Department: Health
Subject:
Government of West Bengal
Department of Health & Family Welfare
State Family Welfare Bureau
Swasthya Bhawan
GN 29, Sector V, Salt Lake, Kolkata-700091
No. H/SFWB/1L-01-2013/2113(53) Date: 17.12.2013
CIRCULAR
1-13) The Principal/Director, IPGMER, Kolkata MCH, NRS MCH, R G Kar MCH, CNMCH/Sagar Dutta MCH, Medinipur MCH, Burdwan MCH, BSMCH, Murshidabad MCH, Maldah MCH, North Bengal MCH, Kalyanl MCH,
14-26) The MSVP, IPGMER, Kolkata MCH, NRS MCH, R G Kar MCH, CNMCH, Sagar Dutta MCH, Medinipur MCH, Burdwan MCH, BSMCH, Murshidabad MCH, Maldah MCH, North Bengal MCH, Kalyani MCH,
27-52) The CMOH, North 24 Parganas, Basirhat, Howrah, Hooghly, Nadia, South 24 Parganas, Diamond Harbour, Purba Medenipur, Birbhum, Rampurhat, Bankura, Bishnupur, Puruliya, Paschim Medenipur, Jhargram, Murshidabad, Bardhaman, Assansole, Malda, Uttar Dinajpur, Dakshin Dinajpur, Jalpaiguri, Coochbehar, Darjeeling Health District,
53) The DFWO, Kolkata,
Subject: Labour Room Protocol
Enclosed herewith please find “Labour Room Protocol” prepared by Dr Tridib Banerjee, Chairman, HLTF along with Prof. D Bhattacharya, Principal, Sagar Dutta MCH, Prof. Md Alauddin/ Dept. of G & Obs, Medenipur MCH & Dr S Chakraborty, Associate Professor, Kolkata MCH.
This “Labour Room Protocol” must be made available to every service provider attached to Labour Room/ Maternity ward of all MCH, District Hospital, S D/ S G Hospital, Decentralised Hospitals, Rural Hospital, Block PHC, 24 X 7 PHC and other PHC in the state with instruction to follow the protocol strictly.
Instruction for using labour room protocols:
Do a rapid initial assessment to diagnose any condition which need immediate attention e.g- imminent delivery, ecclampsia, active bleeding per vagina, shock etc,
Always observe infection prevention practices while providing clinical careChange shoes in labour room
Wear protective apron
Wash hand before and after patient examination following six steps
Wear sterile glove before examination
Decontaminate glove in .5% chlorine solution after examination
Decontaminate all used instruments in .5% chlorine solution before, washing
Dispose of all waste materials according to colour coding
Clearance of waste basket during each duty shift along with swabbing of labour room floor.
Diagnose a patient in shock and manage accordingto protocol (Page 1)
Diagnose a patient in labor and manage according to protocol (Page 1)
Shift the patient in active phase: of labor and manage according to protocol (Page 2)
Manage second stage of labor and manage according to protocol using a partograph and never use misoprostol tablet oral/ vaginal without a record (Page 2)
Provide active management of 3rd stage of labor to ALL mothers according to protocol (Page 4)
Manage immediate post partum period according to protocol (Page 5]
Diagnose and manage PPH and other third stage complication according to protocol (Page 8)
Diagnose and manage severe pre eclampsia and eclampsia according to protocol (Page 5)
Follow therapeutic antibiotic protocol in sepsis cases according to protocol (Page 13)
Follow PPTCT protocol
Counsel all mothers for HIV testing
If tested reactive husband should be counseled
Provide Nevirapine prophylaxis (single tablet 200 mg) to all reactive mothers at the onset of labour/ before cesarean section
Provide Nevirapine prophylaxis to all babies of reactive mothers (syrup: 0.1 mg/kg body weight)
Do not apply any identification tag on a reactive mother or baby.
Labour Room Protocols
1. Shock
Collapse of circulation resulting in critical reduction of tissue perfusion.
Life threatening;
Needs urgent and intensive treatment.
