Perinatal Care Manual 4 Edition

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PERINATAL CARE MANUAL

4TH EDITION
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MINISTRY OF HEALTH MALAYSIA
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PERINATAL CARE MANUAL
4TH EDITION
Division of Family Health Development

Ministry of Health Malaysia
2020 (4th Edition)
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FOREWORD
Malaysia has seen incredible progress in perinatal care services since our
independence, which was translated into improved survival of mother and child. In the
current era of Sustainable Development Goals (SDGs), provision of quality services for
mother and child throughout antenatal, intrapartum and postnatal is the main strategy to
further reduce the mortality rates.
This Perinatal Care Manual was first published in 2002 and has been reviewed
throughout the years with the aim to provide updated guidance for healthcare providers
who are involved in caring for mothers and newborn.
This fourth edition has a slightly different approach where it emphasises on the
complete pregnancy-cycle for each condition. This is to prioritise person-centred health
and wellbeing. Processes and procedures involved during antenatal, intrapartum and
postnatal were also specifically outlined in detail.
It is my hope that this manual will complement with other existing related guidelines and
improve the quality of care given to mothers and newborn. The energy, effort and
commitment of the working group and editorial board to bring forth this manual are
greatly appreciated.
We would like to acknowledge and express our gratitude to Jabatan Kesihatan Negeri
Sabah for the permission to adopt their Sabah Shared Obstetric Care Guidelines.
Dr. Faridah binti Abu Bakar

Director
Family Health Development Division
Ministry of Health
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MEMBERS OF WORKING GROUPS
(In Alphabetical Order)
Pn. Aleijjah bt. Ali Dr. Bong Yee Khiun

Ketua Penyelia Jururawat Kesihatan Pakar Psikiatri
Kanan, Hospital Kuala Lumpur
Sektor Kesihatan Ibu
Bahagian Pembangunan Kesihatan Dr. Carol Lim Kar Koong
Keluarga, KKM Pakar Perunding Kanan O&G
Ketua Jabatan O&G,
Cik Amalina bt.Muhamad Hospital Ampang, Selangor
Penolong Pengarah,
Sektor Pemakanan Ibu, Pn. Chen Phaik Guan
Bahagian Pemakanan, KKM Pengajar Jururawat
Institut Latihan KKM
Dr. Amelia Hazreena bt.Hamidon Sg.Buloh, Selangor
Pakar Perubatan Keluarga
KK Greentown, Perak Dr. Faridah bt Abu Bakar
Pengarah
Pn. Amizam bt. Tamby Ahmad Bahagian Pembangunan Kesihatan
Pengajar Jururawat Keluarga, KKM
Institut Latihan KKM
Sg. Buloh, Selangor Dato’ Dr. Ghazali Bin Ismail
Pakar Perunding Kanan O&G
Dr. Amy Nur Diyana bt. Mohamed Nasir Ketua Jabatan O&G, Hospital Sultan
Ketua Penolong Pengarah Ismail, Johor Bahru, Johor
Sektor Kesihatan Kanak-Kanak
Bahagian Pembangunan Kesihatan Dr. Habsoh bt. Hat
Keluarga, KKM Pakar Perunding Perubatan Keluarga,
KK Bandar Sungai Petani
Dr. Angeline Wan Seng Lian Kedah
Pakar Perunding Neonatologi
Ketua Jabatan Pediatrik Assoc. Prof. Dato’ Dr. Hamizah bt.
Hospital Pakar Sultanah Fatimah Ismail
Muar, Johor Head Department Of O&G
International Islamic University
Dr. Azianey bt. Yusof @ Abdullah Malaysia, Kuantan, Pahang
KK Kepala Batas, Pulau Pinang Dr. Haris Njo Suharjono
Pakar Perunding Kanan O&G
Dato’ Dr. Bavanandan Naidu Gopal Ketua Jabatan O&G
Pakar Perunding O&G Dan Jabatan O&G Hospital Umum Sarawak
Hospital Sultanah Bahiyah
Alor Setar, Kedah Dr. Irmi Zarina bt. Ismail
Pensyarah Jabatan Perubatan
Keluarga Fakulti Perubatan Sains
Kesihatan, Universiti Putra Malaysia,
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Dr. Izwana bt. Hamzah Dr. Majdah bt. Mohamed
Pakar Perubatan Kesihatan Awam Pakar Perubatan Kesihatan Awam
Pegawai Kesihatan Keluarga Negeri Sektor Kesihatan Ibu
JKN Perlis Bahagian Pembangunan Kesihatan
Keluarga, KKM
Dr. J. Ravichandran
Pakar Perunding Kanan O&G, Dr. Mariam bt. Nawawi
Ketua Perkhidmatan O&G Kebangsaan, Pegawai Kesihatan Keluarga Negeri
Ketua Jabatan O&G JKN Pahang
Hospital Sultanah Aminah,
Johor Bahru, Johor Pn. Mimah bt. Jantan
Ketua Penyelia Jururawat Kesihatan
Pn. Jamilah bt. Ahmad JKN Terengganu
Pegawai Sains (Pemakanan)
JKN Melaka Pn. Munah bt. Abd. Rahman
Pn. Jaminah bt. Yahaya JKN Pahang
JKN Sarawak Dr. Muniswaran A/L Ganeshan
Pakar O&G
Pn. Kamisah Barukang Hospital Kuala Lumpur
Jabatan Kesihatan WP Labuan Dr. Naemah bt. Sharifuddin
Dr. Krishnan Kumar KK Sg. Chua, PKD Hulu Langat,
Pakar Perunding Kanan O&G, Selangor
Ketua Jabatan O&G
Hospital Tuanku Jaafar, Dr. Nik Rubiah bt Nik Abdul Rashid
Seremban, Negeri Sembilan Pakar Perunding Kesihatan Awam
Sektor Kesihatan Remaja
Dr. Leow Poy Lee Bahagian Pembangunan Kesihatan
Pakar Perunding Kanan Neonatologi Keluarga, KKM
Ketua Jabatan Pediatrik
Hospital Melaka Pn. Noor Aini bt. Karimon
Pn. Lidwina Amir Sektor Kesihatan Ibu
Ketua Penyelia Jururawat Kesihatan Bahagian Pembangunan Kesihatan
Sektor Kesihatan Kanak-Kanak Keluarga, KKM
Bahagian Pembangunan Kesihatan
Keluarga, KKM Dr. Nor Azam b.Kamaruzaman
Pakar Perunding Perubatan Keluarga
Dr. Mairin Dulasi KK Chini, Pahang
Pakar O&G
Hospital Seberang Jaya Dr. Noraini bt. Jali
Pulau Pinang Pakar Perunding Perubatan Keluarga
KK Sg. Besar, Selangor
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Dr. Noran bt. Hashim Pn. Paridah bt. Samad
Pakar Perubatan Kesihatan Awam, Penyelia Jururawat Kesihatan
JKN Kelantan KK Selandar, Melaka
Dr. Norasiah bt. Hashim Dr. Radziah bt. Mohamad

Pakar Perubatan Keluarga Pakar Perubatan Kesihatan Awam,
KK Kuala Pilah, Negeri Sembilan JKN Sarawak
Pn. Norasimah bt. Kassim Dr. Rafidah bt. Md Noor

Pegawai Dietetik, Pakar Perubatan Kesihatan Awam,
Bahagian Pembangunan Kesihatan JKN Pulau Pinang
Keluarga, KKM
Pn Rashadiba bt. Ibrahim @ Rahman
Pn. Norhashimah bt. Hassan Ketua Penolong Pengarah Kanan,
Penyelia Jururawat Kesihatan Sektor Pemakanan Bayi dan Kanak-
KK Tanah Merah, Kelantan kanak Bawah 5 tahun,
Bahagian Pemakanan, KKM
Pn. Norlela bt. Hassan
Ketua Penyelia Jururawat Kesihatan Pn. Rohaya bt. Ramli
PKD Tampin, Negeri Sembilan Ketua Penyelia Jururawat Kesihatan
PKD Larut Matang & Selama, Perak
Dr. Nurly Zahureen bt. Mustapha
Pakar Perubatan Kesihatan Awam, Pn. Rohayu bt. Mohamad
JKN Pahang Ketua Jururawat Kesihatan,
KK Bukit Changgang,Selangor
Pn. Nurul Ashikin bt. Ag Ismail
Ketua Penyelia Jururawat Kesihatan (KA) Dr. Rokiah bt. Mohd
JKN Sabah Pakar Perubatan Kesihatan Awam
Timbalan Pengarah (Keluarga)
Pn. Nurul Huda bt. Ibrahim Bahagian Pembangunan Kesihatan
Pegawai Dietetik, Keluarga, KKM
Keluarga, KKM Pn. Rokiah bt. Samin
Penyelia Jururawat
Pn. Nurul Zaiza bt. Zainudin Hospital Sultanah Aminah,
Penolong Pengarah Kanan Johor Bahru, Johor
Sektor Pemakanan Ibu,
Bahagian Pemakanan, KKM Dr. Rozita bt. Zakaria
Dr. Nurzeiti Yuslinda bt. Yusof Klinik Kesihatan Presint 18
Pakar Perubatan Keluarga Wilayah Persekutuan, Putrajaya
KK Selayang Baru, Selangor
Pn. S. Kalyani R Sangaran
Dr. Nurzeti bt. Shaikh Ahmad Ketua Penyelia Jururawat Kesihatan
Pakar Perubatan Keluarga PKD Kuala Pilah, Negeri Sembilan
Hospital Angkatan Tentera Tuanku Mizan
Kuala Lumpur
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Dr. Sarah bt. Awang Dahlan Dr. Tuty Aridzan Irdawati bt.
Ketua Penolong Pengarah Mohsinon
Sektor Kesihatan Ibu Ketua Penolong Pengarah Kanan
Bahagian Pembangunan Kesihatan Sektor Kesihatan Ibu
Keluarga, KKM Bahagian Pembangunan Kesihatan
Keluarga, KKM
Dr. Sham Su Lia
Pakar Perubatan Keluarga Dr. Umi Adzlin bt. Silim
KK Rompin, Pahang Pakar Psikiatri
Hospital Kuala Lumpur
Dr. Siti Halimatul Saadiah bt. Hasan
Pakar Psikiatri Pn. Wan Nora bt. Wan Salleh
Hospital Kuala Lumpur Penyelia Jururawat Kesihatan
Jabatan Kesihatan Kelantan
Dr. Siti Khatijah bt. Abdul Rahim
Pakar Perubatan Kesihatan Awam Dr. Yusnita bt. Yatim
JKN Johor Pakar Perubatan Keluarga
KK Peramu Jaya, Pahang
Dr. Siti Zaleha bt. Suleiman
Pakar Perunding Perubatan Keluarga Dr. Zaiton bt. Yahya
KK Merlimau, Melaka Pakar Perubatan Keluarga
KK Sandakan, Sabah
Dato’ Dr. Sudesan Raman
Pakar Perunding Kanan O&G Pn Zaleha bt. Samin
Ketua Jabatan O&G, Hospital Tawau Penyelia Jururawat Kesihatan
KK Ayer Keroh
Dr. Suresh Kumar PKD Melaka Tengah, Melaka
Pakar O&G
Hospital Sultanah Aminah, Johor Bahru Dr. Zamzaireen bt Zainal Abidin
Ketua Penolong Pengarah
Pn. Suzana bt. Kipli Sektor Kesihatan Remaja
Penyelia Jururawat Kesihatan Bahagian Pembangunan Kesihatan
Sektor Kesihatan Ibu Keluarga, KKM
Keluarga, KKM Dato’ Dr. Zuraidah bt. Abd Latif
Pakar Perunding Kanan Pediatrik
Dr. Tan Hui Sui Ketua Jabatan Pediatrik
Pakar Pediatrik Hospital Ampang, Selangor
Hospital Ampang, Selangor
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EDITORIAL COMMITTEE
CHAIRMAN
Dr. J. Ravichandran
Pakar Perunding Kanan O&G,
Ketua Perkhidmatan O&G Kebangsaan,
Ketua Jabatan O&G
Hospital Sultanah Aminah,
Johor Bahru, Johor
MEMBERS
Dr. Sharmini Diana Parampalan Dr. Tan Chew Khang

Pakar Perunding Kanan O&G, Ketua Pakar Perunding Kanan O&G, Ketua
Jabatan O&G, Jabatan O&G,
Hospital Pulau Pinang Hospital Seri Manjung, Perak
Dr. Zaharita bt. Bujang Dr. Suzaini bt Mat Daud

Pakar Perunding Perubatan Keluarga Pakar Perunding Perubatan Keluarga
Klinik Kesihatan Taman Universiti Klinik Kesihatan Simpang Empat,
Johor Bahru, Johor Kangar, Perlis
Dr. Majdah bt. Mohamed Dr. Tuty Aridzan Irdawati bt.

