Strengthening Reproductive Health Management and Service Delivery in West Bank and Gaza

1. National and Unified Obstetric and Newborn care Guidelines and Protocols Strengthening Reproductive Health Management and Service Delivery in West Bank and Gaza

2. National and Unified Obstetric and Newborn care Guidelines and Protocols

3. Guidelines • Normal delivery • Breastfeeding • Normal care to the newborn • High risk cases (1 : medical conditions) • High risk cases (2 : obstetrical conditions) • Obstetrical Emergencies • Newborn High Risk and Emergencies • Obstetrical procedures • Neonatal procedures • Quality assessment National and Unified Obstetric and Newborn care Guidelines and Protocols

4. Guidelines • Normal delivery • Breastfeeding • Normal care to the newborn • High risk cases (1 : medical conditions) • High risk cases (2 : obstetrical conditions) • Obstetrical Emergencies • Newborn High Risk and Emergencies • Obstetrical procedures • Neonatal procedures • Quality assessment National and Unified Obstetric and Newborn care Guidelines and Protocols

5. High Risk Cases 1st SECTION : The Mother and Foetus Topic 4: High risk cases A. Medical conditions B. Obstetrical conditions National and Unified Obstetric and Newborn care Guidelines and Protocols

6. High Risk Cases : obstetrical conditions • 1st SECTION : Mother and foetus • Topic 4: High risk cases • B.Obstetrical conditions • Management of severe pre-eclampsie • Antepartum Haemorrhage • Management of Pre-labor Rupture of Membranes • Management of preterm labour • Management of Breech Presentation at term • Management of twins labour at term • Management of previous uterine scar National and Unified Obstetric and Newborn care Guidelines and Protocols

7. High Risk Cases : obstetrical conditions For all Cases of High risk pregnancies, the following steps must be achieved These actions represent the First Step and general rules They are usually achieved by midwives or paramedical staff National and Unified Obstetric and Newborn care Guidelines and Protocols

8. High Risk Cases : obstetrical conditions • ·Receive & admit the woman. • ·Obtain initial history including; gestational age, complains, onset of bleeding, amount, fetal movements, antenatal care, previous obstetrics history, medical & surgical history. • ·Perform abdominal exam assessing for Fundal height, lie, presentation, gestation. • ·Check & document fetal heart sounds. • ·Check & document initial vital signs. (Temp, BP, Pulse, Respiration) • ·Perform CTG for 20 minutes. • ·Withdraw blood for CBC, Blood type & RH, save blood for X-match, PT & PTT, electrolytes, KFT, LFT, urine analysis. • ·Observe closely • ·Check vital signs especially Pulse & BP every 15-30 minutes, temp every 4 h. • Notify Physician if diastolic BP 100 mmhg. National and Unified Obstetric and Newborn care Guidelines and Protocols

9. High Risk Cases : obstetrical conditions ·Keep on continues monitoring if possible. If not available, check & document fetal heart sounds every 15 min. ·Insert Canula to K.V.O. & for fluid therapy & medication. ·Maintain strict intake & output records hourly. ·Check all urine. ·Keep emergency trolley at bed side. ·Assess for signs / symptoms of worsening hourly: ·Administer medication as per Physician order following medication protocols. ·Encourage Lateral recumbent position. ·Provide support, coaching & encouragement during process of labour & deliver ·Assist the physician during delivery. National and Unified Obstetric and Newborn care Guidelines and Protocols

10. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Topic 4, B High Risk cases. Subtopic 1 Management of Severe Pre – Eclampsia Standard Statement Severe pre-eclampsia and eclampsia are major causes of maternal and feral morbidity and mortality. The risks are reduced by intensive monitoring and aggressive management. National and Unified Obstetric and Newborn care Guidelines and Protocols

11. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Definition Indicators of severe disease: 1) severe hypertension MAP – mean arterial pressure >125 mmHg or Diastolic BP – diastolic pressure > 110mmHg or SBP – systolic BP> 170 mmHg measured by automated oscillometric devices(Dinamap) with the correct size of cuff on 2 occasions (check Dinamap readings intermittently and compare with standard methods.) 2. Proteinuria (3+ or 4+ on dipstick or >3g / 24 hours) 3. Oliguria (<500 mls / 24 hours) 4. Symptoms: headache, visual symptoms, epigastric pain. 5. Signs: - hyperreflexia especially with more than 2 beats of ankle clonus - rapidly developing generalized oedema - hepatomegaly with tenderness 6. Haematological and biochemical signs - platelet count <100x109/1 - urate>0.45 mmol/1 National and Unified Obstetric and Newborn care Guidelines and Protocols

12. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Pre Eclampsia is a very severe condition The complications can affect qThe kidney qThe Hemostatic system qThe Brain qThe Cardio-vascular system qThe Liver qThe Ocular system National and Unified Obstetric and Newborn care Guidelines and Protocols

13. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 PROCESS: in case of preeclampsia In labor ward , specific ations for paramedical staff • Observe closely (Toxemic Chart). • Notify Physician if diastolic BP 100 mmhg. • Check all urine for protein. • Assess for signs / symptoms of worsening hourly • Observe closely for signs / symptoms of abruptio placenta & uteroplacental insufficency • Place the patient in a single quite room, decrease environmental stimuli as much as possible with special midwife • Do not leave the patient alone. • Manage labour as per normal protocol. • Notify the paediatrician to be attend delivery. • If asymptomatic, anticipate normal delivery. • Continue close observation especially during the 2nd stage • Give oxytocin 10 units i.v. after delivery of the anterior shoulder • · Observe for signs / symptoms of pulmonary oedema, National and Unified Obstetric and Newborn care Guidelines and Protocols

14. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Assess for signs / symptoms of worsening hourly: q Headache q Blurred vision q Epigastric pain (Right upper quadrant pain) q Change in level of consciousness. q Nausea & vomiting National and Unified Obstetric and Newborn care Guidelines and Protocols

15. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Observe closely for signs / symptoms of abruptio placenta • Abdominal Pain • Vaginal bleeding • Maternal tachycardia • Foetal distress National and Unified Obstetric and Newborn care Guidelines and Protocols

16. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • Observe for signs / symptoms of pulmonary edema • Chest Tightness • Shortness of breath • Shallow, rapid respiration. • Wheezing • Tachycardia • Watch for signs of DIC & seizures. National and Unified Obstetric and Newborn care Guidelines and Protocols

17. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • PRINCIPLES OF MANAGEMENT: • Control of blood pressure • Prevent convulsions using MgSo4 as per guidelines. • Treat eclampsia(as per protocol.) • Restore plasma volume and maintain urine output • Perform baseline investigations and monitor progress • Prevent complications • Plan management of the pregnancy • Consider use of Dexamethasone in preterm if not contraindicated even in severe cases. • Plan postpartum management National and Unified Obstetric and Newborn care Guidelines and Protocols

18. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • Control of blood pressure • Slowly reduce blood pressure to safe levels • (MAP<125mmHg, Diastolic BP<105mmHg), • Avoid hypotension. • Aim to keep MAP between 115-125 mmHg (Diastolic BP between 90- 105 mmHg) • confirm the BP reading with Mercury Sphygmomanometer. when “Dinamap” (automatic BP reading machine) is used to record patient’s blood pressure. National and Unified Obstetric and Newborn care Guidelines and Protocols

19. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • Prevent convulsions using MgSo4 • Anticonvulsants are indicated : • if there is severe hypertension which cannot be controlled by antihypertensives • and also proteinuria 3+ or 4+ • and hyper-reflexia (indicated by the presence of ankle clonus 2 or more beats) National and Unified Obstetric and Newborn care Guidelines and Protocols

20. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • Treatment eclampsia : Principles • If a patent presents with eclampsia, • initial management should aim at • control of convulsions • maintaining the airway • and preventing trauma to the patient • (see protocol.) National and Unified Obstetric and Newborn care Guidelines and Protocols

21. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Restore plasma volume and maintain urine output Expansion of the plasma volume prior to antihypertensive therapy minimizes the risk of hypotension and may improve the hypertension per se. Hypovolaemia is an important feature of pre-eclampsia caused by the loss of plasma proteins into the interstitial space and the urine. This is a Consultant decision National and Unified Obstetric and Newborn care Guidelines and Protocols

22. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Plan management of the pregnancy timing of delivery hospital equipped with SCBU (Special care baby unit) National and Unified Obstetric and Newborn care Guidelines and Protocols

23. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 MANAGEMENT GUIDELINES DURING DELIVERY Timing of delivery deliver most patients with pre-eclampsia once the situation is under control. Fetal Assessment assess fetal well-being by CTG and ultrasound scan. Mode of delivery IUGR and fetal hypoxia are common and so a caesarean section is the most appropriate form of delivery. Induction Induction of labour should be in labour ward (with continuous monitoring). Epidural anaesthesia If an epidural is used together with antihypertensive agents, hypotension may ensue, so measure BP at least every 15 mins. And preload the patient with 500 mls N saline IV. National and Unified Obstetric and Newborn care Guidelines and Protocols

24. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 MANAGEMENT GUIDELINES DURING DELIVERY 2nd Stage of Labor Ventouse/Forceps delivery can be used if obstetrically indicated Oxytocin and Methergin oxytocin 10 iu i.v. should be given, with delivery of the anterior shoulder. If necessary an i.v. infusion of Oxytocin can be given after delivery. Syntometrine and Methergin areCONTRINDICATED 3rd Stage of labor A physiological third stage is contraindicated Corticoids Consider use of Dexamethasone in preterm if not contraindicated, even in severe cases National and Unified Obstetric and Newborn care Guidelines and Protocols

25. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • RECOGNISE & PREVENT THE FOLLOWING COMPLICATIONS • Acute renal failure: • Coagulopathy • Cerebral haemorrhage • Cardiovascular complications • Hepatic complications • Ocular complications National and Unified Obstetric and Newborn care Guidelines and Protocols

26. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • RECOGNISE & PREVENT THE FOLLOWING COMPLICATIONS • Acute renal failure: Oliguria is common and may be improved by the treatment of hypovolaemia National and Unified Obstetric and Newborn care Guidelines and Protocols

27. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • RECOGNISE & PREVENT THE FOLLOWING COMPLICATIONS • Coagulopathy • Mild coagulation abnormalities, particularly a low platelet count. • In severe cases disseminated intravascular coagulation (DIC) occurs with • reduced platelet count, • elevated prothrombin time, • elevated fibrin degradation products, • low fibrinogen levels • and reduced factor VIII activity. • Treatment involves replacement of coagulation factors with fresh frozen plasma, cryoprecipitate and platelets • the haematologist’s opinion should be sought early in the case of abnormal clotting studies. • Early delivery of the fetus is desirable. National and Unified Obstetric and Newborn care Guidelines and Protocols

28. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • RECOGNISE & PREVENT THE FOLLOWING COMPLICATIONS • Cerebral haemorrhage (Rare complication. ) The risk can be reduced by : • prevention of eclampsia, • control of hypertension • and correction of coagulation abnormalities National and Unified Obstetric and Newborn care Guidelines and Protocols

29. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • RECOGNIZE & PREVENT THE FOLLOWING COMPLICATIONS • Cardiovascular complications may complicate pre-eclampsia • Hypertensive cardiac failure, • cardiomyopathy • and coronary artery insufficiency . Seek a Cardiologist opinion. National and Unified Obstetric and Newborn care Guidelines and Protocols

30. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • RECOGNIZE & PREVENT THE FOLLOWING COMPLICATIONS • Hepatic complications Pre-eclampsia may be complicated by hepatic enlargement, haemorrhage and even rupture. • Liver failure may occur in severe cases and is treated by supportive therapy. • This may present as part of the HELLP syndrome • haemolysis/hypertension, • elevated liver transaminases, • low platelet count National and Unified Obstetric and Newborn care Guidelines and Protocols

31. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • RECOGNIZE & PREVENT THE FOLLOWING COMPLICATIONS • Ocular complications Eclampsia may be preceded by visual disturbance, particularly seeing flashing lights or stars. Retinal haemorrhage or detachment and macular oedema may cause reduced acuity National and Unified Obstetric and Newborn care Guidelines and Protocols

32. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • MANAGEMENT of SEVERE PRE-ECLAMPSIA : ASSESSMENT • Transfer the patient to labour ward. • Initiate an emergency observation chart for each patient • Record the vital parameters • Investigate Lab tests: (1-4 repeated every 12 hours) • Manage labour according to protocol : National and Unified Obstetric and Newborn care Guidelines and Protocols

33. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • 1. Transfer the patient to labour ward • If • diastolic BP>110mm Hg, • systolic BP>170mm Hg, • MAP>125mm Hg on two occasions 5-10 mins apart. National and Unified Obstetric and Newborn care Guidelines and Protocols

34. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • 2. Initiate an emergency observation chart • foreach patient providing a complete record of the patient’s observations, fluid balance and investigation results as indicated below: • Gestational age and size • Amount of amniotic fluid • Uterine irritability or contractions • Fetal condition – clinical and CTG Check FHR every 15 minutes. • Other pregnancy complications • multiple pregnancy, • preterm labour, • abruption. • Weight of patient National and Unified Obstetric and Newborn care Guidelines and Protocols

35. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • 3. Record the followings parameters: • Blood pressure using dinamap • (every 15 mins or every 5 mins if Map>140mmHg). • Confirm with the mercury sphygmomanometer. • Fluid balance, input/output chart, test for proteinuria (hourly) – catheterize. • Reflexes (normal, absent, increased with ankle clonus). • Oedema (distribution, degree, presence of effusions). • Pulse rate (every 15 mins). • Temperature (4 hourly). • Optic fundi (12 hourly). • Pulse-oxymetry. National and Unified Obstetric and Newborn care Guidelines and Protocols

36. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • 4. Investigate the following Lab tests 1-4 repeated every 12 h. • Full blood count – haemoglobin (N.B high = haemoconcentration) and platelets. • Coagulation screen (including FDPs if any other abnormality). • Renal function tests – creatinine, urea electrolytes, urate. • Liver function tests and serum protein levels. • Hourly urine collection for protein, • if time prior to delivery allow, collect a 24 hour urine for • protein and creatinine clearance. • MSU for microscopy (evidence of renal disease – granular casts, rule out infection) National and Unified Obstetric and Newborn care Guidelines and Protocols

37. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • 5. Manage labour as followed • Consider expediting. • All inductions of labour performed in labour ward (including prostin method). • Preload patients with an additional 500 mls N-saline (0.9%) before epidural. • Consider ventouse/forceps delivery if indicated. • Oxytocin (syntocinone) 10 iu i.v. (NO syntometrine in third stage. ) National and Unified Obstetric and Newborn care Guidelines and Protocols

38. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 TREATMENT REGIMENS FOR SEVERE PRE-ECLAMPSIA (see separate leaflet for doses) Initial control of BP: Hydralazine – DO NOT mix with dextrose Labetalol – Not to be used with ASTHMA or CARDIAC PATHOLOGY. Nifedipine (Retard Tablets): (be careful if Mgso4 is used as well.) Maintain BP by: Hydralazine Labetalol Nifedipine (Retard Tablets); be aware that Nifedipine potentiates the action of magnesium sulphate Magnesium Sulfate : its efficacy is well established in treatment. National and Unified Obstetric and Newborn care Guidelines and Protocols

39. High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 • ABOUT MAGNESIUM SULFATE • (see separate leaflet for regimen and doses) • Indications for Magnesium Sulfate: • Severe hypertension (MAP> 125 mmHg, Diastolic BP> 110 mmHg) after 1 hour of parenteral therapy and proteinuria 3+ or 4+ plus hyper-reflexia with clonus (4 beats or more) or epigastric pain. • Contraindications of Magnesium Sulfate: • Renal failure or severe oliguria • Cardiac disease • Bolus dose • Must be given through a separate cannula. Initially, administer 20 ml (4g) of magnesium sulphate i.v.as 20% solution over 10 minutes. • Alternate method: dilute 4 g MgSO4 in 80 ml of N/S to end up with 100 ml solution and infuse it slowly 10 ml/minute • To be administered by resident doctor. National and Unified Obstetric and Newborn care Guidelines and Protocols

40. High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 Topic 4, B High Risk Cases Stopped Here Subtopic 2 Management of Ante partum Hemorrhage Standard Statement Obstetric hemorrhage (APH, PPH, Bleeding in early pregnancy) is one of the 3 most common causes of maternal death in the developing countries. National and Unified Obstetric and Newborn care Guidelines and Protocols

41. High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 ETIOLOGY Bleeding from the genital tract after 24 weeks gestation may be due to : • Placenta previa • Placental abruption • Local conditions of cervix, vagina, vulva • Vasa previa • Consider other rare lesions e.g. hemorrhoids • Bleeding disorders. National and Unified Obstetric and Newborn care Guidelines and Protocols

