OB

1. Lecture 1 NCM 109A Pathologic OB
CARE FOR PREGNANT CLIENTS WITH PREEXISTING OR NEWLY ACQUIRED
DISEASE.
Cardiac Disease
-May be the result of CHD or RHD
-May affect pregnancy but are definitely affected by pregnancy
Classification of Heart Diseases
Class I -Uncompromised. No limitation of physical activity, asymptomatic with ordinary
activity.
Class II - Slightly compromised, requiring slight limitation of physical activity. Patient is
comfortable at rest, but ordinary physical activity causes fatigue, palpitations, or anginal
pain.
Class III - Markedly compromised. Marked limitation pf physical activity. Patient is
comfortable at rest, but less than ordinary activity causes excessive fatigue,
palpitation, dyspnea, or anginal pain.
Class IV - Inability to perform any physical activity without discomfort. Symptoms of cardiac
insufficiency even at rest.
NOTE : In general, maternal and fetal risks for class I and II disease are small but are
greatly increased with class III and IV
Ventricular Septal Defect (VSD)
• Left to Right shunting
• asymptomatic, but fatigue or symptoms of pulmonary congestion may occur.
• May precipitate hearth failure or dysrhythmias
• bacterial endocarditis is common.
Patent Ductus Arteriosus
• Left to Right shunting
• Communicating shunt between the pulmonary artery and aorta.
Tetralogyof Fallot
• Right to Left Shunting
• ventricular septal defect, pulmonary valve stenosis, right ventricular hypertrophy,
displacement of the aorta toward the right ventricle
• S/Sx:
 Cyanosis
 Clubbing of the fingernails (proliferation of capillaries to transport
blood to the extremities).
 Inability to tolerate activity
Rheumatic Heart Disease
• Rheumatic fever causes carditis or inflammation of the 3 layers of the heart.
• Inflammation causes swelling of the valve.
• Valvular dysfunction (mitral stenosis)
• Aschoff’s bodies (fibrinoid necroti deposits) develop in the myocardium.
Cardiomegaly and heart failure may develop with rheumatic heart
disease
• Warning signs: persistent rales at the base of the lungs, dyspnea on
exertion, cough and hemoptysis, progressive edema, tachycardia.
Peripartum Cardimyopathy

2. • occurs in the last months of pregnancy due to a dysfunction of the left ventricle,
causing an enlarged heart, tachycardia, rales or first 5 months postpartum in woman
with no previous hx
Risk factors:
• Obesity
• history of cardiac disorders (myocarditis)
• use of certain medications
• Smoking
• Alcoholism
• multiple pregnancies
• malnourished
Mitral Valve Prolapsed
• Incidence is on young women, appears to be inherited
• The leaflets of the mitral valve prolapsed into the left atrium during ventricular
contractions.
• Considered benign condition, asymptomatic and can tolerate pregnancy as well.
Antepartal Management
• 1st
half of pregnancy, visits q 2 weeks
• 2nd
half = weekly visits; blood volume reaches maximum @ 28-30 weeks
• Assess VS, activity level/fatigue, stress level
• Assess for factors increasing stress on heart (anxiety and activity evel)
• Frequent rest periods to strict bed rest
• Adequate sleep
• Low sodium diet
• Teach client to recognize and report signs of infection
• Compare v/s to baseline and normal values expected during pregnancy
• Reinforce an promote compliance with physician’s plan of care
• Teach danger signals for individual client
Intrapartal Management
• Medical management: client is frequently delivered with use of forceps to shorten
“pushing” stage of labor
• Classes I & II
• Spontaneous labor
• Normal L&D expected
• Monitor closely for any changes
• Classes III & IV
• May have labor induced
• May need to be hospitalized preL&D (labor and delivery)
• Require invasive cardiac monitoring
Use of low forceps with lumbar epidural anesthesia recommended
• Enormous stress- can be fatal to fetus r/t ↓ oxygen and blood supply
• Assessment of mother :Vital signs
• Pulse rate >100 and/or respiratory rate > 25 may indicate decompensation
• Lung sounds, dyspnea, etc
• During pushing, encourage shorter, more moderate pushing to ↓ exertion, encourage
complete relaxation between pushes
• Fetal considerations
• Continuous electronic fetal monitoring
• During pushing, encourage shorter, more moderate pushing to ↓ exertion, encourage
complete relaxation between pushes
• Check v/s q 15 minutes or more frequently if indicated

3. • Check FHR q 15 minutes
• Monitor client’s responses to stress of labor and watch for signs of decompensation
• Administer oxygen and pain medication as ordered, prn
• Position client in side-lying/low semi-fowler’s position
• Provide calm atmosphere
• Encourage “open-glottall” pushing during 2nd
stage of labor
Possible Nursing Diagnosis
• Impaired gas exchange related to pulmonary edema secondary to cardiac
decompensation
• Fear related to effects of maternal cardiac condition on fetus
Knowledge deficit
Evaluation/OUtcomes
• The mother:
• Is able to discuss condition and impact on pregnancy
• Participates in developing and adheres to health care regimen
• Delivers a healthy infant
• Is free of complications
• Is able to care for infant
Postpartal Management
• Facilitate nonstressfull mother/baby interactions
• Help mother plan for rest and activity patterns t homes, as well as household care as
indicated
COMPLICATIONS OF HEART DISEASE IN PREGNANCY
1. Heart failure
A. Signs of acute heart failure-
- Cough with blood-tinge mucus
- Irregular, rapid pulse
- Intense dyspnea, chest pains
- Cyanosis
- Pulmonary edema
- Cold, clammy extremities
2. Spontaneous Abortion
3. Premature labor; prematurity
4. Intrauterine growth retardation; fetal distress
PRINCIPLES OF MANAGEMENT IN CARDIAC DSE IN PREGNANCY
1. Early, regular, frequent prenatal care
2. Adequate rest: No activity that induces fatigue, breathlessness
3. Prevention of infection and anemia
4. Avoidance of activity that decrease oxygenation of the blood:
- smoking
- high-altitude living (the higher you go, the thinner is the air: difficult
breathing
- overcrowding/ air pollution
- flying in unpressurized planes
5. Prevention of emotional stress
6. Proper nutrition:
- High in protein , iron
- Low in sodium, fats and carbohydrates
- High in fluids and roughage to prevent constipation
- Small, frequent meals

4. 7. Weight control
8. Early hospitalization: 1-2 weeks before labor for adequate rest
Induction of premature labor is not advocated.
9. Continuous monitoring in labor:
a. NO LITHOTOMY - increases cardiac load
b. Semi to high flower’s position to improve breathing
c. Continuous monitoring of vital signs- particularly PR every 15 mins
to detect early signs of cardiac failure & pulmonary edema
d. Nothing per orem (NPO)
e. Oxygen PRN
f. Analgesia &anesthesia to eliminate pushing & to relieve pain
g.NO PUSHING; delivery is often by FORCEPS to shorten 2nd stage
h. STRICT ASEPSIS to prevent infection
i. Continued fetal monitoring
10. Frequent monitoring in Puerperium
a. Bedrest
b. Ambulation usually by 4-5 days to prevent development of thromboembolism.
In the presence of heart failure, ambulation may be about a week after the
condition has cleared up
c. Frequent monitoring of pulse rate and respiration
d. Prevention of infection; check temperature 4 hours
e. Provision of contraception to allow adequate interval b/w pregnancies (2
years or more)
Oral contraceptive pills and IUD are not recommended. Pills can predispose
mother to thrombo-embolic diseases whereas IUD can be a factor to infection.
Remember:
A pregnant woman with heart disease should avoid
infection, excessive weight gain, edema and anemia
because these conditions increase the workload of
the heart.
Diabetes Mellitus
General information
• chronic disease caused by improper metabolic interaction of CHO, fats, CHON, and
insulin
• Interaction of pregnancy and diabetes may cause serious complications of pregnancy
• Classifications:
• type 1: IDDM (formerly called juvenile-onset); onset before age 40
• Type 2: NIDDM (formerly called maturity onset); onset after age 40
• Type 3: gestational; onset during pregnancy, reversal after termination of pregnancy
• Type 4: secondary; occurs after pancreatic infections or endocrine d/o
Pathophysiology of DM
• Without insulin in the cells accumulation in the blood results to hyperglycemia.
• Body attempts to dilute glucose POLYDIPSIA (excessive thirst)
• Fluids from the intracellular spaces drawn in the vascular bed dehydration at the
cellular level fluid volume excess in the vascular compartment.
• Kidney attempts to excrete large volume of the fluid & the heavy solutes load of
glucose (osmotic diuretic). POLYURIA / GLYCOSURIA.
• Without glucose the cell will starve weight loss ingestion of large amount of food
(POLYPHAGIA)
ASSESSMENT
• s/s of dm

5. • Elevated glucose levels in blood and urine. Urine tests for elevated blood glucose
less reliable in pregnancy. Blood tests (more accurate) used as follows:
• 1-hour GTT: usually done for screening on all pregnant women24-28 weeks pregnant
• 3-hour GTT: used where results from 1-hour GTT>140mh/dl
• HbA1c: glycosylated hgb: reflects passt 4-12 weeks blood levels of serum glucose.
• Gestational DM (GDM)
• Refers to a condition of glucose intolerance that affects women during pregnancy. Its
duration usually only lasts over the pregnancy period.
• Develops in the mother between the 5th and 6th month of pregnancy. This form of
diabetes is usually controlled by diet, exercise, routine blood sugar checks and
medicine
• Significance of diabetes in pregnancy
• Interaction of estrogen, progesterone and cortisol raise maternal resistance to insulin
(ability to use glucose at the cellular level)
• If the pancreas cannot respond by producing additional insulin, excess glucose
moves across placenta to fetus, where fetal insulin metabolizes it, and acts as growth
hormone, promoting macrosomia
• Maternal insulin levels need to be carefully monitored during pregnancy to avoid
widely fluctuating levels of blood glucose
• Dose may drop during 1st
trimester, then rise during 2nd
trimester and 3rd
trimesters of
diabetic mother
Signs and Symptoms of Gestational Diabetes
• Increased Thirst
• Increased Urination
• Unexplained Weight Loss
• Constant Tiredness / Lethargic
• Nausea
• Frequent Infections / Sick days
• Impaired Vision
Maternal Risk Factors for GDM
• Age 25 or >
• Marked obesity
• Prior history of GDM
• Diabetes mellitus in 1stdegree relative
• Hx of abnormal glucose tolerance
• Hx of poor obstetric outcomes
Maternal Effects of GDM
*Hydramnios- fetal hyperglycemia, consequent fetal diuresis and PROM (large
fetus or overdistention of the uterus
*Macrosomia- fetus weigh more than 4000or 8.8 lbs.
*Labor difficulty- shoulder dystocia, injury to the birth canal/ fetus
Fetal Effects of GDM
• Congenital Malformation
• Neural tube defect- congenital defect in closure of the bony
encasement of the spinal cord or skull. Includes anencephaly, spina bifida,
meningocele, & myelomeningocele).
• Caudal Regression Syndrome- malformation that result when the sacrum,
lumbar spine and lower extremities fails to develop.
• Cardiac Defects
• Variation in Fetal Size
• Normally fetal growth is related to maternal vascular integrity.

