[ { "content": "================================================== PAGE 1 ==================================================\nSLCOG Guideline \n \n SLCOG Guideline \n \n Intrapartum Fever \n \n J Karunasinghea on behalf of the Sri Lanka College of Obstetricians and Gynaecologists\n \n Correspondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo \n08.\n E-mail: slcogoffice@gmail.com", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_000", "page_number": 1, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 40, "chunk_size": 401 } }, { "content": "1. Scope and background \n a. Infectious causes \n This guideline is focused on the aetiologies, manage- \n b. Non-infectious causes \n ment, and potential consequences of intrapartum fever. \n a. Most common infection related aetiologies are\n Management of some of the specific causes of \n \n• Intraamniotic infection (IAI) \n intrapartum fever will be briefly discussed. Note that \n the scope of this guideline is restricted only to intra- \n• Urinary tract infection\n partum care. \n• Respiratory tract infection including H1N1\n influenza \n The guideline will not provide information about", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_001", "page_number": 1, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 82, "chunk_size": 583 } }, { "content": "influenza \n The guideline will not provide information about \n• Any other pre-existing infection which could\n management of septicaemia and Group B streptococcal present as fever during labour\n (GBS) infection in pregnancy (refer relevant guidelines). \n \n• Dengue fever and COVID-19 infection\n For detailed management of Dengue fever and \n which should be given special consideration\n COVID-19, please refer to the National Guidelines. \n during pandemics \n \n2. Summary of key recommendations b. Non-infectious causes \n \n• Use of neuraxial anaesthesia is the most\n 2.1 Definition", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_001", "page_number": 1, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 1, "word_count": 80, "chunk_size": 578 } }, { "content": "• Use of neuraxial anaesthesia is the most\n 2.1 Definition \n common cause of non-infectious cause of\n Intrapartum fever is defined as the elevation of fever at term. \n maternal oral temperature ≥39°C (≥102.2°F) on \n \n• Increased metabolism (eg: thyrotoxicosis),\n one reading or temperature between 38°C \n poor ventilation, delivering in an overheated\n (>100.4°F) to 39°C (102.2°F) on two readings 30 \n room and drug fever are considered as some\n minutes apart in a woman in labour\n1. \n other causes for intrapartum fever.\n Healthcare worker should measure oral temperature", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_001", "page_number": 1, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 572 } }, { "content": "1. \n other causes for intrapartum fever.\n Healthcare worker should measure oral temperature \n Patients with following factors are considered high\n of all women in labour 4 hourly or whenever they \n risk for intrapartum fever – \n show signs and symptoms of febrile illness. \n Temperature should be recorded in the partogram \n• Nulliparity \n routinely. Whenever high temperature is detected, \n• Labour induction \n it should be recorded in a separate temperature chart. \n \n• Prolonged labour \n \n• Premature labour \n 2.2 Aetiology \n \n• Prolonged membrane rupture", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_001", "page_number": 1, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 3, "word_count": 80, "chunk_size": 558 } }, { "content": "• Prolonged labour \n \n• Premature labour \n 2.2 Aetiology \n \n• Prolonged membrane rupture \n Intraamniotic infection (IAI) and neuraxial \n• Multiple digital vaginal examinations\n anaesthesia are the most common causes for \n• Exposure to intrauterine devices: – Intrau-\n intrapartum fever\n2. Aetiology of the intrapartum terine pressure devices/ Foetal scalp\n fever is classified into two categories. electrodes \n Sri Lanka Journal of Obstetrics and Gynaecology 2021; 43: 371-382 \n DOI: http://doi.org/10.4038/sljog.v43i4.8032", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_001", "page_number": 1, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 4, "word_count": 67, "chunk_size": 523 } }, { "content": "DOI: http://doi.org/10.4038/sljog.v43i4.8032 \n a Consultant Obstetrician and Gynaecologist, Castle Street Hospital for Women, Colombo, Sri Lanka\n This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which\n permits unrestricted use, distribution and reproduction in any medium provided the original author and source are credited.\n Vol. 43, No. 4, December 2021 371", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_001", "page_number": 1, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 5, "word_count": 57, "chunk_size": 433 } }, { "content": "================================================== PAGE 2 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_002", "page_number": 2, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "3. Diagnosis and investigations labour and the postpartum period. All healthcare\n professionals should have the knowledge to\n Careful history and systemic examination are required. \n identify the signs and symptoms of sepsis. In\n Special consideration should be given for abdominal \n case of suspected sepsis, a Modified Obstetric\n tenderness, vaginal examination including characteristic \n Early Warning Signs (MOEWS) chart should\n of amniotic fluid and odour. \n be maintained and the patient may need HDU or\n ICU care during the process of labour.\n Investigations", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_003", "page_number": 2, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 565 } }, { "content": "ICU care during the process of labour.\n Investigations \n \n• CTG (cardiotocograph) – All patients with\n intrapartum fever should have a continuous\n Investigations are based on suspected aetiology. \n foetal monitoring with CTG. \n However, there are no specific investigations for \n intrapartum fever. Usually full blood count (FBC), blood \n• General measures should be taken to reduce the\n culture, urine full report (UFR) and urine culture are body temperature by adequate hydration (IV/\n performed according to the suspected aetiology. High oral fluids), removing blankets and clothing,", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_003", "page_number": 2, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 586 } }, { "content": "performed according to the suspected aetiology. High oral fluids), removing blankets and clothing,\n applying a cool wet towel to the skin, lowering\n vaginal swab culture is usually done when there is \n the room temperature, and providing anti-\n evidence of premature rupture of membranes (PROM). \n pyretics like paracetamol. \n In endemic situations, rapid antigen for Dengue fever, \n H1N1 influenza and COVID-19 are vital for immediate \n• Mode of delivery and timing of delivery –\n management. Decisions for timing and mode of delivery\n should be made by the senior consultant", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_003", "page_number": 2, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 2, "word_count": 87, "chunk_size": 576 } }, { "content": "management. Decisions for timing and mode of delivery\n should be made by the senior consultant\n obstetrician considering the following factors\n Biological markers – Many systemic reviews done in \n intra-partum fever concluded that, measurement of a) Severity of maternal infection\n C-Reactive Protein (CRP) is unreliable for detecting b) Duration and stage of labour\n intrauterine infection\n3. c) Gestational age \n d) Foetal viability \n \n4. Management \n \n• There is no indication to deliver the foetus", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_003", "page_number": 2, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 3, "word_count": 72, "chunk_size": 501 } }, { "content": "d) Foetal viability \n \n4. Management \n \n• There is no indication to deliver the foetus\n \n• Senior obstetrician’s opinion should be obtained immediately unless the cause of the fever is\n suspected chorioamnionitis. \n in the management of all patients with \n intrapartum fever. It may be beneficial to have \n a multidisciplinary team approach involving the \n5. Management of specific infections\n Obstetrician, Microbiologist, Physician and the \n Management of Intraamniotic infection (Chorio-\n Anaesthetist. \n amnionitis or IAI) \n \n• Neonatology team should be notified and", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_003", "page_number": 2, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 4, "word_count": 78, "chunk_size": 571 } }, { "content": "Anaesthetist. \n amnionitis or IAI) \n \n• Neonatology team should be notified and \n IAI is defined as infection or inflammation of the\n involved for every case of intrapartum fever. amniotic fluid, membranes, placenta and/or decidua\n4.\n The presence of a senior medical officer from \n the neonatology team at the time of delivery is Diagnosis is based on maternal pyrexia 38°C\n the minimum requirement. (100.4°F) orally, and at least the presence of two of\n the following findings\n5. \n \n• Antibiotics – Usually broad-spectrum antibiotics \n \n• Maternal tachycardia (>100bpm)", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_003", "page_number": 2, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 5, "word_count": 85, "chunk_size": 572 } }, { "content": "5. \n \n• Antibiotics – Usually broad-spectrum antibiotics \n \n• Maternal tachycardia (>100bpm) \n with coverage of GBS (Group B streptococcus) \n is initiated in all patients except those with pre- \n• Foetal tachycardia (>160bpm)\n existing infection. Different antibiotic regimens \n• Uterine tenderness\n are used according to the hospital/unit policy \n• Foul odour of the amniotic fluid\n (See Table 1). \n \n• Maternal leukocytosis (>15,000cells/mm3)\n \n• All patients with intrapartum fever should have \n their pulse rate, blood pressure and respiratory Once the diagnosis of the IAI is made, commencement", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_003", "page_number": 2, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 6, "word_count": 84, "chunk_size": 599 } }, { "content": "rate checked every 15 minutes throughout the of broad-spectrum antibiotics and delivery is indicated.\n 372 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_003", "page_number": 2, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 7, "word_count": 22, "chunk_size": 154 } }, { "content": "================================================== PAGE 3 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_004", "page_number": 3, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "6. Maternal and neonatal consequences of contributing causes of intrapartum fever. Many risk\n intrapartum fever factors such as nulliparity, prolonged labour and\n premature rupture of membranes are common to both.\n An individualised approach involving a senior\n 6.1 Maternal consequences \n obstetrician is recommended for management of\n \n• Dysfunctional labour \n labour. In addition, some pre-existing conditions may\n \n• Greater likelihood of caesarean delivery require involvement of a multi-disciplinary team\n \n• Uterine atony management. \n \n• Postpartum haemorrhage", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 568 } }, { "content": "• Uterine atony management. \n \n• Postpartum haemorrhage \n \n8. Recommendations and discussions \n \n• Postpartum endometritis \n \n• Septic pelvic thrombophlebitis 8.1 Definition \n Intrapartum fever is defined as elevation of maternal\n 6.2 Neonatal consequences \n oral temperature 39°C (102.2°F) on one reading\n \n• Meconium Aspiration Syndrome or temperature between 38°C (>100.4°F) to 39°C\n \n• Hyaline Membrane Disease (HMD) (102.2°F) on two readings 30 minutes apart in a\n woman in labour. \n \n• Neonatal Seizures \n \n• Intrapartum stillbirth \n Health care worker should measure oral temperature", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 1, "word_count": 79, "chunk_size": 592 } }, { "content": "• Intrapartum stillbirth \n Health care worker should measure oral temperature\n \n• Early neonatal or infant death of all women in labour 4 hourly or whenever they show\n signs and symptoms of febrile illness. Temperature\n \n• Birth asphyxia \n should be recorded in the partogram routinely.\n \n• Neonatal encephalopathy  cerebral palsy \n Whenever high temperature is detected, it should be\n \n• Needing assisted ventilation \n recorded in a different temperature chart.\n \n7. Postpartum period Elevated body temperature will occur when the\n hypothalamic thermo regulator is reset at the higher", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 586 } }, { "content": "hypothalamic thermo regulator is reset at the higher\n Antibiotics started for confirmed or suspected \n temperature by the endogenous pyrogens produced\n intraamniotic infection should not be continued auto- \n by specific host cells in response to infection, inflam-\n matically in the postpartum period. Continuation of the \n mation, injury or antigenic challenge. In some\n antibiotic treatment should be decided on case-by-case \n instances, due to the inability to reset the thermo-\n basis considering the clinical state and the investi- \n regulatory centre, hyperthermia may occur. For", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 3, "word_count": 81, "chunk_size": 585 } }, { "content": "regulatory centre, hyperthermia may occur. For\n gations. Continuation of the temperature monitoring \n example, recreational drugs like ecstasy can lead to\n chart and close observation of the neonate is recom- \n increase in the core temperature by blocking the\n mended\n4. \n sweating or vasodilatation. In this chapter the term\n fever will be used to describe the rise in maternal\n 7.1 Introduction intrapartum temperature by any mechanism. Obser-\n vations of normal parturient shows a diurnal\n Fever during labour (intrapartum fever) is an important", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 4, "word_count": 80, "chunk_size": 548 } }, { "content": "Fever during labour (intrapartum fever) is an important \n distribution of temperature with a peak from midnight\n clinically relevant obstetric event associated with a \n to 2am and a nadir from 11am to noon\n7. \n range of maternal and neonatal complications. The \n prevalence of intrapartum fever has increased recently \n The temperature should be measured in the oral\n due to increase use of neuraxial anaesthesia. Studies \n sublingual pocket with an electronic thermometer,\n indicate 6.8 percent or 1 in 15 women in labour have \n since this is an accurate and convenient method for\n fever", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 5, "word_count": 90, "chunk_size": 588 } }, { "content": "since this is an accurate and convenient method for\n fever\n6. detecting maternal fever. Mouth breathing, hyper-\n ventilation, ingestion of ice or hot beverages and\n Even though there can be both infectious and non- oxygen administration can affect the oral temperature.\n infectious contributing causes, most pregnant women Temperature measurement should be undertaken at\n with intrapartum fever are presumed to have an least 15 minutes after consuming hot or cold\n intraamniotic infection (IAI) and are managed with beverages\n8. Measurement of axillary temperature will", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 6, "word_count": 83, "chunk_size": 569 } }, { "content": "8. Measurement of axillary temperature will\n broad spectrum antibiotics. IAI and neuraxial have an error of 1°C-2°C lower than the oral\n anaesthesia administration are the two most common temperature\n9. \n Vol. 43, No. 4, December 2021 373", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 7, "word_count": 37, "chunk_size": 238 } }, { "content": "================================================== PAGE 4 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_006", "page_number": 4, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Oral temperature is correlated better with intrauterine longer labour and likely to have intrapartum fever than\n core temperature according to one study. Foetal/ multiparous (risk 13-33%)\n21. There is no difference in\n intrauterine temperature is 0.2°C-0.9°C (0.4°F- the maternal temperature elevation in parturient who\n 1.6°F) higher than maternal oral temperature8,10-\n13. receive CSE (combined spinal and epidural anaesthesia)\n compared to epidural alone. There is no known\n 8.2 Aetiology and risk factors effective method to prevent neuraxial anaesthesia\n related temperature elevation.", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_007", "page_number": 4, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 80, "chunk_size": 590 } }, { "content": "related temperature elevation. \n IAI and neuraxial anaesthesia are the most common \n causes for intra-partum fever. \n Patients with following factors are considered high\n Aetiology of the intrapartum fever is classified into risk for intrapartum fever –\n two categories. \n \n• Nulliparity \n a. Infectious causes \n• Labour induction \n b. Non-infectious causes \n• Prolonged labour \n \n• Premature labour \n a. Most common infection related aetiologies are \n \n• Prolonged membrane rupture \n \n• Intra-amniotic infection (IAI) \n \n• Multiple digital vaginal examinations\n \n• Urinary tract infection", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_007", "page_number": 4, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 1, "word_count": 78, "chunk_size": 589 } }, { "content": "• Multiple digital vaginal examinations\n \n• Urinary tract infection \n \n• Exposure to intrauterine devices: – Intrauterine\n \n• Respiratory tract infection \n pressure devices – Foetal scalp electrodes\n \n• Any other pre-existing infection which could \n be present as fever during labour However above-mentioned conditions are risk factors\n \n• Special consideration should be given to dengue for both IAI and neuraxial anaesthesia. Since there are\n fever and COVID-19 infection no intrapartum clinical or laboratory findings that can\n reliably distinguish IAI and neuraxial anaesthesia related", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_007", "page_number": 4, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 2, "word_count": 81, "chunk_size": 589 } }, { "content": "reliably distinguish IAI and neuraxial anaesthesia related\n b. Use of neuraxial anaesthesia is the most common elevated maternal temperature, broad spectrum anti-\n non-infectious cause of intrapartum fever. biotics are usually administered in this situation,\n resulting in overtreatment of mothers. \n Increased metabolism (eg: thyrotoxicosis), poor \n ventilation, delivering in an overheated room and drug \n Other sources of fever could be due to urinary tract\n fever are also considered as some other causes for \n infection, respiratory tract infection, influenza, pneu-\n intrapartum fever.", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_007", "page_number": 4, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 3, "word_count": 79, "chunk_size": 591 } }, { "content": "infection, respiratory tract infection, influenza, pneu-\n intrapartum fever. \n monia and appendicitis that began during the\n antepartum period. \n The pathophysiology of the intra-partum fever \n associated with neuraxial anaesthesia is not well \n 8.3 Diagnosis and investigations \n understood. It has been attributed to – \n \n• Direct effect of local anaesthetics on endothelial Careful history and systemic examination are required.\n cells, trophoblast cells or leukocytes to induce Special consideration should be given for abdominal", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_007", "page_number": 4, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 4, "word_count": 70, "chunk_size": 533 } }, { "content": "proinflammatory or inhibit anti-inflammatory tenderness, vaginal examination including characteristic\n cytokines release, which will act on thermo- of amniotic fluid and odour.\n regulatory centre to reset the temperature14-\n18. \n \n• Both neuraxial anaesthesia and IAI share same Investigations are based on suspected aetiology.\n risk factors. However, there are no specific investigations for intra-\n partum fever. Usually full blood count (FBC), blood\n \n• Reduced heat loss – parturient with epidural \n culture, urine full report (UFR) and urine culture are", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_007", "page_number": 4, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 5, "word_count": 77, "chunk_size": 558 } }, { "content": "culture, urine full report (UFR) and urine culture are\n anaesthesia have less pain induced hyper- \n performed according to the suspected aetiology. High\n ventilation and less perspiration because of \n vaginal swab culture is usually done when there is\n sympathetic block\n2. \n evidence of premature rupture of membranes (PROM).\n In general, increased in temperature >38°C is usually In endemic situations, rapid antigen for Dengue fever,\n observed 4 hours following insertion of epidural H1N1 influenza and COVID-19 are vital for immediate\n anaesthesia19,", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_007", "page_number": 4, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 6, "word_count": 79, "chunk_size": 554 } }, { "content": "anaesthesia19,\n20. Nulliparous are more likely to have management. \n 374 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_007", "page_number": 4, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 7, "word_count": 17, "chunk_size": 120 } }, { "content": "================================================== PAGE 5 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_008", "page_number": 5, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Biological markers – Many systemic reviews done the NS1 antigen is important since early\n in intra-partum fever concluded that, measurement of intervention with proper fluid management is\n C-Reactive Protein (CRP) is unreliable for detecting necessary. \n intra-uterine infection\n3. \n In suspected COVID-19 infection, rapid antigen\n test is strongly recommended, because symp-\n \n• White Blood Cell count/ Differential count \n tomatic or asymptomatic patients in endemic\n (WBC/DC) – It is recommended to take WBC/ \n situation need early isolation in the management.", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 78, "chunk_size": 563 } }, { "content": "(WBC/DC) – It is recommended to take WBC/ \n situation need early isolation in the management.\n DC in labouring women who are clinically ill or \n Real time PCR has a value if available, for patients\n having a high temperature. Since elevated WBC \n who are found to be having fever despite negative\n count is a normal physiological occurrence in \n Rapid antigen. \n labour, the value of this is limited. The mean \n values of WBC count vary from 10,000 - 29,000 \n \n• High vaginal swab – It is routinely taken in\n cells/microlitre. Usually, the mean count \n women with PROM. Positive culture for", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 1, "word_count": 98, "chunk_size": 590 } }, { "content": "cells/microlitre. Usually, the mean count \n women with PROM. Positive culture for\n increases linearly throughout the labour\n22. With \n potential pathogens does not correlate well with\n other evidence of infection, the presence of \n the risk, or developing chorioamnionitis; how-\n leukocytosis will support the diagnosis, \n ever, they are useful in determining the organisms\n especially when accompanied by a left shift. \n when the chorioamnionitis is diagnosed and\n directing the antibiotic therapy. \n \n• Blood culture – Even though there is no imme-", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 2, "word_count": 78, "chunk_size": 550 } }, { "content": "directing the antibiotic therapy. \n \n• Blood culture – Even though there is no imme- \n diate benefit of doing blood culture in intrapartum \n women, it will be useful for the subsequent 8.4 Management of intra-partum fever\n management as appropriate antibiotic therapy is \n Senior obstetrician’s opinion should be obtained in the\n important in patients with bacteraemia, for the \n management of all patients with intrapartum fever. It\n prevention of progressing to sepsis and shock. \n may be beneficial to have a multidisciplinary team\n It is highly recommended to obtain the blood", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 3, "word_count": 87, "chunk_size": 580 } }, { "content": "may be beneficial to have a multidisciplinary team\n It is highly recommended to obtain the blood \n approach involving the Obstetrician, Microbiologist,\n cultures from the patients with following \n Physician and the Anaesthetist. \n features23,\n24. \n Neonatology team should be notified and involved for\n \n• Fever >39°C (102.2°F) \n every case of intrapartum fever. The presence of a\n \n• Chills senior medical officer from the neonatology team at\n \n• Hypothermia the time of delivery is the minimum requirement.\n \n• Leukocytosis with left shift \n Antibiotics – Usually broad-spectrum antibiotics with", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 4, "word_count": 85, "chunk_size": 597 } }, { "content": "• Leukocytosis with left shift \n Antibiotics – Usually broad-spectrum antibiotics with\n \n• Neutropenia \n coverage of GBS (Group B streptococcus) is initiated\n \n• Development of otherwise unexplained organ in all patients except those with pre-existing infection.\n dysfunction Different antibiotic regimens are used according to the\n hospital/unit policy. \n Usually, blood cultures are not routinely performed in \n patients with suspected IAI as delivery and empirical All patients with intrapartum fever should have their", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 5, "word_count": 70, "chunk_size": 521 } }, { "content": "antibiotic therapy is effective in 80-90% of these pulse rate, blood pressure and respiratory rate checked\n patients. every 15 mins throughout the labour and the postpartum\n period. All healthcare professionals should know the\n \n• Urine tests – Urinary dipstick is important in a signs and symptoms of sepsis. In case of sepsis, patient\n labouring woman for the rapid diagnosis of a may need HDU or ICU care. In case of suspected\n urinary tract infection. This is easy to perform, sepsis, a Modified Obstetric Early Warning Signs", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 6, "word_count": 86, "chunk_size": 529 } }, { "content": "urinary tract infection. This is easy to perform, sepsis, a Modified Obstetric Early Warning Signs\n convenient and low cost. Sample could be (MOEWS) chart should be maintained and the patient\n obtained from a clean catch midstream urine, may need HDU or ICU care during the process of\n straight catheter, or an indwelling catheter. Urine labour. \n culture is important when the patient is clinically \n ill, but not practical as a first line diagnosis test. Clinical signs and symptoms of sepsis are – pyrexia,\n hypothermia, tachycardia, tachypnoea, hypoxia,", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 7, "word_count": 86, "chunk_size": 557 } }, { "content": "hypothermia, tachycardia, tachypnoea, hypoxia,\n \n• Rapid antigen test – In dengue fever detecting hypotension, oliguria, impaired consciousness and\n Vol. 43, No. 4, December 2021 375", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 8, "word_count": 25, "chunk_size": 182 } }, { "content": "================================================== PAGE 6 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_010", "page_number": 6, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "failure to respond to treatment. These signs including 8.5 Management of specific infections\n pyrexia, may not always be present and are not \n Management of Intra-amniotic infection (Chorioa-\n necessarily related to the severity of the sepsis\n25. Refer \n mnionitis or IAI). \n to quick Sequential Organ Failure Assessment (qSOFA) \n score for early detection of suspected patients with \n IAI is defined as infection or inflammation of the\n sepsis Table \n2. \n amniotic fluid, membranes, placenta and/or decidua.\n CTG (cardiotocograph) \n Diagnosis is based on maternal pyrexia 38°C", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 82, "chunk_size": 578 } }, { "content": "CTG (cardiotocograph) \n Diagnosis is based on maternal pyrexia 38°C\n (100.4°F) orally, and at least the presence of two of\n All patients with intrapartum fever should have a \n the following findings \n continuous foetal monitoring with CTG. \n \n• Maternal tachycardia (>100bpm) \n Intrauterine infection is associated with abnormal foetal \n \n• Foetal tachycardia (>160bpm) \n heart trace, but there is no specific CTG pattern that \n indicate early onset neonatal sepsis. \n• Uterine tenderness \n \n• Foul odour of the amniotic fluid \n Foetal tachycardia may occur due to maternal pyrexia", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 582 } }, { "content": "• Foul odour of the amniotic fluid \n Foetal tachycardia may occur due to maternal pyrexia \n or intrauterine infection. If Foetal tachycardia occurred \n• Maternal leukocytosis (>15,000cells/mm3)\n secondary to maternal pyrexia, foetal tachycardia will \n subside once the normalisation of the maternal tem- Other clinical and laboratory criteria are insensitive for\n perature is achieved. IAI. \n Changes in baseline variability or new onset decele- “Triple I” is another terminology proposed by an\n rations must prompt measurement of maternal mean expert panel in 2015, replacing IAI, which indicate", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 596 } }, { "content": "arterial pressure (MAP), hypoxia and acidaemia. intra uterine infection, inflammation or both1, \n27. The\n organisms involved in the chorioamnionitis usually\n General measures present in the lower genital tract. \n Measures should be taken to reduce the body tem- \n Usually, a presumptive diagnosis is made depending\n perature by adequate hydrations (IV/oral fluids), \n on the above findings. However, for the definitive\n removing blankets and clothing, applying a cool wet \n diagnosis of IAI amniotic fluid gram stain, culture or\n towel to the skin, lowering the room temperature and", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 3, "word_count": 84, "chunk_size": 582 } }, { "content": "towel to the skin, lowering the room temperature and \n placental histology showing features of an infection is\n providing anti-pyretics like paracetamol. \n necessary. \n Mode of delivery and timing of delivery – Decisions Even though the positive amniotic fluid culture is the\n for timing and mode of delivery should be made by gold standard for the diagnosis, it is of limited value in\n the senior consultant obstetrician considering the clinical practice as the results may not be available for\n following factors up to 3 days from sampling. Maternal C-Reactive", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 4, "word_count": 87, "chunk_size": 562 } }, { "content": "following factors up to 3 days from sampling. Maternal C-Reactive\n protein and Leukocytosis have low sensitivity and\n a) Severity of maternal infection \n specificity to detect the chorioamnionitis. Combination\n b) Duration and stage of labour of maternal blood and amniotic fluid biomarkers\n (interleukin 6 >7.9ng/ml, Glucose <15mg/dl) could\n c) Gestational age \n improve the accuracy of the diagnosis. Ultrasono-\n d) Foetal viability graphic evaluation of the foetal thymus is more\n sensitive to diagnose chorioamnionitis than the foetal", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 5, "word_count": 75, "chunk_size": 538 } }, { "content": "sensitive to diagnose chorioamnionitis than the foetal\n There is no indication to deliver the foetus immediately biophysical profile\n26. Foetuses complicated with\n unless the cause of the fever is suspected chorioa- chorioamnionitis were found to have small thymus in\n mnionitis. ultrasound scan. \n Expediting the delivery with maternal instability may Delivery is indicated once the diagnosis of intraamniotic\n increase the risk of maternal and foetal mortality unless infection is made. It is also important to treat with", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 6, "word_count": 76, "chunk_size": 523 } }, { "content": "the infection is intrauterine. broad-spectrum antibiotics with the coverage of group\n 376 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 7, "word_count": 19, "chunk_size": 137 } }, { "content": "================================================== PAGE 7 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_012", "page_number": 7, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "B streptococcus to reduce the maternal and neonatal Patient with severe lower respiratory tract infection\n morbidity. Patient should initially be started on intra- may need to be positioned comfortably in propped-up\n venous antibiotics\n2. See the Table 1 below for regimens (Fowler’s) position. They need close monitoring of\n of antibiotic combinations. vital signs, especially the respiratory rate and oxygen\n saturation. Patients with severe respiratory failure may\n Usually, the IAI is associated with labour abnormalities, \n need transferring to intensive care unit (ICU) and early", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_013", "page_number": 7, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 83, "chunk_size": 585 } }, { "content": "need transferring to intensive care unit (ICU) and early\n caesarean section, uterine atony, PPH, endometritis and \n delivery. \n septic pelvic thrombophlebitis. Chorioamnionitis is very \n important as it can lead serious maternal complications \n Management of dengue fever \n such as septic shock, postpartum haemorrhage, adult \n respiratory syndrome, intensive care admissions and \n The management of dengue fever depends on the phase\n rarely maternal death. Forty – seventy percent of pre- \n of the fever. Patients in the critical or leaking phase,", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_013", "page_number": 7, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 1, "word_count": 76, "chunk_size": 548 } }, { "content": "of the fever. Patients in the critical or leaking phase,\n term birth and 1-13% of term births with preterm \n are considered in the high-risk category and need to\n rupture of membranes or spontaneous labour are \n be managed in an ICU setting during labour. (See\n complicated with chorioamnionitis\n28. Early onset \n National guidelines on dengue fever in pregnancy).\n neonatal meningitis, neurodevelopment delay, \n pneumonia, respiratory distress, sepsis and death are \n some of the neonatal complications of IAI. Management of COVID-19 \n In a pandemic situation patient may present without", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_013", "page_number": 7, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 588 } }, { "content": "In a pandemic situation patient may present without\n Management of UTI any symptoms or fever. Therefore, all patients presen-\n ting to labour suite may need a COVID-19 screening\n Urinary tract infections are common during pregnancy. \n The presence of fever, flank tenderness, nausea, with Rapid antigen or Real time PCR.\n vomiting, costo-vertebral angle tenderness, with or \n without lower urinary tract symptoms like – dysuria, Early diagnosis and patient isolation at the appropriate\n frequency, urgency, suprapubic pain and haematuria, setting is of paramount importance, with adequate", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_013", "page_number": 7, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 3, "word_count": 84, "chunk_size": 588 } }, { "content": "may indicate the presence of upper or complicated personal protective equipment (PPE). Maternal pulse\n urinary tract infection. Simple cystitis may present rate, blood pressure, respiratory rate and oxygen\n without fever. Empirical antibiotic treatment is indicated saturation should be monitored throughout the labour.\n for UTI. Commencement of the antibiotic regimen is \n customised according to the unit/hospital policy. This \n Decision making in labour should be precise to avoid\n may need to be changed according to the sensitivity \n obstetric emergencies, since the delay is anticipated in", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_013", "page_number": 7, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 4, "word_count": 83, "chunk_size": 595 } }, { "content": "obstetric emergencies, since the delay is anticipated in\n pattern of the urine culture and clinical response later. \n transferring, organising and performing procedures\n with adequate isolation and personal protective\n Management of respiratory tract infection \n equipments (PPE). Patients who are on prophylaxis\n Upper respiratory tract infections will present with enoxaparin should be discontinued of it, 12 hours before\n nasal congestion, rhinorrhoea, sore throat, malaise and the onset of labour or induction. (see the national", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_013", "page_number": 7, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 5, "word_count": 72, "chunk_size": 532 } }, { "content": "cough. Fever, if present is usually of low grade. These guideline on Management of COVID-19 infection in\n patients do not need any specific antibiotics, except pregnancy). \n for symptomatic management and simple antipyretics. \n If the patient present with sudden onset rigors followed \n 8.6 Maternal and neonatal consequences of\n by fever, productive cough, purulent sputum and \n intrapartum fever \n pleuritic chest pain high possibility of pneumonia \n should be considered. Treatment and management are Neonatal consequences \n similar to the non-pregnant individual, but chest", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_013", "page_number": 7, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 6, "word_count": 79, "chunk_size": 577 } }, { "content": "similar to the non-pregnant individual, but chest \n \n• Meconium Aspiration Syndrome \n X-Ray could be delayed until after delivery. Pregnant \n mothers can be treated safely with Azithromycin or/ \n \n• Hyaline Membrane Disease (HMD) \n and Ceftriaxone. \n \n• Neonatal Seizures \n Antiviral prophylaxis should commence immediately \n \n• Intrapartum stillbirth \n if indicated for mothers suspected to have H1N1 \n influenza. \n• Early neonatal or infant death \n Vol. 43, No. 4, December 2021 377", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_013", "page_number": 7, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 7, "word_count": 67, "chunk_size": 484 } }, { "content": "================================================== PAGE 8 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_014", "page_number": 8, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "• Birth asphyxia \n• Postpartum endometritis \n \n \n• Neonatal encephalopathy and cerebral palsy \n• Septic pelvic thrombophlebitis\n \n• Needing assisted ventilation \n Maternal outcome depends on the causes of the\n When the labouring woman is having fever, peripartum intrapartum fever. Almost all the women with\n transfer of the infection to the fetus is one the major intrapartum fever are likely to receive antibiotics. One\n concerns. The presence of intraamniotic infection can study indicated that even low risk nulliparous women", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_015", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 77, "chunk_size": 529 } }, { "content": "give rise to short term effects to the new-born like with intrapartum fever have double the chance of\n septicaemia, meningitis and pneumonia. Long term requiring a caesarean delivery or assisted vaginal\n outcomes are cerebral palsy and neurodevelopmental delivery than those without intrapartum fever regardless\n delay. of receiving neuraxial anaesthesia\n32. \n \n Once the micro-organisms enter the foetal mucosa, it \n9. Clinical governance\n \n induces a localised and subsequently a systemic \n Possibility of chorioamnionitis should be suspected\n inflammatory response called foetal inflammatory", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_015", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 1, "word_count": 79, "chunk_size": 594 } }, { "content": "inflammatory response called foetal inflammatory \n whenever a woman in labour develop fever as it is a\n response syndrome (FIRS). FIRS affect multiple organ \n condition associated with high perinatal morbidity and\n functions including the hematopoietic system, immune \n mortality. All measures should be taken to prevent the\n system, thymus heart, adrenal glands, skin, lung, brain \n occurrence of chorioamnionitis. \n and gut29,\n30. \n \n• Optimum sterility should be maintained during\n There is no definite method to differentiate intrapartum vaginal examinations and procedures like artificial", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_015", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 2, "word_count": 80, "chunk_size": 593 } }, { "content": "rupture of membranes, membrane sweeping,\n fever due to neuraxial anaesthesia from chorio- \n Foley catheter insertion etc. \n amnionitis. Hence, there is increased tendency for \n neonatal sepsis screening and treating with antibiotics. \n• Minimise the number of vaginal examinations,\n However, fever due to neuraxial anaesthesia is not especially for those with prelabour rupture of\n associated with increased rate of proven sepsis. But, membranes and those who are in labour.\n even in the absence of documented infection, neuraxial \n \n• Plan the vaginal examination in such a way that", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_015", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 3, "word_count": 85, "chunk_size": 583 } }, { "content": "• Plan the vaginal examination in such a way that\n anaesthesia related intra-partum pyrexia may be \n only the decision-making staff member will\n associated with adverse neonatal outcome. When the \n perform it. Avoid repeated vaginal examinations\n mother is having temperature during labour, neonate \n done by different categories of staff in short\n should be closely observed for sepsis. Especially \n intervals. \n neonates with low birth weight, prematurity, and \n hypothermia at birth, maternal Group B streptococcal \n All mothers with intrapartum fever should have their", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_015", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 4, "word_count": 80, "chunk_size": 572 } }, { "content": "All mothers with intrapartum fever should have their\n colonization, preeclampsia and maternal hypertension \n management discussed with the senior obstetrician and\n should have a full septic screening\n31. should also get neonatal team involvement.\n Maternal consequences All mothers who are suspected of having\n chorioamnionitis should be counselled regarding their\n \n• Labour abnormalities (dysfunctional labour) \n management and possible neonatal consequences.\n \n• Greater likelihood of caesarean delivery \n Maintenance of partogram and MOEWS chart in\n \n• Uterine atony", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_015", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 5, "word_count": 74, "chunk_size": 570 } }, { "content": "Maintenance of partogram and MOEWS chart in\n \n• Uterine atony \n suspected sepsis are of paramount importance in the\n \n• Postpartum haemorrhage management. \n 378 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_015", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 6, "word_count": 30, "chunk_size": 208 } }, { "content": "================================================== PAGE 9 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_016", "page_number": 9, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Annexure \n1. Intrapartum fever management algorithm", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_017", "page_number": 9, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 51 } }, { "content": "================================================== PAGE 10 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_018", "page_number": 9, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 125 } }, { "content": "Table \n1. Different antibiotic regimens to be used in intrapartum fever\n \n Regimen Doses \n \n \n1. Ampicillin and Gentamycin Ampicillin IV 2g every 6 h and Gentamicin 2mg/kg\n IV load followed by 1.5mg/kg 8 h or 5mg/kg IV\n every 24 h \n \n \n2. Cefuroxime + Metronidazole Cefuroxime 750mg IV 8 h + Metronidazole 500mg\n IV 8 h \n \n \n3. Ceftriaxone, Metronidazole and clarithromycin Ceftrixone 1g IV every 24 h, Metronidazole IV\n 500mg every 8 h, and clarithromycin 500mg oral\n every 12 h \n \n \n4. Ampicillin and Azithromycin Ampicillin 1.5g IV every 6 h and Azithromycin oral\n 500mg every 24 h", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_019", "page_number": 9, "content_type": "medication_dosage", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 95, "chunk_size": 584 } }, { "content": "500mg every 24 h \n \n \n5. Ampicillin 3g IV every 6 \n \n \n6. Piperacillin-Tazobactum 4.5g IV every 8 h \n \n \n7. Ertapenem 1g IV every 24 h \n \n \n8. Mild penicillin allergy – Cefuroxime and Cefuroxime 1.5g loading dose,750mg 8 h and\n Gentamycin Gentamicin 2mg/kg IV load followed by 1.5mg /kg\n every 8 h or 5mg/kg IV every 24 h \n \n \n9. For severe penicillin allergy – Clindamycin Clindamycin 600-800mg IV every 8h or Vancomycin\n or Vancomycin and Gentamicin 1g IV every 12h (slow infusion over 1 hr) and\n Gentamycin 2mg/kg IV load followed by 1.5 mg/kg\n every 8 h or 5mg/kg IV every 24 h", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_019", "page_number": 9, "content_type": "medication_dosage", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 1, "word_count": 101, "chunk_size": 581 } }, { "content": "Gentamycin 2mg/kg IV load followed by 1.5 mg/kg\n every 8 h or 5mg/kg IV every 24 h \n \n IV- Intravenous, h - hourly", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_019", "page_number": 9, "content_type": "medication_dosage", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 2, "word_count": 22, "chunk_size": 114 } }, { "content": "Table \n2. qSOFA scoring \n \n Parameter Value Score \n \n Blood pressure < 100mmHg 1 \n \n Respiratory rate > 22 bpm 1 \n Level of consciousness GCS < 15 1 \n \n Score of 2 or more: suggestive of sepsis", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_020", "page_number": 9, "content_type": "general", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 33, "chunk_size": 193 } }, { "content": "380 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_021", "page_number": 9, "content_type": "general", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 51 } }, { "content": "================================================== PAGE 11 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_022", "page_number": 9, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 125 } }, { "content": "References human fetus. J Obstet Gynaecol Br Commonw\n 1969; 76: \n503. \n \n1. Higgins RD, Saade G, Polin RA, Grobman WA, \n Buhimschi IA, Watterberg K, et al. Evaluation and \n14. Smulian JC, Bhandari V, Vintzileos AM, et al.\n management of women and newborns with a Intrapartum fever at term: serum and histologic\n maternal diagnosis of chorioamnionitis: Summary markers of inflammation. Am J Obstet Gynecol\n of a Workshop. Obstet Gynecol. 2016; 127(3): 2003; 188: \n269. \n 426-\n36. \n \n15. Goetzl L, Evans T, Rivers J, et al. Elevated maternal", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_023", "page_number": 9, "content_type": "maternal_care", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 86, "chunk_size": 539 } }, { "content": "269. \n 426-\n36. \n \n15. Goetzl L, Evans T, Rivers J, et al. Elevated maternal\n \n2. Katherine TC. Intrapartum fever. In: Up To Date, and fetal serum interleukin-6 levels are associated\n Vincenzo B (Ed), David LH (Ed), Up To Date, with epidural fever. Am J Obstet Gynecol 2002;\n Waltham, MA. (Accessed on July 20, 2021.) 187: \n834. \n \n3. Evers AC, Nijhuis L, Koster MP, Bont LJ, Visser \n16. De Jongh RF, Bosmans EP, Puylaert MJ, et al.\n The influence of anaesthetic techniques and type\n GH. Intrapartum fever at term: diagnostic markers \n of delivery on peripartum serum interleukin-6", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_023", "page_number": 9, "content_type": "maternal_care", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 1, "word_count": 96, "chunk_size": 581 } }, { "content": "GH. Intrapartum fever at term: diagnostic markers \n of delivery on peripartum serum interleukin-6\n to individualize the risk of fetal infection: a review. \n concentrations. Acta Anaesthesiol Scand 1997; 41:\n Obstet Gynecol Surv. 2012; 67(3): \n187. \n \n853. \n \n4. Committee on Obstetric. Practice Committee \n \n17. Sultan P, David AL, Fernando R, Ackland GL.\n Opinion No. \n712. Intrapartum management of \n Inflammation and epidural-related maternal fever:\n intraamniotic infection. Obstet Gynecol 2017; \n proposed mechanisms. Anesth Analg 2016; 122:\n 130(2): e95-e\n101. \n \n1546.", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_023", "page_number": 9, "content_type": "maternal_care", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 2, "word_count": 76, "chunk_size": 575 } }, { "content": "proposed mechanisms. Anesth Analg 2016; 122:\n 130(2): e95-e\n101. \n \n1546. \n \n5. Newton ER. Chorioamnionitis and intraamniotic \n \n18. Wohlrab P, Boehme S, Kaun C, et al. Ropivacaine\n infection. Clin Obstet Gynecol 1993; 36: \n795. \n activates multiple proapoptotic and inflammatory\n \n6. Towers CV, Yates A, Zite N, et al. Incidence of signaling pathways that might subsume to trigger\n fever in labor and risk of neonatal sepsis. Am J epidural-related maternal fever. Anesth Analg 2020;\n Obstet Gynecol 2017; 216: 596.e\n1. 130: \n321. \n \n7. Acker DB, Schulman EB, Ransil BJ, et al. The", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_023", "page_number": 9, "content_type": "maternal_care", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 3, "word_count": 90, "chunk_size": 581 } }, { "content": "Obstet Gynecol 2017; 216: 596.e\n1. 130: \n321. \n \n7. Acker DB, Schulman EB, Ransil BJ, et al. The \n19. Lieberman E, Lang JM, Frigoletto F Jr, et al.\n normal parturient’s admission temperature. Am J Epidural analgesia, intrapartum fever, and neonatal\n Obstet Gynecol 1987; 157: \n308. sepsis evaluation. Pediatrics 1997; 99: \n415.\n \n8. Banerjee S, Cashman P, Yentis SM, Steer PJ. \n20. Goetzl L, Rivers J, Zighelboim I, et al. Intrapartum\n epidural analgesia and maternal temperature\n Maternal temperature monitoring during labor: \n regulation. Obstet Gynecol 2007; 109: \n687.", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_023", "page_number": 9, "content_type": "maternal_care", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 4, "word_count": 86, "chunk_size": 572 } }, { "content": "Maternal temperature monitoring during labor: \n regulation. Obstet Gynecol 2007; 109: \n687.\n concordance and variability among monitoring \n sites. Obstet Gynecol 2004; 103: \n287. \n21. Goetzl L. Epidural analgesia and maternal fever: a\n clinical and research update. Curr Opin\n \n9. Wartzek T, Mühlsteff J, Imhoff M. Temperature \n Anaesthesiol 2012; 25: \n292. \n measurement. Biomed Tech (Berl) 2011; 56: \n241. \n \n22. Acker DB, Johnson MP, Sachs BP, Friedman EA.\n \n10. Sciscione AC, Zainia T, Leet T, et al. A new device \n The leukocyte count in labor. Am J Obstet Gynecol", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_023", "page_number": 9, "content_type": "maternal_care", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 5, "word_count": 86, "chunk_size": 569 } }, { "content": "The leukocyte count in labor. Am J Obstet Gynecol\n for measuring intrauterine temperature. Am J \n 1985; 153: \n737. \n Obstet Gynecol 2001; 184: \n1431. \n \n23. Bates DW, Sands K, Miller E, et al. Predicting\n \n11. Macaulay JH, Randall NR, Bond K, Steer PJ. \n bacteremia in patients with sepsis syndrome.\n Continuous monitoring of fetal temperature by \n Academic Medical Center Consortium Sepsis\n non-invasive probe and its relationship to maternal \n Project Working Group. J Infect Dis 1997; 176:\n temperature, fetal heart rate, and cord arterial \n \n1538. \n oxygen and pH. Obstet Gynecol 1992; 79:", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_023", "page_number": 9, "content_type": "maternal_care", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 6, "word_count": 89, "chunk_size": 593 } }, { "content": "1538. \n oxygen and pH. Obstet Gynecol 1992; 79: \n469. \n \n24. Smith-Elekes S, Weinstein MP. Blood cultures.\n \n12. Adamson SK Jr, Towell ME. Thermal Homeostasis \n Infect Dis Clin North Am 1993; 7: \n221.\n in the fetus and newborn. Anesthesiology 1965; \n 26: \n531. \n25. Royal College of Obstetricians and Gynaecologists.\n Bacterial Sepsis in Pregnancy. Green-top Guideline\n \n13. Walker D, Walker A, Wood C. Temperature of the No. 64a. London: RCOG; \n2012.\n Vol. 43, No. 4, December 2021 381", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_023", "page_number": 9, "content_type": "maternal_care", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 7, "word_count": 76, "chunk_size": 486 } }, { "content": "================================================== PAGE 12 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_024", "page_number": 10, "content_type": "guidelines", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 125 } }, { "content": "26. Catańo Sabogal CP, Fonseca J, Garcķa-Perdomo features, and clinical significance. Am J Obstet\n HA. Validation of diagnostic tests for histologic Gynecol 2015; 213(4 Suppl): S29-S\n52.\n chorioamnionitis: systematic review and meta- \n \n30. Gotsch F, Romero R, Kusanovic JP, et al. The\n analysis. Eur J Obstet Gynecol Reprod Biol 2018; \n fetal inflammatory response syndrome. Clin Obstet\n 228: 13-\n26. \n Gynecol 2007; 50(3): 652-\n83. \n \n27. Ona S, Easter SR, Prabhu M, et al. Diagnostic \n \n31. Paules C, Moreno E, Gonzales A, et al. Amniotic\n validity of the proposed eunice kennedy shriver", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_025", "page_number": 10, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 91, "chunk_size": 590 } }, { "content": "validity of the proposed eunice kennedy shriver \n fluid sludge as a marker of intra-amniotic infection\n national institute of child health and human \n and histological chorioamnionitis in cervical\n development criteria for intrauterine inflammation \n insufficiency: a report of four cases and literature\n or infection. Obstet Gynecol 2019; 133(1): 33-\n9. \n review. J Matern Fetal Neonatal Med 2016; 29(16):\n \n28. Tita AT, Andrews WW. Diagnosis and management 2681-\n4. \n of clinical chorioamnionitis. Clin Perinatol 2010; \n \n32. American Association of Pro-Life Obstetricians\n 37(2): 339-\n54.", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_025", "page_number": 10, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 591 } }, { "content": "32. American Association of Pro-Life Obstetricians\n 37(2): 339-\n54. \n Gynecologists. AAPLOG practice bulletin no. 3:\n \n29. Kim CJ, Romero R, Chaemsaithong P, et al. Acute previable induction of labor for chorioamnitis.\n chorioamnionitis and funisitis: definition, pathologic Issues Law Med 2018; 33(2): 247-\n56.", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_025", "page_number": 10, "content_type": "clinical_protocol", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 2, "word_count": 43, "chunk_size": 311 } }, { "content": "382 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Intrapartum-fever-Dec-4.pdf", "section": "Section_026", "page_number": 10, "content_type": "general", "source_file": "Intrapartum-fever-Dec-4.pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 51 } }, { "content": "================================================== PAGE 1 ==================================================\nHyperglycaemia", "metadata": { "document_name": "abc.pdf", "section": "Section_000", "page_number": 1, "content_type": "general", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 5, "chunk_size": 123 } }, { "content": "Sri Lanka College of Endocrinologists \n Sri Lanka College of Obstetricians and Gynaecologists \n \n Ceylon College of Physicians \n \n Sri Lanka Medical Nutrition Association \n College of Chemical Pathologists of Sri Lanka", "metadata": { "document_name": "abc.pdf", "section": "Section_001", "page_number": 1, "content_type": "general", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 28, "chunk_size": 218 } }, { "content": "================================================== PAGE 2 ==================================================\nHyperglycaemia in Pregnancy", "metadata": { "document_name": "abc.pdf", "section": "Section_002", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 7, "chunk_size": 136 } }, { "content": "Page No \n \n Recommendation 1 -Screening of pre-gestational Diabetes…… 3 \n \n Recommendation 2 –Preconception care for women with diabetes 4", "metadata": { "document_name": "abc.pdf", "section": "Section_003", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 18, "chunk_size": 138 } }, { "content": "Recommendation 3 –Screening and diagnosis of GDM ....................... 5\n \n Recommendation 4 –Management of HIP............................................ 6", "metadata": { "document_name": "abc.pdf", "section": "Section_004", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 15, "chunk_size": 159 } }, { "content": "Recommendation 5- Pharmacological treatment of HIP ..................... 9\n \n Recommendation 6- Antenatal care ....................................................... 12\n \n Recommendation 7 –Intrapartum management ................................... 13\n \n Recommendation 8 –Postpartum management .................................... 15\n \n Recommendation 9 –Child care ............................................................... 17\n \n Recommendation 10 –Women with GDM and fetal loss ...................... 18", "metadata": { "document_name": "abc.pdf", "section": "Section_005", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 42, "chunk_size": 512 } }, { "content": "Disclaimer: National consensus document on hyperglycemia in pregnancy is developed\n to be of assistance to health care professionals by providing guidance and\n recommendations for particular areas of practice. This document should not be\n considered inclusive of all proper approaches or methods, or exclusive of others. National\n consensus document cannot guarantee any specific outcome, nor do they establish a\n standard of care. This document is not intended to dictate the treatment of a particular\n patient. Treatment decisions must be made based on the independent judgment of health", "metadata": { "document_name": "abc.pdf", "section": "Section_006", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 86, "chunk_size": 589 } }, { "content": "patient. Treatment decisions must be made based on the independent judgment of health\n care providers and each patient’s individual circumstances.", "metadata": { "document_name": "abc.pdf", "section": "Section_006", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 1, "word_count": 20, "chunk_size": 146 } }, { "content": "================================================== PAGE 3 ==================================================\nHyperglycaemia in Pregnancy", "metadata": { "document_name": "abc.pdf", "section": "Section_007", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 7, "chunk_size": 136 } }, { "content": "Hyperglycaemia in Pregnancy (HIP) is a common medical condition during pregnancy\n and the prevalence is rising in Sri Lanka. The majority is gestational diabetes mellitus\n (GDM) with the remainder being primarily pre-gestational diabetes (Flow chart 1). HIP is\n associated with adverse fetal outcomes such as macrosomia, intrauterine fetal death,\n shoulder dystocia, birth injuries, hyperbilirubinemia, polycythemia, neonatal\n \n hypoglycemia, respiratory distress syndrome, childhood obesity, glucose intolerance and", "metadata": { "document_name": "abc.pdf", "section": "Section_008", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 65, "chunk_size": 516 } }, { "content": "hypoglycemia, respiratory distress syndrome, childhood obesity, glucose intolerance and\n diabetes in later adolescence. Maternal complications associated with HIP are increased\n incidence of miscarriages, pre-eclampsia, cesarean delivery, increased chance of\n developing type 2 DM later in life (approximately 50% in 5 to 10 years).", "metadata": { "document_name": "abc.pdf", "section": "Section_008", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 1, "word_count": 43, "chunk_size": 332 } }, { "content": "Flow chart 1-Classifiacation of hyperglycaemia in pregnancy", "metadata": { "document_name": "abc.pdf", "section": "Section_009", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 7, "chunk_size": 59 } }, { "content": "================================================== PAGE 4 ==================================================\nRecommendation 1 -Screening for pre-gestational diabetes mellitus \n \n 1.\n1. Undiagnosed diabetes mellitus in the community is on the rise .Undiagnosed pre-\n gestational diabetes is diagnosed if the diagnostic criteria for diabetes mellitus are met\n during the first trimester.", "metadata": { "document_name": "abc.pdf", "section": "Section_010", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 42, "chunk_size": 385 } }, { "content": "1.\n2. Patients who are already diagnosed with type 1 diabetes and type 2 diabetes are\n under this category and they do not need further investigations for diagnosis during\n pregnancy. \n \n 1.\n3. Fetal complications, mostly congenital anomalies are seen in this category.Therefore,\n universal screening at the booking visit is essential to diagnose pre-gestational diabetes\n mellitus. \n \n 1.\n4. Standard diagnostic criteria used for non pregnant adults are used for diagnosis of\n pre-gestational diabetes mellitus \n \n 1.\n5. Tests recommended are", "metadata": { "document_name": "abc.pdf", "section": "Section_011", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 78, "chunk_size": 543 } }, { "content": "FBS ≥ 126 mg/dL \n OR \n Diagnose Pregestational DM \n PPBS ≥ 200 mg/dL \n OR \n HbA1c ≥ 6.5%", "metadata": { "document_name": "abc.pdf", "section": "Section_012", "page_number": 1, "content_type": "medication_dosage", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 16, "chunk_size": 88 } }, { "content": "1.\n6. If, FBS is between 100 -125 mg/dL OR PPBS is 140-199 mg/dL proceed to 75 g\n \n two hour OGTT and diagnose GDM as per table \n1.", "metadata": { "document_name": "abc.pdf", "section": "Section_013", "page_number": 1, "content_type": "medication_dosage", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 28, "chunk_size": 131 } }, { "content": "================================================== PAGE 5 ==================================================\nRecommendation 2- Preconception care for women with diabetes \n mellitus", "metadata": { "document_name": "abc.pdf", "section": "Section_014", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 180 } }, { "content": "Preconception care includes detection and management of hyperglycemia,other\n metabolic and weight abnormalities prior to conception. \n \n Screening of women in the reproductive age who are planning pregnancy \n \n 2.\n1. FBS / 75 g 2 hour OGTT should be carried out prior to pregnancy to detect\n undiagnosed diabetes. \n 2.\n2. This should be advocated through the eligible couple registry maintained by the\n \n primary health care staff.", "metadata": { "document_name": "abc.pdf", "section": "Section_015", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 64, "chunk_size": 431 } }, { "content": "Women with diabetes \n Prior to conception, women with preexisting diabetes will need the following:\n \n 2.\n3. Optimization of HbA1c to < 6.5%, if it can be achieved without significant\n hypoglycemia.", "metadata": { "document_name": "abc.pdf", "section": "Section_016", "page_number": 1, "content_type": "general", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 30, "chunk_size": 198 } }, { "content": "2.\n4. Medications which are not safe at conception or embryopathic drugs should be\n discontinued. \n \n 2.\n5. Change of antihyperglycaemic drugs which are not safe during pregnancy to\n insulin.", "metadata": { "document_name": "abc.pdf", "section": "Section_017", "page_number": 1, "content_type": "medication_dosage", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 29, "chunk_size": 191 } }, { "content": "2.\n6. Folic acid supplementation with 5mg/day \n \n 2.\n7. Baseline screening for retinopathy, nephropathy and appropriate treatment as\n needed. \n \n 2.\n8. Cardiac screening and treatment as needed in symptomatic women or pre-existing\n heart disease.", "metadata": { "document_name": "abc.pdf", "section": "Section_018", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 34, "chunk_size": 246 } }, { "content": "2.\n9. Self-monitoring of blood glucose is recommended. Targets for fasting and post-\n prandial glucose can be individualized. FBG: <100mg/dL & 2 hour PPBG <140 mg/dL\n are recommended.", "metadata": { "document_name": "abc.pdf", "section": "Section_019", "page_number": 1, "content_type": "medication_dosage", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 28, "chunk_size": 183 } }, { "content": "================================================== PAGE 6 ==================================================\nRecommendation 3 – Diagnosis of GDM", "metadata": { "document_name": "abc.pdf", "section": "Section_020", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 10, "chunk_size": 144 } }, { "content": "3.\n1. Any degree of glucose intolerance with onset or first recognition during\n pregnancy can be termed GDM ,whether or not the condition persists after\n pregnancy. \n 3.\n2. All pregnant women should be routinely screened for GDM as Sri Lankan\n population falls under high risk group.", "metadata": { "document_name": "abc.pdf", "section": "Section_021", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 46, "chunk_size": 283 } }, { "content": "All pregnant women should be screened for \n \n hyperglycemia in pregnancy", "metadata": { "document_name": "abc.pdf", "section": "Section_022", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 10, "chunk_size": 72 } }, { "content": "3.\n3. Standard 75g 2 hour OGTT ( Fasting - minimum of 8 hour / 1 hour / 2\n hour) should be used for diagnosis of GDM and the procedure is given in detail in\n annexure..", "metadata": { "document_name": "abc.pdf", "section": "Section_023", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 36, "chunk_size": 168 } }, { "content": "3.\n4. In women with negative pre pregnancy screening and who had normal\n range of FBS/PPBS in early pregnancy ,75 g 2 hour OGTT is to be carried out\n between 20 to 28 weeks of gestation If that is normal, need to repeat OGTT in\n third trimester is only if clinically indicated.", "metadata": { "document_name": "abc.pdf", "section": "Section_024", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 52, "chunk_size": 277 } }, { "content": "3.\n5. Diagnostic criteria for diagnosis of GDM are given in Table \n1.", "metadata": { "document_name": "abc.pdf", "section": "Section_025", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 69 } }, { "content": "Test FPG 1 h PG 2 h PG Diagnosis \n 75g 2h ≥ 100 mg/dL ≥ 180 mg/dL ≥ 140 mg/dL 1 or more \n \n OGTT positive \n value(s)", "metadata": { "document_name": "abc.pdf", "section": "Section_026", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 26, "chunk_size": 116 } }, { "content": "================================================== PAGE 7 ==================================================\nRecommendation 4 –Management of HIP", "metadata": { "document_name": "abc.pdf", "section": "Section_027", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 144 } }, { "content": "4.\n1. Recommended therapeutic targets- self monitoring of blood glucose (SMBG)\n \n 4.1.\n1. Self monitoring of blood glucose (SMBG) should be done fasting /pre\n breakfast and 2 hour post-prandial (4 times per day) to achieve glycemic targets\n and improve pregnancy outcomes. Daily SMBG is superior to less frequent\n monitoring. \n \n 4.1.\n2. Monitoring blood glucose before going to bed at night could be done to\n prevent nocturnal hypoglycemia in patients on Insulin. \n \n 4.1.\n3. Frequency of SMBG will vary according to treatment plan and availability\n of resources.", "metadata": { "document_name": "abc.pdf", "section": "Section_028", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 86, "chunk_size": 564 } }, { "content": "4.\n2. Plasma glucose targets \n \n 4.2.1 Fasting and 2 h PPG monitoring is recommended with target values as per\n Table 2 \n \n Table 2 Plasma glucose targets (applies to both venous and capillary)\n \n mg/dL \n Fasting / Premeal < 95 \n \n 1 h PPG < 140 \n 2 h PPG < 120", "metadata": { "document_name": "abc.pdf", "section": "Section_029", "page_number": 1, "content_type": "medication_dosage", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 48, "chunk_size": 261 } }, { "content": "*(Please report to SLCOG /SLCE regarding difficulties in achieving recommended\n blood sugar targets for revision)", "metadata": { "document_name": "abc.pdf", "section": "Section_030", "page_number": 1, "content_type": "general", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 15, "chunk_size": 113 } }, { "content": "4.\n3. HbA1c \n \n HbA1c is not recommended for diagnosis of GDM,", "metadata": { "document_name": "abc.pdf", "section": "Section_031", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 11, "chunk_size": 62 } }, { "content": "================================================== PAGE 8 ==================================================\n4.\n4. Non-pharmacological treatment of HIP \n \n 4.4.\n1. Medical Nutrition Therapy (MNT) should be started soon after the\n diagnosis of HIP by a nutritionist /qualified personnel and reviewed in each\n trimester. \n \n 4.4.\n2. Aim of MNT is to achieve normoglycemia, provide adequate maternal\n weight gain, provide adequate fetal growth, prevent ketosis and achieving other\n general aims of MNT. \n \n 4.4.\n3. MNT is the cornerstone of treatment, especially for GDM. 80%-90% of", "metadata": { "document_name": "abc.pdf", "section": "Section_032", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 75, "chunk_size": 579 } }, { "content": "4.4.\n3. MNT is the cornerstone of treatment, especially for GDM. 80%-90% of\n \n GDM could be managed with MNT alone. .Hypocaloric diet leading to ketosis is\n not recommended.", "metadata": { "document_name": "abc.pdf", "section": "Section_032", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 1, "word_count": 28, "chunk_size": 173 } }, { "content": "4.4.\n4. MNT is a diet-based approach to patients, considering their medical,\n psychological ,dietary history, body weight and period of gestation.\n \n 4.4.\n5. A tailored diet should be created individually for each patient and\n \n monitored \n \n 4.4.\n6. MNT should be continued throughout the pregnancy. \n \n 4.4.\n7. An ideal dietary composition is 45-55% carbohydrates, 15-20% protein and\n 20-30 % fat with less than 10% of saturated fat from total daily calorie\n \n requirement. Consistent carbohydrate diet is important to maintain a consistent", "metadata": { "document_name": "abc.pdf", "section": "Section_033", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 80, "chunk_size": 542 } }, { "content": "requirement. Consistent carbohydrate diet is important to maintain a consistent\n \n blood glucose level throughout the day. Adjusting the type and amount of\n carbohydrate to achieve the desired postprandial blood sugars is important.\n \n Distribute carbohydrate-containing foods into smaller, frequent meals evenly\n \n spaced throughout the day. \n \n 4.4.\n8. It is best not to allow more than 10-12 hours between the last evening meal\n \n and the next morning meal. \n \n 4..4.\n9. Complex carbohydrates with low glycemic index are preferred.\n \n 4.4.", "metadata": { "document_name": "abc.pdf", "section": "Section_033", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 1, "word_count": 77, "chunk_size": 542 } }, { "content": "4..4.\n9. Complex carbohydrates with low glycemic index are preferred.\n \n 4.4.\n10. Plate model for diet can be used to educate patients about the composition\n of each meal. \n \n 4.4.\n11. Calorie allowance varied according to the nutritional status of pregnant women.\n \n  Underweight - 40 Kcal / present pregnant weight (Kg) / day", "metadata": { "document_name": "abc.pdf", "section": "Section_033", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 2, "word_count": 53, "chunk_size": 328 } }, { "content": "================================================== PAGE 9 ==================================================\n Normal weight- 30 Kcal / present pregnant weight (Kg) / day \n \n  Overweight- 24 Kcal / present pregnant weight (Kg)/ day \n \n  Obese- 12-15 Kcal / present pregnant weight (Kg) / day \n \n 4.4.\n12. MNT for HIP to be supervised by trained professionals in nutrition and\n frequency of reviewing depends on the blood sugar control and weight gain.", "metadata": { "document_name": "abc.pdf", "section": "Section_034", "page_number": 1, "content_type": "general", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 63, "chunk_size": 453 } }, { "content": "4.4.\n13. Sample diet plan for sedentary mothers is given in the annexure.", "metadata": { "document_name": "abc.pdf", "section": "Section_035", "page_number": 1, "content_type": "general", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 73 } }, { "content": "4.\n5. Exercise /physical activity \n \n 4.5.\n1. Planned physical activity of 30 mins per day is recommended ( based on\n \n obstetrician’s evaluation of the patient’s physical capacity). \n \n E.g. walking briskly, arm exercises while seated in a chair for 10 mins after each\n \n meal will achieve this goal. \n \n 4.5.2 .Other exercises which the pregnant woman can carry out are flexibility and\n strength training, yoga and deep breathing. While doing exercises excessive\n \n abdominal muscular contraction should be avoided. \n \n 4.5.", "metadata": { "document_name": "abc.pdf", "section": "Section_036", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 77, "chunk_size": 526 } }, { "content": "abdominal muscular contraction should be avoided. \n \n 4.5.\n3. Exercises can be performed in the standing, sitting or lying positions.\n \n 4.5.\n4. Exercise may not be recommended if any medical or obstetric contra\n indication exists.", "metadata": { "document_name": "abc.pdf", "section": "Section_036", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 1, "word_count": 34, "chunk_size": 231 } }, { "content": "================================================== PAGE 10 ==================================================\nRecommendation 5- Pharmacological treatment of HIP", "metadata": { "document_name": "abc.pdf", "section": "Section_037", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 10, "chunk_size": 160 } }, { "content": "5.\n1. Pharmacological therapy should be considered if one fails to achieve glycemic\n targets with non-pharmacological therapy within target days. \n \n 5.\n2. Pharmacological treatment should be started if capillary plasma glucose targets are\n not achieved at any point of pregnancy after a trial MNT alone. \n \n 5.3 Algorithm based guidance on initiation of treatment considering fasting or 2 h PPBG\n is suggested (flowchart 2).", "metadata": { "document_name": "abc.pdf", "section": "Section_038", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 63, "chunk_size": 425 } }, { "content": "================================================== PAGE 11 ==================================================\nPharmacological treatment of HIP based on SMBG", "metadata": { "document_name": "abc.pdf", "section": "Section_039", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 11, "chunk_size": 156 } }, { "content": "FBS ≥ 126 mg/dL FBS ≥ 110-125mg/dL FBS ≥ 95-109 mg/dL \n or or or \n \n 2h PPG ≥ 200 mg/dL 2h PPG ≥ 140-199 mg/dL 2h PPG ≥ 120- 139mg/dL", "metadata": { "document_name": "abc.pdf", "section": "Section_040", "page_number": 1, "content_type": "medication_dosage", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 29, "chunk_size": 133 } }, { "content": "Start Start \n \n non pharmacological treatment non pharmacological treatment \n And \n \n Insulin \n T1 & T3 \n T1& T3 -3 days \n complicated T2 1 week \n T2 - 1 week \n Uncomplicated T2- 2 weeks", "metadata": { "document_name": "abc.pdf", "section": "Section_041", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 29, "chunk_size": 186 } }, { "content": "Blood glucose control \n Blood glucose control \n achieved \n not achieved", "metadata": { "document_name": "abc.pdf", "section": "Section_042", "page_number": 1, "content_type": "general", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 71 } }, { "content": "Flow chart 2-Algorithm based guidance on initiation of treatment in HIP \n \n (T1/T2/T3 -Trimesters)", "metadata": { "document_name": "abc.pdf", "section": "Section_043", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 98 } }, { "content": "================================================== PAGE 12 ==================================================\n5.\n4. Insulin and Metformin are recommended for treatment of HIP (pre-\n gestational / GDM) as pharmacological therapy. \n \n 5.\n5. Recommended Insulins: Soluble / rapid acting insulin, human intermediate\n acting insulin (Isophane), pre-mix insulin are recommended for use during\n pregnancy. Among ultra-short acting analogues aspart and lispro are safe. Among\n long acting analogues, detemir is recommended. Required initial dose of", "metadata": { "document_name": "abc.pdf", "section": "Section_044", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 64, "chunk_size": 540 } }, { "content": "long acting analogues, detemir is recommended. Required initial dose of\n intermediate acting/long acting insulin is 0.2 to 0.5 U/kg. Obese women may need\n higher doses. Treatment should be titrated to reach the targets. \n \n 5.\n6. Recommended approach to initiate insulin:", "metadata": { "document_name": "abc.pdf", "section": "Section_044", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 1, "word_count": 40, "chunk_size": 271 } }, { "content": "Step 1: Fasting hyperglycemia should be controlled first by Isophane/ basal\n insulin detemir at bed time at a dose of 0.2U/kg or Metformin.. The dose should\n be titrated twice a week to reach the target blood glucose. \n \n Step 2: Post meal blood glucose should be controlled by bolus insulins ( short\n \n acting insulin or ultra short acting analogue insulin ) and the dose should be\n titrated as frequently as possible to reach the post-meal targets. This is the gold\n standard basal bolus regimen recommended in pregnancy.", "metadata": { "document_name": "abc.pdf", "section": "Section_045", "page_number": 1, "content_type": "medication_dosage", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 86, "chunk_size": 523 } }, { "content": "standard basal bolus regimen recommended in pregnancy. \n \n  Only bolus insulin may be needed in some cases of HIP where FPG is well\n controlled with non-pharmacological therapy and only PPG targets are to be\n achieved. \n  Premixed insulin can be considered on individual basis where patients are\n unwilling to or unable to take basal bolus regimen.", "metadata": { "document_name": "abc.pdf", "section": "Section_045", "page_number": 1, "content_type": "medication_dosage", "source_file": "abc.pdf", "chunk_index": 1, "word_count": 56, "chunk_size": 350 } }, { "content": "5.\n7. Oral antidiabetic drugs (OAD): Metformin could be continued for women\n with PCOS who were already on metformin prior to conception. Insulin is added\n if, metformin alone is inadequate to maintain target PG levels. Metformin is the\n \n only oral medication recommended for use during pregnancy. Use of \n sulphonylureas are not recommended.", "metadata": { "document_name": "abc.pdf", "section": "Section_046", "page_number": 1, "content_type": "medication_dosage", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 52, "chunk_size": 343 } }, { "content": "================================================== PAGE 13 ==================================================\nRecommendation 6- Antenatal care", "metadata": { "document_name": "abc.pdf", "section": "Section_047", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 142 } }, { "content": "6.1 -First appointment: (joint diabetes and antenatal clinic) \n \n Counseling should be given about need for glycaemic control preferably at the first\n antenatal visit in early T\n1. Thorough clinical history should be taken. Medications should\n be reviewed. \n \n 16 weeks: Routine clinical and laboratory assessment should be done. \n 20 weeks: Fetal anomaly scan should be done as per available expertise. \n 24 weeks: Routine care to be offered. \n \n 28 weeks: Ultrasound/ monitoring of fetal growth and amniotic fluid volume should be\n offered.", "metadata": { "document_name": "abc.pdf", "section": "Section_048", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 80, "chunk_size": 542 } }, { "content": "28 weeks: Ultrasound/ monitoring of fetal growth and amniotic fluid volume should be\n offered. \n 32 weeks: Ultrasound /monitoring of fetal growth and amniotic fluid volume should be\n offered. \n 34 weeks: Routine care should be offered. \n 36 weeks: Ultrasound /monitoring of fetal growth and amniotic fluid volume should be\n offered. \n \n 6.\n2. Aspirin 75/100 mg a day from 12 weeks on wards is recommended as diabetes is a\n risk factor for pre-eclampsia. \n \n 6.3 Counseling and planning should be done with regard to following issues:\n –timing, mode and management of delivery.", "metadata": { "document_name": "abc.pdf", "section": "Section_048", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 576 } }, { "content": "–timing, mode and management of delivery. \n –analgesia and anaesthesia (including anaesthetic assessment for women with\n comorbidities, such as obesity or autonomic neuropathy). \n –changes to therapy during and after delivery. \n \n –initial care of the baby. \n –initiation of breastfeeding and the effect of breastfeeding on glycemic control.\n - contraception and follow-up. \n \n 6.3 -Other maternal assessment \n \n Urine for ketone bodies during severe hyperglycemia, during weight loss treatment or to\n detect possible starvation ketosis should be done. Psychological assessment is", "metadata": { "document_name": "abc.pdf", "section": "Section_048", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 2, "word_count": 76, "chunk_size": 580 } }, { "content": "detect possible starvation ketosis should be done. Psychological assessment is\n recommended to detect anxiety, depression, eating disorders and stress.", "metadata": { "document_name": "abc.pdf", "section": "Section_048", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 3, "word_count": 19, "chunk_size": 151 } }, { "content": "================================================== PAGE 14 ==================================================\nRecommendation 7 –Intrapartum management \n \n 7.\n1. Timing and route of delivery:", "metadata": { "document_name": "abc.pdf", "section": "Section_049", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 15, "chunk_size": 190 } }, { "content": "7.1.\n1. In general, women with pre-pregnancy diabetes or who receive insulin therapy,\n schedule obstetrician review at 36-37 weeks for planning their delivery be accomplished\n by 40 weeks. In a women with HIP if elective delivery is indicated it is to be considered\n by 38 weeks + 6 days of gestation. . \n \n 7.1.\n2. For women on diet control and/or women having optimal glycaemic control and,\n carrying a normally grown baby, there is insufficient evidence to suggest the best time for\n delivery. \n \n 7.1.\n3. Diabetes alone is not an indication for a caesarean section. \n \n 7.1.", "metadata": { "document_name": "abc.pdf", "section": "Section_050", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 95, "chunk_size": 578 } }, { "content": "delivery. \n \n 7.1.\n3. Diabetes alone is not an indication for a caesarean section. \n \n 7.1.\n4. The obstetrician should make the decision after discussing with the woman.\n \n 7.1.\n5. Planned delivery should be arranged in the day time, when all supports are more\n easily available.", "metadata": { "document_name": "abc.pdf", "section": "Section_050", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 1, "word_count": 44, "chunk_size": 279 } }, { "content": "Recommendation 7.2 - Delivery: \n \n 7.2.\n1. Patients on MNT with good glycemic control do not require active glucose\n management during labor. \n \n 7.2.\n2. If the patient is on MNT, plasma glucose monitoring is recommended 4 to 6\n hourly.Those on medication, frequent glucose monitoring, ideally hourly monitoring is\n needed. \n \n 7.2.\n3. Glycemia is managed with IV insulin infusion with dextrose aiming to keep target\n capillary BG values if required.. \n \n 7.2.\n4. Goal of intra-partum capillary plasma glucose level is between 72-126 mg/dL.", "metadata": { "document_name": "abc.pdf", "section": "Section_051", "page_number": 1, "content_type": "medication_dosage", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 540 } }, { "content": "7.2.\n5. Assessment for anesthesia should be done on 3rd trimester if GDM/ pre-existing\n diabetes is complicated with co-morbid conditions. If LSCS is carried out , plasma\n glucose should be monitored every 30 to 60 minutes.", "metadata": { "document_name": "abc.pdf", "section": "Section_052", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 36, "chunk_size": 223 } }, { "content": "================================================== PAGE 15 ==================================================\n7.2.\n6. Steroid usage during pregnancy \n \n If Dexamethasone/Bethamethasone (Celestone Chronodose®) is prescribed by the\n obstetric consultant, pre-empt consequent hyperglycaemia by intensifying management\n 12 hours after first steroid dose as follows: \n \n• Women with optimal glycaemic control on diet alone: intensify Medical Nutritional\n Therapy \n \n• Women with suboptimal glycaemic control on diet alone: commence insulin", "metadata": { "document_name": "abc.pdf", "section": "Section_053", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 58, "chunk_size": 534 } }, { "content": "Therapy \n \n• Women with suboptimal glycaemic control on diet alone: commence insulin\n \n• Women on insulin: increase total daily insulin dose by 20-40% . \n \n Return to previous management after 5 days in those who do not deliver before this.", "metadata": { "document_name": "abc.pdf", "section": "Section_053", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 1, "word_count": 39, "chunk_size": 240 } }, { "content": "================================================== PAGE 16 ==================================================\nRecommendation 8–Postpartum management", "metadata": { "document_name": "abc.pdf", "section": "Section_054", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 7, "chunk_size": 148 } }, { "content": "8.1 –Day after delivery \n \n 8.1.\n1. Those who were on metformin could stop the medication. \n \n 8.1.\n2. Mothers on MNT and metformin can reduce the intensity of glucose\n monitoring..", "metadata": { "document_name": "abc.pdf", "section": "Section_055", "page_number": 1, "content_type": "medication_dosage", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 29, "chunk_size": 181 } }, { "content": "8.1.\n3. Mothers who were on low dose insulin (<0.5units/kg/day) can stop and\n monitor glucose levels. \n \n 8.1.\n4. Mothers who were on > 1unit/kg/day may reduce the dose to 50% while\n those on 0.5-1unit/kg/day need individualized clinical decision.", "metadata": { "document_name": "abc.pdf", "section": "Section_056", "page_number": 1, "content_type": "medication_dosage", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 38, "chunk_size": 247 } }, { "content": "8.2 –Breastfeeding recommendation \n \n 8.2.\n1. All types of insulins and metformin can be safely used in lactating women.\n \n 8.2.\n2. Women with diabetes who are breastfeeding should continue to avoid any\n drugs for the treatment of diabetes complications that were discontinued for safety\n reasons in the pre-conception period.", "metadata": { "document_name": "abc.pdf", "section": "Section_057", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 48, "chunk_size": 326 } }, { "content": "8.3- All mothers with history of gestational diabetes should be counseled about screening\n for diabetes during every subsequent pregnancy \n . \n \n 8.3.\n1. After delivery at least 1 fasting and 1 postprandial PG should be measured\n before discharge in mothers who were managed with MNT. \n -Fasting and PPPG should be monitored for at least 24 hours who were\n managed with insulin. \n -When the mother is back on her regular diet prescribed, if blood glucose\n remains elevated, continued monitoring is warranted and possibility of type 2\n diabetes should be considered.", "metadata": { "document_name": "abc.pdf", "section": "Section_058", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 88, "chunk_size": 565 } }, { "content": "diabetes should be considered. \n -If immediate post-delivery blood glucose is suggestive of DM, then it\n should be confirmed by FPG or post-prandial plasma glucose.", "metadata": { "document_name": "abc.pdf", "section": "Section_058", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 1, "word_count": 24, "chunk_size": 164 } }, { "content": "================================================== PAGE 17 ==================================================\n8.3.\n2. Women with GDM should be screened for diabetes 6 to 12 weeks’ post-\n partum (linked to child immunization) with 75g 2 hour OGTT using non-\n pregnant OGTT criteria. Using A1c% is not recommended because of pre-partum\n management of hyperglycemia during pregnancy, . \n \n 8.3.\n3. If plasma glucose is normal, re-assessment should be done annually with\n standard investigations. \n \n 8.3.\n4. If pre-diabetes is detected, mothers should be put on MNT and/or", "metadata": { "document_name": "abc.pdf", "section": "Section_059", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 569 } }, { "content": "8.3.\n4. If pre-diabetes is detected, mothers should be put on MNT and/or\n metformin and should be followed accordingly to standard protocol. \n \n 8.3.\n4. Incorporating a post-partum calendar to ensure screening after index GDM\n \n and synchronizing with immunization calendar is advised. \n \n 8.3.\n5. Family planning \n -All reliable methods of family planning can be used as appropriate for the\n needs of the individual woman with diabetes. \n \n 8.3.\n6. Screening for all components of metabolic syndrome should be offered.", "metadata": { "document_name": "abc.pdf", "section": "Section_059", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 1, "word_count": 77, "chunk_size": 519 } }, { "content": "================================================== PAGE 18 ==================================================\nRecommendation 9 –Child care \n \n 9.\n1. HIP is associated with increased risk of newborn complications including excessive\n birthweight/ macrosomia, birth injuries, birth asphyxia, respiratory distress,\n hypoglycemia, hypocalcaemia, hypomagnesemia, polycythemia, hyperbilirubinemia,\n thrombocytopenia, congenital anomalies and cardiomyopathy. \n \n It is also associated with an increased risk of obesity, and metabolic syndrome in the\n offspring during childhood and adulthood.", "metadata": { "document_name": "abc.pdf", "section": "Section_060", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 59, "chunk_size": 585 } }, { "content": "9.1.\n1. At the time of delivery, birth weight, gestational age, congenital abnormalities if\n any, and blood glucose at birth should be noted.", "metadata": { "document_name": "abc.pdf", "section": "Section_061", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 23, "chunk_size": 141 } }, { "content": "9.1.2 Women with diabetes should breast feed their babies a soon as possible (within 30\n minutes) after birth, and then at frequent intervals (every 2-3-hours) for the first few\n days of life.", "metadata": { "document_name": "abc.pdf", "section": "Section_062", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 32, "chunk_size": 192 } }, { "content": "9.1.\n3. First newborn blood glucose should be checked after the first feed and then before\n each subsequent feed for the first 24- 48 hours of life, to ensure that pre-feed BG is\n maintained at a minimum of 2.0 mmol/L (36 mg/dl). Glucometer calibrated for neonatal\n use should be utilized for this purpose.", "metadata": { "document_name": "abc.pdf", "section": "Section_063", "page_number": 1, "content_type": "medication_dosage", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 53, "chunk_size": 306 } }, { "content": "9.1.4 .If capillary plasma glucose values are below 2.0 mmol/litre on 2 consecutive\n readings despite maximal support for feeding, if there are abnormal clinical signs or if the\n baby will not feed orally effectively, use additional measures such as cup/tube feeding or\n intravenous dextrose. \n \n 9.1.\n5. Test blood glucose levels in babies of women with diabetes who present with\n clinical signs of hypoglycaemia (jitteriness, staring, apnea, siezures ect. ) and treat those\n who are hypoglycaemic with intravenous dextrose as soon as possible.", "metadata": { "document_name": "abc.pdf", "section": "Section_064", "page_number": 1, "content_type": "general", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 82, "chunk_size": 545 } }, { "content": "9.1.\n6. Blood tests for polycythemia, hyperbilirubinemia, hypocalcemia, hypomagnesemia\n should be carried out if clinical signs are present", "metadata": { "document_name": "abc.pdf", "section": "Section_065", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 18, "chunk_size": 139 } }, { "content": "9.1.\n7. Regular medical check-ups of baby/child should be carried out to monitor weight\n for age to detect childhood obesity. Parental counseling should be done at every visit to\n adopt healthy lifestyle and healthy eating habits to avoid obesity.", "metadata": { "document_name": "abc.pdf", "section": "Section_066", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 39, "chunk_size": 247 } }, { "content": "================================================== PAGE 19 ==================================================\nRecommendation 10 –Women with GDM and fetal loss", "metadata": { "document_name": "abc.pdf", "section": "Section_067", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 12, "chunk_size": 158 } }, { "content": "These women require special attention of the health care professionals. Special attention\n should be paid to their psychological well-being with referral to a mental health\n professional as and when needed. Since there is no subsequent baby immunization visits,\n \n these women should be screening with standard OGTT 6-12 weeks after pregnancy loss.", "metadata": { "document_name": "abc.pdf", "section": "Section_068", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 51, "chunk_size": 348 } }, { "content": "================================================== PAGE 20 ==================================================\nAnnexure \n \n \n1. Procedure of 75 g two hour OGTT", "metadata": { "document_name": "abc.pdf", "section": "Section_069", "page_number": 1, "content_type": "clinical_protocol", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 158 } }, { "content": " The woman should have had no diet restrictions in the previous 3 days and\n participated in usual physical activity. \n \n  The pregnant woman must reach the laboratory early morning, after overnight\n \n fasting. She must not have taken even coffee/tea. \n \n  Minimum time required for fasting is 8 hours and fasting should not exceed 14 hours.\n \n  On arrival at the laboratory, a blood sample is drawn and she is given a drink\n \n consisting of 75 gm of anhydrous glucose dissolved in a large glass of water (300\n \n ml).", "metadata": { "document_name": "abc.pdf", "section": "Section_070", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 89, "chunk_size": 520 } }, { "content": "consisting of 75 gm of anhydrous glucose dissolved in a large glass of water (300\n \n ml). \n \n  Two more blood samples are drawn at one hour and two hours respectively, after\n drinking the glucose drink. The time is measured from the moment she begins to\n \n drink the glucose solution. \n \n  If the patient arrives non fasting, only the two-hour blood samples should be taken\n \n after the glucose drink. \n \n  The woman must be seated during this period with minimal physical activity.\n \n  She must refrain from eating or drinking anything else, until the test is completed.", "metadata": { "document_name": "abc.pdf", "section": "Section_070", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 1, "word_count": 96, "chunk_size": 575 } }, { "content": "================================================== PAGE 21 ==================================================\n2, Suggested daily meal plans for sedentary normal weight, underweight and\n overweight pregnant mothers. \n \n Food Group Meal Normal Underweigh Over \n weight t weight \n Breakfast \n Cereals Boiled cowpea/green gram 1 cup 1 cup 1 cup \n Oil Scraped Coconut 1 tbs 1 tbs 1 tbs \n Snack \n Cereal & oil Thriposha (with coconut 1 tbs)( without sugar) 3 tbs 3 tbs 3 tbs\n Fruit papaw 1 piece 1 piece 1 piece \n Lunch \n Cereal Rice 1 ⅓cups 1⅔ cups 1 cups \n Vegetable Green leaves 3 tbs 3 tbs 3 tbs", "metadata": { "document_name": "abc.pdf", "section": "Section_071", "page_number": 1, "content_type": "general", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 90, "chunk_size": 593 } }, { "content": "Lunch \n Cereal Rice 1 ⅓cups 1⅔ cups 1 cups \n Vegetable Green leaves 3 tbs 3 tbs 3 tbs \n Beans/long beans/wing beans 2 tbs 2 tbs 2 tbs \n Carrots/ pumpkin/beet root 2 tbs 2 tbs 2 tbs \n Fish/meat Fish/ chicken 2 pieces 2 pieces 2 pieces \n Oil Gravy 2tbs 3 tbs 2 tbs \n Snack \n Milk Full cream Milk powder 2 tbs( without sugar) 1 cup 1 cup 1 cup\n Fruit Guava 1 small 1 small 1 small \n Oil Peanuts - 1 tbs - \n \n Dinner \n Cereal Rice 1 ⅓ cups 1⅔ cups 1 cup \n Vegetable Vegetable 6 tbs 6 tbs 6 tbs \n Fish/meat/egg Fish/ chicken 1 pieces 2 pieces 1 pieces \n Oil Gravy 2tbs 3tbs 2 tbs \n Snack", "metadata": { "document_name": "abc.pdf", "section": "Section_071", "page_number": 1, "content_type": "general", "source_file": "abc.pdf", "chunk_index": 1, "word_count": 116, "chunk_size": 582 } }, { "content": "Fish/meat/egg Fish/ chicken 1 pieces 2 pieces 1 pieces \n Oil Gravy 2tbs 3tbs 2 tbs \n Snack \n Milk Full cream Milk powder 2 tbs ( without sugar) 1 cup 1 cup 1 cup\n Water minimum of 8 glasses per day", "metadata": { "document_name": "abc.pdf", "section": "Section_071", "page_number": 1, "content_type": "general", "source_file": "abc.pdf", "chunk_index": 2, "word_count": 39, "chunk_size": 197 } }, { "content": "*This menu is only an example for sedentary pregnant mothers. Amounts and the type of the\n foods are varying according the individuals’ height, current weight, activity levels, culture,\n preferences and availability.", "metadata": { "document_name": "abc.pdf", "section": "Section_072", "page_number": 1, "content_type": "general", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 31, "chunk_size": 216 } }, { "content": "================================================== PAGE 22 ==================================================\nReferences \n \n \n1. Metzger BE. Proceedings of the third international workshop-conference on\n \n gestational diabetes mellitus. Diabetes. 1991;40( 2):1–\n201. \n \n \n2. Clinical practice recommendations 2001: gestational diabetes mellitus.Diabetes\n \n Care 2001; 24 (1): 77–\n79.", "metadata": { "document_name": "abc.pdf", "section": "Section_073", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 36, "chunk_size": 383 } }, { "content": "3. Metzger BE, Coustan DR.Summary and recommendations of the Fourth \n \n International Workshop Conference on Gestational Diabetes Mellitus. Diabetes\n \n Care 1998; 21 (2) : 161–\n167.", "metadata": { "document_name": "abc.pdf", "section": "Section_074", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 25, "chunk_size": 181 } }, { "content": "4. Mitanchez D.Foetal and neonatal complications in gestational diabetes: perinatal\n \n mortality, congenital malformations, macrosomia, shoulder dystocia, birth\n \n injuries, neonatal complications. Diabetes Metab. 2010 ;36(6 ):617-\n27.\n \n \n5. IADPSGCP, International Association of Diabetes and Pregnancy Study Groups\n \n Recommendations on the Diagnosis and Classification of Hyperglycemia in\n \n Pregnancy. Diabetes Care 2010;33(3): 676-\n682.", "metadata": { "document_name": "abc.pdf", "section": "Section_075", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 51, "chunk_size": 442 } }, { "content": "6. National Institute for Health and Care Excellence (NICE) (2015) Diabetes in\n \n pregnancy: management of diabetes and its complications from preconception to\n \n the postnatal period. Clinical guideline NG3 (2015).", "metadata": { "document_name": "abc.pdf", "section": "Section_076", "page_number": 1, "content_type": "maternal_care", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 29, "chunk_size": 215 } }, { "content": "7. American Diabetes Association (2014) Standards of medical care in diabetes—\n \n 2016.Diabetes Care 2016;39( 1):94–98 .", "metadata": { "document_name": "abc.pdf", "section": "Section_077", "page_number": 1, "content_type": "general", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 16, "chunk_size": 120 } }, { "content": "8. South Asian Federation of Endocrine Societies (SAFES) GDM action plan and\n \n recommendations \n2017.", "metadata": { "document_name": "abc.pdf", "section": "Section_078", "page_number": 1, "content_type": "guidelines", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 14, "chunk_size": 102 } }, { "content": "================================================== PAGE 23 ==================================================\n2", "metadata": { "document_name": "abc.pdf", "section": "Section_079", "page_number": 1, "content_type": "general", "source_file": "abc.pdf", "chunk_index": 0, "word_count": 5, "chunk_size": 111 } }, { "content": "================================================== PAGE 1 ==================================================\nSLCOG Guideline \n \n SLCOG Guideline \n \n Postnatal care during hospital stay \n \n D L W Dasanayakea on behalf of Sri Lanka College of Obstetricians and Gynaecologists\n \n Correspondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo \n08.\n E-mail: slcogoffice@gmail.com", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_000", "page_number": 1, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 44, "chunk_size": 417 } }, { "content": "1. Scope and background 2.2 Pain management \n The purpose of this guideline is to describe the routine A stepwise approach using multi-model combination\n essential postnatal care during hospital stay and provide of agents should be prescribed.\n currently available best evidence to health care \n professionals to provide optimal care for postnatal Acetaminophen (Paracetamol) should be prescribed for\n mothers and newborns. This guideline also recom- perineal discomfort and pain following uncomplicated\n mends management options depending on the vaginal delivery.", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_001", "page_number": 1, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 77, "chunk_size": 564 } }, { "content": "mends management options depending on the vaginal delivery. \n resources available in the local setting. The guideline \n explains the postnatal care except management of Non-Steroidal Ante-Inflammatory Drugs (NSAID’s)\n psychological wellbeing as it is separately addressed such as diclofenac and ibuprofen with acetaminophen\n by another guideline. are relatively safe during postpartum period and should\n be prescribed for postnatal women with more severe\n Immediate postpartum period is critical phase of the pain. \n life for both mother and infant, setting the stage for an", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_001", "page_number": 1, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 1, "word_count": 80, "chunk_size": 574 } }, { "content": "life for both mother and infant, setting the stage for an \n ongoing process of optimizing health and well-being. When, a multimodal approach to analgesia using\n First 24 hours of delivery where both mother and baby NSAID’s and acetaminophen given simultaneously on\n within the facility will provide excellent opportunity a set schedule is insufficient, a milder opioid (codeine)\n for health professionals to initiate essential postnatal should be considered especially for caesarean delivery\n care for them and continue thereafter. for enhanced recovery.", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_001", "page_number": 1, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 2, "word_count": 80, "chunk_size": 554 } }, { "content": "care for them and continue thereafter. for enhanced recovery. \n \n When caesarean delivery is conducted following general\n \n2. Summary of key recommendations anaesthesia or when intrathecal long acting opioids are\n not used for spinal anaesthesia, Transversus Abdominis\n 2.1 Immediate postpartum monitoring \n Plane field block (TAP block) should be considered as\n it provides excellent postoperative pain control and\n Modified Obstetric Early Warning System improves postoperative analgesia.\n (MOEWS) should be used to monitor vital para-", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_001", "page_number": 1, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 3, "word_count": 72, "chunk_size": 537 } }, { "content": "(MOEWS) should be used to monitor vital para- \n meters to recognize early abnormalities of postnatal Stronger opioid analgesics (morphine, diamorphine and\n women. pethidine) are best reserved for women with inadequate\n pain control with sufficient doses of multimodal\n Monitoring with MOEWS chart should be continued approach. \n for two hours for vaginal delivery and four hours \n for caesarean delivery. Drowsiness from opioids use can be interfered with\n maternal activities and breast feeding.", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_001", "page_number": 1, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 4, "word_count": 70, "chunk_size": 496 } }, { "content": "Sri Lanka Journal of Obstetrics and Gynaecology 2021; 43: 269-276 \n \n DOI: http://doi.org/10.4038/sljog.v43i3.8021", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_002", "page_number": 2, "content_type": "general", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 12, "chunk_size": 114 } }, { "content": "a Consultant Obstetrician and Gynaecologist, Mahamodara Teaching Hospital, Galle", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_003", "page_number": 2, "content_type": "general", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 80 } }, { "content": "================================================== PAGE 2 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_004", "page_number": 2, "content_type": "guidelines", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "2.3 Perineal/surgical wound care To ensure that normal bladder function resumes,\n women should be left no more than six hours following\n For the uncomplicated vaginal delivery, cold packs \n delivery without voiding. \n could be applied for 10 to 20 minutes as it helps to \n improve pain and edema at the episiotomy site. \n If the woman has not passed urine successfully by six\n hours following delivery, prompt action should be taken\n Postnatal women should change perineal pad frequently \n by the obstetric team. \n (4 to 6 hours) and have shower at least daily to keep \n the perineum clean.", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_005", "page_number": 2, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 95, "chunk_size": 590 } }, { "content": "(4 to 6 hours) and have shower at least daily to keep \n the perineum clean. \n Effort to assist urination should be advised, such as\n taking a warm bath or shower. If these measures are\n Vaginal douching is not recommended in the early \n not successful, prompt assessment of bladder volume\n pueperium. \n and catheterization should be done. \n The vulva should be cleaned from anterior to posterior \n Where the Post Voidal Residue (PVR) is >150 or the\n and not vice versa, to prevent the possibility of fecal \n women is unable to void, an indwelling catheter should", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_005", "page_number": 2, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 1, "word_count": 93, "chunk_size": 562 } }, { "content": "women is unable to void, an indwelling catheter should\n contamination of traumatized area. \n be inserted for 24 hours. \n If a woman has painful defecation or constipation, \n Offer removal of the urinary bladder catheter once a\n laxatives should be prescribed for easy bowel motion. \n woman is mobile after a regional anaesthetic for\n caesarean birth, but no sooner than 12 hours.\n Routine antibiotics are not recommended for first and \n second degree perineal tears or episiotomy. \n 2.5 Care for the newborn baby \n Health professionals should follow a standard protocol", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_005", "page_number": 2, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 569 } }, { "content": "2.5 Care for the newborn baby \n Health professionals should follow a standard protocol \n Aim for a full clinical examination around one hour\n for management of Obstetric Anal Sphincter Injuries \n after birth, when the baby has had his/her first\n for the additional recommended care. \n breastfeeding. The baby should be checked again before\n discharge. \n A visual assessment of the perineum and vaginal \n examination should be carried out in all postnatal women \n Clean dry cord care is recommended for babies born\n prior to discharge to assess healing, breakdown and \n in health facility.", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_005", "page_number": 2, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 3, "word_count": 89, "chunk_size": 588 } }, { "content": "prior to discharge to assess healing, breakdown and \n in health facility. \n presence of foreign bodies. \n Bathing should be delayed until 24 hours after birth. If\n Standard dressings should be removed 24 hours after \n it is not possible due to cultural reasons, bathing should\n the caesarean delivery and thereafter consider applying \n be delayed at least six hours. \n a soft dressing. \n The new born baby should be clothed with one or two\n Assement of wound should be done for signs of \n layers of cloth with hat/cap for ambient temperature.\n infection, separation or dehiscence.", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_005", "page_number": 2, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 4, "word_count": 91, "chunk_size": 580 } }, { "content": "layers of cloth with hat/cap for ambient temperature.\n infection, separation or dehiscence. \n Immunization should be promoted as per the Expanded\n The woman should be encouraged to wear loose, \n Immunization Programme. \n comfortable clothes and cotton underwear. \n Gentle cleaning and drying the wound should be carried 2.6 Postpartum contraception\n out daily. \n Discussion on Postpartum Family Planning (PPFP)\n Removal of sutures or clips should be arranged in 5 to should be initiated prior to discharge which should be", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_005", "page_number": 2, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 5, "word_count": 75, "chunk_size": 521 } }, { "content": "7 days of caesarean delivery. a continuum of antenatal contraception counselling.\n The couple should be informed that they are at risk of\n 2.4 Postpartum bladder care \n pregnancy as early as four weeks after delivery if the\n Every postnatal woman should be educated from the woman is not exclusively breastfeeding.\n labour ward to empty the bladder every 4 to 6 hours \n and,t he time and volume of first void following delivery For women with no other medical illnesses, there is\n must be recorded in the maternal notes. no restriction for the use of the following methods", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_005", "page_number": 2, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 6, "word_count": 95, "chunk_size": 572 } }, { "content": "must be recorded in the maternal notes. no restriction for the use of the following methods\n 270 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_005", "page_number": 2, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 7, "word_count": 24, "chunk_size": 144 } }, { "content": "================================================== PAGE 3 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_006", "page_number": 3, "content_type": "guidelines", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "during the immediate postpartum period: Post-Partum \n3. Introduction \n Intra uterine Devices (PPIUD) and progestogen \n Postnatal period is a time of great change, physically,\n implants. \n mentally and socially for mothers, infants and families.\n While many mothers transition through this time\n If couple requests PPIUD, it should be offered to \n uneventfully, others find it overwhelming or develop\n women within 48 hours of delivery. \n significant health issues that may persist for weeks\n and months after giving birth. Postnatal care of the", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_007", "page_number": 3, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 78, "chunk_size": 544 } }, { "content": "and months after giving birth. Postnatal care of the\n If the couple wishes to have postpartum sterilization, \n woman and her newborn baby, is the weakest and the\n it should be arranged within 48 hours after delivery. \n most neglected component of reproductive health care.\n Global data shows that almost half of the post natal\n Lactational Amenorrhoea (LAM) alone should not be \n maternal deaths occur within the first 24 hrs of child-\n promoted as a method of contraception due to its high \n birth1 and one million of newborns died on the first\n failure rate. \n day2,", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_007", "page_number": 3, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 1, "word_count": 93, "chunk_size": 568 } }, { "content": "birth1 and one million of newborns died on the first\n failure rate. \n day2,\n3. As the first day of the postpartum period carries\n the highest risk of adverse outcomes for the woman\n 2.7 Lactation management \n and her baby, it is essential that comprehensive postnatal\n care is initiated immediately after delivery and continued\n Every effort should be taken to commence \n until the woman is discharged from hospital.\n breastfeeding within the first hour after delivery. \n Essential postnatal care which should be commenced\n Support must be immediately available for new", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_007", "page_number": 3, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 2, "word_count": 87, "chunk_size": 569 } }, { "content": "Essential postnatal care which should be commenced\n Support must be immediately available for new \n on the first postpartum day itself include: pain manage-\n mothers to initiate breast feeding soon after birth. \n ment, perineal care, bladder care, care of the new born,\n postpartum contraception, lactation management and\n Extended support from trained staff should offer \n assessment of psychological wellbeing. \n training of new mothers and then observe and monitor \n breastfeeding during hospital stay. \n The World Health Organization (WHO) recognized", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_007", "page_number": 3, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 3, "word_count": 76, "chunk_size": 554 } }, { "content": "breastfeeding during hospital stay. \n The World Health Organization (WHO) recognized\n the importance of the postnatal management and has\n Women and their newborn baby should stay in hospital \n issued detailed, evidence-based recommendations for\n for at least 24 hours and should not be discharged \n postnatal care\n4. \n early until mother is confident about breast feeding. \n In Sri Lanka, almost all births take place in hospitals\n 2.8 Nutrition and general health advice on with skill birth attendance\n5. Therefore, we have\n discharge excellent opportunity to commence comprehensive", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_007", "page_number": 3, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 4, "word_count": 84, "chunk_size": 583 } }, { "content": "5. Therefore, we have\n discharge excellent opportunity to commence comprehensive\n care for postnatal mothers until they are discharged\n Nurse in charge of health education should talk to \n from the facility. \n women, preferably arrange small group discussions. \n \n4. Recommendations and discussion \n Women should be advised to eat a greater amount and \n variety of healthy foods, dairy products, oils, nuts, \n 4.1 Immediate postpartum monitoring \n seeds, cereals, vegetables, to help her to be well and \n strong. Modified Obstetric Early Warning System (MOEWS)", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_007", "page_number": 3, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 5, "word_count": 79, "chunk_size": 560 } }, { "content": "strong. Modified Obstetric Early Warning System (MOEWS)\n should be used to monitor vital parameters to recognize\n early abnormalities of postnatal women.\n A liquid diet can be offered 2 hours after an uncom- \n plicated cesarean delivery. Women should be reassured \n Monitoring with MOEWS chart should be continued\n that she can eat any normal food. \n for two hours for vaginal delivery and four hours for\n caesarean delivery. \n Continue iron, folic acid and calcium supplementation \n during lactation. \n Early Warning Scoring Systems are a simple, quick-", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_007", "page_number": 3, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 6, "word_count": 82, "chunk_size": 554 } }, { "content": "during lactation. \n Early Warning Scoring Systems are a simple, quick-\n to-use tool based on routine physiological observations.\n Women should avoid sexual intercourse until perineal \n The scoring of these observations can provide an\n wound heals and she feels comfortable, preferably until indication of the overall status of the patient’s condition.\n 4-6 weeks postpartum. Prompt action and urgent medical review when indi-\n Vol. 43, No. 3, September 2021 271", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_007", "page_number": 3, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 7, "word_count": 67, "chunk_size": 461 } }, { "content": "================================================== PAGE 4 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_008", "page_number": 4, "content_type": "guidelines", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "cated, allow for appropriate management of women increase the risk of postpartum complications\n8. Non-\n at risk of deterioration. The MEOWS tool has been pharmacological and pharmacological therapies are\n specifically adopted to reflect the physiological adap- options for pain management. It is also important to\n tations of normal pregnancy and should therefore be consider safety of drug therapy due to concerns of\n used for pregnant, labouring and postnatal women. secretion through breast milk. Multimodal analgesia", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_009", "page_number": 4, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 75, "chunk_size": 520 } }, { "content": "Use of MOEWS, which alerts care providers of poten- uses drugs that have different mechanism of action,\n tial impending critical illnesses, is recommended to which augments analgesic effect9 (Appendix no. 1). A\n improve maternal outcomes and safety\n6. Cochrane review of local analgesia infiltration and\n \n abdominal nerve blocks found that they improved\n 4.2 Postpartum pain management postoperative analgesia for cesarean delivery\n10.\n Acetaminophen and NSAIDs are relatively safe during\n A stepwise approach using multi-model combination \n breast feeding\n11. However, opioids should be used", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_009", "page_number": 4, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 593 } }, { "content": "breast feeding\n11. However, opioids should be used\n of agents should be prescribed. \n cautiously as maternal and neonatal sedation\n12.\n Acetaminophen (Paracetamol) should be prescribed for \n 4.3 Postpartum perineal /surgical wound care\n perineal discomfort and pain following uncomplicated \n vaginal delivery. For the uncomplicated vaginal delivery, cold packs\n could be applied for 10 to 20 minutes as it helps to\n Non-Steroidal Ante-Inflammatory Drugs (NSAID’s) improve pain and edema at the episiotomy site.\n such as diclofenac and ibuprofen with acetaminophen", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_009", "page_number": 4, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 2, "word_count": 78, "chunk_size": 563 } }, { "content": "such as diclofenac and ibuprofen with acetaminophen \n are relatively safe during postpartum period and should Postnatal women should change perineal pad frequently\n be prescribed for postnatal women with more severe (4 to 6 hours) and have shower at least daily to keep\n pain. the perineum clean. \n When, a multimodal approach to analgesia using Vaginal douching is not recommended in the early\n NSAID’s and acetaminophen given simultaneously on pueperium. \n a set schedule is insufficient, a milder opioid (codeine)", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_009", "page_number": 4, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 3, "word_count": 77, "chunk_size": 516 } }, { "content": "a set schedule is insufficient, a milder opioid (codeine) \n should be considered especially for caesarean delivery The vulva should be cleaned from anterior to posterior\n and not vice versa, to prevent the possibility of fecal\n for enhanced recovery. \n contamination of traumatized area. \n When caesarean delivery is conducted following general \n If a woman has painful defecation or constipation,\n anaesthesia or when intrathecal long acting opioids are \n laxatives should be prescribed for easy bowel motion.\n not used for spinal anaesthesia, a Transversus", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_009", "page_number": 4, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 4, "word_count": 80, "chunk_size": 558 } }, { "content": "not used for spinal anaesthesia, a Transversus \n Abdominis Plane field block (TAP block) should be \n Routine antibiotics are not recommended for first and\n considered as it provides excellent postoperative pain \n second degree perineal tears or episiotomy.\n control and improves postoperative analgesia. \n Health professionals should follow a standard protocol\n Stronger opioid analgesics (morphine, diamorphine and \n for management of obstetric anal sphincter injuries for\n pethidine) are best reserved for women with inadequate \n the additional recommended care.", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_009", "page_number": 4, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 5, "word_count": 74, "chunk_size": 564 } }, { "content": "pethidine) are best reserved for women with inadequate \n the additional recommended care. \n pain control with sufficient doses of multimodal \n approach. \n A visual assessment of the perineum and vaginal\n examination should be carried out in all postnatal women\n Drowsiness from opioids use can interfere with \n prior to discharge to assess healing, breakdown and\n maternal activities and breast feeding. \n presence of foreign bodies. \n Pain has been documented as a major concern for most Standard dressings should be removed 24 hours after", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_009", "page_number": 4, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 6, "word_count": 79, "chunk_size": 540 } }, { "content": "TAP block women following childbirth. Management the caesarean delivery and thereafter consider applying\n of postpartum pain, however, is a relatively neglected a soft dressing. \n due to under estimation\n7. Inadequate pain relief could \n lead to interference with mobilization, breastfeeding, Assessment of wound should be done for signs of\n and newborn bonding by impeding mobility, can infection, separation or dehiscence.\n 272 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_009", "page_number": 4, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 7, "word_count": 67, "chunk_size": 477 } }, { "content": "================================================== PAGE 5 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_010", "page_number": 5, "content_type": "guidelines", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "The woman should be encouraged to wear loose, Where the Post Voidal Residue (PVR) is >150 or the\n comfortable clothes and cotton underwear. women is unable to void, an indwelling catheter should\n be inserted for 24 hours. \n Gentle cleaning and drying the wound should be carried \n out daily. Offer removal of the urinary bladder catheter once a\n woman is mobile after a regional anaesthetic for\n Removal of sutures or clips should be arranged in 5 to caesarean birth, but no sooner than 12 hours.\n 7 days of caesarean delivery. \n A small number of women (0.4% to 4%) experience", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 98, "chunk_size": 577 } }, { "content": "7 days of caesarean delivery. \n A small number of women (0.4% to 4%) experience\n Perineal damage can cause significant maternal \n long term bladder dysfunction following child birth\n18.\n morbidity both immediate and long term\n8. Vast majority \n This can cause embarrassment and distress\n19. The\n of perineal trauma is due to intentionally made episio- \n bladder could be an unfortunate victim of child birth.\n tomy to facilitate vaginal delivery. Episiotomy rates vary \n A single episode of bladder over distention can lead to\n considerably in various countries according to individual", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 1, "word_count": 88, "chunk_size": 585 } }, { "content": "considerably in various countries according to individual \n irreversible damage to detrusor muscles\n20. PVR and\n practices and policies of staff and institutions. Overall \n total urine volume are considered as significant finding\n rates of episiotomy in different countries range from \n when a woman is managed for acute urinary retention.\n 8% to 99%\n13. In Sri Lanka, almost all primipara and \n Short while after delivery, retention of urine with\n most of the multipara experience episiotomy. Edema \n bladder distention can be a frequent phenomenon due", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 553 } }, { "content": "bladder distention can be a frequent phenomenon due\n and discomfort may result painful defecation and \n to child birth related denervation an ischemia of the\n interfere with mobilization. Although evidence is limited, \n bladder muscles. Urinary retention is most likely to\n a meta-analysis found that cold pack applied for 10 to \n occur in the first 8 to 12 hours following delivery\n 20 mins. improve perineal discomfort and edema\n14. \n because of its onset may be slow and asymptomatic\n21.\n Laxatives should be administered, in immediate", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 3, "word_count": 83, "chunk_size": 538 } }, { "content": "21.\n Laxatives should be administered, in immediate \n postpartum period, if a women has painful defecation Early diagnosis, interventions and treatment are neces-\n or constipation following perineal trauma, to aid easier sary to prevent permanent bladder damage. Simple\n bowel motion and early discharge from hospital\n15. measures such as education of women regarding\n Routine perinel examination should be carried out by a effective voiding and frequency would prevent most\n doctor before discharge to assess the perineum for of undiagnosed bladder distention. Even though it is", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 4, "word_count": 84, "chunk_size": 579 } }, { "content": "signs of infection and wound breakdowns\n16. NICE recommended by Enhance Recovery After Surgery\n guideline on caesarean delivery recommends to remove (ERAS) society to remove urinary catheter immediately\n standard dressing in 8 to 24 hours but not advised for after caesarean delivery, it is not practically possible in\n negative pressure dressing unless risk of bleeding\n17. \n local setting. \n 4.4 Postpartum bladder care \n 4.5 Care for the newborn baby \n Every postnatal women should be educated from the \n Aim for a full clinical examination around one hour", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 5, "word_count": 85, "chunk_size": 559 } }, { "content": "Aim for a full clinical examination around one hour\n labour ward to empty the bladder every 4 to 6 hours \n after birth, when the baby has had his/her first\n and the time and volume of first void following delivery \n breastfeeding. The baby should be checked again before\n must be recorded in the maternal notes. \n discharge. \n To ensure that normal bladder function resumes, \n Clean dry cord care is recommended for babies born\n women should be left no more than six hours following \n in health facility. \n delivery without voiding. \n Bathing should be delayed until 24 hours after birth. If", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 6, "word_count": 97, "chunk_size": 591 } }, { "content": "delivery without voiding. \n Bathing should be delayed until 24 hours after birth. If\n If the woman has not passed urine successfully by six \n it is not possible due to cultural reasons, bathing should\n hours following delivery, prompt action should be taken \n be delayed at least six hours. \n by the obstetric team. \n The new born baby should be clothed one or two\n Effort to assist urination should be advised, such as layers of cloth with hat/cap for ambient temperature.\n taking a warm bath or shower. If these measures are", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 7, "word_count": 88, "chunk_size": 526 } }, { "content": "taking a warm bath or shower. If these measures are \n not successful, prompt assessment of bladder volume Immunization should be promoted as per the Expanded\n and catheterization should be done. Immunization Programme. \n Vol. 43, No. 3, September 2021 273", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 8, "word_count": 39, "chunk_size": 255 } }, { "content": "================================================== PAGE 6 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_012", "page_number": 6, "content_type": "guidelines", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Newborn period refers to the first twenty-eight days a safe and extremely affective, long acting, reversible\n of life. However first 24 hours of the life is the most method already in place. The main advantage of this\n challenging time of human life, since babies are born method is convenient to mother due to timing of\n to an entirely new surrounding. There are several insertion. \n physiological adaptations occurring in this period in \n the baby, which is essential for their survival. Family 4.7 Lactation management\n Health Bureau has issued a comprehensive guideline", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_013", "page_number": 6, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 90, "chunk_size": 573 } }, { "content": "Health Bureau has issued a comprehensive guideline \n Every effort should be taken to commence breast-\n on new born care for detailed reference\n22. \n feeding within the first hour after delivery.\n 4.6 Postpartum contraception \n Support must be immediately available for new\n mothers to initiate breast feeding soon after birth.\n Discussion on Postpartum Family Planning (PPFP) \n should be initiated prior to discharge which should be \n Extended support from trained staff should offer\n a continuum of antenatal contraception counselling. \n training of new mothers and then observe and monitor", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_013", "page_number": 6, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 1, "word_count": 85, "chunk_size": 591 } }, { "content": "training of new mothers and then observe and monitor\n The couple should be informed that they are at risk of \n breastfeeding during hospital stay. \n pregnancy as early as four weeks after delivery if the \n woman is not exclusively breastfeeding. \n Women and their newborn baby should stay in hospital\n for at least 24 hours and should not be discharged\n For women with no other medical illnesses, there is \n early until mother is confident about breast feeding.\n no restriction for the use of the following methods \n during the immediate postpartum period: Post-Partum", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_013", "page_number": 6, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 2, "word_count": 90, "chunk_size": 568 } }, { "content": "during the immediate postpartum period: Post-Partum \n Breast feeding is considered as the single most effective\n Intra uterine Devices (PPIUD) and progestogen \n low cost intervention to reduce child morbidity and\n implants. \n mortality worldwide\n27. Another effort for encouraging\n breastfeeding practice is “Baby Friendly” hospitals.\n If couple requests PPIUD, it should be offered to \n Support must be available immediately for new\n women within 48 hours of delivery. \n mothers to initiate breastfeeding in maternity facilities.\n It is important to integrate the WHO/UNICEF Ten Steps", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_013", "page_number": 6, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 3, "word_count": 81, "chunk_size": 585 } }, { "content": "It is important to integrate the WHO/UNICEF Ten Steps\n If the couple wishes to have postpartum sterilization, \n of Successful Breastfeeding (established in 1989) that\n it should be arranged within 48 hours after delivery. \n describe what maternity facilities should do to enable\n a successful start to breastfeeding. Improving access\n Lactational Amenorrhoea (LAM) alone should not be \n to skilled breastfeeding counseling and education, has\n promoted as a method of contraception due to its high \n been shown to result in a 90 percent increase in\n failure rate.", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_013", "page_number": 6, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 4, "word_count": 84, "chunk_size": 562 } }, { "content": "been shown to result in a 90 percent increase in\n failure rate. \n exclusive breastfeeding rates for infants up to five\n months of age\n28. Sri Lanka ranks first among 97\n Fertility returns shortly after childbirth in non-breast \n countries globally on breastfeeding rate according to a\n feeding women\n23. Non-use of PPFP would result in \n new survey conducted by the World Breastfeeding\n unplanned and unwanted pregnancies. Closely spaced \n Trends Initiative (WBTi) achieving first “Green” nation\n pregnancies leads to adverse maternal perinatal and \n status in supporting breastfeeding women\n29.", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_013", "page_number": 6, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 5, "word_count": 87, "chunk_size": 595 } }, { "content": "pregnancies leads to adverse maternal perinatal and \n status in supporting breastfeeding women\n29.\n infant outcomes. PPFP enables women to achieve \n healthy interval between births and potentially averting \n 4.8 Nutrition and general health advice on\n 25-40% of maternal deaths and reducing child mortality \n discharge \n by an estimated 10%24,\n25. The post-partum period \n represents the critical window of opportunity for Nurse in charge of health education should talk to\n women to receive family planning services. Discussion \n women, preferably arrange small group discussions.", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_013", "page_number": 6, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 6, "word_count": 80, "chunk_size": 581 } }, { "content": "women, preferably arrange small group discussions.\n on PPFP should be carried out antenatally and further \n discussions and the provision of PPFP should be \n Women should be advised to eat a greater amount and\n initiated soon after delivery. For women with no other variety of healthy foods, dairy products, oils, nuts,\n medical illnesses, there is no restrictions for the use of seeds, cereals, vegetables, to help her to be well and\n the following methods in the immediate postpartum strong. \n period: Post-Partum Intra uterine Devices (PPIUD), \n progestogen implants and progestogen only pills", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_013", "page_number": 6, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 7, "word_count": 90, "chunk_size": 596 } }, { "content": "progestogen implants and progestogen only pills\n26. The A liquid diet can be offered 2 hours after an uncom-\n PPIUD enables women to leave the birth facility with plicated cesarean delivery.\n 274 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_013", "page_number": 6, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 8, "word_count": 39, "chunk_size": 243 } }, { "content": "================================================== PAGE 7 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_014", "page_number": 7, "content_type": "guidelines", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Women should be reassured that she can eat any normal 5.3 Incident reporting\n food. \n The hospital should adopt effective way of incident\n reporting and feedback mechanism for adverse events.\n Continue iron, folic acid and calcium supplementation \n The prompt investigation of particular incident and\n during lactation. \n implementation of recognized recommendations should\n be carried out by the institutions. \n Women should avoid sexual intercourse until perineal \n wound heals and she feels comfortable, preferably until \n References \n 4-6 weeks postpartum.", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_015", "page_number": 7, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 75, "chunk_size": 560 } }, { "content": "wound heals and she feels comfortable, preferably until \n References \n 4-6 weeks postpartum. \n \n1. Every Newborn, An Executive Summary for The\n As postnatal mothers have increased demand for Lancet’s Series. \n2014. \n nutrition due to rapid recovery of pregnancy related \n \n2. The Inter-agency Group for Child Mortality\n physiological changes and breastfeeding, they need high \n Estimation (UN IGME). Levels & Trends in Child\n quality food and greater amount for eating. There are \n Mortality, Report \n2014. United Nations Children’s\n numerous myths and taboos in different cultures, \n Fund.", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_015", "page_number": 7, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 590 } }, { "content": "2014. United Nations Children’s\n numerous myths and taboos in different cultures, \n Fund. \n exposing women to limited intake. Therefore, postnatal \n education and counseling is important, should com- \n3. Lawn JE et al. Every Newborn: Progress,\n plement antenatal education and counseling and should Priorities, and Potential Beyond Survival. Lancet\n be implemented prior to discharge from the hospital. 2014; 384: 189-\n205. \n Ideally, postnatal education and counseling need to be \n \n4. WHO. WHO Recommendations on Postnatal Care\n individualized and flexible, although there could be", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_015", "page_number": 7, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 2, "word_count": 81, "chunk_size": 583 } }, { "content": "individualized and flexible, although there could be \n of the Mother and Newborn. October \n2013.\n barriers to do so\n30. The largest trial to study early \n Geneva: WHO. \n feeding, conventional feeding within 18 hours or early \n feeding within 2 hours, demonstrated a reduction in \n5. Department of Census and Statistics Sri Lanka.