Exported on: 15/11/2022

Essential obstetric and newborn care

Practical guide for midwives, doctors with obstetrics training and health care
personnel who deal with obstetric emergencies
© Médecins Sans Frontières
All rights reserved for all countries. No reproduction, translation and adaptation may be done without
the prior permission of the Copyright owner.

Médecins Sans Frontières. Essential obstetric and newborn care.

2019 Edition
ISBN 978-2-37585-039-8

Contenido
Contributors

Introduction

Abbreviations and acronyms

Chapter 1: Diagnosing and monitoring pregnancy

1.1 Diagnosing pregnancy
1.2 Antenatal consultations
1.3 Monitoring complicated pregnancies

Chapter 2: Bleeding during the first half of pregnancy

2.1 Abortion
2.2 Ectopic pregnancy
2.3 Molar pregnancy (hydatidiform mole)
2.4 Cervicitis
2.5 Functional bleeding

Chapter 3: Bleeding during the second half of pregnancy

3.1 Placenta praevia
3.2 Abruptio placentae
3.3 Uterine rupture
3.4 Diagnosis of bleeding during the second half of pregnancy (summary)

Chapter 4: Pathologies during pregnancy and pregnancy-related disorders

4.1 Iron deficiency anaemia
4.2 Bacterial infections
4.3 Parasitic infections
4.4 Viral infections
4.5 Hypertensive disorders in pregnancy
4.6 Eclampsia
 4.7 Abnormally large uterus
4.8 Polyhydramnios
4.9 Premature rupture of membranes
4.10 T hreatened preterm delivery
4.11 Intrauterine foetal death

Chapter 5: Normal delivery and procedures related to vaginal delivery

5.1 Normal delivery
5.2 Monitoring labour and delivery
5.3 Artificial rupture of the membranes
5.4 Prolapsed cord
5.5 Nuchal cord
5.6 Instrumental delivery
5.7 Symphysiotomy
5.8 Episiotomy
5.9 Perineal repair
5.10 Deinfibulation

Chapter 6: Special deliveries

6.1 Breech presentation
6.2 Twin pregnancy
6.3 Total breech extraction
6.4 Caesarean section

Chapter 7: Labour dystocia and malpresentations

7.1 Prolonged labour
7.2 Obstructed labour
7.3 Labour induction
7.4 T he use of oxytocin during labour
7.5 Shoulder dystocia
7.6 Transverse lie and shoulder presentation
7.7 External version
7.8 Internal version
7.9 Face presentation
7.10 Brow presentation

Chapter 8: T hird stage of labour

8.1 Normal third stage of labour
 8.2 Early postpartum haemorrhage
8.3 Late postpartum haemorrhage
8.4 Uterine inversion
8.5 Cervical and vaginal tears

Chapter 9: Intrauterine procedures

9.1 Precautions required for intrauterine procedures
9.2 Manual removal of the placenta
9.3 Uterine exploration
9.4 Digital curettage
9.5 Manual vacuum aspiration (MVA)
9.6 Instrumental curettage
9.7 Embryotomy

Chapter 10: Newborn care in the maternity hospital

10.1 Routine care and examination
10.2 Neonatal resuscitation
10.3 Care of the sick newborn
10.4 Specific care when the mother has a transmissible infection
10.5 Care of the low birth weight neonates (< 2500 g)
10.6 Criteria for discharge from the maternity hospital

Chapter 11: Postpartum period

11.1 Normal postpartum events
11.2 Postpartum care for the mother
11.3 Postnatal consultations
11.4 Postpartum complications
11.5 Contraception

Chapter 12: Termination of pregnancy

12.1 Care before termination of pregnancy
12.2 Medication abortion
12.3 Aspiration

Appendices
Appendix 1. Antenatal care card
Appendix 2. Intrauterine balloon tamponade
Appendix 3. Breastfeeding
 Appendix 4. Daily amounts required for feeding
Appendix 5. Intravenous maintenance fluids for sick neonates
Appendix 6. Postnatal care card
Appendix 7. Pain management in pregnant or lactating women

Contributors
This guide has been developed by Médecins Sans Frontières, under the supervision of Anne-
Sophie Coutin and Catrin Schulte-Hillen, with valuable contributions from:
Arantza Abril, Séverine Caluwaerts, Cristian Casademont, Maura Daly, Martin De Smet, Eva
Dominguez, Claire Fotheringham, Véronique Grouzard, Sonia Guinovart, Myriam Henkens, Manisha
Kumar, Daphné Lagrou, Evelyne Laissu, Amin Lamrous, Laura Latina, Caroline López Vázquez, Sophie
Pilon, Nele Segers, Laura Sheperis, Nelly Staderini, Clara Van Gulik

Published by
Médecins Sans Frontières

Introduction
According to the World Health Organization, an estimated 800 women die each day from preventable
causes related to pregnancy, delivery and unsafe abortion, as well as 7000 newborns, the majority on
the first day or during the first week of life. Almost all maternal (99%) and neonatal (98%) deaths occur
in resource-limited countries.

Essential obstetric and newborn care is designed to help reduce maternal and neonatal mortality in
unfavorable contexts.

T his guide does not replace years of specialised training and experience. It is intended for midwives,
doctors, and qualified health care personnel who respond to obstetric emergencies.

Not all the procedures described in this guide are within reach of all medical staff. For example, while
many obstetrical procedures fall within a midwife’s scope of practice, she does not perform caesarean
sections – though she usually helps determine that one is indicated. On the other hand, a nurse may be
permitted to perform antenatal or postnatal consultations, with appropriate training. T he medical
demography of resource-limited countries often requires the decentralisation of competencies.
Similarly, it is important to take the paucity of obstetricians in these countries into account, and
recognise that in some countries, general practitioners in remote areas are trained to
perform complicated deliveries. T herefore this guide aims to serve all of these personnel with diverse
qualifications, by describing basic technical procedures and general management of obstetric
emergencies. It can also be used as a training tool.
While some of the methods in this guide, such as symphysiotomy and embryotomy, may appear
obsolete, they have purposely been included for situations in which performing a caesarean section
would be dangerous or impossible.

Broadly speaking, there are two types of medical facilities that provide care for mothers and
newborns: BEmONCs, which dispense Basic Emergency Obstetric and Newborn Care, and CEmONCs,
which offer Comprehensive Emergency Obstetric and Newborn Care. T he geographic distribution of
these facilities should permit proximity to care, in the case of the BEmONCs, with the CEmONCs
serving as reference facilities for more complicated deliveries. T he different procedures and
techniques described in this guide are to be performed in the relevant medical facility.

Despite all efforts, it is possible that certain errors may have been overlooked in this guide. Please
inform the authors of any errors detected.

To ensure that this guide continues to evolve while remaining adapted to field realities, please send
any comments or suggestions.

As treatment protocols are regularly revised, please check this website for updates.

Abbreviations and acronyms

ACT artemisinin-based combination therapy

AL artemether/lumefantrine (coartemether)

AQ amodiaquine

AS artesunate

BCG bacillus Calmette-Guérin

BEmONC basic emergency obstetric and newborn care

BP blood pressure

C° degree Celsius

CEmONC comprehensive emergency obstetric and newborn care

D1 (D2, D3, etc.) Day 1 or first day (Day 2 or 2nd day, Day 3 or 3rd day, etc.)

dl decilitre

g gram

HBV hepatitis B virus

HIV human immunodeficiency virus

IM intramuscular administration

IU international unit

IV intravenous administration

kg kilogram

LMP last menstrual period

M million

mg milligram
ml millilitre

mmHg millimetre of mercury

mmol millimole

MSF Médecins Sans Frontières

MQ mefloquine

MUAC mid-upper arm circumference

MVA manual vacuum aspiration

PMT CT prevention of mother-to-child transmission

PO per os – oral administration

PROM premature rupture of membranes

SC subcutaneous administration

SP sulfadoxine/pyrimethamine

SpO2 saturation of arterial blood with oxygen measured by pulse oximetry

tab tablet

TB tuberculosis

TV tetanus vaccine

UNICEF United Nations Children's Fund

WHO World Health Organization

Chapter 1: Diagnosing and monitoring

pregnancy
1.1 Diagnosing pregnancy

1.2 Antenatal consultations

1.3 Monitoring complicated pregnancies

1.1 Diagnosing pregnancy

1.1.1 Signs and symptoms of pregnancy
T he first sign of pregnancy is amenorrhea a combined with a progressive increase in the size of the
uterus starting 7 to 8 weeks after the last menstrual period.
During the first trimester, breast changes (increased size, tenderness, vascularisation and swollen
areolas), urinary frequency and transitory nausea/vomiting are common.
In the second trimester the mother begins to feel foetal movement and, in some cases, uterine
contractions. Foetal heart tone can be heard.

Signs and symptoms of pregnancy by gestational age are presented in the Table 1.1.

Table 1.1 - Signs and symptoms of pregnancy by gestational age

1.1.2 History and clinical examination
See Section 1.2.

1.1.3 Other investigations

Pregnancy test
While a pregnancy test is not routinely necessary, it is indicated for suspected ectopic pregnancy or
early diagnosis of a pregnancy to be terminated.

Ultrasound
Ultrasound is not routinely necessary.

Notas
(a) For amenorrhoea (absence of menst rual periods) wit hout ot her signs of pregnancy, rule out ot her causes:
physiological (breast f eeding), drug-relat ed (e.g. cont racept ives up t o 3 mont hs af t er st opping,
ant ipsychot ics and cort icost eroids), endocrine (e.g. t hyroid disorder), psychological, nut rit ional, et c.
1.2 Antenatal consultations
1.2.1 Aims of antenatal monitoring
Screening for and management of pathologies: hypertension, anaemia, malaria, syphilis, urinary
tract infection, HIV infection, malnutrition, vitamin and micronutrient deficiencies, etc.
Screening for and management of obstetric complications: uterine scar, abnormal presentation,
premature rupture of membranes, multiple pregnancy, abnormal bleeding (metrorrhagia), etc.
Routine prevention of maternal and neonatal tetanus, anaemia, mother-to-child HIV transmission,
malaria in endemic areas, etc.
Devising a birth plan; counselling; preparation for the birth.

1.2.2 Timing of antenatal consultations

Four antenatal consultations are recommended for uncomplicated pregnancies.
If the woman does not come in until the sixth month or later, try to have at least 2 consultations before
the birth.

Table 1.2 - Schedule of antenatal consultations

Trimester Month Weeks LMP (a) Consultation schedule

1 2-5
First 2 6-9
3 10-13 <= Consultation 1

4 14-17 <= Consultation 2

Second 5 18-21
6 22-26

7 27-30 <= Consultation 3

T hird 8 31-35
9 36-40/41 <= Consultation 4

(a) The gest at ional age is expressed in weeks since last menst rual period (LMP) or, less precisely, in mont hs of
pregnancy. Pregnancy last s 9 mont hs or 40 or 41 weeks LMP, depending on t he count ry.

Closer monitoring may be needed, depending on the problems detected and the patient’s history
(Section 1.3).
1.2.3 First consultation
A. History taking
General feeling about the pregnancy (problems/concerns).
Social context: family situation, screening for sexual, intimate partner and domestic violence, living
conditions, professional activity, etc.
Date of last menstrual period.
Obstetric and surgical history:
Number of prior pregnancies;
Complications during prior pregnancies/deliveries (haemorrhage, infection, prematurity, etc.);
Spontaneous or induced abortion(s);
Children, alive and deceased;
Caesarean section (find out why) or any other uterine surgery;
Instrumental delivery;
Vesicovaginal or rectovaginal fistula;
Medical history and ongoing treatments: hypertension, diabetes, asthma, epilepsy, heart disease,
HIV infection, psychiatric disorder, etc.;
Tetanus immunisation status;
Current complaints: pelvic pain, contractions, fever, urinary symptoms, vaginal bleeding, abnormal
vaginal discharge, etc.

B. Estimating the gestational age and due date

T he gestational age is estimated by counting the number of weeks since the last menstrual period
(weeks LMP) using a calendar or pregnancy wheel.
For example, if the last menstrual period was on 15 December 2018 and the woman is seen on 27
January 2019, the estimated gestational age is 6 weeks LMP.
Always verify that this estimate tallies with the data from the clinical examination (estimate of uterine
size) or the ultrasound.

T he due date is estimated by counting 40 or 41 weeks from the first day of the last menstrual period.
For example, if the date of the last menstrual period was 15 December 2018, the due date is between
22 and 29 September 2019.

T he due date can also be estimated by counting 9 months plus 7 to 14 days from the first day of the
last menstrual period.
If the woman does not know the date of her last menstrual period, the presumed gestational age and
due date is determined based on clinical examination or ultrasound if available a .

C. Clinical examination
In all cases:
Weight
Height (detection of women < 1.50 m)
Blood pressure (patient seated and resting)
Look for abdominal scar.
Look for anaemia, oedema, etc.
Look for foetal heart tones after the end of the first trimester.
Estimate the size of the uterus (gives an estimate of gestational age):
during the first trimester, the size of the uterus is estimated by bimanual examination. At 7
weeks the uterus is the size of a chicken egg, at 10 weeks the size of an orange, and at 12
weeks the uterine fundus extends beyond the symphysis pubis;
from the beginning of the second trimester, the uterus can be felt by abdominal palpation alone;
measure the fundal height, which is the distance between the upper edge of the symphysis pubis
and the fundus (Figure 1.1).

Figure 1.1 - Measuring the fundal height

Estimation of gestational age becomes increasingly approximate as the pregnancy progresses. As a

rough guide:

Table 1.3 - Fundal height according to gestational age

 Fundal height Weeks since last menstrual period

20 cm 18 - 22 weeks LMP

24 cm 22 - 26 weeks LMP

28 cm 26 - 30 weeks LMP

32 cm 30 - 34 weeks LMP

34 cm 33 weeks LMP to term

Note: fundal height and uterine growth may vary with ethnicity. Use the national curves from the
Ministry of Health, if they exist.

Only if indicated:
Genital examination (e.g. to look for mutilation, symptoms of sexually transmitted infection).
Vaginal examination (e.g. if there is doubt about the pregnancy diagnosis).

D. Laboratory tests
Table 1.4 - Recommended screening tests
 Tests Comments

Syphilis Syphilis screening should be performed at the first consultation, as

early as possible in pregnancy.
If the initial test is negative, re-testing is recommended as of 28
weeks LMP for women at high risk of infection or if syphilis
prevalence is ≥ 5% [1] .
If it was not performed during an antenatal consultation, the test
should be performed at delivery.
Use a treponema-specific rapid test (e.g., SD Bioline®).

Malaria In endemic areas, perform a rapid test even if there are no

symptoms.

HIV infection Offer a test to all women who do not know their HIV status.
Perform rapid tests according to the standard algorithm. Testing
cannot be peformed without the patient’s consent. If it was
not performed during an antenatal consultation, it should be
performed at delivery.
If possible, evaluate the immunological status (CD4 count) if
seropositivity is detected, or at the first antenatal consultation for
women who already know that they are HIV positive.

Anaemia Measure haemoglobin (HemoCue).

Hb levels defining anaemia are < 11 g/dl (first and third trimester)
and < 10.5 g/dl (second trimester).
If it was not measured during an antenatal consultation, it should be
measured at delivery.

Urinary tract infection Test for asymptomatic bacteriuria, even if there are no symptoms
(urinalysis with reagent test strips).

E. Antenatal care card

Fill out all relevant information on an individual antenatal care card to monitor the progress of the
pregnancy (Appendix 1).

1.2.4 Subsequent consultations

A. History taking
 Foetal movement felt by the mother.
Current complaints: pelvic pain, contractions, fever, urinary symptoms, vaginal bleeding, abnormal
vaginal discharge, etc.

B. Clinical examination
Be careful when examining a woman lying on her back; the weight of the uterus compresses the inferior
vena cava, which can cause her to feel faint (easily remedied by placing the patient on her left side).

In all cases:
Blood pressure, weight, oedema, fundal height.
Foetal heart tones: should be regular, rapid (110-160/minute), and out of sync with the mother’s
pulse.
Foetal presentation (third trimester):
Palpation:
Cephalic pole: round, hard and regular; there should be a feeling of ballottement between
examiner’s hands; separated from the rest of the body by the indentation of the neck, beyond
which the projection of the shoulder can be palpated.
Pelvic pole: soft; bulkier and less regular than the cephalic pole; no neck indentation.
Types of presentation:
Cephalic: the cephalic pole points towards the mother’s pelvis.
Breech: the cephalic pole is in the uterine fundus.
Transverse: the poles lie in each of the mother’s sides.
Exploring the foetal back:
Press the uterine fundus downward to bend the foetal spine and explore the lateral surfaces of the
uterus. T he back is felt as a hard plane, the limbs as small irregular projections. T he back is
described with reference to the mother’s right or left.
In the third trimester, the foetal heart tones are auscultated in the umbilical region along the foetus’
back, at shoulder level.

Only if indicated:
Genital examination (e.g. to look for symptoms of sexually transmitted infection).
Vaginal examination (e.g. if mother complains of recurring uterine contractions).

Note: a small pelvis b is not predictive of foeto-pelvic disproportion and does not justify scheduling a
caesarean section. Moreover, foeto-pelvic disproportion can occur with a normal-appearing pelvis. In
practice, foeto-pelvic disproportion can only be diagnosed during labour.

C. Laboratory tests
Table 1.5 - Recommended screening tests
 Tests Comments

Urinary tract infection Look for asymptomatic bacteriuria at each consultation.

Malaria In endemic areas, perform a rapid test at each consultation during the
second and third trimesters, unless the woman was tested in the past 4
weeks, the test was positive, and the woman has taken curative
antimalarial treatment as a result.

HIV infection Offer patients who tested negative during the first trimester a new test in
the third trimester. T here is increased risk of mother-to-child
transmission of HIV when seroconversion occurs during pregnancy.

1.2.5 Preventive treatments

Maternal and neonatal tetanus
Pregnant women not vaccinated against tetanus in childhood or adolescence should receive at
least 2 doses of tetanus vaccine (T V) c before giving birth:
the first dose should be administered at the first consultation;
the second dose should be administered at least 4 weeks after the first dose and ideally at
least 2 weeks before the due date to maximize the maternal antibody response and passive
antibody transfer to the infant.
After the birth, continue to a total of 5 doses, according to the schedule below. Once administered,
these 5 doses confer lifelong protection.

Table 1.6 - Vaccination schedule for women who are pregnant or of child-bearing age [2]
 Level of
Dose Schedule
protection

At the first contact with medical services

T V1 0%
or as early as possible during pregnancy

At least 4 weeks after T V1

T V2 80%
and at least 2 weeks before the delivery due date

At least 6 months after T V2

T V3 95%
or during the next pregnancy

At least 1 year after T V3

T V4 99%
or during another pregnancy

At least 1 year after T V4

T V5 99%
or during another pregnancy

Anaemia
Absence of anaemia
If there are no clinical signs of anaemia and no abnormal haemoglobin values:
Administer iron and folic acid supplementation, starting as soon as possible after gestation starts
and continue throughout the rest of the pregnancy. Give either:
ferrous sulfate/folic acid d (tablet containing 200 mg of ferrous sulfate, 65 mg of elemental iron +
400 micrograms of folic acid) PO: 1 tablet once daily
or
multiple micronutrients e (tablet containing 93.75 mg of ferrous sulfate, equivalent to 30 mg of
elemental iron + 400 micrograms of folic acid + other nutrients) PO: 1 tablet once daily
Note: World Health Organization recommends 30 to 60 mg of elemental iron daily. However, a dose
of 60 mg of elemental iron daily is preferred over a dose of 30 mg daily in settings where the
prevalence of anaemia in pregnant women is high (≥ 40%) f[3] .
In areas where hookworm infection is common (areas with warm, moist climates), administer also
an antihelminthic treatment as of the second trimester:
albendazole PO, 400 mg single dose (or mebendazole PO: 100 mg 2 times daily for 3 days)
In areas where malaria is endemic, administer also an intermittent preventive antimalarial treatment
or an antimalarial curative treatment, depending on the results of malaria screening tests (see
below).
Presence of anaemia
If there is clinical evidence of anaemia (pallor of the palms, conjunctivae or tongue) or if haemoglobin is
< 11 g/dl in the first and third trimester or < 10.5 g/dl in the second trimester): see Chapter 4, Section
4.1.

Malaria
In all areas with moderate to high P. falciparum malaria transmissiong prevention consists of:
T he use of insecticide-treated mosquito nets (2 bed nets should be provided).
Malaria testing at each antenatal consultation in the second and third trimesters.
If the test is positive, no matter the region or stage of pregnancy:
Administer curative malaria treatment (Chapter 4, Section 4.3.1).
Wait one month after curative treatment before screening for malaria again.
If the test is negative, intermittent preventive treatment (IPT ) is recommended in African
moderate to high P. falciparum malaria transmission areas:
Start IPT with sulfadoxine-pyrimethamine (SP) [4] as early as possible in the second trimester.
T he aim is to administer at least 3 doses between the second trimester and delivery with an
interval of at least 1 month between each treatment. T here is no maximum number of
treatments as long as a one-month interval is respected. T he SP dose for each treatment is 3
tablets single dose. T his treatment helps reduce the effects of malaria (maternal anaemia and
low birth weight). Do not administer this intermittent treatment to HIV-infected women receiving
co-trimoxazole prophylaxis.

Urinary tract infections

Treat all urinary tract infections including asymptomatic bacteriuria [5] detected by urine
dipstick test (Chapter 4, Section 4.2.3).

HIV infection
If test results are positive, start antiretroviral therapy (Chapter 4, Section 4.4.4).

Vitamin and micronutrient deficiencies

Calcium
Supplementation is recommended for [6] :
All pregnant adolescents (under 20 years old);
All pregnant women with low calcium intake AND at high risk of pre-eclampsia (history of pre-
eclampsia or eclampsia, twin pregnancy, chronic hypertension).
Start supplementation at the first antenatal visit and continue throughout the pregnancy:
calcium carbonate PO: one 1.25 g tablet (equivalent to 500 mg of calcium element) 3 times
 daily
Wait 2 hours between the administration of calcium and ferrous salts.
Vitamin D
Sun exposure and foods are sources of vitamin D. A supplement can be prescribed if there is a risk
of deficiency (low exposure to sunlight, diet poor in vitamin D):
colecalciferol (vitamin D 3) or ergocalciferol (vitamin D 2) PO: 100 000 IU single dose at 6 or 7
months of pregnancy.
Iodine
Iodine deficiency during pregnancy increases the risk of miscarriage, prematurity, severe mental and
growth restriction in the child, and neonatal or infant death. In areas where iodine deficiency is
endemic, iodine supplementation is necessary. Follow national protocol.

Malnutrition
If malnutrition is present, admit the woman into a therapeutic feeding programme. If there
no therapeutic feeding programme, ensure supplementation:
MUAC 190-230 mm: 2 sachets Plumpy'nut or 3 bars BP100 daily;
MUAC < 190 mm: 4 sachets Plumpy'nut or 7 bars BP100 daily.
In the absence of signs of malnutrition but in a context of food insecurity, food supplementation is
recommended for all pregnant women throughout their pregnancy.
In the event of overweight or obesity, provide advice on how to avoid excessive weight gain during
pregnancy.

T he above measures apply to most contexts. Other tests and preventive measures relevant in
the specific context , or included in the national protocol (e.g. Rhesus factor testing and
alloimmunization prophylaxis, screening for cervical cancer, hepatitis B serology, screening for
tuberculosis, etc.), should be taken into account.

1.2.6 Preparation for the birth

Group sessions
Group sessions (10 to 15 women) should be organized to encourage information sharing between
patients, promote the use of available services and address the following:
Importance of skilled birth assistance.
T he purpose of antenatal consultations.
T he recommended screening tests and preventive treatments during pregnancy.
Protection against insect vectors: insecticide-treated mosquito nets, protective clothing, certain
repellents, etc. according to the context (e.g. malaria, dengue, chikungunya, zika).
 Danger signs during pregnancy, labour and delivery, and the importance of quickly seeking medical
care.
T he use of the “birth kit”h , depending on the context.
T he purpose of the postnatal consultation.
Contraception.

Individual sessions
Individual sessions are an opportunity to revisit the subjects discussed in the group sessions and offer
advice tailored to the individual's medical and social situation.
T he choice of topics depends on the stage of pregnancy and the woman’s specific circumstances
(e.g. substance abuse, domestic violence, genital mutilation).
Individual sessions should in all cases include a personalised birth plan (see below).

Birth plan
With the patient, work out a plan appropriate to her medical and social situation:
Site for birth: BEmONC or CEmONC facility, depending on the course of the pregnancy and the
history;
Any necessary arrangements: transportation, family arrangements, etc.

Table 1.7 - Obstetric care facilities

 Facility Minimum package

BEmONC Open 24 hours a day, 7 days a week

Basic Emergency Obstetric and Skilled birth attendant(s)
Newborn Care Possibility of:
parenteral antibiotics
uterotonics
anticonvulsants if pre-eclampsia or eclampsia
Possibility of:
manual removal of the placenta
uterine evacuation (vacuum aspiration)
instrumental delivery (vacuum extraction)
basic neonatal resuscitation

CEmONC Same as BEmONC facility

Comprehensive Emergency PLUS
Obstetric and Newborn Care Possibility of:
surgical management (caesarean section, hysterectomy,
etc.)
blood transfusion
care of low birth weight or sick neonates

Notas
(a) Ult rasound allows accurat e est imat ion of gest at ional age in t he first t rimest er, wit h a margin of error of
approximat ely 7 days. The margin of error is larger in t he second and t hird t rimest ers (about 15 and 20
days, respect ively).

(b) The pelvis is considered small if t he t op of t he sacrum (promont ory) can be reached wit h t he fingers
and/or t he lat eral edges of t he pelvis can be f elt along t heir ent ire lengt h.

(c) Use pref erably Td vaccine (t et anus and dipht heria t oxoids) or, if not available, TT vaccine (t et anus t oxoid).

(d) 200 mg f errous sulf at e (65 mg element al iron) + 400 micrograms f olic acid t ablet s may be replaced by 185
mg f errous f umarat e (60 mg element al iron) + 400 micrograms f olic acid t ablet s.

(e) If using mult iple micronut rient s, check t he amount of iron salt s (sulf at e or f umarat e) is equivalent t o 30 mg
of element al iron per t ablet and t he amount of f olic acid is 400 micrograms per t ablet (UNU/UNICEF/WHO
f ormulat ion).

(f ) According t o t he World Healt h Organizat ion (1993-2005), t he prevalence of anaemia in pregnant women is
57.1% in Af rica, 48.2% in Sout h-East Asia, 44.2% in t he East ern Medit erranean region, 30.7% in t he West ern
Pacific region, 25% in t he European region and 24.1% in t he Americas.
(g) “Moderat e t ransmission” areas: zones where prevalence rat e of malaria is 11 t o 50% during most of t he
year among children aged 2 t o 9 years. “High t ransmission” areas: zones where prevalence rat e of malaria
is over 50% during most of t he year among children aged 2 t o 9 years.

(h) Individual kit given t o women t hat might deliver at home due t o limit ed t ravel possibilit y (remot e or insecure
sit uat ions). It cont ains a plast ic-coat ed clot h t o be spread out on t he floor, a soap (f or cleaning t he
woman’s genit als and washing t he midwif e’s hands), a st ring and a razor blade f or t ying and cut t ing t he
cord and, in some cases, a clot h f or drying t he inf ant .

Referencias
1. World Healt h Organizat ion. WHO Ant enat al Care Randomised Trial: Manual f or t he Implement at ion of t he
New Model. Geneva. 2002. WHO/RHR/01.30.
ht t p://whqlibdoc.who.int /hq/2001/WHO_RHR_01.30.pdf

2. World Healt h Organizat ion. Field manual f or neonat al t et anus eliminat ion. Geneva. 1999.
ht t p://whqlibdoc.who.int /hq/1999/WHO_V&B_99.14.pdf

3. World Healt h Organizat ion. Guideline: Daily iron and f olic acid supplement at ion in pregnant women.
Geneva. 2012.
ht t p://apps.who.int /iris/bit st ream/10665/77770/1/9789241501996_eng.pdf

4. WHO policy brief f or t he implement at ion of int ermit t ent prevent ive t reat ment of malaria in pregnancy
using sulf adoxine-pyrimet hamine (IPTp-SP). April 2013 (revised January 2014).
ht t p://www.who.int /malaria/publicat ions/at oz/ipt p-sp-updat ed-policy-brief -24jan2014.pdf

5. Smaill F, Vazquez JC. Ant ibiot ics f or asympt omat ic bact eriuria in pregnancy (Review). The Cochrane Library
2007, Issue 4.
ht t p://apps.who.int /rhl/reviews/CD000490.pdf

6. World Healt h Organizat ion. WHO recommendat ions on ant enat al care f or posit ive pregnancy experience.
2016.
ht t ps://apps.who.int /iris/bit st ream/handle/10665/250796/9789241549912-
eng.pdf ;jsessionid=011FCED838D9A9884D9D1FC1285B16FB?sequence=1

1.3 Monitoring complicated pregnancies

T he term “complicated pregnancy” refers to any pregnancy in which the mother or infant is at
increased risk due to a particular obstetric or medical pathology or history.

Complicated pregnancies may require higher level monitoring and/or special arrangements for delivery
in a medical/surgical setting.

1.3.1 Situations requiring higher level monitoring

In the following situations, the increased risk exists mainly during pregnancy itself rather than delivery:
 History of preterm delivery or multiple miscarriages (risk of recurrence).
History of unexplained intrauterine foetal death.
Progressive pathology associated with pregnancy such as upper urinary tract infection (risk of
preterm delivery), anaemia (possible exacerbation), hypertension, pre-eclampsia, etc.

1.3.2 Situations requiring special precautions for delivery

In the following situations, the increased risk exists mainly during delivery rather than during pregnancy.

Arrange for delivery in a BEmONC facility:

History of intra-partum intrauterine foetal death or death in the first day of life (risk of recurrence).
History of haemorrhage during a prior delivery (risk of recurrence and maternal death).
History of forceps or vacuum delivery (risk of recurrence).
Height less than 1.50 m (risk of foeto-pelvic disproportion).
Primiparity (risk of obstructed labour).
Limp, hip dislocation, polio sequelae with frank pelvic asymmetry (risk of obstructed labour).
Grand multiparity i.e. 5 deliveries or more (risk of uterine atony, uterine atony-related haemorrhage,
uterine rupture).

Note: it is essential that all BEmONC facilities have an effective system for referring patients to a
CEmONC facility.

Arrange for delivery in a CEmONC facility:

In situations that routinely require caesarean section:
History of uterine rupture;
History of caesarean section with vertical (classical) incision or more than two caesarean
births;
Transverse lie.
In situations where there is a high risk that emergency caesarean or complex obstetrical
manoeuvres will be needed:
History of caesarean section with low uterine segment transverse incision;
History of uterine scar (perforated uterus or myomectomy);
History of vesico-vaginal fistula;
History of symphysiotomy;
History of third or fourth degree tear;
Breech presentation, in particular in primipara.
1.3.3 Situations requiring closer monitoring during pregnancy
AND special precautions for delivery (CEmONC)
History of abruptio placentae, severe pre-eclampsia or eclampsia.
Pre-eclampsia (risk of eclampsia, coagulopathy, maternal death, abruptio placentae, intrauterine
growth restriction, intrauterine foetal death) or eclampsia.
Bleeding (risk of preterm delivery, foetal distress, intrauterine foetal death, anaemia, maternal
death).
Severe anaemia (risk of small foetus, prematurity, neonatal anaemia, increased vulnerability in case
of haemorrhage). Transfusion should be available in case of severe anaemia during the third
trimester.
Multiple pregnancy (risk of obstructed labour, preterm delivery, hypertension, diabetes, intrauterine
growth restriction and postpartum haemorrhage).
Preterm rupture of membranes (risk of infection, preterm delivery and intrauterine foetal death).

Chapter 2: Bleeding during the first half

of pregnancy
2.1 Abortion

2.2 Ectopic pregnancy

2.3 Molar pregnancy (hydatidiform mole)

2.4 Cervicitis

2.5 Functional bleeding

2.1 Abortion
Ending of pregnancy, either spontaneous (miscarriage) or induced (termination of pregnancy) before 22
weeks LMP.

In countries where termination of pregnancy is legally restricted, induced abortions are often
performed under poor conditions (non-sterile equipment, inappropriate equipment and/or substances,
unqualified health care personnel, etc.). Complications (trauma, bleeding and severe infection) are
common and may be life-threatening.
For termination of pregnancy, see Chapter 12.

2.1.1 Diagnosis
Signs and symptoms
– T hreatened abortion or missed abortion: light bleeding, abdominal pain, closed cervix.
– Incomplete abortion: more or less severe bleeding, abdominal pain, uterine contractions, expulsion of
products of conception, open cervix.
– Trauma to the vagina or cervix or the presence of a foreign bodies are strongly suggestive of unsafe
abortion. Look for complications, especially infection.

Additional investigations
– A pregnancy test is useful if the history and clinical examination are inconclusive.
– Ultrasound is useful for confirming failed pregnancy or the presence of retained products of
conception after incomplete abortion.

2.1.2 Differential diagnosis

T he main differential diagnoses are: ectopic pregnancy, cervicitis, ectropion (eversion of the cervical
mucosa, which is more fragile and may bleed easily on contact, especially after a vaginal examination
or sexual intercourse), cervical polyp, and functional uterine bleeding.

2.1.3 Management
Threatened abortion
– Advise the patient to reduce activity. Either the threat of abortion recedes, or abortion is inevitable.
– Look for a possible infectious cause (malaria or sexually transmitted infection) and treat it.
– Treat pain according to severity (Appendix 7).

Missed abortion
If there are no signs of infection and/or no heavy bleeding, there is no urgency to perform uterine
evacuation.
– Before 13 weeks LMP
Uterine evacuation can be performed by:
• medication: misoprostol 600 micrograms sublingually or 800 micrograms vaginally (in the posterior
fornix). Bleeding and cramping can be expected to start within 3 hours. If expulsion has not started
within 3 hours, administer additional doses of misoprostol every 3 hours; max. 3 doses in total[1] .
or
• manual vacuum aspiration (Chapter 9, Section 9.5).
– Between 13 and 22 weeks LMP
mifepristone PO: 200 mg single dose, and 1 to 2 day later, misoprostol 400 micrograms sublingually
or intravaginally (into the posterior fornix), every 4 to 6 hours until labour starts, to be repeated if
necessary the following day
or
misoprostol alone 400 micrograms sublingually or intravaginally (into the posterior fornix), every 4 to 6
hours until labour starts, to be repeated if necessary the following day
In case of 2 or more previous uterine scars or grand multiparity or overdistention of the uterus:
• Preferably use the combined regimen mifepristone + misoprostol, as fewer numbers of
misoprostol doses are required.
• Reduce the dose of misoprostol to 200 micrograms every 6 hours.
• Closely monitor the mother for possible signs of impending rupture (heart rate, blood pressure, uterine
contractions, pain).

Ongoing or incomplete abortion without signs of infection

General measures
– Measure heart rate, blood pressure, temperature; assess severity of bleeding.
– In the event of heavy bleeding:
• insert an IV line (16-18G catheter) and administer Ringer lactate;
• closely monitor heart rate, blood pressure, bleeding;
• prepare for a possible transfusion: determine the patient’s blood type, select potential donors or
ensure that blood is available. If transfusion is necessary, only use blood that has been screened (HIV-
1, HIV-2, hepatitis B, hepatitis C, syphilis, and malaria in endemic areas).
– Treat pain according to severity (Appendix 7).
– Remove products of conception from the vagina and cervix, if present.
– Look for a cause (e.g. malaria or sexually transmitted infections) and treat it.
– Afterwards, provide iron + folic acid supplementation or, in the event of severe anaemia, a blood
transfusion.
Uterine evacuation
– Before 13 weeks LMP
Uterine evacuation is usually required due to retained products of conception, which can cause
bleeding and infection. T here are 2 options:
• Instrumental evacuation: manual vacuum aspiration (Chapter 9, Section 9.5) or, if not available,
instrumental curettage (Chapter 9, Section 9.6). Aspiration under local anaesthesia is the method of
choice [2] . It is technically easier to perform, less traumatic and less painful than curettage.
• Medication: misoprostol 400 micrograms sublingually or 600 micrograms PO single dose [3]
– Between 13 and 22 weeks LMP
• Instrumental evacuation in case of haemorrhage: manual vacuum aspiration (Chapter 9, Section 9.5)
or instrumental curettage (Chapter 9, Section 9.6) or digital curettage (Chapter 9, Section 9.4).
• Medication: misoprostol 400 micrograms sublingually every 3 hours until expulsion. In the absence of
expulsion after 3 additional doses, consider instrumental evacuation.
In case of 2 or more previous uterine scars or grand multiparity or overdistention of the uterus: same
precautions as for missed abortion (see above).

Septic abortion
In the event of septic abortion (fever, abdominal pain, tender uterus, foul-smelling discharge), as above
AND:
– Remove foreign bodies from the vagina and cervix, if present; clean wounds.
– Perform uterine evacuation as soon as possible, irrespective of gestational age.
– Administer antibiotherapy as soon as possible:
amoxicillin/clavulanic acid IV (dose expressed in amoxicillin): 1 g every 8 hours + gentamicin IM: 5
mg/kg once daily
or
ampicillin IV: 2 g every 8 hours + metronidazole IV: 500 mg every 8 hours + gentamicin IM: 5
mg/kg once daily
Continue until the fever disappears (at least 48 hours), then change to:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin) to complete 5 days of treatment
Ratio 8:1: 3000 mg daily (= 2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (= 1 tablet of 875/125 mg 3 times daily)
or
amoxicillin PO: 1 g 3 times daily + metronidazole PO: 500 mg 3 times daily, to complete 5 days of
treatment
For very severe infection (infected perforated uterus or peritonitis), treat for 10 days.
– Check and/or update tetanus immunisation (Table 2.1).
Table 2.1 - Tetanus prophylaxis
 Unsafe abortion,
Immunisation status Spontaneous abortion
with wound or foreign bodies

Not immunised
Begin immunisation against tetanus
or Begin immunisation against
+
Immunisation status tetanus
Human tetanus immune globulin
unknown

Tetanus booster
Incompletely immunised Tetanus booster +
Human tetanus immune globulin

Fully immunised
Last booster dose:

< 5 years No prophylaxis No prophylaxis

5 to 10 years No prophylaxis Tetanus booster

Tetanus booster
> 10 years
Tetanus booster +
Human tetanus immune globulin

Referencias
1. IPAS. Clinical Updat es in Reproduct ive Healt h. March 2018. ht t ps://ipas.azureedge.net /files/CURHE18-
march-ClinicalUpdat esinReproduct iveHealt h.pdf

2. IPAS. Clinical Updat es in Reproduct ive Healt h. Ut erine evacuat ion: Replace sharp curet t age wit h aspirat ion
or medicat ions. December 5, 2018. ht t ps://www.ipas.org/clinical-updat es/general/ut erine-evacuat ion

3. World Healt h Organizat ion. Medical management of abort ion. Geneva, 2018.
ht t ps://apps.who.int /iris/bit st ream/handle/10665/278968/9789241550406-eng.pdf ?ua=1

2.2 Ectopic pregnancy

Implantation of the fertilized egg outside of the uterine cavity, usually in the Fallopian tube. Other
locations (abdominal, ovarian, cervical) are less common. Predisposing factors are history of
peritonitis or pelvic infection.
2.2.1 Diagnosis
Signs and symptoms
Symptoms common to tubal, abdominal or ovarian ectopic pregnancy:
– Recent history of intermittent abdominal pain, a few weeks of amenorrhea, which may be followed
by vaginal bleeding or menstrual irregularity, nausea and vomiting, occasional dizziness or faintness.
– Examination: abdominal tenderness often unilateral; guarding, possible adnexal mass, cervical and
posterior fornix tenderness.

In the event of tubal pregnancy:

– Blood may collect in the Fallopian tube (haematosalpinx). T he symptoms above may then be more
severe and prolonged, with a painful adnexal mass.
– Bleeding may gradually seep into the abdominal cavity over several days or weeks. T he blood
accumulates in the Pouch of Douglas and form a haematoma (haematocele). If a haematocele forms
– especially if it is large – there may be other signs and symptoms:
• irritation of the bladder or rectum with urinary frequency, dysuria, rectal cramps and low grade fever;
• bulging and increased pain in the posterior fornix, with a pelvic mass with poorly defined borders and
uneven consistency that pushes the uterus forward;
• anaemia.

In the event of sudden Fallopian tube rupture, the tube’s blood vessels are often damaged.
A haemoperitoneum (bloody effusion into the peritoneal cavity) develops quickly.
On examination:
– distended, tender abdomen, shifting dullness;
– exquisite pain in the Pouch of Douglas;
– scapular pain;
– hypovolaemic shock due to bleeding (rapid, weak or unmeasurable pulse, very low or unmeasurable
blood pressure, tachypnoea, pallor, cold sensation, damp skin, agitation and anxiety).

