Wits Obstetrics 2017 PDF

1 TABLE OF CONTENTS Page Introduction 3 List of abbreviations 5 Chapter 1: Antenatal care 7 Objectives of antenatal c...

1 TABLE OF CONTENTS Page Introduction 3 List of abbreviations 5 Chapter 1: Antenatal care 7 Objectives of antenatal care 7 Antenatal Clinic 7 The first antenatal visit 7 Information for pregnant women 14 Subsequent and referral antenatal visits 15 Assessment of fetal well being 16 Management of common antenatal problems 18 Chapter 2: Labour, delivery and puerperium 22 Diagnosis of labour 22 Admission of a woman in labour 22 General care of women in labour 24 Routine monitoring of the first stage of labour 25 The partogram: alert and action lines 25 Analgesia in labour 26 Fetal monitoring 26 The second stage of labour 28 The third stage of labour 29 The fourth stage of labour 29 Home delivery – ‘born before arrival’ 31 Abnormalities of the first stage of labour 32 Emergencies during labour and prolonged second stage 36 Instrumental delivery 39 Caesarean section 41 Immediate care of the newborn 44 Abnormalities of the third and fourth stages of labour 48 Primary postpartum haemorrhage 50 Cardiopulmonary resuscitation (CPR) in pregnancy 54 The unconscious obstetric patient 57 The normal puerperium 58 Secondary postpartum haemorrhage 58 Puerperal sepsis 59 Lactation and lactation suppression 62 Chapter 3: Hypertension in pregnancy 64 Definitions 64 Pathophysiology of pre-eclampsia 66 Management of hypertensive disorders of pregnancy 67 Labour and delivery in hypertensive disorders 73 Postpartum care 73  2 Chapter 4: Common obstetric problems 74 Intrauterine growth restriction 74 Intrauterine death 77 Antepartum haemorrhage 78 Multiple pregnancy 84 Breech presentation and transverse lie 87 Preterm labour 89 Prelabour rupture of the membranes 92 Chorioamnionitis 94 Suspected prolonged pregnancy 94 Induction of labour with a live baby 95 Rhesus incompatibility 98 Previous caesarean section 98 Poor obstetric history 100 Chapter 5: Fetal medicine 103 The Fetal Medicine Unit 103 The ultrasound scan at 11-14 weeks 103 The ultrasound scan at 18-23 weeks 104 Women for referral to the Fetal Medicine Unit 105 Postnatal investigation 106 Chapter 6: Medical disorders 108 Anaemia and transfusion 108 Diabetes mellitus 112 Thyroid disease 117 Cardiac disease 118 Anticoagulation 120 Thromboembolic disease 122 Asthma 123 Jaundice 125 Epilepsy 126 Chapter 7: Infectious conditions 127 Sexually transmitted infections 127 HIV infection in pregnancy 129 Group B streptococcal infection 136 Urinary tract infection 136 Pneumonia and tuberculosis 137 Malaria 140 Chapter 8: Terminology, audit and statistics 142 Audit 144 Essential statistics 144 Perinatal deaths 145 Maternal deaths 146 Audit meetings 147  3 Wits Obstetrics 2017 Early release edition Introduction This guidelines book is an update of the 2013 ‘Wits Obstetrics’ obstetric clinical guidelines for the Department of Obstetrics and Gynaecology at the University of the University of the Witwatersrand, originally the ‘Obstetrical Handbook for Doctors’ produced in 1998, rewritten in 2003, and updated in 2007 as ‘CHB Obstetrics’ for Chris Hani Baragwanath Hospital. This edition has the same format, with much of the content aligned with the national Department of Health’s Guidelines for Maternity Care in South Africa. The content applies in general to the three referral hospitals attached to the Wits academic department – Charlotte Maxeke Johannesburg Academic Hospital, Rahima Moosa Mother and Child Hospital, and Chris Hani Baragwanath Academic Hospital. The booklet may have value in other Johannesburg and Gauteng Province hospitals, and also in hospitals elsewhere in South Africa. The guidelines recommend management of common obstetric conditions at primary and referral level, based on local experience and evidence-based practice. They are not intended as strict protocols nor as standard operating procedures, but rather as a guide to safe effective management of common obstetric problems. The guidelines should be most useful to interns, medical officers and registrars. A special thank you to the following people who participated in reviewing the book, and made valuable contributions toward its improvement: Prof Y Adam Dr S Bhoora Dr M Bothma Dr L Chauke Dr A Chrysostomou Dr W Edridge Dr J Jeebodh Prof H Lombaard Dr S Maswime Dr C Mnyani Prof E Nicolaou Dr R Nyakoe Dr N Pirani Dr H Rhemtula Dr A Wise  4 Our eternal gratitude to Prof Eckhart Buchmann, the past