SAVING MOTHERS

POLICY AND MANAGEMENT

GUIDELINES FOR COMMON
CAUSES OF MATERNAL
DEATHS

ISBN 1-875017-61-5

FOREWORD
The National Department of Health recognises the need to reduce maternal mortality in our
country. It therefore set up, and strongly supported, the working of the National Committee
on Confidential Enquiries into Maternal Deaths (NCCEMD). The Saving Mothers publication
was the beginning of the process of highlighting deaths in pregnancy and these policy
Guidelines are another step towards reducing maternal deaths in the next few years.
These Policy Guidelines were developed by the Collaborative Guidelines Group which
consisted of a wide range of health professionals involved in the care of pregnant women.
Representatives of nursing, medical and administrative groups was sought and obtained.
The consultation process was extensive and draft guidelines were circulated, revised, and
re-circulated to the various groups. There was consultation with representatives from
medical schools and nursing colleges, DENOSA, SAMA, the College of Obstetricians and
Gynecologists, and the NCCEMD. A special effort has been made to make the Guidelines
applicable to the situation in South Africa. The Guidelines presented here are not casting
stones, and as new developments occur and proven to be benefit, they will be
included in revised versions of the guidelines. However, these guidelines are drawn from
the best information available today and are the most suitable to South African conditions in
2000.
Each institution (clinic, community center, hospital) should use the Policy Guidelines to
create institutional guidelines, which provides maternity care, and should then be
implemented into clinical practice. Appropriate implementation is important so that all staff
are not only aware of the guidelines, but utilize them constantly. Guidelines, however, are of
little value unless some kind of audit occurs at regular intervals. Feedback will lead to
updates in guidelines and further improvements in clinical practice.
The National Department of Health therefore intends to inspect institutions during the period
2001/2002, to ensure that guidelines are available at all sites of maternity care in the
country.

CONTENTS

PAGE NO:

CHAPTER ONE
POLICY AND MANAGEMENT GUIDELINES

1.1.

DIFFERENCES BETWEEN GUIDELINES AND PROTOCOLS

1.2.

LEVELS OF CARE

CHAPTER TWO
A SYSTEMATIC APPROACH TO EXAMINING AN ILL
PREGNANT PATIENT
2.1.

SYSTEMATIC EVALUATION FOR THE PRESENCE OF

ORGAN DYSFUNCTION

6
7

2.1.1. THE BIG FIVE

2.1.2. THE FORGOTTEN FOUR

11

2.1.3. THE CORE ONE

13

CHAPTER THREE
GUIDELINES FOR THE MANAGEMENT OF HYPERTENSION
IN PREGNANCY

24

3.1.

DEFINITION.

24

3.2.

HYPERTENSIVE DISEASES IN PREGNANCY

AFFECT MANY ORGANS.

24

GENERAL MEASURES TO PREVENT MATERNAL

DEATHS FROM HYPERTENSIVE DISEASES.

25

3.4.

HOW IS BLOOD PRESSURE TAKEN IN PREGNANCY?

26

3.5.

WHAT IS ABNORMAL BLOOD PRESSURE?

26

3.6.

WHAT IS DANGEROUSLY ABNORMAL?

26

3.7.

WHICH PATIENTS ARE MORE AT RISK?

26

3.3.

CONTENTS

PAGE NO:

3.8.

SPECIFIC MEASURES.

27

3.9.

DELIVERY

29

3.10.

PEURPERIUM.

30

3.11.

INDICATIONS FOR REFERRAL OR DIRECT REFERRAL

TO LEVEL THREE CARE
(TERTIARY, CENTRAL OR TEACHING HOSPITAL)

30

3.12.

PREREQUISITE FOR REFERRAL FOR SECONDARY HOSPITAL

31

3.13.

TRANSPORT

31

3.14.

PATIENTS WHO MAY BE DELIVERED IN A LEVEL TWO CARE

(DISTRICT, SECONDARY OR REGIONAL HOSPITAL)

31

ESSENTIAL SPECIAL INVESTIGATIONS FOR

PATIENTS WITH SEVERE PRE-ECLAMPSIA / ECLAMPSIA

33

3.16.

INDICATIONS FOR TERMINATION OF PREGNANCY

33

3.17.

PREREQUISITE FOR EXPECTANT MANAGEMENT

IN LEVEL THREE HOSPITAL

33

3.18.

DRUGS FOR CHRONIC CONTROL OF HYPERTENSION

34

3.19.

MANAGEMENT NOT RECOMMENDED OR TO BE USED

WITH GREAT CAUTION

34

3.20.

COMMENTS

34

3.21.

REFERENCES

34

3.15.

CHAPTER FOUR
GUIDELINES FOR THE PREVENTION AND TREATMENT OF
PREGNANCY RELATED SEPSIS

35

4.1.

INTRODUCTION

35

4.2.

DEFINITION

36

CONTENTS

PAGE NO:

4.3.

SPECIFIC PREVANTATIVE MEASURES

36

4.4.

ASSESSMENT AND EVALUATION OF THE SEVERITY

OF SEPSIS, COMPLICATING AN ABORTION

38

ASSESSMENT AND EVALUATION OF THE SEVERITY OF

PEURPERAL SEPSIS

39

SYSTEMATIC EVALUATION OF POST PARTUM/ABORTION

PATIENTS FOR THE PRESENCE OF ORGAN DYSFUNCTION

40

4.7.

MANAGEMENT AT DIFFERENT LEVELS OF CARE

42

4.8.

REFERRAL CRITERIA

44

4.9.

OBSERVATIONS POST PROCEDURE

45

4.10.

BASIC GUIDELINES FOR OBSERVATIONS

45

4.11.

CONCLUSION

46

4.12.

REFERENCES

47

4.5.
4.6.

CHAPTER FIVE
GUIDELINES MANAGEMENT OF OBSTETRIC HAEMORRHAGE

48

5.1.

INTRODUCTION

48

5.2.

GENERAL PREVENTATIVE MEASURES

48

5.3.

SPECIFIC PREVENTATIVE MEASURES

49

5.4.

PROBLEM RECOGNITION

50

5.5

MANAGEMENT AND REFERRAL GUIDELINES

51

5.6.

OBSERVATION GUIDELINES

53

5.7.

AUDIT

54

5.8.

CONCLUSION

54

5.9.

REFERENCES

54

CONTENTS

PAGE NO:

CHAPTER SIX
GUIDELINES FOR VAGINAL DELIVERY AFTER
CAESAREAN SECTION

55

6.1.

ANTENATAL CARE

55

6.2.

PLACE OF VAGINAL DELIVERY

55

6.3.

PATIENTS CONSENT

55

6.4.

ADVANTAGES OF VBAC

56

6.5.

DISADVANTAGES OF VBAC

56

6.6.

ADVANTAGES OF ELECTIVE CAESAREAN SECTION (C/S)

56

6.7.

DISADVANTAGES OF ELECTIVE CAESAREAN SECTION

56

6.8.

CONTRAINDICATIONS FOR VBAC

56

6.9.

CIRCUMSTANCES SUITABLE FOR VBAC

58

6.10.

MANAGEMENT OF TRIAL OF LABOUR

58

6.11.

REFERENCES

59

CHAPTER SEVEN
GUIDELINES FOR RESUSCITATION IN PREGNANCY

60

7.1.

PREVENTION OF CIRCUMSTANCES LEADING TO COLLAPSE

60

7.2.

ENSURING PREPAREDNESS FOR CARDIO

PULMONARY RESUSCITATION

61

7.3.

MANAGEMENT OF CARDIO-RESPIRATORY ARREST

61

7.4.

COMPLICATIONS DURING OBSTETRIC ANAESTHESIA

62

7.5.

PROTOCOL FOR MANAGEMENT OF FAILED INTUBATION.

67

CHAPTER ONE
POLICY AND MANAGEMENT GUIDELINES
The National Department of Health has stated that the Maternal Mortality Ratio in South Africa is
Far too high and that a significant number of the maternal deaths are preventable. This is clearly
illustrated in the Saving Mothers: Report on Confidential Enquiries into Maternal Deaths in
South Africa. One of the key strategies to achieve this reduction in maternal deaths is to have
clearly spelt out treatment regimen for the common conditions that cause maternal deaths.
There is hierarchy of strategies used when developing ways of treating patients. Initially there
Is a statement of policy or the problem, e.g. preventable deaths due to complications of
Eclampsia must be prevented. Then, the basic tenants required to achieve this, in broad
principle, are elucidated, e.g. in eclampsia, the airway of the patient must be ensured, the blood
pressure convulsions must be controlled and further convulsion prevented and the fetus
should be delivered. Thereafter more detail is added, but this detail becomes dependant upon
the situation in which the health workers treating the patient find themselves. For example, the
protocol for the managing eclampsia in a clinic is different from that in a tertiary hospital,
although the basic principles remain the same. So in a clinic, the protocol would concentrate on
ensuring that first aid is adequately performed, i.e. control of airway, blood pressure and
convulsions and transferring the patient safely to an appropriate institution for delivery of the
fetus. Hence the policy is carried out but at different institutions depending on their capability. A
detailed protocol that is developed in an institution would for example have the phone numbers
of the relevant referral centers and criteria for referral documented in the statement. This detail
can obviously only be done at the institutional level, and at national or provincial level this would
be inappropriate.

1.1. DIFFERENCE BETWEEN GUIDELINES AND PROTOCOLS

Guidelines are principles and protocols are detail.

A guideline on hypertension will say for

example that the blood pressure be controlled and which drugs are suitable.

A protocol

should say which drug, which dosage regime is used in the particular institution and also where
the drug is kept (if necessary).
There is a natural three tier system of guidelines and protocols as illustrated above. A Policy
Guideline indicates the policy regarding managing a certain condition. A Management
Guideline gives where more details are given so that various institutions are able to choose
what is most suitable for them. An Institutional Protocol is where, in each institution, the
management guidelines have been adapted to suit the particular institution and the treatment
protocol is given in considerable detail.
For example: the policy guideline for managing incomplete abortions will state among other
Things that an uncomplicated incomplete abortion less than 12 weeks pregnant should be
managed at a community health center or level one institution. An evacuation of the uterus
should be performed within 6 hours of admission and it can be safely performed as an outpatient
procedure using a manual vacuum aspirator. Prior to evacuation prophylactic antibiotics should
be given. Analgesia should be given where required. After the evacuation the patient should be
advised with respect to contraception use.
The management guideline will indicate how to diagose an uncomplicated incomplete
abortion, which tests are required to make the diagnosis, what the choices are regarding
prophylactic antibiotics and analgesia for the evacuation of the uterus.
The institutional protocol will state what tests should be done e.g. a copper sulphate test,
haemoglobin meter, or laboratory test, to assess for anaemia.