Anticipate/expect shock in obstetrics when there is:
Bleeding (abortion, ectopic, APH, PPH)
Infection ( septic abortion, puerperal sepsis)
Trauma (rupture uterus, uterine inversion)
Initial Management:
Shout for help
Rapidly evaluate vitals,
Resuscitate if needed
Start 02 inhalation
Ensure patent airway
Rapid TV fluid with RL
Diagnosis:
Restlessness, confusion, unconsciousness, sweating
Cold and clammy skin
Fast and weak pulse, low blood pressure
Subnormal temperature
Rapid breathing, pallor
Oliguria
Management: At BEmOC
Mobilize help
Oxygen inhalation (6 – 8 litres/min).
Ensure patent airway (turn onto her side)
Raise foot end.
Keep the woman warm.
Rapid infusion of ringer lactate (1st choice)/normal saline to restore blood volume (1 liter in 20 minutes) – start two IV line
Inj. Morphine sulphate 15 mg IM.
Steroid hormones-Inj. Hydrocortisone (500-1000 mg) is useful in all types of shock.
Catheterize the bladder.
Monitor vital signs for evidence of improvement.
Manage the specific cause for shock.
Refer to higher centre for further management if needed (e.g., of specific cause) & blood transfusion if needed (with donor).
At CEmOC
General management of shock is as in BEmOC.
Transfuse as necessary.
Treat the specific cause as early as possible and suitable.
Monitor for evidence of improvement.
2. Diagnosis of Labour:
Anticipate labour if the woman in third trimester of pregnancy has
Painful intermittent uterine contraction with increasing frequency and intensity
Show.
Watery vaginal discharge/ sudden gush of water
Confirm onset of labour if there is
Regular, painful uterine contractions of > 20 secs duration and at least once every 10 mins.
Progressive cervical dilatation and effacement or
Cervical dilatation of >= 4 cms
Stages and phases of labour :
First Stage-
Latent phase – cervix = 4 cm:4-6 hours
Dilatation rate >= 1 cm/hour
Second Stage- cervix -10 cms
If cervix is not dilated at initial examination and
Pain persists – reexamine after 6 hours. If there is effacement and dilatation diagnose labour. If still no cervical change – diagnose false/ pre-labour.
Pain subsides – observe for 24 hours.
Obstetric care and management:
Careful monitoring of
Progress of Labour
Foetal wellbeing
Maternal wellbeing
Early identification of abnormality/complication
Timely intervention.
3. Care during latent phase:
Note-
Pulse: 2 hourly
Respiration, temperature and B.P.: 4 hourly
Uterine contraction: 1-2 hourly
F.H.S.: hourly
Descent: before each P/V examination
Cervical dilatation and effacement, station of head and character of liquor (if membranes ruptured) at each P/V examination (6 hours after initial assessment).
Protein and acetone in urine when passed.
Intervention only for specific indication, e.g. Foetal distress.
4. Care during active phase:
Start plotting on partograph all events of labour once the woman is in active phase, The WHO partograph is modified by excluding the latent phase and beginning plotting at 4 cm cervical dilatation in active phase to make it simpler and easier to use. Record the following on the partograph.
Using the Partograph:
Patient information:
Fill out name, para, hospital number, date and time of admission, and time of rupture of membranes; or time elapsed since rupture of membranes (if rupture occurred before charting on the partograph began.
Foetal heart rate;. Record every half hour.
Amniotic fluid: Record status of membrane & the Colour /nature of amniotic fluid at every vaginal examination:
” I: membranes intact
” C: membranes ruptured clear fluid
” M: meconium stained fluid
” B: blood stained fluid
” A: liquor absent
Moulding:
” 1+: Sutures apposed
” 2+: Sutures overlapped but reducible
” 3+: Sutures overlapped and not reducible
Cervical dilatation: Assessed at every vaginal examination and marked with a cross (x). Begin plotting on partograph at 4 cm cervical dilatation. Expect 1 cm or more/ hour dilatation thereafter.
Alert line: A line starts at 4cm of cervical dilatation to the point of expected full dilation at the rate of 1 cm per hour. With normal progress, the cervicograph will remain on or to the left of the alert line.