6. • Without vascular impairment, glucose and oxygen are easily transported to
the fetus.
• Woman is hyperglycemic so as the fetus.
• Maternal insulin do not cross the placental barrier fetus produces insulin by
the 10th
week gestation.
• Fetal macrosomia result- elevates levels of blood glucose stimulates
excessive production of insulin, that acts as a powerful growth hormone.
Neonatal Effects of GDM
• Hypoglycemia – fetal insulin production was accelerated during pregnancy to
metabolize excessive glucose received from the mother.
constant hyperglycemia leads to hyperplasia and hypertrophy of the islets of
langerhans in the fetal pancreas
maternal glucose supply is abruptly withdraw at birth, the level of neonatal insulin
exceeds the available glucose, and hypoglycemia develops rapidly.
• Hypocalcemia – last half of pregnancy large amount of calcium are tranported across
the placenta from the mother to the fetus.
at birth this transfer is abruptly stopped, leading to a dramatic decrease in the total
and ionized calcium.
mostly occurs after 3 days of life
• Hyperbilirubinemia – fetus who experiences recurrent hypoxia compensates by
production of additional erythrocytes to carry oxygen supplied by the mother.
after birth excess erythrocytes are broken down, releasing large amount of bilirubin
into the neonates circulation
• Respiratory Distress syndrome – fetal hyperinsulinemia retards, which is essential for
synthesis of surfactant needed to keep the new born’s alveoli open after birth.
Antepartum Management of Diabetic Woman
• Goals
• Maintain balance between insulin & glucose during pregnancy
• Healthy mother & newborn
• Prenatal care
• Education
• Referrals
• Glucose monitoring & recording
• Dietary regulation
• Importance of glucose control
• Changes in insulin requirements
• Insulin use: purpose, types, administration
• Planned exercise program
• Glucose monitoring
• Self monitoring daily (ac, hs plus!!)
• Fasting levels may be assessed weekly
• Accurate record
• ptoms of hypo/hyperglycemia & how to treat
• Hazards of smoking
• Support groups and community resources
Dietary considerations:
• ↑ Caloric intake by ~ 300 kcal/day 1st
trimester need 30 kcal/kg IBW, ↑ to 35kcal/kg
2nd
and 3rd
trimesters
• Calories: 40-50% from complex CHO, 15%-20% from protein 35%, from fat
• Knowledge of food groups & exchanges important
• 3 meals, 3 snacks (bedtime very important!)
• Bedtime snack needs to have protein & complex CHO to prevent hypoglycemia

7. Pharmacology
• Glucose monitoring
• Self monitoring daily (ac, hs plus!!)
• Fasting le Most require insulin – Human
• Oral hypoglycemics never used
• Most receive combination of intermediate and regular insulin, lots of different
schedules- must be individualized
• Fasting levels may be assessed weekly
• Accurate record
• Most require insulin – Human
• Oral hypoglycemics never used
• Most receive combination of intermediate and regular insulin, lots of different
schedules- must be individualized
Fetal well-being
• Maternal serum alpha-fetoprotein (AFP) at 16-20 wks
• Ultrasound at 18 and 28 wks
• May do fetal biophysical profiles (BPP)
• Daily fetal activity monitoring begun at 28 wks
• Nonstress testing (NST) weekly usually begun at 28 wks, ª to 2x/wk at 32 wks
Intrapartum management
• Timing of birth
• Cesarean indications:
• Nonreassuring fetal status
• Vascular changes
• Labor management
• Closely monitor glucose levels!
• May use 2 IV lines, (1) D5W & (2) saline for insulin to be given as needed.
• D/C IV insulin with completion of 3rd
stage of labor
Postpartum management: Insulin
• Insulin needs usually ↓ significantly 1st
24 hours for all types of women
• Managed with sliding scale initially, reestablish insulin requirements individually
• If GDM insulin is usually not required
• Reassess at 6 weeks & q 3 years if normal
• Pregnancy is a kind of “stress test” that often predicts future diabetic problems
• Breastfeeding
• Evidence suggests that breast fed infants have less risk of developing DM
• ↑ Calories by 500-800 kcal over prepreg requirements
• Insulin needs to be individualized
• Glucose monitoring continues !
Potential Nursing Diagnoses for the Diabetic Woman with gestational
Hypertension
• Risk for altered nutrition: more than body requirements related to imbalance between
oral intake and available insulin
• Risk for injury related to possible complications secondary to hypo/ hyperglycemia
• Altered family processes related to need for hospitalization secondary to DM
• Knowledge deficit related to new diagnosis of GDM ………..and more!
Desired Outcomes for the Diabetic Woman, Baby and Family
• Able to discuss condition and impact on pregnancy, labor, birth, and postpartum.

8. • Absence of hyper/hypoglycemia.
• Gives birth to a healthy newborn.
• Able to care for self, including monitoring and intervening blood sugar levels.
• Able to care for newborn.
THYROID DISEASES
KINDS:
• 1. Hyperthyroidism or Maternal Thyrotoxicosis:
due to very elevated thyroxine levels that causes fast metabolism in the body
resulting in low birth weight infant
• Signs and Symptoms:
a. Tachycardia
b. Enlarged thyroid gland
c. Exopthalmus
d. Weakness
e. Sweating
f. Failure to gain weight normally
• Thyroid Storm – a major complication of hyperthyroidism manifested by:
a. fever
b. tachycardia
c. severe dehydration
d. occasional cardiac decompensation
Other topics to be studied:
• HELPP syndrome
• Multiple Pregnancy
• Isoimmunization
• Fetal Death
• Surgical Interventions for Birth
• Care for clients with postpartum complications
• Postpartum Hemorrhages
• Thrombophlebitis
• Mastitis
• Urinary System Disorders
• Cardiovascular System Disorders
• Reproductive System Disorders
• Emotional and Psychological Complications of the Puerperium
HELLP syndrome is a rare but serious condition that can happen when you’re pregnant or
right after you have your baby. HELLP stands for the different things that happen when you
have it:
Hemolysis: This is the breakdown of red blood cells. These cells carry oxygen from
your lungs to your body.
Elevated Liver Enzymes:When levels are high, it could mean there’s a problem with
your liver.
Low Platelet Count: Platelets help your blood clot.
HELLP syndrome is a life-threatening pregnancycomplication usually considered to
be a variant of preeclampsia. Both conditions usually occur during the later stages of
pregnancy, or sometimes after childbirth.

9. HELLP syndrome was named by Dr. Louis Weinstein in 1982 after its characteristics:
H(hemolysis, which is the breaking down of red blood cells)
EL(elevated liver enzymes)
LP(low platelet count)
HELLP syndrome can be difficult to diagnose, especially when high blood pressure
and protein in the urine aren't present. Its symptoms are sometimes mistaken for
gastritis, flu, acute hepatitis, gall bladder disease, or other conditions.
The mortality rate of HELLP syndrome has been reported to be as high as 30%. That's
why it's critical for expecting mothers to be aware of the condition and its symptoms
so they can receive earlydiagnosis and treatment.
What It Is
HELLP syndrome causes problems with your blood, liver, and blood pressure. If left
untreated, these issues can hurt you and your baby.
There may be a link between HELLP syndrome and preeclampsia and eclampsia.
Preeclampsia is when a pregnant woman has high blood pressureand damage to other
organs such as her liver and kidneys. It usually starts after 20 weeks of pregnancy.
Eclampsia is a more severe form of preeclampsia that includes seizures.
HELLP syndrome can cause major complications. These include:
 Seizures
 Stroke
 Liver rupture
 Placental abruption (separation of the placenta from the wall of the uterus before the
baby is born)
Placental abruption can cause bleeding, affect your baby’s growth, and lead to premature
birth or stillbirth.
Causes
Doctors don’t know what causes HELLP syndrome. Your chance of it is higher if you’ve had
it before. Most women who get it have high blood pressure first. But you can get HELLP with
normal blood pressure.
Experts think your odds may be higher if you:
 Are older than 25
 Are Caucasian
 Have given birth two or more times before
Symptoms
These often come on quickly. They include:

10.  Fatigue
 Blurred vision
 Sudden weight gain
 Swelling, especially in the face and hands
 Headache
 Nausea or vomiting
 Seizures
 Pain in the upper right part of your belly
 Nosebleed
 Bleeding that doesn’t stop as quickly as usual
Diagnosis
If you have symptoms of HELLP syndrome, talk to your doctor. She’ll do a physical exam
and tests to check for things like:
 High blood pressure
 Pain in the upper right side of your belly
 Enlarged liver
 Swollen legs
 Liver function
 Blood platelet count
 Bleeding into your liver
Treatments
The main solution for HELLP syndromeis to give birth as soon as possible. This means your
baby may have to be born early. The risks are too serious for you and your baby if you stay
pregnant with HELLP syndrome.
Treatment may also include:
 Corticosteroid medicine to help your baby’s lungs develop more quickly
 Medicine for high blood pressure
 Meds to prevent seizures
 Blood transfusion
Prevention
There’s no way to prevent HELLP syndrome. The best thing you can do is keep yourself
healthy before and during pregnancy and watch for early signs of the condition. The
following steps can help:
 See your doctor regularly for prenatal visits.
 Tell your doctor if you’ve had any high-risk pregnancies or someone in your family
has had HELLP syndrome, preeclampsia, or other blood pressure problems.
 Know the symptoms and call your doctor ASAP if you have them.
SYMPTOMS OF HELLP SYNDROME
The physical symptoms of HELLP Syndrome may seem at first like preeclampsia. Pregnant
women developing HELLP syndrome have reported experiencing one or more of these
symptoms:

