THE UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH AND SOCIAL WELFARE

EMERGENCY OBSTETRIC
AND
NEWBORN CARE JOB AID

September 2015
 MINISTRY OF HEALTH AND SOCIAL WELFARE

TABLE OF CONTENTS

Contents
TABLE OF CONTENTS 2
Abbreviations 6
FOREWORD 8
ACKNOWLEDGEMENT 9
CHAPTER 1 10
INTRODUCTION 10
How to use the Emergency Obstetric and Newborn Care (EmONC) Job Aid 10
CHAPTER 2 11
ABCD PRINCIPLES OF RESUSCITATION 11
CHAPTER 3 12
SEVERE ANAEMIA IN PREGNANCY 12
Management of severe anaemia in pregnancy 12
Dispensary & health centre 12
If not in labour 12
If in labour 13
Hospital 13
If not in labour 13
If in labour 13
CHAPTER 4 15
MALARIA IN PREGNANCY 15
Management of malaria in pregnancy 15
Dispensary & health centre 15
Uncomplicated malaria 15
Severe malaria 16
Hospital 16
Uncomplicated malaria 16
Severe malaria 16
CHAPTER 5 18
HYPERTENSIVE DISORDERS OF PREGNANCY 18
Mild to moderate pre-eclampsia 18
Management of mild to moderate pre-eclampsia 18
Dispensary & health centre 18
Hospital 18
Severe pre-eclampsia (imminent eclampsia) 18
Management of severe pre-eclampsia 19
Dispensary & health centre 19
Hospital 19
CHAPTER 6 20
ECLAMPSIA 20
Signs of eclampsia 20
Management of severe pre eclampsia and eclampsia 20
Dispensary & health centre 20

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Hospital 21
1.Control convulsions 21
Probable reasons for recurrent fits 21
Monitor for toxicity 21
Eclampsia during labour 23
Care after delivery 23
Eclampsia management flow chart 24
CHAPTER 7 25
PROLONGED LABOUR 25
Symptoms and signs 25
Management of prolonged labour 25
Dispensary & health centre 25
Hospital 25
Subsequent management will depend on the identified cause 26
Prolonged labour management flow chart 27
CHAPTER 8 28
OBSTRUCTED LABOUR 28
Symptoms and signs 28
Early obstruction 28
Prolonged obstruction 28
Management of obstructed labour 28
Dispensary & health centre 28
Hospital 28
CHAPTER 9 29
ANTEPARTUM HAEMORRHAGE 29
Placenta praevia 29
Symptoms 29
Signs 29
Management of placenta praevia 29
Dispensary & health centre 29
Hospital 29
Abruptio placenta 30
Symptoms 30
Signs 30
Management of abruptio placenta 30
Dispensary & health centre 30
Hospital 30
CHAPTER 10 32
POSTPARTUM HAEMORRHAGE (PPH) 32
Primary PPH 32
Symptom 32
Signs 32
Management of primary PPH 32
Dispensary & health centre 32
1.Uterine atony - palpate the fundus of the uterus, If fundus is soft; 32
2.Retained placenta 33
3.Tears of the birth canal 33

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Hospital 33
1.Uterine atony 34
2.Retained placenta 34
3.Tears of the birth canal; 35
4.Coagulopathy 35
Secondary PPH 36
Symptoms 36
Signs 36
Dispensary & health centre 36
Hospital 36
CHAPTER 11 39
ABORTION 39
Threatened abortion 39
Management of threatened abortion 39
Dispensary & health centre 39
Hospital 39
Inevitable abortion 40
Management of inevitable abortion 40
Dispensary & health centre 40
Hospital 40
Incomplete abortion 41
Management of incomplete abortion 41
Dispensary & health centre 41
Hospital 41
Complete abortion 42
Management of complete abortion 42
Dispensary & health centre 42
Hospital 42
Septic abortion 43
Management of septic abortion 43
Dispensary & health centre 43
Hospital 43
Molar abortion 44
Management of molar abortion 44
Dispensary & health centre 44
Hospital 45
CHAPTER 12 46
RUPTURED ECTOPIC PREGNANCY 46
Management of ruptured ectopic pregnancy 46
Dispensary & health centre 46
Hospital 46
CHAPTER 13 47
PUERPERAL SEPSIS 47
Management of puerperal sepsis 47
Dispensary & health centre 47
Hospital 47
CHAPTER 14 48

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BIRTH ASPHYXIA 48
Management of birth asphyxia 48
Dispensary & health centre 48
Figure 1. Helping Baby to Breath 50
NEONATAL SEPTICAEMIA 51
Management of neonatal septicaemia 51
Dispensary and health centre 51
Hospital 51

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Abbreviations

ABCD Airway, Breathing, Circulation, Disability

ALu Artemether/Lumefantrine
APH Ante partum Haemorrhage
BP Blood Pressure
CPR Cardiopulmonary Resuscitation
C/S Caesarean Section
DIC Disseminated Intravascular Coagulopathy
DL Decilitre
EmONC Emergency Obstetric and Newborn Care
FFP Fresh Frozen Plasma
FPD Foeto-Pelvic Disproportion
g Gram
Hb Haemoglobin
hCG Human Chorionic Gonadotrophin
IM Intramuscular
IU International Units
IV Intravenous
Kg Kilogram
lt Litre
Mg Milligram
ML Millilitre
MmHg Millimetre of Mercury
MMR Maternal Mortality Ratio
mRDT Malaria Rapid Diagnostic Test
MVA Manual Vacuum Aspiration
NGT Nasogastric Tube
NS Normal Saline
PPH Postpartum Haemorrhage
RL Ringers Lactate
SP Sulfadoxine Pyrimethamine
TDHS Tanzania Demographic Health Survey
UPT Urine for Pregnancy Test
WBC White blood cell

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FOREWORD

An estimated 283,000 women worldwide die every year as a result of complications

of pregnancy and childbirth, with 99% of these deaths occurring in Sub-Saharan
Africa and Asia. In Tanzania, each year approximately 8,000 women and girls die
due to pregnancy and delivery complications. The World Health Organization
estimates that 1 out of 10 women in Tanzania are at risk of dying during pregnancy
and childbirth.

Although some of these complications cannot be prevented or reliably predicted,

they can be treated if appropriate emergency care is timely provided. To effectively
reduce maternal deaths Emergency Obstetric Care (EmOC) should be available,
accessible, affordable and of good quality.

In an effort to improve the quality and availability of obstetric care in Tanzania,

the Reproductive and Child Health Section of the Ministry of Health (RCHS), in
collaboration with other partners developed an Emergency Obstetric Care Job Aid.
The Job Aid is intended to serve as a quick reference tool to health care providers.
This tool will enhance maternity care providers ability to diagnose, manage, and
refer obstetric complications. With new development in medical sciences, it has
created a need for revising this document in the effort to improve the quality of care.

This tool is for doctors, clinical nurses and other health professionals
responsible for providing reproductive and child health care at the dispensary,
health centre and hospital level.

I recommend the Emergency Obstetric Care Job Aid to be used at all public, voluntary
agency and private health facilities to ensure uniformity in providing quality
Emergency Obstetric Care.

Dr. Donan Mmbado

Permanent Secretary

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ACKNOWLEDGEMENT

The Ministry of Health and Social Welfare, wishes to acknowledge with sincere
gratitude all those who in one way or another contributed to the revision and
printing of the Emergency Obstetric Care Job Aid. The Ministry is grateful to the
following organizations and individuals;

The Reproductive and Child Health Section, for ensuring the review and printing of
the job aid. UNICEF Tanzania, for technical and �inancial support to print the revised
document. Muhimbili University College of Health Sciences and Muhimbili National
Hospital for providing technical assistance.

The team of experts who reviewed the Job Aid at different stages including;

Dr. R. Rumanyika Bugando Medical Centre

Dr. F. Mtati�ikolo Bombo regional hospital
Dr. N. Mzee Dodoma regional hospital
Dr. T. Wangwe Muhimbili University College of Health Sciences
Prof. P. Muganyizi Muhimbili University College of Health Sciences
Dr. H. Kidanto Muhimbili National hospital
Dr. A. Makuwani Reproductive and child health section
Dr. M. Massi Jhpiego
Dr. J. Cassian Kibaha COTC
Dr. H. Mshiu Reproductive and child health section
Sr. E. Malingumu Reproductive and child health section
Sr. P. Rweibawo Reproductive and child health section
Sr. Chibehe Jhpiego
Sr.G. Tibaijuka Jhpiego
Sr. J. Mhando productive and child health services
Dr. K. Winani Reproductive and child health section

Dr. Margreth Mhando

Ag Chief Medical of�icer

viii EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 CHAPTER 1

INTRODUCTION

Maternal and Newborn deaths remain alarmingly high in Tanzania. Currently,

Maternal Mortality Ratio (MMR) stands at 454 per 100,000 live births and Newborn
Mortality Rate is 26 per 1,000 live births (TDHS 2010). These maternal and newborn
deaths are largely preventable if all women and newborn receive prompt and
appropriate care for obstetric and newborn complications.
This Obstetric and Newborn Care Job Aid has been developed to help health care
providers to correctly identify obstetrics and newborn complications and make
timely and appropriate decisions for managing and/or referring patients. This Job
Aid is intended for health care providers at all levels.