In general, a cervical pregnancy (very rare) most closely resembles an incomplete abortion. It is often
discovered due to massive bleeding during vacuum aspiration or curettage to evacuate the uterus.

Additional investigations
– Pregnancy test: usually positive; in case of haematocele, however, it may exceptionally be negative.
– Ultrasound: shows an empty uterus, and in some cases an adnexal mass (haematosalpinx or
haematocele) or fluid/blood in the abdominal cavity (haemoperitoneum).
If ultrasound is unavailable and there is still some doubt, culdocentesis (Pouch of Douglas puncture)
may be useful to look for a haemoperitoneum. T he procedure is pointless when laparotomy is clearly
indicated.
– Culdocentesis:
• Perform general (ketamine) or local (1% lidocaine) anaesthesia.
• Swab the perineum, vagina and cervix with 10% povidone iodine.
• Push the posterior vaginal wall down using a speculum. Grasp the posterior lip of the cervix with Pozzi
forceps and lift the cervix upward.
• Puncture the posterior fornix using a long, large-bore needle (e.g. spinal needle 20G) held as close to
horizontal as possible, and aspirate with a 20-ml syringe.
• An aspirate containing non-clotting blood indicates haemoperitoneum.
Figure 2.1 - Puncture of the posterior fornix

2.2.2 Differential diagnosis

T he main differential diagnoses for ectopic pregnancies are abortion, salpingitis, ovarian abscess,
appendicitis and diverticulitis.
When haematocele is suspected, also consider pyosalpinx, fibroma, or pelvic abscess from another
cause.
When haemoperitoneum is suspected, also consider gastric or duodenal perforation or ovarian cyst
rupture.

2.2.3 Management
When the diagnosis of ectopic pregnancy is highly likely:
– Prepare for laparotomy or refer urgently to a CEmONC facility.
– Insert an IV line (16-18G catheter) and administer Ringer lactate.
– Closely monitor: heart rate, blood pressure and bleeding.
– Prepare for a possible transfusion, determine the patient’s blood type, select potential donors or
ensure that blood is available. If transfusion is necessary, only use blood that has been screened (HIV-
1, HIV-2, hepatitis B, hepatitis C, syphilis, and malaria in endemic areas).

Special cases
– In case of cervical pregnancy, temporarily stop the bleeding, if possible, using intracervical Foley
catheter compression or cerclage before considering total hysterectomy.
– Abdominal pregnancy is treated by laparotomy. Depending on its location, removing the placenta
may be very difficult and cause severe bleeding; in that case, leave the placenta in place.

2.3 Molar pregnancy (hydatidiform mole)

Pathological pregnancy due to cystic degeneration of the placenta (abnormal proliferation of the
chorionic villi). T he mole presents in the form of translucent vesicles, 1 to 2 cm in diameter, connected
by filaments like a cluster of grapes. In most cases there is neither foetus nor amniotic sac.

2.3.1 Diagnosis
Signs and symptoms
– Spontaneous bleeding of variable severity.
– Uterus larger and softer than expected for gestational age.
– No foetal heart tone, movements, or poles at five months.
– Nausea and vomiting that is more frequent and lasts longer than in a normal pregnancy.
Occasionally:
– Oedema, proteinuria, or hypertension if the pregnancy is advanced;
– Enlarged ovaries, weight loss, mild jaundice;
– Slow, fragmentary, incomplete abortion, occasionally accompanied by heavy bleeding with expulsion
of vesicles.

Additional investigations
– T he pregnancy test is always positive.
– Ultrasound shows a heterogeneous, vesicular placenta filling the entire uterine cavity.

2.3.2 Management
– Refer to a CEmONC facility: risk of bleeding and complicated uterine evacuation.
– Insert an IV line (16-18G catheter) and administer Ringer lactate.
– Closely monitor: heart rate, blood pressure and bleeding.
– Prepare for a possible transfusion, determine the patient’s blood type, select potential donors or
ensure that blood is available. If transfusion is necessary, only use blood that has been screened (HIV-
1, HIV-2, hepatitis B, hepatitis C, syphilis, and malaria in endemic areas).
– Evacuate the mole using aspiration, or if not available, digital curettage or careful instrumental
curettage (Chapter 9). T he evacuation should be done under oxytocin, 20 IU in 1 litre of Ringer lactate
or 0.9% sodium chloride administered over 2 hours (160 drops/minute) to prevent bleeding and reduce
the risk of perforation (the uterine wall is thin and weakened). No debris should remain after uterine
evacuation. If possible, perform an ultrasound to make sure the uterus is empty.
– Provide effective contraception for at least one year, or perform tubal ligation if desired.

2.3.3 Follow-up
In approximately 10 to 15% of patients, the mole develops into persistent trophoblastic disease or
choriocarcinoma.

Two weeks after the evacuation, perform an ultrasound if possible to be sure the uterus is empty. If
ultrasound is not available and bleeding persists, consider a second aspiration (even when done
correctly, retention of molar debris is not uncommon).

Eight weeks after the evacuation, perform the first follow-up pregnancy test. T he test does not
become negative immediately after the evacuation, but it should be negative within 8 weeks.
• If the test is negative, perform a pregnancy test every 4 to 8 weeks for 1 year.
• If the test is positive after 8 weeks or becomes positive during subsequent follow-up despite
effective contraception, refer the patient to rule out or treat persistent trophoblastic disease or
choriocarcinoma.

2.4 Cervicitis
Inflammation of the cervix caused by a number of pathogens – Chlamydia trachomatis and Neisseria
gonorrhoeae in more than 40% of cases.

2.4.1 Diagnosis
Light vaginal bleeding.
Cervix red, inflamed, infected (purulent discharge).
Possible concomitant vaginitis (foul-smelling vaginal discharge).
2.4.2 Management
Administer antibiotics active against chlamydia and gonococcus to the patient and her partner
(Chapter 4, Section 4.2.2).
An inflamed cervix and/or cervical lesions may indicate dysplasia or cancer. See the patient again 3
months after delivery to re-examine the cervix.

2.5 Functional bleeding

Bleeding that is usually light, endometrial in origin, with no apparent cause. T his is a diagnosis of
exclusion, after the other causes of bleeding discussed in this chapter have been ruled out.

2.5.1 Diagnosis
Light bleeding.
Normal size uterus; long, closed posterior cervix; no adnexal mass.

2.5.2 Management
Reassure the patient; no medication indicated.

Chapter 3: Bleeding during the second

half of pregnancy
3.1 Placenta praevia

3.2 Abruptio placentae

3.3 Uterine rupture

3.4 Diagnosis of bleeding during the second half of pregnancy (summary)

3.1 Placenta praevia

Abnormal implantation of the placenta in the lower uterine segment, rather than in the uterine fundus.

T he primary risk factors for placenta praevia are multiparity and a history of caesarean section.
Even under good circumstances (possibility of blood transfusion, high quality surgical setting), maternal
and foetal mortality and the risk of postpartum haemorrhage are high.

3.1.1 Different types of placenta praevia

T here are 4 types of placenta praevia:
Complete placenta praevia (Figure 3.1a), in which the placenta completely covers the internal
cervical os;
Partial placenta praevia, in which the placenta partially covers the internal cervical os;
In either of these cases, vaginal delivery is not possible.
Marginal placenta praevia (Figure 3.1b), in which the placenta touches, but does not overlap, the
internal os;
Lateral placenta praevia, in which the placenta is inserted in the lower segment, but more than 2 cm
from the internal cervical os.

Figures 3.1 - Placenta praevia

3.1a - Complete 3.1b - Marginal

3.1.2 Diagnosis
Signs and symptoms
In a woman more than 22 weeks LMP:
Sudden, bright red bleeding associated with uterine contractions (not always felt by the patient).
T he foetus often presents high, pushed up by the placenta; the uterus is soft.
Foetal heart tone usually heard.
Examination with a speculum shows blood flowing from the cervical os.
Ultrasound
Ultrasound is the method of choice for diagnosing placenta praevia. It makes it possible:
To avoid a vaginal examination that may trigger massive haemorrhage.
To determine whether or not the placenta is covering the cervix, and thus the preferred route of
delivery.

If ultrasound is not available or is not reliable, careful digital vaginal examination may be
performed but only in the operating room, with resources at hand for immediate management of
massive haemorrhage (IV line(s), transfusion, emergency caesarean section if necessary). Digital
vaginal examination may reveal displacement of the cervix and deformation of the lower uterine
segment by the placenta praevia. Rather than the hard foetal presentation, one feels a spongy
mass. If possible, try to determine whether the placenta covers the entire cervix, or only part.
Once the diagnosis is established, do not perform another digital vaginal examination.

3.1.3 Management
Insert an IV line (16-18G catheter) and administer Ringer lactate.
Measure heart rate and blood pressure; assess the severity of the bleeding, measure haemoglobin.
Prepare for a possible transfusion, determine the patient’s blood type, select potential donors or
ensure that blood is available. If transfusion is necessary, only use blood that has been screened
(HIV-1, HIV-2, hepatitis B, hepatitis C, syphilis, and malaria in endemic areas).
If the uterus is scarred or there is a history of placenta praevia, consider the possibility of placenta
accreta and prepare to perform a hysterectomy.
If anaemia is present, treat according to severity.

Labour has not yet started and bleeding is minor to moderate

Rest and monitoring: a sudden, massive haemorrhage is always possible, even if bleeding has
completely stopped.
In the event of complete or partial placenta praevia:
the patient should remain hospitalized or close to a CEmONC facility;
prolong the pregnancy, if possible, up to at least 34 weeks LMP (before 34 weeks LMP,
consider foetal lung maturation with dexamethasone, Chapter 4, Section 4.10.2).
Perform a caesarean section:
between 34 and 37 weeks LMP, despite prematurity, if the situation is unstable (recurrent
bleeding);
after 37 weeks LMP after a single episode of bleeding that has stopped.

Labour has not yet started and bleeding is heavy

Try a tocolytic agent to reduce contractions and bleeding (Chapter 4, Section 4.10.2).
 At the same time, prepare for caesarean section (regardless of the placenta's position or foetal
viability), in case the bleeding persists or there is massive, uncontrolled bleeding (caesarean section
to save the life of the mother).
In remote areas, arrange a transfer to a CemONC facility. Be careful of the risk of exacerbating the
bleeding if transport conditions are difficult.

Labour has started

Complete placenta praevia and/or heavy bleeding: caesarean section.
Placenta praevia not complete and minor bleeding: attempt vaginal delivery; rupture the membranes
as soon as they are accessible, in such a way that the foetal head compresses the placental
vessels and cuts off the bleeding.

Be careful of postpartum haemorrhage, which is common with all forms of low-lying placenta,
due to the weaker retraction of the lower uterine segment. Do not hesitate to remove the
placenta manually and explore the uterine cavity. Administer oxytocin routinely (Chapter 8,
Section 8.1).

3.2 Abruptio placentae

Premature separation of the normally implanted placenta, prior to foetal expulsion with formation of a
haematoma between the placenta and the uterine wall. T he haematoma completely or partially
separates the placenta from the uterine wall.

Abruptio placentae (or placental abruption) often occurs with trauma or in cases of hypertension or
pre-eclampsia.

T his can trigger a clotting disorder in the mother, with a risk of severe secondary haemorrhage
(disseminated intravascular coagulation).

Emergency uterine evacuation (vaginal or caesarean) is needed to save the lives of the mother and
foetus, no matter what the stage of pregnancy.

3.2.1 Diagnosis
Abruptio placentae is diagnosed clinically. It should be suspected when one or more of the following
signs are present:
– Sudden, severe, continuous abdominal pain;
– Uterus in spasm, feels hard, “woody”;
– Sudden, light, blackish bleeding; the bleeding may be heavy if there is an associated clotting disorder;
– Shock, out of proportion to the severity of the external bleeding (intra-uterine bleeding): rapid or
weak or undetectable pulse, very low or undetectable blood pressure; tachypnoea, pallor, sensation of
cold, damp skin, agitation and anxiety.
– Foetal hypoxia, depending on the size of the placental abruption: foetal heart rate slows or foetal
heart tone disappear.
– When the membranes rupture, the fluid is uniformly red.

Sometimes the picture is incomplete: there may be no vaginal bleeding or uterine spasm, or no foetal
distress.

Ultrasound, when available, is useful for verifying foetal vitality.

3.2.2 Management
See also algorithm.
– Insert an IV line (16-18G catheter) and administer Ringer lactate.
– Measure heart rate and blood pressure; assess the severity of the bleeding. If there are no clots,
consider the possibility of a clotting disorder.
– In remote areas, arrange a transfer to a CEmONC facility, if possible, in anticipation of the need to
transfuse, perform a caesarean section or hysterectomy, and manage post-partum haemorrhage.

To assess clotting disorders [1] :

– Take 2 ml of blood into a dry, clean, glass tube (approximately 10 mm x 75 mm).
– Hold the tube in a closed fist to keep it warm (± 37 °C).
– After 4 minutes, tip the tube slowly to see if a clot is forming then, tip it again every minute until the
blood clots and the tube can be turned upside down.
– Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests clotting
disorders.
For blood transfusion:
– Determine the patient’s blood type;
– Select potential donors for possible transfusion of fresh whole blood;
– If transferred, the woman should be accompanied by family members who are potential blood
donors;
– If there is moderate bleeding and no clotting disorder, transfuse packed red blood cells or whole
blood;
– If there is massive bleeding and/or a clotting disorder, transfuse fresh whole blood (drawn less than 4
hours and unrefrigerated) or packed red blood cells or whole blood combined with fresh frozen plasma;
– Blood or other blood products must have been screened (HIV-1, HIV-2, hepatitis B, hepatitis
C, syphilis, and malaria in endemic areas).

Delivery should be done quickly, ideally before the onset of clotting disorders. When not indicated
initially, caesarean section becomes imperative if labour progresses too slowly – even in the event of
intrauterine foetal death.

Do not prescribe salbutamol to relax the uterine spasm.

Management of abruptio placentae

Referencias
1. World Healt h Organizat ion. Managing complicat ions in pregnancy and childbirt h. A guide f or midwives and
doct ors. Geneva 2017.
ht t p://apps.who.int /iris/bit st ream/handle/10665/255760/9789241565493-eng.pdf ?sequence=1
3.3 Uterine rupture
Tear in the uterine wall, in most cases during labour.

In a CEmONC or BEmONC facility, uterine rupture can be reduced by monitoring the progress of labour
with partograph, and vigilant, rational use of oxytocin and prostaglandins.

3.3.1 Circumstances in which uterine rupture occurs

– Obstructed labour.
– Grand multiparas (5 deliveries or more).
– When excessive amounts of uterotonic (oxytocin or misoprostol) are used.
– Prior history of uterine surgery: caesarean section, especially classical (Figure 3.2); uterine
perforation; myomectomy.
Figure 3.2 - Uterine rupture on a classical caesarean section scar

3.3.2 Diagnosis
Diagnosis is clinical. A rupture may be diagnosed during labour or after delivery. T hough the initial
symptoms may be subtle – particularly in cases of scarred uterus – the signs are usually obvious.

During labour
– Impending rupture:
• maternal agitation;
• increasingly severe abdominal pain that persists between contractions; abdominal guarding;
• often, Bandl’s ring (Figures 3.3 and 3.4), a sign of obstructed labour. At first glance the Bandl’s ring
may look like a distended bladder.
Figure 3.3 - Mechanism of Bandl’s ring formationa

Figure 3.4 - Impending rupture: hourglass uterus “Bandl's ring”

– Rupture:
• shoulder-tip pain or increased pain on inspiration, a sign of haemoperitoneum. Sometimes the pain is
sudden, during a contraction, and the patient describes a “tearing” sensation. T he pain may be less
obvious in cases of posterior uterine rupture.
• hypovolaemic shock due to bleeding (rapid or weak or unmeasurable pulse, very low or undetectable
blood pressure, tachypnoea, cold sensation, damp skin, agitation or anxiety).
• contractions stop.
• slow foetal heart rate or no heart tones.
• sometimes feels like foetus can be palpated just below the skin if large, complete rupture. Foetus is
usually dead.

After delivery
A rupture may be discovered during a haemorrhage: uterine exploration after delivery of the placenta
reveals the rupture.

3.3.3 Management
See also algorithm.
– Insert 2 IV lines (16-18G catheter) and administer Ringer lactate.
– Measure heart rate and blood pressure; assess the severity of the bleeding.
– Insert a Foley urinary catheter.
– Emergency laparotomy with rapid caesarean section, fluid replacement and, in most cases, blood
transfusion.
– Depending on the type of rupture, the patient’s condition, the time between rupture and laparotomy
and whether there are signs of infection, suture the uterus or perform hysterectomy.

Keep the surgery as brief as possible, as these patients are often in poor general condition (anaemic, in
particular).

A sub-umbilical midline incision is preferable (better exposure), sometimes with peri-umbilical extension.

T he tear is usually in the lower segment, anterior and low. Enlarge the tear to allow extraction of the
foetus.

Check the integrity of the bladder, which may have been injured if it is very adherent to the lower uterine
segment (continuous suture in one or two planes and urinary catheterisation for at least 7 days).

Attempt repair whenever possible. Before suturing the uterine muscle, trim ragged, bruised edges.

In the event of uterine infection or extensive rupture with severe bruising around the wound or suture
repair is not possible, perform a subtotal hysterectomy with ovarian conservation.
Given the risk of another uterine rupture during subsequent pregnancies, bilateral tubal ligation may be
advised or indicated. T his is best discussed before surgery. T he patient’s consent is required.

Management of uterine rupture

Notas
(a) Adapt ed f rom Primary Surgery Vol.1 – Non-Trauma: The surgery of labour. German Societ y of Tropical
Surgery.
ht t p://www.primary-surgery.org/ps/vol1/ht ml/sect 0016.ht ml

3.4 Diagnosis of bleeding during the

second half of pregnancy (summary)
Table 3.1 - Aetiological diagnosis
 Placenta praevia Abruptio placenta Uterine rupture

History

Twin pregnancy Pre-eclampsia Long labour

Caesarean Primipara Primipara
section Trauma Dystocia
Bleeding during Grand multipara (≥ 5)
a previous Caesarean section
pregnancy Overuse of uterotonic

Clinical signs

Bleeding Bright red blood Bleeding without Variable

Painless warning sign
bleeding, Light flow of blackish
spontaneous or blood, or sudden bright
after vaginal red bleeding
exam or sexual Bleeding with severe,
intercourse constant uterine and
lower back pain

Haemorrhagic Blood loss Blood loss not always Blood loss not always
shock visible visible visible
Shock Shock out of Shock out of proportion
proportional to proportion to the to the amount of visible
amount of amount of visible bleeding (intra-abdominal
bleeding bleeding (intra- bleeding)
abdominal or
retroplacental bleeding)
Diffuse haemorrhage

Uterus Soft uterus Painful, continuous Foetus sometimes expelled

Contractions, if contraction ("woody into the abdominal cavity:
present, are uterus") uterus is retracted into a ball,
intermittent Foetal position hard to the foetus felt under the skin
Foetus high and determine (hard uterus
mobile and haematoma)

Vaginal exam Soft, spongy Cervix often closed

placenta
 Perform only one, Vaginal exam not helpful in
very cautious, diagnosis of abruptio
vaginal exam if placenta.
ultrasound is not
available.

Foetal heart Normal in the Absent or weak Absent or weak

tones absence of
maternal shock

Chapter 4: Pathologies during pregnancy

and pregnancy-related disorders
4.1 Iron deficiency anaemia

4.2 Bacterial infections

4.3 Parasitic infections

4.4 Viral infections

4.5 Hypertensive disorders in pregnancy

4.6 Eclampsia

4.7 Abnormally large uterus

4.8 Polyhydramnios

4.9 Premature rupture of membranes

4.10 T hreatened preterm delivery

4.11 Intrauterine foetal death

4.1 Iron deficiency anaemia

Anaemia is defined as a haemoglobin (Hb) level below 11 g/dl during the first and third trimester and
below 10.5 g/dl during the second trimester.
Pre-existing anaemia due, for example, to nutritional deficiency or malaria may be aggravated by
pregnancy.

Anaemia increases the risk of intrauterine growth restriction and preterm birth. It increases vulnerability
in the event of haemorrhage, particularly postpartum haemorrhage.

4.1.1 Diagnosis
– Clinical signs: pallor of the conjunctivae, mucous membranes, palms, and the soles of the feet;
fatigue, dizziness, tachycardia, heart murmur.
– Signs of serious illness: intense pallor, impaired consciousness, dyspnoea, Hb level below 7 g/dl.
– Measure Hb level using HemoCue.

4.1.2 Treatment
ferrous sulfate/folic acid (co-formulated tablet containing 200 mg ferrous sulfate equivalent to 65 mg
elemental iron + 400 micrograms folic acid a ) PO: 1 tablet 2 to 3 times daily until Hb level rises to
normal, then change to preventive treatment [1] (Chapter 1, Section 1.2.5).
Addition of ascorbic acid (vitamin C) PO, 500 mg once daily, improves iron absorption.

In areas where hookworm is endemic, add an anthelmintic treatment as of the second trimester
(Chapter 1, Section 1.2.5).

In areas where malaria is endemic, add intermittent preventive (Chapter 1, Section 1.2.5) or curative
(Section 4.3.1) antimalarial treatment, depending on the malaria test result.

In the event of severe anaemia:

– Transfusion is indicated in the following cases:
Less than 36 weeks LMP:
• Hb ≤ 5 g/dl, even if there are no signs of decompensation
• Hb > 5 g/dl and < 7 g/dl if there are signs of decompensation or sickle cell disease or severe malaria
or serious bacterial infection or pre-existing heart disease
36 weeks LMP or over:
• Hb ≤ 6 g/dl, even if there are no signs of decompensation
• Hb > 6 g/dl and < 8 g/dl if there are signs of decompensation or sickle cell disease or severe malaria
or serious bacterial infection or pre-existing heart disease
– In the third trimester:
Arrange for delivery in a CEmONC facility.
Given the risk of haemorrhage and rapid decompensation during delivery, be prepared for transfusion
for any woman whose Hb is < 7 g/dl, even if anaemia is relatively well-tolerated.

Notas
(a) 200 mg f errous sulf at e (65 mg element al iron) + 400 micrograms f olic acid t ablet s may be replaced by 185
mg f errous f umarat e (60 mg element al iron) + 400 micrograms f olic acid t ablet s.

Referencias
1. World Healt h Organizat ion. Guideline: Daily iron and f olic acid supplement at ion in pregnant women.
Geneva. 2012.
ht t p://apps.who.int /iris/bit st ream/10665/77770/1/9789241501996_eng.pdf

4.2 Bacterial infections

For clinical signs and diagnosis, refer to the Clinical guidelines, MSF.

In addition to antimicrobial therapy, administer paracetamol PO (1 g 3 times daily) in case of axillary

temperature ≥ 38.5 °C.

4.2.1 Syphilis
Syphilis can cause spontaneous abortion, intrauterine death, foetal growth restriction, preterm labour,
polyhydramnios, and congenital syphilis.

– For the mother:

benzathine benzylpenicillin IM a : 2.4 MIU per injection (half-dose in each buttock)
Early syphilis (primary, secondary, or latent infection of less than 12 months duration): single dose
Late latent syphilis (infection of more than 12 months duration or of unknown duration): one injection
weekly for 3 weeks [1]
Administer the same treatment to the sexual partner(s).

Note: a Jarisch-Herxheimer reaction may occur after the first dose of penicillin, especially in patients
with early syphilis. T he patient presents with some of the following symptoms: abrupt onset of fever,
chills, muscle pain, tachycardia, flushing, exacerbated skin rash or mild hypotension, usually within 2 to 5
hours. T he treatment is symptomatic (paracetamol PO, 1 g every 6 hours). T he reaction is most often
moderate, however severe reactions may occur [2] .

For penicillin-allergic patients only, use erythromycin PO: 500 mg 4 times daily for 14 days (early
syphilis) or 30 days (late latent syphilis). T he effectiveness of erythromycin in all stages of syphilis and
its ability to prevent the stigmata of congenital syphilis are both highly questionable, and many failures
have been reported.

– For the neonate, see Chapter 10, Section 10.4.1.

4.2.2 Gonorrhoea
Gonorrhoea can cause premature rupture of membranes, preterm labour, and severe neonatal
conjunctivitis.
Gonorrhoea is often associated with chlamydial infection.

– For the mother:

Treat simultaneously for gonorrhoea and chlamydia [3] :
ceftriaxone IM: 250 mg single dose (or, if not available, cefixime PO: 400 mg single dose)
+
azithromycin PO: 1 g single dose
Give the same treatment to the sexual partner(s).

– For the neonate, see Chapter 10, Section 10.4.2.

4.2.3 Urinary tract infections (including asymptomatic

bacteriuria)
Asymptomatic bacteriuria and cystitis, if left untreated, can lead to pyelonephritis and preterm labour.

Asymptomatic bacteriuria
Asymptomatic bacteriuria is defined as the presence of leukocytes and nitrites in urine, with no urinary
symptoms.
If only leukocytes are detected in urine, repeat the dipstick test after vulval toilet with soap and
water. If, on repeat, leukocytes without nitrites are again detected, diagnose asymptomatic bacteriuria
and treat as acute cystitis.

Acute cystitis
Cystitis is defined as urinary symptoms and the presence of leukocytes and/or nitrites in urine.
Antibiotherapy for acute cystitis:
fosfomycin-tromethamine PO: 3 g single dose or cefixime PO: 200 mg 2 times daily for 5 days
Inform the patient that cystitis symptoms should disappear within 2 to 3 days. If not, she should
consult again.
Advise the patient to drink 1.5 litres of water daily.

Acute pyelonephritis
Acute pyelonephritis can progress to maternal sepsis and preterm labour. Early treatment is important
in preventing these complications.
– Look for signs of serious illness (sepsis or septic shock, dehydration) or complications (urinary tract
obstruction, renal abscess) or risk of complications (functional or structural abnormality of the urinary
tract (lithiasis, malformation, etc.) or severe immunodepression.
– Admit to inpatient department; bed rest.
– Increase fluid intake: 1.5 litres of water daily.
– Antibiotherapy:
• Uncomplicated pyelonephritis:
Start with ceftriaxone IM or slow IV injection (over 3 minutes) b : 1 g once daily then change to oral
route after 24 to 48 hours of apyrexia with:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin) to complete 10 to 14 days of
treatment
Ratio 8:1: 2000 mg daily (= 2 tablets of 500/62.5 mg 2 times daily)
Ratio 7:1: 1750 mg daily (= 1 tablet of 875/125 mg 2 times daily)
or
cefixime PO: 200 mg 2 times daily to complete 10 to 14 days of treatment

• Severe or complicated pyelonephritis or absence of clinical improvement after 24 hours of

treatment:
ceftriaxone slow IV injection (over 3 minutes) or infusion (over 30 minutes) b : 1 g once daily then
amoxicillin/clavulanic acid PO or cefixime PO as above
+ gentamicin IM or slow IV (over 3 minutes): 5 mg/kg once daily for the first 3 days of treatment
– In the event of threatened preterm delivery: see Section 4.10.

Notas
(a) Only t he IM rout e may be used. To reduce t he pain during t he inject ion, t he powder can be reconst it ut ed
wit h 8 ml of 1% lidocaine (wit hout epinephrine).

(b) The diluent used t o prepare cef t riaxone f or IM inject ion cont ains lidocaine. Do not administ er cef t riaxone
reconst it ut ed wit h t his diluent int ravenously. For IV administ rat ion, use wat er f or inject ion only.

Referencias
1. Cent ers f or Disease Cont rol and Prevent ion. Syphilis Pocket Guide f or Providers. 2017.
ht t ps://www.cdc.gov/st d/syphilis/Syphilis-Pocket -Guide-FINAL-508.pdf

2. Yang CJ, Lee NY, Lin YH, et al. Jarisch-Herxheimer react ion af t er penicillin t herapy among pat ient s wit h
syphilis in t he era of t he HIV inf ect ion epidemic: incidence and risk f act ors. Clin Inf ect Dis. 2010 Oct
15;51(8):976-9. doi: 10.1086/656419.
ht t p://cid.oxf ordjournals.org/cont ent /51/8/976.f ull.pdf ht t p://cid.oxf ordjournals.org/cont ent /51/8/976.f ull.p
df

3. Updat e t o CDC's Sexually Transmit t ed Diseases Treat ment Guidelines, Inf ect ions Weekly August 10, 2012 /
61(31);590-594.
ht t p://www.cdc.gov/mmwr/preview/mmwrht ml/mm6131a3.ht m?s_cid=mm6131a3_w
4.3 Parasitic infections
For clinical signs and diagnosis, see Clinical guidelines, MSF.

4.3.1 Malaria [1]

Malaria in pregnancy is associated with low birth weight, increased risk of anaemia and, in low
transmission areas, an increased risk of severe malaria and death.
T he diagnosis should be confirmed by rapid test or microscopic examination (thick or thin smear).

Uncomplicated falciparum malaria

T he treatment of choice in all trimesters is an artemisinin-based combination therapy (ACT ) for 3 days.

Table 4.1 - Dosage of ACT

 ACT Formulation Dosage

artemether/lumefantrine Co-formulated tablets, 4 tab 2 times daily on D1, D2,

(AL or co-artemether) 20 mg artemether/120 mg D3
lumefantrine per tab,
blister of 24 tab

Co-formulated tablets, 1 tab 2 times daily on D1, D2,

80 mg artemether/480 mg D3
lumefantrine per tab,
blister of 6 tab

artesunate (AS) Co-formulated tablets, 2 tab once daily on D1, D2, D3

+ amodiaquine (AQ) 100 mg AS/270 mg AQ base
per tab,
blister of 6 tab

Co-blister containing: 4 tab AS + 4 tab AQ once daily

12 tab 50 mg AS on D1, D2, D3
+ 12 tab 153 mg AQ base

artesunate/mefloquine Co-formulated tablets, 2 tab once daily on D1, D2, D3

(AS/MQ) 100 mg AS/220 mg MQ per tab,
blister of 6 tab

dihydroartemisine/piperaquine Coformulated tablets, Women 36 to 59 kg

(DHA/PPQ) 40 mg DHA/320 mg PPQ 3 tab once daily on D1, D2, D3
Blister of 9 tab

Coformulated tablets, Women 60 to 79 kg

40 mg DHA/320 mg PPQ 4 tab once daily on D1, D2, D3
Blister of 12 tab

Note: the combination AS/SP is contra-indicated in HIV-infected women taking co-trimoxazole

preventive therapy.

Quinine is an alternative:
quinine PO: 10 mg/kg 3 times daily for 7 days
In South-East Asia and Amazon region, quinine should be given in combination with clindamycin PO:
10 mg/kg 2 times daily for 5 days.
Doxycycline is contra-indicated.
Severe malaria
artesunate slow IV (or, if not feasible, IM into the anterior thigh):
2.4 mg/kg on admission then 12 hours and 24 hours after admission (H0, H12, H24), then once daily
Note: dilution of the artesunate solution depends on the route of administration (10 mg/ml for IV route,
20 mg/ml for IM route), refer to the guide Essential drugs, MSF.
or, if not available,
artemether IM (into the anterior thigh):
3.2 mg/kg on admission then 1.6 mg/kg once daily

As soon as the patient can tolerate oral treatment (but after at least 24 hours of parenteral treatment),
administer a 3-day course of ACT (Table 4.1).
Do not use the combination AS/MQ if the patient developed neurological signs during the acute phase.

IV quinine (± clindamycin) is an alternative.

quinine IV infusion (dosage is expressed in quinine dihydrochloride):
Loading dose: 20 mg/kg diluted in glucose solution (5% or 10%), administered over 4 hours.
T hen 5% glucose to keep the vein open over the next 4 hours.
T hen maintenance dose: 10 mg/kg over 8 hours, every 8 hours (or, better, alternate 4 hours of quinine
diluted in 5% glucose and 4 hours of 5% glucose).
Do not administer loading dose to patients who have received oral quinine or mefloquine within the
previous 24 hours. In these cases, start with the maintenance dose.
Monitor the patient closely (risk of pulmonary oedema and hypoglycaemia).
As soon as the patient has received at least 3 doses of parenteral quinine and can tolerate oral
treatment, change to quinine PO to complete 7 days of treatment or administer a 3-day course of
ACT (Table 4.1).
If the combination AS/MQ is used as oral completion treatment following IV quinine, start AS/MQ 12
hours after the last dose of quinine.

Malaria due to P. vivax, P. malariae, P. ovale, P. knowlesi

Irrespective of the age of the pregnancy:
chloroquine PO:
D1, D2: 10 mg base/kg
D3: 5 mg base/kg

Although P. vivax is considered benign, severe cases have been reported. T he treatment of severe
malaria should be the same whatever the species.

4.3.2 Ancylostomiasis (hookworms) and ascariasis

albendazole PO: 400 mg single dose (or, if not available, mebendazole PO: 100 mg 2 times daily for 3
days)
Do not administer during the first trimester of pregnancy. Wait until the second trimester before
administering treatment.

In the event of ancylostomiasis, treat the associated anaemia (Section 4.1).

Referencias
1. World Healt h Organizat ion. Guidelines f or t he t reat ment of malaria. Third edit ion, Geneva, 2015.
ht t p://apps.who.int /iris/bit st ream/handle/10665/162441/9789241549127_eng.pdf ?sequence=1

4.4 Viral infections

For clinical signs and diagnosis, refer to the Clinical guidelines, MSF.

4.4.1 Genital herpes

If the mother has visible herpetic lesions at time of childbirth:
– Limit vaginal exams; no artificial rupture of membranes.
– Discuss caesarean section on a case-by-case basis.
– For the mother:
• Pain management: paracetamol PO (Appendix 7).
• Antiviral treatment: aciclovir PO, 400 mg 3 times daily for 7 days
In immunocompromised patients, continue the treatment until symptoms resolve.
• Prophylactic treatment (aciclovir PO: 400 mg 4 times daily as of 36 weeks LMP and until delivery)
can be proposed to reduce the risk of recurrent herpes at delivery.
– For the neonate, see Chapter 10, Section 10.4.3.

4.4.2 Varicella (chickenpox)

T here is a risk of severe maternal varicella pneumonia and severe neonatal varicella.
Administration of aciclovir PO (800 mg 5 times daily for 7 days) as soon as possible after the onset of
rash may reduce these risks [1] .

4.4.3 Hepatitis
Hepatitis B
Without intervention, mother-to-child transmission of the hepatitis B virus (HBV) is high (up to 90%).
– For the mother: no special obstetric measures.
– For the neonate: routine hepatitis vaccination as soon as possible within 24 hours after birth has
been demonstrated to prevent 70 to 95% of infections [2] (Chapter 10, Section 10.1).

Hepatitis E
Hepatitis E carries a very high mortality rate for pregnant women (20% during the third trimester). It can
cause spontaneous abortion, preterm delivery, and intrauterine foetal death.

T he virus is acquired by fecal-oral route (primarily by drinking contaminated water). T he virus can cause
outbreaks, especially in situations where large numbers of people are gathered (refugees, displaced
persons), when hygiene and sanitation are poor.

Treatment is symptomatic (good hydration, avoidance of hepatotoxic medications). Prevention (water,

hygiene, sanitation) is the only protection against the disease.

4.4.4 HIV infection

Mother-to-child HIV transmission may occur at any time during pregnancy, labour, delivery and the
breastfeeding period. With no intervention, the risk of transmission is approximately 15 to 25% and 20
to 45% if the child is breastfed [3] . T his risk may be reduced to less than 2%.

Offer HIV testing to all pregnant women with unknown HIV status when they come for ante- or
postnatal consultations or delivery.
HIV negative women should also be re-tested at their first antenatal consultation, during the third
trimester and during the breastfeeding period.

For antiretroviral therapy protocols in mothers and children, refer to specialised prevention of mother-
to-child transmission (PMT CT ) guides.

Ante-natal care
HIV-infected pregnant women need antiretroviral therapy regardless of their CD4 count and clinical
stage. T he treatment should start as soon as possible, regardless of gestational age and should be
taken for life.

Intra-partum care
– Continue (or start) antiretroviral therapy.
– Observe standard precautions to avoid contact with blood and body fluids.
– Avoid:
• prolonged labour;
• prolonged rupture of membranes;
• early artificial rupture of membranes;
• invasive procedures such as episiotomy or instrumental delivery. However, they must be performed if
they are necessary.
– T he criteria for induction of labour are the same as for non HIV-infected women.
– Delay cord clamping for 1-3 minutes.
– Administer antiretroviral prophylaxis to the neonate immediately after birth.
– Prevention and treatment of postpartum haemorrhage: as for non HIV-infected women.

A planned caesarean section can be beneficial if the viral load is detectable. However, given the risks
associated with the intervention (surgical, anaesthetic and infectious) and the risk of uterine rupture
during subsequent pregnancies, caesarean section is not recommended routinely.

Postpartum care
– For the mother: continue (or start) antiretroviral therapy.
– For the neonate: systematic antiretroviral prophylaxis and early diagnosis of infection.

Referencias
1. Clinical pract ice guideline of t he Societ y of Obst et ricians and Gynaecologist s of Canada. Management of
Varicella Inf ect ion (Chickenpox) in Pregnancy, No. 274, March 2012.
ht t p://sogc.org/wp-cont ent /uploads/2013/01/gui274CPG1203E.pdf ?1668a1

2. Hepat it is B. Epidemiology and Prevent ion of Vaccine-Prevent able Diseases. The Pink Book.
ht t p://www.cdc.gov/vaccines/pubs/pinkbook/hepb.ht ml#hepA

3. World Healt h Organizat ion, UNFPA. HIV t ransmission t hrough breast f eeding. A review of available evidence.
Geneva, 2004.
ht t p://www.unf pa.org/webdav/sit e/global/shared/document s/publicat ions/2004/hiv_t ransmission.pdf

4.5 Hypertensive disorders in pregnancy

Gestational hypertension and chronic hypertension may be complicated by pre-eclampsia. Pre-
eclampsia carries a significant risk of complications:
– Placental abruption, HELLP syndrome a , eclampsia, stroke, maternal death;
– Foetal growth restriction, foetal distress, foetal death.
T he goal of antihypertensive treatment is to prevent maternal complications of severe hypertension.
Treatment is administered if systolic blood pressure is ≥ 160 mmHg or if diastolic blood pressure is ≥
110 mmHg. T he objective of treatment is to lower blood pressure to around 140/90 mmHg.
Antihypertensive treatment does not improve foetal prognosis. It should be carried out with caution. It
is essential to preserve placental perfusion and to avoid excessive fall in maternal blood pressure.

4.5.1 Diagnosis
 Pathologies Definitions [1]

Hypertension In a pregnant woman, seated and at rest, measured

twice:
Systolic blood pressure (SBP) ≥ 140 mmHg
and/or
Diastolic blood pressure (DBP) ≥ 90 mmHg

Severe hypertension SBP ≥ 160 mmHg and/or DBP ≥ 110 mmHg

Gestational hypertension Hypertension isolated (with no proteinuria or other signs

of pre-eclampsia) develops after 20 weeks LMP.

Pre-eclampsia without severe Hypertension after 20 weeks LMP

features and
proteinuria on dipstick urinalysis (1+ or more) with no signs
of end-organ damage (see below) or severe
hypertension.

Pre-eclampsia with severe features Hypertension after 20 weeks LMP with or without
proteinuria on dipstick urinalysis
and
One or more signs of end-organ damage:
• severe headache, tinnitus
• visual disturbances
• epigastric pain, nausea, vomiting
• hyperreflexia (overactive knee-jerk response, twitching
and spasms)
• oliguria (urine output < 400 ml/day or < 30 ml/hour)
• pulmonary oedema
• thrombocytopenia (platelet count < 100 000/mm³)
• renal impairment (serum creatinine level > 1.1 mg/dl)
• altered hepatic function (elevated transaminases over
twice the normal value)

OR

Hypertension after 20 weeks LMP

and
Proteinuria on dipstick urinalysis
and
Severe hypertension, persistent despite treatment
 Chronic hypertension Hypertension predating the pregnancy or develops
before 20 weeks LMP

Notes:
• In pre-eclampsia, other symptoms may be observed: dark urine, low urine output, sudden onset or
increase in oedema of the legs and hands. T hese symptoms alone do not confirm the diagnosis of
pre-eclampsia, but call for monitoring of blood pressure and proteinuria.
• Abnormally high proteinuria is no longer considered a severe feature in pre-eclampsia. Nevertheless, if
it is not possible to perform regular and reliable monitioring of blood creatinine levels, heavy proteinuria
(3+ or more on dipstick urinalysis) should be considered as a criteria for referral to a CEmONC facility.
• In women with proteinuria and no hypertension, consider urinary tract infection, contamination of urine
with blood or vaginal secretions, nephropathy. In these cases, monitor to ensure early detection of
pre-eclampsia.