Pakar Perubatan Kesihatan Awam Mohsinon
Sektor Kesihatan Ibu Ketua Penolong Pengarah Kanan
Bahagian Pembangunan Kesihatan Sektor Kesihatan Ibu
Keluarga, KKM Bahagian Pembangunan Kesihatan
Keluarga, KKM
Dr. Sarah bt. Awang Dahlan Pn. Hasniza bt. Mat Reffein
Ketua Penolong Pengarah Ketua Penyelia Jururawat
Sektor Kesihatan Ibu Sektor Kesihatan Ibu
Bahagian Pembangunan Kesihatan Bahagian Pembangunan Kesihatan
Keluarga, KKM Keluarga, KKM
Pn. Siti Fatimah Az-Zahra bt. Mohd Pn. Nur Fatin Syahirah bt. Hasbullah
Nasir Pegawai Penyelidik
Pegawai Penyelidik Sektor Kesihatan Ibu
Sektor Kesihatan Ibu Bahagian Pembangunan Kesihatan
Bahagian Pembangunan Kesihatan Keluarga, KKM
Keluarga, KKM
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OVERVIEW OF CONTENTS
NO. CONTENT PAGE
1 Foreword 5
2 Members of Working Groups 6
3 Editorial Committee 10
4 Abbreviations & Acronyms 12
5 How to Use This Manual 16
6 Objectives 18
7 SECTION A: MATERNAL CARE
CHAPTER 1 : Processes and Procedures of Pre pregnancy Care 27
CHAPTER 2 : Processes and Procedures of Antenatal Care 75
CHAPTER 3 : Processes and Procedures of Intrapartum Care 107
CHAPTER 4 : Processes and Procedures of Postnatal Care 139
CHAPTER 5 : Medical Complications in Pregnancy 159
CHAPTER 6 : Antenatal Complications 225
CHAPTER 7 : Intrapartum Complications 245
CHAPTER 8 : Postnatal Complications 261
CHAPTER 9 : Obstetric Emergencies 279
8 SECTION B: NEONATAL CARE
CHAPTER 10 : Overview of Newborn Care 315
CHAPTER 11 : Resuscitation and Stabilisation 337
CHAPTER 12 : Early Newborn Care 357
CHAPTER 13 : Breastfeeding and Weight Monitoring 395
CHAPTER 14 : Specific Perinatal Conditions Related To Maternal 407

Comorbidities
9 SECTION C: PERINATAL NUTRITION CARE
CHAPTER 15 : Perinatal Nutrition Care 419
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ABBREVIATIONS AND ACRONYMS
AADK Agensi Anti-Dadah Kebangsan (National CEMD Confidential Enquiries into Maternal
Anti-drugs Agency) Deaths
ABC Alternative Birthing Centre CHF Congestive Heart Failure
ACE-I Angiotensin-converting enzyme inhibitor CKD Chronic Kidney Disease
ACR Albumin-to-Creatinine Ratio CNS Central Nervous System
ADHD Attention Deficit Hyperactivity Disorder CO Carbon Monoxide
AED Anti-Epileptic Drugs CPD Cephalopelvic Disproportion
AFI Amniotic Fluid Index CPG Clinical Practice Guidelines
AIDS Acquired Immunodeficiency Syndrome CTG Cardiotocography
AMO Assistant Medical Officer CTPA Computed Tomography Pulmonary

Angiogram
ANA Antinuclear Antibody CVD Cardiovascular Diseases
APH Antepartum Haemorrhage CVS Cerebrovascular Diseases
APS Antiphospholipid Syndrome CVT Cerebral Venous Thrombosis
ARB Angiotensin Receptor Blocker CXR Chest X-ray
ART Antiretroviral Therapy DBP Diastolic Blood Pressure
ATD Anti-Thyroid Drugs DCDA Dichorionic Diamniotic
ATT Anti Tetanus Toxoid DIVC Disseminated Intravascular

Coagulopathy
BCG Bacillus Calmette–Guerin DM Diabetes Mellitus
BD Bis in die (Latin) - Twice Daily DOT Directly Observed Treatment
BMI Body Mass Index DVT Deep Vein Thrombosis
BP Blood Pressure ECG Electrocardiogram
bpm Beats per Minute ECV External Cephalic Version
BTL Bilateral Tubal Ligation EDD Expected Date of Delivery
C&S Culture and sensitivity EEG Electroencephalogram
CBT Cognitive Behavioural Therapy eGFR Estimated Glomerular Filtration Rate
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EOD Every Other Day HPT Hypertension
EPDS Edinburgh Postnatal Depression Score HPV Human Papillomavirus
ESA Erythropoietin Stimulating Agent HSG Hysterosalpingogram
ESR Erythrocyte Sedimentation Rate HVS High Vaginal Swab
ESRF End Stage Renal Failure IAP Intrapartum Antibiotic Prophylaxis
FAS Foetal Alcohol Syndrome ICD-10 International Classification of Diseases-

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FASD Foetal Alcohol Spectrum Disorder ICSI Intracytoplasmic Sperm Injection
FBC Full Blood Count ID Infectious Disease
FBS Fasting Blood Sugar IDA Iron-deficiency Anaemia
FHR Foetal Heart Rate IgG Immunoglobulin G
FKC Foetal Kick Chart ILI Influenza-like illness
FMH Foetal Maternal Haemorrhage IM Intramuscular
FMS Family Medicine Specialist IOL Induction of Labour
FPA Family Planning Association IPT Interpersonal Psychotherapy
FRHAM Federation of Reproductive Health IUCD Intrauterine Contraceptive Device

Associations Malaysia
GBS Group B Streptococcus IUD Intrauterine Death
GDM Gestational Diabetes Mellitus IUGR Intrauterine Growth Retardation
GINA Global Initiative for Asthma IVF In vitro Fertilisation
GTT Gestational Transient Thyrotoxicosis JKN Jabatan Kesihatan Negeri
GSH Group Screen and Hold KD Klinik Desa
GXM Group & Cross Matching KK Klinik Kesihatan
HCG Human Chorionic Gonadotropin KUB Kidney Ureter & Bladder
HCQ Hydroxychloroquine LBW Low Birth Weight
HDN Hemolytic Disease of Newborn LCB Last Childbirth
HELLP Haemolytic Elevated Liver Enzymes and LFT Liver Function Test
Low Platelet
HIV Human Immunodeficiency Virus LMWH Low Molecular Weight Heparin
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LNMP Last Menstrual Period OT Operation Theatre
LPC Labour Progress Chart PAC Pregnancy Assessment Centre
LPPKN Lembaga Pendudukan dan PBM Patient Blood Management

Pembangunan Keluarga Negara
LRBC Low-risk Birthing Centre PEFR Peak Expiratory Flow Rate
LSCS Lower Segment Caesarean Section PHQ-4 Patient Health Questionnaire-4
LVH Left Ventricular Hypertrophy PIH Pregnancy-induced Hypertension
LVS Lower Vaginal Swab PKD Pejabat Kesihatan Daerah
M&HO Medical and Health Officer POA Period of Amenorrhoea
MCDA Monochorionic Diamniotic POC Product of Conception
MCH Maternal Child Health POCT Point of Care Test
MCV Mean Corpuscular Volume POG Period of Gestation
MFM Maternal Foetal Medicine PPC Pre pregnancy Care
MMR Measles, Mumps and Rubella PPH Postpartum Haemorrhage
MOH Ministry of Health PPROM Premature Prelabour Rupture of

Membrane
MTAC Medication Therapy Adherence Clinic PPT Postpartum Thyroiditis
NAAT Nucleic Acid Amplification Test PR Pulse Rate
NGO Non-governmental Organisation PrEP Pre-exposure Prophylaxis
NNJ Neonatal Jaundice PROM Prelabour Rupture of Membrane
NRT Nicotine Replacement Therapy PTU Propylthiouracil
NTD Neural Tube defect RAADP Routine Antenatal Anti-D Prophylaxis
NYHA New York Heart Association RAI Radioactive Iodine
O&G Obstetric & Gynaecology RBC Red Blood Cell
OERT Obstetric Emergency Retrieval Team RBS Random Blood Sugar
OGDS Oesophagogastroduodenoscopy REDD Revised Expected Date of Delivery
OGTT Oral Glucose Tolerance Test RME Routine Medical Examination
OPD Outpatient Department RP Renal Profile
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RPR Rapid Plasma Reagin VDRL Venereal Disease Research Laboratory
RSAT Rumah Sakit Angkatan Tentera VTE Venous Thromboembolism
RVS Rectovaginal Swab WBC White Blood Cells
SBP Systolic Blood Pressure WHO World Health Organization
SFH Symphysio-fundal Height
SGA Small for Gestational Age
SI Shock Index
SIDS Sudden Infant Death Syndrome
SLE Systemic Lupus Erythematosus
SSRI Selective Serotonin Reuptake Inhibitors
STI Sexually Transmitted Infections
Tdap Tetanus Diphtheria Pertussis (Vaccine)
TDS ter die sumendum (Latin) – Three Times

A Day
TENS Transcutaneous Electrical Nerve
Stimulation
TFT Thyroid Function Test
TIBC Total Iron Binding Capacity
TORCHES Toxoplasmosis, Others (syphilis, varicella

zoster, parvovirus) Rubella,
Cytomegalovirus and Herpes Simplex
TRAb TSH receptor autoantibodies
TSH Thyroid Stimulating Hormone
TTTS Twin-to-twin Transfusion Syndrome
TVS Transvaginal Scan
UPT Urinary Pregnancy Test
UTI Urinary Tract Infection
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HOW TO USE THIS MANUAL
This manual is not intended to replace standard textbooks used for teaching. It is to be
kept at hand at your workplace, which can be referred for guidance. The manual
consists of three main components; maternal, neonatal and perinatal nutrition care. For
maternal component, the manual consist of four main sections; section of processes
and procedures during pre pregnancy, antenatal, intrapartum and postnatal; section of
conditions from pre pregnancy till post puerperium; and section of conditions specific
during antenatal, intrapartum and postnatal; and section of obstetric emergencies.
SECTION A: MATERNAL
Chapter 1 – Processes and Procedures of Pre pregnancy Care

● Focuses on specific groups of women in the reproductive age group with
counselling on appropriate medical care to optimise pregnancy outcomes. It
includes a risk assessment checklist and management of various conditions.
Chapter 2 – Processes and Procedures of Antenatal Care

● Describes activities and screening services for each trimester including
contents of routine antenatal contacts.
Chapter 3 – Processes and Procedures of Intrapartum Care

● Provides understanding of the process of normal labour and delivery which
allows optimal care for the mother and timely recognition and intervention of
abnormal events.
Chapter 4 – Processes and Procedures of Postnatal Care

● Provides information for appropriate care, reassurance and early recognition
of postpartum problems.
Chapter 5 – Medical complications in Pregnancy

● Provides information for appropriate and complete care to manage common
conditions in each stage throughout pregnancy. It also includes pre-existing
conditions prior to pregnancy.
Chapter 6 – Antenatal Complications

● It explains how to diagnose and manage common pregnancy-related
conditions, which can be identified during routine examination of the mother.
It provides standard operating procedures for quick reference in the
management of common complications and high risk cases.
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Chapter 7 – Intrapartum Complications
● Provides information on how to diagnose and manage conditions specifically
during intrapartum.
Chapter 8 – Postnatal Complications

● Provides information and standard operating procedures to diagnose and
manage common conditions specifically during postnatal period.
Chapter 9 – Obstetric Emergencies

● Focuses on timely recognition and management of obstetric emergencies.
SECTION B: NEONATAL CARE

● Outlines the comprehensive approach to neonatal care. Flow charts and
checklists are available to aid health care workers to provide quality care and
to initiate and facilitate referrals when necessary.
SECTION C: PERINATAL NUTRITION CARE

● Outlines nutrition advises as a guide for health professionals to educate
mothers from pre pregnancy stage until postpartum period using holistic
approach.
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OBJECTIVES
General objective:
● To develop a comprehensive manual and reference for general use by health care
providers who are entrusted with the care of mothers and their newborns.
Specific objectives:
● To serve as a guide containing the basic knowledge and skills required in the care
for women beginning at pre pregnancy and extending to the neonatal period.
● To provide management of certain common conditions which occur during the
different stages of pregnancy and neonatal period.
● To serve as a guide for health care providers to meet the expected standard of
care in the delivery of respective services in an endeavour to improve maternal
and neonatal outcomes and reduce morbidity and mortality.
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SECTION A: MATERNAL CARE
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TABLE OF CONTENTS
PAGE
SECTION A: MATERNAL CARE

CHAPTER 1 : Processes and Procedures of Pre Pregnancy Care 27
1.1 Introduction
1.2 Rationale
1.3 Objectives
1.4 Target Groups
1.5 Entry Points
1.6 Place of Pre Pregnancy Care Services
1.7 Setting-up of a Pre Pregnancy Care Service
1.8 Flow Process
1.9 Main Activities during a Pre Pregnancy Visit
Appendices 35-73
Appendix 1-1 Flowchart for Pre Pregnancy Care
Appendix 1-2 Work Processes
Appendix 1-3 Pre Pregnancy Risk Factors
Appendix 1-4 First Assessment of Pre Pregnancy Care
Appendix 1-5 Reassessment of Pre Pregnancy Care
Appendix 1-6 Referral Letter for Pre Pregnancy Care Service
Appendix 1-7 Standard Operating Procedures (SOP)
SOP 1 - Diabetes mellitus
SOP 2 - Hypertension
SOP 3 - Heart disease
SOP 4 - Thyroid disease
SOP 5 - Epilepsy
SOP 6 - Bronchial asthma
SOP 7 - Systemic lupus erythematosus
SOP 8 - Renal disease
SOP 9 - Thalassaemia Major
SOP 10 - Malignancy
SOP 11 - Retroviral Disease
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PAGE
SOP 12 - Post-transplant surgery

SOP 13 - Depression And Anxiety
SOP 14 - Severe Mental Illness
SOP 15 - Substance Use Disorder
Appendix 1-8 Pre Pregnancy Health Education
Appendix 1-9 Pre Pregnancy Counselling
CHAPTER 2 : Processes and Procedures of Antenatal Care 75

2.1 Antenatal Care
2.2 Screening for Risk Factors
2.3 Maternal Vaccination
2.4 Antenatal Care for Uncomplicated and High Risk
Pregnancy
2.5 Health Education
2.6 Home Visits
2.7 Antepartum Foetal Monitoring and Surveillance
2.8 Antenatal Exercise
2.9 Domestic Violence and Abuse
Appendices 91-105
Appendix 2-1 Borang Keizinan Konsultasi Antenatal Secara Maya
Appendix 2-2 Senarai Semak Pemantauan Ibu Antenatal Secara
Virtual untuk Anggota Kesihatan
Appendix 2-3 Sistem Kod Warna dan Senarai Semak Penjagaan
Antenatal
Appendix 2-4 Optional Vaccinations for Pregnant Women
Appendix 2-5 Protocols on Home Visit
CHAPTER 3 : Processes and Procedures of Intrapartum Care 107

3.1 Normal Labour and Safe Delivery
3.2 Intrapartum Monitoring
3.3 Normal Stages of Delivery
3.4 Level of Care for Intrapartum Management
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PAGE
Appendices 126-136
Appendix 3-1 Intrapartum Care Flow Chart (ABC/LRBC)
Appendix 3-2 Practical Points During Transfer of Mothers
Appendix 3-3 Senarai Semak bagi Kelayakan Ibu untuk Bersalin di
ABC/Rumah
Appendix 3-4 Senarai Semak Jagaan Intrapartum di ABC/Rumah
Appendix 3-5 Labour Progress Chart
Appendix 3-6 Senarai Keperluan Peralatan Untuk Menyambut
Kelahiran
Appendix 3-7 Low Risk Birthing Centre (LRBC)
Appendix 3-8 Kriteria Pemilihan Untuk Bersalin di Pusat Bersalin
Berisiko Rendah
CHAPTER 4 : Processes and Procedures of Postnatal Care 139
4.1 Introduction
4.2 Postnatal Contacts
4.3 Frequency of Contacts
4.4 Components of Postnatal Care
4.5 Risk Stratification in Postnatal Stage
4.6 Post-miscarriage/Abortion care
4.7 Postpartum Pre Pregnancy Care
4.8 Contraceptives
4.9 Resuming Sexual Intimacy
4.10 Postnatal Exercises
Appendices 152-158
Appendix 4-1 Borang Keizinan Konsultasi Postnatal Secara Maya
Appendix 4-2 Senarai Semak Pemantauan Ibu dan Bayi Postnatal
Secara Virtual Untuk Anggota Kesihatan
CHAPTER 5 : Medical Complications in Pregnancy 159