editor, for his continued support and contributions. Ebrahim Bera (editor) Department of Obstetrics and Gynaecology School of Clinical Medicine Faculty of Health Sciences University of the Witwatersrand Johannesburg 16 November 2016  5 LIST OF ABBREVIATIONS 3TC – lamivudine AB – asymptomatic bacteriuria ABC – abacavir ABG – arterial blood gas AIDS – acquired immune deficiency syndrome APH – antepartum haemorrhage APHUO – antepartum haemorrhage of unknown origin APS – antiphospholipid syndrome ALT – alanine transaminase ART – antiretroviral therapy ARV – antiretroviral AST – aspartate transaminase AVPU – alert, voice, pain, unresponsive AZT – zidovudine BMV – bag-mask ventilation CPR – cardiopulmonary resuscitation CS – caesarean section CSF – cerebrospinal fluid CT – computerized tomography CTG – cardiotocograph CVP – central venous pressure CVS – chorionic villus sampling (biopsy) DVT – deep vein thrombosis ECG - electrocardiograph ECV – external cephalic version EDD – expected date of delivery EFV – efavirenz FBC – full blood count FDC – fixed dose combination FTC – emtricitabine GCS – Glasgow Coma Scale Hb – haemoglobin HbA1C – glycated haemoglobin hCG – human chorionic gonadotrophin HCT – HIV counseling and testing HIV – human immunodeficiency virus HR – heart rate ICS – inhaled corticosteroids ICU – intensive care unit IO – intra-osseous IM – intramuscular INR – international normalized ratio  6 LIST OF ABBREVIATIONS (contd) IUFD – intrauterine fetal death IUGR – intrauterine growth restriction IV – intravenous LFT – liver function tests LMP – last menstrual period LPV/r – lopinavir/ritonavir M&M – morbidity and mortality MA – maternal age MCA – middle cerebral artery MCS – microscopy, culture and sensitivity MCV – mean cell volume MOU – midwife obstetric unit MSU – midstream urine MUAC – mid-upper arm circumference NB – nasal bone NCCEMD – National Committee on Confidential Enquiries into Maternal Deaths NST – non-stress test NT – nuchal translucency NVP – nevirapine NYHA – New York Heart Association OGTT – oral glucose tolerance test PAPP-A – pregnancy-associated placental protein A PCR – polymerase chain reaction PE – pulmonary embolism PMTCT – prevention of mother-to-child transmission PPH – postpartum haemorrhage PTT – partial thromboplastin time RHZE – rifampicin, isoniazid, pyrazinamide, ethambutol RPR – rapid plasma regain RPV – rilpivarine SC – subcutaneous SFH – symphysis-fundal height TB - tuberculosis TDF – tenofovir TOP – termination of pregnancy U&E – urea and electrolytes VBAC – vaginal birth after caesarean section VF – ventricular fibrillation VT – ventricular tachycardia VL – viral load  7 Chapter 1 Antenatal Care OBJECTIVES OF ANTENATAL CARE Antenatal care attempts to ensure, by antenatal preparation, the best possible pregnancy outcome for women and their babies. This may be achieved by:  Screening for pregnancy problems  Assessment of pregnancy risk – high or low risk  Management of problems that may arise during the antenatal period  Medication that may improve pregnancy outcome  Information given to pregnant women  Physical and psychological preparation for childbirth and parenthood ANTENATAL CLINIC Ideally, only high risk pregnancies and midwife referrals should be managed at hospitals. Women without risk factors are best seen at midwife-run clinics from which they can be referred if necessary. Where a hospital manages low risk pregnant women, these should be separated from the high risk group and be seen by midwives. A list of high risk conditions is given on pages 20 and 21. THE ANTENATAL RECORD This fold-up card, or the relevant pages in the national maternity file, is the essential record of the pregnancy and must be completed at each antenatal clinic visit and retained by the pregnant woman until delivery. Women who present with a card from another province should have that card completed at the clinic, rather than be issued with a new card which would duplicate or mask information from earlier in the pregnancy. The content of antenatal cards may vary between provinces, but most formats are adequate for essential antenatal care. THE FIRST ANTENATAL VISIT Pregnant women should book for antenatal care as soon as pregnancy is detected, even as early as 5-6 weeks’ gestation. Make a complete assessment of gestational age and risk factors at the first antenatal visit. It is not necessary to wait until the second visit before such assessments are finalized. After one visit, a pregnant woman can be regarded as ‘booked’.  