\n thirst and hunger and improved maternal satisfaction, Sri Lanka Demographic and Health Survey \n2016.\n ambulation, and infections\n31. A systematic review and Colombo, Sri Lanka http://www.statistics.gov.lk/", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_015", "page_number": 7, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 3, "word_count": 77, "chunk_size": 536 } }, { "content": "31. A systematic review and Colombo, Sri Lanka http://www.statistics.gov.lk/\n meta-analysis of 17 studies also supported these Resource/en/Health/DemographicAndHealth\n findings\n32. SurveyRep ort-2016-Contents. (Accessed \n30.\n 09.2020) \n \n5. Clinical governance \n6. Singh S, McGlennan A, England A, Simons R.A\n validation study of the CEMACH recommended\n 5.1 Quality of care \n modified early obstetric warning system\n With increasing numbers of births in health facilities, (MEOWS). Anaesthesia 2012(67): 12-\n18.\n attention has shifted to the quality of care, as poor", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_015", "page_number": 7, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 4, "word_count": 74, "chunk_size": 566 } }, { "content": "18.\n attention has shifted to the quality of care, as poor \n \n7. Glazener CMA, Abdalla M, Stroud P, Naji S,\n quality of care contributes to morbidity/mortality and \n Templeton A. Russell IT Postnatal morbidity.\n maternal unsatisfaction. A hospital providing maternity \n Extend, course, prevention and treatment. Br J\n services should have the mission of every pregnant \n Obstet Gynaecol 1995; 102: 286-\n7. \n woman and newborn receives high-quality care \n throughout pregnancy, childbirth and the postnatal \n8. Sleep J. Perineal care: a series of 5 randomized", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_015", "page_number": 7, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 5, "word_count": 82, "chunk_size": 558 } }, { "content": "8. Sleep J. Perineal care: a series of 5 randomized\n period. To accomplish the mission, standard quality control trials, In: Robinson S, Thomson A , Editors.\n assessment procedure should be implemented and Midwives Research and Child-birth. London :\n monitored in regular basis. Chapman and Holl. 1991: 199-\n251. \n \n9. Leung L. From ladder to platform: a new concept\n 5.2 Training for pain management. J Prim Health Care 2012; 4:\n 254-\n8. \n The maternity staff should be regularly trained with \n updated knowledge and skills to provide comprehensive \n10. Bamigboye AA, Hofmeyr GJ. Local anaesthetic", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_015", "page_number": 7, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 6, "word_count": 93, "chunk_size": 598 } }, { "content": "10. Bamigboye AA, Hofmeyr GJ. Local anaesthetic\n postnatal care. Communication and counseling wound infiltration and abdominal nerves block\n workshops should be arranged for health professionals during caesarean section for postoperative pain\n for better communication with postnatal women and relief. Cochrane Database Syst Rev 2009; 3:\n their families. CD\n006954. \n Vol. 43, No. 3, September 2021 275", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_015", "page_number": 7, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 7, "word_count": 56, "chunk_size": 402 } }, { "content": "================================================== PAGE 8 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_016", "page_number": 8, "content_type": "guidelines", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "11. Spigset O, Hagg S. Analgesics and breast-feeding: Urogynaecology Journal, 2003; 14: 119-\n21.\n safety considerations. Paediatr Drugs 2000; 2: www.springerlink.com. \n 223-\n38. \n \n22. National Guidelines for Newborn Care, Family\n \n12. Fahey JO. Best practices in management of Health Bureau, \n2020. \n postpartum pain. J Perinat Neonatal Nurs 2017; \n \n23. Jackson E, Glasier A. Return of ovulation and\n 31: 126-\n36. \n menses in postpartum non lactating women: a\n \n13. Renfew MT, Hannah W, Albert L, Floyed E. systematic review. Obstet Gynecol 2011; 117(3):\n 657-\n62.", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_017", "page_number": 8, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 566 } }, { "content": "657-\n62. \n Practices that minimize trauma to the genital track \n in the child birth: A systematic review of the \n \n24. Campbell MR, Graham WJ. Strategies for reducing\n Literatur. Birth 1998 ; 25: 143-\n60. \n maternal mortality. Getting on with what works,\n Lancet, 2006; 368(9543): 1284-\n99. \n \n14. East CE, Begg L, Henshall NE, Marchant PR, \n Wallace K. Local cooling for relieving pain from \n25. Cleland J, et al. Family planning. The unfinished\n perineal trauma sustained during childbirth. agenda, Lancet 2006; 368(9549): 1810-\n27.\n Cochrane Database of Systematic Reviews 2012,", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_017", "page_number": 8, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 581 } }, { "content": "27.\n Cochrane Database of Systematic Reviews 2012, \n \n26. UK Medical Eligibility Criteria. \n2016. https://\n Issue \n5. Art. No.: CD\n006304. \n www.fsrh.org/standards-and-guidance/ \n \n15. Harvey MA, Pierce M, Alter JE, Chou Q, Diamond documents/ukmec-2016 (Accessed 30.09.2020)\n P, Epp A, et al. Obstetrical anal sphincter injuries \n \n27. Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker\n (OASIS): Prevention, recognition, and repair. \n N, Horton S, et al. Maternal and Child Nutrition\n Clinical Practice Guideline No. \n330. Journal of \n Study Group. Evidence-based interventions for", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_017", "page_number": 8, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 2, "word_count": 79, "chunk_size": 577 } }, { "content": "Clinical Practice Guideline No. \n330. Journal of \n Study Group. Evidence-based interventions for\n Obstetrics and Gynaecology Canada 2015; 37(12): \n improvement of maternal and child nutrition: what\n 1131-\n48. \n can be done and at what cost? The lancet 2013;\n \n16. Bick D. Postpartum management of the perineum. 382(9890): \n452. \n British Journal of Midwifery 2009; 17(9): 571-\n7. \n \n28. Sinha B, Chowdhury R, Sankar MJ, Martines J,\n Taneja S, Mazumder S, et al Interventions to\n \n17. NICE clinical guideline on caesarean section, No. \n improve breastfeeding outcomes: A systematic\n 132, \n2011.", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_017", "page_number": 8, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 3, "word_count": 87, "chunk_size": 593 } }, { "content": "improve breastfeeding outcomes: A systematic\n 132, \n2011. \n review and meta-analysis. ActaPaediatrica 2015;\n \n18. Ian N, Ramsay, Torbet TE. Incidence of abnormal 104: 114-\n34. \n voiding parameters in the immediate postpartum \n \n29. World Breastfeeding Trends Initiative year 2019,\n period. Neurology and urodynamics 1993 (12): \n https://www.worldbreastfeedingtrends.org/wbti-\n 179-\n83. \n country-ranking.php (Accessed 30.09.2020)\n \n19. Lennard, F. To wee or not to wee: that is the \n \n30. World Health Organisation. WHO Recom-\n distention? Journal of the Association of Chartered", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_017", "page_number": 8, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 4, "word_count": 74, "chunk_size": 579 } }, { "content": "30. World Health Organisation. WHO Recom-\n distention? Journal of the Association of Chartered \n mendations on Postnatal Care of the Mother and\n Physiotherapists in Women’s Health 2005; 96: \n Newborn. \n2013. WHO. Geneva Switzerland.\n 41-\n6. \n \n31. Jalilian N, Ghadami MR. Randomized clinical trial\n \n20. Ching-Chung, L, et al. ‘Postpartum urinary \n comparing postoperative outcomes of early versus\n retention: assessment of contributing factors and late oral feeding after cesarean section. J Obstet\n long term clinical impact’ in Australian and New Gynaecol Res 2014; 40: 1649-\n52.", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_017", "page_number": 8, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 5, "word_count": 83, "chunk_size": 582 } }, { "content": "long term clinical impact’ in Australian and New Gynaecol Res 2014; 40: 1649-\n52.\n Zealand Journal of Obstetric Gynaecology, 2002; \n \n32. Hsu YY, Hung HY, Chang YI. Early oral intake and\n 42 (4): 367-\n70. \n gastrointestinal function after cesarean delivery: a\n \n21. Glavind, K. and BjØrk, j . Incidence and treatment systematic review and metaanalysis. Obstet\n of urinary retention postpartum. International Gynecol 2013; 121: \n1327.\n 276 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "section": "Section_017", "page_number": 8, "content_type": "maternal_care", "source_file": "Postnatal-care-during-hospital-stay-Sept-6.pdf", "chunk_index": 6, "word_count": 73, "chunk_size": 486 } }, { "content": "================================================== PAGE 1 ==================================================\nNATIONAL GUIDELINES FOR", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_000", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 7, "chunk_size": 132 } }, { "content": "• Management of Labour \n \n \n• Management of Hypertension, Pre Eclampsia \n and Eclampsia in Pregnancy \n \n \n• Management of Diabetes During Pregnancy \n \n \n• Management of Post-Partum Haemorrhage", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_001", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 25, "chunk_size": 192 } }, { "content": "Family Health Bureau \n \n World Health \n Organization", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_002", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 52 } }, { "content": "================================================== PAGE 2 ==================================================", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_003", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 4, "chunk_size": 108 } }, { "content": "================================================== PAGE 3 ==================================================\nNATIONAL GUIDELINE FOR MATERNAL CARE", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_004", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 145 } }, { "content": "• Management of Labour \n \n Normal Labour \n \n Induction of Labour \n \n Use of Oxytocins in Induction and Augmentation\n \n Foetal Monitoring in Labour \n \n Pain Relief \n \n Acute Inversion of Uterus \n \n• Management of Hypertension, Pre Eclampsia and\n Eclampsia in Pregnancy \n \n \n• Management of Diabetes in Pregnancy \n \n \n• Management of Post-Partum Haemorrhage", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_005", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 47, "chunk_size": 355 } }, { "content": "Family Health Bureau \n \n World Health \n Organization", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_006", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 52 } }, { "content": "================================================== PAGE 4 ==================================================\nThese guidelines are published by the Family Health Bureau, Ministry of\n Health, 231, De Saram Place, Colombo 10, Sri Lanka. \n \n Web: www.familyhealth.gov.lk \n \n Prepared by Sri Lanka College of Obstetrians and Gynaecologists", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_007", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 35, "chunk_size": 334 } }, { "content": "Edited By Dr. Nilmini Hemachnadra, Consultant Community Physician,\n Family Health Bureau & Prof. Hemantha Senanayake, President, Sri Lan-\n ka College of Obstetricians & Gynaecologists.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_008", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 24, "chunk_size": 184 } }, { "content": "Statement of Intent \n \n The main purpose of these guidelines are to improve the quality of\n clinical care provided by the health care providers at all levels. These\n parameters of practice should be considered recommendations\n only. The ultimate judgement regarding a particular clinical\n procedure or a treatment plan must be made by the clinician in\n light of the clinical data gathered from the patient and the diagnosis\n and treatment options available.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_009", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 457 } }, { "content": "ii National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_010", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 5 ==================================================\nForeword from the Secretary to the Ministry of Health", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_011", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 162 } }, { "content": "As a country with a mainly government owned health system, maintenance\n of the uniformity of practices is essential to avoid incurring unnecessary\n expenditure. Incorporation and practice of evidence based cost effective\n interventions in maternal care will ensure further improvement of the\n maternal care indicators. \n \n The availability and use of guidelines will ensure the quality of the care\n provided at each level and facilitate the care provision of practicing\n clinicians for better care. The Ministry of Health having achieved a", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_012", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 539 } }, { "content": "clinicians for better care. The Ministry of Health having achieved a\n satisfactory level in the coverage of services and geared to improve it\n further, is currently moving towards improving the quality of services\n provided. With this view, most of the institutions are now implementing\n quality improvement programmes. \n \n Therefore, this set of guidelines will assist such programmes and auditing\n systems in the maternal care such as maternal mortality reviews,\n \n confidential inquiry into maternal deaths, near-miss inquiries and", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_012", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 76, "chunk_size": 534 } }, { "content": "confidential inquiry into maternal deaths, near-miss inquiries and\n ensure a more objective assessment. These guidelines should be link with\n the quality standards and the implementation at each level needs to be\n ensured. \n \n Sri Lanka College of Obstetricians and Gynaecologists has managed to in\n co-operate the currently available best scientific evidence and the practical\n experience of a large number of experts into these guidelines.\n \n I wish all the healthcare providers would make maximum use of these\n guidelines and contribute to the further improvement of the maternal care", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_012", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 587 } }, { "content": "guidelines and contribute to the further improvement of the maternal care\n in our country.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_012", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 14, "chunk_size": 90 } }, { "content": "Dr. Y.D. Nihal Jayathilake \n Secretary, \n Ministry of Health, \n Sri Lanka \n \n National Guideline for Maternal Care - Volume I iii", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_013", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 19, "chunk_size": 129 } }, { "content": "================================================== PAGE 6 ==================================================\niv National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_014", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 159 } }, { "content": "================================================== PAGE 7 ==================================================\nPreface", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_015", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 5, "chunk_size": 116 } }, { "content": "This national guideline on maternal care is very well-timed, as a greater\n emphasis is being given for improving the quality of maternal and\n newborn care services for further reduction of maternal and newborn\n mortality and morbidity in Sri Lanka. This set of guidelines includes\n the revised versions of some guidelines published in 2007 under HSDP\n \n Phase I and newly developed guidelines. This is an attempt to improve the\n quality and uniformity of clinical care with efficiency, cost effectiveness\n and accountability. \n \n I highly appreciate the contribution made by the Sri Lanka College of", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_016", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 92, "chunk_size": 599 } }, { "content": "and accountability. \n \n I highly appreciate the contribution made by the Sri Lanka College of\n Obstetricians and Gynaecologists in developing these guidelines. Their\n \n experience and updated scientific knowledge is reflected in the guidelines.\n Further, these guidelines have been developed considering the policies,\n facilities and resources available in the country. As such this set of\n guidelines will be considered as national guidelines for the conditions\n described.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_016", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 64, "chunk_size": 474 } }, { "content": "Dr. P. G. Mahipala \n Director General of Health Services, \n Ministry of Health, \n Sri Lanka.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_017", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 14, "chunk_size": 92 } }, { "content": "================================================== PAGE 8 ==================================================\nMessage from the president of Sri Lanka College of\n \n Obstetricians", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_018", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 14, "chunk_size": 176 } }, { "content": "It is with a great sense of achievement that I issue this statement for the\n \n Sri Lanka National Guidelines in obstetrics. There is evidence that the\n introduction of guideline-based practice will reduce maternal mortality.\n We hope that this effect will be duplicated in Sri Lanka.\n \n I must compliment the Guideline Development Group of our College.\n This document is testimony to their hard work and their commitment to\n \n improving the quality of care delivered to our women. The group consisted\n of obstetricians from varying seniority and from hospitals representing", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_019", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 88, "chunk_size": 573 } }, { "content": "of obstetricians from varying seniority and from hospitals representing\n all categories of specialist units in the country. We were therefore able to\n develop our guidelines taking into considerations the ground realities in\n Sri Lanka. I was heartened by the maturity shown by the younger members,\n who contributed immensely to the many points that were debated while\n these were being developed. We have used the latest available evidence\n \n and taken into account what would be feasible in a Sri Lankan Unit. For\n what we have recommended as improvements to the existing practice we", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_019", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 92, "chunk_size": 585 } }, { "content": "what we have recommended as improvements to the existing practice we\n have had agreement from the Ministry of Health to procure these.\n \n I wish also to acknowledge our general membership who contributed to\n these guidelines via email and at a meeting where their views were sought.\n \n It is always a challenge to produce guidelines that will be put into use in\n everyday practice and it is probable we have achieved this primary goal by\n having a broad based input. \n \n The World Health Organization and the UNFPA supported this activity.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_019", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 89, "chunk_size": 539 } }, { "content": "The World Health Organization and the UNFPA supported this activity.\n Dr. Nilmini Hemachandra of the Family Health Bureau helped get the\n final product into a form that was easily understood by the non-specialist.\n \n We are grateful for the advice given by Obstetric Anaesthetists Drs. Saroja\n \n vi National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_019", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 54, "chunk_size": 346 } }, { "content": "================================================== PAGE 9 ==================================================\nJayasinghe and Ramani Pallemulla. The guideline on diabetes mellitus\n complicating pregnancy had major inputs from the Nirogi Matha project\n \n and many endocrinologists. \n \n To conclude I wish to restate my wish and fervent hope that these\n guidelines will help save the lives of many Sri Lankan mothers.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_020", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 50, "chunk_size": 413 } }, { "content": "Prof. Hemantha Senanayake \n President, \n Sri Lanka College of Obstetricians & Gynaecologists", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_021", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 11, "chunk_size": 92 } }, { "content": "National Guideline for Maternal Care - Volume I vii", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_022", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 10 ==================================================\nGuideline Development Committee \n \n Dr. Asoka Weerakkody (Chairman) \n \n Prof. Hemantha Senanayake \n Prof. Malik Goonawardena \n Dr. Ananda Ranatunga \n \n Dr.UDP Ratnasiri \n Dr. Sunil Fernando \n \n Dr. Harsha Atapattu \n Dr. Mangala Dissanayake \n Dr. Chandina Wedamistri \n \n Dr. Jeevan Marasinghe \n Dr. Tiran Dias \n \n Dr. Asanka Jayawardena", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_023", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 43, "chunk_size": 445 } }, { "content": "viii National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_024", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 11 ==================================================\nContent page \n \n Page \n Message from the Secretary of Ministry of Health iii\n Preface v \n Message from the President of the Sri Lanka College of\n Obstetricians and Gynecologists vi \n Guideline Development Committee viii \n List of Abbreviations xiii \n List of Tables xiv \n \n Disclaimer xv \n Introduction xvi \n A Management of Labour 3 \n \n1. Introduction 3 \n \n2. Diagnosis of labour 3 \n \n3. Management of Labour 4 \n 3.1 General considerations 4", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_025", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 552 } }, { "content": "2. Diagnosis of labour 3 \n \n3. Management of Labour 4 \n 3.1 General considerations 4 \n 3.1.1 Communication between women and healthcare\n professionals/workers 4 \n 3.1.2 Preparation of mothers to transfer to labour room 4\n 3.1.3 Documentation 5 \n 3.1.4 Mobilization and Positioning 5 \n 3.1.6 Hygiene during labour 5 \n 3.1.7 Pain relief in labour 6 \n 3.\n2. Management of the three stages of labour 6\n 3.2.\n1. Management of the first stage of labour 6\n 3.2.1.1 Latent phase 6 \n 3.2.1.2 Active phase 7 \n 3.2.1.2a. Admitting women to the Labour room 7", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_025", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 546 } }, { "content": "3.2.1.1 Latent phase 6 \n 3.2.1.2 Active phase 7 \n 3.2.1.2a. Admitting women to the Labour room 7\n 3.2.1.2b. Management of active phase of first stage 8\n 3.2.1.\n3. Delayed progress of first stage of labour 9\n 3.2.\n2. Management of second stage of labour 10\n 3.2.2.\n1. Passive second stage of labour (descent phase) 10\n 3.2.2.\n2. Active second stage of labour (expulsive phase) 11\n 3.2.2.\n3. Observations for women and babies in the second stage of labour 12\n 3.2.2.\n4. Women’s position and pushing in the second stage of labour 12\n 3.2.2.\n5. Intrapartum interventions to reduce perineal trauma 13", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_025", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 100, "chunk_size": 595 } }, { "content": "3.2.2.\n5. Intrapartum interventions to reduce perineal trauma 13\n 3.2.2.\n6. Delivery 13 \n 3.2.3 Third stage of Labour 14 \n 3.2.3.1 Active management of third stage of labour 14\n 3.2.3.2 Delayed third stage 15 \n 4 Care for the newborn baby 15 \n 5 Perineal care 17 \n National Guideline for Maternal Care - Volume I ix", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_025", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 53, "chunk_size": 315 } }, { "content": "================================================== PAGE 12 ==================================================\nB Guideline on Induction of Labour 19 \n \n 1 Introduction 19 \n 2 Definition 19 \n 3 General Principles 19 \n 4 Indications 19 \n 4.1 Otherwise uncomplicated pregnancy continuing \n beyond 40 weeks 19 \n 4.2 Pre labour rupture of membranes at term 20 \n 4.3 Preterm prelabour rupture of membranes (PPROM) 20\n 4.4 Intrauterine death 20 \n 4.5 History of precipitate labour 20 \n 4.6 Suspected macrosomia 20 \n 4.7 Fetal growth restriction 21 \n 4.8 Older mothers 21", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_026", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 562 } }, { "content": "4.6 Suspected macrosomia 20 \n 4.7 Fetal growth restriction 21 \n 4.8 Older mothers 21 \n 5 Induction under specific circumstances 21 \n 5.1 Breech presentation 21 \n 5.2 Previous CS 21 \n \n6. Methods of induction 21 \n 6.1 Mechanical 21 \n 6.2 Surgical 22 \n 6.3 Pharmacological 22 \n 6.3.1 Oxytocin 22 \n 6.3.2 Prostaglandins 22 \n 6.3.3 Mifepristone 23 \n \n7. Complications 24 \n 7.1 Hyperstimulation 24 \n 7.2 Cord prolapse 24 \n 7.3 Uterine rupture 25 \n 7.4 Failed induction 25 \n C Guideline for Use of Oxytocin for Induction and Augmentation\n of labour 27 \n D Guideline on fetal monitoring in labour 30", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_026", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 592 } }, { "content": "of labour 27 \n D Guideline on fetal monitoring in labour 30 \n E Guideline on Pain Relief in Labour 34 \n 1 Methods of pain relief in labour 34 \n 1.1 Non-pharmacological methods of pain relief 35\n 1.2 Pharmacological methods of pain relief in labour 35\n 1.2.1 Oral paracetamol/paracetamol& codeine compound 35\n 1.2.2 Opioids 35 \n 1.2.2.A. Pethidine 35 \n 1.2.2.B. Morphine 36 \n 1.2.2.C. Fentanyl 36 \n 1.2.3 Inhalational analgesia – Entonox 36 \n 1.2.4 Regional Anaesthesia 37 \n x National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_026", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 80, "chunk_size": 523 } }, { "content": "================================================== PAGE 13 ==================================================\nF Guidelines to maintain the partograph 39 \n \n G Guideline on acute puerperal inversion of the uterus 41\n 1 Introduction 41 \n 2 Definition 41 \n 3 Prevention 41 \n 4 Pathophysiology (and clinical correlation) 41\n 5 Classification 42 \n 6 Clinical Presentation and diagnosis 42 \n 7 Management 43 \n 7.1 General measures 43 \n 7.2 Repositioning the uterus 43 \n 7.2.1 Manual replacement of uterus 43 \n 7.2.2 Hydrostatc reduction 44 \n 7.2.3 Tocolytics 45 \n 7.2.4 General Anaesthesia 45", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_027", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 586 } }, { "content": "7.2.2 Hydrostatc reduction 44 \n 7.2.3 Tocolytics 45 \n 7.2.4 General Anaesthesia 45 \n 7.2.5 Surgical methods 45 \n 8 Debriefing 46 \n H Management of Hypertensive Disease in Pregnancy 47\n 1 Introduction 49 \n 2 Definitions 49 \n 3 Screening for Hypertension during pregnancy 50\n 4 Prevention of hypertensive disorders in pregnancy 50\n 5 Management of Chronic Hypertension 51 \n 6 Management of severe pre eclampsia 52 \n 6.1 General Considerations 52 \n 6.2 Specific Management 52 \n 6.2.1 Anti-hypertensive drugs 53 \n 6.2.1.1 Labetalol orally or intravenously 53 \n 6.2.1.2 Hydralazine intravenously 54", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_027", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 593 } }, { "content": "6.2.1.1 Labetalol orally or intravenously 53 \n 6.2.1.2 Hydralazine intravenously 54 \n 6.2.1.3 Oral Nifedipine 55 \n 6.2.2 Prevention of convulsions 55 \n 6.2.3 Fluid Balance 56 \n 6.2.4 In utero/neonatal transfer 56 \n 6.2.5 Delivery 57 \n 6.2.6 Post-delivery 57 \n 6.2.7 Follow up 58 \n I Management of Eclampsia 59 \n 1 Definition 59 \n 2 Diagnosis 59 \n 3 Time of onset of eclampsia 59 \n 4 Comorbidities 59 \n 5 Prevention 60 \n 6 Management 60 \n 6.1 General considerations 60 \n 6.\n2. During the seizure 61 \n National Guideline for Maternal Care - Volume I xi", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_027", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 550 } }, { "content": "================================================== PAGE 14 ==================================================\n6.\n3. As soon as possible following a seizure 61 \n 6.\n4. Management of seizures in women receiving \n magnesium sulphate 62 \n \n7. Delivery 62 \n \n8. Transfer of a woman who has had a seizure to another institution 63\n \n9. Postpartum management 63 \n \n10. Counselling 64 \n J Management of Diabetes during Pregnancy 67 \n 1 Purpose 67 \n 2 Screening 67 \n 2.1 Target groups for screening 67 \n 2.2 Recommended tests 68 \n 3 Management – Women with established Diabetes 70\n 3.1 Pre Pregnancy care 70", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_028", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 85, "chunk_size": 598 } }, { "content": "3 Management – Women with established Diabetes 70\n 3.1 Pre Pregnancy care 70 \n 3.2 Antenatal Care 71 \n 3.3 Medical nutrition therapy (MNT) 72 \n 3.4 Exercise 72 \n 4 Glyceamic control and Monitoring 73 \n 4.1 Glyceamic Control 73 \n 4.2 Monitoring of glycaemic control 74 \n 5 Delivery and intra natal care 74 \n 5.1 Timing of delivery 74 \n 5.2 Labour care 75 \n 6 Post natal care 75 \n 6.1.a Neonatal care 75 \n 6.1.b Immediate post partum care 76 \n 6.2 At hospital discharge 76 \n 6.3 Late Postnatal care and follow up 77 \n 7 Family Planning 77 \n K Management of Primary Post Partum Haemorrhage 81", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_028", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 98, "chunk_size": 589 } }, { "content": "7 Family Planning 77 \n K Management of Primary Post Partum Haemorrhage 81 \n 1 Introduction 81 \n 2 Definition 81 \n 3 Prevention of Post Partum Haemorrhage 81 \n 4 Prediction of Post Partum Haemorrhage 82 \n 5 Management of Primary PPH 83 \n 5.1 General measures 83 \n 5.2 Specific measures 84 \n 5.2.1 Establish a cause for the bleeding 84 \n 5.2.\n2. Management of atonic haemorrhage 85 \n 5.2.3 Management of traumatic PPH 86 \n 5.2.4 Rupture of the uterus 87 \n 5.2.5 Coagulopathy causing PPH 87 \n \n6. Resuscitation and Fluid management 87 \n \n7. Debriefing 88 \n \n8. Risk Management 89 \n Appendix 1 90", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_028", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 94, "chunk_size": 592 } }, { "content": "7. Debriefing 88 \n \n8. Risk Management 89 \n Appendix 1 90 \n Appendix 2 92 \n Appendix 3 94 \n xii National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_028", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 25, "chunk_size": 143 } }, { "content": "================================================== PAGE 15 ==================================================\nList of Abbreviations \n \n WHO World Health Organization \n UNFPA United Nations Population Fund \n UNICEF United Nations Children’s Fund \n SLCOG Sri Lanka College of Obstetricians and Gynaecologists\n NICE National Institutive of Clinical excellency\n RCOG Royal College of Obstetricians and Gynaecologists\n FHR Fetal Heart Rate \n CPD Cephalo Pelvic Disproportion \n NALS Neonatal Advanced Life Support \n PPROM Preterm prelabour rapture of the Membranes\n CS Caesarean Section", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_029", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 65, "chunk_size": 580 } }, { "content": "PPROM Preterm prelabour rapture of the Membranes\n CS Caesarean Section \n CTG Cardiotocography \n \n IV Intravenous \n IM Intra muscular \n IU International Units \n EFM Electronic Fetal Monitoring \n TENS Transcutaneous electrical nerve stimulation\n HELLP Haemolysis, elevated liver enzymes and low platelet\n HDU High dependency unit \n ICU Intensive care unit \n PGDM Pre gestational diabetes mellitus \n GDM Gestational Diabetes Mellitus \n OGCT Oral glucose Challenge Test \n OGTT Oral Glucose Tolerance test \n PPBS Post Prandial Blood Sugar \n MNT Medical Nutrition therapy", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_029", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 73, "chunk_size": 565 } }, { "content": "OGTT Oral Glucose Tolerance test \n PPBS Post Prandial Blood Sugar \n MNT Medical Nutrition therapy \n DENO Diabetic Educator Nursing officer \n SMBG Self-monitoring of blood glucose \n AC Abdominal Circumference \n SHO Senior House Officer \n CBG Capillary Blood Glucose \n ENC Essential New-born Care \n DM Diabetes Mellitus \n DMPA Depot Medroxy Progesterone Acetate \n BMI Body Mass Index \n PPH Post Partum Haemorrhage \n \n National Guideline for Maternal Care - Volume I xiii", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_029", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 64, "chunk_size": 468 } }, { "content": "================================================== PAGE 16 ==================================================\nList of Tables \n \n Guidelines for ruse of oxytocin for induction and augmentation of labour\n \n Table 1 mU/minute administered at different rates of administration\n according to drop rate \n \n Table 2 mU/minute infused per minute when administered via an infusion\n pump \n \n Guideline on fetal monitoring in labour \n \n Table 1 Definitions of normal, suspicious and pathological FHR rates\n Table 2 Classification of fetal heart rate patterns", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_030", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 67, "chunk_size": 547 } }, { "content": "Guideline for screening, diagnosis and management of diabetes in pregnant\n women \n \n Table 1 Target values in glycaemic control", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_031", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 18, "chunk_size": 127 } }, { "content": "xiv National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_032", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 17 ==================================================\nDisclaimer", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_033", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 5, "chunk_size": 120 } }, { "content": "These guidelines are based on current best available evidence and\n consensus opinion of the Guideline Development committee of\n the Sri Lanka College of Obstetricians & Gynaecologists. They are\n neither intended to replace the process of critical evaluation of\n every case and nor it is intended to dictate an exclusive course of\n \n management or treatment. It must be interpreted with reference to\n individual patient needs, available resources and limitations unique\n to the institution and variations in local populations.\n \n Medicine is a continually evolving science and the users must have", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_034", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 88, "chunk_size": 595 } }, { "content": "Medicine is a continually evolving science and the users must have\n regard to relevant information, research or material, which may\n have been published or become available subsequently.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_034", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 27, "chunk_size": 186 } }, { "content": "National Guideline for Maternal Care - Volume I xv", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_035", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 18 ==================================================\nIntroduction", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_036", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 5, "chunk_size": 122 } }, { "content": "Clinical Guidelines are systematically developed statements which assist\n clinicians and patients in making decisions about appropriate treatment\n for specific conditions based on the best scientific evidence at the time of\n development. Guidelines are not intended to limit the clinical freedom;\n however, clinicians are expected to follow these recommendations as the\n \n basis for their decision making. Availability of resources, the existing\n situations, and the expectations of individual client needs to be considered.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_037", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 524 } }, { "content": "situations, and the expectations of individual client needs to be considered.\n \n The guidelines are intended to guide all health care workers in all levels\n of institutions where maternity care is being provided. Although these\n guidelines are mainly targeted for the government sector institutions, use\n \n in the private sector institutions where maternity care is being provided,\n is also encouraged. \n \n These guidelines are developed by the guideline development committee\n of the Sri Lanka College of Obstetricians and Gynaecologists in", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_037", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 77, "chunk_size": 541 } }, { "content": "of the Sri Lanka College of Obstetricians and Gynaecologists in\n consultation with other relevant specialists such as anaesthesiologists,\n physicians, endocrinologists, and haematologists etc. The existing\n \n national guidelines developed in 2007, NICE guidelines on intranatal\n care, WHO guidelines and RCOG guidelines were perused and mixed\n with the local scenarios and expert opinion. The latest available scientific\n evidences were considered and included where ever necessary. Then, the\n draft guidelines were presented to the wider forum of obstetricians and", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_037", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 76, "chunk_size": 565 } }, { "content": "draft guidelines were presented to the wider forum of obstetricians and\n consensuses were arrived. After that the guidelines were handed over to\n \n the Ministry of Health and consensus was built with the participation\n of multi-disciplinary team including medical administrators, provincial\n health authorities, representatives from SLCOG and other relevant\n professional colleges, and national programme managers.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_037", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 54, "chunk_size": 414 } }, { "content": "xvi National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_038", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 19 ==================================================\nManagement of Labour", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_039", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 7, "chunk_size": 130 } }, { "content": "================================================== PAGE 20 ==================================================\n2 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_040", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 159 } }, { "content": "================================================== PAGE 21 ==================================================\nManagement of Normal Labour \n \n \n1. Introduction \n \n The aim of this guideline is to provide recommendations to care providers\n in the management of a healthy woman with a single fetus in labour at\n term (37-42weeks). It does not cover the care of women with complicated\n pregnancies. \n \n The objective of this guideline is to ensure optimal management of\n women in labour, detect any abnormalities, take appropriate action,", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_041", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 534 } }, { "content": "women in labour, detect any abnormalities, take appropriate action,\n prevent complications and thus make childbirth safer; and also to make\n sure that these women are treated with respect and compassion, and kept\n well informed and well supported throughout labour.\n \n \n2. Diagnosis of Labour \n \n Labour is diagnosed by the presence of regular, painful intermittent\n contractions, which are of increasing frequency, duration and intensity,\n leading to progressive cervical effacement and dilatation.\n \n Note: for the purpose of this guideline, labour is also diagnosed in the", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_041", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 575 } }, { "content": "Note: for the purpose of this guideline, labour is also diagnosed in the\n presence of painful contractions occurring at a frequency of 2 in 10\n minutes or more.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_041", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 28, "chunk_size": 160 } }, { "content": "Definitions: \n \n Latent phase of the first stage of labour – from the commencement\n of labour to a cervical dilatation of up to 4 cm. (This is a period\n of time, not necessarily continuous, when there are painful\n contractions and some cervical changes including cervical\n effacement and dilatation up to 4cm take place)\n \n Active phase of the first stage of labour – commences at a cervical\n dilatation of 4cm and ends with full dilatation. (There are regular\n painful contractions and progressive cervical dilatation from 4cm\n up to full dilatation).", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_042", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 88, "chunk_size": 552 } }, { "content": "================================================== PAGE 22 ==================================================\nIf the diagnosis of labour is uncertain, observation should continue and\n reassessment made in four hours. \n \n Any woman who is diagnosed as not being in labour, but continues to\n complain of pain, would require careful reassessment by an experienced\n medical officer. Possible diagnoses of placental abruption and non-\n obstetric causes should be considered. Fetal compromise should be\n excluded. \n \n \n3. Management of labour \n \n 3.\n1. General considerations \n \n 3.1.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_043", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 578 } }, { "content": "excluded. \n \n \n3. Management of labour \n \n 3.\n1. General considerations \n \n 3.1.\n1. Communication between women and healthcare professionals/\n workers \n \n \n• Greet the mother with a smile and a personal welcome\n \n• Treat them with respect and dignity \n \n \n• Assure privacy \n \n• Establish a good rapport with the laboring women asking\n about their wants and concerns and address them\n \n• Maintain a calm and confident approach which will reassure\n women that the situation is under control \n \n• Assess the woman’s knowledge of strategies for coping with", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_043", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 84, "chunk_size": 552 } }, { "content": "• Assess the woman’s knowledge of strategies for coping with\n pain and provide balanced information to find out which\n available approaches are acceptable to her \n \n• Ask her permission before all procedures and observations,\n focusing on the woman rather than technology or the\n documentation \n \n 3.1.\n2. Preparation of mothers to transfer to labour room\n \n \n• Shaving or trimming of perineal hair may be necessary to\n facilitate unhindered performance and repair of the episiotomy.\n \n \n• Efforts must be made to minimize faecal soiling. Where\n an enema is deemed necessary, a medicated enema is", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_043", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 92, "chunk_size": 596 } }, { "content": "an enema is deemed necessary, a medicated enema is\n recommended. \n (These two steps should not be considered mandatory)\n 4 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_043", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 27, "chunk_size": 170 } }, { "content": "================================================== PAGE 23 ==================================================\n• Women should be encouraged to have a companion of her\n choice during labour, depending on the facilities and clinical\n situation. \n \n 3.\n1. \n3. Documentation \n \n \n• Admit the mother to the labour room and complete the\n ‘handing over’ form \n \n \n• Enter relevant notes on the BHT and start a partogragh (see\n page 39) \n \n• Review clinical notes and reassess risk factors.\n \n• Accurate documentation of all observations and interventions\n must be made, with timing.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_044", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 78, "chunk_size": 574 } }, { "content": "• Accurate documentation of all observations and interventions\n must be made, with timing. \n \n• All obstetric examinations and procedures carried out must\n be documented in the clinical notes. Each entry must be\n accompanied by a plan for management and be signed by the\n responsible person. \n \n 3.1.\n4. Mobilization and Positioning \n \n \n• Women should be encouraged and helped to move about\n and adopt whatever positions they find most comfortable\n throughout labour. \n \n• They need to be encouraged to void urine at regular intervals.\n \n 3.1.\n5. Eating and drinking in labour", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_044", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 577 } }, { "content": "3.1.\n5. Eating and drinking in labour \n \n \n• Mothers must be encouraged to consume clear, non-\n fizzy liquids during labour. Isotonic solutions such as oral\n rehydration fluid and king coconut water are more beneficial\n than water. \n \n \n• In addition to clear fluids, women in the latent phase may\n consume light solids e.g. biscuits and fruits.\n \n 3.1.\n6. Hygiene measures during labour \n \n \n• Strict asepsis must be maintained during labour.\n \n• Instruments should be available in packets\n National Guideline for Maternal Care - Volume I 5", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_044", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 541 } }, { "content": "================================================== PAGE 24 ==================================================\n• Use proper hand washing technique. \n \n \n• Use of double gloves and disposable gloves is encouraged.\n \n 3.1.\n7. Pain relief in labour \n \n Relief of pain should be a major consideration (please refer guidelines on\n pain relief during labour in page 34) \n \n 3.\n2. Management of the three stages of labour \n \n The practice of maintaining a labour room ‘notice board’ - a ‘white\n board’ on which the status of all women in labour is summarized", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_045", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 78, "chunk_size": 550 } }, { "content": "board’ on which the status of all women in labour is summarized\n and updated regularly is encouraged. This would convey at a glance\n to all care providers women who require additional attention. The\n age, parity status, risk factors, salient findings at each assessment\n and any abnormalities noted must be included in this.\n \n 3.2.\n1. Management of first stage of labour \n \n 3.2.\n1. \n1. Latent phase \n \n It is important to recognize the latent phase of labour, since its prolongation\n could lead to maternal exhaustion, dehydration and acidosis, leading to", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_045", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 88, "chunk_size": 557 } }, { "content": "could lead to maternal exhaustion, dehydration and acidosis, leading to\n fetal compromise and dysfunctional labour. \n \n Women in the latent phase of labour would be best managed in the\n antenatal ward. \n \n Women in the latent phase of labour must be assessed on a regular basis,\n as follows: \n \n \n• Check the fetal heart and maternal pulse half hourly\n \n• Check temperature four hourly \n \n• Consider vaginal examination four hourly, depending on the\n contraction pattern and initial cervical dilatation\n \n• Document the colour of amniotic fluid if the membranes\n rupture", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_045", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 87, "chunk_size": 570 } }, { "content": "================================================== PAGE 25 ==================================================\n• Use of a sanitary pad may indicate early, the presence of\n meconium. \n \n \n• Consider the requirement for analgesia. \n \n It is important to inform the mother and reassure her that it is common to\n have slow progress in the latent phase. \n \n The latent phase is considered prolonged when it lasts more than 12 hours\n in a primigravida and 8 hours in a multigravida. In these situations an\n experienced medical officer (with a minimum one year of experience in", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_046", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 82, "chunk_size": 569 } }, { "content": "experienced medical officer (with a minimum one year of experience in\n the field) must reassess the mother with a view of augmentation of labour.\n \n 3.2.1.\n2. Active phase \n \n 3.2.1.2a. Admitting women to the Labour Room \n \n All pregnant women diagnosed as being in active phase of the first stage of\n labour need to be admitted to the labour room. \n \n The initial assessment of a woman in the labour room should include:\n \n \n• Listening to her story, considering her emotional and\n psychological needs and reviewing her clinical records\n \n• Physical observation: temperature, pulse, blood pressure", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_046", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 93, "chunk_size": 598 } }, { "content": "• Physical observation: temperature, pulse, blood pressure\n \n• Length, strength and frequency of contractions\n \n• Abdominal palpation: fundal height, lie, presentation, position\n and station \n \n• Vaginal loss: show, liquor, blood \n \n \n• Assessment of woman’s pain including her wishes for coping\n with labour along with the range of options for pain relief\n \n• The fetal heart rate (FHR) should be auscultated preferably with\n a hand held Doppler for a minimum of 1 minute immediately\n after a contraction \n \n• The maternal pulse should be recorded to differentiate between", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_046", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 573 } }, { "content": "after a contraction \n \n• The maternal pulse should be recorded to differentiate between\n maternal pulse and FHR \n \n• A vaginal examination should be offered", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_046", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 24, "chunk_size": 156 } }, { "content": "================================================== PAGE 26 ==================================================\nHealth care Professionals who conduct vaginal examination should:\n \n \n• Be sure that there is a valid indication for vaginal examination\n that it will add important information to the decision making\n process \n \n \n• Be aware that for many women who may already in pain,\n highly anxious and in an unfamiliar environment, vaginal\n examination can be very distressing \n \n• Ensure the woman’s consent, privacy, dignity and comfort", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_047", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 536 } }, { "content": "• Ensure the woman’s consent, privacy, dignity and comfort\n \n• Explain the reason for examination and what will be involved,\n and \n \n• Explain the findings and their impact sensitively to the woman\n \n 3.2.1.2b. Management of active phase of first stage \n \n Monitoring must be conducted as instructed in the partogram and\n findings recorded accordingly. \n \n Use of a sanitary pad may indicate presence of meconium early.\n \n Women in the active phase of labour must be assessed on a regular basis,\n as follows: \n \n \n• Check the fetal heart and maternal pulse every 15 minutes ;", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_047", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 92, "chunk_size": 575 } }, { "content": "as follows: \n \n \n• Check the fetal heart and maternal pulse every 15 minutes ;\n \n• Check temperature and blood pressure four hourly;\n \n \n• Vaginal examination four hourly or earlier, depending on the\n clinical situation; \n \n• Frequency of contractions should be monitored as follows:\n The interval between two contractions should be assessed by\n palpation of the abdomen \n During active labor usually there are at least three contractions\n per ten minutes. In other words the interval between two\n contractions should be three minutes \n \n \n• Document the colour of amniotic fluid if the membranes", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_047", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 91, "chunk_size": 596 } }, { "content": "contractions should be three minutes \n \n \n• Document the colour of amniotic fluid if the membranes\n rupture; \n \n• Consider the requirement for analgesia, (which now becomes\n more important). \n 8 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_047", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 36, "chunk_size": 242 } }, { "content": "================================================== PAGE 27 ==================================================\nIntermittent auscultation of the fetal heart is best performed using\n hand-held Doppler devices. The fetal heart rate must be counted\n for one minute, beginning immediately after a contraction.\n \n The mother may continue to consume clear fluids in the active phase.\n \n She must be encouraged to assume any position that she is comfortable in\n and to avoid the dorsal position. \n \n Women who have the following conditions are recommended to be have", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_048", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 557 } }, { "content": "Women who have the following conditions are recommended to be have\n to continuous electronic fetal monitoring: \n \n \n• Significant meconium staining of amniotic fluid,\n \n• Abnormal Fetal heart rate detected by intermittent\n auscultation (< 110 beats per minute; > 160 beats per minute;\n any decelerations after a contraction) \n \n• Fresh vaginal bleeding and \n \n \n• Maternal pyrexia. \n \n In women with spontaneous labour progressing normally, routine\n early amniotomy and use of oxytocin is not recommended.\n \n 3.2.1.\n3. Delayed progress of first stage of labour", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_048", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 560 } }, { "content": "3.2.1.\n3. Delayed progress of first stage of labour\n \n Delayed progress is diagnosed when there is progress of less than\n two cm in four hours. Slowing of progress in a woman who has\n previously been progressing satisfactorily must also be considered\n as a delay. \n \n It is extremely important that delay in progress is assessed by an\n experienced medical officer. \n \n This assessment must take into account: \n \n• the uterine contractions, \n \n• descent and position of the fetal head \n \n \n• features of early obstruction of labor (caput and moulding), and\n \n• The fetal condition", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_048", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 92, "chunk_size": 579 } }, { "content": "• features of early obstruction of labor (caput and moulding), and\n \n• The fetal condition \n National Guideline for Maternal Care - Volume I 9", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_048", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 24, "chunk_size": 142 } }, { "content": "================================================== PAGE 28 ==================================================\nIn women with delay in the active phase of the first stage, every effort must\n be made to find a cause for the delay. This may either be due to inadequate\n contractions or obstruction due to CPD, mal-presentation or malposition\n (such as occipito-posterior position), or a combination of these.\n \n In cases of inadequate contractions: \n \n \n• Amniotomy must be performed if membranes are still intact.\n \n• Following that, the woman must be reassessed in two hours", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_049", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 572 } }, { "content": "• Following that, the woman must be reassessed in two hours\n \n• In case there is inadequate progress, augmentation with\n oxytocin must be considered. \n \n• The situation must be reassessed after four hours or earlier if\n required. \n \n Multiparous women with delayed progress: \n \n• Must be viewed with extreme caution. \n \n \n• It is very important to exclude mechanical causes of delay\n before considering oxytocin. \n \n• Use of oxytocin in multipara with obstructed labour could be\n extremely dangerous. \n \n In all cases where progress is slow in spite of adequate contractions a", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_049", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 576 } }, { "content": "extremely dangerous. \n \n In all cases where progress is slow in spite of adequate contractions a\n careful assessment must be made to exclude obstruction of labour.\n \n Attention must be paid to effective pain relief and to correcting dehydration\n in those situations. \n \n After paying attention to the above,Cesarean section must be considered\n where the progress continues to be slow after four hours (less than two\n cm) of commencing oxytocin. \n \n 3.2.\n2. Management of second stage of labour \n \n 3.2.2.\n1. Passive second stage of labour (descent phase)", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_049", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 554 } }, { "content": "3.2.2.\n1. Passive second stage of labour (descent phase)\n \n \n• Is diagnosed when full cervical dilatation is reached in the\n absence of involuntary expulsive efforts by the mother.\n \n• Bearing down must be discouraged at this stage.\n \n 10 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_049", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 46, "chunk_size": 286 } }, { "content": "================================================== PAGE 29 ==================================================\n• Intermittent auscultation of the fetal heart should be done\n immediately after a contraction for at least one minute, at least\n every 10 minutes. The maternal pulse should be palpated if\n there is suspected fetal bradycardia or any other FHR anomaly\n to differentiate the two heart rates. \n \n \n• Presence of meconium must be noted. \n \n 3.2.2.\n2. Active second stage of labour (expulsive phase)\n \n \n• Is diagnosed when the mother gets the urge to bear down with\n full dilatation.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_050", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 82, "chunk_size": 590 } }, { "content": "• Is diagnosed when the mother gets the urge to bear down with\n full dilatation. \n \n• Intermittent auscultation of the fetal heart should be done\n immediately after a contraction for at least one minute, at least\n every 5 minutes. The maternal pulse should be palpated if there\n is fetal bradycardia or any other FHR anomaly\n \n• Presence of meconium must be noted. \n \n Use of a hand-held Doppler device is recommended (in preference to a\n Pinnard) for fetal heart rate monitoring in the second stage.\n \n Women must be encouraged to continue consuming clear fluids during\n the second stage.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_050", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 97, "chunk_size": 589 } }, { "content": "Women must be encouraged to continue consuming clear fluids during\n the second stage. \n \n Support by the labour companion must be continued.\n \n Total time durations allowed for the second stage of labour are as follows:\n \n Primigravida: \n \n• Birth would be expected to take place within 2 hours of the\n start of the active second stage in most women.\n \n• A diagnosis of delay in the active second stage should be made\n when it has lasted 1 hour and need to seek the advice from a\n health professional trained in the assisted/ Operative vaginal\n birth if birth is not imminent. \n \n Multigravida:", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_050", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 99, "chunk_size": 594 } }, { "content": "birth if birth is not imminent. \n \n Multigravida: \n \n \n• Birth would be expected to take place within 1 hours of the\n start of the active second stage in most women.\n National Guideline for Maternal Care - Volume I 11", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_050", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 38, "chunk_size": 217 } }, { "content": "================================================== PAGE 30 ==================================================\n• A diagnosis of delay in the active second stage should be made\n when it has lasted 30 minutes and requires advice from a health\n professional trained in assisted/ operative vaginal birth if birth\n is not imminent. \n \n \n• Delay in the second stage in a multiparous woman must raise\n suspicion of disproportion or malposition. \n \n One further hour is permitted for women in each category with an\n epidural analgesia. \n \n 3.2.2.\n3. Observations for women and babies in the second stage of", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_051", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 597 } }, { "content": "epidural analgesia. \n \n 3.2.2.\n3. Observations for women and babies in the second stage of\n labour: \n All observations should be documented on the partogragh.\n \n \n• Chart blood pressure and pulse hourly \n \n• Continue four hourly temperature recording \n \n• Vaginal examination must be offered after an hour in the active\n second stage after abdominal palpation and assessment of\n vaginal loss \n \n \n• Half hourly documentation of frequency of contractions\n \n• Ongoing consideration of the woman’s emotional and\n psychological needs \n \n In addition:", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_051", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 78, "chunk_size": 546 } }, { "content": "• Ongoing consideration of the woman’s emotional and\n psychological needs \n \n In addition: \n \n• Assessment of progress should include maternal behavior,\n effectiveness of pushing and fetal wellbeing, taking into\n account fetal position and station at the onset of the second\n stage. These factors will assist in deciding the timing of further\n vaginal examination and the need for obstetric review.\n \n• Ongoing consideration should be given to the woman’s position,\n hydration, coping strategies and pain relief throughout the\n second stage. \n \n 3.2.2.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_051", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 79, "chunk_size": 552 } }, { "content": "hydration, coping strategies and pain relief throughout the\n second stage. \n \n 3.2.2.\n4. Women’s position and pushing in the second stage of labour:\n \n Although most deliveries in Sri Lanka are conducted in the dorsal/\n McRobert’s position, women may be encouraged to adopt squatting, semi\n upright or lateral positions to aid the expulsion phase.\n 12 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_051", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 61, "chunk_size": 399 } }, { "content": "================================================== PAGE 31 ==================================================\nWomen should be informed that in the second stage, they should be\n guided by their own urge to push. \n \n If pushing is ineffective, strategies to assist birth such as support and\n encouragement and change of position can be used.\n \n In primigravida in whom contractions have become weak and there\n is no evidence of fetal compromise or obstruction, oxytocin may\n be administered as an infusion. In this case, the expulsive phase", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_052", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 538 } }, { "content": "be administered as an infusion. In this case, the expulsive phase\n may be continued under close observation for a further 30 minutes.\n Delivery must be considered at the end of this period.\n \n 3.2.2.\n5. Intrapartum interventions to reduce perineal trauma\n \n Either the ‘hands on’ (guarding the perineum and flexing the baby’s head)\n or the ‘hands poised’ (with hands off the perineum and baby’s head but in\n readiness) techniques can be used to facilitate spontaneous birth.\n \n A routine episiotomy should not be carried out during spontaneous\n vaginal birth.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_052", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 559 } }, { "content": "A routine episiotomy should not be carried out during spontaneous\n vaginal birth. \n \n Episiotomy should only be performed selectively, in women in whom there\n is a clinical need such as instrumental birth or suspected fetal compromise\n or a high chance of perineal tears. \n \n Where episiotomy is performed, Mediolateral episiotomy, performed at\n 45 – 60 degrees from the midline directed to the right side, beginning at\n the vaginal fourchette is preferred to the median episiotomy. It should be\n performed at the time of crowning of the fetal head.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_052", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 549 } }, { "content": "performed at the time of crowning of the fetal head.\n \n Episiotomy should be performed after infiltration of the perineum up to\n 20 ml of 1% lignocaine. \n \n 3.2.2.\n6. Delivery \n \n The fetal head should not be allowed to extend till occiput is felt below\n the symphysis pubis. The perineum should be supported during delivery\n of the head. Once the head is delivered the woman should be discouraged\n from bearing down. Following restitution and external rotation, shoulders\n \n National Guideline for Maternal Care - Volume I 13", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_052", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 84, "chunk_size": 526 } }, { "content": "================================================== PAGE 32 ==================================================\nmust be delivered appropriately with directed traction on the fetal head.\n The baby must be delivered onto the mother’s abdomen. Breastfeeding\n should be initiated within 30 minutes of birth. \n \n 3.2.\n3. Third stage of Labour \n \n The third stage of labour is the period from the complete delivery of the\n baby to the complete delivery of the placenta and membranes.\n \n 3.2.3.\n1. Active Management of the third stage of labour", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_053", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 535 } }, { "content": "3.2.3.\n1. Active Management of the third stage of labour\n \n Active management of the third stage of labour is recommended for all\n mothers. \n \n This includes; \n \n \n• Routine use of uterotonic drugs: Oxytocin 5 IU intravenously\n soon after the delivery of the baby or 10 IU intramuscularly,\n \n• Delayed cord clamping (2 minutes after the birth) and cutting\n of the cord \n \n• Followed by controlled cord traction. This must be followed by\n uterine massage. \n \n Delayed clamping of the cord allows for placental transfusion,\n which reduces neonatal and infant iron deficiency and anemia.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_053", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 91, "chunk_size": 584 } }, { "content": "which reduces neonatal and infant iron deficiency and anemia.\n This policy should be followed unless the baby is born in a poor\n condition or if the mother is bleeding or is Rhesus iso-immunized.\n \n Clamp and cut the cord close to the perineum. A hand should be placed\n above the symphysis pubis to stabilize the uterus by applying counter\n traction during controlled cord traction. Application of cord traction\n when the uterus is relaxed could lead to acute inversion of the uterus.\n \n After delivery, the placenta must be placed on a flat surface and the maternal", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_053", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 94, "chunk_size": 566 } }, { "content": "After delivery, the placenta must be placed on a flat surface and the maternal\n surface examined for completeness. On the fetal surface the blood vessels\n must be traced to exclude a succenturiate lobe. Completeness of the fetal\n membranes must be ensured.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_053", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 41, "chunk_size": 256 } }, { "content": "14 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_054", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 33 ==================================================\nObservations in the immediate postpartum period include:\n \n \n• Inspection for continued fresh bleeding, \n \n• Check pulse, blood pressure, uterine contraction, and the level\n of the fundus every 15 minutes up to 2 hours\n \n• Her general physical condition, as shown by her colour,\n respiration and her own report of how she feels\n \n Experienced medical personnel should be informed in any one the\n following instances: \n \n• Continuing fresh bleeding;", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_055", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 558 } }, { "content": "following instances: \n \n• Continuing fresh bleeding; \n \n• Elevation of the level of the fundus; \n \n \n• Increase of pulse rate above 100 or by 30 beats per minute;\n \n• Drop in systolic blood pressure below 100 or by 30 mmHg.\n \n The level of the fundus must be marked on the skin using a marker to\n make observations more objective. \n \n 3.2.3.\n2. Delayed third stage \n \n Delayed third stage is diagnosed when the placenta is not delivered within\n 30 minutes of active management. \n \n The first step in managing delayed third stage of labour is:", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_055", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 91, "chunk_size": 542 } }, { "content": "The first step in managing delayed third stage of labour is:\n \n• To proceed to intraumbilical vein oxytocin, in a dose of 50 IU\n in 30 ml of 0.9% sodium chloride solution.\n \n• A period of 30 minutes is allowed and controlled cord traction\n is attempted again. \n \n \n• If the placenta is not delivered by this method, manual removal\n of placenta is proceeded to. \n \n \n4. Care for the newborn baby \n \n Effective care at birth is needed in anticipation of problems with the\n transition from in utero dependent life to extra utero independent\n existence and to provide support to ensure stabilization.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_055", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 100, "chunk_size": 596 } }, { "content": "National Guideline for Maternal Care - Volume I 15", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_056", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 34 ==================================================\n• Skilled birth attendant (Medical Officer, Nursing Officer and\n Midwive) is responsible for the care. \n \n \n• The care at birth is same irrespective of birthing place or person\n attending to birth. \n \n• At least one health care provider trained in neonatal\n resuscitation must be physically available at the time of birth of\n all infants irrespective of risk status. \n \n• This person must actually be present in the delivery room\n before the birth of the baby.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_057", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 570 } }, { "content": "• This person must actually be present in the delivery room\n before the birth of the baby. \n \n• The attending personnel should document the details of the\n baby such as time of birth, weight, gender and any other\n relevant information in all cases. \n \n The aims of neonatal care following birth include the following:\n \n• Establishment of respiration (as per NRP guidelines)\n \n \n• Prevention of hypothermia (Refer to newborn guideline)\n \n• Establishment of breast feeding (Refer to newborn guideline)\n \n• Prevention of infection (Refer to newborn guideline)", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_057", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 86, "chunk_size": 557 } }, { "content": "• Prevention of infection (Refer to newborn guideline)\n \n• Detection of danger signs (Refer to newborn guideline)\n \n Following basic steps should be followed at the time of birth;\n \n \n1. Call out the time of birth \n \n2. Deliver the baby onto the mother’s abdomen or into her arms\n \n3. Dry baby with a warm towel or a warm piece of cloth\n \n4. Wipe baby’s eye \n \n5. Assess baby’s breathing while drying \n \n \n6. Make sure that there is no second baby \n \n7. Change gloves or remove the first layer of gloves\n \n8. Clamp and cut the umbilical cord", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_057", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 96, "chunk_size": 541 } }, { "content": "7. Change gloves or remove the first layer of gloves\n \n8. Clamp and cut the umbilical cord \n \n9. Put the baby between mother’s breast for skin to skin care\n \n10. Place an identity label on baby \n \n \n11. Cover mother and baby with warm clothes \n \n12. Put a hat on baby’s head \n \n The Apgar score at 1 and 5 minutes should be recorded for all births.\n 16 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_057", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 74, "chunk_size": 400 } }, { "content": "================================================== PAGE 35 ==================================================\nInitiation of breast feeding should be aimed for within 1hour after birth.\n \n Head circumference, birth weight, length and other measurements should\n be carried out once the first feed is complete. A health care professional\n should examine the baby to detect any physical abnormality and to\n identify any problems that require referral. \n \n \n5. Perineal Care \n \n Perineal or genital trauma caused by either episotomy or tearing need to\n be repaired.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_058", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 560 } }, { "content": "Perineal or genital trauma caused by either episotomy or tearing need to\n be repaired. \n \n Before assessing for genital trauma: \n \n \n• Explain to the woman what they are going to do and why\n \n• Offer some analgesia \n \n• Ensure good lighting \n \n• Position the woman so that she is comfortable and the genital\n structures can be seen clearly. \n \n The initial assessment should be performed gently and with sensitivity\n and may be done in the immediate period following birth preferably as\n soon as the placenta is delivered. \n \n Classification of perineal trauma", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_058", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 560 } }, { "content": "soon as the placenta is delivered. \n \n Classification of perineal trauma \n \n First degree: Injury to skin only \n \n Second Degree: Injury to the perineal muscles but not the anal\n sphincter \n \n Third degree: Injury to the perineum involving the anal sphincter\n complex \n \n Fourth degree: Injury to the perineum involving the anal sphincter\n complex and anal epithelium \n \n Perineal repair should only be undertaken with tested effective analgesia\n in place using infiltration with up to 20ml of 1% lignocaine or equivalent,\n or by topping up the epidural, as soon as possible by a medical officer.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_058", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 90, "chunk_size": 596 } }, { "content": "or by topping up the epidural, as soon as possible by a medical officer.\n National Guideline for Maternal Care - Volume I 17", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_058", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 23, "chunk_size": 124 } }, { "content": "================================================== PAGE 36 ==================================================\nThe preferred suture material is rapidly absorbable polyglactin acid.\n \n The following basic principles should be observed when performing\n perineal repairs: \n \n \n• Perineal trauma should be repaired using aseptic techniques.\n \n \n• Equipment should be checked and swabs and needles counted\n before and after the procedure \n \n• Good lighting is essential to see and identify the structures\n involved. \n \n• Difficult injuries should be repaired by an experienced medical", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_059", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 578 } }, { "content": "involved. \n \n• Difficult injuries should be repaired by an experienced medical\n officer in the theatre under regional or general anaesthesia. An\n indwelling catheter should be inserted for 24 hours to prevent\n urinary retention. \n \n• Good anatomical alignment of the wound should be achieved,\n and consideration given to the cosmetic result.\n \n• Rectal examination should be carried out after completing the\n repair to ensure that suture material has not accidently been\n inserted through the rectal mucosa. \n \n \n• Following completion of repair, an accurate detailed account", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_059", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 84, "chunk_size": 575 } }, { "content": "• Following completion of repair, an accurate detailed account\n should be documented covering the extent of the trauma, the\n method of repair and the materials used. \n \n• Information should be given to the woman regarding the extent\n of the trauma, pain relief, diet, hygiene and the importance of\n pelvic floor exercises.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_059", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 51, "chunk_size": 322 } }, { "content": "18 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_060", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 37 ==================================================\nGuideline on Induction of Labour \n \n \n1. Introduction \n \n This guideline aims to provide evidence based guidance on induction of\n labour to make the process more logical, effective and safer. It also aims to\n empower women undergoing induction of labour. \n \n \n2. Definition \n \n Induction of labour is defined as initiation of labour by artificial means.\n \n \n3. General Principles \n \n \n• Induction of labour should be performed only in specialist", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_061", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 555 } }, { "content": "3. General Principles \n \n \n• Induction of labour should be performed only in specialist\n obstetric units when there is a clear indication that its benefits\n outweigh risks. \n \n \n• A senior clinician must make the decision. \n \n• The reason/s should be clearly explained to the patient, who\n should give her consent. \n \n• Maternal and fetal wellbeing should be monitored closely.\n \n• Adequate pain relief should be an essential part of the\n management plan, since it is recognized that labor is more\n painful when it is induced. \n \n \n• Prior to induction of labour, the cervix should be favourable", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_061", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 95, "chunk_size": 595 } }, { "content": "painful when it is induced. \n \n \n• Prior to induction of labour, the cervix should be favourable\n (Modified Bishop score 7 or more). If it is not, an attempt should\n be made to ripen the cervix. \n \n• Decisions regarding induction of labour should be made taking\n into account not only the clinical scenario but also the woman’s\n views, the availability of local facilities and cost effectiveness of\n the available methods. \n \n \n4. Indications \n \n 4.1 Otherwise uncomplicated pregnancy continuing beyond 40 weeks\n \n Induction of labour is recommended for low-risk women who are known", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_061", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 90, "chunk_size": 582 } }, { "content": "Induction of labour is recommended for low-risk women who are known\n with certainty to have reached 41 weeks of gestation.\n National Guideline for Maternal Care - Volume I 19", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_061", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 29, "chunk_size": 174 } }, { "content": "================================================== PAGE 38 ==================================================\nHowever, it is good practice to assess fetal wellbeing around 40 weeks to\n select women for conservative management until 41 weeks gestation.\n \n The recommended assessments include fetal biometry (at least abdominal\n circumference) and amniotic fluid index (lower cut-off = 7 cm).\n \n 4.2 Prelabour rupture of membranes at term \n \n In the absence of evidence fetal compromise or maternal infection delayed\n induction of labour after 24 hours is acceptable.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_062", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 565 } }, { "content": "induction of labour after 24 hours is acceptable. \n \n This may be carried out using either oxytocin infusion or prostaglandins.\n \n 4.3 Preterm prelabour rupture of membranes (PPROM) \n \n Patients with PPROM without evidence of infection or fetal compromise\n should be offered induction after the completion 34 weeks.\n \n 4.4 Intrauterine death \n \n This is a very traumatic time for the woman. Most women would want\n to be delivered as early as possible and their wishes need to be respected.\n \n Amniotomy and repeated vaginal examinations are best avoided.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_062", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 554 } }, { "content": "Amniotomy and repeated vaginal examinations are best avoided.\n \n Prostaglandins are preferred for induction of labour in these women.\n \n Amniotomy is preferred in the presence of abruption placentae.\n \n 4.5 History of precipitate labour \n \n There are no studies comparing outcomes in induced versus spontaneous\n labour. \n \n 4.6 Suspected macrosomia \n \n In the presence of good clinical and ultrasound evidence of macrosomia\n or a history of previous shoulder dystocia, there should be a low threshold\n for early induction of labour. \n \n 20 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_062", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 587 } }, { "content": "================================================== PAGE 39 ==================================================\n4.7 Fetal growth restriction \n \n The decision for induction of labour in a growth restricted fetus should be\n individualized based on period of gestation at onset, presence or absence\n of fetal compromise. \n \n 4.8 Older mothers \n \n There is growing evidence that the risk of stillbirth is higher in older (>40\n yrs) women near term. \n \n Women over 40 years should be offered induction between 39-40 weeks.\n \n \n5. Induction under specific circumstances \n \n 5.1 Breech presentation", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_063", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 75, "chunk_size": 589 } }, { "content": "5. Induction under specific circumstances \n \n 5.1 Breech presentation \n \n Presentation per se, is not a contraindication to induction.\n \n 5.2 Previous CS \n \n There is no contraindication to induction of labour in a woman with a\n past caesarean section. \n \n Use of either oxytocin or prostaglandins increases the risk of scar\n dehiscence or rupture. \n \n This risk may be lower with artificial separation of membranes or Foley\n catheter. \n \n \n6. Methods of induction \n \n This section does not make a distinction between methods of ripening the\n cervix and induction of labour. \n \n 6.1 Mechanical", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_063", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 86, "chunk_size": 593 } }, { "content": "cervix and induction of labour. \n \n 6.1 Mechanical \n \n There is good evidence that artificial separation of membranes reduces the\n need for formal induction. This method is recommended to be performed\n with due regard to asepsis, at 40 weeks gestation.\n National Guideline for Maternal Care - Volume I 21", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_063", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 47, "chunk_size": 304 } }, { "content": "================================================== PAGE 40 ==================================================\nWhere the cervix will not admit a finger, massaging around the cervix in\n the vaginal fornices will have a similar effect. \n \n Extra-amniotic balloon catheter is an effective method of ripening of the\n cervix. A Foley catheter is inserted through the cervix and the balloon\n inflated with 40 – 60 ml of saline. This may be left in situ for a maximum\n of 48 hours. Following its removal, induction of labour may be proceeded\n to using another method.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_064", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 559 } }, { "content": "to using another method. \n \n In the presence of evidence of infection, artificial separation of membranes\n and extra-amniotic Foley catheter must not be used. \n \n 6.2 Surgical \n \n Amniotomy is a definitive mode of induction of labour. It should be\n undertaken only if one is committed to deliver within 24 hours. Therefore\n it should be done only when the cervix is ripe and prior cervical assessment\n by an experienced clinician is essential. \n \n The risk of cord prolapse should be appreciated and steps taken to\n minimise or to recognize it early.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_064", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 550 } }, { "content": "minimise or to recognize it early. \n \n Amniotomy alone may be capable of initiation of labour and it is\n recommended that oxytocin be started after a period of observation of at\n least two hours. \n \n 6.3 Pharmacological \n \n 6.3.1 Oxytocin \n \n Use of oxytocin when membranes are intact is not recommended.\n \n For details of how to use oxytocin please refer to the guideline on oxytocin\n \n 6.3.2 Prostaglandins \n \n Prostaglandin E2 (PGE2) \n \n These are very effective in inducing labour and are available as vaginal gel,\n tablet or controlled release pessary.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_064", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 557 } }, { "content": "tablet or controlled release pessary. \n 22 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_064", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 14, "chunk_size": 90 } }, { "content": "================================================== PAGE 41 ==================================================\nAll preparations carry a risk of hyperstimulation.\n \n Intracervical route does not offer any increase in efficacy.\n \n Combined use with oxytocin is particularly dangerous. A minimum of six\n hours from the last vaginal tablet/gel should be allowed before oxytocin\n is started. \n \n Prior to use of prostaglandins the Bishop score should be assessed and\n the woman should be monitored electronically to determine the fetal\n condition and frequency of contractions.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_065", "page_number": 1, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 571 } }, { "content": "condition and frequency of contractions. \n \n After administration the fetal heart should be monitored electronically\n when contractions begin. After confirmation of normal heart rate pattern\n monitoring should be done by intermittent auscultation.\n \n A second dose may be considered after a minimum interval of 6 hours\n after the first, depending on the change of Bishop score, the condition of\n the fetus and frequency of contractions. \n \n The dosages are 3 mg for vaginal tablets and 0.5 mg for vaginal gel.\n \n Misoprostol \n \n This drug is widely used worldwide for a variety of indications in", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_065", "page_number": 1, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 90, "chunk_size": 595 } }, { "content": "Misoprostol \n \n This drug is widely used worldwide for a variety of indications in\n pregnancy. (In Sri Lanka, it is not licensed at present).\n \n Nevertheless, it is very effective in inducing labour (more than PGE2),\n especially in mid trimester fetal death. \n \n Sensitivity of the uterus increases markedly with advancing pregnancy.\n \n This guideline recommends that it should not be used for induction of\n labour with a mature live fetus. \n \n 6.3.3 Mifepristone \n \n It is a powerful anti-progesterone and is very useful as an adjunct to", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_065", "page_number": 1, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 538 } }, { "content": "6.3.3 Mifepristone \n \n It is a powerful anti-progesterone and is very useful as an adjunct to\n misoprostol in cases of intrauterine death. (It is not licenced in Sri Lanka\n at present) \n National Guideline for Maternal Care - Volume I 23", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_065", "page_number": 1, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 39, "chunk_size": 237 } }, { "content": "================================================== PAGE 42 ==================================================\n8. Complications \n \n 8.1 Hyperstimulation \n \n This is a well-recognized complication of induction of labour with\n pharmacological methods. It could have serious consequences including\n rupture of the uterus, aminiotic fluid embolism, precipitate labor and fetal\n compromise. \n \n It is defined either as a contraction free interval of less than sixty seconds\n and/or contractions lasting more than ninety seconds.\n \n If diagnosed, the prostaglandin tablet must be retrieved from the vagina", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_066", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 598 } }, { "content": "If diagnosed, the prostaglandin tablet must be retrieved from the vagina\n or oxytocin infusion stopped immediately and a rapid infusion of 0.9%\n sodium chloride via a fresh giving set administered.\n \n If still not resolved, tocolytics should be given if available e.g. terbutaline\n 250 µg IV or SC. Since this is not available in Sri Lanka, salbutamol\n inhaler may be tried. \n \n 8.2 Cord prolapse \n \n This is more likely with amniotomy when the head is high and poorly\n applied to the cervix. \n \n Precautions to avoid and to detect this early include palpation for cord", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_066", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 92, "chunk_size": 569 } }, { "content": "Precautions to avoid and to detect this early include palpation for cord\n presentation, palpation for the cord immediately after amniotomy and the\n fetal heart sounds auscultated immediately afterwards.\n \n If cord prolapse is diagnosed help must be called immediately. Assess\n cervical dilatation and effect delivery if fully dilated. If not fully dilated\n and cord pulsations are present, insert a Foley catheter into the bladder\n and fill it with 500 ml saline. Place the mother in the knee-elbow position\n and displace the presenting part away from the pelvis by keeping pressure", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_066", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 89, "chunk_size": 582 } }, { "content": "and displace the presenting part away from the pelvis by keeping pressure\n inserting a hand in the vagina. Transport for immediate caesarean section\n in this position.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_066", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 26, "chunk_size": 167 } }, { "content": "24 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_067", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 43 ==================================================\n8.3 Uterine rupture \n \n Please also refer to section 5.2 in this guideline\n \n Extra care must be exercised in grandmultipara and in women with\n scarred uteri. \n \n 8.4 Failed induction \n \n Failed induction is defined as labour failing to start after one cycle of\n treatment with medical methods or for 12 hours of amniotomy.\n \n It does not necessarily indicate caesarean section in case medical or\n mechanical methods.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_068", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 68, "chunk_size": 527 } }, { "content": "It does not necessarily indicate caesarean section in case medical or\n mechanical methods. \n \n The clinical situation (maternal and fetal condition) must be reassessed\n and discussed with the woman. \n \n In case of failure to induce labor using one cycle of prostaglandins another\n cycle may be administered as described above. Depending on the clinical\n situation it is best that the second cycle is delayed for 24 hours. In case of\n amniotomy, failed induction of labour indicates caesarean section.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_068", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 76, "chunk_size": 500 } }, { "content": "National Guideline for Maternal Care - Volume I 25", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_069", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 44 ==================================================\n26 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_070", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 160 } }, { "content": "================================================== PAGE 45 ==================================================\nGuideline for Use of Oxytocin for Induction and\n \n Augmentation of labour \n \n Oxytocin is an invaluable drug when used carefully. However, it has\n the potential to cause uterine hyperstimulation, which could result in\n amniotic fluid embolism, uterine rupture and fetal distress, all of which\n are life threatening. \n \n Multigravidae are particularly susceptible to the above consequences\n and extra care must be taken to exclude obstruction before a decision is", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_071", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 572 } }, { "content": "and extra care must be taken to exclude obstruction before a decision is\n made to use oxytocin in a multigravid woman during labour. Experienced\n personnel must be involved in this decision. \n \n Use of oxytocin for induction and/or augmentation of labour results in\n a higher risk of rupture of a scarred uterus. Therefore, in such women\n oxytocin should be used only with the concurrence of a Consultant.\n \n Its effects will depend on the concentration of the infusion and the volume\n infused per minute. \n \n To achieve this predictably, use of infusion pumps is recommended.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_071", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 92, "chunk_size": 576 } }, { "content": "infused per minute. \n \n To achieve this predictably, use of infusion pumps is recommended.\n \n Where a gravity-assisted drip system is used, a burette may be used to\n improve accuracy. Such systems however, may deliver variable volumes\n depending on many factors including the position of the arm into which\n it is infused. \n \n Irrespective of the method of administration, oxytocin must be\n administered in incremental doses at intervals of 30 minutes, to achieve\n a contraction free interval of two minutes. Once this level is reached, the", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_071", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 83, "chunk_size": 540 } }, { "content": "a contraction free interval of two minutes. Once this level is reached, the\n infusion rate may be continued at the same level, while closely monitoring\n the contractions. \n \n Hyperstimulation is defined either as a contraction free interval of less\n than sixty seconds and/or contractions lasting more than ninety seconds.\n In this situation the infusion must be stopped immediately.\n \n Oxytocin is administered with 5 units in 500 ml of 0.9% sodium chloride\n solution. In situations where infusion pumps are not available, oxytocin\n National Guideline for Maternal Care - Volume I 27", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_071", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 89, "chunk_size": 584 } }, { "content": "================================================== PAGE 46 ==================================================\nmay be administered starting at a drop rate of 15 per minute and increased\n at rates of 15 drops per minute every 30 minutes, up to a maximum of 60\n drops per minute. An approximate conversion to mU/minute is given in\n table \n1. \n \n Table 1: mU/minute administered at different rates of administration\n according to drop rate \n \n Drop rate/min Equivalent mU/min. \n \n 15 7.5 \n 30 15 \n 45 22.5 \n \n 60 30 \n (based on 5U of oxytocin in 500 ml saline)", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_072", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 556 } }, { "content": "15 7.5 \n 30 15 \n 45 22.5 \n \n 60 30 \n (based on 5U of oxytocin in 500 ml saline) \n \n Table 2 gives mU infused per minute when administered via an infusion\n pump. \n \n Table 2: mU infused per minute when administered via an infusion\n pump. \n \n TIME AFTER STARTING OXYTOCIN DOSE VOLUME INFUSED \n (MINS) (MU/MIN) DOSE (10U IN 500MLS MLS/HR)\n RATE \n 0 1 3 \n 30 2 6 \n 60 4 12 \n 90 8 24 \n 120 12 36 \n 150 16 48 \n 180 20 60 \n 210 24 72 \n 240 28 84 \n 270 32 96 \n \n Oxytocin must not be administered to women with intact membranes. It is\n recommended that women on oxytocin infusions should have continuous", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_072", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 108, "chunk_size": 595 } }, { "content": "recommended that women on oxytocin infusions should have continuous\n electronic fetal monitoring. \n 28 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_072", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 21, "chunk_size": 150 } }, { "content": "================================================== PAGE 47 ==================================================\nContinuous EFM during administration of oxytocin:\n \n \n• If the CTG is normal, oxytocin may be continued in incremental\n doses until the woman is experiencing 4 or 5 contractions every\n 10 minutes. \n \n \n• If the FHR trace is suspicious, this should be reviewed by an\n experienced medical officer \n \n• If the FHR trace is classified as abnormal/pathological oxytocin\n infusion should be stopped and a full assessment of the fetal\n condition undertaken by an experienced medical officer.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_073", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 594 } }, { "content": "National Guideline for Maternal Care - Volume I 29", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_074", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 48 ==================================================\nGuideline on fetal monitoring in labour \n \n Fetal monitoring in labour could be done by : \n \n \n• Intermittent auscultation (preferably by a hand held Doppler\n device) \n \n• Intermittent or continuous electronic monitoring\n \n Intermittent auscultation is recommended for low-risk women in\n spontaneous labour. \n \n Electronic monitoring is recommended when: \n \n• The baby’s growth is restricted \n \n• There is significant meconium staining of amniotic fluid", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_075", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 65, "chunk_size": 563 } }, { "content": "• The baby’s growth is restricted \n \n• There is significant meconium staining of amniotic fluid\n \n \n• Abnormal fetal heart rate detected by intermittent auscultation\n \n• Fresh vaginal bleeding \n \n• Maternal pyrexia \n \n• Use of oxytocin for augmentation or induction of labour\n \n \n• Women with a scarred uterus \n \n• Women on epidural analgesia \n \n Intermittent auscultation \n \n This could be done by using either a Pinnard’s stethoscope or preferably a\n hand-held Doppler device. \n \n Auscultation should be carried out immediately after a contraction for\n one full minute.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_075", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 571 } }, { "content": "Auscultation should be carried out immediately after a contraction for\n one full minute. \n \n The maternal pulse should be palpated if there is suspected fetal\n bradycardia or any other FHR anomaly to differentiate the two heart rates.\n \n The normal rate is between 110 – 160 beats per minute in a term fetus.\n \n The frequency of auscultation should be as specified in the partogram.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_075", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 62, "chunk_size": 382 } }, { "content": "30 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_076", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 49 ==================================================\nElectronic fetal monitoring (EFM) \n \n EFM is carried out by external cardiotocography (CTG).\n \n The following are recommended at the commencement of a CTG.\n \n \n1. The paper speed must be set at 1 cm per minute.\n \n2. The date and time settings on the machine must be validated.\n \n3. The CTG must be labeled with the mother’s name, BHT number\n and date and time. \n \n4. Maternal heart rate should be noted on the CTG.\n \n5. The presence and the point at which the fetal heart rate is best", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_077", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 90, "chunk_size": 594 } }, { "content": "5. The presence and the point at which the fetal heart rate is best\n heard must be delineated by auscultation and the probe placed\n at that point. \n \n \n6. Ensure that the contraction probe is functioning properly and\n used for the recording. \n \n7. The woman should be positioned in such a way that aortocaval\n compression is avoided. \n \n8. It should be interpreted without delay and the categorization\n recorded as either normal or suspicious or pathological, as per\n table 1, and signed by the responsible officer. The entry on the\n BHT must include a plan for management.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_077", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 95, "chunk_size": 573 } }, { "content": "BHT must include a plan for management. \n \n9. If the CTG is categorized as suspicious or abnormal, the\n Consultant must be informed. \n \n \n10. For the management plan the overall clinical picture must be\n taken into account. e.g. the rate of progress of labour, presence\n or absence of fetal growth restriction, meconium staining of\n amniotic fluid and the evolution of the CTG abnormalities.\n Table 1: Definitions of normal, suspicious and pathological FHR traces\n \n Category Definition \n Normal An FHR trace in which all four features are classified as\n reassuring", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_077", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 87, "chunk_size": 565 } }, { "content": "Normal An FHR trace in which all four features are classified as\n reassuring \n \n Suspicious An FHR trace with one feature classified as non-reassuring\n and the remaining features classified as reassuring\n Pathological An FHR trace with two or more features classified as non-\n reassuring or one or more classified as abnormal\n National Guideline for Maternal Care - Volume I 31", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_077", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 59, "chunk_size": 377 } }, { "content": "================================================== PAGE 50 ==================================================\nTable 2: Classification of fetal heart rate patterns\n \n Feature Baseline Variability Decelerations Accelerations\n (bpm) (bpm) \n Reassuring 110–160 ≥ 5 None Present \n Non-reassuring 100–109 < 5 for 40–90 Typical variable The absence of\n 161–180 minutes decelerations with accelerations\n over 50% of with otherwise \n contractions, normal trace is\n occurring for over of uncertain\n 90 minutes significance \n Abnormal < 100 < 5 for 90 Either atypical \n > 180 minutes variable", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_078", "page_number": 2, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 581 } }, { "content": "90 minutes significance \n Abnormal < 100 < 5 for 90 Either atypical \n > 180 minutes variable \n Sinusoidal decelerations with \n pattern ≥ _10 over 50% of \n minutes contractions or late \n decelerations, both \n for over 30 \n minutes \n Further useful information on FHR patterns \n \n \n• If repeated accelerations are present with reduced variability,\n the FHR trace should be regarded as reassuring.\n \n \n• True early uniform decelerations are rare and benign, and\n therefore they are not significant. \n \n• Most decelerations that occur during labor are variable.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_078", "page_number": 2, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 557 } }, { "content": "• Most decelerations that occur during labor are variable.\n \n• If a bradycardia occurs in the baby for more than 3 minutes,\n urgent medical aid should be sought and preparations\n should be made to urgently expedite the birth of the baby, i.e.\n immediate commencement of cesarean section. This could\n include moving the woman to theatre if the fetal heart has\n not recovered by 9 minutes. If the fetal heart recovers within\n 9 minutes the decision to deliver should be reconsidered in\n conjunction with the woman if the post-recovery tracing is\n reassuring.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_078", "page_number": 2, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 91, "chunk_size": 556 } }, { "content": "conjunction with the woman if the post-recovery tracing is\n reassuring. \n \n• A tachycardia in the baby of 160–180 bpm, where accelerations\n are present and no other adverse features appear, should not be\n regarded as suspicious. However, an increase in the baseline\n \n 32 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_078", "page_number": 2, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 50, "chunk_size": 319 } }, { "content": "================================================== PAGE 51 ==================================================\nheart rate, even within the normal range, with other non-\n reassuring or abnormal features should increase concern. In\n such cases inquiry must be made to ascertain if the fetus was\n active during the recording. \n \n When women are having continuous EFM, systematic assessment of above\n definitions and classification should be undertaken with every review.\n \n During episodes of abnormal FHR patterns, if woman is lying supine,\n advise her to adopt the left lateral position", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_079", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 584 } }, { "content": "National Guideline for Maternal Care - Volume I 33", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_080", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 52 ==================================================\nGuideline on Pain Relief in Labour \n \n Adequate relief of pain is a basic right of every mother in labour. It is the\n duty of every member of the obstetric team to endeavor to achieve this.\n \n Poor management of pain during labour will result in maternal exhaustion\n leading to: \n \n \n• acidosis, \n \n \n• dysfunctional labour and \n \n• fetal distress. \n \n• Loss of morale and a negative birth experience could have\n significant long-term effects.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_081", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 75, "chunk_size": 553 } }, { "content": "• Loss of morale and a negative birth experience could have\n significant long-term effects. \n \n A well-informed, well supported mother will be more in control of events\n and in a better position to deal with pain than one who is not. Therefore,\n it is important to keep the mother informed of the progress of labour and\n the condition of the fetus throughout the process. \n \n Reassurance plays a major adjunctive role in pain relief.\n \n Prenatal education should include information regarding the available\n methods of pain relief and their accessibility.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_081", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 555 } }, { "content": "methods of pain relief and their accessibility. \n \n Non pharmacological methods of pain relief such as breathing and\n relaxation techniques should be introduced during the antenatal period.\n \n It is well recognized that women who have a birth companion will tolerate\n pain better and require less analgesia. The policy of allowing a birth\n companion must therefore be encouraged. \n \n \n1. Methods of pain relief in labour \n \n The selection of the method of pain relief should be based on the patient\n preference, availability of resources and the institutional protocols.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_081", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 570 } }, { "content": "preference, availability of resources and the institutional protocols.\n Following methods can be used.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_081", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 13, "chunk_size": 102 } }, { "content": "34 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_082", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 53 ==================================================\n1.1 Non-pharmacological methods of pain relief \n \n \n• Breathing techniques, \n \n• Transcutaneous electrical nerve stimulation (TENS),\n \n• Massaging, \n \n• Relaxation techniques, \n \n• Positioning and movement \n \n Any of these methods can be used to relieve pain during labour\n \n 1.\n2. Pharmacological methods of pain relief in labour\n \n 1.2.\n1. Oral paracetamol/paracetamol & codeine compound:\n \n These oral preparations can be used safely in the latent phase of labour.\n \n 1.2.\n2. Opioids", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_083", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 596 } }, { "content": "These oral preparations can be used safely in the latent phase of labour.\n \n 1.2.\n2. Opioids \n \n 1.2.2.A. Pethidine \n \n Pethidine is safe and effective in the latent and early active phase. The dose\n is 1-1.5 mg/kg IM, repeated after 4 – 6 hours. Administration of a third\n dose should be done only with the concurrence of senior personnel.\n \n It is generally avoided where delivery is anticipated within 4 hours.\n \n Maternal side effects include nausea, vomiting and a reduction in gastric\n motility with a subsequent increase in gastric acidity. Therefore, it should", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_083", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 90, "chunk_size": 568 } }, { "content": "motility with a subsequent increase in gastric acidity. Therefore, it should\n be administered coupled with metoclopramide 5 mg IV or 10 mg IM.\n \n Neonatal respiratory depression is a recognized consequence of\n administration of opioids to the mother. Naloxone, a pure opioid\n antagonist should be available for treatment in all facilities administering\n opioids for analgesia. Naloxone is given to the baby in a dose of 100μg /kg\n IV. It has a short duration of action and additional doses may be required.\n If no improvement is seen with the first dose of naloxone, the cause of", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_083", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 94, "chunk_size": 579 } }, { "content": "If no improvement is seen with the first dose of naloxone, the cause of\n neonatal respiratory depression is more likely to be a factor other than\n opioids.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_083", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 27, "chunk_size": 155 } }, { "content": "National Guideline for Maternal Care - Volume I 35", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_084", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 54 ==================================================\n1.2.2.B. Morphine \n \n This has a longer duration of action than pethidine and may be particularly\n useful in women who require analgesia in early labour.\n \n The dose is 0.15 mg/kg IM should be administered with metoclopramide.\n The side effects and neonatal effects are similar to those of pethidine.\n \n 1.2.2.C. Fentanyl \n \n Intravenous fentanyl/ramifentanyl may be administered in either a High\n Dependency or Intensive Care Unit settings under the supervision of an\n anaesthesiologist.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_085", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 598 } }, { "content": "Dependency or Intensive Care Unit settings under the supervision of an\n anaesthesiologist. \n \n The dose is 50-100μg per hour as an intravenous infusion.\n \n Pain relief occurs in 3-5 minutes after commencement.\n \n 1.2.\n3. Inhalational analgesia – Entonox \n \n Entonox is a 50:50 mixture of nitrous oxide and oxygen and it has a very\n short half-life. The onset of action is 30sec to one minute.\n \n The mother should receive clear and definite instructions about its correct\n use. It should only be self-administered. \n \n She should start using entonox through the controlled valve at the very", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_085", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 91, "chunk_size": 590 } }, { "content": "She should start using entonox through the controlled valve at the very\n beginning of the contraction. The mother should be advised to stop using\n Entonox inhalation in the contraction free interval.\n \n Longer and deeper breaths give better result. There is no limit on the\n duration of its use. \n \n Women should be informed that Entonox will make them feel nauseous\n and light-headed. \n \n Entonox is contraindicated in women with intestinal obstruction,\n pneumothorax, middle ear and sinus disease, and following cerebral air-\n contrast studies.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_085", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 81, "chunk_size": 546 } }, { "content": "pneumothorax, middle ear and sinus disease, and following cerebral air-\n contrast studies. \n \n 36 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_085", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 21, "chunk_size": 145 } }, { "content": "================================================== PAGE 55 ==================================================\n1.2.\n4. Regional Anaesthesia \n \n A. Epidural analgesia \n \n Epidural analgesia is the most effective form of pain relief in labour.\n Therefore, Its greater use should be encouraged.\n \n It can be given either as a bolus with top-ups or as a continuous infusion.\n Continuous administration via a syringe pump is preferred to ‘top-ups’,\n since it is safer. \n \n The continuous availability of an anesthesiologist is a prerequisite to", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_086", "page_number": 2, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 538 } }, { "content": "since it is safer. \n \n The continuous availability of an anesthesiologist is a prerequisite to\n offering epidural analgesia. It is also essential that staff on site is trained for\n its setting up, monitoring and to recognize complications early. Facilities\n should be available for emergency resuscitation.\n \n Before offering epidural analgesia, women should be informed its risks\n and benefits and its implications on labour: \n \n \n• It provides more effective pain relief than other methods\n \n• It will not increase the length of the first and the passive second\n stages of labour.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_086", "page_number": 2, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 88, "chunk_size": 582 } }, { "content": "• It will not increase the length of the first and the passive second\n stages of labour. \n \n• It may however increase the length of the expulsive phase\n and increase the likelihood of an instrumental delivery. An\n additional hour is allowed in the expulsive phase therefore.\n \n• It does not increase the chance of cesarean section\n \n• It does not cause long-term backache. \n \n \n• It needs to be accompanied by a more intensive level of\n monitoring. \n \n Care and observations for women with regional analgesia in labour\n \n• Intravenous access should be secured prior to commencing", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_086", "page_number": 2, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 95, "chunk_size": 579 } }, { "content": "• Intravenous access should be secured prior to commencing\n regional analgesia. \n \n• Following additional observations should be carried out for\n women with regional analgesia \n ➢ During establishment of regional analgesia or after top up\n bolus blood pressure should be measured every 5 minutes\n for 15 minutes. \n \n National Guideline for Maternal Care - Volume I 37", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_086", "page_number": 2, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 55, "chunk_size": 367 } }, { "content": "================================================== PAGE 56 ==================================================\n➢ If the woman is not pain free within after each\n administration, the anaesthetist should be called.\n \n ➢ Hourly assessment of the level of sensory block should be\n undertaken. \n \n• Women with regional analgesia should be encouraged to move\n and adopt whatever positions they find most comfortable\n throughout labour. \n \n• Once established, regional analgesia should be continued\n until after completion of the third stage of labour and when\n necessary until perineal repair is done.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_087", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 78, "chunk_size": 594 } }, { "content": "necessary until perineal repair is done. \n \n• Women should be allowed one additional hour in the second\n stage of labor, depending on maternal and foetal condition.\n Thereafter pushing during contractions should be actively\n encouraged. \n \n• Continuous EFM is recommended for at least 30 minutes during\n establishment of regional analgesia and after administration of\n each bolus.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_087", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 55, "chunk_size": 380 } }, { "content": "38 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_088", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 57 ==================================================\nGuidelines to maintain the partograph", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_089", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 147 } }, { "content": "National Guideline for Maternal Care - Volume I 39", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_090", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 58 ==================================================\n40 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_091", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 160 } }, { "content": "================================================== PAGE 59 ==================================================\nGuideline on Acute Puerperal Inversion of the Uterus\n \n \n1. Introduction \n \n The aim of this guideline is to provide recommendations for the\n management of acute puerperal inversion of the uterus, which is a rare\n and life threatening condition. The main reason for its high mortality rate\n is delay in instituting appropriate treatment, which leads to postpartum\n hemorrhage and rapid development of shock out of proportion to\n haemorrhage. \n \n \n2. Definition", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_092", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 570 } }, { "content": "hemorrhage and rapid development of shock out of proportion to\n haemorrhage. \n \n \n2. Definition \n \n It is defined as ‘the turning inside out of the fundus into the uterine cavity’.\n \n \n3. Prevention \n \n Mismanagement of the third stage of labor is recognized as the main\n cause, although 50% have no identifiable cause. The common initiating\n factor seems to be a traction force on the fundus of a relaxed uterus.\n Proper retraction of the uterus in the third stage is the primary factor in\n preventing an inversion. There is no reliable data to suggest that it recurs\n in a future pregnancy.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_092", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 97, "chunk_size": 592 } }, { "content": "in a future pregnancy. \n \n The importance of the active management of the third stage could not be\n over-emphasized. (Please refer Section 3 of the PPH Guideline and the\n section on management of delayed third stage (section 3.2.3 in the Normal\n Labor Guideline for details) \n \n \n4. Pathophysiology (and clinical correlation) \n \n As the inversion progresses, the adnexae with their ligaments get drawn\n into the inverting uterine fundus and become increasingly stretched. This\n produces significant pain and vagal stimulation, leading to neurogenic\n shock.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_092", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 80, "chunk_size": 556 } }, { "content": "produces significant pain and vagal stimulation, leading to neurogenic\n shock. \n \n An inverted uterus becomes trapped within the cervix creating\n progressive oedema and congestion due to interruption of venous and\n lymphatic drainage. Oedema and congestion will increase the firmness\n of the inverted segment, making reduction more difficult. Interruption\n National Guideline for Maternal Care - Volume I 41", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_092", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 56, "chunk_size": 407 } }, { "content": "================================================== PAGE 60 ==================================================\nof the venous drainage will lead to significant haemorrhage. A partially\n separated placenta would add to this. \n \n \n5. Classification \n \n Although acute, subacute and chronic varieties have been described, this\n guideline would address only the acute variety as it is life threatening.\n \n This occurs soon after birth, just before or after the delivery of the placenta.\n \n Three degrees of inversion have been described, depending on the", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_093", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 548 } }, { "content": "Three degrees of inversion have been described, depending on the\n level of the inverted fundus. In practice, second-degree inversion is the\n commonest. The fundus has come past the cervical os, but is still within\n the vagina. \n \n \n6. Clinical Presentation and Diagnosis \n \n Prompt diagnosis is vital. \n \n The key to diagnosis is awareness and a high degree of suspicion.\n The following are early warnings: \n \n• A degree of shock that is out of proportion to overt blood loss\n \n• A retained placenta \n \n \n• Placenta delivered but ‘with some difficulty’", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_093", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 552 } }, { "content": "• A retained placenta \n \n \n• Placenta delivered but ‘with some difficulty’ \n \n• Severe, sustained unexplained pain in the third stage.\n \n In this situation: \n \n• Feel for the fundus. If absent or ‘cupped’, acute inversion is\n probable diagnosis; \n \n• Confirm by a vaginal examination: \n \n• Look for a hard mass which looks and feels like a huge\n ulcerated fibroid polyp (sometimes described as a foetal\n head); \n \n• The cervix is not to be seen or felt in the normal position,\n instead it could be felt as a ring around the base of the\n ‘mass’;", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_093", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 93, "chunk_size": 544 } }, { "content": "instead it could be felt as a ring around the base of the\n ‘mass’; \n \n \n• In incomplete cases, the inverted fundus may be felt\n through the cervical canal in the lower uterine cavity.\n 42 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_093", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 42, "chunk_size": 235 } }, { "content": "================================================== PAGE 61 ==================================================\n7. Management \n \n 7.1 General measures: \n \n Early diagnosis is vital. Treat it as a life-threatening emergency.\n \n First attempts at reduction should be made at the place where it is\n diagnosed, without moving to theatre. \n \n If these attempts fail, move to theatre and give a general anesthetic without\n delay (see section 7.2.4). \n \n Early involvement of experienced personnel and teamwork are absolutely\n essential. \n \n Treat shock aggressively, not forgetting the neurogenic element.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_094", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 597 } }, { "content": "essential. \n \n Treat shock aggressively, not forgetting the neurogenic element.\n \n Provide adequate pain relief \n \n Replace the blood loss, which could be considerable, especially if the\n placenta has partially or completely separated. \n \n Do not attempt to remove the placenta, if still attached.\n \n 7.2 Repositioning the uterus \n \n Reposition the uterus as soon as possible; the sooner it is done the easier\n and better. It reverses the shock and reduces PPH.\n \n Non-surgical methods \n \n 7.2.1 Manual replacement of uterus. \n (Johnson’s maneuver)", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_094", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 76, "chunk_size": 548 } }, { "content": "Non-surgical methods \n \n 7.2.1 Manual replacement of uterus. \n (Johnson’s maneuver) \n \n The operator introduces two thirds of his forearm in to the vagina and\n extends the hand at the wrist to place the palm on the inverted fundus and\n fingertips at the utero-cervical junction. Lifting the uterus above the level\n of the umbilicus creates adequate tension for the cervical ring to dilate and\n for the fundus to revert to its normal position.\n \n National Guideline for Maternal Care - Volume I 43", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_094", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 79, "chunk_size": 496 } }, { "content": "================================================== PAGE 62 ==================================================\nThis could be helped by ‘working the fingers up’ gradually from the cervical\n ring towards the fundus, with gentle but persistent pressure applied.\n \n Where the uterus is too hard to respond, consider tocolytics (see below).\n \n Once reduced, hold the fundus in place for a few minutes (making a fist\n inside the uterus with upward pressure on the fundus helps).\n \n Administer uterotonics (Ergometrine 0.25 mg i.v. or oxytocin 5-10 IU i.v", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_095", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 547 } }, { "content": "Administer uterotonics (Ergometrine 0.25 mg i.v. or oxytocin 5-10 IU i.v\n followed by oxytocin infusion at the rate of 10 IU per hour), whilst the\n hand is still inside. When the uterus begins to contract, slowly remove the\n hand. \n \n This manouvre is possible only soon after the event, and would need\n adequate analgesia. Unless it is possible to administer either a general\n anesthetic immediately, administer pethidine 50 mg iv slow and proceed\n with the maneuvres. \n \n Give antibiotics (e.g. cephradine 1g and metronidazole 500 mg IV).\n \n 7.2.2 Hydrostatc reduction (O’Sullivan 1945)", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_095", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 90, "chunk_size": 588 } }, { "content": "7.2.2 Hydrostatc reduction (O’Sullivan 1945) \n \n Several novel and useful modifications have been made to this procedure\n lately, principally to circumvent the problem of inadequate water seal,\n which has been the major cause of failure in the past.\n \n Insert 6 cm silastic ventouse cup into vagina, making sure that it is directed\n at the posterior vaginal fornix and not at, or cupping the fundus. Place\n hand at introitus to maintain seal between cup and vagina.\n \n (Alternatively 500ml balloon catheter can be placed in vagina. If neither is", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_095", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 545 } }, { "content": "(Alternatively 500ml balloon catheter can be placed in vagina. If neither is\n available, use a wide tube; a standard giving set will not do).\n \n Connect via IV giving set to a bag of warmed normal saline placed 1- 1.5\n metres above the patient. \n \n Infuse normal saline (typically 2 litres) into vagina to reduce the uterus by\n hydrostatic pressure.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_095", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 58, "chunk_size": 349 } }, { "content": "44 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_096", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 63 ==================================================\nOnce reduced, remove the placenta if still attached and proceed as in the\n previous section. \n \n Where a balloon is used, it would be advisable to leave it for 12-24 hours\n to prevent re-inversion and reduce haemorrhage. \n \n Saline embolisation and fluid overload leading to pulmonary oedema are\n only theoretical risks as long as one sticks to hydrostatic pressure only.\n \n 7.2.3 Tocolytics \n \n Where repositioning is difficult due to retraction of the uterine muscle", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_097", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 75, "chunk_size": 578 } }, { "content": "7.2.3 Tocolytics \n \n Where repositioning is difficult due to retraction of the uterine muscle\n and the constriction of the cervical ring, tocolytics could be helpful. But\n given this could cause PPH, it would have to be a considered and a senior\n decision. They are safest given in the theatre setting.\n \n Various preparations have been used; ideally it should be readily available,\n with quick onset and short duration of action. E.g.\n \n Turbutaline 0 .25mg i.v. slowly (not available in Sri Lanka at present);\n \n Salbutamol 0.25mg in 10 ml saline i.v. slowly;", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_097", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 561 } }, { "content": "Salbutamol 0.25mg in 10 ml saline i.v. slowly; \n \n Nitroglycerine 0.1mg i.v. slowly or sublingually (acts within 90 seconds)\n \n 7.2.4 General Anaesthesia \n \n If the initial attempt at manual replacement fails, it is safest to move the\n patient to the theatre and to administer general anaesthesia. This allows\n for muscle relaxation, pain relief and elimination of the neurogenic\n contribution to the shock. \n \n 7.2.5 Surgical methods \n \n If managed properly in the early stages, resort to surgery should be a rare\n occurrence.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_097", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 78, "chunk_size": 527 } }, { "content": "National Guideline for Maternal Care - Volume I 45", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_098", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 64 ==================================================\nHuntingdon’s operation \n \n After a laparotomy, the indrawn uterine cup is identified near the region\n of the cervix with the tubes and round ligaments pulled into the cup. By\n the use of two Allis forceps the uterus is pulled out of the constriction ring\n in a progressive fashion and restored to its normal position. The serosa of\n the uterus will invariably sustain lacerations and these are repaired with\n absorbable sutures.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_099", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 538 } }, { "content": "the uterus will invariably sustain lacerations and these are repaired with\n absorbable sutures. \n \n Use of a silastic vacuum cup from above instead of Allis forceps has been\n shown to circumvent this problem. \n \n Haultain’s operation \n \n In this procedure the constriction in the region of cervix is incised\n posteriorly using a longitudinal incision. As in the Huntingdon’s method\n two Allis forceps are used to pull the uterus to its normal position. The\n incision is repaired with interrupted sutures. Uterotonics are given to\n maintain contraction of the uterus. \n \n Hysterectomy", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_099", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 86, "chunk_size": 583 } }, { "content": "maintain contraction of the uterus. \n \n Hysterectomy \n \n When all the above methods fail, a hysterectomy will become the only\n viable option. However, it must be remembered that given the distorted\n anatomy, this must be undertaken by a surgeon of considerable experience.\n \n \n8. Debriefing \n Although there is no evidence of a recurrence risk, it is sensible to advise\n the woman to deliver in a specialized Unit next time, and the third stage\n to be managed actively by experienced personnel.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_099", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 77, "chunk_size": 494 } }, { "content": "46 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_100", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 65 ==================================================\nManagement of \n \n Hypertensive disease", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_101", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 148 } }, { "content": "National Guideline for Maternal Care - Volume I 47", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_102", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 66 ==================================================\n48 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_103", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 160 } }, { "content": "================================================== PAGE 67 ==================================================\nManagement of Hypertensive Disease in Pregnancy\n \n \n1. Introduction \n \n Hypertension in pregnancy is an important cause of direct maternal deaths\n in Sri Lanka. Early identification, aggressive and intensive treatment of\n its complications is important in reducing the resulting morbidity and\n mortality. \n \n \n2. Definitions \n \n Chronic Hypertension: \n \n Women with pre-existing hypertension or hypertension detected before", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_104", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 56, "chunk_size": 533 } }, { "content": "Chronic Hypertension: \n \n Women with pre-existing hypertension or hypertension detected before\n 20th week of gestation in the absence of trophoblastic disease and\n persisting more than 42 days post partum. \n \n Gestational Hypertension \n \n A) Pregnancy Induced Hypertension: \n \n Hypertension unaccompanied by proteinuria developing after 20 weeks of\n gestation and resolving within 42 days of delivery.\n \n B) Pre Eclampsia: \n \n Pregnancy induced hypertension associated with significant proteinuria\n (300mg/l or 500mg/ 24 hours or dipstick 2+ or more).\n \n Severe Preeclampsia:", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_104", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 73, "chunk_size": 575 } }, { "content": "(300mg/l or 500mg/ 24 hours or dipstick 2+ or more).\n \n Severe Preeclampsia: \n \n Defined as Pre-eclampsia with severe hypertension and/or with symptoms,\n and/or biochemical and/or haematological impairment.\n \n The clinical features of severe pre-eclampsia (in addition to hypertension\n and proteinuria) are:", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_104", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 39, "chunk_size": 307 } }, { "content": "National Guideline for Maternal Care - Volume I 49", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_105", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 68 ==================================================\n• Severe headache \n \n \n• Visual disturbance such as blurring or flashing before eyes,\n scotomas \n \n• Epigastric or hypochondrial pain and/or nausea & vomiting\n \n• Clonus (3 beats or more) \n \n• Papilloedema \n \n• Liver tenderness \n \n \n• Oliguria (less than 400 ml per day or 0.5 mg/Kg/hour over a 4\n hour period) \n \n• Platelet count falling to below 100 x 106/l \n \n• Abnormal liver enzymes (ALT or AST rising to above 70IU/l)\n \n• HELLP syndrome \n \n Severe Hypertension:", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_106", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 577 } }, { "content": "• HELLP syndrome \n \n Severe Hypertension: \n \n Defined as systolic blood pressure ≥ 160 mmHg and/or diastolic blood\n pressure ≥110 mmHg. \n \n Eclampsia: \n \n Defined as the development of convulsions and/or unexplained coma\n during pregnancy or postpartum in patients with features of preeclampsia.\n \n \n3. Screening for Hypertension during pregnancy \n \n Blood pressure must be measured in every clinic visit by a Medical Officer\n and results recorded and plotted in the pregnancy record.\n \n Proteinuria must be tested for at every clinic visit.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_106", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 76, "chunk_size": 541 } }, { "content": "Proteinuria must be tested for at every clinic visit.\n \n If blood pressure is more than 140/90 mmHg on two occasions at least 2\n hours apart, refer for specialist care. \n \n \n4. Prevention of hypertensive disorders in pregnancy\n \n Advise women at high risk of pre-eclampsia to take 75 mg of aspirin daily\n from 12 weeks until delivery of the baby. Women at high risk are:\n \n 50 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_106", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 72, "chunk_size": 424 } }, { "content": "================================================== PAGE 69 ==================================================\nThose with any one of the following risk factors:\n \n \n• Hypertensive disease during a previous pregnancy\n \n• Chronic kidney disease \n \n• Autoimmune disease such as systemic lupus erythematosis or\n antiphospholipid syndrome \n \n• Type 1 or type 2 diabetes \n \n• Chronic hypertension \n \n \n• Multiple pregnancy \n \n Or, any TWO or more of the following \n \n• First pregnancy \n \n• Age 40 years or older \n \n• Pregnancy interval of more than 10 years", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_107", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 550 } }, { "content": "• First pregnancy \n \n• Age 40 years or older \n \n• Pregnancy interval of more than 10 years \n \n \n• Body mass index (BMI) of 35 kg/m² or more at first visit\n \n• Family history of preeclampsia \n \n Contraindications such as allergy, gastritis, peptic ulcer disease must be\n taken into account. \n \n Advice women who have the above risk factors to ensure a higher intake of\n calcium to achieve a daily intake of at least 1000 mg taking into account the\n average intake by Sri Lankan women the recommended supplementation\n level is 600 mg. \n \n \n5. Management of Chronic Hypertension", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_107", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 95, "chunk_size": 575 } }, { "content": "level is 600 mg. \n \n \n5. Management of Chronic Hypertension \n \n Women with chronic hypertension must be managed in specialist units.