more
must be ordered by a doctor

I

Administration
For the induction of labour pitocin is always given in an intravenous
drip. The starting and maximum dosage of pitocin depends on the
parity and is as follows:

I

179

Dosage of Pitocin
Time

Nullipara
Drops/min
U/L

- 1/a hr
*/2 - 1
hr
1
- I’/a hr
172 - 2 hr
2
- 272 hr
272 - 3 hr
3
- 372 hr
3 72 - 4 hr
4
- 472 hr
4 72 and more

5
5
5
5
10
10
10
10
10
10

0

10
20
30
40
20
30
40
40
40
40

Appendix B

Para 1-5
U/L
Drops/min

1
1
1
1
2
2
2
4
4
4

10
20
30
40
20
30
40
20
30
40

Para 6 or more
U/L
Drops/min

~TiT

io

l/2
*/2
‘/2

20
30
40
20
30
40
20
30
40

1
1
1
2
2
2

DRUGS USED FOR HYPERTENSION
IN PREGNANCY AND ECLAMPSIA
1.

As soon as regular, strong contractions develop, the speed of the drip
is not further increased. It may even have to be reduced.

Observations
Check regularly:
- the contractions and the resting tone of the uterus
- the fetal heart rate
- the blood pressure

The main problems with the lytic cocktail are:
- the mother becomes semiconscious and is therefore
helpless as well as uncooperative.
- the baby is heavily sedated too. After birth it may have
problems with breathing, with feeding and in maintaining
its temperature.

Failed induction
If there are no contractions after six hours inform the doctor.

Intrauterine death
In cases of intrauterine death higher doses of pitocin may be
necessary. Ask the gynaecologist about this.

The dosages of these drugs in the lytic cocktail
First dose : pethidine
50 mg b s1qw (5 _ 10 minutes)
chlorpromazine 25 mg Viy injection
diazepam
10 mg I
i.v. drip for continued sedation’.
pethidine
100 mg
chlorpromazine 50 mg in 1 litre of i.v. fluid
diazepam 20 - 40 mg

ACCELERATION OF THE ACTIVE PHASE
This is only allowed in nulliparae! For details about the indication
see Chapter 22. The concentration and speed of the pitocin drip are
the same as for the induction of labour.
ACCELERATION OF THE SECOND STAGE
This is only allowed: - in a nullipara
- in a multipara for the second twin.
Delivery needs to be effected fairly quickly and therefore a higher
dose of pitocin is used:
- start with the maximum concentration of pitocin at 10 drops
per minute
- increase the speed of the drip faster than you would during an
induction
- stay with the patient all the time and observe the contractions
carefully!

THIRD STAGE OF LABOUR
In patients with high blood pressure pitocin 5 units i.m. can be used
instead of ergometrine. For the use of pitocin in patients with post
partum haemorrhage, see Chapter 34.
180

THE LYTIC COCKTAIL
The action of the drugs in the cocktail is as follows:
- pethidine gives pain relief; particularly important during
labour or after caesarean section.
- chlorpromazine (= Largactil) sedates and lowers the
blood pressure. The blood pressure lowering effect can be
quite dramatic when it is given intravenously, so inject it
slowly!!
- diazepam (= Valium) sedates and is an anticonvulsant.

2.

MAGNESIUM SULPHATE
This acts as an anticonvulsant when given intravenously or
intramuscularly. It does not sedate the patient and she stays
conscious and can cooperate. The baby is unaffected.
The main problems with magnesium sulphate are:
- it depresses the uterine contractions; pitocin may be
needed to correct this.
- an overdose of magnesium sulphate causes respiratory
paralysis. Magnesium sulphate is excreted by the kidneys.
Overdoses are therefore most likely to happen when the
urine output is low because then the excretion of
magnesium sulphate is also delayed.

181

■T1
Dosage. Magnesium sulphate is given in the following dosages:

5.

First dose i : 4 gm (= 20 ml of a 20% solution) by slow i.v. injection
Repeat doses

•- •>

I

: Again 4 gm by slow i.v. injection, but preferable is:
4 gm (8 ml of a 50% solution) by i.m. injection
Do not give a repeat dose if:
- the urine output is less than 100 ml in four hours
- the respiratory rate is less than 16 per minute
- the knee reflexes are absent

£
The antidote of magnesium sulphate is Calcium gluconate.