5.1 Haematological Disorders in Pregnancy
5.1.1 Anaemia in Pregnancy
5.1.2 Thalassaemia in Pregnancy
5.1.3 Thrombocytopenia in Pregnancy
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PAGE
5.1.4 Rhesus Isoimmunisation in Pregnancy

5.2 Hypertensive Disorder in Pregnancy
5.2.1 Gestational Hypertension/ Pre Eclampsia
5.2.2 Chronic Hypertension in Pregnancy
5.3 Diabetes in Pregnancy
5.3.1 Gestational Diabetes Mellitus
5.3.2 Pre-existing Diabetes in Pregnancy
5.4 Thyroid Disorders in Pregnancy
5.4.1 Hyperthyroidism in Pregnancy
5.4.2 Hypothyroidism in Pregnancy
5.5 Bronchial Asthma in Pregnancy
5.6 Cardiac Disease in Pregnancy
5.6.1 Heart Disease in Pregnancy
5.6.2 Peripartum Cardiomyopathy
5.7 Infectious Disease in Pregnancy
5.7.1 Retroviral Disease
 HIV in Pregnancy
 Serodiscordant Couple
5.7.2 Syphilis in Pregnancy
5.7.3 Hepatitis B in Pregnancy
5.7.4 Tuberculosis in Pregnancy
5.7.5 Chickenpox in Pregnancy
5.7.6 Group B Streptococcus Infection in Pregnancy
5.7.7 Dengue in Pregnancy
5.7.8 Malaria in Pregnancy
5.8 Kidney Disease in Pregnancy
5.8.1 Urinary Tract Infection
5.8.2 Chronic Kidney Disease
5.9 Connective Tissue Diseases in Pregnancy
5.9.1 Rheumatoid Arthritis
5.9.2 Systemic Lupus Erythematosus (SLE)
5.9.3 Antiphospholipid Syndrome (APS)
5.10 Neurological disorder in pregnancy
 Epilepsy
5.11 Thromboembolism
5.12 Obesity in Pregnancy
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PAGE
5.13 Smoking in Pregnancy

5.14 Teenage Pregnancy
5.15 Mental Disorders in Pregnancy
5.16 Alcohol Abuse in Pregnancy
5.17 Substance Abuse in Pregnancy
CHAPTER 6 : Antenatal Complications 225

6.1 Unsure of dates
6.2 Preterm Labour
6.3 Preterm Prelabour Rupture of Membrane (PPROM)
6.4 Prelabour Rupture of Membrane (PROM)
6.5 Uterus Larger Than Dates
6.6 Uterus Smaller Than Dates
6.7 Breech at Term
6.8 Malpresentation
6.9 Multiple Pregnancy
6.10 Previous Caesarean Section
6.11 Reduced Foetal Movement
6.12 Postdates
6.13 Hyperemesis Gravidarum
6.14 Recurrent Miscarriage
6.15 Previous History of Unexplained Intrauterine Death
(IUD)
6.16 History of Foetal Abnormality
6.17 Symptomatic Vaginal Discharge
6.18 Advanced Maternal Age
6.19 Maternal Sepsis
CHAPTER 7 : Intrapartum Complications 245

7.1 False labour
7.2 Abnormal Labour Progress Chart (LPC) / Early Labour
Monitoring Record
7.3 Abnormal Partograph
7.4 Obstructed Labour
7.5 Management of Abnormal Foetal Heart Rate (FHR)
Patterns
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PAGE
Appendices 251-260
SOP 1 – Meconium Stained Liquor
SOP 2 - Abnormal Foetal Heart Rate
SOP 3 - Prolonged Labour
Appendix 7-2 Guidelines for Performing Lower Segment Caesarean
Section (LSCS) at District Hospitals without Specialist
CHAPTER 8 : Postnatal Complications 261

8.1 Mental Health in Postnatal Period
8.2 Coping with Death
8.3 Maternal Deaths
8.4 Perinatal Loss
Appendices 274-278
SOP 1 - Perineal Wound Problem
SOP 2 - Post Caesarean Care
SOP 3 - Heart Diseases
SOP 4 - Urinary Retention
SOP 5 - Urinary Incontinence
SOP 6 - Subinvolution of uterus
SOP 7 - Secondary Postpartum Haemorrhage
SOP 8 - Puerperal Pyrexia
SOP 9 - Breast Engorgement
SOP 10 - Deep Vein Thrombosis
SOP 11 - Pulmonary Embolism
CHAPTER 9 : Obstetric Emergencies 279

9.1 Red Alert System
9.2 Referral Systems and Retrieval & Resuscitation Team
9.3 Cord Prolapse
9.4 Uterine Rupture
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PAGE
9.5 Shoulder Dystocia

9.6 Maternal Collapse
9.7 Uterine Inversion
9.8 Severe Pre-eclampsia
9.9 Eclampsia
9.10 Obstetric Haemorrhage
9.11 Puerperal Sepsis
9.12 Postpartum Psychosis
9.13 Perinatal Suicide and Parasuicide
9.14 Postpartum with Infanticide Risk
Appendices 305-308
SOP 1 - Maternal Pyrexia
SOP 2 - Cord Prolapse
SOP 3 - Shoulder Dystocia
SOP 4 - Postpartum Haemorrhage
SOP 5 - Antepartum Haemorrhage
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CHAPTER 1
PROCESSES AND PROCEDURES OF

PRE PREGNANCY CARE
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CHAPTER 1: PROCESSES AND PROCEDURES OF PRE PREGNANCY CARE
1.1 INTRODUCTION
‘Every mother has the right to expect her baby to be born

alive and healthy just as every baby has the right to a living
and healthy mother.’
Making pregnancy safer is an important component of maternal and

child health (MCH) services. The profile of a woman embarking
upon pregnancy changes as our nation develops. A greater number
of them are being categorised as high risk pregnancies. Pre
pregnancy care with early intervention and treatment can reduce
the incidence of maternal and neonatal complications in these
women.
The couple or women with good physical and psychological health,

living in a good socioeconomic environment, will benefit both the
mother and child. As such, pre pregnancy assessment and
consultation can assist the couple and women in reproductive age
to choose the appropriate time to conceive and thus reduce the risk
of complications to the mother and baby.
Definition:
Preconception care is the provision of biomedical, behavioural and
social health interventions to women and couples before conception
occurs. It aims at improving their health status, and reducing
behaviours and individual and environmental factors that contribute
to poor maternal and child health outcomes. Its ultimate aim is to
improve maternal and child health, in both the short and long term.
(Meeting to Develop A Global Consensus on Preconception Care to

Reduce Maternal and Childhood Mortality and Morbidity. Geneva,
World Health Organization, 2013).
1.2 RATIONALE
In making pregnancy safer, policies are primarily focused on

optimising antenatal and intrapartum care. The increase in the
number of high risk pregnancies requires readily available
formalised pre pregnancy care services. As such, pre pregnancy
care should be formalised into our health care services. Evidence
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suggests that appropriate pre pregnancy care has improved
pregnancy outcomes.
Analysis of maternal death from published reports on Confidential

Enquiries into Maternal Deaths (CEMD) 2012-2014 showed that
four main causes of maternal deaths are complications from
associated medical conditions (20.7%), postpartum haemorrhage
(16.7%), hypertensive disorders in pregnancy (11.8%) and
pulmonary embolism (11.5%). These causes of deaths are
associated with the current prevalence of non-communicable
disease (NCDs) in Malaysia. National Health and Morbidity Survey
(NHMS) revealed an increasing trend of diabetes prevalence
among Malaysians above 18 years old;11.2% (NHMS 2011), 13.4%
(NHMS2015) and 18.3% (NHMS2019). Overweight and obesity
prevalence has also increased; overweight prevalence was 29.1%
(NHMS 2006), 29.4% (NHMS 2011), 30% (NHMS 2015) and 30.4%
(NHMS2019), while obesity prevalence was 14% (NHMS 2006),
15.1% (NHMS 2011), 17.7% (NHMS 2015) and 19.7%
(NHMS2019). Overweight and obesity is one of the risk factors
linked to adverse obstetric outcomes, as well as contributed to
perinatal mortality and morbidity.
1.3 OBJECTIVES
General objective:
To provide couples, men and women in the reproductive age group
with an avenue to achieve a planned, safe and successful
pregnancy.
Specific objectives:
i. To identify women with medical conditions and/or at risk if pregnant
and offer them with pre pregnancy care
ii. To enable prospective parents and women in reproductive age
group to plan for pregnancy through:
●
Provision of appropriate and adequate information.
●
Health promotion and education
●
Counselling
iii. To screen and counsel future mothers appropriately for early
intervention and treatment, aimed to reduce maternal and perinatal
morbidity and mortality.
iv. To emphasise the practice of healthy lifestyle and initiative in
making pregnancy safer to prospective parents and family
members.
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1.4 TARGET GROUPS
Women in reproductive age group (15-49 years old) with:
i. Chronic medical conditions:

● Hypertension
● Heart disease
● Diabetes mellitus
● Thyroid disease
● Epilepsy
● Bronchial asthma
● Connective tissue diseases such as SLE
● Renal disorders
● Blood disorders
● Malignancy
● Transplant surgery (example liver & renal)
● Mental illnesses (example: mood disorder, schizophrenia)
ii. Infectious diseases:

● HIV
● Active tuberculosis under treatment
● Hepatitis B or C
iii. Lifestyle risks:

● Smoking, alcoholism and substance abuse:
These may have teratogenic effects resulting in foetal
abnormalities and growth restriction.
● Obesity: Metabolic disorders have a detrimental effect
during pregnancy both on the feotus and mother. It may
also affect the mode of delivery.
Note: Clients with inherited structural or genetic abnormalities and family

history of genetic disorder require shared care with related specialties.
1.5 ENTRY POINTS
i. Outpatient Department (OPD)

● Wellness Clinic
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● Community Clinic
● Premarital HIV Screening Programme
● Adolescent Health Services
● Community Outreach Programme
● Non-communicable Diseases Programme
ii. Maternal and Child Health (MCH) Services

● Family Planning Services
● Child Health Services
● Postnatal Services
iii. Specialised Clinic

● Cardiology Clinic
● Nephrology Clinic
● General Medicine Clinic
● Paediatric Clinic
● Obstetrics & Gynaecological Clinic
● Other specialist clinic
iv. Hospital Inpatient (All disciplines)

v. Ambulatory Care Centre
vi. Others:
● LPPKN (Lembaga Penduduk & Pembangunan Keluarga Negara)
● RSAT (Rumah Sakit Angkatan Tentera)
● FPA (Family Planning Association)
● FRHAM (Federation of Reproductive Health Association of
Malaysia)
● University Hospitals
● General Practitioners
● Private Medical Centres
1.6 PLACE OF PRE PREGNANCY CARE SERVICES
● O&G Specialist Clinic

o Coordinator/ provider of pre pregnancy care services at hospital
level, preferably under the supervision of Maternal Foetal
Medicine Specialist.
o Other specialist clinics (i.e., medical/surgical/psychiatric etc.)
should also involve actively in referring to pre pregnancy care
services.
● Health Clinic
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o At primary care level, pre pregnancy care will be integrated into
current (MCH/OPD) services, headed by Family Medicine
Specialists (FMS)/ Medical & Health Officer (M&HO).
● Outpatient services at district hospitals
o Hospital without specialists (visiting O&G Specialists and other
specialists of other disciplines).
1.7 SETTING UP A PRE PREGNANCY CARE SERVICE
● Scope
o Identification of clients
o Receive referral
o Assessment
o Management :
- Therapeutics
- Referrals
- Counselling
- Supplementation
- Health education
● Clinic Schedule
o Integrated/dedicated
● Specialties (as appropriate)
1.8 FLOW PROCESS (refer Appendix 1-1 and Appendix 1-2)
1.9 MAIN ACTIVITIES DURING A PRE PREGNANCY VISIT
i. Identification of pre pregnancy risk factors (Appendix 1-3)

ii. Assessment of the client:
● History taking
● Physical examination
● Clinical laboratory tests
iii. Appropriate management according to identified risk factors
● Appropriate treatment and management
● Investigations
● Health education
● Counselling
● Appropriate referral
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iv. Criteria for referral:
● For determination of fitness for pregnancy in certain medical
conditions (e.g., heart disease, connective tissue disease).
● Shared care for preparation of pregnancy especially among
clients with poorly optimised conditions.
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APPENDIX 1-1
FLOWCHART FOR PRE PREGNANCY CARE
Identification of
Client
Referral to Medical Officer
Assessment:
- History of illness
- Physical examination
- Laboratory investigations
- Exploring pregnancy plan
Management:
- Optimizing risk (medical and biopsychosocial)
- Healthy lifestyle
- Family planning as per requirement
- Folic acid supplementation
- Referral to relevant specialties
Yes No
Pregnancy
intention?
Yes No
Pregnancy
suitability?
Allow pregnancy Family Planning
Follow-up and Reassessment
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APPENDIX 1-2
WORK PROCESSES
No. WORK PROCESS RESPONSIBILITY

1. Identification of client;
Identify/receive referral from entry points as mentioned in paragraph 1.5 Paramedics /

Medical Officers /
● Outpatient clinic
Specialist
● Maternal and child health clinic
● Specialist Clinics in Hospital
● Ambulatory care centre
● Private Clinic / hospital
● NGO and others
2. Assessment by Medical Officer/ Specialist : Medical Officer /

Specialist
● Full history taking
● Physical examinations
● Laboratory Investigations
● Exploring pregnancy intention and plan
● Suitability of pregnancy assessment
● Fill–up first assessment form (Appendix 1-4)
3. Management: Paramedics
● Optimising risk (medical and biopsychosocial) Medical Officer
● Healthy lifestyle FMS
● Family planning as per requirement Dietician/ Nutritionist
● Folic acid supplementation Specialists
● Referral to relevant specialties
4. Follow-up schedule Paramedics
Medical Officer
Reassessment of risk and pregnancy intention
FMS
Dietician
Specialists
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APPENDIX 1-3
PRE PREGNANCY RISK FACTORS
General Risk factors

● Age
- Women less than 18 years old - Teenage pregnancies are associated with poor
maternal and foetal outcomes.
- Women above 40 years old - Advanced maternal age is associated with higher
prevalence of medical illnesses and foetal chromosomal abnormalities.
● Lifestyle
- Smoking, alcoholism and substance abuse: These may have teratogenic effect
resulting in foetal abnormalities and growth restriction
- High risk sexual behavior: Increases the risk of maternal and foetal infection.
- Obesity/underweight: Metabolic disorders have detrimental effects during
pregnancy both on the feotus and mother. It may also affect the mode of
delivery.
- Pets: Some household pets such as cats and birds may be associated with
infections (e.g., toxoplasmosis, psittacosis and bird flu). Infections or exposure of
these allergens to mothers with bronchial asthma can affect a pregnant mother
and may result in poor foetal outcome.
● Chronic medical conditions:

- Hypertension
- Heart disease
- Diabetes mellitus
- Thyroid disease
- Epilepsy
- Bronchial asthma
- Connective tissue disease (eg.; SLE)
- Renal disorders
- Blood disorders
- Malignancy
- Transplant surgery
- Mental illness (e.g.; mood disorder, schizophrenia)
● Infectious diseases
- Communicable diseases ( e.g., HIV, active tuberculosis, hepatitis B or C)
● Family history
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- Congenital structural abnormalities
● Social history
- Domestic violence
- Socioeconomic status
- Marginalised group
- Single mothers
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APPENDIX 1-4
FIRST ASSESSMENT OF PRE PREGNANCY CARE
O&G History Medical History Medications Psychosocial Risk:
Menarche …………… DM 1. ……………... Smoking

Cycle:………………… HPT 2. ……………... Alcohol
3. ….…………..
Para : ………………… Asthma 4. ……………... Obesity
LCB: ……………………. CVD 5. ……………... Substance abuse
Vaccination:…….…….. Mental High-risk sexual behaviour
Others Social risk (e.g.,
marginalized group,
single mother, domestic
violence)
Contraception: Physical Examination: Lab investigations:
Pill Height (m) :……………. Pallor: ………………. Hb (g/dL): ………………………..