How to use the Emergency Obstetric and Newborn Care (EmONC)

Job Aid

This Job Aid is organized by complications or conditions and their management. For
each obstetric and newborn complications or conditions, the following information
is presented;
A definition of complication or condition based on clinical diagnosis.
Symptoms with which the patient may present with.
Clinical signs that enable providers to identify and diagnose the complication
or
condition.
Detailed guidance for managing the complication or condition according to
the level of health care i.e. dispensary, health centre and hospital.
Clinical flow charts which is presented for some obstetric and newborn
complications at the end of each topic where appropriate. The flow charts
illustrate the sequence of steps involved in diagnosing and managing
complications or conditions and are designed to assist providers in taking
quick actions to manage the complication or condition, to stabilize and/or
refer the patient as appropriate. Before describing key steps of the EmONC,
a chapter on ABCD of resuscitation has been added. This will enable health
care provider to provide standardized care to all critically ill patients.

EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID 1

 CHAPTER 2

ABCD PRINCIPLES OF RESUSCITATION

These are principles of resuscitation, aimed at structural approach to make sure that
all life threatening conditions are taken care. This approach need to be followed when
caring all seriously sick patients and especially to those who are not fully conscious.
In these principles A stand for Airway, B for Breathing, C for Circulation and D for
Disability

1. Airway:
Look for signs of airways obstruction i.e. noise breathing, when present open
airway by;
• Tilting the head and lifting the chin, if no response
• Perform jaw thrust
• Suck the secretions if necessary
2. Breathing:
• Look, listen and feel for breathing
• If no breathing assist ventilation with ambubag and mask
• Give oxygen 4-6lts/minute for adults and 2lts/minute for children
• If breathing condition improve, keep the patient on recovery position
3. Circulation:
• Tilt the patient to the left lateral position using pillows, to reduce
inferior vena cava compression if pregnant
• Assess circulation by palpating radial or carotid arteries
• Give Normal Saline (NS)/Ringers Lactate (RL) 2lts using wide bore
cannulae (G 16- 18) if the pulse is rapid and thin (tachycardia)
• Auscultate for heart beats if absent perform cardiac massage by
continuously depressing sternum fast with 30 deep compression
strokes and give 2 shots of ventilation using ambubag and mask
4. Disability:
• Assess for any disability compromising patient’s condition
• Re- asses of the patient condition and determine the cause

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 CHAPTER 3

SEVERE ANAEMIA IN PREGNANCY

Anaemia in pregnancy is a condition where Haemoglobin (Hb) level is less than 11.0
g/dl (WHO) and less than 8.5 g/dl (Tanzania standards). The patient is said to be
severely anaemic when the haemoglobin is less than 7.0g/dl.

Symptoms;
• Tiredness/general body weakness
• Exertional dyspnoea (shortness of breath when active)
• Headache
• Dizziness
• Palpitations (awareness of heart beats)
• Paroxysmal nocturnal dyspnoea (waking up at night, feeling breathless)
• Swelling of the face, hands, legs

Signs;
• Oedema
• Severe pallor of mucous membranes, conjunctiva, palms and nail beds
• Signs of heart failure;
- Tachycardia (pulse rate more than 100 beats/min)
- Dyspnoea (difficulty in breathing)
- Orthopnoea (difficulty in breathing while lying flat)
- Tachypnoea (respiratory rate more than 24 breaths/minute)
- Elevated jugular venous pressure (prominent neck veins)
- Basal crepitations (crackle sounds along the lung bases)
- Enlarged, tender liver

Management of severe anaemia in pregnancy

Dispensary & health centre

If not in labour:
• Prop up the patient or put the patient in a sitting position
• Check Hb
• Administer intravenous (IV) Frusemide (Lasix) 80 mg stat if the woman has
the last three signs of heart failure (elevated jugular venous pressure, basal
crepitations and enlarged tender liver)
• Insert an indwelling urethral catheter
• Give oxygen 4-6lts/minute and keep the patient in well ventilated room
REFER to hospital immediately in a propped-up position with an escort of a nurse

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Do not give iv fluids

If in labour;
• Prop up the patient or put the patient in a sitting up position
• Give IV Frusemide (Lasix) 80 mg stat if the patient has the last three signs of
heart failure (elevated jugular venous pressure, basal crepitations and enlarged
tender liver)
• Insert an indwelling urethral catheter
• Give oxygen 4-6lts/minute
• Conduct delivery while the patient is in semi-sitting position
• Assist second stage by vacuum extraction
• Do active management of third stage of labour by;
i. Giving intramuscular (IM) Oxytocin 10 IU within one minute of birth
of the baby (do not give Ergometrine or Misoprostol)
ii. Applying controlled cord traction while applying counter traction on
the uterus
iii. Massaging the uterus following delivery of placenta and palpating/
massaging the uterus every 15 minutes for 2 hours
• Give another dose of IV Frusemide 80 mg
• Monitor vital signs (blood pressure, pulse rate, temperature and respiratory
rate) every half an hour while arranging for referral

REFER the patient with an escort of a nurse to hospital after delivery

Do not give IV fluids

Hospital
If not in labour:
• Prop up the patient or put the patient in a sitting position
• Give Frusemide 80 mg IV stat if the woman has signs of heart failure
• Obtain blood for Hb, grouping and cross-matching
• Insert an indwelling urethral catheter
• Transfuse packed cells SLOWLY one unit over 6 hours

Only one unit can be Transfused in 24 Hours

• Give Frusemide 80 mg IV stat 30 minutes before the transfusion

• Give oxygen 4-6lts/minute
• Investigate and treat the underlying cause of anaemia

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If in labour;
• Nurse patient in a propped-up position
• Obtain blood for Hb, grouping and cross-matching
• Insert an indwelling urethral catheter
• Give IV Frusemide 80 mg stat
• Give Oxygen 4-6lts/ minute
• Conduct delivery while the patient is in semi-sitting position
• Discourage the woman from bearing down with contractions
• Assist second stage by vacuum extraction
• Do active management of third stage of labour by;
i. Giving IM Oxytocin 10 IU within one minute of birth of the baby
(Do not give Ergometrine or Misoprostol)
ii. Applying controlled cord traction while applying counter traction on the
uterus
iii. Massaging the uterus following delivery of placenta and palpating/
massaging the uterus every 15 minutes for 2 hours
• Give another dose of IV Frusemide 80 mg
• Monitor vital signs (blood pressure, pulse rate, temperature and respiratory
rate) every half an hour
• Monitor input/output
• Monitor closely for signs of heart failure during post-partum period
• Investigate and treat the underlying cause of anaemia
• Give FeFol 1 tablet twice a day for 3 months and re-assess the condition of
the patient every 4 weeks

Important note;
• Insert cannula to keep vein open, avoid IV fluid
• Do not give blood transfusion while in labour
• Transfuse packed cells 24 hours post delivery
• Transfuse slowly, one unit to run for 6 hours

EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID 5

 CHAPTER 4

MALARIA IN PREGNANCY

Malaria is an infection caused by a blood parasite (Plasmodium species) that is

transmitted by the female anopheles mosquito

Symptoms of uncomplicated malaria in pregnancy;

• Fever or history of fever lasting a few days
• Feeling cold, shivering
• Headache
• Loss of appetite
• Body malaise
• Abdominal pain
• Joint pain
• Nausea, vomiting, diarrhoea

Symptoms and signs of severe malaria in pregnancy:

If the mother presents with the above symptom(s) and any of the following;
• Severe anaemia
• Jaundice
• Change of behaviour (hallucinations, delusions, agitation)
• Convulsions (repetitive abnormal muscular movements)
• Haemoglobinuria (dark brown or positive Hb on dipstick urine)
• Acidosis
• Oliguria (urine output< 30mls/hour) or acute renal failure
• Bleeding tendency (easy bleeding or oozing on bruising or setting a drip)
• Pulmonary oedema or difficulty in breathing
• Hypoglycaemia (low blood glucose i.e. <2.5 mmol/L)
• Hyperparasitaemia (≥ 1000 asexual parasites per 200 WBC)

Management of malaria in pregnancy

Dispensary & health centre

Uncomplicated malaria:
• Perform malaria Rapid Diagnostic Test (mRDT)
• If the mRDT is positive and the woman is in the first trimester give Quinine
tablets 10 mg/kg body weight 8hrly for 7 days
• If the woman is in the second or third trimester give a full course of
Artemether/Lumefantrine (ALu) 4 tablets at the time of diagnosis, 4 tablets
after 8 hours from the initial dose, then 4 tablets twice daily (morning and
evening) for the following two days. The total course consists of 24 tablets

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• Give Paracetamol 1 g by mouth 8hrly for 3 days

Do not give ALu in the first trimester unless when

Considered lifesaving to the mother and quinine is contraindicated

Severe malaria:
• First trimester, give an initial dose of 10 mg Quinine dihydrochloride
salt/kg body weight IV in 5% Dextrose 500 mls to run for 4 hours
• Second and third trimester give initial dose of injection Artesunate 2.4mg/
kg IM stat
• If the patient is unconscious insert nasogastric tube (NGT) for feeding and
medication
• Insert an indwelling urethral catheter
• Monitor input/output
• Monitor vital signs (temperature, blood pressure, pulse rate and respiratory
rate) every 30 minutes
REFER to hospital with an escort of a nurse

Hospital
Uncomplicated malaria:
• Perform mRDT, if positive do blood smear for parasites count
• If mRDT is positive and the woman is in the first trimester, give Quinine
tablets 10 mg/kg body weight by mouth 8hrly for 7 days
• If the woman is in the second or third trimester give a 3-day course of ALu
by mouth, 4 tablets at the time of diagnosis, 4 tablets after 8 hours from the
initial dose, then 4 tablets twice daily (morning and evening) for the following
two days. The total course consists of 24 tablets
• Give Paracetamol 1 g by mouth 8hrly for 3 days