4.5.2 Management of gestational and chronic hypertension

– Rest; monitoring once weekly: BP, proteinuria.
– Assess the risk of foetal growth restriction (fundal height).
– Normal sodium and caloric intake.
– Inform the patient about the warning signs that require urgent medical attention (severe headache,
tinnitus, visual disturbances, epigastric pain, nausea, vomiting, dyspnea). In the event of proteinuria or
other warning signs developing, treat as for pre-eclampsia.
– If SBP ≥ 160 mmHg or DBP ≥ 110 mmHg, administer an antihypertensive treatment:
labetalol PO: 100 mg 2 times daily then increase if necessary in 100 to 200 mg increments until an
effective dose is reached, usually 200 to 400 mg 2 times daily. If higher daily doses are required, divide
in 3 doses (max. 2.4 g daily)
or
methyldopa PO: 250 mg 2 or 3 times daily for 2 days, then increase if necessary, in 250 mg increments
every 2 to 3 days, until an effective dose is reached, usually around 1.5 g daily (max. 3 g daily)

Notes:
• In case of treatment failure, these drugs can be combined.
• Do not stop antihypertensive treatment abruptly.
• Diuretics and angiotensin-converting-enzyme inhibitors (enalapril, etc.) are contra-indicated.
• If the mother is taking labetalol, monitor the neonate for at least 72 hours after birth (risk of
hypoglycaemia, bradycardia and respiratory distress).

4.5.3 Management of pre-eclampsia without severe features

Before 37 weeks LMP
– Admit as inpatient; rest; monitoring: BP, proteinuria.
– Assess the risk of foetal growth restriction (fundal height).
– Normal sodium and caloric intake.
– Do not stop uterine contractions if they occur; let the woman deliver.
– If SBP ≥ 160 mmHg or DBP ≥ 110 mmHg, administer an antihypertensive treatment (Section 4.5.2).

Pre-eclampsia is an evolving condition, always deteriorating. As soon as even a single sign of severe
pre-eclampsia appears or in case of heavy proteinuria (3+ or more on dipstick urinalysis), transfer to a
CEmONC facility.

After 37 weeks LMP

– Admit as inpatient; rest; same monitoring and antihypertensive treatment.
– Induce labour as soon as the cervix is favourable (or before if the mother's condition deteriorates or
in case of true intrauterine growth restriction).

4.5.4 Management of pre-eclampsia with severe features

Care is best organized with a multi-disciplinary team comprising obstetrician, anaesthesiologist and
midwife.

Delivery
Delivery should take place within 24 hours, either vaginally or by caesarean section, depending on the
state of the cervix, gestational age and condition of the foetus.

Magnesium sulfate treatment

To reduce the risk of eclampsia, administer magnesium sulfate. One of the following regimens may be
used:
 magnesium Loading dose: 4 g by IV infusion in 100 ml of 0.9% sodium chloride over 15 to 20
sulfate minutes
5 g ampoule T hen
(500 mg/ml, Maintenance dose: 10 g IM (5 g in each buttock), followed by 5 g IM every 4 hours
10 ml) (change sides with each injection)
IV/IM Continue this treatment for 24 hours after delivery.
protocol

or

magnesium Loading dose: 4 g by IV infusion in 100 ml of 0.9% sodium chloride over 15 to 20

sulfate minutes
5 g ampoule T hen
(500 mg/ml, Maintenance dose: 1 g per hour by continuous infusion.
10 ml) Continue this treatment for 24 hours after delivery.
IV protocol

• Verify the dosage written on the ampoules (there are different dosages).
• T here is a risk of potentially lethal overdose of magnesium sulfate. Have calcium gluconate,
the antidote of magnesium sulfate, immediately available (1 g ampoule).

During administration, monitor:

– Patellar reflex (knee-jerk), BP, heart rate and respiratory rate every 15 minutes for the first hour of
treatment. If there are no signs of overdose, continue monitoring every hour.
– Urine output every hour (insert Foley catheter).

Manifestations of magnesium sulfate overdose start with disappearance of the patellar reflex then
hypotension, arrhythmia, respiratory depression (< 12 breaths/minute). If the patellar reflex disappears,
stop magnesium sulfate immediately and administer calcium gluconate (1 g IV).

If urine output drops (< 30 ml/hour or 100 ml/4 hours): stop magnesium sulfate and deliver as quickly as
possible.

Antihypertensive treatment
– If SBP ≥ 160 mmHg or DBP ≥ 110 mmHg, administer an antihypertensive treatment (Section 4.5.2).
– If the oral route is impossible, use parenteral labetalol or hydralazine. When administering, monitor the
mother’s BP and heart rate and the foetal heart rate.

T he dose is adjusted according to changes in BP. Hypertension is controlled when DBP is between 90
and 100 mmHg and SBP between 130 and 150 mmHg.
 Respect dosage and administration rate. Administering too much of the drug, or administering it
too quickly, can provoke a sudden, excessive fall in maternal BP, with placental hypoperfusion
and foetal death. DBP should not go below 90 mmHg. In the event of hypotension, use Ringer
lactate solution to bring the DBP back up to 90-100 mmHg. Proceed with caution and monitor
the patient closely as there is a risk of fluid overload and pulmonary oedema.

One of the following regimens may be used:

labetalol One dose of 20 mg (4 ml) over at least one minute. Check BP 5 and 10 minutes after
slow IV injection. If hypertension remains uncontrolled, administer another dose of 20 mg and
(ampoule of check BP. Administer additional doses, of 40 mg then 80 mg with 10 minutes between
100 mg in each dose as long as hypertension is not controlled. Do not exceed a total dose of
20 ml, 5 300 mg.
mg/ml)

or

hydralazine Dilute 20 mg (1 vial of hydralazine reconstituted in 1 ml of water for injection) in 9 ml

slow IV of 0.9% sodium chloride to obtain 10 ml of solution containing 2 mg hydralazine/ml.
(20 mg/1 ml Administer 5 mg (2.5 ml of the diluted solution) over 2 to 4 minutes. Monitor BP for 20
vial) minutes. If hypertension remains uncontrolled, repeat injection. Continue repeating if
necessary, waiting 20 minutes between each injection. Do not exceed a total dose of
20 mg.

or

hydralazine Dilute 100 mg (5 vials of reconstituted hydralazine) in 500 ml of 0.9% sodium chloride
IV infusion or Ringer lactate to obtain a 200 micrograms/ml solution.
(20 mg/1 ml T he initial dose is 200 to 300 micrograms/minute; the maintenance dose is 50 to 150
vial) micrograms/minute.
Administer by increasing the rate up to 20 drops/minute (max. 30 drops/minute),
monitoring the BP every 5 minutes.
As soon as the hypertension is controlled, gradually reduce the rate (15 drops/minute,
then 10, then 5) until stopping infusion. Stopping abruptly can trigger a hypertensive
crisis.
Notes:
• If the mother receives labetalol, monitor the newborn for at least 72 hours after birth (risk of
hypoglycaemia, bradycardia and respiratory distress).
• If anaesthesia is necessary, avoid ketamine. Whenever possible, use spinal anaesthesia.
• Oxytocin may be used in pre-eclampsia, but requires BP monitoring: drops and elevations in BP have
been described in rare cases.
• Methylergometrine is contraindicated.
• Pre-eclampsia can appear up to 7 days after delivery (and on rare occasions up to 6 weeks).

4.5.5 Secondary prophylaxis for severe pre-eclampsia

acetylsalicylic acid PO: 75 to 150 mg once daily starting at 12 weeks LMP and continuing until 36
weeks LMP reduces the risk of recurrence during the next pregnancy. If this prophylactic treatment is
feasible, recommend that the woman comes for consultation as soon as she knows she is pregnant.
T here is no point in starting this treatment after 20 weeks LMP [2] .

During the next pregnancy, calcium supplementation is recommended [3] in women with low calcium
intake (Chapter 1, Section 1.2.5).

Notas
(a) The HELLP syndrome (haemolysis, elevat ed liver enzymes, low plat elet s) is a pot ent ial lif et hreat ening
complicat ion f or bot h t he mot her and f oet us).

Referencias
1. Societ y f or t he St udy of Hypert ension in Pregnancy. The classificat ion, diagnosis and management of t he
hypert ensive disorders of pregnancy: A revised st at ement f rom t he ISSHP. Pregnancy Hypert ens. 2014
Apr;4(2):97 104.

2. World Healt h Organizat ion. Prevent ion and t reat ment of pre-eclampsia and eclampsia. Summary of
recommendat ions. Geneva, 2011. WHO/RHR/11.30.
ht t p://www.who.int /reproduct ivehealt h/publicat ions/mat ernal_perinat al_healt h/rhr_11_30/en/

3. World Healt h Organizat ion. Calcium supplement at ion in pregnant women. 2013.
ht t p://apps.who.int /iris/bit st ream/10665/85120/1/9789241505376_eng.pdf

4.6 Eclampsia
4.6.1 Diagnosis
Convulsions during the third trimester of pregnancy, most commonly in a context of pre-eclampsia.
Eclampsia can also occur within 48 hours after delivery (and up to 6 weeks after delivery).

Consider other causes of convulsions, such as meningitis and severe malaria (their incidence is
increased in pregnant women).

4.6.2 Management
– Protect against injury, maintain airway, place in recovery position.
– Seizures: magnesium sulfate a as for severe pre-eclampsia (Section 4.5.4). Continue treatment for
24 hours after delivery or 24 hours after the last seizure, whichever was more recent.
– Nursing care, hydration, Foley catheter insertion; monitoring as for severe pre-eclampsia (Section
4.5.4).
– Oxygen: 4 to 6 litres/minute.
– If SBP ≥ 160 mmHg or DBP ≥ 110 mmHg: antihypertensive treatment as for severe pre-eclampsia
(Section 4.5.4).
– Delivery within 24 hours, either vaginally or by caesarean section, depending on the state of the
cervix, gestational age and condition of the foetus.

4.6.3 Secondary prophylaxis

Administer acetylsalicylic acid PO, as for pre-eclampsia (Section 4.5.5).

Notas
(a) If magnesium sulf at e is not available, use diazepam: 10 mg slow IV (or by rect al rout e), t hen 40 mg in a 500
ml of 5% glucose administ ered over 24 hours. Vent ilat ion equipment must be immediat ely available.

4.7 Abnormally large uterus

4.7.1 Diagnosis
Fundal height greater than the presumed gestational age.
T he possible causes are:
– Incorrect due date;
– Multiple pregnancy, polyhydramnios, molar pregnancy;
– A large-for-gestational-age foetus (foetal macrosomia).

4.7.2 Management
– Verify the due date (date of last menstrual period).
– Perform ultrasound, if possible.
– Depending on the diagnosis: twin pregnancy (Chapter 6, Section 6.2), polyhydramnios (Section 4.8),
molar pregnancy (Chapter 2, Section 2.3).
– In the event of foetal macrosomia:
T here is an increased risk of foeto-pelvic disproportion. Anticipate the need for referral to a CEmONC
facility during labour for caesarean section if necessary. If referral is difficult (distance, security, etc.),
refer patient prior to onset of labour.
T he risk of postpartum haemorrhage is increased: routinely insert an IV line.
Other risks associated with foetal macrosomia include dynamic dystocia, prolonged labour, shoulder
dystocia and perineal tear at delivery.

4.8 Polyhydramnios
Excess amniotic fluid (more than 2 litres at term). T here are two clinical situations:
– In the second trimester: acute polyhydramnios;
– In the third trimester: chronic polyhydramnios.

4.8.1 Acute polyhydramnios (rare but serious)

Diagnosis
– Rapid increase in the size of the uterus
– Painful abdomen, abdominal pressure, dyspnoea
– Distended, hard uterus, foetus cannot be palpated

Usually associated with foetal malformation, sometimes a complicated twin pregnancy.

Management
Do not intervene; let the patient abort or deliver spontaneously.

4.8.2 Chronic polyhydramnios

Diagnosis
– More moderate increase in the size of the uterus, occurring in spurts
– Foetus cannot be palpated
– Receding head on vaginal examination, fluid wave
– Foetal heartbeat muffled

Management
– Look for diabetes and treat if found.
– Examine the neonate for malformation.
– Risk of neonatal hypoglycaemia (Chapter 10, Section 10.3.4).

Notes:
In acute and chronic polyhydramnios:
– Do not puncture or drain amniotic fluid during pregnancy: risk of infection.
– Use of oxytocin during labour is dangerous and oxytocin should be administered with caution as the
over-distended uterus may rupture.
– Amniotomy carries risk of cord prolapse. In the event of cord prolapse, a caesarean section may be
considered taking into account gestational age and potential presence of foetal malformation. In the
event of acute polyhydramnios in the second trimester, perform vaginal delivery.
– Risk of postpartum haemorrhage (routinely insert an IV line).

4.9 Premature rupture of membranes

Discharge of amniotic fluid before the onset of labour, due to a leak or frank rupture of the amniotic
sac.

4.9.1 Diagnosis
In case of doubt, perform speculum examination: look for fluid pooling in the vagina or leaking from
cervical os when patient coughs.

Differential diagnosis: urinary incontinence, expulsion of the mucus plug, leucorrhoea.

4.9.2 Risks
– Intra uterine infection; suspect infection in case of maternal fever associated with one or more of the
following signs: persistent foetal tachycardia or foetal death, foul-smelling or purulent amniotic fluid,
uterine contractions. Never administer a tocolytic agent, no matter what the gestational age, when
intra-uterine infection is suspected.
– Prolapsed cord.
– Pre-term birth, if the rupture occurs before 37 weeks LMP.

4.9.3 Management
– In the event of preterm rupture of membranes, look for a maternal cause (e.g. urinary or genital tract
infection) and treat accordingly.
– Admit to inpatient department and monitor: temperature, heart rate, blood pressure, uterine
contractions, foetal heart tone, abnormal amniotic fluid (foul-smelling, purulent).
– Vaginal examinations: as few as possible, always with sterile gloves and only if the woman is in labour
or induction of labour is planned.
– Antibiotherapy:
• For the mother:

Diagnosis Treatment

Preterm (< 37 weeks) amoxicillin PO: 1 g 3 times daily for 7 days

and Do not use amoxicillin/clavulanic acid (increased incidence of
No infection and no labour necrotizing enterocolitis in neonates).

Preterm (< 37 weeks) ampicillin IV: 2 g, then 1 g every 4 hours during labour until
and the child is born (whether the patient received amoxicillin PO
No infection and labour in progress beforehand)
Do not continue antibiotics after delivery.

Term (≥ 37 weeks) ampicillin IV: 2 g, then 1 g every 4 hours during labour until
and the child is born
No infection and rupture of Do not continue antibiotics after delivery.
membranes ≥ 12 hours, whether in
labour or not

Presence of infection whether in ampicillin IV: 2 g every 8 hours

labour or not, regardless of the + metronidazole IV: 500 mg every 8 hours
duration of the rupture + gentamicin IM: 5 mg/kg once daily
Continue IV administration for 48 hours after fever
disappears then, change to amoxicillin + metronidazole PO
to complete 7 days of treatment.

• For the neonate: see Chapter 10, Section 10.1.1 and Section 10.3.3.
– If there are uterine contractions:
• Before 34 weeks LMP: tocolytic agent, except if there are signs of intra-uterine infection.
• After 34 weeks LMP, the risk of infection is greater than the risk of preterm birth: do not administer
tocolytics.
– Induction of labour:
• In the event of infection, induce labour immediately (Chapter 7, Section 7.3).
• If there is no infection:
- At term: if labour does not start spontaneously, induce labour 12 to 24 hours after rupture of
membranes;
- Before term: monitor and, if there are no complications, perform induction at 37 weeks LMP. [1]
– For preterm rupture (< 37 weeks LMP), transfer the mother, if possible, to a facility where the
preterm neonate can receive intensive care.

– Prepare the foetus for preterm birth:

After 26 weeks LMP and before 34 weeks LMP, help lung maturation with dexamethasone IM: 6 mg
every 12 hours for 48 hours. In the event of severe maternal infection, start antibiotherapy prior to
dexamethasone.

Referencias
1. Morris JM, Robert s CL, Bowen JR, Pat t erson JA, Bond DM, Algert CS, Thornt on JG, Crowt her CA; PPROMT
Collaborat ion. Immediat e delivery compared wit h expect ant management af t er pret erm pre-labour rupt ure
of t he membranes close t o t erm (PPROMT t rial): a randomised cont rolled t rial. Lancet . 2016 Jan
30;387(10017):444-52.

4.10 Threatened preterm delivery

Regular uterine contractions and cervical changes before 37 weeks LMP.

4.10.1 Risk factors

– Preterm rupture of membranes before 37 weeks LMP
– Maternal infection
– Pregnancy-related disorder (e.g. pre-eclampsia, polyhydramnios, placenta praevia)
– Multiple pregnancy
– Cervical insufficiency
– Age < 18 years
– Malnutrition

4.10.2 Management
– Look for and treat any maternal infection; always perform urinalysis (dipstick test); perform rapid
malaria test in endemic areas.
– Let the woman deliver:
• If > 34 weeks LMP and membranes have ruptured.
• If labour is too advanced to be stopped (cervix effaced, 5 cm dilation), no matter what gestational
age.
• If the mother’s life is threatened (poor general condition, pre-eclampsia, eclampsia, abruptio
placentae, severe haemorrhage, etc.), no matter what gestational age.
• If foetal death is confirmed (no foetal movements and no foetal heart tones at several checks or
ultrasound confirmation of foetal death).

– Otherwise, try to stop the contractions:

• Strict bed rest in a medical setting. Bed rest alone may be enough for mild forms (contractions but no
cervical changes).
• Tocolytic therapy:
T he main objective is to postpone delivery in order to administer corticosteroids for accelerating
foetal lung maturation.
nifedipine PO (immediate release tablet): 10 mg to be repeated every 15 minutes if uterine
contractions persist (max. 4 doses or 40 mg), then 20 mg every 6 hours. Never administer sublingually
(risk of placental hypoperfusion and foetal death); always use the oral route. Duration of the treatment
is 48 hours.

– Prepare the foetus for preterm birth:

After 26 weeks LMP and before 34 weeks LMP, help lung maturation with dexamethasone IM: 6 mg
every 12 hours for 48 hours. In case of severe maternal infection, start antibiotherapy prior to
dexamethasone.

4.10.3 Preterm delivery

– Delivery is usually rapid and often breech.
– Avoid aggressive treatment (drugs or procedures), but above all, avoid a long labour. Expulsion should
be rapid: consider episiotomy, even if the foetus is small; before 34 weeks LMP vacuum extraction is
contra-indicated, use forceps if instrumental extraction is required.
– Prepare for neonatal resuscitation (Chapter 10, Section 10.2). Closely monitor neonate's
temperature (risk of hypothermia) and blood glucose (risk of hypoglycaemia).

4.10.4 Preventing preterm delivery

– Treatment of infections and other disorders during pregnancy.
– Rest for women with predisposing factors: multiple pregnancy, polyhydramnios, previous preterm
delivery.

4.11 Intrauterine foetal death

Foetal death from 23 weeks LMP, prior to labour.
4.11.1 Diagnosis
Diagnosis is confirmed by ultrasound.

If ultrasound is not available, the following signs suggest foetal death but are not sufficiently sensitive
to justify a hasty, rash decision. Errors are common. Repeat the exam, do not rush.
– Absence or cessation of foetal movements—the usual reason for consultation.
– Fundal height too small for gestational age, or decrease in fundal height from a prior visit.
– Absence of foetal heart tone.
– Sometimes, breast engorgement indicating the end of the pregnancy.

4.11.2 Management
– If the mother has no life-threatening disorder:
• Treat any maternal pathology (anaemia, malaria, etc.).
• If it is certain that the foetus is dead, induce labour.
• If there is any uncertainty, see the woman again at regular intervals (e.g., once a week) and wait for
labour to start spontaneously; this generally occurs within 15 to 20 days of foetal death.

– If the mother has a life-threatening disorder (eclampsia, placenta praevia, abruptio placentae,
intrauterine infection, severe maternal disease such as congestive heart failure): urgently induce labour.

– If the amniotic sac has been ruptured for more than 12 hours: antibiotherapy (Section 4.9.3) and
induction of labour.

– During labour, in cases of malpresentation or foetopelvic disproportion:

• Try everything possible to avoid a caesarean section; accept a long labour, and perform destructive
delivery. Caesarean section should only be performed as a last resort.
• Caesarean section is performed right away only in cases of complete placenta praevia and/or
haemorrhage, where there is a risk of maternal death or uterine rupture.

– Carefully examine the placenta (possibility of retained fragments).

– Perform a manual exploration of the uterus if there is retained placenta or any sign of bleeding
(coagulation disorders). Give routine antibiotic prophylaxis (cefazolin or ampicillin slow IV a , 2 g single
dose).
– After delivery:
Mothers are at risk of psychological problems after a stillbirth; perinatal death is associated with
increased rates of postpartum depression.
Psychological support should be offered to all women at the maternity hospital and in postpartum
period.
Inhibition of lactation may be of psychological importance for some women following intrauterine
death (Chapter 11, Section 11.2.1).
Staff should avoid persuading parents to see and hold the neonate but should strongly support such
desires when expressed (however, this is discouraged if the neonate has been mutilated in case of
embryotomy or presents severe malformations). In this case, prepare the neonate as usual, cleaned
and wrapped. T he body must be given to the parents if they want to organize a funeral.

4.11.3 Induction of labour

– In the third trimester, if the cervix is favourable (Bishop's score ≥ 6): oxytocin and rupture
membranes.
– In the third trimester, if the cervix is not favourable or in the second trimester, administer by order of
preference:

mifepristone mifepristone PO: 200 mg single dose

+ +
misoprostol 1 to 2 days later misoprostol as indicated below, depending on gestational age

or, if not available

misoprostol Between 23 and 26 weeks LMP

alone 200 micrograms sublingually or intravaginally, every 4 to 6 hours until labour starts, to
be repeated if necessary the following day
Between 27 and 33 weeks LMP
100 micrograms sublingually or intravaginally every 4 to 6 hours until labour starts, to
be repeated if necessary the following day
As of 34 weeks LMP
25 micrograms intravaginally every 6 hours or 25 micrograms PO every 2 hours, to
be repeated if necessary the following day
– In case of prior caesarean section or grand multiparity or overdistention of the uterus, given
increased risk of uterine rupture:
• If oxytocin is used, see Chapter 7, Section 7.4.4 for precautions for use.
• If a misoprostol is used:
Preferably use the combined regimen mifepristone + misoprostol, as fewer numbers of
misoprostol doses are required.
Reduce the dose of misoprostol between 23 and 33 weeks LMP:
- 23 to 26 weeks LMP: 100 micrograms every 6 hours
- 27 to 33 weeks LMP: 50 micrograms every 6 hours
• Closely monitor the mother for possible signs of impending rupture (heart rate, blood pressure, uterine
contractions, pain).
• As of 34 weeks LMP, consider using a Foley catheter 24 hours after administration of mifepristone
and before administration of misoprostol in order to increase cervical dilation and reduce the total
dose of misoprostol used.

Notas
(a) For pat ient s wit h a hist ory of immediat e hypersensit ivit y react ion t o penicillin (urt icaria, respirat ory
problems or oedema): clindamycin IV 900 mg single dose + gentamicin IV 5 mg/kg single dose.

Chapter 5: Normal delivery and

procedures related to vaginal delivery
5.1 Normal delivery

5.2 Monitoring labour and delivery

5.3 Artificial rupture of the membranes

5.4 Prolapsed cord

5.5 Nuchal cord

5.6 Instrumental delivery

5.7 Symphysiotomy

5.8 Episiotomy

5.9 Perineal repair

5.10 Deinfibulation
5.1 Normal delivery

5.1.1 General recommendations

Personnel should wear personal protective equipment (gloves, goggles, clothing and eye protection) to
prevent infection from blood and other body fluids.

Ensure a calm reassuring environment and provide the woman as much privacy as possible during
examinations and delivery. Encourage her to move about freely if desired and to have a person of her
choice to accompany her.

Anticipate the need for resuscitation at every birth. T he necessary equipment should be ready at hand
and ready for use.

5.1.2 Diagnosing the start of labour

– Onset of uterine contractions: intermittent, rhythmic pains accompanied by a hardening of the uterus,
progressively increasing in strength and frequency;
And
– Cervical changes: progressive shortening (effacement) and dilation (Figure 5.1):
• in a primipara, the cervix will first efface then, dilate;
• in a multipara, effacement and dilation occur simultaneously.

Repeated contractions without cervical changes should not be considered as the start of labour.
Repeated contractions that are ineffective (unaccompanied by cervical changes) and irregular, which
spontaneously stop and then possibly start up again, represent false labour. In this case, do not rupture
the membranes, do not administer oxytocin.
Likewise, cervical dilation with few or no contractions should not be considered the start of labour.
Multiparous women in particular may have a dilated cervix (up to 5 cm) at term before the onset of
labour.
If in doubt, in both cases, re-examine 4 hours later. If the cervix has not changed labour has not begun
and the woman does not need to be admitted to the delivery room.

5.1.3 Stages of labour

First stage: dilation and foetal descent, divided into 2 phases
1) Latent phase: from the start of labour to approximately 5 cm of dilation. Its duration varies
depending on the number of prior deliveries.
2) Active phase: from approximately 5 cm to complete dilation[1] . During this phase the cervix dilates
faster than during the latent phase. T he time to dilate varies with the number of previous deliveries. As
a rule, it does not last longer than 10 hours in a multipara and 12 hours in a primipara.
Figure 5.1 - Dilation curve in the primipara (in a multipara, the curve is shifted to the left)

Second stage: delivery of the infant

Begins at full dilation.

Third stage: delivery of the placenta

See Chapter 8.

5.1.4 First stage: dilation and descent of the foetus

T he indicators being monitored are noted on the partograph (Section 5.2).

Uterine contractions
– Contractions progressively increase in strength and frequency: sometimes 30 minutes apart early in
labour; closer together (every 2 to 3 minutes) at the end of labour.
– A contraction can last up to a minute.
– T he uterus should relax between contractions.
– Watch the shape of the uterus in order to spot a Bandl’s ring (Chapter 3, Section 3.3.2).

General condition of the patient

– Monitor the heart rate, blood pressure and temperature every 4 hours or more often in case of
abnormality.
– Ask the woman to empty her bladder regularly (e.g. every 2 hours).
– Keep the woman hydrated (offer her water or tea).
– Encourage the woman to move about freely during labour. Position changes and walking around help
relieve the pain, enhances the progress of labour and helps foetal descent. Pain can also be relieved by
massage or hot or cold compresses. Midwife support helps manage pain.
– Routinely insert an IV line in the following situations: excessively large uterus (foetal macrosomia,
multiple pregnancy or polyhydramnios), known anaemia and hypertension.

Foetal heart rate

Foetal heart rate monitoring
Use a Pinard stethoscope or foetal Doppler, every 30 minutes during the active phase and every 5
minutes during active second stage, or as often as possible. Listen to and count for at least one whole
minute immediately after the contraction. Normal foetal heart rate is 110 to 160 beats per minute.
T he foetal heart rate may slow down during a contraction. If it becomes completely normal again as
soon as the uterus relaxes, there is probably no foetal distress.
If the foetal heart rate heard immediately after the end of a contraction is abnormal (less than 100
beats per minute or more than 180 beats per minute), continue foetal heart rate monitoring for the next
3 contractions to confirm the abnormality.

Management of abnormal foetal heart rate

– In all cases:
• Insert an IV line.
• Check maternal vital signs: heart rate, blood pressure and temperature.
• Check the uterine tonus. If hypertonic, look for excessive administration of oxytocin (which should
therefore be stopped) or placental abruption (Chapter 3, Section 3.2).
• Check the colour of the amniotic fluid: meconium-stained (greenish) amniotic fluid combined with
foetal heart rate abnormalities is suggestive of true foetal distress.

− If the foetal heart rate is less than 100 beats/minute:

• Stop administering oxytocin if an infusion is in progress.
• Check for vaginal bleeding: bleeding may suggest placental abruption or uterine rupture.
• Raise the patient or place her on her left side. Laying on her back the uterus creates pressure on the
vena cava, which may be the cause of low foetal heart rate.
• Correct possible hypotension by fluid replacement (Ringer lactate) to bring the systolic blood
pressure ≥ 90 mmHg.
• Perform a vaginal examination to look for cord prolapse.
− If the foetal heart rate is more than 180 beats/minute:
T he most common cause is maternal febrile infection.
• Look for the cause of the infection (uterine infection, pyelonephritis, malaria, etc.) and treat.
• Treat the fever (paracetamol).
• In case of fever of unknown origin, administer antibiotics as for a prolonged rupture of membranes
(Chapter 4, Section 4.9).

If the abnormal foetal heart rate persists or the amniotic fluid becomes stained with meconium, deliver
quickly. If the cervix is fully dilated and the head engaged, perform instrumental delivery (vacuum
extractor or forceps, depending on the operator’s skill and experience); otherwise consider caesarean
section.

Dilation during active phase

– T he cervix should remain soft, and dilate progressively. Dilation should be checked by vaginal
examination every 4 hours if there are no particular problems (Figures 5.2).
– No progress in cervical dilation between two vaginal examinations is a warning sign.
– Action must be taken if there is no progress for 4 hours: artificial rupture of membranes,
administration of oxytocin, caesarean section, depending on the circumstances.
Figures 5.2 - Estimating cervical dilation

Amniotic sac
– T he amniotic sac bulges during contractions and usually breaks spontaneously after 5 cm of dilation
or at full dilation during delivery. Immediately after rupture, check the foetal heart rate and if necessary
perform a vaginal examination in order to identify a potential prolapse of the umbilical cord (Section
5.4). Once the membranes are ruptured, always use sterile gloves for vaginal examination.
– Note the colour of the amniotic fluid: clear, blood-stained, or meconium-stained.
Meconium staining by itself, without abnormal foetal heart rate, is not diagnostic of foetal distress, but
does require closer monitoring—in particular, a vaginal examination every 2 hours. Action must be taken
if dilation fails to progress after 2 hours.

Foetal progress
– Assess foetal descent by palpating the abdomen (portion of the foetal head felt above the
symphysis pubis) before performing the vaginal examination.
– At each vaginal examination, in addition to dilation, check the presentation, the position and the
degree of foetal descent.
– Look for signs that the foetal head is engaged:
On vaginal examination, the presenting part prevents the examiner's fingers from reaching the sacral
concavity (Figures 5.3a and 5.3b). T he presence of caput (benign diffuse swelling of the foetal head)
can lead to the mistaken conclusion that the foetal head is engaged.
T he distance between the foetal shoulder and the upper edge of the symphysis pubis is less than 2
finger widths (Figures 5.3c and 5.3d).
 Figures 5.3 - Diagnosing engagement

5.3b - Presenting part engaged: fingers in the

5.3a - Presenting part not engaged: fingers in
vagina cannot reach the sacral concavity (if
the vagina can reach the sacral concavity​
caput absent)

5.3c - Head not engaged: the shoulder is more 5.3d - Head engaged: the shoulder is less than 2
than 2 finger widths above the symphysis​ finger widths above the symphysis​

– Use reference points on the foetal skull to determine the position of the head in the mother's pelvis.
It is easier to determine the position of the head after the membranes have ruptured, and the cervix is
more than 5 cm dilated. When the head is well flexed, the anterior (diamond-shaped) fontanelle is not
palpable; only the sagittal suture and the posterior (triangular) fontanelle are. T he posterior fontanelle is
the landmark for the foetal occiput, and thus helps give the foetal position. In most cases, once the
head is engaged, rotation of the head within the pelvis brings the foetal occiput under the mother's
symphysis, with the posterior fontanelle along the anterior midline.
5.1.5 Second stage: delivery of the infant
Fundal pressure is always contra-indicated.

T his stage is often rapid in a multipara, and slower in a primipara. It should not, however, take longer
than 2 hours in a multipara and 3 hours in a primipara

If there is a traditional delivery position and no specific risk for the mother or child has been
established, it is possible to assist a delivery in a woman on her back, on her left side, squatting or on
all fours (Figures 5.4).

Figures 5.4 - Delivery position

– Rinse the vulva and perineum with clean water.

– T he bladder should be emptied, naturally if possible. In cases of urinary retention only, insert a urinary
catheter using sterile technique (sterile gloves; sterile, single use catheter).
– If labour is progressing well and there is no foetal heart rate abnormality, let the woman follow her
own urge to push. In other cases, expulsive effort should be directed. T he woman should push during
the uterine contraction. Pushing may be done either with held breath (after a deep inhalation, glottis
closed, abdominal muscles and diaphragm contracted, directed toward the perineum) or with
exhalation. Expulsive effort is maintained for long as possible: in general, 2 to 3 pushes per contraction.
– Between contractions, the woman should rest and breathe deeply. T he birth attendant should
monitor the foetal heart rate after each contraction.
– T he head begins to stretch the perineum, which becomes progressively thinner; the vaginal opening
distends, the labia spread apart, and the occiput appears. In a cephalic presentation, the head usually
emerges occiput anterior: the infant is born looking down, the occiput pivoting against the symphysis
(Figures 5.5). T he head goes into slight extension. T he birth attendant must guide this motion and
prevent any abrupt expulsive movement, with one hand supporting the occiput. T he other hand can
support the chin through the perineum. Cover the anal area with a compress (Figures 5.6).
Figures 5.5 - T he different stages of occiput-anterior delivery

Figures 5.6 - Progressive delivery of the head

During this final phase—an active one for the birth attendant—the woman should stop all expulsive
efforts and breathe deeply. With one hand, the birth attendant controls the extension of the head and
moves it slightly side-to-side, in order to gradually free the parietal protuberances; if necessary (not
routinely), the chin can be lifted with the other hand (Figure 5.7).
Figure 5.7 - Bringing the perineum under the chin

– At the moment of delivery, the perineum is extremely distended. Controlling the expulsion can help
reduce the risk of a tear. Episiotomy (Section 5.8) is not routinely indicated. In an occiput-posterior
delivery (Figure 5.8), where perineal distension is at a maximum, episiotomy may be helpful.

Figure 5.8 - Occiput-posterior delivery

– T he head, once delivered, rotates spontaneously by at least 90°. T he birth attendant helps this
movement by grasping the head in both hands and exerting gentle downward traction to bring the
anterior shoulder under the symphysis and then deliver it then, smooth upward traction to deliver the
posterior shoulder (Figures 5.9).
To reduce the risk of perineal tears, control the delivery of the posterior shoulder.
Figures 5.9 - Delivery of shoulders

– Place the neonate on mother's chest. For neonatal care, see Chapter 10, Section 10.1.

5.1.6 Oxytocin administration

Administer oxytocin to the mother immediately and then deliver the placenta (Chapter 8, Section 8.1.2).

5.1.7 Umbilical cord clamping

See Chapter 10, Section 10.1.1.

Referencias
1. World Healt h Organizat ion. WHO recommendat ions Int rapart um care f or a posit ive childbirt h experience,
Geneva, 2018.
ht t p://apps.who.int /iris/bit st ream/handle/10665/272447/WHO-RHR-18.12-eng.pdf ?ua=1 [Accessed 18 june
2018]

5.2 Monitoring labour and delivery

5.2.1 Partograph
T he partograph is a tool for monitoring maternal and foetal wellbeing during the active phase of labour,
and a decision-making aid when abnormalities are detected. It is designed to be used at any level of
care.
Its central feature is a graph used to record the progress of cervical dilation, as determined by vaginal
examination.
Start the graph at 5 cm of dilation, and 3 contractions every 10 minutes. In certain situations, e.g.
induction of labour, it is started at 4 cm of dilation.

Indicators are plotted on the graph each time they are checked:

– Maternal indicators:
• Vital signs (heart rate, blood pressure and temperature)
• T ime of spontaneous or artificial rupture of the membranes
• Uterine contractions (number per 10 minutes and duration)
• Urine output
• Drugs administered (oxytocin, antibiotics, etc.)

– Foetal indicators:
• Foetal heart rate
• Amniotic fluid (colour, odour and quantity)
• Descent of the foetal head and head moulding

5.2.2 Interpreting the WHO partograph

T he WHO partograph has two diagonal lines: an alert line and an action line.

T he alert line goes from 4 to 10 cm and corresponds to an average dilation rate of 1 cm per hour. If
the labour curve crosses to the right of this alert line, this means that the dilation is less than 1 cm per
hour. In this case, transfer to a CEmONC facility must be considered if the woman is at an outpatient
clinic or a BEmONC facility. If the woman is at a CEmONC facility, closer monitoring is required.

T he action line is located 4 hours to the right of the alert line. If the dilatation curve crosses this line,
decisions must be made (augmentation of labour, artificial rupture of membranes, caesarean section,
etc.). See Chapter 7.

The WHO partograph

5.2.3 Immediate postpartum maternal monitoring
– Vital signs (heart rate, blood pressure, temperature and respiratory rate), blood loss and uterine
retraction:
• between Hour 0 and Hour 2: every 15 to 30 minutes
• between Hour 2 and Hour 4: every hour
– Verify that the woman drinks and urinates.
– Check if there are other treatment indications, e.g., antibiotherapy for prolonged rupture of
membranes with intra-uterine infection (Chapter 4, Section 4.9.3), anaemia (Chapter 4, Section 4.1),
etc.
– In case of caesarean section, see Chapter 6, Section 6.4.

For monitoring and care following the immediate postpartum, see Chapter 11, Section 11.2 and
Section 11.4.

5.3 Artificial rupture of the membranes

Rupture of the amniotic sac using an amnihook (or, if not available, the claw from half of a Kocher
forceps).

5.3.1 Indications
– To speed up dilation if labour fails to progress.
– To speed up delivery once the cervix is fully dilated if labour fails to progress.
– As an adjunct to oxytocin for induction of labour (Chapter 7, Section 7.3.2).
– To try to stop the bleeding during labour in case of partial placenta praevia (be careful not to
perforate the placenta).

5.3.2 Precautions
– Polyhydramnios (risk of cord prolapse): re-examine immediately after rupture to make sure that the
cord did not end up below the presenting part.
– Use sterile technique (infection risk as a result of opening the amniotic cavity to pathogens).

5.3.3 Contra-indications
Absolute
– Complete placenta praevia
– Transverse lie

Relative
– Dilation less than 5 cm, irregular contractions (false labour, latent phase).
– Breech presentation prior to full dilation (keep the amniotic sac intact as long as possible).
– HIV or hepatitis B infection (or context of high-prevalence) prior to full dilation: keep the amniotic sac
intact as long as possible to reduce the risk of mother-to-child transmission.
– Presenting part not engaged: risk of cord prolapse.

5.3.4 Technique
(Figure 5.10)

– Place the woman on her back with knees bent and thighs apart.
– Wear sterile gloves.
– Swab the perineum and the vagina with 10% povidone iodine.
– With one hand, prepare access to the sac (hand well into the cervix). With the other hand, slide the
amnihook between the fingers of the first hand—which spreads the vagina and the cervix and guides
the tip—and make a small cut in the sac as it bulges during a contraction. Let the fluid drain slowly then,
use a finger to enlarge the opening.
– Note the colour of the amniotic fluid (clear, greenish, or blood-stained). Isolated meconium staining,
in the absence of an abnormal foetal heart rate, is not diagnostic of foetal distress, but requires closer
monitoring.
– Make sure the cord has not prolapsed.
– Check the foetal heart rate before and after amniotomy.

Figure 5.10 - Artificial rupture of membranes

5.4 Prolapsed cord

T he umbilical cord drops in front of the presenting part, usually when the membranes rupture (due to
low insertion or excessive length, transverse or breech presentation, sudden rupture of the amniotic
sac, excess amniotic fluid, twin pregnancy).
Compression of the cord between maternal tissues and the foetus (Figures 5.11 and 5.12) during
contractions causes foetal distress and rapid foetal death.

Figure 5.11 - Cord coming out of the vaginal opening

Figure 5.12 - Compression of the cord by the presenting part

5.4.1 Diagnosis
– Amniotic sac has ruptured: cord can be felt between the fingers and, if the foetus is still alive,
pulsations can be felt.
– Foetal distress: foetal heart rate is slow and irregular.

5.4.2 Management
Foetus dead or nonviable (extreme premature)
No specific intervention, vaginal delivery, no caesarean section.
Foetus alive
T his is an obstetric emergency, deliver immediately:

– T he woman in knee-chest (Figure 5.13) or Trendelenburg (dorsal decubitus, head down) position to
take the pressure off the cord.
– Manually push the presenting part toward the uterine fundus to relieve pressure on the cord. Do not
remove hand until extraction of the foetus by caesarean section. If it is difficult to maintain manual
elevation of the foetus through the vagina, fill the bladder with 500 ml of 0.9% sterile sodium chloride
to maintain upward displacement.
– Caesarean section, holding the presenting part of the cord via the vagina until extraction. Check for
foetal heart tones right before the procedure. If foetal heart tone is no longer heard, it is better to let
vaginal delivery proceed (the foetus is already dead).
– If the presenting part is engaged and the cervix fully dilated, it will not be possible to push the
presenting part back; perform vaginal extraction quickly: instrumental delivery (Section 5.6) or total
breech extraction (Chapter 6, Section 6.3).