11.  Headache
 Nausea/vomiting/indigestion with pain after eating
 Abdominal or chest tenderness and upper right upper side pain (from liver distention)
 Shoulder pain or pain when breathing deeply
 Bleeding
 Changes in vision
 Swelling
Signs to look for include:
 High blood pressure
 Protein in the urine
The most common reasons for mothers to become critically ill or die are liver rupture or stroke
(cerebral edema or cerebral hemorrhage). These can usually be prevented when caught in time.
If you or someone you know has any of these symptoms, please see a healthcare provider
immediately.
TREATMENT OF HELLP SYNDROME
Most often, the definitive treatment for women with HELLP Syndrome is the delivery of their baby.
During pregnancy, many women suffering from HELLP syndrome require a transfusion of some
form of blood product (red cells, platelets, plasma). Corticosteroids can be used in early
pregnancy to help the baby's lungs mature. Some healthcare providers may also use certain
steroids to improve the mother's outcome, as well.
WHO'S AT RISK OF GETTING HELLP SYNDROME?
Among pregnant women in the United States, 5 to 8% develop preeclampsia. It's estimated that
15% of those women will develop evidence of HELLP syndrome. This mean as many as 48,000
women per year will develop HELLP syndrome in the US.
We can help lower the cases of HELLP syndrome by properly and quickly diagnosing and
treating preeclampsia.
WHAT CAN I DO TO PREVENT HELLP SYNDROME?
Unfortunately, there's currently no way to prevent this illness. The best thing to do is:
 Get yourself in the good physical shape before getting pregnant
 Have regular prenatal visits during pregnancy
 Inform your care providers about any previous high-risk pregnancies or family history of
HELLP syndrome, preeclampsia, or other hypertensive disorders

12.  Understand the warning signs and report them to your healthcare provider immediately
 Trust yourself when "something just doesn't feel right"
HOW HELLP SYNDROME IS CLASSIFIED
The severity of HELLP syndrome is measured according to the blood platelet count of the mother
and divided into three categories, according to a system called "the Mississippi classification."
 Class I (severe thrombocytopenia): platelets under 50,000/mm3
 Class II (moderate thrombocytopenia): platelets between 50,000 and 100,000/mm3
 Class III (AST > 40 IU/L, mild thrombocytopenia): platelets between 100,000 and
150,000/mm3
HOW HELLP SYNDROME AFFECTS BABIES
If a baby weighs at least 2 pounds (over 1000 grams) at birth, he or she has the same survival
rate and health outcome of non-HELLP babies of the same size.
Unfortunately, babies under 2 pounds at delivery don't fare as well. Several studies have
suggested these babies will need longer hospital stays and will have a higher chance of needing
ventilator care. Unfortunately, right now doctors can't predict the scope of the medical problems
that these small babies will encounter at birth and later in life.
In developed countries, the stillbirth rate (in utero death of the baby after 20 weeks) is 51 out of
every 1,000 pregnancies. This rate is higher than both severe preeclampsia and eclampsia.
Overall perinatal mortality from HELLP Syndrome (stillbirth plus neonatal death) ranges from 7.7
to 60%. Most of these deaths are attributed to abruption of the placenta (placenta prematurely
separating from the uterus), placental failure with intrauterine asphyxia (fetus not getting enough
oxygen), and extreme prematurity.
RISK OF GETTING HELLP IN FUTUREPREGNANCIES
Women with a history of HELLP syndrome are at increased risk of all forms of preeclampsia in
subsequent pregnancies. The rate of preeclampsia in subsequent pregnancies ranges from 16 to
52%, with higher rates if the onset of HELLP syndrome was in the second trimester. The rate of
recurrent HELLP syndrome ranges from 2 to 19% depending upon the patient population studied.
Types of multiple pregnancy

13. A multiple pregnancy is when you are pregnant with twins, triplets or more. Three babies or
more is called a ‘higher order’ pregnancy, and it’s rare – occurring in just 1 in 50 multiple
pregnancies. Find out more about the different types of multiple pregnancy here.
How do multiple pregnancies occur?
Multiple pregnancies occur when more than one embryo implants in your uterus (womb).
This can happen if you release more than one egg during the menstrual cycle and each egg
is fertilised by a sperm. Sometimes, a fertilised egg spontaneously splits into 2, resulting in
identical embryos.
Multiple pregnancies are more common than they used to be, mainly because of the
increasing use of in vitro fertilisation (IVF).
Fertility drugs often cause more than one egg to be released from the ovaries. IVF can result
in a multiple pregnancy if more than one fertilised embryo is transferred to the uterus and
develops. Sometimes, one of these eggs may split into twins after it is transferred.
Women aged 35 and older are more likely to release more than one egg during ovulation, so
they are more likely to have a multiple pregnancy. You are also more likely to have a
multiple pregnancy if you have a history of twins in your family.
Diagnosis of multiple pregnancy
Signs you may be expecting multiple babies include:
 You gain weight rapidly at the start of the pregnancy.
 You have severe morning sickness.
 More than one heartbeat is picked up during a prenatal examination.
 The uterus is larger than expected.
A multiple pregnancy is confirmed by an ultrasound scan, usually in the first trimester (the
first 12 weeks). The ultrasound will confirm the type of multiple pregnancy, whether there is
one placenta or 2, and how many amniotic sacs there are. These are all important factors for
later in the pregnancy and it’s important to identify them as early as possible.
If you are carrying multiple babies, you will have to see your doctor more often than women
who are expecting one baby. While most multiple pregnancies progress smoothly, there’s a
higher chance of the babies being born prematurely, having a low birth weight, or for you to
have other complications with your pregnancy.
Types of multiple pregnancy
The most common type of multiples are:
Fraternal twins
Two separate eggs are fertilised and implant in the uterus. The babies are siblings who
share the same uterus — they may look similar or different, and may either be the same
gender (2 girls or 2 boys) or of different genders. A pregnancy with fraternal twins is
statistically the lowest risk of all multiple pregnancies since each baby has its own placenta
and amniotic sac. You will sometimes hear fraternal twins referred to as ‘dizygotic’ twins,
referring to 2 zygotes (fertilised eggs).
Identical twins

14. Identical twins are formed when a single fertilised egg is split in half. Each half (embryo) is
genetically identical, so the babies share the same DNA. That means the babies will share
many characteristics. However, because their appearance is influenced by the environment
as well as by genes, sometimes identical twins can look quite different. Identical twins may
share the same placenta and amniotic sac, or they may have their own placenta and
amniotic sac. You will sometimes hear identical twins referred to as ‘monozygotic’, referring
to one zygote (fertilised egg).
Triplets and ‘higher order multiples’ (HOMs)
Triplets, quadruplets, quintuplets, sextuplets or more can be a combination both of identical
and fraternal multiples. For example, triplets can be either fraternal (trizygotic), forming from
3 individual eggs that are fertilised and implanted in the uterus; or they can be identical,
when one egg divides into 3 embryos; or they can be a combination of both.
If you are having 3 babies or more, you will need a lot of support throughout your pregnancy.
CARRYING A MULTIPLE PREGNANCY
In order to achieve the best outcome with a multiple pregnancy, the expectant mother must
work as part of the health care team. A nearly total change in lifestyle can be expected,
especially after about 20 weeks into the pregnancy.
Metabolic and Nutritional Considerations
There is an increased need for maternal nutrition in multiple pregnancies. An expectant
mother needs to gain more weight in a multiple pregnancy, especially if she begins the
pregnancy underweight. With multiples, weight gain of approximately 37-54 lb. is
recommended for normal-weight women. The pattern of weight gain is important too.
Healthy birth weights are most likely achieved when the mother gains nearly one pound per
week in the first 20 weeks. The increase in fetal growth with appropriate nutrition and weight
gain may greatly improve pregnancy outcome at a minimum of cost.
Activity Precautions
Many physicians who manage multiple pregnancies believe that a reduction in activities and
increased rest prolongs these pregnancies and improves outcomes. However, routine
hospitalization for bed rest in multiple pregnancy has not been shown to prevent preterm
birth. Women with high-order multiple pregnancies usually are advised to avoid strenuous
activity and employment at some time between 20 and 24 weeks. Bed rest improves uterine
blood flow and may be helpful for fetal growth problems. Intercourse generally is
discouraged when bed rest is recommended.
Monitoring a Multiple Pregnancy
Since preterm birth and growth disturbances are the major contributors to newborn death
and disability in multiples, frequent obstetric visits and close monitoring of the pregnancy are
needed.
Prenatal diagnosis using a variety of new techniques can be done near the end of the first
trimester to screen for Down syndrome and other genetic abnormalities. Amniocentesis may
be performed between 16 and 20 weeks. Amniocentesis may be complicated and difficult to
perform in twins and triplets and may not be possible in high-order multiple pregnancies.
However, reasonable data exist for the use of serum screening in the setting of multiple
pregnancies and can be a helpful tool to assess risk of these and other conditions.

15. Many physicians perform cervical examinations every week or two beginning early in
pregnancy to determine if the cervix is thinning or opening prematurely. If an exam or
ultrasound shows that the cervix is thinning or beginning to dilate prematurely, a cerclage, or
suture placed in the cervix, may prevent or delay premature dilatation. However,
preventative cerclage has not been shown to prevent preterm birth in twins or triplets.
Tocolytic agents are medications that may slow or stop premature labor. These medications
are given in hospital “emergency” settings in an attempt to stop premature labor. It is
important to attempt to delay delivery to minimize the risks of premature delivery. Ultrasound
examinations in the second trimester can identify some birth defects. Assessment of fetal
growth by ultrasound every 3 to 4 weeks during the second half of pregnancy is commonly
performed.
Every multiple pregnancy should be considered at high risk, and obstetricians experienced
with the management of multiple gestations should provide care. A neonatal intensive care
unit nursery should be available to provide immediate and comprehensive support to
premature newborns.
Method of Delivery
Vaginal delivery of twins may be safe in some circumstances. Many twins can be delivered
vaginally if the lowest infant is in the head-first position. Most triplets will be delivered by
cesarean section. Appropriate anesthesia and neonatal support are essential, whether
delivery is performed vaginally or requires cesarean section. Delivery of multiples requires
planning by the entire medical team and availability of full intensive-care support following
birth.
Psychosocial Effects of Multiples on a Family
Although the majority of women with a multiple pregnancy do very well, their families may
experience significant stress. If prolonged hospitalization is needed, arrangements must be
made for work, home, and family care.
Even when medical problems are overcome and the infants survive without disability, the
effect of multiple births on family life is substantial. The impact of a multiple birth clearly
affects the parents, but also the babies, other siblings, and the extended family. Financial
stresses are common, due to the additional costs of feeding, clothing, housing, and caring
for multiple children. Postpartum depression also is more common after delivery of multiple
pregnancies in both the mother and the father and may be long-term.
Psychological counseling and support groups may provide a lifeline for the parents of
multiples, who may feel isolated or depressed. Most physicians can provide appropriate
referrals to a mental health professional or a support group. For more information, see the
ASRM Patient Fact Sheet titled Challenges of Parenting Multiples.
Isoimmunization
Isoimmunization (Sometimes called Rh sensitization, hemolytic disease of the fetus, Rh
incompatibility)
What is isoimmunization?
A condition that happens when a pregnant woman's blood protein is incompatible with the
baby's, causing her immune system to react and destroy the baby's blood cells.
What causes isoimmunization?
When the proteins on the surface of the baby's red blood cells are different from the mother's
protein, the mother's immune system produces antibodies that fight and destroy the baby's

