ML – Version 009

PREGNANCY, CHILDBIRTH AND POSTPARTUM MANAGEMENT GUIDELINE Effective Date: April 2022
Review Date: April 2026

Institution name: DIRECTORATE GENERAL OF PRIMARY HEALTH CARE, MINISTRY OF HEALTH

Document title: PREGNANCY, CHILDBIRTH AND POSTPARTUM MANAGEMENT
GUIDELINE
Approval process
Name Title Institution Date Signature
Written by TEAM FOR TEAM FOR DEPT. OF MAY AS PER
DEVELOPING THE DEVELOPING THE WOMAN 2021 ATTACHED
PREGNANCY, PREGNANCY, AND CHILD LIST
CHILDBIRTH AND CHILDBIRTH AND HEALTH –
POSTPARTUM POSTPARTUM DGPHC
MANAGEMENT MANAGEMENT
GUIDELINE GUIDELINE

Reviewed by TEAM FOR TEAM FOR DEPT. OF MARCH DR.

DEVELOPING THE DEVELOPING THE WOMAN 2022 JAMILA AL
PREGNANCY, PREGNANCY, AND CHILD ABRI
CHILDBIRTH AND CHILDBIRTH AND HEALTH -
POSTPARTUM POSTPARTUM DGPHC
MANAGEMENT MANAGEMENT
GUIDELINE GUIDELINE

Validated by DR QAMRA AL- DG OF QAC MINISTRY

SARIRI OF
HEALTH
Approved DR SAID AL LAMKI DG OF PHC MINISTRY
by OF
HEALTH

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PREGNANCY, CHILDBIRTH AND POSTPARTUM

MANAGEMENT GUIDELINE
Level- 1

A Guide for Nurses, Midwives and Doctors

Third Edition 2022

Department of Woman & Child Health

Directorate General for Primary Health Care
Ministry of Health
Sultanate of Oman

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PREGNANCY, CHILDBIRTH AND POSTPARTUM

MANAGEMENT GUIDELINE
Level- 1

A Guide for Nurses, Midwives and Doctors

Third Edition 2022

Department of Woman & Child Health

Directorate General for Primary Health Care
Ministry of Health
Sultanate of Oman

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Acknowledgements
Acknowledgements with gratitude to all contributors & reviewers for their effort in updating
this guideline manual:
Contributors from Woman & Child Health Department:
● Dr. Jamila Al-Abri, Consultant, Director – Department of Woman & Child Health (DWCH)
● Dr. Fatima Al Hinai, Consultant, DWCH
● Dr. Badriya Al Qassabi, Specialist Family Medicine, DWCH
● Dr. Omaima Abdel Wahab, Senior Medical Officer, DWCH
● SN. Ameera Al Shoaibi, Midwife, DWCH
Edited by: Ms. Juanita Singh Roshmi Albert, Public Health Specialist, DWCH

Contributors from Primary Health Care Institutions:

● Dr. Nabila Al Wahaibi, Senior Consultant Family medicine, Wadi Kabeer Health Centre
● Dr Faiza Al Fadhil, Senior Consultant Family Medicine, MCH section, Muscat governorate
● Dr. Ahdab Abdul Hafeez, Specialist Obstetrics and gynaecology, Al Seeb Poly Clinic
● Dr. Azza Al Kharosi, Senior specialist in Family Medicine, Manah Health Centre
● Dr. Zulaikha Issa Al Balushi, Senior specialist in Family Medicine, Abu Bagra Health Centre
● Dr. Samiya Al Khaldi, Senior specialist in Family Medicine, Al Qasbiya Health Center
● Dr. Munira Al Salmi, Medical officer (Obs/gyne), Rustaq Health Center

Reviewers from Primary Health Care:

● Dr Moza Al Abri, Consultant Family medicine, DWCH
● Dr Sara Al Waili , Senior specialist in Family Medicine , MCH section , Al Dahira governorate

Reviewers from Secondary & Tertiary Health Care:

● Dr. Tamima Al Dughaishi, Senior Consultant Obstetrics & Gynecology, SQUH
● Dr. Sumaya Al Amri, Senior Consultant Obstetrics & Gynaecology, The Royal Hospital
● Dr. Chitra Jha, Senior Consultant Obstetrics & Gynaecology, The Royal Hospital
● Dr. Qamaryia Ambu Saidi, Consultant Obstetrics & Gynecology, Nizwa Hospital

Contributors from National Diabetic & Endocrine Centre & NCD Department
● Dr. Nada Hareb Al Sumri, Senior Specialist, Department of Non-Communicable Diseases

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● Dr Muna Al Hakmani, Senior consultant, Department of Non-Communicable Diseases

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Contents
Acknowledgements ................................................................................................................................................ 4

Acronyms – Abbreviations ................................................................................................................................... 12

Definitions ............................................................................................................................................................ 14

Chapter 1............................................................................................................................................................... 17

1.1 Introduction ................................................................................................................................................ 18

1.2 Purpose ....................................................................................................................................................... 19

1.3 Scope .......................................................................................................................................................... 19

1.4 Structure of the guidelines ......................................................................................................................... 20

1.5 What is new in this updated edition of the guidelines?.............................................................................. 21

Chapter 2............................................................................................................................................................... 22

2.1 Standards of care ........................................................................................................................................ 23

2.2 Basic Ante-Natal Care ............................................................................................................................... 24

2.3 Common symptoms and medical conditions in pregnancy ....................................................................... 51

2.3.1 Common symptoms in pregnancy ........................................................................................................ 51

2.3.2 Management of Nausea and Vomiting in Pregnancy, and Hyperemesis Gravidarum ....................... 55

2.3.3 Anaemia in Pregnancy .......................................................................................................................... 62

2.3.4 Venous thromboembolism (VTE) ........................................................................................................ 67

2.3.5 Diabetes in Pregnancy: ......................................................................................................................... 80

2.3.6 Hypertension in Pregnancy ................................................................................................................... 92

2.3.7 Thyroid diseases in pregnancy ........................................................................................................... 107

2.3.8 Sickle Cell Disease (SCD) in pregnancy ............................................................................................ 114

2.3.9 Intrahepatic Cholestasis of Pregnancy ................................................................................................ 119

2.3.10 Thrombocytopenia in pregnancy ...................................................................................................... 121

2.3.11 Pregnancy with RH negative blood group ........................................................................................ 126

2.3.12 ABO Incompatibility ........................................................................................................................ 129

2.3.13 Urinary tract infections (UTI)........................................................................................................... 130

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2.3.14 Vaginal discharge during pregnancy ................................................................................................ 134

2.3.15 HIV in pregnancy ............................................................................................................................. 136

2.3.16 Syphilis in pregnancy: ...................................................................................................................... 141

2.3.17 Chicken pox (varicella) in pregnancy ............................................................................................... 146

2.3.18 Common counselling on lifestyles in Pregnancy ............................................................................. 151

2.4 Obstetric Complications ........................................................................................................................... 155

2.4.1 Vaginal bleeding in early pregnancy .................................................................................................. 155

2.4.2 Vaginal bleeding in later pregnancy and labour ................................................................................. 159

2.4.3 Fever during pregnancy and labour .................................................................................................... 161

2.4.4 Abdominal pain in pregnancy............................................................................................................. 162

2.4.5 Missed Abortion / Miscarriage ........................................................................................................... 166

2.4.6 Decreased foetal movements .............................................................................................................. 166

2.4.7 Pre-mature Rupture of Membranes (PROM) ..................................................................................... 168

2.5 Normal labour .......................................................................................................................................... 170

2.5.1 Supportive care during labour and childbirth ..................................................................................... 171

2.5.2 Diagnosis and confirmation of labour ................................................................................................ 173

2.5.3 Diagnosis of stage and phase of labour .............................................................................................. 174

2.6 Routine post-natal care............................................................................................................................. 193

2.7 Postnatal complications............................................................................................................................ 199

2.7.1 Vaginal bleeding after childbirth (post-partum haemorrhage) ........................................................... 199

2.7.2 Fever after childbirth .......................................................................................................................... 203

2.7.3 Breast Engorgement ........................................................................................................................... 205

2.7.4 Breast Infection................................................................................................................................... 206

2.7.5 Psychological morbidity ..................................................................................................................... 207

2.8 Emergencies ............................................................................................................................................. 212

2.8.1 Management of emergencies .............................................................................................................. 212

2.8.2 Rapid initial assessment...................................................................................................................... 213

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2.8.3 Shock .................................................................................................................................................. 215

2.8.4 Communicating with women and their families................................................................................. 218

2.9 Common procedures ................................................................................................................................ 222

2.9.1 Infection prevention ............................................................................................................................ 222

2.9.2 Anaesthesia and analgesia .................................................................................................................. 224

2.9.3 Episiotomy .......................................................................................................................................... 226

2.9.4 Repair of vaginal and perineal tears ................................................................................................... 230

Chapter 3............................................................................................................................................................. 232

3.1 Prerequisites to implement the guidelines ............................................................................................... 233

3.2 Human resources needed in ANC and PNC clinic: ................................................................................. 233

3.3 Responsibilities in ANC and PNC clinic ............................................................................................... 233

Chapter 4............................................................................................................................................................. 235

4.1 Document History and Version Control .................................................................................................. 236

4.2 Annexes .................................................................................................................................................... 237

Annex 1: Vaccination in Pregnancy ............................................................................................................... 237

Annex 2: Instruction to women on how to take thromboprophylaxis injection (how to take the injection) . 238

Annex 3: Edinburgh Postnatal Depression Scale1 (EPDS) ........................................................................... 240

4.3 References ................................................................................................................................................ 241

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List of Tables

TABLE 1: LABORATORY TESTS TO BE PERFORMED DURING ANC AND PNC VISITS ................................................................................. 29
TABLE 2: MOST COMMON OBSTETRIC INDICATIONS FOR ULTRASOUND EXAMINATION BY TRIMESTER .................................................... 31
TABLE 3: GUIDELINES OF WEIGHT GAIN IN PREGNANCY ........................................................................................................................ 35
TABLE 4: VACCINATION IN PREGNANCY ................................................................................................................................................. 38
TABLE 5: DRUGS CONTRAINDICATED IN PREGNANCY .............................................................................................................................. 41
TABLE 6: CRITERIA FOR THE DELIVERY IN PRIMARY CARE INSTITUTION.................................................................................................. 42
TABLE 7: CRITERIA FOR THE DELIVERY IN SECONDARY CARE ................................................................................................................. 42
TABLE 8: CRITERIA FOR THE DELIVERY IN TERTIARY CARE ..................................................................................................................... 44
TABLE 9: TASKS OF ANC VISITS ............................................................................................................................................................. 45
TABLE 10: INDICATIONS FOR REFERRAL TO SECONDARY CARE DUE TO RISK FACTORS ............................................................................ 49
TABLE 11: INDICATIONS FOR REFERRAL TO SECONDARY CARE DUE TO OTHER CONDITIONS .................................................................... 50
TABLE 12: COMPLICATIONS OF HYPEREMESIS GRAVIDARUM .................................................................................................................. 55
TABLE 13: MOTHERISK PUQE-24 SCORING SYSTEM ............................................................................................................................... 56
TABLE 14: DIFFERENTIAL DIAGNOSIS FOR NAUSEA AND VOMITING IN PREGNANCY ................................................................................ 57
TABLE 15: STRATEGIES TO REDUCE THE SIDE EFFECTS OF ORAL IRON AND IMPROVE TOLERABILITY OF IRON ......................................... 64
TABLE 16: RISK FACTORS FOR VENOUS THROMBOEMBOLISM AND RISK ASSESSMENT SCORING .............................................................. 69
TABLE 17: RISK SCORE FOR THROMBOPROPHYLAXIS ............................................................................................................................. 70
TABLE 18: THROMBOPROPHYLAXIS DURING PREGNANCY AND POSTPARTUM .......................................................................................... 76
TABLE 19: CURRENT INSTITUTE OF MEDICINE (IOM) WEIGHT GAIN GUIDELINES ................................................................................... 87
TABLE 20: MINIMUM MONITORING REQUIRED FOR PREGNANT WOMEN ON ORAL THERAPY .................................................................... 87
TABLE 21: RISK FACTORS FOR PREECLAMPSIA AT ANC BOOKING ASSESSMENT.................................................................................... 94
TABLE 22: SAFE ANTIHYPERTENSIVE MEDICATION IN PREGNANCY ....................................................................................................... 101
TABLE 23: SAFE ANTIHYPERTENSIVE DRUGS CAN BE USED DURING BREAST FEEDING ........................................................................... 104
TABLE 24: PREVALENCE OF HYPERTENSIVE DISORDERS IN A FUTURE PREGNANCY ............................................................................... 106
TABLE 25: PLATELET COUNT ................................................................................................................................................................ 122
TABLE 26: DETECTION, CLASSIFICATION AND MANAGEMENT OF UTI IN PREGNANCY .......................................................................... 131
TABLE 27: SPECIFIC MANAGEMENT OF VAGINAL DISCHARGE DURING PREGNANCY............................................................................... 135
TABLE 28: CONTRAINDICATIONS TO AEROBIC EXERCISE DURING PREGNANCY.................................................................................... 151
TABLE 29: DIFFERENTIAL DIAGNOSIS OF VAGINAL BLEEDING IN EARLY PREGNANCY ........................................................................... 158
TABLE 30: TYPES OF BLEEDING ............................................................................................................................................................. 159
TABLE 31: DIFFERENTIAL DIAGNOSIS OF VAGINAL BLEEDING IN LATER PREGNANCY (ANTEPARTUM HAEMORRHAGE): ........................ 160
TABLE 32: DIAGNOSIS OF FEVER DURING PREGNANCY AND LABOUR .................................................................................................... 161
TABLE 33:DIAGNOSIS AND MANAGEMENT OF WOMAN EXPERIENCING ABDOMINAL PAIN IN PREGNANCY ............................................. 163
TABLE 34: CONDITIONS DURING LABOUR REQUIRING IMMEDIATE REFERRAL........................................................................................ 170
TABLE 35: DIAGNOSIS OF STAGE AND PHASE OF LABOUR ...................................................................................................................... 174
TABLE 36: DURATION OF EACH STAGE OF LABOUR................................................................................................................................ 177
TABLE 37: DIAGNOSIS OF VAGINAL BLEEDING AFTER CHILDBIRTH ....................................................................................................... 200
TABLE 38: DIAGNOSIS OF FEVER AFTER CHILDBIRTH ............................................................................................................................ 204
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TABLE 39: DISTINGUISHING PERIPARTUM DEPRESSION FROM THE BABY BLUES .................................................................................. 207
TABLE 40: CRITERIA FOR MAJOR DEPRESSIVE DISORDER ..................................................................................................................... 209
TABLE 41: RAPID INITIAL ASSESSMENT & MANAGEMENT CONSIDERATIONS ....................................................................................... 214

List of Figures
FIGURE 1: GREEN CARD .......................................................................................................................................................................... 24
FIGURE 2: EFFACEMENT AND DILATATION OF THE CERVIX ................................................................................................... 173
FIGURE 3: ABDOMINAL PALPATION FOR DESCENT OF THE FOETAL HEAD ......................................................................... 174
FIGURE 4: ASSESSING DESCENT OF THE FOETAL HEAD BY VAGINAL EXAMINATION; 0 STATION IS AT THE LEVEL OF
THE ISCHIAL SPINE (SP) .................................................................................................................................................................. 175
FIGURE 5: LANDMARKS OF THE FOETAL SKULL ........................................................................................................................ 175
FIGURE 6: OCCIPUT TRANSVERSE POSITIONS ............................................................................................................................. 176
FIGURE 7: OCCIPUT ANTERIOR POSITIONS................................................................................................................................... 176
FIGURE 8: WELL-FLEXED VERTEX ................................................................................................................................................. 176
FIGURE 9: SAMPLE PARTOGRAM FOR NORMAL LABOUR ........................................................................................................ 179
FIGURE 10: BREECH PRESENTATION.............................................................................................................................................. 186
FIGURE 11: HOLD THE BABY ............................................................................................................................................................ 187
FIGURE 12: LOVSET’S ANOEUVRE .................................................................................................................................................. 188
FIGURE 13: DELIVERY OF THE SHOULDER THAT IS POSTERIOR ............................................................................................. 189
FIGURE 14: THE MAURICE AU SMELLIE VEIT MANŒUVRE ...................................................................................................... 190
FIGURE 15: ASSISTANT PUSHING FLEXED KNEES FIRMLY TOWARDS CHEST ..................................................................... 191
FIGURE 16: GRASPING THE HUMERUS OF THE ARM THAT IS POSTERIOR AND SWEEPING THE ARM ACROSS THE
CHEST ................................................................................................................................................................................................. 192
FIGURE 17: INITIATING BREASTFEEDING ..................................................................................................................................... 197
FIGURE 18: ATTACHING TO BREAST .............................................................................................................................................. 197
FIGURE 19: INFILTRATION OF PERINEAL TISSUE WITH LOCAL ANAESTHESIA................................................................... 227
FIGURE 20: MAKING THE INCISION WHILE INSERTING TWO FINGERS TO PROTECT BABY'S HEAD ............................... 228
FIGURE 21: REPAIR OF EPISIOTOMY ............................................................................................................................................... 229

List of Algorithms

ALGORITHM 1: ASSESSMENT AND MANAGEMENT OF NAUSEA AND VOMITING OF PREGNANCY ............................... 59

ALGORITHM 2: ASSESSMENT AND MANAGEMENT OF NAUSEA AND VOMITING OF PREGNANCY AT SECONDARY
HEALTH CARE LEVEL ....................................................................................................................................................................... 61
ALGORITHM 3: ASSESSMENT AND MANAGEMENT OF ANEMIA IN PREGNANCY .............................................................. 65
ALGORITHM 4: ANTENATAL THROMBOPROPHYLAXIS ACCORDING TO RISK .................................................................. 74
ALGORITHM 5: POSTNATAL THROMBOPROPHYLAXIS ACCORDING TO RISK SCORE ...................................................... 75
ALGORITHM 6: SCREENING FOR DIABETES IN PREGNANCY .................................................................................................. 85
ALGORITHM 7: HYPERTENSION IN PREGNANCY ....................................................................................................................... 93

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ALGORITHM 8: SUMMARY OF ASSESSMENT AND MANAGEMENT OF PREGNANT WOMEN WITH HIGH BLOOD
PRESSURE .......................................................................................................................................................................................... 100
ALGORITHM 9: POSTPARTUM HYPERTENSION ........................................................................................................................ 105
ALGORITHM 10: DIAGNOSIS AND MANAGEMENT OF HYPOTHYROIDISM ........................................................................ 110
ALGORITHM 11: WHEN PRESENTED WITH A PATIENT WITH SICKLE CELL CRISIS IN PREGNANCY ............................ 117
ALGORITHM 12: INTRAHEPATIC CHOLESTASIS OF PREGNANCY ........................................................................................ 120
ALGORITHM 13: DIFFERENTIAL DIAGNOSIS OF VAGINAL BLEEDING IN EARLY PREGNANCY ................................... 134
ALGORITHM 14: HIV TESTING IN PREGNANCY ........................................................................................................................ 137
ALGORITHM 15: SCREENING AND MANAGEMENT OF REACTIVE SYPHILIS SEROLOGY IN PREGNANCY ................. 142
ALGORITHM 16: FLOWCHART FOR MANAGEMENT OF CONGENITAL SYPHILIS .............................................................. 143
ALGORITHM 17: DIAGNOSIS AND MANAGEMENT OF VARICELLA IN PREGNANCY ....................................................... 148
ALGORITHM 18: ASSESSMENT AND MANAGEMENT PREGNANT WOMEN WITH EARLY PREGNANCY BLEEDING.. 157
ALGORITHM 19: ABDOMINAL PAIN IN PREGNANCY .............................................................................................................. 162
ALGORITHM 20: ASSESSMENT AND MANAGEMENT OF SUSPECTED PERINATAL DEPRESSION .................................. 210

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Acronyms – Abbreviations
ABS Antibody Screening Test GDM Gestational Diabetes Mellitus
ANC Antenatal Care Gm Gram
APH Antepartum Haemorrhage Hb Haemoglobin
ART assisted reproductive technology HIV Human Immunodeficiency Virus
BMI Body Mass Index ICT Indirect Coomb's test
BP Blood Pressure IM Intramuscular
BS Blood Sugar IU International Unit
CBC Complete Blood Count IUD Intrauterine Device
Cm Centimetre IUGR Intrauterine Growth Restriction
CPHL Central Public Health Laboratory IUI Intrauterine Insemination
dL Decilitre IVF In Vitro Fertilisation
DM Diabetes Mellitus LBW Low Birth Weight
DNA Deoxyribonucleic Acid PE pulmonary embolism
DVT deep vein thrombosis IVDU intravenous drug user
DWCH Department of Woman and Child IPC Intermittent pneumatic
Health compressions
ELIZA Enzyme Linked Immunosorbent PID Pelvic Inflammatory Disease
Assay
FBS Fasting Blood Sugar LSCS Lower Segment Caesarean
Section
FHS Foetal heart Sounds mcg Microgram
mg Milligram STD Sexually Transmitted Diseases
SCD Sickle cell disease TPHA Treponema Pallidum
Haemagglutination Assay
mi Millilitre TSH Thyroid Stimulating Hormone
mmHg Millimetres of Mercury TT Tetanus Toxoid
Mmol Millimoles UTI Urinary Tract Infection
NWCCP National Women & Child Care Plan VDRL Venereal Disease Research
Laboratory
OGTT Oral Glucose Tolerance Test VZIG Anti-Varicella Zoster Human
Immunoglobulin

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PGBS Post Glucose Blood Sugar VZV Varicella Zoster Virus

PHC Parent Health Centre WB Western Blot Test
PNC Postnatal Care SLE Systemic lupus erythematosus
PPH Postpartum Haemorrhage VTE Venous thromboembolism
PROM Premature rupture of Membranes LMWH low molecular weight heparin
RPR Rapid Plasma Reagin WHO World Health Organisation
RBS Random Blood Sugar GP General Practitioner
RPHL Regional Public Health Laboratory OHSS Ovarian hyperstimulation
syndrome
RT-PCR Real time polymerase chain reaction IBD inflammatory bowel disease
SCBU Special Care Baby Unit TFT Thyroid Function Test

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Definitions
Term Definition
Amniotic fluid the liquid that surrounds a growing foetus in the uterus
Amniotic sac the sac around the foetus inside the uterus
Antenatal a term that means ˜before birth’ (alternative terms are ˜prenatal’
and ˜antepartum’)
Antepartum haemorrhage bleeding from the vagina in pregnancy >24-week gestation
Apgar score a test given one minute after a baby is born, then again five
minutes later, that assesses a baby’s appearance (skin colour),
pulse, grimace (reflex), activity (muscle tone) and respiration. A
perfect Apgar score is 10; typical Apgar scores are seven, eight
or nine. A score lower than seven means that the baby might need
help in breathing
Assisted reproductive technology any procedure performed to help achieve a pregnancy like IVF
Artificial rupture of membranes when a healthcare practitioner bursts the sac holding the
amniotic fluid using an instrument with a pointy tip. Often used
to speed up a labour that has slowed
Baby blues mild depression that follows childbirth for the first 10 days;
usually the result of hormonal swings. Usually resolves
spontaneously
Braxton Hicks contractions a tightening of the uterus that may feel like a labour contraction.
Braxton Hicks contractions are not painful and do not get
stronger and closer together like true contractions (also called
˜false labour’)
Contraction the often strong and painful tightening of the uterus during
labour that causes the woman’s cervix to dilate and that helps
push the foetus through the birth canal
Crowning time during labour when the foetus’s head has reached the
external vaginal opening and can be seen from the outside
Dilation the opening of the cervix, measured as the diameter of the cervix
in centimetres

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Ectopic pregnancy when a fertilised egg implants and grows outside of the uterus,
usually in the fallopian tube. In most cases, an ectopic pregnancy
is not viable.
First-degree tear a tear involving only the perinatal skin that occurs at the time of
delivery that doesn’t always require stitches
First trimester the first 13 weeks of pregnancy
Full term when a pregnancy is a normal duration (≥ 37 weeks gestation)
Home birth labour and delivery that takes place at home, with or without the
supervision of a midwife
Low birth weight when a baby weighs less than 2,500 grams at birth
Multiple pregnancy when a woman is carrying more than one foetus
Neonatal period the time from a baby’s birth to four weeks of age
Perineum the area between the vagina and anus
Postnatal a term meaning ˜after birth’
Postnatal depression A depressive symptom that persists for more than 2 weeks after
birth
Primary postpartum haemorrhage Loss of > 500 ml of blood within 24th of delivery.
(PPH)
Premature labour when a baby is born before 37 weeks gestation
Second-degree tear a tear of the perineum involving both skin and muscles, but not
the anus. Second-degree tears often require stitches
Second-stage labour the time from the complete dilation of the cervix (10 cm) to the
birth
Secondary postpartum Excessive blood loss PV >24 hr after delivery. Peak incidence:
haemorrhage (PPH) 5-7 d after delivery
Second trimester the time from 14 week to the end of 26 week of pregnancy
Stillbirth the death of a baby after 20 weeks’ gestation but before birth
Stretch marks discoloured stripy patterns that can appear on the abdomen,
breasts, buttocks or legs during pregnancy because of skin
stretching. They usually fade slowly after delivery
Third- or fourth-degree tear a severe tear of the perineum involving the skin, muscles, and
anus. Stitches are used to repair these tears

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Third-stage labour the time from the birth of the baby to the birth of the placenta
Third trimester the time from 27week of pregnancy onwards
Vacuum cap or ventose a suction cap that is sometimes used during birth to help to pull
the baby out of the birth canal
VBAC (vaginal birth after when a woman has a vaginal birth after having had one or more
caesarean) previous caesarean sections

Definitions of different types of referrals: -

Routine appointment Appointment should be given within two weeks or as requested by the
referring doctor.
Urgent appointment Appointment should be given within 48 hours in consultation with the
concerned department.
Emergency referral Patients should be escorted immediately with I.V. line has been
inserted, via an ambulance and a medical attendance (nurse,
midwife or a doctor). The doctor on-call in the referring hospital
should be informed earlier by the phone

Definitions of pregnancy stages based on months and weeks:

Trimester Month Week

First Trimester 1 1–4

2 5–8
3 9 – 13
Second Trimester 4 14 -17
5 18- 21
6 22- 26
Third Trimester 7 27- 30
8 31- 35
9 36-40

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Chapter 1
1.1 Introduction
1.2 Purpose
1.3 Scope
1.4 Structure of the guidelines
1.5 What is new in this edition of the guidelines?

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1.1 Introduction

The Sultanate of Oman has accomplished great achievements within the health sector over a short
period of time. These achievements have been widely recognized and acclaimed by various
international organisations, including the World Health Organisation (WHO), The United Nations
Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA).
Oman has made significant achievements in reducing perinatal mortality from 15 per 1000 births
in 2007 to 14.1 per 1000 births in 2019. In addition, the infant mortality rate has dropped from 64
in 1980 to 7.6 per 1000 live births in the year 2020. The antenatal coverage and the percentage of
mothers delivered under the supervision of skilled personnel are maintained at 99% during the past
five years (MOH, 2020). Since the establishment of the National Maternal Deaths Surveillance
and Review system by the Ministry of Health (MOH) in 1991, each maternal death has been
reviewed to identify lessons to be learned to prevent similar deaths. Since then, the Maternal
mortality ratio (MMR), has also shown a slight decline from 27.37 in 1991 to 14.1 in 2019 per
100,000 live births. However, it increased during the COVID-19 pandemic to reach 29.4 per
100,000 in 2020.
Antenatal care (ANC) and Postnatal care (PNC) can be defined as the care provided by skilled
health care professionals to pregnant women in order to ensure the best health conditions for both
mother and baby during pregnancy and postnatal period. The components of ANC and PNC
include risk identification, prevention and management of pregnancy – related or concurrent
diseases, health education and health promotion.
Quality of maternal health care delivery is ensured by putting in place a standard client maternal
health record and a parent healthcare-facility-based antenatal register, both providing information
on the profile of each pregnant woman, risks factors, obstetrics and medical conditions, health care
needs, plans and management carried out during antenatal (ANC), prenatal (PN) & postnatal
(PNC) and their outcomes. Furthermore, health care provider's knowledge and skills are kept
updated by pre- and in-service training on assessed job needs.
Development and update of this operative guideline by the Ministry of Health Oman (MOH) aim
to provide a clear, evidence- based ANC practices that empowers health care providers knowledge
and keep them updated with the evidence-based practices. Thus, ensuring the best possible
standard of health care delivery, and through this effort, achieve a further reduction in maternal
mortality, stillbirth and neonatal mortality.

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The interventions described in this guideline are based on the latest available scientific evidence,
from the World Health Organisation (WHO) as well as from other well-known international
organizations such as Royal College of Obstetrics and Gynaecologists (RCOG), the National
Institute for Health and Care Excellence (NICE) GUIDELINES, the American College of
Obstetrics and Gynaecologists (ACOG), the American Academy of Family Physicians (AAFP),
(American Thyroid Association (ATA) etc.
This updated edition includes new evidence-base guidelines for management of medical problems
with pregnancy which include GDM, Hypertension, thyroid diseases, venous thromboembolism
(VTE), hyperemesis gravidarum, sickle cells disease, pregnancy induced cholestasis, varicella
infection and vaginal discharge.
This updated “Pregnancy & childbirth guidelines level 1” third edition is designed for the use of
doctors and nurses working at primary health care facilities (Health centres with or without
deliveries, polyclinics and small hospitals). However, it can be also used in higher healthcare
facilities when applicable in managing some obstetrics and medical conditions.

1.2 Purpose

These guidelines aim to provide guidance on routine antenatal care at primary health care level. It
addresses the detection of pregnancy- related complications and the prevention of concurrent
disease at routine ANC visits. It doesn’t address the subsequent treatment of such complications
or disease, where the consequence of detection is referral for additional management or specialist
care. Thus, management of the women of high-risk pregnancies is beyond the scope of this
guideline (Level 1). It will be further covered in Pregnancy & Childbirth Management Guidelines
(Level 2).

1.3 Scope

These guidelines cover all aspects of routine antenatal care, intrapartum and postnatal care
provided at primary health care level as well as management of obstetrics and medical
complications at primary healthcare level. However, it can be also used in higher healthcare
facilities when applicable in managing some obstetrics and medical conditions.

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1.4 Structure of the guidelines

Chapter 1: This chapter provides an introduction to the guideline, along with the purpose and
scope. It also provides the structural framework of the guideline that can help the reader access the
different parts of this document with ease.

Chapter 2: This chapter covers all aspects of antenatal care through the following sections:
2.1 Basic tasks of Antenatal care.
2.2 Management of common symptoms and medical problems such as nausea and vomiting,
anaemia, hypertension, diabetes, thyroid diseases, sickle cell disease, urinary tract infections,
vaginal discharge, HIV and chickenpox.
2.3 The common obstetric complications encountered during antenatal period such as bleeding,
abdominal pain, fever, loss or decreased foetal movements and premature rupture of membranes.
2.4 Normal labour and childbirth, including use of the partogram and active management of the
third stage of labour. This section aims to provide the healthcare worker with the information
needed to differentiate between the normal process and a complication.
2.5 The routine Postnatal Care (PNC) and complications. It describes and outlines post-natal
check-up for special conditions as well as a number of postnatal complications.
2.6 Clinical principles of managing complications and emergencies during pregnancy and
childbirth. It also contains general principles of care, including infection prevention, fluid
replacement and local anaesthesia.
2.7 Common procedures that may be necessary in some conditions. These procedures are not
intended to be detailed “how-to do” instructions but rather a summary of the main steps associated
with each procedure.

Chapter 3: This chapter outlines what is required for the implementation of the guidelines,
including human resources, and roles and responsibilities of different stakeholders.

Chapter 4: This chapter provides the annexures and links to references that were used in the
developing of these guidelines.

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1.5 What is new in this updated edition of the guidelines?

The following is a list of topics that were newly addressed in this updated edition of the guidelines: -
● Instructions about use of ultrasound in basic ANC care
● Nutritional assessment during pregnancy
● Management of common symptoms and medical complications during pregnancy:
o Common symptoms during pregnancy
o Nausea and vomiting
o Thromboembolic disease
o Sickle cell disease
o Intrahepatic cholestasis of pregnancy
o Thrombocytopenia in pregnancy
● Updates on management of thyroid disease in pregnancy
● Common counselling on lifestyles during pregnancy (travel, exercise, intercourse,
smoking, breast feeding, and traditional medicines)
● Perinatal depression
● Obstetric warning alarm system in the emergency section

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Chapter 2
2.2 Standards of care
2.2 Basic Antenatal care
2.3 Common symptoms and medical conditions during pregnancy
2.3.1 Common symptoms in pregnancy
2.3.2 Management of Nausea and Vomiting in Pregnancy, and Hyperemesis Gravidarum
2.3.3 Anaemia in Pregnancy
2.3.4 Venous thromboembolism (VTE)
2.3.5 Diabetes in Pregnancy
2.3.6 Hypertension in Pregnancy
2.3.7 Thyroid diseases in pregnancy
2.3.8 Sickle Cell Disease (SCD) in pregnancy
2.3.9 Intrahepatic Cholestasis of Pregnancy
2.3.10 Thrombocytopenia in pregnancy
2.3.11 Pregnancy with RH negative blood group
2.3.12 ABO Incompatibility
2.3.13 Urinary tract infections (UTI)
2.3.14 Vaginal discharge during pregnancy
2.3.15 HIV in pregnancy
2.3.16 Syphilis in pregnancy
2.3.17 Chicken pox (varicella) in pregnancy
2.3.18 Common counselling on lifestyles in Pregnancy
2.4 Obstetric complications
2.5 Normal labour
2.6 Routine Postnatal care and complications
2.7 Emergency
2.8 Common procedures

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2.1 Standards of care

a) Pregnancy and childbirth management is an integral part of the Woman and Child Health
(WCH) services and are provided in all governorates of the Sultanate of Oman. Standardised
antenatal care (ANC), intrapartum care and postnatal care (PNC) services with health education
should be provided by trained health care personnel.
b) Total of eight ANC and two PNC visits should be achieved by the end of a normal pregnancy
and childbirth. ANC and PNC should be provided to all women and should be tailored to the
needs of individual woman and the local community.
c) Registration of the woman (antenatal booking) should be carried out in the parent health
institution as soon as a pregnancy is confirmed, preferably less than 13 weeks of gestation. A
comprehensive physical examination (including cardiovascular, respiratory, abdominal systems
examinations, breast and thyroid examinations. etc.) should be carefully performed for all
pregnant women during the first ANC visit for booking by a trained doctor.
d) All pregnant women should be allowed to carry their own Maternal Health Record (Green card)
issued to them at the time of first booking.
e) All pregnant women should receive appropriate information about the number and timing of
antenatal visits and to be given an opportunity to discuss the schedule and the type of care with
their health providers
f) All pregnant women should be referred at 22-24 weeks to the obstetrician for routine assessment
and anomaly scan. Obstetricians should document in the recommendation section in the
Maternal Health Record if any specific future plans for the women during ANC labour or PNC
period as indicated.
g) Referral should be made to the obstetrician for high-risk cases as outlined in these guidelines.
Clear management instructions should be provided by the obstetricians if a high-risk patient is
referred back to the primary health care for routine ANC care.
h) Delivery should only be conducted by a trained health personal. All trained members of the
WCH/EPI outreach teams should provide information and health education to the community.
i) Maternal Health Record (HP-194)- Green Card and ANC Register should be used for ANC and
PNC documentation.
j) New-born baby Child Health Record (HP-140) and EPI Register should be used for health
status, immunization & follow up documentation.

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2.2 Basic Ante-Natal Care

Routine Ante-Natal Care (ANC) of 8 antenatal visits is considered to be adequate for

uncomplicated pregnancy. Refer to (table 7) for the schedule of standardised ANC visits including
the tasks that to be performed at each visit. Each antenatal visit has a focused content. Longer time
slots should be allocated to allow comprehensive assessment and discussion.

At the time of booking (First Antenatal care visit), all women should receive appropriate
information about the number and timing of antenatal visits and to be given an opportunity to
discuss the schedule and the type of care with their healthcare providers.

The following should be done at the ANC clinic:

a) Record of Personal Information:
At the first visit all the personal information should be documented as per the “Maternal Health
Record” (Green Card) and Al Shifa system.

FIGURE 1: GREEN CARD

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b) History Taking:
At the first visit ANC the history as per the Maternal Health Record parameters which includes
preconception care, current and previous obstetrical & gynaecological risks, medical history,
current danger signs & symptoms, birth spacing history and family medical history should be
documented (See Maternal Health Record for details).
With regard to their current pregnancy, women should also be asked about the following:
● Exposure to radiation
● Drugs taken during 1st trimester
● Fever, rash in 1st trimester
● Current medication and Allergy

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Clinical Examination of Pregnant Women:

● Measurement of weight and body mass index (BMI): Maternal weight and height should
be measured at the first ANC visit. The woman’s Body Mass Index (BMI) should
be calculated (weight [kg]/height [m] ². If abnormal BMI (< 18 or > 25) the nutritional
status should be assessed.
● Measurement of blood pressure: The blood pressure (BP) measurement should be
recorded carefully at booking and during each ANC visit. Measure blood pressure in sitting
position, if diastolic blood pressure is above 90 mmHg, (repeat after 1 hour rest), if diastolic
blood pressure is still ≥90 mmHg, ask the woman if she has; severe headache, blurred
vision, shortness of breath, epigastric pain and check protein in urine. The case should be
graded as high risk and to be followed more closely.
● Systemic Examination: This includes examination for pallor, jaundice, lymph nodes,
thyroid, cardiovascular system, chest, abdomen, oedema, skeletal system and dental
problems.
● Breast Examination: Breast should be examined at booking, then as indicated for any skin,
nipple changes or lumps.
● Obstetric Examination:
The specific Obstetric examinations recommended at each visit include:
- Estimation of foetal size at each antenatal appointment to detect small - or large for
gestational age foetus. Symphysis-fundal height should be measured at each antenatal
appointment from 24 weeks of gestation. A discrepancy ≤ 4 cm between the fundal
height and the gestational age is acceptable. Patients should be referred for growth scan
and an obstetric opinion, by an urgent appointment if discrepancy of > 4 cm was noted.
- Foetal heart sounds to be checked by Doppler foetal heart recorder in every ANC visit
and feeling of foetal movements to be checked with mother in every ANC visits
- Foetal presentation should be assessed by abdominal palpation from 32-34 weeks
onward, when presentation is likely to influence the plan of delivery.