Figure 5.13 - Knee-chest position

5.5 Nuchal cord

T he umbilical cord is looped around the neck of the foetus; this may cause foetal distress and halt the
progress of birth after delivery of the head.

Nuchal cord does not become visible until after the head is delivered.

If the loop is loose, slip it over the neonate's head.

If the loop is tight and/or has several turns, clamp the cord with 2 Kocher forceps and cut between the
2 forceps (Figure 5.14). Unwind the cord, complete the delivery and perform neonatal resuscitation, if
necessary.

Note: the possibility of a nuchal cord is the reason why 2 Kocher forceps and a pair of scissors must
be ready at the time of delivery.
Figure 5.14 - Cut between 2 forceps as soon as the head is delivered

5.6 Instrumental delivery

T he choice of extraction instrument (vacuum extractor or forceps) depends on the experience and skill
of the operator.

T he conditions for use are the same for both instruments:

– Full dilation.
– Regular uterine contractions.
– Head engaged.
– Accurate diagnosis of the head position.
– Amniotic sac ruptured.
– Bladder empty.

5.6.1 Vacuum extractor

Flexion and traction device for facilitating delivery of the foetus.
T here are various models, but all have:
– A metal, plastic or silicone suction cup, which must be sterilized between each patient.
– A connection to a vacuum system controlled by a pressure gauge. T he vacuum is produced by
means of a manual pump or electrical device.
– A handle for applying traction.

Indications
– Failure to progress due to insufficient or ineffective expulsive effort despite good uterine
contractility (using oxytocin, if necessary).
– Foetal distress during delivery.
– Perineum unable to stretch enough (combine with episiotomy).
– Difficulty with extraction during caesarean section (if possible, use a Vacca Reusable OmniCup®-
type vacuum extractor with built-in pump).

Contra-indications
– Breech, transverse, face or brow presentation.
– Preterm neonate (< 34 weeks): the bones of the skull are too soft.
– Head not engaged.
– Cervix not fully dilated.

Technique
– Place the woman on her back with knees bent and thighs apart.
– Swab the perineum and the vagina with 10% povidone iodine.
– Empty the bladder (insert a sterile urinary catheter).
– Prepare the sterile part of the instrument (the cup), using sterile gloves.
– Insert the cup into the vagina (Figures 5.15) and apply it to the scalp, as close as possible to the
posterior fontanelle—that is, anteriorly for occiput anterior presentations.
– With one hand holding the cup, circle the cup with one finger of the other hand to make sure that no
vaginal or cervical tissue is caught under it. Applying traction can tear the cervix or vagina if there is
vacuum extractor suction on those tissues (risk of massive haemorrhage).

Figures 5.15 - Inserting the cup into the vagina

– If required have an assistant connect the cup to the vacuum system.
– Hold the cup to the foetus' head with one hand.
– Pump to reach a negative pressure. Check for trapped vaginal or cervical tissue before starting
traction. Sit on a small foot rest or kneel; this gives a good traction angle and helps to stay balanced.
T he traction, applied with the dominant hand, should be perpendicular to the plane of the cup.
– Traction should be applied in sync with the uterine contractions and the pushing, which the woman
should continue. Stop pulling the moment the uterine contraction stops. T he direction of traction
varies according to the head's progress: first downward, then horizontal, then increasingly vertical
(Figures 5.16).

Figures 5.16 - Vacuum extractor traction: axis varies depending on the progress of the head

– If the cup is positioned incorrectly or the traction is too sudden, the cup can detach. If this happens,
re-apply it (but no more than 3 times).
– When the hand is able grasp the foetus' chin, turn off the suction, remove the vacuum extractor and
finish the delivery in the normal fashion.
– While episiotomy is not routine, it can be useful, especially if the perineum is too resistant.
Note: when there is a significant pre-existing caput, application of the vacuum extractor can be
ineffective and forceps may be necessary.

Do not apply suction for more than 20 minutes: the indication is probably incorrect, and there is a risk
of scalp necrosis. Birth usually occurs in less than 15 minutes.
Make no more than 3 attempts at traction if there is no progress (the mother's pelvis is probably
impassable).
In case of failure, perform a caesarean section.

5.6.2 Forceps
T he use of forceps requires special expertise, and forceps should be used by trained birth attendant
only.
Forceps can be used even without the mother pushing.
Forceps can be used when a vacuum extractor cannot be used as in a mentum anterior face
presentation.

Indications
– As for vacuum extraction.
– Breech presentation with retention of the aftercoming head.

Contra-indications
– Transverse lie or brow presentation.
– Head not engaged.
– Cervix not fully dilated.

5.7 Symphysiotomy
Partial incision of the cartilage of the symphysis pubis such that the two pubic bones separate by
about 2 cm, allowing enough room for passage of an entrapped, live foetus.

T his procedure should be done in combination with episiotomy (Section 5.8) and instrumental delivery
(Section 5.6).

5.7.1 Indications
T his life-saving technique may be useful as a procedure of last resort:
– In situations where caesarean section is indicated but not feasible a :
• Head engaged and arrested for more than an hour, and vacuum extraction alone has already failed or
is likely to do so.
• Foeto-maternal disproportion due to a pelvis that is slightly too narrow: after the trial of labour has
failed, and at least 3/5 of the head has descended into the pelvic cavity.
– In the event of shoulder dystocia when other manoeuvres have failed.
– In the event of entrapped aftercoming head in a breech when other manoeuvres have failed.

5.7.2 Conditions
– Membranes ruptured, full dilation.
– T he foetal head is not palpable above the symphysis pubis or by less than 2/5 (Figure 5.17).

5.7.3 Contra-indications
– Head not engaged.
– Brow presentation.
– Dead foetus perform an embryotomy (Chapter 9, Section 9.7).
– Cervix not fully dilated.
– Severe cephalo-pelvic disproportion, with head above the symphysis by more than 2/5 (Figure 5.17).

Figure 5.17 - Position of the foetal head

5.7.4 Equipment
– Scalpel, suturing equipment, delivery set with episiotomy scissors
– Vacuum extractor
– Foley catheter
– Sterile drape, compresses and gloves
– 10% povidone iodine
– 1% lidocaine

5.7.5 Technique
– Patient in lithotomy position, abduction supported by two assistants who maintain an angle of less
than 90° between the patient's thighs (Figure 5.18).

Figure 5.18 - Supported lithotomy position

– Shave the incision site; swab the pubic and perineal region with 10% povidone iodine.
– Place a sterile fenestrated drape over the symphysis.
– Insert the Foley catheter, which allows location of the urethra throughout the procedure.
– Local anaesthesia: 10 ml of 1% lidocaine, infiltrating the skin and subcutaneous tissues superior,
anterior, and inferior to the symphysis, along the midline, down to the cartilage. Infiltrate the episiotomy
region as well.
– With the index and middle fingers of the hand inserted into the vagina, push the urethra to the side
(Figures 5.19 and 5.20). Place the index finger in the groove formed by the cartilage between the two
pubic bones, in such a way that it can feel the scalpel's movements. T he catheterized urethra must be
pushed out of scalpel's reach.
Figure 5.19 - Finger pushing the urethra out of the way

Figure 5.20 - Finger pushing the head and urethra out of the way

– Incision:
• Locate the upper edge of the symphysis.
• Introduce the scalpel 1 cm below this point, perpendicular to the skin, exactly on the midline.
• Cut down until the cartilage: it should feel elastic; if it feels bony, gently withdraw the blade and
recheck the location.
• First tilt the blade toward the top, use a small back-and-forth motion (Figure 5.21), always along the
midline, and in that way section 2/3 of the cartilage to the upper edge of the symphysis, going slightly
past it.
• T hen, turn the blade around toward the bottom, and repeat the sectioning manoeuvre down to the
lower edge. T he procedure is complete when the pubic bones move apart. T he assistants continue to
hold apart the thighs making sure they do not move further apart: the widening of the symphysis pubis
must not exceed 2 to 2.5 cm (the width of a thumb).
Figure 5.21 - Scalpel moves back and forth

– Do not cut the vagina.

– Perform an episiotomy; use a vacuum extractor to deliver the neonate.
– One or two stitches suffice to close the wound after delivery.

5.7.6 Post-operative care

– Have the mother rest on her side (avoid forced abduction of the thighs) for 7 to 10 days. Mobilization
with aid is possible as of Day 3 if the woman can tolerate the discomfort. No heavy work for 3
months.
– Remove the Foley catheter after 3 days, except if haematuria present during catheterization or in
case of obstructed labour (Chapter 7, Section 7.2.5).
– Routine treatment for pain as for caesarean section (Chapter 6, Section 6.4.5).

5.7.7 Complications
– Bleeding at the site of the wound: compression bandage.
– Local infection: daily dressings and antibiotherapy (amoxicillin PO: 1 g 3 times daily for 5 days).
– Stress incontinence: uncommon and temporary.
– Gait problems: prevented through bed rest.
– Injury to the urethra or bladder: leave the catheter in place for 10 to 14 days and consult a specialist.
– Osteomyelitis: extremely rare if rigorous sterile technique has been used.

Notas
(a) Caesarean sect ion is not f easible because surgical condit ions are inadequat e or surgical int ervent ion
 would t ake t oo long or t here is a high risk of t rauma t o mot her and f oet us or t he woman ref uses
caesarean sect ion.

5.8 Episiotomy
Incision on the perineum

5.8.1 Indications
Episiotomy can cause infection, haemorrhage and/or chronic pain. It should not be done routinely.
Simple first- and second-degree tears heal as well or better than an episiotomy.

Episiotomy should be routinely performed in case of symphysiotomy.

Episiotomy should be considered in the following situations:

– Prolonged delivery, especially if foetal heart rate slows, when completion of the delivery is being
obstructed by the perineum.
– Instrumental delivery (forceps or vacuum extraction).
– Shoulder dystocia.
– Occiput posterior, face, or breech delivery.
– Oedematous or scarred perineum that does not stretch properly.
– History of third and fourth degree tears.
– Excision (clitoral circumcision with partial or total clitoridectomy, often with removal of the labia
minora). Excision causes a loss of perineal elasticity, with a risk of a prolonged delivery and perineal
tears. Episiotomy may be necessary but may not completely prevent tearing.

5.8.2 Equipment
– Delivery sets containing 2 pairs of scissors
– 10% povidone iodine, sterile compresses
– 1% lidocaine

5.8.3 Technique
– Swab the perineum with 10% povidone iodine.
– Administer local anaesthesia by infiltration with 10 ml of 1% lidocaine.
– Perform the episiotomy when the perineum is thinned and widened, distended by the foetus, which
appears at the vaginal opening: during a push, make a straight 4 cm cut using sterile scissors, obliquely
down and out at a 45° angle from the posterior vulvar commissure. Protect the foetus with the other
hand (Figure 5.22).
Figure 5.22 - Cutting the perineum

– T he episiotomy can be done to the right or the left, depending on whether the operator is right- or
left-handed.
– T he scissors used for the episiotomy, now contaminated, should be put aside immediately. T hey
must not be used for other procedures, like cutting the cord (this is why all delivery sets must include 2
pairs of scissors).

To suture the perineum, see Section 5.9.

5.9 Perineal repair

During delivery the perineum can tear causing different degrees of vulvovaginal lacerations: superficial
(first-degree tear), or deeper, affecting the muscle tissue (second-degree tear, equivalent to an
episiotomy).

Two adjacent tissues may also be damaged:

– T he anal sphincter muscle, which is red and fleshy. A tear in this sphincter can be recognized by the
loss of the anus' radial appearance (third-degree tear). Repair of the muscle is essential to prevent
faecal incontinence.
– T he rectal mucosa, which is smooth and whitish, extending from the anus. A tear in rectal mucosa
(fourth-degree tear) must be sutured to prevent anal fistula with incontinence and infection.

All genital mutilations – that is, clitoral circumcision (Type I mutilation), clitoral circumcision with removal
of the labia minora (Type II mutilation), and infibulation (Type III mutilation, Section 5.10) – are
associated with a risk of perineal tears during expulsion.

5.9.1 Equipment
– Suture set containing sterile scissors, dissecting forceps and needle holder
– 10% povidone iodine
– 1% lidocaine
– One or two Dec 3 (2/0) absorbable sutures
– A rapidly absorbable suture for closing the skin or, if not available, a non-absorbable Dec 3 (2/0)
suture
– Sterile drape and gloves
– Good lighting

5.9.2 Technique
T he perineum should not be sutured until after the placenta is delivered.
– Swab the perineum and vagina with povidone iodine 10%.
– Position a sterile aperture drape. Make a tampon from sterile compresses, to be inserted into the
vagina to absorb the intra-uterine bleeding while suturing (caution: do not forget to remove them after
finishing sutures).
– Assess the size and number of tears. If episiotomy was performed, check to make sure it did not
tear further, and look for other tears. If necessary, use vaginal retractors to expose the entire vaginal
wall.
– Use local anaesthesia (lidocaine 1%) in all the involved tissues except the rectal mucosa. For
complex and/or third- or fourth-degree tears, do the suturing in the operating theatre under general or
spinal anaesthesia.

Superficial vulvar tears (first-degree)

– If they are not bleeding and confined to the area near the vaginal opening: basic care, no suturing.
– If they are bleeding or deep: simple continuous or interrupted suture using absorbable suture material.

Episiotomy or simple second-degree perineal tears (second-degree)

– Locate the apex of the cut/tear and place a first stitch there.
– Suture the vaginal mucosa going from the inside out, to just behind the hymenal remnants, using a
continuous or interrupted figure-of-eight absorbable suture; stitches should be close enough to
prevent lodging of lochia in the following days, but not too deep, to avoid going into the rectum (Figure
5.23).
– Next, suture the muscle layer with 2 or 3 absorbable figure-of-eight sutures (Figure 5.24) or
continuous suture.
– Close the skin with rapidly absorbable or non-absorbable suture material, using interrupted (simple or
vertical mattress) stitches; begin by placing the first stitch, without tying it, on the posterior
commissure (Figure 5.25). Because the tissues will be oedematous in the days following the birth, avoid
tying the knots too tight. Continuous subcuticular suture using absorbable suture materials is also
possible.
Perform a rectal examination to make sure that no stitches can be felt in the rectum. Remove
compresses from inside the vagina.
Figure 5.23 - Suturing the mucosa Figure 5.24 - Suturing the muscle

Figure 5.25 - Suturing the skin

Rupture of the anal sphincter (third-degree)
– Administer an antibiotic prophylaxis (cefazolin IV 2 g + metronidazole IV 500 mg single dose).
– A tear in the muscular ring can result in retraction of the 2 torn ends of the muscle, now hidden in the
tissues. Insert a finger into the rectum to locate the 2 ends.
– Suture the sphincter with 2 or 4 absorbable horizontal mattress sutures (Figure 5.26).
– Continue in the same sequence as in the preceding case.

Figure 5.26 - Suturing the anal sphincter

Tear in the rectal mucosa (fourth-degree)

– Administer an antibiotic prophylaxis (cefazolin IV 2 g + metronidazole IV 500 mg single dose).
– Protect the wound from faecal material by placing a compress in the rectum (as with the vaginal
tampon, do not forget to remove it).
– Suture the rectal mucosa, going from high to low, using absorbable, interrupted stitches (Figures
5.27).
– Continue in the same sequence as in the preceding case.
 Figures 5.27 - Suturing the rectal mucosa

5.9.3 Post-operative care

– In all cases, the vulva should be cleansed with soap and water and dried when the patient urinates or
defecates, at least 2 times daily.
– For non-absorbable sutures: remove the stitches between the 5th and 8th day.
– Routine analgesia: paracetamol and/or ibuprofen (especially if there is perineal oedema). See
Appendix 7.
– For third- and fourth-degree tears, a laxative may be given to prevent passage of hard stools over
the sutured rectal mucosa.

5.9.4 Management of complications

Haematoma
– Remove the stitches and drain.
– If there are no signs of infection and the bleeding has stopped, re-suture the episiotomy either
completely or partially (to allow spontaneous drainage), or leave a drain in place.

Infection
– Remove the stitches, drain and, if necessary, remove necrotic tissues
– In the event of minor infection: no antibiotic; drainage is enough.
– In the event of severe infection: antibiotherapy for 5 days:
amoxicillin/clavulanic acid PO
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
or
amoxicillin PO: 1 g 3 times daily + metronidazole PO: 500 mg 3 times daily

5.10 Deinfibulation
Infibulation or Type III genital mutilation refers to clitoral circumcision with partial or complete removal
of the clitoris, often combined with removal of the labia minora, in addition to vulvar occlusion with
partial or complete removal of the labia majora, the edges of which are sealed together. All that is left
is a residual opening at the base of the vulva for the passage of urine and menstrual blood.

Infibulation may interfere with the ability to monitor cervical dilation and with the normal childbirth
process.
It can cause prolonged retention of the foetus against the perineum, increasing the risk of severe
maternal tissue damage (tears and fistula) and the risk of foetal distress and death.

Deinfibulation, performed during pregnancy or labour, may be necessary for the birth of the child.
Double episiotomy is not an acceptable substitute for deinfibulation.

5.10.1 Equipment
– Suture set containing: sterile scissors, dissecting forceps and needle holder
– 10% povidone iodine
– 1% lidocaine
– One or two Dec 3 (2/0) absorbable sutures
– Sterile drape, compresses and gloves

5.10.2 Technique
– Ask the woman to urinate.
– Administer local anaesthesia with 1% lidocaine.
– Swab the perineum and vagina with 10% povidone iodine.
– Insert one finger of one hand in the opening in the vulva to protect the urethra.
– With the other hand, use scissors to cut the midline anterior strip of scar tissue; this allows access to
the vagina and urethra.
– Ensure haemostasis with a continuous suture along each edge.
After delivery, the opening of the vulva allows free passage of urines and lochia.

Women should never be re-infibulated.

Postoperative care is identical to that for a perineal tear or episiotomy.

Chapter 6: Special deliveries

6.1 Breech presentation

6.2 Twin pregnancy

6.3 Total breech extraction

6.4 Caesarean section

6.1 Breech presentation

Presentation of the feet or buttocks of the foetus.

6.1.1 The different breech presentations

– In a complete breech presentation, the legs are tucked, and the foetus is in a crouching position
(Figure 6.1a).
– In a frank breech presentation, the legs are extended, raised in front of the torso, with the feet near
the head (Figure 6.1b).
– In a footling breech presentation (rare), one or both feet present first, with the buttocks higher up and
the lower limbs extended or half-bent (Figure 6.1c).

Figures 6.1 - Breech presentations

6.1.2 Diagnosis
– T he cephalic pole is palpable in the uterine fundus; round, hard, and mobile; the indentation of the
neck can be felt.
– T he inferior pole is voluminous, irregular, less hard, and less mobile than the head.
– During labour, vaginal examination reveals a “soft mass” divided by the cleft between the buttocks,
with a hard projection at end of the cleft (the coccyx and sacrum).
– After rupture of the membranes: the anus can be felt in the middle of the cleft; a foot may also be
felt.
– T he clinical diagnosis may be difficult: a hand may be mistaken for a foot, a face for a breech.

6.1.3 Management
Route of delivery
Before labour, external version (Chapter 7, Section 7.7) may be attempted to avoid breech delivery.

If external version is contra-indicated or unsuccessful, the breech position alone – in the absence of
any other anomaly – is not, strictly speaking, a dystocic presentation, and does not automatically
require a caesarean section. Deliver vaginally, if possible – even if the woman is primiparous.

Breech deliveries must be done in a CEmONC facility, especially for primiparous women.

Favourable factors for vaginal delivery are:

– Frank breech presentation;
– A history of vaginal delivery (whatever the presentation);
– Normally progressing dilation during labour.

T he footling breech presentation is a very unfavourable position for vaginal delivery (risk of foot or
cord prolapse). In this situation, the route of delivery depends on the number of previous births, the
state of the membranes and how far advanced the labour is.

During labour
– Monitor dilation every 2 to 4 hours.
– If contractions are of good quality, dilation is progressing, and the foetal heart rate is regular, an
expectant approach is best. Do not rupture the membranes unless dilation stops.
– If the uterine contractions are inadequate, labour can be actively managed with oxytocin.

Note: if the dilation stales, transfer the mother to a CEmONC facility unless already done, to ensure
access to surgical facility for potential caesarean section.
At delivery
– Insert an IV line before expulsion starts.
– Consider episiotomy at expulsion. Episiotomy is performed when the perineum is sufficiently
distended by the foetus's buttocks.
– Presence of meconium or meconium-stained amniotic fluid is common during breech delivery and is
not necessarily a sign of foetal distress.
– T he infant delivers unaided, as a result of the mother's pushing, simply supported by the birth
attendant who gently holds the infant by the bony parts (hips and sacrum), with no traction. Do not pull
on the legs.
Once the umbilicus is out, the rest of the delivery must be completed within 3 minutes, otherwise
compression of the cord will deprive the infant of oxygen.
Do not touch the infant until the shoulder blades appear to avoid triggering the respiratory reflex
before the head is delivered.
– Monitor the position of the infant's back; impede rotation into posterior position.

Figures 6.2 - Breech delivery

​

6.1.4 Breech delivery problems

Posterior orientation
If the infant’s back is posterior during expulsion, take hold of the hips and turn into an anterior position
(this is a rare occurrence).

Obstructed shoulders
T he shoulders can become stuck and hold back the infant's upper chest and head. T his can occur
when the arms are raised as the shoulders pass through the mother's pelvis. T here are 2 methods for
lowering the arms so that the shoulders can descend:

1 - Lovset's manoeuvre
• With thumbs on the infant's sacrum, take hold of the hips and pelvis with the other fingers.
• Turn the infant 90° (back to the left or to the right), to bring the anterior shoulder underneath the
symphysis and engage the arm. Deliver the anterior arm.
• T hen do a 180° counter-rotation (back to the right or to the left); this engages the posterior arm,
which is then delivered.

Figures 6.3 - Lovset's manoeuvre

6.3a - Turning the infant to bring down the anterior shoulder

6.3b - Downward traction and descent of shoulders along the midline (sacral-pubic) axis

6.3c - Delivering the anterior arm and shoulder

2 - Suzor’s manoeuvre
In case the previous method fails:
• Turn the infant 90° (its back to the right or to the left).
• Pull the infant downward: insert one hand along the back to look for the anterior arm. With the
operator thumb in the infant armpit and middle finger along the arm, bring down the arm (Figure 6.4a).
• Lift infant upward by the feet in order to deliver the posterior shoulder (Figure 6.4b).

Figures 6.4 - Suzor's manoeuvre

6.4a - Bringing down the anterior arm

6.4b - Delivering the posterior shoulder

Head entrapment
T he infant's head is bulkier than the body, and can get trapped in the mother's pelvis or soft tissue.

T here are various manoeuvres for delivering the head by flexing it, so that it descends properly, and
then pivoting it up and around the mother's symphysis. T hese manoeuvres must be done without delay,
since the infant must be allowed to breathe as soon as possible. All these manoeuvres must be
performed smoothly, without traction on the infant.

1 - Bracht's manoeuvre
• After the arms are delivered, the infant is grasped by the hips and lifted with two hands toward the
mother's stomach, without any traction, the neck pivoting around the symphysis.
• Having an assistant apply suprapubic pressure facilitates delivery of the aftercoming head.

Figures 6.5 - Bracht's manoeuvre

2 - Modified Mauriceau manoeuvre

In case the previous method fails:
• Infant's head occiput anterior.
• Kneel to get a good traction angle: 45° downward.
• Support the infant on the hand and forearm, then insert the index and middle fingers, placing them on
the infant’s maxilla. Placing the index and middle fingers into the infant’s mouth is not recommended, as
this can fracture the mandible.
• Place the index and middle fingers of the other hand on either side of the infant's neck and lower the
infant's head to bring the sub-occiput under the symphysis (Figure 6.6a).
• T ip the infant’s head and with a sweeping motion bring the back up toward the mother's abdomen,
pivoting the occiput around her symphysis pubis (Figure 6.6b).
• Suprapubic pressure on the infant's head along the pelvic axis helps delivery of the head.
• As a last resort, symphysiotomy (Chapter 5, Section 5.7) can be combined with this manoeuvre.

Figures 6.6 - Modified Mauriceau manoeuvre

6.6a - Step 1
Infant straddles the birth attendant's forearm; the head, occiput anterior, is lowered to bring the
occiput in contact with the symphysis.

6.6b - Step 2
T he infant's back is tipped up toward the mother's abdomen.

3 - Forceps on aftercoming head

T his procedure can only be performed by an operator experienced in using forceps.

6.2 Twin pregnancy

Simultaneous development of two foetuses in the uterine cavity.
More than two foetus can exceptionally develop in the uterine cavity.

6.2.1 Diagnosis
– T he diagnosis is suspected in the second half of pregnancy when the uterus is abnormally large.
– Two poles of the same type (e.g., two heads) or three poles are felt.
– Two distinct foetal heart tones are heard.
– T he diagnosis can be confirmed by ultrasound.

6.2.2 Management during pregnancy

Close monitoring, more frequent antenatal consultations, screening for and management of
complications such as anaemia, placenta praevia, prematurity, and pre-eclampsia.

6.2.3 Management during delivery

Twin deliveries (and all multiple deliveries) should take place in a CEmONC facility, if possible.

Delivering the first twin

– Insert an IV line before expulsion starts.
– Deliver the first twin in the same way as a singleton.
– When the cord is cut, leave a clamp on the placenta side, as there may be an anastomosis with the
second twin's circulation.
– Never administer oxytocin for active management of the third stage of labour before the second
twin is delivered.
– Vaginal delivery is possible when the first twin is breech. Twins who are locked at the chin is a rare
complication, seen when the first twin is breech and the second vertex. If this occurs, attempt to
continue the vaginal delivery. T he mortality and morbidity among such twins is high.

– External version is contra-indicated.

– If the first twin is in a transverse lie (unusual): schedule a caesarean section.

Rest period
– Usually 15 minutes; should not exceed 30 minutes. Take advantage of the pause in contractions to
study the presentation of the second twin.
– Immediately after delivery of the first twin, an assistant should hold the second twin in a vertical
position by placing hands laterally on either side of the uterus. T his is done to prevent the foetus from
assuming a transverse lie, in the now too large uterus.
– Continue heart rate monitoring of the second twin. In the event of abnormal heart rate,
expedite delivery of the second twin.
– If the presentation is normal, as well as the foetal heart rate, await spontaneous delivery.
– If contractions have not resumed after 15 to 30 minutes, administer an escalating-dose oxytocin
infusion (Chapter 7, Section 7.4) to speed up the birth of the second twin.

Delivering the second twin

– If presentation of the second twin is longitudinal (vertex or breech): proceed as with a normal vertex
or breech delivery. Delivery of the second twin is usually faster.
– For a transverse lie, attempt external version (Chapter 7, Section 7.7) or perform internal version
(Chapter 7, Section 7.8) if conditions are favourable (full dilation, soft uterus) to bring the foetus to a
breech position, then perform total breech extraction (Section 6.3).
Note: in case of multiple pregnancies with more than two fetuses, proceed as with second twin.

Delivering the placenta

– After the second twin is born, administer:
• oxytocin routinely: 5 to 10 IU by IM or slow IV
• cefazolin or ampicillin slow IV a : 2 g single dose if internal manoeuvres were performed.
– T here is a significant risk of haemorrhage due to uterine atony. If there is any doubt, perform manual
removal of placenta and/or uterine cavity exploration.

Notas
(a) For pat ient s wit h a hist ory of immediat e hypersensit ivit y react ion t o penicillin (urt icaria, respirat ory
problems or oedema): clindamycin IV 900 mg single dose + gentamicin IV 5 mg/kg single dose.

6.3 Total breech extraction

Breech extraction of the second twin, in particular when the condition of the foetus requires rapid
extraction (foetal distress); may be preceded by internal version for transverse foetal lie.

T his technique requires experience in obstetrical manoeuvres. If possible, it should be performed in a

CEmONC facility. Prepare for a caesarean section in case the total breech extraction fails.
6.3.1 Relative contra-indication
– Scarred uterus (risk of uterine rupture)

6.3.2 Technique
– Routinely insert an IV line.
– Empty bladder.
– Proceed slowly; it may be necessary to pause periodically to allow the uterus to re-soften.
– Insert a hand into the uterus and bring down one foot.
– Do not rupture the membranes right away (they will rupture on their own when the foot is pulled down,
or will be ruptured artificially once the foot is down).
– Delivering the foot:

Complete breech (Figures 6.7a and 6.7c)

• Grasp one or both ankles with one hand, index and middle finger straddling the back of the foot;
• Apply gentle traction to bring the leg to the vulva.

Frank breech (Figures 6.7b and 6.7c)

• Grasp a single foot, and bring it down by bending the knee until the lower leg is against the thigh, then
continue bringing it down until the leg is fully extended;
• If a hand is grasped rather than a foot, push it back up and start over (feel for the bend at the ankle).

Figures 6.7 - Total breech extraction

6.7a - Grasping one or both feet in the complete breech
6.7b - Grasping the anterior foot in the frank breech

6.7c - Bringing one foot down

– Delivering the breech (Figures 6.8)

• Apply gentle, continuous, downward traction on the leg to deliver the anterior hip, the foetal back
anteriorly.
• Once the anterior hip has been delivered, pull gradually upward to deliver the posterior hip.
• Once the pelvis is out, with thumbs on the loins, take hold of the hips and pelvis with the other fingers.
Pull the pelvis downward, keeping the back anterior, until the tips of the shoulder blades are seen.

Figures 6.8 - Delivery of the breech in a total breech extraction

6.8a - Downward traction to deliver the anterior hip

6.8b - Upward traction to deliver the posterior hip

– Deliver the shoulders and head: Lovset and Bracht manoeuvres (Section 6.1.4).
– Explore the uterus to rule out uterine rupture.
– Routine antibiotic prophylaxis after clamping the cord: cefazolin or ampicillin slow IV a , 2 g single
dose.

Notas
(a) For pat ient s wit h a hist ory of immediat e hypersensit ivit y react ion t o penicillin (urt icaria, respirat ory
problems or oedema): clindamycin IV 900 mg single dose + gentamicin IV 5 mg/kg single dose.
6.4 Caesarean section
Performing a caesarean section requires technical expertise and good obstetric knowledge for
determining appropriate indications. T here can be difficulties (haemorrhage, difficulty extracting the
foetus, etc.) and complications (bladder injury, uterine tear, foetal trauma, etc.). Compared to vaginal
delivery, caesarean section is associated with higher maternal mortality and an increased risk of
complications for future pregnancies, regardless of the setting in which it is performed.

6.4.1 Indications
Absolute
T hese situations threaten directly the life of the mother (1 to 2% of all deliveries) [1] :
– Severe, uncontrolled ante-partum bleeding (tachycardia and hypotension).
– Malpresentation that cannot be turned (shoulder, brow or chin-posterior face).
– Absolute foeto-pelvic disproportion (partograph showing a failure to progress in the active phase of
labour despite good uterine dynamics) and no possibility of instrumental extraction.
– Uterine rupture.
– History of 3 or more caesarean sections.

Relative
T he decision to perform caesarean section should consider the risk/benefit for the mother and the
infant in the given context: access to services and the availability and level of neonatal care.
T he risks to the mother should be evaluated in the short term (death, infection, thrombo-embolism,
etc.) and the medium/long term (future uterine rupture, placenta praevia or accreta during another
pregnancy, etc.). In contexts with difficult access to services and a high fertility rate, the risks to the
mother often outweigh the potential benefits to the infant. In any case, information about alternatives
to caesarean section with corresponding risks and benefits should be shared with the woman, enabling
her to make a choice.

Note: when a caesarean is planned, it should be done at 39 weeks LMP or later. Before 39 weeks LMP,
caesarean births without labour – even when not premature (37-38 weeks LMP) – are associated with
a high risk of neonatal respiratory distress. T hat risk exists regardless of the estimated foetal weight. If
the due date is uncertain and there is a very high risk of uterine rupture (e.g., history of severe uterine
rupture or more than 3 prior caesarean sections), consider caesarean section prior to onset of labour,
during the ninth month, with preparation for managing neonatal respiratory distress. In other indications,
it is better to wait until the woman goes into labour to do the caesarean section. Under those
circumstances, if the patient lives far away, suggest that she move near the facility where she will
deliver during her ninth month, either with family or at a residential facility (maternity waiting home).
6.4.2 Prerequisites for performing a caesarean section
– Skilled human resources for determining whether surgery is indicated, administering the anaesthesia
and performing the surgery.
– Appropriate facilities (operating room, sterilisation, post-operative recovery room and blood
transfusion).
– Appropriate equipment.
– Appropriate care and monitoring.

6.4.3 Pre-operative care

– Patient’s consent.
– Anaesthesia evaluation.
– Routine prophylaxis of gastric acid aspiration:
cimetidine PO (effervescent tablet): 200 mg in 30 ml of water, 20 minutes prior to surgery

6.4.4 Peri-operative care

– Standard surgical skin preparation.
– Foley catheter insertion.
– Routine antibiotic prophylaxis: cefazolin slow IV a : 2 g single dose (to be preferably administered 60
minutes prior to incision) [2] .
– Administer the appropriate antibiotherapy in case of b :
• prolonged rupture of membranes or intra-uterine infection (Chapter 4, Section 4.9);
• peritonitis, infected or prolonged uterine rupture, septic shock.

– Administration of oxytocin:
• 10 IU by slow IV injection routinely after clamping the cord, then,
• 20 IU in 1 litre of Ringer lactate administered over 2 hours at a rate of 160 drops per minute (in the
event of persistent haemorrhage, up to 60 IU max.).

6.4.5 Post-operative care

– Close initial monitoring:
Vital signs, bleeding, analgesia, etc. in the recovery room.
Transfer to inpatient unit after consulting anaesthetist.
– Analgesics (by oral route whenever possible):
• Routine analgesics on a fixed schedule:
D0 to D1, tramadol: 50 mg every 8 hours
D0 to D3, ibuprofen: 400 mg every 8 hours
D0 to D5, paracetamol: 1 g every 6 hours
Adjust according to the pain self-assessment. If necessary, add morphine: 10 mg every 4 hours.
• Routine, regular pain self-assessment (self-assessment scale): see Clinical guidelines, MSF.
• Respect the contra-indications; avoid non-steroidal anti-inflammatory drugs in situations where
clotting and renal function may be compromised (sepsis, pre-eclampsia).

T he surgeon may infiltrate the wound at the end of the procedure with levobupivacaine 0.5% (150 mg
or 2 mg/kg, max. 30 ml); this provides increased pain relief in the first 4 to 8 hours after surgery.

– T hromboprophylaxis (low molecular-weight heparin):

Not done routinely for uncomplicated caesarean sections.
Desirable in the event of:
• Caesarean section with hysterectomy.
• History of deep vein thrombosis.
• Two risk factors for thromboembolism (infection, prolonged labour, pre-eclampsia, severe bleeding or
sickle cell disease).

– Infusion and IV catheter:

If uncomplicated caesarean section:
• D0: one litre of 5% glucose and one litre of Ringer lactate over 24 hours.
• D1: remove the IV catheter.

– Feeding:
• Spinal anaesthesia: fluids may be resumed 2 hours post-operatively.
• General anaesthesia: fluids may be resumed 4 hours post-operatively.
• Uncomplicated caesarean section (no hysterectomy or pelvic peritonitis): light meal may be given 6
hours post-operatively. It is not necessary to wait until the patient passes gas.

– Urinary catheter:
Routine removal on D1, unless:
• Blood-stained urine when catheter is removed.
• Urine output < 500 ml per 24 hours.
• Peri/post-operative complication (wait to consult the surgeon and/or anaesthetist).

– Early mobilisation:
• D0: mobilisation at the edge of the bed beginning 6 hours post-operatively.
• D1: patient out of bed for the first time.
– Dressing and suture removal:
• If hygiene conditions are good: uncover wound on D1.
• Otherwise, remove dressing on D5 (or at discharge if stay less than 5 days). T here is no need to
change the dressing every day.
• Remove skin sutures (if not absorbable) on D7.

– Cleaning:
Simple shower; no intravaginal cleansing.

– Breastfeeding:
• Begin breastfeeding as soon as possible.
• Monitor the neonate (risk of drowsiness if the mother receives tramadol or morphine).

– Documentation:
• Operative report.
• On discharge: give patient a document specifying the reason for the caesarean section and the type
of hysterotomy performed (classical/low transverse), to aid in deciding the route of delivery for a
subsequent pregnancy.

Notas
(a) In pat ient s wit h a hist ory of immediat e hypersensit ivit y react ion t o penicillin (urt icaria, respirat ory problems
or oedema): clindamycin IV 900 mg single dose + gentamicin IV 5 mg/kg single dose.

(b) Int raut erine f oet al deat h, t inged or meconium-st ained amniot ic fluid and an init ial at t empt t o ext ract
vaginally are not indicat ions f or ant ibiot herapy.

Referencias
1. UON Net work. Tackling Unmet Need f or Major Obst et ric Int ervent ions. Concept s, General Principles and
Int ernat ional Net work, 2018.
ht t p://www.uonn.org/wp-cont ent /uploads/2018/09/guide1.pdf

2. Sullivan SA, Smit h T, Chang E, et al. Administ rat ion of cef azolin prior t o skin incision is superior t o cef azolin
at cord clamping in prevent ing post cesarean inf ect ious morbidit y: a randomized, cont rolled t rial. Am J
Obst et Gynecol 2007; 196; 455.e1-455.e5.

Chapter 7: Labour dystocia and

malpresentations
7.1 Prolonged labour

7.2 Obstructed labour

7.3 Labour induction

7.4 T he use of oxytocin during labour

7.5 Shoulder dystocia

7.6 Transverse lie and shoulder presentation

7.7 External version

7.8 Internal version

7.9 Face presentation

7.10 Brow presentation

7.1 Prolonged labour

Excessively prolonged active or pushing phase of labour. T he term “prolonged labour” applies only at
or after 5 cm dilation and 3 contractions per 10 minutes. Before that point, it is a “false labour” or
prolonged latent phase.

Prolonged labour can be due to foeto-pelvic disproportion (mechanical dystocia) and/or inadequate
contractions (dynamic dystocia) and/or ineffective maternal pushing efforts in the second stage of
labour.

T he main risks of prolonged labour are obstruction (Section 7.2) and foetal distress.

7.1.1 Diagnosis
– Arrest of cervical dilation for 4 hours during the active phase
or
– Protracted foetal engagement or descent after more than 2 hours of complete dilation in a multipara
and 3 hours of complete dilation in a primipara

7.1.2 Management
See algorithms below.
For general patient care during labour, see Chapter 5, Section 5.1.4.

Notes:
– Oxytocin is contra-indicated in case of frank foeto-pelvic disproportion (risk of uterine rupture).
– In the event of foetal distress (baseline < 100/minute or deceleration > 5 minutes or repetitive
decelerations after contraction for a period > 30 minutes) a and if the foetus is viable:
• At complete dilation, with the presenting part engaged: instrumental delivery (Chapter 5, Section 5.6);
• Prior to complete dilation, or at complete dilation with presenting part not engaged: consider
caesarean section earlier than in the algorithms, but the context needs to be taken into account when
deciding a caesarean section for exclusive foetal indication (Chapter 6, Section 6.4).
In either case, do not use—or stop, if already using—oxytocin.
– If the foetus is dead, avoid caesarean section whenever possible. Allow more time for dilation and
engagement. Consider embryotomy (Chapter 9, Section 9.7).

Management of arrest of cervical dilation for 4 hours during the active phase
For other presentations, see breech presentation (Chapter 6, Section 6.1), transverse lie and shoulder
presentation (Section 7.6), face presentation (Section 7.9), brow presentation (Section 7.10).

Management of protracted foetal engagement or descent after more than 2 hours of complete
dilation in a multipara and 3 hours of complete dilation in a primipara

For other presentations (breech, shoulder, chin-posterior face, or brow presentations): caesarean
section.

Notas
(a) In case a cardiot ocograph is used, abnormal variabilit y can also indicat e f oet al dist ress. For more
inf ormat ion, see FIGO Int rapart um Fet al Monit oring Guidelines
ht t ps://www.figo.org/news/available-view-figo-int rapart um-f et al-monit oring-guidelines-0015088

7.2 Obstructed labour

Active labour which lasts longer than 24 hours, sometimes several days with insurmountable barrier
preventing the foetal descent.