\n Anticipate the development of superimposed pre eclampsia in these\n women. This combination adds risks to both mother and baby. ACE\n inhibitors should be discontinued in women who are planning pregnancy\n and its use avoided during pregnancy. \n \n Treatment of mild to moderate hypertension \n \n Since there is no consensus on the value of treating mild to moderate\n hypertension, this guideline will not address this issue.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_107", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 554 } }, { "content": "hypertension, this guideline will not address this issue.\n \n National Guideline for Maternal Care - Volume I 51", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_107", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 17, "chunk_size": 111 } }, { "content": "================================================== PAGE 70 ==================================================\n6. Management of Severe Pre-Eclampsia \n \n The basic outline of management \n \n \n• Admit to hospital and inform Consultant \n \n• Observe and monitor \n \n• Control blood pressure \n \n• Prevent seizures \n \n \n• Look for complications – such as HELLP / pulmonary oedema/\n cerebral haemorrhage \n \n• Strict fluid balance \n \n• In utero transfer where necessary and safe \n \n• Timing of Delivery \n \n \n• Continue vigilance post delivery \n \n• Follow up \n \n 6.\n1. General Considerations", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_108", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 579 } }, { "content": "• Continue vigilance post delivery \n \n• Follow up \n \n 6.\n1. General Considerations \n \n• Severe preeclampsia is a life threatening condition.\n \n \n• The only known cure is delivery of the baby. \n \n• The immediate task is to determine the urgency to effect\n delivery. \n \n• Stabilization of the mother’s condition within an acceptable\n time frame prevents maternal complications and may improve\n fetal condition. \n \n• The management has to be individualized depending on the\n clinical condition and available resources. \n \n \n• The dangers will continue into the immediate postpartum\n period. \n 6.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_108", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 592 } }, { "content": "• The dangers will continue into the immediate postpartum\n period. \n 6.\n2. Specific Management \n \n Admit women who have severe preeclampsia and inform the Consultant.\n Treat hypertension if: \n \n• Systolic blood pressure ≥ 160 mmHg, or if \n \n \n• Diastolic blood pressure ≥ 110 mmHg, or if \n \n• Mean arterial pressure ≥ 125 mmHg, \n 52 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_108", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 61, "chunk_size": 380 } }, { "content": "================================================== PAGE 71 ==================================================\nAim to maintain blood pressure at around 130-140/90-100 mmHg.\n \n The main cause of maternal death in severe preeclampsia is poorly\n controlled systolic hypertension causing cerebral haemorrhage.\n \n A rapid fall in maternal blood pressure as a result of antihypertensive\n treatment may cause fetal heart rate abnormalities & compromise,\n especially in growth restricted/compromised fetuses.\n \n Where resources allow, it is recommended to monitor fetal heart with", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_109", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 67, "chunk_size": 571 } }, { "content": "Where resources allow, it is recommended to monitor fetal heart with\n continuous CTG during and for 60 minutes after commencing anti-\n hypertensive therapy. \n \n Aim to stabilize blood pressure before delivery.\n \n 6.2.\n1. Anti-hypertensive drugs \n \n Oral anti hypertensives may be used when the blood pressure is <180/110\n mmHg. Blood pressure must be monitored at 15-minute intervals and\n intravenous anti hypertensives resorted to in case of an adequate response\n is not obtained within 30 minutes. \n \n The commonly used antihypertensive drugs for acute control are given", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_109", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 572 } }, { "content": "The commonly used antihypertensive drugs for acute control are given\n below. One or the other may be used depending on availability and\n familiarity. \n \n 6.2.1.1 Labetalol orally or intravenously \n \n This should be avoided in women with a history of bronchial asthma.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_109", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 40, "chunk_size": 267 } }, { "content": "- 200mg orally stat (only if blood pressure is <180/110 mm Hg)\n - repeated hourly for up to 4 hours \n or \n - 20 mg IV over two minutes \n \n• Record blood pressure after 10 minutes. \n \n \n• If either value is still above 160 mm Hg systolic and/or 110\n mmHg diastolic, give 40 mg iv over 2 minutes.\n \n• Record blood pressure after 10 minutes. \n National Guideline for Maternal Care - Volume I 53", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_110", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 391 } }, { "content": "================================================== PAGE 72 ==================================================\n• If the blood pressure is still above 160 mm Hg systolic and/or\n 110 mmHg diastolic, give hydralazine 10 mg iv. For instructions\n regarding giving a fluid bolus with i.v. hydralazine, see the next\n section of this guideline. \n \n \n• If the blood pressure is still above 160 mm Hg systolic and/\n or 110 mmHg diastolic, start an IV infusion of labetolol,\n starting at 40 mg/hour, doubling dose at half hourly intervals\n as required to a maximum of 160 mg/hour.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_111", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 83, "chunk_size": 568 } }, { "content": "as required to a maximum of 160 mg/hour. \n \n• Where these measures fail, the mother must be moved to a\n high-dependency area or an intensive care unit.\n \n If blood pressure is controlled by the above, continue monitoring the\n blood pressure at 15 minute intervals for 1 hour and at 30 minute intervals\n thereafter. \n \n Additional bolus doses as described above may be administered if the\n blood pressure increases above 160 mmHg systolic and/or 110 mmHg\n diastolic. \n \n 6.2.1.\n2. Hydralazine intravenously: \n \n \n• 5 - 10 mg IV bolus over 2 minutes.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_111", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 548 } }, { "content": "diastolic. \n \n 6.2.1.\n2. Hydralazine intravenously: \n \n \n• 5 - 10 mg IV bolus over 2 minutes. \n \n• This must be accompanied by a fluid bolus of 5ml/kg of 0.9%\n sodium chloride or ringer lactate solution over 30 min, started\n at the same time as iv hydralazine (this helps vasodilatation &\n prevents drastic hypotension). This should not be used in the\n presence of pulmonary oedema. \n \n• Record blood pressure at 15 minute intervals. \n \n• Repeat boluses of 5 - 10 mg IV after a 15 minute interval may\n be given if necessary up to a maximum of 20 mg (the effect of", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_111", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 100, "chunk_size": 563 } }, { "content": "be given if necessary up to a maximum of 20 mg (the effect of\n a single dose can last up to 6 hours). \n \n \n• If the response to above doses is inadequate, give labetolol\n bolus doses as described above. \n \n• If no lasting effect with above boluses, consider an infusion of\n hydralazine 2.0 mg/hour increasing by 0.5 mg/hour as required\n (2-20 mg/hour usually required).", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_111", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 64, "chunk_size": 369 } }, { "content": "54 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_112", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 73 ==================================================\n6.2.1.\n3. Oral Nifedipine \n \n \n• Oral nifedipine may be used where the blood pressure is <\n 180/110 mm Hg, in asymptomatic patients. \n \n• Give 10 mg orally. \n \n \n• Repeat at 20 minute intervals up to a maximum of 40 mg.\n \n• If there is no response proceed to intravenous labetalol or\n hydralazine. \n \n 6.2.\n2. Prevention of convulsions \n \n Magnesium sulphate \n \n \n• Magnesium sulphate is the anticonvulsant of choice.\n \n• It should be given to any woman with features of impending/", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_113", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 83, "chunk_size": 591 } }, { "content": "• It should be given to any woman with features of impending/\n imminent eclampsia (presence of clonus, severe headache,\n visual disturbances, and dizziness). \n \n• The loading dose may be given even when the status of renal\n function is uncertain, since it is unlikely that toxic levels of\n magnesium could be reached with this dose alone.\n \n• Give loading dose of 4 G IV over 10 minutes. There are two\n methods of giving magnesium sulphate intravenously.\n \n o Diluted to a total volume of 20 ml with 0.9% sodium\n chloride solution, given via an infusion pump or ‘manually’.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_113", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 96, "chunk_size": 573 } }, { "content": "chloride solution, given via an infusion pump or ‘manually’.\n o Diluted to a total volume of 80 ml with 0.9% sodium\n chloride solution via a burette \n \n• Immediately after the loading dose, start infusion of 1 G IV per\n hour. Continue this infusion for at least 24 hours after delivery.\n \n• Where there are difficulties with intravenous access, magnesium\n sulphate may be administered intramuscularly. Give 5 G deep\n intramuscularly into each buttock with 1 ml of 2% lignocaine\n in the same syringe. \n \n \n• If intramuscular magnesium sulphate is continued as", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_113", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 90, "chunk_size": 558 } }, { "content": "in the same syringe. \n \n \n• If intramuscular magnesium sulphate is continued as\n maintenance therapy, give 5G to alternate buttocks 4 hourly,\n with 1ml of 2% lignocaine in the same syringe.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_113", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 30, "chunk_size": 189 } }, { "content": "National Guideline for Maternal Care - Volume I 55", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_114", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 74 ==================================================\n• Monitor the mother to ensure hourly urine output of 30 ml per\n hour, respiratory rate >16/ minute, oxygen saturation >90%\n and presence of patellar reflexes. \n \n \n• These should be recorded every 30 minutes. \n \n• Should signs of toxicity appear, the antidote is calcium\n gluconate, 1 G intravenously (10 ml of 10% solution), given\n over 10 minutes. \n \n• Magnesium sulphate may be used safely in women who have\n previously received nifedipine \n \n 6.2.\n3. Fluid Balance", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_115", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 579 } }, { "content": "previously received nifedipine \n \n 6.2.\n3. Fluid Balance \n \n \n• Restrict total fluid intake to 80 ml per hour.\n \n• Accurate recording of fluid balance is essential.\n \n• Selective colloid expansion may be necessary prior to\n pharmacological vasodilatation to prevent maternal\n hypotension and fetal compromise or in oliguria with a low\n central venous pressure. \n \n \n• The volumes of all drugs administered must be taken into\n account and appropriate reduction of the volume of crystalloids\n must be made. \n \n• Colloid (e.g. Hetastarch) should be administered only after", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_115", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 84, "chunk_size": 569 } }, { "content": "must be made. \n \n• Colloid (e.g. Hetastarch) should be administered only after\n discussion with the anaesthetist. \n \n• Diuretics must be restricted to specific instances only e.g. for\n women with pulmonary oedema. \n \n• Avoid non-steroidal analgesia until fluid recovery.\n \n 6.2.\n4. In utero/neonatal transfer: \n \n \n• If a Unit does not have access to HDU/ICU or is unable to\n cope with maternal complications, or with maturity of the\n baby, it may be appropriate to consider antenatal transfer of\n the mother. \n \n• However, maternal safety must not be jeopardised and each", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_115", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 88, "chunk_size": 572 } }, { "content": "the mother. \n \n• However, maternal safety must not be jeopardised and each\n case should be considered on its clinical merits.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_115", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 20, "chunk_size": 125 } }, { "content": "56 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_116", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 75 ==================================================\n• Steps must be taken to bring down blood pressure from very\n high levels (e.g. using nifedipine). \n \n \n• Women with imminent/impending eclampsia must be\n administered a loading dose of magnesium (IM or IV) before\n transfer (see 6.2.2) \n \n• It is recommended that where possible telephone advice is\n obtained from the relevant specialist unit before transfer.\n \n• The patient must be accompanied by a member of staff who is\n capable of dealing with a seizure while the patient in transit.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_117", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 83, "chunk_size": 598 } }, { "content": "capable of dealing with a seizure while the patient in transit.\n The required drugs and equipment must be made available.\n \n• Full details of the case, including treatment given should\n accompany the patient. \n \n 6.2.\n5. Delivery \n \n \n• Urgency of delivery depends on the maternal and fetal\n conditions. \n \n• Either caesarean section or induction of labour is appropriate\n depending on the urgency and favourability of the cervix.\n \n \n• Institute adequate pain relief. Severe preeclampsia is not a\n contraindication for opioid or epidural anaesthesia (see below).", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_117", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 84, "chunk_size": 563 } }, { "content": "contraindication for opioid or epidural anaesthesia (see below).\n It is accepted that epidural anaesthesia helps to bring down the\n blood pressure. \n \n• Spinal or epidural anaesthesia is safe in the presence of a\n platelet count >80,000/dl. \n \n• Maternal condition should be optimised before delivery.\n \n• It is inappropriate to deliver an unstable mother for foetal\n reasons. \n \n• Ergometrine should not be used during the third stage.\n \n 6.2.\n6. Post-delivery \n \n \n• Maintain vigilance as a high proportion of eclamptic seizures\n occur after delivery.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_117", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 553 } }, { "content": "• Maintain vigilance as a high proportion of eclamptic seizures\n occur after delivery. \n \n• High dependency care should be provided as clinically\n indicated.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_117", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 23, "chunk_size": 157 } }, { "content": "National Guideline for Maternal Care - Volume I 57", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_118", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 76 ==================================================\n• Continue close monitoring, including fluid balance, platelets,\n liver enzymes and creatinine until they have returned to\n normal values. \n \n \n• Magnesium sulphate if started should be continued for 24\n hours after the delivery or after the last fit, whichever is later.\n \n• Review anti-hypertensive medication as indicated. Some may\n need to continue oral medication for a few weeks. Methyldopa\n is best avoided following delivery because of its tendency to\n cause depression.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_119", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 75, "chunk_size": 588 } }, { "content": "is best avoided following delivery because of its tendency to\n cause depression. \n \n• Review magnesium sulphate medication as indicated.\n \n 6.2.\n7. Follow up \n \n \n• Inform Public Health Midwife and/or Medical Officer of\n Health. \n \n• Review in 2 weeks (instead of 4 weeks) if discharged on\n antihypertensives. \n \n• Depending on the clinical picture, some patients may need:\n \n o Long term follow up for blood pressure \n o Hematological investigations for conditions such as anti-\n phospholipid syndrome, thrombophilia \n \n• Debrief the patient.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_119", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 79, "chunk_size": 543 } }, { "content": "phospholipid syndrome, thrombophilia \n \n• Debrief the patient. \n \n• Advice preconceptual counseling & check prior to the next\n pregnancy. \n \n• Women may be advised regarding the risk of developing\n hypertensive disease in a future pregnancy as follows:\n \n o Risk of gestational hypertension - 53% (1 in 2)\n o Risk of preeclampsia – 16% (1 in 6) \n o Risk of preeclampsia if she had severe hypertension or\n HELLP syndrome or eclampsia or the birth occurred\n before 34 weeks – 25% (1 in 4); & 55% (1 in 2) if the birth\n occurred before 28 weeks gestation.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_119", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 94, "chunk_size": 552 } }, { "content": "58 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_120", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 77 ==================================================\nManagement of Eclampsia \n \n \n1. Definition: \n \n Eclampsia is defined as the development of convulsions and/or\n unexplained coma during pregnancy or postpartum in patients with\n features of preeclampsia. \n \n \n2. Diagnosis: \n \n \n• Hypertension is considered the hallmark for the diagnosis of\n eclampsia. However, in 16% of the cases hypertension may be\n absent. \n \n \n• Eclampsia is usually associated with proteinuria, but this may\n be absent in 14% of cases.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_121", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 567 } }, { "content": "• Eclampsia is usually associated with proteinuria, but this may\n be absent in 14% of cases. \n \n• Clinical features of imminent eclampsia include:\n Severe frontal headache, \n Visual symptoms (halos, scotomas etc.) \n \n Epigastric or right hypochondrial pain, \n Liver tenderness, \n Clonus (3 beats or more) \n \n \n3. Time of onset of eclampsia \n \n The onset of eclamptic convulsions can be antepartum, intrapartum, or\n postpartum. \n \n Antepartum eclampsia \n Almost all cases (91%) develop eclampsia at or beyond 28 weeks\n \n Postpartum eclampsia", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_121", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 75, "chunk_size": 540 } }, { "content": "Almost all cases (91%) develop eclampsia at or beyond 28 weeks\n \n Postpartum eclampsia \n Although most cases of postpartum eclampsia occur within the first 48\n hours, some cases develop beyond 48 hours, up to 4 weeks postpartum\n (late postpartum eclampsia). In these cases, an extensive neurological\n evaluation is needed to rule out the presence of other cerebral pathology.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_121", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 57, "chunk_size": 375 } }, { "content": "National Guideline for Maternal Care - Volume I 59", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_122", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 78 ==================================================\n4. Comorbidities \n \n \n• Eclampsia is often complicated by comorbidities (Box 1).\n \n• These are more common among women who develop eclampsia\n at earlier periods of gestation. \n \n Box \n1. \n \n \n• Abruptio placentae \n \n• Disseminated intravascular coagulopathy \n \n• Pulmonary oedema \n \n• Acute renal failure \n \n \n• Aspiration pneumonia \n \n• HELLP syndrome (Haemolysis, elevated liver enzymes, low\n platelets)", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_123", "page_number": 2, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 58, "chunk_size": 515 } }, { "content": "5. Prevention \n \n Administration of magnesium sulphate to women with features of\n impending/imminent eclampsia (presence of clonus, severe headache,\n visual disturbances, dizziness) is the only known preventive measure.\n \n \n6. Management \n \n 6.1 General considerations \n \n 6.1.1 The priorities in management are to support respiratory and\n cardiovascular function, prevent injury and further seizures\n and to control hypertension. \n 6.1.2 Magnesium sulphate is the anticonvulsant of choice. It must\n be administered as soon as possible. See section 6.2.2 of the", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_124", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 561 } }, { "content": "be administered as soon as possible. See section 6.2.2 of the\n severe preeclampsia guideline for details. \n 6.1.3 The bolus dose of magnesium sulphate must be given even\n to women with unknown renal function or oliguria/anuria\n since this dose is unlikely to elevate magnesium levels to toxic\n ranges.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_124", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 47, "chunk_size": 301 } }, { "content": "60 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_125", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 79 ==================================================\n6.1.4 Eclampsia dictates delivery (or induction) once the maternal\n condition is stabilized, irrespective of the foetal condition or\n maturity. A decision regarding the mode and time of delivery\n will require to be made early. \n \n 6.1.5 There is no place for prolongation of the pregnancy in these\n women, unless under rare, exceptional circumstances.\n 6.1.6 For details on administration of medications and intravenous\n fluids and care of women receiving magnesium sulphate and", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_126", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 588 } }, { "content": "fluids and care of women receiving magnesium sulphate and\n intravenous antihypertensives, refer the guideline on severe\n preeclampsia. \n \n 6.\n2. During the seizure – \n \n o Turn the patient to a side and support her in that position.\n o Suck out secretions from the mouth. \n o Administer oxygen via a face mask. \n o Most eclamptic seizures resolve spontaneously.\n \n o It is imprudent to diagnose fetal hypoxia based on fetal\n bradycardia during a seizure. This usually recovers\n spontaneously following the seizure \n o Fetal bradycardia persisting beyond 10 minutes following", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_126", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 86, "chunk_size": 574 } }, { "content": "spontaneously following the seizure \n o Fetal bradycardia persisting beyond 10 minutes following\n the seizure should raise suspicion of abruptio placentae.\n \n 6.\n3. As soon as possible following a seizure \n \n o Attempt to establish intravenous access.\n o Obtain blood for full blood count, liver transaminases,\n blood urea, electrolytes and blood for cross-match.\n o Start magnesium sulphate (intravenous bolus and\n infusion or intramuscular – details in guideline on severe\n preeclampsia section 6.2.2.). \n \n o Treat blood pressure as appropriate. \n o Insert an indwelling catheter.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_126", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 81, "chunk_size": 583 } }, { "content": "o Treat blood pressure as appropriate. \n o Insert an indwelling catheter. \n o Monitor respiratory rate, urine output, reflexes, SpO\n2.\n (Please refer the guideline on severe preeclampsia for\n further details). \n \n National Guideline for Maternal Care - Volume I 61", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_126", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 39, "chunk_size": 264 } }, { "content": "================================================== PAGE 80 ==================================================\no Check for comorbidities (Box 1). \n \n o Inform the Consultant and establish a plan of management\n \n 6.\n4. Management of seizures in women receiving magnesium sulphate\n \n 6.4.1 Women developing a seizure while on magnesium sulphate\n \n o 10% of women receiving magnesium sulphate will develop\n a second seizure. \n o Administer magnesium sulphate 2 grams diluted to 10 ml\n with 0.9% sodium chloride solution over 5 minutes.\n o Increase the magnesium sulphate infusion to 2 grams per", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_127", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 590 } }, { "content": "o Increase the magnesium sulphate infusion to 2 grams per\n hour with monitoring as above. \n \n 6.4.2 Women developing more than one seizure while on magnesium\n sulphate \n \n o Call a Neurology team for advice. If one is not available,\n obtain advice from a medical team. \n o Consultant must be informed. \n o Inform the anaesthetic team if still not in an intensive care\n setting. \n \n o Second line anticonvulsants must be considered after\n discussing with anaesthetist. \n o If the woman develops further seizures, consider moving to\n intensive care for neuromuscular paralysis and ventilation.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_127", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 90, "chunk_size": 591 } }, { "content": "intensive care for neuromuscular paralysis and ventilation.\n o These women will require a full neurological evaluation,\n including imaging. \n \n \n7. Delivery \n \n o Eclampsia is not an indication for caesarean section.\n o Consider caesarean section in women who are not in\n labour with a Bishop score below \n7. \n \n o Women who are in labour may be allowed to continue to\n delivery, in the absence of obstetric complications.\n \n 62 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_127", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 74, "chunk_size": 476 } }, { "content": "================================================== PAGE 81 ==================================================\no Labour may be induced where necessary using either\n prostaglandins or amniotomy and oxytocin infusion.\n \n o Epidural or spinal anaesthesia may be administered in\n women with platelet counts above 80,000/cu mm.\n o General anaesthesia is best avoided where possible since it\n increases the risk of aspiration and failed intubation due to\n airway oedema. It is also associated with marked increases\n in systemic and cerebral pressures during intubation and", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_128", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 565 } }, { "content": "in systemic and cerebral pressures during intubation and\n extubation. Women with airway or laryngeal oedema may\n require ‘awake intubation’ under fibre optic observation\n with facilities available for immediate tracheostomy. The\n level of increase in systemic or cerebral pressures may be\n reduced by pretreatment with labetalol or nitroglycerine\n injections. \n \n \n8. Transfer of a woman who has had a seizure to another institution\n \n o In case it is required to transfer a woman who has\n had an eclamptic seizure, this must be done only after", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_128", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 544 } }, { "content": "had an eclamptic seizure, this must be done only after\n administering a bolus of magnesium sulphate. (See section\n 6.2.2 of the severe preeclampsia guideline for details). The\n patient should ideally be accompanied by a doctor and\n emergency drugs/equipment (e.g. Ambu bag) must be\n available. \n \n \n9. Postpartum management \n \n o Continue administration of magnesium sulphate and\n monitoring as described in the guideline on severe\n preeclampsia. \n o Women with abnormal renal function, preexisting\n hypertension and abruption placentae (due to use of larger", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_128", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 79, "chunk_size": 558 } }, { "content": "hypertension and abruption placentae (due to use of larger\n than normal volumes of fluids) are at particularly high\n risk of pulmonary oedema. They will require appropriate\n monitoring \n o Antihypertensive therapy may be changed to oral and\n continued .", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_128", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 38, "chunk_size": 253 } }, { "content": "National Guideline for Maternal Care - Volume I 63", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_129", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 82 ==================================================\n10. Counselling \n \n 10.\n1. Women should be advised that in a subsequent pregnancy:\n \n o The rate of preeclampsia is approximately 25%.\n \n o Rate of eclampsia is 2%. \n o These rates are substantially higher in women who develop\n eclampsia in the second trimester. \n o Taking high-dose calcium from early pregnancy (600 mg\n daily) and aspirin (75 mg daily) may reduce this risk.\n \n 10.\n2. Regarding long term risk of hypertension \n \n o There is no increase of risk in women who were", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_130", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 590 } }, { "content": "2. Regarding long term risk of hypertension \n \n o There is no increase of risk in women who were\n normotensive before the pregnancy. \n o Multigravidae who develop eclampsia may be at high risk.\n \n Acknowledgement: \n \n The following article was used as a resource in developing this guideline:\n Baha M Sibai, Diagnosis, Prevention and Management of Eclampsia.\n Obstetrics & Gynecology, 2005; 105 (2): 402 - \n410.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_130", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 63, "chunk_size": 411 } }, { "content": "64 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_131", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 83 ==================================================\nManagement of Diabetes \n \n during Pregnancy", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_132", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 153 } }, { "content": "National Guideline for Maternal Care - Volume I 65", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_133", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 84 ==================================================\n66 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_134", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 160 } }, { "content": "================================================== PAGE 85 ==================================================\nGuideline for screening, diagnosis and management of\n \n diabetes in pregnant women \n \n \n1. Purpose \n \n The purpose of this guideline is to provide guidance on screening for\n gestational diabetes mellitus (GDM) and the management of pregnancies\n complicated pre-gestational (PGDM) and GDM in the Sri Lankan setting.\n \n \n2. Screening \n \n 2.1 Target groups for screening \n \n Being South Asian and pregnant places a woman in Sri Lanka at a higher", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_135", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 552 } }, { "content": "Being South Asian and pregnant places a woman in Sri Lanka at a higher\n risk for diabetes during pregnancy. Therefore, universal screening, using a\n diagnostic test is recommended for all Sri Lankan women.\n \n A. All pregnant women should be screened for diabetes at the\n first visit unless they are already known to have Diabetes*. This\n should be performed as early as possible, preferably before 12\n weeks, in order to diagnose previously undetected diabetes.\n B. Screening using fasting blood glucose, random blood glucose,\n 50g glucose challenge test, HBA or urinalysis for reducing\n IC", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_135", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 92, "chunk_size": 590 } }, { "content": "50g glucose challenge test, HBA or urinalysis for reducing\n IC \n substances is not recommended. \n C. Those who are negative for diabetes at the first visit should be\n screened for GDM again at 24-28 weeks. \n D. Women who are known diabetics should not undergo further\n screening or diagnostic tests. They should be commenced\n on glycaemic control measures immediately under the\n supervision of obstetrician or physician. \n *Diagnostic criteria for pre pregnancy diabetes are\n any one of the following \n \n FBS ≥126mg/dl \n RBS >200mg/dl \n \n HbA1c >6.1%", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_135", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 550 } }, { "content": "any one of the following \n \n FBS ≥126mg/dl \n RBS >200mg/dl \n \n HbA1c >6.1% \n \n National Guideline for Maternal Care - Volume I 67", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_135", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 20, "chunk_size": 129 } }, { "content": "================================================== PAGE 86 ==================================================\n2.2 Recommended tests \n \n A. One stage, non- fasting 75g OGCT as described by the\n Diabetes in Pregnancy Study Group of India (DIPSI) is\n recommended for screening at the first visit and at 28 weeks.\n A 2- hour blood glucose of more than 140mg/dl confirms\n gestational diabetes. This is the recommended test for both\n field and institutional levels.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_136", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 61, "chunk_size": 459 } }, { "content": "One stage Non- fasting 75 g OGCT \n \n In this method 75g oral glucose load is given to the woman\n irrespective of the fasting status. Therefore a woman could be\n subjected to a GTT at any time, without the woman having to\n fast.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_137", "page_number": 2, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 42, "chunk_size": 227 } }, { "content": "A load of 75g of glucose dissolved in 300 ml water is given over\n 3-5 minutes. The water may be flavoured with lime juice.\n \n The plasma glucose level is measured after a period of two\n hours. \n \n (The main advantage of this test is that it would be the best way to\n \n ensure universal screening. The advantages include reduced cost, the\n ability to make a diagnosis in one test and the woman not requiring\n to fast for the test. The test has been validated against the WHO and\n HAPO criteria and been found to correlate well with them (3),(4).", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_138", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 98, "chunk_size": 544 } }, { "content": "HAPO criteria and been found to correlate well with them (3),(4).\n Data also shows that glucose levels are not significantly affected by\n the fasting status and that the non-fasting glucose level effectively\n predicts adverse effects for the mother and baby (5),(6).)", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_138", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 41, "chunk_size": 267 } }, { "content": "B. Three-point oral GTT - In the event of an equivocal screening\n result or when resources permit, the three point OGTT is\n recommended. For those who undergo three point OGTT the\n following cut off should be used for diagnosis.\n \n 68 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_139", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 48, "chunk_size": 282 } }, { "content": "================================================== PAGE 87 ==================================================\nThree-point oral GTT \n \n This is probably the most accepted diagnostic test in the world\n today. \n \n The woman should attend for the test having fasted for eight hours\n or more, having had a diet unrestricted in carbohydrates.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_140", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 40, "chunk_size": 336 } }, { "content": "Blood is first drawn for estimation of fasting plasma glucose.\n \n The woman is then given a solution of 75 G glucose dissolved in\n 300 ml of water to be taken within 10 minutes. Squeezing a lime\n into this water will make the solution more palatable without\n interfering with the result.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_141", "page_number": 2, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 50, "chunk_size": 287 } }, { "content": "Blood is then drawn at 60 and 120 minutes for estimation of\n plasma glucose. \n \n C. In situations where neither of the above tests is possible,\n (Inability to tolerate glucose or non availability of facilities)\n two-stage screening using a 2 hour PPBS is an alternative. The\n cut off blood glucose value to refer for a OGTT is ≥120mg/dl.\n \n 2 hour Post Prandial Blood Glucose Testing (PPBS)\n \n Advice the woman to have normal diet", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_142", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 430 } }, { "content": "The time of starting the meal needs to be noted. The meal should\n be completed within 15 minutes. \n \n The two-hour cut off is calculated from the time of starting the\n meal. \n \n At the end of two hours blood sample should be tested for blood\n sugar levels using glucometer or other laboratory method.\n \n National Guideline for Maternal Care - Volume I 69", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_143", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 61, "chunk_size": 354 } }, { "content": "================================================== PAGE 88 ==================================================\n3. Management – Women with established Diabetes \n \n 3.\n1. Pre Pregnancy care \n \n The importance of avoiding unplanned pregnancy is an essential\n component of diabetes education for women with diabetes.\n \n Women with diabetes who are planning to become pregnant and their\n families should be offered information on how diabetes affects pregnancy\n and how pregnancy affects diabetes. \n \n Discuss their plans for pregnancy and reinforce an appropriate", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_144", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 68, "chunk_size": 558 } }, { "content": "Discuss their plans for pregnancy and reinforce an appropriate\n contraceptive method. Any type of contraception can be used except for\n women BMI > 25kg/m2 where DMPA should not be used. Pregnancy is\n contraindicated if the woman has proliferative retinopathy, stage 2 or\n above Chronic kidney Disease or major cardiac disease.\n \n All women with diabetes wishing to conceive MUST be encouraged to\n seek specialist advice to ensure satisfactory glycaemic control (HbA1C <\n 6.1%) before conception. \n \n Ideally the decision to embark on pregnancy in known diabetics should be", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_144", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 86, "chunk_size": 573 } }, { "content": "Ideally the decision to embark on pregnancy in known diabetics should be\n decided on based on her HbA1C . A value of 6.1 or below would be ideal\n if safely achievable. Women whose levels are above 10% should be strongly\n advised against conception until good glycaemic control is achieved, in\n view of higher risk of congenital anomalies. \n \n Stress that good planning and control will help to achieve pregnancy\n outcome to be equivalent to that of a non-diabetic women. They should\n be informed that establishing good glycaemic control before conception", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_144", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 89, "chunk_size": 554 } }, { "content": "be informed that establishing good glycaemic control before conception\n and maintaining this throughout pregnancy will reduce the risk of\n miscarriage, congenital malformation, still births and neonatal deaths.\n \n Women who are using either metformin or insulin for glycaemic control\n should be advised that these are safe for use during the peri-conception\n period and into their pregnancy. \n \n Self-testing of blood sugar should be encouraged where ever economically\n feasible. \n \n 70 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_144", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 75, "chunk_size": 534 } }, { "content": "================================================== PAGE 89 ==================================================\nWomen must be encouraged to achieve a normal weight before becoming\n pregnant, especially those with a body mass index above 25 kg/m\n2. They\n must receive advice about reducing weight using lifestyle modification.\n \n Known diabetics should be assessed for diabetic nephropathy and\n retinopathy before and during pregnancy. (see below)\n Start Folic acid 5 mg daily when trying to conceive.\n \n 3.\n2. Antenatal Care \n \n At the first visit", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_145", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 545 } }, { "content": "3.\n2. Antenatal Care \n \n At the first visit \n \n \n• Refer for specialist care immediately once identified. These\n women are best managed with combined inputs from a\n physician and an obstetrician. \n \n \n• Start/ continue Folic acid 5 mg daily up-to 12 weeks of\n gestation. Change to 1mg daily from 12 weeks onwards.\n \n• Low dose Aspirin 75mg should be commenced, if there is no\n contraindication. \n \n• Check HbA1c (ideally 6.1% or less). \n \n• Dating ultrasound scan using either crown rump length or\n head circumference is recommended.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_145", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 85, "chunk_size": 533 } }, { "content": "• Dating ultrasound scan using either crown rump length or\n head circumference is recommended. \n \n• Women with pre-existing diabetes mellitus must be screened\n for diabetic end-organ damage (retinopathy, nephropathy and\n cardiovascular disease) \n \n \n• Retinopathy screening is recommended at least twice during\n pregnancy (at first contact and at 28 weeks).\n \n• Women with serum creatinine >120 µmol/litre or 24 hour\n urinary protein excretion exceeding 300mg must be referred\n for renal specialist’s advice. \n \n• Women with complicated diabetes should be managed at a", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_145", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 81, "chunk_size": 568 } }, { "content": "for renal specialist’s advice. \n \n• Women with complicated diabetes should be managed at a\n tertiary care institution by a multidisciplinary team\n \n Antenatal Appointments \n \n \n• These women must be identified as high risk and managed\n almost entirely by a specialist Obstetrician led team.\n \n National Guideline for Maternal Care - Volume I 71", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_145", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 51, "chunk_size": 344 } }, { "content": "================================================== PAGE 90 ==================================================\n• Public Health Midwife should visit such women once in every\n 2 weeks (refer guideline on domiciliary care for high risk\n pregnancies). \n \n \n• Review by the obstetric/diabetic team once every 2 weeks\n throughout the pregnancy \n \n• Anomaly scans at 18-20 weeks and Obstetric reviews at 22-24,\n 28, 32 and 36-37 weeks with ultrasound growth assessments.\n \n• If required, antenatal steroids for fetal lung maturity may be\n used. Women should be admitted to hospital for glycaemic", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_146", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 587 } }, { "content": "used. Women should be admitted to hospital for glycaemic\n control during therapy since glucose levels rise in response to\n steroids. \n \n• More attention should be given to the woman with diabetes\n during antenatal preparation for breast feeding as they\n need to start and establish breast feeding quickly to prevent\n hypoglycaemia of newborn. \n \n• Refer to dental surgeon for screening and maintenance of oral\n hygiene. \n \n 3.\n3. Medical nutrition therapy (MNT) \n \n MNT is the cornerstone of the management of diabetes in pregnancy.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_146", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 532 } }, { "content": "MNT is the cornerstone of the management of diabetes in pregnancy.\n Women must be referred to a dietician/ diabetic educator nurse where\n one is available. \n \n Emphasis the importance of small frequent meals, food with low glycaemic\n index and the dietary advice should be culture sensitive.\n \n 3.\n4. Exercise \n \n Exercise has an insulin-like action and women with GDM and pre-existing\n diabetes complicating pregnancy. Therefore, diabetic women must be\n encouraged to engage in regular exercise. \n \n The intensity of exercise would depend on the woman’s level of fitness,", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_146", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 572 } }, { "content": "The intensity of exercise would depend on the woman’s level of fitness,\n presence of complications and familiarity with exercise.\n \n Ideally this should be at least 30 minutes per day of an activity, which\n leaves her slightly breathless. \n \n 72 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_146", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 46, "chunk_size": 293 } }, { "content": "================================================== PAGE 91 ==================================================\nWomen on insulin must be aware of the tendency to hypoglycaemia\n during exercise. \n \n \n4. Glyceamic control and Monitoring \n \n 4.\n1. Glyceamic Control \n \n 4.1.\n1. The aim is to achieve optimum glycaemic control throughout the\n day for the duration of the pregnancy (avoiding hypoglycaemia).\n \n The target values for glycaemic control are given below:\n \n Table \n1. Target values in glycemic control \n \n Fasting and pre-meal 2 hour post meal", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_147", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 549 } }, { "content": "Table \n1. Target values in glycemic control \n \n Fasting and pre-meal 2 hour post meal\n \n Venous plasma 70 - 90 (3.9 – 5.0 mMol/L) Below 120 mg/dl (6.7 mMol/L)\n Capillary blood 80 – 103 (4.4 – 5.7 mMol/L) 118 mg/dl (6.5 mMol/L)\n \n (The equivalent capillary blood values were derived using a conversion\n formula7) \n \n Refer to Diabetic Educator Nursing Officer (DENO) where one is available.\n At diagnosis, offer diet/ lifestyle advice with a recorded glycaemic\n assessment within 1-2 weeks. \n \n Majority of these women can achieve optimal glycaemia with modest\n changes in diet and exercise.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_147", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 92, "chunk_size": 590 } }, { "content": "changes in diet and exercise. \n \n Consider insulin and /or metformin treatment if suboptimal glycaemia\n persists despite diet and exercise modifications. The choice of these\n treatments will depend on physician and patient preferences.\n \n Ideally the insulin regimen should be adjusted to achieve targets: in most\n cases with moderate to severe hyperglycaemia three doses of short acting\n pre prandial insulin combined with a single dose of basal insulin at bed\n time is required. However, twice daily dose of pre mixed 30:70 insulin", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_147", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 80, "chunk_size": 533 } }, { "content": "time is required. However, twice daily dose of pre mixed 30:70 insulin\n has high patient compliance with adequate control of blood sugar in most\n cases. If blood sugar is not controlled by this twice daily regimen, adding\n metformin or soluble insulin to cover lunch is an alternative.\n National Guideline for Maternal Care - Volume I 73", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_147", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 56, "chunk_size": 337 } }, { "content": "================================================== PAGE 92 ==================================================\nACE inhibitors, statins and ARBs are contraindicated during pregnancy\n \n 4.\n2. Monitoring of glycaemic control \n \n Self-monitoring of blood glucose (SMBG) with close liaison with the\n diabetic team is recommended for those who are able to afford a glucometer\n and test strips. (However, in view of variable quality of glucometers women\n must be advised to crosscheck the values occasionally with estimations\n made by a reliable laboratory.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_148", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 549 } }, { "content": "made by a reliable laboratory. \n \n For women who cannot afford the cost of SMBG, monitoring with regular\n 6 point blood glucose monitoring should be offered. \n \n The frequency of such monitoring should be decided by the overall\n glyceamic control, presence or absence of fetal macrosomia and the period\n of gestation;: with at least four weekly reviews in pregnancy two weekly\n reviews in late pregnancy \n \n Schedule ultrasound measurement of AC at 28, 32 and 36 weeks. If AC >\n 90 centile at any stage, consider insulin therapy to target 2 hour PPBS to", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_148", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 91, "chunk_size": 553 } }, { "content": "90 centile at any stage, consider insulin therapy to target 2 hour PPBS to\n be less than 100mg/dl but avoiding hypoglycaemia. \n \n If crossing centiles or AC <10 centile, do AFI and request obstetrician\n review. \n \n Insulin requirements change throughout the pregnancy. If requirements\n are falling (or maternal hypoglycaemia occurs frequently) request early\n obstetrician review for fetal assessment. \n \n HbA1c is not a reliable indicator of glycaemic control in the second\n and third trimesters. \n \n \n5. Delivery and intra natal care \n \n 6.\n1. Timing of delivery", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_148", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 563 } }, { "content": "and third trimesters. \n \n \n5. Delivery and intra natal care \n \n 6.\n1. Timing of delivery \n \n For women with pre-pregnancy diabetes or who receive insulin therapy,\n schedule obstetrician review at 36-37 weeks for planning their delivery at\n 38-39 weeks. \n \n 74 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_148", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 46, "chunk_size": 307 } }, { "content": "================================================== PAGE 93 ==================================================\nFor women on diet control and/or women having optimal glycaemic\n control and, carrying a normally grown baby, there is insufficient evidence\n to suggest the best time for delivery. \n \n Diabetes alone is not an indication for a caesarean section.\n \n The obstetrician should make the decision after discussing with the\n woman. \n \n Delivery should be arranged in the day time, when all supports are more\n easily available. \n \n 5.\n2. Labour care", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_149", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 551 } }, { "content": "easily available. \n \n 5.\n2. Labour care \n \n Second tier obstetric on-call (SHO/Registrar) should be informed of any\n woman with diabetes at the onset of labour. He/she should be present\n for the delivery. It is recommended to involve the medical team in the\n management of difficult cases. \n \n Inform on-call neonatal team of any planned/ imminent delivery of a\n diabetic mother. \n \n During labour and birth, capillary blood glucose should be monitored\n 1-2 hourly in women with diabetes and maintained at between 4 and 7\n mmol/litre. (72 – 126 mg/dl). These CBG records should be entered in the", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_149", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 94, "chunk_size": 595 } }, { "content": "mmol/litre. (72 – 126 mg/dl). These CBG records should be entered in the\n partogram. \n Hartmann’s/ normal saline or Insulin-dextrose – potassium (GIK)\n infusion should be started if the values are lower or higher respectively.\n \n \n6. Post natal care \n \n 6.1a. Neonatal care \n \n Handover care of newborn, to neonatal team. \n \n Ensure delivery-to-abdomen and initiate breastfeeding as early as possible\n (within first ½ to 1 hour) unless specific concerns prevent such action.\n \n Take all suitable ENC measures to avoid hypothermia.\n \n National Guideline for Maternal Care - Volume I 75", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_149", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 584 } }, { "content": "================================================== PAGE 94 ==================================================\nBlood glucose testing should be carried out routinely in babies of women\n with diabetes at 2–4 hours after birth. The mother must be informed about\n this antenatally to avoid unnecessary distress. \n \n Neonatal blood glucose values below 36 mg/dl (2 mMol/L) should trigger\n action. \n \n Blood tests for polycythaemia, hyperbilirubinaemia, hypocalcaemia and\n hypomagnesaemia should be carried out for babies with clinical signs.\n \n 6.1b. Immediate post partum care", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_150", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 571 } }, { "content": "6.1b. Immediate post partum care \n \n It is recommended that the mother be tested for RBS within 4 hours of\n delivery. The decision to manage maternal diabetes with insulin or oral\n medication should be made within the first 48 hours after delivery and\n prior to discharge from hospital. \n \n If the mother received insulin in the antenatal period, it is recommended\n that the dose needs adjustments to pre pregnant doses in those with type\n 2 diabetes mellitus or be maintained on diet alone in those with GDM.\n This decision should be based on her post partum blood glucose value. If", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_150", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 98, "chunk_size": 583 } }, { "content": "This decision should be based on her post partum blood glucose value. If\n FBG exceed 126mg/dl or RBS exceeds 200mg/dl, insulin in a lower dose\n (usually half of the antenatal dose) or metformin would be required. This\n decision is best left to the managing physician who should be responsible\n for the woman’s long term care. \n \n 6.\n2. At hospital discharge \n \n Inform MOH and area public health midwife (PHM) through woman’s\n pregnancy record. \n \n For women with pre- gestational diabetes, prescribe suitable hypoglycaemic", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_150", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 81, "chunk_size": 523 } }, { "content": "pregnancy record. \n \n For women with pre- gestational diabetes, prescribe suitable hypoglycaemic\n agent, restart statins, schedule follow up clinic date at the medical clinic.\n For women who developed GDM, give a date or make arrangements to\n screen for DM at 6 weeks postpartum. \n \n Discuss and help to decide on the suitable contraceptive method.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_150", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 52, "chunk_size": 348 } }, { "content": "76 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_151", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 95 ==================================================\n6.\n3. Late Postnatal care and follow up \n \n At 6 -8 weeks postpartum, all women with GDM are screened for diabetes\n mellitus. The test of screening is ideally the 75g OGTT. FBS is an alternative\n if resources are limited. Women whose fasting venous plasma glucose is\n above 100 mg/dl (5.5 mMol/L) must be referred for further evaluation.\n \n Women who have been diagnosed with GDM and are screen-negative at\n the 6 week review should receive lifestyle advice and screening for diabetes", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_152", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 594 } }, { "content": "the 6 week review should receive lifestyle advice and screening for diabetes\n mellitus annually with at least a FBS. The importance of maintaining a\n normal BMI and the contribution of breastfeeding to weight loss must be\n emphasized. \n \n \n7. Family Planning \n \n 8.1 All reliable methods of family planning can be used as\n appropriate for the needs of the individual woman with\n diabetes. \n 8.2 For women with BMI >25kg/m2, DMPA is best avoided.\n 8.3 Women with type 2 diabetes should be advised to complete\n their family within 5-10 years of diagnosis of diabetes in view", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_152", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 93, "chunk_size": 572 } }, { "content": "their family within 5-10 years of diagnosis of diabetes in view\n of possible development of complications. \n \n References (need to add the sections taken from NIROGI guide)\n \n \n1. NICE, clinical guideline 63 Diabetes in pregnancy: management\n of diabetes and its complications from pre-conception to the\n postnatal period. 2008, National Institute for Health and\n Clinical Excellence. \n \n2. Seshiah V., Das AK.,BalajiV et al., Gestational Diabetes Mellitus\n - Guidelines. Journal of the Association of Physicians of India.\n \n2006. 54: 622- 628", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_152", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 78, "chunk_size": 543 } }, { "content": "- Guidelines. Journal of the Association of Physicians of India.\n \n2006. 54: 622- 628 \n \n3. IADPSGCP, International Association of Diabetes and\n Pregnancy Study Groups Recommendations on the Diagnosis\n and Classification of Hyperglycemia in Pregnancy. Diabetes\n Care, \n2010. 33(3): p. 676-\n682. \n \n \n4. Kuhl C. Insulin Secretion and insulin resistance inpregnancy\n and GDM. Implications for diagnosis andmanagement.\n Diabetes 1991;40(December (Suppl. 2)):18–\n24.\n National Guideline for Maternal Care - Volume I 77", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_152", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 70, "chunk_size": 514 } }, { "content": "================================================== PAGE 96 ==================================================\n5. Gough WW, Shack MJ, Bennett PH, Burch TA, Miller\n M.Evaluation of glucose in the Pima Indians by longitudinal\n studies. Diabetes 1970;19(Suppl. 1):\n388. \n \n \n6. Pettitt DJ, Bennett PH, Hanson RL, Narayan KM, KnowlerWC.\n Comparison of World Health Organization and National\n Diabetes Data Group procedures to detect abnormalities\n of glucose tolerance during pregnancy. Diabetes Care\n 1994;17(November (11)):1264–\n8. \n \n7. Haeckel R., Brinck U, Colic D. et al., Comparability of Blood", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_153", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 596 } }, { "content": "8. \n \n7. Haeckel R., Brinck U, Colic D. et al., Comparability of Blood\n Glucose Concentrations Measured in Different Sample Systems\n for Detecting Glucose Intolerance. Clinical Chemistry \n2002. 48:\n (6); 936-\n939.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_153", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 31, "chunk_size": 213 } }, { "content": "78 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_154", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 97 ==================================================\nManagement of \n \n Postparum Haemorrhage", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_155", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 149 } }, { "content": "National Guideline for Maternal Care - Volume I 79", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_156", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 98 ==================================================\n80 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_157", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 160 } }, { "content": "================================================== PAGE 99 ==================================================\nGuideline on Managementof Primary post Partum\n Haemorrhage \n \n \n1. Introduction \n \n The aim of this guideline is to provide evidence based recommendations\n in the management of primary post partum haemorrhage (PPH). This is\n the commonest direct cause of maternal death globally and in Sri Lanka.\n The objective of this guideline is to ensure anticipation, prevention, early\n detection and timely and appropriate management of PPH.\n \n \n2. Definition", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_158", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 68, "chunk_size": 559 } }, { "content": "detection and timely and appropriate management of PPH.\n \n \n2. Definition \n \n For the purpose of this guideline PPH is defined as blood loss of 500 ml or\n more from the genital tract within 24 hours of the birth of a baby. Blood\n loss of over 1000 ml is defined as major PPH. \n \n Irrespective of blood loss, the appearance of cardiovascular instability (i.e.\n tachycardia and hypotension) signifies major obstetric hemorrhage.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_158", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 68, "chunk_size": 426 } }, { "content": "• Since blood volume differs between persons, blood loss must\n be individualized. \n In general, blood volume = body weight in Kg÷12 (e.g. in a 60\n kg woman 60/12 = 5 litres) \n \n \n• The loss of 40% or more of the blood volume is life threatening\n and will be defined as a massive obstetric hemorrhage e.g.\n 2400 ml in a 60 Kg woman. \n \n \n3. Prevention of Post Partum Haemorrhage \n \n Active management of the third stage of labour is the cornerstone\n of prevention of primary PPH. For details please refer guideline on\n management of third stage of labor.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_159", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 96, "chunk_size": 553 } }, { "content": "management of third stage of labor. \n \n Anemia in pregnancy should be corrected during antenatal period.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_159", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 15, "chunk_size": 104 } }, { "content": "National Guideline for Maternal Care - Volume I 81", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_160", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 100 ==================================================\n4. Prediction of Post Partum Haemorrhage \n \n PPH occurs most often in women without risk factors. Therefore the\n blood group of every woman who goes into labor must be known.\n \n However, there are known risk factors associated with PPH, as listed in\n Box \n1. Such women should be advised to deliver in a specialist obstetric\n unit under extra vigilance. Out of these, abruptio placentae and placenta\n praevia have a particularly higher risk. \n \n Box 1 \n \n Risk Factors for PPH", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_161", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 587 } }, { "content": "praevia have a particularly higher risk. \n \n Box 1 \n \n Risk Factors for PPH \n \n Risks existing prior to labour \n Grand multiparity \n \n Previous PPH \n Fibroids complicating pregnancy \n \n Anaemia complicating pregnancy \n Pre-existing haemorrhagic conditions \n \n Treatment with anticoagulants \n Obesity \n \n Pre-eclampsia/gestational hypertension \n Uterine over distension e.g. multiple pregnancy, etc.\n \n Large baby (>4 kg) \n Chorio-amnionitis \n \n Dengue infection", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_161", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 50, "chunk_size": 461 } }, { "content": "Any woman with risk factors should have intravenous access established\n with either a 16 or 14-gauge cannula and a sample of blood taken and\n preserved.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_162", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 25, "chunk_size": 152 } }, { "content": "82 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_163", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 101 ==================================================\n5. Management of Primary PPH \n \n In Sri Lanka, the usual practice has been to commence treatment when\n there is continuing bleeding despite uterine massage irrespective of the\n amount of blood lost. It is recommended that this practice be continued.\n \n It is good practice to estimate and record blood loss in all deliveries.\n \n 5.1 General measures \n \n \n• Call for help. \n \n \n• Maintain a calm atmosphere. \n \n• Keep the mother (and labor companion/family) informed and", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_164", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 77, "chunk_size": 580 } }, { "content": "• Maintain a calm atmosphere. \n \n• Keep the mother (and labor companion/family) informed and\n reassure the mother regularly. \n \n• Assess, monitor and record: general condition, estimated\n blood loss, pulse, blood pressure and respiratory rate (every 15\n minutes) \n \n• Insert a Foley catheter and monitor urine output hourly.\n \n• Commence an ongoing chronological record of patient’s\n condition and interventions. It is recommended that one\n member of staff is delegated specifically for this task and to\n coordinate with other relevant disciplines.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_164", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 79, "chunk_size": 548 } }, { "content": "coordinate with other relevant disciplines.\n \n \n• Ensure there is intravenous access with two wide (14 – 16 G)\n bore cannulae. \n \n• Send blood for cross matching and baseline full blood count.\n In cases of massive haemorrahge, other investigations such as\n clotting profile will be needed. \n \n• Start Ringer’s lactate (Hartmann’s) solution.\n \n• Identify the cause of bleeding. \n \n \n• Keep the woman warm. \n \n• Pay attention to the temperature of labor room, operating\n theatre, intravenous fluids, blood, blood products and\n fluids used for lavage. Hypothermia is known to promote\n coagulopathy.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_164", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 89, "chunk_size": 595 } }, { "content": "fluids used for lavage. Hypothermia is known to promote\n coagulopathy. \n \n• Where available, the early involvement of the anesthetic team,\n even while the patient is still in the labor room is recommended.\n \n National Guideline for Maternal Care - Volume I 83", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_164", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 41, "chunk_size": 259 } }, { "content": "================================================== PAGE 102 ==================================================\n• Give oxygen via a face mask at a minimum rate of 8L/minute\n (where suitable masks are available, oxygen must be given at a\n rate of10-15L/min). \n \n \n• If deterioration of the patient is greater than expected for the\n visible blood loss, internal hemorrhage is the probable cause.\n \n• Check for completeness of the placenta. If incomplete or in\n doubt consider exploration of the uterus under anesthesia.\n \n• The Consultant must be informed in the situations listed in\n Box \n2. \n \n Box", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_165", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 597 } }, { "content": "• The Consultant must be informed in the situations listed in\n Box \n2. \n \n Box \n2. Situations in which the Consultant must be informed\n \n \n1. Blood loss of >1000 ml \n \n2. Pulse rate of >100/minute \n \n3. Systolic blood pressure <100 mm Hg \n \n \n4. Drop of systolic blood pressure by 30 mmHg \n \n5. Increase of pulse rate by >30 beats/minute \n \n6. Increasing fundal height \n \n7. Deterioration of the patient out of proportion to the overt\n blood loss. \n \n 5.2 Specific measures \n \n 5.2.1 Establish a cause for the bleeding \n \n Palpate the uterine fundus.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_165", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 550 } }, { "content": "5.2.1 Establish a cause for the bleeding \n \n Palpate the uterine fundus. \n \n A poorly contracted uterus usually indicates atonic PPH, which is the\n commonest cause. However, the possibility of concomitant genital tract\n trauma needs to be considered. \n \n If the uterus is well contracted, the genital tract must be inspected for\n trauma with adequate exposure, in good light.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_165", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 56, "chunk_size": 375 } }, { "content": "84 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_166", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 103 ==================================================\n5.2.\n2. Management of atonic haemorrhage \n \n \n• Start uterine massage by ‘rubbing up the fundus’.\n \n \n• Clear the cervical canal and vagina of blood clots by vaginal\n examination. \n \n• Administer either ergometrine maleate 0.5 mg slow IV or\n methyl ergometrine 0.2 mg slow IV or oxytocin 5 IU IV and\n start an infusion of 40 IU in 500 ml of Hartmann’s solution at\n 125 ml per hour via an infusion pump. \n \n• Start bimanual compression of uterus.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_167", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 556 } }, { "content": "125 ml per hour via an infusion pump. \n \n• Start bimanual compression of uterus. \n \n• If the bleeding fails to abate completely in 5- 10 minutes\n administer/repeat ergometrine 0.5mg IV. \n \n• If the bleeding fails to abate completely in a further 10 minutes\n administer misoprostol 800µg per rectally or sublingually.\n \n \n• If the bleeding fails to abate completely in a further 10 minutes\n proceed to uterine balloon tamponade and inform the\n Consultant. At the same time, administer tranexamic acid 1\n g by slow IV over 10 minutes. This dose may be repeated after", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_167", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 93, "chunk_size": 564 } }, { "content": "g by slow IV over 10 minutes. This dose may be repeated after\n 30 minutes if necessary and later if bleeding recommences.\n For details of the method of balloon tamponade please refer\n appendix \n1. \n \n• Balloon tamponade is an important step in managing patients\n who continue to bleed despite medical measures. It should\n always be considered before resorting to surgical measures.\n \n• If the institution does not have personnel trained in the use\n of balloon tamponade, the woman must be transferred to a\n higher institution, at the point where the administration of", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_167", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 92, "chunk_size": 567 } }, { "content": "higher institution, at the point where the administration of\n ergometrine and oxytocin infusion has failed to stop bleeding.\n \n• Temporizing measures such as manual aortic compression and\n sand bags to compress the uterus are recommended while the\n patient is in transit. \n \n \n• Inform the receiving institution. \n \n• After the balloon is inserted and the vagina packed (to keep\n the balloon in the uterus), the woman’s vital parameters and\n the level of the fundus must be monitored carefully. Where\n these indicate the woman is continuing to bleed, she should", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_167", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 88, "chunk_size": 561 } }, { "content": "these indicate the woman is continuing to bleed, she should\n \n National Guideline for Maternal Care - Volume I 85", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_167", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 4, "word_count": 19, "chunk_size": 113 } }, { "content": "================================================== PAGE 104 ==================================================\nbe moved to the theatre, since the situation would indicate the\n need for a laparotomy. \n \n \n• She should be shifted to the theatre without delay in this\n situation. \n \n• Prior to laparotomy the woman must be examined under\n anesthesia for tears in the genital tract. \n \n• In case laparotomy is needed it is best to keep the patient in\n the modified Lloyd Davis position so that observations for\n bleeding could be done with minimum inconvenience and\n delay.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_168", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 569 } }, { "content": "bleeding could be done with minimum inconvenience and\n delay. \n \n• The surgical measures would depend on the woman’s condition.\n “Too little too late” is the main contributor to mortality in\n PPH. Surgical measures include brace (compression) sutures\n (see appendix 2), uterine de-vascularization (See appendix\n 3), haemostatic mattress sutures to bleeding sinusoids, box\n sutures to include the bleeding lower segment in placenta\n previa, internal iliac ligation and hysterectomy.\n \n• The “sandwich technique” involves inserting a balloon\n tamponade after the application of brace sutures.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_168", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 590 } }, { "content": "tamponade after the application of brace sutures.\n \n \n• It is important that hysterectomy is resorted to sooner than\n later. \n \n• Hypothermia is a particular risk in the theatre environment.\n Measures must be taken to minimize the loss of heat from the\n woman. \n \n 5.2.3 Management of traumatic PPH \n \n \n• Exclude high vaginal and cervical tears before suturing\n episiotomy. \n \n• When the apex of the tear or episiotomy is not visible, apply a\n suture at the highest visible point, pull downwards and apply\n continuous sutures at progressively higher points until the\n apex is reached.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_168", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 92, "chunk_size": 585 } }, { "content": "continuous sutures at progressively higher points until the\n apex is reached. \n \n• Examine for paravaginal and broad ligament haematomata\n with a combined per vaginal and per rectal examination.\n \n \n• The management should be individualized according to the\n situation. \n 86 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_168", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 47, "chunk_size": 322 } }, { "content": "================================================== PAGE 105 ==================================================\n• Paravaginal hematomas of more than 5 cm diameter will\n usually require surgical evacuation. A bleeding point is usually\n present and must be looked for. In cases where it is difficult to\n control bleeding, a Foley catheter with its balloon inflated may\n be left in the cavity. Packing of the vagina may also be useful.\n \n \n• Cervical tears must be identified by systematic inspection of\n the cervix using Green-Armytage forceps and sutured.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_169", "page_number": 4, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 553 } }, { "content": "the cervix using Green-Armytage forceps and sutured.\n \n• In case of multiple tears with venous oozing, it may be better to\n insert a balloon catheter into the vagina or to pack the vagina\n with moistened vaginal packs than to try to suture all the tears.\n \n 5.2.4 Rupture of the uterus \n \n \n• Rupture of the uterus must be suspected when the general\n condition is deteriorating out of proportion to the visible\n blood loss and there is continuing bleeding in the presence of a\n contracted uterus. \n \n• This is particularly so in a woman with a scarred uterus.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_169", "page_number": 4, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 96, "chunk_size": 559 } }, { "content": "contracted uterus. \n \n• This is particularly so in a woman with a scarred uterus.\n \n• Immediate involvement of a Consultant and surgical\n intervention are important in this situation.\n \n 5.2.5 Coagulopathy causing PPH \n \n \n• This could be due to coagulopathy following death in utero,\n abruptio placentae, severe preeclampsia, HELLP syndrome,\n sepsis, amniotic fluid embolism, acute fatty liver, pulmonary\n immune thrombocytopenia, Von Willebrand’s disease etc.\n \n• It could also be due to suboptimal management of the PPH.\n \n \n• Early involvement of a haematologist or transfusion medicine", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_169", "page_number": 4, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 590 } }, { "content": "• Early involvement of a haematologist or transfusion medicine\n specialist will be important in this situation. Where available,\n thromboelastometry would be useful in this situation.\n \n \n6. Resuscitation and Fluid management \n \n PPH up to 1000 ml \n \n• Commence a crystalloid infusion of 2-3 times the estimated\n blood loss. \n \n National Guideline for Maternal Care - Volume I 87", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_169", "page_number": 4, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 56, "chunk_size": 379 } }, { "content": "================================================== PAGE 106 ==================================================\nPPH of more than 1000 ml \n \n \n• PPH of over 1000 ml should be managed in consultation with\n other relevant specialists e.g. anesthesiologists, hematologists,\n transfusion specialists etc. \n \n• Assess airway, breathing and circulation. \n \n• Give oxygen via face mask. \n \n• Keep the woman warm and flat. \n \n• Transfuse warmed blood as soon as possible. \n \n \n• Until blood is available, warm crystalloids (up to 2 litres)\n and colloids (up to 1-2 litres) may be transfused as rapidly as", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_170", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 594 } }, { "content": "and colloids (up to 1-2 litres) may be transfused as rapidly as\n required, up to a maximum of 3.5 litres in total.\n \n• Depending on urgency, group-specific blood may be given\n until cross-matched blood is available. \n \n• If group-specific blood is not available, O Rhesus D negative\n blood could be given. \n \n• Blood transfusion should be individualized according to the\n situation. When available, involve blood transfusion specialist/\n Haematologist. Where three or more units of blood are being\n transfused, an equal number of packs of fresh frozen plasma", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_170", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 558 } }, { "content": "transfused, an equal number of packs of fresh frozen plasma\n must also be transfused. If available, thromboelastometry will\n enable factor-specific replacement. \n \n \n• Due consideration must be given to keeping transport facilities\n available to obtain blood and blood products from another\n institution. \n \n \n7. Debriefing \n \n \n• It is possible that a major PPH could result in significant\n psychological morbidity. \n \n• This could be minimized by timely debriefing of the patient\n and her family, preferably by the Consultant. \n \n• This should be done immediately after the event, before", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_170", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 589 } }, { "content": "• This should be done immediately after the event, before\n discharge and at the postnatal visit or at any time as requested\n by her or the family.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_170", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 27, "chunk_size": 146 } }, { "content": "88 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_171", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 107 ==================================================\n8. Risk Management \n \n \n• It is good practice to conduct a case review with the members\n of the team involved in the management and other staff as soon\n as possible after the event. \n \n The spirit of such a meeting should be one of lessons learnt rather\n than of apportioning blame.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_172", "page_number": 4, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 54, "chunk_size": 393 } }, { "content": "National Guideline for Maternal Care - Volume I 89", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_173", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 108 ==================================================\nAppendix 1 \n \n Insertion of a ‘condom catheter’ \n \n This may be performed as an independent procedure or following\n inspection of the cervix and upper vagina for trauma.\n \n Therefore, whenever it is planned to inspect the cervix, or where there is\n an indication that medical therapy may fail to bring the bleeding under\n control, keep the materials needed for insertion of a condom catheter\n ready. \n \n \n1. Explain to the mother the need to insert a condom catheter", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_174", "page_number": 4, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 577 } }, { "content": "ready. \n \n \n1. Explain to the mother the need to insert a condom catheter\n and explain the procedure briefly. Be reassuring.\n \n \n2. Wear a pair of sterile gloves. \n \n3. The required items are: \n \n• Size 20 – 22 (or largest available) Foley catheter,\n \n• A condom, \n \n• Sterile No. 0 or 1 suture, \n \n \n• A bottle of warmed saline, \n \n• Intravenous infusion set released from the pack\n \n• Arrange these items on a sterile towel laid on a side trolley.\n \n4. Take the Foley catheter out of the packing. \n \n \n5. Unfold the condom over the end of the Foley catheter to about", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_174", "page_number": 4, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 101, "chunk_size": 568 } }, { "content": "5. Unfold the condom over the end of the Foley catheter to about\n two thirds of its length. Hand tie it to the catheter firmly, using\n several rounds of sterile suture at a point about 2 cm distal to\n the open end of the condom. \n \n6. Have an assistant connect the infusion set to the bottle of\n warmed normal saline suspended 4-6 feet above the patient.\n \n7. Connect the other end to the catheter, run saline into the\n condom to make sure the system is water tight by holding the\n catheter tip upwards. \n \n8. Afterwards, empty the balloon of the saline and leave it on the", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_174", "page_number": 4, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 106, "chunk_size": 573 } }, { "content": "catheter tip upwards. \n \n8. Afterwards, empty the balloon of the saline and leave it on the\n sterile trolley, ready for insertion. \n \n9. Wash the condom with either warm saline or 5% povidone\n iodine lotion. \n \n 90 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_174", "page_number": 4, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 43, "chunk_size": 262 } }, { "content": "================================================== PAGE 109 ==================================================\n10. Place the woman either in the dorsal or lithotomy position and\n expose the cervix by using one or two Sim’s speculae.\n \n \n11. Grasp the anterior lip of the cervix with a sponge holder.\n \n12. Now insert the entire condom catheter system into the uterus.\n You may keep the condom catheter between the index and\n middle fingers and introduce it like exploring the uterus (or\n doing a pelvic examination). \n \n13. Reconnect the catheter to a giving set and start filling the", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_175", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 85, "chunk_size": 584 } }, { "content": "doing a pelvic examination). \n \n13. Reconnect the catheter to a giving set and start filling the\n condom with warmed saline. \n \n14. Keep watching the cervix for the balloon to bulge out of it and\n stop filling it any further for now. You may notice cessation of\n bleeding from the uterine cavity. \n \n15. At this point pack the vagina with a moist vaginal pack (Two\n inch ribbon gauze pack or a gauze towel) around the catheter\n in a circumferential manner. \n \n \n16. Continue filling till the gravity aided filling stops. Usually 400\n – 500 ml is needed.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_175", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 95, "chunk_size": 553 } }, { "content": "16. Continue filling till the gravity aided filling stops. Usually 400\n – 500 ml is needed. \n \n17. Proximal end of the catheter is folded and a tight tie placed on\n it to prevent backflow. \n \n18. Insert a size 12 Foley catheter to the bladder.\n \n19. Mark the level of the fundus on the abdomen with a marker\n pen. Start a pulse and blood pressure chart.\n \n \n20. Give tranexamic acid 1 G slow i.v. and repeat after 8 hours.\n \n21. Keep pack and the condom catheter for 12 – 18 hours.\n \n22. Consider appropriate antibiotic prophylaxis.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_175", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 95, "chunk_size": 532 } }, { "content": "22. Consider appropriate antibiotic prophylaxis.\n \n23. If there is no vaginal bleeding and vital signs are stable, plan to\n remove the catheter at a convenient time, after 12 hours.\n \n \n24. Release half the instilled volume of saline. Do not remove the\n pack at this stage. \n \n25. Observe for bleeding through the pack. \n \n26. 30 minutes later remove the vaginal pack, without removing\n the condom catheter. \n \n27. If there is no further bleeding for another 30 minutes, release\n the total volume of instilled saline and remove the condom\n catheter gently.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_175", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 89, "chunk_size": 556 } }, { "content": "the total volume of instilled saline and remove the condom\n catheter gently. \n \n National Guideline for Maternal Care - Volume I 91", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_175", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 4, "word_count": 21, "chunk_size": 131 } }, { "content": "================================================== PAGE 110 ==================================================\nAppendix 2 \n \n Brace sutures, the best known of which is the modified B-Lynch sutures\n are very useful in the presence of a bleeding atonic uterus.\n \n The uterus is exteriorized. An absorbable No. 2 suture (or highest gauge\n available) on a curved ‘hand-needle’ is passed anteroposteriorly through\n the uterus above the reflection of the bladder about 2 cm medial to the\n lateral edge. \n \n The process is repeated on the contralateral side. The sutures are tied", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_176", "page_number": 5, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 78, "chunk_size": 572 } }, { "content": "lateral edge. \n \n The process is repeated on the contralateral side. The sutures are tied\n tightly over the fundus, with an assistant manually squeezing the uterus.\n Additional sutures may be applied medially.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_176", "page_number": 5, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 31, "chunk_size": 209 } }, { "content": "92 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_177", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 111 ==================================================\nNational Guideline for Maternal Care - Volume I 93", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_178", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 161 } }, { "content": "================================================== PAGE 112 ==================================================\nAppendix 3 \n \n Steps of uterine de-vascularization technique \n \n (Adapted from: Salah A. AbdRabbo.Stepwise uterine devascularization:\n A novel technique for management of uncontrollable postpartum\n hemorrhage with preservation of the uterus AJOG 1994 Volume 171\n Number 3) \n \n Step 1: Bilateral uterine vessel ligation \n \n In this step the uterine arteries are ligated at the level where they run along\n the uterine border beside the upper part of the lower uterine segment (Fig.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_179", "page_number": 5, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 590 } }, { "content": "the uterine border beside the upper part of the lower uterine segment (Fig.\n 1 Note: Steps I and II in the diagram constitute step 1 in our description.\n We recommend that both sides are done in one step.).\n \n Fig. 1.Sites of uterine artery ligation in steps 1, 2 (upper arrow), and 3\n (lower arrow).U.U.S., Upper uterine segment; L.U.S., Lower uterine\n segment.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_179", "page_number": 5, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 61, "chunk_size": 362 } }, { "content": "94 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_180", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 113 ==================================================\nWith the surgeon on the right side of the patient, the uterus is grasped and\n elevated to the contralateral side. A large needle (48 mm or greater) with\n number 1 absorbable suture is passed through the avascular area of the\n left broad ligament from anterior to posterior and then brought forward,\n guided by the four fingers of the left hand, through the myometrium from\n posterior to anterior 2 cm medial to the left uterine vessels, and the suture\n is tied.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_181", "page_number": 5, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 572 } }, { "content": "posterior to anterior 2 cm medial to the left uterine vessels, and the suture\n is tied. \n \n This process is repeated on the contralateral side.\n \n In these two steps there is no need for bladder mobilization, because the\n sutures were not placed low. Also, there is no need for a peritoneal incision\n in cases having vaginal deliveries; however, in cases having caesarean\n section the suture should be placed below the level of the transverse\n uterine incision, under the reflected peritoneal flap.\n \n Step 2: Low bilateral uterine vessel ligation", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_181", "page_number": 5, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 547 } }, { "content": "Step 2: Low bilateral uterine vessel ligation \n \n This step is reserved only for cases having continued lower uterine segment\n haemorrhage diagnosed at caesarean section and not controlled by step \n1.\n \n In this step the bladder is reflected downwards and lower bilateral uterine\n vessel ligation is performed at the lower part of the lower uterine segment,\n 3 to 5 cm below the upper ligatures, with the same technique in step \n1. At\n this level the uterine artery is ligated after its cervicovaginal branch turns\n abruptly upward to extend along the uterine margin. This ligature would", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_181", "page_number": 5, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 2, "word_count": 94, "chunk_size": 587 } }, { "content": "abruptly upward to extend along the uterine margin. This ligature would\n obliterate most of the branches of the uterine artery to the lower uterine\n segment and a branch of considerable size that extends to the upper\n portion of the cervix. It is important to include a significant amount of\n myometrium to avoid damage to the uterine vessels and to obliterate some\n of the intramyometrial ascending arterial branches of the cervicovaginal\n artery (Fig. 1).", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_181", "page_number": 5, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 3, "word_count": 73, "chunk_size": 457 } }, { "content": "National Guideline for Maternal Care - Volume I 95", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_182", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 114 ==================================================\nStep 3: Ligation of uterine/ovarian arterial anastomosis\n \n This step is indicated in continued uterine bleeding in spite of performing\n step 1.The uterus is grasped and pulled to the contralateral side by the\n left hand, and a large needle with a number 1 absorbable suture is passed\n through the avascular area in the broad ligament from anterior to posterior,\n at the level of the ovarian ligament. The needle is then passed anteriorly 2", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_183", "page_number": 5, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 551 } }, { "content": "at the level of the ovarian ligament. The needle is then passed anteriorly 2\n cm medial to the edge of the uterine wall, to include the uterine muscle.\n The suture is tied anteriorly.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_183", "page_number": 5, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 1, "word_count": 33, "chunk_size": 183 } }, { "content": "96 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_184", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 115 ==================================================\nNational Guideline for Maternal Care - Volume I 97", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_185", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 161 } }, { "content": "================================================== PAGE 116 ==================================================\n98 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "section": "Section_186", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 161 } }, { "content": "================================================== PAGE 1 ==================================================\nSLCOG Guideline \n \n SLCOG Guideline \n \n Management of thrombocytopaenia in pregnancy \n \n D L W Dasanayakea, Y Costab, A Weerawardanac on behalf of Sri Lanka College of Obstetricians and\n Gynaecologists \n \n Correspondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo \n08.\n E-mail: slcogoffice@gmail.com", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_000", "page_number": 1, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 48, "chunk_size": 455 } }, { "content": "1. Scope and background 2.2 Diagnosis of specific causes for thrombo-\n cytopaenia \n This guideline aims to describe the diagnostic approach \n to investigating thrombocytopaenia found in pregnancy, \n A multidisciplinary approach with the haematologist\n followed by a brief discussion on managing specific \n and the obstetrician is required for optimal care.\n causes of thrombocytopaenia. This provides evidence- \n based information to health professionals to formulate \n If thrombocytopenia is confirmed, careful history,\n a rational care pathway.", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_001", "page_number": 1, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 546 } }, { "content": "If thrombocytopenia is confirmed, careful history,\n a rational care pathway. \n examination and laboratory workup is essential for the\n diagnosis. \n A platelet count of less than 150×109/L is defined as \n thrombocytopenia. Maternal thrombocytopaenia is in \n A blood picture examination is vital to find the cause\n most cases mild and has no adverse outcome for both \n for thrombocytopenia. Microangiopathic hemolytic\n mother and fetus. Rarely a platelet count may be the \n anaemia (MAHA) in the blood picture, which is a\n presenting feature of a significant disorder with life", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_001", "page_number": 1, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 1, "word_count": 85, "chunk_size": 575 } }, { "content": "presenting feature of a significant disorder with life \n hemolytic process with red cell fragmentation and\n threatening complications. Therefore management of \n thrombocytopenia, can be associated with severe\n thrombocytopaenia during pregnancy is challenging in \n Preeclampsia(PE), HELLP syndrome, TTP (Throm-\n both diagnostic as well as management of delivery. \n botic Thrombocytopaenic Purpura), aHUS (atypical\n Haemolytic Uraemic Syndrome), AFLP(Acute Fatty\n \n2. Summary of key recommendations Liver in Pregnancy) and Disseminated Intravascular\n Coagulation (DIC). \n 2.1 Initial assessment", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_001", "page_number": 1, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 2, "word_count": 71, "chunk_size": 593 } }, { "content": "Coagulation (DIC). \n 2.1 Initial assessment \n A platelet count below 150×109/L should warrant To differentiate between above conditions apart from\n assessment for thrombocytopaenia during a good clinical assessment, serum creatinine, lactate\n pregnancy. Errors during blood collection and dehydrogenase (LDH), Prothrombin Time (PT),\n automated haematology analysis may yield falsely Activated Partial Thromboplastin Time (APPT), liver\n low values. Hence low platelet counts should be \n function tests (bilirubin direct/ indirect, albumin, total\n reconfirmed with a repeat Full Blood Count (FBC)", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_001", "page_number": 1, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 3, "word_count": 76, "chunk_size": 594 } }, { "content": "reconfirmed with a repeat Full Blood Count (FBC) \n protein, transferases, and alkaline phosphatase) and\n and a request for a manual platelet count. \n ultrasound scan of abdomen are required.\n Sri Lanka Journal of Obstetrics and Gynaecology 2021; 43: 259-268 \n DOI: http://doi.org/10.4038/sljog.v43i3.8020 \n a Consultant Obstetrician and Gynaecologist, Mahamodara Teaching Hospital, Galle, Sri Lanka\n bConsultant Haematologist, Colombo North Teaching Hospital, Ragama, Sri Lanka\n c Consultant Haematologist, De Zoysa Maternity Hospiatl for Women, Colombo, Sri Lanka", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_001", "page_number": 1, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 4, "word_count": 72, "chunk_size": 564 } }, { "content": "c Consultant Haematologist, De Zoysa Maternity Hospiatl for Women, Colombo, Sri Lanka\n Vol. 43, No. 3, September 2021 259", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_001", "page_number": 1, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 5, "word_count": 19, "chunk_size": 121 } }, { "content": "================================================== PAGE 2 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_002", "page_number": 2, "content_type": "guidelines", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Gestational Thrombocytopaenia (GT) is the most FBC should be monitored at 2-4 weeks intervals or\n common reason for low platelets in pregnancy. It is a more frequently if indicated.\n diagnosis of exclusion. GT commonly develops in the \n latter half of the pregnancy, and the platelet count is If the platelet count is less than 30×109/L or bleeding\n usually above 70×109/L. The diagnosis of GT is less manifestations are present, first-line therapy is oral\n likely if the platelet count falls below 70×109/L. corticosteroids, and if a rapid platelet increment is", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_003", "page_number": 2, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 89, "chunk_size": 562 } }, { "content": "required as in impending delivery or significant blee-\n Incidence of Immune-Thrombocytopaenic Purpura ding, intravenous immunoglobulin (IVIg) should be\n (ITP) is approximately in 1/1000-1/10 000 pregnancies. administered. \n It is the commonest cause of a low platelet count \n Treatment to increase the platelet count for delivery is\n presenting in the first and second trimesters. \n initiated by 36 weeks or earlier if early delivery is\n planned. \n PE is the most common cause of thrombocytopenia \n associated with MAHA presenting in the late second", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_003", "page_number": 2, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 1, "word_count": 79, "chunk_size": 549 } }, { "content": "associated with MAHA presenting in the late second \n Delivery should be planned in a setting where 24 hours\n or the third trimester of pregnancy. Infrequently, it \n blood bank facilities and ICU care are available.\n may appear during the first week postpartum. \n The obstetric team should liaise with the haematologist,\n HELLP syndrome may be a variant of PE characterized \n the transfusion physician and the anaesthetist when\n by more severe thrombocytopenia, more fulminant \n planning delivery. \n MAHA and profoundly elevated liver function tests.", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_003", "page_number": 2, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 2, "word_count": 80, "chunk_size": 549 } }, { "content": "planning delivery. \n MAHA and profoundly elevated liver function tests. \n Platelets count of at least 50×109 /L should be obtained\n Even though it is rare, microangiopathies such as TTP, \n for safe delivery. \n aHUS and AFLP should be carefully looked into when \n the woman presents with acute clinical features. \n If platelet count of less than 50×109/L, platelet\n concentrate should be available on-site for transfusion\n Patients with Antiphospholipid Syndrome (APLS) and \n if necessary. \n Systemic Lupus Erythematosus (SLE) may also present \n with thrombocytopenia.", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_003", "page_number": 2, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 3, "word_count": 79, "chunk_size": 567 } }, { "content": "if necessary. \n Systemic Lupus Erythematosus (SLE) may also present \n with thrombocytopenia. \n Caesarean delivery is reserved for obstetric indications\n only. \n Antinuclear Antibodies (ANA), thyroid function test, \n antiphospholipid antibodies and viral screening should At a platelet count of ≥ 80×109/L, in the absence of\n be considered if clinically indicated. \n other hemostatic abnormalities, regional anaesthesia\n can be performed. \n 2.3 Management of GT \n IgG antibodies in ITP are known to cross the placenta,\n Antenatal platelet count should be monitored every 2", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_003", "page_number": 2, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 4, "word_count": 77, "chunk_size": 571 } }, { "content": "Antenatal platelet count should be monitored every 2 \n causing thrombocytopenia in the fetus and neonate.\n to 4 weeks. \n The occurrence of intracranial haemorrhage (ICH) is\n a major neonatal concern. Measures should be taken\n No special management is required. \n to avoid traumatic delivery to the baby and the mother\n during delivery. Scalp electrodes, fetal blood sampling,\n When the platelet count is less than 100×109/L, the vacuum and difficult forceps delivery should be\n woman should be referred to an anaesthetist prior to avoided. If instrumental delivery is indicated, forceps", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_003", "page_number": 2, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 5, "word_count": 87, "chunk_size": 586 } }, { "content": "delivery. is the choice. \n GT is not associated with neonatal thrombocytopenia. Prophylactic measures should be taken to prevent\n Postpartum Haemorrhage (PPH), which includes active\n management of the third stage of labour, oxytocin\n 2.4 Management of ITP in pregnancy \n infusion and intravenous tranexamic acid.\n In ITP, a multidisciplinary approach involving the \n obstetrician, haematologist, anaesthetist, transfusion Pregnant women who are on long term steroids should\n physician and neonatologist are required for optimal have regular blood sugar monitoring with PPBS and", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_003", "page_number": 2, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 6, "word_count": 78, "chunk_size": 577 } }, { "content": "care. blood pressure monitoring. \n 260 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_003", "page_number": 2, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 7, "word_count": 12, "chunk_size": 86 } }, { "content": "================================================== PAGE 3 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_004", "page_number": 3, "content_type": "guidelines", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Non-Steroidal Anti-Inflammatory drugs (NSAIDs) Other etiologies such as TTP and HUS are considered\n should be avoided for postpartum or postoperative rare in pregnancy but carry high morbidity and\n analgesia in women with thrombocytopenia due to mortality for both the mother and fetus\n3.\n increased hemorrhagic risk. \n \n4. Recommendations and discussion \n \n 2.5 Management of thrombocytopaenia due \n 4.1 Initial assessment \n to PE, HELLP syndrome and AFLP \n A platelet count below 150×109/L should warrant", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 506 } }, { "content": "to PE, HELLP syndrome and AFLP \n A platelet count below 150×109/L should warrant\n Urgent delivery should be arranged as it is the mainstay assessment for thrombocytopaenia during pregnancy.\n of treatment. Errors during blood collection and automated\n haematology analysis may yield falsely low values.\n Maternal corticosteroids should be administered Hence low platelet counts should be reconfirmed with\n considering fetal maturity to reduce fetal respiratory a repeat FBC and a request for a manual platelet count.\n morbidity. All new patients presenting with thrombocytopenia", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 577 } }, { "content": "morbidity. All new patients presenting with thrombocytopenia\n need reconfirmation of the low platelet number with a\n If DIC present, supportive care with FFP, platelet and repeat FBC and a manual platelet count. The repeat\n cryoprecipitate should be administered with advice FBCsample should be taken from a direct, uncom-\n from the haematologist. plicated venipuncture and added into an EDTA tube\n and mixed well. This will prevent minute clot formation\n in the sample leading to erroneously low platelet values.\n 2.6 Management of thrombotic thrombo-", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 552 } }, { "content": "in the sample leading to erroneously low platelet values.\n 2.6 Management of thrombotic thrombo- \n Assessing the manual platelet count will exclude any\n cytopaenic purpura/atypical hemolytic uraemic \n errors in automated platelet analysis. \n syndrome \n If large platelet aggregates are detected in the blood\n Despite the diagnostic challenge, plasma exchange \n smear taken from an EDTA sample with thrombo-\n (plasmapheresis) needs to be commenced as soon as \n cytopenia reported in the automated FBC results, it is\n TTP/aHUS is suspected. Management requires a", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 3, "word_count": 78, "chunk_size": 560 } }, { "content": "TTP/aHUS is suspected. Management requires a \n considered as EDTA induced pseudo thrombocytopenia.\n multidisciplinary approach with the transfusion \n If it is necessary to obtain the accurate platelet number,\n physician, the obstetrician and the haematologist. \n blood should be collected into acitrated tube and sent\n Plasma transfusions should be given if there is any \n to the laboratory for analysis within 15 minutes of\n delay in plasmapheresis. \n collection. As the platelets can undergo deterioration\n in a citrated sample, immediate analysis is vital, and", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 4, "word_count": 79, "chunk_size": 563 } }, { "content": "in a citrated sample, immediate analysis is vital, and\n In TTP, plasmapheresis should continue daily until \n the laboratory should be informed of the procedure\n the platelet count is maintained in the normal range \n before collecting blood from the patient to a citrated\n (>150×109/L) for a minimum of 2 days. \n sample. When thrombocytopenia is confirmed, careful\n history, examination, and laboratory workup are needed\n Platelet transfusions are contraindicated as they are \n to arrive at a diagnosis. \n known to precipitate or exacerbate thrombosis. \n History should include. \n \n3. Introduction", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 5, "word_count": 85, "chunk_size": 596 } }, { "content": "known to precipitate or exacerbate thrombosis. \n History should include. \n \n3. Introduction \n \n• recent history of fever (to exclude viral infections\n Thrombocytopenia is a common haematological such as dengue fever) \n condition affecting 7-10% of the pregnant population\n1. \n \n• the presence of severe headaches and other\n It occurs four times more frequently in pregnancy than \n neurological manifestations (seen in PE and TTP)\n in non-pregnant women and is the second leading cause \n of blood disorders in pregnancy after anaemia\n2. \n• past history of thrombocytopenia (favouring ITP)", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 6, "word_count": 85, "chunk_size": 587 } }, { "content": "2. \n• past history of thrombocytopenia (favouring ITP)\n Thrombocytopaenia is defined as a platelet count of \n• symptomatic anaemia and recurrent infections\n less than 150×109/L. \n (bone marrow failure/haematological malignancy)\n \n• past history of pregnancy-associated thrombo-\n GT accounts for 70-80% of all cases of thrombo- \n cytopenia \n cytopaenia in pregnancy. Hypertensive disorders \n explain approximately 20% of thrombocytopenia, and \n• history of connective tissue disorders (SLE and\n immune thrombocytopenia accounts for about 3-4%. APLS) \n Vol. 43, No. 3, September 2021 261", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 7, "word_count": 78, "chunk_size": 585 } }, { "content": "================================================== PAGE 4 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_006", "page_number": 4, "content_type": "guidelines", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "• hypothyroidism The incidence of ITP is approximately in 1/1000-\n 1/10 000 pregnancies. It is the commonest cause of a\n \n• liver disease \n low platelet count presenting in the first and second\n \n• drug history trimesters\n6. \n \n• past and family history of bleeding disorders (rare \n PE is the most common cause of thrombocytopenia\n inherited bleeding disorders such as type IIB Von \n associated with MAHA presenting in the late second\n Willebrand disease). \n or third trimester of pregnancy. Infrequently, it may\n appear during the first week postpartum\n7.", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_007", "page_number": 4, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 87, "chunk_size": 557 } }, { "content": "or third trimester of pregnancy. Infrequently, it may\n appear during the first week postpartum\n7.\n On examination, it is uncommon to detect bleeding \n manifestations unless the platelet count is significantly \n HELLP syndrome may be a variant of PE characterized\n low. It is vital to check the blood pressure (PE, HELLP \n by more severe thrombocytopenia, more fulminant\n syndrome), abdominal tenderness (PET, HELLP syn- \n MAHA and profoundly elevated liver function tests\n5.\n drome, AFLP), anaemia, lymphadenopathy, hepatos- \n Even though it is rare, microangiopathies such as TTP,", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_007", "page_number": 4, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 1, "word_count": 84, "chunk_size": 581 } }, { "content": "Even though it is rare, microangiopathies such as TTP,\n plenomegaly (haematological malignancy) and \n aHUS and AFLP should be carefully looked into when\n neurological manifestations (severe PE, TTP). \n the woman presents with acute clinical features.\n Reduction of serum platelet counts is arbitrarily \n Patients with APLS and SLE may also present with\n considered mild if the count is <150×109/L, moderate \n thrombocytopenia. \n at 50-100×109/L and severe at <50×109/L. \n ANA, thyroid function test, antiphospholipid antibodies", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_007", "page_number": 4, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 2, "word_count": 71, "chunk_size": 527 } }, { "content": "at 50-100×109/L and severe at <50×109/L. \n ANA, thyroid function test, antiphospholipid antibodies\n 4.2 Diagnosis of specific causes for thrombo- and viral screening should be considered if clinically\n indicated. \n cytopaenia \n GT is a condition with mild to moderate platelet drop\n A multidisciplinary approach with the haematologist \n and is a diagnosis of exclusion. The platelet count in\n and the obstetrician is required for optimal care. \n GT is usually above 70×109/L. The patient is asymp-\n tomatic, and thrombocytopenia is commonly detected", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_007", "page_number": 4, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 3, "word_count": 78, "chunk_size": 549 } }, { "content": "tomatic, and thrombocytopenia is commonly detected\n If thrombocytopenia is confirmed, careful history, \n in the second half of pregnancy. The platelet count\n examination and laboratory workup is essential for the \n spontaneously reverts to normal within the first two\n diagnosis. \n months of postpartum but can recur in subsequent\n pregnancies. \n A blood picture examination is vital to find the cause \n for thrombocytopenia. MAHA in the blood picture, a \n The incidence of ITP is approximately in 1/1000-1/10\n hemolytic process with red cell fragmentation and", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_007", "page_number": 4, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 4, "word_count": 80, "chunk_size": 560 } }, { "content": "hemolytic process with red cell fragmentation and \n 000 pregnancies. It is the commonest cause of a low\n thrombocytopenia, can be associated with severe PE, \n platelet count presenting in the first and second\n HELLP syndrome, TTP, aHUS, AFLP and DIC\n4. \n trimesters\n6. Despite improved understanding of the\n pathophysiology, there is no specific diagnostic test,\n To differentiate between above conditions apart from \n and, like GT, it is a diagnosis of exclusion. The presence\n a good clinical assessment, serum creatinine, lactate of other autoimmune phenomena or a low platelet count", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_007", "page_number": 4, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 5, "word_count": 88, "chunk_size": 586 } }, { "content": "dehydrogenase (LDH), Prothrombin Time (PT), during pre-pregnancy can help to diagnose.\n Activated Partial Thromboplastin Time (APPT), liver \n function tests (bilirubin direct/ indirect, albumin, total Thrombocytopaenia associated with hypertensive\n protein, transferases, and alkaline phosphatase) and disorders is the most frequent causes in the late second\n ultrasound scan abdomen are required. trimester onwards8.Therefore PE screening should be\n carried out to rule out hypertensive variants (HELLP,\n GT is the most common reason for low platelets in AFLP). \n pregnancy", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_007", "page_number": 4, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 6, "word_count": 75, "chunk_size": 574 } }, { "content": "GT is the most common reason for low platelets in AFLP). \n pregnancy\n5. It is a diagnosis of exclusion. GT \n commonly develops in the latter half of the pregnancy, HELLP syndrome, which affects 0.6% of pregnant\n and the platelet count is usually above 70×109/L. The women, is a severe variant of pre-eclampsia. However,\n diagnosis of GT is less likely if the platelet count falls in 15-20% of cases of HELLP syndrome, neither\n below 70×109/L. hypertension nor proteinuria is present\n9.\n 262 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_007", "page_number": 4, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 7, "word_count": 88, "chunk_size": 538 } }, { "content": "================================================== PAGE 5 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_008", "page_number": 5, "content_type": "guidelines", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "AFLP occurs in 1 in 5000 to 10 000 pregnancies and GT does not require treatment except periodic moni-\n is more common with multiple gestations than in toring of platelet count. The thrombocytopenia resolves\n singletons. Up to 75% of women present with nausea spontaneously. If the thrombocytopenia persists\n or vomiting, and 50% have abdominal pain or signs beyond 6 to 8 weeks, the patient should undergo further\n and symptoms similar to PE. Although it is often haematological investigations.\n difficult to differentiate HELLP from AFLP, evidence", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 85, "chunk_size": 549 } }, { "content": "difficult to differentiate HELLP from AFLP, evidence \n of hepatic insufficiency, including hypoglycemia, DIC, 4.4 Management of ITP in pregnancy\n or encephalopathy, is seen more often in AFLP\n5. \n In ITP, a multidisciplinary approach involving the\n obstetrician, haematologist, anaesthetist, transfusion\n TTP is an acute life-threatening disorder associated \n physician and neonatologist, is required for optimal\n with thrombocytopenia, MAHA and microvascular \n care. \n thrombosis. It results from a deficiency of the \n enzymeADAMTS13, required to cleave secreted ultra-", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 1, "word_count": 73, "chunk_size": 570 } }, { "content": "enzymeADAMTS13, required to cleave secreted ultra- \n FBC should be monitored at 2-4 weeks intervals or\n large von Willebrand factor molecules (ULVWF). An \n more frequently if indicated. \n inherited deficiency or acquired reduction of \n ADAMTS13 due to IgG autoantibodies to ADAMTS13 \n If the platelet count is less than 30 ×109/L or bleeding\n leads to persistence of ULVWF molecules resulting in \n manifestations are present, first-line therapy is oral\n abnormal platelet aggregation and microvascular \n corticosteroids, and if a rapid platelet increment is", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 2, "word_count": 78, "chunk_size": 557 } }, { "content": "corticosteroids, and if a rapid platelet increment is\n thrombosis. Pregnancy is an important precipitant of \n required as in impending delivery or significant bleeding,\n acute TTP, accounting for approximately 5-10% of all \n IVIg should be given. \n cases of TTP in women\n4. TTP classically consists of \n a pentad of thrombocytopenia, MAHA, neurological \n Treatment to increase the platelet count for delivery is\n signs, renal impairment and fever. However, TTP \n initiated by 36 weeks or earlier if early delivery is\n commonly presents without the full spectrum of the \n planned.", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 3, "word_count": 86, "chunk_size": 579 } }, { "content": "commonly presents without the full spectrum of the \n planned. \n pentad. Laboratory features indicating a diagnosis of \n TTP are MAHA with many schistocytes in the blood \n Delivery should be planned in a setting where 24 hours\n picture, increased Lactate dehydrogenase (LDH), \n blood bank facilities and ICU care are available.\n which is often out of proportion to the degree of \n haemolysis due to associated tissue ischemia, normal The obstetric team should liaise with the haematologist,\n PT/APTT and possibly elevated serum creatinine the transfusion physician and the anaesthetist when\n level", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 4, "word_count": 87, "chunk_size": 596 } }, { "content": "level\n10. planning delivery. \n aHUS is a rare MAHA associated with pregnancy. The Platelets count of at least 50×109 /L should be obtained\n majority of cases occur during the postpartum period. for safe delivery. \n The patient has MAHA, thrombocytopenia and severe \n renal impairment. The outcome is severe, with two- If platelet count of less than 50×109/L, platelet\n thirds of cases developing end-stage renal failure within concentrate should be available on-site for transfusion\n one month\n4. if necessary. \n Caesarean delivery is reserved for obstetric indications\n 4.3 Management of GT", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 5, "word_count": 88, "chunk_size": 591 } }, { "content": "4. if necessary. \n Caesarean delivery is reserved for obstetric indications\n 4.3 Management of GT \n only. \n Antenatal platelet count should be monitored every 2 \n to 4 weeks. At a platelet count ≥ 80×109/L, regional anaesthesia\n can be performed in the absence of other hemostatic\n No special management is required. abnormalities. \n When the platelet count is less than 100×109/L, the IgG antibodies in ITP are known to cross the placenta,\n woman should be referred to an anaesthetist prior to causing thrombocytopenia in the fetus and neonate.", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 6, "word_count": 84, "chunk_size": 545 } }, { "content": "delivery. The occurrence of intracranial haemorrhage (ICH) is\n a major neonatal concern. Measures should be taken\n GT is not associated with neonatal thrombocytopenia. to avoid traumatic delivery to the baby and the mother\n Vol. 43, No. 3, September 2021 263", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_009", "page_number": 5, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 7, "word_count": 40, "chunk_size": 258 } }, { "content": "================================================== PAGE 6 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_010", "page_number": 6, "content_type": "guidelines", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "during delivery. Scalp electrodes, fetal blood sampling, ding, platelet transfusion in conjunction with IVIg can\n vacuum and difficult forceps delivery should be be considered\n9. \n avoided. If instrumental delivery is indicated, forceps \n is the choice. After delivery, close monitoring of the neonate is\n required as 21% to 28% will develop thrombocytopenia\n Prophylactic measures should be taken to prevent presumably from passive transfer of maternal auto-\n Postpartum Haemorrhage (PPH), which includes active antibodies (IgG) against platelet antigens\n13. Less than", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 569 } }, { "content": "13. Less than\n management of the third stage of labour, oxytocin 1% of neonates develop intracranial hemorrhage\n14. Risk\n infusion and intravenous tranexamic acid. for thrombocytopenia is increased if siblings had\n thrombocytopenia at delivery. Maternal platelet count\n Pregnant women who are on long term steroids should during pregnancy does not impact the risk of\n have regular blood sugar monitoring with PPBS and thrombocytopenia in the neonate\n15. The mode of\n blood pressure monitoring. delivery is determined by the obstetric indications, with", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 551 } }, { "content": "blood pressure monitoring. delivery is determined by the obstetric indications, with\n avoidance of procedures associated with an increased\n haemorrhagic risk to the fetus, such as fetal scalp\n Non-Steroidal Anti-Inflammatory drugs (NSAIDs) \n electrode/fetal blood sampling and operative vaginal\n should be avoided for postpartum or postoperative \n delivery\n14. A cord blood sample should be taken to\n analgesia in women with thrombocytopenia due to \n check neonatal platelet count. Intramuscular injection\n increased hemorrhagic risk. \n of vitamin K should not be given if the platelet count is", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 594 } }, { "content": "increased hemorrhagic risk. \n of vitamin K should not be given if the platelet count is\n not available, but intravenous or subcutaneous vitamin\n In ITP, a multidisciplinary approach involving the \n K can be administered. \n obstetrician, haematologist, transfusion physician, \n anaesthetist and neonatologist, is required for optimal \n care. 4.5 Management of thrombocytopaenia due \n to Pre-eclampsia/HELLP/AFLP \n Women with no bleeding manifestations and platelet \n Urgent delivery should be arranged as it is the mainstay\n counts above 30×109/L do not require any treatment \n of treatment.", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 3, "word_count": 79, "chunk_size": 590 } }, { "content": "counts above 30×109/L do not require any treatment \n of treatment. \n until 36 weeks gestation\n9. \n Maternal corticosteroids should be administered\n If the platelet count is <30×109/L or bleeding mani- \n considering fetal maturity to reduce fetal respiratory\n festations are present, first-line therapy is oral \n morbidity. \n corticosteroids 0.25-1mg/kg daily (dose to be adjusted \n to achieve a safe platelet count) or if a rapid platelet \n If DIC present, supportive care with FFP, platelet and\n increment is required as in impending delivery or", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 4, "word_count": 79, "chunk_size": 546 } }, { "content": "increment is required as in impending delivery or \n cryoprecipitate should be administered with advice\n significant bleeding, IVIg 1g/kg\n9. \n from the haematologist. \n IVIg has a relatively rapid therapeutic response (within \n PET affects 4% of all first pregnancies\n16. Thrombo-\n 1-3 days). Prednisolone shows a therapeutic response \n cytopenia is the commonest abnormality, occurring in\n within 2-14 days\n11. \n up to 50% of women with pre-eclampsia. HELLP\n syndrome is a serious complication specific to preg-\n Current recommendations aim for a platelet count of", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 5, "word_count": 81, "chunk_size": 564 } }, { "content": "Current recommendations aim for a platelet count of \n nancy characterized by haemolysis, elevated liver\n ≥ 50×109/L prior to labour and delivery as the risk of \n enzymes, and low platelets. It occurs in about 0.5-\n cesarean delivery is present with everylabour\n9. \n 0.9% of pregnancies and 10-20% of cases with severe\n pre-eclampsia\n17. As delivery is the definitive mode of\n For spinal anaesthesia, the British Committee for \n treatment for maternal concerns, steroid should be\n Haematology and Anaesthetic Guideline standards \n administered for fetal lung maturity. Supportive care", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 6, "word_count": 85, "chunk_size": 583 } }, { "content": "administered for fetal lung maturity. Supportive care\n recommends a threshold of >80×1012,\n13. An anaesthetic \n with the correction of clotting derangement following\n consultation in the third trimester to discuss options delivery should be arranged. Careful observation is\n for delivery is required. needed to detect DIC as a complication in 20% of\n women with HELLP syndrome\n18. AFLP treatment\n While platelet transfusion alone is generally not effective consists of supportive management and resuscitation", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 7, "word_count": 72, "chunk_size": 508 } }, { "content": "in ITP, if an adequate platelet count has not been of the mother and prompt delivery of the fetus, irres-\n achieved and delivery is emergent, or if there is blee- pective of the gestational age.\n 264 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_011", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 8, "word_count": 43, "chunk_size": 247 } }, { "content": "================================================== PAGE 7 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_012", "page_number": 7, "content_type": "guidelines", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "4.6 Management of thrombotic thrombo- thrombocytopenic purpura in pregnancy, Semin\n cytopaenic purpura and atypical haemolytic Hematol. 2000; 37(3): 275-\n89. \n uraemic syndrome \n7. Terry Gernsheimer, Andra H. James,Roberto Stasi:\n How I treat thrombocytopenia in pregnancy: Blood\n Despite the diagnostic challenge, plasma exchange 2013; 12(1): 38-\n47. \n (plasmapheresis) needs to be commenced as soon as \n \n8. Provan D and et al. International consensus report\n TTP/aHUS is suspected. Management requires a \n on the investigation and management of primary", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_013", "page_number": 7, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 555 } }, { "content": "TTP/aHUS is suspected. Management requires a \n on the investigation and management of primary\n multidisciplinary approach with the transfusion immune thrombocytopenia. Blood 2010; 115(2):\n physician, the obstetrician and the haematologist. 168-\n86. \n Plasma transfusions should be given if there is any \n \n9. Rajasekhar A, Gernsheimer T, Stasi R, James AH.\n delay in plasmapheresis. \n Clinical Practice Guide on Thrombocytopenia in\n Pregnancy. American Society of Hematology.\n In TTP, plasmapheresis should continue daily until Available at http://www.hematology.org/Clinicians/", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_013", "page_number": 7, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 1, "word_count": 73, "chunk_size": 578 } }, { "content": "the platelet count is maintained in the normal range Guidelines-Quality/Quick-Reference.aspx. 2013;\n (>150×109/L)for a minimum of 2 days. Accessed on 14.04.\n2021. \n \n10. Scully M, Hunt BJ, Benjamin S, Liesner R, Rose\n Platelet transfusions are contraindicated as they are P, Peyvandi F, Cheung B, Machin SJ; British\n known to precipitate or exacerbate thrombosis. Committee for Standards in Haematology.\n Guidelines on the diagnosis and management of\n Plasmapheresis is the first-line therapy in TTP and thrombotic thrombocytopenic purpura and other", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_013", "page_number": 7, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 2, "word_count": 77, "chunk_size": 549 } }, { "content": "Plasmapheresis is the first-line therapy in TTP and thrombotic thrombocytopenic purpura and other\n aHUS. Plasmapheresis removes substances promoting thrombotic microangiopathies. Br J Haematol 2012;\n platelet-aggregation and is successful with TTP but is 158(3): 323-\n35. \n less successful with HUS. Plasma infusion should be \n11. Ciobanu AM, Colibaba S, Cimpoca B, Peltecu G,\n considered if there is any delay in plasmapheresis. Panaitescu AM. Thrombocytopenia in Pregnancy.\n Maedica (Bucur) 2016; 11(1): 55-\n60. \n Clinical governance \n12. Gill KK, Kelton JG. Management of idiopathic", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_013", "page_number": 7, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 3, "word_count": 81, "chunk_size": 585 } }, { "content": "60. \n Clinical governance \n12. Gill KK, Kelton JG. Management of idiopathic\n thrombocytopenic purpura in pregnancy. Semin\n According to the national recommendation, all pregnant \n Hematol. 2000; 37(3): 275-\n89. \n women should have a FBC at booking and repeated at \n \n13. Eslick R, McLintock C. Managing ITP and\n 26 to 28 weeks of gestation. Haemoglobin and platelet \n thrombocytopenia in pregnancy. Platelets 2020; 31:\n count should be recorded in maternity notes. \n 300-\n6. \n \n14. Provan D, Arnold DM, Bussel JB, et al. Updated\n References \n international consensus report on the investigation", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_013", "page_number": 7, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 4, "word_count": 87, "chunk_size": 594 } }, { "content": "References \n international consensus report on the investigation\n \n1. Verdy E, Bessous V, Dreyfus M, Kaplan C, and management of primary immune thrombo-\n Tchernia G, Uzan S. Longitudinal analysis of cytopenia. Blood Adv 2019; 3(22): 3780-\n817.\n platelet count and volume in normal pregnancy. \n \n15. Payne SD, Resnik R, Moore TR, et al. Maternal\n Thrombosis and Haemostasis 1997; 77: 806-\n7. \n characteristics and risk of severe neonatal thrombo-\n \n2. Gernsheimer T, James AH, Stasi R. How I treat cytopenia and intracranial hemorrhage in preg-", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_013", "page_number": 7, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 5, "word_count": 83, "chunk_size": 543 } }, { "content": "2. Gernsheimer T, James AH, Stasi R. How I treat cytopenia and intracranial hemorrhage in preg-\n thrombocytopenia in pregnancy blood 2013; nancies complicated by autoimmune thrombo-\n 121(1): 38-\n47. cytopenia. Am J Obstet Gynecol 1997; 177: 149-\n55.\n \n3. Burrows RF, Kelton JG. Thrombocytopenia at \n16. HernÃindez-DÃaz S, Toh S, Cnattingius S. Risk of\n delivery: a prospective survey of 6715 deliveries. pre-eclampsia in first and subsequent pregnancies:\n American Journal of Obstetrics and Gynecology prospective cohort study BMJ 2009; 338: b2255\n 1990; 162: 732-", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_013", "page_number": 7, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 6, "word_count": 83, "chunk_size": 564 } }, { "content": "1990; 162: 732-\n4. doi:10.1136/BMJ.b2255, assessed on 14.04.\n2021.\n Thrombosis and Haemostasis,1997; 77: 806- \n807.\n \n4. Mari R. Thomas, Susan Robinson, Marie A. Scully: \n \n17. Kirkpatrick CA. The HELLP syndrome. ActaClin\n How we manage thrombotic microangiopathies in \n Belg. 2010; 65(2): 91-\n7. \n pregnancy: British Journal of Haematology 2016; \n \n18. Martin JN Jr, Rinehart BK, May WL, Magann EF,\n (173): 821-\n30. \n Terrone DA, Blake PG. The spectrum of severe\n \n5. Douglas B. Cines, Lisa D. Levine: Thrombo- \n pre-eclampsia: comparative analysis by HELLP", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_013", "page_number": 7, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 7, "word_count": 82, "chunk_size": 558 } }, { "content": "5. Douglas B. Cines, Lisa D. Levine: Thrombo- \n pre-eclampsia: comparative analysis by HELLP\n cytopenia in pregnancy: Blood 2017; 130(21): \n (hemolysis, elevated liver enzyme levels, and low\n 2271-\n7. \n platelet count) syndrome classification. Am J\n \n6. Gill KK, KeltonJG Management of idiopathic Obstet Gynecol. 1999; 180(6 Pt 1): 1373-\n84.\n Vol. 43, No. 3, September 2021 265", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_013", "page_number": 7, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 8, "word_count": 56, "chunk_size": 377 } }, { "content": "================================================== PAGE 8 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_014", "page_number": 8, "content_type": "guidelines", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Diagnosis Proportion Pathophysiology \n \n Gestational Thrombocytopenia About 75% Physiological dilution, \n \n accelerated destruction \n \n Immune Thrombocytopenic About 3% Immune destruction, \n Purpura (ITP) suppressed production", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_015", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 21, "chunk_size": 226 } }, { "content": "Thrombotic Thrombocytopenic Peripheral consumption, \n Purpura (TTP) microthrombi \n \n Atypical Haemolytic Uraemic Peripheral consumption, \n Syndrome (aHUS) microthrombi", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_016", "page_number": 8, "content_type": "general", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 15, "chunk_size": 167 } }, { "content": "Pre-eclampsia, Eclampsia, About 15-20% Peripheral consumption, \n Haemolysis, Elevated liver enzymes microthrombi \n and low platelet count \n syndrome (HELLP)", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_017", "page_number": 8, "content_type": "general", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 17, "chunk_size": 156 } }, { "content": "Hereditary thrombocytopenia Bone marrow \n underproduction \n \n Pseudo thrombocytopenia Laboratory artefact", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_018", "page_number": 8, "content_type": "general", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 105 } }, { "content": "Viral infections: HIV, Epstein-Barr virus Secondary autoimmune \n thrombocytopenia, Marrow \n suppression", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_019", "page_number": 8, "content_type": "general", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 10, "chunk_size": 103 } }, { "content": "Medications: heparin-induced Immunological reaction", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_020", "page_number": 8, "content_type": "medication_dosage", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 4, "chunk_size": 51 } }, { "content": "Leukaemia/Lymphoma Failure of platelet production,\n bone marrow infiltration \n \n Severe Vitamin B12 or Folate Deficiency Failure of platelet production", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_021", "page_number": 8, "content_type": "general", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 18, "chunk_size": 151 } }, { "content": "266 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_022", "page_number": 8, "content_type": "general", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 51 } }, { "content": "================================================== PAGE 9 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_023", "page_number": 8, "content_type": "guidelines", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Initial detection of a pregnant woman with thrombocytopenia. Confirm thrombo-\n cytopenia with repeat FBC and manual platelet count", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_024", "page_number": 8, "content_type": "general", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 18, "chunk_size": 130 } }, { "content": "Thrombocytopenia confirmed \n Good clinical assessment \n Blood picture and haematology referral", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_025", "page_number": 8, "content_type": "general", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 10, "chunk_size": 94 } }, { "content": "MAHA absent in blood picture \n LFT, ANA,TSH, Viralstudies, US scan abdomen, \n DAT, PT/APTT \n MAHA present in the blood picture \n If underlying pathology detected treat the cause \n LFT, PET screening, LDH, PT/APTT, Creatinine,\n US scan abdomen, RBS", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_026", "page_number": 8, "content_type": "general", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 36, "chunk_size": 247 } }, { "content": "Monitor counts, Regular \n haematological review, \n Steroids, Anticoagulation \n \n Severe PET, HELLP, TTP, aHUS \n AFLP Plasmapheresis, \n Stabilize the mother Deliver the baby \n \n If the platelet count less than 70×109/L \n with no identifiable cause, ITP should \n be considered", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_027", "page_number": 8, "content_type": "guidelines", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 35, "chunk_size": 274 } }, { "content": "• Monitor counts \n \n• Avoid NSAIDs /Aspirin \n \n• Treatment to elevate count if bleeding or platelet less than 30×109/L \n \n• Take haematology advice regarding IM injections \n \n \n• Elevate platelet count to 50×109/L for antenatal procedures \n \n• At 35-36wk, treat to keep platelet count above 80×109/L to allow epidural anaesthesia and delivery\n \n• Document the need to avoid traumatic delivery – avoid ventouse, forceps, scalp sampling, scalp electrodes\n \n• Inform neonatologist – paediatric alert to be sent", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_028", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 507 } }, { "content": "• Inform neonatologist – paediatric alert to be sent \n \n \n• Cord blood for neonatal platele count, if less than normal-monitor for thrombocytopenia,\n nadir 3-5 days", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_028", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 1, "word_count": 25, "chunk_size": 164 } }, { "content": "================================================== PAGE 10 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_029", "page_number": 8, "content_type": "guidelines", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 125 } }, { "content": "1. New presentation of thrombocytopenia in 1st / 2nd trimester: \n Check for: drugs: pre-pregnancy FBC: medical disorder; auto-immune phenomena:\n renal/liver functions \n \n2. Presentation of patient with known platelet disorder \n Platelet count >100×109/l Platelet count <80 - 100×109/l", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_030", "page_number": 8, "content_type": "medication_dosage", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 37, "chunk_size": 284 } }, { "content": "In all cases exclude presence red cell fragments \n indicating thrombotic microangiopathy", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_031", "page_number": 8, "content_type": "general", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 11, "chunk_size": 88 } }, { "content": "In 1st/2nd trimester low \n Monthly checks by midwife / GP \n platelet counts probabably\n Refer back if platelet count \n secondary to immune \n Anytime: \n 80-100 109/l bleeding 2nd/3rd trimesters process. \n Fever, \n Refer back if known ITP in 3rd BP, Proteinuria Monitor monthly, treat if\n neurological \n trimester LFTs bleeding or platelet count\n signs, \n – Check maternal platelet count: PET; HELLP <20-30×109/l \n If ≤34 weeks: try \n creatinine \n risk of low neonatal platelet count Raise platelet count to \n Likely TTP \n to stabilize, \n – ensure measures to avoid >50×109/l for ante-natal", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_032", "page_number": 8, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 0, "word_count": 85, "chunk_size": 593 } }, { "content": "Likely TTP \n to stabilize, \n – ensure measures to avoid >50×109/l for ante-natal \n If ≥34 weeks: \n Plasmapheresis \n traumatic delivery and check cord procedures. \n platelet count \n Advise avoidance of \n NSAIDS, aspirin, IM \n injections. \n Assess balance of risks. \n Deliver when possible \n From 35-36 weeks, aim to raise platelet count >80×109 /l if possible, to allow for epidural. May require\n combination of treatments \n Monitor more frequently, depending on level, treatment and rate of change of platelet count", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_032", "page_number": 8, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 1, "word_count": 73, "chunk_size": 517 } }, { "content": "Monitor more frequently, depending on level, treatment and rate of change of platelet count\n Document need for atraumatic delivery: advise avoid ventouse, rotational forceps, scalp clips/sampling\n Ensure paediatric alert sent \n Take cord sample to assess neonatal platelet count. If < normal, needs monitoring over next few days –\n nadir is at 2-5 days \n Safe levels of platelets for interventions \n Intervention Platelet count \n Antenatal, no invasive procedures planned >20 \n Vaginal delivery >50 \n Operative or instrumental delivery >50 \n Epidural anaesthesia >80", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_032", "page_number": 8, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 2, "word_count": 79, "chunk_size": 566 } }, { "content": "Vaginal delivery >50 \n Operative or instrumental delivery >50 \n Epidural anaesthesia >80 \n 268 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "section": "Section_032", "page_number": 8, "content_type": "maternal_care", "source_file": "Management-of-thrombocytopaenia-in-pregnancy-Sept-5.pdf", "chunk_index": 3, "word_count": 19, "chunk_size": 142 } }, { "content": "================================================== PAGE 1 ==================================================\nSri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_000", "page_number": 1, "content_type": "general", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 11, "chunk_size": 156 } }, { "content": "Please cite this paper as: Abeywardane A, Rajapakse L, Marleen S, Kadotgajan T, Lanerolle S,\n Dodampahala S H, on behalf of the Sri Lanka College of Obstetricians and Gynaecologists. Blood\n Transfusion in Pregnancy.", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_001", "page_number": 1, "content_type": "maternal_care", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 33, "chunk_size": 215 } }, { "content": "Sri Lanka College of Obstetricians and Gynaecologists", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_002", "page_number": 1, "content_type": "general", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 7, "chunk_size": 53 } }, { "content": "================================================== PAGE 2 ==================================================\nSLCOG Guideline \n \n SLCOG Guideline \n \n Blood transfusion in pregnancy \n \n A Abeywardanea, L Rajapakseb, S Marleenc, T Kadotgajand, S Lanerolled, S H Dodampahalae on behalf\n of the Sri Lanka College of Obstetricians and Gynaecologists \n \n Correspondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo \n08.