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Rule of thumb in Obstetrics and Gynaecology
Background
Obstetrics and gynaecology (OB/GYN) in sub-Saharan Africa face unique challenges due to limited healthcare resources, high rates of maternal and child mortality, and various cultural practices. Nevertheless, there are several rules of thumb and regional guidelines that help healthcare providers manage common obstetric and gynaecological issues effectively. The following are key areas in obstetrics and gynaecology, focusing on practical rules and guidelines tailored to the region.
Rules of thumb
1. Antenatal Care (ANC)
Antenatal care is essential for improving maternal and foetal outcomes. However, in sub-Saharan Africa, many women receive limited ANC due to healthcare access challenges.
Rules of Thumb
Early and Regular Visits:
Encourage pregnant women to attend at least four ANC visits, starting as early as possible (within the first trimester especially after the first missed period). Early visits are critical for confirmation and location of pregnancy to pick ectopic pregnancy early which is a leading cause of morbidity and mortality, screening and managing complications such as hypertension and infections.
Basic Screenings:
Even in resource-limited settings, focus on basic screenings such as:
Blood pressure (for pre-eclampsia)
Urinalysis (U.T.I, Pre-eclampsia)
Haemoglobin levels (for anaemia)
Blood group and Rhesus Typing
Genotype- (Haemoglobinopathies in Pregnancy)
Blood glucose (for gestational diabetes)
Hepatitis B and C
HIV and syphilis testing
Nutrition and Supplements:
Counsel women on proper nutrition and ensure they receive folic acid, iron and calcium supplements.
Guidelines
WHO ANC Guidelines: Recommend at least eight ANC visits, although in low-resource settings, four is considered a minimum. The guidelines emphasize early detection of pregnancy complications, HIV testing, and malaria prophylaxis.
2. Management of Pre-Eclampsia and Eclampsia
Pre-eclampsia and eclampsia are significant causes of maternal and foetal mortality in sub-Saharan Africa.
Rules of Thumb
Early Detection:
Measure blood pressure and test urine for protein at every ANC visit. A systolic BP of ≥140 mmHg or diastolic BP of ≥90 mmHg with proteinuria after 20weeks of gestation should raise suspicion of pre-eclampsia.
Magnesium Sulphate for Eclampsia:
Administer magnesium sulphate as the drug of choice to prevent and treat seizures in eclampsia. In areas with limited access to IV magnesium, intramuscular (IM) administration is an alternative.
Antihypertensives:
Manage hypertension with antihypertensives such as methyldopa (Aldomet), Nifedipine and Labetalol and severe hypertensive disorder with intravenous hydralazine or labetalol if available. Immediate delivery is indicated in cases of severe pre-eclampsia after 34 weeks of gestation or earlier if maternal or foetal health is compromised.
Guidelines
WHO Guidelines on Hypertensive Disorders in Pregnancy: Recommend magnesium sulphate for eclampsia prevention and treatment. They also advocate the early identification of risk factors and timely intervention to prevent complications.
3. Postpartum Haemorrhage (PPH)
PPH is the leading cause of maternal mortality in sub-Saharan Africa, particularly in rural areas with limited access to emergency obstetric care.
Rules of Thumb
Active Management of the Third Stage of Labor:
This includes:
Administering uterotonics (e.g., oxytocin) immediately after the birth of the baby.
Controlled cord traction to deliver the placenta.
Uterine massage after delivery.
First-Line Treatment for PPH:
Administer oxytocin or misoprostol if oxytocin is unavailable. Ergot Alkaloids like ergometrine is useful in the absence of hypertensive disorders of pregnancy or other contraindication to its use. Manual compression and uterine massage are essential if uterotonics are inaccessible.
Referral for Surgery:
If bleeding cannot be controlled with medical measures, refer the patient to a higher-level facility for surgical interventions such as uterine tamponade, compression sutures such as B-Lynch, Uterine artery/Internal Iliac artery Ligation or hysterectomy.
Guidelines
WHO Guidelines on PPH: Emphasize active management of the third stage of labour, the use of oxytocin, and referral systems for cases where medical management fails.
4. Infections in Pregnancy
Sub-Saharan Africa has a high burden of infectious diseases, many of which can complicate pregnancy (e.g., malaria, HIV, syphilis, and urinary tract infections).
Rules of Thumb
Malaria Prevention:
Use intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine (SP) for all pregnant women living in malaria-endemic areas, starting in the second trimester.