Important side effects can be : tachycardia and fluid
retention.

Dose : 10 ml of a 10% solution i.v.

3.

t

ALTERNATIVES
Phenergan. This can be used in the lytic cocktail instead of
diazepam. The dose is 25 mg in the first intravenous
injection and 50 mg in the drip.
If you do not have the other drugs for the lytic cocktail, you
may be able to use Diazepam alone. Give repeated intrave
nous doses of 10 - 20 mg to stop the convulsions and keep the
patient well sedated. You may need large amounts of
diazepam to achieve this : 100 mg or more per 24 hours.

Paraldehyde. This is an effective and safe alternative to the
cocktail. It sometimes works where the cocktail has failed.
The dose is 10 ml i.m. every four to six hours.

4.

I
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i

Methyldopa (= Aldomet). Slow acting. The full effect is seen
only after two to five days. Its action is too slow to be of much
use in eclampsia. It is useful for the longterm treatment of
severe hypertension in pregnancy. Starting dose : 250 mg qid
per os, may increase to 500 mg qid.
Important side effects are : sedation, haemolytic anaemia,
hepatitis.

6.

DRUGS BEST AVOIDED
Ergometrine i.m. or i.v. may cause a sudden rise of
bloodpressure and worsening of preeclampsia or eclampsia. It
should be avoided in all patients with high bloodpressure.

Reserpine should if possible be avoided during pregnancy. It
may cause breathing problems with the baby after birth.

Sodium phenobarbitone. This is a good anticonvulsant
and sedative but it can cause respiratory depression. The
dose is 200 mg i.m. and this can be repeated every four to six
hours.

I

J
I

BLOODPRESSURE LOWERING DRUGS
Hydralazine (= Apresoline). Quick-acting, can be given
orally, i.m. or i.v. The effect lasts up to four hours. In
eclampsia the i.m. route is probably the most useful.
- intramuscular : 10 mg stat. Check blood pressure hourly.
Repeat whenever the diastolic blood pressure is 110 mg Hg
or more.
- intravenously : 5 mg stat. Check the blood pressure every
15 minutes. Repeat dose whenever the diastolic blood
pressure is 110 mm Hg or more.

DIURETICS
Frusemide (= Lasix). Quick-acting, can be given orally, i.m.
or i.v. The usual dose with eclampsia is 40 mg two to five
times per 24 hours. It should not be given before delivery
because it would reduce further the already too small
circulating bloodvolume. It is used after delivery when the
circulation becomes overloaded with oedema fluid. If
persistent oliguria or anuria is suspected, 200 mg i.v. may be
given in one dose.

182

183

Appendix C

Appendix D

CARE OF THE VACUUM EXTRACTOR

EQUIPMENT NEEDED FOR SYMPHYSIOTOMY

The vacuum extractor consists of:
- vacuum bottle of glass
- plastic bung with:
- vacuum gauge
- connection piece + screw cap
- vacuum pump
- rubber tubing
- vacuum extractor cups of 40, 50 and 60 mm diameter
- bottom plates for the cups, made of silicone or rubber
- traction chain attached to the cup
- traction handle
- white locking ring for the tubing

i

l

CLEANING AND STERILISATION
- vacuum bottle can be rinsed with water
- the gauge does not need cleaning and should never come
in touch with water (always keep bottle and gauge
upright)
- The pump does not need cleaning
- Cups, traction handle, white ring and tubing can be
sterilised in 3% savlon in spirit or 0.5% hibitane in 70%
methylated spirit. They can be kept in the solution ready
for use.
• Do not boil the tubing : it perishes very quickly that way.
• After use, clean everything carefully before putting it back
into the solution.
• Do not lose the white ring.

Instruments
- 2 gallipots
- 2 sponge holders
- 10 or 20 ml syringe and needles
- episiotomy scissors
- 2 medium size artery forceps for the umbilical cord
- needle holder
- toothed dissecting forceps
- scalpel with a fixed handle*
- vacuum extractor

Sundries
- towels
- gauze swabs
- cetrimide solution 0.5%
- iodine solution 2%
- lignocaine solution 2%
- plain catheter FG 18 or 20
- Foley’s catheter FG 18 or 20
- mucus extractor
- chromic 0 or 1 suture
- suture needles: round-bodied and cutting

*One type of vacuum extractor has the chain attached to the cup and directed
through the tubing. These vacuum extractors have no white locking ring.