The authors of management guidelines have ensured that their management guidelines fall
within the policy guidelines. It is essential that each institution takes the management guidelines
and adapts them for their particular institution.
The policy guidelines set a minimum set of national requirements.
Figure 1 illustrates the hierarchy in developing a treatment regimen.
Figure 1.1. The hierarchy of strategies in developing treatment regimens
Policy
(preventable maternal deaths should be
prevented. The causes of preventable
deaths
are known see Saving Mothers Report)
Policy Guidelines
(Statement in broad principle
what should be done to prevent specific
preventable causes of maternal death)
Management guideline
(what should be done at each site)
Health Centre/ Subdistrict Hospital

District/Secondary
Hospital

Tertiary

Institutional protocols
(Detail added to the management
Guideline appropriate to the area)
Area A

Area B

Sub-District Hospital

Sub-District Hospital

Tertiary Hospital

Tertiary Hospital

Every institution upon receiving the policy guidelines and the national management guidelines
should develop their institutional guidelines. The National Department of Health and the

Provincial Maternal, Child and Womens Health units will assist in the process. The aim is for
each institution to have its institutional guidelines by 2002. To judge the success of this,
assessors will visit institutions to see the protocols and whether the health workers are
conversant with them.
1.2 LEVELS OF CARE:
There is considerable confusion with regard to the definitions of the various levels of health care.
The following list gives the designations, together with the staff composition and the services
provided at each level.
Level Designation
Clinic
1

Staff
Registered midwife

Health center / midwife

Services provided
Antenatal and postnatal care

Midwife, sometimes with

Above + 24 hour

delivery
Obstetric unit

Advanced Diploma in Mid-

service

Wifery plus sometimes

Visiting Medical Officers
(Mos)
Subdistrict hospital

District, Secondary, or

Above + Mos + visiting

Above + 24 hour caesarean

Specialists

section service

MOs + Specialists +

Regional hospital

Intensive Care Unit

Tertiary, Central, or

Above +

Teaching hospital

Superspecialists

All complex deliveries

Strength of evidence: it is customary to grade the evidence, on which clinical statements are
based, accordingh to the strength of such evidence,viz.:

Grade A

Evidence from randomized controlled trials.

Grade B

Evidence from other robust experimental or observational studies.

Grade C

The evidence is more limited, but the advice relies on expert opinion and has the

endorsement of respected authorities. The relevant textbook may be qyoted, if the evidence
is applicable to South African conditions, and there is consensus regarding such evidence in
South Africa.

Grade D

There is local evidence from observational studies.

The evidence differs

from the opinion quoted in current textbooks. There is no consensus regarding such
evidence in South Africa, nor has consensus been sought.

CHAPTER TWO
A SYSTEMATIC APPROACH TO EXAMINING AN ILL PREGNANT PATIENT

One of the major areas of substandard care identified in the Saving Mothers: Report on
Confidential Enquiry into Maternal Deaths in South Africa was the poor initial assessment of the
patient. This occurred in about 30% of cases. All health care workers are trained in the
traditional method of history taking, clinical examination and special investigations when
assessing a patient. However, it is often difficult to assimilate the multiple abnormalities found
and to formulate a management plan in a very patient with multi-organ disease, the very types
of cases described In the maternal mortality report.
The systematic approach described below is meant to refocus the health worker on evaluating a
patient using a simple easy to remember examination method, and if used should identify the
major problems. Please remember that a relevant history must be taken on all occasions.
The rationale behind this approach is that a patient has a real risk of death when an organ
system fails and is not supported, or the cause of the failure is not treated. An example is the
postpartum woman who has a clinical insult of an atonic uterus and a subsequent postpartum
haemorrhage. If unsupported and untreated she would develop cardiovascular dysfunction as
her intravascular volume falls. She would initially demonstrate a tachycardia and tachypnoea. In
other words a systematic response to her falling intravascular volume. If no intervention takes
place she will go on to develop a weak thready pulse, low blood pressure, cold peripheries, poor
urine output and even a depressed Glasgow coma scale. Her circulatory system is now failing
and needs urgent support and treatment to save her life. If this is not forthcoming, she will die.
Figure 2.1 diagrammatically demonstrates how this case example progressively climbs up the
iceberg from the invisible depths (the unrecognized clinical insult of a postpartum haemorrhage,
the systematic response and the organ dysfunction) to the pinnacle where she is now obvious but
unfortunately dead! The signs of a systemic response and dysfunction of her circulatory system
were present earlier on in her disease process. If picked up and if support was given to her
circulatory system, her life would have been saved.

One can give other examples of clinical insults (diseases) that affect multiple organs such as
pre-eclampsia/eclampsia. The

same progressive ascent of

the iceberg occurs, but this

time

involving multiple organ systems, e.g. possibly the central nervous system, the circulatory and
respiratory systems, as well as the renal, hepatic and haematological systems.

All of these

systems have early signs manifesting in the form of a systemic response or dysfunction prior to
overt failure and then death of the patient. Table 2.1 gives a breakdown of the type of organ
system dysfunction and failure seen in a typical referral population of obstetric patients seen in
Pretoria over a two-year period. If health care workers are to save maternal lives, they have to
know how to identify and investigate each of these types of organ dysfunction and how to
support and manage them. Failling this, they will be ineffective and pregnant women suffering a
severe clinical insult will die.
The

basic principle used to put a particular case together and decide what therapy and

management is required is to evaluate each organ system systematically for sign s of a systemic
response or organ dysfunction. If an abnormality is detected,

this serve as a trigger to

investigate and initiate support of that particular organ. Thereafter one must identify the cause
and address the cause. In this way on examination each potential problem identified on history
can be evaluated and the systemic effects of the problem documented and managed.
2.1. SYSTEMATIC EVALUATION FOR THE PRESENCE OF ORGAN DYSFUNCTION
The clinical signs of organ dysfunction, with the special investigations required, as well as the
supportive treatment, which must be given, are as follows. As an aid de memoir, the organ
systems are grouped into the acutely life sustaining Big Five, the often neglected Forgotten
Four and the organ system central to obstetrics, the Core One:

2.1.1. THE BIG FIVE:

1. Central Nervous system:

Clinical signs:

drowsiness
confusions
convulsions
delirium
decreased level of consciousness
Glasgow Coma Scale < 14/15 (see Table 2.2)
Hypertension
Hypotension

Special investigations:
Haematocrit
Blood glucose
Urea & electrolytes
liver function tests
blood gas analysis or pulse oxymetry and, if indicated,
investigations for intracerebral haemorrhage
brain abscess or meningitis
lumbar puncture

Supportive treatment:
dependant on the cause e.g. magnesium sulphate
administer oxygen
glucose etc.

2. Circulatory system:
Clinical signs:
hypotension < 90 mm Hg systolic pressure
tachycardia >90 beats per minute
cold and clammy extremities
pulmonary oedema
gallop
hepatomegaly
arrhythmias
or hypertension
blood pressure >140/90 mmHg

Special investigations:
urine test for protein
haematocrit
chest X-ray
and possibly an ECG,

Supportive treatment:
For shock adequate venous access
possibly with a high flow line or central venous pressure monitoring
fluid replacement
inotrope support
For hypertension control blood pressure, if necessary prevent convulsions

1.

Respiratory system:

Clinical signs:

tachypnoea > 20 breaths per minute

use of the accessory respiratory muscles
central or peripheral cyanosis

Special investigations:
pulse oxymetry (saturation < 90%)
blood gas analysis (paO2 (mmHg)< 3 times FiO2, acidosis and
alkalosis)
chest X-ray.

Supportive treatment:
oxygen via nasal prongs or face mask
CPAP mask
intubation and ventilation
treat pneumonia if necessary or pulmonary oedema if diagnosed

2.

Hepatic system:

Clinical signs:

Jaundice
Hepatomegaly
coke-coloured urine (HELLP)
epigastric pain

Special investigations:
blood glucose
raised liver enzymes ALT
AST
LDH
Haemoglobin
liver sonar

Supportive treatment nil per os, dextrose water injection

10

5. Renal system:
Clinical sign: (NB: the patient must have an indwelling catheter, and the urinary output
must

be carefully charted) oliguria (< 1ml urine/kg/hr or < 30ml/hr), anuria, or

very concentrated urine, coke coloured urine

Special investigations: urine dipstix, raised urea

Supportive

treatment: rehydration

and

fluid

and

creatinine,

replacement.

If

urine

there

microscopy

is progressive

Renal failure dopamine, diurectic, dialysis

2.1.2.

THE FORGOTTEN FOUR:

1. Haematological system:
Clinical signs: pallar,

petechiae, bruising, bleeding from the gums or infusion sites, deep

venous thrombosis

Special investigations: low Hb (<10g/dl), haematocrit (< 30%), low or high white
cell count, low platelet count (< 100x109/l), raised fibrinogen degradation products
or D-dimers, prolonged INR or PTT

Supportive treatment blood

as

needed, treatment of

DIC, whether with

frozen plasma, freeze dried plasma or heparin

2. Immunological system (any of the following):

Clinical signs:
pyrexia >38oC
hypothermia <36oC
lymphadenopathy
tachycardia
tachypnoea

Special investigations:
increased or decreased white cell count (>11,000 or <4,000)
HIV-testing

11

fresh

Supportive treatment: aggressive treatment of th underlying sepis

appropriate antibiotics (gram positive, gram negative and
anaerobiccover)
conservative surgery (e.g. evacuation of uterus), aggressive
surgery(e.g.

laparotomy, hysterectomy)

3. Endocrine system (Thyroid, Breasts, Diabetes):

Clinical signs:
polyuria
polydipsia
confusion
convulsions
ketones and glucose in urine
tachycardia
sweating
pyrexia
engorged breasts

Special investigation:
blood glucose
TSH
white cell count

Supportive treatment: correction of any metabolic abnormalities

4. Gastrointestinal system:
Clinical signs: abdominal distension
ileus
peritonitis
haematemesis
diarrhoe

12

Special investigations: abdominal X-rays (supine & erect)

U&E

Supportive treatment: nil per os

nasogastric tube
parenteral nutrition

2.1.3.

THE CORE ONE:

Genital system:

Clinical signs: Examine uterus for pregnancy or abortion as indicated on history

Special investigations:

Dependent on primary problem, e.g. cardiotocograph

for

assessing fetal well being, sonar for fetal size estimate etc.
In summary, every ill pregnant woman should be assessed systematically in this manner,
covering all her organ systems (see figure 2.2).
In order to highlight the most common causes of maternal mortality as documented in the
Saving Mothers report, and the organ systems that were involved in these diseases, the
following tables give a disease-specific approach that can be followed after all the organ
systems have been assessed.
Hypertension caused 23.2% of all maternal deaths with complications of the central nervous
system and of the circulatory system each occurring in

38.9% of cases, respiratory system

complications in 15.3% and renal and haematological systems each in 9.9% of cases (Table2.3).
Obstetric haemorrhage (both antepartum and postpartum) occurred in 13.3% of maternal deaths
and was complicated by hypovolaemic shock,

disseminated intravascular coagulopathy and

cardiac failure in 82.2%, 21.3% and 9.3% of cases respectively (Table 2.4).
13

Pregnancy-related sepsis was found in 11.9% of maternal deaths and was complicated by septic
shock, multi-organ failure, respiratory failure and immune system failure in 73.2%, 24.4%, 17.1%
and 14.6% of cases respectively (see Table 2.5).
Cardiac disease caused 5% of maternal deaths (see Table 2.6) and AIDS was responsible for
14.5% of the deaths (see Table 2.7).
Knowing the common causes of maternal deaths has enabled the National Committee on
Confidential Enquiries into Maternal Deaths to make ten key recommendations to try and
prevent these deaths at a national, provincial, regional and district level (refer Saving Mothers:
Report on Confidential Enquiry into Maternal Deaths in South Africa). However, this report has
also highlighted the types of complications and organ dysfunction/failures that these pregnant
women developed. Knowledge on how to detect, diagnosis and manage these complications will
help health care workers to save the individual lives of women who develop these common
diseases in pregnancy.