7.2.1 Diagnosis
– Patient dazed, anxious, agitated, in pain
– Dehydration and possible hypovolaemic shock
– Possible distended bladder
– Imminent uterine rupture (pathological retraction ring, hourglass shape, see Chapter 3, Section 3.3)
– Frequent amniotic infection (fever, foul-smelling amniotic fluid)

On vaginal examination:
– Oedema of the cervix.
– Depending on the presentation:
• Vertex: caput that may reach the vaginal opening, but vertex itself not engaged and pelvis seems
narrow;
• Breech: retention of aftercoming head;
• Transverse: neglected shoulder, prolapsed arm and hand.

– Foetus often dead or in life-threatening condition.

7.2.2 Possible causes

– Foeto-pelvic disproportion (including malpresentations).
– Pushing with an incompletely dilated cervix.

7.2.3 Complications
– Uterine rupture.
– Intrauterine infection, septicaemia, peritonitis.
– Compression injuries to the bladder and rectum, leading to the formation of fistulae.
– High maternal and foetal mortality.

7.2.4 Management
– Insert an IV line (16-18G catheter), fluid resuscitation (Ringer lactate or 0.9% sodium chloride).
– Insert a Foley catheter, if it is possible without damaging the urethra. Otherwise, insert suprapubic
catheter. Relieving the bladder distension is sometimes enough to produce delivery.
– Depending on the cause of the obstruction and the medical equipment available:
• T he foetus is alive and viable: caesarean section.
• T he foetus is non-viable or if there is no possibility of caesarean section: symphysiotomy, episiotomy
and vacuum extraction.
• T he foetus is dead: embryotomy (Chapter 9, Section 9.7).
– Antibiotherapy for prolonged rupture of membranes or a rupture of unknown duration (Chapter 4,
Section 4.9) or for intrauterine infection (Chapter 11, Section 11.4.2).
– T here is a significant risk of postpartum haemorrhage due to uterine atony: if active management of
third stage labour fails, quickly perform manual removal of placenta (Chapter 9, Section 9.2) then,
administer oxytocin (Haemorrhage due to uterine atony, Table 7.2).
– Speculum examination: if tissue necrosis, excision under sterile conditions.
– Perineal and vulvar toilet 2 times daily.

7.2.5 Prevention/management of vaginal fistulae a

– Encourage the patient to drink 4 to 5 litres of water daily.

– Leave the Foley catheter in place for 14 days, then:
• If there is no fistula: remove the Foley catheter.
• If the fistula is ≤ 4 cm diameter, attempt conservative treatment. Leave the Foley catheter in place
for at least 4 to 6 weeks to allow fistula to heal. Keep the catheter in place as long as the fistula is not
closed and as long as a gradual decrease of its diameter is observed at each weekly inspection.
• If the fistula is > 4 cm diameter or the conservative treatment fails or the patient has fistula for over 3
months, refer or register the patient for surgical treatment.

Notas
(a) For more inf ormat ion: Obst et ric Fist ula - Guiding principles f or clinical management and programme
development . World Healt h Organizat ion, Geneva 2006.
ht t p://whqlibdoc.who.int /publicat ions/2006/9241593679_eng.pdf ?ua=1

7.3 Labour induction

Triggering labour artificially before it begins naturally.

Broadly speaking, induction is a two-step sequence: the first part involves cervical ripening
(effacement, mid-position, early dilation), the second, induction of contractions that dilate the cervix.

7.3.1 Indications
Induction of labour is not an emergency procedure. It should be done only when there is a clear
indication, in a CEmONC facility (refer if necessary) to allow rapid intervention in the event of
complications (e.g., uterine rupture or foetal distress).

When referral to a CEmONC facility is not possible or there is limited (or no) foetal monitoring,
indications are restricted to the following situations:
– Intrauterine foetal death (Chapter 4, Section 4.11);
− Maternal indication for termination of pregnancy and non-viable foetus;
− Severe pre-eclampsia and eclampsia (Chapter 4, Section 4.5 and Section 4.6);
− Premature rupture of membranes with infection (Chapter 4, Section 4.9).

Note: pregnancy over 41 weeks LMP is traditionally considered an indication for inducing labour. T his
indication is only applicable if the due date is known with certainty.

7.3.2 Methods [1]

Administration of prostaglandins
misoprostol PO: one 25 microgram tablet every 2 hours until good contractions are obtained; max. 8
doses or 200 micrograms per 24 hours
Wait 4 hours after the last dose of misoprostol before using oxytocin during labour.

Notes:
– If 25 microgram misoprostol tablets are not available, dissolve a 200 microgram tablet of
misoprostol in 200 ml of water and administer 25 ml of this solution (25 ml = 25 micrograms).
– T he oral route should be preferred [2] . If oral administration is not possible (vomiting, impaired
consciousness), use vaginal route (25 micrograms of misoprostol into the posterior fornix every 6
hours until good contractions are obtained).
– Note, in the event of intrauterine foetal death, dose of misoprostol may be different depending on
gestational age: see Chapter 4, Section 4.11.

Artificial rupture of membranes and administration of oxytocin

Artificial rupture of membranes (Chapter 5, Section 5.3) is performed while applying gentle pressure (if
needed) on the head through the abdomen to prevent cord prolapse.

Administration of oxytocin alone

T his is not as effective as the other methods, but may be used in the following situation:
– Prostaglandins not available or contra-indicated;
– Bishop score ≥ 6 (Table 7.1);
– Artificial rupture of membranes not feasible because the foetal head is too high.
– Artificial rupture of membranes not recommended (HIV infected patient, breech presentation).
Mechanical method using a Foley catheter balloon
Wear sterile gloves. With a speculum in place, insert a 16-18G Foley catheter into the cervical canal,
guiding it with fingers or forceps.
Inflate the balloon with sterile water until it is well inflated in the cervix (30-50 ml) and apply continuous
light pressure (catheter taped to the inner thigh) for 12 to 24 hours.

Notes:
– Limited evidence supports simultaneous use of a Foley catheter and oxytocin as a safe and
effective method for induction of labour. [3]
– A Foley catheter should only be used simultaneously with a uterotonic, if delivery cannot be delayed
(e.g. eclampsia). In this case, misoprostol should be preferred. [4] [5]

Stripping the membranes

During the vaginal examination, if the cervix is open, insert one finger into the internal os and separate
the membranes with a circular motion. T his can help start labour, or at least cervical ripening, in the
following hours or days.

7.3.3 Conditions
T he choice of induction method depends on the initial degree of cervical ripening. T he riper the cervix,
the more effective and rapid the induction.
Assessment of the cervix is facilitated by a scoring system for cervical ripening: the Bishop score.

Table 7.1 - Bishop score (the higher the score, the riper the cervix)

Criteria 0 1 2 3

1 finger 2 fingers > 2 fingers

Cervical dilation (at the internal os) closed
(< 2 cm) (2-3 cm) (≥ 4 cm)

long mid-length short effaced

Cervical length
(≥ 4 cm) (2-4 cm) (1-2 cm) (< 1 cm)

Position of the foetal head relative to

–3 –2 –1 or 0 +1 or +2
the ischial spines, in cm (foetal station)

Cervical consistency firm medium soft –

Cervical position posterior mid position – –

T he cervix is considered ripe, that is, favourable to induction, if the score is 6 or greater. Labour is
induced by artificially rupturing the membranes and administering oxytocin.

If the cervix is unfavourable or unripe (score below 6, with at most a long, firm, posterior cervix), ripen
the cervix using a prostaglandin before triggering contractions with oxytocin or, if prostaglandins are
not available or contra-indicated, use a mechanical method and then oxytocin.

7.3.4 Special situations

– Scarred uterus:
• Foetus alive and viable: prostaglandins are contra-indicated:
- the cervix is favourable: artificial rupture of membranes and oxytocin.
- the cervix is unfavourable: mechanical induction and oxytocin or caesarean section.
For precautions for use of oxytocin see Section 7.4.4. It is contra-indicated in women with 2 or more
uterine scars.
• Foetus alive but non-viable: as for intrauterine foetal death.

– Grand multiparity and/or overdistended uterus:

For precautions for use of oxytocin see Section 7.4.4.
Whatever method used, induction of labour should be approached with caution as there is a risk of
uterine rupture.

– Intrauterine foetal death: Chapter 4, Section 4.11.

Referencias
1. Word Healt h Organizat ion. WHO recommendat ions f or induct ion of labour. Geneva, 2011.
ht t p://whqlibdoc.who.int /publicat ions/2011/9789241501156_eng.pdf ?ua=1

2. Chen W, Xue J, Peprah MK, Wen SW, Walker M, Gao Y, Tang Y. A syst emat ic review and net work met a-
analysis comparing t he use of Foley cat het ers, misoprost ol, and dinoprost one f or cervical ripening in t he
induct ion of labour. BJOG. 2016 Feb;123(3):346-54.
ht t ps://obgyn.onlinelibrary.wiley.com/doi/f ull/10.1111/1471-0528.13456

3. A. Dhanya Mackeen; Danielle E. Durie; Monique Lin; Christ opher K. Huls; Emma Qureshey; Michael J. Paglia;
Haiyan Sun; Ant hony Sciscione. Foley Plus Oxyt ocin Compared Wit h Oxyt ocin f or Induct ion Af t er
Membrane Rupt ure: A Randomized Cont rolled Trial. Obst et rics & Gynecology. 131(1):4–11, JAN 2018.

4. Levine LD, Downes KL, Elovit z MA, Parry S, Sammel MD, Srinivas SK. Mechanical and
Pharmacologic Met hods of Labor Induct ion: A Randomized Cont rolled Trial. Obst et Gynecol. 2016
Dec;128(6):1357-1364.

5. Al-Ibraheemi Z , Brust man L, Bimson BE, Porat N, Rosenn B. Misoprost ol Wit h Foley Bulb Compared
Wit h Misoprost ol Alone f or Cervical Ripening: A Randomized Cont rolled Trial. Obst et Gynecol. 2018
Jan;131(1):23-29.
7.4 The use of oxytocin during labour

7.4.1 Indications
– Induction of labour.
– Correction of a dynamic dystocia: delayed dilation in a woman in active phase of labour, with arrest
for more than 4 hours, due to inadequate uterine contractions. T he membranes must have been
ruptured.
– Contractions fail to resume 15 minutes after the birth of a first twin.

7.4.2 Risks of using oxytocin during labour

– Maternal risk: uterine rupture, especially in a scarred uterus, but in a unscarred uterus as well,
particularly if it is overdistended (multiparity, polyhydramnios, multiple pregnancy) or if there is major
foeto-pelvic disproportion.
– Foetal risk: foetal distress due to uterine hypertony (uterine contraction without relaxation).

7.4.3 Contra-indications to the use of oxytocin during labour

– Obvious foeto-pelvic disproportion, including malpresentation (brow, transverse, etc.).
– Complete placenta praevia.
– Spontaneous uterine hypertony.
– Foetal distress.
– Two or more prior caesarean sections.
– Prior classical caesarean section (vertical uterine incision).
– Absence of indication.

7.4.4 Situations requiring special precautions

– Prior single low transverse caesarean section.
– Grand multiparity (5 deliveries or more).
– Overdistended uterus.

T hese factors increase the risk of uterine rupture. Oxytocin may be used provided the following
precautions are respected:
1. maximum infusion rate of 30 drops/minute for 5 IU in 500 ml (i.e. 15 milli-units per minute);
2. assess maternal and foetal status before every dosage increase;
3. interval of at least 30 minutes between dose increases;
4. do not increase dosage (possibly even decrease dosage) if satisfactory uterine contractions and
progress of cervical dilation.
7.4.5 Conditions for oxytocin use
– Given the risk to both mother and foetus, use of oxytocin during labour requires:
• close maternal monitoring (check for hyperstimulation, dystocia and imminent rupture at least every
30 minutes);
• close foetal monitoring (check for decelerations in heart rate at least every 30 minutes);
• proximity to an operating theatre, in order to perform prompt caesarean section if needed.
– Position the patient on her left side.

In the event of foetal distress, uterine hyperkinesia (more than 5 contractions in 10 minutes) or uterine
hypertony (absence of uterine relaxation): stop the oxytocin.
After delivery, however, there is no risk of uterine rupture or foetal distress, and oxytocin can be used
more readily.
Table 7.2 - Use of oxytocin
Indications Before Technique Monitoring
administration during
administration

During labour

Labour • On vaginal Dilute 5 IU in 500 ml or 10 IU in 1 litre of • Appearance

induction exam, assess Ringer lactate or 0.9% sodium chloride and quality of
cervical dilation to obtain a solution of 10 milliunits per contractions,
and effacement, ml. uterine
and engagement Start at 5 drops/minute, then increase relaxation.
(Bishop score ≥ by 5 drops/minute every 30 minutes, until • Foetal heart
6, Table 7.1). contractions are effective (3 to 4 rate.
• Verify the contractions of more than 40 seconds • General
absence of in 10 minutes). condition of the
foetal distress. On average, 20 drops/minute results in mother.
satisfactory uterine contractions. Do • Cervical
not exceed 60 drops/minute. dilation.
Once the neonate has delivered: use the Rupture the
existing IV line to administer the membranes as
appropriate dose of oxytocin for soon as possible.
prevention of postpartum haemorrhage; If the woman has
let the current infusion finish. not gone into
labour after 12
hours: stop the
infusion and
consider
caesarean
section.

Correction of • Cervix at least 5 As for labour induction. • Resumption or

dynamic cm on vaginal augmentation of
dystocia exam. contractions,
• Spontaneous or uterine
artificial rupture relaxation.
of membranes. • Foetal heart
• No foeto-pelvic rate.
disproportion. • General
condition of the
mother.
• Cervical
dilation.
 No Verify that • Start or resume oxytocin infusion. • Resumption or
contractions presentation is • As for labour induction, but increase more augmentation of
15 minutes vertical (not rapidly: by 5 drops every 5 minutes. contractions,
after the birth transverse). uterine
of first twin relaxation.
• Foetal heart
rate.

Note: outside of labour, oxytocin is use as below

Haemorrhage • First, manually IV infusion over 2 hours of 20 IU in 1 litre of • Heart rate,

due to uterine remove the Ringer lactate or 0.9% sodium chloride blood pressure,
atony placenta, if (160 drops/minute). At the same time, give 5 blood loss.
needed. to 10 IU by slow IV injection; repeat if • Uterine
• Routine uterine necessary until the uterus becomes firm retraction.
exploration. and contracted (max. 60 IU total dose).

After 10 IU by slow IV injection after clamping the Uterine

caesarean cord then IV infusion over 2 hours of 20 IU retraction.
section in 1 litre of Ringer lactate or 0.9% sodium
chloride (160 drops/minute).

Prevention of Verify that there 5 to 10 IU by slow IV or IM injection, before

postpartum is no second twin. or after the third stage, depending on staff
haemorrhage expertise.

7.5 Shoulder dystocia

Delivery cannot progress after the head is out, because the shoulders are impacted in the pelvis.

T his is a life-threatening emergency for the foetus (distress, rapid death by asphyxiation).

Additional assistants are required. Explain the situation to the assistants and the patient to obtain their
cooperation.

7.5.1 Management
T he HELPERR mnemonic is a useful tool for addressing this emergency [1] :
 H Call for Help

E Evaluate for Episiotomy

L Legs (the McRoberts manoeuvre)

P Suprapubic Pressure

E Enter manoeuvres (internal rotation)

R Remove the posterior arm

R Roll the patient

H: Call for help.

E: Evaluate for episiotomy

Episiotomy is not routinely needed since the shoulder is impacted on the bony pelvis.
However, it can be performed to make more room for manoeuvres.

T he recommended time for attempting manoeuvres is 30 to 60 seconds each. An assistant should

inform the operator how much time has passed.

L: McRoberts manoeuvre (hyperflexion of the mother's thighs)

Ask two assistants to push the patient’s knees firmly toward her chest. T his manoeuvre alone is
effective in releasing a shoulder in more than 70% of cases.

P: Suprapubic pressure
While maintaining the hyperflexion of the thighs, an assistant presses firmly just above the symphysis
pubis to try to reduce the diameter of the shoulders and lower the anterior shoulder under the
symphysis while the operator applies continuous downward traction on the foetal head. Do not apply
fundal pressure, as this will impact the shoulder and can result in uterine rupture.
E: Internal manoeuvres
If this fails, perform internal rotation manoeuvres while maintaining the hyperflexion of the thighs. T here
are several options, depending on whether there is easier access to the anterior or posterior shoulder:
– Rubin’s manoeuvre: insert the fingers of one hand behind the anterior shoulder and push toward the
foetal chest to try to free the shoulder.
− Wood’s corkscrew manoeuvre, to be combined with Rubin’s manoeuvre: place two fingers of the
free hand against the front of the posterior shoulder and apply pressure to free the shoulders by
turning (in a corkscrew manner).
− Reverse Wood’s corkscrew manoeuvre: similar, but rotating in the opposite direction.

R: Remove the posterior arm

If this fails, bring down one foetal arm to reduce the diameter of the shoulders and allow delivery:
– Kneel to get the proper axis of traction.
– Reach in to find the posterior arm, and bring it to the vaginal opening: slide the whole hand behind the
foetus' head and move it along his posterior arm up to his elbow (if the back of the foetus is toward
the operator's right side, the left hand is used, if the back is toward the operator’s left side, the right
hand is used). Bend the arm and grasp the forearm or wrist and draw across the foetal chest to the
vaginal opening. T he delivery can then continue.

R: Roll the patient onto her hands and knees

Roll the patient to “all-fours position”. T he pelvic diameters increase in this position.

Carefully examine the vagina after these manoeuvres, since lacerations are common.

Above all, do not:

– Apply excessive traction to the foetal head, as this can rupture the brachial plexus on the side
of the anterior shoulder.
– Pivot the head by twisting the neck, as this can also cause neurological injury.

7.5.2 Methods of last resort

– General anaesthesia to relax the muscles.
– Fracture of the foetal clavicle by direct pressure on the middle part of the clavicle (difficult to
perform deliberately).
– Symphysiotomy (Chapter 5, Section 5.7).
– Embryotomy in case of foetal death and failure of the manoeuvres (Chapter 9, Section 9.7).
– Push the head back in (very difficult), then perform caesarean section.

Referencias
1. Elizabet h G. Baxley, Robert W. Gobbo. Shoulder Dyst ocia. Am Fam Physician. 2004 Apr 1;69(7):1707-1714.
ht t p://www.aaf p.org/af p/2004/0401/p1707.ht ml
7.6 Transverse lie and shoulder
presentation
A transverse lie constitutes an absolute foeto-pelvic disproportion, and vaginal delivery is impossible.

T his is an obstetric emergency, because labour is obstructed and there is a risk of uterine rupture and
foetal distress.

7.6.1 Diagnosis
– T he uterus is very wide: the transverse axis is virtually equivalent to the longitudinal axis; fundal height
is less than 30 cm near term.
– On examination: head in one side, breech in the other (Figures 7.1a and 7.1b). Vaginal examination
reveals a nearly empty true pelvis or a shoulder with—sometimes—an arm prolapsing from the vagina
(Figure 7.1c).

Figures 7.1 - Transverse lie and shoulder presentation

7.1a - Dorso-inferior (back down) left shoulder 7.1b - Dorso-superior (back up) left shoulder
presentation presentation
7.1c - Neglected shoulder presentation

7.6.2 Possible causes

– Grand multiparity (5 deliveries or more)
– Uterine malformation
– Twin pregnancy
– Prematurity
– Placenta praevia
– Foeto-pelvic disproportion

7.6.3 Management
T his diagnosis should be made before labour begins, at the last prenatal visit before the birth.

At the end of pregnancy

Singleton pregnancy
– External version 4 to 6 weeks before delivery, in a CEmONC facility (Section 7.7).
– If this fails, delivery should be carried out by caesarean section, either planned or at the beginning of
labour (Chapter 6, Section 6.4.1).

Twin pregnancy
– External version is contra-indicated.
– If the first twin is in a transverse lie (unusual): schedule a caesarean section.
– If the second twin is in a transverse lie: there is no indication for caesarean section, but plan delivery
in a CEmONC facility so that it can be performed if necessary. Deliver the first twin and then, assess
the foetal position and give a few minutes for the second twin to adopt a longitudinal lie. If the second
twin stays in a transverse lie, and depending on the experience of the operator, perform external
version (Section 7.7) and/or internal version (Section 7.8) on the second twin.

During labour, in a CEmONC facility

Foetus alive and membranes intact
– Gentle external version, between two contractions, as early as possible, then proceed as with normal
delivery.
– If this fails: caesarean section.

Foetus alive and membranes ruptured

– Complete dilation:
• Multipara with relaxed uterus and mobile foetus, and an experienced operator: internal version and
total breech extraction.
• Primipara, or tight uterus, or immobile foetus, or engaged arm, or scarred uterus or insufficiently-
experienced operator: caesarean section.

– Incomplete dilation: caesarean section.

Caesarean section can be difficult due to uterine retraction. Vertical hysterotomy is preferable. To
perform extraction, grasp a foot in the fundus (equivalent to a total breech extraction, but by
caesarean section).

Foetus dead
Embryotomy for transverse lie (Chapter 9, Section 9.7.7).

During labour, in remote settings where surgery is not available

Foetus alive and membranes intact
Try to refer the patient to a CEmONC facility. If not feasible:
– Attempt external version as early as possible.
– If this fails, wait for complete dilation.
– Perform an external version (Section 7.7) combined with an internal version (Section 7.8), possibly
placing the woman in various positions (Trendelenburg or knee-chest).

Foetus alive and membranes ruptured

Try to refer the patient to a CEmONC facility. If not feasible:
– Complete dilation:
• Put the woman into the knee-chest position.
• Between contractions, push the foetus back and try to engage his head.
• Vacuum extraction (Chapter 5, Section 5.6.1) and symphysiotomy (Chapter 5, Section 5.7) at the
slightest difficulty.
– Incomplete dilation: Trendelenburg position and watchful waiting until complete dilation.

Foetus dead
Try to refer the patient, even if referral takes some time.
If not feasible, embryotomy for transverse lie (Chapter 9, Section 9.7.7).

7.7 External version

A procedure to convert:
– a transverse lie into a longitudinal (cephalic or breech) presentation,
or
– a breech presentation into a cephalic presentation.

7.7.1 Conditions
– Pregnancy near term (37 weeks LMP)
– Prior to labour, or at the very start of labour
– Relaxed uterus
– No obstacle to vaginal delivery
– Membranes intact

External version is very rarely associated with complications. Complications have, however, been
reported (placental abruption, rupture of a scarred uterus and foeto-maternal haemorrhage).
T herefore, this manoeuvre should only be attempted in a CEmONC facility.

7.7.2 Contra-indications
Absolute
– Placenta praevia or other obstacle to vaginal delivery (tumour, fibroid)
– Twin pregnancy (for the first twin)

Relative
– Foetal distress
– Severe intrauterine growth restriction
– Prematurity
– Scarred uterus
– Untreated HIV infection

Note: in the event of transverse lie when referral is not possible, in the interest of the mother external
version may be attempted to permit vaginal delivery, without taking into account relative contra-
indications.

7.7.3 Technique
– Woman lying on her back, legs half bent, bladder empty.
– Perform when the uterus is relaxed.
– First, push back the breech or shoulder, which is often down in the pelvis (vertical movement), then
attempt rotation slowly, and always in the direction of foetal flexion: thus bringing either the head or
the breech to the pelvic inlet by the shortest possible route (Figures 7.2).
– Monitor the foetal heart rate after each attempt, and stop if the rate slows. In most cases, foetal
heart rate abnormalities improve within 30 minutes.

Figures 7.2 - Version to convert a breech presentation to a cephalic presentation

7.8 Internal version

Manual intrauterine procedure to convert one presentation to another, usually a transverse lie into a
breech.

7.8.1 Indications and conditions

– Shoulder presentation during labour, at complete dilation with a relaxed uterus. T his manoeuvre
should be performed with extreme caution (risk of uterine rupture).
– Delivery of a second twin in cephalic presentation or transverse lie: version to bring the foetus into
the breech position and allow a total breech extraction (Chapter 6, Section 6.3).
– Conditions necessary in all cases: normal pelvis, presenting part not engaged, bladder empty.
– Grasping one or both feet is best done through membranes that have been left intact [1] .

7.8.2 Technique
– Strict asepsis: swab perineum with 10% povidone iodine, wear sterile gloves.
– Perform spinal anaesthesia if possible.
– Insert the hand and determine the position of the foetus:
• with the fingers in the form of a cone, go through the vaginal opening and the cervix toward the
fundus;
• hold the fundus in place with the other hand on the abdomen.
– Grasp one foot or, if possible, both feet, firmly, without haste but not too slowly, since a prolonged
manoeuvre might cause the uterus to contract (Figure 7.3a). It is better not to rupture the membranes
immediately because the uterine retraction and lack of amniotic fluid will make it difficult to grasp and
move the foetus. T he membranes will spontaneously rupture when pulling the foot or will be artificially
ruptured once the foot is down.
– Pull the foot/feet gently to the vaginal opening (Figure 7.3b).
– T he delivery then continues normally as a breech delivery. For the second twin proceed with total
breech extraction (Chapter 6, Section 6.3).
– Manually explore the uterus after delivery of the placenta (to look for uterine rupture), and administer
routinely antibiotic prophylaxis (cefazolin or ampicillin slow IV: 2 g single dose) a .

Figures 7.3 - Internal version

7.3a - Catch hold of one foot (preferably both feet)

7.3b - Bring the foot/feet down to the vaginal opening

Notas
(a) For pat ient s wit h a hist ory of immediat e hypersensit ivit y react ion t o penicillin (urt icaria, respirat ory
problems or oedema): clindamycin IV 900 mg single dose + gentamicin IV 5 mg/kg single dose.

Referencias
1. J Rabinovici, G Barkai, B Reichman, D M Serr, S Mashiach. Int ernal podalic version wit h unrupt ured
membranes f or t he second t win in t ransverse lie. Obst et rics and Gynecology; 1988; 71(3 Pt 1):428-30.

7.9 Face presentation

7.9.1 Diagnosis
– Palpation of the mother's abdomen at the start of labour: palpate the occipital region; a cleft
between the head and the back will be palpable, due to hyperextension of the head.
– On vaginal examination: no suture or fontanelle can be felt; orbits, nose, mouth, ears and chin
palpable. Palpation of the chin is essential to confirm the diagnosis.

7.9.2 Management
Determine the orientation of the chin—anterior (at the mother's pubis) or posterior.

The chin is anterior

Vaginal delivery is possible. Labour may be slow, patience is required.
If uterine contractions are inadequate, oxytocin may be used.
Episiotomy is usually needed during delivery (Figures 7.4), given the maximum amount the perineum can
stretch.
If instrumental delivery is necessary, use forceps. Vacuum extraction is contra-indicated for a live
fœtus.

Figures 7.4 - Chin anterior: delivery possible

The chin is posterior

Vaginal delivery is not possible (Figure 7.5). A caesarean section must be arranged. Refer if necessary.

Figure 7.5 - Chin posterior: impaction

If caesarean section is not feasible and referral is not possible, attempt the following manoeuvres:

– Flex the head to obtain a vertex presentation: with one hand in the vagina, grasp the top of the skull
and flex the neck, using the other hand, on the abdomen, to apply pressure to the foetal chest and
buttocks. Obviously, the presenting part must not be engaged, and it is often hard—or impossible—to
keep the head flexed (Figures 7.6).

Figures 7.6 - Manoeuvre to convert face to vertex presentation

– Rotate the head to bring the chin anteriorly: push the face and chin back to free the shoulders from
the pelvic inlet then, turn the head within the pelvic cavity, using a hand on the abdomen to help the
rotation by applying pressure to the shoulders. In this way, the chin is brought to the front (Figures 7.7).

Figures 7.7 - Rotation manoeuvre to bring the chin anteriorly

– Version: internal podalic version, then total breech extraction (Figure 7.8).
Figure 7.8 - Internal podalic version

All these manoeuvres are difficult and pose a significant risk of uterine rupture. T hey must be done
when the uterus is not contracting. Whenever possible, caesarean section should be performed
instead.

7.10 Brow presentation

Brow presentation constitutes an absolute foeto-pelvic disproportion, and vaginal delivery is
impossible (except with preterm birth or extremely low birth weight).

T his is an obstetric emergency, because labour is obstructed and there is a risk of uterine rupture and
foetal distress.

7.10.1 Diagnosis
– Head is high; as with a face presentation, there is a cleft between the head and back, but it is less
marked.
– On vaginal examination the brow, orbits, anterior fontanelle and, occasionally, the eyes and bridge of
the nose are palpable (Figures 7.9). But it is not possible to palpate:
• the chin (it is not a face presentation),
• the posterior fontanelle (it is not a vertex presentation).
Figures 7.9 - Brow presentation

Any mobile presenting part can subsequently flex. T he diagnosis of brow presentation is, therefore, not
made until after the membranes have ruptured and the head has begun to engage in a fixed
presentation. Some brow presentations will spontaneously convert to a vertex or, more rarely, a face
presentation.

During delivery, the presenting part is slow to descend: the brow is becoming impacted.

7.10.2 Management
Foetus alive
– Perform a caesarean section. When performing the caesarean section, an assistant must be ready
to free the head by pushing it upward with a hand in the vagina.

– As a last resort, if caesarean section is impossible, attempt two manoeuvres:

• Convert the brow presentation to a face presentation: between contractions, insert the fingers
through the cervix and move the head, encouraging extension (Figures 7.10).
• Attempt internal podalic version (Section 7.9).

Both these manoeuvres pose a significant risk of uterine rupture. Vacuum extraction, forceps and
symphysiotomy are contra-indicated.
Figures 7.10 - Manoeuvre to convert brow to face presentation

Foetus dead
Perform an embryotomy if the cervix is sufficiently dilated (Chapter 9, Section 9.7) otherwise, a
caesarean section.

Chapter 8: Third stage of labour

8.1 Normal third stage of labour

8.2 Early postpartum haemorrhage

8.3 Late postpartum haemorrhage

8.4 Uterine inversion

8.5 Cervical and vaginal tears

8.1 Normal third stage of labour

T he third stage of labour refers to the period that starts immediately after delivery of the infant and
ends with the completed delivery of the placenta and its attached membranes.
T here is a significant risk of haemorrhage during this stage. All patients require close monitoring and
routine prevention of postpartum haemorrhage (PPH).

8.1.1 Description
T his stage usually lasts 5 to 15 minutes.

– After the infant is delivered, there is a rest period without contractions that lasts, on average, 10
minutes. Use this time to take care of the neonate. Watch the mother carefully, however, for signs of
PPH, which can occur at any time.
– T hen, contractions resume, the placenta separates spontaneously. On abdominal palpation the
uterine fundus can be felt ascending and then descending again, corresponding to the
migration/descent of the placenta. When the entire placenta has reached the vagina, the uterus
retracts and forms a hard ball above the pubic bone.
– T he blood loss accompanying delivery of the placenta should not exceed 500 ml.

In the absence of PPH, a maximum delay of 30 to 45 minutes is tolerated for the expulsion of the
placenta. After that, the placenta should be removed manually (Chapter 9, Section 9.2).

8.1.2 Routine prevention of postpartum haemorrhage

Active management of third stage of labour
Active management of third stage of labour consists in the administration of oxytocin before placental
expulsion, followed by controlled cord traction then uterine massage to help retraction of the uterus.

After the birth, palpate the mother's abdomen to be sure she is not carrying twins. Administration of 5
or 10 IU oxytocin slow IV or IM immediately after the birth (after the birth of the last infant in a multiple
pregnancy) AND before delivery of the placenta accelerates separation of the placenta, facilitates its
delivery and helps prevent PPH.

T hen, after clamping and cutting the cord, deliver the placenta with controlled cord traction (during a
contraction with counter pressure to the uterus, with a hand placed on the abdomen). Uncontrolled
traction on the cord (i.e., done without a contraction or counterpressure) is contra-indicated, as it can
cause tearing of the placenta and, afterwards, retention of placental fragments with risk of bleeding
and infection.

When oxytocin is used prior to placental delivery, there is, in theory, and especially if the injection is not
done immediately (i.e. within 3 minutes), a risk of retained placenta. For this reason, the birth attendant
who administers oxytocin immediately after birth must be able to perform manual removal of the
placenta, should it be necessary. If these conditions are not met, oxytocin should be administered
after placental expulsion.

Administration of oxytocin after placental delivery

If oxytocin has not been given prior to placental delivery, it should be administered after the placenta
has been completely delivered. However, this is less effective in preventing PPH.
oxytocin slow IV or IM: 5 or 10 IU

Uterine exploration to remove any placental fragments will be more difficult after injecting oxytocin. Be
sure that the placenta is complete before administering oxytocin.
In addition, massage the uterus to help uterine retraction.

8.1.3 Monitoring
– Heart rate, blood pressure, the amount of blood loss, while waiting for the placenta to deliver and
after placental expulsion (every 15 minutes for the first hour, then every 30 minutes for the next hour)
as the risk of PPH persists.
– Placental separation: press down on the abdomen just above the pubic bone. If the cord does not
retract when pressure is applied, the placenta has separated (Figure 8.1). To facilitate expulsion from
the vagina if it seems to be going slowly after the separation, apply moderate pressure to the uterine
fundus, directed toward the vagina.
– T he uterus retracts and remains retracted.

Figure 8.1 - Placental separation has occurred if the cord fails to retract with abdominal pressure

8.1.4 Examination of the placenta

Examine the placenta to verify that it has been completely expelled. T he uterus can only retract
properly if it is empty. Sooner or later, retained debris will lead to haemorrhage or infection.

Examination of the membranous sac

Straighten the sac by inserting a hand into it, looking for a vessel that ends abruptly— indicating that
there might be a succenturiate lobe remaining in the uterus—or for a tear pointing to retained
membrane. In these cases, manual uterine exploration may be required (Chapter 9, Section 9.3).

Examination of the maternal surface of the placenta

Regular, bright red cotyledons. Any holes, roughened or depressed areas, or any deep cuts that fail to
line up when the cotyledons are brought together may suggest retained placenta, requiring uterine
exploration.

8.2 Early postpartum haemorrhage

Early postpartum haemorrhage is defined as bleeding that occurs within 24 hours (usually immediately)
after delivery of the placenta. T he volume exceeds the normal 500 ml third stage blood loss.

Close delivery room monitoring is crucial for 2 hours post-partum, in order to rapidly identify and treat
postpartum haemorrhage (PPH).
Blood loss is often underestimated (up to 50%).
Delay in treatment can lead to coagulation disorders, with a risk of massive, diffuse bleeding.

T he four main causes of PPH are:

– Uterine atony (70% of cases): the placenta has been expelled, but the uterus fails to retract. T he
uterus gets larger, extends, and becomes soft. Factors for uterine atony include: overstretching
(polyhydramnios, multiple pregnancy, foetal macrosomia), prolonged labour and infection
(chorioamniotitis). It can be the cause or an aggravating factor of the PPH.
– Obstetric trauma (20% of cases): uterine rupture, particularly in case of vaginal delivery in women
with a scarred uterus but also in women without uterine scarring; cervical and vaginal
lacerations; uterine inversion.
– Retained placenta (10% of cases): the entire placenta or a fragment of the placenta remains in the
uterus.
– Coagulation disorders (< 1% of cases): see Chapter 3, Section 3.2.2.

8.2.1 Management during the first 30 minutes

– Ask for help as resuscitation measures and obstetric management must be performed in parallel.
– Record in a chart: results of the initial evaluation, monitoring and actions, indicating the times.

Table 8.1 - Initial management

 Resuscitation Initial obstetric management

− Lay the patient flat. – Evaluate and monitor blood loss.

− Monitor: blood pressure – Remove the placenta manually if it has not yet delivered.
(BP), heart rate, – Perform uterine massage to expel any clots and aid uterine
consciousness, respiratory contraction (to be repeated every 15 minutes for the first 2 hours
rate, SpO2 (if available). after PPH).
Objectives: systolic BP ≥ 90 – Insert a Foley catheter: keeping bladder empty facilitates uterine
mmHg, SpO2 ≥ 95%, normal retraction.
level of consciousness, urine – Perform uterine exploration to remove any blood clots or
output ≥ 30 ml/hour. placental fragments and check for absence of uterine rupture.
– If systolic BP < 90 mmHg, – Administer oxytocin to correct potential uterine atony or ensure
elevate the legs (keep, or uterine retraction: 5 to 10 UI by slow IV then, start an IV infusion
replace, the patient's feet in with 20 IU in 1 litre of Ringer lactate or 0.9% sodium chloride,
the delivery table stirrups). administered over 2 hours (160 drops/minute).
– Insert 2 IV lines (catheter 16- − Inspect the birth canal, check for injury to the cervix or vagina
18G). using retractors.
– Fluid replacement: Ringer – If bleeding persists 15 minutes after initiating oxytocin and only if
lactate or 0.9% sodium uterine atony is suspected, administer:
chloride (1 litre in 15 minutes to misoprostol sublingually (b) : 800 micrograms [1] and/or
be repeated as required). methylergometrine IM: 0.2 mg
– Add 1 g of tranexamic acid
(in patient < 15 years, 15
mg/kg, max. 1 g) in the first litre
used for fluid resuscitation.
– Oxygen (15 litres/minute).
– Determine the patient’s
blood type, select potential
donors or make sure that
blood is available (a) .
– Measure haemoglobin level
(HemoCue).

(a) If t ransf usion is perf ormed, t he blood must have been t est ed (HIV-1, HIV-2, hepat it is B, hepat it is C and
syphilis, and malaria in endemic areas).
(b) If t he sublingual rout e is not f easible, administ er t he same dose rect ally.

8.2.2 Management of persistent haemorrhage

Table 8.2 - Management after the first 30 minutes
 Resuscitation Further obstetric management

− Continue fluid replacement. − In the event of persistent atony: insert an

− Administer a second dose of tranexamic intrauterine balloon(c) .
acid 30 minutes after the first dose: 1 g (15 − Additional measures if necessary (Section 8.2.3).
mg/kg in patient < 15 years, 1 g max.) in a − If bleeding continues, perform the following:
bag of 100 ml of 0.9% sodium chloride • Conservative surgical treatment:
administered over 15 minutes. Do not - Stepwise ligation of the uterine blood supply (round
administer further tranexamic acid. ligaments, utero-ovarian arteries, uterine arteries);
− Administer blood transfusion in dedicated - Uterine compression suture (B-Lynch or other type
vein if: suture) a
• massive haemorrhage (> 1500 ml), or • Radical surgical treatment: hysterectomy with
• haemodynamic instability, or adnexal preservation. Subtotal hysterectomy is
• coagulation disorders, or preferable, as it limits the operative time.
• haemoglobin ≤ 7 g/dl
Transfuse fresh whole blood or packed red
blood cells or whole blood + fresh frozen
plasma in the event of massive haemorrhage
and/or coagulation disorders.

(c) If an int raut erine balloon is insert ed in a BEmONC f acilit y, it is imperat ive t o t ransf er t he pat ient t o a
CEmONC f acilit y in order t o have surgical resources on hand should t hey be necessary.

8.2.3 Management of immediate massive haemorrhage

In the event of 150 ml of blood loss per minute or shock:

− Perform initial management as quickly as possible and do not wait 30 minutes to perform further
obstetric management (intrauterine balloon tamponade, surgical procedures).
− Start transfusion as quickly as possible.
− If necessary, perform one of the additional compression measures below.

Aortic compression
Apply pressure to the abdominal aorta (just above the umbilicus) until the femoral pulse is no longer
palpable, for example, the time it takes to insert an intrauterine balloon or start laparotomy (Figure 8.2).
Figure 8.2 - Aortic compression

Bimanual uterine compression (Figure 8.3 and Figure 8.4).

Figure 8.3 - Uterine compression between fingers in the vagina and a hand on the abdomen
Figure 8.4 - Uterine compression between the fist and a hand on the abdomen

8.2.4 Cause-specific management

If the following causes are identified, additional specific management is required.

Obstetric trauma
– Uterine rupture: Chapter 3, Section 3.3.
– Cervical or vaginal tears: Section 8.5.
– An episiotomy can bleed: temporarily stop arterial bleeding with a clamp and suture as quickly as
possible.
– Uterine inversion: Section 8.4.

Retained placenta
– Immediate manual removal if the placenta has not yet delivered and/or routine uterine exploration to
remove any clots or placental debris (allows good uterine retraction) and to verify that there was no
uterine rupture (for vaginal deliveries with a scarred uterus, in particular).
– Perform manual placenta removal and manual uterine exploration under anaesthesia. Do not proceed
without anaesthesia unless anaesthesia cannot be performed immediately.
– Give routine antibiotic prophylaxis (Chapter 9, Section 9.1.2).
– In rare cases, it is impossible to remove the placenta manually because there is no cleavage plane
between the placenta and the uterine wall (placenta accreta). In this event, refer for hysterectomy.

Coagulation disorders
– In the event of coagulation disorders, transfuse:
• fresh whole blood (blood freshly collected, for less than 4 hours, and that has not been refrigerated),
or
• packed red blood cells or whole blood + fresh frozen plasma.
– Coagulation disorders may be the cause and the result of PPH. Active management of PPH reduces
the risk of secondary coagulation disorders.

