Dr. Ram Manohar Lohia Combined
Hospital , Lucknow
Quality Operating
Process
Document No :
RML/OBG/01
Manual Of Operations
Obstetrics and Gynaecology
Date of Issue :
15/1/2008
Service Name :
Obstetrics and Gynaecology
Date Created :
15-01-2008
Chief Medical Superintendent
Approved By :
Name
:
Signature :
Head – Department of Obstetrics
and Gynecology
Reviewed By :
Name :
Signature :
Director
Issued By :
Name :
Signature :
Head of the Department
Responsibility of Updating :
Name :
Signature :
1
Manual of Operation
Dr. Ram Manohar Lohia Combined
Hospital , Lucknow
Quality Operating
Process
Document No :
RML/OBG/01
Manual Of Operations
Obstetrics and Gynaecology
Date of Issue :
15/1/2008
Page of Contents
Sl.Order Particulars
A
Purpose
B
Scope
C
Responsibility
D
Departmental Hierarchy
E
Policy
F
OPD Services
G
Emergency services
H
Inpatient Services
I
Diagnostic Services
J
Support Services
K
Provision for Care
L
Inpatient Admission
M
Referral of Patients to other specialty
N
Transfer of Patient to other hospital
O
Management of High Risk Pregnancy
2
Manual of Operation
Dr. Ram Manohar Lohia Combined
Hospital , Lucknow
Quality Operating
Process
Document No :
RML/OBG/01
Manual Of Operations
Obstetrics and Gynaecology
Date of Issue :
15/1/2008
A.
Purpose:
To provide comprehensive care in the specialty of Gynecology and Obstetrics
including management care of high risk pregnancy
B.
Scope:
Extends to all staff and patients under the purview of department of obstetric and
gynecology
C.
Responsibility: Consultant doctor, Medical Officers, Nurses of the department of Obstetric and
Gynaecology.
D.
Departmental Hierarchy:
Head – Department of Obstetrics and Gynaecology
Senior Consultant – Obstetrics and Gynaecology
Consultant – Obstetrics and Gynaecology
Nursing Staff – Obstetrics and Gynaecology
Ward Boys/Ayas
E. Policy :
i. Consultants: full time consultants of varied experience are available in the hospital between
8.00 a.m. and 2.00 p.m. Between 2.00 p.m. and 8.00 a.m. consultants are available on call and
will be able to reach the hospital within 20 min.
ii. Medical Officers trained in Obstetrics and Gynaecology are available twenty hours in the
hospital
iii .Nurses: suitably qualified nurses, experienced in midwifery provide care in the delivery suites
and women wing .
iv Pediatric consultants are available between 8.00 am to 2.00pm.Between 2.00 pm to 8.00 am
consultants are available on call and they would be able to reach the hospital within 20 mins.
OPD Services:
The OB&G outpatient clinics functions six days a week from 8:00 am in the morning to 2:00 pm in the
afternoon. The services aim at providing diagnostic, curative, preventive, and rehabilitative services on an
ambulatory basis.
3
Manual of Operation
Dr. Ram Manohar Lohia Combined
Hospital , Lucknow
Quality Operating
Process
Document No :
RML/OBG/01
Manual Of Operations
Obstetrics and Gynaecology
Date of Issue :
15/1/2008
G. Emergency Services:
The Emergency department of the hospital functions round the clock with qualified gynecologist
available 24 hrs. Senior consultants are available round the clock on call.
H. Inpatient Services:
The inpatient services are meant for patients requiring regular monitoring in the inpatient care facility of
the hospital.
Patients in labor are admitted for the delivery in the obstetric ward.
I. Diagnostic services:
a. 24 hr on call laboratory services for routine and urgent tests like clotting profile.
b. Radiologists to perform USG on a 24 hr on call basis .
c. Blood and blood component storage facility and facility for cross matching.
J. Support services:
a. Surgical/ Anesthetic services
b. Infection control
c. Pharmacy
d. Physiotherapy
e. Dietetic services
f. Technical equipment support services
K. Provision of care
a. Antenatal
i. 24 hrs emergency
ii. Antenatal well being programme to prepare patients for delivery.
iii. Consultation with dietician for diet modifications if required.
b. Intranatal
i.
Well Equipped Labour Room Facility
ii. Trained nursing support for high risk cases
iii. 24 hr OT availability
iv. Facility for instrument vaginal delivery
4
Manual of Operation
Dr. Ram Manohar Lohia Combined
Hospital , Lucknow
Quality Operating
Process
