FINAL_DRAF_LAYOUT_Handbook_of_Obstetrics_Guideline_PDF.pdf

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MEDICAL DEVELOPMENT DIVISION HANDBOOK OF OBSTETRICS GUIDELINE
MINISTRY OF HEALTH MALAYSIA
MOH/P/PAK/535.24(GU)-e
MEDICAL DEVELOPMENT DIVISION

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HANDBOOK OF OBSTETRICS GUIDELINE

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HANDBOOK
OF OBSTETRICS GUIDELINE

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MOH Handbook of Obstetrics Guideline
was developed by the
Obstetrical & Gynaecological and Paediatric Services Unit of the
Medical Development Division,
Ministry of Health Malaysia
in collaboration with
Jawatankuasa Pengurusan dan Perkembangan O&G KKM (JPPOBG)
www.moh.gov.my
Published in 2024
catalogue record of this document is available from the Institute of
Medical Research, Ministry of Health;
MOH/P/PAK/534.24(GU)-e
It is also available from the National Library of Malaysia:
e ISBN 978-967-25780-5-5
All rights reserved.
No part of this publication may be reproduced or distributed in any
form or any means, or stored in a database or retrieval system, without
prior written permission of the Ministry of Health, Malaysia
ii

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The Jawatankuasa Pengurusan dan Perkembangan O&G (JPPOBG) compiled the guidelines
as an educational aid to good clinical practice. The information provides general advice
for consideration by clinicians and other relevant health professionals, and should not be
relied on as a substitute for proper assessment with respect to the particular circumstances
of each case and the needs of any patient. The ultimate judgment regarding a particular
treatment or clinical procedure must be made by the clinician or other health professionals
in light of clinical data presented by the patient and the diagnostic and treatment options
available.
The contents of the guidelines are not intended to be prescriptive directions defining
a single course of management. This information has been prepared based on the
information available at the time of its preparation, and each practitioner should be
cognizant of the relevant information, research or material which may have been published
or become available subsequently. Whilst the authors endeavour to ensure that information
is accurate and current at the time of preparation, they take no responsibility for matters
arising from changed circumstances or information or material that may have become
subsequently available. The rapid advances in medical science mean that drug dosages,
laboratory tests and diagnosis in particular, should be independently verified.
DISCLAIMER
iii

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Preface
The practice of obstetrics involves decision-making during a major transitional period of
a woman’s life, which frequently culminates in the most challenging, final 10 centimeter
journey through the birth canal. Decision-making which is professionally responsible,
empowers women, provides them a sense of autonomy and increases their satisfaction
of clinical care received. In order to provide this, the attending clinician has to be able to
provide evidenced-based and accepted professional standards of care.
With this in mind, various guidelines have been drawn by different states and hospitals in
Malaysia over the years to guide clinicians. The purpose of this handbook is to provide a
compendium of these local guidelines with contemporary updates from reputable sources
such as the Clinical Practice Guidelines (CPG) and training manuals from the Ministry of
Health, publications from the World Health Organization (WHO), International Federation of
Gynaecology and Obstetrics (FIGO) and guidelines from other international societies. The
catalyst for this endeavor was mooted during the “Bengkel Halatuju Perkhidmatan O&G” in
June 2022.
The guideline editorial committee comprised of members of the Jawatankuasa Kecil
Garis Panduan dan Amalan Klinikal, subcommittee of the Jawatankuasa Pengurusan dan
Perkembangan O&G (JPPOBG) who drafted a scope based on existing local guidelines
followed by nomination and amendment of the scope until a consensus was achieved.
Various guidelines were compared and literature review was conducted by each member
on their assigned topic to ensure that the contents were up to date. Individual topics were
then discussed, amended and refined in various stages, first within the guideline editors
and sent for internal review by all state consultants and other stakeholders.
This handbook was designed for brevity and usability in mind, meant to aid the trainee or
clinician during their daily encounter with obstetric patients within facilities (hospitals)
of the Ministry of Health (MOH).
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BY DIRECTOR-GENERAL OF HEALTH MALAYSIA
FOREWORD
Pregnancy, childbirth an the puerperium has been the number one cause of hospitalization
in hospitals for the past decade. The Obstetrics and Gynaecology (O&G) service is
unquestionably one of those with a lot of litigation and workload.
We are combined in our commitment to make sure that O&G services at the Ministry
of Health are provided with excellent quality and the highest calibre through the
Jawatankuasa Pengurusan and Perkembangan O&G KKM (JPPOBG) under the auspices of
the Medical Development Division, Ministry of Health Malaysia (MOH).
The achieve Goal 3 in the 2030 Agenda of Sustainable Development Goals adopted
by all the United Nations Members States in 2015, MOH is commited to ensuring that
women in Malaysia are provided with consistent, high-quality, evidence-based maternity
care. Malaysia has succeded in lowering the Maternal Mortality Rate since the 1960s as a
result of ongoing efforts to improve the quality of services, including training for medical
professionals an also practising evidence-based medicine.
I would like to convey my gratitude to everyone who contributed, whether directly of
indirectly to the creation of this handbook guidelines. All of these efforts should be fruitful
for everyone concerned.
DATUK DR. MUHAMMAD RADZI BIN ABU HASSAN
Director-General of Health Malaysia
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BY DIRECTOR OF MEDICAL DEVELOPMENT DIVISON,
MEDICAL PROGRAMME, MINISTRY OF HEALTH MALAYSIA
FOREWORD
Evidence-based medicine has been given priority in numerous recent guidelines. It is our
duty to determine which citeria, principally in terms of availability and case complexity,
are appropriate for the current state of affairs in this nation. Regardless of their backround,
giving patients the greatest care our priority.
Thus, the creation of the Handbook of Obstetrics Guideline is regarded as a commendable
attempt to enhance service quality through standardising and elevating the bar for health
care provided by the O&G services. The Medical Development Division remains dedicated
to organising plans, putting strategies in action, and carrying out MOH policies in close
collaboration with the fraternity.
Given that our contributors can contribute to the realisation of this handbook guidelines
while still managing their existing wordload, recognition and gratitude are due for this kind
of dedication.
I would like to congratulate and acknowledge the effort of the drafting committee,
especially the Jawatankuasa Kecil Garis Panduan dan Amalan Klinikal, Jawatankuasa
Pengurusan dan Perkembangan O&G KKM (JPPOBG) and other contributors for this great
initiative in preparing this edition. Thank you.
DATO’ DR. MOHD AZMAN BIN YACOB
Director of Medical Development Division
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1.
2.
3.
4.
5.
6.
7.
8.
1.
2.
3.
4.
5.
6.
Antenatal specialist clinic
Combined (obstetric-medical) clinic
Early pregnancy assessment unit
Prenatal screening/diagnosis
Mid-trimester screening/anomaly scan
Inter hospital multidisciplinary referral
In-utero transfer
Obstetric retrieval team
Pregnancy dating
Bleeding in early pregnancy
Management of miscarriage
Pregnancy of unknown location
Molar pregnancy
Nausea & vomiting in pregnancy
2
3
5
6
7
8
11
13
16
18
20
22
24
26
CONTENTS
TABLE OF
Referrals - 1
- 15
Early Pregnancy Problems
A
B
SECTION
SECTION
vii

10
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Multiple pregnancy
Cervical insufficiency
Rhesus negative in pregnancy
Placenta praevia
Placenta accreta spectrum
Uterus larger than dates
Uterus smaller than dates
Abnormal lie and unstable lie at term
Breech presentation
Postdate pregnancy
Vaginal birth after Caesarean Section (VBAC)
Reduced fetal movement
Intrauterine fetal death (IUFD)
Anemia in pregnancy
Hypertensive disorders in pregnancy
Diabetes mellitus in pregnancy
Venous thromboembolism
Heart disease in pregnancy
Thyroid disease
Bronchial asthma
Hepatitis B
HIV in pregnancy
Syphilis in pregnancy
30
37
40
45
48
51
53
56
58
62
64
67
69
74
77
82
88
92
99
102
106
109
114
Antenatal Problems
Selected Medical Disorders
in Pregnancy
C
D
SECTION
SECTION
viii
- 29
- 73

11
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Maternal collapse
Amniotic fluid embolism
Obstetric haemorrhage
Preeclampsia with severe features and Eclampsia
Uterine inversion
Maternal Sepsis
Shoulder dystocia
Cord prolapse
Assisted vaginal breech delivery
Acute management of obstetric thromboembolism
First stage of labour
Second stage of labour
Third stage of labour
Episiotomy
Obstetric anal sphincter injury (OASIS): Third and Fourth
Degree Perineal Tears
Induction of labour/Augmentation
Operative vaginal delivery
Term prelabour rupture of membranes (Term PROM)
Preterm prelabour rupture of membranes (PPROM)
Preterm labour
152
159
162
182
192
198
203
212
215
221
120
122
124
125
127
129
134
140
143
147
Obstetric Emergencies
Intrapartum Care (Normal
and Abnormal Labour)
F
E
SECTION
SECTION
ix
- 119
- 151

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1.
2.
3.
1.
2.
3.
4.
5.
6.
7.
8.
Routine postpartum care
Contraception
Postpartum placement of intrauterine contraceptive device
Compilation of recommendations for antenatal
corticosteroids to reduce neonatal morbidity and mortality
Oxytocin Induction/Augmentation Regime
Antibiotic prophylaxis in labour and delivery
Common drugs and dosages in pregnancy
Use of misoprostol in the medical management of
miscarriage and termination of pregnancy
PPH box checklist
PPH management checklist
Resuscitative hysterotomy instrument checklist
226
227
234
244
249
251
254
277
280
281
284
Postpartum Care
Appendix
G
H
SECTION
SECTION
x
- 225
- 243

1
Referrals
A
SECTION

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Referrals (from health clinics and
non-specialist hospital)
This chapter covers urgent and non-urgent referrals of obstetrics cases for specialist
care. The use of SBAR (situation, background, assessment and recommendation) tool is
recommended to facilitate effective communication between referring and referral centres.
Antenatal Specialist Clinic
A1.
Fetal indications:
i. Suspected fetal growth restriction (FGR)
ii. Fetal macrosomia or large for gestational age (LGA)
iii. Polyhydramnios (AFI > 25 cm or DVP > 8cm)
iv. Oligohydramnios (AFI < 5 cm or DVP < 2 cm)*
v. Malpresentation after 36 weeks’ gestation
vi. Antepartum haemorrhage (APH) follow-up
vii. Suspected placenta praevia
viii.Intrauterine fetal death (IUFD)
ix. Multiple pregnancies
x. Suspected fetal anomaly (if MFM unit not available)
Maternal indications:
i. History of recurrent miscarriages (3 consecutive first trimester miscarriages)
ii. Previous spontaneous preterm deliveries
iii. History-indicated cervical cerclage and cases requiring cervical surveillance
iv. Maternal obesity (BMI > 40 at booking)
v. History of uterine or cervical surgeries
vi. Hypertensive disease in pregnancy
vii. Gestational diabetes and pre-existing diabetes in pregnancy
viii. Stable maternal medical disorders such as epilepsy, bronchial
asthma, hyperthyroidism, hypothyroidism**
1.
2.

3
Combined (Obstetric-Medical) Clinic
A2.
Maternal cardiac conditions:
i. Any cardiac cases with modified WHO classification risk classes II, III and IV
ii. Ischaemic heart disease
iii. Chronic rheumatic heart disease
iv. Heart rate abnormalities/arrhythmias
v. Congenital heart disease
Maternal renal conditions:
i. Chronic kidney disease
ii. Acute renal disease
iii. Lupus nephritis
Maternal respiratory conditions:
i. Restrictive lung disease
ii. Reversible lung disease
1.
2.
3.
ix. Maternal mental health problems in pregnancy or history of
postpartum depression/psychosis
x. Active substance abuse in pregnancy
xi. Malignancy in pregnancy
xii. Medico-legal cases in pregnancy e.g. OSCC
This list is not exhaustive and further discussion with referral centres is
recommended for cases requiring antenatal specialist clinic review.
*Cases with borderline low AFI or DVP may be referred to antenatal specialist
clinic assessment as well for confirmation of diagnosis.
**Unstable or poorly controlled conditions may require urgent combined
clinic appointment or admission.
Adapted from:
1. Penang State Obstetrics Protocol, 2021.

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Maternal neurological conditions:
i. Myasthenia gravis
ii. Myotonic dystrophy
iii. Epilepsy.
iv. Stroke (ischaemic/haemorrhagic).
v. Guillain-Barre syndrome
vi. Multiple sclerosis
vii. Spinal cord injury
viii.Migraine
Maternal endocrinological conditions:
i. Poorly controlled diabetes or diabetes with complications (retinopathy,
nephropathy, end organ involvement) or Type I diabetes
ii. Thyroid disease
iii. Diabetes insipidus
iv. Prolactinomas
v. Adrenal disease
vi. Calcium metabolism and parathyroid disease
Maternal rheumatological conditions:
i. Systemic lupus erythematosus (SLE)
ii. Antiphospholipid syndrome (APS)
iii. Rheumatoid arthritis
iv. Psoriatic arthritis
v. Vasculitis
Maternal gastroenterological conditions
i. Intrahepatic cholestasis of pregnancy
ii. Acute fatty liver of pregnancy
iii. Hepatitis in pregnancy
iv. Liver cirrhosis +/- portal hypertension
v. Inflammatory bowel disease
4.
6.
5.
7.

5
Maternal haematological conditions
i. Immune thrombocytopenia
ii. Bleeding disorders
iii. Clotting disorders
iv. Blood malignancies
Maternal infective conditions
i. Viral hepatitis
ii. Tuberculosis
iii. Malaria
iv. HIV
8.
9.
recommended for cases requiring combined clinic review.
Adapted from:
Early Pregnancy Assessment Unit (EPAU)
A3.
Vaginal bleeding and/or pain in early pregnancy
Rupture of membranes in early pregnancy
Pregnancy of unknown location (PUL)
Nausea and vomiting in pregnancy (NVP)
1.
2.
3.
4.
(Only stable cases should be reviewed in EPAU. Unstable cases should be
discussed directly with referral centres for immediate management)
This list is not exhaustive, and further discussion with referral centres is
recommended for cases requiring EPAU assessment.

6
Prenatal Screening/Diagnosis
A4.
DESCRIPTION Prenatal screening Prenatal diagnosis
What it is To screen for chances of fetus
having aneuploidy or genetic
disorder
To diagnose if fetus actually
has a certain disorder
Type Non-invasive Invasive
Methods Combined test (nuchal
translucency, maternal age, +/-
nasal bone, tricuspid valve flow,
ductus venosus, PAPP-A and
free β-hCG) Maternal cell-free
DNA (NIPT) Quadruple blood
screening test (AFP, hCG, uE3,
inhibin A)
Chorionic villous sampling
(CVS)
Amniocentesis
Timing Combined test (11 to 13+6
weeks,
CRL 45-84mm)
NIPT (11 weeks onwards)
Quadruple blood screening test
(14 weeks onwards)
CVS (11 to 14+6
weeks)
Amniocentesis (15 weeks
onwards)
Indication Advanced maternal age
History of inherited genetic
disorder
Parental wishes
Previous aneuploidies
Abnormal morphological scan
High-risk from screening test
High-risk heritable genetic
disorder.
Adapted from:
1. Obstetrics and Gynaecology Protocol, State of Kedah, 2019.
References:
1. Neocleous AC et. al. First Trimester Noninvasive Prenatal Diagnosis: A Computational
Intelligence Approach. Journal of Biomedical and Health Informatics.2015.2462744,
IEEE.
2. Navaratnam K et. al. Amniocentesis and Chorionic Villus Sampling. BJOG: An
International Journal of Obstetrics & Gynaecology. 2021;129(1):e1- e15

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Mid-trimester Screening/Anomaly Scan
A5.
Performed between 18-22 weeks, to refer earlier if indication arises. The following
list is the indication for mid-trimester screening by MFM, however if the services
are not available, scans can be performed by general O&G specialists.
Indications:
1. Pre-existing diabetes mellitus in pregnancy or high HbA1c*
2. Parent with heritable structural anomalies (such as cleft lip, cardiac lesion)
3. Family history of heritable genetic anomalies
4. Exposure to teratogenic drugs just prior to or during early pregnancy
5. Placenta praevia anterior with previous lower segment caesarean section for
placenta accreta spectrum assessment.
6. Detection of structural anomaly in current pregnancy
7. Previous pregnancy with structural anomalies*
8. Previous pregnancy with genetic disorders or aneuploidies
9. History of intrauterine death
10.History or risk of fetal anaemia
11.Monochorionic twin pregnancies or higher order multiple pregnancies
12.Positive results for infections (Toxoplasmosis, Chickenpox, Rubella, CMV,
HSV, VDRL)
13.Maternal age* ≥40
14.Abnormal/high-risk first trimester screening
*Discussion with referral MFM centres.
recommended for cases requiring anomaly scans.
Adapted from:
3. Hospital Tuanku Ja’afar, Negeri Sembilan O&G Protocol, 2018.

8
Inter Hospital Multidisciplinary Referrals
A6.
Multidiciplinary referral.
1.
Flowchart 1: Multidisciplinary referral for obstetric cases (medical/surgical conditions)
Adapted from:

9
Referral to paediatric team (this list is not exhaustive and to refer to local
paediatric guidelines)
Fetal reasons:
i. Prematurity < 36 weeks
ii. Birth Weight < 1.7 kg or > 4 kg
iii. Any congenital anomalies
iv. Presumed fetal compromise
v. Grunting/flat baby
vi. APGAR score < 7 at 5 minutes
vii. Multiple pregnancies
Maternal reasons:
i. Active chickenpox/recent infection within 7 days of infection
ii. Active herpes simplex 2 and vaginal delivery
iii. Pulmonary tuberculosis (untreated or sputum still positive)
iv. Hepatitis B or C positive
v. Rhesus negative mother
vi. Unbooked/unscreened mother
vii. HIV positive mother
viii. Congenital heart disease (if no anomaly scan done)
ix. Maternal SLE
x. Maternal diabetes on hypoglycaemic agents
2.

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Intrapartum events:
i. Foul-smelling liquor or chorioamnionitis
ii. Prolonged leaking or any leaking with vaginal GBS infection
iii. Instrumental delivery
iv. Cord prolapse
v. Meconium-stained liquor
vi. Severe APH requiring delivery eg bleeding placenta praevia
vii. Maternal pyrexia
viii. Abruptio placenta
ix Any emergency caesarean section with suspected fetal compromise
x. Any caesarean section done under general anaesthesia
Adapted from:
1. Sarawak General Hospital, Labour Ward Manual, 2020.

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In-utero Transfer
A7.
Flowchart 2: In-utero transfer
INDICATIONS
FOR IN-UTERO
TRANSFER
1. Maternal medical or surgical condition requiring specialist
support.
2. Fetal medical or surgical condition requiring iatrogenic
delivery at specialist centre with facilities and capacity for
neonatal management
3. Antenatally diagnosed potentially lethal fetal conditions.
4. High risk of spontaneous or iatrogenic birth a unit
without facility to manage the newborn (usually due ti
prematurity).
RISK
PRESENT
1. Pregnancy less than 22 weeks gestation for fetal reasons.
2. Antenatally diagnosed potentially lethal fetal conditions.
3. Active labour.
4. Maternal condition which may require intervention
during (eg anterpartum haemorrhage or uncontrolled
hypertension)
5. Known maternal or fetal compromise requiring
immediate delivery, including abnormal
cardiotocograph.

12
ARRANGE
FOR
TRANSFER
1. Discuss case with referral obstetrician and paediatrician.
2. Recommend antenatal corticosteroids from threshold of
viability* to 34+6
days of gestation; for 35+0
to 36+6
weeks of
gestation, short term respiratory benefits should be weighed
against risk of neonatal hypoglycaemia and long-term
Neurodevelopmental concerns.
3. Consider tocolysis to complete antenatal corticosteroids, not
recommended in preterm prelabour rupture of membranes.
4. Recommend maternal antibiotics administration in suspected
or confirmed clinical chorioamnionitis, preterm prelabour
rupture of membranes, and preterm labour with intact
membranes with risk of vaginal GBS infection.
5. Discuss maternal magnesium sulphate administration to
prevent cerebral palsy based on individual cases from 23+0
to 23+6
week gestation, offer from 24+0
to 29+6
week of
gestation, and should be considered from 30+0
to 33+6
week
of gestation.
Adapted from:
3. Department of Obstetrics and Gynaecology, Hospital Tengku Ampuan Afzan, Kuantan.
Department of Obstetrics and Gynaecology, Kulliyyah of Medicine, IIUM, Kuantan. A
Quick Guide to Labour Ward Management. 2019.
References:
1. Preterm Labour and Birth. NICE guideline {NG25}. Published 20 November 2015.
2. Stock SJ et al. Antenatal Corticosteroids to Reduce Neonatal Morbidity and Mortality.
BJOG: An International Journal of Obstetrics & Gynaecology. 2022;129(8):p.e35-e60.
3. Thomson AJ. Care of Women Presenting with Suspected Preterm Prelabour Rupture of
Membranes from 24+0
Weeks of Gestation. BJOG: An International Journal of Obstetrics
& Gynaecology. 2019;126(9):p.e152-e166.
4. Watson H et al. All The Right Moves: Why in utero Transfer is Both Important for the
Baby and Difficult to Achieve and New Strategies for Change. F1000Research.2020.9(Fa
cultyRev):979.
5. Soe A et al. Perinatal Management of Pregnant Women at the Threshold of Infant
Viability (The Obstetric Perspective). RCOG: Scientific Impact Paper No. 41. 2014.

13
Obstetric Retrieval Team
A8.
Each hospital should have a clear individualized workflow for the obstetrics
retrieval process, taking into consideration the local logistic limitations.
The following is a synopsis of the Obstetric Retrieval Team’s operations:
Purpose
1. Resuscitation of unstable obstetric patients by retrieval team from specialist
centre.
2. Subsequent transfer to specialist centre for further care.
Indications
Unstable obstetrics patients in district hospital, health clinics and private
healthcare facilities, e.g. (not exhaustive):
1. Massive antepartum or postpartum hemorrhage, with ongoing bleeding
2. Maternal collapse
3. Obstetric shock
4. Life-threatening complications during surgery which is not able to be
managed by referring centre
Information required from referring centre
1. Situation
2. Severity of patient condition
3. Ascertain whether blood is needed for resuscitation and maternal blood
group if required
4. Determination of location
Plan of Actions
1. Effective communication with referring center for updates
2. Inform consultant on call
3. Activate retrieval team including booking of ambulance/helicopter/boat as
required
4. Gather retrieval equipment and tools

14
Team members may include:
1. Obstetric specialist
2. Obstetric medical officer
3. Anaesthetist
4. Anaesthetic medical officer
5. Midwife/staff nurse
6. Ambulance driver +/- PPK or flying squad
7. Assistant Medical Officer if necessary
8. Paediatric medical officer/specialist if necessary
Retrieval equipment and tools
1. Delivery set (O&G team)
2. Obstetric haemorrhage kit (O&G team) – refer to Appendix (PPH Box and
Management Checklist)
3. Intubation set, inotropes, oxygen supply, defibrillator (by anaesthetic/
emergency department)
4. Medications, syringes, needles, infusion pumps, fluid expanders, Foley’s
catheter, nasogastric tube as necessary
5. +/- blood products
6. +/-transport incubator with Neopuff (by paediatric department)
7. +/- portable ultrasound machine
Subsequent Management
1. Depart to location – to inform referring centre about estimated time of arrival
2. Provide immediate resuscitation
3. Transfer patient to referral centre
4. Update team in referral center including team in Emergency Department
about estimated time of arrival
Adapted from:
1. Department of Obstetrics and Gynaecology, Hospital Tengku Ampuan Afzan, Kuantan.
Department of Obstetrics and Gynaecology, Kulliyyah of Medicine, IIUM, Kuantan. A
Quick Guide to Labour Ward Management. 2019.
2. Obstetrics & Gynaecology Department, Hospital Tuanku Fauziah, Kangar, Perlis.
Obstetrics Protocol. 2020-2025.
3. Sabah Obstetric Shared Care Guidelines. 2020.

15
Early Pregnancy
Problems
B
SECTION

16
Early Pregnancy Problems
This chapter covers common early pregnancy problems encountered by managing
doctors, including pregnancy dating issues, bleeding in early pregnancy, pregnancy
of unknown location, miscarriages, molar pregnancy, and nausea and vomiting in
pregnancy.
Pregnancy Dating
B1.
Flowchart 3: Approach to determine gestational age

17
Gestational age Parameters measured Management
< 9 weeks CRL Use LMP if USG date within +/- 5 days of
LMP, otherwise use ultrasound REDD.
9-13+6
weeks CRL Use LMP if USG date within +/- 7 days of
14+0
– 15+6
BPD, HC, AC, FL Use LMP if USG date within +/- 7 days of
16+0
– 21+6
22+0
– 27+6
LMP, otherwise use ultrasound REDD.*
≥ 28 weeks BPD, HC, AC, FL Use LMP if USG date within +/- 21 days of
LMP, otherwise use ultrasound REDD.*
Determination of dates based on ultrasonography:
*requires serial growth scans to exclude small/large for gestational age babies
Adapted from:
Reference:
1. ACOG. Methods for Estimating the Due Date. Committee Opinion, Number 700, May
2017.

18
Bleeding in Early Pregnancy
B2.
Flowchart 4: Management of bleeding in early pregnancy

19
Adapted from:
3. Penang State Gynaecology Protocol, 2021.
4. Perak State Gynaecology Protocol, 2021.
5. Sabah Obstetric Shared Care Guidelines, 2020.
Reference:
1. NICE guideline [NG126]. Ectopic Pregnancy and Miscarriage: Diagnosis and Initial
Management. April 2019.

20
Management of miscarriage
B3.
Diagnosis Criteria Expectant
Management
Medical
Management
Surgical
Management
Threatened
miscarriage
Confirmed IUP
with embryo /
fetal heartbeat and
presents with vaginal
bleeding.
and
No history of
previous miscarriages
IUP confirmed with
scan, presents with
vaginal bleeding.
and
Has history of
miscarriage
1. If bleeding
worsens or persists
beyond 14 days,
return for assessment
2. If bleeding stops,
advice to start or
continue routine
antenatal care
1. If bleeding
worsens or persists
beyond 14 days,
return for assessment
2. If bleeding stops,
advice to start or
continue routine
antenatal care
-
1. Offer
vaginal
micronized
progesterone
400mg BD
2. If fetal
heartbeat
confirmed,
continue
progesterone
until 16
completed
weeks of
pregnancy
-
Incomplete/
Missed
miscarriage
Risks rendering
women unsuitable
for expectant
management:
1. Increased risk of
bleeding (e.g., late
first trimester) or,
2. Previous adverse
and/or traumatic
experience with
pregnancy or,
Not suitable
for expectant
management
1. Offer
medical
management
2. Offer
vaginal
misoprostol
(oral is an
acceptable
alternative) –
refer appendix
for regime
1. Offer
surgical
management
where clinically
appropriate: -
Manual
vacuum
aspiration
under local
anesthetic
or

21
Diagnosis Criteria Expectant
Management
Medical
Management
Surgical
Management
Incomplete/
Missed
miscarriage
3. Increased risk
from effects of
haemorrhage (e.g.,
coagulopathies
or unable to have
blood transfusion) ,or
4. Evidence of
infection
Women with
miscarriage who
do not have
risks mentioned
above (suitable
for expectant
management)
1. Expectant
management for 7 to
14 days
2. If resolution
of bleeding and
pain indicate that
miscarriage has
completed, advise
women to take a UPT
after 3 weeks and to
return if UPT positive
3. Offer a repeat
scan after 7 to 14
days and the process
of miscarriage has
not begun or if there
is persisting and/or
increasing bleeding
and pain (suggesting
incomplete
miscarriage).
Discuss all options
(continued
expectant, medical
and surgical
management).
3. Offer pain
relief and anti-
emetics.
4. Repeat UPT
after 3 weeks
and to return if
UPT positive.
Discuss option
to allow women
to make
informed choice
Surgical
management
in theater
Discuss
option to
allow women
to make
informed
choice
Reference:

22
Pregnancy of Unknown Location
B4.
Flowchart 5: Management of pregnancy of unknown location

23
Adapted from:
Reference:

24
Molar Pregnancy
B5.
Flowchart 6 : Approach to Molar Pregnancy

25
*This guideline does not cover the management of complex molar pregnancies such
as ectopic molar or twin pregnancy of a viable fetus with presumptive coexisting molar
pregnancy.
Adapted from:
Reference:
1. Tidy J et al. GTG 38: Management of Gestational Trophoblastic Disease. BJOG: An
International Journal of Obstetrics & Gynaecology. 2020;128(3): e1-e27.

26
Nausea and Vomiting in Pregnancy
B6.
Flowchart 7: Management of nausea and vomiting in pregnancy

27
Motherisk PUQE-24 scoring system
Recommended antiemetics
*Complications:
1. Continued nausea and vomiting and inability to keep down oral antiemetics
2. Continued nausea and vomiting associated with ketonuria and/or weight loss (greater
than 5% of body weight) despite oral antiemetics
3. Confirmed or suspected comorbidity
4. Abnormal urea and electrolytes
5. Haematemesis
6. Persistent ketonuria after day case hydration
7. Second attendance for day case hydration
In the last 24 hours, for how long
have you felt nauseated or sick to
your stomach?
Not at all
(1)
1 hour or
less (2)
2-3 hours
(3)
4-6 hours
(4)
More than
6 (5)
In the last 24 hours have you
vomited or thrown up?
7 or more
times (5)
5-6 times
(4)
3-4 times
(3)
1-2 times
(2)
I did not
throw up
(1)
In the last 24 hours how many
times have you had retching
or dry heaves without bringing
anything up?
No time
(1)
1-2 times
(2)
3-4 times
(3)
5-6 times
(4)
7 or more
times (5)
First line Cyclizine 50mg PO, IM or IV, 8 hourly
Prochlorperazine 5-10 mg PO 6-8 hourly; 12.5mg IM/IV 8 hourly, 25mg PR daily
Promethazine 12.5-25mg 4-8 hourly PO, IM, IV or PR
Chlorpromazine 10-25mg 4-6 hourly PO, IV or IM; or 50-100mg 6-8 hourly PR
Second line Metoclopramide 5-10mg 8 hourly PO, IV or IM (maximum 5 days’ duration)
Domperidone 10mg 8 hourly PO; 30-60 mg 8 hourly PR
Ondansetron 4-8 mg 6-8 hourly PO; 8mg over 15 minutes 12 hourly IV
Third line Corticosteroids: hydrocortisone 100mg twice daily IV and once clinical
improvement occurs, convert to prednisolone 40-50 mg daily PO, with the
dose gradually tapered until the lowest maintenance dose that controls the
symptoms is reached

28
Adapted from:
References:
1. Shehmar M et al. GTG 69: The Management of Nausea and Vomiting of Pregnancy and
Hyperemesis Gravidarum. RCOG 2016.
2. Consensus Statement on Management of Hyperemesis Gravidarum. KKM.600-
27/7/1jld.6(61), 25 February 2020.

29
Antenatal Problems
C
SECTION

30
Multiple Pregnancy
C1.
1) Overview
a. Background incidence: 1 in 80 pregnancies.
b. Monozygous twinning rates are relatively constant. Incidence: 4 per 1000
births.
c. Dizygous twinning rates vary enormously depending on age, parity, racial
background and assisted conception techniques.
d. Overall, perinatal and maternal morbidity is higher in multiple pregnancies
than in singletons.
e. Preterm delivery and complications of prematurity are the main contributors
to adverse outcomes.
2) Antenatal Follow-up
a. Ultrasound should be done at the time of diagnosis of twin pregnancy to
determine chorionicity.
b. Ultrasound for chorionicity should be done before 13+6
weeks of gestation.
c. Referral to O&G team to confirm chorionicity, counseling and outline
antenatal follow-up plan.
d. Antenatal care should be shared between Specialist hospitals and the MCH
clinic.
e. All monochorionic (MC) twins or higher order pregnancy (≥3) required
follow-up with an O & G specialist clinic.
f. Consider inpatient surveillance for higher order pregnancy after 26-28
weeks till delivery.
g. Uncomplicated Monochrionic (MCDA & MCMA): 2 weekly after 16 weeks
until delivery.
h. Uncomplicated Dichorionic Diamniotic (DCDA): 4 weekly until 28 weeks
then 2 weekly until delivery.

31
3) Risk of Twin Pregnancies
* Good Practice Points During Ultrasound Scan
1. Look for separating membrane – lack of separating membrane suggests a
monoamniotic twin (MCMA).
2. Determine Chorionicity:
Ø
Ø Number of placental mass: 2 separate masses suggest dichorionic
Ø
Ø Lambda or T-sign (1st
trimester): Lambda = Dichorionic; T-sign =
Monochorionic
Ø
Ø Thickness of the separating membrane: <2mm in monochorionic twins
Ø
Ø Gender discrepancy suggests DCDA twins
Ø
Ø Label the fetuses according to “right and left” or “upper and lower”
Ø
Ø If unsure of dates, follow the date of the larger twin
Ø
Ø If unable to determine chorionicity after assessed by O&G specialist, to
treat as MCDA twins
3. Calculation of growth discrepancies: EFW (larger fetus) – EFW (smaller fetus)
/ EFW (larger fetus) x 100%
4. Measurement of DVP: Abnormal if < 2 cm or > 8 cm
Maternal Risk Fetal Risk
Anaemia Fetal Growth Restriction
Preterm Delivery Congenital Anomalies
Hypertension Twin to Twin transfusion syndrome
Antepartum Haemorrhage Polyhydramnios
Polyhydramnios Cord accident
Increased risk of operative delivery Increased risk of operative delivery
Postpartum Haemorrhage

32
The challenges of managing monochorionic pregnancies arise from the
vascular placental anastomoses that are almost universal and connect the
umbilical circulation of both twins:
a. Twin-to-twin transfusion syndrome (TTTS) – 10-15% of monochorionic
pregnancies
b. Twin reversed arterial perfusion (TRAP) sequence – 1%
c. Twin anaemia polycythaemia sequence (TAP) – 1%
d. Selective fetal growth restriction (sFGR), commonly due to unequal
placental sharing and velamentous cord insertion – 25-35%
e. Consequence of the co-twin fetal demise – 2.6%
f. Management of discordant malformations
g. Monochorionic, monoamniotic pregnancies with risk of cord entanglement
– 1%
4) Twin-to-Twin Transfusion Syndrome
a. Ultrasound examinations between 16-24 weeks focus primarily on detection
of TTTS.
b. After 24 weeks, the main purpose is to detect fetal growth restriction, which
may be concordant or discordant.
c. The Quintero classification system of TTTS has some prognostic value but
the course of condition is unpredictable and may involve improvement or
rapid deterioration.
d. Laser ablation of vascular connection is the recommended treatment for the
majority of pregnancies with TTTS that requires intervention (stage II-IV),
and urgent referral to a laser surgery facility should be considered.
e. Early referral is recommended to allow optimal treatment before the onset
of severe disease and cervical shortening.
f. Laser treatment is done between 16-26 weeks and can be considered
between 26-28 weeks.

33
6) Selective Fetal Growth Restriction
a. More common especially in monochorionic twins – 10% incidence.
b. Estimate fetal weight discordance using 2 or more biometric parameters at
each ultrasound scan from 20 weeks.
c. Consider a 25% or greater in size between twins as a clinically important
indicator of fetal growth restriction.
d. Doppler velocimetry is used to evaluate the haemodynamic status of the 2
fetuses.
e. Abnormal doppler (umbilical artery) may lead to 40% risk of IUD of affected
twin.
5) The Quintero Classification System
STAGE Classification
I
There is discrepancy in amniotic fluid volume with oligohydramnios
of a maximum vertical pocket (MVP) < 2cm in one sac and
polyhydramnios in other sac (MVP > 8cm).
II The bladder of the donor twin is not visible.
III
Doppler studies are critically abnormal in either twin and are
characterised as abnormal or reversed end-diastolic velocities in
the umbilical artery, reverse flow in the Ductus venosus or pulsatile
umbilical venous flow
IV
Ascites, pericardial or pleural effusion, scalp edema or overt
hydrops present.
V One or both babies are dead.

34
7) Death of one of a monochorionic twin pair
a. Death of one twin in a monochorionic pair may result in death or
neurological disability in the survivor.
b. Chance that the surviving twin in a monochorionic twin will either die or
suffer major morbidity is up to 17%.
c. These events occur around the time of fetal death, postulated due to
agonal hypotension as the blood volume of the survivor is ‘dumped’
precipitously into the corpse of the co-twin through shared vascular
communications, or possibly due to the release of thromboplastins from the
deceased twin into the shared circulation.
d. One of the advantages of laser therapy (or cord ligation) in TTTS is that it
provides some neuroprotection for the surviving twin in the event of co-twin
demise.
e. Delivery of survivors at preterm gestation will not prevent further damage
unless there is evidence of cardiotocography (CTG) abnormalities or
significant fetal anaemia.
f. Ongoing ultrasound or MRI assessment of the brain in the survivor to
diagnose neurological damage secondary to hypovolaemia may be
appropriate.
8) Delivery
a. Uncomplicated MCMA: by 32-34 weeks
b. Uncomplicated MCDA: by 36-37 weeks
c. Uncomplicated DCDA: by 37-38 weeks
d. Uncomplicated triplet: offer delivery at 35 weeks
e. Complicated twin pregnancies: decision is made on a case by case basis
after detailed review by O&G specialist / consultant.
f. Can be vaginal birth or caesarean section.**
**Twin Birth Study
• No significant benefit of planned caesarean sections for twins vs planned
vaginal birth.
• It is reasonable to aim for vaginal delivery if the first twin is cephalic and
mother has no previous caesarean sections.

35
g. Caesarean section is recommended in:
Ø
Ø Non-cephalic first twin
Ø
Ø Women with previous LSCS/ uterine scar
Ø
Ø MCMA twins
Ø
Ø Any other complicated twin pregnancy.
9) Management of Twin in Labour
Labour Stage Remarks
Upon admission
of labour ward
/ 1st
stage of
labour
• Intravenous line +/- IV Hydration
• Blood test: FBC, GSH
• Ultrasound assessment to determine:
-
- presentation of each fetus
-
- liquor volume
-
- placental site
-
- viability of each twin, fetal heart location of
each twin to ease the CTG fetal cardiac probe
placement.
-
- estimated fetal weight (if not recently performed)
• Consult specialist before induction of labour or
augmentation
• Inform specialist when patient admit to labour room
• Inform paediatric team to standby for 2nd
stage
• Continuous CTG monitoring of both fetuses,
considering inserting an internal probe for the leading
twin.
• Always compare both twin tracings to ensure that 2
different heart rates are being traced and the same
twin is not being monitored twice. Ideally, both twins
should be traced by one machine.

36
Labour Stage Remarks
Second stage of
labour
• Medical officer to standby during delivery
• Ultrasound machine to standby – to confirm the
presentation of 2nd
twin after delivery of 1st
twin
• Delivery of 1st
twin as per singleton and medical
officer should help to stabilise the 2nd
twin in a
longitudinal lie.
• Clamp the cord using plastic cord clamps and cut in
between the clamps, postpone taking any sample for
cord blood until the 2nd
twin is delivered.
• Perform abdominal palpation to confirm the lie
and presentation of the 2nd
twin. May use the
transabdominal ultrasound scan
• Continuous CTG monitoring
• Consider to commence oxytocin infusion if
contraction is inadequate after delivery of 1st
twin.
• Consider performing ECV or internal podalic version
if in non-longitudinal lie.
• If it is a longitudinal lie, encourage pushing with each
contraction.
• Once the 2nd
twin delivered, clamped and cut the
cord as usual.
• Proceed to withdraw any cord blood as necessary.
• Cord pH should be taken if the baby is not vigorous.
Third stage of
labour
• Give uterotonic agent after delivery of 2nd
twin as
prophylaxis of postpartum haemorrhage.
• Deliver the placenta using controlled cord traction
• Check placenta to confirm chorionicity and ensure
placenta and membrane are complete
• Start oxytocin infusion as there is a risk of uterine
atony and PPH following delivery of multiple
pregnancies.

37
Adapted from:
2. Sabah Obstetric Shared Care Guidelines 4th
Edition, June 2020.
3. Obstetrics Protocol, O&G Department, Hospital Tuanku Fauziah, Kangar Perlis.
5. A Quick Guide to Labour Room Management, Hospital Tengku Ampuan Afzan Kuantan
& IIUM, 3rd
Edition .
6. Sarawak General Hospital Labour Ward Manual, 2020.
7. Obstetrics & Gynaecology Protocol, State of Kedah, 2019.
References:
1. Royal College of Obstetricians and Gynaecologists. Management of Monochorionic
Twin Pregnancy. Green-top Guideline No.51. London: ROCG; 2017.
2. NICE guideline (NG137). Twin and Triplet Pregnancy, 2019
Cervical Insufficiency
C2.
1) Overview
a. Cervical insufficiency is the inability of the uterine cervix to retain a
pregnancy in the second trimester in the absence of clinical contractions,
labour, or both.
b. Presentation:
Ø
Ø Vaginal discharge, show or sensation of pressure at perineum
Ø
Ø History of painless dilatation of the cervix
Ø
Ø History of rupture of membranes before onset of contractions
c. Investigation:
Ø
Ø Blood: FBC
Ø
Ø Imaging: Transvaginal ultrasound at 16-24 weeks of gestation for
Ø
Ø cervical length shortening, of <25mm.
Ø
Ø Others: HVS C&S

38
2) Management
a. Pregnant women with a history of previous preterm birth and/or second
trimester loss or with risk factors such as history of multiple D&C or history
of cervical surgery should be referred to an O & G specialist clinic for further
assessment and management.
b. Serial TVS surveillance should be performed for women with a history of
spontaneous mid-trimester loss or preterm birth suspected secondary to
cervical insufficiency.
3) Cervical Cerclage
a. Cervical Cerclage may be offered to women with recurrent spontaneous
mid trimester loss or preterm birth (history indicated).
b. Cervical cerclage should be offered to women with history of one or more
spontaneous mid trimester loss or preterm birth, with TVS surveillance
of cervical length of 25mm or less, and before 24 weeks of gestation
(ultrasound indicated).
c. Rescue cerclage:
Ø
Ø In cases with cervical dilatation of 4cm or less without membrane
prolapse beyond the external os
Ø
Ø Decision by senior obstetrician depending on period of gestation
Ø
Ø Inform couple that even with rescue cerclage in severe preterm delivery,
there’s risk of neonatal morbidity and mortality
Ø
Ø Rule out chorioamnionitis before the procedure.
d. Transvaginal cervical cerclage should be removed at 36-37 weeks.
e. If delivered by elective LSCS, suture removal could be done together.
f. In PPROM at 24-34 weeks without infection or preterm labour, can delay
removal of cerclage for 48 hours until complete prophylactic steroids.
g. Cervical cerclage is not recommended in women with incidental findings
of cervical shortening of 10-25mm and without history of spontaneous
mid-trimester loss, preterm birth or other known risk factor, but may be
beneficial for women with short cervix less than 10mm.
h. Cervical cerclage is not recommended for funneling of the cervix in the
absence of cervical shortening of 25mm or less.
i. Cervical cerclage is not recommended in women with multiple pregnancy
since evidence suggests increase in preterm delivery and pregnancy loss.

