OBS HC PROTOCOL 2021 - Final

OBSTETRICS
MANAGEMENT PROTOCOL
For Health Centers
MAY 2021
Obstetrics Management Protocol for Health Centers. MOH, Ethiopia.
LIST OF CONTRIBUTERS
Name Organization
Dr Berhanu Kebede Yekatit 12 Hospital
Dr Gelane Lelisa Yekatit 12 Hospital
Dr Eyasu Mesfin AAU
Sheleme Humnessa MOH
Sr. Zemzem Mohammed MOH
Dr Mulat Adefris MOH/EH
Etenesh Gebreyohanes MOH
Zenebe Akale MOH
Dr Meseret Zelalem MOH
Dr Mengistu Tefera Engenderhealth
Dr Fikremelekot Temesgen AAU
Dr Hailemariam Segni JSI/Transform PHC
Dr Dereje Nigussie Abt Associate
Dr Wassie Lingerh MOH/EH
Takele Yeshwas MOH
Dr Nega Tesfaw MSI
Dr Fikru Abebe Adama Teaching Hospital
Melese Takele IESO
Dr Kiros Terefe University of Gondar
Dr Goitom Gebreysus AAU
Likelesh Lemma MOH
Dr Wondimu Gudu SPMMC
Hinsermu Bayu Arsi University
Belayneh Ayanaw EMWA
Sr Eyerusalem Meseret Kotebe Metropolitan University
Sr Roza Teshome AAU
Sr Haweni Adugna AAU
Dr Solomon Kumbi AAU
Sr Aster Teshome MOH
Dr Zelalem Demeke CHAI
Sr Roza Teshome AAU
Dr Mahbub Ali UNFPA
Melaku Temir EMWA
Sr Senait Birhanu Kotebe Health Center
Dr Eskinder Kebede AAU
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ACRONYMS
AIDS Acquired Immuno IUFD Intrauterine Fetal Death

deficiency Syndrome IUGR Intrauterine Growth Restriction
AMTSL Active Management of Third IV Intravenous
Stage of Labor LAM Lactational Amenorrhea
ANC Antenatal care Method
APH Antepartum Hemorrhage LMP/LNMP Last normal menstrual period
ARM Artificial Rupture of MRN Medical Record Number
Membranes MTCT Mother To Child Transmission
AZT Azidothymidine MVA Manual Vacuum Aspiration
BCG Bacille Calmette Guerin mU milli Units
BMI Body Mass Index NRFHR Non Reassuring Fetal Heart
BP Blood Pressure Rate
BPM Beats Per Minute NVP Niverapine
CBC Complete Blood Count OPD Out Patient Department
COC Combined Oral Contraceptive OPV Oral Polio Vaccine
CPD Cephalo Pelvic Disproportion PID Pelvic Inflammatory Disease
CS Cesarean Section PIH Pregnancy Induced
DM Diabetes Mellitus Hypertension
DPT Diphtheria, Pertusis, Tetanus PMTCT Prevention of mother to
DT Diphtheria, Tetanus child transmission
DTR Deep Tendon Reflex PO Per Oral
DVT Deep Venous Thrombosis PPFP Postpartum Family Planning
EDD Expected date of Delivery PPH Postpartum Hemorrhage
FBS Fasting Blood Sugar PROM Premature Rupture of
FHR Fetal Heart Rate Membranes
FP Family planning Rh Rhesus
FPD Feto Pelvic Disproportion RMC Respectful Maternity Care
GA Gestational Age ROM Rupture of Membranes
HAART Highly Active Anti RR Respiratory Rate
Retroviral Treatment SFH Symphysis Fundal Height
HBsAg Hepatitis B Surface Antigen STD Sexually Transmitted
hCG Human Chorionic Diseases
Gonadothrophin STI Sexually Transmitted
Hct Hematocrit Infection
Hgb Hemoglobin TB Tuberculosis
HIV Human Immunodeficiency UTI Urinary Tract Infection
Virus VDRL Venereal Disease Research
IM Intramuscular Laboratory
ITN Insecticide Treated Net WBC White Blood Cell
IU International Unit WHO World Health Organization
IUD Intrauterine device
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Dr Yirgu G/Hiwot AAU
LIST OF TABLES
Table 1. Categories of disrespect and abuse with recommended standard of care.

Table 2. Rapid initial assessment principles for selected danger signs.
Table 3. Diagnostic approach of a patient with difficulty in breathing.
Table 4. Summary of approach for diagnosis and management of abortion.
Table 5. Medical management regimens for abortions at ≤ 9 weeks of gestation.
Table 6. Diagnosis and management of complications related to abortion.
Table 7. Classification of Abruptio placenta
Table 8. Latent phase of first stage of labor follow up chart.
Table 9. Neonatal resuscitation
Table 10. Risk factors associated with need for resuscitation.
Table 11. 24 hours postnatal care services (First 24 hours after birth).
Table 12. First PNC visit at day 3 (48 -72 hours after birth)
Table 13. Second PNC visit (between 6th-7th day 73 hours and 7 days after delivery).
Table 14. Third PNC visit (6th week)
Table 15. Postpartum danger signs for the mother and the baby.
Table 16. Diagnosis of Puerperal Fever.
Table 17. Classification of abnormal labor
Table 18. ALGORITHM FOR SCREENING AND TREATMENT OF ANEMIA DURING PREGNANCY.
Table 19. Events associated with feto-maternal hemorrhage and dose of Anti-D.
Table 20. Rates of HIV transmission during pregnancy, labor and delivery, and breastfeeding.
Table 21. Enhanced Post-natal Prophylaxis (e-PNP) for HIV Exposed Infants
Table 22. Dosage of Co-trimoxazole preventive therapy in infants and children
Table 23. Clinical findings of uncomplicated and complicated malaria.
LIST OF ANNEXES
Annex 1. Contact schedule, risk identification, list of interventions at each contact.

Annex 2. ANC INFORMATION GATHERING AND CLASSIFYING FORM.
Annex 3. Initial physical evaluation plus promotive and preventive care.
Annex 4. Postpartum Hemorrhage (PPH) Management Algorithm for Health Center
Annex 5. Algorithm for management of pregnant woman presenting with convulsion
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LIST OF FIGURES
Figure 1. ANC classification diagram.

Figure 2. Partograph
Figure 3. Stages of fetal descent through the pelvic cavity.
Figure 4. Perineal Support
Figure 5. Figure showing steps of Essential Newborn Care.
Figure 6. Steps in resuscitation
Figure 7. Neonatal resuscitation flow algorithm
Figure 8. Bimanual compression
Figure 9. Technique for compression of abdominal aorta
Figure 10. Manual replacement of placenta
Figure 11. Types of breech presentation.
Figure 12. Pinard’s maneuver.
Figure 13. Holding the baby.
Figure 14. Delivery of Arms and Shoulders.
Figure 15. Lovset’s Maneuver.
Figure 16. Classical method (delivery of posterior shoulder).
Figure 17. Mauriceau Smellie Veit Maneuver (MSV).
Figure 18. Face presentation
Figure 19. Brow presentation
Figure 20. Transverse lie
Figure 21. Types of occipito posterior positions.
Figure 22. The three tumors and ring of Bandl.
Figure 23. Flexion point.
Figure 24. Applying a vacuum cup.
Figure 25. Applying traction
Figure 26. Post partum contraception options for breast feeding women.
Figure 27. Post partum contraception options for non-breast feeding women.
Figure 28. Outline of the management of Rh D- negative pregnancy.
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TABLE OF CONTENTS
TABLE OF CONTENTS........................................................................................................................................ i
FORWORD ......................................................................................................................................................iii
ACRONYMS..................................................................................................................................................... iv
ACKNOWLEDGEMENT ......................................................................................................................................v
LIST OF CONTRIBUTERS ................................................................................................................................... vi
LIST OF TABLES .............................................................................................................................................. vii
LIST OF ANNEXES ........................................................................................................................................... vii
LIST OF FIGURES ............................................................................................................................................. ix
1. RESPECTFUL MATERNITY CARE..................................................................................................... 1

2. RAPID INITIAL ASSESSMENT AND MANAGING EMERGENCIES ..................................................... 5
MANAGING A PATIENT IN “SHOCK” ................................................................................................................ 8
MANAGING A PATIENT WITH DIFFICULTY IN BREATHING ...............................................................................10
3. PRECONCEPTION CARE ............................................................................................................... 12

4. ANTENATAL CARE ....................................................................................................................... 15
5. BLEEDING IN EARLY PREGNANCY ............................................................................................... 26
ABORTION .....................................................................................................................................................26
ECTOPIC PREGNANCY ....................................................................................................................................31
MOLAR PREGNANCY ......................................................................................................................................31
6. HYPEREMESIS GRAVIDARUM...................................................................................................... 33
7. ANTEPARTUM HEMORRHAGE (APH) .......................................................................................... 36
PLACENTAL ABRUPTION ................................................................................................................................36
PLACENTA PREVIA .........................................................................................................................................38
8. MULTIPLE PREGNANCY ............................................................................................................... 39

9. PREMATURE / PRE-LABOR RUPTURE OF MEMBRANES (PROM) ................................................ 41
10. NORMAL LABOR AND DELIVERY ................................................................................................. 44
MANAGEMENT DURING FIRST STAGE OF LABOR ...........................................................................................46
MANAGEMENT DURING SECOND STAGE........................................................................................................51
11. THIRD STAGE OF LABOR ............................................................................................................. 55

12. CARE FOR THE NEWBORN AT BIRTH .......................................................................................... 57
ESSENTIAL NEWBORN CARE (ENC) .................................................................................................................57
NEONATAL RESUSCITATION ...........................................................................................................................61
13. BASIC POSTPARTUM / POSTNATAL CARE ................................................................................... 65

14. POSTPARTUM HEMORRHAGE .................................................................................................... 70
PRIMARY PPH ................................................................................................................................................70
MANAGEMENT OF SECONDARY PPH..............................................................................................................74
15. PUERPERAL FEBRILE MORBIDITIES ............................................................................................. 76
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16. PSYCHOLOGICAL MORBIDITIES DURING PUERPERIUM .............................................................. 81
17. PRETERM LABOR ......................................................................................................................... 84
18. MALPRESENTATION .................................................................................................................... 87
BREECH PRESENTATION .................................................................................................................................88
FACE PRESENTATION .....................................................................................................................................94
BROW PRESENTATION ...................................................................................................................................94
TRANSVERSE LIE (SHOULDER PRESENTATION) ...............................................................................................95
COMPOUND PRESENTATION .........................................................................................................................96
19. MALPOSITIONS ........................................................................................................................... 97

OCCIPUT POSTERIOR POSITION ......................................................................................................................97
PERSISTENT OCCIPUT TRANSVERSE POSITION ................................................................................................98
20. PROLONGED AND OBSTRUCTED LABOR ................................................................................... 100

PROLONGED LABOR..................................................................................................................................... 100
OBSTRUCTED LABOR.................................................................................................................................... 101
21. UTERINE RUPTURE .................................................................................................................... 105

22. POST TERM PREGNANCY .......................................................................................................... 107
23. VACUUM DELIVERY................................................................................................................... 109
24. FAMILY PLANNING .................................................................................................................... 113
25. ANEMIA DURING PREGNANCY ................................................................................................. 117
26. MANAGEMENT OF Rh-D NEGATIVE PREGNANT WOMEN ........................................................ 120
27. HIV IN PREGNANCY ................................................................................................................... 123
28. HYPERTENSIVE DISORDERS IN PREGNANCY ............................................................................. 129
GESTATIONAL HYPERTENSION ..................................................................................................................... 130
PRE-ECLAMPSIA ........................................................................................................................................... 130
ECLAMPSIA .................................................................................................................................................. 131
29. URINARY TRACT INFECTION IN PREGNANCY ............................................................................ 134

30. MALARIA IN PREGNANCY ......................................................................................................... 136
REFERENCES ................................................................................................................................................141
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RESPECTFUL MATERNITY CARE
INTRODUCTION
Respectful Maternity Care (RMC) refers to care organized for and provided to all women in a
manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and
mistreatment, and enables informed choice and continuous support during pregnancy, labour and
childbirth, and postnatal period.
RMC is an attitude that permeates each word, action, thought, and non-verbal communication
involved in the care of women during pregnancy, childbirth, and the postnatal period. Provision
of RMC is in accordance with a human rights-based approach to reduce maternal and neonatal
mortality and morbidity. See table 1 below for categories of disrespect and abuse with
recommended standard of care.
Table 1. Categories of disrespect and abuse with recommended standard of care.
Category of
disrespect & Example for D&A Recommended standard of care
abuse
Physical abuse  Slapping, pinching,  Staff should conduct procedures devoid of physical
pushing, beating harm.
 Clients should be protected from emotional, physical
and sexual abuse.
Non-consented  Doing procedure and  Staff should take time to explain: procedures,
care /or providing diagnosis, progress, results and options.
medication without  Information should be given in an open and friendly
verbal or oral consent. manner and be encouraged to ask questions.
Non-  Lack of privacy  Women should never be exposed unnecessarily

confidential (laboring in public or during examinations.
care disclosure of patient  Staff should actively protect women’s privacy and
information) confidentiality.
 Staff should not discuss or disclose client
information to non-health care staff.
Non-dignified  Intentional  Staff should be polite and use appropriate language,
care (including humiliation, rough gestures in communicating with clients.
verbal abuse) treatment, shouting,  Curtains and screens should be used and clients
blaming, laughing at should be covered with linen when examined.
patient
 Not introducing self,
not calling patient by
name.
1
Category of
disrespect & Example for D&A Recommended standard of care
abuse
Discrimination  Discrimination based  Staff should provide all the required services to all
based on on age, ethnicity, clients equally.
attributes religion and finance
Abandonment  Women left alone  On arrival at facility every pregnant woman in labor
or denial of during labor and birth should be evaluated by skilled person immediately
care  Failure to provide  Every woman in labor should be attended, followed,
monitoring and delivered or referred if necessary.
intervene when
needed
Detention in  Detention of  Patient/ families should not be detained in health
facilities patient/family in facility after delivery due to payment related
health facility after reasons.
delivery usually due
to failure to pay.
POTENTIAL CONTRIBUTORS TO DISRESPECT AND ABUSE

 Service delivery related:
o Lack of standards, leadership and supervision.
o Lack of accountability mechanisms at health facility.
o Lack of appropriate drugs, supply and equipment.
 Provider related:
o Discriminatory behaviour against certain sub-groups of women based on ethnicity, age,
infectious disease status (e.g. HIV), financial and educational status of woman.
o Provider demotivation related to weak health systems (e.g. shortages of human
resources & professional development opportunities).
o Provider status (e.g. behavioral, physical and emotional status).
EFFECTIVE COMMUNICATION AND SUPPORTIVE CARE FOR RMC

Have effective communication:
 Speak in a calm quiet manner.
 Be sensitive to any cultural or religious considerations and respect her views.
 Ask the woman whom she would like to be present (accompany).
 Listen to what the woman and her family have to say and encourage them to ask and
express their concerns; try not to interrupt.
 Use supportive nonverbal communications such as nodding and smiling.
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 Answer the woman’s questions directly in a calm and understandable manner.
 If a woman must undergo a procedure; explain to her the nature of the procedure and
its risks and help to reduce her anxiety.
 Ask the woman to repeat back to you the key points to ensure her understanding.
Provide supportive care

 A woman should be made to feel as comfortable as possible when receiving care.
 Respect the woman’s choices and preferences including birthing position,
companionship during maternity care, procedures and treatment.
 Emotional and psychological support for patients (or family members) with
undesirable outcome (e.g. still birth).
 Provide adequate pain management options.
ORGANIZATIONAL CONSIDERATIONS
Staffing:
 There should be adequate number of competent and trained staff with appropriate skills
mix (health work force), working in multidisciplinary teams that are able to provide
respectful and continuous care to all women.
 There should be regular practice-based training on RMC provision to enable effective
delivery of RMC services that meet the social, cultural and linguistic needs of women
and orientation of new staff.
Supply:
 Health education materials in written or pictorial format, accessible and available in the
languages of the communities served by the health care facility.
 A standard informed consent form.
 Information (written or pictorial such as leaflets) for the woman and her companion.
 Essential medicines for maternal and new-born health care that is available in sufficient
quantities at all times.
Equipment:
Basic and adequate equipment for maternal and new-born health care that is available in sufficient
quantities at all times in the health facility.
Infrastructure:
The facility should ensure the presence of enhanced physical environment including:-
 Rooming-in to allow women and their babies to remain together.
 Clean, appropriately illuminated and well ventilated maternity service area that
maintains privacy, and are adequately equipped and maintained.
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 Continuous energy supply in the labor, childbirth and neonatal areas.
 Clean and accessible bathrooms for use by pregnant women, laboring and postnatal
mothers.
 Safe drinking water and a hand hygiene station with soap or alcohol-based hand rubs.
 Curtains, screens, partitions and sufficient bed capacity.
 Facilities for labor companions, including physical private space for the woman and her
companion.
Supervision and monitoring:

 Regular supportive supervision by labor ward/facility leaders.
 Staff meetings to review RMC practices.
 Easily accessible mechanism (e.g. a suggestion box) for service users and providers to
submit complaints and suggestions to management.
 Establishment of accountability mechanisms to prevent mistreatment or violations.
 Establishment of informed consent procedures.
Strengthening referral linkage:

Good-quality supervision, communication and transport linkage between facilities needs
to be established to ensure that referral pathways are efficient.
4
RAPID INITIAL ASSESSMENT AND MANAGING
EMERGENCIES
DEFINITION
Rapid initial assessment and emergency management means immediate identification and
recognition of specific problems for taking quick action to save the life of the patient during
arrival to the facility.
Implementing a rapid initial assessment scheme:

All staff at the health facility should perform a Quick Check of a woman who presents with an
emergency condition.
QUICK CHECK
 Look at the woman:
o Did someone carry her into the health institution? (possible sign of shock)
o Is there blood on her clothing or on the floor beneath her? (sign of bleeding in
pregnancy)
o Is she grunting or bearing down? (possible signs of advanced labor)
 Ask the woman or her companion whether she has or has recently had:
o Vaginal bleeding
o Severe headache / blurred vision
o Convulsion or loss of consciousness
o Difficulty breathing
o Fever
o Severe abdominal pain
o Labor pain
 If the woman has or recently had ANY of the above danger signs, or signs and symptoms
of advanced labor, immediately:
o Call for help
o Focus on the woman
o Do not leave the woman alone
RAPID INITIAL ASSESSMENT

Refer to table 2 below for approach in rapid initial assessment for selected danger signs.
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Table 2. Rapid initial assessment principles for selected danger signs.
Assess Danger signs Consider
Airway and LOOK FOR:

breathing • Cyanosis • Severe anemia
• Respiratory distress • Heart failure
• Pneumonia
EXAMINE: • Asthma
• Skin: pallor
• Lungs: wheezing or rales
Circulation EXAMINE:
(signs of • Skin: cold • Shock
shock) • Pulse: fast (110 or more) and weak
• Blood pressure: low (systolic less than
90 mm Hg)
Vaginal ASK IF: Early pregnancy:

bleeding (early • Pregnant, length of gestation • Abortion
or late • Recently given birth • Ectopic pregnancy
pregnancy or
• Placenta delivered • Molar pregnancy
after child
birth) Late pregnancy:
EXAMINE:
• Abruptio placentae
• Vulva: amount of bleeding, placenta
retained • Placenta previa
• Genital tract laceration • Ruptured uterus
• Uterus: atony After delivery:
• Bladder: full • Atonic uterus
• Tears of cervix and vagina
DO NOT DO A VAGINAL EXAM AT • Retained placenta
THIS STAGE • Inverted uterus
Unconscious ASK IF:

or convulsing • Pregnant
• Length of gestation • Eclampsia
• Malaria
EXAMINE:
• Epilepsy
• Blood pressure: high
• Tetanus
• Temperature: 38°C or more
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Assess Danger signs Consider
Fever ASK IF:
• Weak, lethargic • Urinary tract infection
• Frequent, painful urination • Malaria
EXAMINE: • Metritis
• Temperature: 38°C or more • Pelvic abscess
• Unconscious • Peritonitis
• Neck: stiffness • Mastitis
• Lungs: shallow breathing, consolidation • Complications of abortion
• Abdomen: severe tenderness • Pneumonia
• Vulva: purulent discharge
• Breasts: tender
Abdominal ASK IF: • Ovarian cyst/torsion

pain • Pregnant, length of gestation • Appendicitis
• Ectopic pregnancy
EXAMINE:
• Blood pressure: low (systolic less than • Possible term or preterm
90 mm Hg) labor
• Pulse: fast (110 or more) • Amnionitis
• Temperature: 38°C or more • Abruptio placentae
• Abdomen/Uterus: tender
• Ruptured uterus
EMERGENCY MANAGEMENT PRINCIPLES
Preventing emergencies
 Careful planning
 Following clinical guidelines / protocols
 Close monitoring of the woman
Responding to an emergency
Clinical team members should know their roles and their function. In addition they should
know:
 Clinical situations and their diagnosis and treatments.
 Drugs and their use, administration and side effects.
 Emergency equipments: how each function and how to use.
7
Initial management
In managing an emergency:
 Call for help.
 Do not leave the woman unattended.
 Have one person go for help and have another person gather emergency equipment and
supplies (e.g. oxygen cylinder, emergency kit).
 If the woman is unconscious, assess the airway, breathing and circulation.
 If shock is suspected, immediately begin treatment. Even if signs of shock are not
present, keep shock in mind as you evaluate the woman further because her status may
worsen rapidly.
 Position the woman lying down on her left side with her feet elevated.
 Loosen tight clothing.
 Perform a quick examination including vital signs and skin color.
 Estimate the amount of blood lost and assess symptoms and signs.
 Talk to the woman and help her to stay calm. Ask what happened and what symptoms
she is experiencing.
MANAGING A PATIENT IN “SHOCK”
INTRODUCTION
Shock is characterized by failure of the circulatory system to maintain adequate perfusion of
vital organs. Suspect or anticipate shock if at least one of the following is present:
 Bleeding in early pregnancy
 Bleeding in late pregnancy or labor
 Bleeding after childbirth
 Infection (e.g. unsafe or septic abortion, amnionitis, metritis, pyelonephritis)
 Trauma (e.g. injury to uterus or bowel during abortion, ruptured uterus, tears of genital
tract).
DIAGNOSIS
Diagnose shock if the following symptoms and signs are present:
 Fast, weak pulse (110 per minute or more)
 Low blood pressure (systolic less than 90 mmHg)
 Other symptoms and signs of shock include:
o Pallor (inner eyelid, palms or around mouth)
o Cold and clammy skin
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o Rapid breathing (30 breaths per minute or more)
o Anxiousness, confusion or unconsciousness
o Decreased urine output (less than 30 ml per hour).
MANAGEMENT
 CALL FOR HELP. Urgently mobilize all available personnel.
 Assess the airway, breathing and circulation.
 Turn the woman onto her side to minimize the risk of aspiration.
 Start an IV infusion (two if possible) using a large-bore (16-gauge or largest available)
cannula or needle.
 Collect blood for haemoglobin and bedside clotting test just before infusion of fluids.
o Rapidly infuse IV fluids (normal saline or Ringer’s lactate) initially at the rate of
1 L in 15–20 minutes.
o Give at least 2 L of the fluids in the first hour. This is over and above fluid
replacement for ongoing losses.
NOTE: A more rapid rate of infusion is required in the management of shock resulting
from bleeding. Aim to replace 2–3 times the estimated blood loss.
 Give oxygen at 6–8 L per minute by mask or nasal cannula.
 Elevate the legs to increase return of blood to the heart (if possible, raise the foot end of
the bed) and keep the woman warm.
 Monitor vital signs (every 15 minutes) and blood loss.
 Catheterize the bladder and monitor fluid intake and urine output.
Determining and managing the cause of shock