8 HISTORY TAKING This follows the check-list on the antenatal record  Gestational age – last menstrual period, cycle regularity and previous contraception  Current pregnancy, especially last menstrual period  Previous pregnancies, any complications and outcomes  Medical conditions, previous surgery, and psychiatric problems  Familial and genetic disorders, also considering ethnic origin, e.g sickle cell  Allergies  Use of medications,  Use of alcohol, tobacco and other substances  Family and social circumstances  Plans for contraception after the pregnancy SCREENING TO DETECT TUBERCULOSIS (TB) All women infected with human immunodeficiency virus (HIV) should be asked if they have experienced the following symptoms:  Cough for two weeks  Fever  Drenching night sweats  Weight loss Women with any one or more of these symptoms should provide sputum for TB testing and be followed up, and/or be further investigated. PHYSICAL EXAMINATION  General examination, including weight, heart rate, colour of mucous membranes, mid-upper arm circumference (MUAC), blood pressure (BP), and a check for oedema.  Systemic examination, including teeth and gums, breasts, thyroid, and heart  Pregnancy examination, including inspection and palpation of the pregnant uterus, with measurement of the symphysis-fundal height (SFH) in cm, and systematic palpation using Leopold’s method – fundal, lateral, Pawlik and pelvic grips  9 ESTIMATION OF GESTATIONAL AGE Indicate clearly on the antenatal card (top left above the symphysis-fundal height graph how the gestational age was estimated. The first estimation of gestational age, with the expected date of delivery, will be used for the remainder of the pregnancy and must not be changed unless important new information becomes available. Ultrasound This is extremely useful for measuring gestational age. An ultrasound scan at 24 weeks is an accurate indicator of gestation, and overrides other methods of gestational age estimation. An ultrasound estimate of >24 weeks is less reliable but is still useful when there is uncertainty about the date of a woman’s last menstrual period. Last menstrual period (LMP) This is valid if the woman is sure of her dates, and where palpation of the uterus and SFH measurement are compatible with the given dates. Use Naegele’s rule: Expected date of delivery (EDD) = first day of last menstrual period plus 7 days, minus 3 months, plus 1 year. Example: If LMP is on 5 October 2016, EDD will be on 12 July 2017. Symphysis-fundal height (SFH) measurement This is used if the dates from the last menstrual period are unknown or wrong, and if there is no ultrasound estimation of gestational age, provided that the pregnancy is otherwise normal. The measured SFH is plotted onto the 50 th centile line on the SFH graph, allowing the corresponding gestational age to be read from the graph. Examples are shown on pages 11, 12 & 13. Palpation The SFH measurement is of little value at 40 seconds) – use oxytocin if necessary Equipment and techniques vary. Disposable Kiwi hard and soft cups, soft Silc cups and Bird metal cups (anterior 50 and 60 mm, and posterior 50 mm) are available. Hard cups give better traction force, and for these at least 3-4 minutes should be given for the cup to become securely attached to the head vacuum. A negative suction pressure of 0.7 to 0.8 Bar is needed for effective traction. Important practical points and precautions  Check and test the equipment thoroughly before using it  Check the fetal heart rate just before starting the procedure  Apply traction only during contractions, with maternal pushing  Traction must be in a direction perpendicular to the vacuum cup  During traction with the dominant hand, keep fingers of the other hand on the vacuum cup and head, to feel for decent and detect incipient cup detachment  Failed vacuum extraction is an indication for caesarean section: - There should be noticeable descent with each pull - The vacuum cup must not be applied for more than 30 minutes - No more than 2 cup detachments are allowed - No more than 3 pulls (one pull = one contraction) are allowed  Write up the procedure fully: operator, indication, clinical findings included level of head in fifths, time taken, cup type and size, number of pulls, number of detachments, and baby’s condition at birth FORCEPS DELIVERY Forceps delivery is associated with greater maternal trauma and pain than vacuum extraction, but is useful for face presentation, unconscious women and women with cardiac disease. Wrigley or Anderson forceps are used. In addition to those that apply to vacuum extraction, the following precautions must be observed:  Forceps delivery must be done or supervised by an experienced person  Fetal head position must be direct occipito-anterior  The head must be 0/5 palpable above the brim (outlet forceps)  Use pudendal block for analgesia  41 PUDENDAL BLOCK Transvaginal pudendal block can be employed for any vaginal delivery where analgesia is needed, but is especially useful for forceps delivery. 