Do not give ALu in the first trimester unless when considered

Lifesaving to the mother and Quinine is contraindicated

Severe malaria
• Apply ABCD principles of resuscitation
• Perform the following investigations;
- mRDT, if positive do blood smear for parasites count
- Blood slide (BS) for malaria parasites once a day until negative
- Blood glucose
- Check Hb
- White blood cell count, total and differential
- Blood culture if septicaemia is suspected
- Cerebral spinal fluid examination if meningitis is suspected
- Urinalysis

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• First trimester, give 10 mg Quinine dihydrochloride salt/kg body weight IV

in 5% Dextrose 500 mls 8hrly doses (to run for 4 hours and rest 4 hours).
Discontinue Quinine infusion as soon as the patient is able to take by mouth
and continue with Quinine tablets, 10 mg/kg body weight 8hrly to complete
7 days of treatment
• Second and third trimester give injection Artesunate 2.4mg/kg IM/IV at 0
hour (admission), then at 12hrs and 24hrs (For dilution see box below)
• Give blood transfusion if indicated
• Monitor vital signs (temperature, BP, pulse rate and respiratory rate) every
30 minutes until the patient is stable, then every 4 hours for 24 hours
• Give 50mls of 50% Dextrose (in 10mls bolus) I.V or 125mls of 10% Dextrose
IV when blood glucose is less than 2.5mmol/ litre. Where Dextrose is not
available sugar water should be prepared by mixing 20gm of sugar(4 level
tea spoons) with 200mls of clean water 50mls of this solution is given orally
or by NGT if unconscious
• Insert a NGT for feeding if unconscious
• Insert indwelling urethral catheter for continuous bladder drainage if
unconscious or renal failure is suspected
• Monitor input/output

Administration and dosage;

The vial of Artesunate powder should be mixed with 1 ml of 5% Sodium Bicarbonate solu-
tion (provided in each box) and shaken 2-3 minutes for better dissolving. Then add 5%
Dextrose or Normal Saline

Injectable Artesunate has 2-steps dilutions;

Step 1

• The powder for injection should be diluted with 1ml of 5% Sodium Bicarbonate and shaken
vigorously till the solution becomes clear

Step 2

• For slow IV infusion (3-4 minutes), add 5 ml of 5% Dextrose or Normal Saline, to obtain
Artesunate concentration of 10 mg/ml
•
• For deep IM injection, add 2 ml of 5% Dextrose or Normal Saline to obtain Artesunate
concentration of 20 mg/ml

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 CHAPTER 5

HYPERTENSIVE DISORDERS OF PREGNANCY

Hypertension is blood pressure (BP) 140/90 mmHg or greater, on two occasions at

least four hours apart or elevated systolic BP >30mmHg, or diastolic BP 15mmHg
from the baseline

Mild to moderate pre-eclampsia

Majority of the patients are asymptomatic
Signs;
• Two readings of systolic BP 140 – 160 mmHg taken 4 hours apart
• Two readings of diastolic BP 90 – 100 mmHg taken 4 hours apart
• Proteinuria nil or +
• Normal tendon reflexes

Management of mild to moderate pre-eclampsia

Dispensary & health centre

• Advice the woman to have adequate rest at home and avoid strenuous
activities
• Advise patient to eat a normal balanced diet and plenty of oral fluids
• Give tablets Methyldopa (Aldomet) 250 mg 8hrly for 7 days
REFER to hospital

Hospital
• Initiate or continue with Methyldopa (Aldomet) 250-500mg 8hrly while
attending antenatal clinic
• Encourage the patient to have adequate rest at home and avoid strenuous
work
• Advise the patient to eat a normal balanced diet and to drink plenty of fluids
• Schedule antenatal visits every 2 weeks up to 32 weeks and every week
thereafter
• Recommend to deliver in the hospital and should be delivered at 37completed
weeks of gestation
• Advice the patient to come immediately to hospital in case of severe headache,
blurred vision, nausea or upper abdominal pain
• If not responding to treatment (i.e. if the systolic BP is more than 160 mmHg
or the diastolic BP is more than 100 mmHg or if there is proteinuria of ++ or
more) manage as severe pre eclampsia

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Severe pre-eclampsia (imminent eclampsia)

Presence of high BP as well as symptoms and signs indicating that the pregnant
woman may get eclamptic fits at any moment

Symptoms;
• Severe headache
• Visual disturbances, blurred vision or seeing stars/halos
• Upper abdominal /epigastric pain
• Nausea and/or vomiting
Signs;
• Systolic BP more than 160 mmHg
• Diastolic BP more than 110 mmHg
• Hyper-reflexia (increased deep tendon reflexes)
• Proteinuria of ++ or more
• Oliguria (urine output less than 30 mls/ hour)
• Oedema of face, hands, or generalized oedema may be present

Management of severe pre-eclampsia

Dispensary & health centre

Once the diagnosis of severe pre-eclampsia (imminent eclampsia) has been made,
manage the woman as described for eclampsia

Hospital
Once the diagnosis of severe pre-eclampsia (imminent eclampsia) has been made,
admit the woman and manage as described for eclampsia

10 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 CHAPTER 6

ECLAMPSIA

Eclampsia is a condition peculiar to pregnancy and post-partum periods,

characterized by elevated BP and tonic-clonic convulsions which are not caused by
epilepsy, severe malaria, meningitis, hypoglycaemia or other causes of convulsions

Signs of eclampsia:
Convulsions (fits) and elevated BP 160/110 mmHg or more PLUS any of the signs
below;
• Hyper-reflexia (increased deep tendon reflexes)
• Proteinuria of ++ or more
• Oliguria (urine output less than 30 mls/ hour)
• Coma (unconsciousness)

Eclamptic fits may occur in absence of significant rise of BP

Management of severe pre eclampsia and eclampsia

Dispensary & health centre
• Protect the patient from injury, but do not restrain
• Apply ABCD principles of resuscitation
• Give loading dose of injection Magnesium Sulphate(MgSO4)
i. Using one syringe of 20mls;
- Draw 8mls of 50% MgSO4
- Add 12mls of water for injection to make it 20mls of 20% MgSO4
- Give IV slowly over 5 minutes
ii. Using two 10ml syringes;
- Draw 10mls (5gms) of 50% MgSO4 into each syringe
- Add 1ml of 2% Lignocaine in each syringe
- Give deep IM in each buttock
NB. If it is not possible to give IV dose give IM dose only10gm as 50% MgSO4
deep IM:
• Commence IV RL/NS
• Insert an indwelling urethral catheter
• Monitor vital signs, reflexes and foetal heart rate every half an hour
REFER to hospital with an escort of a nurse with detailed clinical notes

If convulsions recur within 15 minutes;

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- Draw 4mls of 50% of MgSO4 (2gm)

- Add 6mls of water for injection to make it 10 mls of 20% MgSO4
- Give IV slowly over 5 minutes

If the mother is about to deliver or referral is not immediately possible;

• Deliver the mother by assisted vaginal delivery
• While waiting for transportation to hospital continue to give maintenance
dose of MgSO4 (50%) 5g IM mixed with 1 ml of 2% Lignocaine 4hrly until
the ambulance arrives
• Monitor vital signs, reflexes and foetal heart rate every half an hour
REFER to hospital with an escort of a nurse for further management

Hospital
Admit in a quiet room and apply ABCD principles of resuscitation

1. Control convulsions:

Give loading dose of injection Magnesium Sulphate;

i. Using one 20mls syringe;
- Draw 8mls of 50% MgSO4
- Add 12mls water to make it 20mls of 20% of MgSO4
- Give IV slowly over 5 minutesmptly with 10gm as 50% MgSO4 deep I
i. Using two 10mls syringes;
- Draw 10mls (5gms) of 50% MgSO4 into each syringe, add 1mls of
2% Lignocaine in each syringe then give deep IM into each buttock

If convulsions recur within 15 minutes;

- Draw 4mls of 50% of MgSO4 (2gm)
- Add 6mls of water for injection to make it 10 mls of 20% MgSO4
- Give IV slowly over 5 minutes

Probable reasons for recurrent fits;

Recurrent fits occur in 10-15% of patients, in such cases, the therapeutic level of
MgSO4 may not have been reached
Consider other causes of recurrent convulsions;
• Is the blood pressure controlled?
• Has the proper bolus combination (IV & IM) given?
• Have the differential diagnoses correctly been ruled?
• Is there a brain damage?