HIV Testing and Treatment:
Universal HIV testing should be offered during ANC, and antiretroviral therapy (ART) should be initiated promptly in HIV-positive women to prevent mother-to-child transmission (PMTCT).
Syphilis Screening:
Conduct syphilis screening early in pregnancy and treat positive cases with penicillin to prevent congenital syphilis.
Hepatitis B and C Screening: screening in pregnancy to prevent and reduce maternal to child transmission and chronic hepatitis in mother and children- Give positive mothers with high viral load antiviral- Tenofovir from 28weeks gestation and Give babies of positive mothers active and passive vaccination within the first 12hours of birth
Blood group and Rhesus Typing- Routine booking test to identify those women with rhesus D negative and administer anti-D immunoglobulin at 28 & or 34weeks in women who are unsensitized to prevent isoimmunization and haemolytic disease of fetus and newborn and within 72hours of delivery if baby is rhesus positive.
Genotype- The prevalence of haemoglobinopathies especially HbSS is highest in sub-Saharan Africa, screening help manage the complications associated and reduce the morbidity and mortality.
Guidelines
WHO Guidelines on Malaria in Pregnancy: Recommend IPT with SP and the use of insecticide-treated bed nets (ITNs). HIV management guidelines stress universal screening and ART initiation for HIV-positive pregnant women.
WHO PMTCT Guidelines: Highlight the importance of early ART initiation and breastfeeding advice for HIV-positive mothers.
WHO guidelines on Hepatitis B in Pregnancy
RCOG guideline on blood transfusion in obstetrics
British Society of Haematology Guidelines
5. Labor and Delivery
Access to skilled care during labour is critical to reduce maternal and neonatal mortality. Many births in sub-Saharan Africa still occur at home without skilled birth attendants.
Rules of Thumb
Skilled Birth Attendance:
Encourage deliveries in healthcare facilities or with the assistance of skilled birth attendants (midwives or trained healthcare workers).
Partograph Use:
Use a partograph to monitor labour progression and detect complications such as prolonged labour or foetal distress early. This tool is especially important in resource-limited settings.
Emergency Obstetric Care (EmOC):
Identify and refer cases requiring EmOC early (e.g., obstructed labour, foetal distress, PPH). Establish clear referral pathways to higher-level facilities.
Guidelines
WHO Recommendations for Intrapartum Care: Emphasize continuous monitoring of labour using the partograph, promoting skilled birth attendance, and ensuring timely access to EmOC
6. Caesarean Sections
While caesarean sections can save lives, they are often underutilized in sub-Saharan Africa due to lack of access to surgical facilities and skilled personnel.
Rules of Thumb
Indications for C-Section:
Perform C-sections for clear obstetric indications such as obstructed labour, foetal distress, or placenta previa.
Avoid Unnecessary C-Sections:
Ensure that C-sections are performed only when medically indicated to avoid complications and unnecessary surgical risks.
Referral to Surgical Centers:
In cases where C-sections are indicated but unavailable at the point of care, immediate referral to a center with surgical capacity is crucial.
Guidelines
WHO Recommendations on C-Section: Encourage C-sections only for medical indications and promote timely access to surgical interventions for complicated deliveries.
7. Family Planning and Contraception
Access to family planning services is vital for improving maternal and child health outcomes, reducing unwanted pregnancies, and preventing unsafe abortions.
Rules of Thumb
Contraceptive Counselling:
Provide comprehensive counselling on available contraceptive methods, emphasizing the importance of spacing pregnancies. Contraceptive counseling should start during pregnancy so as to be informed about available methods and make choice soon after birth.
Long-Acting Reversible Contraceptives (LARC):
Promote LARC methods such as intrauterine devices (IUDs) and implants, which are cost-effective and have high efficacy, especially in areas with limited access to healthcare.
Postpartum Contraception:
Encourage postpartum contraceptive use, as many women in sub-Saharan Africa do not return for postpartum care.
Guidelines
WHO Family Planning Guidelines: Recommend offering a broad range of contraceptive options, including LARC, and providing services at all points of care, including during ANC and postpartum visits.
8. Cervical Cancer Screening and Prevention
Cervical cancer is a leading cause of cancer deaths among women in sub-Saharan Africa, largely due to limited screening and vaccination programs.