Suspected foetal malpresentation should be confirmed by an ultrasound

assessment.

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Risk grading (every visit)

Risk grading should be done at booking and at every visit and to be updated in both the Maternal
Health Record. If any of the listed conditions is present, consider the pregnancy as high risk.
1. Current Obstetrics and Gynaecology risks
● Age < 15 or ˃ 40 years
● BMI ≥ 30
● Gestational diabetes Mellitus
● Pregnancy induced hypertension (PIH)
● Diastolic BP ≥ 90mmHg at first trimester
● Antepartum haemorrhage
● Thrombocytopenia
● Pelvic tumour
● Current multiple pregnancy
● Intrauterine growth restriction
● Surgery on reproductive tract (myomectomy, removal of septum, cone biopsy, cervical cerclage)
● Assisted reproductive e.g., IVF
● RH antibodies isoimmunisation
2. Previous Obstetrics and Gynaecology risks
● Preeclampsia/eclampsia
● Caesarean Section
● Preterm labour
● Premature Rupture of Membranes
● Three or more consecutive miscarriages during 1st trimester
● Second Trimester miscarriage
● Postpartum haemorrhage
● Deep Venous Thrombosis (DVT), Pulmonary Embolism (PE)
● Infertility (primary/secondary)
● Surgery on reproductive tract (myomectomy, removal of septum, cone biopsy, cervical cerclage)
● Low birth weight ˂ 2500 gm
● Macrosomia ≥ 4000 gm
● Foetal or neonatal death
● Rh antibodies Isoimmunisation
● Malformation or chromosomally abnormal child

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3. Medical risks
● Hypertension
● Diabetes mellitus
● Anaemia ≤7 g/dl
● Renal diseases
● Cardiac diseases
● Sickle Cell disease
● Thalassemia Major
● Chronic Hepatitis
● HIV / Syphilis
● Psychiatric Disorder
● Epilepsy
● Genetic Disorders
● Thyroid Disorders
● Airways conditions
● Previous anaesthesia complications
4. Current medical signs
● Severe Pallor
● Persistent headache
● Blurring of vision
● Generalized oedema
● convulsion
● Unilateral leg oedema
● Calf tenderness
● Difficult breathing
● Vaginal bleeding or leaking
● Persistent or severe
● abdominal pain
● Unexplained persistent fever
Every effort should be done to trace ANC defaulters including home visits as per the need
and feasibility.

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Laboratory Tests
There are certain tests to be conducted during each ANC visit as shown in the table below (1)
marks the test to be done.

TABLE 1: LABORATORY TESTS TO BE PERFORMED DURING ANC AND PNC VISITS

Laboratory test At booking 12-14 22-24 28-30 32-34 36 38 40 6 weeks
Weeks Weeks Weeks Weeks Weeks Weeks Weeks PNC

Blood group & rh

✔
factor
Antibody screening
✔* ✔*
(ABS)*
Sickling (if not known)
✔
Haemoglobin (gm/dl)
✔ ✔ ✔ ✔
Platelet’s count
✔ ✔
RPR (rapid plasma
✔
regain) for syphilis★★
TPHA (if RPR + ve)

HIV antibody test★★ ✔

Urinalysis

Urine microscopy
✔ ✔
(screening for
asymptomatic
bacteriuria)
Glucose
✔
Ketones
✔
Urine for albumin ✔ ✔ ✔ ✔ ✔ ✔ ✔
Urine culture & ✔
sensitivity if indicated
Blood sugar test
(Venous sample)
RBS /FBS
✔
OGTT ✔*** ✔ ✔***
*
Antibody screening test to be done for pregnant women at booking and 28 weeks, if her Rh factor is negative& husband Rh factor
is positive.
**HIV antibody test & RPR test if not done at booking.
***OGTT to be done when indicated (refer to algorithm).

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Screening investigations (must be done at booking visit, if missed need to be done in the next visits):

● All pregnant women should be offered screening for HIV infection

Counselling (pre-testing information) to the woman will be given before collecting the blood
sample. HIV result test should be documented in the green card as reactive /non-reactive

● All pregnant women should be screened for syphilis infection

Screening for Syphilis should be offered because treatment of syphilis is beneficial to
the mother and foetus
If a pregnant woman is found to have a positive RPR Confirm the diagnosis by
performing TPHA and sexual partner should be screened for syphilis

● All pregnant women must perform RBS or FBS for screening of diabetes and then
follow-up according to guideline see page .
OGTT (oral glucose tolerance test): by using 75 g of anhydrous glucose or 82.5 g of
glucose monohydrate should be done as the guideline.

● All pregnant women should be tested for blood group and Rh factor status. Antibody
screening test to be done for Rh negative pregnant women at booking and repeated 28
weeks, if husband is Rh positive.

● All pregnant women should be tested for Sickle Cell Anaemia

If the pregnant woman found to be positive, electrophoresis test should be done to know the
status whether sickle cell trait or disease and documented in the green card.

● All pregnant women must be offered urine test for microscopy, glucose, ketones and
albumin (Urine GKP)
Urine albumin should be done at every ANC visit.
Asymptomatic bacteriuria is common in pregnant women and there is evidence that treatment of
such cases reduces the risk of pyelonephritis and leads to better outcomes of pregnancy
Women should be offered routine screening for asymptomatic bacteriuria by midstream urine
culture early in pregnancy
If urine microscope showed more than 20 WBCs per high power field, urine for culture

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sensitivity is to be done
Mid-stream specimen of the urine should be sent for culture in cases of symptoms of
urinary tract infection
Urine examination requires a clean–catch mid-stream specimen to minimize the possibility of
contamination. Patients should be educated on how to collect the specimen

Note: Urine for protein should be done whenever high blood pressure is detected (diastolic
blood pressure ≥ 90 mmHg).

c) Ultrasonography in Antenatal Care:

● Ultrasound assessment is an essential component in antenatal care. It monitors foetal
parameters and pregnancy progress. It should be done for all pregnant women.
● The timing and frequency depend on the indications for the examination which vary for each
trimester.
● Unnecessary routine use of ultrasound should be avoided in an uncomplicated pregnancy.

The most common obstetric indications for ultrasound examination by trimester are listed in
the table

TABLE 2: MOST COMMON OBSTETRIC INDICATIONS FOR ULTRASOUND EXAMINATION BY TRIMESTER

Booking Ultrasound at First trimester Second and Third Trimester ultrasound
(In secondary care setting)

Confirmation of the presence of an Anomaly scan at 22 -24 weeks for all pregnant
intrauterine gestational sac (IUGS) women.
Confirmation of Foetal cardiac activity Growth scan at 32-34 weeks, if indicated (e.g.,
(viability) GDM, hypertensive disorders, thyroid, SCD,
CKD, Infections, etc)
Dating of pregnancy (gestation age) and Evaluation and follow up for any obstetric
estimation of Expected Date of Delivery problems seen; (e.g. IUGR, amniotic fluids
(EDD) problems, placental abnormalities , foetal
presentation abnormalities)
Diagnosis of multiple gestations

Estimation of Gestational Age and Expected Date of Delivery (EDD):

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● An accurately assigned EDD early in prenatal care is vital for timing of appropriate obstetric
care; scheduling ANC visits, evaluation of foetal growth; and designing interventions to
prevent preterm births, post term births, and related morbidities.
● Crown – rump length (CRL) is the most precise parameter used for ultrasound dating in first
trimester (up to 13+6 weeks). Beyond 13+6 weeks, Bi parietal Diameter (BPD) & Head
Circumference (HC) are the preferable measurement. It is considered accurate to within five
to seven days in the first trimester, 10 to 14 days in the second trimester & third trimester.
● As soon as data from the last menstrual period (LMP), the first accurate ultrasound
examination, or both are obtained, the gestational age and the EDD should be determined,
discussed with the patient, and documented clearly in the green card.
● EDD for a pregnancy that resulted from In- Vitro Fertilization (IVF) should be assigned using
the age of the embryo and the date of transfer.

Crown–rump length measurement is used to determine gestational age up to 13+6 weeks.

Beyond 14 weeks, head circumference (HC), biparietal diameters (BPD) or femoral length
(FL) are the preferable measurement.

The most common foetal biometric measurements used in antenatal ultrasound are:
● Bi-Parietal Diameter (BPD)
● Head Circumference (HC)
● Femoral Length (FL)
● Abdominal Circumference (AC)
● Amniotic Fluid Index (AFI)
● Estimated Foetal Weight (eFW)

Ultrasound examinations that should be done and documented clearly in green card and Al
Shifa system include:
1. Confirmation of intrauterine gestational sac (IUGS).
2. Number of foetuses – Single, Multiple
3. Foetal Cardiac activity – Present or Absent
4. Foetal biometric measurements - CRL , BPD, HC, FL, AC, (if trained doctor/radiographer)

Common abnormal Ultrasound Findings that need to be referred to obstetrician and

gynaecology for further evaluation:
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1. Absence of intrauterine gestation sac (IUGS), to rule out ectopic pregnancy

2. Absent foetal cardiac activity – missed abortion / miscarriage.
3. Abnormal amniotic fluid measurements

d) Nutrition care for Pregnancy

Counselling on lifestyle interventions, such as written and verbal instructions about nutrition by a dietitian
and exercise, throughout pregnancy is effective in preventing excess gestational weight gain and related
complications.
Main Recommendations
 A healthy diet contains adequate energy, protein, vitamins and minerals, obtained through the
consumption of a variety of foods, including green and orange vegetables, meat, fish, beans, nuts,
whole grains and fruit.
 Include additional food in 2nd and 3rd trimester in amount appropriate to meet healthy pregnancy
weight gain.

 Pregnant women need a balanced eating plan including:

 Grains: Include breads, cereals, and pastas made with whole grain flours, as well as brown rice,
whole grain corn.
 Fruits: All types of fruits, including fresh, frozen, dried or canned without added sugars.
 Vegetables: A variety of colourful vegetables, fresh, frozen or canned with no added salt should
be included. Raw sprouts should be avoided.
 Protein foods: Choose lean protein from meat, poultry, fish, eggs, beans and peas, peanut butter,
soy products and nuts. Pregnant women should avoid eating tilefish, shark, swordfish, marlin,
orange roughy and king mackerel, and limit white (albacore) tuna to four ounces per week. Deli,
luncheon meats and hot dogs should be reheated to 165°F, if consumed.
 Dairy: This includes low-fat or fat-free milk, cheese, yogurt and fortified soymilk. Unpasteurized
milk and some soft cheeses that are made from unpasteurized milk also should be avoided.
 Avoid extra calories from added sugars and solid fats, which can lead to unhealthy weight gain.
Advise healthful fats from foods such as avocados, nuts and seeds as well as vegetable oils
including canola and olive oil. Limit items like soft drinks, sweets and fried foods.

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 Key Nutrients for Healthy Pregnancy:

 Folic acid (folate): risk of neural tube defects. Take folic acid supplements (400 micrograms) every
day from stopping contraception until 13wk pregnant. Eat foods containing folate, eg. green
vegetables, brown rice, fortified bread, and cereals.
 Iron: Eat iron-rich foods, e.g., red meat, beans, lentils, green vegetables, and fortified cereals. Fruit,
fruit juice, and vegetables help with iron absorption

Foods to avoid
Raw/undercooked meat, eggs, and ready meals Risk of food posing:
 Only eat well-cooked meat- hot right through, with no pink bits left
 Only eat eggs cooked until white and yolk are solid. Shop mayonnaise and mousses are safe but
avoid home-made dishes containing raw egg
 Ensure ready meals are piping hot all the way through

Liver products and vitamin A supplements Too much vitamin A can harm a baby’s development.
Avoid eating liver and supplements containing vitamin A or fish liver oils.

Some types of fish Eat ≥ 2 portions of fish per week (including 1 of oily fish-mackerel, sardines,
fresh – not canned – tuna, or trout) but:
 Avoid shark, swordfish, or marlin, and limit tuna to 2 steaks or 4 cans weekly. Mercury in these
fish can harm a baby’s nervous system
 Only eat 1-2 portions of oily fish per week
 Avoid raw shellfish, as they can cause food poisoning.
Other Recommendations:
 Follow safe food handling practices
 Wash hands after handling raw meat
 Keep raw meat separate from foods ready to eat
 Limit caffeine intake (coffee & tea) to 300 mg per day. Advice <4 cups of coffee as high level can
cause miscarriage or low birth weight
 Recommend adequate intake of fluids – 2.5 litres/day.

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TABLE 3: GUIDELINES OF WEIGHT GAIN IN PREGNANCY

Guidelines of Weight Gain in Pregnancy
BMI (Pre – pregnancy) Recommended Weight Gain (during pregnancy)
<18.5 13-18 kg
18.5 - 24.9 11- 16 kg
25.0 – 29.9 7– 11 kg
≥ 30 5 - 9 kg
* American Academy of Family Physicians

All pregnant women should receive counselling on nutrition by dietitian at least twice in
pregnancy (at booking, and 32 weeks)

The most important conditions that pregnant women must have dietary counselling to
improve the outcomes
1. Constipation:
Advise pregnant women to:
 Enjoy a wide variety of foods that are high in fibre, such as vegetables, legumes, fruit and
wholegrains and drink plenty of water.
 Being physically active can also help with reducing constipation.
 Wheat bran or other fibre supplements can be used to relieve constipation in pregnancy if the
condition fails to respond to dietary modification, based on a woman’s preferences and
available options.

2. Nausea and vomiting:

Some suggestions that may help include:
 Eat some dry bread, biscuits or cereal before getting up in the morning. Get up slowly, avoiding
sudden movements.
 Drink liquids between, rather than with, meals to avoid bloating, as this can trigger vomiting.
 Avoid large meals and greasy, highly spiced foods.
 Suck on something sour like a lemon.
 Relax, rest and get into the fresh air as much as possible. Keep rooms well ventilated and odour
free.
 Try food and drinks containing ginger, such as ginger tea, as these sometimes relieve nausea
 Ginger, chamomile, vitamin B6 are recommended for the relief of nausea in early pregnancy,
based on a woman’s preferences and available options
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3. GDM:
 Medical nutrition therapy (MNT) is essential for the management of GDM that assist in
achieving and maintaining glycemia and reducing the risk of adverse maternal and neonatal
outcomes. Pregnant women should provide adequate amounts of macronutrients to support
pregnancy, based on nutrition assessment. Thus, a referral to a dietitian/ nutritionist is crucial.
 Aiming for consistent carbohydrate intake at meals and snacks to help optimize glycaemic
control
 For women with pre-existing diabetes, individualizing timing, and spacing of meals and snacks
based on the stage of pregnancy, lifestyle preference, medications and treatment goals
 Encouraging women with GDM to eat 3 meals with 2 or more snacks per day
 Choosing high fibre, low glycaemic index carbohydrate foods
 Maintaining healthy weight
 Include fresh wholesome foods – whole fruits instead of fruit juices, whole grains/ multigrain
flours instead of refined flours
 Include adequate intake of fluids – 2.5 litres/day
 Eat less junk food, bakery products, fried foods, salted foods
 Minimize sugars and artificial sweeteners
 Avoid alcohol and tobacco in all forms
 Avoid saccharin and cyclamate.

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e) Immunization
Women should be fully immunized before they get pregnant in order to protect the infant against
many diseases. The most common vaccines advised in pregnancy:
1. Tetanus, diphtheria, and pertussis (Tdap) vaccine should be given during each
pregnancy irrespective of the woman’s history of receiving Tdap. To maximize maternal
antibody response and passive antibody transfer to the infant, optimal timing for Tdap
administration is between 27 and 36 weeks of gestation, although it may be given at any time
during pregnancy.
2. Annual influenza vaccine (inactivated) is recommended during any trimester for all women
who are or will be pregnant during influenza season. For travellers, vaccination is
recommended ≥2 weeks before departure if vaccine is available.
3. Certain vaccines, including meningococcal and hepatitis A and B vaccines that are considered
safe during pregnancy, may be indicated based on risk.
4. Rabies postexposure prophylaxis with rabies immune globulin and vaccine should be
administered after any moderate- or high-risk exposure to rabies
 Most live-virus vaccines, including measles-mumps-rubella vaccine, varicella vaccine, and live
attenuated influenza vaccine, are contraindicated during pregnancy
 Check women’s status of Rubella immunization, if not immunized or if immunization status is
not known, immunize the woman after delivery and give advice not to conceive for the next 3
months to prevent congenital Rubella syndrome
 Postexposure prophylaxis of a nonimmune pregnant woman exposed to measles or varicella
may be provided by administering immune globulin (IG) within 6 days for measles or
varicella-zoster IG within 10 days for varicella.

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TABLE 4: VACCINATION IN PREGNANCY

Vaccine Before During After Type of
pregnancy pregnancy pregnancy vaccine
Seasonal Yes Yes Yes Inactivated
Influenza
T dap Yes Yes, vaccinate Yes, Toxoid /
if indicated during each immediately inactivated
pregnancy ideally postpartum, if
between 27-36 not received
weeks of gestation previously
Hepatitis B Yes Yes, if indicated Yes, if Inactivated
if indicated indicated
Hepatitis A Yes, if Yes, if indicated Yes, if Inactivated
indicated indicated

Meningococcal If indicated If indicated If indicated Inactivated

-polysaccharide
- conjugate
Varicella Yes, if No Yes, if Live attenuated
indicated, indicated, give
avoid immediately
conception postpartum if
for 3 moths susceptible to
Varicella.
MMR Yes, if No Yes, if Live attenuated
indicated, indicated, give
avoid immediately
conception postpartum if
for 3 susceptible to
months Rubella

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f) Health Education
Pregnant women should be offered proper information and support to enable them to make
informed decisions regarding their care during pregnancy. Women’s choices should be recognized
as an integral part in the decision-making process. They must be offered opportunities to attend
antenatal educational sessions and be given written information about antenatal care.
At the first contact, pregnant women should be offered information about: the pregnancy-care
services and options available, lifestyle considerations, including dietary information. Health
education leaflets should be offered as they are designed to provide information on many aspects
related to pregnancy in all 3 trimesters. Booklet No.1 should be given at booking, No.2 at 13-15
weeks visit and No.3 at 28 weeks visit. Now all are available for all women with QR code over
the green card.

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Drug Prescription
● All drugs should be avoided or prescribed cautiously for clear and specific indications and
the lowest effective therapeutic dose should be used.
● Folate supplementation: decrease the risk of neural tube defects (open spina bifida,
anencephaly, encephalocele) by 72%. Pregnant women should be advised to take folic acid
of 400 microgram daily from when pregnancy is being planned until 13 weeks of gestation.
● Pregnant woman ≥ 12 weeks gestation (Hb ≥ 11gm/dL) should be given a standard dose
of ferrous sulphate, and folic acid daily.
● Pregnant woman less than 12-week gestation diagnosed with mild to moderate iron
deficiency anaemia (Hb ≤ 11gm/dL) should be offered ferrous sulphate, and folic acid
daily.
● All women should be informed at the booking appointment about the importance for their
own and their baby’s health of maintaining adequate vitamin D stores during pregnancy
and while breastfeeding.
● Pregnant women should be informed that vitamin A supplementation (intake greater than
700 micrograms) might be teratogenic and therefore it should be avoided.
● Aspirin 75 mg -150 mg is recommended for the prevention of preeclampsia in women at
high risk of developing the condition
● The following table illustrates some drugs with their possible effect on the foetus:

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TABLE 5: DRUGS CONTRAINDICATED IN PREGNANCY

Drug Harmful effects /Remarks

Warfarin Punctate chondrodysplasia Avoid, especially in first trimester.
Do not stop Warfarin dose in a pregnant woman with valvular cardiac
disease, discuss with cardiologist/ senior obstetrician.

Heparin Overdoses may cause foetal haemorrhage.

Prolonged dosage of unfractionated heparin causes maternal
osteoporosis.
Maternal benefit may outweigh risks.
Antiepileptic drugs IUGR, Mild microcephaly, Cleft palate Maternal benefit may outweigh
risk.
Don’t stop, discuss with neurologist.
Amino- glycosides Ototoxic, especially for foetus
Tetracycline Deposited in teeth and bone
Chloramphenicol In late pregnancy, may cause “Gray Baby” syndrome
Prostaglandin Avoid e.g., NSAID
Synthetase
inhibitors
Synthetic oestrogen to be avoided unless indicated
and progestogen
Glucocorticoids Cleft-lip/palate. If maternal use is essential, try to reduce the dose

g) Plan of Delivery
The assessment for delivery should take place at every antenatal visit. The decision depends on
the present and the past medical and obstetrical history.
The following tables illustrate the criteria for planning on the place of delivery:

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TABLE 6: CRITERIA FOR THE DELIVERY IN PRIMARY CARE INSTITUTION

(ONLY WHERE DELIVERY SERVICES ARE AVAILABLE)
Parity 1-7
Normal Weight (40- 80 Kg) and height (≥ 152 cm)
Fundal height measurements correspond to gestational age
No significant medical diseases
No major pregnancy complications (present or past)
No previous still birth or neonatal death
No previous low birth weight baby (<2500 g)
No previous high birth weight (≥ 4000 g)
Adequate haemoglobin level (≥ 11g/dl)

TABLE 7: CRITERIA FOR THE DELIVERY IN SECONDARY CARE

Age < 15 years or > 40 years

Parity ≥ 8

Primigravida

Height less than 152 cm

Body weight <40 kg OR BMI > 30

Previous pregnancy problems

Previous still birth or neonatal death

Previous difficult delivery or prolonged labour (including 3rd stage complication)

Previous low birth weight baby (< 2500 g)

Previous high birth weight baby (≥ 4000 g)

History of infertility (primary or secondary) for ≥ 3 years

Previous surgery on reproductive tract (myomectomy, removal of septum, cone

biopsy, caesarean section, cervical cerclage)

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Current Medical History

Diabetes mellitus (uncomplicated)

Essential hypertension★

Renal diseases with or without Hypertension

Sexually transmitted diseases

Haemoglobinopathies (sickle cell disease, Thalassemia Major) ★

Other significant medical diseases

Current Obstetrical History

Antepartum haemorrhage

Pre-eclampsia

Polyhydramnios

IUGR (moderate)

Premature labour or rupture of membranes (34-37) weeks

Multiple pregnancy

Malpresentation

Cervical incompetence

Premature rupture of the membranes (28-33) weeks

Preterm labour (before 34 weeks)

Oligohydramnios

Anaemia (Hb < 11 gm/dL)

Post maturity (≥ 42 weeks)

★
Some cases might need to deliver in the tertiary care; cases should be evaluated according to the
severity of the condition.

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TABLE 8: CRITERIA FOR THE DELIVERY IN TERTIARY CARE

Current medical History
Diabetes mellitus with severe complications
Heart disease (unless mild and well tolerated)
Renal disease with Hypertension, impaired renal function, or renal transplant
Positive cases of HIV and active Hepatitis B
Current Obstetrical History
Rhesus antibodies / atypical antibodies.
IUGR (severe)

Place of delivery of a foetus with abnormality (compatible with life) depends on the
type of the abnormality. The delivery should be conducted in a place where SCBU
facilities are available, and the decision should be shared between the obstetrician and the
paediatrician.

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TABLE 9: TASKS OF ANC VISITS

When Tasks (Always begin with Rapid Assessment and Management)

• History taking including: Ask the woman about her present pregnancy
status, preconception history, medical & obstetrical history, history of
previous pregnancies, and check her for general danger signs
• Profiling
• Explain to the mother all the services available will be provided during
antenatal visits
• Clinical examinations; breast, systemic, weight, height, BMI, BP and fundal
height
First Visit
• Laboratory tests: Urine tests (for albumin, ketones, glucose, microscopy),
at Booking
Hb, Blood group & Rh factor, ABS, RBS, OGTT (if indicated), VDRL, HIV,
(preferably
sickling test & urine culture if indicated
before 12
• Ultrasound for dating (if available), best to be done from 8-12 weeks
weeks)
• Risk grading
• Supplementation of folic acid (5mg)
• Supplementation of Aspirin (if indicated)
• Counsel on: Danger signs, exposure to X-Rays & teratogenic substance,
clinic attendance, nutritional advice, information on pregnancy signs and
symptoms
• Refer to dietician for diet counselling
• Discuss the mode of delivery
• Clinical examinations: BP, systemic examination, fundal height &foetal
heart sounds
• Laboratory tests: no routine laboratory tests at this visit, unless not done at
booking or missed labs.
Second
• Ultrasound for dating (only if not done before)
Visit
• Risk grading
(13-15
• Supplementation of folic acid & iron
weeks)
• Supplementation of Aspirin (if indicated)
• Counsel on: Danger signs, diet, and supplementation
• Refer to obstetrician for anomaly scan at 22-24
• Discuss the mode of delivery

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When Tasks (Always begin with Rapid Assessment and Management)

Clinical examinations: BP, systemic examination, fundal height, foetal heart
sounds & ask about foetal movement
Refer to obstetrician for anomaly scan (if not referred earlier) to be done at
Third Visit this visit
(22-24 Laboratory tests: OGTT, urine albumin and CBC (if indicated)
weeks Risk grading
Obstetrician Supplementation of folic acid and iron
visit) Supplementation of Aspirin (if indicated)
Counsel on: Danger signs, diet, exercise, compliance of iron and management
of common symptoms
• Discuss the mode of delivery
Clinical examinations: BP, systemic examination, fundal height, foetal heart
sounds and ask about foetal movement
Laboratory tests: Hb, urine albumin, ABS test (if indicated), give anti-D if Rh-
Fourth
negative) IU 1500- 1250)
Visit
Risk grading
(28-30
Supplementation of folic acid & iron
weeks)
Supplementation of Aspirin (if indicated)
Counsel on: Danger signs, preparation for lactation, foetal movement
Discuss the mode of delivery
Clinical examinations: BP, systemic examination, fundal height, foetal heart
sounds, ask about foetal movement
Laboratory tests: no routine laboratory tests at this visit apart from urine
albumin,
Fifth Visit
Pelvic grip
(32-34
Risk grading
weeks)
Supplementation of folic acid & iron
Refer to dietician for diet counselling and breastfeeding
Counsel on: Danger signs, Preparing for delivery including the mode and place
for delivery, signs of onset of labour

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When Tasks (Always begin with Rapid Assessment and Management)

Clinical examinations: BP, systemic examination, fundal height, foetal heart

sounds, ask about foetal movement and presentation, foetal lie, and engagement
Laboratory tests: Hb
Sixth Visit Risk grading
(36-weeks) Supplementation of folic acid and iron
Counsel on signs of onset of labour, danger signs, foetal movements, the need to
review by the obstetrician (if not delivered on the expected date), postnatal visit,
caring of new-born baby breast feeding and birth spacing methods

Clinical examinations: BP, systemic examination, fundal height, foetal heart

sounds, ask about foetal movement and presentation, foetal lie, and engagement
Laboratory tests: no investigations needed in this visit, Hb (if not done at 36
weeks)
Seventh Risk grading
Visit Supplementation of folic acid and iron
(38 weeks) Counsel on signs of onset of labour, danger signs, foetal movements, the need to
review by the obstetrician (if not delivered on the expected date), postnatal visit,
caring of new-born baby breast feeding and birth spacing methods
Make sure to give the woman appointment at 40 weeks at secondary care (if
not delivered by then) to plan for delivery
Clinical examinations: BP, systemic examination, fundal height, foetal heart
Eighth
sounds, ask about foetal movement and presentation, foetal lie, and engagement
Visit
Risk grading
(40 weeks)
Refer to secondary care (if not delivered) to plan for delivery

Note: Follow-up after a missed appointment (defaulters) to be undertaken by the maternity service.
Follow-up should be via a method of contact that is appropriate to the woman, may include: text
message or telephone call.

Every effort should be done to trace ANC defaulters

including home visits as per the need and feasibility.

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h) Referral to Secondary / Tertiary Care Level

The routine ANC care is to be at the parent institution. All cases should be referred once to the secondary
care at 22-24 weeks for assessment. In addition, any woman with any conditions in Table 7 should be
referred to secondary care. The table shows the time at which to refer the case.

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TABLE 10: INDICATIONS FOR REFERRAL TO SECONDARY CARE DUE TO RISK FACTORS

Risk factors for referral at booking

Medical history Obstetric / Gynaecological history
Hypertension Pre-eclampsia/ eclampsia

Diabetes Mellitus 3 or more consecutive 1st trimester miscarriage

Renal Disease Thrombosis/ Embolus

Cardiac disease RH isoimmunisation

Sickle Cell Disease Malformation/ chromosomally abnormal child

Thalassemia Major Previous foetal and neonatal death

Chronic Hepatitis Surgery on reproductive tract
HIV Pelvic tumour
Psychiatric Disorders Previous preterm, low birth weight or macrosomia
Epilepsy Previous second trimester miscarriage / cervical
incompetence
Genetic Disorders Previous PROM

Connective tissue disorder VTE Score ≥ 4

Risk factors for later referral Time of referral

Previous APH/PPH At 24 weeks

Previous caesarean section At 32 weeks

Intrauterine growth restriction Whenever suspected/detected

Multiple pregnancy Whenever suspected/ detected

Polyhydramnios/Oligohydramnios Whenever suspected/ detected

VTE score ≥3 At 28 weeks

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TABLE 11: INDICATIONS FOR REFERRAL TO SECONDARY CARE DUE TO OTHER CONDITIONS

Other conditions needing referral (not classified as risk Time of referral

factors)
History of Thyroid disorders At booking
History of previous Hydatidiform Mole At booking
Conception following Clomid (after 2 years of infertility) or At booking
IUI or IVF
Pregnancy following prolonged infertility (more than 3 At booking
years) with spontaneous conception
Previous obstructed labour At 32 weeks
Placenta praevia At 32 weeks
Foetal Malpresentation, unstable lie At 36 weeks by urgent
appointment

If any significant medical or obstetric problems are detected (other than those
mentioned) the doctors should use their clinical judgment for referral to secondary care
level.

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2.3 Common symptoms and medical conditions in pregnancy

2.3.1 Common symptoms in pregnancy

Acute abdominal pain (page 161)

Back pain Affects 50% of pregnant women, usually from the second trimester onwards and worse
in the evenings, it may interfere with sleep and activities
Management: Encourage light exercises (unless contraindicated e.g., pre-eclampsia), treat with
simple analgesia if needed, use hot or cold compresses, +/- massage. Regular exercise throughout
pregnancy is recommended to prevent low back pain as well as pelvic pain. Other treatment options
include physiotherapy, support belts. and acupuncture.
Note: if persistent and severe back pain refer the woman for evaluation

Breast Pain: Most common early in pregnancy, associated with darkening and enlarging of nipples
at around 12 weeks.
Management: Reassurance, use cotton supportive bras.

Carpal tunnel syndrome: Affects around 30% of pregnant women. It results from compression of
the median nerve within the carpal tunnel in the hand. The symptoms may include tingling, burning
pain, numbness and a swelling sensation in the hand that might affect sensory and motor function of
the hand.
Management: Reassure usually resolves after pregnancy, wrist splint at night may help, use simple
analgesia if needed, if sever refer to secondary care for physiotherapy/ steroid injections. If does not
resolve after pregnancy , refer for orthopaedic assessment

Constipation: Affects up to 40 % of pregnant women, usually associated with poor dietary fibre
and fluid intake, in addition to the increase in the levels of progesterone that affect gastric motility
and increase transit time.
Management: increase fluids and dietary fibres intake (found in vegetables, nuts, fruit and whole
grains) as well as daily exercise. If necessary, use a bulk –forming laxative, e.g., ispaghula husk for
women with troublesome constipation that is not relieved by dietary modification or fibre
supplementation. Avoid bowel stimulants (e.g. senna) as they increase uterine activity.

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Cramps of leg: Affects 1 in 3 in late pregnancy, it is abnormal sensation of cramps in lower legs,
worse at night. The aetiology is not known. It may be due to the change in blood circulation and
stress on the leg muscles due to the increase in the body weight.
Management Non-pharmacological therapies, such as muscle stretching, relaxation, heat therapy,
dorsiflexion of the foot and massage, raising the foot of the bed by 20 cm can provide some relief.
Woman can be advised to take calcium and magnesium oral supplementation.
Note: - DVT should be ruled out, not to be missed.

Haemorrhoids: Also called pills, are swollen veins around the anus. May be associated with itching,
pain and bleeding. It affects 8% of women in the third trimester. Management: Advice to increase
fibre intake and drinking adequate amount of water to avoid constipation. If clinical symptoms
remain troublesome, standard haemorrhoid creams /suppository can be considered and treat
constipation if present.

Headache: Usually tension headache. Check BP and urine for protein to exclude pre-eclampsia
(page 97)
Management: Treat with rest and simple analgesia if needed. Migraine may increase or decrease in
pregnancy.

Heartburn: Common complaint during pregnancy, affects 70% of women in third trimester.
Heartburn is not harmful and not associated with adverse outcomes on mother or foetus. Therefore,
the management is intended to provide relief of symptoms rather than to prevent harm to the foetus
or mother.
Management: Reassure not harmful, advise woman to avoid fatty meals and gastric irritants such
as caffeine, fizzy drinks, replacing the large meals with small portions and frequent meals, avoid
eating late at night, maintaining upright positions, especially after meals, rising the head of the bed
in sleeping. Consider prescribing antacids preparation to women with persisting symptoms despite
lifestyle modifications. They are unlikely to cause harm in recommended dosages. Antacids may
impair absorption of other drugs. Therefore, advise the woman, she should not take antacids within
two hours of taken iron and folic acid supplements.
Note: Pre-eclampsia can present with epigastric pain. Check BP and urine protein if epigastric
pain unresponsive to simple antacids

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Hypotension: common symptom of early pregnancy. Check if there is any bleeding.

Management: Advice to avoid standing suddenly and avoid hot baths.

Itching/pruritus common symptom in pregnancy, exclude intrahepatic cholestasis (page 118) and other
skin conditions.
Management: moistening creams, oily calamine lotions.

Nausea and vomiting (page 56).

Skin changes: Pigmentation (e.g., linea nigra), spider naevi, abdominal striae, chloasma /melasma,
palmer erythema, other skin rashes (page 124)
Management: moistening creams and oily calamine lotions, avoid exposure to sun, use sunscreen. Pre-
existing skin conditions (e.g., atopic dermatitis, psoriasis, fungal infections, cutaneous tumours) may
exacerbate during pregnancy. Need symptomatic treatment and referral to dermatologist as needed

Sweating and feeling hot: Common in pregnancy. Check apyrexial. If apyrexial, reassure normal in
pregnancy. If pyrexial, look for the source of infection. Fever in pregnancy (page 166)

Symphysis pubis dysfunction: Affects 3% of pregnant women. Symphysis separate causing discomfort
and pain in the pelvic area radiating to the lower back, upper thighs and perineum. Some women feel or
hear click on the pelvic area. The pain can be worsening when walking, going up or down the stairs and
turning over in bed and resolved by rest. It can be due to posture and hormonal changes during pregnancy
that causes stretching and loosening of ligaments and muscles or due to previous damage to pelvis due to
any accident.

Management: treat with simple analgesia, exercises to strengthen pelvic floor, stomach, back and hip
muscles, advice rest on semi- recumbent position when in pain, referral to secondary care for
physiotherapy. Generally, resolves after delivery but if persists refer to orthopaedics

Urinary frequency: Check urine microscopy -UTI is common in pregnancy and associated with
premature delivery (page 134)

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Vaginal bleeding (page 161)

Vaginal discharge: Usually increase in pregnancy. Investigate if smelly, itchy, sore or associated with
dysuria. (page 139)

Varicose veins: Pregnancy can aggravate pre-existing varicose veins. Some women may notice the
varicose veins for the first time during pregnancy due to hormonal changes and the growing uterus,
which cause pressure on the veins in the pelvis. It causes aching legs, fatigue, itch and ankle /foot
swelling.
Management: if ankles are swollen, exclude pre-eclampsia (check BP, dipstick urine for
proteinuria). Advice the woman to elevate legs when setting, use compression stockings. Avoid
standing for long periods of time. Complications include thrombophlebitis- treat with ice packs,
elevation, support stockings and analgesia.

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2.3.2 Management of Nausea and Vomiting in Pregnancy, and Hyperemesis Gravidarum

Definitions
Nausea and vomiting of pregnancy (NVP)
Nausea and vomiting of pregnancy affect about 80% of pregnancy. It is diagnosed when the onset
of nausea and vomiting is in the first trimester of pregnancy, and other causes of nausea and vomiting
have been excluded.

Hyperemesis gravidarum
Hyperemesis gravidarum is the severe form of nausea and vomiting of pregnancy. It can be
diagnosed when there are persistent nausea and vomiting of pregnancy with weight loss of more
than 5% pre-pregnancy weight loss, dehydration and electrolyte imbalance.
Complications
Although nausea and vomiting are considered as common disorders in pregnancy they can lead to
severe maternal mortality and morbidity. In the last 10 years one maternal death & maternal near
miss cases (Wernicke’s encephalopathy) were reported in Oman.

TABLE 12: COMPLICATIONS OF HYPEREMESIS GRAVIDARUM

Maternal complications
● Hypokalemia causes lethargy, skeletal muscle weakness and cardiac arrhythmia,
● Hyponatremia and central pontine myelinolysis, Wernicke’s encephalopathy,
● Vitamin B6/B12 deficiency causes anaemia and peripheral neuropathy,
● Malnutrition,
● Mallory-Weiss oesophageal tears,
● Venous thromboembolism (due to dehydration and immobilisation)
● Psychological morbidity
Foetal complications
● Growth restriction,
● Wernicke’s encephalopathy is associated with a 40% incidence of foetal death,
● there is No increased risk of congenital malformations

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Classification of severity of nausea and vomiting of pregnancy

Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of
nausea and vomiting of pregnancy into (mild, moderate and severe). It can be used to track
progress with treatment. (Institute of Obstetricians and Gynaecologists, Nov 2015)

TABLE 13: MOTHERISK PUQE-24 SCORING SYSTEM

Question Score
In the last 24 hours, for how Not at all ≤ 1hour 2-3 hours 4-6 hours ≥ 7 hours
long have you felt nauseated (1) (2) (3) (4) (5)
or sick to your stomach?
In the last 24 hours, have I did not 1-2 3-4 5-6 ≥7
you vomited or thrown up? throw up (2) (3) (4) (5)
(1)
In the last 24 hours, how None 1-2 3-4 5-6 ≥7
many times have retching or (1) (2) (3) (4) (5)
dry heaves without throwing
up?
Total scores Mild: ≤6 Moderate: 7-12 Severe: 13-15
*Adopted from (Lowe, 2019)

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Management of Nausea and vomiting of pregnancy and hyperemesis gravidarum

a) Management at Primary Health care:
● History and physical examination should be focused to exclude other diagnoses. Physical
examination should include palpation of the abdomen for abdominal tenderness and signs
of peritonism, assessment for neck stiffness and signs of raised intracranial pressure if
history suggestive of central nervous cause.