\n E-mail: slcogoffice@gmail.com \n \n \n1. Purpose and scope \n3. Strategies to minimise the requirement\n \n for transfusion", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_003", "page_number": 1, "content_type": "maternal_care", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 65, "chunk_size": 576 } }, { "content": "1. Purpose and scope \n3. Strategies to minimise the requirement\n \n for transfusion \n Blood transfusion is an essential component of \n emergency obstetric care and, at times, lifesaving, but \n 3.\n1. Optimisation of haemoglobin during the\n it is not without risks. This guideline aims to provide \n antenatal period \n guidance on the appropriate use of blood products, \n which would neither compromise nor expose the 3.1.\n1. Diagnosis \n patient to unnecessary risks associated with trans- \n All pregnant women should be screened for anaemia\n fusion. Strategies to optimise the haemoglobin (Hb)", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_003", "page_number": 1, "content_type": "maternal_care", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 1, "word_count": 86, "chunk_size": 590 } }, { "content": "fusion. Strategies to optimise the haemoglobin (Hb) \n at the booking visit and 28 weeks. Anaemia in\n level at delivery and minimise blood loss at delivery \n pregnancy is defined as first-trimester Hb less than\n are also discussed. \n 11g/dL, second and third-trimester Hb less than 10.5g/dL,\n and postpartum Hb less than 10g/dL according to the\n \n2. Introduction British Committee for Standards in Haematology\n3. If\n the Hb level is less than the relevant thresholds, consider\n Obstetric haemorrhage remains a leading cause of direct \n haematinic deficiency once haemoglobin-opathies have", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_003", "page_number": 1, "content_type": "maternal_care", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 587 } }, { "content": "haematinic deficiency once haemoglobin-opathies have\n maternal deaths in Sri Lanka, accounting for 15.4% \n been excluded. \n of total maternal deaths in \n20201. Eventhough a large \n majority of patients with obstetric haemorrhage survive \n 3.1.\n2. Treatment and management \n uneventfully with timely interventions, it re-mains an \n important cause of severe maternal morbidity. Oral iron should be the preferred first-line treatment\n for iron deficiency anaemia. Parenteral iron is indicated\n In 2022, the prevalence of anaemia among pregnant when oral iron is not tolerated or absorbed, patient", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_003", "page_number": 1, "content_type": "maternal_care", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 3, "word_count": 82, "chunk_size": 594 } }, { "content": "women in Sri Lanka was 29.1%\n2. A significant pro- compliance is in doubt or if the woman is approaching\n portion of pregnant women with anaemia may require term when there is insufficient time for oral supple-\n blood transfusion if it is not addressed in a timely mentation to be effective. Women should receive\n manner. Transfusion services in Sri Lanka are rapidly information on improving dietary iron intake and the\n improving, with all blood components prepared with factors affecting the absorption of dietary iron.\n 100% volunteer donations, which are mandatorily", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_003", "page_number": 1, "content_type": "maternal_care", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 4, "word_count": 90, "chunk_size": 571 } }, { "content": "100% volunteer donations, which are mandatorily \n tested for HIV 1 and 2, Hepatitis B, Hepatitis C, Syphilis Meta-analysis of randomised trials on the antenatal use\n and Malaria. of iron, with or without folic acid, showed a 50%\n Sri Lanka Journal of Obstetrics and Gynaecology 2023; 45: 143-150 \n DOI: http://doi.org/ \n a Consultant Transfusion Physician, Sri Jayewardenepura General Hospital, Sri Lanka.\n bConsultant Obstetrician and Gynaecologist, District General Hospital, Matale, Sri Lanka.\n c Consultant Obstetrician and Gynaecologist, Sri Jayewardenepura General Hospital, Sri Lanka.", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_003", "page_number": 1, "content_type": "maternal_care", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 5, "word_count": 80, "chunk_size": 591 } }, { "content": "c Consultant Obstetrician and Gynaecologist, Sri Jayewardenepura General Hospital, Sri Lanka.\n dConsultant Obstetrician and Gynaecologist, Castle Street Hospital for Women, Sri Lanka.\n e Professor in Obstetrics and Gynaecology, Faculty of Medicine, University of Colombo, Sri Lanka.\n Vol. 45, No. 3, September 2023 143", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_003", "page_number": 1, "content_type": "maternal_care", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 6, "word_count": 43, "chunk_size": 318 } }, { "content": "================================================== PAGE 3 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_004", "page_number": 2, "content_type": "guidelines", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "reduction in the risk of anaemia in the third trimester group confirmation if the blood group has not been\n or at delivery4,\n5. Parenteral iron therapy offers a shorter done before. In a woman at high risk of emergency\n duration of treatment and a quicker response but is transfusion, e.g., placenta previa, with no clinically\n more invasive. Intravenous iron preparation should be significant alloantibodies, group and screen samples\n administered with all resuscitation facilities available should be sent once a week to exclude or to identify", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_005", "page_number": 2, "content_type": "clinical_protocol", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 85, "chunk_size": 545 } }, { "content": "immediately, as severe allergic reactions are possible. \n any new antibody formation and to keep blood available\n Anaemia not due to haematinic deficiency should be \n if necessary. Close liaison with the transfusion\n managed in close conjunction with a haematologist and \n physician/team is essential. \n transfusion physician. \n 4.\n3. Blood product specifications in pregnancy and\n 3.\n2. Strategies to minimise blood loss at delivery \n puerperium \n Women at high risk of haemorrhage should be delivered \n ABO and RhD identical or compatible red cell units", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_005", "page_number": 2, "content_type": "clinical_protocol", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 1, "word_count": 80, "chunk_size": 555 } }, { "content": "ABO and RhD identical or compatible red cell units\n in a hospital with facilities to manage massive bleeding. \n should be transfused. If clinically significant red cell\n Active management of the third stage of labour is \n antibodies are present, blood negative for the relevant\n recommended to reduce postpartum blood loss. \n red cell antigen should be cross-matched for\n transfusion. Where complex antibodies or rare red cell\n \n4. General principles of blood transfusion \n phenotypes are identified, provision of compatible blood\n 4.\n1. Consent may take time, and when transfusions are needed in", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_005", "page_number": 2, "content_type": "clinical_protocol", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 2, "word_count": 89, "chunk_size": 596 } }, { "content": "4.\n1. Consent may take time, and when transfusions are needed in\n such instances, inform the transfusion laboratory in\n Valid informed consent should be obtained where \n advance to avoid potential delays in the provision of\n possible before blood transfusion. In case of an \n blood. All patients receiving transfusions should be\n emergency, where it is not feasible to get consent prior \n closely monitored throughout the transfusion to\n to transfusion, transfusions should not be delayed, but \n identify signs of transfusion reactions and adverse", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_005", "page_number": 2, "content_type": "clinical_protocol", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 3, "word_count": 81, "chunk_size": 547 } }, { "content": "identify signs of transfusion reactions and adverse\n information on blood transfusion should be provided \n retrospectively. events early and act promptly. \n Where transfusion of all or a specific blood component \n 4.\n4. Intraoperative cell salvage \n is refused, or an advanced directive exists, detailed \n counselling should be arranged with a transfusion Intraoperative cell salvage could be considered in\n physician where available. This should be documented patients who are expected to have a blood loss of more", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_005", "page_number": 2, "content_type": "clinical_protocol", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 4, "word_count": 74, "chunk_size": 515 } }, { "content": "in the patient’s clinical records and communicated to than 500ml or more than 10% of the patient’s estimated\n all relevant healthcare professionals. Following detailed blood volume if facilities are available\n6. However, such\n counselling, should the patient not consent for facilities are currently unavailable in Sri Lanka.\n transfusion of blood and blood products, legal guidance \n should be sought. \n \n5. Management of obstetric haemorrhage \n with blood components \n 4.\n2. Requirements for group and screen samples \n Clinicians should familiarise themselves with the\n and cross-matching", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_005", "page_number": 2, "content_type": "clinical_protocol", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 5, "word_count": 82, "chunk_size": 590 } }, { "content": "Clinicians should familiarise themselves with the\n and cross-matching \n existing guidelines on the management of PPH and\n All women should have their blood group and red cell \n protocols for managing major obstetric haemorrhage,\n antibody status checked at booking and 28 weeks \n including the mechanical strategies employed to reduce\n gestation. If red cell antibodies are detected in the \n postpartum blood loss\n7. \n booking sample, further testing of maternal blood \n should be done to determine the specificity and the \n 5.\n1. When should red cells be used?", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_005", "page_number": 2, "content_type": "clinical_protocol", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 6, "word_count": 84, "chunk_size": 561 } }, { "content": "should be done to determine the specificity and the \n 5.\n1. When should red cells be used? \n titre of antibody/antibodies detected and to assess the \n likelihood of haemolytic disease of the foetus and The decision to transfuse should be made on clinical\n newborn. and haematological grounds. Although the aim of blood\n transfusion in a bleeding patient is to maintain Hb more\n Group and screen samples used for the provision of than 8g/dL, patients with acute haemorrhage can have\n blood in pregnancy should be less than 3 days old. normal Hb and clinical evaluation in this situation is", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_005", "page_number": 2, "content_type": "clinical_protocol", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 7, "word_count": 97, "chunk_size": 588 } }, { "content": "This should accompany a separate sample for blood extremely important. \n 144 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_005", "page_number": 2, "content_type": "clinical_protocol", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 8, "word_count": 18, "chunk_size": 124 } }, { "content": "================================================== PAGE 4 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_006", "page_number": 3, "content_type": "guidelines", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "In an emergency where the patient’s blood group is FFP should ideally be of the same ABO group as the\n unknown, group O RhD-negative red cells should be recipient. If unavailable, FFP of a compatible ABO group\n given until the blood group is established and then is acceptable. The blood group of cryoprecipitate is\n switch to group-specific red cells. In case of a severe not considered in the local context, considering the\n haemorrhage, if there is a history of clinically significant \n production method. \n red cell antibodies being present, close liaison with the", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_007", "page_number": 3, "content_type": "emergency_procedure", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 92, "chunk_size": 568 } }, { "content": "production method. \n red cell antibodies being present, close liaison with the \n transfusion physician is essential to avoid delay in \n Clinicians should be aware that these blood components\n transfusion. Once bleeding is controlled, restoring Hb \n must be ordered as soon as a need for them is\n to physiological levels with red cell transfusions is not \n anticipated, as there will always be a short delay in\n indicated\n8. \n supply because of the need for thawing and recons-\n tituting. \n 5.\n2. In what circumstances should fresh frozen \n plasma (FFP) and cryoprecipitate be used? \n 5.", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_007", "page_number": 3, "content_type": "emergency_procedure", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 1, "word_count": 91, "chunk_size": 586 } }, { "content": "5.\n2. In what circumstances should fresh frozen \n plasma (FFP) and cryoprecipitate be used? \n 5.\n3. When should platelets be used? \n When available, point-of-care testing-guided FFP and \n cryoprecipitate transfusions are preferable to optimise Aim to maintain the platelet count above 50×109/l in an\n haemostatic management\n9. If results of point-of-care acutely bleeding patient. A platelet transfusion trigger\n or haemostatic testing are unavailable and haemorrhage of 75×109/l is recommended to provide a margin of", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_007", "page_number": 3, "content_type": "emergency_procedure", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 2, "word_count": 73, "chunk_size": 517 } }, { "content": "continues, FFP at a dose of 12-15 ml/kg should be safety. If results of point-of-care testing or haemostatic\n administered for every six units of red cell concentrates testing are not available and haemorrhage is continuing,\n (RCC)\n5. Early use of FFP should be considered for four units of platelet concentrates should be adminis-\n conditions with a suspected coagulopathy, such as tered after eight or more units of red cell concentrates\n14.\n placental abruption or amniotic fluid embolism, or The platelets should be ABO group identical or\n where detection of PPH has been delayed\n10.", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_007", "page_number": 3, "content_type": "emergency_procedure", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 3, "word_count": 94, "chunk_size": 587 } }, { "content": "where detection of PPH has been delayed\n10. \n compatible. To avoid the development of anti-D\n antibodies, RhD-negative platelet concentrates should\n If the haemorrhage is ongoing, subsequent FFP \n be given where possible to RhD-negative women of\n transfusion should be guided by the results of clotting \n childbearing potential. \n tests aiming to maintain prothrombin time (PT) and \n activated partial thromboplastin time (APTT) ratios at \n Platelets may not be readily available in some hospitals;\n less than 1.5 times normal\n8. It is essential that", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_007", "page_number": 3, "content_type": "emergency_procedure", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 4, "word_count": 80, "chunk_size": 550 } }, { "content": "less than 1.5 times normal\n8. It is essential that \n therefore, their need should be anticipated, and good\n regular full blood counts and coagulation screens (PT, \n communication with the transfusion team should be\n APTT and fibrinogen) are performed during the \n bleeding episode. The drawbacks of early FFP are maintained. The platelet count should not be allowed\n that the majority of women with PPH will have normal to fall below 50×109/l in the acutely bleeding patient,\n coagulation at the time of FFP administration and that as this represents the critical level for haemostasis.", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_007", "page_number": 3, "content_type": "emergency_procedure", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 5, "word_count": 92, "chunk_size": 586 } }, { "content": "it is associated with an increased risk of transfusion- Such a low platelet count may be anticipated when\n associated circulatory overload (TACO) and trans- approximately two blood volumes have been replaced\n fusion-related acute lung injury (TRALI). FFP results \n by fluid or blood components. A platelet transfusion\n in a relatively small increment in fibrinogen level10,\n11. \n trigger of 75×109/l is recommended in a patient with\n ongoing bleeding to provide a margin of safety.\n Cryoprecipitate at a standard dose of 10 units should \n be administered relatively early in major obstetric", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_007", "page_number": 3, "content_type": "emergency_procedure", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 6, "word_count": 88, "chunk_size": 590 } }, { "content": "be administered relatively early in major obstetric \n If RhD-positive platelets are transfused to a RhD-\n haemorrhage. Subsequent cryoprecipitate transfusion \n negative woman of childbearing potential, anti-D\n should be guided by fibrinogen results, aiming to keep \n immunoglobulin should be administered. A dose of 250\n levels above 2g/l. RCTs do not support the early \n iu anti-D immunoglobulin is sufficient to cover 5 adult\n unselected use of fibrinogen replacement therapy, and \n administering fibrinogen supplementation to women therapeutic doses of platelets given within a 6-week", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_007", "page_number": 3, "content_type": "emergency_procedure", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 7, "word_count": 80, "chunk_size": 587 } }, { "content": "with PPH who have fibrinogen levels of >2 g/l is unlikely period. This may be given subcutaneously to minimise\n to have added benefit8,12,\n13. bruising and haematomas in thrombocytopenic women.\n Vol. 45, No. 3, September 2023 145", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_007", "page_number": 3, "content_type": "emergency_procedure", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 8, "word_count": 37, "chunk_size": 229 } }, { "content": "================================================== PAGE 5 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_008", "page_number": 4, "content_type": "guidelines", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "6. How should intrapartum anaemia be individual basis. The risk of RBC alloimmunisation\n managed? and the potential clinical impact should be considered\n when balancing the risks and benefits of RBC trans-\n In anaemic women who are not actively bleeding, if \n fusion. Non-transfusion therapies, such as iron, should\n the Hb is less than 8g/dL in labour or in the immediate \n be considered as a part of the treatment of postpartum\n postpartum period, the decision to transfuse should \n anaemia. \n be made according to the individual’s medical history \n and symptoms. Where transfusion is indicated,", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_009", "page_number": 4, "content_type": "maternal_care", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 91, "chunk_size": 597 } }, { "content": "and symptoms. Where transfusion is indicated, \n \n8. How should women who decline blood \n transfusion of a single unit of red cell concentrate \n should be followed by clinical reassessment to products be managed? \n determine the need for further transfusions. \n Hb should be optimised prior to delivery to prevent\n avoidable anaemia. Consent/refusal of blood compo-\n \n7. How should women with postpartum nents or other transfusion-sparing techniques should\n anaemia be managed in the postnatal be discussed in detail and clearly documented during\n the antenatal period. The use of pharmacological,", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_009", "page_number": 4, "content_type": "maternal_care", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 1, "word_count": 86, "chunk_size": 596 } }, { "content": "the antenatal period. The use of pharmacological,\n period? \n mechanical and surgical procedures to avert the use\n If the Hb is more than 7g/dL in the postnatal period, of banked blood and blood components should be\n where there is no ongoing or threat of bleeding, the considered early. Medicolegally, withholding blood\n decision to transfuse should be made on an informed products in life-saving situations is not permitted.", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_009", "page_number": 4, "content_type": "maternal_care", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 2, "word_count": 66, "chunk_size": 425 } }, { "content": "146 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_010", "page_number": 4, "content_type": "general", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 51 } }, { "content": "================================================== PAGE 6 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_011", "page_number": 4, "content_type": "guidelines", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Appendix \n1. Massive obstetric haemorrhage protocol", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_012", "page_number": 4, "content_type": "clinical_protocol", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 51 } }, { "content": "================================================== PAGE 7 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_013", "page_number": 4, "content_type": "guidelines", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Appendix \n2. Algorithm for Rotem-guided PPH management", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_014", "page_number": 4, "content_type": "clinical_protocol", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 7, "chunk_size": 54 } }, { "content": "148 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_015", "page_number": 4, "content_type": "general", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 51 } }, { "content": "================================================== PAGE 8 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_016", "page_number": 4, "content_type": "guidelines", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Appendix \n3. Sample consent form for transfusion of blood and blood components", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_017", "page_number": 4, "content_type": "general", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 12, "chunk_size": 78 } }, { "content": "================================================== PAGE 9 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_018", "page_number": 4, "content_type": "guidelines", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "References Society for Haematology Guideline. Br J Haematol.\n 2022; 198(4): 654-\n67. \n \n1. Annual Health Bulletin \n2020. Ministry of Health, \n \n9. Snegovskikh D, Souza D, Walton Z, Dai F, Rachler\n Sri Lanka. \n R, Garay A, et al. Point-of-care viscoelastic testing\n \n2. Amarasinghe GS, Agampodi TC, Mendis V, improves the outcome of pregnancies complicated\n Malawanage K, Kappagoda C, Agampodi SB. by severe postpartum hemorrhage. J Clin Anesth.\n Prevalence and aetiologies of anaemia among first 2018; 44: 50-\n6. \n trimester pregnant women in Sri Lanka; the need", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_019", "page_number": 4, "content_type": "clinical_protocol", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 85, "chunk_size": 562 } }, { "content": "6. \n trimester pregnant women in Sri Lanka; the need \n \n10. Mavrides E, Allard S, Chandraharan E, Collins P,\n for revisiting the current control strategies. BMC \n Green L, Hunt BJ, Riris S, Thomson AJ on behalf\n Pregnancy Childbirth. 2022; 22(1): \n16. \n of the Royal College of Obstetricians and Gynae-\n \n3. Pavord S, Daru J, Prasannan N, Robinson S, cologists. Prevention and management of post-\n Stanworth S, Girling J, et al. UK guidelines on the partum haemorrhage. BJOG 2016; 124: e106-e\n149.\n management of iron deficiency in pregnancy. Br J \n \n11. McNamara H, Kenyon C, Smith R, Mallaiah S,", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_019", "page_number": 4, "content_type": "clinical_protocol", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 1, "word_count": 97, "chunk_size": 597 } }, { "content": "management of iron deficiency in pregnancy. Br J \n \n11. McNamara H, Kenyon C, Smith R, Mallaiah S,\n Haematol. 2020; 188(6): 819-\n30. \n Barclay P. Four years’ experience of a ROTEM.\n \n4. Haider BA, Olofin I, Wang M, Spiegelman D, Ezzati Anaesthesia. 2019; 74(8): 984-\n91.\n M, Fawzi WW. Anaemia, prenatal iron use, and \n \n12. Collins PW, Cannings-John R, Bruynseels D,\n risk of adverse pregnancy outcomes: systematic \n Mallaiah S, Dick J, Elton C, et al. Viscoelastometric-\n review and meta-analysis. BMJ: British Medical guided early fibrinogen concentrate replacement\n Journal. 2013; 346: f", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_019", "page_number": 4, "content_type": "clinical_protocol", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 2, "word_count": 90, "chunk_size": 590 } }, { "content": "Journal. 2013; 346: f\n3443. during postpartum haemorrhage: OBS2, a double-\n blind randomized controlled trial. Br J Anaesth.\n \n5. Royal College of Obstetricians and Gynaecologists. \n 2017; 119(3): 411-\n21. \n Blood Transfusion in Obstetrics. Green-top \n Guideline No. \n47. London: RCOG; \n2015. \n13. Wikkelso AJ, Edwards HM, Afshari A, Stensballe\n J, Langhoff-Roos J, Albrechtsen C, et al. Pre-\n \n6. Carroll C, Young F. Intraoperative cell salvage. BJA \n emptive treatment with fibrinogen concentrate for\n Educ. 2021; 21(3): 95-\n101. \n postpartum haemorrhage: randomized controlled", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_019", "page_number": 4, "content_type": "clinical_protocol", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 3, "word_count": 80, "chunk_size": 579 } }, { "content": "Educ. 2021; 21(3): 95-\n101. \n postpartum haemorrhage: randomized controlled\n \n7. Guidelines for the Blood Transfusion Services in trial. Br J Anaesth. 2015; 114(4): 623-\n33.\n the United Kingdom. \n \n14. Collins P, Abdul-Kadir R, Thachil J, Coagulation\n www.transfusionguidelines.org.uk \n SoWsHIiTaHaoDI. Management of coagulopathy\n \n8. Stanworth SJ, Dowling K, Curry N, Doughty H, associated with postpartum hemorrhage: guidance\n Hunt BJ, Fraser L, et al. Haematological from the SSC of the ISTH. J Thromb Haemost.\n management of major haemorrhage: a British 2016; 14(1): 205-\n10.", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_019", "page_number": 4, "content_type": "clinical_protocol", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 4, "word_count": 81, "chunk_size": 579 } }, { "content": "150 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "section": "Section_020", "page_number": 5, "content_type": "general", "source_file": "6-SLJOG-1-Guideline-Page-143-150-1.pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 51 } }, { "content": "================================================== PAGE 1 ==================================================\nNATIONAL GUIDELINES FOR", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_000", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 7, "chunk_size": 132 } }, { "content": "• Management of Labour \n \n \n• Management of Hypertension, Pre Eclampsia \n and Eclampsia in Pregnancy \n \n \n• Management of Diabetes During Pregnancy \n \n \n• Management of Post-Partum Haemorrhage", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_001", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 25, "chunk_size": 192 } }, { "content": "Family Health Bureau \n \n World Health \n Organization", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_002", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 52 } }, { "content": "================================================== PAGE 2 ==================================================", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_003", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 4, "chunk_size": 108 } }, { "content": "================================================== PAGE 3 ==================================================\nNATIONAL GUIDELINE FOR MATERNAL CARE", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_004", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 145 } }, { "content": "• Management of Labour \n \n Normal Labour \n \n Induction of Labour \n \n Use of Oxytocins in Induction and Augmentation\n \n Foetal Monitoring in Labour \n \n Pain Relief \n \n Acute Inversion of Uterus \n \n• Management of Hypertension, Pre Eclampsia and\n Eclampsia in Pregnancy \n \n \n• Management of Diabetes in Pregnancy \n \n \n• Management of Post-Partum Haemorrhage", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_005", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 47, "chunk_size": 355 } }, { "content": "Family Health Bureau \n \n World Health \n Organization", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_006", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 52 } }, { "content": "================================================== PAGE 4 ==================================================\nThese guidelines are published by the Family Health Bureau, Ministry of\n Health, 231, De Saram Place, Colombo 10, Sri Lanka. \n \n Web: www.familyhealth.gov.lk \n \n Prepared by Sri Lanka College of Obstetrians and Gynaecologists", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_007", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 35, "chunk_size": 334 } }, { "content": "Edited By Dr. Nilmini Hemachnadra, Consultant Community Physician,\n Family Health Bureau & Prof. Hemantha Senanayake, President, Sri Lan-\n ka College of Obstetricians & Gynaecologists.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_008", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 24, "chunk_size": 184 } }, { "content": "Statement of Intent \n \n The main purpose of these guidelines are to improve the quality of\n clinical care provided by the health care providers at all levels. These\n parameters of practice should be considered recommendations\n only. The ultimate judgement regarding a particular clinical\n procedure or a treatment plan must be made by the clinician in\n light of the clinical data gathered from the patient and the diagnosis\n and treatment options available.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_009", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 457 } }, { "content": "ii National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_010", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 5 ==================================================\nForeword from the Secretary to the Ministry of Health", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_011", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 162 } }, { "content": "As a country with a mainly government owned health system, maintenance\n of the uniformity of practices is essential to avoid incurring unnecessary\n expenditure. Incorporation and practice of evidence based cost effective\n interventions in maternal care will ensure further improvement of the\n maternal care indicators. \n \n The availability and use of guidelines will ensure the quality of the care\n provided at each level and facilitate the care provision of practicing\n clinicians for better care. The Ministry of Health having achieved a", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_012", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 539 } }, { "content": "clinicians for better care. The Ministry of Health having achieved a\n satisfactory level in the coverage of services and geared to improve it\n further, is currently moving towards improving the quality of services\n provided. With this view, most of the institutions are now implementing\n quality improvement programmes. \n \n Therefore, this set of guidelines will assist such programmes and auditing\n systems in the maternal care such as maternal mortality reviews,\n \n confidential inquiry into maternal deaths, near-miss inquiries and", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_012", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 76, "chunk_size": 534 } }, { "content": "confidential inquiry into maternal deaths, near-miss inquiries and\n ensure a more objective assessment. These guidelines should be link with\n the quality standards and the implementation at each level needs to be\n ensured. \n \n Sri Lanka College of Obstetricians and Gynaecologists has managed to in\n co-operate the currently available best scientific evidence and the practical\n experience of a large number of experts into these guidelines.\n \n I wish all the healthcare providers would make maximum use of these\n guidelines and contribute to the further improvement of the maternal care", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_012", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 587 } }, { "content": "guidelines and contribute to the further improvement of the maternal care\n in our country.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_012", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 14, "chunk_size": 90 } }, { "content": "Dr. Y.D. Nihal Jayathilake \n Secretary, \n Ministry of Health, \n Sri Lanka \n \n National Guideline for Maternal Care - Volume I iii", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_013", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 19, "chunk_size": 129 } }, { "content": "================================================== PAGE 6 ==================================================\niv National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_014", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 159 } }, { "content": "================================================== PAGE 7 ==================================================\nPreface", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_015", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 5, "chunk_size": 116 } }, { "content": "This national guideline on maternal care is very well-timed, as a greater\n emphasis is being given for improving the quality of maternal and\n newborn care services for further reduction of maternal and newborn\n mortality and morbidity in Sri Lanka. This set of guidelines includes\n the revised versions of some guidelines published in 2007 under HSDP\n \n Phase I and newly developed guidelines. This is an attempt to improve the\n quality and uniformity of clinical care with efficiency, cost effectiveness\n and accountability. \n \n I highly appreciate the contribution made by the Sri Lanka College of", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_016", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 92, "chunk_size": 599 } }, { "content": "and accountability. \n \n I highly appreciate the contribution made by the Sri Lanka College of\n Obstetricians and Gynaecologists in developing these guidelines. Their\n \n experience and updated scientific knowledge is reflected in the guidelines.\n Further, these guidelines have been developed considering the policies,\n facilities and resources available in the country. As such this set of\n guidelines will be considered as national guidelines for the conditions\n described.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_016", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 64, "chunk_size": 474 } }, { "content": "Dr. P. G. Mahipala \n Director General of Health Services, \n Ministry of Health, \n Sri Lanka.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_017", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 14, "chunk_size": 92 } }, { "content": "================================================== PAGE 8 ==================================================\nMessage from the president of Sri Lanka College of\n \n Obstetricians", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_018", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 14, "chunk_size": 176 } }, { "content": "It is with a great sense of achievement that I issue this statement for the\n \n Sri Lanka National Guidelines in obstetrics. There is evidence that the\n introduction of guideline-based practice will reduce maternal mortality.\n We hope that this effect will be duplicated in Sri Lanka.\n \n I must compliment the Guideline Development Group of our College.\n This document is testimony to their hard work and their commitment to\n \n improving the quality of care delivered to our women. The group consisted\n of obstetricians from varying seniority and from hospitals representing", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_019", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 88, "chunk_size": 573 } }, { "content": "of obstetricians from varying seniority and from hospitals representing\n all categories of specialist units in the country. We were therefore able to\n develop our guidelines taking into considerations the ground realities in\n Sri Lanka. I was heartened by the maturity shown by the younger members,\n who contributed immensely to the many points that were debated while\n these were being developed. We have used the latest available evidence\n \n and taken into account what would be feasible in a Sri Lankan Unit. For\n what we have recommended as improvements to the existing practice we", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_019", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 92, "chunk_size": 585 } }, { "content": "what we have recommended as improvements to the existing practice we\n have had agreement from the Ministry of Health to procure these.\n \n I wish also to acknowledge our general membership who contributed to\n these guidelines via email and at a meeting where their views were sought.\n \n It is always a challenge to produce guidelines that will be put into use in\n everyday practice and it is probable we have achieved this primary goal by\n having a broad based input. \n \n The World Health Organization and the UNFPA supported this activity.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_019", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 89, "chunk_size": 539 } }, { "content": "The World Health Organization and the UNFPA supported this activity.\n Dr. Nilmini Hemachandra of the Family Health Bureau helped get the\n final product into a form that was easily understood by the non-specialist.\n \n We are grateful for the advice given by Obstetric Anaesthetists Drs. Saroja\n \n vi National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_019", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 54, "chunk_size": 346 } }, { "content": "================================================== PAGE 9 ==================================================\nJayasinghe and Ramani Pallemulla. The guideline on diabetes mellitus\n complicating pregnancy had major inputs from the Nirogi Matha project\n \n and many endocrinologists. \n \n To conclude I wish to restate my wish and fervent hope that these\n guidelines will help save the lives of many Sri Lankan mothers.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_020", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 50, "chunk_size": 413 } }, { "content": "Prof. Hemantha Senanayake \n President, \n Sri Lanka College of Obstetricians & Gynaecologists", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_021", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 11, "chunk_size": 92 } }, { "content": "National Guideline for Maternal Care - Volume I vii", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_022", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 10 ==================================================\nGuideline Development Committee \n \n Dr. Asoka Weerakkody (Chairman) \n \n Prof. Hemantha Senanayake \n Prof. Malik Goonawardena \n Dr. Ananda Ranatunga \n \n Dr.UDP Ratnasiri \n Dr. Sunil Fernando \n \n Dr. Harsha Atapattu \n Dr. Mangala Dissanayake \n Dr. Chandina Wedamistri \n \n Dr. Jeevan Marasinghe \n Dr. Tiran Dias \n \n Dr. Asanka Jayawardena", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_023", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 43, "chunk_size": 445 } }, { "content": "viii National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_024", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 11 ==================================================\nContent page \n \n Page \n Message from the Secretary of Ministry of Health iii\n Preface v \n Message from the President of the Sri Lanka College of\n Obstetricians and Gynecologists vi \n Guideline Development Committee viii \n List of Abbreviations xiii \n List of Tables xiv \n \n Disclaimer xv \n Introduction xvi \n A Management of Labour 3 \n \n1. Introduction 3 \n \n2. Diagnosis of labour 3 \n \n3. Management of Labour 4 \n 3.1 General considerations 4", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_025", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 552 } }, { "content": "2. Diagnosis of labour 3 \n \n3. Management of Labour 4 \n 3.1 General considerations 4 \n 3.1.1 Communication between women and healthcare\n professionals/workers 4 \n 3.1.2 Preparation of mothers to transfer to labour room 4\n 3.1.3 Documentation 5 \n 3.1.4 Mobilization and Positioning 5 \n 3.1.6 Hygiene during labour 5 \n 3.1.7 Pain relief in labour 6 \n 3.\n2. Management of the three stages of labour 6\n 3.2.\n1. Management of the first stage of labour 6\n 3.2.1.1 Latent phase 6 \n 3.2.1.2 Active phase 7 \n 3.2.1.2a. Admitting women to the Labour room 7", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_025", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 546 } }, { "content": "3.2.1.1 Latent phase 6 \n 3.2.1.2 Active phase 7 \n 3.2.1.2a. Admitting women to the Labour room 7\n 3.2.1.2b. Management of active phase of first stage 8\n 3.2.1.\n3. Delayed progress of first stage of labour 9\n 3.2.\n2. Management of second stage of labour 10\n 3.2.2.\n1. Passive second stage of labour (descent phase) 10\n 3.2.2.\n2. Active second stage of labour (expulsive phase) 11\n 3.2.2.\n3. Observations for women and babies in the second stage of labour 12\n 3.2.2.\n4. Women’s position and pushing in the second stage of labour 12\n 3.2.2.\n5. Intrapartum interventions to reduce perineal trauma 13", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_025", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 100, "chunk_size": 595 } }, { "content": "3.2.2.\n5. Intrapartum interventions to reduce perineal trauma 13\n 3.2.2.\n6. Delivery 13 \n 3.2.3 Third stage of Labour 14 \n 3.2.3.1 Active management of third stage of labour 14\n 3.2.3.2 Delayed third stage 15 \n 4 Care for the newborn baby 15 \n 5 Perineal care 17 \n National Guideline for Maternal Care - Volume I ix", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_025", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 53, "chunk_size": 315 } }, { "content": "================================================== PAGE 12 ==================================================\nB Guideline on Induction of Labour 19 \n \n 1 Introduction 19 \n 2 Definition 19 \n 3 General Principles 19 \n 4 Indications 19 \n 4.1 Otherwise uncomplicated pregnancy continuing \n beyond 40 weeks 19 \n 4.2 Pre labour rupture of membranes at term 20 \n 4.3 Preterm prelabour rupture of membranes (PPROM) 20\n 4.4 Intrauterine death 20 \n 4.5 History of precipitate labour 20 \n 4.6 Suspected macrosomia 20 \n 4.7 Fetal growth restriction 21 \n 4.8 Older mothers 21", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_026", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 562 } }, { "content": "4.6 Suspected macrosomia 20 \n 4.7 Fetal growth restriction 21 \n 4.8 Older mothers 21 \n 5 Induction under specific circumstances 21 \n 5.1 Breech presentation 21 \n 5.2 Previous CS 21 \n \n6. Methods of induction 21 \n 6.1 Mechanical 21 \n 6.2 Surgical 22 \n 6.3 Pharmacological 22 \n 6.3.1 Oxytocin 22 \n 6.3.2 Prostaglandins 22 \n 6.3.3 Mifepristone 23 \n \n7. Complications 24 \n 7.1 Hyperstimulation 24 \n 7.2 Cord prolapse 24 \n 7.3 Uterine rupture 25 \n 7.4 Failed induction 25 \n C Guideline for Use of Oxytocin for Induction and Augmentation\n of labour 27 \n D Guideline on fetal monitoring in labour 30", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_026", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 592 } }, { "content": "of labour 27 \n D Guideline on fetal monitoring in labour 30 \n E Guideline on Pain Relief in Labour 34 \n 1 Methods of pain relief in labour 34 \n 1.1 Non-pharmacological methods of pain relief 35\n 1.2 Pharmacological methods of pain relief in labour 35\n 1.2.1 Oral paracetamol/paracetamol& codeine compound 35\n 1.2.2 Opioids 35 \n 1.2.2.A. Pethidine 35 \n 1.2.2.B. Morphine 36 \n 1.2.2.C. Fentanyl 36 \n 1.2.3 Inhalational analgesia – Entonox 36 \n 1.2.4 Regional Anaesthesia 37 \n x National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_026", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 80, "chunk_size": 523 } }, { "content": "================================================== PAGE 13 ==================================================\nF Guidelines to maintain the partograph 39 \n \n G Guideline on acute puerperal inversion of the uterus 41\n 1 Introduction 41 \n 2 Definition 41 \n 3 Prevention 41 \n 4 Pathophysiology (and clinical correlation) 41\n 5 Classification 42 \n 6 Clinical Presentation and diagnosis 42 \n 7 Management 43 \n 7.1 General measures 43 \n 7.2 Repositioning the uterus 43 \n 7.2.1 Manual replacement of uterus 43 \n 7.2.2 Hydrostatc reduction 44 \n 7.2.3 Tocolytics 45 \n 7.2.4 General Anaesthesia 45", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_027", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 586 } }, { "content": "7.2.2 Hydrostatc reduction 44 \n 7.2.3 Tocolytics 45 \n 7.2.4 General Anaesthesia 45 \n 7.2.5 Surgical methods 45 \n 8 Debriefing 46 \n H Management of Hypertensive Disease in Pregnancy 47\n 1 Introduction 49 \n 2 Definitions 49 \n 3 Screening for Hypertension during pregnancy 50\n 4 Prevention of hypertensive disorders in pregnancy 50\n 5 Management of Chronic Hypertension 51 \n 6 Management of severe pre eclampsia 52 \n 6.1 General Considerations 52 \n 6.2 Specific Management 52 \n 6.2.1 Anti-hypertensive drugs 53 \n 6.2.1.1 Labetalol orally or intravenously 53 \n 6.2.1.2 Hydralazine intravenously 54", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_027", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 593 } }, { "content": "6.2.1.1 Labetalol orally or intravenously 53 \n 6.2.1.2 Hydralazine intravenously 54 \n 6.2.1.3 Oral Nifedipine 55 \n 6.2.2 Prevention of convulsions 55 \n 6.2.3 Fluid Balance 56 \n 6.2.4 In utero/neonatal transfer 56 \n 6.2.5 Delivery 57 \n 6.2.6 Post-delivery 57 \n 6.2.7 Follow up 58 \n I Management of Eclampsia 59 \n 1 Definition 59 \n 2 Diagnosis 59 \n 3 Time of onset of eclampsia 59 \n 4 Comorbidities 59 \n 5 Prevention 60 \n 6 Management 60 \n 6.1 General considerations 60 \n 6.\n2. During the seizure 61 \n National Guideline for Maternal Care - Volume I xi", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_027", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 550 } }, { "content": "================================================== PAGE 14 ==================================================\n6.\n3. As soon as possible following a seizure 61 \n 6.\n4. Management of seizures in women receiving \n magnesium sulphate 62 \n \n7. Delivery 62 \n \n8. Transfer of a woman who has had a seizure to another institution 63\n \n9. Postpartum management 63 \n \n10. Counselling 64 \n J Management of Diabetes during Pregnancy 67 \n 1 Purpose 67 \n 2 Screening 67 \n 2.1 Target groups for screening 67 \n 2.2 Recommended tests 68 \n 3 Management – Women with established Diabetes 70\n 3.1 Pre Pregnancy care 70", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_028", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 85, "chunk_size": 598 } }, { "content": "3 Management – Women with established Diabetes 70\n 3.1 Pre Pregnancy care 70 \n 3.2 Antenatal Care 71 \n 3.3 Medical nutrition therapy (MNT) 72 \n 3.4 Exercise 72 \n 4 Glyceamic control and Monitoring 73 \n 4.1 Glyceamic Control 73 \n 4.2 Monitoring of glycaemic control 74 \n 5 Delivery and intra natal care 74 \n 5.1 Timing of delivery 74 \n 5.2 Labour care 75 \n 6 Post natal care 75 \n 6.1.a Neonatal care 75 \n 6.1.b Immediate post partum care 76 \n 6.2 At hospital discharge 76 \n 6.3 Late Postnatal care and follow up 77 \n 7 Family Planning 77 \n K Management of Primary Post Partum Haemorrhage 81", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_028", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 98, "chunk_size": 589 } }, { "content": "7 Family Planning 77 \n K Management of Primary Post Partum Haemorrhage 81 \n 1 Introduction 81 \n 2 Definition 81 \n 3 Prevention of Post Partum Haemorrhage 81 \n 4 Prediction of Post Partum Haemorrhage 82 \n 5 Management of Primary PPH 83 \n 5.1 General measures 83 \n 5.2 Specific measures 84 \n 5.2.1 Establish a cause for the bleeding 84 \n 5.2.\n2. Management of atonic haemorrhage 85 \n 5.2.3 Management of traumatic PPH 86 \n 5.2.4 Rupture of the uterus 87 \n 5.2.5 Coagulopathy causing PPH 87 \n \n6. Resuscitation and Fluid management 87 \n \n7. Debriefing 88 \n \n8. Risk Management 89 \n Appendix 1 90", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_028", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 94, "chunk_size": 592 } }, { "content": "7. Debriefing 88 \n \n8. Risk Management 89 \n Appendix 1 90 \n Appendix 2 92 \n Appendix 3 94 \n xii National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_028", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 25, "chunk_size": 143 } }, { "content": "================================================== PAGE 15 ==================================================\nList of Abbreviations \n \n WHO World Health Organization \n UNFPA United Nations Population Fund \n UNICEF United Nations Children’s Fund \n SLCOG Sri Lanka College of Obstetricians and Gynaecologists\n NICE National Institutive of Clinical excellency\n RCOG Royal College of Obstetricians and Gynaecologists\n FHR Fetal Heart Rate \n CPD Cephalo Pelvic Disproportion \n NALS Neonatal Advanced Life Support \n PPROM Preterm prelabour rapture of the Membranes\n CS Caesarean Section", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_029", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 65, "chunk_size": 580 } }, { "content": "PPROM Preterm prelabour rapture of the Membranes\n CS Caesarean Section \n CTG Cardiotocography \n \n IV Intravenous \n IM Intra muscular \n IU International Units \n EFM Electronic Fetal Monitoring \n TENS Transcutaneous electrical nerve stimulation\n HELLP Haemolysis, elevated liver enzymes and low platelet\n HDU High dependency unit \n ICU Intensive care unit \n PGDM Pre gestational diabetes mellitus \n GDM Gestational Diabetes Mellitus \n OGCT Oral glucose Challenge Test \n OGTT Oral Glucose Tolerance test \n PPBS Post Prandial Blood Sugar \n MNT Medical Nutrition therapy", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_029", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 73, "chunk_size": 565 } }, { "content": "OGTT Oral Glucose Tolerance test \n PPBS Post Prandial Blood Sugar \n MNT Medical Nutrition therapy \n DENO Diabetic Educator Nursing officer \n SMBG Self-monitoring of blood glucose \n AC Abdominal Circumference \n SHO Senior House Officer \n CBG Capillary Blood Glucose \n ENC Essential New-born Care \n DM Diabetes Mellitus \n DMPA Depot Medroxy Progesterone Acetate \n BMI Body Mass Index \n PPH Post Partum Haemorrhage \n \n National Guideline for Maternal Care - Volume I xiii", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_029", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 64, "chunk_size": 468 } }, { "content": "================================================== PAGE 16 ==================================================\nList of Tables \n \n Guidelines for ruse of oxytocin for induction and augmentation of labour\n \n Table 1 mU/minute administered at different rates of administration\n according to drop rate \n \n Table 2 mU/minute infused per minute when administered via an infusion\n pump \n \n Guideline on fetal monitoring in labour \n \n Table 1 Definitions of normal, suspicious and pathological FHR rates\n Table 2 Classification of fetal heart rate patterns", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_030", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 67, "chunk_size": 547 } }, { "content": "Guideline for screening, diagnosis and management of diabetes in pregnant\n women \n \n Table 1 Target values in glycaemic control", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_031", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 18, "chunk_size": 127 } }, { "content": "xiv National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_032", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 17 ==================================================\nDisclaimer", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_033", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 5, "chunk_size": 120 } }, { "content": "These guidelines are based on current best available evidence and\n consensus opinion of the Guideline Development committee of\n the Sri Lanka College of Obstetricians & Gynaecologists. They are\n neither intended to replace the process of critical evaluation of\n every case and nor it is intended to dictate an exclusive course of\n \n management or treatment. It must be interpreted with reference to\n individual patient needs, available resources and limitations unique\n to the institution and variations in local populations.\n \n Medicine is a continually evolving science and the users must have", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_034", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 88, "chunk_size": 595 } }, { "content": "Medicine is a continually evolving science and the users must have\n regard to relevant information, research or material, which may\n have been published or become available subsequently.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_034", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 27, "chunk_size": 186 } }, { "content": "National Guideline for Maternal Care - Volume I xv", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_035", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 18 ==================================================\nIntroduction", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_036", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 5, "chunk_size": 122 } }, { "content": "Clinical Guidelines are systematically developed statements which assist\n clinicians and patients in making decisions about appropriate treatment\n for specific conditions based on the best scientific evidence at the time of\n development. Guidelines are not intended to limit the clinical freedom;\n however, clinicians are expected to follow these recommendations as the\n \n basis for their decision making. Availability of resources, the existing\n situations, and the expectations of individual client needs to be considered.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_037", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 524 } }, { "content": "situations, and the expectations of individual client needs to be considered.\n \n The guidelines are intended to guide all health care workers in all levels\n of institutions where maternity care is being provided. Although these\n guidelines are mainly targeted for the government sector institutions, use\n \n in the private sector institutions where maternity care is being provided,\n is also encouraged. \n \n These guidelines are developed by the guideline development committee\n of the Sri Lanka College of Obstetricians and Gynaecologists in", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_037", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 77, "chunk_size": 541 } }, { "content": "of the Sri Lanka College of Obstetricians and Gynaecologists in\n consultation with other relevant specialists such as anaesthesiologists,\n physicians, endocrinologists, and haematologists etc. The existing\n \n national guidelines developed in 2007, NICE guidelines on intranatal\n care, WHO guidelines and RCOG guidelines were perused and mixed\n with the local scenarios and expert opinion. The latest available scientific\n evidences were considered and included where ever necessary. Then, the\n draft guidelines were presented to the wider forum of obstetricians and", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_037", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 76, "chunk_size": 565 } }, { "content": "draft guidelines were presented to the wider forum of obstetricians and\n consensuses were arrived. After that the guidelines were handed over to\n \n the Ministry of Health and consensus was built with the participation\n of multi-disciplinary team including medical administrators, provincial\n health authorities, representatives from SLCOG and other relevant\n professional colleges, and national programme managers.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_037", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 54, "chunk_size": 414 } }, { "content": "xvi National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_038", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 19 ==================================================\nManagement of Labour", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_039", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 7, "chunk_size": 130 } }, { "content": "================================================== PAGE 20 ==================================================\n2 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_040", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 159 } }, { "content": "================================================== PAGE 21 ==================================================\nManagement of Normal Labour \n \n \n1. Introduction \n \n The aim of this guideline is to provide recommendations to care providers\n in the management of a healthy woman with a single fetus in labour at\n term (37-42weeks). It does not cover the care of women with complicated\n pregnancies. \n \n The objective of this guideline is to ensure optimal management of\n women in labour, detect any abnormalities, take appropriate action,", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_041", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 534 } }, { "content": "women in labour, detect any abnormalities, take appropriate action,\n prevent complications and thus make childbirth safer; and also to make\n sure that these women are treated with respect and compassion, and kept\n well informed and well supported throughout labour.\n \n \n2. Diagnosis of Labour \n \n Labour is diagnosed by the presence of regular, painful intermittent\n contractions, which are of increasing frequency, duration and intensity,\n leading to progressive cervical effacement and dilatation.\n \n Note: for the purpose of this guideline, labour is also diagnosed in the", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_041", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 575 } }, { "content": "Note: for the purpose of this guideline, labour is also diagnosed in the\n presence of painful contractions occurring at a frequency of 2 in 10\n minutes or more.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_041", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 28, "chunk_size": 160 } }, { "content": "Definitions: \n \n Latent phase of the first stage of labour – from the commencement\n of labour to a cervical dilatation of up to 4 cm. (This is a period\n of time, not necessarily continuous, when there are painful\n contractions and some cervical changes including cervical\n effacement and dilatation up to 4cm take place)\n \n Active phase of the first stage of labour – commences at a cervical\n dilatation of 4cm and ends with full dilatation. (There are regular\n painful contractions and progressive cervical dilatation from 4cm\n up to full dilatation).", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_042", "page_number": 1, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 88, "chunk_size": 552 } }, { "content": "================================================== PAGE 22 ==================================================\nIf the diagnosis of labour is uncertain, observation should continue and\n reassessment made in four hours. \n \n Any woman who is diagnosed as not being in labour, but continues to\n complain of pain, would require careful reassessment by an experienced\n medical officer. Possible diagnoses of placental abruption and non-\n obstetric causes should be considered. Fetal compromise should be\n excluded. \n \n \n3. Management of labour \n \n 3.\n1. General considerations \n \n 3.1.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_043", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 578 } }, { "content": "excluded. \n \n \n3. Management of labour \n \n 3.\n1. General considerations \n \n 3.1.\n1. Communication between women and healthcare professionals/\n workers \n \n \n• Greet the mother with a smile and a personal welcome\n \n• Treat them with respect and dignity \n \n \n• Assure privacy \n \n• Establish a good rapport with the laboring women asking\n about their wants and concerns and address them\n \n• Maintain a calm and confident approach which will reassure\n women that the situation is under control \n \n• Assess the woman’s knowledge of strategies for coping with", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_043", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 84, "chunk_size": 552 } }, { "content": "• Assess the woman’s knowledge of strategies for coping with\n pain and provide balanced information to find out which\n available approaches are acceptable to her \n \n• Ask her permission before all procedures and observations,\n focusing on the woman rather than technology or the\n documentation \n \n 3.1.\n2. Preparation of mothers to transfer to labour room\n \n \n• Shaving or trimming of perineal hair may be necessary to\n facilitate unhindered performance and repair of the episiotomy.\n \n \n• Efforts must be made to minimize faecal soiling. Where\n an enema is deemed necessary, a medicated enema is", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_043", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 92, "chunk_size": 596 } }, { "content": "an enema is deemed necessary, a medicated enema is\n recommended. \n (These two steps should not be considered mandatory)\n 4 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_043", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 27, "chunk_size": 170 } }, { "content": "================================================== PAGE 23 ==================================================\n• Women should be encouraged to have a companion of her\n choice during labour, depending on the facilities and clinical\n situation. \n \n 3.\n1. \n3. Documentation \n \n \n• Admit the mother to the labour room and complete the\n ‘handing over’ form \n \n \n• Enter relevant notes on the BHT and start a partogragh (see\n page 39) \n \n• Review clinical notes and reassess risk factors.\n \n• Accurate documentation of all observations and interventions\n must be made, with timing.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_044", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 78, "chunk_size": 574 } }, { "content": "• Accurate documentation of all observations and interventions\n must be made, with timing. \n \n• All obstetric examinations and procedures carried out must\n be documented in the clinical notes. Each entry must be\n accompanied by a plan for management and be signed by the\n responsible person. \n \n 3.1.\n4. Mobilization and Positioning \n \n \n• Women should be encouraged and helped to move about\n and adopt whatever positions they find most comfortable\n throughout labour. \n \n• They need to be encouraged to void urine at regular intervals.\n \n 3.1.\n5. Eating and drinking in labour", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_044", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 577 } }, { "content": "3.1.\n5. Eating and drinking in labour \n \n \n• Mothers must be encouraged to consume clear, non-\n fizzy liquids during labour. Isotonic solutions such as oral\n rehydration fluid and king coconut water are more beneficial\n than water. \n \n \n• In addition to clear fluids, women in the latent phase may\n consume light solids e.g. biscuits and fruits.\n \n 3.1.\n6. Hygiene measures during labour \n \n \n• Strict asepsis must be maintained during labour.\n \n• Instruments should be available in packets\n National Guideline for Maternal Care - Volume I 5", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_044", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 541 } }, { "content": "================================================== PAGE 24 ==================================================\n• Use proper hand washing technique. \n \n \n• Use of double gloves and disposable gloves is encouraged.\n \n 3.1.\n7. Pain relief in labour \n \n Relief of pain should be a major consideration (please refer guidelines on\n pain relief during labour in page 34) \n \n 3.\n2. Management of the three stages of labour \n \n The practice of maintaining a labour room ‘notice board’ - a ‘white\n board’ on which the status of all women in labour is summarized", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_045", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 78, "chunk_size": 550 } }, { "content": "board’ on which the status of all women in labour is summarized\n and updated regularly is encouraged. This would convey at a glance\n to all care providers women who require additional attention. The\n age, parity status, risk factors, salient findings at each assessment\n and any abnormalities noted must be included in this.\n \n 3.2.\n1. Management of first stage of labour \n \n 3.2.\n1. \n1. Latent phase \n \n It is important to recognize the latent phase of labour, since its prolongation\n could lead to maternal exhaustion, dehydration and acidosis, leading to", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_045", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 88, "chunk_size": 557 } }, { "content": "could lead to maternal exhaustion, dehydration and acidosis, leading to\n fetal compromise and dysfunctional labour. \n \n Women in the latent phase of labour would be best managed in the\n antenatal ward. \n \n Women in the latent phase of labour must be assessed on a regular basis,\n as follows: \n \n \n• Check the fetal heart and maternal pulse half hourly\n \n• Check temperature four hourly \n \n• Consider vaginal examination four hourly, depending on the\n contraction pattern and initial cervical dilatation\n \n• Document the colour of amniotic fluid if the membranes\n rupture", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_045", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 87, "chunk_size": 570 } }, { "content": "================================================== PAGE 25 ==================================================\n• Use of a sanitary pad may indicate early, the presence of\n meconium. \n \n \n• Consider the requirement for analgesia. \n \n It is important to inform the mother and reassure her that it is common to\n have slow progress in the latent phase. \n \n The latent phase is considered prolonged when it lasts more than 12 hours\n in a primigravida and 8 hours in a multigravida. In these situations an\n experienced medical officer (with a minimum one year of experience in", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_046", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 82, "chunk_size": 569 } }, { "content": "experienced medical officer (with a minimum one year of experience in\n the field) must reassess the mother with a view of augmentation of labour.\n \n 3.2.1.\n2. Active phase \n \n 3.2.1.2a. Admitting women to the Labour Room \n \n All pregnant women diagnosed as being in active phase of the first stage of\n labour need to be admitted to the labour room. \n \n The initial assessment of a woman in the labour room should include:\n \n \n• Listening to her story, considering her emotional and\n psychological needs and reviewing her clinical records\n \n• Physical observation: temperature, pulse, blood pressure", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_046", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 93, "chunk_size": 598 } }, { "content": "• Physical observation: temperature, pulse, blood pressure\n \n• Length, strength and frequency of contractions\n \n• Abdominal palpation: fundal height, lie, presentation, position\n and station \n \n• Vaginal loss: show, liquor, blood \n \n \n• Assessment of woman’s pain including her wishes for coping\n with labour along with the range of options for pain relief\n \n• The fetal heart rate (FHR) should be auscultated preferably with\n a hand held Doppler for a minimum of 1 minute immediately\n after a contraction \n \n• The maternal pulse should be recorded to differentiate between", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_046", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 573 } }, { "content": "after a contraction \n \n• The maternal pulse should be recorded to differentiate between\n maternal pulse and FHR \n \n• A vaginal examination should be offered", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_046", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 24, "chunk_size": 156 } }, { "content": "================================================== PAGE 26 ==================================================\nHealth care Professionals who conduct vaginal examination should:\n \n \n• Be sure that there is a valid indication for vaginal examination\n that it will add important information to the decision making\n process \n \n \n• Be aware that for many women who may already in pain,\n highly anxious and in an unfamiliar environment, vaginal\n examination can be very distressing \n \n• Ensure the woman’s consent, privacy, dignity and comfort", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_047", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 536 } }, { "content": "• Ensure the woman’s consent, privacy, dignity and comfort\n \n• Explain the reason for examination and what will be involved,\n and \n \n• Explain the findings and their impact sensitively to the woman\n \n 3.2.1.2b. Management of active phase of first stage \n \n Monitoring must be conducted as instructed in the partogram and\n findings recorded accordingly. \n \n Use of a sanitary pad may indicate presence of meconium early.\n \n Women in the active phase of labour must be assessed on a regular basis,\n as follows: \n \n \n• Check the fetal heart and maternal pulse every 15 minutes ;", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_047", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 92, "chunk_size": 575 } }, { "content": "as follows: \n \n \n• Check the fetal heart and maternal pulse every 15 minutes ;\n \n• Check temperature and blood pressure four hourly;\n \n \n• Vaginal examination four hourly or earlier, depending on the\n clinical situation; \n \n• Frequency of contractions should be monitored as follows:\n The interval between two contractions should be assessed by\n palpation of the abdomen \n During active labor usually there are at least three contractions\n per ten minutes. In other words the interval between two\n contractions should be three minutes \n \n \n• Document the colour of amniotic fluid if the membranes", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_047", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 91, "chunk_size": 596 } }, { "content": "contractions should be three minutes \n \n \n• Document the colour of amniotic fluid if the membranes\n rupture; \n \n• Consider the requirement for analgesia, (which now becomes\n more important). \n 8 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_047", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 36, "chunk_size": 242 } }, { "content": "================================================== PAGE 27 ==================================================\nIntermittent auscultation of the fetal heart is best performed using\n hand-held Doppler devices. The fetal heart rate must be counted\n for one minute, beginning immediately after a contraction.\n \n The mother may continue to consume clear fluids in the active phase.\n \n She must be encouraged to assume any position that she is comfortable in\n and to avoid the dorsal position. \n \n Women who have the following conditions are recommended to be have", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_048", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 557 } }, { "content": "Women who have the following conditions are recommended to be have\n to continuous electronic fetal monitoring: \n \n \n• Significant meconium staining of amniotic fluid,\n \n• Abnormal Fetal heart rate detected by intermittent\n auscultation (< 110 beats per minute; > 160 beats per minute;\n any decelerations after a contraction) \n \n• Fresh vaginal bleeding and \n \n \n• Maternal pyrexia. \n \n In women with spontaneous labour progressing normally, routine\n early amniotomy and use of oxytocin is not recommended.\n \n 3.2.1.\n3. Delayed progress of first stage of labour", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_048", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 560 } }, { "content": "3.2.1.\n3. Delayed progress of first stage of labour\n \n Delayed progress is diagnosed when there is progress of less than\n two cm in four hours. Slowing of progress in a woman who has\n previously been progressing satisfactorily must also be considered\n as a delay. \n \n It is extremely important that delay in progress is assessed by an\n experienced medical officer. \n \n This assessment must take into account: \n \n• the uterine contractions, \n \n• descent and position of the fetal head \n \n \n• features of early obstruction of labor (caput and moulding), and\n \n• The fetal condition", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_048", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 92, "chunk_size": 579 } }, { "content": "• features of early obstruction of labor (caput and moulding), and\n \n• The fetal condition \n National Guideline for Maternal Care - Volume I 9", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_048", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 24, "chunk_size": 142 } }, { "content": "================================================== PAGE 28 ==================================================\nIn women with delay in the active phase of the first stage, every effort must\n be made to find a cause for the delay. This may either be due to inadequate\n contractions or obstruction due to CPD, mal-presentation or malposition\n (such as occipito-posterior position), or a combination of these.\n \n In cases of inadequate contractions: \n \n \n• Amniotomy must be performed if membranes are still intact.\n \n• Following that, the woman must be reassessed in two hours", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_049", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 572 } }, { "content": "• Following that, the woman must be reassessed in two hours\n \n• In case there is inadequate progress, augmentation with\n oxytocin must be considered. \n \n• The situation must be reassessed after four hours or earlier if\n required. \n \n Multiparous women with delayed progress: \n \n• Must be viewed with extreme caution. \n \n \n• It is very important to exclude mechanical causes of delay\n before considering oxytocin. \n \n• Use of oxytocin in multipara with obstructed labour could be\n extremely dangerous. \n \n In all cases where progress is slow in spite of adequate contractions a", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_049", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 576 } }, { "content": "extremely dangerous. \n \n In all cases where progress is slow in spite of adequate contractions a\n careful assessment must be made to exclude obstruction of labour.\n \n Attention must be paid to effective pain relief and to correcting dehydration\n in those situations. \n \n After paying attention to the above,Cesarean section must be considered\n where the progress continues to be slow after four hours (less than two\n cm) of commencing oxytocin. \n \n 3.2.\n2. Management of second stage of labour \n \n 3.2.2.\n1. Passive second stage of labour (descent phase)", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_049", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 554 } }, { "content": "3.2.2.\n1. Passive second stage of labour (descent phase)\n \n \n• Is diagnosed when full cervical dilatation is reached in the\n absence of involuntary expulsive efforts by the mother.\n \n• Bearing down must be discouraged at this stage.\n \n 10 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_049", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 46, "chunk_size": 286 } }, { "content": "================================================== PAGE 29 ==================================================\n• Intermittent auscultation of the fetal heart should be done\n immediately after a contraction for at least one minute, at least\n every 10 minutes. The maternal pulse should be palpated if\n there is suspected fetal bradycardia or any other FHR anomaly\n to differentiate the two heart rates. \n \n \n• Presence of meconium must be noted. \n \n 3.2.2.\n2. Active second stage of labour (expulsive phase)\n \n \n• Is diagnosed when the mother gets the urge to bear down with\n full dilatation.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_050", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 82, "chunk_size": 590 } }, { "content": "• Is diagnosed when the mother gets the urge to bear down with\n full dilatation. \n \n• Intermittent auscultation of the fetal heart should be done\n immediately after a contraction for at least one minute, at least\n every 5 minutes. The maternal pulse should be palpated if there\n is fetal bradycardia or any other FHR anomaly\n \n• Presence of meconium must be noted. \n \n Use of a hand-held Doppler device is recommended (in preference to a\n Pinnard) for fetal heart rate monitoring in the second stage.\n \n Women must be encouraged to continue consuming clear fluids during\n the second stage.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_050", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 97, "chunk_size": 589 } }, { "content": "Women must be encouraged to continue consuming clear fluids during\n the second stage. \n \n Support by the labour companion must be continued.\n \n Total time durations allowed for the second stage of labour are as follows:\n \n Primigravida: \n \n• Birth would be expected to take place within 2 hours of the\n start of the active second stage in most women.\n \n• A diagnosis of delay in the active second stage should be made\n when it has lasted 1 hour and need to seek the advice from a\n health professional trained in the assisted/ Operative vaginal\n birth if birth is not imminent. \n \n Multigravida:", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_050", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 99, "chunk_size": 594 } }, { "content": "birth if birth is not imminent. \n \n Multigravida: \n \n \n• Birth would be expected to take place within 1 hours of the\n start of the active second stage in most women.\n National Guideline for Maternal Care - Volume I 11", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_050", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 38, "chunk_size": 217 } }, { "content": "================================================== PAGE 30 ==================================================\n• A diagnosis of delay in the active second stage should be made\n when it has lasted 30 minutes and requires advice from a health\n professional trained in assisted/ operative vaginal birth if birth\n is not imminent. \n \n \n• Delay in the second stage in a multiparous woman must raise\n suspicion of disproportion or malposition. \n \n One further hour is permitted for women in each category with an\n epidural analgesia. \n \n 3.2.2.\n3. Observations for women and babies in the second stage of", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_051", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 597 } }, { "content": "epidural analgesia. \n \n 3.2.2.\n3. Observations for women and babies in the second stage of\n labour: \n All observations should be documented on the partogragh.\n \n \n• Chart blood pressure and pulse hourly \n \n• Continue four hourly temperature recording \n \n• Vaginal examination must be offered after an hour in the active\n second stage after abdominal palpation and assessment of\n vaginal loss \n \n \n• Half hourly documentation of frequency of contractions\n \n• Ongoing consideration of the woman’s emotional and\n psychological needs \n \n In addition:", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_051", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 78, "chunk_size": 546 } }, { "content": "• Ongoing consideration of the woman’s emotional and\n psychological needs \n \n In addition: \n \n• Assessment of progress should include maternal behavior,\n effectiveness of pushing and fetal wellbeing, taking into\n account fetal position and station at the onset of the second\n stage. These factors will assist in deciding the timing of further\n vaginal examination and the need for obstetric review.\n \n• Ongoing consideration should be given to the woman’s position,\n hydration, coping strategies and pain relief throughout the\n second stage. \n \n 3.2.2.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_051", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 79, "chunk_size": 552 } }, { "content": "hydration, coping strategies and pain relief throughout the\n second stage. \n \n 3.2.2.\n4. Women’s position and pushing in the second stage of labour:\n \n Although most deliveries in Sri Lanka are conducted in the dorsal/\n McRobert’s position, women may be encouraged to adopt squatting, semi\n upright or lateral positions to aid the expulsion phase.\n 12 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_051", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 61, "chunk_size": 399 } }, { "content": "================================================== PAGE 31 ==================================================\nWomen should be informed that in the second stage, they should be\n guided by their own urge to push. \n \n If pushing is ineffective, strategies to assist birth such as support and\n encouragement and change of position can be used.\n \n In primigravida in whom contractions have become weak and there\n is no evidence of fetal compromise or obstruction, oxytocin may\n be administered as an infusion. In this case, the expulsive phase", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_052", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 538 } }, { "content": "be administered as an infusion. In this case, the expulsive phase\n may be continued under close observation for a further 30 minutes.\n Delivery must be considered at the end of this period.\n \n 3.2.2.\n5. Intrapartum interventions to reduce perineal trauma\n \n Either the ‘hands on’ (guarding the perineum and flexing the baby’s head)\n or the ‘hands poised’ (with hands off the perineum and baby’s head but in\n readiness) techniques can be used to facilitate spontaneous birth.\n \n A routine episiotomy should not be carried out during spontaneous\n vaginal birth.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_052", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 559 } }, { "content": "A routine episiotomy should not be carried out during spontaneous\n vaginal birth. \n \n Episiotomy should only be performed selectively, in women in whom there\n is a clinical need such as instrumental birth or suspected fetal compromise\n or a high chance of perineal tears. \n \n Where episiotomy is performed, Mediolateral episiotomy, performed at\n 45 – 60 degrees from the midline directed to the right side, beginning at\n the vaginal fourchette is preferred to the median episiotomy. It should be\n performed at the time of crowning of the fetal head.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_052", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 549 } }, { "content": "performed at the time of crowning of the fetal head.\n \n Episiotomy should be performed after infiltration of the perineum up to\n 20 ml of 1% lignocaine. \n \n 3.2.2.\n6. Delivery \n \n The fetal head should not be allowed to extend till occiput is felt below\n the symphysis pubis. The perineum should be supported during delivery\n of the head. Once the head is delivered the woman should be discouraged\n from bearing down. Following restitution and external rotation, shoulders\n \n National Guideline for Maternal Care - Volume I 13", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_052", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 84, "chunk_size": 526 } }, { "content": "================================================== PAGE 32 ==================================================\nmust be delivered appropriately with directed traction on the fetal head.\n The baby must be delivered onto the mother’s abdomen. Breastfeeding\n should be initiated within 30 minutes of birth. \n \n 3.2.\n3. Third stage of Labour \n \n The third stage of labour is the period from the complete delivery of the\n baby to the complete delivery of the placenta and membranes.\n \n 3.2.3.\n1. Active Management of the third stage of labour", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_053", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 535 } }, { "content": "3.2.3.\n1. Active Management of the third stage of labour\n \n Active management of the third stage of labour is recommended for all\n mothers. \n \n This includes; \n \n \n• Routine use of uterotonic drugs: Oxytocin 5 IU intravenously\n soon after the delivery of the baby or 10 IU intramuscularly,\n \n• Delayed cord clamping (2 minutes after the birth) and cutting\n of the cord \n \n• Followed by controlled cord traction. This must be followed by\n uterine massage. \n \n Delayed clamping of the cord allows for placental transfusion,\n which reduces neonatal and infant iron deficiency and anemia.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_053", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 91, "chunk_size": 584 } }, { "content": "which reduces neonatal and infant iron deficiency and anemia.\n This policy should be followed unless the baby is born in a poor\n condition or if the mother is bleeding or is Rhesus iso-immunized.\n \n Clamp and cut the cord close to the perineum. A hand should be placed\n above the symphysis pubis to stabilize the uterus by applying counter\n traction during controlled cord traction. Application of cord traction\n when the uterus is relaxed could lead to acute inversion of the uterus.\n \n After delivery, the placenta must be placed on a flat surface and the maternal", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_053", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 94, "chunk_size": 566 } }, { "content": "After delivery, the placenta must be placed on a flat surface and the maternal\n surface examined for completeness. On the fetal surface the blood vessels\n must be traced to exclude a succenturiate lobe. Completeness of the fetal\n membranes must be ensured.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_053", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 41, "chunk_size": 256 } }, { "content": "14 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_054", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 33 ==================================================\nObservations in the immediate postpartum period include:\n \n \n• Inspection for continued fresh bleeding, \n \n• Check pulse, blood pressure, uterine contraction, and the level\n of the fundus every 15 minutes up to 2 hours\n \n• Her general physical condition, as shown by her colour,\n respiration and her own report of how she feels\n \n Experienced medical personnel should be informed in any one the\n following instances: \n \n• Continuing fresh bleeding;", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_055", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 558 } }, { "content": "following instances: \n \n• Continuing fresh bleeding; \n \n• Elevation of the level of the fundus; \n \n \n• Increase of pulse rate above 100 or by 30 beats per minute;\n \n• Drop in systolic blood pressure below 100 or by 30 mmHg.\n \n The level of the fundus must be marked on the skin using a marker to\n make observations more objective. \n \n 3.2.3.\n2. Delayed third stage \n \n Delayed third stage is diagnosed when the placenta is not delivered within\n 30 minutes of active management. \n \n The first step in managing delayed third stage of labour is:", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_055", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 91, "chunk_size": 542 } }, { "content": "The first step in managing delayed third stage of labour is:\n \n• To proceed to intraumbilical vein oxytocin, in a dose of 50 IU\n in 30 ml of 0.9% sodium chloride solution.\n \n• A period of 30 minutes is allowed and controlled cord traction\n is attempted again. \n \n \n• If the placenta is not delivered by this method, manual removal\n of placenta is proceeded to. \n \n \n4. Care for the newborn baby \n \n Effective care at birth is needed in anticipation of problems with the\n transition from in utero dependent life to extra utero independent\n existence and to provide support to ensure stabilization.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_055", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 100, "chunk_size": 596 } }, { "content": "National Guideline for Maternal Care - Volume I 15", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_056", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 34 ==================================================\n• Skilled birth attendant (Medical Officer, Nursing Officer and\n Midwive) is responsible for the care. \n \n \n• The care at birth is same irrespective of birthing place or person\n attending to birth. \n \n• At least one health care provider trained in neonatal\n resuscitation must be physically available at the time of birth of\n all infants irrespective of risk status. \n \n• This person must actually be present in the delivery room\n before the birth of the baby.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_057", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 570 } }, { "content": "• This person must actually be present in the delivery room\n before the birth of the baby. \n \n• The attending personnel should document the details of the\n baby such as time of birth, weight, gender and any other\n relevant information in all cases. \n \n The aims of neonatal care following birth include the following:\n \n• Establishment of respiration (as per NRP guidelines)\n \n \n• Prevention of hypothermia (Refer to newborn guideline)\n \n• Establishment of breast feeding (Refer to newborn guideline)\n \n• Prevention of infection (Refer to newborn guideline)", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_057", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 86, "chunk_size": 557 } }, { "content": "• Prevention of infection (Refer to newborn guideline)\n \n• Detection of danger signs (Refer to newborn guideline)\n \n Following basic steps should be followed at the time of birth;\n \n \n1. Call out the time of birth \n \n2. Deliver the baby onto the mother’s abdomen or into her arms\n \n3. Dry baby with a warm towel or a warm piece of cloth\n \n4. Wipe baby’s eye \n \n5. Assess baby’s breathing while drying \n \n \n6. Make sure that there is no second baby \n \n7. Change gloves or remove the first layer of gloves\n \n8. Clamp and cut the umbilical cord", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_057", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 96, "chunk_size": 541 } }, { "content": "7. Change gloves or remove the first layer of gloves\n \n8. Clamp and cut the umbilical cord \n \n9. Put the baby between mother’s breast for skin to skin care\n \n10. Place an identity label on baby \n \n \n11. Cover mother and baby with warm clothes \n \n12. Put a hat on baby’s head \n \n The Apgar score at 1 and 5 minutes should be recorded for all births.\n 16 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_057", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 74, "chunk_size": 400 } }, { "content": "================================================== PAGE 35 ==================================================\nInitiation of breast feeding should be aimed for within 1hour after birth.\n \n Head circumference, birth weight, length and other measurements should\n be carried out once the first feed is complete. A health care professional\n should examine the baby to detect any physical abnormality and to\n identify any problems that require referral. \n \n \n5. Perineal Care \n \n Perineal or genital trauma caused by either episotomy or tearing need to\n be repaired.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_058", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 560 } }, { "content": "Perineal or genital trauma caused by either episotomy or tearing need to\n be repaired. \n \n Before assessing for genital trauma: \n \n \n• Explain to the woman what they are going to do and why\n \n• Offer some analgesia \n \n• Ensure good lighting \n \n• Position the woman so that she is comfortable and the genital\n structures can be seen clearly. \n \n The initial assessment should be performed gently and with sensitivity\n and may be done in the immediate period following birth preferably as\n soon as the placenta is delivered. \n \n Classification of perineal trauma", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_058", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 560 } }, { "content": "soon as the placenta is delivered. \n \n Classification of perineal trauma \n \n First degree: Injury to skin only \n \n Second Degree: Injury to the perineal muscles but not the anal\n sphincter \n \n Third degree: Injury to the perineum involving the anal sphincter\n complex \n \n Fourth degree: Injury to the perineum involving the anal sphincter\n complex and anal epithelium \n \n Perineal repair should only be undertaken with tested effective analgesia\n in place using infiltration with up to 20ml of 1% lignocaine or equivalent,\n or by topping up the epidural, as soon as possible by a medical officer.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_058", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 90, "chunk_size": 596 } }, { "content": "or by topping up the epidural, as soon as possible by a medical officer.\n National Guideline for Maternal Care - Volume I 17", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_058", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 23, "chunk_size": 124 } }, { "content": "================================================== PAGE 36 ==================================================\nThe preferred suture material is rapidly absorbable polyglactin acid.\n \n The following basic principles should be observed when performing\n perineal repairs: \n \n \n• Perineal trauma should be repaired using aseptic techniques.\n \n \n• Equipment should be checked and swabs and needles counted\n before and after the procedure \n \n• Good lighting is essential to see and identify the structures\n involved. \n \n• Difficult injuries should be repaired by an experienced medical", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_059", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 578 } }, { "content": "involved. \n \n• Difficult injuries should be repaired by an experienced medical\n officer in the theatre under regional or general anaesthesia. An\n indwelling catheter should be inserted for 24 hours to prevent\n urinary retention. \n \n• Good anatomical alignment of the wound should be achieved,\n and consideration given to the cosmetic result.\n \n• Rectal examination should be carried out after completing the\n repair to ensure that suture material has not accidently been\n inserted through the rectal mucosa. \n \n \n• Following completion of repair, an accurate detailed account", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_059", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 84, "chunk_size": 575 } }, { "content": "• Following completion of repair, an accurate detailed account\n should be documented covering the extent of the trauma, the\n method of repair and the materials used. \n \n• Information should be given to the woman regarding the extent\n of the trauma, pain relief, diet, hygiene and the importance of\n pelvic floor exercises.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_059", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 51, "chunk_size": 322 } }, { "content": "18 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_060", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 37 ==================================================\nGuideline on Induction of Labour \n \n \n1. Introduction \n \n This guideline aims to provide evidence based guidance on induction of\n labour to make the process more logical, effective and safer. It also aims to\n empower women undergoing induction of labour. \n \n \n2. Definition \n \n Induction of labour is defined as initiation of labour by artificial means.\n \n \n3. General Principles \n \n \n• Induction of labour should be performed only in specialist", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_061", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 555 } }, { "content": "3. General Principles \n \n \n• Induction of labour should be performed only in specialist\n obstetric units when there is a clear indication that its benefits\n outweigh risks. \n \n \n• A senior clinician must make the decision. \n \n• The reason/s should be clearly explained to the patient, who\n should give her consent. \n \n• Maternal and fetal wellbeing should be monitored closely.\n \n• Adequate pain relief should be an essential part of the\n management plan, since it is recognized that labor is more\n painful when it is induced. \n \n \n• Prior to induction of labour, the cervix should be favourable", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_061", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 95, "chunk_size": 595 } }, { "content": "painful when it is induced. \n \n \n• Prior to induction of labour, the cervix should be favourable\n (Modified Bishop score 7 or more). If it is not, an attempt should\n be made to ripen the cervix. \n \n• Decisions regarding induction of labour should be made taking\n into account not only the clinical scenario but also the woman’s\n views, the availability of local facilities and cost effectiveness of\n the available methods. \n \n \n4. Indications \n \n 4.1 Otherwise uncomplicated pregnancy continuing beyond 40 weeks\n \n Induction of labour is recommended for low-risk women who are known", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_061", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 90, "chunk_size": 582 } }, { "content": "Induction of labour is recommended for low-risk women who are known\n with certainty to have reached 41 weeks of gestation.\n National Guideline for Maternal Care - Volume I 19", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_061", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 29, "chunk_size": 174 } }, { "content": "================================================== PAGE 38 ==================================================\nHowever, it is good practice to assess fetal wellbeing around 40 weeks to\n select women for conservative management until 41 weeks gestation.\n \n The recommended assessments include fetal biometry (at least abdominal\n circumference) and amniotic fluid index (lower cut-off = 7 cm).\n \n 4.2 Prelabour rupture of membranes at term \n \n In the absence of evidence fetal compromise or maternal infection delayed\n induction of labour after 24 hours is acceptable.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_062", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 565 } }, { "content": "induction of labour after 24 hours is acceptable. \n \n This may be carried out using either oxytocin infusion or prostaglandins.\n \n 4.3 Preterm prelabour rupture of membranes (PPROM) \n \n Patients with PPROM without evidence of infection or fetal compromise\n should be offered induction after the completion 34 weeks.\n \n 4.4 Intrauterine death \n \n This is a very traumatic time for the woman. Most women would want\n to be delivered as early as possible and their wishes need to be respected.\n \n Amniotomy and repeated vaginal examinations are best avoided.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_062", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 554 } }, { "content": "Amniotomy and repeated vaginal examinations are best avoided.\n \n Prostaglandins are preferred for induction of labour in these women.\n \n Amniotomy is preferred in the presence of abruption placentae.\n \n 4.5 History of precipitate labour \n \n There are no studies comparing outcomes in induced versus spontaneous\n labour. \n \n 4.6 Suspected macrosomia \n \n In the presence of good clinical and ultrasound evidence of macrosomia\n or a history of previous shoulder dystocia, there should be a low threshold\n for early induction of labour. \n \n 20 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_062", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 587 } }, { "content": "================================================== PAGE 39 ==================================================\n4.7 Fetal growth restriction \n \n The decision for induction of labour in a growth restricted fetus should be\n individualized based on period of gestation at onset, presence or absence\n of fetal compromise. \n \n 4.8 Older mothers \n \n There is growing evidence that the risk of stillbirth is higher in older (>40\n yrs) women near term. \n \n Women over 40 years should be offered induction between 39-40 weeks.\n \n \n5. Induction under specific circumstances \n \n 5.1 Breech presentation", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_063", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 75, "chunk_size": 589 } }, { "content": "5. Induction under specific circumstances \n \n 5.1 Breech presentation \n \n Presentation per se, is not a contraindication to induction.\n \n 5.2 Previous CS \n \n There is no contraindication to induction of labour in a woman with a\n past caesarean section. \n \n Use of either oxytocin or prostaglandins increases the risk of scar\n dehiscence or rupture. \n \n This risk may be lower with artificial separation of membranes or Foley\n catheter. \n \n \n6. Methods of induction \n \n This section does not make a distinction between methods of ripening the\n cervix and induction of labour. \n \n 6.1 Mechanical", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_063", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 86, "chunk_size": 593 } }, { "content": "cervix and induction of labour. \n \n 6.1 Mechanical \n \n There is good evidence that artificial separation of membranes reduces the\n need for formal induction. This method is recommended to be performed\n with due regard to asepsis, at 40 weeks gestation.\n National Guideline for Maternal Care - Volume I 21", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_063", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 47, "chunk_size": 304 } }, { "content": "================================================== PAGE 40 ==================================================\nWhere the cervix will not admit a finger, massaging around the cervix in\n the vaginal fornices will have a similar effect. \n \n Extra-amniotic balloon catheter is an effective method of ripening of the\n cervix. A Foley catheter is inserted through the cervix and the balloon\n inflated with 40 – 60 ml of saline. This may be left in situ for a maximum\n of 48 hours. Following its removal, induction of labour may be proceeded\n to using another method.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_064", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 559 } }, { "content": "to using another method. \n \n In the presence of evidence of infection, artificial separation of membranes\n and extra-amniotic Foley catheter must not be used. \n \n 6.2 Surgical \n \n Amniotomy is a definitive mode of induction of labour. It should be\n undertaken only if one is committed to deliver within 24 hours. Therefore\n it should be done only when the cervix is ripe and prior cervical assessment\n by an experienced clinician is essential. \n \n The risk of cord prolapse should be appreciated and steps taken to\n minimise or to recognize it early.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_064", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 550 } }, { "content": "minimise or to recognize it early. \n \n Amniotomy alone may be capable of initiation of labour and it is\n recommended that oxytocin be started after a period of observation of at\n least two hours. \n \n 6.3 Pharmacological \n \n 6.3.1 Oxytocin \n \n Use of oxytocin when membranes are intact is not recommended.\n \n For details of how to use oxytocin please refer to the guideline on oxytocin\n \n 6.3.2 Prostaglandins \n \n Prostaglandin E2 (PGE2) \n \n These are very effective in inducing labour and are available as vaginal gel,\n tablet or controlled release pessary.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_064", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 557 } }, { "content": "tablet or controlled release pessary. \n 22 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_064", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 14, "chunk_size": 90 } }, { "content": "================================================== PAGE 41 ==================================================\nAll preparations carry a risk of hyperstimulation.\n \n Intracervical route does not offer any increase in efficacy.\n \n Combined use with oxytocin is particularly dangerous. A minimum of six\n hours from the last vaginal tablet/gel should be allowed before oxytocin\n is started. \n \n Prior to use of prostaglandins the Bishop score should be assessed and\n the woman should be monitored electronically to determine the fetal\n condition and frequency of contractions.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_065", "page_number": 1, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 571 } }, { "content": "condition and frequency of contractions. \n \n After administration the fetal heart should be monitored electronically\n when contractions begin. After confirmation of normal heart rate pattern\n monitoring should be done by intermittent auscultation.\n \n A second dose may be considered after a minimum interval of 6 hours\n after the first, depending on the change of Bishop score, the condition of\n the fetus and frequency of contractions. \n \n The dosages are 3 mg for vaginal tablets and 0.5 mg for vaginal gel.\n \n Misoprostol \n \n This drug is widely used worldwide for a variety of indications in", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_065", "page_number": 1, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 90, "chunk_size": 595 } }, { "content": "Misoprostol \n \n This drug is widely used worldwide for a variety of indications in\n pregnancy. (In Sri Lanka, it is not licensed at present).\n \n Nevertheless, it is very effective in inducing labour (more than PGE2),\n especially in mid trimester fetal death. \n \n Sensitivity of the uterus increases markedly with advancing pregnancy.\n \n This guideline recommends that it should not be used for induction of\n labour with a mature live fetus. \n \n 6.3.3 Mifepristone \n \n It is a powerful anti-progesterone and is very useful as an adjunct to", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_065", "page_number": 1, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 538 } }, { "content": "6.3.3 Mifepristone \n \n It is a powerful anti-progesterone and is very useful as an adjunct to\n misoprostol in cases of intrauterine death. (It is not licenced in Sri Lanka\n at present) \n National Guideline for Maternal Care - Volume I 23", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_065", "page_number": 1, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 39, "chunk_size": 237 } }, { "content": "================================================== PAGE 42 ==================================================\n8. Complications \n \n 8.1 Hyperstimulation \n \n This is a well-recognized complication of induction of labour with\n pharmacological methods. It could have serious consequences including\n rupture of the uterus, aminiotic fluid embolism, precipitate labor and fetal\n compromise. \n \n It is defined either as a contraction free interval of less than sixty seconds\n and/or contractions lasting more than ninety seconds.\n \n If diagnosed, the prostaglandin tablet must be retrieved from the vagina", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_066", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 598 } }, { "content": "If diagnosed, the prostaglandin tablet must be retrieved from the vagina\n or oxytocin infusion stopped immediately and a rapid infusion of 0.9%\n sodium chloride via a fresh giving set administered.\n \n If still not resolved, tocolytics should be given if available e.g. terbutaline\n 250 µg IV or SC. Since this is not available in Sri Lanka, salbutamol\n inhaler may be tried. \n \n 8.2 Cord prolapse \n \n This is more likely with amniotomy when the head is high and poorly\n applied to the cervix. \n \n Precautions to avoid and to detect this early include palpation for cord", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_066", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 92, "chunk_size": 569 } }, { "content": "Precautions to avoid and to detect this early include palpation for cord\n presentation, palpation for the cord immediately after amniotomy and the\n fetal heart sounds auscultated immediately afterwards.\n \n If cord prolapse is diagnosed help must be called immediately. Assess\n cervical dilatation and effect delivery if fully dilated. If not fully dilated\n and cord pulsations are present, insert a Foley catheter into the bladder\n and fill it with 500 ml saline. Place the mother in the knee-elbow position\n and displace the presenting part away from the pelvis by keeping pressure", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_066", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 89, "chunk_size": 582 } }, { "content": "and displace the presenting part away from the pelvis by keeping pressure\n inserting a hand in the vagina. Transport for immediate caesarean section\n in this position.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_066", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 26, "chunk_size": 167 } }, { "content": "24 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_067", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 43 ==================================================\n8.3 Uterine rupture \n \n Please also refer to section 5.2 in this guideline\n \n Extra care must be exercised in grandmultipara and in women with\n scarred uteri. \n \n 8.4 Failed induction \n \n Failed induction is defined as labour failing to start after one cycle of\n treatment with medical methods or for 12 hours of amniotomy.\n \n It does not necessarily indicate caesarean section in case medical or\n mechanical methods.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_068", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 68, "chunk_size": 527 } }, { "content": "It does not necessarily indicate caesarean section in case medical or\n mechanical methods. \n \n The clinical situation (maternal and fetal condition) must be reassessed\n and discussed with the woman. \n \n In case of failure to induce labor using one cycle of prostaglandins another\n cycle may be administered as described above. Depending on the clinical\n situation it is best that the second cycle is delayed for 24 hours. In case of\n amniotomy, failed induction of labour indicates caesarean section.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_068", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 76, "chunk_size": 500 } }, { "content": "National Guideline for Maternal Care - Volume I 25", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_069", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 44 ==================================================\n26 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_070", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 160 } }, { "content": "================================================== PAGE 45 ==================================================\nGuideline for Use of Oxytocin for Induction and\n \n Augmentation of labour \n \n Oxytocin is an invaluable drug when used carefully. However, it has\n the potential to cause uterine hyperstimulation, which could result in\n amniotic fluid embolism, uterine rupture and fetal distress, all of which\n are life threatening. \n \n Multigravidae are particularly susceptible to the above consequences\n and extra care must be taken to exclude obstruction before a decision is", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_071", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 572 } }, { "content": "and extra care must be taken to exclude obstruction before a decision is\n made to use oxytocin in a multigravid woman during labour. Experienced\n personnel must be involved in this decision. \n \n Use of oxytocin for induction and/or augmentation of labour results in\n a higher risk of rupture of a scarred uterus. Therefore, in such women\n oxytocin should be used only with the concurrence of a Consultant.\n \n Its effects will depend on the concentration of the infusion and the volume\n infused per minute. \n \n To achieve this predictably, use of infusion pumps is recommended.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_071", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 92, "chunk_size": 576 } }, { "content": "infused per minute. \n \n To achieve this predictably, use of infusion pumps is recommended.\n \n Where a gravity-assisted drip system is used, a burette may be used to\n improve accuracy. Such systems however, may deliver variable volumes\n depending on many factors including the position of the arm into which\n it is infused. \n \n Irrespective of the method of administration, oxytocin must be\n administered in incremental doses at intervals of 30 minutes, to achieve\n a contraction free interval of two minutes. Once this level is reached, the", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_071", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 83, "chunk_size": 540 } }, { "content": "a contraction free interval of two minutes. Once this level is reached, the\n infusion rate may be continued at the same level, while closely monitoring\n the contractions. \n \n Hyperstimulation is defined either as a contraction free interval of less\n than sixty seconds and/or contractions lasting more than ninety seconds.\n In this situation the infusion must be stopped immediately.\n \n Oxytocin is administered with 5 units in 500 ml of 0.9% sodium chloride\n solution. In situations where infusion pumps are not available, oxytocin\n National Guideline for Maternal Care - Volume I 27", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_071", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 89, "chunk_size": 584 } }, { "content": "================================================== PAGE 46 ==================================================\nmay be administered starting at a drop rate of 15 per minute and increased\n at rates of 15 drops per minute every 30 minutes, up to a maximum of 60\n drops per minute. An approximate conversion to mU/minute is given in\n table \n1. \n \n Table 1: mU/minute administered at different rates of administration\n according to drop rate \n \n Drop rate/min Equivalent mU/min. \n \n 15 7.5 \n 30 15 \n 45 22.5 \n \n 60 30 \n (based on 5U of oxytocin in 500 ml saline)", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_072", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 556 } }, { "content": "15 7.5 \n 30 15 \n 45 22.5 \n \n 60 30 \n (based on 5U of oxytocin in 500 ml saline) \n \n Table 2 gives mU infused per minute when administered via an infusion\n pump. \n \n Table 2: mU infused per minute when administered via an infusion\n pump. \n \n TIME AFTER STARTING OXYTOCIN DOSE VOLUME INFUSED \n (MINS) (MU/MIN) DOSE (10U IN 500MLS MLS/HR)\n RATE \n 0 1 3 \n 30 2 6 \n 60 4 12 \n 90 8 24 \n 120 12 36 \n 150 16 48 \n 180 20 60 \n 210 24 72 \n 240 28 84 \n 270 32 96 \n \n Oxytocin must not be administered to women with intact membranes. It is\n recommended that women on oxytocin infusions should have continuous", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_072", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 108, "chunk_size": 595 } }, { "content": "recommended that women on oxytocin infusions should have continuous\n electronic fetal monitoring. \n 28 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_072", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 21, "chunk_size": 150 } }, { "content": "================================================== PAGE 47 ==================================================\nContinuous EFM during administration of oxytocin:\n \n \n• If the CTG is normal, oxytocin may be continued in incremental\n doses until the woman is experiencing 4 or 5 contractions every\n 10 minutes. \n \n \n• If the FHR trace is suspicious, this should be reviewed by an\n experienced medical officer \n \n• If the FHR trace is classified as abnormal/pathological oxytocin\n infusion should be stopped and a full assessment of the fetal\n condition undertaken by an experienced medical officer.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_073", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 594 } }, { "content": "National Guideline for Maternal Care - Volume I 29", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_074", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 48 ==================================================\nGuideline on fetal monitoring in labour \n \n Fetal monitoring in labour could be done by : \n \n \n• Intermittent auscultation (preferably by a hand held Doppler\n device) \n \n• Intermittent or continuous electronic monitoring\n \n Intermittent auscultation is recommended for low-risk women in\n spontaneous labour. \n \n Electronic monitoring is recommended when: \n \n• The baby’s growth is restricted \n \n• There is significant meconium staining of amniotic fluid", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_075", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 65, "chunk_size": 563 } }, { "content": "• The baby’s growth is restricted \n \n• There is significant meconium staining of amniotic fluid\n \n \n• Abnormal fetal heart rate detected by intermittent auscultation\n \n• Fresh vaginal bleeding \n \n• Maternal pyrexia \n \n• Use of oxytocin for augmentation or induction of labour\n \n \n• Women with a scarred uterus \n \n• Women on epidural analgesia \n \n Intermittent auscultation \n \n This could be done by using either a Pinnard’s stethoscope or preferably a\n hand-held Doppler device. \n \n Auscultation should be carried out immediately after a contraction for\n one full minute.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_075", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 571 } }, { "content": "Auscultation should be carried out immediately after a contraction for\n one full minute. \n \n The maternal pulse should be palpated if there is suspected fetal\n bradycardia or any other FHR anomaly to differentiate the two heart rates.\n \n The normal rate is between 110 – 160 beats per minute in a term fetus.\n \n The frequency of auscultation should be as specified in the partogram.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_075", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 62, "chunk_size": 382 } }, { "content": "30 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_076", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 49 ==================================================\nElectronic fetal monitoring (EFM) \n \n EFM is carried out by external cardiotocography (CTG).\n \n The following are recommended at the commencement of a CTG.\n \n \n1. The paper speed must be set at 1 cm per minute.\n \n2. The date and time settings on the machine must be validated.\n \n3. The CTG must be labeled with the mother’s name, BHT number\n and date and time. \n \n4. Maternal heart rate should be noted on the CTG.\n \n5. The presence and the point at which the fetal heart rate is best", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_077", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 90, "chunk_size": 594 } }, { "content": "5. The presence and the point at which the fetal heart rate is best\n heard must be delineated by auscultation and the probe placed\n at that point. \n \n \n6. Ensure that the contraction probe is functioning properly and\n used for the recording. \n \n7. The woman should be positioned in such a way that aortocaval\n compression is avoided. \n \n8. It should be interpreted without delay and the categorization\n recorded as either normal or suspicious or pathological, as per\n table 1, and signed by the responsible officer. The entry on the\n BHT must include a plan for management.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_077", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 95, "chunk_size": 573 } }, { "content": "BHT must include a plan for management. \n \n9. If the CTG is categorized as suspicious or abnormal, the\n Consultant must be informed. \n \n \n10. For the management plan the overall clinical picture must be\n taken into account. e.g. the rate of progress of labour, presence\n or absence of fetal growth restriction, meconium staining of\n amniotic fluid and the evolution of the CTG abnormalities.\n Table 1: Definitions of normal, suspicious and pathological FHR traces\n \n Category Definition \n Normal An FHR trace in which all four features are classified as\n reassuring", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_077", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 87, "chunk_size": 565 } }, { "content": "Normal An FHR trace in which all four features are classified as\n reassuring \n \n Suspicious An FHR trace with one feature classified as non-reassuring\n and the remaining features classified as reassuring\n Pathological An FHR trace with two or more features classified as non-\n reassuring or one or more classified as abnormal\n National Guideline for Maternal Care - Volume I 31", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_077", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 59, "chunk_size": 377 } }, { "content": "================================================== PAGE 50 ==================================================\nTable 2: Classification of fetal heart rate patterns\n \n Feature Baseline Variability Decelerations Accelerations\n (bpm) (bpm) \n Reassuring 110–160 ≥ 5 None Present \n Non-reassuring 100–109 < 5 for 40–90 Typical variable The absence of\n 161–180 minutes decelerations with accelerations\n over 50% of with otherwise \n contractions, normal trace is\n occurring for over of uncertain\n 90 minutes significance \n Abnormal < 100 < 5 for 90 Either atypical \n > 180 minutes variable", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_078", "page_number": 2, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 581 } }, { "content": "90 minutes significance \n Abnormal < 100 < 5 for 90 Either atypical \n > 180 minutes variable \n Sinusoidal decelerations with \n pattern ≥ _10 over 50% of \n minutes contractions or late \n decelerations, both \n for over 30 \n minutes \n Further useful information on FHR patterns \n \n \n• If repeated accelerations are present with reduced variability,\n the FHR trace should be regarded as reassuring.\n \n \n• True early uniform decelerations are rare and benign, and\n therefore they are not significant. \n \n• Most decelerations that occur during labor are variable.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_078", "page_number": 2, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 557 } }, { "content": "• Most decelerations that occur during labor are variable.\n \n• If a bradycardia occurs in the baby for more than 3 minutes,\n urgent medical aid should be sought and preparations\n should be made to urgently expedite the birth of the baby, i.e.\n immediate commencement of cesarean section. This could\n include moving the woman to theatre if the fetal heart has\n not recovered by 9 minutes. If the fetal heart recovers within\n 9 minutes the decision to deliver should be reconsidered in\n conjunction with the woman if the post-recovery tracing is\n reassuring.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_078", "page_number": 2, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 91, "chunk_size": 556 } }, { "content": "conjunction with the woman if the post-recovery tracing is\n reassuring. \n \n• A tachycardia in the baby of 160–180 bpm, where accelerations\n are present and no other adverse features appear, should not be\n regarded as suspicious. However, an increase in the baseline\n \n 32 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_078", "page_number": 2, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 50, "chunk_size": 319 } }, { "content": "================================================== PAGE 51 ==================================================\nheart rate, even within the normal range, with other non-\n reassuring or abnormal features should increase concern. In\n such cases inquiry must be made to ascertain if the fetus was\n active during the recording. \n \n When women are having continuous EFM, systematic assessment of above\n definitions and classification should be undertaken with every review.\n \n During episodes of abnormal FHR patterns, if woman is lying supine,\n advise her to adopt the left lateral position", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_079", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 584 } }, { "content": "National Guideline for Maternal Care - Volume I 33", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_080", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 52 ==================================================\nGuideline on Pain Relief in Labour \n \n Adequate relief of pain is a basic right of every mother in labour. It is the\n duty of every member of the obstetric team to endeavor to achieve this.\n \n Poor management of pain during labour will result in maternal exhaustion\n leading to: \n \n \n• acidosis, \n \n \n• dysfunctional labour and \n \n• fetal distress. \n \n• Loss of morale and a negative birth experience could have\n significant long-term effects.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_081", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 75, "chunk_size": 553 } }, { "content": "• Loss of morale and a negative birth experience could have\n significant long-term effects. \n \n A well-informed, well supported mother will be more in control of events\n and in a better position to deal with pain than one who is not. Therefore,\n it is important to keep the mother informed of the progress of labour and\n the condition of the fetus throughout the process. \n \n Reassurance plays a major adjunctive role in pain relief.\n \n Prenatal education should include information regarding the available\n methods of pain relief and their accessibility.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_081", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 555 } }, { "content": "methods of pain relief and their accessibility. \n \n Non pharmacological methods of pain relief such as breathing and\n relaxation techniques should be introduced during the antenatal period.\n \n It is well recognized that women who have a birth companion will tolerate\n pain better and require less analgesia. The policy of allowing a birth\n companion must therefore be encouraged. \n \n \n1. Methods of pain relief in labour \n \n The selection of the method of pain relief should be based on the patient\n preference, availability of resources and the institutional protocols.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_081", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 570 } }, { "content": "preference, availability of resources and the institutional protocols.\n Following methods can be used.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_081", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 13, "chunk_size": 102 } }, { "content": "34 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_082", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 53 ==================================================\n1.1 Non-pharmacological methods of pain relief \n \n \n• Breathing techniques, \n \n• Transcutaneous electrical nerve stimulation (TENS),\n \n• Massaging, \n \n• Relaxation techniques, \n \n• Positioning and movement \n \n Any of these methods can be used to relieve pain during labour\n \n 1.\n2. Pharmacological methods of pain relief in labour\n \n 1.2.\n1. Oral paracetamol/paracetamol & codeine compound:\n \n These oral preparations can be used safely in the latent phase of labour.\n \n 1.2.\n2. Opioids", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_083", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 596 } }, { "content": "These oral preparations can be used safely in the latent phase of labour.\n \n 1.2.\n2. Opioids \n \n 1.2.2.A. Pethidine \n \n Pethidine is safe and effective in the latent and early active phase. The dose\n is 1-1.5 mg/kg IM, repeated after 4 – 6 hours. Administration of a third\n dose should be done only with the concurrence of senior personnel.\n \n It is generally avoided where delivery is anticipated within 4 hours.\n \n Maternal side effects include nausea, vomiting and a reduction in gastric\n motility with a subsequent increase in gastric acidity. Therefore, it should", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_083", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 90, "chunk_size": 568 } }, { "content": "motility with a subsequent increase in gastric acidity. Therefore, it should\n be administered coupled with metoclopramide 5 mg IV or 10 mg IM.\n \n Neonatal respiratory depression is a recognized consequence of\n administration of opioids to the mother. Naloxone, a pure opioid\n antagonist should be available for treatment in all facilities administering\n opioids for analgesia. Naloxone is given to the baby in a dose of 100μg /kg\n IV. It has a short duration of action and additional doses may be required.\n If no improvement is seen with the first dose of naloxone, the cause of", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_083", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 94, "chunk_size": 579 } }, { "content": "If no improvement is seen with the first dose of naloxone, the cause of\n neonatal respiratory depression is more likely to be a factor other than\n opioids.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_083", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 27, "chunk_size": 155 } }, { "content": "National Guideline for Maternal Care - Volume I 35", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_084", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 54 ==================================================\n1.2.2.B. Morphine \n \n This has a longer duration of action than pethidine and may be particularly\n useful in women who require analgesia in early labour.\n \n The dose is 0.15 mg/kg IM should be administered with metoclopramide.\n The side effects and neonatal effects are similar to those of pethidine.\n \n 1.2.2.C. Fentanyl \n \n Intravenous fentanyl/ramifentanyl may be administered in either a High\n Dependency or Intensive Care Unit settings under the supervision of an\n anaesthesiologist.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_085", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 598 } }, { "content": "Dependency or Intensive Care Unit settings under the supervision of an\n anaesthesiologist. \n \n The dose is 50-100μg per hour as an intravenous infusion.\n \n Pain relief occurs in 3-5 minutes after commencement.\n \n 1.2.\n3. Inhalational analgesia – Entonox \n \n Entonox is a 50:50 mixture of nitrous oxide and oxygen and it has a very\n short half-life. The onset of action is 30sec to one minute.\n \n The mother should receive clear and definite instructions about its correct\n use. It should only be self-administered. \n \n She should start using entonox through the controlled valve at the very", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_085", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 91, "chunk_size": 590 } }, { "content": "She should start using entonox through the controlled valve at the very\n beginning of the contraction. The mother should be advised to stop using\n Entonox inhalation in the contraction free interval.\n \n Longer and deeper breaths give better result. There is no limit on the\n duration of its use. \n \n Women should be informed that Entonox will make them feel nauseous\n and light-headed. \n \n Entonox is contraindicated in women with intestinal obstruction,\n pneumothorax, middle ear and sinus disease, and following cerebral air-\n contrast studies.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_085", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 81, "chunk_size": 546 } }, { "content": "pneumothorax, middle ear and sinus disease, and following cerebral air-\n contrast studies. \n \n 36 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_085", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 21, "chunk_size": 145 } }, { "content": "================================================== PAGE 55 ==================================================\n1.2.\n4. Regional Anaesthesia \n \n A. Epidural analgesia \n \n Epidural analgesia is the most effective form of pain relief in labour.\n Therefore, Its greater use should be encouraged.\n \n It can be given either as a bolus with top-ups or as a continuous infusion.\n Continuous administration via a syringe pump is preferred to ‘top-ups’,\n since it is safer. \n \n The continuous availability of an anesthesiologist is a prerequisite to", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_086", "page_number": 2, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 538 } }, { "content": "since it is safer. \n \n The continuous availability of an anesthesiologist is a prerequisite to\n offering epidural analgesia. It is also essential that staff on site is trained for\n its setting up, monitoring and to recognize complications early. Facilities\n should be available for emergency resuscitation.\n \n Before offering epidural analgesia, women should be informed its risks\n and benefits and its implications on labour: \n \n \n• It provides more effective pain relief than other methods\n \n• It will not increase the length of the first and the passive second\n stages of labour.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_086", "page_number": 2, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 88, "chunk_size": 582 } }, { "content": "• It will not increase the length of the first and the passive second\n stages of labour. \n \n• It may however increase the length of the expulsive phase\n and increase the likelihood of an instrumental delivery. An\n additional hour is allowed in the expulsive phase therefore.