Injection CVS: ………….……. Pap smear : ……………………..
Weight (kg):…………….. Resp: ……………….. Others : …………………………
IUCD
Thyroid: …….………
2
Implanon BMI (kg/m ):…………
Condom
BP (mmHg):…………..
Others (e.g., rhythm
method, withdrawal PR :………………..
etc)
Nil
Pregnancy Intention: Yes/ No
Suitable for pregnancy: Yes / No
Care plan :
1. ………………………………………………………………………………………………………………………………
2. …………………………………………………………………………………………………………………………………
3. …………………………………………………………………………………………………………………………………
Follow up:
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APPENDIX 1-5
REASSESSMENT OF PRE PREGNANCY CARE
Date PPC Component

Family Planning Method: ……………………………..
Not relevant
Lifestyle Modification Healthy dietary advise
Exercise and weight loss
advise
Stress management advise
Exercise and physical activity
Avoidance of high risk
behaviours and stop
smoking
Optimisation of disease Yes
No
Referral Yes
Unit/Department…………………
No
Not relevant
Pregnancy intention Yes
explored?
No
Suitable for pregnancy? Yes
No
Folic acid supplementation Yes
No
Not relevant
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APPENDIX 1-6
REFERRAL LETTER
PRE PREGNANCY CARE SERVICE
FROM : ………………………
TO : ………………………
CLIENT’S IDENTIFICATION:
NAME : …………………………………………. I.C NO.:…………..…………………

AGE : …..….
BRIEF MEDICAL HISTORY : ……………………………………….…………………….

…………………………………………………………………………………….……………
RELEVANT INVESTIGATIONS : …………………………………………………………

………………………………………………………………………………….………………
MEDICATIONS: :…………………………………….………….…………………………..
………………………………………………………….………………………………………
REASONS FOR REFERRAL:
Pregnancy preparation Contraception

……………………………………..
Others : ……………………………
Date : ………………….. …………………
Doctor’s signature, name, & designation : …………..…..
FEEDBACK
To : …………………………………………………………….
Client’s Name : …………….………………………………..
Age : ………...……. IC :……………………..…………..……
We have assessed the client above and our plan is as below:
The client is fit /unfit for pregnancy:

We send her back for your care
We will follow-up the client
Date : ………………….. Doctor’s signature, name & designation: ……………

Chop : …………………..
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APPENDIX 1-7
STANDARD OPERATING PROCEDURES (SOP)
Standard operating procedure is designed to assist health care providers in managing the patient. The conditions are
selected based on risk factors present.
SOP 1: DIABETES MELLITUS

Care plan
Lab
Assessment investigations Classification Level of
Management Level of care
and PE findings personnel
● Disease severity ● FBS ● Uncomplicated ● Management according MO/ FMS/ Health Clinics /
● Complications ● HbA1c diabetes with to CPG Management of Physician/ Hospital ±
● Comorbidities ● Lipid profile complications Type 2 Diabetes Mellitus Endocrinologist specialist
Glycemic control ● Renal profile (i.e., (6th ed), 2020 and CPG
and optimisation ● LFT nephropathy, Management of Diabetes
● Urine albumin/ retinopathy, in Pregnancy, 2017
protein neuropathy, ● Refer to appropriate
● Funduscopy coronary heart disciplines –
● ECG disease etc.) multidisciplinary
● Blood pressure management
● Screening for
complications and
comorbidities
● Optimisation of
pregnancy risks –
stabilisation of blood
sugar – add insulin
therapy if glycemic
control not achieved
● Discussion on timeline
for pregnancy planning
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Care plan
Lab
(to consider patient’s
pregnancy needs)
● Full medication review,
discontinue potential
teratogenic medications
● Folic acid
supplementation
5mg/daily at least 3
months before
conception
● Family planning
● Pregnancy risks to
mother and feotus.
Maternal risks:
1. Polyhydramnios
2. Pre-eclampsia
3. Micro and macrovascular complications: nephropathy, retinopathy, vasculopathy, neuropathy etc.
4. Increased risk of operative delivery
5. Recurrent urinary tract infection or vulvo-vaginal infections
Foetal risks:
1. Risk of neural tube defect for mothers with pre-existing diabetes (e.g., anencephaly, Arnold-Chiari malformation, spina bifida,
ventriculomegaly)
2. Cardiovascular malformation: atrioventricular septal defect, transposition of great arteries
3. Macrosomia leading to shoulder dystocia and possible brachial plexus injury
4. Hypoglycemia, hypocalcemia
5. Jaundice, polycythemia
Risk of intrauterine death is up to 50% in uncontrolled diabetes
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SOP 2: HYPERTENSION
Lab Care plan

● Disease severity ● FBS Types: ● Refer to appropriate MO/ Health
● Complications ● Lipid profile ● Essential HPT disciplines – FMS/Physician Clinic/Hospital ±
● Comorbidities ● Renal profile ● Secondary HPT multidisciplinary specialist
● Blood pressure ● Urine approach
control and microalbumin / Severity: ● Management
optimisation protein ● Uncomplicated according to CPG
● ECG HPT Management of
● CXR (if ● HPT with target Hypertension (5th ed),
indicated) organ damage 2018
● Ultrasound (TOD) eg: LVH, ● Family planning
kidney, ureter & retinopathy,
bladder to look proteinuria
for renal artery ● HPT with target
stenosis and organ
other conditions complications
in young (TOC) eg: heart
hypertensions failure, renal failure
1. In young HPT, the cause needs to be ascertained because:
a. Some causes may be familial and can affect the feotus
b. Other causes may be detrimental to the health of the women (e.g. Conn’s syndrome and pheochromocytoma)
2. Risks of hypertension in pregnancy include:
a. Superimposed pre-eclampsia: Essential hypertension is a predisposing factor for superimposed pre-eclampsia (risk:
15-20%). This risk may be higher in secondary hypertension (especially secondary to a renal cause)
b. Intrauterine growth restriction (IUGR)
c. Pulmonary oedema
* Risks mentioned above are especially associated with severe uncontrolled hypertension at conception and renal
hypertension
3. Risk-benefit analysis of therapeutics
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a. Minimise number of drugs
b. Switch to safer drug options
4. Therapeutics:
a. Methyldopa is the safest choice of drug during pregnancy. Most women on antihypertensives before pregnancy will be
switched to methyldopa
b. Prolonged use of beta-blockers has been found to be associated with small for gestational age (SGA)
c. Diuretics are associated with:
i. reduction in utero-placental blood flow causing IUGR
ii. increase in viscosity of maternal blood leading to VTE
d. ACE inhibitors are contraindicated in pregnancy as they are associated with severe neonatal outcomes such as renal
agenesis and pulmonary hypoplasia
e. Angiotensin receptor blockers (ARBs) are contraindicated in pregnancy and breastfeeding. They are associated with
an increased risk of fetopathy (e.g. pulmonary hypoplasia, limb contractures, and calvarial hypoplasia)
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SOP 3: HEART DISEASE
Lab Care plan

● NYHA ● FBS ● NYHA Class I – IV ● Refer to appropriate MO/ FMS/ Health Clinic /
Functional ● Lipid profile ● WHO Class I – IV disciplines – Physician/ Hospital ±
Classification ● ECG multidisciplinary Cardiologist specialist
● WHO Risk ● CXR (if approach
Classification indicated) ● Management
● Heart disease ● Echo- according to Clinical
with comorbidity cardiography Practice Guideline
● Renal profile Heart Disease in
● Exercise stress Pregnancy 2016
test ● Family counselling
● Blood pressure sessions with
emphasis on
contraception must be
given.
● Discuss and educate
risk of pregnancy with
cardiac disease
1. Cardiac disease is one of the leading causes of maternal death. Pregnancy increases cardiac workload by approximately
30% and this further increases by 20% during the intrapartum period. Diseased hearts may not be able to withstand this load.
2. Congenital heart lesions can be inherited and the risk of foetal congenital heart disease is approximately 4%. This is
significantly higher than the general malformation rate of 2%
3. All women of reproductive age who attend regular follow-up at cardiology clinics should be given pre pregnancy counselling.
4. Cardiac contraindications for pregnancy:
a. Primary pulmonary hypertension
b. Severe secondary pulmonary hypertension
c. Severe fixed output lesions (e.g., severe mitral stenosis, severe aortic stenosis)
d. Cardiac failure of any cause
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e. Non-resolved peripartum cardiomyopathy of pregnancy
Since termination of pregnancy should be considered in unplanned pregnancy in the above conditions, early referral to O&G
specialists should be made.
5. Therapeutics:
a. Antiarrhythmic and anti-coagulation drugs should be thoroughly discussed
i. Most antiarrythmic drugs are well-tolerated and generally safe
ii. Warfarin use is associated with an increased risk of foetal anomalies (estimated at 5-10 %) and a high risk of
late foetal loss (approximately 10%). Women requiring lifelong warfarin therapy should be counselled on risk of
miscarriage and foetal demise
b. Anti-failure medication (e.g., digoxin and diuretics) can be continued in pregnancy
c. ACE inhibitors are contraindicated in pregnancy but are safe during breastfeeding
d. Statins are generally contraindicated however if it is necessary for patients with coronary artery disease and
hypercholesterolemia, hydrophilic agents should be preferred over lipophilic ones
i. Lipophilic: Atorvastatin, lovastatin, and simvastatin
ii. hydrophilic: pravastatin, rosuvastatin, and fluvastatin
(*Lipophilic statins cross the blood-brain barrier more readily, which may lead to central nervous system complaints.
However, this is rare.)
e. Low dose aspirin (100 – 150 mg OD) is safe in pregnancy and breastfeeding. However, the dose for cardiac disease is
usually higher. Dose may need to be lowered during pregnancy towards term (36 weeks) due to increased risk of
bleeding and transfusion
f. Beta blockers are the gold standard treatment for fixed output lesions such as mitral and aortic stenosis. In these
instances, they should be continued. However, prophylaxis beta blockers should be discontinued.
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SOP 4: THYROID DISEASE
Care plan
Lab investigations
Assessment Classification Level of
and PE findings Management Level of care
personnel
● Hypothyroid and ● FBS ● Euthyroid ● Refer to appropriate MO/FMS/ Health Clinic/
hyperthyroid ● Lipid profile ● Hyperthyroid disciplines – MDT Physician/ Hospital ±
symptoms ● TSH/free T4/free ● Hypothyroid approach Endocrinologist/ specialist
● Stability of thyroid T3 ● Management surgeon
disease on ● ECG according to Clinical
treatment ● Blood pressure Practice Guidelines
● FBC Management of
● Neck ultrasound (if Thyroid Disorders
indicated) 2019 and other
relevant guidelines
● Family planning
1. When disease is well-controlled, pregnancy is usually uncomplicated. Uncontrolled disease are associated with miscarriage,
IUGR, preterm labor and intrauterine foetal death (IUD)
2. Antibody positive hyperthyroidism can cause foetal thyrotoxicity as IgG can pass through placenta, but it is rare
3. Complications of pregnancy such as UTI, labour or Caesarean section may precipitate thyroid storm especially in uncontrolled
disease
4. If conception occurs in uncontrolled disease, therapy such as beta-blockers can increase risk of SGA/IUGR. Achieving control of
disease may take months and pose risk to the feotus
5. Women who have been treated for years with antithyroid drugs should be referred to the endocrinologist/ physician for
consideration for radioactive iodine (RAI) or surgical management. Women who wish to avoid foetal exposure to drugs can be
advised to await resolution of disease and weaning off of treatment.
6. If unable to wean off medications, RAI can be considered to make women euthyroid/hypothyroid. Thyroxine carries negligible risk
to the feotus
7. Weigh the risk and benefits of therapeutic agents of choice. Continuation of drugs in pregnancy is vital as uncontrolled disease is
detrimental to foetal and maternal health.
8. Explain increased vigilance is required in pregnancy with increased frequency of antenatal visits with shared care between
combined clinics and fetomaternal specialists
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SOP 5: EPILEPSY
Care plan
Lab investigations and PE
findings Management Level of care
personnel
Seizure-free ● Neurological examination Controlled / ● All women in the MO/ FMS/ Hospital with
interval ● EEG test uncontrolled reproductive age who are Physician/ specialist
● Regular blood test : FBC, diagnosed to have epilepsy Neurologists /Health
LFT [depends on types of and plan to conceive should Clinics
anti-epileptic drugs (AED] be referred to the pre
● Therapeutic drug pregnancy service.
monitoring level if not ● Refer to appropriate
compliant or poorly disciplines for
controlled seizure, or multidisciplinary approach
suspect overdose ● Management according to
Consensus Guidelines on
the Management of Epilepsy
2017 and other relevant
guidelines.
● Family planning counselling
– Refer WHO Medical
Eligibility Criteria for
Contraceptive Use 2015 for
drug interaction between
AEDs and hormonal
contraceptives.
● Folic acid 5mg daily for at
least 3 months prior to
conception continue at least
until the end of first trimester
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to reduce the incidence of
major congenital
malformations and to reduce
the risk of AED-related
cognitive deficits
1. Ideally, women should be advised against getting pregnant until they become seizure-free and are off AEDs. However, for
various personal, cultural or religious reasons, this is seldom possible or practical. Hence, in all women with childbearing
potential, the risk of teratogenicity while on AEDs and the risk of recurrent seizures if AEDs were to be withdrawn must be
discussed long before they wish to conceive. The latter risk is low if the patient has been seizure-free for more than 2 years
and tapering is done gradually.
2. If AED withdrawal is impossible, effort to achieve monotherapy and lowest effective dose should be attempted before
conception. Switching to a less teratogenic AED should be done before conception; switching during pregnancy is likely to be
not beneficial because most teratogenic effects take place in the first trimester. For the above reason, contraception should
be practised till AED adjustment is achieved.
3. Shared decision should be made with the patient regarding the choice and dose of Anti-epileptic Drugs (AEDs), based on the
risk to the feotus and control of seizures.
4. Enzyme-inducing AEDs can increase the chance of combined oral contraceptive failure.
5. Teratogenicity risks depend on types of AED and dose:
▪ Monotherapy : 4-8%
▪ Polytherapy : 15%
▪ Combination of valproate, carbamazepine and phenytoin : 50%
▪ Phenytoin monotherapy : not related to increased risk of major foetal malformation
▪ Valproate >1000mg daily: high risk for foetal malformation
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SOP 6: BRONCHIAL ASTHMA
Lab Care plan

