{"id":7444,"date":"2026-06-20T03:18:20","date_gmt":"2026-06-20T03:18:20","guid":{"rendered":"https:\/\/gothi.gov.eg\/?page_id=7444"},"modified":"2026-06-20T03:24:07","modified_gmt":"2026-06-20T03:24:07","slug":"%d8%b7%d8%a8-%d9%86%d8%b3%d8%a7%d8%a1-%d9%88%d8%aa%d9%88%d9%84%d9%8a%d8%af","status":"publish","type":"page","link":"https:\/\/gothi.gov.eg\/?page_id=7444","title":{"rendered":"\u0637\u0628 \u0646\u0633\u0627\u0621 \u0648\u062a\u0648\u0644\u064a\u062f"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"7444\" class=\"elementor elementor-7444\" 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class=\"elementor-element elementor-element-8ddfb63 e-flex e-con-boxed e-con e-parent\" data-id=\"8ddfb63\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3a419a47 elementor-widget elementor-widget-text-editor\" data-id=\"3a419a47\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\n<ol class=\"wp-block-list\">\n<li><\/li>\n<\/ol>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-4209050 e-flex e-con-boxed e-con e-parent\" data-id=\"4209050\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7dcb9cc elementor-widget__width-initial elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"7dcb9cc\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation_delay&quot;:250,&quot;_animation&quot;:&quot;fadeInUp&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">\u0637\u0628 \u0646\u0633\u0627\u0621 \u0648\u062a\u0648\u0644\u064a\u062f\n<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b45d451 ui-e-animation-acc-basic ui-e-animation-ico-fade elementor-widget elementor-widget-uicore-accordion\" data-id=\"b45d451\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;collapsible&quot;:&quot;true&quot;,&quot;active_hash&quot;:&quot;no&quot;,&quot;accordion_animation&quot;:&quot;ui-e-animation-acc-basic&quot;}\" data-widget_type=\"uicore-accordion.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t        <div class=\"ui-e-accordion\" >\n\n                            <div class=\"ui-e-accordion-item ui-e-item ui-open\" role=\"button\" tabindex=\"0\" aria-expanded=\"true\" aria-controls=\"ui-e-acc-1\" id=\"ui-e-non-clinical-interventions-to-reduce-overall-cesarean-sections\">\n\n                    <h5 class=\"ui-e-accordion-title ui-e-title ui-right\">\n\n                                                    <span class=\"ui-e-accordion-icon ui-e-icon ui-e-right\" aria-hidden=\"true\">\n\n                                <span class=\"ui-e-accordion-icon-closed\">\n                                    <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-down\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M207.029 381.476L12.686 187.132c-9.373-9.373-9.373-24.569 0-33.941l22.667-22.667c9.357-9.357 24.522-9.375 33.901-.04L224 284.505l154.745-154.021c9.379-9.335 24.544-9.317 33.901.04l22.667 22.667c9.373 9.373 9.373 24.569 0 33.941L240.971 381.476c-9.373 9.372-24.569 9.372-33.942 0z\"><\/path><\/svg>                                <\/span>\n\n                                                                    <span class=\"ui-e-accordion-icon-opened\">\n                                        <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-up\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M240.971 130.524l194.343 194.343c9.373 9.373 9.373 24.569 0 33.941l-22.667 22.667c-9.357 9.357-24.522 9.375-33.901.04L224 227.495 69.255 381.516c-9.379 9.335-24.544 9.317-33.901-.04l-22.667-22.667c-9.373-9.373-9.373-24.569 0-33.941L207.03 130.525c9.372-9.373 24.568-9.373 33.941-.001z\"><\/path><\/svg>                                    <\/span>\n                                \n                            <\/span>\n                        \n                                                <span class=\"ui-e-accordion-title-text ui-e-title-text\" >\n                                                        Non-Clinical Interventions to reduce overall cesarean sections                        <\/span>\n\n                    <\/h5>\n\n                    <div class=\"ui-e-accordion-content ui-e-content\" style=\"\" aria-labelledby=\"ui-e-non-clinical-interventions-to-reduce-overall-cesarean-sections\" id=\"ui-e-acc-1\">\n                        <div id=\"yui_3_18_1_1_1781924509337_20\" class=\"activity-header\" data-for=\"page-activity-header\">\n<div id=\"intro\" class=\"activity-description\">\n<div class=\"no-overflow\">\n<h5>&#8220;last update: 8 February 2024&#8221;\u00a0\u00a0<\/h5>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chaptersnavigation\">\n<div class=\"container-fluid tertiary-navigation\">\n<div class=\"row\">\n<div class=\"navitem ms-auto\">\u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chapter\" class=\"box py-3 generalbox book_content\">\n<h3 class=\" ccnMdlHeading\">&#8211; Executive summary<\/h3>\n<div class=\"no-overflow\">\n<p dir=\"ltr\">\u00a0<\/p>\n<p><strong><span lang=\"EN-GB\"><u>\u27a1\ufe0fIntroduction<\/u><\/span><\/strong><\/p>\n<p><span lang=\"EN\">The number of women who deliver by Cesarean section has increased steadily in Egypt over the last three decades, from 4.6% in 1992\u00a0<\/span><span lang=\"EN\">(1)<\/span><span lang=\"EN\">\u00a0to 51.8% in 2014\u00a0<\/span><span lang=\"EN\">(2)<\/span><span lang=\"EN\">.<\/span><\/p>\n<p><span lang=\"EN\">Cesarean birth is associated with short- and long-term risks that can extend many years beyond the current delivery and affect the health of the woman, the child, and future pregnancies. High rates of cesarean section are associated with substantial health-care costs\u00a0<\/span><span lang=\"EN\">(3)<\/span><span lang=\"EN\">.<\/span><\/p>\n<p><span lang=\"EN\">The factors contributing to the rise in cesarean section rates are complex, and identifying interventions to address them is challenging. Factors associated with cesarean births include changes in the characteristics of the population such as increase in the prevalence of multiple pregnancies, assisted reproduction, and increase in the proportion of nulliparous women with advanced age. Other non-clinical factors such as women increasingly wanting to determine how and when their child is born, generational shifts in work and family responsibilities, physician factors, increasing fear of medical litigation, as well as organizational, economic and social factors have all been implicated in this increase\u00a0<\/span><span lang=\"EN\">(4)<\/span><span lang=\"EN\">.<\/span><\/p>\n<p><span lang=\"EN\">The sustained, unprecedented rise in cesarean section rates in Egypt is a major public health concern. There is an urgent need for evidence-based guidance to address the trend. This is the national guideline on non-clinical interventions (defined as interventions applied independently of a clinical encounter between a health-care provider and a patient in the context of patient care).<\/span><\/p>\n<p><span lang=\"EN\">The objective of this guideline is to provide evidence-based recommendations on non-clinical interventions specifically designed to reduce cesarean sections. Clinical interventions that could help to reduce cesarean section rates are being prepared in a second guideline.<\/span><\/p>\n<p><strong><span lang=\"EN-GB\"><u>\u27a1\ufe0fTarget audience<\/u><\/span><\/strong><\/p>\n<p><span lang=\"EN\">The primary audience for this guideline includes health-care professionals including obstetricians, midwives, nurses, and general medical practitioners, as well as managers of maternal and child health programs and public health policymakers in Egypt.<\/span><\/p>\n<p><strong><span lang=\"EN-GB\"><u>\u27a1\ufe0fGuideline development methods<\/u><\/span><\/strong><\/p>\n<p><span lang=\"EN\">We used the GRADE-Adolopment methodology for the guideline adaptation process\u00a0<\/span><span lang=\"EN\">(5)<\/span><span lang=\"EN\">. Briefly, this included, identifying and training guideline panelists, prioritizing questions and outcomes, identifying existing guideline\u00a0<\/span><span lang=\"EN\">(6)<\/span><span lang=\"EN\">, assessing quality and adaptability of the identified guideline, reviewing GRADE evidence tables and EtD frameworks, and formulating and grading strength of recommendations.<\/span><\/p>\n<p><span lang=\"EN\">The identified existing guideline was developed by the WHO in accordance with standard procedures set out in the WHO\u00a0<i>handbook for guideline development\u00a0<\/i><\/span><i><span lang=\"EN\">(7)<\/span><\/i><i><span lang=\"EN\">.<\/span><\/i><span lang=\"EN\">\u00a0The evidence, in the identified guideline, on the effectiveness of interventions was derived from an updated Cochrane review of 29 studies\u00a0<\/span><span lang=\"EN\">(8)<\/span><span lang=\"EN\">.\u00a0<\/span><\/p>\n<br \/>\n<p>\u00a0<\/p>\n<\/div>\n<\/div>\n<div class=\"mt-5 mb-5 activity-navigation\">\n<div class=\"row\">\n<div class=\"col-md-4\">\n<div class=\"float-left ui_kit_btn\">\u00a0<\/div>\n<\/div>\n<div class=\"col-md-4\">\n<div class=\"mdl-align\">\n<div class=\"urlselect\"><label class=\"sr-only\" for=\"jump-to-activity\">Jump to activity<\/label><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>                    <\/div>\n\n                <\/div>\n                            <div class=\"ui-e-accordion-item ui-e-item\" role=\"button\" tabindex=\"0\" aria-expanded=\"false\" aria-controls=\"ui-e-acc-2\" id=\"ui-e-rationalizing-the-use-of-caesarean-section-in-egypt-through-implementing-10-group-classification-system\">\n\n                    <h5 class=\"ui-e-accordion-title ui-e-title ui-right\">\n\n                                                    <span class=\"ui-e-accordion-icon ui-e-icon ui-e-right\" aria-hidden=\"true\">\n\n                                <span class=\"ui-e-accordion-icon-closed\">\n                                    <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-down\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M207.029 381.476L12.686 187.132c-9.373-9.373-9.373-24.569 0-33.941l22.667-22.667c9.357-9.357 24.522-9.375 33.901-.04L224 284.505l154.745-154.021c9.379-9.335 24.544-9.317 33.901.04l22.667 22.667c9.373 9.373 9.373 24.569 0 33.941L240.971 381.476c-9.373 9.372-24.569 9.372-33.942 0z\"><\/path><\/svg>                                <\/span>\n\n                                                                    <span class=\"ui-e-accordion-icon-opened\">\n                                        <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-up\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M240.971 130.524l194.343 194.343c9.373 9.373 9.373 24.569 0 33.941l-22.667 22.667c-9.357 9.357-24.522 9.375-33.901.04L224 227.495 69.255 381.516c-9.379 9.335-24.544 9.317-33.901-.04l-22.667-22.667c-9.373-9.373-9.373-24.569 0-33.941L207.03 130.525c9.372-9.373 24.568-9.373 33.941-.001z\"><\/path><\/svg>                                    <\/span>\n                                \n                            <\/span>\n                        \n                                                <span class=\"ui-e-accordion-title-text ui-e-title-text\" >\n                                                        Rationalizing the use of caesarean section in Egypt through implementing 10 group Classification system                        <\/span>\n\n                    <\/h5>\n\n                    <div class=\"ui-e-accordion-content ui-e-content\" style=\"display:none;\" aria-labelledby=\"ui-e-rationalizing-the-use-of-caesarean-section-in-egypt-through-implementing-10-group-classification-system\" id=\"ui-e-acc-2\">\n                        <div id=\"yui_3_18_1_1_1781924530107_20\" class=\"activity-header\" data-for=\"page-activity-header\">\n<div id=\"intro\" class=\"activity-description\">\n<div class=\"no-overflow\">\n<h5>&#8220;last update: 12 June 2025\u00a0<strong>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0<\/strong><a href=\"https:\/\/lms.ehc.gov.eg\/lms\/pluginfile.php\/1311\/mod_book\/intro\/Rationalizing%20the%20use%20of%20caesarean%20section%20in%20Egypt%20through%20implementing%2010%20group%20Classification%20system.pdf\" target=\"_blank\" rel=\"noopener\"><u><strong>Download Guideline<\/strong><\/u><\/a><u><\/u><\/h5>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chaptersnavigation\">\n<div class=\"container-fluid tertiary-navigation\">\n<div class=\"row\">\n<div class=\"navitem ms-auto\">\u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chapter\" class=\"box py-3 generalbox book_content\">\n<h3 class=\" ccnMdlHeading\">&#8211; Objectives<\/h3>\n<div class=\"no-overflow\">\n<p dir=\"ltr\">\u00a0<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Be aware of the cs rate and its burden on health system .<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Help you to recognize the absolute indications of cs .<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Help you in assessing and validating the relative indications of CS.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Helps you to understand and implement the Robson Classification and build the Report Table using your own data<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Identify the complications of CS<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0To help healthcare facilities and obstetricians in adopting and using the Robson Classification. It presents a standard approach to implement and interpret this classification<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Explains the variables and definitions used and how to produce and interpret the Report Table<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Highlights challenges that you may encounter and shares useful experiences and examples from users<\/p>\n<\/div>\n<\/div>                    <\/div>\n\n                <\/div>\n                            <div class=\"ui-e-accordion-item ui-e-item\" role=\"button\" tabindex=\"0\" aria-expanded=\"false\" aria-controls=\"ui-e-acc-3\" id=\"ui-e-the-diagnosis-and-management-of-ectopic-pregnancy-pregnancy-of-unknown-location\">\n\n                    <h5 class=\"ui-e-accordion-title ui-e-title ui-right\">\n\n                                                    <span class=\"ui-e-accordion-icon ui-e-icon ui-e-right\" aria-hidden=\"true\">\n\n                                <span class=\"ui-e-accordion-icon-closed\">\n                                    <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-down\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M207.029 381.476L12.686 187.132c-9.373-9.373-9.373-24.569 0-33.941l22.667-22.667c9.357-9.357 24.522-9.375 33.901-.04L224 284.505l154.745-154.021c9.379-9.335 24.544-9.317 33.901.04l22.667 22.667c9.373 9.373 9.373 24.569 0 33.941L240.971 381.476c-9.373 9.372-24.569 9.372-33.942 0z\"><\/path><\/svg>                                <\/span>\n\n                                                                    <span class=\"ui-e-accordion-icon-opened\">\n                                        <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-up\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M240.971 130.524l194.343 194.343c9.373 9.373 9.373 24.569 0 33.941l-22.667 22.667c-9.357 9.357-24.522 9.375-33.901.04L224 227.495 69.255 381.516c-9.379 9.335-24.544 9.317-33.901-.04l-22.667-22.667c-9.373-9.373-9.373-24.569 0-33.941L207.03 130.525c9.372-9.373 24.568-9.373 33.941-.001z\"><\/path><\/svg>                                    <\/span>\n                                \n                            <\/span>\n                        \n                                                <span class=\"ui-e-accordion-title-text ui-e-title-text\" >\n                                                        The diagnosis and management of ectopic pregnancy &amp; pregnancy of unknown location                        <\/span>\n\n                    <\/h5>\n\n                    <div class=\"ui-e-accordion-content ui-e-content\" style=\"display:none;\" aria-labelledby=\"ui-e-the-diagnosis-and-management-of-ectopic-pregnancy-pregnancy-of-unknown-location\" id=\"ui-e-acc-3\">\n                        <div id=\"yui_3_18_1_1_1781924546522_24\" class=\"activity-header\" data-for=\"page-activity-header\">\n<div id=\"intro\" class=\"activity-description\">\n<div id=\"yui_3_18_1_1_1781924546522_23\" class=\"no-overflow\">\n<h5 id=\"yui_3_18_1_1_1781924546522_22\">&#8220;last update: 2 July \u00a02025&#8221;<span id=\"yui_3_18_1_1_1781924546522_21\"><strong id=\"yui_3_18_1_1_1781924546522_20\">\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0<a href=\"https:\/\/lms.ehc.gov.eg\/lms\/pluginfile.php\/1319\/mod_book\/intro\/The%20diagnosis%20and%20management%20of%20ectopic%20pregnancy%20%20pregnancy%20of%20unknown%20location.pdf\"><u>Download Guideline<\/u><\/a><br \/><\/strong><\/span><\/h5>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chaptersnavigation\">\n<div class=\"container-fluid tertiary-navigation\">\n<div class=\"row\">\n<div class=\"navitem ms-auto\">\u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chapter\" class=\"box py-3 generalbox book_content\">\n<h3 class=\" ccnMdlHeading\">&#8211; Executive Summary<\/h3>\n<div class=\"no-overflow\">\n<p dir=\"ltr\">\u00a0<\/p>\n<p>This guideline offers evidence-based recommendations on the management of ectopic pregnancy and pregnancy of unknown location. The recommendations are intended to provide healthcare professionals with practical guidance on appropriate and timely diagnosis and choosing the best evidence-based treatment modality of ectopic pregnancy resulting in improving health outcomes for people with this potentially fatal condition.<\/p>\n<h4><strong><u>List of Recommendations:<\/u><\/strong><\/h4>\n<p>\u00a0<\/p>\n<p>\u00a0<\/p>\n<table border=\"1\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p align=\"center\"><strong>Recommendation<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strength<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Counselling and documentation<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Women should be given information at the time of diagnosis of an ectopic pregnancy regarding their diagnosis and management. They should be counselled regarding signs of clinical deterioration when they should present for review and given information about emergency contacts<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Diagnosis of tubal ectopic pregnancy<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>A urinary beta-human chorionic gonadotrophin (\u03b2-hCG) test should be performed in all women of reproductive age presenting to a maternity or adult general hospital\/unit with abdominal pain, vaginal bleeding, gastrointestinal symptoms, dizziness, or collapse<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>A thorough gynaecological, obstetric, medical, and surgical history should be taken to assess for risk factors for ectopic pregnancy in women who present with the above symptoms; however, half of women with an ectopic pregnancy will have no known risk factors<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>A physical examination, including measurement of vital signs, should be performed to assess haemodynamic stability in women presenting with the above symptoms<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>There should be prompt escalation of care if there are any red flag symptoms on triage assessment or abnormal vital signs in the presence of a positive urinary HCG<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>All the above women are recommended to undergo ultrasound scanning<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Consider a transabdominal ultrasound scan for women with an enlarged uterus or other pelvic pathology, such as fibroids or an ovarian cyst<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Offer women who attend an early pregnancy a transvaginal ultrasound scan to identify the location of the pregnancy and whether there is a fetal pole and heartbeat. If a transvaginal ultrasound scan is unavailable or unacceptable to the woman, offer a transabdominal ultrasound scan and explain the limitations of this method of scanning<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>When carrying out a transvaginal ultrasound scan in early pregnancy, look for these signs indicating there is a tubal ectopic pregnancy: An adnexal mass, moving separate to the ovary, comprising a gestational sac containing a yolk sac and\/or fetal pole (with or without fetal heartbeat)<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>When carrying out a transvaginal ultrasound scan in early pregnancy, look for these signs indicating a high probability of a tubal ectopic pregnancy: An adnexal mass, moving separately to the ovary, with an empty gestational sac (\u201ctubal ring\u201d or \u201cbagel sign\u201d) or a complex, inhomogeneous adnexal mass, moving separate to the ovary. If these features are present, take into account other intrauterine and adnexal features on the scan, the woman\u2019s clinical presentation, and serum HCG levels before making a diagnosis<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>When carrying out a transvaginal ultrasound scan in early pregnancy, look for these signs indicating a possible ectopic pregnancy: An empty uterus or collection of fluid within the uterine cavity (pseudo-sac). If these features are present, take into account other intrauterine and adnexal features on the scan, the woman\u2019s clinical presentation, and serum HCG levels before making a diagnosis<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>When carrying out a transabdominal or transvaginal ultrasound scan in early pregnancy, look for a moderate to large amount of free fluid in the peritoneal cavity or pouch of Douglas, which might represent hemoperitoneum. If this is present, take into account other intrauterine and adnexal features of the scan, the woman\u2019s clinical presentation, and HCG levels before making a diagnosis<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>When carrying out a transabdominal or transvaginal ultrasound scan during early pregnancy, scan the uterus and adnexa to see if there is a heterotopic pregnancy<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>All ultrasound scans should be performed or directly supervised and reviewed by appropriately qualified healthcare professionals with training in, and experience of, diagnosing ectopic pregnancies<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Be aware that women with a pregnancy of unknown location could have an ectopic pregnancy until the location is determined<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Do not use serum HCG measurements to determine the location of the pregnancy<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>In a woman with a pregnancy of unknown location, place more importance on clinical symptoms than on serum HCG results, and review the woman&#8217;s condition if any of her symptoms change, regardless of previous results and assessments<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Use serum HCG measurements only for assessing trophoblastic proliferation to help to determine subsequent management<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Take 2 serum HCG measurements as near as possible to 48 hours apart (but no earlier) to determine subsequent management of a pregnancy of unknown location. Take further measurements only after review by a senior healthcare professional<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Regardless of serum HCG levels, women with a pregnancy of unknown location should be counseled about what to do if they experience any new or worsening symptoms, including details about how to access emergency care 24 hours a day. Advise women to return if there are new symptoms or if existing symptoms worsen<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>For a woman with an increase in serum HCG levels greater than 63% after 48 hours:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0Inform her that she is likely to have a developing intrauterine pregnancy (although the possibility of an ectopic pregnancy cannot be excluded).<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0Offer her a transvaginal ultrasound scan to determine the location of the pregnancy between 7 and 14 days later. Consider an earlier scan for women with a serum HCG level greater than or equal to 1,500 IU\/liter.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0If a viable intrauterine pregnancy is confirmed, offer her routine antenatal care.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0If a viable intrauterine pregnancy is not confirmed, refer her for immediate clinical review by a senior gynaecologist<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>For a woman with a decrease in serum HCG levels greater than 50% after 48 hours: inform her that the pregnancy is unlikely to continue but that this is not confirmed and provide her with information about where she can access support and counselling services. Ask her to take a urine pregnancy test 14 days after the second serum HCG test, and explain that:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0if the test is negative, no further action is necessary.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0if the test is positive, she should return to the early pregnancy assessment service for clinical review within 24 hours<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>For a woman with a decrease in serum HCG levels less than 50%, or an increase less than 63%, refer her for clinical review in the early pregnancy assessment service within 24 hours<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>For women with a pregnancy of unknown location, when using serial serum HCG measurements, do not use serum progesterone measurements as an adjunct to diagnose either viable intrauterine pregnancy or ectopic pregnancy.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Diagnosis of Pregnancy of unknown location<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Pregnancy of unknown location is a transient state in the diagnostic process, leading to a final diagnosis of viable or nonviable intrauterine pregnancy, ectopic pregnancy, or persistent pregnancy of unknown location<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\u00a0<\/td>\n<td width=\"108\">\u00a0<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>If pregnancy location cannot be determined on a TVUS, serial serum \u03b2-hCG measurements should be used in conjunction with a woman\u2019s history and symptoms to guide management<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Diagnosis of interstitial\/cornual pregnancy<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\"><strong>\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Interstitial:<\/strong>\u00a0Many are diagnosed at first trimester scanning by the presence of an eccentric gestational sac. A thin surrounding myometrial layer helps to distinguish this from an angular intrauterine pregnancy. A further sonographic sign is the presence of an echogenic line running from the endometrial cavity to the gestational sac<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Cornual:<\/strong>\u00a0Presentation may be delayed and is usually with abdominal pain. About 50% present after rupture and morbidity is high. The sensitivity of ultrasound diagnosis is low. The appearance is of a gestation sac separate from an empty unicornuate uterus which is identified by the single interstitial tube. The sac is mobile and surrounded by a thick myometrial layer. A vascular pedicle may be seen joining the gestational sac and the lateral aspect of the empty unicornuate uterus.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Diagnosis of Cervical pregnancy<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\"><strong>\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Implantation is within the cervical canal. Common predisposing factors are curettage, caesarean section or cervical surgical procedures. Usually, the first complaint is of painless vaginal bleeding and speculum examination may reveal an open external cervical os with a fleshy mass protruding<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Ultrasound shows a gestation sac distal to a closed internal cervical os. Doppler demonstration of surrounding vasculature helps distinguish a cervical pregnancy from a displaced intrauterine pregnancy. In addition, gentle pressure with the transvaginal probe may elicit the \u201csliding sign\u201d whereby a miscarrying sac is seen to slide within the cervical canal unlike the cervical pregnancy which is fixed<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Diagnosis of ovarian pregnancy<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\"><strong>\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Apart from the few cases with a clear-cut yolk sac or fetal pole visible in the ovary, ultrasound diagnosis is difficult. The ring surrounding an EP usually shows greater echogenicity than the surrounding ovarian tissue unlike the ring of a corpus luteum cyst which is less echogenic. If laparoscopy for suspected EP reveals that the tubes are normal a close inspection of the ovaries should be performed. Typically, an ovarian EP has the appearance of a cystic haemorrhagic mass<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Diagnosis of abdominal pregnancy<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\"><strong>\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Diagnosis is difficult and is usually made intraoperatively<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Diagnosis of CS scar pregnancy<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\"><strong>\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Ultrasound imaging is the primary imaging modality for CSEP diagnosis, although a correct and timely determination can be difficult. The initial finding of a low, anteriorly located gestational sac should raise concern for a possible CSEP and warrants further investigation<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Transvaginal ultrasound imaging is the optimal modality for the evaluation of suspected CSEP because it provides the highest image resolution. Grayscale combined with color Doppler ultrasound imaging is recommended for CSEP diagnosis<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>US criteria to diagnose CSEP: (1) an empty uterine cavity and endocervix; (2) placenta, gestational sac, or both embedded in the hysterotomy scar; (3) a triangular (at 8 weeks of gestation) or rounded or oval (at &gt;8 weeks of gestation) gestational sac that fills the scar \u201cniche\u201d (the shallow area representing a healed hysterotomy site); (4) a thin (&lt; 3 mm) or absent myometrial layer between the gestational sac and bladder; (5) a prominent or rich vascular pattern at or in the area of a cesarean scar; and (6) an embryonic or fetal pole, yolk sac, or both, with or without fetal cardiac activity. All of these criteria may not be observed especially with very early diagnosis and before fetal cardiac activity, the patient should have confirmation of pregnancy (for example, a positive pregnancy test result). Bulging or ballooning of the lower uterine segment in the midline sagittal transabdominal view has also been considered to be supportive of CSEP diagnosis<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>In cases in which ultrasound imaging is inconclusive, MRI could be considered as an adjunct study. Given the risks associated with delayed diagnosis<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Hysteroscopy and laparoscopy can be used to confirm a diagnosis at the time of planned operative intervention. With laparoscopic examination, CSEP has been described as an ecchymotic bulge with a \u201csalmon-red\u201d appearance beneath the bladder at the level of the previous cesarean scar with an otherwise normal-appearing uterus<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Expectant management of tubal ectopic pregnancy<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\"><strong>\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Offer expectant management as an option to women who:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0Are clinically stable and pain-free and<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0Have a tubal ectopic pregnancy measuring &lt;35 mm with no visible heartbeat on transvaginal ultrasound scan and<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0Have serum hCG levels of \u22641000 IU\/L and<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0Are able to return for follow-up<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>For women with a tubal ectopic pregnancy being managed expectantly, repeat hCG levels on days 2, 4, and 7 after the original test, and:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0If hCG levels drop by \u226515% from the previous value on days 2, 4, and 7, then repeat weekly until a negative result (&lt;20 IU\/L) is obtained<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0If hCG levels do not fall by 15%, stay the same, or rise from the previous value, review the woman\u2019s clinical condition and seek senior advice to help decide further management<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Advise women that, based on limited evidence, there seems to be no difference following expectant or medical management in:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0The rate of ectopic pregnancies ending naturally<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0The risk of tubal rupture<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0The need for additional treatment, but that they might need to be admitted urgently if their condition deteriorates<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0Health status, depression or anxiety scores. Advise women that the time taken for ectopic pregnancies to resolve and future fertility outcomes are likely to be the same with either expectant or medical management<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Methotrexate treatment for tubal ectopic pregnancy<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Offer systemic methotrexate to women who have no significant pain and have an unruptured tubal ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat and have a serum hCG level less than 1,500 IU\/litre and do not have an intrauterine pregnancy (as confirmed on an ultrasound scan) and are able to return for follow-up<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Methotrexate should only be offered on a first visit when there is a definitive diagnosis of an ectopic pregnancy, and a viable intrauterine pregnancy has been excluded. Offer surgery where treatment with methotrexate is not acceptable to the woman. For women with ectopic pregnancy who have had methotrexate, take 2 serum hCG measurements in the first week (days 4 and 7) after treatment and then 1 serum hCG measurement per week until a negative result is obtained. If hCG levels plateau or rise, reassess the woman&#8217;s condition for further treatment<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Women receiving methotrexate for the management of tubal ectopic pregnancy can be advised that there is no effect on ovarian reserve<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>It is recommended that women treated with methotrexate wait at least 3 months before trying to conceive again<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Surgical treatment for tubal ectopic pregnancy<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Offer surgery as a first-line treatment to women who are unable to return for follow-up after methotrexate treatment or who have any of the following:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0an ectopic pregnancy and significant pain<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0an ectopic pregnancy with an adnexal mass of 35 mm or larger<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0an ectopic pregnancy with a fetal heartbeat visible on an ultrasound scan<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0an ectopic pregnancy and a serum hCG level of 5,000 IU\/litre or more<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Offer the choice of either methotrexate or surgical management to women with an ectopic pregnancy who have a serum hCG level of at least 1,500 IU\/litre and less than 5,000 IU\/litre, who are able to return for follow-up and who meet all of the following criteria:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0no significant pain<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0no intrauterine pregnancy (as confirmed on an ultrasound scan). Advise women who choose methotrexate that their chance of needing further intervention is increased and they may need to be urgently admitted if their condition deteriorates<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Laparoscopy for tubal ectopic pregnancy<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>When surgical treatment is indicated for women with an ectopic pregnancy, it should be performed laparoscopically whenever possible, taking into account the condition of the woman and the complexity of the surgical procedure.