Document No :
RML/OBG/01
Manual Of Operations
Obstetrics and Gynaecology
Date of Issue :
15/1/2008
L. Inpatient Admission:
The patient requiring in-patient care would be suggested so in writing by the treating consultant. No
patient admitted in IPD facilities without written request of treating consultant, on duty the staff nurse
receives the patient.
a. Normal Working Hours ( 8.00 am to 2.00 pm)
During normal working hours of the hospital, the patient is seen in the OPD clinic of the consultant
doctor who after assessing the patient determines the need for inpatient admission. Incase the patient is
to be admitted, the same is indicated in writing in the patient’s case sheet (Refer to admission policy ).
If the patient is directly taken to the emergency department of the Female Wing, the Obs and Gynae
Consultant on duty will undertake the initial treatment and the available senior consultant (on call) is
immediately informed if required. The patient is seen by the senior consultant immediately (if required)
and treatment initiated by the senior consultant. Incase the patient need inpatient admission the same is
indicated in the patients case sheet and the admission procedure is initiated as per the admission policy
of the hospital.
b.Non peak hours (2.00 pm to 8.00 am) :
Patient is directly taken to the emergency department of the female wing , the on duty OBS and Gynae
consultant will undertake the initial treatment and the senior consultant on call is immediately informed
(if required). The senior consultant on call will reach the hospital within a maximum time gap of 20
minutes.
On arrival the senior consultant examines the patient and initiates the treatment. Incase the patient is to
be admitted , the treating doctor on call indicates the same in writing. The patient is admitted as per the
hospital policy and treatment is initiated.
M.Referral of patient to other specialty:
If the primary treating consultant of the patient feels the need to refer the patient to consultants of some
other specialty, a referral slip is filled by the primary treating consultant of the patient with details
relating to the patients complain, diagnosis and treatment initiated.
The referral slip is attaché with the patient case record for the perusal of the referred consultant.
N.Transfer of patient to other hospital:
If the patient cannot be treated in the hospital due to non availability of the required medical care e.g.
dedicated intensive unit facilities, the patient will be transferred to Medical College and Hospital as per
the Transfer Policy of the hospital.
5
Manual of Operation
Dr. Ram Manohar Lohia Combined
Hospital , Lucknow
Quality Operating
Process
Document No :
RML/OBG/01
Manual Of Operations
Obstetrics and Gynaecology
Date of Issue :
15/1/2008
O.Management of High Risk Pregnancy
A high risk pregnancy is one in which some condition puts the mother, the developing fetus , or both at
higher than normal risk for complications during or after the pregnancy and birth.
1.Diagnosis:
A woman with a high-risk pregnancy will need closer monitoring than the average pregnant woman.
Such monitoring may include more frequent visits with the primary caregiver, tests to monitor the
medical problem, blood tests to check the levels of medication, amniocentesis, serial ultrasound
examination, and fetal monitoring. These tests are designed to track the original condition, survey for
complications, verify that the fetus is growing adequately, and make decisions regarding whether labor
may need to be induced to allow for early delivery of the fetus.
Nutritional Assessment of the patient forms an integral part of the diagnosis process. This is done to
ensure the nutritional status of the mother and fetus .The findings of the patient’s nutritional and the
clinicians recommendations on the same are documented in the patient care record.
2.Treatment
Treatment varies widely with the type of disease, the effect that pregnancy has on the disease, and the
effect that the disease has on pregnancy. Additional tests may help determine the need for changes in
medication or additional treatment.
The Obstetric department of Dr.Ram Manohar Lohiya Combined Hospital is competent to handle high