Give maintenance dose:

Using one 10mls syringe;
- Draw 10mls of 50% MgSO4
- Add 1ml of 2% Lignocaine
- Give deep IM in alternate buttock 4hrly
- Continue same treatment for 24 hours after delivery or last convulsion,
whichever is last

12 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 MINISTRY OF HEALTH AND SOCIAL WELFARE

Monitor for toxicity:

Withhold or delay MgSO4 if any of the following;
- Respiratory rate less than 16/minute
- Patellar reflexes absent
- Urine output less than 30mls/hour

If respiratory arrest occurs;

- Assist ventilation with bag and mask or call anaesthetist for intubation
- Give Calcium Gluconate 1gm (10mls of 10%) over 2-5 minutes until
respiration begins. The administration may be repeated every hour if
needed up to 8 injections for 24 hours

2. Control the blood pressure

• Record BP every hour
• Start Hydralazine if the diastolic BP is 110 mmHg or more
• Give Hydralazine 10 mg IV slowly every half an hour until diastolic BP falls to
100 mmHg

3. Control the fluid balance

• Give IV RL/NS slowly 1lt in 6-8 hours (40-50 drops/minute)
• Insert an indwelling urethral catheter
• Monitor input/output

Avoid diuretics except in cases of oliguria, anuria or pulmonary

oedema

4. Prophylaxis against pneumonia

• Give IV Ampicillin 500mg 6hrly until patient is able to swallow, followed by
caps Amoxicillin 500 mg 6hrly for 5 days

5. Investigations
• Do a bed-side clotting time
• Take blood for;
- Full blood picture (FBP)
- Random blood glucose
- Serum creatinine and blood urea
- Liver function tests
- Malaria parasites
• Do lumbar puncture for cerebral spinal fluid examination if meningitis is
suspected

6. Deliver the woman

• Patients with eclampsia should be delivered within 6-8 hours after the onset
of fits, even if the foetus is premature. Vaginal delivery is safer mode of
delivery

EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID 13

 MINISTRY OF HEALTH AND SOCIAL WELFARE

Eclampsia before labour;

• Give RL/NS 1-1.5lts
• Induce labour if cervix is favourable and there are no contraindications to
vaginal delivery
• Perform Caesarean Section (C/S) for obstetric indication(s), or if difficulty
vaginal delivery is anticipated
•

Don’t rush for C/S-Resuscitate/stabilize the patient before surgery

Eclampsia during labour;

• Allow vaginal delivery if labour is progressing well and there are no
contraindications to vaginal delivery
• Assist the second stage of labour by doing low cavity vacuum extraction
• Do active management of third stage of labour

Do not give Ergometrine

Care after delivery;

Fits can occur after delivery, therefore continue with observation and treatment
as necessary for at least 48 hours post-delivery
• If the patient has fits after delivery, continue MgSO4 treatment for 24 hours
after the last fit
• Monitor input/output
• Avoid diuretics unless there is oliguria or pulmonary oedema
• Continue tabs Methyldopa 250-500 mg 8hrly until BP is back to normal
• Keep the patient in hospital until condition is stabilized

14 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 MINISTRY OF HEALTH AND SOCIAL WELFARE

Eclampsia management flow chart

Shout for help and mobilize resources

Apply ABCD principles of resuscitation
Prevent her from injuries
Give a loading dose of MgSO4 4g (20%) IV for
5 min PLUS 10g (50%) IM
Insert an indwelling urethral catheter
Give IV Hydralazine if indicated
Monitor vital signs

NO
IS PATIENT IN LABOUR?

YES

Assess progress: Near second stage?

NO YES

Monitor urine output

If not in hospital REFER immediately
Monitor vital signs
with an escort of a nurse
Monitor progress of labour
Deliver with vacuum extraction
Perform active management of
third stage of labour (Do not use
REFER Ergometrine)

REFER

At Hospital
Apply ABCD principles of resuscitation
Start or continue with MgSO4 as per protocol
Insert an indwelling urethral catheter and monitor urine output
Start or continue IV Hydralazine if indicated, 10mg slowly every half hour until DBP falls to
100mmHg
Monitor vital signs
If not yet delivered, deliver the woman 6-8 hours after the onset of fits. Perform C/S if indicated.

EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID 15

 CHAPTER 7

PROLONGED LABOUR

This is labour which lasts more than 12 hours in the active phase

Symptoms and signs;

These will depend on the cause

Management of prolonged labour

Dispensary & health centre

• Apply ABCD principles of resuscitation

• Determine the cause;
- Assess uterine contractions and level of descent
- Do a vaginal examination to assess cervical dilatation, signs of obstruction
(moulding and caput) and signs of foetal distress (colour of liquor and foetal
heart rate)
• Start partograph
• Give IV RL/NS as appropriate
• Insert an indwelling urethral catheter
• Give IV Ampicillin 1g and IV Metronidazole 500 mg stat
REFER the patient with an escort of a nurse to a facility where C/S can be performed

NB: If the cervix is fully dilated, no sign of obstruction, the presenting part is vertex
and the descent is below 2/5;
• Do a low cavity vacuum extraction if it can be done at the facility
• If vacuum extraction cannot be done or if it fails after three pulls, REFER
patient to hospital immediately with an escort of a nurse

Hospital
• Apply ABCD principles of resuscitation
• Determine the cause;
- Assess uterine contractions and level of descent
- Do a vaginal examination to assess cervical dilatation, signs of obstruction
(moulding and caput) and signs of foetal distress (colour of liquor and foetal
heart rate)
• Start or continue partograph
• Give IV RL/NS as appropriate

16 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 MINISTRY OF HEALTH AND SOCIAL WELFARE

• Insert an indwelling urethral catheter

• Give IV Ampicillin 1g 6hrly for 24-hours, PLUS Metronidazole 500 mg IV 8hrly
for 24 hours. Then, change to caps Amoxicillin 500 mg and tabs Metronidazole
400 mg 8hrly for 5 days OR give IV Ceftriaxone 1g IV 12hrly for 5 days and
Metronidazole 500 mg IV 8hrly for 24 hours, then continue tabs Metronidazole
400mg 8hrly for 5 days

Avoid Gentamicin before operation as it may interact with muscle

relaxants

Subsequent management will depend on the identified cause:

i. If foetal-pelvic disproportion;
Perform Caesarean Section

ii. If uterine inertia:

Augment labour with oxytocin as follows;
- Primigravidae 5 IU in 500 mls of RL/NS
- Multiparas 2.5 IU in 500 mls of RL/NS

NB: If the cervix is fully dilated, no sign of obstruction, the presenting part is vertex
and the descent is below 2/5;
- Do a low cavity vacuum extraction
- If vacuum extraction fails after three pulls, perform C/S

EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID 17

 MINISTRY OF HEALTH AND SOCIAL WELFARE

Prolonged labour management flow chart

Apply ABCD principle of resuscitation

Check vital signs (BP, PR, RR, Temp)
Assess uterine contractions
Check foetal size, presentation and descent of presenting
part and foetal heart rate
Check cervical dilation, moulding and caput
Insert an indwelling urethral catheter

YES
NO
Are uterine contractions strong?

NO NO Are there signs of

Are presentation, descent and obstruction or foetal-pelvic
cervical dilatation favourable? disproportion?

YES

Is 2nd stage imminent beyond

reasonable doubt?
YES
YES

NO Perform low cavity vacuum

extraction if no spontaneous
delivery

Give antibiotics
REFER with an escort of a nurse and carry a delivery kit

At the Hospital
Obtain blood for Hb, grouping and cross-matching
Augment labour, perform vacuum extraction or C/S
as appropriate
Start or continue with antibiotics

18 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 CHAPTER 8

OBSTRUCTED LABOUR

This implies mechanical obstruction and failure of progressive descent of the

presenting part, despite of adequate uterine contractions

Symptoms and signs:

Early obstruction;
• Abnormal partograph findings (i.e. poor cervical dilatation and poor descent of
the presenting part)
• Foetal distress may or may not be present

Prolonged obstruction;
• Maternal distress
• Bandl’s ring (distension of lower segment and formation of a retraction ring)
• Uterine contractions, in primigravidae ends up into tetanic contractions and in
multipara may result in uterine rupture
• Foetal heart rate may be irregular or absent
• Arrested foetal descent
• Vulva may be swollen
• Cervix may be fully dilated in case of obstruction at the outlet
• Excessive caput formation and severe moulding in cephalic presentation
• Offensive liquor if labour has been prolonged

Management of obstructed labour

Dispensary & health centre
• Apply ABCD principles of resuscitation
• Give IV RL/NS 1-2 lts fast, using a large-bore cannula (G 16-18)
• Insert an indwelling urethral catheter to monitor output
• Obtain blood for Hb
• Administer IV Ampicillin 1g stat and Metronidazole 500 mg stat
• REFER to hospital urgently with an escort of a nurse carrying a delivery kit

Hospital
• Apply ABCD principles of resuscitation
• Give IV RL/NS 1-2lts fast, using a large-bore cannula (G 16-18)
• Insert an indwelling urethral catheter to monitor output
• Obtain blood for Hb, grouping and cross-matching
• Give IV Ampicillin 1g 6hrly for 24hours, PLUS Metronidazole 500mg 8hrly for 24

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 MINISTRY OF HEALTH AND SOCIAL WELFARE

hours. Then, change to caps Amoxicillin 500mg and tabs Metronidazole 400mg
8hrly for 5 days OR give IV Ceftriaxone 1g 12hrly for 5 days and Metronidazole
500 mg 8hrly for 24 hours, then continue tabs 400mg 8hrly for 5 days
• Deliver the woman by C/S

In case of prolonged obstruction or injured bladder or blood

stained urine, leave indwelling urethral catheter for at least 14
days

20 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 CHAPTER 9

ANTEPARTUM HAEMORRHAGE

Bleeding from the genital tract between 28 weeks of gestation and before delivery
of the baby

Placenta praevia
This refers to an abnormally implanted placenta in the lower segment of the uterus

Symptoms;
• Painless, unprovoked vaginal bleeding of variable amounts
• Foetal movements are present
Signs;
• Shock if bleeding is severe
• Bright red vaginal bleeding
• Non-tender, soft uterus and foetal parts usually palpable
• High presenting part
• Foetal distress if blood loss is severe

