Preterm Premature Rupture Of Membranes (PPROM)

Guidelines

-Confirm reports of Hb, blood group, VDRL/ HIV, and urinalysis are ready and normal. If not, get them done.

-Send blood for spot test for HIV if not done earlier to emergency lab and check the report.

- Get complete blood count done.

-Check if she has received tetanus immunization (at least 2 doses, if the last dose prior to pregnancy was given > 5 years ago, and 1 dose if the last dose prior to pregnancy was given < 5 years ago).

-If leaking >12 hours, send high vaginal swab.

-Get CRP and ASLO titers done, if available.

-Refer: Appendix 3

-Consider tocolysis if there are no contraindications to tocolysis or continuation of pregnancy

Treatment Orders

-Complete bed rest

-Shave/ clip hair prepare private parts

-No vaginal or speculum examination

-Sterile vulval pad

-TPR, FHS 1/2 hourly

-Save all pads

-Antibiotics (See antibiotics policy)

-Inj. Betamethasone (or Dexamethasone) 12 mg im stat, to be repeated after 24 hours.

Inform if

• P>120/min
• T > 38 0 C
• Uterine activity
• Foul smell of vaginal fluid
• FHR > 160/min

Premature Rupture Of Membranes (PROM)

Guidelines

-Confirm reports of Hb, blood group, VDRL/ HIV, and urinalysis are ready and normal. If not, get them done.

-Send blood for spot test for HIV if not done earlier to emergency lab and check the report.

-Check if she has received tetanus immunization (at least 2 doses, if the last dose prior to pregnancy was given > 5 years ago, and 1 dose if the last dose prior to pregnancy was given < 5 years ago).

-If leaking >12 hours, send high vaginal swab

-Inform Unit concerned immediately for definitive decision on induction of labor.

-Refer: Appendix 3

Treatment Orders

-Complete bed rest

-Shave/ clip hair prepare private parts

-No vaginal or speculum examination

-Sterile vulval pad

-TPR, FHS 1/2 hourly

-Save all pads

-Antibiotics

Inform if

• P>120/min
• T > 38 0 C
• FHR > 160/min
• Foul smell of vaginal fluid

Rh-Negative Gravida

Guidelines

-IV access through # 18 cannula.

- Confirm reports of Hb, blood group, VDRL/ HIV, and urinalysis are ready and normal. If not, get them done.

-Send blood for spot test for HIV if not done earlier to emergency lab and check the report. -Check if she has received tetanus immunization (at least 2 doses, if the last dose prior to pregnancy was given > 5 years ago, and 1 dose if the last dose prior to pregnancy was given < 5 years ago).

-Check Rh antibody titre (Indirect Coombs’ test -ICT).

-Send blood for grouping and cross matching and confirm availability.

-Counseling for possible need for Rh-immune globulin after delivery (for financial preparation).

Treatment Orders

-Shave/ clip hair and prepare private parts

-Simple enema stat

-Lateral position

-TPR,FHS 1/2 hourly

Inform if

• P > 120/min
• FHR > 160 or <110/min or irregular
• Meconium in amniotic fluid

-Early clamping of cord, no milking of cord.

-No prophylactic Oxytocin drip in 4th stage

-Collect cord blood for Hb, blood group, direct Coombs’ test, bilirubin

-Give

Inj Methyl ergometrine 0.1mg IV/ 0.2 mg IM/

Inj. PGF 2 a 125 m g i.m. a fter delivery of placenta

Rheumatic/Non-Cyanotic Congenital Heart Disease

Guidelines

-IV access through # 18 cannula.

-Send blood for grouping and cross matching and confirm availability.

-Confirm reports of Hb, blood group, VDRL/ HIV, and urinalysis are ready and normal. If not, get them done.

-Send blood for spot test for HIV if not done earlier to emergency lab and check the report.

-Check if she has received tetanus immunization (at least 2 doses, if the last dose prior to pregnancy was given > 5 years ago, and 1 dose if the last dose prior to pregnancy was given < 5 years ago).

-Obtain ECG and serum electrolyte levels.

-Check the 2D echocardiography report, if any.

-Check if patient is on anticoagulants and cardiac drugs.

-Medical/ cardiology call, if required.

-Inform lecturer on call.

Treatment Orders

-Shave/ clip hair and prepare private parts

-Simple enema stat

-Back rest /left lateral position

-Nasal moist oxygen- 2 litres/min

-Liquids orally

-TPR, FHS 1/2 hourly

-I/O chart

-M/C urine 2 hourly

-Antibiotics (see antibiotic policy).

-No Atropine, Methyl ergometrine, ß agonists

-Keep ready

• Resuscitation kit,
• Inj Frusemide,
• Cava fix,
• Forceps trolley

-Inform if

• P > 120/min
• FHR > 160 or <110/min or irregular
• Meconium in amniotic fluid

• R >20/min
• U/O < 60 ml/2 hrs.

Patient Who Is On Warfarin Comes In Labour

Guidelines

-Admit the patient.

-Withhold next dose of Warfarin.

-Send PT, INR (international normalised ratio).

-Confirm availability of FFP, whole blood.

-Give Inj. Vitamin K1 10 mg iv slowly over 3-5 min.e.g. Kenadione (Phytokenadione)

-If INR > 2.5- give FFP at full dilatation or before cesarean section.

-If INR < 2.5-confirm availability of FFP, whole blood.

-If anticoagulation is required, only then IV heparin drip should be started at the rate of

1000 u/hour.

-Consult hematologist.

Post delivery:

-Patients on anticoagulation should NOT be given anticoagulation immediately.

-It has to be given at least 12 hours after delivery or as advised by the hematologist

Patient Who Is On Heparin Comes In Labour

Guidelines

-Admit the patient.

-Withhold next dose of Heparin.

-Confirm availability of FFP, whole blood and Inj. Protamine sulphate- antagonist of Heparin

-Send PT/APTT/platelet count

-If APTT > twice of control value- stop Heparin, give FFP, whole blood at full dilatation/ cesarean section.

-If patient still has bleeding Inj. Protamine sulphate can be given as 1mg for 100 u of Heparin dose taken by the patient.

-If APTT < twice the control value- confirm availability of FFP, whole blood.

-If patient requires anticoagulation, then only give Heparin at the rate of 1000 u/hour.

Post delivery:

-Patients on anticoagulation should NOT be given anticoagulation immediately.

-It has to be given at least 12 hours after delivery or as advised by the hematologist

Previous LSCS

Guidelines

-Confirm reports of Hb, blood group, VDRL/ HIV, and urinalysis are ready and normal. If not, get them done.

-Send blood for spot test for HIV if not done earlier to emergency lab and check the report. Do ward Hb if report > 1 month old and patient looks clinically anemic.

-Check if she has received tetanus immunization (at least 2 doses, if the last dose prior to pregnancy was given > 5 years ago, and 1 dose if the last dose prior to pregnancy was given < 5 years ago).

-IV access through # 18 cannula- collect and send blood for grouping cross matching and confirm availability.

-Inform lecturer on call

-Check presentation.

-Pelvic adequacy by a qualified obstetrician if not already done antenatally.

-Ultrasonography- anomalies and placental localisation.

Treatment Orders

-Nil by mouth

-IV fluids

-Simple enema stat

-Lateral position

-Shave/ clip hair and prepare abdomen, back (if hairy), and private parts

-TPR, FHS 1/2 hourly

-Consent for LSCS (with sterilization if desired)

Inform if

• P > 120/min
• FHR > 160 or < 110/min or irregular
• Scar tenderness
• Hematuria