42. High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 • ACTIONS: If moderate or major bleeding • Keep NPO till further decision form the consultant or Registrar/Senior resident. • First step PLUS the followings, • Call for help. • Consider taking obstetric emergency trolley bedside. • Insert IV Canula G 14 & initiate Hartmann's solution/Ringer lactate. • Insert catheter. • Measure intake & output Q ½ hour. • Observe & measure bleeding closely & consider weighing linens & saving soaked pads for review. National and Unified Obstetric and Newborn care Guidelines and Protocols

43. High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 • ACTIONS: If Minor ante partum hemorrhage • Obtain a detailed history (precipitating factors and amount of blood Loss), • Perform a general examination • Check gestation. • Check & evaluate the CTG. &ultrasound reports for placental site. • Perform gentle speculum examinations, unless known to have major placenta previa or if no ultrasound report available • Check lab results & give anti D if Rhesus negative. • Transfer to ward if no signs of major bleeding, significant uterine tenderness or fetal distress. • If term consider induction of labor after discussing with Consultant. • If preterm give dexamethazone (as detailed in PTL protocol) National and Unified Obstetric and Newborn care Guidelines and Protocols

44. High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 • Obtain a detailed history • (noting precipitating factors and amount of blood Loss), • Time of the onset of bleeding & the activities at the time prior to the bleeding. • History of previous episode of bleeding • Amount of bleeding • Any history of • pain, • trauma, • sexual intercourse • & uterine contractions. National and Unified Obstetric and Newborn care Guidelines and Protocols

45. High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 • Perform a general examination especially • for signs of uterine tenderness. • Check the vital signs Immediately. • Estimate the blood loss • Immediate assessment of the abdomen • Fundal height • Consistency of the abdomen • Position of the fetus • Uterine contractions or irritability • Uterine tenderness • Presence of fetal heart National and Unified Obstetric and Newborn care Guidelines and Protocols

46. High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 ALGORITHM : Antepartum hemorrhage : first steps Ante partum hemorrhage Blood sample Group, Count Rh ? Neg Pos • Associated severe signs • qMajor bleeding • qFetal distress • qUterine tenderness Anti D National and Unified Obstetric and Newborn care Guidelines and Protocols

47. High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 Present Associated severe tenderness Absent Speculum : Col - Vagina Abnormal Normal Term ? Refer < 37 sem >= 37 sem Cervix ? Corticoids + follow-up US CTG BLOOD Ex Non Favourable Favourable ALGORITHM : Antepartum hemorrhage : first steps Induction National and Unified Obstetric and Newborn care Guidelines and Protocols

48. High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 • Specific rules • Catheterize for accurate monitoring of urinary output • 2. Record observations on observation chart and measure all blood loss accurately (consider weighing soaked linen) keep all pads for review • 3. Inform • Anesthetist • Neonatal unit • 4. Discuss with consultant • If clotting studies are abnormal discuss with hematologisit • 6. Give • ranitidine 50 mg in 20 mls saline slowly (over 2 mins) IV (unless already given orally) • and metoclopramide 10mg (over 2 mins) IV. National and Unified Obstetric and Newborn care Guidelines and Protocols

49. High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 • Specific rules • Delivery should be effected. • If no evidence of placenta previa, the cervix is favorable and there is no fetal distress, induction of labor may be appropriate, labour often progresses rapidly in the event of APH due to placental abruption. • There should be early recourse to caesarean section if blood loss increases or if there are subtle signs of maternal shock e.g. increasing tachycardia or fetal distress. Fit young woman maintain their blood pressure despite extensive bleeding • In all other circumstances proceed immediately to caesarean section. • The patient should be closely monitored in the labor ward until her condition is satisfactory. Observations continued in ICU observation chart. • DO NOT give diclofenac (Voltarol) : Risk of bleeding & renal shut down. National and Unified Obstetric and Newborn care Guidelines and Protocols

50. High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 If Major ante partum HH (blood loss in excess of 1000 mls) or abruption resulting in fetal death, add the following steps Always inform consultant Collect obstetric emergency trolley. Cross match at least 6 units of blood. Give Oxygen Blood transfusion as soon as possible Deliver by caesarean section immediately if the fetus is still alive. In the event of fetal death, mode of delivery is to be decided by Consultant.  Decision for a vaginal delivery will be considered with an overall view of the patient’s clinical scenario. Clotting studiesshould be repeated every 4 hours for the first 12 hours. After delivery, maintain an Oxytocin infusion in Hartmann’s solution National and Unified Obstetric and Newborn care Guidelines and Protocols