Rules of Thumb
Screening with Visual Inspection with Acetic Acid (VIA):
In resource-limited settings, VIA is a low-cost and effective screening tool for cervical cancer. Screen women starting at age 30.
HPV Vaccination:
Promote the use of the human papillomavirus (HPV) vaccine in young girls, ideally before sexual debut, to reduce the risk of cervical cancer. HPV vaccine is now incorporated into the NIS (National Immunization Scheme) in Nigeria.
Guidelines
WHO Cervical Cancer Screening and Treatment Guidelines: Recommend VIA in low-resource settings and support HPV vaccination programs for girls aged 9–14.
General Challenges in OB/GYN in Sub-Saharan Africa:
1. Limited Access to Care: Many women, especially in rural areas, have limited access to skilled healthcare providers, contributing to high maternal and neonatal mortality rates.
2. Cultural Barriers: Traditional beliefs and practices often influence maternal healthcare-seeking behaviour and family planning choices.
3. Health System Infrastructure: Shortages of essential supplies (e.g., uterotonics, antibiotics, blood transfusions) and the lack of skilled personnel in emergency obstetric care are ongoing challenges.
9. Maternal and Neonatal Sepsis
Maternal and neonatal sepsis is a major cause of mortality in sub-Saharan Africa, particularly in areas with inadequate hygiene practices during delivery and limited access to antibiotics.
Rules of Thumb
Early Detection:
Screen for signs of infection in mothers and newborns, such as fever, foul-smelling vaginal discharge (maternal), or poor feeding, lethargy, and fever (neonatal).
Hygiene During Delivery:
Ensure that deliveries occur in clean environments, following sterile techniques for vaginal examinations and deliveries to prevent infection.
Early Antibiotic Therapy:
Administer broad-spectrum antibiotics promptly in cases of suspected maternal or neonatal sepsis. Ampicillin and gentamicin are commonly recommended first-line antibiotics in many regions due to their availability and cost.
Guidelines
WHO Maternal and Neonatal Sepsis Guidelines: Recommend clean delivery practices, early identification of sepsis symptoms, and prompt antibiotic treatment to prevent complications.
10. Unsafe Abortion
Unsafe abortion is a significant contributor to maternal morbidity and mortality in sub-Saharan Africa, especially in countries where access to safe abortion services is restricted or illegal.
Rules of Thumb
Post-Abortion Care (PAC):
Ensure that women presenting with complications from unsafe abortion receive immediate medical care, including uterine evacuation (manual vacuum aspiration or misoprostol) and antibiotics. Evaluate for Sexually Transmitted Infections including HIV/AIDS and other reproductive healthcare services, Health care provider and community partnership.
Contraceptive Counselling:
Offer contraceptive counselling and services to all women following abortion to prevent future unintended pregnancies and reduce the risk of repeat unsafe abortions.
Non-Judgmental Care:
Provide compassionate, non-judgmental care to women seeking post-abortion care, as stigma often prevents women from accessing timely services.
Guidelines
WHO Safe Abortion Guidelines: Advocate for the availability of safe abortion services where legal, and post-abortion care (including counselling and contraception) in all settings. The guidelines also emphasize training healthcare providers in the management of abortion complications.
11. Maternal Nutrition
Good maternal nutrition is crucial for the health of both the mother and the developing foetus. Malnutrition, especially in rural and low-income settings in sub-Saharan Africa, can lead to adverse pregnancy outcomes.
Rules of Thumb
Iron and Folate Supplementation:
Iron-deficiency anaemia is prevalent in pregnant women across sub-Saharan Africa. Supplementation with iron and folic acid during pregnancy is crucial to prevent anaemia and associated complications such as preterm delivery.
Balanced Diet:
Encourage a balanced diet that includes adequate protein, iron, calcium, and folic acid. Where access to a varied diet is limited, provide fortified foods or supplements.
Vitamin A Supplementation:
In regions with high prevalence of vitamin A deficiency, supplementation is recommended to improve maternal health and reduce the risk of night blindness.
Guidelines
WHO Maternal Nutrition Guidelines: Recommend routine iron and folic acid supplementation, calcium for women at risk of pre-eclampsia, and vitamin A supplementation in areas where deficiency is common.
12. Maternal Mental Health
Maternal mental health is often overlooked in sub-Saharan Africa, where the focus tends to be on physical health. However, mental health issues such as postpartum depression and anxiety are prevalent and can have long-term effects on both mother and child.