16. cells. Red cell destruction can make the baby anemic well before birth. Although the Rh(D)
protein is the most common one, several other proteins can cause this problem, including
among proteins KELL, Kidd, Duffy, and others.
What are the symptoms of isoimmunization?
The mother will not have symptoms from isoimmunization but for the baby symptoms can
range from mild to dangerous. Even mild, the incompatibility causes destruction of the red
blood cells without showing other effects. When the process is severe enough, the baby can
become very anemic and, in some cases may die. After birth, the baby's skin and whites of
the eyes will appear yellow (jaundice) and the baby will have low muscle tone (hypotonia)
and lethargy.
How is isoimmunization diagnosed?
Women at risk for isoimmunization can be identified at prenatal visits with tests that measure
blood type, Rh type and antibody screening. Occasionally the specific incompatibility is
diagnosed before birth through amniocentesis. If isoimmunization is diagnosed, we monitor
the severity of the baby's anemia utilizing ultrasound. After birth, there may also be a
positive reading on a blood test called Coombs, higher-than-normal levels of bilirubin from
blood samples from the baby's umbilical cord, and signs of red blood cell destruction in the
infant's blood.
What is the treatment for isoimmunization?
If the baby's anemia is severe, one of the following two options are available. If the baby is
mature enough to safely move to delivery, the baby is delivered and placed in the intensive
care nursery for transfusions and other therapies under the direction of the neonatologists. If
the baby is too premature to safely deliver, red blood cells are transfused to the baby before
it is born by inserting a needle into the baby's umbilical cord and administering red blood
cells.
How can isoimmunization be prevented?
Once identified as having Rh negative blood type, the pregnant and/or newly delivered mom
can be given RhoGAM (Rh-immune globulin).
Rh Incompatibility and Isoimmunization
Definition
Rh factor is a protein that may be found on the surface of red blood cells. If you carry this
protein, your blood is Rh positive. If you don't carry this protein, your blood is Rh negative.
Sometimes a mother with Rh-negative blood is pregnant with a baby that has Rh-positive
blood. This can cause a problem if the baby's blood enters the mother's blood flow. The Rh-
positive blood from the baby will make the mother's body create antibodies. This is called
isoimmunization. The antibodies will attack any Rh-positive blood cells. This will not cause a
problem for the mother. However, the antibodies can pass to the developing baby and
destroy some of the baby's blood cells.
Fortunately, Rh incompatibility is often prevented with an immunization. If the condition is not
prevented, the baby may need care.
Causes
A baby's Rh status is determined from the mother and father. If the mother is Rh negative
and the father is Rh positive, the baby has at least a 50% chance of being Rh positive.
However, Rh isoimmunization will only happen if the baby's Rh-positive blood enters the

17. mother's blood flow. In most pregnancies, the mother's and baby's blood will not mix. The
baby's blood may come into contact with the mother's blood flow during:
 Miscarriage
 Induced abortion
 Ectopic pregnancy
 Trauma during pregnancy
 Amniocentesis or other invasive testing procedures related to pregnancy—rare
The mix in blood happens most often at the end of pregnancy. This means it is rarely a
problem in a woman's first pregnancy. The mother's antibodies could affect a future
pregnancy with a baby with Rh-positive blood even if the blood is not mixed.
A woman can also become sensitized to Rh-positive blood if she receives an
incompatible blood transfusion .
Risk Factors
Factors that put you at risk for Rh incompatibility include being an Rh-negative pregnant
woman who:
 Had a prior pregnancy with a baby that was Rh positive
 Had a prior blood transfusion or amniocentesis
 Did not receive Rh immunization prophylaxis during a prior pregnancy with an Rh-
positive baby
Symptoms
Symptoms and complications will only affect the baby. The complications occur when
standard preventive measures are not taken. The symptoms can vary from mild to severe.
Symptoms that can develop in the baby include:
 Swelling of the body, which may be associated with heart failure or respiratory
problems.
 Jaundice
 Anemia
A complication of untreated jaundice is kernicterus, a syndrome which can affect the baby's
nervous system. Contact your doctor right away if your baby:
 Has a yellow or orange appearance to the skin
 Does not sleep
 Is hard to wake up
 Is not breastfeeding or has difficulty sucking from a bottle
 Is restless or fussy
Call for emergency medical help if your baby has:
 High pitched crying or crying that won't stop
 A bowed body
 A stiff, limp, or floppy body
 Strange eye movements
Diagnosis
You cannot detect Rh incompatibility on your own. A blood test can determine whether you
are Rh positive or Rh negative. The blood test will also look for Rh antibodies or monitor the

18. levels of antibodies through pregnancy. If the antibody levels are high, anamniocentesis can
determine if the fetus is ill.
It is important to have a blood test at the beginning of pregnancy.
Treatment
Rh incompatibility is almost completely preventable using immunization. The best treatment
is prevention.
If Rh incompatibility does occur, then the baby may need treatment based on symptoms
such as:
Mild Symptoms
Full recovery is expected for mild Rh incompatibility. Treatment may include:
 Aggressive hydration
 Phototherapy —light therapy to treat skin conditions
Swelling of the Body (Hydrops fetalis)
More severe condition that may require:
 Intrauterine fetal transfusion—to replace blood cells that are being destroyed during
pregnancy
 Early induction of labor
 A direct transfusion of packed red blood cells which are compatible with the infant's
blood
 An exchange transfusion to remove the mother's antibodies
 Control of heart failure and fluid retention
Kernicterus may be treated with:
 Exchange transfusion—replacing baby's blood with blood with Rh-negative blood
cells
 Phototherapy
Both hydrops fetalis and kernicterus are more severe conditions. Long-term problems can
also develop with severe cases, including:
 Cognitive delays
 Movement disorders
 Hearing loss
 Seizures
Prevention
If a mother is at risk for Rh incompatibility, then an injection of Rho immune globulin will be
given at week 28 of the pregnancy. A second injection will be given within 72 hours after
delivery. These injections will block the mother's body from developing antibodies. Women
at risk may also be given these injections after a miscarriage, induced abortion, or ectopic
pregnancy. These injections will protect the current pregnancy and future pregnancies.
Routine prenatal care should help identify, manage, and treat any complications of Rh
incompatibility.
Red blood cell isoimmunisation describes the production of antibodies in response to an
isoantigen present on an erythrocyte.

19. Maternal isoimmunisation occurs when the mother’s immune system in sensitised to antigens
on fetal erythrocytes, resulting in the production of IgG antibodies.
In subsequent pregnancies, these antibodies can cross the placenta and attack the fetal red
blood cells – leading to haemolysis and anaemia (known as haemolytic disease of the newborn).
In this article, we shall look at the pathophysiology of red blood cell isoimmunisation, how it is
screened for, and how it is prevented during pregnancy.
Pathophysiology
In red blood cell isoimmunisation, maternal antibodies are formed in response to surface
antigens on fetal erythrocytes. It occurs when the fetal cells enter the maternal circulation via
a ‘sensitising event‘ – such as an antepartum haemorrhage or abdominal trauma. It can also
occur during delivery.
There are rarely any problems during the primary exposure. However, in subsequent
pregnancies, maternal antibodies can cross the placenta and attack the fetal red blood cells (if
they carry the same surface antigen). This leads to haemolysis and subsequent fetal anaemia.
There are more than 50 different surface antigens capable of inducing maternal isoimmunisation.
The most common set is the Rhesus D blood group – for which individuals are either positive
(RhD+) or negative (RhD-).
Rhesus D isoimmunisation is only possible in RhD- women, and occurs when they come into
contact with the blood of a RhD+ fetus:
 A woman is RhD-, and her partner is RhD+. She becomes pregnant with a fetus that is
also RhD+. During childbirth, she comes into contact with the fetal (RhD+) blood, and antibodies
are produced (known as anti-D antibodies).
 She later becomes pregnant with a second child that is also RhD+.
 The woman’s anti-D antibodies cross the placenta during this pregnancy and enter the
fetal circulation, which contains RhD+ blood. They bind to the fetus’ RhD antigens on its
erythrocyte surface membranes.
 This causes the fetal immune system to attack and destroy its own RBCs, leading to
fetal anaemia. This is termed haemolytic disease of the newborn (HDN).
Anti-D Immunoglobulin
If a sensitising event occurs, maternal isoimmunisation can be prevented via the administration
of Anti-D immunoglobulin. It binds to any RhD+ cells in the maternal circulation, and no
immune response is stimulated.
Note: Anti-D immunoglobulin is never required in RhD+ women, as they cannot generate anti-D
antibodies.
Indications for Use
In Rhesus D negative women, the administration of anti-D immunoglobulin should be considered
following any sensitising event:

20.  Invasive obstetric testing (e.g amniocentesis or chorionic villus sampling)
 Antepartum haemorrhage (APH)
 Ectopic pregnancy
 External cephalic version
 Fall or abdominal trauma
 Intrauterine death
 Miscarriage
 Termination of pregnancy
 Delivery (normal, instrument or caesarean section)
Investigations and Management
In the UK, sensitising events in RhD- women are managed according to their gestation (see
Table 1).
There are two main blood tests that should be considered following a sensitising event:
 Maternal blood group and antibody screen – determines ABO and RhD blood
groups, and detects any antibodies directed against RBC surface antigens (except A and B).
 Feto-maternal haemorrhage (FMH) test – also known as the Kleihauer test, this
assesses how much fetal blood has entered the maternal circulation. If there has been a
sensitising event after 20 weeks gestation, this test is used to determine how much anti-D
immunoglobulin should be administered.
After delivery, the Rhesus status of the baby should be checked. If the baby is RhD+ (and the
mother is RhD-), a FMH test should be performed, and at least 500 IU of anti-D immunoglobulin
administered. The dose can be increased depending on the size of the FMH.
Table 1 – Management of Sensitising Events
Less than 12 weeks’ gestation
Indications: Ectopic pregnancy, molar pregnancy, termination or
heavy uterine bleeding
Investigations: Maternal blood group and antibody screen (to
confirm RhD-, and that no anti-D antibodies are already formed).
Dose: 250 IU anti-D, within 72 hours of the event.
12-20 weeks’ gestation
Indications: All potential sensitising events
Investigations: Maternal blood group and antibody screen (to
confirm RhD-, and that no anti-D antibodies are already formed).
Dose: 250 IU anti-D, within 72 hours of the event.
Greater than 20 weeks’ gestation
Indications: All potential sensitising events
Investigations: Maternal blood group and antibody screen (to
confirm RhD-, and that no anti-D antibodies are already formed).
Feto-maternal haemorrhage test.
Dose: 500 IU within 72 hours of the event (dose can be increased
depending on the size of the FMH
What is Maternal Alloimmunization?
Alloimmunization, often called Rh-isoimmunization or Rh incompatibility was first described
in Rh negative women with an Rh-positive fetus, but it can occur with many other blood type
incompatibilities. It is a condition that may occur during pregnancy when there is an

