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Labour Room Protocol

“Labour Room Protocol” must be made available to every service provider attached to Labour Room/ Maternity ward of all MCH, DH, SDH, RH, BPHC.

Government of West Bengal
Department of Health & Family Welfare
State Family Welfare Bureau
Swasthya Bhawan
GN 29, Sector V, Salt Lake, Kolkata-700091

No. H/SFWB/1L-01-2013/2113(53) Date: 17.12.2013

1-13) The Principal/Director, IPGMER, Kolkata MCH, NRS MCH, R G Kar MCH, CNMCH/Sagar Dutta MCH, Medinipur MCH, Burdwan MCH, BSMCH, Murshidabad MCH, Maldah MCH, North Bengal MCH, Kalyanl MCH,

14-26) The MSVP, IPGMER, Kolkata MCH, NRS MCH, R G Kar MCH, CNMCH, Sagar Dutta MCH, Medinipur MCH, Burdwan MCH, BSMCH, Murshidabad MCH, Maldah MCH, North Bengal MCH, Kalyani MCH,

27-52) The CMOH, North 24 Parganas, Basirhat, Howrah, Hooghly, Nadia, South 24 Parganas, Diamond Harbour, Purba Medenipur, Birbhum, Rampurhat, Bankura, Bishnupur, Puruliya, Paschim Medenipur, Jhargram, Murshidabad, Bardhaman, Assansole, Malda, Uttar Dinajpur, Dakshin Dinajpur, Jalpaiguri, Coochbehar, Darjeeling Health District,

53) The DFWO, Kolkata,

Subject: Labour Room Protocol

Enclosed herewith please find “Labour Room Protocol” prepared by Dr Tridib Banerjee, Chairman, HLTF along with Prof. D Bhattacharya, Principal, Sagar Dutta MCH, Prof. Md Alauddin/ Dept. of G & Obs, Medenipur MCH & Dr S Chakraborty, Associate Professor, Kolkata MCH.

This “Labour Room Protocol” must be made available to every service provider attached to Labour Room/ Maternity ward of all MCH, District Hospital, S D/ S G Hospital, Decentralised Hospitals, Rural Hospital, Block PHC, 24 X 7 PHC and other PHC in the state with instruction to follow the protocol strictly.

Sd/- Commissioner, Family Welfare &
Secretary to Govt. of West Bengal.

Instruction for using labour room protocols:

  1. Do a rapid initial assessment to diagnose any condition which need immediate attention e.g- imminent delivery, ecclampsia, active bleeding per vagina, shock etc,
  2. Always observe infection prevention practices while providing clinical careChange shoes in labour room
    Wear protective apron
    Wash hand before and after patient examination following six steps
    Wear sterile glove before examination
    Decontaminate glove in .5% chlorine solution after examination
    Decontaminate all used instruments in .5% chlorine solution before , washing
    Dispose of all waste materials according to colour coding
    Clearance of waste basket during each duty shift along with swabbing of labour room floor.
  3. Diagnose a patient in shock and manage accordingto protocol (Page 1)
  4. Diagnose a patient in labor and manage according to protocol (Page 1)
  5. Shift the patient in active phase: of labor and manage according to protocol (Page 2)
  6. Manage second stage of labor and manage according to protocol using a partograph and never use misoprostol tablet oral/ vaginal without a record (Page 2)
  7. Provide active management of 3rd stage of labor to ALL mothers according to protocol (Page 4)
  8. Manage immediate post partum period according to protocol (Page 5]
  9. Diagnose and manage PPH and other third stage complication according to protocol (Page 8)
  10. Diagnose and manage severe pre eclampsia and eclampsia according to protocol (Page 5)
  11. Follow therapeutic antibiotic protocol in sepsis cases according to protocol (Page 13)
  12. Follow PPTCT protocol
    Counsel all mothers for HIV testing
    If tested reactive husband should be counseled
    Provide Nevirapine prophylaxis (single tablet 200 mg) to all reactive mothers at the onset of labour/ before cesarean section
    Provide Nevirapine prophylaxis to all babies of reactive mothers (syrup: 0.1 mg/kg body weight)
    Do not apply any identification tag on a reactive mother or baby.

Labour Room Protocols

1. Shock

Anticipate/expect shock in obstetrics when there is:

Initial Management:

Diagnosis:

Management: At BEmOC

At CEmOC

2. Diagnosis of Labour:

Anticipate labour if the woman in third trimester of pregnancy has

Confirm onset of labour if there is

Stages and phases of labour :

If cervix is not dilated at initial examination and

Obstetric care and management:

Careful monitoring of

Early identification of abnormality/complication
Timely intervention.

3. Care during latent phase:

Note-

4. Care during active phase:

Start plotting on partograph all events of labour once the woman is in active phase, The WHO partograph is modified by excluding the latent phase and beginning plotting at 4 cm cervical dilatation in active phase to make it simpler and easier to use. Record the following on the partograph.

Using the Partograph:

Patient information:
Fill out name, para, hospital number, date and time of admission, and time of rupture of membranes; or time elapsed since rupture of membranes (if rupture occurred before charting on the partograph began.
Foetal heart rate;. Record every half hour.

Amniotic fluid: Record status of membrane & the Colour /nature of amniotic fluid at every vaginal examination:

” I: membranes intact
” C: membranes ruptured clear fluid
” M: meconium stained fluid
” B: blood stained fluid
” A: liquor absent

Moulding:

” 1+: Sutures apposed
” 2+: Sutures overlapped but reducible
” 3+: Sutures overlapped and not reducible

Cervical dilatation: Assessed at every vaginal examination and marked with a cross (x). Begin plotting on partograph at 4 cm cervical dilatation. Expect 1 cm or more/ hour dilatation thereafter.