investigations
Classification Level of Level of
Assessment and PE Management
personnel care
findings
Assessment of asthma ● PEFR ● Well-controlled ● Refer to appropriate MO/FMS/Physician Health
control according to ● Spirometry ● Partly controlled disciplines – / Respiratory Clinics/
guidelines (i.e., GINA, ● CXR (if ● Uncontrolled multidisciplinary physicians Hospital ±
Asthma Control Test indicated) approach specialist
Scoring) ● Management according
to Clinical Practice
Guidelines Management
of Asthma in Adults
2017 or other related
guideline
● Family planning
1. The natural history of asthma during pregnancy is extremely variable. Asthma may worsen, improve or remain unchanged
during pregnancy.
2. Asthma is more likely to become severe or worsen during pregnancy in women with pre-existing severe asthma.
3. During PPC counselling, the following should be emphasised:
▪ patient education on good asthma control
▪ frequent monitoring (4 – 6 weeks)
▪ maintenance, reliever and anti-leukotriene should be continued
▪ stepping down medication should be done after delivery if asthma is well controlled
4. Asthma medications are safe in pregnancy. There is a greater risk to both mother and baby if asthma is poorly controlled.
These include all inhalers – reliever and preventer, and steroid tablets.
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SOP 7: SYSTEMIC LUPUS ERYTHEMATOSUS
Care plan
Lab investigations and
Assessment Classification Level of Level of
PE findings Management
personnel care
● Disease activity ● Renal profile N/A ● Refer to appropriate MO/ FMS/ Health
● Autoantibody ● Auto-antibodies test disciplines – Physician/ Clinics/
profile (anti-Ro, anti-La, anti- multidisciplinary Rheumatologist Hospital ±
● Comorbidities cardiolipin, lupus approach specialist
anticoagulant) ● Management according
● Urinalysis to guidelines (i.e. EULAR
● ESR Recommendations 2016)
● Family planning
● Review medications –
the goal is to maintain
disease control on
medications with best
safety profile during
pregnancy
1. Assessment of the risk of pregnancy including:
▪ Disease activity and major organ involvement
▪ Hypercoagulability state
▪ Other concurrent medical disorders that may impact pregnancy
▪ Previous obstetric outcome
2. Pregnancy is allowed if:
▪ Disease is quiescent for ≥ 6 months
▪ BP well controlled
▪ eGFR> 60ml/min
▪ proteinuria <1g/day (proteinuria 2+)
3. Use of hydroxychloroquine (HCQ) is recommended in women with SLE preconceptionally and throughout pregnancy.
Discontinuation of HCQ is related to an increased risk for SLE exacerbations during pregnancy
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SOP 8: RENAL DISEASE
Care plan
Lab Investigations and
PE findings Management Level of care
personnel
● CKD Staging (CKD 1 ● FBS ● CKD Stage 1 ● Refer to MO/ FMS/ Health Clinic/
– 5 with or without ● Lipid profile –5 appropriate Physician/ Hospital ±
proteinuria) ● Renal profile ● Renal disease disciplines – Nephrologist specialist
● Assessment for other ● Microalbuminuria with multidisciplinary
concurrent medical ● 24hrs urine protein/ comorbidity approach
conditions albumin-to-creatinine ● Management
ratio (ACR) according to
● eGFR Clinical Practice
● Ultrasound KUB Guidelines
● ECG Management of
● CXR (if indicated) Chronic Kidney
● lupus anticoagulant, Disease 2018
ANA ● Family planning
● HIV, VDRL, Hep B/C
(for women on dialysis)
Maternal Risk
1. Renal workload is tremendously increased in pregnancy with an increased GFR and a physically enlarged kidney
2. Rate of renal function deterioration and worsening of proteinuria during pregnancy correlates significantly with CKD
stages.
● Renal function deteriorates more in CKD stage 3/4 compared with stage 2 (60% vs 14.3%)
● Doubling of proteinuria as CKD stage progresses are 20.5%, 86.5% and 70% in stage 1, 3 and 4 – 5 respectively
3. Women with severe impairment need daily dialysis during pregnancy, which is associated with increased morbidity and
mortality. The only risk modifying intervention is renal transplantation. Realistic options should be offered and counselled
accordingly.
4. All women with unexplained proteinuria/hematuria should have a referral to medical for renal work-up and be referred to the
pre pregnancy clinic
5. Adverse maternal outcomes (pre-eclampsia, hypertension and caesarean delivery) are significantly higher as CKD stage
advances.
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6. Risks of preterm delivery and IUGR correlate with maternal renal function and level of proteinuria.
7. Pregnancy may be considered in women with mild renal impairment (serum creatinine <125 μmol/L), well controlled blood
pressure and without significant proteinuria (<1 g/day).
8. Pregnancy should be avoided in women with either:
a. moderate to severe renal impairment
b. poorly controlled hypertension
c. heavy proteinuria
d. active systemic disease
9. Aim to conceive when:
a. Cause of renal impairment has been optimised
b. Doses of drugs for treatment are minimised
c. Hypertension (if present) is well-controlled
10. Women with moderate to severe impairment should be advised for more permanent methods of contraception.
11. Safety of treatment:
a. Calcium: safe in pregnancy
b. Activated Vitamin D: data is scarce but reassuring
c. Erythropoietin is safe
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SOP 9: THALASSAEMIA MAJOR
Care plan
Lab investigations and
Classification Level of
Assessment PE findings Management Level of care
personnel
● Review of ● FBP ● Mild ● Counselling on MO/FMS/ Health Clinics
transfusion ● Renal profile ● Moderate risk of pregnancy Physician/ Hospital ±
requirements ● LFT ● Severe – she needs to Paediatrician specialist
● Assess compliance ● Iron studies ● Symptomatic/ be fully informed
with chelation ● Hb electrophoresis for asymptomatic about how
therapy and body both women and thalassaemia
iron burden partner affects
● Screen for end-organ ● DNA analysis (if pregnancy and
damage indicated) vice versa
● TFT ● Family planning
● Family screening ● Refer for genetic
● Look for counselling if the
organomegaly need arises
● Transfusion
where indicated
1. Aggressive chelation in the preconception stage
▪ reduce and optimise body iron burden
▪ reduce end-organ damage
2. As diabetes is common in patients with thalassaemia, women with diabetes should be referred to endocrinologists (Refer
SOP for PPC in Diabetes for such women)
▪ Serum fructosamine is preferred for monitoring (target serum fructosamine concentrations < 300 nmol/l for at least 3
months pre-conception)
3. Assessment by a cardiologist
▪ Echocardiogram, electrocardiogram (ECG) and T2* cardiac MRI
4. Assessment of liver iron concentration using a FerriScan® or liver T2* (if it is available)
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▪ Ideal liver iron should be < 7 mg/g (dry weight)
5. Bone density scan to document any pre-existing osteoporosis.
6. Serum vitamin D concentrations to be optimised with supplements.
7. To measure ABO and full blood group genotype and antibody titres
8. Iron chelators should be reviewed. Deferasirox or deferiprone should be ideally discontinued 3 months before conception
9. Offer genetic counselling if the partner is a carrier of a haemoglobinopathy that may adversely interact with the woman’s
genotype
10. Consider in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) with a pre-implantation genetic diagnosis (PGD) in
the presence of haemoglobinopathies in both partners to avoid a homozygous or compound heterozygous pregnancy
11. Hepatitis B vaccination is recommended in HbsAg negative women who are transfused or may be transfused.
12. Hepatitis C status should also be determined.
13. Offer penicillin prophylaxis for all women who have undergone a splenectomy.
14. All women who have undergone a splenectomy should be vaccinated for pneumococcus and Haemophilus influenzae type
B
15. Folic acid (5 mg) is recommended to all women who are planning to conceive to prevent neural tube defects.
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SOP 10: MALIGNANCY
Diagnostic Care plan

Lab
criteria and
Assessment investigations
Differential Management Level of personnel Level of care
and PE findings
diagnosis
● Stage of disease Refer specific Refer specific Refer to multidisciplinary MO/ FMS/ other Secondary
● Disease activity – guidelines guidelines team (oncology, primary related specialist care
remission/active team, O&G team) if
planning for pregnancy
1. Even though the incidence of malignancy occurring during pregnancy is low ranging from 0.02-0.1%, diagnosing it during a
pregnancy is a challenge to the clinicians. The list of common cancers occurring in pregnancy are cervical cancer
(1:2,000−1:10,000), breast cancer (1:3,000−1:10,000), ovarian cancer (1:10,000−1:100,000), leukaemia
(1:75,000−1:100,000), lymphoma (1:1,000−1:6,000), colon cancer (1:13,000) and malignant melanoma
(1:1,000−1:10,000).
2. With appropriate treatment of the cancer, pregnancy itself does not appear to be associated with worse cancer outcomes.
Pregnant women diagnosed with breast cancer can receive treatment comparable with non-pregnant women leading to a
similar survival when matched for stage at diagnosis.
Foetal Risk
1. The risk of miscarriage and congenital anomalies does not increase with surgery. Preterm deliveries usually occurred
in cases after abdominal surgery and peritonitis
2. The risk of major malformations, spontaneous abortions, and foetal death may be increased when chemotherapy is
instituted during the first trimester and it is advisable that the chemotherapy should be delayed until 14 weeks of
gestation.
3. Even though no evidence of teratogenic effect was demonstrated from chemotherapy exposure in the second and third
trimester, the risk for low birth weight and foetal growth restriction may be increased. The reported foetal malformation
from exposure to chemotherapy in the second and third trimester rates range from 1.3% to 3.8%, similar to the rate
reported for the general population. Chemotherapy exposure of 5-fluorouracil, doxorubicin, and cyclophosphamide
(FAC) in the second and third trimester does not cause teratogenic effects. Few studies that evaluated the use of
taxanes (T), such as docetaxel (D) and paclitaxel (P), demonstrated no increase in the occurrence of foetal defects and
other maternal complications when used in the second and third trimesters of pregnancy.
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4. However, trastuzumab is associated with oligohydramnios and anhydramnios, even when given in the second and third
trimesters and not recommended in pregnancy.
5. Methotrexate is teratogenic. The most common abnormalities following methotrexate exposure in utero demonstrated
by a few case studies are skull, hand, and limb deformities such as hydrocephalus, hypoplasia of frontal and orbital
bones, micrognathia, microcephaly, hypertelorism, low set ears and upsweep of the frontal hairline, dysmorphic
features, short proximal limbs, low set ears, small chin and mouth, mongoloid slant and a systolic heart murmur.
6. Women who stopped taking methotrexate even up to 6 months prior to conception are still at risks of developing
spontaneous abortion.
7. The foetal central nervous system during 8 to 25 weeks after conception is sensitive to radiation, and a radiation
exposure dose of >0.1 Gy could decrease the intelligence quotient. Radiation in the second and third trimesters is
correlated with carcinogenic effects within the first decade of life, such as the development of solid tumours and
leukaemia.
Pre pregnancy management

1. A woman with malignancy who considers pregnancy has to be managed by multidisciplinary teams taking into
consideration the balance of effect on maternal and foetal health.
2. In view of the effect of treatments on feotus, women with malignancy have to consider the problems of diagnostic
activities being hindered by pregnancy, the need to delay the institution of chemotherapy to the second or third
trimester and also radiotherapy to postpartum, the reduced options of chemotherapy.
3. Even though, therapeutic abortion does not provide a better outcome when appropriate treatment for cancer is given,
termination of pregnancy should be considered when there is a need for immediate treatment of the disease especially
in abdominal and pelvis malignancy.
4. In women who wish to be pregnant, a concurrent folic acid may be helpful to reduce the neural tube defects in the
feotus of women taking methotrexate.
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SOP 11: RETROVIRAL DISEASE
Diagnostic
Care plan
Lab investigations and criteria and
Assessment
PE findings Differential Level of
diagnosis personnel
● Asympt ● FBC WHO clinical ● Antiretroviral MO/FMS/ Health Clinic/
omatic ● LFT classification therapy (ART) as Infectious Disease Hospital ±
● Sympto ● HBV/HCV criteria of severity indicated in Physician/ General specialist
matic ● CD4/CD8 ratio accordance to the Physician
● Viral load Malaysian
● VDRL & other STI Consensus
screening Guidelines on
● Renal profile Antiretroviral
● Physical examination Therapy 2017
for opportunistic ● Family Planning:
infections/ AIDS Emphasise on dual-
defining complex protection
● STI workup
● In general, the existing ART is to be continued throughout pregnancy and after delivery.
● Special effort must be made to determine the current CD4 and viral load during the early stage of pregnancy.
● Consultation with an infectious-disease physician is strongly recommended if the patient is experiencing virological failure.
● Dual protection contraception should be advised
● Look for evidence of opportunistic infections, HIV-related illnesses and evaluation for possible STIs
● Counsel regarding risk of transmission to the feotus
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SOP 12: POST TRANSPLANT SURGERY
Lab Diagnostic Care plan