14

Maternal Death
DEATH
ORGAN FAILURE

ORGAN DYSFUNCTION

Severe acute
Maternal
morbidity

SYSTEMIC INFLAMMATORY
RESPONSE SYNDROME

CLINICAL INSULT

PREGNANT POPULATION

FIGURE 2.1: Diagrammatic sequence of events from a normal healthy pregnancy

to death in a pregnant population

15

Fig 2.2: Schematic diagram of a systematic approach to examining and managing an ill
pregnant woman

Assess the big five organs

Assess the forgotten four

Assess the core one

Support that organ

Identify organ dysfunction
failure

Identify cause

Address the cause

16

Table 2.1: Summary of the prevalence of organ systems dysfuction or failure

complicating near misses and maternal deaths. Values are given as percentages of the
total group.

Near miss

Death

n = 300

n = 59

Central nervous system dysfunction

10

27

Circulatory dysfunction

41

31

Respiratory dysfunction

15

42

Gastrointestinal & hepatic dysfunction

13

Renal dysfunction

19

29

Haematological dysfunction

17

15

Immunological dysfunction (sepsis)

16

25

Endocrine dysfunction

17

Table 2.2: Glasgow coma scale

Signs

Glasgow
scale

coma

OPEN EYES
Spontaneously

On command

On pain stimulus

Nil

BEST VERBAL RESPONSE:

Orientated

Confused conversation

Inappropriate words

Incomprehensible sounds

Nil

BEST MOTOR RESPONSE:

Obeys commands

Localizes pain

Withdraws

Flexion to pain

Nil

A count less than 10 a reduction of 3 or more points, regardless of the initial count,
indicates serious brain damage

18

Table 2.3: Hypertensive disorders of pregnancy

Organ system

Trigger

Clinical response

Central Nervous

Headache, blurred vision, nausea

Magnesium sulphate, delivery

system:

& vomiting
GCS < 14

CT scan, delivery, ICU, ventilation

Circulatory

Severe hypertension: diastolic 110

IV line, 300ml fluid bolus,

system

mmHg or greater

parenteral anti-hypertensives

Pulmonary oedema: tachycardia,

Oxygen, arterial blood gas, pulse

tachypnoea, gallop, basal

oxymeter, chest X Ray,

crepitations

furosemide, intubation, ICU,

ventilation, delivery

Respiratory

Tachypnoea

As for pulmonary oedema

Oliguria (<30ml/hour), raising urea

Check fluid balance, replace

& creatinine

losses, delivery, low dose

system
Renal System

dopamine, high dose furosemide,

nephrology consult, dialysis
Haematological

oozing from drip/puncture sites,

FBC, INR, PTT, platelet

system

low platelet count

transfusion if delivery, surgery or

bleeding

19

Table 2.4: Obstetric Haemorrhage

Organ system

Trigger

Clinical response

Circulatory

Hypotension < 90 mmHg

2 large bore IV lines, 1-2 litres

system

systolic pressure,tachycardia >

Ringers lactate, 500 ml colloid, blood

90 beats per minute, cold and

transfusion, CVP, Foleys catheter,

clammy extremities

oxygen

Pulmonary oedema:

Oxygen, blood gas, saturation monitor,

tachycardia, tachypnoea,

chest X Ray, furosemide, intubation,

gallop, basal crepitations

ICU, ventilation

Haematological

Oozing from drip/puncture

FBC, INR, PTT, plasma (frozen or

system

sites, low platelet count

freeze dried), platelet transfunsion if

delivery, surgery or bleeding,
empty uterus

20

Table 2.5: Pregnancy-related sepsis.

Organ system

Trigger

Clinical response

Immunological

Sepsis:

system

hypothermia <36C, tachycardia,

looking for tenderness, sub-

tachypnoea, white cell count

involution, open or necrotic cervix,

above 11,000 or below 4,000

FBC, U& E, chest x-ray, urine

> 38C,

Abdominal & baginal examination

microscopy, broad spectrum

parenteral antibiotics, referral, DIC
screen, evacuation uterus, reassessment within 24 hours,
laparotomy, hysterectomy
Septic shock: systolic blood

IV fluids, CVP, FBC, U&E, DIC

pressure > 90 mmHg not

screen, blood gas, chest x-ray,

responsive to 1 litre Ringers

antibiotics,hysterectomy, ICU,

lactate, oliguria, mental confusion

ventilation

Multi-organ dysfunction:

As for septic shock

biochemical evidence of
failure/dysfunction of 2 or more
organ systems
Tachypnoea, use of the accessory

Arterial blood gas, oxygen, chest

respiratory muscles, oxygen

X-ray, ICU, ventilation, remove

saturation <90%, paO2 (mmHg)<3

source of sepsis (antibiotics,

times FiO2

evacuation, hysterectomy)

Respiratory
system

21

Table 2.6: Cardiac disease.

Organ system

Trigger

Clinical response

Circulatory

History of cardiac disease or

FBC, chest X-ray, ECG, internal

system

rheumatic fever, orthopnoea,

specialist assessment,

dyspnoea

echocardiography

Pulmonary oedema: worsening

Oxygen, arterial blood gas, pulse

dyspnoea, tachycardia,

oxymeter, chest X Ray,

tachypnoea, gallop, basal

furosemide, intubation, ICU,

crepitations

ventilation

22

Table 2.7: AIDS

Organ system

Trigger

Clinical response

Immunological

Early disease (WHO stage 2):

Counsel all pregnant women to

system

persistent generalized

have an HIV test, alter lifestyle,

lymphadenopathy, recurrent upper

termination of pregnancy, anti-

respiratory tract infections,

retrovirals for prevention of

unintentional weight loss (< 10%

mother-to-child transmission, keep

body weight), shingles,

membranes intact as long as

seborrhoeic dermatitis, popular

possible, avoid invasive

urticaria-like pruritic eruption,

techniques (e.g amniocentesis,

fungal nail infenctions, angular

fetal scalp samples, episiotomy,

cheilitis

assisted delivery etc), avoid breast

feeding if possible (?exclusive
breast feeding)

Late disease (WHO stage 3):

As above plus antibiotic cover for

unintentional weight loss (> 10%

all surgical interventions,

body weight), diarrhoea or fever >

supplementation of diet with

1 month, oropharyngeal

vitamins and minerals

candidiasis, oral hairy leukoplakia,

vulvovaginal candidiasis > 1
month, pulmonary tuberculosis,
severe bacterial infections
AIDS (WHO STAGE 4):

As above plus prophylactic

Opportunistic infections (e.g. PCP,

antibiotic cover during labour

extra-pulmonary tuberculosis,
cerebral toxoplasmosis etc.),
malignancies (e.g. Kaposis
sarcoma, lymphoma), HIV
encephalopathy

23

CHAPTER THREE
GUIDELINES FOR THE MANAGEMENT OF
HYPERTENSION IN PREGNANCY
Hypertensive disease in pregnancy is one of the 5 major causes of maternal mortality in South
Africa. This important fact should always be remembered when pregnant mothers are provided
with information
peurperium.

and education during visits

for antenatal care, during labour or in the

This important information should also be given to communities and relatives of

pregnant mothers.

3.1 DEFINITION
A blood pressure of 140/90 mmHg or more during pregnancy is indicative of any hypertensive
disease. The condition is called pre-eclampsia when proteinuria develops for the first time after
20 weeks gestation. Eclampsia is the name of the condition when hypertension and proteinuria
in pregnancy is complicated by convulsions.

3.2 HYPERTENSIVE DISEASES IN PREGNANCY AFFECT MANY ORGANS

Although one usually considers blood pressure and proteinuria to define hypertensive diseases,
It does not mean that other important organs are not involved. Severe pre-eclampsia affects
Many organs because the primary pathology involves endothelial cells and they are present in
every organ. It is necessary to know how these organs are affected as this will help the health
worker to diagnose complications at an early stage.

Central nervous system: Severe headache

Changes in behaviour, decreased levels of consciousness
Restlessness
Hyperreflexia
Visual disturbance

24

Convulsions
Coma

Cardiovascular system: Severe hypertension

Headache
Oedema

Renal system:

Proteinuria
Poor urinary output (less than 1ml/kg/hr
Haematuria (from haemolysis)

Haematological system: Petechiae

Bruising
Bleeding from puncture sites
aundice (from haemolysis)

Liver:

Jaundice
Upper abdominal pain

Placenta:

Poor fetal growth

Fetal distress

Respiratory system:

Pulmonary oedoma shortness of breath

3.3 GENERAL MEASURES TO PREVENT MATERNAL DEATHS FROM

HYPERTENSIVE DISEASE
1. See that all pregnant women receive antenatal care.
2. healthcare workers attending to pregnant women should be aware of the risks of high
blood pressure in pregnancy.
3. healthcare workers should know which pregnant women have a high risk of developing
hypertension or its complications.
4. Magnesium sulphate

must be freely

available at all antenatal clinics and

services and personnel should have the knowledge t o administer it.

25

emergency

5. Healthcare

workers should know how to use drugs for

the management

of acute

hypertension.
6. Proper systems of referral and transport should be in place and known by healthcare
Workers.

3.4 HOW IS BLOOD PRESSURE TAKEN IN PREGNANCY?

Use the correct size cuff.

Patient may sit or lie on her side.

Cuff should be on the level of the heart.

Use Korotkoff 5 sound (where the sounds disappear) to determine diastolic value.

Only use Korotkoff 4 sound (where the sound muffles) when s ound 5 approaches zero.

3.5 WHAT IS ABNORMAL?

Blood pressure of 140/90 mmHg of more at 2 occasions or more at least 6 hours apart.

Rise in diastolic blood pressure of 15 mmHg or more above values in early pregnancy.

Rise in systolic blood pressure of 30 mmHg or more above values in early pregnancy.

3.6 WHAT IS DANGEROUSLY ABNORMAL?

Blood pressure of 160/110 mmHg or more.

Proteinuria, ++ on dipstix in a clean catch urine specimen.

Complaints such as severe headache, abdominal pain and blurring of vision.

Convulsions.

Coma.

3.7 WHICH PATIENTS ARE MORE AT RISK?

Hypertension before pregnancy.

Hypertension early in pregnancy.

26

Hypertension and/or convulsions in a previous pregnancy.

Previous intrauterine death due to complications of hypertension.

No antenatal care.

History of previous/present renal disease.

Medical complications such as diabetes.

Elderly primigravidae.

3.8 SPECIFIC MEASURES

Management of hypertension / pre-eclampsia when detected at the antenatal clinic:

Blood

pressure

> 160/110 mmHg,

headache, vomiting,

of vision, patients of 35 years or older,

teenagers,

nausea, epigastric

pain, blurring

++ proteinuria admit/ask

for advice

from referral centre.

Blood pressure < 160/110 mmHg, no proteinuria, no symptoms: Advise bed rest . Enquire
about transport and home surroundings. Review in 2-3 days. If in doubt, admit. Evidence
is

that

these

(Magee et

al.,

patients
1999;

should be
Also

antihypertensives decreases

in

started

on

Cochrane

the number of

antihypertensives

Library).