risk pregnancies. For this there are trained are qualified and trained Consultants & well trained nursing
staff. Facilities for undertaking such pregnancies are available in the hospital. Incase of associated
complication the Medical college and hospital has fully equipped Intensive Care Units functional on an
24hrs basis. The High Risk pregnancies include the following but are not exhaustive:
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
Pre Eclampsia & Eclampsia
Intra Uterine Growth retardation
Post Partum haemorrhage
Non-reassuring Fetal heart Tracing
Premature rupture of membrane
Post Dated Pregnancy
Prolonged Labour
Cord Prolapse
Placenta Previa
Diabetes Completing Pregnancy
Obstructed Labour
6
Manual of Operation
Dr. Ram Manohar Lohia Combined
Hospital , Lucknow
Quality Operating
Process
Document No :
RML/OBG/01
Manual Of Operations
Obstetrics and Gynaecology
Date of Issue :
15/1/2008
MANAGEMENT OF IMMINENT ECLAMPSIA or ECLAMPSIA
OBSERVATIONS
Pulse oximeter
BP
Respiration
temperature
ECG
Test urine for protein
Hourly urine output
Fluid balance charts
pH monitor – continuously
DO NOT LEAVE PATIENT ALONE
Place in semi prone position
Call for HELP –Duty obstetric and anaesthetic
registrar; senior midwife Inform consultants –
mobstetrician and anaesthetic on call
AIRWAY
BREATHING
CONTROL
SEIZURES
CIRCULATION
Assess
Maintain patency
Start oxygen
INVESTIGATIONS
FBP & platelets
U&E
Urate
LFTs
Coagulation screen
Group & hold serum
24-hour urine collections for:
* total protein and creatinine
clear
* Catecholamines
Assess
Patent airway
Ventilate as required
Evaluate pulse & BP
If absent, initiate CPR and cell expert team
Secure IV access safely as soon as possible
Loading Dose MgSO4:
4 g MgSO4in 20% solution IV over 10-15 minutes
Add 8 ml of 50% MgSo4 solution to 12 ml of N Saline = 4 g in 20 ml = 20%
Solution
Maintenance Dose MgSo4:
CONTROL
HYPERTENSIO
N
If not
Postpartum
DELIVER
1 g per hour infusion
Add 25g MgSO4 (50 ml) to 250 ml N Saline
1 g MgSO4 = 12 ml per hour IV
If seizure continues / recur: MgSo4 2 g if < 70 kg and 4 g if > 70 kg IV as per loading dose over 5-10 mins.
If fails: Diazepam 10 ml IV or Thiopentone 50 mg IV and IPPV
Monitor: Hourly urine output
Respiratory rate, oxygen saturation & patellar reflexes – every 10 minutes for first two hours
and
then every 30 minutes
Check serum magnesium levels every day if infusion is continued for > 24 hours
Stop infusion: Check magnesium levels and review management with consultant if:
There is no Urine
placeoutput
for continuation
of pregnancy if eclampsia ensues
< 100 ml in 4 hours
“STABILISE”
THE
MOTHER
BEFORE
DELIVERY
Or if
Patellar reflexes are absent
Or
if
Respiratory
rate
<16
breaths
/
minute
DELIVERY ISA TEAM EFFORT involving obstetricians, midwives, anaethetists
Or
if paediatricians
Oxygen saturation < 90%
and
Antidote:
10% Calcium gluconate 10 ml IV over 10 minutes
Ergometrine should not be used in severe pre-eclampsia and eclampsia
………………………………………………………………………………………………………………………
………………………….
Consider prophylaxis against thromboembolism
Treat Hypertension if: SBP≥170 mm Hg, or DBP ≥ 110 mmHg, or MAP≥ 125 mmHg
Maintain
vigilance as the majority of eclamptic seizures occur after delivery.
Aim to reduce BP TO AROUND 130-140/90-100 mmHg
Beware of maternal hypotension and fetal heart rate abnormalities – monitor foetal hypoxia with
continuous cardiotocography (CTG)
Hydralazine: 10 mg IV slowly
Repeated doses of Hydralazine 5 mg IV at 20 minute interval may be given if necessary
Close liaison with anaesthetists: may require plasma expansion
Labetalol: 50 mg IV slowly; if BP still uncontr4olled
If necessary repeat after 20 minutes or direct IV infusion of 200 mg in 200 ml N Saline, starting at 40
7
Manual of Operation
Dr. Ram Manohar Lohia Combined
Hospital , Lucknow
Quality Operating
Process
Document No :
RML/OBG/01
Manual Of Operations
Obstetrics and Gynaecology
Date of Issue :
15/1/2008
MANAGEMENT OF IUGR
Suspect IUGR on clinical examination
Confirm gestational age
Ultrasound evaluation
Classify IUGR
Maternal and foetal assessment
Management of actiological factors
> 37
wks
Terminatio
n of
pregnancy
<28
wks
28-37
wks
Conservative
management
Terminatio
n