39
j. For multiple pregnancy with cervical length of <15mm or those with past
history of typical cervical insufficiency, there may be an advantage for
cerclage, with limited evidence.
k. Contraindication for cervical cerclage:
Ø
Ø Advanced preterm labour
Ø
Ø PPROM / Chorioamnionitis
Ø
Ø Antepartum Haemorrhage
Ø
Ø Fetal Distress
Ø
Ø Fetal Anomalies
Ø
Ø Intrauterine death
4) Progesterone
a. May offer to women with a history of recurrent spontaneous mid trimester
loss or preterm birth.
b. May continue in women who had cervical cerclage done.
c. To be continued until 34 weeks of gestation.
d. Choices of progesterone depend on local availability.
Flowchart 8: Approach to Cervical Insufficiency
Adapted from:
Edition, June 2020
2. Obstetrics & Gynaecology Protocol, State of Kedah, 2019
References:
1. NICE guideline (NG25): Preterm labour and birth, 2015
2. ACOG guideline
3. SOGC guideline (No. 373) : Cervical insufficiency and cervical cerclage,2019

40
Rhesus Negative in Pregnancy
C3.
1) Overview
a. There is a risk of isoimmunization in which Rhesus positive red blood cells
enter the circulation of a Rhesus negative woman.
b. The degree of the risk will vary with the amount of Rhesus antigen to which
she is exposed.
c. Rhesus isoimmunization against Rhesus antigen may result in hemolytic
disease of the fetus and newborn.
d. During pregnancy, a small proportion of women (1.5%) develop Rhesus
antibodies during their first pregnancy; most such immunization takes place
after 28 weeks of gestation.
e. Incidence of Rhesus isoimmunization can be reduced from 0.2 to 0.06%
with the combination of antenatal anti-D immunoglobulin to all unsensitized
Rhesus negative women and further dose after such women given birth to a
Rhesus positive child.
2) Antenatal Follow-up
a. Check blood group & Rh type in all antenatal cases at first visit.
b. If a woman is rhesus negative, check husband’s/partner’s blood group & Rh
type.
c. Check INDIRECT Coombs test at booking and 28 weeks.
d. Women with a positive INDIRECT Coombs test need further testing to
confirm the presence of anti-D antibodies.
e. DO NOT repeat Coombs test/anti-D antibody screening if the woman has
already been given anti-D in the current pregnancy.
f. Women with anti-D antibodies (with no history of previous anti-D
prophylaxis given) are considered sensitized and require close monitoring of
antibody levels (if available) and signs of fetal anaemia.
g. Women who are already sensitized would NOT benefit from anti-D
prophylaxis.
h. Ideally, sensitized women should be followed up by maternal-fetal-medicine
units in a specialist centre.

41
3) Potentially Sensitizing Events
a. Miscarriage, which required surgical evacuation regardless gestation
b. Miscarriage, Threatened miscarriage: >12 weeks gestation
c. Ectopic pregnancy
d. Evacuation of molar pregnancy
e. Termination of pregnancy by either surgical or medical methods
f. Amniocentesis, Chorionic villus biopsy and cordocentesis
g. Antepartum haemorrhage
h. External cephalic version
i. Intrauterine death and stillbirth
j. In-utero therapeutic interventions (transfusion, surgery, insertion of shunts,
laser)
k. Abdominal trauma (sharp/blunt, open/closed)
l. Delivery – Normal, Instrumental or Caesarean section
m. Intraoperative cell salvage
4) Anti-D Prophylaxis
Routine
antenatal anti-D
prophylaxis
(RAADP)
Ø
Ø All Rh D negative pregnant women who have not
been previously sensitized should be given RAADP
either with a single dose regimen or two dose
regimen
Ø
Ø Single dose regimen: 1500 IU given at 28 – 30 weeks
Ø
Ø Double dose regimen: 1250 IU given at 28 and 34
weeks
Less than
12 weeks of
gestation
Ø
Ø Feta-maternal haemorrhage (FMH) test not required
Ø
Ø Minimum dose: 250 IU within 72 hours of event
12 to 20 weeks of
gestation
Ø
Ø FMH test not required
Ø
Ø
Ø If continue bleeding: RhoGAM® minimum 6 weekly
interval
Potentially sensitizing events

42
12 to 20 weeks of
gestation
Ø
Ø FMH test not required
Ø
Ø
Ø If continue bleeding: RhoGAM® minimum 6 weekly
interval
20 weeks
gestation to term
Ø
Ø FMH test (Kleihauer-Betke test) required to allow
calculation of additional RhoGAM®doses
Ø
Ø If FMH > 4mL is detected, follow-up samples are
required at 48 hrs following an intravenous dose of
anti-D or 72 hrs following an Intramuscular dose to
check for clearance of fetal cells
Ø
Ø For any potentially sensitising events, minimum dose
of 500 IU RhoGAM® should be administered within
72 hrs regardless of whether the woman has already
received RAADP at 28 weeks
Ø
Ø In the event of continual uterine bleeding (clinically
judged to represent the same sensitising event),
minimum of 500 IU RhoGAM® should be given at 6
weekly interval.
Ø
Ø If further intermittent uterine bleeding, estimation of
FMH should be done at 2 weekly interval.
Ø
Ø If the 2 weekly FMH test shows the presence of fetal
cells, additional RhoGAM® should be administered
Ø
Ø The additional dose should be calculated: IM 125 IU
or IV 100 IU for each mL of fetal red cells detected
(minimum 500 IU)
Following
delivery
of Rhesus D
positive
child
Ø
Ø Give RhoGAM® 500 IU within 72 hrs following
delivery if:
o
o Baby is confirmed to be Rh D positive
o
o Cord blood sample cannot be obtain
o
o If there’s an intrauterine fetal death (IUFD) and
hence no sample can be obtained from the baby

43
5) Delivery
a. Timing of delivery: follows obstetric indication.
b. Check the antenatal history of RAADP.
c. Ensure the availability of 1-2 units of packed cells before induction, vaginal
delivery or caesarean section.
d. Fetal monitoring / labour augmentation as in normal cases.
e. If LSCS, intra-operatively: remove placenta by CCT, avoid MRP to minimize
the risk of feto-maternal haemorrhage.
f. At delivery, remember to send cord blood for ABO and Rhesus grouping.
g. If suspected hemolytic disease of newborn or in the presence of maternal
antibodies (sensitised mother), to send cord blood for haemoglobin level,
Direct coomb’s test, serum bilirubin.
6) Kleihauer-Betke Testing
a. To quantify the amount of FMH.
b. Ideally should be done in all rhesus negative women post-delivery.
c. Kleihauer-Betke test should be done if a higher degree of fetal-maternal
haemorrhage is suspected (i.e LSCS, MRP etc).
d. Maternal blood should be taken within 1-2 hours of delivery to allow
sufficient time for dispersal of fetal cells in the maternal circulation.
e. If the amount of FMH exceeds the dose of RAADP, give additional
RhoGAM® based on the calculation of 125 IU/mL of FMH.
f. Repeat Kleihauer testing after 72 hours to ensure that fetal cells have been
cleared.
g. Repeat RhoGAM® if fetal cells are still present in the repeat Kleihauer
testing.
h. When large doses of RhoGAM® (> 15,000 IU), be wary of hemolytic
reaction due to intended destruction of foreign RhD +ve red cells.

44
Flowchart 9: Management of Rhesus Negative in Pregnancy
Adapted from:
Edition, June 2020
3. Obstetrics Protocol, O&G Department, Hospital Tuanku Fauziah, Kangar Perlis
4. Sarawak General Hospital Labour Ward Manual, 2020
References:
1. Royal College of Obstetricians and Gynaecologists. The Management of Women with
Red Cell Antibodies during Pregnancy. Green-top Guideline No.65. London: ROCG;
2014
2. British Committee for Standards in Haematology (BCSH) Guideline for the Use of Anti-D
Immunoglobulin for the Prevention of Hemolytic Disease of the Fetus and Newborn;
2014

45
Placenta Praevia
C4.
1) Overview
a. Majority of women who were told to have a low-lying placenta during the
2nd trimester will “resolve”, with only 1 in 200 having this condition at
delivery.
b. At 18-24 weeks, if the placenta extends beyond the internal cervical os by
15-25mm, the probability of placenta praevia at delivery is 20%.
c. If it extends by >25mm, this likelihood is increased to 40-100%.
d. Transvaginal ultrasound is safe in the presence of placenta praevia and is
more accurate than transabdominal ultrasound in locating the placenta.
e. In the absence of transvaginal ultrasound, ensure transabdominal
ultrasound is done with a FULL BLADDER to increase accuracy.
f. For pregnancies beyond 16 weeks of gestation, the placenta is:
Ø
Ø Normal: if placental edge is ≥ 20mm from the internal os
Ø
Ø Low-lying: if the placental edge is <20mm from the internal os
Ø
Ø Praevia: if the placenta is overlying the internal os.
2) Management
a. Women with placenta praevia who remain asymptomatic, no history of
antepartum haemorrhage, required careful counseling and specialist input
before contemplating outpatient care. This may vary depending on local
settings.
b. Any home-based care requires close proximity to the hospital, constant
presence of companions and full informed consent from the woman.
c. Women with placenta praevia with history of antepartum haemorrhage
should be admitted and managed as inpatients.
d. Women must be educated to come to hospital immediately if they
experience any bleeding, contractions or period-like abdominal pain.
e. In women with an underlying caesarean section or uterine scar, MUST rule
out placenta accreta spectrum (PAS).
f. Suspected placenta accreta preferably be confirmed by ultrasound by
a Maternal-Fetal specialist. MRI is not routinely required to confirm the
diagnosis.

46
g. Mode of delivery: via caesarean section
h. Timing of delivery: 36-37 weeks for uncomplicated placenta previa.
Earlier delivery may be considered depending on history of antepartum
haemorrhage, fetal growth and other obstetric problems/indication.
i. In low-lying placenta (between 10 to 20mm from the internal os):
Ø
Ø Success rate of vaginal delivery varies from 56-93% and may depend on
the thickness of the placental edge and other ultrasound findings.
Ø
Ø Option for vaginal delivery can be discussed if the woman is very keen
for vaginal delivery and has no previous history of APH.
Ø
Ø Scan must be repeated by a specialist.
Ø
Ø Woman and her partner must be counseled.
Ø
Ø Delivery must be in a specialist centre that can perform emergency
caesarean section for placenta praevia in the event of excessive bleeding.
Gestation Ultrasound Findings Action
16 – 32 weeks Placenta edge
overlapping os / < 20
mm from internal os.
Use LMP if USG date within +/- 5 days of
32 – 36 weeks Placenta edge
mm from internal os.
Placenta edge ≥ 20 mm
from internal os
Rescan at 36 weeks.
Manage as normal pregnancy.
36 weeks
(No history of
bleeding)
Placenta edge
overlapping os / <
20 mm from internal
os (TVS confirmed by
Specialist)
Admit and book for elective LSCS between
36-37 weeks.
For placenta within 10 mm to 20 mm
from internal os, vaginal delivery can be
considered in women who are keen after
assessment and counseling by a specialist.

47
Gestation Ultrasound Findings Action
APH – one
episode at any
gestation
Placenta edge
mm from internal os
Admit for observation. Ensure blood is
available at all times. Repeat scan at 32 – 36
weeks to recheck placenta edge using TVS.
Specialist to decide if considering discharge.
The risk of requiring emergency delivery
correlates with the number of episodes of
APH :
• One episode (OR 7.5)
• Two episodes (OR 14)
• Three episodes (OR 27)
Adapted from:
Edition, June 2020
Reference:
1. Royal College of Obstetricians and Gynaecologists. Placenta Praevia and Placenta
Accreta: Diagnosis and Management. Green-top Guideline No.27a. London: ROCG;
2018

48
Placenta Accreta Spectrum (PAS)
C5.
1) Overview
a. A morbidly adherent placenta includes placenta accreta, increta and
percreta as it penetrates through the decidua basalis into and then through
the myometrium and is associated with maternal and fetal morbidity and
mortality.
b. Women at increased risk are those with placenta praevia WITH a previous
uterine scar (lower segment caesarean section, myomectomy or repeat
D&C).
c. All women with placenta praevia and a previous uterine scar must have
at least an ultrasound performed by 28 weeks gestation by a skilled and
experienced operator to determine if she has placenta accreta spectrum.
d. Ultrasound doppler has a sensitivity of 82.4% and specificity of 96.8% to
diagnose accrete.
e. MRI is a useful adjunct in evaluation of placenta accreta spectrum.
f. Counseling with couples and appropriate preoperative preparation should
be made.
2) Clinical Assessment
a. Ultrasound features for diagnosis were as follows:
Ø
Ø Loss of the “clear zone”: loss or irregularity of the hypoechoic plane in
the myometrium underneath the placental bed.
Ø
Ø Bladder wall interruption: Loss or interruption of the bright bladder
wall (the hyperechoic band between the uterine serosa and the bladder
lumen).
Ø
Ø Myometrial thinning: thinning of the myometrium overlying the placenta
to <1mm or undetectable.
Ø
Ø Placental bulge: deviation of the uterine serosa away from the expected
plane, caused by an abnormal bulge of placental tissue into the
neighbouring organ.
Ø
Ø Abnormal placental lacunae: presence of numerous lacunae including
some that are large and irregular.
Ø
Ø Focal exophytic mass: placental tissue seen breaking through the uterine
serosa and extending beyond it. Most often seen inside a filled urinary
bladder.

49
3) Management
a. In women with no history of antepartum haemorrhage, delivery should be
planned between 35-37 weeks.
b. Woman’s haemoglobin level must be optimized to above 10g/L before
surgery.
c. Couples should be counseled thoroughly regarding the possible risk and
complications including the need for hysterectomy. Consent should be
obtained.
d. The anaesthetist must be informed regarding the risk of PPH and need for
hysterectomy.
e. The blood bank specialist must be informed regarding the possible need
for activation of massive transfusion protocol (MTP).
4) During Surgery
a. Surgery must be carried out by a senior O&G surgeon, where possible, 2
competent surgeons should perform the surgery as speed is of essence.
b. Prophylactic bilateral internal iliac artery balloon occlusion by interventional
radiologist may be considered if service is available.
c. Bilateral ureteric stenting may be considered if service is available.
d. Surgical approach (abdomen): midline skin incision.
e. Any adhesions must be dissected and the bladder must be dissected down
carefully in anticipation of hysterectomy.
b. Colour doppler:
Ø
Ø Uterovesical hypervascularity : Striking amount of colour Doppler signal
between the myometrium and posterior wall of bladder.
Ø
Ø Subplacental hypervascularity: Striking amount of colour Doppler signal
seen in the placental bed.
Ø
Ø Bridging vessels: Vessels appearing to extend from the placenta across
the myometrium and beyond the serosa in the bladder or other organs.
Ø
Ø Placental lacunae feeder vessels: Vessels with high velocity blood flow
leading from the myometrium into the placental lacunae.
Ø
Ø 3D intraplacental hypervascularity: Complex, irregular arrangement of
numerous placental vessels, exhibiting tortuous courses and varying
calibers.

50
f. Uterine incision should be done at a site distant from the placenta, and
delivering the baby without disturbing the placenta.
g. After delivery of the baby, await spontaneous separation of the placenta.
h. If the placenta does not separate, do not try and perform MRP, but proceed
with hysterectomy instead.
i. Blood products should be transfused early rather than late. Anticipate DIVC.
j. Double ligation in all vascular pedicles is a good practice.
k. In massive haemorrhage, internal iliac artery ligation/occlusion may be
considered if expertise is available.
l. Consider abdominal drain insertion at the end of surgery if there is a massive
haemorrhage.
Adapted from:
Edition, June 2020
2. A Quick Guide to Labour Room Management, Hospital Tengku Ampuan Afzan Kuantan
& IIUM, 3rd
Edition
Reference:
1. Royal College of Obstetricians and Gynaecologists. Placenta Praevia and Placenta
Accreta: Diagnosis and Management. Green-top Guideline No.27a. London: ROCG;
2018

51
Uterus Larger Than Dates
C6.
1) Overview
a. Diagnosed when the symphysio-fundal height (SFH) is more than the
gestational age.
b. Clinical fundal height (CFH) is an alternative to SFH and it is more practical
to be use. There are some opinion that clinical fundal height is based on
landmarks and less affected by height and weight.
c. Need to determine the patient’s date accurately.
d. Identify women with risk factors: diabetes mellitus, obesity, previous history
of macrosomia etc.
e. Possible causes:
Ø
Ø Wrong date
Ø
Ø Multiple pregnancy
Ø
Ø Polyhydramnios
Ø
Ø Macrosomia / Large for gestational age
Ø
Ø Congenital anomalies
Ø
Ø Pelvic tumour: fibroids, ovarian cysts
2) Management
a. Measure the clinical fundal height using measuring tape.
b. Abdomen palpation to estimate liquor volume and estimated fetal weight.
c. Ultrasound examination: to exclude multiple pregnancies, polyhydramnios
or pelvic tumour.
d. Measurement of fetal biometry and plot growth chart : to look for
macrosomia / large for gestational age.
e. Further management depends on underlying causes.

52
3) Macrosomia / Large for gestational age (LGA)
a. Refer O&G specialist by 36 weeks for assessment and plan of delivery.
b. Discuss regarding possible pregnancy outcomes.
c. For hospital delivery with the team that are trained for shoulder dystocia
management and with caesarean section facility.
d. Risk of prolonged labour / obstructed labour in vaginal delivery.
e. Risk of shoulder dystocia in vaginal delivery.
f. Decision for mode of delivery: vaginal delivery vs caesarean section should
be discussed with the woman.
g. Other risk factors should be taken into account during discussion and
decision making on mode of delivery:
Ø
Ø Previous shoulder dystocia
Ø
Ø Presence of diabetes mellitus in index pregnancy
Ø
Ø Clinical estimated fetal weight (EFW)
Ø
Ø Ultrasound parameters of abdominal circumference and EFW
Ø
Ø Previous pregnancy outcomes
Adapted from:
Edition, June 2020
2. Obstetrics Protocol, O&G Department, Hospital Tuanku Fauziah,, Kangar Perlis
3. Penang State Obstetrics Protocol, 2021

53
Uterus Smaller Than Dates
C7.
1) Overview
a. Diagnosed when symphysio-fundal height (SFH) is less than gestational age.
b. Clinical fundal height (CFH) is an alternative to SFH and it is more practical
to be use. There are some opinion that clinical fundal height is based on
landmarks and less affected by height and weight.
c. Need to determine the patient’s date accurately.
d. Identify women with risk factors.
e. Possible causes:
Ø
Ø Wrong date
Ø
Ø Oligohydramnios/ Anhydramnios
Ø
Ø Small for gestational age/ fetal growth restriction
f. Optimize modifiable preconception risk factors: eg stop smoking /
substance abuse, aim for good control of hypertension/DM.
2) Management
a. Abdomen palpation to estimate liquor volume and estimated fetal weight.
b. Ultrasound examination to measure fetal biometry, liquor volume.
c. Plot growth chart with the serial scan findings.
d. Further management depends on underlying causes
3) Small for Gestational Age (SGA)
a. Defined as fetal abdominal circumference (AC) or estimated fetal weight
(EFW) <10th
centile.
b. Heterogeneous group comprising fetuses that have failed to achieve the
growth potential and fetuses that are constitutionally small.
c. Can be categorised according to:
Ø
Ø Normal SGA: No structural anomalies, with normal liquor, normal
umbilical artery doppler waveform and normal growth velocity.
Ø
Ø Fetal growth restriction (FGR): majority are due to placental insufficiency.
(other causes: Structural anomalies, chromosomal & other genetic
anomalies; intrauterine infections).
d. Risk factors and possible causes are shown in next table.

54
Maternal risk factors Fetal causes PLACENTAL CAUSES
i. Nutrition - anorexic mothers, low
booking BMI.
ii. Smoking
iii. Alcohol and drugs abuse
iv. Maternal therapeutic drug
administration - beta blockers,
anticonvulsants
v. Maternal diseases – cardiorespiratory
compromised, sickle cell diseases,
diabetic complicated with
microvascular diseases, chronic
hypertension with renal impairment
vi. Advanced maternal age
vii. VF pregnancy
i. Chromosomal
/ other genetic
anomaly i.e.
trisomy 18
i. Structural
anomalies i.e.
Major cardiac
defects
i. Intrauterine fetal
infections
i. Placenta mosaicism
– chromosomes 16
and 22 (reduced
placenta bulk
and placenta
dysfunction
ii. Placental
insufficiency i.e.
pre-eclampsia,
connective tissue
disease
e. Detection: by abdominal palpation and measurement of clinical fundal
height that showed uterus smaller than date.
f. Ultrasound biometry:
Ø
Ø Abdominal circumference (AC) and estimated fetal weight (EFW) are the
most accurate diagnostic measurements to predict SGA.
Ø
Ø Comparison of the head and abdominal circumference will indicate
whether the fetus is symmetrically or asymmetrically small.
g. Ultrasound doppler (to detect placental insufficiency):
Ø
Ø Umbilical artery doppler studies correlate well with the risk of fetal
hypoxia.
Ø
Ø In high risk pregnancies with absent end diastolic flow (AEDF), 80% of
fetuses will be hypoxic and 46% will be acidaemic.
h. Management:
Ø
Ø Ultrasound anatomical assessment of small fetuses to look for structural
anomalies.
Ø
Ø For chromosomal study if indicated.
Ø
Ø Blood investigation: e.g. TORCHES if suspected intrauterine infections.
i. Normal SGA fetus:
Ø
Ø Conservative management by fetal surveillance with fortnightly
monitoring.
Ø
Ø Fetal assessment includes biometry, umbilical artery doppler waveform
and liquor volume.
Ø
Ø Role of CTG: unclear
Ø
Ø For delivery if there’s evidence of fetal compromise.
Ø
Ø Consider labour induction by 39 to 40 weeks.

55
j. Growth-restricted fetus:
Ø
Ø Between 28-32 weeks: with reverse end diastolic flow or absent
end diastolic flow to admit for CTG, +/- BPP, +/- venous doppler
(frequency will depend on severity of fetal growth restriction), antenatal
steroids, neuroprotection with magnesium sulfate. Consider delivery if
pathological CTG or abnormal BPP.
Ø
Ø In most cases, this will require in-patient management.
Ø
Ø If > 32 weeks with absent or reverse end diastolic flow, for delivery.
Ø
Ø If normal end diastolic flow, consider delaying delivery until at least 37
weeks, provided other surveillance findings are normal.
Ø
Ø Timing of delivery: balancing the risk of continuing pregnancy against
risk of prematurity.
Ø
Ø Delivery timing to be decided by senior O&G specialist / MFM
specialist.
Ø
Ø Delivery in hospital with neonatal expertise and facilities.
Adapted from:
Edition, June 2020
Reference:
1. Royal College of Obstetricians and Gynaecologists. The Investigation and Management
of the Small-for-Gestational-Age Fetus. Green-top Guideline No.31. London: ROCG;
2014

56
Abnormal and Unstable Lie at Term
C8.
1) Overview
a. Lie: Relationship between long axis of fetus and long axis of uterus / in
relation to maternal spine.
b. Abnormal Lie: Transverse, Oblique or Unstable
c. Spontaneous version to longitudinal lie occurs in 80-85% of women.
d. Underlying causes:
Ø
Ø High parity
Ø
Ø Pendulous abdomen
Ø
Ø Uterine abnormalities (eg. bicornuate uterus or fibroids)
Ø
Ø Pelvic inlet contracture and/or fetal macrosomia
Ø
Ø Polyhydramnios
Ø
Ø Placenta praevia
Ø
Ø Fetal anomaly (eg hydrocephalus)
Ø
Ø Wrong date / prematurity
Ø
e. Complications:
Ø
Ø Cord presentation or prolapse if membrane ruptures at labour onset
leading to fetal hypoxia
Ø
Ø Obstructed labour leading to uterine rupture
2) Management
a. Confirm that the gestational age and dates are correct.
b. Look for underlying causes or associated contributing factors mentioned.
c. Abdominal palpation to confirm the lie and assess for polyhydramnios.
d. Ultrasonography to confirm the lie, fetal back direction, liquor volume,
estimated fetal weight and to exclude causes.
e. Inform women of need for prompt admission to hospital if membranes
rupture or when labour symptoms present.
f. Hospital admission from 37-38 weeks to observe lie if logistic issues.
g. If unstable lie, for elective caesarean section at 39-40 weeks of gestation.
h. If reverts to longitudinal lie with cephalic presentation, option of induction
or discharge and weekly follow-up.
i. Immediate clinical assessment if membranes rupture or signs of labour.
j. May consider attempting an external version to cephalic presentation for
immediate delivery/stabilizing induction if indicated.

57
Adapted from:
Flowchart 10: Management of abnormal lie at term

58
Breech Presentation
C9.
1) Overview
a. Breech presentation occurs when the fetal buttocks or lower extremities
present into the maternal pelvis.
b. The incidence of breech presentation decreases with gestational age, from
about 20% at 28 weeks to 3-4% at term.
c. It is imperative to exclude prematurity and wrong dates before attempting
ECV or elective caesarean section.
d. There are 3 types of breech presentation: frank/extended, flexed/complete
and footling.
2) Management
a. Evaluate for the associated factors:
Ø
Ø Prematurity
Ø
Ø Placenta Praevia
Ø
Ø Cephalopelvic disproportion
Ø
Ø
Ø Polyhydramnios
Ø
Ø Fetal anomalies (eg hydrocephalus, anencephaly, cystic hygroma)
Ø
Ø Uterine anomalies
Ø
Ø Pelvic tumour
b. Ultrasound assessment:
Ø
Ø To confirm date
Ø
Ø Exclude fetal and uterine anomalies
Ø
Ø Placental localization
Ø
Ø Type of breech
Ø
Ø Exclude hyperextension of neck
Ø
Ø Fetal weight assessment
Ø
Ø Liquor volume
c. Discuss with the patient on the options of management after evaluation and
ultrasound assessment.

59
a. ECV is the transabdominal manipulation of a breech-presenting fetus
into a cephalic presentation.
b. Can be performed any time after 36-37 weeks gestation.
c. It is safe if performed by trained doctors, and the risk of an emergency
caesarean section within 24 hours is approximately 0.5%.
d. Success rates of ECV are 30-80%.
e. Spontaneous reversion to breech presentation after successful ECV
occurs in less than 2-5%.
f. Absolute contraindication:
Ø
Ø Placenta praevia
Ø
Ø Major uterine abnormality
Ø
Ø Ruptured membranes
Ø
Ø Recent antepartum haemorrhage (within 7 days)
Ø
Ø Multiple pregnancy (except for 2nd
twin)
Ø
Ø Abnormal CTG
g. Relative contraindication:
Ø
Ø Uterine scar
Ø
Ø Oligohydramnios
Ø
Ø Fetal growth restriction
Ø
Ø Major fetal anomalies
Ø
Ø Unstable lie
Ø
Ø Severe hypertensive or other medical disorders
h. Before the procedure:
Ø
Ø Obtain written consent
Ø
Ø Documentation of ultrasound findings
Ø
Ø Empty bladder
Ø
Ø Baseline CTG
Ø
Ø IV access – consider IV salbutamol 100μg prior to procedure
i. CTG should be done post-procedure
j. In non-sensitised rhesus negative women, to give IM anti-D
prophylaxis (within 72 hours) and consider a test for fetomaternal
haemorrhage.
k. Possible complications:
Ø
Ø Placental abruption
Ø
Ø Uterine rupture
Ø
Ø Fetomaternal haemorrhage
Ø
Ø Fetal bradycardia
Ø
Ø Non-reactive CTG
Ø
Ø Rupture membrane and cord prolapse
Ø
Ø Preterm labour
3) Management Options
3.1 Option 1: External Cephalic Version (ECV)

60
a. Careful woman selection and availability of skilled birth attendants are
essential.
b. The decision to offer assisted breech delivery should be made by a
specialist.
c. Pre-requisites:
Ø
Ø Appropriate case selection; criteria must be met.
Ø
Ø Birth in a specialist hospital with facilities for immediate caesarean
section.
Ø
Ø Availability of trained/skilled attendants.
Ø
Ø Spontaneous onset of labour (induction of labour in breech must
be specialist/consultant decision).
d. Women and partners should be fully counseled on the risks and
benefits.
e. Contraindications:
Ø
Ø High-risk pregnancy
Ø
Ø Contraindications for vaginal delivery e.g Footling breech
Ø
Ø Hyperextended neck on ultrasound
Ø
Ø Estimated fetal weight <2.5kg or >3.5kg
Ø
Ø Previous uterine scar
Ø
Ø Fetal abnormalities
Ø
Ø Evidence or/suspected fetal compromise eg: FGR
Ø
Ø Cord around neck
Ø
Ø Fetopelvic disproportion e.g hydrocephalus
f. Augmentation is discouraged and if required, only with specialist
approval.
g. Intrapartum monitoring as per usual and progress of labour should be
similar to cephalic presentation.
h. Possible complications:
Ø
Ø Head entrapment after delivery of the body
Ø
Ø Birth asphyxia (due to cord compression and head entrapment)
Ø
Ø Cervical spine and basal skull injuries
Ø
Ø Dislocation and bone fractures (eg humerus, clavicle, femur)
Ø
Ø Intracranial haemorrhage (secondary to sudden decompression of
fetal head)
Ø
Ø Nerve injuries (brachial and cervical plexus injury)
Ø
Ø Intra abdominal injury (liver and spleen injury)
i. Refer to “Section E: Breech Delivery” for methods of Assisted Breech
Vaginal Delivery
3.2 Option 2: Assisted Vaginal Breech Delivery

61
a. This option is considered if ECV is contraindicated, failed or declined
by the woman, and vaginal breech delivery is not an option.
b. Elective caesarean section appointment should be between 38-39
weeks if no other obstetric indication.
3.3 Option 3: Elective Caesarean Section
Adapted from:
Edition, June 2020
Reference:
1. External Cephalic Version and Reducing the Incidence of Term Breech Presentation.
BJOG, 2017.
2. Royal College of Obstetricians and Gynaecologists. Management of Breech
Presentation. Green-top Guideline No.20b. London: ROCG; 2017

62
Postdate Pregnancy
C10.
1) Overview
a. Post-date pregnancy is defined as pregnancy beyond 40 completed weeks.
b. Stillbirth rate steadily rises with gestational age and postdate pregnancy are
associated with higher perinatal morbidity & mortality.
c. Physiological changes in a post-date pregnancy:
Ø
Ø Placental changes: Senescence/aging, infarct and calcification
Ø
Ø Amniotic fluid changes: Oligohydramnios (linked to diminished fetal
urination), presence of meconium
Ø
Ø Fetal changes: Intrauterine malnutrition, macrosomia / LGA
2) Management
a. Ensure the patient’s dates are correct.
b. Determine patient’s last normal menstrual pattern, last childbirth,
contraceptive usage, date of urinary pregnancy test and date of early scan.
c. Determine patient’s uterine size, liquor volume clinically.
d. Consider ultrasound for liquor volume assessment where possible.
e. If sure of dates and no risk factors or acute fetal/maternal compromise, offer
induction of labour at EDD + 7 days.
f. If risk factors present (eg bad obstetric history, SGA, reduce liquor,
subfertility etc), for labour induction.

63
Flowchart 11: Management of post date
Adapted from:
Refer Section E for Induction of Labour

64
Vaginal Birth After Caesarean Section (VBAC)
C11.
1) Overview
a. Planned VBAC is appropriate and may be offered to the majority of women
with a singleton pregnancy of cephalic presentation at 37 completed
weeks or beyond who have had a single previous lower segment caesarean
delivery, with or without history of vaginal birth.
b. Success rate of planned VBAC is 72-75%.
c. Women with one or more previous vaginal birth, particularly previous VBAC,
is associated with a planned VBAC success rate of 85-90%.
d. Planned VBAC is contraindicated in women with previous uterine rupture
or classical caesarean scar and in women who have other absolute
contraindications to vaginal birth.
e. Trial of scar should only be carried out in hospitals with O&G specialists.
f. Planned VBAC is associated with an approximately 1 in 200 (0.5%) risk of
uterine rupture.
2) Management
a. All women with a previous caesarean section should be assessed
thoroughly during the antenatal period.
b. Previous caesarean section operative notes should be reviewed and
documented.
c. Determine as accurately as possible the indication and any complications of
the previous caesarean section.
d. In women with complicated uterine scars, caution should be exercised
and decisions should be made on a case-by-case basis by a specialist with
access to the details of previous surgery.
e. Be certain of gestation age. Routine dating scan is recommended.
f. Counseling checklist should be used during decision of VBAC / repeat
caesarean section. A patient information leaflet should be provided with the
consultation.
g. Assess the risk in current pregnancy before counseling.
h. Counsel and decide mode of delivery around 34-36 weeks depending on
risk factors as well as woman’s preference.
i. Antenatal counseling of women with a previous caesarean birth should be
documented in the notes.

65
3) Induction of labour
a. Women should be counseled regarding risk of scar rupture with different
methods of labour induction.
b. Decision of labour induction should be made by an O & G specialist.
c. Mechanical methods of induction have been found to be effective and
associated with lower risk of scar rupture as compared to medical induction.
d. Use of prostaglandins is still acceptable but it can increase the risk of
uterine rupture by 2 fold.
e. Selection of cases for prostaglandin induction should be decided only by an
O & G specialist / consultant.
f. Suggest for more frequent CTG monitoring for induction with prostaglandin
in women with previous scar.
j. Absolute/Relative contraindications for VBAC:
Ø
Ø 2 or more previous caesarean section
Ø
Ø Previous classical or upper segment uterine incision
Ø
Ø Previous cornual pregnancy
Ø
Ø Previous extensive tear in or extended uterine incision involving upper
segment (eg J incision, T-inversion etc)
Ø
Ø Previous myomectomy with uterine cavity breached
Ø
Ø History of Uterine rupture
Ø
Ø Patient refused trial of scars
Ø
Ø Non-cephalic presentation
Ø
Ø Multiple pregnancies
Ø
Ø Macrosomia / LGA
Ø
Ø Interdelivery interval of < 12 months
Ø
Ø With absolute contraindication for vaginal delivery eg placenta previa

66
4) Intrapartum management (in active phase of labour)
a. Keep Nil by mouth with intravenous hydration.
b. Hourly vital signs monitoring (half hourly pulse rate monitoring)
c. Functioning large bore cannula in-situ
d. Send blood for FBC + GSH/GXM
e. Continuous CTG monitoring
f. Epidural analgesia if available
g. Increasing requirement for pain relief in labour should raise awareness of
possibility of scar dehiscence or impending uterine rupture
h. Judicious use of oxytocin augmentation if indicated and discussion with
specialist is required
i. Oxytocin augmentation preferably be given via infusion pump
j. Early consideration of caesarean section if no significant progress after 6-8
hours of labour
k. Monitor for signs of uterine rupture / dehiscence:
Ø
Ø Maternal pulse > 100 bpm
Ø
Ø Maternal BP < 100/60 mmHg
Ø
Ø Abnormal CTG
Ø
Ø Persistent suprapubic pain/abdominal pain even in between contractions
Ø
Ø Haematuria
Ø
Ø Increase PV bleeding
Ø
Ø Loss of station of presenting part
Adapted from:
Edition, June 2020.
Reference:
1. Royal College of Obstetricians and Gynaecologists. Birth After Previous Caesarean Birth.
Green-top Guideline No.45. London: ROCG; 2015.

67
Reduced Fetal Movement
C12.
1) Overview
a. Perceived fetal movements are defined as the maternal sensation of any
discrete kick, flutter, swish or roll.
b. Most women are aware of fetal movements by 18-20 weeks of gestation
(Quickening).
c. In primiparity, quickening is perceived around 20 weeks; in multiparity, as
early as 16 weeks.
d. It is important to educate women to record fetal movement in daily fetal
movement charts.
e. Women should be advised to be aware of their baby’s individual pattern of
movements.
f. Consider reduce fetal movement if:
Ø
Ø <10 fetal movement / day
Ø
Ø Progressively longer in a day to reach 10 kicks
Ø
Ø No movement in 2 hours
Ø
Ø Any subjective feeling of reduced fetal movement including strength
and frequency of fetal movement
*No clear consensus on what constitutes a definition of reduced fetal
movement, criteria above may be use.
2) Management
a. Review history of patients.
b. Check for current obstetric risk factor eg. fetal growth restriction,
fetal anomaly, Hypertensive disorder, Gestational Diabetes or other
complications.
c. Review past obstetric history particularly in regards to previous intrauterine
death/stillbirth or medical disorders.
d. Perform physical examination. Check vital signs, symphysio-fundal height,
clinical liquor volume and estimated fetal weight.
e. Check and document fetal heartbeat by daptone or ultrasound.

68
f. Fetal heart assessment using Daptone after 24 weeks of gestation (over 1
minute):
Ø
Ø Normal: FHR 110-160 bpm
Ø
Ø Abnormal: Absent, Irregular, Bradycardia (FHR <110 bpm), Tachycardia
(FHR >160 bpm).
g. Perform ultrasound to check biometry measurement, locate and show to
mother the fetal heart activity, liquor volume and UA doppler (if indicated).
h. CTG should be done if pregnancy is over 28 weeks of gestation.
i. If CTG normal, to admit for CTG monitoring and further evaluation if risk
factors are present.
j. If CTG is suspicious/pathological with the presence of any risk factor,
consult a specialist for decision of delivery.
k. Delivery timing as per obstetric indication. Refer to section E: Induction &
Augmentation of labour.
Adapted from:
Edition, June 2020
Reference:
1. Royal College of Obstetricians and Gynaecologists. Reduced Fetal Movement. Green-
top Guideline No.57. London: ROCG; 2011

69
Intrauterine Fetal Death (IUFD)
C13.
1) Overview
a. Intrauterine fetal death refers to fetuses with no signs of life in-utero after 22
weeks of pregnancy or weight of > 500gm if uncertain gestational age.
b. It is known to occur in 1 in 200 babies.
c. Intrauterine death is often a traumatic and emotional event for the parents
and family.
d. The diagnosis of intrauterine death should be confirmed by 2 doctors
independently before informing the woman in a sensitive manner.
e. Events leading to or related to IUFD must be documented clearly.
f. Possible causes:
Ø
Ø Maternal: Diabetes Mellitus, Hypertension, Septicaemia
Ø
Ø Fetal malformation
Ø
Ø Infections
Ø
Ø Immune disorders eg. Rh incompatibility, connective tissue disorder
Ø
Ø Cord accident
Ø
Ø Placental insufficiency, abruption
Ø
Ø Twin-to twin transfusion
Ø
Ø Fetal maternal haemorrhage etc
2) Investigations
a. Ultrasound features in intrauterine death:
Ø
Ø Absence of fetal heart activity
Ø
Ø Non-pulsatile aorta
Ø
Ø Spalding sign – irregular overlapping of skull bones
Ø
Ø Robert’s sign – appearance of gas shadow in heart chambers and great
vessels
Ø
Ø Absence of fetal movement

70
b. Maternal blood investigations:
Ø
Ø FBC/ BUSE/Creatinine/ LFT/ Coagulation profile
Ø
Ø Blood & Rhesus group (if unknown)
Ø
Ø VDRL
Ø
Ø TORCHES (if hydrops)
Ø
Ø Kleihauer-Betke test (to detect possibility of large feto-maternal
Ø
Ø haemorrhage)
Ø
Ø Lupus anticoagulant and anticardiolipin antibodies (6 weeks post
delivery)
Ø
Ø HbA1c
c. Tests should be directed to identify scientifically proven causes of
intrauterine fetal death.
d. Offer surgical post-mortem examination of the fetus. (Counseling should
only be done by specialist/consultant as this is a sensitive issue in our
community)
e. Consider photographic documentation of all fetuses with dysmorphism.
This should be done after obtaining parental consent
f. “Babygram” only in the presence of structural/skeletal deformities
g. Karyotype when indicated
h. Fetal intracardiac blood can be taken if needed for further investigations i.e.
viral serology, karyotyping, Full blood picture
i. Placental Swab C&S
j. Placental tissue for histopathological examination
k. Parental consent must be obtained before taking any samples or
performing any invasive procedure on the fetus and documented clearly in
the case notes

71
3) Management
a. Need to exclude life threatening condition such as placenta abruption,
chorioamnionitis, scar dehiscence and severe pre-eclampsia
b. Mode of delivery: aim for vaginal delivery
c. Screen for DIVC before induction of labour
d. Induction of labour as for viable pregnancy
e. Send investigations as mentioned
f. Third stage of labour – to watchout for PPH
g. Consider antibiotic, eg if suspected infection
h. Detailed examination of fetus should be performed and documented
clearly by the managing medical officer/specialist
i. Detailed examination of placental and umbilical cord should be performed
and documented clearly too
j. Offer woman the option of isolation room/single room after delivery if
available, consider transfer to gynecology ward instead of usual postnatal
ward
k. Suppression of lactation with Tab Cabergoline 1mg on the first day after
delivery
l. Offer bereavement counseling prior to discharge
4) Follow-up
a. During follow-up, all investigation results should be available.
b. Patients should be informed of the findings and subsequent plan in her next
pregnancy and prevent measures if any.
c. If chromosomal or structural abnormality, need to counsel regarding risk of
recurrence.