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Surgeons providing care to women with ectopic pregnancy should be competent to perform laparoscopic surgery.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Commissioners and managers should ensure that equipment for laparoscopic surgery is available.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Salpingectomy and salpingotomy<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\"><strong>\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Offer a salpingectomy to women undergoing surgery for an ectopic pregnancy unless they have other risk factors for infertility<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Consider salpingotomy as an alternative to salpingectomy for women with risk factors for infertility such as contralateral tube damage<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Inform women having a salpingotomy that up to 1 in 5 women may need further treatment. This treatment may include methotrexate and\/or a salpingectomy.<\/p>\n<p>For women who have had a salpingotomy, take 1 serum hCG measurement at 7 days after surgery, then 1 serum hCG measurement per week until a negative result is obtained<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Advise women who have had a salpingectomy that they should take a urine pregnancy test after 3 weeks. Advise women to return for further assessment if the test is positive<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Management of Cervical ectopic pregnancy<\/p>\n<p>Cervical dilation and curettage may provoke bleeding. Infiltration of the cervix with a haemostatic vasoconstricting agent, followed by the placement of cervical sutures to temporarily occlude the descending branches of the uterine arteries followed by suction curettage (without dilation) and post-curettage cervical canal balloon tamponade has proven successful in treating first trimester cervical pregnancies. Another treatment option is uterine artery embolisation which has been used in combination with MTX 1B<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Management of Interstitial and cornual pregnancy<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>The optimal method of treatment for interstitial ectopic pregnancy has not been determined and needs further research. Cases should be managed on an individual patient basis and a consultant Obstetrician\/Gynaecologist should be involved in decision making and management.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Expectant management of interstitial ectopic pregnancy should be used with caution due to the high mortality associated with rupture of an interstitial ectopic pregnancy but can be considered when \u03b2-hCG levels are falling and the pregnancy is non-viable.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Intramuscular or local methotrexate treatment may be considered in asymptomatic women who fit the criteria for medical management, with follow up serum \u03b2-hCG levels.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Surgical management may be considered for interstitial ectopic pregnancy and is required when there is evidence of rupture, with follow up \u03b2-hCG levels.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Laparoscopic linear cornuostomy is carried out in a similar manner to salpingostomy for EP including allowing spontaneous closure of the corneal incision.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Cornual resection is another option. Surgical cornual excision is usually preferred either by laparoscopy or open surgery and avoids the risk of recurrence.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Treatment for a rudimentary horn ectopic pregnancy is excision of the rudimentary horn via laparoscopy or laparotomy.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Management of ovarian pregnancy<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Optimum management is resection of the ovarian pregnancy with preservation of healthy ovarian tissue. Follow-up hCG monitoring is recommended. MTX is appropriate for persistent trophoblast and has also been used for primary treatment but is limited in this regard due to the need for laparoscopic and histologic confirmation of diagnosis.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Management of Heterotopic pregnancy<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Clinicians should not offer systemic methotrexate in the presence of a desired intrauterine pregnancy.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Management of Cesarean scar pregnancy<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>We recommend against expectant management of cesarean scar ectopic pregnancy.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>We suggest that operative resection (with transvaginal or laparoscopic approaches when possible) or ultrasound-guided uterine aspiration be considered for the surgical management of cesarean scar ectopic pregnancy and that sharp curettage alone be avoided.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>We suggest intra-gestational methotrexate for the medical treatment of cesarean scar ectopic pregnancy, with or without other treatment modalities.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>We recommend that systemic methotrexate alone not be used to treat cesarean scar ectopic pregnancy.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>In patients who choose expectant management and continuation of a cesarean scar ectopic pregnancy, we recommend repeated cesarean delivery between 34 0\/7 and 35 6\/7 weeks of gestation.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>We recommend that patients with a cesarean scar ectopic pregnancy be advised of the risks of another pregnancy and counseled regarding effective contraceptive methods, including long-acting reversible contraception and permanent contraception.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Management of abdominal ectopic pregnancy<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Clinicians may choose either laparotomy or laparoscopy to excise an abdominal pregnancy<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Anti-D immunoglobulin prophylaxis<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Offer anti-D immunoglobulin prophylaxis at a dose of 250 IU (50 micrograms) to all rhesus-negative women who have a surgical procedure to manage an ectopic pregnancy or a miscarriage.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Do not offer anti-D immunoglobulin prophylaxis to women who:<\/p>\n<p>\u2013\u00a0\u00a0 receive solely medical management for an ectopic pregnancy.<\/p>\n<p>\u2013\u00a0\u00a0 have a pregnancy of unknown location.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Do not use a Kleihauer test for quantifying feto-maternal haemorrhage.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><strong>Follow up<\/strong><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>An early pregnancy ultrasound scan at 6 weeks\u2019 gestation should be performed in any subsequent pregnancy due to the increased risk of ectopic pregnancy recurrence.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<\/div>                    <\/div>\n\n                <\/div>\n                            <div class=\"ui-e-accordion-item ui-e-item\" role=\"button\" tabindex=\"0\" aria-expanded=\"false\" aria-controls=\"ui-e-acc-4\" id=\"ui-e-prevention-and-treatment-of-hypertension-in-pregnancy\">\n\n                    <h5 class=\"ui-e-accordion-title ui-e-title ui-right\">\n\n                                                    <span class=\"ui-e-accordion-icon ui-e-icon ui-e-right\" aria-hidden=\"true\">\n\n                                <span class=\"ui-e-accordion-icon-closed\">\n                                    <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-down\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M207.029 381.476L12.686 187.132c-9.373-9.373-9.373-24.569 0-33.941l22.667-22.667c9.357-9.357 24.522-9.375 33.901-.04L224 284.505l154.745-154.021c9.379-9.335 24.544-9.317 33.901.04l22.667 22.667c9.373 9.373 9.373 24.569 0 33.941L240.971 381.476c-9.373 9.372-24.569 9.372-33.942 0z\"><\/path><\/svg>                                <\/span>\n\n                                                                    <span class=\"ui-e-accordion-icon-opened\">\n                                        <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-up\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M240.971 130.524l194.343 194.343c9.373 9.373 9.373 24.569 0 33.941l-22.667 22.667c-9.357 9.357-24.522 9.375-33.901.04L224 227.495 69.255 381.516c-9.379 9.335-24.544 9.317-33.901-.04l-22.667-22.667c-9.373-9.373-9.373-24.569 0-33.941L207.03 130.525c9.372-9.373 24.568-9.373 33.941-.001z\"><\/path><\/svg>                                    <\/span>\n                                \n                            <\/span>\n                        \n                                                <span class=\"ui-e-accordion-title-text ui-e-title-text\" >\n                                                        Prevention and Treatment of Hypertension in Pregnancy                        <\/span>\n\n                    <\/h5>\n\n                    <div class=\"ui-e-accordion-content ui-e-content\" style=\"display:none;\" aria-labelledby=\"ui-e-prevention-and-treatment-of-hypertension-in-pregnancy\" id=\"ui-e-acc-4\">\n                        <div id=\"yui_3_18_1_1_1781924565542_24\" class=\"activity-header\" data-for=\"page-activity-header\">\n<div id=\"intro\" class=\"activity-description\">\n<div id=\"yui_3_18_1_1_1781924565542_23\" class=\"no-overflow\">\n<h5 id=\"yui_3_18_1_1_1781924565542_22\">&#8220;last update: 2 July \u00a02025&#8221;<span id=\"yui_3_18_1_1_1781924565542_21\"><strong id=\"yui_3_18_1_1_1781924565542_20\">\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0<a href=\"https:\/\/lms.ehc.gov.eg\/lms\/pluginfile.php\/1320\/mod_book\/intro\/Prevention%20and%20Treatment%20of%20Hypertension%20in%20Pregnancy.pdf\"><u>Download Guideline<\/u><\/a><br \/><\/strong><\/span><\/h5>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chaptersnavigation\">\n<div class=\"container-fluid tertiary-navigation\">\n<div class=\"row\">\n<div class=\"navitem ms-auto\">\u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chapter\" class=\"box py-3 generalbox book_content\">\n<h3 class=\" ccnMdlHeading\">&#8211; Executive Summary<\/h3>\n<div class=\"no-overflow\">\n<p dir=\"ltr\">\u00a0<\/p>\n<p>EHC has developed the present evidence-informed recommendations with a view to promoting the best possible clinical practices for the\u00a0<b>Prevention and Treatment of Hypertension in Pregnancy<\/b>.<\/p>\n<h4><a name=\"_Toc199938564\"><\/a><u>List of Recommendations<\/u><\/h4>\n<table border=\"1\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p align=\"center\"><a name=\"_Hlk194483205\"><\/a><b>Recommendation<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strength<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Definitions And Classification<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>HDPs should be classified according to the criteria and definitions presented in \u201cGlossary\u201d<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Diagnose Hypertension in pregnancy when systolic blood pressure is \u2265140mmHg and\/or diastolic blood pressure is \u226590mmHg, based on the average of\u00a0<i>at least<\/i>\u00a02 measurements, taken at least 15minutes apart, using the same arm.<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Severe hypertension (sBP \u2265 160 and\/or dBP \u2265 110 mmHg), can be confirmed within a short interval (minutes) to facilitate timely antihypertensive therapy<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Gestational hypertension is hypertension that develops for the first time at &gt; 20 weeks, without evidence of preeclampsia<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Women with gestational hypertension should undergo testing for preeclampsia to rule it out.<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Diagnose preeclampsia in women with new onset hypertension after 20 weeks and new-onset proteinuria or one\/more adverse conditions (defined as a maternal end organ complication or evidence of uteroplacental dysfunction)<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><a name=\"_Hlk197959319\"><\/a><b>Preeclampsia superimposed on chronic hypertension is diagnosed by the development of 1 or more characteristics of preeclampsia (i.e., new-onset proteinuria or 1 or more adverse conditions) superimposed on chronic hypertension<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Do not use an elevation in BP to make a diagnosis of preeclampsia superimposed on chronic hypertension.<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b>Risk factors<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Risk factors for developing preeclampsia should be included in the antenatal assessment of all pregnant women.<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Screening<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>All pregnant women should be screened for their risk of developing preeclampsia early in the pregnancy.<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The screening tool utilized should be determined based on the locally available resources<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Blood Pressure measurement<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>During every antenatal visit, screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy is strongly recommended<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Testing For Proteinuria<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Screen for proteinuria with urinary dipstick at first visit and at each subsequent visit<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>More definitive testing for proteinuria (by urinary protein:creatinine ratio or 24-hour urine collection) is encouraged when there is a suspicion of preeclampsia, including: \u22651+ dipstick proteinuria in women with hypertension and rising blood pressure and in women with normal blood pressure, but symptoms or signs\u00a0<\/b><b>suggestive of preeclampsia\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>When quantitative methods are not available or rapid decisions are required, a urine protein dipstick reading can be substituted using 2+ as the discriminant value<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Proteinuria testing does not need to be repeated once significant proteinuria in the setting of confirmed pre-eclampsia has been detected<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Biomarkers and ultrasonography screening<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The use of a combined first trimester screen (combined maternal features, biomarkers and sonography) to identify women at risk of developing preeclampsia is conditionally recommended based on local availability and access to the required resources<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Risk Reduction<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Low dose Aspirin<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>To reduce the risk of developing preeclampsia, pregnant women with one high risk factor or two or more moderate risk factors for developing preeclampsia should receive low dose aspirin (100 mg -150 mg daily) beginning at 12 weeks gestation and till delivery.<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The use of aspirin at bedtime is conditionally recommended<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Cessation of aspirin between 34 weeks gestation and birth is conditionally recommended. Exact timing of cessation should be based on individualized clinical judgment and informed, shared decision taking with the women<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Oral calcium Supplementation<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The use of supplemental calcium is strongly recommended in pregnant women with low dietary calcium intake (&lt;1g\/day) for the prevention of preeclampsia, preterm birth, and gestational hypertension<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Calcium supplementation at doses of 1.5\u20132.0 g elemental calcium\/day is recommended from the first antenatal visit till delivery, to reduce the risk of developing preeclampsia<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Education<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Pregnant women with hypertension or with risk factors for developing preeclampsia should be educated about the symptoms and signs that require immediate attention and referral to health care facilities.<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>A clear referral plan should be discussed with each woman<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Educate pregnant women to seek a healthcare professional immediately if they experience any of the symptoms of pre-eclampsia<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Exercise and diet<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Moderate intensity exercise, in the form of aerobic, stretching and\/or muscle resistance exercises, for a total of 2.5-5 hours a week, as recommended exercise regimen for general pregnancy wellbeing is encouraged.<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>What is Not recommended for risk reduction<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Dietary salt restriction, for prevention of preeclampsia, is not recommended given the lack of evidence of benefit<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The use of oral omega-3 long-chain polyunsaturated fatty acids LCPUFA<\/b><b>\u00a0<\/b><b>supplementation for the prevention<\/b><b>\u00a0<\/b><b>of preeclampsia, is not recommended<\/b><b>\u00a0<\/b><b>until more data are available<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The use of oral garlic supplementation,<\/b><b>\u00a0<\/b><b>specifically for the prevention of<\/b><b>\u00a0<\/b><b>preeclampsia, is not recommended<\/b><b>\u00a0<\/b><b>until more data are available<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The use of oral vitamin C<\/b><b>\u00a0<\/b><b>and E supplementation,<\/b><b>\u00a0<\/b><b>specifically for the prevention<\/b><b>\u00a0<\/b><b>of preeclampsia,<\/b><b>\u00a0<\/b><b>is not recommended until<\/b><b>\u00a0<\/b><b>more data are\u00a0<\/b><b>available<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>There is inadequate<\/b><b>\u00a0<\/b><b>data to recommend for<\/b><b>\u00a0<\/b><b>the use or against the<\/b><b>\u00a0<\/b><b>use of oral magnesium<\/b><b>\u00a0<\/b><b>supplementation specifically<\/b><b>\u00a0<\/b><b>for the prevention of<\/b><b>\u00a0<\/b><b>preeclampsia. More data on<\/b><b>\u00a0<\/b><b>the safety profile is required<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The use of progesterone<\/b><b>\u00a0<\/b><b>replacement, specifically<\/b><b>\u00a0<\/b><b>for the prevention of<\/b><b>\u00a0<\/b><b>preeclampsia, is not<\/b><b>\u00a0<\/b><b>recommended until more<\/b><b>\u00a0<\/b><b>data are available<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The use of statins, specifically<\/b><b>\u00a0<\/b><b>for the prevention of<\/b><b>\u00a0<\/b><b>preeclampsia, is not<\/b><b>\u00a0<\/b><b>recommended until more<\/b><b>\u00a0<\/b><b>data are available<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The use of low molecular<\/b><b>\u00a0<\/b><b>weight heparin (LMWH)<\/b><b>\u00a0<\/b><b>alone (without aspirin) in<\/b><b>\u00a0<\/b><b>women without a history<\/b><b>\u00a0<\/b><b>of thrombophilia or APLS<\/b><b>\u00a0<\/b><b>can be considered if a<\/b><b>\u00a0<\/b><b>contraindication to aspirin is<\/b><b>\u00a0<\/b><b>present.<\/b><b>\u00a0<\/b><b>The decision to use LMWH<\/b><b>\u00a0<\/b><b>(at a prophylactic dose)<\/b><b>\u00a0<\/b><b>should be\u00a0<\/b><b>individualized\u00a0<\/b><b>based on women\u2019s clinical<\/b><b>\u00a0<\/b><b>and obstetric history and<\/b><b>\u00a0<\/b><b>through a shared, informed decision-making process<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>LMWH should not replace the use of aspirin in women without contraindications to aspirin<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The use of low molecular<\/b><b>\u00a0<\/b><b>weight heparin (LMWH)<\/b><b>\u00a0<\/b><b>in addition to aspirin for<\/b><b>\u00a0<\/b><b>prevention of preeclampsia<\/b><b>\u00a0<\/b><b>in women without a<\/b><b>\u00a0<\/b><b>history of<\/b><b>\u00a0t<\/b><b>hrombophilia<\/b><b>\u00a0<\/b><b>or APLS is not<\/b><b>\u00a0<\/b><b>recommended<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The use of nitric oxide (either in donor or precursor forms) for the prevention of preeclampsia is not recommended until more data are available<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The use of metformin, specifically for the prevention of preeclampsia is not recommended until more data are available<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The use of oral vitamin D supplementation for the prevention of preeclampsia, is not recommended until more data are available<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The use of proton pump inhibitors for prevention of preeclampsia is not recommended until more data are available<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The use of clopidogrel for<\/b><b>\u00a0<\/b><b>prevention of preeclampsia<\/b><b>\u00a0<\/b><b>is not<\/b><b>\u00a0<\/b><b>recommended until<\/b><b>\u00a0<\/b><b>human data are available<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>TREATMENT OF PRE-ECLAMPSIA SYNDROME AND GESTATIONAL HYPERTENSION<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p><b><u>Hospital Admission Versus\u00a0<\/u><\/b><b><u>Ambulatory Outpatient Management<\/u><\/b><b><u><\/u><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Ambulatory outpatient management at home is an option only for women with mild to moderate gestational hypertension and\u00a0<u>requires frequent fetal and maternal evaluation<\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Hospitalization is appropriate for Women with gestational hypertension in whom adherence to frequent monitoring is a concern and for patients diagnosed with preeclampsia<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Ambulatory outpatient management<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>At each antenatal care visit, following the detection of hypertension in pregnancy, a systematic clinical evaluation of symptoms, signs, laboratory investigations and fetal wellbeing must be performed<\/b><b><u><\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Frequency of appointments is based on the individual clinical needs; suggested review is initially weekly to fortnightly (every 2 weeks) at a minimum<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Women with non-severe hypertension during pregnancy should not be offered antihypertensive drug treatment when adequate resources for good quality antenatal care follow-up may be lacking<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Inpatient Care<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Women with preeclampsia should have additional tests to detect multisystem involvement, and should have fetal surveillance to assure fetal wellbeing<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>A clear referral plan for patients with severe preeclampsia must be developed and implemented in every health care unit<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Complete bed rest is not advised for fear of thromboembolism, however minimal activities with 2 hours afternoon nap and 8 hours night sleep is recommended<\/b>.<b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Non-severe hypertension should be treated with the first-line agents oral methyldopa, labetalol, or nifedipine<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Severe hypertension in pregnancy (i.e., sBP \u2265 160 mmHg or dbp \u2265 110 mmHg) requires\u00a0<i>urgent\u00a0<\/i>antihypertensive therapy, in a monitored setting<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Severe hypertension should be treated with the first-line agents oral nifedipine, oral labetalol, IV labetalol, or IV hydralazine<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The target BP for antihypertensive therapy should be a dBP of 85 mmHg, regardless of sBP<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Use of corticosteroid (either betamethasone or dexamethasone) is recommended in women with preeclampsia who are at risk of birth at &lt; 34 weeks\u2019 gestation<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>There are insufficient data to recommend routine use of corticosteroid in women with preeclampsia who are at risk of birth between 34- and 36-weeks\u2019 gestation. Delivery should not be delayed for the administration of steroids in the late preterm period<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The use of magnesium sulphate for fetal neuroprotection in women with preeclampsia at risk of preterm birth at &lt; 30 weeks\u2019 gestation is strongly recommended<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>As part of expectant management, in-utero transfer to a tertiary-level centre with neonatal intensive care capacity should be considered<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Inpatient Expectant care versus Delivery<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Inpatient Expectant care<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Women with mild to moderate gestational hypertension or preeclampsia without severe features, expectant management up to 37 0\/7 weeks of gestation is recommended<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>In low-resource setting where maternal and neonatal care and adequate resources for close monitoring by healthcare personnel may be lacking or is not available, the GDG recommend against expectant management for preeclampsia with severe hypertension or other severe features<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Capabilities for the evaluation of fetal wellbeing and detection of fetal compromise should be available in healthcare facilities providing care for pregnant women with hypertensive disorders<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Transfer of women with hypertension of pregnancy should be considered in situations where the health care provider believes that the health care facility is unequipped to manage the complications of hypertension of pregnancy<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Birth and Delivery<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Time of Birth<\/u><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Initiate birth at\u00a0<\/b><b>\u2265<\/b><b>\u00a037 weeks gestation, in women with preeclampsia<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>At &lt; 37 weeks gestation, the decision on expectant management with continued surveillance is appropriate for women with non-severe preeclampsia.