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National and Unified Obstetric and Newborn care
Guidelines and Protocols
Strengthening
Reproductive Health Management
and Service Delivery
in West Bank and Gaza
National and Unified Obstetric and Newborn care
Guidelines and Protocols
Guidelines
1. Normal delivery
2. Breastfeeding
3. Normal care to the newborn
4. High risk cases (1 : medical conditions)
5. High risk cases (2 : obstetrical
conditions)
6. Obstetrical Emergencies
7. Newborn High Risk and Emergencies
8. Obstetrical procedures
9. Neonatal procedures
10.Quality assessment
National and Unified Obstetric and Newborn care Guidelines and Protocols
Guidelines
1. Normal delivery
2. Breastfeeding
3. Normal care to the newborn
4. High risk cases (1 : medical conditions)
5. High risk cases (2 : obstetrical conditions)
6. Obstetrical Emergencies
7. Newborn High Risk and Emergencies
8. Obstetrical procedures
9. Neonatal procedures
10. Quality assessment
National and Unified Obstetric and Newborn care Guidelines and Protocols
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
High Risk Cases : obstetrical conditions
1st SECTION : Mother and foetus
Topic 4: High risk cases
B. Obstetrical conditions
1.
2.
3.
4.
5.
6.
7.
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
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
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
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
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
High Risk Cases : obstetrical conditions
Definition
Severe Pre – Eclampsia 1
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
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
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
High Risk Cases : obstetrical conditions
Severe Pre – Eclampsia 1
Assess for signs / symptoms of worsening hourly:
q
q
q
q
q
Headache
Blurred vision
Epigastric pain (Right upper quadrant pain)
Change in level of consciousness.
Nausea & vomiting
National and Unified Obstetric and Newborn care Guidelines and Protocols
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
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
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
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
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
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
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
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
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
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 are CONTRINDICATED
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
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
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
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
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
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
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
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
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
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
High Risk Cases : obstetrical conditions
Severe Pre – Eclampsia 1
2. Initiate an emergency observation chart
for each 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
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
High Risk Cases : obstetrical conditions
Severe Pre – Eclampsia 1
4. Investigate the following Lab tests 1-4 repeated every 12 h.
o Full blood count – haemoglobin (N.B high = haemoconcentration)
and platelets.
o Coagulation screen (including FDPs if any other abnormality).
o Renal function tests – creatinine, urea electrolytes, urate.
o Liver function tests and serum protein levels.
o 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
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
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
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 hyperreflexia 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
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
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
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
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
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
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
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
q
Major bleeding
q
Fetal distress
q
Uterine tenderness
Anti D
National and Unified Obstetric and Newborn care Guidelines and Protocols
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 ?
Non Favourable
ALGORITHM :
Antepartum hemorrhage :
first steps
Favourable
Induction
Corticoids
+
follow-up
US
CTG
BLOOD Ex
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2
Specific rules
1. 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
5. 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
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
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 studies should 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
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2
Blood transfusion as soon as possible
1. If life threatening bleeding, other relevant blood groups.
(i.e. Rh O –ve blood) are given with out cross matching.
2. If the patient is showing signs of coagulation defects, further
steps are taken to obtain blood products i.e.
•
•
•
Fresh Frozen Plasma
Platelets
Cryoprecipitate
3. CVP line is to be considered ( inserted by the anesthetist)
4. If there has been an abruption extensive enough to result in fetal
death the patient will always require at least 4 units of blood
whatever the initial hemoglobin level and this should be given as
soon as the cross match is completed
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2
In the event of fetal death,
the mode of delivery is to be decided by the Consultant.
1. Induction of labor with very careful observation of maternal
condition may be appropriate if the maternal condition is stable
and if labor progresses rapidly.
2. Even if the fetus is dead, immediate caesarean section may well
be preferable UNLESS the cervix is found to be at least 4 cms
dilated in which case it may be reasonable to perform an ARM
and augment labour with oxytocin.