TABLE 14: DIFFERENTIAL DIAGNOSIS FOR NAUSEA AND VOMITING IN PREGNANCY

● Molar pregnancy
● Ovarian torsion
● Gastrointestinal (Gastritis/peptic ulcer, reflux oesophagitis, cholecystitis, pancreatitis, bowel
obstruction)
● Urinary tract infection
● Metabolic and endocrine disorders (Diabetic ketoacidosis, hyperthyroidism, uremia, Addison’s
disease)
● Central nervous system causes (e.g., migraine, tumour, infection, vestibular disease)
● Cardiac causes: pulmonary embolism - myocardial infarction.

● Woman weights need to be recorded as a baseline and to monitor any loss of weight.
● Unless indicated, no need to perform investigations for women with PUQE score ≤6.
● Complete blood count, Urea and electrolytes (U&E), Liver function test (LFT) and thyroid function
test (TFT) should be done for those with PUQE score ≥ 7.
● Ketonuria alone should not be used to assess the severity of NVP but should be interpreted in light of
the overall clinical picture of patient.
● Treatment should aim to correct hypovolemia, electrolyte imbalances and ketosis, provide
symptomatic relief in form of anti-emetic medication, and thromboprophylaxis.
● There is no evidence to support the effectiveness of dietary restrictions, woman is advised to avoid
personal triggers of nausea.
● Woman should be offered a psychological support with emphasis that the condition is self-limiting.

b) Criteria for referral to secondary care:

● PUQE score 7-12 with dehydration or ketonuria not responding to IV fluid or with abnormal blood
investigations.

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● Women with weight loss

● PUQE score ≥13 or if insulin dependent diabetic (Koren, May 2002)
● The following algorithm shows the assessment and management of nausea and vomiting of pregnancy
at primary health care level:

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ALGORITHM 1: ASSESSMENT AND MANAGEMENT OF NAUSEA AND VOMITING OF PREGNANCY

Take detail history and complete PUQE score

Perform clinical examination including Temperature, PR, BP, RR, signs of dehydration (decreased skin turgor, dry mucous
membranes, decreased urine output, concentrated urine, and postural drop in blood pressure), abdominal examination - other
examination as guided by history
Exclude other causes e.g., infections, gastrointestinal, endocrine, metabolic, cardiac, and CNS causes, drug history, etc.
Check urine ketones
Consider need for performing investigations: urine routine, blood glucose, U&E, TFT, LFT
Early ultrasound scan (if not done before) to confirm viability, gestational age and to rule out multiple or molar pregnancy

Moderate NVP
Mild NVP Severe NVP
PUQE score 7-12
PUQE score ≤ 6 PUQE score ≥13
Ketonuria, clinically

Weight patient and record it. Keep in observation room

Antiemetic Weight patient and record it Correct hypovolemia
Advise on diet and fluids If woman is unable to tolerate oral fluid Refer to secondary care
Discharge home if no signs of and ketotic, start IV fluid. (Hartmann’s hospital for evaluation and
dehydration and ketosis (Ringer lactate) or sodium chloride management
0.9%). Infuse 1st litre in 1-2 hour, then
reassess.
Discontinue IV fluid when ketonuria has
Dietary advice resolved, no sign of dehydration and
Modification of the amount and size of women is able to maintain oral fluid.
meals consumed throughout the day, Antiemetic
Weight patient after fluids and record it
to have frequent smaller amounts of
Discharge home if well otherwise admit to
food and fluids. the ward (local hospital) or referred to
secondary care for admission
The meals should contain more
carbohydrate than fat and acid. Antiemetics used in the management of nausea and vomiting in pregnancy:

Protein-rich meals also decrease First line:

symptoms. Promethazine (Phenergan) 10 –25 mg 4–8 hourly PO,2.5 mg IM, OR
Lighter snacks, including nuts, dairy Prochlorperazine (Stemetil) 5–10 mg 6–8 hourly PO
products, and beans. Second line:
Drinks that contain electrolytes and Metoclopramide (Primperan) 5–10 mg 8 hourly PO, IV or IM
other supplements are advised.
Domperidone 10 mg 8 hourly PO; 30–60 mg 8 hourly PR
To avoid foods or food preparations Note: The woman should be asked about previous adverse reactions to antiemetic
that trigger nausea. therapies. Drug-induced extrapyramidal symptoms and oculogyric crises can occur with the
Ginger was found effective in reducing use of phenothiazine and metoclopramide. If this occurs, immediately discontinue these
nausea and vomiting in women with medications.
mild and moderate symptoms.

Lifestyle advice: To avoid stress and take rest as required to alleviate symptoms
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c) Management at secondary care level

● Exclude other causes of nausea and vomiting. Perform laboratory investigation as indicated
including U&E, LFT, TFT. U&E might need to be repeated daily to assess electrolyte balance in
severe cases.
● Correct hypovolemia with IV fluids if the woman is unable to tolerate oral fluids. Dextrose-
containing solutions can precipitate Wernicke’s encephalopathy in women with thiamine
deficiency
● Start input/output chart
● Refer the woman to dietician
● Naso-gastric feeding or total parental nutrition (TPN)) may be required in severe and protracted
cases in particular when there is:
- Significant weight loss or failure to achieve an appropriate gestational weight gain
- Low body mass index (BMI) or underweight
- Significant vitamin deficiencies
- Persistently abnormal LFTs
● Criteria for discharge
- No ketones in the urine
- Tolerating oral fluids and food without vomiting
● On discharge from hospital arrange follow-up antenatal care to include monitoring for foetal
growth restriction. Appropriate antiemetic prescription should be provided to the woman
● Repeat assessment with repeated admission

The following algorithm shows the assessment and management of nausea and vomiting of
pregnancy at secondary health care level:

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ALGORITHM 2: ASSESSMENT AND MANAGEMENT OF NAUSEA AND VOMITING OF PREGNANCY AT

SECONDARY HEALTH CARE LEVEL

Exclude other causes of nausea and vomiting in pregnancy.

laboratory investigation e.g., LFT, TFT, U&E etc.
Record PUQE score daily on assessment and management checklist
Weight patient and record
Early ultrasound scan (if not done before) to confirm viability, gestational age and to rule out multiple or molar
pregnancy
Correct hydration with IV fluids if the woman is unable to tolerate oral fluids and ketotic using
Hartmann’s or sodium chloride 0.9%. Infuse first litre over 1-2 hours and then reassess,
Correct
including urine ketone testing. If required further IV fluids should be run at rate of 1000mls
hypovolemia,
over 4 hours, followed by further assessment.
electrolyte
If the serum potassium level is found to be less than 3.2mmol/l, potassium supplements
imbalance and
should be given. *
ketosis
Maintaining strict fluid balance record.
Check each urine sample for ketones
Insulin-dependent diabetics must be managed carefully to prevent hypo- and hyperglycemia.
Daily U & E to assess electrolyte balance in severe cases

Prevent Provide antiemetics.

vomiting Patients with severe hyperemesis may require more than one antiemetic to control symptoms.
Encourage small, frequent oral fluids and foods based on the patient’s personal preference
Provide vitamin
supplementation Provide vitamin supplementation

& nutrition Nutrition advice

support Consider nasogastric & parenteral feedings in very severe cases

Prevent VTE Assess risk for venous thromboembolism (VTE) and provide thromboprophylaxis

Provide
Reassure the woman and allow to rest
psychological
support

*Fluid replacement in the management of nausea and vomiting in pregnancy

Intravenous (IV) fluids: Normal saline with KCl or Hartmann solution
If K+ is normal to give one litre of Hartmans over 2 hours
If K+ is (3.2-3.4) give 0.9% sodium chloride and K+ 40 mmol/L - 250 ml/hour
If K+ is (3.5-3.9) give one litre of 0.9% sodium chloride with 20 mmol/litre - 500ml/hour
If K+ is < 3.2 needs admission for further management refer to secondary/tertiary care
Note: Dextrose-containing solutions can precipitate Wernicke’s encephalopathy in women with thiamine deficiency

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2.3.3 Anaemia in Pregnancy

Definition: -
Anaemia in pregnancy is defined as haemoglobin concentration Hb < 11 g/dl. Iron deficiency
anaemia (IDA) is the most common cause of anaemia in pregnancy and associated with increased
risk of maternal morbidity and mortality
Routine supplements
● Combined iron and folic acid preparations (Fefol tablets) are available, started from 13 weeks
of gestation.
● Daily folic acid (400 microgram) is required before 13 weeks' gestation to reduce the incidence
of neural tube defects.

Risk factors for IDA in pregnancy: -

● Multiple pregnancies
● Poor diet and lacking iron - rich food
● Previous gastrointestinal diseases
● Medications that decrease absorption of iron like antacids, multivitamins.
● Short interval between pregnancies

Complications:
Untreated IDA in pregnancy can be associated with significant adverse consequences for mother
and child: -
● Low birth weight
● Preterm birth
● Increased risk of postnatal haemorrhage (PPH)
● Perinatal and neonatal mortality
● Fatigue, weakness, poor quality of life may lead to postpartum depression
● Potential implications for future neurodevelopment of the infant

Diagnosis
1. Clinical symptoms and signs: - are non‐specific and cannot be relied on for diagnostic purposes.
Fatigue is the most common symptom, in addition to pallor, weakness, headache, palpitations,

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dizziness, dyspnoea, irritability and restless legs. Haemoglobin levels outside the normal range
for pregnancy should be investigated and iron supplementation considered if indicated
2. Laboratory testing: -
● Low Haemoglobin (Hb), mean cell volume (MCV) and mean cell haemoglobin (MCH) are
suggestive of iron deficiency, and it should be routinely checked for all pregnant women at
booking and 28 wks., and 36 weeks
● Low serum ferritin is diagnostic of iron deficiency in pregnancy. However, a normal ferritin
level does not exclude iron deficiency, as pregnancy is associated with a physiological rise
in acute phase proteins including ferritin.

Management of Iron Deficiency Anaemia in Pregnancy

1. Rapid assessment of the patient (see Algorithm 3)
2. Dietary advice
● All pregnant women should receive general dietary advice at booking visit.
● Once women become iron‐deficient in pregnancy, she should be referred and seen
regularly.
● It is not possible to ensure repletion through diet alone and oral supplementation of
ferrous is needed
● Education and counselling regarding diet may improve iron intake and enhance
absorption

Counselling dietary advice for pregnant women

 To take diet rich in iron folate such as liver, kidney heart, lean meat, egg yolk, shellfish,
dried beans, legumes, dried fruits, green leafy vegetables, whole cereals and jaggery.
 To take vitamin C containing food such as orange, lemon, kiwi, mango, papaya, etc
 Do not overcook green leafy vegetables.
 Do not consume milk, tea, coffee or antacids with food or within two hours of taking iron
tablets

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3. Oral iron and folic acid supplements

● Women should be counselled how to take oral iron supplements correctly. This should be on
an empty stomach, at least 1 hour before meal, take with water or a source of vitamin C. Other
medications, multivitamins and antacids should not be taken at the same time
● Iron is known to cause gastric irritation, nausea and constipation/diarrhoea, affecting
compliance There are strategies to reduce the side effects of oral iron and improve tolerability
of iron tablets. Shown in Table 3
● Multivitamins usually have insufficient iron to correct anaemia and, furthermore, often contain
other minerals that interfere with iron absorption; thus, it should not be prescribed alone to
correct IDA.
● Repeat Hb testing is required 2–3 weeks after commencing treatment for established anaemia,
to assess compliance, correct administration and response to treatment.
● If response to oral iron replacement is poor, compliance should be confirmed and concomitant
causes that may be contributing to the anaemia considered, such as folate deficiency or
malabsorption, consider referral for IV iron.

TABLE 15: STRATEGIES TO REDUCE THE SIDE EFFECTS OF ORAL IRON AND IMPROVE TOLERABILITY OF IRON

Strategies to reduce the side effects of oral iron and improve tolerability of iron:
 Reducing the dose (e.g., once daily) or the frequency (every other day).
 Making dietary modifications (e.g., taking iron with food) although this may reduce
absorption.
 Switching to a formulation with a lower amount of elemental iron (e.g., ferrous
gluconate, ferrous furate, etc
 Switching from a tablet to a liquid, for each it is easier to titrate the dose
 Slow release and enteric‐coated forms should be avoided
 Once a tolerated dose is found, the patient can sometimes increase the dose slowly as
tolerated

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ALGORITHM 3: ASSESSMENT AND MANAGEMENT OF ANEMIA IN PREGNANCY

 Take detail history: - weakness, fatigue, palpitation, vomiting, poor diet, medications
 Identify risk factors: - multiple pregnancy, poor diet, gastrointestinal diseases, medications that
decrease absorption of iron like antacids, multivitamins, short interval between pregnancies
 Perform clinical examination including vitals: pulse ate, Blood Pressure, pallor
 Exclude other causes e.g., bleeding, gastrointestinal causes, drug history, etc.
 Early ultrasound scan (if not done before) to confirm viability, gestational age and to rule out
multiple or molar pregnancy

Classification of Anaemia in pregnancy based on Haemoglobin level

Mild Anaemia Moderate Anaemia Severe Anaemia

(Hb 10.9-10 g/dl) (Hb 9.9 -7 g/dl) (Hb 6.9 - ≤4 g/dl)

Fefol capsule (ferrous sulphate All pregnant ladies with Stabilize (if needed)
150 mg +Folic acid 5mg) daily moderate and severe anaemia
Refer as an emergency
dose. should be investigated to rule
at any stage of pregnancy
Monitor Hb level and out other causes of anaemia and

compliance every 4 weeks. treated accordingly.

Start ferrous sulphate tab of 200
Health education, check
mg two to three times daily + Folic
compliance and correct use of
acid tablet.
medications
Monitor Hb level and
Refer to dietician
compliance every 4 weeks.
Investigate for other causes of
Health education
anaemia if no improvement and
treat accordingly Refer to dietician

Refer to secondary care by Refer to secondary care by

routine appointment if the routine appointment if the patient

patient is fully compliant but is not responding after one month

not responding to the treatment for consideration of IV iron.

for further assessment and If gestational age ≥ 34wks refer

management. as urgent.

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Postpartum anaemia
Definition:
Postnatal anaemia is defined as an Hb <10 mg/l. The risk of postnatal anaemia is reduced by
identification and management of iron deficiency in the antenatal period.
Post-partum care:
● After delivery, women with blood loss ≥ 500 ml, those with uncorrected anaemia detected in
the antenatal period or those with symptoms suggestive of anaemia postnatal should have their
Hb checked within 48 h of delivery.
● All women should be tested for Hb level at 6 weeks postnatal visit.
● All women with Hb ≤ 10 g/ in the postpartum period should be given an iron supplementation
for 3-6 months
● Women who are previously intolerant of, or do not respond to, oral iron and/or where the
severity of symptoms of anaemia requires prompt management should be referred to secondary
care for IV iron.

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2.3.4 Venous thromboembolism (VTE)

Introduction
Venous thromboembolism (VTE) is a collective term that describes deep vein thrombosis (DVT)
and pulmonary embolism (PE). Pregnant women have a four to five-fold increased risk of
thromboembolism as compared to non-pregnant women. The risk for VTE increases with
gestational age, reaching a maximum just after delivery.
Thromboprophylaxis (thrombosis prevention): is medical treatment to prevent the development
of thrombosis in women considered at high risk for developing thrombosis.
Pulmonary embolism (PE) is one of the leading causes of maternal deaths. In Oman, between
2008 and 2017 the total maternal deaths were 135 out of them 16 were due to thromboembolism.
Eleven cases occurred during postnatal period and five were during antenatal period. Also, based
on maternal near-miss review between 2016 and 2017, five cases suffered pulmonary embolism.
The mortality and morbidity associated with venous thromboembolism (VTE) in obstetric patients
can be reduced by up to two thirds by taking appropriate measures in time.

1. Risk factors for Venous thromboembolism:

It is recommended that any pregnant woman should be assessed using VTE risk factors. The
following should be considered:
● The strongest personal risk factor for VTE in pregnancy is a history of VTE. Many antenatal
VTE occur in the first trimester and therefore prophylaxis for women with previous VTE should
begin early in pregnancy.
● Risks of recurrent VTE appear higher for those with a family history and deficiencies of the
naturally occurring anticoagulants, particularly type 1 antithrombin deficiency.
● Obesity is recognized as a major risk factor for the development of VTE in pregnancy and the
puerperium
● Personal history of Thrombophilia. Family history of VTE increase the risk for developing VTE.
● Caesarean section is a significant risk factor for post-partum VTE and women who have an
emergency caesarean section are at a greater risk as compared to those who have an elective
caesarean section. Women who have vaginal delivery are also at risk of thromboembolism.
● Obstetric risk factors: pre-eclampsia, ART/IVF, multiple pregnancy, prolonged labour >24 hour,
PPH ˃1 litre, preterm ˂ 37 weeks birth, stillbirth.

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● Other risk factors include Medical co-morbidities e.g., cancer, heart failure, active SLE,
inflammatory polyarthropathy or inflammatory bowel disease, nephrotic syndrome, Type I
diabetes with nephropathy, sickle cell disease, current intravenous drug user, woman age ˃35
years, parity ≥ 3, smoking, immobility e.g., Paraplegia and gross varicose vein.
2. Risk Assessment for Venous Thromboembolism in pregnancy and puerperium
● All women should undergo documented assessment of risk factors for VTE in antenatal and
repeated postpartum. A formal VTE risk assessment with numerical scoring is recommended
(Table 16).
● Risk assessment should be done at:
- Pre-pregnancy,
- Early pregnancy at booking,
- At 28th weeks of pregnancy, and
- Intrapartum or within 6 hours after birth,
● Risk assessment should be repeated if the woman is admitted to hospital for any reason or
develops complications
● Risk assessment should be done by a trained doctor. If midwife is running the ANC, then the
assessment can be done by the trained midwife.

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TABLE 16: RISK FACTORS FOR VENOUS THROMBOEMBOLISM AND RISK ASSESSMENT SCORING
Risk Factors Score
Pre-existing risk factors
Previous history of VTE (except single event provoked by major surgery) 4
Previous history of VTE provoked by major surgery 3
Thrombophilia - 3
o Heritable: Antithrombin Deficiency Protein C, Protein S Deficiency Factor V Leiden,
Prothrombin Gene mutation
o Acquired: Antiphospholipid Syndrome, Persistent Lupus Anticoagulant Persistent
moderate /high titre anti cardiolipin antibodies or Persistent beta 2 glycoprotein
antibodies
*Any case already diagnosed of thrombophilia should be referred to haematologists
Medical co-morbidities e.g., cancer, heart failure, active SLE, inflammatory 3
polyarthropathy or inflammatory bowel disease, nephrotic syndrome, Type I diabetes with
nephropathy, sickle cell disease, current intravenous drug user
Family history of unprovoked or estrogen provoked VTE in first degree relative 1
Age ˃35 years 1
Obesity BMI from 30-39 kg/m2 at booking 1
Obesity BMI ≥ 40 kg/m2 at booking 2
Parity ≥ 3 1
Smoking 1
Paraplegia 1
Gross varicose veins 1
Obstetrics risk factors in (current pregnancy)
Pre-eclampsia 1
ART/IVF (Assisted Reproductive Technology/ In vitro Fertilisation) 1
Multiple pregnancy 1
Emergency Cesarean Section 2
Elective Cesarean section 1
Mid cavity or rotational operative delivery 1
Prolonged labour >24 hour 1
PPH ˃1 litre or transfusion 1
Preterm ˂ 37 weeks of birth 1
Stillbirth in current pregnancy 1
New onset / transient risk factors ( in current pregnancy )
Any surgical procedure in pregnancy or puerperium 3
Hyperemesis** /dehydration 3
Ovarian hyperstimulation Syndrome (sever type only)- is a complication of fertility
treatment (assisted reproduction technology). 4

Immobility 1
Current systemic infection 1
Long hours of travel ˃ 8 hours. 1
*ART assisted reproductive technology, IVF in vitro fertilisation

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**Hyperemesis gravidarum: is the severe form of nausea and vomiting of pregnancy. It can be
diagnosed when there is persistent nausea and vomiting with dehydration and electrolyte imbalance.
***Ovarian Hyper Stimulation Syndrome: is a complication of fertility treatment (assisted
reproduction technology)

TABLE 17: RISK SCORE FOR THROMBOPROPHYLAXIS

Antenatal Postpartum
Risk Score
Thromboprophylaxis Thromboprophylaxis
Consider
If total score ≥ 4 Thromboprophylaxis for 6 weeks
thromboprophylaxis from
(antenatal) postnatal
the first trimester
Consider Thromboprophylaxis for 6 weeks
If total score 3 (antenatal) thromboprophylaxis from postnatal (Postnatal risk
28 weeks reassessment to be made)
Consider thromboprophylaxis for
If total score ≥ 2 postnatal -
at least 10 days
New Onset/ Transient
Consider
potentially reversible risk Consider thromboprophylaxis
thromboprophylaxis
factors

3. Referral to obstetricians
● Any pregnant woman with history of VTE should be referred immediately at booking to obstetrician
for initiation of thromboprophylaxis.
● Any pregnant woman with VTE risk factors scores ≥ 4 should be referred at booking to secondary/
tertiary care for initiation of thromboprophylaxis.
● Any pregnant woman with VTE risk factors scores 3 should be referred to obstetrician during the
antenatal care for initiation of prophylaxis at 28 weeks.

4. Advice to pregnant women:

Discuss the risk of VTE in pregnancy and the importance of seeking urgent medical assistance if
symptoms develop

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Symptoms and signs of pulmonary embolism and deep vein thrombosis:

Pulmonary embolism:
● Dyspnoea (most common symptom of PE)
● Palpitations/tachycardia
● Chest pain
● Haemoptysis
● Hypoxia/cyanosis
● Tachypnoea
● Hypotension
● Collapse

Deep vein thrombosis

● In pregnancy is often proximal and may not present with usual features of distal DVT
● Unilateral leg pain
● Swelling in an extremity with pitting oedema
● Increase in calf/thigh circumference particularly of 2 cm or more
● Increased temperature
● Prominent superficial veins
● Pitting oedema
● Importance of mobilization and hydration in preventing VTE in pregnancy and after birth.

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5. Thromboprophylaxis according to risk assessment

● Initiation of thromboprophylaxis according to VTE risk assessment should be done by
obstetrician at secondary / tertiary health care institutions. The dose and duration of
thromboprophylaxis agent to be clearly documented in the Maternal Health Record (Green
card), with the plan for follow-up.
● The management of following conditions should be taken by haematologist with expertise in
thrombosis in pregnancy and after delivery.
- Women with previous confirmed VTE
- Woman with multiple pervious VTE (no other risk factors)
- Women with previous VTE and with family history of antithrombin deficiency, regardless
of family history (homozygous prothrombin gene mutation or factor V Leiden and
combined thrombophilia (companions’ heterozygous cases)
- Woman with previous VTE and acquired thrombophilia (antiphospholipid syndrome), no
long –term oral anticoagulation
● Women receiving antenatal LMWH should be advised to stop LMWH if they have vaginal
bleeding or labour signs.
● Women receiving antenatal LMWH (prophylactic dose), and planned for elective caesarean
section, should receive LMWH on the day prior to delivery, but not later than 18:00 hours.
Any morning dose on the day of delivery should be omitted.
● Risk assessment should be performed in each woman at least once following delivery and
before discharge.
● Start or resume thromboprophylaxis 4-6 hours after vaginal delivery and 6-8 hours after
caesarean section.
● Women with multiple previous VTE and woman with previous VTE and heritable
thrombophilia consider high dose of LMWH antenatally and postpartum till they return to oral
anticoagulants (these will mostly be on lifelong anticoagulants, so may go back to warfarin
earlier than 6 weeks )
● Woman delivered with high risk of haemorrhage due to major antepartum haemorrhage,
coagulopathy, progressive wound hematoma, suspected intra-abdominal bleeding and
postpartum haemorrhage ask haematologist for advice, restart LMWH as soon as possible
when haemorrhage is reduced, after measuring patient’s risk factor and benefit for prophylaxis
and with the aid of lab results assuring safety of resumption of prophylactic dose.

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● Woman at very high risk of thrombosis where regional anesthetic technique may be required
or there is an increased risk of haemorrhage ask haematologist for advice. Avoid regional
techniques for at least 12 hours after the previous dose of LMWH. Avoid regional techniques
for at least 24 hours after the last dose of LMWH, if the patient on a therapeutic regimen of
LMWH. Avoid LMWH for 4 hours after use of spinal anaesthesia or after the epidural catheter
has been removed within 12 hours of the most recent injection

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ALGORITHM 4: ANTENATAL THROMBOPROPHYLAXIS ACCORDING TO RISK

 Any previous VTE except a single event related to HIGH RISK

major surgery
Requires prophylaxis with LMWH from
first trimester of pregnancy

Any one of
 single previous VTE related to major surgery
 High risk thrombophilia + no VTE INTERMEDIATE RISK
 Cancer, heart failure, active SLE, inflammatory Poly
Requires prophylaxis with LMWH from 28
arthropathy or IBD, nephrotic syndrome, Type I DM
weeks of pregnancy
with nephropathy, SCD, current intravenous drug
user
Requires LMWH
SELECT ALL THAT APPLY Risk score prophylaxis from the
Score ≥ 4
At every assessment time of assessment
 Age >35 years 1
 Obesity BMI ˃ 30-39 kg/m2 at booking 1
Requires LMWH
 Obesity BMI ≥ 40 kg/m2 at booking 2
 Parity ≥ 3 1 prophylaxis from 28
Score 3
 Multiple pregnancy 1 weeks,
 Smoker 1
 Gross varicose veins 1
No need for
 Pre-eclampsia in current pregnancy 1
 ART/IVF* 1 Less than 3 thromboprophylaxis
 Immobility, e.g., paraplegia 1 risk factors Advice mobilisation and
 Family history of unprovoked VTE in first 1
avoidance of dehydration
degree relative

Transient risk factors Risk score

 Hospital admission ˃ 3 days 4
 OHSS (first trimester only) 4 Consider LMWH prophylaxis
 Any surgery (pregnancy or postpartum) 3 While in the hospital or until
 Severe hyperemesis or dehydration 3 resolves
requiring IV fluid
 Infection requiring admission to hospital 1
 Long hours of travel ˃ 8 hours 1

ART: artificial reproductive technology, BMI: body mass index, IBD: inflammatory bowel disease, IVF: in-vitro
fertilisation, LMWH: low molecular weight heparin, OHSS: Ovarian hyperstimulation syndrome, PE: pulmonary
embolism, SCD: Sickle cell disease, SLE: systemic lupus erythematosus, VTE: venous thromboembolism, IVDU:
intravenous drug user

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ALGORITHM 5: POSTNATAL THROMBOPROPHYLAXIS ACCORDING TO RISK SCORE

Any one of
HIGH RISK

 Any previous VTE At least 6 weeks postnatal

 Anyone requiring LMWH during pregnancy from first
prophylactic LMWH
trimester
 Low-risk thrombophilia + family history
 High risk thrombophilia

Any one of
INTERMEDIATE RISK
 Caesarean section in labour
 Readmission or prolonged admission (≥ 3 days) in the
puerperium  At least 10 days postnatal
 BMI ≥ 40 kg/m2 at booking prophylactic LMWH
 Any surgical procedure in the puerperium except immediate  NB: If persisting or > 3
repair of the perineum
risk factors consider
 Medical comorbidities e.g., cancer, heart failure, active SLE,
IBD or inflammatory Poly arthropathy; nephrotic syndrome, extending
type I DM with nephropathy, sickle cell disease, current IVDU thromboprophylaxis with
LMWH
Any one of Risk score

 Age > 35 years 1

 Obesity (BMI ≥ 30 kg/m2) 1
Two or more
 Parity ≥ 3 1
risk factors
 Smoker 1
 Elective caesarean section 1
 Current systemic infection 1
 Immobility, e.g., paraplegia, PGP, long-distance 1
travel Less than 2 risk
 Current pre-eclampsia 1
factors
 Multiple pregnancy 1
 Preterm delivery in this pregnancy (< 37+0 1
weeks)
 Stillbirth in this pregnancy 1 Lower Risk
 Mid-cavity rotational or operative delivery 1 Early mobilisation and avoidance
 Prolonged labour (> 24 hours) 1 of dehydration
 PPH > 1 liter or blood transfusion 1

ART: artificial reproductive technology, BMI: body mass index, IBD: inflammatory bowel disease, IVF: in-
vitro fertilisation, LMWH: low molecular weight heparin, OHSS: Ovarian hyperstimulation syndrome, PE:
pulmonary embolism, SCD: Sickle cell disease, SLE: systemic lupus erythematosus, VTE: venous
thromboembolism, IVDU: intravenous drug user

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6. Agents for Thromboprophylaxis:

● Low Molecular Weight Heparin (LMWH) are the agents of choice for antenatal and postnatal
thromboprophylaxis.
● Unfractionated heparin (UFH) can be used as alternative in woman with risk of bleeding or
have allergic reactions to LMWH.
● The following table illustrates the suggested thromboprophylactic doses for LMWH antenatal
and postnatal:

TABLE 18: THROMBOPROPHYLAXIS DURING PREGNANCY AND POSTPARTUM

Weight (Kg) Enoxaparin Sodium (LMWH)
< 50 20 mg (2000 units) once daily
50-90 40 mg (4000 units) once daily
91-130 60 mg (6000 units) once daily OR 2 divided doses
131-170 80 mg (8000units) daily 2 divided doses
>170 0.6mg (60 units) /kg/day - 2 divided doses
High prophylactic dose for women weighing 50–90 kg 40 mg (4000 units) 12 hourly
Unfractionated heparin (UFH)
Alternative to enoxaparin sodium in women with risk of bleeding OR allergic reactions
to LMWH:
unfractionated heparin (UFH) dose: 5000-10000 units every 12 hours, to be administered
with monitoring

Remarks:
● Counsel the patient on LMWH during pregnancy and to stop the LMWH injection if she has
vaginal bleeding or labour signs.
● Thromboprophylaxis should be started as soon as the immediate risk of haemorrhage is reduced.
● If the patient has had exposure to unfractionated heparin (UFH), monitor platelet count.
● Do not monitor anti-Xa levels when LMWH used for thromboprophylaxis.
● Reduce LMWH dose in patients with renal impairment.

Contraindication / cautions of LMWH thromboprophylaxis

● In women at risk of bleeding after careful consideration of the balance of risks of bleeding and
thrombosis.

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● Previous or current allergic reactions to LMWH

● Active bleeding, coagulopathy or low platelets (fewer than 75 x 109 /l). to be delayed
● Known bleeding disorder (e.g., haemophilia, von Willebrand’s disease or acquired
coagulopathy)
● Active antenatal or postpartum bleeding or considered at increased risk of major haemorrhage
● Acute stroke (hemorrhagic or ischemic) in previous 4 weeks
● Severe renal disease (glomerular filtration rate [GFR] < 30 ml/minute
● Severe liver disease with prolonged prothrombin time.
● Uncontrolled hypertension (blood pressure > 200 mmHg systolic or > 120 mmHg diastolic)

Note:
⮚ Warfarin is restricted in pregnancy to the few situations where heparin is considered
unsuitable, e.g., in women with mechanical heart valves.
⮚ Low dose aspirin is Not recommended as thromboprophylactic agent in obstetric patients

7. Instruction to women on how to take thromboprophylaxis injection (how to take the injection)
can be found in Annex 2.

8. Follow-up of woman on thromboprophylaxis

● Ensure woman received guidance on how to take the LMWH injection, her daily dose, the site
of injection, the rate of injection, infection control measures, and the disposal of the syringe
after each use
● Advice the woman to get the injection in the nearest primary health institution if she did not
receive training on how to give herself the injection or not sure what to do.
● If she missed taking the injection should take it as soon as possible, the next dose should be
taken 24hours later and to keep a note of the new time.
● Counsel the woman to stop LMWH injection if she has vaginal bleeding or labour signs and to
attend to hospital.
● If the patient has had prior exposure to un fractioned heparin (UFH), monitor platelet count
● Do NOT monitor anti- Xa-levels when LMWH used for thromboprophylaxis
● Reduce LMWH dose in patients with renal impairment

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9. Instructions to woman on safe disposal of used heparin syringes

Ensure the following instructions were clearly given to the woman on thromboprophylaxis and her
concerns and quires were answered.

1. Place the syringes in a sharps disposal container immediately after they have been used.
 DO NOT bend or break the needles after use.
 DO NOT recap the needles after use.
 DO NOT remove the needles after use.
 If you don’t have “sharp container” you can use a plastic bottle with tight cap as sharp
 container.
 Close the “sharp container”/ bottle cap tightly after each use
 Be careful not to fill the container more than ¾ of its capacity
 Wash your hands immediately after disposing the syringe.
 Keep the container out of reach of children

2. Dispose of used sharps disposal containers according to your health facility guidelines.
 When the container is ¾ full, take it to the nearest health facility
 Give the container to the focal for disposal medical waste in the health facility.
 DO NOT throw sharp containers in trash
 DO NOT put in sharp containers in recycling bin.

3. If someone is accidentally pricked with a used needle, advise him/her to wash the area around
the puncture and visit the nearest health facility for medical advice.

4. Make sure the health education material (booklet) is given to the woman on
thromboprophylaxis.

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10. Responsibilities
Responsibilities of doctors in antenatal care clinic at primary health care
 History taking to identify VTE risk factors during pregnancy.
 Apply risk assessment scoring for VTE for all pregnant women.
 Refer all pregnant women with score ≥3 to obstetrician for further evaluation and management.
 Document all relevant information in the maternal health record (green card).
 Report any side effects from thromboprophylaxis use and refer accordingly.
Responsibilities of obstetricians at secondary / tertiary health care
 Reassess all referred pregnant women for VTE risk.
 Provide counselling on importance of thromboprophylaxis and when to report any side effects.
 Provide thromboprophylaxis agents (type, frequency and duration).
 To put clear plan for follow up.
 Document of the plan for management and follow up in the patient’s file and in the maternal health
record (green card).
 Document and record client’s information and thromboprophylaxis dose and duration on the
educational leaflet.
Responsibilities of midwife / nurse (outpatient clinics and inpatient in the ward)
 Provide Counselling on importance of thromboprophylaxis and report any side effects.
 Explain to the client how to give self-injection and storage and disposable instructions.
 Explain to one of the client’s family members how to give heparin injection if the client refused
self-injection
 Monitor LMWH use during pregnancy
Responsibilities of pharmacist
 Provide prescription review for appropriateness
 Double check prepared medication
 Provide patient counselling regarding the medication usage, importance of adherence, Instruction in
the injection technique, dose, storage, Safe disposal and importance on thromboprophylaxis when to
report drug related problem
 Instruct the patient what to do with the leftover of the heparin injections
 Keep records for any returned medicines

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2.3.5 Diabetes in Pregnancy:

Introduction:
The ongoing epidemic of obesity and diabetes has led to a higher rate of type-2 diabetes in women
of childbearing age, resulting in an increase in the number of pregnant women with undiagnosed
type-2 diabetes. Also, when obese women become pregnant, they have higher risk of developing
gestational diabetes mellitus (GDM)

Types of Diabetes in Pregnancy

a) Diabetes detected during pregnancy including:
1. Gestational Diabetes Mellitus (GDM): An abnormal glucose tolerance with onset or first
recognition during pregnancy
2. Overt Diabetes: A diagnosis of overt diabetes can be made in women who meet any of the
following criteria at their initial prenatal visit:
● Fasting plasma glucose ≥7.0 mmol/l [≥126 mg/dL], and Random plasma glucose ≥11.1
mmol/l [≥ 200 mg/dL]
Or
● HbA1C ≥6.5% using a standardized assay.
-
b) Pre-existing diabetes including:
1. Type-2 Diabetes: caused by insulin resistance or relative insulin deficiency. It is often
associated with obesity.

2. Type-1 Diabetes: caused by absolute insulin deficiency with positive autoimmune markers
which destroy pancreatic β-cells, (anti-islet cell abs, anti-GAD abs, and low c-peptid), and
history of diabetic ketoacidosis.

Significance of diabetes in pregnancy: The adverse outcomes may include:

● Increased risk of miscarriage
● Increased risk of congenital anomalies
● Pre-eclampsia
● Hydramnios
● Foetal macrosomia

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● Foetal organomegaly (hepatomegaly, cardiomegaly)

● Birth trauma
● Perinatal mortality
● Neonatal respiratory problems and metabolic complications (hypoglycemia,
hyperbilirubinemia, hypocalcaemia)
● Development of obesity and diabetes during childhood.

Note: Pregestational/Overt diabetes - Leads to more congenital anomalies

GDM - Leads to more macrosomia and premature delivery
The risk of complication in Overt Diabetic women is twice as much as in GDM

Treatment of pre-existing Diabetes when planning pregnancy

 Glycemic Control:
Women with diabetes, planning pregnancy should strive to achieve blood glucose and
haemoglobin A1C (HbA1C) levels as close to normal as possible while avoiding hypoglycemia.
Overweight and obese women need to lose weight prior to conception.

 Adjustment of Medical Therapy:

● In women on insulin therapy, the multi dose regimen (MDI) is the most appropriate option
to facilitate target achievement and to allow flexible dosing adjustment during pregnancy.
The insulin dose may need to be increased as pregnancy advances.

● The physiology of pregnancy necessitates frequent titration of insulin to match changing

requirements and underscores the importance of daily and frequent self-monitoring of
blood glucose.