<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>At 34+0 till 36+6 weeks gestation for women with preeclampsia in presence of any feature of severity initiation of delivery should is considered. Delivery should not be delayed for the administration of steroids in the late preterm period<u><\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>From fetal viability until &lt;34+0 weeks gestation, Expectant management should be considered, but only in hospitals where very preterm infants and sick mothers can be cared for. Initiation of birth is considered in the absence of available resources for maternal and neonatal care<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Maternal stabilization and labor management of pre-eclampsia and eclampsia<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Prevention and treatment of convulsions<\/u><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The prevention of eclampsia is empirically based on the timely delivery once preeclampsia has been diagnosed<u><\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Prophylactic magnesium sulphate with an intravenous loading dose of 4g followed by maintenance at 1g\/hr for 24 hours in total or time of last seizure is strongly recommended in women at risk of eclampsia or recurrent eclampsia<\/b><b><u><\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>There is inadequate evidence to support an alternative magnesium regimen or the use of anticonvulsants for the prevention of eclampsia<\/b><b><u><\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>It is recommended that magnesium sulfate should be used for the prevention and treatment of seizures in women with severe hypertension or severe preeclampsia, or eclampsia and birth is planned within 24 hours<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The prophylactic use of magnesium sulfate for the prevention of seizures in women with gestational hypertension or preeclampsia without severe features is Conditionally recommended<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Women with eclampsia should receive magnesium sulphate to prevent recurrent seizures<\/b><b><u><\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Control of acute severe hypertension<\/u><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Severe hypertension in pregnancy (i.e., sBP \u2265 160 mmHg or dBP \u2265 110 mmHg) requires\u00a0<i>urgent\u00a0<\/i>antihypertensive therapy, in a monitored setting<u><\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Severe hypertension should be treated with the first-line agents oral nifedipine, oral labetalol, intravenous (IV) labetalol, or IV hydralazine<u><\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The target BP for antihypertensive therapy should be a dBP of 85 mmHg, regardless of sBP<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Non-severe hypertension should be treated with the first-line agents oral methyldopa, labetalol, or nifedipine<u><\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Control of other complications: HELLP syndrome<\/u><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>For women with severe preeclampsia with features of HELLP expectant management is harmful. Plan birth as soon as feasible<u><\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Platelet transfusion should be considered if a woman\u2019s platelet count is &lt;20 _ 109\/L before vaginal delivery or &lt;50 _ 109\/L before cesarean delivery, or at any time if there is excessive active bleeding, known platelet dysfunction, rapidly falling platelet count, or coagulopathy<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Vaginal delivery is the preferred modality, unless urgent delivery is necessary for maternal stabilization or for fetal indications. The delivery options should be discussed by a multidisciplinary team and consider the safest mode of delivery to the mother, how fast she is expected to deliver, what are the resources of blood products and other supportive mechanisms available, and can she sustain a surgery<u><\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>In rapidly progressing preeclampsia with severe features or HELLP syndrome, vaginal delivery may be attempted if cervical conditions are favorable and delivery is anticipated within a short timeframe (e.g., \u22642 hours). If labor progress is slow (&gt;6 hours)<\/b><b>\u00a0<\/b><b>or maternal\/fetal status worsens, immediate cesarean delivery is indicated<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>In small to medium size health care facilities, it is important to estimate whether their blood bank can support a massive blood trans fusion and, if necessary, contact regional or larger hospitals for assistance or for transferring the patient<u><\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Mode of Birth<\/u><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>For women with any HDP, vaginal delivery should be considered unless a cesarean delivery is required for obstetrical indications.<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Vaginal delivery may require early cervical ripening and induction<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>If urgent or emergent delivery is required for maternal and\/or fetal indications, an emergency cesarean delivery may be indicated<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Urgency ot Birth<\/u><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Health facilities in Egypt should provide local protocols of management for their health care providers in accordance with WHO recommendations.<u><\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>GDG recommends to\u00a0<u>nationally adopt a color-triage system for acute obstetric emergencies (Modified Early obstetric warning score -MEOWS)<\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>TREATMENT OF CHRONIC HYPERTENSION<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Expectant Management<\/u><\/b><b><u><\/u><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Offer expectant management for women with Chronic hypertension who are &lt;37 weeks and, whose blood pressure is lower than 160\/110 mmHg with or without antihypertensive treatment, unless there are other medical indications62<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Offer antihypertensive treatment to pregnant women who have chronic hypertension and who are not already on treatment if they have sustained systolic blood pressure of 140 mmHg or higher or sustained diastolic blood pressure of 90 mmHg or higher<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The target BP for antihypertensive therapy should be a dBP of 85 mmHg, regardless of sBP<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Consider labetalol to treat chronic hypertension in pregnant women. Consider nifedipine for women in whom labetalol is not suitable or methyldopa if both labetalol and nifedipine are not suitable. Base the choice on any pre-existing treatment, side-effect profiles, risks (including fetal effects) and the woman&#8217;s preference<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Continue with existing antihypertensive treatment if safe in pregnancy, or switch to an alternative treatment, unless sustained systolic blood pressure is less than 110 mmHg or sustained diastolic blood pressure is less than 70 mmHg or the woman has symptomatic hypotension<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Offer pregnant women with chronic hypertension aspirin 150 mg once daily from 12 weeks<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Give the same advice on rest, exercise and work to women with chronic hypertension or at risk of hypertensive disorders during pregnancy as healthy pregnant women<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Offer PLGF testing between 20\u201336+6 weeks to rule out pre-eclampsia in women with chronic hypertension if clinical suspicion arises<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>In chronic hypertension with suspected pre-eclampsia, monitor proteinuria 1\u20132x weekly alongside BP checks<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>A complete blood count and levels of serum transaminases, lactate dehydrogenase, and uric acid should<\/b><b>\u00a0be\u00a0<u>checked on diagnosis then weekly<\/u><\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Timing of birth<\/u><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Do not offer planned early birth (<i>before 37 weeks<\/i>) to women with chronic hypertension whose blood pressure is lower than 160\/110 mmHg, with or without antihypertensive treatment, unless there are other medical indications<u><\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Offer planned birth to women with chronic hypertension whose blood pressure is lower than 160\/110 mmHg with or without antihypertensive treatment after 37 weeks<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Determination of timing should be agreed between the woman and the obstetrician. Initiation of delivery can be offered at 38+0 to 39+6 weeks<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Offer planned early birth before 37 weeks<\/b>\u00a0<b>to women with chronic hypertension or gestational hypertension if inability to control maternal blood pressure despite using 3 or more classes of antihypertensives in appropriate doses or if any of the known features of severe superimposed preeclampsia develop<\/b><b><u><\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Care for women with hypertension during labor and postpartum<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Intrapartum Care<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>During labour, measure blood pressure hourly. In women with severe hypertension measure blood pressure every 15 to 30 minutes until blood pressure is less than 160\/110 mmHg.<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Continue use of antenatal antihypertensive treatment during labour<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Do not preload women who have severe pre-eclampsia with intravenous fluids before establishing low-dose epidural analgesia or combined spinal epidural analgesia<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Do not routinely limit the duration of the second stage of labour in women with controlled hypertension<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Consider operative or assisted birth in the second stage of labour for women with severe hypertension whose hypertension has not responded to initial treatment<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>As women with preeclampsia are at increased risk of postpartum hemorrhage, the third stage of labour should be actively managed<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Ergometrine should not be administered to women with any hypertensive disorder of pregnancy, particularly preeclampsia or gestational hypertension; alternative oxytocic drugs should be considered<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"630\">\n<p align=\"center\"><b><u>Postpartum care for women with HDP<\/u><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>There remains inadequate data to suggest the superiority of a single agent or group of agents in selecting antihypertensives for the management of hypertension in the postpartum period. The choice of antihypertensive (beta-blockers, methyldopa, hydralazine, nifedipine, enalapril, clonidine) should be made through a shared decision-making process, particularly in breastfeeding\/lactating women<u><\/u><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Women should be informed of the long-term risks associated with preeclampsia, gestational hypertension and chronic hypertension and the importance of postpartum follow up prior to discharge from hospital<\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Antihypertensive therapy administered antepartum should be continued after birth. Also, consideration should be given to administering antihypertensive therapy for any hypertension diagnosed before six days postpartum<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>The target dBP for postpartum antihypertensive treatment should be 85 mmHg, as antenatally<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Non-steroidal anti-inflammatory drugs (NSAIDs) for postpartum analgesia may be used in women with pre-eclampsia if other analgesics are ineffective, and there is no acute kidney injury (AKI) or other risk factors for it<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Breastfeeding is recommended<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Counselling should be provided about the risks of gestational hypertension (at least 4%) or pre-eclampsia (at least 15%) in future pregnancy<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>At 3 months postpartum, all women should be reviewed to ensure that BP, urinalysis, and any laboratory abnormalities have normalised. If proteinuria or hypertension persist, then appropriate referral for further investigations should be initiated<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>At 6 months postpartum, where possible, all women should be reviewed again, at which point we suggest that BP \u2265 120\/80 mmHg lead to discussion of lifestyle change<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"514\">\n<p><b>Following hypertensive pregnancy, particularly pre-eclampsia, counselling should be provided about the heightened health risks for the mother (particularly cardiovascular) and the offspring<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"116\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>\u00a0<\/p>\n<br \/>\n<p>\u00a0<\/p>\n<\/div>\n<\/div>\n<div class=\"mt-5 mb-5 activity-navigation\">\n<div class=\"row\">\n<div class=\"col-md-4\">\n<div class=\"float-left ui_kit_btn\">\u00a0<\/div>\n<\/div>\n<div class=\"col-md-4\">\n<div class=\"mdl-align\">\n<div class=\"urlselect\">\u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>                    <\/div>\n\n                <\/div>\n                            <div class=\"ui-e-accordion-item ui-e-item\" role=\"button\" tabindex=\"0\" aria-expanded=\"false\" aria-controls=\"ui-e-acc-5\" id=\"ui-e-placenta-accreta-spectrum-pas-diagnosis-and-management\">\n\n                    <h5 class=\"ui-e-accordion-title ui-e-title ui-right\">\n\n                                                    <span class=\"ui-e-accordion-icon ui-e-icon ui-e-right\" aria-hidden=\"true\">\n\n                                <span class=\"ui-e-accordion-icon-closed\">\n                                    <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-down\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M207.029 381.476L12.686 187.132c-9.373-9.373-9.373-24.569 0-33.941l22.667-22.667c9.357-9.357 24.522-9.375 33.901-.04L224 284.505l154.745-154.021c9.379-9.335 24.544-9.317 33.901.04l22.667 22.667c9.373 9.373 9.373 24.569 0 33.941L240.971 381.476c-9.373 9.372-24.569 9.372-33.942 0z\"><\/path><\/svg>                                <\/span>\n\n                                                                    <span class=\"ui-e-accordion-icon-opened\">\n                                        <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-up\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M240.971 130.524l194.343 194.343c9.373 9.373 9.373 24.569 0 33.941l-22.667 22.667c-9.357 9.357-24.522 9.375-33.901.04L224 227.495 69.255 381.516c-9.379 9.335-24.544 9.317-33.901-.04l-22.667-22.667c-9.373-9.373-9.373-24.569 0-33.941L207.03 130.525c9.372-9.373 24.568-9.373 33.941-.001z\"><\/path><\/svg>                                    <\/span>\n                                \n                            <\/span>\n                        \n                                                <span class=\"ui-e-accordion-title-text ui-e-title-text\" >\n                                                        Placenta Accreta Spectrum (PAS): Diagnosis and Management                        <\/span>\n\n                    <\/h5>\n\n                    <div class=\"ui-e-accordion-content ui-e-content\" style=\"display:none;\" aria-labelledby=\"ui-e-placenta-accreta-spectrum-pas-diagnosis-and-management\" id=\"ui-e-acc-5\">\n                        <div id=\"yui_3_18_1_1_1781924585973_20\" class=\"activity-header\" data-for=\"page-activity-header\">\n<div id=\"intro\" class=\"activity-description\">\n<div id=\"yui_3_18_1_1_1781924585973_28\" class=\"no-overflow\">\n<h5 id=\"yui_3_18_1_1_1781924585973_27\">&#8220;last update: 14 July \u00a02025&#8221;<span id=\"yui_3_18_1_1_1781924585973_26\"><strong id=\"yui_3_18_1_1_1781924585973_25\">\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0<\/strong><a href=\"https:\/\/lms.ehc.gov.eg\/lms\/pluginfile.php\/1323\/mod_book\/intro\/Placenta%20Accreta%20Spectrum%20%28PAS%29%20Diagnosis%20and%20Management.pdf\"><strong><u>Download Guideline<\/u><\/strong><\/a><br \/><\/span><\/h5>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chaptersnavigation\">\n<div class=\"container-fluid tertiary-navigation\">\n<div class=\"row\">\n<div class=\"navitem ms-auto\">\u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chapter\" class=\"box py-3 generalbox book_content\">\n<h3 class=\" ccnMdlHeading\">&#8211; Executive Summary<\/h3>\n<div class=\"no-overflow\">\n<p dir=\"ltr\">\u00a0<\/p>\n<p>This guideline offers evidence-based recommendations on Placenta Accreta Spectrum. The recommendations are intended to provide healthcare professionals with practical guidance on diagnosis and management of Placenta Accreta Spectrum which can significantly reduce complications and improve the outcome for affected women and their infants.<\/p>\n<div>\n<p><b>List of Recommendations<\/b><b><\/b><\/p>\n<\/div>\n<table border=\"1\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p align=\"center\"><b>Recommendation<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\"><b>Strength<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p><b>What are the risk factors for women with placenta accreta spectrum?<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>The major risk factors for placenta accreta spectrum are history of accreta in a previous pregnancy, previous caesarean delivery and other uterine surgery, including repeated endometrial curettage. This risk rises as the number of prior caesarean sections increases.<\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">Strong Recommendation<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Women requesting elective caesarean delivery for non-medical indications should be informed of the risk of placenta accreta spectrum and its consequences for subsequent pregnancies.<\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p><b>How can placenta accreta spectrum be suspected and diagnosed antenatally?<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Antenatal diagnosis of placenta accreta spectrum is crucial in planning its management and has been shown to reduce maternal morbidity and mortality.<\/p>\n<\/td>\n<td valign=\"top\" width=\"132\">\n<p align=\"center\">Strong Recommendation<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Ultrasound assessment of placental location should be part of routine obstetric care, particularly in women undergoing cesarean section delivery.<\/p>\n<\/td>\n<td valign=\"top\" width=\"132\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Previous caesarean delivery and the presence of an anterior low-lying placenta or placenta praevia should alert the antenatal care team of the higher risk of placenta accreta spectrum.<b><\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"132\">\n<p align=\"center\">Strong Recommendation<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p><b>Ultrasound screening and diagnosis of placenta accreta spectrum<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Ultrasound imaging is highly accurate when performed by a skilled operator with experience in diagnosing placenta accreta spectrum.<b><\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">Strong Recommendation<b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Refer women with any ultrasound features suggestive of placenta accreta spectrum to a specialist unit with imaging expertise.<\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">Strong Recommendation<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Standardised definitions should be used in reporting and consideration given to using a template.<\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Women with a history of previous caesarean section seen to have an anterior low-lying placenta or placenta praevia at the routine fetal anomaly scan should be specifically screened for placenta accreta spectrum.<\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">Strong Recommendation<b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Patients with previous one or more CS and diagnosed as CS scar pregnancy at 5-6 weeks of gestation are at high risk of developing placenta accreta. They should be counseled and referred to a tertiary hospital for termination of pregnancy.<\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">Strong Recommendation<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p><b>Is there a role for magnetic resonance imaging (MRI) in the diagnosis of placenta accreta spectrum?<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Clinicians should be aware that the diagnostic value of MRI and ultrasound imaging in detecting placenta accreta spectrum is similar when performed by experts.\u00a0<b><\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">Strong Recommendation<b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>MRI may be used to complement ultrasound imaging to assess the depth of invasion and lateral extension of myometrial invasion, especially with posterior placentation and\/or in women with ultrasound signs suggesting parametrial invasion.<\/p>\n<\/td>\n<td valign=\"top\" width=\"132\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Women with a history of previous cesarean delivery or uterine surgery who are found to have an anterior low-lying placenta or placenta previa should be considered at increased risk for placenta accreta spectrum, even if imaging does not confirm the diagnosis.<\/p>\n<\/td>\n<td valign=\"top\" width=\"132\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p><b>Where should women with placenta accreta spectrum be cared for?<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Women diagnosed with placenta accreta spectrum should be cared for by a multidisciplinary team in a specialist centre with expertise in diagnosing and managing invasive placentation.<\/p>\n<\/td>\n<td valign=\"top\" width=\"132\">\n<p align=\"center\">GPS<b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Prevention and treatment of anemia during the antenatal period is recommended for women with placenta praevia, a low-lying placenta or accreta as for any pregnant woman.<\/p>\n<\/td>\n<td valign=\"top\" width=\"132\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Delivery for women diagnosed with placenta accreta spectrum should take place in a specialist centre with logistic support for immediate access to blood products, adult intensive care unit and neonatal intensive care unit by a multidisciplinary team with expertise in complex pelvic surgery.<b><\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">Strong Recommendation<b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p><b>When should delivery be planned for women with placenta accreta spectrum?<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>In the absence of risk factors for preterm delivery in women with placenta accreta spectrum, planned delivery at 35<sup>+0<\/sup>\u00a0to 36<sup>+6<\/sup>\u00a0weeks of gestation provides the best balance between fetal maturity and the risk of unscheduled delivery.<b><\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">GPS<b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p><b>Planning delivery of women with suspected placenta accreta spectrum<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Once the diagnosis of placenta accreta spectrum is made, a contingency plan for emergency delivery should be developed in partnership with the woman, including the use of an institutional protocol for the management of maternal hemorrhage. \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b><\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p><b>What should be included in the consent form for caesarean section in women with suspected placenta accreta spectrum?<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Any woman giving consent for caesarean section should understand the risks associated with caesarean section in general, and the specific risks of placenta accreta spectrum in terms of massive obstetric hemorrhage, increased risk of lower urinary tract damage, the need for blood transfusion and the risk of hysterectomy.<b><\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">Strong recommendation<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Additional possible interventions in the case of massive hemorrhage should also be discussed, including cell salvage and interventional radiology where available.<\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">Conditional recommendation<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p><b>What healthcare professionals should be involved?<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>The elective delivery of women with placenta accreta spectrum should be managed by a multidisciplinary team, which should include senior anesthetists, obstetricians and gynecologists with appropriate experience in managing the condition and other surgical specialties if indicated. In an emergency, the most senior clinicians available should be involved.<b><\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">Strong Recommendation<b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p><b>What anesthetic is most appropriate for delivery?<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>The choice of anesthetic technique for caesarean section for women with placenta accreta spectrum should be made by the anesthetist conducting the procedure in consultation with the woman prior to surgery.<b><\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">GPS<b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>The woman should be informed that the surgical procedure can be performed safely with regional anesthesia but should be advised that it may be necessary to convert to general anesthesia if required and asked to consent to this.<\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">GPS<b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p><b>What surgical approach should be used for women with placenta accreta spectrum?<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Intravenous tranexamic acid should be administered at the commencement of surgery because it reduces intraoperative blood loss.<\/p>\n<\/td>\n<td valign=\"top\" width=\"132\">\n<p align=\"center\">Strong recommendation<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Caesarean section hysterectomy with the placenta left in situ is preferable to attempting to separate it from the uterine wall.<\/p>\n<\/td>\n<td valign=\"top\" width=\"132\">\n<p align=\"center\">Strong recommendation<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>When the extent of the placenta accreta is limited in depth and surface area, and the entire placental implantation area is accessible and visualised (i.e., completely anterior, fundal or posterior without deep pelvic invasion), uterus preserving surgery may be appropriate, including partial myometrial resection.<b><\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">Conditional recommendation<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Uterus preserving surgical techniques should only be attempted by surgeons working in teams with appropriate expertise to manage such cases and after appropriate counselling regarding risks and with informed consent.<b><\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">Conditional recommendation<b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>There are currently insufficient data to recommend the routine use of ureteric stents in placenta accreta spectrum. The use of stents may have a role when the urinary bladder is invaded by placental tissue.<b><\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p><b>What surgical approach should be used for women with placenta percreta?<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>There is limited evidence to support uterus preserving surgery in placenta percreta and women should be informed of the high risk of peripartum and secondary complications, including the need for secondary hysterectomy.<b><\/b><\/p>\n<\/td>\n<td width=\"132\">\n<p align=\"center\">GPS<b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p><b>When is interventional radiology indicated?<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"132\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>Larger studies are necessary to determine the safety and efficacy of interventional radiology before this technique can be advised in the routine management of placenta accreta spectrum.\u00a0<b><\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"132\">\n<p align=\"center\">Strong recommendation<b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p><b>How are women with undiagnosed or unsuspected placenta accreta spectrum best managed at delivery?<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"132\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>If at the time of an elective repeat caesarean section, where both mother and baby are stable, it is immediately apparent that placenta percreta is present on opening the abdomen, the caesarean section should be delayed until the appropriate staff and resources have been assembled and adequate blood products are available. This may involve closure of the maternal abdomen and urgent transfer to a specialist unit for delivery.\u00a0<b><\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"132\">\n<p align=\"center\">\u00a0<\/p>\n<p align=\"center\">\u00a0<\/p>\n<p align=\"center\">GPS<b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p>In case of unsuspected placenta accreta spectrum diagnosed after the birth of the baby, the placenta should be left in situ and an emergency hysterectomy performed.\u00a0<b><\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"132\">\n<p align=\"center\">\u00a0<\/p>\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><b>\u00a0<\/b><\/p>\n<p>\u00a0<\/p>\n<\/div>\n<\/div>\n<div class=\"mt-5 mb-5 activity-navigation\">\n<div class=\"row\">\n<div class=\"col-md-4\">\n<div class=\"float-left ui_kit_btn\">\u00a0<\/div>\n<\/div>\n<div class=\"col-md-4\">\n<div class=\"mdl-align\">\n<div class=\"urlselect\">\u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>                    <\/div>\n\n                <\/div>\n                            <div class=\"ui-e-accordion-item ui-e-item\" role=\"button\" tabindex=\"0\" aria-expanded=\"false\" aria-controls=\"ui-e-acc-6\" id=\"ui-e-the-diagnosis-and-management-of-endometriosis\">\n\n                    <h5 class=\"ui-e-accordion-title ui-e-title ui-right\">\n\n                                                    <span class=\"ui-e-accordion-icon ui-e-icon ui-e-right\" aria-hidden=\"true\">\n\n                                <span class=\"ui-e-accordion-icon-closed\">\n                                    <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-down\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M207.029 381.476L12.686 187.132c-9.373-9.373-9.373-24.569 0-33.941l22.667-22.667c9.357-9.357 24.522-9.375 33.901-.04L224 284.505l154.745-154.021c9.379-9.335 24.544-9.317 33.901.04l22.667 22.667c9.373 9.373 9.373 24.569 0 33.941L240.971 381.476c-9.373 9.372-24.569 9.372-33.942 0z\"><\/path><\/svg>                                <\/span>\n\n                                                                    <span class=\"ui-e-accordion-icon-opened\">\n                                        <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-up\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M240.971 130.524l194.343 194.343c9.373 9.373 9.373 24.569 0 33.941l-22.667 22.667c-9.357 9.357-24.522 9.375-33.901.04L224 227.495 69.255 381.516c-9.379 9.335-24.544 9.317-33.901-.04l-22.667-22.667c-9.373-9.373-9.373-24.569 0-33.941L207.03 130.525c9.372-9.373 24.568-9.373 33.941-.001z\"><\/path><\/svg>                                    <\/span>\n                                \n                            <\/span>\n                        \n                                                <span class=\"ui-e-accordion-title-text ui-e-title-text\" >\n                                                        The diagnosis and management of endometriosis                        <\/span>\n\n                    <\/h5>\n\n                    <div class=\"ui-e-accordion-content ui-e-content\" style=\"display:none;\" aria-labelledby=\"ui-e-the-diagnosis-and-management-of-endometriosis\" id=\"ui-e-acc-6\">\n                        <div id=\"yui_3_18_1_1_1781924604647_22\" class=\"activity-header\" data-for=\"page-activity-header\">\n<div id=\"intro\" class=\"activity-description\">\n<div id=\"yui_3_18_1_1_1781924604647_21\" class=\"no-overflow\">\n<h5 id=\"yui_3_18_1_1_1781924604647_20\">&#8220;last update: 28 July \u00a02025&#8221;<span id=\"yui_3_18_1_1_1781924604647_31\"><strong id=\"yui_3_18_1_1_1781924604647_30\">\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0\u00a0<a href=\"https:\/\/lms.ehc.gov.eg\/lms\/pluginfile.php\/1340\/mod_book\/intro\/The%20diagnosis%20and%20management%20of%20endometriosis.pdf\"><u>Download Guideline<\/u><\/a><br \/>\u00a0<\/strong><\/span><\/h5>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chaptersnavigation\">\n<div class=\"container-fluid tertiary-navigation\">\n<div class=\"row\">\n<div class=\"navitem ms-auto\">\u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chapter\" class=\"box py-3 generalbox book_content\">\n<h3 class=\" ccnMdlHeading\">&#8211; Executive Summary<\/h3>\n<div class=\"no-overflow\">\n<p dir=\"ltr\">\u00a0<\/p>\n<p>This guideline offers evidence-based recommendations on diagnosis and management of female pelvic endometriosis. The recommendations are intended to provide healthcare professionals with practical guidance on appropriate and timely diagnosis and choosing the best evidence-based treatment modality of female pelvic endometriosis. resulting in improving health outcomes for people with this potentially disabling condition.<\/p>\n<div>\n<p><strong><u>List of Recommendations<\/u><\/strong><\/p>\n<\/div>\n<div align=\"center\">\n<table border=\"1\" width=\"100%\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Recommendation<\/span><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b><span lang=\"EN-GB\">Strength<\/span><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Diagnosis of endometriosis<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Symptoms:<\/b><\/p>\n<p>Clinicians should consider the diagnosis of endometriosis in individuals presenting with the following cyclical and non-cyclical signs and symptoms: dysmenorrhea, deep dyspareunia, dysuria, dyschezia, painful rectal bleeding or haematuria, shoulder tip pain, catamenial pneumothorax, cyclical cough\/haemoptysis\/ chest pain, cyclical scar swelling and pain, fatigue, and infertility<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Signs:<\/b><\/p>\n<p><b>\u00a0<\/b>Offer an abdominal and pelvic examination to people with suspected endometriosis to identify abdominal masses and pelvic signs, such as reduced organ mobility and enlargement, tender nodularity in the posterior vaginal fornix, and visible vaginal endometriotic lesions.