Notas
(a) For more inf ormat ion on B-Lynch sut ure: A Comprehensive Text book of Post part um Hemorrhage
2n d Edit ion. Sect ion 9, Chapt er 51: Therapy f or Non-at onic Bleeding, C. B-Lynch and H. Shah. Conservat ive
Surgical Management .
ht t p://www.glowm.com/pdf /PPH_2nd_edn_Chap-51.pdf

Referencias
1. World Healt h Organizat ion. WHO recommendat ions f or t he prevent ion and t reat ment of post part um
haemorrhage. Geneva, 2012.
ht t p://apps.who.int /iris/bit st ream/10665/75411/1/9789241548502_eng.pdf

8.3 Late postpartum haemorrhage

Excessive vaginal bleeding from 24 hours to 6 weeks after delivery.

8.3.1 Diagnosis
A combination of the following signs: foul-smelling vaginal bleeding, fever, a uterus that is soft and
larger than expected, general deterioration, anaemia.

8.3.2 Causes
– Retained placenta or blood clots with secondary infection (endometritis).
– Rarely, persistent trophoblastic disease or choriocarcinoma.

8.3.3 Management
– Admit to inpatient department.
– Administer immediately an antibiotherapy:
amoxicillin/clavulanic acid IV (dose expressed in amoxicillin): 1 g every 8 hours + gentamicin IM: 5
mg/kg once daily
or
ampicillin IV: 2 g every 8 hours + metronidazole IV: 500 mg every 8 hours + gentamicin IM: 5
mg/kg once daily

Continue until the fever disappears (at least for 48 hours), then change to:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin) to complete 5 days of treatment
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
or
amoxicillin PO: 1 g 3 times daily + metronidazole PO: 500 mg 3 times daily, to complete 5 days of
treatment

– Manually explore the uterus when cervical dilation permits, otherwise perform digital curettage
(Chapter 9, Section 9.4) or instrumental curettage with the widest curette available (Chapter 9, Section
9.6) and administer a uterotonic agent (oxytocin IM or slow IV: 5 to 10 UI, or, if not available,
methylergometrine IM: 0.2 mg or misoprostol sublingually: 800 micrograms).

8.4 Uterine inversion

Uterus turns inside-out, typically as the placenta is delivered. Usually due to uterine atony (grand
multiparity) or forceful traction on the cord.

8.4.1 Diagnosis
– Usually, intense pelvic pain with feeling of “something coming down” and haemorrhage of variable
severity, quickly followed by hypovolaemic shock.
– Uterine fundus not apparent on abdominal palpation, protrudes into the vagina, or protrudes from the
vaginal opening (Figures 8.5 and 8.6).
Figure 8.5 - T he inverted uterus does not reach the vaginal opening

Figure 8.6 - T he uterus is totally inverted and protrudes through the vaginal opening

8.4.2 Management
– Treat the shock and the haemorrhage immediately: see Resuscitation, Table 8.1. Blood transfusion in
the event of immediate massive haemorrhage.
– Administer tranexamic acid IV (Section 8.2.1) in the event of massive haemorrhage or if bleeding
persists after 15 minutes of initial management.
– Trendelenburg position (dorsal decubitus, head down).
– Insert a Foley catheter and monitor urine output.
– Perform general anaesthesia if possible.
– If uterotonic treatment is in progress, stop it long enough to reduce the inversion.
– Swab the perineum with 10% povidone iodine.
– If the placenta has not detached, do not perform manual removal until after reducing the inversion.
– While compressing the uterus, push it gradually back through the cervix with one hand (Figures 8.7),
toward the umbilicus, to return it to its normal position. Use the other hand, placed on the abdomen, to
hold the uterus in place.
– If necessary, explore the uterus (gently, to avoid recurrence) in order to remove any clots.
– Give routine antibiotic prophylaxis (Chapter 9, Section 9.1.2).
– Resume or start uterotonic treatment: oxytocin slow IV or IM: 5 or 10 IU (or, if not available,
methylergometrine IM: 0.2 mg or misoprostol sublingually: 800 micrograms).
Figure 8.7 - Manual reduction of the inverted uterus

If manual reduction of the uterus fails, consider abdominal surgery: reduction of the inversion with
possible section of the retracted oedematous cervix, or even delayed hysterectomy after necrosis
develops.

8.5 Cervical and vaginal tears

Tears occur during delivery, and are more common in cases of cervical oedema, large foetus, or
instrumental extraction (forceps or vacuum extractor).
A special sterile set containing vaginal retractors and long instruments should be available in every
maternity ward for exploration and treatment of deep cervical and vaginal tears.

8.5.1 Diagnosis
Suspect a tear in cases of postpartum haemorrhage where there is good uterine retraction and uterine
rupture has been ruled out.
T he source of the bleeding is discovered during inspection of the birth canal, with careful examination
of the vagina and cervix using two vaginal retractors.

8.5.2 Management
– Insert an IV line (16-18G catheter) and administer Ringer lactate or 0.9% sodium chloride.
– In the event of blood loss > 500 ml, see Section 8.2.
– If possible, perform spinal or general anaesthesia to get good exposure.
– An assistant is usually needed to present the tissues using retractors. Good lighting is essential.
– Swab the perineum with 10% povidone iodine.
– Gently pull the cervix toward the outside using atraumatic forceps (ring forceps, for example) and
assess the extent of the tears:
• Small cervical tear, minimal bleeding: should heal spontaneously with no suturing and without
complications.
• Larger cervical tear, heavy bleeding: a few Dec 3 (2-0) absorbable figure-of-eight sutures in a single
layer. Place the initial suture above the apex of laceration to control retracted arteries (Figure 8.8).
• T he vaginal walls should also be sutured in the event of a bleeding laceration. For multiple vaginal
lacerations with friable tissue that tears on suturing, insert a vaginal pack and remove after 24 hours.
Insert a Foley catheter while the pack is in place.
• If the tear extends up to the uterus (lower segment), transfer the patient to a surgical setting for
laparotomy.
Figure 8.8 - Cervical tear

Chapter 9: Intrauterine procedures

9.1 Precautions required for intrauterine procedures

9.2 Manual removal of the placenta

9.3 Uterine exploration

9.4 Digital curettage

9.5 Manual vacuum aspiration (MVA)

9.6 Instrumental curettage

9.7 Embryotomy

9.1 Precautions required for intrauterine

procedures
T here are 2 types of intrauterine procedures:
– Manual: manual removal of the placenta, uterine exploration, and digital curettage;
– Instrumental: manual vacuum aspiration (MVA), instrumental curettage, and embryotomy.

9.1.1 Precautions common to all intrauterine procedures

Bladder emptying
T his facilitates the procedure and reduces the risk of bladder injury.
– Have the patient urinate on her own.
– Insert a sterile urinary catheter only if the patient does not urinate on her own.

Asepsis
– Cleanse the vulva and perineum with the povidone iodine scrub (or, if not available, ordinary soap).
Rinse and dry. T hen, swab the vulva and perineum with 10% povidone iodine solution.
– Use sterile drapes, sterile compresses and sterile gloves (sterile gynaecological gloves, with long
cuffs, for manual procedures).

Anaesthesia
All procedures should be performed under anaesthesia. A procedure may be done without anaesthesia
on two conditions: it is a life-threatening emergency (e.g. postpartum haemorrhage due to retained
placenta) and anaesthesia cannot be performed immediately.
For manual vacuum aspiration, a combination of premedication and local anaesthetic (paracervical
block) provides adequate anaesthesia.

Protection of personnel
All intrauterine procedures expose the practitioner to the risk of blood-borne pathogen infection.
Personal protective equipment is essential (gloves, gown, rubber or plastic apron, mask, protective
eyewear).

9.1.2 Specific precautions for manual procedures

For all manual intrauterine procedures, add:
– Antibiotic prophylaxis before the procedure:
cefazolin or ampicillin slow IV a : 2 g single dose
AND
– A uterotonic agent (right after the procedure) to improve uterine contraction:
oxytocin IM or slow IV: 5 to 10 IU single dose

Notas
(a) For pat ient s wit h a hist ory of immediat e hypersensit ivit y react ion t o penicillin (urt icaria, respirat ory
 problems or oedema): clindamycin IV 900 mg single dose + gentamicin IV 5 mg/kg single dose.

9.2 Manual removal of the placenta

Evacuation of the placenta from the uterus by hand.

9.2.1 Indications
– Placenta not yet expelled 30 to 45 minutes after delivery.
– Haemorrhage prior to spontaneous expulsion of the placenta.

9.2.2 Technique
Figure 9.1 - Manual removal of placenta

– Follow precautions common to all intrauterine procedures (Section 9.1.1) and specific precautions
for manual procedures (Section 9.1.2).
– Cup the fundus with one hand and hold it down.
– Advance the other hand into the uterus, supinated, directly to the fundus and locate the cleavage
plane between the uterine wall and the placenta with the fingertips. T his hand is inserted all the way up
to the forearm in the genital tract.
– Once the cleavage plane has been located, use the side of the supinated hand like a spoon to detach
the placenta and bring it out.
– Immediately reinsert the hand to perform uterine exploration.
On very rare occasions, it is impossible to remove the placenta manually because there is no cleavage
plane between the placenta and the uterine wall (placenta accreta). In this event, refer for
hysterectomy.

9.3 Uterine exploration

Manual exploration of the uterine cavity to verify the integrity of the uterus and remove any placental
debris or blood clots interfering with contraction and, hence, haemostasis.

9.3.1 Indications
– Suspected uterine rupture.
– Suspected retained products after examination of the expelled placenta.
– Postpartum haemorrhage within 24 hours of delivery.
– Routinely after manual removal of the placenta.

Note: in the event of postpartum haemorrhage, rule out vaginal or cervical tear, especially if the
placenta appears complete and the uterus is well-contracted (Chapter 8, Section 8.5).

9.3.2 Technique
– Follow precautions common to all intrauterine procedures (Section 9.1.1) and specific precautions
for manual procedures (Section 9.1.2).
– Routine uterine exploration: two faces, two sides, one fundus, two horns. Use the fingers to search
for placental debris and remove by hand.
– Ensure uterine retraction using abdominal massage: when the uterus retracts it resembles a firm ball.

9.4 Digital curettage

Use of finger(s) to remove placental fragments or blood clots detected late after an abortion or
delivery, when insufficient cervical dilation renders uterine exploration impossible (however the cervix
must be sufficiently open to allow insertion of one finger, two if possible).

9.4.1 Indication
– Delayed detection of haemorrhagic abortion or retained placenta, where uterine exploration cannot
be performed.

9.4.2 Technique
Figure 9.2 - Exploration of the uterus with two fingers

– Follow precautions common to all intrauterine procedures (Section 9.1.1) and specific precautions
for manual procedures (Section 9.1.2).
– Insert the index finger, and the middle finger if possible, into the uterine cavity; cup the uterus through
the abdomen with the other hand.
– Systematically explore and remove any remaining fragments.

9.5 Manual vacuum aspiration (MVA)

Evacuation of the uterine contents using suction.

9.5.1 Indications
– Incomplete abortion before 13 weeks LMP
– Molar pregnancy
– Termination of pregnancy before 13 weeks LMP (see Chapter 12)

Note: beyond 13 weeks LMP, MVA is ineffective, except in case of molar pregnancy.

9.5.2 Precautions
– Purulent cervicitis and pelvic infection: start antibiotics before performing the procedure.
– Coagulation disorders: risk of haemorrhage. MVA must be performed in a facility where emergency
surgery and blood transfusion are available.
9.5.3 Equipment
– MVA set:
2 Ipas MVA Plus® 60-ml syringes
2 bottles of silicone for lubricating the syringe
20 sets of Ipas Easy Grip® flexible cannulae (4, 5, 6, 7, 8, 9, 10, 12 mm) sterile, single use
5 double-ended Hegar’s uterine dilators (3-4, 5-6, 7-8, 9-10, 11-12 mm)
1 Pozzi forceps, tenaculum
1 Collin vaginal speculum
1 uterine sound
1 Cheron dressing forceps
1 100-ml gallipot
1 stainless steel instrument basket
All the equipment is autoclavable, except the cannulae, which are strictly single use.

– For the procedure:

1 sterile drape for laying out the sterile equipment
1 aperture drape to place over the patient’s vulva
povidone iodine scrub solution or, if not available, ordinary soap
10% povidone iodine dermal solution
sterile compresses and gloves
absorbent pad to place under the patient’s buttocks
1 bright light

– For local anaesthesia:

long sterile needle (either 22G LP or 21G IM)
1% lidocaine (without epinephrine) + sterile syringe and needle

9.5.4 Technique
Follow precautions common to all intrauterine procedures (Section 9.1.1).

Preparing the patient

If the patient has a purulent cervicitis or pelvic infection, start antibiotherapy before performing the
MVA (increased risk of uterine perforation). For antibiotherapy, see Section 9.6.6.

Cervical ripening
– T he cervix is open: no cervical ripening with misoprostol.
– T he cervix is closed: misoprostol 400 micrograms single dose, sublingually 1 to 3 hours before the
procedure or vaginally into the posterior fornix, 3 hours before the procedure [1] to open the cervix and
prevent traumatic cervical dilation.
Antibiotic prophylaxis
One hour before the procedure: doxycycline PO 200 mg single dose or azithromycin PO 1 g single
dose.

Oral premedication
One hour before the procedure: ibuprofen PO 800 mg single dose
Only in the event of excessive anxiety: diazepam PO 10 mg single dose

Note: in case of incomplete abortion with heavy bleeding, the procedure cannot be delayed. In such
cases:
– Do not administer oral premedication;
– If the context permits (CEmONC facility and anaesthetist available), perform the procedure under IV
conscious sedation or general anaesthesia;
– If IV conscious sedation or general anaesthesia is not feasible, replace the oral premedication
with diclofenac IM: 75 mg

Preparing the equipment

Prepare several cannulae of different sizes:
– As a rule of thumb, the cannula diameter should correspond roughly to the gestational age in weeks
LMP. For example, at 10 weeks LMP, choose a cannula that is 8 to 10 mm in diameter.
– In practice, the diameter of the cannula inserted will depend on the dilation obtained. For example, if
at 10 weeks LMP it is only possible to easily dilate up to a No. 8 dilator, use an 8-mm cannula.

Paracervical block
– Prepare the local anaesthetic: draw up 20 ml of 1% lidocaine.
– Insert the speculum; apply 10% povidone iodine solution on the cervix and vagina.
– Place the Pozzi forceps on the anterior cervix at 12 o'clock and apply gentle traction to the cervix in
order to see the transition between the cervix and the vaginal wall. Injections for the paracervical block
are given in this transition zone.
– Perform 4 injections, 3 to 5 ml each, at 4 sites around the cervix (2, 5, 7 and 10 o'clock sites), to a
maximum depth of 2 to 3 mm; do not exceed 20 ml in total.

Dilation
Dilate the cervix if the cervical canal cannot accommodate the cannula appropriate for gestational
age (or the size of the uterus). Dilation should be smooth and gradual:
– With one hand, pull the forceps attached to the cervix and keep traction in order to bring the cervix
and the uterine body into the best possible alignment.
– With the other hand, insert the smallest diameter dilator; then switch to the next larger dilator.
Continue in this way, using the next size dilator each time, until obtaining dilation appropriate to the
cannula to be inserted, without ever relaxing the traction on the cervix.
– Insert the dilator through the internal os. A loss of resistance may be felt: this indicates that there is
no need to advance the dilator any further. T his loss of resistance is not necessarily felt. In such case,
it can be assumed that the internal os has been penetrated when the dilator has been inserted 5 cm
beyond the external os.
– Do not force the cervix with the dilators (risk of rupture or perforation, especially when the uterus is
very retro- or anteverted).

Aspiration
– Maintain traction on the cervix with one hand by holding the Pozzi forceps.
– With the other hand, gently insert the cannula into the uterine cavity. Rotating the cannula while
applying gentle pressure facilitates insertion. Slowly and cautiously push the cannula into the uterine
cavity until it touches the fundus; then pull back 1 cm.
– Attach the prepared (i.e. under vacuum) sterile syringe to the cannula.
– Release the valves on the syringe to perform the aspiration. T he contents of the uterus should be
visible through the syringe (blood and the whitish products of conception).
– Hold the syringe by the tube (not the plunger) once a vacuum has been established in the syringe and
the cannula has been inserted into the uterus; otherwise, the plunger can go back in, pushing the
aspirated tissue or air back into the uterus.
– Carefully (risk of perforation) suction all areas of the uterus, gently rotating the cannula back and
forth 180°. Take care not to lose the vacuum by pulling the cannula out of the uterine cavity.
– If the syringe is full, close the valves, disconnect the syringe from the cannula, empty the contents,
re-establish the vacuum, and reconnect the syringe to the cannula and continue the procedure.
– Stop when the uterus is empty, as indicated by a foamy, reddish-pink aspirate, with no tissue in the
syringe. It is also possible to assess the emptiness of the uterus by passing the cannula over the
surface of the uterus: if a grating sensation is felt or the uterus contracts around the cannula, assume
that the evacuation is complete.
– Close the valve, detach the syringe and then, remove the cannula and the forceps. Check for
bleeding before removing the speculum.

In a surgical setting, aspiration can be done using a cannula connected to the electric suction machine,
with a maximum pressure of 800 millibars.

Examining the aspirated contents

To confirm that the uterus has been emptied, check the presence and quantity of debris, estimating
whether it corresponds to the gestational age.
T he debris consists of villi, foetal membranes and, beyond 9 weeks, foetal fragments. To inspect the
tissues visually, place them in a compress or strainer, and rinse them with water.

Routine ultrasound to confirm complete uterine evacuation is not recommended.

9.5.5 Patient follow-up

– Do not administer an uterotonic routinely, except in the event of molar pregnancy.
– After the procedure, mild bleeding continues without clots. Monitor vital signs and blood loss for at
least 2 hours. Settle the patient comfortably during monitoring period.
– Pain is usually moderate, and relieved by paracetamol and/or ibuprofen (Appendix 7).
– Check and update tetanus vaccination if unsafe abortion is suspected (Chapter 2, Section 2.1.3).
– T he patient can go home if the vital signs are stable, she can walk, and she has been given the
following information:
• cramps will continue for a few days (give an analgesic);
• bleeding will last for 8 to 10 days;
• menstrual periods will resume within 4 to 8 weeks;
• she will be fertile again within 8 to 10 days (offer contraception, Chapter 11, Section 11.5);
• advice on hygiene; no vaginal douches;
• signs and symptoms requiring consultation: prolonged bleeding (more than 2 weeks), bleeding heavier
than normal menstrual periods, severe pain, fever, chills, malaise, fainting.

9.5.6 Complications
– Incomplete evacuation of the uterus due to the use of a cannula too small or to interrupted suction:
start over.
– Perforated uterus, bleeding, pelvic infection: see Section 9.6.6.
– Air embolism: very rare; can occur when the plunger of the syringe is pushed while the cannula is still
inside the uterine cavity.
– Haematometra: in the hours following the procedure, retention of blood in the uterine cavity. T he
uterus becomes distended and extremely sensitive. Treat by re-evacuating the uterus, administering an
oxytocic agent and massaging the uterus.

For more information on MVA: Performing Uterine Evacuation with the Ipas MVA Plus®Aspirator and
Ipas EasyGrip®Cannulae: Instructional Booklet (second edition, 2007).
https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.194.935&rep=rep1&type=pdf

Referencias
1. Ipas. (2018). Clinical Updat es in Reproduct ive Healt h. L. Cast leman & N. Kapp (Eds.). Chapel Hill, NC: Ipas.
ht t ps://ipas.azureedge.net /files/CURHE18-march-ClinicalUpdat esinReproduct iveHealt h.pdf

9.6 Instrumental curettage

Removal of placental fragments after incomplete abortion, or incomplete delivery of the placenta,
using an instrument (curette).

9.6.1 Indications
– Retained placenta or blood clots after incomplete abortion:
Curettage is not the method of choice. It is only used if:
• Before 13 weeks LMP: MVA is not available or is not effective;
• After 13 weeks LMP: the cervix is not dilated enough naturally to perform digital curettage.

– Retained placenta or blood clots after childbirth:

• Immediately after delivery, it is always possible to perform uterine exploration or digital curettage;
there is no reason to perform instrumental curettage.
• After delivery, instrumental curettage is used only in exceptional circumstances—when the cervix is
not dilated enough naturally to allow uterine exploration or digital curettage.

9.6.2 Precautions
T he procedure should be performed in a CEmONC facility.

9.6.3 Equipment
Curettage set:
1 set of 3 blunt-edge curettes
1 DeBakey tissue forceps
2 vaginal retractors
8 Hegar’s uterine dilators (4, 6, 8, 10, 12, 14, 16, 18 mm)
1 Pozzi forceps, tenaculum
1 Collin vaginal speculum
1 uterine sound
1 Cheron dressing forceps
1 100-ml gallipot
1 stainless steel instrument basket

9.6.4 Technique
Follow precautions common to all intrauterine procedures (Section 9.1.1).

Preparing the patient

– If the patient has a purulent cervicitis or pelvic infection, start antibiotherapy before performing the
curettage (increased risk of uterine perforation). For antibiotherapy, see Section 9.6.6.
– In the event of incomplete second trimester abortion or after childbirth: antibiotic prophylaxis
(cefazolin or ampicillin slow IV a : 2 g single dose).
– Cervix preparation: as for manual vacuum aspiration (Section 9.5.4).

General or spinal anaesthesia

If not available, use premedication + paracervical block, as for manual vacuum aspiration (Section
9.5.4).

Dilation
As for manual vacuum aspiration (Section 9.5.4).

Curettage
Figure 9.3 - Curettage

– With one hand, pull the Pozzi forceps attached to the cervix and keep traction in order to bring the
cervix and the uterine body into the best possible alignment.
– Choose the largest possible curette, since the smaller the curette, the greater the risk of trauma. T he
limit is the degree of dilation obtained with the dilators.
– T he sound can be used, but it is not compulsory. T he depth of the uterus can also be assessed by
gently advancing the curette to the uterine fundus and noting the length.
– Explore from the fundus down toward the cervix, in order to bring the debris outward, avoiding
perforation. Hold the curette lightly between the thumb and index finger, with the handle resting against
the tips of the other fingers, thus allowing an oscillatory motion. Do not grasp the curette with the
entire hand.
T he goal is to detach the fragments without abrading the mucous membranes. Do not necessarily
expect the gritty sensation felt through the curette when curettage is too deep.
When the procedure is finished, verify that the uterus is empty: no more tissue comes out with the
curette. T here is a rough feeling as it passes over the entire uterine surface.

9.6.5 Patient follow-up

After abortion
Same follow-up and advice as after MVA (Section 9.5.5).

After childbirth
Routinely administer oxytocin IM or slow IV: 5 or 10 IU.

9.6.6 Complications
Persistent bleeding
– Incomplete evacuation of the uterus: start over.
– Uterine atony: administer 5 to 10 IU oxytocin slow IV.
– Vaginal or cervical lacerations (common with unsafe abortions): suture if necessary.

Perforation of the uterus

– Perforation by dilators or curettes: bleeding, instrument goes in too far, pain.
– T he treatment is rest plus antibiotics for 5 days:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin):
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1 ratio: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
or
amoxicillin PO: 1 g 3 times daily + metronidazole PO: 500 mg 3 times daily
In the event of fever with foul smelling vaginal discharge, treat for 10 days.
– If the patient is in a BEmONC facility, refer her to a CEmONC facility.
– Monitor for peritoneal signs (pain or guarding) in the following days. Appearance of these signs
necessitates laparotomy for investigation of possible lesions of the abdominal organs.
– Possible bladder injury and, potentially, subsequent fistula if the bladder was not emptied prior to
curettage. If this happens, place a urinary catheter immediately and leave in place for 7 days; this
usually allows the bladder to heal.

Infections
– Endometritis, salpingitis, pelvic peritonitis, and septicaemia must be prevented by strict asepsis, non-
traumatic procedures and prophylactic antibiotics in post-childbirth and second trimester abortion
(Section 9.1.2) cases.
– In a febrile patient with pelvic infection, start antibiotherapy:
amoxicillin/clavulanic acid IV (dose expressed in amoxicillin): 1 g every 8 hours + gentamicin IM: 5
mg/kg once daily
or
ampicillin IV: 2 g every 8 hours + metronidazole IV: 500 mg every 8 hours + gentamicin IM: 5
mg/kg once daily
Continue until the fever resolves (at least 48 hours), then change to:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin) to complete 5 days of treatment
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
or
amoxicillin PO: 1 g 3 times daily + metronidazole PO: 500 mg 3 times daily, to complete 5 days of
treatment
In the event of perforation, treat for 10 days.

Notas
(a) In pat ient s wit h a hist ory of immediat e hypersensit ivit y react ion t o penicillin (urt icaria, respirat ory problems
or oedema): clindamycin IV 900 mg single dose + gentamicin IV 5 mg/kg single dose.

9.7 Embryotomy
Destructive operation to reduce the volume of a dead foetus to facilitate vaginal delivery when
obstruction prevents this from occurring naturally.
T here are several types of embryotomy:
– Craniotomy: a procedure in which a perforation is made in the foetal skull to reduce the volume of the
foetal head which prevents delivery. It can be done on either an obstructed cephalic presentation or an
entrapped aftercoming head in a breech.
– Cranioclasis: a procedure to crush the bones of the foetal skull. It is done if necessary after
craniotomy in order to allow extraction of the foetal head.
– Decapitation: a procedure in which the foetus is decapitated to relieve impaction due to a transverse
lie.
– Evisceration: a procedure in which an incision is made in the abdomen or thorax in the case of a mass
or fluid collection (ascites) which is preventing delivery of the foetus.
– Cleidotomy: a procedure in which one or both clavicles are cut to reduce the biacromial diameter in
case of a shoulder dystocia not resolved by other manoeuvres.

Embryotomy, especially as often performed on a fragile and infected uterus, carries the risk of trauma
(e.g., uterine rupture, cervical or vaginal injury, and damage to maternal soft tissue with fistula). T his risk
is especially high in the event of decapitation.

Few people have experience with these procedures. T he operators must have the knowledge of
obstetrics, must feel comfortable performing obstetric manoeuvres and must have skills to manage
potential complications.

Some practitioners would rather perform a caesarean section on a dead foetus than have to mutilate
a foetus. However, independently of the mode of delivery (by caesarean section or vaginally),
obstructed labour carries a significant risk of puerperal infection, fistula and postpartum haemorrhage.
In addition, caesarean section can place the mother at significant risk in terms of both survival and
function. T he objective of embryotomy is to reduce such risks.

Embryotomy should be performed in a CEmONC facility (refer if necessary, even if the referral takes
time).

9.7.1 General conditions and precautions

T here is no urgency in extracting the foetus. T he priority is maternal intensive care (intravenous line, IV
hydration, antibiotic therapy for prolonged rupture of membranes or infection, and urinary
catheterisation).
T he embryotomy can be performed once the mother is stable, under the following conditions:
– Confirm foetal death: no heart tones on foetal Doppler or ultrasound.
– Confirm the obstacle to vaginal delivery due to size and/or presentation.
– Make sure there is adequate access to the foetus: full or nearly full dilation and ruptured membranes.
– Insert a Foley catheter.
– Perform the procedure in the operating room under strict aseptic conditions and anaesthesia; always
prepare for laparotomy in case of uterine rupture.
– Take time to explain to the mother and family the expected benefits (avoiding caesarean section)
and potential complications (possible laparotomy if the event of embryotomy failure or uterine rupture).
Obtain the patient’s consent.
– After extracting the foetus, routinely check:
• the uterine cavity (uterine exploration with antibiotic prophylaxis, Section 9.3);
• the vaginal walls (use the vaginal retractors in the curettage set, for example, to get adequate
exposure).
– After the procedure, routinely administer oxytocin IM or slow IV: 5 IU or 10 IU.
– In the event of obstructed labour, leave the Foley catheter in place for 14 days to reduce the risk of
fistula formation.
– Care for the body of the infant: suture the skin wounds; clean and wrap up the infant to show/give him
to the parents or family, depending on their choice.

9.7.2 Contra-indications
– Doubt about whether the foetus is dead or alive
– Uterine rupture
– Incomplete dilation

9.7.3 Equipment
– Smellie perforator (Figure 9.4)
– Dubois scissors or large, curved scissors (Figure 9.5)
– Braun cranioclast (Figure 9.6)
– 4 Faure forceps
9.7.4 Craniotomy for obstructed cephalic presentation
Figure 9.7 - Embryotomy with the Smellie perforator
– Have an assistant place both palms on the mother's abdomen to apply downward pressure on the
foetal head toward the pelvis.
– Insert one hand, shaped like a channel, into the vagina, in contact with the foetal head.
– Using the other hand, slide the perforator along the channel formed by the first hand (to protect the
vagina) until it makes contact with the foetal head. T his can be done under direct vision after retraction
with vaginal retractors.
– T he perforation should be made in the centre of the skull to protect the mother's soft tissues. It is
easier to do it in a fontanelle. Rotate the instrument to make the perforation, and then remove it so
that the cerebrospinal fluid and/or brain matter can drain through the hole.
– Once the cerebrospinal fluid spills out, the head should collapse and delivery should be easy; if not,
apply traction to the skull with 3 or 4 forceps, gripping the scalp around the perforation. If necessary,
perform cranioclasis.

Note: if the foetus is hydrocephalic, perforation can be replaced by needle aspiration.

9.7.5 Cranioclasis
– Insert the cranioclast’s solid jaw into the opening made by the perforator. T he hollow jaw is placed
beside the skull similar to the placement of obstetric forceps.
– Adjust the two jaws with the screw and extract the head in the most favourable orientation.

9.7.6 Craniotomy for entrapped aftercoming head in a breech

Figure 9.8 - Craniotomy for retention of the aftercoming head
– Have an assistant place both palms n the mother's abdomen to apply downward pressure on the
foetal head toward the pelvis.
– Pull the body of the foetus out and down to gain access to the occiput. If necessary, retract the
anterior vaginal wall using a vaginal wall retractor.
– Insert the perforator (or scissors, if there is no perforator) under the occiput. Rotate the instrument
to make the perforation. Open and close to cut up the contents.
– Remove the perforator and apply traction to the trunk. If the head remains trapped, traction can be
applied directly to the skull with forceps attached around the perforation.

Note: if the foetus is hydrocephalic, perforation can be replaced by needle aspiration.

9.7.7 Decapitation for transverse lie

T his is the most difficult type of embryotomy to perform, and the one carrying the greatest risk of
maternal trauma.

If the foetus is big and/or hard to access, embryotomy cannot be done and caesarean section is the
first and only option. Be aware that the caesarean section will be complicated, with potentially difficult
foetal extraction and the risk of enlargement of the hysterotomy.

Embryotomy can be attempted if the foetus is small and easy to access. First try internal version
(Chapter 7, Section 7.8) in the operating room under anaesthesia and total breech extraction (Chapter
6, Section 6.3), with or without craniotomy.
Figure 9.9 - Decapitation using scissors

– Determine the exact position of the foetus (position of the head and neck and which arm is
prolapsed.
– In case of neglected shoulder presentation (Chapter 7, Section 7.6.1), have an assistant apply
traction to the prolapsed arm (do not try to section the arm first, as it can be used to pull the body
downward).
– Slide one hand behind the foetus and surround the neck with thumb and index finger, like a necklace.
– With the other hand, slide the closed scissors into the channel formed by the first hand, keeping them
flat against the hand. It is imperative to approach the neck at a right angle.
– Using fingers to control and guide, section the neck bit by bit, in the hollow of the hand, opening the
scissor blades only slightly each time.
– After decapitation, bring the arms down one after the other and deliver the body.
– To deliver the head, grasp the neck stump and pull downward, performing the delivery as for retention
of the aftercoming head, fingers in the foetus’ mouth.

9.7.8 Evisceration
– Initially, attempt to puncture the abdomen with a needle. T his might be sufficient to reduce the foetal
ascites to allow delivery.
– In case of failure (either insufficient fluid reduction or a solid mass), use scissors to incise, under
vision, the abdominal wall and remove the organs.

9.7.9 Cleidotomy
It is difficult to cut one or both clavicles with Dubois scissors and there is a high risk of cutting maternal
tissue. It should not be attempted unless all of the obstetrical manoeuvres described in Chapter
7, Section 7.5.1. have failed after several attempts.

For more information on destructive delivery, see: Primary Surgery: Non-Trauma v.1. 1990.
https://storage.googleapis.com/global-help-publications/books/help_primarysurgery.pdf [Accessed 12
December 2018]

Chapter 10: Newborn care in the

maternity hospital
10.1 Routine care and examination

10.2 Neonatal resuscitation

10.3 Care of the sick newborn

10.4 Specific care when the mother has a transmissible infection

10.5 Care of the low birth weight neonates (< 2500 g)

10.6 Criteria for discharge from the maternity hospital

10.1 Routine care and examination

10.1.1 In the first hours of life

Anticipate the need for resuscitation at every birth. T he necessary equipment should be ready
at hand and ready for use.

Initial assessment
At birth, dry thoroughly and rapidly assess the neonate’s condition:
 The neonate

• Is not breathing spontaneously or has difficulty • Is breathing or crying spontaneously

breathing • Has good muscle tone and responds when
• Has poor muscle tone stimulated
• Has a heart rate less than or equal to 100 • Has a heart rate above 100 beats/minute
beats/minute • Becomes pink rapidly
• Has persistent central cyanosis at 1 minute

Commence resuscitation Proceed to routine care

Section 10.2

Note: if the amniotic fluid is meconium-stained but the neonate is breathing spontaneously, wipe the
face and start routine care as below.

Thermoregulation
– At birth:
• dry the neonate with a clean, dry cloth;
• wrap the neonate in another clean, dry cloth;
• place the neonate against the mother’s (dried) body and cover with a dry cloth or blanket.
– Perform a full clinical examination with the neonate under an infant warmer.
– Cover the head with a cap to reduce heat loss.
– Axillary temperature should be kept between 36 and 37 °C, and the neonate should have pink, warm
feet.
– Keep the neonate in a warm room (between 23 and 25 °C).
– Delay bathing the neonate until 24 hours after birth. If it is not possible for cultural reasons, delay for
at least 6 hours.

For low birth weight neonates, see Section 10.5.

Cord clamping and cord care

– Wait at least 1 to 3 minutes before clamping the cord (especially neonates weighing less than 2500
g).
– Clamp the cord with two Kocher forceps 10 cm from the umbilicus and cut between the two forceps.
Use sterile blade or scissors; a different pair than those used for episiotomy.
– T ie off the cord with a Barr clamp or sterile thread (double ligature), leaving a 2 to 3 cm stump.
– Disinfect the umbilicus: apply 7.1% chlorhexidine digluconate (delivering 4% chlorhexidine) to the
tip, stump and base of the cord. If not available, disinfect with 10% povidone iodine. Put a single
application at birth.

Apgar score
T he Apgar score is evaluated at 1 and 5 minutes after birth and recorded in the neonate's medical
chart and health record.
T he score is a tool for monitoring the neonate’s adaptation to extra-uterine life. It is not used to
determine whether resuscitation is indicated; this should be evaluated at birth, based on whether or not
there is spontaneous respiratory effort, without waiting for the 1-minute assessment.
In case of resuscitation, the Apgar score is determined retrospectively.
If the Apgar score is ≤ 4 at 1 minute or ≤ 6 at 5 minutes, the midwife should call the doctor and should
initiate necessary steps based on the neonate’s needs.

Table 10.1 - Apgar score

Items
0 1 2
evaluated/score

Extreme pallor
(a) Cyanotic extremities
Skin colour or central Totally pink
No central cyanosis
cyanosis

Abnormal (slow, irregular,

Respiration None Normal
etc.)

Heart rate 0 ≤ 100/minute > 100/minute

Good
Hypotonia
Muscle tone Absent Complete flexion of
Incomplete flexion of limbs
limbs

Responsiveness
Nil Grimace Good, vigorous cry
(after stimulation)

(a) A healt hy neonat e is usually born cyanot ic but t urns pink wit hin 30 seconds af t er breat hing st art s. In
 neonat es wit h dark skin, it may be more dif ficult t o assess skin colour change. If so, look at t he soles of
t he f eet , palms of t he hands and mucous membranes t o assess f or t he change f rom blueish t o pink.

Table 10.2 - Significance of the Apgar score

1-minute score 5-minute score

0-4 Asphyxia 0-6 Asphyxia

5-7 Difficulty adapting 7-8 Difficulty adapting

8 - 10 Good adaptation 9 - 10 Good adaptation

Feeding
– Put the neonate to the breast as soon as possible within an hour of birth.
– Breastfeeding on demand day and night (at least 8 times per 24 hours, i.e. every 3 hours).
– For more information, see Appendix 3.
– In the event of maternal HIV infection, see Appendix 3, Section 3.7.

For low birth weight neonates, see Section 10.5.

Clinical examination and assessment of risk factors

A full clinical examination of the neonate should be completed in the delivery room as soon as possible,
under an infant warmer, by the birth attendant.
T he priority is to recognise danger signs that may indicate severe illness (Section 10.3.1) and to assess
for risk factors for infection and hypoglycaemia.
Record all observations on a monitoring sheet.
A. Routine clinical examination
– Vital signs:
• respiratory rate: normal range 30 to 60 breaths/minute
• heart rate: normal range 100 to 160 beats/minute
• temperature: normal range ≥ 36 °C and < 37.5 °C
– Weight (weigh the neonate naked on an appropriate scale, calibrated beforehand)
– Skin: see danger signs, Section 10.3.1.
– Head: fontanelles, eyes, ears, oral cavity (palate, mucous membranes)
– Chest: respiratory effort, heart sounds, breath sounds
– Abdomen: shape, size, umbilicus, genital organs, anus, spine
– Extremities: limbs, feet, hands
– Neurology: posture, tone, reflexes (sucking, grasp, response to stimulation)

B. Assessment for risk factors for neonatal infection

Prophylactic antibiotics for 48 hours (Section 10.3.3) is indicated if the neonate presents with:
– 1 major risk factor (except if, for PROM ≥ 18 hours or for maternal fever, the mother received
adequate antibiotic therapy i.e. at least 2 doses of IV ampicillin administered 4 hours apart with the last
dose administered within 4 hours prior to birth)
OR
– 3 minor risk factors (or more)

Major risk factors Minor risk factors

Maternal fever (≥ 38 °C) before or during labour in Preterm or birth weight < 2000 g
preterm

Prolonged rupture of membranes (PROM) ≥ 18 hours Resuscitation at birth

Foul-smelling, cloudy amniotic fluid Meconium stained amniotic fluid

Twin with clinical signs of infection Home delivery (Chapter 11,

Section 11.3.3)
C. Assessment for risk factors for hypoglycaemia
– Check blood glucose within one hour of birth in neonates with one of the following risk factors:
• Birth weight < 2500 g or > 4000 g
• Maternal diabetes
• Mother treated with labetalol
• Difficulty breastfeeding (difficulty with sucking or attaching to the breast)
– If blood glucose is normal (≥ 2.5 mmol/l or ≥ 45 mg/dl), observe that the neonate is breastfed at least
every 3 hours. Check blood glucose before each meal until there are 3 consecutive normal results.
– If blood glucose is < 2.5 mmol/l or < 45 mg/dl, see hypoglycaemia, Section 10.3.4.

D. Assessment for mother-to-child transmissible diseases

If not done prior to birth, check if the mother may have any disease transmissible to the
neonate (Section 10.4).

Preventive treatments
Gonococcal conjunctivitis
As soon as possible, preferably within an hour of birth: apply a 1 cm strip of 1% tetracycline eye
ointment in each eye.
Note: if the mother has a symptomatic genital infection at the time of delivery, see Section 10.4.

Haemorrhagic disease of the newborn

Administer phytomenadione (vitamin K1) IM in the anterolateral aspect of the thigh within the first few
hours of life:
Neonate weighing 1500 g or more: 1 mg single dose (0.1 ml if 2 mg/0.2 ml ampoule)
Neonate weighing less than 1500 g: 0.5 mg single dose (0.05 ml if 2 mg/0.2 ml ampoule)

Rickets and vitamin D deficiency

Neonates particularly at risk (preterm, low birth weight, maternal malnutrition, contexts with prevalence
of vitamin D deficiency) and if possible all neonates should receive vitamin D for 6 months:
colecalciferol (vitamin D 3) or ergocalciferol (vitamin D 2) PO:
Preterm or neonates living in contexts of high risk vitamin D deficiency: 600 to 1200 IU once daily
Term neonates: 400 to 800 IU once daily
Note: the number of IU per drop of oral solution varies according to manufacturers. Check instructions
for use.

Mother-to-child HIV transmission

All neonates of HIV-infected mothers should receive antiretroviral treatment as soon as possible.
See the specific PMT CT protocol.