1. Use a guarded needle with an introducer if available 2. Use lidocaine 1% solution 3. For the right pudendal nerve, identify the right ischial spine with the right index and middle fingers 4. Pass the needle next to the fingers and inject about 2 mL of lidocaine into the sacrospinous ligament 5. Inject a further 2 mL just beyond the sacrospinous ligament 6. Withdraw the needle out of the ligament and inject about 5 mL just lateral and above the ischial spine 7. Repeat the procedure on the left side 8. Inject any remaining lidocaine along the track of a proposed episiotomy 9. Remember to withdraw the syringe plunger before every injection to prevent accidental intravascular injection CAESAREAN SECTION Surgical techniques vary according to the circumstances, and experience of the operator. The Joel-Cohen transverse abdominal approach is preferred NOTES ON CAESAREAN SECTION  Give sodium citrate 30 mL orally 30 minutes before the expected start of the operation, not necessarily at the time of booking  Give metoclopramide 10 mg IM 30 minutes before the start of the operation  Just before starting the operation, ensure that: - Tubal ligation has been considered with the necessary consent signed if that is the woman’s choice - The fetal heart can still be heard - The indication for operation is still valid, and known to the woman - The fetal presentation and position are known  Give a broad spectrum antibiotic as a single dose, eg Cefazolin 1 g IV, one hour before the procedure, irrespective of whether the operation is elective or emergency  Consider a vertical skin incision with previous vertical incision, or risk of intra- operative haemorrhage (antepartum haemorrhage, severe pre-eclampsia), difficult delivery (transverse lie, prolonged second stage), or postoperative infection (prolonged labour or rupture of membranes, offensive liquor)  42  Consider a vertical uterine incision (classical, but usually down into the lower segment) for extensive lower segment adhesions, lower uterine leiomyomas, transverse lie, poorly formed lower segment (especially with preterm breech presentation) and cervical cancer (high vertical incision)  Ensure that oxytocin 2.5 units is given IV slowly after delivery of the baby, to be repeated after 3 minutes if the uterus does not contract adequately  Take special care in caesarean delivery where the head is deeply engaged. Ask for help in pushing the baby up from below, or consider a ‘reverse breech’ method. Get senior help if inexperienced with such situations  For persistent excessive bleeding, inform the anaesthetist and get senior help. Identify and control bleeding points, also manage as for persistent postpartum haemorrhage including uterotonics and tranexamic acid  Immediate postoperative IV fluids are usually Ringer-Lactate 1 L with 40 units oxytocin over 8 hours (5 units/hour), followed by 1 L of Plasmalyte over 8 hours (125 mL/hour)  Start postoperative mobilisation and feeding as soon as the woman feels strong enough and hungry  Prescribe postoperative intravenous broad-spectrum antibiotics (e.g. Co- amoxyclav 1.2 g IV 8 hourly) for women where there has been offensive liquor (chorio-amnionitis) during labour  Prescribe postoperative analgesia: Morphine 0.1 mg/kg IM 6 hourly with metoclopramide 10 mg IM 6 hourly for 24 hours.  Add ibuprofen 400 mg 8 hourly orally and paracetamol 1 g 6 hourly orally.  Avoid ibuprofen in patients with renal dysfunction, severe pre-eclampsia, asthma, or a history of peptic ulcers. Give tramadol 100 mg orally 6 hourly  Consider thromboembolism prophylaxis for women who may be at risk (enoxaparin 40 mg daily SC while in hospital from 12 hours post-op and not bleeding) – e.g. women who are obese (>100 kg; BMI >30 kg/m2), or have co- morbidity such as hypertension and other medical conditions  Discharge the woman from hospital on the third postoperative day if she is feeling well, is apyrexial, and has a heart rate