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>If rectal endometriosis is suspected, a rectal examination may also be proactively performed to confirm the status of the bowel wall.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Diagnostic imaging<\/b><b><u><\/u><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Women with suspected endometriosis, further diagnostic steps, including imaging, should be considered even if the clinical examination is normal<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians are recommended to use imaging (US or MRI) in the diagnostic work-up for endometriosis, but they need to be aware that a negative finding does not exclude endometriosis, particularly superficial peritoneal disease<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Offer a transvaginal ultrasound scan to all women with suspected endometriosis, even if pelvic or abdominal examination is normal, to: identify ovarian endometriomas and deep endometriosis<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>If a transvaginal scan is declined or not appropriate, consider transabdominal ultrasound scan of the pelvis<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Do not use pelvic MRI as the primary investigation to diagnose endometriosis in people with symptoms or signs suggestive of endometriosis.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Consider pelvic MRI to assess the extent of deep endometriosis involving the bowel, bladder or ureter<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Laparoscopy: surgical diagnosis<\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>In patients with negative imaging results, or where empirical treatment (hormonal contraceptives or progestogens) was unsuccessful, consider offering laparoscopy for the diagnosis and treatment of suspected endometriosis<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Laparoscopic identification of endometriotic lesions should be confirmed by histopathologic examination of the lesions. However, a negative histology does not entirely rule out the disease<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>The procedure should be performed by a trained laparoscopic surgeon, who should perform and document a systematic inspection of the pelvis and abdomen<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Biomarker:<\/b><\/p>\n<p>Do not use serum CA125 to diagnose endometriosis.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Treatment of endometriosis associated pain<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Pain control in endometriosis<\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>For women with pain associated with endometriosis-, consider a short trial (for example, 3 months) of a non-steroidal anti-inflammatory drug (NSAID) alone or in combination with paracetamol, if not contraindicated. If such a trial does not provide adequate pain relief, consider other forms of pain management and referral for secondary or tertiary care center<span lang=\"EN-GB\">.<\/span><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Advise patients that there is no evidence for or against the use of anti-neuropathic medications for pain associated with endometriosis<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Women with endometriosis should be referred to a pain specialist and\/or a condition-specific specialist at any stage if:<\/p>\n<p>\u2022 pain is severe and unresponsive to simple analgesics.<\/p>\n<p>\u2022 the pain substantially limits daily activities.<\/p>\n<p>\u2022 any underlying health condition has deteriorated.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Hormonal treatment for endometriosis<\/b><b><u><\/u><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>It is recommended to offer women hormone treatment (combined hormonal contraceptives, progestogens, GnRH agonists or GnRH antagonists) as one of the options to reduce endometriosis-associated pain<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>The GDG recommends that clinicians take a shared decision-making approach and take individual preferences, side effects, individual efficacy, costs, and availability into consideration when choosing hormone treatments for endometriosis-associated pain<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>When appropriate a levonorgestrel-releasing intrauterine system or an etonogestrel-releasing subdermal implant to reduce endometriosis-associated pain can be used<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>It is recommended to prescribe women GnRH agonists to reduce endometriosis-associated pain, although evidence is limited regarding dosage or duration of treatment<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b><span lang=\"EN-GB\">Strong<\/span><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>The GDG recommends that GnRH agonists are prescribed as second line (for example if hormonal contraceptives or progestogens have been ineffective) due to their side-effect profile<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b><span lang=\"EN-GB\">GPS<\/span><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians should consider prescribing combined hormonal add-back therapy alongside GnRH agonist therapy to prevent bone loss and hypoestrogenic symptoms<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>In women with endometriosis-associated pain refractory to other medical or surgical treatment, it is recommended to prescribe aromatase inhibitors, as they reduce endometriosis-associated pain. Aromatase inhibitors may be prescribed in combination with oral contraceptives, progestogens, GnRH agonists or GnRH antagonists<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Surgical management for endometriosis<\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Laparoscopic management should be done by an expert in laparoscopic surgery<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>When surgery is performed, clinicians may consider excision instead of ablation of endometriosis to reduce endometriosis-associated pain<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>It can be concluded that LUNA is not beneficial as an additional procedure to conventional laparoscopic surgery for endometriosis, PSN is beneficial for treatment of endometriosis-associated midline pain as an adjunct to conventional laparoscopic surgery<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>When performing surgery in women with ovarian endometrioma, clinicians should perform cystectomy instead of drainage and coagulation,<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>When performing surgery for ovarian endometrioma, specific caution should be used to minimize ovarian damage<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians can consider performing surgical removal of deep endometriosis, as it may reduce endometriosis-associated pain and improves quality of life<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>The GDG recommends that patients undergoing surgery particularly for deep endometriosis are informed on potential risks, benefits, and long-term effect on quality of life<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Due to the heterogeneity of patient population, presentation, surgical approaches and techniques, it is difficult to make definitive recommendations on the specific techniques to be applied for the treatment of pain associated with deep endometriosis<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>In case of bowel endometriosis, a conservative approach should be chosen whenever possible.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Hysterectomy for endometriosis associated pain<\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians can consider hysterectomy (with or without removal of the ovaries) with removal of all visible endometriosis lesions, in those women who no longer wish to conceive and failed to respond to more conservative treatments.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>The GDG recommends that when hysterectomy is performed, a total hysterectomy is preferred<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>When a decision is made whether to remove the ovaries, the long-term consequences of early menopause and possible need for hormone replacement therapy should be considered<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Studies should evaluate factors that can be assessed prior to surgery and can predict a clinically meaningful improvement of pain symptoms. Such prognostic markers can be used to select patients that may benefit from endometriosis surgery<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Women may be offered postoperative hormone treatment to improve the immediate outcome of surgery for pain in women with endometriosis if not desiring immediate pregnancy<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Non-medical interventions in endometriosis<\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>No recommendations can be made for any specific non-medical intervention (Chinese medicine, nutrition, electrotherapy, acupuncture, physiotherapy, exercise, and psychological interventions) to reduce pain or improve quality of life measures in women with endometriosis, as the potential benefits and harms are unclear.<b><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Treatment of endometriosis associated infertility<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Ovarian suppression<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>In infertile women with endometriosis, clinicians should not prescribe ovarian suppression treatment to improve fertility.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Women seeking pregnancy should not be prescribed postoperative hormone suppression with the sole purpose to enhance future pregnancy rates.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Those women who cannot attempt to or decide not to conceive immediately after surgery may be offered hormone therapy as it does not negatively impact their fertility and improves the immediate outcome of surgery for pain<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>In infertile women with endometriosis, clinicians should not prescribe pentoxifylline, other anti-inflammatory drugs or letrozole outside ovulation-induction to improve natural pregnancy rates.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Surgical treatment<\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>The GDG recommends that the decision to perform surgery should be guided by the presence or absence of pain symptoms, patient age and preferences, history of previous surgery, presence of other infertility factors, ovarian reserve, and estimated Endometriosis Fertility Index (EFI).<b><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Operative laparoscopy could be offered as a treatment option for endometriosis-associated infertility in rASRM stage I\/II endometriosis as it improves the rate of ongoing pregnancy.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians may consider operative laparoscopy for the treatment of endometrioma-associated infertility as it may increase their chance of natural pregnancy, although no data from comparative studies exist.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Although no compelling evidence exists that operative laparoscopy for deep endometriosis improves fertility, operative laparoscopy may represent a treatment option in symptomatic patients wishing to conceive.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Assessing the need for assisted reproduction after surgery<\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Women should be counselled of their chances of becoming pregnant after surgery. To identify patients that may benefit from ART after surgery, the Endometriosis Fertility Index (EFI) should be used as it is validated, reproducible and cost-effective. The results of other fertility investigations such as their partner\u2019s sperm analysis should be taken into account.<b><u><\/u><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Medically assisted reproduction<\/span><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b><span lang=\"EN-GB\">\u00a0<\/span><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>IUI with endometriosis<\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>In infertile women with rASRM stage I\/II endometriosis, clinicians may perform intrauterine insemination (IUI) with ovarian stimulation, instead of expectant management or IUI alone, as it increases pregnancy rates.<b><u><\/u><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Although the value of IUI in infertile women with rASRM stage III\/IV endometriosis with tubal patency is uncertain, the use of IUI with ovarian stimulation could be considered.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>ART in women with endometriosis<\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>ART can be performed for infertility associated with endometriosis, especially if tubal function is compromised, if there is male factor infertility, in case of low EFI and\/or if other treatments have failed<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>A specific protocol for ART in women with endometriosis cannot be recommended. Both GnRH antagonist and agonist protocols can be offered based on patients\u2019 and physicians\u2019 preferences as no difference in pregnancy or live birth rate has been demonstrated<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Women with endometriosis can be reassured regarding the safety of ART since the recurrence rates are not increased compared to those women not undergoing ART.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>In women with endometrioma, clinicians may use antibiotic prophylaxis at the time of oocyte retrieval, although the risk of ovarian abscess formation following follicle aspiration is low.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Medical therapies as an adjunct to MAR<\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>The extended administration of GnRH agonist prior to ART treatment to improve live birth rate in infertile women with endometriosis is not recommended, as the benefit is uncertain.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>There is insufficient evidence to recommend prolonged administration of the COC\/progestogens as a pre-treatment to ART to increase live birth rates.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Surgical therapies as an adjunct to MAR<\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians are not recommended to routinely perform surgery prior to ART to improve live birth rates in women with rASRM stage I\/II endometriosis, as the potential benefits are unclear.<b><u><\/u><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians are not recommended to routinely perform surgery for ovarian endometrioma prior to ART to improve live birth rates, as the current evidence shows no benefit and surgery is likely to have a negative impact on ovarian reserve.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Surgery for endometrioma prior to ART can be considered to improve endometriosis-associated pain or accessibility of follicles.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>The decision to offer surgical excision of deep endometriosis lesions prior to ART should be guided mainly by pain symptoms and patient preference as its effectiveness on reproductive outcome is uncertain due to lack of randomised studies<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Non-medical management strategies for infertility<\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>No recommendation can be made to support any non-medical interventions (nutrition, Chinese medicine, electrotherapy, acupuncture, physiotherapy, exercise, and psychological interventions) to increase fertility in women with endometriosis. The potential benefits and harms are unclear.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Fertility Preservation<\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>In case of extensive ovarian endometriosis, clinicians should discuss the pros and cons of fertility preservation with women with endometriosis. The true benefit of fertility preservation in women with endometriosis remains unknown<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Impact of endometriosis on pregnancy and pregnancy outcome<\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Patients should not be advised to become pregnant with the sole purpose of treating endometriosis, as pregnancy does not always lead to improvement of symptoms or reduction of disease progression.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Complications related directly to pre-existing endometriosis lesions are rare, but probably under-reported. Such complications may be related to their decidualization, adhesion formation\/stretching and endometriosis-related chronic inflammation. Although rare, they may represent life-threatening situations that may require surgical management.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians should be aware that there may be an increased risk of first trimester miscarriage and ectopic pregnancy in women with endometriosis.<u><\/u><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians should be aware of endometriosis-associated complications in pregnancy, although these are rare. As these findings are based on low\/moderate quality studies, these results should be interpreted with caution and currently do not warrant increased antenatal monitoring or dissuade women from becoming pregnant.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Endometriosis recurrence<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Prevention of endometriosis recurrence<\/b><\/p>\n<p>When surgery is indicated in women with an endometrioma, clinicians should perform ovarian cystectomy, instead of drainage and electrocoagulation, for the secondary prevention of endometriosis-associated dysmenorrhea, dyspareunia, and non-menstrual pelvic pain. However, the risk of reduced ovarian reserve should be taken into account<b><u><\/u><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians should consider prescribing the postoperative use of a levonorgestrel-releasing intrauterine system (52 mg LNG-IUS) or a combined hormonal contraceptive for at least 18\u201324 months for the secondary prevention of endometriosis-associated dysmenorrhea<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>After surgical management of ovarian endometrioma in women not immediately seeking conception, clinicians are recommended to offer long-term hormone treatment (e.g. combined hormonal contraceptives) for the secondary prevention of endometrioma and endometriosis-associated related symptom recurrence.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>For the prevention of recurrence of deep endometriosis and associated symptoms, long-term administration of postoperative hormone treatment can be considered<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Long-term administration of progestogen may reduce the recurrence of ovarian endometriotic cysts.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Treatment of recurrent endometriosis<\/b><\/p>\n<p>Any hormone treatment or surgery can be offered to treat recurring pain symptoms in women with endometriosis<b><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><a name=\"_Hlk194991150\"><\/a><b><span lang=\"EN-GB\">Adolescent Endometriosis<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Clinical symptoms:<\/b><\/p>\n<p>In adolescents, clinicians should take a careful history and consider the following symptoms as suggestive of the presence of endometriosis:<\/p>\n<p>-chronic or a-cyclical pelvic pain, particularly combined with nausea, dysmenorrhea, dyschezia, dysuria, dyspareunia<\/p>\n<p>-cyclical pelvic pain<b><u><\/u><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Clinical examination<\/b><\/p>\n<p>In case of virgin written informed consent from the patient and her parents before rectal examination<u><\/u><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>The recommendations for clinical examination in adults can be applied.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Imaging<\/b><\/p>\n<p>In case of virgin written informed consent from the patient and her parents before rectal u\/s<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Pelvic imaging with ultrasonography, regardless of findings on pelvic examination, also should be considered during evaluation for secondary dysmenorrhea.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Transvaginal ultrasound is recommended to be used in adolescents in whom it is appropriate non virgin, as it is effective in diagnosing ovarian endometriosis.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>If a transvaginal scan is not appropriate, MRI, trans abdominal, trans-perineal, or trans rectal scan may be considered.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Laboratory parameters<\/b><\/p>\n<p>Serum biomarkers (e.g., CA-125) are not recommended for diagnosing or ruling out endometriosis in adolescents.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Diagnostic laparoscopy<\/b><\/p>\n<p>In adolescents with suspected endometriosis where imaging is negative and imperical medical treatments (with NSAIDs and\/or hormonal contraceptives) have not been successful, diagnostic laparoscopy may be considered.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>The appearance of endometriosis may be different in an adolescent than in an adult woman. In adolescents, endometriotic lesions are typically clear or red and can be difficult to identify for gynecologists unfamiliar with endometriosis in adolescents.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>If a laparoscopy is performed, clinicians may consider taking biopsies to confirm the diagnosis histologically, although negative histology does not entirely rule out the disease.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Medical treatment<\/b><\/p>\n<p>Nonsteroidal anti-inflammatory drugs should be the mainstay of pain relief for adolescents with endometriosis.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>In adolescents with severe dysmenorrhea and\/or endometriosis-associated pain, Clinicians should prescribe hormonal contraceptives or progestogens<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>In adolescents with laparoscopically confirmed endometriosis and associated pain in whom hormonal contraceptives or progestogen therapy failed, clinicians may consider prescribing GnRH agonists combined with add-back therapy for up to 1 year, as they are effective and safe.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>If GnRH agonist treatment is considered, it should be used only after careful consideration and discussion of potential side effects and potential long-term health risks with a practitioner in a secondary or tertiary care setting<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Combined medical and surgical treatment.<\/b><\/p>\n<p>In adolescents with endometriosis, clinicians should consider postoperative hormone therapy, as this may suppress recurrence of symptoms<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Menopause and Endometriosis<\/span><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Treatment of endometriosis in postmenopausal women<\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians may consider surgical treatment for postmenopausal women presenting with signs of endometriosis and\/or pain to enable histological confirmation of the diagnosis of endometriosis<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians should acknowledge the uncertainty towards the risk of malignancy in postmenopausal women. If a pelvic mass is detected, the work-up and treatment should be performed according to national oncology guidelines<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>For postmenopausal women with endometriosis-associated pain, clinicians may consider aromatase inhibitors as a treatment option especially if surgery is not feasible.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Menopausal symptoms in women with a history of endometriosis<\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians may consider combined menopausal hormone therapy (MHT) for the treatment of postmenopausal symptoms in women (both after natural and surgical menopause) with a history of endometriosis<\/p>\n<\/td>\n<td width=\"16%\">\n<p><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians should avoid prescribing estrogen-only regimens for the treatment of vasomotor symptoms in postmenopausal women with a history of endometriosis, as these regimens may be associated with a higher risk of malignant transformation<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians should continue to treat women with a history of endometriosis after surgical menopause with combined estrogen-progestogen at least up to the age of natural menopause.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Menopause-related major health concerns in women with endometriosis<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians should be aware that women with endometriosis who have undergone an early bilateral salpingo-oophorectomy as part of their treatment have an increased risk of diminished bone density, dementia, and cardiovascular disease. It is also important to note that women with endometriosis have an increased risk of cardiovascular disease, irrespective of whether they have had an early surgical menopause<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Extra pelvic endometriosis<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians should be aware of symptoms of extra-pelvic thoracic endometriosis, such as cyclical shoulder pain, cyclical spontaneous pneumothorax, cyclical cough, or nodules which enlarge during menses.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>It is advisable to discuss diagnosis and management of extra-pelvic &amp; thoracic endometriosis in a multidisciplinary team in a center with sufficient expertise<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>For abdominal extra-pelvic endometriosis, surgical removal is the preferred treatment, when possible, to relieve symptoms. Hormone treatment may also be an option when surgery is not possible or acceptable<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Asymptomatic endometriosis<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Treatment<\/b><\/p>\n<p>Clinicians should inform and counsel women about any incidental finding of endometriosis<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians should not routinely perform surgical excision\/ablation for an incidental finding of asymptomatic endometriosis at the time of surgery<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Clinicians should not prescribe medical treatment in women with incidental finding of endometriosis<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Monitoring<\/b><\/p>\n<p>Routine ultrasound monitoring of asymptomatic endometriosis can be considered.<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Primary prevention of endometriosis<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>Although there is no direct evidence of benefit in preventing endometriosis in the future, women can be advised of aiming for a healthy lifestyle and diet, with reduced alcohol intake and regular physical activity<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>The usefulness of hormonal contraceptives for the primary prevention of endometriosis is uncertain<\/p>\n<\/td>\n<td width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<br \/>\n<p>\u00a0<\/p>\n<\/div>\n<\/div>\n<div class=\"mt-5 mb-5 activity-navigation\">\n<div class=\"row\">\n<div class=\"col-md-4\">\n<div class=\"float-left ui_kit_btn\">\u00a0<\/div>\n<\/div>\n<div class=\"col-md-4\">\n<div class=\"mdl-align\">\n<div class=\"urlselect\">\u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>                    <\/div>\n\n                <\/div>\n                            <div class=\"ui-e-accordion-item ui-e-item\" role=\"button\" tabindex=\"0\" aria-expanded=\"false\" aria-controls=\"ui-e-acc-7\" id=\"ui-e-recommendations-on-the-clinical-interventions-for-the-prevention-of-the-primary-cesarean-section\">\n\n                    <h5 class=\"ui-e-accordion-title ui-e-title ui-right\">\n\n                                                    <span class=\"ui-e-accordion-icon ui-e-icon ui-e-right\" aria-hidden=\"true\">\n\n                                <span class=\"ui-e-accordion-icon-closed\">\n                                    <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-down\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M207.029 381.476L12.686 187.132c-9.373-9.373-9.373-24.569 0-33.941l22.667-22.667c9.357-9.357 24.522-9.375 33.901-.04L224 284.505l154.745-154.021c9.379-9.335 24.544-9.317 33.901.04l22.667 22.667c9.373 9.373 9.373 24.569 0 33.941L240.971 381.476c-9.373 9.372-24.569 9.372-33.942 0z\"><\/path><\/svg>                                <\/span>\n\n                                                                    <span class=\"ui-e-accordion-icon-opened\">\n                                        <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-up\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M240.971 130.524l194.343 194.343c9.373 9.373 9.373 24.569 0 33.941l-22.667 22.667c-9.357 9.357-24.522 9.375-33.901.04L224 227.495 69.255 381.516c-9.379 9.335-24.544 9.317-33.901-.04l-22.667-22.667c-9.373-9.373-9.373-24.569 0-33.941L207.03 130.525c9.372-9.373 24.568-9.373 33.941-.001z\"><\/path><\/svg>                                    <\/span>\n                                \n                            <\/span>\n                        \n                                                <span class=\"ui-e-accordion-title-text ui-e-title-text\" >\n                                                        Recommendations on The Clinical Interventions For The Prevention of The Primary Cesarean Section                        <\/span>\n\n                    <\/h5>\n\n                    <div class=\"ui-e-accordion-content ui-e-content\" style=\"display:none;\" aria-labelledby=\"ui-e-recommendations-on-the-clinical-interventions-for-the-prevention-of-the-primary-cesarean-section\" id=\"ui-e-acc-7\">\n                        <div id=\"yui_3_18_1_1_1781924625328_21\" class=\"activity-header\" data-for=\"page-activity-header\">\n<div id=\"intro\" class=\"activity-description\">\n<div class=\"no-overflow\">\n<h5>&#8220;last update: 4 August \u00a02025&#8221;<strong>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0<\/strong><strong><u><a href=\"https:\/\/lms.ehc.gov.eg\/lms\/pluginfile.php\/1346\/mod_book\/intro\/000%20Clinical%20Interventions%20for%20the%20Prevention%20of%20primary%20CS%20EHC.pdf\">Download Guideline<\/a><\/u><\/strong><strong><u><br \/><\/u><\/strong><u><\/u><\/h5>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chaptersnavigation\">\n<div class=\"container-fluid tertiary-navigation\">\n<div class=\"row\">\n<div class=\"navitem ms-auto\">\u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chapter\" class=\"box py-3 generalbox book_content\">\n<h3 class=\" ccnMdlHeading\">&#8211; Executive Summary<\/h3>\n<div class=\"no-overflow\">\n<p dir=\"ltr\">\u00a0<\/p>\n<p>This guideline offers evidence-based recommendations on the clinical interventions for the safe prevention of the primary cesarean section. The recommendations are intended to provide healthcare professionals caring for pregnant women with practical guidance on how to safely avoid the primary cesarean section.<\/p>\n<p>\u00a0<\/p>\n<p>List of Recommendations<\/p>\n<p>\u00a0<\/p>\n<table border=\"1\" width=\"682\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td width=\"546\">\n<p align=\"center\"><a name=\"_Hlk195048094\"><\/a><b>Recommendation<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\"><b>Strength of Recommendation<\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1. Measures During ANC and Before Labor<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><a name=\"_Hlk204260415\"><\/a><b>1.1. Planning of Birth<\/b><b><\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.1.1.<\/b>\u00a0Discuss the benefits and risks of both caesarean and vaginal birth with women, taking into account their circumstances, concerns, priorities and plans for future pregnancies. (See Appendix I)<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.1.2.<\/b>\u00a0Fetal presentation should be assessed and documented beginning at 36 0\/7 weeks of gestation to guide the plan of management.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.2. Breech Presentation &amp; Other Fetal Malpresentation<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.2.1.\u00a0<\/b>Offer women who have an uncomplicated singleton breech pregnancy after 36+0 weeks, external cephalic version by an experienced obstetrician, unless:<\/p>\n<p>\u27a1\ufe0f\u00a0the woman is in established labor<\/p>\n<p>\u27a1\ufe0f\u00a0there is fetal compromise<\/p>\n<p>\u27a1\ufe0f\u00a0the woman has ruptured membranes or vaginal bleeding<\/p>\n<p>\u27a1\ufe0f\u00a0the woman has any other medical conditions (for example, severe hypertension) that would make external cephalic version inadvisable.