Vaccinations
T he monovalent Hepatitis B and BCG vaccines are recommended as soon as possible after birth for
all neonates, including low birth weight and preterm neonates. T he oral polio vaccine is recommended
at birth in endemic areas or areas at risk of poliovirus importation.
For the oral Polio vaccine, the dose administered at birth is an extra dose (called and recorded as
“Dose 0”). It does not count as one of the 3 doses required by the Expanded Programme on
Immunization during the postnatal period.
T he hepatitis B birth dose is to prevent mother-to-child transmission of the virus. It should be
administered as soon as possible, preferably in the delivery room, or at least within the first 24 hours of
life. While it may still be administered after that time, the later the vaccine is administered, the less
effective the protection[1] [2] .

Table 10.3 - Neonatal vaccination

Vaccine Contra-indications Dose/route of administration

Hepatitis B None but use only the monovalent One dose = 5 to 10 micrograms (follow
monovalent vaccine manufacturer's instructions)
IM injection, anterolateral thigh

Polio oral None One dose = 2 drops (approximately 0,1 ml)

bivalent Oral route
(poliovirus
types 1 and
3)
Dose 0

BCG Neonate whose mother has active One dose = 0.05 ml

(b) Intradermal injection, deltoid region
tuberculosis (Section 10.4.6)
(junction of lower 2/3 and upper 1/3 lateral
aspect of upper arm)

(b) St art t he neonat e on isoniazid prevent ive t herapy, and administ er t he BCG vaccinat ion when t he isoniazid
t herapy is complet ed.

10.1.2 After the first hours of life

Neonatal (and maternal) mortality is the highest in the first 24 hours after birth. Women are encouraged
to stay for 24 hours in the maternity.
For the first 24 hours (or more if the mother stays in maternity longer than 24 hours), monitor the
neonate and record observations in the neonate's monitoring sheet:
– Monitor:
• Danger signs
• Temperature, heart and respiratory rate 2 times daily
• Weight once daily
• Urine and stool
– Keep cord clean, dry and exposed to the air (no dressing).
– Observe breastfeeding.

For low birth weight neonates, see Section 10.5.

For the discharge criteria of the neonate, see Section 10.6.

Referencias
1. Weekly epidemiological record/Relevé épidémiologique hebdomadaire : Hepat it is B vaccines/Vaccins ant i-
hépat it e B, 2 oct ober 2009, 84th year/2 oct obre 2009, 84e année, No. 40, 2009, 84, 405–420.
ht t p://www.who.int /wer/2009/wer8440.pdf

2. Vaccines. Sixt h edit ion by St anley Plot kin, Walt er Orenst ein and Paul Of fit (2013).

10.2 Neonatal resuscitation

10% of neonates need help breathing properly at birth; this help comes in the form of tactile
stimulation and/or airway clearing.

For half of them, these procedures are not sufficient, and if the neonate is not breathing or is gasping
despite stimulation/suction, ventilation is needed as of the first minute of life.
A small percentage of ventilated newborns will require more advanced resuscitation.

T he birth attendant in charge of the delivery is also responsible for the newborn. S/he should start
resuscitation immediately then, if necessary, call for help.

10.2.1 Basic resuscitation a

Hypothermia compromises resuscitation. Resuscitation should be done in a heated room, if

possible under an infant warmer.
Steps 1 to 5 should be performed in the first minute of life. Record all procedures on the monitoring
sheet.

1 - Stimulate the neonate by drying

Tactile stimulation can trigger spontaneous breathing. It is done by drying the neonate.
If the neonate starts to breathe or cry within 5 seconds, proceed to routine care (Section 10.1).
If not, stop stimulation and proceed to step 2.

2 - Clear the airway

Lay the neonate on the back with the head in a neutral position (Figure 10.1); avoid flexion or
hyperextension of the neck, as this can obstruct the airway.

Figure 10.1 - Head position for clearing the airway

Only in cases where there are copious secretions, suction the mouth gently i.e., not too deeply
(maximum depth 2 cm from the lips) – and quickly (maximum duration 5 seconds) with a bulb syringe.
If neonate is still not breathing or not breathing well, proceed to step 3.

3 - Stimulate the neonate

Rub the back and the soles of the feet vigorously but not roughly (do not shake, slap or hang the infant
by the feet, etc.). If the neonate is having difficulty breathing or still not breathing after 5 seconds: stop
active stimulation, and proceed to steps 4 and 5.

4 - Clamp and cut the cord

If not already done, clamp and cut the cord.

5 - Perform bag-mask ventilation (room air)

Fit the mask over the nose and mouth. Press firmly to prevent air leaks. Hold it with one hand, with the
thumb on one side and the index and middle fingers on the other (Figures 10.2 and 10.3). With the other
hand, squeeze the bag at a rate of 30 to 60 breaths/minute for 60 seconds. Ventilation is effective if
the chest rises and falls.
Attention, excessive ventilation pressure can cause a pneumothorax.
If the chest fails to rise:
– Check the connection between the bag and the mask;
– Correct the position of the mask on the face;
– Correct the head position.
Figure 10.2 - Mask position

Figure 10.3 - Manual ventilation

Check every minute for spontaneous respiratory effort (look for chest movement); do not take the
mask off the neonate’s face to check for spontaneous breathing.
Continue manual ventilation until there is spontaneous respiratory effort.

6 - Oxygenation
If oxygen is available: connect the ambu bag to an oxygen reservoir after 2 minutes of ventilation,
setting it at a 2 litres/minute flow rate. Ventilation is a priority and should not be interrupted to connect
the oxygen (have an assistant connect the oxygen).

Stop resuscitation if the neonate has:

– No heart rate after 10 minutes.
– No spontaneous respiration after 20 minutes of effective ventilation, even if the heart rate is
adequate.

10.2.2 After resuscitation

Re-evaluate all vital signs, look for danger signs and measure blood glucose. Perform a retroactive
Apgar score assessment (Section 10.1.1).
Record the results on a monitoring sheet.
Transfer to a neonatal care unit is indicated if one of the following is present:
– T he neonate was ventilated with a mask for 2 minutes or more.
– T he Apgar score was ≤ 4 at 1 minute or ≤ 6 at 5 minutes.
– Any danger sign is present (Section 10.3.1).
Keep the mother and neonate together where possible.

If the neonate appears well (no indications for transfer) or if transfer is necessary but impossible:
– Keep under observation for at least 24 hours.
– Every 2 hours, check for any danger signs (Section 10.3.1) and monitor vital signs.
– Ensure routine care (Section 10.1).
– Begin breastfeeding as soon as possible.

If the neonate deteriorates during close observation, refer to Section 10.3 for further management.

Notas
(a) For more inf ormat ion, ref er t o t he Helping Babies Breat he t raining course.

10.3 Care of the sick newborn

10.3.1 Danger signs

Danger signs may present at delivery or develop within hours or days after birth.
All neonates should be examined for danger signs at birth, during their stay in maternity or at the first
post-natal visit if born at home.
If any of the following signs are present, treat immediately (Section 10.3.2) and transfer to a neonatal
care unit.
 Danger signs

Temperature • Hyperthermia (axillary temperature > 38 °C)

• Hypothermia (axillary temperature < 35.5 °C)

Neurological • Bulging fontanelle

signs • Hypotonia
• Lethargy or coma
• Unable to breastfeed
• Seizures including subtle or abnormal movements:
– deviation of the eyes with or without spasms, eyelid blinking
– sucking, smacking or other mouth movements
– swimming or pedalling movements

Respiration • Apnoea or bradypnoea (RR < 30/minute)

• Tachypnoea (RR > 60/minute)
• Severe chest indrawing
• Grunting

Heart • Tachycardia (HR > 180/minute)

• Prolonged capillary refill time (> 2 seconds)

Abdomen Severe abdominal distension

Skin colour • Generalised cyanosis (blue colouring)

• Extreme pallor
• Extensive jaundice (yellow colouring)

Skin • Umbilicus red or oozing blood or pus

• Numerous or large pustules

Joints Swollen, painful joint (irritability when moved) with reduced joint movement

Blood glucose Recurrent hypoglycaemia (blood glucose level < 2.5 mmol/litre or < 45 mg/dl on
more than 2 episodes)

10.3.2 General management

– Stabilise the neonate before transfer to the neonatal unit:
• Position the head to open the airway.
• Administer oxygen with an appropriate nasal cannula, at a maximum flow rate of 2 litres/minute (aim
for SpO2 90-95%).
• In the case of apnoea or if RR < 20/minute: perform bag and mask ventilation (Section 10.2.1).
• Check blood glucose and/or treat for hypoglycaemia (Section 10.3.4).

– While awaiting transfer:

• Keep neonate warm in a room at 23-25 °C wrapped in a blanket or under an infant warmer, and cover
the head with a cap.
• Closely monitor temperature, respiratory rate and SpO2.
• Start treatment for neonatal infection (Section 10.3.3).
• Ensure routine neonatal care (Section 10.1).
• Start or continue feeding (Appendix 4). Only if necessary, compliment feeds with a nasogastric tube
and/or IV fluids (Appendix 5).

In the case of severe respiratory distress, abdominal distension, or coma, do not feed the
neonate by mouth. Start IV fluids if possible (Appendix 5).

10.3.3 Neonatal infection

Neonates suspected to have severe neonatal infection
Danger signs may indicate an underlying severe infection which requires transfer to a neonatal unit and
antibiotic therapy.

While awaiting transfer to a neonatal unit, start antibiotic therapy:

– T he first line treatment is the combination of ampicillin IV + gentamicin IM. Ampicillin is preferably
used IV; the IM route is an option if the context does not permit proper IV administration. To avoid
multiple IM injections, however, it may be better to use procaine benzylpenicillin IM + gentamicin IM.
– If meningitis is suspected, do not use procaine benzylpenicillin.
– If the infection is cutaneous in origin, replace the ampicillin with cloxacillin IV. a
– Total treatment duration is 7 to 10 days according to clinical response. Gentamicin should be
stopped after 5 days of treatment.

Table 10.5 - Antibiotic dosages

 Birth weight
Antibacterial
≤ 2000 g > 2000 g

ampicillin 50 mg/kg every 12 hours 50 mg/kg every 8 hours

IV/IM injection If meningitis: If meningitis:
100 mg/kg every 12 hours 100 mg/kg every 8 hours

gentamicin 3 mg/kg every 24 hours 5 mg/kg every 24 hours

IM injection

procaine benzylpenicillin b 50 000 IU/kg every 24 hours

IM injection If meningitis: do not administer.

cloxacillin 25 mg/kg every 12 hours 25 mg/kg every 8 hours

IV infusion

Prophylactic treatment for asymptomatic neonates with risk factors for infection
In asymptomatic neonates (absence of danger signs) in whom the assessment for risk factors for
neonatal infection at birth was positive (Section 10.1.1, Clinical examination and assessment of risk
factors):
– Administer antibiotics for 48 hours [1] : ampicillin IV + gentamicin IM or procaine benzylpenicillin IM
+ gentamicin IM. See Table 10.5 for dosage.
– Monitor for danger signs (Section 10.3.1). If the neonate presents at least one danger sign, treat as
suspected severe infection as below.
– If the neonate has not presented any of the danger signs during the first 48 hours, stop the
antibiotics and keep under observation for 24 to 48 hours.
– If the neonate has not presented any of the danger signs during the observation period or during
clinical examination for discharge: send home. In this case, tell the parents which signs require
immediate consultation.

Note: neonates born at home, seen for the first time after 72 hours of age and present no signs of
infection, do not need prophylactic antibiotics even if a maternal risk factor is identified.

10.3.4 Hypoglycaemia
Hypoglycaemia is common in neonates but often asymptomatic or presents with non-specific
signs. Recurrent or persistent hypoglycaemia can lead to neurological sequelae.
Diagnosis
– Blood glucose < 2.5 mmol/l or < 45 mg/dl.
– Blood glucose is measured on a sample of capillary blood taken from the lateral aspect of the heel
using a lancet or 24G needle.

Always check blood glucose:

– In neonates at risk of hypoglycaemia (Section 10.1.1, Clinical examination and assessment of risk
factors)
– In neonates presenting with one of these signs:
• Hypothermia
• Irritability or tremors
• Bradypnoea or apnoea or cyanosis
• Hypotonia or poor response to stimulation or impaired consciousness
• Seizures

Management
Moderate hypoglycaemia (2 to 2.4 mmol/litre or 35 to 44 mg/dl) and asymptomatic
– Feed neonate immediately (preferably breast milk).
– If no milk is available, give 5 ml/kg of 10% glucose PO over 5 to 10 minutes.
– Check blood glucose after 30 minutes:
• If it is normal (≥ 2.5 mmol/litre or ≥ 45 mg/dl), ensure the neonate feeds regularly and check blood
glucose again before each feed until there are 3 consecutive normal results.
• If it remains < 2.5 mmol/litre or < 45 mg/dl), treat as recurrent hypoglycaemia.

Severe hypoglycaemia (< 2 mmol/litre or < 35 mg/dl) or symptomatic or recurrent

– Give 5 ml/kg of 10% glucose PO or via gastric tube over 5 to 10 minutes, or if IV line already in place,
give 2 ml/kg of 10% glucose slow IV (2 to 3 minutes).
– Check blood glucose after 30 minutes:
• If it is normal (≥ 2.5 mmol/litre or ≥ 45 mg/dl), ensure the neonate feeds regularly, recheck blood
glucose after 30 minutes and then before each feed until there are 3 consecutive normal results.
• If it is < 2.5 mmol/litre or < 45 mg/dl, or the neonate is still symptomatic, give a second dose of 10%
glucose (5 ml/kg PO or 2 ml/kg IV) and transfer to a neonatal unit. While awaiting transfer, start a
continuous infusion of 10% glucose (80 ml/kg/24 hours) if possible and continue to monitor blood
glucose.

Note: only if it is impossible to give an infusion or place a gastric tube, 1 ml/kg of 50% glucose can be
administered sublingually.

10.3.5 Jaundice
Neonatal jaundice is generally harmless, but severe jaundice can cause acute encephalopathy,
potentially leading to neurological sequelae and death.

Diagnosis
– Yellow colouring of the skin and sclerae due to increased levels of bilirubin in the blood. It appears
first on the face, and then moves to the chest and then the extremities.
– T he examination should be done in day light. It is done by pressing the neonate's skin and looking to
see if it is yellow immediately after the pressure is removed.
– Assess criteria for transfer to a neonatal care unit:

Table 10.6 - Criteria for transferring neonates with severe jaundice to neonatal unit

Age Criteria for transfer

Day 1 Any visible jaundice

Day 2 < 1500 g or risk factors (a) *: any visible jaundice

> 1500 g: moderate jaundice (head, chest, lower body, thighs)

Day 3 or < 1500 g or risk factors*: extensive jaundice (head, chest, lower body, arms, thighs,
later lower leg)
> 1500 g: very extensive jaundice (head, chest, lower body, arms, thighs, lower leg,
hands and feet)

(a) Risk f act ors include:

– ABO or Rh f act or incompat ibilit y bet ween mot her and neonat e.
– Inadequat e milk int ake (dehydrat ion, weight loss).
– G6PD deficiency: consider if severe jaundice in f amily hist ory or in prevalent regions (sub-Saharan Af rica,
Arabic peninsula and part s of Asia/Medit erranean).
– Neonat al inf ect ion
– Cephalohaemat oma/bruising

Management
Neonate does not have criteria for transfer
– Put neonate on breast 8 to 12 times per day.
– Monitor extent of jaundice for 12 to 18 hours.
– If all well the neonate can be discharged. Give mother routine discharge advice (Section 10.6) and
specific advice regarding the jaundice: to return if stools become pale and urine becomes dark or
jaundice prolonged beyond 2 weeks.
Neonate needs to be transferred
– Put neonate on breast 8 to 12 times per day for first few days if able to breastfeed. Supplement with
expressed breast milk or infant formula if necessary. Use gastric tube if oral intake is not possible.
– Begin treatment for infection, if present (Section 10.3.3).

10.3.6 Seizures
Seizures in neonates are often subtle, featured as any unusual repetitive or stereotypic movement
(Section 10.3.1).
– Check blood glucose and/or treat for hypoglycaemia (Section 10.3.4).
– Treat with phenobarbital IV if the seizure lasts more than 3 minutes, or recurs (> 2 to 3 episodes in
one hour), or is associated with cardiorespiratory disturbance:
• First dose: 20 mg/kg by slow IV infusion over 30 minutes. Phenobarbital should never be administered
as a rapid direct IV injection. Phenobarbital may be given IM (undiluted) if there is no IV access.
• If seizures persist 30 minutes after, administer a second dose of phenobarbital 10 mg/kg by slow IV
infusion over 30 minutes. If still no IV access, give the second dose of phenobarbital 10 mg/kg
(undiluted) IM at least 60 minutes after the first IM dose.
Do not give more than 40 mg/kg in total.
– Any neonate that required treatment with phenobarbital should be transferred to a neonatal care unit.
– Monitor the neonate closely while awaiting transfer. Ensure ventilation equipment is available as there
is a risk of respiratory depression.

Notas
(a) Due t o t he risk of local necrosis, cloxacillin should be administ ered by IV inf usion in 5% glucose or 0.9%
sodium chloride over 30 t o 60 minut es (or if not possible, by slow IV inject ion over at least 5 minut es).

(b) Do not administ er procaine benzylpenicillin by IV rout e.

Referencias
1. World Healt h Organizat ion. Pocket book of hospit al care in children. Guidelines f or t he management of
common childhood illnesses, second edit ion, 2013.
ht t p://www.who.int /mat ernal_child_adolescent /document s/child_hospit al_care/en/

10.4 Specific care when the mother has a

transmissible infection
10.4.1 Syphilis
– Look for signs of syphilis in all neonates of mothers in case of positive syphilis test and/or suspected
maternal syphilis infection:
• Mucocutaneous rash, grey patches, papules and bullae followed by desquamation of the skin on the
palms and soles of the feet;
• Sepsis, jaundice, anaemia, enlarged lymph nodes and abdominal distension with hepatosplenomegaly.
– Verify that the mother received an adequate treatment for syphilis at least one month before delivery
(see Chapter 4, Section 4.2.1).
– Based on the findings, administer one of the following treatments:

Criteria Treatment

Neonate has clinical signs of syphilis benzylpenicillin IV:

or D1 to D7: 50 000 IU/kg (= 30 mg/kg) every 12
Mother did not receive adequate treatment hours
during pregnancy D8 to D10: 50 000 IU/kg (= 30 mg/kg) every 8
hours
or
benzylpenicillin procaine IM:
D1 to D10: 50 000 IU/kg (= 50 mg/kg) every 24
hours

Neonate has no clinical signs of syphilis benzathine benzylpenicillin IM:

and 50 000 IU/kg (= 37.5 mg/kg) single dose
Mother received adequate treatment during
pregnancy

– In addition to “standard” precautions, use “contact” precautions (gloves and protective gown) at
each contact with the neonate during the first 24 hours after starting the treatment.

10.4.2 Genital gonococcal and/or chlamydial infection

Neonates of mothers with purulent cervical discharge at the time of delivery may be asymptomatic or
may present with symptomatic conjunctivitis.
– For neonates with symptomatic conjunctivitis (whether the mother is symptomatic or not) or born to
mothers who were symptomatic at the time of delivery (even if they are asymptomatic):
• Clean each eye with 0.9% sodium chloride at least 4 times daily until discharge disappears.
• Administer at birth a single dose of ceftriaxone IM: 50 mg/kg; max. 125 mg (or cefotaxime IM: 100
mg/kg if ceftriaxone is contraindicated).

– If the conjunctivitis persists 48 hours after the ceftriaxone injection, administer :

azithromycin PO: 20 mg/kg once daily for 3 days (or, if azithromycin is not
available, erythromycin PO: 12.5 mg/kg 4 times daily for 14 days)

– If the symptoms appear after 7 days of life, administer simultaneously ceftriaxone IM + azithromycin
or erythromycin PO, as above.

10.4.3 Genital herpes

Neonates of mothers who have active genital herpes lesions at the time of delivery may present with
neonatal herpes.
T he neonate is usually asymptomatic at birth. T he symptoms appear sometime within the first 4 weeks
of life (usually between 7 and 14 days of life).

– Look for signs of neonatal herpes:

• Vesicular lesions on skin, mouth and/or eyes (only in 45% of neonates).
• Cerebral involvement: encephalitis and seizures.
• Non-specific signs of disseminated infection (irritability, lethargy, fever, poor feeding).

– Management depends on the neonate’s risk at birth:

 Criteria for risk of herpes infection Treatment [1]

High

Neonate with signs of herpes

OR
Mother has primary genital herpes lesions at the
moment of delivery Immediately apply one dose of 3% aciclovir
OR eye ointment in each eye at birth. (a)
Mother has genital herpes lesions at the moment of Refer to neonatal care unit for IV aciclovir
delivery and it is unknown whether it is a primary or treatment.
recurrent infection
OR
Mother with recurrent genital herpes lesions at the
moment of delivery
WIT H
at least one of the following risk factors:
• rupture of membranes ≥ 6 hours before delivery
(even if caesarean section)
• birth weight < 2000 g or preterm ≤ 37 weeks
• neonatal skin laceration or maternal HIV infection

Low Immediately apply one dose of 3% aciclovir

eye ointment in each eye at birth. (a)
Neonate is asymptomatic Observe for 5 days:
AND • If the neonate becomes symptomatic: refer
Mother has recurrent genital herpes lesions at the to neonatal care unit for IV aciclovir
moment of delivery treatment.
AND • If the neonate remains asymptomatic:
Absence of risk factors in previous column. discharge; ask parents to seek urgent
attention if symptoms appear.

(a) In t his case, wait 12 hours bef ore applying t et racycline eye oint ment (Sect ion 10.1.1, Preventive treatments).

– In addition to “standard” precautions, use “contact” precautions (gloves and protective gown) at
each contact with the neonate for 24 hours after the start of treatment.

10.4.4 Hepatitis B infection

T he neonate is asymptomatic.
Hepatitis B vaccine should be given to the neonate at birth, regardless of the mother’s serological
status (Section 10.1.1, Vaccinations).
10.4.5 HIV infection
T he neonate is asymptomatic.
Antiretroviral prophylaxis should be started immediately after birth: refer to the PMT CT guides.
For breastfeeding: see Appendix 3, Section 3.7.

10.4.6 Active tuberculosis

For all neonates born to mothers with active tuberculosis at birth:
– Do not administer BCG.
– Administer preventive therapy with isoniazid PO: 10 mg/kg once daily for 6 months.
– Administer the BCG vaccine after completion of isoniazid therapy.
– Do not separate the mother from the neonate (breastfeeding, etc.), but observe the rules for
transmission prevention.
For more information, refer to the guide Tuberculosis, MSF.

Referencias
1. Neonat al herpes simplex virus inf ect ion: Management and prevent ion, Gail J Demmler-Harrison, UpToDat e,
Lit erat ure review current t hrough: Oct 2013, last updat e: Mar 7, 2013.

10.5 Care of the low birth weight neonates

(< 2500 g)
Low birth weight indicates prematurity (less than 37 weeks) or intrauterine growth restriction or a
combination of the two.

Low birth weight neonates, whether preterm or not, are at significant short-term risk of hypothermia,
hypoglycaemia, apnoea, respiratory distress, jaundice, infection, anaemia, dehydration and feeding
problems, and at significant long-term risk of poor psychomotor development.

Neonates who are sick or who weigh less than 1500 g should be referred to a neonatal care unit
whenever possible.
Neonates who weigh 1500 to 2500 g, regardless of the term, are managed in the maternity hospital if
they are not sick, according to the recommendations below.
10.5.1 Kangaroo care
Figures 10.4 - Kangaroo care

T he Kangaroo mother care a is a method of caring for neonates that involves putting them on the
mother's chest skin-to-skin, preferably 24 hours a day.
T his method can be used for all non-sick neonates less than 2500 g (prematurity and/or intrauterine
growth restriction).

T he neonate is placed vertically against the mother’s chest (may wear nappy and socks); the mouth
should always be able to reach the nipple. Keep the neonate in position using a cloth.
If needed, use a blanket to keep the mother and neonate warm.
When the mother is sleeping, her bust should be raised and the neonate should be monitored.

T he objectives of the Kangaroo care are:

– To keep the neonate warm and to prevent or treat hypothermia.
– To help get breastfeeding started and keep it going.
– To foster the mother-infant bond and reduce the neonate’s stress.
– To reduce episodes of apnoea and bradycardia in preterm neonates.

Note: the skin-to-skin contact can also be done by the father, another family member or a wet-nurse
during periods when the mother is not available.

10.5.2 Thermoregulation
– Cover the neonate’s head to reduce heat loss.
– Make sure that the room temperature is between 23-25 °C.
– Use the Kangaroo care (Section 10.5.1).
10.5.3 Feeding
– Exclusive breastfeeding is the best choice (Appendix 3).
– If sucking is ineffective but the swallowing reflex is present, express the milk manually or using a
breast pump and feed the neonate using a cup/spoon (Appendix 3, Section 3.2 and Section 3.3).
– If sucking is ineffective and the swallowing reflex is poor or absent, express the milk and feed the
neonate using a gastric tube (Appendix 3, Section 3.2 and Section 3.4).
– For the daily amounts required for feeding, see Appendix 4.
– If the mother does not have enough milk:
• In the first 72 hours of life, make up the required amounts with 10% glucose PO.
• After 72 hours of life, make up the amount with infant formula (or if not available, use diluted F 100
milk b ).
At the same time, continue to stimulate the mother’s milk production (breast pump and the
“supplementary nursing" technique, Appendix 3, Section 3.5).
– In all cases, try putting the neonate to the breast periodically to test if breastfeeding is effective or
not.
– In the event of regurgitation:
• Administer each meal very slowly.
• Hold the neonate tilted slightly head-up.
– In the event of vomiting, abdominal distension, blood in the stool or greenish, foul-smelling stool,
stop feeding and call the doctor immediately.
– Very low birth weight neonates (< 1500 g) have a high risk of developing acute necrotising
enterocolitis with early oral feeding. For the first 48 hours, give a 10% glucose IV continuous infusion
(Appendix 5). If the neonate is clinically stable, very small amounts of breast milk of 10 ml/kg per day
can be started on D1 while awaiting transfer to a neonatal care unit.
– If it is not possible to administer an IV infusion or to transfer to a neonatal care unit, give expressed
breast milk and 10% glucose together orally (Appendix 4).

10.5.4 Monitoring
Same monitoring as for a neonate > 2500 g, plus:
– Daily weighing;
– Temperature every 4 hours;
– Blood glucose test before every meal or every 3 hours until there are 3 consecutive normal results. In
the event of hypoglycaemia, see Section 10.3.4.

Notas
(a) For more inf ormat ion: World Healt h Organizat ion. Kangaroo mot her care: a pract ical guide. 2003.
ht t p://apps.who.int /iris/bit st ream/handle/10665/42587/9241590351.pdf ?sequence=1

(b) Dilut ed F-100 milk: 1 sachet (456 g) of F-100 milk in 2800 ml of wat er.
10.6 Criteria for discharge from the
maternity hospital

– No danger signs (Section 10.3.1).

– Appropriate management of neonatal infection (Section 10.3.3 and Section 10.4) and risk factors
for neonatal infection (Section 10.1.1, Assessment for risk factors for neonatal infection).
– Healthy neonate: good breastfeeding on demand, normal respiration and temperature, etc.
– Weight > 1500 g.

AND

– Preventive treatments and BCG, hepatitis B and polio (0) vaccines administered (Section 10.1.1).
– Clinical record filled out (including discharge weight).
– Postnatal visit appointment (Chapter 11, Section 11.3) given.
– Single use 3 g sachets of 7.1% chlorhexidine digluconate given to complete 7 days of cord care
at home in settings with harmful practices (e.g. application of milk, soil, honey, butter, dung on the
cord stump). Show the mother how to apply the product on the cord.

AND
 Information for the mother
– Breastfeeding: Appendix 3.
– Care for the baby:
• Wash the baby with soap and water once daily, and immediately dry with a towel or cloth to avoid
the baby getting cold.
• Cord care: clean with soap and water each time it is soiled, rinse well and dry then let it uncovered.
Do not apply any harmful substances on the cord. T he cord falls between the fifth and fifteenth day
after birth.
• Kangaroo care if weight < 2500 g (Section 10.5.1).
• Lay baby on the back.
• Use a mosquito net day and night when the baby sleeps.
• Keep the baby away from sick (contagious) children and adults.
• Wash hands before and after caring for the baby.
– Danger signs requiring a consultation:
• Difficulty with or unable to breastfeed properly.
• Abnormal movements
• Trouble breathing
• Abnormal colouring
• Redness or purulent discharge from the umbilicus
• Fever

Chapter 11: Postpartum period

11.1 Normal postpartum events

11.2 Postpartum care for the mother

11.3 Postnatal consultations

11.4 Postpartum complications

11.5 Contraception

11.1 Normal postpartum events

T he postpartum period extends from delivery to six weeks after delivery. T his is the time it takes for
the uterus to return to its initial size and for pregnancy-related biological and hormonal changes to
disappear.

11.1.1 Uterine involution

– After the delivery of placenta, the uterus contracts and becomes hard. It is palpable below the
umbilicus.
– Around the fifth or sixth day, it is halfway between the navel and the symphysis pubis.
– Around the tenth day, it is at the symphysis pubis.
– After 6 weeks, it returns to its normal size.
– T he internal os closes between the eighth and twelfth day.

11.1.2 Lochia
Vaginal discharge, which is bloody during the first 3 days and then blood-tinged. It is usually odourless
and stops after 15 to 21 days.

11.1.3 Lactation
– T he first two days: secretion of yellowish colostrum.
– Around the third day, breast tenderness, sometimes accompanied by a short-lived fever of 38-38.5
°C. T he composition of the milk changes: mature milk, which is whiter and more abundant.

11.1.4 Return of menstrual periods

T he first menstrual period usually occurs between the sixth and eighth week in women who are not
breastfeeding.

11.2 Postpartum care for the mother

More than 60% of maternal deaths occur in the post-partum period and 45% of postpartum deaths
occur within the first 24 hours. Women should therefore remain in the health care facility for at least 24
hours [1] after delivery.

11.2.1 In the maternity hospital

Following the immediate postpartum (Chapter 5, Section 5.2.2), monitor during the first day (and daily if
the patient stays for more than 24 hours):
– Vital signs (heart rate, blood pressure, temperature, respiratory rate) 2 times daily.
– Uterine involution.
– Vaginal bleeding.
– Perineal tear/episiotomy scar.
– Urination and bowel movement.
– Signs of anaemia (if present, measure haemoglobin).
Record all information in the patient’s chart.
In case of caesarean section, see Chapter 6, Section 6.4.

Inform and advise the mother:

– Personal hygiene (clean the perineum daily with soap and water, change sanitary napkins every 4 to 6
hours).
– Mobilisation and ambulation to prevent thrombosis.
– Care of the neonate (Chapter 10, Section 10.6).
– Breastfeeding (Appendix 3).
– Maternal signs requiring immediate consultation:
• significant vaginal bleeding (e.g., sanitary napkin needs to be changed every 20 to 30 minutes during
1 to 2 hours and/or expulsion of clots in several occasions),
• headache with visual disturbance or nausea and vomiting; seizures,
• difficult or rapid breathing,
• fever,
• significant abdominal pain,
• foul-smelling vaginal discharge,
• urinary leakage,
• hot, red, painful breast,
• emotional instability, depression, etc.
– Contraception (Section 11.5).

Special situations: intrauterine foetal death or neonatal death or child abandonment.

In the absence of contra-indication (cardiac valvulopathy, hypertension, preeclampsia, history of

postpartum psychosis), lactation may be suppressed by using:
cabergoline PO: 1 mg single dose on the first day postpartum to inhibit lactation or 0.25 mg every 12
hours for 2 days to suppress established lactation.

Note: the use of cabergoline is limited to the above particular situations.

If cabergoline is not available or contra-indicated:
– Do not use any other dopamine agonists such as bromocriptine.
– Do not compress the breasts by a bandage (uncomfortable and ineffective).
– Wearing a bra at all times (day and night) and paracetamol can reduce the discomfort of lactation. In
the absence of stimulation, milk production stops within one to two weeks.

In addition, psychological support should be offered to all women concerned at the maternity hospital
and in postpartum period. See Chapter 4, Section 4.11.2.

11.2.2 Upon discharge

– If there is no clinical anaemia, continue iron + folic acid supplementation for 3 months [1] (Chapter
1, Section 1.2.5). In case of anaemia, see Chapter 4, Section 4.1.
– Give vitamin A (retinol PO: 200 000 IU single dose) in countries where night blindness is a public health
problem (follow national recommendations).
– Schedule an appointment for the postnatal consultation (Section 11.3).
– Verify that information and advice were given.

Referencias
1. World Healt h Organizat ion. WHO recommendat ions on post nat al care of t he mot her and newborn. 2013.
ht t p://www.who.int /mat ernal_child_adolescent /document s/post nat al-carerecommendat ions/en/

11.3 Postnatal consultations

11.3.1 Timing of postnatal consultations

Two postnatal consultations, for the mother and neonate, should be offered within the first 6 weeks
after delivery:
– T he first within the first week, especially for women who delivered at home (Section 11.3.2
and Section 11.3.3). For patients who delivered in a health care facility and stayed there for more than
24 hours, the discharge consultation for the mother and neonate is considered the first postnatal
consultation.
AND
– T he second within 4 to 6 weeks for a routine clinical examination and to address any potential
complications.
If the neonate weighs less than 2000 g, a weekly consultation is recommended for the first month, and
then at 6 weeks.

11.3.2 For the mother

– Assess vital signs: heart rate, blood pressure, temperature, respiratory rate.
– Assess uterine involution.
– Assess the healing of the incision in cases of caesarean section.
– Examine the vulva and perineum: look for tears, assess the healing of episiotomy or sutured wound,
and appearance and odour of lochia.
– Inquire about urination and bowel movement. In the event of urine leakage, look for potential fistula
(Chapter 7, Section 7.2.5).
– Check for breast lesions.
– Look for signs of anaemia. If there is no clinical anaemia, continue iron + folic acid supplementation
for 3 months (Chapter 1, Section 1.2.5). In the event of clinical anaemia, see Chapter 4, Section 4.1.
– If malnutrition is present (MUAC ≤ 230 mm), place the woman into a therapeutic feeding
programme. In situations where food is scarce, food supplementation is recommended for all breast-
feeding women even in absence of signs of malnutrition.
– Perform a dipstick urinalysis if there are any symptoms of urinary tract infection and/or fever and/or
hypertension.
– Offer HIV counselling and testing if not done during pregnancy or delivery.
– Note the mother-infant interaction, and the mother’s psychological state.
– Provide information on contraception (time until fertility returns, available contraceptive methods,
efficacy, benefits, constraints, and adverse effects of each method) and provide contraceptive if
desired (Section 11.5).
– Administer vitamin A if indicated; only if not done after delivery (Section 11.2.2).
– Complete tetanus vaccination if necessary.
– Give information and advice: signs requiring immediate consultation (Section 11.2.1), hygiene,
breastfeeding, use of insecticide-treated mosquito nets for mother and neonate.

11.3.3 For the neonate

– Repeat full clinical examination including:
• Vital signs, danger signs, signs of neonatal infection (Chapter 10, Section 10.3.1), signs of infection
transmissible from mother (Chapter 10, Section 10.4).
• Weight, height, any abnormalities (Chapter 10, Section 10.1.1, Routine clinical examination).
– Check haemoglobin if any signs of anaemia (pallor of conjunctivae, palms of the hands and soles of
the feet).
– Refer to neonatal care unit if:
• Danger signs/signs of infection (start treatment while waiting for transfer)
• Haemoglobin < 10 g/dl
– Evaluate risk factors for neonatal infection (Chapter 10, Section 10.3.2). Note that home delivery is,
in itself, a (minor) risk factor for neonatal infection.
– Assess breastfeeding: attachment to breast, frequency/interval between feeds (Appendix 3),
hydration status.
– Check if routine care was provided at birth. If the neonate was born at home and/or did not receive
routine care at birth (Chapter 10, Section 10.1), complete the following:
1 - Cord care
• Clean cord with soap and water if soiled, then dry.
• Apply 7.1% chlorhexidine digluconate.
• In settings where harmful practices to the cord are common, continue treatment at home as
indicated in Section 10.6.
2 - Other routine care
• Tetracycline eye ointment (if neonate seen within 7 days after birth).
• Vitamin K1.
• Routine vaccinations: BCG, hepatitis B monovalent, polio 0.
• Provide vitamin D supplement until age 6 months (Chapter 10, Section 10.1.1).
• Ensure antiretroviral prophylaxis where necessary (Chapter 10, Section 10.4).

11.3.4 Postnatal care card

Register all relevant information on an individual postpartum follow-up card (Appendix 6).

11.4 Postpartum complications

11.4.1 Excessive uterine bleeding

Usually the amount of lochia is similar to a normal menstrual period. If the discharge is heavier, consider
retained placenta and/or endometritis.
In case of suspected retained placenta:
– Digital curettage or manual vacuum aspiration or extremely cautious instrumental curettage, with
antibiotic coverage (Chapter 9).
– Antibiotherapy for 5 days:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin):
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
or
amoxicillin PO: 1 g 3 times daily + metronidazole PO: 500 mg 3 times daily

11.4.2 Infectious complications

Look for an infection in patients with fever higher than 38 °C for more than 48 hours.

Postpartum endometritis and salpingitis

Clinical features
– Fever, usually high
– Abdominal and/or pelvic pain, foul-smelling or purulent vaginal discharge
– Uterus enlarged, soft, painful when mobilized; open cervix; swelling in the posterior fornix

Management
– Admit to inpatient department; administer antibiotherapy:
amoxicillin/clavulanic acid IV (dose expressed in amoxicillin): 1 g every 8 hours + gentamicin IM: 5
mg/kg once daily
or
ampicillin IV: 2 g every 8 hours + metronidazole IV: 500 mg every 8 hours + gentamicin IM: 5
mg/kg once daily
Continue this treatment 48 hours after resolution of fever and other clinical signs [1] .

For early, minor forms (no fever, minor pain), outpatient treatment is possible with:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin) for 5 to 7 days:
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)

– Look for retained placenta and perform uterine evacuation after 24 to 48 hours of antibiotherapy. If
the patient is haemodynamically unstable due to haemorrhage or infection, perform uterine evacuation
immediately.

Pelvic abscess or peritonitis

A complication of untreated puerperal endometritis/salpingitis.
Clinical features
– Abdominal guarding or spasm, ileus, pelvic mass

Management
– Laparotomy or, in case the abscess is confined to the Pouch of Douglas, colpotomy to drain the
abscess.
– Same antibiotherapy as for postpartum endometritis and salpingitis.

Other infectious complications

– Abscess after caesarean section.
– Lymphangitis and breast abscess (Section 11.4.3).
– Pyelonephritis (Chapter 4, Section 4.2.3).

Note: in case of fever, systematically test for malaria in endemic areas.

11.4.3 Breast-related complications

Cracked nipples
Clinical features
– Nipple erosion and intense pain when starting to nurse.
– No fever (except when associated with lymphangitis).

Management
– Clean with soap and clean water before and after each feeding; dry carefully.
– Observe the neonate while nursing, and correct the position if necessary. Cracked nipples are often
caused by incorrect latching onto the breast.

Breast engorgement
Clinical features
– Bilateral pain 2 to 3 days after childbirth; firm, painful breasts.

Management
– Cold or warm compresses (before nursing); more frequent nursing.
– Gentle manual expression (Appendix 3) before nursing, if the neonate cannot latch onto the overly
distended breast or after nursing to finish emptying the breast.
Engorgement subsides in 24 to 48 hours.

Lymphangitis
Clinical features
– Unilateral pain, 5 to 10 days after childbirth. Local inflammation, red, hot painful with no fluctuation.
– High fever (39-40 °C); enlarged axillary lymph node.
– No pus in the milk collected on a compress.

Management
– Empty the breast by nursing the neonate frequently on the involved side. If the mother finds nursing
too painful, temporarily stop nursing on the painful side (but empty the breast manually) and continue
breastfeeding with the other breast.
– Routine analgesia (paracetamol PO, Appendix 7).

Breast infections (mastitis, abscess)

Clinical features
– Mastitis:
• Firm, red, painful, swollen area of one breast associated with fever.
• Axillary lymph node may be enlarged.
• Purulent discharge from the nipple.
– Breast abscess: fluctuant, tender, palpable mass.

Management
– Temporarily stop nursing on the affected side. Carefully express all milk from the infected breast
(manually).
– Routine analgesia (paracetamol PO, Appendix 7); cold or warm compresses.
– Antibiotherapy with activity against staphylococci may prevent progression to breast abscess
(cloxacillin PO: 1 g 3 times daily for 7 days).
– Breast abscess: urgent drainage as the abscess can quickly spread, and antibiotherapy as above.