Management of placenta praevia

Dispensary & health centre

• Shout for help and mobilize resources
• Apply ABCD principles of resuscitation
• Give IV RL/NS using a large-bore cannula, at least 2lts in the first hour
• Obtain blood for Hb
REFER to hospital with an escort of a nurse

NEVER perform a digital vaginal examination

Hospital
• Shout for help and mobilize resources
• Apply ABCD principles of resuscitation
• Give IV RL/NS using a large-bore cannula, at least 2lts in the first hour
• Obtain blood for Hb, grouping and cross match- Ensure blood is readily available
• If the bleeding is mild or has stopped, patient is not in shock, foetus is alive and
premature;
i. Do a gentle speculum examination to exclude local causes of bleeding
ii. Do ultra sound to confirm the diagnosis

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 MINISTRY OF HEALTH AND SOCIAL WELFARE

iii. If placenta praevia is confirmed and no episode of heavy vaginal bleeding,

manage expectantly and do an elective C/S at 37 weeks
• Correct anaemia, give tab. FeFol twice daily until 4 weeks post-delivery, then
continue with one tablet daily for 8 weeks
• If bleeding is heavy do emergency C/S regardless of the gestation age

Abruptio placenta

This refers to premature separation of a normally implanted placenta before

delivery of the baby

Symptoms;
• Abdominal pain
• Dark coloured vaginal bleeding of various amounts
• Majority of patients report loss of foetal movements
Signs;
• Variable degrees of shock
• Pallor
• Fundal height may be greater than gestational age
• Hard and tender uterus
• Difficult to palpate foetal parts
• Foetal heart beats usually not heard
• Dark vaginal bleeding

Sometimes the degree of shock does not correspond with the

amount of per vaginal bleeding
In concealed Abruptio placenta per vaginal bleeding will be absent

Management of abruptio placenta

Dispensary & health centre

• Shout for help and mobilize resources
• Apply ABCD principles of resuscitation
• Give IV RL/NS using a large-bore cannula, at least 3lts or more in the first
hour
• Insert an indwelling urethral catheter
• Monitor input/output
• Give Diclofenac 75 mg IM stat
• Give oxygen 4-6lts/minute if necessary
• Obtain blood for Hb
• Monitor vital signs blood pressure, pulse rate and respiratory rate
Urgently REFER the patient to hospital with an escort of a nurse

22 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 MINISTRY OF HEALTH AND SOCIAL WELFARE

Hospital
• Shout for help and mobilize resources
• Apply ABCD principles of resuscitation
• Give IV RL/NS using a large-bore cannula, at least 3lts or more in the first
hour
• Insert an indwelling urethral catheter
• Monitor input/output
• Give Diclofenac 75 mg IM or Pethidine 100mg IM stat
• Obtain blood for Hb, grouping, cross-matching and bedside clotting time to
exclude coagulopathy (a stable clot should be formed within 7 minutes)
• Give Oxygen 4-6lts/minute if necessary
• Monitor vital signs blood pressure, pulse rate and respiratory rate
• Ensure availability of blood (at least 4 units) and Fresh Frozen Plasma (FFP)
4 units
• Do a gentle vaginal examination, if the cervix is favourable and no
contraindications for vaginal delivery;
i. Do artificial rupture of membranes (ARM)
ii. Augment labour with Oxytocin as follows;
- Primigravidae, 5 IU in 500 mls RL/NS
- Multiparas, 2.5 IU in 500 mls of RL/NS
• Monitor labour using a partograph
• Perform active management of third stage of labour
• After delivery, estimate blood loss including the retroplacental clot
• Continue with Oxytocin 20 IU in 500 mls RL/NS for 6 hours
• Give a tablet of FeFol twice daily for 3 month and review every 4 weeks
• Perform an emergency C/S if;
i. Delivery is not imminent and the foetus is alive
ii. There is heavy bleeding threatening the woman’s life
iii. There is obstetric indication(s)

EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID 23

 CHAPTER 10

POSTPARTUM HAEMORRHAGE (PPH)

Postpartum haemorrhage (PPH) refers to blood loss of 500mls or more from the
genital tract after delivery of the baby
Primary PPH - if it occurs within 24 hours of delivery
Secondary PPH - if it occurs between 24 hours and six weeks after delivery

• Remember that usually blood loss is underestimated

• In anaemic patients, blood loss of less than 500 mls may be life
threatening

Primary PPH
Symptom;
• Excessive genital bleeding

Signs;
• Variable degrees of shock
• Pallor

Management of primary PPH

Dispensary & health centre
• Shout for help and mobilize resources
• Apply ABCD principles of resuscitation
• Give IV RL/NS using a large-bore cannula, at least 3lts or more in the first
hour
• Insert an indwelling urethral catheter
• Monitor vital signs Blood Pressure, Pulse Rate, Respiratory Rate and
Temperature
• Establish the cause of bleeding which may be;
- Uterine atony
- Retained placenta
- Tears of the birth canal
- Coagulopathy

24 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 MINISTRY OF HEALTH AND SOCIAL WELFARE

Subsequent management will depend on the identified cause:

1. Uterine atony - palpate the fundus of the uterus, If fundus is

soft;
- Massage the fundus of the uterus
- Repeat Oxytocin 10 IU IM
- Empty urinary bladder
- Do digital evacuation of products of conception or membranes
- If the uterus remains atonic perform bimanual compression of the
uterus
- Give Oxytocin 20 IU in 500mls of RL/NS to run at a rate of 60 drops/
minute OR Ergometrine 0.25mg IM start
- Give a loading dose of IV Ampicillin 1g PLUS Metronidazole 500mg

REFER immediately. A nurse should accompany the patient as fundal

massage or even bimanual compression may be necessary on the way
to slow the bleeding

2. Retained placenta
• Retained and bleeding;
- Give Oxytocin 10 IU IM
- Make sure the urinary bladder is empty
- Perform controlled cord traction. If this fails to deliver the placenta
and bleeding continues, do a vaginal examination
a. If the cervix is wide open;
- Give Diclofenac 75mg IM stat
- Perform manual removal of the placenta
- Examine placenta for completeness
- Give IV Ampicillin 1g 6hrly for 24 hours, IM Gentamycin 80mg
12hrly for 24 hours and IV Metronidazole 500mg 8hrly for
24-hours
- Continue with caps Amoxillin 500mg 8hrly, IM Gentamycin
80mg 12hrly and tabs Metronidazole 400mg 8hrly for 5 days
- Observe for vaginal bleeding at the facility for 24 hours
b. If the cervix is closed;
- Give a loading dose of IV Ampicillin 1g PLUS Metronidazole
500mg
- REFER to hospital with Oxytocin 20 IU in 500mls RL/NS with
an escort of a nurse
• Retained and not bleeding;
- This may be placenta accreta
- Give IV RL/NS
- Urgently REFER patient to hospital with an escort of a nurse

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 MINISTRY OF HEALTH AND SOCIAL WELFARE

3. Tears of the birth canal

- Inspect vagina and perineum for tears
- Repair first and second degree perineal tears in the labour ward
- Before referral;
i. Ligate any obvious visible bleeding blood vessel(s)
ii. If cervical tear, clump it with sponge holding forceps (Note:
Release the forceps every 30minutes and re-clamp)
- Give a loading dose of IV Ampicillin 1g PLUS Metronidazole 500mg
REFER 30 and 40 degree tears to hospital

Hospital
• Shout for help and mobilize resources
• Apply ABCD principles of resuscitation
• Give IV RL/NS using a large-bore cannula, at least 3lts or more in the first
hour
• Insert an indwelling urethral catheter
• Monitor vital signs Blood Pressure, Pulse Rate, Respiratory Rate and
Temperature
• Establish the cause of bleeding which may be;
- Uterine atony
- Retained placenta
- Tears of the birth canal
- Coagulopathy

Subsequent management will depend on the identified cause:

1. Uterine atony - palpate the fundus of the uterus, if fundus is

soft;
- Massage the fundus of the uterus
- Repeat Oxytocin 10 IU IM
- Empty urinary bladder
- Do digital evacuation of products of conception or membranes
- If the uterus remains atonic perform bimanual compression of the
uterus
- Give Oxytocin 20 IU in 500mls of RL/NS to run at a rate of 60 drops/
minute OR Ergometrine 0.25mg IM start
- If bleeding continues, proceed with hysterectomy

2. Retained placenta:
• Retained and bleeding;
- Give Oxytocin 10 IU IM
- Make sure the urinary bladder is empty
- Perform controlled cord traction. If this fails to deliver the placenta
and bleeding continues, do a vaginal examination
a. If the cervix is wide open;
- Give Diclofenac 75mg IM stat or IM Pethidine 100mg stat

26 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 MINISTRY OF HEALTH AND SOCIAL WELFARE