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Conditional<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.2.2.<\/b>\u00a0Before carrying out a caesarean birth for an uncomplicated singleton breech pregnancy, carry out an ultrasound scan to check that the baby is in the breech position. Do this as late as possible before the caesarean birth procedure.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.3. Suspected Fetal Macrosomia<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.3.1<\/b>\u00a0Cesarean delivery to avoid potential birth trauma should be limited to estimated fetal weights of at least 4500 g in women without diabetes and at least 4000 g in women with diabetes.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.4. Twin Gestations<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.4.1.<\/b>\u00a0Perinatal outcomes for twin gestations in which \ufb01rst twin is in cephalic presentation are not improved by cesarean delivery. Thus, women with either cephalic\/cephalic presenting twins or cephalic\/non-cephalic presenting twins should be counseled to attempt vaginal delivery.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.5. Predicting Caesarean Birth for Cephalopelvic Disproportion<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.5.1.<\/b>\u00a0Do not use pelvimetry for decision making about mode of birth.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.5.2.<\/b>\u00a0Do not use the following for decision making about mode of birth, as they do not accurately predict cephalopelvic disproportion:<\/p>\n<p>\u27a1\ufe0f\u00a0maternal shoe size<\/p>\n<p>\u27a1\ufe0f\u00a0maternal height<\/p>\n<p>\u27a1\ufe0f\u00a0estimations of fetal size (ultrasound or clinical examination).<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.6. Mother-To-Child Transmission of Hepatitis<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.6.1\u00a0<\/b>Hepatitis B virus:<b>\u00a0<\/b>Do not offer pregnant women with hepatitis B a planned caesarean birth for this reason alone, as mother-to-baby transmission of hepatitis B can be reduced if the baby receives immunoglobulin and vaccination.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.6.2\u00a0<\/b>Hepatitis C virus: Do not offer women who are infected with hepatitis C a planned caesarean birth for this reason alone.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.7. Body Mass Index<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.7.1.\u00a0<\/b>Do not use a BMI of over 50 kg\/m2 alone as an indication for planned caesarean birth.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.8. Cesarean On Maternal Request<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.8.1<\/b>\u00a0If a pregnant woman\u00a0 with no medical indication for a caesarean birth requests a caesarean birth:<\/p>\n<p>\u27a1\ufe0f\u00a0discuss and explore the reasons for the request<\/p>\n<p>\u27a1\ufe0f\u00a0address concerns they have about the birth as pain and pain relief options<\/p>\n<p>\u27a1\ufe0f\u00a0discuss the overall benefits and risks of CS birth compared with vaginal birth (See Appendix I)<\/p>\n<p>\u27a1\ufe0f\u00a0Document the discussion and the decision taken<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.8.2.<\/b>\u00a0Don\u2019t do cesarean section on request without a written informed \u00a0consent from the woman indicating that this is a CS on request in absence of a medical or obstetric indication.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p><b>1.9. Head Engagement in A Primigravida<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>1.9.1<\/b>\u00a0Non-engagement of the head in a primigravida should not be considered as an only factor requiring cesarean birth.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"546\">\n<p><b>2. Measures During Labor<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.1. Induction of Labor<\/b><b><\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.1.1.\u00a0<\/b>Before 41 0\/7 weeks of gestation, induction of labor generally should be performed based on maternal and fetal medical indications. Inductions at \u2265 41 0\/7 weeks of gestation should be performed to reduce risk of cesarean delivery and risk of perinatal morbidity and mortality.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.1.2<\/b>\u00a0Cervical ripening methods should be used when labor is induced in women with unfavorable cervix.<\/p>\n<p>\u00a0<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.2. First Stage of Labor: Latent Phase<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.2.1<\/b>\u00a0The use of the following definition of the latent phase of the first stages of labor is recommended for practice: The latent first stage is a period of time characterized by:<\/p>\n<p>\u27a1\ufe0f\u00a0Painful uterine contractions and<\/p>\n<p>\u27a1\ufe0f\u00a0variable changes of the cervix, including some degree of effacement and slower progression of dilatation up to 5 cm for first and subsequent labors.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.2.2\u00a0<\/b>A prolonged latent phase (eg, &gt;20 hours in nulliparous women and &gt;14 hours in multiparous women)\u00a0<u>should not<\/u>\u00a0be an indication for cesarean delivery.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.2.3.\u00a0<\/b>These durations are not recommended as an indication for intervention when maternal and fetal condition are reassuring.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.2.4.\u00a0<\/b>If slow progress is suspected, assess to identify:<\/p>\n<p>\u27a1\ufe0f\u00a0Developing complications<\/p>\n<p>\u27a1\ufe0f\u00a0Reassuring maternal and fetal condition<\/p>\n<p>\u27a1\ufe0f\u00a0Emotional and physical needs<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.3. First Stage of Labor: Active Phase<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.3.1.\u00a0<\/b>The use of the following definition of the active phase of the first stages of labor is recommended for practice:<\/p>\n<p>\u27a1\ufe0f\u00a0The active first stage is a period of time characterized by regular painful uterine contractions, and a substantial degree of cervical effacement and more rapid cervical dilatation from 5 cm until full dilatation for first and subsequent labors.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.3.2<\/b>\u00a0Use a partogram with a 4-hour action line to monitor progress of women in spontaneous labor with an uncomplicated singleton pregnancy at term starting in the active phase, to reduce the likelihood of caesarean birth.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.3.3.\u00a0<\/b>Regarding the Partogram<b>:\u00a0<\/b>A minimum cervical dilatation rate of 1 cm\/hour throughout active first stage is not recommended for identification of\u00a0<a class=\"autolink\" title=\"Normal Labor\" href=\"https:\/\/lms.ehc.gov.eg\/lms\/mod\/book\/view.php?id=744\">normal labor<\/a>\u00a0progression and a slower than 1-cm\/hour cervical dilatation rate alone should not be a routine indication for obstetric intervention.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.3.4.\u00a0<\/b>A cervical dilatation of 0.5 cm per hour (2 cm in 4 hours) is considered normal in the active phase.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.3.5.\u00a0<\/b>Protracted labor (slower progress than is usual) is diagnosed when in:<\/p>\n<p>\u00b7\u00a0Nulliparous women: a cervical dilatation of &lt;\u00a0 2 cm in 4 hours is found<\/p>\n<p>\u00b7\u00a0Multiparous women: a cervical dilatation of &lt; 2 cm in 4 hours or a slowing in the progress of labor<b><\/b><\/p>\n<p>If delay is suspected, check descent and rotation of the baby&#8217;s head and changes in the strength, duration and frequency of uterine contractions (uterine atony).<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.3.6.\u00a0<\/b>For women with intact membranes in whom delay in the established first stage of labor is confirmed:<\/p>\n<p>\u27a1\ufe0f\u00a0consider amniotomy if membranes are intact,<b><\/b><\/p>\n<p>\u27a1\ufe0f\u00a0oxytocin if inertia was diagnosed and<b><\/b><\/p>\n<p>\u27a1\ufe0f\u00a0a repeat vaginal examination 2 hours later.<b><\/b><\/p>\n<p>\u27a1\ufe0f\u00a0If oxytocin is used, ensure that the time between increments of the dose is no more frequent than every 30 minutes and increase oxytocin until there are 4\u20135 contractions in 10 minutes.<\/p>\n<p>\u27a1\ufe0f\u00a0If cervical dilatation has increased by less than 2 cm after 4 hours of oxytocin, review is required to assess the need for caesarean section.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.3.7.<\/b>\u00a0Labor may not naturally accelerate until a cervical dilatation threshold of 5 cm is reached. Therefore, the use of medical interventions to accelerate labor and birth (such as oxytocin augmentation or caesarean section) before this threshold is not recommended, provided fetal and maternal conditions are reassuring.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.3.8.\u00a0<\/b>Arrest in labor (complete cessation of progress) is diagnosed at cervical dilatation of 6 cm or more with ruptured membranes and no or limited cervical change for 4 hours of adequate contractions.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.3.9.\u00a0<\/b>Cesarean delivery for active-phase arrest in \ufb01rst stage of labor should be reserved for women \u2265 6 cm of dilation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.4. Fetal Heart Rate Monitoring<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.4.1.\u00a0<\/b>Intermittent auscultation of the fetal heart rate with either a Doppler ultrasound device or Pinard fetal stethoscope is recommended for healthy pregnant women in labor.<b><\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.4.2.\u00a0<\/b>Standardization of protocol of the intermittent auscultation is important for health care planning and medico-legal purposes and, therefore, the WHO adopted the following protocol:<\/p>\n<p>\u00b7\u00a0Interval: Auscultate every 15\u201330 minutes in active first stage of labor, and every 5 minutes in the second stage of labor.<\/p>\n<p>\u00b7\u00a0Duration: Each auscultation should last for at least 1 minute; if the FHR is not always in the normal range (i.e. 110\u2013160 bpm), auscultation should be prolonged to cover at least three uterine contractions.<\/p>\n<p>\u00b7\u00a0Timing: Auscultate during a uterine contraction and continue for at least 30 seconds after the contraction<\/p>\n<p><s>\u00b7\u00a0<\/s>Recording: Record the baseline FHR (as a single counted number in beats per minute) and the presence or absence of accelerations and decelerations<s><\/s><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p>\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.5. Second stage of labor<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.5.1.\u00a0<\/b>The use of the following definition and duration of the second stage of labor is recommended for practice: The second stage is the period of time between full cervical dilatation and birth of the baby, during which the woman has an involuntary urge to bear down, as a result of expulsive uterine contractions.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">STRONG<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.5.2.\u00a0<\/b>The duration of the second stage varies from one woman to another:<\/p>\n<p>\u27a1\ufe0f\u00a0In first labor, birth is usually completed within 2 hours<\/p>\n<p>\u27a1\ufe0f\u00a0In subsequent labors, birth is usually completed within 1 hour.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.5.3.\u00a0<\/b>Before diagnosing arrest of labor in second stage, if maternal and fetal conditions permit, allow for:<\/p>\n<p>\u27a1\ufe0f\u00a0At least 1 h of pushing in multiparous women<\/p>\n<p>\u27a1\ufe0f\u00a0At least 2 h of pushing in nulliparous women<\/p>\n<p>Longer durations may be appropriate on individualized basis (e.g., with use of epidural analgesia or with fetal malposition) as long as maternal and fetal conditions are reassuring and progress is being documented.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.5.4.\u00a0<\/b>Delay in active second stage is diagnosed when:<\/p>\n<p>\u27a1\ufe0f\u00a0In nulliparous woman (any of): either insufficient flexion\/rotation\/descent\u00a0<u>within 1 hour<\/u>\u00a0or the second stage duration is\u00a0<u>&gt; 2 hours<\/u>.<\/p>\n<p>\u27a1\ufe0f\u00a0In multiparous woman (any of): either insufficient flexion\/rotation\/descent\u00a0<u>within 30 minutes<\/u>\u00a0or the second stage duration\u00a0<u>is &gt; 1 hour<\/u>.<\/p>\n<p>Longer durations may be appropriate where maternal and fetal condition is optimal.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.5.5.\u00a0<\/b>A specific absolute maximum length of second stage (passive plus active) has not been identified. Rather than rigid time limits, base decision-making on continuing assessment of:<\/p>\n<p>\u27a1\ufe0f\u00a0Maternal physical and emotional condition<\/p>\n<p>\u27a1\ufe0f\u00a0Fetal condition<\/p>\n<p>\u27a1\ufe0f\u00a0Progress of labor<\/p>\n<p>\u27a1\ufe0f\u00a0Maternal preferences<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">GPS<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"546\">\n<p><b>2.5.6.\u00a0<\/b>Operative vaginal delivery in second stage of labor by experienced and well-trained physicians should be considered safe, acceptable alternative to cesarean delivery. Training in, and ongoing maintenance of, practical skills related to operative vaginal delivery should be encouraged.<\/p>\n<\/td>\n<td valign=\"top\" width=\"136\">\n<p align=\"center\">Strong<\/p>\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<br \/>\n<p>\u00a0<\/p>\n<p>\u00a0<\/p>\n<p>\u00a0<\/p>\n<\/div>\n<\/div>\n<div class=\"mt-5 mb-5 activity-navigation\">\n<div class=\"row\">\n<div class=\"col-md-4\">\n<div class=\"float-left ui_kit_btn\">\u00a0<\/div>\n<\/div>\n<div class=\"col-md-4\">\n<div class=\"mdl-align\">\n<div class=\"urlselect\">\u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>                    <\/div>\n\n                <\/div>\n                            <div class=\"ui-e-accordion-item ui-e-item\" role=\"button\" tabindex=\"0\" aria-expanded=\"false\" aria-controls=\"ui-e-acc-8\" id=\"ui-e-primary-postpartum-hemorrhage\">\n\n                    <h5 class=\"ui-e-accordion-title ui-e-title ui-right\">\n\n                                                    <span class=\"ui-e-accordion-icon ui-e-icon ui-e-right\" aria-hidden=\"true\">\n\n                                <span class=\"ui-e-accordion-icon-closed\">\n                                    <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-down\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M207.029 381.476L12.686 187.132c-9.373-9.373-9.373-24.569 0-33.941l22.667-22.667c9.357-9.357 24.522-9.375 33.901-.04L224 284.505l154.745-154.021c9.379-9.335 24.544-9.317 33.901.04l22.667 22.667c9.373 9.373 9.373 24.569 0 33.941L240.971 381.476c-9.373 9.372-24.569 9.372-33.942 0z\"><\/path><\/svg>                                <\/span>\n\n                                                                    <span class=\"ui-e-accordion-icon-opened\">\n                                        <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-up\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M240.971 130.524l194.343 194.343c9.373 9.373 9.373 24.569 0 33.941l-22.667 22.667c-9.357 9.357-24.522 9.375-33.901.04L224 227.495 69.255 381.516c-9.379 9.335-24.544 9.317-33.901-.04l-22.667-22.667c-9.373-9.373-9.373-24.569 0-33.941L207.03 130.525c9.372-9.373 24.568-9.373 33.941-.001z\"><\/path><\/svg>                                    <\/span>\n                                \n                            <\/span>\n                        \n                                                <span class=\"ui-e-accordion-title-text ui-e-title-text\" >\n                                                        Primary Postpartum Hemorrhage                        <\/span>\n\n                    <\/h5>\n\n                    <div class=\"ui-e-accordion-content ui-e-content\" style=\"display:none;\" aria-labelledby=\"ui-e-primary-postpartum-hemorrhage\" id=\"ui-e-acc-8\">\n                        <div id=\"yui_3_18_1_1_1781924642384_20\" class=\"activity-header\" data-for=\"page-activity-header\">\n<div id=\"intro\" class=\"activity-description\">\n<div class=\"no-overflow\">\n<h5>&#8220;last update: 17 December \u00a02025&#8221;<strong>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0<a href=\"https:\/\/lms.ehc.gov.eg\/lms\/pluginfile.php\/1411\/mod_book\/intro\/Dec%202025%20PPH.pdf\"><u>Download Guideline<\/u><\/a><\/strong><\/h5>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chaptersnavigation\">\n<div class=\"container-fluid tertiary-navigation\">\n<div class=\"row\">\n<div class=\"navitem ms-auto\">\u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chapter\" class=\"box py-3 generalbox book_content\">\n<h3 class=\" ccnMdlHeading\">&#8211; Executive Summary<\/h3>\n<div class=\"no-overflow\">\n<p dir=\"ltr\">\u00a0<\/p>\n<p>This guideline offers evidence-based recommendations on prevention and management of postpartum hemorrhage. The recommendations are intended to provide healthcare professionals with practical guidance on risk prevention, treatment interventions and improving health outcomes for cases of postpartum hemorrhage.<\/p>\n<div>\n<p><b>List of Recommendations<\/b><b><\/b><\/p>\n<\/div>\n<table border=\"1\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p align=\"center\"><b>Recommendation<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strength<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1. PREVENTION OF POSTPARTUM HEMORRHAGE<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.1 Risk Assessment:<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.1.1.<\/b>\u00a0Risk factors for PPH may present antenatally or intrapartum; care plans must be modi\ufb01ed as and when risk factors arise.<\/p>\n<\/td>\n<td valign=\"top\" width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.1.2.\u00a0<\/b>Clinicians must be aware of risk factors for PPH and should take these into account when counselling women about place of delivery.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.1.3.<\/b>\u00a0Women with known risk factors for PPH should only be delivered in a hospital with a blood bank on site.<u><\/u><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.1.4.\u00a0<\/b>An individualized risk assessment for postpartum hemorrhage should be documented upon arrival to a labor unit and updated throughout labor and delivery.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.2 Risk Factors<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.2.1<\/b>\u00a0Consider the following\u00a0<b>antenatal risk factors<\/b>\u00a0for PPH<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Age &gt; 35<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Obesity (BMI &gt;35)<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0More than 3 prior births<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Previous PPH<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Previous Cesarean section with placenta previa or PAS<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Previous uterine surgery<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Presence of uterine fibroid<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Multiple pregnancy<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Polyhydramnios<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Fetal macrosomia<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Anemia<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Known coagulopathy or other bleeding disorders<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.2.2.<\/b>\u00a0Consider the following\u00a0<b>intrapartum risk factors<\/b>\u00a0for PPH<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Oxytocin use in labor<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Prolonged second stage<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Prolonged third stage<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Retained placenta<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Manual removal of placenta<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Assisted vaginal birth<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Cesarean section whether elective or emergency<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Perineal trauma<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Uterine rupture<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0General anaesthesia<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Infection<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Non-cephalic presentation<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Precipitate labor<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.3. Antenatal Risk Management<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.3.1. Antenatal anemia<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.3.1.1.<\/b>\u00a0Antenatal anemia should be investigated and treated appropriately as this may reduce the morbidity associated with PPH.<b><\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.3.2. Maternal blood disorders<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p>\u00a0<b>1.3.2.1.<\/b>\u00a0Involve specialist physician to:<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Optimize coagulation profile prior to birth<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Advise on birth options (e.g. mode of birth)<\/p>\n<p><b>1.3.2.2.\u00a0<\/b>Seek anesthetic opinion regarding options for analgesia during labor and birth<b><\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.3.3. Abnormal placentation<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.3.3.1.<\/b>\u00a0Determine placental site and if abnormal placental adherence is suspected (PAS):<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Refer to a center equipped for placenta accreta management.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Involve multidisciplinary team including urologist, general surgeon, vascular surgeon,\u00a0 hematologist, senior anaesthetist and ICU specialist in preoperative planning.<b><\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.4. Intrapartum Risk Management<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.4.1. Management of third stage of labor<\/b><\/p>\n<p>The use of uterotonics for prevention of PPH during the third stage of labor<\/p>\n<p>is recommended for all births.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.4.2. Cord clamping:<\/b><\/p>\n<p><b>1.4.2.1.<\/b>\u00a0Late cord clamping (performed approximately 1 to 3 minutes after birth) is recommended for all births while initiating simultaneous essential newborn care.<\/p>\n<p><b>1.4.2.2.\u00a0<\/b>Early cord clamping (&lt;1 minute after birth) is not recommended unless the neonate is asphyxiated and needs to be moved immediately for resuscitation.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.4.3. Controlled cord traction:<\/b><\/p>\n<p><b>1.4.3.1<\/b>\u00a0Consider Controlled cord traction (CCT) as part of active\/modified active management of third stage as it may.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.4.3.2.<\/b>\u00a0Providers employing CCT should only do so after signs of placental separation, and traction should be performed with uterine contraction as these measures reduce the risk of uterine inversion, cord avulsion, and partial detachment of the placenta.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<br \/>\n<p>\u00a0<\/p>\n<table border=\"1\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.5. Prophylactic Uterotonics:<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.5.1. Oxytocin:<\/b><\/p>\n<p><b>1.5.1.1.\u00a0<\/b>In most circumstances, oxytocin is the prophylactic uterotonic of choice.<\/p>\n<p><b>1.5.1.2<\/b>\u00a0For vaginal birth<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If vaginal birth with IV access: Oxytocin 10 IU IV injected slowly over 3\u20135 minutes is recommended in preference to IM<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If vaginal birth without IV access: Oxytocin 10 IU IM<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b><u>To be transferred ransfer to rational:<\/u><\/b>\u00a0When compared with IM, IV oxytocin reduces the risk of PPH, need for blood transfusion 60-62 and incidence of retained placenta with no significant difference in side effects (e.g. hypotension and tachycardia) between routes 60,61<\/p>\n<p><b>1.5.1.3.<\/b>\u00a0For CS birth:<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Oxytocin 5 IU IV over 1\u20132 minutes<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Monitor for hemodynamic impact<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Avoid rapid IV bolus administration<\/p>\n<p><b>1.5.1.4.\u00a0<\/b>If cardiovascular compromise exists (e.g. hypovolemia, shock, cardiac disease), use caution with IV administration.\u00a0<b><u>Rational\u00a0<\/u><\/b>it may result in transient hemodynamic instability\u00a0<b><u>61, 65<\/u><\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.5.2. Ergometrine<\/b>:<\/p>\n<p><b>1.5.2.1\u00a0<\/b>Ergometrine can be given IM or, in life-saving circumstances, as a slow IV injection.<\/p>\n<p><b>1.5.2.2.<\/b>\u00a0Ergometrine should not be used in patients with essential or gestational hypertension, or in patients on HIV protease inhibitors.<\/p>\n<p><b>1.5.2.3.<\/b>\u00a0Though undisputedly extremely effective, potential adverse effects limit ergometrine to a second-line agent.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.5.3. Carbetocin<\/b>:<\/p>\n<p><b>1.5.3.1.<\/b>\u00a0Routinely use\u00a0<b><i>oxytocin<\/i><\/b>\u00a0<b><i>in preference to carbetocin<\/i><\/b>\u00a0if vaginal birth and cold-chain storage of oxytocin can be guaranteed (e.g. hospital setting).<\/p>\n<p><b>1.5.3.2.<\/b>\u00a0If vaginal birth and cold-chain storage of uterotonics cannot be guaranteed:<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Carbetocin is an effective alternative uterotonic<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0IM is preferred route of administration<\/p>\n<p><b>1.5.3.2.\u00a0<\/b>If CS birth under regional anesthetic: IV carbetocin may be considered as a cost effective uterotonic<\/p>\n<p><b>1.5.3.3.<\/b>\u00a0If CS birth under general anesthetic: Carbetocin is not recommended due to insufficient evidence.<\/p>\n<p><b>1.5.3.4.<\/b>\u00a0If used: used as a single dose only, not for repeated use<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.5.4. Misoprostol<\/b>:<\/p>\n<p><b>1.5.4.1.<\/b>\u00a0Not recommended if alternative injectable uterotonics are available<\/p>\n<p><b>1.5.4.2.\u00a0<\/b>Use only if no other injectable uterotonic is available (e.g. due to unexpected birth in low resource setting or if storage conditions for uterotonics are inadequate).<\/p>\n<p><b>1.5.4.3.\u00a0<\/b>The dose is<b>\u00a0<\/b>600 micrograms orally or sublingual single dose immediately after birth<\/p>\n<p><b>1.5.4.4.\u00a0<\/b>If in a low resource setting with limited PPH treatment capability, consider use if:<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0an injectable uterotonic has been administered AND<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0continued bleeding is anticipated and\/or blood loss is estimated to be greater than or equal to 350 mL \u00a0<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.6. Tranexamic Acid (TXA) For Prophylaxis in High Risk Women<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.6.1.\u00a0<\/b>Tranexamic acid can be used as a prophylactic agent as an adjunct to uterotonics in patients at\u00a0<b><i>high risk for postpartum hemorrhage.<\/i><\/b><\/p>\n<p><b>1.6.2.<\/b>\u00a0Use TXA\u00a0<b><i>within 3 hours<\/i><\/b>\u00a0<b><i>of birth<\/i><\/b>\u00a0of the baby in a fixed dose of 1 g in 10 mL IV over 10 minutes (100 mg\/min i.e. 1 ml \/minute)<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.7. Immediate Postpartum Risk Management<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.7.1. Uterine massage:<\/b><\/p>\n<p>Sustained uterine massage is not recommended as an intervention to prevent PPH in women who have received prophylactic oxytocin.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.7.2. Uterine tonus assessment:<\/b><\/p>\n<p>Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.7.3. Nipple stimulation &amp; breast feeding:<\/b><\/p>\n<p>Nipple stimulation and\/or early breastfeeding may increase uterine activity but has not been shown to reduce bleeding or incidence of PPH.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>1.7.4. Observation for women with risk factors in the first 2 hours postpartum:<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Vital signs: Respiratory rate, pulse rate, and blood pressure, every 15-30 minutes in the first hour and every 30 minutes in the second hour.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Blood Loss every 15-30 minutes by visualizing the labia and perineum and be alert for slow steady trickle.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Temperature every 30 minutes<\/p>\n<p>\u00b7\u00a0 \u00a0 \u00a0 \u00a0Uterine tonus assessment<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Urine output: after the first 2 hours<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0After the first 2 hours continue as clinically indicated<b><\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>2. RECOGNITION OF PPH<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>2.1. General Principles In Diagnosis of PPH<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>2.1.1\u00a0<\/b>Early recognition of postpartum hemorrhage (before deterioration in vital signs) is recommended and should be the goal in order to improve outcomes.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>2.1.2.\u00a0<\/b>Clinical signs and symptoms of hypovolemia should be included in the assessment of PPH. However, clinicians should be aware that the signs of hypovolemic shock become less sensitive in pregnancy.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>2.1.4.\u00a0<\/b>Consider initiation of response to PPH when there is excessive bleeding in the first 24 hours post birth, judged clinically, or through estimation of blood loss volume (&gt; 500 ml after VD or 1000ml after CS), or changes in the hemodynamic state.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>2.2 Visual Assessment of The Amount of Postpartum Blood Loss<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>2.2.1.\u00a0<\/b>Visual estimation of blood loss<b>\u00a0<\/b>is always subjective and can be imprecise and often leads to underestimation of large volumes or overestimation of small volumes<\/p>\n<p><b>2.2.2.<\/b>\u00a0When conducting visual assessment of blood loss, consider the volume, nature and speed of blood loss.<\/p>\n<p><b>2.2.3.<\/b>\u00a0Simulated scenarios and pictorial guides may improve staff accuracy\u00a0\u00a0<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>2.3. Quantitative Measurement of The Amount of Postpartum Blood Loss<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>2.3.1<\/b>\u00a0Consider that quantitative measurement, provides a more accurate assessment of blood loss when compared with visual estimation.<\/p>\n<p><b>2.3.2.\u00a0<\/b>Consider measurement of blood loss by blood collection drapes for vaginal deliveries,5,10 or the weighing of swabs and weigh blood-soaked items (e.g. linen, pads, swabs, drapes) to quantify volume.5,60 If weighing, 1 gram is equivalent to 1 mL blood loss.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>2.4. Diagnosis of PPH &amp; Assessment of Hemodynamic Compromise<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>2.4.1.\u00a0<\/b>PPH can be minor (500\u20131000 ml blood loss) or major (more than 1000 ml blood loss). The condition becomes worse if the patient lost &gt;2000 mL of blood.<\/p>\n<p><b>2.4.2. Diagnose minor PPH (blood loss 500-1000 mL) if there are:<\/b>\u00a0<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Normal blood pressure<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Mild increase in heart rate (but &lt;100 beats\/minute)<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Palpitation<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Lightheadedness<\/p>\n<p><b>2.4.3. Diagnose major PPH (blood loss from 1000-2000 mL) if there are:\u00a0<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Drop of blood pressure below the original average of the patient<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Tachycardia (\u2265 100 beats\/minute)<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Sweating<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Weakness<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>2.4.4.\u00a0<\/b>Signs of hemodynamic compromise are a late indicator of PPH and may not be evident until large volumes of blood are lost (e.g. up to 25% of total blood volume or greater than 1500 mL).<\/p>\n<p><b>2.4.5.