*A disposable blade on a handle can be used but is rather sharp and thin. Be careful
not to cut too deep or too far and do not break the blade.

184

185

■
Appendix E

Appendix F

EQUIPMENT NEEDED
FOR DESTRUCTIVE OPERATIONS

EQUIPMENT FOR THE EXAMINATION UNDER
ANAESTHESIA FOR ANTEPARTUM
HAEMORRHAGE

Instruments
- 2 gallipots
- 4 sponge holders: - 2 for cleaning,
- 2 for inspection of the cervix
- 2 or 3 Sims’ specula, preferably different sizes
- scalpel handle and blade
- strong pair of scissors
- Sim’s perforator
- 4 volsellum forceps or strong Kochers or Willet’s forceps
- decapitation saw - handles and thimble
- toothed dissecting forceps
- needle holder
'■I

Sundries
- towels
- gauze swabs
- cetrimide solution 0.5%
- plain catheter Fg No. 18 or 20
- Foley’s catheter FG No. 18 or 20
- chromic 0 or 1 sutures
- suture needles: round-bodied and cutting

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Instruments
- gallipot
- 2 sponge holders
- 2 or 3 Sims’ specula, preferably different sizes
- Kochers forceps for rupturing the membranes

1

Sundries
- towels
- gauze swabs
- cetrimide solution 0.5%
- plain catheter FG No. 18 or 20
• Have the caesarean section set ready for immediate use!

1

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186

187

1

Appendix G

Appendix H

EQUIPMENT FOR THE THEATRE
PROCEDURES FOR POSTPARTUM
HAEMORRHAGE

EQUIPMENT NEEDED FOR THE REPAIR
OF A THIRD DEGREE PERINEAL TEAR

Instruments
- gallipot
- 4 sponge holders:

- 2 for cleaning
- 2 for inspection of the cervix
- 2 or 3 Sims’ specula, preferably different sizes
- needle holder
- toothed dissecting forceps
- scissors

Drugs
- pitocin ampoules to a total of at least 40 units of pitocin
- ergometrine 0.5 mg ampoules

Sundries
- towels
- gauze swabs
- plain catheter size FG 18 or 20
- cetrimide solution 0.5%
- chromic 0 or 1 sutures
- suture needles: round-bodied and cutting

Instruments
- gallipot
- 2 sponge holders
- 4 Allis’ forceps
- 4 small artery forceps or Kochers forceps
- needle holder
- toothed dissecting forceps
- scissors

Sundries
- towels
- gauze swabs
- plain catheter FG 18 or 20
- cetrimide solution 0.5%
- chromic 0 and 2/0 sutures
- suture needles: round-bodied and cutting

j

188

189

Appendix L

FURTHER READING
The following list is not by any means exhaustive but it does contain
books I used while preparing this manual and found to be
particularly useful.

R.H. Philpott, K.E. Sapire, J.H.M. Axton Obstetrics, Family
Planning and Paediatrics, University of Natal Press, 1977.
This work holds the middle between a manual and a textbook for the
tropics. It is well written and although it is mainly directed at the
poorer parts of the Republic of South Africa, much of its advice is
directly applicable in Malawi. Unfortunately this book is not easy to
get hold of.

General
M. F. Myles: Textbook for midwives ELBS and Churchill Living
stone. 1981. After many revisions still a standard text. Its tone is
rather dogmatic and it is mainly directed at conditions in the United
Kingdom.
N. A. Beischer + E.V. Mackay: Obstetrics and the Newborn: for
midwives and medical students. Saunders, 1979.
This book’s main strength is its beautiful illustrations. It is also
well written although the organisation of the chapters is in places
somewhat unusual making certain items difficult to find. It does
have a detailed table of contents and a good index.
D. Llewellyn-Jones: Foundamentals of Obstetrics and Gynaecology:
Volume 1: Obstetrics. ELBS, 1982.
This book is very well written and very useful as an introductory
text.
R.C. Benson et al.: Current Obstetrics and Gynaecologic Diagnosis
and treatment, Lange, Medical Publications, 1984.

I
!