72
Flowchart 12: Management of Intrauterine Fetal Death
Adapted from:
Edition, June 2020.
2. Obstetrics Protocol, O&G Department, Hospital Tuanku Fauziah, Kangar Perlis.
Reference:
1. Royal College of Obstetricians and Gynaecologists. Late Intrauterine Fetal Death and
Stillbirth. Green-top Guideline No.55. London: ROCG; 2010.

73
Selected Medical
Disorders in Pregnancy
D
SECTION

74
Anemia in Pregnancy
D1.
1) Overview
a. About a 1/3 of pregnant Malaysian women have anemia in pregnancy, of
which the majority are due to iron deficiency anemia (IDA).
b. Presumptive diagnosis of IDA is therefore reasonable and iron
supplementation can be started, with an expected rise of Hb of >1g/dL in
two weeks.
c. Conventionally, 30-100mg/day of elemental iron has been suggested
as prophylaxis and 100-200mg/day for treatment. However, recent data
suggests lower doses of 40-80 mg/day have a similar effect to higher doses.
d. Iron supplement should be taken on an empty stomach and in the morning,
where hepcidin levels are lowest.
Definition of anemia by trimester Definition of anemia by severity
1st
trimester <11.0 g/dL Mild 9-11 g/dL
2nd
& 3rd
trimester <10.5 g/dL Moderate 7-9 g/dL
Postpartum <10.0 g/dL Severe <7 g/dL
Forms of oral iron preparation
(mg/tablet) (mg) (%)
Ferrous fumarate 90 mg (Obimin) 30 33
Ferrous fumarate 350 mg (Zincofer) 115 33
Ferrous sulfate 525 mg (Iberet) 105 20
Ferrous gluconate 250 mg (Sangobion) 30 12
Iron polymaltose 370 mg (Maltofer) 100 27
Elemental iron content

75
Hb Body weight 35-<70 kg ≥ 70kg
< 10g/dL 1500mg 2000mg
10g/dL or more 1000mg 1500mg
2) Indications for parenteral iron therapy
a. Unable to tolerate oral iron or non-compliance (ex. complex patient factors).
b. Approaching term with insufficient time for oral iron to be effective (ex.
moderate IDA beyond 34 weeks gestation.
c. IDA should be confirmed by a serum ferritin < 15 ng/ml prior to parenteral
use.
d. Total iron deficit can be estimated via the Ganzoni formula or using the
simplified method (Dignass 2015).
3) Ganzoni formula
a. Total iron deficit (mg)= {body weight (kg) x [target-actual Hb (g/L)]} x
0.24+iron depot (500mg)
Simplified method for calculation of iron deficit
Source: UK guidelines on the management of iron deficiency anemia in pregnancy 2019
b. Recombinant human erythropoietin (rhEPO) should not be routinely used
beyond the context of anemia associated with end-stage renal disease.
c. When indicated, mothers can be reassured that (rhEPO) has a high
molecular weight and does not cross the placenta.
4) Other causes of anemia other than IDA
a. Thalassemia is one of the most common causes of anemia in pregnancy. An
estimated 6.8% of Malaysians are carriers, with HbE/beta Thalassemia and beta
thalassemia major the most common forms reported in the registry.

76
5) Intrapartum considerations
a. Delivery in tertiary centres with adequate blood bank support
b. Group, screen and hold
c. Ensuring IV access available
d. Active management of third stage
6) Postpartum considerations
a. In selected cases where there is no active bleeding, cardiac compromise
or significant symptoms, parenteral iron may be considered in place of
transfusion.
b. Women with IDA require 40-80 mg/day of elemental iron for 3 months.
b. Hb Electrophoresis to exclude beta Thalassemia if MCH<27 pg/cell or
Mentzer index (MCV/RBC) <13.
c. Hb DNA analysis is required to confirm suspicion of alpha Thalassemia
d. Stool for ova/cyst to exclude hookworm infection.
e. Peripheral blood film to exclude red cell membrane disorders such as
Southeast Asian Ovalocytosis (SAO) which is inherited in an autosomal
dominant manner. It is also helpful where there is suspicion of haemolytic
conditions or where there is coexistent bicytopenia or pancytopenia.
f. The patient’s partner should be screened if thalassemia or SAO is
diagnosed.
Low MCV (<80fL) Normal MCV (80-100fL) High MCV (>100fL)
Thalassemia
Hookworm infection
Anemia of chronic ds
Sideroblastic anemia
Lead poisoning
Acute haemorrhage
Autoimmune haemolytic
Thyroid diseases
Marrow suppression
Hereditary spherocytosis
Paroxysmal nocturnal
haemoglobinuria
Anemia of chronic disease
Folate deficiency
B12 deficiency
Drug-induced
(Zidovudine)
Acute
myelodysplastic
syndrome
Adapted from:
Edition, 2020.
Reference:
1. UK guidelines on the management of anemia in pregnancy 2019.

77
Hypertensive Disorders in Pregnancy
D2.
1) Overview
a. The definition and classification of hypertensive disorders in pregnancy
(HDP) can be found elsewhere and will not be repeated. However, two
conditions, white-coat hypertension and masked hypertension may be
worth mentioning.
b. White-coat HPT does not require treatment unless BP in the clinic exceeds
160/110 mmHg. Women are at higher risk of developing gestational HPT
and preeclampsia than normotensive women.
c. Masked HPT occurs when clinic BP is normal but raised when measured at
home. This should be sought when women present with unexplained end
organ damage such as retinopathy or left ventricular hypertrophy.
2) Management of non-severe hypertension
a. WHO recommends either labetalol or methyldopa as first line agents.
b. Maintain BP control between 110-140/80-85mmHg (ISSHP suggests to
focus on the diastolic BP, keeping it below 85mmHg). A tighter BP control
has been shown to reduce the risk of severe HPT and possibly, preterm
birth.
Severity Management
Mild
140-149/
90-99mmhg
Ø
Ø Consider starting anti-HPT if persistent
Ø
Ø Outpatient management with BP monitoring 2x/week
Ø
Ø Serial fetal growth monitoring 4-6 weekly
Ø
Ø -onsider delivery at 37-40 weeks
Moderate
150-159/
100-110mmhg
Ø
Ø Start anti-HPT
Ø
Ø Inpatient stabilization of BP may be required
Ø
Ø Shared care between hospital and health clinics
Ø
Ø Serial fetal growth monitoring 4-6 weekly
Ø
Ø Consider delivery at 37 weeks if preeclampsia develops

78
3) Management of severe hypertension
Flowchart 13: Management of severe hypertension
a. Inpatient stabilization of BP is recommended.
b. Initial BP goal is to achieve systolic BP<150mmHg and diastolic 80-
100mmHg rather than rapid normalization of BP to avoid placental
hypoperfusion.
c. Consider MgS04
if severe HPT with concomitant preeclampsia.
d. Continuous fetal monitoring.
e. Delivery should be considered in the term fetus once BP stabilizes.
f. If BP normalizes, fetal growth should be monitored 2-4 weekly.

79
4) Preeclampsia (PET)
a. Can arise de novo or in 25% of women with underlying chronic HPT
b. Diagnosed when there is gestational hypertension with new-onset of one or
more of the following features, after 20 weeks of gestation:
New onset of Description
Significant
proteinuria
24-hour urine protein of ≥ 300 mg/day or urine protein/
creatinine ratio of ≥ 30 mg/mmol
End organ
dysfunction
Maternal
-acute kidney injury (creatinine > 90 umol/L)
-liver involvement (AST/ALT > 40 IU/L)
-neurological complications (eclampsia, altered mental
status, blindness, stroke, clonus, severe headaches,
persistent visual scotomata)
-haematological complications (thrombocytopenia, DIC,
hemolysis)
Uteroplacental
-Fetal growth restriction, abnormal umbilical artery
waveform analysis or stillbirth
*PET is diagnosed even in the absence of proteinuria, once new-onset end organ
dysfunction is present
c. Admit at the point of diagnosis and perform FBC, LFT, renal profile.
Coagulation profile and LDH are not routine unless there is concomitant
thrombocytopenia or if haemolysis is suspected.
d. MgS04
is indicated in the event of PET with severe hypertension and either:
Ø
Ø difficult BP control, or
Ø
Ø biochemical derangement, or
Ø
Ø complication of PET such as pulmonary oedema, HELLP or abruption
e. MgS04
is also indicated for fetal neuroprotection if delivery is expedited
prior to 30 weeks of gestation.
f. There is no rationale to “run dry” a preeclamptic woman as she is already at
risk of acute kidney injury (AKI).
g. On the other hand, excessive use of intravenous fluids can lead to acute
pulmonary oedema.

80
h. To ensure euvolemia, insensible losses should be replaced (30 mL/h) along
with anticipated urinary losses (0.5–1 mL/kg per hour). In averaged sized
women, this is approximately 60–80 mL/h.
i. Diuretics should not be used in oliguric women unless there is evidence of
pulmonary oedema.
j. Time of delivery:
*Management of eclampsia will be covered under Section E: Obstetric emergencies and
MgS04
regimen can be found in the Appendix
Total fluid replacement in fasting patients =
Urine output + insensible losses (30ml/hr)
Delivery in women with PET should be considered if she develops either
one of below:
Ø
Ø Recurrent episodes of severe hypertension despite maintenance with 3
anti-HPT
Ø
Ø Progressive thrombocytopenia, abnormal renal profile or AST/ALT
Ø
Ø Acute pulmonary oedema
Ø
Ø Neurological complications such as severe intractable headache,
repeated scotoma or convulsions *
Ø
Ø Non-reassuring fetal status
≥37+0
weeks Delivery indicated regardless of symptoms.
34 to 36+6
weeks
Delivery may be indicated as decided by the specialist.
Antenatal corticosteroids may be considered in the event
of pre labour caesarean section.
<34 weeks Delivery may be indicated as decided by the specialist.
Antenatal corticosteroids should be given.
5) Postpartum considerations
a. Labetalol, nifedipine, hydralazine, amlodipine, atenolol, metoprolol,
captopril and enalapril can be used in breastfeeding.
b. Methyldopa should be avoided due to risks of postpartum depression.
c. VTE assessment and contraception advice.
d. Women should be educated on the role of PET prophylaxis in subsequent
pregnancies and the long- term cardiovascular risk.

81
6) Prevention of preeclampsia
a. Use of low-dose aspirin can reduce the risk of preterm preeclampsia by over
62% when started prior to 16 weeks of gestation.
b. Women with risk factors should be started on 150mg aspirin/night (wt
>40kg) or 100mg/night (wt<40kg) at 11-14 weeks until 36 weeks or when
PET develops.
c. Calcium carbonate 1g BD can also be started by 20 weeks of gestation
as our population has a presumptively low calcium intake. Calcium
supplementation reduces the risk of both preterm and term preeclampsia.
Major
- HPT ds in previous pregnancies
- Chronic HPT
- Chronic renal ds
- Autoimmune ds like SLE or APS
- Type 1 or 2 diabetes
Minor
- Primigravida
- Birth interval > 10 years
- Multiple pregnancies
- Family history of PET
- Age ≥ 40 years
- BMI ≥30kg/m2
Start aspirin and calcium carbonate if
≥1 major or ≥2 minor risk factor (NICE)
*First trimester PET screening using maternal characteristics, mean uterine artery PI &
PAPP-A/PlGF has a higher detection rate than NICE (82% vs 41%). First trimester PET
screening can be offered, where available
Adapted from:
Reference:
1. Garovic et al. Hypertension in pregnancy: a scientific statement from the American Heart
Association. Hypertension. 2022;79:e21–e41.
2. ISSHP classification, diagnosis & management recommendations for international
practice 2018.
3. Magee LA, von Dadelszen P et al. Management of Hypertension in Preg.4. Maternal-
Fetal Medicine 3(2):p 124-135, April 2021.

82
Diabetes Mellitus in Pregnancy
D3.
1) Overview
a. Universal screening for gestational diabetes mellitus (GDM) is
recommended in the Malaysian Clinical Practice Guideline 2017 (CPG) as
shown below:
Flowchart 14: Screening for GDM

83
2) Frequency of blood sugar monitoring
- body mass index >27 kg/m2
- previous history of GDM
- first degree relative with DM
- history of macrosomia > 4kg
- bad obstetric history
- glycosuria ≥ 2+ on two occasions
- current obstetric risk factors
(essential HPT, pregnancy-induced
HPT, polyhydramnios, current use of
corticosteroids)
Diet/OHA/Single dose
insulin
Fasting glucose & postprandial glucose till target
achieved. Repeat at intervals 1-2 weeks thereafter.
Multiple dose insulin GDM: 2-3X/day, 2-3 days a week
Pregestational: 3x/day, daily
**Risk factors
b. Overt DM is diagnosed when the FPG is ≥ 7.0mmol/L or 2-HPP ≥11.0
mmol/L.
c. Further screening for GDM beyond the 24-28 week period is not
recommended. Women diagnosed “late” do not have higher diabetes-
related adverse outcomes but have increased elective caesarean rates
(Shindo 2021).
d. Target for blood sugar profile are: fasting 4.0-5.3mmol/L and 2-HPP
4.0-6.7mmol/L.
e. If blood glucose targets are not met with diet and exercise changes within 1
to 2 weeks, offer metformin or insulin.
f. The Malaysian CPG (2017) recommends metformin as the first line
treatment, although ADA (2022) recommends insulin instead, due to long-
term childhood metabolic concerns from more recent studies.
g. 50% of women on metformin may still require insulin to optimize blood
sugar.
h. Fetal growth should be monitored in women on metformin due to risks of
small for gestational age (SGA).
i. Metformin should not be used to prevent gestational DM, even in high risk
women (ex. Obesity, PCOS)
*Refer CPG Management of Diabetes in Pregnancy 2017 for more details.

84
3) Overview of management
Trimester Gestational DM Pregestational or overt DM
1st
Trimester
OR
at booking
• Dietary advice
+/- diabetic
educator
• Confirm
viability and
EDD
• Refer dietician, diabetic educator
• Review blood sugar profile, medications,
including anti-HPT and statins
• Start insulin therapy if indicated
• HbA1c, retinopathy screening, serum
creatinine
• Consider VTE prophylaxis if proteinuria
in nephrotic range
• Aspirin 150 mg ON
• Shared care with FMS
• First trimester screening where available.
2nd
-3rd
trimester
• Repeat
mOGTT
24-28 weeks
in women
with risk
factors (and
previously
normal
mOGTT)
• Refer antenatal diabetic clinic if poor
control
• Start calcium carbonate 1g BD
• Repeat retinopathy screening each
trimester
• Anomaly screening 18-22weeks.
• Monthly growth scans from 26-28 weeks onwards
• Discuss mode and timing of delivery
• Refer anaesthetist if necessary.

85
Trimester Gestational DM Pregestational or overt DM
Timing of
delivery
• GDM good
control
• GDM/Pre-
existing DM
on treatment
• Poorly-
controlled
GDM/pre-
existing DM
with maternal
or fetal
complications
• 40+0
to 40+6
weeks
• 37+0
to 38+6
weeks
• Consider delivery even prior to 37+0
weeks
4) Intrapartum insulin monitoring
a. Blood sugar should be monitored 4 hourly in women with GDM on diet
control, 1-2 hourly in women with Type 2 DM/GDM on treatment. The aim
is to keep blood sugar 4.0-7.0mmol/L.
b. Women with Type 1 diabetes or when blood glucose is >7.0mmol/L should
be started on insulin infusion as below and monitored hourly.
Where antenatal corticosteroids are indicated, IM
Dexamethasone 6 mg twice daily x 4 doses with close
monitoring of blood sugar is suggested. Temporary
use of metformin and insulin may be considered during
the hypergylcaemic effect. Sliding scale while receiving
dexamethasone is also acceptable.

86
Flowchart 15: Insulin infusion

87
Although tight intrapartum glucose control (4.0-7.0 mmol/L) is recommended
by the CPG and NICE guidelines, the authors are aware of the recent
recommendations suggesting that a “less tight” or pragmatic glycaemic targets
(5.0-8.0 mmol/L) be used. The advantage of a pragmatic target includes less use
of IV insulin infusions and staffing burden, more maternal mobility and less risk of
maternal hypoglycaemia.
5) Postpartum
a. Women with GDM on insulin should discontinue insulin immediately after
delivery. Fasting, premeal and pre-bed blood glucose should be monitored.
b. Women with overt or preexisting DM should reduce their insulin by 1/2
to 2/3 and monitor blood sugar to establish optimal dose (may refer to
endocrinologist if service is available).
c. Breastfeeding further reduces the insulin requirement and lowers the risk of
developing diabetes.
d. OGTT should be repeated 6 weeks postpartum in women with GDM.
Reference:
1. CPG Management of Diabetes in Pregnancy 2017.
2. American Diabetes Association. Management of Diabetes in Pregnancy: Standards of
Medical Care in Diabetes 2022.
3. Shindo R, et al. Impact of gestational diabetes mellitus diagnosed during the third
trimester on pregnancy outcomes: a case-control study. BMC Pregnancy Childbirth.
2021 Mar 24;21(1):246.
4. Joint British Diabetes Societies for inpatient care. Managing diabetes and
hyperglycaemia during labour and birth February 2023.

88
Venous Thromboembolism
D4.
1) Overview
a. Obstetric venous thromboembolism (VTE) is one of the major causes of
maternal deaths. The cause-specific maternal mortality ratio due to VTE
ranged from 2.5 to 4.7 per 100,000 live births between 2012-2016.
b. Prevention of VTE is one of the key pillars in reducing deaths due to VTE
and further details can be found in the National CEMD Training Manual.
2) Diagnosis of venous thromboembolism
Flowchart 16: Approach to VTE.
Source: VTE Training Manual 2018

89
a. Less than 3% of women with pulmonary embolism (PE) would have a pulse
oximetry reading of <90%.
b. ECG may show T-inversion (20%), S1Q3T3 pattern (15%) or right bundle
branch block (18%) in a minority of women with PE.
c. The use of echocardiogram remains undefined in PE, but may show right
ventricular changes (RV) such as RV dysfunction, dilatation or free wall
hypokinesia if performed.
d. D-dimer is not routinely performed. D-dimer levels increase progressively
by 2 to 6-fold in pregnancy, and vary based on different laboratory assays
and analyzers. No useful cut-off values have been found to discriminate
against women with or without VTE in pregnancy.
e. Recommended imaging:

90
3) Treatment options in acute thromboembolism
Hemodynamically stable Hemodynamically unstable
Treatment dose of subcutaneous
LMWH.
(eg; Enoxaparin 1mg/kg BD or
Tinzaparin 175u/kg daily)
No routine monitoring of anti-Xa
activity unless:
1. Extreme of weight
2. Develops new thrombus
3. Renal impairment
(Aim peak anti-Xa levels, 3 hours
post injection of 0.5-1.2u/ml)
1. Heparin infusion
• Loading Dose – 80 units/kg*
• Maintenance – 18 units/kg/hour
• and maintain aPTT 1.5 to 2.5
*Omit loading dose if given
thrombolysis earlier
2. Thrombolysis
3. Thoracotomy / surgical
embolectomy
a. In women with high index of suspicion VTE, LMWH should be started
pending confirmatory testing.
b. Thrombolysis has been associated with a reduction in death and recurrent
PE compared to heparin but its use should be restricted to cases of
hemodynamically unstable women with massive PE due to the fetal and
maternal risks of bleeding.
c. Treatment dose of LMWH should be continued throughout the rest of the
pregnancy and up to 6 weeks postpartum, and until at least 3 months of
treatment has been given in total. This is to reduce the risk of recurrent VTE.
d. Inferior vena cava (IVC) filters may be considered in women with iliac vein
VTE and recurrent pulmonary embolism despite adequate anticoagulation.
4) Intrapartum
a. Treatment dose of LMWH should be discontinued 24 hours prior to
induction or elective caesarean and IV heparin infusion discontinued 6
hours prior, to reduce the risk of regional anaesthesia and bleeding.
b. Women should be advised to stop LMWH if they have per vaginal bleeding
or signs and symptoms of labour and seek immediate medical attention.

91
c. Vaginal delivery is not contraindicated in women who present in
spontaneous labour while on LMWH but regional anaesthesia should be
avoided if this occurs within 24 hours of the last dose of LMWH.
d. Protamine sulfate is usually not required unless women are on subcutaneous
heparin with markedly deranged aPTT.
e. Surgical drains (subrectus or subcutaneous) should be considered
intraoperatively.
f. Interrupted skin closure may facilitate drainage of any haematoma later.
5) Postpartum
a. Women who had a VTE event within 3 months of delivery should be started
on prophylactic dose of LMWH 4-6 hours post delivery. Treatment dose can
be given 12 hours later.
b. Women who had developed VTE late in pregnancy should receive
treatment dose of LMWH postpartum up to 6 weeks and no less than 3
months duration in total.
c. Intermittent pneumatic compression (IPC) devices should not be used in
women with a recently diagnosed DVT due to the uncertain risk of causing
PE.
d. Based on the SOX-trial, graduated compression stockings or
thromboembolic deterrent (TED) stockings are no longer routinely
recommended after DVT to prevent post-thrombotic syndrome. However,
they may be useful in women who are symptomatic.
e. Breastfeeding is not contraindicated in women receiving LMWH or
unfractionated heparin.
f. Combined oral hormonal contraceptives should be avoided.
g. Traditionally depot medroxyprogesterone acetate (DMPA) is considered
safe, but recent data have shown an association between DMPA and
norethindrone use with thromboembolism, patients need to be counseled
about this risk (Cockrum RH 2022)
Reference:
1. National Technical Committee, Confidential Enquiries into Maternal Deaths. Prevention
& Treatment of Thromboembolism in Pregnancy & Puerperium: A Training Manual 2018.
2. Royal College of Obstetricians & Gynaecologists. Green-top Guideline 37b.
Thromboembolic disease in Pregnancy and Puerperium: Acute Management. 2015.

92
Heart Disease in Pregnancy
D5.
1) Overview
a. Most common cause of indirect maternal deaths in Malaysia.
b. Comprises a heterogenous group of disease ranging from congenital
structural, valvular, ischaemic to arrhythmias. Readers are referred to the
MOH CPG on Cardiac disease in pregnancy 2016 and the European Society
of Cardiology (ESC) Guideline on Cardiac disease in pregnancy 2018 for
details of specific diseases. The general principles will be discussed in this
section.
2) Preconception counseling
a. Essential in all women with cardiac diseases. Contraception should be
discussed in women of reproductive age who are not ready to start a family.
b. Review of cardiac medications is imperative and alternatives to medications
which are contraindicated in pregnancy such as ACE inhibitors, Angiotensin
receptor blockers (ARB) and ivabradine should be sought.
c. Maternal risks, fetal outcomes and plans for pregnancy care should be
discussed.
d. Up to date with vaccination, including rubella vaccination and receive pre
pregnancy folic acid and dental review.
3) Cardiac interventions prior to conception
a. Catheter ablation should be considered in women with symptomatic
supraventricular tachycardia (SVT) or ventricular tachycardia (VT).
b. Implantable cardiac devices (ICD) should be considered in women with
arrhythmias and high risk of sudden cardiac death.
c. Prepregnancy intervention is recommended in women with severe mitral
stenosis (MS) or symptomatic severe aortic stenosis (AS).

93
4) Risk stratification
a. The most important predictors of maternal outcomes are the modified
World Health Organization (mWHO) class and functional status of women,
based on the New York Heart Association (NYHA) Classification.
b. Presence of cyanosis, obstructive left heart lesions, mechanical valve
prosthesis use and need for anticoagulation in pregnancy increases the risk
of pregnancy.
c. Non-cardiac risk factors such as obesity , hypertension and diabetes and
obstetric risk factors such as multiple pregnancy also increase the risk of
poor outcomes.
d. Termination of pregnancy may be appropriate in some women and this
should be discussed in a multidisciplinary team (MDT) setting.
5) Modified World Health Organization classification of maternal
cardiovascular risk (adapted from ESC 2018)
mWHO
Class
Risk Cardiac conditions
I
• No detectable
increased risk
of maternal
mortality and no/
mild increase in
morbidity.
• 2.5-5% maternal
cardiac event
rate
• Pulmonary stenosis, patent ductus
arteriosus (PDA), mitral valve prolapse
(uncomplicated, small or mild).
• Successfully repaired atrial septal defect
(ASD), ventricular septal defect (VSD),
PDA, anomalous pulmonary venous
drainage.
• Isolated atrial or ventricular ectopic beats.
II
• Small increased
risk of maternal
mortality or
moderate
increase in
morbidity.
• 5.7-10.5%
maternal cardiac
event rate
• Unoperated ASD/VSD
• Repaired Tetralogy of Fallot
• Most arrhythmias

94
mWHO
Class
Risk Cardiac conditions
II-III
• Between classes
II–III, depending
on the individual.
• 10-19% maternal
cardiac event
rate
• Mild left ventricular impairment (EF >45%)
• Hypertrophic cardiomyopathy
• Native or tissue valvular heart disease not
considered Class I or II
III
• Significantly
increased risk
of maternal
mortality or
severe morbidity.
• Expert
counseling
required.
• 19-27% maternal
cardiac event
rate
• Moderate LV impairment (EF 30-45%)
• Previous peripartum cardiomyopathy
without LV residual impairment
• Mechanical valve
• Systemic right ventricle
• Fontan circulation
• Unrepaired cyanotic heart lesion
• Moderate mitral stenosis (MS)
• Severe asymptomatic aortic stenosis (AS)
• Other complex congenital heart disease
• Aortic dilatation 40–45 mm in Marfan
syndrome or 45–50 mm in bicuspid aortic
valve.
• Ventricular tachycardia
IV
• Pregnancy is
contraindicated
• 40-100%
maternal cardiac
event rate
• Pulmonary arterial hypertension of any
cause.
• Severe LV dysfunction (EF<30%, NYHA
III–IV).
• Previous peripartum cardiomyopathy with
any residual impairment of LV function.
• Severe MS, severe symptomatic AS
• Aortic dilatation >45mm in Marfan
syndrome or >50mm in bicuspid aortic
valve.
• Native severe coarctation of the aorta.
• Fontan circulation with any complication.

95
6) Genetic counseling and fetal assessment
Risk of inheriting cardiac defects increases in the offspring and counseling by a
maternal fetal specialist and geneticist may be useful.
a. Marfan syndrome, hypertrophic cardiomyopathy (HCM) and long QT
syndrome and Holt-Oram are some examples of autosomal dominant (AD)
conditions.
b. 22q.11 deletion and Noonan syndrome are also inherited in an AD manner
but the majority of cases are due to de novo mutation.
c. Genetic counseling is also essential in women with known carrier status
of hereditary pulmonary arterial hypertension (PAH) or pulmonary veno-
occlusive disease.
d. Women with congenital cardiac disease should have detailed anomaly
screening, fetal echocardiography and serial growth scans.
e. First trimester screening, where available, can also increase the index of
suspicion of underlying cardiac disease if the nuchal is thickened.
f. Lesion specific risk of cardiac disease in the offspring is shown in the
following table.
Source: MOH CPG Cardiac disease in pregnancy 2016
7) Lesion specific risk of cardiac disease in the fetus:

96
8) Antenatal care pathway for women with cardiac disease
Flowchart 17: Approach to women with cardiac disease
Modified from MOH CPG Cardiac disease in pregnancy 2016

97
a. Timing of delivery is individualized and depends on the women’s cardiac
status, co-morbidities and fetal well-being.
b. Caesarean section is not routine in all women with cardiac disease but can
be considered in the following conditions:
c. Women with mechanical heart valves who are on warfarin should have a
clear plan of bridging therapy.
d. Antibiotic prophylaxis for endocarditis is not routine and should be reserved
for women with previous infective endocarditis, prosthetic heart valves and
complex congenital cardiac disease (operated or unoperated).
e. Prolonged and difficult labours should be avoided.
f. Epidural anaesthesia is the anaesthesia of choice in labour and should be
titrated carefully to avoid hypotension.
g. Prostaglandin F2α should be avoided.
h. Resuscitative hysterotomy may be required to facilitate resuscitation in the
event of maternal collapse.
• NYHA Class III or IV
• LVEF <30%
• Severe obstructive cardiac lesions
• Severe pulmonary hypertension or
Eisenmenger syndrome
• Marfan’s syndrome Ao root >
45mm
• Acute or chronic aortic
dissection
• On oral anticoagulation within
last 7 days
• Obstetric indications

98
10) Postpartum care
Source: MOH CPG Cardiac disease in pregnancy 2016
Reference:
1. Ministry of Health Malaysia. Clinical Practice Guidelines: Cardiac disease in pregnancy.
2016.
2. European Society of Cardiology (ESC) Guideline: Cardiac disease in pregnancy 2018.

99
Thyroid Disease
D6.
1) Overview
2) Hyperthyroidism
a. Gestational transient thyrotoxicosis (GTT) and Graves’ disease are the most
common causes. New onset thyroid disease is rare in pregnancy.
b. GTT usually only requires supportive treatment for hyperemesis and usually
serum T4 normalizes by 14-18w of gestation. Symptoms may overlap with
Graves’; neither hCG or ultrasound helpful to distinguish the conditions.
c. Presence of thyrotropin receptor antibody (TRAb) is highly suggestive of
Graves’. Anti-thyroid peroxidase antibody (anti-TPO) can be present in both.
Maternal thyroid status FREE T4 TSH
Overt hyperthyroidism Increased Decreased
Subclinical hyperthyroidism Normal limits Decreased
Suspect TSH resistance/assay interference Increased Increased
Overt hypothyroidism Decreased Increased
Subclinical hypothyroidism Normal limits Increased
Secondary hypothyroidism Decreased Decreased
Carbimazole (Cbz) Propylthiouracil (PTU)
Cutis aplasia, abdominal wall
defects, atresia of digestive, urinary
and respiratory (choanal atresia)
tract, ventricular septal defect.
Less severe face and neck malformation
such as preauricular sinus/cysts, urinary
tract defects in boys.
Avoid use in first trimester
Recommended in first trimester if
treatment needed
*Off medications if euthyroid & on low dose (≤10 mg Cbz/day or ≤100 mg PTU/day).
Monitor monthly clinically and TFT.
*Use 1:10 ratio as a guide when switching (ex. 20mg Cbz=200 mg PTU) but divide PTU
into 2-3 doses a day due to shorter half-life

100
d. Joint management by O&G and physician/endocrinologist, aiming to keep
fT4 at the upper limits of normal.
e. Propranolol can be used safely for symptomatic patients and can also
reduce the peripheral effects of thyroid hormone, including conversion of
inactive T4 to T3.
f. TRAb can cross the placenta and cause fetal hyperthyroidism. Women with
raised TRAb >3X upper limit require close fetal monitoring.
g. Retrosternal extension of goiter warrants referral to the anaesthetist
+/-otorhinolaryngologist.
h. Intrapartum obstetric management is generally unchanged.
i. Postpartum antithyroid therapy is continued in doses similar to preceding
pregnancy (may refer to endocrinologist for further management).
Breastfeeding is not contraindicated.
3) Hypothyroidism
a. Hashimoto’s thyroiditis and Graves’ disease are the most common causes in
pregnancy. Post-thyroidectomy /radioactive iodine ablation (RAI) are next.
b. Levothyroxine (LT4) is the treatment of choice and should be taken prior to
breakfast, on an empty stomach to optimize compliance.
c. By 4-6 weeks of gestation, there is progressive increase in LT4 requirement
till about 16-20 weeks. This usually plateaus in the 3rd trimester.
d. Dose increments of 30-50% are expected during pregnancy, esp in post-
RAI.
e. Trimester-specific TSH representative of the Malaysian pregnant population
is the ideal reference range but is currently unavailable.
f. Therefore, the following targets of treatment are recommended:
g. Women with subclinical hypothyroidism (SCH) can be managed as shown
in the chart below. Untreated SCH has been associated with miscarriage,
preterm birth, small for gestational age, preeclampsia and abruption.
Trimester TSH target
Hypothyroidism & planning to conceive
1st
trimester
2nd
and 3rd
trimester
Postpartum
<2.5 mIU/L
<2.5 mIU/L
< 3.0 mIU/L
<4.2 mIU/L
(as per non-pregnant adults)

101
4) Postpartum thyroiditis
a. Occurs in 1-17% of women but up to 50% of women with antimicrosomal
antibodies (ex. Anti-TPO).
b. Most cases are asymptomatic and presents 3-4 month postpartum
c. Both hypo and hyperthyroidism can occur
d. Most patients recover spontaneously
h. Untreated hypothyroidism may lead to neurological cretinism
i. There is a high rate of progression to overt hypothyroidism in untreated
women, with a 10-year incidence of 42% in women with TSH > 6 mIU/L.
Flowchart 18: Approach to hypothyroidism in pregnancy
j. Only very small amounts of LT4 cross the placenta and women should be
reassured that there is no risk of fetal thyrotoxicosis.
k. Breastfeeding is not contraindicated in women on LT4 replacement.
Reference:
1. CPG Management of thyroid diseases 2019.
2. Handbook of Obstetric Medicine,5th
ed 2015.

102
Bronchial Asthma
D7.
1) Overview
a. Bronchial asthma is the most common respiratory disorder in pregnancy,
affecting 3-12% of women. Around 6% of women require hospitalization for
exacerbations.
b. Antenatally, women should be advised on smoking cessation, avoidance
of triggers and have their technique of using metered-dose inhalers (MDI)
reassessed.
c. Inhaled corticosteroids should not be stopped and women reassured of
their safety.
d. Down-titration of asthma medications is a low-priority in pregnancy.
e. Closer follow up 4-6 weekly may be required and any exacerbations treated
aggressively.
f. The Asthma Control Test (ACT) is a patient self-administered tool, which is
useful for identifying those with poorly controlled asthma (see below).
g. The scores range from 5 (poor control of asthma) to 25 (complete control of
asthma), with higher scores reflecting greater asthma control. An ACT score
≥ 20 indicates well-controlled asthma.
h. Asthma in pregnancy is associated with low birth weight, small for
gestational age, preterm birth and preeclampsia.
i. Influenza vaccination is strongly recommended to be given in pregnancy.
j. Aspirin for preeclampsia prophylaxis is not contraindicated in women
without previous aspirin allergies. In women with allergies, consider aspirin
desensitisation or prescribe calcium carbonate instead, at 20 weeks of
gestation.
k. Subcutaneous Omalizumab (recombinant humanized IgG1 monoclonal
anti-IgE antibody) has been used in some pregnant women with poorly
controlled Ig-E mediated asthma. Observational studies have not shown an
increased risk of congenital anomalies.
a. Induction of labour with prostaglandin E2 can be used safely.
b. Patients on oral steroids (prednisolone ≥7.5mg/day for more than 2 weeks
prior to delivery) should receive IV hydrocortisone 50–100mg 6 to 8 hourly
to cover the stress of labour until oral medication is restarted.

103
c. Some women with poorly-controlled symptoms, recent asthmatic attack,
exercise-induced or cold-induced asthma (considering ambient temperature
in labour ward) may benefit from intrapartum steroids.
d. All forms of pain relief may be used safely.
e. Regional is preferable to general anaesthesia- decreased risk of chest
infection and atelectasis.
f. Consider mechanical methods in the event of PPH as prostaglandin F2α
(Carborpost) may increase the risk of bronchospasm. Ergometrine/oxytocin
may be used for PPH prophylaxis.
-ACT score ranges from 5 to 25
-A score of ≥ 20 indicates well-controlled asthma
Source: MOH CPG Management of Asthma 2017

104
SpO2
PR
RR
Measure ABG: (severe
hypoxia, normal of PaCO2
)
CXR (if pneumothrax or
consoliation suspected)
Monitor PEF
3) Management of acute exacerbation
Modified from MOH CPG Management of Asthma 2017
Continue oral prednisolone
5-7 days
Step up usual controller
Follow up 1-2 weeks
Written Asthma Action plan
MILD TO MODERATE
RR: 20 -30/min
PR: 100 - 120/min
SpO2
: 90 - 95%
PEF: >50% predicted or best
Maintain SpO2
>94%
β2
-agonist pMDI
preferable with spacer
(4 puffs up to a maximum
of 10 puffs) or nebuliser
(salbutamol 5mg);
repeat every 20 minutes for
1 hour
Prednisolone 1 mg/1kg
with maximum of 50mg
Continue of increase
usual treatment
RR: >30/min
PR: >120/min
SpO2
: <90%
PEF: <50% predicted or best
Maintain SpO2
>94%
Administrator:
β2
-agonist (salbutamol
2.5-5 mg) via oxygen driven
nebuliser, repeat every 20
minutes for 1 hour
Ipratorium bromide
nebuliser 0.5 mg every 5 - 6
hours
IV hydrocortisone 200 mg or
prednisolone 1 mg/kg with
maximum of 50 mg
No
improvement
No
improvement
Improvement
Improvement
Features of severe asthma
and any of the folllowing:
O PaO2
: >60 mmHg
O Normal or PaCO2
O Hypotension
O Silent chest
O PEF: <33%
Maintain SpO2
>94%
Administrator:
β2
-agonist (salbutamol 5 mg) via
oxygen driven nebuliser, repeat
every 20 minutes for 1 hour
Ipratorium bromide nebuliser
0.5 mg every 4 - 6 hours
IV hydrocortisone 200 mg or
prednisolone 1 mg/kg with
maximum of 50 mg
LIFE-THREATENING
FEATURES
Consider IV magnesium sulphate
1.2 - 2 g infusion cover 20
minutes
Consider intubation
Senior specialists may consider
use of IV β2
-agonist or IV
aminophyline
SpO2
PR RR
Measure ABG: (severe
hypoxia, normal of PaCO2
)
CXR (if pneumothrax or
consoliation suspected)
Monitor PEF
Monitor concious level - to
consider intubation if panties
become drowsy
SEVERE
FURTHER ASSESSMENT
INITIAL ASSESSMENT
MONITOR PROGRESS
LIFE-THREATENING
REFER FOR ADMISSION REFER FOR CRITICAL CARE

105
4) Postpartum care
a. Asthma medications are safe in breastfeeding.
b. Non-steroidal anti-inflammatory agents (NSAIDs) should be avoided where
possible.
c. Beta-blockers should be avoided as other antihypertensives are available.
5) Prevention of asthma in the offspring
a. Breastfeeding may reduce the risk of subsequent childhood asthma.
b. Despite initial data showing that high dose Vitamin D (4400 IU/day)
supplementation in pregnancy vs low dose (400 IU/day) can reduce the
risk of asthma in offspring, this benefit was not sustained beyond the first
3 years of life (Litonjua AA et al. NEJM 2020). Weighing against the risk of
toxicity, high dose Vitamin D is not routinely recommended.
Reference:
1. MOH. Clinical practice guidelines: Management of asthma 2017.
2. Global Initiative for Asthma: Pocket guide for asthma management and prevention
2020.

106
Hepatitis B
D8.
1) Overview
a. Hepatitis B-associated deaths in adults are largely due to infections
acquired at birth or the first 5 years of life.
b. The national immunization programme for Hepatitis B began in 1989 and
has been a notifiable disease since 2010.
c. 12.6 in 100,000 cases of Hepatitis B were notified in 2015, with
approximately half of the patients diagnosed between 20-40 years of age.
d. The National Strategic Plan for Hepatitis B and C (2019-2023) recommends
routine HbsAg screening during the initial visit.
2) Acute Hepatitis B infection
a. Usually mild and not associated with increased maternal mortality or
teratogenicity. Acute viral hepatitis is a common cause of jaundice in
pregnancy.
b. Antivirals are usually not indicated except in acute liver failure.
c. 10% risk of perinatal transmission. Antivirals may be required if HBV DNA
remains high at the time of delivery.
3) Chronic Hepatitis B infection (HBsAg +ve> 6 months)
a. Liver function test should be checked every trimester.
b. HBV DNA viral load should be checked if ALT is raised.
c. HBV DNA viral load should be routinely checked at 26-28 weeks and
tenofovir disoproxil fumarate (TDF) 300mg/day started if HBV DNA ≥ 5.3
log10 IU/mL (≥ 200,000 IU/mL).
d. Studies have shown that mothers may transmit HBV to her infant even when
the infant receives the timely birth dose vaccine, HBIG and completes the
hepatitis B vaccine series beyond this threshold.
e. Risk of transmission is as high as 85% in HBeAg +ve mothers, without
intervention.
f. Tenofovir (TDF) is the drug of choice and should be started from 28 weeks
of pregnancy. It can either be stopped at delivery or at 4 weeks postpartum.

107
a. Hepatitis B infection is not an indication for caesarean section.
b. It is reasonable to avoid fetal scalp sampling or fetal scalp electrodes,
especially in women with high viral load.
c. Whilst WHO recommends delayed cord clamping in women with HIV, there
is no specific recommendation in Hepatitis B (WHO 2014).
5) Postpartum
a. Stop Tenofovir at delivery or at 4 weeks postpartum.
b. Postpartum flares (2 to 3 fold increase in ALT to >3 times the upper limit)
may occur in up to 15-25% of women but are usually asymptomatic.
c. Hepatitis B immune globulin (HBIG) and HBV vaccine should be
administered to their newborn <12 hours after delivery.
d. Breastfeeding is not contraindicated.
g. Lamivudine and telbivudine should not be used as they have a low barrier
to drug resistance mutations, unless tenofovir is contraindicated (ex. Renal
impairment)
h. Invasive diagnostic procedures should not be withheld, but women should
be counseled on increased risk of transmission if viral load is ≥ 7.0 log10 IU/
mL (SMFM)

108
6) Algorithm for antiviral treatment in Chronic Hepatitis B in pregnancy
Source: WHO PMTCT of Hepatitis B Virus: Guidelines on antiviral prophylaxis in pregnancy 2020
Reference:
1. WHO. Prevention of mother-to-child transmission of Hepatitis B Virus: Guidelines on
antiviral prophylaxis in pregnancy 2020.
2. Terrault et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B:
AASLD 2018 hepatitis B guidance.
3. Lee H et al. Hepatitis B and pregnancy. Uptodate Dec 2022.