<\/b>\u00a0<b>Don\u2019t wait for the following to diagnose major PPH as blood loss is already &gt;2000 mL and the condition would be severe enough to be of poorer prognosis:<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Systolic blood pressure drops below 70-80 mmHg\u00a0<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Tachycardia (120-140 beats\/minute)<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Restlessness, confusion and pallor<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Oliguria<\/p>\n<p><b>2.4.6.\u00a0<\/b>Conversely, compromise may occur earlier in women with:<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Gestational hypertension with proteinuria<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Anemia<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Dehydration<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Small stature<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Cardiac disease<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>3. RESPONDING TO AND MANAGEMENT OF PPH<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>3.1. General Principles In Responding To PPH<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>3.1.1.<\/b>\u00a0Bleeding after labor is an emergency and responding to it should not be delayed and should start as early as possible and goes hand in hand with the rest of management (Communication with the patient, senior staff, resuscitation investigation, and monitoring).<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>3.1.2.<\/b>\u00a0Use an approach that involves maintaining hemodynamic stability while simultaneously identifying and treating the cause of blood loss.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>3.1.3.\u00a0<\/b>The urgency and measures undertaken to resuscitate and arrest hemorrhage need to be tailored to the amount of blood loss (which is usually underestimated), the patient general condition, and the degree of shock.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>3.1.4<\/b>\u00a0<b>The GDG recommends adoption of the EMOTIVE bundle<\/b>\u00a0<b>(Early detection, Massage, Oxytocics, Tranexamic acid, IV fluids, Examination &amp; Escalation) as the standard first-response protocol for all cases of postpartum hemorrhage<\/b>. Initiate all components within 15 minutes of PPH diagnosis to ensure rapid, standardized, and evidence-based management, with ongoing monitoring and escalation\u00a0as\u00a0needed, see Appendix II.<b><\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>3.2. Communication And Multidisciplinary Care:<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>3.2.1.\u00a0<\/b>Communication with the patient and her birthing partner is important, and clear information of what is happening should be given from the outset.<\/p>\n<p><b>3.2.2.\u00a0<\/b>Relevant staff with an appropriate level of expertise should be alerted of PPH.<\/p>\n<p><b>3.2.3.\u00a0<\/b>The \ufb01rst-line obstetric and anesthetic staff should be alerted when women present with minor PPH (blood loss 500\u20131000 ml) without clinical shock<\/p>\n<p><b>3.2.4.<\/b>\u00a0A multidisciplinary team involving senior members of staff should be\u00a0<span lang=\"EN-GB\">called<\/span>\u00a0to attend to women with major PPH (blood loss of more than 1000 ml) and ongoing bleeding or clinical shock<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>3.3. Responding To &amp; Managing Minor PPH<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>3.3.1. Measures for minor PPH (blood loss 500\u20131000 ml) without clinical shock:<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Establish IV access: 2 wide bore IV cannulas (Orange 14G &amp; Grey 16G) are to be inserted. 14G for \ufb02uid and blood replacement &amp; 16G for pharmacologic therapy\u00a0<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Urgent venipuncture and obtain 20 ml of blood for:<\/p>\n<p>o\u00a0\u00a0\u00a0Grouping &amp; cross-matching<\/p>\n<p>o\u00a0\u00a0\u00a0Full blood count<\/p>\n<p>o\u00a0\u00a0\u00a0Coagulation screen, including \ufb01brinogen, if available<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Pulse, respiratory rate and blood pressure recording every 15 minutes<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Commence warmed crystalloid infusion.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b><i>If bleeding is rapid and patient continues to bleed, consider starting the full protocol for major PPH<\/i><\/b>.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In minor PPH, there are no firm criteria for initiating red cell transfusion. The decision to provide blood transfusion should be based on both clinical and hematological assessment.<b><\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>3.4. Identification of The Cause (the 4Ts)<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>3.4.1.<\/b>\u00a0If blood loss after delivery seems increased, start the measures of minor PPH and immediately assess for the\u00a0<b>T<\/b>one of the uterus, the presence of\u00a0<b>T<\/b>rauma, any retained\u00a0<b>T<\/b>issue or\u00a0<b>T<\/b>hrombin activity.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Tone:\u00a0<\/b>massage the fundus to see whether the uterus is atonic or well contracted.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Tissue:\u00a0<\/b>retained placental fragment. Inspect the placenta for a missing part. Also suspect retained placental fragment or pieces of membranes as a cause if there is atonic fundus unresponsive to uterotonics.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Trauma:\u00a0<\/b>if fundus is well contracted, blood clotting is ok and no placental remnants, explore birth canal for improperly repaired birth tract injuries.<b><\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Thrombin:\u00a0<\/b>The fundus is contracted (may be atonic) and the blood is not clotting.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Other unknown causes:\u00a0<\/b>if all of the above is normal, assess for uterine rupture\/ inversion, concealed bleeding (e.g. vault hematoma, internal hemorrhage after CS) and non-genital causes (e.g. subcapsular liver rupture).<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>3.5. Responding To &amp; Managing Major PPH<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>3.5.1. Full protocol for major PPH (blood loss greater than 1000 ml) and continuing to bleed or clinical shock:<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>A and B<\/b>: assess\u00a0<b>A<\/b>irway and\u00a0<b>B<\/b>reathing<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>C<\/b>\u00a0\u2013 evaluate\u00a0<b>C<\/b>irculation<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Position the patient flat<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Insert two peripheral cannulas (14 gauge) if not inserted before<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Immediately draw 20 mL of blood for:<\/p>\n<p>o\u00a0\u00a0\u00a0Cross-matching (4 units of blood minimum)<\/p>\n<p>o\u00a0\u00a0\u00a0Full blood count<\/p>\n<p>o\u00a0\u00a0\u00a0Coagulation screen (PT, INR, aPTT including \ufb01brinogen, if available)<\/p>\n<p>o\u00a0\u00a0\u00a0Chemistry pro\ufb01le (Serum Creatinine, SGOT, SGPT, Albumin, LDH, Blood Sugar)<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Keep the woman warm using appropriate available measures<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Transfuse blood as soon as possible.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Until blood is available, infuse up to 3.5 L of warmed crystalloids as Lactated Ringer\u2019s (1\u20132 mL for every 1 mL of blood loss)<b><sup>2<\/sup><\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Stop fluid once blood is ready.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0The best equipment available should be used to achieve rapid warmed infusion of fluids.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Special blood filters should not be used, as they slow infusions.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If actively bleeding, transfuse early and do not wait unnecessarily for laboratory results and use clinical assessment as the main determinant<\/p>\n<p><b>3.5.2. Blood transfusion:<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>3.5.2.1.<\/b>\u00a0If actively bleeding, transfuse early, do not wait unnecessarily for laboratory results. The clinical picture should be the main determinant of the need for blood transfusion and time should not be unnecessarily spent awaiting laboratory results.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>3.5.2.2. Packed RBCs:<\/b><\/p>\n<p>o\u00a0\u00a0\u00a0Provide emergency blood (Packed RBCs) with immediate issue of group O, rhesus D (RhD)-negative, with a switch to group-speci\ufb01c blood as soon as feasible.<b><\/b><\/p>\n<p>o\u00a0\u00a0\u00a0Single Hb\/hematocrit estimations may be misleading and can lead to delays in initiating red cell transfusion, serial measurements may be helpful to monitor ongoing progress.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>3.5.2.2. Transfusion of FFP:<\/b><\/p>\n<p>o\u00a0\u00a0\u00a0Administration of FFP should be guided by coagulation pro\ufb01le test results and whether bleeding is continuing.<\/p>\n<p>o\u00a0\u00a0\u00a0But if coagulation profile results are not available and bleeding is continuing,\u00a0<b><i>after 4 units of red blood cells<\/i><\/b>, 4 units of FFP should be infused until test results are known.<\/p>\n<p>o\u00a0\u00a0\u00a0If coagulation profile results are not available, early FFP should be considered for conditions with a suspected coagulopathy, such as placental abruption or amniotic \ufb02uid embolism, or where detection of PPH has been delayed.<\/p>\n<p>o\u00a0\u00a0\u00a0If prothrombin time\/activated partial thromboplastin time is more than 1.5 times normal and hemorrhage is ongoing, more units of FFP are likely to be needed to correct coagulopathy.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>3.5.2.3.<\/b>\u00a0Clinicians should be aware that these blood components must be ordered as soon as a need for them is anticipated, as there will always be a short delay in supply because of the need for thawing.<\/p>\n<p><b>3.5.3. Cryoprecipitate For Fibrinogen Replacement<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0A plasma fibrinogen level of greater than 2 g\/l should be maintained, if test is available, during ongoing PPH.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Cryoprecipitate should be used for fibrinogen replacement.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Physician should be aware that fibrinogen below 3 g\/l and especially below 2 g\/l is associated with progression of bleeding, increased RBC and blood component requirements, and the need for invasive procedures.<\/p>\n<p><b>3.5.4. Transfusion of platelets<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0During PPH, platelets should be transfused when the platelet count is less than 75 \u00d7 10<sup>9<\/sup>\/l (75000 \/ mm<sup>3<\/sup>) based on laboratory monitoring.<b><\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0The platelets should ideally be group compatible. RhD-negative women should receive RhD-negative platelets.<\/p>\n<p><b>3.5.5.<\/b>\u00a0Use Continued Resuscitation with lab-guided replacement to\u00a0<b><i>maintain the following lab parameters<\/i><\/b>:<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Hb greater than 8 gm%<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Platelet count greater than 50 \u00d7 109 \/l (50000\/mm<sup>3<\/sup>)<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Prothrombin time (PT) less than 1.5 times normal<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Activated partial thromboplastin time (APTT) less than 1.5 times normal\u00a0<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Fibrinogen level greater than 2 g\/l.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>3.5.5. Tranexamic acid (TXA)<\/b><b><\/b><\/p>\n<p><b>3.5.5.1.\u00a0<\/b>Tranexamic acid can be used in\u00a0<b><i>all patients as an adjunct to uterotonics<\/i><\/b>\u00a0in the setting of postpartum hemorrhage regardless of whether the bleeding is due to genital tract trauma or other causes.<\/p>\n<p><b>3.5.5.2.<\/b>\u00a0Give TXA\u00a0<b><i>as early as possible<\/i><\/b>,\u00a0<i>ideally\u00a0<\/i><i>within 3 hours of birth<\/i>, in a fixed dose of 1 g in 10 mL (100 mg\/mL) IV at 1 mL per minute (i.e., over 10 minutes).<\/p>\n<p><b>3.5.5.3.\u00a0<\/b>A second dose of 1 g IV may be administered if bleeding continues after 30 minutes of the first dose or for bleeding that stops but restarts within 24 hours of completing the first dose.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>4. MONITORING AND INVESTIGATIONS IN MAJOR PPH<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>4.1\u00a0<\/b>Immediate venipuncture (20 ml) for:<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Cross-matching (4 units of Packed RBCs minimum)<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0FBC<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Coagulation screen (PT, INR, aPTT including \ufb01brinogen, if available)<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Chemistry pro\ufb01le (Serum Creatinine, SGOT, SGPT, Albumin, LDH, Blood Sugar)<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Repeat as necessary<\/p>\n<p><b>4.2\u00a0<\/b>Continuous pulse, blood pressure and respiratory rate recording (preferably using oximeter, electrocardiogram and automated blood pressure recording when available) and Monitor temperature every 15 minutes.<\/p>\n<p><b>4.3.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Foley\u2019s catheter to monitor urine output<\/p>\n<p><b>4.4.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Documentation of \ufb02uid balance, blood, blood products and procedures.<\/p>\n<p><b>4.5.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Consider transfer to intensive therapy unit once the bleeding is controlled or monitoring at high dependency unit on delivery suite, if appropriate.<\/p>\n<p><b>4.6.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Consider objective scoring system for monitoring as the MEOWS Score (see Appendix II)<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>5. ROLE OF THE ANESTHETIST IN THE MANAGEMENT OF PPH<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p>The management of PPH requires a multidisciplinary approach: Allow the anesthetist to play a crucial role in maintaining hemodynamic stability and, in determining and administering the most appropriate method of anesthesia.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>6. PAIN MANAGEMENT<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p>Consider pain relief requirements during initial resuscitation and all subsequent treatments<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>7. PHARMACOLOGICAL AND MECHANICAL STRATEGIES IN MANAGEMENT OF PPH<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>7.1.<\/b>\u00a0Clinicians should be prepared to use a combination of pharmacological, mechanical and surgical methods to arrest PPH. These methods should be directed towards the causative factor.<b><\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>7.2.<\/b>\u00a0When uterine atony is perceived to be a cause of the bleeding, then a sequence of pharmacological and mechanical measures (in the form of uterine massage and urinary bladder catheterization) should be instituted until the bleeding stops.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>7.3<\/b>\u00a0Stopping the bleeding should not be delayed and should start as early as possible and\u00a0<b><i>goes hand in hand with the rest of management above<\/i><\/b>\u00a0(Communication and multidisciplinary approach, Resuscitation, Investigation, and Monitoring)<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>7.4.<\/b>\u00a0The most common cause of primary PPH is uterine atony. The initial management of PPH should, therefore, involve measures to stimulate myometrial contractions. Thus, mechanical and pharmacological measures should be instituted\/administered as needed.<\/p>\n<p><b>7.5.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Palpate the uterine fundus and rub it to stimulate contractions and expel its contents (\u2018rubbing up the fundus\u2019)<\/p>\n<p><b>7.6.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b>Ensure that the bladder is empty (Foley catheter &amp; leave in place)<\/p>\n<p><b>7.7\u00a0<\/b><b><i>First line pharmacological therapy for uterine atony\u00a0<\/i><\/b>(<b><i>Oxytocin<\/i><\/b>):<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Give oxytocin 5 IU IV over 1-2 minutes (even if had the prophylactic dose before). The dose may be repeated, only once, after \ufb01ve minutes but consider the maximum dose for IV oxytocin which is 10 IU IV.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Rapid IV bolus administration may cause hypotension, tachycardia, arrhythmia and myocardial ischemia.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Continue with oxytocin IV infusion 40 IU in 500 mL of either 0.9% sodium chloride (saline) or compound sodium lactate (Ringer\u2019s lactate) at a rate of 5-10 IU\/hour via:<\/p>\n<p>o\u00a0\u00a0\u00a0Using ordinary IV line about adjust it to deliver 20-40 drop\/minute<\/p>\n<p>o\u00a0\u00a0\u00a0Infusion pump, if available, equals to 62.5\u2013125 mL per hour<\/p>\n<p>o\u00a0\u00a0\u00a0Minimum infusion duration is 2 &#8211; 4 hours; use clinical judgement.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Oxytocin infusion may be a safer alternative to a bolus dose of oxytocin in some women (e.g. major cardiovascular disorders)<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If the patient had induction of labor (IOL) with oxytocin, you may use the same infusion but at increased rate.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If IV access unavailable or delayed, oxytocin 10 IU IM can be administered<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If carbetocin has already been given, consider non-oxytocin uterotonic instead<\/p>\n<p><b>7.8\u00a0<\/b><b><i>Supplemental therapy if no adequate response:<\/i><\/b>\u00a0give the following:<\/p>\n<p><b>7.8.1.\u00a0\u00a0\u00a0<\/b>Ergometrine maleate:<\/p>\n<p>o\u00a0\u00a0\u00a00.25 &#8211; 0.5 mg IV over 1-2 minutes (dilute 250 micrograms in 5 mL 0.9% sodium chloride) that may be repeated every 5 minutes to a maximum of 1 mg<\/p>\n<p>o\u00a0\u00a0\u00a0It is contraindicated with retained placenta, severe hypertension, pre-eclampsia, eclampsia severe\/persistent sepsis, renal, hepatic, vascular, or cardiac disease<\/p>\n<p><b>7.8.2.\u00a0\u00a0\u00a0<\/b>Misoprostol:<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Consider misoprostol if alternative uterotonics unavailable or contraindicated (e.g. asthma, hypertension) or if bleeding not effectively controlled with oxytocin.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Give 800 mcg sublingual (rapid onset of action with side effects more likely)<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Or 1000 mcg per rectum (slow absorption but prolonged effect)<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Consider clinical circumstances when determining optimal route<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Side e\ufb00ects: Hyperthermia is a common side e\ufb00ect (&gt;38 C is common) and malignant hyperthermia &gt; 40 C has been reported in 1 &#8211; 14% of cases<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>8. SURGICAL TREATMENTS OF PPH<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>8.1.<\/b>\u00a0If pharmacological measures fail to control the hemorrhage, surgical interventions should be initiated sooner rather than later and the most experienced, anesthetist and obstetrician should be called to be involved in the management.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>8.2.<\/b>\u00a0<b>Transfer the patient to the operative theatre<\/b>\u00a0flat with high-flow oxygen and\u00a0<b><i>perform an examination under anesthesia<\/i><\/b>\u00a0for the exclusion of the presence of remnants (to be evacuated if present) and dealing with any birth tract injuries if found<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>8.3. Bimanual Compression:\u00a0<\/b>The use of bimanual uterine compression is recommended as a temporary measure until appropriate care is available for the treatment of PPH due to uterine atony after vaginal delivery<b><\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>8.4.<\/b>\u00a0<b>Intrauterine balloon tamponade:<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If bimanual compression has been e\ufb00ective consider the use of intrauterine balloon tamponade (e.g. Bakri Balloon) as balloon is an appropriate \ufb01rst-line \u2018surgical\u2019 intervention for most women where uterine atony is the only or main cause of hemorrhage after the success of bimanual uterine compression.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0After insertion, assess blood loss:<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If bleeding continues, balloon tamponade may be ineffective\u2014review aetiology of PPH, check balloon placement and consider other surgical interventions.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If bleeding ceases on insertion, monitor fundal height, uterine cramping and signs of increased blood loss regularly<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Balloon is left for 6 hours if bleeding stopped and removed in presence of senior sta\ufb00 lest the return of bleeding.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>8.5.<\/b>\u00a0<b>If bimanual compression is ineffective or balloon tamponade fail:<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Consider exploratory laparotomy when less invasive approaches fail to control bleeding. In the setting of a vaginal delivery, it is common to use a midline vertical abdominal incision for laparotomy, to optimize exposure and reduce risk of surgical bleeding. In the setting of cesarean birth, the existing surgical incision may be used.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Conservative surgical interventions (compression sutures and\/or arterial ligation) may be attempted as a second line, depending on clinical circumstances and available expertise.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Timing is critical. Surgical interventions should be initiated sooner rather than later.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Weigh bene\ufb01ts of conservative versus aggressive management (hysterectomy)<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>8.6 Hemostatic uterine suture (e.g. B-Lynch suture)<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Judiciously apply aortic compression (below the level of the renal arteries) as a temporary measure<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Consider B-Lynch compression or other compression suture<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0It is preferable that a laminated diagram of the brace suture technique, as B-lynch suture, be kept in theatre.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>8.7. Arterial ligation: Stepwise arterial ligation for uterine devascularization may be considered depending on clinical circumstances and available expertise:<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Bilateral uterine artery ligation<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Bilateral utero-ovarian artery ligation<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If expertise available, bilateral internal iliac artery ligation<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>8.8. Hysterectomy:<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p>8.8.1. Resort to hysterectomy early (sooner rather than later) especially if:<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Life is threatened (hemodynamic unstable patient),<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Bleeding continues after use of conservative treatment options<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0blood transfusion is limited or not an option.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In cases of placenta accreta or uterine rupture.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p>8.8.2.\u00a0\u00a0\u00a0Subtotal (Supra-Vaginal) hysterectomy is quicker and safer in Major PPH and in packing of the abdomen, use hot packs.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p>8.8.3.\u00a0\u00a0\u00a0Ideally and when feasible, a second experienced clinician should be involved in the decision for hysterectomy.<b><\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p>8.8.4.\u00a0\u00a0\u00a0In rare situations in spite of compression, arterial ligation and hysterectomy, bleeding from undefined origin might persist in the pelvis (undefined diffuse venous bleeding or bleeding due to DIC). Tight pelvic packing with radio-opaque packs, done by a senior obstetrician, may be a last resort to be followed by temporarily closing the abdomen, stabilization of the patient condition by multidisciplinary team, then reopening the abdomen again to remove the packs and reassess hemostasis after\u00a024-48\u00a0hours.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>9.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b><b>RISK MANAGEMENT<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>9.1.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b><b>\u00a0Training and Preparation<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p>Every maternity unit should have a multidisciplinary protocol for the management of PPH.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p>All staff involved in maternity care should receive training in the management of obstetric emergencies, including the management of PPH.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p>Training for PPH should be multidisciplinary and multiprofessional including team rehearsals.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p>All cases of PPH involving a blood loss of greater than 1500 ml should be the subject of a formal clinical incident review.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>9.2.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b><b>\u00a0Documentation<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p>Accurate documentation of a delivery with PPH is essential.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>9.3.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b><b>\u00a0Consent<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p>If treatment is likely to affect woman\u2019s fertility, prioritize gaining informed consent.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p><b>10.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b><b>Postnatal Care<\/b><\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p>Upon discharge: Educate about signs, symptoms and self-referral regarding persistent or increasing bleeding, infection and risk of secondary PPH, postnatal depression, and venous thromboembolism<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p>Oral iron supplementation, either alone or in combination with folic acid, may be provided to postpartum women for 6\u201312 weeks after delivery for reducing the risk of anemia.<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"563\">\n<p>Offer the woman and family debriefing\/clinical disclosure by senior team members, preferably by clinicians who were at the event<\/p>\n<p>Offer additional opportunities for discussion\/debrief six weeks postpartum<\/p>\n<\/td>\n<td width=\"115\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>\u00a0<\/p>\n<br \/>\n<p>\u00a0<\/p>\n<\/div>\n<\/div>\n<div class=\"mt-5 mb-5 activity-navigation\">\n<div 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                                <\/span>\n                                \n                            <\/span>\n                        \n                                                <span class=\"ui-e-accordion-title-text ui-e-title-text\" >\n                                                        The management of nausea and vomiting during pregnancy                        <\/span>\n\n                    <\/h5>\n\n                    <div class=\"ui-e-accordion-content ui-e-content\" style=\"display:none;\" aria-labelledby=\"ui-e-the-management-of-nausea-and-vomiting-during-pregnancy\" id=\"ui-e-acc-9\">\n                        <div id=\"yui_3_18_1_1_1781924669830_24\" class=\"activity-header\" data-for=\"page-activity-header\">\n<div id=\"intro\" class=\"activity-description\">\n<div id=\"yui_3_18_1_1_1781924669830_23\" class=\"no-overflow\">\n<h5 id=\"yui_3_18_1_1_1781924669830_22\">&#8220;last update: 30 December \u00a02025&#8221;<span id=\"yui_3_18_1_1_1781924669830_21\"><strong id=\"yui_3_18_1_1_1781924669830_20\">\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0<u><a href=\"https:\/\/lms.ehc.gov.eg\/lms\/pluginfile.php\/1414\/mod_book\/intro\/Nausea_Vomiting%20guideline%20final.pdf\" target=\"_blank\" rel=\"noopener\">Download Guideline<\/a><\/u><\/strong><\/span><\/h5>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chaptersnavigation\">\n<div class=\"container-fluid tertiary-navigation\">\n<div class=\"row\">\n<div class=\"navitem ms-auto\">\u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chapter\" class=\"box py-3 generalbox book_content\">\n<h3 class=\" ccnMdlHeading\">&#8211; Executive Summary<\/h3>\n<div class=\"no-overflow\">\n<p dir=\"ltr\">\u00a0<\/p>\n<p>This guideline offers evidence-based recommendations on the management of nausea and vomiting during pregnancy. The recommendations are intended to provide healthcare professionals with practical guidance on appropriate and timely diagnosis and choosing the best evidence-based treatment modality of nausea and vomiting during pregnancy resulting in improving health outcomes for people with this condition that may considerable affect fetal and maternal health.<\/p>\n<div>\n<p><b>List of Recommendations<\/b><b><\/b><\/p>\n<\/div>\n<table border=\"1\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p align=\"center\"><b>Recommendation<\/b><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strength<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><b>Diagnosis of nausea and vomiting during pregnancy<\/b><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>NVP is diagnosed when onset is prior to 16 weeks of gestation and other causes of nausea and vomiting have been excluded.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>HG is diagnosed when symptoms start in early pregnancy, nausea and\/or vomiting are severe enough to cause an inability to eat and drink normally and strongly limits daily activities of living (see the differential diagnosis of NVP in appendix1).<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>An objective and validated index of nausea and vomiting such as the PUQE tool (see appendix 2) can be used to classify the severity of NVP and HG.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Clinicians should be aware of the features in history, examination and investigation that allow appropriate assessment of NVP and HG and to monitor severity.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Ketonuria is not an indicator of dehydration in pregnancy and should not be used to assess severity.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><b>Non-Pharmacological therapies of NVP and HG<\/b><b><\/b><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Avoid an empty stomach at all times, with small and frequent meals every 1\u20132h.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Prevent a full stomach (ie. not mixing solid with liquid, avoiding large meals).<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Eat dry food, high-protein snacks, and crackers in the morning before arising.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Avoid strong tasting and spicy food, eliminate supplemental iron.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Ginger, has shown a beneficial effect in reducing nausea symptoms, but not in reducing vomiting.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>We recommend against acupuncture, acupressure and hypnosis.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><b>Pharmacological therapies<\/b><b><\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Combinations of different drugs should be used in women who do not respond to a single antiemetic.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>For women with persistent or severe HG, non-oral routes may be necessary and more effective than an oral regimen<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><b>Stepwise approach for mild and moderate NVP without hypovolemia:<\/b><\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0Doxylamine\/pyridoxine (vitamin B6) is recommended as the first-line therapy for mild-moderate NVP: Doxylamine\/pyridoxine 20\/20mg PO at night, increase additional 10\/10 mg in morning and 10\/10mg at lunchtime if required.<\/p>\n<p><b>If no adequate response, ADD antihistaminic:<\/b><\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0Cyclizine 50 mg PO, IM or IV 8 hourly<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0Promethazine 12.5\u201325 mg 4\u20138 hourly PO, IM or IV.<\/p>\n<p><b>If no adequate response, ADD dopamine antagonists:<\/b><\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0Prochlorperazine 5\u201310 mg 6\u20138 hourly PO (or 3 mg buccal); 12.5 mg 8 hourly IM\/IV; 25 mg PR daily.