\n \n• It does not increase the chance of cesarean section\n \n• It does not cause long-term backache. \n \n \n• It needs to be accompanied by a more intensive level of\n monitoring. \n \n Care and observations for women with regional analgesia in labour\n \n• Intravenous access should be secured prior to commencing", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_086", "page_number": 2, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 95, "chunk_size": 579 } }, { "content": "• Intravenous access should be secured prior to commencing\n regional analgesia. \n \n• Following additional observations should be carried out for\n women with regional analgesia \n ➢ During establishment of regional analgesia or after top up\n bolus blood pressure should be measured every 5 minutes\n for 15 minutes. \n \n National Guideline for Maternal Care - Volume I 37", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_086", "page_number": 2, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 55, "chunk_size": 367 } }, { "content": "================================================== PAGE 56 ==================================================\n➢ If the woman is not pain free within after each\n administration, the anaesthetist should be called.\n \n ➢ Hourly assessment of the level of sensory block should be\n undertaken. \n \n• Women with regional analgesia should be encouraged to move\n and adopt whatever positions they find most comfortable\n throughout labour. \n \n• Once established, regional analgesia should be continued\n until after completion of the third stage of labour and when\n necessary until perineal repair is done.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_087", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 78, "chunk_size": 594 } }, { "content": "necessary until perineal repair is done. \n \n• Women should be allowed one additional hour in the second\n stage of labor, depending on maternal and foetal condition.\n Thereafter pushing during contractions should be actively\n encouraged. \n \n• Continuous EFM is recommended for at least 30 minutes during\n establishment of regional analgesia and after administration of\n each bolus.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_087", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 55, "chunk_size": 380 } }, { "content": "38 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_088", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 57 ==================================================\nGuidelines to maintain the partograph", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_089", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 147 } }, { "content": "National Guideline for Maternal Care - Volume I 39", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_090", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 58 ==================================================\n40 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_091", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 160 } }, { "content": "================================================== PAGE 59 ==================================================\nGuideline on Acute Puerperal Inversion of the Uterus\n \n \n1. Introduction \n \n The aim of this guideline is to provide recommendations for the\n management of acute puerperal inversion of the uterus, which is a rare\n and life threatening condition. The main reason for its high mortality rate\n is delay in instituting appropriate treatment, which leads to postpartum\n hemorrhage and rapid development of shock out of proportion to\n haemorrhage. \n \n \n2. Definition", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_092", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 570 } }, { "content": "hemorrhage and rapid development of shock out of proportion to\n haemorrhage. \n \n \n2. Definition \n \n It is defined as ‘the turning inside out of the fundus into the uterine cavity’.\n \n \n3. Prevention \n \n Mismanagement of the third stage of labor is recognized as the main\n cause, although 50% have no identifiable cause. The common initiating\n factor seems to be a traction force on the fundus of a relaxed uterus.\n Proper retraction of the uterus in the third stage is the primary factor in\n preventing an inversion. There is no reliable data to suggest that it recurs\n in a future pregnancy.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_092", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 97, "chunk_size": 592 } }, { "content": "in a future pregnancy. \n \n The importance of the active management of the third stage could not be\n over-emphasized. (Please refer Section 3 of the PPH Guideline and the\n section on management of delayed third stage (section 3.2.3 in the Normal\n Labor Guideline for details) \n \n \n4. Pathophysiology (and clinical correlation) \n \n As the inversion progresses, the adnexae with their ligaments get drawn\n into the inverting uterine fundus and become increasingly stretched. This\n produces significant pain and vagal stimulation, leading to neurogenic\n shock.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_092", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 80, "chunk_size": 556 } }, { "content": "produces significant pain and vagal stimulation, leading to neurogenic\n shock. \n \n An inverted uterus becomes trapped within the cervix creating\n progressive oedema and congestion due to interruption of venous and\n lymphatic drainage. Oedema and congestion will increase the firmness\n of the inverted segment, making reduction more difficult. Interruption\n National Guideline for Maternal Care - Volume I 41", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_092", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 56, "chunk_size": 407 } }, { "content": "================================================== PAGE 60 ==================================================\nof the venous drainage will lead to significant haemorrhage. A partially\n separated placenta would add to this. \n \n \n5. Classification \n \n Although acute, subacute and chronic varieties have been described, this\n guideline would address only the acute variety as it is life threatening.\n \n This occurs soon after birth, just before or after the delivery of the placenta.\n \n Three degrees of inversion have been described, depending on the", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_093", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 548 } }, { "content": "Three degrees of inversion have been described, depending on the\n level of the inverted fundus. In practice, second-degree inversion is the\n commonest. The fundus has come past the cervical os, but is still within\n the vagina. \n \n \n6. Clinical Presentation and Diagnosis \n \n Prompt diagnosis is vital. \n \n The key to diagnosis is awareness and a high degree of suspicion.\n The following are early warnings: \n \n• A degree of shock that is out of proportion to overt blood loss\n \n• A retained placenta \n \n \n• Placenta delivered but ‘with some difficulty’", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_093", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 552 } }, { "content": "• A retained placenta \n \n \n• Placenta delivered but ‘with some difficulty’ \n \n• Severe, sustained unexplained pain in the third stage.\n \n In this situation: \n \n• Feel for the fundus. If absent or ‘cupped’, acute inversion is\n probable diagnosis; \n \n• Confirm by a vaginal examination: \n \n• Look for a hard mass which looks and feels like a huge\n ulcerated fibroid polyp (sometimes described as a foetal\n head); \n \n• The cervix is not to be seen or felt in the normal position,\n instead it could be felt as a ring around the base of the\n ‘mass’;", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_093", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 93, "chunk_size": 544 } }, { "content": "instead it could be felt as a ring around the base of the\n ‘mass’; \n \n \n• In incomplete cases, the inverted fundus may be felt\n through the cervical canal in the lower uterine cavity.\n 42 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_093", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 42, "chunk_size": 235 } }, { "content": "================================================== PAGE 61 ==================================================\n7. Management \n \n 7.1 General measures: \n \n Early diagnosis is vital. Treat it as a life-threatening emergency.\n \n First attempts at reduction should be made at the place where it is\n diagnosed, without moving to theatre. \n \n If these attempts fail, move to theatre and give a general anesthetic without\n delay (see section 7.2.4). \n \n Early involvement of experienced personnel and teamwork are absolutely\n essential. \n \n Treat shock aggressively, not forgetting the neurogenic element.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_094", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 597 } }, { "content": "essential. \n \n Treat shock aggressively, not forgetting the neurogenic element.\n \n Provide adequate pain relief \n \n Replace the blood loss, which could be considerable, especially if the\n placenta has partially or completely separated. \n \n Do not attempt to remove the placenta, if still attached.\n \n 7.2 Repositioning the uterus \n \n Reposition the uterus as soon as possible; the sooner it is done the easier\n and better. It reverses the shock and reduces PPH.\n \n Non-surgical methods \n \n 7.2.1 Manual replacement of uterus. \n (Johnson’s maneuver)", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_094", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 76, "chunk_size": 548 } }, { "content": "Non-surgical methods \n \n 7.2.1 Manual replacement of uterus. \n (Johnson’s maneuver) \n \n The operator introduces two thirds of his forearm in to the vagina and\n extends the hand at the wrist to place the palm on the inverted fundus and\n fingertips at the utero-cervical junction. Lifting the uterus above the level\n of the umbilicus creates adequate tension for the cervical ring to dilate and\n for the fundus to revert to its normal position.\n \n National Guideline for Maternal Care - Volume I 43", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_094", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 79, "chunk_size": 496 } }, { "content": "================================================== PAGE 62 ==================================================\nThis could be helped by ‘working the fingers up’ gradually from the cervical\n ring towards the fundus, with gentle but persistent pressure applied.\n \n Where the uterus is too hard to respond, consider tocolytics (see below).\n \n Once reduced, hold the fundus in place for a few minutes (making a fist\n inside the uterus with upward pressure on the fundus helps).\n \n Administer uterotonics (Ergometrine 0.25 mg i.v. or oxytocin 5-10 IU i.v", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_095", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 547 } }, { "content": "Administer uterotonics (Ergometrine 0.25 mg i.v. or oxytocin 5-10 IU i.v\n followed by oxytocin infusion at the rate of 10 IU per hour), whilst the\n hand is still inside. When the uterus begins to contract, slowly remove the\n hand. \n \n This manouvre is possible only soon after the event, and would need\n adequate analgesia. Unless it is possible to administer either a general\n anesthetic immediately, administer pethidine 50 mg iv slow and proceed\n with the maneuvres. \n \n Give antibiotics (e.g. cephradine 1g and metronidazole 500 mg IV).\n \n 7.2.2 Hydrostatc reduction (O’Sullivan 1945)", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_095", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 90, "chunk_size": 588 } }, { "content": "7.2.2 Hydrostatc reduction (O’Sullivan 1945) \n \n Several novel and useful modifications have been made to this procedure\n lately, principally to circumvent the problem of inadequate water seal,\n which has been the major cause of failure in the past.\n \n Insert 6 cm silastic ventouse cup into vagina, making sure that it is directed\n at the posterior vaginal fornix and not at, or cupping the fundus. Place\n hand at introitus to maintain seal between cup and vagina.\n \n (Alternatively 500ml balloon catheter can be placed in vagina. If neither is", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_095", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 545 } }, { "content": "(Alternatively 500ml balloon catheter can be placed in vagina. If neither is\n available, use a wide tube; a standard giving set will not do).\n \n Connect via IV giving set to a bag of warmed normal saline placed 1- 1.5\n metres above the patient. \n \n Infuse normal saline (typically 2 litres) into vagina to reduce the uterus by\n hydrostatic pressure.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_095", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 58, "chunk_size": 349 } }, { "content": "44 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_096", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 63 ==================================================\nOnce reduced, remove the placenta if still attached and proceed as in the\n previous section. \n \n Where a balloon is used, it would be advisable to leave it for 12-24 hours\n to prevent re-inversion and reduce haemorrhage. \n \n Saline embolisation and fluid overload leading to pulmonary oedema are\n only theoretical risks as long as one sticks to hydrostatic pressure only.\n \n 7.2.3 Tocolytics \n \n Where repositioning is difficult due to retraction of the uterine muscle", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_097", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 75, "chunk_size": 578 } }, { "content": "7.2.3 Tocolytics \n \n Where repositioning is difficult due to retraction of the uterine muscle\n and the constriction of the cervical ring, tocolytics could be helpful. But\n given this could cause PPH, it would have to be a considered and a senior\n decision. They are safest given in the theatre setting.\n \n Various preparations have been used; ideally it should be readily available,\n with quick onset and short duration of action. E.g.\n \n Turbutaline 0 .25mg i.v. slowly (not available in Sri Lanka at present);\n \n Salbutamol 0.25mg in 10 ml saline i.v. slowly;", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_097", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 561 } }, { "content": "Salbutamol 0.25mg in 10 ml saline i.v. slowly; \n \n Nitroglycerine 0.1mg i.v. slowly or sublingually (acts within 90 seconds)\n \n 7.2.4 General Anaesthesia \n \n If the initial attempt at manual replacement fails, it is safest to move the\n patient to the theatre and to administer general anaesthesia. This allows\n for muscle relaxation, pain relief and elimination of the neurogenic\n contribution to the shock. \n \n 7.2.5 Surgical methods \n \n If managed properly in the early stages, resort to surgery should be a rare\n occurrence.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_097", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 78, "chunk_size": 527 } }, { "content": "National Guideline for Maternal Care - Volume I 45", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_098", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 64 ==================================================\nHuntingdon’s operation \n \n After a laparotomy, the indrawn uterine cup is identified near the region\n of the cervix with the tubes and round ligaments pulled into the cup. By\n the use of two Allis forceps the uterus is pulled out of the constriction ring\n in a progressive fashion and restored to its normal position. The serosa of\n the uterus will invariably sustain lacerations and these are repaired with\n absorbable sutures.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_099", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 538 } }, { "content": "the uterus will invariably sustain lacerations and these are repaired with\n absorbable sutures. \n \n Use of a silastic vacuum cup from above instead of Allis forceps has been\n shown to circumvent this problem. \n \n Haultain’s operation \n \n In this procedure the constriction in the region of cervix is incised\n posteriorly using a longitudinal incision. As in the Huntingdon’s method\n two Allis forceps are used to pull the uterus to its normal position. The\n incision is repaired with interrupted sutures. Uterotonics are given to\n maintain contraction of the uterus. \n \n Hysterectomy", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_099", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 86, "chunk_size": 583 } }, { "content": "maintain contraction of the uterus. \n \n Hysterectomy \n \n When all the above methods fail, a hysterectomy will become the only\n viable option. However, it must be remembered that given the distorted\n anatomy, this must be undertaken by a surgeon of considerable experience.\n \n \n8. Debriefing \n Although there is no evidence of a recurrence risk, it is sensible to advise\n the woman to deliver in a specialized Unit next time, and the third stage\n to be managed actively by experienced personnel.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_099", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 77, "chunk_size": 494 } }, { "content": "46 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_100", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 65 ==================================================\nManagement of \n \n Hypertensive disease", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_101", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 148 } }, { "content": "National Guideline for Maternal Care - Volume I 47", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_102", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 66 ==================================================\n48 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_103", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 160 } }, { "content": "================================================== PAGE 67 ==================================================\nManagement of Hypertensive Disease in Pregnancy\n \n \n1. Introduction \n \n Hypertension in pregnancy is an important cause of direct maternal deaths\n in Sri Lanka. Early identification, aggressive and intensive treatment of\n its complications is important in reducing the resulting morbidity and\n mortality. \n \n \n2. Definitions \n \n Chronic Hypertension: \n \n Women with pre-existing hypertension or hypertension detected before", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_104", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 56, "chunk_size": 533 } }, { "content": "Chronic Hypertension: \n \n Women with pre-existing hypertension or hypertension detected before\n 20th week of gestation in the absence of trophoblastic disease and\n persisting more than 42 days post partum. \n \n Gestational Hypertension \n \n A) Pregnancy Induced Hypertension: \n \n Hypertension unaccompanied by proteinuria developing after 20 weeks of\n gestation and resolving within 42 days of delivery.\n \n B) Pre Eclampsia: \n \n Pregnancy induced hypertension associated with significant proteinuria\n (300mg/l or 500mg/ 24 hours or dipstick 2+ or more).\n \n Severe Preeclampsia:", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_104", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 73, "chunk_size": 575 } }, { "content": "(300mg/l or 500mg/ 24 hours or dipstick 2+ or more).\n \n Severe Preeclampsia: \n \n Defined as Pre-eclampsia with severe hypertension and/or with symptoms,\n and/or biochemical and/or haematological impairment.\n \n The clinical features of severe pre-eclampsia (in addition to hypertension\n and proteinuria) are:", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_104", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 39, "chunk_size": 307 } }, { "content": "National Guideline for Maternal Care - Volume I 49", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_105", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 68 ==================================================\n• Severe headache \n \n \n• Visual disturbance such as blurring or flashing before eyes,\n scotomas \n \n• Epigastric or hypochondrial pain and/or nausea & vomiting\n \n• Clonus (3 beats or more) \n \n• Papilloedema \n \n• Liver tenderness \n \n \n• Oliguria (less than 400 ml per day or 0.5 mg/Kg/hour over a 4\n hour period) \n \n• Platelet count falling to below 100 x 106/l \n \n• Abnormal liver enzymes (ALT or AST rising to above 70IU/l)\n \n• HELLP syndrome \n \n Severe Hypertension:", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_106", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 577 } }, { "content": "• HELLP syndrome \n \n Severe Hypertension: \n \n Defined as systolic blood pressure ≥ 160 mmHg and/or diastolic blood\n pressure ≥110 mmHg. \n \n Eclampsia: \n \n Defined as the development of convulsions and/or unexplained coma\n during pregnancy or postpartum in patients with features of preeclampsia.\n \n \n3. Screening for Hypertension during pregnancy \n \n Blood pressure must be measured in every clinic visit by a Medical Officer\n and results recorded and plotted in the pregnancy record.\n \n Proteinuria must be tested for at every clinic visit.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_106", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 76, "chunk_size": 541 } }, { "content": "Proteinuria must be tested for at every clinic visit.\n \n If blood pressure is more than 140/90 mmHg on two occasions at least 2\n hours apart, refer for specialist care. \n \n \n4. Prevention of hypertensive disorders in pregnancy\n \n Advise women at high risk of pre-eclampsia to take 75 mg of aspirin daily\n from 12 weeks until delivery of the baby. Women at high risk are:\n \n 50 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_106", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 72, "chunk_size": 424 } }, { "content": "================================================== PAGE 69 ==================================================\nThose with any one of the following risk factors:\n \n \n• Hypertensive disease during a previous pregnancy\n \n• Chronic kidney disease \n \n• Autoimmune disease such as systemic lupus erythematosis or\n antiphospholipid syndrome \n \n• Type 1 or type 2 diabetes \n \n• Chronic hypertension \n \n \n• Multiple pregnancy \n \n Or, any TWO or more of the following \n \n• First pregnancy \n \n• Age 40 years or older \n \n• Pregnancy interval of more than 10 years", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_107", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 550 } }, { "content": "• First pregnancy \n \n• Age 40 years or older \n \n• Pregnancy interval of more than 10 years \n \n \n• Body mass index (BMI) of 35 kg/m² or more at first visit\n \n• Family history of preeclampsia \n \n Contraindications such as allergy, gastritis, peptic ulcer disease must be\n taken into account. \n \n Advice women who have the above risk factors to ensure a higher intake of\n calcium to achieve a daily intake of at least 1000 mg taking into account the\n average intake by Sri Lankan women the recommended supplementation\n level is 600 mg. \n \n \n5. Management of Chronic Hypertension", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_107", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 95, "chunk_size": 575 } }, { "content": "level is 600 mg. \n \n \n5. Management of Chronic Hypertension \n \n Women with chronic hypertension must be managed in specialist units.\n Anticipate the development of superimposed pre eclampsia in these\n women. This combination adds risks to both mother and baby. ACE\n inhibitors should be discontinued in women who are planning pregnancy\n and its use avoided during pregnancy. \n \n Treatment of mild to moderate hypertension \n \n Since there is no consensus on the value of treating mild to moderate\n hypertension, this guideline will not address this issue.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_107", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 554 } }, { "content": "hypertension, this guideline will not address this issue.\n \n National Guideline for Maternal Care - Volume I 51", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_107", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 17, "chunk_size": 111 } }, { "content": "================================================== PAGE 70 ==================================================\n6. Management of Severe Pre-Eclampsia \n \n The basic outline of management \n \n \n• Admit to hospital and inform Consultant \n \n• Observe and monitor \n \n• Control blood pressure \n \n• Prevent seizures \n \n \n• Look for complications – such as HELLP / pulmonary oedema/\n cerebral haemorrhage \n \n• Strict fluid balance \n \n• In utero transfer where necessary and safe \n \n• Timing of Delivery \n \n \n• Continue vigilance post delivery \n \n• Follow up \n \n 6.\n1. General Considerations", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_108", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 579 } }, { "content": "• Continue vigilance post delivery \n \n• Follow up \n \n 6.\n1. General Considerations \n \n• Severe preeclampsia is a life threatening condition.\n \n \n• The only known cure is delivery of the baby. \n \n• The immediate task is to determine the urgency to effect\n delivery. \n \n• Stabilization of the mother’s condition within an acceptable\n time frame prevents maternal complications and may improve\n fetal condition. \n \n• The management has to be individualized depending on the\n clinical condition and available resources. \n \n \n• The dangers will continue into the immediate postpartum\n period. \n 6.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_108", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 592 } }, { "content": "• The dangers will continue into the immediate postpartum\n period. \n 6.\n2. Specific Management \n \n Admit women who have severe preeclampsia and inform the Consultant.\n Treat hypertension if: \n \n• Systolic blood pressure ≥ 160 mmHg, or if \n \n \n• Diastolic blood pressure ≥ 110 mmHg, or if \n \n• Mean arterial pressure ≥ 125 mmHg, \n 52 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_108", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 61, "chunk_size": 380 } }, { "content": "================================================== PAGE 71 ==================================================\nAim to maintain blood pressure at around 130-140/90-100 mmHg.\n \n The main cause of maternal death in severe preeclampsia is poorly\n controlled systolic hypertension causing cerebral haemorrhage.\n \n A rapid fall in maternal blood pressure as a result of antihypertensive\n treatment may cause fetal heart rate abnormalities & compromise,\n especially in growth restricted/compromised fetuses.\n \n Where resources allow, it is recommended to monitor fetal heart with", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_109", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 67, "chunk_size": 571 } }, { "content": "Where resources allow, it is recommended to monitor fetal heart with\n continuous CTG during and for 60 minutes after commencing anti-\n hypertensive therapy. \n \n Aim to stabilize blood pressure before delivery.\n \n 6.2.\n1. Anti-hypertensive drugs \n \n Oral anti hypertensives may be used when the blood pressure is <180/110\n mmHg. Blood pressure must be monitored at 15-minute intervals and\n intravenous anti hypertensives resorted to in case of an adequate response\n is not obtained within 30 minutes. \n \n The commonly used antihypertensive drugs for acute control are given", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_109", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 572 } }, { "content": "The commonly used antihypertensive drugs for acute control are given\n below. One or the other may be used depending on availability and\n familiarity. \n \n 6.2.1.1 Labetalol orally or intravenously \n \n This should be avoided in women with a history of bronchial asthma.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_109", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 40, "chunk_size": 267 } }, { "content": "- 200mg orally stat (only if blood pressure is <180/110 mm Hg)\n - repeated hourly for up to 4 hours \n or \n - 20 mg IV over two minutes \n \n• Record blood pressure after 10 minutes. \n \n \n• If either value is still above 160 mm Hg systolic and/or 110\n mmHg diastolic, give 40 mg iv over 2 minutes.\n \n• Record blood pressure after 10 minutes. \n National Guideline for Maternal Care - Volume I 53", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_110", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 391 } }, { "content": "================================================== PAGE 72 ==================================================\n• If the blood pressure is still above 160 mm Hg systolic and/or\n 110 mmHg diastolic, give hydralazine 10 mg iv. For instructions\n regarding giving a fluid bolus with i.v. hydralazine, see the next\n section of this guideline. \n \n \n• If the blood pressure is still above 160 mm Hg systolic and/\n or 110 mmHg diastolic, start an IV infusion of labetolol,\n starting at 40 mg/hour, doubling dose at half hourly intervals\n as required to a maximum of 160 mg/hour.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_111", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 83, "chunk_size": 568 } }, { "content": "as required to a maximum of 160 mg/hour. \n \n• Where these measures fail, the mother must be moved to a\n high-dependency area or an intensive care unit.\n \n If blood pressure is controlled by the above, continue monitoring the\n blood pressure at 15 minute intervals for 1 hour and at 30 minute intervals\n thereafter. \n \n Additional bolus doses as described above may be administered if the\n blood pressure increases above 160 mmHg systolic and/or 110 mmHg\n diastolic. \n \n 6.2.1.\n2. Hydralazine intravenously: \n \n \n• 5 - 10 mg IV bolus over 2 minutes.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_111", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 548 } }, { "content": "diastolic. \n \n 6.2.1.\n2. Hydralazine intravenously: \n \n \n• 5 - 10 mg IV bolus over 2 minutes. \n \n• This must be accompanied by a fluid bolus of 5ml/kg of 0.9%\n sodium chloride or ringer lactate solution over 30 min, started\n at the same time as iv hydralazine (this helps vasodilatation &\n prevents drastic hypotension). This should not be used in the\n presence of pulmonary oedema. \n \n• Record blood pressure at 15 minute intervals. \n \n• Repeat boluses of 5 - 10 mg IV after a 15 minute interval may\n be given if necessary up to a maximum of 20 mg (the effect of", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_111", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 100, "chunk_size": 563 } }, { "content": "be given if necessary up to a maximum of 20 mg (the effect of\n a single dose can last up to 6 hours). \n \n \n• If the response to above doses is inadequate, give labetolol\n bolus doses as described above. \n \n• If no lasting effect with above boluses, consider an infusion of\n hydralazine 2.0 mg/hour increasing by 0.5 mg/hour as required\n (2-20 mg/hour usually required).", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_111", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 64, "chunk_size": 369 } }, { "content": "54 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_112", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 73 ==================================================\n6.2.1.\n3. Oral Nifedipine \n \n \n• Oral nifedipine may be used where the blood pressure is <\n 180/110 mm Hg, in asymptomatic patients. \n \n• Give 10 mg orally. \n \n \n• Repeat at 20 minute intervals up to a maximum of 40 mg.\n \n• If there is no response proceed to intravenous labetalol or\n hydralazine. \n \n 6.2.\n2. Prevention of convulsions \n \n Magnesium sulphate \n \n \n• Magnesium sulphate is the anticonvulsant of choice.\n \n• It should be given to any woman with features of impending/", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_113", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 83, "chunk_size": 591 } }, { "content": "• It should be given to any woman with features of impending/\n imminent eclampsia (presence of clonus, severe headache,\n visual disturbances, and dizziness). \n \n• The loading dose may be given even when the status of renal\n function is uncertain, since it is unlikely that toxic levels of\n magnesium could be reached with this dose alone.\n \n• Give loading dose of 4 G IV over 10 minutes. There are two\n methods of giving magnesium sulphate intravenously.\n \n o Diluted to a total volume of 20 ml with 0.9% sodium\n chloride solution, given via an infusion pump or ‘manually’.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_113", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 96, "chunk_size": 573 } }, { "content": "chloride solution, given via an infusion pump or ‘manually’.\n o Diluted to a total volume of 80 ml with 0.9% sodium\n chloride solution via a burette \n \n• Immediately after the loading dose, start infusion of 1 G IV per\n hour. Continue this infusion for at least 24 hours after delivery.\n \n• Where there are difficulties with intravenous access, magnesium\n sulphate may be administered intramuscularly. Give 5 G deep\n intramuscularly into each buttock with 1 ml of 2% lignocaine\n in the same syringe. \n \n \n• If intramuscular magnesium sulphate is continued as", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_113", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 90, "chunk_size": 558 } }, { "content": "in the same syringe. \n \n \n• If intramuscular magnesium sulphate is continued as\n maintenance therapy, give 5G to alternate buttocks 4 hourly,\n with 1ml of 2% lignocaine in the same syringe.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_113", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 30, "chunk_size": 189 } }, { "content": "National Guideline for Maternal Care - Volume I 55", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_114", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 74 ==================================================\n• Monitor the mother to ensure hourly urine output of 30 ml per\n hour, respiratory rate >16/ minute, oxygen saturation >90%\n and presence of patellar reflexes. \n \n \n• These should be recorded every 30 minutes. \n \n• Should signs of toxicity appear, the antidote is calcium\n gluconate, 1 G intravenously (10 ml of 10% solution), given\n over 10 minutes. \n \n• Magnesium sulphate may be used safely in women who have\n previously received nifedipine \n \n 6.2.\n3. Fluid Balance", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_115", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 579 } }, { "content": "previously received nifedipine \n \n 6.2.\n3. Fluid Balance \n \n \n• Restrict total fluid intake to 80 ml per hour.\n \n• Accurate recording of fluid balance is essential.\n \n• Selective colloid expansion may be necessary prior to\n pharmacological vasodilatation to prevent maternal\n hypotension and fetal compromise or in oliguria with a low\n central venous pressure. \n \n \n• The volumes of all drugs administered must be taken into\n account and appropriate reduction of the volume of crystalloids\n must be made. \n \n• Colloid (e.g. Hetastarch) should be administered only after", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_115", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 84, "chunk_size": 569 } }, { "content": "must be made. \n \n• Colloid (e.g. Hetastarch) should be administered only after\n discussion with the anaesthetist. \n \n• Diuretics must be restricted to specific instances only e.g. for\n women with pulmonary oedema. \n \n• Avoid non-steroidal analgesia until fluid recovery.\n \n 6.2.\n4. In utero/neonatal transfer: \n \n \n• If a Unit does not have access to HDU/ICU or is unable to\n cope with maternal complications, or with maturity of the\n baby, it may be appropriate to consider antenatal transfer of\n the mother. \n \n• However, maternal safety must not be jeopardised and each", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_115", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 88, "chunk_size": 572 } }, { "content": "the mother. \n \n• However, maternal safety must not be jeopardised and each\n case should be considered on its clinical merits.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_115", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 20, "chunk_size": 125 } }, { "content": "56 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_116", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 75 ==================================================\n• Steps must be taken to bring down blood pressure from very\n high levels (e.g. using nifedipine). \n \n \n• Women with imminent/impending eclampsia must be\n administered a loading dose of magnesium (IM or IV) before\n transfer (see 6.2.2) \n \n• It is recommended that where possible telephone advice is\n obtained from the relevant specialist unit before transfer.\n \n• The patient must be accompanied by a member of staff who is\n capable of dealing with a seizure while the patient in transit.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_117", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 83, "chunk_size": 598 } }, { "content": "capable of dealing with a seizure while the patient in transit.\n The required drugs and equipment must be made available.\n \n• Full details of the case, including treatment given should\n accompany the patient. \n \n 6.2.\n5. Delivery \n \n \n• Urgency of delivery depends on the maternal and fetal\n conditions. \n \n• Either caesarean section or induction of labour is appropriate\n depending on the urgency and favourability of the cervix.\n \n \n• Institute adequate pain relief. Severe preeclampsia is not a\n contraindication for opioid or epidural anaesthesia (see below).", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_117", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 84, "chunk_size": 563 } }, { "content": "contraindication for opioid or epidural anaesthesia (see below).\n It is accepted that epidural anaesthesia helps to bring down the\n blood pressure. \n \n• Spinal or epidural anaesthesia is safe in the presence of a\n platelet count >80,000/dl. \n \n• Maternal condition should be optimised before delivery.\n \n• It is inappropriate to deliver an unstable mother for foetal\n reasons. \n \n• Ergometrine should not be used during the third stage.\n \n 6.2.\n6. Post-delivery \n \n \n• Maintain vigilance as a high proportion of eclamptic seizures\n occur after delivery.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_117", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 553 } }, { "content": "• Maintain vigilance as a high proportion of eclamptic seizures\n occur after delivery. \n \n• High dependency care should be provided as clinically\n indicated.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_117", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 23, "chunk_size": 157 } }, { "content": "National Guideline for Maternal Care - Volume I 57", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_118", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 76 ==================================================\n• Continue close monitoring, including fluid balance, platelets,\n liver enzymes and creatinine until they have returned to\n normal values. \n \n \n• Magnesium sulphate if started should be continued for 24\n hours after the delivery or after the last fit, whichever is later.\n \n• Review anti-hypertensive medication as indicated. Some may\n need to continue oral medication for a few weeks. Methyldopa\n is best avoided following delivery because of its tendency to\n cause depression.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_119", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 75, "chunk_size": 588 } }, { "content": "is best avoided following delivery because of its tendency to\n cause depression. \n \n• Review magnesium sulphate medication as indicated.\n \n 6.2.\n7. Follow up \n \n \n• Inform Public Health Midwife and/or Medical Officer of\n Health. \n \n• Review in 2 weeks (instead of 4 weeks) if discharged on\n antihypertensives. \n \n• Depending on the clinical picture, some patients may need:\n \n o Long term follow up for blood pressure \n o Hematological investigations for conditions such as anti-\n phospholipid syndrome, thrombophilia \n \n• Debrief the patient.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_119", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 79, "chunk_size": 543 } }, { "content": "phospholipid syndrome, thrombophilia \n \n• Debrief the patient. \n \n• Advice preconceptual counseling & check prior to the next\n pregnancy. \n \n• Women may be advised regarding the risk of developing\n hypertensive disease in a future pregnancy as follows:\n \n o Risk of gestational hypertension - 53% (1 in 2)\n o Risk of preeclampsia – 16% (1 in 6) \n o Risk of preeclampsia if she had severe hypertension or\n HELLP syndrome or eclampsia or the birth occurred\n before 34 weeks – 25% (1 in 4); & 55% (1 in 2) if the birth\n occurred before 28 weeks gestation.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_119", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 94, "chunk_size": 552 } }, { "content": "58 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_120", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 77 ==================================================\nManagement of Eclampsia \n \n \n1. Definition: \n \n Eclampsia is defined as the development of convulsions and/or\n unexplained coma during pregnancy or postpartum in patients with\n features of preeclampsia. \n \n \n2. Diagnosis: \n \n \n• Hypertension is considered the hallmark for the diagnosis of\n eclampsia. However, in 16% of the cases hypertension may be\n absent. \n \n \n• Eclampsia is usually associated with proteinuria, but this may\n be absent in 14% of cases.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_121", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 567 } }, { "content": "• Eclampsia is usually associated with proteinuria, but this may\n be absent in 14% of cases. \n \n• Clinical features of imminent eclampsia include:\n Severe frontal headache, \n Visual symptoms (halos, scotomas etc.) \n \n Epigastric or right hypochondrial pain, \n Liver tenderness, \n Clonus (3 beats or more) \n \n \n3. Time of onset of eclampsia \n \n The onset of eclamptic convulsions can be antepartum, intrapartum, or\n postpartum. \n \n Antepartum eclampsia \n Almost all cases (91%) develop eclampsia at or beyond 28 weeks\n \n Postpartum eclampsia", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_121", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 75, "chunk_size": 540 } }, { "content": "Almost all cases (91%) develop eclampsia at or beyond 28 weeks\n \n Postpartum eclampsia \n Although most cases of postpartum eclampsia occur within the first 48\n hours, some cases develop beyond 48 hours, up to 4 weeks postpartum\n (late postpartum eclampsia). In these cases, an extensive neurological\n evaluation is needed to rule out the presence of other cerebral pathology.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_121", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 57, "chunk_size": 375 } }, { "content": "National Guideline for Maternal Care - Volume I 59", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_122", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 78 ==================================================\n4. Comorbidities \n \n \n• Eclampsia is often complicated by comorbidities (Box 1).\n \n• These are more common among women who develop eclampsia\n at earlier periods of gestation. \n \n Box \n1. \n \n \n• Abruptio placentae \n \n• Disseminated intravascular coagulopathy \n \n• Pulmonary oedema \n \n• Acute renal failure \n \n \n• Aspiration pneumonia \n \n• HELLP syndrome (Haemolysis, elevated liver enzymes, low\n platelets)", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_123", "page_number": 2, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 58, "chunk_size": 515 } }, { "content": "5. Prevention \n \n Administration of magnesium sulphate to women with features of\n impending/imminent eclampsia (presence of clonus, severe headache,\n visual disturbances, dizziness) is the only known preventive measure.\n \n \n6. Management \n \n 6.1 General considerations \n \n 6.1.1 The priorities in management are to support respiratory and\n cardiovascular function, prevent injury and further seizures\n and to control hypertension. \n 6.1.2 Magnesium sulphate is the anticonvulsant of choice. It must\n be administered as soon as possible. See section 6.2.2 of the", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_124", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 561 } }, { "content": "be administered as soon as possible. See section 6.2.2 of the\n severe preeclampsia guideline for details. \n 6.1.3 The bolus dose of magnesium sulphate must be given even\n to women with unknown renal function or oliguria/anuria\n since this dose is unlikely to elevate magnesium levels to toxic\n ranges.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_124", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 47, "chunk_size": 301 } }, { "content": "60 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_125", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 79 ==================================================\n6.1.4 Eclampsia dictates delivery (or induction) once the maternal\n condition is stabilized, irrespective of the foetal condition or\n maturity. A decision regarding the mode and time of delivery\n will require to be made early. \n \n 6.1.5 There is no place for prolongation of the pregnancy in these\n women, unless under rare, exceptional circumstances.\n 6.1.6 For details on administration of medications and intravenous\n fluids and care of women receiving magnesium sulphate and", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_126", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 588 } }, { "content": "fluids and care of women receiving magnesium sulphate and\n intravenous antihypertensives, refer the guideline on severe\n preeclampsia. \n \n 6.\n2. During the seizure – \n \n o Turn the patient to a side and support her in that position.\n o Suck out secretions from the mouth. \n o Administer oxygen via a face mask. \n o Most eclamptic seizures resolve spontaneously.\n \n o It is imprudent to diagnose fetal hypoxia based on fetal\n bradycardia during a seizure. This usually recovers\n spontaneously following the seizure \n o Fetal bradycardia persisting beyond 10 minutes following", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_126", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 86, "chunk_size": 574 } }, { "content": "spontaneously following the seizure \n o Fetal bradycardia persisting beyond 10 minutes following\n the seizure should raise suspicion of abruptio placentae.\n \n 6.\n3. As soon as possible following a seizure \n \n o Attempt to establish intravenous access.\n o Obtain blood for full blood count, liver transaminases,\n blood urea, electrolytes and blood for cross-match.\n o Start magnesium sulphate (intravenous bolus and\n infusion or intramuscular – details in guideline on severe\n preeclampsia section 6.2.2.). \n \n o Treat blood pressure as appropriate. \n o Insert an indwelling catheter.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_126", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 81, "chunk_size": 583 } }, { "content": "o Treat blood pressure as appropriate. \n o Insert an indwelling catheter. \n o Monitor respiratory rate, urine output, reflexes, SpO\n2.\n (Please refer the guideline on severe preeclampsia for\n further details). \n \n National Guideline for Maternal Care - Volume I 61", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_126", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 39, "chunk_size": 264 } }, { "content": "================================================== PAGE 80 ==================================================\no Check for comorbidities (Box 1). \n \n o Inform the Consultant and establish a plan of management\n \n 6.\n4. Management of seizures in women receiving magnesium sulphate\n \n 6.4.1 Women developing a seizure while on magnesium sulphate\n \n o 10% of women receiving magnesium sulphate will develop\n a second seizure. \n o Administer magnesium sulphate 2 grams diluted to 10 ml\n with 0.9% sodium chloride solution over 5 minutes.\n o Increase the magnesium sulphate infusion to 2 grams per", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_127", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 590 } }, { "content": "o Increase the magnesium sulphate infusion to 2 grams per\n hour with monitoring as above. \n \n 6.4.2 Women developing more than one seizure while on magnesium\n sulphate \n \n o Call a Neurology team for advice. If one is not available,\n obtain advice from a medical team. \n o Consultant must be informed. \n o Inform the anaesthetic team if still not in an intensive care\n setting. \n \n o Second line anticonvulsants must be considered after\n discussing with anaesthetist. \n o If the woman develops further seizures, consider moving to\n intensive care for neuromuscular paralysis and ventilation.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_127", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 90, "chunk_size": 591 } }, { "content": "intensive care for neuromuscular paralysis and ventilation.\n o These women will require a full neurological evaluation,\n including imaging. \n \n \n7. Delivery \n \n o Eclampsia is not an indication for caesarean section.\n o Consider caesarean section in women who are not in\n labour with a Bishop score below \n7. \n \n o Women who are in labour may be allowed to continue to\n delivery, in the absence of obstetric complications.\n \n 62 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_127", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 74, "chunk_size": 476 } }, { "content": "================================================== PAGE 81 ==================================================\no Labour may be induced where necessary using either\n prostaglandins or amniotomy and oxytocin infusion.\n \n o Epidural or spinal anaesthesia may be administered in\n women with platelet counts above 80,000/cu mm.\n o General anaesthesia is best avoided where possible since it\n increases the risk of aspiration and failed intubation due to\n airway oedema. It is also associated with marked increases\n in systemic and cerebral pressures during intubation and", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_128", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 565 } }, { "content": "in systemic and cerebral pressures during intubation and\n extubation. Women with airway or laryngeal oedema may\n require ‘awake intubation’ under fibre optic observation\n with facilities available for immediate tracheostomy. The\n level of increase in systemic or cerebral pressures may be\n reduced by pretreatment with labetalol or nitroglycerine\n injections. \n \n \n8. Transfer of a woman who has had a seizure to another institution\n \n o In case it is required to transfer a woman who has\n had an eclamptic seizure, this must be done only after", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_128", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 544 } }, { "content": "had an eclamptic seizure, this must be done only after\n administering a bolus of magnesium sulphate. (See section\n 6.2.2 of the severe preeclampsia guideline for details). The\n patient should ideally be accompanied by a doctor and\n emergency drugs/equipment (e.g. Ambu bag) must be\n available. \n \n \n9. Postpartum management \n \n o Continue administration of magnesium sulphate and\n monitoring as described in the guideline on severe\n preeclampsia. \n o Women with abnormal renal function, preexisting\n hypertension and abruption placentae (due to use of larger", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_128", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 79, "chunk_size": 558 } }, { "content": "hypertension and abruption placentae (due to use of larger\n than normal volumes of fluids) are at particularly high\n risk of pulmonary oedema. They will require appropriate\n monitoring \n o Antihypertensive therapy may be changed to oral and\n continued .", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_128", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 38, "chunk_size": 253 } }, { "content": "National Guideline for Maternal Care - Volume I 63", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_129", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 82 ==================================================\n10. Counselling \n \n 10.\n1. Women should be advised that in a subsequent pregnancy:\n \n o The rate of preeclampsia is approximately 25%.\n \n o Rate of eclampsia is 2%. \n o These rates are substantially higher in women who develop\n eclampsia in the second trimester. \n o Taking high-dose calcium from early pregnancy (600 mg\n daily) and aspirin (75 mg daily) may reduce this risk.\n \n 10.\n2. Regarding long term risk of hypertension \n \n o There is no increase of risk in women who were", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_130", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 590 } }, { "content": "2. Regarding long term risk of hypertension \n \n o There is no increase of risk in women who were\n normotensive before the pregnancy. \n o Multigravidae who develop eclampsia may be at high risk.\n \n Acknowledgement: \n \n The following article was used as a resource in developing this guideline:\n Baha M Sibai, Diagnosis, Prevention and Management of Eclampsia.\n Obstetrics & Gynecology, 2005; 105 (2): 402 - \n410.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_130", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 63, "chunk_size": 411 } }, { "content": "64 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_131", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 83 ==================================================\nManagement of Diabetes \n \n during Pregnancy", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_132", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 153 } }, { "content": "National Guideline for Maternal Care - Volume I 65", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_133", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 84 ==================================================\n66 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_134", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 160 } }, { "content": "================================================== PAGE 85 ==================================================\nGuideline for screening, diagnosis and management of\n \n diabetes in pregnant women \n \n \n1. Purpose \n \n The purpose of this guideline is to provide guidance on screening for\n gestational diabetes mellitus (GDM) and the management of pregnancies\n complicated pre-gestational (PGDM) and GDM in the Sri Lankan setting.\n \n \n2. Screening \n \n 2.1 Target groups for screening \n \n Being South Asian and pregnant places a woman in Sri Lanka at a higher", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_135", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 552 } }, { "content": "Being South Asian and pregnant places a woman in Sri Lanka at a higher\n risk for diabetes during pregnancy. Therefore, universal screening, using a\n diagnostic test is recommended for all Sri Lankan women.\n \n A. All pregnant women should be screened for diabetes at the\n first visit unless they are already known to have Diabetes*. This\n should be performed as early as possible, preferably before 12\n weeks, in order to diagnose previously undetected diabetes.\n B. Screening using fasting blood glucose, random blood glucose,\n 50g glucose challenge test, HBA or urinalysis for reducing\n IC", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_135", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 92, "chunk_size": 590 } }, { "content": "50g glucose challenge test, HBA or urinalysis for reducing\n IC \n substances is not recommended. \n C. Those who are negative for diabetes at the first visit should be\n screened for GDM again at 24-28 weeks. \n D. Women who are known diabetics should not undergo further\n screening or diagnostic tests. They should be commenced\n on glycaemic control measures immediately under the\n supervision of obstetrician or physician. \n *Diagnostic criteria for pre pregnancy diabetes are\n any one of the following \n \n FBS ≥126mg/dl \n RBS >200mg/dl \n \n HbA1c >6.1%", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_135", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 550 } }, { "content": "any one of the following \n \n FBS ≥126mg/dl \n RBS >200mg/dl \n \n HbA1c >6.1% \n \n National Guideline for Maternal Care - Volume I 67", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_135", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 20, "chunk_size": 129 } }, { "content": "================================================== PAGE 86 ==================================================\n2.2 Recommended tests \n \n A. One stage, non- fasting 75g OGCT as described by the\n Diabetes in Pregnancy Study Group of India (DIPSI) is\n recommended for screening at the first visit and at 28 weeks.\n A 2- hour blood glucose of more than 140mg/dl confirms\n gestational diabetes. This is the recommended test for both\n field and institutional levels.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_136", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 61, "chunk_size": 459 } }, { "content": "One stage Non- fasting 75 g OGCT \n \n In this method 75g oral glucose load is given to the woman\n irrespective of the fasting status. Therefore a woman could be\n subjected to a GTT at any time, without the woman having to\n fast.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_137", "page_number": 2, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 42, "chunk_size": 227 } }, { "content": "A load of 75g of glucose dissolved in 300 ml water is given over\n 3-5 minutes. The water may be flavoured with lime juice.\n \n The plasma glucose level is measured after a period of two\n hours. \n \n (The main advantage of this test is that it would be the best way to\n \n ensure universal screening. The advantages include reduced cost, the\n ability to make a diagnosis in one test and the woman not requiring\n to fast for the test. The test has been validated against the WHO and\n HAPO criteria and been found to correlate well with them (3),(4).", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_138", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 98, "chunk_size": 544 } }, { "content": "HAPO criteria and been found to correlate well with them (3),(4).\n Data also shows that glucose levels are not significantly affected by\n the fasting status and that the non-fasting glucose level effectively\n predicts adverse effects for the mother and baby (5),(6).)", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_138", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 41, "chunk_size": 267 } }, { "content": "B. Three-point oral GTT - In the event of an equivocal screening\n result or when resources permit, the three point OGTT is\n recommended. For those who undergo three point OGTT the\n following cut off should be used for diagnosis.\n \n 68 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_139", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 48, "chunk_size": 282 } }, { "content": "================================================== PAGE 87 ==================================================\nThree-point oral GTT \n \n This is probably the most accepted diagnostic test in the world\n today. \n \n The woman should attend for the test having fasted for eight hours\n or more, having had a diet unrestricted in carbohydrates.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_140", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 40, "chunk_size": 336 } }, { "content": "Blood is first drawn for estimation of fasting plasma glucose.\n \n The woman is then given a solution of 75 G glucose dissolved in\n 300 ml of water to be taken within 10 minutes. Squeezing a lime\n into this water will make the solution more palatable without\n interfering with the result.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_141", "page_number": 2, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 50, "chunk_size": 287 } }, { "content": "Blood is then drawn at 60 and 120 minutes for estimation of\n plasma glucose. \n \n C. In situations where neither of the above tests is possible,\n (Inability to tolerate glucose or non availability of facilities)\n two-stage screening using a 2 hour PPBS is an alternative. The\n cut off blood glucose value to refer for a OGTT is ≥120mg/dl.\n \n 2 hour Post Prandial Blood Glucose Testing (PPBS)\n \n Advice the woman to have normal diet", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_142", "page_number": 2, "content_type": "medication_dosage", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 430 } }, { "content": "The time of starting the meal needs to be noted. The meal should\n be completed within 15 minutes. \n \n The two-hour cut off is calculated from the time of starting the\n meal. \n \n At the end of two hours blood sample should be tested for blood\n sugar levels using glucometer or other laboratory method.\n \n National Guideline for Maternal Care - Volume I 69", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_143", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 61, "chunk_size": 354 } }, { "content": "================================================== PAGE 88 ==================================================\n3. Management – Women with established Diabetes \n \n 3.\n1. Pre Pregnancy care \n \n The importance of avoiding unplanned pregnancy is an essential\n component of diabetes education for women with diabetes.\n \n Women with diabetes who are planning to become pregnant and their\n families should be offered information on how diabetes affects pregnancy\n and how pregnancy affects diabetes. \n \n Discuss their plans for pregnancy and reinforce an appropriate", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_144", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 68, "chunk_size": 558 } }, { "content": "Discuss their plans for pregnancy and reinforce an appropriate\n contraceptive method. Any type of contraception can be used except for\n women BMI > 25kg/m2 where DMPA should not be used. Pregnancy is\n contraindicated if the woman has proliferative retinopathy, stage 2 or\n above Chronic kidney Disease or major cardiac disease.\n \n All women with diabetes wishing to conceive MUST be encouraged to\n seek specialist advice to ensure satisfactory glycaemic control (HbA1C <\n 6.1%) before conception. \n \n Ideally the decision to embark on pregnancy in known diabetics should be", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_144", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 86, "chunk_size": 573 } }, { "content": "Ideally the decision to embark on pregnancy in known diabetics should be\n decided on based on her HbA1C . A value of 6.1 or below would be ideal\n if safely achievable. Women whose levels are above 10% should be strongly\n advised against conception until good glycaemic control is achieved, in\n view of higher risk of congenital anomalies. \n \n Stress that good planning and control will help to achieve pregnancy\n outcome to be equivalent to that of a non-diabetic women. They should\n be informed that establishing good glycaemic control before conception", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_144", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 89, "chunk_size": 554 } }, { "content": "be informed that establishing good glycaemic control before conception\n and maintaining this throughout pregnancy will reduce the risk of\n miscarriage, congenital malformation, still births and neonatal deaths.\n \n Women who are using either metformin or insulin for glycaemic control\n should be advised that these are safe for use during the peri-conception\n period and into their pregnancy. \n \n Self-testing of blood sugar should be encouraged where ever economically\n feasible. \n \n 70 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_144", "page_number": 2, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 75, "chunk_size": 534 } }, { "content": "================================================== PAGE 89 ==================================================\nWomen must be encouraged to achieve a normal weight before becoming\n pregnant, especially those with a body mass index above 25 kg/m\n2. They\n must receive advice about reducing weight using lifestyle modification.\n \n Known diabetics should be assessed for diabetic nephropathy and\n retinopathy before and during pregnancy. (see below)\n Start Folic acid 5 mg daily when trying to conceive.\n \n 3.\n2. Antenatal Care \n \n At the first visit", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_145", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 545 } }, { "content": "3.\n2. Antenatal Care \n \n At the first visit \n \n \n• Refer for specialist care immediately once identified. These\n women are best managed with combined inputs from a\n physician and an obstetrician. \n \n \n• Start/ continue Folic acid 5 mg daily up-to 12 weeks of\n gestation. Change to 1mg daily from 12 weeks onwards.\n \n• Low dose Aspirin 75mg should be commenced, if there is no\n contraindication. \n \n• Check HbA1c (ideally 6.1% or less). \n \n• Dating ultrasound scan using either crown rump length or\n head circumference is recommended.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_145", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 85, "chunk_size": 533 } }, { "content": "• Dating ultrasound scan using either crown rump length or\n head circumference is recommended. \n \n• Women with pre-existing diabetes mellitus must be screened\n for diabetic end-organ damage (retinopathy, nephropathy and\n cardiovascular disease) \n \n \n• Retinopathy screening is recommended at least twice during\n pregnancy (at first contact and at 28 weeks).\n \n• Women with serum creatinine >120 µmol/litre or 24 hour\n urinary protein excretion exceeding 300mg must be referred\n for renal specialist’s advice. \n \n• Women with complicated diabetes should be managed at a", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_145", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 81, "chunk_size": 568 } }, { "content": "for renal specialist’s advice. \n \n• Women with complicated diabetes should be managed at a\n tertiary care institution by a multidisciplinary team\n \n Antenatal Appointments \n \n \n• These women must be identified as high risk and managed\n almost entirely by a specialist Obstetrician led team.\n \n National Guideline for Maternal Care - Volume I 71", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_145", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 51, "chunk_size": 344 } }, { "content": "================================================== PAGE 90 ==================================================\n• Public Health Midwife should visit such women once in every\n 2 weeks (refer guideline on domiciliary care for high risk\n pregnancies). \n \n \n• Review by the obstetric/diabetic team once every 2 weeks\n throughout the pregnancy \n \n• Anomaly scans at 18-20 weeks and Obstetric reviews at 22-24,\n 28, 32 and 36-37 weeks with ultrasound growth assessments.\n \n• If required, antenatal steroids for fetal lung maturity may be\n used. Women should be admitted to hospital for glycaemic", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_146", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 587 } }, { "content": "used. Women should be admitted to hospital for glycaemic\n control during therapy since glucose levels rise in response to\n steroids. \n \n• More attention should be given to the woman with diabetes\n during antenatal preparation for breast feeding as they\n need to start and establish breast feeding quickly to prevent\n hypoglycaemia of newborn. \n \n• Refer to dental surgeon for screening and maintenance of oral\n hygiene. \n \n 3.\n3. Medical nutrition therapy (MNT) \n \n MNT is the cornerstone of the management of diabetes in pregnancy.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_146", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 532 } }, { "content": "MNT is the cornerstone of the management of diabetes in pregnancy.\n Women must be referred to a dietician/ diabetic educator nurse where\n one is available. \n \n Emphasis the importance of small frequent meals, food with low glycaemic\n index and the dietary advice should be culture sensitive.\n \n 3.\n4. Exercise \n \n Exercise has an insulin-like action and women with GDM and pre-existing\n diabetes complicating pregnancy. Therefore, diabetic women must be\n encouraged to engage in regular exercise. \n \n The intensity of exercise would depend on the woman’s level of fitness,", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_146", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 572 } }, { "content": "The intensity of exercise would depend on the woman’s level of fitness,\n presence of complications and familiarity with exercise.\n \n Ideally this should be at least 30 minutes per day of an activity, which\n leaves her slightly breathless. \n \n 72 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_146", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 46, "chunk_size": 293 } }, { "content": "================================================== PAGE 91 ==================================================\nWomen on insulin must be aware of the tendency to hypoglycaemia\n during exercise. \n \n \n4. Glyceamic control and Monitoring \n \n 4.\n1. Glyceamic Control \n \n 4.1.\n1. The aim is to achieve optimum glycaemic control throughout the\n day for the duration of the pregnancy (avoiding hypoglycaemia).\n \n The target values for glycaemic control are given below:\n \n Table \n1. Target values in glycemic control \n \n Fasting and pre-meal 2 hour post meal", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_147", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 549 } }, { "content": "Table \n1. Target values in glycemic control \n \n Fasting and pre-meal 2 hour post meal\n \n Venous plasma 70 - 90 (3.9 – 5.0 mMol/L) Below 120 mg/dl (6.7 mMol/L)\n Capillary blood 80 – 103 (4.4 – 5.7 mMol/L) 118 mg/dl (6.5 mMol/L)\n \n (The equivalent capillary blood values were derived using a conversion\n formula7) \n \n Refer to Diabetic Educator Nursing Officer (DENO) where one is available.\n At diagnosis, offer diet/ lifestyle advice with a recorded glycaemic\n assessment within 1-2 weeks. \n \n Majority of these women can achieve optimal glycaemia with modest\n changes in diet and exercise.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_147", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 92, "chunk_size": 590 } }, { "content": "changes in diet and exercise. \n \n Consider insulin and /or metformin treatment if suboptimal glycaemia\n persists despite diet and exercise modifications. The choice of these\n treatments will depend on physician and patient preferences.\n \n Ideally the insulin regimen should be adjusted to achieve targets: in most\n cases with moderate to severe hyperglycaemia three doses of short acting\n pre prandial insulin combined with a single dose of basal insulin at bed\n time is required. However, twice daily dose of pre mixed 30:70 insulin", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_147", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 80, "chunk_size": 533 } }, { "content": "time is required. However, twice daily dose of pre mixed 30:70 insulin\n has high patient compliance with adequate control of blood sugar in most\n cases. If blood sugar is not controlled by this twice daily regimen, adding\n metformin or soluble insulin to cover lunch is an alternative.\n National Guideline for Maternal Care - Volume I 73", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_147", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 56, "chunk_size": 337 } }, { "content": "================================================== PAGE 92 ==================================================\nACE inhibitors, statins and ARBs are contraindicated during pregnancy\n \n 4.\n2. Monitoring of glycaemic control \n \n Self-monitoring of blood glucose (SMBG) with close liaison with the\n diabetic team is recommended for those who are able to afford a glucometer\n and test strips. (However, in view of variable quality of glucometers women\n must be advised to crosscheck the values occasionally with estimations\n made by a reliable laboratory.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_148", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 549 } }, { "content": "made by a reliable laboratory. \n \n For women who cannot afford the cost of SMBG, monitoring with regular\n 6 point blood glucose monitoring should be offered. \n \n The frequency of such monitoring should be decided by the overall\n glyceamic control, presence or absence of fetal macrosomia and the period\n of gestation;: with at least four weekly reviews in pregnancy two weekly\n reviews in late pregnancy \n \n Schedule ultrasound measurement of AC at 28, 32 and 36 weeks. If AC >\n 90 centile at any stage, consider insulin therapy to target 2 hour PPBS to", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_148", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 91, "chunk_size": 553 } }, { "content": "90 centile at any stage, consider insulin therapy to target 2 hour PPBS to\n be less than 100mg/dl but avoiding hypoglycaemia. \n \n If crossing centiles or AC <10 centile, do AFI and request obstetrician\n review. \n \n Insulin requirements change throughout the pregnancy. If requirements\n are falling (or maternal hypoglycaemia occurs frequently) request early\n obstetrician review for fetal assessment. \n \n HbA1c is not a reliable indicator of glycaemic control in the second\n and third trimesters. \n \n \n5. Delivery and intra natal care \n \n 6.\n1. Timing of delivery", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_148", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 563 } }, { "content": "and third trimesters. \n \n \n5. Delivery and intra natal care \n \n 6.\n1. Timing of delivery \n \n For women with pre-pregnancy diabetes or who receive insulin therapy,\n schedule obstetrician review at 36-37 weeks for planning their delivery at\n 38-39 weeks. \n \n 74 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_148", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 46, "chunk_size": 307 } }, { "content": "================================================== PAGE 93 ==================================================\nFor women on diet control and/or women having optimal glycaemic\n control and, carrying a normally grown baby, there is insufficient evidence\n to suggest the best time for delivery. \n \n Diabetes alone is not an indication for a caesarean section.\n \n The obstetrician should make the decision after discussing with the\n woman. \n \n Delivery should be arranged in the day time, when all supports are more\n easily available. \n \n 5.\n2. Labour care", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_149", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 551 } }, { "content": "easily available. \n \n 5.\n2. Labour care \n \n Second tier obstetric on-call (SHO/Registrar) should be informed of any\n woman with diabetes at the onset of labour. He/she should be present\n for the delivery. It is recommended to involve the medical team in the\n management of difficult cases. \n \n Inform on-call neonatal team of any planned/ imminent delivery of a\n diabetic mother. \n \n During labour and birth, capillary blood glucose should be monitored\n 1-2 hourly in women with diabetes and maintained at between 4 and 7\n mmol/litre. (72 – 126 mg/dl). These CBG records should be entered in the", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_149", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 94, "chunk_size": 595 } }, { "content": "mmol/litre. (72 – 126 mg/dl). These CBG records should be entered in the\n partogram. \n Hartmann’s/ normal saline or Insulin-dextrose – potassium (GIK)\n infusion should be started if the values are lower or higher respectively.\n \n \n6. Post natal care \n \n 6.1a. Neonatal care \n \n Handover care of newborn, to neonatal team. \n \n Ensure delivery-to-abdomen and initiate breastfeeding as early as possible\n (within first ½ to 1 hour) unless specific concerns prevent such action.\n \n Take all suitable ENC measures to avoid hypothermia.\n \n National Guideline for Maternal Care - Volume I 75", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_149", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 584 } }, { "content": "================================================== PAGE 94 ==================================================\nBlood glucose testing should be carried out routinely in babies of women\n with diabetes at 2–4 hours after birth. The mother must be informed about\n this antenatally to avoid unnecessary distress. \n \n Neonatal blood glucose values below 36 mg/dl (2 mMol/L) should trigger\n action. \n \n Blood tests for polycythaemia, hyperbilirubinaemia, hypocalcaemia and\n hypomagnesaemia should be carried out for babies with clinical signs.\n \n 6.1b. Immediate post partum care", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_150", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 571 } }, { "content": "6.1b. Immediate post partum care \n \n It is recommended that the mother be tested for RBS within 4 hours of\n delivery. The decision to manage maternal diabetes with insulin or oral\n medication should be made within the first 48 hours after delivery and\n prior to discharge from hospital. \n \n If the mother received insulin in the antenatal period, it is recommended\n that the dose needs adjustments to pre pregnant doses in those with type\n 2 diabetes mellitus or be maintained on diet alone in those with GDM.\n This decision should be based on her post partum blood glucose value. If", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_150", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 98, "chunk_size": 583 } }, { "content": "This decision should be based on her post partum blood glucose value. If\n FBG exceed 126mg/dl or RBS exceeds 200mg/dl, insulin in a lower dose\n (usually half of the antenatal dose) or metformin would be required. This\n decision is best left to the managing physician who should be responsible\n for the woman’s long term care. \n \n 6.\n2. At hospital discharge \n \n Inform MOH and area public health midwife (PHM) through woman’s\n pregnancy record. \n \n For women with pre- gestational diabetes, prescribe suitable hypoglycaemic", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_150", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 81, "chunk_size": 523 } }, { "content": "pregnancy record. \n \n For women with pre- gestational diabetes, prescribe suitable hypoglycaemic\n agent, restart statins, schedule follow up clinic date at the medical clinic.\n For women who developed GDM, give a date or make arrangements to\n screen for DM at 6 weeks postpartum. \n \n Discuss and help to decide on the suitable contraceptive method.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_150", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 52, "chunk_size": 348 } }, { "content": "76 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_151", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 95 ==================================================\n6.\n3. Late Postnatal care and follow up \n \n At 6 -8 weeks postpartum, all women with GDM are screened for diabetes\n mellitus. The test of screening is ideally the 75g OGTT. FBS is an alternative\n if resources are limited. Women whose fasting venous plasma glucose is\n above 100 mg/dl (5.5 mMol/L) must be referred for further evaluation.\n \n Women who have been diagnosed with GDM and are screen-negative at\n the 6 week review should receive lifestyle advice and screening for diabetes", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_152", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 594 } }, { "content": "the 6 week review should receive lifestyle advice and screening for diabetes\n mellitus annually with at least a FBS. The importance of maintaining a\n normal BMI and the contribution of breastfeeding to weight loss must be\n emphasized. \n \n \n7. Family Planning \n \n 8.1 All reliable methods of family planning can be used as\n appropriate for the needs of the individual woman with\n diabetes. \n 8.2 For women with BMI >25kg/m2, DMPA is best avoided.\n 8.3 Women with type 2 diabetes should be advised to complete\n their family within 5-10 years of diagnosis of diabetes in view", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_152", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 93, "chunk_size": 572 } }, { "content": "their family within 5-10 years of diagnosis of diabetes in view\n of possible development of complications. \n \n References (need to add the sections taken from NIROGI guide)\n \n \n1. NICE, clinical guideline 63 Diabetes in pregnancy: management\n of diabetes and its complications from pre-conception to the\n postnatal period. 2008, National Institute for Health and\n Clinical Excellence. \n \n2. Seshiah V., Das AK.,BalajiV et al., Gestational Diabetes Mellitus\n - Guidelines. Journal of the Association of Physicians of India.\n \n2006. 54: 622- 628", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_152", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 78, "chunk_size": 543 } }, { "content": "- Guidelines. Journal of the Association of Physicians of India.\n \n2006. 54: 622- 628 \n \n3. IADPSGCP, International Association of Diabetes and\n Pregnancy Study Groups Recommendations on the Diagnosis\n and Classification of Hyperglycemia in Pregnancy. Diabetes\n Care, \n2010. 33(3): p. 676-\n682. \n \n \n4. Kuhl C. Insulin Secretion and insulin resistance inpregnancy\n and GDM. Implications for diagnosis andmanagement.\n Diabetes 1991;40(December (Suppl. 2)):18–\n24.\n National Guideline for Maternal Care - Volume I 77", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_152", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 70, "chunk_size": 514 } }, { "content": "================================================== PAGE 96 ==================================================\n5. Gough WW, Shack MJ, Bennett PH, Burch TA, Miller\n M.Evaluation of glucose in the Pima Indians by longitudinal\n studies. Diabetes 1970;19(Suppl. 1):\n388. \n \n \n6. Pettitt DJ, Bennett PH, Hanson RL, Narayan KM, KnowlerWC.\n Comparison of World Health Organization and National\n Diabetes Data Group procedures to detect abnormalities\n of glucose tolerance during pregnancy. Diabetes Care\n 1994;17(November (11)):1264–\n8. \n \n7. Haeckel R., Brinck U, Colic D. et al., Comparability of Blood", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_153", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 596 } }, { "content": "8. \n \n7. Haeckel R., Brinck U, Colic D. et al., Comparability of Blood\n Glucose Concentrations Measured in Different Sample Systems\n for Detecting Glucose Intolerance. Clinical Chemistry \n2002. 48:\n (6); 936-\n939.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_153", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 31, "chunk_size": 213 } }, { "content": "78 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_154", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 97 ==================================================\nManagement of \n \n Postparum Haemorrhage", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_155", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 149 } }, { "content": "National Guideline for Maternal Care - Volume I 79", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_156", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 98 ==================================================\n80 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_157", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 160 } }, { "content": "================================================== PAGE 99 ==================================================\nGuideline on Managementof Primary post Partum\n Haemorrhage \n \n \n1. Introduction \n \n The aim of this guideline is to provide evidence based recommendations\n in the management of primary post partum haemorrhage (PPH). This is\n the commonest direct cause of maternal death globally and in Sri Lanka.\n The objective of this guideline is to ensure anticipation, prevention, early\n detection and timely and appropriate management of PPH.\n \n \n2. Definition", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_158", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 68, "chunk_size": 559 } }, { "content": "detection and timely and appropriate management of PPH.\n \n \n2. Definition \n \n For the purpose of this guideline PPH is defined as blood loss of 500 ml or\n more from the genital tract within 24 hours of the birth of a baby. Blood\n loss of over 1000 ml is defined as major PPH. \n \n Irrespective of blood loss, the appearance of cardiovascular instability (i.e.\n tachycardia and hypotension) signifies major obstetric hemorrhage.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_158", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 68, "chunk_size": 426 } }, { "content": "• Since blood volume differs between persons, blood loss must\n be individualized. \n In general, blood volume = body weight in Kg÷12 (e.g. in a 60\n kg woman 60/12 = 5 litres) \n \n \n• The loss of 40% or more of the blood volume is life threatening\n and will be defined as a massive obstetric hemorrhage e.g.\n 2400 ml in a 60 Kg woman. \n \n \n3. Prevention of Post Partum Haemorrhage \n \n Active management of the third stage of labour is the cornerstone\n of prevention of primary PPH. For details please refer guideline on\n management of third stage of labor.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_159", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 96, "chunk_size": 553 } }, { "content": "management of third stage of labor. \n \n Anemia in pregnancy should be corrected during antenatal period.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_159", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 15, "chunk_size": 104 } }, { "content": "National Guideline for Maternal Care - Volume I 81", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_160", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 100 ==================================================\n4. Prediction of Post Partum Haemorrhage \n \n PPH occurs most often in women without risk factors. Therefore the\n blood group of every woman who goes into labor must be known.\n \n However, there are known risk factors associated with PPH, as listed in\n Box \n1. Such women should be advised to deliver in a specialist obstetric\n unit under extra vigilance. Out of these, abruptio placentae and placenta\n praevia have a particularly higher risk. \n \n Box 1 \n \n Risk Factors for PPH", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_161", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 587 } }, { "content": "praevia have a particularly higher risk. \n \n Box 1 \n \n Risk Factors for PPH \n \n Risks existing prior to labour \n Grand multiparity \n \n Previous PPH \n Fibroids complicating pregnancy \n \n Anaemia complicating pregnancy \n Pre-existing haemorrhagic conditions \n \n Treatment with anticoagulants \n Obesity \n \n Pre-eclampsia/gestational hypertension \n Uterine over distension e.g. multiple pregnancy, etc.\n \n Large baby (>4 kg) \n Chorio-amnionitis \n \n Dengue infection", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_161", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 50, "chunk_size": 461 } }, { "content": "Any woman with risk factors should have intravenous access established\n with either a 16 or 14-gauge cannula and a sample of blood taken and\n preserved.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_162", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 25, "chunk_size": 152 } }, { "content": "82 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_163", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 101 ==================================================\n5. Management of Primary PPH \n \n In Sri Lanka, the usual practice has been to commence treatment when\n there is continuing bleeding despite uterine massage irrespective of the\n amount of blood lost. It is recommended that this practice be continued.\n \n It is good practice to estimate and record blood loss in all deliveries.\n \n 5.1 General measures \n \n \n• Call for help. \n \n \n• Maintain a calm atmosphere. \n \n• Keep the mother (and labor companion/family) informed and", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_164", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 77, "chunk_size": 580 } }, { "content": "• Maintain a calm atmosphere. \n \n• Keep the mother (and labor companion/family) informed and\n reassure the mother regularly. \n \n• Assess, monitor and record: general condition, estimated\n blood loss, pulse, blood pressure and respiratory rate (every 15\n minutes) \n \n• Insert a Foley catheter and monitor urine output hourly.\n \n• Commence an ongoing chronological record of patient’s\n condition and interventions. It is recommended that one\n member of staff is delegated specifically for this task and to\n coordinate with other relevant disciplines.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_164", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 79, "chunk_size": 548 } }, { "content": "coordinate with other relevant disciplines.\n \n \n• Ensure there is intravenous access with two wide (14 – 16 G)\n bore cannulae. \n \n• Send blood for cross matching and baseline full blood count.\n In cases of massive haemorrahge, other investigations such as\n clotting profile will be needed. \n \n• Start Ringer’s lactate (Hartmann’s) solution.\n \n• Identify the cause of bleeding. \n \n \n• Keep the woman warm. \n \n• Pay attention to the temperature of labor room, operating\n theatre, intravenous fluids, blood, blood products and\n fluids used for lavage. Hypothermia is known to promote\n coagulopathy.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_164", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 89, "chunk_size": 595 } }, { "content": "fluids used for lavage. Hypothermia is known to promote\n coagulopathy. \n \n• Where available, the early involvement of the anesthetic team,\n even while the patient is still in the labor room is recommended.\n \n National Guideline for Maternal Care - Volume I 83", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_164", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 41, "chunk_size": 259 } }, { "content": "================================================== PAGE 102 ==================================================\n• Give oxygen via a face mask at a minimum rate of 8L/minute\n (where suitable masks are available, oxygen must be given at a\n rate of10-15L/min). \n \n \n• If deterioration of the patient is greater than expected for the\n visible blood loss, internal hemorrhage is the probable cause.\n \n• Check for completeness of the placenta. If incomplete or in\n doubt consider exploration of the uterus under anesthesia.\n \n• The Consultant must be informed in the situations listed in\n Box \n2. \n \n Box", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_165", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 597 } }, { "content": "• The Consultant must be informed in the situations listed in\n Box \n2. \n \n Box \n2. Situations in which the Consultant must be informed\n \n \n1. Blood loss of >1000 ml \n \n2. Pulse rate of >100/minute \n \n3. Systolic blood pressure <100 mm Hg \n \n \n4. Drop of systolic blood pressure by 30 mmHg \n \n5. Increase of pulse rate by >30 beats/minute \n \n6. Increasing fundal height \n \n7. Deterioration of the patient out of proportion to the overt\n blood loss. \n \n 5.2 Specific measures \n \n 5.2.1 Establish a cause for the bleeding \n \n Palpate the uterine fundus.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_165", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 550 } }, { "content": "5.2.1 Establish a cause for the bleeding \n \n Palpate the uterine fundus. \n \n A poorly contracted uterus usually indicates atonic PPH, which is the\n commonest cause. However, the possibility of concomitant genital tract\n trauma needs to be considered. \n \n If the uterus is well contracted, the genital tract must be inspected for\n trauma with adequate exposure, in good light.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_165", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 56, "chunk_size": 375 } }, { "content": "84 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_166", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 103 ==================================================\n5.2.\n2. Management of atonic haemorrhage \n \n \n• Start uterine massage by ‘rubbing up the fundus’.\n \n \n• Clear the cervical canal and vagina of blood clots by vaginal\n examination. \n \n• Administer either ergometrine maleate 0.5 mg slow IV or\n methyl ergometrine 0.2 mg slow IV or oxytocin 5 IU IV and\n start an infusion of 40 IU in 500 ml of Hartmann’s solution at\n 125 ml per hour via an infusion pump. \n \n• Start bimanual compression of uterus.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_167", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 556 } }, { "content": "125 ml per hour via an infusion pump. \n \n• Start bimanual compression of uterus. \n \n• If the bleeding fails to abate completely in 5- 10 minutes\n administer/repeat ergometrine 0.5mg IV. \n \n• If the bleeding fails to abate completely in a further 10 minutes\n administer misoprostol 800µg per rectally or sublingually.\n \n \n• If the bleeding fails to abate completely in a further 10 minutes\n proceed to uterine balloon tamponade and inform the\n Consultant. At the same time, administer tranexamic acid 1\n g by slow IV over 10 minutes. This dose may be repeated after", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_167", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 93, "chunk_size": 564 } }, { "content": "g by slow IV over 10 minutes. This dose may be repeated after\n 30 minutes if necessary and later if bleeding recommences.\n For details of the method of balloon tamponade please refer\n appendix \n1. \n \n• Balloon tamponade is an important step in managing patients\n who continue to bleed despite medical measures. It should\n always be considered before resorting to surgical measures.\n \n• If the institution does not have personnel trained in the use\n of balloon tamponade, the woman must be transferred to a\n higher institution, at the point where the administration of", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_167", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 92, "chunk_size": 567 } }, { "content": "higher institution, at the point where the administration of\n ergometrine and oxytocin infusion has failed to stop bleeding.\n \n• Temporizing measures such as manual aortic compression and\n sand bags to compress the uterus are recommended while the\n patient is in transit. \n \n \n• Inform the receiving institution. \n \n• After the balloon is inserted and the vagina packed (to keep\n the balloon in the uterus), the woman’s vital parameters and\n the level of the fundus must be monitored carefully. Where\n these indicate the woman is continuing to bleed, she should", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_167", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 88, "chunk_size": 561 } }, { "content": "these indicate the woman is continuing to bleed, she should\n \n National Guideline for Maternal Care - Volume I 85", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_167", "page_number": 3, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 4, "word_count": 19, "chunk_size": 113 } }, { "content": "================================================== PAGE 104 ==================================================\nbe moved to the theatre, since the situation would indicate the\n need for a laparotomy. \n \n \n• She should be shifted to the theatre without delay in this\n situation. \n \n• Prior to laparotomy the woman must be examined under\n anesthesia for tears in the genital tract. \n \n• In case laparotomy is needed it is best to keep the patient in\n the modified Lloyd Davis position so that observations for\n bleeding could be done with minimum inconvenience and\n delay.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_168", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 569 } }, { "content": "bleeding could be done with minimum inconvenience and\n delay. \n \n• The surgical measures would depend on the woman’s condition.\n “Too little too late” is the main contributor to mortality in\n PPH. Surgical measures include brace (compression) sutures\n (see appendix 2), uterine de-vascularization (See appendix\n 3), haemostatic mattress sutures to bleeding sinusoids, box\n sutures to include the bleeding lower segment in placenta\n previa, internal iliac ligation and hysterectomy.\n \n• The “sandwich technique” involves inserting a balloon\n tamponade after the application of brace sutures.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_168", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 590 } }, { "content": "tamponade after the application of brace sutures.\n \n \n• It is important that hysterectomy is resorted to sooner than\n later. \n \n• Hypothermia is a particular risk in the theatre environment.\n Measures must be taken to minimize the loss of heat from the\n woman. \n \n 5.2.3 Management of traumatic PPH \n \n \n• Exclude high vaginal and cervical tears before suturing\n episiotomy. \n \n• When the apex of the tear or episiotomy is not visible, apply a\n suture at the highest visible point, pull downwards and apply\n continuous sutures at progressively higher points until the\n apex is reached.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_168", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 92, "chunk_size": 585 } }, { "content": "continuous sutures at progressively higher points until the\n apex is reached. \n \n• Examine for paravaginal and broad ligament haematomata\n with a combined per vaginal and per rectal examination.\n \n \n• The management should be individualized according to the\n situation. \n 86 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_168", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 47, "chunk_size": 322 } }, { "content": "================================================== PAGE 105 ==================================================\n• Paravaginal hematomas of more than 5 cm diameter will\n usually require surgical evacuation. A bleeding point is usually\n present and must be looked for. In cases where it is difficult to\n control bleeding, a Foley catheter with its balloon inflated may\n be left in the cavity. Packing of the vagina may also be useful.\n \n \n• Cervical tears must be identified by systematic inspection of\n the cervix using Green-Armytage forceps and sutured.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_169", "page_number": 4, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 553 } }, { "content": "the cervix using Green-Armytage forceps and sutured.\n \n• In case of multiple tears with venous oozing, it may be better to\n insert a balloon catheter into the vagina or to pack the vagina\n with moistened vaginal packs than to try to suture all the tears.\n \n 5.2.4 Rupture of the uterus \n \n \n• Rupture of the uterus must be suspected when the general\n condition is deteriorating out of proportion to the visible\n blood loss and there is continuing bleeding in the presence of a\n contracted uterus. \n \n• This is particularly so in a woman with a scarred uterus.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_169", "page_number": 4, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 96, "chunk_size": 559 } }, { "content": "contracted uterus. \n \n• This is particularly so in a woman with a scarred uterus.\n \n• Immediate involvement of a Consultant and surgical\n intervention are important in this situation.\n \n 5.2.5 Coagulopathy causing PPH \n \n \n• This could be due to coagulopathy following death in utero,\n abruptio placentae, severe preeclampsia, HELLP syndrome,\n sepsis, amniotic fluid embolism, acute fatty liver, pulmonary\n immune thrombocytopenia, Von Willebrand’s disease etc.\n \n• It could also be due to suboptimal management of the PPH.\n \n \n• Early involvement of a haematologist or transfusion medicine", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_169", "page_number": 4, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 590 } }, { "content": "• Early involvement of a haematologist or transfusion medicine\n specialist will be important in this situation. Where available,\n thromboelastometry would be useful in this situation.\n \n \n6. Resuscitation and Fluid management \n \n PPH up to 1000 ml \n \n• Commence a crystalloid infusion of 2-3 times the estimated\n blood loss. \n \n National Guideline for Maternal Care - Volume I 87", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_169", "page_number": 4, "content_type": "emergency_procedure", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 56, "chunk_size": 379 } }, { "content": "================================================== PAGE 106 ==================================================\nPPH of more than 1000 ml \n \n \n• PPH of over 1000 ml should be managed in consultation with\n other relevant specialists e.g. anesthesiologists, hematologists,\n transfusion specialists etc. \n \n• Assess airway, breathing and circulation. \n \n• Give oxygen via face mask. \n \n• Keep the woman warm and flat. \n \n• Transfuse warmed blood as soon as possible. \n \n \n• Until blood is available, warm crystalloids (up to 2 litres)\n and colloids (up to 1-2 litres) may be transfused as rapidly as", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_170", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 594 } }, { "content": "and colloids (up to 1-2 litres) may be transfused as rapidly as\n required, up to a maximum of 3.5 litres in total.\n \n• Depending on urgency, group-specific blood may be given\n until cross-matched blood is available. \n \n• If group-specific blood is not available, O Rhesus D negative\n blood could be given. \n \n• Blood transfusion should be individualized according to the\n situation. When available, involve blood transfusion specialist/\n Haematologist. Where three or more units of blood are being\n transfused, an equal number of packs of fresh frozen plasma", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_170", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 558 } }, { "content": "transfused, an equal number of packs of fresh frozen plasma\n must also be transfused. If available, thromboelastometry will\n enable factor-specific replacement. \n \n \n• Due consideration must be given to keeping transport facilities\n available to obtain blood and blood products from another\n institution. \n \n \n7. Debriefing \n \n \n• It is possible that a major PPH could result in significant\n psychological morbidity. \n \n• This could be minimized by timely debriefing of the patient\n and her family, preferably by the Consultant. \n \n• This should be done immediately after the event, before", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_170", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 589 } }, { "content": "• This should be done immediately after the event, before\n discharge and at the postnatal visit or at any time as requested\n by her or the family.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_170", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 27, "chunk_size": 146 } }, { "content": "88 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_171", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 107 ==================================================\n8. Risk Management \n \n \n• It is good practice to conduct a case review with the members\n of the team involved in the management and other staff as soon\n as possible after the event. \n \n The spirit of such a meeting should be one of lessons learnt rather\n than of apportioning blame.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_172", "page_number": 4, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 54, "chunk_size": 393 } }, { "content": "National Guideline for Maternal Care - Volume I 89", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_173", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 108 ==================================================\nAppendix 1 \n \n Insertion of a ‘condom catheter’ \n \n This may be performed as an independent procedure or following\n inspection of the cervix and upper vagina for trauma.\n \n Therefore, whenever it is planned to inspect the cervix, or where there is\n an indication that medical therapy may fail to bring the bleeding under\n control, keep the materials needed for insertion of a condom catheter\n ready. \n \n \n1. Explain to the mother the need to insert a condom catheter", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_174", "page_number": 4, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 577 } }, { "content": "ready. \n \n \n1. Explain to the mother the need to insert a condom catheter\n and explain the procedure briefly. Be reassuring.\n \n \n2. Wear a pair of sterile gloves. \n \n3. The required items are: \n \n• Size 20 – 22 (or largest available) Foley catheter,\n \n• A condom, \n \n• Sterile No. 0 or 1 suture, \n \n \n• A bottle of warmed saline, \n \n• Intravenous infusion set released from the pack\n \n• Arrange these items on a sterile towel laid on a side trolley.\n \n4. Take the Foley catheter out of the packing. \n \n \n5. Unfold the condom over the end of the Foley catheter to about", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_174", "page_number": 4, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 101, "chunk_size": 568 } }, { "content": "5. Unfold the condom over the end of the Foley catheter to about\n two thirds of its length. Hand tie it to the catheter firmly, using\n several rounds of sterile suture at a point about 2 cm distal to\n the open end of the condom. \n \n6. Have an assistant connect the infusion set to the bottle of\n warmed normal saline suspended 4-6 feet above the patient.\n \n7. Connect the other end to the catheter, run saline into the\n condom to make sure the system is water tight by holding the\n catheter tip upwards. \n \n8. Afterwards, empty the balloon of the saline and leave it on the", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_174", "page_number": 4, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 106, "chunk_size": 573 } }, { "content": "catheter tip upwards. \n \n8. Afterwards, empty the balloon of the saline and leave it on the\n sterile trolley, ready for insertion. \n \n9. Wash the condom with either warm saline or 5% povidone\n iodine lotion. \n \n 90 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_174", "page_number": 4, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 43, "chunk_size": 262 } }, { "content": "================================================== PAGE 109 ==================================================\n10. Place the woman either in the dorsal or lithotomy position and\n expose the cervix by using one or two Sim’s speculae.\n \n \n11. Grasp the anterior lip of the cervix with a sponge holder.\n \n12. Now insert the entire condom catheter system into the uterus.\n You may keep the condom catheter between the index and\n middle fingers and introduce it like exploring the uterus (or\n doing a pelvic examination). \n \n13. Reconnect the catheter to a giving set and start filling the", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_175", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 85, "chunk_size": 584 } }, { "content": "doing a pelvic examination). \n \n13. Reconnect the catheter to a giving set and start filling the\n condom with warmed saline. \n \n14. Keep watching the cervix for the balloon to bulge out of it and\n stop filling it any further for now. You may notice cessation of\n bleeding from the uterine cavity. \n \n15. At this point pack the vagina with a moist vaginal pack (Two\n inch ribbon gauze pack or a gauze towel) around the catheter\n in a circumferential manner. \n \n \n16. Continue filling till the gravity aided filling stops. Usually 400\n – 500 ml is needed.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_175", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 95, "chunk_size": 553 } }, { "content": "16. Continue filling till the gravity aided filling stops. Usually 400\n – 500 ml is needed. \n \n17. Proximal end of the catheter is folded and a tight tie placed on\n it to prevent backflow. \n \n18. Insert a size 12 Foley catheter to the bladder.\n \n19. Mark the level of the fundus on the abdomen with a marker\n pen. Start a pulse and blood pressure chart.\n \n \n20. Give tranexamic acid 1 G slow i.v. and repeat after 8 hours.\n \n21. Keep pack and the condom catheter for 12 – 18 hours.\n \n22. Consider appropriate antibiotic prophylaxis.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_175", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 95, "chunk_size": 532 } }, { "content": "22. Consider appropriate antibiotic prophylaxis.\n \n23. If there is no vaginal bleeding and vital signs are stable, plan to\n remove the catheter at a convenient time, after 12 hours.\n \n \n24. Release half the instilled volume of saline. Do not remove the\n pack at this stage. \n \n25. Observe for bleeding through the pack. \n \n26. 30 minutes later remove the vaginal pack, without removing\n the condom catheter. \n \n27. If there is no further bleeding for another 30 minutes, release\n the total volume of instilled saline and remove the condom\n catheter gently.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_175", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 89, "chunk_size": 556 } }, { "content": "the total volume of instilled saline and remove the condom\n catheter gently. \n \n National Guideline for Maternal Care - Volume I 91", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_175", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 4, "word_count": 21, "chunk_size": 131 } }, { "content": "================================================== PAGE 110 ==================================================\nAppendix 2 \n \n Brace sutures, the best known of which is the modified B-Lynch sutures\n are very useful in the presence of a bleeding atonic uterus.\n \n The uterus is exteriorized. An absorbable No. 2 suture (or highest gauge\n available) on a curved ‘hand-needle’ is passed anteroposteriorly through\n the uterus above the reflection of the bladder about 2 cm medial to the\n lateral edge. \n \n The process is repeated on the contralateral side. The sutures are tied", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_176", "page_number": 5, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 78, "chunk_size": 572 } }, { "content": "lateral edge. \n \n The process is repeated on the contralateral side. The sutures are tied\n tightly over the fundus, with an assistant manually squeezing the uterus.\n Additional sutures may be applied medially.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_176", "page_number": 5, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 31, "chunk_size": 209 } }, { "content": "92 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_177", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 111 ==================================================\nNational Guideline for Maternal Care - Volume I 93", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_178", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 161 } }, { "content": "================================================== PAGE 112 ==================================================\nAppendix 3 \n \n Steps of uterine de-vascularization technique \n \n (Adapted from: Salah A. AbdRabbo.Stepwise uterine devascularization:\n A novel technique for management of uncontrollable postpartum\n hemorrhage with preservation of the uterus AJOG 1994 Volume 171\n Number 3) \n \n Step 1: Bilateral uterine vessel ligation \n \n In this step the uterine arteries are ligated at the level where they run along\n the uterine border beside the upper part of the lower uterine segment (Fig.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_179", "page_number": 5, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 590 } }, { "content": "the uterine border beside the upper part of the lower uterine segment (Fig.\n 1 Note: Steps I and II in the diagram constitute step 1 in our description.\n We recommend that both sides are done in one step.).\n \n Fig. 1.Sites of uterine artery ligation in steps 1, 2 (upper arrow), and 3\n (lower arrow).U.U.S., Upper uterine segment; L.U.S., Lower uterine\n segment.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_179", "page_number": 5, "content_type": "clinical_protocol", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 61, "chunk_size": 362 } }, { "content": "94 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_180", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 113 ==================================================\nWith the surgeon on the right side of the patient, the uterus is grasped and\n elevated to the contralateral side. A large needle (48 mm or greater) with\n number 1 absorbable suture is passed through the avascular area of the\n left broad ligament from anterior to posterior and then brought forward,\n guided by the four fingers of the left hand, through the myometrium from\n posterior to anterior 2 cm medial to the left uterine vessels, and the suture\n is tied.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_181", "page_number": 5, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 572 } }, { "content": "posterior to anterior 2 cm medial to the left uterine vessels, and the suture\n is tied. \n \n This process is repeated on the contralateral side.\n \n In these two steps there is no need for bladder mobilization, because the\n sutures were not placed low. Also, there is no need for a peritoneal incision\n in cases having vaginal deliveries; however, in cases having caesarean\n section the suture should be placed below the level of the transverse\n uterine incision, under the reflected peritoneal flap.\n \n Step 2: Low bilateral uterine vessel ligation", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_181", "page_number": 5, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 547 } }, { "content": "Step 2: Low bilateral uterine vessel ligation \n \n This step is reserved only for cases having continued lower uterine segment\n haemorrhage diagnosed at caesarean section and not controlled by step \n1.\n \n In this step the bladder is reflected downwards and lower bilateral uterine\n vessel ligation is performed at the lower part of the lower uterine segment,\n 3 to 5 cm below the upper ligatures, with the same technique in step \n1. At\n this level the uterine artery is ligated after its cervicovaginal branch turns\n abruptly upward to extend along the uterine margin. This ligature would", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_181", "page_number": 5, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 2, "word_count": 94, "chunk_size": 587 } }, { "content": "abruptly upward to extend along the uterine margin. This ligature would\n obliterate most of the branches of the uterine artery to the lower uterine\n segment and a branch of considerable size that extends to the upper\n portion of the cervix. It is important to include a significant amount of\n myometrium to avoid damage to the uterine vessels and to obliterate some\n of the intramyometrial ascending arterial branches of the cervicovaginal\n artery (Fig. 1).", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_181", "page_number": 5, "content_type": "guidelines", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 3, "word_count": 73, "chunk_size": 457 } }, { "content": "National Guideline for Maternal Care - Volume I 95", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_182", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 114 ==================================================\nStep 3: Ligation of uterine/ovarian arterial anastomosis\n \n This step is indicated in continued uterine bleeding in spite of performing\n step 1.The uterus is grasped and pulled to the contralateral side by the\n left hand, and a large needle with a number 1 absorbable suture is passed\n through the avascular area in the broad ligament from anterior to posterior,\n at the level of the ovarian ligament. The needle is then passed anteriorly 2", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_183", "page_number": 5, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 551 } }, { "content": "at the level of the ovarian ligament. The needle is then passed anteriorly 2\n cm medial to the edge of the uterine wall, to include the uterine muscle.\n The suture is tied anteriorly.", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_183", "page_number": 5, "content_type": "general", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 1, "word_count": 33, "chunk_size": 183 } }, { "content": "96 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_184", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 115 ==================================================\nNational Guideline for Maternal Care - Volume I 97", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_185", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 161 } }, { "content": "================================================== PAGE 116 ==================================================\n98 National Guideline for Maternal Care - Volume I", "metadata": { "document_name": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "section": "Section_186", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-32-01-guideline-2013-eng-national-guideline-for-maternalcare-(1) (1).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 161 } }, { "content": "================================================== PAGE 1 ==================================================\nManagement of Uncomplicated labour \n \n \n• Painful contractions \n \n• Show \n \n• Effacement & progressive Review after 2 hours \n dilatation of cervix \n Establishedlabour \n Transfer to the labour suite \n Identify risk factors by, \n Episiotomy o Review antenatal records. o Avoiding faecal soiling", "metadata": { "document_name": "Management-of-Normal-Labourchart.pdf", "section": "Section_000", "page_number": 1, "content_type": "maternal_care", "source_file": "Management-of-Normal-Labourchart.pdf", "chunk_index": 0, "word_count": 43, "chunk_size": 401 } }, { "content": "Identify risk factors by, \n Episiotomy o Review antenatal records. o Avoiding faecal soiling \n 2.Cord - c lam M p e A di t o t - h la e t e ti r m al e E o p f i c si r o o t w o o o m n i D E y n g x e a t a m il i e n d a t c i l o i n n ical history o o S O h r a a v l i f n lu g i d o s f perineal hair\n Urine for protein o IV access \n o Left Lateral recombinant \n position \n Monitoring by Partogram \n Maintain Partogram*(X) \n Progress of labour \n o Cervical dilatation \n o Decent of the presenting part \n o Uterine contractions Routine \n care in Maternal condition", "metadata": { "document_name": "Management-of-Normal-Labourchart.pdf", "section": "Section_000", "page_number": 1, "content_type": "maternal_care", "source_file": "Management-of-Normal-Labourchart.pdf", "chunk_index": 1, "word_count": 139, "chunk_size": 570 } }, { "content": "o Decent of the presenting part \n o Uterine contractions Routine \n care in Maternal condition \n o Pulse, BP, Temperature & hydration. labour suit Pain relief \n o Evaluation of drugs(oxytocin, antibiotics, Opioid -Pethidine \n Anti hypertensives, Analgesics Regional analgesia-Epidural \n o Undistended bladder-catheterize if Other-spinal analgesia \n indicated Combined spinal-epidural analgesia \n Inhalational analgesia-Entonox \n Fetal condition Pudendal block for \n o Intermittent auscultation of fetal heart \n episiotomy/forceps/vacuum \n o Liquor volume \n o Meconeum in liquor \n Positioning", "metadata": { "document_name": "Management-of-Normal-Labourchart.pdf", "section": "Section_000", "page_number": 1, "content_type": "maternal_care", "source_file": "Management-of-Normal-Labourchart.pdf", "chunk_index": 2, "word_count": 68, "chunk_size": 590 } }, { "content": "episiotomy/forceps/vacuum \n o Liquor volume \n o Meconeum in liquor \n Positioning \n Second stage Most comfortable \n position Diagnosis \n Supine position-avoided (cid:57) Vaginal examination \n Descent phase- for full dilatation \n -Not to bear down (cid:57) Perineal distention \n -Fetal heart assessed (cid:57) Anal dilatation \n every 15 mints \n Expulsive phase- \n -Encourage to bear down \n -Fetal heart assessed after \n each contraction Episiotomy \n - Medio-lateral \n Episiotomy \n At the time of \n Delivery Delivery crowning \n Third stage \n 1.Oxytocics 3.Controlled \n cord traction \n Active", "metadata": { "document_name": "Management-of-Normal-Labourchart.pdf", "section": "Section_000", "page_number": 1, "content_type": "maternal_care", "source_file": "Management-of-Normal-Labourchart.pdf", "chunk_index": 3, "word_count": 71, "chunk_size": 588 } }, { "content": "Delivery Delivery crowning \n Third stage \n 1.Oxytocics 3.Controlled \n cord traction \n Active \n management \n 2.Cord clamp \n \n5. Observation for signs of \n o Haemorrhage \n o Utrine fundal level \n o Evidence of collapse \n o Respiratory difficulty \n o Unusual behaviouror \n Monitoring o Abdominal pain \n Mother should be \n closely monitored in \n the labour room for \n at least two hours \n ruobal \n fo \n egats \n dnoceS \n ruobal \n fo \n egats \n drihT \n mutrap-tsoP \n All \n steps \n in \n the \n management \n of \n labour \n should \n be \n documented \n in \n the \n bed \n head \n ticket \n All \n steps \n in \n the", "metadata": { "document_name": "Management-of-Normal-Labourchart.pdf", "section": "Section_000", "page_number": 1, "content_type": "maternal_care", "source_file": "Management-of-Normal-Labourchart.pdf", "chunk_index": 4, "word_count": 80, "chunk_size": 594 } }, { "content": "of \n labour \n should \n be \n documented \n in \n the \n bed \n head \n ticket \n All \n steps \n in \n the \n management \n of \n labour \n should \n be \n carried \n out \n under \n aseptic \n conditions \n Not in labour Observe in antenatal ward \n Uncertain \n Admission CTG to be \n done in all three groups \n and interpreted before \n decision is made (Y) \n 4.Examine the \n placenta \n Sri Lanka College of Obstetrics and Gynaecology \n Health sector development Project \n Guidelines- Management of Uncomplicated labour", "metadata": { "document_name": "Management-of-Normal-Labourchart.pdf", "section": "Section_000", "page_number": 1, "content_type": "maternal_care", "source_file": "Management-of-Normal-Labourchart.pdf", "chunk_index": 5, "word_count": 67, "chunk_size": 497 } }, { "content": "================================================== PAGE 1 ==================================================\nSLCOG Guideline \n \n SLCOG Guideline \n \n Assisted Vaginal Delivery \n \n D Senadheeraa, C Jayasundarab, I A Jayawardaneb on behalf of the Sri Lanka College of Obstetricians and\n Gynaecologists \n \n Correspondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo \n08.\n E-mail: slcogoffice@gmail.com", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_000", "page_number": 1, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 46, "chunk_size": 443 } }, { "content": "1. Introduction, background and \n3. Identification and assessment of \n evidence \n epidemiology \n Search strategy: External guidelines, systemic reviews\n Management of second stage of labour frequently \n and Cochrane revives were searched assessing available\n necessitates assisted birth, to avoid a potentially \n evidence and the best practices. \n hazardous second stage caesarean section. In the \n United Kingdom 10% to 15% of all women undergo \n assisted vaginal birth, even though rate is much lower 4.Summary of recommendations\n in Sri Lanka\n1. Instrumental delivery when performed", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_001", "page_number": 1, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 585 } }, { "content": "in Sri Lanka\n1. Instrumental delivery when performed \n  Whenever possible, strive to provide continuous\n correctly by a trained clinician, results in satisfactory \n support during labour, one to one care and the\n feto-maternal outcomes\n2. However, clinician should be \n choice of a labour companion. Available evidence\n aware that serious and rare complications, such as sub- \n suggests this can reduce instrumental delivery\n galeal and intracranial haemorrhage, skull fractures \n rate and promote normal vaginal delivery.\n and spinal cord injury, can occur particularly in the", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_001", "page_number": 1, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 578 } }, { "content": "rate and promote normal vaginal delivery.\n and spinal cord injury, can occur particularly in the \n untrained hands as well as with repeated failed  Epidural analgesia may increase the duration of\n attempts\n3. Mastering the art of safe assisted delivery is active second stage and the need for instru-\n an essential skill in the modern obstetrician’s armament. mental vaginal birth.\n  Encourage upright or lateral positions in second\n \n2. Purpose and scope \n stage of labour (in women not on epidural\n analgesia). This reduces the need for instru-", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_001", "page_number": 1, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 2, "word_count": 87, "chunk_size": 548 } }, { "content": "stage of labour (in women not on epidural\n analgesia). This reduces the need for instru-\n The aim of this guideline is to provide evidence-based \n mentation. \n recommendations on the use of forceps and vacuum. \n This guidance is intended not only for practicing  Allow delayed pushing (passive second stage)\n specialists, but also for trainee registrars, senior in women with epidural analgesia. This may\n registrars who are expected to develop competency in reduce the need for rotational and mid-pelvic\n the use of both vacuum and forceps for non-rotational assisted vaginal birth.", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_001", "page_number": 1, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 3, "word_count": 89, "chunk_size": 584 } }, { "content": "the use of both vacuum and forceps for non-rotational assisted vaginal birth.\n birth and at least one technique for rotational birth. \n  Do not routinely discontinue epidural analgesia\n Recommendations made in this document may serve \n during pushing as this increases the woman’s\n for all grades of medical staff involved in women’s \n pain with no evidence of a reduction in the\n health and labour management. The scope of this \n incidence instrumental delivery. \n guideline includes indications, procedures, governance \n and follow up issues relating to assisted vaginal birth.", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_001", "page_number": 1, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 4, "word_count": 85, "chunk_size": 580 } }, { "content": "and follow up issues relating to assisted vaginal birth. \n Sri Lanka Journal of Obstetrics and Gynaecology 2021; 43: 335-347 \n DOI: http://doi.org/10.4038/sljog.v43i4.8029 \n a Consultant Obstetrician and Gynaecologist, De Soysa Hospital for Women, Colombo, Sri Lanka\n bConsultant Obstetrician and Gynaecologist, De Soysa Hospital for Women, Senior Lecturer, University of Colombo,\n Sri Lanka \n This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_001", "page_number": 1, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 5, "word_count": 68, "chunk_size": 521 } }, { "content": "permits unrestricted use, distribution and reproduction in any medium provided the original author and source are credited.\n Vol. 43, No. 4, December 2021 335", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_001", "page_number": 1, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 6, "word_count": 24, "chunk_size": 158 } }, { "content": "================================================== PAGE 2 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_002", "page_number": 2, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": " Operators should appreciate that no indication  Non-rotational low-pelvic and lift out assisted\n forinstrumental delivery is absolute, and that vaginal births have a low probability of failure,\n prudent clinical judgment is required in each hence most procedures can be attempted safely\n situation. in the labour room. \n  Suspected fetal bleeding disorders and pre-  Assisted vaginal births that have a higher risk\n disposition to fractures are relative contrain- of failure should be termed a trial of instru-\n dications for assisted vaginal birth. mental delivery and is best attempted in an", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_003", "page_number": 2, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 91, "chunk_size": 598 } }, { "content": "dications for assisted vaginal birth. mental delivery and is best attempted in an\n \n operation theater, where immediate CS can be\n  Presence of blood borne viral infection in a \n resorted to. \n woman is not an absolute contraindication for \n assisted vaginal birth.  The operator should choose the instrument most\n  Vacuum is not contraindicated following a fetal appropriate to the clinical circumstances and\n blood sampling or application of a fetal scalp their level of skill. \n electrode. \n  Forceps and vacuum extraction are associated", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_003", "page_number": 2, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 544 } }, { "content": "electrode. \n  Forceps and vacuum extraction are associated\n  There is a higher risk of sub-galeal haemorrhage with different benefits and risks.\n and scalp trauma with vacuum extraction \n  Failure to complete the birth with a single instru-\n compared to forceps at preterm gestation. \n ment is more likely with vacuum extraction, but\n  Vacuum is contraindicated below 32 weeks maternal perineal trauma is more likely with\n of gestation and should only be used with forceps. \n extreme caution between 32+0 and 36+\n0. \n  Soft cup vacuum extractors have a higher rate", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_003", "page_number": 2, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 2, "word_count": 91, "chunk_size": 569 } }, { "content": "extreme caution between 32+0 and 36+\n0. \n  Soft cup vacuum extractors have a higher rate\n  Safe assisted vaginal birth requires not only of failure but a lower incidence of neonatal\n technical expertise, but also careful assessment scalp trauma. \n of each clinical situation, clear communication \n  Rotational births should be performed by\n with the woman and other healthcare personnel. \n experienced operators; the choice of instrument\n  Ultrasound assessment of the fetal head position depending on the clinical circumstances and", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_003", "page_number": 2, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 3, "word_count": 80, "chunk_size": 536 } }, { "content": " Ultrasound assessment of the fetal head position depending on the clinical circumstances and\n prior to assisted vaginal birth can be attempted expertise of the individual.\n where uncertainty exists following clinical \n  The options include, Manual rotation followed\n examination. \n bydirect traction with forceps or vacuum,\n  Routine use of abdominal or perineal ultrasound Rotational vacuum extraction or Kielland’s\n for assessment of the station, flexion and rotational forceps. \n descent of the fetal head in the second stage is \n  It is recommended to complete vacuum-", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_003", "page_number": 2, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 4, "word_count": 84, "chunk_size": 577 } }, { "content": "descent of the fetal head in the second stage is \n  It is recommended to complete vacuum-\n not recom mended and is not a substitute for \n assisted birth with not more than three pulls to\n clinical examination. \n bring the fetal head on to the perineum.\n  For procedures in the labour room, verbal \n (Additional gentle pulls may be used only to ease\n consent should be obtained and documented in \n the head out of the perineum). \n the notes. \n  If there is minimal descent with the first pull of\n  When mid-pelvic or rotational birth is indicated, \n a vacuum, consider if the application is sub-", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_003", "page_number": 2, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 5, "word_count": 104, "chunk_size": 598 } }, { "content": "a vacuum, consider if the application is sub-\n the risks and benefits of assisted vaginal birth \n optimal, the fetal position has been incorrectly\n should be compared with the risks and benefits \n diagnosed or if there is cephalopelvic dispro-\n of second stage caesarean section, for the given \n portion. \n circu-mstances and skills of the operator. \n  Discontinue vacuum-assisted birth where there\n  Prior written consent is recommended for a trial is no evidence of progressive descent with\n of assisted vaginal birth in the operating theatre. moderate traction during each pull of a correctly", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_003", "page_number": 2, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 6, "word_count": 91, "chunk_size": 597 } }, { "content": "applied instrument. \n  Operators must achieve expertise in spon- \n taneous vaginal birth prior to commencing  Discontinue vacuum-assisted birth if there have\n training on assisted vaginal birth. been two ‘pop-offs’ of the instrument.\n 336 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_003", "page_number": 2, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 7, "word_count": 41, "chunk_size": 288 } }, { "content": "================================================== PAGE 3 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_004", "page_number": 3, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": " The use of sequential instruments is associated  A single prophylactic dose of intravenous\n with an increased risk of trauma to the infant amoxicillin and clavulanic acid should be\n as well as obstetric anal sphincter injury considered following assisted vaginal birth as it\n (OASI). Operator needs to balance the risks of significantly reduces confirmed or suspected\n caesarean birth vs forceps following failed maternal infection compared to placebo.\n vacuum and may consider forceps extraction. \n  Reassess women after assisted vaginal birth for", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 82, "chunk_size": 552 } }, { "content": "vacuum and may consider forceps extraction. \n  Reassess women after assisted vaginal birth for\n  Abandon forceps delivery when the forceps venous thromboembolism risk and the need for\n cannot be applied easily, the handles do not lock thromboprophylaxis. \n or if there is lack of progressive descent with \n  Highlight the risk of urinary retention and the\n moderate traction and birth is not imminent \n importance of bladder emptying in the\n following three pulls with a correctly applied \n postpartum period. Timing and volume of the\n instrument by an experienced operator.", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 1, "word_count": 88, "chunk_size": 577 } }, { "content": "postpartum period. Timing and volume of the\n instrument by an experienced operator. \n first void urine should be monitored and docu-\n  Discontinue rotational forceps birth if rotation mented. \n is not easily achieved with gentle pressure. \n  A post void residual should be measured if\n  If there is minimal descent with the first pull of \n urinary retention is suspected. \n theforceps, consider if the application is \n  For women who had regional analgesia for a\n incorrect, the position has been incorrectly \n trial in theatre, recommend indwelling catheter", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 562 } }, { "content": "incorrect, the position has been incorrectly \n trial in theatre, recommend indwelling catheter\n diagnosed or there is cephalopelvic dispro- \n portion. in situ following birth, to prevent covert urinary\n retention. \n  There is increased risk of fetal head impaction \n at caesarean birth following a failed instrumental  Review women before hospital discharge with\n delivery and the operator should be prepared a confirmatory vaginal examination. Discuss the\n to disimpact the fetal head using recognized indication for assisted vaginal birth, management", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 3, "word_count": 77, "chunk_size": 554 } }, { "content": "to disimpact the fetal head using recognized indication for assisted vaginal birth, management\n maneuvers. of any complications and advice for future\n births. \n  Mediolateral episiotomy should be discussed \n with the woman and tailored to the circum-  Documentation for assisted vaginal birth should\n stances. include information on the assessment, decision\n making and conduct of the procedure, a plan\n  When performing a mediolateral episiotomy, the \n for post natal care and information for subse-\n cut should be at a 60-degree angle to the midline", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 4, "word_count": 83, "chunk_size": 554 } }, { "content": "for post natal care and information for subse-\n cut should be at a 60-degree angle to the midline \n quent pregnancies – standardized proforma is\n and initiated when the head is crowning the \n recommended. \n perineum. \n \n5. Avoiding assisted vaginal birth \n Evidence suggests, continuous one to one care and labour companionship can reduce the need for assisted\n vaginal birth\n4. Use of epidural analgesia may increase the need for instrumental delivery\n5. Adopting an upright or\n lateral position during second stage reduces the need for assisted vaginal delivery\n6. If on epidural it is not", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 5, "word_count": 93, "chunk_size": 591 } }, { "content": "6. If on epidural it is not\n recommended to routinely discontinue during second stage, as this will not reduce need of assisted vaginal\n delivery but increases pain and distress to the woman\n7. \n \n Vol. 43, No. 4, December 2021 337", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_005", "page_number": 3, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 6, "word_count": 40, "chunk_size": 231 } }, { "content": "================================================== PAGE 4 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_006", "page_number": 4, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "6. Classification of instrumental delivery as outlet, low and mid cavity assisted birth\n in forceps delivery", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_007", "page_number": 4, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 16, "chunk_size": 108 } }, { "content": "Outlet Low Mid \n Fetal scalp visible without Fetal skull is at station Fetal head is no more than one-\n separating the labia +2cm, but not on the fifth palpable per abdomen\n \n Fetal skull has reached the perineum perineum Leading point of the skull is at\n Two subdivisions: station 0 or +1cm \n Rotation does not exceed 45° \n \n1. Non-rotational ≤45° Two subdivisions: \n \n2. Rotational >45° \n1. Non-rotational ≤45° \n \n2. Rotational >45°", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_008", "page_number": 4, "content_type": "general", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 434 } }, { "content": "7. The performing clinician should take 7.2 Abdominal examination \n a relevant concise history and carry out \n• Estimated fetal weight. \n \n systematic examination to identify any \n• Assessment of engagement of the fetal head,\n contraindications: descent, the number of fifths palpable abdo-\n \n• Check obstetric, general, and medical history. minally. The head should be ≤1/5 palpable per\n abdomen. \n \n• Birth weight of previous baby/babies and \n \n• Identification of the position of the fetal back\n assessment of EFW in the index pregnancy. \n and sinciput, (This examination is not always", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_009", "page_number": 4, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 87, "chunk_size": 588 } }, { "content": "assessment of EFW in the index pregnancy. \n and sinciput, (This examination is not always\n \n• Assessment of progress in the first stage (noting \n possible, but an attempt should be made).