21. incompatibility between your blood type and your baby’s blood type. During pregnancy, red
blood cells from your unborn baby can cross into your bloodstream through the placenta. If
your blood type is different than your baby’s, your immune system may treat the baby’s
blood cells as if they were a foreign substance and produce antibodies against them. Those
antibodies can cross back through the placenta and attack your baby’s red blood cells. This
is called hemolytic disease of the fetus, a condition in which red blood cells are destroyed
faster than the body can replace them. Without enough red blood cells, your baby won’t get
enough oxygen.
If hemolytic disease is left untreated it may lead to serious problems, such as brain damage;
hydrops fetalis (abnormal amounts of fluid build-up in two or more body areas); seizures;
problems with mental function, movement, hearing and speech, or even death.
Alloimmunization does not usually cause problems during a first pregnancy because the
baby often is born before many of the antibodies develop. However, once the antibodies
have formed, your body does not get rid of them, so any subsequent babies are more likely
to have problems if they have the same blood type as the first baby.
How is Alloimmunization diagnosed?
All mothers are tested for the development of antibodies three times during pregnancy: at
their first prenatal visit, at 28 weeks’ gestation, and at delivery. If there is Alloimmunization
during your pregnancy, it is important that you and your fetus be evaluated by a Maternal-
Fetal Medicine specialist for hemolytic disease of the fetus. If your newborn has hemolytic
disease he/she should be evaluated by a Neonatologist. Symptoms of hemolytic disease in
your fetus or newborn may include:
 An abnormally large amount of amniotic fluid
 Jaundice (yellowing of the skin and eyes)
 Decreased muscle tone
 Lethargy
 Signs of red blood cell destruction in your baby’s blood
If your doctor suspects Alloimmunization, testing will confirm the diagnosis. Common tests
for diagnosing Alloimmunization include:
 A blood test to detect antibodies that are stuck to the surface of red blood cells
(known as a direct Coombs test)
 Testing of either or both the father of the baby or the fetus by amniocentesis to
determine the fetus’ blood type
 Ultrasound examination of the blood flow velocity in the fetal brain
 Directly testing the fetal blood type and blood count by cordocentesis
 A blood test to look for higher-than-normal levels of bilirubin in your baby’s umbilical
cord blood
Can Alloimmunization be prevented?
Rh-isoimmunization (incompatibility to the Rh blood type) is preventable, and prevention is
preferable to treatment. Rh negative women are given injections of a medicine called Rh
immune globulin (RhoGAM) to keep their body from making Rh antibodies. If you have Rh-
negative blood, you’ll need this medication every time you are pregnant with a baby with Rh-
positive blood. There are certain events (for example miscarriage, or chorionic villus
sampling) expose you to Rh-positive blood, and could therefore affect your unborn child. If
you are treated with Rh immune globulin immediately after one of these events, you may be
able to avoid Rh incompatibility during your pregnancy.
How is Maternal Alloimmunization treated?

22. If there is severe hemolytic disease of the fetus, then a Maternal-Fetal Medicine specialist
can give your fetus in-utero transfusions. These can be lifesaving and prevent many of the
complications of hemolytic disease.
After delivery, if your baby has a mild case of hemolytic disease your doctor may treat the
condition with phototherapy (light therapy). In some cases, your baby may also need one or
more blood transfusions.
Fetal Deaths
Fetal death refers to the spontaneous intrauterine death of a fetus at any time during pregnancy.
Fetal deaths later in pregnancy (at 20 weeks of gestation or more, or 28 weeks or more, for
example) are also sometimes referred to as stillbirths. In the United States, State laws require the
reporting of fetal deaths, and Federal law mandates national collection and publication of fetal
death data. Most states report fetal deaths of 20 weeks of gestation or more and/or 350 grams
birthweight. However, a few states report fetal deaths for all periods of gestation. Fetal death
data is published annually by the National Center for Health Statistics, in reports and as
individual-record data files.
Intrauterine fetal demise is the clinical term for stillbirth used to describe the death of a baby
in the uterus. The term is usually applied to losses at or after the 20th week of gestation.
Fetal demise is defined differently around the world, based on the gestational age and
weight of the fetus. In some places, the threshold can range from at least 16 weeks to at
least 26 weeks with a weight of at least 400 grams to at least 500 grams.
Pregnancies that are lost earlier are considered miscarriages and are treated differently by
medical examiners. Parents of a stillborn baby, for example, will receive a birth and death
certificate while those of a miscarried fetus will not.
To many who have experienced such loss, the line between a stillbirth and miscarriage can
often seem arbitrary but should in no way suggest that a parent's emotional response is any
more or less profound.
Incidence and Causes of Stillbirth
According to the Centers for Disease Control and Prevention, fetal death occurs in roughly 1
in 100 pregnancies in the U.S. Early stillbirth (occurring from 20 to 27 weeks) is only slightly
more common than late stillbirth (28 weeks or later). According to the CDC, there are
approximately 24,000 stillborn births in the United States.1
All told, about one in every four stillbirths will be unexplained. Of those with a diagnosed
cause, the most common will include:
 Placental dysfunction leading to fetal growth restriction
 Placental abruption and other placental disorders (such as vasa previa)
 Genetic abnormalities
 Congenital birth defects
 Umbilical cord complications
 Uterine rupture
Risk Factors for Stillbirth

23. There are several factors2
that can place a woman at greater risk for stillbirth. Some are
factors you can control; others you can't. Among them:
 Your general health and well-being are key in determining your ability to carry a
child to term. Hypertension, diabetes, lupus, kidney disease, thyroid disorders, and
thrombophilia are just some of the conditions associated with stillbirth. Smoking,
alcohol, and obesity can also contribute.
 Ethnicity and race also play a part, both in terms of genetic disposition and the
socioeconomic barriers that prevent some mothers from accessing perinatal care.
African American women are today twice as likely to have a stillbirth compared to
white women.
 Advanced maternal age isn't the factor it used to be thanks to advance perinatal
technologies. Still, women older than 35 are more likely to have unexplained
stillbirths than younger women.
 Carrying more than one baby increases your risk of stillbirth. As a result, in women
undergoing in vitro fertilization (IVF), it is often recommended that one embryo per be
transferred per cycle to reduce the chance of a stillbirth.
 Domestic violence can affect women of all races and economic standing. However,
in poorer communities, high rates of unemployment, drug use, and incarceration can
combine to place a mother and unborn child at even greater risk.
 A history of pregnancy problems, including fetal growth restriction and preterm
delivery, translates to a higher risk of stillbirth in a subsequent pregnancy.
Meanwhile, women who have had a previous stillbirth are two to 10 times more likely
to experience another.
What Happens If You Experience a Stillbirth
The most common sign of a stillbirth is when a mother no longer feels her baby moving. If
your doctor confirms that your baby is, in fact, stillborn, you will likely be given two options:
 Inducing labor with medication so it begins within a few days
 Waiting for labor to occur naturally within a week or two
If you experience a stillbirth, it's natural to feel an often dizzying array of emotions. Don't try
to swallow them. Instead, turn to your support network (including your friends, family, and
medical professional) for help in coming to terms with your loss.
If you find yourself unable to cope, seek professional help from a licensed counselor or
mental health professional. Ask your doctor or obstetrician for referrals.
In the end, coming to term with a stillbirth is not an event; it's a process. Give yourself time
and don't close yourself off. Things will get better.
Surgical Labor & DeliveryIntervention
Whether you’ve decided to have a traditional childbirth experience or have opted for a more
natural childbirth, surgical intervention may be necessary if there are complications or if your
health care provider thinks it’s safest for your baby.
The two most common surgical interventions are C-sections (caesarian sections) and
episiotomies.
C-section

24. A C-section, also known as a caesarian section, is a surgical procedure to remove a fetus from
its mother’s uterus. Some C-sections are planned and scheduled in advance, and some are
considered emergency C-sections. When a woman cannot safely deliver her baby through the
vaginal canal, doctors will perform a C-section.
Some reasons for C-sections include:
 the mother has delivered a child by C-section in the past
 the baby is in distress
 the baby is too large to fit through the vaginal canal
 the baby is not in the proper position to allow for vaginal delivery (he or she is
positioned feet, shoulders or bottom down rather than top of the head down)
 labor is not progressing normally
 there are complications with the placenta
 the mother has a medical condition that could be passed to the baby through the
vaginal canal (such as HIV infection or other sexually transmitted diseases)
 the mother is carrying twins or multiples
During a C-section, an anesthesiologist will provide medication to block pain from the waist down
with an epidural or a spinal block. Usually moms get to stay awake for the procedure so they can
see their babies as soon as they are delivered, but in some cases, doctors may need to give
general anesthesia so the mother is asleep for the surgery. Once the anesthesia has taken effect,
the doctor will make an incision in the abdomen and separate the muscles to expose the uterus,
and then will make another incision in the uterus. After the uterine incision is made, the doctor will
pull the baby out. The baby’s mouth and nose will be suctioned, and then the umbilical cord will
be clamped and cut. The doctor will then remove the placenta from the uterus, close the uterus
with dissolvable stitches and close the abdominal incision with additional stitches or surgical tape.
The skin is closed with a stitch under the skin, or staples. Staples are removed within a few days.
If you have a C-section, you may have to stay in the hospital a bit longer than if you deliver your
baby vaginally. Your recovery may take a little bit longer as well. However, most C-sections don’t
involve complications, so you should be back to feeling good within a short time.
Episiotomies
An episiotomy is an intentional cut to the area of the skin and muscle between the vagina and the
rectum. This area is called the perineum. Although episiotomies used to be common as a
preventive measure (to try to avoid natural tearing that can happen during childbirth), they are not
typically done anymore unless there is a complication during a vaginal birth or the baby needs to
be removed quickly.* A health care provider may choose an episiotomy if the baby is too big or
there isn’t enough room, or the baby is in distress and needs to be removed quickly.
If you do need an episiotomy, your health care provider will likely give you a local anesthetic to
numb the area and will then use surgical scissors to make a small cut in the perineum. The cut is
made just before you’re about to give birth. After your baby is born, the health care provider will
give you additional local anesthetic before giving you stitches to close up the incision. The level
and duration of discomfort after an episiotomy (or a natural tear) varies from woman to woman.