- Perform manual removal of the placenta

- Examine the placenta for completeness
- Give Oxytocin 10 IU IM stat then 20 IU in 500mls RL/NS at
approximately 30-40 drops/minute for 4-6 hours
- Give IV Ampicillin 1g 6hrly for 24 hours, IM Gentamycin 80mg
12hrly for 24 hours and IV Metronidazole 500mg 8hrly for
24-hours
- Continue with Amoxillin caps 500mg 8hrly, IM Gentamycin
80mg 12hrly and tabs Metronidazole 400mg 8hrly for 5 days
- Observe for vaginal bleeding at the facility for 24 hours
b. If the cervix is closed;
- Perform manual removal of the placenta in theatre under
general anaesthesia
- Give Oxytocin 10 IU IM stat and Oxytocin 20 IU in 500mls RL /
NS at approximately 30-40 drops/minute for 4-6 hours
- If manual removal fails proceed with hysterectomy
- Give IV Ampicillin 1g 6hrly for 24 hours, IM Gentamycin 80mg
12hrly for 24 hours and IV Metronidazole 500mg 8hrly for
24-hours
- Continue with caps Amoxillin 500mg 6hrly, IM Gentamycin
80mg 12hrly and tabs Metronidazole 400mg 8hrly for 5 days
c. Retained tissue/membrane
- Do evacuation of uterus using sharp wide curette
- Give Oxytocin 10 IU IM stat then 20 IU in 500mls RL /NS at
approximately 30-40 drops/minute for 4-6 hours
- Give IV Ampicillin 1g 6hrly for 24 hours, IM Gentamycin 80mg
12hrly for 24 hours and IV Metronidazole 500mg 8hrly for
24-hours
- Continue with caps Amoxillin 500mg 8hrly, IM Gentamycin
80mg 12hrly and tabs Metronidazole 400mg 8hrly for 5 days
- Observe for vaginal bleeding at the facility for 24 hours
d. Retained and not bleeding;
- This may be abnormal implantation of the placenta to uterine
muscles (accreta, increta, percreta)
- Give IV RL/NS
- Perform Hysterectomy
- Give IV Ampicillin 1g 6hrly for 24 hours, IM Gentamycin 80mg
12hrly for 24 hours and IV Metronidazole 500mg 8hrly for 24
hours
- Continue with caps Amoxillin 500mg 8hrly, IM Gentamycin
80mg 12hrly and tabs Metronidazole 400mg 8hrly for 5 days

3. Tears of the birth canal;

- Inspect the cervix, vagina and perineum for tears
- Repair first and second degree perineal tears in the labour ward
- Repair cervical, third and fourth degree perineal tears in theatre under

EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID 27

 MINISTRY OF HEALTH AND SOCIAL WELFARE

general anaesthesia
- Give IV RL/NS
- Give IV Ampicillin 1g 6hrly for 24 hours, IM Gentamycin 80mg 12hrly for
24 hours and IV Metronidazole 500mg 8hrly for 24 hours
- Continue with caps Amoxillin 500mg 8hrly, IM Gentamycin 80mg 12hrly
and tabs Metronidazole 400mg 8hrly for 5 days

4. Coagulopathy
- Give whole blood 2 units and Fresh Frozen Plasma (FFP) 4 units

Subsequent Care
- Monitor vital signs; BP , PR, Temp, RR every 30 minutes until patient is
stable then 4hrly for 24 hours
- Continue with IV fluids for at least 24 hours
- Monitor input/output
- Recheck Hb and assess the need for blood transfusion after 24 hours
- Continue with antibiotics
- Give FeFol 1 tablet twice a day for 3 months and review every 4 weeks

Avoid Gentamicin before operation as it may interact with muscle

relaxants

Secondary PPH
Symptoms;

Signs;
• Offensive per vaginum bleeding or discharge from the cervical os
• Variable degrees of shock
• Pallor
• Sub-involuted tender uterus

Management of secondary PPH

Dispensary & health centre
• Shout for help and mobilize resources
• Apply ABCD principles of resuscitation
• Give RL/NS 2-4lts in the first 2 hours
• Check Hb
• Give Oxytocin 10 IU or Ergometrine 0.25mg IM stat if not anaemic
• Give IV Ampicillin 1g 6hrly for 24 hours, IM Gentamycin 80mg 12hrly for 24
hours and IV Metronidazole 500mg 8hrly for 24-hours
• Continue with caps Amoxillin 500mg 6hrly, IM Gentamycin 80mg 12hrly and
tabs Metronidazole 400mg 8hrly for 7 days

If cervix is open;
- Explore uterus by gloved fingers to remove large clots, placental fragments

28 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 MINISTRY OF HEALTH AND SOCIAL WELFARE

and membranes
- Give IV Oxytocin 20 IU in 500mls of RL/NS run for 4-6hrs
- Observe for 24 hours
- Continue with oral antibiotics
- Give FeFol one tablet twice daily for 3 months and review at 4 weeks interval

REFER urgently with an escort of a nurse if;

• Cervix is closed
• Bleeding does not stop
• Patient is severely pale

Hospital
• Shout for help and mobilize resources
• Apply ABCD principles of resuscitation
• Give RL/NS 2-4lts in the first 2 hours
• Check Hb, grouping and cross matching
• Give Oxytocin 10 IU or Ergometrine 0.25mg IM stat if not anaemic
• Give IV Ampicillin 1 g 6hrly for 24 hours, IM Gentamycin 80 mg 12hrly for 24
hours and IV Metronidazole 500mg 8hrly for 24hours
• Continue with caps Amoxillin 500mg 6hrly, IM Gentamycin 80mg 12hrly and
tabs Metronidazole 400mg 8hrly for 7 days

If cervix is open;
- Explore uterus by gloved fingers to remove large clots, placental fragments
and membranes
- Give IV Oxytocin 20 IU in 500mls of RL/NS run for 4-6hrs
- Observe for 24 hours
- Continue with oral antibiotics
- Give FeFol one tablet twice daily for 3 months and review at 4 weeks interval

If cervix is closed and/or bleeding continues;

- Perform evacuation of the uterus with wide sharp currette under general
anaesthesia
- Continue with antibiotics
- Give blood transfusion if indicated
- Monitor vital signs – BP, PR and Temp every 30 minutes until when patient is
stable then 4hlry for 24hrs
- Monitor input/output
- Give analgesics as required
- Give FeFol one tablet twice daily for 3 months and review at 4 weeks
interval

Avoid Gentamicin before operation as it may interact with

muscle relaxants

EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID 29

 MINISTRY OF HEALTH AND SOCIAL WELFARE

POSTPARTUM HAEMORRHAGE MANAGEMENT FLOW CHART

Shout for help and mobilize resources

Apply ABCD principles of resuscitation
Massage fundus of the uterus
Give Oxytocin 10 IU IM or Ergometrine 0.25 mg IM (if patient is
not anaemic) and 20 IU in 500mls RL/NS
Obtain blood for Hb, grouping and cross-matching if possible
Insert indwelling urethral catheter

IS PLACENTA OUT?
YES NO

YES Try to deliver by controlled cord traction

Examine: Is the placenta if it fails;
complete? Perform manual removal of the
placenta
Give oxytocin 20 I.U IV in 500mls
NO RL/NS to run for 4-6 hours
Give broad spectrum antibiotics
Perform digital evacuation Is the uterus well Observe for 24 hours
of the uterus contracted? If manual removal of placenta fails
REFER with running IV fluids
YES
NO
NO
Are there cervical, vaginal or
perineal tear(s)?
Massage and squeeze clots
Perform bimanual compression of
YES the uterus
Give oxytocin 20 I.U IV in 500mls
Repair perineal or RL/ NS to run for 4-6 hours
vaginal tears
REFER

BLEEDING CONTROLLED?
BLEEDING
CONTROLLED? NO YES
REFER with Monitor patient and
YES NO IV fluid while continue with oxytocin
compressing Refer for blood
Monitor patient REFER with IV RL/NS the uterus transfusion if very pale

At Hospital
Continue resuscitation with IV RL/NS, insert urethral catheter
Give blood transfusion if severely anaemic
Identify cause of bleeding and manage appropriately

30 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 CHAPTER 11

ABORTION

This is loss or termination of pregnancy before 28 weeks of gestation

Threatened abortion
Vaginal bleeding before 28 weeks of gestation with a closed cervix

Symptoms;
• Slight or no lower abdominal pain /cramps
• Slight to moderate PV bleeding
• The bleeding is not accompanied with clot(s)

Signs;
• Stable general condition
• Fundal height corresponds to gestational age
• Uterus remains soft and non-tender
• Cervix is closed
• Slight or no bleeding per cervical os

Management of threatened abortion

Dispensary & health centre
• Advice the couple/woman for her to have adequate bed rest at home
• Advice the couple/woman for her to avoid strenuous activities and sexual
intercourse until all the symptoms have subsided
• Schedule a follow up within 7 days
• Advice the woman to come immediately if;
- Bleeding becomes heavy
- She experiences offensive discharge
- She has severe abdominal pain

REFER to hospital if;

- Bleeding recurs
- She has fever
- She experiences offensive discharge
- She has severe abdominal pain
- Rest at home is not possible

Hospital
• Perform ultrasound to confirm gestational age and foetal viability.