● In the first trimester, there is often a decrease in total daily insulin requirements, and
women with type 1 diabetes, may experience increased hypoglycemia.

● In the second trimester, rapidly increasing insulin resistance requires weekly or bi- weekly
increases in insulin dose to achieve glycemic targets.

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● All oral hypoglycemic medications except metformin should be stopped and replaced with
insulin.

● Folic acid 5 mg OD needs to be supplemented 3 months before withdrawing contraception

and continued until breastfeeding.

 Retinal assessment:
● A baseline assessment of diabetic retinopathy is recommended to assess for any treatable
condition which can be stabilized preconception. Women with established retinopathy
should have retinal assessment done once in each trimester because of the risk of
progression during pregnancy.

● In addition, rapid implementation of tight glycemic control in the setting of retinopathy is

associated with worsening of retinopathy.

 Renal assessment:
Measuring urine albumin to creatinine ratio, serum creatinine, should assess renal functions, and
estimated Glomerular Filtration Rate (GFR) before conception. Any significant changes can be
assessed by nephrologist and stabilized prior to conception. Refer to nephrologist if the serum
creatinine>120 umol/l or eGFR<60 ml/min

 Control of Hypertension:
It is important to control blood pressure prior to conception to avoid deterioration post conception.
ACE inhibitors and Angiotensin Receptor Blockers (ARBs) should be replaced with safer
medication like Labetalol and Methyldopa.

 Thyroid function:
Thyroid function should be assessed before pregnancy

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Checklist for with Pre-existing Diabetes

Attain preconception HbA1C <7.0%
Assess and manage any diabetic complication
Shift to multiple daily insulin (MDI), in patients on premixed insulin.
Achieve good blood pressure control on safe anti-hypertensive medication.
Supplement Folic Acid 5 mg OD: 3 months pre-conception
Discontinue potential teratogenic medications e.g.: ACE-inhibitors/ARB’s, Statins, etc.

Gestational Diabetes Mellitus (GDM)

GDM is defined as a condition associated with maternal hyperglycemia less severe than that found
in patients with overt diabetes but associated with an increased risk of adverse pregnancy outcome.
Pregnancy is characterised by insulin resistance and hyperinsulinaemia. The resistance results
from placental secretion of diabetogenic hormone, as well as increased maternal adipose
deposition, decreased exercise, and increased caloric intake. GDM occurs when the pancreatic
function is not sufficient enough to overcome the insulin resistance created by changes in
diabetogenic hormones during pregnancy

Risk factors for developing GDM:

● BMI ≥ 30
● Past history of GDM
● First-degree relative with diabetes
● Previous history of macrosomia (baby weight ≥4 kg)
● History of previous unexplained IUFD
● Women with polycystic ovary syndrome
● A1C ≥5.7%, impaired fasting glucose (IFG), or impaired glucose tolerance (IGT) on a previous
diabetes screening test
● Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis
nigricans)

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Screening and diagnostic testing:

When to screen:
Universal screening is recommended at first prenatal visit, irrespective of the trimester.

The International Association of Diabetes and Pregnancy Study Groups (IADPSG) and
American Diabetes Association (ADA) criteria for a positive two-hour 75-gram oral
glucose tolerance test for the diagnosis of gestational diabetes:
Fasting ≥5.1 mmol/L (≥92 mg/dL)
And /OR
Two-hour PP ≥8.5 mmol/L (≥153 mg/dL)

Oral Glucose Tolerance Test

What is Oral Glucose Tolerance Test (OGTT)?
Oral Glucose Tolerance Test is a test designed to assess the body response to glucose. In OGTT, the
patient is given a glucose solution and blood samples are drawn afterword at intervals to measure how
well the body cells are able to absorb glucose.
Instructions for doing OGTT in pregnant woman:
 OGTT is usually done between 24-28 weeks as a screening for gestational diabetes or early at booking
if woman has risk factors (Algorithm 6)
 There is no need to instruct the woman to prepare or change her diet before the test (low carbohydrate
diet in the 3 days before the test is not recommended)
 The woman is required to fast for 8-10 hours. Advise her not to eat or drink anything except sips of
water.
 Collect venous sample for the fasting plasma glucose immediately when the woman reached the clinic
in the morning.
 Then, give her to drink the oral glucose solution (75 g of anhydrous glucose or 82.5 g of glucose
monohydrate) within 3-5 minutes.
 Collect the second blood samples after 2 hours.
 The women must stay in the clinic for 2 hours and should not eat or drink or do any exercise during
the 2 hours.
Note: There is no need to wait for the result of fasting plasma glucose before given the oral glucose
solution. Also, do not use glucometer to check the FBS.

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ALGORITHM 6: SCREENING FOR DIABETES IN PREGNANCY

All pregnant women at registration

Do FBS / RBS

If FBS <5.1 mmol/l If RBS 7.0 – 11.0 If FBS 5.1 – 6.9 If FBS ≥7.0 mmol/l
or RBS <7.0mmol/l mmol/l mmol/l or RBS ≥11.1 mmol/l

If low risk for GDM Overt Diabetes*

If high risk for Do OGTT
GDM treatment
GDM

Do OGTT at 22- Refer to an

24 weeks of Obstetrician and
If FBS If FBS <5.1
Gestation Diabetologist or to a
≥5.1mmol/l or mmol/l or
combined clinic if
2 hrs PG ≥8.5 2hrs PG
available
mmol/l <8.5mmol/l

GDM Repeat OGTT at 22 – 24

**
weeks of Gestation

Diagnostic Criteria for

positive OGTT for the If two blood
Diagnosis of GDM: glucose values are

FBS ≥ 5.1 mmol/l

OR
Two hours ≥ 8.5 mmol/l Refer to Dietician and follow the Initiate oral
blood Glucose profile by Family hypoglycaemic
* physician. (If Family physician is not medication (Metformin)
Confirm the diagnosis
available refer to Diabetologist
by doing Glycosylated
/Obstetrician)
Hb
** If FBS≥7.0mmol/l If uncontrolled
diagnose Overt Diabetes.

Target capillary blood glucose values: Pre-Prandial: ≤5.3mmol/l, 2hrs Post-Prandial:

≤6.7mmol/l

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Do OGTT at 22-24 weeks of Gestation

If FBS ≥5.1mmol/l or 2 hrs PG ≥8.5 mmol/l
If FBS <5.1 mmol/l or 2hrs PG <8.5mmol/l
Refer to an Obstetrician and Diabetologist or to a combined clinic if available
If two blood glucose values are abnormal

GDM
Repeat OGTT at 22 – 24 weeks of Gestation**
Refer to Dietician and follow the blood Glucose profile by Family physician. (If Family physician is not
available refer to Diabetologist /Obstetrician)
Target capillary blood glucose values: Pre-Prandial: ≤5.3mmol/l, 2hrs Post-Prandial: ≤6.7mmol/l
Initiate oral hypoglycemic medication (Metformin)
If uncontrolled
*Confirm the diagnosis by doing Glycosylated Hb
** If FBS≥7.0mmol/l diagnose Overt Diabetes.

Diagnostic Criteria for positive OGTT for the

Diagnosis of GDM:
FBS ≥ 5.1 mmol/l
OR
Two hours ≥ 8.5 mmol/l

Management of GDM and Overt Diabetes:

Rationale for treatment: Identifying women with GDM is important because appropriate therapy
can decrease foetal and maternal morbidity, particularly macrosomia.
1. Management of lifestyle:
 A. Nutritional therapy:
All patients with GDM should receive nutritional counselling by a registered dietician (when
possible) upon diagnosis and be placed on an appropriate diet. The goals of medical nutritional
therapy are to:
● Achieve normoglycemia
● Prevent ketosis
● Provide adequate weight gain

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● Contribute to foetal well-being

Calorie allotment: Calorie allotment is based on ideal body weight and is calculated based on the
current weight of the pregnant woman. The suggested caloric intake is approximately:
● 30 kcal per kg current weight per day in pregnant women (BMI 22 to 25).
● 24 kcal per kg current weight per day in overweight pregnant women (BMI 26 to 29).
● 12 to 15 kcal per kg current weight per day for obese pregnant women (BMI >30).
● 40 kcal per kg current weight per day in pregnant women (BMI <22).

TABLE 19: CURRENT INSTITUTE OF MEDICINE (IOM) WEIGHT GAIN GUIDELINES

Pre-Pregnancy BMI Recommended range of Rate of weight gain in 2nd and
total weight gain (Kg) 3rd Trimester (in kg/week)
BMI <18.5 12.5 – 18.0 0.51(0.44-0.58)
BMI 18.5 - 24.9 11.5 – 16.0 0.42(0.35-0.5)
BMI 25.0 - 29.9 7.0 – 11.5 0.28(0.23-0.33)
BMI > or = 30 5.0 – 9.0 1.22(0.17-0.27)
N.B: Calculations assume a 0.5 to 2 kg weight gain in the first trimester
 B. Exercise:
The ADA encourages a program of moderate exercise (e.g., walking for 30 minutes) as part of the
treatment plan for women with GDM when there are no medical or obstetrical contraindications to
this level of physical activity.
2. Glucose monitoring:
Multiple daily self-measurements of blood glucose are important as they help in identifying women
who should begin an antihyperglycaemic agent and appears to decrease the risk of macrosomia.
More frequent monitoring is advised for patients on insulin therapy, ideally should be done daily,
pre and post meals.

TABLE 20: MINIMUM MONITORING REQUIRED FOR PREGNANT WOMEN ON ORAL THERAPY
Fasting Post Breakfast Pre-Lunch Post Lunch Pre-dinner Post Dinner
Sunday ✔
Monday ✔
Tuesday ✔
Wednesday ✔
Thursday ✔
Friday ✔

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Note: Glycaemic targets:

Premeal - ≤5.3 mmol/L (95 mg/dL)
2 h Post meal- ≤ 6.7 mmol/L (120 mg/dL)

3. Medical therapy:
 A. Oral hypoglycemic agents:
Women with diabetes may be advised to use Metformin as an adjunct or alternative before starting
insulin. Metformin can be initiated at a dose of 500mg twice daily and increased up to 2.5g/day.
Dose increments should be done over 3-5 days both to reduce gastrointestinal side effects and to
permit identification of the minimum dose required for adequate glycemic control.

 B. Injectable:
Insulin (Detemir, NPH, Regular Insulin, Aspart, Lispro all fall in Category B of US -FDA),
Glargine in category C.
Insulin:
● None of the currently available insulin preparations have been demonstrated to cross the
placenta.
● Approximately 15% of women with GDM require insulin therapy because target glucose
levels are exceeded despite, they are being on dietary therapy and metformin.
● As a basal supplement with an intermediate to long-acting preparation NPH, glargine,
detemir supresses hepatic glucose production and maintain near normoglycemia in the
fasting state. So, if fasting blood glucose concentration is high, intermediate-acting insulin,
such as NPH (or other basal insulin e.g., detemir or glargine if available) is given before
bedtime.
● As a pre-meal (prandial) bolus dose of short-acting (regular) or rapid-acting Lispro or
Aspart, to cover the extra requirements after food is absorbed. If post prandial blood
glucose level is high, insulin Aspart or insulin Lispro can be given before meals (doses
should be individualized based on blood glucose elevation, small doses 2-4 unites can be
started if mild elevation and should be adjusted bi-weekly).
● If both pre-prandial and postprandial blood glucose concentrations are high, then initiate a
four-injection regimen per day, and this should be individualized. If the readings showed
marked hyperglycemia, then insulin doses can be calculated as follows:

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● A total dose of:

- (0.7 unit/kg up to week 12),
- (0.8 unit/kg for weeks 13 to 26),
- (0.9 unit/kg for weeks 26 to 36), and
- (1.0 unit/kg for weeks 36 to term).

● Use 50% of TDD for basal insulin and 50% for pre-meal rapid-acting insulin boluses
● Patients with T1D
● 10-14 weeks gestation: period of increased insulin sensitivity; insulin dosage may need to
be reduced accordingly.
● 14-35 weeks gestation: insulin requirements typically increase steadily.
● >35 weeks gestation: insulin requirements may level off or even decline.
● In severely obese woman, the initial doses of insulin may need to be increased to 1.5 to 2.0
units/kg to be able overcome the combined insulin resistance of pregnancy and obesity.
● Avoid hypoglycemia as frequent hypoglycemia can be associated with intrauterine growth
restriction.

 C. Asprin:
● Add Aspirin (75 mg – 150 mg) from 12 weeks of gestation.

4. Peri- and Post-partum management:

 Peri-partum management:
● Maternal hyperglycemia should be avoided during labour to reduce the risk of foetal
acidosis and neonatal hypoglycemia.
● Maternal blood glucose levels should be kept between 4.0 -7.0 mmol/L.
● Women should receive adequate glucose during labour in order to meet the high energy
requirements. Routine IV Dextrose and IV insulin protocols may be helpful
● Post-partum follow-up:
● Encourage women to breastfeed post-delivery.
● Metformin may be used during breast-feeding.

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● Because GDM may represent pre-existing undiagnosed type 2 or even type 1 diabetes,
women with GDM should be tested for persistent diabetes or prediabetes at 6–12 weeks
postpartum with a 75g OGTT using non-pregnancy criteria for diagnosis.
● For those with Type 1 diabetes, advised to continue pre pregnancy insulin doses.
● Both metformin and intensive lifestyle intervention prevent or delay progression to
diabetes in women with a history of GDM.
● We recommend that all women who have had gestational diabetes receive counselling on
lifestyle measures to reduce the risk of type 2 diabetes, and the need for regular diabetes
screening, especially before any future pregnancies.

 Contraception:
● Any type of contraception is acceptable.
● Low-dose oestrogen-progestin oral contraceptives may be used in women with a history of
GDM as long as there is no medical contraindication.
● Progestin-only (but not combined oestrogen-progestin) oral contraceptives (OCs) have
been associated with an increased risk of developing type-2 diabetes in women with recent
GDM.

Future risks:
These patients are at high risk for recurrent GDM, impaired glucose tolerance, and overt
diabetes over the subsequent five years.
Recurrence: One-third to two-thirds of women with GDM will have GDM in their
subsequent pregnancy.

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5. Follow-up and prevention of type-2 Diabetes Mellitus

All women with previous GDM should undergo an oral glucose tolerance test 6 to 12 weeks after
delivery, using a two-hour 75-gram oral glucose tolerance test. An abnormal fasting blood glucose
level is diagnostic.
a) Diagnose diabetes, if fasting glucose level is ≥7 mmol/L (126 mg/dl) and/or 2-hour post
glucose level is ≥11.1 mmol/L (200mg/dl),
b) Diagnose impaired fasting glucose if fasting blood glucose level is 5.5-6.9 mmol/L (100-125
mg/dl) and
c) Diagnose impaired glucose, tolerance if the 2-hour post glucose load ranges from 7.8-11
mmol/L (140-200 mg/dl)

Follow-ups:
Those with impaired glucose tolerance should be counselled about their risk for developing
overt diabetes and referred for proper management.
They should have annual assessment of their glycaemic status
Women with normal glucose tolerance should be counselled regarding their risk of
developing GDM in subsequent pregnancies and Type 2 diabetes in the future, long-term
follow up is essential. Reassessment of glycaemic status should be undertaken every two
years

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2.3.6 Hypertension in Pregnancy

• Hypertensive disorders during pregnancy are one of the leading causes of maternal morbidity
and mortality.
• Hypertension in pregnancy is associated with higher rates of preterm birth, placental abruption,
intrauterine growth restriction, stillbirths, and perinatal mortality.
• Early detection and management of women with high risk factor is critical to the management of
pregnancy-induced hypertension and the prevention of convulsions. These women should be
followed up regularly and given clear instructions on when to return to their health care provider.

Screening for hypertension should be done all pregnant women in each ANC visits

Classification of Hypertension in pregnancy:

There are three major hypertensive disorders that occur in pregnant women:
1. Chronic hypertension
2. Gestational hypertension
3. Preeclampsia - eclampsia

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ALGORITHM 7: HYPERTENSION IN PREGNANCY

Pregnant women with blood pressure >= 140/90

(on two occasions at least one hour)

If HTN before pregnancy OR If High BP first discovered

High BP before 20 weeks gestational after 20 weeks gestational age
age

1 or more of the following:

Proteinuria, End-organ dysfunction,
foetal growth effects

No Yes

Chronic Gestational Pre- eclampsia &

Hypertension hypertension eclampsia

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Preconception Care of Women in Reproductive Age with Hypertension Include:

● Counselling about the risks of hypertension during pregnancy
● All women with chronic HTN, should be counselled earlier in their hypertension clinics
about the need to change their medication regimen if they become pregnant or planning for
pregnancy.
● Women who have chronic hypertension should be evaluated annually for end-organ effects
(e.g., renal insufficiency, retinopathy, ventricular hypertrophy,).
● Hypertension should be controlled prior to conception.
● Offer pregnant women with hypertension advice on weight management, exercise, healthy
eating and lowering the amount of salt in their diet.
● Advice early registration and monitoring after pregnancy confirmation
● Folic acid should be prescribed for all women at preconception care 3 months before
pregnancy and continue on it till the end of pregnancy
●
Risk Factors for Preeclampsia at ANC Booking Assessment

TABLE 21: RISK FACTORS FOR PREECLAMPSIA AT ANC BOOKING ASSESSMENT

Moderate risk factors include: High risk factors include:

● First pregnancy ● Hypertensive disease in a previous
● Age 40 years or older pregnancy
● Pregnancy interval of more than 10 years ● Chronic kidney disease
● Body mass index (BMI) ≥ 35 kg/m2 at first ● Autoimmune disease, such as systemic lupus
visit erythematosus or antiphospholipid syndrome
● Family history of pre-eclampsia ● Type 1 or type 2 diabetes
● Multiple pregnancy ● Chronic hypertension

Note: Aspirin (75 mg – 150 mg) per day is recommended for pregnant women with at
least two moderate risk factors or at least one high risk factor for preeclampsia to take as
early as pregnancy is confirmed (preferably 12 weeks) and consider for continuation until
36 weeks of gestation.

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Management of Hypertension in Pregnancy and Postpartum

1. Chronic Hypertension in Pregnancy

Definition:
Chronic hypertension is diagnosed by BP of 140/90 mm Hg and above (on two occasions taken at
least four hours apart) that is present at the booking visit, or before 20 weeks, or if the woman is
already taking antihypertensive medication or persisted high BP 12 weeks after delivery.

Classification:
● Mild HTN: BP (140/90 – 149/99 mmHg)
● Moderate HTN BP 150-159 /100 –109 mmHg
● Severe HTN: BP ≥ 160/110 mmHg
● Assess the risk factors for preeclampsia (see Table 10)

Antenatal Management of Chronic Hypertension:

1. Do baseline investigations (if not done for the last 3 months): RFT, uric acid, LFT, TFT,
urine albumin creatinine ratio and ECG for all cases.
2. Start/adjust antihypertensive medication:
a. Chronic HTN on medication:
- Discuss the case with obstetrician by phone
- Continue treatment, if safe to do so unless blood pressure is < 110/70 mmHg or the
woman has symptomatic hypotension.
- Change to safe drugs in pregnancy i.e., Stop ACE inhibitors, ARBs and diuretics within
2 days (if not stopped pre pregnancy) and offer safe alternatives (see table 15)

b. Chronic HTN not on medications or diagnosed at booking:

- Monitor by BP chart for 5 days
- Discuss the case with obstetrician by phone
- Initiate antihypertensive therapy if persistent systolic BP ≥140 mmHg or diastolic BP
of 90 mmHg, or signs of hypertensive target-organ damage.

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- Treat with first line drug Labetalol 200 mg (based on the BP chart), nifedipine 20 mg
for women in whom labetalol is not suitable, or methyldopa 250 mg if both labetalol
and nifedipine are not suitable.)
- Aim: BP < 135/85mmHg (Don’t lower BP to less than 130 /80 mmHg)
- Start 75 mg of Aspirin daily from 12 week till birth
Instruct woman to report any symptoms suggestive of preeclampsia, decreased foetal
movement, vaginal bleeding and signs of preterm labour

3. Do ultrasound scan: Routine (dating scan, anomaly scan) plus additional foetal growth
scans every 4 weeks until delivery.
4. Refer to obstetrician in secondary care:
- Mild – Refer the case with urgent appointment
- Moderate HTN: Discuss the case with obstetrician and refer as advised
- Severe HTN: Escort as EMERGENCY after stabilization
5. Antenatal follow up:
- Pregnant women should be following up in secondary / tertiary care
- They can be given additional antenatal appointments in Health center as advised by
obstetrician (shared care)

2. Gestational hypertension
Definition:
- Not known hypertensive
- Elevated blood pressure first detected after 20weeks of gestation in the absence of
proteinuria or new signs of end organ dysfunction
- BP readings should be documented on two occasions at least four hours apart.

Classification
- Mild HTN: BP (140/90 – 149/99 mmHg)
- Moderate HTN BP 150-159 /100 –109 mmHg
- Severe HTN: BP ≥ 160/110 mmHg

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Antenatal Management of gestational hypertension

1. Do full assessment which should include history, examination and assessment of risk
factors
2. Measure full blood count, liver function and renal function at presentation
3. Discuss the case with obstetrician by phone
4. Start antihypertensive medication as follow:
a) Mild – Moderate gestational HTN:
- Start anti-hypertensive treatment if BP remains above 140/90 mmHg.
- Treat with first line oral Labetalol 200 mg (based on BP chart). Alternatives include
Methyldopa and Nifedipine SR.
- Aim of BP below 135/85 mmHg
- Measure BP and check for proteinuria once to twice weekly (depending on BP) until BP
is 135/85 mmHg or less
- Measure full blood count, liver function and renal function at presentation and then
weekly
- Refer mild cases with urgent appointment
- For moderate cases, discuss with obstetrician and refer accordingly
b) Severe gestational HTN:
- Give intravenous hydralazine or labetalol (oral or Intravenous), repeat the dose every 15
minutes
- Test for proteinuria and look for signs and symptoms of pre-eclamspia/eclampsia and
managed accordingly (algorithm)
- Stabilize and escort to secondary / tertiary care as emergency as soon as possible
- Note: until escorting the patient measure BP every 15minutes
Note: The cases with gestational hypertension should be followed up at secondary and tertiary
hospitals for plan of management

3. Pre-eclampsia
Definition:
- New onset of hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) after
20 weeks of pregnancy and the coexistence of one or more of the following new-onset
conditions:

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i. Proteinuria (urine protein: creatinine ratio of 30 mg/mmol or more or albumin:

creatinine ratio of 8 mg/mmol or more, or at least 1 g/litre [2+] on dipstick
testing) or
ii. Other maternal organ dysfunction:
- Renal insufficiency (creatinine 90 micromol/litre or more)
- Liver involvement (elevated transaminases [alanine aminotransferase or
aspartate aminotransferase over 40 IU/litre] with or without right upper quadrant
or epigastric abdominal pain)
- Pulmonary oedema
- Neurological complications such as eclampsia, altered mental status, blindness,
stroke, clonus, severe headaches or persistent visual scotomata
- Haematological complications such as thrombocytopenia (platelet count below
150,000/microlitre), disseminated intravascular coagulation or haemolysis
- HELLP syndrome
Haemolysis, elevated liver enzymes and low platelet count.

iii. Uteroplacental dysfunction such as foetal growth restriction, abnormal

umbilical artery doppler waveform analysis, or stillbirth.

- BP readings should be documented on two occasions at least four hours apart. If systolic
BP ≥ 160 mmHg or diastolic ≥ 110 mmHg confirmation within minutes is sufficient
- Look for symptoms and signs of severe preeclampsia (severe headaches, visual
scotomata, nausea or vomiting, epigastric pain, oliguria and severe hypertension, as well
as progressive deterioration in laboratory blood tests such as rising creatinine or liver
transaminases or falling platelet count, or failure of foetal growth or abnormal Doppler
findings.)

Classification
● Preeclampsia
● Preeclampsia superimposed on chronic hypertension

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Antenatal management of pre-eclampsia:

1. Carry out a full clinical assessment at each antenatal appointment
2. If BP 150/100 to159/109 mmHg: Give Intravenous hydralazine or intravenous labetalol (if
injection is not available give oral labetalol 200 mg) and escort as emergency to secondary
/ tertiary hospital
3. If BP ≥ 160/110mmHg or there is symptoms or signs of severe preeclampsia:
- Treat women with severe hypertension who are in critical care during pregnancy or after
birth immediately with one of the following:
- labetalol (oral or intravenous) or
- Intravenous hydralazine (if available)
- Give magnesium sulphate (loading dose 4 g (Prepare 8 ml of 50% magnesium sulphate
solution + 12 ml of normal saline). To be given slowly IV over 15-20 minutes.),
followed by an infusion of 1 g/hour maintained for 24 hours. If the woman has had an
eclamptic fit, the infusion should be continued for 24 hours after the last fit. If patient
developed respiratory arrest, stop magnesium sulphate and give calcium gluconate
(Antidote for MgSo4) 1 g (10 ml of 10% solution) IV slowly until respiration begins.
Note: Do not use diazepam, phenytoin or other anticonvulsants as an alternative to
magnesium sulfate in women with eclampsia.

● Stabilize and Escort the patient to secondary / tertiary hospital. Repeat BP measurement
after 15–30 minutes when waiting for the ambulance
● Severe hypertension can be confirmed within a short interval (minutes)

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ALGORITHM 8: SUMMARY OF ASSESSMENT AND MANAGEMENT OF PREGNANT WOMEN WITH HIGH

BLOOD PRESSURE
At any antenatal visit, pregnant women with blood pressure
>= 140/90 (at least 2 readings within one hour)

• Medical History: - known case of HTN (with or without treatment), Chronic kidney disease, Type 1 or 2
diabetes, autoimmune disease such as systemic lupus erythematosus or anti phospholipid syndrome
• Past obstetric history: - hypertensive diseases in previous pregnancies
• Family History: - HTN, pre-eclampsia
• Risk factors for developing Pre-eclampsia: first pregnancy, Age 40 yrs. or older, pregnancy interval of more
than 10 yrs., multiple pregnancy
• Clinical examination: BMI >30, Pulse, pedal edema, puffiness in face, hands and feet, weight gain, abdominal
examination
• Do baseline investigations: urine dipstick for protein, urine microscopy, CBC, U&E, LFT, Uric acid, urine
albumin to creatinine ratio.
• Ultrasound: foetal viability, gestational age, foetal weight

Danger symptoms & signs of pre-eclampsia

 Headache, visual disturbance, vomiting, epigastric pain, puffiness in hands, feet and face
 Proteinuria
 End organ dysfunction (Renal insufficiency, Elevated liver enzymes, low platelets)
 Foetal growth restriction

No Yes

Mild to Moderate (Bp Severe Pre- eclampsia &

140-159/90-109) (Bp >=160/110) eclampsia

 Start oral antihypertensive medications  Give Hydralazine 5 g IV or

 Give Hydralazine 5 g IV or
(Labetalol 200 mg, nifidiine 20 mg SR if Labetalol 200 mg orally for all
Labetalol 200 mg orally for
labetalol not suitable, Methyldopa 250 patients.
all patients.
mg if both labetalol and nifidipine are not  If BP >=160/110 Give
 Stabilize the patient and
suitable) Magnesium sulphate IV
escort as emergency to
 Start aspirin 75- 150 mg for all patients  Be aware of possible respiratory
hospital for further
once daily from 12 weeks. arrest due to magnesium sulphate,
assessment and
 Refer to secondary care as urgent investigations to rule out. give anti dot (calcium gluconate)
appointment. IV slowly.
 Discharge home with BP chart  Manage convulsions (page)
 If in labour, expedite delivery if
Follow up BP chart and urine
possible
protein after one week  Stabilize the patient and escort
as emergency to hospital.
Upgrade treatment gradually
UNONTROLL If any Danger
aim for target BP of 135/85
signs appear any
Re-assess Danger signs.
times

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TABLE 22: SAFE ANTIHYPERTENSIVE MEDICATION IN PREGNANCY

Usual
Drug Starting dose effective Max dose Remarks
dose
Labetalol 100 mg tab twice 200 to 800 2400mg • First line of treatment
daily mg in two • Labetalol should be used
or three in cautious in women with
divided history of asthma & heart
Injection 20 mg doses. failure
IV over 2 minutes
initially then 40-
80 mg IV every Total dose
10 minutes should not
exceed 300
mg
Methyldopa 250 mg tabs two 1000 mg in 3000 mg •Contraindicated in
to three times a 2-3 divided depression
day doses
Nifedipine 20 mg BID 30 to 90 mg 120 mg • can be added as a second
SR OD line treatment
Hydralazine 5mg IV slowly Only for 20 mg • Only for severe
IV over 3-4 minutes, emergency hypertension; BP ≥ 160/110
if IV not possible mmHg
give IM

d) Eclampsia
Definition:
A convulsive condition associated with pre-eclampsia.
Antenatal management:
● Maintain ABC (Airway, Breathing, Circulation)
● Manage convulsions
- Gather equipment (airway, suction, mask and bag, oxygen) and give oxygen at 4-6 L
per minute.

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- Protect the woman from injury but do not actively restrain her.
- Start an IV line and infuse IV fluids (maintenance dose: 80 ml/hr or 1ml/kg/hr) after the
convulsion.
- Give anticonvulsive drug: 4 g of 20 % magnesium sulphate loading dose. To be given
slowly IV over 5-15 minutes. · If unable to give IV, give 10 g of magnesium sulphate
IM divided into 2 doses; give 5 g (10 ml of 50% solution) IM deep in upper outer
quadrant of each buttock with 1 ml of 2% lignocaine in the same syringe.
- Recurrent fits should be treated with a further dose of 2–4 g given intravenously over 5
to 15 minutes.

To Prepare 4 g of 20 % magnesium sulphate take 8 ml of 50% magnesium

sulphate solution (4 mEq / ml) + 12 ml of normal saline

- Note: in case of respiratory arrest (caused by magnesium sulphate):

- Assist ventilation with face mask and bag
- Give calcium gluconate 1 g (10 ml of 10% solution) IV slowly until calcium
gluconate begins to antagonize the effects of magnesium sulphate and respiration
begins.
● Position the woman on her left side to reduce risk of aspiration of secretions, vomit and
blood.
● Give antihypertensive medications such as labetalol oral or IV as first line, if still BP
uncontrolled, give Hydralazine 5 mg IV, slowly over 3-4 minutes, if diastolic BP ≥ 100
mmHg. If IV not possible give IM, if diastolic blood pressure remains > 90 mmHg, repeat
the dose at 30-minute intervals until diastolic BP is around 90 mmHg. Do not give more
than 20 mg in total.
● Aspirate the mouth and throat as necessary.
● Monitor vital signs (pulse, blood pressure, and respiration), reflexes and foetal heart rate
hourly.
● If in labour, expedite delivery if possible
● Do Not give ergometrine after delivery
● Escort as an emergency after resuscitation (If not in labour)

New onset postpartum hypertension may be due to onset of preeclampsia or HELLP

syndrome after delivery

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Treatment of hypertension during the postnatal period, including during breastfeeding

● Postpartum Hypertension and pre-eclampsia are either persistent or exacerbated
hypertension in women with previous hypertensive disorders of pregnancy or a new onset
condition present for the first time in the postnatal period.
● 81 % of new onset hypertension (Gestational hypertension and pre-eclampsia) usually
resolves and normalize with 3 months post-partum, but it can be persistent up to 6 months
● It is important to advice the women to seek medical help if they develop severe headaches
or if blood pressure increases to severe levels.
● Advise women with hypertension who wish to breastfeed that their treatment can be
adapted to accommodate breastfeeding, and that the need to take antihypertensive
medication does not prevent them from breastfeeding.
● Explain to women with hypertension who wish to breastfeed that:
- most antihypertensive medicines taken while breastfeeding only lead to very low
levels in breast milk, so the amounts taken in by babies are very small and would be
unlikely to have any clinical effect
- As antihypertensive agents have the potential to transfer into breast milk: advise women
to monitor their babies for drowsiness, lethargy, pallor, cold peripheries or poor feeding.
● Most common medications that can be used and considered safe during breast feeding:
⮚ First- line treatment: ACE inhibiters: (enalapril, captopril, avoid all other ACE
inhibiters) except in women of African family origin, in whom a Calcium Channel
blocker: (Nifedipine SR or amlodipine) would be used as first- line.
⮚ Second - line treatment: Beta blockers (less secreted in milk): Labetalol,
metoprolol, propranolol, avoid other beta blockers (highly secreted in milk) such
as atenolol.
● For women with hypertension in the postnatal period, if blood pressure is not controlled
with a single medicine, consider a combination of nifedipine (or amlodipine) and enalapril.
If this combination is not tolerated or is ineffective, consider either:
- Adding labetalol or atenolol to the combination treatment or
- Swapping 1 of the medicines already being used for labtalol or atenolol
● When treating women with antihypertensive medication during the postnatal period, use
medicines that are taken once daily when possible.
● Treat women with hypertension in the postnatal period who are not breastfeeding and who
are not planning to breastfeed as any non-pregnant women.
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TABLE 23: SAFE ANTIHYPERTENSIVE DRUGS CAN BE USED DURING BREAST FEEDING
Class Drugs considered save Avoid- potentially harmful, No or Limited data
Beta blockers Labetalol, propranolol, Avoid atenolol, no data for other beta blockers
metoprolol
Calcium channel Nifedipine, amlodipine Limited data for Diltiazem, verapamil
blockers Avoid other calcium channel blockers
ACE inhibiters Captopril, enalapril Other ACE inhibiters
Angiotensin None No data
receptor
blockers
Thiazide None Limited data
diuretics
Other Methyldopa, Hydralazine Limited data for Prazocin

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ALGORITHM 9: POSTPARTUM HYPERTENSION

Postpartum Hypertension

Measure blood pressure: (BP chart to be given at discharge from hospital): -

Daily for the first 2 days after birth
At least once between day 3 and day 5,
Then as clinically indicated if antihypertensive treatment is changed after birth.

Chronic Hypertension Gestational Pre-eclampsia

Hypertension

Chronic hypertension usually Usually resolve spontaneously within Usually resolve spontaneously
persists after delivery and patient 3 to 6 months post-partum
within 3 to 6 months post-
needs to continue her medications: If woman was on antihypertensive
partum
medications in pregnancy: -
If not breast feeding, to Woman should be followed up
Continue antihypertensive
resume her medications that she at secondary / tertiary care and
treatment, if required (choices of safe
was using before pregnancy and antihypertensive during breast feeding if referred to primary care a clear
refer her to hypertension clinic shown in table) action plan must be written.
in health centre for follow up. Reduce the dose of antihypertensive Women should be advised to
If breast feeding, choose one treatment if their blood pressure falls
seek medical attention if they
below 130/80 mmHg.
antihypertensive medication develop severe headaches or if
Stop the medications if blood
safe in breast feeding as in blood pressure increases to
pressure <110/80
(table) and refer her to If a woman has taken methyldopa to severe levels.
hypertension clinic in health treat gestational hypertension, stop Measure platelet count,
centre for follow up. within 2 days after the birth and change transaminases and serum
Aim to keep blood pressure to an alternative treatment if necessary
creatinine 48–72 hours after
to avid postpartum depression
lower than 140/90 mmHg birth, if normal do not repeat
If not on antihypertensive
medications: - Check for proteinuria at 6–8
Start medications if Blood Pressure weeks after birth.
>150/90

Refer the woman for a medical review at Hypertension Clinic in health centre at 2 weeks & 6 weeks postpartum

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Risk of recurrence of hypertensive disorders in future pregnancies: -

TABLE 24: PREVALENCE OF HYPERTENSIVE DISORDERS IN A FUTURE PREGNANCY

Type of hypertension in ● Risks in future
previous or current pregnancy
Gestational hypertension ● gestational hypertension in future is about ≈11% to 15%
(up to 1 in 7 women)
● pre-eclampsia - about ≈7% (1 in 14 women)
● chronic hypertension in the future is about ≈3% (up to 1
in 34 women)
pre-eclampsia ● gestational hypertension in future about ≈6% to 12% (up
to 1 in 8 women)
● pre-eclampsia in future is up to about ≈16% (1 in 6
women)
● If birth was at 28–34 weeks1: ≈33% (1 in 3 women)1
● If birth was at 34–37 weeks: ≈23% (1 in 4 women
● chronic hypertension in the future is about ≈2% (up to 1
in 50 women)

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2.3.7 Thyroid diseases in pregnancy

▪ Thyroid diseases are commonly encountered during pregnancy. Women may already
have the diagnosis prior to conception or may be first diagnosed after becoming pregnant.
▪ If untreated during pregnancy is might be associated with an increased risk of
miscarriage, premature birth, placental abruption, hypertensive disorders, growth
restriction and foetal neurocognitive and developmental abnormalities

Preconception Care
Women with hypothyroidism should be counselled about:
▪ The importance of immediate monitoring at the onset of pregnancy
▪ To notify their physician immediately, after a missed menstrual cycle or positive home
pregnancy test, to adjust their doses, by increasing their medication by two additional
doses per week

Women with hyperthyroidism should be counselled about:

▪ Discussion of available treatment, (long term anti thyroid medication, radioactive iodine
ablation, and subtotal thyroidectomy) and potential adverse effects, as well as the impact
on future pregnancies
▪ A significant increase in congenital malformations and neonatal hypothyroidism has
been reported when hyperthyroidism is not controlled in the first trimester of pregnancy
▪ Although radioactive iodine ablation is not associated with long term consequences on
gonadal function, fertility, or pregnancy outcomes, women should wait six months after
the therapeutic dose is administrated.
▪ The importance of achieving euthyroidism before conception.

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Thyroid Disease Screening in Pregnancy

▪ Universal TSH screening for thyroid disease in pregnancy is not recommended.
▪ Targeted screening by Thyroid Stimulating Hormone (TSH) is recommended for women
at high risks, including women with history of
- Thyroid disease
- Current or past use of thyroid therapy
- Any therapeutic intervention for hyperthyroidism e.g., surgery, radioactive iodine
- Postpartum thyroid dysfunction
- Symptoms suggestive of thyroid dysfunction
- Examination findings goitre, nodules, etc.
- Type 1 diabetes mellitus
- Autoimmune disorder
- Infertility
- Morbid obesity, (BMI >= 40)
- Recurrent miscarriage
- Previous delivery of infant with thyroid disease
- Family history of autoimmune thyroid disease
The optimal method to screen is to do Thyroid Stimulating Hormone (TSH).