109
HIV In Pregnancy
D9.
1) Overview
a. Routine screening for HIV should be performed at booking and again 12
weeks later in women with high risk behaviour.
b. Women who are already on ART (antiretroviral therapy) before pregnancy
should continue their pre-pregnancy ART throughout pregnancy and after
delivery. (Avoid the combination of didanosine and stavudine in pregnancy
due to risk of lactic acidosis)
c. For women in whom HIV is diagnosed in pregnancy/ART naïve, the choice
and timing of starting ART is summarized below:
Presenting
CD4 count
Timing of ART initiation in newly-diagnosed, non-
labouring women
< 350 cells/μL
-
- Start ART as soon as possible.
-
- Start ART even in the first trimester in women with
opportunistic infections or WHO clinical stage 3/4 HIV
infection.
> 350 cells/μL
-
- Start ART at 14 weeks of pregnancy.
-
- ART is given primarily for PMTCT (prevention of mother-
to-child transmission).
-
- Consider starting earlier if viral load > 100,000 copies/ml.

110
Flowchart 19: Approach to HIV positive mother pregnancy
*AZT=Zidovudine; NRTI=Nucleoside transcriptase inhibitor; EFV=Efavirenz; NVP=Nevirapine
2) Choice of ART for PMTCT (Prevention of mother-to-child transmission)
a. 2 NRTI + [NNRTI OR Boosted Protease Inhibitor OR Integrase strand
transfer inhibitor].
b. Preferred treatment: Tenofovir (TDF) + Emtricitabine (FTC) + Efavirenz (EFV)
c. Other regimes are also acceptable, depending on the ID Physician.
d. In women starting ART after 28 weeks, consider Raltegravir–based ART as
Raltegravir crosses the placenta rapidly.

111
3) Additional antenatal considerations
a. Check CD4 count in early pregnancy and at delivery.
b. Check viral load as baseline, 2 weeks after starting treatment (if newly
started in pregnancy), 24 weeks, 32 to 36 weeks and at delivery.
c. Delay invasive antenatal procedures such as amniocentesis until the viral
load is < 50 copies/ml. Non-invasive prenatal testing should be offered.
d. If an urgent invasive procedure is needed, ART should be initiated to
include raltegravir and also a single dose of nevirapine 2 to 4 hours prior to
the procedure.
e. Serial growth scans should be performed from 26-28 weeks onwards.
f. Watch out for complications of HIV/AIDS, e.g. Kaposi sarcoma, chest
infection, herpes simplex.
4) Mode of delivery and intrapartum considerations
a. External cephalic version is not contraindicated in women planning for
vaginal delivery and viral load is <50 copies/ml.
b. Delivery should take place in hospitals with a paediatrician.
c. Universal precaution, personal protective equipment and use of blunt
needles is advised.
d. BHIVA recommends that if women are suitable for vaginal delivery,
management should not differ from HIV-negative women, including the use
of instrumental delivery (forceps preferred).
e. Fetal scalp electrode and fetal blood sampling are unlikely to increase the
risk of viral transmission, although it would be sensible to avoid this until
more robust evidence is available.
f. Delayed cord clamping is not contraindicated in women allowed vaginal
delivery (WHO 2014).
g. Intrapartum IV AZT should be used if:
Ø
Ø Women are untreated and present in labour or rupture of membranes,
OR
Ø
Ø Viral load of >1000 copies/ml in women who present in labour, with
rupture of membranes or planned for caesarean section.
Viral load at 32-36 weeks Mode of delivery
< 50 copies
50 – 399 copies
≥ 400 copies/unknown viral load
Vaginal delivery
Consider planned LSCS
Planned LSCS recommended

112
h. Intrapartum IV AZT can be considered in women with a viral load between
50 and 1000 HIV RNA copies/mL, regardless of mode of delivery.
i. Dose of IV AZT: 2 mg/kg/H for one hour, followed by 1 mg/kg/H until cord
clamping.
j. Allow at least 3 hours of infusion prior to elective caesarean section as
the cord blood-to-maternal zidovudine levels are higher than those who
received less than 3 hours of infusion (ACOG Opinion #751; 2018).
k. Continue regular oral ART but omit oral AZT during AZT infusion.
l. In the event of an emergency caesarean section, there is no need to
complete 3 hours of AZT infusion prior to the operation. However, the
paediatric team needs to be informed post-delivery to ensure adequate
post-exposure prophylaxis.
5) Intrapartum considerations in women presenting with rupture of
membranes
Timing of rupture of
membranes (ROM)
Management
Beyond 37wks
-
- Aim for early induction/augmentation and
delivery within 24 hours
-
- Mode of delivery depends on viral load
-
- Low threshold to start antibiotics if suspected
chorioamnionitis as the risk of MTCT is increased
34-37wks
-
- Management as per term PROM, with addition
of antibiotics for GBS prophylaxis
Before 34 wks
-
- Antenatal corticosteroids
-
- Multidisciplinary discussion with paediatrician
and infectious disease physician
-
- May benefit from optimizing viral load in some
cases, prior to delivery
6) Handling of the placenta by patients
a. Use double gloves and an apron.
b. For women who wish to bring home the placenta for cultural or religious
purposes, the placenta should be immersed in Sodium Hypochlorite 1:10
for 10 minutes.
c. Drain out and carefully seal in double plastic bags before handing over to
patient/relatives.

113
7) Postpartum
a. Refer to the ID physician regarding the continuation of ART. ART should be
continued for life unless the woman is not motivated to be compliant, and
her CD4 count is >350 cells/μl.
b. Cessation of ART should be monitored by the ID team to minimize the risk
of drug resistance.
c. Baby should be referred to the paediatric team for further management and
post-exposure prophylaxis.
d. Generally, most forms of contraceptives can be used in women on ART,
although higher dose estrogens may be required with some ARTs. There is
concern about the efficacy of subdermal implants in patients on Efavirenz.
Updated individual ART interactions can be found at University of Liverpool
HIV Drug Interaction Checker (https://www.hiv-druginteractions.org/).
e. Yearly cervical smears are advised.
8) Breastfeeding
a. Breastfeeding is not recommended as it is associated with a 14% chance of
vertical transmission.
b. Suppressive maternal ART significantly reduces, but does not eliminate,
the risk of vertical transmission of HIV through breastfeeding. The
undetectable=untransmittable (U=U) statement applies only to
sexual transmission, and there is currently lack of data to apply this to
breastfeeding.
c. Suppression of lactation can be considered.
d. Provide them with 2 pairs of disposable latex/rubber gloves.
e. Educate them on the safe handling of the placenta at home.
f. For women who do not wish to bring home the placenta, discard
appropriately as biohazard clinical wastes.
Reference:
1. Malaysian Consensus on Antiretroviral Therapy 2017.
2. BHIVA guidelines for the management of HIV in pregnancy and postpartum 2018 (2020
third interim update).
3. KKM. Garis Panduan Pengukuhan Program Pencegahan Jangkitan HIV dan Sifilis dari
Ibu-ke-Anak 2021.

114
Syphilis in Pregnancy
D10.
1) Overview
a. Universal screening using RPR/VDRL is performed at booking. TPHA is
required for confirmation as low levels of false-positive VDRL occur in other
conditions such as SLE (12%) and pregnancy (0.7%).
b. 3% of women may have false-negative results (-ve VDRL but +ve TPHA) due
to prozone phenomenon.
c. For high risk mothers, syphilis screening is repeated at 28-32 weeks.
2) Special considerations in pregnancy
a. Doxycycline and tetracycline are teratogenic and should not be used in
pregnancy
b. Jarisch-Herxheimer reaction is more common in pregnancy, occuring in 50%
of Syphilis of unknown duration, 60-90% of secondary Syphilis and more
than 90% of primary Syphilis, reflecting the level of spirochetemia.
d. All newly diagnosed Syphilis should be notified. Screen for other sexually-
transmitted diseases including Hepatitis B/C.
e. Contact tracing of sexual partners within past 90 days (if primary Syphilis)
and up to past 2 years (if secondary or early latent Syphilis).
f. Risk of congenital Syphilis is higher with early Syphilis due to higher levels
of spirochetemia.
Early Syphilis (<2 years)
-
- Primary Syphilis
-
- Secondary Syphilis
-
- Latent Syphilis
Late Syphilis (>2 years)
-
- Late latent Syphilis
-
- Tertiary Syphilis
Cardiovascular
Neurosyphilis
Early (onset< 2 years old) Late (>2 years old)
Acquired
Congenital

115
NB. If drugs are missed ≥ 1 day during treatment, the whole course is repeated
c. The onset of Jarisch-Herxheimer reaction is usually 2-12 hours after
treatment and women should be cautioned about symptoms such
as fever, malaise, joint pain, change in fetal movements (70%) and
contraction pain (60%).
d. Penicillin desensitisation as inpatient should be considered in
women with a history of mild-moderate penicillin allergies as
neither erythromycin nor azithromycin can prevent maternal-to-child
transmission.
e. ONLY penicillin can prevent maternal-to-child transmission. There is
insufficient evidence to show the same effect in ceftriaxone at the time of
writing.
f. For women treated with alternative regimens, the newborn needs to be
treated by the paediatric team.
g. More than 30 days must have passed between the last dose of treatment
to the time of birth to be considered protective against maternal-to-child
transmission.
Likely stage
Recommended
treatment
*Alternative treatment
(ONLY if penicillin allergy and
failed desensitisation)
Infection within
past 2 years:
- Primary
- Secondary
- Latent
Benzathine Penicillin
G, 2.4 MU IM in a
single dose;
OR
Procaine penicillin G,
600,000 units IM daily
for 10 days
Ceftriaxone 500 mg IM daily for
10 days;
OR
Erythromycin Ethylsuccinate 800
mg QID PO x 14 days;
OR
Azithromycin 2 g PO x single
dose

116
NB. If drugs are missed ≥ 2 weeks between weekly doses, the whole course is repeated.
*For cardiovascular syphilis, consider prednisolone 40-60 mg OD for 3 days, starting 24
hours before the antibiotics.
NB. For neurosyphilis, consider prednisolone 40-60 mg OD for 3 days starting 24 hours
before the antibiotics.
Likely stage
Recommended
treatment
*Alternative treatment
(ONLY if penicillin allergy and
failed desensitisation)
Infection more
than 2 years:
- Late latent
- Gummatous
- Cardiovascular *
Benzathine penicillin
G, 2.4 MU IM weekly
X 3 weeks (Day 1, 8 &
15);
OR
Procaine penicillin G,
600,000 units IM daily
for 14 days
Erythromycin 500 mg QID PO for
28 days;
OR
Erythromycin ES 800mg QID PO
for 28 days
Neurosyphilis Benzylpenicillin 4
MU IV 4 hourly for 14
days;
OR
Procaine Penicillin 2.4
MU IM daily;
PLUS
Probenecid 500 mg
PO 6 hourly, both for
14 days.
Ceftriaxone 2 g IM (with
Lidocaine as diluent); OR IV (with
water for injection as diluent
NOT Lidocaine) for 10-14 days (if
no anaphylaxis to penicillin)
3) Maternal surveillance
a. Abstain from sexual intercourse for 2 weeks after the patient and partner
have completed treatment.
b. RPR/VDRL should be performed monthly till 4-fold reduction/non-reactive.
Thereafter, RPR/VDRL is repeated two-monthly till delivery.

117
4) Antenatal fetal surveillance
a. Transplacental passage of spirochetes can occur at any stage in pregnancy.
They have been found in pregnancy tissues as early as 9 weeks of gestation.
b. Depending on the stage of the infection, there is a 40% chance of stillbirth
and 30-40% chance of congenital Syphilis if left untreated.
c. Fetuses with congenital Syphilis may exhibit fetal hepatomegaly (80%), fetal
anemia (33%), placentomegaly (27%), polyhydramnios (12%) or hydrops
(10%).
d. These features are rarely seen prior to 16-18 weeks of gestation as the fetus
is yet to be able to mount an inflammatory response.
e. Severe features such as hydrops and fetal anemia are first to resolve if
treatment is successful.
f. Serial growth scans after 26-28 weeks is recommended due to risk of fetal
growth restriction.
a. Timing and mode of delivery is per routine obstetric indications in
uncomplicated cases.
b. In some cases it may be reasonable to delay planned induction to allow
time for maternal antibiotics to confer fetal protection.
c. There are no recommendations against amniotomy, fetal blood sampling
or delaying cord clamping, especially in women who have completed
treatment.
d. VDRL/RPR should be repeated intrapartum or early postpartum to allow
comparison with titres in the newborn.
6) Postpartum
a. The paediatrician should be notified after birth and alerted if women have
incomplete treatment, completed treatment less than 30 days ago or failed
to demonstrate a 4-fold titre reduction after treatment ( see table below).
b. Breastfeeding is not contraindicated if there are no active syphilitic ulcers
on the breast.
c. A follow-up plan should be coordinated with the family medicine specialist/
genitourinary medical team.

118
Newborn should be considered for treatment with
penicillin if any of these:
Ø
Ø Mother has incomplete treatment course
Ø
Ø Mother was treated with non-penicillin medication
Ø
Ø Mother completed treatment <30 days prior to birth
Ø
Ø Mother failed to demonstrate a 4-fold reduction in VDRL/RPR
Ø
Ø Mother is suspected of or at high risk of reinfection after treatment was given
Ø
Ø Active signs of infection in newborn
Ø
Ø Positive CSF-VDRL in newborn
Ø
Ø Abnormal CSF in newborn (ex WBC> 5/mm3 or protein >50 mg/dl)
Ø
Ø Newborn RPR/VDRL at least 4-fold more than maternal titres
Reference:
1. WHO Guideline on syphilis screening and treatment for pregnant women. 2017.
2. MOH. Garis panduan pengukuhan program pencegahan jangkitan HIV dan sifilis dari
ibu-ke-anak. 2021.

119
Intrapartum
Care (Normal &
abnormal labour
E
SECTION

120
First Stage of Labour
E1.
a. The first stage of labour is characterized by regular painful contractions
which are increasing in intensity, frequency and duration. It is associated with
progressive cervical effacement and dilatation up to full dilatation.
b. It is divided to:
ú
ú Latent phase of labour: cervical os from closed to 3 cm.
ú
ú Active phase of labour: cervical os from 4 cm* to 10 cm.
(*WHO Labour Care Guide 2020 uses 5 cm to define the onset of active phase of
labour, and may be adopted by any labour unit)
c. A complete assessment of a pregnant woman in labour should be done during
admission. A high-risk case should be reviewed directly by a medical officer or
specialist.
d. During the latent phase of labour, fetal monitoring for pregnancy can be done
by intermittent auscultation with handheld doppler ultrasound (daptone) or
intermittent cardiotocogram (CTG) as required.
e. A partogram is commenced once the labour progresses to active phase or
earlier in certain circumstances, such as if amniotomy was performed.
f. Monitoring of maternal and fetal conditions will be charted on partogram.
g. Maternal monitoring:
Ø
Ø Blood pressure 4 hourly (more frequent in hypertensive disorders)
Ø
Ø Temperature 4 hourly
Ø
Ø Pulse rate 4 hourly
Ø
Ø Frequency of contractions half-hourly and pain score
Ø
Ø Urine output +/- urine ketone 4 hourly
Ø
Ø Vaginal examination 4 hourly
Ø
Ø Woman’s wishes, expectations and concerns
h. Fetal monitoring:
Ø
Ø Once in the active phase of labour, monitor fetal heart rate every 15 – 30
minutes. (If daptone is used, perform auscultation during and immediately
after contraction for at least 1 minute).
Ø
Ø High-risk women in active phase will require continuous CTG monitoring
i. Mother-friendly care should be encouraged throughout the labour in order to
promote Baby Friendly Hospital Initiatives.

121
j. A satisfactory labour progress is defined by:
Ø
Ø Contractions which are progressively increasing in frequency and duration.
Ø
Ø Rate of cervical dilatation of at least 0.5 cm per hour in primigravidas and 1
cm per hour in multigravidas during active phase.
Ø
Ø Presenting part remains well applied to the cervix with good descent.
k. Hyperstimulation is defined as:
Ø
Ø More than 5 contractions in 10 minutes over a 30-minute period; or
Ø
Ø Each contraction lasts more than 2 minutes in duration.
l. Meconium-stained liquor
Ø
Ø A specialist input should be obtained.
Ø
Ø Interpretation of CTG or fetal blood sampling should be done with caution
when the liquor is meconium-stained.
Ø
Ø A trained healthcare professional in neonatal life support should be readily
available during the delivery.
Adapted from:
1. Sarawak General Hospital’s Labour Ward Manual 2020.
2. Obstetrics and Gynaecology Protocol State of Kedah 2019.

122
Second Stage of Labour
E2.
a. The second stage of labour is defined as the period from the full dilatation of
the cervix until the delivery of the baby.
b. It is divided into passive and active second stage of labour:
Ø
Ø Passive: Full dilatation of cervix in the absence of involuntary expulsive
contractions.
Ø
Ø Active: Full dilatation of cervix with expulsive contractions or with active
maternal effort.
c. Passive second stage of labour can be allowed up to one hour if there is no
evidence of maternal or fetal compromise.
d. In the event of prolonged second stage of labour, refer to a specialist if baby is
not delivered after:
Ø
Ø Nulliparous: 2 hours of active second stage with regional anaesthesia, or 1
hour without regional anaesthesia.
Ø
Ø Multiparous: 1 hour of active second stage with or without regional
anaesthesia.
e. Shortening of the second stage of labour may be indicated in women with
certain medical conditions (eg: cardiac diseases, hypertensive disorders in
pregnancy etc).
f. Appropriate universal precaution should be practiced including gowning,
gloves with or without goggles.
g. Episiotomy is performed only if indicated. Give local anaesthesia if an
episiotomy is required.
h. A paediatric doctor should be on standby for high-risk cases and instrumental
deliveries.
i. Ensure all medical equipment and gasses required for delivery and baby
resuscitation are available and functioning.
j. Fetal monitoring during second stage of labour:
Ø
Ø Monitor fetal heart rate can be achieved with CTG monitoring continuously
or with daptone monitoring every 5 minutes after each contraction for one
minute.
Ø
Ø CTG interpretation can be challenging especially when the mother is
bearing down.

123
Adapted from:
1. Obstetrics Protocol O&G Department Hospital Tuanku Fauziah Kangar Perlis 2020-
2025.
2. Obsterics and Gynaecology Protocol State of Kedah 2019.
3. Penang State Obstetrics Protocol 2021.
k. Intervention may be needed either via instrumental delivery or caesarean
section in the following conditions:
Ø
Ø Prolonged second stage
Ø
Ø Pathological CTG
Ø
Ø Moderate and thick meconium stained liquor
l. Give uterotonic when the anterior shoulder of the fetus is delivered. Options
will be either Syntocinon 1 ml (10 IU) or intramuscular Syntometrine 1ml
(oxytocin 5IU and Ergometrine 0.5mg)
m. Syntometrine should be avoided if the woman has heart disease or
hypertension.

124
Third Stage of Labour
E3.
a. The third stage of labour is defined as the period from the birth of the baby to
the expulsion of the placenta.
b. Signs of placenta separation:
Ø
Ø Gushing of blood
Ø
Ø Lengthening of the umbilical cord
Ø
Ø Uterus becomes globular and raised
c. Delayed cord clamping is recommended for at least 1 minute unless the baby
needs to be moved for immediate resuscitation or mother needs resuscitation.
d. Active management of the third stage of labour includes:
Ø
Ø Routine use of uterotonic drugs. Commonly used agents are intramuscular
oxytocin 10IU or intramuscular Syntometrine (oxytocin 5IU and Ergometrine
0.5mg).
Ø
Ø Controlled cord traction once signs of placenta separation are being
observed.
e. Consider starting 40 IU oxytocin in 500mls normal saline infusion over 4-6
hours in mothers with high risk of postpartum haemorrhage, such as grand
multiparity and obesity.
f. The placenta completeness and also the umbilical cord vessels are checked
and documented.
g. Mother should be monitored regularly for an hour. Reassessment should be
done before transferring mother to postnatal ward. This is to ensure the vital
signs are stable, uterus well contracted with no excessive lochia loss and
perineal checked.
h. Prolonged third stage of labour is diagnosed when the placenta is not
delivered within 30 minutes from the delivery of the baby. Retained placenta
is an obstetric emergency which can cause postpartum haemorrhage. Thus, it
needs to be attended to immediately and manual removal of placenta should
be planned if needed.
Adapted from:
2. Obsterics and Gynaecology Protocol State of Kedah 2019.
3. Obstetrics Protocol O&G Department Hospital Tuanku Fauziah Kangar Perlis 2020-
2025.

125
Episiotomy
E4.
a. Episiotomy is a surgical incision made at the perineum to widen the vaginal
opening to facilitate the delivery of a baby.
b. Restricted use of episiotomy is recommended as evident by Cochrane review.
c. 5-10 mls of lignocaine (1% or 2%) should be infiltrated to the perineum before
episiotomy.
d. When episiotomy is indicated, the mediolateral technique is recommended,
with the angle is 60 degrees away from the midline when the perineum is
distended.
Repair of episiotomy/second degree tear
a. Good lighting and exposure to assess the type and extent of perineal tear
is important (especially third or fourth degree tear). If there is any doubt
or difficulty in determining the degree of tear, it is advisable to examine the
patient in the operating theater under anaesthesia.
b. Use proper surgical instruments and suture material (use rapidly absorbed
polyglactin 910 or polyglactin 2-0 braided suture).
c. Figure of eight sutures should be avoided because they are haemostatic in
nature and may cause tissue ischaemia.
d. Identify the apex of the vaginal tear, anchor suture 1 cm above the apex.
*Picture copied from Negeri Sembilan O&G Protocol 2018

126
e. Repair the vaginal mucosa using continuous or interrupted suturing technique
towards the hymenal ring and tie proximal to the ring.
f. Identify the transverse perineal muscle and bulbocavernosus muscles on
each side of the perineal tear. Approximate both ends of the muscles with
transverse interrupted or continuous sutures.
g. Repair the perineal skin using continuous or subcuticular technique.
Subcuticular sutures are associated with less pain and higher maternal
satisfaction.
h. Perform vaginal examination to evacuate remnants of blood clot, and to
ensure no vaginal haematoma or foreign body being missed.
i. Perform a per rectal examination to assess the anal tone and to make sure
sutures did not extend beyond the anal mucosa which poses risk of anovaginal
fistula formation.
j. Ensure correct instrumental and swab count at the end of the repair.
k. Document the procedure and the estimated blood loss.
l. Standard: Overall episiotomy rate in normal vaginal delivery should not be
more than 30%.
Adapted from:

127
Obstetric Anal Sphincter Injury (OASIS):
Third and Fourth Degree Perineal Tears
E5.
a. OASIS should be repaired in operation theater to ensure sterility, good
lighting, optimal positioning and adequate anaesthesia.
b. Repair must be conducted by a trained clinician or by a trainee under
supervision.
c. Prophylactic antibiotics are recommended to reduce the risk of postoperative
infections and wound dehiscence.
Classification of
Perineal Tear Degree of injury
First-degree tear Injury to perineal skin and/or vaginal mucosa.
Second-degree tear Perineal muscles injury.
Third-degree tear:
Grade 3a tear
Grade 3b tear
Grade 3c tear
Anal sphincter complex injury:
Less than 50% external anal sphincter (EAS) thickness
torn.
More than 50% EAS thickness torn.
Both EAS and internal anal sphincter (IAS) are torn.
Fourth-degree tear Anal sphincter complex (EAS and IAS) and anorectal
mucosa injury.
Perineal Tear Techniques Suture Choices
Partial thickness EAS tear
Full thickness EAS tear
IAS tear
End-to-end technique
Overlapping or end-to-
end technique.
Interrupted or mattress
sutures without
overlapping the IAS.
Monofilament sutures
eg: PDS 3-0
or
Braided sutures eg:
polyglactin 2-0
Anorectal mucosa tear Continuous or interrupted
sutures
Polyglactin 3-0
d. When repairing the EAS and IAS, the burying of surgical knots beneath the
superficial perineal muscles is recommended to minimize the risk of knot and
suture migration to the skin.

128
Adapted from:
Reference:
1. The Management of Third- and Fourth-Degree Perineal Tear. Green-top Guideline
No.29. June 2015.
End-to-end
technique for
repair EAS
Overlapping
technique for
repair EAS
e. Repair vaginal mucosa, perineal muscle and skin as described in episiotomy/
second-degree tear chapter.
f. Perform vaginal examination to evacuate remnants of blood clot, and to ensure
no vaginal haematoma or foreign body being missed.
g. Perform a per rectal examination to make sure sutures did not extend
from vagina beyond the anal mucosa which poses risk of anovaginal fistula
formation.
h. Ensure correct instrumental and swab count at the end of the repair.
i. Document the procedure and the estimated blood loss.
j. Postoperative laxative (syrup lactulose) is recommended to reduce the risk of
wound dehiscence.
k. Referral to physiotherapist for pelvic floor muscle exercises.
l. Antibiotics, laxatives and follow-up of women should follow the local protocols.
m. Debriefing and audit should be carried out after the OASIS incident.
n. 60-80% of women are asymptomatic 12 months following delivery and EAS
repair.
o. Women who sustained OASIS should be counseled on mode of delivery in their
subsequent pregnancy.
p. Women with OASIS before and who are symptomatic or have abnormal
endoanal ultrasonography and/or manometry should be counseled regarding
the option of elective caesarean section.
Picture adapted from Hospital Tuanku Ja’afar, Negeri Sembilan O&G Protocol, 2018

129
Induction of Labour (IOL) /Augmentation
E6.
1) Overview
3) Indications of IOL
2) Prerequisites for IOL:
a. Review of maternal history.
b. Confirmation of gestational age of fetus.
c. Assessment of indications and contraindications of IOL.
d. Confirmation of fetus presentation and engagement.
e. Vaginal examination to assess for Bishop score and membrane (intact/
rupture).
f. Assessment of fetal wellbeing. (A normal CTG before IOL).
g. Women being counseled and informed consent obtained.
Term Definition
Induction of
labour (IOL)
Artificial initiation of labour
Augmentation
of labour
Active intervention during labour to promote the frequency,
duration and amplitude of uterine contractions.
Indications of IOL Timing of IOL
Post-dated in uncomplicated
pregnancy
• 40 weeks + 7 days
GBS positive
Non-GBS
• IOL as soon as ROM is confirmed.
• IOL within 24 hours after ROM
Term pre-labour rupture of membranes (ROM)
36 - 37 weeks
34 – 35 weeks + 6 days
Less than 34 weeks
• IOL if spontaneous labour has not
commenced within 24 hours.
• IOL is not routinely recommended unless
there are maternal or fetal indications.
• IOL is not generally recommended,
with exceptions only following careful
consideration.
Preterm pre-labour rupture of membranes (PPROM)

130
Indications of IOL Timing of IOL
Constitutionally small healthy fetus
FGR
• Not to be allowed post-date
• Timing depends on the severity of
IUGR and presence of evidence of
fetal compromise.
• Consider IOL for term FGR.
• IOL is not recommended for severe
FGR
Intrauterine fetal death (IUFD) • Timing depends on a woman’s wishes
and presence of complications eg:
coagulopathy (risk increases after 4
weeks of IUFD).
Reduced fetal movement (RFM) • Consider IOL if RFM at term.
Oligohydramnios • Timing of delivery prior to term
will depend on gestational age,
underlying etiology and fetal
wellbeing.
• Consider IOL if oligohydramnios at
term.
Requiring treatment
Well-controlled with diet and no
evidence of macrosomia
• 37 - 38 weeks + 6 days
• 40 weeks
Well-controlled on anti-
hypertensive
Well-controlled not requiring
treatment
• 37 – 38 weeks
• 40 weeks
Monochorionic diamniotic
Dichorionic diamniotic
• 36 – 37 weeks
• 37 – 38 weeks
Gestational diabetes/ diabetes mellitus
Hypertensive disorders
Twin pregnancy
Small-for gestational age (SGA) & Fetal growth restriction (FGR)

131
4) Contraindications of IOL:
a. Previous classical/ inverted T/ J-incision caesarean section
b. Previous hysterotomy
c. Previous myomectomy with entry into uterine cavity/ extensive dissection
d. Previous uterine rupture
e. Suspected macrosomia (≥ 4kg)
f. Suspected cephalopelvic disproportion
g. Cord presentation
h. Breech
i. Active genital herpes
j. Malpresentation
Favourable cervix: Score ≥ 7
Unfavourable cervix: Score < 7
5) Modified Bishop Score
Cervix Score 0 1 2 3
Dilatation (cm) <1 1-2 3-4 >4
Length (cm) >4 3-4 1-2 <1
Station -3 -2 -1/0 +1/+2
Consistency Firm Medium Soft -
Position Posterior Middle Anterior -
6) Counseling on IOL
a. Indications
b. Methods
c. Potential risks
d. Success/failure rate
e. Timing and place of IOL
f. Options of pain relief
g. Options if IOL unsuccessful
h. Alternatives if IOL is declined

132
Indications Benefits Risks/Contraindications
Membrane
sweeping
• To promote
spontaneous labour
and reduce IOL
with other methods.
• Reduce post date
significantly if done
between 39 – 40
weeks.
• Applicable to
both favourable
and unfavourable
cervix.
• No evidence
of increased
maternal
and neonatal
infections.
• Associated with
discomfort and vaginal
bleeding.
Mechanical
method
(Transcervical
catheter/
Foley catheter/
Hygroscopic
stents)
• For relatively
high risk IOL with
prostaglandin E2
(PGE2): previous
caesarean section,
grand multiparity.
• Lower risk of
hyperstimulation.
• No evidence
of increased
infections.
• Contraindicated in
ruptured membranes,
active herpes and GBS,
antepartum haemorrhage
cases.
Amniotomy
• Favourable cervix
(Bishop score ≥7)
• Amniotomy alone
should not be
considered a
primary method of
IOL unless there
are specific clinical
reasons.
• May reduce
length of labour.
• Reveal colour
and smell of
liquor.
• Caution in high
presenting parts, risk of
cord prolapse.
• Trauma to cervix or fetal
scalp, bleeding.
Vaginal
prostaglandin
E2 (PGE2)
• Unfavourable cervix
(bishop score <7).
• Regime:
First dose 3 mg
followed by second
dose 3 mg after
6 hours if labour
is not established
(Maximum 2 doses).
• Decision for
third dose only
by specialist/
consultant after
careful clinical
evaluation.
• Ripening and
softening of
cervix
• Contraindicated in
known hypersensitivity,
sign of maternal/
fetal compromise,
chorioamnionitis, vaginal
bleeding.
• Caution in multiple
pregnancy, parity > 5,
previous caesarean scar/
uncomplicated uterine
surgery, cardiovascular
disease, epilepsy and
glaucoma.
• Can cause gastrointestinal
upset (nausea, vomiting
or diarrhoea)
• 4% risk of
hyperstimulation.
Method for Induction of Labour

133
Cervix Score Indications Benefits Risks/
Contraindications
Intravenous
oxytocin with
amniotomy
• Preferred method
if bishop scores
favourable.
• For cases with
relatively high risk
with PGE2 (previous
caesarean scar,
high station and
polyhydramnios)
• Initial dose: 1-2
milliunits/minute,
titrates half-hourly
until good uterine
contractions are
achieved.
• Maximum dose: 32
milliunits/min for
primigravida and
16 milliunits/min for
multipara.
• Shorten duration
of labour.
• Decrease risk of
chorioamnionitis
and neonatal
infection in term
prelabour rupture
of membrane
cases.
• Should not start
within 6 hours after
vaginal PGE2.
• Risk of
hyperstimulation.
• Caution in patients
with previous
caesarean sections.
Method for Induction of Labour
Adapted from:
1. Induction of labour, Obstetrics Protocol, Hospital Raja Permaisuri Bainun Ipoh 2021.
Reference:
1. Guidelines on induction of labour 2021, Ministry of Health Malaysia

134
Operative Vaginal Delivery
E7.
1) Indications
a. Vaginal birth can be assisted by vacuum or forceps for maternal and fetal
indications:
b. Safe operative vaginal delivery requires a careful assessment of the clinical
situation, clear communication with the woman and healthcare personnel
who is credentialed in the chosen procedure.
Prerequisites
(Full
abdominal
and vaginal
examination)
F - fully dilated os.
O - occiput anterior or posterior (for forceps).
R - rupture of membranes.
C - cephalopelvic disproportion excluded, caput and
moulding < 2+, catheterisation of bladder, adequate
contraction.
E - engagement of head (≤ 1/5 head palpable per abdomen).
P - pain relief (local anaesthesia or pudendal block), pelvis is
deemed adequate.
S - Skills, supervision, sterility.
Ø
Ø Prolonged second stage
• Nulliparous: 2 hours of active second stage with regional anaesthesia,
or one hour without regional anaesthesia.
• Multiparous: 1 hour of active second stage with or without regional
anaesthesia,
Ø
Ø Class III or IV cardiac disease
Ø
Ø Hypertensive crisis
Ø
Ø Cerebral vascular disease
Ø
Ø Myasthenia gravis
Ø
Ø Spinal cord injury
Ø
Ø Maternal exhaustion
Ø
Ø Presumed fetal compromise
Ø
Ø Delivery of after-coming head in breech presentation (Forceps)
Maternal
Safety Criteria for Operative Vaginal Delivery
Fetal

135
2) Classification of Operative Vaginal Delivery:
Preparation
of mother
Preparation
of staff
Ø
Ø Clear explanation and informed consent taken.
Ø
Ø Trust and full cooperation established.
Ø
Ø Operator has adequate knowledge, experience and skills.
Ø
Ø Adequate facilities: equipment, bed, lighting.
Ø
Ø Backup plan: access to the operating theater if operative
vaginal delivery unsuccessful.
Ø
Ø Anticipation of complications (perineal trauma, postpartum
haemorrhage, shoulder dystocia).
Ø
Ø Presence of personnel trained in neonatal resuscitation.
Outlet
Ø
Ø Fetal skull on the perineum.
Ø
Ø Fetal scalp visible without separating the labia.
Ø
Ø Sagittal suture is in antero-posterior diameter/ right or left
OA or OP position (rotation < 45 degree).
Low
Ø
Ø Leading point of the skull (not caput) is at station +2 or
more but not on the perineum.
Ø
Ø Two subdivisions:
• Non-rotational ≤ 45 degree
• Rotational > 45 degree
Mid
Ø
Ø Fetal head no more than 1/5 palpable per abdomen
Ø
Ø Leading point of the skull at station 0 or +1 cm
Ø
Ø Two subdivisions:
• Non-rotational ≤ 450
• Rotational > 450
High
Ø
Ø Fetal head is 2/5 or more palpable per abdomen
Ø
Ø Leading point of skull above ischial spines.
Ø
Ø NOT RECOMMENDED for operative vaginal delivery.

136
3) Contraindications:
a. Head palpable per abdomen > 1/5
b. Evidence of relative or absolute cephalopelvic disproportion (eg: clinically
big baby, suspected macrosomia)
c. Cervix not fully dilated
d. Station above ischial spine
e. Unable to determine fetal position
f. Abnormal presentation except for after-coming head in vaginal breech
delivery
g. Vacuum should not be performed for gestation less than 34 weeks
h. Confirmed or high probability of fetal bleeding disorders (eg: alloimmune
thrombocytopenia)
i. Fetal predisposition to bony fracture eg: osteogenesis imperfecta
4) Choices of instruments:
Forceps Vacuum
Types
Ø
Ø Simpsons, Neville-Barnes
(low/mid cavity)
Ø
Ø Wrigley’s (Outlet)
Ø
Ø Kielland’s (rotational)
Ø
Ø Piper (Aftercoming head of
breech presentation)
Ø
Ø Soft/ silicone cup
Ø
Ø Metal cup: Malmstrom/Birds
Ø
Ø Kiwi Omnicup
Benefits
Ø
Ø Does not require chignon
formation.
Ø
Ø More likely to succeed
especially in maternal
exhaustion.
Ø
Ø Useful for aftercoming
head in breech delivery
Ø
Ø Easier learning curve.
Ø
Ø Can be used in fetal occipital
transverse position.
Ø
Ø Less genital tract trauma risk.
Risks
Ø
Ø Significant perineal tear:
20%
Ø
Ø OASIS: 8-12%
Ø
Ø Facial nerve palsy: rare
Ø
Ø Skull fracture: rare
Ø
Ø Higher failure rate.
Ø
Ø Significant perineal tear: 10%
Ø
Ø OASIS: 1-4%
Ø
Ø Cephalohaematoma: 1 - 12%
Ø
Ø Retinal haemorrhage: 17 - 38%
Ø
Ø Subgaleal bleeding: 3 - 6/1000.
Ø
Ø Facial/scalp laceration: 10%
Ø
Ø Hyperbilirubinemia: 5 - 15%
Ø
Ø Intracranial haemorrhage: 5 - 15/10,000
Ø
Ø Fetal death: very rare

137
a. Atraumatic insertion
b. Hold the handle of the left blade like a pencil with your left hand. Gently
insert the right hand to protect the left vagina wall. Introduce the blade in
between contractions. (Picture 1)
c. Gently slide and swing the left blade upward along the pelvic curve. The
right hand guides the blade while guarding the lateral vagina wall
d. Repeat the same for the right blade. (Picture 2)
e. The blades should lock easily. (Picture 3)
f. Ensure the suture lies in the midline with the shanks. The posterior
fontanelle is one finger breadth above the shanks. The lambdoid suture is
equidistant from the forceps blades. (Picture 4)
g. Angle of traction:
Ø
Ø Apply force perpendicular to the handle and downwards to maintain and
increase flexion. (Pajot’s maneuver)
Ø
Ø Once the posterior fontanelle is below the symphysis pubis, the handles
are elevated in a “J” direction.
h. Remove both the blades after the head is delivered.
5) Forceps Delivery Techniques
Pictures adapted from Sarawak General Hospital’s Labour Ward Manual 2020.
1
3
2
4

138
6) Vacuum Delivery Techniques
Pictures copied from Sarawak General Hospital’s Labour Ward Manual 2020.
a. Atraumatic insertion
b. Place the cup over the sagittal suture at the flexion point (centre of the cup
is 3 cm anterior to the posterior fontanelle). (Picture 1)
c. Turn on the suction pressure to achieve 60 – 80 kPa. The increment of
pressure can be either rapid or stepwise.
d. Ensure no vagina or cervical tissue is caught in between the cup. (Picture 2)
e. During contraction, apply traction perpendicular to the cup with the axis of
traction following the pelvic curve. (Picture 3)
f. Remove the cup once the fetal head is delivered by releasing the suction
pressure and allowing the cup to detach spontaneously.
7) Abandon operative vaginal delivery if:
a. Difficulty in applying the instruments.
b. No evidence of progressive descent with each pull.
c. No evidence of imminent birth after 3 pulls.
d. Birth not imminent within 20 minutes.
e. Vacuum cup slips two times.
Operative vaginal delivery that has a higher risk of failure should be considered a
trial and be attempted in a place where immediate recourse to caesarean section
can be undertaken.
1 3
2

139
8) Higher rates of failure are associated with:
a. Maternal BMI > 30kg/m2
b. Short maternal stature
c. Head circumference > 95th centile.
d. Occipito-posterior position
e. Mid-cavity birth or 1/5 of head is palpable per abdomen
9) Sequential instruments
a. The use of sequential instruments is associated with an increased risk of
trauma to the infant. However, the operator needs to balance the risks of
caesarean birth following failed vacuum extraction with the risk of forceps
birth following failed vacuum extraction. The decision for sequential
instruments must be made by a specialist.
b. Please alert paediatric teams when there is failed vacuum extraction,
sequential use of instruments or failed forceps extraction due to increased
neonatal morbidity.
10) Post procedure
a. Examine the perineum for tear and repair accordingly.
b. A single dose of IV broad spectrum antibiotic within an hour post-delivery is
recommended to prevent infection.
c. Provide regular oral analgesia (eg: NSAIDs and paracetamol).
d. Ensure mother can void normally.
e. Document the procedure.
Adapted from:
1. Obstetrics Protocol O&G Department Hospital Tuanku Fauziah Kangar Perlis 2020-2025
Reference:
1. Assisted Vaginal Birth. Green-top Guideline No.26. April 2020.
2. Operative Vaginal Delivery, Obstetrics Protocol Hospital Raja Permaisuri Bainun, Ipoh.
2021.

140
Term Prelabour Rupture of Membranes (Term PROM)
E8.
1) Overview
a. Term PROM is defined as spontaneous rupture of membranes with a latent
period before the onset of uterine activity, occurring after 37 weeks of
gestation.
b. Clinical assessment of Term PROM aims to confirm the leaking liquor and to
evaluate for evidence of intrauterine infection, abruptio placentae and fetal
compromise.
4) Investigations
a. Full blood count to look for leukocytosis.
b. Low vaginal and anorectal swab (can use a single swab) for culture and
sensitivity to test for Group B Streptococcus (GBS).
c. Transabdominal ultrasound to assess the fetal presentation and liquor
volume.
d. CTG to assess fetal well-being.
2) History: Involuntary gushing of fluid, dribbling along the thigh and recurrent
dampness are highly suggestive of leaking liquor.
3) Physical examination
a. Vital signs to look for fever or hypothermia, maternal tachycardia,
hypotension.
b. Abdominal palpation for symphysio-fundal height, contraction, uterine
tenderness, fetal lie and presentation.
c. Sterile speculum examination to look for pooling of liquor at the posterior
fornix spontaneously or after cough impulse. Also, to assess the cervical
length, os, presence of per vaginal bleeding, meconium or foul-smelling
liquor.
d. Presence of liquor can be supported by litmus paper test or other
commercial test kit to test for insulin-like growth factor-binding protein I
(IGFBP-I) or placental alpha microglobulin-I (PAMG-I).
e. Avoid unnecessary digital vaginal examination as it can increase the risk of
chorioamnionitis, postpartum endometritis and neonatal infection.