Determine the cause of shock after the woman is stabilized.
1. If heavy bleeding is suspected as a cause of shock:
 Take steps simultaneously to stop bleeding (e.g. oxytocics, uterine massage, NASG,
bimanual compression, aortic compression).
 Reassess the woman’s condition for signs of improvement.
 Consider referral for further management.
2. If infection is suspected as the cause of shock:
 Give the woman a loading combination of antibiotics to cover aerobic and anaerobic
infections:
o Ampicillin 2 g IV PLUS Gentamicin 5 mg/kg body weight IV PLUS
metronidazole 500 mg IV.
 Refer urgently.
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NOTE: Continue antibiotic administration until she reaches the hospital.
3. If trauma is suspected as the cause of shock, refer for surgical intervention.
Reassessment:
 Reassess the woman’s response to the IV fluids within 30 minutes to determine if her
condition is improving. Signs of improvement include:
o Stabilizing pulse (rate of 90 per minute or less).
o Increasing blood pressure (systolic 100 mm Hg or more).
o Improving mental status (less confusion or anxiety).
o Increasing urine output (30 mL per hour or more).
 If the woman’s condition improves:
o Adjust the rate of infusion of IV fluids to 1 L in 6 hours.
o Continue management for the underlying cause of shock.
o If the woman’s condition fails to improve or stabilize, urgent referral.
Further management:
 Continue to infuse IV fluids, adjusting the rate of infusion to 1 L in 6 hours and maintain
oxygen at 6–8 L per minute.
 Closely monitor the woman’s condition.
 Perform laboratory tests including hematocrit, blood group and Rh, and consider referral
/ consultation for transfusion if needed.
MANAGING A PATIENT WITH DIFFICULTY IN BREATHING
GENERAL MANAGEMENT:
 Make a rapid evaluation of the general condition of the woman including vital signs.
 Turn the woman on her left side.
 Start IV infusion.
 Give oxygen at 4–6 L per minute by mask or nasal cannula.
 Obtain haemoglobin.
DIAGNOSIS
Refer to table 3 below for diagnostic approach of a woman who presents with difficulty of
breathing.
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Table 3. Diagnostic approach of a patient with difficulty in breathing.
Symptoms and signs typically Symptoms and signs

Probable diagnosis
present sometimes present
• Difficulty in breathing • Lethargy and fatigue • Severe anemia

• Pallor of conjunctiva, tongue, • Flat or concave nails
nail beds and/or palms
• Haemoglobin 7g /dL or less
• Hematocrit 20% or less
• Symptoms and signs of severe • Oedema • Heart failure due to

anemia • Cough anemia
• Rales
• Swelling of legs
• Enlarged liver
• Prominent neck veins
• Difficulty in breathing • Irregular heart beat • Heart failure due to heart

• Diastolic murmur and/or • Enlarged heart disease
• Harsh systolic murmur with • Rales
palpable thrill • Cyanosis (blueness)
• Cough
• Swelling of legs
• Enlarged liver
• Prominent neck veins
• Difficulty in breathing • Congested throat Rapid • Pneumonia
• Fever breathing
• Cough with expectoration • Rhonchi / rales
• Chest pain
• Difficulty in breathing • Cough with expectoration • Bronchial asthma

• Wheezing • Rhonchi / rales
• Difficulty in breathing • Rales • Pulmonary oedema
• Hypertension • Frothy cough associated with pre-
eclampsia
• Proteinuria
a Withhold fluids and give frusemide 40 mg IV once.
SPECIFIC MANAGEMENT
For specific management of each condition refer to appropriate sections in this document and
other relevant national protocols.
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PRECONCEPTION CARE
DEFINTION
Preconception care is the provision of biomedical, behavioral and social health interventions to
women and couples before conception occurs to increase the chance of having good obstetric
outcome.
OBJECTIVE
• Management of long-term health conditions that affect pregnancy and fetal outcomes.
• Assistance in ceasing risky behaviors that affect pregnancy and fetal outcomes.
• Promoting healthy behaviors.
INTERVENTIONS
Pre-conception care comprises a range of interventions aimed at identifying and modifying
medical, behavioral and social risks during reproductive years.
Reproductive planning
• Reproductive planning helps to prevent unintended pregnancy, age-related infertility and
fetal teratogen exposure. It may also improve health and pregnancy outcomes.
• Offer appropriate contraception advice for those not desiring pregnancy or until chronic
medical conditions are stabilized.
Screening for modifiable risk factors

• Take a thorough history, assessing historical and ongoing risks that may affect future
pregnancies.
• Reproductive history may provide important clues about future pregnancy risks.
o Poor obstetric outcome (early neonatal death, still birth and birth defects,
particularly neural tube defects)
o History of previous gestational diabetes mellitus
o Previous history of preterm birth
o Previous history of small for gestational age baby
• Assessment of pre-existing medical conditions (hypertension, diabetes, epilepsy, renal
disease, autoimmune conditions, cardiac and other conditions).
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Management of medical conditions and medications
There are specific medical conditions associated with adverse pregnancy outcomes if untreated
or treated poorly.
A. Stabilization or referral to hospital for stabilization of chronic medical conditions prior to
conception
• Hypertension should be controlled.
• Diabetes mellitus: For women with type 1 or type 2 diabetes, good glycemic control
should be achieved before conception.
• Asthma: Poorly controlled asthma tends to worsen during pregnancy.
• Thromboembolism: Women with a history of thromboembolism have an increased risk of
recurrence during pregnancy.
• Hypothyroidism: Women with hypothyroidism require increased doses of thyroxine early
and throughout pregnancy; this is especially important during the first trimester.
• Autoimmune disease: Patients should be counseled that the best time to attempt
conception is during periods of inactive disease.
• Medical conditions which are contraindications to pregnancy (e.g. primary pulmonary
hypertension).
B. Review medications, over-the-counter preparations and vitamins
Any medication with teratogenic potential should be stopped and replaced, or referred to hospital
as appropriate. Some of the known teratogenic medications include:-
• Angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists.
• Isotretinoin (Accutane): used for therapy of a variety of skin conditions.
• Anticonvulsant therapy particularly hydantoin or valproic acid.
• Vitamin A supplements.
Immunizations and infectious diseases
• Screening for sexually transmissible infections (STIs) where indicated.
• Discuss with the patient about TORCH infections (e.g. syphilis) including methods to
reduce exposure and transmission.
• Screen for hepatitis B and C and advice on vaccination if hepatitis B test is negative.
• Vaccination for diphtheria and tetanus.
• Avoid conceiving for at least 28 days after receiving any live attenuated vaccinations such
as the measles, mumps and rubella (MMR) vaccine.
Supplementations
Folic Acid:
• All women, from the moment they begin trying to conceive until 12 weeks of gestation,
are recommended to take a folic acid supplement (400 μg folic acid daily).
13
 Women who have had a foetus diagnosed as affected by a neural tube defect or have
given birth to a baby with a neural tube defect should take high-dose supplementation (5
mg folic acid daily); and be advised to increase their food intake of folate.
Iron:
• Women with iron deficiency identified by blood tests should take oral supplement with at
least 60 mg of elemental iron daily.
Lifestyle and Behaviors:

• Caffeine: limit coffee intake
• Smoking, alcohol and illicit drugs: abstinence is advised in the preconception period and
during pregnancy.
• Weight control:
o Overweight (BMI 25–29.9 kg/m2) and obese (BMI >30 kg/m2) women should
be advised to lose 5–10 % of their body weight prior to conception.
o Underweight women should be provided dietary advice and advice on behavior
techniques to help them achieve a target weight range.
• Exercise: Moderate-intensity physical activity is recommended (for 150 minutes per week
or 30 minutes per day on most days).
Psychosocial aspects:
• Screen for domestic violence.
• Screen for mental health conditions.
• Treat, link to appropriate care or refer identified conditions as required.
NOTE: Women should also receive cervical cancer screening and breast examination
during preconception care.
14
ANTENATAL CARE
DEFINITION
ANC is defined as the complex of interventions that a pregnant woman and adolescent girl
receive from skilled health care professionals in order to ensure the best health conditions for
both mother and baby during pregnancy.
PURPOSE
ANC reduces maternal and perinatal morbidity and mortality through:
• Screening, diagnosis and management of the risk factors and pregnancy-related
complications.
• Identification of women and girls at increased risk of developing complications.
• Provides an important opportunity to prevent and manage concurrent diseases through
integrated service delivery.
• Ensuring referral to an appropriate level of care.
COMPONENTS
• Health promotion and disease prevention
• Screening, diagnosis and management or referral for disease
• Birth planning and complication readiness.
ANC CONTACTS
Antenatal care models with a minimum of eight contacts are recommended. The first contact
is scheduled to take place in the first trimester (up to 12 weeks of gestation), two contacts
scheduled in the second trimester (at 20 and 26 weeks of gestation) and five contacts scheduled
in the third trimester (at 30, 34, 36, 38 and 40 weeks). The details are described below in Annex
1.
During each ANC contact, gather and interpret information (History, P/E, Investigations),
classify the type of care (basic versus specialized), develop care plan, implement care plan
(take action) and evaluate care plan.
THE FIRST ANTENATAL CONTACT
Confirmation of pregnancy and gestational age

Confirmation of pregnancy, complete assessment of gestational age (LNMP, EDD and
Gestational age) are made at the first antenatal visit.
15
• Last menstrual period is valid if the woman is sure of her dates and reliable (three
consecutive menses and no use of hormonal contraceptives)
• Ultrasound scan for gestational age estimation for women who are unsure of dates with
SFH measurement less than 24 weeks.
History taking
Take a full and relevant history including current pregnancy, previous pregnancies (any
complications and outcomes), medical conditions (including psychiatric problems, and
previous operations), intimate partner violence, familial and genetic disorders, allergies, use of
medications, use of substances (alcohol, tobacco and other substances), family and social
circumstances.
Physical examination
Do a general examination including weight, height, heart rate, colour of mucous
membranes/conjunctivae, blood pressure, check for oedema, and palpation for lymph nodes.
Do a systemic examination including teeth and gums, breasts, thyroid, and heart and lung
examination.
Examine the abdomen including inspection and palpation of the pregnant uterus; measurement
of the symphysis-fundal height (SFH), presentation of the fetus (third trimester) and
auscultation of the fetal heart beat (after 20 weeks)
Investigations
• Determine the essential screening investigations (Hemoglobin, HIV test, urine analysis,
blood group, VDRL, HBsAg) (see annex 1). Hemoglobin is preferably determined with
hemoglobinometer or complete blood count (when available).
• Ultrasound scan before 24 weeks of gestation
• Indirect coomb’s test for Rh negative women.
• Urine test
o Urine strip test and microscopy (albumin, sugar, ketone, WBC etc.)
o Urine midstream gram stain to diagnose asymptomatic bacteriuria (ASB)
Advice and counseling:

Certain essential information should be provided to all pregnant women. This includes:
• Danger signs and symptoms of pregnancy: Severe headache, blurring of vision,
abdominal pain (not discomfort), leakage of liquor from the vagina, vaginal bleeding
and decreased fetal movements. A woman that experiences any of these symptoms
should come to health facility immediately.
• Self-care in pregnancy: Diet and exercise, personal hygiene and breast care, avoid
unnecessary use of medications, limit use of caffeine, avoid substance use (alcohol,
tobacco and recreational drugs)
16
• Birth preparedness and complication readiness (delivery plan): At the end of her ANC
contact, all pregnant women should be given a provisional delivery plan: The expected
date of delivery, the expected place of delivery, the expected mode of delivery, a
transport plan for emergency or delivery (including important contact numbers) and the
practice of home delivery should be discouraged.
• Institutional delivery: Advice the patient about the importance of institutional delivery
• Maternity waiting home: If mothers are leaving far from the delivery centre, they will
be admitted to maternity waiting home which is located near or within health centers in
their final weeks of pregnancy to bridge the geographical gap in obstetric care.
• Newborn/infant care: Plans for infant feeding and techniques, details of follow up care,
immunization and where this can be obtained.
• Family planning: Counsel on future pregnancies and use of postpartum contraception.
Assessment and planning

The final assessment is interpreting the gathered information. It involves making diagnosis and
evaluating for presence of any risk factors and classifying the type of care. The final assessment
includes
• Risk factor identified (a list of risk factors is provided in annex 2 below)
• The best estimate of gestational age
• A plan for management or appropriate referral for any problems.
Use the ANC classifying form in the FMOH integrated pregnancy, labour, delivery, newborn
and postnatal care card for more detail information to gather detailed information during first
visit (annex 2 and annex 3).
NOTE: If any ONE or more of the above risk factors are identified, the woman is eligible for
specialized antenatal care (require closer follow up or referral to higher facility). Those
classified under basic care needs a minimum of eight contacts while those having pre-existing
or newly developed problems will be followed in a specialized care setting. Refer to figure 1
below for the classification algorithm.
17
GATHER INFORMATION
(All Women)
• Interpret
• Identify Pre-existing or Developing Problems
No Classify specialized care Yes
• Specialized care
Transfer of patients
Basic Care • Additional investigations
throughout ANC
and follow ups, including
referral care
Figure 1. ANC classification diagram.
SUBSEQUENT ANTENATAL VISITS

Content of subsequent antenatal visits are
• Ask about general well-being, fetal movements, danger symptoms and any problems.
• Check the blood pressure, heart rate, weight and color of the mucous membranes and
conjunctivae.
• Measure the symphysis-fundal height (SFH) and compare with previous measurements.
• Palpate the presenting part after 34 weeks of gestation
• One step screening using 75 gm glucose at 24 to 28 wks, if the woman is high risk for
diabetes. If test result is abnormal refer for further evaluation and management.
• Repeat investigations
o Repeat HIV counseling and testing during third trimester preferably between28
to 36 weeks for those tested negative at the initial visit
o Repeat blood tests: Hgb at 32 and 38 weeks.
o Repeat urine test at 26 to 34 weeks
• Repeat information for danger signs pregnancy, and review delivery and transport plans,
as well as feeding and contraception choices.
• Document the detail contact schedule, risk identification, list of intervention at each
contact.
MEDICATIONS AND VACCINES
18
• Td vaccination - two doses, on the first visit and four weeks after the initial dose
(regardless of the gestational age of her first contact)
• Iron and folic acid supplements: daily oral iron and folic acid supplementation with 30
mg to 60 mg of elemental iron and 400 μg (0.4 mg) of folic acid
• Daily calcium supplementation: 1.5–2.0 g oral elemental calcium starting from 14 weeks
of gestation
• If there is asymptomatic bacteriuria give amoxicillin 500 mg PO TID for seven days.
• Preventive antihelminthic treatment- Preventive chemotherapy (deworming), using
single-dose albendazole (400 mg) or mebendazole (500 mg) is recommended after the
first trimester
• If indirect coomb’s test is negative, administer anti-D immunoglobulin at 28 weeks and
immediately after delivery after cord blood check-up.
PHYSIOLOGICAL SYMPTOMS IN PREGNANCY
Nausea and vomiting, heartburn, leg cramps, low back and pelvic pain, constipation, varicose
veins and edema are common during pregnancy. Refer to the following box for options of
available interventions.
WOMAN-HELD CASE NOTES
Intervention for common physiological symptoms based on a woman’s preferences

and available options.
Nausea and vomiting – Ginger, chamomile, vitamin B6 are recommended for the relief
of nausea in early pregnancy.
Heartburn– Advice on diet and lifestyle (avoidance of large, fatty meals and alcohol,
cessation of smoking, and raising the head of the bed to sleep) is recommended to prevent
and relieve heartburn in pregnancy. Antacid preparations can be used depending on the
women’s symptoms.
Leg cramps – Magnesium, calcium or non-pharmacological treatment options can be
used for the relief of leg cramps in pregnancy.
Low back and pelvic pain – Regular exercise throughout pregnancy, treatment options
such as physiotherapy, support belts can be used.
Constipation– dietary modification, high fibre diet, regular bowel habit and adequate
fluid intake.
Varicose veins and oedema– Non-pharmacological options, such as compression

stockings, leg elevation and water immersion.
19
It is recommended that each pregnant woman carries her own case notes during pregnancy to
improve continuity, quality of care and her pregnancy experience.
This standardized document is the principal record of the pregnancy and it must be completed
at each antenatal clinic visit and retained by the mother until delivery, after which it will be
kept at the place of confinement or final referral.
Record of attendance, risk factors / results of special investigations, appointment date and
information on danger signs of pregnancy are components of Woman-held case notes.
LINKAGE AND REFERRAL
Antepartum referral
Pregnant women who are eligible for referral to higher facilities for specialized antenatal care
and closer follow up or hospital delivery during antepartum period include those with:
Obstetric history:
• Previous stillbirth/ previous neonatal death
• Previous low birth weight baby
• Previous fetal macrosomia (> 4kg)
• Previous pregnancy admission for hypertension or pre-eclampsia/eclampsia
• Previous caesarean section/ previous myomectomy
• Previous cone biopsy / previous cervical cerclage
Current pregnancy:
• Diagnosed or suspected multiple pregnancy

• Age <16 years/ Age ≥ 35 years
• Rhesus isoimmunization in previous or current pregnancy
• Pregnancy beyond 41 weeks
• Vaginal bleeding
• Pelvic mass
• Systolic blood pressure ≥ 140 mmHg and/or diastolic pressure ≥ 90 mmHg
General medical conditions:
• Diabetes mellitus, cardiac disease, kidney disease, epilepsy, asthma on medication,

active tuberculosis, known substance abuse including alcohol, any severe medical
condition
• HBsAg positive.
Intrapartum referral
Risk factors requiring hospital delivery:
20
• High risk of postpartum hemorrhage
• Severe anemia and anemia not responding to iron tablets
• Large or small for date uterus
• Breech or transverse lie
• Extensive vulvar warts that may obstruct vaginal delivery
• Abnormal glucose screening (GTT or random blood sugar)
• Reduced fetal movements after 28 weeks
• Further risk factors that arise during antenatal care
21
Annex 1. Contact schedule, risk identification, list of interventions at each contact.
Eight schedule of ANC contacts
(weeks of gestation)
Contents of Care st nd rd
1 2 3 4th 5th 6th 7th 8th
12 20 26 30 34 36 38 40
Date of contact
Gestational age
Present Pregnancy History (complaint)
History
Past Pregnancy History

Medical History and Surgical History
Mental Health
Family/Social History
General Appearance
Physical Examination
Blood pressure
Weight
Pallor
Breast
Chest
Abdominal Fundal height (wks)
examination Fetal heart beat
Presentation
Pelvic assessment (as required/indicated)
Ultrasound (up to 24 weeks of gestation)
Hemoglobin
Blood group, RH
Investigations
RPR/VDRL
HIV (PITC)
HBsAg
Urine test
Screening for active TB for HIV positives
Indirect coomb’s test for RH negatives
75 gm oral glucose test (for those at risk)

22
Eight schedule of ANC contacts (weeks of gestation)
Contents of Care
1st 2nd 3rd 4th 5th 6th 7th 8th
12 20 26 30 34 36 38 40
Date of contact
Preventive anti-helminthic treatment
Medications & vaccines
Malaria prevention with ITN, and early

diagnosis and treatment
Td vaccination
Anti-D immunoglobulin at 28 weeks (for
those unsensitised RH negatives)
Iron and folic acid supplements
Daily calcium supplementation
F
Nutrition/healthy eating
Advice and counselling
PMTCT counselling and testing

Family planning counselling
Breast feeding counselling
Hygiene
Avoidance of harmful traditional practices
Reduce caffeine intake
Gender based violence specially IPV
Birth Preparedness and Complication
Readiness plan
Assessment (diagnosis, danger signs
identified)
Action taken
Next Appointment
Name and Signature
23
Annex 2. ANC INFORMATION GATHERING AND CLASSIFYING FORM.
Date: _______ ANC Reg. No: _________ Medical Record Number (MRN):___________
Name of Client: ____ _______ Name of Facility: _______
Woreda:__________ Kebele:_________ House No: Age (Years):_________
LMP: / / EDD:____/____/
Gravida: Para:________ Number of children alive:_______ Marital Status:
INSTRUCTIONS to Fill Classifying form: Answer all of the following questions by placing a
cross mark in the corresponding box.
OBSTETRIC HISTORY No Yes
1. Previous stillbirth or neonatal loss?
2. History of 3 or more consecutive spontaneous abortions?
3. Birth weight of last baby > 4000g
4. Last pregnancy: hospital admission for hypertension or pre-
eclampsia/eclampsia?
5. Previous surgery on reproductive tract? (Myomectomy, removal of septum,
fistula repair, cone biopsy, CS, repaired uterine rupture, cervical cerclage)
CURRENT PREGNANCY No Yes

6. Diagnosed or suspected multiple pregnancy?
7. Age less than 16 years?
8. Age more than 35 years?
9. Isoimmunization Rh (-) in current or in previous pregnancy
10. Vaginal bleeding
11. Pelvic mass
12. Systolic blood pressure ≥ 140 mmHg and/or diastolic pressure ≥ 90 mmHg,
GENERAL MEDICAL No Yes
13. Diabetes mellitus
14. Renal disease
15. Cardiac disease
16. Chronic Hypertension
17. Known 'substance' abuse (including heavy alcohol drinking, Smoking)
18. Any other severe medical disease or condition TB, HIV, Ca, DVT...
A "Yes" to any ONE of the above questions (i.e., ONE shaded box marked with a cross) means
that the woman is not eligible for the basic component of the new antenatal care mode and
requires closer follow up or referral to specialty care. If she needs more frequent ANC visits use
and attach additional recording sheets.
24
Table5.2
Annex 3. Initial physical evaluation plus promotive and preventive care.
Gynecologic Counseling / testing, HIV + care and

General examination
examination follow up
General Appearance Danger signs in

____________________ Y N
pregnancy and delivery
Pallor Y N Vulvar Y N
Birth preparedness
ulcer Y N
advised
Jaundice Y N Pelvic Y N MOTHER HIV test
mass Y N
accepted
HIV test result _________

Chest Y N Uterine ________
abnormality size wks. HIV test result received
with post-test Y N
counseling
Cervical Y N
Counseled on Infant Y N
Lesion
Heart Y N Referred for care,
abnormality Y N
treatment and support
PARTNER HIV test Y N
Partner test result _________
25
BLEEDING IN EARLY PREGNANCY
DEFINITION
Bleeding in early pregnancy is vaginal bleeding which occurs during the first 28 weeks of
pregnancy.
CAUSES
 Abortion
 Ectopic pregnancy
 Molar pregnancy
 Local causes
ABORTION
DEFINITION
Abortion is termination of pregnancy before viability (less than gestational age of 28 weeks or
a weight of fetus less than 1000 grams).
CLASSIFICATION
1. Based on gestational age:

 1st trimester abortion (less than or equal to 12 weeks of gestation)
 2nd trimester abortion (12 to 28 weeks of gestation)
2. Based on causes:
 Spontaneous abortion: is when miscarriage occurs by itself, without any external
aid.
 Induced abortion: is medical or surgical termination of pregnancy before the time
of fetal viability.
o Safe abortion: is defined as a procedure performed by a person having
necessary skills and in an environment which fulfils the minimum medical
standards.
o Unsafe abortion: is defined as a procedure performed either by persons lacking
necessary skills or in an environment lacking the minimum medical standards
or both.
26
3. Based on clinical stage:
 Threatened abortion (pregnancy may continue)
 Inevitable abortion (pregnancy will not continue and will proceed to incomplete/
complete abortion)
 Incomplete abortion (products of conception are partially expelled)
 Complete abortion (products of conception are completely expelled)
 Missed abortion (fetal death without expulsion of the fetal parts)
NOTE: Septic abortion is any type of abortion complicated by infection.
DIAGNOSIS
Symptoms and signs:

 Symptoms and signs typically present are shown below in table 4.
Investigations:
 Hematocrit
 Blood group and Rh
 Depending up on the condition the following investigations may be done:-
o Urine hCG test
o Ultrasound
MANAGEMENT
The type of management depends on the type of abortion, gestational age and clinical
condition. It can be observation, uterine evacuation (medical abortion or MVA) or referral. The
diagnosis and management approach for abortion is summarized below in table 4.
27
Table 4. Summary of approach for diagnosis and management of abortion.
Symptoms and signs Symptoms and signs sometimes Probable