If Thyroid Stimulating Hormone (TSH) is abnormal refer the patient with urgent referral to
physician/endocrinologist and obstetrician, (She should be informed about the risk of delay
review by medical team on her and foetus, if she is following in another hospitals, she may need
to arrange early appointment with them)

Most common thyroid diseases encountered in pregnancy:

- Hypothyroidism
- Hyperthyroidism and thyroid storm
- Thyroid nodules and cancers
- Postpartum thyroiditis

Hypothyroidism
Maternal hypothyroidism is defined as the presence of an elevated TSH and a decreased serum
FT4 concentration during gestation, with both concentrations outside the (trimester-specific)
reference ranges.

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▪ Clinical symptoms include: - cold intolerance, muscle cramps, weight gain, oedema, dry skin,
hair loss
▪ The most frequent cause of hypothyroidism is autoimmune thyroid disease (Hashimoto's
thyroiditis), where Thyroid Peroxidase Ab (TPOAb) enzyme is high and can be detected in
approximately 30%–60% of pregnant women with an elevated TSH concentration
▪ It is appeared to be a greater risk for adverse events in women who are TPOAb positive
compared to those who are TPOAb negative, even when thyroid function is identical.
▪ Decisions about treatment must be based on both measurement of thyroid function and TPOAb
status

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Diagnosis and Management of Hypothyroidism

ALGORITHM 10: DIAGNOSIS AND MANAGEMENT OF HYPOTHYROIDISM

TPO Ab: thyroid peroxidase antibody

Note:

Appropriate management results in improved outcomes, demonstrating the importance of

proper diagnosis and treatment.

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Hypothyroidism Follow-up:
▪ In women known case of hypothyroidism, Levothyroxine is titrated to achieve a goal
of serum thyroid-stimulating hormone (TSH) level less than 2.5 mIU /L.
▪ All women with overt and subclinical hypothyroidism (treated or untreated) or those at risk for
hypothyroidism (e.g., patients who underwent thyroid surgery, treated with radioactive iodine
or have positive autoimmune antibodies) should be monitored with a serum TSH measurement
every 4 weeks until 20 week gestation, it should be measured again at 24 to 28 weeks and 32 to
34 weeks gestation

Postpartum care of Hypothyroidism:

▪ Women with hypothyroidism should be referred to physician with an early appointment for
further management and follow up
▪ Levothyroxine should be decreased to the pre- pregnancy dosage over a four-week period
and further adjustment should be guided by TSH levels six weeks after delivery then after 3 and
6 months.
▪ More than 50% of women with Hashimoto's thyroiditis required an increase in the pre
gestational thyroid hormone dose in the postpartum period, due to an exacerbation of
autoimmune thyroid dysfunction post-partum
▪ Levothyroxine can be stopped for women with thyroid autoimmunity whose having normalized
or decreased TSH at delivery. Repeat serum TSH at 6 weeks post-partum.

Hyperthyroidism with pregnancy

▪ Hyperthyroidism is less common than hypothyroidism
▪ It can be physiologic change in pregnancy due to the high β-hCG levels like in cases of multiple
gestation and molar pregnancies
▪ It can be induced transiently by hyperemesis gravidarum.
▪ Diagnoses is bases on the clinical symptoms.
▪ Clinical symptoms of hyperthyroidism include: - Tachycardia, nervousness, tremors, heat
intolerance, sweating, weight loss, diarrhea, goiter, eye signs in case of Graves’ Disease,
pretibial myxedema.

Types of hyperthyroidism in pregnancy:

A. Known hyperthyroidism

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B. Overt hyperthyroidism
C. HCG - induced hyperthyroidism
D. Subclinical hyperthyroidism

Management & Follow-up of Hyperthyroidism in Pregnancy

Refer pregnant woman with hyperthyroidism as urgent to physician /endocrinologist
▪ Patients on anti-thyroid medications if presented with fever, sore throat, do CBC if available
and consult the on call physician and refer the patient to rule out agranulocytosis
▪ Follow up throughout pregnancy should be done at secondary/ tertiary care
Thyroid Nodules Detected During Pregnancy
▪ Prevalence: 1-2%, 90-95% of solitary nodules are benign
▪ Aside from history and physical examination, order TSH, then refer her to physician for further
management.
Thyroid Storm (medical emergency)
▪ Also referred to as thyrotoxic crisis, is an acute, life-threatening, hyper metabolic state induced
by excessive release of thyroid hormones in individuals with thyrotoxicosis.
▪ Clinical features include (fever, tachycardia, cardiac arrhythmia, CNS abnormalities, cardiac
myopathy leading to heart failure and pulmonary hypertension)
▪ Patients should be treated in an ICU setting for close monitoring of vital signs and for access to
invasive monitoring and inotropic support, if necessary.
▪ Initial stabilization and management at primary health care includes:
- Supportive measures (connect on cardiac monitor, supplemental oxygen, and intravenous
fluids. Dextrose solutions are the preferred intravenous fluids to cope with continuously high
metabolic demand.
- Aggressively control hyperthermia by applying ice packs and by administering paracetamol
- Administer beta blocker drugs (e.g., propranolol) to minimize sympathomimetic symptoms
orally at a dose of 60-80 mg
- Administer intravenous hydrocortisone 100 mg to decrease peripheral conversion of T4 to
T3. This may also be useful in preventing relative adrenal insufficiency due to
hyperthyroidism and improving vasomotor symptoms.
▪ Escort the patient to secondary care for correcting the hyperthyroid state by administering a
loading dose of antithyroid medications and close monitoring.

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Post-partum care of women with hyperthyroidism

● Refer woman to continue follow up with secondary care.

Postpartum Thyroiditis
▪ Postpartum thyroiditis is defined as an abnormal TSH level within the first 12 months
postpartum
▪ It is the most common form of postpartum thyroid dysfunction and may present as hyper- or
hypothyroidism
▪ Refer urgently to physician whenever detected
▪ Propranolol is the recommended treatment for symptomatic hyperthyroidism
▪ Levothyroxine is indicated for the hypothyroidism in women who are symptomatic,
breastfeeding, or who wish to become pregnant

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2.3.8 Sickle Cell Disease (SCD) in pregnancy

▪ SCD is a group of inherited Autosomal Recessive disorders caused by mutation in the ‘sickle’
gene, which affects haemoglobin structure. It includes sickle cell anaemia (HbSS) and the
heterozygous disorders of combination of haemoglobin S with other abnormal haemoglobin.
▪ Sickle cell trait is a combination of haemoglobin S with normal haemoglobin A

Complications
SCD is associated with both maternal and foetal complications and is a common cause of
maternal mortality and severe morbidity. It is one of the leading causes of maternal near-miss
and contributed to 6 maternal deaths between 2008 and 2021

a) Maternal complications: -
▪ Premature labour
▪ Acute painful crises during pregnancy
▪ Increase in spontaneous miscarriage
▪ Antenatal hospitalization
▪ Delivery by caesarean section
▪ Infection
▪ Thromboembolic events
▪ Increase risk of pre-eclampsia and pregnancy-induced hypertension
▪ Acute chest syndrome

b) Foetal complications
▪ Restricted uterine growth
▪ Perinatal mortality

c) Preconception care
▪ Woman with SCD should be advised to plan their pregnancy to optimize their health and
reduce complications. Woman should be advised to discuss her intention to conceive with
her hematologist/ physician.
▪ All medications need to be reviewed and adjusted by treating hematologist/ physician such
as: Hydroxyurea and ACE I /ARBs which are commonly used in pregnancy to reduce the

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acute attacks and renal compilations respectively, should be stopped at least 3 months
before conception because of teratogenic effect.
▪ Vaccination status should be determined and updated before pregnancy. Women should
be given:
▪ H. influenza type b and the conjugated meningococcal C vaccine as a single dose if they
have not received these vaccinations before.
▪ Pneumococcal vaccine every 5 years.
▪ Hepatitis B vaccine if needed based on her immune status
▪ Influenza vaccine annually
▪ Folic acid (5 mg) should be given once daily preconceptually and throughout pregnancy
▪ Woman should be counselled that SCD is associated with both maternal and foetal
complications as mentioned above.

d) Antenatal care
▪ Booking visit
- Many women with SCD conceive without preconception care. Therefore, all above
actions outlined under preconception care should take place as early as possible and the
woman should be referred to secondary care for review by an obstetrician and a
hematologist /physician.
- Take detailed history of the disease including complications, blood transfusion, ICU
admissions and surgeries in the past.
- Take detailed history of previous pregnancies, outcome and any complications.
- Review medications: if taking hydroxycarbamide, ACE inhibitors or ARBs, these
should be stopped
- Perform clinical examination as outline in the booking visit. It is important to record
baseline blood pressure, and to determine splenic size.
- Women with SCD should be referred to haematologist or physician (if haematologist
not available) and to be screened for end organ damage (if this has not been undertaken
preconceptually).
- Women with SCD should avoid precipitating factors of sickle cell crises such as
exposure to extreme temperatures, dehydration, hypoxia, overexertion, and stress
- Persistent vomiting can lead to dehydration and sickle cell crisis and women should be
advised to seek medical advice early.

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- Give Influenza vaccine if it has not been given in the previous year.
- Check haemoglobinopathy status of husbands of all women with SCD or SCT.
- VTE scoring should be done at booking

e) Investigations:
▪ CBC, blood group, Hb electrophoresis, reticulocyte count, antibodies screen
▪ LFT, RFT, urea & electrolytes
▪ HIV/hepatitis antigen B& C
▪ Serum ferritin if anaemic
▪ Urine culture & sensitivity
▪ Viability scan

f) Medications:
▪ Folic acid 5 mg OD
▪ Iron supplement may be given to woman with anaemia and low ferritin levels
▪ Low dose Aspirin 75 mg once daily from 12 weeks of gestation to reduce risk of
developing pre-eclampsia
▪ Prophylactic antibiotics in post splenectomy patients: Penicillin V 250 mg twice daily

Sickle cell crisis

▪ Painful crisis is the most frequent complication of SCD during pregnancy.
▪ About 27% to 50% of women with SCD having a painful crisis during pregnancy.

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ALGORITHM 11: WHEN PRESENTED WITH A PATIENT WITH SICKLE CELL CRISIS IN PREGNANCY

STEP 1
Rapidly assess the woman for emergency medical complications requiring intervention

STEP 2
Ask the woman if this is a typical sickle pain or not, the precipitating factors, fever,

STEP 3
Examine the site of pain, look for signs of infection.

STEP 4
Start hydration with 0.45% saline or 0.45% saline with 5% dextrose at 80 ml/hrs

STEP 5
Start analgesia.

Assess level of pain

before starting
analgesia

If Moderate to Severe Pain

If Mild Pain - Tramadol 50 mg IV/IM OR
- Paracetamol oral/IV (if available ) can be - Morphine: Loading dose: 0.1 mg/kg IV. If no response
given. NSAIDs should be used only between 12 after 15 minutes, give a second dose of 0.05 mg/kg.
and 28 weeks of gestation. Another 0.05 mg/kg can be repeated in another 15
- Keep patient under observation and pain to minutes.
be assessed after 30 minutes. - Maintenance infusion: infusion rate 0.04 mg/kg=40
- If pain persist give Tramadol 50 mg and refer microgram/kg/hr, syringe pump 10 mg (5 ampoules) +45
the woman to secondary care for evaluation. ml saline.
Postnatal care - Refer to woman to secondary care hospital as
emergency for evaluation and admission.

STEP 6
Monitor pain, sedation, vital signs, respiratory rate and oxygen saturation every 20–30 minutes until
pain is controlled and signs are stable, then monitor every 2 hours (hourly if receiving parenteral
opiates)

Note: Pethidine should be avoided because of the risk of toxicity and pethidine-associated seizures in patients with SCD
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▪ Provide routine postnatal care

▪ The risk of sickle cell crisis remains increased, it can occur in 25% of women and was
more common following general anaesthesia, so to reduce the risk:
- Women should be encouraged for hydration and early mobilization.
- Thromboprophylaxis in the form of low-molecular-weight heparin is recommended
from 28 weeks, during hospital admissions and postnatally for 6 weeks irrespective of
the mode of delivery.
- Crises should be managed as for non-pregnant women. NSAIDs are routinely
administered in the postpartum period and can be used during breastfeeding.
- Breastfeeding should be encouraged, as in women without SCD.
▪ Advice on birth spacing:
- Progesterone only pills are preferred in the first 6 months.
- Combined Oral contraceptives (COCs) may be prescribed after 6 months with close
monitoring of liver function and blood pressure. No additional risk of thromboembolic
disease in women with SCD was observed with lower dose of COC pills.
- Intrauterine device in SCD increases the risk of infection and menorrhagia.
- Levonorgestrel releasing IUD is the preferred choice for women with SCD. As per
WHO recommendation benefits should outweigh risks.

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2.3.9 Intrahepatic Cholestasis of Pregnancy

Introduction
▪ Intrahepatic Cholestasis of Pregnancy (ICP) is a multifactorial condition characterized by
unexplained pruritus in the absence of a skin rash with abnormal liver function tests
(LFTs), both which resolve after birth. It frequently develops in late pregnancy in
individuals who are genetically predisposed.
▪ ICP has no clear aetiology, and it is believed to be a multifactorial disorder with
environmental, hormonal, and genetic contributions.
▪ It has been associated with an increased foetal mortality, warranting close antenatal
surveillance with obstetrician. Thus, early recognition, treatment, and timely delivery are
important.
Complications: -
▪ Maternal
- Intense pruritus, which may become so intolerable causing lack of sleep.
- Increased incidence of premature birth
- Steatorrhea and vitamin K deficiency due to fat malabsorption that can cause a
postpartum haemorrhage if not corrected by the time of delivery
▪ Foetal
- An increased risk for foetal distress /death (due to increased likelihood of meconium
passage)
Clinical presentation:
▪ Intense pruritus +_ excoriation, affecting any part of the body but particularly the palms
of the hands and soles of the feet, with no other skin manifestations
▪ It is often worse at night
▪ Typically presents in the third trimester
Differential Diagnoses
▪ Acute Fatty Liver of Pregnancy
▪ Gallstones (cholestasis)
▪ Hepatitis in Pregnancy
▪ Preeclampsia
▪ Dermatitis and other skin problems that cause pruritus in pregnancy like Pemphigoid
gestationis, atopic eruption of pregnancy (prurigo of pregnancy)

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ALGORITHM 12: INTRAHEPATIC CHOLESTASIS OF PREGNANCY

Take detail history: - Profound itching begin with the palms of the hands and soles of
the feet without evidence of a rash, worse at night, Jaundice. Less common symptoms
include dark urine, pale stool, right upper quadrant pain, nausea and steatorrhea
Perform clinical examination including Temperature, PR, BP, jaundice, abdominal
examination, skin examination
Exclude other causes e.g., Acute Fatty Liver of Pregnancy, Gallstones (cholestasis),
Hepatitis in Pregnancy, Preeclampsia, Dermatitis and other skin problems that cause
pruritus in pregnancy like Pemphigoid gestationis, atopic eruption of pregnancy (prurigo
of pregnancy), etc.
Check urine protein
Perform investigations (if available): LFT, UE, coagulation profile
Ultrasound scan (if not done before) to confirm viability, gestational age

Give symptomatic treatment to relieve pruritus such as Rule out

topical emollient, topical steroid and antihistamines pre-eclampsia

Refer urgently to secondary care for further investigations (bile acids,

Liver functions Tests, coagulation profile) & intensive foetal surveillance
and monitoring. This will be associated with a significant reduction in the
stillbirth rate

Antepartum monitoring:
Repeat LFT weekly until delivery
Patients with persistent pruritus and normal biochemistry, LFT
should be repeated every 1-2 weeks
Early delivery recommended after 37 + 0 weeks of gestation
Ultrasound to assess foetal growth every 2 weeks and BPP and
Doppler weekly

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Post-natal follow up and care:

● Pruritis usually disappears in the first few days following delivery accompanied by
normalization of serum bile acids and other liver tests.
● Repeat liver biochemical tests 4-6 weeks after delivery to confirm resolving, if
laboratory abnormalities do not return to normal, refer the woman to a physician to
assess for underlying hepatobiliary diseases.
● Avoid oestrogen- containing contraception as it may increase the risk of recurrent
cholestasis

Recurrence in future pregnancies:

● Cholestasis can recur during subsequent pregnancies in 60-70 percent of women with ICP

2.3.10 Thrombocytopenia in pregnancy

Definition: -
● Thrombocytopenia is defined as drop in platelets count less than 150 x 109/L (The
normal serum level of platelets in pregnancy is 150–400 x 109/L.)
● During pregnancy there is a general drop in platelet count, particularly during the last
trimester.
● Thrombocytopenia occurs in 8-10% of all pregnancies. In most cases,
thrombocytopenia is mild and benign, but it can be associated with severe complications
for mother and foetus. The severity is classified as follow:
● The most common cause of thrombocytopenia in pregnancy is gestational
thrombocytopenic accounting for 75% of the cases.

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TABLE 25: PLATELET COUNT

Category Platelet count
Mild >100 x 109/L
Moderate 50-100 x 109/L
Severe <50 x 109/L

Differential diagnosis of thrombocytopenia in pregnancy

● Gestational Thrombocytopenia
● Immune Thrombocytopenic Purpura (ITP)
● Thrombotic Thrombocytopenic Purpura (TTP)
● Pre-eclampsia, Eclampsia, Haemolysis, Elevated liver enzymes and low platelet count
syndrome (HELLP)
● Haemolytic Uraemic Syndrome (HUS)
● Hereditary thrombocytopenia
● Pseudo thrombocytopenia
● Viral infections (HIV, Epstein-Barr virus, cytomegalovirus, parvovirus, Hepatitis B
visrus)
● Medications (heparin, furosemide, etc)
● Leukaemia/Lymphoma
● Severe Vitamin B12 or Folate Deficiency
● Splenomegaly

Assessment and evaluation of all women with thrombocytopenia in pregnancy:

 Take history: - bleeding (epistaxis, bleeding from gum, hematuria, gastrointestinal

bleeding, easy bruising), previous history of thrombocytopenia, history of drugs
(heparin, furosemide, etc), family history of Thrombocytopenia.
 Perform clinical examination including Vitals: Pulse Rate, Blood Pressure, pallor,
signs of bleeding ((Petechial, ecchymosis, purpura -usually only present if platelets <50
x 109/L), splenomegaly, hepatomegaly
 Investigations e.g., CBC, Coagulation screening (to be done in secondary), Peripheral
blood smear, Renal function test, Liver function test, HIV serology-if not done before
 Early ultrasound scan (if not done before) to confirm viability, gestational age and to
rule out multiple or molar pregnancy

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Gestational Thrombocytopenia
● Defines as drop in platelets count usually mild to moderate (platelets counts between 150 -
80, if less than 80 exclude other causes) (NIH2020)
● Diagnosis of exclusion
● Incidental finding on CBC
● Woman usually asymptomatic
● Typically occurs in 3rd trimester
● Spontaneous resolution after 1-2 months following delivery
● May recur in subsequent pregnancy
● Small risk of neonatal thrombocytopenia

NB: Check platelet count at third trimester

Management
● Refer to secondary care hospital for evaluation if platelets < 100
● Council the patient to report immediately, if she developed any bleeding signs
● Avoid traumatic instrumental vaginal delivery to minimize the risk of bleeding
● Verify that counts return to normal after delivery

Immune Thrombocytopenic Purpura (ITP)

● Adult ITP usually a chronic condition occurring in second to third decade of life. It is more common
in female than male. It accounts for about 3% of thrombocytopenia in pregnancy.
● Diagnosis is by exclusion, however, in two-third of the cases the diagnosis is already established
before pregnancy.
● Woman may have signs of purpura, bruising, mucosal bleeding
● Two thirds of cases are self-limiting

Management
● Pre-conception counselling for those with established diagnosis of ITP before pregnancy:
● ITP may relapse or worsen during pregnancy.
● About one-third of women will require treatment during pregnancy, most commonly around the time
of delivery. The treatment might carry both maternal and foetal risks.

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● There is a small risk of haemorrhage at delivery.

● It is not possible to predict accurately whether a neonate will be affected. The risk is high if a sibling
has had thrombocytopenia, or the mother has undergone splenectomy.
● The risk of intracranial haemorrhage for the foetus/neonate is very low.

Antenatal care:
 Refer to secondary care hospital for multidisciplinary care

Labour/ delivery
 Woman with ITP should be referred for delivery at secondary care hospital

Thrombocytopenia associated with hypertensive disorders

- See Hypertensive Disorders in Pregnancy section (page 91).

Thrombotic Thrombocytopenic Purpura (TTP)

 A rare life-threatening disorder occurred in 1: 25,000 pregnancies.

 Onset can vary from first trimester to postpartum period
 TTP that occurred before pregnancy, can relapse during pregnancy
 Signs are due to a severe deficiency of von Willebrand factor (vWf) cleaving protein are:
 Microangiopatic haemolytic anaemia
 Thrombocytopenia
 Neurological symptoms (from headache to coma)
 Renal dysfunction
 Fever
 Abnormal U&E
Management
 Refer as emergency to secondary care hospital

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2.3.11 Pregnancy with RH negative blood group

● RhD negative women who carry an RhD positive foetus may produce antibodies to the foetal
RhD antigens after a fetomaternal haemorrhage (FMH). These antibodies may then cross the
placenta in future pregnancies and cause haemolytic disease if the foetus is RhD positive.
● A woman can also be sensitised by a previous miscarriage, spontaneous or elective abortion
or amniocentesis or other invasive procedure
● If a pregnant woman is Rh negative, husband should be tested for Rh typing and results should
be documented in the Maternal Health Record. If the husband is Rh negative, no further
management is required. If husband is Rh positive, a regular screening for Rh antibodies by
performing coomb's test is required.

Management
● Indirect Coomb's test should be performed at the following intervals
- At first visit (booking)
- At 28-30 weeks visit
● If Coomb’s test showed to be positive, patient should be referred to the secondary /tertiary
care with urgent appointment for Indirect Coomb’s Test (ICT) titration

Prophylaxis for Women Who are Rh Negative

Antenatal Prophylaxis
● All Rh-negative pregnant women who have not been previously sensitised should be given
immunoglobulin (RAADP) either with an offered routine antenatal prophylaxis with anti-D
IU), or two-dose 1500-mcg = 1250 single dose regimen at around 28 weeks (250 -300
regimen (100 mcg =500 IU given at 28 and 34 weeks)
Note: If Anti-D immunoglobulin is missed at 28 weeks, do ICT and give as soon as
possible.
● Rh negative women who have received routine antenatal prophylaxis should receive
additional anti-D Ig when they are undergoing any potential sensitising procedures like ECV,
amniocentesis or has antepartum haemorrhage within 72 hours of the event. If, exceptionally,
this deadline has not been met some protection may be offered if anti-D immunoglobulin is
given up to 10 days after the sensitizing event

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● Before giving anti D immunoglobulin prophylaxis at 28 weeks, it is important to send a

sample for blood group antibody screen. Then, if antibody screen is negative no need to repeat
anti body screen (coomb’s test) again after second dose or after delivery as it will show
positive because of anti-D immunoglobulin which was given
● Anti D immunoglobulin prophylaxis (single dose regimen or two-dose regimen), should be
given even if anti-D immunoglobulin is given due to sensitizing event, as for example if anti
D is given for amniocentesis, it will cover that event only, but it will not replace the
prophylaxis dose

Routine antenatal anti-D immunoglobulin Prophylaxis is indicated for all pregnant

women who are Rh negative and who are not known to be sensitized to Rh D antigen
Anti D immunoglobulin Prophylaxis following sensitizing events should always be.
administered as soon as possible

Prophylaxis Following miscarriages

● Spontaneous miscarriage
- Complete or incomplete miscarriage after 12 weeks of gestation, need prophylaxis
- Incomplete miscarriage before 12 weeks of gestation where there is D&C, need
prophylaxis
- Complete miscarriage before 12 weeks when there is no instrumentation, doesn’t need
to receive anti D

● Threatened miscarriage
- All non-sensitised Rh-negative women with threatened miscarriage after 12 weeks of
gestation need prophylaxis
- All non-sensitised Rh-negative women with threatened miscarriage before 12 weeks of
gestation where the bleeding is heavy or repeated or where there is associated abdominal
pain and gestation is approaching 12 weeks of gestation, need prophylaxis
- Prophylaxis is not required if bleeding stops, and foetus is viable
- Dosage: one dose of 1250-1500 IU Anti-D intramuscular injection with no need for
repeated dose until 28 weeks of gestation if pregnancy continues.

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Postnatal Prophylaxis
● At least 1250-1500 IU of Anti-D immunoglobulin should be given within 72 hours following
delivery of a Rh-positive infant. It can be given up to 10-day post-partum
● Note: Blood sampling for grouping and Rh status of the infant should be performed
immediately after birth.

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2.3.12 ABO Incompatibility

ABO incompatibility usually arises when the woman blood group is O and develops either anti A,
or anti B antibodies. The women usually have a history of either:
● Blood transfusion
● Unexplained still birth
● Unexplained neonatal death
● Baby with severe jaundice in neonatal period

Management
● All pregnant women should be screened for antibodies by doing the indirect Coomb's test
(ICT) at the following intervals
- At first visit (booking)
- At 28-30 weeks visit

● If coomb’s test showed to be positive, patient should be referred to the secondary care
with urgent appointment for ICT titration

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2.3.13 Urinary tract infections (UTI)

Definition: -
UTI is defined as the presence of at least 100,000 organisms per milliliter of urine in an
asymptomatic patient, or as more than 100 organisms/ml of urine with accompanying pyuria (>7
white blood cells /ml) in a symptomatic patient A diagnosis of UTI should be supported by a
positive culture for uropathogen, particularly in patients with vague symptoms. UTI during
pregnancy is classified into 2 groups: symptomatic & asymptomatic UTI. E coli is the most
common cause of UTI, accounting for approximately 70-80% of cases in pregnancy. It originates
from faecal flora colonising the periurethral area, causing an ascending infection.

Risk factors for complicated UTI in pregnancy include the following:

● Immunosuppression
● Pre-existing diabetes
● Recurrent or persistent UTIs before pregnancy
● Sickle cell anaemia
● Neurogenic bladder
● Tobacco use
● Age < 20 years
● Late presentation for prenatal care
● Low socioeconomic status

Possible complications of untreated bacteriuria during pregnancy:

● Pyelonephritis
● Pre- term birth
● Low birth weight
● Pre- eclampsia. (Rates of preeclampsia in patients with UTI compared with those without
reported UTI were 31.1% vs 7.8%, respectively)
● Septic shock
● Increased perinatal mortality

Differential diagnosis
The differential diagnosis of urinary tract infection (UTI) in pregnancy includes the following:

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● Vaginal infections
● Cervicitis
● Chlamydial Genitourinary Infections
● Nonbacterial and Non-infectious Cystitis
● Ectopic Pregnancy
● Nephrolithiasis
● Sexually transmitted infection (e.g., gonorrhoea, nongonococcal urethritis)
● Threatened or incomplete miscarriage
The following table shows the detection and management of UTI during pregnancy:

TABLE 26: DETECTION, CLASSIFICATION AND MANAGEMENT OF UTI IN PREGNANCY

Assess Probable When to refer to secondary

Management
(signs & symptoms) Diagnosis care

● Typical: ● Do urine test (microscopy and culture if If the infection reoccurs

- Dysuria indicated by the microscopy) for three or more times
- Increased frequency and ● Give Paracetamol despite adequate
urgency of urination ● Start antibiotics (see below box) treatment, refer by
Cystitis ● Encourage to increase fluid intake by routine appointment
● Other (Atypical): mouth

- Retropubic / suprapubic ● Repeat urine culture after 1 week from the

pain Abdominal pain last dose of the antibiotics (if the initial
test was positive)
● Typical: ● Do urine test (microscopy and culture) Refer as emergency
- Dysuria ● Give Paracetamol whenever suspected
Spiking fever /Chills ● Hydration of the patient For admission and IV
Increased frequency and ● Refer for further management antibiotics
urgency of urination
- Abdominal pain
Acute
● Other (Atypical): Pyelonephritis
- Retropubic / suprapubic
pain
- Loin pain /tenderness.
Tenderness in rib cage
- Anorexia
- Nausea /vomiting

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Treatment of urinary tract infections in pregnancy: -

● Behavioural methods
- Women with UTI should be counselled about behavioural methods that ensure good
hygiene and reduce bacterial contamination of the urethral meatus, thereby preventing
inadequate treatment and recurrent infection. It includes the following:
- Wipe front-to-back after urinating or defecating
- Wash hands before and after using the toilet
- Clean the urethral meatus first when bathing
● Antibiotic therapy
- Oral antibiotics are the treatment of choice for asymptomatic bacteriuria and cystitis.
- Treatment is most commonly initiated empirically before culture and susceptibility
results return.
- If treatment fails, check urine for culture and sensitivity if available, and treat with an
appropriate antibiotic for the organism.
- Urine culture to be repeated one week after the last dose of the antibiotics
- Current oral regimens are summarised below
Antibiotics to be used in management of cystitis:

Amoxicillin 500 mg orally three times daily (alternative: 850 mg orally two times
daily) for 5-7 days (to be continued for 10 days if culture was positive)

Alternative:

Cephalexin 500 mg orally four times per day for 5-7

days

OR
Amoxicillin- Clavulanate 500/125 mg TID, if not available, then Amoxicillin
Clavulanate 375 mg plus amoxicillin 250mg three times per day for 5 days
((alternative: amoxicillin – clavulanate 875/125 mg orally two times daily for 5-7
days)
OR
Nitrofurantoin 100 mg bid 5-7 days. (If G6PD normal)

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Recurrent Cystitis
● Pregnant women who have three or more episodes of cystitis or bacteriuria should be
started on daily antibiotic prophylaxis for the remainder of pregnancy.
● Daily antibiotics should also be considered in pregnant women after one episode of
pyelonephritis.
● Regimens for daily prophylaxis includes cephalexin 250-500 mg nightly or nitrofurantoin
100 mg nightly,
● In patients who are immunosuppressed or have medical conditions that would increase
the risk of complications from cystitis, they should be started on antibiotic prophylaxis
after one episode of cystitis.
Pyelonephritis
● Pyelonephritis should be referred and treated in Secondary Care
● The standard course of treatment for pyelonephritis consists of hospital admission and
intravenous (IV) administration of antibiotics until the patient has been afebrile for 48
hours.
● The recommended IV antibiotic would be a broad-spectrum beta-lactam, such as
ceftriaxone.
● Once culture results with susceptibilities become available and the patient is clinically
improved, treatment can be transitioned to an oral antibiotic regimen.
● Patients should be discharged with 10-14 days of antibiotic treatment, and then will need
daily prophylactic antibiotics for the remainder of pregnancy.
● IV fluids must be administered with caution. Patients with pyelonephritis can become
dehydrated because of nausea and vomiting and need IV hydration. However, they are at
high risk for the development of pulmonary oedema and acute respiratory distress
syndrome (ARDS).
● Fever should be managed with antipyretics (Paracetamol) and nausea and vomiting with
antiemetics. If fever persists beyond 24 hours, urine and blood cultures should be repeated
and a renal ultrasound should be performed.

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2.3.14 Vaginal discharge during pregnancy

Vaginal infections in pregnancy are common and important because they can cause
spontaneous abortion, pre-term labour and chorioamnionitis. Several infections such as
gonorrhoea, chlamydia, group B streptococci, HIV and herpes virus can be transmitted
during labour directly to the foetus.

Diagnosis:
For the diagnosis of vaginal discharge during pregnancy, the following chart can be used.

ALGORITHM 13: DIFFERENTIAL DIAGNOSIS OF VAGINAL BLEEDING IN EARLY PREGNANCY

All pregnant patients complaining of vaginal discharge or vulvar itching / burning

History: duration, frequency, abdominal pain, dyspareunia, dysuria and past h/o PROM and/or preterm labour
Examination:
 Inspect (by speculum) for abnormal discharge (colour, odour), vulvovaginal erythema
 Take high vaginal swab for culture.
 Palpate for lower abdominal tenderness.

With Abdominal pain

Without Abdominal Pain & no
abdominal tenderness on palpation

Thick cheesy white Copious, malodourous Thin, off-

discharge that adherent to yellow-green discharge white
Abnormal vaginal the vaginal wall, with without pruritus, dysuria, discharge,
discharge with vulvar and vulvar and vaginal vulvar oedema unpleasant
vaginal oedema & erythema “fishy odour”
erythematic cervix

Trichomoniasi
Possibility of Candidiasis Bacterial
s
Chorioamnionitis Vaginosis

Give treatment
Refer as emergency to (see Table 20)
hospital for management. If symptoms persist,
refer to secondary care.

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Specific Management

TABLE 27: SPECIFIC MANAGEMENT OF VAGINAL DISCHARGE DURING PREGNANCY

Remarks / When to refer to secondary
Diagnosis Treatment
care
Drug option • Vaginal swab should be done if recurrent
• Clotrimazole 500 mg vaginal (more than 2 times in spite of treatment
suppositories inserted in the vagina as a
single dose (preferred) • If no response to the treatment. Refer by
• Clotrimazole or Miconazole vaginal routine appointment
cream one full applicator inserted in the
vagina daily for 7 days
Candidiasis
• Alternative:
• Nystatin suppositories, each contain
100,000 unit every night for 7-14 nights
• If have vulvovaginits: give antifungal
with steroid skin cream (low to mid
potency topical corticosteroids
preparations are (preferred)
• Metronidazole 500 mg orally twice a day • Routine treatment of sex partners is not
for 7 days recommended
OR • Follow-up visits are unnecessary if
Bacterial • Metronidazole 250 mg orally three times symptoms resolve
Vaginosis a day for 7 days • Use condom during the treatment
OR • Refer by routine appointment for
• Clindamycin cream 2% one full applicator persistent symptoms
(5 g) bed intra-vaginally at time for 7 days

• Metronidazole 2 g in a single dose at any • Counsel, use Condom

stage of pregnancy • All symptomatic pregnant women
OR should be treated at any pregnancy stage
Trichomona • Metronidazole 500 mg orally twice a day • Sex partners should be treated
s vaginalis for 7 days • Rescreening at 3 months following
OR initial infection can be considered
• Metronidazole 250 mg orally three times a • Refer by routine referral if symptoms
day for 7 days persistent

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2.3.15 HIV in pregnancy

● The risk of mother-to-child transmission of human immunodeficiency virus (HIV) during

pregnancy, delivery, and breastfeeding is as high as 25-30% in the absence of treatment.
● With the implementation of HIV testing, counselling, antiretroviral medication, delivery
by caesarean section prior to onset of labour for those with high viral load, and discouraging
breastfeeding, vertical transmission can be decreased to less than 2%
● The exact mechanism of mother-to-child transmission of HIV remains unknown.
Transmission may occur during intrauterine life, delivery, or breastfeeding.
● All women registering with ANC clinic should be screened for HIV as shown in the
following Algorithm:

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ALGORITHM 14: HIV TESTING IN PREGNANCY

WOMAN AT ANC CLINIC

 Verbal consent (following a counselling session)

 Collect 5 cc of blood sample in Serum Separating Tube (SST- Tube Red cap with gel)
 If PHC facility has laboratory, centrifuge the blood and separate the serum. Put in the
plain tube before dispatching to the Regional Public Health laboratory (RPHL)
 If PHC facility has no laboratory send the whole blood to the Regional Public Health
laboratory (RPHL).

AT REGIONAL PUBLIC HEALTH LABORATORY (RPHL)

ELISA Test

If ELISA test is negative,

Inconclusive Positive
no further test is required.
result ELISA Test
Report to PHC facility

SEND TO CENTRAL PUBLIC HEALTH LABORATORY

(CPHL) AT DARSAIT

In case samples cannot be dispatched on the same day, keep it in the refrigerator at temp. 4 - 8 0 C,
transfer the sample within 24 hours. While transporting to RPHL, ensure that appropriate temperature
is maintained (4- 80 C).

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HIV TESTING IN PREGNANCY (contd.)

CENTRAL PUBLIC HEALTH LABORATORY (CPHL)

Repeat test on the same sample sent from RPHL

Negative
Inconclusive result: Positive
ELISA test:
Re-bleed after 3 months ELISA Test
Report on Negative Result

Positive Western Blot

(WB) test
 Confirm HIV infection
urgently;
 Request for re-bleed
sample to confirm
patient’s identity

Report to
If ELISA Test & WB are
 Dept of Woman & Child Health (DWCH),
still inconclusive, then
 HIV/ AIDS Control Section
conduct RT-PCR
 PHC facility

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HIV TESTING IN PREGNANCY (contd.)

Reporting on the results of HIV positive cases by CPHL.

Send report to DWCH and HIV/AIDS Control Section and PHC facility

HIV/AIDS CONTROL DWCH

SECTION - Data entry on the reported HIV+

cases
Inform HIV focal physician - Compile and prepare the final report
- Follow up and monitoring of cases
through WCH counsellor

HIV FOCAL
PHYSICIAN HIV COUNSELLORS
(HIV/AIDS) AT PHC
- Fill the (PR 83) HIV FOCAL DOCTOR
- Trace & counsel the - Break the news, counsel;
notification form
contacts (husband and - Arrange referral to HIV Focal Physician
- Follow up with HIV
children < 15 years) and at secondary Health care
Counsellor
arrange for their testing - Maintain records of HIV+ results
- Team up with
- Liaise with WCH
Obstetrician to manage
counsellors
the index case
WCH COUNSELLORS
- Inform HIV counsellor - Counsel the HIV+ women
- Screen contacts and - Keep the record on the women and action
manage as per the need taken; send to DWCH as and when
requested.
- Do follow up of the cases
- Liaise with HIV counsellors (HIV/AIDS)
for case follow up.