141
5) Management of Term PROM
6) Intrapartum antibiotic prophylaxis (IAP)
a. IAP is indicated in:
Ø
Ø GBS bacteriuria identified antenatally.
Ø
Ø GBS carrier detected incidentally or by intentional testing.
Ø
Ø Previous infant with early- or late-onset GBS disease.
Ø
Ø Previous pregnancy GBS carrier and not keen for GBS testing in late
pregnancy this time (50% likelihood of maternal GBS carriage in current
pregnancy. If keen for GBS testing, it should be carried out at 35-37
weeks of gestation or 3-5 weeks prior to the anticipated delivery date,
then offer IAP if still positive for GBS).
b. There is insufficient evidence to justify the routine use of prophylactic
antibiotics immediately after the diagnosis of Term PROM in the absence of
an indication for GBS IAP. It should be weighed against the risk of antibiotic
resistance and anaphylactic reaction.
c. However, for women being managed expectantly, the duration of rupture of
membrane is more prolonged, thus, there is a role for antibiotics to reduce
infectious morbidity.
Expectant Induction of labour
Ø
Ø 79% will progress into labour
spontaneously within 12 hours,
95% within 24 hours.
Ø
Ø 50% will deliver within 33 hours
and 95% deliver within 94 – 107
hours.
Ø
Ø Reduced time from rupture of
membranes to delivery.
Ø
Ø Reduce the rates of chorioamnionitis
and endometritis.
Ø
Ø Reduce admission to neonatal
intensive care units.
Ø
Ø No increase in caesarean delivery or
operative vaginal delivery.
Ø
Ø Higher maternal satisfaction.
Expectant Induction of labour
Ø
Ø If maternal GBS status is
negative or unknown, expectant
management up to 24 hours can
be an option if mother declines
IOL after adequate counseling
regarding risk of prolonged
leaking and both mother and fetal
conditions are reassuring.
Ø
Ø IOL should be offered in:
Ø
Ø GBS carrier mother
Ø
Ø Prolonged leaking > 24 hours
Ø
Ø Prostaglandins and oxytocin are
equally effective.
Ø
Ø Prostaglandin is associated with
higher rates of chorioamnionitis as
compared to oxytocin.

142
d. The practice of administration of antibiotics in Term PROM with prolonged
leaking may differ according to hospitals (initiation of antibiotic at 12 or 18
hours of leaking).
7) Choice of antibiotic
a. IAP with benzylpenicillin or ampicillin reduces the incidence of early-onset
neonatal GBS disease.
b. Benzylpenicillin has a narrow-spectrum of activity thus it is less likely to
promote antibiotic resistance.
c. Dosage: IV ampicillin 2g stat then 1g 4 hourly or IV Benzylpenicillin 3g stat
then 1.5g 4 hourly or IV Clindamycin 900mg stat then 8 hourly in women
with penicillin allergy.
8) Monitoring (Assess for signs of chorioamnionitis)
a. Fever > 37.40
C
b. Maternal tachycardia
c. Uterine tenderness
d. Fetal tachycardia
e. Foul-smelling liquor
f. Leukocytosis.
Adapted from:
1. Obstetrics Protocol O&G Department Hospital Tuanku Fauziah Kangar Perlis 2020-2025.
4. Obstetrics and Gynaecology Protocol State of Kedah 2019.
Reference:
1. Prelabour Rupture of Membranes, ACOG Practice Bulletin, Number 188, Jan 2018.
2. Cochrane review: Planned early birth versus expectant management (waiting) for
prelabour rupture of membranes at term (37 weeks or more) 2017.
3. Cochrane review: Antibiotics for prelabour rupture of membranes at or near term 2014.
4. Prevention of early-onset neonatal Group B Streptococcal disease. Green-top guideline
No.36. September 2017.
5. Term prelabour rupture of membranes (Term PROM). The Royal Australian and New
Zealand College of Obstetricians and Gynaecologists Statement. March 2017.

143
Preterm Prelabour Rupture of Membranes (PPROM)
E9.
1) Overview
a. PPROM is defined as spontaneous rupture of membranes before the onset
of regular uterine contraction prior to 37 weeks.
b. It complicates up to 3% of pregnancies and is associated with 30-40% of
preterm births.
c. Clinical assessment of PPROM aims to confirm the leaking liquor and
to evaluate for intrauterine infection, abruptio placentae and fetal
compromise.
3) Physical examination
a. Vital signs to look for fever or hypothermia, maternal tachycardia,
hypotension.
b. Abdominal palpation for symphysio-fundal height, contraction, uterine
tenderness, fetal lie and presentation.
c. Sterile speculum examination to look for pooling of liquor at the posterior
fornix spontaneously or after cough impulse. Also, to assess the cervical
length, os, presence of per vaginal bleeding, meconium or foul-smelling
liquor.
d. Presence of liquor can be supported by a litmus paper test or other
commercial test kit to test for insulin-like growth factor-binding protein I
(IGFBP-I) or placental alpha microglobulin-I (PAMG-I).
e. Avoid unnecessary digital vaginal examination as it can increase the risk of
chorioamnionitis, postpartum endometritis and neonatal infection.
2) History: Involuntary gushing of fluid, dribbling along the thigh and recurrent
dampness are highly suggestive of leaking liquor.
4) Investigations
a. Full blood count to look for leukocytosis.
b. C-reactive protein.
c. Low vaginal and anorectal swab (can use a single swab) for culture and
sensitivity to test for Group B Streptococcus (GBS).
d. Transabdominal ultrasound to assess the presentation and liquor volume.
e. CTG to assess fetal well-being.

144
5) Management
a. Start T. Erythromycin Ethylsuccinate (EES) 400mg BD (dose may be adjusted
for high BMI patients) for 10 days.
b. Antenatal corticosteroid requirement:
c. Admit woman for monitoring for at least 48 -72 hours:
Ø
Ø Blood pressure, pulse rate and temperature 4 hourly.
Ø
Ø Fetal heart rate monitoring 4 hourly.
Ø
Ø Uterine contraction/tenderness 4 hourly.
Ø
Ø Pad charting – to inform if any change of liquor colour or smell.
d. Consider hospital outpatient expectant management after initial inpatient
monitoring for women who live near to hospital and able to come back for
follow up.
Ø
Ø Ensure appropriate counseling on signs and symptoms of
chorioamnionitis and to seek medical attention early if unwell.
Ø
Ø Biweekly full blood count (to monitor for white cell count trend) and
C-reactive protein.
Ø
Ø Weekly liquor volume.
Below 24
weeks
Consultant-led discussion with the woman.
24+0
– 34+6
weeks
Offer to all women if preterm birth is anticipated (established
preterm labour, PPROM or planned preterm birth).
35+0
– 36+6
weeks
Short term respiratory benefit should be weighed against
the risk of neonatal hypoglycaemia and long-term
neurodevelopmental concerns.

145
6) Further management will depend on gestational age:
36 – 37
weeks
Ø
Ø IOL if spontaneous labour has not commenced within 24
hours.
34 – 35
weeks +
6 days
Ø
Ø IOL is not routinely offered unless there are maternal or fetal
indications.
Ø
Ø Weigh the balance between the benefits and risks of delivery
or expectant management.
Ø
Ø Decision to prolong a pregnancy with PPROM should
be discussed between specialist and the woman after
considering the individual risk factors.
Ø
Ø If leaking has stopped, vital signs are stable, blood and
ultrasound scan parameters are normal, consider allowing
hospital outpatient management. Timing of birth should be
discussed with women on an individual basis with careful
consideration of patient preference and ongoing clinical
assessment.
Ø
Ø Tocolysis is not recommended as it does not significantly
improve perinatal outcome.
Less than
34 weeks
Ø
Ø IOL is not generally recommended, with exceptions only
following careful consideration.
Ø
Ø Expectant management.
Ø
Ø Consider tocolysis if the woman is in labour to allow time for
completion of antenatal corticosteroid provided there is no
evidence of maternal or fetal compromise.
Ø
Ø Allow labour if completed antenatal corticosteroid.
Ø
Ø If leaking has stopped, vital signs are stable, blood and
ultrasound scan parameters are normal, consider allowing
hospital outpatient management. Timing of birth should be
discussed with women on an individual basis with careful
consideration of patient preference and ongoing clinical
assessment.

146
8) Fetal Neuroprotection with IV MgSO4
9) If chorioamnionitis is suspected, delivery is indicated irrespective of
the gestational age
a. Take blood and urine for culture and sensitivity and start IV broad spectrum
antibiotics.
b. Aim for vaginal delivery unless suspected fetal compromised or other
obstetric indications.
c. After delivery, take a placental swab at the chorion-amnion interface to
send for culture and sensitivity.
Adapted from:
Reference:
1. Care of women presenting with suspected preterm prelabour rupture of membranes
from 24+0 weeks of gestation. Green-top guideline No. 73. June 2019.
2. Guidelines on Induction of Labour2021, Ministry of Health Malaysia.
3. Magee LA, De Silva DA, Sawchuck D et. al. NO. 376 Magnesium sulphate for fetal
neuroprotection. J Obstet Gynaecol Can 2019;41(4):505-522
7) PPROM happened at the threshold of viability or earlier before 24 weeks
a. Mid-trimester PPROM, especially when it is associated with anhydramnios,
has a somber prognosis (fetal lung hypoplasia and limb contracture).
b. Paediatric team should be informed if delivery is anticipated. Women
should have the opportunity to meet the paediatric team for counseling.
Gestational age Magnesium sulfate usage in imminent preterm birth
or at least 4 hours prior to a planned preterm birth
23+0
to 23+6
weeks Should be discussed based on individual cases.
24+0
to 29+6
weeks Should be offered.
30+0
to 33+6
weeks Should be considered.

147
Preterm Labour
E10.
1) Overview
Preterm labour is defined as onset of labour (characterized by regular uterine
contraction with cervical dilatation and effacement leading to descent of the
fetus) from 22+0
to 36+6
weeks of gestation.
2) Identify predisposing factors
a. PPROM
b. Infection
c. Placental abruption
d. Placenta praevia
e. Multiple pregnancy
f. Polyhydramnios
g. Trauma
h. Fetal anomaly
3) Assessments
a. Vital signs
Ø
Ø Blood pressure (hypertensive disorders in pregnancy can lead to
placental abruption, hypotension can be due to septic shock or
haemorrhagic shock in placental abruption)
Ø
Ø Pulse rate
Ø
Ø Temperature (tachycardia and fever will indicate underlying infection).
b. Abdominal examination
Ø
Ø Symphysio-fundal height
Ø
Ø Fetal lie and presentation
Ø
Ø Uterine irritability/tenderness
Ø
Ø Signs of other intra abdominal infections.
c. Speculum examination
Ø
Ø Cervical dilatation, fetal presentation, membrane intact or not, presence
of liquor or blood.
d. Ultrasound scan
Ø
Ø Fetal parameters, lie, presentation and estimated fetal weight
Ø
Ø Placenta site
Ø
Ø Amniotic fluid index
Ø
Ø Transvaginal scan to assess cervical length (a cervical length of < 15mm
increases the likelihood of preterm birth within the next 7 days).

148
4) Investigation
Ø
Ø Full blood count for haemoglobin, total white cell count and platelet count.
Ø
Ø Urine FEME and culture and sensitivity to rule out urinary tract infection.
Ø
Ø Low vaginal swab and rectal swab to rule out infection/ group B
streptococcus.
5) Management
a. The aim of management is to optimize the fetal outcome while ensuring
maternal well-being is not compromised.
b. Antenatal corticosteroid
c. Proven to reduce rates of neonatal death, respiratory distress syndrome and
intraventricular haemorrhage.
d. Dosage: IM Dexamethasone 12 mg BD x 2 doses or IM Dexamethasone 6
mg BD x 4 doses for women with diabetes and delivery is not imminent.
e. Maximal benefit of antenatal corticosteroid is achieved 24 hours and up to
7 days after completion of the 24 mg dexamethasone.
f. Birth should not be delayed for antenatal corticosteroid if the indication for
birth is impacting the health of the woman or her baby.
g. WHO recommends a single rescue course of antenatal corticosteroids
if women below 34 weeks gestation remain at high risk of preterm birth
and more than 7 days have elapsed since previous treatment. However,
women should be informed that currently there is limited evidence to
recommend this practice as there is no reduction in serious morbidity or
long-term benefits have been seen, but it may reduce the need for neonatal
respiratory support.
h. Antenatal corticosteroid therapy should be used with caution in
chorioamnionitis or ongoing systemic infection.
Below 24 weeks Consultant-led discussion with the woman.
24+0
– 34+6
weeks Offer to all women if preterm birth is anticipated
(established preterm labour, PPROM or planned
preterm birth).
35+0
– 36+6
weeks Short term respiratory benefit should be weighed
against the risk of neonatal hypoglycaemia and long-
term neurodevelopmental concerns.

149
6) Tocolysis
a. Tocolysis is recommended for spontaneous preterm labour between 24+0
and 34+6
weeks.
b. It permits a course of antenatal corticosteroids to be administered, and
enables transfer of the mother to a facility with better neonatal care if
needed.
c. Contraindications: maternal or fetal compromise, vaginal bleeding,
placental abruption or intrauterine infection.
d. WHO considered nifedipine to be the preferred option as the balance of
benefits and harms, cost, acceptability and feasibility was superior to other
tocolytic agents.
e. Oxytocin receptor antagonists and nitric oxide are more costly.
f. Betamimetics have higher side effects, which may sometimes be life-
threatening.
g. Nifedipine
Ø
Ø Loading dose: 20mg every 30 minutes x 3 doses
Ø
Ø Maintenance dose: 20 mg TDS for 2 days
Ø
Ø Monitoring: uterine contraction, blood pressure, pulse rate, fetal heart
rate monitoring.
Ø
Ø CTG monitoring can be done from 28 weeks of gestation onwards.
Ø
Ø Side effects: flushing, headache, hypotension, tachycardia, palpitation,
giddiness or nausea.
7) Fetal Neuroprotection with IV Magnesium sulfate
a. Magnesium sulfate has been proven to reduce the incidence of cystic
periventricular leukomalacia and cerebral palsy in preterm birth.
Gestational age Magnesium sulfate usage in established preterm labour
or having a planned preterm birth within 24 hours.
23+0
to 23+6
weeks Should be discussed based on individual cases.
24+0
to 29+6
weeks Should be offered.
30+0
to 33+6
weeks Should be considered.
b. Dosing:
Ø
Ø Loading dose: Intravenous 4g bolus over 15 minutes
Ø
Ø Maintenance dose*: Intravenous 1g/hour until delivery or for 24 hours
(whichever sooner).
* One meta-analysis has not shown any benefit of maintenance dose
after loading compared with loading dose alone (8).

150
8) Intrapartum antibiotic as GBS prophylaxis
a. Offer antibiotics during labour to women who are in preterm labour.
b. IV ampicillin 2g stat then 1g 4 hourly or IV Benzylpenicillin 3g stat then
1.5g 4 hourly or IV clindamycin 900mg stat then 8 hourly in women with
penicillin allergy.
9) Delivery
a. Allow vaginal delivery if cephalic presentation.
b. Episiotomy should not be done routinely.
c. If women are less than 34 weeks of gestation, avoid fetal scalp electrode,
fetal scalp sampling and vacuum assisted delivery.
d. A normal cardiotocography trace is reassuring, but an abnormal trace does
not necessarily indicate fetal hypoxia or acidosis especially in extreme
preterm labour between 23+0
and 25+6
weeks of gestation.
c. Monitoring:
Ø
Ø Monitor for magnesium toxicity hourly by checking the blood pressure,
pulse rate, respiratory rate and deep tendon reflexes.
Adapted from:
2. Obstetrics Protocol O&G Department Hospital Tuanku Fauziah Kangar Perlis 2020-2025.
Reference:
1. Preterm labour and birth. NICE guideline. November 2015.
2. Antenatal corticosteroids to reduce neonatal morbidity and mortality. Green-top
guideline No. 74. July 2022.
3. WHO recommendations on antenatal corticosteroids for improving preterm birth
outcomes 2022.
4. WHO recommendation on tocolytic therapy for improving preterm birth outcomes
2022.
5. Prevention of early-onset neonatal Group B Streptococcal disease. Green-top guideline
No.36. September 2017.
6. Care of women presenting with suspected preterm prelabour rupture of membranes
from 24+0 weeks of gestation. Green-top guideline No. 73. June 2019.
7. Magee LA, De Silva DA, Sawchuck D et. al. NO. 376 Magnesium sulphate for fetal
neuroprotection. J Obstet Gynaecol Can 2019;41(4):505-522.
8. Crowther CA, Middleton PF, Voysey M et al. Assessing the neuroprotective benefits for
babies with antenatal magnesium sulphate: an individual participant data meta-analysis.
PLoS Med 2017;14:e1002398.

151
Obstetric Emergencies
F
SECTION

152
Maternal Collapse
F1.
Definition
An acute event involving the cardiorespiratory systems and/or central
nervous systems, resulting in a reduced or absent conscious level
(and potentially cardiac arrest and death), at any stage in pregnancy
and up to 6 weeks after birth.
Causes
Diagnosis Unresponsive woman with no breathing or abnormal breathing
4Hs 4Ts 1E
Ø
Ø Hypovolaemia
-
- Bleeding
(including non-
obstetric causes)
-
- Septic shock
-
- Neurogenic
shock
Ø
Ø Hypoxaemia
-
- Cardiomyopathy
-
- Acute pulmonary
oedema
-
- Myocardial
infarction
-
- Aortic dissection
Ø
Ø Hypo/
hyperkalaemia
Ø
Ø Hypothermia
Ø
Ø Thromboembolism
-
- Pulmonary
embolism
-
- Amniotic fluid
embolism
-
- Air embolism
Ø
Ø Toxicity
-
- Local anaesthetic
-
- Anaphylaxis
-
- Magnesium
toxicity
Ø
Ø Tension
pneumothorax
Ø
Ø Tamponade (cardiac)
Ø
Ø Eclampsia
-
- Intracranial
haemorrhage

153
Early
assessment
D – Danger
Ø
Ø Assess for danger especially if collapse happens in a community
setting
R – Response
Ø
Ø Assess for response by tapping on a woman’s shoulder and saying
“Hello! Hello! Are you ok?”
A – Alert
V – Responding to verbal stimulus
P – Responding to pain stimulus
U – Unresponsive
Ø
Ø If there is response, put the woman in recovery position
Ø
Ø If there is no response to call for help and trigger CODE BLUE/RED
ALERT (depending on local code)
Management
Call for help – Assign a person to call for help and provide situation and
location; trigger CODE BLUE or RED ALERT (depending on the local
protocol); at least 4 responders for BLS
Effective communication in the resuscitation team which consists of a
leader, provider of compressions, scriber, runner and etc.
ABC is no longer recommended in the 2015 ILCOR (International
Liaison Committee on Resuscitation) Guidelines.
C – Circulation
Check for pulse immediately if patient unresponsive;
Ø
Ø If pulse is present, check breathing
• If pulse is present and there is abnormal breathing, administer one
breath every 5-6 seconds and reassess pulse every 2 minutes
• If pulse is present and breathing is normal, to put patient in
recovery position

154
Management
Ø
Ø If pulse is absent, start effective chest compression; note the time:
• Manual left uterine displacement is recommended to reduced
aortocaval compression if uterus is > 20 weeks size i.e. palpable
above umbilicus
• After 30 compressions, open airways (A) and deliver 2 rescue
breaths (B)
• Use bag-valve-mask with oropharyngeal airway and 100% oxygen
with flow rate of at least 15 L/min
• Hold mask using E-C or E-O method
• Open airway with head tilt-chin lift (avoid moving the neck if
cervical spine injury is suspected)
• Deliver each breath over 1 second and watch for chest rise
• If no chest rise, reopen airway, improve seal and try again
• Attach AED/cardiac monitor and SpO2
monitor if available
Ø
Ø Check rhythm/pulse every 2 minutes (5 cycles of 30:2)
• Check for pulse for 5-10 seconds
• If no pulse or unsure, resume CPR
• If AED is attached and shock is recommended, administer shock
followed by immediate CPR for another 2 minutes before next
rhythm check
Ø
Ø Advanced airway management with cuffed endotracheal tube should
be attempted once expertise available
Ø
Ø CPR should be continued until ROSC or a decision to stop by
obstetrician.
Management
Resuscitative Hysterotomy/Perimortem caesarean section (PMCS):
Ø
Ø If there is no return of spontaneous circulation (ROSC) within 4
minutes, resuscitative hysterotomy/PMCS should be performed in all
women above 20 weeks of gestation
Ø
Ø There is no need to check fetal viability before proceeding with
delivery
Ø
Ø It should be done at the site of collapse
Ø
Ø The minimum equipment required should be fixed blade scalpel and 2
umbilical cord clamps (Refer to Appendix)
Ø
Ø If resuscitation is successful, transfer to operating theater for proper
anaesthesia and to control bleeding and complete the operation
Ø
Ø CPR should be continued during resuscitative hysterotomy/PMCS
Management

155
Management
Concurrent management
Ø
Ø To look for reversible causes and treat accordingly; full assessment
from head to toe
Ø
Ø In hospital setting:
• Insert 2 large bore cannula above level of diaphragm
• Blood investigations – FBC, Coagulation profile, Renal Profile, LFT,
GXM, blood glucose
• Fluid resuscitation
• Insert CBD
Subsequent management
Ø
Ø If resuscitation is successful, patient should be transferred to intensive
care unit
Ø
Ø Monitoring of fetus should be carried out if not delivered
Ø
Ø Debrief of patient, husband and family
Ø
Ø Proper documentation
Effective Cardiopulmonary Resuscitation
Rate /min Depth Ratio Location Special features
100-120
Ø
Ø 5-6 cm.
Ø
Ø Ensure full recoil
in between
compressions
without losing
contact
30:2 Ø
Ø Lower half of
sternum.
Ø
Ø Rescuer’s shoulders
should be above the
patient’s chest and
both arms should be
straight
Ø
Ø Apply backboard
if available
Ø
Ø Perform manual
Left Uterine
Displacement
(LUD)

156
Manual Left Uterine Displacement (LUD)
E-C and E-O methods
Manual left uterine displacement by the 2-handed
method from the left of the patient
E-C methods
Manual left uterine displacement by the 1-handed
method from the right of the patient
E-O methods

157
Flowchart 20: Summary of the management of maternal collapse

158
Adapted from:
1. O&G Protocol, State of Kedah, 2019.
2. Penang Stage Obstetric Protocol, 2021.
3. Obstetrics Protocol, O&G Department, Hospital Tuanku Fauziah, Kangar, Perlis, 2020-
2025.
4. Sarawak Advanced Life Support in Obstetric (SALSO) Course Manual 2022.
Reference:
1. Chu J, Johnston TA, Geoghegan J, on behalf of the Royal College of Obstetricians
and Gynaecologists. Maternal Collapse in Pregnancy and the Puerperium. BJOG
2020;127:e14-e52.
2. 2020 AHA Basic Life Support Guidelines.

159
Amniotic Fluid Embolism
F2.
Definition
Ø
Ø A condition in which amniotic fluid, fetal cells, hair or other debris
enters the maternal pulmonary circulation, causing cardiovascular
collapse.
Ø
Ø It is rare, sudden and unpredictable with high mortality rate of 60-
80%
Clinical
presentation
Ø
Ø High index of suspicion
Ø
Ø Classical clinical triad of sudden hypoxia, hypotension and followed
by coagulopathy, commonly occurs in relation to labour and
delivery; rarely occurs in first and second trimester
Risk factors
Ø
Ø High parity
Ø
Ø Amniotomy
Ø
Ø Induction or augmentation of labour
Ø
Ø Caesarean section
Ø
Ø Excessive uterine contraction
Ø
Ø Overdistension of uterus or high intrauterine pressure (i.e. in
placental abruption)
Ø
Ø Rupture of uterus
Diagnosis
It is a clinical diagnosis based on the typical clinical presentation
Absence of specific diagnostic test to diagnose or refute the diagnosis
of AFE
Early
assessment
Ø
Ø Assessment as in maternal collapse (refer to Maternal Collapse
Chapter)
Ø
Ø Early assessment cardiac status i.e. – ECG (Right axis deviation)
Ø
Ø ABG
Ø
Ø CXR – pulmonary oedema and perihilar infiltrates
Ø
Ø Early assessment of clotting status – coagulation profile, Fibrinogen
level

160
Management
Principles of management in AFE:
1. Call for help – trigger RED ALERT OR CODE BLUE depending on
the clinical situation
2. Immediate high-quality cardiopulmonary resuscitation - refer to
Maternal Collapse Chapter; with standard basic life support and
advanced life support protocols
3. Multidisciplinary involvement – anaesthetist, physician, blood bank
specialist and O&G specialist, paediatrician
4. Consider delivery in cardiac arrest with amniotic fluid embolism;
in cases where patient has ROSC before delivery via resuscitative
hysterotomy/PMCS
5. Adequate oxygenation and ventilation with haemodynamic support
– to maintain maternal cardiac output
a. Avoid excessive fluid resuscitation
b. Inotropic support for the right ventricular failure
c. Decrease pulmonary afterload
6. Correct coagulopathy – activate Massive Transfusion Protocol if
necessary
a. Uterine atony is a common complication of AFE; aggressive
management of uterine atony is recommended (refer to
Obstetric Haemorrhage Chapter)
b. Careful assessment and management for genital tract trauma
especially in operative vaginal delivery
7. Post-resuscitation monitoring in intensive care unit with
multidisciplinary teams’ involvement
8. Documentation and debriefing

161
Flowchart 21: Summary of the management of AFE
Adapted from:
2025.
3. A Quick Guide to Labour Room Management, Department of O&G, Hospital Tengku
Ampuan Afzan, Kuantan & Department of O&G, Kulliyyah of Medicine, IIUM, Kuantan,
3rd
Edition.
Reference:
1. Society for Maternal-Fetal Medicine (SMFM) with the assistance of Pacheco LD, Saade
G, et al. Amniotic fluid embolism: diagnosis and management. Am J Obstet Gynecol
2016;215:B16-24.

162
Obstetric Haemorrhage
F3.
Definition
Obstetric haemorrhage encompasses bleeding from genital tract during
pregnancy (antepartum haemorrhage) and after delivery (postpartum
haemorrhage)
Antepartum Haemorrhage (APH)
Bleeding from genital tract occurring after 22 weeks of pregnancy
Postpartum Haemorrhage (PPH)
1. Primary PPH – Bleeding from genital tract occurring within 24 hours
after delivery
• ≥ 500 ml after vaginal delivery
• ≥ 1000 ml after caesarean section
2. Secondary PPH – Abnormal bleeding occurring after 24 hours up to
42 days after delivery
Early
assessment
Early assessment in obstetric haemorrhage to determine:
1. The severity of the haemorrhage
2. The cause(s) of bleeding
Assessment should be comprehensive, quick and precise, including
examination from head to toe, assessment of patient’s conscious level,
alertness and vital signs.
Assessment of the severity of the haemorrhage can be based on:
1. Visual estimation of blood loss according to picture below
-
- The assessment should be continuous process
-
- Tend to underestimate blood loss
-
- The visualized vaginal bleeding in concealed placental abruption
might not be representative of the severity of the situation
2. Clinical signs and symptoms of hypovolaemic shock
-
- Tachycardia is the early signs of hypovolaemia
-
- The clinical signs and symptoms of shock according to the stages
of shock is shown in Table 1
3. Obstetric Shock Index (OSI)
-
- Shock index is the ratio of heart rate to systolic BP
-
- It is used as an early marker of compromise
-
- For pregnant population, normal SI ranges from 0.7-0.9; SI ≥ 1
predicts adverse clinical outcome

163
Definition
Assessment to identify the cause(s) of bleeding:
Management
Principles of management obstetric haemorrhage are:
1. Call for help and resuscitation according to the severity of the
situation
2. Fluid resuscitation and blood transfusion to be done simultaneously
with management to arrest bleeding
3. In non-specialist hospital, transfer patient once patient is stabilized
and bleeding controlled with temporary method; anti-shock garment
is recommended in PPH if available
4. Post-event monitoring in HDU or ICU depending on the severity;
documentation and debriefing
Antepartum haemorrhage Postpartum haemorrhage
1. Placental abruption
2. Placenta praevia
3. Local causes (including
uterine rupture)
4. Indeterminate APH
5. Vasa praevia
Primary PPH
1. Tone (uterine atony)
2. Trauma (including uterine
rupture)
3. Tissue (retained placenta or
tissue)
4. Thrombin (coagulopathy)
Secondary PPH
1. Infection (most common)
2. Retained product of conception
3. Unrecognized genital tract
trauma
4. Bleeding disorder
5. Persistent trophoblastic disease
(uncommon)
6. Others – chronic subinvolution
of uterus, uterine AV
malformation (rare)

164
Management
Major obstetric haemorrhage
Minor obstetric
haemorrhage with no
evidence of shock
1. Call for help – to involve obstetrician
and medical officers, anaesthetist
and anaesthetic medical officers,
midwives, blood bank personnel, and
identify runners.
2. Trigger RED ALERT once there is
MASSIVE HAEMORRHAGE (blood
loss ≥ 1500ml) or when the patient is
clinically unstable, regardless of the
blood loss.
3. Assessment and resuscitation:
Ø
Ø Assess DR CAB – manage as per
Maternal Collapse Chapter if
patient collapses
Ø
Ø Place the patient flat and warm
the patient
Ø
Ø Oxygen supplementation at the
rate of 15 L/min via facemask
Ø
Ø Set 2 large bore intravenous
cannula – 14G or 16G
Ø
Ø Take blood for FBC, Coagulation
screen, renal profile and GXM 4
pints packed cells
Ø
Ø Fluid resuscitation with crystalloid
while waiting for blood products
Ø
Ø Blood transfusion is usually
needed; transfusion with Safe O if
the need arises
Ø
Ø Activate Massive Transfusion
Protocol (MTP)
4. Monitor vital signs every 15 minutes
or more often until patient is
stabilised
5. Continue to assess the blood loss and
OSI if there is ongoing lost
6. Monitor fetus in APH
7. Arrest bleeding according to the
cause of bleeding.
1. Call for help –
obstetrician and
medical officers and
midwives
2. Assessment and
resuscitation:
Ø
Ø Set 1 large bore
intravenous cannula;
may consider
second cannula if
bleeding continues.
Ø
Ø Take blood for FBC,
Coagulation screen
and GXM 2 pints
packed cells
Ø
Ø Fluid resuscitation;
blood transfusion
rarely needed
3. Monitor vital signs
every 15 minutes
4. Continue to assess the
blood loss and OSI if
there is ongoing lost
5. Monitor fetus in APH
6. Arrest bleeding
according to the cause
of bleeding
Management

165
Clinical stages of shock
Visual estimation of blood loss
A. Sanitary pads
Stage
Blood loss (ml) (%
of blood volume)
based on body
weight of 50 kg
Pulse
rate
(beats
per min)
Blood
pressure
Respiratory
rate
(breaths per
min)
Mental
status
Urine
output
(ml/H)
I
Up to 750 ml
(< 15%)
< 100 Normal 14 - 20 Normal > 30
II
750 – 1500 ml
(15 – 30%)
> 120
Normal
but may
have
narrow
pulse
pressure
20 - 30 Anxious 20 – 30
III
1500 – 2000 ml
(30 – 40%)
> 120 Reduced 30 - 40 Confused 5 – 15
IV
> 2000 ml
(> 40%)
> 140
Very low,
can be not
recordable
> 35 Lethargic Nil

166
B. 500 ml kidney dish
C. Linen Protector

167
D. Sarong
E. Vaginal pack
Source: Hospital Tuanku Ja’afar, Negeri Sembilan O&G Protocol, 2018.

168
Antepartum Haemorrhage (APH)
F3.1
Definition Bleeding from genital tract occurring after 22 weeks of pregnancy
Causes of
APH
1. Placental abruption
2. Placenta praevia
3. Local causes
4. Indeterminate APH
5. Vasa praevia
Clinical
presentation
Refer to Table Clinical Presentation and Assessment of APH.
Early
assessment
1. Assessment of the severity of the haemorrhage can be based on
visual estimation of blood loss, clinical signs and symptoms of
hypovolaemic shock and Obstetric Shock Index (OSI).
2. Visual estimation of blood loss may not be representative in
concealed placental abruption.
3. Assessment to determine the cause based on the clinical presentation
shown in Table Clinical Presentation and Assessment of APH.
Classification of APH according to severity
Spotting
Minor
Major
Massive
Staining, streaking or blood spotting noted on underwear
or sanitary protection
Blood loss less than 50 ml that has settled
Blood loss of 50-1000 ml with no signs of clinical shock
Blood loss > 1000 ml and/or signs of clinical shock
Source: Green top guideline No. 63. Antepartum Haemorrhage. Royal
College of Obstetricians and Gynaecologists. 2011.

169
Management
1. Call for help
2. Fluid resuscitation and blood transfusion as per obstetric
haemorrhage
3. In non-specialist hospital, transfer patient to center with O&G
specialist for further management once patient is stabilized
4. Arrest bleeding according to the causes:
Ø
Ø
Ø Placenta praevia
Ø
Ø Local cause
• Bleeding usually stops with compression or packing
• Delivery is rarely indicated
• In case of suspected carcinoma of cervix, biopsy should be
taken.
Ø
Ø Indeterminate APH
• Diagnosis of exclusion
• For in-patient care and monitoring
• Expectant management as outpatient after discharge with
careful monitoring of fetal growth by FMS/O&G
• Delivery by 40 weeks gestation

170
Table
Clinical
presentation
and
assessment
of
APH

171
Flowchart 22: Management of APH secondary to placental abruption

172
Flowchart 23: Management of APH secondary to placenta praevia

173
Postpartum Haemorrhage (PPH)
F3.2
Primary PPH Secondary PPH
Definition
Bleeding from genital tract
occurring within 24 hours after
delivery:
• ≥ 500 ml after vaginal delivery
• ≥ 1000 ml after caesarean
section
Abnormal bleeding from genital
tract occurring after 24 hours up to
42 days after delivery
Causes of
primary PPH
4T’s:
1. Tone (uterine atony)
2. Trauma (including uterine
rupture)
3. Tissue (retained placenta or
tissue)
4. Thrombin
1. Infection (most common)
2. Retained product of conception
3. Unrecognized genital tract
trauma
4. Bleeding disorder
5. Persistent trophoblastic disease
(uncommon)
6. Others – chronic subinvolution
of uterus, uterine AV
malformation (rare)
Clinical
presentation
Refer to Table: Clinical Presentation and assessment of PPH
Early
assessment
Assessment of the severity of the haemorrhage can be based on visual
estimation of blood loss, clinical signs and symptoms of hypovolaemic
shock and Obstetric Shock Index (OSI).
Assessment to determine the cause of PPH based on the clinical
presentation shown in Table : Clinical Presentation and assessment of
PPH

174
Management
1. Call for help.
2. Fluid resuscitation and blood transfusion as per obstetric
haemorrhage.
3. Arrest bleeding according to the causes as shown in Arrest bleeding
according to the causes of Primary PPH and Table: Arrest bleeding in
Secondary PPH
4. Intravenous tranexamic acid infusion can be used in management of
PPH from any cause (WOMAN Trial):
Ø
Ø Dose: 1gm (100 mg/ml); infuse over 10 minutes (1 ml/min).
Dose can be repeated if bleeding continues after 30 minutes or
rebleeding occurs within 24 hours.
Ø
Ø It should be given early in PPH.
Ø
Ø It can be given in all causes of bleeding.
5. In district hospital, transfer patient once patient is stabilized and
bleeding controlled with temporary method; anti-shock garment is
recommended if available

175
Table
Clinical
presentation
and
assessment
of
PPH

176
Causes Urgent Management
Tone
1. Perform uterine massage.
2. Empty urinary bladder with continuous bladder drainage.
3. Oxytocics (1st
line uterotonics)
Ø
Ø Oxytocin – IM Pitocin bolus 10 units or IV Pitocin bolus 5 units slow
bolus over 1 – 2 minutes.
• Dose may be repeated after 5 minutes – up to a total dose of
10 units.
• Start IV oxytocin infusion 40 units in 1 pint normal saline for 4
hours (125 ml/H).
Ø
Ø Syntometrine – IM 1 ampoule stat (5 units oxytocin and 0.5 mg
ergometrine); contraindicated in hypertension and cardiac disease.
4. Carboprost (Haemabate)
Ø
Ø IM 250 μg stat; can repeat up to a maximum of 8 doses at 15
minute intervals.
Ø
Ø HOWEVER, IF THE BLEEDING CONTINUES AFTER 3 DOSES,
CONSIDER SURGICAL METHODS TO STOP BLEEDING.
5. *Uterine tamponade with Bakri balloon (or Rusch balloon/modified
uterine tamponade with Foley’s catheter) * considered 1st line surgical
intervention.
Temporary measures while awaiting medications to work/ awaiting
theater/transfer:
- Bimanual uterine compression (Figure 4)
- Aortic compression (Figure 5)
- Anti-shock garment during transfer if available
*VAGINAL PACKING IS CONTRAINDICATED IN THE MANAGEMENT
OF PPH SECONDARY TO UTERINE ATONY, AS IT MAY CAUSE
HAEMATOMETRA WHICH MAY PERPETUATE UTERINE ATONY.
Causes of Primary PPH and its Management

177
Tone
6. If uterine tamponade fails or bleeding continues, the options of
surgical intervention include:
Ø
Ø Uterine preservation:
• B-lynch brace suture
• Uterine arteries ligation
• Internal iliac arteries ligation
Ø
Ø Hysterectomy – resort to hysterectomy sooner as it is potentially
lifesaving
Trauma
1. Vulval/vaginal tears
Ø
Ø Attempt immediate repair.
Ø
Ø If repair is not feasible or bleeding continues, control the bleeding
temporarily with vaginal packing while awaiting transfer or
definitive management.
Ø
Ø Examination under anaesthesia, repair may be indicated
Ø
Ø Embolization of bleeding vessel can be considered if service is
available
2. Uterine rupture
Ø
Ø There should be a high index of suspicion for uterine rupture in
PPH.
Ø
Ø Examination under anaesthesia would be necessary.
Ø
Ø Exploratory laparotomy and uterine repair/hysterectomy is
required in uterine rupture; hence early referral to O&G specialist
is of paramount importance and the patient should be transferred
as soon as possible after resuscitation.
3. Extended uterine tear
Ø
Ø Can occur during difficult caesarean i.e., deeply engaged
presenting part, deflexed fetal head, obstructed labour, fetal
malposition or abnormal lie.
Ø
Ø Can result in broad ligament haematoma, bladder/ureteric injury.
Ø
Ø Requires experienced surgeons to repair.
Ø
Ø Ensure adequate exposure of tear:
a. Exteriorised uterus
b. Extension of incision if needed
c. Good assistance and retraction
d. Further deflection of bladder downward (to avoid bladder/
ureteric injury)
e. Use the suction catheter to clear the surgical field

178
Tone
Ø
Ø Identify apex of tear and suture in 2 layers; if apex cannot be
identified and extends beyond the cervix, combined abdomino-
perineal approach may be necessary.
Ø
Ø If the tear extends laterally, open the broad ligament to secure the
apex. (Beware of potentially dangerous engorged venous plexus.)
• In this process, identification of ureter is crucial to prevent
ureteric injury
Ø
Ø Insert drain upon closing the abdomen.
Ø
Ø In non-specialist hospitals, haemostasis with abdominal packing
may be considered as a last resort if bleeding continues.
Ø
Ø Consider activating retrieval team if theirs is difficulty in securing
bleeding in such cases in non-specialist hospital
Ø
Ø Coagulopathy needs to be corrected during transfer and before
relaparotomy.
Tissue
1. If there is major bleeding secondary to retained placenta/tissue,
urgent manual removal of placenta/tissue (MRP) is indicated.
2. Temporary measures to control bleeding:
Ø
Ø Start IV oxytocin 40 units infusion if the patient is actively bleeding.
Ø
Ø Arrange for urgent manual removal of placenta (MRP)
Ø
Ø It should ideally be done in an OT setting.
Ø
Ø However, if the patient is haemodynamically unstable and OT not
available, a bedside MRP can be done.
3. Preparation for OT
Ø
Ø Take consent.
Ø
Ø Give preoperative IV antibiotics – IV Ampicillin 2g single dose
according to National Antibiotic Guideline (may vary according to
local protocol)
Ø
Ø Monitor vital signs every 15 minutes.
Ø
Ø Pad charting to monitor bleeding while awaiting OT or during
transfer.
Ø
Ø Ensure the patient is under spinal or general anaesthesia in OT.
Ø
Ø Ensure the patient is in a lithotomy position.
Ø
Ø Ensure bladder is being drained.
Ø
Ø Oxytocin infusion if started earlier should be stopped during the
procedure.

179
Tissue
4. Removal of placenta:
Ø
Ø Introduce the operator’s hand into the uterine cavity by following
the umbilical cord.
Ø
Ø Stabilize the uterus bimanually and identify a plane of cleavage. By
moving the fingers from side to side (see-saw pattern), extend the
plane of cleavage until the whole placenta is free from the uterine
wall. Remove the placenta in one bulk.
5. Ensure uterine cavity is empty
Ø
Ø Check placenta and membrane for completeness.
Ø
Ø If not complete, digitally re-explore the uterine cavity to remove
any remnants.
Ø
Ø Once empty, start IV oxytocin 40 units infusion at 125mls/H to
maintain uterine contractility.
Thrombin
Transfusion of blood components is the mainstay of management in PPH
secondary to coagulopathy. Uterine tamponade and vaginal packing
can be done to stop the bleeding temporarily while correcting the
coagulopathy.
Urgent
Management
1. Intravenous tranexamic acid 1 g (10 ml) over 10 minutes.
2. Broad spectrum intravenous antibiotics – usually intravenous
cefuroxime/ceftriaxone and metronidazole.
3. Give uterotonics as indicated.
Subsequent
Management
1. For surgical evacuation of the uterus where retained tissue is
suspected – the procedure can be done immediately in the event of
massive bleeding, or after 12 hours of antibiotic cover, with the last
dose of antibiotic given within an hour of the procedure.
2. Procedure should be performed by an experienced obstetrician
and preferably under ultrasound guidance as the risk of uterine
perforation is significantly higher.
3. In massive bleeding with an empty uterus, uterine tamponade with
balloon catheter may be considered with antibiotic cover.
* When conservative measures fail, and bleeding is massive, surgical
measures such as hysterectomy may be undertaken.
Arresting bleeding in Secondary PPH

180
Bimanual compression
B-Lynch brace suture
Anterior view Posterior view Anterior view
Source: Sarawak Advanced Life Support in Obstetric (SALSO) Course Manual 2022
Aortic compression

181
Adapted from:
1. O&G Protocol, State of Kedah, 2019
2025.
3rd
Edition.
Reference:
1. Green top guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians
and Gynaecologists. 2011.
2. Mavrides E, Allard S, Chandraharan E, Collins P Green L, Hunt Bj, Riris S, Thompson Aj
on behalf of Royal College of Physicians. Prevention and management of postpartum
haemorrhage. BJOG 2016.
3. National Technical Committee – Confidential Enquiries into Maternal Deaths. Training
manual on management of postpartum haemorrhage. 2016.
4. WHO. WHO recommendations for the prevention and treatment of postpartum
haemorrhage. Geneva: World Health Organisation. 2012.
5. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality,
hysterectomy, and other morbidities in women with post-partum haemorrhage
(WOMAN): an international randomized, double-blind, placebo-controlled trial. Lancet
2017; 389: 2105 – 16.