Action line: Parallel and four hours to the right of the alert line.
Descent assessed by abdominal palpation: Recorded as a circle (O) at every abdominal examination. At 0/5 the sinciput is at the level of the symphysis pubis.
Hours: Refers to the time elapsed since onset of active phase of labour (observed or extrapolated)
Time: Record actual clock time.
Contractions: Chart every half hour. Count the number of contractions in a 10 minutes time period, and their duration in seconds
Less than 20 seconds
Between 20 and 40 seconds
More than 40 seconds
Oxytocin: Record the amount of oxytocin per volume IV fluids in drops per minute every 30 minutes when used.
Drugs given: Record any additional drugs given.
Pulse: Record every 30 minutes and mark with a dot (.)
Blood pressure: Record every 2 hours and mark with arrows.
Temperature: Record every 2 hours.
Protein, acetone and volume: Record when urine is passed.
5. Management of second stage of labour
Diagnosis of Second Stage:
Urge to defaecate.
Urge to bear down.
Membranes spontaneously rupture.
Cervix is no longer palpable i.e. fully dilated.
Conduct of Delivery;
Shift the patient to the delivery table, if such transfer is needed, when second stage is diagnosed
Monitor FHR every five minutes.
Put her on the position of her choice – preferably in dorsal or semi-recumbent position.
Maintain cleanliness.
Wash perineal area with an antiseptic solution and use sterile/clean drapes.
When head is crowning the perineum, decide as to the need of episiotomy or otherwise (neither routinely required nor to be routinely avoided).
If needed make a mediolateral episiotomy.
When occiput hinges below symphysis pubis, apply gentle downward pressure to the occiput with left hand to prevent sudden extension while a pad in the other hand supports the perineum to enable controlled delivery of head rather than a sudden pop out.
Once head is delivered, palpate foetal neck for any loop of cord. Slip it over the head if loose; if tight, cut it between two clamps.
Clear the baby’s mouth and oropharynx of mucous with a mucous sucker, if needed, before the body delivers. Deliver the shoulders by depressing the head posteriorly so that lateral flexion of the body occurs. The rest of the baby automatically follows.
Cut the cord between clamps.
Note birth time.
Do essential and basic new born care.
Give the baby to mother and let the baby start suckling if the baby is well (breathing/crying) and start resuscitation if unwell.
Palpate the abdomen to rule out presence of additional baby.
6. Active Management of third stage of labour
Inj. Oxytocin 10 units IM after delivery of foetus (within 1 min).
Look for placental seperation. Place the left hand on lower abdomen to detect the contraction of uterus. (After delivery, uterus is at or just below the level of umbilicus. It also ensures early detection of blood collecting inside the uterus.)
Signs of placental seperation:
Uterus becomes contacted, hard and globular,
Uterus rises just above umbilicus;
Extra Vulval lengthening of umbilical cord;
A gush of blood frequently appears;
On pushing the uterus up in the abdomen, the cord does not recede back.
Deliver placenta (after its seperation) by controlled
Cord traction while raising the uterus gently upward by adominal hand.
Massage the uterus (after delivery of placenta) to keep it contracted.
Inspect the placenta & membranes for completeness.
Inspect vagina and perineum for any tears.
Repair tears/ episiotomy if any.
Note: Oxytocics for third stage management:
| OXYTOCIN | ERGOMEIRINE/ METHYL ERGOMETRINE | PROSTAGLANDIN 15-Methyl PGF2a | MISOPROSTOL |
| Cheap No contra indication Safe – no side effects Effective – quick action Less heat labile 10 units IM |
Cheapest Important contraindications Side effects – sometimes serious Effective Heat labile 0.2 mg IM/IV |
Costly Some contraindications Some side effects Effective Highly heat labile 125-250 meg IM |
Less costly No significant contraindication No significant side-effect Effective Highly heat stable 600 meg orally |
Oxytocin – first choice (but never give IV bolus)
Misoprostol – has a promise
Prostaglandin – effective but costly
Ergometrine/Methyl ergometrine – has contraindications & side effects
Use other oxytocic if oxytocin is not available.