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Remember:
• If HIV testing was not performed at the booking visit, for any reason, it should be done in
the subsequent visit
Make sure it is done and documented in the green card as reactive or non- reactive
• Counselling is one vital service to be provided following HIV screening. It will be offered at
different points of contact and by a trained health provider using standard proper
counselling materials
• Delivery should be arranged in a facility that matches mother’s needs, i.e.,
secondary/tertiary
• Rapid HIV testing should be done during the labour/post-partum for women who have not
. (been subjected to the test during the antenatal period (un-booked)
• HIV positive results should be treated with sensitivity and only trained counsellor should
inform the patient about the results
• Woman and child health head section should keep the record of the HIV positive women
and send it to DWCH. Follow up and monitoring of cases through MCH counsellor

For further details refer to following MOH Guidelines:

 HIV Testing in Pregnancy, Standard Operative Procedure Guideline – Dept. of Family
and community Heath-DGHA. MOH Oman. 2nd Edition 2011
 HIV Management in Primary Health Care, A guide for health care workers, National
AIDS Program, Dept. of communicable diseases, DGDSC.MOH Oman. 4 th Edition
2019

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2.3.16 Syphilis in pregnancy:

Syphilis is caused by the bacterium Treponema pallidum. The infection is most commonly
transmitted through sexual contact (vaginal, oral, or anal sex). Birth defects can occur in infants
born to women who are infected with syphilis prior to or during pregnancy. Congenital syphilis
causes foetal or perinatal death in 40% of the infants affected.
Main clinical manifestations in the mother
In primary syphilis, a sore or multiple sores appear at the site where the bacterium entered the
body – typically near the genitals, the rectum, or the oral cavity. The sores are usually firm, round
and painless.
In secondary syphilis, fever, swollen lymph nodes and skin rash, and wart-like genital lesions
(condyloma lata) can be seen. In latent stage, there are no signs or symptoms.
In tertiary syphilis, several medical problems affecting the heart, neurologic system and other
organs can be seen. Individuals with the infection move from one stage to the next in the absence
of treatment.
Main clinical manifestations in the infant
Early congenital syphilis: - some infants with early congenital syphilis are asymptomatic at birth
and some might present as rhinitis (“snuffles”), hepatosplenomegaly, skin rash with desquamation,
chorioretinitis and pigmentary chorioretinopathy (salt and pepper type), glaucoma, cataracts,
interstitial keratitis, optic neuritis, periostitis and cortical demineralization of metaphysis and
diaphysis areas of long bones, anaemia and thrombocytopenia. Some clinical signs consistent with
congenital syphilis – such as hydrops and hepatosplenomegaly – might be detected by ultrasound
during pregnancy. Infants who remain undiagnosed and untreated can progress to late congenital
syphilis
Late congenital syphilis, present in numerous additional clinical manifestations, including, but
not limited to saddle nose due to destruction of cartilage, frontal bossing due to periostitis, tibial
thickening (saber shins), joint swelling (clutton joints), perforation of hard palate, abnormal tooth
development (Hutchinson’s teeth, mulberry molars), interstitial keratitis, neurologic deafness and
optic atrophy. Infants might be born without clinical signs of syphilis but go on to develop late-
stage manifestations of congenital syphilis that include developmental delay, neurologic
manifestations and late congenital syphilis physical signs.

Congenital syphilis is preventable with prompt action

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ALGORITHM 15: SCREENING AND MANAGEMENT OF REACTIVE SYPHILIS SEROLOGY IN PREGNANCY

Routine Antenatal Screening Assessment of maternal syphilis by Obstetric Team

All pregnant women at initial booking (TPHA: POSITIVE)

Check blood taken for HIV & syphilis serology Manage as HIGH RISK Pregnancy

Take sexual history, identify STI risk factors

Record test results in Green Card and Al Shifa (e.g.,
Check for previous Hx of and Rx for syphilis
Reactive/Non-reactive)
Review obstetric history (e.g., stillbirths)
If initial blood test is RPR positive
Look for symptoms & signs of infection: chancre,
Reflexively test sample for TPHA and RPR titre; rash, lymphadenopathy

If necessary, send blood sample to local lab for these If maternal syphilis treatment required:
tests Complete Surveillance Form CS-OBS and send
to Governorate Head of WCH and copy to Head
Action based on TPHA and RPR titre results of Communicable Diseases
If TPHA is positive… Refer Husband for testing in Health Centre and
Make urgent eReferral to Obs & Gynae as ‘walk- advise no sexual contact until both parties treated
in’ at secondary/tertiary hospital (preferably in A. RPR titre ≥ 1:8; TPHA positive, then code A51.9
same hospital as mother’s planned delivery) (Early syphilis) on Al Shifa and treat:
Benzathine penicillin 2.4 MU i/m x 1 dose if
Give patient a copy of the eReferral
<28w gestation; or

Document serological test results on Al-Shifa and Benzathine penicillin 2.4 MU i/m x 2 doses one
mother’s antenatal Green Card, e.g., TPHA week apart if >28w gestation

Reactive or Non-reactive; RPR titre value B. RPR ≤ 1:4, TPHA positive, code A53.0 on Al
Shifa. (Diagnosis covers late or indeterminate stage
Complete Surveillance Form CS-ANC and send to
syphilis, previous Hx/Rx of syphilis with risk of re-
Governorate Head of WCH and copy to Head of
infection; previous syphilis treatment not adequate
Communicable Diseases
or not documented):
If TPHA is negative… Benzathine penicillin 2.4 MU i/m weekly x 3
LATE BOOKERS (booking after 20w gestation)
doses
Make sure these mothers are screened for HIV & syphilis at
booking. Repeat maternal RPR titre at delivery.
UNBOOKED MOTHERS Screen for HIV & syphilis on See Notes if patient has penicillin allergy.
admission Emphasise importance of completing treatments
N.B. RPR is the screening test in MOH facilities. VDRL and
and refer to Paediatric team for post-natal
RPR titres are NOT interchangeable. Use only VDRL or
assessment of child.
only RPR titres when evaluating a patient’s response to
treatment.

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ALGORITHM 16: FLOWCHART FOR MANAGEMENT OF CONGENITAL SYPHILIS

BY PAEDIATRIC TEAM

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Treatment
● Penicillin G is the only known effective antimicrobial for preventing maternal transmission to the
foetus and treating foetal infection.
● Some evidence suggests that additional therapy is beneficial for pregnant women. For women
who have primary, secondary, or early latent syphilis, a second dose of benzathine penicillin 2.4
million units IM can be administered 1 week after the initial dose.
● When syphilis is diagnosed during the second half of pregnancy, management should include a
sonographic foetal evaluation for congenital syphilis. However, this evaluation should not delay
therapy. Sonographic signs of foetal or placental syphilis (i.e., hepatomegaly, ascites, hydrops,
foetal anaemia, or a thickened placenta) indicate a greater risk for foetal treatment failure; cases
accompanied by these signs should be managed in consultation with obstetric specialists.
Evidence is insufficient to recommend specific regimens for these situations.
● Women treated for syphilis during the second half of pregnancy are at risk for premature labour
and/or foetal distress if the treatment precipitates the Jarisch-Herxheimer reaction. These
women should be advised to seek obstetric attention after treatment if they notice any fever,
contractions, or decrease in foetal movements. Stillbirth is a rare complication of treatment, but
concern for this complication should not delay necessary treatment. No data are available to
suggest that corticosteroid treatment alters the risk for treatment-related complications in
pregnancy.
● Missed doses are not acceptable for pregnant women receiving therapy for late latent syphilis.
Pregnant women who miss any dose of therapy must repeat the full course of therapy.
● All women who have syphilis should be offered testing for HIV infection.

Management of Sex Partners

● The partner of the infected woman should be evaluated clinically and serologically and treated
accordingly.

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Special Considerations

Penicillin Allergy
● No proven alternatives to penicillin are available for treatment of syphilis during pregnancy.
Pregnant women who have a history of penicillin allergy should be desensitized and treated with
penicillin. Skin testing or oral graded penicillin dose challenge might be helpful in identifying
women at risk for acute allergic reactions
● Tetracycline and doxycycline are contraindicated in the second and third trimester of pregnancy.
Erythromycin and azithromycin should not be used, because neither reliably cures maternal
infection nor treats an infected foetus. Data are insufficient to recommend ceftriaxone for
treatment of maternal infection and prevention of congenital syphilis.

HIV Infection
● Placental inflammation from congenital infection might increase the risk for perinatal
transmission of HIV. All women with HIV infection should be evaluated for syphilis and receive
a penicillin regimen appropriate for the stage of infection.

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2.3.17 Chicken pox (varicella) in pregnancy

Definition:
Chicken pox (varicella) is the primary infection with varicella-zoster virus (VZV; a highly
contagious human herpesvirus 3), which is transmitted by respiratory droplets and by direct
personal contact with vesicle fluid. The incubation period is 1-3 weeks, and the disease is
infectious 48 hours before the rash appears till the vesicle’s crusts over.

Pregnant women who have no history or uncertain history of previous infection must be
advised to avoid contact with chickenpox patients and shingles during pregnancy and to
immediately inform health care workers of potential exposure.

Preconception care

● Advise women with no past history of immunity to chickenpox (no past history of
chickenpox infection or vaccination): To take varicella vaccine (live attenuated virus),
two doses, given 4 to 8 weeks. Immunity from the vaccine may persist for up to 20
years. If she received varicella vaccine, she should avoid pregnancy for 3 months and
to avoid contact with other susceptible pregnant women

● Advised woman to avoid contact with chickenpox patients and shingles during
pregnancy and to immediately inform health care workers of potential exposure

● Counsel women that a previous history of chickenpox infection is 97–99 % predictive

of the presence of serum varicella antibodies

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Risks Associated with Varicella Virus Infection in Pregnancy

A) Maternal risks:
● Pneumonia
● Hepatitis
● Encephalitis (This condition is associated with high mortality rate)
.
B) Foetal risks:
● Foetal Varicella Syndrome (very rare): If the mother developed the disease or acquired
the infection before 20 weeks (up to 28 weeks in some cases) of pregnancy. Foetal
Varicella Syndrome characterized by one or more of: Skin scarring in a dermatomal
distribution, eye defects (microphthalmia, chorioretinitis, and cataracts), hypoplasia of the
limbs, neurological abnormalities (microcephaly, cortical atrophy, mental retardation and
dysfunction of bowel & bladder sphincter.
● Varicella Infection of the Newborn: More likely if maternal infection occurs in the last
4 weeks of a woman’s pregnancy

The risk of spontaneous miscarriage does not increase if chickenpox occurs in the first trimester

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Management of Chicken Pox with Pregnancy

For the diagnosis and management of chicken pox during pregnancy, the following chart can
be used.
ALGORITHM 17: DIAGNOSIS AND MANAGEMENT OF VARICELLA IN PREGNANCY

Maternal Exposure to Varicella

No history of natural infection with Well document history

significant exposure★

Reassure the woman

Obtain Varicella – Zoster IgG

Positive - Immune Negative – Not Immune

Reassure the woman Refer to hospital for prophylaxis anti

varicella zoster immunoglobulin★★

If she develops chicken pox

If No infection

Reassure the woman

Severe disease Mild disease (skin lesions mainly)

Refer to secondary care Refer to secondary care for

prescription oforal acyclovir within
hospital as emergency
24 hours of onset of rash

Refer the woman to detailed ultrasound and appropriate follow-up

★
History:

a) Evaluate susceptibility: A self-reported past history of varicella among pregnant women is a powerful predictor of
antibodies to varicella infection.

b) Defining exposure: Significant exposure to Varicella infection is defined as household contact, face to face contact
with an index case, or sharing the same hospital room with a contagious patient.
★★ Anti varicella zoster human immunoglobulin: 1gm by deep intramuscular injection, second dose required if
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Clinical conditions that may be faced in ANC clinic:

Problem 1:
Pregnant women present with history of contact with chicken pox patient

a. Careful history must be taken to confirm the significance of the contact and the. susceptibility
of the patient.
b. If the woman had previous immunity against chicken pox reassure the woman
c. If the woman with uncertain or no previous history of chickenpox and she had a significant
exposure, blood sample should be taken and send for serology (IgG) to determine VZV
Immunity or non-immunity
i. If IgG positive i.e., immune to VZV, reassure the pregnant woman that neither she
nor her baby is at risk
ii. If IgG negative i.e., not immune to VZV, the pregnant woman should be referred
to obstetrician to be offered immunoglobulin (VZIG) as soon as possible. (Less
than 10 days since the contact
d. Advise the woman that she is potentially infectious from 8-28 days after contact
e. Advise not immune woman for postpartum varicella immunization

Problem 2:
Pregnant woman who develops the rash of chicken pox

a. Symptomatic treatment and hygiene should be advised.

b. Oral Antivirus (Acyclovir)
- If the woman presents < 24 hours of the appearance of the rash and she is ≥ 20
weeks of gestations, prescribe acyclovir
- If the woman presents < 24 hours of the appearance of the rash and she is < 20weeks
of gestation, consider acyclovir (Acyclovir is not licensed for use in pregnancy and the
risks and benefits of its use should be discussed with the woman

c. Ultrasound: Women who develop chickenpox less than 28 weeks of gestation should be
referred to obstetrician, at 16–20 weeks or 5 weeks after infection for discussion and detailed
ultrasound examination.
d. Advise woman to avoid contact with potentially susceptible individuals (neonate & other
pregnant woman)

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Problem 3:
Postpartum woman who develops the rash of chickenpox

If birth occurs within the 7 days period following the onset of the maternal rash, or if the
mother develops the chickenpox rash within the 7 days period after birth there is a significant
risk of varicella infection of the newborn.
a. Refer as emergency to neonatologist / pediatrician as the neonate should be given
VZIG
b. Women with chickenpox should breastfeed if they wish and well enough to do so
Remember:
● Post-exposure prophylaxis is targeted to susceptible hosts who do not have a history
of infection or serologic evidence of prior exposure.
● Post-exposure prophylaxis is not needed among women who were immunized with
varicella vaccine in the past
● Patients need careful follow-up for signs of infection despite passive immunization
● Those who are infected despite post-exposure prophylaxis should be treated for
varicella infection
● Varicella vaccine is contraindicated during pregnancy
● Women who are vaccinated postpartum can be reassured that it is safe to breastfeed

Varicella vaccine is contraindicated during pregnancy

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2.3.18 Common counselling on lifestyles in Pregnancy

A. Exercise in pregnancy
● Patients with uncomplicated pregnancies should be encouraged to engage in physical activity
as it is safe and not associated with adverse outcomes
● Regular physical activity during pregnancy can sustain and improve cardiovascular fitness;
improve mood; decrease postpartum recovery time; and decrease the risks of gestational
diabetes mellitus, excessive weight gain, operative delivery, caesarean delivery, and
preeclampsia, decrease the risk of thrombosis and thromboembolic events.
● Exercise recommendations should take into consideration any obstetric complications or pre-
existing medical conditions (table 28)

TABLE 28: CONTRAINDICATIONS TO AEROBIC EXERCISE DURING PREGNANCY

● Significant heart disease
● Incompetent cervix with or without cercelage
● Intrauterine growth restriction
● Multiple gestation
● Persistent or unexplained vaginal bleeding
● Placenta Previa after 26 to 28 weeks’ gestation
● Preeclampsia or pregnancy-induced hypertension
● Preterm labour
● Restrictive lung disease
● Ruptured membranes
● Severe anemia
● Uncontrolled chronic medical conditions
● Hypertension / Thyroid disease
● Type 1 diabetes mellitus
● Seizure disorders

● At least 30 minutes of moderate exercise on most days of the week is a reasonable

activity level for most pregnant women
● Pregnant women should avoid activities that put them at risk of falls or abdominal
injuries

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● Pregnant women should be informed of the potential dangers of certain activities during
pregnancy, for example, contact sports, high-impact sports and vigorous racquet sports
that may involve the risk of abdominal trauma, falls or excessive joint stress, and scuba
diving, which may result in foetal birth defects and foetal decompression disease.

B. Sexual intercourse in pregnancy

● Pregnant woman should be informed that sexual intercourse in pregnancy is not known
to be associated with any adverse outcomes e.g., Preterm delivery or abortions
● Women can continue to have sex during pregnancy; however, in certain situations (e.g.,
placenta previa), avoiding sex is generally recommended

C. Alcohol in pregnancy
● Alcohol passes freely across the placenta to the foetus
● Women planning a pregnancy and pregnant woman should advised to avoid drinking
alcohol
● Alcohol has an adverse effect on the foetus such as foetal alcohol syndrome (can cause
brain damage and growth problems)
D. Smoking in pregnancy
● Maternal cigarette smoking in pregnancy is associated with an increased risk of perinatal
mortality, sudden infant death syndrome, placental abruption, preterm premature
rupture of membranes, ectopic pregnancies, placenta previa, preterm delivery,
miscarriage, low birth weight and the development of cleft lip and cleft palate in
children.
● At booking; smoking status of pregnant woman and her partner should be discussed and
provide information about the risks of smoking to the foetus and the hazards of exposure
to passive smoking.
● Pregnant women should be informed about the specific risks of smoking during
pregnancy (such as the risk of having a baby with low birthweight and preterm birth).
The benefits of quitting at any stage should be emphasised.
● Provide support on how to stop smoking: (). if she has further concerns can be
encouraged to use Stop Smoking Service if available by providing details on when,
where, and how to access them.

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E. Air travel in pregnancy

● In the absence of obstetric or medical complications, air travel generally safe for
pregnant women up to four weeks before the due date.
● Most commercial airlines allow pregnant travellers to fly until 36 weeks’ gestation.
Some limit international travel earlier in pregnancy
● The pretravel evaluation of a pregnant traveller should begin with a careful medical and
obstetric history, with particular attention paid to gestational age and evaluation for
high-risk conditions.
● Long flights are associated with an increased risk of venous thrombosis. Certain
preventive measures should be advised to minimize these risks, including use of support
stockings and periodic movement of the lower extremities, avoidance of restrictive
clothing, occasional ambulation, and maintenance of adequate hydration.
● Malaria prophylaxis
● Malaria may be much more serious in pregnant than in nonpregnant women and is
associated with high risks of illness and death for both mother and child.
● Malaria in pregnancy may be characterized by heavy parasitemia, severe anaemia, and
sometimes profound hypoglycemia, and may be complicated by cerebral malaria and
acute respiratory distress syndrome. Placental sequestration of parasites may result in
foetal loss due to abruption, premature labour, or miscarriage. An infant born to an
infected mother is most likely had a low birth weight, and, although rare, congenital
malaria is a concern.
● Because no prophylactic regimen provides complete protection, pregnant women should
avoid or delay travel to malaria-endemic areas. However, if travel is unavoidable,
pregnant women should take precautions to avoid mosquito bites, and use of an effective
prophylactic regimen is essential.
● Chloroquine and mefloquine are the drugs of choice for pregnant women for
destinations with chloroquine-sensitive and chloroquine-resistant malaria, respectively.
Doxycycline is contraindicated because of teratogenic effects on the foetus after the
fourth month of pregnancy. Primaquine is contraindicated in pregnancy because the
infant cannot be tested for G6PD deficiency, putting the infant at risk for haemolytic
anaemia. Atovaquone-proguanil is not recommended because of lack of available safety
data.

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F. Breastfeeding
● Generally, it's safe to continue breast-feeding while pregnant — as long as taking care
about eating a healthy diet and drinking plenty of fluids.
● Breastfeeding should be recommended as the best feeding method for infants
● Breastfeeding contraindications include maternal human immunodeficiency virus
infection, chemical dependency, and use of certain medications

G. Hair treatments
● Although hair dyes and treatments have not been explicitly linked to foetal malformation,
they should be avoided during early pregnancy
H. Herbal therapies
● Pregnant women should avoid herbal therapies with known harmful effects to the foetus,
such as ginkgo, ephedra, and ginseng, and should be cautious of substances with unknown
effects

I. Seat-belt use
● Pregnant women should use a seat belt, above and below the gravid abdomen but not cross.

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2.4 Obstetric Complications

2.4.1 Vaginal bleeding in early pregnancy

• Vaginal bleeding occurs during the first 22 weeks of pregnancy.
• Physical examination findings, laboratory testing, and ultrasonography can be used to
diagnose the cause of first trimester bleeding and provide appropriate management

Ask about:
• bleeding when start, how much blood lost, still bleeding or stopped, is the bleeding
increasing or decreasing, history a recent abortion, history of fainting and history of
abdominal pain

General Management
• Perform a rapid evaluation of the general condition of the woman, including vital signs
(pulse, blood pressure, respiration, temperature)
• If shock is suspected, immediately begin treatment (see page105). Even if signs of shock.
(are not present, keep shock in mind as you evaluate the woman further because her
status may worsen rapidly. If shock immediately develops, it is important to begin
treatment
• If the woman is in shock, consider ruptured ectopic pregnancy and start infusing IV fluids
(Inserts 2 large I.V lines (No.14-16)

Differential Diagnosis
• Consider ectopic pregnancy in any woman with anaemia, pelvic inflammatory
disease (PID), threatened miscarriage or unusual complaints of abdominal pain
• Consider abortion in any woman of reproductive age that has a missed
period (delayed menstrual bleeding with more than one month since her last menstrual
period) and has one or more of the following:
- Bleeding
- Cramping
- Partial expulsion of products of conception
- Dilated cervix or
- Smaller uterus than expected

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Remember:
• The patient should be stabilized before transfer
• Perform Rapid Evaluation of general condition of the patient
• Keep shock in mind even if signs of shock not present
• Refer all cases of vaginal bleeding in early pregnancy as an indicated to hospital

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ALGORITHM 18: ASSESSMENT AND MANAGEMENT PREGNANT WOMEN WITH EARLY PREGNANCY
BLEEDING
Early pregnancy bleeding < 22 weeks

Rapid assessment and management (RAM)

History:
Amount of bleeding (heavy* or spotting), presence or absence of clots or Products Of
conception (POC), Abdominal pain.
Symptoms of hypovolemia: dizziness, palpitation
Clinical Examination: Vital signs: Heart Rate, Blood Pressure, Peritoneal signs, abdomen
Speculum examination It can help identify non obstetric causes of bleeding, such as. If
products of conception are visible
Ultrasound: - confirm IUGS, cardiac activity.

Hemodynamically stable Hemodynamically unstable

Spotting /light bleeding OR active heavy bleeding with or without POC
NO POC at present OR abdominal pain – peritoneal signs
IUGS confirmed in Ultrasound OR no IUGS seen in Ultrasound

Threatened miscarriage: - light bleeding Ectopic pregnancy: - abdominal pain +/-, bleeding
**/spotting, No clots or POC, abdominal pain +/-
+/-, fainting, No IUGS seen in ultrasound
, closed cervix, foetal cardiac activity +
Incomplete miscarriage: - heavy bleeding, partial
Missed abortion / miscarriage: - No foetal expulsion of POC, abdominal pain, dilated cervix,
cardiac activity in ultrasound, bleeding +/-, uterus smaller than date
abdominal pain+/-
Inevitable miscarriage: - heavy bleeding, no
Complete miscarriage: - history of heavy
expulsion of POC, abdominal pain and cramps,
bleeding & passing POC (BUT now decrease
dilated cervix, uterus corresponds to date
bleeding or no bleeding & clots at present,
abdominal pain +/-, closed uterus
Molar pregnancy: -: - heavy bleeding, POC
resemble grapes, abdominal pain, dilated cervix,
Local causes: - vaginitis, cervicitis, or a cervical
uterus larger than date
polyp

Discuss the case with If at any time, the

Stabilize (Insert 2 big IV cannulas
Obstetrician patient became & start IV fluids)
Refer the Patient to the hemodynamically
Discuss the case with Obstetrician
hospital as urgent unstable, or heavy
bleeding or POC Escort the Patient to the hospital
as emergency
appeared.

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• Use the following table to make a diagnosis and if any of the conditions listed is suspected and refer as
indicated to secondary / tertiary hospital

TABLE 29: DIFFERENTIAL DIAGNOSIS OF VAGINAL BLEEDING IN EARLY PREGNANCY

Probable
Assessment (Signs & Symptoms) Management & Advise
Diagnosis
• Light ★ bleeding Threatened • Refer with urgent
• Closed cervix abortion appointment to secondary
• Uterus corresponds to dates care
Two or more of the following signs: Ectopic • Insert an IV line and give
• abdominal pain pregnancy fluids
• fainting • Refer as emergency to
• pale hospital
• very weak
• History of heavy bleeding★★ but Complete • If no fever or severe bleeding
- now decreasing, or abortion refer with urgent
- no bleeding at present appointment to secondary
• Closed cervix care
• Uterus smaller than dates
• Light cramping/lower abdominal pain
• History of expulsion of products of
conception
• Heavy ★★ bleeding Inevitable • Insert an IV line and give
• Dilated cervix abortion fluids
• Uterus corresponds to dates • Refer to hospital
• Cramping/lower abdominal pain as emergency
• No expulsion of products of
Conception
• Heavy★★ bleeding Incomplete • Insert an IV line and give
• Dilated cervix abortion fluids
• Uterus smaller than dates • Refer to hospital
• lower abdominal pain as emergency
• Partial expulsion of products of conception

• Heavy★★ bleeding Molar • Insert IV line

• Dilated cervix pregnancy • Give IV fluids
• Uterus larger than dates rapidly
• Partial expulsion of products of conception • Refer to hospital as
which emergency
resemble grapes
• Cramping /lower abdominal pain
★
Light bleeding: takes some time for a clean pad or cloth to be soaked

★★
Heavy bleeding: takes five minutes for a clean pad or cloth to be soaked

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2.4.2 Vaginal bleeding in later pregnancy and labour

Problems
• Vaginal bleeding after 22 weeks of pregnancy.
• Vaginal bleeding in labour before delivery

TABLE 30: TYPES OF BLEEDING

Type of Bleeding Probable Diagnosis Action

Blood-stained mucus Onset of labour Proceed with management

(show) of normal labour and Childbirth
Any other bleeding Antepartum haemorrhage Determine cause using Table 21
after 22 weeks of • Abruptio Placenta
gestation • Placenta Previa
• Ruptured uterus
Bleeding during labour bleeding more than 100 Stabilized & refer as emergency to
ml since labour began hospital
• Abruptio Placenta
• Placenta Previa
• Ruptured uterus

General Management of Vaginal Bleeding

• Call for help. Urgently mobilize all available personnel
• Perform a rapid evaluation of the general condition of the woman, including vital signs
(Pulse, blood pressure, respiration, temperature)
• If shock is suspected, immediately begin treatment see page105 , Even if signs of
shock is not present, keep shock in mind as you evaluate the woman further because her
status may worsen rapidly. If shock develops, it is important to begin treatment
immediately
- Insert two large IV lines and infuse IV fluids
- Do not do a vaginal examination at this stage
- Check Maternal Health Record for previous ultrasound results
- Use the following table to make a diagnosis and if any of the conditions listed is
suspected
- Refer as emergency
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Diagnosis & Management of Vaginal Bleeding

Use the following table for diagnosis and management.

TABLE 31: DIFFERENTIAL DIAGNOSIS OF VAGINAL BLEEDING IN LATER PREGNANCY (ANTEPARTUM HAEMORRHAGE):

Presenting Symptom Symptoms and Signs Sometimes Probable Diagnosis &

and Other Symptoms Present Management
and Signs Typically
present
• Bleeding after 22 • Shock Abruptio placenta,
weeks gestation • Tense/tender uterus
• Intermittent or • Decreased/ absent • Do not do
constant abdominal foetal vaginal examination
pain . movements • Insert IV line
• Foetal distress or absent foetal • Give IV fluids rapidly
heart sounds • Refer to hospital as
emergency
• Bleeding • Shock Ruptured uterus,
(intra- abdominal • Rapid maternal pulse
and/or (vaginal • Abdominal distension/ • Do not do
• Severe abdominal free fluid vaginal examination
pain (may decrease • Abnormal uterine contour • Insert IV line
(after rupture • Tender abdomen • Give IV fluids rapidly
• Easily palpable foetal parts • Refer to hospital as
• Absent foetal movements and emergency
foetal heart sounds
• Bleeding after 22 • Shock Placenta praevia
weeks gestation • Bleeding may be precipitated by
intercourse • Do not do
• Relaxed uterus vaginal examination
• Foetal presentation (not in • Insert IV line
pelvis/ lower uterine pole • Give IV fluids rapidly
feels (empty • Refer to hospital as
• Normal foetal condition emergency

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2.4.3 Fever during pregnancy and labour

Problem
A woman has fever (temperature 38°C or more) during pregnancy or labour.

General Management
● Encourage adequate rest
● Encourage to increase fluid intake by mouth or start IV fluids if indicated
● Paracetamol 1 gm can be given 4-6 hourly
● Use tepid sponge to help decrease temperature

Diagnosis & Management

Use the following table for diagnosis and management of fever during pregnancy.

TABLE 32: DIAGNOSIS OF FEVER DURING PREGNANCY AND LABOUR

Presenting Symptom and Symptoms and Signs Probable Diagnosis &

Other Symptoms and Sometimes Present Management
Signs Typically
Present
• Dysuria • Retro pubic/suprapubic pain/ • Acute pyelonephritis
• Spiking fever/chill tenderness • Refer as emergency to
• Increased frequency • Loin pain/tenderness secondary care
and urgency of urination • Tenderness in rib
• Abdominal pain cage
• Anorexia
• Nausea/vomiting
• Foul-smelling vaginal • Lower abdominal pain • Septic abortion
discharge in first 22 • Prolonged bleeding • Refer as emergency
weeks • Purulent cervical to secondary care
• Fever discharge
• Tender uterus • Rebound tenderness
• Fever/chills • History of loss of fluid • Chorioamnionitis
• Foul-smelling watery • Light vaginal bleeding • Refer as emergency to
discharge after 22 weeks • Tender uterus secondary care
• Abdominal pain • Rapid foetal heart rate
• Fever • Signs of consolidation • Pneumonia / viral
• Difficulty in breathing • Congested throat infection
• Cough with expectoration • Rapid breathing • Refer as emergency
• Chest pain • Rhonchi/ rales to secondary care

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2.4.4 Abdominal pain in pregnancy

● Abdominal pain in pregnancy represents a diagnostic and therapeutic challenge and can
occur due to obstetric causes as well for causes that are unrelated to pregnancy.
● It is very crucial to identify patients who have a serious or even life-threatening conditions
and require urgent intervention as delay in diagnosis and treatment can lead to increase
maternal and foetal/newborn morbidity and mortality.

Abdominal pain at early Pregnancy: -

● The woman is experiencing abdominal pain in the first 22 weeks of pregnancy
● Abdominal pain may be the first presentation in serious complications such as abortion
or ectopic pregnancy

Abdominal pain at late Pregnancy and after childbirth: -

● The woman is experiencing abdominal pain after 22 weeks of pregnancy
● The woman is experiencing abdominal pain during the first six weeks after childbirth

ALGORITHM 19: ABDOMINAL PAIN IN PREGNANCY

Abdominal Pain in pregnancy

Pregnancy Gynaecological Other Non-

related Gynaecological

Early pregnancy Ovarian cyst (torsion, Surgical

Ectopic pregnancy haemorrhage, rupture) Acute Appendicitis
Abortions Acute Cholecystitis
Molar pregnancy Degeneration of uterine Acute pancreatitis
Late pregnancy fibroid Peptic ulcer
Labour/pre-term Renal stones
Placental abruption Biliary cholic
Rupture of uterus Medical
Pre- Gastroenteritis
eclampsia/HELLP Sickle cell crisis
Chorioamnionitis Other causes
Psychological
Infections
Herpes zoster
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Diagnosis & Management

Use the following table for diagnosis and management of woman experiencing abdominal pain in
pregnancy
TABLE 33:DIAGNOSIS AND MANAGEMENT OF WOMAN EXPERIENCING ABDOMINAL PAIN IN PREGNANCY
Probable Diagnosis Symptoms and Signs Management and Referral
to Secondary care
Pregnancy – related (early pregnancy)
Ectopic pregnancy • Abdominal pain. • Insert IV line
• Fainting • Give IV fluids
• Pale rapidly
• Very weak
• Tender adnexal mass Escort to hospital as
• Amenorrhea emergency
• Cervical
motion tenderness
Miscarriages ● Vaginal bleeding It depends on the situation
/Abortions ● Abdominal pain See section
● Open/closed cervix
● Presence or not of tissues and clots
Molar pregnancy ★★ • Insert IV line
• Heavy bleeding • Give IV fluids
• Dilated cervix rapidly
• Uterus larger than dates Escort to hospital as
• Partial expulsion of products of conception emergency
which resemble grapes
Cramping /lower abdominal pain
Pregnancy related (late pregnancy)
Possible preterm • Palpable contractions Refer as
labour • Blood-stained mucus discharge (show) or emergency
watery discharge before 37 weeks to hospital
• Cervical dilatation and effacement
• Light★ vaginal bleeding
Possible term labour • Palpable contractions Conduct labour if facilities
• Blood-stained mucus discharge (show) or available in the health
watery discharge at or after 37 weeks institution or refer as
• Cervical dilatation and effacement emergency to the nearest
• Light vaginal bleeding delivering institution
Placental abruption • Bleeding after 22 weeks gestation
Intermittent or constant abdominal pain • Do not do
• Shock vaginal examination
• Tense/tender uterus • Insert IV line
• Decreased/ absent • Give IV fluids rapidly
foetal Refer to
. movements hospital
Foetal distress or absent foetal heart sounds as emergency

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Uterine rupture • Bleeding (intra- abdominal • Do not do

and/or (vaginal vaginal examination
• Severe abdominal pain (may decrease (after • Insert IV line
rupture • Give IV fluids rapidly
• Shock
• Rapid maternal pulse Refer to
• Abdominal distension/ hospital
free fluid as emergency
• Abnormal uterine contour
• Tender abdomen
• Easily palpable foetal parts
• Absent foetal movements and foetal heart
sounds

Choriamnionitis • Foul-smelling watery vaginal discharge after Refer as emergency

22 weeks gestation
• Fever/chills
• History of loss of fluids
• Tender uterus rapid heart rate
• Light vaginal bleeding
Gynaecological
Ovarian cyst (torsion, • Abdominal pain • Insert IV line
haemorrhage, • Adnexal mass on vaginal examination • Give IV fluids
rupture) • Palpable, tender discrete mass in lower rapidly
abdomen
• Light★ vaginal bleeding Escort to hospital as
emergency
Fibroid red • Lower abdominal pain • Insert IV line
degeneration • Give IV fluids
Twisted pedunculated rapidly
fibroids (torsion)
Escort to hospital as
emergency
Endometritis • Lower abdominal pain • Insert IV line
• Fever/chills • Give IV fluids
• Purulent, foul- smelling lochia rapidly
• Tender uterus
• Light vaginal bleeding Escort to hospital as
• Shock emergency

Pelvic abscess • Lower abdominal pain and distension • Insert IV line

• Persistent spiking fever/ chills • Give IV fluids
• Tender uterus rapidly
• Poor response to antibiotics
• Swelling in adnexa or pouch of Douglas Escort to hospital as
emergency

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Medical & Surgical

Appendicitis • Rt Lower abdominal pain, sometimes Refer as emergency
higher than expected.
• Low-grade fever
• Rebound tenderness
• Nausea/vomiting
• Increased white blood cells
Acute pyelonephritis • Dysuria
• Spiking fever/chills Refer as emergency
• Increased frequency
and urgency of urination
• Abdominal pain Retro
pubic/suprapubic pain/ tenderness
• Loin pain/tenderness
• Tenderness in rib cage
• Anorexia
• Nausea/vomiting
Peritonitis • Low-grade fever/chills
• Lower abdominal pain
• Absent Refer as emergency
bowel sounds Rebound tenderness
• Abdominal
distension
• Anorexia
• Nausea/vomiting
• Shock
Cystitis • Dysuria Manage as in Table 19
• Increased frequency
and urgency of urination
• Abdominal pain
• Retro pubic/ suprapubic pain/ tenderness

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2.4.5 Missed Abortion / Miscarriage

Definition:
Absent foetal heart activity and/or cessation of pregnancy related symptoms before 24 weeks of
pregnancy.

Diagnosis
By ultrasound (Trans-vaginal / abdominal ultrasound):
● Intrauterine sac (>20 mm mean diameter) with no obvious yolk sac or foetus, OR
● Absence of foetal heart activity in a pregnancy with crown-rump length of > 6 mm

General management:
● Repeat ultrasound examination at interval of 1 to 2 weeks to confirm the diagnosis
● After confirming the diagnosis, discuss the case and refer to the secondary care as advised to
decide on the mode of management.

2.4.6 Decreased foetal movements

Definition
Foetal movements are less than 10 movements per 12 hours.

Diagnosis

a. History
• Check when last had food or fluids
• Check maternal activity
• Check for any significant risk factors

b. Examination
• Check symphysis pupis height (SPH)
• Check foetal heart activity by Doppler

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c. Management:
1. If < 28 weeks, or gave history of not taking food
● Advise her to take food and observe for movements for the next 1 hour
● Check for foetal heart activity
● If normal movements and normal foetal heart activity: reassure the women and provide kick
chart
● If no movements and/or abnormal foetal heart activity: refer to the secondary care as
emergency

2. If ≥ 28 weeks and/or risk factors: Refer to the secondary care as emergency

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2.4.7 Pre-mature Rupture of Membranes (PROM)

Definition:
Rupture of membranes with vaginal loss of amniotic fluid before labour has begun. It can occur
either when the foetus is immature (preterm or before 37 weeks) or when it is mature (term).

Diagnosis:
Maternal history:
• Gestational age
• Time of rupture of membranes
• Description of liquor (colour, consistency, presence of meconium-stained liquor)
• Symptoms of infection
- Fever
- Maternal tachycardia
- Yellowish vaginal discharge

Examination:
• Sterile speculum examination
- Presence of pool of fluid in the vagina
- Nitrazine test: amniotic fluid will turn paper blue
- Microscopic examination of vaginal fluid show ferning due to the presence of sodium
chloride under estrogen effect
- Examination for lanugo hair

• Abdominal examination: determine foetal lie, presentation, heart rate and presence of
Contraction

Note:
Nitrazine test is the most practical and of help, but false positive rate is 17% due to contamination
with urine, blood or semen.