Investigations criteria and
Level of Level of
Assessment and PE Differential Management
personnel care
findings diagnosis
● Transplanted organ ● Renal profile N/A ● Multidisciplinary MO /FMS /O&G Tertiary
function ● LFT team approach specialist/ hospitals
● Graft rejection ● Lung ● Family planning Transplantation unit
● Dosage and teratogenicity function
of immunosuppressive tests
drugs ● EEG, ECG
● Foetal and maternal risks ● Urine
protein
● Blood sugar
profile
1. Counselling on family planning and pregnancy including individualised maternal and foetal risks, alternatives, and
timing.
2. Timing of pregnancy: avoid pregnancy during the first year post-transplantation (preferably 2 years) when the risk
of rejection is greatest and immunosuppressive therapy is most aggressive.
3. Contraception should be emphasised during first year post-transplant (fertility is not affected by
immunosuppressive medications): Long-acting reversible contraception is effective and options include the
etonogestrel implant, copper intrauterine device (IUCD), and levonorgestrel-releasing IUCD.
4. For renal transplant patients, vaginal delivery should not be impaired, as the pelvic allograft does not obstruct the
birth canal in most patients. The obstetrician should review operative notes from the transplant procedure to
confirm location of the allograft and ureter. A renal ultrasound might also aid in precise location. This information
should be placed in the prenatal record to guide the surgeon if a caesarean delivery is performed.
5. In post-transplant patients, offer advise on mediations and assisted reproductive technology if reproductive ability is
impaired
6. The American Society of Transplantation consensus criteria for timing of pregnancy :
a. No rejection in the past year
b. Adequate and stable graft function
c. No acute infections that might impact the foetus
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d. Maintenance immunosuppression at stable dosing
7. Review medications for teratogenic risk. Immunosuppressants like mycophenolic acid (eg, mycophenolate mofetil),
mammalian target of rapamycin (mTOR) inhibitors (e.g.; sirolimus and everolimus) should not be used during
pregnancy given its high risks of adverse foetal effects and should be stopped 6 weeks before conception.
Glucocorticoids (e.g. prednisolone), calcineurin inhibitors (e.g.; cyclosporine and tacrolimus) and purine synthesis
inhibitors such as azathioprine are considered safe in pregnancy.
8. Vaccination against influenza, pneumococcus, hepatitis B, and tetanus should be administered before conception.
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SOP 13: DEPRESSION AND ANXIETY

investigations criteria and
Level of Level of
Assessment and PE Differential Management
personnel care
findings diagnosis
● Disease Status: TFT (if it has Common Types: ● Counsel on risk-benefit MO/ FMS/ Health
Acute/Remission not been done Depression of treatment options in Psychiatrist Clinic/
● Functionality e.g before) ● Major pregnancy. Hospital ±
work, interpersonal depressive ● For mild-moderate specialist
and activity of daily disorder depression/anxiety with
living ● Persistent low risk of relapse, aim
● Comorbidities: other depressive to achieve remission
psychiatric illness or disorder and complete treatment
with medical (dysthymia) before pregnancy.
illnesses Anxiety ● For moderate-severe
● Psychosocial risks ● Generalised depression and/or high
e.g unemployment, anxiety risk of relapse, counsel
poor social support disorder on risk-benefit of
● Suicidal risks ● Panic medications.
disorder ● If medication is
● Other anxiety indicated but the patient
disorder refuses, offer adequate
Severity: support, refer to FMS or
● Mild psychiatrist, or offer
● Moderate intensive psychotherapy
● Severe with if available.
psychosis or
suicidality
1. Depression and anxiety are common mental disorders.
2. Depression is the leading cause of disability worldwide and is a major contributor to the overall global burden of
disease.
3. Depression can lead to suicide and devastating psychosocial adverse effects.
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4. Suicide is classified as direct maternal mortality in Malaysia.
5. Educate patients on the risk of untreated depression and anxiety on pregnancy and feotus
6. Emphasise on the importance of recognizing symptoms of depression and anxiety
a. Feeling depressed or loss of interest
b. Disturbed sleep and appetite
c. Poor concentration
d. Feeling lethargic
e. Hopeless, excessive guilt and having suicidal ideation
7. Counsel on the risk-benefit analysis of treatment options to reach a shared decision on a treatment plan.
f. Risks of medication i.e. Selective Serotonin Reuptake Inhibitor (SSRI): no risk of teratogenicity, low absolute
risks of miscarriage, premature delivery, neonatal adaptation syndrome and primary pulmonary
hypertension
g. Risk of untreated depression: miscarriage, premature delivery, low birth weight, poor antenatal self-care,
interpersonal conflict, functional impairment, mother-baby bonding/attachment difficulties, low breastfeeding
initiation, long term behavioural problems in offsprings, suicide and infanticide.
h. Assess previous history of depression and anxiety (how many episodes and severity) and medication history
8. Aim to complete treatment before getting pregnant if that is possible (only for mild and moderate
depression/anxiety with low risk of relapse). Maintenance treatment of 6-9 months after remission
9. If medication is indicated for severe depression/anxiety but the patient refuses, offer adequate support, refer to
FMS or psychiatrist, or offer intensive psychotherapy if available.
10. Arrange for psychological intervention:
a. Provide counselling and emotional support in primary care or O&G setting
b. Arrange for brief psychological interventions (eg brief cognitive behaviour therapy) by trained personnel in
primary care
c. Referral to tertiary centre for psychological intervention
11. Baseline psychosocial investigations: corroborative history from social support
12. Early booking when pregnant
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SOP 14: SEVERE MENTAL ILLNESS

investigation criteria and
Level of Level of
Assessment s and PE Differential Management
personnel care
findings diagnosis
● Disease status: in ● FBS Types: ● Refer to FMS or MO/ FMS/ Health
remission or ● Lipid profile ● Schizophre Psychiatrist Psychiatrist Clinic/
presence of ongoing nia ● Multidisciplinary team Hospital ±
symptoms ● Bipolar involving psychiatrist, specialist
● medication side Disorder O&G, FMS and social
effects ● History of worker
● Functionality and postpartum ● Counsel on risk-benefit of
capacity to consent psychosis treatment options in
● Comorbidities: ● Other pregnancy.
metabolic syndrome psychotic ● Counsel patient and
and substance use disorders family for compliance,
● Psychosocial risk: monitoring and social
Social support and support
treatment adherence ● Continue medication if
● Risk of self-neglect, patient is stable and
aggression and self- medications are not
harm contraindicated in
pregnancy
● If patient refuses
medication or switching is
required, refer immediately
to FMS or Psychiatrist
Remarks
1. Severe mental illness includes psychotic disorders, schizophrenia and bipolar disorder.
2. Schizophrenia and bipolar disorder have a prevalence of around 1 in 100 in the general population. Postpartum
psychosis has a prevalence of 1 in 1,000 pregnancies.
3. There is an increased risk of relapse of pre-existing mental disorders during the perinatal period, usually following
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cessation of medication.
4. Preconception planning should start as soon as possible for women with severe mental illness that plan to
conceive. Contraception is important if they are not planning to conceive.
5. Detailed counselling regarding the risk-benefit of medication during the pregnancy, the possibility of relapse and
effects to the feotus must be given to the woman and her partner. Preconception planning will also involve
discussion on types of medication used if she plans to breastfeed.
6. Medication:
a. Continue medication if patient is stable and medications are not contra-indicated in pregnancy
b. Valproate and carbamazepine should not be used in women who plan to conceive.
c. Lithium should not be used in the first trimester of pregnancy.
d. Patients on Clozapine should be referred to psychiatrist for management
e. Continue depot antipsychotic if patient is responding well and has a previous history of non-adherence with
oral medication.
f. Avoid benzodiazepine unless for short-term treatment of severe anxiety and agitation
g. Choose the drug with the lowest risk profile for the woman, feotus and baby, taking into account previous
response to medication.
h. Use the lowest effective dose, aiming for a single drug regime but taking into account response to
medication.
i. Start patient early on folate supplements
7. Educate patients and partner on risk of relapse, risk-benefit of continuing or starting medication
8. Emphasise the importance of follow-up and compliance
9. Optimise patient’s mental state
a. Optimise medication or switch to low impact medication
b. Offer psychological support
c. Close monitoring for relapse
10. Assist in substance abstinence
11. Advise on early booking when pregnant
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SOP 15: SUBSTANCE USE DISORDER
Diagnostic Care plan
Lab
criteria and
investigations Level of
Assessment Differential Management Level of care
diagnosis
● Obtain thorough and ● Urine for Types: ● Brief MO/ FMS/ Health Clinic or
adequate history: drugs (rapid ● Alcohol psychological Psychiatrist Hospital with
substance, alcohol, test) ● Nicotine intervention e.g Psychiatrist/
tobacco ● Infectious ● Cannabis Brief Psychiatrist with
● Comorbidities: disease ● Amphetami Motivational subspeciality
medical and screening ne-type Interviewing addiction
psychiatric conditions stimulant ● Nicotine
● Complications: bio- ● Opioid replacement
psycho-social therapy
● Psychosocial history: ● Methadone
History of partner or replacement
spouse taking therapy
substances. History of ● Refer to
forensic/criminal appropriate
history discipline
1. Preconception planning should start as soon as possible for women with substance use disorder who plan to
conceive.
2. Contraception is important if they are not planning to conceive.
3. Detailed counselling regarding the risk-benefit of replacement therapy and medication during the pregnancy, the
possibility of relapse and effects to the feotus must be given to the woman and her partner.
4. Preconception planning will also involve discussion on types of replacement therapy and medication used if she
plans to breastfeed.
5. Replacement Therapy and Medication:
a. Nicotine replacement therapy is safe during pregnancy under supervision of a clinician. A combination of
cognitive behavioural therapy and counselling with nicotine replacement therapy is the most effective
strategy to achieve smoking cessation during pregnancy.
b. Methadone Replacement Therapy in pregnancy improves many of the adverse consequences of maternal
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and foetal outcomes associated with untreated opioid use. Infants exposed to methadone during pregnancy
typically require treatment for withdrawal symptoms after delivery. Methadone is recommended to be
continued during pregnancy.
6. Counsel patients on the risk of substances on pregnancy and feotus.
7. Counsel patients and family on risk-benefit of starting or continuing replacement therapy
8. Emphasise the importance of recognizing symptoms of withdrawal for each substance.
9. Inform patients on the potential risks of substances and the availability of non-pharmacological intervention and
pharmacological intervention.
10. Emphasise on the importance of follow-up and adherence
11. Aim of treatment is to reach substance abstinence before pregnancy.
12. Offer counselling and psychological support in primary care or O&G setting
13. Arrange for brief psychological interventions e.g brief motivational interviewing by trained personnel in primary care
14. Referral to tertiary centre for psychological intervention and pharmacological intervention which not available in
primary care
15. Close monitoring for relapse
16. Early booking when pregnant
Reference
1. Mental Health Care in the Perinatal Period. Australian Clinical Practice Guideline. October 2017
2. NICE Antenatal and postnatal mental health. December 2014
3. Clinical Practice Guidelines on Major Depressive Disorder, Ministry of Health Malaysia 2020 (work in progress)
4. Guidelines for the identification and management of substance use and substance use disorders in pregnancy
(WHO 2014)
5. Mental Health Gap Action Programme Intervention Guide Version 2.0 (WHO 2016)
6. Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence (WHO 2009)
7. The ASSIST Project-Alcohol, Smoking and Substance Involvement Screening Test. (World Health Organization
2009
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APPENDIX 1-8
PRE PREGNANCY HEALTH EDUCATION
1. Towards a healthy and happy family

A healthy married couple is the basic foundation for a happy family. Factors
which influence the health of an individual, family and the community include:
● Lifestyle
● Genetics/familial factors
● Environmental factors
2. Practising a healthy lifestyle
Balanced diet A diet which contains all the necessary nutrients in the
right proportions according to caloric needs and right
proportion. Ensure adequate fluid intake.
Social interactions Husband and wife must be supportive and actively

participate in enhancing each other’s health.
Couples should practice mutual respect and consent for a
satisfying and equitable sexual relationship.
Good daily living habit All men and women in reproductive age should have a
healthy lifestyle; avoid unhealthy habits like smoking,
consuming alcohol and other types of drug abuse.
Relaxation Regular exercise decreases stress and lowers the risk of

heart disease, stroke and hypertension.
Adequate rest and sleep Six to eight hours of sleep a day to ensure adequate rest.
3. Genetic factors
Couple, men and women with:-
• Consanguineous marriage (e.g., autosomal recessive disorders)
• Previous child with genetic disorders (e.g., thalassaemia)
• Family history of genetic disorders (e.g., autosomal recessive disorders)
• Women at risk for aneuploidy or chromosomal anomaly (e.g., Down’s Syndrome)
• Male disorders (e.g., X-linked disorders – Duchenne Muscular Dystrophy,
Haemophilia)
• Unexplained/uninvestigated foetal loss should be counselled for possible genetic
problems.
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4. Family Planning
It is encouraged for couples to plan their pregnancy in order to contribute positively
to the eventual maternal and foetal outcome especially if the women’s condition is
not yet optimised. Health care providers should be consulted regarding the
appropriate and effective contraceptive method.
5. Pregnancy and Birth

• Physical maturity and age of the mother
The appropriate age for a woman to get pregnant is at the legal age 18 and
above. Women above 40 years are at higher risk of pregnancy complications.
• Preventing infections
Men and women in reproductive age group are advised about infections such as
sexually transmitted diseases as well as lifestyle diseases which can affect
reproductive potential and the unborn child. Hepatitis B, varicella and rubella
vaccinations may be advised to all women who are not immune.
• Antenatal health care
Couples who are planning to start a family should be in optimal health. A
pregnant woman and her partner should attend an antenatal clinic before 12
weeks of gestation.
• Supplementation
Folic acid supplementation should be emphasised to all women at least 3 months
prior to a pregnancy.
• Breastfeeding
Breast milk is the best option for the newborn as it contains all the necessary
nutrients, in the right proportions, for the optimum health and growth of the
newborn. Exclusive breastfeeding for the first 6 months of the newborn and
encouraged to continue for at least 2 years.
• Childbirth
Each pregnant woman must be advised on the appropriate place of delivery.
• Child care
Every child must be immunised according to the recommended schedule.
6. Screening
• Cervical cancer screening (i.e.; pap smear, HPV DNA test) according to national
guideline
• STI (sexually transmitted infection) screening as indicated
• Clinical breast examination
• Diabetes and hypertension screening should be offered at least annually
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7. Vaccination
• Check for rubella status.
If the mother is not rubella immune, offer rubella vaccination together with
contraception, as pregnancy is contraindicated for three months following
vaccination. If the mother is unsure of her status, check for Rubella IgG to
confirm immunity.
• Hepatitis B vaccination
Enquire regarding the patient’s Hepatitis B vaccination. If the women has
not been vaccinated, offer Hepatitis B vaccination
• Varicella (chickenpox)
Offer and discuss benefits of vaccination pre pregnancy if the mother has
never had a varicella Infection. If unsure, check for varicella IgG to
confirm immunity.
• COVID-19 vaccination
If the woman have not received COVID-19 vaccination, offer and discuss
the benefit of vaccination.
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APPENDIX 1-9
PRE PREGNANCY COUNSELLING
A recommendation for pre pregnancy counselling should be given to all men and
women with risk of pregnancy complications. Such counselling can reduce the
incidence of maternal and foetal mortality and morbidity.
A. Objectives of pre pregnancy counselling include:
1. Conducting an initial assessment