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 MINISTRY OF HEALTH AND SOCIAL WELFARE

• Advice the couple/woman for her to have adequate bed rest at home.
• Advise the couple/woman for her to avoid strenuous activities and sexual
intercourse until all the symptoms have subsided.
• Advice the woman to come immediately if bleeding becomes heavy, when she
experiences offensive discharge or severe abdominal pain
• Admit the patient and manage appropriately if;
- The foetus is dead
- Bleeding recurs
- She has fever
- She has foul smelling vaginal discharge
- She has severe abdominal pain
- Unable to rest at home

Inevitable abortion
Abortion is said to be inevitable when it is not possible for the pregnancy to continue
and the cervix is dilated, but all the products of conception are in situ

Symptoms;
• Moderate or severe per vaginal bleeding which may be accompanied with
clots
• Severe lower abdominal pain
• Significant draining of liquor if membranes have ruptured

Signs;
• The cervix is dilated with evidence of imminent expulsion of products of
conception and/or ruptured membranes
• Fundal height may correspond with gestational age
• Presence of uterine contractions

Management of inevitable abortion

Dispensary & health centre
• Apply ABCD principles of resuscitation
• Check Hb
• Give IV RL/NS 2lts
• Perform MVA if gestation age is below 12 weeks
• Augment the process by administering Oxytocin 20 IU in 500mls RL/NS at
40-60 drops/minute if gestation age is above 12 weeks
• Manage as incomplete abortion if after augmentation some products of
conception remain in the uterus
• Manage as complete abortion if all product of conception are expelled
REFER to hospital if MVA is not possible and/or bleeding is persisting

Hospital
• Apply ABCD principles of resuscitation
• Obtain blood for Hb , grouping and cross-matching

32 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 MINISTRY OF HEALTH AND SOCIAL WELFARE

• Give IV RL/NS 2lts

• Perform MVA if gestation age is below 12 weeks
• Augment the process by administering Oxytocin 20 IU in 500mls RL/NS at
40-60 drops/minute if gestation age is above 12 weeks
• Manage as incomplete abortion if after augmentation some products of
conception remain in the uterus
• Manage as complete abortion if all product of conception are expelled

Incomplete abortion
Some of the products of conception have been retained in the uterine cavity and
there is persistent lower abdominal pain, continuing per vaginum bleeding and
open cervix

Symptoms;
• Cramping lower abdominal pain
• PV bleeding accompanied with clots/products of conception

Signs;
• Slight to profuse PV bleeding accompanied with clots/products of conception
• Clots/ products of conception protruding through the cervical os
• Fundus smaller than dates
• The cervix is dilated and products of conception may be felt in the cervix on
digital examination

Management of incomplete abortion

Dispensary & health centre
• Apply ABCD principles of resuscitation
• Check Hb
• Give IV RL/NS 2lts
• Perform digital evacuation of products of conception
• Perform MVA if gestation age is below 12 weeks
• Give Oxytocin 10 IU IM or Ergometrine 0.25mg IM or oral Misoprostol 600µg
stat
• Give caps Amoxicillin 500mg PLUS tabs Metronidazole 400mg orally 8hrly
for 5 days
• Counsel for family planning and provide contraceptives

REFER patient with an escort of a nurse if;

i. MVA is not possible
ii. The gestation age is more than 12 weeks
iii. Patient is severely anaemic

Hospital
• Apply ABCD principles of resuscitation
• Obtain blood for Hb, grouping and cross-matching

EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID 33

 MINISTRY OF HEALTH AND SOCIAL WELFARE

• Give blood transfusion if indicated

• Give IV RL/NS 2lts
• Perform digital evacuation of products of conception
• Perform MVA if gestation age is below 12 weeks
• Evacuate uterus in theatre with sharp curette under general anaesthesia if
pregnancy is more than 12 weeks
• Give Oxytocin 10IU IM or Ergometrine 0.25mg IM stat
• Give caps Amoxicillin 500mg PLUS tabs Metronidazole 400mg orally 8hrly
for 5 days
• Give analgesics as required
• Counsel for family planning and provide contraceptives

Complete abortion
Products of conception are completely expelled

Symptoms;
• Expulsion of products of conception
• Minimal or no PV bleeding

Signs;
• Uterus smaller than dates and often well contracted
• Cervix may or may not be closed

Management of complete abortion

Dispensary & health centre
• If patient is stable;
- Give caps Amoxicillin 500 mg PLUS tabs Metronidazole 400mg 8hlry
for 5 days
- Counsel for family planning and provide appropriate contraceptive
method
- Give FeFol 1 tablet twice daily for 3 months and reassess after every
4 weeks
• If patient is in shock;
- Shout for help and mobilize resources
- Apply ABCD principles of resuscitation
- Give IV RL/NS 3lts or more in the first hour
- Insert an indwelling urethral catheter
- Give IV Ampicillin 1g and Metronidazole 500mg stat
- Obtain blood for Hb
REFER patient to hospital with an escort of a nurse

Hospital
• If patient is stable;
- Give caps Amoxicillin 500mg PLUS tabs Metronidazole 400mg 8hlry
for 5 days
- Counsel for family planning and provide appropriate contraceptive

34 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 MINISTRY OF HEALTH AND SOCIAL WELFARE

method
- Give FeFol 1 tablet twice daily for 3 months and reassess after every
4 weeks
• If patient is in shock;
i. Shout for help and mobilize resources
ii. Apply ABCD principles of resuscitation
iii. Give IV RL/NS 3lts or more in the first hour
iv. Obtain blood for Hb, grouping and cross-matching
v. Give blood transfusion if indicated
vi. Insert an indwelling urethral catheter
vii. Start or continue with IV Ampicillin 1g 6hrly and Metronidazole
500mg 8hrly for 24-48 hours then change to caps Amoxicillin 500mg
PLUS tabs Metronidazole 400mg 8hly for 5 days
viii. Counsel for family planning and provide appropriate contraceptive
method on discharge
ix. Give FeFol 1 tablet twice daily for 3 months and reassess after every
4 weeks

Septic abortion
An abortion complicated with infection

Symptoms;
• Abdominal pain following history of abortion
• Fever may be present
• Foul smelling PV discharge which may be mixed with blood

Signs;
• Fever
• May be in shock or/and jaundiced
• Tender uterus, there may be rebound tenderness
• Offensive PV discharge which may be mixed with blood
• Cervix is usually open

Management of septic abortion

Dispensary & health centre
• Apply ABCD principles of resuscitation
• Give IV RL/NS 3lts or more in the first hour
• Insert an indwelling urethral catheter
• Obtain blood for Hb
• Give IV Ampicillin 2g AND Metronidazole 500mg AND Gentamicin 80mg IM
stat

REFER patient to hospital with an escort of a nurse

Hospital
• Apply ABCD principles of resuscitation

EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID 35

 MINISTRY OF HEALTH AND SOCIAL WELFARE

• Give IV RL/NS 4lts or more in 24 hours

• Insert an indwelling urethral catheter
• Obtain blood for Hb, grouping and cross-matching
• Give blood transfusion if indicated
• Perform endocervical swab for culture and sensitivity
• Give IV Ampicillin 2g stat AND Metronidazole 500mg stat
• Evacuate the uterus with sharp wide curette under general anaesthesia
• When the patient is stable continue with;
i. IV Ampicillin 1g 6hrly for 24-48 hours, then caps Amoxylline
500mg 6hrly for 7 days
ii. IM Gentamicin 80mg 12hrly for 7days
iii. IV Metronidazole 500mg 8hrly for 24-48 hours, then tabs
400mg 8hrly for 7days
• If no response with the above antibiotics within 3 days;
- Adjust according to culture and sensitivity
- OR if no culture sensitivity services switch to IV Cephalosporins
such as Ceftriaxone or Cefuroxime 1g 12hrly for 5 days
• Monitor input and output
• Counsel for family planning and provide appropriate contraceptive method
• Give FeFol one tablet twice a day for 3 months and review after every 4 weeks

Presence of generalized peritonitis or pelvic abscess requires

urgent laparotomy

Molar abortion
A molar pregnancy is characterized by abnormal proliferation of the chorionic villi
leading to multiple grape-like vesicles usually in the absence of embryo or normal
placental tissue

Symptoms;
• Exaggerated pregnancy symptoms
• Abdominal pain
• Heavy PV bleeding
Signs;
• Expulsion of vesicles/grape-like tissues
• Absence of foetal parts
• Uterus doughy
• Fundal height usually greater than gestational age
• Cervix dilated

Management of molar abortion

Dispensary & health centre

• Apply ABCD principles of resuscitation
• Give IV RL/NS 2lts

36 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 MINISTRY OF HEALTH AND SOCIAL WELFARE

• Check blood for Hb

REFER to hospital with an escort of a nurse

Hospital
• Apply ABCD principles of resuscitation
• Give IV RL/RL 2lts in the first hour
• Obtain blood for Hb, grouping and cross-matching
• Suction curettage is the treatment of choice, either by manual vacuum
aspiration if the fundal height is less than 12 weeks, or by suction machine if
more than 12 weeks
• Give Oxytocin 20 IU in 500mls of RL/NS to run at 60 drops/minute
• Give blood transfusion if indicated

Post evacuation care

• Continue Oxytocin drip for at least 6 hours
• Insert an indwelling urethral catheter
• Take chest x-ray
• Check UPT after 8-weeks, if still positive check after 4-weeks, if still positive
refer to consultant hospital
• If facilities allow monitor the patient using serum beta hCG levels
• Give combined oral contraceptives for one year

During follow up, do the following;

• Ask for history of cough, difficulty in breathing, abnormal PV bleeding,
persistent headache or fits
• Examine the chest for crepitations
• Check uterine fundal height
• Pelvic examination for vaginal purple lesions and adnexal masses
• Investigations; chest x-ray, UPT, serum beta hCG (if facilities allow)

REFER for specialized care if any of the following is discovered;

i. Abnormal chest x-ray
ii. Abnormal vagina bleeding
iii. If the UPT becomes positive after 12 weeks
iv. Presence of a purple vaginal lesion
v. Persistent headache, fits or features of increased intra cranial pressure

EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID 37

 CHAPTER 12

RUPTURED ECTOPIC PREGNANCY

This is a pregnancy which is implanted outside the uterine cavity, commonly in the
fallopian tubes. Bleeding occurs when the site of implantation ruptures or tubal
abortion occurs