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Management:
• If history and speculum examination show evidence of leakage, refer to the secondary care as
emergency
• If Nitrazine test is positive, refer to the secondary care as emergency
• If history, examination and Nitrazine test are not suggestive of rupture of membranes, reassure
the patient and advise her to observe by applying a clean pad
• Instruct the women to report immediately if signs of leaking liquor
reoccur

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2.5 Normal labour

• Greet the woman and make her comfortable

• Perform a rapid evaluation of the general condition of the woman including vital signs
(pulse, blood pressure, respiration, temperature)
• Perform a rapid evaluation of the maternal health record
• Assess foetal condition
- Listen to the foetal heart rate immediately after a contraction
- Count the foetal heart rate for a full minute (after contraction) at least once every
- minutes during the active phase and every five minutes during the second 15
stage
- If there are foetal heart rate abnormalities (less than 110 or more than 160 beats
- per minute), suspect foetal distress
- If the membranes have ruptured, note the colour of the draining amniotic fluid
- Presence of thick meconium indicates the need for close monitoring and possible
- intervention for management of foetal distress
- Absence of fluid draining after rupture of the membranes is an indication of
- reduced volume of amniotic fluid, which may be associated with foetal distress

TABLE 34: CONDITIONS DURING LABOUR REQUIRING IMMEDIATE REFERRAL

Condition Transfer to

Primigravida Secondary care

Foetal Malpresentation Secondary care

Foetal distress (abnormal foetal heart rate, thick Secondary care

meconium, blood-stained liquor)
Ruptured membranes more than 24 hours Secondary care

Prolonged labour (poor dilatation despite Secondary care

good contractions)
Prelabour rupture of membranes (before 22 weeks) Secondary care

Uncontrolled premature labour (before 37 weeks) Secondary care

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2.5.1 Supportive care during labour and childbirth

● Encourage the woman to have personal support from a person of her

- choice throughout labour and birth (if permissible in the institution)
- Arrange seating for the companion next to the woman
- Encourage the companion to give adequate support to the woman during labour and
childbirth (rub her back, wipe her brow with a wet cloth, assist her to move about

● Ensure good communication and support by staff

- Explain all procedures, seek permission and discuss findings with the woman
- Provide a supportive, encouraging atmosphere for birth that is respectful of
the woman’s wishes
- Ensure privacy and confidentiality

● Maintain cleanliness of the woman and her environment

- Encourage the woman to wash herself or bath or shower at the onset of labour (if
possible, in the providing institution).
- Clean the vulva and perineal areas before each examination.
- Wash your hands with soap before and after each examination.
- Ensure cleanliness of labouring and birthing area(s).
- Clean up all spills immediately

● Ensure mobility
- Encourage the woman to move about freely
- Encourage the woman to empty her bladder regularly
-
Note: Do not routinely give an enema to women in labour.

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● Encourage the woman to eat light meals, drink water, nutritious liquid drinks are
important, even in late labour to avoid dehydration
● Teach breathing techniques for labour and delivery
● Encourage the woman to breathe out more slowly than usual and relax with
expiration
● Help the woman in labour who is anxious, fearful or in pain
- Give her praise, encouragement and reassurance
- Give her information on the process and progress of her labour
- Listen to the woman and be sensitive to her feelings

● If the woman is distressed by pain

- Encourage mobility, as comfortable for her
- Suggest change of position
- Encourage companion to
- Massage the woman’s back if she finds this helpful
- Hold the woman’s hand and sponge her face between contractions
- Encourage her to use the breathing technique
- Encourage warm bath or shower, if available

Note: Analgesics drugs during labour apart from paracetamol to be avoided

● Barbiturates and sedatives should not be used to relieve anxiety in labour

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2.5.2 Diagnosis and confirmation of labour

● Suspect or anticipate labour if the woman has

- Intermittent abdominal pain after 22 weeks gestation
- Pain often associated with blood-stained mucus discharge (show)
- Watery vaginal discharge or a sudden gush of water

● : Confirm the onset of labour if there is

- Cervical effacement, i.e., the progressive shortening and thinning of the cervix during
labour; and
- Cervical dilatation, i.e., the increase in diameter of the cervical opening measured in
centimetres

FIGURE 2: EFFACEMENT AND DILATATION OF THE CERVIX

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2.5.3 Diagnosis of stage and phase of labour

TABLE 35: DIAGNOSIS OF STAGE AND PHASE OF LABOUR

- Symptoms and Signs Stage Phase

Cervix not dilated False labour/ Not in labour

Cervix dilated less than 3 cm First - Latent
- Cervix dilated 3-9 cm First Active
- Rate of dilatation typically one cm per hour or more
- Foetal descent begins
- Cervix fully dilated (10 cm) Second Early
- Foetal descent continues (non-
- No urge to push expulsive)
- Cervix fully dilated (10 cm) Second Late (expulsive)
- Presenting part of foetus reaches pelvic floor
- Woman has the urge to push

Note: Third stage of labour begins with delivery of the baby and ends with the
expulsion of the placenta.
- Descent Assessment
- Abdominal Palpation
- By abdominal palpation, assess descent in terms of fifths of foetal head palpable
above the symphysis pubis:
- A head that is entirely above the symphysis pubis is five-fifths (5/5) palpable
- A head that is entirely below the symphysis pubis is zero-fifths (0/5) palpable

FIGURE 3: ABDOMINAL PALPATION FOR DESCENT OF THE FOETAL HEAD

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Vaginal Examination
● Vaginal examination is used to assess descent by relating the level of the foetal
presenting part to the Ischial spines of the maternal pelvis.

Note: When there is a significant degree of caput or moulding, assessment by abdominal

palpation using fifths of head palpable is more useful than assessment by vaginal exam.

FIGURE 4: ASSESSING DESCENT OF THE FOETAL HEAD BY VAGINAL EXAMINATION; 0 STATION IS

AT THE LEVEL OF THE ISCHIAL SPINE (SP)

Presentation and Position Assessment

Determine the presenting part:
● The most common presenting part is the vertex of the foetal head. If the vertex is not the
presenting part, manage as a malpresentation
● If the vertex is the presenting part, use landmarks on the foetal skull to determine the
position of the foetal head in relation to the maternal pelvis

FIGURE 5: LANDMARKS OF THE FOETAL SKULL

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Determine the Position of the Foetal Head

● The foetal head normally engages in the maternal pelvis in an occipital transverse
position, with the foetal occiput transverse in the maternal pelvis.

FIGURE 6: OCCIPUT TRANSVERSE POSITIONS

● With descent, the foetal head rotates so that the foetal occiput is anterior in the maternal
pelvis (occiput anterior positions). Failure of an occiput transverse position to rotate to
an occiput anterior position should be managed as an occiput posterior position.

FIGURE 7: OCCIPUT ANTERIOR POSITIONS

● An additional feature of a normal presentation is a well-flexed vertex with the occiput

lower in the vagina than the sinciput.

FIGURE 8: WELL-FLEXED VERTEX

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Assessment of Progress of Labour

● Once diagnosed, progress of labour is assessed by:
● Measuring changes in cervical effacement and dilatation during the latent phase
● Measuring the rate of cervical dilatation and foetal descent during the active phase
● Assessing further foetal descent during the second stage
● Progress of the first stage of labour should be plotted on a partogram once the woman
enters the active phase of labour. A sample partogram is shown in Figure 12.

TABLE 36: DURATION OF EACH STAGE OF LABOUR

Stage of Labour Primigravida Multipara

First stage 6- 18 hours 2- 10 hours

Second stage 30 minutes to 3 hours 5- 30 minutes

Third stage 0- 30 minutes 0- 30 minutes

Vaginal Examinations
Vaginal examinations should be carried out at least once every four hours during the first
stage of labour and after rupture of the membranes. Plot the findings on a partogram.
● At each vaginal examination, record the following
- colour of amniotic fluid
- cervical dilatation and effacement
- descent (can also be assessed abdominally)
● If the cervix is not dilated on first examination, it may not be possible to diagnose
labour
● If contractions persist, re-examine the woman after four hours for cervical changes. At
this stage, if there is effacement and dilatation, the woman is in labour if there is no
change, the diagnosis is false labour
● In the second stage of labour, perform vaginal examinations once every hour

Using of Partogram
Fill all the required information in the front page of the Composite Obstetric Record
Plotting the Partogram:
● The partogram is designed to record all important information about the woman and
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foetus during labour. It is a tool for making decisions

● The progress of labour is recorded as a simple graph with the time on the horizontal
axis and the various important features of labour on the vertical axis
● All observations such as BP, foetal heart, uterine contractions are charted by plotting the
value of that observation, on the vertical axis, against the appropriate time, on the
horizontal axis. In this way trends are easily recognized
● The findings of every vaginal examination (cervix dilatation and descent) are plotted
on the partogram
● The midwife or doctor can see at a glance the condition of the mother and foetus, and
the progress of labour
● The partogram provides valuable guidance in the management of labour
● The partogram is started when the cervix is 3 cm dilated
● Every 30 minutes
- Count the foetal heart
- Time the uterine contractions
- Take the maternal pulse
● Every two hours Take the maternal blood pressure
● Every four hours:
- Take maternal temperature
- Test the urine
- Perform a vaginal examination

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FIGURE 9: SAMPLE PARTOGRAM FOR NORMAL LABOUR

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Use of Partogram in Active Management of Labour

● Alert line: As soon as the cervix is found to be cm or more dilated on vaginal examination,
3 an Alert line is drawn in red obliquely upward, along the expected rate of dilatation of 1
cm per hour.
● The Alert line indicates the expected rate of dilatation during the active phase of labour
● If on subsequent vaginal examination the cervical dilatation is to the right of the Alert line the
doctor should be informed as it gives in indication that labour is not progressing as it
should be.
● Action line: Is drawn parallel to the alert line, 4 hours to the right. This shows when some
action should be taken
● If, on any vaginal assessment, the cervical dilatation is delayed or more to the 2 hours right of
the Alert line i.e., on the Action line or beyond, some action should be taken to ensure
that labour progresses safely.

Progress of First Stage of Labour

● Findings suggestive of satisfactory progress in the first stage of labour are
- Regular contractions of progressively increasing frequency and duration
- Rate of cervical dilatation at least 1 cm per hour during the active phase of labour
(cervical dilatation on or to the left of alert line)
- Cervix well applied to the presenting part
- Findings suggestive of unsatisfactory progress in the first stage of labour are Irregular
and infrequent contractions after the latent phase OR
- Rate of cervical dilatation slower than 1 cm per hour during the active phase of labour
- (cervical dilatation to the right of alert line)
OR
- Cervix poorly applied to the presenting part
Note: Unsatisfactory progress in labour can lead to prolonged labour.

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Progress of Second Stage of Labour

● Findings suggestive of satisfactory progress in the second stage of labour are
- Steady descent of foetus through birth canal
- Onset of expulsive (pushing) phase

● Findings suggestive of unsatisfactory progress in second stage of labour are

- Lack of descent of foetus through birth canal
- Failure of expulsion during the late (expulsive) phase

If there are foetal heart rate abnormalities (less than 110 or more than 160 beats per
minute), suspect foetal distress and refer the patient to the secondary care as
emergency
Positions or presentations in labour other than occiput anterior with a well- flexed
vertex are considered malposition or malpresentation and refer the patient to the
secondary care as emergency
If unsatisfactory progress of labour or prolonged labour is suspected refer patient to
the secondary care as emergency

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Progress of Foetal Condition

Evaluate the woman for signs of distress:

● If the woman’s pulse is increasing, she may be dehydrated or in pain. Ensure
adequate hydration via oral or IV routes
● If the woman’s blood pressure decreases, suspect haemorrhage
● If ketones are present in the woman’s urine, suspect poor nutrition and give oral
nutritious drinks and IV fluids.

Progress of Maternal Condition

Normal childbirth
Once the cervix is fully dilated and the woman is in the expulsive phase of the second stage (when she
feels the urge to push), encourage the woman to push.

Note: Episiotomy is no longer recommended as a routine procedure. There is no evidence that routine
episiotomy decreases perineal damage, future vaginal prolapse or urinary incontinence.
Episiotomy (Page 117) should be considered in the case of:
Complicated vaginal delivery (breech, shoulder dystocia, forceps, vacuum (extraction
Scarring from female genital cutting or poorly healed third or fourth degree tears
Foetal distress

● Ask the woman to pant or give only small pushes with contractions as the baby’s head delivers
● To control birth of the head, place the fingers of one hand against the baby’s head to keep it
flexed (bent)
● Continue to gently support the perineum as the baby’s head delivers
● Once the baby’s head delivers, ask the woman not to push
● Feel around the baby’s neck for the umbilical cord
- If the cord is around the neck but is loose, slip it over the baby’s head
- If the cord is tight around the neck, doubly clamp and cut it before unwinding it from around
the neck

Completion of Delivery:
● Allow the baby’s head to turn spontaneously

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● After the head turns, place a hand on each side of the baby’s head. Tell the woman to push
gently with the next contraction
● Reduce tears by delivering one shoulder at a time
Note: If there is difficulty delivering the shoulders, suspect shoulder dystocia.

● Lift the baby’s head anteriorly to deliver the shoulder that is posterior
● Support the rest of the baby’s body with one hand as it slides out
● Place the baby on the mother’s abdomen. Thoroughly dry the baby, wipe the eyes and assess the
baby’s breathing
Note: Most babies begin crying or breathing spontaneously within 30 seconds of birth:
- If the baby is crying or breathing (chest rising at least 30 times per minute) leave the baby
with the mother
- If baby does not start breathing within 30 seconds, call for help and take steps to resuscitate
the baby

Anticipate the need for resuscitation and have a plan to get assistance for every baby

● Clamp and cut the umbilical cord immediately after delivery of the baby
● Ensure that the baby is kept warm and in skin-to-skin contact on the mother’s chest. Wrap the
baby in a soft, dry cloth, cover with a blanket and ensure the head is covered to prevent heat loss
● If the mother is not well, ask an assistant to care for the baby
● Palpate the abdomen to rule out the presence of an additional baby(s) and proceed
● with active management of the third stage

Active Management of the Third Stage:

Active management of the third stage (active delivery of the placenta) helps to prevent postpartum
haemorrhage. Active management of the third stage of labour includes:

A. Immediate oxytocin
B. Controlled cord traction and
C. Uterine massage

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Oxytocin

● Within one minute of delivery of the baby, palpate the abdomen to rule out the presence of an
additional baby(s) and give oxytocin 10 units IM
● Oxytocin is preferred because it is effective 2 to 3 minutes after injection, has minimal side
effects and can be used in all women. If oxytocin is not available, give ergometrine mg IM 0.2

Do not give ergometrine to women with pre-eclampsia, eclampsia, high blood

pressure and cardiac conditions because it increases the risk of convulsions and
cerebrovascular accidents.

Controlled Cord Traction:

1. Clamp the cord close to the perineum using sponge forceps within one minute of delivery. Hold
the clamped cord and the end of forceps with one hand.
2. Wait for signs of placenta separation: gush of blood and lengthening of the cord
3. Place side of the other hand (usually left) above symphysis pubis with palm facing towards the
mother’s umbilicus. This applies counter traction to the uterus during controlled cord traction.
This helps to prevent inversion of the uterus.
4. Keep slight tension on the cord and await a strong uterine (minutes).
5. When the uterus becomes rounded or the cord lengthens, very gently pull downward on the cord
to deliver the placenta. Continue to apply counter traction to the uterus with the other hand
6. If the placenta does not descend during 30 to 40 seconds of controlled cord traction (i.e., there
are no signs of placental separation), do not continue to pull on the cord.
- Gently hold the cord and wait until the uterus is well contracted again. If
necessary, use a sponge forceps to clamp the cord closer to the perineum as it lengthens
- With the next contraction, repeat controlled cord traction with counter traction

Never apply cord traction (pull) without applying counter traction (push) above the pubic
bone with the other hand

7. As the placenta delivers, the thin membranes can tear off. Hold the hands and gently turn it
until the membranes are twisted
8. Slowly pull to complete the delivery placenta in two

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9. If the membranes tear, gently examine the upper vagina and cervix and use a sponge forceps to
remove any pieces of membrane that are present
10. Inspect the placenta to be sure none of it is missing. If a portion of the maternal surface is
missing or there are torn membranes with vessels, suspect retained placental fragments, transfer
the patient to the secondary care as emergency
11. If uterine inversion occurs, transfer the patient to the secondary care as emergency
12. If the cord is pulled off, transfer the patient to the secondary care as emergency

Uterine Massage:
● Immediately massage the fundus of the uterus through the woman’s abdomen until the
uterus is contracted
● Perform uterine palpation and inspect for excessive vaginal bleeding every 15 minutes for
the first two hours
● Ensure that the woman has passed urine before shifting to the ward or discharge

Examination for Vaginal Tears:

● Examine the woman carefully and only repair 1st and 2nd degree vaginal tears, lacerations
and episiotomy
● If 2nd degree vaginal tear was difficult to repair, refer to the secondary care as emergency
● Refer the patient to the secondary care for the repair of 3rd degree vaginal tears and
cervical tears as an emergency
Fourth Stage Assessment:
● Assess estimated blood loss at delivery
● Measure vital signs
● Assess uterine tone uterus should be firm, central and located at the umbilicus. If uterus is
deviated from central position, soft and/or distended, check the bladder, if palpable,
encourage the mother to pass urine or insert a urinary catheter

Management of women presenting with active labour and diagnosed with malpresentation:

Delivery with malpresentation should not be carried out in a primary health care. If women
presented in labour every effort should be taken to transfer patient to the secondary care.
Delivery can only be conducted if woman is an advanced stage of labour and there is no
time to transfer.
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Breach Presentation:
● Review general care principles and start an IV infusion. Provide emotional support and
encouragement
● Perform needed manoeuvres gently and without undue force

Complete or Frank Breech

FIGURE 10: BREECH PRESENTATION

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Delivery of the Buttocks and Legs

● Once the buttocks have entered the vagina and the cervix is fully dilated, tell the woman
she can bear down with the contractions
● If the perineum is very tight, perform an episiotomy (page117.(
● Let the buttocks deliver until the lower back and then the shoulder blades are seen
● Gently hold the buttocks in one hand, but do not pull
● If the legs do not deliver spontaneously, deliver one leg at a time
- Push behind the knee to bend the leg
- Grasp the ankle and deliver the foot and leg
- Repeat for the other leg
● Hold the baby by the hips, as shown in (figure 10). Do not hold the baby by the flanks or
abdomen as this may cause kidney or liver damage

Do not pull the baby while the legs are being delivered

FIGURE 11: HOLD THE BABY

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Delivery of the Arms

Arms are Felt on Chest
● Allow the arms to disengage spontaneously one by one. Only assist if necessary
● After spontaneous delivery of the first arm, lift the buttocks towards the mother’s abdomen
to enable the second arm to deliver spontaneously
● If the arm does not spontaneously deliver, place one or two fingers in the elbow and bend
the arm, bringing the hand down over the baby’s face

Arms are Stretched above the Head or Folded around the Neck
Use Lovset's manoeuvre (Figure 12)
● Hold the baby by the hips and turn half a circle, keeping the back uppermost and applying
downward traction at the same time, so that the arm that was posterior becomes anterior
● .and can be delivered under the pubic arch
● Assist delivery of the arm by placing one or two fingers on the upper part of the arm. Draw
the arm down over the chest as the elbow is flexed, with the hand sweeping over the face
● To deliver the second arm, turn the baby back half a circle, keeping the back uppermost and
applying downward traction, and deliver the second arm in the same way under the
pubic arch

FIGURE 12: LOVSET’S ANOEUVRE

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Baby’s Body Cannot Be Turned

If the baby’s body cannot be turned to deliver the arm that is anterior first, deliver the shoulder that is
posterior see (Figure 12):
● Hold and lift the baby up by the ankles
● Move the baby’s chest towards the woman’s inner leg. The shoulder that is posterior
should deliver
● Deliver the arm and hand
● Lay the baby back down by the ankles. The shoulder that is anterior should now deliver
● Deliver the arm and hand

FIGURE 13: DELIVERY OF THE SHOULDER THAT IS POSTERIOR

Delivery of the Head

● Deliver the head by the Mauriceau Smellie Veit manoeuvre as follows:
● Lay the baby face down with the length of its body over your left hand and forearm
● Place the first and second fingers of this hand on the baby’s cheekbones beside the nose
● Use the other hand to grasp the baby’s shoulders with the middle finger pushing on the
occiput
● Apply gentle traction downward and backwards direction until delivery of foetal chin
followed by upward guidance of face and forehead over perineum
Note: Ask an assistant to push above the mother’s pubic bone as the head delivers. This helps to keep
the baby’s head flexed.
● Raise the baby, still astride the arm, until the mouth and nose are free

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FIGURE 14: THE MAURICE AU SMELLIE VEIT MANŒUVRE

Shoulder Dystocia
Problem
The foetal head has been delivered but the shoulders are stuck and cannot be delivered.

General Management
● Be prepared for shoulder dystocia at all deliveries, especially if a large baby is anticipated
● Have several persons available to help

Shoulder dystocia cannot be predicted

Diagnosis
● The foetal head is delivered but remains tightly applied to the vulva
● The chin retracts and depresses the perineum
● Traction on the head fails to deliver the shoulder, which is caught behind the symphysis
pubis

Management
● Make an adequate episiotomy to reduce soft tissue obstruction and to allow space for
manipulation
● With the woman on her back, ask her to flex both thighs, bringing her knees as far

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up as possible towards her chest. Ask two assistants to push her flexed knees firmly up onto her
chest

FIGURE 15: ASSISTANT PUSHING FLEXED KNEES FIRMLY TOWARDS CHEST

● Wearing sterile gloves apply firm, continuous traction downwards on the foetal head to
move the shoulder that is anterior under the symphysis pubis
Note: Avoid excessive traction on the foetal head as this may result in brachial plexus injury.

- Have an assistant simultaneously apply suprapubic pressure downwards to assist

delivery of the shoulder
Note: Do not apply fundal pressure. This will further impact the shoulder and can result in
uterine rupture.

● If the shoulder still is not delivered

- Insert a hand into the vagina
- Apply pressure to the shoulder that is anterior in the direction of the baby’s sternum
to rotate the shoulder and decrease the diameter of the shoulders
- If needed, apply pressure to the shoulder that is posterior in the direction of the
sternum

● If the shoulder still is not delivered despite the above measures

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- Insert a hand into the vagina

- Grasp the humerus of the arm that is posterior and, keeping the arm flexed at the elbow,
sweep the arm across the chest. This will provide room for the shoulder that is anterior to
move under the symphysis pubis

FIGURE 16: GRASPING THE HUMERUS OF THE ARM THAT IS POSTERIOR AND
SWEEPING THE ARM ACROSS THE CHEST

● If all of the above measures fail to deliver the shoulder, other options include
- Fracture the clavicle to decrease the width of the shoulders and free the shoulder
that is anterior
- . Apply traction with a hook in the axilla to extract the arm that is posterior

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2.6 Routine post-natal care

Routine post-natal care

It is the care given to the women and her baby for the first six weeks after delivery.
Aims of post-natal care:
● To promote the physical, mental & emotional health of the mothers and their babies
● To reduce the mortality and morbidity of mothers and their babies

Tasks of postnatal care

1. Basic care: To ensure basic care of all newborn
2. Bonding: To assist bonding between mother and babies by rooming in and minimizing
separation unless medically indicated
3. Breastfeeding: To initiate breastfeeding within half to 1 hour of delivery and
establishing it by supporting & counseling the mother
4. Birth spacing: To counsel period mothers about options for birth spacing in post-natal
5. Education: To provide information on baby care including hygiene & child safety

Basic care of newborns:

Ensuring Warmth
At birth
● Warm delivery room: Temperature should be 25-28º C, no draught
● Dry baby: immediately after birth, place the baby on a warm, clean and dry surface. Dry the
whole body and hair thoroughly, with a dry cloth
● Asses the newborn for the Apgar score
● Skin-to-skin contact: Leave the baby on the mother’s chest (after cord cut) after birth.
● Cover the baby with a soft dry cloth of complications, wrap the baby
● If the mother cannot keep the baby skin-to-skin because in a clean, warm cloth and place in a cot.
Cover with a blanket. Use a radiant warmer if room not warm or baby is pre-term

Subsequently
● Explain to the mother that keeping baby warm is important for the baby to remain healthy
● Dress the baby or wrap in soft dry clean cloth. Cover the head with a cap for the first few
days

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● Ensure the baby is dressed or wrapped and covered with a blanket

● If the mother and baby must be separated, ensure that baby is dressed or wrapped and
covered with a blanket
● Assess warmth every 4 hours by touching the baby’s feet: if feet are cold use skin-to-skin
contact, add extra blanket and reassess
● Keep the room warm for the mother and baby. If the room is not warm enough, always
cover the baby with a blanket and/or use skin-to-skin contact

At home
● Explain to the mother that babies need one more layer of clothes than older children or adults
● Keep the room or part of the room warm, especially in cold climate
● During the day, dress or wrap the baby
● At night, let the baby sleep with the mother or within easy reach to facilitate breastfeeding
Hygiene:
Eye care
● It is normal for a newborn baby to have some crusting or a little discharge
● Wash the baby eyes with clean water
Do not put any antibiotics unless advised by physician

Cord care
● Wash hands before and after cord care
● Do not put anything on the stump
● Fold nappy (diaper) below stump
● Keep cord stump loosely covered with clean clothes
● If stump is soiled, wash it with clean water and soap. Dry it thoroughly with clean cloth
● If umbilicus is red or draining pus or blood, examine the baby and refer to the paediatrician
● Explain to the mother that she should seek care if the umbilicus is red or draining pus or blood

Remember:
● Do not bandage the stump or abdomen
● Do not apply any substances or medicine to stump
● Do not touch the stump unnecessarily

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Bath
At Birth:
● Only remove blood or meconium
● Do not remove vernix
● Do not bathe the baby before 6 hours
Later and at home:
● Wash the face, neck, underarms daily
● Wash the buttocks when soiled. Dry thoroughly
● Bath when necessary
● Ensure the room is warm, no draught
● Use warm water for bathing
● Thoroughly dry the baby, dress and cover after bath

Immunization
● Give all the required immunizations according to the national immunization schedule
● Give Vitamin A 200,000 IU to mother within 15 days after delivery, preferably before
discharge
● Give Rubella Vaccine to mother if indicated
● Advise when to return for next immunization

Ensure Nutrition through Breast Feeding

● Ask the mother to help the baby attach when the baby seems to be ready. Signs of
readiness to suckle include opening the mouth, rooting or searching, looking around, and
moving.
● If the mother is ill and unable to breastfeed, help her to express breast milk and feed the
baby by cup.
● Explain to the mother how to hold her baby during breastfeeding. She should
● Hold the baby in skin-to-skin contact, if possible.
● Hold the baby's head and body straight so that the baby faces her breast, with the baby's
nose near her nipple.
● Support the baby's whole body, not just the neck and shoulders.
● Explain to the mother how to encourage her baby to attach. She should:
● Touch the baby's lips with her nipple.

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● Wait until the baby's mouth is opening wide.

● Move the baby quickly onto her breast, so that the baby's lower lip is well below the nipple.

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FIGURE 17: INITIATING BREASTFEEDING

● Assess attachment on the breast and suckling. Help the mother if she wishes. Especially if
she is a first time or very young mother. Signs of correct attachment:
- Baby's chin touches the breast.
- Baby's mouth is wide open with the lower lip curled out.
- More of the areola is visible above than below the mouth.
- Baby suckles with slow, deep sucks and pauses sometimes.

FIGURE 18: ATTACHING TO BREAST

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Neonatal screening:

● Blood should be collected for routine screening from umbilical cord at birth or by heel
puncture subsequently
● Hearing test to be performed before discharge

Documentation
Maternal Health Record: The details of labour should be entered in the Maternal Health
Record.
Child Health Record: Every child must be issued a Child Health Record and all entries
should be completed before discharge from the maternity ward. The child health checks
done at birth should be done in the first 24 hours and be entered in the Child Health Record.

Post-natal visits to clinic

● The mother should visit the health centre at 2 weeks and then at 6 weeks postnatal
● Check blood pressure, pulse and temperature
● The investigations to be performed at 6-week visit
- HB level
- urine microscopy
- TFT (if indicted)
- OGTT (if indicated)

● Women should be examined by the doctor for: uterus, perineum, vagina/lochia, LSCS
wound (if went under caesarean section) and breast & nipples
● Further counselling on breast feeding and lactation should be given at this stage
● Counselling on the appropriate methods of birth spacing should be re-emphasized on
● Screen all women for postpartum depression
● All women with low haemoglobin in the postpartum period should be offered iron
supplementation for 3-6 months

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2.7 Postnatal complications

2.7.1 Vaginal bleeding after childbirth (post-partum haemorrhage)

Postpartum haemorrhage is defined as blood loss sufficient to cause hemodynamic instability.

Problems

● Increased vaginal bleeding within the first 24 hours after childbirth (immediate PPH)
● Increased vaginal bleeding after the first 24 hours after childbirth till 6 weeks postpartum
(delayed PPH). Usually caused by endometriosis

Continuous slow bleeding or sudden bleeding is an emergency intervene early and

aggressively

Prevention
● Active management of 3rd stage
● Prophylactic Oxytocin
● Controlled Cord traction
● Inspection of placenta and lower genital tract

Active management of the third stage should be practised on all women in labour because
it reduces the incidence of PPH due to uterine atony

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Diagnosis of Vaginal Bleeding

TABLE 37: DIAGNOSIS OF VAGINAL BLEEDING AFTER CHILDBIRTH

Presenting Symptom and

Symptoms and Signs
Other Symptoms and Probable Diagnosis
Sometimes Present
Signs Typically Present
Immediate PPH Atonic uterus
Uterus soft and not Shock See Medical Management
contracted (Page
Tears of cervix, vagina or
perineum If grade 1 suture
Complete placenta
Immediate PPH (page 126)
Uterus contracted
Grades 2, 3 and 4 refer as
emergency
Placenta not delivered
within 30 minutes after Immediate PPH★ Retained placenta, Refer as
delivery Uterus contracted emergency
No tears in the genital tract
Portion of maternal surface
Immediate PPH★ Retained placental fragments
of placenta missing or torn
Uterus contracted Refer as emergency
membranes with vessels
Shock
Uterine fundus not felt on
Inverted uterus Inverted uterus Refer as
abdominal palpation Slight
apparent at vulva emergency
or intense pain
Immediate PPH★★
Immediate PPH* (bleeding
is intra-abdominal and/or Shock
Ruptured uterus Refer as
vaginal) Severe abdominal Tender abdomen Rapid
emergency
pain (may maternal pulse
decrease after rupture)
★
Bleeding may be light if a clot blocks the cervix or if the woman is lying on her back.
★★
There may be no bleeding with complete inversion.

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General Management:

● Call for help. Urgently mobilize all available personnel

● Perform a rapid evaluation of the general condition of the woman, including vital signs
(pulse, blood pressure, respiration, temperature)
● Check airway and give 100% oxygen by mask/bag
● Insert 2 IV lines (14 G), take blood for CBC, clotting, cross match 4 units and start IV
fluids
● Give warmed crystalloid & colloid IV fluids as rapidly as needed while awaiting blood
Specific Management:

● Catheterize urinary bladder

● Rub the uterus +/- bimanual compression
● Packing of any visible perineal laceration with sterile gauze to tamponed bleeding transport.
Medical management:
● Give syntometrin (oxytocin 5 IU/ ergometrine 0.5 mg) IM injection.
● If still bleeding, start oxytocin drip 40 IU in 500 ml of 0.9% normal saline.
● Check pulse and BP every 15 minutes and treat shock as on (page105(
● Refer the patient as EMERGENCY to hospital

Tears of Cervix, Vagina or Perineum

● Postpartum bleeding with a contracted uterus is usually due to a cervical or vaginal tear.
● Examine the woman carefully and repair 1st degree tears of vagina and perineum (page
126 .If bleeding continues transfer the patient to the secondary as emergency. (
● Patients with 2nd, 3rd and 4th degree vaginal tears and cervical tears should be stabilized
and then referred to the secondary care as emergency

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Retained Placenta

There may be no bleeding with retained placenta

● Apply controlled cord traction to remove the placenta

● Note: Avoid forceful cord traction and fundal pressure, as they may cause uterine inversion.
● If the placenta is not expelled, start the medical management (if not already started)
● Ensure that the bladder is empty. Catheterize the bladder, if necessary. If the placenta
is undelivered after 30 minutes of oxytocin stimulation and controlled cord traction
transfer as EMERGENCY
● Note: Very adherent tissue may be placenta accreta. Efforts to extract a placenta that does not
separate easily may result in heavy bleeding or uterine perforation, which usually requires
hysterectomy. Transfer the patient as EMERGENCY to hospital.

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2.7.2 Fever after childbirth

Problem
Woman has fever (temperature 38°C or more) occurring more than 24 hours after delivery.

General Management
Needs to be taken seriously and to be investigated and referred to secondary care if needed.
● Encourage bed rest
● Ensure adequate hydration by mouth or IV
● Use a fan or tepid sponge to help decrease temperature
● Paracetamol 1 gm every 4-6 hours or as needed
● If shock is suspected, immediately begin management. Even if signs of shock are not present;
keep shock in mind as you evaluate the woman further because her status may worsen rapidly. If
shock develops, it is important to begin management immediately
Use the following table for diagnosis and management.

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TABLE 38: DIAGNOSIS OF FEVER AFTER CHILDBIRTH

Presenting Symptom Symptoms and Signs Probable Diagnosis/

and Other Symptoms Sometime Present management & when to refer
and Signs Typically
Present
Breast pain and Hard enlarged breasts Both Breast engorgement
tenderness breasts affected For management (see below)
Breast pain and Inflammation preceded by Mastitis
tenderness Reddened, engorgement Treat with antibiotics (see
wedge-shaped area on Usually only one breast below)
breast affected
Firm, very tender breast Fluctuant swelling in breast Breast abscess
Overlying erythema Draining pus Refer as emergency to the
surgeon for drainage and
antibiotics.
Dysuria Retro pubic/suprapubic pain Acute pyelonephritis, Refer as
Spiking fever/chills Loin pain/tenderness emergency
Increased frequency and Tenderness in rib cage
urgency of urination Anorexia
Abdominal pain Nausea/vomiting
Spiking fever despite Calf muscle tenderness Deep vein thrombosis Refer as
antibiotics emergency
Fever/chills Light ★ vaginal bleeding Endometritis
Lower abdominal pain Shock Refer as emergency
Purulent, foul-smelling
lochia Tender uterus
Lower abdominal pain Poor response to antibiotics Pelvic abscess Refer as
and distension Swelling in adnexa or pouch emergency
Persistent spiking of Douglas
fever/chills Tender
uterus
Low-grade fever/chills Rebound tenderness Peritonitis
Lower abdominal pain Abdominal distension
Absent bowel sounds Anorexia Nausea/vomiting Refer as emergency
Shock

Fever Clinical signs of Pneumonia

Difficulty in breathing consolidation Congested
Cough with throat Refer as emergency
expectoration Chest pain Rapid breathing Rhonchi/
rales
★
Light bleeding: takes longer than 5 minutes for a clean pad or cloth to be soaked.

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2.7.3 Breast Engorgement

Breast engorgement is an exaggeration of the lymphatic and venous engorgement that occurs
before lactation. It is not the result of over distension of the breast with milk.
If the woman breastfeeding her baby:
● If the woman is breastfeeding and the baby is not able to suckle, encourage the woman to express
milk by hand or with a pump to soften around the areola so the baby can latch on the breast
● If the woman is breastfeeding and the baby is able to suckle:
- Encourage the woman to breastfeed more frequently, using both breasts at each
feeding
- Show the woman how to hold the baby and help it attach
Relief measures before feeding may include
● Apply warm compresses to the breasts just before breastfeeding, or encourage the
woman to take a warm shower
● Massage the woman’s neck and back
● Have the woman express some milk manually before breastfeeding and wet the nipple
area to help the baby latch on properly and easily
Relief measures after feeding may include
● Support breasts with a binder or brassiere
● Apply cold compress to the breasts between feedings to reduce swelling and pain
● Give Paracetamol 1gm by mouth as needed
● Advice the patient to report back if no response within 24 hours
If the woman not breast feeding:
 Support breasts with a binder or brassiere
 Apply cold compresses to the breasts to reduce swelling and pain
 Avoid massaging or applying heat to the breasts
 Avoid stimulating the nipples
 Give Tab Paracetamol 1gm as needed
 Give Tab Cabergoline 1mg as single dose
 Give tab Bromocriptine 2.5 mg two times per day for 5 days
 Follow up in three days to ensure response

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2.7.4 Breast Infection

a) Mastitis
● Treat with antibiotics
- Cap Cloxacillin 500 mg four times per day for 10 -14 days
OR
- Tab Augmentin 375 mg + Cap amoxicillin 500mg two times per day for days 14- 10 days
OR
- Cap Cephalexin 500 mg four times per day for 10-14

● If beta-lactam allergy:
- days Tab Clarithromycin 500 mg PO BID for 10-14
● Encourage the woman to
- Continue breastfeeding
- Support breasts with a binder or brassiere
- Apply cold compresses to the breasts between feedings to reduce swelling and pain
● Give Paracetamol 1gm by mouth as needed
● Follow up in three days to ensure response

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2.7.5 Psychological morbidity

Peripartum depression
● Perinatal depression is defined as a major depressive disorder that is identified during
pregnancy or within four weeks postpartum to one year.
● It is underdiagnosed and complicates 10% to 15% of pregnancies, resulting in
significant morbidity for the mother and infant.
● If not detected and treated properly, it can be associated with significant maternal and
foetal morbidities like poor nutrition, poor weight gain, distress, pre-eclampsia,
prematurity, low birth weight, neurodevelopmental delays, and issues with
maternal/infant bonding.
● Maternal suicide is a common cause of peripartum mortality

Baby blues
● Defines as mild depressive symptoms such as sleep disturbance, anxiety, or irritability
who do not meet the criteria for peripartum depression.
● Symptoms of the baby blues usually develop during the first few days after delivery
and resolve spontaneously within 10 days.
● It must be distinguished from perinatal depression which differs in the severity and
duration of symptoms.