3. A caesarean section may still be necessary unless progress of
labor is rapid.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2
ClinicaL assessment
ALGORITHM
Ante partum or Per
partum haemorrhage
Intensive care if necessary
+ Ultrasound
Placenta previa
Abruptio placentae
Type ?
Type I or II
See Algorithm Placenta
previa I or II
Type III or IV
See Algorithm Placenta
previa III or IV
See Algorithm
Abruptio Placentae
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2
Placenta previa I or II
ALGORITHM
Placenta previa
Type I or II
Blood Loss Amount ?
Minimal blod loss
Excessive blood loss
Term ?
Vital signs ?
< 37 weeks
> 37 weeks
Observe
Monitor
untill 37 weeks
Vaginal delivery
+
Manual delivery of placenta
Normal
Pre-shock
ARM
if in Labour
+ Oxytocics
Failure
Dystocia
Hemorrhage
Ceasarean
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2
ALGORITHM
Placenta previa
Type III or IV
Placenta previa III or IV
Blood Loss Amount ?
Minimal blod loss
Excessive blood loss
Term ?
< 37 weeks
Observe
Monitor
untill 37 weeks
in Hospital
> 37 weeks
Caesarean
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2
General Assessment
ALGORITH
M Abruptio
Placentae
Fœtal Status
Dead
Alive
Fœtal Distress ?
DIC ?
YES
Resuscitation
Transfer in ICU
NO
YES
NO
Cervical Maturity
Induction
Non favourable
cervix
Normal
Failure
Caesarean
Favourable cervix
ARM
Shock
Dystocia
Normal
Vaginal delivery
Manual delivery of placenta
Ocytocics
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3
Topic 4, B
High Risk Cases
Subtopic 3
Management of pre-labor rupture
membranes
Standard
Statement
Manage as an inpatient - gestational age is the
single most important element.
Definition
PROM premature rupture of membranes is
membrane rupture occurring before the ondet
of labour, irrespective of gestation
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3
Management : Specific Actions
1. Admit the woman and follow the routine admission procedures.
2. Conduct a detailed history with particular focus on dates.
3. Perform a complete physical exam and search for contractions.
4. Confirm membranes status by performing a sterile speculum exam,
5. Conduct the following investigations:
1.
Complete blood count
2.
Intracervical and HVS for culture and sensitivity
3.
MSU for culture and sensitivity
4.
Ultrasound assessment of fetal status if labour is not advanced.
5.
CTG if pregnancy reached 28 weeks.
6. If labour is inevitable: Inform neonatal unit and check cot state.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3
Management of PROM according to Gestational age
Gestation between 26-33 weeks + 6 j
If not associated with uterine contractions, conservative management
If contractions, to suppress labour is an Consultant’s decision
Conservative management
TOCOLYSIS
If uterine contractions, suppress labour after excluding contra indications.
STEROIDS : Steroids enhance fetal lung maturity:
2 doses of 12mg betamethazone/dexamethasone IM 12 h apart in the first 24 hours
Repeat the course only once if PROM occurred before 29 weeks.
ANTIBIOTICS:
Give a single course of
erythromycin 500 mg 6 hourly for 5 days.
Alternatively Augmentin 375 mg 8 hourly for 7 days.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3
Contra indications to tocolyse
1. Fetal death
2. Fetal distress
3. Fetal abnormality incompatible with survival
4. Chorioamnionitis
5. Antepartum haemorrhage
6. Medical conitions: Cardiac disease and Hyperthyroidism
7. Obstetric indication for delivery e.g. severe pereclampsia etc.
8. Advanced labour i.e. cervical dilatation of 4cm or more
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3
Management of PROM according to Gestational age
Gestation between 26-33 weeks + 6 j
: Conservative M. : Follow-UP
• Daily palpation for tender uterus, assessment of liquor color & CTG.
• Check white cell count + CRP twice/week.
• Weekly Scan for estimated fetal weight and biophysical profile
If there is any evidence of infection, hemorrhage or fetal distress then
labor should be induced or rarely a caesarean section may be appropriate
(Consultants must be aware of such cases).