Clear

acute hypertensive

e.g.

evidence

methyl
that

dopa.

use

of

episodes etc. Grade A

evidence.
Emergency management of patient with a blood pressure of 160/110 mmHg or more:

Preload with 300ml Ringers lactate solution over 20 minutes.

Use one of the rapid acting drugs to lower the blood pressure.

Control diastolic blood pressure at 90-100 mmHg.

Consider giving magnesium sulphate prophylactically.

Exclude fetal distress clinically or by a cardiotocograph.

Assess renal function (urea or creatinine), platelet count and liver function tests (AST all
that required; full liver fuction tests are expensive and unnecessary).

27

Assess fetal condition and gestational age.

Obtain consultant / or experienced advice.

Consider induction of labour.

Arrange for delivery/indication of labour/transfer.

Give steroids to enhance lung maturity if gestational age is 27 34 weeks.

Magnesium sulphate:

Magnesium sulphate is the best drug to arrest and prevent further convulsions Grade A
evidence. (The Eclampsia Collaborative Group. Lancet 1995;345:1455-63).

Its use in the prevention of convulsions in women with pre-eclampsia is

less certain.

Prophylactic use of magnesium sulphate therefore depends on individual guidelines.

Emergency management of eclampsia:

Turn woman onto her side, preferably left lateral.

Clear airway and insert oropharyngeal airway, give oxygen.

Call for help.

Set up an intravenous line with Ringers Lactate / plasmolyte.

Dilute 4 g magnesium sulphate (8 ml 50% solution) with 12 ml normal saline.

Give slowly intravenously over 4 minutes.

Inject 5 g (10 ml 50% solution ) into each buttock.

Insert Foleys catheter and measure output hourly.

Measure blood pressure every 15 minutes,

until stabilized. Control blood pressure using

rapidly acting antihypertensives. E.g. dihydralazine, nifedipine, labetalol. Note potential of

severe hypotension

if using

nifedipine

and magnesium sulphate. Keep diastolic

pressure between 90 and 100 mmHg.

Monitor fetal condition.

Limit fluids to 80 ml/hour.

Arrange for transfer / indication of labour/delivery, depending on level of care.

28

blood

Continue with magnesium sulphate, 5 g IM every 4 ours, providing the urinary output is
More that 100 ml in 4 hours, the patella reflex is present and the respiratory rate is above 16
per minute.

MgSO4 should be given for up to 24 hours following delivery.

Continue observations at frequent intervals for at least 24 hours following delivery. These

patients should preferably be kept in a high care area, or a specifically Surpervised,

designated bed for one to one nursing. Keep longer, If necessary.

An alternate to the intramuscular use is the intravenous administration. Following

the

intravenous loading dose of 4 g, a continuous infusion of 1 g/hr is given.

Calcium gluconate, 10 ml of a 10% solution, is given intravenously in case of magnesium

sulphate toxicity.

3.9 DELIVERY:
Patients with severe hypertensive disease often present in established labour at Primary health
Care centers. This implies that there will be no time refer the patient to hospital. Health care
workers working in primary health care centres should therefore be able to deliver these patients
safely. However, if there is sufficient time, the patient should be referred, following the
instructions as given under the section Emergency Management of Eclampsia.
First stage of labour:

Monitor blood pressure at least every hour.

Assess urinary output hourly.

Assess fetal condition half hourly.

Continue with magnesium sulphate.

Ensure good pain relief.

Keep accurate partogram.

Have emergency treatment ready: oxygen, suction, airway, calcium gluconate.

Watch out for change in mental state or alertness.

29

Transfer if there is any delay in progress.

Obtain advice from your referral centre.

Second stage of labour:

Take blood pressure every 15 minutes.

Listen to fetal heart after every contraction.

Ensure good progress.

Deliver by vacuum extraction if there is poor progress and easy delivery is foreseen.

Transfer in cases of poor progress or where easy delivery is not possible.

DO NOT GIVE ERGOMETRINE OR SYNTROMETRINE.

Third stage of labour:

Prevent or control postpartum bleeding with oxytocin.

Take blood pressure immediately after delivery.

Control blood pressure between 140/90 and 150/100 mmHg.

Continue with magnesium sulphate for 24 hours.

Watch carefully for 24 hours.

3.10 PUERPERIUM:

Recommend family planning. Women over the age of 30 years, or who have 5 children,
should be strongly advised to have tubal ligation prior to discharge from hospital.

Emphasise postpartum follow up after 6-12 weeks.

Consider antihypertensive treatment if necessary.

3.11. INDICATIONS OR REFERRAL OR DIRECT REFERRAL TO LEVEL THREE CARE

(TERTIARY, CENTRAL OR TEACHING) HOSPITAL:

Comatose or semicomatose patient, other signs of c entral nervous system damage.

Signs of poor coagulation.

Abruptio placentae or antepartum haemorrhage.

30

Prematurity 28 to 32 weeks (in general terms, this usually means estimated fetal weights of <
1500 g).

Platelet count below 100 000 mm3, or rapidly decreasing counts.

Urine output less than 60 ml in 4 hours.

Postpartum haemorrhage.

Renal failure.

Coagulation deficiency.

Abnormal liver function tests.

Lung oedema.

Underlying cardiac disease.

Fetal death associated with severe hypertension.

3.12. PREREQUISITES FOR REFERRAL TO SECONDARY HOSPITAL:

Exclusion of indications for referral to tertiary hospital.

Facilities to do a Caesarean section within 40 minutes.

Safe anaesthetic service.

Facilities for electronic monitoring of the fetal heart rate.

Laboratory facilities to do

~ platelet counts
~ blood gases
~ renal function
~ electrolytes

3.13. TRANSPORT:
Very sick patients will often be transported from remote hospitals. Certain patients will need to
be transferred directly to a tertiary hospital, even if it means a longer journey, to avoid wasting
valuable time by late transfer from the secondary to the tertiary hospital. On the other hand, the
patient may be needed to be transferred

to the secondary hospital first for stabilisation or

delivery and only be transferred to the tertiary hospital. Careful planning and consultation

31

with the receiving hospital is therefore necessary before transfer. Where possible, transfer
should always be discussed with relatives of the patient.
The following essential guidelines are recommended:

Consult with receiving hospital.

Send

essential

information

with

patient

e.g.

antenatal

care,

treatment

received,

investigations done. N.B.: It is National Policy for case notes to accompany the patient.

Patient is to be accompanied by an experienced midwife / healthcare worker.

The following facilities must be available:

Oxygen

Suction

Laryngoscope

Endotracheal tubes

Air way

Delivery pack

Resuscitation for newborn

The following drugs should be available and the healthcare worker should know how to use it
safely.

Magnesium sulphate

Calcium gluconate

Dihydralazine (Nepresol )

Oxytocin

3.14. PATIENTS WHO MAY BE DELIVERED IN A LEVEL TWO (DISTRICT, SECONDARY OR

REGIONAL ) HOSPITAL:

Before 28 weeks gestation.

After 34-36 weeks, or babies weighing > 1500 g.

32

No other complications

than

severe

pre-eclampsia or eclapmsia.

(N.B. hospitals with

Specialists which have areas for intensive / high care, specialist paediatricians, ventilation
for

small

babies and experienced

anaesthetists, can

usually

manage

most cases

of

hypertension).
3.15. ESSENTIAL SPECIAL INVESTIGATIONS FOR PATIENTS WITH SEVERE PREECLAMPSIA / ECLAMPSIA:

Urea and electrolytes.

Serum creatinine.

Platelet count (if < 100 000/mm3 do AST, see earlier liver function tests).

Non-stress test.

Coagulation profile on specific clinical indications e.g. bleeding

petechial

haemorrhages,

haematuria associated

with low

from venepuncture sites,

platelet counts, bruising

and

jaundice.

Brian scan when indicated clinically depressed Glasgow Coma Scale that

persists for 24

hours.

Chest x-ray when indicated e.g. history or signs of aspiration.

Blood gases when indicated clinically depressed Glasgow Coma Scale < 9. Note that a pulse oxymeter
should be used in all cases.

Blood glucose if AST elevated.

3.16. INDICATIONS FOR TERMINATION OF PREGNANCY:

Eclampsia.

Severe pre-eclampsia before 24-26 weeks that does not respond to expectant management
(Grade C evidence).

Before 28 weeks on maternal request or doctors advice.

Renal failure.

3.17. PREREQUISITES FOR EXPECTANT MANAGEMENT IN LEVEL THREE HOSPITAL:

Sufficient nursing facilities.

33

Laboratory services serum creatinine and platelet count at least twice weekly.

Facilities for electronic monitoring of the fetal heart rate every 6-24 hours.

Ultrasound facilities.

Neonatal intensive care unit.

Performance of Caesarean section within 30 minutes.

Administration of betamethasone between 28 and 33 weeks to enhance lung maturity.

3.18. DRUGS FOR CHRONIC CONTROL OF HYPERTENSION:

Aim:

130/85 to 140/90 mmHg (Grade B evidence: Magee et al.)

First drug:

Methyldopa: 500 mg 6 hourly or 750 mg every 8 hours.

Add 2nd drug:

Nifedipine: 10-30 mg 8 hourly (start with 10 mg)

(Grade D evidence).

Add 3rd drug:

Prazosin: 1-7 mg every 8 hours (start with 1 mg) (Grade D ).

3.19. MANAGEMENT NOT RECOMMENDED OR TO BE USED WITH GREAT CAUTION

Plasma volume expansion (does not refer to preloading before antihypertensive therapy).

Central venous pressure to control plasma volume expansion.

Use of diazepam to arrest convulsions. In circumstances where the patient is extremely

restless, give clonezepam 1mg i.v.i. slowly.

3.20. COMMENTS
As facilities of different hospitals and provinces differ, these

guidelines may be adapted to suit

local conditions better. Care of all patients should be individualised and the guidelines should
not be followed if the attending obstetrician is certain that alternative therapy is better.
3.21. REFERENCES
Eclampsia trial Collaborative Group. Which anticonvulsant for women with Eclampsia? Evidence
from the Collaborative Eclampsia Trial. Lancet 1995; 345: 1455-63.
Magee LA et al. Management of hypertension in pregnancy. Br Med J 1999; 318: 1332-6.

34

CHAPTER FOUR
GUIDELINES FOR THE PREVENTION AND TREATMENT OF
PREGNANCY-RELATED SEPSIS

4.1. INTRODUCTION
Pregnancy-related sepsis is the fourth commonest cause of all maternal deaths in South Africa,
being responsible for 19% of direct, and 12% of all maternal deaths. Pregnancy- related sepsis
includes cases of septic abortion and puerperal sepsis. According to the Confidential Enquiries
into Maternal Deaths in South Africa, there were 67 maternal deaths attributable to pregnancyrelated sepsis in 1998. Of these, 26 occurred as a result of septic abortion These deaths are
still underreported.
The major errors committed by health workers were (i) failure to diagnose septic abortions, (ii)
failure to recognise the severity of puerperal sepsis and septic abortions, and (iii) significant
delays in management, combined with poor observations. The medical personal generally
failed to recognize the problem of sepsis and take appropriate action, according to standard
management protocols.This was due to either very superficial assessment of patients or lack of
monitoring thereafter1.
For these guidelines, individual recommendations have been graded according to the level of
evidence on which they are based.
Grade A: randomised controlled trials
Grade B: other robust experimental or observational studies
Grade C: more limited evidence but the advice relies on expert opinion and has the
endorsement of respected authorities.