TABLE 39: DISTINGUISHING PERIPARTUM DEPRESSION FROM THE BABY BLUES

Characteristic Baby Blues Peripartum Depression
Duration Less than 10 days More than 2 weeks
Onset Within 2 to 3 days Often within the first month, may
postpartum occur up to the first year
Prevalence 80% 5% to 7%
Severity Mild dysfunction Moderate to severe dysfunction
Suicidal ideation Not present May be present

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Risk factors

● Previous history of depression

● Antenatal depression
● High levels of postnatal stress
● Stressful life events (e.g., marital conflict, intimate partner violence or emigration) during
pregnancy or after delivery.
● Unintended/unwanted pregnancy
● Poor social and financial support in the
● Young age (e.g., age <25 years
● Single marital status
● Perinatal anxiety symptoms and disorders
● Perinatal sleep disturbance
● Adverse pregnancy and neonatal outcomes (e.g., including caesarean surgery, stillbirth,
preterm birth, very low birth weight, and neonatal death).
● Postpartum blues (mild depressive symptoms) [
● Breastfeeding difficulty/shorter duration/cessation
● Childcare stress such as inconsolable infant crying, difficult infant temperament, or infant
sleep disturbance
● Season of delivery (e.g., postpartum depression may increase during the time of year when
daylight is diminished)
● Family history of postpartum depression or psychiatric illness

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TABLE 40: CRITERIA FOR MAJOR DEPRESSIVE DISORDER

A. Five (or more) of the following symptoms have been present during the same 2-
week period and represent a change from previous functioning; at least one of the
symptoms is either (1) depressed mood or (2- ) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another medical condition.
1. Depressed mood most of the day, nearly every day
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day
3. Significant weight loss when not dieting or weight gain
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day
6. Fatigue or loss of energy nearly every day

7. Feelings of worthlessness or excessive or inappropriate guilt

8. Diminished ability to think or concentrate nearly every day
9. Recurrent thoughts of death, recurrent suicidal ideation or a suicide attempt
B. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning
C. The episode is not attributable to the physiological effects of a substance or to
another medical condition
Note: Criteria A-C represent a major depressive episode

Screening for depression

● Screening for depression in pregnancy and postpartum period should be done for women
with risk factors of depression
● Edinburg Postnatal Depression Scale, a 10 -item, self-administered questionnaire is
exclusively used worldwide. The score 12 and above is indicating need for further
depression assessment and must be referred to psychiatrist for further assessment.
Women with postpartum depression should be evaluated also for bipolar disorder, postpartum
psychosis and suicide risk and referred for emergent psychiatric evaluation when appropriate

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ALGORITHM 20: ASSESSMENT AND MANAGEMENT OF SUSPECTED PERINATAL DEPRESSION

Woman presents with risk factors or symptoms of depression during pregnancy (third
trimester) or in postpartum period

Screen using (EPDS) tool

Score less than 12 Score more than 12

Do full assessment including detailed medical history, family

Depression is not likely
history, obstetric and social history, clinical examination,
investigations to rule out medical conditions like thyroid diseases,
anaemia, infections
Assess woman suicidal thoughts, intent to harm her infant
Reassurance
Consider family support
Offer educational materials
on peripartum depression Mild to moderate Severe depression With suicidal
depression
thoughts

Counselling Emergency case:

Psychological support Refer as emergency to
Listen to the women and provide encouragement psychiatry for admission
Assure the mother that the condition is common. Ensure mother is not left
Assist the mother to rethink the image of motherhood (cognitive alone with the baby
behaviour therapy)
Refer to psychiatrist for reassessment and starting of SSRI

If no response after 2 weeks

refers as urgent to psychiatrist

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Prognosis:
The prognosis for postpartum depression is good with early diagnosis and treatment.
More than two-thirds of women recover within a year.
Providing a companion during labour may prevent postpartum depression.

POSTPARTUM PSYCHOSIS

● Postpartum psychosis typically occurs around the time of delivery and affects less than
● of women %1
● The cause is unknown, although about half of the women experiencing psychosis also
● have a history of mental illness
● Postpartum psychosis is characterized by abrupt onset of delusions or hallucinations,
insomnia, a preoccupation with the baby, severe depression, anxiety, despair and
suicidal
● or infanticide impulses
● Care of the baby can sometimes continue as usual
● Prognosis for recovery is excellent but about 50% of women will suffer a relapse with
● subsequent deliveries

Management
● Provide psychological support and practical help (with the baby as well as with home
(care
● Avoid dealing with emotional issues when the mother is unstable
● Refer as emergency to psychiatric hospital

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2.8 Emergencies

2.8.1 Management of emergencies

Severe maternal morbidity and mortality are often preventable in many cases

Preventing Emergencies
Most emergencies can be prevented by:
● Careful planning
● Following clinical guidelines
● Close monitoring of the woman

Team members should know:

● Clinical situations and their diagnoses and treatments

● Drugs and their use, administration and side effects
● Emergency equipment and how it functions

The ability of a facility to deal with emergencies should be assessed and reinforced by
frequent practice emergency drills

Initial Management
● Stay calm, think logically
● Do not leave the woman unattended
● Talk to the woman and help her to stay calm. Ask what happened and what symptoms
● she is experiencing
● Perform a quick examination including vital signs (blood pressure, pulse, respiration,
temperature) and skin colour. Estimate the amount of blood lost if any and assess
● symptoms and signs
● Make one person team leader
● Call for help
● If the woman is unconscious, assess the circulation, airway and breathing
● If shock is suspected, immediately begin treatment Even if signs of shock
are not present, keep shock in mind
● Position the woman on her left side with her feet elevated. Loosen tight clothing
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2.8.2 Rapid initial assessment

Always begin a clinical visit with Rapid assessment and management (RAM)
Check for emergency signs first if present, provide emergency treatment and refer Danger Signs:
● Severe pallor
● Persistent headache
● Blurring of vision
● Generalized oedema
● Convulsions
● Unilateral leg oedema
● Calf tenderness
● Difficult breathing
● Vaginal bleeding or leaking
● Persistent or severe abdominal pain
● Unexplained persistent fever

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TABLE 41: RAPID INITIAL ASSESSMENT & MANAGEMENT CONSIDERATIONS

Assess Danger Signs Consider / Management

Circulation (Signs Cold and moist skin Weak rapid Shock (Haemorrhagic or septic
of shock) pulse (≥110) shock) see page 105
Blood pressure: low (systolic
<90 mm Hg)
Airway and Cyanosis Respiratory distress Severe anaemia, see Table 13
breathing pale Heart failure Pneumonia Asthma
Wheezing or crepitations Pulmonary embolism

Stabilize the patient and refer as

urgent / emergency according to
patient condition
Vaginal bleeding If in early pregnancy or not Abortion
Assess pregnancy aware about pregnancy Ectopic pregnancy Molar
status Assess pregnancy
amount of
bleeding
See Vaginal bleeding in early
pregnancy
Table 21
Late pregnancy and during Abruptio placenta Ruptured uterus
labour Placenta Previa
Examine:
Vulva: amount of bleeding See Vaginal bleeding in later
Do not do a vaginal examination pregnancy, (Table 23)
at this stage
Postpartum Atonic uterus Tears of cervix and
Ask if: vagina
● Recently given birth, Retained placenta Inverted uterus
Placenta delivered or not.
Examine: See Vaginal bleeding after
● Vulva: amount of bleeding, childbirth, ( Table 30 )
obvious tears
● Uterus: atony Bladder: full.

Do not do a vaginal examination

at this stage
Unconscious or Ask if Eclampsia
Convulsing ● pregnant, length of gestation Malaria
Convulsing (now or recently) Epilepsy
● If unconscious, ask relative Tetanus
“has there been a recent
convulsion?”
Examine: See Management of Convulsions
blood pressure: (page 56)
Temperature: 38 C or more.

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High grade fever Ask if: Urinary tract infection See Table
● Very fast breathing 19
● Stiff neck Endometritis
● Lethargy Pelvic abscess
● Very weak/not able to stand Peritonitis
● Frequent, painful urination Mastitis
Examine: Meningitis
● temperature: 38°C or more Malaria
neck stiffness Pneumonia/ H1N1
● lungs: air entry See Fever after childbirth. Table
● abdomen: severe tenderness 31
vulva: purulent discharge
Breast tenderness Complications of abortion

See Vaginal bleeding in early

pregnancy,
Table 21
Abdominal pain Ask if Ovarian cyst
Pregnant, length of gestation Appendicitis
Examine Ectopic pregnancy
blood pressure pulse Possible term or preterm labour
temperature: 38°C or more Chorioamnionitis
abdominal examination Abruptio placenta
Ruptured uterus

See Abdominal pain in early, later

pregnancy and after childbirth, (
Table 25 and Table 26

2.8.3 Shock

Shock is characterized by failure of the circulatory system to maintain adequate perfusion of the vital
organs. Shock is a life-threatening condition that requires immediate and intensive treatment.
Suspect or anticipate shock if at least one of the following is present:

● Bleeding in early pregnancy (e.g., abortion, ectopic or molar pregnancy)

● Bleeding in late pregnancy or labour (e.g., placenta praevia, abruptio placenta, ruptured (uterus
● Bleeding after childbirth (e.g., ruptured uterus, uterine atony, tears of genital tract, retained
(placenta or membranes
● Infection (e.g., unsafe or septic abortion, Chorioamnionitis, Endometritis, acute
(pyelonephritis
● Trauma (e.g., injury to uterus or bowel during abortion, ruptured uterus, tears of genital tract)

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Symptoms and Signs

● Diagnose shock if the following symptoms and signs are present:
● Fast, weak pulse (110 per minute or more)
● Low blood pressure (systolic less than 90 mm Hg)
● Other symptoms and signs of shock include:

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● Pallor
● Sweatiness or cold clammy skin
● Rapid breathing (rate of 30 breaths per minute or more)
● Anxiousness, confusion or unconsciousness
● Scanty urine output (less than 30 mL per hour)

Management of Shock Immediate Management

● Call for help. Urgently mobilize all available personnel
● Monitor vital signs (pulse, blood pressure, respiration, temperature)
● If the woman is unconscious, turn her onto her side to minimize the risk of aspiration if
she vomits and to ensure that an airway is open
● Keep the woman warm but do not overheat her, as this will increase peripheral circulation and
reduce blood supply to the vital organs
● Keep the head low

Specific Management
● Start an IV infusion (two if possible) using a large-bore (16-gauge or largest available) cannula
or needle. Collect blood for estimation of haemoglobin and crossmatch just before infusion of
fluids
● Rapidly infuse IV fluids (normal saline or Ringer’s lactate) initially at the rate of 1L in 15-20
minutes
Note: Avoid using plasma substitutes (e.g., dextran). There is no evidence that plasma substitutes
are superior to normal saline in the resuscitation of a shocked woman, and dextran can be harmful
in large doses.
● Give at least 2 L of these fluids in the first hour; then give fluid replacement for ongoing
losses.
Note: A more rapid rate of infusion is required in the management of shock resulting from bleeding.
Aim to replace two to three times the estimated fluid loss.

Do not give fluids by mouth to a woman in shock

● Continue to monitor vital signs (every 15 minutes) and blood loss

● Catheterize the bladder and monitor fluid intake and urine output
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● Give oxygen at 6-8 L per minute by mask or nasal cannula

● Stabilize and escort to hospital
● Intravenous replacement fluids are first-line treatment for hypovolaemia. Initial treatment with
these fluids may be lifesaving and can provide some time to control bleeding and obtain blood
for transfusion if it becomes necessary.

2.8.4 Communicating with women and their families

Good communication skills are required for all health care providers to build women trust and
confidence.
All staff should:
● Respect the woman’s dignity and right of privacy
● Be sensitive and responsive to the woman’s needs
● Be non-judgmental about the decisions that the woman and her family have made thus
far regarding her care

Rights of women
● Providers should be aware of the rights of women when receiving maternity care services:
● Every woman has the right to get information about her health
● Every woman has the right to discuss her concerns with her health care providers
● A woman should be informed before any procedure. Consent should be taken
● The woman has a right to express her views about the service she receives

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Communication skills
● Speak in a calm, quiet manner and assure the woman that the conversation is confidential. Be
sensitive to any cultural or religious considerations and respect her views. In addition:
● Encourage the woman and her family to speak honestly and completely about events
during the complication
● Listen to what the woman and her family have to say and encourage them to express
their concerns; try not to interrupt
● Respect the woman’s sense of privacy
● Use supportive nonverbal communication such as nodding and smiling
● Answer the woman’s questions directly in calm, reassuring manner
● Explain what steps will be taken to manage the situation or complication
● Ask the woman to repeat back to you the key points to assure her understanding
● If a woman must undergo a surgical procedure, explain to her the nature of the
procedure and its risks and help to reduce her anxiety. Women who are extremely anxious
have a more difficult time during surgery and recovery

Emotional and Psychological Support

● Emergency situations are often very disturbing for all concerned and evoke a range of
emotions that can have significant consequences.

Emotional and Psychological Reactions:

● How each member of the family reacts to an emergency situation depends on the:
● Marital status of the woman and her relationship with her partner
● Social situation of the woman/couple and their cultural and religious practices, beliefs and
expectations
● Personalities of the people involved and the quality and nature of social, practical and
emotional support
● Nature, gravity and prognosis of the problem and the availability and quality of the health
care services

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Common reactions to obstetric emergencies or death include:

● Denial
● Guilt
● Anger
● Depression and loss of self-esteem
● Isolation
● Disorientation

General Principles of Communication and Support

● While each emergency situation is unique, the following general principles offer guidance.
Communication and genuine empathy are probably the most important keys to effective care.
● Emotional and Psychological Support

At the time of the event

● Greet the women and introduce yourself
● Listen attentively. The woman/family will need to discuss their hurt and sorrow
● Show empathy
● Tell the woman/family about what is happening
● Be honest
● If language is a barrier to communication, find a translator
● Do not pass the problem on to nursing staff or junior doctors
● Both during and after the event, provide as much privacy as possible for the woman and
her family
● Encourage family support

After the Event

● Give practical assistance, information and emotional support
● Respect traditional beliefs and customs and accommodate the family’s needs as far as
possible
● Provide counselling for the woman/family and allow for reflection on the event
● Explain the problem to help reduce anxiety and guilt
● Listen and express understanding and acceptance of the woman’s feelings. Nonverbal
communication may speak louder than words

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● Repeat information several times and give written information, if possible. People
experiencing an emergency will not remember much of what is said to them
● Health care providers may feel anger, guilt, sorrow, pain and frustration in the face of obstetric
emergencies that may lead them to avoid the woman/family. Showing emotion
is not a weakness
● Remember to care for staff who themselves may experience guilt, grief, confusion and
other emotions

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2.9 Common procedures

2.9.1 Infection prevention

● Infection prevention has two primary objectives

- Prevent major infections when providing services
- Minimize the risk of transmitting serious diseases such as hepatitis B and HIV/AIDS to
the woman and to service providers and staff, including cleaning and housekeeping
personnel.
● The recommended infection prevention practices are based on the following principles
● Every person (patient or staff) must be considered potentially infectious
● Hand washing is the most practical procedure for preventing cross-contamination
● Wear gloves before touching anything wet, broken skin, mucous membranes, blood or other
body fluids (secretions or excretions)
● Use barriers (protective goggles, face masks or aprons) if splashes and spills of any body fluids
(secretions or excretions) are anticipated
● Use safe work practices, such as not recapping or bending needles, proper instrument
processing and proper disposal of medical waste.

Hand Washing
● Vigorously rub together all surfaces of the hands lathered with plain or anti-microbial soap.
Wash for 15-30 seconds and rinse with a stream of running or poured water. Or rub your
hands with an antiseptic solution
● Wash hands
- Before and after examining each patient (or having any direct contact)
- After exposure to blood or any body fluids (secretions or excretions), even if gloves were
worn
- After removing gloves because the gloves may have holes in them

Gloves and Gowns

● Wear gloves
- When performing a procedure
- When handling soiled instruments, gloves and other items

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- When disposing of contaminated waste items (cotton, gauze or dressings)

● A separate pair of gloves must be used for each woman to avoid cross contamination
● A clean, but not necessarily sterile, gown should be worn during all delivery procedures
- If the gown has long sleeves, the gloves should be put over the gown sleeves to avoid
contamination of the gloves
- Ensure that gloved hands are held above the level of the waist and do not come into
contact with the gown

Basic Principles for Procedures:

Before any simple (non-operative) procedure, it is necessary to:
● Gather and prepare all supplies. Missing supplies can disrupt a procedure
● Explain the procedure and the need for it to the woman and obtain consent
● Provide adequate pain medication according to the extent of the procedure planned. Estimate
the length of time for the procedure and provide pain medication accordingly
● Place the patient in a position appropriate for the procedure being performed. The most
common position used for obstetric procedures (e.g., manual vacuum aspiration) is the
lithotomy position
● Wash hands with soap and water and put on gloves appropriate for the procedure
● If the vagina and cervix need to be prepared with an antiseptic for the procedure (e.g.
(manual vacuum aspiration
- Apply antiseptic solution (e.g., iodophors, chlorhexidine) three times to the vagina and
cervix using a high-level disinfected or sterile ring forceps and a cotton or gauze swab
- Gently insert a sterile speculum or retractor(s) into the vagina
● If the skin needs to be prepared with an antiseptic for the procedure
- Apply antiseptic solution (e.g., iodophors, chlorhexidine) three times to the area using a
high-level disinfected or sterile ring forceps and a cotton or gauze swab. If the swab is
held with a gloved hand, do not contaminate the glove by touching unprepared skin
- Begin at the centre of the area and work outward in a circular motion away from the area
- At the edge of the sterile field discard the swab
● Never go back to the middle of the prepared area with the same swab. Keep your arms and
elbows high and surgical dress away from the surgical field

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2.9.2 Anaesthesia and analgesia

Local Anaesthesia
● Local anaesthesia (lignocaine with or without adrenaline) is used to infiltrate tissue and block
the sensory nerves.
● Because a woman with local anaesthesia remains awake and alert during the
procedure, it is especially important to ensure
- Counselling to increase cooperation and minimize her fears
- Good communication throughout the procedure as well as physical reassurance from the
provider, if necessary
- Time and patience, as local anaesthetics do not take effect immediately
● Emergency drugs and equipment (suction, oxygen, resuscitation equipment) should be readily
available and in usable condition, and all members of the operating team trained in their use
Lignocaine
● Lignocaine preparations are usually 2% or 1% and require dilution before use (Box 1). For
most obstetric procedures, the preparation is diluted to 0.5%, which gives the maximum effect
with the least toxicity.
● Preparation of lignocaine 0.5% solution

Combine:
Lignocaine 2%, one part
Normal saline or sterile distilled water, three parts (do not use glucose solution as it
. (increases the risk of infection
OR
lignocaine 1%, one part

General Principles for Anaesthesia and Analgesia

● The keys to pain management and comfort of the woman is
- Supportive attention from staff before, during and after a procedure (helps reduce anxiety
and lessen pain)
- A provider who is comfortable working with women who are awake and who is trained
to use instruments gently
- The selection of an appropriate type and level of pain medication

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Tips for performing procedures on women who are awake include

- Explain each step of the procedure before performing it
- Use lignocaine diluted solution in adequate amount
- Check the level of anaesthesia by pinching the area with forceps. If the woman feels the
pinch, wait two minutes and then retest
- Wait a few seconds after performing each step or task for the woman to prepare for the
next one
- Move slowly, without jerky or quick motions
- Handle tissue gently and avoid undue retraction, pulling or pressure
- Use instruments with confidence
- Avoid saying things like “this won’t hurt” when, in fact, it will hurt; or “I’m
almost finished” when you are not
- Talk with the woman throughout the procedure
● The need for supplemental analgesic or sedative medications (by mouth, IM or IV) will
depend on
- The emotional state of the woman
- The procedure to be performed
- The anticipated length of the procedure
- The skill of the provider and the assistance of the staff

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2.9.3 Episiotomy

Episiotomy should not be performed routinely.

● Review for indications
Episiotomy should be considered in the case of:

Complicated vaginal
scarring from female genital cutting or poorly healed previous third- or fourth-
degree tears
Foetal disease

● Apply antiseptic solution to the perineal area

● Provide emotional support and encouragement. Use local infiltration with lignocaine
● Make sure there are no known allergies to lignocaine or related drugs
● Infiltrate beneath the vaginal mucosa, beneath the skin of the perineum and deeply
into the perineal using about 10 mL 0.5% lignocaine solution
Note: Aspirate (pull back on the plunger) to be sure that no vessel has been penetrated. If blood is
returned in the syringe with aspiration, remove the needle. Recheck the position carefully and try
again. Never inject if blood is aspirated. The woman can suffer convulsions and death if IV
injection of lignocaine occurs.

● At the conclusion of the set of injections, wait two minutes and then pinch the incision site
with forceps. If the woman feels the pinch, wait two more minutes and then retest

Anaesthetize early to provide sufficient time for effect

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FIGURE 19: INFILTRATION OF PERINEAL TISSUE WITH

LOCAL ANAESTHESIA

● Wait to perform episiotomy until

● The perineum is thinned out; and the baby’s head is visible during a contraction cm of 4-3

Performing an episiotomy will cause bleeding. It should not, therefore, be done too early

● Wearing sterile gloves, place two fingers between the baby’s head and perineum
● Use scissors to cut the perineum about 3-4 cm in the Medio lateral direction
● Control the baby’s head and shoulders as they deliver, ensuring that the shoulders have
● rotated to the midline to prevent an extension of the episiotomy
● Carefully examine for extensions and other tears and repair (see below)

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Repair of Episiotomy
● Apply antiseptic solution to the area around the episiotomy
● Consider giving another dose of lignociane
● Close the vaginal mucosa using continuous 2-0 suture
- Start the repair about 1 cm above the apex (top) of the episiotomy. Continue the suture to
the level of the vaginal opening
- At the opening of the vagina, bring together the cut edges of the vaginal opening
- Bring the needle under the vaginal opening and out through the incision and tie

FIGURE 20: MAKING THE INCISION WHILE INSERTING

TWO FINGERS TO PROTECT BABY'S HEAD
● Close the perineal muscle using interrupted 2-0 sutures
● Close the skin using interrupted (or subcuticular) 2-0
● Perform rectal examination after repair of episiotomy to make sure sutures are not felt in
the rectal mucosa

It is important that absorbable sutures be used for closure. Polyglycolic sutures are
preferred over chromic catgut for their tensile strength, non-allergenic properties and
lower probability of infectious complications and episiotomy breakdown. Chromic catgut
is an acceptable alternative but is not ideal.

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FIGURE 21: REPAIR OF EPISIOTOMY

Post episiotomy care:

Advise the patient to come back if
● Leaking of urine or stool
● Hard painful lump on or near the wound
● Bright red blood coming from wound
● Pain getting worse or the wound appears open

Information for woman

● Keep the area clean and dry
● Change the sanitary pads every 2-4 hours
● Drink plenty of water and eat lots of fibre to prevent constipation
● Take analgesics for pain
● Use sitz bath for 20 minutes (warm water increase circulation and help healing, cold
(water relieves pain faster
● Do Kegel exercises (squeeze the muscle that you use to hold in urine, do this ten times per day,
and increase the strength and period of contraction in the following (days
● Avoid antiseptics

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Complications
1. If a haematoma occurs, open and drain. If there are no signs of infection and bleeding has
stopped, reclose the episiotomy
2. If there are signs of infection, open and drain the wound. Remove infected sutures and debride
the wound
● If the infection is mild, antibiotics are not required
● If the infection is severe but does not involve deep tissues, give a combination of antibiotics
- Oral Cloxacillin 500 mg four times per day and oral Metronidazole mg three times per
day for five days 400
OR
- Oral Augmentin 375mg with amoxicillin 250mg three times per day for five days
- Oral Cephalexin 500 mg two times per day for five days

● If the infection is deep, involves muscles and is causing necrosis to refer the patient to
secondary care debridement as emergency for intravenous antibiotics and surgical

3. If there is episiotomy dehiscence (gapping):

● Small defect may heal spontaneously
● Some defects require surgical closure, needs referral back to the delivery hospital
● Early re-suturing within the first two weeks of labour gives favourable results than
conservative management

2.9.4 Repair of vaginal and perineal tears

There are four degrees of tears that can occur during delivery:

● First degree tears involve the vaginal mucosa and connective tissue
● Second degree tears involve the vaginal mucosa, connective tissue and underlying muscles
● Third degree tears involve complete transaction of the anal sphincter
● Fourth degree tears involve the rectal mucosa

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It is important that absorbable sutures be used for closure. Polyglycolic sutures are
preferred over chromic catgut for their tensile strength, non-allergenic properties and
lower probability of infectious complications. Chromic catgut is an acceptable alternative
but is not ideal.

Repair of First-Degree Tears

Most first-degree tears close spontaneously without sutures.
● Provide emotional support and encouragement. Use local infiltration with Lignocaine
● Ask an assistant to check the uterus and ensure that it is contracted
● Carefully examine the vagina, perineum and cervix
● If the tear is long and deep through the perineum, inspect to be sure there is
no second-, third- or fourth-degree tear
● If the underlying muscles are involved, refer the patient to the secondary care as
emergency for repair

Second, third and fourth perineal tears should be transferred to hospital after stabilizing

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Chapter 3

3.1 Prerequisites to implement the guidelines

3.2 Human resources
3.3 Tasks and responsibilities in ANC and PNC clinic

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3.1 Prerequisites to implement the guidelines

● Availability of all recommended investigations, emergency drugs and vaccines
● Availability of this updated guidelines in each ANC clinic
● Availability of the needed educational materials to pregnant women
● Training of the health care workers on how to use the guidelines

3.2 Human resources needed in ANC and PNC clinic:

● Trained Nurses /Midwives
● Trained doctors
● Dietician
● Health Educator

3.3 Responsibilities in ANC and PNC clinic

A. Trained Nurses/ Midwife: -

● Register the pregnant women at booking and issue maternal health record (green card)
● Take detailed medical, surgical and obstetric history
● Risk grading assessment in every visit with rapid assessment for danger signs
● Check: - weight, height, BMI, Blood pressure (BP), pulse
● Provide information about the antenatal care services
● Provide proper health education and support
● Ensure that pregnant women are fully vaccinated
● Trace blood investigations
● Follow up defaulters of pregnant women.
● Refer the pregnant women to doctor, dietitian & health educator

B. Trained doctors:
● Do rapid assessment for danger signs
● Perform clinical examination of the pregnant women including: - systemic examination, breast,
thyroid, cardiovascular, chest, abdominal examination.
● Asses for VTE scoring for all pregnant women, refer those with score 3 and above to secondary
care to start heparin injections.
● Take blood investigations

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● Trace pending investigations in each visit

● Perform the booking (dating) scan and arrange for referral to secondary care for anomaly scan
and growth scan if needed.
● Provide folic acids, fefol and other needed medications to pregnant women
● Refer all high-risk pregnant women to secondary care as indicated (table)
● Participate in awareness activities in pregnancy

C. dietician
● Provide proper information and nutritional assessment and advice
● Follow up the referred pregnant women who need dietary consultation
● Participate in awareness activities related to nutrition in pregnancy

D. Health educators
● Provide proper health education and support

E. Department of Women & Child health in Ministry of Health.

● Review and update the guideline based on available new evidence base guidelines and according
to best practices of an expert group in the country.
● Disseminate ANC guidelines to all Women and Child health sections in governorates
● Plan and organize training workshops to train doctors and nurses on how to use ANC guidelines.
● Monitor and evaluate service provision in all health institutions

F. Sections of Women &Child health in the Governorates

● Disseminate ANC guidelines to all Primary health care institutions in governorates
● Participate in training of the concerned health care workers on how to use the ANC guidelines

G. Directorate General of Medical Supplies

● Maintain continuous supply of the recommended medications in all health institutions

H. Directorate of specialized clinics

I. Disseminate the guidelines to all private clinics
J. Provide the recommended laboratory services

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Chapter 4

4.1
4.2 Annexes
4.3 References

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4.1 Document History and Version Control

Document History and Version Control

Version Description of Amendment Author Review

Date

01 Initial Release – 1st Edition Team for Developing 2010

the Pregnancy,
Childbirth and
Postpartum
Management
Guideline

02 2nd Edition Team for Developing 2016

the Pregnancy,
Childbirth and
Postpartum
Management
Guideline

03 3rd Edition Team for Developing 2022

the Pregnancy,
Childbirth and
Postpartum
Management
Guideline

Written by Reviewed by Approved by

Team for Developing the Team for Developing the Dr Said Al Lamki
Pregnancy, Childbirth and Pregnancy, Childbirth and
Postpartum Management Postpartum Management
Guideline Guideline

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4.2 Annexes

Annex 1: Vaccination in Pregnancy

Vaccine Before During After Type of

pregnancy pregnancy pregnancy vaccine
Hepatitis B Yes, if Yes, if Yes, if Inactivated
indicated indicated indicated
Seasonal Influenza Yes Yes Yes Inactivated
MMR Yes, if No Yes, if Live
indicated, indicated, give attenuated
avoid immediately
conception postpartum if
for 3 susceptible to
months Rubella
Meningococcal If indicated If indicated If indicated Inactivated
-polysaccharide
- conjugate
Varicella Yes, if No Yes, if Live
indicated, indicated, give attenuated
avoid immediately
conception postpartum if
for 3 moths susceptible to
Varicella.

Note: - life attenuated vaccine must be avoided during pregnancy and women should wait for 3 months
post vaccine if they are planning for pregnancy

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Annex 2: Instruction to women on how to take thromboprophylaxis injection (how to take the
injection)

STEP 1:
Wash your hands and make sure that the area
you are going to inject is clean before you
begin. Be sure to use different area (site) to
inject each day to help to prevent bruising (see
figure)

STEP 2
Open the back and remove the syringe, make sure the
medicine is clear and has nothing floating in it. If you see
anything in the medicine don’t use
Do not squeeze the syringe to remove the air bubble as you
may lose some of the medicine and then not have a full dose.

STEP 3
You need to make sure that you inject LMWH into fatty
tissue. To do this, pinch afold of skin between the thumb
and fingers of one hand.
- If you are going to inject in your abdomen (tummy
area) it is best to do this while sitting.
- If you are using your outer thigh, it is best to do this
when sitting or lying down.
- If you decide to inject into your (buttock) you may not
need to pinch any skin as there should already be enough
of layer of fatty tissue.
LMWH must not be injected into the muscle as it won't be
absorbed properly.

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STEP 4
Hold the syringe with your other hand. Insert the entire
needle into the fold of skin at a 45-90 degree angle. Then
slowly press the plunger down until the full dose of
LMWH has been given

STEP 5
Remove the needle while letting go of the fold of skin.
Dispose of the syringe into yellow “sharp” box you have
been given.

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Annex 3: Edinburgh Postnatal Depression Scale1 (EPDS)

In the past 7 days

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4.3 References

● Ministry of Health Sultanate Oman - Annual Health Report 2019

● WHO (2016). WHO recommendations on antenatal care for a positive pregnancy experience.
https://www.who.int/publications/i/item/9789241549912
● Managing complications in pregnancy and childbirth: A guide for midwives and doctors Wold
Health Organisation 2017
● Oxford Handbook of general practice, Pregnancy, Chapter 22, fifth edition, 2020
● Antenatal care, NICE guideline Published: 19 August 2021.www.nice.org.uk/guidance/ng201
● Academy of Nutrition & Dietetics (AND). (2021). Eating Right During Pregnancy.
https://www.eatright.org/health/pregnancy/what-to-eat-when-expecting/eating-right-during-
pregnancy
● Alberta Health Services. (2019). Nutrition Guideline: Pregnancy.
https://www.albertahealthservices.ca/assets/info/nutrition/if-nfs-ng-pregnancy.pdf
● Department of Health, State Government of Victoria, Australia (Victoria Health). (2019).
Pregnancy and Diet. https://www.betterhealth.vic.gov.au/health/HealthyLiving/pregnancy-
and-diet
● IDF. (2017). An educational manual with advice on having a healthy baby. https://idf.org/e-
library/guidelines/97-having-a-baby-now-is-the-time-to-learn-more-about-gestational-
diabetes.html
● Zhang, M., Zhou, Y., Zhong, J. et al. (2019). Current guidelines on the management of
gestational diabetes mellitus: a content analysis and appraisal. BMC Pregnancy
Childbirth 19, 200. https://doi.org/10.1186/s12884-019-2343-2
● The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum. Royal
College of Obstetricians and Gynaecologists. 69, R. G.-t. (June 2016).
● Institute of Obstetricians and Gynaecologists, R. C. (Nov 2015). Hyperemesis and nausea /
vomiting in pregnancy.
● Koren, G. (May 2002). Motherisk—PUQE (pregnancy-unique quantification of emesis and
nausea) scoring system for nausea and vomiting of pregnancy. Am J Obstet Gynecol.
● Lowe, S. (2019). Guideline for the Management of Nausea and Vomiting In Pregnancy and
Hyperemesis Gravidarum. Society of Obstetric Medicine of Australia and New Zealand.

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● UK guidelines on the management of iron deficiency in pregnancy, Sue Pavord, Jan Daru,
Nita Prasannan, Susan Robinson, Simon Stanworth, Joanna Girling, on behalf of the BSH
Committee ctober 2019
● Blood transfusion in obstetrics, RCOG, Green-top Guideline No. 47, May 2015
● Department of Obstetrics and Gynecology, Royal hospital (2015), Thromboprophylaxis in
Pregnancy - The - OBG GUD - GUD/OBG/CLN/01/Vers.2.0.
● Sultan Qaboos University Hospital, Department of Obstetrics and Gynecology, Antenatal
Thromboprophylaxis Document No: Obg-Obg-Pro-047, Version No :01 Originated
Date:22/2/2016 Revision, Dr. Manahil Hassan
● Royal College of obstetricians & Gynecologists (RCOG) (2015), Reducing the Risk of Venous
Thromboembolism during Pregnancy and the Puerperium- – Guidelines 2015. Available at
(Gynaecologists, 2015) (https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-
37a.pdf)
● Oxford Universality Hospital, Maternity Hospital, Silver Star Midwife, Clot prevention:
informaiton for women taking LMWH (https://www.ouh.nhs.uk/patient-
guide/leaflets/files/10707Pclot.pdf)
● Queensland Clinical Guidelines. Venous thromboembolism (VTE) in pregnancy and the
puerperium. Guideline MN20.9-V6-R25. Queensland Health. 2020. Available from:
http://www.health.qld.gov.au/q
● Hypertension in pregnancy: diagnosis and management, NICE guidelines 2019
● Gestational Hypertension and Preeclampsia, ACOG 2020
● Hypertensive disorders in pregnancy, AAFP 2014
● Management of Sickle Cell Disease in Pregnancy, NICE guideline 2011
● Sickle Cell Disease Management Guidelines, National committee of improving service for inherited
blood disorders- MOH Jaunary 2013
● Management of Sickle Cell Disease in Pregnancy, Nizwa Hospital Protocol
● Obstetric Cholestasis (Green-top Guideline No. 43), 2011
● The Pregnant Patient: Managing Common Acute Medical Problems, Am Fam
Physician. 2018 Nov 1;98(9):595-602.
● Intrahepatic cholestasis of pregnancy, UPTODATE, 2018
● Liver disease in pregnancy, AAFP 1999

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● Management of thyroid disease during pregnancy and the post-partum, American Thyroid
Association 2017
● Thyroid disease in pregnancy, American Family Physician 2014,
http://www.aafp.org/afp/2014/0215/p273.html
● Diabetes Mellitus, National Clinical Management Guidelines, 2021, section 6: Diabetes in
Pregnancy
● Guidelines for Management of Mental disorders in primary health care –MOH, Third edition ,2020
● Integrated Management of Pregnancy and Childbirth. Managing Complications in Pregnancy and
childbirth: A guide for midwives and doctors. World Health Organization, Department of
Reproductive Health and Research .2017
● Integrated Management of Pregnancy and Childbirth. “Pregnancy, Childbirth, Postpartum and
newborn care” A guide for essential practice, WHO, United
● Nations Population Fund, UNICEF, The World Bank,3rd edition -2015.
● http://www.who.int/maternal_child_adolescent/documents/imca-essential-practice-guide/en
● Pregnancy & Childbirth Management Guidelines Level 2 guideline - Department of Family &
Community Health, 2010
● WHO recommendations for Prevention and treatment of pre-eclampsia and eclampsia. Geneva.
World Health Organization. 2011
http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/97892415483
/en/35
● American Academy of Family Physician (AAFP), Hypertensive disorders of pregnancy., Jan 15
20016 http://www.aafp.org/afp/2016/0115/p121.html
● Task Force on Hypertension in Pregnancy, The American College of Obstetrician and
Gynaecologists. Hypertension in Pregnancy, 2012-2013
https://www.acog.org/~/media/Task%20Force%20and%20Work%20Group%20Reports/public/H
ypertensioninPregnancy.pdf
● NICE clinical guideline 43. Obesity, guidance on the prevention, identification, assessment and
management of overweight and obesity in adults and children, 2006.
https://www.nice.org.uk/guidance/cg189/evidence/obesity-update-appendix-p- 6960327450
● NICE clinical guideline 63, Diabetes in pregnancy, management of diabetes & complications from
pre – conception to postnatal period, March 2008
https://www.nice.org.uk/guidance/cg63/evidence

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● Diabetes Mellitus Management Guidelines. The national Diabetic and Endocrine Centre, MOH,
Sultanate of Oman 3rd edition 2015
● STI CASE MANAGEMENT; STI Control Program, DCDSC, DGHA (HQ), Ministry of Health
Oman- 2021
● Parker J, Wray J, Gooch A, Robson S, Qureshi H. A British Committee for Standards in
Haematology (BCSH). Guidelines for the use of prophylactic anti-D immunoglobulin , July 2008.
www.bcshguidelines.com/documents/Anti- D_bcsh_07062006.pdf
● Nicolle LE, Bradley S, Colgan R, et al. Clin. Infectious Diseases Society of America guidelines for
the diagnosis and treatment of asymptomatic bacteriuria in adults. Infect Dis 2005;
40:643. http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-
Patient_Care/PDF_Library/Asymptomatic%20Bacteriuria.pdf
● Emilie Katherine Johnson, MD, MPH; Chief Editor: Edward David Kim, MD, FACS Urinary tract
infection in pregnancy. emedicine, 2015, http://emedicine.medscape.com/article/452604-overview
● Arch Med Sci. Urinary tract infections in pregnancy: old and new unresolved diagnostic and
therapeutic problems, 2015 Mar 16; 11(1): 67–77
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4379362/
 CDC, vaccination in pregnancy www.cdc.gov/vaccines/pregnancy/hcp/guidelines.html.
 CDC, syphilis during pregnancy, STI treatment guidelines, 2021.
 WHO recommendations on maternal and newborn care for a positive postnatal experience, 30
March 2022- Guideline

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