25. We recommend that you use a cold pack immediately after your baby is born and then on and off
for the following 24 hours to help reduce the pain and keep the swelling down.
Whether you have an episiotomy or you tear naturally during childbirth, you will likely heal within
four to six weeks after you deliver your baby. You shouldn’t have sex before your health care
provider examines you and gives you the okay to resume sexual activity.
*Although recent research shows that episiotomies heal more slowly than natural tears and have
higher risk of infection and complications, some doctors still perform them to prevent tearing. If
you are concerned about whether or not your doctor will perform an episiotomy, ask him or her
before you go into labor. Talk about the risks and benefits, and find out what circumstances might
cause your doctor to perform one. If you are uncomfortable with having one, let your doctor know.
Overview of Surgical Obstetrical Procedures
The successful management of labor and delivery requires a balanced use of medical and
surgical practices. Most pregnancies end with uncomplicated vaginal deliveries. Pregnant
women in labor have the right to attendants who can manage obstetric complications as they
arise and who can transfer patients to a higher level of care as needed.
The presence of skilled birth attendants at all deliveries facilitates normal deliveries and the
identification and referral of complications, but their effectiveness is limited by available
referral resources. Although birth attendants may be able to accommodate minor
complications, the benefit of their ability to identify major morbidity is limited if patients lack
timely access to higher levels of care.
A majority of obstetric complications that require surgical intervention occurs peridelivery.
Obstructed labor from a number of causes, including malpresentation and large fetal size,
can necessitate one of a number of procedures to facilitate fetal delivery. Following delivery,
hemorrhage from a number of etiologies, including lacerations and uterine atony, can
similarly require one of a number of lifesaving procedures to help stop ongoing bleeding.
Operative Vaginal Delivery
Operative vaginal delivery, such as delivery assisted with forceps or a vacuum, requires
trained providers as well as available instruments (Hale and Dennen 2001); its use in LMICs
is often limited to the hospital setting. Vacuums require a fundamental level of training before
routine use, and forceps require potentially more training, in addition to provision of the
actual devices. The WHO is developing variations on a vacuum to provide a low-cost and
easy-to-use device that can be widely implemented by birth attendants to reduce morbidity
and mortality (FIGO 2012). Some devices are reusable; after the initial investment in the
device, the subsequent cost largely consists of training providers to effectively and safely
use it. The use of operative vaginal delivery techniques in the appropriate clinical
circumstance might prevent the need for an inaccessible but otherwise necessary cesarean
delivery. Additionally, manual or digital rotation of the fetal head without the use of forceps
can help to guide the head through the pelvis to facilitate vaginal delivery (Le Ray and others
2007), but it requires a similar level of training. In sum, the minimal costs associated with
providing the devices, as well as training for management of the second stage of labor, can
help reduce morbidity and mortality without requiring the use of an operating theater.
Shoulder Dystocia
Shoulder dystocia and its association with poor fetal outcomes and brachial plexus injuries
make it a feared obstetrical complication (Baskett, Calder, and Arulkumaran 2007; O’ Grady
and others 2008). Shoulder dystocia results from delivery of the fetal head, with a dystocia at
the level of the shoulder that obstructs delivery. It is more common with large infants,
particularly with relatively large shoulder widths born to mothers with diabetes. Attempts at

26. delivery may cause permanent nerve injury, and delay in delivery may cause hypoxic injury
or death.
Several maneuvers have been described for delivery. Most techniques involve rotation of the
fetal shoulder from the anterior-posterior orientation to a more oblique position, where the
more generous dimensions of the pelvis might permit shoulder delivery. Specific surgical
instruments may be needed for operative management without successful resolution of the
dystocia. Successful management of a shoulder dystocia depends primarily on the training
of the attending providers.
Intentional pubic symphysiotomy, where the pubic bone is broken to facilitate fetal delivery,
is controversial because it can cause significant maternal morbidity and chronic pain. Its
implementation should be performed only by experienced providers when all other options
have failed and cesarean delivery is not available. Significantly, it is only necessary without
timely access to safe cesarean delivery.
Genital Tract Lacerations
Lacerations of the genital tract, which can occur spontaneously or result from an episiotomy,
are the second most common cause of postpartum hemorrhage. They can occur at any level,
including the perineum, sulci, cervix, or the broad ligament in the abdomen; without
spontaneous hemostasis, they will require repair. The use of routine episiotomy in obstetrics
has evolved, with studies demonstrating the cost-effectiveness of its selective rather than
routine use (Borghi and others 2002). An attendant with available suture can repair a
majority of perineal lacerations without referral, but severe lacerations can threaten or end a
mother’s life. Complicated lacerations can bleed profusely; ongoing bleeding can exhaust
clotting factors, resulting in an inability to clot and death. Similarly, hematomas can occur;
even without visible bleeding, large volumes of blood can accumulate in the pelvis following
vaginal delivery. Depending on their location, prompt identification and treatment can be life
saving.
Abnormal Fetal Presentation
Breech Presentation. In most pregnancies, the fetus moves into the safest position of head
down at approximately 36 weeks. However, this movement does not occur in 4 percent of
cases, resulting in breech presentation (Baskett, Calder, and Arulkumaran 2007), and its
incidence rises dramatically with prematurity. Breech presentation is associated with inferior
fetal outcomes, as a result of both the antenatal risk factors and the perinatal risk of birth
injury at delivery.
Ideally, a breech presentation is identified before delivery so that consideration can be given
to attempting the external turning of the fetus. This technique is optimally performed near 36
weeks, when the success rate is generally better than 50 percent. Although external version
can effectively make a mother a candidate for vaginal delivery and decrease morbidity, it
carries the risk of manually traumatizing the placenta or the fetus, necessitating immediate
delivery. It should only take place when the fetal status can be confirmed, and intervention,
including cesarean delivery, is immediately available. Unfortunately, in LMICs where
antenatal care is scant, breech presentation may not be identified until labor, and delivery
has to be facilitated either by emergent cesarean or by unanticipated vaginal breech delivery.
Large studies have demonstrated improved fetal outcomes in breech presentation with
cesarean delivery (Hannah and others 2000; Hannah and others 2002); safe cesarean
delivery is preferred, when available, unless practitioners are trained to manage breech labor
and its complications. Birth attendants should be trained in the maneuvers to assist intact
delivery in cases in which breech delivery is inevitable or advisable. Particularly in the
absence of antenatal care, a possible clinical scenario is a vaginal breech delivery in

27. progress, and fetal outcome will depend on a present provider who can safely deliver the
fetus.
Other Presentation. Malpresentation, in which neither the fetal vertex nor the breech is the
presenting part, as with a transverse presenting fetus (where the fetus is sideways), is a
universal indication for cesarean delivery. Without a safe and timely cesarean delivery, the
pregnancy can end with obstructed labor and its sequelae, or fetal demise.
Multiple Gestation
Delivery of more than one fetus is inherently more complicated (Baskett, Calder, and
Arulkumaran 2007). Contraindications to vaginal delivery include three or more fetuses, an
exceedingly uncommon event in the absence of assisted reproductive technology.
Fortunately, the presenting fetus will usually be head down in the pelvis and can be
managed essentially as a singleton labor. Following delivery of the first twin, and if the
second twin does not present vertex, attempts can be made to externally rotate the fetus to
vertex and proceed with vaginal delivery. Otherwise, breech extraction of the second twin
can be considered. In multifetal deliveries, vaginal delivery has lower maternal morbidity
than cesarean delivery, but a combined vaginal delivery and cesarean delivery is more
morbid than either. If vaginal delivery of a second twin is doubtful, particularly in the absence
of a provider comfortable with breech extraction, cesarean delivery may be considered
primarily.
Postpartum Hemorrhage
Postpartum hemorrhage is a dreaded complication akin to the most severe surgical trauma.
The average blood losses for a routine vaginal delivery and a cesarean delivery are
commonly accepted to be 500 mls and 1,000 mls, respectively; blood loss in excess of these
values is considered to be hemorrhage. The causes of postpartum hemorrhage are as
follows, in the order of frequency, with optimal management based on underlying etiology
(O’Grady and others 2008):
 Uterine atony
 Lacerations
 Retained placenta, including abnormal placentation
 Uterine rupture
 Uterine inversion
 Coagulopathy
Uterine Atony. Uterine atony accounts for approximately 80 percent of all postpartum
hemorrhage (O’Grady and others 2008). Risk factors include uterine overdistension,
prolonged labor, multiparity, infection, and use of uterine relaxants. Medical uterotonics,
where available, can be administered to assist uterine tone, including pitocin, misoprostol,
and ergots or prostaglandins. Consideration may also be given to draining the bladder, given
that a distended bladder can contribute to uterine atony. Mechanically, bimanual massage
can at least temporize uterine atony. Without medical or surgical interventions, effective
bimanual massage can be life saving. Research has suggested that effective bimanual
massage is optimized when two parties coordinate to help compress the atonic uterus and
stop maternal hemorrhage (Andreatta, Perosky, and Johnson 2012). Active management of
the delivery of the placenta itself can significantly help prevent atonic hemorrhage and limit
the need for additional uterotonics (Stanton and others 2009).

28. If hemorrhage continues despite these maneuvers, surgical management should be
considered. Surgical management can include blunt or sharp curettage of the uterus,
particularly with a large curette to minimize the risk of perforating the fragile peripartum
uterus and necessitating abdominal surgery. Otherwise, laparotomy can be used to access
the uterus and perform maneuvers such as compression sutures, ligation of uterine vessels,
or ultimately hysterectomy for definitive management. Delays in or the unavailability of
surgical interventions can lead to uncontrolled hemorrhage, disseminated intravascular
coagulopathy, and death. For persistent hemorrhage, the uterus can be packed to
tamponade and temporize the bleeding. This procedure can be done either with packing or
with a balloon catheter to help drain the uterine cavity while providing tamponade. Surgical
management may still be fundamentally needed, but maternal survival may depend on the
ability to transport to provide abdominal surgery.
Retained Placenta. Following delivery of the placenta, any remnant of the products of
conception can contribute to uterine atony and ongoing vaginal bleeding. Retained products
may be suspected with difficult extrusion of the placental membranes. In any scenario in
which retained products of conception are suspected, consideration should be given to the
possibility of placenta accreta because further placental bed manipulation could contribute to
catastrophic hemorrhage and death. Surgical curettage may be needed to remove persistent
retained products and arrest hemorrhage if placental abnormalities are not present.
Uterine Inversion. Inversion of the uterus can occur as a result of overzealous traction on a
placenta or from fundal pressure in the third stage of labor. With inversion, on examination,
the fundus may be noted to have descended or prolapsed into the vagina. A skilled
attendant can use gentle manual replacement of the fundus back to its appropriate station,
and effort may be needed to avoid relapse of the prolapse. Without successful manual
replacement, other techniques may be urgently needed in the face of ongoing hemorrhage
or maternal shock (Baskett, Calder, and Arulkumaran 2007). Nonsurgically, intravaginal
pressure can be increased with infusion of intravenous fluids while the introitus is blocked,
which may reduce the inversion. Surgically, the abdomen can be entered with a Pfannenstiel
incision or otherwise to gain exposure to the uterus. In the Huntington procedure, the round
ligaments are elevated and followed medially, eventually restoring the inverted fundus.
Alternatively, with the Haultian procedure, the inversion is incised vertically, permitting
appropriate reapproximation of the fundus.
Blood Transfusion. The WHO considers access to safe blood transfusion be a key
lifesaving intervention (WHO 2008). The availability of blood transfusions at the time of
obstetric emergency can be life saving. Accordingly, blood transfusion services should be
considered part of emergency obstetric management capacity. Blood transfusion availability
is severely limited in LICs and LMICs, and efforts to make it available locally can save lives.
Cesarean Delivery
Prolonged labor can lead to uterine rupture, which can lead to rapid fetal or maternal
exsanguination. In settings of prolonged and obstructed labor, eventual cesarean section
has a significantly increased risk of maternal morbidity or potentially death, compared with
timely cesarean delivery.
Indications. The indications for cesarean delivery are numerous, and its potential to reduce
associated morbidity is significant. The decision to proceed is influenced by a number of
factors, including the training of the operator, the operative and clinical resources, and the
variables of the clinical presentation. The caveat is that cesarean delivery is a more morbid
procedure: blood loss is increased, recovery time is lengthened, and potentially inferior fetal
outcomes can occur. In certain scenarios, however, a cesarean is necessary and inevitable
to save a life or lives. Efforts to develop evidence-based best practices for cesarean delivery
are ongoing (Berghella, Baxter, and Chauhan 2005; Dahlke and others 2013).