Exclude contraindications if using methyl ergometrine & remain cautious about side effects
7. Immediate postpartum care
Closely monitor for first 6 hours.
Pulse, respiration, temperature, B.P., G.C
Vaginal bleeding.
Uterine hardness.
@ Every 15 mins, for 2 hours.
@ Every 30 mins. for 2 hours.
@ Every hour for 2 hours.
Massage the uterus every 15 mins to maintain contraction.
If stable (and there is no contraindication) give her something to drink when she feels thirsty and something to eat when she is hungry.
Keep the baby in skin contact with mother.
Initiate exclusive breast feeding within 1 hour.
10. Pre eclampsia/Eclampsia
Problem:
Pregnant woman has high BP
Pregnant or recently delivered woman complains of headache/ blurred vision/blindness/epigastric/bomiting/oliguria/anuria.
Pregnant or recently delivered woman is unconscious or has convulsions
Initial management:
Mobilize help
Rapid evaluation of vitals
Resuscitation if needed
O2 inhalation
If unconscious/convulsing
Place her on her side
Ensure clear airway
Protect from injury
Aspirate her mouth and throat after fit if needed
Diagnosis:
Hypertension: BP >= 140/ 90 mm Hg or an increase of 30 mm Hg systolic or 20 mm Hg diastolic
Before 20 weeks – chronic hypertension
After 20 weeks – Gestational hypertension (PIH)
Pre eclampsia: Hypertension + Proteinuria
Mild-
BP < 160/110 mm Hg, urine protein < 2+, without symptom
Severe-
BP >= 160/110 mm Hg, urine protein > 2+
Headache, visual disturbance/blindness/diplopia, epigastric pain, vomiting, oliguria; (also known as ominous or danger signs of omminent/impending eclampsia – indicating that the women may develop eclampsia any time)
Eclampsia: Pre eclampsia plus convulsion and/ or coma.
Diagnose and treat any convulsion during pregnancy and within one week of child birth as eclampsia unless proved otherwise.
Note:
1. Oedema- As 50 % normal pregnant Women may have oedema –
neither its presence conforms nor does its absence excludes the diagnosis of pre eclampsia. More over hypertension and proteinuria are mainly prognostically important, But suspect pre eclampsia if there is Oedema or excessive/rapid weight gain.
2. Prevention of Pre eclampsia and Eclampsia:
Fluid and salt restriction does not help.
Beneficial effect of aspirin/calcium -not yet proved
Pre eclampsia is not preventable. But-early detection and management of pre eclampsia will prevent the complication of eclampsia;
Management: At BEmOC
Management of Gestational Hypertension and Mild Pre eclampsia:
Rest, normal diet.
Monitor BP and proteinuria.
No salt restriction./ sedative/ anticonvulsant/ diuretic
Methyldopa, (up to 500mg QID))7 Labetolol (100 mg TID)/ Nifedipine (5-10 mg TID) if diastolic BP > 100mm Hg – maintain it between 90-100mm Hg
Monitor foetal growth, wellbeing and maternal wellbeing
Plan delivery at term, or earlier in case of
Significant IUGR
Worsening proteinuria/ unsatisfactory BP control
Refer to higher centre in such cases.
Management of Severe Pre eclampsia:
Prevent convulsion with MgSO4 as in eclampsia (loading dose)
Rapidly control BP with Nifedipine 5 – 10 mg orally (or administer 3-4 drops intra nasally by puncturing the capsule) – repeat after 10 -15 mins, if needed, to lower DBP between
90-100 mmHg/ Labetolol Inj. can also be used (vide note at end. of section)
If delivery is not imminent within a short period (few hours), refer to higher center. (Delivery should be planned within 24 hours)
If delivery is imminent
Conduct delivery carefully monitoring foeto maternal well being.
Manage 3rd stage actively with oxytocin 10 units IM.
Remain vigilant in Post Partum period.