Rules of Thumb
Screening for Depression:
Screen for depression and anxiety during ANC visits and postpartum check-ups, especially in women with a history of mental health issues or those experiencing significant stress, especially found among those that are first time mothers and had operative delivery.
Provide Support Networks:
Encourage family and community support for new mothers, as social isolation can increase the risk of postpartum depression. Involvement of partners and families in maternal care can improve maternal mental health outcomes.
Referral for Mental Health Services: In cases of severe depression or mental health disorders, refer patients to mental health services, where available. Psychological counselling and pharmacotherapy (e.g., SSRIs) may be needed.
Guidelines
WHO Maternal Mental Health Guidelines: Emphasize the importance of integrating mental health services into routine maternal care, particularly in screening for and managing postpartum depression and other mood disorders.
13. Sexually Transmitted Infections (STIs)
STIs such as syphilis, gonorrhoea, and HIV are prevalent in sub-Saharan Africa, and untreated infections can have severe consequences for maternal and foetal health.
Rules of Thumb
Routine Screening:
Screen for common STIs such as syphilis, HIV, and gonorrhoea during antenatal visits. Early detection and treatment of STIs can prevent complications such as congenital infections, preterm labour, and maternal morbidity.
Partner Treatment:
Where possible, provide treatment for the sexual partners of infected women to reduce the risk of reinfection and to promote the overall health of the community.
Prevention Counselling:
Educate pregnant women and their partners on safe sexual practices, condom use, and STI prevention. In HIV-positive women, ART is critical to prevent vertical transmission.
Guidelines
WHO Guidelines on STI Management: Recommend syndromic management of STIs in resource-limited settings and advocate for routine screening and treatment of syphilis and gonorrhoea in pregnancy. HIV-positive women should be started on ART as soon as possible to prevent mother-to-child transmission.
14. Obstetric Fistula
Obstetric fistula, often a consequence of obstructed labour, is a devastating condition affecting many women in sub-Saharan Africa due to limited access to skilled obstetric care.
Rules of Thumb
Prevention through Skilled Care:
The most effective way to prevent obstetric fistula is through timely access to skilled birth attendants and emergency obstetric care, particularly C-sections for obstructed labour.
Early Detection:
Identify women at risk of obstructed labour early in pregnancy (e.g., those with a history of prolonged labour, young maternal age, or small pelvis) and plan for delivery in a facility capable of performing C-sections.
Surgical Repair:
For women with established fistulas, referral for surgical repair is essential. Many fistulas can be successfully repaired with surgery, improving both physical health and quality of life.
Guidelines
WHO Guidelines on Obstetric Fistula: Focus on the prevention of fistula through improved access to emergency obstetric care and provide recommendations for the surgical repair of fistulas. Rehabilitation and psychosocial support are also emphasized.
15. Breast and Reproductive Cancers
Breast cancer and reproductive cancers (e.g., cervical, ovarian) are significant health concerns in sub-Saharan Africa, where screening programs are often underdeveloped.
Rules of Thumb
Breast Self-Exams:
Encourage women to perform regular breast self-examinations and report any abnormalities such as lumps or changes in breast tissue to a healthcare provider.
Early Screening for Cervical Cancer:
Promote cervical cancer screening using visual inspection with acetic acid (VIA) or Pap smears, particularly for women aged 30 and above. Screening should be done at least every five years where feasible.
Referral for Advanced Care:
Women with abnormal screening results or confirmed cancers should be referred to higher-level facilities with the capacity for biopsy, surgery, chemotherapy, or radiotherapy.
Guidelines
WHO Cancer Prevention Guidelines: Stress the importance of early detection through breast self-examinations, clinical breast exams, and cervical cancer screening. Vaccination against HPV is also a key preventive measure for cervical cancer.
Conclusion
In sub-Saharan Africa, the management of obstetrics and gynaecological conditions requires context-specific approaches that prioritize maternal and newborn health in a region where resources are scarce. Also involves adapting international guidelines to the region’s unique challenges, including limited resources, access to care, and cultural factors. Effective rules of thumb, based on local needs and available resources, are critical for improving maternal and neonatal health outcomes. Continued investment in training, healthcare infrastructure, and community education and most importantly political will is vital to further reduce maternal and child mortality in the region. Adherence to key rules of thumb and guidelines from the WHO and other organizations can help reduce maternal and neonatal mortality while improving access to quality care. Continued efforts to improve healthcare infrastructure, education, and access to essential drugs and services are critical to improving outcomes.