182
Preeclampsia with Severe Features and Eclampsia
F4.
Presentation
Blood pressure
Central nervous
system
Cardiorespiratory
system
Renal
Liver
Haematological
Fetal
complications
Ø
Ø Severe hypertension (SBP ≥ 160 or DBP ≥ 110)
Ø
Ø Headache; blurring of vision; Eclampsia;
Intracerebral haemorrhage/ Cerebrovascular
accident
Ø
Ø Pulmonary oedema
Ø
Ø Cardiac dysfunction/myocardial ischaemia or
infarction
Ø
Ø Renal impairment
Ø
Ø Elevated liver enzymes
Ø
Ø Subcapsular haematoma
Ø
Ø Haemolysis and low platelet
Ø
Ø DIVC
Ø
Ø Fetal growth restriction/abnormal doppler/
abnormal liquor volume
Ø
Ø Intrauterine death
Ø
Definition of
Preeclampsia
Hypertension (BP ≥ 140/90) developed after 20 weeks of gestation with
one of the following Preeclampsia defining features:
1. Proteinuria of ≥300 mg/day or urine protein/creatinine ratio of ≥30
mg/mmol
2. Maternal organ dysfunction:
a. Renal insufficiency (creatinine ≥ 90 mmol/L)
b. Liver involvement (elevated transaminases and/or severe right
upper quadrant or epigastric pain)
c. Neurological complications (eclampsia, altered mental status,
blindness, stroke or more commonly hyperreflexia when
accompanied by clonus, severe headaches and persistent visual
scotomata)
d. Haematological complications (thrombocytopenia, DIC,
haemolysis)
3. Uteroplacental dysfunction – Fetal growth restriction
4. Others – pulmonary oedema, placental abruption, oliguria, epigastric
pain/RHC pain
Diagnosis Patient presented with any one of the severe features listed above
Severe Features of Preeclampsia

183
Management
1. Call for help to involve O&G
Specialist/medical officers,
midwives, paediatrician/ medical
officers, anaesthetist, blood bank
specialist if necessary.
2. Manage as per maternal collapse
in maternal collapse Chapter
3. Resuscitation and stabilisation
of patient including advanced
airway management and fluid
resuscitation in abruptio placenta
4. Definitive management done
simultaneously with resuscitation:
Ø
Ø Control and prevent further
seizure
Ø
Ø Control blood pressure
Ø
Ø Fluid management
Ø
Ø Monitoring of mother and fetus
Ø
Ø Delivery
Definitive management:
1. Control and prevent further
seizure
2. Control blood pressure
3. Fluid management
4. Monitoring of mother and
fetus
5. Delivery
Ø
Ø Delivery is indicated in
ALL preeclampsia with
severe features EXCEPT
in cases where fetal
growth restriction is the
ONLY severe feature of
preeclampsia especially
at early gestation; In
such circumstances,
delay in delivery may be
indicated with careful
fetal surveillance to allow
maturity of the fetus
Early
assessment
1. Comprehensive history to elicit the symptoms of severe features and
complication of preeclampsia
2. Examination from head to toe
Ø
Ø Blood pressure and heart rate, SpO2
Ø
Ø Systemic examination – cardiovascular, lungs and abdomen
Ø
Ø Reflexes and clonus
3. Investigation – FBC, Renal profile, LFT, Coagulation profile in
suspected DIVC or in abruptio placenta, LDH in cases of HELLP
Syndrome
Preeclampsia with acute events
(eclampsia, acute pulmonary
oedema, abruptio placenta or
maternal collapse)
Preeclampsia with
severe features
(but clinically stable)
1. Post delivery monitoring in high dependency unit/intensive care unit
2. Debriefing of patient and family
3. Documentation

184
Magnesium Sulfate as the agent of choice to control
and prevent seizure
F4.1
1) Dose and dilution of intravenous Magnesium Sulphate:
Indications
Infusion pump Syringe pump
Dose 4 g 1 g/H 1 g/H
Concentration
1 ampoule
= 2.47 g/5 ml
1 ampoule
= 2.47 g/5 ml
Withdraw 2 ampoules
(5 g/10 ml) of MgSO4
+
40 ml of normal saline
= 5 g/50 ml (1 g/10 ml)
Preparation
Withdraw 8 ml (4 g)
of MgSO4
+ 12 ml of
normal saline = 20 ml
Withdraw 10
ampoules (50 ml) of
MgSO4
+ 450 ml of
normal saline
Infusion rate: 10 ml/H
(1 g/H)
Continue infusion of
MgSO4
for 24 hours
after delivery or last
seizure, whichever
occurs later.
Administration
To give 4 g MgSO4
in
slow bolus over 15 – 20
minutes
(1 g/H)
MgSO4
for 24 hours
seizure, whichever
occurs later.
(1 g/H)
MgSO4
for 24 hours
seizure, whichever
occurs later.
Maintenance dose
In cases where seizure occurs after administration of MgSO4
, a further bolus of 2–4g
(2 g if weight < 70 kg) MgSO4
can be given with close monitoring of Mg level. Serum
magnesium can be taken before the repeated bolus of MgSO4
if the situation allows.

185
2) Dose and dilution of intramuscular Magnesium Sulphate
*Source: International Society of Study for Hypertension in Pregnancy, 2021
Loading dose Maintenance dose
Dose
Total of 14 g
(IM 5 g each buttock + IV 4 g)*
5 g every 4 hours (alternate
buttocks)
Concentration 1 ampoule = 2.47 g/5 ml 1 ampoule = 2.47 g/5 ml
Preparation
Withdraw 2 ampoules (5 g/10
ml) of MgSO4
+ 1ml of local
anaesthesia (for each buttock)
*Refer above table for IV
preparation
Withdraw 2 ampoules (5 g/10 ml) of
MgSO4
+ 1ml of local anaesthesia
Administration
Deep intramuscular injection into
each buttock
*Refer above table for IV
administration
Deep intramuscular injection into
alternate buttock every 4 hourly
until 24 hours after delivery or last
seizure, whichever occurs late
In cases where seizure occurs after administration of MgSO4
, a further bolus of 5 g
intramuscular MgSO4
can be given with close monitoring of Mg level. Serum magnesium
can be taken before the repeated bolus of MgSO4
if the situation allows.

186
Control of Blood Pressure
F4.2
There is a need to urgently control BP in severe hypertension, as BP of ≥ 160/110
mmHg is associated with risk of stroke in pregnancy.
Major considerations in controlling blood pressure in severe hypertension
1. Oral nifedipine and parenteral labetalol are the agents of choice when BP is ≥
160/110 mmHg as both are equally effective.
a. However, when systolic blood pressure is ≥ 180 mmHg, blood pressure
should be controlled more rapidly with intravenous antihypertensive agents.
b. Parenteral hydralazine is used when labetolol is contraindicated or fails to
control BP.
c. Intravenous glyceryl trinitrate (GTN) can be considered in cases of resistant
hypertension.
2. In the acute setting of stabilisation of severe hypertension, aim to lower BP to
non-severe level instead of normalization of blood pressure.
3. Target BP should be 140 – 159/90 – 109 mmHg to avoid maternal hypotension
and thus, avoid compromising uteroplacental perfusion.
4. Blood pressure should be monitored regularly at interval of 5 – 10 minutes to
identify maternal hypotension.
5. Close fetal monitoring is recommended while trying to control the BP. If the
gestation is less than 28 weeks, fetal heart rate should be checked at 5 – 10
minutes interval with daptone.
6. The dosage and dilution of intravenous antihypertensive may differ from
centres to centres.

187
Maternal Monitoring
F4.3
1. Monitoring for MgSO4
toxicity
Ø
Ø Therapeutic level of serum Mg – 1.7-3.5 mmol/L
Ø
Ø Antidote for Mg toxicity – calcium gluconate (1g calcium gluconate (10ml of
10% solution) given over 10 minutes slow bolus)
2. Frequency and target monitoring for Magnesium toxicity:
3. Management of suspected Magnesium toxicity:
Parameters Interval of monitoring Target
Blood pressure 15 minutes ≤135/85 mmHg
Pulse rate 15 minutes 60 - 100 bpm
Respiratory rate
SpO2
30 minutes
30 minutes
16 breaths per minute
≥95%
Urine output Hourly ≥0.5ml/kg/hour
Deep tendon reflex of knee Hourly Presence of reflexes
Situation Assessment Management
Reduced urine
output (<0.5ml/
kg/H for over 4
hours)
Ø
Ø Hydration status
Ø
Ø Lungs examination
Ø
Ø Review fluid balance
Ø
Ø Check deep tendon
reflexes, respiratory rate,
heart rate
Ø
Ø Send renal profile and
serum Mg if available
Ø
Ø If tendon reflex is ABSENT,
STOP MgSO4
infusion
Ø
Ø If tendon reflex is
present, adjust infusion
rate according to serum
creatinine and Mg as
number 4.
Absence of deep
tendon reflex
Ø
Ø Check respiratory rate
and heart rate
Ø
Ø
Ø Stop MgSO4
infusion
Ø
Ø Perform ECG for evidence
of prolonged PR interval or
wide QRS complex
Ø
Ø Consider restarting infusion
at lower dose when reflexes
return

188
Situation Assessment Management
Respiratory
depression
Ø
Ø Check respiratory rate
and heart rate
Ø
Ø
Ø Stop MgSO4
infusion
Ø
Ø Maintain airway, put patient
in recovery position
Ø
Ø Consider giving IV calcium
gluconate
Respiratory arrest Ø
Ø Assessment is per
maternal collapse (DR
CAB)
Ø
Ø
Ø Stop MgSO4
infusion
Ø
Ø Maintain airway with
intubation and ventilation
Ø
Ø Give IV calcium gluconate
Serum
Magnesium Normal Elevated Not available
Within
therapeutic level
(1.7-3.5 mmol/L)
1 g/H 0.5 g/H with VERY careful
monitoring of urine output
and deep tendon reflex with
serial serum magnesium level
every 4 – 6 hours
Elevated 0.5 g/H STOP -
Not available 0.5 g/H STOP STOP
Serum Creatinine
4. Infusion rate of MgSO4
infusion according for serum creatinine and Mg in
cases with reduced urine output but presence of deep tendon reflex:
Fetal monitoring
F4.4
1. Ultrasound for fetal biometry, liquor volume +/- umbilical artery Doppler if
available.
2. Close fetal heart monitoring especially during control of BP. If electronic fetal
monitoring is not available, fetal heart rate should be monitored with daptone
at 15 minutes interval.

189
Gestational age Timing of Delivery
≥ 37 weeks
Delivery is indicated; mode of delivery is dependent on
maternal and fetal condition.
34 to 36+6
weeks
Delivery may be indicated and a decision for delivery should
be made in consultation with a specialist.
Antenatal corticosteroids may be considered. However,
delivery should NOT be delayed for completion of
corticosteroids if urgent delivery is indicated.
< 34 weeks
Decisions for delivery should be made in consultation with a
specialist/consultant.
Antenatal corticosteroids should be administered. However,
delivery should NOT be delayed for completion of
corticosteroids if urgent delivery is indicated.
Fluid Management
Time of Delivery
F4.5
F4.6
1. Total fluid given to women with severe hypertension (60-80 ml/H of crystalloid).
2. Strict input and output charting.
3. Fluid challenge, when indicated, should be done with careful assessment of the
woman’s hydration status and after consultation with a specialist.
4. Oral fluid restriction is not routinely practiced except in cases of proven
fluid overload, i.e., in acute pulmonary oedema. Women with fluid overload
should be managed in a high dependency unit/intensive care unit with co-
management from anaesthetist and physician.
5. Diuretics should NOT be given in the event of oliguria unless there is evidence
of acute pulmonary oedema.
1. The definitive management of severe hypertension in pregnancy is the
delivery of the placenta.
2. Timing of delivery in Preeclampsia with severe features/Eclampsia:
Women with pre-eclampsia are likely to have intravascular depletion due to loss of
fluid into extracellular space. This is due to reduced intravascular oncotic pressure
compounded by increased endothelial permeability due to endothelial injury.
General principles of fluid management are as below:

190
Flowchart 24: Summary of the preeclampsia with severe features/Eclampsia

191
Adapted from:
3rd
Edition.
Reference:
1. LA Magee, P von Dadelszen, W Stones, M Mathai. The FIGO textbook of pregnancy
hypertension. The Global Library of Women’s Medicine. October 2016.
2. L.A. Magee et al. The 2021 International Society of the Study of Hypertension in
Pregnancy classification, diagnosis & management recommendations for international
practice. Pregnancy hypertension: An International Journal of Women’s Cardiovascular
Health 27 (2022) 148-169.
3. NICE Guideline. Hypertension in Pregnancy: Diagnosis and management. 2019.
4. National Technical Committee – Confidential Enquiries into Maternal Deaths. Training
manual on hypertensive disorders in pregnancy. 3rd
Edition. 2018.

192
Uterine Inversion
F5.
Definition
Inversion of the fundus of the uterus into the endometrial cavity with
or without placenta being attached, turning the uterus partially or
completely inside out.
Risk factors
1. Implantation of placenta at the fundus, especially in cases of placenta
accreta spectrum
2. Uterine atony
3. Manual removal of placenta
4. Short umbilical cord
5. Congenital weakness of the uterus in connective tissue disorders
6. Iatrogenic – mismanagement of 3rd stage, in which there is excessive
traction on the umbilical cord and excessive fundal pressure before
separation of placenta
Clinical
presentations
1. High index of suspicion
2. Sudden unexplained maternal collapse or hypotension with
bradycardia
3. Postpartum haemorrhage
4. Severe abdominal pain
5. Absence of uterine fundus from abdominal palpation or uterine
dimple palpable
6. Mass protruding from vagina
7. Polypoidal red mass in the vagina with placenta attached
8. The severity of uterine inversion is being shown in figures below.
Early
assessment
1. Quick general examination for signs of hypovolaemia
2. Vital signs – hypotension and bradycardia may be present
3. Abdominal examination – uterine fundus not palpable or there may
be a dimple at the fundal area
4. Perineal examination – a mass in the vagina or outside the introitus
and assessment of blood loss
5. Investigations – FBC, Coagulation profile, Crossmatching for blood
Management
1) Resuscitation:
Ø
Ø Call for help and initiate red alert/code red - O&G specialist/
consultant, medical officers, midwives, anaesthetic team
Ø
Ø Resuscitation – check pulse, airway and breathing and CPR if
necessary; resuscitate as in obstetric haemorrhage
Ø
Ø Do not remove the attached placenta when the uterus is still
inverted

193
Management
2) Immediate replacement of uterus:
a. Manual replacement (Johnson Maneuver)
Ø
Ø Replace first the part of uterus which inverted last
b. Hydrostatic repositioning (O’Sullivan’s technique)
Ø
Ø Uterine rupture must be excluded first
Ø
Ø The inverted uterus is held within the vagina by the operator
and the introitus sealed with the 2 hands of an assistant
Ø
Ø 2 liters or more of warm saline is then infused into the vagina
using a large rubber tube held 1-2 meters above the patient.
The other end of rubber tube is place into posterior fornix of
vagina (A silicone vacuum cup attached to a large rubber tube
can also be used to produce a better seal)
3) Surgery – if all other attempts fail
a. Huntington’s operation
Ø
Ø Allis forceps are placed within the dimple of the inverted
uterus and gentle upward traction is applied on the clamps
with a further placement of forceps on the advancing fundus.
b. Hydrostatic repositioning (O’Sullivan’s technique)
Ø
Ø Incise the cervical ring posteriorly with a longitudinal incision.
This facilitates uterine replacement by Huntington’s method.
This is aided by an assistant from below.
*Consider uterine compression suture after successful replacement
of uterus
Management
4) Tocolytics – can be used during replacement of uterus:
Ø
Ø IV Salbutamol 75-150 mcg bolus, or
Ø
Ø S/C Terbutaline 0.25 mg
5) Maintenance of uterine contractility post reversion:
Ø
Ø Attendant’s hand should remain in the uterine cavity until a firm
contraction is sustained
Ø
Ø Uterotonics are given to maintain uterine contractility and prevent
re-inversion.
6) Watch out for postpartum haemorrhage
7) Debrief the couple
8) Proper documentation
Management

194
Severity of uterine inversion
F5.1
A. First degree
May feel a dimple at the top of
the fundus
Inverted uterus might not be
obvious as the fundus does not
herniate through the internal os
Inverted uterus herniates through
the cervical os with the entire
uterus still within vagina
The vagina is inverted
Uterine fundus will not be felt per
abdomen
The entire uterus is inverted and
protrudes outside the vulva
B. Second degree
C. Third degree
D. Fourth degree

195
Manual replacement (Johnson Maneuver)
F5.2
Replace the part of the uterus which inverted last,
first.
The other hand is used to support the fundus of the
uterus and helps in pushing the uterus in.
Note that the fundus is not yet replaced.
The lower part of the uterus is gradually replaced.
Once the uterus is in the abdomen, the supporting
hand is used to support the uterus on the abdomen.
The fundus, which is the part of the uterus to invert
first, is the last part that is replaced.
Keep your hand in the uterus and give oxytocics.
Once you feel the uterus contracting, do MRP.
Keep the hand in the uterus until the uterus is firmly
contracted on your hand.
Subsequently, gradually remove your hand

196
Hydrostatic repositioning (O’Sullivan’s technique)
F5.3
Insert one hand into introitus with
the tube connected to the drip.
Seal the opening with the help of an
assistant to prevent water leakage.

197
Flowchart 25: Summary of the management of uterine inversion
Adapted from:
2025.
3rd
Edition.
Reference:
1. Bhalla R, Wuntakal R, Odejinmi F, Khan RU. Review: Acute inversion of the uterus. The
Obstetrician & Gynaecologist. 2009; 11: 13-18.

198
Maternal Sepsis
F6.
Causes and
presentation
Call for Call for Call for
System Causes Presentation
Genitourinary Pelvic infection
(Chorioamnionitis,
Endometritis, abscess,
retained placenta)
Urinary tract infection/
Pyelonephritis
Secondary PPH, pelvic
pain, foul smelling vaginal
discharge
Abdominal pain, dysuria,
frequency,
Loin pain
Gastrointestinal AGE Diarrhoea/ vomiting
Respiratory URTI/ Influenza/
Covid-19
Pneumonia
Cough, sore throat,
rhinorrhea,
Shortness of breath
Central nervous
System
Meningitis/ encephalitis/
Abscess
Headache, confusion,
fitting
Dermatological Surgical site infection Pain, wound redness
Others Mastitis Breast pain,
engorgement, redness
Definition
Ø
Ø Sepsis is defined as organ dysfunction resulting from infection during
pregnancy, childbirth, post-abortion or postpartum period.
Ø
Ø Septic shock is defined as persistent hypoperfusion despite
adequate fluid replacement therapy.
Diagnosis
Ø
Ø High index of suspicion
Ø
Ø Screening for sepsis: Obstetrically Modified Quick Sequential Organ
Failure Assessment Score (omqSOFA)
A. Respiratory rate ≥ 25/min
B. Altered mentation (GCS < 15)
C. Systolic blood pressure ≤ 90mmHg
Ø
Ø All patients with an omqSOFA score of ≥ 2 are considered at high
risk of sepsis and should be resuscitated accordingly and referred to
a specialist

199
Early
assessment
Ø
Ø Screen for most likely source of sepsis by taking a focused history
based on the presenting complaint and perform a quick systemic
examination through all systems to ensure no other sources of sepsis
Ø
Ø Screen for sepsis with omqSOFA score as above
Ø
Ø Investigations:
• Blood
-
- FBC for raised white cell counts, thrombocytopenia or
thrombocytosis
-
- Blood cultures and sensitivity
-
- Blood gasses and lactate if indicated
-
- Renal profile, liver function test, coagulation profile and blood
glucose level in severe cases
• Urine
-
- FEME, cultures and sensitivity
Ø
Ø High vaginal swab for cultures and sensitivity
Ø
Ø Ultrasound scan for retained product of conception, pelvic collection
or haematoma
Management
Ø
Ø Call for help – if patient is unstable or unresponsive
Ø
Ø Resuscitation – Check for circulation, airway and breathing; CPR if
necessary
Ø
Ø Fluid resuscitation – 2 large bore cannulas; take blood as listed
above; fluid resuscitation as per Hour-1-bundle; CBD insertion with
or without oxygen supplementation
Ø
Ø Hour-1 Bundle:
• Measure lactate level if available
• Obtain blood cultures before administering antibiotics.
• Administer broad spectrum antibiotics.
• Begin rapid administration of 20 ml/kg crystalloid for hypotension
or if lactate level ≥ 4 mmol/L.
• Apply vasopressors if hypotensive during or after fluid
resuscitation to maintain MAP ≥ 65 mmHg. Use norepinephrine
as the first choice.

200
Management
Ø
Ø Re-measure lactate if initial lactate is > 2 mmol/L.
Ø
Ø Consider CTG in pregnant patients > 28 weeks.
Ø
Ø Perform imaging if necessary
Ø
Ø Any patient with sepsis in a non-specialist hospital should be
transferred to a specialist hospital as soon as possible.
Ø
Ø Other interventions after stabilisation depending on the source of
sepsis:
• Retained POC – evacuation of POC
• Abscess - surgical drainage
• Close monitoring of patients: ICU/HDU management/monitoring
when indicated.
Ø
Ø Delivery:
• Should be considered if delivery would be beneficial to mother or
baby or both
• Decision for antenatal corticosteroid should be individualized

201
Flowchart 26: Summary of the management of maternal sepsis

202
Adapted from:
Reference:
1. Surviving sepsis campaign. International guidelines for management of sepsis and
septic shock. 2016.
2. Singer, Mervyn et al. The Third International Consensus Definitions for Sepsis and Septic
Shock (Sepsis-3). JAMA, Vol 315, Number 8 (2016): 801-810.
3. WHO. Statement on Maternal Sepsis. 2017.
4. Greer O, Shah NM, Johnson MR. Maternal sepsis update: current management
and controversies. The Obstetrician & Gynaecologist 2020;22:45-55. https://doi.
org/10.1111/tog.12623.

203
Shoulder Dystocia
F7.
Risk factors
Antepartum risks Intrapartum risks
1. Macrosomia
2. Maternal diabetes
3. Previous history of shoulder
dystocia
4. Maternal obesity
5. Induction of labour
6. Maternal short stature
1. Prolonged first stage
2. Prolonged second stage
3. Oxytocin augmentation
4. Assisted vaginal delivery
Definition
A vaginal cephalic delivery that requires additional obstetric maneuvers
to deliver the fetus after the head has been delivered and gentle
traction has failed.
Ø
Ø Unpredictable
Ø
Ø Overall incidence 0.58-0.70%
Ø
Ø 48% occurs in infants with birth weight < 4kg
Diagnosis
Delay in delivery of shoulder with normal axial traction after delivery of
head.
Other signs include:
Ø
Ø ‘Head bobbing’ – Baby’s head appears during contraction but
disappears again in between contractions
Ø
Ø ‘Turtle neck’ - Baby’s head is retracted tightly against the perineum
Ø
Ø Failure of restitution of the fetal head
Ø
Ø Failure of descent of shoulders
Early
assessment
Ø
Ø Assessment for signs of shoulder dystocia as listed above
Ø
Ø Note the time of delivery of the fetal head
Ø
Ø Note the direction the fetus is facing

204
Management
Ø
Ø Call for help - O&G specialist, medical officers, midwives, paediatric
team
Ø
Ø Instruct mother to stop pushing as further pushing without
maneuvers will worsen the impaction
Ø
Ø Brings mother’s buttock to the edge of bed and break the bed
Ø
Ø Maneuvers to be employed to deliver baby (HELPERR):
i. H – Help
• Asking for extra personnel
• At least 4 persons are needed to perform the maneuvers for
shoulder dystocia and another person should standby for
neonatal resuscitation.
ii. E – Episiotomy
• Do a generous episiotomy if an episiotomy is not performed; may
extend the wound if it is done
• Episiotomy is done to provide space to carry out the maneuvers
to overcome the shoulder dystocia.
iii. L – Legs (McRobert’s Maneuver)
• Refer to Figure 1
• Flex the knees, then flex and externally rotate the hips
• Delivery via routine traction in an axial direction
• The patient can remain in this position through the rest of the
maneuvers if the dystocia is still not resolved
iv. P- Suprapubic Pressure (Rubin 1)
• Up to 90% of shoulder dystocia can be resolved with a
combination of McRobert’s maneuver and suprapubic pressure.

205
viii.R – Repeat the above procedures from McRobert’s maneuver
• If the above maneuvers are unsuccessful, all maneuvers may be
tried again.
• The order in which each maneuver is attempted may be revised.
Management
v. E – Enter the pelvis for internal maneuvers: Rubin 2 and Wood’s
Screw Maneuver (WSM)
a. Rubin 2
• Insert 2 fingers to the posterior aspect of anterior shoulder
• Push anterior shoulder toward the fetal chest to rotate the
fetal shoulder into oblique diameter
• Axial traction is applied once anterior shoulder is in oblique
diameter
b. Wood’s Screw Maneuver (WSM)
• Enter the vagina for WSM; Refer to Figure 4 and 5
vi. R – Remove the posterior arm
• Insert your hand into the vagina in front of the fetus. Insert your
left hand if the fetus is facing the maternal right and vice versa.
• Identify the posterior arm and elbow. Ensure the elbow is flexed
across the front of the body. Grasp the hand and wrist and deliver
the arm by sweeping it across the chest and face.
• This procedure can be associated with humeral fracture, maternal
lacerations and third-degree perineal tears.
vii.R – Roll over
• It may be easier to remove the posterior arm when the mother
is in this position, as the baby is pulled by gravity, creating more
space for you to put your hand in and deliver the posterior arm.
• This procedure may not be feasible for obese mothers or when
the delivery bed is small.

206
Management
ix. Other maneuvers
a. Posterior axillary sling traction (PAST)
• Fold a suction tubing in half and use your index finger to pass
the folded end through the baby’s posterior axilla.
• Use your other hand to pull the loop through and clamp both
ends of the tubing using an artery forceps.
• Use the tubing to track upwards and outwards. Once the
posterior shoulder is delivered, the baby should be able to be
delivered with routine axial traction.
b. Symphysiotomy
• Cut the symphysis pubis to allow delivery of the anterior
shoulder.
c. Cleidotomy
• Purposefully break one or both clavicles using your thumb to
reduce the biacromial diameter.
d. Zavanelli maneuver
• Push the baby’s head back into the uterus and proceed with
an emergency caesarean section
Active management of 3rd
stage and management of complications:
Maternal complications Fetal complications
1. Postpartum haemorrhage –
11%
a. Uterine atony
b. Genital tract trauma
c. Uterine rupture
2. 3rd
and 4th
degree tear – 3.8%
3. Litigation
1. Prolonged first stage
2. Prolonged second stage
3. Oxytocin augmentation
4. Assisted vaginal delivery
Ø
Ø Proper documentation – timing of events; sequence of maneuver;
personnel involved and baby condition
Ø
Ø Debriefing of patient and partner
Ø
Ø Arrange follow-up for patient and baby postnatally
Management

207
Figure 1: McRobert’s Maneuver
Figure 2: Suprapubic Pressure (Rubin 1)
Hyperflex the hips
Externally rotate the hips
Flex the knees
Preferably done with 2 assistants, one at
each side of the patient.
Increases the inlet diameter by
straightening the lumbosacral lordosis
thereby removing the sacral promontory as
an obstruction.
Assistant should stand on a platform
Pressure is applied at the suprapubic
region, and not on the symphysis pubis/
pubic bone with a “CPR” hand over the
fetus’s anterior shoulder to rotate it to an
oblique position
Either continuous pressure or a rocking
motion can be used.
The direction of pushing should be in
the direction of where the baby is facing.
Attempt routine axial traction while doing
this manoeuvre

208
Figure 3: Rubin 2
Figure 4: Wood’s Screw Maneuver
Use two fingers to apply pressure to the posterior aspect of the anterior shoulder while the
other hand applies pressure to the anterior aspect of the posterior shoulder.
Attempt to displace the shoulder into an oblique diameter, thereby reducing the impacted
anterior shoulder. If this fails, the procedure is completed by continuing the rotation a full
180 degrees, making the anterior shoulder the posterior shoulder, allowing the delivery to
be accomplished.
Anterior shoulder
Insert 2 fingers and apply
pressure on the posterior aspect
toward fetal chest
Rotate anterior shoulder to an
oblique diameter
Anterior shoulder
Apply pressure on the posterior
aspect
Posterior shoulder
Apply pressure on the anterior
aspect

209
Figure 5: Direction of WSM
Figure 6: Removal of Posterior Arm
Figure 7: All-Four Position in Roll Over Maneuver
Oblique position
Displace into an oblique position.
If fail to deliver, rotate a full 180o.
Rotate 180o
Flex the forearm at the elbow if the forearm
is extended
Deliver the arm by grasping the wrist and
sweeping it across the chest and face
This position is called “on all-
fours”, knee-chest position or
hands-and-knee position.

210
Flowchart 27: Summary of the management of shoulder dystocia

211
Adapted from:
2025.
3rd
Edition.
Reference:
1. Green-top guideline No. 42: Shoulder dystocia. Royal College of Obstetricians and
Gynaecologists. 2012.
2. Hoek J, Verkouteren B, Can Hamont D. BMJ Case Rep 2019;12:226882. doi:10.1136/
bcr-2018-226882.

212
Cord Prolapse
F8.
Definition
Descent of the umbilical cord through the cervix alongside (occult) or
past the presenting part (overt) in the presence of ruptured membranes.
Diagnosis
Ø
Ø Pulsating tubular structure felt during vaginal examination with/
without fetal bradycardia
Ø
Ø Loop of cord seen outside vagina.
Ø
Ø Abnormal fetal heart rate pattern soon after membrane rupture,
either spontaneous or artificial.
Early
assessment
Ø
Ø Immediate assessment if the delivery is imminent – Vaginal
examination to determine: cervical dilatation/ station/presenting part
Ø
Ø Check fetal heart rate/determine if the fetus is alive.
Fetus Maternal Iatrogenic/ procedure
related
Ø
Ø Prematurity or
low birthweight
Ø
Ø Multiple
pregnancies
Ø
Ø Fetal anomaly
-anencephaly
Ø
Ø Malpresentation
Ø
Ø Unengaged
presenting part
Ø
Ø Abnormal lie
– transverse,
oblique and
unstable lie
Ø
Ø Multiparity
Ø
Ø Pelvic tumour
Ø
Ø Contracted pelvis
Ø
Ø Polyhydramnios
Ø
Ø Prelabour rupture
of membranes
Ø
Ø Artificial rupture of
membrane with high
station of presenting
part
Ø
Ø Vaginal manipulation
during ARM
Ø
Ø Cervical ripening
balloon (large balloon
catheter)
Ø
Ø External cephalic
version (during
procedure)
Ø
Ø Internal podalic version
Ø
Ø Placement of fetal
scalp electrode/
fetal scalp sampling/
intrauterine pressure
transducer
Risk Factors

213
Management
Ø
Ø Call for help - O&G specialist, medical officers, midwives, paediatric
team
Ø
Ø Continue CTG
Ø
Ø Secure IV cannula
Ø
Ø Do not manipulate the cord
Imminent delivery Non-imminent delivery
Ø
Ø Drain bladder
Ø
Ø Expedite delivery
Ø
Ø Vaginal delivery if fetal heart
rate is reassuring
Ø
Ø Prepare for instrumental
delivery or caesarean delivery
if fetal distress
Fetus is viable:
Ø
Ø Elevate the presenting part by
placing 2 pillows under mother’s
buttocks
Ø
Ø An assistant to insert two
fingers into vagina and maintain
fingers in the vagina to elevate
presenting part
Ø
Ø Inflate bladder with normal
saline
Ø
Ø Arrange transfer to hospital with
specialist (consider tocolysis
during transfer)
Ø
Ø Arrange for category 1 caesarean
section if the fetus is still alive
Ø
Ø To empty the bladder upon
caesarean section
Ø
Ø Assistant may withdraw the
fingers upon delivery of baby
Fetus is not viable:
Ø
Ø Aim vaginal delivery if the fetus
is in longitudinal position
Ø
Ø Active management of 3rd
stage
Ø
Ø Debrief the couple
Ø
Management

214
Flowchart 28: Summary of the management of cord prolapse
Adapted from:
1. O&G Protocol, State of Kedah,2019.
2025.
3rd
Edition.
Reference:
1. Green-top Guideline No. 50. Umbilical Cord Prolapse. Royal College of Obstetrician &
Gynaecologist. November 2014.

215
Assisted Vaginal Breech Delivery
F9.
Definition Fetal buttock +/- feet felt during vaginal examination
Early
assessment
Ø
Ø Assess if delivery is imminent – cervical dilatation/station/ membrane
intact or ruptured
Ø
Ø Ensure no cord presentation/prolapse or footling breech, which is
contraindicated for assisted vaginal breech delivery
Ø
Ø If delivery is not imminent, assess suitability for assisted vaginal
delivery; otherwise, caesarean section is indicated
Management
i. Call for help – O&G medical officers or specialist, paediatric team,
midwife
Ø
Ø Delivery should be conducted by the most experienced
personnel
Ø
Ø Paediatric team should be standby for neonatal resuscitation
ii. Delivery in lithotomy position with maternal buttocks at the end
of the bed
iii. Drain bladder
iv. Ensure continuous fetal heart rate monitoring
v. Vaginal breech delivery:
Ø
Ø “Hands-off” technique
Ø
Ø Keep fetal spine facing up during delivery
Ø
Ø Deliver legs using Pinard’s maneuver once knees are visible
Ø
Ø Hold baby over bony pelvis with towel
Ø
Ø Deliver baby’s arms once scapulae are visible (Lovset’s maneuver
only needed for extended arms)
Ø
Ø Deliver head using Mauriceau-Smellie-Veit (MSV) maneuver once
posterior hairline is visible
Ø
Ø Forceps can be used for after-coming head
Additional maneuvers for head entrapment:
Ø
Ø Suprapubic pressure
Ø
Ø Forceps
Ø
Ø Dührssen’s cervical incision
vi. Active management of 3rd
stage
Ø
Ø Watch out for PPH and check for perineal trauma
Ø
Ø Debrief mother and partner
Ø

216
Delivery of the buttocks
Allow breech to descend with
contractions and maternal effort.
Encourage active pushing ONLY
when the breech has descended to
the pelvic floor and is visible.
Do not pull the baby out.
Traction will lead to extension of the
fetal head as well as fetal arms and
further complicate the delivery.

217
Delivery of the legs
Ø
Ø Wait until the anus is visible over the fourchette before carrying out an episiotomy.
Ø
Ø Protect the fetal bottom from being cut with your left hand.
Ø
Ø The breech will usually be delivered with the sacrum to the right or left of the mother.
Do not allow the sacrum to turn posteriorly.
Ø
Ø Insert two fingers at the hip to guide the sacrum anteriorly as the mother pushes the
baby out.
Ø
Ø Keep the sacrum anterior while awaiting delivery of the fetal legs.
Ø
Ø Extended legs can be “walked” out by the ‘Pinard manoeuvre’ – apply gentle pressure
on the popliteal fossa to encourage flexion of the knee and lateral rotation of the thigh.
Ø
Ø Grasp the fetal foot and deliver the leg.
Ø
Ø Deliver the anterior leg first, then rotate the baby slightly to deliver the opposite leg.
Ø
Ø Conventionally, a loop of cord is brought down if the cord is tight. If the cord is loose,
do not manipulate the cord as this may lead to vasospasm.
Ø
Ø Very rarely, a short cord will prevent descent of the body. This will require cord division
and quick delivery.

218
Delivery of the body
Delivery of the arms
Once the baby is partially out,
wrap the baby in a warm clean
towel. This is to keep the baby
warm as well as to prevent the
baby from slipping out of your
hands!
Hold the baby only at the pelvic
bony regions and legs.
Thumbs on sacrum
Index fingers on ASIS
Last 3 fingers on thigh
DO NOT hold the abdomen
(soft tissue) or chest.
Ø
Ø Allow the baby to descend with maternal effort.
Ø
Ø Once the scapula is visible, you can expect the arms to deliver spontaneously.
Ø
Ø If the arm does not deliver spontaneously, suspect nuchal arm/extended arms and
proceed with Lovset’s maneuver.

219
Delivery of the head
Nuchal arm/Extended arm
Lovset’s manoeuvre is done by holding the
baby at the hips and applying downward
traction while rotating the baby 90 degree
to bring one shoulder anteriorly under the
pubic arch.
Insert two fingers and sweep over the
anterior shoulder until you reach the elbow.
Flex the elbow to sweep the hand over the
baby’s face and deliver the hand.
Subsequently, laterally flex the baby and
maintain downward traction while turning
the baby 180o
in the opposite direction.
Make sure the baby’s back is facing upwards
during turning. Deliver the other arm in a
similar manner.
The action of turning the baby helps to
bring the nuchal arm in front of the baby’s
head, allowing delivery of the arms.

220
Mauriceau-Smellie-Veit method
Ø
Ø Allow baby to hang down with support until the posterior hairline can be seen.
Ø
Ø Place your index and middle finger on baby’s maxillary prominence while supporting the
baby on your forearm.
Ø
Ø Do not to insert finger into baby’s mouth! (Risk of jaw fracture & TM joint dislocation.)
Ø
Ø Place your other hand over the baby’s shoulders with your middle finger over the
occiput.
Ø
Ø Use both hands to flex the baby’s head and deliver in the direction of the birth canal.
Ø
Ø You can also ask an assistant to apply suprapubic pressure to help flex the baby’s head.
Ø
Ø Burns-Marshall technique is no longer advised due to risk of over-extension of the fetal
neck.
Adapted from:
2025.
4. Hospital Tuanku Jaafar, Negeri Sembilian O&G Protocol, 2018.
Reference:
1. Green-top guideline No. 20b: Management of breech presentation. Royal College of
Obstetricians and Gynaecologists. 2017.

221
Presentation
The blockage of blood vessels by a thrombus carried through the
bloodstream from its site of formation
Acute Management of Obstetric Thromboembolism
F10.
Definition
The blockage of blood vessels by a thrombus carried through the
bloodstream from its site of formation
Diagnosis
DVT – Compression duplex sonography showing filling defects in deep
veins
PE – Presence of filling defect in Computed Tomography of Pulmonary
Angiography (CTPA) or presence of ventilation-perfusion mismatch on
Ventilation/Perfusion scan (V/Q scan)
Early
assessment
1. Assessment of general condition to see whether patient is
haemodynamically stable:
Ø
Ø Conscious level
Ø
Ø Vital signs
Ø
Ø Systemic examination of lungs, cardiovascular system and
bilateral lower limbs
2. Blood investigations: FBC, coagulation profile, renal profile and liver
function test (D-dimer is not recommended)
3. ECG – sinus tachycardia, S1Q3T3, right axis deviation
4. CXR – can be omitted in strong suspicion for pulmonary embolism
unless there is suspicion for other lung pathology
5. Imaging (depending on presentation)
Ø
Ø DVT – Compression duplex sonography
Ø
Ø PE with signs and symptoms of DVT – Compression duplex
sonography +/- CTPA or V/Q scan (if compression duplex
sonography is positive, CTPA or V/Q scan can be avoided)
Ø
Ø PE without signs and symptoms of DVT – CTPA or V/Q scan
(CTPA is preferred if CXR showed abnormality.
DVT
(Deep Venous Thromboembolism)
PE
(Pulmonary embolism)
Ø
Ø Severe pain and oedema of the
leg and thigh
Ø
Ø Warm, tender and swollen leg
Ø
Ø Pale, cool extremity with
diminished pulsation
(phlegmasia alba dolens)
Ø
Ø Sudden maternal collapse
Ø
Ø Dyspnoea, chest pain,
haemoptysis,
Ø
Ø Tachypnoea, tachycardia, fever,
cyanosis

222
Maternal collapse or
haemodynamically unstable (In
massive PE)
Haemodynamically stable
1. Call for help
Ø
Ø Multidisciplinary approach
– obstetrician, physician,
haematologist, anaesthetist,
interventional radiologist
2. Manage as per Maternal
Collapse Chapter.
3. Resuscitation and stabilisation
of patient including advanced
airway management .
4. Definitive management options:
Ø
Ø Intravenous heparin infusion
Ø
Ø Thrombolytic therapy
Ø
Ø Thoracotomy or Surgical
embolectomy.
1. Low molecular weight heparin
(LMWH) should be started
upon suspicion of VTE until
the diagnosis is excluded
by the objective testing,
unless treatment is strongly
contraindicated.
2. If compression duplex
sonography is negative but
clinical suspicion of DVT is
high, anticoagulants can
be continued but repeated
compression duplex
sonography should be done on
day 3 and 7.
3. In suspicion of PE, if the
objective testing is negative
but the suspicion remains
high, LMWH treatment should
be continued until repeated
objective testing rules PE out.
4. LMWH dosage should
be based on booking or
prepregnancy weight.
Management

223
Flowchart 29: Summary of the acute management of obstetric thromboembolism

224
Adapted from:
2025.
3rd
Edition.
Reference:
1. Green-top guideline No. 37b: Thromboembolic disease in pregnancy and the
puerperium: Acute Management. Royal College of Obstetricians and Gynaecologists.
2015.
2. National Technical Committee Confidential Enquiries into Maternal Death. A Training
Manual: Prevention & Treatment of Thromboembolism in Pregnancy and Puerperium..
2nd
Edition. January 2018.