Management
typically present present diagnosis
• Light bleeding o Cramping / lower abdominal pain Threatened  Advise to avoid strenuous activity & sexual intercourse
• Closed cervix o Uterus softer than normal abortion  Bed rest is not necessary
 If bleeding stops, follow at ANC
• Uterus corresponds to  If bleeding continues or aggravates, manage/ refer
dates
• Heavy bleeding o Cramping / lower abdominal pain Inevitable  If bleeding occurs in pregnancy less than 12 weeks perform
abortion MVA or MA (if ≤9 weeks)
• Dilated cervix o Tender uterus
 If bleeding occurs in pregnancy greater than 12 weeks: secure IV
• Uterus corresponds to o No expulsion of products of line (normal saline or Ringer ‘s lactate) and refer
dates conception
o Leakage of liquor
• Heavy bleeding o Cramping / lower abdominal pain Incomplete  If bleeding occurs in pregnancy less than 12 weeks, evacuate the
abortion uterus with MVA or MA (if ≤9 weeks)
• Dilated cervix o Partial expulsion of products of
conception  If bleeding occurs in pregnancy greater than 12 weeks: secure IV
• Uterus smaller than dates line (normal saline or Ringer ‘s lactate) and refer
• Light bleeding o Light cramping / lower abdominal Complete  Evacuation of the uterus is usually not necessary
pain abortion  Observe for heavy bleeding
• Closed cervix
 Reassure the woman
• Uterus smaller than dates o History of expulsion of products of
conception  Ensure follow-up of the woman after treatment
• Uterus softer than normal  Counsel on family planning
 Do ultrasound for confirmation (if available)
• Pregnancy symptoms o Brownish vaginal discharge Missed  Confirm diagnosis with ultrasound
absent o Cervix closed
abortion  If less than 12 weeks MVA or MA (if ≤9 weeks)
• Uterine size smaller than  If more than 12 weeks refer
dates
a. Light bleeding: takes longer than 5 minutes for a clean pad or cloth to be soaked.
b. Heavy bleeding: takes less than 5 minutes for a clean pad or cloth to be soaked.
Obstetrics Management Protocol for Health Centers. MOH, Ethiopia. 28

MEDICAL ABORTION
Medical abortion (MA) is termination of pregnancy using drugs (Mifepristone and
Misoprostol). See table 5 below for the regimens / doses of medical management as outpatient.
Table 5. Medical management regimens for abortions ≤ 9 weeks of gestation.
Safe Abortion Care (SAC) Incomplete Abortion Missed Abortion
• Mifepristone 200 mg PO • Misoprostol 600 • Misoprostol 600 mcg

day one mcg PO buccal/ sublingual (may be
repeated every 3 hours for
AND OR two additional doses)
• Misoprostol 800 µg • Misoprostol 400 OR
vaginal/ buccal/ sublingual mcg buccal
36 to 48 hours later /sublingual • Misoprostol 800 mcg
vaginally
POST ABORTION CARE

 Post abortion family planning:
o All clients with post abortion and safe abortion care should be counselled on all
contraception options before, during and after the procedure as part of abortion care.
o IUCD can be used immediately after both medical (after confirmation of complete
expulsion) and surgical abortion but infections and severe anemia should be ruled
out.
o Hormonal contraception (implants, injectable and pills) can be used immediately
after the procedure.
o Condoms can be used immediately.
 Rh-immunoglobulin (Anti-D) should be administered to all Rh-negative un-sensitized
women within 72 hours.
 Identify any other reproductive health service that the woman might need. For example,
some women may need:
o Treatment for sexually transmitted infections
o Cervical cancer screening
o A tetanus prophylaxis or tetanus booster
29
COMPLICATIONS
Diagnosis (sign and symptoms) and management of complications related to abortion is shown
below in table 6.
Table 6. Diagnosis and management of complications related to abortion.
Symptoms and Signs Complication Management
• Chills or sweats (rigors) Sepsis Antibiotics* as soon as

• Fever possible before
attempting manual
• Foul smelling vaginal discharge
vacuum aspiration
• Rebound tenderness
• Tender uterus
*continue antibiotics
• Abdominal/ uterine tenderness
until the woman is fever-
• Slightly low blood pressure free for 48 hours.
• Fast weak pulse (110 or more) Shock Refer management of

• Hypotension (systolic < 90 mmHg) shock on page -8.
• Pallor of the conjunctiva and buccal

mucosa or palms
• Sweating
• Fast breathing (30 or more breaths
per minute)
• Anxiousness, confusion or
unconsciousness
• Nausea / vomiting Intra-abdominal Refer urgently.

• Shoulder pain injury
• Fever
• Abdominal pain, cramping
• Distended abdomen
• Decreased bowel sounds
• Tense and hard abdomen
• Rebound tenderness
• Observation of bowel content,
omental fat per vagina
30
ECTOPIC PREGNANCY
DEFINITION
An ectopic pregnancy is implantation of a fertilized ovum outside the uterine cavity.
RISK FACTORS
• History of STI / PID
• History of ectopic pregnancy
• Prior tubal surgery
• History of infertility
DIAGNOSIS
• Symptoms and signs
o Amenorrhea
o Vaginal bleeding
o Abdominal / pelvic pain
o Fainting
o Signs and symptoms of shock
o Abdominal tenderness / rebound tenderness
o Closed cervix
o Uterus slightly larger than normal
o Tender adnexal mass
o Cervical motion tenderness
• Imaging (ultrasound)
MANAGEMENT
• Open IV line/s and manage if there is shock.
• Refer urgently.
MOLAR PREGNANCY
DEFINITION
Molar pregnancy is an abnormal proliferation of chorionic villi.
31
CLASSIFICATION
• Complete mole
• Partial mole
DIAGNOSIS
• Signs and symptoms:
o Nausea / vomiting
o Vaginal bleeding
o Partial expulsion of products of conception, which resemble grapes (vesicles)
o Cramping / lower abdominal pain
o Uterus larger than dates
o Uterus softer than normal
o No evidence of a fetus (complete mole)
o Hyperthyroidism
o Preeclampsia before 20 weeks of gestation
• Investigation:
o CBC
o Blood group and Rh
o Serum ß-hCG (preferably) otherwise urine hCG
o Ultrasound
MANAGEMENT
• Open an IV line and refer.
32
HYPEREMESIS GRAVIDARUM
DEFINITION
Hyperemesis Gravidarum (HG) is severe form of nausea and vomiting during pregnancy
resulting in dehydration and weight loss.
RISK FACTORS
 Multiple pregnancy
 Previous history
 Family history
 Young age
 Primigravity
 Molar pregnancy
DIAGNOSIS
Signs and symptoms:
 Severe nausea and vomiting
 Dehydration: Loss of skin elasticity, sunken eyeballs, dry mucus membranes and lips
 Vital sign derangement
 Confusion
 Fainting
 Weight loss (more than 5%)
 Symptom and signs of complications
NOTE: The diagnosis of hyperemesis is considered in the presence of severe nausea and
vomiting after exclusion of other causes of nausea and vomiting during pregnancy.
Investigations:
 Urinalysis
 Stool exam
 CBC
 RBS
 Pelvic ultrasound
DIFFERENTIAL DIAGNOSIS (DDX)

 Peptic ulcer disease
33
 Pyelonephritis
 Gastroenteritis
 Hepato-biliary diseases (hepatitis, cholecystitis)
 Diabetic ketoacidosis
MANAGEMENT
Mild to moderate cases
 Ketonuria +2 or less
 Diagnosis confirmed
 Signs of dehydration
IV fluids / medications
 Infuse the first litre over 1-2 hours then 1000mls over 4 hours (2 Bags over 5 to 6 hrs),
followed by further assessment, including urine ketone testing.
 Discharge the patient from outpatient care if improved within 24 hours with PO
medications and dietary advice.
Or
 Refer the woman if:-
o Ketonuria above +2
o Persistent vomiting / failed OPD management
PO Medications
 Vitamin B6 (pyridoxine):- 10 – 25 mg PO BID-QID and Meclizine 25 mg PO TID, or

 Metoclopramide:- 5 - 10 mg PO TID, or
 Promethazine:- 12.5 - 25 mg PO TID to QID, or
 Chlorpromazine 12.5 mg IM BID
Dietary Advice:
 Avoid full or empty stomach.
 Restriction of coffee, and spicy, odorous, fatty, acidic and overly sweet foods.
 Advise on taking Ginger containing preparations.
 Preferably take protein rich, salty, low fat, bland and dry snacks/meals (e.g. nuts,
pretzels (derek kita, dabo kolo)).
 Encourage fluid intake (better tolerated if cold, clear, and carbonated or sour).
 Advise on taking peppermint containing products (candy, chewing gum) as it can
reduce postprandial nausea.
34
 Advise not to take drugs that may cause nausea and vomiting, e.g. iron supplement
should be temporarily discontinued.
 Counsel on avoiding of environmental triggers: - stuffy rooms, strong odors (e.g.
perfume, chemicals, food, and smoke), heat, humidity, noise, and visual or physical
motion (e.g. flickering lights, driving) should be avoided.
NOTE: Severe cases (weight loss > 5%, ketonuria above +2, persistent vomiting) of hyperemesis
gravidarum need inpatient treatment and should be referred to a hospital.
COMPLICATIONS
Maternal Fetal
 Esophageal tear or rupture  Preterm delivery
 Peripheral neuropathy due to B6  Stillbirth
and B12 deficiency  Miscarriage
 Wernicke's encephalopathy  Fetal growth restriction
 Liver and renal failure  Fetal death
35
ANTEPARTUM HEMORRHAGE (APH)
DEFINITION
Ante-partum haemorrhage (APH) is vaginal bleeding from the 28th week of gestation till the
fetus (last fetus in case of multiple pregnancy) is delivered.
CLASSIFICATION (CAUSES)
Placental causes
 Abruptio placentae
 Placenta previa
 Rare causes: vasa previa and other placental abnormalities
Non-Placental causes
 Heavy show
 Uterine rupture / dehiscence
 Local lesions of the cervix, vagina and vulva
 Systemic bleeding disorders
 Indeterminate: causes of bleeding not identified even after delivery and examining the
placenta.
PLACENTAL ABRUPTION
DEFINITION
Placental abruption (also called abruptio placentae) is a separation of the normally implanted
placenta before delivery of the fetus.
RISK FACTORS
Previous history of abruptio placentae, hypertension, multiparity, maternal age greater than 35
years, multiple pregnancy, PROM, distorted uterine cavity, abnormal placenta, low socio-
economic status, smoking, trauma (e.g. domestic violence, ECV), polyhydramnios, short cord,
amniocentesis and others.
36
CLASSIFICATION
Table 7. Classification of Abruptio placenta
Clinical presentation Mild (Grade1) Moderate (Grade 2) Severe (Grade 3)

Amount of blood <400 mL 400-1000mL >1000mL
Uterine irritability Normal / slightly Tetanic, reactive, board
Increased
(pain/tenderness) increased like, tender on palpation
Fetal condition Normal Abnormal / rarely Fetal distress or death

death common
Mild, postural
Shock Absent Severe and always present
hypotension
DIAGNOSIS
The clinical presentation of abruptio placenta mainly depends on the extent of placental
separation, rate of separation and flow of blood through the cervix (concealed/ revealed).
 Vaginal bleeding: menstrual-like (dark), totally concealed or the amount is less than the
degree of the shock
 Abdominal pain/ (uterine) tenderness
 NRFHRP or absent fetal heart beat
 Coagulation defect: frank bleeding (epistaxis, ecchymosis, petechiae)
INVESTIGATIONS:
 CBC (HCT, platelet count)
 Blood group and Rh
 Bedside clotting test
 Ultrasound (if available): fetal assessment and for exclusion of placenta previa
TREATMENT:
• Start an IV infusion and do Hgb, blood group & Rh
• If preterm, Dexamethasone 6mg IV stat
• Refer urgently accompanied by a health provider.
If the patient is in shock, follow management of shock AND REFER.
COMPLICATIONS
 Hemorrhagic shock (acute kidney injury, congestive heart failure)
 DIC
 Utero-placental insufficiency that may lead to IUGR, fetal distress or IUFD
 PPH
37
PLACENTA PREVIA
DEFINITION
Placenta previa is defined as the presence of placental tissue over or adjacent to the cervical os.
CLASSIFICATIONS
Placenta previa: Internal cervical os is covered partially or completely by placenta.
Low lying: Placenta lies within 2 cm of the cervical os but doesn’t cover it.
RISK FACTORS
 Scarred uterus: previous uterine surgery (CS, myomectomy), uterine curettage
 Previous history of placenta previa
 Large placenta: Multiple pregnancy, diabetes, smoking, syphilis, Rh incompatibility
 High parity and advanced maternal age
DIAGNOSIS
 Vaginal bleeding: bright red, painless and recurrent
 Ultrasound (if available) for placental localization and fetal wellbeing assessment
TREATMENT
• Start an IV infusion and do Hgb, blood group & Rh
• If preterm, Dexamethasone 6mg IV stat
• Refer urgently accompanied by health care provider.
If the patient is in shock, follow management of shock AND REFER
NOTE: Do not do vaginal examination.
COMPLICATIONS
 PPH
 Hemorrhagic shock
 Fetal distress or IUFD
38
MULTIPLE PREGNANCY
DEFINITION
Multiple pregnancy is development of more than one fetus in a pregnant uterus at the same
time.
CLASSIFICATION
 Based on number of fetuses:
o Twins (two fetuses)
o Triplets (three fetuses)
o Other higher order multiple pregnancies (more than three fetuses).
 Based on zygosity:
o Monozygotic, dizygotic, etc.
RISK FACTORS
 Family history of multiple pregnancy particularly on the maternal side
 Previous history of multiple pregnancy
 History of ovulation induction or in vitro fertilization
 Age greater than 35 years
DIAGNOSIS
History:
 Excessive vomiting
 Leg swelling
 Abdomen bigger than previous pregnancies in a parous woman
 Excess maternal weight gain
 Breathlessness, easy fatigability, palpitation during later months of pregnancy
 Exaggerated fetal movements (kicks)
Physical examination:
 Fundal height is large for date
 Palpation of more than two fetal poles
 Two fetal heart beats heard at the same time by two health providers & differing in rate
by at least 10 beats per minute.
39
Ultrasonography:
 Prenatal ultrasound is important in the early diagnosis of a multiple gestation and
determining placentation (chorionicity).
MANAGEMENT
 As soon as a diagnosis of multiple pregnancy is made or suspected and if not in labor
REFER to a hospital for complete evaluation.
 Mode of Delivery (if in labor)
o First baby (Twin –A) vertex presentation:
 Allow labor to progress as a single vertex presentation and monitor progress
of labor using a partograph.
NOTE: Refer early if twin B does not deliver within 30 minutes of delivery of twin
A (do not do total breech extraction).
o First baby (Twin A) Non-vertex presentation:
 Open IV line and refer urgently to a hospital for cesarean delivery.
COMPLICATIONS
 Maternal:
o Hyperemesis gravidarum
o Spontaneous abortion
o Anemia
o Pregnancy-induced hypertension/ pre-eclampsia
o Polyhydramnios
o Retained placenta
o Post-partum hemorrhage
 Placental / fetal complications:
o Placenta previa o Congenital anomalies
o Abruptio placentae o Conjoined twins
o Placental insufficiency o Interlocking of twins
o Preterm delivery o Twin to twin transfusion syndrome
(TTTS)
o Low birth weight
o Delayed delivery of the second
o Malpresentation
twin
o Cord prolapse
40
PREMATURE / PRE-LABOR RUPTURE OF MEMBRANES
(PROM)
DEFINITION
Premature / pre-labor rupture of fetal membranes is rupture of membranes (ROM) before the
onset of labor.
Prolonged PROM is rupture of membranes of > 12 hours duration.
CLASSIFICATION
 Term PROM: is rupture of membranes at or after 37 completed weeks of gestation.
 Preterm PROM: is rupture of membranes before 37 completed weeks of gestation.
RISK FACTORS
 Mechanical factors: multifetal gestation, polyhydramnios, pulmonary diseases, cervical
conization/ LEEP/ cerclage.
 Urogenital infections: UTI, cervicitis, GBS, bacterial vaginosis.
 Previous history of PROM or preterm labor.
 Second trimester and third trimester bleeding (e.g. abruptio placenta).
 Other risk factors: low socioeconomic status, nutritional deficiencies, low BMI, smoking
and connective tissue disorders.
DIAGNOSIS
History:
 A sudden "gush" or intermittent or continuous leaking of clear or pale-yellow fluid from
the vagina before the onset of labor.
 Duration of leakage
 In addition ask for symptoms of chorioamnionitis and other complications:-
o Fever
o Fetal movement
o Prolapsed cord
o Abdominal painOffensive vaginal discharge
 Vital signs: mainly check for fever and tachycardia.
41
Abdominal examination: Common findings include:-
 Abdominal tenderness
 Fundal height may be less than the GA
 Mal-presentations and abnormal lie
 Fetal tachycardia
Pelvic examination:-
NOTE: Avoid digital pelvic examination in all cases of preterm PROM.
 Inspection of the external genitalia: leakage of liquor per vaginum, and note the amount,
color and odor.
Speculum examination:-
 Perform a sterile speculum examination using sterile gloves and speculum.
 Observation of amniotic fluid coming out of the cervical canal and/ or presence of
prolapsed cord.
 If active leakage is not visible apply slight fundal pressure or use Valsalva maneuver or
let her cough to provoke leakage of amniotic fluid from the cervix.
 Pooling in the vaginal fornix needs further evaluation as the collection may be due to
excessive vaginal discharge or urine.
 Presence of meconium, vernix caseosa or lanugo hair in the fluid pooling indicates
PROM and presence of uriniferous smell suggests urinary incontinence.
 Inspect for cervical dilatation (open or closed)
Pad test:-
 Can be helpful when there is no pooling & no visible leakage from cervix.
 Place a vaginal pad over the vulva and encourage moving around.
 Examine the pad an hour later visually and by smelling (odour).
 Wetting with no urine and no vaginal discharge (vaginitis) may suggest PROM.
Investigations
 Ultrasound examination
 CBC
 Urinalysis
MANAGEMENT
Management of PROM depends on the gestational age (term or preterm), presence of
chorioamnionitis (maternal fever, tachycardia, uterine tenderness, offensive vaginal discharge
and fetal tachycardia) or other complications of PROM, and presence of other obstetric risk
conditions.
42
Term PROM
 Cephalic presentation, no complications of PROM and no other obstetric risk (APH,
previous caesarean, multiple pregnancy, or hypertension) without labor:
o Admit to the labor ward.
o Monitor maternal vital signs every hour.
o Monitor fetal heart beat every 30 minutes.
o If labor does not start within 8 hours after rupture of membranes – Refer after
administering initial dose of antibiotics (Ampicillin 2 gram IV).
o If there is chorioamnionitis or other complications of PROM, or other obstetric risk
factors: refer as soon as possible after initiating IV antibiotics:-
 Ampicillin 2 g IV, OR
 Ampicillin 2 g IV PLUS Gentamicin 5 mg/kg body weight IV if there is
chorioamnionitis.
 If labor has already ensued but no evidence of infections:
o Admit to labor ward.
o Manage as per standard labor management protocols.
o If the membrane rupture has exceeded 8 hours, cover with broad spectrum antibiotic
(2gm IV Ampicillin QID till delivery).
Preterm PROM
 Ascertain gestational age and assess for complications.
 If chorioamnionitis is present provide initial dose of antibiotics (Ampicillin 2gm IV and
Erythromycin 250 mg P.O).
 Refer immediately.
COMPLICATIONS
Maternal: Chorioamnionitis, abruptio placentae, retained placenta and hemorrhage, maternal
sepsis, and higher risk for cesarean delivery.
Fetal and Neonatal: Infection, umbilical cord compression as a result of oligohydramnios, frank
or occult umbilical cord prolapse, fetal death, preterm birth and associated complications (RDS,
NEC, IVH, etc), neonatal infections, long-term sequelae such as cerebral palsy, pulmonary
hypoplasia and restriction deformities.
43
NORMAL LABOR AND DELIVERY
DEFINITION
Labor is a process of regular uterine contractions resulting in progressive cervical effacement
and dilatation which ends in the delivery of the fetus, placenta and membranes.
Normal labor and delivery: Labour is considered normal when the following conditions are
fulfilled:
• Laboring mother without any apparent risk (e.g. pre-eclampsia, previous scar, etc.)
• Labor should start spontaneously
• Labor should start at term
• Vertex presentation
• Spontaneous vertex delivery with minimal assistance
• Normal duration for all stages of labor and
• Good neonatal and maternal outcome
False labor: False labor is irregular uterine contractions prior to actual labor pains resembling
those of normal labor. Signs of false labour are:-
• Mild pain and irregular contractions
• There is no blood-stained mucous discharge (show)
• No progressive cervical dilatation observed on follow up
STAGES OF LABOR
First stage of labor:
The period between onset of regular uterine contractions and full cervical dilatation. It is
subdivided into two phases: -
Latent phase: The phase of labor between the onset of regular uterine contraction to 5 cm of
cervical dilatation (often slow & unpredictable rate of cervical dilatation).
Active phase: The phase of labor after 5 cm of cervical dilatation to full cervical dilatation
(more rapid rate of cervical dilatation)
Second stage of labor:
The stage of labor from full cervical dilatation to delivery of the last fetus (often associated with
involuntary urge to push due to expulsive uterine contractions).
Third stage of labor:
The stage of labor from delivery of the last fetus to the delivery of the placenta & membranes.
44
DIAGNOSTIC CRITERIA OF TRUE LABOR
Regular, rhythmic uterine contractions (≥ 2 contractions in 10 minutes) with one or more of the
following conditions:
• Rupture of the membranes
• Cervical effacement of ≥ 80 %
• Cervical dilatation of 4 centimeters
• Bloody show (if fetal membranes are ruptured or if digital vaginal examination was
done within the past 48 hours, show shouldn’t be used as diagnostic criteria).
NOTE: Always rule out false labor to avoid unnecessary intervention.
ADMISSION CRITERIA
• All women with diagnosis of labour (latent and active) should be admitted.
• Mothers with certain risk factors should be referred as per the guidance provided under
linkage and referral (page 54 below).
ADMISSION PROCEDURE
• Warm and friendly acceptance.
• Immediate assessment of maternal and fetal conditions to check for signs of imminent
delivery.
• Review ANC record and revise her birth preparedness plan (e.g. PPFP).
• Appropriate history and physical examination (including vaginal examination).
• Perform laboratory investigations which are not determined during ANC (e.g. blood
group and Rh, urine analysis, VDRL, HBsAg and HIV test).
• If urine analysis and hemoglobin / hematocrit are not determined within the past two
weeks, repeat the test.
• If serology for HIV is positive refer to section on intrapartum care of HIV positive
pregnant women for PMTCT (page 126).
• Inform and regularly update client and attendants about her condition and the status of
labor.
• Provide loose fitting gown (if possible).
• Revise her postpartum contraception plan, counsel and prepare accordingly. However,
if the client is in active labor postpone the counseling to the immediate postpartum
period.
45
MANAGEMENT DURING FIRST STAGE OF LABOR
LATENT PHASEOF FIRST STAGE OF LABOR (LFSOL)

If the client is in LFSOL and fulfils admission criteria, admit and follow using the “latent phase
follow-up chart” below (table 8).
During the latent phase follow:
• Uterine contraction, FHR and PR every 1 hour
• BP every 4 hours (if indicated more frequently)
• Cervical condition every 4 hours but should also be done after spontaneous rupture of
membranes, in the presence of abnormal FHR or before giving analgesia.
Table 8. Latent phase of first stage of labor follow up chart.