In the case of suspected sepsis antibiotics should be commenced
immediately.
If the results of an HVS suggest a specific organism appropriate antibiotics
Otherwise commence cefuroxime 1.5g loading dose then 750 mg 8 hourly
IV and metronidazole 1g PR 12 hourly.
Labor will be induced by an Oxytocin infusion and managed as for
preterm labor.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3
Management of PROM according to Gestational age
Gestation between 34-37 weeks
These patients should be discussed with the Consultant on call as be
appropriate to treat them either as for preterm or as for term
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3
Management of PROM according to Gestational age
Gestation >37 weeks
1.
expectant
management
is
preferable
as
labor
will
ensure
spontaneously within 24 hours in 70-90 % of these women.
2. Digital vaginal examination is not indicated.
3. IF pyrexia, offensive vaginal discharge, B hemolytic streptococcus carrier
Oxytocin immediately to induce labor:
Intravenous penicillin 3 g, then 1.5 g four-hourly until delivery.
Clindamycin 900 mg intravenously eight-hourly if allergy
Avoid Broad-spectrum antibiotics such as ampicillin,
4. If meconium, fetal tachycardia or decelerations,
consider delivery by LSCS.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3
EXPECTANT MANAGEMENT SHOULD BE :
1. Admit to antenatal bed
2. Observe 4 hourly pulse, temperature
3. Fetal heart rate CTG twice daily.
4. Vaginal examination if painful contractions start.
5. No prophylactic antibiotics.
6. Labor should be induced at 6 am approximately 24 hours after
rupture of the membranes.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3
INDUCTION OF LABOR preferably induced by PGE2 (Prostin)
Nulliparous with Bishop score of < 4, should receive 3 mg prostin,
Nulliparous with Bishop score of > 4 and All Multiparous
should receive 1.5 mg prostin.
Prostin dose can be repeated Q/6 hours up to 3 doses, 4th dose can be
given after evaluation by Consultant.
If the cervix is favorable, patient is transferred to labour ward and
labor is induced with oxytocin. (oxytocin should be commenced after the
elapse of 6 houres after the last prostin dose).
If cervix remained unfavourable, patient may rest for 24 hour and
another course of IOL with prostin pessaries is re-used thereafter.
If after six doses of prostaglandin the cervix remains unfavorable for ARM,
the mode of delivery has to be reviewed by the consultant concerned.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3
PROM
ALGORITHM : PROM 1
Yes
Induction
+
Antibiotics
Clinical Signs ?
Pyrexia
Offensive Vaginal
discharge
B streptococus Carrier
+
WBC , CRP, CTG, US
NO
Term ?
< 34 wks
Normal
VD
34-36 wks
>36 wks
Failure
Fetal
destress
See Algorithm PROM 2
Caesarean
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3
PROM
ALGORITHM : PROM 2
No Clinical Signs – No Biological Signs
Term ?
< 34 wks
Antibiotics
Cortocoids
Tocolysis
Caesarean
>36 wks
Wait
Contractions ?
Yes
34-36 wks
No
Wait 24 hrs
Labour
Normal
VD
No labour
Induction
Follow-up
Failure
Fetal destress
Normal VD
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
preterm labor 4
Topic 4, B
High Risk Cases
Subtopic 4
Management of preterm labor
Standard
Statement
As PTL remains one of the most important
causes of bad obstetric outcome, always admit
patients and involve consultant.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
preterm labor 4
Ethical considerations
 Do not suppress labor after 34 weeks in view of the excellent
neonatal facilities in Tertiary Hospitals.
 Spontaneous miscarriages between 20 and 24 weeks gestation
are usually managed in the labor ward and should be treated them as
for preterm labor. However, during labor, fetal monitoring is not
usually appropriate and vaginal delivery should be planned
regardless of presentation.