Symptoms;
• A short period of amenorrhoea of about 6-8 weeks, but this may be absent in
some patients
• Fainting attacks
• Severe generalized abdominal pain, sometimes radiating to the shoulder
• There may be a history of infertility
• Bleeding if present may be intermittent and chocolate brown

Signs;
• Pallor (moderate to severe)
• Signs of shock may be present
• Tender distended abdomen with guarding and rebound tenderness
• Signs of intra-peritoneal fluid may be present (shifting dullness and fluid
thrill)
• Positive cervical excitation test
• Bulging Pouch of Douglas

Management of ruptured ectopic pregnancy

Dispensary & health centre
• Apply ABCD principles of resuscitation
• Give IV RL/NS 2lts in the first hour and continue with fluid infusion as
required
• Obtain blood for Hb
• Insert an indwelling urethral catheter
• Monitor input and output
REFER to hospital with an escort of a nurse

Hospital
• Apply ABCD principles of resuscitation
• Give IV RL/NS 2lts in the first hour and continue with fluid infusion as
required
• Obtain blood for Hb, grouping and cross matching
• Insert an indwelling urethral catheter
• Monitor input and output
• Perform laparotomy urgently
• Give blood transfusion as required after arresting the haemorrhage
If there are clear symptoms and signs of ruptured ectopic
pregnancy, urgent laparotomy should be done

38 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 CHAPTER 13

PUERPERAL SEPSIS
Infection of the reproductive organs at any time from delivery to 6 weeks postpartum

Symptoms;
• Fever
• Lower abdominal pain
• Abnormal lochia (purulent, foul smelling lochia)
• Vaginal bleeding may be present
Signs;
• Fever
• Tachycardia (increased pulse rate, 100 beats/minute or more)
• Lower abdominal tenderness with or without rebound tenderness
• Sub-involuted uterus
• Abnormal lochia may be present

Management of puerperal sepsis

Dispensary & health centre

• Apply ABCD principles of resuscitation
• Give IV RL/NS if in shock
• Give IV Ampicillin 2gms AND Metronidazole 500mg AND Gentamicin 80mg
IM stat
• Give antipyretic as required
REFER patient to hospital with an escort of a nurse

Hospital
• Apply ABCD principles of resuscitation
• Obtain blood for Hb, grouping and cross-matching
• Give IV RL/NS 4lts or more in 24 hours
• Insert an indwelling urethral catheter
• Monitor input and output
• Perform endocervical swab for culture and sensitivity
• Give IV Ampicillin 2g stat then 1g 6hrly for 24-48 hours, then caps Amoxylline
500mg 6hrly for 7 days
• Give Gentamicin 80mg IM 12hrly for 7 days
• Give IV Metronidazole 500mg 8hrly for 24-48 hours, then tabs 400mg 8hrly
for 7 days
• If no response with the above antibiotics within 3 days;
vi. Adjust according to culture and sensitivity
vii. OR if no culture sensitivity services switch to IV Cephalosporins such

EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID 39

 MINISTRY OF HEALTH AND SOCIAL WELFARE

as Ceftriaxone or Cefuroxime 1g 12hrly for 5 days

• Give FeFol one tablet once/day for 3-months and review after every 4-weeks
• Counsel for family planning and provide appropriate contraceptive method
•
Presence of generalized peritonitis or pelvic abscess requires
urgent laparotomy

40 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 CHAPTER 14

BIRTH ASPHYXIA

Failure to establish spontaneous, regular respiration within a minute of birth

Signs;
• Irregular, laboured breathing or no breathing
• Weak or no cry
• Pallor or cyanosis
• Muscle weakness or limp (hypotonia)
• Slow or irregular heart beat below 100 beats/minute (bradycardia)
• A poor response to stimulation

Management of birth asphyxia

Dispensary & health centre
• Call for help and mobilize resources
• Apply ABCD principles of resuscitation of the newborn
- Position the baby on the flat surface with the neck slightly extended to
open the airway
- Clear the airway by suctioning the mouth first then the nose
- Place the mask on the newborn’s face so that it covers the chin, mouth
and nose, forming a seal between mask and the face
- Give 3 strokes of rescue breath using ambubag and mask;
• If no chest rising determine why, rectify problem and continue
to ventilate
• If the chest is rising, ventilate at the rate of 40 breaths/minute,
quickly assess the baby for spontaneous breathing
• If breathing is normal stop ventilating and give to mother (skin
to skin) and continue to monitor
• If the baby is not breathing after 1 min or is not breathing well
call for help and improve ventilation
- If the baby’s heart rate is normal and breathing is irregular or slow
continue to ventilate for 3-5min until the baby is breathing well. Stop
ventilating and monitor baby with mother
- If there is no breathing at all after 20 min of ventilation and no heart
beats stop ventilating and provide emotional support

REFER the baby if;

• There is not breathing and heart beat is normal or slow while
continuing ventilation
• Has severe sub-costal in-drawing (laboured breathing) while assisting
ventilation
Hospital

EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID 41

 MINISTRY OF HEALTH AND SOCIAL WELFARE

• Call for help and mobilize resources

• Apply ABCD principles of resuscitation of the newborn
- Position the baby on the flat surface with the neck slightly extended to
open the airway
- Clear the airway by suctioning the mouth first then the nose
- Place the mask on the newborn’s face so that it covers the chin, mouth
and nose, forming a seal between mask and the face
- Give 3 strokes of rescue breath using ambubag and mask;
• If no chest rising determine why, rectify problem and continue
to ventilate
• If the chest is rising, ventilate at the rate of 40 breaths/minute,
quickly assess the baby for spontaneous breathing
• If breathing is normal stop ventilating and give to mother (skin
to skin) and continue to monitor
- If the baby is not breathing after 1 min or is not breathing well call for
help and improve ventilation
- If the baby’s heart rate is normal and breathing is irregular or slow
continue to ventilate for 3-5min until the baby is breathing well. Stop
ventilating and monitor baby with mother
• If NO heart beats or there is severe bradycardia (heart beats less than 40/
minute);
- Stimulate the heart using the index and middle fingers (Do the
compressions by counting one and two and three and four and five
then ventilate)
- Do five Cardiopulmonary Resuscitation (CPR) cycles then reassess
baby’s breathing and heart rate
- If the heart rate is more than 80 beats/min stop heart compression
continue ventilating until the baby is breathing well and the heart rate
is more than 100 beats/min
- If the heart rate is less than 80 beats/minute continue CPR for 15-30
minutes and transfer the newborn to a special baby care unit/room
for further observation and management if available
- If there is no breathing at all after 20 min of ventilation and no heart
beats, stop ventilating and provide emotional support
• Prevent heat loss by placing the baby skin-to-skin on the mother’s chest,
covering the baby’s body and head or placing the baby under a radiant heater
• Ensure feeding of the newborn as follows;
- If the baby is pink in colour and has sucking reflex, encourage the
mother to begin breastfeeding
- If the baby has difficulty in breathing and/or poor sucking reflex,
insert a NGT for feeding
- If the baby has no sucking reflex and/or convulsions, insert an IV line
and give 10% dextrose 40-60 mls/kg body weight
• Give IV Ampiclox 50 mg/kg body weight 12hrly PLUS Gentamicin 5 mg/kg
body weight IM as a single daily dose for 5 days
• Monitor the following during the next 24 hours;
i. Convulsions
ii. Breathing pattern
iii. Urine output
iv. Temperature

42 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID

 MINISTRY OF HEALTH AND SOCIAL WELFARE

Figure 1. Helping Baby to Breath

EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID 43

 MINISTRY OF HEALTH AND SOCIAL WELFARE

NEONATAL SEPTICAEMIA
This is an infection of the blood from a colonized area or from a local infection in a
newborn

Symptoms;
• Poor feeding
• Lethargy
• Few movements
• Low body temperature
• Convulsions
• Yellow colouration of skin and conjunctiva/sclera

Signs;
• Irritability
• Respiratory distress
• Jaundice
• Hyper or Hypothermia
• Low Apgar scores without fetal distress
• Floppiness

A high index of suspicion is important in the diagnosis and

treatment of neonatal infection

Management of neonatal septicaemia

Dispensary and health centre

• Apply ABCD principles of resuscitation of the newborn
• Keep the baby warm
• Expose the baby if febrile
• Continue to feed the baby;
- The newborn baby needs 40 to 50 mls every 3 hours
- If the baby is too weak to suck, help the mother express her breast
milk, give the milk with a small cup
- If the mother does not have enough breast milk, complement with
alternative feeding while continuing expressing the breasts
REFER the baby with an escort of a nurse

Hospital
• Apply ABCD principles of resuscitation of the newborn
• Keep the baby warm
• Expose the baby if febrile
• Give IV Ampiclox 100-150mg/kg body weight AND Gentamycin 5 -7.5mg/
kg body weight IM 12hrly once a day for 10-14 days OR Ceftriaxone 50-
80mg/kg body weight IV or IM once per day for 10-14 days
• Continue to feed the baby;
- The newborn baby needs 40 to 50 mls every 3 hours
- If the baby is too weak to suck, help the mother express her breast
milk, give the milk with a small cup or use a nasogastric feeding tube
- If the mother does not have enough breast milk, complement with
alternative feeding while continuing expressing the breasts

44 EMERGENCY OBSTETRIC AND NEWBORN CARE JOB AID