Name ______________________________________ Age ______ MRN _________________
Admission diagnosis__________________________________ Status of membranes____________
If ruptured duration in hours________ Admission date ________________ Time _________
Cervical
0 Uterine Colour of
Date Time BP PR RR T FHR dilatation & Remark Sign.
contractions liquor
effacement
ACTIVE PHASE OF FIRST STAGE OF LABOR

All observations and findings should be recorded on the partograph (figure 2) if the client
presents with cervical dilatation of ≥5 cm.
NOTE: Partograph is started by plotting the cervical dilatation on the alert line.
Parts of the partograph

• Identification
• Fetal condition
• Labor progress
• Maternal condition
46
Figure 2. Partograph
47
VAGINAL EXAMINATION DURING LABOR FOLLOW UP
Vaginal examination is done to evaluate cervical dilatation, station, fetal position, fetal
presentation, pelvic adequacy, status of liquor, molding and caput. The frequency of vaginal
examination is every 4 hours but can be repeated:-
• After spontaneous rupture of membranes
• When there is abnormal FHR (NRFHR), and

• If symptoms are suggesting for second stage of labor (to confirm the diagnosis).
1. MONITORING FETAL CONDITION:

FHR:
• Use Pinnard fetoscope or Doppler fetoscope device
• Count the FHR immediately after contraction for 1 min, every 30 min for low risk
pregnancy and every 15 min for high-risk pregnancy.
• Continuous electronic FHR monitoring is preferred to monitor high-risk pregnancies.
• Normal FHR for a term fetus is 120-160 BPM. If FHR is <120 or >160, manage as non-
reassuring fetal heart rate (NRFHR).
Grading of meconium: assess the status of liquor for meconium or blood

• Clear liquor
• Grade I - Good volume of liquor, lightly meconium stained
• Grade II - Reasonable volume with a heavy suspension of meconium
• Grade III - Thick meconium / particulate matter which is undiluted
NOTE: A newly appearing meconium is an alarming sign.
Grading of molding:
• No molding - The cranial bones are separate along the suture lines
• Grade I- Fetal cranial bones are touching each other along the suture lines
• Grade II- Fetal cranial bones are overlapping but can be separated
• Grade III- Fetal cranial bones are overlapping & are not separable
2. MONITORING PROGRESS OF LABOR

Uterine contraction:
• Frequency (uterine contractions per 10 min), duration and intensity of each contraction
are determined by palpation every 30 minutes.
48
Descent of fetal head
• Assess descent of the fetal head during abdominal palpation before vaginal examination
as shown below in figure 3.
5/5 4/5 3/5 2/5 1/5 0/5

Abdomen
Pelvic Brim
Head accommodates full Head accommodates two

width of five fingers above fingers above the
the symphysis pubis symphysis pubis
Descent is 5/5 Descent is 2/5 (engaged)
Figure 3. Stages of fetal descent through the pelvic cavity.
Cervical dilatation
• The dilatation of the cervix is plotted using “X” on the alert line when starting
partograph. Start the partograph at 5 cm of dilation.
• If the client’s partograph crosses the alert line, while the progress of labor is not
adequate the woman should be transferred to a health facility where caesarean delivery
is possible.
3. MATERNAL CONDITION MONITORING:
Vital signs
• Pulse rate - half hourly (30’)
• Temperature and BP - every 4 hours (more frequently if indicated)
49
Urine
• Monitor urine output
• Test urine for ketone and protein
Maternal position
• Avoid supine position.
• The mother should not be confined to bed unless contraindicated (e.g. sedated patient,
for frequent monitoring, high head and ruptured membranes).
• She can assume any position comfortable to her (left lateral, right lateral, sitting)
irrespective of the stage of labor.
Nutrition - Oral intake

• In general, encourage oral intake of liquid diet (tea, juice) but not hard foods.
• Consider non-particulate fluid diet as a source of water and energy for those mothers
staying longer before delivery (e.g. small sips of sweetened tea or water).
Companionship in labor
• Encourage the partner to accompany the spouse who is in labor.
• Partner support and education should start during antenatal care and continue
throughout child birth.
Pain management
• All available pain management options should be informed to the client. Provision of
pain relief should be individualized based on availability, preference and request.
• Options of pain relief in labor can be non-pharmacologic or pharmacologic.
• Non pharmacologic pain management options include continuous emotional support,
massaging (back rubbing) and hot compress (back).
• Pharmacological options include opioids such as pethidine, diamorphine and fentanyl.
• Whenever opioids are used during labor (>4 cm), all preparations should be made to
treat neonatal respiratory depression. This includes preparation of ventilation,
oxygenation, gentle stimulation and judicious use of the opioid antagonist naloxone.
50
PHARMACOLOGICAL PAIN MANAGEMENT
Opioids alone (pethidine, diamorphine and fentanyl are options)
Pethidine injection: 50 mg IM initially. Assess after ½ hr and if not adequate and side effects
not troublesome, repeat 50 mg. Onset of action is within 10 - 20 min and lasts for 2-4 hours.
Pethidine injection: 25- 5 0 mg IV, onset of action immediately and effect lasts for 1.5 -2 hrs.
Repeat doses every 1-2 hours depending on the level of sedation. Always check respiratory
depressant effect of pethidine on the mother as well as the neonate.
MANAGEMENT DURING SECOND STAGE
MATERNAL CARE AND WELLBEING EVALUATION

• BP monitoring: every 1 hour (if indicated more frequently)
• PR, temp. and RR: every 30 minutes
• Evaluate general condition: fatigue and state of hydration
• Evaluate for the presence of the urge to push and /or effort
• She can attain any position until the presenting part is visible or delivery is imminent
• The woman should be encouraged to empty her bladder before delivery
FETAL STATUS MONITORING

• FHR - Every 15 min for low-risk pregnancy
• FHR- Every 5 min for high-risk pregnancy (or if available, using continuous FHR
monitoring)
• Evaluate the status of liquor (progress of meconium staining) during pelvic examination
LABOR PROGRESS EVALUATION

• Evaluate the degree of descent and or station every1 hour
• Look for extent of caput and degree of molding
PREPARATION FOR DELIVERY

• Notify the labor ward staff that delivery is imminent.
• Take the woman to the delivery room (if it is a separate room).
• Make sure all equipment for delivery and newborn care (e.g. well-equipped, pre-
warmed neonatal corner) are available.
• The birth attendant should wash hands and wear complete personal protection
equipment (gloves, gown, apron, mask, cap and eye protection).
51
• Sterile draping in such a way that only the immediate area around the vulva is exposed.
• Perineal care: clean the vulva and perineum with antiseptics / tap water (downward and
away from the introitus). Wipe feces downwards. Avoid routine vaginal cleansing.
ASSISTANCE OF SPONTANEOUS DELIVERY

Goal: Reduction of maternal trauma, prevention of fetal injury and initial support of the
newborn.
Perineal protection (hands on birth)

Perform perineal guard support during childbirth (figure 4) to reduce perineal trauma &
facilitation of birth.
Figure 4. Perineal Support
Delivery of the Head

• Support the perineum to prevent rapid delivery and to assist extension of the head.
• Check for presence of cord around the neck and disentangle from the head or if tight,
clamp at two sites to cut the cord.
• After delivery of the head, wipe the mouth and nose (routine suctioning of oropharynx
is not recommended).
Episiotomy:
• Routine performance of episiotomy should be avoided and individualization is
important.
• Indications for episiotomy:
o imminent perineal tear
o perineal resistance for fetal head descent (tight perineum)
o presence of fetal / maternal indication for expedited delivery
52
• Timing of episiotomy: when the presenting part distends the vulva 2-3cms (unless early
delivery is indicated)
• Type: Medio-lateral episiotomy is recommended
NOTE: Analgesia / anaesthesia should be given before episiotomy is performed and during
repair.
Delivery of the rest of the body

• After delivery of the head, allow restitution.
• Hold on both sides of the head and gently pull the head downwards to deliver the
anterior shoulder.
• Deliver the posterior shoulder by pulling upwards after the delivery of the anterior
shoulder.
• The rest of the body usually follows easily. Support the baby’s body with both hands
and place the baby on the mother’s abdomen.
• Dry the newborn’s body with clean and dry towel. Remove the wet towel and wrap the
newborn with a dry towel.
• Record the time, APGAR score and sex of the baby.
• Inform the mother.
Cord Clamping
• Delay cord clamping for 1-3 minutes after delivery or until cord pulsation is absent
(either of the two which comes first).
• Clamp the cord immediately in the following conditions: preterm baby, low birth
weight, neonatal asphyxia, Rh isoimmunized pregnancy or HIV.
• Clamp the cord 4-5 cm away from the umbilicus.
• Take cord blood if indicated.
53
LINKAGE AND REFERRAL
MOTHERS WHO ARE NOT ELIGIBLE TO LABOR IN HEALTH CENTER
 Previous caesarean section scar or myomectomy scar

 Age <16 years
 < 37 wks of gestation
 Suspected intrauterine growth restriction
 Suspected fetal macrosomia
 Multiple pregnancy
 Antepartum hemorrhage
 Rh isoimmunization (indirect Coomb’s test positive)
 Malpresentation
 Preeclampsia and other hypertension disorders
 Severe anemia
 Pelvic mass
 Extensive vulvar warts that may obstruct vaginal delivery
 Prolonged premature rupture of the membranes
 General medical conditions: diabetes mellitus, cardiac disease, kidney disease,
epilepsy, asthma on medication and active tuberculosis
MOTHERS ELIGIBLE FOR REFERRAL DURING LABOR
 Suspected chorioamnionitis or offensive liquor

 Prolonged labor
 FHB < 120 and > 160, if delivery is not imminent
 Meconium-stained liquor
o Grade 1 in latent and early active first stage of labor
o All thick meconium (grade ≥ 2) (if delivery is not imminent)
 Cord prolapse / presentation (if delivery is not imminent)
 Failed vacuum delivery
 Cephalopelvic disproportion
 Obstructed labor
54
THIRD STAGE OF LABOR
DEFINITION
Third stage of labor is the time interval from the delivery of the last fetus up to the expulsion of
the placenta.
During this stage, there is a significant risk of hemorrhage. In Ethiopia, nearly half of the total
number of maternal deaths is contributed by hemorrhage which can be largely prevented.
Therefore, all mothers require close monitoring and routine prevention of postpartum
hemorrhage (PPH) through active management of third stage of labor (AMTSL).
ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR (AMTSL)
AMTSL refers to a sequence of clinical actions taken by a skilled birth attendant to facilitate
the delivery of the placenta, by promoting uterine contraction and placental expulsion. Every
woman who delivered vaginally in the health facility should be managed with AMTSL.
COMPONENTS OF AMTSL
1. Administer uterotonic medication within one minute of the birth of the last baby.
Drugs used for AMTSL:

Oxytocin: the preferred drug for AMTSL and 1st line drug for PPH caused by uterine
atony.
Ergometrine: the 2nd line drug for PPH though associated with more serious adverse
events. Ergometrine is contraindicated in hypertensive women and in those with
cardiac problems.
Misoprostol: is cheap and stable at room temperature.
NOTE: Uterotonics require proper storage:
 Oxytocin: 2 - 8° C, protect from freezing
 Ergometrine: 2 - 8° C, and protect from light and freezing.
 Misoprostol: room temperature, in a closed container.
Use of uterotonic agents:

 Within one minute of the delivery of the baby, palpate the abdomen to rule out the
presence of an additional fetus(s).
 Within one minute of the delivery of the baby, give uterotonic medication.
 Give oxytocin 10 IU IM injected deep into the thigh muscles. It is effective 2-3
minutes after injection. It has minimal side effects and can be used in all mothers.
55
 If oxytocin is not available, administer other uterotonic agents (within one minute of
delivery):
o Carbetocin 100 micrograms IV or IM, or
o Ergometrine 0.2 mg IM, or
o Misoprostol 600 mcg oral
2. Controlled cord traction
a. Clamp the cord close to the perineum within 1-3 minutes after delivery or after cord
pulsation stops (either of the two whichever comes first). Early cord clamping (< 1
min) is recommended if the neonate is asphyxiated and needs resuscitation.
b. Place the other hand just above the woman’s pubic bone and stabilize the uterus by
applying counter-pressure during controlled cord traction.
c. Keep slight tension on the cord and wait for strong uterine contraction.
d. With strong uterine contraction, gently pull downward on the cord to deliver the
placenta. Continue to apply counter-pressure to the uterus.
e. If the placenta does not descend, wait until the uterus contracts and repeat the
controlled cord traction with the next contraction.
f. As the placenta delivers, hold the placenta in two hands and gently turn it until the
membranes are twisted. Slowly pull to complete the delivery.
g. If the placenta remains undelivered for 30 minutes after delivery of the fetus,
manage as retained placenta (see management of retained placenta, page 73).
h. Inspect both the placenta and fetal membranes for completeness.
3. Verification of uterine tone and uterine massage if the uterus is not well contracted.
a. Immediately check for contraction and if the uterus is soft, massage the fundus of the
uterus until the uterus is well contracted.
b. Assess uterine tone every 15 minutes for the first 2 hours after delivery. If the uterus
is atonic, massage the uterus.
c. Teach the woman how to assess uterine tone and massage her own uterus.
d. Estimate and record blood loss.
NOTE: - Sustained uterine massage is not recommended as an intervention to prevent

postpartum hemorrhage.
- Provide post-natal family planning counseling for informed choice & decisions
(implement when applicable).
56
CARE FOR THE NEWBORN AT BIRTH
ESSENTIAL NEWBORN CARE (ENC)
DEFINITION
Essential newborn care (ENC) is care given to all newborn infants at birth to optimize their
chances of survival and wellbeing.
ENC starts before birth and extends to postnatal period.
COMPONENTS
• Prevent hypothermia
• Observe for the first breath (spontaneous breathing)
• If there is any difficulty to establish spontaneous breathing, immediately start resuscitation
• Cord and eye care
• Provide vitamin k
• Put the baby skin to skin contact with mother
• Start exclusive breast feeding within one hour of birth.
• Measure newborn’s weight
• Vaccination with BCG, HBV and polio 0
PREPARATION FOR ENC DURING BIRTH

• Every delivery should be attended with the anticipation of need for newborn resuscitation
• Personnel should always wash hands with soap and water and use PPE
• Keep the delivery room warm
• Prepare the newborn corner / resuscitation area
o Turn on the radiant warmer before the baby is delivered
o Prepare functional self-inflating bag
o Prepare functional bulb suction or suction device with catheter
o Prepare stethoscope, clock and thermometer
STEPS IN ESSENTIAL NEWBORN CARE (ENC)
57
Step 1: Dry and stimulate
• Deliver the baby on clean, dry towel draped over the mother’s abdomen.
• Immediately dry the whole body (including the head and limbs).
• Stimulate by rubbing the back or flicking the soles of the feet.
• Remove the wet towel and wrap with dry towel to keep the baby warm.
• Let the baby stay in skin to skin contact on the mother’s abdomen.
Step 2: Evaluate Breathing
• While drying and stimulating newborn check if the baby is breathing.
• Always keep the head in a slightly extended position.
• If the baby is not crying or breathing immediately cut the cord, call for help and shift to
resuscitation corner (see below).
• If the baby cries or breathes well, continue routine essential newborn care.
• Do not do suction of the mouth and nose as a routine. Do it only if there is thick meconium,
mucus or blood obstructing the airway.
NORMAL BREATHING
Normal breathing rate in a newborn baby is 30 to 60 breaths per minute. The baby should
not have any chest in-drawing or grunting. Small babies (less than 2.5 kg at birth or born
before 37 weeks gestation) may have some mild chest in-drawing and may periodically stop
breathing for few seconds.
Step 3. Cord care

• If the baby does not need resuscitation, clamp the cord within 1-3 minutes after birth or
after cord pulsations are absent (whichever comes first).
• Tie the cord 2 fingers from the baby’s abdomen and another tie 2 finger away from the
first tie, and then cut the cord between the first and the second tie. Make sure it is tied well
with no oozing of blood.
• The cord may be tied by using sterile cotton ties, elastic bands, or pre -sterilized disposable
cord tie.
• Cut the cord with sterile scissors or surgical blade, under a piece of gauze in order to avoid
splashing of blood.
• At every delivery, a clean separate pair of scissors or blade should be designated for this
purpose.
• Apply 4% Chlorhexdine immediately after cutting the cord and then daily for 7 days.
• Check for bleeding / oozing and re-tie if necessary.
58
• Advise the mother not to cover the cord with the diaper or bandage as it may delay healing
and introduce infection.
Step 4. Keep the newborn warm (prevent hypothermia)
• Support the mother to keep the baby warm by placing skin-to-skin contact on her chest.
• Cover the baby’s body and head with pre-warmed clean cloth including hat and socks.
• Use a blanket to cover the baby and the mother.
• Keep the newborn with the mother.
• Delay bathing for at least 24 hours.
Step 5. Initiate breastfeeding in the first one hour
• Support immediate initiation of breast feeding within one hour of birth.
• Advise to breastfeed on demand day and night and no less than 8-12 times a day.
• Newborns should be exclusively breastfed for the first six months of life to achieve
optimal growth, development and health.
Early initiation of breastfeeding

Means initiating breastfeeding within the first hour of birth, with counselling for correct
positioning.
Step 6. Administer eye drops / eye ointment

• Wash hands with soap and water
• Clean from medial to lateral side
• Apply tetracycline eye ointment on both eyes over the lower conjunctiva within 1 hour of
birth usually after initiating breast feeding.
Step 7. Administer vitamin K
• Give vitamin K 1 mg IM on the anterior lateral tie (for babies less than 34 weeks gestation
give 0.5 mg).
Step 8. Place the newborn’s identification
• Put newborn identification band on the baby preferably on the wrist and/or ankle.
Step 9. Measure newborn’s weight
• Weigh the newborn when it is stable and warm
• Place clean linen or other alternatives on the pan of the weighing scale
• Remove clothes and place the baby on the weighing scale
• Never leave the baby unattended on the scale
• Record the baby ’s weight in the delivery summary and inform the mother
59
Step 10. Record all observations and treatment
• Record all findings and care provided for the newborn on the mother’s chart and the
registration book.
NOTE: The steps in essential new born care are summarized in figure 5 below.
Figure 5. Figure showing steps of Essential Newborn Care.
60
NEONATAL RESUSCITATION
Neonatal resuscitation is a lifesaving intervention for a newborn who fail to initiate and maintain
spontaneous and adequate breathing at birth.
While providing essential newborn care identify babies in need of resuscitation as shown below
in table 9.
Table 9. Neonatal resuscitation
Assessment Decision
• No need for resuscitation or suctioning.

• Baby is crying
• Start skin-to-skin contact and breastfeeding.
• Baby is not crying but his chest is • No need for resuscitation or suctioning.
rising regularly between 30 to 60 times
in a minute • Start skin-to-skin contact and breastfeeding.
• Respiratory rate below 30 • Start resuscitation immediately.
• Baby is gasping • Start resuscitation immediately.
• Baby is not breathing • Start resuscitation immediately.
THE 3A, GOLDEN RULES OF RESUSCITATION

1. Anticipation: Identify those newborns that are at high risk for birth asphyxia; always
anticipate and prepare for resuscitation (see the risk factors in table 10 below).
2. Adequate preparation: Skilled providers can undertake the steps of resuscitation.
3. Act on time: There should not be any delay in identifying newborns that need
resuscitation and action should be taken immediately.
PREPARATION FOR RESUSCITATION

• Change your gloves
• Tie and cut the cord first
• Tell the mother that her baby is having difficulty to breath and that you are going to help
• Lightly wrap the baby in a warm dry towel or cloth
• Leave the face and upper chest free for observation
• Immediately transfer the baby to a newborn corner which is warm, clean and dry surface
under an overhead heat source
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Table 10. Risk factors associated with need for resuscitation.
Maternal risk factors before labor Risk factors during labor
• Pre-eclampsia and eclampsia • Foul smelling amniotic fluid
• Previous fetal or neonatal death • Unusual vaginal bleeding before delivery
• Maternal infection (HIV, STD, Malaria) • Prolonged rupture of membranes > 18 hours
• Multiple gestation • Precipitate labor
• Premature rupture of membranes • Shoulder dystocia
• Decreased fetal activity • Prolonged labor (>24 hours)
• Post-term gestation • Prolapsed cord
• Bleeding in second or third trimester • Fetal bradycardia
• Maternal diabetes • Meconium
• Age <16 or >35 years • Narcotics administered to mother
• Anemia • Instrumental delivery
• No prenatal care
BASIC STEPS IN RESUSCITATION

The figure below (figure 6) illustrates the relationship between resuscitation procedures and the
number of newly born babies who need them. At the top are the procedures needed by all
newborns. At the bottom are procedures needed by very few.
Always needed
Dry, warm, clear airway and (100%)
stimulate
Ventilation Needed less

bag and mask frequently (10-15%)
Chest
compressions
Rarely needed
Meds (10-15%)
Figure 6. Steps in resuscitation
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NEONATAL RESUSCITATION ACTION PLAN
Neonatal resuscitation can be done using the action plan developed by WHO, the action plan is
shown in the neonatal resuscitation flow chart / algorithm below (figure 7).
► Dry the infant immediately with a clean cloth.

► Keep warm by skin-to-skin contact and covered.
Look for
Breathing or crying Routine care
movements
► Stimulate by rubbing the back 2 to 3 times.

► Suction only if had meconium stained liquor or the mouth
breathing
or nose is full of secretions.
► CALL FOR HELP.