35

4.2. DEFINITIONS
An abortion is the ending of pregnancy before the fetus is viable.

The World Health

Organisations definition of less than 22 weeks gestation, or a birth weight Of < 500g are used.
Thereafter, it is called preterm labour.
A safe abortion is defined as any abortion where the temperature is 37,20 C, the pulse is <90
beats per minute, the respiratory rate is < 20 breaths

per minute, the uterine size is < 12 weeks,

and the ward haemoglobin concentration is > 10g/dl. Furthermore, there are no clinical signs of
infection, no system or organ failure and no suspicious findings on evacuation of the uterus. An
unsafe abortion is defined as anything else.
Puerperal sepsis is defined as pyrexia of 380C, on two separate occasions within the first
fourteen days post-delivery, excluding the first 24 hours, if observations are taken on a 4- to 6hourly basis.
4.3. SPECIFIC PREVENTATIVE MEASURES
Good aseptic technique, when performing any procedure, including a vaginal delivery, is still
The corner-stone in the prevention of sepsis and very easily not adhered to.
1.

Abortion
Abortion care should encompass a strategy for minimizing the risk of post-abortion infective
morbidity, in patients with safe incomplete abortions.
Recommendations:

Antibiotic prophylaxis, using a single dosage oral regimen, covering both C.trachomatis and
the anaerobes which characterize bacterial vaginosis. The most suitable drug appears to be
doxycycline (Vibramycin). (Grade B)2,3

Suction

curettage

is

safe

under

local

anaesthesia, which

is

preferable

to

general

anaesthesia.(Grade B)4.
contents without delay (i.e . within 6 hours). (Grade B)4 .

Evacuation

Ensure haemoglobin of 10 grams per decilitre or more.

of

the uterine

36

2. Preterm

prelabour rupture of

the membranes/Prolonged prelabour rupture of

the

membranes
Recommendations

Antibiotics in therapeutic dosage, covering for Group B Streptococcus, Mycoplasma and

Ureaplasma.(Grade A)5

Only a sterile speculum examination to be done, to confirm the diagnosis. No digital

examination must be performed, until the patient is in active Labour.(Grade B)6

Counselling for HIV-testing and possibly more aggressive treatment, if

the

patient is

HIV-positive, because of diminished signs of sepsis.(Grade C)

Use of an antiseptic cream, when doing digital examinations (Grade C).

3. Caesarean section/Puerperal pyrexia

Recommendations

Antibiotic prophylaxis, using a single dosage regimen, prior to all elective and emergency
caesarean sections.(Grade A)7

Antibiotics in therapeutic dosage, using a 3-day intravenous regimen, for all emergency
caesarean sections, where the patient is at high risk of sepsis, such as prolonged rupture
of the membranes or obstructed labour. (Grade A)7

Prompt

and

comprehensive

work-up

of every case of puerperal pyrexia, including

investigations for respiratory tract infection, urinary tract

infection,

mastitis,

wound

infection and pelvic infection.

Prompt management of subinvolution of the uterus, lower abdominal tenderness, a foulsmelling vaginal discharge, or an open cervix, coupled with signs of sepsis.

Early mobilization and more aggressive usage of prophylactic anticoagulation.

Counselling for HIV-testing, in the presence of puerperal sepsis, with a view to more
aggressive management, if the patient is HIV-positive.

37

2.4 ASSESSMENT AND EVALUATION OF THE SEVERITY OF SEPSI,COMPLICATING AN

ABORTION
Three categories of abortion, with regard to the clinical severity thereof, can be distinguished:

Low Risk Abortion

Temperature 37,20 C
Pulse <90 beats per minute
Respiratory rate <20 breaths per minute
Ward haemoglobin >10g/dl
No clinical signs of infection;
No system- or organ failure; and
No suspicious findings on evacuation of the uterus.

Moderate Risk

Unsafe Abortion

Temperature 37,3-37,90 C, or
Offensive products of conception, or
Localised peritonitis
Uterine size 12 16 weeks
Pulse 90- 119 beats per minute
Respiratory rate 20-24 breaths per minute.

High Risk (Severe)

Temperature 380 C, or

Unsafe Abortion

Respiratory rate > 24 breaths per minute

Organ failure, or
Peritonitis, or
Pulse 120 beats per minute, or
Presence of a foreign body or mechanical injury, on evacuation of
the uterus,or
Systolic blood pressure <90 mmHg
Uterine size >16 weeks .

If on examining a woman with an abortion, there are signs of peritonitis, or the uterus is more
than 16 weeks size, she has a high risk (severe) unsafe abortion, and is at very high risk of
organ failure

or

death.

When examining any woman with an abortion, the organ systems

38

must

be systematically evaluated for signs of organ dysfunction. If there is any abnormal

clinical finding, suggesting organ failure, prompt special investigations must be done to confirm
such

organ

failure and

supportive treatment

start supportive

treatment. If these investigations cannot be done or

cannot be offered, the patient must be referred to a higher level of care,

without delay .
4.5.

ASSESSMENT AND EVALUATION OF THE SEVERITY OF PUERPERAL SEPSIS

Important considerations, when assessing the severity of puerperal sepsis:
Endometritis may present without significant pyrexia, thus daily observations and
examinations are essential.
Severe intra-uterine infection could already have been present at delivery. Therefore,
risk factors in the history, such as obstructed labour, prolonged rupture of the
membranes, or chorioamniotis, must be looked for.
Lochia need not necessarily be excessive, or foul-smelling.
Postpartum infections can initially be asymptomatic, especially in immuno-compromised
patients. The patients temparature is, therefore, a poor indicator of the severity of the
infection.
-

Signs of peritonitis may be absent, even when there is free pus in the abdomen. This
is especially so in puerperal and immuno-compromised patients.

Any abnormal observations in a postpartum patient must prompt the systematic

evaluation of this patients for any signs of organ dysfunction. A sub-involuted, tender,
uterus, an open cervical os, excessive and/or foul-smelling lochia, signs of peritonitis and/or
lieus, are all pointers to pelvic sepsis. A non-genital origin of sepsis, such as a urinary tract
infection, breasts engorgement or mastitis, infection of an episiotomy or other wound,
thrombophlebitis, and a respiratory tract infection must be excluded. Examination, to find the
origin of the sepsi, followed by appropriate antibiotic treatment, must be carried out, as soon as
the diagnosis of postpartum sepsis is made. HIV-testing should be offered, and if the patient is

39

HIV-positive, treatment should be aggressive. Early referral, in cases where there is no or poor
response to the treatment, is essential, so that a timely evaluation of the need for
hysterectomy can be made.
4.6

SYSTEMATIC EVALUATION OF POSTPARTUM/ARBOTION PATIENTS FOR THE

PRESENCE OF ORGAN DYSFUNCTION

The clinical signs of organ dysfunction,with the special investigations required, as well as the
supportive treatment, which must be given, are as follows:

Central Nervous System

Clinical signs confusion, delirium, decreased level of consciousness, Glasgow Coma
Scale < 14/15
Special investigations - blood glucose, blood gas analysis or pulse oxymetry, and, if
indicated, investigation for brain abscess or septic emboli
Supportive treatment treatment of underlying sepsis

Circulatory system
Clinical signs hypotension < 90 mm Hg systolic pressure, tachycardia > 100 beats per
minute, cold and clammy extremities, pulmonary oedema, hepatomegaly, arrhythmias
Special investigations chest X-ray, and possibly an ECG
Supportive treatment adequate venous access, possibly with a high flow lior central
Venous pressure monitoring, fluid replacement, inotrope support

Respiratory system
Clinical signs tachypnoea > 22 breaths per minute, use of the accessory respiratory
muscles, central or peripheral cyanosis

40

Special investigations pulse oxymetry (saturation < 90%), blood gas analysis (pao2 < 3
times Fio2, acidosis,and alkalosis), X-ray.
Supportive treatment oxygen via nasal prongs or face mask, CPAP mask, intubation
and ventilation.

Gastrointestinal and hepatic systems

Clinical signs jaundice, hepatomegaly
Special investigations - blood glucose, raised liver enzymes ALT, AST, LDH
Supportive treatment treatment of the underlying sepsis

Renal System
Clinical signs (NB: the patient must have indwelling catheter, and the urinary output
must be carefull charted) - oliguria (<1ml urine/kg/hr or < 30ml/hr), anuria, or very
concentrated urine
Special investigations urine dipstix, raised urea and creatinine
Supportive treatment - rehydration and fluid replacement. If there is progressive renal
failure - diuretics,dialysis

6.

Genital System
Clinical signs - pus or foul-smelling products of conception, a very tender uterus,
peritonism, signs of trauma or foreign body, subinvolution of the uterus, an open cervical
os.
Special investigations - pre-evacuation culdocentesis, prompt evacuation of uterus,
examination for non-genital sepsis, possibly hysterectomy, to remove the origin of the
sepsis.

41

Haematological system
Clinical signs - pallor, petechiae, bruising, bleeding from the gums or infusion sites, deep
venous thrombosis
Special investigations low Hb (<10g/dl), haematocrit (<30%), low or high white cell
count, low platelet count (<100x109/1), raised fibrinogen degradation products or

D-

dimmers, prolonged INR or PTT

Supportive treatment - blood as needed, treatment of DIC, whether with fresh frozen
plasma or heparin

Immuunological system (any of the following)

Clinical signs - pyrexia > 38C, lymphadenopathy
Special investigations - increased or decreased white cell count, HIV-testing
Supportive treatment - aggressive treatment of the underlying sepsis

Endocrine System (Thyroid, Breasts, Diabetes)

Special investigation - blood glucose
Supportive treatment - correction of any metabolic abnormalities

4.6. MANAGEMENT AT DIFFERENT LEVELS OF CARE

The principles of management are: to resuscitate the patient, to empty the uterus and to
remove the septic focus. Prior to discharge the patients ward haemoglobin concentration,
Rhesus status and syphilis serology should be known, and contraceptive advice must be
given. Where possible, counseling for HIV-testing should be provided and the test carried
out, if requested.
1. Level 1(excluding sub-district hospitals with 24-hour theatre facilities and blood available)
Abortion (safe abortions only)
-

Prompt evacuation of the uterus, preferably by manual vacuum aspiration (MVA),

under local anaesthesia.

42

- Antibiotic prophylaxis
Postpartum:
- Referral to the next level, if the patient has puerperal pyrexia.
2. Level 1 (sub-district hospitals with 24-hour theatre facilities and blood available) and level 2
Abortion:
-

resuscitation of the patient

prompt evacuation of the uterus, preferably by MVA, but with the facilities for
evacuation in theatre, for moderately unsafe abortions

Antibiotics in therapeutic dosage, for unsafe abortions

Referral of all patients, where there is dysfunction of 2 or more organ systems,

and/or where it is contemplated to change antibiotics. Such patients may require
urgent laparotomy.
Puerperal sepsis:
-

Intravenous antibiotic coverage

Special investigations, to localize the origin of the sepsis

Prophylactic anticoagulation, in case of pelvic thrombophlebitis

Referral of all patients, where there is dysfunction of 2 or more organ sytems, and/or
where it is contemplated to change antibiotics. Such patients may require urgent
laparotomy.