• full history (medical, surgical, past obstetric, psychiatric, family, social and
substance use history)
• general physical examination
• identification of appropriate screening tests if necessary
• discussion on pregnancy planning
2. Allaying or reducing anxiety

It is necessary to reduce anxiety in women with chronic medical illness. Counselling
should include:
• The effect of pre-existing disorder on pregnancy and pregnancy on the
disorder.
• The likelihood of possible recurrence of previous complications and how this
may possibly be reduced (e.g., intrauterine or neonatal death, hypertension,
deep vein thrombosis, miscarriage or preterm labour, mechanical problems of
labour or delivery).
3. Determining fitness for pregnancy

Pregnancy should be deferred and contraception should be offered to allow further
evaluation and management of known disorders or new findings (e.g., anaemia,
heart disease, diabetes and hypertension). Treatment and optimisation of medical
and surgical disorders may be required. Reproductive issues should be managed
appropriately.
4. Follow up
• Follow-up interval : 6 -12 monthly (based on patient’s condition)
• Until patient has no risk for pregnancy
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B. Factors Affecting Pregnancy
1. Social behaviour
• Common social behaviours affecting pregnancy:
Smoking - Miscarriage, low birth weight, placenta previa, placenta

abruption, infant respiratory tract infection, sudden infant
death syndrome, impaired fertility
Alcohol - Miscarriage, foetal alcohol syndrome, placenta abruption,
foetal intrauterine growth restriction (IUGR), low birth
weight, central nervous system abnormalities
Cocaine - Abortion, premature birth, placental abruption, IUGR,
congenital anomalies, neonatal central nervous system
(CNS) dysfunction
Caffeine - Low birth weight, IUGR
• Any form of substance abuse can affect pregnancy and its outcome.
2. Medication
A potential preventable group of disorders are drug-induced anomalies. Medications
during pregnancy should be avoided as far as possible.
Table 1.1: Effects of medications on pregnancy
AGENTS EFFECTS
Anti-convulsions Incidence of congenital malformations in children born to

epileptic mothers is about 6%. This appears to be largely due
to teratogenic effects of anticonvulsant. Combining drugs
increases the incidence of congenital defects
Sodium valproate Increase risk of neural tube defect to about 1/1000
pregnancies. Long term neurological implication to the baby
Lithium carbonate Increase in cardiovascular abnormality
Warfarin Various congenital malformations including abnormalities of

the central nervous system, nose and bony epiphyses
Alcohol Low birth weight, microcephaly, congenital heart disease and
mental retardation
Androgens Teratogenesis in first trimester, virilisation of female feotus
Atropine Foetal tachycardia
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AGENTS EFFECTS
Beta–blockers IUGR
Diazepam Respiratory depression
Cyclophosphamide Teratogenesis in first trimester

Diuretics IUGR
Diethyl-stilboesterol Genital anomalies, male infertility, female may develop clear
cell carcinoma of the vagina many years later
Methadone Maternal symptoms of withdrawal inducing foetal compromise
and abruption
Foetal complications are smaller-than-normal head size, low
birth weight, IUGR, preterm delivery, unspecified structural
anomalies and foetal withdrawal syndrome
Methotrexate Neural tube defects
Mycophenolate mofetil Multiple congenital malformations including facial, heart,

(Immunosuppressive renal, ear, eye and tracheo-esophageal malformations
drug)
Phenytoin Embryopathy includes dysmorphic facial features,
microcephaly and motor and intellectual retardation
Tetracycline Tooth enamel hypoplasia and cataract
Terbutaline Hypoglycaemia
Thalidomide Phocomelia
Angiotensin converting Oligohydramnios, bone malformation, prolonged hypotension

enzyme inhibitor (ACE-i) and renal failure
and angiotensin receptor
blocker (ARB)
3. Nutritional status
Nutritional deficiency in women of reproductive age affects not only the general
health but also the fertility capacity. Folic acid supplementation is essential to
prevent neural tube defects.
4. Medical history
Pre-existing medical conditions may adversely affect mother and feotus. Pre
pregnancy intervention is important in counselling regarding risk and in optimising
medical management.
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CHAPTER 2
PROCESSES AND PROCEDURES OF ANTENATAL
CARE
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CHAPTER 2: PROCESSES AND PROCEDURES OF ANTENATAL CARE
2.1 ANTENATAL CARE
● Antenatal care should address both medical and psychological

needs of the woman. Periodic antenatal health check-ups are
necessary to establish rapport between the woman and health care
providers. Health care providers should deliver individualised health
promotional messages.
2.1.1 Antenatal visit
● Early antenatal care (first trimester) is important to screen women for

risk factors, identify those with bad obstetric history and manage
women with medical complications as these may have bearing on
the progress of the pregnancy and its outcome.
● Activities during the antenatal visits should include the
spouse/partner or family members as it will provide emotional
support to the expectant mother. Their involvement enhances
mother’s compliance; identify her needs and wants; and discuss the
plan for delivery.
2.1.2 Frequency of visits
● Below is the suggested schedule for antenatal contacts including

options for virtual consultations for eligible mothers:
Table 2.1: Schedule for Antenatal Visits
Gestation
Mode of
Primigravida Multigravida consultation
<12 <12 Physical
16 - 20 16 - 20 Physical
24-26 24-26 Physical or virtual
28 – 30 28 – 30 Physical
32 – 34 32 – 34 Physical or virtual
35 - 36 35 - 36 Physical
37 38 Physical
38 40 Physical
39 Physical
40 Physical
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● For high-risk pregnancy and other colour tags, more frequent visits
are required. Low-risk mothers can be offered alternative antenatal
contacts through virtual consultations if the requirements are fulfilled.
● The reduced physical visits can potentially benefit both mothers and
healthcare providers by focusing more on the quality of the visits.
This flexibility also provides ease of access for low-risk mothers as
they will be at the comfort of their home.
2.1.3 Booking visit
● The first visit is very important and should be done as soon as

possible (preferably before 12 weeks of gestation). Even if the first
visit may be later in pregnancy, it is still regarded as the booking
visit.
● First routine medical examination (RME) by a doctor should be done
during the booking visit or within 2 weeks after the booking visit. The
following information should be recorded:
a. History
● Detailed menstrual history
o Last normal menstrual period (LNMP)
o Regularity of cycles
o Contraceptive usage
*refer for dating ultrasound scan if mother’s period is irregular,

stopped contraceptive pills less than 6 months or unsure of LNMP
● Medical history
o Allergies
o History of blood transfusion
o Medical conditions
o Infections
o Drug history (traditional medication and other self-prescribed
medicines)
● Past surgical history
● Past obstetric history

o Previous recurrent miscarriage or termination of pregnancy
o Intrauterine growth restriction and preterm labour
o Previous LSCS, instrumentation, PPH, anaemia etc
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o Intrauterine death
o History of baby with congenital abnormality
o Early or late neonatal death
● Family history
o Medical disorders such as diabetes mellitus, hypertension
o Multiple pregnancy
o Congenital anomalies
● Socioeconomic background
o Occupation of both the woman and her partner
o Smoking, drugs and alcohol consumption
o Education level
b. Physical examination
● Relevant physical examination should be performed :
o Height o Scars of previous

o Weight operation
o Blood pressure o Palpation: uterine size/
o Pallor, cyanosis, jaundice other masses
o Oral hygiene o Vaginal examination
o Clubbing (when indicated)
o Thyroid enlargement & o Oedema
signs of hypo/ o Varicose veins
hyperthyroidism o The mother’s gait: any
o Cardiovascular system bony deformity of pelvis
o Respiratory system o Spine:
o Breast kyphosis/scoliosis
o Abdomen
c. Laboratory Investigations
● Urinalysis: protein (albumin), sugar (glucostix), UFEME (when
indicated)
● Blood :
o Haemoglobin, ABO and Rhesus group
o Syphilis (VDRL) – if positive, performs TPHA and refers to
treatment.
o HIV (Rapid test) – if reactive proceed with confirmatory test
o Hepatitis B (HBsAg) antigen (if indicated)
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o Thalassaemia screening (if indicated)
o Tuberculosis (if indicated, from TB screening questions)
o Malaria – all mothers who are suspected having signs and
symptoms of Malaria must be screened
● Definition of suspected malaria: Mother with high grade fever
with signs & symptoms listed:
▪ Headache
▪ Malaise & fatigue
▪ Abdominal pain
▪ Myalgia & joint pain
▪ Chills & rigor
▪ Sweating
▪ Loss of appetite
▪ Vomiting
(Refer to The Management Guidelines of Malaria in Malaysia
2013)
● Priority to the high risk mothers:

▪ Orang Asli
▪ Those who stay near forest
▪ Living in, or returning from, endemic area/countries (Papua
New guinea, Pakistan, Indonesia, Bangladesh, India,
Myanmar, Nepal and Philippines)
▪ Close contact with malarial case
▪ Involved in high-risk activities (e.g.; logging, agriculture,
recreation, army & hunting within 6 weeks
d. Ultrasound scan for viability/ dating

● It is recommended to perform an ultrasound examination during the
booking visit, if it is available.
e. Management
● Folic acid and iron supplementation to be given at booking if the
patient can tolerate it. Combined preparation can be used. Refer
WHO recommendations on micronutrient supplement for pregnancy
(Table 15.3).
● Nutritional advise
● Health education e.g. smoking cessation
● Give information on the antenatal screening test i.e. indications,
benefits and limitations
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2.1.4 Subsequent physical visits
During the visits:

● Heamoglobin level monthly
● Ask relevant symptoms if problems arise
● Weight and blood pressure
● Urine for protein and glucose
● Symphysio-fundal height
● Assess the lie, presentation of the feotus and head engagement
especially after 36 weeks
● Second RME by Medical Officer between 32 to 36 weeks POA
2.1.5 Virtual visits

● Virtual consultation is an option to be given to eligible mothers when
all requirements are fulfilled. It is not compulsory.
● Virtual consultation is proposed only for white-coded mothers. Green-
coded mothers should be assessed by medical officers for suitability
of virtual consultation according to the criteria as in Table 2.2.
● Refer Garis Panduan Peluasan Pelaksanaan Klinik Virtual (Virtual
Clinic), Bahagian Pembangunan Kesihatan Keluarga, 2020 on the
details for requirement of virtual consultation.
● Refer Appendix 2-1 – Consent form for antenatal virtual
consultations and Appendix 2-2 – Checklist for antenatal virtual
consultations.
Table 2.2 : Criteria for mothers to be eligible for virtual consultations
For first virtual consultation For second virtual consultation

● White-coded ● White-coded
● Green-coded - Mothers who are coded ● Green-coded - Mothers who are coded
green due to these factors are allowed green due to these factors are allowed
for virtual consultations: for virtual consultations:
o Primigravida / pseudoprimigravida o Rhesus negative
(only for < 36 years old) o Primigravida / pseudoprimigravida
o Grandmultipara ≥ 5 (only for < 36 years old)
o Age 36-39 (only for multigravida) o Grandmultipara ≥ 5
o Pre pregnancy/ booking weight < o Pre pregnancy/ booking weight <
45 kg 45 kg
o Height < 145cm o Height < 145cm
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For first virtual consultation For second virtual consultation
o History of gynaecological surgery o Age 35-39 (only for multigravida)
(eg: fibroid, cyst) o History of gynaecological surgery
o Unsure of dates (eg: fibroid, cyst)
o History of recurrent miscarriages (≥ o Unsure of dates
3 consecutive miscarriages) o History of recurrent miscarriages (≥
o History of baby with birth weight > 3 consecutive miscarriages)
4kg o History of baby with birth weight >
o History of 3rd and 4th degree 4kg
perineal tear o History of 3rd and 4th degree
o History of retained placenta perineal tear
o History of postpartum o History of retained placenta
haemorrhage o History of postpartum
o History of instrumental delivery haemorrhage
o Birth spacing <2 years or > 5 years o History of instrumental delivery
o Birth spacing <2 years or > 5 years
Mothers with the condition as below are not eligible for virtual consultation:
● Mothers with social issues (e.g.: poor social support)
● Mothers with previous history of poor compliance to advise or missed
appointments
2.2 SCREENING FOR RISK FACTORS

● Checklist should be assessed and documented. The care plan
should be based on the protocol given based on Garis Panduan
Senarai Semak bagi Penjagaan Kesihatan Ibu Mengikut Sistem Kod
Warna. Refer Appendix 2-3 for risk stratification based on colour
coding.
2.3 MATERNAL VACCINATION

● Anti-tetanus vaccination (tetanus toxoid, TT)
o Primigravida – at quickening and second dose 4 weeks later
o Multigravida – a single dose is given between quickening and
before 37 weeks of gestation
**Tdap may be administered if available in place of ATT
● Optional vaccination can be given if available. Refer Appendix 2-4.
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● COVID-19 vaccination – if the mother has not received the vaccine,
offer and give advise on its importance
2.4 ANTENATAL CARE FOR UNCOMPLICATED AND HIGH RISK

PREGNANCY
2.4.1 Routine antenatal care for uncomplicated pregnancies
Visits Gestation Content of care

1 Before 12 weeks ● Weight, height, body mass index (BMI)
● Blood pressure, pulse rate
● Full physical examination including mental health
assessment
● Ultrasound to confirm the date
● Full blood count
● Urine protein and sugar
● Blood group and rhesus status
● HIV screening
● Syphilis screening
● Hepatitis B screening(if indicated)
● GDM screening (i.e.; OGTT) if indicated
● VTE risk assessment
● Antenatal colour coding based on risk factors
2 16-20 weeks ● Weight

● Haemoglobin level
● Review lab investigation results
● Targeted scan if indicated
● Placental localization
3 24 – 26 weeks ● Weight
● Foetal heart rate auscultation
● GDM screening (i.e.; OGTT) if indicated
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4 28 – 30 weeks ● Weight
● Educate on foetal kick chart
● Anti-tetanus vaccination

● Foetal kick chart

● FBC
● Birth plan
7 38 weeks ● Weight
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● Hospital admission for assessment or induction
2.4.2 Routine antenatal care for high risk pregnancies
Please refer to the respective sections for each specific condition. More
frequent visits are required for high risk pregnancies. Below are
additional cares to basic antenatal management whenever indicated:
● Other investigations related to the conditions (e.g.; renal function,

HbA1c, thyroid function, ECG)
● Shared care / combined care / multidisciplinary management – with
documented antenatal care plan
● Growth scans
● Detailed scan
● Documented delivery plan
2.5 HEALTH EDUCATION
Health education should be provided for mother and spouse/ family

members. The topics should include:
● Diet during pregnancy (Section C: Perinatal Nutrition Care)