 A pediatrician should be informed of the impending delivery, after
22 weeks gestation although it should be clearly explained to the
parents that this is to assess the baby and not necessarily to provide
active resuscitation for the baby.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
preterm labor 4
Management : Specific Actions
All women with suspected preterm labor is seen by the physician
Check gestation by dates and scan results.
Examine to determine size and presentation
Evaluate the CTG.
Inform neonatal unit
The following investigations are required
• Full blood count
• MSU-consider urgent microscopy if there is proteinuria
• Speculum and intracevical swab (ICS & HVS)
If membranes intact and contractions, a vaginal examination
Search the etiology
If membranes are ruptured refer to PROM protocol.
If contractions are 3/10’ or more commence TOCOLYSIS ritodrine
and give steroids
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
preterm labor 4
TOCOLYSIS : SUPPRESSION OF PRETERM LABOR
1. It is rarely indicated after 34 weeks gestation and is unlikely to
be successful once cervical dilatation is 4 cms or more.
2. Only indicated in order to delay delivery by 48 hours to allow
Dexamethazon in fetal maturation or to allow in utero transfer
3. If a tocolytic drug is used, ritodrine no longer seems the best
choice.
Atosiban or nifedipine appear preferable as they
have fewer adverse effects and seem to have comparable
effectiveness.
Nifedipine Regimen should be the first choice now
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
preterm labor 4
TOCOLYSIS : Regimen for intravenous ritodrine infusion
An infusion using a syringe pump ritodrine (Yutopar) in % dextrose.
The infusion is commenced at 1 ml/hr and increased every 10 mins
from 1-2-3-4-5-6 to maximum (400 µg /min) or until contractions cease or
maternal pulse > 140 bpm or systolic BP>160 mmHg.
Strict fluid balance records are needed
urine should be tested for glucose and ketones.
Pulmonary edema is recognized
Once contractions have ceased the infusion is left at that rate for 1
hour
The infusion is then reduced by 1 ml/hr every 30 mins until the lowest
rate required keeping the patient contraction free is reached.
The infusion should be discontinued once the patient has been
contraction free for 6-8 hours.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
preterm labor 4
TOCOLYSIS : Monitoring whilst on ritodrine:
1. Watch for alert symptoms Discontinue infusion if any symptom
2. Check maternal pulse Discontinue the infusion if > 120 pm.
3. Check the Blood Pressure Discontinue infusion if the BP drops.
4. Estimate blood glucose levels caution if diabetic patients
5. Strict record of fluid balance input/output chart
6. Auscultate lung fields Discontinue infusion if pulmonary oedema
and give lasix.
7. Check blood urea and electrolytes.
8. Practice ECG 24 hourly ( potassium deficiency)
9. U + Es
10. CTG : contractions and FHR .
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
preterm labor 4
TOCOLYSIS : Monitoring whilst on ritodrine:
Discontinue infusion if any of the followings alert symptoms
q Palpitations
q Tremors
q Nausea
q Vomiting
q Headache
q Restlessness
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
preterm labor 4
TOCOLYSIS : Contraindications to ritodrine:
1. Absolute contraindications:
 Ante partum hemorrhage
 Chorioamnionitis
 Eclampsia/fulminating pre-eclampsia
 Intrauterine fetal death
 Maternal cardiac disease
2. Relative contraindications:
 Diabetes mellitus
 Rupture of membranes.
Ritodrine is indicated in order to delay labor for 48 hours after the
administration of steroid unless there are any signs of infection
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
preterm labor 4
TOCOLYSIS : Side effects of Ritodrine:
 Pulmonary edema
(indicated by dry cough /chest pain /dyspnea)
 Tachycardia, palpitations
 Anxiety, sweating
 Tremor
 Hypokalaemia
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
preterm labor 4
TOCOLYSIS : Regime for Nifedipine Tocolysis:
 10 mgs orally (NOT SUBLINGUAL)
repeated every 20 minutes up to a maximum of 40 mgs.
 Maintenance 10-20 mgs tid for 48 hrs.