Referral to a higher level, if there is poor or no response to treatment

Level 3 (including level 2 institutions with the specialist expertise to perform a
hysterectomy, and with high care facilities).

Abortion and postpartum:

-

Prompt evacuation of the uterus in theatre, for high risk abortions, and evacuation of the need
for hysterectomy.

Supportive care, for single or multi organ failure, in an ICU or high care facility.

43

Careful evaluation of the need for laparotomy, where there is dysfunction of 2

or

more organ systems, and/or where it is contemplated to change antibiotics.

4.8.

REFERRAL CRITERIA
1. Level 1 / Community or primary health care level, sub-district hospitals ( without 24hour theatre facilities) Abortion: referral of any patient who has anything other than a spontaneous safe
abortion. A safe abortion is defined as a uncomplicated abortion, i.e. where the patient
has no tachycardia, anaemia, pyrexia, or foul-smelling products of conception, and the
uterine size is < 12 weeks.
Postpartum sepsis: refeffal of any patient, where the sepsis is thought to be of genital
origin.
2. Level 1 sub-district hospitals (i.e. hospitals which have blood products available, 24-hour
anaesthetic facilities and the expertise to perform an evacuation of the uterus in theatre) and
Level 2 district or regional hospitals
Referral of any patient with signs of organ failure, except for anaemia, or if supportive
treatment would not be available, if needed.
Referral of any patient (septic abortion or puerperal sepsis) with a poor or no response to
intravenous antibiotics.
3. Level 2 (institutions with 24-hour consultant cover and intensive care /high care facilities
available, which can provide adequate treatment and support for post-abortion or postpartum
patients with single or multi-organ failure) and Level 3/ tertiary or central hospitals.

44

4.9

OBSERVATIONS POST PROCEDURE

Any observations to be carried out, should be specified as any other therapeutic modality, with
specific instructions as to what must be charted, the frequency of each observation, and that the
physician in charge of the patient must be contacted immediately, if any abnormal findings are
obtained. Specified in this context means, as prescribed on the prescription sheet or by
standing orders.
There is no point in carrying out any observations if the attending physician is not called for or
Does not respond to abnormal clinical signs, or takes an inappropriate time to respond. All
observations must be charted, any abnormalities noted and reported to the sister-in-charge, who
must decide whether or not to consult the medical staff. If the sister-in-charge or the doctor are
consulted, their names must appear in the nursing notes. Lack of written documentation will be
interpreted as a failure to carry out the required observations, or that consultation did not occur.

4.10
2.

BASIC GUIDELINES FOR OBSERVATIONS:

Post-normal vaginal delivery
-

Blood pressure, temperature, pulse rate, and respiratory rate. Abdominal examination,
to check that the uterus is well-contracted. Check on any excessive vaginal bleeding ,
directly post delivery

Ward haemoglobin concentration must be checked within 24 hours of delivery and

must be known before the patient is discharged.

Temperature, blood pressure, pulse rate, respiratory rate, and vaginal pad checks to
be charted every 30 minutes for 2 hours, then 6 hourly until discharge, if normal.

Education of patients, regarding the basic observations which they can make
themselves, and for which they can seek medical help, if such observations are
abnormal.

45

2.

Post-uncomplicated evacuation of uterus/MVA

-

blood pressure, pulse rate, respiratory rate, checks on any excessive vaginal bleeding,
directly post-procedure

Ward haemoglobin concentration must be checked within 24 hours of delivery and must
be known before the patient is discharged

Temperature, blood pressure, pulse rate, respiratory rate, and vaginal pad checks hourly for
2 hours, and then 6 hourly until discharge, if normal.

3.

post-caesarean section/theatre evacuation

-

Ward haemoglobin concentration must be checked within 24 hours of delivery and must
be known before the patient is discharged

Temperature, blood pressure, pulse rate, respiratory

rate, urinary output and vaginal pad

Checks for excessive bleeding 30 minutes for the first hour, then hourly for 4
hours, then 6 hours for 24 hours and 12 hourly

until discharge (provided the

observations are normal).

4. Abortion puerperal sepsis complicated by single or multi-organ dysfunction
-

Continuous to every 15-30 minutes evaluation of the blood pressure, respiratory rate,
and pulse rate, according to the ICU or high care protocol of the facility. Temperature
and urinary output hourly, as well as other parameters, such as central venous pressure.

4.11. CONCLUSION
Adequate initial assessment of septic cases, i.e. taking a history, examining the patient and
identifying the problem(s), will go a long way towards curbing the incidence of unnecessary
pregnancy-related sepsis. Prompt and appropriate treatment, with regard to the level of care
needed, should be instituted, with referral to a higher level, as soon as indicated. Identification
of patients at high risk for the development of sepsis and the use of prophylactic antibiotics, to
prevent sepsis, are advisable. Follwing the emergency event, the

necessary

observations

must be done thoroughly and frequently, and abnormal findings must be acted upon promptly.

46

Sepsis-related maternal mortality and morbidity can be at least reduced, by high quality postabortion and postpartum care, at all levels of the health care system. These levels include:
-

the community level (with staff who have had basic health training, including traditional birth
attendants)

the primary level (with nurses, trained midwives, and in some cases doctors)

the first referral level (district hospitals)

the secondary and tertiary levels (regional, provincial or teaching hospitals).

4.12 REFERENCES
1. Saving Mothers. Report on Confidential Enquiries into martenal Deaths in South Africa 1998.
2. Sawaya G, Grady D, Kerlikowske K, Grimes D. Antibiotics at the time of induced abortions:
the case for universal prophylaxis based on

a meta-analysis. Obstet Gynecol 1996;

87(5):884-90.
3. May W, Gulmezoglu AM, Ba-Thike K. Anti-biotics in incomplete abortions. Department of
Reproductive Health and Research, WHO,Geneva 1999.
4. Fawcus S, Mcintyre J, Jewkes R et al. Management of incomplete abortions at South African
provincial hospitals. S Afr Med J 1997; 87: 438-442.
5. Mercer M, Miodovnik M, Thurnau G et al. A Multicenter randomized masked trial of
antibiotics vs. placebo therapy after preterm premature rupture of

he membranes. Am J

Obstet Gynecol 1996;174:304.

6. Schutte M, Treffers P, Kloosterman G

et al. Management of

premature rupture of

membranes: the risk of vaginal examination to the infant. Am J Obstet Gynecol 1983;146:
395.
7. Keirse MJNC Ohlsson A, Treffers PE, Grant J: p149,152,155,322-26. In Enkin M, Keirse
MJNC, Renfrew M, Neilson J (eds): A Guide to Effective care in Pregnancy and childbirth.
Oxford University Press, New York, 1995.

47

CHAPTER FIVE
GUIDELINES: MANAGEMENT OF OBSTETRIC HAEMORRHAGE
5.1 INTRODUNCTION:
The goal is provinces should be to reduce deaths due to haemorrhage to less than 10% of
their total maternal deaths. This can be achieved by focusing mainlt on the quicker attainable
reduction in deaths due to postpartum haemorrhage1
5.2 GENERAL PREVENTATIVE MEASURES:
1. permanent contraception must be positively encouraged for all women with a parity of > 5
and/or in the age group > 35 years. This could be female postpartum or interval sterilization
or vasectomy for the male partner.
2. All pregnant women should receive antenatal care from early in pregnancy.
3. Routine iron supplementation is required to all antenatal women to minimize anaemia during
pregnancy and delivery.
4. A referral network from primary through to tertiary level of care must be in place in each
region. Women attending primary health care facilities must know which hospital to attend in
the event of an emergency.
5. Anaemic patients with Hb < 8g% must deliver at level 2 care institutions
6. the mother as a monitor concept must be taught to all pregnant women. Following
delivery of the placenta the mother must:

know how to feel for eterine relaxation and how to rub up her uterus if it relaxes

know to call for help if the amount of bleeding increases

48

5.3 SPECIFIC PREVENTATIVE MEASURES:

1. an effective and functional ambulance transport infrastructure must exist in all provinces.
Obstetric haemorrhage must always receive the highest priority

for emergency

transport.

2. Establish good communication links between different levels of care to enable Immediate
action in the receiving hospital when patients are referred, which must include:

No delays on admission

Direct access to the labour ward

Prompt initial assessment by the person in charge of the labour ward

3. Identify all women with a risk factor for postpartum haemorrhage for delivery at subdistrict
and level 2 hospital;

i.e. women with multiple pregnancies, polyhydramnios, grande

multiparas and previous postpartum haemorrhage that required blood transfusion.

4. Continuing in-service training

regarding

the

emergency

management of postpartum

haemorrhage at Level 1 and 2 care must be maintained.

5. Emergency management especially

at level 1 care must be improved and

standard

protocols for managing postpartum haemorrhage must be known by all health workers at an
institution who deal with pregnant women2. Where d eliveries are infrequent and podtpartum
haemorrhage is consequently rare, fire drills should be performed to ensure the staff is familiar
with what to do with a postpartum haemorrhage.
6. Use a partogram for all women in labour to enable the early recognition and prompt
management of prolonged labour3.
7. The active management of the third stage should be practiced. There is overwhelming
evidence that active management significantly

reduces the incidence of

postpartum

haemorrhage4. The oxcytocin drug used during the active management of the third stage
should preferably

be 5U oxytocin given by intramuscular injection. Oxytocin has the

advantage over Syntometrine and Ergometrine that it is not degraded by direct light and
49

need not be kept continuously in a fridge. The shelf life at normal room temperature is one
month. Oxytocin is not contra-indicated in patients with hypertention or heart valve lesions.
8. Oxytocin must always be used with caution during labour:

Labour is not to be augmented in multigravid patients once in the active phase of the
First stage of labour, unless discussed with a specialist.

Discontinue

oxytocin following

induction of labour (e.g for prelabour

rupture

of

membranes) once in established labour.

9. Take the following into account when discharging patients postpartum:

Patients at risk for postpartum haemorrhage must not be discharged early.

Examine each patient for a well-contracted uterus before discharge.

Iron supplementation must continue for

one month postpartum if

the postpartum

haemoglobin concentration is less than 10 g/dl.

10. Blood

must

be

available

at

all

hospitals providing

level 2

care and level 1 hospitals where

caesarean sections are performed.

11. Caesarean
Adequately

sections
trained

must

only

be

performed

person is regarded as

by

one who

adequately
has

trained

performed

at

persons.
least

15-20

(An
caesarean

sections under supervision).

5.4 PROBLEM RECOGNITION:
1. Any

amount of bleeding

that appears

more

than

normal

during and following

the third

stage

of labour.
2. Any

patient

with

signs

of

shock

(tachycardia

haemorrhage.

50

and/or

low

blood

pressure) due

to

5.5. MANAGEMENT AND REFERRAL GUIDELINES:

1.

The

initial

emergency

management

of a ll

patients

with

postpartum haemorrhage

must

include:

Step 1:
The uterus must immediately be rubbed up. This will cause the uterus to contract and
reduce the blood loss.

Step 2:
Call for help. One health worker alone will not be able to manage a postpartum haemorrhage.

Step 3:
A rapid intravenous infusion of 20 units oxytocin in a litre of intravenous fluids must be
started. Once again make sure that the uterus is well contracted.

These

three

steps

must

always

be carried

out

irrespective of the cause of the

postpartum haemorrhage.