225
Postpartum Care
G
SECTION

226
ROUTINE POSTPARTUM CARE
G1.
All postpartum women should receive routine postpartum care which include the
following:
1. Vitals sign checks half hourly for 2 times, if normal then 4 hourly (frequency of
monitoring should be tailored from case to case basis).
2. Analgesia administration tailored based on the pain score system.
3. Documented venous thromboembolism score assessment.
4. Assessment of woman’s bladder function by ensuring that she is able to
pass urine normally within 4-6 hours after delivery or after removal of urinary
catheter for caesarean section case.
5. Support and help they need to start breastfeeding (which should include
observing at least 1 effective feed).
6. Assessment of the baby’s health (including physical inspection and
observation-by paediatric team).
7. Discussion on various types of contraception which is suitable for them.
8. Perineal check or caesarean section wound check before discharge from
hospital.
9. Advise on Cervical Cancer Screening Programme.
10.Advise on interpregnancy interval (IPI) of less than 12 months between
childbirth and conceiving again is associated with an increased risk of preterm
birth, low birthweight and small for gestational age (SGA) babies. WHO
recommends a 24-month IPI after childbirth.
11.Discussion on the discharge plans and medications and what to expect in the
subsequent postnatal review at the maternal-child healthcare clinic.
12.Proper communication with maternal-child healthcare clinics on postnatal care
plans especially in high risk patients.

227
Contraception
G2.
1) Introduction
Birth control, also known as contraception and fertility control, is a method
or device used to prevent pregnancy. Planning, making available, and use of
birth control is called family planning. Family planning is a key intervention
in reducing maternal, newborn and child mortality and morbidity through
preventing unintended pregnancies, as well as those that are spaced too
closely together.
Information on methods of contraception should be offered to women during
both antenatal and postnatal periods. This would allow them to have time to
think and discuss with their partner regarding what form of contraception they
would like to use after delivery.
Decision-making regarding contraceptive methods usually requires the need
to make trade-offs among the advantages and disadvantages of different
methods, and these vary according to individual circumstances, perceptions
and interpretations. Factors to consider when choosing a particular
contraceptive method include the characteristics of the potential user, the
baseline risk of disease, the adverse effects profile of different products, cost,
availability and patient preferences.
Prior to Day 21 postpartum, no contraception method is required. In non-
breastfeeding women, ovulation may occur as early as Day 28. As sperm can
survive for up to 7 days in the female genital tract, contraceptive protection is
required from Day 21 onwards if pregnancy is to be avoided.
2) Medical Eligibility Criteria of Contraceptive Use (UKMEC/WHOMEC)
Medical Eligibility Criteria (MEC) offers guidance to providers of contraception
regarding who can use contraceptive methods safely. These evidence-based
recommendations do not indicate a best method for a woman nor do they
consider efficacy (and this includes drug interactions or malabsorption). The
recommendations allow for consideration of the possible methods that could
be used safely by individuals with certain health conditions (e.g. hypertension)
or characteristics (e.g. age) to prevent an unintended pregnancy.

228
Where resources for clinical judgment are limited, such as in community-based
services, the four-category classification framework can be simplified into two
categories. With this simplification, a classification of Category 1 or 2 indicates
that a woman can use a method, and a classification of Category 3 or 4 indicates
that a woman is not medically eligible to use the method.
Most contraceptive users are medically fit and can use any available contraceptive
method safely. However, some medical conditions are associated with potential
or theoretical increased health risks when certain contraceptive methods are
used, either because the method adversely affects the condition or because the
condition or its treatment affects the safety of the contraceptive.
Definition of MEC
MEC DEFINITION OF CATEGORY
Category 1
A condition for which there is no restriction for the use of the
method.
Category 2
A condition where the advantages of using the method
generally outweigh the theoretical or proven risks.
Category 3
A condition where the theoretical or proven risks usually
outweigh the advantages of using the method. The provision of
a method requires expert clinical judgment and/or referral to a
specialist contraceptive provider, since use of the method is not
usually recommended unless other more appropriate methods
are not available or not acceptable.
Category 4
A condition which represents an unacceptable health risk if the
method is used.

229
Method Typical use (%) Perfect use (%)
No method 85 85
Fertility awareness-based methods 24 0.4–5
Female diaphragm 12 6
Male condom 18 2
Combined hormonal contraception* 9 0.3
Progestogen-only pills 9 0.3
Progestogen-only injectables 6 0.2
Copper intrauterine device 0.8 0.6
Levonorgestrel-releasing intrauterine
system
0.2 0.2
Progestogen-only implant 0.05 0.05
Female sterilization 0.5 0.5
Vasectomy 0.15 0.1
3) Types of contraception
Women should be informed during pregnancy about the effectiveness of
different contraceptives, including the superior effectiveness of long-acting
reversible contraception (LARC), when choosing an appropriate method to use
after pregnancy.
Percentage of women experiencing an unintended pregnancy within the
first year of use with typical use and perfect use (modified from Trussell,
2011).
*Includes combined oral contraception, transdermal patch and vaginal rings. Long-acting
reversible contraceptive methods have been highlighted in gray

230
Condition
Cu-IUD
LNG-IUS
IMP
DMPA
POP
CHC
Category
1
1
1
1
1
1
1
a)
0
to
<6
weeks
1
1
1
2
1
4
b)
≥6
weeks
to
<6
months
(primarily
breastfeeding)
1
1
1
1
1
2
c)
≥6
months
1
1
1
1
1
1
See
below
*
In
the
presence
of
other
risk
factors
for
VTE,
including
immobility,
transfusion
at
delivery,
body
mass
index
≥30
kg/m2,
postpartum
haemorrhage,
post-caesarean
delivery,
pre-eclampsia
or
smoking,
use
of
CHC
may
pose
an
additional
increased
risk
for
VTE.
Summary
of
UK
Medical
Eligibility
Criteria
for
Contraceptive
Use
(UKMEC)
categories
applicable
to
women
after
childbirth.
Condition
Cu-IUD
LNG-IUS
IMP
DMPA
POP
CHC
a)
0
to
<3
weeks
(i)
With
other
risk
factors
for
VTE*
(ii)
Without
other
risk
factors
1
1
1
1
1
1
2
2
1
1
4
3
b)
3
to
<6
weeks
(i)
With
other
risk
factors
for
VTE*
(ii)
Without
other
risk
factors
1
1
1
1
1
1
2
1
1
1
3
2
c)
≥6
weeks
1
1
1
1
1
1
Condition
Cu-IUD
LNG-IUS
IMP
DMPA
POP
CHC
a)
0
to
<48
hours
1
1
1
1
1
1
b)
48
hours
to
<4
weeks
3
3
1
1
1
1
c)
≥4
weeks
1
1
1
1
1
1
d)
Postpartum
sepsis
4
4
1
1
1
1
See
below
See
above
Postpartum
(in
breastfeeding
women)
Postpartum
(in
non-breastfeeding
women)
Postpartum
(in
breastfeeding
or
non-breastfeeding
women,
including
post-caesarean
section)

231
Condition Cu-IUD LNG-IUS IMP DMPA POP CHC
History of high blood pressure
during pregnancy
1 1 1 1 1 2
History of cholestasis
(pregnancy-related)
1 1 1 2 1 2
Diabetes (history of
gestational disease)
1 1 1 1 1 1
Healthcare providers should discuss with the woman any personal characteristics or existing
medical conditions, including those that have developed during pregnancy, which may
affect her medical eligibility for contraceptive use.
Summary of UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) categories
applicable to a woman with a history of pregnancy-related conditions.

232
4) Other forms of contraception
a. Barrier methods
Male and female condoms can be safely used by women after childbirth.
Women choosing to use a diaphragm should be advised to wait at least 6
weeks after childbirth before having it fitted because the size of diaphragm
required may change as the uterus returns to normal size.
b. Lactational amenorrhoea method (LAM)
LAM is over 98% effective in preventing pregnancy. Only effective in
patients who:
Ø
Ø Breastfeed exclusively (no other liquids or solids given to the baby).
Ø
Ø Remain amenorrhoea after delivery.
Ø
Ø Within 6 months postpartum period.
Methods of contraception
the woman is medically
eligible to use
Initiation <21 days after
childbirth
Initiation ≥21 days
after childbirth
Copper intrauterine device
Levonorgestrel-releasing
intrauterine system
None for insertion
0 to <48 hours
Insertion between 48 hours
and <4 weeks may not be
appropriate (UKMEC 3)
None
7
Progestogen-only pill (traditional/
desogestrel)
None 2
Diabetes (history of gestational
disease)
None 7
Combined hormonal
contraception
Use not recommended 7*
*Except Qlaira® which requires 9 days of additional contraceptive precautions
Requirements for abstinence or additional contraception when a method of
contraception (which the woman is medically eligible to use) is initiated after
childbirth.
Number of days of additional contraceptive
precautions required (days)

233
c. Fertility awareness method (FAM)
Fertility awareness methods (FAM) can be used by women after childbirth.
However, women should be advised that because FAM relies on the
detection of the signs and symptoms of fertility and ovulation, its use may
be difficult after childbirth and during breastfeeding.
d. Female sterilisation
Female sterilisation is a safe option for permanent contraception after
childbirth. Women should be advised that some LARC methods are as, or
more, effective than female sterilisation and may confer non-contraceptive
benefits. However, women should not feel pressured into choosing LARC
over female sterilization. Procedure should be done after the postpartum
period ideally, so that uterus is fully involute and allow women to have
adequate time to make decisions (risk of regret if done immediately after
childbirth). Failure rate is 1:200.
e. Male sterilisation
Male sterilisation is also a safe option for permanent contraception.
Vasectomy- Interrupting the vas deferens with an intention to provide
permanent contraception. Procedure done by urologist under local
anaesthesia in an outpatient setting. Need additional contraception until
semen analysis shows no more sperm, usually after 12 weeks. Failure rate is
1:2000.
f. Emergency contraception (EC)
Emergency contraception (EC) is indicated for women who have had
unprotected sexual intercourse (UPSI) from 21 days after childbirth, but
is not required before this. Oral EC levonorgestrel 1.5 mg (LNG-EC)
and ulipristal acetate 30 mg (UPA-EC) are safe to use from 21 days after
childbirth. Women who breastfeed should be advised not to breastfeed and
to express and discard milk for a week after they have taken UPA-EC. The
copper intrauterine device (Cu-IUD) is safe to use for EC from 28 days after
childbirth.

234
Postpartum Placement of Intrauterine
Contraceptive Device (PPIUD)
G3.
1) Overview
a. Immediately following childbirth represents a valuable opportunity for the
woman or couple to learn about and take advantage of family planning
services available. Information regarding various types of contraception
should always be readily available and easily accessible to a woman.
b. The postpartum IUD (PPIUD), inserted within 10 minutes or up to 48 hours
after birth:
Ø
Ø Is readily accessible for women who deliver at health care facilities/
hospitals.
Ø
Ø Has no effect on the amount or quality of breast milk.
Ø
Ø Is reversible and can be removed at any time (with immediate return to
fertility)—should the woman’s contraceptive or reproductive desires
change.
Ø
Ø Does not require any daily action on the part of the user to be effective
Ø
Ø Is safe for use by women living with HIV (but not as prevention of
HIVtransmission).
c. The intrauterine contraceptive device (IUCD) is a highly effective, long-
acting, reversible family planning method that is safe for use by most
postpartum women—including those who are breastfeeding. It is
also relatively inexpensive and convenient and has a very low rate of
complications.
d. Associated complications: Rate of uterine perforation: 2 in 1000.
Rate of expulsion: 1 in 20. In the context of PPIUD, Copper IUCD are
recommended now. Types of Copper IUCDs: 3 years- Cu250 and 5 years-
Cu375.
e. Mechanism of action: Copper IUCDs act by preventing fertilization. Copper
ions decrease sperm motility and function by altering the uterine and tubal
fluid environment, thus preventing sperm from reaching the fallopian tube
and fertilizing the egg.

235
2) Timing of PPIUD insertion
a. PPIUD insertion refers only to those IUDs placed during the immediate or
early postpartum period (within 10 minutes or up to 48 hours after birth*).
b. IUDs inserted during the immediate postpartum period (postplacental
and intra-caesarean) have the highest rates of retention, but the IUD can
be safely inserted at any time during the early postpartum period, that is,
within the first 48 hours after the birth.
c. The three types of PPIUD insertion are:
Ø
Ø Postplacental: Immediately following the delivery of the placenta in a
vaginal birth, the IUD is inserted before the woman leaves the delivery
room.
Ø
Ø Intra-caesarean: Immediately following the removal of the placenta
during a cesarean section, the IUD is inserted before closure of the
uterine incision, before the woman leaves the operating theater.
Ø
Ø Early postpartum: Not immediately following the delivery/removal of
the placenta but within 2 days/48 hours of the birth (preferably within 24
hours, such as on the morning of postpartum Day 1), the IUD is inserted
during a separate procedure.
*The IUD should not be inserted between 48 hours and 4 weeks postpartum
because of an overall increase in the risk of complications, especially infection
and expulsion. IUDs inserted at 4 weeks postpartum and beyond are
considered interval IUDs, rather than PPIUDs, because the same technique and
services are required.
f. Copper ions also produce an inflammatory reaction that is toxic to sperm
and eggs (ova), preventing pregnancy. These actions are largely local with
no measurable increase in the woman’s serum copper level.
g. The most common side effects associated with the copper-bearing:
Ø
Ø A change in the amount and duration of menstrual flow and an increase
in the amount of menstrual cramping (this is the most common reason
for removal).
Ø
Ø Changes in bleeding patterns, such as spotting/light bleeding (between
periods), in the first few weeks.
Ø
Ø Discomfort or cramping during IUD insertion and for the next several
days.

236
3) Medical eligibility criteria for PPIUD
Below listed are Category 3 and Category 4 MEC for PPIUD and if a woman
has one of the conditions listed below, PPIUD should not be offered to that
woman.
Category 3 Category 4
Ø
Ø Between 48 hours and 4 weeks
postpartum.
Ø
Ø Chorioamnionitis.
Ø
Ø Prolonged rupture of membranes
(PROM) >18 hours.
Ø
Ø Extensive genital trauma where
insertion may disrupt the repair.
Ø
Ø High individual risk of chlamydia
and gonococcal infection (partner
has current purulent discharge or
STI).
Ø
Ø Benign trophoblastic disease.
Ø
Ø Lupus with severe
thrombocytopenia.
Ø
Ø Puerperal sepsis.
Ø
Ø Postpartum endometritis.
Ø
Ø Unresolved postpartum
haemorrhage.
Ø
Ø Pregnancy (known or suspected).
Ø
Ø Unexplained vaginal bleeding.
Ø
Ø Current PID, gonorrhea, or
chlamydia.
Ø
Ø Acute purulent (pus-like)
discharge.
Ø
Ø Distorted uterine cavity.
Ø
Ø Malignant trophoblastic disease.
Ø
Ø Known pelvic tuberculosis.
Ø
Ø Genital tract cancer (cervical or
Ø
Ø endometrial).

237
4) PPIUD insertion techniques
Post placental/Early postpartum insertion of the IUD using forceps:
STEPS PICTORIAL GUIDANCE
Ensure counseling regarding PPIUD was
done appropriately and the patient signed
the consent for PPIUD insertion if she
agrees.
Manage the labour and delivery as usual,
taking extra precautions to minimize the risk
of postpartum haemorrhage.
Before inserting the PPIUD, check for
perineal tears and repair them if needed.

238
Prepare the PPIUD Tray and the IUCD.
• Antiseptic solution (Chlorhexidine)
• Gauzes
• Sterile green towels
• Long ring forceps/ placental forceps
• Sims speculum
The IUCD should be held just at the edge of
the placental forceps so that the IUCD will
be easily released from the forceps when
they are opened at the uterine fundus.
Clean the vulva and also vagina with the
antiseptic solution.
Gently grasp the anterior lip of the cervix
with the ring forceps. (The speculum may
be removed at this time, if necessary.) Let
the forceps out of your hand, keeping them
attached to the cervix.
While avoiding touching the walls of the
vagina, insert the placental forceps—which
are holding the IUCD—through the cervix
and into the lower uterine cavity.
Gently move the IUCD further into the
uterus, toward the point where slight
resistance is felt against the back wall of
the lower segment of the uterus. Be sure to
keep the placental forceps firmly closed.

239
“Elevate” the uterus:
• Place the base of your nondominant
hand on the lower segment of the uterus
(midline, just above the pubic bone with
the fingers toward the fundus).
• Through the abdominal wall, push the
entire uterus superiorly (in the direction
of the woman’s head).
• Maintain this position to stabilize the
uterus during insertion.
• Gently move the IUCD upward toward
the fundus, in an angle toward the
umbilicus.
• Lowering the dominant hand (the
IUCD/forceps-holding hand), so that
the forceps can pass easily through the
vagino-uterine angle.
Continue gently advancing the forceps until
the uterine fundus is reached, when you will
feel a resistance. Confirm that the end of
the forceps has reached the fundus.
The broad ring at the distal end of the
placental forceps makes it extremely unlikely
that the forceps will perforate the uterine
fundus.
While continuing to stabilize the uterus,
open the forceps, tilting them slightly
toward midline, to release the IUCD at the
fundus.

240
Keeping the forceps slightly open, slowly
remove them from the uterine cavity, being
careful not to dislodge the IUCD. Do this by:
• Sweeping the forceps to the side wall of
the uterus.
• Sliding the instrument against the side of
the uterine wall.
If the forceps close and/or catch the strings
of the IUCD, the forceps can inadvertently
pull the IUCD down from its fundal position,
and increase the risk of expulsion.
Slowly remove forceps—keeping them
slightly open.
Check for the IUCD strings. If the IUCD
strings are visible at the lower part of the
vagina or reached out from the introitus, the
IUCD has not been adequately placed at
the fundus and the chance of spontaneous
expulsion is higher.
Can use a scan to see placement of the
IUCD:
• If IUCD is correctly placed at the fundus
and strings are long, then the strings can
be trimmed off using a suture scissor.
• If placement of IUCD is not at the
fundus, the IUCD needs to be removed
and the same IUCD can be used for
reinsertion at the same setting.

241
Tell the woman that the IUCD has been
successfully placed and provide her with
post-insertion counseling, including IUCD
instructions.
IUCD-Card to be produced and attached
the card to her antenatal book and an
appointment must be given 4-6 weeks later
for trimming of the IUCD strings and also
scan for IUCD location.
Name of user:
Identification number:
Place of IUCD insertion:
Type of IUCD:
Date of IUCD inserted:
Next clinic appointment:
Date for IUCD removal/replacement:
Phone number to get further help:
PPIUD Card:
Pictures by: Dr. Vivian Chong Sin Yue
Intra Caesarean insertion.
For intra caesarean insertion, the woman has been counseled and prepared prior to the
start of the operation, preferably during the antenatal period. Typically, manual insertion is
sufficient (as opposed to instrumental insertion) because the provider can easily reach the
uterine fundus. After the placenta is removed, the provider:
Ø
Ø Holds the IUCD between the index and middle fingers of the hand, passes it through
the uterine incision and places it at the uterine fundus.
Ø
Ø Slowly withdraws the hand, ensuring that the IUCD remains properly placed.
Ø
Ø Closes the uterine incision, taking special care not to incorporate the IUCD strings into
the suture.
Ø
Ø The IUCD strings can be pointed toward the cervix but should NOT be pushed through
the cervical canal. This helps prevent both uterine infection (caused by contamination
of the uterine cavity with vaginal flora) and displacement of the IUCD from the fundus
(caused by drawing the strings downward toward the cervical canal).

242
5) Take-Home Information/Advice for PPIUD User
Provide reassurance and advise the woman to:
1. Expect lochia but note heavy bleeding or blood clots.
2. Be aware that postpartum symptoms, such as intermittent vaginal bleeding
and cramping, are normal for the first 4 to 6 weeks postpartum—and may
be hard to distinguish from IUCD side effects.
3. Take paracetamol or other pain relievers as needed.
4. Regarding possible IUCD expulsion:
Ø
Ø Spontaneous expulsion is most likely to occur during the first 3 months
postpartum.
Ø
Ø Check the bed sheets in the morning and your undergarments when you
change clothes.
Ø
Ø At 4-6 weeks postpartum, you may be able to feel the IUCD strings. It is
not necessary to check for them, but if you do, do not pull on them.
Ø
Ø Your provider will check for the strings when you return for your
postpartum visit. That is why it is important for you to return to see the
same provider, or at least someone in the same clinic, who is aware of
PPIUD services.
5. Continue to exclusively breastfeed your baby, as appropriate; the IUCD and
breastfeeding do not interfere with each other.
6. Remember that the IUCD does not protect against STIs and HIV.
7. Resume intercourse at any time you feel ready; the IUCD offers full
protection against pregnancy immediately upon insertion.
8. Return for removal of the IUCD anytime you wish or depending on the
duration of coverage of that particular IUCD. After the IUCD is removed,
fertility will return immediately.
9. Return for assessment if heavy menstrual bleeding, severe lower abdominal
discomfort, unusual vaginal discharge, fever or not feeling well.
References:
1. FSRH UKMEC April 2016 (Amended September 2019).
2. FSRH Contraception After Pregnancy Jan 2017.
3. WHO MEC Book 2015 5th
Edition.
4. Postnatal Care NICE Guideline NG194 April 2021.
5. Global PPIUD Reference Manual USAID (Amended Oct 2013).

243
Appendix
H
SECTION

244
Compilation of recommendations for antenatal
corticosteroids to reduce neonatal morbidity and mortality
Whilst the use of antenatal or prenatal corticosteroids (ACS) has established benefit, recent
evidence on long term neurodevelopmental outcomes has resulted in additional concerns
in its use in late term and term babies. Several organizations have issued statements
or guidelines and three of these are extracted below; from the World Association of
Perinatal Medicine & Perinatal Medicine Foundation (WAPM), International Federation of
Gynaecology & Obstetrics (FIGO) and Royal College of Obstetricians & Gynaecologists
(RCOG).
It is hoped that this will be useful for individual units to draft their local guidelines based on
the neonatal support available to them.
1) Gestational age for use
W
A
P
M
Ø
Ø A single course of ACS should be administered between 24+0
and 33+6
weeks of gestation in women at high-risk of PTB within the next 7 days. It
should be considered between 22+0
and 23+6
weeks of gestation.
Ø
Ø The decision should be based on local standards regarding periviable
neonatal support and availability of neonatal facilities, following appropriate
consultation to the parents.
F
I
G
O
Ø
Ø For women with singleton pregnancies where active neonatal care is
appropriate, for whom preterm birth is anticipated between 24+0
and 34+0
weeks of gestation, prenatal corticosteroids should be offered to improve
outcomes for the baby.
R
C
O
G
Ø
Ø Corticosteroids should be offered to women between 24+0
and 34+6
weeks’
gestation in whom imminent preterm birth is anticipated (either due to
established preterm labour, preterm prelabour rupture of membranes or
planned preterm birth)
Ø
Ø Before 24+0
weeks, the obstetric and neonatal team should discuss the
administration of ACS in the context of her individual circumstances and
preferences

245
2) Timing of anticipated preterm birth
3) Dosage
W
A
P
M
Ø
Ø Women at high-risk of PTB within the next 7 days.
F
I
G
O
Ø
Ø Prenatal corticosteroids should ideally be given 18 to 72 hours (and
certainly no more than 1 week) before preterm birth is anticipated.
However, if preterm birth is expected within 18 hours, prenatal
corticosteroids should still be administered.
R
C
O
G
Ø
Ø A course of antenatal corticosteroids given within the 7 days prior to
preterm birth reduces perinatal and neonatal death and respiratory distress
syndrome.
W
A
P
M
Ø
Ø Either betamethasone (2 doses of 12 mg IM in a 24 hr interval) or
dexamethasone (4 doses of 6 mg IM at 12 hr intervals) may be administered
for fetal lung maturation.
F
I
G
O
Ø
Ø Where prenatal corticosteroids are given to improve fetal outcomes,
appropriate regimens include two doses of betamethasone acetate/
phosphate 12 mg (=one course) IM 24 hr apart, or two doses of
dexamethasone phosphate 12mg (=one course) IM 24 hr apart.
R
C
O
G
Ø
Ø It is recommended that 24mg dexamethasone phosphate is given
intramuscularly in two divided doses of 12 mg 24 hr apart or four divided
doses of 6 mg 12 hr apart
Ø
Ø An alternative is 24 mg betamethasone sodium phosphate/acetate mix
given intramuscularly in two divided doses of 12 mg 24 hours apart

246
4) Repeating doses
5) Late preterm
W
A
P
M
Ø
Ø Repeated doses of ACS following an initial course of ACS are not
recommended.
Ø
Ø A single rescue course of ACS is not routinely recommended. It may be
administered up to 33+6 weeks of gestation in women at high-risk of PTB
within the next 7 days when a course of ACS has been administered at least
14 days before.
F
I
G
O
Ø
Ø In women in whom preterm birth is expected within 72 hours and who have
had one course of corticosteroids more than a week ago, one additional
course of prenatal corticosteroids could be given to improve outcomes for
the baby.
R
C
O
G
Ø
Ø No reduction in serious morbidity or long-term benefits have been
seen with repeat corticosteroids but babies who receive repeat doses
of antenatal corticosteroids are smaller (lower birth weight and reduced
length).
Ø
Ø There is limited evidence to recommend repeat courses of antenatal
corticosteroids if a woman remains at imminent risk of preterm birth seven
days after administration of antenatal corticosteroids. However, a further
course may reduce the need for neonatal respiratory support.
Ø
Ø The maximum number of corticosteroid courses given in any one pregnancy
should not exceed three.
W
A
P
M
Ø
Ø A single course of ACS is not routinely recommended between 34+0
and
36+6
weeks of gestation in women at high-risk of PTB within the next 7 days
because of the current uncertainty regarding the benefit to risk ratio.
F
I
G
O
Ø
Ø Prenatal corticosteroids should not be offered routinely to women in whom
late preterm birth is anticipated. Instead, the use of prenatal corticosteroids
should be considered in light of the balance of risks and benefits for
individual women.
R
C
O
G
Ø
Ø Clinicians and women should consider the balance of risks and benefits of
corticosteroids in women in whom imminent preterm birth is anticipated
from 35+0
to 36+6
weeks’ gestation

247
6) Term prelabour caesarean section
7) Fetal Growth Restriction (FGR)
W
A
P
M
Ø
Ø ACS are not routinely recommended before scheduled cesarean section at
term because of the current uncertainty regarding the benefit to risk ratio. In
the absence of other indications, a scheduled cesarean section should not
be performed before 39+0
weeks of gestation.
F
I
G
O
Ø
Ø Prenatal corticosteroids should not be given routinely before cesarean
section at term.
R
C
O
G
Ø
Ø For women undergoing planned caesarean birth between 37+0
and 38+6
weeks an informed discussion should take place with the woman about the
potential risks and benefits of a course of ACS. Although ACS may reduce
admission to the neonatal unit for respiratory morbidity, it is uncertain if
there is any reduction in respiratory distress syndrome, transient tachypnoea
of the newborn or neonatal unit admission overall, and ACS may result
in harm to the neonate which includes hypoglycaemia and potential
developmental delay.
W
A
P
M
Ø
Ø In cases complicated with FGR, ACS should be administered at the same
dosage and indications as in appropriate for gestational age (AGA) fetuses.
F
I
G
O
Ø
Ø None
R
C
O
G
Ø
Ø If imminent preterm birth is likely, a course of antenatal corticosteroids
should be offered to women whose babies are thought to be either small-
for-gestational age (SGA) or to have fetal growth restriction, but women
should be counseled about the lack of evidence to guide care.
Ø
Ø Women with a SGA fetus between 24+0
and 35+6
weeks of gestation where
delivery is being considered should receive a single course of antenatal
corticosteroids.

248
8) Glucose monitoring in women with diabetes
W
A
P
M
Ø
Ø After the administration of ACS, screening with glucose tolerance tests
should be delayed for at least one week.
Ø
Ø Close monitoring of the maternal blood glucose levels is recommended for
women with diabetes in the following days after the administration of ACS
F
I
G
O
Ø
Ø None
R
C
O
G
Ø
Ø Diabetes is not an absolute contraindication. Additional insulin should be
given according to an agreed protocol and close monitoring should be
undertaken.
Ø
Ø Maternal blood glucose levels rise shortly after administration of
corticosteroids and can remain elevated for up to 5 days.

249
Infusion should be accurately and precisely administered via a Syringe Driver or
Volumetric Infusion Pump. Infusion via a Syringe Driver is preferred due to safety reasons
and in cases where fluid management needs to be monitored more strictly.
Infusion via Syringe Driver
Dilution:
Dilute 10 units (1 ml) of Oxytocin (Pitocin®) in 49 ml of Normal Saline 0.9% or Hartmann’s
Solution.
Hence, 1 milliunit (mU)/min of Oxytocin = 0.3 mls/hr.
Rate:
Start at 1 mU/min (0.3 mls/hr) and increase at 30 minutes intervals with the following
incremental regime. Titrate against the uterine contraction aiming for a maximum of 4 in 10
minutes.
Note: Dilutions of oxytocin regime may vary according to local hospital standard operating procedure.
Caution must be taken not to exceed safety limits of oxytocin induction/augmentation regime.
Oxytocin Dose (mU/min) Infusion Rate (ml/hr)
1 0.3
2 0.6
4 1.2
6 1.8
8 2.4
10 3.0
12 3.6
22 6.6
24 7.2
26 7.8
28 8.4
30 9.0
14 4.2
16 4.8
18 5.4
20 6.0
INCREMENTAL REGIME USING SYRINGE DRIVER
If requirement exceeds 12 mU/min or 3.6 ml/hr, consult a Medical Officer.
Maximum 30 mU/min
Maximum recommended dose by the manufacturer is 20 mU/min. A dose greater than this
can only be administered after review by a Specialist/Consultant.

250
Infusion via Volumetric Infusion Pump (only when Syringe Driver is not available)
Dilution:
Dilute 10 units of Oxytocin (Pitocin®) in 500mls of normal saline 0.9% or Hartmann’s
solution.
Rate:
Start at 1 mU/min (3 ml/hr) and increase at 30 minutes intervals with the following
incremental regime. Titrate against the uterine contraction aiming for a maximum of 4 in 10
minutes.
Note: Dilutions of oxytocin regime may vary according to local hospital standard operating procedure.
Caution must be taken not to exceed safety limits of oxytocin induction/augmentation regime.
Oxytocin Dose (mU/min) Infusion Rate (ml/hr)
1 3
2 6
4 12
6 18
8 24
10 30
12 36
22 66
24 72
26 78
28 84
30 90
14 4.2
16 4.8
18 5.4
20 6.0
INCREMENTAL REGIME USING VOLUMETRIC INFUSION PUMP
If requirements exceed 12 mU/min or 36 ml/hr, consult a Medical Officer.
Maximum 30 mU/min
Maximum dose by the manufacturer is 20mU/min. A dose greater than this can only be
administered after review by a Specialist/Consultant.

251
Antibiotics Prophylaxis in Labour and Delivery
Condition
Types of Antibiotics
(Dosage and Route)
Remarks
Caesarean
Section
A single dose of
IV broad-spectrum
antibiotics (e.g. IV
Cefazolin 2 g).
Timing of administration should be within 60
minutes before the skin incision.
If the woman is already on antibiotics, then the
most recent dose should have been administered
within 60 minutes prior to the skin incision.
BMI > 30 kg/m2
may require a weight-adjusted
dose.
In a complicated caesarean section with massive
PPH, a second dose of IV Cefazolin 1g can be
given after 4 hours.
Preferred antibiotics may change from time to
time.
Manual removal
of placenta
A single dose of IV
Ampicillin 2 g.
May vary according to local hospital protocol.
3rd
& 4th
degree
perineal tears
A single dose of
IV broad-spectrum
antibiotics (e.g. IV
Cefuroxime 1.5g)
Antibiotics can be continue up to 1 week if there
is concerns of fecal contamination (T. Cefuroxime
500mg BD and T. Metronidazole 400mg TDS)
May vary according to local hospital protocol.
Instrumental
deliveries
A single dose of IV
Augmentin 1.2 g or
IV Clindamycin 900
mg stat can be given
instead in women with
penicillin allergy.
Timing should be within one hour of delivery in
women without any contraindications.

252
Condition
(Dosage and Route)
Remarks
Preterm labour IV Ampicillin 2 g stat
and 1 g 4 hourly
until delivery or IV
Benzylpenicillin 3 g
stat and 1.5 g 4 hourly
clindamycin 900 mg
stat then 8 hourly in
women with penicillin
allergy)
In established preterm labour, antibiotics should
be started to cover for Group B streptococcus
as the rate of GBS infection in preterm labour is
much higher.
Pre-labour
Rupture of
Membranes
(PROM)
IV Ampicillin 2 g stat
and 1 g 4 hourly or IV
Benzylpenicillin 3 g
stat and 1.5 g 4 hourly
Clindamycin 900 mg
stat then 8 hourly in
women with penicillin
allergy.
Antibiotics are started after 12 hours of leaking
liquor if the woman is still undelivered.
Different hospitals may have different
thresholds for starting antibiotics in women with
leaking liquor, depending on their paediatric
counterparts.
Preterm Pre-
labour rupture
of membranes
(PPROM)
Conservative:
T.Erythromycin
Ethylsuccinate 400 mg
BD for 10 days.
Intrapartum:
IV Ampicillin 2 g stat
then 1 g 4 hourly till
delivery.
Consider delivery if the woman is still leaking
after 36 weeks.
Ragged
membranes
Antibiotics are not
routinely required.
The woman should be advised regarding the
slight risk of endometritis and counseled about
the signs & symptoms of endometritis.

253
Condition
(Dosage and Route)
Remarks
Prophylaxis
against Infective
Endocarditis
IV Ampicillin 2g and IV
Gentamicin 1.5 mg/kg
(max 120 mg) stat.
IV Vancomycin 1 g
over 1 hour plus IV
Gentamicin 80 mg
stat.
Timing of administration should be within 60
minutes to caesarean section or at the onset of
ruptured membranes.
Give a second dose 6 hours after the first dose.
For patient with allergies to penicillin or if there is
enterococcus concern.
Give a second dose 6 hours later.
Cervical cerclage No role for antibiotics. -
Recurrent UTI or
pyelonephritis
(more than 2
episodes)
Consider prophylactic
antibiotics with T.
Cephalexin 250 mg
OD.
Prophylactic antibiotics continued until delivery.
Note: The preferred or suitable antibiotics may change from time to time based on hospital-based
antibiotics resistance surveillance.

254
Common Drugs and Dosages in Pregnancy
Avoid polypharmacy where possible!
1. Timing of exposure
a. Pre embryonic phase (from conception to day 17 post conception)
All or nothing phenomenon”. Insult could lead to death, miscarriage/resorption or
intact survival.
b. Embryonic phase (day 18 post-conception to day 55)
Crucial period of organogenesis. The earlier the insult, the greater the effect. Insults
could lead to congenital malformations.
c. Fetal phase (from 8 weeks to term)
Impact depends on placental transfer. No association with structural malformations.
2. Basic principles:
a. Medications should only be prescribed for clear indications when the benefit
outweighs the risk.
b. Medications should be used in the smallest effective dose for the shortest period of
time.
c. If possible, try to avoid medications in the first trimester.
d. Only use medications that have been proven to be safe in pregnancy.
e. If unsure, contact the pharmacist or specialist for clarification.

255
3. Drugs to Be Avoided in Pregnancy
Absolute contraindication
Antifungal drugs
Griseofulvin
Ketoconazole
Itraconazole
Fluconazole
Terbinafine
Anti-inflammatory drugs
NSAIDS (3rd trimester)
COX-2 inhibitors
Colchicines
Antihelminthic drugs
Mebendazole
Cardiovascular drugs
ACE inhibitors
Angiotensin II receptor inhibitors
Spironolactone
Cytotoxic drugs
Methotrexate
Cyclophosphamide
Busulphan
Vitamin A analogues
Acitretin
Isotretinoin
Endocrine drugs
Radioactive Iodine
Sex hormones
Octreotide
Other drugs
Thalidomide
Mefloquine
Bisphosphonates
Statins and fibrates
Tamoxifen
Nicotine
Mycophenolate mofetil
Live vaccines
MMR, Sabin, Varicella
Relative contraindication
Antibiotics
Tetracycline
Ciprofloxacin
Aminoglycosides
Chloramphenicol
Trimethoprim (1st
trimester)
Nitrofurantoin (near term)
Dapsone (3rd
trimester)
Endocrine drugs
Carbimazole
Chlorpropamide
Psychotropic drugs
Lithium
Cardiovascular drugs
Beta blockers
Minoxidil
Diuretics
All diuretics
Anticoagulant
Warfarin
Anticonvulsants
Phenobarbitone
Phenytoin
Sodium valproate
Carbamazepine
Lamotrigine

256
4. Dosage of Medications in Obstetrics
A. Uterotonic agents
Name Dosage & Route Contraindications Side effects
Oxytocin
(1 amp = 10 IU/ml)
Augmentation for Labour
IV Infusion
Standard dilution (10 IU / 50
ml of NS)
Start at 1 mIU/min or 0.3 ml/
hour
(Titrate every 30 minutes –
maximum 9 ml/hour or 30
mIU/min)
Management of PPH
Bolus
IM 10 IU / IV 5 IU (may repeat
every 5 minutes – maximum
10-20 IU)
IV Infusion
Standard dilution (40 IU / 500
ml of NS)
Start at 125 ml/hour (infusion
over 4 hours)
Fetal compromise,
Uterine
hypertonicity,
Cephalopelvic
disproportion,
Hypersensitivity to
oxytocin
Water
intoxication,
hyponatremia,
nausea,
vomiting,
arrhythmias,
anaphylaxis
Oxytocin/
Ergometrine
(1 amp = 5 IU
oxytocin + 0.5 mg
ergometrine/1 ml
IM 1 ampoule
(Repeat every 5 minutes,
maximum of 5 ml (5 amp)/24
hours
IV not recommended
Cardiac diseases
Hypertensive crisis
PET
Nausea,
vomiting,
headache,
dizziness,
tinnitus,
abdominal pain.
Carboprost
(1 amp = 250
μg/1ml)
Deep IM 250 μg
(Repeat every 15 min – max
dose 2 mg (x8))
Cardiac, renal or
hepatic disease,
caution in
glaucoma, asthma,
hypertension,
Epilepsy
Nausea,
vomiting,
diarrhoea,
hyperthermia,
flushing,
bronchospasm
Carbetocin
(1 amp = 100
μg/1ml)
Long-acting
synthetic oxytocin
IV 1 ampoule administered
via bolus injection over 1
minute.
Hepatic,renal
disease
Hypersensitivity
to oxytocin or
carbetocin.
Nausea,
vomiting,
flushing,
abdominal
pain, pruritus,
headache

257
B. Prostaglandins
Gemeprost
(1 pessary = 1 mg)
Cessation of
production by
the manufacturer
globally in 2022.
1 mg vaginally x 3 hourly
(Maximum 5 pessaries per day)
Unexplained
bleeding, previous
caesarean, placenta
praevia, obstructive
airway disease,
cardiovascular
insufficiency, raised
intraocular pressure
Bleeding,
pain, nausea,
vomiting,
diarrhoea,
headache,
weakness, chills,
flushing
Prostin E2
(1 tab = 3 mg)
3 mg vaginally x 6 hourly
(Maximum 2 pessaries per day)
Use with caution
in cases with
underlying:
Cardiac diseases
Hypertensive crisis
PET, CPD, previous
uterine surgery
Nausea,
vomiting,
headache,
dizziness,
tinnitus,
abdominal pain
Misoprostol
(1 tab = 200 ug)
Approved to be
used as Ubat
Kelulusan Khas
(UKK) circa
November 2022.
(Individual unit/
department
need to apply for
approval to import
the drug)
Deep IM 250 μg
(Repeat every 15 min – max
dose 2 mg (x8))
Cardiac, renal or
hepatic disease,
caution in
glaucoma, asthma,
hypertension,
Epilepsy
Nausea,
vomiting,
diarrhoea,
hyperthermia,
flushing,
bronchospasm
Dosing depends on indication. It can be administered orally or as a
vaginal pessary.
Please refer “Appendix: Use of misoprostol in the medical
management of miscarriage and termination of pregnancy” available
in this guideline.

258
C. Hypertensive crisis
1. IV labetalol should be the first-line management provided there are no
contraindications.
2. A small subgroup of the population is resistant to labetalol; if there is no response
after 3 bolus doses, consider conversion to hydralazine.
3. Avoid sublingual nifedipine.
Labetalol
(1 amp =
25 mg/ 5ml)
Bolus
1st
dose: 25 mg (5 ml); given in
2 minutes.
2nd
dose: 50 mg; given in 2
minutes if BP is ≥ 160/110
mmHg 30 minutes after the 1st
bolus.
3rd dose: 50 mg may be given
if SBP is ≥ 180 mmHg 30
minutes after the 2nd bolus and
rapid BP control is desired.
IV Infusion
Use pure labetalol (25 mg/5
ml) and start infusion at 4 ml/
hr (20 mg/hr). Titrate every
30 minutes by 4 ml. Maximum
32mls/hr (160mg/hr)
Bronchial Asthma,
congestive cardiac
failure, AV heart
block
Hypotension,
sweating,
headache, ankle
oedema, nasal
congestion,
dizziness,
tiredness
Hydralazine
a) Nepresol
(1 amp = 25
mg/2 ml)
Bolus
Dilute 1 amp + 8 ml water (1 ml
= 2.5 mg)
Give 5 mg (2 ml) slow bolus
Repeat at 30 minutes interval
(Maximum of 2 boluses)
IV infusion
Infusion pump
2 amp Nepresol (50 mg) + 46
ml NS (1 ml/1 mg)
Start at 1 ml/hour and titrate
by 1 ml/hr every 30 minutes
(Maximum 10 ml/hr)
Idiopathic SLE,
Heart failure,
tachycardia,
thyrotoxicosis,
dissecting
aneurysm, aortic or
mitral stenosis
Tachycardia,
palpitations,
flushing, angina
symptoms,
headache,
dizziness, GI
disturbances

259
b) Apresoline
(1 amp = 20
mg/1 ml)
Bolus
Dilute 1 amp + 9 ml water (1 ml
=2 mg)
Give 5mg (2.5 ml) slow bolus
Repeat at 30 minute intervals
(Maximum of 2 boluses)
IV infusion
Syringe pump
2 amp Apresoline (40 mg =
2ml) + 38 ml NS (1 ml/1 mg)
Start at 1 ml/H and titrate
by 1 ml/hr every 30 minutes
(Maximum 10 ml/hr)
Nifedipine
(1 tab = 10 mg)
PO 10 mg STAT
Repeated dose of 10mg can be
given 30 minutes later if BP is ≥
160/110mmHg
Total dosage should not
exceed 20mg (a total of 2
doses)
Hepatic dysfunction,
GI obstruction,
inflammatory bowel
disease.
Headache,
flushing, heat
sensation,
tachycardia,
palpitations,
hypotension,
dizziness
Glyceryl
trinitrate
(1 amp = 50
mg/10 ml)
IV Infusion
Syringe pump
2 mls (10 mg) + 48 mls NSD5%
to get 200 mcg/ml
OR
Infusion pump
10 mls (50mg) + 240 mls
NSD5% to get 200 mcg/ml
Starting dose of 5 – 10 mcg/
min (1.5 – 3 ml/hr). Titrate at a
rate of 5 – 10 mcg/min (1.5 – 3
ml/hr) every 5 – 10 minutes
(maximum 200 mcg/min or 60
ml/hr)
Cardiomyopathy,
aortic or mitral
stenosis, conditions
with increased
intracranial pressure,
closed angle
glaucoma, hepatic
or renal dysfunction.
Headache,
flushing,
dizziness,
nausea,
tachycardia.