 Patient must be monitored for BP and pulse
 CTG monitoring is essential.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
ALGORITHM :
PRETERM LABOUR 1
preterm labor 4
Contractions
Vag Exam
Cerv. Dilat. >4
cm
Cerv. Dilat. <4
cm
CTG
Term ?
Risk
Assesment
>= 34 wks
Weak
Mild
< 34 wks
High
Refer
Or Transfer
See Algorithm Preterm 2
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
OK
preterm labor 4
Weak
Mild
High
Rest
Progestin
Rest
Progestin
Rest
Progestin
Failure
Orally
tocolytic
IV
Tocolytic
corticoids
OK
ALGORITHM :
PRETERM LABOUR 1
Failure
OK
Failure
>= 34 wks
Term ?
Stop
Treat
< 34 wks
Refer
Or
Transfer
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
preterm labor 4
STEROID THERAPY : PROMOTING PULMONARY MATURITY
1. All women with potential or actual threatened preterm labor
between 24 and 35 weeks should be given steroids even if
delivery is imminent.
2. 2 doses of 12 mg Betamethasone/dexamethasone IM given 12
hours apart
3. Aim to delay labor for a further 24 hours for maximum benefit
4. Rupture of the membranes is not a contra-indication to steroid
therapy
5. Diabetic patient -see diabetes protocol
6. Repeated doses of Betamethasone/dexamethosone if the
first doses were given before 29 completed weeks after
discussion with the consultant in charge.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
preterm labor 4
DELIVERY:
 Breech presentations discussed with the Consultant
 Cephalic presentation should be allowed to deliver vaginally
 CTG (and Fetal Scalp Sampling)
 Episiotomy
 Elective forceps delivery is not necessary.
 Pediatricians present at all preterm deliveries .
 A swab should be taken from the placenta
 and the placenta sent to histology
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
Breech presentation 5
Topic 4, B
High Risk Cases
Subtopic 5
Management Breech presentation at term
Standard
Statement
Even if a clear management plan is written in the
notes, consultant Must be informed upon
admission as the management needs to be
individualized
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
Breech presentation 5
Management :
1. Obtain initial history
2. Perform abdominal exam
3. Perform the routine admission procedures.
4. Check CBC, Blood type & Rh, save blood for X-match.
•
external cephalic version (ECV) in absence of contraindications
1. term frank or complete breech singleton : caesarean section.
2. Primigravidae with breech presentation by CS.
3. Deliver all footling breech by CS.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
Breech presentation 5
Specific Actions in case of breech presentation
1. Do not induce/and or use Oxytocin to accelerate labor.
Induction or augmentation may be justified in selected cases.
(Consultant decision).
2. Breech extraction ONLY in the case of a second Twin or dead fetus
3. Only senior doctor with proven experience should conduct the
delivery.
4. Forceps should be available in advance.
5. When the fetal heart rate trace is suspicious, fetal blood sampling
6. An Anesthetist as well as pediatrician should attend the delivery.
7. Explain the delivery procedure to the patient and her husband.
8. Allow pregnancy to continue up to 40 weeks +10 days
9. PROM and pre-term labour are managed as in relevant protocol.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
Breech presentation 5
All women with an uncomplicated breech pregnancy at term
(37-42 weeks) should be offered external cephalic version
(ECV) in the absence of contraindications.
1. ECV should be undertaken by consultant or a well trained
registrar under direct consultant supervision.
2. Tocolysis is helpful, and should be used as a routine in
primigravidas.
3. Perform ECV while the mother awake and facilities for
emergency CS delivery are available nearby.
4. Confirm fetal; well being with cardiotocography before and
after ECV, Ultrasound guidance can be helpful.
5.
Do not use regional anaesthesia to facilitate ECV, evidences is
insufficient to support its use.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
Breech presentation 5
PARTICULAR CONDITIONS : 1. If Multigravidae:
May be considered for vaginal breech delivery if:
 No other obstetrics/medical problem
 Clinically adequate pelvis.