This book is USA based and contains much information in a concise
format. It is more a book to look things up in than to read from cover
to cover.
Books particularly directed at the tropics
J. Lawson and K.S. Stewart: Obstetrics and Gynaecology in the
tropics, ELBS.
First published in 1967 this book has become a classic. Although it
is now no longer altogether up to date, it is extremely well written
and makes excellent background reading, particularly for obstruct
ed labour.

P.R. Myerscough: Munro Kerr’s Operative Obstetrics, ELBS, 1982.
Although this book was not especially written for the tropics, the
present author travelled widely and he often comments on
conditions like those that occur in Malawi. It is in places rather
long-winded but it is sound and makes good and often amusing
reading.
192
i

II

193

INDEX

+ : indicates that the subject is mentioned again on the
.
o pages until the end
following
of the chapter. Capital letter under “Chapter” indicates Appendix.

A
Abcesses, in puerperal sepsis
Abdominal pregnancy
Abnormal presentation
- breech
- brow
- compound
- cord
- face
- head + arm
- head + foot
- head + hand
- shoulder
Abruptio placentae
Acceleration of labour
Active phase of labour
- definition of
- prolonged
- protracted
- secondary arrest of
Adhesions
Aldomet
Anaemia
Anaesthesia
- for caesarean section
- examination under
- for antepartum haemorrhage ..
- for postpartum haemorrhage . .
- spinal
Andros score
............
Antepartum haemorrhage
Antibiotics
- before caesarean section
- in chorioamnionitis
- with destructive operations
- in premature rupture of membranes
- in puerperal sepsis
Apgar score
Apresoline
Artificial rupture of membranes
Aspiration of meconium
Augmentation of labour
B
Bacteroides fragilis
Bladder
- catheteristion of
- fistula
- repair of injuries
- suprapubic aspiration of

194

Chapter
53 +
4

Page
160
10

3 +, 24+
26
27
30 +
25
27
27
27
28 +
16
23

7+, 75
78
79
83
77
79
79
79
80
33, 35, 37-38
73

20
22
22
22
44
B
19 +

56
64 +
64 +
64 +
128, 131

44

124

40, F.
49, G.
44
24
16 +, 40

111
150
124
76
33 +, 111

44
13
48
12
53
57 +
B
39 +
58
22, A.

123
26
142
25
163 +
174 +

109 +
177
66

53

160, 164

38
55
47
38

108
168-169
141
108

52 +

Bleeding
- antepartum
- during caesarean section
- postpartum
- resuscitation after
- Blood pressure
- high
Blood transfusion
- in anaemia
- after bloodloss
- risks of
Breech presentation
- causes of
- caesarean section for ...
- in labour
- in pregnancy
- “stuck”
- varieties of
Brow presentation
C
Caesarean section
- for abruptio placentae
- anaesthesia for
- antibiotics for
- bleeding during
- for breech presentation
- classical
- for a constriction ring
- elective
- for fetal distress
- incisions in the uterus
- for obstructed labour
- for placenta praevia
- postoperative orders
- pregnancy following.................................... • • •
- preparation for
- repeat
- techniques
- for transverse lie
Carcinoma of the cervix
- causing antepartum haemorrhage
- management during pregnancy or labour ...
Catheterisation, technique
Cephalopelvic disproportion
- causing a protracted active phase
- causing secondary arrest
- diagnosis
- risk factors for
- screening for
Cervical stitch
Cervix
- dystocia of
.....................
- carcinoma of
- erosion of

195

Chapter
16 +
44
34 +, 54
35 +

Page
33 +
126
95 +, 166
100 +

18 +

42 +

19
35
35

54
101 +
101 +

3
24 +, 44
24 +
3
48
3
26

9
75, 130
75
9
148
9
78

44 +
16
44
44
44
3, 24 +, 44
44
44
5, 44
33
44
32, 44
16, 44
44
5
44
5, 44
44 +
28, 44

123 +
37
124-125
123
126
9, 75 +, 130
127
131
12, 13, 123

16
16
38

33
38
108

22
22
22
2

14

64-66
67-68
65
6
6+
28

22
16
16

63
33, 38
39

2 4

125-128
129
130
131
12
123
12, 128-129
125 +
80, 130

incompetence of
polyp of
- oedema of
prolapse of, postpartum
tear of
Chlamydia
Chlorpromazine
Chorioamniotis
Clotting defect
- diagnosis
- in intrauterine death
in antepartum haemorrhage
in postpartum haemorrhage
Compound presentation
Confusion
Conjugate
- diagonal
- true
Constriction ring
Contractions, recording on the labourgraph
Convulsions .
Cord, umbilical
- presentation
- prolapse
Craniotomy
D
Decapitation
Descent of fetal head, assessment and recording
Destructive operations
Diagonal conjugate
Diazepam
Drop foot
Dystocia