Step 4:
The patients bladder

must now be emptied. A full bladder may cause poor

contracrion

of the uteres with resultant haemorrhage.

Step 5:
All

patients

managed at level 1 care where bleeding persists follwing

the initial

steps

must be referred to the next level care where the cause of the haemorrhage must be
determined and further management instituted according to the cause.

patients with retained placentas must always have an intravenous infusion of 20 units
oxytocin in a litre inserted.

Their observations need to be done every 15 minutes and check continuously

the uterus remains well contracted. Transfer to an appropriate level of
arranged.

51

care

whether

must

be

Manual removal of the placenta can be performed at level 1 care in a remote setting by
an appropriately trained person.

3.

During and

following the third stage of

labour any amount of bleeding that appears more

than normal requires an intravenous infusion with 20 units oxytocin.

4.

Any patient with signs of shock (tachycardia and/or low blood pressure) due to haemorrhage
requires

at

least

two

intravenous

infusion and rapid administration of

crystalloids (i.e.

Plasmolyte B, Ringers lactate, rehydration fluid, etc.).

All patients managed at level 1 (primary care level) without 24 hour theatre facilities and
personnel capable of managing PPH, must then be referred as acute emergencies.

Patients

already

at

an

appropriate

level of care

require

blood

for

transfusion

and

managed as acute emergencies.

5.

An atonicuterus not responding

to steps 1 to 3

must

be bimanually compressed while the

patient is transferred to the next level of care.

6.

Abraptio placentae:

Active resuscitation and prompt

referral to a level 2 or level 3 hospital is

mandatory

when the diagnosis of abruptio placentae with an intra-uterine death has been made.

The route of delivery in the event of abruptio placentae with an intra-uterine death

is

always vaginally,unless there are obstetric indicationsfor caesarean section.

7. Placenta praevia:

patient

with a previous caesarean section and

anterior

placenta praevia must be

delivered in a level 2 hospital by:

One with expertise

to

continue with

a total

The is a risk for a morbidly adherent placenta.

52

abdominal

hysterectomy, if

required

5.6. OBSERVATION GUIDELINES

Poor observations contributed significantly to the death of women dying from postpartum
haemorrhage. The following important improvements are required with regards to observations
of patients at risk for postpartum haemorrhage:

Identify women at high risk of postpartum haemorrhage.

Adhere to accepted nursing norms in observing these postpartum women. Keep these

patients under observation for longer (6 hours) in the labour wards.

Ensure ongoing observations once transferred to postnatal wards.

The following postpartum observations must be done on all patients and noted in their records
following completion of the first stage of labour:

Whether the uterus is well contracted or not.

The pulse and blood pressure.

Whether there is excessive vaginal bleeding or not.

Whether the episiotomy was sutured and an inspection for perineal and vaginal tears
was done.

Whether the placenta was completely delivered.

Observations must be documented, interpreted and action taken if abnormal

If the third stage was normal, the placenta delivered completely, and the observations mentioned
above was normal:
The observations need to be repeated following one hour.
It is important to check continuously whether the uterus remains well contracted during
this hour.
If the third stage was abnormal, the placenta delivered incompletely, and of the observations
mentioned above was abnormal:
The observations need to be done every 15 minutes until the patients
stabilized.

53

condition has

During this time it is important to check continuously whether the uterus remains well
contracted.

5.7. AUDIT:
To ensure that the changes

are

implemented,

audit

needs

to

be

done regarding obstetric

haemorrhage at all levels o care.

5.8. CONCLUSION:
Careful observation, prompt recognition and

the initial emergency management will lead to a

rapid reduction in maternal deaths due to of postpartum haemorrhage.

5.9. REFERENCES:
1.

Kwast BE. Postpartum haemorrhage: its contribution to maternal

mortality. Midwifery 1991:

7:64-70
2.

Theron GB, Editor. Perinatal Education Programme, Manual I, Maternal Care,. Cape Town:
Perinatal Education Trust; 1993.
Available from:
Editor-in-Chief, Perinatal Education Programme, PO Box 34502, Groote Schuur Hospital, 7937.
Ph/Fax 021-618030

3.

Kwast BE, Lennox CE, Farley TMM. World Health Organization partograph in management of
labour. Lancet 1994; 343: 1399-1404

4.

Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management of

the third

Stage of labour (Cochrane Review). In: The Cochrane Library, Issue 3, 1999. Oxford: Update
Software

54

CHAPTER SIX
GUIDELINES FOR VAGINAL DELIVERY AFTER
CAESAREAN SECTION

Vaginal birth after caesarean section (VBAC) is a safe and desirable procedure likely to succeed
in about 60% of patients attempting it. The risks of VBAC is uterine rupture which although
uncommon, ranging from % to 2% is dependent on patient selection and intrapartum care.
Failure of VBAC with subsequent emergency caesarean

section carries a higher morbidity and

mortality than an elective caesarean section. Selection of patients and intrapartum management are
important for safety and success. These guidelines are intended to enhance both safety and
successful outcome. These guidelines are intended particularly for South African circumstances,
especially those prevailing in level 1 and level 2 health facilities.
6.1.

ANTENATAL CARE
This can be provided at all levels of health care. Patients with previous caesarean section
however, must be booked as high risk patients and referred for medical assessment as early as
possible in pregnancy and again at 36 weeks gestation. Decision for VBAC should be made at
36 weeks, not earlier, and may yet need to be revised and reviewed before term in changing
circumstances.

6.2.

PLACE OF VAGINAL DELIVERY

Delivery must take in a unit adequately equipped and staffed for emergency caesarean
section. It must be possible to perform caesarean section within 30 minutes of the decision being
made.

6.3.

PATIENTS CONSENT
Patients must be provided with a clear explanation of both the advantages and disadvantages of
VBAC, including the knowledge that the procedure may fail and emergency caesarean section

55

Become necessary after hours of labour. Ideally this discussion should take place in the
antenatal period before the stress and discomfort of labour clouds decision making. The patient
must be willing and co-operative.
6.4.

6.5.

ADVANTAGES OF VBAC
1.

Avoidance of caesarean section with its possible complications and post-operative pain.

2.

psychological satisfaction brought about by the accomplishment of a natural birth.

3.

saving in cost to the patient and / or state.

DISADVANTAGES OF VBAC
1.

Possible failure to make progress during labour with an emergency caesarean section, which
is associated with a slightly higher incidence of complications.

2.

A very small but real risk of uterine rupture which may lead to fetal death and / or
hysterectomy.

3.
6.6.

Labour pains.

ADVANTAGES OF ELECTIVE CAESAREAN SECTION (C/S)

1.

Lower complication rate than emergency C/S.

2.

No risk of uterine rupture during labour.

6.7. DISADVANTAGES OF ELECTIVE CAESAREAN SECTION

1. Higher complication rate than an uneventful vaginal delivery.
2. Eliminates all future chances of natural birth.
6.8. CONTRA-INDICATIONS FOR VBAC
1.

Patients who decline the procedure after clear explanation should be delivered by elective
caesarean section.

2.

Previous classical caesarean section (including so-called vertical lower segment section).

56

3.

Previous surgery involving the uterine fundus.

4.

Previous uterine rupture.

5.

Grossly contracted pelvis carries such small chance of success that VBAC is not
appropriate. It is clearly shown that routine pelvimetry, either clinically or by radiologically, is
not a useful predictor of success in VBAC (Grade B evidence) (Thubisi et al. 1993; Russell &
Richards, 1971). Imaging pelvimetry is of no proven benefit but clinical evidence of a grossly
contracted pelvis should make VBAC inappropriate

6.

Fetal size is of some importance in South Africa experience. It has been shown that VBAC
is rarely successful if the baby weighs more than 3200 grams (Van der Walt et al., 1994).
The fetal weight is difficult to estimate accurately, but using symphysis-fundal height (SFH) is
useful. If the SFH is greater than 36 cms., elective caesarean section should be considered
instead (Grade D Evidence).

7.

Any medical or obstetric condition that precludes safe vaginal delivery is not suitable.

8.

Patients who have had two or more caesarean sections should be delivered by elective
caesarean section

9.

If the previous section ended in delivery of a stillborn infant, or one associated

with an early neonatal death, as a result of difficult labour, VBAC may be an unwise option.
Very careful consideration must be given before embarking on another attempt at vaginal
delivery where a previous effort ended in disaster.

Successful vaginal delivery in preceding pregnancies are not a guarantee of safety or success in
subsequent VBAC and each pregnancy must be carefully considered and assessed afresh
despite previous good outcome.
If facilities are not present to enable emergency caesarean section, then it is safer for the patient
to delivered there by elective caesarean section, or alternately to be referred before labour to
a more suitable institution. These deficiencies may include lack of a surgeon, anaesthetist or
other staff as well as equipment. Referral and transfer in labour are

57

associated

With delays leading to greatly increased morbidity and mortality. Such transfer must be avoided,
if necessary by performing elective caesarean section before labour.
6.9. CURCUMSTANCES SUITABLE FOR VBAC
1. An informed consenting co-operative patient with one previous caesarean section. (Some
women with two previous caesarean sections may possibly be suitable for VBAC, but most
obstetricians will prefer elective caesarean section).
2. Clinically no obviously gross pelvic contracture.
3. Baby of average size, i.e., SFH not over 36 cms.
4. No malpresention or multiple pregnancy.
5. Doctor immediately available throughout labour, capable of

monitoring

labour

and

performing emergency caesarean section if necessary.

6. Available theatre facilities and support staff for emergency caesarean section within 30
minutes.
6.10. MANAGEMENT OF TRIAL OF LABOUR
1. The labour must be conducted in a facility

as described above, capable of emergency

caesarean section within 30 minutes.

2. Patients in apparent latent phase of labour should remain in an area of supervision.
3. A qualified midwife must be present in the labour ward at all times.
4. An intravenous line should be set up in labour.
5. Indwelling catheterization of the bladder is not necessary.
6. Continuous electronic monitoring is ideal, but VBAC may be conducted without it, provided
meticulous and very close clinical monitoring is performed.
7. Analgesia should be provided in the usual way with Pethedine and Aterax (or similar)
Epidural analgesia should be avoided unless given by a very expienced physician.
8. The partogram must be used to monitor progress labour.

58

9. Induction and augmentation of labour with oxytocin are not allowed. Poor progress is an
indication for emergency C/S.
10. Pain and tenderness involving the lower abdomen are NOT reliable indications of uterine
rapture.
The trial should be abandoned in favour of emergency caesarean section :
1. There is poor progress as shown by the partogram graph crossing the alert line.
2. The fetal heart shows tachycardia or decelerations (except early dips in the late first stage).
3. There is sudden vaginal bleeding or haematuria.
Delivery in the second stage should follow ordinary obstetric practice but a prolonged second
stage should be avoided. Emergency caesarean section is to a difficult operative
vaginal delivery.
Exploration of the uterus after delivery to determine that it is intact is unnecessary and unreliable
unless postpartum haemorrhage is present.
Post-partum haemorrhage or signs of maternal cardio-vascular instability should raise serious
consideration of the possibility of uterine rupture.
6.11. REFERENCES
1. Van der Walt WA, Cronje HS, Bam RH. Vaginal delivery after one caesarean section. Int J
Gynecol Obstet 1994; 46: 271-277.
2. Russell JGB, Richard B. A review of pelvimetry data. Br J Radiol 1971; 44: 70-784.
3. Thubisi M, Ebrahim A, Moodley J, Shweni PM. Vaginal delivery after previous caesarian
section: is x-ray pelvimetry necessary? Br J Obstet Gynenaecol 1993; 100: 421-424.
4. Flamm BL, Newman LA, Thomas SJ, Fallon D, Yeshida MM. Vaginal birth after Caesarean
delivery: results of a 5 year multicenter collaborative study. Obstet Gynecol 1990; 76: 750.
5. Van Roosmalen J. Vaginal birth after caesarean section in rural Tanzania. Int J Gynecol
Obstet 1991; 34: 211.