 Scan estimation of F.W, Not more than 3500 gm at 38 weeks ,
 of frank or complete breech.
Explain to the mother and give her time to discuss the choice with her
husband/relatives.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
Breech presentation 5
PARTICULAR CONDITIONS : 2. If trial of labor (in breech)
Trial of labour in breech presentation : consultant’s decision
1. Vaginal breech delivery should be carried out by the most senior
Doctor available
2. Immediate vaginal Examination if SROM.
3. Ask for Blood grouping and X – Matching.
4. Epidural analgesia can be employed.
5. Full dilatation of the cervix confirmed by experienced midwife or
obstetrician
6. Keep on continuous electronic fetal heart monitoring.
Stop trial of labour and consider C/S if :



Rate of cervical dilatation is < 1cm/hr
If the breech fails to descend.
If there is evidence of fetal distress.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
Breech presentation 5
PARTICULAR CONDITIONS :Preterm breech delivery

Up to 28 weeks allow for vaginal delivery.

28 – 34 weeks : Individual Consultant decision.

35-37 weeks : Manage as term breech regarding.
Do not perform ECV before term (37 weeks)
There is insufficient evidence to support routine caesarean section
for the delivery of preterm breech
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
Twins at Term 6
Topic 4, B
High Risk Cases
Subtopic 6
Management of Twins at Term in labor
Standard
Statement
Twin pregnancy is associated with higher
perinatal mortality especially in the second
twin, and increased maternall morbidity. -
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
Twins at Term 6
Specific Actions
Inform the Consultant of the admission
If the first twin is Breech , perform C/S
epidural analgesia if the woman desired so.
Obstetric Registrar, anesthetist, pediatricians to be present
Oxytocin infusion prepared for use in second stage
Once the first twin is delivered,
 Clamp the cord and divide. Do NOT give syntometrine.
 Check presentation of the 2nd twin abdominally, vaginally (and US Scan)
 If contractions have not recommenced after 5 mins start an infusion of 10
IU Oxytocin
Once the presenting part has descended into the pelvis, perform an
ARM
Aim for delivery of the second twin within 20 mins of the first if possible.
The third stage managed actively.
After delivery : infusion of 10u Oxytocin in 500 mls Hartmann’s
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
Twins at Term 6
Specific Actions
If the presenting part fails to descend, consider
q a controlled ARM for a cephalic Presentation;
q breech extraction for
q a breech presentation
q or persistent transverse lie.
Breech extraction should be performed by grasping a foot PRIOR to
rupturing the membranes and apart from extreme fetal distress should
only be performed by an experienced registrar or Consultant.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
Trial of labor 7
Topic 4, B
High Risk Cases
Subtopic 7
TRIAL of scar management (Trial of labor)
Definition
This will include patients with a previous
caesarean section, hysterotomy, myomectomy,
uterine perforation.
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
Trial of labor 7
MANAGEMENT
Check that a decision for vaginal delivery has been made at a senior
level (If no decision has been made, discuss with the Consultant )
Give ranitidine 150mg orally 6 hourly during labor
Inform Anaesthetist
Perform 2 hourly vaginal examinations to check progress
Watch for signs of scar dehiscence
Assess the case carefully before using Oxytocin (on consultant’s order)
Epidural analgesia could be used, however, do not epidural opiates
as these may mask the pain of dehiscence /rupture.
Progress in labor has to be almost ideal without much delay.
Aim to achieve simple vaginal delivery at full dilatation.
Be aware of post partum bleeding
Do not palpate or inspect the previous scar after delivery, as a routine
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
Trial of labor 7
Watch for signs of scar dehiscence






Maternal tachycardia
Vaginal bleeding
Abnormal CTG
inco-ordinate or cessation of uterine activity
Severe lower abdominal pain present between
contractions
Presenting part getting higher
National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions
End of module 5
High Risk Cases
obstetrical conditions
National and Unified Obstetric and Newborn care Guidelines and Protocols