260
D. Eclampsia
Magnesium
Sulphate
(1 amp = 2.47 g/5
ml)
Loading dose
IV : IV 4 g MgSO4
(8 ml) + 12
ml of NS given over 15 – 20 min
OR
IM : IM 5 g (10 ml) + 1 ml LA
each buttock (Total 10 g) + IV
4 g MgSO4
(8 ml) + 12 ml of
NS given over 15 – 20 min
Recurrent fits
IV – Repeat IV 2 g MgSO4
(4 ml) + 8 ml NS over 15 min
OR
IM – Repeat IM 5 g MgSO4
+
1 ml LA
Maintenance
IV - 24.7 g (10 amp = 50 ml)
+ 450 ml NS run at 21 ml/H
(1 g /H) (Volumetric infusion)
OR
IV - 5 g (2 amp = 10 ml) + 40
ml NS run at 10 ml/H (1 g /H)
(Syringe Driver)
OR
IM – 5 g MgSO4
(10 ml) +
1 ml LA every 4 hours in
alternate buttock
Heart block, renal
failure, myasthenia
gravis
Nausea,
vomiting,
flushing,
hypotension,
muscle
weakness,
blurring
of vision,
diplopia, loss of
reflexes, CNS
depressions,
respiratory
depression,
cardiac arrest,
coma
Diazepam
(1amp=10mg/2ml)
(1 tab =
5mg/10mg)
Bolus
IV 10 mg over 2 min
Rectal
10 mg (Tablet)
Myasthenia gravis,
severe liver disease,
narrow- angle
glaucoma, severe
breathing problem,
or sleep apnea
Drowsiness,
feeling tired,
muscle
weakness
Calcium
gluconate
(1 amp = 10 ml
= 1g) MgSO4
Antidote
1 g Calcium gluconate (10
ml of 10% solution = 1 amp)
Slow bolus over 10 min
Hypercalcemia
disorders
Constipation,
dry mouth,
increased thirst

261
E. Tocolysis
Salbutamol and ritodrine infusions are not recommended as first-line for tocolysis in
view of the adverse effects.
Nifedipine
(1 tab = 10 mg)
Loading
20mg every 30 minutes x 3
doses
Maintenance
20 mg TDS for 48 hours
GI obstruction,
inflammatory bowel
disease
Headache,
flushing, heat
sensation,
tachycardia,
palpitations,
hypotension,
dizziness,
paraesthesia
Salbutamol
sulphate
(1 amp
= 0.5 mg/1 ml)
For
hyperstimulation/
External Cephalic
Version (ECV)
Dilute 1 ampoule in 9 ml of
normal saline.
Label syringe as 50 μg per ml.
Inject 2 ml (100 μg) by slow IV.
Placenta praevia,
abruption,
antepartum
haemorrhage
Tachycardia,
hypotension,
nausea,
vomiting,
headache,
hyperglycaemia,
hypokalemia
Atosiban
(1 vial =
37.5mg/5mls)
A minimum of 4 vials of
atosiban is required for one
course of treatment.
To be given in 3 steps:
Step 1: Slow bolus over 1
minute.
Dose: 6.75mg
Preparation: Withdraw 0.9mls
of undiluted atosiban =
6.75mg
Step 2: High dose loading
infusion over 3 hours.
Dose: 54mg
Preparation: Withdraw 4mls
(balance from the 1st
vial) +
5mls (2nd
vial) = 9mls. Add
this 9mls of atosiban to 81
mls of normal saline in a
microchamber. Withdraw
18mls of the solution and put
aside for Step 3 later. Then
now give the remaining 72mls
at 24mls/H(18mg/H)
Use with caution in
women with liver
disease
Hyperglycaemia,
headache/
dizziness,
tachycardia,
hypotension,
nausea,
vomiting,
fever(rare),
rash(rare)

262
Step 3: Low dose
maintenance infusion over
15 hours.
Dose: 88.5mg
Preparation: Add 18mls of the
solution from Step 2 just now
to 10mls of undiluted atosiban
(3rd
vial and 4th
vial) =28mls of
solution.
Add in 62mls of normal saline
in a microchamber = 90mls of
solution.
To give this solution infusion
at 6mls/H(6mg/H).
Low dose atosiban infusion
can be prolonged up to
45 hours if continuous
suppression is needed.

263
F. Anticoagulant
1. Heparin
(1000 units/ml)
1)Bolus – SC 5000 IU (75
units/kg) followed by BD
dosing
2) Infusion (IV)
Start at 1000 IU/H
(25000 IU heparin in 50 ml
5% Dextrose or NS (500 IU/
ml) – titrate based on APTT
levels
Bovine-based
Relatively
inexpensive
Advantages: Shorter
half life (4 hours)
and more complete
reversal of activity
with protamine
sulphate.
Contraindicated
in: Haemophilia,
haemorrhagic
disorders,
thrombocytopenia,
recent cerebral
haemorrhage, liver
disease, peptic
ulcer disease, major
trauma
Allergic reactions,
thrombocytopenia,
osteoporosis,
haemorrhage,
hyperkalemia,
alopecia,
urticaria, rebound
hyperlipidaemia
2. Low
molecular
weight heparin
a) Enoxaparin
Sodium
100 mg/ml
40 mg = 0.4 ml
60 mg = 0.6 ml
Prophylactic dose
S/C 20 mg OD (below 50 kg)
S/C 40 mg OD (50 – 90 kg)
S/C 60 mg OD (91 – 130 kg)
S/C 80 mg OD (131 – 170 kg)
S/C 0.6 mg/kg/day (> 170 kg)
High prophylactic dose
S/C 40 mg BD
Treatment dose
1 mg/kg 12 hourly (antenatal)
& 1.5 mg/kg/daily (postnatal)
Porcine-based
Relatively high cost
Advantages:
Effective and safer
than unfractionated
heparin. Anti-Xa
monitoring is not
required.
Contraindicated in:
Known
hypersensitivity to
Enoxaparin, active
major bleeding
event.
Haemorrhage,
bruises, allergic
reactions

264
b) Nadroparin
Calcium
9500 IU/mL
2850 IU = 0.3ml
3800 IU = 0.4ml
5700 IU= 0.6ml
9500 IU = 1.0ml
c) Fondaparinux
(5 mg/ml)
Prophylactic dose
S/C 2850 IU OD (<100kg)
S/C 3800 IU OD (>100kg)
Treatment dose
86 IU/kg BD or 171 IU/kg
OD
Prophylactic dose
S/C 2.5 mg OD
Treatment dose
S/C 5.0 mg OD
Porcine-based
Relatively high cost
Advantages: Effective and
safer than unfractionated
heparin. Anti-Xa monitoring
is not required.
Contraindicated in
Known hypersensitivity to
nadroparin,
haemorrhagic
cerebrovascular accident,
severe renal impairment
(creatinine clearance less
than 30 ml/min)
Synthetic pentasaccharide
Safety/efficacy in pregnancy
is not proven. Long half
life (18 hours). No antidote
available.
To be considered in cases
with heparin hypersensitivity
or heparin induced
thrombocytopenia cases.
Fondaparinux use in
pregnancy should be in
conjunction with a consultant
haematologist with
expertise in haemostasis and
pregnancy.
Haemorrhage
bruises,
allergic
reactions
Haemorrhage,
bruises,
allergic
reactions

265
G. Medical disorders in pregnancy
1. Hypertension/Pregnancy Induced Hypertension (PIH)
Methyldopa
(1 tab = 250 mg)
PO 250 mg – 1g TDS
(Maximum dose 3 g/day)
Active/acute liver
disease,
To be discontinued
after delivery (can
potentially cause
postpartum blue)
Sedation,
headache, asthenia,
haemolytic
anaemia, drug
fever, rash
Labetalol
(1 tab = 100 mg
or 200 mg)
PO 100 – 400 mg TDS
(Maximum dose 2400 mg/
day)
Bronchial Asthma
Congestive cardiac
failure
AV heart block
Headache,
dizziness, tiredness,
nasal congestion,
sweating, ankle
oedema
Nifedipine
(1 tab = 10mg)
PO 10 mg TDS
(Maximum dose 20 mg
TDS)
GI obstruction,
inflammatory bowel
disease
Headache, flushing,
heat sensation,
tachycardia,
palpitations,
hypotension,
dizziness,
paraesthesia
Prazosin
(1 tab = 1mg)
PO 1 mg TDS
(Maximum dose 5mg TDS)
Other antihypertensive
medications with better
safety profile should be
used first in pregnancy
before resorting to Prazosin.
Angina pectoris Headache,
drowsy, nausea,
palpitations,
orthostatic
hypotension
Aspirin
(1 tab = 300 mg)
Weight: >40kg
PO 150 mg ON Active peptic
ulcer disease,
haemophilia
Bronchospasm,
asthmatic attack,
GI haemorrhage
Cardiprin
(1 tab = 100mg)
Weight: <40kg
PO 100mg ON Active peptic
ulcer disease,
haemophilia
Bronchospasm,
asthmatic attack,
GI haemorrhage
Calcium
carbonate*
(1 tab = 500 mg)
PO 1 g BD – QID Conditions
associated with
hypercalcaemia &
hypercalciuria
GI disturbances,
bradycardia,
arrhythmias
* Calcium lactate has a bioavailability of only 9%, and the usual dosage will never achieve the
desired levels.

266
2. Hypertension in Postnatal Period
3. Cardiac
Adenosine, verapamil, propranolol and atenolol are safe while amiodarone is
contraindicated in pregnancy.
Amlodipine
(1 tab = 10mg)
PO 5-10 mg OD
(Max 10 mg/day)
Heart failure Nausea, dizziness,
headache, upset
stomach, swelling
of lower limbs
Enalapril
(1 tab = 10mg)
PO 5-10mg
(Maximum 40mg/day)
Aortic valve
stenosis, renal
artery stenosis, renal
impairment
Dizziness, cough,
palpitations
Captopril
(1 tab= 12.5mg)
PO 12.5-25 mg TDS
(Maximum 450 mg/day)
Aortic valve
stenosis, renal
artery stenosis,renal
impairment,
hyperkalemia
DIzziness, cough,
palpitations
Atenolol
(1 tab = 50mg)
PO 25-50 mg OD
(Maximum 100mg/day)
Heart block,
asthma, sinus
bradycardia, sinus
node dysfunction,
pulmonary edema
Nausea, vomiting,
dizziness, upset
stomach
Metoprolol
(1 tab = 50mg)
PO 50mg BD
(Maximum 450 mg/day)
Heart block,
asthma, sinus
bradycardia, sinus
node dysfunction,
pulmonary edema
Dizziness, tiredness,
depression,
diarrhea
Warfarin
(1 tab = 1, 2, 5 mg)
Antidote:
Oral/parenteral
Vitamin K
PO based on target INR Hemorrhagic
tendencies, recent
surgery
Warfarin
embryopathy (2%),
haemorrhage,
hypersensitivity

267
4. Diabetes
5. SLE & Connective tissue diseases
Metformin and Glibenclamide are considered safe in pregnancy although there is a
paucity of data on the possible long-term implications.
Ø
Ø Mycophenolate Mofetil (MMF), cyclophosphamide, methotrexate and
chlorambucil are contraindicated in pregnancy.
Ø
Ø Azathioprine is safe in pregnancy. Maternal white cell count may be used for
monitoring.
Ø
Ø Cyclosporine and tacrolimus are also safe in pregnancy.
Name Dosage & Route
Mechanism of
action
Side effects
Insulin
Ultra short-
acting
Short-Acting
Intermediate-
acting
Long-acting
Administer immediately
before meals
Administer 30 minutes
before meals (used for
sliding scale)
Administer once or twice a
day
Administer once or twice a
day
Onset: 12 – 30 min
Peak: 0.5 – 3 H
Duration: 3 – 5 H
Onset: 30 min
Peak: 2.5 – 5 H
Duration: 4 – 24 H
Onset: 1 – 2 H
Peak: 4 – 12 H
Duration: 4 – 24 H
Onset: 3 – 4 H
Peak: Not seen
Duration: ≥ 24 H
Hypoglycaemia
Localized allergic
reaction
Metformin
(1 tab = 500
mg/850 mg)
PO 500 mg OD/BD/TDS
(Max 2 g daily)
Diabetic coma,
impaired renal/liver
function, recent MI,
lactic acidosis
Insulin
Ultra short-acting
Glibenclamide
(1 tab = 5 mg)
PO 2.5 – 5 mg/day
(Max 10 mg bd)
Renal/liver
impairment, type
1 DM, diabetic
ketoacidosis, use
with Bosentan
GI disturbances,
lactic acidosis,
weight loss

268
6. Respiratory
7. Thyroid diseases
Ø
Ø “Aspirin sensitivity” – women with asthma should be asked regarding aspirin
sensitivity.
Ø
Ø Prostaglandin E2 should be avoided in severe acute asthma.
Ø
Ø Women with thyroid diseases should continue their pre-existing medications
until they are reviewed by a physician.
Ø
Ø L-Thyroxine is safe in pregnancy, and the dose may need to be increased in
pregnancy due to increased demands.
Ø
Ø Both PTU and carbimazole have potential teratogenic effects (2 – 4%).
Ø
Ø In the first trimester, PTU is preferred over carbimazole. However, the decision
to switch between medications should be made by a physician on a case by
case basis.
Ø
Ø Thyroid function tests should be done 6 – 8 weekly throughout pregnancy
(those on treatment, TFT may be done 4 weekly)
Ø
Ø Women must be informed that the benefits of anti-thyroid medications
outweigh the risks of thyrotoxicosis/thyroid storm in pregnancy.
Ø
Ø It is safe to breastfeed on PTU, carbimazole and thyroxine.
Name Dosage & Route Side effects
Prednisolone
(1 tablet
= 5 mg)
PO 1 mg/kg
Up to 60 mg daily
Dyspepsia, peptic ulceration, abdominal
distension, ulceration, candidiasis,
musculoskeletal effects, Cushing’s
syndrome, euphoria, striae, bruising
Hydrocortisone
(1 ml = 100 mg)
IV 200 mg stat &
100 mg 3 – 4 times in 24
hours
Similar as above
Salbutamol
sulphate
( 1 amp – 1 ml =
0.5 mg)
IV/SC bolus 0.5 mg
Repeat every 4 hours
Aerosol 100 – 200 μg up to 2
hourly
Tachycardia, hypotension, nausea,
vomiting, headache, hyperglycaemia,
hypokalemia

269
Propylthiouracil (D)
(1 tablet = 50 mg)
PO 200 – 400 mg daily in 2 –
3 divided doses then titrate
accordingly.
Neonatal goiter and
hypothyroidism, face and
neck cysts, urinary tract
abnormalities in male babies.
Maternal hepatitis,
neutropenia, vasculitis,
aplastic anemia,
thrombocytopenia, lupus-like
syndrome.
Carbimazole (D)
(1 tablet = 5 mg, 10
mg)
PO 20 – 60 mg in 2 – 3 divided
doses (during initiation).
PO 5 – 15 mg daily for maintenance.
Neonatal goiter and
hypothyroidism, aplasia cutis,
choanal/esophageal atresia,
abdominal wall defects, eye,
urinary system and VSD.
Maternal neutropenia,
agranulocytosis, urticaria rash.
Propranolol (C) &
(D) in the 2nd
& 3rd
trimester
(1 tab = 40 mg)
PO 40 mg TDS.
Discontinue once there is clinical
improvement.
No harm to the fetus in short
term use.
Maternal bradycardia,
hypotension.
Thyroxine (A)
(1 tablet = 50 μg,
100 μg)
PO 100 – 200 μg /day. Tachycardia, tremor,
headache, flushing, sweating.

270
Hepatic enzymes
inducer:
Phenytoin (D)
(1 tablet = 100 mg)
Carbamazepine(D)
(1 tablet = 200 mg)
PO 300 – 400
mg daily in 3 or 4
divided doses
PO 600 mg/day
AV block, hepatic
disease
Nystagmus, ataxia,
slurred speech,
confusion, gingival
hyperplasia, nausea,
vomiting, fetal
hydantoin syndrome
Dizziness, dry mouth,
GI disturbance
Sodium Valproate (D)
(1 tablet = 200 mg)
PO 1000 – 2000
mg/day
Active liver disease Liver dysfunction, GI
disorders, weight gain
Lamotrigine (C)
(1 tablet = 100 mg)
PO 100 – 200 mg
daily in 1 or 2
divided doses
Avoid abrupt
withdrawal. Renal &
liver failure.
Rash, GI disturbances,
headache, nausea,
dizziness, hallucination
Folic Acid (A) 5 mg
preconception up
to 12 weeks of
pregnancy
8. Neurological
Ø
Ø Never stop anti-epileptic drugs without consulting a physician/neurologist.
Ø
Ø The risk of congenital abnormalities in the fetus depends on the type, number
and dose of AEDs (Anti-epileptic drugs).
Ø
Ø Phenytoin, phenobarbital, carbamazepine, lamotrigine, sodium valproate,
topiramate all cross the placenta and are potentially teratogenic.
Ø
Ø Newer anticonvulsants such as levetiracetam and gabapentin are not teratogenic
in animals.
Ø
Ø Women with epilepsy who are planning to get pregnant should inform their
doctors to allow switching to a pregnancy-friendly anti-epileptic drug prior to
conceiving. Aim for monotherapy and the lowest dose with adequate seizure
control.
Ø
Ø Phenytoin, primidone, carbamazepine and phenobarbitone are hepatic enzyme
inducers. COCP may not be suitable for women on these drugs.

271
Zidovudine (AZT)
(1 tab = 100 mg)
(Retrovir)
(1 amp = 200
mg/20 ml)
Combivir
(1 tablet = 300
mg Zidovudine
+ 150 mg
lamivudine)
PO 500 – 600 mg
daily in divided
doses
Infusion (prior to
LSCS)
2 mg/kg infusion 3
hours prior to LSCS
Anaemia, abnormal
liver function
Anaemia, taste
disturbances, chest pain,
influenza like symptoms
Didanosine
(1 tablet = 200
mg)
PO 250 – 400 mg in
1 – 2 divided doses
Pancreatitis,
peripheral
neuropathy,
lactic acidosis,
lipodystrophy
Pancreatitis, diabetes,
liver failure, anaphylactic
reactions, rhabdomyolysis
Lamivudine (3TC)
(1 tablet = 150 mg)
PO 150 mg BD or
300 mg OD
Hepatitis Peripheral neuropathy,
rhabdomyolysis, nasal
symptoms
Kaletra
(1 tab = 133.3
mg of lopinavir &
ritonavir 33.3 mg)
3 capsules BD Pancreatitis, prolong
QT interval
Electrolyte disturbances
Efavirenz
(1 tab = 50
mg/600 mg)
PO 200 – 600 mg
daily
Chronic hepatitis,
history of seizures,
renal impairment
Rash, Steven-Johnson
Syndrome, GI
symptoms, fatigue, sleep
disturbances, impaired
concentration
Nevirapine
(1 tab = 200 mg)
PO 200 mg OD/BD
400 mg OD
Chronic hepatitis,
liver impairment
Rash, Steven-Johnson
Syndrome, nausea,
hepatitis, toxic epidermal
necrolysis, headache
9. Dermatology
10. HIV
Ø
Ø Topical steroid, emollients and coal tar are safe in pregnancy.
Ø
Ø Tetracycline and retinoids are contraindicated in pregnancy.

272
11. Gastrointestinal
Proton pump inhibitors are safe in pregnancy.
Antihistamines:
Promethazine
(1 tab = 10 mg)
Cyclizine
(1 tab = 50 mg)
PO 10 – 20 mg
BD/TDS
PO 50 mg TDS
Epilepsy, urinary
retention, glaucoma,
renal impairment, heart
failure
Drowsiness, headache,
dry mouth, urinary
retention, GI
disturbances
Phenothiazines:
Chlorpromazine
(1 tab = 25 mg)
Prochlorperazine
(stemetil)
(1 tab = 5 mg)
PO 10 – 25 mg
TDS
PO 5 – 10 mg
BD/TDS
Epilepsy, urinary
retention, glaucoma,
renal impairment, heart
failure
Sedation, hypotension
extrapyramidal
symptoms (dystonia),
respiratory depression
Metoclopramide (1
tab = 10 mg)
PO 5 – 10 mg
TDS
IM/IV 5 – 10 mg
8 hourly
GI obstruction,
perforation or
haemorrhage
Extrapyramidal
side effects,
hyperprolactinemia,
tardive dyskinesia,
drowsiness, rash
Pyridoxine (Vit B6)
(I tab = 10 mg)
PO 10 – 25 mg
TDS
Allergy to pyridoxine Headache, nausea,
drowsiness, numbness,
tingling of arms/legs
Thiamine (Vit B1)
(1 tab = 10 mg)
PO 10 – 25 mg
OD
Allergy to thiamine Anaphylactic shock if
given IV
Ondansetron
(5HT3 antagonist)
(1 tab = 4 mg)
(1 amp – 2 ml = 4
mg)
PO 8 mg BD
IV 8 mg bolus
Prolonged QT interval,
hepatic dysfunction
Constipation, headache,
hiccups, hypotension,
arrhythmia, movement
disorders

273
12. Analgesia
Epidural
medications:
A) Bupivacaine
(8 – 10 ml of 0.25%
solution)
B) Ropivacaine
(10 – 20 ml of 2 mg/
ml solution)
C) Lidocaine/
Lignocaine
(8 – 10 ml of 1.5%
solution)
20 – 25 mg
20 – 40 mg
Continuous infusion:
6 – 14 ml/H of 2 mg/ml
solution
Dosage : 12 – 28 mg/H
120 – 150 mg
Systemic infections,
bleeding tendencies,
spinal deformities
Postdural puncture
headaches,
restlessness,
tremors,
convulsions,
perioral numbness,
paraesthesia,
hypotension,
bradycardia,
arrhythmia,
hypersensitivity
Local anaesthetic
agents:
Lidocaine/Lignocaine
(1% solution-
1ml=10mg)
Local infiltration,
pudendal block
Max dose: 3 mg/kg
E.g: 70 kg patient.
70kg x3mg =210mg.
Heart block, heart
failure, arrhythmia,
myasthenia gravis
Toxicity
Opioids:
1) Pethidine
(1 amp = 50 mg/
ml)
2) Tramadol
(Tramal)
(1 tab = 50 mg)
(1 vial = 50mg)
1) 50 – 100 mg
IM/SC every
4 – 6 hours
2) 20 – 50 mg IV
PO 50 mg TDS
IV /IM/SC 50 mg TDS
Hypothyroidism,
asthma, renal or
hepatic failure
Hypersensitivity,
alcohol intoxication
Constipation,
drowsiness,
confusion,
headache,
hypotension,
tachycardia,
pruritus, flushing
Nausea, vomiting,
dizziness, dry
mouth
NSAIDS:
Diclofenac Sodium
(Voltaren)
(1 tab = 25 mg, 50
mg, 75 mg)
(1 amp = 50 mg/2 ml)
Mefenamic Acid
(Ponstan)
(1 tab = 250 mg)
PO 50 mg/75 mg TDS
IM 50 mg TDS
Supp 100 mg BD
PO 500 mg TDS
Third trimester,
severe PET, upper
GI bleed, renal
impairment,
asthmatic
Nausea, vomiting,
abdominal
cramps, diarrhoea,
GI bleed,
bronchospasm

274
13. Antibiotics
Ø
Ø The Penicillin and Cephalosporin group of antibiotics are generally safe in
pregnancy.
Ø
Ø Aminoglycosides, chloramphenicols, quinolones, tetracyclines and antifungal
medications are best avoided in pregnancy.
Ø
Ø Antibiotics should only be initiated if there are clear indications and benefits,
especially in women with intact membranes.
Erythromycin Ethyl
Succinate
(1 tablet = 400 mg)
PO 400 mg BD GI side effects
Abnormal liver function
Cefalexin
(1 tab = 250 mg)
PO 250 – 500 mg BD
Prophylaxis dose 250 mg OD
GI disturbances
Cefuroxime
(1 tab = 250 mg)
(1 vial = 750 mg)
PO 250 – 500 mg BD
IV 750 mg – 1.5 g TDS
GI disturbances, diarrhoea,
vomiting, nausea, rash, drug
fever, anaphylaxis
Cefoperazone
(1 vial = 1 g)
IV 1 – 2 g BD Hypersensitivity, Vit K
deficiency, neutropenia
Ampicillin
(1 capsule = 250 mg)
(1 vial = 500 mg)
PO 250 – 500 mg TDS
IV 500 mg – 2 g 4/6 hourly
Nausea, vomiting, diarrhoea,
rash, colitis
Metronidazole
(I tab = 200 mg)
(1 vial – 100 ml=500 mg)
PO 200 – 400 mg TDS
IV 500 mg TDS
Avoid alcohol or in porphyria
patients, GI & taste
disturbances, mucositis
Clavulanic Acid/
Amoxicillin
(1 tab = 625 mg)
(1 vial = 600 mg)
PO 625 mg BD/TDS
IV 1.2 g TDS
Diarrhoea, nausea, vomiting,
colitis, rash
Sulbactam/Ampicillin
(1 tab = 375 mg)
(1 vial = 0.75 g/1.5 g)
PO 375 mg – 750 mg BD
IM/IV 1.5 g TDS
Diarrhoea, abdominal cramps,
nausea, rash, itching
Doxycycline
(1 tab = 100 mg)
PO 100 mg BD GI effects, rash, hypersensitivity
Ceftriaxone
(1 vial = 1 g)
IV/Deep IM 1 – 2 g daily Urine & gall bladder
precipitates, pancreatitis,
prolongation of PT
Azithromycin
(1 tab = 250 mg)
PO 1g STAT (STD)
PO 500 mg OD x 3/7
GI disturbances, hearing
impairment, taste disturbances,
dizziness, vertigo, rash

275
14. Antiviral
15. Supplements
Aciclovir
(1 tab = 200 mg/400 mg)
Varicella infection
PO 800 mg 5 times daily x 5/7
Herpes
PO 200 mg 5 times daily or
PO 400 mg TDS x 5/7
GI side effects,
abdominal pain, rash, pruritus
Oseltamivir
(1 tab = 75mg)
Influenza A and B
PO 75mg BD x 5/7
GI side effects,
abdominal pain, nausea and
vomiting
Name Dosage & Route
Folic acid (1 tab = 5 mg) Low-risk pregnancies 400 μg OD - oral
High-risk pregnancies 5 mg OD - oral
(Periconception and up to 12 weeks of pregnancy)
Vitamin D (1 tab = 10 μg/400IU) PO 10 μg/day for all women
PO 20 μg/day for women at high risk of PE
Calcium Carbonate (1 tab = 500 mg) PO 1 g BD/QID
Ferrous Fumarate (1 tab = 200 mg) PO 200 mg – 400 mg OD/BD
Ferrous Sulphate (1 tab = 200 mg) PO 200 mg – 400 mg OD/BD
16. Other important medications
Cabergoline
(1 tablet = 0.5 mg)
Lactation prevention – 1 mg x
1 dose
Lactation suppression - 0.25 mg
BD for 2 days (Total of 1mg)
Hypotension, dizziness, vertigo,
headache, abdominal pain
Recombinant activated
factor VII (Novo7)
(1 vial = 1 mg)
IV infusion 60 – 120 μg/
kg over 3 – 5 min (consider
repeating after 30 – 60 min)
Nausea, thrombotic events
(MI or CVA), fever, pain, rash,
allergic reaction
Dexamethasone
(1 amp = 8 mg/2 ml)
IM 12 mg 12 hourly x 1/7 or
IM 6 mg 12 hourly x 2/7
Hyperglycaemia, headache,
dizziness, nausea, pain over
injection site
To induce lactation
Metoclopramide
(1 tab – 10 mg)
Domperidone
(1 tab – 10 mg)
PO 10 mg TDS
PO 10 mg TDS
GI obstruction, perforation or
haemorrhage
GI disturbances

276
Antibiotics
Chloramphenicol
Co-trimoxazole
Penicillins
Tetracyclines
Sulphonamides
Rifampicin
Anticonvulsants
Phenobarbitone
Phenytoin
Carbamazepine
Antifungal
Griseofulvin
Antiviral
Nevirapine
Ritonavir
Herbal remedies
St John’s wort
Alprazolam
Diazepam
Beta-blockers
Corticosteroids Cyclosporin
Tricyclic antidepressants Xanthines
Anticoagulants Benzodiazepines
Lamotrigine
H. Drug interactions
1. Drugs that decrease the effectiveness of COCP
2. Drugs whose clearance can be increased by COCP
3. Drugs whose effect can be decreased by COCP

277
Caution in
-
- Previous caesarean section (risk of
uterine rupture <0.3%)
-
- Conditions that exacerbate hypotension
ex. Cardiovascular or cerebrovascular
disease
Adverse effects
-
- nausea, vomiting, diarrhoea, abdominal
pain
-
- frequent painful uterine contractions
-
- vaginal bleeding
-
- headache and dizziness
Indications
Medical management of miscarriage/fetal loss (up to 23+6 weeks of gestation)
Termination of pregnancy (<22+0 week of gestation)
Prerequisite
- Decision for use by specialist
- Usage in a Ministry of Health Facility
- Usage on a named-patient basis
Use of misoprostol in the medical management of
miscarriage and termination of pregnancy
Gemeprost (Cervagem) has previously been used for medical evacuation of missed
miscarriage, medical termination of pregnancy and cervical preparation prior to
instrumentation of the uterus. With the cessation of its production by the manufacturer
globally, misoprostol, a synthetic analogue of prostaglandin E1 is now the alternative,
having been approved to be used as Ubat Kelulusan Khas (UKK) by Ministry of Health’s
circa November 2022.
Contraindications
-
- Hypersensitivity to Misoprostol or any
other prostaglandin agent
-
- Underlying coagulation disorders
-
- Pelvic infection or sepsis
-
- Uncertainty about pregnancy viability
-
- Suspected or confirmed ectopic
pregnancy
-
- Molar pregnancy
-
- Presence of uterine scar niche in
women with one previous uterine scar

278
Dose
Route Vaginal route preferable due to lower incidence of side effects.
Max dose 2 times per course
Repeated
course
If is required, consider the next day and at least 3 hours from last dose
During
review
Reassess if the patient is suitable for next dose of Misoprostol, avoid if
contracting, os open or excessive bleeding
Dose Misoprostol 400 mcg 4-6 hourly
Route Vaginal route preferable due to lower incidence of side effects.
Max dose Up to 5 doses per course
Repeated
course
If is required, discuss with consultant and rest for at least 24 hours after the
last dose
During
review
Reassess if the patient is suitable for next dose of Misoprostol, avoid if
contracting, os open or excessive bleeding
Additional
precautions
-
- Perform ultrasound to exclude uterine niche in women > 20 weeks of
gestation AND a uterine scar before induction
-
- Women with two or more previous scars
-
- Women requiring a repeat course
-
- Uterus beyond 24 weeks
Generally no changes of Misoprostol dosage is required for women with previous uterine
scar.
Induction regime for first trimester
Induction regime for second trimester
Missed Miscarriage
(up to 12+6 weeks)
Termination of pregnancy
(up to 12+6 weeks)
Fetal loss
13+0 to 23+6 weeks
Termination of pregnancy
(up to 21+6 weeks)
Misoprostol 800 mcg 3 hourly Misoprostol 800 mcg 3-12 hourly

279
Flowchart 29: Procedure for misoprostol usage
Reference:
1. Morris JL, Winioff B, Dabash R, et al. FIGO’s updated recommendations for misoprostol
used alone in gynecology and obstetrics. Int J Gynecol Obstet, 138:362-366

280
PPH Box Checklist
Suggested PPH Box Checklist
(Please ensure all items are replenished after use)
Items Quantity
IV Cannula size 14, 16, 18 gauge
IV drip set
Micropore/Plaster to secure cannula
Gelafundin 500 ml
Normal saline 500 ml
Oxytocin 10 IU/ml
(Fridge Item- Retrieve when needed)
or
alternatively Heat-stable Carbetocin
Syntometrine
Carboprost/ Haemabate 250 μg/ml
(Fridge Item- Retrieve when needed)
Tranexamic Acid (1 g/10 ml)
Water for injection 10 ml
Sterile vaginal pack
Syringe 5 ml, 10 ml
Hypodermic Needle 21 (green), 23 (blue) gauge
Bakri Balloon with manual
Foley catheter size 24 F
Urine bag
3 of each size
3 units
3 rolls
1 pint
2 pints
10 ampoules
1 ampoule
2 ampoules
4 ampoules
1 ampoule (room temperature)
5 ampoules
3 packs
3 of each size
3 of each size
1 unit
2 units
2 unit (1 for Urine drainage, 1 for
Bakri system drainage)

281
PPH Management Checklist
PPH Management Checklist
Hospital/Clinic
Date
Patient’s name
Age
IC No
Time of call for help
Called by
: ____________________
: ____________________
: ____________________
: ____________________
: ___________________
: _____________AM/PM
: ____________________
Initial Management Time
Oxygen given
Head bed down
Branula No. 1
Branula No. 2
Branula No. 3
Team Member Name
On-call O&G Specialist
On-call MO
On-call Anaesthetic MO
On-call Anaesthetist
Time arrived

282
Time
HR
BP
Obstetric
Shock
Index
Type
Volume
Time
Time
Observations
Fluids/blood/blood
products
FBC
GXM
_______units
Urinary
catheter
PT/PTT
Placenta
delivered
Yes
No
Blood
sent
Time

283
Drug
Dose
Time
Syntometrine
IM
1
ampoule
Time
Ergometrine
IM/IV
500
μg
/
1
amp
(if
normal
BP)
Oxytocin
40
units
in
500ml
NS
at
125
ml/H
Carbetocin
IM/IV
100
mcg/
1
amp
Tranexamic
acid
IV
1g
Haemabate
(Carboprost)
IM
250
μg
/
1
amp
Haemabate
(Carboprost)
IM
250
μg
/
1
amp
Haemabate
(Carboprost)
IM
250
μg
/
1
amp
Haemabate
(Carboprost)
IM
250
μg
/
1
amp
Name
O&G
specialist
called
(If
from
non-specialist
hospital)
:
_____________________________
Time:
________________
AM
/
PM
Form
filled
by:
________________________________________
Signature:
_____________________
“PPH
management
Checklist”
should
be
filled
for
every
case
of
PPH”

284
Resuscitative Hysterotomy Instrument Checklist
Every hospital has its very own Resuscitative Hysterotomy Box. An example of Resuscitative
Hysterotomy Box is listed as below:
Note: Resuscitative Hysterotomy Box should be checked and replenished after each use immediately.
Expiry dates of certain disposable items should be checked by in-charge personnel every month.
Items Quantity
Resuscitative Hysterotomy Set
• Scalpel Handle No. 3
• Hegar Mayo Needle Holder
• Standard Dressing Forceps
• Suture Scissor
• Green Armytage Forceps
• Stainless Steel Kidney Dish
1
1
1
1
2
1
Skin Prep Towel 4
Sterile Abdominal Pack 1
Chlorhexidine gluconate 2% with Isopropyl Alcohol 70% solution 100mls x 2
Sterile Scalpel Blade No. 10 1
Sutures Vicryl/ Ecosorb 1 3
Sutures Dafilon/ Nylon 1
Cord Clamp 2
Adapted from:
1. Sarawak General Hospital’s Labour Ward Manual 2020 Edition.
2. Obstetric Protocol (O&G Department Hospital Tuanku Fauziah Kangar, Perlis) 2020- 2025.
3. Obstetric and Gynaecology Protocol State of Kedah 2019.
4. Obstetric and Gynaecology Protocol HTJ Negeri Sembilan 2018.
Reference:
1. National Antimicrobial Guideline 2019 MOH.
2. Malaysia CPG On Management of Hypertension 5th
Edition 2018.
3. NICE Clinical Guideline 107 On Hypertension in Pregnancy 2019.
4. Greentop Guideline No. 37a Reducing the Risk of Venous Thromboembolism during
Pregnancy and the Puerperium 2015.
5. World Association of Perinatal Medicine and Perinatal Medicine Foundation. Clinical
Practice Guideline. The use of antenatal corticosteroids for fetal maturation, 2022.
6. FIGO. Good practice recommendations on the use of prenatal corticosteroids to
improve outcomes and minimize harm in babies born preterm, 2021.
7. RCOG.Antenatal corticosteroids to reduce neonatal morbidity and mortality, 2022.

285
DRAFTING COMMITTEE OF HANDBOOK
OF OBSTETRICS GUIDELINE
Advisors
CHAIRMAN
Dato’ Dr Mohd. Azman bin Yacob
Director
Medical Development Division
Ministry of Health Malaysia
Dato’ Dr. Mohd Rushdan Bin Md Noor
National Head of O&G Services
2021 – 2023
Datuk Dr. Wan Ahmad Hazim Wan Ghazali
National Head of O&G Services
2023 - Present
Dr. Rafaie Bin Amin
Sarawak State Head of O&G Services
Consultant O&G (MFM)
Hospital Umum Sarawak

286
CONTRIBUTORS
Dr. Kanddy Loo Chin Yee
Consultant O&G (Gynae-Oncology)
Dr. Voon Hian Yan
Dr. Tan Lee Na
Dr. Chai Ming Cheng
O&G Specialist
Hospital Sarikei
Dr. Woon Shu Yuan
O&G Specialist (Reproductive
Medicine Trainee)
Hospital Wanita & Kanak-Kanak Sabah
Dr. Teo Wan Sim
O&G Specialist
Hospital Serian
Dr. Nor Hayati binti Ibrahim
Deputy Director
Medical Development Division of MOH
Dr Jafanita binti Jamaludin
Senior Principal Assistant Director
& Head of Unit
O&G and Paediatrics Services Unit
Dr Siti Nur Aishah binti Rahmat
Senior Principal Assistant Director
Dr Mohamad Afiq Farhan Ahmad Safian
Principal Assistant Director
Puan Siti Rahmah Abdul Rashid
Head Nurse

287
Internal Reviewers
Datuk Dr. Tham Seng Woh
Melaka State Head of O&G Services
O&G Consultant
Hospital Melaka
Dato’ Dr. Rozihan Ismail
Pahang State Head of O&G Services
Consultant O&G (Urogynaecology)
Hospital Tengku Ampuan Afzan Kuantan
Dr Rafaie bin Amin
Sarawak State Head of O&G Services
Dr. Ab Rahim bin Abd Ghani
Johor State Head of O&G Services
Consultant O&G
Hospital Pakar Sultanah Fatimah Muar
Dr Faridah binti Mohd Yusof
Terengganu State Head of O&G Services
Consultant O&G (Urogynaecology)
Hospital Sultanah Nur Zahirah Kuala
Terengganu
Dr Sharmini Diana Parampaklan
Penang State Head of O&G Services
Consultant O&G
Hospital Pulau Pinang
Dr Haris Tham Seong Wai
Consultant O&G (Reproductive)
Hospital Raja Permaisuri Bainun Ipoh
Dr Nik Ahmad Nik Abdullah
Consultant O&G (Gynae-Oncology)
Hospital Raja Perempuan Zainab II
Kota Bharu
Dr Shahril Abu Bakar
Consultant O&G
Hospital Tuanku Azizah Kuala Lumpur
Dr Hoong Farn Weng Michael
Hospital Wanita dan Kanak-Kanak Sabah
Dr Darminder Chopra
Consultant O&G
Hospital Sungai Buloh
Dr Sharifa Azlin binti Hamid
Hospital Sultanah Bahiyah Alor Setar
Dr Noor Aini Harun
Consultant O&G
Hospital Tuanku Fauziah Kangar
Dr Choi Yee Xian
O&G Specialist
Hospital Tuanku Ja’afar Seremban

288
External Reviewers
Prof Dato’ Dr. Hamizah binti Ismail
Professor in Obstetrics and Gynecology
Department of Obstetrics and Gynaecology
Sultan Ahmad Shah Medical Center @IIUM
Kulliyyah of Medicine
International Islamic University Malaysia
Prof Madya Rahana Abdul Rahman
Head of MFM Unit
Consultant Obstetrics and Gynaecology
Hospital Canselor Tuanku Muhriz
Universiti Kebangsaan Malaysia
Dr Rahmah Binti Saaid
Senior Lecturer and Consultant
Department of Obstetrics & Gynaecology
University Malaya Medical Centre
Faculty of Medicine
Universiti Malaya
Dr Engku Husna Engku Ismail
Medical Lecturer/ Obstetrician & Gynaecologist
Department of Obstetrics & Gynaecology
School of Medical Sciences
Universiti Sains Malaysia

289

290
Block E1, Parcel E,
Federal Government Administrative Centre,
62590 Putrajaya, Malaysia
Tel.: +603-8883 1047
http://www.moh.gov.my

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