► Transfer to newborn resuscitation area.
if
► Position the head/neck slightly extended. well
continues to
► Start positive pressure ventilation with mask and self- breathe well
A inflating bag within 1 min of birth *
► Make sure the chest is moving adequately.
If HR
Check the heart rate (HR) with a stethoscope. ► Chest compressions

until HR ≥ 100/min
► Give higher oxygen
HR 60–100/min: concentration.
HR > 100/min:
► Take ventilation If HR remains at <
► Continue to ventilate at
corrective steps. 60/min, consider:
40 breaths per min.
► Continue to ventilate at ► Other ventilatory
► Every 1–2 min stop to
40 breaths per min. support.
see if breathing
► Consider higher ► IV adrenaline.
spontaneously.
oxygen concentration. ► Refer where possible
► Stop ventilating when
► Suction, if necessary. If no HR for > 10 min
respiratory rate is > 30
► Reassess every 1–2 or remains <60/min
breaths per min.
min. for 20 min,
► Give post resuscitation
care. discontinue
If HR
A and B are basic resuscitation steps
Figure 7. Neonatal resuscitation flow algorithm
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POST RESUSCITATION CARE
Infants who require resuscitation are at risk for deterioration after their vital signs have returned
to normal.
Once adequate ventilation and circulation has been established:
• Stop ventilation
• Maintain thermal stability
• Return the baby to the mother for skin-to-skin contact as soon as possible
• Closely monitor breathing difficulties, signs of asphyxia and anticipate need for further
care
WHEN TO STOP RESUSCITATION

It is appropriate to consider discontinuing after effective resuscitation efforts if:
• If the baby starts breathing or crying
• If breathing is >30/min and regular
• Infant is not breathing and heart beat is not detectable beyond 10 min
• If no spontaneous breathing and heart rate remains below 60/min after 20 min of effective
resuscitation
DOCUMENTATION AND COUNSELING

• Document the resuscitation process and its outcome.
• Explain to the mother and / or parents about what possibly has happened to the newborn
and provide grief counseling.
• Give them the dead newborn if they wish.
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BASIC POSTPARTUM / POSTNATAL CARE
DEFINITION:
Post-natal care is care that is provided to a mother and her newborn baby/ies after delivery and
within the first 42 days after child birth.
24 HOURS POSTNATAL CARE AND STAY

The quality of care the mother and new born receive in the first 24 hours after delivery is crucial
in making sure the mother and neonate stay healthy beyond the immediate postnatal period. See
table 11 below for the postnatal care services that should be provided in the first 24 hours. The
recommended duration of stay for mothers & new-borns in the health facility is 24 hours after
delivery.
Table 11. 24 hours postnatal care services (First 24 hours after birth).
A. MATERNAL CARE
• Measure and document blood pressure (BP) every 15 min in the first 1hour. Then 2 nd,
3rd & 4th hours, & every 4 hours until discharge.
• Encourage ambulation.
• Encourage voiding of urine & check urination.
• Check uterine tone & presence of vaginal bleeding every 15 minutes for first 2 hours.
• Inspect episiotomy site (if done) immediately, at two hours & just before discharge.
• Encourage early initiation of BF.
• Counsel about family planning and provide if needed.
• Counsel on danger symptoms / signs and respond to maternal concerns appropriately.
• Counsel for return visit.
B. NEWBORN CARE
• Monitor the newborn/s every 15min for the first hour and then before discharge.
• Provide essential new born care.
• Warm baby by keeping mother and baby together, skin to skin contact.
• Initiate BF with in the first one hour.
• Assess the newborn as per standards: check on breathing; movements; swelling and
bruises over the presenting part; abdomen for pallor and distension; malformations; feel
the tone; feel for warmth (if cold, or very warm, measure temperature); umbilical stamp;
passage of meconium; weigh the baby.
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• Inform the mother about danger signs of new born health (failure to feed, convulsion,
fast breathing, lethargy....)
• Immunization with BCG, OPV-0 and birth dose of HBV (also appropriate cord care and
vitamin K as is recommended in the section on neonatal care)
• Advise on cord care.
• Counsel to delay bathing until after 24 hours.
• Counsel on appropriate clothing of the newborn for ambient temperature (one to two
layers of clothes more than adults and use of hats / caps).
• Encourage communication and play with the newborn.
• Schedule return visit
POSTNATAL CARE (PNC) CONTACTS AFTER THE FIRST 24 HRS STAY

At least three additional PNC contacts are recommended for all mothers and new-borns after
the first 24 hours stay in a health facility. These contacts can take place either at a health facility
or at home, depending on the specific situation.
1. First visit should be at day 3 (48-72 hours) after delivery.
2. Second visit should be between 6th- 7th day after delivery.
3. Third visit should be at 6th week.
When appropriate, the second & third visits can also be scheduled at any time (i.e., the second
visit can be scheduled anytime between the 3nd day and the 7th day & the third can be between
the 7th day and the 6th week.)
Components of postnatal care services

See tables (table 12, table 13 and table 14) below for the detailed components of each PNC visit:
Table 12. First PNC visit at day 3 (48 -72 hours after birth)
A. CARE FOR THE MOTHER: IMMEDIATE PPC

• Ask for any complaints & inquire the presence of excessive vaginal bleeding, fever,
symptoms of anemia, headache, fatigue, breast swelling & pain, urinary complaints
including incontinence, perineal pain & bowel function.
• Check vital signs & do physical examination with emphasis on relevant systems (breast,
abdomen, genitourinary systems, and look for leg swelling for DVT). Advise on
ambulation.
• Breastfeeding progress should be assessed at each postnatal contact.
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• Counsel on appropriate disposal of soiled pads & personal hygiene.
• Counsel on post-partum nutrition.
• Counsel on danger signs
• Counsel about family planning and provide if needed.
• Evaluate mother for psychological / emotional well being & when problems identified
link to mental health services.
B. CARE FOR THE NEWBORN: IMMEDIATE PPC

• Assessment of the newborn as per standards on breathing; swelling over the presenting
part; movements; abdomen for pallor and distension; malformations; feel the tone; feel
warmth (if cold, or very warm, measure temperature).
• Observe how the baby is breast feeding.
• Advise exclusive BF.
• Observe skin for pallor and jaundice.
• Immunization with BCG, OPV-0 and birth dose of HBV if not provided already.
• Advise on direct sunlight exposure.
• Counsel on danger signs (see table 15 below).
Table 13. Second PNC visit (between 6th-7th day 73 hours and 7 days after delivery).
A. CARE FOR THE MOTHER: EARLY PPC

• Assess general well-being.
• Assessment for signs of postpartum complications.
• Assess breastfeeding progress.
• Ask about presence of breast pain.
• Check if breasts are swollen, red or tender, or has sore nipples.
• Assess emotional wellbeing, what family and social support they have and their usual
coping strategies for dealing with day-to-day matters (when mental health issue is
identified take appropriate measure).
• All women and their families / partners should be encouraged to tell their health care
provider about any changes in mood, emotional state and behavior that are outside of the
woman’s normal pattern.
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B. CARE FOR THE NEWBORN: EARLY PPC
• Assessment of the newborn as per standards on breathing; movements; the presenting
part for swelling and bruises; abdomen for pallor and distension; malformations; feel the
tone; feel for warmth: if cold, or very warm, measure temperature; weigh the baby.
• Concerns about breastfeeding and wellbeing of baby as mother perceives it.
• Assess general condition of baby: active, feeding well and frequently.
• Observe how baby is breastfeeding.
• Observe skin for signs of pallor and jaundice.
• Immunization with BCG, birth dose of HBV and OPV-0 if not provided already.
• Advise on direct sunlight exposure.
Table 14. Third PNC visit (6th week)
A. CARE FOR THE MOTHER: LATE PNC

• Take history and do physical examination
• Assess for signs of postpartum complications
• Counsel on appropriate nutrition, and micronutrient supplementation
• Counsel on safe sex practices
• Counsel on breastfeeding and support as needed
• Counsel on personal hygiene
• Encourage on continued use of ITN for women living in malaria endemic areas
• Routine offering of HIV testing if not already done
• Plan for revisit for immunization of the baby
• Counsel and provide FP methods if needed
• Evaluate mother for psychological wellbeing and when problems identified link to
mental health services
B. CARE FOR THE BABY: LATE PNC

• Identify warning signs of complications
• Routine examination of the baby
• Advise on directs sunlight exposure
• Immunization according to the national EPI program
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POST PARTUM DANGER SIGNS
Danger signs for the mother and the baby that need to be looked for during their stay in the
facility and communicated to the mother before discharge are listed below in table 15.
Table 15. Postpartum danger signs for the mother and the baby.
Mother Baby
• Sudden and profuse blood loss • Cord red or draining pus

• Fainting, dizziness and palpitations • Suckling poorly
• Fever, shivering, abdominal pain, • Eyes swollen, sticky or draining pus
and/or offensive vaginal discharge • Cold to touch in spite of re-warming
• Abdominal pain, calf pain, redness or • Hot to touch despite undressing
swelling
• Difficulty of breathing
• Shortness of breath or chest pain
• Lethargy
• Excessive tiredness
• Convulsions
• Severe headache accompanied by
visual disturbances
• Urine dribbling or pain on micturition
FAMILY PLANNING:
• All postpartum women should receive family planning education and counseling& when
accepted service should be provided before discharge.
• Women should be informed about the advantages of birth spacing for at least two years
before getting pregnant again and on the different family planning options.
• Women should also be given a choice between the different family planning methods at
every contact (ANC, early labor & postpartum visits).
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POSTPARTUM HEMORRHAGE
DEFINITION
Post partum hemorrhage refers to excessive bleeding following delivery (>500 ml in vaginal
delivery or >1000 ml in Cesarean Delivery) or bleeding resulting in derangement of vital signs
or a drop in Hct of > 10 % from the baseline.
CLASSIFICATION
• Primary PPH: PPH occurring within 24 hrs
• Secondary PPH: PPH occurring from 24 hrs until 6 wks after delivery
PRIMARY PPH
CAUSE
1. Atonic Uterus
• Definition: Atonic uterus is failure of the uterus to contract after delivery.
• Diagnosis: Hypotonic, floppy uterus and expulsion of clots when the uterus is
compressed.
2. Genital tract tear / laceration.
• Lacerations of the genital tract (uterus, cervix, vagina or perineum) during delivery.
• Risk factors: Feto-pelvic disproportion, instrumental deliveries, precipitate labor,
scarred uterus, episiotomy, delivery through non-fully dilated cervix, tight perineum.
• Diagnosis:
o Active vaginal bleeding with a contracted uterus.
o Laceration detected on exploration of the genital tract.
3. Retained placental tissue
• Definition: Failure to deliver the placenta and membranes fully (or delivered only
partially) following delivery of the baby.
• Risk factors: Mismanagement of third stage of labor, abnormal placentation (morbidly
adherent placenta, succenturiate lobe), constriction of the cervix or lower uterine
segment.
• Diagnosis: Placental inspection (incomplete cotyledons and/or membranes), continued
bleeding, ultrasound (retained echogenic tissue in the uterine cavity).
70
4. Coagulation failure
• It is a condition in which the blood's ability to coagulate (form clots) is impaired.
• Risk factors:
o Acquired coagulopathy: abruptio placentae, IUFD, amniotic fluid embolism,
severe pre-eclampsia / eclampsia, sepsis, administration of excessive IV fluids.
o Systemic bleeding disorders
• Diagnosis:
o Assess for risk factors
o Oozing from vein puncture sites
o Bedside coagulation (clotting and bleeding time) test: Failure of a clot to form
after 7 minutes or a soft clot that breaks down easily suggests coagulopathy.
5. Acute inversion of the uterus
• Definition: The uterus turns inside-out partially or completely during or after delivery
of the placenta.
• Classification
o First degree: Fundus is within the uterus not extending beyond the cervix.
o Second degree: The inversion extends out of the cervix and is limited to within
the vagina.
o Third degree: A complete inversion to the perineum.
o Fourth degree: A total inversion of the uterus with the vagina.
• Risk factors: Mismanagement of third stage of labor, adherent placenta, short cord.
• Diagnosis:
o On abdominal palpation,
 A dimple with active vaginal bleeding, pain and shock.
 Disproportionately small or absent uterus.
o Soft and easily bleeding mass felt inside the vagina.
o With the placenta detached the inverted uterus is described as cherry red mass.
PREVENTION
• Prevention / treatment of anemia
• Skilled birth attendance
• Active management of third stage of labor.
71
MANAGEMENT
General management
 Call for help, urgently mobilize all the required available personnel. This involves
alerting the managing team, calling the most senior/ experienced provider and alerting
the liaison team.
 Evaluate for ABC: make a rapid evaluation of the general condition of the woman
including vital signs (pulse, blood pressure, respiration, temperature).
 Start an IV line and infuse fluids, establish two IV lines if necessary.
 Check if the uterus is contracted. If not, massage it to expel blood and blood clots.
 Position the patient flat.
 Give Oxygen by mask or nasal catheter.
 Give oxytocin 10 units IM (if not given during the 3rd stage of labor).
 Give Tranexamic acid 1gm in 10 ml IV over 10 min within 3 hours of birth. If bleeding
continues after 30 minutes or if bleeding restarts within 24 hours of completing the first
dose, administer second dose of TXA 1gm IV.
 Take blood (5 mL) for hemoglobin (Hgb) / hematocrit (Hct).
 Catheterize the bladder.
 Check if the placenta is expelled and examine the placenta to ascertain completeness.
 Examine the cervix, vagina and perineum for tears.
 Apply NASG.
 Monitor vital signs.
 Provide specific treatment for the identified specific cause (see below).
Specific Management
Atonic uterus:
 Continue to massage the uterus.
 Administer oxytocin 20-40 IU/ 1 litre normal saline or Ringer‘s lactate solution and
infuse at 60 drops/ minute.
o Continue dose at a rate of 40 drops/ minute for at least 6 hrs OR (if oxytocin is
not available).
o Give misoprostol 800 mcg stat rectally, orally or sublingual.
 If bleeding continues:
o Check placenta again for completeness.
o If there are signs of retained placental tissue remove the tissue.
o Assess clotting status using a bedside clotting test.
NOTE: If coagulopathy is diagnosed refer urgently.
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• Perform bimanual compression of the uterus (see figure 8 below), compress the aorta
(see figure 9 below) or apply NASG to decrease the bleeding.
• If bleeding continues: refer immediately accompanying the mother and continue to
provide the above measures.
Figure 8. Bimanual compression Figure 9. Technique for

compression of abdominal aorta
Tears of Cervix, Vagina or Perineum:

 Repair bleeding tears and lacerations.
 Refer urgently if bleeding cannot be controlled or if it is a cervical tear that extends into
the uterus or if the apex is not visualized.
 If there is no tear that accounts for the PPH, check for uterine rupture.
Retained Placenta:
 If the placenta is not expelled within 30 minutes after delivery of a baby, in the absence
of hemorrhage, the woman should be observed for further 30 minutes, before manual
removal placenta is attempted.
 Steps for manual removal of the placenta:-
1. Review general care principles and start IV infusion (if not already done).
2. Give pethidine and diazepam IV slowly (do not mix in the same syringe).
3. Give a single dose of prophylactic antibiotic.
4. Wear sterile long sleeve gloves and perform manual removal of the placenta.
NOTE: If the placenta does not separate from the uterine surface by gentle lateral
movement of the fingertips at the line of cleavage, suspect adherent placenta,
stop the procedure and urgently refer providing supportive care.
5. Give oxytocin 20 units in 1 L IV fluid at 60 drops per minute.
6. If there is continued heavy bleeding, give ergometrine 0.2 mg IM or misoprostol.
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7. Examine the woman carefully and repair any tear to the cervix or vagina.
Retained placental fragments:
 Feel inside the uterus for placental fragments.
 Remove placental fragments by hand, gauze curettage or sponge/ ovum forceps.
 If this procedure fails (may be due to adherent placenta) and/ or bleeding continues, refer
urgently.
Acute inversion of the uterus:
 If the woman is in severe pain, give pethidine 1 mg/kg body weight (maximum of 100 mg)
IM or IV slowly or give morphine 0.5 mg/ kg body weight.
 Immediate manual replacement of the uterus by applying gentle transvaginal pressure.
o Wearing sterile gloves, grasp the inverted uterus and push it through the cervix in
the direction of the umbilicus to its normal anatomic position, using the other
hand to support the uterus (see figure 10 below).
o If the placenta is still attached, manually remove the placenta after correction.
 Refer the mother urgently if manual replacement fails.
Figure 10. Manual replacement of placenta
See annex 4 below for management algorithm of PPH.
MANAGEMENT OF SECONDARY PPH
• Resuscitate and refer.
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Annex 4. Postpartum Hemorrhage (PPH) Management Algorithm for Health Center
Diagnosis
 BP<90/60mmhg
 Pulse rate >110bpm
Whenever PPH occurs
 Excessive bleeding >500ml Call out for help
 Hct drop of > 10% from baseline
General management
 Evaluate for ABC (Airway, Breathing, circulation)
 Secure IV line and give IV fluids
 Give Oxygen by Mask or Nasal catheter
 Check if the uterus is contracted  If not massage Oozing from Consider
 Check Hemoglobin or hematocrit vein puncture Coagulopathy
 Bedside bleeding and clotting tests
site
 Catheterize the bladder
 Monitor Vital signs
 Continue fundal Massage
Is placenta delivered and complete?  Oxytocin 20-40 IU in 1 litter of fluid
Yes
 Tranexamic acid 1gm in 10ml IV over
10min within 3 hours of birth
NO
Manual exploration of the Uterus Contracted Uterus Contracted Uterus Soft uterus still
still bleeding no bleeding bleeding
Indistinct cleavage Distinct

plane cleavage plane Explore for trauma Continue Oxytocin Presumed uterine atony
Consider Morbidly Manual removal of

Adherent placenta the placenta
Vaginal/perineal Cervical laceration Cervical Laceration No lower genital
Laceration with no extension with extension tract trauma seen
Refe
Repair Repair Refer Explore the Uterus
r
Retained Ruptured Uterine inversion Nothing found

placenta Uterus still bleeding
fragments
 Continue fundal
 Remove Refer Replace the Uterus Massage
Refer  Misoprostol 800 _gm
 If fails refer with analgesia
(PR, PO, Sublingual)
 Consider referral if
bleeding continues
Refer if not successful
NOTE: When appropriate apply bimanual compression, aortic compression or NASG

at any stage of the management.
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PUERPERAL FEBRILE MORBIDITIES
DEFINITION
Puerperal fever, also known as postpartum fever is defined as temperature of 38.0°C or higher
during the first 10 days postpartum, exclusive of the first 24 hours.
RISK FACTORS
• Prolonged and premature rupture of the membranes
• Prolonged labor
• Frequent vaginal examination
• Retained placental fragments or membranes
• Anemia and poor nutrition during pregnancy
• Immune compromised state
• Genital or urinary tract infection prior to delivery
• Cesarean birth
• Obesity
• Diabetes
• Indwelling urinary catheter
DIAGNOSIS & MANAGEMENT
Signs and symptoms

To identify possible causes of a postpartum febrile morbidity using signs and symptoms see table
16 below.
Investigations
• Blood film
• CBC including ESR
• Urinalysis
• Stool exam
• Abdominopelvic ultrasound when available (for retained product of conceptus &
peritoneal fluid collection).
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Presenting symptoms & sign Symptoms & sign sometimes Probable diagnosis
typically present present
• Fever / Chills • Light vaginal bleeding Metritis
• lower abdominal pain
• Purulent foul-smelling lochia
• Tender Uterus
• Lower abdominal pain and • Poor response for antibiotics Pelvic abscess
distension • Swelling in adnexa or
• Spiking fever / Chills pouch of Douglas
• Tender uterus
• Fever / chills • Rebound tenderness Peritonitis
• Lower abdominal pain • Abdominal distension
• Absent bowel sound • Nausea / vomiting
• Abdominal tenderness
• Breast pain and tenderness • Hard enlarged breast Breast engorgement
• 3-5 days after delivery • Both breasts affected
• Breast pain and tenderness • Inflammation preceded by Mastitis
• Reddened, wedge shaped area engorgement
on breast • Usually one breast affected
• 3-4 week after delivery
• Firm, very tender breast • Fluctuant swelling on breast Breast abscess
• Overlying erythema • Draining pus
• Fever • Hardened wound Wound Abscess /
• Wound with Pussy discharge • Purulent discharge Cellulites
• Painful and tender wound • Reddened area around
• Erythema and edema beyond wound
edge of incision
• Spiking fever / chills • Suprapubic or lower Cystitis
• Dysuria abdominal pain
• Increased frequency and
urgency of urination
• Spiking fever / chills • Costovertebral angle Acute Pyelonephritis
• Dysuria tenderness
• Increased frequency and • Nausea / vomiting
urgency of urination, flank • Anorexia
pain
• Fever • Rapid breathing Pneumonia
• Difficulty in breathing • Rhonchi/ Rales
• Cough with expectoration and
• Chest pain
• Fever chills • Enlarged Spleen Malaria
• Headache • Convulsion
• Muscle / joint pain • Jaundice
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• Coma (when severe)
• Anemia
Table 16. Diagnosis of Puerperal Fever.
TREATMENT
Treatment protocol for breast engorgement, mastitis and metritis is as follows:
Metritis
• Resuscitate as needed.
• Give the initial dose of a combination of antibiotics
o Ampicillin 2 g IV every 6 hours; PLUS
o Gentamicin 5 mg/kg body weight IV every 24 hours; PLUS
o Metronidazole 500 mg IV every 8 hours.
• Refer immediately to a hospital with appropriate pre-referral care
Breast engorgement
Breastfeeding woman:
• If the baby is not able to suckle, encourage the woman to express milk
• If the baby is able to suckle, encourage her to breastfeed more frequently, using both
breasts during each feeding. Show her how to hold the newborn and help it attach.
• Relief measures before feeding may include:
o Apply warm compresses to the breasts just before breastfeeding, or encourage the
woman to take a warm shower.
o Support breasts with a binder or brassiere.
o Apply cold compress to the breasts between feedings to reduce swelling and pain.
o Give paracetamol 500 mg -1 gram or Ibuprofen 400 mg every 6-8 hours by mouth
as needed.
• Follow up 3 days after initiating management to ensure response.
Not breastfeeding:
If the woman is not breastfeeding:

• Support breasts with a binder or brassiere.
• Apply cold compresses to the breasts to reduce swelling and pain.
• Avoid massaging or applying heat to the breasts.
• Avoid stimulating the nipples.
• Give paracetamol 500 mg to 1 gram or Ibuprofen 400 mg every 6-8 hours by mouth as
needed.
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Mastitis
• Treat with antibiotics:
o Cloxacillin 500 mg by mouth four times per day for 10 days
o OR Erythromycin 500 mg by mouth three times per day for 10 days.
• Encourage the mother to:
o Continue breastfeeding
o Support breasts with a binder or brassiere
o Apply cold compresses to the breasts between feedings to reduce swelling and
pain.
• Give paracetamol 500 mg -1 gram or Ibuprofen 400 mg 6-8 hours orally as needed.
Breast abscess:
• Start treatment with antibiotics:
o Cloxacillin 500 mg orally four times a day for 10 days
o OR Erythromycin 500mg oral three times a day for 10 days.
• And refer the woman, advising her to support breasts with a binder or brassiere.
Infection of perineal and abdominal wounds

• If there is superficial fluid or pus, open and drain the wound with care not to disrupt facial
sutures in case of abdominal wounds.
• If there is necrotic tissue and wide area of erythema refer after appropriate general care.
• If infection is superficial and does not involve deep tissues, monitor for development of
an abscess and give a combination of antibiotics:
o Ampicillin 500 mg orally, four times a day for 5 days
o Metronidazole 500 mg orally, three times a day for 5 days
o Place a damp dressing in the wound and have the woman return to change the
dressing every 24 hours.
• If the infection is deep it involves muscles and causes necrosis (necrotizing fasciitis), start
a combination of antibiotics (below) and refer urgently to a higher facility:
o Ampicillin 2gm IV every 6 hours
o Gentamicin 5 mg/kg body weight IV every 24 hours
o Metronidazole 500 mg IV every 8 hours
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• For perineal wound infection open the wound, provide toileting with ample amount of
saline and advice on frequent washing at home with clean water. Give oral analgesics and
broad spectrum antibiotics (Amoxicillin 500 mg TID for 7 days).
• If infection involves muscles and is causing necrosis (necrotizing fasciitis), start a
combination of antibiotics (above) and refer urgently.
• If the patient has pelvic abscess, peritonitis and acute pyelonephritis provide initial
supportive care (hydration, analgesics/ antipyretics and a dose of Ampicillin 2 g IV every
6 hours; PLUS, Gentamicin 5 mg/kg body weight IV every 24 hours; PLUS metronidazole
500 mg IV every 8 hours) and urgently refer her to a hospital.
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PSYCHOLOGICAL MORBIDITIES DURING
PUERPERIUM
INTRODUCTION
Postpartum emotional distress is fairly common after pregnancy and ranges from mild blues,
postpartum depression to psychosis. Postpartum psychosis can pose a threat to the life of the
mother or baby.
RISK FACTORS
• Previous history of depression or psychosis
• Depressive symptoms during pregnancy
• Family history of depression or psychosis
• Stress around child care
• Marital conflict
• Stressful life events in the previous 12 months
• Lack of perceived social support from family and friends for the pregnancy
• Lack of emotional and financial support from the partner
• First pregnancy
MATERNITY BLUES / POSTPARTUM BLUES