\n secondary arrest). \n \n• Examination for distension of the lower uterine\n \n• Assessment of second stage of labour. \n segment or formation of a retraction ring\n \n• Assessment of frequency and strength of uterine \n (Bandl’s ring), indicating labour may have\n contractions and noting any contraindications \n become obstructed. \n for the use of oxytocin infusion. \n 7.3 Vaginal examination", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_009", "page_number": 4, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 1, "word_count": 84, "chunk_size": 573 } }, { "content": "become obstructed. \n for the use of oxytocin infusion. \n 7.3 Vaginal examination \n 7.1 Assessment of feto-maternal status \n \n• To confirm full dilatation of the cervix and\n \n• Evaluation of the physical and emotional state \n station of the presenting part (should be at or\n of the mother and her ability to participate \n below spines). \n actively in birth. \n \n• Grade the degree of moulding as mild, moderate,\n \n• Give clear explanation and obtain informed \n or severe. \n consent and document on her hospital notes. \n \n• Note the position, extent of de-flexion and", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_009", "page_number": 4, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 2, "word_count": 88, "chunk_size": 564 } }, { "content": "consent and document on her hospital notes. \n \n• Note the position, extent of de-flexion and\n \n• Reduce maternal discomfort by administering \n asynclitism of fetal head. (see below)\n appropriate analgesia (Consider local or \n \n• Estimate the capacity of the pelvis relative to\n regional). \n the size of the baby. Special note of pubic arch\n \n• Confirm the bladder is empty. If on catheter, \n and sacrospinous ligaments. \n remove it or deflate the balloon. \n \n• Accurate account of the findings should be\n \n• Note colour of amniotic fluid for the presence \n documented. (Lack of appreciation of the", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_009", "page_number": 4, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 3, "word_count": 93, "chunk_size": 597 } }, { "content": "• Note colour of amniotic fluid for the presence \n documented. (Lack of appreciation of the\n of meconium or blood. \n situation and delivery by wrong method in\n \n• Assessment of fetal wellbeing. \n wrong place by inexperienced staff can cause\n \n• Always use aseptic techniques. increased fetal and maternal morbidity.)\n 338 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_009", "page_number": 4, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 4, "word_count": 56, "chunk_size": 369 } }, { "content": "================================================== PAGE 5 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_010", "page_number": 5, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "7.4 Preparation of Staff \n5. Blood-stained urine. \n \n• The operator should have necessary knowledge, \n6. Bleeding from the vagina.\n experience, and skill. \n \n \n• Confirm the adequacy of facilities and availability Note: Severe or increasing moulding of the head that\n of the theatre if a need arises. fails to rotate descend despite of strong uterine\n \n• Backup plan in case of failure. contractions is also a clinical finding suggestive of\n CPD/obstructed Labour. \n \n• Inform senior staff. \n \n• Consider complications like shoulder dystocia, \n \n• If a diagnosis of obstructed labour is made,", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 90, "chunk_size": 592 } }, { "content": "• Consider complications like shoulder dystocia, \n \n• If a diagnosis of obstructed labour is made,\n perineal trauma, and post-partum haemorrhage. \n delivery should be undertaken immediately by\n \n• Presence of the Neonatal team. caesarean section. \n 7.5 Recognition of obstructed labour/CPD 7.6 Estimation of the level of fetal head – Per\n CPD may be defined as the inability of the fetus to Abdomen (P/A) and Vaginally (V/E) (This helps\n pass safely through the birth canal for mechanical in assessment of progress at subsequent", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 528 } }, { "content": "pass safely through the birth canal for mechanical in assessment of progress at subsequent\n reasons. These mechanical reasons include, relative examination and on decision regarding mode\n sizes of maternal pelvis and fetal presenting part, which \n of delivery) \n may vary, considerably in their three-dimensional sizes \n and shapes and in the degree to which the fetal head \n1. P/A- 5/5 the fetal head is completely palpable above\n may undergo compression without injury to the brain. upper border of symphysis pubis.\n V/E-3 cm. digital examination at this stage is hardly", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 2, "word_count": 87, "chunk_size": 572 } }, { "content": "V/E-3 cm. digital examination at this stage is hardly\n CPD is either true disproportion, when even the smallest \n possible. \n diameters of the presenting part are too big to pass \n through the pelvis, or relative disproportion caused by \n2. P/A- 4/5 the lower portion of the head is just below\n larger presenting diameters of the head that are the upper border of the symphysis pubis.\n commonly associated with transverse and posterior \n V/E -2cm station (difficult examination of head).\n positions of the occiput, which results from de-flexion", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 3, "word_count": 85, "chunk_size": 544 } }, { "content": "positions of the occiput, which results from de-flexion \n \n3. P/A -3/5 Occipitofrontal diameter of the head may\n and asynclitism of the head. \n be palpable just above the upper border of the\n symphysis pubis. \n The distinction between the two types of disproportion \n may be impossible to make but should be attempted V/E -1cm station. \n because correction of the malposition in the case of \n \n4. P/A- 2/5 the head is engaged. On one side, usually\n relative disproportion, either by enhancing uterine \n the side of sinciput, the head may be easily palpable", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 4, "word_count": 89, "chunk_size": 556 } }, { "content": "the side of sinciput, the head may be easily palpable\n contractions with oxytocin or by manipulating the fetal \n while on the other, the side of the occiput; it may\n head with an instrument or manually, may allow safe \n not be so easily palpable. \n vaginal delivery of the baby. Unfortunately, there is no \n V/E -0 cm station. \n reliable test that will diagnose CPD with certainty before \n the onset of labour. It may be suspected if there is a \n5. P/A -1/5 the fetal head is engaged; the head, usually", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 5, "word_count": 88, "chunk_size": 502 } }, { "content": "5. P/A -1/5 the fetal head is engaged; the head, usually\n history of previous difficult labours or from the the sinciput, may be just palpated with the fingers\n findings on clinical examination or when delay occurs on one side only. \n in the late active phase of the first stage of labour or V/E +1cm station.\n pelvic (Decent) phase of the second stage. \n \n6. P/A 0/5 the head is deeply engaged; neither the\n occiput nor the sinciput are palpable abdominally.\n  Signs of obstructed labour V/E +2cm. \n \n1. Significant caput and moulding. \n• If the station is at the level of ischial spines or", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 6, "word_count": 103, "chunk_size": 592 } }, { "content": "1. Significant caput and moulding. \n• If the station is at the level of ischial spines or\n higher vaginally, instrumental delivery is\n \n2. Tenderness and ‘ballooning’ of lower uterine \n contra-indicated4,\n5. \n segment. \n If it is necessary to deliver the baby at this\n \n3. Formation of uterine retraction ring. \n stage, either due to maternal or fetal distress,\n \n4. Presence of oedema of cervix and/or vulva. it should be by a caesarean section.\n Vol. 43, No. 4, December 2021 339", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_011", "page_number": 5, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 7, "word_count": 78, "chunk_size": 481 } }, { "content": "================================================== PAGE 6 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_012", "page_number": 6, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "7.7 Use of oxytocin for slow progress in second Ventouse is more likely to fail in the presence of\n stage excessive caput. The vacuum extraction causes less\n maternal trauma but may increase the risk of cephal-\n Use of oxytocin (especially in a nulliparous women) \n hematoma, retinal haemorrhage and certain types of\n may be better than premature instrumental delivery with \n intra-cranial haemorrhage in the fetus compared to\n a high fetal head station for the treatment of delay in \n forceps delivery\n12. Maternal perineal trauma is more\n the second stage of labour6,7,8,\n9.", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_013", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 91, "chunk_size": 576 } }, { "content": "forceps delivery\n12. Maternal perineal trauma is more\n the second stage of labour6,7,8,\n9. \n likely with forceps but ability to complete delivery with\n \n• In a nulliparous woman with inefficient single instrument is more likely with forceps.\n uterine contractions, and with absence of \n signs of fetal distress, contractions can be Regional analgesia is advisable for difficult forceps\n stimulated with oxytocin to achieve 4-5 delivery when done in theater, and a pudendal block\n contractions per 10 minutes. when conducted in the labour room. Ventouse extrac-", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_013", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 1, "word_count": 84, "chunk_size": 560 } }, { "content": "contractions per 10 minutes. when conducted in the labour room. Ventouse extrac-\n tion can be performed without regional analgesia.\n \n• However, in a multiparous woman, \n Perineal infiltration for episiotomy would suffice.\n inefficient uterine action is less common and \n However, operator should confirm adequacy of\n caution is required before introducing \n analgesia with the woman prior to application of the\n oxytocin to increase uterine contraction due \n instruments. \n to risk of hypertonic contractions and uterine \n rupture. Careful assessment should be made", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_013", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 2, "word_count": 78, "chunk_size": 566 } }, { "content": "to risk of hypertonic contractions and uterine \n rupture. Careful assessment should be made \n \n• Application of rotational forceps needs training and\n by an experienced clinician/consultant, to \n experience. If not adequately trained/experienced\n exclude disproportion before administering \n on the technique, manual rotation followed by non-\n oxytocin for delay in the first or second stages \n rotational forceps/ vacuum or rotational vacuum\n of labour. \n delivery or LSCS would be prudent. \n \n• Oxytocin should not be routinely used in \n women with previous caesarean delivery.", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_013", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 3, "word_count": 79, "chunk_size": 579 } }, { "content": "• Oxytocin should not be routinely used in \n women with previous caesarean delivery. \n \n9. Trial of instrumental delivery \n Need should be discussed with on-call \n consultant/Senior clinician before aug- Adequate assessment of the case will generally resolve\n mentation. any doubts prior to attempting an instrumental delivery.\n Operator should first ensure adequate analgesia for\n {Rate of uterine rupture doubles with use of Syn- \n examination has been provided. If the operator is\n tocinon after previous C/S, compared to non-use of \n uncertain about the position of the fetal head, degree", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_013", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 4, "word_count": 86, "chunk_size": 592 } }, { "content": "uncertain about the position of the fetal head, degree\n Syntocinon9,10,\n11. Earliest signs of uterine dehiscence/ \n of engagement, instrument delivery should not be\n rupture can be fetal distress, abdominal pain (in the \n undertaken. \n region of scar), vaginal bleeding and blood-stained \n urine. If the pain ‘breaks through’ despite epidural \n When the operator is uncertain about the likelihood of\n analgesia, scar dehiscence should be considered.} \n success or expect a difficult delivery a formal trial of\n ventouse/forceps in the operating theater should be", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_013", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 5, "word_count": 80, "chunk_size": 562 } }, { "content": "ventouse/forceps in the operating theater should be\n \n8. Choice of instrument attempted where immediate resorting into caesarean\n section can be done. Failure in the labour room without\n The choice, judgement and the skill of the operator \n preparation for immediate C/S), has shown to increase\n dictates the outcome rather than the instrument itself. \n fetal morbidity and mortality13,\n14. \n Following factors needs to be considered in decision- \n making: Vacuum and forceps birth has been associated with\n higher incidence of episiotomy, pelvic floor tearing,\n \n• Experience of operator.", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_013", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 6, "word_count": 85, "chunk_size": 589 } }, { "content": "higher incidence of episiotomy, pelvic floor tearing,\n \n• Experience of operator. \n levator ani avulsion and obstetric anal sphincter injury\n \n• Station and position of head. \n compared to spontaneous vaginal birth. Meticulous\n \n• Size of the baby. examination for perineal or obstetric anal sphincter\n injuries (OASIS) should be undertaken. Care should\n \n• Degree of caput/moulding. \n be taken on the management decision and expert\n \n• Maternal exhaustion – physical/mental. opinion should be sought when in doubt.\n 340 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_013", "page_number": 6, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 7, "word_count": 82, "chunk_size": 568 } }, { "content": "================================================== PAGE 7 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_014", "page_number": 7, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "9.1 Probable indications for a trial in theatre 10.3 Prerequisites of ventouse delivery\n \n \n• Head palpable abdominally 1/5 i.e., station +1 \n• Full dilatation of cervix and ruptured\n (mid cavity instrumental delivery). (If the station membranes. \n of the head is higher than this, instrumental \n \n• Careful pelvic examination to assess adequacy\n delivery is contra-indicated. Beware of the caput \n of pelvis, with special attention to architecture\n at the spines, whilst the actual head is much \n of pelvis to assess sacral hollow, ischial spines\n higher.) \n and sub-pubic arch.", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_015", "page_number": 7, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 86, "chunk_size": 579 } }, { "content": "of pelvis to assess sacral hollow, ischial spines\n higher.) \n and sub-pubic arch. \n \n• Severe caput/moulding \n \n• Fully engaged head and any de-flexion of head\n \n• Non occipito-anterior (OA) positions such as OP identified. \n and OT positions. \n \n• Full explanation of the procedure and verbal\n \n• Deflexed/Asynclitic head. \n consent of the woman, and need for her co-\n \n• Protracted 1st stage of labour, prolonged 7-10cm operation emphasized.\n interval. \n \n• Good regular contractions should be present.\n \n• Fetal macrosomia/borderline CPD. (HC ≥95th \n (If they are less frequent, then Oxytocin", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_015", "page_number": 7, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 595 } }, { "content": "• Fetal macrosomia/borderline CPD. (HC ≥95th \n (If they are less frequent, then Oxytocin\n centile / EFW ≥4kg/ BMI above 30.) \n infusion should be set-up and caution needed\n \n• Any condition, which may lead to failure of in multiparous women and women with\n instrumental delivery. previous section). \n \n10. Vacuum extraction / ventouse delivery 10.4 Basic rules \n Rigid/soft silicon cups can be used for OA positions \n• The delivery should be completed in no longer\n than 15 minutes following application of the\n and posterior cups should be used for non-OA positions.", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_015", "page_number": 7, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 2, "word_count": 89, "chunk_size": 567 } }, { "content": "and posterior cups should be used for non-OA positions. \n cup. (Fifteen minutes is given as the maximum\n Hand-held vacuum cup (kiwi omni cup) can be used \n time allowed, but the average time from\n for both OA and non-OA positions. \n insertion of the cup to delivery is normally\n six minutes15,16). \n 10.1 Indications for ventouse delivery \n \n• The head should be delivered with no more\n \n• Delayed second stage \n than 3 synchronized pulls with maternal\n \n• Fetal distress in the second stage with fetal expulsive force. \n head below ‘0’ station (see above)", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_015", "page_number": 7, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 3, "word_count": 90, "chunk_size": 556 } }, { "content": "head below ‘0’ station (see above) \n \n• The procedure is abandoned if there is no\n \n• Maternal conditions requiring a short second descent after 2 pulls (actual head should\n stage (severe PET, cardiac disease) descend and not just the caput).\n \n• Delivery of the 2nd twin (only if cephalic). \n• The cup should be reapplied no more than\n twice (discontinue after two pop-offs).\n 10.2 Contraindications for ventouse delivery \n \n• The cup must be applied on flexion point. (Bird\n \n• Face/brow/breech presentation et.al demonstrated provided the cup is applied", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_015", "page_number": 7, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 4, "word_count": 88, "chunk_size": 556 } }, { "content": "• Face/brow/breech presentation et.al demonstrated provided the cup is applied\n correctly over the flexion point and traction\n \n• Marked active bleeding from fetal blood \n directed along the pelvic axis, autorotation of\n sampling site or maternal immune thrombo- \n fetal head would occur in >90% of the fetal\n cytopenia in pregnancy. \n OP and OT positions\n17. \n \n• Vacuum is contraindicated below 32 weeks \n• Anterior placement of the cup (in relation to\n of gestation and should be used with extreme flexion point) will aggravate de-flexion, and", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_015", "page_number": 7, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 5, "word_count": 84, "chunk_size": 546 } }, { "content": "of gestation and should be used with extreme flexion point) will aggravate de-flexion, and\n caution between 32+0 and 36+0 and should off-center placement of the cup will cause\n be discussed with consultant on-call). asynclitism. Both the situations will increase\n failure rate due to larger diameter of engage-\n \n• Fetal head per abdomen >1/5 palpable. \n ment and increase the chance of fetal injury.\n \n• Apparent CPD. \n \n• After checking the correct application and\n \n• Inexperience with the use of the equipment. ensuring that no maternal tissue is included in\n Vol. 43, No. 4, December 2021 341", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_015", "page_number": 7, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 6, "word_count": 95, "chunk_size": 597 } }, { "content": "================================================== PAGE 8 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_016", "page_number": 8, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "the cup, pressure is raised to 0.8kg/cm2 almost \n• Maternal conditions requiring short second\n straightaway. There is no advantage in stage. \n stepwise increase in pressure. \n• Delivery of the head at cesarean section.\n \n \n• Traction on the apparatus should coincide \n 11.2 Choice of forceps over ventouse \n with uterine contractions and maternal \n voluntary effort. To avoid the cup detach- \n• After coming head in breech vaginal delivery.\n ment, ‘finger thumb’ position of the other \n \n• Face presentation (Mento-anterior).\n hand is used. \n \n• Pre-term infants <36 weeks.", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_017", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 85, "chunk_size": 573 } }, { "content": "• Face presentation (Mento-anterior).\n hand is used. \n \n• Pre-term infants <36 weeks. \n \n• The use of sequential instruments is associated \n \n• Women under anesthesia and unable to\n with an increased risk of trauma to the infant. \n generate substantial expulsion. \n However, the operator should assess the risk \n of performing a second stage caesarean \n• A heavily bleeding scalp sample site.\n section with a deeply impacted fetal head \n• Significant caput in OA positions, when\n versus a forceps delivery following a failed \n ventouse cup is likely to come off.\n vacuum.", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_017", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 1, "word_count": 88, "chunk_size": 571 } }, { "content": "versus a forceps delivery following a failed \n ventouse cup is likely to come off.\n vacuum. \n \n• Beware of shoulder dystocia, after the ven- 11.3 Pre-requisites for forceps delivery\n touse delivery. The association is co-incidental \n \n• Appropriately experienced operator.\n rather than causal. \n \n• Rupture of membranes. \n \n• Fully dilated cervix. \n 10.5 Place of episiotomy for ventouse delivery \n \n• Clear knowledge of the position of the fetal\n Episiotomy should be discussed with the woman prior \n head (use of USS will be helpful if uncertain\n to any instrumental delivery and formal consent", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_017", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 2, "word_count": 89, "chunk_size": 596 } }, { "content": "head (use of USS will be helpful if uncertain\n to any instrumental delivery and formal consent \n findings). \n obtained and documented. Episiotomy is not routinely \n \n• Clinically adequate pelvis. \n required for ventouse delivery. Clinical judgement is \n \n• Fetal head engaged at station +1 or lower\n advised. \n (1/5 or less palpable abdominally).\n Episiotomy may be necessary in case of: \n \n• Adequate analgesia (regional/pudendal block).\n \n• Rigid perineum. \n \n• Empty bladder. \n \n• Big baby. \n• An adequately informed and consented\n (verbal) patient. \n \n• Fetal distress to hasten the delivery.", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_017", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 3, "word_count": 86, "chunk_size": 596 } }, { "content": "(verbal) patient. \n \n• Fetal distress to hasten the delivery. \n \n• Availability of pediatric support.\n If the perineum seems to be splitting an episiotomy is \n often performed to limit the damage\n18. Episiotomy \n (The careful abdominal/pelvic examination for the fetal\n should be done under anesthesia. (Local block if \n head station, position and fetal size is carried out as in\n regional anesthesia is not insitu). Episiotomy is always \n ventouse protocol.) \n given medio-lateral (median, increases chance of 3rd / \n 4th degree tear. Premature episiotomy should be avoided", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_017", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 4, "word_count": 84, "chunk_size": 574 } }, { "content": "4th degree tear. Premature episiotomy should be avoided \n• If episiotomy is given it should be\n and should be given at the time of crowning. (In case meticulously sutured. Vaginal and rectal\n the instrument fails to deliver the baby and C/S is examination is mandatory after instrumental\n required). delivery. \n \n• The woman and her partner if available are\n \n11. Forceps delivery debriefed regarding the procedure.\n 11.1 Indications \n• Accurate, legible documentation of the\n procedure should made. Postoperative care\n \n• Delay in the 2nd stage of labour.", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_017", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 5, "word_count": 86, "chunk_size": 556 } }, { "content": "procedure should made. Postoperative care\n \n• Delay in the 2nd stage of labour. \n plan including prescription of antibiotics,\n \n• Fetal distress in the second stage. \n analgesia and thromboprophylaxis should be\n \n• After coming head of breech delivery. carried out when needed. \n 342 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_017", "page_number": 8, "content_type": "clinical_protocol", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 6, "word_count": 49, "chunk_size": 331 } }, { "content": "================================================== PAGE 9 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_018", "page_number": 9, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "11.4 Management of a failed attempted \n• Routine bladder emptying should be\n forceps delivery encouraged after instrumental vaginal birth to\n prevent urinary retention. It is prudent to\n \n• If the forceps cannot be applied easily, or if \n document the timing and the volume of the\n the blades does not lock, or if there is lack of \n first void urine following an instrumental\n decent with moderate traction and maternal \n delivery. \n pushing, it is prudent to abandon the forceps \n delivery and resort to an emergency caesarean \n \n14. Postnatal psychological morbidity \n section.", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_019", "page_number": 9, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 89, "chunk_size": 579 } }, { "content": "14. Postnatal psychological morbidity \n section. \n \n• When attempting rotational forceps, the \n• Difficult childbirth can leave a traumatic\n rotation should be achieved with ease and if experience in women and ultimately result in\n not should discontinue the procedure. fear of future childbirth. It will also impact\n quality of life with her partner and family,\n \n• The procedure should be abandoned and \n ultimately leading to psychological morbidity.\n resorted to an emergency caesarean section \n if the birth is not imminent even after 3 pulls \n• Shared decision making with the woman,", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_019", "page_number": 9, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 589 } }, { "content": "if the birth is not imminent even after 3 pulls \n• Shared decision making with the woman,\n of a correctly applied instrument and a correct good communication, and continuous support\n direction in traction. during and immediately after the childbirth\n have the potential to reduce the psychological\n \n• If resorted to an emergency caesarean section \n morbidity following instrumental childbirth.\n due to failed forceps, the obstetrician should \n be aware that there is an increased risk of \n• It is best practice to discuss the indications", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_019", "page_number": 9, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 2, "word_count": 83, "chunk_size": 538 } }, { "content": "be aware that there is an increased risk of \n• It is best practice to discuss the indications\n head impaction and be ready to dis-impact for the instrumental delivery, how the\n the head with known maneuvers. complications were managed and to advise\n regarding future births. This should ideally be\n \n• The neonatology team should be informed \n done by the obstetrician who attended the\n clearly about the failed forceps as there is \n procedure. \n increased risk of neonatal morbidity following \n caesarean section for failed forceps. \n• It should be informed that there is a high", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_019", "page_number": 9, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 3, "word_count": 93, "chunk_size": 579 } }, { "content": "caesarean section for failed forceps. \n• It should be informed that there is a high\n possibility of a successful spontaneous vaginal\n \n12. Prophylactic antibiotics birth in the future pregnancies. \n \n• Following instrumental vaginal birth, it is \n \n15. Clinical governance \n recommended to give a single prophylactic \n dose of intravenous antibiotics to prevent 15.1 Proper documentation\n maternal infection. \n a. Documentation should include detailed\n \n• Amoxicillin and clavulanic acid single dose can \n information on the assessment, decision making\n be used for this purpose after confirming", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_019", "page_number": 9, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 4, "word_count": 82, "chunk_size": 595 } }, { "content": "information on the assessment, decision making\n be used for this purpose after confirming \n and conduct of the procedure, a plan for\n allergy status. \n postnatal care and counselling for future\n pregnancies. \n \n13. Postnatal care following instrumental \n b. Use of a standard proforma for this purpose is\n delivery \n recommended and is best to be audited at\n \n• Postnatal care following instrumental vaginal regular intervals. \n delivery requires the need to assess the \n c. Training the staff with using mannequins and\n requirement of thromboprophylaxis to prevent", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_019", "page_number": 9, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 5, "word_count": 82, "chunk_size": 565 } }, { "content": "c. Training the staff with using mannequins and\n requirement of thromboprophylaxis to prevent \n accreditation of the trainees. \n thromboembolism, adequate pain relief, \n voiding function, pelvic floor rehabilitation and \n 15.2 Obtaining cord blood \n debriefing about the events in current birth \n and about future births. \n d. If facilities are available, cord blood be obtained\n \n• For pain relief NSAIDs and paracetamol in instrumental delivery, and this should include\n administered is adequate. arterial as well as venous blood sampling. The\n Vol. 43, No. 4, December 2021 343", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_019", "page_number": 9, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 6, "word_count": 83, "chunk_size": 580 } }, { "content": "================================================== PAGE 10 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_020", "page_number": 10, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 125 } }, { "content": "PH and base deficit can be documented in the in Labor Ward management, Scotland: Elsevier\n patient operative notes. Science Limited, \n2002. \n \n e. Institutes may strive to provide obstetric care \n8. O’Connel MO, Hussain J, Maeclennan FA, Lindow\n units with required facilities to perform cord SW. Factors associated with prolonged second\n blood gases. stage of labour – a case-controlled study of 364\n nulliparous labours. J Obstet Gynaecol 2003; 23:\n 255-\n7. \n 15.3 Risk management \n \n9. Paterson CM, Saunders NG, Wadsworth J. The\n Adverse outcomes, including failed instrumental", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_021", "page_number": 10, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 86, "chunk_size": 580 } }, { "content": "9. Paterson CM, Saunders NG, Wadsworth J. The\n Adverse outcomes, including failed instrumental \n characteristics of the second stage of labour in\n deliveries, major obstetric haemorrhage, fetal injuries, \n 25,069 singleton deliveries in the North West\n and morbidity, OASI, shoulder dystocia and associated \n Thames Health Region \n1988. BJOG 1992; 99:\n complications should trigger risk management meeting \n 377-\n80. \n with unit consultant. Adequate steps can be taken to \n reduce these events in the future and to properly \n10. Arulkumaran S, Ingemarsson I, Ratnam SS. Oxy-", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_021", "page_number": 10, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 574 } }, { "content": "10. Arulkumaran S, Ingemarsson I, Ratnam SS. Oxy-\n manage such complications. Frequent audits should tocin augmentation in dysfunctional labour after\n previous caesarean section. BJOG 1989; 96:\n be undertaken on these complication rates and trends. \n 939-\n41. \n References \n11. Chelmow D, Laros RK. Maternal and Neonatal\n Outcomes After Oxytocin Augmentation in Patients\n \n1. NHS Maternity Statistics, England 2016-17 \n Undergoing a Trial of Labour After Prior Cesarean\n [https://digital.nhs.uk/data-information/ \n Delivery. Obstet Gynecol 1992; 80: 966-\n71.", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_021", "page_number": 10, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 2, "word_count": 73, "chunk_size": 558 } }, { "content": "[https://digital.nhs.uk/data-information/ \n Delivery. Obstet Gynecol 1992; 80: 966-\n71.\n publications/statistical/nhs-maternity-statistics/ \n 2016-17]. \n12. Weerasekera DS, Premartane S. A randomised\n prospective trial of the obstetric forceps versus\n \n2. Demissie K, Rhoads GG, Smulian JC, Balasubra- \n vacuum extraction using defined criteria. J Obstet\n manian BA, Gandhi K, Joseph KS, et al. Operative \n Gynaecol 2002; 22: 344-\n5. \n vaginal delivery and neonatal and infant adverse \n outcomes: population based retrospective analysis. \n13. Miksovsky P, et al. CME Review Article: Obstetric", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_021", "page_number": 10, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 3, "word_count": 74, "chunk_size": 592 } }, { "content": "13. Miksovsky P, et al. CME Review Article: Obstetric\n BMJ 2004; 329: 24-\n9. vacuum extraction: state of the art in the new\n millennium. Obstet Gynecol Survey 2001; 56: 736-\n \n3. Towner D, Castro MA, Eby-Wilkens E, Gilbert \n \n51. \n WM. Effect of mode of delivery in nulliparaous \n women on neonatal intracranial injury. N Engl J \n14. Lowe B. Fear of failure: a place for trial of\n Med 1999; 341: 1709-\n14. instrumental delivery. BJOG 1987; 94: 60-\n6.\n \n4. NHS Maternity Statistics, England 2016-17 [https:/ \n15. Johanson R, Cox C, Grady K, Howell C. Managing", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_021", "page_number": 10, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 4, "word_count": 95, "chunk_size": 558 } }, { "content": "15. Johanson R, Cox C, Grady K, Howell C. Managing\n /digital.nhs.uk/ data-and information /publications/ obstetric emergencies and trauma, The MOET\n statistical/nhs-maternity-statistics/ 2016-17]. last Course Manual. RCOG Press \n2003.\n accessed 04 February \n2021. \n \n16. Johanson RB, et al. North Staffordshire/Wigan\n \n5. Philpott RH. The recognition of cephalopelvic assisted delivery trial. BJOG 1989; 96: 537-\n44.\n disproportion. Clinics in Obstet Gynaecol 1982; \n \n17. Bird GC. The importance of flexion in vacuum\n 9: 609-\n24. \n extraction delivery. BJOG 1976; 83: 194-\n200.", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_021", "page_number": 10, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 5, "word_count": 79, "chunk_size": 578 } }, { "content": "9: 609-\n24. \n extraction delivery. BJOG 1976; 83: 194-\n200.\n \n6. Murphy DJ, et al. Cohort study of operative \n \n18. De Jonge ETM, Lindeque BG. A properly\n delivery in the second stage of labour and standard \n conducted trial of a ventouse can prevent\n of obstetric care. BJOG 2003; 110: 610-\n15. \n unexpected failure of instrumental delivery. SAMJ\n \n7. Kean LH, Baker PN, Edelstone DI. Best Practice 1991; 70: 545-\n6. \n 344 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_021", "page_number": 10, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 6, "word_count": 78, "chunk_size": 471 } }, { "content": "================================================== PAGE 11 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_022", "page_number": 11, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 125 } }, { "content": "================================================== PAGE 12 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_023", "page_number": 11, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 125 } }, { "content": "346 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_024", "page_number": 11, "content_type": "general", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 51 } }, { "content": "================================================== PAGE 13 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_025", "page_number": 11, "content_type": "guidelines", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 125 } }, { "content": "POSTPARTUM BLADDER CARE FOLLOWING \n INSTRUMENTAL DELIVERY", "metadata": { "document_name": "Assisted-vaginal-delivery-Dec-1.pdf", "section": "Section_026", "page_number": 11, "content_type": "maternal_care", "source_file": "Assisted-vaginal-delivery-Dec-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 57 } }, { "content": "================================================== PAGE 1 ==================================================\nSri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_000", "page_number": 1, "content_type": "general", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 11, "chunk_size": 156 } }, { "content": "SLCOG \n Thyroid Disease in Pregnancy and the \n \n Postpartum Period", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_001", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 66 } }, { "content": "Please cite this paper as: de Silva PHP, Waththuhewa DY, Lanerolle S, Dodampahala HS, Silva R,\n Mathota C, on behalf of the Sri Lanka College of Obstetricians and Gynaecologists. Thyroid Disorders in\n Pregnancy and Postpartum Period", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_002", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 36, "chunk_size": 232 } }, { "content": "Sri Lanka College of Obstetricians and Gynaecologists", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_003", "page_number": 1, "content_type": "general", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 7, "chunk_size": 53 } }, { "content": "================================================== PAGE 2 ==================================================", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_004", "page_number": 1, "content_type": "general", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 4, "chunk_size": 108 } }, { "content": "================================================== PAGE 3 ==================================================\nSLCOG Guideline \n \n SLCOG Guideline \n \n Thyroid disease in pregnancy and the postpartum period \n \n P H P de Silvaa, D Y Waththuhewab, Sanath Lanerollec, H S Dodampahalad, Ruwan Silvae, C Mathotaf\n on behalf of the Sri Lanka College of Obstetricians and Gynaecologists \n \n Correspondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo \n08.\n E-mail: slcogoffice@gmail.com \n \n Background by three-fold. Maternal Thyroid-Binding Globulin level", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_005", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 68, "chunk_size": 591 } }, { "content": "Background by three-fold. Maternal Thyroid-Binding Globulin level\n \n increases due to the increased hepatic synthesis under\n Thyroid disease in pregnancy, Hypothyroidism and \n oestrogen stimulation. TSH receptors in the thyroid\n Hyperthyroidism (thyrotoxicosis) can lead to adverse \n gland are weakly stimulated by Human Chorionic\n pregnancy outcomes. It can also affect foetal \n Gonadotropin (hCG) hormone. Therefore, the total\n development and contribute to negative outcomes in \n thyroxine (T4) and triiodothyronine (T3) levels\n infancy and childhood\n1.", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_005", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 1, "word_count": 71, "chunk_size": 556 } }, { "content": "thyroxine (T4) and triiodothyronine (T3) levels\n infancy and childhood\n1. \n increase, although free T4 levels are altered slightly\n and usually fall during the late course of pregnancy\n1.\n Worldwide, the most common cause of hypo- \n thyroidism is an inadequate dietary intake of iodine. \n During pregnancy, Thyroid Stimulating Hormone\n Universal Salt Iodination (USI) was first introduced in \n (TSH) levels initially rise with conception and then fall\n Sri Lanka in 1995, which led to a remarkable decrease \n during the first trimester as the increased T4, T3 levels", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_005", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 566 } }, { "content": "during the first trimester as the increased T4, T3 levels\n in the prevalence of iodine deficiency and goitre\n2. \n suppress the hypothalamic Thyroid Releasing Hormone\n Updated data regarding the prevalence of thyroid \n (TRH) thus in turn suppressing the release of TSH\n disease in the Sri Lankan population is relatively sparse. \n from the pituitary gland\n6. \n According to population-based studies done in Sri \n Lanka, prevalence of goitre was found to be around \n After the first trimester, TSH levels normalize to\n 6.8% while that of subclinical hypothyroidism was", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_005", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 3, "word_count": 86, "chunk_size": 566 } }, { "content": "6.8% while that of subclinical hypothyroidism was \n baseline levels and can increase gradually in the third\n found to be approximately 4-5% with females being \n trimester due to the presence of Placental Deiodinase.\n the most commonly affected group3,4,\n5. It is also \n In Hyperemesis Gravidarum, increased hCG levels can\n interesting to note that the prevalence of the presence \n result in a benign transient biochemical hyperthyroidism\n of thyroid auto-antibodies has been observed to be \n in around 60% of cases. \n rising following the introduction of USI\n4.", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_005", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 4, "word_count": 84, "chunk_size": 561 } }, { "content": "in around 60% of cases. \n rising following the introduction of USI\n4. \n Foetal thyroid gland starts functioning at about 12\n Physiological changes of thyroid function weeks after gestation. However, maternal T4 is\n transferred to the foetus throughout the pregnancy and\n during pregnancy \n is considered to be important factor for foetal neural\n During an average pregnancy, the volume of the thyroid development. This is of particular significance during\n gland increases by 10-30% and the iodine uptake rises the first 12 weeks. At birth, about 30% of umbilical", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_005", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 5, "word_count": 86, "chunk_size": 563 } }, { "content": "Sri Lanka Journal of Obstetrics and Gynaecology 2022; 44: 117-123 \n DOI: http://doi.org/10.4038/sljog.v44i2.8055 \n a Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka\n bSenior Registrar, Colombo North Teaching Hospital, Ragama, Sri Lanka \n c Consultant Obstetrician and Gynaecologist, Castle Street Hospital for Women, Colombo 8, Sri Lanka\n dProfessor in Obstetrics and Gynaecology Department of Obstetrics and Gynaecology, University of Colombo,\n Sri Lanka", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_005", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 6, "word_count": 62, "chunk_size": 501 } }, { "content": "Sri Lanka \n e Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka\n f Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka\n Vol. 44, No. 2, June 2022 117", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_005", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 7, "word_count": 33, "chunk_size": 235 } }, { "content": "================================================== PAGE 4 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_006", "page_number": 2, "content_type": "guidelines", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "cord-measured T4 is derived from the maternal thyroid. Therefore, a history of anti-thyroid drugs or presence of\n Thyroid Receptor Antibodies in the mother should be communicated to the neonatal physician.\n \n Thyroid function tests during pregnancy \n \n SLCOG recommends the following cut-off limits in Thyroid Function Tests during pregnancy in accor-dance\n with the reference ranges accepted by the American Thyroid Association\n7. \n \n Hormone 1st trimester 2nd trimester 3rd trimester \n \n TSH 0.1 - 2.5 mIU/L 0.2 - 3.0 mIU/L 0.3 - 3.0 mIU/L", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_007", "page_number": 2, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 80, "chunk_size": 541 } }, { "content": "TSH 0.1 - 2.5 mIU/L 0.2 - 3.0 mIU/L 0.3 - 3.0 mIU/L \n \n Total T 4 6.5 - 10.1 ug/dl 7.5 - 10.3 ug/dl 6.3 - 9.7 ug/dl \n \n Total T 3 97 - 149 ng/dl 117 - 169 ng/dl 123 - 162 ng/dl", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_007", "page_number": 2, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 1, "word_count": 43, "chunk_size": 176 } }, { "content": "Free T 4 0.8 - 1.7 ng/dl 0.6 - 1.0 ng/dl 0.5 - 0.8 ng/dl \n \n Free T 3 4.1 - 4.4 pg/ml 4.0 - 4.4 pg/ml 4.0 - 4.4 pg/ml", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_008", "page_number": 2, "content_type": "general", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 30, "chunk_size": 117 } }, { "content": "Early Gestational Hyperthyroidism (EGH) \n EGH is a recognized new entity in the spectrum of thyroid disease in pregnancy, usually presenting with Hyperemesis\n Gravidarum and mildly symptomatic hyperthyroidism. It is more common in people of Asian descent. Management\n includes supportive care and hydration. We recommend not starting antithyroid medications for this condition.\n However, many with symptoms would require beta blockers to control symptoms which can generally be\n discontinued in the second trimester\n1.", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_009", "page_number": 2, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 518 } }, { "content": "discontinued in the second trimester\n1. \n \n With regard to thyroid functions, four clinical entities can be deduced apart from the normal euthyroid status.\n These are \n \n• Overt Hyperthyroidism \n \n• Subclinical Hyperthyroidism \n \n• Overt Hypothyroidism \n \n \n• Subclinical Hypothyroidism \n Table 1 demonstrates the associated changes in thyroid function tests for each condition.\n \n Table \n1. Pregnancy associated changes in thyroid function \n tests in thyroid disorders indicated above \n Maternal Status Thyroid Stimulating Free T4 Level \n Hormone (TSH) Status", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_009", "page_number": 2, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 1, "word_count": 74, "chunk_size": 560 } }, { "content": "Maternal Status Thyroid Stimulating Free T4 Level \n Hormone (TSH) Status \n \n \n• Overt Hyperthyroidism Decrease Increase \n \n \n• Subclinical Hyperthyroidism Decrease Unchanged \n \n• Overt Hypothyroidism Increase Decrease \n \n \n• Subclinical Hypothyroidism Increase Unchanged \n \n Table \n1. Abbreviations: T4, thyroxine; TSH, thyroid-stimulating hormone. *The level of TSH decreases in early pregnancy\n because of weak TSH receptor stimulation due to substantial quantities of human chorionic gonadotropin during the first", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_009", "page_number": 2, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 2, "word_count": 63, "chunk_size": 516 } }, { "content": "12 weeks of gestation. After the first trimester, TSH levels return to baseline values.\n \n 118 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_009", "page_number": 2, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 3, "word_count": 22, "chunk_size": 142 } }, { "content": "================================================== PAGE 5 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_010", "page_number": 2, "content_type": "guidelines", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Hyperthyroidism \n• Aim to achieve rapid and optimal control with\n the lowest dose of medications to maintain\n Hyperthyroidism occurs in about 1 in 500 pregnancies \n euthyroid state with free T4 level at upper limit\n and is most commonly due to Graves’ Disease. De \n of normal range. \n novo cases can be due to solitary toxic adenomas, \n toxic multinodular goitre, subacute thyroiditis, acute \n• Antithyroid medication response is delayed and\n thyroiditis (viral/de Quervain’s) or due to medications takes 3-4 weeks. Once response is achieved,", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_011", "page_number": 2, "content_type": "medication_dosage", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 82, "chunk_size": 542 } }, { "content": "(Iodine/Lithium/Amiodarone). Increased thyroid dose should be gradually reduced to main-\n activity in pregnancy can lead to the aggravation of tenance dose for 12-18 months\n6.\n Grave’s thyrotoxicosis in the first trimester and puer- \n Eg: Carbimazole starting dose 15-40 mg, then\n perium. Generally, auto-immune thyroid diseases are \n reduced to 5-15mg, \n relatively quiescent during pregnancy due to the \n PTU starting dose 150-400 mg, then reduced to\n relatively immune-suppressive state of pregnancy. \n 50-150 mg. \n Well controlled disease can achieve good maternal and", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_011", "page_number": 2, "content_type": "medication_dosage", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 1, "word_count": 79, "chunk_size": 572 } }, { "content": "50-150 mg. \n Well controlled disease can achieve good maternal and \n• Both drugs can cross the placenta (PTU less\n foetal outcomes. If untreated however, can lead to than Carbimazole) and can result in foetal\n miscarriage, fetal loss, fetal growth restriction, preterm hypothyroidism and goitre.\n labour and increased perinatal mortality. Thyroid \n \n• Both drugs can cause congenital abnormalities\n antibodies can cross the placenta and result in foetal \n (2-4%) although more severe with Carbimazole.\n and neonatal thyrotoxicosis. \n \n• Carbimazole and Methimazole, when used in the", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_011", "page_number": 2, "content_type": "medication_dosage", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 2, "word_count": 83, "chunk_size": 582 } }, { "content": "and neonatal thyrotoxicosis. \n \n• Carbimazole and Methimazole, when used in the\n Hyperthyroidism will lead to maternal sinus tachycardia, first trimester can cause a rare side effect;\n supraventricular tachycardia, atrial fibrillation, thyroid Aplasia Cutis of the foetus (Foetus is born with\n storm and heart failure. the absence of certain layers of skin, most often\n on the scalp, but also on the trunk, and/or arms\n and legs). \n Clinical features \n \n• PTU can cause a rare complication i.e. liver\n Resembles early normal pregnancy symptoms; heat \n failure of the mother (1 in 10,000).", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_011", "page_number": 2, "content_type": "medication_dosage", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 3, "word_count": 89, "chunk_size": 588 } }, { "content": "Resembles early normal pregnancy symptoms; heat \n failure of the mother (1 in 10,000).\n intolerance, palpitations, tachycardia, palmar erythema, \n \n• Doses below 15mg/day of Carbimazole and\n vomiting, emotional lability and goitre. De novo cases \n 150mg/ day of PTU are unlikely to cause foetal\n usually present in the early second trimester. \n effects. \n Discriminating features; \n• We recommend starting PTU for newly diag-\n \n• Weight loss nosed cases in the first trimester and then con-\n verting to Carbimazole in the second trimester\n \n• Persistent tachycardia", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_011", "page_number": 2, "content_type": "medication_dosage", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 4, "word_count": 82, "chunk_size": 565 } }, { "content": "verting to Carbimazole in the second trimester\n \n• Persistent tachycardia \n and onwards. It is preferable to continue low\n \n• Sleeping pulse > 100 per minute dose Carbimazole without changing drugs if\n already diagnosed and under control with\n \n• Tremor \n Carbimazole since preconception period.\n \n• Lid lag \n \n• “Block and replace” therapy is not recom-\n \n• Exophthalmos \n mended. \n \n• Symptoms predating the pregnancy \n \n• Both drugs can cause a drug urticaria in 1-5%\n of patients and the medication should be\n Management \n changed to a different preparation.", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_011", "page_number": 2, "content_type": "medication_dosage", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 5, "word_count": 85, "chunk_size": 562 } }, { "content": "of patients and the medication should be\n Management \n changed to a different preparation. \n \n• Normal ranges for pregnancy trimesters should be \n \n• Rarely both drugs may cause agranulocytosis\n used for assessment and the diagnosis is by raised \n and result in neutropenia, thus patients should\n levels of free T4 and T3 and suppressed TSH. \n be monitored for symptoms with Full Blood\n Count at an early point of the treatment process.\n Antithyroid Drugs (ATD) \n \n• Grave’s Disease can relapse in postpartum,\n \n• Medications used are Carbimazole, Methimazole", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_011", "page_number": 2, "content_type": "medication_dosage", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 6, "word_count": 85, "chunk_size": 559 } }, { "content": "• Grave’s Disease can relapse in postpartum,\n \n• Medications used are Carbimazole, Methimazole \n therefore all mothers should be re-tested in 2-4\n and Propylthiouracil (PTU). months after delivery. \n Vol. 44, No. 2, June 2022 119", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_011", "page_number": 2, "content_type": "medication_dosage", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 7, "word_count": 34, "chunk_size": 229 } }, { "content": "================================================== PAGE 6 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_012", "page_number": 3, "content_type": "guidelines", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "• Breastfeeding is safe if it is on low doses of Diagnosis should be made clinically in severe-level\n drugs and needs foetal thyroid function thyrotoxicosis patients with evidence of decom-\n monitoring in the case of mother taking higher pensation. Burch-Wartofsky point scale or Japanese\n doses. Thyroid Association categories can be used to decide\n on the need for aggressive treatment. \n Beta Blockers \n Supportive care, starting PTU recommended for\n \n• Will provide symptom control in the early phase control of thyroxin production from both in gland and", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_013", "page_number": 3, "content_type": "medication_dosage", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 85, "chunk_size": 558 } }, { "content": "of treatment and during relapse. Eg: Propranolol peripheral conversion (preferred over Carbimazole/\n 40mg three times daily. Methimazole), beta blockers, glucocorticoid therapy\n \n• It will also reduce peripheral conversion of T\n4. with strict ICU / HDU care is useful for control of\n effect or symptoms and to revive decompensated\n \n• Can be discontinued after the achievement of \n systems. \n the antithyroid medication response. As it is used \n for a short duration, it will not cause harmful Poor respondents should be offered plasmapheresis\n foetal effects. and emergency surgery\n10. \n Surgery", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_013", "page_number": 3, "content_type": "medication_dosage", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 1, "word_count": 88, "chunk_size": 596 } }, { "content": "foetal effects. and emergency surgery\n10. \n Surgery \n Foetal/ Neonatal monitoring \n \n• Can be done for those who present with large \n \n• Transplacental passage of thyroid stimulating\n goitre causing dysphagia and stridor, confirmed \n antibodies results in foetal or neonatal\n or suspected thyroid malignancy or if allergic \n thyrotoxicosis which will cause a 25% mortality\n to antithyroid medication. If indicated it is done \n if untreated. \n in the second trimester. Need close follow up \n and treatment for hypothyroidism as 25-50% \n• Mothers known to be positive for thyroid anti-", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_013", "page_number": 3, "content_type": "medication_dosage", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 583 } }, { "content": "and treatment for hypothyroidism as 25-50% \n• Mothers known to be positive for thyroid anti-\n will be hypothyroid following surgery. bodies, antibody level testing should be done in\n early pregnancy. If titers are high or do not fall\n \n• 1-2% of patients will develop hypocalcemia due \n with treatment, foetal ultrasound should be\n to removal of the parathyroid gland. \n offered to detect foetal growth restriction in\n second and third trimesters. Looking for Goitre\n Radio-active Iodine \n and tachycardia should be done after delivery.", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_013", "page_number": 3, "content_type": "medication_dosage", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 3, "word_count": 81, "chunk_size": 536 } }, { "content": "Radio-active Iodine \n and tachycardia should be done after delivery.\n \n• As it is taken up by foetal thyroid and causes Thyroid function tests in cord blood and neonate\n foetal thyroid ablation, radio-iodine therapy is should be performed\n11.\n contra-indicated in pregnancy and post-partum. \n \n• Foetal thyrotoxicosis should be treated with\n \n• Radio-iodine scans for diagnostic purposes are antithyroid medications to the mother, with\n also contra-indicated in pregnancy and thyroxine replacement if she is euthyroid.\n breastfeeding. Breastfeeding should be withheld", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_013", "page_number": 3, "content_type": "medication_dosage", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 4, "word_count": 79, "chunk_size": 567 } }, { "content": "breastfeeding. Breastfeeding should be withheld \n \n• Neonate should be closely monitored by the\n for 24 hrs if radio iodine tests done postpartum. \n Paediatric team. Following diagnosis of thyroid\n disease, it should be treated as soon as possible.\n Thyroid Storm – Diagnosis and Management \n However, the abnormalities will settle once\n A rare disorder with a mortality rate of 8-25% which maternal antibodies are completely cleared after\n presents with multi-organ dysfunction. Symptoms around 4th month of life.\n include; pyrexia, tachycardia, arrhythmia, heart failure,", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_013", "page_number": 3, "content_type": "medication_dosage", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 5, "word_count": 81, "chunk_size": 573 } }, { "content": "include; pyrexia, tachycardia, arrhythmia, heart failure, \n delirium, stupor or coma, liver failure, vomiting and Subclinical Hyperthyroidism\n diarrhoea. \n Subclinical Hyperthyroidism is reported in about\n Precipitants; sudden withdrawal of ATD, following 0.8-1.7 percent of pregnant women12,\n13. Diagnosis is\n radio-iodine treatment, stress due trauma (surgery) or done using low TSH levels with normal free T4, T3\n acute febrile illness. Thus, ensuring euthyroid status levels. This diagnosis not shown to be associated with", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_013", "page_number": 3, "content_type": "medication_dosage", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 6, "word_count": 70, "chunk_size": 526 } }, { "content": "of the mother at the elective caesarean section or at an effect on pregnancy. Therefore, treatment is not\n labour is of paramount importance. recommended. \n 120 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_013", "page_number": 3, "content_type": "medication_dosage", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 7, "word_count": 32, "chunk_size": 208 } }, { "content": "================================================== PAGE 7 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_014", "page_number": 4, "content_type": "guidelines", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Hypothyroidism Mothers who are well controlled and euthyroid at\n conception can achieve good maternal and foetal\n Hypothyroidism affects around 1% of pregnancies. \n outcomes. \n Most women will have a positive family history of \n auto-immune hypothyroidism and will be diagnosed Diagnosis of hypothyroidism is done when TSH level\n and placed on treatment prenatally. Most common types is over the reference range for the gestational age of\n are Atrophic Thyroiditis and Hashimoto’s Thyroiditis pregnancy and the free T4/T3 levels are below the", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_015", "page_number": 4, "content_type": "clinical_protocol", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 542 } }, { "content": "(Auto-Immune Thyroiditis and goitre). Hashimoto’s lower limit of normal. \n Thyroiditis is the most common cause of hypothy- \n Adverse perinatal outcomes could be reduced by\n roidism in developed countries. In contrast, worldwide, \n appropriate therapy. \n the most common cause of hypothyroidism is the \n inadequate dietary intake of iodine. \n Clinical features \n Hypothyroidism can also be iatrogenic; due to radio- \n Symptoms may resemble normal pregnancy symptoms;\n iodine therapy, thyroidectomy, and due to medications \n lethargy, tiredness, weight gain, hair loss, dry skin,", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_015", "page_number": 4, "content_type": "clinical_protocol", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 1, "word_count": 77, "chunk_size": 578 } }, { "content": "lethargy, tiredness, weight gain, hair loss, dry skin,\n (Antithyroid drugs, Iodine, Lithium, Amiodarone). It \n constipation, fluid retention and goitre.\n can also be associated with other auto-immune \n diseases. Discriminating features; \n \n• Cold intolerance \n Hashimoto Thyroiditis is an autoimmune disease that \n destroys thyroid cells by cell and antibody-mediated \n• Bradycardia \n immune responses. The pathology of the disease \n \n• Delayed ankle reflex \n involves the formation of antithyroid antibodies that \n target and destroy the thyroid tissue, causing pro- \n Management", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_015", "page_number": 4, "content_type": "clinical_protocol", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 2, "word_count": 75, "chunk_size": 580 } }, { "content": "target and destroy the thyroid tissue, causing pro- \n Management \n gressive fibrosis. Most patients develop antibodies to \n a variety of thyroid antigens, the most common of \n• Normal ranges for pregnancy trimesters should\n which is anti-thyroid peroxidase (anti-TPO, previously be used for assessment, and diagnosed by\n named Anti-microsomal antibody). Many also form reduced levels of free T4, T3 and increased\n antithyroglobulin (anti-Tg) and TSH receptor-blocking TSH. \n antibodies (TBII). \n• Presence of auto-antibodies will help the\n diagnosis but is not recommended to be per-", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_015", "page_number": 4, "content_type": "clinical_protocol", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 3, "word_count": 82, "chunk_size": 583 } }, { "content": "• Presence of auto-antibodies will help the\n diagnosis but is not recommended to be per-\n Pregnancy has no effect on hypothyroidism. Twenty- formed (anti-thyroid peroxidase antibody)\n five percent of women will require higher requirements routinely. \n of thyroxine dosing during the course of the preg- \n \n• Thyroxine does not freely cross the placenta\n nancy. If untreated, it can lead to miscarriage, fetal \n except for very slight amounts. This will not\n loss, foetal anaemia and low birthweight. Foetal thyroid cause foetal thyrotoxicosis.\n functions begin around the 12th week of gestation.", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_015", "page_number": 4, "content_type": "clinical_protocol", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 4, "word_count": 88, "chunk_size": 595 } }, { "content": "functions begin around the 12th week of gestation. \n \n• Women who are already on levothyroxine\n Thus, the foetus is dependent on maternal thyroxine \n therapy can continue the same dose guided by\n during early gestation. Therefore, if untreated, hypothy- \n thyroid function tests (TFT). \n roidism and severe maternal iodine deficiency will \n \n• Women who are under replacement therapy need\n affect fetal neuro-development leading to cretinism \n adjustment of dose and TFT should be repeated\n (condition of severe physical and mental retardation \n after 4-6 weeks.", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_015", "page_number": 4, "content_type": "clinical_protocol", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 5, "word_count": 81, "chunk_size": 562 } }, { "content": "(condition of severe physical and mental retardation \n after 4-6 weeks. \n specifically due to deficiency of thyroid hormones \n during early pregnancy, hypothyroidism, spastic motor \n• Immediate replacement therapy should be\n disorder and deaf mutism-congenital deafness that started for newly diagnosed hypothyroidism\n results in inability to speak). Untreated maternal with a starting dose of 100 μμμμμg/day. If in case\n of history of cardiac disease, a lower dose\n hypothyroidism has a higher chance of low birth- \n should be introduced.", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_015", "page_number": 4, "content_type": "clinical_protocol", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 6, "word_count": 76, "chunk_size": 539 } }, { "content": "hypothyroidism has a higher chance of low birth- \n should be introduced. \n weight. In rare cases, maternal thyroid antibodies could \n cross the placenta and cause foetal hypothyroidism \n• If dose adjustments are made during pregnancy,\n but this is extremely rare. the dose should be reduced to pre-pregnancy\n dose after delivery to prevent hyperthyroidism.\n Vol. 44, No. 2, June 2022 121", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_015", "page_number": 4, "content_type": "clinical_protocol", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 7, "word_count": 59, "chunk_size": 387 } }, { "content": "================================================== PAGE 8 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_016", "page_number": 5, "content_type": "guidelines", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Subclinical Hypothyroidism dose, because thyroid hormone requirements increase\n during pregnancy. If new onset hypothyroidism has\n Include the group of women who do not have \n been detected, the woman should be treated with\n symptoms and signs suggestive of thyroid dysfunction \n levothyroxine to normalize her TSH values.\n and who present with high TSH and normal thyroxine \n levels. It is common in the presence of anti-thyroid \n antibodies. Evidence reports improved pregnancy Foetal / Neonatal Hypothyroidism\n outcome in women supplemented with thyroxine in", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_017", "page_number": 5, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 561 } }, { "content": "outcome in women supplemented with thyroxine in \n Occur due to transplacental passage of maternal anti-\n the presence of anti-thyroid antibodies. However, TSH \n thyroid antibodies with incidence of 1 in 180,000\n level between 2.5-4.0 mU/L in asymptomatic patients \n pregnancies. \n does not require treatment\n5. \n We recommend screening of all neonates with TSH\n Controlled Anti Thyroid Screening trial (CATS) and \n levels via Guthrie Heel Prick Neonatal Screening test.\n Maternal-Foetal Medicine Units Networks randomized \n trials published in 2017 demonstrated no difference in", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_017", "page_number": 5, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 1, "word_count": 79, "chunk_size": 578 } }, { "content": "trials published in 2017 demonstrated no difference in \n neuro cognitive functions of babies born to mothers Postpartum Thyroiditis\n with sub clinical hypothyroidism up to the age of 5 in \n Incidence around 1-17% of pregnancies and is more\n both arms of treatment or no treatment. Recently CATs \n common among women with anti-thyroid peroxidase\n study in its publication of follow up at 9 years also \n (anti-TPO) antibodies. It is usually asymptomatic and\n confirmed no difference in the neurodevelopment of \n present around 3-4 months postpartum. It can present", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_017", "page_number": 5, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 562 } }, { "content": "present around 3-4 months postpartum. It can present\n the offspring. However, reading through published trials \n as transient hyperthyroidism, transient hypothyroidism\n some have shown higher incidences of preterm birth, \n or as a biphasic disease (first hyperthyroidism followed\n abruption, admission to (PBU) premature baby unit, \n by prolonged hypothyroidism). Small, painless goitre\n Preeclampsia and gestational diabetes14,15,16,\n17. But some \n can be present in about 50% of women. \n studies have not shown the same results18,19,\n20. There-", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_017", "page_number": 5, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 3, "word_count": 73, "chunk_size": 546 } }, { "content": "can be present in about 50% of women. \n studies have not shown the same results18,19,\n20. There- \n fore our conclusion is at present there is no clinical \n Treatment should be guided by symptom control while\n advantage in treatment of subclinical hypothy- \n most recover spontaneously without treatment. 3-4%\n roidism unless there is the presence of anti-thyroid \n of women will have permanent hypothyroidism and\n antibodies of the mother. \n about 10-25% of women will have recurrence in future\n pregnancies. \n We recommend thyroxine replacement with 25-50", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_017", "page_number": 5, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 4, "word_count": 82, "chunk_size": 556 } }, { "content": "pregnancies. \n We recommend thyroxine replacement with 25-50 \n microgram/ day for prenatal women with positive \n Most women with positive antibodies will develop\n antibodies and subclinical hypothyroidism and titration \n postpartum depression despite thyroid status.\n of TSH to normal levels. \n SLCOG is of the view, that uncomplicated thyroid\n Untreated severe hypothyroidism in the mother can \n disease could be managed by the Obstetrics and\n lead to impaired brain development in the foetus. Given \n Gynaecology Consultant with clear knowledge of the", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_017", "page_number": 5, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 5, "word_count": 76, "chunk_size": 553 } }, { "content": "Gynaecology Consultant with clear knowledge of the\n ambiguity in outcome of many studies in evaluating \n disease process. \n pros and cons of treating subclinical hypothyroidism, \n there is no world-wide consensus of opinion regarding \n References \n screening all women for hypothyroidism during \n pregnancy. \n1. Studd L. Progress in Obstetrics and Gynaecology.\n Volume \n18. \n General recommendation is to check a woman’s TSH \n \n2. ICCIDD, UNICEF, WHO. Assessment of iodine\n as soon as pregnancy is confirmed in women at high \n deficiency disorders and monitoring their", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_017", "page_number": 5, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 6, "word_count": 80, "chunk_size": 568 } }, { "content": "as soon as pregnancy is confirmed in women at high \n deficiency disorders and monitoring their\n risk for thyroid disease, such as those with prior \n elimination: a guide for programme managers.\n treatment for hyper- or hypothyroidism, a family history \n Geneva: World Health Organisation; \n2007.\n of thyroid disease, a personal history of autoimmune \n disease, and those with a goiter. \n3. Chandrasinghe P, Fernando R, Nandasena S,\n Pathmeswaran A. Epidemiology of goitres in Sri\n Women with established hypothyroidism should have Lanka with geographic information system", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_017", "page_number": 5, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 7, "word_count": 82, "chunk_size": 571 } }, { "content": "Women with established hypothyroidism should have Lanka with geographic information system\n a TSH test as soon as pregnancy is confirmed. They mapping: population-based cross-sectional study.\n also should immediately increase their levothyroxine World J Endocr Surg 2015; 7(3): 55-\n9.\n 122 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_017", "page_number": 5, "content_type": "maternal_care", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 8, "word_count": 47, "chunk_size": 337 } }, { "content": "================================================== PAGE 9 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_018", "page_number": 6, "content_type": "guidelines", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "4. Fernando RF, Chandrasinghe PC, Pathmeswaran maternal age? Clin Endocrinol (Oxf) 2016; 84:\n AA. The prevalence of autoimmune thyroiditis after 121-\n6. (Level II-3) \n universal salt iodisation in Sri Lanka. Ceylon Med \n \n14. Tudela CM, Casey BM, McIntire DD, Cunningham\n J 2012; 57(3): 116-\n19. \n FG. Relationship of subclinical thyroid disease to\n \n5. Gunawardane IK, Somasundaram N. Update on the incidence of gestational diabetes. Obstet\n subclinical thyroid disease. Sri Lanka Journal of Gynecol 2012; 119: 983-\n8. (Level II-3)\n Diabetes, Endocrinology and Metabolism 2013; 3:", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_019", "page_number": 6, "content_type": "clinical_protocol", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 85, "chunk_size": 581 } }, { "content": "8. (Level II-3)\n Diabetes, Endocrinology and Metabolism 2013; 3: \n \n15. Wilson KL, Casey BM, McIntire DD, Halvorson\n 84-\n7. \n LM, Cunningham FG. Subclinical thyroid disease\n \n6. Thyroid disease in pregnancy. ACOG Practice and the incidence of hypertension in pregnancy.\n Bulletin No.\n223. American College of Obstetricians Obstet Gynecol 2012; 119: 315-\n20. (Level II-3)\n and Gynaecologists. Obstet Gynecol 2020; 135: \n \n16. Casey BM, Dashe JS, Wells CE, McIntire DD,\n e261-\n74. \n Byrd W, Leveno KJ, et al. Subclinical hypothy-", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_019", "page_number": 6, "content_type": "clinical_protocol", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 1, "word_count": 79, "chunk_size": 527 } }, { "content": "e261-\n74. \n Byrd W, Leveno KJ, et al. Subclinical hypothy-\n \n7. Alexander EK, Pearce EN, Brent GA, Brown RS, roidism and pregnancy outcomes. Obstet Gynecol\n Chen H, Dosiou C, et al. 2017 guidelines of the 2005; 105: 239-\n45. (Level II-2)\n American Thyroid Association for the diagnosis \n \n17. Korevaar TI, Derakhshan A, Taylor PN, Meima\n and management of thyroid disease during \n M, Chen L, Bliddal S, et al. Association of thyroid\n pregnancy and the postpartum. Thyroid 2017; 27: \n function test abnormalities and thyroid auto-\n 315-\n89. \n immunity with preterm birth: a systematic review", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_019", "page_number": 6, "content_type": "clinical_protocol", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 2, "word_count": 93, "chunk_size": 590 } }, { "content": "315-\n89. \n immunity with preterm birth: a systematic review\n \n8. Dong AC, Stagnaro-Green A. Differences in and meta-analysis. Consortium on Thyroid and\n diagnostic criteria mask the true prevalence of Pregnancy-Study Group on Preterm Birth\n thyroid disease in pregnancy: a systematic review [published erratum appears in JAMA 2019; 322:\n and meta-analysis. Thyroid 2019; 29: 278-\n89. 1718]. JAMA 2019; 322: 632-\n41. (Systematic\n Review and MetaAnalysis \n \n9. Harding KB, Peña?Rosas JP, Webster AC, Yap CM, \n Payne BA, Ota E, et al. Iodine supplementation", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_019", "page_number": 6, "content_type": "clinical_protocol", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 3, "word_count": 82, "chunk_size": 554 } }, { "content": "9. Harding KB, Peña?Rosas JP, Webster AC, Yap CM, \n Payne BA, Ota E, et al. Iodine supplementation \n18. Sheehan PM, Nankervis A, Araujo Júnior E, Da\n for women during the preconception, pregnancy SC. Maternal thyroid disease and preterm birth:\n and postpartum period. systematic review and meta-analysis. J Clin\n Cochrane Database of Systematic Reviews 2017, Endocrinol Metab 2015; 100: 4325-\n31.\n Issue \n3. Art. No.: CD\n011761. DOI: 10.1002/ (Systematic Review and Meta-Analysis)\n 14651858.CD\n011761. \n \n19. Cleary-Goldman J, Malone FD, Lambert-", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_019", "page_number": 6, "content_type": "clinical_protocol", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 4, "word_count": 80, "chunk_size": 546 } }, { "content": "14651858.CD\n011761. \n \n19. Cleary-Goldman J, Malone FD, Lambert-\n \n10. Ross DS, Burch HB, Cooper DS, Greenlee MC, Messerlian G, Sullivan L, Canick J, Porter TF, et al.\n Laurberg P, Maia AL, Rivkees SA, Samuels M, Maternal thyroid hypofunction and pregnancy\n Sosa JA, Stan MN, Walter MA. 2016 American outcome. Obstet Gynecol 2008; 112: 85-\n92. (Level\n Thyroid Association Guidelines for Diagnosis and II-3) \n Management of Hyperthyroidism and Other Causes \n \n20. Casey BM, Dashe JS, Spong CY, McIntire DD,\n of Thyrotoxicosis. Thyroid 2016; 25: 10 \n Leveno KJ, Cunningham GF. Perinatal significance", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_019", "page_number": 6, "content_type": "clinical_protocol", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 5, "word_count": 90, "chunk_size": 597 } }, { "content": "of Thyrotoxicosis. Thyroid 2016; 25: 10 \n Leveno KJ, Cunningham GF. Perinatal significance\n DOI: 10.1089/thy.2016.\n0229. \n of isolated maternal hypothyroxinemia identified\n \n11. Pearce EN. Management of thyrotoxicosis: in the first half of pregnancy. Obstet Gynecol\n preconception, pregnancy, and the postpartum 2007; 109: 1129-\n35. (Level II3)\n period. Endocr Pract 2019; 25: 62-\n8. \n \n21. Leung AKC, Leung AAC. Evaluation and\n \n12. Casey BM, Dashe JS, Wells CE, McIntire DD, management of the child with hypothyroidism.\n Leveno KJ, Cunningham FG. Subclinical World J Pediatr. 2019; 15(2): 124-", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_019", "page_number": 6, "content_type": "clinical_protocol", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 6, "word_count": 85, "chunk_size": 595 } }, { "content": "Leveno KJ, Cunningham FG. Subclinical World J Pediatr. 2019; 15(2): 124-\n134. [PubMed]\n hyperthyroidism and pregnancy outcomes. Obstet \n \n22. Yuan J, Sun C, Jiang S, Lu Y, Zhang Y, Gao XH,\n Gynecol 2006; 107: 337-\n41. (Level II-2) \n Wu Y, Chen HD. The Prevalence of Thyroid\n \n13. Diéguez M, Herrero A, Avello N, Suárez P, Delgado Disorders in Patients With Vitiligo: A Systematic\n E, Menéndez E. Prevalence of thyroid dysfunction Review and Meta-Analysis. Front Endocrinol\n in women in early pregnancy: does it increase with (Lausanne). 2018; 9: \n803.\n Vol. 44, No. 2, June 2022 123", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_019", "page_number": 6, "content_type": "clinical_protocol", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 7, "word_count": 95, "chunk_size": 582 } }, { "content": "================================================== PAGE 10 ==================================================", "metadata": { "document_name": "SLJOG-June-2022-Page-115-124.pdf", "section": "Section_020", "page_number": 7, "content_type": "general", "source_file": "SLJOG-June-2022-Page-115-124.pdf", "chunk_index": 0, "word_count": 4, "chunk_size": 109 } }, { "content": "================================================== PAGE 1 ==================================================\nManagement of Puerperal sepsis", "metadata": { "document_name": "puerperal-sepsis.pdf", "section": "Section_000", "page_number": 1, "content_type": "clinical_protocol", "source_file": "puerperal-sepsis.pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 139 } }, { "content": "If very ill \n Septicaemic\n If evidence of in shock \n in respiratory distress\n septicaemia, bleeding tendency\n Midwifery level Non specialist unit present attend to present \n Specialized Unit Manage in ICU\n resuscitation and \n Post partum visits \n transfer \n (cid:131) Assess-signs of shock, septicaemia, anaemia & treat accordingly immediately\n Fe ver/purulent vaginal (cid:131) Abdominal examination for uterine size and tenderness \n (cid:131) Physical examination & Ultrasound to\n discharge/pelvic pain (cid:131) Check for uterine haemorrhage & control it rule out:", "metadata": { "document_name": "puerperal-sepsis.pdf", "section": "Section_001", "page_number": 1, "content_type": "emergency_procedure", "source_file": "puerperal-sepsis.pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 567 } }, { "content": "discharge/pelvic pain (cid:131) Check for uterine haemorrhage & control it rule out: \n (cid:131) Penicillin 2 million units IV/IM every 6 hours +gentamicin 80mg Pelvic abscess\n (cid:131) Amoxycillin- clavulinic acid -1.2 g intravenous 8 hourly or 625mg oral 8 hourly/bd Pelvic thromboplebitis\n (cid:131) (IV/IM every 8 hourly +metronidazole) 500mg every 8 hours orally. Retained products\n Admit (cid:131) IV fluids-I litre, 5% dextrose or N. saline rapidly followed by (cid:131) Culture and sensitivity test for vaginal", "metadata": { "document_name": "puerperal-sepsis.pdf", "section": "Section_001", "page_number": 1, "content_type": "emergency_procedure", "source_file": "puerperal-sepsis.pdf", "chunk_index": 1, "word_count": 74, "chunk_size": 519 } }, { "content": "Assume Puerperal sepsis immediately (cid:131) 3000 mls every 24 hours. discharge, Gram stain \n (cid:131) Renal,liver, coagulation profiles\n (cid:131) Vital signs every 6 hours \n (cid:131) Blood culture \n (cid:131) Continue IV therapy\n Amoxycillin- clavulinic acid (Amoxyclav)-\n 1.2g intravenous 8 hourly with or without\n gentamicin \n If response is poor, \n Imipenem 500 mg intravenous 8 hourly\n Very sick (high fever, altered Admit immediately- Or \n consciousness, rapid pulse-Assume Ticarcillin-clavulinic acid 3.2 g\n If possible accompany the patient", "metadata": { "document_name": "puerperal-sepsis.pdf", "section": "Section_001", "page_number": 1, "content_type": "emergency_procedure", "source_file": "puerperal-sepsis.pdf", "chunk_index": 2, "word_count": 72, "chunk_size": 552 } }, { "content": "If possible accompany the patient \n critically ill. intravenous 8 hourly.may be used in place\n of Amoxycillin- clavulinic acid\n (Amoxyclav). \n Yes Improvement in 24 hours (cid:131) Review and change antibiotic based on\n No Transfer to specialist sensitivity \n hospital \n Appropriate management of complications\n (cid:131) Retained placental fragments- Evacuate\n Needs an ultrasound to Continue IV antibiotics for 3 days only when the patient is stable.\n exclude retained products – (cid:131) Pelvic abscess, \n No Transfer to specialist", "metadata": { "document_name": "puerperal-sepsis.pdf", "section": "Section_001", "page_number": 1, "content_type": "emergency_procedure", "source_file": "puerperal-sepsis.pdf", "chunk_index": 3, "word_count": 73, "chunk_size": 535 } }, { "content": "exclude retained products – (cid:131) Pelvic abscess, \n No Transfer to specialist \n Placental segments as a cause hospital (cid:131) Thromboplebitis,\n of sepsis \n Yes Resolved completely \n Refer to specialist unit for \n ultrasound or further advice \n Low risk \n At risk \n Discontinue IV \n Discharge the patient Alarming \n Oral antibiotics for 4-7 days \n Check haemoglobin and treat anaemia Assessment \n Sri Lanka College of Obstetrics and Gynaecology\n Advice to return if following recurres Health sector development Project\n \n• Fever Referral Guidelines- Management of Puerperal sepsis", "metadata": { "document_name": "puerperal-sepsis.pdf", "section": "Section_001", "page_number": 1, "content_type": "emergency_procedure", "source_file": "puerperal-sepsis.pdf", "chunk_index": 4, "word_count": 79, "chunk_size": 586 } }, { "content": "• Fever Referral Guidelines- Management of Puerperal sepsis\n \n• Vaginal discharge \n \n• Pelvic pain", "metadata": { "document_name": "puerperal-sepsis.pdf", "section": "Section_001", "page_number": 1, "content_type": "emergency_procedure", "source_file": "puerperal-sepsis.pdf", "chunk_index": 5, "word_count": 14, "chunk_size": 98 } }, { "content": "================================================== PAGE 1 ==================================================\nManagement of Medical Disease Complicating Pregnancies\n \n 1 Bronchial Asthma \n 2 Tuberculosis \n 3 Influenza A & B Virus Infection Including H1N1\n \n 4 Liver Disease \n 5 Renal Disease \n \n 6 Thyroid Disease \n 7 Rheumatoid Arthritis \n \n 8 Systemic Lupus Erythematosus \n 9 Immune Thrombocytopaenic Purpura \n \n 10 Antiphospholipid Syndrome \n 11 HIV \n \n 12 Syphilis \n 13 Malaria", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_000", "page_number": 1, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 53, "chunk_size": 480 } }, { "content": "================================================== PAGE 2 ==================================================\nThese guidelines are published by the Family Health Bureau, Ministry of\n Health, 231, De Sarem Place, Colombo 10, Sri Lanka \n \n Web. www.fhb.health.gov.lk \n \n Prepared by Ceylon College of Physicians together with the Sri Lanka\n College of Obstetricians and Gynaecologists, National STD and AIDS\n Control Progarmme, Anti Malaria Campaign and National Program for\n Tuberculosis Control and Chest Diseases \n \n Edited by Dr. Camaline Motha and Dr. Nilmini Hemachandra", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_001", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 573 } }, { "content": "Edited by Dr. Camaline Motha and Dr. Nilmini Hemachandra\n Copyright @ 2015 Ministry of Health", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_001", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 15, "chunk_size": 93 } }, { "content": "Statement of Intent \n \n The main Purpose of these guidelines are to improve the quality of\n clinical care provided by the health care providers at all levels. These\n parameters of practice should be considered as recommendations\n only. The ultimate judgement regarding a particular clinical procedure\n or a treatment plan must be made by the clinician in light of the clini-\n cal data gathered from the patient and the diagnosis and treatment\n options available.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_002", "page_number": 1, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 462 } }, { "content": "II National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_003", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 3 ==================================================\nPreface", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_004", "page_number": 1, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 5, "chunk_size": 116 } }, { "content": "This national guideline on maternal care is very well-timed, as a greater\n emphasis is being given for improving the quality of maternal care services\n for further reduction of maternal and newborn mortality and morbidity\n in Sri Lanka. This set of guidelines has addressed the relatively rare but\n important disease entities which is matching with the epidemiological\n transition of causality of maternal deaths from direct causes to indirect\n causes. This is an attempt to improve the quality and uniformity of clinical\n care with efficiency, cost effectiveness and accountability.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_005", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 87, "chunk_size": 583 } }, { "content": "care with efficiency, cost effectiveness and accountability.\n \n I highly appreciate the contribution made by Ceylon College of Physicians,\n Sri Lanka College of Obstetricians and Gynaecologists and relevant public\n health programmes in developing these guidelines. Their experience and\n updated scientific knowledge is reflecting in the guidelines.\n \n Further, these guidelines have been developed considering the policies,\n facilities, and resources available in the country. As such this set of\n guideline will be considered as national guidelines for the conditions\n described.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_005", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 77, "chunk_size": 580 } }, { "content": "guideline will be considered as national guidelines for the conditions\n described. \n \n Dr. P. G. Mahipala \n \n Director General of Health Services, \n \n Ministry of Health, \n \n Sri Lanka", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_005", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 25, "chunk_size": 184 } }, { "content": "National Guideline for Maternal Care - Volume II III", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_006", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 4 ==================================================\nMessage from the President of Ceylon College of \n Physicians \n \n This", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_007", "page_number": 1, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 14, "chunk_size": 178 } }, { "content": "IV National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_008", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 5 ==================================================\nMessage from the President of Sri Lanka College of\n Obstetricians and Gynaecologists \n \n This", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_009", "page_number": 1, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 17, "chunk_size": 202 } }, { "content": "National Guideline for Maternal Care - Volume II V", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_010", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 6 ==================================================\nContributors for the guideline development \n Ceylon College of Physicians \n \n Coordinated and compiled by Dr Carmeline Motha Message from the Minister of Health\n Message from the Secretary of Ministry of Health\n Prof Chandrika Wijeyaratne Preface\n \n Dr Priyankara Jayawardana Message from the President Ceylon College of Physicians\n Dr Ravini Karunatillake Message from the President of Sri Lanka College of\n Obstetricians and Gynaecologists\n Dr Geethal Perera", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_011", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 67, "chunk_size": 569 } }, { "content": "Obstetricians and Gynaecologists\n Dr Geethal Perera \n Guideline Development committee\n Prof. Priyadarshani Galappatthy \n List of Abbreviations\n Dr Inoshi Atukorala \n List of Tables\n Dr. Senani Williams \n Disclaimer\n Dr Bernadene Fernandopulle \n Introduction\n Dr Durgadevi Moratuwagama \n1. Bronchial Asthma in Pregnancy\n Dr Noel Somasundaram 1.1 Introduction\n Dr Charles Antonypillai 1.2 Women with pre-existing bronchial asthma\n Dr Madunil Niriella 1.3 When to suspect bronchial asthma in a previously\n healthy woman\n Dr Hasitha Wijewantha \n 1.4 Management of bronchial asthma in pregnancy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_011", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 75, "chunk_size": 589 } }, { "content": "healthy woman\n Dr Hasitha Wijewantha \n 1.4 Management of bronchial asthma in pregnancy\n Dr Mananjala Senanayake \n 1.4.1 Pharmacological management\n Dr Shamila De Silva \n 1.4.2 Adjuvant therapy for bronchial asthma\n Dr Sandhya Seneviratne \n 1.5 Indications for transfer to intensive care unit (ICU)\n 1.6 Antenatal care\n Sri Lanka College of Obstetricians and Gynaecologists\n 1.7 Delivery\n 1.8 Postpartum care\n Prof. Hemantha Senanayake \n \n2. Management of Tuberculosis during Pregnancy\n Dr. U.D.P. Rathnasiri \n 2.1 How does tuberculosis spread?\n Dr. Janaki Kumarasinghe \n 2.2 Risk of infection", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_011", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 79, "chunk_size": 592 } }, { "content": "2.1 How does tuberculosis spread?\n Dr. Janaki Kumarasinghe \n 2.2 Risk of infection\n Dr. Ajitha Wijesundara \n 2.3.1 Who is a TB suspect?\n Dr. Harsha Atapattu \n 2.3.2 Case of a ‘Bacteriological confirmed TB’\n 2.3.3 Case of a ‘clinically diagnosed TB’\n National STD and AIDS control Programme \n 2.4 Common symptoms of pulmonary tuberculosis\n Anti-Malaria Campaign \n 2.5 Investigations\n National Program for Tuberculosis Control and Chest Diseases\n 2.6 TB treatment regimens\n Family Health Bureau \n 2.6.1 Intensive phase\n 2.6.2 Continuation phase\n 2.6.3 Standard code for TB treatment regimens", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_011", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 82, "chunk_size": 589 } }, { "content": "2.6.1 Intensive phase\n 2.6.2 Continuation phase\n 2.6.3 Standard code for TB treatment regimens\n VI National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_011", "page_number": 1, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 4, "word_count": 22, "chunk_size": 147 } }, { "content": "================================================== PAGE 7 ==================================================\nMessage from the Minister of Health \n Message from the Secretary of Ministry of Health\n Preface \n Message from the President Ceylon College of Physicians\n \n Message from the President of Sri Lanka College of\n Obstetricians and Gynaecologists \n Guideline Development committee \n List of Abbreviations \n List of Tables \n Disclaimer \n Introduction \n \n1. Bronchial Asthma in Pregnancy \n 1.1 Introduction \n 1.2 Women with pre-existing bronchial asthma", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_012", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 63, "chunk_size": 555 } }, { "content": "1. Bronchial Asthma in Pregnancy \n 1.1 Introduction \n 1.2 Women with pre-existing bronchial asthma \n 1.3 When to suspect bronchial asthma in a previously\n healthy woman \n 1.4 Management of bronchial asthma in pregnancy\n 1.4.1 Pharmacological management \n 1.4.2 Adjuvant therapy for bronchial asthma \n 1.5 Indications for transfer to intensive care unit (ICU)\n 1.6 Antenatal care \n 1.7 Delivery \n 1.8 Postpartum care \n \n \n2. Management of Tuberculosis during Pregnancy\n 2.1 How does tuberculosis spread? \n 2.2 Risk of infection \n 2.3.1 Who is a TB suspect?", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_012", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 78, "chunk_size": 555 } }, { "content": "2.1 How does tuberculosis spread? \n 2.2 Risk of infection \n 2.3.1 Who is a TB suspect? \n 2.3.2 Case of a ‘Bacteriological confirmed TB’ \n 2.3.3 Case of a ‘clinically diagnosed TB’ \n 2.4 Common symptoms of pulmonary tuberculosis \n 2.5 Investigations \n 2.6 TB treatment regimens \n 2.6.1 Intensive phase \n 2.6.2 Continuation phase \n 2.6.3 Standard code for TB treatment regimens \n \n National Guideline for Maternal Care - Volume II VII", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_012", "page_number": 2, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 63, "chunk_size": 432 } }, { "content": "================================================== PAGE 8 ==================================================\n2.6.4 Monitoring of sputum smear- positive pulmonary TB 4.1.\n8. Preeclampsia\n 2.6.5 Treatment during pregnancy 4.1.\n9. HELLP Syndrome\n 2.6.6 Treatment during breast feeding 4.1.\n10. Acute Fatty Liver of Pregnancy (AFLP)\n \n 2.6.7 Management of a new born child of a mother with 4.\n2. Liver disease coincidental to pregnancy\n active TB 4.2.\n1. Non alcoholic fatty liver disease (NAFLD)\n 2.6.8 Directly Observed Treatment 4.2.\n2. Dengue infection", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_013", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 552 } }, { "content": "2.6.8 Directly Observed Treatment 4.2.\n2. Dengue infection\n 2.6.9 Interruption of treatment (Lost to follow up) 4.2.\n3. Acute viral hepatitis\n 2.6.9.\n1. Measures to minimize treatment interruption 4.2.\n4. Gall stone disease\n 2.6.9.2 Management of patients who interrupt treatment 4.2.\n5. Sepsis\n 2.7 Notification 4.\n3. Acute liver failure\n 2.8 Contact screening \n5. Renal disease in pregnancy\n 2.9 Preventive Treatment 5.\n1. Introduction\n \n3. Management of Influenza A & B Virus Infection Including 5.\n2. Pre-existing renal disease\n H1N1 in pregnancy \n 5.2.\n1. Diabetic nephropathy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_013", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 86, "chunk_size": 581 } }, { "content": "2. Pre-existing renal disease\n H1N1 in pregnancy \n 5.2.\n1. Diabetic nephropathy\n 3.1 Introduction \n 5.2.\n2. Adult onset polycystic kidney disease\n 3.2 Protection against infection \n 5.2.\n3. Lupus nephritis\n 3.3 Case identification \n 5.2.\n4. Other Glomerulonephritides\n 3.4 Seeking medical care \n 5.\n3. Renal disease occurring during pregnancy\n 3.5 Management in the hospital \n 5.3.\n1. Urinary tract infections (UTI)\n 3.6 Laboratory diagnosis \n 5.3.1.\n1. Lower UTI\n 3.7 Antiviral therapy \n 5.3.1.\n2. Upper UTI\n 3.8 Management of Labour \n 5.3.1.\n3. Asymptomatic bacteriuria (AB)\n 3.9 New born care", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_013", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 595 } }, { "content": "3.8 Management of Labour \n 5.3.1.\n3. Asymptomatic bacteriuria (AB)\n 3.9 New born care \n 5.3.\n2. Preeclampsia\n 3.10 Discharged criteria \n 5.3.\n3. Acute fatty liver of pregnancy (AFLP)\n 3.11 Notification \n 5.3.\n4. Haemolytic Uraemic Syndrome (HUS) / Thrombotic Thrombo\n 3.12 Safety of HealthCare workers cytopaenicPurpura (TTP)\n \n4. Liver Disease in pregnancy 5.\n4. Acute kidney injury (AKI)\n 4.\n1. Introduction 5.\n5. Chronic kidney disease\n 4.2 Pre-existing liver disease 5.5.\n1. Preconception care\n 4.1.\n1. Chronic viral hepatitis 5.5.\n2. Antenatal care\n 4.1.\n2. Cirrhosis 5.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_013", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 85, "chunk_size": 575 } }, { "content": "1. Preconception care\n 4.1.\n1. Chronic viral hepatitis 5.5.\n2. Antenatal care\n 4.1.\n2. Cirrhosis 5.\n6. Renal transplantation\n 4.1.\n3. Autoimmune hepatitis 5.\n7. Women on long term renal dialysis\n 4.1.\n4. Wilsons disease 5.\n8. Indications for renal biopsy during pregnancy\n 4.2.3 Liver disease specific to pregnancy \n6. Thyroid disease in pregnancy\n 4.1.\n5. When to suspect liver disease 6.\n1. Introduction\n 4.1.\n6. Hyperemesis gravidarum 6.\n1. Hypothyroidism in pregnancy\n 4.1.\n7. Intrahepatic cholestasis of pregnancy 6.1.\n1. Definitions\n VIII National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_013", "page_number": 2, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 4, "word_count": 91, "chunk_size": 593 } }, { "content": "================================================== PAGE 9 ==================================================\n2.6.4 Monitoring of sputum smear- positive pulmonary TB 4.1.\n8. Preeclampsia\n2.6.5 Treatment during pregnancy 4.1.\n9. HELLP Syndrome \n2.6.6 Treatment during breast feeding 4.1.\n10. Acute Fatty Liver of Pregnancy (AFLP)\n \n2.6.7 Management of a new born child of a mother with 4.\n2. Liver disease coincidental to pregnancy\nactive TB 4.2.\n1. Non alcoholic fatty liver disease (NAFLD)\n2.6.8 Directly Observed Treatment 4.2.\n2. Dengue infection", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_014", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 548 } }, { "content": "2.6.8 Directly Observed Treatment 4.2.\n2. Dengue infection \n2.6.9 Interruption of treatment (Lost to follow up) 4.2.\n3. Acute viral hepatitis\n2.6.9.\n1. Measures to minimize treatment interruption 4.2.\n4. Gall stone disease\n2.6.9.2 Management of patients who interrupt treatment 4.2.\n5. Sepsis\n2.7 Notification 4.\n3. Acute liver failure \n2.8 Contact screening \n5. Renal disease in pregnancy \n2.9 Preventive Treatment 5.\n1. Introduction", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_014", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 64, "chunk_size": 434 } }, { "content": "3. Management of Influenza A & B Virus Infection Including 5.\n2. Pre-existing renal disease\nH1N1 in pregnancy \n 5.2.\n1. Diabetic nephropathy \n3.1 Introduction \n 5.2.\n2. Adult onset polycystic kidney disease \n3.2 Protection against infection \n 5.2.\n3. Lupus nephritis \n3.3 Case identification \n 5.2.\n4. Other Glomerulonephritides \n3.4 Seeking medical care \n 5.\n3. Renal disease occurring during pregnancy \n3.5 Management in the hospital \n 5.3.\n1. Urinary tract infections (UTI) \n3.6 Laboratory diagnosis \n 5.3.1.\n1. Lower UTI \n3.7 Antiviral therapy \n 5.3.1.\n2. Upper UTI \n3.8 Management of Labour", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_015", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 86, "chunk_size": 595 } }, { "content": "5.3.1.\n1. Lower UTI \n3.7 Antiviral therapy \n 5.3.1.\n2. Upper UTI \n3.8 Management of Labour \n 5.3.1.\n3. Asymptomatic bacteriuria (AB) \n3.9 New born care \n 5.3.\n2. Preeclampsia \n3.10 Discharged criteria \n 5.3.\n3. Acute fatty liver of pregnancy (AFLP) \n3.11 Notification \n 5.3.\n4. Haemolytic Uraemic Syndrome (HUS) / Thrombotic Thrombo\n3.12 Safety of HealthCare workers cytopaenicPurpura (TTP)", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_015", "page_number": 3, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 56, "chunk_size": 390 } }, { "content": "4. Liver Disease in pregnancy 5.\n4. Acute kidney injury (AKI)\n4.\n1. Introduction 5.\n5. Chronic kidney disease \n4.2 Pre-existing liver disease 5.5.\n1. Preconception care \n4.1.\n1. Chronic viral hepatitis 5.5.\n2. Antenatal care \n4.1.\n2. Cirrhosis 5.\n6. Renal transplantation \n4.1.\n3. Autoimmune hepatitis 5.\n7. Women on long term renal dialysis\n4.1.\n4. Wilsons disease 5.\n8. Indications for renal biopsy during pregnancy\n4.2.3 Liver disease specific to pregnancy \n6. Thyroid disease in pregnancy\n4.1.\n5. When to suspect liver disease 6.\n1. Introduction \n4.1.\n6. Hyperemesis gravidarum 6.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_016", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 93, "chunk_size": 584 } }, { "content": "4.1.\n5. When to suspect liver disease 6.\n1. Introduction \n4.1.\n6. Hyperemesis gravidarum 6.\n1. Hypothyroidism in pregnancy\n4.1.\n7. Intrahepatic cholestasis of pregnancy 6.1.\n1. Definitions\n National Guideline for Maternal Care - Volume II IX", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_016", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 37, "chunk_size": 241 } }, { "content": "================================================== PAGE 10 ==================================================\n6.2.\n2. Management of hypothyroidism in pregnancy 11.\n7. Counsel HIV positive woman on family planning\n 6.\n2. Hyperthyroidism in pregnancy 11.\n8. Infant feeding with HIV\n 6.2.\n1. Definitions \n12. Prevention and management of Syphilis during pregnancy\n \n 6.2.\n2. Management of overt hyperthyroidism in pregnancy 12.\n1. Introduction\n 6.\n3. Postpartum thyroid dysfunction (PPTD) 12.\n2. Screening for syphilis\n \n7. Rheumatoid arthritis 12.\n3. Diagnosis of syphilis\n 7.\n1. Introduction 12.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_017", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 594 } }, { "content": "7. Rheumatoid arthritis 12.\n3. Diagnosis of syphilis\n 7.\n1. Introduction 12.\n4. Treatment of maternal syphilis\n 7.\n2. Preconception care 12.4.\n1. Treatment of primary, secondary and early latent syphilis\n 7.\n3. Antenatal care 12.4.\n2. Late latent syphilis:\n 7.\n4. Delivery 12.\n5. Follow up\n 7.\n5. Postpartum care 12.\n6. Allergy to penicillin\n \n8. Systemic Lupus Erythematosus 12.\n7. Treatment of partners\n 8.\n1. Introduction 12.\n8. Diagnosis of congenital syphilis\n 8.2 Preconception care 12.\n9. Treatment of the baby\n 8.3 Antenatal care \n13. Guidelines on malaria chemotherapy and management of", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_017", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 94, "chunk_size": 595 } }, { "content": "8.3 Antenatal care \n13. Guidelines on malaria chemotherapy and management of\n 8.4 Delivery patients with malaria during pregnancy\n \n 8.5 Postpartum care 13.1 Introduction\n 8.6 Contraception 13.2 Patients likely to have malaria\n 8.7 Neonatal lupus syndrome 13.3 Notification of malaria patients\n 8.8 Treatment of lupus nephritis (LN) in pregnancy. 13.\n4. Diagnosis of malaria\n 8.9 Other autoimmune connective tissue disease 13.\n5. Monitoring during treatment and follow up of patients\n \n9. Immune thrombocytopaenic purpura 13.6 Treatment of patients with malaria\n 9.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_017", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 80, "chunk_size": 565 } }, { "content": "9. Immune thrombocytopaenic purpura 13.6 Treatment of patients with malaria\n 9.\n1. Introduction 13.7 Mono-infection with Plasmodium vivax\n 13.8 Uncomplicated mono-infection with Plasmodium falciparum\n 9.2 Management of ITP in pregnancy \n 13.9 Uncomplicated mixed infections with P. falciparum and P.vivax\n 9.\n3. Neonate of a mother with ITP \n 13.10 Severe P. falciparum malaria\n 9.\n4. Thrombotic thrombocytopaenicpurpura (TTP) \n 13.11 Patients infected with other malaria parasites\n \n10. Antiphospholipid syndrome \n 13.12 Chemoprophylaxis for malaria\n 10.\n1. Introduction \n 10.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_017", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 75, "chunk_size": 577 } }, { "content": "10. Antiphospholipid syndrome \n 13.12 Chemoprophylaxis for malaria\n 10.\n1. Introduction \n 10.\n2. Management of APS during pregnancy \n \n11. Prevention and management of HIV in pregnancy \n 11.\n1. Primary prevention strategies \n 11.\n2. Screening for HIV during pregnancy \n 11.\n2. When the confirmatory test results is negative\n 11.\n3. When the screening test is positive \n 11.\n4. Support to the HIV positive woman \n 11.\n5. Delivery care \n 11.\n6. Post partum care \n X National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_017", "page_number": 3, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 4, "word_count": 80, "chunk_size": 512 } }, { "content": "================================================== PAGE 11 ==================================================\n6.2.\n2. Management of hypothyroidism in pregnancy 11.\n7. Counsel HIV positive woman on family planning\n6.\n2. Hyperthyroidism in pregnancy 11.\n8. Infant feeding with HIV\n6.2.\n1. Definitions \n12. Prevention and management of Syphilis during pregnancy\n \n6.2.\n2. Management of overt hyperthyroidism in pregnancy 12.\n1. Introduction\n6.\n3. Postpartum thyroid dysfunction (PPTD) 12.\n2. Screening for syphilis", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_018", "page_number": 4, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 64, "chunk_size": 511 } }, { "content": "7. Rheumatoid arthritis 12.\n3. Diagnosis of syphilis \n7.\n1. Introduction 12.\n4. Treatment of maternal syphilis \n7.\n2. Preconception care 12.4.\n1. Treatment of primary, secondary and early latent syphilis\n7.\n3. Antenatal care 12.4.\n2. Late latent syphilis: \n7.\n4. Delivery 12.\n5. Follow up \n7.\n5. Postpartum care 12.\n6. Allergy to penicillin", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_019", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 56, "chunk_size": 340 } }, { "content": "8. Systemic Lupus Erythematosus 12.\n7. Treatment of partners\n8.\n1. Introduction 12.\n8. Diagnosis of congenital syphilis \n8.2 Preconception care 12.\n9. Treatment of the baby \n8.3 Antenatal care \n13. Guidelines on malaria chemotherapy and management of\n8.4 Delivery patients with malaria during pregnancy \n \n8.5 Postpartum care 13.1 Introduction \n8.6 Contraception 13.2 Patients likely to have malaria \n8.7 Neonatal lupus syndrome 13.3 Notification of malaria patients\n8.8 Treatment of lupus nephritis (LN) in pregnancy. 13.\n4. Diagnosis of malaria\n8.9 Other autoimmune connective tissue disease 13.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_020", "page_number": 4, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 87, "chunk_size": 597 } }, { "content": "4. Diagnosis of malaria\n8.9 Other autoimmune connective tissue disease 13.\n5. Monitoring during treatment and follow up of patients", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_020", "page_number": 4, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 20, "chunk_size": 131 } }, { "content": "9. Immune thrombocytopaenic purpura 13.6 Treatment of patients with malaria\n9.\n1. Introduction 13.7 Mono-infection with Plasmodium vivax\n 13.8 Uncomplicated mono-infection with Plasmodium falciparum\n9.2 Management of ITP in pregnancy \n 13.9 Uncomplicated mixed infections with P. falciparum and P.vivax\n9.\n3. Neonate of a mother with ITP \n 13.10 Severe P. falciparum malaria \n9.\n4. Thrombotic thrombocytopaenicpurpura (TTP) \n 13.11 Patients infected with other malaria parasites", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_021", "page_number": 4, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 64, "chunk_size": 478 } }, { "content": "10. Antiphospholipid syndrome \n 13.12 Chemoprophylaxis for malaria \n10.\n1. Introduction \n10.\n2. Management of APS during pregnancy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_022", "page_number": 4, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 17, "chunk_size": 130 } }, { "content": "11. Prevention and management of HIV in pregnancy \n11.\n1. Primary prevention strategies \n11.\n2. Screening for HIV during pregnancy \n11.\n2. When the confirmatory test results is negative \n11.\n3. When the screening test is positive \n11.\n4. Support to the HIV positive woman \n11.\n5. Delivery care \n11.\n6. Post partum care \n National Guideline for Maternal Care - Volume II XI", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_023", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 63, "chunk_size": 372 } }, { "content": "================================================== PAGE 12 ==================================================\nList of Abbreviations \n \n This", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_024", "page_number": 4, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 140 } }, { "content": "XII National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_025", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 13 ==================================================\nDisclaimer \n \n This guidance is intended to provide general advice to streamline the\n management and maintain overall quality of patient care. It should\n never be relied on as a substitute for proper clinical assessment with\n respect to the particular circumstances and needs of each patient\n under your care. It is the responsibility of each Practitioner to have\n regard to the particular circumstances of each individual patient, and\n the application of this guidance.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_026", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 75, "chunk_size": 580 } }, { "content": "the application of this guidance. \n \n This guidance has been prepared having regard to the information\n available at the time of its preparation. Medicine is a continually\n evolving science and the users must have regard to relevant information,\n research or material, which may have been published or become\n available subsequently.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_026", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 49, "chunk_size": 333 } }, { "content": "National Guideline for Maternal Care - Volume II XIII", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_027", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 53 } }, { "content": "================================================== PAGE 14 ==================================================\nIntroduction \n \n Clinical Guidelines are systematically developed statements which assist\n clinicians and patients in making decisions about appropriate treatment\n for specific conditions based on the best scientific evidence at the time of\n development. Guidelines are not intended to limit the clinical freedom;\n however, clinicians are expected to follow these recommendations as the\n basis for their decisions. Availability of resources, the existing situations,", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_028", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 65, "chunk_size": 576 } }, { "content": "basis for their decisions. Availability of resources, the existing situations,\n and the expectations of individual client needs to be considered.\n \n The guidelines are intended to guide all health care workers in all\n levels of institutions where maternity care is provided. Although these\n guidelines are mainly targeted for the government sector institutions, use\n in the private sector institutions where maternity care is provided, is also\n encouraged. \n \n These guidelines are developed by expert group from the Ceylon College of", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_028", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 77, "chunk_size": 534 } }, { "content": "encouraged. \n \n These guidelines are developed by expert group from the Ceylon College of\n Physicians and consensus were obtained from the guideline development\n group of the Sri Lanka College of Obstetricians and Gynaecologists in\n consultation with other relevant specialists such as anaesthesiologists,\n physicians, endocrinologists, and haematologists etc. The existing national\n and international guidelines, and WHO guidelines were perused and\n mixed with the local scenarios and expert opinion. The latest available\n scientific evidences were considered and included where ever necessary.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_028", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 78, "chunk_size": 595 } }, { "content": "scientific evidences were considered and included where ever necessary.\n Then, the draft guidelines were presented to the wider forum of experts and\n consensuses were reached. After that the guidelines were handed over to\n the Ministry of Health and consensus were built with the participation\n of multi-disciplinary team including medical administrators, provincial\n health authorities, representatives from SLCOG and other relevant\n professional colleges, and national programme managers.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_028", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 65, "chunk_size": 490 } }, { "content": "XIV National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_029", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 15 ==================================================\nBronchial Asthma", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_030", "page_number": 4, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 126 } }, { "content": "National Guideline for Maternal Care - Volume II 1", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_031", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 16 ==================================================\n2 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_032", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 160 } }, { "content": "================================================== PAGE 17 ==================================================\n1.Bronchial asthma in pregnancy \n \n 1.\n1. Introduction \n \n ➢ The majority of women with bronchial asthma (BA) have an\n uncomplicated pregnancy. \n \n ➢ Poorly controlled BA is associated with maternal and perinatal\n morbidity and mortality, including, \n o Spontaneous abortion \n \n o Fetal growth restriction \n \n o Preterm delivery \n \n o Low birth weight babies \n \n 1.\n2. Women with pre-existing bronchial asthma \n \n ➢ Optimise control of bronchial asthma in those with poorly", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_033", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 583 } }, { "content": "➢ Optimise control of bronchial asthma in those with poorly\n controlled disease. This should be done in the preconception\n period or at least in early pregnancy. \n ➢ Women who are on prophylactic medication for BA should\n continue it during pregnancy. \n \n ➢ The course of BA is pregnancy is variable. \n \n o One third of women experience improvement in symptoms,\n one third worsening and one third remain unchanged.\n \n o Women with poorly controlled asthma, are more likely to\n experience worsening of symptoms during pregnancy.\n o Worsening of symptoms is most likely in the second and third", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_033", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 94, "chunk_size": 591 } }, { "content": "o Worsening of symptoms is most likely in the second and third\n trimesters. \n \n o In the last month of pregnancy and during the peripartum\n period, patients are least likely to have an asthma attack.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_033", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 34, "chunk_size": 199 } }, { "content": "National Guideline for Maternal Care - Volume II 3", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_034", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 18 ==================================================\n1.\n3. When to suspect bronchial asthma in a previously\n healthy woman", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_035", "page_number": 4, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 16, "chunk_size": 179 } }, { "content": "➢ BA is a clinical diagnosis based on the recognition of\n characteristic pattern of symptoms and signs in the absence of\n an alternative explanation. \n \n Diagnosis of bronchial asthma", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_036", "page_number": 4, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 28, "chunk_size": 183 } }, { "content": "Clinical features that increase the Clinical features that lower the\n probability of asthma probability of asthma \n Wheeze, cough, difficulty \n Isolated cough in the absence of\n breathing, chest tightness and \n wheezeor difficulty breathing\n audible wheeze on auscultation, \n Repeatedly normal physical \n particularly if these symptoms: \n examination of chest when \n -- are frequent and recurrent \n symptomatic \n -- are worse at night and in the \n Normal peak expiratory flow \n early morning \n rate (PEFR) or spirometry \n -- occur in response to, or are \n when symptomatic", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_037", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 80, "chunk_size": 572 } }, { "content": "early morning \n rate (PEFR) or spirometry \n -- occur in response to, or are \n when symptomatic \n worse after, exercise or other \n No response to a trial of asthma\n triggers such as exposure to pets, \n therapy \n cold or damp air or with \n Clinical features suggestive of\n emotions or laughter. \n an alternative diagnosis \n Especially in the presence of, \n a personal history of atopic \n disorder unexplained \n pulmonary eosinophilia \n family history of atopic disorder \n and/or asthma \n history of improvement in \n symptoms in response to \n adequate therapy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_037", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 556 } }, { "content": "and/or asthma \n history of improvement in \n symptoms in response to \n adequate therapy \n ➢ When the diagnosis of BA is doubtful, objective assessment\n should be carried out. \n 4 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_037", "page_number": 4, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 35, "chunk_size": 226 } }, { "content": "================================================== PAGE 19 ==================================================\nBox 1.1 Objective assessment of bronchial asthma\n \n Bronchial asthma is confirmed by demonstrating reversibility of airflow\n obstruction by spirometry or peak expiratory flowmetry during the\n symptomatic stage. \n \n• A FEV1/FVC ratio <0.7 on spirometry, suggests an obstructive\n element and probable asthma \n \n \n• Reversibility testing - An increase in FEV1 of > 400ml or peak\n expiratory flow rate (PEFR) of >15% of baseline PEFR after inhalation\n of", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_038", "page_number": 4, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 560 } }, { "content": "expiratory flow rate (PEFR) of >15% of baseline PEFR after inhalation\n of \n \n a. Salbutamol 400 µg (100 µg *4) via a spacer device\n \n OR \n b. Inhaled corticosteroids ( Beclomethasone 200µg BD) for 6-8\n weeks or oral steroids 30mg OD for 14 days \n \n - confirms a diagnosis of bronchial asthma.\n \n It is important to assess the PEFR and document the highest/best reading\n It is \n for an individual patient for monitoring of disease.\n PEFR should be recorded as the best of three forced expiratory blows\n from total lung capacity with a maximum pause of two seconds before\n blowing.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_038", "page_number": 4, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 96, "chunk_size": 579 } }, { "content": "from total lung capacity with a maximum pause of two seconds before\n blowing. \n \n ➢ When to consider a diagnosis other than bronchial asthma–\n Red flag symptoms/ signs \n \n o Constitutional symptoms /inadequate weight gain in\n pregnancy /loss of appetite \n o Haemoptysis \n o Excessive sputum production \n o Pleuritic chest pain \n o Elevated JVP/significant murmurs \n o Crackles on auscultation of the lungs \n Cardiac disease in particular should be excluded, when symptoms are\n atypical and not responding to conventional antiasthma medications.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_038", "page_number": 4, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 77, "chunk_size": 544 } }, { "content": "National Guideline for Maternal Care - Volume II 5", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_039", "page_number": 4, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 20 ==================================================\n1.\n4. Management of bronchial asthma in pregnancy \n \n 1.4.\n1. Pharmacological management \n \n ➢ Medications used in the non pregnant population have been\n shown to be safe in pregnancy in treatment doses.\n ➢ Harm to the fetus from severe or chronically undertreated\n asthma outweighs any small risk from the medications used to\n control asthma. \n \n ➢ Women should be informed of the importance of continuing Inhaled corticosteroid", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_040", "page_number": 4, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 539 } }, { "content": "➢ Women should be informed of the importance of continuing Inhaled corticosteroid\n their asthma medications during pregnancy to ensure good Eg. Beclomethasone\n Via HFA inhaler(MDI) 250-500µg/day OR\n asthma control. \n DP caps 400-800µg/day\n in twice daily divided doses.\n ➢ Management is similar to that outside pregnancy.\n \n• Assess control in 2 weeks\n - If inadequate control, start a preparation of combined\n Stepwise approach to pharmacological management of pre-existing\n long acting ß2 agonist (laba) and steroid\n or newly diagnosed bronchial asthma", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_040", "page_number": 4, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 79, "chunk_size": 554 } }, { "content": "long acting ß2 agonist (laba) and steroid\n or newly diagnosed bronchial asthma \n Eg. Salmeterol/Fluticasone or Formeterol/Budesonide\n preparation\n Day time symptoms > 3 times/week \n Night time symptoms > 2 times/month \n Limitation of daily activities \n Severe attack/s requiring hospital Assess control in 2 weeks\n admission/s \n Rescue medication \n (bronchodilators/anticholinergics)>3 \n Good response to LABA Response to LABA but No response to LABA*\n times/week Continue LABA and control still inadequate Stop LABA\n \n• Use a combination Increase inhaled steroid\n inhaled corticosteroids", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_040", "page_number": 4, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 76, "chunk_size": 588 } }, { "content": "• Use a combination Increase inhaled steroid\n inhaled corticosteroids\n inhaler with higher dose to 800µg/day\n steroid content\n \n• Eg: 400/800µg/day\n if no to all if yes>1 \n via HFA haler\n Contril still inadequate\n Trial of add on therapy\n \n• Leukotriene receptor antagonists\n Mild intermittent BA Persistent BA \n \n• Theophyllines\n Oral/inhaled bronchodilators as Requires prevebtive therapy\n required (inhaledcorticosteroids) \n Inhaled short-acting ß2 agonists - see below* \n Inhaled ipratropium bromide \n Control still inadequate\n ß2 agonist tablets or syrup \n Theophyllines", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_040", "page_number": 4, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 75, "chunk_size": 575 } }, { "content": "Control still inadequate\n ß2 agonist tablets or syrup \n Theophyllines \n• High dose inhaled corticosteroid\n (2000mcg/day)or\n -Short-acting inhaled ß2 agonists \n havea faster onset of action and \n \n• Use oral steroids at lowest dose for\n fewer sideeffects then the adequate control\n alternatives. \n 6 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_040", "page_number": 4, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 4, "word_count": 49, "chunk_size": 347 } }, { "content": "================================================== PAGE 21 ==================================================\nt Persistent BA \n \n ➢ Start patient at a dose of inhaled corticosteroids appropriate to\n the severity of disease. \n ➢ Titrate the dose of inhaled corticosteroid to the lowest dose at\n which effective control of asthma is achieved.\n ➢ Before initiating a new medication, practitioners should recheck\n adherence to inhaler technique and help eliminate trigger factors.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_041", "page_number": 5, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 59, "chunk_size": 476 } }, { "content": "Inhaled corticosteroid \n Eg. Beclomethasone \n Via HFA inhaler(MDI) 250-500µg/day OR\n DP caps 400-800µg/day \n in twice daily divided doses. \n \n• Assess control in 2 weeks \n - If inadequate control, start a preparation of combined\nStepwise approach to pharmacological management of pre-existing\n long acting ß2 agonist (laba) and steroid\nor newly diagnosed bronchial asthma \n Eg. Salmeterol/Fluticasone or Formeterol/Budesonide\n preparation \nDay time symptoms > 3 times/week \nNight time symptoms > 2 times/month \nLimitation of daily activities", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_042", "page_number": 5, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 541 } }, { "content": "Night time symptoms > 2 times/month \nLimitation of daily activities \nSevere attack/s requiring hospital Assess control in 2 weeks\nadmission/s \nRescue medication \n(bronchodilators/anticholinergics)>3 \n Good response to LABA Response to LABA but No response to LABA*\ntimes/week Continue LABA and control still inadequate Stop LABA\n \n• Use a combination Increase inhaled steroid\n inhaled corticosteroids \n inhaler with higher dose to 800µg/day\n steroid content \n \n• Eg: 400/800µg/day \nif no to all if yes>1 \n via HFA haler \n Contril still inadequate \n Trial of add on therapy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_042", "page_number": 5, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 572 } }, { "content": "if no to all if yes>1 \n via HFA haler \n Contril still inadequate \n Trial of add on therapy \n \n• Leukotriene receptor antagonists\nMild intermittent BA Persistent BA \n \n• Theophyllines \nOral/inhaled bronchodilators as Requires prevebtive therapy\nrequired (inhaledcorticosteroids) \nInhaled short-acting ß2 agonists - see below* \nInhaled ipratropium bromide \n Control still inadequate \nß2 agonist tablets or syrup \nTheophyllines \n• High dose inhaled corticosteroid\n (2000mcg/day)or \n-Short-acting inhaled ß2 agonists \nhavea faster onset of action and \n \n• Use oral steroids at lowest dose for", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_042", "page_number": 5, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 79, "chunk_size": 588 } }, { "content": "havea faster onset of action and \n \n• Use oral steroids at lowest dose for\nfewer sideeffects then the adequate control \nalternatives. \n National Guideline for Maternal Care - Volume II 7", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_042", "page_number": 5, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 30, "chunk_size": 186 } }, { "content": "================================================== PAGE 22 ==================================================\nBox 1.2 Medication summary \n \n Relievers (For quick relief) \n \n ➢ Short acting bronchodilators (SABA) \n \n• Inhaled salbutamol (HFA -100 µg per puff, DP capsules-\n 200 µg, 400 µg ) or oral salbutamol \n \n• Iptratropium inhalers ( DP capsules -20 µg, HFA - 40 µg\n per puff) \n \n• Oral theophyllines – Theophylline 125 mg bd or modified\n release formulations for short periods only ( Since serum\n level monitoring is not available and protein binding\n could change in pregnancy)", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_043", "page_number": 5, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 80, "chunk_size": 583 } }, { "content": "level monitoring is not available and protein binding\n could change in pregnancy) \n - Metered dose inhalers should preferably be used with a\n spacer device, especially in the third trimester.\n Preventers (Long term control medications) \n \n ➢ Inhaled corticosteroids (ICS) \n \n• ICS are more effective when taken twice rather than once\n daily. \n \n• There is little evidence of benefit for dosage frequency\n more than twice daily. \n \n• Titrate the dose of inhaled corticosteroid to the lowest\n dose at which effective control of asthma is maintained.\n ➢ Long acting beta 2 agonists (LABA)", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_043", "page_number": 5, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 90, "chunk_size": 585 } }, { "content": "dose at which effective control of asthma is maintained.\n ➢ Long acting beta 2 agonists (LABA) \n \n• These should always be given in combination with ICS.\n \n• Combined inhaler preparations are available. \n Eg: Salmeterol/Fluticasone \n Formoterol/ Budesonide \n \n ➢ Leukotriene receptor antagonists \n Eg: Montelukast 10mg once daily, usually at night", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_043", "page_number": 5, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 48, "chunk_size": 347 } }, { "content": "8 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_044", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 23 ==================================================\n1.4.\n2. Adjuvant therapy for bronchial asthma \n \n ➢ Women with recurrent exacerbations related to gastro\n oesophageal reflux disease or allergic rhinosinusitis, need control\n of these with appropriate medication and lifestyle measures.\n \n o Antihistamines - No teratogenicity reported\n - Sedating antihistamines used towards the latter part of\n pregnancy may adversely affect the neonate\n \n o Intranasal steroids- Beclamethasone, Budesonide and\n Fluticasone are safe \n \n o Antacids", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_045", "page_number": 5, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 67, "chunk_size": 591 } }, { "content": "o Intranasal steroids- Beclamethasone, Budesonide and\n Fluticasone are safe \n \n o Antacids \n - Omeprazole and H2 receptor blockers are safe\n \n ➢ Active and passive smoking and indoor air pollution to be\n avoided \n Prevention of acute deterioration \n \n ➢ A register of patients at risk may help primary care health\n professionals to identify patients who are at high risk of\n deterioration.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_045", "page_number": 5, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 58, "chunk_size": 389 } }, { "content": "National Guideline for Maternal Care - Volume II 9", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_046", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 50 } }, { "content": "================================================== PAGE 24 ==================================================\n1.5.Indications for transfer to the intensive care unit (ICU)\n !O\" \n \" \n ➢ Deteriorating PEFR despite appropriate treatment\n ➢ Persisting or worsening hypoxia \n 10 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_047", "page_number": 5, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 35, "chunk_size": 322 } }, { "content": "================================================== PAGE 25 ==================================================\n➢ Hypercapnia or inappropriate eucapnea (see box below)\n \n ➢ Arterial blood gas analysis showing a fall in pH or rising H +\n concentration \n ➢ Exhaustion, feeble respiration \n \n ➢ Drowsiness, confusion, altered conscious state\n ➢ Respiratory arrest \n \n Box 1.3 Interpretation of arterial blood gas in pregnancy\n \n ➢ Due to progesterone driven increase in minute ventilation the\n following changes are expected in healthy pregnant women\n \n o High Pao2 \n o Hypocapnia", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_048", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 575 } }, { "content": "following changes are expected in healthy pregnant women\n \n o High Pao2 \n o Hypocapnia \n o Respiratory alkalosis \n Oxygen saturation remains unaltered \n 1.\n6. Antenatal care \n \n ➢ If patient’s disease is under control, the patient does not require\n any additional monitoring or interventions. \n \n ➢ However, if the patient is on preventive therapy and\n disease not adequately controlled, refer to a physician for\n optimising management and formulating a plan for the rest of\n pregnancy. \n ➢ In the event of uncontrolled/severe BA, regular growth\n monitoring of the fetus should be performed.\n 1.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_048", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 88, "chunk_size": 595 } }, { "content": "monitoring of the fetus should be performed.\n 1.\n7. Delivery \n \n ➢ Worsening disease is generally not a problem at this time due to\n endogenous steroid production at time of labour.\n \n ➢ Women should continue their routine asthma medications\n during labour. \n ➢ In the absence of acute severe asthma, caesarean section is\n performed only for obstetric indications. \n \n ➢ If anaesthesia is required, regional anaesthesia is preferred\n over general anaesthesia. \n National Guideline for Maternal Care - Volume II 11", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_048", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 77, "chunk_size": 513 } }, { "content": "================================================== PAGE 26 ==================================================\n➢ Women who have received a dose of prednisolone > 7.5\n mg/day for more than two weeks prior to delivery, should\n be commenced on hydrocortisone 100mg 6 hourly during\n labour. \n ➢ Prostaglandin E2 could be safely used for induction of\n labour. \n \n ➢ Prostaglandin F2α (Carboprost/Hemobate) used to treat\n postpartum haemorrhage due to uterine atony may cause\n bronchospasm. \n ➢ Ergometrine may cause bronchospasm, though Syntometrine\n does not. \n \n 1.\n8. Postpartum care", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_049", "page_number": 5, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 580 } }, { "content": "➢ Ergometrine may cause bronchospasm, though Syntometrine\n does not. \n \n 1.\n8. Postpartum care \n \n ➢ All medications used in control and treatment of asthma is safe\n to be used during breastfeeding. \n \n ➢ Maternal dose of up to 20 mg of prednisolone daily is\n considered safe. \n \n ➢ Women on higher doses of prednisolone should be advised to\n breastfeed after a lapse of 3-4 hours of taking the steroid.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_049", "page_number": 5, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 66, "chunk_size": 403 } }, { "content": "References \n \n \n1. British guideline on the management of asthma; A national\n clinical guideline. British Thoracic Society, Scottish Intercollegiate\n Guidelines Network \n2014. \n \n2. National asthma education and prevention program. Quick\n Reference from the Working Group Report on managing asthma\n during pregnancy: Recommendations for pharmacological\n treatment. Update \n2004. \n \n3. Vanessa E. Murphy, Michael Schatz. Asthma in pregnancy: a hit for\n two. European respiratory Review 2014; 23: 64–\n68. \n \n \n4. Mina Gaga, Eleftherios Zervas. Breathing for two: pregnancy, asthma", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_050", "page_number": 5, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 578 } }, { "content": "68. \n \n \n4. Mina Gaga, Eleftherios Zervas. Breathing for two: pregnancy, asthma\n and respiratory failure. European Respiratory Review 2014; 23: 5–\n7.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_050", "page_number": 5, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 21, "chunk_size": 149 } }, { "content": "12 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_051", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 27 ==================================================\nTuberculosis", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_052", "page_number": 5, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 5, "chunk_size": 122 } }, { "content": "National Guideline for Maternal Care - Volume II 13", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_053", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 28 ==================================================\n14 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_054", "page_number": 5, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 161 } }, { "content": "================================================== PAGE 29 ==================================================\n2. MANAGEMENT OF TUBERCULOSIS DURING PREGNANCY \n \n Tuberculosis is an infectious disease caused by the bacillus\n Mycobacterium tuberculosis and occasionally by Mycobacterium bovis\n and Mycobacterium africanum. Tuberculosis commonly affects the lungs,\n but it can affect any other organ in the body. \n 2.\n1. How does tuberculosis spread? \n \n The bacteria that cause tuberculosis usually spread through air. When a\n patient with infectious pulmonary tuberculosis coughs, sneezes or laughs,", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_055", "page_number": 5, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 597 } }, { "content": "patient with infectious pulmonary tuberculosis coughs, sneezes or laughs,\n bacilli are expelled into the air in the form of tiny droplets. These droplets\n dry up rapidly to form droplet nuclei and may remain suspended in the\n air for several hours. Adequate through and through ventilation removes\n and dilutes these droplet nuclei, and direct sunlight quickly kills the\n bacilli, but they can survive in the dark for several days. When a healthy\n person inhales these droplet nuclei containing the tubercle bacilli, he/she\n may become infected. \n 2.\n2. Risk of infection", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_055", "page_number": 5, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 571 } }, { "content": "may become infected. \n 2.