<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0Metoclopramide 5\u201310 mg 8 hourly PO, IV\/IM\/SC.<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0Domperidone 10 mg 8 hourly PO; 30 mg 12 hourly PR.<\/p>\n<p><b>If no adequate response, ADD:<\/b><\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0Ondansetron 4 mg 8 hourly or 8 mg 12 hourly PO; 8 mg over 15 minutes 12 hourly IV; 16 mg daily PR (Women taking ondansetron may require laxatives if constipation develops).<\/p>\n<p><b>If no adequate response, ADD:<\/b><\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0Hydrocortisone 100 mg twice daily IV and once clinical improvement occurs, convert to prednisolone 40\u201350 mg daily PO, with the dose gradually tapered (by 5-10 mg per week) until the lowest maintenance dose that controls the symptoms is reached (Corticosteroids should be reserved for cases where standard therapies have failed; when initiated they should be prescribed in addition to previously started effective antiemetics.<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0Women taking corticosteroids should have their blood pressure monitored and a screen for diabetes mellitus).<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Acid-reducing agents can be used as adjunctive therapy in patients with heartburn\/acid reflux and NVP.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>In women with severe NVP or HG, input could be sought from other allied professionals.<b><\/b><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Women with previous or current NVP or HG should consider avoiding iron-containing preparations if these exacerbate symptoms or consider alternative route of administering iron.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Histamine type-2 receptor blockers or proton pump inhibitors may be used for women developing gastro-oesophageal reflux disease, oesophagitis or gastritis.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><b>Management of NVP-HG with hypovolemia<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Hospital admission for close monitoring and ongoing treatment is appropriate for those with persistent inability to tolerate oral intake resulting in hypovolemia requiring intravenous replacement fluid, and failure of oral and\/or intravenous antiemetic therapy.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>The goal of inpatient management is to restore oral intake to enable adequate hydration and nutrition and use of oral antiemetic therapy after discharge.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>The decision to discharge needs to be individualized based on the patient&#8217;s ability to access outpatient resources.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>A baseline electrocardiogram is indicated in patients with electrolyte abnormalities requiring replacement.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><b>Fluid replacement:<\/b><\/p>\n<p>&#8211;\u00a0\u00a0\u00a0Aggressively rehydrate with up to 2 liters of IV crystalloid over two hours (preferably with lactated Ringer&#8217;s due to decreased incidence of acute kidney injury compared with normal or isotonic saline).<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0After initial resuscitation, titrate IV fluids to maintain urine output at least 100 mL\/hour or continue at a rate of 125 to 150 mL\/hour, with close monitoring of oral intake and urine output.<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0Then switch to dextrose-saline (dextrose 5% in 0.45% saline) at a rate of 150 mL\/hour. For patients with normal potassium levels, add 10 mEq potassium chloride for each 500 ml.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Urea and serum electrolyte levels should be checked daily in women requiring intravenous fluids.<\/p>\n<p><a name=\"_Hlk215926052\"><\/a>In patients with electrolyte imbalance, consult intensive care specialist to correct the imbalance.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><b>Thiamine<\/b>:<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0To reduce the risk of Wernicke encephalopathy, 100 to 200 mg thiamine (vitamin B1) should be added to the initial fluid resuscitation and then daily thereafter while the patient is taking nothing-by-mouth or for two to three days in patients with oral intake.<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0If Wernicke encephalopathy is suspected, treat with 200 to 500 mg IV every eight hours for 2 to 7 days, followed by 250 mg once daily for an additional 3 to 5 days, followed by maintenance therapy 100 mg daily until no longer at risk for deficiency. Thiamine should be administered before administering glucose.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><b>Other vitamins:<\/b><\/p>\n<p>&#8211;\u00a0\u00a0\u00a0A multivitamin may be given intravenously each day (folic acid and pyridoxine).<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0Vitamin K addition is not necessary unless to treat a coagulopathy (add 150 mcg vitamin K).<b><\/b><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><b>Antiemetics:<\/b><\/p>\n<p>&#8211;\u00a0\u00a0\u00a0Begin with ondansetron 4 mg intravenously (IV push) once every eight hours upon hospitalization for intravenous fluid therapy and may increase to 8 mg IV every eight hours. After the patient has stabilized, ondansetron is discontinued.\u00a0<b>OR<\/b><\/p>\n<p>&#8211;\u00a0\u00a0\u00a0Intravenous dimenhydrinate 50 mg every four to six hours, metoclopramide 5 to 10 mg every eight hours, or promethazine 12.5 to 25 mg every four to six hours is an alternative to ondansetron.<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0Parenteral medications can be discontinued and oral medications started after 24 to 48 hours of gastrointestinal rest and when the patient is tolerating oral intake.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><b>Thromboprophylaxis<\/b>:<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0Women admitted with HG should be offered thromboprophylaxis with low-molecular-weight heparin and those being managed as outpatients should be assessed for VTE risk.<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0Graduated compression stockings should be used when low-molecular-weight heparin is contra-indicated.<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0Thromboprophylaxis can be discontinued upon discharge providing no other indications exist for continuation of thromboprophylaxis.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><b>Management of patients with refractory NVP and HG<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"108\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Consider testing for H. pylori infection in patients unresponsive to standard therapy, who have symptoms beyond the first trimester, who require multiple hospitalizations, or who have symptoms of gastroesophageal reflux disease.<b><\/b><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Conditional<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><b>Enteral or parenteral nutrition<\/b><\/p>\n<\/td>\n<td valign=\"top\" width=\"108\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>When all other medical therapies have failed to sufficiently manage symptoms, enteral tube feeding or parenteral nutrition should be considered with a referral to a specialized physician in clinical enteral and parenteral nutrition in parallel to ongoing medical therapies.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><b>Hospitalization<\/b><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Inpatient care should be considered if there is at least one of the following:<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0Continued nausea and vomiting and inability to keep down oral antiemetics.<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0Continued nausea and vomiting associated with clinical dehydration or weight loss (greater than 5% of body weight), despite oral antiemetics.<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0Confirmed or suspected comorbidity (such as urinary tract infection and inability to tolerate oral antibiotics).<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0Comorbidities such as epilepsy, diabetes, HIV, hypoadrenalism or psychiatric disease where symptoms and inability to tolerate oral intake and medication could present further complications.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><b>Antenatal care after hospital discharge<\/b><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">\u00a0<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Women should only be discharged once:<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0Appropriate antiemetic therapy has been tolerated.<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0Adequate oral nutrition and hydration have been tolerated.<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0Management of concurrent conditions is completed.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">GPS<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>At the time of discharge, it is essential that women are advised to continue with their antiemetics for at least one week and that they know how to access further care.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Women with severe NVP or HG who have continued symptoms into the late second or the third trimester should be offered serial scans to monitor fetal growth.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><b>Long-term effects of NVP and HG on women<\/b><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>There is no evidence of significant impact on long-term all-cause mortality.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Women who experience HG in pregnancy are at increased risk of<a name=\"_Hlk208849700\"><\/a>\u00a0PND, anxiety, and PTSD<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Women with previous HG should be advised that there is a risk of recurrence in future pregnancies.<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p><b>Future pregnancies<\/b><\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"570\">\n<p>Early use of lifestyle\/ dietary modifications and antiemetics that were useful in the index pregnancy is advisable to reduce the risk of NVP and HG in the current pregnancy<\/p>\n<\/td>\n<td width=\"108\">\n<p align=\"center\">Strong<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<br \/>\n<p>\u00a0<\/p>\n<\/div>\n<\/div>\n<div class=\"mt-5 mb-5 activity-navigation\">\n<div class=\"row\">\n<div class=\"col-md-4\">\n<div class=\"float-left ui_kit_btn\">\u00a0<\/div>\n<\/div>\n<div class=\"col-md-4\">\n<div class=\"mdl-align\">\n<div class=\"urlselect\"><label class=\"sr-only\" for=\"jump-to-activity\">Jump to activity<\/label><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>                    <\/div>\n\n                <\/div>\n                            <div class=\"ui-e-accordion-item ui-e-item\" role=\"button\" tabindex=\"0\" aria-expanded=\"false\" aria-controls=\"ui-e-acc-10\" id=\"ui-e-normal-labor\">\n\n                    <h5 class=\"ui-e-accordion-title ui-e-title ui-right\">\n\n                                                    <span class=\"ui-e-accordion-icon ui-e-icon ui-e-right\" aria-hidden=\"true\">\n\n                                <span class=\"ui-e-accordion-icon-closed\">\n                                    <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-down\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M207.029 381.476L12.686 187.132c-9.373-9.373-9.373-24.569 0-33.941l22.667-22.667c9.357-9.357 24.522-9.375 33.901-.04L224 284.505l154.745-154.021c9.379-9.335 24.544-9.317 33.901.04l22.667 22.667c9.373 9.373 9.373 24.569 0 33.941L240.971 381.476c-9.373 9.372-24.569 9.372-33.942 0z\"><\/path><\/svg>                                <\/span>\n\n                                                                    <span class=\"ui-e-accordion-icon-opened\">\n                                        <svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-up\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M240.971 130.524l194.343 194.343c9.373 9.373 9.373 24.569 0 33.941l-22.667 22.667c-9.357 9.357-24.522 9.375-33.901.04L224 227.495 69.255 381.516c-9.379 9.335-24.544 9.317-33.901-.04l-22.667-22.667c-9.373-9.373-9.373-24.569 0-33.941L207.03 130.525c9.372-9.373 24.568-9.373 33.941-.001z\"><\/path><\/svg>                                    <\/span>\n                                \n                            <\/span>\n                        \n                                                <span class=\"ui-e-accordion-title-text ui-e-title-text\" >\n                                                        Normal Labor                        <\/span>\n\n                    <\/h5>\n\n                    <div class=\"ui-e-accordion-content ui-e-content\" style=\"display:none;\" aria-labelledby=\"ui-e-normal-labor\" id=\"ui-e-acc-10\">\n                        <div id=\"yui_3_18_1_1_1781924684538_20\" class=\"activity-header\" data-for=\"page-activity-header\">\n<div id=\"intro\" class=\"activity-description\">\n<div class=\"no-overflow\">\n<h5>&#8220;last update: 30 April \u00a02026&#8221;<strong>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0<a href=\"https:\/\/lms.ehc.gov.eg\/lms\/pluginfile.php\/1445\/mod_book\/intro\/Normal%20Labor..pdf\" target=\"_blank\" rel=\"noopener\"><u>Download Guideline<\/u><\/a><\/strong><\/h5>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chaptersnavigation\">\n<div class=\"container-fluid tertiary-navigation\">\n<div class=\"row\">\n<div class=\"navitem ms-auto\">\u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"mod_book-chapter\" class=\"box py-3 generalbox book_content\">\n<h3 class=\" ccnMdlHeading\">&#8211; Executive Summary<\/h3>\n<div class=\"no-overflow\">\n<p dir=\"ltr\">\u00a0<\/p>\n<p>This guideline offers evidence-based recommendations on diagnosis and management of normal labor and delivery. The recommendations are intended to provide healthcare professionals with practical guidance on appropriate care and management of women in normal labor. With the aim that proper management of labor would decrease number of unindicated cesarean sections.<\/p>\n<div>\n<p><b>List of Recommendations<\/b><b><\/b><\/p>\n<\/div>\n<div align=\"center\">\n<table border=\"1\" width=\"100%\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Recommendation<\/span><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b><span lang=\"EN-GB\">Strength<\/span><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><a name=\"_Hlk221568999\"><\/a><b><span lang=\"EN-GB\">History taking:<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0 \u00a0Review history, pregnancy notes and screening results including:<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Gestational age<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Past history (medical, obstetric, gynecological, surgical, social, family)<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Medications, allergies<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Pregnancy complications<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Investigation results (including placental location)<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Ask her about the length, strength and frequency of her contractions<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Ask about fetal movements in the last 24 hours<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Ask for vaginal losses<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Review if there are any antenatal or intrapartum risk factors for fetal hypoxia (see the NICE guideline on fetal monitoring in labor)<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Review ER visit history and clinical circumstances at each visit<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Assess emotional and psychological needs<\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Geneal examination:<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Temperature, pulse, respiratory rate, blood pressure (BP), and urinalysis<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Assess nutrition and hydration status and general appearance<\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Abdominal examination<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p><b><span lang=\"EN-GB\">\u00a0<\/span><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Observation, and palpation including:<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0fundal height, fetal lie, attitude, presentation, position, engagement\/descent<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Record time of maternal account of regular, painful contractions:<\/p>\n<p>Assess strength, frequency, duration and resting tone for 10 minutes<\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Auscultation of FHS<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Intermittent auscultation using either a Pinard stethoscope or a handheld Doppler ultrasound device (e.g. Doptone\u00ae or SonicAid\u00ae).<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Auscultate the fetal heart rate for a minimum of 1 minute immediately after a contraction; palpate the woman&#8217;s pulse to differentiate between the heartbeats of the woman and the baby.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Differentiate between maternal and fetal heartbeat.<\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Vaginal examination<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><a name=\"_Hlk221569313\"><\/a><b>Indication of VE<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If there is uncertainty about whether the woman is in established labor, a vaginal examination may be helpful after a period of assessment, but is not always necessary<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If the woman appears to be in established labor, offer a vaginal examination.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If spontaneous rupture of membranes (SROM) suspected, consider a dry sterile speculum examination.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Routine clinical pelvimetry on admission in labor is not recommended for healthy pregnant women.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Assess and record vaginal loss<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Discharge\u2014note color, odor, consistency<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Blood\u2014note color, volume<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Liquor\u2014note color, volume, odor, consistency<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Presence of meconium<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Document the presence or absence of meconium.<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If meconium is present, consider the character of the meconium.<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Meconium may increase the risk to the baby means that:<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Continuous CTG monitoring may be advised<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Healthcare professionals trained in advanced neonatal life support are needed as soon as the baby is born.<\/p>\n<p><b>Contraindication to VE<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Antepartum hemorrhage<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Ruptured membranes and not in labor<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Placenta previa<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Placental position unknown<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Suspected preterm labor<\/p>\n<p><b>Prior to VE<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Review history and most recent ultrasound scan result<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Explain procedure and gain verbal consent prior to each examination<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Ensure the woman&#8217;s privacy, dignity and comfort<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Ensure bladder is empty<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Perform abdominal examination and FHR auscultation<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Tap water may be used if cleansing is required before vaginal examination.<\/p>\n<p><b>During VE<u><\/u><\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Maintain privacy, dignity and respect<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Keep the woman informed of findings during the examination<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Perform VE between contractions<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Assessment:<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Observe general appearance of perineal and vulval area<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Position of cervix\u2014posterior, mid, anterior<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Dilatation<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Effacement<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Consistency\u2014soft, medium, firm<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Application of presenting part<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Membranes intact\/no membranes felt<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Liquor\u2014note color, volume, odor<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Fetal station: level of presenting part in relation to ischial spines (- 3 to + 3)<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Presence of caput and molding<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Fetal position and attitude<\/p>\n<p><b>After VE<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Discuss any potential impact on the birth plan<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Auscultate FHR<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Document findings<\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Laboratory investigation:<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Hb concentration (if not performed in the past month)<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Blood group and Rh typing (if not performed before)<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In Rh negative mothers with Rh positive husband, request indirect Coomb\u2019s test if available<\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Admission<\/span><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Criteria for admission to labor ward<\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Admission decisions should take into account:<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Maternal and fetal wellbeing<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Labor progress (e.g., dilation, contractions)<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Complicating risk factor indicating hospital admission.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Criteria of admission to labor ward in low-risk women:<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Active stage of labor<\/p>\n<p>&#8211;\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0ROM<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Women with cervical dilatation &lt; 5cm and good uterine contractions should be observed for 2 hours and admit to labor ward if the cervix dilates 1 cm or more.<\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">General Care and support for normal labor<\/span><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Providers, senior staff and all healthcare professionals should ensure that in all birth settings there is a culture of respect for each woman as an individual undergoing a significant and emotionally intense life experience, so that the woman is in control, is listened to and is cared for with compassion, and that appropriate informed consent is sought.<\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b><span lang=\"EN-GB\">GPS<\/span><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Maintain the minimum level of birth intervention compatible with safety.<\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Eating and drinking<\/span><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Explain to the woman or pregnant person that they should drink during labor when they are thirsty, and that isotonic drinks may be more beneficial than water. Also explain that there is no benefit to drinking any more than normal, and overconsumption may be harmful.<b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b><span lang=\"EN-GB\">\u00a0<\/span><\/b><\/p>\n<p align=\"center\"><b><span lang=\"EN-GB\">Strong<\/span><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><span lang=\"EN-GB\">\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/span>Inform the woman or pregnant person that they can eat a light diet in established labor if they wish, unless they have received opioids or they develop risk factors that make a caesarean birth more likely.<b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b><span lang=\"EN-GB\">\u00a0<\/span><\/b><\/p>\n<p align=\"center\"><b><span lang=\"EN-GB\">Conditional<\/span><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Fluid intake and output:<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Discuss with the woman or pregnant person that:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0it is important to drink during labor when thirsty<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0it is important to regularly empty the bladder<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0excessive intake of oral or intravenous fluids may be harmful as this can cause hyponatremia (a sodium level of less than 130 mmol\/L in a pregnant woman or pregnant person) and lead to maternal and neonatal seizures or death<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0their midwife will ask about and check up on their fluid intake and output throughout labor<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0fluid balance monitoring may be advised during labor to reduce the risk of hyponatremia or dehydration<\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Monitor and record fluid balance, if:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0there are any concerns about fluid intake, for example the woman or pregnant person is drinking too much (also take into account fluid intake before labor care began)<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0the woman or pregnant person is receiving intravenous fluids<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0the woman or pregnant person is receiving an oxytocin infusion<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0there are any concerns about fluid output, for example there is an inability to pass urine, nausea, vomiting or diarrhea there are certain medical conditions, such as hemorrhage or pre-eclampsia<\/p>\n<\/td>\n<td valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If there is a positive fluid balance of 1500 ml or more, or there are clinical concerns (for example, signs and symptoms of hyponatremia):<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0explain to the woman or pregnant person that it is possible they are developing, or have developed, hyponatremia<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0request an obstetric review<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0offer a blood test to check their sodium level<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0advise that they will need to be transferred to an obstetric setting if they are currently in a midwifery-led setting<\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b><span lang=\"EN-GB\">Conditional<\/span><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Do not routinely advise oral fluids or give intravenous fluids for the treatment of ketonuria in pregnant women who are not diabetic.<\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Pain management<\/span><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0When women are observed or admitted for pain or fatigue in latent labor, techniques such as education and support, oral hydration, positions of comfort, and nonpharmacologic pain management techniques (such as breathing exercises, having a shower or bath, massage or application of warm packs) may be beneficial.<\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b><span lang=\"EN-GB\">Conditional<\/span><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Hygiene<\/span><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Routine hygiene measures taken by staff caring for women in labor, including standard hand hygiene and single-use non-sterile gloves, are appropriate to reduce cross-contamination between women, babies and healthcare professionals.<\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b><span lang=\"EN-GB\">GPS<\/span><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Perineal\/pubic shaving<\/span><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend against routine perineal\/pubic shaving prior to giving vaginal birth.<\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b><span lang=\"EN-GB\">Conditional<\/span><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Enema on admission<\/span><\/b><\/p>\n<\/td>\n<td colspan=\"2\" valign=\"top\" width=\"16%\">\n<p align=\"center\"><b><span lang=\"EN-GB\">\u00a0<\/span><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend against administration of an enema for reducing the use of labor augmentation.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Return\/remain at home<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0&#8211;\u00a0If there is no indication for immediate admission, and the woman returns or remains at home, provide information on:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0When to return\/make contact, including if:<\/p>\n<p>&#8211;\u00a0\u00a0Increased frequency, strength and duration of contractions<\/p>\n<p>&#8211;\u00a0\u00a0Increased pain or discomfort requiring additional support<\/p>\n<p>&#8211;\u00a0\u00a0Vaginal bleeding and\/\/or membrane rupture<\/p>\n<p>&#8211;\u00a0\u00a0Reduced or concern about fetal movements<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Plan an agreed time for reassessment at each contact<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">First stage of labor<\/span><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Latent phase:<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0&#8211;\u00a0Duration<b>\u00a0of the latent stage:\u00a0<\/b>Women should be informed that a standard duration of the latent first stage has not been established<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0 Assessment<b>\u00a0in latent phase:<\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Review birth plan and provide individualized support including:<\/p>\n<p>&#8211;\u00a0\u00a0Encourage ongoing resilience and positive self-belief<\/p>\n<p>&#8211;\u00a0Rest, hydration, nutrition, mobilization, support<\/p>\n<p>&#8211;\u00a0Reassurance<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Slow progress in latent stage:<u><\/u><\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Limited high-quality evidence to provide a contemporary definition<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Historically, limits of more than 20 hours (nulliparous women) and more than 14 hours (multiparous women) were applied to identify prolonged latent phase<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Limits not recommended as an indication for intervention when maternal and fetal condition are reassuring<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Labor may not naturally accelerate until a cervical dilatation threshold of 5 cm is reached. Therefore, the use of medical interventions to accelerate labor and birth (such as oxytocin augmentation or caesarean section) before this threshold is not recommended, provided fetal and maternal conditions are reassuring<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>If slow progress is suspected, assess to identify:<\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Developing complications<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Reassuring maternal and fetal condition<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Emotional and physical needs<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Active phase of 1<sup>st<\/sup>\u00a0stage<\/span><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><span lang=\"EN-GB\">\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/span><b>Duration<\/b><b>\u00a0of the active first stage:\u00a0<\/b>The duration of active first stage (from 5 cm until full cervical dilatation) usually does not extend beyond 12 hours in first labors, and usually does not extend beyond 10 hours in subsequent labors.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Progress<\/b><b>\u00a0of the first stage of labor:\u00a0<\/b>In active labor, cervical dilatation of 0.5 cm per hour (2 cm in 4 hours) is considered normal<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Consider all aspects of labor progress including:<\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Maternal behavior<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Fetal condition<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Cervical dilatation and rate of change<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Descent and rotation of the fetal head<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Strength, duration and frequency of contractions<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Parity<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Previous labor history<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Slowing of progress in the multiparous woman<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend against the use of active management of labor for prevention of delay in labor.