The most common psychological disorder that occurs in the postpartum period is this condition.
Diagnosis
• Mild and often rapid mood swings from elation to sadness
• Irritability, anxiety
• Decreased concentration
• Insomnia, tearfulness and crying spells.
Commonly postpartum women develop these features within 2-3 days of delivery. Symptoms
typically peak on the 5th postpartum day and resolve within 2 weeks.
Management
Postpartum blues typically resolve over time and with conservative management. Supportive
treatment is indicated, and sufferers can be reassured that the dysphoria is transient. Advise on:
• Adequate time for sleep and rest, and continuous family support.
• The newborn should be taken care of by someone else during night time.
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• Patients should be monitored for development of more severe psychiatric disturbances,
including postpartum disorders.
• Care givers (family) should be counseled on significance, need for vigilance & supportive
measures.
• If the symptoms don’t resolve within 2 weeks, please refer to a hospital.
POSTPARTUM DEPRESSION
Affects up to 30% of women and typically occurs in the early postpartum weeks or months and
may persist for a year or longer.
Diagnosis
In nearly all respects, postpartum depression is similar to other major and minor depressions.
Symptoms must be present for most of the day, every day, for at least 2 weeks.
Symptoms include:
• Depressed mood
• Loss of interest or pleasure in most or all activities
• Insomnia or hypersomnia
• Change in appetite
• Change in weight
• Psychomotor retardation or agitation
• Low energy, poor concentration, thoughts of worthlessness or guilt, recurrent thoughts
about death or suicide.
The prognosis for postpartum depression is good with early diagnosis and treatment. More than
two-thirds of women recover within a year.
Management
Providing a companion during labor may prevent postpartum depression. Once established,
postpartum depression requires psychological counseling and practical assistance which
includes:
• Providing psychological support and practical help (with the baby and through home
care).
• Listening to the woman and providing encouragement and support.
• Link to mental health service providers if present in the institution but if not referral to a
hospital for further psychiatric consultation and management
POSTPARTUM PSYCHOSIS
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Postpartum psychosis is the most severe puerperal mental disorder and typically occurs around
the time of delivery (within 2 weeks). It affects less than 1% of women. The cause is unknown,
although about half of the women with pre-existing psychotic illness are at highest risk, and those
with prior episodes of postpartum depression.
Diagnosis
Postpartum psychosis is characterized by:
• Abrupt onset of delusions or hallucinations Insomnia, a preoccupation with the baby
• Severe depression, anxiety
• Despair and suicidal or infanticidal impulses.
Prognosis for recovery is excellent but some of the affected women will suffer a relapse with
subsequent deliveries.
Management
The course of postpartum psychosis is variable and depends on the type of underlying illness.
The clinical course of bipolar illness or schizoaffective disorder in puerperal women is
comparable to that for non-pregnant women.
They usually require hospitalization for pharmacological treatment and long-term psychiatric
care is needed.
In the presence of the above symptoms link to mental health service providers in the
institution but if not, refer to a hospital where there is a mental health unit.
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PRETERM LABOR
DEFINITION
Preterm labor refers to the onset of labor before 37 completed weeks of gestational age.
CLASSIFICATION
 Early preterm: less than 34 weeks of gestation
 Late preterm: ≥ 34 weeks of gestation
RISK FACTORS
 Socio-demographic conditions: low socioeconomic status, maternal age <18 years,
unsupported / unwanted pregnancy, smoking, alcohol consumption, excess physical work
/ activity.
 Medical conditions: UTI, malaria, HIV, syphilis, bacterial vaginosis, DM, hypertension,
anemia, asthma, thyroid diseases, obesity, under nutrition.
 Gynaecologic conditions: congenital uterine anomalies, cervical insufficiency, myoma
(intramural/ submucus), uterine synechiae.
 Obstetric conditions: previous history, family history, multifetal gestation, short inter
pregnancy interval (<6 months), polyhydramnios, fetal macrosomia, fetal malformations,
poor ANC, placental abruption and early vaginal bleeding during the index pregnancy,
amniocentesis, ECV, cervical procedures during pregnancy.
DIAGNOSIS
History:
 Abdominal cramps and back pain
 Pelvic or lower abdominal pressure
 Changes in type and amount of vaginal discharge (mucus, bloody or leakage of watery
fluid)
 Four uterine contractions per 20 minutes or eight contractions per 60 minutes which are
accompanied by one of the following:
o Rupture of membranes
o Cervical dilation greater than 2 cm
o Cervical effacement exceeding 80%
o Progressive cervical dilatation and effacement on follow up
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Investigations
 WBC with differential count
 Urine analysis
 Ultrasound
MANAGEMENT
 Refer urgently after pre-referral care is provided.
 Pre-referral management includes:
o Dexamethasone 6 mg IM stat (document the time given on referral paper).
o Tocolysis:
 Secure IV line and provide Nifedipine 20 mg PO stat (document the time given
on referral paper).
 Monitor vital signs (blood pressure and pulse rate) every 30 minutes on the
way of referral. Give IV fluid if the client becomes hypotensive.
NOTE:- Contraindications for tocolytics include preterm prelabor rupture of

membranes (PPROM), chorioamnionitis, antepartum hemorrhage, cardiac
disease, fetal death, fetal congenital abnormality not compatible with life, cervical
dilatation >4 cm and effacement >80%.
o Antibiotics:
 Antibiotics should be administered for spontaneous preterm labour with
unknown GBS status.
 Administer Ampicillin 2gm IV as initial loading dose.
 Delivery: Attend delivery only in case of imminent delivery.
o Attend the labor and provide essential newborn care.
o Start Kangaroo mother / father care.
o Immediately refer very low birth weight and very premature (<2000 gm and GA
<34 weeks) neonates.
o Make sure the neonate is transferred with the mother to hospital for better care.
COMPLICATIONS
 Maternal complications
o Increased operative delivery
 Fetal / neonatal Complications
o Preterm birth and prematurity
o Birth Injury
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o Perinatal / neonatal asphyxia
o Hypothermia
o Hyperbilirubinemia
o Hypoglycemia
PREVENTION
 Detect early and manage treatable risk factors (infectious and chronic medical
conditions).
 Identification of pregnancy complications which can lead to premature delivery and early
referral.
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MALPRESENTATION
DEFINITION
• Malpresentations are all fetal presentations other than vertex.
CLASSIFICATION / TYPES
• Breech
• Face
• Brow
• Shoulder
• Compound
PREDISPOSING FACTORS
• Maternal:
o Contracted pelvis
o Pelvic tumors: uterine myoma, ovarian tumors etc.
o Uterine anomalies: bicornuate uterus, uterine septum etc.
o High parity
• Fetal and placental:
o Prematurity
o Fetal anomaly (e.g. hydrocephalus, anencephaly)
o Polyhydramnios / oligohydramnios
o Multiple pregnancy
o Placenta previa
DIAGNOSTIC APPROACH
• Clinical assessment (History, obstetric palpation and digital vaginal examination in labor).
• Ultrasound is mainly used to confirm clinical diagnosis and to investigate for predisposing
factors.
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BREECH PRESENTATION
DEFINITION
Breech presentation is when the fetal buttock and / or feet are the presenting part occupying the
lower pole of the uterus.
CLASSIFICATION
• Frank breech: The lower extremities extended at knee and flexed at hip.
• Complete or flexed breech: The lower extremities flexed both at hip and knee.
• Footling breech /incomplete breech: When one or both of the baby’s feet lie below the
breech.
See figure 11 below.
Frank Breech Complete Breech Footling Breech
Figure 11. Types of breech presentation.
DIAGNOSIS
Clinical assessment
• The mother may report sub costal discomfort when the head occupies the fundus rather than
the lower segment.
• Identify the following predisposing factors
o Multiparty
o Previous history of breech presentation.
o Preterm pregnancy
o Contracted pelvis
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o Fetal congenital anomalies
o Uterine malformation or presence of tumor previa.
On abdominal palpation (Leopold's maneuvers):

• The head is felt as hard, globular and ballotable mass at the fundus and the breech will be
soft and bulky at the lower pole of the uterus.
• FHB loudest just above the umbilicus (may be lower with engagement).
On pelvic examination
• On vaginal examination in early labor; soft and irregular parts are felt through the cervical
opening.
• Palpation of ischial tuberosities, sacrum and the feet by the sides of the buttock.
• In frank breech hard feel of the sacrum is felt and often mistaken for the head. Ischial
tuberosities, anal opening and sacrum will be felt.
• To differentiate from face presentation ischial tuberosities and anal opening will be
identified in straight line.
• Perform clinical pelvimetry and look for cord presentation or prolapse.
Ultrasound
• To confirm clinical diagnosis.
• To estimate fetal weight, and to investigate for fetal anomalies and other predisposing
factors.
MANAGEMENT
• Ideally, every breech birth should take place in a hospital with the ability to perform an
emergency caesarean section.
• At term or in early labor, refer to Hospital.
• In case of advanced labor review for indications, ensure that all conditions for vaginal
breech delivery are met.
• Refer urgently if one of the following conditions are identified in advanced labor:
o Footling breech
o Estimated fetal weight (clinical or ultrasound) > 3500 gm
o Extended or deflexed neck, or
o The presence of compounding factors such as:
 Previous CS
 Elderly primigravida
 History of infertility
 Bad obstetric history
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 Intra Uterine Growth Restriction (IUGR)
 Post term pregnancy
 Any degree of contracted pelvis
 Uterine dysfunction, prolonged labor or failure to progress in labor
VAGINAL BREECH DELIVERY

• If there is no time for referral (advanced labor or imminent delivery), the delivery can be
conducted at health center.
• The most experienced provider in breech delivery should attend the delivery.
• The mother has to be counseled for the relative risk of perinatal mortality and morbidity
compared with vertex presentation and ensuring availability of emergency set up.
First stage of labor

First stage of labor is monitored using partograph with close fetal monitoring as in cephalic
presentation.
• Secure IV line
• Consider analgesics as labor pain management
• Immediate vaginal examination at rupture of membranes to rule out cord prolapse
• Avoid ARM
• Meconium is common with breech labors and presence of meconium alone is not considered
as a sign of fetal asphyxia.
• The mother should be instructed not to push until the cervix is fully dilated.
Second stage of labor

Once the cervix is fully dilated and the buttocks have entered the vagina tell the woman to bear
down with the contractions.
Delivery of the buttocks and legs:

• If indicated (e.g. tight perineum), perform an episiotomy.
• As the buttocks get delivered, gently guide the sacrum anteriorly. Wait till body is born to
the level of the umbilicus (no other manipulation at this stage).
• Sweep each leg away from the midline. If the legs do not deliver spontaneously, assist
delivery of one leg at a time, by lateral rotation of thighs and flexion of knees.
• Splint the median thigh of the fetus with fingers positioned parallel to the femur and exert
pressure laterally so as to sweep the legs away from the mid line or (Pinard’s maneuver).
See figure 12 below.
• Pushing behind the knee so that it bends; then grasp the ankle and deliver the foot and leg.
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.
Figure 12. Pinard’s maneuver.
• Wait till body is born to the level of the umbilicus. Put fingers on the anterior superior iliac
crests and thumbs on the sacrum to apply downward rotational traction (figure 13). Use a
dry towel to wrap around the hips (not the abdomen) to help with gentle traction of the
infant. Do not hold the baby by the flanks or abdomen as this may cause kidney or liver
damage.
Figure 13. Holding the baby.
Delivery of the arms and shoulders

• When both scapulae are visible the body is rotated 900. Allow the arms to disengage
spontaneously one by one. Only assist if necessary.
• If the arm does not spontaneously deliver, locate the humerus, place one or two fingers in
the elbow and laterally sweep the arm across the chest.
• Rotate the body 1800 to deliver the other arm.
• See figure 14 below for the steps to follow.
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1 2 3
4 5 6
Figure 14. Delivery of Arms and Shoulders.
• If the arms are trapped in the birth canal, use classical method (delivering posterior
shoulder) or Lovset’s maneuver (figure 15).
o Lovset’s maneuver: Hold the fetus around the bony pelvis with thumbs across the
sacrum. The fetus is turned through half a circle (1800) while downward traction is
applied at the same time, so that the posterior arm emerges under pubic arch and then
hooked. The position is restored and anterior arm is delivered in the same manner.
o Delivering posterior shoulder: Hand is introduced along the curve of sacrum while
the baby is pulled slightly upwards (figure 16). First post arm is delivered by applying
firm pressure over the arm and pushing over the baby’s face.
1. 2.
3.
Figure 15. Lovset’s Maneuver.
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Figure 16. Classical method (delivery of posterior shoulder).
Delivery of the after coming Head

• When the nape of the neck is visible, apply fundal pressure to maintain flexion and deliver
the upcoming head.
• Mauriceau Smellie Veit Maneuver (MSV): Index and middle finger of one hand are
applied over the maxilla, to flex the head, while the fetal body rests on the palm of the same
hand and forearm. Fetal legs straddle the forearm. Two fingers of the other hand are hooked
over the fetal neck and grasp the fetal shoulders. Apply gentle downward traction to deliver
the head. See figure 17 below.
Figure 17. Mauriceau Smellie Veit Maneuver (MSV).
COMPLICATIONS OF BREECH DELIVERY

Maternal
• Soft tissue injury
Fetal
• Asphyxia • Organ damage and fracture
• Arrest of after coming head • Increased perinatal morbidity and
• Brachial plexus injury (Erbs palsy) mortality
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FACE PRESENTATION
DEFINITION
• Hyperextension of the head with the face being the leading part (figure 18).
• Fetal chin (mentum) is used as a reference point.
Figure 18. Face presentation
DIAGNOSIS
• Suggestive abdominal finding: groove may be felt between the occiput and the back
(Leopold III).
• On vaginal examination:
o Fetal chin, mouth and nose palpated.
o The mouth with the two malar bone prominences makes a triangle (unlike in breech
where the anal orifice with two trochanteric eminences is in a line).
o Mento-anterior: chin anterior position
o Mento-posterior: chin posterior position
MANAGEMENT
• Mento-anterior: If the pelvis is grossly adequate, progress of labor is good and labor has
advanced; attend labor.
• Persistent mento-posterior: Refer for cesarean delivery.
BROW PRESENTATION
DEFINITION
Brow presentation occurs when there is partial extension of the fetal head making the occiput
higher than the sinciput. (Figure 19)
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Figure 19. Brow presentation
DIAGNOSIS
• Suggestive abdominal findings
o Occiput felt above sinciput
• On vaginal examination
o Anterior fontanelle and orbit are felt
NATURAL COURSE
• In brow presentation, engagement is usually impossible and arrest disorder is common.
MANAGEMENT
• Refer urgently
TRANSVERSE LIE (SHOULDER PRESENTATION)
DEFINITION:
Transverse lie is when the long axis of the fetus is perpendicular to the long axis of the uterus.
Shoulder presentation is when the shoulder is the presenting part in a transverse lie. See figure 20
below.
Figure 20. Transverse lie
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DIAGNOSIS
• Abdominal findings:
o Neither the fetal head nor the breech are felt in the upper and lower parts of the
uterus.
o The abdomen is transversely elongated than longitudinally.
o Fundal height is less than the gestation age.
• Vaginal finding:
o The shoulder or the prolapsed arm is felt.
• Ultrasound is helpful to confirm the diagnosis.
MANAGEMENT
• If detected before 36 weeks of GA follow her until 36weeks of GA for possible
spontaneous rotation.
• If detected at or after 36 weeks of GA or during labor at any GA, refer immediately to
hospital (CEmONC facilities).
• If it is a term pregnancy or if the woman is in labor, refer to hospital (CEmONC facilities)
NOTE: Neglected shoulder presentation leads to obstructed labor and associated

complications.
COMPOUND PRESENTATION
DEFINITION
• Compound presentation is when fetal extremities prolapse alongside the main presenting
part, usually the hand alongside the fetal head.
DIAGNOSIS
• On vaginal examination: irregular mobile tissue / mass adjacent to the larger presenting
part.
MANAGEMENT
• Don’t manipulate the extremity
• Refer immediately
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MALPOSITIONS
DEFINITION
• Malpositions are abnormal positions of the vertex (other than occipito-anterior position)
of the fetal head relative to the maternal pelvis.
CLASSIFICATION / TYPES
• Occiput posterior position
• Persistent occiput transverse position
OCCIPUT POSTERIOR POSITION
DEFINITION
When the occiput is posterior in relation to the maternal pelvis (figure 21).
Direct Occipitoposterior Left Occipitoposterior Right Occipitoposterior
Figure 21. Types of occipito posterior positions.
CAUSES AND RISK FACTORS

• Nulliparity
• Inadequate power (contraction and poor pushing)
• Contracted pelvis
DIAGNOSIS
• Suggestive abdominal findings:-
o Flattened lower part of the abdomen
o Anteriorly palpable fetal limbs
o Fetal heart heard in the flank area
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• On vaginal digital examination:-
o Posterior fontanelle towards the sacrum
o Anterior fontanelle felt anteriorly if neck is flexed
MANAGEMENT
• If pelvis is adequate and signs of CPD or any condition that require cesarean delivery is
ruled out, expect vaginal delivery with close follow up.
• If the cervix is fully dilated:-
o Attend delivery as occiput posterior
o Vacuum assisted delivery if indicated
• If there is poor progress of labor and /or sign of CPD, urgently refer to a hospital.
PERSISTENT OCCIPUT TRANSVERSE POSITION
DEFINITION
Persistent occiput transverse position is defined as an occiput transverse position that is
maintained for an hour or more in the second stage of labor.
Usually, small fetuses can be delivered in occiput transverse position while others rotate
anteriorly or posteriorly after the fetal head descends in to the pelvic floor.
CLASSIFICATION
• High transverse arrest (arrest above station +2 on a -5 cm to + 5 cm scale)
• Deep transverse arrest (arrest below station +2 on a -5 cm to + 5 cm scale)
CAUSES AND RISK FACTORS

• Inadequate power (contraction and poor pushing)
• Platypelloid and android pelvis
• Fetal head long occipitofrontal diameter
DIAGNOSIS
• On vaginal examination:-
o The fetal sagittal suture and fontanelles are palpable in the transverse diameter of
the pelvis.
o The fetal ears can be palpated superiorly under the symphysis and inferiorly above
the sacrum / coccyx.
NOTE: There may be anterior or posterior asynclitism.
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MANAGEMENT
• Expectant management: If there is progress in descent and the fetal heart rate is
reassuring, expectant management is the preferred option. Partial or complete rotation
may still occur spontaneously.
• If there is any abnormality in the progress of labor or high transverse arrest, refer to
institutions with caesarean delivery service.
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PROLONGED AND OBSTRUCTED LABOR
PROLONGED LABOR
DEFINITION
Prolonged labor is labor lasting more than 12 hours or an active phase of over 6 hours.
CAUSES
• Power: Inadequate power due to poor or uncoordinated uterine contraction.
• Passenger: If fetal head is too large to pass through the mother‘s pelvis, or the fetal
presentation is abnormal.
• Passage: Small maternal pelvis, abnormal shape of the pelvis, or if there is soft tissue
tumor in the pelvis.
DIAGNOSIS
• Using the partograph if cervicogram crosses the alert or action line.
• The following table (table 17) shows diagnostic criteria for prolonged labor.
CLASSIFICATION
• See table 17 below for the classification.
Table 17. Classification of abnormal labor
Diagnostic Criteria Preferred

Labor Pattern Exceptional Rx
Rx
Nulliparas Multiparas
FIRST STAGE PROLONGATION DISORDER
Prolonged Latent
(from onset of painful, >20hrs >14hrs
regular contractions) • Oxytocin
Bed rest
• C/S delivery for
Prolonged latent urgent problems
(confirmed true labor) > 8hrs >8hrs
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PROTRACTION DISORDERS
• Expectant/ Support
Active phase dilatation <1.2 cm/hr <1.5 cm/hr
• ARM
• Augmentation
Descent <1 cm/hr <2 cm/hr • C/S for CPD or contraindication for
oxytocin use
ARREST DISORDERS
Arrest of cervical
>2 hr >2 hr • No contraindication for
dilatation
augmentation-Oxytocin
Arrest of descent >1 hr >1 hr • CPD- C/S
No descent in late active • Contraindication for
Failure of Descent augmentation - C/S
stage
SECOND STAGE DISORDERS
> 2 hrs > 1 hr