29. Preoperative Preparation. Once the decision is made to proceed, the patient is moved to
the operating theater, and the appropriate anesthesia, whether regional or general, is
administered. The abdomen is prepared in a sterile manner. A Foley catheter may be placed
to help minimize the presence of the bladder in the operative field and to provide an accurate
assessment of urine output. A single dose of antibiotic prophylaxis within 30 minutes before
incision is associated with decreased risk of infection. The risk of venous thromboembolism
during routine cesarean delivery is low in the absence of other risk factors, and routine
medical thrombolytic prophylaxis is not recommended (Dahlke and others 2013).
Incision. The Pfannenstiel incision, transversely in the lower abdomen, has classically been
described for cesarean delivery. A midline vertical incision may be considered for better
exposure. Alternatives to the Pfannenstiel or midline vertical incisions include the Joel-
Cohen technique and the Misgav-Ladach method in which blunt dissection is used and may
decrease blood loss and operative time, although studies have not shown significant
decreases in morbidity or mortality
The uterus is incised in the lower nonmuscular portion to facilitate fetal delivery.
Occasionally, a contraction ring or “Bandl’s ring” can be seen in prolonged obstructed labor
at the time of cesarean delivery. Its treatment requires perpendicular incision, through the
ring and muscle of the uterus, to relax the tension and permit delivery, with significant future
morbidity associated with the incision. Notably, any uterine incision that extends up into the
thick muscle significantly compromises the uterus and increases the risk of uterine rupture in
a future pregnancy. It is considered a contraindication to a future trial of labor, sentencing
the patient to indicated cesarean deliveries for all future pregnancies.
Delivery. The fetus is delivered through the uterine incision, with morbidity associated with
cesarean delivery increasing if the fetal head has engaged in the pelvis and labor has taken
longer, as with obstructed labor. Techniques to facilitate a challenging cesarean delivery
may include breech extraction, use of the vacuum extractor, or use of one or two forceps
blades to facilitate delivery through the hysterotomy. Morbidity includes hemorrhage,
infection, or uterine excision extension into the nearby anatomy of either the major
vasculature or the urinary tract.
If the placenta does not easily separate, occult placenta accreta may be considered. If
accreta is suspected, manual removal should be avoided; if spontaneous delivery does not
occur, then hysterectomy should be considered. The uterus may be exteriorized to facilitate
exposure for closure, although this may increase patient discomfort and nausea, as well as
risk of avulsion of adhesions to the uterus, if present.
Uterine closure then takes place quickly in the face of bleeding from the hysterotomy edges
and from the uterus. Atony should be addressed while surgery continues with bimanual
massage used as needed. If the patient desires an intrauterine device for contraception, it
can be placed at this time directly at the level of the fundus, with the strings trimmed and
introduced near or through the cervix.
Obstetric Hemorrhage at Time of Cesarean Delivery. Hemorrhage following cesarean
differs from that following vaginal delivery in that there is already access to the abdominal
cavity, improving the odds of successful definitive management. Conservative measures can
also be taken, including medicines and bimanual massage. Without quick resolution, a stitch
can be placed bilaterally around the large uterine vessels to decrease active hemorrhage
from the uterus. Hypogastric artery ligation can similarly decrease the blood flow and rate of
blood loss, although its dissection is technically challenging and should only be undertaken
by an operator sufficiently trained in and comfortable with the procedure. Tamponade and
packing can be performed and left in place to arrest bleeding as well.
If atony is the underlying issue and the outlined steps have not stopped the bleeding,
compression sutures may be helpful in the scenario in which bimanual massage is effective,
but as soon as the hands are removed uterine tone is lost.

30. When ongoing hemorrhage is significant and not easily abated, definitive management with
hysterectomy should be strongly considered because delay will only increase morbidity. The
B-Lynch suture is described as passing a stitch on a large needle across the hysterotomy
about halfway toward the side. The stitch is then taken to the posterior of the uterus, where it
is passed transversely at approximately the level of the anterior low uterine segment
hysterotomy. It is brought back anterior, where it is thrown vertically across the hysterotomy
on the other side. The two ends of the suture are tied down while an assistant has maximally
compressed and folded the uterus on itself, so that when the stitch is tied down, the uterus is
as compressed as possible because any relaxation will contribute to bleeding from atony.
Other types of compression sutures are described as passing anterior to posterior in the
body of the uterus to tamponade sequential pockets throughout the cavity. If compression
sutures are performed, care should be taken not to obstruct cavity outflow given that
hematometra or pyometra can result.
Abnormal Placentation and Cesarean Hysterectomy
When the placenta grows into tissue beyond its normal boundaries, it can embed in that
tissue and cause catastrophic hemorrhage with attempted removal. The term placenta
accreta encompasses placenta increta (where placenta grows into the uterine wall)
and percreta (where placenta grows into nearby tissue including bowel and bladder). Risk
factors include previous uterine scarring from surgical procedures, including previous
cesarean section.
Antenatal diagnosis can be achieved with ultrasound imaging in combination with clinical
history. With antenatal diagnosis, preparations should be made at the onset of labor to plan
for delivery in a scheduled setting, ready for the probability of cesarean hysterectomy and
the need for blood products, if available. Even in settings with full obstetric resources,
placenta accreta can lead to poor maternal outcomes. The aggressive hemorrhage
associated with incomplete placental separation can quickly lead to disseminated
coagulopathy and require massive blood transfusions to maintain maternal life.
Suspicion of placenta percreta before delivery calls for the coordination of a team of
surgeons in a facility with resources to maximize the likelihood of safe delivery. Cesarean
delivery should be undertaken, with consideration for a midline vertical incision to facilitate a
potential hysterectomy. Following exposure of the gravid uterus, a uterine incision may be
made to avoid disruption of the placental bed if its location is known. In cases of diagnostic
certainty, cesarean hysterectomy can be accomplished without attempting placental delivery,
decreasing the risk of morbidity associated with hemorrhage. In cases in which accreta is not
identified until the time of delivery, a balloon catheter can be used to tamponade the uterine
cavity, potentially avoiding further surgical morbidity.
Following delivery, the hysterectomy is performed; in these cases, the caliber of the
vasculature is significantly generous and the anatomy can be distorted. Care must be taken
to skeletonize the engorged uterine vessels while ensuring safe distance from the ureters to
prevent their injury.
There is no definitive answer for when to deliver suspected placenta accreta, although it is
frequently done between 34 weeks and 36 weeks to balance neonatal survival against risk of
onset of labor and emergent delivery in the setting of acute hemorrhage
Effectiveness and Cost-Effectiveness of Obstetric Surgery
The need to prove the cost-effectiveness of operative obstetrics to decrease the tragedy of
preventable maternal mortality or morbidity may be offensive to some. Regardless, the
provision of safe cesarean delivery to prevent obstructed labor in LMICs has been
demonstrated to be cost-effective, with a positive net economic return to those societies.
Safe Cesarean Delivery

31. Numerous studies have demonstrated the significant cost-effective benefits of providing
access to safe cesarean delivery in countries where it is not currently available (table 5.2)
(Grimes and others 2014). Separate analysis finds that the provision of cesarean for
obstructed labor, malpresentation, or fetal distress in these countries would cost US$73 for
each DALY averted in Sub-Saharan Africa, and US$2,638 in South-East Asia (Adam and
others 2005).
Overview of Studies Evaluating the Cost-Effectiveness of Cesarean Delivery.
A study in Guinea finds that the provision of cesarean delivery for obstructed labor was very
cost-effective at US$18 per year of life saved (Jha, Bangoura, and Ranson 1998). A study in
the Democratic Republic of Congo reinforces the challenges and the importance of providing
emergency obstetric services during humanitarian crises; it further demonstrates that
financial investments can significantly improve maternal and neonatal mortality (Deboutte
and others 2013).
One of the major sequelae of not having access to safe cesarean delivery is obstetric fistula
resulting from obstructed labor (see chapter 6). An estimated 3 million women suffer from
obstetric fistula worldwide. Obstetric fistula can result in societal marginalization, in addition
to significant medical morbidities that are frequently permanent (Wall 2006). One analysis
that examines only the impact of obstructed labor sequelae finds that the provision of safe
cesarean delivery where not available would avert 16,800 maternal deaths in one year
(Alkire and others 2012). This study, which analyzes countries where the number of
cesarean deliveries provided is inadequate to meet demand, finds that approximately 1
million DALYs would be saved by providing accessible cesarean delivery to 90 percent of
the pregnancies complicated by obstructed labor (Alkire and others 2012). The cost-
effectiveness associated with providing cesarean delivery services at this level varies widely
by country, from US$251 for each DALY averted in countries with higher maternal morbidity
risks to US$3,462 per DALY averted in other countries analyzed.
Free or Subsidized Surgical Care
The provision of safe cesarean delivery services implies inherent costs to individuals without
subsidized cesarean delivery that prevent implementation of indicated cesarean deliveries.
This provision of free intrapartum services that include cesarean delivery is associated with
increased rates of supervised labor and increased utilization of needed cesarean delivery
(Lawn and others 2009). This scenario has been evaluated in Senegal, where the provision
of free cesarean delivery helped to increase the rate to greater than 5 percent (Witter and
Diadhiou 2008; Witter and others 2010). The US$461 cost associated with each additional
cesarean delivery was judged to be beneficial, given that it represents a cesarean delivery
that would otherwise not be provided. Similarly, in Ghana, a policy removing patient
responsibility for costs at birth and postpartum was associated with an increase in attended
births and institutional delivery (Lawn and others 2009; Witter and others 2007).
In India, Janani Suraksha Yojana, a cash incentive program to promote attended obstetric
delivery, encouraged the practice, but it also raised concerns regarding the targeting of
funding to the poorest in the population (Lim and others 2010). Subsidizing and encouraging
safe obstetric delivery and free cesarean delivery in areas where the infrastructure exists to
provide the services risks exacerbating disparities between areas where access to safe and
timely cesarean delivery is available and areas where it is not available regardless of cost
(Witter and others 2010).
In addition, care must be taken in auditing cesarean delivery rates in areas where costs are
subsidized to ensure that the system does not develop a supratherapeutic cesarean rate.
Overall, however, the evidence clearly indicates that the provision of financial incentives, or
the removal of disincentives, can help improve access to emergency obstetric care (Briand
and others 2012).