- cervical
- shoulder

Chapter
14 +
16
22
51
34 +, 49 +
53
56 Bl
13

Page
27 +
33, 39
71
155
95, 150 +
160, 164
172
26

15
15 +
16
34
27, 29
56 +

31
30 +
36-37
95, 98
79, 81
171 +

1
1
29, 39, 44
20
17+, 18

2
2
82, 110, 131
57
40 +.42-46

29, 30
30
48

81, 83
83, 84
142 - 144

48
20
48 +, El
1
Bl
55

145 +
57
142 +
2

14, 22
43

29, 64
121

169

Fibroids, found at caesarean section
Fistula
- rectal
- urinary
Fits in pregnancy
Forceps, obstetric
Furosemide

G
Gestational age, estimation of
Gonococci

- for antepartum haemorrhage ...
- Postpartum haemorrhage
External cephalic version, technique

17, 18
18
53, 54
48

40 +, 42 +
46
160, 164, 166
144 +

40, Fl
49, G1
37

111
150
106

25
21
12
20, 33
33 +
53 +

77
62
25
58, 91
91 +
160

F
Face presentation
False labour
Fern test
Fetal heart rate ..
Fetal distress ....
Fever postpartum

196

I
I

Page
131

55
55
17, 18
41
18, B2

169
168
40 +, 42 +
112
44

6
53

144+
160

14 +

27 +

16 + 40
44
34, 49, 56
35
16
18+, Bl +
18, B3
48
18+, Bl +

33+, 111 +
126
95 + 150+, 166
100 +
33
42 +
51
148
42+

34, 49, 54
46
45

98, 151, 166135 +
132 +

14 +
A1-A2
29
15 +
10 +

28

18

46

21
32
21+, 22+, 23+
31
20

62
86
62 + 64 + 72
85
56 +

34 +
50
56, Bl
7
B2

95 +
153
172
16

20
21

56
62 +

H
Habitual abortions, pregnancy following
Haemorrhage
- antepartum
- during caesarean section
- postpartum
- resuscitation after
Heavy show
High blood pressure
Hydralazine
Hydrocephalus
Hypertension
Hysterectomy, subtotal
- for postpartum haemorrhage
- technique of
- versus repair of ruptured uterus ...

I
Incompetent cervix
Induction of labour
Internal podalic version, indication for
Intrauterine death
Intrauterine growth retardation

82
30 +
20

K
Kidney failure

E

Eclampsia
- imminent
Endometritis
Eviscertion
Examination under anaesthesia

Chapter
44

L

Labour
- false
- obstructed
- prolonged
- trial of scar
Labourgraph, plotting on, symbols for
Laceration
- causing postpartum haemorrhage
- third degree perineal
Largactil
Large for dates
Lasix
Latent phase of labour
- definition of
- prolonged

197

s

I

I

O’

-

s
B

I

M
Magnesium sulphate
Malpresentation
Manual removal of the placenta . . .
Meconium
- aspiration
- in fetal distress
Membranes
- artificial rupture of
- premature rupture of
mental confusion
Methyldopa
Moulding, grading and recording of

j!

h

I

Chapter
32
53
18, Bl

- prolonged versus obstructed labour
Lung abcess
Lytic cocktail

Page
89
161
43

43
18, B1-B2
see: abnormal presentation
150
49
58
33

177
93

39
12+, 13
56 +
B3
20

109
24 +, 26
171 +

N
Nalorphine
Naloxone
Nerve injury
Newborn, resuscitation of

57, JI
57
55
57

176
176
169
174 +

O
Obstructed labour
- caesarean section for
- complications following
- destructive operations for
Ovarian cyst/tumour at caesarean section
Oxytocin
......................................