Alert line: A line starts at 4cm of cervical dilatation to the point of expected full dilation at the rate of 1 cm per hour. With normal progress, the cervicograph will remain on or to the left of the alert line.

Action line: Parallel and four hours to the right of the alert line.

Descent assessed by abdominal palpation: Recorded as a circle (O) at every abdominal examination. At 0/5 the sinciput is at the level of the symphysis pubis.

Hours: Refers to the time elapsed since onset of active phase of labour (observed or extrapolated)

Time: Record actual clock time.

Contractions: Chart every half hour. Count the number of contractions in a 10 minutes time period, and their duration in seconds

Oxytocin: Record the amount of oxytocin per volume IV fluids in drops per minute every 30 minutes when used.

Drugs given: Record any additional drugs given.
Pulse: Record every 30 minutes and mark with a dot (.)
Blood pressure: Record every 2 hours and mark with arrows.
Temperature: Record every 2 hours.
Protein, acetone and volume: Record when urine is passed.

5. Management of second stage of labour

Diagnosis of Second Stage:

Conduct of Delivery;

6. Active Management of third stage of labour

Signs of placental seperation:

Uterus becomes contacted, hard and globular,

Note: Oxytocics for third stage management:

OXYTOCIN ERGOMEIRINE/ METHYL ERGOMETRINE PROSTAGLANDIN 15-Methyl PGF2a MISOPROSTOL
  • Cheap
  • No contra indication
  • Safe – no side effects
  • Effective – quick action
  • Less heat labile
  • 10 units IM
  • Cheapest
  • Important contra­indications
  • Side effects – sometimes serious
  • Effective
  • Heat labile
  • 0.2 mg IM/IV
  • Costly
  • Some contra­indications
  • Some side effects
  • Effective
  • Highly heat labile
  • 125-250 meg IM
  • Less costly
  • No significant contraindication
  • No significant side-effect
  • Effective
  • Highly heat stable
  • 600 meg orally

7. Immediate postpartum care

Closely monitor for first 6 hours.

@ Every 15 mins, for 2 hours.
@ Every 30 mins. for 2 hours.
@ Every hour for 2 hours.
Massage the uterus every 15 mins to maintain contraction.
If stable (and there is no contraindication) give her something to drink when she feels thirsty and something to eat when she is hungry.
Keep the baby in skin contact with mother.
Initiate exclusive breast feeding within 1 hour.

10. Pre eclampsia/Eclampsia

Problem:

Initial management:

Diagnosis:

Hypertension: BP >= 140/ 90 mm Hg or an increase of 30 mm Hg systolic or 20 mm Hg diastolic
Before 20 weeks – chronic hypertension
After 20 weeks – Gestational hypertension (PIH)

Pre eclampsia: Hypertension + Proteinuria

Eclampsia: Pre eclampsia plus convulsion and/ or coma.

Diagnose and treat any convulsion during pregnancy and within one week of child birth as eclampsia unless proved otherwise.

Note:

1. Oedema- As 50 % normal pregnant Women may have oedema –

neither its presence conforms nor does its absence excludes the diagnosis of pre eclampsia. More over hypertension and proteinuria are mainly prognostically important, But suspect pre eclampsia if there is Oedema or excessive/rapid weight gain.

2. Prevention of Pre eclampsia and Eclampsia:

Management: At BEmOC

Management of Gestational Hypertension and Mild Pre eclampsia:

Management of Severe Pre eclampsia:

Management of Eclampsia:

MAGNESIUM SULPHATE REGIMEN

Loading dose:

Maintenance dose:

Post Partum Care

Management: At CEmOC

Management of Gestational Hypertension and Mild Pre eclampsia:

Management of Severe Pre eclampsia:

Management of Eclampsia:

Note:

1. Labetalol in IV titrating doses can also be used to control BP rapidly & smoothly

2. In deciding the mode/route of delivery also keep in mind the need for urgent delivery which may vary from mild to severe pre eclampsia and eclampsia and also in individual cases.

11. Post Partum Haemorrhage

Problem: Heavy/excessive or more than normal bleeding after child birth

Note:

Immediate PPH

Initial management

Features:

Placenta not expelled

Diagnosis: Retained placenta

Management: At BEmOC

At CEmOC

Features:

Diagnosis: Atonic Uterus.

Management: At BEmOC

At CEmOC

Features:

Diagnosis: Genital tears

Management: At BEmOC

At CEmOC

Features:

Diagnosis: Retained placental bits

Management: At BEmOC

At CEmOC

Features:

Diagnosis: Inversion of uterus

Management: At BEmOC

At CEmOC

Prevent PPH: Correct anaemia antenatally
Do active management of 3rd stage for all parturient _
Remain vigilant in immediate postpartum period

Note: Cervical injuries

Delayed PPH

Features:

Management: At BEmOC

At CEmOC:

12. Identification and management of foetal distress

Evidences of foetal distress in labour

Management: At BEmOC

At CEmOC

13. Fever after child birth (Puerperal pyrexia)

Fever (temperature >= 38° C or 100.4 F) more than 24 hours after delivery.

General Care:

Features:

Diagnosis: Puerperal sepsis (metritis)

Management: At BEmOC

At CEmOC

Note: Pelvic abscess – Lower abdominal pain and distension, persistent, spiking fever, tender swelling in fomix/POD, poor response to antibiotic.
Peritonitis Fever, severely ill, abdominal pain and distension, absent bowel sound, rebound tenderness, vomiting, shock, oliguria.

Features:

Diagnosis: Puerperal fever due to other cause.

Management:

Note: To prevent puerperal sepsis:

Guidelines, Source