Maintain MgSO4 for 24 hours as in eclampsia, continue antihypertensive till DBF is 90 mm Hg
Management of Eclampsia:
Control convulsion: MgSO4 (loading dose)
Control BP: as in severe pre eclampsia
If there is convulsion/coma
Place her on her side
Protect from injury
Ensure clear airway
Give oxygen: 4-6 L/min
Aspirate her mouth and throat if needed especially after fit
IV Fluid: Ringer Lactate – about 40 drops per/min
Catheterize the bladder
Note output
Check for pulmonary oedema (basal creps)
Look for complications
Never leave the patient alone.
If delivery is not imminent, refer to higher centre after these primary treatment and loading dose of MgSO4 & initial dose of antihypertensive (such patients should deliver within 12 hours)
If delivery is imminent
Conduct delivery – and expedite & curtail 2nd stage if needed
Actively manage third stage
Remain vigilant in post partum period.
MAGNESIUM SULPHATE REGIMEN
Loading dose:
Give magnesium sulphate (as 20% solution) 4gm IV in over 5 inins.
Follow immediately with 10gm of 50% magnesium sulphate solution (5gm in each buttock) deep 1
If convulsion recurs after 15 mins give 2gm MgSO4 (as 20% solution) IV in over 5 mins.
Maintenance dose:
5 gm magnesium sulphate (50% solution) with 1 ml 2% lignocaine IM every 4 hours in alternate buttock.
Continue, treatment for 24 hours after delivery or the last convulsion whichever is later,
Watch
Respiratory rate
Patellar reflex and
Urinary output
With hold maintenance dose of MgSO4 if respiratory rate is below 16/mins, patellar reflexes are absent/sluggish, urinary output is less than 30 ml/hour for the preceding 4 hours.
The drug can be restarted when the finding returns to normal.
In case of respiratory arrest, give calcium, gluconate 1 gm (10 ml of 10% solution) IV slowly and assist ventilation until respiration begins and the effects of MgS.04 are antagonized.
Post Partum Care
Continue MgSO4 for 24 hours after delivery or last convulsion whichever is later
Continue antihypertensive (Nifedipine 5-10 mg orally TID/ oral Labetolol 100 mg TID adjusted according to BP) till DBP is 90 mm Hg
Maintain intake output chart and infuse IV fluid accordingly: avoid pulmonary oedema.
Oral feeding as early as possible.
Note pulse, respiration, temperature and BP initially half-hourly for 6 hours, then 4 hourly.
Look for complications
Refer to higher centre even after delivery in case of
Oliguria
Continued coma/uncontrolled convulsion
Suspected DIC, HELLP syndrome
Any other complication
Management: At CEmOC
Management of Gestational Hypertension and Mild Pre eclampsia:
Treat as in BEmOC
Monitor BP, proteiuria, maternal condition, foetal growth & wellbeing
Use additional antihypertensive if required
Spontaneous labour may ensue at term, otherwise, plan delivery at term, or earlier in case of
Significant IUGR/compromised foetal wellbeing
Worsening proteinuria/ unsatisfactory BP control
Decide termination of pregnancy considering risk Vs benefit of further in utero stay Vs delivery
Vaginal delivery feasible – Induce labour (ARM, oxytocin drip) (after ripening of cervix with dinoprostone gel if necessary)
Vaginal delivery not feasible/induction not possible – Do caesarean section
Management of Severe Pre eclampsia:
Institute antihypertensive, anticonvulsant (MgSO4) and general management as in BEmOC
Plan delivery within 24 hours
In labour
Vaginal delivery possible – monitor labour, expedite if needed & conduct delivery
Vaginal delivery not feasible – Do caesarean section
Not in labour
Vaginal delivery feasible – Induce labour (ARM, oxytocin drip) (after ripening of cervix with dinoprostone gel if necessary)
Vaginal delivery not feasible/induction not possible – Do caesarean section
Manage labour & postpartum period as in BEmOC
Management of Eclampsia:
Antihypertensive,, anticonvulsant (MgSO4) and general management as in BEmOC
Terminate pregnancy without delay. Attempt delivery within 12 hours.
In labour
Vaginal delivery possible – mo
Sd/- Commissioner, Family Welfare &
Secretary to Govt. of West Bengal.