59

CHAPTER SEVEN
GUIDELINES FOR RESUSCITATION IN PREGNANCY
Collapse in pregnancy may occur as a result of several catastrophic events such as pulmonary
embolism, amniotic fluid embolism, severe haemorrahage leading to hypovolaemia, acquired or
congenital heart disease, anaesthetuc complications, failed intubation, congestive cardiac failure
etc. In the 1998 Report on Confidential Enquiries into maternal deaths in South Africa acute
collapse and embolism accounted for 7.3% all deaths and 4.8% were from anaesthetic
complications.
In all deaths, substandard care in relation to resuscitation was present in 28.8% of the cases. The
goal of this chapter is to provide guidelines on resuscitation in order to prevent deaths due to
failure to resuscitate.
It is impossible to perform effective cardiac massage in the third trimester of pregnancy as the
gravid uterus prevents venous return from the legs and effective cardiac filling. When
cardiovascular collapse occurs in the operating room the doctor must deliver the baby
immediately if there is to be any maternal recovery. Outside the operating room,
emergency operative delivery must performed as part of the resuscitation if there is no
immediate response to simple measures.
7.1.

Prevention of Circumstances Leading To Collapse

Detailed initial assessment of patients

Detailed management plan for those at risk

Continuous monitor for those at risk

Accurate documentation and interpretation of findings

Prompt intervention when problems arise

60

7.2. Ensuring preperedness for Cardiopulmonary Resuscitation

All medical and nursing staff must be able to administer basic cardiopulmonary resuscitation

(CPR)
A protocol for CPR should be clearly displayed in the obstetric unit.

An emergency trolley with all the necessary drugs and equipment must be immediately
available.

7.3.

Daily checks to ensure that drugs are not expired and equipment must be good working order

MANAGEMENT OF CARDIO-RESPIRATORY ARREST

1.

Administer a firm precordial thump.

2.

Call for help, for a defibrillator, for intubation equipment, for a doctor to do caesarean section if in the
third trimester and undelivered.

3.

Begin cardiopulmonary resuscitation, using the principle of ABC (airway, breathing, compression).
Perform external cardiac compression at a rate of 100/minute. Give breaths (lasting two seconds each)
at a rate of one for every five compressions, or two every 15 compressions if alone.

4.

Attach electrocardiogragh leads and intubate using cricoid pressure.

Ventilate with 100% oxygen.

5.

in the presence of ventricular fibrillator or pulseless ventricular tachycardia, defibrillate,

starting at 200 J, increasing to 200-300 J, and then to 360 J if necessary.

6.

Give epinephrine (adrenaline) 0.01 mg/kg every 3 minutes, intravenously or into the endotracheal tube

7.

Reassess for heartbeat and breathing every minute.

8.

If resuscitation has not been successful in 4 minutes, and if the gestational age is more than 24 weeks,
perform immediate operative delivery at the site of resuscitation.

9.

Continue cardiopulmonary resuscitation during operation.

61

10. Treat the cause of the arrest.

11. Arrange for follow up care: transfer to a higher level of care for intensive care
management.
Ensure that appropriate treatment is maintained throughout the transfer process. Unless there is
complete recovery of consciousness and spontaneous respiration, maintain tracheal intubation
and mechanically or manually assisted ventilation throughout the transfer. Ensure that the patient
is accompanied by appropriately trained or experienced personnel.
It essential that after resuscitation a detailed post resuscitation plan be drawn up, documented
and the necessary

observations and instructions prescribed. These patients, if

not being

managed in an intensive care unit, should be observed in a high care area. The patient should
be kept in that area for at least 12 hours following the incident, and after she is stable.
Accurate input and output charts should always be kept. Fluid overloading can occur following
intra-operative resuscitation. Patients requiring intra-operative resuscitation should be observed
in a high care area for at least 12 hours. Careful monitoring of the respiratory rate (and where
possible pulse oximetry) is vital as it is often the first sign of pulmonary oedema in these
situations. A fall in oxygen saturation is another very useful indicator of pulmonary oedema.
7.4.

COMPLICATIONS DURING OBSTETRIC ANAESTHESIA

For all methods of obstetric anaesthesia a specially prepared difficult airway tray or trolley
Should be available in the room where anaesthesia is induced. Atropine 0.5mg should be
immediately

available (i.e predrawn

in a syringe). All resuscitation drugs and equipment

(including a defibrillator) should be readily available. Epinephrine (adrenaline), ephedrine and

phenylephrine

should

be

available

within

the

room where is induced. For regional

anaesthesia (spinal or epidural) ephedrine 5mg/ml, thiopentone 25mg/ml and succinylcholine 50

mg/ml should be immediately available (i.e. predrawn). For induction of general anesthesia,
cricoid pressure should be applied by a trained assistant. An obstetric wedge (or equivalent) is

62

mandatory in all cases . A freely flowing intravenous infusion

should be secured before

commencing anaesthesia.
Spinal Hypotension
Prevention
1. Do not transfer the patient from trolley to table once the spinal block has been
administered. Perform the spinal with the patient on the operating table.
2. Ensure effective uterine displacement.
3. Correct any pre-existing hypovolaemia using appropriate intravenous fluid therapy.
Treatment
1. Increase the intravenous infusion to maximum flow rate.
2. Ephedrine bolus 5 10 mg IV (repeat up to 25-50 mg).
3. If no response,administer phenylephrine in repeated doses of 50 100 micrograms.
4. Do not tilt the patient into the head-down (Trendellenberg) position.subarachnoid position.
High Motor Block
Sensory neuronal to a level of thoracic dermatomes T2-4 is necessary

for successful

regional anaesthesia for caesarean section. Inevitably, there is an accompanying motor

neural blockade which is usually a little less extensive than the sensory block. Higher sensory
levels are often seen and are of little consequence. However, if the motor blockade extends to
the 15th cervical level or higher, diaphragmatic movement is affected and severe respiratory
compromise occurs. Without immediate intervention, apnoea and hypoxic cardiac arrest will
follow.
Prevention
Unfornately, the occurrence of high motor block is unpredictable. The most important aspects
of care are constant vigilance following neuraxial injection of local anaesthetic, maintaining
verbal contact with the patient, and immediate immediate intervention to prevent hypoxia. Always
administer epidural

anaesthesia

in small (3ml)

63

aliquots in case the catheter is in the

subarachnoid position. Onset of spinal anaesthesia is probably more controllable with use of
hyperbaric solutions. Never give more than the recommended dose of local anaesthetic
.

Symptoms and Signs

Patient complains of difficulty breathing: this is a common complaint in supine pregnant
patients and does not necessarily indicate high motor blockade. However, the upper
sensory

level should be checked immediately, looking for an

unusually high block.

Patient complains of numbness of arms or is observed to rub her fingers against her
thumbs: this is an indication of a high sensory

level and the anaesthetist should be

immediately alert to the possibility of high motor blockade.

Patient makes unusual movements of arms and shoulders: this is an indication of the
patients awareness of muscle weakness due to lower cervical blockade. Immediate action
must be taken to prevent hypoxia associated with progression above C5.

Failure of verbal response, apnoea or unconsciousness demand immediate action.

Bradycardia is uncommon: treat immediately with atropine 0.5mg. If patient is apnoeic or

unconscious, attend immediately to airway management and oxygenation.

Hypotension is common and is not specific feature of high motor block. If severe it can be
accompanied by loss of consciousness, which may mimic high motor block.

Treat

immediately with ephedrine and attend to airway management and oxygetation.

Treatment
Administer 100% oxygen at the first sign of distress. If the patient is still conscious and
breathing spontaneously, observe for progression of block. If the patient is

apnoeic,

manually assist ventilation.

Tracheal intubation with circoid

pressure. Even if apnoeic, the patient may still be

conscious. Administer thiopentone and

succinylcholine (suxamethonium) before intubation.

Mechanically assisted ventilation.

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Check for carotid pulsation: if absent, commence CPR. Electromechanical dissociation

(presence of ECG signal on monitor without effective cardiac output) can occur.

Maintain blood pressure.

Administer ephedrine iv.

Increase rate rate of intravenous fluid administration

Administer epinephrine (adrenaline) bolus if no response.

Administer volatile anaesthesia:

consciousness will otherwise return with successful

resuscitation.

Do not administer further doses of muscle relaxant: maintain mechanical ventilation and
anaesthesia until the completion of surgery.

At completion of surgery, discontinue anaesthesia and allow the return of spontaneous

ventilation.

If spontaneous ventilation or a full return to consciousness does not occur, do not extubate the
patient. Recommence mechanical ventilation and transfer to an intensive care unit.

Failed Intubation
Death following failed intubation is caused by hypoxia. The most important aspects of care are
to recognize the problem promptly and to maintain a patent airway and oxygenation. Hypoxic
cardiac arrest is often associated with persistent fruitless attempts an intubation. Difficult or
failed intubation is an uncommon event (occurring in 1 in 200 to 1in 1000 general anaesthetics
for caesarean section), so it is important that a preplanned drill or algorithm is enacted
whenever it occurs. All anaesthetics providing obstetric anaesthesia should have a thorough
familiarity with such an algorithm and a difficult intubation tray or tray or trolley must be immediately
available.
Prevention is best achieved by avoiding general anaesthesia in obstetrics. However, this is not
always possible. If a general anaesthetic has to be administered, the patient should be
questioned about any previous anaesthetics and examined for any obvious risk factors.

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Risk factors for difficult intubation include:

Difficulty with visualization of the oropharyngeal structures (Mallampati grades 3 and 4)

Short neck

Obesity

Problems with the maxillary incisors (protruding, single or missing incisors)

Receding mandible

Difficulty Airway Trolley

This should be prepared and readily available at all times in all maternity operating theatres.
Essential equipment will including:

Laryngoscopes of different sizes and designs

Endotracheal tubes of assorted sizes

Laryngeal masks of different sizes

Cricothyrotomy equipment

Endotracheal tube stylets

Oesophageal dilator (gum-elastic or silastic bougie)

A self-inflating resuscitation (Ambu) bag

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7.5 PROTOCOL FOR MANAGEMENT OF FAILED INTUBATION

Failed intubation

Maintain cricoid pressure, ventilate with

100% oixygen, prepare for cricothyrotomy

Fetal distress
Requiring immediate
delivery

Ventilation easy

Minimal or no
fetal distress

Ventilation difficult

Insert laryngeal
mask airway

Ventilation easy
Volatile agent
With 10%
oxygen

Continue
ventilation with
Cricoid pressure

Ventilation difficult

Cricothyrotomy

Ventilation
easy

Deliver baby
Maintain cricoid pressure
Do not turn the patient on her side
Do not administer additional doses of succinylcholine
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Ventilation
difficult
Wake patient