\n2. Risk of infection \n \n An individual’s risk of infection depends on the extent of exposure to an\n infectious source and susceptibility of the individual to infection. The\n risk of infection is therefore high in a person who has close, prolonged\n exposure to a person with sputum smear positive pulmonary TB. The risk\n of transmission of infection from sputum smear-negative pulmonary TB\n is low and with extrapulmonary TB, still lower. \n 2.3.\n1. Who is a TB suspect? \n \n A TB suspect is a person who presents with symptoms or signs suggestive", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_055", "page_number": 5, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 93, "chunk_size": 570 } }, { "content": "1. Who is a TB suspect? \n \n A TB suspect is a person who presents with symptoms or signs suggestive\n of TB, particularly cough of two weeks or more. \n \n 2.3.\n2. Case of a “Bacteriologically confirmed TB”\n \n A patient whose biological specimen is positive by smear microscopy,\n culture or WRD (such as Xpert MTB/RIF. \n 2.3.\n3. A case of a “Clinically diagnosed TB” \n \n One who does not fulfil the criteria for bacteriologica confirmation but\n has been diagnosed with active TB by a clinician who has decided to give\n the patient a full course of TB treatment. This definition includes cases", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_055", "page_number": 5, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 99, "chunk_size": 589 } }, { "content": "National Guideline for Maternal Care - Volume II 15", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_056", "page_number": 6, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 30 ==================================================\ndiagnosed on the basis of X-ray abnormalities or suggestive histology and\n extra pulmonary cases without laboratory confirmation.\n \n Clinically diagnosed cases subsequently found to be bacteriologically\n positive (before or after starting treatment) should be reclassified as\n bacteriologically confirmed. \n 2.\n4. Common symptoms of pulmonary tuberculosis \n \n The clinical presentation of tuberculosis in pregnant women is similar to\n that in non-pregnant patients.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_057", "page_number": 6, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 63, "chunk_size": 575 } }, { "content": "that in non-pregnant patients. \n \n Respiratory symptoms: \n \n Cough – usually more than two weeks \n Shortness of breath \n Chest pain \n Haemoptysis (blood stained sputum) \n Constitutional Symaptoms: \n \n Fever and night sweats \n Loss of appetite \n Loss of weight \n Tiredness (Fatigue) \n However, prevalence surveys worldwide revealed that TB can be presented\n without cough also. \n \n Symptoms of Extrapulmonary TB \n \n The symptoms depend on the organ involved. Patients may present with\n constitutional features of the disease – fever, night sweats, loss of weight,", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_057", "page_number": 6, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 76, "chunk_size": 562 } }, { "content": "constitutional features of the disease – fever, night sweats, loss of weight,\n and loss of appetite or local symptoms related to the site of the disease.\n \n 2.\n5. Investigations \n Sputum Smear microscopy \n Sputum smear microscopy is the most reliable and cost effective method\n of diagnosing infectious cases of pulmonary tuberculosis cases. Whenever\n tuberculosis is suspected in a patient who has had a cough of two weeks\n or more, three sputum samples should be collected and examined by\n microscopy for Acid-Fast Bacilli (AFB).", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_057", "page_number": 6, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 531 } }, { "content": "16 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_058", "page_number": 6, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 31 ==================================================\nCollection of sputum samples \n \n A PTB suspect should submit three sputum samples for microscopy. Three\n early morning samples are preferable. However due to practical reasons,\n sputum samples are taken in the following manner:\n Patient should be advised to collect sputum after coughing following a\n deep inspiration and it should not be saliva. \n \n First spot specimen - Supervised spot specimen at the first visit", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_059", "page_number": 6, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 67, "chunk_size": 526 } }, { "content": "First spot specimen - Supervised spot specimen at the first visit\n \n Early morning specimen - Patient is given a sputum container to collect\n early morning specimen on the following day. \n \n Second spot specimen - Second supervised spot specimen is collected\n when the patient returns with the early morning specimen, on the\n following day. \n Chest X-ray \n \n The chest X-ray has a limited role in confirming the diagnosis of pulmonary\n tuberculosis. Diagnosis of tuberculosis by means of X-ray alone is\n unreliable. Abnormalities seen on a chest X-ray may be mimicked by a", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_059", "page_number": 6, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 90, "chunk_size": 572 } }, { "content": "unreliable. Abnormalities seen on a chest X-ray may be mimicked by a\n variety of other conditions. However chest X-ray is helpful particularly\n to diagnose PTB in a suspect whose sputum smears are negative for AFB.\n \n The decision to start on anti-TB treatment on patients should not be based\n solely on abnormal chest X-ray findings and all efforts should be made to\n perform sputum microscopy. \n In pregnancy, chest X-rays should be avoided as far as possible, especially\n during the first trimester, because of the adverse effects of x-rays on the\n foetus.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_059", "page_number": 6, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 90, "chunk_size": 559 } }, { "content": "during the first trimester, because of the adverse effects of x-rays on the\n foetus. \n \n Therefore, diagnosis will depend more on sputum examination when a\n pregnant mother presents with symptoms suggestive of tuberculosis.\n However, if an X-ray is absolutely necessary, this may be done with the\n abdomen covered with a lead apron. \n Sputum Culture for AFB \n \n Culture examination of sputum for AFB is more sensitive and specific\n than direct smear microscopy and may be useful in detecting cases where\n the number of organisms are fewer than can be detected by direct smear", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_059", "page_number": 6, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 91, "chunk_size": 575 } }, { "content": "the number of organisms are fewer than can be detected by direct smear\n \n National Guideline for Maternal Care - Volume II 17", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_059", "page_number": 6, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 4, "word_count": 22, "chunk_size": 125 } }, { "content": "================================================== PAGE 32 ==================================================\nmicroscopy. But this is more expensive and takes at least 6-8 weeks to get\n the results. \n \n Under ideal circumstances pre-treatment sputum cultures for AFB should\n be performed on all PTB patients. \n WHO recommended Rapid diagnostic tests \n \n There are new rapid diagnostic methods available for detection of TB such\n as Xpert MTB/Rif and line probe assay. \n \n Xpert MTB/Rif \n \n Xpert MTB/Rif is an automated nucleic acid amplification test", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_060", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 551 } }, { "content": "Xpert MTB/Rif \n \n Xpert MTB/Rif is an automated nucleic acid amplification test\n recommended by WHO for early detection of TB and resistance to\n rifampicin which is used as an indicator of multidrug resistance. The test\n takes around two hours, and requires minimal man power to perform.\n Xpert/Rif can detect TB bacteria at much lower concentrations.\n Line probe assay \n \n Line probe assay is a molecular method of diagnosing TB and the\n most common genetic mutations causing resistance to rifampicin and\n isoniazid. This technology can diagnose MDR-TB directly from smear", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_060", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 573 } }, { "content": "isoniazid. This technology can diagnose MDR-TB directly from smear\n positive sputum specimens and from culture isolates providing results in\n five hours. This test does not work well on smear negative specimens.\n At present, these tests are offered for selected categories of patients\n (MDRTB suspects) due to limited availability. \n \n 2.\n6. TB treatment regimens \n \n Treatment regimens consist of two phases: \n \n1. Initial intensive phase \n \n2. Continuation phase \n \n 2.6.1.Intensive phase \n During the initial intensive phase, there is rapid killing of TB bacilli.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_060", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 80, "chunk_size": 566 } }, { "content": "2.6.1.Intensive phase \n During the initial intensive phase, there is rapid killing of TB bacilli.\n Infectious patients quickly become non-infectious (within about two\n weeks) and symptoms improve. Most patients with sputum smear-positive\n pulmonary TB becomes smear negative within two months. Directly\n Observed Therapy (DOT) is essential in the initial phase to ensure that\n the patient takes every single dose. This prevents development of drug\n \n 18 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_060", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 72, "chunk_size": 502 } }, { "content": "================================================== PAGE 33 ==================================================\nresistance. The risk of development of drug resistance is higher during the\n early stages of anti-TB treatment, when there are more bacilli.\n \n 2.6.2.Continuation Phase \n During the continuation phase, fewer drugs are necessary, but for a longer\n period. The sterilizing effect of the drugs eliminates the remaining bacilli,\n thus preventing subsequent relapses. \n \n Patients who have taken anti-tuberculosis drugs previously are much", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_061", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 64, "chunk_size": 544 } }, { "content": "Patients who have taken anti-tuberculosis drugs previously are much\n more likely to develop drug resistance, which may have been acquired\n through inadequate prior chemotherapy. Such patients require a stronger\n regimen consisting of more drugs and for a longer period.\n \n Therefore, before starting treatment, it is essential to question all\n patients closely and carefully to determine whether or not they have\n previously taken treatment for tuberculosis, so that they can be given\n the proper treatment regimen. \n 2.6.3.Standard code for TB treatment regimens", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_061", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 563 } }, { "content": "the proper treatment regimen. \n 2.6.3.Standard code for TB treatment regimens \n \n There is a standard code for TB treatment regimens and each anti-\n tuberculosis drug has an abbreviation. \n \n H – Isoniazid \n R - Rifampicin \n Z - Pyrazinamide \n E - Ethambutol \n S – Streptomycin \n A TB treatment regimen consists of two phases, the intensive phase and\n the continuation phase. The number before a phase is the duration of that\n phase in months. A subscript number (e.g. 3) after a letterindicates the\n number of doses of that drug per week. No subscript number after a letter", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_061", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 93, "chunk_size": 574 } }, { "content": "number of doses of that drug per week. No subscript number after a letter\n indicates that the treatment is daily. \n E.g.: 4 HR means 4 months of Isoniazid and Rifampicin daily.\n 5 H3 R3 E3 means 5 months of Isoniazid, Rifampicin and Ethambutol\n three times a week", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_061", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 47, "chunk_size": 263 } }, { "content": "National Guideline for Maternal Care - Volume II 19", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_062", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 34 ==================================================\nBox 2.1 Case definitions, Treatment Categories and \n Recommended Regimens \n \n Case Definition Treatment Treatment Regimen \n Category IntensiveContinuation \n Phase Phase \n New cases CAT 1 2 HRZE 4 HR \n - PTB smear-positive \n - PTB smear-negative \n - Extrapulmonary TB \n Re-treatment cases CAT II 2HRZES 5 HRE \n - Relapses / 1 HRZE \n -Treatment after failure \n -Treatment after lost to follow up \n (smear-positive) \n 2.6.4.Monitoring of sputum smear-positive pulmonary TB\n patients", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_063", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 68, "chunk_size": 589 } }, { "content": "(smear-positive) \n 2.6.4.Monitoring of sputum smear-positive pulmonary TB\n patients \n Response to treatment should be monitored by sputum smear examination\n For sputum smear positive PTB patients, sputum smear examinations\n should be performed at the end of the intensive phase of treatment\n (i.e.,second month), during the fifth month and ai the end of treatment.\n Negative sputum smears indicate good treatment progress.\n For sputum smear negative patients also follow up sputum smear\n examinations should be performed at the end of two months, at the 5th", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_063", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 557 } }, { "content": "examinations should be performed at the end of two months, at the 5th\n month and at the end of the treatment period. \n \n 2.6.5.Treatment during Pregnancy \n \n Anti-TB treatment should be started as soon as the diagnosis is made,\n and the full course of treatment given. The basic principles of treatment\n are the same in pregnancy. Most anti-TB drugs are safe for use during\n pregnancy except streptomycin. \n Streptomycin should not be given because it can cause oto-toxicity in\n the foetus. \n \n Pregnant mothers should be given pyridoxine 10mg daily along with\n INAH.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_063", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 89, "chunk_size": 567 } }, { "content": "the foetus. \n \n Pregnant mothers should be given pyridoxine 10mg daily along with\n INAH. \n \n Vitamin K should be administered at birth to the infant of a mother taking\n rifampicin because of the risk of post-natal haemorrhage.\n \n 20 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_063", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 44, "chunk_size": 281 } }, { "content": "================================================== PAGE 35 ==================================================\n2.6.\n6. Treatment during breast-feeding \n \n A patient who has TB and is breast-feeding should receive the full course of\n anti-TB treatment. Properly taken treatment is the best way of preventing\n transmission of TB to her baby. All anti-TB drugs are compatible with\n breast-feeding. A patient taking anti-TB treatment can continue to\n breastfeed her baby in the normal way. \n Breastfeeding should be avoided only in cases where the mother has dual\n TB/HIV infection. \n \n 2.6.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_064", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 77, "chunk_size": 586 } }, { "content": "TB/HIV infection. \n \n 2.6.\n7. Management of a newborn child of a mother with active TB\n \n \n• Do not separate the child from the mother unless she is acutely ill.\n \n \n• If the mother is sputum smear negative, and if the infant has no\n evidence of congenital TB, BCG is given to the infant.\n \n If the mother is sputum smear-positive at the time of delivery, infant\n should be carefully examined for evidence of active disease.\n - If the infant is ill at birth and congenital TB is suspected, a full\n course of anti-TB treatment should be given.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_064", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 96, "chunk_size": 542 } }, { "content": "course of anti-TB treatment should be given. \n \n - If the child is well, give prophylactic treatment with INAH 5mg/ kg\n body weight, daily for three months. BCG is withheld.\n \n \n• The Mantoux skin test is done after three months.\n \n - If the Mantoux test is negative and the child is well, prophylactic\n treatment with INAH is stopped and child is given BCG.\n \n - If the Mantoux test is positive, careful examination of the child for\n active TB is done including a chest X-ray. \n \n - If active disease is diagnosed, a full course of anti-TB treatment\n should be commenced.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_064", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 98, "chunk_size": 572 } }, { "content": "- If active disease is diagnosed, a full course of anti-TB treatment\n should be commenced. \n \n - If the physical examination and the chest X-ray are normal, INAH\n chemoprophylaxis is continued up to six months and BCG is given.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_064", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 38, "chunk_size": 227 } }, { "content": "National Guideline for Maternal Care - Volume II 21", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_065", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 36 ==================================================\n2.6.\n8. Directly Observed Treatment \n \n Directly Observed Treatment (DOT) is one of the important elements\n of the internationally recommended strategy for TB control. Directly\n Observed Treatment means that an observer watches the patient swallow\n their tablets. This ensures that a TB patient takes the right anti-tuberculosis\n drugs, in the right doses at the right intervals without interruption and\n ensures that the patient completes the full course of treatment. WHO", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_066", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 583 } }, { "content": "ensures that the patient completes the full course of treatment. WHO\n recommendation is to provide DOTs throughout the whole treatment\n period. \n DOT Providers – \n \n The following categories will provide Direct Observation of Treatment.\n \n \n• Health workers at state health care facilities \n \n• Field health care workers \n \n \n• General practitioners \n \n• Trained volunteers \n \n \n• Community leaders \n \n Public health staff especially Public Health Nursing sisters and Public\n Health Midwives can play a significant role as DOT providers for", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_066", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 76, "chunk_size": 540 } }, { "content": "Health Midwives can play a significant role as DOT providers for\n antenatal and postnatal mothers in their areas who are on treatment.\n Provision of drugs for the DOT Centres - \n \n Drugs for each patient will be delivered to the DOT centres from the\n District Chest Clinic by the PHI or any other staff assigned by the DTCO.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_066", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 57, "chunk_size": 324 } }, { "content": "2.6.\n9. Interruption of treatment (lost to follow up)\n \n Directly Observed Treatment adapted to the needs of the patient is the\n best method of avoiding treatment interruption. However, even with\n directly observed treatment during the intensive period and during the\n continuation phase of treatment, which may be self-administered, there\n may be treatment interruption.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_067", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 53, "chunk_size": 371 } }, { "content": "22 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_068", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 37 ==================================================\n2.6.9.1.Measures to minimize treatment interruption\n \n At the time of registration of a TB patient, the staff must educate the patient\n and the family regarding the duration of treatment and the importance of\n adherence to treatment. \n It is vital to record the patient’s address and other relevant addresses\n e.g. parents or work place etc. in order to help locate the patients who\n interrupt treatment. As far as possible, the address should be verified at\n the beginning of treatment.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_069", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 597 } }, { "content": "the beginning of treatment. \n \n Public Health Midwives in their field visits and at antenatal clinics should\n inquire about uninterrupted continuation of treatment from patients and\n should encourage them to continue treatment. \n \n 2.6.9.\n2. Management of patients who interrupt treatment\n \n It is important to take action on defaulters immediately. Patients should\n be contacted the day after missing a dose during the intensive phase and\n as soon as possible during the continuation phase. It is important to find\n out the reason for the patient’s absence in order to take appropriate action", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_069", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 593 } }, { "content": "out the reason for the patient’s absence in order to take appropriate action\n and continue treatment. \n \n 2.\n7. Notification \n \n At the point of diagnosis, all tuberculosis patients should be notified using\n TB notification Form (H 816).", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_069", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 36, "chunk_size": 237 } }, { "content": "2.\n8. Contact screening \n \n Household contacts of all TB patients (adults and children >5 years)\n should be screened for symptoms of TB. Those who have symptoms\n suggestive of TB should be investigated with sputum smears irrespective\n of the duration of the symptoms. \n \n Children under the age of 5 years should be screened with chest X-ray and\n Mantoux test.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_070", "page_number": 7, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 58, "chunk_size": 360 } }, { "content": "National Guideline for Maternal Care - Volume II 23", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_071", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 38 ==================================================\n2.\n9. Preventive treatment \n \n The aim of preventive treatment is to prevent progression of M.\n tuberculosis infection to disease. \n \n Primary chemoprophylaxis \n When a person is exposed to TB bacilli, but not yet infected eg. newborn\n breastfed baby of a sputum smear-positive mother \n \n Secondary chemoprophylaxis \n \n A person who is infected, but not yet developed clinical disease\n e.g. tuberculin positive close contacts of sputum smear-positive patients.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_072", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 68, "chunk_size": 570 } }, { "content": "e.g. tuberculin positive close contacts of sputum smear-positive patients.\n In Sri Lanka, chemoprophylaxis is given for the following groups:\n \n \n• Breast fed infants of sputum smear-positive mothers.\n \n \n• Household contacts below 5 years of age of sputum smear-positive\n patients, who do not have evidence of active disease.\n Prophylactic treatment in Sri Lanka is – INAH 5mg/ kg body weight\n for 6 months. \n For further details refer ‘General Manual for Tuberculosis Control’\n published by National Program for Tuberculosis Control and Chest\n Diseases.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_072", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 555 } }, { "content": "24 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_073", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 39 ==================================================\nInfluenza A & B Virus Infection \n \n Including H1N1", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_074", "page_number": 7, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 12, "chunk_size": 160 } }, { "content": "National Guideline for Maternal Care - Volume II 25", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_075", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 40 ==================================================\n26 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_076", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 161 } }, { "content": "================================================== PAGE 41 ==================================================\n3. Management of Influenza A & B Virus Infection \n Including H1N1 in Pregnancy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_077", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 17, "chunk_size": 188 } }, { "content": "3.\n1. Introduction \n \n With the presence of community transmission of influenza A/B (including\n H1N1) virus infection, it is important to note that pregnancy is considered\n as a high risk condition. \n The disease may become more severe during pregnancy and there is a\n high risk of mortality due to complications especially in pregnant women\n with co morbidities such as diabetes, heart disease, bronchial asthma,\n cancer and anaemia. H1N1 infection is also associated with increased risk\n of adverse pregnancy outcomes such as spontaneous abortion, preterm\n birth and foetal distress.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_078", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 87, "chunk_size": 585 } }, { "content": "of adverse pregnancy outcomes such as spontaneous abortion, preterm\n birth and foetal distress. \n \n The objective of this document is to provide all healthcare providers,\n both in preventive and curative sectors with specific guidelines to follow\n aiming to mitigate untoward consequences following H1N1 infection.\n 3.\n2. Protection against infection", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_078", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 48, "chunk_size": 350 } }, { "content": "A. Pregnant women and women in reproductive age \n group should be educated on early clinical \n manifestations of influenza virus infection. \n Clinical Manifestations \n \n• Fever along with cough \n \n• Sore throat \n \n• Rhinorrhoea \n \n• Headache \n \n• Muscle pain \n \n• Malaise \n B. They should avoid unnecessary travel, crowded public\n places and public transport as much as possible.\n \n C. They should be advised to stay at home and encourage to\n practice cough and sneeze etiquette (covering mouth and nose\n when coughing or sneezing) or wear a face mask (at least a", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_079", "page_number": 7, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 88, "chunk_size": 563 } }, { "content": "when coughing or sneezing) or wear a face mask (at least a\n home- made mask) if they have fever and flu-like symptoms.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_079", "page_number": 7, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 22, "chunk_size": 118 } }, { "content": "National Guideline for Maternal Care - Volume II 27", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_080", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 42 ==================================================\nD. Pregnant women and new mothers should avoid providing\n care of persons with influenza like illnesses, except for their own\n newborns. \n E. All preventive measures to avoid transmission of infection\n should be taken by health care workers when attending to\n pregnant women. \n \n F. Anyone with respiratory symptoms should not provide care for\n the pregnant women, the mother and newborn baby.\n \n G. Care for symptomatic pregnant women (with fever and flu-like", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_081", "page_number": 7, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 570 } }, { "content": "G. Care for symptomatic pregnant women (with fever and flu-like\n symptoms), should be organized in a separate area in the clinic\n or OPD whenever possible. \n \n 3.\n3. Case identification \n Suspected Case: \n An individual presenting with acute febrile respiratory illness (fever > 38\n oC) with the spectrum of disease from influenza-like illness (cough, sore\n throat, shortness of breath) to pneumonia. \n \n Probable case: \n An individual tested positive for influenza A, but hasn’t subtyped by\n reagents used to differentiate influenza virus strains.\n \n Confirmed Case of H1N1 infection:", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_081", "page_number": 7, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 84, "chunk_size": 585 } }, { "content": "reagents used to differentiate influenza virus strains.\n \n Confirmed Case of H1N1 infection: \n An individual tested positive for influenza A (H1N1) 2009 by real time\n RT-PCR \n Note: A negative PCR result does not rule out that a person may be in-\n fected with influenza A (H1N1) 2009 virus. Results should be interpreted\n in conjunction with the available clinical and epidemiological information.\n \n 3.\n4. Seeking medical care \n \n A) Pregnant mothers should consult a qualified physicians (either\n in government or private sector) immediately if they have above", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_081", "page_number": 7, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 562 } }, { "content": "in government or private sector) immediately if they have above\n symptoms (fever with cough, sore throat, rhinorrhea, headache,\n muscle pain, malaise). \n \n B) Suspected cases should be admitted to a hospital for specialized\n care, for management. \n \n 28 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_081", "page_number": 7, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 44, "chunk_size": 302 } }, { "content": "================================================== PAGE 43 ==================================================\nC) If they present with features of complicated influenza or pro\n gressive disease such women may need ICU care.\n \n \n• Manifestations of cardio-respiratory distress (e.g. short\n ness of breath either during physical activity or while\n resting / dyspnoea tachypnea, hypoxia, low blood pres\n sure). \n \n• Radiological signs of lower respiratory tract disease\n (e.g. pneumonia) \n \n• Central nervous system (CNS) involvement (e.g. al\n tered mental status, unconsciousness, drowsiness, re", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_082", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 592 } }, { "content": "tered mental status, unconsciousness, drowsiness, re\n curring or persistent convulsions (seizures), confusion,\n severe weakness or paralysis) \n \n• Severe dehydration \n D) Medical Officers of Health and other healthcare workers in\n volved in provision of care to pregnant mothers should\n highlight signs and symptoms of influenza illness in all health\n education activities, especially in routine antenatal clinics.\n E) Public Health Midwives and other field officials should refer any\n pregnant mother with fever and flu-like symptoms for proper\n medical care without delay.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_082", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 79, "chunk_size": 574 } }, { "content": "pregnant mother with fever and flu-like symptoms for proper\n medical care without delay. \n \n F) It is important note that pregnant mothers and postpartum\n mothers can rapidly progress to severe form of the infection\n within a short period of time. Hence high degree of suspicion\n and vigilance is needed in treating influenza infection.\n All pregnant mothers with influenza like illness should be admitted\n to a hospitals with specialist care. \n \n 3.\n5. Management in the hospital \n \n A) Provide a disposable/surgical facemask to the patient.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_082", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 542 } }, { "content": "3.\n5. Management in the hospital \n \n A) Provide a disposable/surgical facemask to the patient.\n \n B) Ask to practice good hand hygiene and washing hands often\n using simple disinfectants such as soap. Discourage nose\n picking and limit touching the eyes, nose and mouth.\n \n C) Attending health care providers should wear face masks\n properly whenever in contact with infected/suspected mother.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_082", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 58, "chunk_size": 393 } }, { "content": "National Guideline for Maternal Care - Volume II 29", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_083", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 44 ==================================================\nD) Isolation – care for symptomatic patients should be organized in\n a separate area in the antenatal ward (cohort isolation).\n \n E) Consultant or the clinician of the highest rank (Senior\n Registrar/ Registrar/ SHO) should be informed immediately on\n admission. \n \n F) Institutions managing pregnant women should request\n adequate stocks of oseltamivir \n G) Consider transferring patients only if required specialized care.\n \n H) Most of the infected pregnant women can be managed", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_084", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 591 } }, { "content": "H) Most of the infected pregnant women can be managed\n effectively if oseltamivir is started early. It is a must to start\n oseltamivir when influenza is suspected without waiting for\n laboratory confirmation. \n \n 3.\n6. Laboratory Diagnosis \n \n A) Upper respiratory samples are the most appropriate laboratory\n specimens. Samples should be taken from the deep nostrils\n (nasal swab), throat swab and nasopharynx (nasopharyngeal\n swab). Nasopharyngeal aspirate and bronchial aspirate gives the\n best diagnostic yield. \n B) Upper respiratory samples should be collected in to a special", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_084", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 582 } }, { "content": "best diagnostic yield. \n B) Upper respiratory samples should be collected in to a special\n Viral Transport Medium (VTM) obtained from the Medical\n Research Institute (MRI). \n \n C) Health care workers should adhere to appropriate standard\n precautions when collecting specimens since this may expose\n to respiratory secretions from patients. Surgical mask and\n gloves are appropriate for obtaining upper respiratory tract\n samples and N95 mask, gown and gloves are recommended\n in aerosol generating procedures like aspirating respiratory\n secretions.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_084", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 75, "chunk_size": 550 } }, { "content": "in aerosol generating procedures like aspirating respiratory\n secretions. \n D) Avoid collecting samples in open areas in the ward/clinic.\n \n E) These specimens should be sent to the MRI in ice packs without\n delay, using special request form developed by the MRI for this\n purpose.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_084", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 43, "chunk_size": 281 } }, { "content": "30 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_085", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 45 ==================================================\nF) A detailed clinical history indicating the justification for the\n investigation should be included in the request.\n \n G) If there is a delay in transportation, place the sample temporally\n in the freezer compartment (4-8 Co) in the fridge for 24-48 hr.\n NEVER store the sample in deep freezer section in the fridge.\n \n 3.\n7. Antiviral therapy \n \n Consultant or his delegate caring for the pregnant mother should start\n antiviral therapy immediately in suspected cases.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_086", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 77, "chunk_size": 581 } }, { "content": "antiviral therapy immediately in suspected cases.\n Dose: Oseltamivir 75 mg twice a day for 5 days. \n \n In severe cases higher doses (150 mg) and longer duration of treatment\n may be considered. \n \n Drug supply: Arrangements should be made to make 24hr availability of\n antiviral drugs in the hospital and /or obstetric and gynaecological wards.\n \n The antiviral drug is safe for use even in the first trimester.\n All pregnant mothers with severe/complicated disease or signs of\n progression of the disease (or even suspected cases) should be treated\n with oseltamivir.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_086", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 568 } }, { "content": "progression of the disease (or even suspected cases) should be treated\n with oseltamivir. \n \n Treatment should be initiated as soon as possible, without delay\n \n Treatment with antiviral medications should begin without waiting\n for collecting specimen or results of diagnostic testing.\n \n Chemoprophylaxis is NOT recommended in pregnancy\n \n The patient should be provided with necessary supportive therapy\n (adequate nutrition and oral fluids) and medication (eg antipyretics,\n antibiotics where indicated, rehydration etc.). \n \n Oxygen saturation should be monitored by pulse oximetry, whenever", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_086", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 77, "chunk_size": 596 } }, { "content": "Oxygen saturation should be monitored by pulse oximetry, whenever\n possible. Supplement oxygen should be provided to correct hypoxaemia.\n Severe cases may need care at an Intensive Care Unit. Therefore ensure\n the availability of such facilities beforehand. \n Non-steroidal Anti Inflammatory Drugs. (NSAIDs) should be avoided.\n \n National Guideline for Maternal Care - Volume II 31", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_086", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 53, "chunk_size": 381 } }, { "content": "================================================== PAGE 46 ==================================================\nSince there is high risk of foetal distress and preterm labour, consider\n administration of corticosteroids for promotion of fetal lung maturation\n where applicable. \n \n 3.\n8. Management of Labour \n \n A) Organize separate areas for labour and delivery for infected or\n suspected pregnant mothers \n \n B) Provided routine intrapartum and postpartum care.\n \n C) Provide appropriate interventions where indicated for specific\n complications related to childbirth, the postpartum/postnatal", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_087", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 67, "chunk_size": 594 } }, { "content": "complications related to childbirth, the postpartum/postnatal\n period or the newborn. \n D) Tocolytics can be used as for any other obstetric case.\n \n E) Since there is a higher risk of fetal distress, discuss with\n anaesthesiologist the risks and benefits of vaginal\n delivery and caesarean delivery. Consider the risks of\n anaesthesia in a severely ill woman. \n \n F) Reduce the length of stay in the postnatal ward to the minimum\n required by maternal and newborn condition. \n G) Anyone (including health care workers) with respiratory\n symptoms should not provide care for the pregnant woman or", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_087", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 91, "chunk_size": 596 } }, { "content": "symptoms should not provide care for the pregnant woman or\n the mother and newborn baby. \n \n 3.\n9. Newborn Care \n \n A) Do not separate the baby from the mother even if the mother\n has influenza A pandemic (H1N1). Institute rooming –in.\n \n B) Mothers should wear a disposable/surgical facemask and\n practice good hand hygiene and hand washing with soap and\n water regularly before feeding or handing the baby.\n \n C) Support mothers to initiate breastfeeding within one hour of\n giving birth and to breastfeed frequently and exclusively on", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_087", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 537 } }, { "content": "giving birth and to breastfeed frequently and exclusively on\n demand. If mother is ill, she should be helped to express her\n breast milk and feed it to the infant. \n \n 32 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_087", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 38, "chunk_size": 219 } }, { "content": "================================================== PAGE 47 ==================================================\nD) Antivirals not a contraindication for breastfeeding.\n \n E) Newborns of infected mothers should be closely observed for\n possible development of infection. \n \n F) Newborn infants are unlikely to have typical influenza signs.\n Influenza or its complications in newborn infants may begin\n with less typical signs such as apnoea, fever, fast breathing,\n cyanosis, excessive sleeping, lethargy, feeding poorly and\n dehydration.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_088", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 62, "chunk_size": 535 } }, { "content": "cyanosis, excessive sleeping, lethargy, feeding poorly and\n dehydration. \n G) Newborn infants with severe or deteriorating illness and those\n at risk of more severe or complicated illness should promptly be\n treated with antiviral drugs. \n \n Oseltamivir dose for babies: 3mg/kg twice daily for 5 days\n \n H) Mothers who are breast feeding may continue breastfeeding\n while ill and receiving oseltamivir. \n \n 3.\n10. Discharged Criteria \n \n Pregnant mothers could be discharged after completion of 4 days of\n treatment if she has clinically recovered. Decision on discharging those", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_088", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 578 } }, { "content": "treatment if she has clinically recovered. Decision on discharging those\n with severe disease should be taken by the treating clinicians based on\n their clinical judgment. \n \n 3.\n11. Notification: \n \n All admitted cases should be notified using routine procedure to the\n relevant Medical Officer of Health by the treating clinicians.\n Medical Officer – Maternal and Child Health (MO – MCH) should notify\n all suspected cases of H1N1 in pregnancy to Epidemiology Unit.\n \n In the event of a maternal death, notification should be sent without delay", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_088", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 83, "chunk_size": 546 } }, { "content": "In the event of a maternal death, notification should be sent without delay\n to the Family Health Bureau. It should be emphasized that a post mortem\n is mandatory in all maternal deaths. \n \n In addition to routine notification, all suspected or confirmed pregnant\n women/ newborns/children with H1N1 should be notified to family\n Health Bureau. \n \n National Guideline for Maternal Care - Volume II 33", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_088", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 62, "chunk_size": 400 } }, { "content": "================================================== PAGE 48 ==================================================\n3.\n12. Safety of Health Care Workers \n \n Please refer to the General Circular No: 01-37/2009 Interim Guidelines\n for Clinical Management and Laboratory Investigation of Patients with\n Pandemic Influenza A (H1N1) \n2009. Virus Infection in a Setting with\n Sustained Transmission issued by Director General Services, Ministry of\n Health and Website of Epidemiology Unit www.epid.gov.lk\n \n Care of pregnant HCW \n \n Pregnant health care workers should be reassigned to non-contaminated", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_089", "page_number": 7, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 590 } }, { "content": "Care of pregnant HCW \n \n Pregnant health care workers should be reassigned to non-contaminated\n or low risk areas eg. Orthopaedic units, dermatology Units.\n They should be given high priority to receive Personal Protection\n Equipments.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_089", "page_number": 7, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 33, "chunk_size": 235 } }, { "content": "34 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_090", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 49 ==================================================\nLiver Disease", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_091", "page_number": 7, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 123 } }, { "content": "National Guideline for Maternal Care - Volume II 35", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_092", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 50 ==================================================\n36 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_093", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 161 } }, { "content": "================================================== PAGE 51 ==================================================\n4. Liver disease in pregnancy \n \n 4.\n1. Introduction \n \n ➢ Liver dysfunction is known to affect up to 3% percent of\n pregnancies and is a leading cause of maternal mortality and\n morbidity in Sri Lanka.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_094", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 38, "chunk_size": 312 } }, { "content": "Box 4.1: Normal biochemical changes during pregnancy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_095", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 7, "chunk_size": 52 } }, { "content": "Total bilirubin No change or slight decrease\n AST/ALT No change \n \n Alkaline phosphatase Increased by 200-400% (placenta\n and bone) \n Gamma glutamyltransferase No change or slight decrease\n Albumin Decreased \n Prothrombin time/INR No change \n Platelets No change/mild decrease \n \n Total cholesterol and triglyceride increased \n \n National Guideline for Maternal Care - Volume II 37", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_096", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 49, "chunk_size": 381 } }, { "content": "================================================== PAGE 52 ==================================================\n➢ Therefore, any increase in alanine aminotransferase (ALT), as\n partate aminotransferase (AST),serum bilirubin and INR in\n pregnancy warrants further evaluation.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_097", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 24, "chunk_size": 272 } }, { "content": "4.\n2. Pre-existing liver disease \n \n Pre conception care \n \n ➢ Risks of complications in the mother and fetus depends on the\n underlying condition and severity. \n ➢ The woman should be assessed by a specialist physician prior\n to pregnancy for advice on suitability for pregnancy, review and\n optimizing medication and target organ screening.\n \n 4.2.\n1. Chronic viral hepatitis \n \n ➢ Women should be reviewed by a hepatologist early in\n pregnancy for plan of management during pregnancy; Refer\n for hepatology opinion if the maternal viral load is high in the\n third trimester.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_098", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 88, "chunk_size": 577 } }, { "content": "for hepatology opinion if the maternal viral load is high in the\n third trimester. \n \n ➢ Vertical transmission of hepatitis B during pregnancy is\n thought to be mainly transplacental even though transmission\n through secretions are also documented. However, studies\n to date have not shown any conclusive evidence of benefit of\n caesarean section over vaginal delivery. Mode of delivery should\n be based on obstetric indications. \n ➢ Mother to baby transmission is proportional to the maternal\n viral DNA and e antigen level. \n ➢ All babies born to hepatitis B surface antigen positive mothers", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_098", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 90, "chunk_size": 593 } }, { "content": "viral DNA and e antigen level. \n ➢ All babies born to hepatitis B surface antigen positive mothers\n should receive hepatitis B immunoglobulin and the first dose of\n the hepatitis B vaccine within 12 hours of birth.\n \n ➢ Patients with chronic viral hepatitis C are monitored closely,\n but there is no place for treatment during pregnancy. Mother\n to baby transmission rate of Hepatitis C has been shown to be\n higher with prolonged rupture of membranes.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_098", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 74, "chunk_size": 452 } }, { "content": "38 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_099", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 53 ==================================================\n4.2.2.Cirrhosis \n \n ➢ All patients with cirrhosis should be managed in a tertiary care\n center with facilities for endoscopy and variceal ligation.\n \n ➢ Women with suspected portal hypertension should have an\n upper endoscopy ideally in the preconception stage or at least in\n the second trimester to look for esophageal varices.\n \n o Management of esophageal varices: \n -Prophylactic banding especially if the risk\n of bleeding is high, such as ‘red signs’ on varices or in", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_100", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 584 } }, { "content": "of bleeding is high, such as ‘red signs’ on varices or in\n patents with decompensated cirrhosis \n -Avoidance of vaginal delivery due to risk of rupture of\n varices during the second stage of labour.\n -Continuations of beta blockers( Eg: Propranolol )\n throughout pregnancy with close maternal and fetal\n monitoring \n o Management of upper GI bleeding: \n -Endoscopic banding is the treatment of choice\n -Broad spectrum antibiotics (preferably a 3rd\n generation cephalosporin such as IV Ceftriaxone) is\n recommended \n -Vassopressin is contraindicated; Terlipressin has not\n been studied in pregnancy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_100", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 85, "chunk_size": 597 } }, { "content": "recommended \n -Vassopressin is contraindicated; Terlipressin has not\n been studied in pregnancy \n -There is inadequate evidence for Octreotide, though\n if endoscopy and banding are delayed due to\n unavoidable circumstances, this may be\n considered. However this should not be considered an\n alternative to timely endoscopy. \n ➢ Patients with cirrhosis should be screened with ultrasound\n specifically looking for the presence of a splenicartery\n aneurysm and if present referred to a tertiary care center for\n management", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_100", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 72, "chunk_size": 520 } }, { "content": "4.2.\n3. Autoimmune hepatitis \n \n ➢ Steroids and Azathioprine could be continued during\n pregnancy. \n \n National Guideline for Maternal Care - Volume II 39", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_101", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 22, "chunk_size": 154 } }, { "content": "================================================== PAGE 54 ==================================================\n➢ Flares are infrequent during pregnancy though postpartum\n flares are expected. \n \n o Close surveillance postpartum with review at 6 weeks is\n recommended. \n \n 4.2.\n4. Wilsons disease \n \n ➢ Lowering the dose of D-penicillamine during the first trimester\n is recommended with maintenance on the lowest dosage during\n all trimesters. \n ➢ Reduce D-penicillamine to a minimal dose of 300–600 mg/\n day in the last trimester in order to avoid copper deficiency", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_102", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 565 } }, { "content": "day in the last trimester in order to avoid copper deficiency\n in the fetus and insufficient wound healing after caesarean\n section or episiotomy. \n \n o If caesarean section is planned, the dose of\n Penicillamine should be limited to 250 mg/day\n for 6 weeks before delivery and postoperatively until\n wound healing is complete \n ➢ Breast feeding under chelation therapy is not recommended.\n \n 4.\n3. Liver disease specific to pregnancy \n \n 4.3.\n1. When to suspect liver disease \n \n Symptoms: \n Pruritus, right hypochondrial pain, dark coloured urine or", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_102", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 551 } }, { "content": "Symptoms: \n Pruritus, right hypochondrial pain, dark coloured urine or\n yellow discoloration of eyes, vomiting and swelling of feet (sudden onset\n in latter part of pregnancy), drowsiness and flu like symptoms.\n \n Signs: \n Icterus, peripheral oedema out of proportion to the gestational\n period/rapid onset or associated with hypertension, right hypochondrial\n tenderness, splenomegaly, reduced level of consciousness and liver flaps.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_102", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 57, "chunk_size": 434 } }, { "content": "40 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_103", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 55 ==================================================\nBox 4.2: First line Investigations in a pregnant woman suspected with\n liver disease \n \n Investigation Finding Comments \n SGOT (AST) Any rise warrants Mild elevation \n SGPT(ALT) evaluation Dengue infection (SGOT>SGPT)\n Preeclampsia/HELLP syndrome(SGOT>SGPT)\n Intrahepatic cholestasis of pregnancy (ICP)\n Hyperemesis gravidarum \n Acute fatty liver of pregnancy (AFLP )\n Marked elevation (Serum level >1000 U/L)\n Acute viral hepatitis \n Drug induced liver disease including", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_104", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 62, "chunk_size": 581 } }, { "content": "Acute viral hepatitis \n Drug induced liver disease including\n Paracetamol overdose \n Hypoxic hepatic injury \n Mild elevation in otherwise asymptomatic\n individual \n Preexisting fatty liver disease\n Cirrhosis \n Serum Any rise warrants Mild elevation \n bilirubin evaluation Hyperemesis gravidarum (HG)\n Acute fatty liver of pregnancy (AFLP) –early\n stage \n Haemolysis, elevated liver enzymes and low\n platelets (HELLP) \n Sepsis \n Marked elevation \n Cholestatic viral hepatitis \n Late stage of AFLP \n Any cause of obstructive jaundice\n FBC Thrombocytopaenia Cirrhosis with portal hypertension", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_104", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 72, "chunk_size": 589 } }, { "content": "Any cause of obstructive jaundice\n FBC Thrombocytopaenia Cirrhosis with portal hypertension\n Severe pre eclampsia \n HELLP syndrome \n Liver failure \n PT/INR Any rise needs further Prolongation suggests liver failure\n evaluation \n Gamma GT Any rise needs further Prolonged in cholestatic and drug induced liver\n evaluation disease \n Alkaline Isolated elevation is \n phosphatase normal in pregnancy \n Further evaluation of a woman with suspected liver disease\n Details are specified under individual liver disease below.\n National Guideline for Maternal Care - Volume II 41", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_104", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 77, "chunk_size": 570 } }, { "content": "================================================== PAGE 56 ==================================================\n4.3.\n2. Hyperemesis gravidarum \n \n ➢ Patients present with persistent vomiting, weight loss,\n dehydration +/- ketosis usually from 4th to 20 th week\n of pregnancy. \n ➢ Affects 1-1.5% of pregnancies. \n ➢ Is more common with molar pregnancy, preexisting diabetes,\n and multiple pregnancies. \n ➢ Usually has no effect on fetal outcome, unless prolonged and\n associated with nutritional deficiencies. \n ➢ Liver dysfunction includes: \n o Increased transaminases in 50% (in the lower\n hundreds)", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_105", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 598 } }, { "content": "➢ Liver dysfunction includes: \n o Increased transaminases in 50% (in the lower\n hundreds) \n o An increase in bilirubin being less common with\n jaundice found only occasionally \n o Severity of liver disease correlates with vomiting\n ➢ Management includes: \n o Hydration, with monitoring of fluid balance and\n electrolytes. \n o Endoscopic insertion of a NJ tube should be considered\n in very severe cases when adequate nutrition and\n hydration cannot be maintained by other means.\n o Antiemetics \n 4.3.3.Intrahepatic cholestasis of pregnancy \n ➢ Prevalence is around 2/1000 of pregnancies.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_105", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 84, "chunk_size": 587 } }, { "content": "4.3.3.Intrahepatic cholestasis of pregnancy \n ➢ Prevalence is around 2/1000 of pregnancies. \n ➢ Typically presents with pruritus at around 25 to 32 weeks of\n gestation. \n o Pruritus is severe at night and affects palms and soles\n ➢ No maternal complications except for pruritus, which could be\n distressing. \n ➢ Fetal complications include premature labor and sudden fetal\n death. \n ➢ Pruritus and liver dysfunction resolve after delivery.\n ➢ High risk of recurrence in a subsequent pregnancy.\n ➢ Liver dysfunction includes: \n o Elevated aminotransferase levels (10 to 20 fold)", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_105", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 577 } }, { "content": "➢ Liver dysfunction includes: \n o Elevated aminotransferase levels (10 to 20 fold)\n o Jaundice in 10%-25% of patients, 2-4 weeks after\n pruritus; Bilirubin is usually less than 5mg/d\n o Rise in alkaline phosphatase levels upto fourfold with a\n normal or mildly elevated GGT \n o Elevated fasting serum bile acid levels (>10 µmol/L)\n 42 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_105", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 61, "chunk_size": 383 } }, { "content": "================================================== PAGE 57 ==================================================\nwhich is the most specific and sensitive marker of ICP;\n This could rise upto 100 fold \n o Deficiency of Vit K if liver functions are severely\n deranged \n ➢ Management includes: \n o Symptomatic therapy \n - Ursodeoxycholic acid (UDCA) 10 to 15 mg/kg body\n weight per day \n - Fat soluble vitamin supplementation in severe\n steatorrhoea \n o Close monitoring and early delivery of the fetus.\n \n 4.3.\n4. Pre eclampsia \n ➢ Preeclampsia is the occurrence of hypertension, proteinuria +/-", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_106", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 590 } }, { "content": "4.3.\n4. Pre eclampsia \n ➢ Preeclampsia is the occurrence of hypertension, proteinuria +/-\n oedema after 20 weeks of pregnancy. \n ➢ It affects around 3% of pregnancies; Is the commonest cause of\n hepatic tenderness in pregnancy \n ➢ Liver involvement, indicates severe preeclampsia.\n ➢ Liver dysfunction includes: \n o Increase in serum aminotransferase levels which is\n usually mild. SGOT is usually more than SGPT.\n o Jaundice which is not common and usually associated\n with serum bilirubin level less than 5 mg/dL\n o Subcapsular haematoma which could occur with severe\n liver derangement", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_106", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 88, "chunk_size": 588 } }, { "content": "o Subcapsular haematoma which could occur with severe\n liver derangement \n ➢ Management includes: \n o Close monitoring of maternal and fetal well being\n o Delivery is the definitive therapy \n - No specific therapy is needed for hepatic involvement\n of preeclampsia; It’s significance is as an indicator of\n severe disease. \n \n 4.3.\n5. HELLP Syndrome \n ➢ Severe preeclampsia is complicated in 2%-12% of cases by\n hemolysis (H), elevated liver enzymes (EL), and low platelet\n count (LP). \n ➢ Diagnosis requires the presence of all 3 laboratory criteria.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_106", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 83, "chunk_size": 551 } }, { "content": "count (LP). \n ➢ Diagnosis requires the presence of all 3 laboratory criteria.\n ➢ Most patients present in the 3rd trimester, but 25% present in\n the postpartum period.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_106", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 27, "chunk_size": 167 } }, { "content": "National Guideline for Maternal Care - Volume II 43", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_107", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 58 ==================================================\nBox 4.3- Diagnostic Criteria for HELLP Syndrome\n \n Haemolysis \n -Fragmented red blood cells /LDH >600 U/L/\n Elevated indirect bilirubin \n Elevated liver enzymes \n - AST>70U/L \n Low platelets \n - Plt ct< 150×109 \n ➢ Most patients present with upper abdominal pain and\n tenderness, nausea, vomiting, malaise, headache, oedema,\n hypertension and proteinuria. \n \n ➢ The diagnosis of HELLP syndrome must be quickly established\n because of the necessity for immediate delivery considering the", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_108", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 596 } }, { "content": "because of the necessity for immediate delivery considering the\n maternal and fetal risk. \n ➢ Liver dysfunction includes: \n \n o Raised aminotransferase levels from mild to 10-20 fold\n \n o Mildly elevated serum bilirubin; Jaundice is\n uncommon \n \n ➢ Management includes \n : \n o Delivery as the definitive therapy \n \n 4.3.\n6. Acute Fatty Liver of Pregnancy (AFLP) \n \n ➢ This almost exclusively occurs in the third trimester; rarely in\n late second trimester. \n \n ➢ Common presentations are anorexia, nausea, vomiting and\n right upper quadrant pain.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_108", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 78, "chunk_size": 546 } }, { "content": "➢ Common presentations are anorexia, nausea, vomiting and\n right upper quadrant pain. \n ➢ Patient may have jaundice, hypertension, peripheral oedema,\n ascites and hepatic encephalopathy. \n \n ➢ Patient may present with hepatic failure; therefore is associated\n with significant maternal and perinatal morbidity and mortality.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_108", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 42, "chunk_size": 324 } }, { "content": "44 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_109", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 59 ==================================================\n➢ About 50% of patients with AFLP have preeclampsia, and there\n is overlap with HELLP syndrome. \n \n ➢ Women with AFLP have an increased risk of recurrence in a\n future pregnancy. \n ➢ The main differential diagnoses for acute liver failure in the\n third trimester are AFLP, HELLP, and fulminant viral hepatitis.\n \n – In comparison with HELLP syndrome, patients\n with AFLP are more likely to develop coagulopathy,\n hypoglycemia, encephalopathy,DIC, and renal failure", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_110", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 574 } }, { "content": "hypoglycemia, encephalopathy,DIC, and renal failure\n \n ➢ Liver dysfunction include: \n o Mild to severe elevation of aminotransferases (usually\n upto 300 to 500U/L) \n \n o Mild elevation of serum bilirubin which is usuallyless\n than 5mg/dL but higher in severe or complicated\n disease \n \n Box 4.4- Swansea diagnostic criteria for diagnosis of acute fatty liver\n of pregnancy \n Six or more of the following features in the absence of another\n explanation suggests a diagnosis of AFLP \n \n \n• Vomiting \n \n \n• Abdominal pain \n \n• Polydipsia/polyuria \n \n \n• Encephalopathy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_110", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 79, "chunk_size": 565 } }, { "content": "• Vomiting \n \n \n• Abdominal pain \n \n• Polydipsia/polyuria \n \n \n• Encephalopathy \n \n• High bilirubin (>14 μmol/L) \n \n \n• Hypoglycaemia (<4 mmol/L) \n \n• High uric acid (>340 μmol/L) \n \n \n• Leucocytosis (>11×106/L)", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_110", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 27, "chunk_size": 211 } }, { "content": "National Guideline for Maternal Care - Volume II 45", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_111", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 60 ==================================================\n➢ Other typical abnormalities are: \n \n o Normochromic, normocytic anaemia \n o Thrombocytopaenia \n \n ➢ Management \n \n o Early referral to a specialist care center on suspicion of\n AFLP \n \n o Consider immediate delivery to avoid adverse maternal\n and fetal outcome \n \n o Intensive care to manage complications of liver failure\n ➢ Most patients improve in 1 to 4 weeks postpartum, although a\n cholestatic phase with rising bilirubin and alkaline phosphatase\n may persist.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_112", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 578 } }, { "content": "cholestatic phase with rising bilirubin and alkaline phosphatase\n may persist. \n \n ➢ Recovery can occur in days or be delayed for months but is\n complete with no signs of chronic liver disease.\n \n ➢ Liver transplantation has a very limited role because of the\n great potential for recovery with delivery, but ideally may have\n a place in patients whose clinical course continues to deteriorate\n with advancing fulminant hepatic failure. \n 4.\n4. Liver disease coincidental to pregnancy \n \n 4.4.\n1. Non alcoholic fatty liver disease (NAFLD)", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_112", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 538 } }, { "content": "4. Liver disease coincidental to pregnancy \n \n 4.4.\n1. Non alcoholic fatty liver disease (NAFLD) \n \n ➢ Incidental detection of fatty liver on USS with isolated, mild\n elevation in liver transaminases suggest NAFLD.\n \n ➢ First diagnosis of NAFLD during pregnancy should be made\n only after excluding other causes of liver dysfunction.\n \n ➢ Patient should have a plan for follow up after delivery.\n 4.4.\n2. Dengue infection \n \n ➢ It is associated with fever, myalgia, arthralgia, headache and\n vomiting. \n \n 46 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_112", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 557 } }, { "content": "================================================== PAGE 61 ==================================================\n➢ High transaminases (SGOT>SGPT) and thrombocytopenia is\n seen. \n \n ➢ Dengue antigen (Ag) is positive on day 1-2 of fever while\n Dengue IgM/IgG is positive on day 5-7 of illness.\n 4.4.\n3. Acute viral hepatitis \n \n ➢ It usually follows the same disease course as the non pregnant\n population. \n \n o Exceptions are hepatitis E and herpes simplex\n infection, which have significant mortality and\n morbidity in pregnancy \n ➢ High transaminase levels typically over 1000 U/L, +/- recent", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_113", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 78, "chunk_size": 591 } }, { "content": "morbidity in pregnancy \n ➢ High transaminase levels typically over 1000 U/L, +/- recent\n history of fever, vomiting and right hypochondrial pain suggest\n viral hepatits though AFLP could present in a similar way.\n (Elevation of transaminases is usually <1000U/L, in AFLP).\n \n ➢ Hep A IgM/Hep B s Ag/HCV antibodies/Hep E Ab should be\n requested for confirmation of viral hepatitis.\n \n ➢ Breast feeding in patients with Viral Hepatitis\n \n o Hepatitis A and E –Breast feeding can be continued\n o Hepatitis B –Once the baby is immunized, the benefits", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_113", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 86, "chunk_size": 546 } }, { "content": "o Hepatitis B –Once the baby is immunized, the benefits\n outweighs risk of transmission Therefore breast feeding\n should not be delayed. However it should be avoided if\n the nipples are cracked \n \n o Hepatitis C - Benefits outweighs risk of transmission;\n Therefore breast feeding should not be delayed. If\n nipples are cracked, expressed breast milk can be used\n \n Hepatitis E infection \n ➢ Acute infection with Hep E virus may result in fulminant\n hepatitis with risk of liver failure. \n \n Herpes simplex virus (HSV) hepatitis \n \n ➢ High transaminase levels may occur.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_113", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 88, "chunk_size": 570 } }, { "content": "Herpes simplex virus (HSV) hepatitis \n \n ➢ High transaminase levels may occur. \n \n National Guideline for Maternal Care - Volume II 47", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_113", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 20, "chunk_size": 134 } }, { "content": "================================================== PAGE 62 ==================================================\n➢ HSV DNA is positive. \n \n ➢ Consider Acyclovir. \n 4.4.\n4. Gall stone disease \n \n ➢ Gallstones are more common in pregnancy, especially during\n the second and third trimester and should be considered,\n especially in the presence of characteristic abdominal pain.\n \n ➢ Patients with symptomatic gall stones should be managed\n in a tertiary care centre where facilities for ERCP and\n laparoscopic cholecystectomy are available. \n \n ➢ ERCP can be performed if it is absolutely necessary with", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_114", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 77, "chunk_size": 598 } }, { "content": "➢ ERCP can be performed if it is absolutely necessary with\n adequate radiation protection. \n ➢ Pregnancy itself does not increase frequency or severity of\n ERCP related complications. \n \n ➢ Cholecystectomy is best performed in the second trimester.\n o Laparoscopic cholecystectomy is preferred over open\n surgery. \n \n 4.4.\n5. Sepsis \n ➢ This mimics liver disease in pregnancy. \n \n ➢ Biochemical abnormalities include: \n \n o High WBC \n o Elevated serum bilirubin \n o Mild –moderate elevation in liver transaminases\n o Coagulopathy and DIC- high INR and \n thrombocytopaenia.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_114", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 80, "chunk_size": 572 } }, { "content": "o Coagulopathy and DIC- high INR and \n thrombocytopaenia. \n \n ➢ Blood culture should be obtained and IV antibiotics\n commenced early. \n 4.5.Acute liver failure \n \n Definition: \n The presence of coagulopathy (international normalized ratio [INR] >1.5)\n and any degree of encephalopathy occurring within 24 weeks of the first\n \n 48 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_114", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 53, "chunk_size": 378 } }, { "content": "================================================== PAGE 63 ==================================================\nonset of symptoms of liver disease in patients without previous history of\n liver impairment. \n Causes of acute liver failure include, \n Acute viral hepatitis, AFLP, Paracetamol poisoning, autoimmune\n hepatitis, Budd-Chiari syndrome. \n \n Management of acute liver failure \n \n General measures: \n \n ➢ The patient should be managed in an intensive care unit under the\n care of the obstetrician and hepatologist/gastrointestinal physician.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_115", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 61, "chunk_size": 546 } }, { "content": "care of the obstetrician and hepatologist/gastrointestinal physician.\n \n \n1. Close monitoring of mean arterial pressure, serum electrolytes,\n fluid balance, renal functions and blood sugar values.\n \n2. Elevate the head of the bed 30° and maintain the head in a\n neutral position. \n \n \n3. Lactulose may be used to ensure regular bowel opening.\n \n \n4. Although oral Metronidazole is beneficial in patients with\n chronic hepatic encephalopathy, the benefit of these\n drugs in acute liver failure is controversial as the pathogenesis\n of acute liver failure is related to cerebral edema as opposed to", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_115", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 88, "chunk_size": 596 } }, { "content": "of acute liver failure is related to cerebral edema as opposed to\n ammonia excess. \n \n5. 3rd generation cephalosporin is the choice of prophylactic\n antibiotic. \n \n \n6. Consider IV N- Acetyl cysteine (NAC) - 150mg/Kg over 1\n hour, 50mg/Kg over 4 hours, 150mg/Kg over 24 hours.\n Last dose should be repeated for 3 days. \n \n \n7. Monitor with daily liver function tests including INR and\n clinical assessment of level of consciousness including\n liver flaps. \n \n8. If sepsis is suspected, treat with IV antibiotics.\n \n Specific measures:", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_115", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 534 } }, { "content": "liver flaps. \n \n8. If sepsis is suspected, treat with IV antibiotics.\n \n Specific measures: \n \n The patient should be referred to the hepatologist for investigation and\n treatment of the underlying cause for acute liver failure.\n National Guideline for Maternal Care - Volume II 49", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_115", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 42, "chunk_size": 281 } }, { "content": "================================================== PAGE 64 ==================================================\nReferences \n \n \n1. Joshi D, James A, Quaglia A, Westbrook RH, Heneghan MA\n Liver disease in pregnancy. Lancet 2010; 375: 594–\n605.\n \n \n2. Patton H, Misel M, Gish RG et al Acute Liver Failure in\n Adults: An Evidence-Based Management Protocol for\n Clinicians Gastroenterology & Hepatology2012 Volume 8, Issue\n 3 March 2012 161-\n173. \n \n3. Gami N et al.An approach to diagnosis and management of\n acute fatty liver of pregnancy International Journal", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_116", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 556 } }, { "content": "acute fatty liver of pregnancy International Journal\n of Reproduction, Contraception, Obstetrics and Gynecology\n 2013 March;2(1):104-\n108. \n \n \n4. Ibdah JA Acute fatty liver of pregnancy: An update on\n pathogenesis and clinical implications World Journal of\n Gastroenterology 2006 December 14; 12(46): 7397-\n7404.\n \n5. Lee WM, HynanLS, Rossaro L, Fontana RJ, Stravitz RT, et al\n Intravenous n-acetylcysteine improves transplantfree survival\n in early stage non-acetaminophen acute liver failure\n Gastroenterology. 2009 September ; 137(3): 856–\n864.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_116", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 72, "chunk_size": 548 } }, { "content": "Gastroenterology. 2009 September ; 137(3): 856–\n864.\n \n \n6. Allen AM , Hay JE Review article: the management of cirrhosis\n in women Alimentary Pharmacology and Therapeutics 2014;\n 40: 1146–\n1154.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_116", "page_number": 7, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 29, "chunk_size": 195 } }, { "content": "50 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_117", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 65 ==================================================\nRenal Disease", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_118", "page_number": 7, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 123 } }, { "content": "National Guideline for Maternal Care - Volume II 51", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_119", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 66 ==================================================\n52 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_120", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 161 } }, { "content": "================================================== PAGE 67 ==================================================\n5. Renal disease in pregnancy \n \n 5.\n1. Introduction \n \n Renal disease could be either pre-existing or diagnosed for the first time\n in pregnancy. Renal impairment is associated with significant maternal\n and feotal morbidity and mortality. \n \n Physiological changes in renal system in pregnancy\n \n1. Increase in proteinuria \n o Proteinuria increases upto 300mg/d by the third\n trimester of pregnancy \n - 24 h urine collection for urinary protein excretion", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_121", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 566 } }, { "content": "trimester of pregnancy \n - 24 h urine collection for urinary protein excretion\n and measurement of creatinine clearance remains the\n gold standard for measurement of renal function in\n pregnancy \n \n2. Decrease in serum creatinine levels \n o Serum creatinine falls by an average of 0.4 mg/dL to a\n pregnancy range of 0.4 to 0.8 mg/dL. \n - Hence, a serum creatinine of 1.0 mg/dL, although\n normal in a non-pregnant individual, reflects\n renal impairment in a pregnant woman \n \n3. Dilatation of the renal tract with increased incidence of reflux\n nephropathy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_121", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 86, "chunk_size": 555 } }, { "content": "3. Dilatation of the renal tract with increased incidence of reflux\n nephropathy \n o The urinary collecting system (renal calyces, pelvis, and\n ureters) dilate. The dilated collecting systems can hold\n up to 300 mL of urine and hence serves as a reservoir\n for bacteria. \n o In the later stages of pregnancy, mechanical\n compression of the ureter against the pelvic\n brim may lead to hydroureter and hydronephrosis.\n o Hydronephrosis occurs on the right in 90% of cases\n due to dextrorotation of the uterus by the sigmoid\n colon. \n Pregnancy and kidney disease", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_121", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 89, "chunk_size": 560 } }, { "content": "due to dextrorotation of the uterus by the sigmoid\n colon. \n Pregnancy and kidney disease \n The main determinant of pregnancy outcome is the degree of renal\n impairment.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_121", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 26, "chunk_size": 169 } }, { "content": "National Guideline for Maternal Care - Volume II 53", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_122", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 68 ==================================================\nEffect of pregnancy on kidney disease: \n \n Worsening proteinuria \n Loss of kidney function- may be irreversible \n Effect of kidney disease on pregnancy: \n \n Preterm delivery \n Fetal growth restriction (FGR) \n Intrauterine death \n Preeclampsia \n \n 5.\n2. Pre-existing renal disease \n \n Preconception care \n \n ➢ All women with renal disease should be seen by a nephrologist\n prior to becoming pregnant. \n ➢ Women should be counselled on the risk of pregnancy,", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_123", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 67, "chunk_size": 566 } }, { "content": "prior to becoming pregnant. \n ➢ Women should be counselled on the risk of pregnancy,\n depending on the underlying renal disease and baseline renal\n functions. \n ➢ An individualized care plan including cardiac assessment\n should be performed, in view of increased risk of coronary\n artery disease. \n Fertility \n \n ➢ Fertility rates are thought to decline proportionately with\n declining renal function. Women with CKD stage ≥ 3 (GFR <\n 30ml/min/1.73m2) are generally less fertile. \n Contraception \n \n ➢ Use of contraceptives should be advocated until it is safe for the\n woman to become pregnant.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_123", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 88, "chunk_size": 595 } }, { "content": "➢ Use of contraceptives should be advocated until it is safe for the\n woman to become pregnant. \n ➢ Most contraceptives could be used in women with renal\n impairment. \n o Oestrogen containing contraceptives should be avoided\n in women with hypertension and those at increased\n risk of thrombosis (eg: nephrotic syndrome).\n ➢ Intra uterine device (IUD) could be used.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_123", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 57, "chunk_size": 366 } }, { "content": "54 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_124", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 69 ==================================================\n5.2.\n1. Diabetic nephropathy \n \n ➢ The presence of diabetic nephropathy is a risk factor for\n increased perinatal morbidity and mortality.\n o A favourable outcome is to be expected with\n - Serum creatinine <1.4 mg/dl (124 mmol/L)\n - Proteinuria <1 g/24 h \n - Normal blood pressure \n o Serum creatinine >2 mg/dL (176 mmol/L) is the best\n predictor of the risk of pregnancy induced decline in\n maternal kidney function leading to end stage renal\n disease (ESRD) during pregnancy or shortly", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_125", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 82, "chunk_size": 597 } }, { "content": "maternal kidney function leading to end stage renal\n disease (ESRD) during pregnancy or shortly\n afterwards. \n Management \n ➢ Multidisciplinary care with involvement of the obstetrician and\n nephrologist. \n ➢ Attain normotension and euglycaemia in the preconception\n stage, with counselling on the risk of worsening proteinuria and\n its implications on pregnancy. \n ➢ Angiotensin receptor inhibitors (ACEI) and angiotensin\n receptor blockers (ARB) must be withheld in pregnancy.\n ➢ During pregnancy, 75mg of Aspirin should be commenced at 12\n weeks of gestation and continued until delivery.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_125", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 591 } }, { "content": "weeks of gestation and continued until delivery.\n ➢ Aim to maintain blood pressure < 135/85mHg throughout\n pregnancy with monthly assessment of renal functions (serum\n creatinine, electrolytes and proteinuria). \n ➢ Fetal growth monitoring after 28 weeks. \n 5.2.\n2. Adult onset polycystic kidney disease \n \n ➢ Normotensive women with normal renal function generally\n have uncomplicated pregnancies, though there is an increased\n risk of maternal complications such as hypertension and\n preeclampsia. \n ➢ Cerebral imaging for aneurysm should be performed before", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_125", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 76, "chunk_size": 559 } }, { "content": "preeclampsia. \n ➢ Cerebral imaging for aneurysm should be performed before\n pregnancy, and if present, consider elective caesarean as mode\n of delivery. \n ➢ The patient and the spouse should be counselled regarding the\n risks of giving birth to an offspring who has a 50% chance of\n developing this condition later in life", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_125", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 51, "chunk_size": 322 } }, { "content": "National Guideline for Maternal Care - Volume II 55", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_126", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 70 ==================================================\n5.2.\n3. Lupus nephritis \n \n ➢ Pregnancy is safe if, \n o in remission with ≤10 mg daily of prednisone for 6\n months \n o Serum creatinine is < 1.4 mg/dL \n o Blood pressure is well controlled \n ➢ Women with class III or IV lupus nephritis are at increased risk\n of hypertension and renal flares. \n ➢ Complications of poorly controlled disease include,\n o spontaneous abortions \n o fetal growth restriction \n o premature delivery \n - Especially in the presence of antiphospholipid\n antibodies", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_127", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 598 } }, { "content": "o premature delivery \n - Especially in the presence of antiphospholipid\n antibodies \n ➢ Azathioprine and Prednisolone are safe in pregnancy.\n 5.2.\n4. Other Glomerulonephritides \n ➢ Assessment for suitability of pregnancy and optimization of\n disease should be undertaken in the preconception stage.\n o Aim for disease remission for at least six months before\n planning pregnancy \n ➢ Focal segmental glomerulosclerosis (FSGS) and \n membranocapillary glomerulonephritis (MCGN) are generally\n associated with poor prognosis with risk of worsening renal\n impairment in pregnancy.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_127", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 76, "chunk_size": 575 } }, { "content": "associated with poor prognosis with risk of worsening renal\n impairment in pregnancy. \n ➢ Minimal change and membranous glomerulonephritis usually\n have a good outcome. \n ➢ Women with significant proteinuria are at high risk of deep vein\n thrombosis; Need for thromboprophylaxis during pregnancy\n and the postpartum period should be discussed. \n 5.\n3. Renal disease occurring during pregnancy \n \n 5.3.\n1. Urinary tract infections (UTI) \n 5.3.1.\n1. Lower UTI \n ➢ Take a single urine sample for culture before empiric\n antibiotic is started.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_127", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 78, "chunk_size": 539 } }, { "content": "1. Lower UTI \n ➢ Take a single urine sample for culture before empiric\n antibiotic is started. \n ➢ A seven day course of treatment is normally sufficient.\n ➢ A urine culture should be performed two weeks after\n completion of antibiotic treatment as a test of cure.\n Monthly urine cultures should be checked thereafter\n until delivery. \n 56 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_127", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 63, "chunk_size": 388 } }, { "content": "================================================== PAGE 71 ==================================================\nBox 5.1: Empiric antibiotic therapy for lower UTI\n \n• Nitrofurantoin 100 mg 6 hourly \n - Avoid in G6PD deficiency \n - Do not prescribe in the last 2 to 4 weeks of pregnancy\n \n• Amoxicillin 500 mg 8 hourly \n \n• Coamoxiclav 625 mg 12 hourly \n \n• Cephalexin 500 mg 8 hourly \n \n 5.3.1.\n2. Upper UTI \n ➢ The incidence of pyelonephritis is higher in pregnancy\n due to the physiological changes of the urinary tract.\n ➢ The risk of renal impairment secondary to", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_128", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 564 } }, { "content": "➢ The risk of renal impairment secondary to\n pyelonephritis is also higher in pregnancy compared to\n the non-pregnant population \n \n Box 5.2: Empiric antibiotic therapy for upper UTI\n \n• Ceftriaxone 1-2 g IV or IM daily \n \n• Aztreonam 1 g IV 8-12 hourly \n \n• Piperacillin-tazobactam 3.375-4.5 g IV 6 hourly\n \n• Cefepime 1 g IV 12 hourly \n \n• Imipenem-cilastatin 500 mg IV 6 hourly \n \n• Ampicillin 2 g IV 6 hourly \n \n• Gentamicin 3-5 mg/kg/day IV in 3 divided doses\n ➢ After clinical improvement parenteral therapy can be\n switched to oral therapy for a total treatment duration\n of 7-10 days.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_128", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 99, "chunk_size": 592 } }, { "content": "switched to oral therapy for a total treatment duration\n of 7-10 days. \n ➢ Those with complicated disease may require a longer\n course of antibiotic. \n ➢ Monthly urine cultures must be checked till delivery.\n ➢ Ultrasound scan of KUB should be done to look for\n obstruction, calculi or anatomical abnormalities.\n 5.3.1.\n3. Asymptomatic bacteriuria (AB) \n \n ➢ Asymptomatic bacteriuria is diagnosed when two\n consecutive voided urine specimens grow >105cfu/\n mL of the same bacterial species or a single\n catheterised specimen grows >105cfu/mL of an\n uropathogen, in the absence of symptoms of", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_128", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 89, "chunk_size": 591 } }, { "content": "catheterised specimen grows >105cfu/mL of an\n uropathogen, in the absence of symptoms of\n urine infection.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_128", "page_number": 7, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 15, "chunk_size": 106 } }, { "content": "National Guideline for Maternal Care - Volume II 57", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_129", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 72 ==================================================\n➢ Treatment of asymptomatic bacteriuria in pregnancy\n reduces the risk of pyelonephritis, preterm delivery and\n low birth weight babies. \n ➢ Asymptomatic bacteriuria in pregnancy is usually\n treated with a short course (3-7 days) of antibiotics,\n similar to that used in treatment of low UTI.\n ➢ All pregnant women should be screened for bacteriuria\n during the first trimester. \n 5.3.\n2. Preeclampsia \n \n ➢ Pre eclampsia (BP ≥ 140/90 mmHg, proteinuria ≥ 300mg/day", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_130", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 574 } }, { "content": "5.3.\n2. Preeclampsia \n \n ➢ Pre eclampsia (BP ≥ 140/90 mmHg, proteinuria ≥ 300mg/day\n +/- peripheral oedema, occurring after 20 weeks of gestation)\n is the commonest medical complication in pregnancy and is\n more common in women with preexisting hypertension and\n chronic renal disease of any cause or severity.\n ➢ Renal impairment could accompany severe preeclampsia, which\n is usually reversible following delivery. \n ➢ Women with the following risk factors should be commenced\n on 75mg of Aspirin at 12 weeks of pregnancy and continued", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_130", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 537 } }, { "content": "on 75mg of Aspirin at 12 weeks of pregnancy and continued\n until delivery, in order to reduce the risk of preeclampsia.\n o Pre-existing types 1 or 2 diabetes mellitus\n o History of hypertensive disease in pregnancy\n o Women with systemic lupus erythematosus (SLE) or\n antiphospholipid syndrome \n o Women with preexisting hypertension, irrespective of\n the aetiology \n o Women with chronic renal impairment, irrespective of\n the aetiology \n 5.3.\n3. Acute fatty liver of pregnancy (AFLP) \n ➢ This condition, which usually occurs in the third trimester, is", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_130", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 553 } }, { "content": "➢ This condition, which usually occurs in the third trimester, is\n primarily a disease of the liver which causes acute kidney injury\n (AKI) in severe cases. \n ➢ Management of renal impairment is similar to that described\n under AKI below. (AFLP is dealt with in detail in the section\n on ‘liver disease in pregnancy’) \n 5.3.\n4. Haemolytic Uraemic Syndrome (HUS) / Thrombotic\n Thrombocytopaenic Purpura (TTP) \n \n ➢ These thrombotic microangiopathies belong to a spectrum of\n disease, though they are two different entities.\n \n 58 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_130", "page_number": 7, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 89, "chunk_size": 577 } }, { "content": "================================================== PAGE 73 ==================================================\n➢ It typically occurs within in the last trimester and up to 8-10\n weeks postpartum. \n ➢ Acute kidney injury is a feature. \n ➢ Plasma exchange is the treatment of choice.\n \n 5.\n4. Acute kidney injury (AKI) \n \n AKI is defined as any one of the following (Acute Kidney Injury\n Network criteria) : \n \n• Increase in serum creatinine by ≥ 0.3 mg/dL (≥26.5 μmol/l)\n within 48 hours or, \n \n• Increase in serum creatinine to ≥1.5 times baseline, which is", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_131", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 556 } }, { "content": "within 48 hours or, \n \n• Increase in serum creatinine to ≥1.5 times baseline, which is\n known or presumed to have occurred within the prior 7 days or\n \n• Urine volume <0.5 ml/kg/hour for 6 hours, \n in an individual without pre-existing renal impairment\n Box 5.3: Causes of AKI in pregnancy \n \n \n1. Massive PPH \n \n2. Acute pyelonephritis \n \n3. Preeclampsia \n \n4. Diabetic nephropathy \n \n5. Glomerulonephritides \n \n6. Acute fatty liver of pregnancy \n \n7. Thrombotic thrombocytopaenic purpura/Haemolytic\n uraemic syndrome \n Management \n \n ➢ Management is similar to that outside pregnancy.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_131", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 586 } }, { "content": "uraemic syndrome \n Management \n \n ➢ Management is similar to that outside pregnancy.\n ➢ Stabilise the patient and arrange transfer to a tertiary care center\n with facilities for dialysis/CVVH and for multidisciplinary care.\n Management of hyperkalaemia associated with AKI\n ➢ Hyperkalaemia is defined as serum K concentration > 5.5\n mmol/L. \n ➢ In an emergency, K+ measured from an arterial or venous\n blood sample using a blood gas analyser is acceptable whilst\n awaiting the results from a formal laboratory measurement.\n ➢ ECG monitoring is recommended for all patients with serum", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_131", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 87, "chunk_size": 583 } }, { "content": "➢ ECG monitoring is recommended for all patients with serum\n K+ value ≥ 6.5 mmol/L.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_131", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 15, "chunk_size": 83 } }, { "content": "National Guideline for Maternal Care - Volume II 59", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_132", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 74 ==================================================\nBox 5.4: Pharmacological management of hyperkalaemia\n \n• 10ml of 10% Calcium gluconate over 10 minutes into a peripheral\n vein if ECG shows features suggestive of hyperkalaemia. (Tall\n peaked T waves, small/absent P waves, wide QRS complex)\n - Repeat ECG in 10 minutes- If no improvement repeat same\n dosage; Could give 3 doses in total \n \n• Insulin Actrapid (short acting insulin) 10 units in 50 mL of 50%\n glucose over 30 minutes (via intravenous infusion).", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_133", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 78, "chunk_size": 569 } }, { "content": "glucose over 30 minutes (via intravenous infusion).\n \n• Monitor blood glucose after 15mins, 30mins and then hourly for\n up to 6 hours as there is a risk of late hypoglycaemia.\n \n• Nebulised salbutamol 10-20mg. \n \n• Serum potassium should be assessed at least 1, 2, 4, 6 and 24\n hours after identification and treatment of hyperkalaemia.\n \n• Arrange transfer to a nephrology center in whom hyperkalaemia\n cannot be controlled \n 5.\n5. Chronic kidney disease \n \n 5.5.\n1. Preconception care \n \n ➢ The degree of renal insufficiency, rather than the underlying", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_133", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 554 } }, { "content": "5.5.\n1. Preconception care \n \n ➢ The degree of renal insufficiency, rather than the underlying\n renal diagnosis, is the primary determinant of outcome, with\n the exception of scleroderma and polyarteritis nodosa, which\n generally have a poor prognosis. \n ➢ Factors generally associated with unfavourable pregnancy\n outcome include: \n o Estimated GFR of ≤40 ml/min/1.73m2 \n o Proteinuria ≥1 g/d \n o Serum creatinine ≥ 1.4g/dL \n - Complications in the presence of any of the above include,\n accelerated progression towards end stage renal disease (ESRD)\n and preterm delivery.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_133", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 574 } }, { "content": "accelerated progression towards end stage renal disease (ESRD)\n and preterm delivery. \n ➢ Review by a nephrologist for advise on suitability for pregnancy\n and review and optimizations of medications is mandatory.\n Anaemia \n \n ➢ Consider erythropoietin when the Hb < 9g/dL and the iron\n stores are replete. \n Bone disease \n \n ➢ Phosphate binders and vitamin D analogues are currently used\n \n 60 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_133", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 66, "chunk_size": 443 } }, { "content": "================================================== PAGE 75 ==================================================\nwith no adverse effects. There is limited experience with\n Cinacalcet and Lanthanum carbonate. \n \n 5.5.\n2. Antenatal care \n ➢ Arrange for regular review by the nephrologist.\n ➢ Patient should be assessed in the antenatal clinic every 2 weeks\n until 32 weeks and weekly thereafter. \n o BP should be carefully monitored \n \n Aim to: \n - Maintain blood pressure below 150/100 mmHg and\n diastolic BP above 80 mmHg in women with\n uncomplicated chronic hypertension", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_134", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 568 } }, { "content": "diastolic BP above 80 mmHg in women with\n uncomplicated chronic hypertension \n - Maintain blood pressure below 140/90 mmHg in those\n with target organ damage secondary to chronic\n hypertension (eg: renal impairment) \n o Serum creatinine and 24 hour protein excretion should\n be monitored monthly \n o Fetal growth should be closely monitored\n ➢ If renal impairment is progressive, with no evidence of a\n reversible cause, termination of pregnancy should be considered\n at the earliest. \n o If only proteinuria is increasing, with no evidence of\n fetal growth restriction, pregnancy can be continued", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_134", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 597 } }, { "content": "fetal growth restriction, pregnancy can be continued\n under close monitoring by the nephrologist and\n obstetrician \n ➢ Dialysis is required when the GFR falls to less than 20ml/\n min/1.73m\n2. \n o At least 20 hours of dialysis per week is required with\n the aim of maintaining blood urea below 60mg/dL\n 5.\n6. Renal transplantation \n ➢ Fertility rates increase dramatically after transplantation.\n ➢ Women with a renal transplant should be referred to a\n nephrologist for advise on suitability of pregnancy and\n optimisation of the underlying renal condition.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_134", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 557 } }, { "content": "optimisation of the underlying renal condition.\n ➢ Graft rejection rates are similar to the general population.\n ➢ In general, fetal outcome is good. \n o Risk of preterm birth and small for gestational age\n babies increase in the presence of maternal\n hypertension and impaired baseline renal graft\n function \n National Guideline for Maternal Care - Volume II 61", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_134", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 56, "chunk_size": 362 } }, { "content": "================================================== PAGE 76 ==================================================\n➢ Calcineurin inhibitors, steroids, and Azathioprine are safe for\n use in pregnant transplant recipients. \n o Screening for gestational diabetes is important, with\n prolonged use of steroids. \n \n 5.\n7. Women on long term renal dialysis \n ➢ It is not advisable to become pregnant because pregnancy\n usually leads to volume overload, exacerbation of hypertension\n and preeclampsia. \n ➢ If patient wishes to continue pregnancy, then frequency and", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_135", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 68, "chunk_size": 553 } }, { "content": "and preeclampsia. \n ➢ If patient wishes to continue pregnancy, then frequency and\n duration of dialysis should be increased to 20 hours per week\n and blood urea maintained below 60 mg/dL. \n \n 5.\n8. Indications for renal biopsy during pregnancy \n \n ➢ Rapidly progressive renal failure (RPRF) with no obvious cause\n ➢ Symptomatic nephrotic syndrome– not a universal indication\n Renal biopsy is best avoided after 32 weeks of gestation, at which time the\n risks and benefits of biopsy versus delivery should be considered.\n \n References", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_135", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 533 } }, { "content": "risks and benefits of biopsy versus delivery should be considered.\n \n References \n \n \n1. Mathiesen ER, Ringholm L, Feldt-Rasmussen B, et al Obstetric\n Nephrology: Pregnancy in Women with Diabetic \n Nephropathy—The Role of Antihypertensive Treatment Clin J\n Am Soc Nephrol 2012; 7: 2081–\n2088. \n \n \n2. Vellanki K. Pregnancy in Chronic Kidney Disease Advances in\n Chronic Kidney Disease 2013;20 (30): 223-\n228. \n \n \n3. Carmona F, Font J, Moga I, et al. Class III-IV proliferative lupus\n nephritis and pregnancy: a study of 42 cases. Am J Reprod\n Immunol. 2005;53(4):182-\n188.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_135", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 573 } }, { "content": "nephritis and pregnancy: a study of 42 cases. Am J Reprod\n Immunol. 2005;53(4):182-\n188. \n \n4. Susana M, Nuno F, Andreia B, et al Acute kidney injury in\n pregnancy: a clinical challenge J nephrol 2012; 25(01): 19- \n30.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_135", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 37, "chunk_size": 218 } }, { "content": "62 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_136", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 77 ==================================================\nThyroid Disease", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_137", "page_number": 8, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 125 } }, { "content": "National Guideline for Maternal Care - Volume II 63", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_138", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 78 ==================================================\n64 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_139", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 161 } }, { "content": "================================================== PAGE 79 ==================================================\n6. Thyroid disease in pregnancy \n \n 6.\n1. Introduction \n \n ➢ Thyroid dysfunction in pregnancy includes hyperthyroidism\n and hypothyroidism. \n \n ➢ Hypothyroidism is commoner than hyperthyroidism and is\n known to affect around 2.5-3% of pregnancies.\n \n ➢ Prevalence of hyperthyroidism in pregnancy is around 0.1-1%.\n ➢ Important changes in thyroid physiology during pregnancy\n include: \n o 10% increase in size of the thyroid gland in iodine\n replete women", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_140", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 67, "chunk_size": 564 } }, { "content": "include: \n o 10% increase in size of the thyroid gland in iodine\n replete women \n o Lowering of thyroid stimulating hormone (TSH) in\n the first trimester due to effect of serum hCG, with\n gradual increase thereafter with advancing pregnancy,\n but still below the non pregnant reference range\n o Serum TSH > 4 µIU/mL by the third trimester in\n nearly one fifth of women with autoimmune thyroid\n dysfunction \n o Development of postpartum thyroid dysfunction in 33-\n 50% of women with thyroid autoimmunity\n ➢ Testing for thyroid functions \n o Total binding globulin (TBG) increases by around 50", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_140", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 94, "chunk_size": 591 } }, { "content": "➢ Testing for thyroid functions \n o Total binding globulin (TBG) increases by around 50\n % by 6-8 weeks of pregnancy and remains high until\n delivery. Therefore, the free fraction of thyroxine (FT4)\n should be assessed, in addition to serum TSH level.\n o Free T3 assay is not reliable and therefore should not be\n routinely performed unless the patient is clinically\n thyrotoxic with a low TSH and normal FT\n4.\n \n o The optimal method to assess serum FT4 during\n pregnancy is measurement of T4 in the dialysate or\n ultrafiltrate of serum samples employing on-line", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_140", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 93, "chunk_size": 563 } }, { "content": "ultrafiltrate of serum samples employing on-line\n extraction/liquid chromatography/tandem mass\n spectrometry (LC/MS/MS). This method \n is not routinely available and immunoassay methods\n are employed for assessment of thyroid function in Sri\n Lanka. \n National Guideline for Maternal Care - Volume II 65", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_140", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 39, "chunk_size": 303 } }, { "content": "================================================== PAGE 80 ==================================================\nBox 6.1: Normal reference range for thyroid hormones in pregnancy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_141", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 14, "chunk_size": 175 } }, { "content": "Trimester SerumTSH FT4 (pg/ml) \n (µIU/mL) \n First 0.1-2.5 0.83-1.27 \n Second 0.2-3.0 0.71-1.05 \n Third 0.3-3.0 0.72-1.06 \n 6.\n2. Hypothyroidism in pregnancy \n \n 6.2.\n1. Definitions \n \n Overt hypothyroidism \n \n Definition: \n ➢ TSH above 2.5 µIU/mL with free T4 below the trimester\n specific reference range or \n ➢ TSH >10 µIU/mL, irrespective of the free T4 level\n Adverse effects of overt hypothyroidism include: \n \n Maternal complications \n \n \n• Gestational hypertension \n \n• Placental abruption \n \n• Postpartum haemorrhage \n \n Fetal complications \n \n \n• Fetal loss \n \n• Premature birth", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_142", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 75, "chunk_size": 587 } }, { "content": "• Postpartum haemorrhage \n \n Fetal complications \n \n \n• Fetal loss \n \n• Premature birth \n \n• Low birth weight \n \n• Neonatal respiratory distress \n \n• Impaired neurocognitive development in the offspring\n Subclinial hypothyroidism (SCH) \n \n Definition: \n \n ➢ TSH between 2.5-10 µIU/mL with normal FT4 level SCH is\n known to be associated with infertility, fetal loss, preterm\n delivery and neonatal respiratory distress. SCH needs\n to be treated in pregnancy. \n 66 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_142", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 71, "chunk_size": 512 } }, { "content": "================================================== PAGE 81 ==================================================\nIsolated hypothyroxinaemia \n \n Definition: \n \n ➢ Normal TSH with FT4 below the trimester specific reference\n range. \n \n There is no conclusive evidence of benefit of treating with levothyroxine\n during pregnancy. \n 6.2.\n2. Management of hypothyroidism in pregnancy\n \n Preconception care \n \n ➢ Pregnancy should be planned, with TSH levels maintained\n below 2.5 µIU/mL. \n ➢ If pregnancy is unplanned, the dose of thyroxine should be", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_143", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 63, "chunk_size": 540 } }, { "content": "below 2.5 µIU/mL. \n ➢ If pregnancy is unplanned, the dose of thyroxine should be\n increased by 25-50% of the preconception dose as early as possi\n ble in pregnancy, while awaiting the TSH result.\n Antenatal management \n \n ➢ The aim of treatment should be maintenance of TSH within the\n trimester specific reference range. \n ➢ TSH should be assessed every 4-6 weeks to ensure that the\n woman is euthyroid. \n ➢ If the TSH fails to normalise while the patient is compliant with\n medication, refer her to the endocrinologist/physician for fur\n ther management.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_143", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 556 } }, { "content": "medication, refer her to the endocrinologist/physician for fur\n ther management. \n ➢ Levothyroxine is the treatment of choice for overt and subclini\n cal hypothyroidism. \n ➢ Advise on general measures that enhance the absorption of\n thyroxine. \n o To take thyroxine on an empty stomach upon waking\n in the morning with a lapse of at least half an hour until\n the first drink or meal \n o To take iron and calcium supplements at separate\n times of day \n Hypothyroidism diagnosed for the first time in pregnancy\n ➢ TSH should be normalised as rapidly as possible with the aim of", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_143", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 95, "chunk_size": 575 } }, { "content": "➢ TSH should be normalised as rapidly as possible with the aim of\n achieving the trimester specific reference range.\n ➢ The usual starting dose of thyroxine is 2µg/Kg/d (maximum of\n 2.5 µg /Kg/d). \n National Guideline for Maternal Care - Volume II 67", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_143", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 42, "chunk_size": 250 } }, { "content": "================================================== PAGE 82 ==================================================\n➢ The dose should be titrated according to the thyroid status of\n the woman assessed by serum TSH. \n \n Women with pre-existing hypothyroidism \n ➢ A TSH should be performed as soon as possible. \n o If the TSH is within the trimester specific reference\n range, \n - Continue the same dose of thyroxine and ar\n range for review at 4-6 weeks with a TSH\n value. \n o If the TSH is above the trimester specific reference\n range, \n - Modify the thyroxine dose as follows", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_144", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 571 } }, { "content": "range, \n - Modify the thyroxine dose as follows \n \n Box 6.2: Dose increment based on serum TSH level\n TSH level Dose increment \n (µIU/mL) (as a percentage of thyroxine dose)\n 2.5-10 25-50% \n 10-20 50-75% \n >20 75-100% \n Postpartum management \n ➢ Thyroxine is safe during breast feeding. \n ➢ Most women could be changed over to the prepregnancy dose\n of thyroxine. \n ➢ A follow up TSH at 6 weeks postpartum is recommended.\n ➢ Neonatal TSH should be tested by one week. \n \n Screening for hypothyroidism in pregnancy \n \n ➢ There is no evidence on benefit of routine screening for thyroid", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_144", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 93, "chunk_size": 584 } }, { "content": "➢ There is no evidence on benefit of routine screening for thyroid\n dysfunction in pregnancy. \n ➢ All pregnant women should be clinically evaluated at the\n booking visit for any of the features listed below.\n o A family history of autoimmune thyroid disease or\n hypothyroidism \n o Presence of a goitre \n o Presence of thyroid antibodies, primarily thyroid per\n oxidase antibodies \n o Symptoms or clinical signs suggestive of \n hypothyroidism \n o Women with type 1 diabetes mellitus, or other\n 68 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_144", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 544 } }, { "content": "================================================== PAGE 83 ==================================================\nautoimmune disorders \n o Women with infertility \n o Women with a prior history of miscarriage or preterm\n delivery \n o Women with prior therapeutic head or neck irradiation\n or prior thyroid surgery \n o Women currently receiving levothyroxine replacement\n o Women living in a region presumed to be iodine defi\n cient \n ➢ A serum TSH level should be performed in women with any of\n the risk factors mentioned above and managed accordingly.\n 6.\n3. Hyperthyroidism in pregnancy \n \n 6.3.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_145", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 593 } }, { "content": "6.\n3. Hyperthyroidism in pregnancy \n \n 6.3.\n1. Definitions \n \n Overt hyperthyroidism \n \n Definition: \n ➢ Low serum TSH with an elevated free FT4 level (according to\n the trimester specific reference range). \n \n Adverse effects of maternal hyperthyroidism include:\n \n Maternal complications \n \n• Miscarriage \n \n• gestational hypertension \n \n• thyroid storm \n \n• maternal congestive heart failure \n Fetal complications \n \n• Prematurity \n \n• low birth weight \n \n• fetal growth restriction \n \n• stillbirth \n \n• neonatal goitre \n - Subclinical hyperthyroidism (Low TSH with normal FT4)", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_145", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 74, "chunk_size": 580 } }, { "content": "• stillbirth \n \n• neonatal goitre \n - Subclinical hyperthyroidism (Low TSH with normal FT4)\n and isolated hyperthyroxinaemia does not require treat\n ment in pregnancy. \n ➢ Causes of hyperthyroidism in pregnancy include:\n o Gestational thyrotoxicosis", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_145", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 33, "chunk_size": 249 } }, { "content": "National Guideline for Maternal Care - Volume II 69", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_146", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 84 ==================================================\n- Commonest cause of hyperthyroidism; Affects 1-3% of\n pregnancies \n - Transient hyperthyroidism due to marked elevation in\n serum hCG; Seen in the first/early second trimester\n - This should be suspected when symptomatic. Eg: tremu\n lousness, heat intolerance, palpitations \n - Associated with hyperemesis gravidarum. More common\n with multiple pregnancies and hydatidiform mole\n - Treatment – Supportive therapy; Hydration and\n antiemetics. Beta blockers may provide symptomatic", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_147", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 68, "chunk_size": 590 } }, { "content": "antiemetics. Beta blockers may provide symptomatic\n benefit. Antithyroid medication is not needed\n o Graves disease \n - Usually pre existing but may present for the first time in\n pregnancy \n - Is associated with thyroid eye signs \n - Characterised by presence of thyroid receptor antibody\n (TRAb ) \n o Toxic multinodular goitre \n o Toxic adenoma \n 6.3.\n2. Management of overt hyperthyroidism in pregnancy\n Preconception care \n \n ➢ Pregnancy should be planned with women rendered euthyroid\n (TSH between 0.3-2.5 µIU/mL) before attempting pregnancy.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_147", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 78, "chunk_size": 548 } }, { "content": "(TSH between 0.3-2.5 µIU/mL) before attempting pregnancy.\n ➢ If 131 I is used to achieve euthyroidism, conception should be\n delayed for a minimum of 6 months (ideally 12 months).\n o These women require a reliable method of contraception\n preferably IUD. \n \n Antenatal management \n \n ➢ First line therapy for hyperthyroidism is antithyroid drugs (ATD).\n \n o Propylthoiuracil (PTU) should be used in the first trimester of\n pregnancy \n o Carbimazole should be started from the second trimester\n onwards \n o The initial dose of ATDs depends on the severity of the", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_147", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 561 } }, { "content": "onwards \n o The initial dose of ATDs depends on the severity of the\n symptoms and the degree of hyperthyroxinemia \n o In general, initial doses of ATDs are as follows:\n - Carbimazole, 10–15 mg daily in divided doses\n 70 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_147", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 46, "chunk_size": 268 } }, { "content": "================================================== PAGE 85 ==================================================\n- PTU, 50–300 mg daily in divided doses \n o Use the smallest possible dose of ATD to maintain\n euthyroidism and keep FT4 in the upper normal range\n \n ➢ For symptomatic relief, beta blockers could be used.\n o Eg. Propranolol 20–40 mg every 6–8 hours \n - The dose should be reduced as early as possible in view\n of risk of fetal growth restriction, fetal bradycardia and\n neonatal hypoglycaemia \n - In the vast majority of cases, beta blockers can be\n discontinued in 2–6 weeks", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_148", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 86, "chunk_size": 585 } }, { "content": "- In the vast majority of cases, beta blockers can be\n discontinued in 2–6 weeks \n ➢ Thyroidectomy in pregnancy is rarely indicated to control\n hyperthyroidism. \n o If required, the optimal time for thyroidectomy is the second\n trimester \n \n ➢ Radioactive iodine treatment is contraindicated during\n pregnancy. \n Monitoring \n \n ➢ Treatment is monitored with FT4 and TSH every 4–6 weeks.\n o Aim to maintain serum FT4 at the upper reference range.\n \n ➢ Fetal monitoring is performed for early detection of\n complications and management. \n \n Graves disease", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_148", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 553 } }, { "content": "complications and management. \n \n Graves disease \n \n ➢ During the first trimester of pregnancy exacerbation of\n symptoms may occur. \n ➢ As pregnancy advances, a gradual improvement in disease\n activity is seen. \n o This will result in a need to decrease the dose of ATDs\n o Discontinuation of all ATD therapy is feasible in 20%–30% of\n patients in the last trimester of gestation\n o The exception are women with high levels of thyroid receptor\n stimulating antibodies (TRAb ), in which case ATD therapy\n should generally be continued until delivery", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_148", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 86, "chunk_size": 548 } }, { "content": "should generally be continued until delivery\n ➢ Indications for ordering a TRAb test in a woman with Graves\n disease include, \n \n National Guideline for Maternal Care - Volume II 71", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_148", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 29, "chunk_size": 181 } }, { "content": "================================================== PAGE 86 ==================================================\no Active maternal hyperthyroidism \n o History of treatment with radioiodine \n o History of delivering an infant with hyperthyroidism\n o History of thyroidectomy for treatment of Graves disease\n - Serum TRAb levels should be determined at 24–28 weeks\n gestation in these women \n - A value over three times the upper limit of normal is an\n indication for close follow up of the fetus \n - Fetal monitoring includes serial ultrasound scan for", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_149", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 548 } }, { "content": "- Fetal monitoring includes serial ultrasound scan for\n assessment of fetal growth, fetal heart rate, amniotic fluid\n volume and goitre \n - The neonate should be reviewed by a paediatrician at birth.\n (TRAb assay is not available in the state sector. Patients\n suspected with Graves disease maybe managed without this\n test considering its cost.) \n Delivery \n ➢ No special precautions are needed during delivery.\n ➢ Women with poorly controlled hyperthyroidism should be closely\n monitored due to risk of exacerbation of thyrotoxic symptoms\n and risk of thyroid storm.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_149", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 85, "chunk_size": 568 } }, { "content": "monitored due to risk of exacerbation of thyrotoxic symptoms\n and risk of thyroid storm. \n \n Box 6.3: Management of thyroid storm \n 1.Propylthiouracil 500-1000mg followed by 250mg 4 hourly\n or \n Carbimazole 60-80 mg 4 hourly \n \n \n2. Oral Propranolol 60-80mg 4-6 hourly \n \n3. Lugols iodine 5 drops oral 6 hourly \n –Start 1 hour after commencement of antithyroid drugs\n \n4. Hydrocortisone 200 mg bolus; 100mg 6 hourly \n \n5. Intravenous hydration \n \n6. Antipyretics \n Postpartum care \n \n ➢ Breast feeding \n o Breastfeeding is safe in mothers on ATDs at moderate doses", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_149", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 564 } }, { "content": "➢ Breast feeding \n o Breastfeeding is safe in mothers on ATDs at moderate doses\n o Mothers should be advised to take their ATDs in divided\n doses immediately following the feed \n ➢ Due to risk of flares postpartum in women with Graves disease,\n a review should be arranged at 6 weeks or before in women with\n poorly controlled disease. \n 72 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_149", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 67, "chunk_size": 389 } }, { "content": "================================================== PAGE 87 ==================================================\n➢ Any form of contraceptive is acceptable. \n \n 6.\n4. Postpartum thyroid dysfunction (PPTD) \n \n Definition: \n ➢ Occurrence of thyrotoxicosis or hypothyroidism within the first\n postpartum year, in a woman without clinically evident thyroid\n disease before pregnancy \n o This usually occurs in thyroid antibody (TPO Ab and antithy\n roglobulin Ab) positive women \n o The prevalence is around 7% and is seen more often in women\n with other autoimmune conditions. Eg. Type 1 diabetes mel", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_150", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 592 } }, { "content": "with other autoimmune conditions. Eg. Type 1 diabetes mel\n litus. \n o The classical course is hyperthyroidism followed by hypothy\n roidism and finally euthyroidism. \n - However, the majority will not show this pattern and may\n present with hyperthyroidism or hypothyroidism alone.\n Hyperthyroid phase \n \n ➢ Thyrotoxic symptoms occur around 3 months postpartum.\n ➢ Graves disease is the main differential diagnosis.\n o Physical stigmata of Graves’ disease, TRAb levels and USS of\n the thyroid will help differentiate between hyperthyroidism\n associated with Graves disease and PPTD.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_150", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 581 } }, { "content": "associated with Graves disease and PPTD. \n - TRAb positivity and high radio iodine uptake by the thy\n roid gland suggest Graves disease \n Hypothyroid phase \n \n ➢ This occurs around 6 months postpartum and lasts for 4-6\n months. \n ➢ More than 50% will be asymptomatic. \n ➢ This stage may be preceded by a thyrotoxic phase.\n Euthyroid phase \n \n ➢ The majority of women with PPTD become euthyroid by 1 year\n postpartum. \n - However 30% of women who develop PPTD will remain hy\n pothyroid at 1 year with risk of permanent hypothyroidism", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_150", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 88, "chunk_size": 532 } }, { "content": "National Guideline for Maternal Care - Volume II 73", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_151", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 88 ==================================================\nFigure 6.1 Management of postpartum thyrold dysfunction Figure 6.2 Management of thyroid nodule in oregnancy\n Figure 1.2 Management of thyroid nodule in pregnancy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_152", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 27, "chunk_size": 272 } }, { "content": "A2(3*(-/\"G-&&*\"&2\"(5\"^2,1$/,&$-'()'\"7$'F%$0,.#&'W790(,1'F--(.,#\",(&')(0'\"7$'+,#B&(-,-'#&1'8#&#B$%$&\"'()'\n W790(,1'+,-$#-$'+20,&B'@0$B&#&.9'#&1'@(-\"P#0\"2%\"Q+2%')&\"#^!!\"", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_153", "page_number": 8, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 2, "chunk_size": 167 } }, { "content": "PO\"\n \"\n 74 National Guideline for Maternal Care - Volume II\n PN\" \n \"", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_154", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 68 } }, { "content": "================================================== PAGE 89 ==================================================\nFigure 6.1 Management of postpartum thyrold dysfunction Figure 6.2 Management of thyroid nodule in oregnancy\n Figure 1.2 Management of thyroid nodule in pregnancy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_155", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 27, "chunk_size": 272 } }, { "content": "A2(3*(-/\"G-&&*\"&2\"(5\"^2,1$/,&$-'()'\"7$'F%$0,.#&'W790(,1'F--(.,#\",(&')(0'\"7$'+,#B&(-,-'#&1'8#&#B$%$&\"'()'\n W790(,1'+,-$#-$'+20,&B'@0$B&#&.9'#&1'@(-\"P#0\"2%\"Q+2%')&\"#^!!\"", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_156", "page_number": 8, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 2, "chunk_size": 167 } }, { "content": "PO\" \n \" \n National Guideline for Maternal Care - Volume II 75\nPN\" \n\"", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_157", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 68 } }, { "content": "================================================== PAGE 90 ==================================================\nReferences \n \n \n1. Satgnaro Green et al. Guidelines of the American Thyroid\n Association for the Diagnosis and Management of Thyroid Disease\n During Pregnancy and Postpartum. Thyroid 2011; 21(10): 1081-\n1125.\n \n \n2. Management of thyroid dysfunction during pregnancy and\n postpartum:An endocrine society clinical practice guideline Journal\n of Clinical Endocrinology & Metabolism 2012;97: 2543–\n2565.\n 3 The Endocrine Society of Sri Lanka’s clinical guidelines on thyroid\n diseases (2013).", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_158", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 599 } }, { "content": "4. Wright H V, Williams D J. Thyrotoxicosis in pregnancy Fetal and\n Maternal Medicine Review 2013; 24(2): 108 – \n128.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_159", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 20, "chunk_size": 117 } }, { "content": "76 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_160", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 91 ==================================================\nRheumatoid arthritis", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_161", "page_number": 8, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 130 } }, { "content": "National Guideline for Maternal Care - Volume II 77", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_162", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 92 ==================================================\n78 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_163", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 161 } }, { "content": "================================================== PAGE 93 ==================================================\n7. Rheumatoid arthritis \n \n 7.\n1. Introduction \n \n ➢ Disease activity in women with rheumatoid arthritis (RA) usually\n improves or remains the same during pregnancy although flares\n could occur postpartum. \n ➢ Women with poorly controlled disease have a greater risk of flares\n in the postpartum period. \n \n 7.\n2. Preconception care \n \n Aims of preconception care: \n \n ➢ To assess suitability for pregnancy \n o Contraindications to pregnancy include moderate /severe", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_164", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 576 } }, { "content": "➢ To assess suitability for pregnancy \n o Contraindications to pregnancy include moderate /severe\n pulmonary hypertension, advanced rheumatoid lung disease\n and advanced renal impairment (serum creatinine > 2.8 mg/\n dL) \n o Specialist assessment is needed for all women with active\n disease \n o Disease remission should be maintained for at least one year\n prior to conception. \n - Disease activity should be assessed by using one of the\n accepted composite disease activity scores. e.g. Disease\n Activity Score (DAS) - DAS 28 or clinical disease activity\n index- CDAI", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_164", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 84, "chunk_size": 568 } }, { "content": "Activity Score (DAS) - DAS 28 or clinical disease activity\n index- CDAI \n ➢ To screen for target organ damage \n o Cardiac, pulmonary and renal assessment (blood pressure,\n serum creatinine, echocardiography and lung function tests)\n should be performed depending on organ involvement\n ➢ To screen for concomitant autoimmune conditions, especially\n autoimmune thyroid dysfunction. \n ➢ To advice contraception until disease activity is controlled\n o Intrauterine Device (IUD) /Oral contraceptive Pill (OCP)/\n Depot Medroxy Progesterone Acetate (DMPA)/Implants are\n acceptable", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_164", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 76, "chunk_size": 573 } }, { "content": "Depot Medroxy Progesterone Acetate (DMPA)/Implants are\n acceptable \n o Emergency contraception in the event of unprotected sexual\n intercourse. \n ➢ Periconceptional folate supplementation- Folic acid at a dose of 5\n mg daily should be commenced. \n ➢ For review of medication and appropriate adjustment prior to\n pregnancy (Box 2.1). \n National Guideline for Maternal Care - Volume II 79", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_164", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 55, "chunk_size": 386 } }, { "content": "================================================== PAGE 94 ==================================================\nBox 7.1 Safety of medications used for rheumatoid arthritis\n in pregnancy \n \n Pregnancy category X \n \n Methotrexate \n Stop for at least 3 months prior to attempting conception.\n Leflunomide \n Conception should be avoided for minimum of 2 years since\n discontinuing Leflunomide. If cholestyramine washout is\n carried out for an special indication, pregnancy must be deferred\n for 3 menstrual cycles after the wash out period.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_165", "page_number": 8, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 65, "chunk_size": 534 } }, { "content": "Pregnancy category D \n \n Non steroidal anti inflammatory drugs (NSAIDS ) \n NSAIDs, including COX-2 inhibitors, are contraindicated in\n the third trimester. Could be used with caution prior to 24 weeks\n of gestation, with intermittent use of those with a short half life.\n Risk of miscarriage in the first trimester. \n Pregnancy category C \n \n Hydroxychloroquine \n Lowest possible dose (200mg ) should be used. \n \n Steroids \n Prednisolone and hydrocortisone are preferred. Lowest possible\n dose should be used. \n \n Pregnancy category B \n \n Sulphasalazine (Category D if used for prolonged periods or", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_166", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 598 } }, { "content": "Pregnancy category B \n \n Sulphasalazine (Category D if used for prolonged periods or\n near term) \n Lowest possible dose (500mg -1g/day ) if absolutely indicated.\n Folate supplementation is encouraged during its use during\n preconception and pregnancy.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_166", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 34, "chunk_size": 251 } }, { "content": "80 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_167", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 95 ==================================================\n7.\n3. Antenatal care \n \n ➢ Frequency of monitoring should vary depending on the patient’s\n disease activity and systemic involvement. \n o All patients should be reviewed by the rheumatologist/\n physician at least every trimester. \n o Women with unstable disease needs more frequent\n monitoring. \n ➢ Review of medications (Refer details in Box 3.1 above ).\n 7.\n4. Delivery \n ➢ No special measures are needed during delivery. Women with", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_168", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 544 } }, { "content": "7.\n4. Delivery \n ➢ No special measures are needed during delivery. Women with\n hip deformities or valgus knee deformities should be considered\n for caesarean section. \n \n 7.\n5. Postpartum care \n \n ➢ Review drugs for suitability for breast feeding.\n \n Box 7.2: Safety of medications during breast feeding\n Safe to continue during lactation \n NSAIDs \n Corticosteroids \n Hydroxychloroquine \n Sulfasalazine1 \n \n Inadequate data regarding lactation –Avoid \n TNFα inhibitors \n Anakinra \n Abatacept \n Rituximab \n Tocilizumab \n Tofacitinib \n Contraindicated during lactation \n Methotrexate \n Leflunomide", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_168", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 71, "chunk_size": 595 } }, { "content": "Tocilizumab \n Tofacitinib \n Contraindicated during lactation \n Methotrexate \n Leflunomide \n Azathioprine 2 \n 1 Use with caution in settings of prematurity, hyperbilirubinemia\n and glucose-6-phosphate dehydrogenase deficiency.\n 2 Avoidance is recommended by the manufacturer, primarily\n based on theoretical risk. \n \n National Guideline for Maternal Care - Volume II 81", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_168", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 43, "chunk_size": 368 } }, { "content": "================================================== PAGE 96 ==================================================\n➢ Advice to take medication immediately after breast feeding\n and preferably postpone the next feed for four hours after taking\n the medication. \n \n ➢ Women should be monitored more frequently, due to risk of\n disease flares. \n o Review at six weeks postpartum, with those with active disease\n reviewed earlier and more frequently. \n References \n \n \n1. Megan L. Krause, Shreyasee Amin and Ashima Makol.\n Use of DMARDs and biologics during pregnancy and lactation", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_169", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 74, "chunk_size": 572 } }, { "content": "Use of DMARDs and biologics during pregnancy and lactation\n in rheumatoid arthritis: what the rheumatologist needs to know.\n Therapeutic Advances in Musculoskeetal Diease 2014, Vol. 6(5)\n 169–\n184.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_169", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 28, "chunk_size": 197 } }, { "content": "2. Varsha Jain and Caroline Gordon. Managing pregnancy in\n inflammatory rheumatological diseases. 2011 Arthritis Research\n & Therapy 2011, 13: 206", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_170", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 20, "chunk_size": 146 } }, { "content": "82 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_171", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 97 ==================================================\nSystemic Lupus Erythematosus", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_172", "page_number": 8, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 7, "chunk_size": 138 } }, { "content": "National Guideline for Maternal Care - Volume II 83", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_173", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 98 ==================================================\n84 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_174", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 161 } }, { "content": "================================================== PAGE 99 ==================================================\n8. Systemic Lupus Erythematosus \n \n 8.\n1. Introduction \n \n ➢ Disease activity of systemic lupus erythematosus (SLE) varies in\n pregnancy. \n o Disease activity in the preconception stage is the most\n important predictor of flares during pregnancy\n o Disease flares commonly involve the skin and musculoskeletal\n system \n o Identifying a disease flare is challenging as physiological\n changes of pregnancy mimic a disease flare\n ➢ Factors associated with an adverse pregnancy outcome include,", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_175", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 600 } }, { "content": "➢ Factors associated with an adverse pregnancy outcome include,\n o Active disease in the preconception stage \n o Lupus nephritis with increased baseline serum creatinine (S\n creatinine >1.4mg/dL). \n o Presence of antiphospholipid syndrome (APS)\n ➢ SLE could present for the first time in pregnancy.\n ➢ Maternal and fetal complications of active disease include,\n Maternal complications \n \n• Hypertensive disorders including preeclampsia, HELLP syndrome\n \n• Gestational diabetes mellitus (GDM) \n \n• Premature rupture of Membranes (PROM)", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_175", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 72, "chunk_size": 535 } }, { "content": "• Gestational diabetes mellitus (GDM) \n \n• Premature rupture of Membranes (PROM) \n \n• Arterial and venous thrombosis especially in the presence of APS\n \n• Catastrophic APS \n \n• Immune thrombocytopaenia \n \n• Infections \n \n• Autoimmue hepatitis \n Fetal complications \n \n• Miscarriage (more common in the presence of APS)\n \n• Fetal growth restriction \n \n• Stillbirth \n \n• Prematurity \n \n• Neonatal lupus. \n (Presence of active disease and lupus nephritis substantially increase the\n risk of fetal loss and prematurity) \n 8.\n2. Preconception care \n \n Aims of preconception care:", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_175", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 79, "chunk_size": 574 } }, { "content": "National Guideline for Maternal Care - Volume II 85", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_176", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 100 ==================================================\n➢ Assess suitability for pregnancy \n o Pregnancy should be avoided in the presence of moderate/\n severe pulmonary hypertension, severe restrictive lung disease\n (forced vital capacity <1L) or advanced renal disease (serum\n creatinine level >2.8 mg/dl). \n o Pregnancy should be deferred if disease remission has not\n been achieved for at least six months. \n - Disease activity score could be assessed using the\n European Consensus Lupus Activity Measurement", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_177", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 567 } }, { "content": "European Consensus Lupus Activity Measurement\n (ECLAM) modified version validated for use in pregnancy\n - Levels of serum complements (C3 and C4) and dsDNA\n may be used for monitoring of disease activity\n ➢ Assessment for other autoantibodies \n o Anti - Ro and anti - La antibodies should preferably be\n assessed to identify risk of complete heart block (CHB) in the\n fetus \n o Anticardiolipin antibodies, lupus antico¬agulant and\n anti β2 glycoprotein should be assessed to detect the presence\n of antiphospholipid syndrome \n ➢ Review of medications \n o Antihypertensives", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_177", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 85, "chunk_size": 572 } }, { "content": "of antiphospholipid syndrome \n ➢ Review of medications \n o Antihypertensives \n - Withhold Angiotensin converting enzyme inhibitors\n (ACEI) and Angiotensin receptor blockers (ARB) in\n pregnancy \n - Give alternative antihypertensives (eg. Calcium channel\n blockers, Methyldopa) \n o Most immunosuppressive drugs (Cyclophosphamide,\n Methotrexate, Mycophenolic acid, Leflunomide) are\n contraindicated during pregnancy. (Refer Box 3.1 –\n Rheumatoid arthritis) \n - They should be discontinued at least 3 months before\n conception \n - Leflunomide has a long half life; Pregnancy should either", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_177", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 72, "chunk_size": 584 } }, { "content": "conception \n - Leflunomide has a long half life; Pregnancy should either\n be deferred for 2 years after discontinuation of the drug or\n a washout procedure should be employed \n ➢ Contraception \n o A contraceptive method should be used until it is safe to\n conceive.