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Do not routinely use amniotomy and or oxytocin to prevent delayed progress in 1st stage of labor.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend against the use of intravenous fluids with the aim of shortening the duration of labor.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend against the use of oxytocin for prevention of delay in labor in women receiving epidural analgesia.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend against routine vaginal cleansing with chlorhexidine during labor for the purpose of preventing infectious morbidities.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Ongoing care during active phase of first stage:<\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Digital vaginal examination (VE)<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Minimize VE: VE at intervals of two hours is recommended for routine assessment of active first stage of labor in low-risk women.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Offer additional VE if:<\/p>\n<p>&#8211;\u00a0\u00a0At time of ROM<\/p>\n<p>&#8211;\u00a0Suspected second stage<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Advice the woman to pass urine regularly to avoid full bladder.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Maternal mobility and position:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0There is little evidence that any one position is optimal in labor<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Avoid supine position as it is associated with adverse effects including<\/p>\n<p>&#8211;\u00a0\u00a0Supine hypotension<\/p>\n<p>&#8211;\u00a0Abnormal FHR<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Fetal heart assessment:<\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend against the use of continuous cardiotocography for assessment of fetal well-being in normal labor<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Intermittent fetal heart rate monitoring: Intermittent auscultation of the fetal heart rate with either a Doppler ultrasound device (e.g. Doptone\u00ae or SonicAid\u00ae) or a Pinard fetal stethoscope is recommended for normal labor.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Interval:<\/b>\u00a0Auscultate every 15\u201330 minutes in active first stage of labor, and every 5 minutes in the second stage of labor.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Duration<\/b>: Each auscultation should last for at least 1 minute; if the FHR is not always in the normal range (i.e. 110\u2013160 bpm), auscultation should be prolonged to cover at least three uterine contractions.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Timing:<\/b>\u00a0Auscultate during a uterine contraction and continue for at least 30 seconds after the contraction.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Recording:<\/b>\u00a0Record the baseline FHR (as a single counted number in beats per minute) and the presence or absence of accelerations and decelerations.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Partogram<\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Start using partogram when active labor is confirmed for documentation and providing a visual overview of progress.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Record the following observations during the first stage of labor in the partogram:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0half-hourly documentation of frequency of contractions<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0hourly pulse<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a04-hourly temperature, blood pressure and respiratory rate as a minimum; in addition to other observations according to situation<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Maternal and fetal warning signs<\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If any of the warning signs are present or developed during labor, consult a specialist care:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0pulse over 120 beats\/minute on 2 occasions 15 to 30 minutes apart<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0a single reading of either raised diastolic blood pressure of 110 mmHg or more or raised systolic blood pressure of 160 mmHg or more<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0either raised diastolic blood pressure of 90 mmHg or more or raised systolic blood pressure of 140 mmHg or more on 2 consecutive readings taken 15 to 30 minutes apart<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0a reading of 2+ of protein on urinalysis and a single reading of either<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0raised diastolic blood pressure (90 mmHg or more) or raised systolic blood pressure (140 mmHg or more)<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0respiratory rate of less than 9 or more than 21 breaths per minute on 2 occasions 15 to 30 minutes apart<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0temperature of 38\u00b0C or above on a single reading, or 37.5\u00b0C or above on 2 consecutive occasions 1 hour apart; for advice on intrapartum antibiotics<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0fresh red bleeding or blood-stained liquor<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0the new appearance of meconium<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0pain reported by the woman that differs from the pain normally associated with contractions<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0confirmed delay in the first stage of labor<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0obstetric emergency, including antepartum hemorrhage, cord prolapse, maternal seizure or collapse, or a need for advanced neonatal resuscitation<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0any non-cephalic presentation, including cord presentation<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0high (4\/5 to 5\/5 palpable) or free-floating head in a nulliparous woman<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0suspected fetal growth restriction or macrosomia<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0suspected anhydramnios or polyhydramnios<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0any alarming fetal heart rate pattern<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>\u00a0Delayed progress in active first stage (protracted labor)<\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If delayed progress in the established first stage is suspected, assess:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0cervical dilatation of less than 2 cm in 4 hours<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0descent and rotation of the baby&#8217;s head\u00a0<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0strength, duration and frequency of uterine contraction<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0condition of fetal membranes<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><span lang=\"EN-GB\">\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/span>Offer the woman support, hydration, and appropriate and effective pain relief.<b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Management of delayed\/protracted first stage or arrest of labor<\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Discuss the findings and the options available with the woman, and support her decision.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0For women with intact membranes in whom delay in the established first stage of labor is confirmed:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0consider amniotomy if membranes are intact<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0oxytocin if inertia was diagnosed and<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0repeat vaginal examination 2 hours later.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If available, offer the woman an epidural analgesia before oxytocin is started or if she requests it later.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If oxytocin is used in the first stage of labor, ensure that the time between increments of the dose is no more frequent than every 30 minutes. Increase oxytocin until there are 3 to 4 contractions in 10 minutes.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Oxytocin must be discontinued immediately if there is abnormality in fetal heart rate is observed.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Consider restarting oxytocin in the first stage of labor if:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Obstetric review has been carried out and the FHR is no longer abnormal.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Base the dose when restarting on a full clinical assessment, taking into consideration the previous dose.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Perform vaginal examination 2 hourly after the oxytocin infusion has led to regular contractions:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If cervical dilatation has increased by less than 2 cm after 4 hours of oxytocin, or there is arrest of labor, further obstetric review is needed by a senior obstetrician to assess whether a caesarean birth is advisable.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Second stage of labor<\/span><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Assessment\u00a0<\/b><b>of women during the second stage of labor<\/b><b><\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Continue with observations of the woman and baby, and assessment of risk as described for the first stage of labor and, but be aware that the frequency of fetal monitoring should increase.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Increase Frequency of observations if clinically indicated.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Vaginal examination<\/b>.<b><\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0To assess progress, the vaginal examination should include:<\/p>\n<p>\u00a7\u00a0\u00a0position of the head<\/p>\n<p>\u00a7\u00a0\u00a0descent<\/p>\n<p>\u00a7\u00a0\u00a0caput and molding<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Fundal pressure<\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Application of manual fundal pressure to facilitate childbirth during the second stage of labor is\u00a0<b>not recommended<\/b>.<b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Techniques<\/b><b>\u00a0for preventing perineal trauma<\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0For women in the second stage of labor, techniques to reduce perineal trauma and facilitate spontaneous birth (including perineal massage, warm compresses and a \u201chands on\u201d guarding of the perineum) are recommended<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Episiotomy policy<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Routine or liberal use of episiotomy is not recommended for women undergoing spontaneous vaginal birth.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If an episiotomy is performed, the recommended technique is a mediolateral episiotomy originating at the vaginal fourchette and usually directed to the right side. The angle to the vertical axis should be between 45 and 60 degrees at the time of the episiotomy.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Perform an episiotomy if there is a clinical need, such as birth with forceps or ventouse or suspected fetal compromise.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Provide tested,\u00a0<b>effective analgesia<\/b>\u00a0before carrying out an episiotomy, except in an emergency because of acute fetal compromise.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Shortening of the 2nd stage<\/span><\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Delay in active second stage is diagnosed when:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In nulliparous woman (any of): either insufficient flexion\/rotation\/descent\u00a0<u>within 1 hour<\/u>\u00a0or the second stage duration\u00a0<u>is &gt; 2 hours<\/u>.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In multiparous woman (any of): either insufficient flexion\/rotation\/descent\u00a0<u>within 30 minutes<\/u>\u00a0or the second stage duration\u00a0<u>is &gt; 1 hour<\/u>.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Longer durations may be appropriate where maternal and fetal conditions are optimal.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0A specific absolute maximum length of second stage (passive plus active) has not been identified. Rather than rigid time limits, base decision-making on continuing assessment of:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Maternal physical and emotional condition<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Fetal condition<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Progress of labor<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Maternal preferences<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Operative vaginal delivery in second stage of labor by experienced and well-trained physicians should be considered safe, acceptable alternative to cesarean delivery.<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Training in, and ongoing maintenance of, practical skills related to operative vaginal delivery should be encouraged.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b><span lang=\"EN-GB\">Third stage of labour<\/span><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Management of third stage of labor<\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0The use of uterotonics for prevention of PPH during the third stage of labor is recommended for all births.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0 \u00a0<b>Cord clamping:<\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Late cord clamping (performed approximately 1 to 3 minutes after birth) is recommended for all births while initiating simultaneous essential newborn care.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Early cord clamping (&lt;1 minute after birth) is not recommended unless the neonate is asphyxiated and needs to be moved immediately for resuscitation.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p><b>\u00a0\u00a0\u00a0\u00a0\u00a0<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<p>\u00a0<\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0 \u00a0<b>Controlled cord traction:<\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Consider Controlled cord traction (CCT) as part of active\/modified active management of third stage as it may.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Providers employing CCT should only do so after signs of placental separation, and traction should be performed with uterine contraction as these measures reduce the risk of uterine inversion, cord avulsion, and partial detachment of the placenta.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<p>\u00a0<\/p>\n<p><b>\u00a0<\/b><\/p>\n<p><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Prophylactic Uterotonics:<\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0 \u00a0\u00a0<b>Oxytocin:<\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In most circumstances, oxytocin is the prophylactic uterotonic of choice.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0For vaginal birth<\/p>\n<p>&#8211;\u00a0If vaginal birth with IV access: Oxytocin 10 IU IV injected slowly over 3\u20135 minutes is recommended in preference to IM<\/p>\n<p>&#8211;\u00a0\u00a0If vaginal birth without IV access: Oxytocin 10 IU IM<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0For CS birth:<\/p>\n<p>&#8211;\u00a0\u00a0Oxytocin 5 IU IV over 1\u20132 minutes<\/p>\n<p>\u00a7\u00a0\u00a0Monitor for hemodynamic impact<\/p>\n<p>\u00a7\u00a0\u00a0Avoid rapid IV bolus administration<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If cardiovascular compromise exists (e.g. hypovolemia, shock, cardiac disease), use caution with IV administration.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0 \u00a0\u00a0<b>Ergometrine<\/b>:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Ergometrine can be given IM or, in life-saving circumstances, as a slow IV injection.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Ergometrine should not be used in patients with essential or gestational hypertension, or in patients on HIV protease inhibitors.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Though undisputedly extremely effective, potential adverse effects limit ergometrine to a second-line agent.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p><b>Conditional<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<p><b>Strong<\/b><\/p>\n<p><b>\u00a0<\/b><\/p>\n<p><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0<b>Carbetocin<\/b>:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Routinely use oxytocin in preference to carbetocin if vaginal birth and cold-chain storage of oxytocin can be guaranteed (e.g. hospital setting).<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If vaginal birth and cold-chain storage of uterotonics cannot be guaranteed:<\/p>\n<p>&#8211;\u00a0\u00a0Carbetocin is an effective alternative uterotonic<\/p>\n<p>&#8211;\u00a0\u00a0IM is preferred route of administration<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If CS birth under regional anesthetic: IV carbetocin may be considered as a cost-effective uterotonic.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If CS birth under general anesthetic: Carbetocin is not recommended due to insufficient evidence.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If used: used as a single dose only, not for repeated use<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Misoprostol<\/b>:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Not recommended if alternative injectable uterotonics are available<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Use only if no other injectable uterotonic is available (e.g. due to unexpected birth in low resource setting or if storage conditions for uterotonics are inadequate).<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0The dose is 600 micrograms orally or sublingual single dose immediately after birth<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If in a low resource setting with limited PPH treatment capability, consider use if:<\/p>\n<p>&#8211;\u00a0\u00a0an injectable uterotonic has been administered and<\/p>\n<p>&#8211;\u00a0\u00a0continued bleeding is anticipated and\/or blood loss is estimated to be greater than or equal to 350 mL \u00a0<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Tranexamic Acid (TXA) For Prophylaxis in High-Risk Women<\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Tranexamic acid can be used as a prophylactic agent as an adjunct to uterotonics in patients at\u00a0<b>high risk for postpartum hemorrhage<i>.<\/i><\/b><\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Use TXA\u00a0<b>within 3 hours<\/b>\u00a0<b>of birth<\/b>\u00a0of the baby in a fixed dose of 1 g in 10 mL IV over 10 minutes (100 mg\/min i.e. 1 ml \/minute)<b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Prolonged third stage<\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Diagnose a prolonged third stage of labor if it is not completed within 30 minutes of the birth with active management or within 60 minutes of the birth with physiological management<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Placenta and membranes examination<\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Perform a thorough examination of the placenta and membranes:<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Placenta<\/b><b>:<\/b><\/p>\n<p>&#8211;\u00a0\u00a0General shape and appearance<\/p>\n<p>&#8211;\u00a0\u00a0Calcification or infarctions<\/p>\n<p>&#8211;\u00a0\u00a0Evidence of abruption<\/p>\n<p>&#8211;\u00a0\u00a0Missing cotyledons<\/p>\n<p>&#8211;\u00a0\u00a0Succenturiate lobe\/s<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Membranes<\/b><b>:<\/b><\/p>\n<p>&#8211;\u00a0\u00a0One amnion and one chorion<\/p>\n<p>&#8211;\u00a0\u00a0Complete or ragged<\/p>\n<p>&#8211;\u00a0Presence of vessels<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Cord<\/b><b>:<\/b><\/p>\n<p>&#8211;\u00a0\u00a0Cord insertion site<\/p>\n<p>&#8211;\u00a0\u00a0Two arteries and one vein<\/p>\n<p>&#8211;\u00a0Velamentous insertion: Vessels noted in membranes<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Immediate Postpartum Risk Management<\/b><b><u><\/u><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0 \u00a0<b>Uterine massage:<\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Sustained uterine massage is not recommended as an intervention to prevent PPH in women who have received prophylactic oxytocin.<b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Uterine tonus assessment:<\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women.<b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Nipple stimulation &amp; breast feeding:<\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Nipple stimulation and\/or early breastfeeding may increase uterine activity but has not been shown to reduce bleeding or incidence of PPH.<b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Observation for women in the first 2 hours postpartum:<\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Vital signs: Respiratory rate, pulse rate, and blood pressure, every 15-30 minutes in the first hour and every 30 minutes in the second hour.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Blood Loss every 15-30 minutes by visualizing the labia and perineum and be alert for slow steady trickle.<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Uterine tonus assessment<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Temperature every 30 minutes<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Urine output: after the first 2 hours<\/p>\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>After the first 2 hours continue as clinically indicated<\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Women<\/b><b>\u00a0who have had regional analgesia or anesthesia:<\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Check that women who have had regional analgesia or anesthesia can perform a straight leg raise by 4 hours after the last anesthetic dose. If not, contact the obstetric anesthetist for urgent review.<b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b><span lang=\"EN-GB\">Strong<\/span><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><a name=\"_Hlk221652262\"><\/a>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Antibiotics use with normal labor:<\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><a name=\"_Hlk194991150\"><\/a><span lang=\"EN-GB\">\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/span>Use according to the local protocols<b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Episiotomy\/1st and 2nd degree perineal tears repair<\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><a name=\"_Hlk221652428\"><\/a>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Ensure that tested effective analgesia is in place, using infiltration with up to 20 ml of 1% lidocaine or equivalent<\/p>\n<\/td>\n<td colspan=\"2\" rowspan=\"11\" width=\"16%\">\n<p align=\"center\"><b><span lang=\"EN-GB\">\u00a0<\/span><\/b><\/p>\n<p align=\"center\"><b><span lang=\"EN-GB\">\u00a0<\/span><\/b><\/p>\n<p align=\"center\"><b><span lang=\"EN-GB\">\u00a0<\/span><\/b><\/p>\n<p align=\"center\"><b><span lang=\"EN-GB\">\u00a0<\/span><\/b><\/p>\n<p align=\"center\"><b><span lang=\"EN-GB\">\u00a0<\/span><\/b><\/p>\n<p align=\"center\"><b><span lang=\"EN-GB\">\u00a0<\/span><\/b><\/p>\n<p align=\"center\"><b><span lang=\"EN-GB\">\u00a0<\/span><\/b><\/p>\n<p align=\"center\"><b><span lang=\"EN-GB\">\u00a0<\/span><\/b><\/p>\n<p align=\"center\"><b><span lang=\"EN-GB\">\u00a0<\/span><\/b><\/p>\n<p align=\"center\"><b><span lang=\"EN-GB\">\u00a0<\/span><\/b><\/p>\n<p align=\"center\"><b><span lang=\"EN-GB\">Strong<\/span><\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Top up the epidural or insert a spinal anesthetic if necessary<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0If the woman reports inadequate pain relief at any point, manage immediately with pharmacological and\/or non-pharmacological measures<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In episiotomy and first\/second degrees tears, the wound should be sutured in order to improve healing.<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Suture use a continuous subcuticular technique<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Undertake perineal repair using a continuous non-locked suturing technique for the vaginal wall and muscle layer.<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Use an absorbable synthetic suture material to suture the perineum.<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Offer rectal non-steroidal anti-inflammatory drugs routinely after perineal repair of first- and second-degree trauma provided these drugs are not contraindicated.<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Ensure that suture material has not been accidentally inserted through the rectal mucosa by carrying out a rectal examination after completing the repair<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0After completion of the repair, document an accurate detailed account covering the extent of the trauma, the method of repair and the materials used<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Give the woman information about the extent of the trauma, pain relief, diet, hygiene and the importance of learning to do pelvic floor exercises, what to expect as they recover, and where and when to seek advice or psychological support if needed.<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><b>Postnatal discharge following uncomplicated vaginal birth<\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><a name=\"_Hlk221652898\"><\/a>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0After\u00a0an uncomplicated vaginal birth in a health care facility, we advise that healthy mothers and newborns receive care in the facility for 12 &#8211; 24 hours after birth.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><a name=\"_Hlk221653074\"><\/a>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Physiological care<\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Respond to requests for pain management<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Consider personal hygiene needs<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Observe emotional and psychological response to labor and birth<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Observe response towards the baby and encourage breast feeding<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Venous thromboembolism (VTE) risk re-assessment<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Iron supplementation is advised.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><a name=\"_Hlk221653136\"><\/a>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Rh D negative blood group<\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Test the baby\u2019s Rh status<\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend Rh D immunoglobulin if maternal indirect Coomb\u2019s test is negative<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><a name=\"_Hlk221653379\"><\/a><b>Intrapartum analgesia<\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><a name=\"_Hlk221653425\"><\/a>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Non-pharmacological pain-relieving strategies<\/b><\/p>\n<p>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Advise women that breathing exercises, and having a shower or bath, may reduce pain during the latent first stage of labor.<b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><a name=\"_Hlk221653782\"><\/a>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Pharmacological analgesia<\/b><b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><a name=\"_Hlk221653890\"><\/a>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Opioid analgesia for pain relief<\/b><\/p>\n<p>&#8211;\u00a0\u00a0Parenteral opioids, such as fentanyl, diamorphine and pethidine, are options for healthy pregnant women requesting pain relief during labor, depending on a woman\u2019s preferences and availability.<a name=\"_Hlk221654018\"><\/a><\/p>\n<p>&#8211;\u00a0\u00a0Inform the woman that these drugs will provide limited pain relief during labor and may have side effects for both her (for example, drowsiness, nausea and vomiting) and her baby (for example, short-term respiratory depression and drowsiness, which may last several days and may make it more difficult to breastfeed).<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>&#8211;\u00a0\u00a0It is not advisable to give opioids if delivery is expected with 3 hours<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>GPS<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>&#8211;\u00a0\u00a0If an intravenous or intramuscular opioid is used, also administer an antiemetic.<b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><a name=\"_Hlk221654209\"><\/a>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Antispasmodic agents<\/b><\/p>\n<p>&#8211;\u00a0\u00a0The use of antispasmodic agents for prevention of delay in labor is not recommended.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p>\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Epidural analgesia for pain relief<\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>\u00a0<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><a name=\"_Hlk221654083\"><\/a>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Epidural analgesia may be offered for healthy pregnant women requesting pain relief during labor, depending on a woman\u2019s preferences and availability.<b><\/b><\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Conditional<\/b><b><\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" width=\"83%\">\n<p><a name=\"_Hlk221654306\"><\/a>\u2013\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<b>Obstetric care and observations for women with epidural analgesia<\/b><\/p>\n<p>&#8211;\u00a0\u00a0Care and observations for women with epidural analgesia should be jointly managed with the anesthetist.<\/p>\n<p>&#8211;\u00a0Insert urinary catheter.<\/p>\n<p><a name=\"_Hlk221654467\"><\/a>&#8211;\u00a0\u00a0Perform continuous cardiotocography for at least 30 minutes during establishment of epidural analgesia and after administration of each further bolus of 10 ml or more.<\/p>\n<p>&#8211;\u00a0On confirmation of full cervical dilatation in a woman with epidural analgesia, unless the woman has an urge to push or the baby&#8217;s head is visible, pushing may be delayed by 1 hour for multiparous women and up to 2 hours for nulliparous women, after which actively encourage her to push during contractions.<\/p>\n<p>&#8211;\u00a0\u00a0Do not routinely use oxytocin in the second stage of labor for women with epidural analgesia.<\/p>\n<p>&#8211;\u00a0\u00a0Continue epidural analgesia until after completion of the third stage of labor and any necessary perineal repair.<\/p>\n<\/td>\n<td colspan=\"2\" width=\"16%\">\n<p align=\"center\"><b>Strong<\/b><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"463\">\u00a0<\/td>\n<td width=\"1\">\u00a0<\/td>\n<td width=\"90\">\u00a0<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<p>\u00a0<\/p>\n<p>\u00a0<\/p>\n<br \/>\n<p>\u00a0<\/p>\n<\/div>\n<\/div>\n<div class=\"mt-5 mb-5 activity-navigation\">\n<div class=\"row\">\n<div class=\"col-md-4\">\n<div class=\"float-left ui_kit_btn\">\u00a0<\/div>\n<\/div>\n<div class=\"col-md-4\">\n<div class=\"mdl-align\">\n<div class=\"urlselect\">\u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>                    <\/div>\n\n                <\/div>\n                    <\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>\u0637\u0628 \u0646\u0633\u0627\u0621 \u0648\u062a\u0648\u0644\u064a\u062f Non-Clinical Interventions to reduce overall cesarean sections &#8220;last update: 8 February 2024&#8221;\u00a0\u00a0 \u00a0 &#8211; Executive summary \u00a0 \u27a1\ufe0fIntroduction The [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-7444","page","type-page","status-publish","hentry"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/pages\/7444","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=7444"}],"version-history":[{"count":4,"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/pages\/7444\/revisions"}],"predecessor-version":[{"id":7449,"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=\/wp\/v2\/pages\/7444\/revisions\/7449"}],"wp:attachment":[{"href":"https:\/\/gothi.gov.eg\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=7444"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}