Further readings
- World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. 28 November 2016. https://www.who.int/publications/i/item/9789241549912 . Accessed 22 September 2024.
- Beech A, Mangos G. Management of hypertension in pregnancy. Aust Prescr. 2021 Oct;44(5):148-152. doi: 10.18773/austprescr.2021.039. Epub 2021 Oct 1. PMID: 34728879; PMCID: PMC8542489.
- Moussa HN, Arian SE, Sibai BM. Management of Hypertensive Disorders in Pregnancy. Women’s Health. 2014;10(4):385-404. doi:10.2217/WHE.14.32
- World Health Organization. WHO recommendations on the assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage. 21 December 2023. https://www.who.int/publications/i/item/9789240085398. Accessed 22 September 2024.
- World Health Organization. WHO recommendations on the assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage [Internet]. Geneva: World Health Organization; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK598981/
- World Health Organization. MALARIA IN PREGNANCY Guidelines for measuring key monitoring and evaluation indicators. 2007. Available from: https://iris.who.int/bitstream/handle/10665/43700/9789241595636_eng.pdf?sequence=1 Accessed 22 September 2024.
- World Health Organization. Prevention of mother-to-child transmission of hepatitis B virus: Guidelines on antiviral prophylaxis in pregnancy. 27 July 2020. https://www.who.int/publications/i/item/978-92-4-000270-8. Accessed 22 September 2024.
- World Health Organization. Updated recommendations on HIV prevention, infant diagnosis, antiretroviral initiation and monitoring. March 2021. https://www.who.int/publications/i/item/9789240022232 Accessed 22 September 2024.
- Royal College of Obstetrics and Gynaecology, RCOG. Blood Transfusion in obstetrics. Green-top Guideline No. 47 May 2015. https://www.rcog.org.uk/media/sdqcorsf/gtg-47.pdf Accessed 22 September 2024.
- Eugene Oteng-Ntim, Sue Pavord, Richard Howard, Susan Robinson, Laura Oakley, Lucy Mackillop, Shivan Pancham, Jo Howard, on behalf of the British Society for Haematology Guidelines Committee. Management of sickle cell disease in pregnancy. A British Society for Haematology Guideline. First published: 19 August 2021. https://doi.org/10.1111/bjh.17671
- World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. 7 February 2018. https://www.who.int/publications/i/item/9789241550215 Accessed 22 September 2024
- World Health Organization. WHO recommendations: non-clinical interventions to reduce unnecessary caesarean sections. 11 October 2018. https://www.who.int/publications/i/item/9789241550338 Accessed 22 September 2024
- World Health Organization. Family Planning – A global handbook for providers, 2022 edition 14 November 2022. https://www.who.int/publications/i/item/9780999203705 Accessed 22 September 2024
- World Health Organization. New recommendations for screening and treatment to prevent cervical cancer. 6 July 2021. https://www.who.int/news/item/06-07-2021-new-recommendations-for-screening-and-treatment-to-prevent-cervical-cancer#:~:text=WHO%20suggests%20using%20either%20of,every%205%20to%2010%20years Accessed 22 September 2024
- Chelsea Catsburg, Anthony B. Miller, Thomas E. Rohan. Adherence to cancer prevention guidelines and risk of breast cancer. First published: 10 April 2014 https://doi.org/10.1002/ijc.28887 Accessed 22 September 2024
- World Health Organization. WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. World Health Organization; 2021 Jul 6. https://onlinelibrary.wiley.com/doi/full/10.1002/ijc.28887?casa_token=lLpnhqishTgAAAAA%3ADbhfaDorz2ccN7RHbOmevWsKdeqz05j8HmJG0ea3F__iQCFU57Zowj3iWaZq69_z2Adwxc1yRrqczS0wTA Accessed 22 September 2024
McCullough ML, Patel AV, Kushi LH, Patel R, Willett WC, Doyle C, Thun MJ, Gapstur SM. Following cancer prevention guidelines reduces risk of cancer, cardiovascular disease, and all-cause mortality. Cancer epidemiology, biomarkers & prevention. 2011 Jun 1;20(6):1089-97. https://aacrjournals.org/cebp/article/20/6/1089/68949/Following-Cancer-Prevention-Guidelines-Reduces Accessed 22 September 2024