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_177", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 43, "chunk_size": 265 } }, { "content": "86 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_178", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 101 ==================================================\nHormonal contraception \n \n - Low dose combined hormonal contraceptive may be used in patients\n with inactive or mild disease activity. In moderate to severe disease\n and with prolonged use, they may be associated with lupus flares and\n thromboembolic risk especially in the presence of APS\n - Progesterone containing oral, injectable or implantable\n contraceptives may be recommended as contraceptives in SLE\n for shorter periods, but use over 2 years could increase the risk of", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_179", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 589 } }, { "content": "for shorter periods, but use over 2 years could increase the risk of\n osteoporosis \n \n Intrauterine contraceptive device \n \n - May be suitable for patients on minimal immunosuppressives for\n long term use. \n 8.\n3. Antenatal care \n \n ➢ Women with major organ involvement or poorly controlled\n disease are best managed in a tertiary care center with\n involvement of a multidisciplinary team. \n \n ➢ Folic acid 5 mg daily should be continued throughout the first\n trimester. \n \n ➢ Aspirin 75mg daily should be commenced at 10- 12 weeks and\n continued until 36 weeks of pregnancy.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_179", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 89, "chunk_size": 575 } }, { "content": "continued until 36 weeks of pregnancy. \n ➢ Women on steroids or heparin should receive supplemental\n calcium and vitamin D \n o Elemental calcium 1200 U (minimum 800 U ) daily.\n o Vitamin D 800-1000 U daily. \n (Vitamin A and D preparations should be avoided as a method of\n supplementing vitamin D due to teratogenic potential of vitamin A).\n \n ➢ Regular review by the rheumatologist/specialist physician should\n be undertaken for assessment of disease activity and control.\n o Those with active disease - at least fortnightly\n o Those in disease remission - monthly", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_179", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 90, "chunk_size": 565 } }, { "content": "o Those with active disease - at least fortnightly\n o Those in disease remission - monthly \n ➢ Close monitoring of blood pressure, blood sugar levels and\n maternal weight gain in women on steroids.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_179", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 33, "chunk_size": 197 } }, { "content": "National Guideline for Maternal Care - Volume II 87", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_180", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 102 ==================================================\n➢ Review of medications \n o Hydroxychloroquine could be continued during pregnancy\n o Azathioprine is safe, provided the dose does not exceed 2 mg/\n kg day \n o Calcineurin inhibi¬tors, Tacrolimus and Cyclosporine could\n be considered in persistent disease activity \n o Most immunosuppressive drugs (Cyclophosphamide,\n Methotrexate, Mycophenolic acid, Leflunomide) are\n contraindicated during pregnancy \n ➢ Fetal monitoring \n o Monitoring of growth and doppler uterine artery blood flow", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_181", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 68, "chunk_size": 596 } }, { "content": "➢ Fetal monitoring \n o Monitoring of growth and doppler uterine artery blood flow\n for detection of fetal growth restriction. \n o Fetal echocardiography if indicated. \n \n 8.\n4. Delivery \n ➢ Women who have been on steroids >7.5mg/day for ≥ 2 weeks\n preceding delivery, should be given IV Hydrocortisone 100mg\n followed by 50 mg 6 hourly for 24 hours from the time of active\n labour. \n \n 8.\n5. Postpartum care \n \n ➢ The risk of disease flare is high. \n o Review all women at 6 weeks and those with active disease at 2\n weeks postpartum.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_181", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 90, "chunk_size": 534 } }, { "content": "o Review all women at 6 weeks and those with active disease at 2\n weeks postpartum. \n \n ➢ In women with APS, heparin should be continued postpartum.\n (Refer section on APS for duration of anticoagulation).\n ➢ Women on lifelong anticoagulation should be converted to\n warfarin prior to discharge. \n \n ➢ Breast feeding- Refer the section on Safety of medications\n during breast feeding Box 3.2 Rheumatoid arthritis for advice on\n medication during breast feeding. \n \n 8.\n6. Contraception \n \n ➢ Refer section on contraception - preconception care in SLE.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_181", "page_number": 8, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 551 } }, { "content": "88 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_182", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 103 ==================================================\n8.\n7. Neonatal lupus syndrome \n \n ➢ Neonatal lupus syndrome represent fetal mani¬festations of\n passively acquired autoimmunity. \n ➢ NLS may manifest as rash, haematologic/hepatic abnormalities or\n cardiac complications. \n \n ➢ These manifestations generally resolve by 6 to 8 months after\n birth. \n \n ➢ All babies born to mothers with SLE need to be reviewed by a\n paediatrician. \n \n 8.\n8. Treatment of lupus nephritis (LN) in pregnancy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_183", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 67, "chunk_size": 547 } }, { "content": "paediatrician. \n \n 8.\n8. Treatment of lupus nephritis (LN) in pregnancy\n \n ➢ Risk of renal flare is high in pregnancy and requires\n differentiation from pre eclampsia. \n Box 8.1: Differentiating features of pre eclampsia and lupus nephritis\n \n Clinical and laboratory Pre eclampsia Lupus nephritis\n features \n Hypertension Onset usually after 20 weeks Onset could be any time\n Urinary sediment Inactive Active \n DNA antibody levels Normal Rising \n Complement levels- C3,C4 Normal More than 25% decline\n \n ➢ If active nephritis is present, glucocorticoids could be prescribed", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_183", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 574 } }, { "content": "➢ If active nephritis is present, glucocorticoids could be prescribed\n to control disease activity, and if necessary Azathioprine can\n be added. (The dose of Azathioprine should not exceed 2 mg/kg\n in a pregnant woman). \n \n ➢ For patients with persistently active nephritis with documented\n or suspected class III or IV lupus nephritis with crescents,\n consider early delivery. \n \n 8.\n9. Other autoimmune connective tissue disease \n \n Systemic Sclerosis \n ➢ Contraindications to pregnancy include moderate/ severe\n pulmonary hypertension, severe pulmonary fibrosis and", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_183", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 78, "chunk_size": 568 } }, { "content": "pulmonary hypertension, severe pulmonary fibrosis and\n advanced renal disease (S,creatinine > 2.8mg/dL).\n National Guideline for Maternal Care - Volume II 89", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_183", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 21, "chunk_size": 157 } }, { "content": "================================================== PAGE 104 ==================================================\n➢ Risk of premature rupture of membranes (PROM) is high.\n \n ➢ Nifedipine given for Raynauds disease may interfere with uterine\n contractions in the latter part of pregnancy. \n ➢ In women with gastrointestinal involvement, \n o nutritional problems and constipations requires specialist\n attention and care \n o anaesthetic review is required due to anticipated problems\n during intubation \n \n Women with undifferentiated autoimmune connective tissue disease", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_184", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 65, "chunk_size": 566 } }, { "content": "during intubation \n \n Women with undifferentiated autoimmune connective tissue disease\n (CTD), dermatomyositis, mixed CTD and overlap syndrome should\n be referred for specialist assessment for gauging of disease activity and\n organ involvement prior to pregnancy. \n References \n \n \n1. Aisha Lateef and Michelle Petri. Management of pregnancy in\n systemic lupus erythematosus . Nature Reviews; Rheumatology.\n \n2012. \n \n \n2. American College of Rheumatology Guidelines for Screening,\n Treatment, and Management of Lupus Nephritis Arthritis Care &\n Research 2012; 64(6): 797–\n808.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_184", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 74, "chunk_size": 577 } }, { "content": "Treatment, and Management of Lupus Nephritis Arthritis Care &\n Research 2012; 64(6): 797–\n808. \n \n3. Petri M, Kim MY, Kalunian KC, Grossman J, Hahn BH,\n Sammaritano LR, et al. Combined oral contraceptives in women with\n systemic lupus erythematosus. New England Journal of Medicine\n 2005;353:2550–\n8. \n \n \n4. Culwell KR, Curtis KM, del Carmen Cravioto M. Safety of\n contraceptive method use among women with systemic lupus\n erythematosus: a systematic review. Obstetrics and Gynecology\n 2009;114:341–\n53. \n \n5. Truitt ST, Fraser AB, Grimes DA et al. Combined hormonal versus", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_184", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 574 } }, { "content": "2009;114:341–\n53. \n \n5. Truitt ST, Fraser AB, Grimes DA et al. Combined hormonal versus\n progestin-only contraception in lactation. Cochrane Database Syst\n Rev. 2003;2:CD003988 (updated 6 May 2008). \n \n \n6. Queenan JT. Contraception and breastfeeding. Clin Obstet Gynecol.\n 2004;47:734-\n9. \n \n7. Anon. FFPRHC Guidance (July 2004): Contraceptive choices for\n breastfeeding women. J Fam Plann Reprod Health Care. 2004;\n 30:181-\n9. \n 90 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_184", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 67, "chunk_size": 482 } }, { "content": "================================================== PAGE 105 ==================================================\nImmune Thrombocytopaenic \n \n Purpura", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_185", "page_number": 8, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 7, "chunk_size": 147 } }, { "content": "National Guideline for Maternal Care - Volume II 91", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_186", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 106 ==================================================\n92 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_187", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 162 } }, { "content": "================================================== PAGE 107 ==================================================\n9. Immune thrombocytopaenic purpura \n \n 9.\n1. Introduction \n \n ➢ Thrombocytopaenia in pregnancy is defined as a platetet count\n <150x 109/L. \n \n ➢ It is the second commonest haematological disorder in pregnancy\n after anaemia, and affects around 7–10% of pregnancies.\n \n ➢ Immune thrombocytopaenic purpura (ITP) is just one of several\n causes in pregnancy and is a diagnosis following exclusion of\n more sinister causes of thrombocytopaenia.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_188", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 66, "chunk_size": 552 } }, { "content": "more sinister causes of thrombocytopaenia. \n ➢ In the absence of an initiating/ underlying cause for\n isolated thrombocytopaenia AND absent lymphadenopathy and\n hepatosplenomegaly, a diagnosis of ITP can be made.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_188", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 29, "chunk_size": 212 } }, { "content": "National Guideline for Maternal Care - Volume II 93", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_189", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 108 ==================================================\n94 National Guideline for Maternal Care - Volume II\n ycneuqerf \n fo \n redro \n ni \n ycnangerp \n ni \n aineapotycobmorht \n fo \n sesuaC \n :1.9 \n xoB \n sgnidnfi \n yrotarobaL \n noitatneserp \n lacinilC \n serutaef \n citsongaiD \n ecnedicnI \n noitidnoC \n )%( \n L/901 \n x 07> \n yllausu \n steletalP\n• \n citamotpmysA\n• \n ni \n aineapotycobmorht \n fo \n esuac \n tsenommoC\n• \n %9-5 \n lanoitatseG \n )%08-07( \n ycnangerp \n ainepotycobmorht \n noisulcxe \n fo \n sisongaid \n a \n sI\n• \n retsemirt \n driht \n ro", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_190", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 61, "chunk_size": 596 } }, { "content": "ycnangerp \n ainepotycobmorht \n noisulcxe \n fo \n sisongaid \n a \n sI\n• \n retsemirt \n driht \n ro \n dnoces \n etal \n ni \n tesnO\n• \n ycnangerp \n edistuo \n lamron \n tnuoc \n teletalP\n• \n ainepotycobmorht \n latanoen \n oN\n• \n mutraptsop \n sevloser \n ainepotycobmorTh\n• \n srh42 \n / nietorp \n eniru \n g3.0 \n >\n• \n ,noisiv \n derrulb \n ,ehcadaeH\n• \n retsemirt \n driht \n ro \n dnoces \n etal \n ni \n tesnO\n• \n %8-5 \n aispmalce \n erP \n ,sesanimasnart \n revil \n detavelE\n• \n amedeo \n ,niap \n cirtsagipe \n dna \n tnemriapmi \n laner \n /dna \n gHmm041 \n ≥PB \n cilotsyS\n• \n sesac \n ereves \n ni \n yhtapolugaoc \n gHmm09", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_190", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 72, "chunk_size": 591 } }, { "content": "laner \n /dna \n gHmm041 \n ≥PB \n cilotsyS\n• \n sesac \n ereves \n ni \n yhtapolugaoc \n gHmm09 \n ≥ PB \n cilotsaid \n ro \n wol \n si \n tnuoc \n llec \n doolb \n etihW\n• \n htiw \n detaicossa \n ,reveF\n• \n retsemirt \n yna \n ni \n neeS\n• \n snoitcefni \n lariV \n egnar \n lamron \n rewol \n eht \n ni \n ro \n dna \n aiglaym \n ,ehcadaeh \n yam \n sesanimasnart \n detavelE\n• \n aiglarhtra \n rucco \n -/+ \n L/901 \n x 001< \n teletalP\n• \n gnideelb \n fo \n sngis \n evah \n yaM\n• \n retsemirt \n yna \n ni \n neeS\n• \n %1< \n PTI \n larehpirep \n no \n steletalp \n egral \n eaihcetep \n ,gnisiurb- \n nees \n si \n ycnangerp \n fo \n edistuo", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_190", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 78, "chunk_size": 585 } }, { "content": "no \n steletalp \n egral \n eaihcetep \n ,gnisiurb- \n nees \n si \n ycnangerp \n fo \n edistuo \n ainepotycobmorTh\n• \n raems \n doolb \n aineapotycobmorht \n latef \n htiw \n detaicosssa \n eb \n yaM\n• \n cihtapoignaorciM\n•\n evah \n lliw \n ytirojaM\n• \n aispmalce \n erp \n fo \n tnairaV\n• \n %1< \n emordnys \n PLLEH \n detavelE \n ;aimeana \n citylomeah \n aispmalceerp \n retsemirt \n driht \n ro \n dnoces \n etal \n ni \n tesno \n %07\n• \n HDL \n mutraptsop \n tesno \n %03 \n nI\n• \n sesanimasnart\n revil \n detavelE\n•", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_190", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 58, "chunk_size": 480 } }, { "content": "================================================== PAGE 109 ==================================================\nNational Guideline for Maternal Care - Volume II 95\n ereves \n ro \n etaredoM\n• \n niap \n lairdnohcopyh \n thgiR\n• \n %10.0< \n fo \n revil \n yttaf \n etucA \n aineapotycobmorht \n ecidnuaJ\n• \n )PLFA( \n ycnangerp \n ,eninitaerc \n ,sTFL \n detavelE\n• \n gnitimov/aesuaN\n• \n ainomma \n ,dica \n ciru \n ,CBW \n yhtapolahpecne \n citapeH\n• \n TTPA/TP \n degnolorP\n• \n aimeacylgopyH\n• \n erom \n noitcnufsyd \n reviL( \n erp/PLLEH \n ni \n naht \n tnacfiingis )aispmalce \n cihtapoignaorciM\n• \n reveF\n• \n retsemirt", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_191", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 62, "chunk_size": 593 } }, { "content": "erp/PLLEH \n ni \n naht \n tnacfiingis )aispmalce \n cihtapoignaorciM\n• \n reveF\n• \n retsemirt \n driht \n ni \n tesnO\n• \n %10.0< \n citobmorTh \n aimeana \n citylomeah \n segnahc \n lausiV\n• \n driht \n gnirud \n nommoc \n tub \n ,retsemirt \n yna \n ni \n tesnO\n• \n cineapotycobmorht \n eninitaerc \n detavelE\n• \n sutats \n latnem \n deretlA\n• \n mutraptsop \n ro \n retsemirt \n /)PTT( \n aruprup \n neercs \n noitalugaoc \n lamroN\n• \n sedosipe \n citobmorTh\n• \n citylomeaH \n HDL \n detavelE\n• \n tnemriapmi \n laneR\n• \n emordnys \n cimearu \n )SUH( \n TTPA \n dna \n RNI \n degnolorP\n• \n eht \n fo \n serutaef \n lacinilC\n• \n snoitacilpmoc", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_191", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 71, "chunk_size": 597 } }, { "content": ")SUH( \n TTPA \n dna \n RNI \n degnolorP\n• \n eht \n fo \n serutaef \n lacinilC\n• \n snoitacilpmoc \n detaler \n ycnangerp \n ot \n yradnoceS\n• \n detanimessiD \n sisylomeaH\n• \n htiw \n noitidnoc \n gniylrednu \n diufl \n citoinma \n ,aispmalce \n erp \n ereves \n sa \n hcus \n ralucsavartni \n rucco \n yam \n eruliaf \n nagroiluM\n• \n yhtapolugaoc \n fo \n ecnedive \n noitpurba \n latnecalp \n ,DUI \n ,msilobme \n )CID( \n noitalugaoc", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_191", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 45, "chunk_size": 401 } }, { "content": "================================================== PAGE 110 ==================================================\n9.\n2. Managementof ITP in pregnancy \n \n Preconception care \n ➢ Disease remission for at least 6 months prior to conception\n should have been achieved. \n \n Antenatal care \n ➢ The mother needs to be followed up in collaboration with a\n haematologist for specialised care. \n ➢ Aim to keep the platelet count > 30 x 109/L throughout\n pregnancy. \n \n Box 9.2: First line treatment for ITP in pregnancy\n \n Steroids \n Oral prednisolone 0.25-0.5 mg/Kg (15-30mg/day) taken as a single", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_192", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 77, "chunk_size": 585 } }, { "content": "Steroids \n Oral prednisolone 0.25-0.5 mg/Kg (15-30mg/day) taken as a single\n dose in the morning +/- proton pump inhibitors. \n ➢ In pregnancy, prednisolone is preferred to dexamethasone, as the\n latter crosses the placenta more readily. \n ➢ The patient should be reviewed in one week to assess the platelet\n count. \n \n o 70-80% responds initially \n o Approximate time to response vary from several days to\n several weeks \n o The steroid dose should be tapered to maintain a safe platelet\n count \n - Regular monitoring for steroid induced diabetes should be\n performed", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_192", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 567 } }, { "content": "96 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_193", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 111 ==================================================\nBox 9.3: Second line treatment (In order of priority)\n \n \n1. IV immunoglobulins \n ➢ This is considered in the absence/inadequate response to\n prednisolone \n ➢ Dose: 1g/kg/day for 1-2 days \n ➢ Up to 80% responds initially; Usually a rapid response, typically\n in 2-4 days \n \n2. Splenectomy \n ➢ Is safe to perform in the second trimester \n ➢ Response rate is 80% \n \n \n3. Azathioprine \n ➢ Dose is 1-2mg/kg/day; Maximum dose is 150mg/day", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_194", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 544 } }, { "content": "➢ Response rate is 80% \n \n \n3. Azathioprine \n ➢ Dose is 1-2mg/kg/day; Maximum dose is 150mg/day\n ➢ Response rate is 40%; Usually a slow response; May need to\n continue for several months \n ➢ Can be used as a steroid sparing agent \n Contraindicated in pregnancy \n ➢ Cyclophosphamide, Mycophenolate, Vincristine, Danazol\n \n Transfusion of platelets has no place in the management of ITP, except\n in the following circumstances: \n - Platelet count <10 x 109 /L with bleeding \n - Need for emergency delivery, surgery or invasive procedures\n with suboptimal platelet count \n - Life threatening bleed", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_194", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 90, "chunk_size": 594 } }, { "content": "with suboptimal platelet count \n - Life threatening bleed \n \n Box 9.4: Management of a life threatening bleed\n \n \n• In the event of a life threatening bleed (Eg. intracranial\n haemorrhage) associated with a low platelet count the following\n should be administered. \n - Platelet transfusion, IV immunoglobulin (1g/kg/day for 1-2\n days) and IV Methyl prednisolone (0.5-1.0 g/d for 3 days)", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_194", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 57, "chunk_size": 386 } }, { "content": "National Guideline for Maternal Care - Volume II 97", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_195", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 51 } }, { "content": "================================================== PAGE 112 ==================================================\n➢ Monitoring during pregnancy should be individualised according\n to the platelet count, the trimester and the trend of platelet rise.\n o Monthly monitoring of platelet count is recommended in 1st\n and 2nd trimesters \n o In the third trimester more frequent monitoring is\n recommended \n ➢ Avoid IM injections and NSAID use when the platelet count is <\n 50 x 109/L. \n ➢ Weigh the risk and benefits in women with a platelet count < 50x\n 109/Lwho require aspirin for obstetric indications.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_196", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 83, "chunk_size": 597 } }, { "content": "109/Lwho require aspirin for obstetric indications.\n Indications for admission \n ➢ If the platelet count is less than < 10 x 109 /L (repeated and\n confirmed) \n ➢ When spontaneous bleeding occurs (irrespective of the platelet\n count) \n Delivery \n ➢ The platelet count should be monitored every week from 36\n weeks onwards. If delivery is planned earlier, weekly monitoring\n from 34 weeks onwards is advised. \n \n ➢ ITP is not an indication for caesarean section. Mode of delivery\n should be based on obstetric indications. \n \n Box 9.5: Safe platelet count for delivery", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_196", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 87, "chunk_size": 566 } }, { "content": "should be based on obstetric indications. \n \n Box 9.5: Safe platelet count for delivery \n \n \n• Vaginal delivery >50 x 109/L \n \n• Caesarean section >50 x 109/L \n \n• Epidural anaesthesia> 80 x 109/L \n \n ➢ If a safe platelet count is not achieved with steroid treatment and\n the patient is close to delivery (>37 weeks of gestation) consider,\n \n o IV immunoglobulin 1g/Kg /day-for 2 consecutive days. The\n response lasts for 2-3 weeks. \n o If IV immunoglobulin is not available, a course of\n i.v.methylprednisolone (1g daily for 3 days) can be given.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_196", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 88, "chunk_size": 547 } }, { "content": "i.v.methylprednisolone (1g daily for 3 days) can be given.\n o If maternal platelet count remains low (<50x 109/L) around\n the time of delivery inspite of all above measures, platelets\n should be available on standby. \n o If the platelet count is < 10x 109/L or if haemorrhage occurs\n with a platelet count < 50 x 109/L at delivery, 6-10 units of\n platelet packs should be given \n 98 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_196", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 74, "chunk_size": 431 } }, { "content": "================================================== PAGE 113 ==================================================\n➢ Paediatric team to be informed at time of delivery.\n Postpartum care \n ➢ Risk of disease flare is increased. \n ➢ Plan to review with a platelet count at one month postpartum and\n if normal at six weeks postpartum. \n ➢ Arrange for long term care after the 6 week review.\n 9.\n3. Neonate of a mother with ITP \n \n ➢ Check the full blood count on a cord blood sample; Maternal\n platelet count is a poor predictor of the neonatal platelet count.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_197", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 552 } }, { "content": "platelet count is a poor predictor of the neonatal platelet count.\n o The platelet count should be reassessed the following day, if\n the initial count is low. \n o Neonates with low platelet count should be monitored as the\n platelet count falls to a nadir between 2-5 days.\n ➢ If the neonatal platelet count is < 50 x 109/L at any time, perform\n a cranial US scan. \n ➢ If the platelet count is < 20 x 109/Lwith evidence of haemorrhage,\n a single dose of IV immunoglobulin (1g/Kg) could be\n administered and repeated as necessary. \n ➢ Platelets should be transfused for life threatening bleeds.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_197", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 102, "chunk_size": 593 } }, { "content": "➢ Platelets should be transfused for life threatening bleeds.\n ➢ Intramuscular vitamin K should be avoided until the platelet\n count is known; Consider giving it orally if the platelet count is\n <50 x 109 /L. \n 9.\n4. Thrombotic thrombocytopaenic purpura (TTP) \n \n ➢ This is a prothrombotic state caused by ultra large Von Willibrand\n factor (Vwf) molecules leading to aggregation and adhesion of\n platelets within the microvasculature. \n ➢ Pregnancy is known to precipitate TTP. It is also associated with\n autoimmune conditions. \n ➢ Without appropriate treatment the mortality is high as 90%.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_197", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 90, "chunk_size": 593 } }, { "content": "autoimmune conditions. \n ➢ Without appropriate treatment the mortality is high as 90%.\n ➢ This can recur in future pregnancies. \n Diagnostic criteria \n o Fever \n o Acute Renal impairment \n o Central nervous system involvement \n o Thrombocytopaenia \n o Microangiopathic haemolytic anaemia \n ➢ Blood picture is helpful in suspected TTP and with very high\n LDH levels helps confirm. \n \n National Guideline for Maternal Care - Volume II 99", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_197", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 63, "chunk_size": 435 } }, { "content": "================================================== PAGE 114 ==================================================\n➢ The pentad need not be fulfilled for diagnosis. \n ➢ A normal coagulation profile is seen. \n \n Management \n ➢ If TTP is suspected, plasma exchange should be instituted as\n early as possible. These patients should be transferred to a\n tertiary care unit urgently where facilities for plasma exchange\n and specialist care is available. \n o If facilities for plasma exchange are not available, cryo poor\n plasma should be infused without delay.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_198", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 73, "chunk_size": 553 } }, { "content": "plasma should be infused without delay. \n o If cryo poor plasma is not available FFP can be given.\n ➢ Platelet transfusion is contraindicated in this situation\n ➢ Once platelet count rises to >50,000 consider LMWH for\n thromboprophylaxis as DVT risk is very high. \n References \n \n \n1. Scully M, Hunt BJ, Benjamin S, Liesner R, et al.Guideline on the\n diagnosis and management of thrombotic \n thrombocytopaenicpurpura and other thrombotic \n microangiopathies. British journal of haematology \n2012.\n \n2. Gernsheimer T, James AH, Stasi R How I treat", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_198", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 546 } }, { "content": "2012.\n \n2. Gernsheimer T, James AH, Stasi R How I treat \n thrombocytopenia in pregnancy. Blood 2013;121(1) : 38-\n47.\n \n3. Clinical Practice Guide on Thrombocytopenia in Pregnancy.\n American society of haematology \n2013.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_198", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 32, "chunk_size": 219 } }, { "content": "100 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_199", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 115 ==================================================\nAntiphospholipid Syndrome", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_200", "page_number": 8, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 136 } }, { "content": "National Guideline for Maternal Care - Volume II 101", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_201", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 116 ==================================================\n102 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_202", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 163 } }, { "content": "================================================== PAGE 117 ==================================================\n10. Antiphospholipid syndrome \n \n 10.\n1. Introduction \n \n ➢ Antiphospholipid syndrome(APS) is an acquired thrombophilic\n state caused by autoantibodies. \n ➢ APS is diagnosed when 1 clinical and 1 laboratory criteria\n (confirmed on two occasions 12 weeks apart) is positive.\n \n Box 10.1: Revised diagnostic criteria for APS\n \n Clinical criteria \n \n \n1. Vascular thrombosis \n \n• One or more clinical episodes of arterial, venous or small\n vessel thrombosis in any tissue or organ", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_203", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 588 } }, { "content": "vessel thrombosis in any tissue or organ \n \n2. Pregnancy related morbidity \n \n• One or more unexplained deaths of a morphologically\n normal fetus at or beyond the 10th week of gestation OR\n \n• One or more premature births of a morphologically normal\n neonate before 34 weeks of gestation, due to eclampsia, severe\n preeclampsia or recognised features of placental insufficiency\n OR \n \n• Three or more unexplained consecutive spontaneous\n miscarriages before 10th week gestation with maternal,\n anatomical, hormonal abnormalities and parental\n chromosomal causes excluded", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_203", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 570 } }, { "content": "anatomical, hormonal abnormalities and parental\n chromosomal causes excluded \n Laboratory criteria (A positive test should be repeated after a\n minimum interval of 12 weeks \n \n \n1. Positive lupus anticoagulant in plasma \n \n2. Anticardiolipin antibody of IgG/IgM present in medium/high\n titres measured by a standardized ELISA test \n \n \n3. Anti β2 glycoprotein 1 of IgG and/or IgM in titre > 99th\n percentile measured by a standardized ELISA test", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_203", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 64, "chunk_size": 445 } }, { "content": "National Guideline for Maternal Care - Volume II 103", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_204", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 118 ==================================================\n➢ Time lapse between the clinical event and laboratory testing\n should not be less than 12 weeks or more than 5 years.\n \n ➢ Lupus anticoagulant (LA), \n o is a coagulation based test \n o should not be tested during pregnancy and until 6 weeks\n postpartum \n o testing should not be performed while on anticoagulants\n ➢ Anticardiolipin (aCL) antibody and anti-β2 glycoprotein 1\n inhibitor (Anti- β2 GP1 ), \n o are immune mediated tests. \n o could be evaluated during pregnancy and while on", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_205", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 597 } }, { "content": "o are immune mediated tests. \n o could be evaluated during pregnancy and while on\n anticoagulation. \n \n 10.\n2. Management of APS during pregnancy \n \n Preconception \n \n ➢ A history of pulmonary embolism needs assessment for\n pulmonary hypertension, which is a contraindication for\n pregnancy. \n \n ➢ Secondary APS (APS associated with autoimmune connective\n tissue disease, commonly SLE) should be excluded in view of\n adverse implications in pregnancy. \n Antenatal care \n \n ➢ Women already on anticoagulation should withhold warfarin\n on confirmation of pregnancy and be reviewed by a", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_205", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 583 } }, { "content": "on confirmation of pregnancy and be reviewed by a\n haematologist/specialist physician for advise on suitable\n anticoagulation during pregnancy. (The different anticoagulation\n regimens are given in Table 6.2 below) \n o Baseline full blood count and coagulation assays should be\n performed prior to commencement of heparin. \n o Low molecular weight heparin (LMWH), throughout\n pregnancy is the preferred. Use of heparin in the first trimester\n with warfarin substituted in the second trimester until\n 36 weeks of gestation, is an alternative when there is\n constraints in accessing LMWH.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_205", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 84, "chunk_size": 586 } }, { "content": "36 weeks of gestation, is an alternative when there is\n constraints in accessing LMWH. \n o LMWH and Aspirin should be commenced in early pregnancy\n once an intrauterine viable fetus is confirmed by ultrasound\n scan. \n 104 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_205", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 43, "chunk_size": 270 } }, { "content": "================================================== PAGE 119 ==================================================\n➢ Graduated compression leg stockings are recommended for\n those at risk of deep vein thrombosis in pregnancy and upto 2\n weeks postpartum \n \n Box 10.2: Preferred treatment in pregnancy in women with\n antiphosholipid syndrome \n Clinical situations Suggested treatment \n aPL positive women with Although there is no evidence of benefit,\n no history of thrombosis or low dose Aspirin is recommended during\n pregnancy loss the antenatal period; Consider 7 days", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_206", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 568 } }, { "content": "pregnancy loss the antenatal period; Consider 7 days\n of thromboprophylaxis with Heparin\n postpartum. \n \n APS and previous recurrent Start low dose Aspirin and fixed dose\n first trimester miscarriage, of Heparin (Eg. Enoxaparin 40 mg\n second/third trimester daily) early in pregnancy once a viable\n loss, severe pre eclampsia, fetus is seen and continue until 7 days\n fetal growth restriction or postpartum. \n placental abruption \n APS and previous venous Aspirin and fixed dose heparin, which is\n thrombosis doubled at 16 – 20 weeks and continued\n until 6 weeks postpartum.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_206", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 85, "chunk_size": 574 } }, { "content": "thrombosis doubled at 16 – 20 weeks and continued\n until 6 weeks postpartum. \n \n ➢ Assessment of Anti X a levels is not routinely recommended in\n pregnancy. It is indicated only in the following situations.\n o In women at extremes of body weight (less than 50 Kg or more\n than 90 Kg) on therapeutic dose of LMWH \n o Renal impairment \n o History of recurrent VTE while on anticoagulation\n - Assessment of anti X a levels is currently not available in\n Sri Lanka. \n Delivery \n \n ➢ Women on warfarin should be changed over to LMWH at 36\n weeks.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_206", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 95, "chunk_size": 541 } }, { "content": "Sri Lanka. \n Delivery \n \n ➢ Women on warfarin should be changed over to LMWH at 36\n weeks. \n \n ➢ Vaginal delivery is the preferred mode; Caesarean section should\n be performed only for obstetric indications.\n ➢ Delivery should be planned.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_206", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 37, "chunk_size": 238 } }, { "content": "National Guideline for Maternal Care - Volume II 105", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_207", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 120 ==================================================\no Prophylactic LMWH should be withheld 12 hours prior to\n delivery \n o Therapeutic LMWH should be withheld 24 hrs prior to\n delivery \n \n Postpartum \n \n ➢ Therapeutic dose of LMWH should be continued for 6 weeks\n postpartum in the event of an acute thrombosis in pregnancy and\n in women who have a history of arterial or venous thrombosis\n outside pregnancy. \n ➢ In women with obstetric manifestatations of APS, 7 days of\n prophylactic LMWH is adequate.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_208", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 77, "chunk_size": 563 } }, { "content": "➢ In women with obstetric manifestatations of APS, 7 days of\n prophylactic LMWH is adequate. \n \n ➢ Early mobilisation, adequate hydration and wearing of\n compression stockings until 2 weeks postpartum should be\n advised. \n \n Contraception \n ➢ Oestrogen containing contraceptives and Depot rpovera are\n contraindicated. \n o Copper IUD is acceptable. \n \n References \n \n \n1. Keeling D, Mackie I, Moore GW, Greer IA. Guidelines on the\n investigation and management of antiphospholipid syndrome.\n British Journal of Haematology 2012; 157: 47–\n58.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_208", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 74, "chunk_size": 541 } }, { "content": "British Journal of Haematology 2012; 157: 47–\n58. \n \n2. Jain V, Gordon C. Managing pregnancy in inflammatory\n rheumatological diseases. Arthritis Research & Therapy 2011; 13:\n206.\n \n \n3. Giannakopoulos B, Krilis SA. How I treat the antiphospholipid\n syndrome. Blood 2009;114: 2020-\n30. \n \n \n4. Galapatthhy P. Management of obstetric antiphospholipid syndrome.\n Sri Lanka prescriber 2013;21(3) 1-\n4.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_208", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 55, "chunk_size": 398 } }, { "content": "106 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_209", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 121 ==================================================\nHIV", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_210", "page_number": 8, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 5, "chunk_size": 114 } }, { "content": "National Guideline for Maternal Care - Volume II 107", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_211", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 122 ==================================================\n108 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_212", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 163 } }, { "content": "================================================== PAGE 123 ==================================================\n11. Prevention And Management Of HIV In \n Pregnancy \n \n 11.\n1. Primary prevention strategies \n \n Raising awareness of antenatal mothers and their partners on HIV,\n AIDS and PMTCT \n \n Information on sexually transmitted infections including HIV and\n syphilis should be included in the general information given to pregnant\n women along with information about other infections and antenatal tests.\n They should be informed: \n ➢ Perinatal transmission of HIV and adverse pregnancy outcomes.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_213", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 598 } }, { "content": "They should be informed: \n ➢ Perinatal transmission of HIV and adverse pregnancy outcomes.\n \n ➢ The potential benefits of knowing their HIV infection status\n by getting tested, both for their own health and to reduce the risk\n of perinatal transmission \n \n ➢ Mother to child transmission of HIV can be greatly reduced\n through antenatal and perinatal treatment with anti-retroviral\n drugs, safer delivery and safer infant feeding practices.\n ➢ Information on facilities for screening \n \n ➢ Information on safe and responsible sexual behaviour and\n practices \n \n 11.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_213", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 565 } }, { "content": "➢ Information on safe and responsible sexual behaviour and\n practices \n \n 11.\n2. Screening for HIV during pregnancy \n \n \n• HIV screening is included in the basic investigation services package\n during pregnancy. Blood samples are collected at the first antenatal\n clinic visit and send to the allocated STD clinic for testing. All\n mothers are to be screened before 12 weeks of gestation for syphilis\n and HIV (preferably at the first visit). \n \n• Antenatal clinic services (MOH clinics and Hospital ANC clinics)\n have to arrange collection of 5cc of blood in a vacutainer tube and", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_213", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 92, "chunk_size": 581 } }, { "content": "have to arrange collection of 5cc of blood in a vacutainer tube and\n transport to the STD clinic for Syphilis and HIV testing. The mode\n of sample transport needs to be locally adopted, after discussions\n with RDHS, MOMCH, MO/STD and MOHs.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_213", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 41, "chunk_size": 239 } }, { "content": "National Guideline for Maternal Care - Volume II 109", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_214", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 124 ==================================================\n• The first blood test is called a screening test. All positive\n screening tests in Sri Lanka are tested with a confirmatory\n test. If the confirmatory test is positive, the woman is considered\n as infected with HIV. \n \n• Assure the woman that her test result is confidential and will be\n shared only with her. \n \n• STD clinics will carry out HIV screening tests on the blood\n samples received from ANC clinics and send reports to the\n relevant officers.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_215", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 82, "chunk_size": 565 } }, { "content": "samples received from ANC clinics and send reports to the\n relevant officers. \n \n• The information on HIV positive reports will be informed to\n the MO, MOH or VOG and measures should be taken to strictly\n maintain the confidentiality of the information. \n \n• The screening test positive pregnant women need to be referred\n to the STD clinic for further management.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_215", "page_number": 8, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 59, "chunk_size": 364 } }, { "content": "Test result should be given only to the relevant person. Do not\n convey any HIV test result (positive or negative) to any other person\n or over the phone. \n \n 11.\n2. When the confirmatory test results is negative:\n \n• Counsel on the importance of staying negative by safer sex\n including use of condoms. \n \n 11.\n3. When the screening test is positive:", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_216", "page_number": 8, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 60, "chunk_size": 351 } }, { "content": "• All pregnant women with HIV should be provided appropriate\n services including institutional care, without stigma and\n discrimination \n \n• Refer them to the STD clinic and further management will be done\n by the STD clinic. \n \n• MOH/MO has to briefly counsel her before sending to STD clinic.\n \n• At the STD clinic she will be subjected to a detail one- to- one pre-\n test counselling session prior to the confirmatory test.\n \n• Select a suitable place where the counselling session could be carried\n out maintaining privacy. \n \n• Discuss the HIV screening test results when the woman is alone or", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_217", "page_number": 8, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 99, "chunk_size": 598 } }, { "content": "out maintaining privacy. \n \n• Discuss the HIV screening test results when the woman is alone or\n with the person of her choice. \n \n• State test results in a neutral tone and explain that this is only a\n screening test and now the confirmatory test has to be done.\n 110 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_217", "page_number": 8, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 57, "chunk_size": 317 } }, { "content": "================================================== PAGE 125 ==================================================\n• Explain to the woman that screening test can be positive due to\n reasons other than HIV (false positive results)\n \n• Give the patient adequate time to express her emotions.\n \n• Explain to her that only if the confirmatory test is positive, there is\n evidence that she is infected with HIV. \n \n• For the confirmatory test, a second sample has to be taken and\n explain this to her. Then refer her to the closest STD clinic. Inform", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_218", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 81, "chunk_size": 541 } }, { "content": "explain this to her. Then refer her to the closest STD clinic. Inform\n her that if she is positive, there are several interventions including\n medications, safe delivery and feeding practices which are able to\n minimize the risk of transmission of HIV to the baby.\n \n• Inform her that support and counselling is available if needed.\n Identify what difficulties or problems the woman foresees and how to\n deal with them \n \n• Encourage her to ask questions \n \n• Ask if she has any concerns. \n When the confirmatory test result is positive the woman will be\n counselled and managed at the STD clinic.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_218", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 100, "chunk_size": 597 } }, { "content": "counselled and managed at the STD clinic.\n \n Maintain the confidentiality of HIV status\n \n \n• Assure the woman that the test result is confidential and will be\n shared only with her. \n \n• Ensure all records are confidential and kept locked away and\n only health care workers taking care of her have access to the\n records. \n \n• Do not enter in the ANC record as HIV positive. Only the date,\n sample for HIV is taken and the date results informed are\n entered in the ANC record. \n 11.\n4. Support to the HIV positive woman \n \n Pregnant women with HIV infection will receive HIV care services at the", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_218", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 104, "chunk_size": 596 } }, { "content": "Pregnant women with HIV infection will receive HIV care services at the\n STD clinic. As the pregnant woman with HIV has to be managed at a ter-\n tiary care centre she will be referred to consultant obstetricians and other\n necessary specialists. You may get involved in the management when you\n are requested to do so by the MOH. \n \n \n• Advise her to get admitted to the hospital as instructed.\n \n• Tell her to take ART medicine as instructed.\n \n• Discuss the infant feeding options \n \n• Counsel her on post partum family planning. \n \n National Guideline for Maternal Care - Volume II 111", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_218", "page_number": 8, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 101, "chunk_size": 588 } }, { "content": "================================================== PAGE 126 ==================================================\n11.\n5. Delivery care - \n \n Avoid suctioning the infants mouth and pharynx, which may cause trau-\n ma to the mucus membranes thus promoting MTCT. \n Clean the eyes of the baby with saline at delivery of the head.\n Clamp the cord as soon as possible to minimise the maternal fetal micro-\n transfusions. \n Cover the umbilical cord with a swab when cutting to prevent blood\n spurting. \n Towel dry the baby. \n Clean the baby’s skin thoroughly before any infusions or injections.\n 11.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_219", "page_number": 9, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 83, "chunk_size": 588 } }, { "content": "Towel dry the baby. \n Clean the baby’s skin thoroughly before any infusions or injections.\n 11.\n6. Post partum care \n \n \n• Be aware of signs of infection following delivery. Like uninfected\n women, HIV positive women are also vulnerable to infection\n following delivery and retained blood and placental tissues.\n Post partum uterine infection is a common and potentially life-\n threatening condition, and early detection and effective treatment are\n important measures to prevent complications. \n \n• Monitor for secondary postpartum haemorrhage \n \n• Manage infected tears or episiotomy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_219", "page_number": 9, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 585 } }, { "content": "• Monitor for secondary postpartum haemorrhage \n \n• Manage infected tears or episiotomy \n \n• Advise women to come back to the same institution if LSCS\n wound infection is observed \n \n• When they are discharged from the healthcare facility women\n should be advised to return to the clinic or inform the PHM if they\n notice symptoms such as fever, lower abdominal pain, burning with\n urination, foul smelling discharge, abnormal bleeding,\n cough, shortness of breath, calf pain (increasing on walking),\n diarrhoea, unusual / abnormal behaviour", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_219", "page_number": 9, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 541 } }, { "content": "diarrhoea, unusual / abnormal behaviour \n \n• Give information on care of the perineum and breasts.\n \n• Instruct her about the safe disposal of lochia and blood-stained\n sanitary wear or other potential infectious materials.\n \n• If contraception has not been discussed before delivery it should be\n done during the early postpartum period (see below).\n 11.\n7. Counsel HIV positive woman on family planning \n Advice and counsel on family planning during antenatal period and post\n partum visits. \n HIV positive women and men should be empowered to take informed", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_219", "page_number": 9, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 86, "chunk_size": 559 } }, { "content": "partum visits. \n HIV positive women and men should be empowered to take informed\n choices relating to their reproductive lives, free of coercion.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_219", "page_number": 9, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 4, "word_count": 22, "chunk_size": 145 } }, { "content": "112 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_220", "page_number": 10, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 127 ==================================================\nThe same contraceptive options which are available to uninfected\n couples are available to HIV infected couples. Most methods are\n considered to be safe and effective for HIV infected women. However,\n as these women are on ART for lifetime, the decision on the suitable\n family planning method should be taken in consultation with the\n Venereologist. \n Protection against both unintended pregnancy and STI is referred to\n as “dual protection”. Condoms are the mainstay of dual protection;", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_221", "page_number": 10, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 78, "chunk_size": 599 } }, { "content": "as “dual protection”. Condoms are the mainstay of dual protection;\n Condoms should be used in combination with another family planning\n method. \n \n Contraceptive counselling may be done by the MOH in consultation\n with the STD clinic. \n During counselling for a contraceptive plan; \n \n \n• Encourage the woman to bring her husband for contraception coun\n selling as it is best that they both decide on a suitable method.\n \n• Discuss their thoughts about having more children.\n \n• Listen carefully to the couples’ views. Correct any factual misunder\n standings.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_221", "page_number": 10, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 85, "chunk_size": 559 } }, { "content": "• Listen carefully to the couples’ views. Correct any factual misunder\n standings. \n \n• If the husband is HIV negative emphasize the importance of using\n condoms to protect him from HIV infection. \n \n• If the husband is HIV positive, explain that although they both have\n HIV they could become infected with another strain of HIV and so it\n is sensible to use condoms to prevent pregnancy and infection.\n \n• Discuss where they could obtain condoms. Demonstrate how to use\n condoms correctly. Provide them with condoms and an information\n leaflet.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_221", "page_number": 10, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 88, "chunk_size": 546 } }, { "content": "condoms correctly. Provide them with condoms and an information\n leaflet. \n \n• If they have decided that they want no more children, discuss vasec\n tomy and female sterilization. \n \n• If they are uncertain about having more children in future, explain\n that waiting at least 2 years after the last birth to become pregnant\n again is healthiest for mother and child. Discuss the need of a\n planned pregnancy. \n \n• Discuss other temporary methods of contraception.\n 11.\n8. Infant feeding with HIV \n \n Counselling and support for safer infant feeding", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_221", "page_number": 10, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 86, "chunk_size": 547 } }, { "content": "11.\n8. Infant feeding with HIV \n \n Counselling and support for safer infant feeding\n The most appropriate infant feeding option for an HIV positive mother\n depends on her individual circumstances, including her health status and\n \n National Guideline for Maternal Care - Volume II 113", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_221", "page_number": 10, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 4, "word_count": 43, "chunk_size": 284 } }, { "content": "================================================== PAGE 128 ==================================================\nthe local situation, the health services availability and the counselling and\n support she is likely to receive. \n \n The expectant mother should be counselled by a counsellor who has\n adequate knowledge on the safer feeding options that are currently rec-\n ommended. The counsellor considers the risk of infants acquiring HIV\n through breast milk with the higher risk of death from causes other\n than HIV, in particular malnutrition and serious illness such as diarrhea", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_222", "page_number": 11, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 580 } }, { "content": "than HIV, in particular malnutrition and serious illness such as diarrhea\n among non-breastfed infants in identifying suitable options. Counselling\n is done by the Venereologist and Paediatrician to assist the mother in ar-\n riving at a decision. \n Currently in Sri Lanka HIV positive pregnant mothers who decide on\n formula feeding are offered formula milk for the baby up to one year of\n age by an NGO.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_222", "page_number": 11, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 65, "chunk_size": 404 } }, { "content": "114 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_223", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 129 ==================================================\nSyphilis", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_224", "page_number": 11, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 5, "chunk_size": 119 } }, { "content": "National Guideline for Maternal Care - Volume II 115", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_225", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 130 ==================================================\n116 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_226", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 163 } }, { "content": "================================================== PAGE 131 ==================================================\n12. Prevention And Management Of Syphilis \n During Pregnancy \n \n 12.\n1. Introduction", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_227", "page_number": 11, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 15, "chunk_size": 195 } }, { "content": "If a woman with untreated syphilis becomes pregnant, or a woman ac-\n quires syphilis during pregnancy, depending on the stage of syphilis, the\n infection can be transmitted to the foetus causing adverse pregnancy out-\n comes including congenital syphilis. Unlike many neonatal infections,\n congenital syphilis (CS) can be effectively prevented, either through pre-\n vention of maternal infection or by detecting the infection early in preg-\n \n nancy and providing adequate treatment.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_228", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 69, "chunk_size": 483 } }, { "content": "12.\n2. Screening for syphilis \n \n \n• All mothers are to be screened before 12 weeks of gestation for Syphi\n \n lis (preferably at the first visit). \n \n \n• Antenatal clinic services (MOH clinics and Hospital ANC clinics)\n have to arrange collection of 5cc of blood in a vacutainer tube and\n transport to the STD clinic for Syphilis and HIV testing. The mode\n of sample transport needs to be locally adopted, after discussions\n with RDHS, MOMCH, MO/STD and MOHs.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_229", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 459 } }, { "content": "• STD clinics have to carry out Syphilis screening tests on the blood\n samples received from ANC clinics and send reports to the relevant\n officers.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_230", "page_number": 11, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 25, "chunk_size": 148 } }, { "content": "• All screening positive samples will be tested further using\n treponemal tests as confirmatory tests.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_231", "page_number": 11, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 15, "chunk_size": 102 } }, { "content": "National Guideline for Maternal Care - Volume II 117", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_232", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 132 ==================================================\n• The information of reactive treponemal reports need to be informed\n to the MO, MOH or VOG and measures should be taken to strictly\n maintain the confidentiality of the information. \n \n \n• The screening test positive pregnant women need to be referred to\n \n the STD clinic for further management. \n \n \n• All pregnant women with Syphilis should be provided appropriate\n services according to the national guidelines including institutional\n care, without stigma or discrimination.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_233", "page_number": 11, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 75, "chunk_size": 591 } }, { "content": "Treatment for syphilis should be provided early in gestation before\n significant fetal damage take place. Treating the mother with penicillin\n during the first and second trimester will prevent faetal wastage due to\n syphilis such as still birth, intrauterine death, abortion or birth of an\n infected child.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_234", "page_number": 11, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 46, "chunk_size": 307 } }, { "content": "12.4.\n1. Treatment of primary, secondary and early latent syphilis\n \n One or two doses of Benzathine benzyl penicillin 2.4 million units\n IM given depending on the stage after excluding allergy.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_235", "page_number": 11, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 30, "chunk_size": 194 } }, { "content": "12.4.\n2. Late latent syphilis: \n \n Benzathine benzyl penicillin 2.4 million units IM once a week for\n consecutive 3 weeks. \n \n Adequate penicillin treatment will end infectivity within 24-48 hrs.\n Pregnant women who miss any dose must repeat the full course of\n therapy.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_236", "page_number": 11, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 41, "chunk_size": 270 } }, { "content": "118 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_237", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 133 ==================================================\n12.\n5. Follow up \n \n Serological (VDRL) follow-up should be at months 1, 2, 3, 6 and 12, then\n 6 monthly until VDRL negative or for 2 years. \n \n A sustained fourfold or greater increase in the VDRL titre suggests re-\n infection or treatment failure and needs to be retreated.\n It is not necessary to retreat pregnant mothers who have positive\n \n treponemal test results and have documented evidence of adequate\n therapy for diagnosis of syphilis previously, so long as there is no evidence", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_238", "page_number": 11, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 85, "chunk_size": 600 } }, { "content": "therapy for diagnosis of syphilis previously, so long as there is no evidence\n of serologic or clinical evidence of re-infection or relapse. Babies born to\n such mothers do not require prophylactic penicillin therapy.\n \n If doubts exist about the adequacy of previous therapy, re-treatment\n should be commenced promptly.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_238", "page_number": 11, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 47, "chunk_size": 320 } }, { "content": "12.\n6. Allergy to penicillin \n \n Erythromycin 500mg four times per day for 14 days in early syphilis and\n for 28 days in late syphilis.(In pregnancy Doxycycline is contraindicated).\n \n When mother is treated with erythromycin baby should be considered as\n a presumptive case of congenital syphilis treat adequately for congenital\n syphilis.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_239", "page_number": 11, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 50, "chunk_size": 340 } }, { "content": "12.\n7. Treatment of partners \n \n Sexual partners should be referred to the STD clinic for assessment. They\n will be treated according to the stage of syphilis, if clinical evidence of\n syphilis is present or if serology is positive. \n \n 12.8.Diagnosis of congenital syphilis", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_240", "page_number": 11, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 42, "chunk_size": 274 } }, { "content": "All babies born to mothers with syphilis, should have\n \n• Clinical evaluation: if lesions (bulbous skin rash, nasal discharge,)\n present carry out dark ground microscopy. \n \n National Guideline for Maternal Care - Volume II 119", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_241", "page_number": 11, "content_type": "guidelines", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 34, "chunk_size": 227 } }, { "content": "================================================== PAGE 134 ==================================================\n• Carry out serological tests \n \n VDRL and TPPA in both mother and baby. Syphilis specific EIA IgM an-\n tibody test of baby (If available) \n \n VDRL titre of the baby is more than fourfold that of the mother or positive\n syphilis specific IgM need to be managed as congenital syphilis .Until 18\n months it’s difficult to differentiate whether mother’s antibodies or babies\n antibodies would give positive VDRL and TPPA results. Placental transfer", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_242", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 75, "chunk_size": 556 } }, { "content": "antibodies would give positive VDRL and TPPA results. Placental transfer\n \n of maternal IgG can give positive results in baby even in the absence of\n congenital syphilis. If clinical signs are present with positive serological\n tests a bone survey should be considered and baby should be treated for\n congenital syphilis \n \n 12.\n9. Treatment of the baby \n \n If the mother had been adequately treated before 36 weeks of POA the risk\n of mother to child transmission (MTCT) is low. However, irrespective of\n mother’s treatment all babies born to mothers with positive treponemal", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_242", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 90, "chunk_size": 576 } }, { "content": "mother’s treatment all babies born to mothers with positive treponemal\n tests are given prophylactic penicillin. \n \n Baby is given one dose of Benzathine penicillin 50,000IU/Kg of Body\n Weight, as prophylactic treatment. \n \n If congenital syphilis could not be excluded, baby need to be treated\n with crystalline penicillin 50,000IU/Kg/day twice day for 7 days and\n three times per day for further 3 days to complete the total of 10 days\n treatment \n \n This should be given to: \n \n \n1. All symptomatic babies \n \n \n2. All asymptomatic babies", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_242", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 81, "chunk_size": 540 } }, { "content": "This should be given to: \n \n \n1. All symptomatic babies \n \n \n2. All asymptomatic babies \n \n i. Whose VDRL titre is a 4 fold higher than that of the mother at\n delivery \n ii. Rising non-treponemal titre (VDRL)", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_242", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 34, "chunk_size": 208 } }, { "content": "120 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_243", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 135 ==================================================\niii. With a reactive syphilis specific IgM antibody test (If available)\n \n iv. Born to mothers who were treated with penicillin <4 weeks before\n delivery \n v. Born to mothers who did not complete the recommended course\n of penicillin during pregnancy \n \n vi. Born to mothers whose non treponemal high titre had not\n dropped four fold at the time of delivery \n \n vii. Born to mothers who were treated with non penicillin regimens\n (Erythromycin) during pregnancy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_244", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 572 } }, { "content": "(Erythromycin) during pregnancy \n \n viii.Born to mothers whose treatment status is unknown or undocu\n mented", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_244", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 14, "chunk_size": 108 } }, { "content": "National Guideline for Maternal Care - Volume II 121", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_245", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 136 ==================================================\n& \n & \n \n 45*%*)*-&+*5&\"$%($\"%\"-&%(2%#$6&+*5&2.7'#-#2!\n \n \n• X&,,$C#!A,&&(!E%&4!#>$!4&#>$%!! \n ! \n \n• \"$.(!#&!`\"MXZ6.$+%$)#!\"GQ!X,'.'C6#$)#'.5!'.)#'#@#'&.!\n \n ! \n \n Z&)'#'H$!OQN\\! \n \n• X&.E'%4!A;!GZZM!! \n \n• B.E&%4!#>$!!%$)@,#)!#&!%$,$H+.#!W*a!A;!#>$!W*6BX! 189:;<44=&%(2%&5(23-%2&2'*3-,&\n \n• a+ %(!C&-;!&E!#>$!#$)#!%$)@,#)!)>&@,(!A$!)$.#!#&!#>$! >(&)*--()%(,&>.&%'(&5(-(?\"$%&\n W *a! *++#)(52& \n \n• b >$.!cdZ!')!($#$C#$(!'#!)>&@,(!A$!'.E&%4$(!#&!", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_246", "page_number": 11, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 29, "chunk_size": 557 } }, { "content": "W *a! *++#)(52& \n \n• b >$.!cdZ!')!($#$C#$(!'#!)>&@,(!A$!'.E&%4$(!#&!\n #> $!%$,$H+.#!W*a!#>+#!'#!')!.&#!\";->',')!! \n ! \n \n• =--&$(6\"%#?(&%(2%&5(23-%2&2'*3-,&>(&\n \n• W *a!)>&@,(!'.E&%4!#>$!%$,$H+.#!ZaW!#&!#%+C$!#>$! ($%(5(,&#$&45(6$\"$).&5()*5,&@/ABC&\n 4 &#>$%! =&D&E&F&G#%'&%'(&4H=&>.&4/!I&&\n \n• W &#>$%!)>&@,(!A$!5'H$.!+!%$E$%%+,!.&#$!#&!H')'#!#>$! \n• J(5*K&$(6\"%#?(&L*%'(52&2'*3-,&>(&\n \"GQ!C,'.'C!!!!!!!8X&.E'($.#'+,'#;!)>&@,(!A$!4+'.#+'.$((&($%(5(,&>.&", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_246", "page_number": 11, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 31, "chunk_size": 569 } }, { "content": "! 2.7'#-#2I& \n N'($&%'( &L*%'(5&\"%%($,&%'(&J<8&)-#$#)& \n• EM4&5(23-%2&2'*3-,&>(&($%(5(,&>.&\n \n• C$ ,&2\"L7-(&2'*3-,&>(&%\"O($&&+*5&5()*$+#5L\"%#*$& !H/&\"2&189:&5(\")%#?(&\"$,&<44=&\n \n• N '($&C$,&2\"L7-(&@%5(7*$(L\"-&%(2%F&7*2#%#?(&2%\"5%& $(6\"%#?(&@$*%&\"2&2.7'#-#2&7*2#%#?(F&\n %'(&L\"$\"6(L($%& \n ! \n 90 Q$#+',$(!a')#&%;?!$F+4'.+#'&.!?)#+5'.5!&E!);->',')!\n 10 \"C%$$.'.5!E&%!&#>$%!\"GB)! \n :0 G%$+#!+CC&%('.5!#&!#>$!)#+5$!&E!);->',')!8-%$E$%+A,;!I'#>!-$.'C',,'.$!4&#>$%!", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_246", "page_number": 11, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 30, "chunk_size": 587 } }, { "content": "20 X&@.)$,!&.!)+E$%!)$F! \n e0 Z%&4&#$!aBO!#$)#'.5! \n J0 d&,,&I!@-!&E!#>$!4&#>$%! \n K0 W+=$!+%%+.5$4$.#!E&%!4+.+5$4$.#!&E!A+A;!8Z%&->;,+F')!-$.'C',,'.!&%!BO!-$.'C',,'.!%$5'4$.&@,(!A$!E&,,&I$(!@-!'.!#>$!\"GQ!C,'.'C!+#!:DeD!+.(!91!4&.#>)!\n ! \n !", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_246", "page_number": 11, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 12, "chunk_size": 255 } }, { "content": "122 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_247", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 137 ==================================================\nMalaria", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_248", "page_number": 11, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 5, "chunk_size": 118 } }, { "content": "National Guideline for Maternal Care - Volume II 123", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_249", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 138 ==================================================\n124 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_250", "page_number": 11, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 13, "chunk_size": 163 } }, { "content": "================================================== PAGE 139 ==================================================\n13. Guidelines on malaria chemotherapy and \n management of patients with malaria during \n pregnancy", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_251", "page_number": 11, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 17, "chunk_size": 210 } }, { "content": "13.\n1. Introduction \n \n With no indigenous malaria cases being reported since October 2012,\n Sri Lanka is currently in the malaria elimination and prevention of re-\n introduction phase. With progressively increasing incidence of imported\n malaria cases in recent years, early diagnosis and treatment of such cases\n have become the highest priority for prevention of re-introduction. Most\n of these infections have been acquired in India, Pakistan, South East\n Asian and African countries. \n Currently, a low level of clinical suspicion in the backdrop of a very low", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_252", "page_number": 11, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 565 } }, { "content": "Currently, a low level of clinical suspicion in the backdrop of a very low\n disease burden has led to a significant delay in diagnosis of malaria cases.\n As a result, there were several patients who presented to the health care\n institutions with uncomplicated fever progressing to develop severe\n malaria while being at the hospital. \n \n 13.\n2. Patients likely to have malaria \n \n Malaria should be suspected in: \n \n \n1. any febrile individual (including foreign nationals):\n − with unexplained fever and a history of recent travel (within1", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_252", "page_number": 11, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 84, "chunk_size": 541 } }, { "content": "− with unexplained fever and a history of recent travel (within1\n year) to a malaria endemic country (esp. India, Pakistan, Haiti\n and African countries). Refer Annex II for a list of countries\n where malaria transmission occurs). \n − belonging to high risk groups e.g. businessmen, pilgrims\n and seamen returning from malaria endemic countries, re-settled\n communities, skilled and unskilled foreign workers, illegal/\n irregular migrants, refugees, asylum seekers, security forces\n returning from peace keeping missions etc. \n − with a history of malaria infection within the past 3 years", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_252", "page_number": 11, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 85, "chunk_size": 589 } }, { "content": "− with a history of malaria infection within the past 3 years\n − with fever of unknown origin \n \n2. any individual presenting with clinical features of severe malaria\n (refer Annex I for clinical features of severe malaria)\n \n3. Patients with anaemia of unknown cause \n \n4. Patients with hepatomegaly and/or splenomegaly\n \n National Guideline for Maternal Care - Volume II 125", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_252", "page_number": 11, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 59, "chunk_size": 376 } }, { "content": "================================================== PAGE 140 ==================================================\n5. Recipients of blood or blood products who develop fever within 3\n months of transfusion \n \n Please note: \n − Malaria can present with non-specific symptoms even if there is\n no fever. \n − Thrombocytopaenia has been a frequent finding among patients\n with malaria reported in the recent years, yet a diagnosis of ma\n laria has not been considered as a result of them being misdi\n agnosed as having dengue. This had led to a delayed malaria diag\n nosis resulting in adverse sequelae.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_253", "page_number": 11, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 595 } }, { "content": "nosis resulting in adverse sequelae. \n 13.\n3. Notification of malaria patients \n \n Any patient strongly suspected of having malaria should immediately be\n notified via telephone to the Regional Malaria Officer (RMO) and Anti\n Malaria Campaign Headquarters. In addition, it should be notified to the\n Medical Officer of Health (MOH) of the area where the patient resides\n following the standard notification procedure (Form H544).\n The AMC will ensure: \n \n − confirmation of diagnosis by species \n − provision of appropriate anti-malarial drugs \n − guidance on treatment", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_253", "page_number": 11, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 82, "chunk_size": 569 } }, { "content": "− provision of appropriate anti-malarial drugs \n − guidance on treatment \n − initiation of rapid response to search for additional cases and\n prevent onward transmission of the disease \n − follow up of the patient in the field in order to achieve radical cure.\n \n The contact numbers of the AMC Headquarters and the RMOs are given\n in Annex III. \n 13.4.Diagnosis of malaria \n \n \n• In every suspected case of malaria, laboratory confirmation by\n microscopic examination of blood smears and/or Rapid\n Diagnostic Test (RDT) is mandatory prior to initiation of anti-", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_253", "page_number": 11, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 87, "chunk_size": 562 } }, { "content": "Diagnostic Test (RDT) is mandatory prior to initiation of anti-\n malarial treatment. Treating malaria based on clinical suspicion\n without laboratory confirmation should be avoided.\n \n \n• If there is a strong clinical suspicion of malaria, and the blood\n smears/RDT are negative at the time of initial testing, a minimum\n of three consecutive blood smears/RDT should be done prior to\n concluding that the patient is negative for malaria.\n 126 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_253", "page_number": 11, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 75, "chunk_size": 491 } }, { "content": "================================================== PAGE 141 ==================================================\n• Blood should be collected for investigations prior to the administration\n of anti-malarials: \n − In all confirmed malaria patients \n − If anti-malarial treatment is required as a life saving measure based on\n clinical suspicion without laboratory confirmation of malaria\n \n• Blood should be collected in the following manner:\n − 2ml of venous blood collected to an EDTA bottle and refrigerated\n until transported to the AMC headquarters.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_254", "page_number": 12, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 550 } }, { "content": "until transported to the AMC headquarters. \n − Dried blood spots on filter paper: drop the blood (approx. 1.5 ml)\n in the syringe on the filter paper labelled with the patient’s name; four\n blood spots with 3 drops per each spot. Air dry for one hour at room\n temperature. Place each filter paper in an individual envelope. Store at\n room temperature until transported to the AMC Headquarters.\n − (please contact AMC Headquarters for details).\n 13.\n5. Monitoring during treatment and follow up of patients\n \n• To ensure an effective parasitological response to the anti-malarial", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_254", "page_number": 12, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 93, "chunk_size": 578 } }, { "content": "• To ensure an effective parasitological response to the anti-malarial\n drugs, a blood smear should be obtained daily and examined over the\n three day that the patient is admitted. If parasitaemia persists beyond\n 3 days blood smears should be taken daily until parasitaemia clears. In\n severe malaria cases, blood smears have to be taken at a higher frequency.\n \n• Thereafter the patient will be followed up to one year (frequency and\n duration will depend on the species) by the AMC field staff.\n \n 13.\n6. Treatment of patients with malaria", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_254", "page_number": 12, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 89, "chunk_size": 542 } }, { "content": "13.\n6. Treatment of patients with malaria \n \n Specific treatment and management of malaria will depend on the para-\n site species causing infection, severity of disease and the biological factors\n of the patient. \n \n• Objectives of treatment: \n − Primary objective of treatment: to ensure rapid and complete elimi-\n nation of the Plasmodium parasite from the patient’s blood in order to\n prevent progression of uncomplicated malaria to severe disease or death.\n − From a public health perspective: to reduce transmission of the in-", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_254", "page_number": 12, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 81, "chunk_size": 531 } }, { "content": "− From a public health perspective: to reduce transmission of the in-\n fection to others by reducing the infectious reservoir and to prevent the\n emergence and spread of resistance to anti-malarial medicines.\n \n• All confirmed malaria patients should be admitted to a medical insti-\n tution for a minimum of 3 days to be managed under supervision.\n \n• If facilities are available, a test for G6PD deficiency should be carried\n out prior to administration of primaquine.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_254", "page_number": 12, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 4, "word_count": 75, "chunk_size": 469 } }, { "content": "National Guideline for Maternal Care - Volume II 127", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_255", "page_number": 13, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 142 ==================================================\n13.6.\n1. Mono-infection with Plasmodium vivax \n \n \n• For radical cure of P. vivax malaria, the patient should be treated with\n chloroquine and primaquine. \n \n• Chloroquine: base at a total dose of 25 mg/kg body weight (bw) over\n three days. This dose should be divided as 10mg/kg on the first and\n second day followed by 5 mg/kg bw on the third day.\n \n• Primaquine: the adult dose is 15mg base (0.25mg/kg per day)\n for fourteen days unless it is contraindicated. The administration of", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_256", "page_number": 13, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 86, "chunk_size": 595 } }, { "content": "for fourteen days unless it is contraindicated. The administration of\n primaquine is not recommended during pregnancy and\n lactation, infancy and in severe G6PD deficiency (<10% of residual\n enzyme activity). \n \n• In patient with mild to moderate G6PD deficiency (10-60% of\n residual enzyme activity) primaquine can be administered in a\n dosage of 0.75 mg/kg weekly for 8 weeks under specialized\n supervision. \n 13.6.\n2. Uncomplicated mono-infection with Plasmodium falciparum\n \n• For radical cure of falciparum malaria, the patient should be treated\n with ACT and primaquine.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_256", "page_number": 13, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 83, "chunk_size": 576 } }, { "content": "with ACT and primaquine. \n \n• Artemisinin based combination Therapy (ACT): Weight appropriate\n dose. Coartem® (containing 20mg of artemether and 120mg of\n lumefantrine) is the ACT used in Sri Lanka. \n \n• Artemisinin and its derivatives should never be used as monotherapy.\n \n• Coartem® tablets are packed in four colour coded blister packs. The\n recommended treatment is 6-dose regimen over a three day period\n according to the weight of the patient as indicated in table \n1.\n Table 13.\n1. Number of ACT (Coartem®) tablets administered based on\n weight of patient", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_256", "page_number": 13, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 88, "chunk_size": 563 } }, { "content": "1.\n Table 13.\n1. Number of ACT (Coartem®) tablets administered based on\n weight of patient \n Interval 5 -14 kg 15 -to 24 kg 25- 34 kg >35 kg \n between doses (Yellow (Blue Pack)(Orange pack)(Green pack)\n \n Pack) \n 0 Hours 1 2 3 4 \n 8 Hours 1 2 3 4 \n 24 Hours 1 2 3 4 \n 36 Hours 1 2 3 4 \n \n 48 Hours 1 2 3 4 \n 60 Hours 1 2 3 4 \n Total 6 12 18 24 \n \n 128 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_256", "page_number": 13, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 86, "chunk_size": 400 } }, { "content": "================================================== PAGE 143 ==================================================\nACT should be taken immediately after a meal or drink containing at\n least 1.2g of fat (e.g. a glass of milk) since its absorption is enhanced by\n co-administration with fat. As low blood levels of ACT with treatment\n failure could potentially result from inadequate fat intake, it is essential\n that patients or carers are informed of the need to take Coartem® with\n milk or fat containing food, particularly on the second or third day of\n treatment.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_257", "page_number": 13, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 80, "chunk_size": 562 } }, { "content": "milk or fat containing food, particularly on the second or third day of\n treatment. \n \n• Primaquine: A weight appropriate single dose of primaquine (0.75mg/\n kg bw) should be administered unless contraindicated, on day 3 of\n treatment or prior to discharge from hospital to destroy gametocytes.\n \n Uncomplicated P. falciparum malaria in infants and young children\n \n \n• ACT (Coartem®) is the first line treatment in infants and young\n children. \n \n• Primaquine should be avoided in children less than 1 year of age.\n \n• An acutely ill child requires careful clinical monitoring as she/he may", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_257", "page_number": 13, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 92, "chunk_size": 591 } }, { "content": "• An acutely ill child requires careful clinical monitoring as she/he may\n deteriorate rapidly. \n \n• Please contact Anti Malaria Campaign Headquarters for further\n guidance. \n Uncomplicated P. falciparum malaria in Pregnancy\n \n \n• 1st Trimester: Uncomplicated falciparum malaria is treated with oral\n quinine sulfate 10mg/kg body weight at 8 hourly intervals plus clinda\n mycin 10 mg/kg bw twice a day for 7 days. If clindamycin in unavail\n able, quinine monotherapy may be given. \n \n• 2nd and 3rd Trimester: Uncomplicated falciparum malaria is treated\n with Coartem®.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_257", "page_number": 13, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 83, "chunk_size": 568 } }, { "content": "• 2nd and 3rd Trimester: Uncomplicated falciparum malaria is treated\n with Coartem®. \n \n• Primaquine should not be administered during pregnancy.\n Uncomplicated P. falciparum malaria during Lactation\n \n \n• Lactating women can receive the recommended dose of Coartem®.\n \n• Primaquine should not be given during lactation.\n 13.6.\n3. Uncomplicated mixed infections with P. falciparum and\n P.vivax \n \n \n• Artemisinin based combination therapy: Coartem® is given at a\n weight appropriate dose. \n \n• Primaquine base: at a dose of 0.25mg/kg bw per day for fourteen\n days unless it is contraindicated.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_257", "page_number": 13, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 85, "chunk_size": 593 } }, { "content": "days unless it is contraindicated. \n \n National Guideline for Maternal Care - Volume II 129", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_257", "page_number": 13, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 4, "word_count": 14, "chunk_size": 91 } }, { "content": "================================================== PAGE 144 ==================================================\n13.6.\n4. Severe P. falciparum malaria \n \n Severe malaria is a medical emergency. After rapid clinical assessment\n and confirmation of the diagnosis, full doses of parenteral antimalarial\n treatment should be started without delay. Patients with severe malaria\n require intensive nursing care, preferably in an intensive care unit where\n possible. Clinical observations should be made as frequently as possible.\n These should include monitoring of vital signs, coma score, and urine", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_258", "page_number": 14, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 72, "chunk_size": 592 } }, { "content": "These should include monitoring of vital signs, coma score, and urine\n output. Blood glucose should also be monitored every four hours, if pos-\n sible, particularly in unconscious patients. \n \n• Intravenous artesunate, 2.4mg/kg bw given on admission (time = 0),\n then at 12 hour and 24 hour, then once a day until the patient is able to\n take oral medication. If intra venous administration is not possible, it can\n also be given as an intramuscular injection. \n \n If parenteral artesunate is NOT available: \n \n \n• Quinine dihydrochloride, 20mg salt/kg bw (loading dose) on admis-", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_258", "page_number": 14, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 91, "chunk_size": 580 } }, { "content": "• Quinine dihydrochloride, 20mg salt/kg bw (loading dose) on admis-\n sion, then 10mg/kg every 8 hours. Each dose is given as a rate controlled\n intra venous infusion diluted in 10ml/kg bw of isotonic fluid over 2-4\n hours at an infusion rate that should not exceed 5mg salt/kg body weight\n per hour. \n The most important adverse effect is hyperinsulinaemic hypoglycaemia.\n Hypotension and cardiac arrest may result from rapid intravenous injec-\n tion. Quinine causes prolongation of the electrocardiograph QT interval.\n Therefore; this administration should be accompanied by frequent blood", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_258", "page_number": 14, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 87, "chunk_size": 590 } }, { "content": "Therefore; this administration should be accompanied by frequent blood\n glucose monitoring to prevent hypoglycaemia and cardiac monitoring.\n \n Duration of parenteral treatment \n Give parenteral antimalarials in the treatment of severe malaria for a\n minimum of 24 hours, even if the patient can tolerate oral medication.\n Follow up on oral treatment \n \n Complete the treatment by giving a full course of Coartem® as soon as the\n patient is able to take oral medication, but not before a minimum of 24\n hours of parenteral treatment. This should be followed by a single dose of\n primaquine.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_258", "page_number": 14, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 91, "chunk_size": 589 } }, { "content": "hours of parenteral treatment. This should be followed by a single dose of\n primaquine. \n Artesunate is dispensed as a powder of artesunic acid. This powder is dis-\n solved in 1ml of 5% sodium bicarbonate to form sodium artesunate. The\n solution is then diluted with 5 ml of 5% dextrose and given immediately\n \n 130 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_258", "page_number": 14, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 4, "word_count": 61, "chunk_size": 364 } }, { "content": "================================================== PAGE 145 ==================================================\nby intravenous bolus (‘push’) injection or by intramuscular injection (to\n the anterior thigh). The solution should be prepared freshly for each ad-\n ministration and should not be stored. \n \n Severe P. falciparum malaria in pregnancy \n \n• 1st Trimester: should be treated with parenteral quinine until clinical\n improvement, followed by oral quinine therapy for a total of 7 days.\n \n \n• 2nd and 3rd Trimester of pregnancy: parenteral artesunate/quinine", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_259", "page_number": 15, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 70, "chunk_size": 564 } }, { "content": "• 2nd and 3rd Trimester of pregnancy: parenteral artesunate/quinine\n can be administered as above. After clinical improvement, Coartem®\n should be administered in the weight appropriate dose.\n Please note: Primaquine should not be administered during pregnancy.\n Severe P. falciparum and P.vivax mixed infections\n \n \n• Parenteral administration of artesunate or quinine dihydrochloride\n followed by a full course of oral Coartem® (as described in manage\n ment of severe falciparum malaria). \n \n \n• These patients should be given a course of primaquine base at a dose", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_259", "page_number": 15, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 81, "chunk_size": 566 } }, { "content": "• These patients should be given a course of primaquine base at a dose\n of 0.25mg/kg per day for fourteen days unless it is contraindicated.\n 13.6.\n5. Patients infected with other malaria parasites\n \n The recommended treatment for malaria caused by P.ovale is the same as\n that given to achieve radical cure in P. vivax malaria, i.e. with chloroquine\n and primaquine. \n \n P. malariae should be treated with the standard regimen of chloroquine as\n for P. vivax malaria, but it does not require radical cure with primaquine.\n \n 13.\n7. Chemoprophylaxis for malaria", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_259", "page_number": 15, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 90, "chunk_size": 561 } }, { "content": "13.\n7. Chemoprophylaxis for malaria \n Chemoprophylaxis is not needed for visitors to Sri Lanka and anyone\n living within the country including pregnant women.\n \n Chemoprophylaxis is recommended for travellers to malaria endemic\n countries (the list of countries where malaria transmission occurs is given\n in Annex II). Contact Anti Malaria Campaign to obtain chemoprophylactic\n drugs and for further details.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_259", "page_number": 15, "content_type": "medication_dosage", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 57, "chunk_size": 409 } }, { "content": "National Guideline for Maternal Care - Volume II 131", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_260", "page_number": 15, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 146 ==================================================\nAnnex I. Severe malaria \n Definition of Severe malaria \n Severe malaria is defined by clinical or laboratory evidence of vital\n organ dysfunction (WHO, 2012). In a patient with P. falciparum asexual\n parasitaemia and no other obvious cause of symptoms, the presence of one\n or more clinical or laboratory features classifies the patient as suffering\n from severe malaria. \n \n Clinical features of severe malaria \n \n• impaired consciousness (including unarousable coma);", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_261", "page_number": 15, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 71, "chunk_size": 580 } }, { "content": "Clinical features of severe malaria \n \n• impaired consciousness (including unarousable coma);\n \n \n• prostration, i.e. generalized weakness so that the patient is\n unable to walk sit up without assistance; \n \n• multiple convulsions-more than two episodes in 24h;\n \n• deep breathing, respiratory distress (acidotic breathing);\n \n \n• acute pulmonary oedema and acute respiratory distress\n syndrome; \n \n• circulatory collapse or shock, systolic blood pressure <80 mm\n Hg in adults and < 50 mm Hg in children; \n \n \n• acute kidney injury;", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_261", "page_number": 15, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 76, "chunk_size": 532 } }, { "content": "Hg in adults and < 50 mm Hg in children; \n \n \n• acute kidney injury; \n \n• clinical jaundice plus evidence of vital organ dysfunction; and\n \n• abnormal bleeding \n \n Laboratory findings \n \n \n• hyperparasitaemia \n \n• hypoglycaemia (blood glucose <2.2 mmol/l or <40mg/dl);\n \n• metabolic acidosis (plasma bicarbonate < 15 mmol/l);\n \n• severe normocytic anaemia (In children: Hb <5g/dl, packed cell\n volume <15%. In adults: Hb<7g/dl, packed cell volume, PCV<\n 20%) \n \n• haemoglobinuria; \n \n• hyperlactataemia (lactate > 5 mmol/l); \n \n• renal impairment (serum creatinine> 265 µmol/l);", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_261", "page_number": 15, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 82, "chunk_size": 578 } }, { "content": "• hyperlactataemia (lactate > 5 mmol/l); \n \n• renal impairment (serum creatinine> 265 µmol/l);\n \n• pulmonary oedema (radiological) \n Reference: \n WHO, 2012, Management of severe malaria, A practical handbook, 3rd\n Ed., World Health Organization \n \n 132 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_261", "page_number": 15, "content_type": "clinical_protocol", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 3, "word_count": 41, "chunk_size": 301 } }, { "content": "================================================== PAGE 147 ==================================================\nAnnex II. \n \n Countries where malaria transmission occurs \n \n Afghanistan Dominican Republic Madagascar SaudiArabia\n Angola Ecuador Malawi Senegal \n Bangladesh Equatorial Guinea Malaysia Sierra Leone\n Belize Eritrea Mali SolomonIslands \n Benin Ethiopia Mauritania Somalia \n Bhutan French Guiana Mayotte South Africa \n Bolivia Gabon Mozambique Sudan \n Botswana Gambia Myanmar Swaziland \n Brazil Ghana Mexico Suriname \n Burkina Faso Guatemala Namibia Thailand", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_262", "page_number": 15, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 57, "chunk_size": 568 } }, { "content": "Brazil Ghana Mexico Suriname \n Burkina Faso Guatemala Namibia Thailand \n Burundi Guinea Niger Timor Leste \n Cambodia Guinea- Bissau Nigeria Togo \n Cameroon Guyana Nepal Tajikistan \n Central African Rep. Haiti Nicaragua Turkey \n Chad Honduras Pakistan Uganda \n China India Panama Tanzania \n Colombia Indonesia Papua New Guinea Vanuatu \n Comoros Iran Peru Vietnam \n Congo Iraq Philippines Venezuela \n Costa Rica Kenya Paraguay Yemen Socotra Island\n Cote d’Ivoire Lao PDR Rwanda Zambia \n Djibouti Liberia Sao Tome & Principe Zimbabwe", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_262", "page_number": 15, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 71, "chunk_size": 530 } }, { "content": "Cote d’Ivoire Lao PDR Rwanda Zambia \n Djibouti Liberia Sao Tome & Principe Zimbabwe\n \n Note: There are some other countries with very limited malaria risk. For\n more details please refer International Travel and Health-2012 at\n http://www.who.int/ith/chapters/ith2012en_countrylist.pdf", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_262", "page_number": 15, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 2, "word_count": 35, "chunk_size": 285 } }, { "content": "National Guideline for Maternal Care - Volume II 133", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_263", "page_number": 15, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 148 ==================================================\nAnnex III.", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_264", "page_number": 15, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 121 } }, { "content": "Telephone numbers related to Anti Malaria \n Campaign \n \n Anti Malaria Campaign Headquarters: \n \n Tele: (011) 2588408, (011) 2368173 \n (011) 2368174 \n (011) 7626626 (hotline) \n e-mail : antimalariacampaignsl@gmail.com\n Website : www.malariacampaign.gov.lk \n \n Regional Malaria Offices \n \n Ampara (063) 2223464 Kandy (081) 2210687 Monaragala (055) 2276698\n \n Anuradhapura (025) 2221844 Kegalle (035) 2222549 Mullaitivu (024) 3248341\n Badulla (055) 2226018 Kilinochchi (024) 3247236 Polonnaruwa (027) 2226018\n \n Batticaloa (065) 2222931 Kurunegala (037) 2222193 Puttalam (032) 2265319", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_265", "page_number": 15, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 66, "chunk_size": 581 } }, { "content": "Batticaloa (065) 2222931 Kurunegala (037) 2222193 Puttalam (032) 2265319\n Hambanthota (047) 2220135 Maho (037) 2275254 Ratnapura (047) 2230301\n \n Jaffna (021) 2227924 Mannar (023) 2222326 Trincomalee (026) 2222584\n Kalmunai (067) 2220206 Matale (066) 2222295 Vavuniya (024) 2222954", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_265", "page_number": 15, "content_type": "general", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 1, "word_count": 36, "chunk_size": 281 } }, { "content": "134 National Guideline for Maternal Care - Volume II", "metadata": { "document_name": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "section": "Section_266", "page_number": 15, "content_type": "maternal_care", "source_file": "lka-mn-21-01-guideline-2015-eng-maternal-care-guide-lines-volume-02-(2).pdf", "chunk_index": 0, "word_count": 9, "chunk_size": 52 } }, { "content": "================================================== PAGE 1 ==================================================\nSri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_000", "page_number": 1, "content_type": "general", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 11, "chunk_size": 156 } }, { "content": "Please cite this paper as: De Silva PHP et al, on behalf of Sri Lanka College of Obstetricians and\n Gynaecologists. Hypertensive disorders of pregnancy", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_001", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 24, "chunk_size": 151 } }, { "content": "Sri Lanka College of Obstetricians and Gynaecologists", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_002", "page_number": 1, "content_type": "general", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 7, "chunk_size": 53 } }, { "content": "================================================== PAGE 2 ==================================================\nSLCOG Guideline \n \n SLCOG Guideline \n \n Hypertensive disorders of pregnancy \n \n P H P De Silvaa, S Lanerolleb, S H Dodampahalac, R Silvad, C Mathotae on behalf of the Sri Lanka\n College of Obstetricians and Gynaecologists \n \n Correspondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo \n08.\n E-mail: slcogoffice@gmail.com", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_003", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 54, "chunk_size": 475 } }, { "content": "Background mortality, there is an inconsistent downward trend.\n Maternal hypertensive disease has reached the level of\n Hypertensive disorders of pregnancy (HDP) as a \n the top second cause of maternal mortality as recently\n group, is one of the leading causes of both maternal \n as 2009 followed by a clearly observed down-trend\n and foetal perinatal mortality/morbidity and resultant \n until 2019, finally posting a fourth-highest cause of\n long term-disability. It accounts for approximately 14% \n maternal mortality in Sri Lanka\n3. \n of all maternal deaths globally\n1.", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_004", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 83, "chunk_size": 572 } }, { "content": "maternal mortality in Sri Lanka\n3. \n of all maternal deaths globally\n1. \n Preeclampsia complicates an approximate 2-8% of\n Hypertensive disorders of pregnancy broadly define a \n pregnancies world-wide. Even in resource-high\n group of conditions closely associated with high blood \n countries, there has been an observed increase in the\n pressure, proteinuria and/or seizures during pregnancy. \n maternal deaths that can be attributed to hypertensive\n Eclampsia is usually a consequence of pre-eclampsia \n disorders\n2. \n consisting of central nervous system seizures which", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_004", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 1, "word_count": 77, "chunk_size": 571 } }, { "content": "disorders\n2. \n consisting of central nervous system seizures which \n often leave the patient unconscious. If untreated, it \n Hypertensive disease is one of the causes that could\n can subsequently lead to death. \n be significantly modified to decrease its negative impact\n on maternal and neonatal health. This guideline is\n The serious consequences of such pre-eclampsia and \n developed to aid in the dissemination of information\n eclampsia are associated with vasospasm, pathologic \n with this objective in mind. \n vascular lesions in multiple organ systems, increased", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_004", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 2, "word_count": 80, "chunk_size": 569 } }, { "content": "with this objective in mind. \n vascular lesions in multiple organ systems, increased \n platelet activation and subsequent activation of the \n Pathophysiology \n coagulation cascade in the microvasculature\n2. \n During an average pregnancy blood pressure generally\n In Sri Lanka, hypertensive disease has remained among falls by a detectable level in the first trimester and\n the top five causes of maternal mortality for the last usually reaches a lowest level in the second trimester.\n two decades\n3. While it has trended down in its It then rises back up to preconception pressure levels", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_004", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 3, "word_count": 89, "chunk_size": 587 } }, { "content": "3. While it has trended down in its It then rises back up to preconception pressure levels\n significance as one of the top causes of maternal at term gestation. \n Sri Lanka Journal of Obstetrics and Gynaecology 2022; 44: 65-73 \n DOI: http://doi.org/10.4038/sljog.v44i1.8046 \n a Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka\n bConsultant Obstetrician and Gynaecologist, Castle Street Hospital for Women, Colombo 8, Sri Lanka\n c Professor in Obstetrics and Gynaecology Department of Obstetrics and Gynaecology,\n University of Colombo, Sri Lanka", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_004", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 4, "word_count": 82, "chunk_size": 590 } }, { "content": "University of Colombo, Sri Lanka \n dConsultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka\n e Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka\n Vol. 44, No. 1, March 2022 65", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_004", "page_number": 1, "content_type": "maternal_care", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 5, "word_count": 35, "chunk_size": 257 } }, { "content": "================================================== PAGE 3 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_005", "page_number": 2, "content_type": "guidelines", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Hypertensive disorders of pregnancy are classified \n• Platelet count (Less than 100 × 109 /l )\n by SLCOG as \n \n• Liver profile (Elevation of liver transaminases twice\n \n1. Preeclampsia – Pregnancy specific disorder with the normal value) \n Hypertension cured following the delivery of the \n \n• Renal insufficiency (creatinine more than 1.1 mg/\n conceptus. \n dl or doubling of serum creatinine concentration\n observed in the absence of other renal disease)\n \n2. Chronic hypertension – Hypertension pre-existing \n the pregnancy due to various causes. \n• Exaggerated neurological reflexes", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_006", "page_number": 2, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 84, "chunk_size": 585 } }, { "content": "the pregnancy due to various causes. \n• Exaggerated neurological reflexes\n \n3. Preeclampsia – Superimposed on chronic \n• Pulmonary oedema \n hypertension. \n \n• Foetal indicators: Such as growth retardation,\n \n4. Hypertension discovered for the first-time during reduction in liquor volume, CTG and doppler\n pregnancy without clinical criteria necessary for waveform-abnormalities are allowed to be used for\n the diagnosis of preeclampsia – May or may not the diagnosis of preeclampsia\n7.\n disappear after delivery. \n It is the clinical experience that after making the", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_006", "page_number": 2, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 1, "word_count": 80, "chunk_size": 567 } }, { "content": "7.\n disappear after delivery. \n It is the clinical experience that after making the\n \n5. Supra-physiological hypertension – Exaggerated \n diagnosis of preeclampsia without proteinuria, most if\n physiological response in the latter part of the \n not all patients subsequently develop proteinuria during\n pregnancy in the presence of multiple pregnancies the time taken for management of such pregnancies.\n without other symptoms or signs of preeclampsia. Longer the time given, more developed the proteinuria.", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_006", "page_number": 2, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 2, "word_count": 70, "chunk_size": 508 } }, { "content": "Hypertension is defined in pregnancy as systolic blood In a case of preeclampsia, the aim is to control blood\n pressure greater than or equal to 140mmhg or a diastolic pressure values at about 140/90mmHg as further\n blood pressure of greater than or equal to 90mmHg or reduction has not shown to improve maternal or foetal\n more, or both, on two occasions at least 4 hours apart outcome in preeclampsia.\n after 20th weeks of gestation, in seated or left lateral \n position with at least ten minutes rest before the As in any medical condition, identifying risk categories", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_006", "page_number": 2, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 3, "word_count": 96, "chunk_size": 571 } }, { "content": "measurement was taken. for development of preeclampsia and taking actions to\n prevent the onset or worsening of the disease is of\n In a woman with a previously normal blood pressure, great importance. \n hypertension is considered to be severe when the \n systolic level reaches 160mmHg or the diastolic level The major risk factors for preeclampsia are;\n reaches 110mmHg with a mean arterial pressure of \n \n1. Preeclampsia in first pregnancy \n more than 130mmHg even on one occasion. \n \n2. Pre-existing renal disease \n Preeclampsia is defined as hypertension found for", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_006", "page_number": 2, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 4, "word_count": 86, "chunk_size": 567 } }, { "content": "2. Pre-existing renal disease \n Preeclampsia is defined as hypertension found for \n3. Autoimmune conditions such as APLS and SLE\n the first time during current pregnancy with significant \n \n4. Diabetes mellitus \n proteinuria (300mg per 24 hours or urine Protein/ \n Creatinine ratio of 30 mg/mmol or more)\n7. If urine \n5. Pre-existing hypertension\n albumin to creatinine ratio is considered an alternative \n for the diagnosis of significant proteinuria, the cut-off Any of the above factors are considered to be major", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_006", "page_number": 2, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 5, "word_count": 77, "chunk_size": 516 } }, { "content": "value of 8mg /mmol is taken as the value for con- indicators for the risk. Therefore, instituting antiplatelet\n sideration\n7. therapy in the form of 75-150mg of aspirin is\n recommended\n8. \n It is not essential to have significant proteinuria for the \n Undermentioned factors are considered lesser risk\n diagnosis of preeclampsia (although it is the most \n factors for occurrence of preeclampsia. \n commonly used supportive evidence for preeclampsia \n in the presence of significant hypertension). However, \n In the presence of more than one such condition, it is", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_006", "page_number": 2, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 6, "word_count": 84, "chunk_size": 562 } }, { "content": "In the presence of more than one such condition, it is\n the absence of significant proteinuria, other parameters \n advisable to start antiplatelet treatment in the form of\n as given below with preeclampsia-specific organ \n 75-150 mg of aspirin from early second trimester until\n involvement could use for the diagnosis of Preec- \n the birth of the baby. \n lampsia. They are; \n 66 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_006", "page_number": 2, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 7, "word_count": 66, "chunk_size": 427 } }, { "content": "================================================== PAGE 4 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_007", "page_number": 3, "content_type": "guidelines", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "1. First pregnancy age 35 years old As in any case of medically important high blood\n pressure management, weight management, exercise,\n \n2. Pregnancy with an interval more than 10 years \n modification of life-style leading to a stress-free life-\n \n3. BMI more than 35 kg/m2 or more at first visit style with sufficient rest, is advocated in hypertension\n in pregnancy. \n \n4. Family history of preeclampsia \n \n5. Multiple pregnancies \n When drug therapy is considered, the following drugs\n are proven for their efficacy and for their safety profile", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_008", "page_number": 3, "content_type": "medication_dosage", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 85, "chunk_size": 548 } }, { "content": "are proven for their efficacy and for their safety profile\n It is said that prophylactic aspirin therapy for above \n for the foetus. There are two categories of drugs. First\n risk categories are preventive of preterm preeclampsia \n used for long term control of blood pressure and the\n when aspirin is started between 12 and 20 weeks of \n second group of drugs are used for rapidly lowering\n gestation optimally before 16 weeks of gestation but it \n of blood pressure. \n has not shown to reduce term-preeclampsia6,\n7. Although \n there is some evidence for early calcium supple-", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_008", "page_number": 3, "content_type": "medication_dosage", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 1, "word_count": 93, "chunk_size": 577 } }, { "content": "7. Although \n there is some evidence for early calcium supple- \n Elevations of both systolic and diastolic blood pressures\n mentation in pregnancy with a favorable effect on \n are associated with negative maternal and foetal\n preeclampsia, there are no accepted guidance for such \n outcomes\n1. \n by other recognized colleges and bodies6,\n7. \n Control of blood pressure during \n It is recommended that achieving better control of pre- \n existing hypertension prior to planned pregnancy is Pregnancy \n beneficial. This has proven value in literature\n7. There", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_008", "page_number": 3, "content_type": "medication_dosage", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 2, "word_count": 81, "chunk_size": 556 } }, { "content": "beneficial. This has proven value in literature\n7. There \n Once blood pressure elevation is diagnosed during\n are no recommendations for salt restriction to prevent \n pregnancy be it pre-existing hypertension or preec-\n preeclampsia or hypertension in pregnancy\n6. \n lampsia, the drugs used are not different. However,\n subcategories of safe medications, if taken by the\n Control of blood pressure before patient prior to the pregnancy, need not change if that\n pregnancy is safe in pregnancy (eg. metoprolol, verapamil, sotalol,\n carvedilol etc.) \n It is recommended that any woman contemplating", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_008", "page_number": 3, "content_type": "medication_dosage", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 3, "word_count": 86, "chunk_size": 596 } }, { "content": "carvedilol etc.) \n It is recommended that any woman contemplating \n pregnancy, if possible, to have a preconception-health \n Two types of medications are used for treatment of\n check, including the measurement of blood pressure. \n Hypertension in pregnancy: \n This is more important when the maternal age is \n \n1. Long-term control of blood pressure \n advanced (more than 35 years), history of renal disease, \n \n2. Rapid lowering of blood pressure. \n relevant medical disorders or with family history of \n early onset hypertensive disorders. If hypertension is", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_008", "page_number": 3, "content_type": "medication_dosage", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 4, "word_count": 80, "chunk_size": 560 } }, { "content": "early onset hypertensive disorders. If hypertension is \n observed, taking steps to control it is recommended Drugs used for long term control of blood\n as well as looking for any underlying pathology. \n pressure \n If essential hypertension or anything else is diagnosed, Taking the availability, cost and side effects of the drugs\n management should be aimed at controlling the blood available in Sri Lanka, the drug of choice for control\n pressure to equal to less than 140/90, using anti- of blood pressure in pregnancy is oral nifedipine slow", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_008", "page_number": 3, "content_type": "medication_dosage", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 5, "word_count": 86, "chunk_size": 545 } }, { "content": "hypertensives considered safe in pregnancy. Any release tablets followed by methyldopa and labetalol\n6.\n woman with the possibility of being pregnant planned \n or otherwise, should avoid ACE Inhibitors or AR Regarding pharmacotherapy for rapidly lowering of\n Blockers. blood pressure in preeclampsia, use of hydralazine IV\n and labetalol IV or oral nifedipine is discussed in our\n If a woman gets pregnant while on ACE inhibitors or previous guidance\n10. \n ARBs, take steps to stop such medications immediately", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_008", "page_number": 3, "content_type": "medication_dosage", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 6, "word_count": 76, "chunk_size": 510 } }, { "content": "10. \n ARBs, take steps to stop such medications immediately \n and offer suitable alternatives. Hydrochlorothiazide is Labetalol IV is very scarce in Sri Lanka. However, it is\n not recommended for this category of women as it to be considered the drug of choice in the absence of\n has shown increased risk of congenital abnormalities contraindications, for use in the presence of tachy-\n and complications of the neonate when the drug is cardia as a manifestation of preeclampsia. IV hydra-\n used in pregnancy. lazine could make the condition of tachycardia worse.\n Vol. 44, No. 1, March 2022 67", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_008", "page_number": 3, "content_type": "medication_dosage", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 7, "word_count": 96, "chunk_size": 594 } }, { "content": "================================================== PAGE 5 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_009", "page_number": 4, "content_type": "guidelines", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Nifedipine used in rapidly controlling blood pressure Cochrane review on all three drugs recently showed\n is quick-release nifedipine which is not commonly no difference between the efficacy12,\n13.\n available in Sri Lanka.", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_010", "page_number": 4, "content_type": "medication_dosage", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 32, "chunk_size": 222 } }, { "content": "Table \n1. Outline of drugs commonly used in control of hypertension14", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_011", "page_number": 4, "content_type": "medication_dosage", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 11, "chunk_size": 69 } }, { "content": "Drug – Mechanism Dose Contraindications Notes \n of action \n \n Methyldopa – 250-750 mg Depression Slow onset of action \n Centrally acting three times a day over 24 hours \n \n dry mouth \n sedation \n depression \n blurred vision \n Withdrawal: rebound \n \n hypertension \n \n Labetolol – Beta blocker 100-400 mg Asthma Bradycardia \n \n with mild alpha every 8 hours Chronic airways Bronchospasm \n vasodilator effect limitation (COPD) Headache \n Nausea \n Scalp tingling \n (labetolol oly) \n \n which usually resolves \n within 24 hours", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_012", "page_number": 4, "content_type": "medication_dosage", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 68, "chunk_size": 521 } }, { "content": "Nifedipine – Calcium 20-60 mg Aortic stenosis Severe headache in first\n channel antagonist slow release 24 hours \n twice a day Flushing \n Tachycardia \n Peripheral oedema \n \n Constipation \n \n Hydralazine – Vasodilator 25-50 mg Flushing \n \n every 8 hours Headache \n Nausea \n Lupus-like syndrome", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_013", "page_number": 4, "content_type": "medication_dosage", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 38, "chunk_size": 292 } }, { "content": "68 Sri Lanka Journal of Obstetrics and Gynaecology", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_014", "page_number": 4, "content_type": "general", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 50 } }, { "content": "================================================== PAGE 6 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_015", "page_number": 4, "content_type": "guidelines", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Management of hypertension detected for of hypertension, until completion of 37 weeks of\n the first time in pregnancy gestation, all patient’s clinical characteristics need to\n be considered in deciding the time of delivery. This\n Mild to moderate hypertension \n includes available infrastructure facilities of neonatal\n It is advised to check blood pressure in seated or left \n care, availability of the theater and available manpower\n lateral position with an appropriate blood pressure cuff, \n resources. \n with an accurate mechanical or mercury sphyg-", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_016", "page_number": 4, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 79, "chunk_size": 555 } }, { "content": "resources. \n with an accurate mechanical or mercury sphyg- \n momanometer, four hours apart for the confirmation \n In the absence of proteinuria and derangement of other\n of the diagnosis. \n above mentioned laboratory parameters identified as\n indicators of preeclampsia before the 35th week of\n Once the diagnosis is confirmed of hypertension, basic \n pregnancy, prediction of onset of preeclampsia can\n preeclampsia screening should be carried on. \n be done using PlGF (Placental Growth Factor) alone\n or in comparison with soluble fms-like tyrosine kinase\n This includes", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_016", "page_number": 4, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 1, "word_count": 80, "chunk_size": 572 } }, { "content": "or in comparison with soluble fms-like tyrosine kinase\n This includes \n (sFlt-1). These blood tests are widely available for\n \n• Urine Full Report \n use in developed countries. Results from PELICAN\n \n• Urine Culture and Antibiotic Sensitivity Test \n study (Table 2) show a cut off value of 100 picogram/\n \n• Urine Protein Quantification ml for PlGF as a high sensitivity test for women heading\n \n• Full Blood Count for preeclampsia which needs delivery within 14 days\n of the test. \n \n• Blood Picture \n \n• Serum Creatinine \n The negative result would give confidence for\n \n• Liver Profile", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_016", "page_number": 4, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 2, "word_count": 93, "chunk_size": 588 } }, { "content": "• Serum Creatinine \n The negative result would give confidence for\n \n• Liver Profile \n outpatient management of women with hypertension\n \n• PT/INR is indicated only when other investigations with pregnancy. As these tests are not available in Sri\n are showing liver involvement Lanka, SLCOG Guidance Committee suggests\n outpatient management with no less than 14 days\n Uric acid is not usually tested. Though some suggest review appointments for women with hypertension in\n predictive value of uric acid level interpreted in relation pregnancy in the absence of any other maternal, foetal,", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_016", "page_number": 4, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 3, "word_count": 88, "chunk_size": 589 } }, { "content": "to the gestation to correlate better with adverse biochemical or ultrasound scan derangement of\n events14,\n15. significance. The blood pressure control also need to\n be at a level for the satisfaction of the obstetrician\n It is mandatory to check for foetal wellbeing with concerned. \n ultrasound scanning with emphasis on foetal biophysical \n profile, foetal doppler parameters and growth para- Though the 2019 NICE guideline gives an aim of\n meters. Further monitoring of foetus with a cardio- keeping control of blood pressure 135/85 mmHg, there", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_016", "page_number": 4, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 4, "word_count": 83, "chunk_size": 548 } }, { "content": "tocographic tracing is essential. These would give an is controversy about the control need for mild to\n assessment of possible foetal effects of preeclampsia. moderate hypertension in pregnancies even with\n In some cases foetal effects maybe the most significant preeclampsia. Treatment of blood pressure has not been\n finding other than the presence of hypertension. shown to have prevented preeclampsia or perinatal\n outcomes. But the evidence shows reduction of\n Aim of management is to achieve maximum possible development of severe blood pressure among treated", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_016", "page_number": 4, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 5, "word_count": 83, "chunk_size": 566 } }, { "content": "maturity of the foetus with no reasonable threat to the women with mild blood pressure. Approximately 10\n mother and the foetus. When the gestation is less than women need to be put on antihypertensive therapy to\n 34 weeks, the opinion is that it is unlikely to be prevent one episode of severe hypertension\n11.\n favourable for achieving vaginal delivery though there \n are no contraindications for vaginal delivery because However, uncontrolled spikes of blood pressure in\n of the condition preeclampsia per se. untreated pregnancies may prompt action for delivery.", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_016", "page_number": 4, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 6, "word_count": 88, "chunk_size": 566 } }, { "content": "of the condition preeclampsia per se. untreated pregnancies may prompt action for delivery.\n Therefore, achieving blood pressure control by\n In the presence of hypertension, be it preeclampsia or pharmaco-therapeutic means would facilitate prolon-\n not, delivery should be aimed at the completion of the gation of the pregnancy to achieve greater maturity of\n 37th week of pregnancy. From the first time of detection the foetus. \n Vol. 44, No. 1, March 2022 69", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_016", "page_number": 4, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 7, "word_count": 71, "chunk_size": 460 } }, { "content": "================================================== PAGE 7 ==================================================\nSLCOG Guideline", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_017", "page_number": 5, "content_type": "guidelines", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 6, "chunk_size": 124 } }, { "content": "Table \n2. PELICAN 2013 study results: Triage PlGF (Placental Growth Factor) test accuracy for\n predicting preeclampsia needing delivery within 14 days for women presenting between\n 20 weeks and 34 weeks plus 6 days gestation7", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_018", "page_number": 5, "content_type": "maternal_care", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 34, "chunk_size": 225 } }, { "content": "Test cut-off Sensitivity Specificity PPV NPV \n (95% CI) (95% CI) (95% CI) (95% CI) \n \n <100pg/ml 0.96 .56 .44 .98 \n (0.89 to 0.99) (0.46 - 0.63) (0.36 to 0.52) (0.93 to 1.00)", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_019", "page_number": 5, "content_type": "general", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 31, "chunk_size": 174 } }, { "content": ">/= 100pg/ml 0.96 .56 .43 .98 \n (0.89 to 0.99) (0.49 to 0.63) (0.36 to 0.51) (0.93 to 1.00)", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_020", "page_number": 5, "content_type": "general", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 18, "chunk_size": 91 } }, { "content": " Date accessed 03/03/2022 \n11. Lowe S, Bowyer L, Lust K, McMahon L, Morton\n M, North R, Paech M, Said J. \n2014. The SOMANZ", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_029", "page_number": 8, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 0, "word_count": 77, "chunk_size": 588 } }, { "content": "11. Lowe S, Bowyer L, Lust K, McMahon L, Morton\n M, North R, Paech M, Said J. \n2014. The SOMANZ\n \n4. Family Health Bureau, Ministry of Health Sri Lanka, \n Guideline for the Management of Hypertensive\n 2019 Report, Date \n Available at: [Accessed\n \n5. Brown MA, Lindheimer MD, de Swiet M, Assche \n 18 March 2022]. \n AV, Moutquin J-M. The classification and diagnosis", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_029", "page_number": 8, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 1, "word_count": 71, "chunk_size": 570 } }, { "content": "18 March 2022]. \n AV, Moutquin J-M. The classification and diagnosis \n \n12. Duley L, MEher S, Jones L. Drugs for treatment\n of the hypertensive disorders of pregnancy: \n statement from the international society for the of very high blood pressure during pregnancy.\n study of hypertension in pregnancy (ISSHP). Cochrane-Database of Systemic Reviews 2013,\n Hypertens Pregnancy 2001; 20 (1): ix-xiv Issue \n7. Art. No.: CD\n001449. (Systemic Review\n and Meta-Analysis) \n \n6. Gestational Hypertension and Preeclampsia. Acog \n Practice Bulletin Number \n202. American College", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_029", "page_number": 8, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 2, "word_count": 79, "chunk_size": 567 } }, { "content": "Practice Bulletin Number \n202. American College \n13. Emergent therapy for acute-onset, severe\n of Obstetricians and Gynecologists. Obstet hypertension during pregnancy and the postpartum\n Gynecol 2019; 133: No.1 period. Committee Opinion No. \n692. American\n College of Obstetricians and Gynecologists,\n \n7. Nice.org.uk. June 25, \n2019. Overview | Hyper- \n Monster Gynecol 2017: 129: e90-\n5. (Level III)\n tension in pregnancy: diagnosis and management | \n Guidance | NICE. [online] Available at: [Accessed 22 Aarnoudse JG, van den Berg PP, Mol BW.\n March 2022] Accuracy of serum uric acid as a predictive test\n for maternal complications in pre-eclampsia:\n \n8. Rolnik DL, Wright D, Poon LC, O’Gorman N, \n bivariate meta-analysis and decision analysis,\n Syngelaki A, de Paco Matallana C, et al. Aspirin \n European Journal of Obstetrics, Gynecology &\n versus placebo in pregnancies at high risk for \n Reproductive Biology 2009; 146(1): 8-\n14.", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_029", "page_number": 8, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 4, "word_count": 85, "chunk_size": 569 } }, { "content": "versus placebo in pregnancies at high risk for \n Reproductive Biology 2009; 146(1): 8-\n14.\n preterm preeclampsia. N Engl J Med 2017; 377: \n 613-\n22. \n15. Lind T, Godfrey KA, Otun H, Philips PR. Changes\n \n9. Hofmeyr GJ, Lawrie TA, Atallah AN, Duley L, in serum uric acid concentrations during normal\n Torloni MR. Calcium supplementation during pregnancy. British Journal of Obstetrics &\n pregnancy for preventing hypertensive disorders Gynaecology 1984; 91 (2): 128-\n32.\n and related problems. Cochrane Database of \n \n16. Abalos E, Duley L, Steyn DW, Henderson-Smart\n Systemic Reviews 2014, Issue", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_029", "page_number": 8, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 5, "word_count": 90, "chunk_size": 595 } }, { "content": "16. Abalos E, Duley L, Steyn DW, Henderson-Smart\n Systemic Reviews 2014, Issue \n6. Art. No.: \n DJ. Antihypertensive drug therapy for mild to\n CD\n001059. (Systematic Review and Meta- \n moderate hypertension during pregnancy.\n Analysis) \n Cochrane Database of Systematic Reviews 2007\n \n10. Senadheera D, Jayasundara DMSC, Jayawardane, (1): CD\n002252. \n Vol. 44, No. 1, March 2022 73", "metadata": { "document_name": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "section": "Section_029", "page_number": 8, "content_type": "clinical_protocol", "source_file": "SLJOG-March-2022-Page-65-73-Final-1.pdf", "chunk_index": 6, "word_count": 55, "chunk_size": 380 } }, { "content": "================================================== PAGE 1 ==================================================\nManagement Rhesus Negative Mother", "metadata": { "document_name": "RhESUS.pdf", "section": "Section_000", "page_number": 1, "content_type": "clinical_protocol", "source_file": "RhESUS.pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 142 } }, { "content": "Routine blood test Identification of Rh-negative mother \n \n Check unexpected antibody levels at A titre of >1:4 \n booking visit, 28,32 and 36 weeks of POA \n First sensitized\n pregnancy. \n Non-sensitized mother Sensitized \n Already mother (Previously \n sensitized \n affected \n Initial procedure is determined by past clinical history. Usually performed at least 4-8 weeks earlier than the previous\n o No potentially sensitizing events point of Significant morbidity due to pregnancy) \n 1ST \n o Threatened miscarriage before Early pregnancy previous \n TRIMESTER 12 weeks complications event", "metadata": { "document_name": "RhESUS.pdf", "section": "Section_001", "page_number": 1, "content_type": "clinical_protocol", "source_file": "RhESUS.pdf", "chunk_index": 0, "word_count": 78, "chunk_size": 588 } }, { "content": "o Threatened miscarriage before Early pregnancy previous \n TRIMESTER 12 weeks complications event \n o Suspected Before 20 Check \n 20 WEEKS \n termination w \n D \n e \n I \n e \n g \n k \n - \n s \n 2 5 \n A \n 0 \n n \n I \n t \n U \n i- p \n b \n a \n lo \n r \n o \n tn \n d \n e rs \n o Ectopic \n 24 WEEKS pregnancy After 20 Rh positive Rh negative \n ROUT INE \n o Sp \n m \n on \n is \n ta \n c \n n \n ar \n e \n r \n o \n ia \n u \n g \n s \n e \n w \n D \n e \n I \n e \n g \n k \n - \n s \n 5 0 \n A \n 0 \n n \n I \n t \n U \n i- P \n se \n o \n n \n t \n s \n e \n i \n n \n ti \n t \n z \n ia \n i \n l \n n \n l \n g \n y \n events Anti-D Ig- \n N \n In \n o \n v e", "metadata": { "document_name": "RhESUS.pdf", "section": "Section_001", "page_number": 1, "content_type": "clinical_protocol", "source_file": "RhESUS.pdf", "chunk_index": 1, "word_count": 123, "chunk_size": 596 } }, { "content": "s \n e \n i \n n \n ti \n t \n z \n ia \n i \n l \n n \n l \n g \n y \n events Anti-D Ig- \n N \n In \n o \n v e \n F \n s \n u \n ti \n r \n g \n th \n a \n e \n ti \n r \n o ns \n CARE o Threatened o Antepartum 500 IU \n 2ND After m 1 is 2 c w ar e r e ia k g s e - TE F S M T F H O R o H Ex a t e e m rn o a r l r h c a e g p e h alic I ≤ A 1: T 3 2 t iter I > A A 1 lb T :3 u 2 t m i / t e inp r atritten C re h r ’ e s c b k l ood I ≥ A 1 T :6 4 titer\n TRIMESTER Anti-D Ig-500 version >1:16 \n 28WEEKS 28w \n IU \n ee ks o Closed abdominal Repeat Amniocent \n injury antibody esis every \n 3RD titers every 2-3 weeks", "metadata": { "document_name": "RhESUS.pdf", "section": "Section_001", "page_number": 1, "content_type": "clinical_protocol", "source_file": "RhESUS.pdf", "chunk_index": 2, "word_count": 164, "chunk_size": 584 } }, { "content": "injury antibody esis every \n 3RD titers every 2-3 weeks \n Anti-D Ig-500 >4ml Red o Intrauterine death 2-4 weeks \n TRIMESTER IU cells \n 32weeks \n o \n Invasive perinatal \n diagnosis \n Additional anti-D Ig The dose to be \n administered should assume that 500iu \n LABOUR of anti-D Ig IVwill \n suppress immunization by 8-10 ml of \n fetal RBC \n Post Partum management \nPOST \n FMH test in (Kleihauer acid elution test), \n Cord blood for, Anti-D Ig \nPARTUM \n Traumatic delivery-LSCS \n o 2ml (Plain bottle)-Grouping & Rh. recommended \n Manual removal of placenta.", "metadata": { "document_name": "RhESUS.pdf", "section": "Section_001", "page_number": 1, "content_type": "clinical_protocol", "source_file": "RhESUS.pdf", "chunk_index": 3, "word_count": 81, "chunk_size": 554 } }, { "content": "o 2ml (Plain bottle)-Grouping & Rh. recommended \n Manual removal of placenta. \n o 2ml (EDTA bottle)-Fetal Hb. because of Norisk \n Stillbirth/IUD. \n o 2ml (Plain bottle)-Serum bilirubin silent FMH Atrisk \n Abdominal trauma in 3rd trimester. \n Sri Lanka C G ol y le n g a e e c o o f l o O g b y s tetrics and o 2ml (Plain bottle)-Direct Coomb’s test. Twin pregnancy (At delivery) Investigation\n Health sector development Project o 2ml (EDTA bottle)-Reticulocyte count \n Guidelines- Management Rhesus Negative Unexplained Hydrops Fetalis \n Mother \n Documenattion\n Mandatory\n Initial procedure is", "metadata": { "document_name": "RhESUS.pdf", "section": "Section_001", "page_number": 1, "content_type": "clinical_protocol", "source_file": "RhESUS.pdf", "chunk_index": 4, "word_count": 91, "chunk_size": 593 } }, { "content": "Mother \n Documenattion\n Mandatory\n Initial procedure is\n determined by past clinical\n history. Usually performed at least\n 4-8 weeks earlier\n than the previous\n point of\n Significant morbidity\n FMH-Feto-Maternal\n Transfusion \n IAT-Indirect Antibody\n Test", "metadata": { "document_name": "RhESUS.pdf", "section": "Section_001", "page_number": 1, "content_type": "clinical_protocol", "source_file": "RhESUS.pdf", "chunk_index": 5, "word_count": 30, "chunk_size": 254 } }, { "content": "================================================== PAGE 1 ==================================================\nManagement of Breech Presentation", "metadata": { "document_name": "Breech.pdf", "section": "Section_000", "page_number": 1, "content_type": "clinical_protocol", "source_file": "Breech.pdf", "chunk_index": 0, "word_count": 8, "chunk_size": 142 } }, { "content": "Clinical \n \n• Abdominal examination: the head of the fetus is in \n the upper part of the uterus. \n Ultra sound \n \n• Auscultation locates the fetal heart at a higher \n location than expected with a vertex presentation. \n• conform the presenting part\n \n• localizatiion of placenta \n \n• Vaginal examination: the buttocks and/or feet are \n• exclusion of \n felt. Thick, dark meconium is normal when abnormalities,etc. \n membranes rupture in the second stage of labour. \n THE DIAGNOSIS OF BREECH CONFIRMED", "metadata": { "document_name": "Breech.pdf", "section": "Section_001", "page_number": 1, "content_type": "clinical_protocol", "source_file": "Breech.pdf", "chunk_index": 0, "word_count": 76, "chunk_size": 499 } }, { "content": "external cephalic \n version (ECV) \n \n uncomplicated ( no extended or \n flexed leg) breech presentation \n at term \n 38 weeks \n \n Delivery \n lateof \n cinortcelE \n )MFE( \n gnirotinom \n prior to 36 \n completed \n Absolute indications for \n Caesarean section \n Feto-pelvic disproportion \n -When the fetal weight is estimated to \n be 3.8 kg or more \n Major degree placenta praevia \n Pelvic or uterine tumors preventing \n descent of presenting part. \n Major degrees of pelvic deformities. \n Vaginal delivery \n Documentation\n Mandatory \n External \n cephalic \n version not \n recommended1 Wait till 36", "metadata": { "document_name": "Breech.pdf", "section": "Section_002", "page_number": 1, "content_type": "clinical_protocol", "source_file": "Breech.pdf", "chunk_index": 0, "word_count": 75, "chunk_size": 590 } }, { "content": "Documentation\n Mandatory \n External \n cephalic \n version not \n recommended1 Wait till 36 \n completed weeks \n 36 weeks \n May be offered tocolysis \n (with beta mimetic drugs) \n to increase the success of \n external cephalic version \n (ECV) \n complicated (extended or \n flexed leg) breech presentation\n at term \n Relative indications for \n Caesarean section \n No indication \n for L.S.C.S Intrauterine growth restriction. \n Previous uterine scar \n Hyperextension of the fetal head \n (Star gazer) \n -When the head cannot be flexed \n Small pelvis or suspicious pelvic \n adequacy \n Footling presentation", "metadata": { "document_name": "Breech.pdf", "section": "Section_002", "page_number": 1, "content_type": "clinical_protocol", "source_file": "Breech.pdf", "chunk_index": 1, "word_count": 76, "chunk_size": 596 } }, { "content": "Small pelvis or suspicious pelvic \n adequacy \n Footling presentation \n Gestation less than 34 weeks \n Indication for \n Caesarean section \n LS.C.S \n present \n Informed \n Decision \n Makingis \n Essential \n X-ray of the \n pelvis to \n confirm \n presentation is \n to be avoided. \n Unsuccessful \n Sri Lanka College of Obstetrics and Gynaecology\n Health sector development Project\n Guidelines- Management of breech presentation", "metadata": { "document_name": "Breech.pdf", "section": "Section_002", "page_number": 1, "content_type": "clinical_protocol", "source_file": "Breech.pdf", "chunk_index": 2, "word_count": 51, "chunk_size": 419 } } ]