11.4.4 Urine leakage

Clinical features
– Look for a possible vesicovaginal fistula, especially after a prolonged labour.

Management
– If there is a fistula: see Chapter 7, Section 7.2.5.
– If there is no fistula, stress incontinence is likely: propose exercises to strengthen the pelvic floor.

Stress incontinence is more common among grand multiparas, after a forceps or vacuum extraction,
and in cases of foetal macrosomia. It usually disappears within 3 months with pelvic floor exercises.
11.4.5 Psychological disorders
“The baby blues”
T his syndrome has its onset within days after the delivery and lasts usually 2 weeks.
It is characterised by mood swings, crying, irritability, anxious worrying centred on the neonate, and
doubts about the ability to be a “good mother”, combined with insomnia, loss of appetite and
concentration problems.
T hese problems generally diminish within a few days. Reassurance, family support and follow-up to
ensure that the patient does not develop depression are usually sufficient.

Postpartum depression
Postpartum depression develops in the first weeks after childbirth; it can be severe and is often
underestimated.
T he characteristic symptoms of depression are sadness, frequent crying, loss of self-confidence,
constant concerns about the child (or, on the contrary, a feeling of indifference), feeling incompetent
as a mother, and feelings of guilt (or even aggressive thoughts toward the child) combined with
insomnia and loss of appetite. T hese symptoms last more than 2 weeks and gradually worsen, leading
to a state of exhaustion.
T he interview should look for possible suicidal thoughts and assess the mother’s ability and desire to
take care of the child (depression can have repercussions for the child’s development).
An understanding and reassuring attitude and help with daily activities by family and friends are
essential.
Antidepressant medication may be necessary (choose an antidepressant compatible with
breastfeeding, which should be continued whenever possible). Refer to the Clinical guidelines, MSF.

Note: postpartum depression is more frequent after a stillbirth or intrauterine foetal death.

Postpartum psychosis
T his occurs less frequently and is characterised by the onset of psychotic symptoms after childbirth.
Symptoms include irritability, major mood swings, delusions, hallucinations, and disorganised, bizarre
and sometimes violent behaviour.
T he patient should be sent to a doctor immediately. Antipsychotic treatment, and usually
hospitalisation, is necessary. Refer to the Clinical guidelines, MSF.

Referencias
1. World Healt h Organizat ion. Managing Complicat ions in Pregnancy and Childbirt h, 2017.
ht t ps://apps.who.int /iris/bit st ream/handle/10665/255760/9789241565493-
eng.pdf ;jsessionid=28797ACA5A26CA683EAD63F667EA7107?sequence=1
11.5 Contraception
Contraceptive methods should be chosen based on the preference of the woman and potential
medical contra-indications identified through clinical history and examination.

T he essential clinical examinations are:

– For hormonal contraception: blood pressure. Oestroprogestogens, also called combined oral
contraceptives (COCs), are contra-indicated in women with hypertension (≥ 140/90
mmHg). Progestogen-only injectables are contra-indicated in women with severe hypertension (≥
160/100 mmHg).
– For an intrauterine device (IUD): speculum and digital vaginal examination. Placement of an IUD is
contra-indicated in case of active genital infection. It is performed after the infection has been
treated.

In all cases, exclude pregnancy (perform pregnancy test if in doubt).

No laboratory testing is required for prescribing contraceptives.

T he effectiveness of contraceptives is measured by the number of unintended pregnancies for every

100 women within the first year of correct regular use of contraception.

Table 11.1 Contraceptive failure rates a

T his table shows the effectiveness of contraceptives from most to least effective with typical use.

Methods Unintended pregnancies per 100 women

Progestogen implants
0.05%
Etonogestrel (ET G) or levonorgestrel (LNG)

Levonorgestrel IUD (LNG-IUD) 0.2%

Copper IUD (Cu-IUD) 0.8%

Progestogen-only injectable
6%
Medroxyprogesterone (DMPA)

Progestogen-only pills (POP)

9%
Levonorgestrel (LNG) or desogestrel

COC
9%
Ethinylestradiol (EE) + levonorgestrel (LNG)
To make a contraceptive choice, women should be advised and informed about the different methods
available and their effectiveness.

11.5.1 Main contraceptive methods

Contraception can be started at any time (according to woman's wishes), as long as it is reasonably
certain that she is not pregnant. T he woman should be informed that the protection may take a few
days and that condoms must be used during this period [1] .

Additional contraception (condoms) is not required if the method is started:

– With a Cu-IUD.
– Within 5 days of the start of her period if the woman uses a POP or a COC.
– Within 7 days of the start of her period if the woman uses a progestogen implant or a LNG-IUD or
a progestogen-only injectable.
– Within 7 days of a first or second trimester abortion, for any method of contraception.
– Within 28 days postpartum, whether the woman is breastfeeding or not; for any method of
contraception.
– After 28 days up to 6 months postpartum if the conditions for lactational amenorrhoea (Section
11.5.2) are met, for any method of contraception.

Outside of these conditions, the delay in protection is 2 days for a POP and 7 days for a progestogen
implant, a LNG-IUD, a progestogen-only injectable or a COC.

Contraceptives can be used immediately after childbirth (or abortion) and during breastfeeding, except
for COCs which can be started at least 21 days after childbirth if the woman is not breastfeeding
and at least 6 weeks after childbirth if the woman is breastfeeding.

All these methods are reversible. Return of fertility is prompt after stopping (or removing)
contraception, with the exception of progestogen-only injectables.

Hormonal contraception
Progestogen implants
One (or two) rods inserted under the skin of the upper arm, under local anaesthesia.
– Protection: 3 years for ET G; 5 years for LNG. After this period the implant must be replaced if this
method of contraception is still desired. It may be removed at anytime by a health professional if the
contraception is no longer desired.
– Specifics to underline: effectiveness does not depend on compliance; bleeding may occur at any
time (irregular) or there may be no monthly bleeding (amenorrhoea); the implant is discreet but palpable
under the skin.
Progestogen-only injectable
One injection every 13 weeks. T here are 2 forms: DMPA-IM administered by IM route by a health
professional and DMPA-SC for self-injection by SC route.
– Protection: 3 months.
– Specifics to underline: no daily administration; discreet method (no evidence of contraception); self-
administration possible (DMPA-SC); long delay in return to fertility (on average 5 months after stopping
injections, sometimes up to 1 year [1] ); bleeding may occur at any time (irregular) or there may be no
monthly bleeding (amenorrhoea).

Oral contraceptives
• POP
One tablet every day at the same time, without interruption, including during menstruation.
– Protection: ceases as soon as the contraceptive is stopped.
– Specifics to underline: effectiveness depends on compliance (risk of forgetting the pill); respect of
precise time pill should be taken (no more than 3 hours late for LNG and 12 hours for desogestrel);
bleeding may occur at any time (irregular) or there may be no monthly bleeding (amenorrhoea).
• COC
One tablet every day, preferably at the same time, without interruption, including during menstruation
(for 28-day pack with 21 active tablets of EE + LNG and 7 inactive tablets of iron salts) b .
– Protection: ceases as soon as the contraceptive is stopped.
– Specifics to underline: effectiveness depends on compliance (risk of forgetting the pill).

For more information on hormonal contraceptives, including contra-indications, drug interactions,

precautions, refer to the guide Essential drugs, MSF.

Intrauterine device
Device inserted in the uterus within 48 hours after childbirth. If not inserted within 48 hours, delay
insertion for 4 weeks [1] .
Can be used by women who have not had children.
T here are 2 types available: hormonal IUDs that release levonorgestrel and copper IUDs.
– Protection: 5 years for a LNG-IUD; 10 years for a Cu-IUD.
After this period the IUD should be changed if this method of contraception is still desired. It can be
removed at any time by a health professional if this contraception is no longer desired.
– Specifics to underline: effectiveness does not depend on compliance; bleeding may occur at any
time (irregular) or there may be no monthly bleeding (amenorrhoea) with LNG-IUD; prolonged bleeding
and cramping particularly in the first few months with Cu-IUDs; IUD strings may be felt by the partner.

11.5.2 Other methods

Condoms
Condoms (male and female) are used for protection against sexually transmitted infections and also as
a temporary method of contraception. T hey are sometimes used simultaneously with another type of
contraception. T heir effectiveness depends on consistent correct use with each act of intercourse.
T he contraceptive failure rate is high (18% for male condoms and 21% for female condoms).

Lactional amenorrhea method

Breastfeeding is an effective (98%) temporary method of contraception but only if all 3 following
conditions are met: 1) the mother’s bleeding has not returned, 2) exclusive breastfeeding day and night,
3) infant is under 6 months old.

Sterilisation
Tubal ligation is an irreversible surgical procedure. It is performed in certain cases (e.g. if a subsequent
pregnancy carries life-threatening risks for the woman and she desires permanent contraception)
during a surgical procedure or caesarean section. Written patient consent is required before
performing the intervention.

11.5.3 Special situations

HIV infection
Condom use helps prevent HIV transmission to a partner, reinfection by other strains of the HIV virus if
the partner is HIV-positive, and transmission of other sexually transmitted infections. HIV-positive
patients should systematically use condoms.

To prevent an unintended pregnancy, another effective method of contraception must also be used.

Treatment with liver enzyme inducers

Liver enzyme inducers reduce the effectiveness of implants and oral contraceptives [2] . For women
taking liver enzyme inducers (rifampicin, rifabutin, efavirenz, nevirapine, lopinavir, ritonavir,
phenobarbital, phenytoin, carbamazepine, griseofulvin, etc.): recommend an IUD or a progestogen-only
injectable.

Emergency contraception
Every woman should be informed about and have access to emergency contraception.
It should be used as soon as possible within 5 days or 120 hours after unprotected or inadequately
protected sex (forgotten pill or condom breaking, etc.).
T here are three possible options:
levonorgestrel PO: 1.5 mg single dose (3 mg single dose in women taking an enzyme inducer [2] )
or ulipristal acetate PO: 30 mg single dose
or a Cu-IUD

Notes:
– T here is no contra-indication for oral emergency contraceptives.
– For women taking liver enzyme inducer(s), use levonorgestrel (3 mg) or a Cu-IUD.
– Placement of the IUD is contra-indicated in case of active genital infection. c

Notas
(a) For more inf ormat ion see: Cent res f or Disease Cont rol and Prevent ion. Ef f ect iveness of Family Planning
Met hods.
ht t ps://www.cdc.gov/reproduct ivehealt h/cont racept ion/unint endedpregnancy/pdf /Cont racept ive_met hod
s_508.pdf

(b) If using 21-day pack: one t ablet daily f or 21 days, f ollowed by a t ablet -f ree int erval of 7 days.

(c) For more inf ormat ion see: World Healt h Organizat ion. Medical eligibilit y crit eria f or cont racept ive use, fif t h
edit ion 2015.
ht t ps://apps.who.int /iris/bit st ream/handle/10665/181468/9789241549158_eng.pdf ?sequence=1

Referencias
1. World Healt h Organizat ion. Family Planning - A global handbook f or providers, 2018.
ht t ps://apps.who.int /iris/bit st ream/handle/10665/260156/9780999203705-eng.pdf ?sequence=1

2. FSRH. Clinical Guidance: Drug Int eract ions wit h Hormonal Cont racept ion, 2018.
ht t ps://www.f srh.org/st andards-and-guidance/document s/ceu-clinical-guidance-drug-int eract ions-wit h-
hormonal/

Chapter 12: Termination of pregnancy

12.1 Care before termination of pregnancy

12.2 Medication abortion

12.3 Aspiration
12.1 Care before termination of pregnancy
T his chapter describes termination of pregnancy (ToP) for intrauterine pregnancies up to 22 weeks
LMP.

12.1.1 Information and counselling

T he decision to end a pregnancy belongs to the patient. Her decision should be respected, and there
should be no judgment. T he role of the health care staff is to allow her to make an informed choice, to
provide safe care and a confidential environment.

Prior to the ToP, ensure information and counselling:

– Listen to the patient: thoughts, feelings, situation, needs and concerns.
– Discuss ToP methods: description, advantages and disadvantages, follow-up.
– Discuss post-abortion contraception options (Chapter 11, Section 11.5).
Staff are required to respect the confidentiality of the consultation, the examination and the
procedure.
T he patient's consent for ToP should be clearly expressed.

12.1.2 History and examination

– In case of doubt perform a pregnancy test. No other laboratory test is routinely required.
– Estimate the gestational age (date of last menstrual period and/or uterine size by bimanual
examination or abdominal palpation); routine ultrasound is not recommended.
– Look for current problems and treat accordingly: sexually transmitted infection (e.g. abnormal vaginal
discharge), signs of ectopic pregnancy, pelvic pain, fever, severe anaemia, etc.
– Take medical and obstetric history: look for contra-indication to ToP and/or subsequent
contraception methods.
– In rare cases where an intrauterine device (IUD) is in place, it should be removed if possible.

12.1.3 Choosing a method

Before 13 weeks LMP
T here are 2 methods: medication abortion and aspiration. Instrumental curettage must not be used.

Table 12.1 - Comparison between the 2 methods

 Medication abortion Aspiration

Advantages • Non-invasive method. • Immediate result.

• Can be done at home. • No absolute contra-indications.
• No antibiotic prophylaxis required. • An IUD can be inserted at the end of
the procedure.

Disadvantages • No immediate result (takes hours to • Invasive method.

days). • (Low) risk of uterine perforation or
• Heavy bleeding and cramping as the cervical laceration.
pregnancy is expelled. • Antibiotic prophylaxis required.
• Aspiration required in the event of
failure.

T he choice of the method depends on the woman's preference and the feasibility in a given context. In
most cases, medication abortion is preferred. Aspiration is also a valid and safe method that should be
used when medication abortion is contra-indicated (coagulation disorders) or has failed or, when in a
given the context, medication abortion is not an option.

Between 13 and 22 weeks LMP

Only medication abortion can be provided.

12.2 Medication abortion

Medication abortion is a safe and effective method of ToP. T he risk of severe complications is less
than 0.1% and the success rate is 97-98%.

T he combination mifepristone + misoprostol is more effective than misoprostol used alone and
reduces the number of misoprostol doses needed, thus reducing its adverse effects. Misoprostol,
however, is an effective and safe option even when used alone.

12.2.1 Precautions
– Coagulation disorders: MVA is preferred, if medication abortion is performed it must be carried out
under observation.
– Chronic adrenal failure and severe uncontrolled asthma: use misoprostol alone.
– In case of 2 or more previous uterine scars, given the risk of uterine rupture:
• Preferably use the combined regimen mifepristone + misoprostol, as fewer numbers of
misoprostol doses are required.
• From 13 to 22 weeks LMP: admit patient for observation; reduce the dose of misoprostol to
200 micrograms; respect a minimum interval of one day between mifepristone and misoprostol.

Note: mifepristone and misoprostol are not indicated for the termination of an ectopic or molar
pregnancy.

12.2.2 Protocol
Before 13 weeks LMP Between 13 and 22 weeks LMP

mifepristone PO: 200 mg single dose mifepristone PO: 200 mg single dose
T hen 1 to 2 days later: T hen 1 to 2 days later:
misoprostol sublingually or vaginally: 800 misoprostol sublingually or vaginally: 400
[1] micrograms every 3 hours until foetal and placental
micrograms
expulsion[2]
If expulsion has not occurred within 24 hours,
give a second dose of 800 micrograms of If mifepristone is not available or contra-indicated:
misoprostol. give misoprostol alone as above.

If mifepristone is not available or contra-

indicated:
misoprostol sublingually or vaginally: 800
micrograms every 3 hours (even if bleeding
starts after the first or second dose); max. 3
doses. [2]

AND

An analgesic or a combination of analgesics:

ibuprofen PO: 800 mg every 8 hours (max. 2400 mg daily); start with misoprostol and continue as
needed after expulsion, up to 3 days max.
If needed, add: codeine PO: 30 to 60 mg every 6 hours (max. 240 mg daily) or tramadol PO: 50 to
100 mg every 6 hours (max. 400 mg daily).
Use one of these 2 drugs alone if ibuprofen is contra-indicated.
Notes:
– All these doses may be used in adults and adolescents over 12 years.
– Depending on the patient's specific constraints, mifepristone and misoprostol can be taken
simultaneously.
– In the event of nausea/vomiting (not routinely): metoclopramide PO: 5 mg per dose for women < 60
kg; 10 mg per dose for women > 60 kg. T he interval between each dose of metoclopramide should be
at least 6 hours.

12.2.3 Patient care

Before 13 weeks LMP
– Medication abortion is performed on an outpatient basis. A single visit is organized to
provide information and counselling on ToP and the medication used for that purpose as well as on
contraception and the specific method chosen by the patient.
– Mifepristone is usually given under direct observation but it is not mandatory. T he woman can choose
to take all medications at home.
– Misoprostol is taken at home 1 to 2 days later (4 tablets of 200 micrograms for the first
dose). Bleeding and cramping are expected to start within 3 hours. In the vast majority of cases this
treatment is successful. If expulsion has not occurred within 24 hours, a second dose (4 tablets of
200 micrograms) should be taken. Women can choose come back in consultation to take the
misoprostol rather than taking it home.
– If misoprostol only regimen is used, provide the patient with the total number of doses (4 tablets of
200 micrograms every 3 hours; a total of 12 tablets).
– Ibuprofen is given to the patient to be taken once cramping starts. Provide quantity to cover 3 days
of treatment.
– All contraceptive methods can be started that same day (implant is inserted or injection given during
the consultation, oral contraceptive is given for a minimum of 3 months) except the IUD which can only
be inserted after expulsion.

Between 13 and 22 weeks LMP

– Due to an increased risk of complications, admit patient for observation after 12 weeks LMP,
however, between 13 and 16 weeks LMP the woman can choose to take the treatment at home,
unless there is a risk of uterine rupture (Section 12.2.1).
– As gestational age increases, expulsion takes more time and is more painful (ensure pain
management accordingly).
– T he foetus is more developed and is usually stillborn. In exceptional cases, transient spontaneous
breathing and/or movements may be observed. T his may be emotionally difficult for both the woman
and medical staff.
– T he disposal of the dead foetus must be handled discreetly and respectfully.
– For women 13-16 weeks LMP who chose to take the treatment at home, provide necessary
information and counselling as above, including considerations regarding the disposal of the foetus.
– For misoprostol, give sufficient doses to ensure treatment for 24 hours (2 tablets of 200 micrograms
every 3 hours; a total of 16 tablets). Advise the woman to stop misoprostol as soon as expulsion has
taken place.

12.2.4 Patient information

Before administering medications, the patient should be informed that:
– Medical abortion is effective and safe. Only 2 out of 100 women will need vacuum aspiration to end
the pregnancy. Complications are rare.
– Misoprostol may have teratogenic effect (this information should be known, in case she changes her
mind after taking the drugs or if the regimen fails).
– During abortion, she will experience cramping, bleeding, expulsion of blood clots, and between 13 and
22 weeks LMP, expulsion of the foetus and placenta.
– Most often there will be no cramping and bleeding after taking mifepristone. Cramping and
bleeding start 1 to 3 hours after taking misoprostol and usually slow down within 24 hours. T hey should
not exceed 48 hours. Light bleeding may last up to 1 month.
– T he abortion will be usually completed within 24 to 48 hours.
– Misoprostol, especially when several doses are taken, can cause nausea, diarrhoea, chills and fever
that should not persist longer than 24 hours after taking the medication.
– Severe pain, heavy bleeding (soaking 2 pads per hour for 2 consecutive hours), foul smelling
discharge and fever lasting more than 24 hours are signs requiring immediate medical attention.
– Menstrual periods will resume within 4 to 8 weeks but fertility returns rapidly; ovulation can occur as
early as 10 days post-abortion. It is recommended to start contraception immediately.

12.2.5 Patient follow-up

– No routine post-abortion consultation is required.
– T he woman is encouraged to come back at any time if she has concerns, complications or
questions.
– T he woman is invited to return for contraception if she did not start a method immediately at the
time of the abortion.
In the event of incomplete abortion, see Chapter 2, Section 2.1.3.

In the event of ectopic pregnancy, see Chapter 2, Section 2.2.3.

In the event of ongoing pregnancy before 13 weeks LMP, perform a vacuum aspiration (Chapter 9,
Section 9.5).

Referencias
1. World Healt h Organizat ion. Medical management of abort ion, 2019.
ht t ps://apps.who.int /iris/bit st ream/handle/10665/278968/9789241550406-eng.pdf ?ua=1

2. IPAS. Clinical Updat es in Reproduct ive Healt h. April 2019.

ht t ps://ipas.azureedge.net /files/CURHE19-april-ClinicalUpdat esInReproduct iveHealt h.pdf

12.3 Aspiration
Vacuum aspiration (either manual or electric) is the alternative to medication abortion.

12.3.1 Precautions
Purulent cervicitis or pelvic infection:
delay aspiration if possible, until antibiotic treatment (Chapter 9, Section 9.6.6) has been
completed.
if aspiration cannot be delayed, start antibiotic treatment before starting the procedure.
Coagulation disorders: risk of haemorrhage. Aspiration must be performed in a facility where
emergency surgery and blood transfusion are available.

12.3.2 Equipment
Chapter 9, Section 9.5.3.

12.3.3 Technique
Follow precautions common to all intrauterine procedures (Chapter 9, Section 9.1.1).
Start antibiotic treatment in case of infection if the abortion cannot be delayed. For antibiotherapy,
see Chapter 9, Section 9.6.6.
For antibiotic prophylaxis, cervix preparation (if necessary), premedication, preparation of
equipment, paracervical block and the procedure, see Chapter 9, Section 9.5.4.
Note: if the patient desires an IUD as her method of contraception, it can be inserted after aspiration,
as long as no pelvic infection is present.

12.3.4 Patient follow-up

Immediate
Settle the patient comfortably during the monitoring period (at least 2 hours).
Monitor vital signs and blood loss.
Pain management: paracetamol and/or ibuprofen (Appendix 7).
T he patient can go home if the vital signs are stable, if she can walk and she has been given the
following information:
Cramps continue for a few days.
Bleeding lasts for 8 to 10 days.
Menstrual periods will resume within 4 to 8 weeks.
Fertility returns rapidly; ovulation can occur as early as 10 days post-abortion. Begin
contraception that same day (Chapter 11, Section 11.5).
Personal hygiene: cleansing with soap and clean water once daily; no vaginal douches.
Seek immediate medical attention in case of severe pain or heavy bleeding, foul smelling
discharge or fever.

Post-abortion consultation
No routine post-abortion consultation is required.
T he woman is encouraged to come back at any moment in case of concerns, complications or
questions.
T he woman is invited to return for contraception if she did not start a method immediately at the
time of the abortion.

12.3.5 Complications
See Chapter 9, Section 9.6.6.

Appendices
Appendix 1. Antenatal care card

Appendix 2. Intrauterine balloon tamponade

Appendix 3. Breastfeeding

Appendix 4. Daily amounts required for feeding

Appendix 5. Intravenous maintenance fluids for sick neonates

Appendix 6. Postnatal care card

Appendix 7. Pain management in pregnant or lactating women

Appendix 1. Antenatal care card

Antenatal care card.pdf

Appendix 2. Intrauterine balloon

tamponade
2.1 Indication
Postpartum haemorrhage due to uterine atony, when uterotonics fail to control bleeding.

An intrauterine balloon is used to reduce intrauterine bleeding and avoid haemostasis hysterectomy.

In a BEmONC facility, an intrauterine balloon can be used to stabilize the patient before referring her to
a CEmONC facility.

2.2 Contra-indications
– Uterine rupture
– Purulent infection of the vagina, cervix or uterus

2.3 Balloon catheter placement

– Assess the need for analgesia/anaesthesia.
– Apply antiseptic solution (10% povidone iodine) to the perineal area.
– Remove any blood clots from the uterus (uterine exploration).
– Insert a Foley catheter.
– Estimate the size of the uterus and record it (for monitoring).
– Insert a speculum. Insert the (uninflated) balloon into the uterus, either manually or with atraumatic
forceps. Make sure that the entire balloon passes the internal cervical os.
– Inflate the balloon with sterile, room temperature 0.9% sodium chloride, until it can be seen in the
cervix (typically, 250 to 300 ml, 500 ml maximum); record the volume used).
– Apply gentle traction to the catheter and tape the end to the patient's thigh.
– Connect the drainage port to a fluid collecting bag (urine bag) to monitor haemostasis.

2.4 Associated treatment

– Continuous infusion of oxytocin: 20 to 40 IU depending on the dose already administered (max. 60 IU
total dose) in 1 litre of Ringer lactate or 0.9% sodium chloride over 8 hours (42 drops/minute).
– Antibiotic treatment: ampicillin IV 1 g + metronidazole IV infusion 500 mg or amoxicillin/clavulanic
acid IV (dose expressed in amoxicillin) 1 g, every 8 hours, until the balloon is removed.
– Start or continue blood transfusion to correct anaemia.

2.5 Patient follow-up

Hourly monitoring: vital signs, urine output, fundal height, vaginal bleeding, volume of blood collected in
the collecting bag, SpO2 (if available).

If there is no blood flowing into the collection bag but the fundal height is increasing, the catheter may
be blocked by clots: check to make sure it is open by instilling 15 to 30 ml of sterile 0.9% sodium
chloride.
If there is no blood flowing into the collection bag, no vaginal flow, no increase in fundal height and the
patient is stable, the bleeding is controlled: leave the balloon in place for 24 hours.
After 24 hours, remove half the injected volume from the balloon and check bleeding and vital signs
after 30 minutes:
– If there is no visible bleeding and the patient is stable, completely deflate and remove the balloon.
– If the bleeding starts up again, re-inflate the balloon for another 6 to 8 hours and/or consider surgery.

If the initial tamponade fails or the bleeding starts again while the inflated balloon is still in place,
surgical treatment is indicated.

Appendix 3. Breastfeeding
Exclusive breastfeeding (no food or drink other than breast milk) for the first 6 months is the best
choice for infants, regardless of the term or birth weight.

For HIV-infected mothers, see Section 3.7.

If the neonate is unable to suck effectively or at all:

– Breast milk can be expressed with a breast pump or by hand (Section 3.2).
– If the neonate has a good swallowing reflex: the milk can then be given by cup, spoon or syringe
(Section 3.3).
– If the neonate cannot swallow effectively or at all: the milk is given with a nasogastric tube (Section
3.4) to prevent aspiration and exhausting the neonate.

If sucking is ineffective, check for hypoglycaemia (Chapter 10, Section 10.3.4) and danger signs
(Chapter 10, Section 10.3.1).

If the neonate is able to suckle but the quantity of maternal milk is not sufficient, the supplemental
suckling technique offers the possibility to feed her/him with infant milk while stimulating milk production
(Section 3.5).

Always make sure that any medications being taken by the mother are compatible with breastfeeding,
and if necessary, adjust the treatment accordingly.

3.1 Breastfeeding success factors

T he factors for success in breastfeeding are:
– Informing pregnant women about breastfeeding benefits and implementation.
– Putting the neonate to the breast early, within an hour of birth.
– Correct and comfortable positioning of mother and neonate. Proper latch-on allows effective
sucking and reduces complications (cracks): the neonate should face the mother’s body, with the chin
against her breast, the nose free and the nipple and most of the areola in the mouth.
– For women with inverted or flat nipples: use techniques to help nipple protrude (nipple massage, use
of breast pump just before the neonate feeds).
– Maintaining exclusive breastfeeding (unless medically contra-indicated).
– Breastfeeding on demand at least 8 times daily day (at least every 3 hours).
– Good hydration (at least 3 litres daily) and a caloric intake > 2500 kcal daily for the mother, as these
directly affect the amount of milk produced.
– Nipple care, washing with clean water before nursing.
– An organisation that allows the mother and neonate to stay together 24 hours a day.
– Help with maintaining lactation even if the mother has to be separated from her neonate (preventing
milk production from stopping due to lack of stimulation).

Do not stop breastfeeding if:

– T he neonate has diarrhoea: explain to the mother that her milk is not causing the diarrhoea.
– T he mother is sick (unless serious condition): explain to the mother that her milk is not of poor quality
because she is sick.

3.2 Hand expression and storage of breast milk

Hand expression is an alternative when a breast pump is not available. Milk is expressed every 2 to 3
hours.
Show the mother the technique. Give her a clean cup or container for collecting the milk. T he container
should be washed, boiled and rinsed with boiled water and air-dried before each use.

Technique
– Wash hands, sit comfortably and hold the container under the breast.
– With the other hand, hold the breast up with four fingers, and place the thumb above the areola.
– Squeeze the areola between the thumb and the fingers while pressing backward toward the rib cage.
– Express each breast for at least 5 minutes, alternating, until the milk stops flowing.
– If the milk fails to flow, check the technique and apply warm compresses to the breasts.

Feed the neonate immediately after expressing the milk (by cup or nasogastric tube).

If the neonate does not take all of the collected milk, it can be stored in a clean container in the
refrigerator (2 to 8 °C) for a maximum of 24 hours a .
Warm the milk (water bath) to body temperature for the next feeding.
If no refrigerator is available, the milk can be stored in a clean container (covered) at room temperature
for up to 4 hours if the ambient temperature is ≤ 22 °C or up to 1 hour if the ambient temperature is >
22 °C.

3.3 Administering the milk by cup or other utensil

T he milk can be administered using a cup, spoon or syringe.
Use a clean (washed, boiled or rinsed with boiled water and air-dried) container/utensil for each feed.

Technique
T he mother should (with help from a carer):
– Measure out the volume of milk needed according to the neonate’s age and weight (Appendix 4).
– Hold the neonate in a half-seated or upright position on her lap.
– Place the cup/spoon gently against the neonate’s lower lip and touch the outside of the upper lip with
the edge of the cup.
– T ilt the cup/spoon so that the milk just reaches the neonate’s lips.
– Let the neonate take the milk at his own pace; never pour the milk into the mouth.
– Stop feeding when the neonate closes the mouth and is no longer interested in feeding.

If the neonate coughs or regurgitates multiple times, or is not able to take a sufficient quantity it
means he/she does not yet have a sufficient swallow reflex. In this case, the neonate should be fed
using a nasogastric tube until a later time.

3.4 Administering the milk by nasogastric tube

Indications
– Preterm or birth weight < 1500 g: poor sucking, limited or no coordination between sucking and
swallowing, tire rapidly.
– Neonates with respiratory distress: risk of aspiration, tire rapidly.
– Sick neonates with little or no sucking and/or hypotonia.
– Neonates with cleft palate, particularly when the cleft is very wide.

Feeding
Before each feed:
– Aspirate the gastric contents and use pH test to verify that the gastric tube is in the correct position.
– Check for signs of feed intolerance (vomiting, distended or tender abdomen, bloody stools). If
present, assess gastric aspirate appearance and volume:
• If the aspirate is clear or milky and < 3 ml/kg: re-inject the aspirate slowly and feed the planned
amount. Re-evaluate aspirate before next feed.
• If the aspirate is clear or milky and ≥ 3 ml/kg: reinject the aspirate slowly and feed planned amount
minus the volume of the residual. Re-evaluate aspirate before next feed. Continue feeds but do not
increase feed volume until aspirate volume is < 3 ml/kg.
• If the aspirate is green, bloody, or fetid: do not re-inject the aspirate; stop the feeding, look for
danger signs (Chapter 10, Section 10.3.1) and necrotizing enterocolitis (blood in stools and painful
abdominal distension). Insert an IV line for maintenance fluid therapy (Appendix 5), start antibiotic
therapy before transferring the neonate to a neonatal care unit.

Administering the milk:

– Take a sterile or clean (washed, rinsed with boiled water and air-dried) syringe, large enough to hold
the total amount of the feeding. Remove the plunger and connect the syringe to the conic end of the
tube.
– Pour the milk into the syringe, which should be held vertically.
– Ask the mother to hold the syringe 10 cm above the neonate and let the milk flow through the tube by
gravity.
– Do not use the plunger of the syringe to force the milk down faster.
Each feeding should last 10 to 15 minutes.

For the daily amounts required for feeding, see Appendix 4.

3.5 “Supplementary nursing” technique

T his technique is used to:
– Maintain breast-feeding when milk production is less than the daily amount needed by the neonate,
or
– In neonates who have difficulty suckling at the breast.

It consists of giving expressed breast milk or infant formula through a feeding tube while stimulating
milk production.

Technique
– Cut off the end of a CH8 gastric tube (1 cm from the holes) and remove the cap from the other end.
– Attach the first end to the nipple using adhesive tape. Place the other end in the cup. T he neonate
should have both the nipple and the tube in the mouth while nursing (Figure 1).
– T he mother should hold the cup 10 cm below breast-level, so that the milk is not sucked up too
quickly.
T he neonate may need 2 or 3 days to adjust to the technique. If, for the first few days, the
neonate does not take all of the milk in the cup, give him the rest with a cup, spoon or syringe.

Figure 1 - "Supplementary nursing" technique

3.6 Management of feeding problems (summary)

Situation Management

Problem with breastfeeding, but Give mother more advice, build her confidence, always
breastfeeding seems possible (milk have a member of the medical team present during
production, sucking and swallowing are breastfeeding, recording observations in the neonate’s
all adequate) chart.

Breastfeeding with inadequate amount • Stimulate milk production by frequent breastfeeding (8

of breast milk (amount of milk produced times daily).
less than neonate’s daily requirements) • Use a breast pump and the “supplementary nursing”
technique.

Ineffective sucking but good swallowing • Express the milk with a breast pump or by hand.
reflex • Administer the milk using a cup, spoon or syringe.

Ineffective sucking and poor or no • Express the milk with a breast pump or by hand.
swallowing reflex • Feed breast milk via a nasogastric tube.

3.7 Breastfeeding in HIV-infected women

To reduce the risk of HIV transmission, mothers should receive long-term antiretroviral therapy.
Exclusive breastfeeding is recommended for the first 6 months of life, with gradual weaning over one
month starting at age 6 months. Stopping breastfeeding abruptly is not recommended.

Breast milk substitutes can be used as an alternative to exclusive breastfeeding only under the
following conditions:
– T here is enough infant formula available for exclusive use to age 6 months.
– T he mother (or the person in charge) is able to prepare the formula under good hygiene conditions
and frequently enough to limit the risk of diarrhoea or malnutrition.
– T here is access to a health care facility offering a full range of paediatric care.

Notas
(a) Managing newborn problems: a guide f or doct ors, nurses, and midwives. World Healt h Organizat ion. 2003.
ht t p://www.who.int /reproduct ivehealt h/publicat ions/mat ernal_perinat al_healt h/9241546220/en/

Appendix 4. Daily amounts required for

feeding
Birth weight ≥ 2500 g
Total (ml/kg/day) Breast milk

D1 60 8 x 23 ml

D2 80 8 x 30 ml

D3 100 8 x 38 ml

D4 120 8 x 45 ml

D5 140 8 x 53 ml

D6 160 8 x 60 ml

D7 160-180 8 x 60-68 ml

D8 and after 160-200* 8 x 60-75 ml

* Up to 220 ml/kg may be given, if necessary for growth.

Birth weight 1500 g – < 2000 g

Total (ml/kg/day) Breast milk

D1 60 8 x 17 ml

D2 80 8 x 23 ml

D3 100 8 x 28 ml

D4 120 8 x 34 ml

D5 140 8 x 40 ml

D6 160 8 x 45 ml

D7 160-180 8 x 45-51 ml

D8 and after 160-200* 8 x 45-56 ml

* Up to 220 ml/kg may be given, if necessary for growth.

Birth weight 1500 g – < 2000 g

 Total (ml/kg/day) Breast milk

D1 60 8 x 13 ml

D2 80 8 x 18 ml

D3 100 8 x 22 ml

D4 120 8 x 26 ml

D5 140 8 x 31 ml

D6 160 8 x 35 ml

D7 160-180 8 x 35-39 ml

D8 and after 160-200* 8 x 35-44 ml

* Up to 220 ml/kg may be given, if necessary for growth.

Birth weight 1250 g – < 1500 g

In principle, neonates with a birth weight < 1500 g should receive 10% glucose in continuous IV infusion
for the first 48 hours of life (Appendix 5). If the neonate is clinically stable, very small amounts of breast
milk of 10 ml/kg per day can be started on D1 while awaiting transfer to a neonatal care unit.
If it is not possible to administer an IV infusion or to transfer to a neonatal care unit, give expressed
breast milk and 10% glucose together orally as per the tables below.
 Total (ml/kg/day) Breast milk 10% glucose

D1 80 12 x 5 ml 12 x 4 ml

D2 100 12 x 7 ml 12 x 4 ml

D3 120 12 x 10 ml 12 x 4 ml

D4 140 12 x 14 ml 12 x 2 ml

D5 160 12 x 18 ml −

D6 160-180 12 x 18-21 ml −

D7 160-200 12 x 18-23 ml −

D8 and after 160-200* 12 x 18-23 ml −

* Up to 220 ml/kg may be given, if necessary for growth.

Birth weight 1000 g – < 1250 g

Total (ml/kg/day) Breast milk 10% glucose

D1 80 12 x 5 ml 12 x 3 ml

D2 100 12 x 6 ml 12 x 3 ml

D3 120 12 x 8 ml 12 x 3 ml

D4 140 12 x 11 ml 12 x 2 ml

D5 160 12 x 15 ml −

D6 160-180 12 x 15-17 ml −

D7 160-200 12 x 15-19 ml −

D8 and after 160-200* 12 x 15-19 ml −

* Up to 220 ml/kg may be given, if necessary for growth.

Appendix 5. Intravenous maintenance
fluids for sick neonates
Where feasible, start IV maintenance fluids in sick neonates that need to be nil by mouth or are unable
to feed sufficiently by mouth, while awaiting transfer to a neonatal care unit.
10% glucose IV infusion: 60 to 80 ml/kg daily for ages D1 and D2
1/5 0.9% sodium chloride + 4/5 10% glucose IV infusion: 100 ml/kg daily for age D3

D1 D2 D3

Birth weight/Age
1/5 0.9% sodium chloride
10% glucose 10% glucose
+ 4/5 10% glucose

≥ 3500 g 9 ml/hour 12 ml/hour 15 ml/hour

3000 g - < 3500 g 8 ml/hour 11 ml/hour 13 ml/hour

2500 g - < 3000 g 7 ml/hour 9 ml/hour 11 ml/hour

2000 g - < 2500 g 5 ml/hour 7 ml/hour 9 ml/hour

Example: for a 2 day old neonate with a birth weight of 2750 g, give 10% glucose IV at 9 ml/hour, then
from age D3, change to 1/5 0.9% sodium chloride + 4/5 10% glucose IV given at 11 ml/hour.

Appendix 6. Postnatal care card

Postnatal care card.pdf

Appendix 7. Pain management in

pregnant or lactating women
 Pregnancy
Analgesics Breastfeeding
th
0-5 From 6 month
months

Level paracetamol PO first first choice first choice

1 1 g every 6 to 8 hours (max. choice
4 g daily)
paracetamol IV
< 50 kg: 15 mg/kg every 6
hours (max. 60 mg/kg daily)
≥ 50 kg: 1 g every 6 hours
(max. 4 g daily)

ibuprofen PO avoid contra-indicated possible

200 to 400 mg every 6 to 8 Treatment must be as short
hours (max. 1200 mg daily) as possible (≤ 5 days).
Respect contra-indications.

acetylsalicylic acid avoid contra-indicated avoid

(aspirin) PO

Level codeine PO possible T he neonate may Use

2 30 to 60 mg every 4 to 6 develop with caution, for a short
hours (max. 240 mg daily) withdrawal period (2-
symptoms, 3 days), at the lowest
respiratory effective dose.
depression and Monitor the mother and the
drowsiness in the neonate: in the event of
event of excessive drowsiness, stop
prolonged treatment.
administration of
large doses at the
end of the third
trimester. Closely
monitor the
neonate.

tramadol PO possible T he neonate may develop drowsiness when the

50 to 100 mg every 4 to 6 mother receives tramadol at the end of the
hours (max. 400 mg daily) third trimester and during breast-feeding.
 tramadol IM, slow IV or Administer with caution, for a short period, at the
infusion lowest effective dose, and monitor the neonate.
50 to 100 mg every 4 to 6
hours (max. 600 mg daily)

Level morphine PO immediate possible T he neonate may develop withdrawal

3 release (MIR) symptoms, respiratory
10 mg every 4 hours, to be depression and drowsiness when the mother
ajusted in relation to pain receives morphine at the end of the
intensity third trimester and during breast-feeding.
morphine PO sustained Administer with caution, for a short period, at
release (MSR) the lowest effective
T he daily dose, and monitor the neonate.
dose is determined
during the initial treatment
with immediate release
morphine (MIR).
If treatment is initiated
directly with MSR:
30 mg every 12 hours, to
be ajusted in relation to pain
intensity
morphine SC, IM
0.1 to 0.2 mg/kg every 4
hours
morphine IV
0.1 mg/kg administered in
fractionated doses (0.05
mg/kg every 10 minutes)
every 4 hours if necessary