Cx favourable  Cx unfavourable

BPP </= 6/10
 BPP>6/10

AFI <5
 AFI – N

Postdated

Deteriorating
maternal/foetal
condition
 BPP <


4/10
 Worsening
Maternal
 Maternal & Fetal
condition
condition stable.


Conservati
ve
Manageme
nt
DFMC
Daily NST,
BPP, AFI
Serial u/s
Betamethason
e
MATERNAL





REST
NUTRITION-HIGH PROTEIN DIET, Zinc, 10%
gluc., 12%aminoacids
O2 Therapy
Hydration
Pharmac. Therapy – Low dose aspirin (60 mg/day),
Glucorticoids
8
Conservative
Management
Terminatio
n
 Foetal malf
 Negative fetal
growth rate
 Worsening
maternal
condition
During
Delivery
 Early ARM
 Early damping of
cord
 Placenta - HPE
Manual of Operation
Dr. Ram Manohar Lohia Combined
Hospital , Lucknow
Quality Operating
Process
Document No :
RML/OBG/01
Manual Of Operations
Obstetrics and Gynaecology
Date of Issue :
15/1/2008
POST – PARTUM HAEMORRHAGE (PPH)
IMMEDIATE MEASURES
 CALL FOR EXTRA HELP
 TWO LARGE BORE IV CANNULAS
 SEND BLOOD FOR CROSS MAATCHING & ARRANGE FOR atleast 2
UNITS OF BLOOD
 RAPIDLY INFUSE NORMAL SALINE/ HAEMACCEL 2 LITRES TILL
BLOOD IS AVAILABLE
 TPR / BP MONITORING
TO FEEL THE UTERUS BY ABDOMINAL PALPATION
UTERUS




ATONIC
MASSAGE THE UTERUS
CATHETARISE THE BLADDER
Inj. METHERGIC 0.2mg IM
20 UNITS OF OXYTOCIN IN 1000Ml of Lactated Ringer / Normal saline IV @
approx. 10 mL/min (200 m u of oxytocin per minute)
EXAMINE THE EXPELLED PLACENTA


UTERUS REMAINS ATONIC

EXPLORATION OF UTERUS FOR RETAINED BITS OF PLACENTA

BLOOD TRANSFUSION

CONTINUE OXYTOCIN DRIP

UTERUS STILL ATONIC

15 Methyl PGF2α - 250µg IM / INTRAMYOMETRIAL
OR

RECTAL MISOPROSTOL UPTO 1000µg
UTERUS HARD &
CONTRACTED
(TRAUMATIC)
EXPLORATION
HAEMOSTATIC
SUTURES ON
THE TEAR SITES
UTERUS STILL ATONIC
UTERINE TAMPONAD



BIMANUAL COMPRESSION
TIGHT INTRAUTERINE PACKING UNDER ANASTHESIA
INSERTION OF A SENGSTAKEN – BLAKEMORE TUBE & INFLATION
STILL ATONIC UTERUS SURGICAL METHODS




LIGATION OF UTERINE ART. & UTERO - OVARIAN ANASTOMOTIC
VESSELS – UNI / BILATERAL
LIGATION OF ANTERIOR DIV. OF INTERNAL ILIAC ARTERY
B - LYNCH BRACE SUTURE
ANGIOGRAPHIC ARTERIAL EMBOSSATION e- GELATIN SPONGE
HYSTERECTOMY
9
Manual of Operation
Dr. Ram Manohar Lohia Combined
Hospital , Lucknow
Quality Operating
Process
Document No :
RML/OBG/01
Manual Of Operations
Obstetrics and Gynaecology
Date of Issue :
15/1/2008
NONREASSURING FOETAL HEART TRACING
Nonreassuring Foetal Heart Tracing
General measures to improve foetal oxygenation
Place the patient in a lateral recumbent position
Administer oxygen at 8 to 10 L per minute
Discontinue Oxytocin
Persistent nonreassuring tracing
Bradycardia or sudden
deep deceleration
Consider the administration of terbutaline, 0.25mg ,subcutaneously
Consider foetal acoustic stimulation, foetal scalp stimulation or foetal
scalp pH measurement while evaluating etiology
Consider umbilical
cord prolapse
Repetitive
variable
decelerations
Repetitive late
decelerations or
sinusoidal tracing
No reassuring
tracing after the
administration of
epidural aneasthesia
Consider
uteroplacental
insufficiency
Consider decelerations
Secondary to anaesthesia
Consider umbilical
cord compression
Immediate cervical
examination
Spongy, pulsatile loop
of cord palpated
Elevate foetal
presenting part and
call for urgent
caesarian delivery
Consider saline
amnioinfusion
Obstetric consultation
and / or caesarian
delivery unless vaginal
delivery is imminent
Turn off epidural
anaesthesia and provide
intravenous hydration
Nonreassuring tracing
in vaginal birth after
previous caesarian
delivery or with the
use of oxytocins or
prostaglandins
Consider uterine
rupture
Baggy, tender,
expanding fundus
Aggressive resuscitation
and urgent laparotomy
No cord palpated
Persistent non reassuring tracing
If problem persists, expedite
delivery either vaginally or if
necessary by caesarian
section
10
Manual of Operation
Dr. Ram Manohar Lohia Combined
Hospital , Lucknow
Quality Operating
Process
Document No :
RML/OBG/01
Manual Of Operations
Obstetrics and Gynaecology
Date of Issue :
15/1/2008
PREMATURE RUPTURE OF MEMBRANES
Consider these measures:
Obstetric consultation
Intravenous hydration
Tocolysis
Trial of elevation of presenting part
Caesarian section