Prolonged second With
With epidural
stage epidural • Depends on identified cause and
> 3.5 hrs presence of complications
> 2.5 hrs
Failure of descent No descent in second stage
MANAGEMENT
• If there is no contraindication for instrumental delivery, perform vacuum delivery.
Otherwise refer.
OBSTRUCTED LABOR
DEFINITION
Obstructed labor is failure of descent of the fetus in the birth canal for mechanical reasons in
spite of good uterine contraction.
NB: It is an outcome of neglected and mismanaged labor.
CAUSES:
Maternal
• Contracted pelvis / cephalopelvic disproportion (commonest)
• Soft tissue abnormalities (e.g. tumor, placenta previa, vaginal septum, tight perineum,
uterine congenital anomalies)
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Fetal
• Macrosomia
• Malpresentations
• Malposition
• Locked twins, conjoined twins
• Fetal anomalies e.g. hydrocephalus
• Shoulder dystocia
DIAGNOSIS
The clinical findings depend on the duration, complications, cause of the obstruction and parity.
History:
• Previous history of prolonged/obstructed labor
• prolonged rupture of the membranes
• Pain full contractions
• Fever
• Previous operative deliveries (instrumental deliveries, cesarean section)
• History of pelvic injury
• General condition of the patient
o Exhausted due to severe pain and lack of sleep
o Anxious, terrified
o Signs of dehydration.
o Deep and rapid respiration
• Vital sign
o Temperature (pyrexia)
o Pulse rate (rapid thready pulse)
o BP (hypotension)
• Abdominal findings
o Distention of the bowel as a result of acidosis and hypokalemia
o Two / Three tumor abdomen (figure 22)
o Abnormal fetal heart rate (tachycardia or bradycardia)
o No fetal heart tone if the fetus dies from anoxia
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Bandl’s ring
Distended lower
Retracted upper uterine segment
uterine segment
Bladder
Figure 22. The three tumors and ring of Bandl.
Genito-urinary
• Vaginal examination findings:-
o Edema of lower vagina and vulva (canula sign)
o Meconium- stained and foul-smelling discharge
o Bleeding may be seen
o Edema of the cervix
o Cervix poorly applied to the head
o Full cervical dilatation usually occurs in cephalic presentation
o Little or no descent of the presenting part
• Fetal Status:-
o Molding
o Depending on the type of fetal presentation, findings may include large caput
succedaneum in cephalic presentation, shoulder with or without prolapsed arm in
transverse lie, brow or face in deflected neck.
o Caput formation makes identification of the presentation and position very
difficult.
MANAGEMENT
• Secure IV line with ringer lactate or normal saline, infuse a liter in 15-20 minutes.
• Start with initial dose of antibiotics with anaerobic coverage (Ampicillin 2gm IV,
Gentamicin 80mg IV and Metronidazole 500mg IV; or Ceftriaxone 1gm IV and
Metronidazole 500mg IV).
• Catheterize bladder
• Urgently refer
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COMPLICATIONS
Early complications:
• Atonic PPH, uterine rupture, peripartum infection (peritonitis, sepsis and septic shock
leading to various organ failures (temporary or permanent)), tetanus, maternal death, fetal
distress, fetal & neonatal infections, fetal and neonatal death.
Late complications:
• Fistula (e.g. vesico-vaginal, rectovaginal) and its aftermath, vaginal stenosis & stricture,
foot drop (sciatic, common peroneal nerve), infertility following postpartum PID or
hysterectomy, psychological trauma due to the painful labor experience, loss of the baby
and social isolation.
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UTERINE RUPTURE
DEFINITION
Uterine rupture: A tear through the uterine wall above the cervical uterine junction during
pregnancy and labor.
PREDISPOSING FACTORS
• CPD, prolonged & obstructed labor
• Malpresentations and malpositions
• Grand multipara
• Previous caesarean section
• Operative delivery
• Cervical tear – may extend
• Abdominal trauma
CLASSIFICATION
 Complete: Where all the three layers of the uterus are involved and there is a direct
communication between the uterine and abdominal cavities.
 Incomplete: In incomplete uterine rupture, the peritoneum covering the uterus remains
intact.
DIAGNOSIS
Clinical features
• Restlessness
• Sudden cessation of uterine contraction
• Vaginal bleeding and hematuria
• Maternal tachycardia, tachypnea and hypotension
• Pallor
• Gross abdominal distention and diffuse abdominal tenderness
• Easily palpable fetal parts in the abdomen
• Absent fetal heart beat
• May complain of shoulder pain
• Loss of station
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CLINICAL FINDINGS
 The clinical findings may vary from mild and non-specific to an obvious clinical crisis
and abdominal catastrophe.
 The classic signs and symptoms of complete uterine rupture are:
o Sudden onset of tearing abdominal pain (sudden feeling of something giving way)
o Cessation of uterine contractions
o Recession of the presenting part
o Absent fetal heart sounds
o Easily palpable fetal parts
o Abnormal uterine contour
o Signs of intra-abdominal hemorrhage
o Tender abdomen
o Vaginal bleeding
o Hemorrhagic shock
o Copious bright red blood through the catheter indicate involvement of the bladder
 Clinical finding of incomplete rupture include:-
o The fetus remains in the uterus and signs of shock may be delayed until after delivery
o Rapid maternal pulse
o Labor pain may continue
o Fetal heart rate abnormalities: this is the most reliable warning sign.
o Vaginal bleeding
MANAGEMENT
• Secure double IV line with ringer or normal saline, infuse a liter in 15-20 minutes
• Intranasal oxygen
• Start with initial dose of antibiotics with anaerobic coverage (Ampicillin 2gm IV,
Gentamicin 80mg IV and Metronidazole 500mg IV; or Ceftriaxone 1gm IV and
Metronidazole 500 mg).
• Catheterize bladder
• Urgently Refer
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POST TERM PREGNANCY
DEFINITION
Post term pregnancy is a pregnancy that advances to or beyond 42 completed weeks or 294 days
of gestation from the first day of the last normal menstrual period (LNMP).
RISK FACTORS
• Previous history of post term
• Nulliparity
• Male fetus of the current pregnancy
• Obesity
• Older maternal age
• Maternal or paternal personal history of postterm birth.
DIAGNOSIS
The diagnosis of post term pregnancy is based on accurate gestational dating. The most common
methods to determine the EDD are:
1. Knowledge of the date of the LMP.
2. Early ultrasound assessment (before 24 weeks).
If LNMP is known and reliable, calculate the gestational age from the given date.
• The given LNMP is said to be reliable if:
o The date of onset of the LNMP is accurately recalled.
o The woman had regular menstrual cycle for at least three cycles before the LNMP.
o She was not using any form of hormonal contraceptives for at least 3 months prior
to the LNMP.
If LNMP is not known or not reliable, use
• History: If date of quickening is recalled accurately, calculate the gestational age by
adding 20 weeks in nullipara or 18 weeks in multipara to the weeks lapsed since the date
of quickening.
• Physical Examination:
o If there is a documented symphysis fundal height determination in early
pregnancy before 20 weeks of gestation calculate the gestational age by adding
the lapsed weeks since the date of the fundal height determination.
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o If there is documented early detection of fetal heart tones, calculate the
gestational age by adding the lapsed weeks since the date of the detected fetal
heart tones.
NOTE: Fetal heart tone is detected at the earliest using fetoscope at 18-20 weeks and
Doppler at 10-12 weeks.
• Diagnostic Tests: If there is a documented early positive pregnancy test, calculate the
gestational age by adding six weeks to the lapsed weeks since the date of the positive
pregnancy test.
NOTE: The earliest possible time for urine pregnancy test to be positive is at 6 weeks from
LNMP. If 36 weeks or more has lapsed from the early first positive urine pregnancy
test, this is termed as post term pregnancy.
MANAGEMENT
• Ultrasound examination and daily fetal kick count between 40 and 41 weeks.
• Refer to hospital if not in labor by 41 weeks.
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VACUUM DELIVERY
DEFINITION
Vacuum delivery is an assisted instrumental vaginal delivery using ventouse (vacuum
extractor).
INDICATIONS
 Prolonged second stage of labor as a result of poor maternal effort / exhaustion.
 Non reassuring fetal heart rate pattern.
 To shorten second stage in:-
o Eclampsia
o Cardiac and cerebrovascular diseases
o Glaucoma
 Cord prolapse in 2nd stage.
PREREQUISITES
 Vertex presentation
 Fully dilated cervix
 Engaged head: Station at +2 and below (+3,+4,+5)
 Ruptured membranes
 Adequate pelvis
 Position of the head must be known
 Functioning equipment
 Provider should be skilled in performing vacuum delivery.
CONTRAINDICATIONS
 CPD
 Gestational age of ≤34 weeks
 Non vertex presentation
PREPARATION
 Explain the procedure and get written consent
 Empty bladder
 Give local anesthesia if episiotomy is required.
 Assemble, check all connections and test the vacuum on a gloved hand.
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 Components of vacuum delivery apparatus:
o Suction cup (metallic or plastic) with different size
o Vacuum pump (electrical or manual)
o Traction devices (handle and connections).
TECHNIQUES OF VACUUM DELIVERY
Application
 Identify the flexion point (see figure 23 below).
 Spread the labia and gently insert the cup angling the device posteriorly (see figure 24
below).
 Apply the appropriate size cup that can fit near to the occiput.
 The center of the cup should be 3 cm anterior to the posterior fontanel and on the sagittal
suture.
 Before creating the vacuum check for correct application and ensure that there is no
maternal soft tissue trapped within the rim of the cup
 If there is maternal tissue entrapment, release and reapply correctly before creating
vacuum.
Figure 23. Flexion point. Figure 24. Applying a vacuum cup.
Vacuum creation
 Create a vacuum of 0.2 kg/cm2 (approximately 200 mmHg) negative pressure to
maintain the cup in position.
 Recheck that maternal tissue is not entrapped.
 Gradually increase the vacuum to 0.8 kg/cm2 (approximately 600 mmHg).
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Apply Traction
 Start traction with uterine contraction with a finger on the scalp next to the cup to prevent
slippage / detachment and assess descent of the vertex (figure 25).
 Pull in line with the pelvic axis and perpendicular to the cup.
 Between contractions, check the fetal heart beat and cup application.
 As soon as the head is delivered, release the vacuum and proceed with the delivery of the
fetus.
Figure 25. Applying traction
Further care
 After delivery inspect the vagina and cervix; and repair if there is any tear or episiotomy.
 Proceed with the immediate neonatal care and examination.
FAILED VACUUM
Diagnosis of failed vacuum is based on any one or more of the following conditions:-
 The head does not advance with each pull.
 The fetus is undelivered after three pulls.
 The fetus is not delivered within 30 minutes of vacuum application.
 The cup that is applied appropriately and pulled in the proper direction with maximum
negative pressure slips off the head twice.
NB: If vacuum delivery fails, immediately refer the mother for cesarean delivery.
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COMPLICATIONS
Fetal complications
 Localized scalp oedema (caput succedaneum or chignon)
 Scalp abrasions/lacerations
 Cephalohematoma
 Subgaleal hemorrhage
 Intracranial hemorrhage
Maternal complications
 Tear / laceration of the vulva, perineum , vagina, and cervix
Management of complications
 Localized scalp oedema (caput succedaneum or chignon) and simple scalp abrasions
usually don’t require any treatment and will subside without any treatment.
 For all other neonatal complications refer the neonate for further management.
 For genital tract tear / laceration, repair or refer accordingly (refer to management of
genital tract tear / laceration, page 73).
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FAMILY PLANNING
INTRODUCTION
Family planning is defined as the ability of individuals and couples to anticipate and attain their
desired number of children and the spacing and timing of their births. It is achieved through use
of contraceptive methods and the treatment of involuntary infertility.
Family planning is a key life-saving intervention for mothers and their children by which it can
avert more than 42% of maternal deaths and 10% of child mortality if couples space their
pregnancies more than 2 years.
CHOOSING A METHOD OF CONTRACEPTION

Providers need to consider the following factors while counselling clients for contraceptive
method choice:
 Availability of a given method
 Efficacy
 Convenience
 Safety
 Duration of action
 Reversibility and time to return of fertility
 Effect on uterine bleeding
 Frequency of side effects and complications
 Protection against sexually transmitted diseases
 Medical contraindications
CATEGORIZATION OF FP BASED ON TIMING OF SERVICE PROVISON:

1. Interval / elective FP
2. Post abortion FP
3. Emergency contraception
4. Postpartum family planning
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POSTPARTUM FAMILY PLANNING (PPFP)
Postpartum family planning (PPFP) is defined as the prevention of unintended pregnancy and
closely spaced pregnancies through the first 12 months following childbirth. Timing could be:
 Post-placental– within10 minutes after delivery of placenta (e.g. IUD, tubal ligation
during CS).
 Immediate postpartum- within 48 hours after delivery (e.g. IUD, bilateral tubal
ligation with mini-laparotomy, vasectomy, implants).
 Early postpartum – 48 hours up to 6 weeks (lactational amenorrhea, condoms,
implants, mini pills)
 Extended postpartum – 6 weeks up to one year after birth. Unique considerations for
providing PPFP (IUCD, implants, tubal legation, vasectomy, condoms, lactational
amenorrhea).
Below are two diagrams (figure 26 and figure 27) depicting the timing and the possible
method options for breastfeeding and non-breast feeding mothers.
Postpartum contraception options for breast feeding women

Immediately after Initiation of FP methods for Breast Feeding Women
delivery up-to 48 hours 6 months
3 Wks 4 weeks 6 weeks 9 months
Lactational Amenorrhea Method - LAM

Progestin only pill - POP
Implants
Condom/ Spermicides
Diaphragm/ Cervical cap
IUD IUD
Female Sterilization Female Sterilization
Emergency Contraception - EC
Combined Pill - COC

Progesterone Injectable (DMPA & NET-
ET)
Male Sterilization
Figure 26. Post partum contraception options for breast feeding women.
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Postpartum contraception options for non-breastfeeding women
Immediately after Initiation of FP methods for Non-Breastfeeding Women

delivery up-to 48 hours
3 Wks 4 weeks 6 weeks 6 months 9 months
Progestin only pill - POP
Implants
Condom/ Spermicides
Diaphragm/ Cervical cap
IUD IUD
Female Sterilization Female Sterilization

Emergency Contraception - EC
Combined Pill - COC

Progesterone Injectable (DMPA & NET-ET)
Male Sterilization
Figure 27. Post partum contraception options for non-breast feeding women.
COUNSELLING
Clients can be counselled during:-
 Preconception
 Antenatal
 Intrapartum but not during active labor
 Immediate post-partum
 During postpartum, immunization, under five and other visits.
During counselling the following issues need to be addressed:
 Ensure that clients have made their decision based on full, free and informed choice
 Counsel on safer sex including use of condoms for dual protection from sexually
transmitted infections (STI) or HIV and pregnancy, particularly for those clients who are
at risk for STI / HIV.
 Counsel clients regarding possible side effect, danger sign and complications related to
the contraception
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Postpartum Family planning:
 Explain that she can become pregnant as early as four weeks after delivery if she is not
exclusively breastfeeding.
 If coupes want to have more children, advise them to wait at least for 2 years after giving
live birth and at least 6 month after failed pregnancy (e.g. Abortion).
 Information on when to start a method after delivery varies depending on whether a
woman is breastfeeding or not (see figure 26 and figure 27 above).
Post-abortion family planning:

 All clients with post abortion and safe abortion should be counselled on all contraception
options before, during and after the procedure as part of abortion care.
 In the post-abortion period, a woman should start using contraceptives as soon as
possible.
 All short acting contraceptives (COC, Depo-Provera, Condoms etc.) can be initiated
immediately after abortion.
 All long acting (IUCD / Implants) and permanent contraceptives can be initiated
immediately; but, if there is a suspicion of incomplete uterine evacuation or any uterine
infection IUCD insertion or female sterilization by tubal ligation should delayed until the
woman is treated.
Linkage and referral

Family panning clients should be referred to other facility if:
 The chosen contraceptive method is not available in the facility e.g. permanent
contraceptives.
 The contraceptive related complication is beyond the health center’s capacity.
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ANEMIA DURING PREGNANCY
DEFINITION
Anemia in pregnancy is defined as a hemoglobin concentration of less than 11 g/dL
(Hematocrit of < 33%).
CLASSIFICATION
1. Mild (10-10.9 g/dl)
2. Moderate (7-9.9 g/dl)
3. Severe (<7g/dl)
COMMON CAUSES OF ANEMIA IN PREGNANCY

In Ethiopia nutritional (iron or folate) deficiency, malaria and hookworm infestation are the
major causes of anemia in pregnancy. Iron deficiency is responsible for approximately 95% of
the anemias during pregnancy, reflecting the increased demand for iron.
DIAGNOSIS
The symptoms and signs may be vague and nonspecific:-
• Symptoms: Easy fatigability, headache, palpitations, dizziness and dyspnoea.
• Signs: Pallor, tachycardia, angular stomatitis, glossitis and koilonychia (spoon nails)
may be present in longstanding severe anemia.
LABORATORY FINDINGS
• Essential workup: hemoglobin / hematocrit; stool for ova and parasites; peripheral blood
morphology; peripheral smear for malaria; red cell indices.
• The red cells usually are hypochromic and microcytic.
TREATMENT
• In an established case of anemia, prompt adequate treatment is necessary.
• Mild & Moderate anemia:
o Rule out intestinal infections (and malaria and treat accordingly)
o Counsel on compliance with treatment
o Reassess at subsequent antenatal visit (4-6 weeks). If anemia persists, refer to
hospital.
• Severe anemia:
o Refer immediately to hospital.
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See table 18 for algorithm for screening and treatment of anemia during pregnancy.
PREVENTION
• Routine supplementation of 30-60 mg of elemental iron for all pregnant women
• Treat malaria & helminthic infections
• Advise on balanced diet
COMPLICATIONS AND THEIR MANAGEMENT

Severe anemia may result in:
• Intrauterine growth restriction
• Preterm labor (for the management refer to section on management of preterm labor,
page 85).
• Congestive heart failure
• Increases risk of antepartum and puerperal infections (for the management refer to
section on management of puerperal infections, page 78)
• Reduced ability to tolerate blood loss during labor and delivery
• Low birth weight
• Increased maternal and perinatal, morbidity and mortality.
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Table 18. ALGORITHM FOR SCREENING AND TREATMENT OF ANEMIA DURING PREGNANCY.
ASK, CHECK, RECORD LOOK, LISTEN, FEEL

(SYMPTOMS) (SIGN) LABORATORY EVIDENCES CLASSIFY TREAT AND ADVISE
• Hemoglobin* <7 g/dl.
AND/OR
• Symptomatic:
o Severe palmar and
conjunctival pallor
OR
Severe anemia Refer immediately to hospital.
• Do you get tired
easily? • Count number of o Any pallor with any of
• Do you feel breaths in 1  >30 breaths per minute
breathless (have  Tires easily
minute
short of breath)
• Look for  Breathlessness at rest
during routine
activities? conjunctival pallor. • Rule out intestinal infections and
• Do you have • Look for palmar malaria and treat accordingly.
palpitation, pallor. • Give double dose of iron (1
dizziness, headache Mild to tablet twice daily) for 3 months.
• Hemoglobin 7-11 g/dl. moderate • Counsel on compliance with
anemia treatment.
• Reassess at next antenatal visit
(4-6 weeks). If anemia persists,
refer to hospital.
* Measure hemoglobin on first, third & eighth ANC visits.
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MANAGEMENT OF Rh-D NEGATIVE
PREGNANT WOMEN
INTRODUCTION
Rhesus isoimmunization or Rhesus D hemolytic disease of the newborn is one of the causes of
Hemolytic Disease of the Newborn (HDN). The disease ranges from mild to severe, and typically
occurs in some pregnancies of Rh-negative women where the fetus's father is Rh positive, leading
to an Rh-positive pregnancy. During birth, the mother may be exposed to the infant's blood, and
this causes the development of antibodies, which may affect the health of subsequent Rh-positive
pregnancies.
PREDISPOSING FACTORS FOR Rh SENSITIZATION

• Spontaneous abortion
• Ectopic pregnancy
• Molar pregnancy
• Induced abortion
• Intrauterine fetal death
• Invasive fetal diagnostic procedures
• External cephalic version
• Abruption / bleeding placenta previa
• Abdominal trauma
• Vaginal bleeding of unknown origin in second or third trimester
DIAGNOSIS:
• BG and Rh
• Partner’s BG and Rh
• Indirect coombs test
MANAGEMENT
The algorithm below (figure 28) shows the approach that is used during management of mothers
who are Rh negative during ANC.
NOTE: No isoimmunization is expected if both the mother and the father are Rh negatives.
In addition, anti-D immunoglobulin should be administered for conditions listed on table 19.
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Rh D Negative
Mother
Father Rh D positive or Father Rh D negative and

uncertain paternity paternity certain
Indirect No further antibody

coombs testing or anti D needed
test
Negative (Unsensitized Positive (Sensitized Rh D

Rh D negative) negative)
Administer Anti D 300µg

Refer for specialized care
IM at gestational age of
28 weeks
Determine the Rh status

of baby at birth (take
cord blood &
determine)
New born Rh D positive New born Rh D

negative
Administer Anti D 300µg IM stat to
the mother within 72 hours (or as No need of Anti D
soon as possible within 28 days)
Figure 28. Outline of the management of Rh D- negative pregnancy.
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Table 19. Events associated with feto-maternal hemorrhage and dose of Anti-D.
Dosage of
Event or Procedure Rh D Immune Globulin
First-trimester abortion 50 µg
Ectopic pregnancy 50 µg
Molar pregnancy 50 µg
Induced second-trimester abortion 300 µg
Fetal death (>10 weeks gestation) 300 µg
Abruption / bleeding placenta previa 300 µg
Abdominal trauma 300 µg
Vaginal bleeding of unknown origin in second or third 300 µg

trimester
COMPLICATIONS:
Fetal / Neonatal Effects

• Hemolytic disease of the newborn
• Fetal / neonatal anemia
• Erythroblastosis fetalis
• Hyperbilirubinemia
• Kernicterus
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HIV IN PREGNANCY
DEFINITION
Prevention of Mother to Child Transmission (PMTCT) is the prevention of transmission of HIV
virus from the mother to the fetus and child during pregnancy, childbirth and breastfeeding.
RISK OF MTCT
The risk of mother to child transmission varies during pregnancy, labor and delivery and
breastfeeding (see table 20 below).
Table 20. Rates of HIV transmission during pregnancy, labor and delivery, and
breastfeeding.
Estimated Risk of MTCT
Timing Transmission rate without Intervention

During pregnancy 10 - 25*
During labor and delivery 35 - 40%
Overall with breastfeeding to 6-14 months 35 - 40*
NOTE: * Rates of transmission vary because of differences in population characteristics such
as maternal CD4+ cell counts, RNA viral load, exclusivity and duration of breastfeeding
Factors that affect the rate of MTCT
Maternal Factors:-
 High maternal viral load
 New or recently acquired maternal HIV infection
 Low CD4 count
 Advanced maternal disease
 Viral or parasitic placental infections during pregnancy, labor and childbirth
 Maternal malnutrition
 Nipple fissures, cracks, mastitis and breast abscess
 Poor ART adherence
 Active lower genital tract infections like herpes simplex
Obstetric and delivery practices:-
123
 Ante-partum procedures (e.g. amniocentesis, external cephalic version)
 Rupture of membrane for more than four hours
 Vaginal delivery compared to CS
 Injuries to birth canal during child birth (vaginal and cervical tears)
 Invasive childbirth procedures (e.g. episiotomy)
 The first fetus in vaginal delivery of multiple pregnancies
 Delayed infant drying and eye care
 Routine vigorous infant airway suctioning
 Instrumental deliveries (vacuum)
 Fetal birth trauma
 Internal fetal monitoring (fetal scalp electrodes/sampling)
Infant factors:-
 First infant in multiple birth
 Pre-maturity and low birth weight
 Longer duration of breastfeeding
 Mixed feeding during the first six months of life
 Oral diseases in child
DIAGNOSIS
 All pregnant women attending maternal health services (i.e. antenatal, labour,
postpartum) should be screened for HIV with serologic tests following the national
PMTCT guideline (using the opt-out approach).
 If test result becomes positive: request laboratory tests (CD4 count & viral load).
 Clinical symptoms and signs of opportunistic infections should be thoroughly looked for,
appropriate laboratory tests should be requested and the clinical stage of the disease
assigned.
 If the test becomes negative, repeat HIV counselling and testing in the third trimester
preferably 28 to 36 weeks or during labor as appropriate.
 All HIV positive pregnant or lactating women should be retested with a second specimen
before initiating ART.
MANAGEMENT
Preconception care
Once a patient is diagnosed to be HIV positive the following should be done:
 Counsel on the diagnosis and link to trained personnel for further counselling.
 Baseline investigations including CD4 and viral load.
124
 Advise on contraception use with focus on avoiding unintended pregnancy; the
preference is to use dual contraception with one of them being condom.
 Advise on general health including good nutrition: adequate caloric intake; consumption
of iron rich foods (beans lentils, meat, liver); iron and folate for three months; iodized
salt.
 Prevention of malaria: use of ITN for women living in malaria endemic areas.
 Screening & treatment for opportunistic infections & STIs.
 Initiate ART / link to PMTCT unit. ART should be initiated for all pregnant and
breastfeeding HIV positive women regardless of clinical stage and CD4 cell count, and
continued lifelong. Discuss on plan for pregnancy and necessary preparations.
 Provision of prophylaxis for opportunistic infections: Co-trimoxazole for stages 2, 3 and
4 HIV/AIDS, and those with CD4 count of ≤ 350.
 Discuss the importance of partner involvement & screening.
 Avoid pregnancy for 6 months after recovery from any chronic infection (e.g. Tb).
 If the patient has plan for pregnancy:-
o Counsel on the impact of HIV on pregnancy.
o Provide accurate information on risk of MTCT.
o Explain available methods for reduction of risk of MTCT.
NOTE: The above mentioned counselling also apply to pregnant mothers.
Antepartum care by visit and trimester of pregnancy

In addition to the ANC, HIV positive pregnant women need special care and should have more
visits. As soon as the patient has a missed period she should visit the antenatal care clinic and
have pregnancy test.
 Once pregnancy is confirmed complete clinical evaluation (detailed history and physical
examination) should be conducted.
 All HIV positive pregnant, laboring and lactating women should be retested at the
initiation of HAART in order to ensure correct diagnosis.
 All HIV positive pregnant, laboring and lactating mothers should be initiated on HAART
for life (TDF, 3TC and DTG).
 HIV positive women already on ART at time of pregnancy should continue and stay on
the same regimen.
 Pregnant women with WHO clinical stages 1 and 2 can safely be initiated on ART in
ANC; however, those diagnosed with advanced HIV disease at ANC (WHO stage 3 and
4) and opportunistic infections should promptly be referred to ART clinic for diagnosis
and treatment of OI and initiation of ART.
 However, following which, at the discretion of the ART clinic provider, they can be
transferred back to PMTCT unit for their on-going care and treatment.
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 Monitoring and support for HAART adherence.
 Early ultrasound for determination of gestational age.
 Routine laboratory screening tests like in any pregnant woman (VDRL, HBsAg, CBC,
Blood group and Rh, and others as needed).
 There is no need to wait for CD4 count result to initiate treatment. CD4 count is important
to monitor response to treatment.
 Viral load monitoring: it is more effective to detect emergence of treatment failure.
 Advise the mother on the importance of having strict ANC follow up with updating
investigations as needed.
 Discuss with the mother the risk of MTCT and the possible complications that can occur
due to the HIV infection including IUGR.
 Administer vaccinations like TD.
 Nutritional supplementation like other pregnant women.
 If available, follow the fetal growth with serial US every 3-4 weeks.
 Discuss on the mode of delivery based the national PMTCT guideline. Routine CS for
the prevention of MTCT is not recommended; rather individualized birth plan based on
the viral load and the duration of HARRT is recommended.
 Discuss on the postpartum infant feeding plan.
 Discuss on post-partum administration of ART to the neonate for reduction of MTCT.
 Assess the patient’s support system and counsel if concerns arise.
Intrapartum care
 Safe delivery practices and avoiding invasive procedures whenever possible:
o Avoid artificial rupture of membranes to shorten labour.
o Expedite delivery whenever there is a spontaneous rupture of membranes.
o Avoid routine episiotomy.
o Limit use of vacuum extraction.
o Avoid repeated vaginal examinations.
o Treat chorioamnionitis with appropriate antibiotics.
 Provide essential newborn care (ENC). See section on essential newborn care, page 57.
 Mode of delivery:-
o For women on HAART, if the viral load is > 1000 copies/ml elective cesarean
delivery at gestational age of 38 weeks should be considered and referred.
o If the viral load is ≤ 1000 copies/ml; since there is no added benefit from cesarean
delivery, the mother should be counselled on vaginal birth preparedness like any other
pregnant women.
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o In the absence of viral load, a woman adherent to HAART for at least one month is
considered to have lower viral load. The route of delivery can be decided based on
clinical judgment of the provider in consultation with the woman.
o The benefits and risks of different modes of delivery including vaginal delivery and
referral for elective cesarean delivery should be discussed with the woman.
o When indicated for other medical or obstetric reasons, referral for cesarean delivery
should be done, as for all pregnant women.
 If the mother is already started on ART it should be continued intrapartum.
 If she is a newly diagnosed HIV patient and not on ART, it should be started intrapartum
and continued post-partum irrespective of the CD4 count.
Post-partum care
 Continue initial ART for those who are initiated earlier.
 Start ART for HIV positive mothers who are breastfeeding even if it was not started
before (currently recommended regimen TDF/3TC/ DTG).
 In general, exclusive breast feeding is recommended for all women. For mothers who
fulfil Acceptable, Feasible, Affordable, Sustainable and Safe (AFASS) feeding, formula
feeding can be considered after thorough discussion with the family.
 For those who do not fulfil AFASS feeding, breastfeeding must be exclusive for six
months and complementary feeding should start at 6th month. Breastfeeding should be
continued until the first year of life but not more than two years.
 Give NVP + AZT syrup for the first 6 weeks and continue NVP syrup only for the next
6 weeks for all HIV exposed infants (see table 21 below for dosing).
Table 21. Enhanced Post-natal Prophylaxis (e-PNP) for HIV Exposed Infants
Infant age/ weight Formulation Dosing
NVP 10 mg/ml 10 mg (1ml ) once daily