32 +
44
55
48
44
Al +

86 +
129-130
168 +
142
132

P
Paraldehyde
Parametritis
Pelvic abcess
Pelvic assessment
Pelvic cellulitis
Pelvimetry
- clinical
- X-ray
Pelvis
- assessment of
- borderline
- contracted
Perforation of the uterus ....
Perineum, third degree tear of
Peritonitis, generalised
Pethidine
Phenergan
Phenobarbitone
Pitocin
Piton-S

198

58

B2
53
53 +
1+
53

160, 164
161 +
2+
160

1+
1

2+
3+

1+
1
1
49
50, Hl
53
Bl
B2
B2
Al +
Al

2+
4
4
152
153 +
161, 163, 165

Placenta
- abruptio of
- manual removal of
- praevia
- retained
Postmaturity
Postpartum haemorrhage
- primary
- resuscitation after
- secondary
- theatre procedures for
Postpartum prolapse of the cervix
Postpartum tubal ligation
Preeclampsia
- complicating obstructed labour
- mild/moderate
- severe
Premature rupture of membranes
- causing chorioamnionitis
Previous caesarean section
- pregnancy with
- with premature rupture of membranes
- trial of scar
Prolapse, postpartum of the cervix
Prolonged active phase
Prolonged latent phase
- versus obstructed labour
- versus the protracted active phase ....
Prolonged second stage
Protracted active phase
Puerperal infections
Puerperal psychosis
R
Rectal fistula
Reserpine .............................................................;...
Resuscitation
- after bloodloss
- of the newborn
Retained placenta
- removal
- with postpartum haemorrhage
- without bleeding
Rupture of the uterus

- presenting as antepartum haemorrhage . . ..
- following obstructed labour
- hysterectomy for
- causing postpartum haemorrhage
- repair of
- during a trial of scar

Chapter
16
49
16, 40, 44
34, 36
11

Page
33 +
150
33 + 111, 130
95 +, 104
22 +

34
35
54
49, G1
51
52

95 +
166
100 +
150 +
153
156 +

32
18
18
12
12

88
47-49
46
24
24

5
12
31
51
22 +
21
32
22
23 +
22
53 +
56 +

12 +
24
85
155
64 +
62
89
64
72 +
64-66
160 +
171 +

55
B3

169

35 +
57 +, JI

100
174

49
34
36

150
95
104

16
32
46 +
34, 49
45 +
31

33, 34
86
135 +
95, 98, 152
132 +

53

160, 164

16

35, 38

y

S
Salpingo-oophoritis
Scar, previous caesarean section
- and antepartum haemorrhage

199

j*

JJ

- in labour
- in pregnancy
Second stage, prolonged
Secondary arrest
Secondary postpartum haemorrhage ...
Septicaemia
......................
Sexually transmitted organisms
Shock
Shoulder dystocia
Shoulder presentation
- caesarean section for
- destructive operations for
- in labour
- of second twin
- also see transverse lie in pregnancy
Small for dates
Sodium bicarbonate
Subphrenic abcess
Suprapubic aspiration of bladder
Symphysiotomy
Syntocinon

T
Third degree perineal tear ...
Transfusion, blood
- in anaemia
- after bloodloss
- risks of
Transverse lie
- caesarean section for ....
- destructive operations for
- in labour
- in pregnancy
Trial of scar
Trichomonas vaginitis
True conjugate
Tubal ligation
Twins
- labour
- pregnancy
U
Umbilical cord, presentation/prolapse of
Unstable lie
Ureter, fistula of

Chapter
31 +
5+
23 +
22 +
54
53
53
35 +
43

Page
85
12 +
72 +
67
166 +
161, 162, 165
160
100 +
121

44
48
28
29
4+
9, 10 +
57, J.l
53
38
42 + D.l
A.l

130
144 - 147
80
81
9+
19, 20 +
176
161, 162
108
116 +

50

153 +

19
35
35

54
101
100

44
48
28 +
4+
31
16
1
5 +KI

130
144-147
80
9+
85
33, 39
2
13, 156 +

29 +
8+

81 +
17
83++
30

V
Vacuum extraction
Vacuum extractor, care of
■■■•
Vaginal examination, frequency of during labour
Vaginal varicosity....................................................
Vaginal warts
Valium
Version
- external cephalic
- internal podalic

4+
55

11 +
168

41 +
Cl
20
16
16
Bl

112 +

57
33, 35, 39
33, 39

37 +
29

106 +
82

200
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