BED REST
STERILE VULVAL PAD
ASEPTIC EXAM WITH ASTERILE SPECULUM
TPR / FHR MONITORING 4TH HRLY.
CBC / ROUTINE ANALYSIS AND CULTURE OF
URINE
 HIGH VAGINAL SWAB FOR CULTURE
 VAGINAL POOL FOR ESTIMATION OF
PHOSPHATIDYL GLYCEROL
 ULTRASONOGRAPHY FOR BPP
 PROPHYLACTIC ANTIBIOTICS – AMPICILLIN /
ERYTHROMYCIN
< 37wks GESTATION
PRETERM PROM
>37 wks. OF GESTATION
TERM PROM IN LABOUR yes DELIVERY
NO
ANY EVEIDENCE OF INFECTION yes IOL
NO
ANY FETAL DISTRESS
yes
<34wks.
(28wks-34wks GESTATION)
CAESAREAN
NO
OBSERVATION in 90% of cases SPONTANEOUS
LABOUR
WITHIN 24HRS.
In 10% cases – no
Spontaneous labour
IOL
successful DELIVERY
Failed
IN LABOUR
PROM
>34wks
(<34 -37 wks GESTATION)
B STERIODS FOR
LUNG MATURITY
NOT IN LABOUR
AS FOR TERM
<3cms dilatation >3cms dilatation WAIT FOR SPONT.
ONSET OF LABOUR FOR
24-- 48 HRS. Success
DELIVERY
CAESAREAN SECTION
TOCOLYTUICS
FAILED
ANY EVIDENCE
GOOD
OF INFECTION
PROGRESS
IOL
yes
OR FETAL DISTRESS OF LABOUR
11
CAESAREAN
NO
CAESAREAN SECTION
DELIVERY
Manual of Operation
Dr. Ram Manohar Lohia Combined
Hospital , Lucknow
Quality Operating
Process
Document No :
RML/OBG/01
Manual Of Operations
Obstetrics and Gynaecology
Date of Issue :
15/1/2008
POST – PARTUM HAEMORRHAGE (PPH)
IMMEDIATE MEASURES
 CALL FOR EXTRA HELP
 TWO LARGE BORE IV CANNULAS
 SEND BLOOD FOR CROSS MAATCHING & ARRANGE FOR atleast 2
UNITS OF BLOOD
 RAPIDLY INFUSE NORMAL SALINE/ HAEMACCEL 2 LITRES TILL
BLOOD IS AVAILABLE
 TPR / BP MONITORING
TO FEEL THE UTERUS BY ABDOMINAL PALPATION
UTERUS




ATONIC
MASSAGE THE UTERUS
CATHETARISE THE BLADDER
Inj. METHERGIC 0.2mg IM
20 UNITS OF OXYTOCIN IN 1000Ml of Lactated Ringer / Normal saline IV @
approx. 10 mL/min (200 m u of oxytocin per minute)
EXAMINE THE EXPELLED PLACENTA


UTERUS REMAINS ATONIC

EXPLORATION OF UTERUS FOR RETAINED BITS OF PLACENTA

BLOOD TRANSFUSION

CONTINUE OXYTOCIN DRIP

UTERUS STILL ATONIC

15 Methyl PGF2α - 250µg IM / INTRAMYOMETRIAL
OR

RECTAL MISOPROSTOL UPTO 1000µg
UTERUS HARD &
CONTRACTED
(TRAUMATIC)
EXPLORATION
HAEMOSTATIC
SUTURES ON
THE TEAR SITES
UTERUS STILL ATONIC
UTERINE TAMPONAD