<2500g + +
0-6 weeks AZT 10 mg/ml 10 mg (1ml ) twice daily
NVP 10 mg/ml 15 mg (1.5ml) once daily
>2500g + +
AZT 10 mg/ml 15 mg( 1.5ml) twice daily
6-12 week NVP 10 mg/ml 20 mg (2ml) Once daily
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 Counsel mothers on the importance of exposed infant follow-up, Co-trimoxazole
preventive therapy (see table 22 below for dosing) and early infant diagnosis.
o DBS for DNA/PCR should be done at sixth week of life and HIV negatives should
be followed as HIV Exposed Infants (HEIs).
o DNA/PCR positive babies should be linked to pediatric ART for chronic HIV/AIDS
care, treatment and follow up.
Table 22. Dosage of Co-trimoxazole preventive therapy in infants and children
Preparation of the Co-trimoxazole suspension and tablets
Suspension per 5 ml Pediatric tablet Single strength adult

Age 200/40 mg 100/20mg tablets (400/80 mg)
< 6 months 2.5 ml 1 tablet ½ tablet
6 months -5 years 5ml 2 tablets ½ tablet
 Do confirmatory rapid HIV antibodies test for DNA/PCR negative HEIs six weeks after
the cessation of breastfeeding.
 Discharge negative babies from follow up after rapid HIV antibody test and link the
positive babies to chronic pediatric HIV care, treatment and follow up.
 Give postpartum family planning counselling and provide the client with family planning
methods of her choice as per the PMTCT guideline and post-partum care section of the
protocol, page 65.
 Immunization and growth monitoring for the baby should be done the same way as non
HIV exposed babies.
 The mother and infant should do their follow up at the MNCH clinic, where they can get
integrated MNCH and HIV care.
 After discharge link the mother to ART clinic in the following scenarios:
o If the baby is DNA/PCR positive.
o If the baby is rapid HIV AB test positive.
o If the mother develops any HIV/AIDS related complications of the disease or its
treatment.
NOTE: Adherence counselling and follow up is mandatory and it should be done for the
mother and infant as a pair.
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HYPERTENSIVE DISORDERS IN PREGNANCY
DEFINITION
Hypertension: A systolic blood pressure of ≥140 mmHg, or diastolic blood pressure of ≥90
mmHg or both in two occasions taken 4 hours or more apart; or a single blood pressure
recording of ≥160/110 mmHg.
Proteinuria: Two urine dipstick measurements of at least 1+ (30 mg per dL) proteinuria taken
six hours apart; or at least 300 mg of protein in a 24-hour urine collection; or a urinary protein /
creatinine ratio of ≥0.3.
CLASSIFICATION
 Gestational hypertension: Hypertension without proteinuria or other features of
preeclampsia developing after the 20th week of pregnancy in a previously normotensive
woman.
 Preeclampsia: A new onset of hypertension and proteinuria after 20 weeks of gestation in

a previously normotensive woman.
o Pre-eclampsia without severe features
o Pre-eclampsia with severe features: Headache, blurred vision, oliguria (<400 ml/24
hours), epigastric or right upper quadrant pain, difficulty of breathing (pulmonary
edema), low platelet count (<100,000/µl), liver enzymes elevated more than twice the
upper limit of normal range, serum creatinine higher than 1.1 mg/dl or a doubling (or
higher) of the baseline serum creatinine concentration in the absence of other renal
disease.
 Eclampsia: Generalized convulsion and / or coma in a woman with preeclampsia where

the convulsion or coma is not attributed to other causes.
 Chronic hypertension: Hypertension that antedates pregnancy or is present before the

20th week of pregnancy or persists after 12 weeks postpartum.
 Superimposed preeclampsia: If proteinuria or other features of pre-eclampsia develop in
a patient with chronic hypertension.
o Superimposed pre-eclampsia without severe features.
o Superimposed pre-eclampsia with severe features.
129
GESTATIONAL HYPERTENSION
MANAGEMENT
 Manage as an outpatient if GA is <36 weeks and if blood pressure is in mild range without
the use of antihypertensive medications.
 Follow-up weekly and check for increasing blood pressure, urine (for proteinuria),
severity features and fetal condition.
 If blood pressure worsens or proteinuria ensues or severity features appear, refer the
patient after pre-referral management. (See pre-referral management below).
 Counsel the woman and her family on danger signs indicating severity features or
eclampsia and provide advice on preparedness for hospital delivery.
 Refer at ≥36 weeks of gestation.
PRE-ECLAMPSIA
RISK FACTORS
First pregnancy, age <18 or >35 years, multiple gestation, history of hypertension, renal disease,
diabetes, obesity, family history of pre-eclampsia.
DIAGNOSIS
Hypertension, proteinuria, severity features.
TREATMENT
 Preeclampsia without severity features: refer immediately but if in labor, refer after pre-
referral management (shown below).
 Preeclampsia with severity features: refer urgently after the following pre-referral
management:-
PRE-REFERRAL MANAGEMENT OF PATIENTS WITH HYPERTENSIVE DISORDERS:
o Open IV line.
o Loading dose of MgSo4 (see box below for the dosing)
o Initial dose of antihypertensive if the systolic blood pressure is 160 mmHg or
higher and/or the diastolic blood pressure is 110 mmHg or higher (see box
below for the dosing).
130
ECLAMPSIA
MANAGEMENT
 Check airway
o Aspirate (suction) the mouth & throat as necessary & ensure open airway.
o Place an oral airway.
 Check breathing
o If breathing, give oxygen by mask at 6 liters per minute.
o If not breathing, ventilate using bag and face mask.
 Check circulation
o Set up IV line.
o Maintain intravascular volume and replace ongoing losses.
o Avoid fluid overload.
 Position the patient on her side (left lateral) and in Trendelenberg (head down) position
to reduce risk of aspiration of secretions, vomitus or blood.
 Place an indwelling catheter.
 Check vital signs.
 Give loading dose of MgSo4 (see box below for the dosing)
 Give initial dose of antihypertensive if the systolic blood pressure is 160 mmHg or higher
and/or the diastolic blood pressure is 110 mmHg or higher (see box below for the dosing).
 Administer initial dose of broad-spectrum IV antibiotics.
 Refer urgently!
NOTE: The management approach for a pregnant woman presenting with convulsion is
summarized below in annex -5.
Box: Loading dose of magnesium sulfate
Loading dose of magnesium sulfate for pre-eclampsia in labor, preeclampsia with

severity features and eclampsia:
 Magnesium sulfate 20% solution, 4g IV over 5 minutes.
 Follow promptly with 10 gm of 50% magnesium sulfate solution, 5 gm in each buttock
as deep IM injection with 1 mL of 2% lidocaine in the same syringe.
 If convulsion recurs after 15 minutes, give 2 gm magnesium sulfate (20% solution) IV
over 5 minutes.
131
Box: Anti hypertensives and their dosing.
Antihypertensives:
 Hydralazine:
o Hydralazine is the drug of choice for acute therapy.
o Give 5 mg IV slowly every 20 minutes until blood pressure is lowered (to diastolic
blood pressure <110 mmHg).
 Repeat hourly as needed or give 12.5 mg IM every 2 hours as needed (If
IV route is not possible).
 The maximum dose is 20 mg per 24 hours.
 Nifedipine:
o As alternative for acute therapy.
o Administer 10 mg orally; repeat dose after 30 minutes if response is inadequate
until optimal blood pressure is reached.
o The maximum total dose is 30 mg in the acute treatment setting.
o Then continue as 10-20 mg PO QID.
o For maintenance therapy give 10-20 mg PO BID.
132
Annex 5. Algorithm for management of pregnant woman presenting with convulsion
Algorithm for management of pregnant woman presenting with convulsion
CALL for HELP
Check airway:
• Clear air way, Check breathing Rapidly evaluate Vital signs
• Insert airway, or
• Intubate as required
Not breathing Breathing
Assist ventilation Give O26L per Open IV line

using bag and face- min by Mask or and run IV fluid
mask Nasal catheter at 80 ml/hr
Manage as Eclampsia and investigate for other cause
If eclampsia is diagnosed or if the cause of convulsion is not Treat other causes according
determined to the diagnosis
Give anti-hypertensive if DBP≥110mmHg or SBP ≥160 Give MgSO4

mmHg Loading dose
 MgSO4 20% solution,4gm IV over 5 min followed by 10gm of 50%
• Hydralazine 5mg IV slowly every 20 min maximum MgSO4 solution,5 gm in each buttock as deep IM with 1ml of 2%
20mg/24 hrs. Lidocaine in the same syringe .
OR
 If convulsions recur after 15 min,give 2gm MgSO4 20% solution
• Labetalol IV over 5min
• Oral 200 mg, repeat after one hour as needed.
– The maximum dose is 1200 mg in 24 hours. Maintenance dose
OR  MgSO4 50% solution 5gm +1ml Lidocaine 2% IM every 4 hrs into
 Intravenous treatment: alternative buttock for 24 hrs after delivery or the last convulsion
whichever occurs last. Before repeat administration, ensure
• Administer 10 mg IV.
RR≥12 per min, Patellar reflex present, Urine output ≥30ml per
• If response is inadequate after 10 minutes, Hr.
administer 20 mg.
• The maximum total dose is 300 mg  Keep antidote ready ( Calcium gluconate 1gm of 10ml of 10%
solution )
• Protect the woman from injury at all times and place her on left lateral position.
• Refer urgently after giving loading dose of MgSO4 and pre-referral care.
133
URINARY TRACT INFECTION IN PREGNANCY
DEFINITION
Urinary tract infection (UTI) is an infection that involves any part of the urinary system (kidney,
ureters, bladder and urethra).
CLASSIFICATION
 Asymptomatic bacteriuria (ASB): A true bacteriuria (>105 bacteria/ml of midstream
clean catch urine) in the absence of specific symptoms of acute UTI.
 Cystitis: Infection of the bladder.
 Acute pyelonephritis: An infection of the upper urinary tract, mainly of the renal pelvis,
which may also involve the renal parenchyma.
RISK FACTORS
 Glycosuria
 Catheterization
 Diabetes
 HIV/AIDS
DIAGNOSIS
History and physical examination:
 Asymptomatic bacteriuria: No symptoms and signs.
 Cystitis
o Dysuria
o Increased frequency and urgency of urination
o Suprapubic / lower abdominal pain
 Pyelonephritis
o Dysuria
o Spiking fever / chills
o Increased frequency and urgency of urination
o Flank pain
o Costovertebral angle (CVA) tenderness
o Anorexia
o Nausea / vomiting
134
Investigation:
 A dipstick of urine specimen.
 Microscopy of urine specimen.
 On-site midstream urine Gram staining is recommended over the use of dipstick tests as
the method for diagnosing ASB in pregnancy.
NOTE: Urine examination requires a clean-catch mid-stream specimen to minimize the

possibility of contamination.
MANAGEMENT
Asymptomatic bacteriuria:
 Amoxicillin 500 mg orally three times a day for seven days; OR
 Cephalexin 250-500mg orally four times a day for seven days.
Cystitis:
 Treat with antibiotics:-
o Amoxicillin 500 mg orally three times a day for seven days; OR
o Cephalexin 500 mg orally two times a day for seven to ten days.
 Repeat urine analysis after the completing the antibiotics to check that the infection has
resolved.
 If the client is not responding to the treatment or develops systemic manifestations refer
for further management.
Acute pyelonephritis:
 Provide supportive care (anti-pain / antipyretics not contraindicated in pregnancy) and
refer immediately.
 Pre-referral care: Before referral take the following measures:-
o If shock is present or suspected, initiate immediate treatment.
o Start an IV infusion and infuse IV fluids at 150 mL per hour.
o Give first dose of IV antibiotics:-
 Ampicillin 2 g IV every six hours; PLUS
 Gentamicin 5 mg/kg body weight IV every 24 hours.
135
MALARIA IN PREGNANCY
DEFINITION
Malaria is an infectious disease caused by protozoan parasites from the Plasmodium family
which affects human Red Blood Cells that can be transmitted by the bite of the female
Anopheles mosquito (the main mode of transmission). Blood contamination and mother to fetal
(vertical transmission) during pregnancy are also potential modes of transmission
CLASSIFICATION:
Based on severity:
• Simple (uncomplicated)
• Sever (complicated) malaria
Based on the etiologic agent:
• P. falciparum
• P. vivax
• P. ovale
• P. malariae
• P. knowlesi Malaria.
NOTE: P. falciparum and P. vivax malaria account for the majority of cases.
DIAGNOSIS:
Clinical Manifestations
The symptoms and signs vary based on the severity of the malaria. Manifestations of severe
malaria, particularly hypoglycemia, cerebral malaria, and pulmonary edema, are usually seen
in non-immune population but are more common in pregnant women. See table 23 below for
clinical findings of uncomplicated and complicated malaria.
INVESTIGATION:
Parasitological diagnosis - Laboratory diagnosis of malaria should be made through
microscopic examination of thick and thin Giemsa-stained blood smears. In microscopic
diagnosis the following three points should be stated clearly:
• Species of the parasite
• Stage of the parasite
• Level of parasitemia
136
Additional laboratory workup to identify presence of complications
• Hemoglobin/hematocrit
• Urinalysis
• Random blood sugar level
Table 23. Clinical findings of uncomplicated and complicated malaria.
Uncomplicated malaria: Complicated malaria
• Fever Signs of uncomplicated malaria, plus
• Shivering / chills • Dizziness
• Headaches • Breathlessness
• Muscle / joint pains • Sleepiness / drowsiness
• Nausea / vomiting • Confusion/coma
• False labor pains • Fits, jaundice, severe dehydration
MANAGEMENT:
Uncomplicated Falciparum Malaria
First Trimester
• Give quinine salt (dihydrochloride or sulfate) 10 mg/kg body weight by mouth three
times daily PLUS clindamycin 300 mg every six hours for seven days.
• If clindamycin is not available, treat with quinine monotherapy:
o Quinine salt (dihydrochloride or sulfate) 10 mg/kg body weight by mouth three
times daily for seven days).
• An Artemisinin-based combination therapy (ACT) can be used if quinine is not
available, or if quinine plus clindamycin fails, or if adherence to seven-day treatment
with quinine cannot be guaranteed. ( Artemether 80 and Lumefantrine 480 mg 1 tab
twice daily for three days)
Second and Third Trimesters

• Treat orally based on national malaria guideline with any of the ACTs (assuming a body
weight of 50 kg or more): E.g. Artemether (80 mg) PLUS Lumefantrine (480 mg) twice
daily for three days;
137
Uncomplicated Plasmodium Vivax, Ovale, Malariae, Knowlesi Malaria
First Trimester
• Areas with Chloroquine-Sensitive P. vivax Parasites: Give chloroquine 10 mg/kg body
weight by mouth once daily for two days followed by 5 mg/kg body weight by mouth
on day three. (Usual adult dose 4, 4 &2 tablets on days 1, 2 & 3 respectively)
• Areas with Chloroquine-Resistant P. vivax Parasites: Before considering second-line
drugs for treatment failure with chloroquine, clinicians should exclude poor patient
compliance and a new infection with P. falciparum. If diagnostic testing is not available,
treat as for falciparum malaria. The treatment option for confirmed chloroquine
resistant vivax malaria is quinine salt (dihydrochloride or sulfate) 10 mg/kg body
weight by mouth three times a day for seven days.
Second and Third Trimesters

• Areas with Chloroquine-Sensitive P. vivax Parasites: either ACT or chloroquine alone
are the two treatment options
• Areas with Chloroquine-Resistant P. vivax Parasites: treat with ACT (see dose above)
• Areas of Mixed Falciparum-Vivax Malaria: In areas of mixed transmission, the
proportions of malaria species and their drug sensitivity patterns vary. If microscopic
diagnosis is available, specific treatment can be prescribed. Where unavailable, assume
the infection is due to P. falciparum and treat accordingly.
Complicated (Severe) Malaria

The patient with severe malaria needs URGENT medical attention. Cases with severe or
complicated malaria need referral for better management to a general or specialized hospital
after applying the following measures.
Pre referral management of the patient with severe malaria:

Start immediate resuscitation measures
• Establish an IV infusion.
• Take blood while establishing an IV line for:
o Malaria blood slide (thick and thin)
o Hematocrit or Hgb estimation
o WBC (total and differential count)
o Glucose level
• Correct hypoglycemia (<2.2 mmol/l OR 40 mg/dl) if present by infusing dextrose over
a period of 3-5 minutes. This can consist of any one of the following:
o 1 ml/kg of 50% dextrose diluted with an equal volume of normal saline IV
slowly over several minutes OR
o 5 ml/kg of 10% dextrose by slow IV infusion OR
138
o For other strengths of dextrose calculate accordingly.
• This should be followed by intravenous infusion of 10% dextrose given slowly.
• Re-check blood glucose every 2-4 hours during the course of treatment, particularly in
the pregnant or comatose patient.
• Administer Artesunate 2.4mg/Kg IV or IM stat (to be repeated after 12 hrs, 24 hours
and then daily).
• When Artesunate is not available Quinine 20 mg per kg diluted in 5% dextrose over four
hours. Then give maintenance dose of quinine 10 mg/kg every 8 hours.
• Transfer with appropriate pre-referral care as soon as feasible.
NOTE: Primaquine & mefloquine are contradicted in pregnancy & breast feeding
139
140
REFERENCES
1. National Mother and Baby Friendly Service Guideline. Federal Ministry of Health of
Ethiopia. 2016
2. EDHS 2016. Central Statistical Agency. Federal democratic republic of Ethiopia. Addis
Ababa, July 2017,
3. FMOH Ethiopia. Basic Emergency Obstetric and Newborn Care (BEmONC) Training
manual. 2018.
4. FMOH Ethiopia. First trimester comprehensive abortion care manual, 2nd edition, 2018.
5. FMOH Ethiopia. National Comprehensive & Integrated Prevention of Mother-to-Child
Transmission of HIV (PMTCT) Guidelines. April 2019.
6. FMOH Ethiopia. Technical and Procedural Guidelines for Safe Abortion Services in
Ethiopia. 2014.
7. Gabbe: Obstetrics: Normal and Problem Pregnancies. 5th ed. 2007.
8. Gabra A (2018) Complications of Hyperemesis Gravidarum; A Disease of Both Mother
and Fetus, Review Article. Crit Care Obst Gyne. Vol.5 No.1:1
9. Gynecology management guidelines in JUSH, Jimma.
10. Ipas, Clinical Updates in Reproductive Health, 2019.
11. Management protocol on selected obstetrics topics for Health Center Federal Democratic
Republic of Ethiopia Ministry of Health January, 2014.
12. Management protocol on selected obstetrics topics for Hospitals Federal Democratic
Republic of Ethiopia Ministry of Health January, 2021.
13. NMS Obstetrics and Gynecology, 6th Edition.
14. Obstetrics Management Protocol for Hospitals. Federal Democratic Republic of Ethiopia,
Ministry of Health January, 2020.
15. Up-to-date 21.1.
16. WHO MEC 5th Edition.
17. WHO recommendations for prevention and treatment of maternal peripartum infections.
2015.
18. WHO. Family Planning: A Global Handbook for Providers. 2018.
19. Williams Obstetrics. 24th edition, 2014.
20. World Health Organization. Clinical practice handbook for safe abortion. 2014.
21. World Health Organization. Managing complications in pregnancy and childbirth: a guide
for midwives and doctors. 2nd ed. 2017.
141
22. World Health Organization. Prevention of mother-to-child transmission of hepatitis B
virus: guidelines on antiviral prophylaxis in pregnancy. July 2020.
23. World Health Organization. WHO recommendations on antenatal care for a positive
pregnancy experience. 2016.
24. World Health Organization. WHO recommendations on interventions to improve preterm
birth outcomes. 2015.
25. World Health Organization. WHO recommendations on maternal health: guidelines
approved by the WHO Guidelines Review Committee. Geneva: 2017.
26. World Health Organization. WHO recommendations: intrapartum care for a positive
childbirth experience. 2018.
27. World Health Organization. WHO recommendations: uterotonics for the prevention of
postpartum hemorrhage. 2018.
142

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OBSTETRICS

For Health Centers

AIDS Acquired Immuno IUFD Intrauterine Fetal Death

Table 1. Categories of disrespect and abuse with recommended standard of care.

Annex 1. Contact schedule, risk identification, list of interventions at each contact.

Figure 1. ANC classification diagram.

1. RESPECTFUL MATERNITY CARE..................................................................................................... 1

3. PRECONCEPTION CARE ............................................................................................................... 12

8. MULTIPLE PREGNANCY ............................................................................................................... 39

11. THIRD STAGE OF LABOR ............................................................................................................. 55

13. BASIC POSTPARTUM / POSTNATAL CARE ................................................................................... 65

15. PUERPERAL FEBRILE MORBIDITIES ............................................................................................. 76

19. MALPOSITIONS ........................................................................................................................... 97

20. PROLONGED AND OBSTRUCTED LABOR ................................................................................... 100

21. UTERINE RUPTURE .................................................................................................................... 105

29. URINARY TRACT INFECTION IN PREGNANCY ............................................................................ 134

Table 1. Categories of disrespect and abuse with recommended standard of care.

Non-  Lack of privacy  Women should never be exposed unnecessarily

POTENTIAL CONTRIBUTORS TO DISRESPECT AND ABUSE

EFFECTIVE COMMUNICATION AND SUPPORTIVE CARE FOR RMC

Provide supportive care

Supervision and monitoring:

Strengthening referral linkage:

Implementing a rapid initial assessment scheme:

RAPID INITIAL ASSESSMENT

Assess Danger signs Consider

Airway and LOOK FOR:

Vaginal ASK IF: Early pregnancy:

Unconscious ASK IF:

Abdominal ASK IF: • Ovarian cyst/torsion

EMERGENCY MANAGEMENT PRINCIPLES

MANAGING A PATIENT IN “SHOCK”

Determining and managing the cause of shock

MANAGING A PATIENT WITH DIFFICULTY IN BREATHING

Symptoms and signs typically Symptoms and signs

• Difficulty in breathing • Lethargy and fatigue • Severe anemia

• Symptoms and signs of severe • Oedema • Heart failure due to

• Difficulty in breathing • Irregular heart beat • Heart failure due to heart

• Difficulty in breathing • Cough with expectoration • Bronchial asthma

Screening for modifiable risk factors

Lifestyle and Behaviors:

THE FIRST ANTENATAL CONTACT

Confirmation of pregnancy and gestational age

Advice and counseling:

Assessment and planning

No Classify specialized care Yes

Figure 1. ANC classification diagram.

SUBSEQUENT ANTENATAL VISITS

MEDICATIONS AND VACCINES

PHYSIOLOGICAL SYMPTOMS IN PREGNANCY

Intervention for common physiological symptoms based on a woman’s preferences

Varicose veins and oedema– Non-pharmacological options, such as compression

LINKAGE AND REFERRAL

• Diagnosed or suspected multiple pregnancy

General medical conditions:

• Diabetes mellitus, cardiac disease, kidney disease, epilepsy, asthma on medication,

Past Pregnancy History

Ultrasound (up to 24 weeks of gestation)