32. Synergy of Providing Obstetric Care with Family Planning Services
An analysis demonstrates that in Mexico, coupling effective family planning with emergency
obstetric services saves costs of US$900,000 per 100,000 women compared with the
current practice (Hu and others 2007).
The cost-effectiveness of safe cesarean delivery and emergency obstetric care can be
significantly enhanced by effective family planning programs involving contraception and
safe abortion (see chapter 7). An analysis in India suggests that combining the cost savings
of effective family planning with the cost savings of providing emergency obstetric care could
amount to savings of US$1.5 billion dollars per year and would help to reduce maternal
mortality by as much as 75 percent (Goldie and others 2010). A similar analysis in
Afghanistan finds that providing access to effective family planning services results in
significant cost savings and reductions in maternal mortality (Carvalho, Salehi, and Goldie
2013). Additional reductions in maternal mortality depend on access to safe cesarean
delivery and emergency obstetric care; in combination with family planning services, such
access could help reduce maternal mortality by as much as 80 percent. In Nigeria, a similar
analysis using a stepwise improvement package of family planning, abortion services, and
emergency obstetric care demonstrates cost-effective improvements in public health (Erim,
Resch, and Goldie 2012).
It is clear from these and other studies that the cost-effectiveness of cesarean delivery has
synergy with other public health interventions involving family planning and abortion care
(Souza and others 2013). The combination of these interventions will be far more effective
than any single intervention in achieving the goals of substantial improvements in maternal
mortality, as in MDG 5 (UN 2013).
An overview of studies evaluating the cost-effectiveness of obstetric interventions in different
countries or areas is limited by the ability of the results from one setting to be generalized to
another. The countries and areas in table 5.2are widely variable, limiting this generalizability.
A consistent theme, however, is that the provision of these fundamental obstetric packages
is profoundly cost-effective or cost saving. The concept of areas where interventions can
save a year of maternal life for less than US$20 or save the life of a reproductive-age
woman for less than US$5,000 argues for the implementation of such programs to help save
lives.
Other Obstetric Surgical Procedures
Little research has been conducted to justify the cost-effectiveness of other obstetric surgical
procedures, in part because safe childbirth and prevention of unnecessary maternal and
neonatal death may be considered goals without the need for cost justification. Additional
shared costs are involved when considering use of the techniques discussed in addition to
cesarean delivery. Cost-effectiveness analysis of other operative obstetric techniques—
including operative vaginal delivery and surgical treatment of postpartum hemorrhage—is
limited in part by the difficulty of associating the costs and benefits of a single intervention.
Although procedures may employ reusable equipment or sutures, these costs are relatively
minor when compared with the cost of provider training to perform these procedures. Given
the significant costs of developing a surgical center with providers trained to perform safe
cesarean delivery, these same providers at these facilities—or elsewhere in the field—can
be readily trained to perform the other obstetric surgical procedures.
Although the WHO estimates that the cesarean rate should be at least 5 percent to 10
percent of deliveries in LMICs to optimize maternal and neonatal outcomes, studies suggest
that cesarean delivery rates higher than 15 percent to 20 percent in these countries may
have greater associated maternal and neonatal surgical morbidity rates, compared with
those for vaginal delivery, without providing significant health benefits (Gibbons and others
2012). The cost of excess cesarean rates in HICs has been estimated to be well over US$2

33. billion annually, suggesting the cost-saving utility of operative vaginal delivery to reduce the
rate of unnecessary cesarean delivery in HICs (Gibbons and others 2012). The costs of both
supplies and obstetric training must be considered in evaluating operative vaginal
techniques, but both are likely to be cost saving compared with a cesarean delivery. This
modeling has limitations when safe alternatives to vaginal delivery, including safe cesarean
delivery, are not available.
Postpartum complications: What you need to know
After childbirth, you're likely focused on caring for your baby. But health problems, some life-
threatening, can happen in the weeks and months afterward and many aren't aware of the
warning signs. Here's what you need to know about postpartum complications.
A growing problem
A pregnancy-related death is the death of a woman while pregnant or within one year of the
end of a pregnancy. More than half the pregnancy-related deaths happen after childbirth.
According to the Centers for Disease Control and Prevention (CDC), the number of reported
pregnancy-related deaths in the United States in 2014 was 18 deaths per 100,000 live births.
That's up from 7.2 deaths per 100,000 live births in 1987. Research also shows racial
disparities. From 2011 to 2014, the pregnancy-related mortality ratios for black women were
more than three times higher than for white women.
Lack of awareness
After childbirth, it's common to experience fatigue and discomfort, such as perineal pain and
uterine contractions. You might not know the difference between a normal recovery and the
symptoms of a complication — or when to seek medical care. If you give birth in a hospital,
your health care team might not identify risk factors for serious postpartum complications
before you are discharged.
Mothers also often don't see a health care provider until four to six weeks after childbirth,
and as many as 40 percent don't attend a postpartum visit, likely due to limited resources.
As a result, most receive little guidance on their postpartum recovery.
Common postpartum complications
According to the CDC, from 2011 to 2014 the most common causes of pregnancy-related
deaths were:
 Cardiovascular diseases
 Other medical conditions often reflecting pre-existing illnesses
 Infection or sepsis
 Excessive bleeding after giving birth (hemorrhage)
 A disease of the heart muscle that makes it harder for your heart to pump blood to
the rest of your body (cardiomyopathy)
 A blockage in one of the pulmonary arteries in the lungs often caused by blood clots
that travel to the lungs from the legs (thrombotic pulmonary embolism)
 Stroke
 High blood pressure (hypertensive) disorders of pregnancy
 A rare but serious condition that occurs when amniotic fluid or fetal material, such as
fetal cells, enters the mother's bloodstream (amniotic fluid embolism)
 Anesthesia complications
Sometimes the cause of a pregnancy-related death is unknown.

34. Risk factors for postpartum complications
The overall risk of dying of a pregnancy-related complication is low. But women with chronic
conditions such as cardiac disease, obesity or high blood pressure are at greater risk of
dying or nearly dying from pregnancy-related complications. If you have these risk factors,
monitoring your postpartum health is particularly important.
Warning signs and symptoms
Many postpartum complications can be successfully treated if they're identified early.
Seek emergency help if you have:
 Chest pain
 Obstructed breathing or shortness of breath
 Seizures
 Thoughts of hurting yourself or your baby
Call your health care provider if you have:
 Bleeding and soaking through more than one pad an hour or blood clots the size of
an egg or bigger
 An incision that isn't healing
 A red or swollen leg that's painful or warm to the touch
 A temperature of 100.4 F (38 C) or higher
 A headache that doesn't get better, even after taking medication, or a bad headache
with vision changes
Prevention tips
Prioritize your postpartum health. Start thinking about your postpartum care plan before you
give birth. After childbirth, talk to your health care provider about your risk of a pregnancy-
related complication and any special follow-up care you might need. Know the signs and
symptoms of a problem.
The American College of Obstetricians and Gynecologists also now recommends that
postpartum care be an ongoing process rather than just a single visit after your delivery.
Have contact with your health care provider within the first three weeks after delivery. Within
12 weeks after delivery, see your health care provider for a comprehensive postpartum
evaluation. If you're having trouble making time for an appointment, talk to your provider.
Reach out to family and friends for help with child care.
During this appointment your health care provider will check your mood and emotional well-
being, discuss contraception and birth spacing, review information about infant care and
feeding, talk about your sleep habits and issues related to fatigue, and do a physical exam.
This might include a check of your abdomen, vagina, cervix and uterus to make sure you're
healing well. This is a great time to talk about any concerns you might have, including
resuming sexual activity and how you're adjusting to life with a new baby.
Also, any time you see a health care provider in the year after childbirth, be sure to share the
date that you gave birth. This can help your provider know that your symptoms might be
related to your recent pregnancy.
Excessive bleeding
While bleeding after giving birth is normal — and most women bleed for 2 to 6 weeks —
some women can experience excessive bleeding after childbirth.

35. Normal postpartum bleeding typically begins immediately after giving birth, whether delivery
happens vaginally or via cesarean section. It’s normal immediately post-birth to bleed heavily
and pass lots of red blood and clots. (It can feel like making up for that 9-month break in your
period all at once!)
In the days after birth, though, bleeding should begin to slow and, over time, you should start
to notice a reduced flow of darker blood that may last for weeks. While there may be
temporary increases in the flow with increased physical activity or after breastfeeding, each
day should bring a lighter flow.
When to check with your doctor
 if your blood flow hasn’t slowed and you continue to pass large clots or bleed red
blood after 3 to 4 days
 if your blood flow has slowed and then suddenly begins to get heavier or returns to
bright red after becoming darker or lighter
 if you’re experiencing significant pain or cramping along with an increase in flow
A range of issues can cause excessive bleeding. In fact, overexertion can cause a
temporary increase. This is often remedied by settling down and resting. (We know how hard
it can be, but take time just to sit and cuddle that precious new baby of yours!)
However, more severe causes — such as a retained placenta or failure of the uterus to
contract — may require medical or surgical intervention.
If you have any questions, speak with your doctor about your concerns.
Infection
Giving birth is no joke. It may result in stitches or open wounds for several reasons.
As unpleasant as it is to think about, vaginal tearing during childbirth is a reality for many
first-time, and even second-, third-, and fourth-time mothers. This typically occurs as the
baby is passing through the vaginal opening, and it often requires stitches.
If you give birth via cesarean delivery, you’ll get stitches or staples at the incision site.
If you have stitches in the vaginal or perineal area, you can use a squirt bottle to clean with
warm water after using the restroom. (Make sure you always wipe from front to back.) You
can use a doughnut-shaped pillow to reduce discomfort when sitting.
While it’s normal for this stitching or tearing to cause some discomfort as it heals, it’s not part
of healthy healing for the pain to suddenly increase. This is one of the signs that the area
might be infected.