BIMANUAL COMPRESSION
TIGHT INTRAUTERINE PACKING UNDER ANASTHESIA
INSERTION OF A SENGSTAKEN – BLAKEMORE TUBE & INFLATION
STILL ATONIC UTERUS SURGICAL METHODS




LIGATION OF UTERINE ART. & UTERO - OVARIAN ANASTOMOTIC
VESSELS – UNI / BILATERAL
LIGATION OF ANTERIOR DIV. OF INTERNAL ILIAC ARTERY
B - LYNCH BRACE SUTURE
ANGIOGRAPHIC ARTERIAL EMBOSSATION e- GELATIN SPONGE
HYSTERECTOMY
12
Manual of Operation
Dr. Ram Manohar Lohia Combined
Hospital , Lucknow
Quality Operating
Process
Document No :
RML/OBG/01
Manual Of Operations
Obstetrics and Gynaecology
Date of Issue :
15/1/2008
PROLONGED PREGNENCY

LSCs
R/o wrong dates/ confirm Gest.age/ Fetal wt > 4-45kg
40-40 6/7 WKS
Maternal Risk factors
Or evidence of fetal compromise
Healthy
Pregnancy
41 wks
Inform women of risks &
benefits of induction Vs
expectant Management
Elective
Induction




Expectant Management



Explain Procedure
Consent
Bishop Score
Ripening & Induction
At 42 wks
Induce
DFMC
NST – Twice weekly
U/s – Fetal size &
AFI Twice weekly
If NST or AFI
Abnormal
Induce
13
Manual of Operation
Dr. Ram Manohar Lohia Combined
Hospital , Lucknow
Quality Operating
Process
Document No :
RML/OBG/01
Manual Of Operations
Obstetrics and Gynaecology
Date of Issue :
15/1/2008
MANAGEMENT OF PRIMARY POSTPARTUM HAEMORRHAGE
TONE
Ensure third stage drug management has been completed
Summon HELP and simultaneously:

Reassure the woman

Massage uterus (rub up)

TISSUE
IV
Ergometrine 0.25mg
TRAUMA
Deliver placenta –
 Indwelling urinary catheter

Controlled cord traction (CCT)

Examine Placenta for completeness
 Placenta undelivered
–
Resuscitation
including:
ASSESS


Oxytocics :
* IV Ergometrine (repeat 0.25mg if necessary)
* IV Metoclopramide 10mg
OR
* IV Syntocinon 10 units (if blood pressure elevated)
CONSIDER * Prostaglandin F2 alpha
Episiotomy
Concentration =1mg/ml
Tears (lower and upper genital
Dose:1 mL intramyometrially or intramuscularly
tract)
repeat up to 5 mL
Manual
removal
of IV
placenta

Insert
large bore
( > or = 16g)

Collect blood for group & cross match FBS,
coagulation studies including D – dimer

Anaesthetist

Continue to measure blood loss

Commence Fluid Balance Chart
TISSUE


PLUS
* Commence IV OXYTOCIN INFUSION
(40 UNITS) 1 litre Hartmann’s or Normal Saline
or 4% Dextrose 1/5 N/Saline @ 4/24 rate
TRAUMA
Delivery placenta –

CONSIDER * 1mg (5 tablets) Misoprostol PR
THROMBIN
Assess
Controlled cord traction
(CCT)
Examine placenta for
completeness

Coagulation studies if fails to respond it first line management / or
not collected at first blood sampling as above.

Episiotomy


Be aware of risk factors
Tears (lower and
upper genital tract)

Multidisciplinary team:

*Obstetrician

Bleeding continues / >1000 ml blood loss
Placenta undelivered manual
removal of placenta
* Haematologist
* Anaesthetist * Midwife
Transfer to OperatingTheatre
CONTINUED RESUSCITATION

ABC (Airway/Breathing/Circulation)

Analgesia management

Continue to Replace Fluid

Massage uterus
* Volume expanders
* Packed cells * Clotting factors
Oxytocic if not already repeated


Bimanual uterine
compression
Aorta compression
Examine under anaesthetic:

Vaginal tears

Cervical tears

Retained products (incomplete
placenta/membranes)

Uterine Rupture
Prostaglandin F2α:
 Concentration=1 mg/mL
 Dose: 1mL
intramyometrially or
intramuscularly, repeat
up to 5 mL.
BLEEDING PERSISTS Consider:
Packing uterus - leave
pack in for maximum 24
hours
IV Antibiotics
14

Uterine artery ligation

Internal iliac artery ligation

B-Lynch suture before
Manual of Operation
Transfer to ICU