● Exercises during and after pregnancy
● Development of the baby
● How to overcome common discomforts in pregnancy
● Preparation for safe delivery – place of delivery, mode of delivery
● Labour process
● Pain relief methods
● Relaxation and breathing techniques
● Basic baby care
● Coping with problems in the first few weeks after delivery
● Education on common disorders in pregnancy (e.g.; hypertensive
diseases in pregnancy, gestational diabetes mellitus, anaemia etc)
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● Breastfeeding – (Refer Section C: Perinatal Nutrition Care)
● Partners and family/ community role in supporting breastfeeding
mothers.
● Importance of vaccination for mother and baby
2.6 HOME VISITS
Home visit during antenatal should be provided for new case, patients
who defaulted follow-up and for high-risk mothers as soon as possible.
Refer Appendix 2-5 for protocols on home visit.
● For normal antenatal mothers, one (1) home visit is adequate

● More frequent home visits are required for high-risk mother
depending on severity of the risk including defaulter mothers
2.7 ANTEPARTUM FOETAL MONITORING AND SURVEILLANCE

There is a higher incidence of foetal compromise in pregnancy with
hypertension, diabetes, heart disorders and other medical disorders.
Foetal monitoring during the antepartum period consists of tests for:
● Foetal growth
● Foetal well being
2.7.1 Fetal growth

● Symphysio-fundal height (SFH) tape measurement should be
performed routinely from 22 weeks onwards in all pregnancies where
the POA is expected to correspond to the centimetres of the SFH.
● If there is a discrepancy between the SFH and POA of ± 3cm, the
patient needs to be re-evaluated with regards to the accuracy of the
LNMP and should be referred for an ultrasound. This can be an early
indicator of impaired fetal growth.
● Maternal weight gain: The antenatal mothers should be weighed at
every antenatal visit.
● There should be a progressive increase in weight throughout
pregnancy. For the 1st trimester, generally the weight gain should be
about 0.5-2.0 kg in total. In the second and third trimester, weight
gains are varied according to women pre pregnancy BMI categories
(by using WHO cut-off). Refer to Table 2.3 for recommended range
of gestational weight gain.
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Table 2.3: Gestational Weight Gain Range for Single Pregnancy
st
Pre pregnancy BMI Total Weight Gain in 1 Mean and range of GWG Total Weight
nd rd
(kg/m²) trimester (kg) in 2 & 3 Trimester (kg) Gain (kg)
Underweight 0.5kg / week

12.5 – 18.0
< 18.5 (0.44-0.58kg)
Normal 0.4kg / week

11.5 – 16.0
18.5 – 24.9 (0.35-0.50kg)
0.5 – 2 kg
Overweight 0.3kg / week
7.0 – 11.5
25.0 – 29.9 (0.23-0.33kg)
Obese
0.2 kg / week
≥ 30.0 5.0 – 9.0
(0.17-0.27kg)
Source: Institute of Medicine, 2009
2.7.2 Ultrasound scanning
● Ultrasound scanning for dating is reliable if the parameters are taken

before 20 weeks. Serial scan should be done every 2 – 3 weeks for
foetal growth assessment if there is suspicion of IUGR or other
disorders.
2.7.3 Fetal monitoring
● Foetal kick chart is an indirect tool for monitoring fetal wellbeing. All
mothers should be given the foetal movement chart (Cardiff ‘count-
to-ten’) for recording of foetal movements from 28 weeks gestation
onwards and should be told to report to any health facility if
movements are less than 10 within 12 hours. This observation
should be done at regular intervals every day.
● Foetal heart auscultation: should be routinely practiced from 22
weeks onward. Foetal heart rate should be taken for at least 30
seconds to determine the rate.
● CTG should be performed in cases where there is an abnormal FHR
by daptone and high risk of foetal compromise such as poorly
controlled hypertension/diabetes, IUGR or postdates.
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2.8 ANTENATAL EXERCISE
Refer Manual Senaman Antenatal & Postnatal Di Klinik Kesihatan,

Bahagian Pembangunan Kesihatan Keluarga, Kementerian Kesihatan
Malaysia, 2014.
2.9 DOMESTIC VIOLENCE AND ABUSE
● Antenatal care is a good opportunity to identify and assist women

who experience domestic violence. Women who are victims of
domestic violence typically experience a phenomenon called
‘learned helplessness’ and are trapped in a ‘cycle of violence’ and
they may not readily come forward for help. There are also many
factors such as fear for their children being taken away that prevents
them from disclosing.
● Healthcare providers to be aware of and be vigilant to the presence
of cues associated with abuse and prompt further if domestic
violence is suspected.
● Recommendations in managing women involved in domestic
violence include:
1. Create an environment for asking about domestic violence
- Display information in suitable places (e.g.; waiting areas)
about the support for those affected by domestic violence and
abuse.
- Ensure frontline staff are familiar with procedure regarding
victims of domestic abuse
2. Ask questions about domestic violence

- Provide each woman with the opportunity for a one-to-one
consultation, without her partner, a family member or a legal
guardian present, on at least one occasion. For example
during physical examination or ultrasound examination.
- Be alert to the signs of abuse and raise the issue
- Use verbal and non-verbal communication skills to develop
trust
- Assure abused women about privacy, safety and
confidentiality issues
- Be compassionate, supportive and respectful towards abused
women
- Do not pressure women to disclose; simply raising the issue
can help them
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3. Response to women who disclose abuse and provide first line
support
- Listen
- Inquire about needs
- Validate women’s disclosure
- Enhance safety and providing support
- Do not pressure the woman to make immediate decisions
about her situation or offer advise or reassurances
prematurely.
4. Ensure safety
- Initial safety assessment
- Immediate risk: does she and her children require an
immediate place of safety
- Future risk: does she require help to prevent future risk e.g
police report
- Referral to police, social worker, support group, legal advise if
indicated
- Note-taking for legal purposes
- Mandatory reporting only if children are involved
- Continuing care
5. Help patient prepare an emergency plan

- Assist patient make a plan in case she needs to leave
- Appropriate referral for help e.g social worker
6. Plan for continuation of care

- Consider your patient’s safety as a paramount issue. A woman
is usually a good judge of her own safety.
- Empower her to take control of decision-making; ask what she
needs and present choices of actions she may take and
services available.
- Respect the knowledge and coping skills she has developed.
- Provide emotional support.
- Ensure confidentiality–the woman may suffer additional abuse
if her partner suspects she has disclosed the abuse.
- High-risk discharge notification to the nearest clinic.
- Ensure patients remain within the system. Obtain telephone
numbers and addresses. Early postnatal home visit is
essential.
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Reference:
1. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience.

2016: WHO
2. NICE Clinical guideline [CG110] Pregnancy and complex social factors: a model
for service provision for pregnant women with complex social factors. September
2010.
3. NICE Public health guideline [PH50] Domestic violence and abuse: multi-agency
working. February 2014.
4. Hegarty K, O'Doherty L. Intimate partner violence - identification and response in
general practice. Aust Fam Physician. 2011 Nov;40(11):852-6.
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APPENDIX 2-1
BORANG KEIZINAN KONSULTASI ANTENATAL SECARA MAYA
Konsultasi antenatal secara maya adalah penyampaian perkhidmatan kesihatan secara

maya (virtual), langsung (live) dan interaktif yang merangkumi konsultasi klinikal dan
pelan rawatan pelanggan di antara anggota kesihatan dan pelanggan. Konsultasi
antenatal secara maya merupakan satu inisiatif yang dilaksanakan bagi memastikan
penjarakan sosial dan menyediakan perkhidmatan kesihatan yang berterusan setaraf
dengan kemajuan teknologi.
Saya telah diberi penerangan oleh anggota kesihatan tentang pelaksanaan konsultasi
antenatal secara maya dan bersetuju:
1. Untuk menyertai sesi konsultasi antenatal secara maya.

2. Maklumat klinikal semasa sesi konsultasi boleh dikongsi dengan anggota
kesihatan lain untuk tujuan rujukan sekiranya perlu, bagi kesinambungan
perawatan.
3. Sebarang rakaman video atau audio sepanjang sesi konsultasi postnatal secara
maya tidak boleh ditular/ dikongsi/ disebar kepada pihak luar oleh kedua-dua pihak
4. Rakaman tidak boleh digunakan sebagai bukti untuk tindakan undang-undang
terhadap KKM
5. Anggota kesihatan yang bertugas boleh memberhentikan konsultasi jika:
a. berlaku gangguan akses capaian internet atau sebarang masalah teknikal.
b. jenis perbualan tiada berkaitan dengan tujuan konsultasi kesihatan saya
6. Saya berhak untuk tidak meneruskan konsultasi antenatal secara maya atas
pilihan saya sendiri.
7. Saya akan hadir ke klinik sekiranya terdapat keperluan untuk pemeriksaan
lanjutan.
8. Konsultasi secara maya boleh menyebabkan kelewatan dalam rawatan
berbanding konsultasi bersemuka.
Ditandatangani:
-------------------------------------- ---------------------------------------
(Ibu) (Saksi*)
Nama : Nama :
No. Kad pengenalan: No. Kad pengenalan:
Tarikh: Jawatan :
Tarikh :
Cop jawatan:
** Saksi boleh terdiri dari Pakar Perubatan Keluarga/ Pegawai Perubatan/ Jururawat/ Penolong Pegawai
Perubatan
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APPENDIX 2-2
SENARAI SEMAK PEMANTAUAN IBU ANTENATAL SECARA VIRTUAL UNTUK

ANGGOTA KESIHATAN
KONSULTASI VIRTUAL PERTAMA PADA 24-26 MINGGU

No. Soalan Jawapan Tindakan
1. Untuk meneruskan konsultasi secara virtual, pastikan anggota kesihatan dapat
melihat imej ibu sehingga sekurang-kurangnya ke paras dada. Ini bagi
membolehkan anggota kesihatan dapat melihat penampilan ibu secara keseluruhan.
2. Bertanya khabar ibu? Sihat / tidak Jika ibu tidak sihat, nasihat
sihat ibu untuk datang klinik
3. Setuju untuk teruskan konsultasi Ya / Tidak Jika ibu tidak bersetuju untuk
secara virtual? teruskan konsultasi secara
virtual, beri temujanji klinik
4. Demam Ya / Tidak Jika ya, nasihat ibu untuk
datang ke klinik dan
maklumkan kepada doktor
5. Masalah pernafasan Ya / Tidak Jika ya, nasihat ibu untuk
6. Sakit kepala/ pening / loya/ muntah/ Ya / Tidak Jika ya, nasihat ibu untuk
mata kabur datang ke klinik dan
7. Sakit dada /berdebar-debar Ya / Tidak Jika ya, minta ibu untuk
segera ke hospital
8. Edema di kaki/ tangan/ muka Ya / Tidak Jika edema di kaki, tanya
secara mendadak lebih lanjut sehingga tahap
mana. Jika sehingga lutut,
nasihat ibu untuk datang ke
klinik.
Jika edema di tangan atau

muka, nasihat ibu untuk
datang ke klinik
9. Sakit dada/ susah nafas/ betis Ya / Tidak Jika ya, minta ibu untuk
bengkak/ sakit / kemerahan segera ke hospital
10. Pemakanan - selera makan Normal/ Jika kurang selera makan,
kurang selera beri nasihat mengenai
pemakanan atau nasihat
untuk datang ke klinik jika
perlu
11. Contractions Ya / Tidak Jika ya, minta ibu untuk
segera ke hospital
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KONSULTASI VIRTUAL PERTAMA PADA 24-26 MINGGU
12. Pecah air ketuban / leaking Ya / Tidak Jika ya, minta ibu untuk
segera ke hospital
13. Pendarahan per-vagina Ya / Tidak Jika ya, minta ibu untuk
segera ke hospital
14. Kesihatan mental Ya / Tidak Jika ya kepada salah satu,
o Sejak kebelakangan ini, adakah nasihat ibu untuk datang ke
anda sering diganggu perasaan klinik.
murung atau sedih?
o Sejak kebelakangan ini, adakah
anda sering kehilangan minat
atau keseronokan dalam
melakukan kerja harian?
15. Kepatuhan pengambilan ubat / Ya / Tidak Jika tidak patuh, nasihat ibu
suplemen dan tekankan mengenai
kepentingan kepatuhan
kepada pengambilan ubat /
suplemen tersebut
16. Soalan umum : Ya / Tidak Jururawat nasihat ibu apa
o Adakah mempunyai masalah yang perlu dilakukan dan jika
lain? – contohnya masalah perlu, berbincang dengan
kencing, buang air besar, corak doktor.
tidur terganggu
17. Adakah ibu tahu temujanji Ya / Tidak Jika tidak, maklumkan tarikh
seterusnya? temujanji.
Nasihat ibu untuk hubungi
klinik/hospital atau datang ke
klinik/hospital jika
mempunyai sebarang
masalah.
Nota:
1. Jika ibu diminta untuk ke hospital, jururawat / pegawai perubatan perlu beritahu
mengenai kes kepada pihak hospital/ PAC dan memaklumkan status ibu jika terdapat
sebarang perubahan (Rujuk Garis panduan Perkhidmatan Kecemasan dan Ambulans
di Fasiliti Kesihatan Primer).
2. Jururawat perlu melakukan tindak susul ke atas perancangan pengendalian/
penjagaan ibu.
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KONSULTASI VIRTUAL KEDUA PADA 32-34 MINGGU
membolehkan anggota kesihatan dapat melihat penampilan ibu secara keseluruhan.
2. Bertanya khabar ibu? Sihat / tidak Jika ibu tidak sihat, nasihat ibu
sihat untuk datang klinik
3. Setuju untuk teruskan konsultasi Ya / Tidak Jika ibu tidak bersetuju untuk
secara virtual? teruskan konsultasi secara
virtual, beri temujanji klinik
4. Demam Ya / Tidak Jika ya, nasihat ibu untuk
maklumkan kepada pegawai
perubatan
5. Masalah pernafasan Ya / Tidak Jika ya, nasihat ibu untuk
maklumkan kepada pegawai
perubatan
6. Sakit kepala/ pening / loya/ Ya / Tidak Jika ya, nasihat ibu untuk
muntah/ mata kabur datang ke klinik
7. Sakit dada / berdebar-debar Ya / Tidak Jika ya, minta ibu untuk ke
hospital dengan segera
8. Edema di kaki/ tangan/ muka Ya / Tidak Jika edema di kaki, tanya lebih
secara mendadak lanjut sehingga tahap mana.
Jika sehingga lutut, nasihat ibu
untuk datang ke klinik.
Jika edema di tangan atau
muka, nasihat ibu untuk datang
ke klinik
9. Sakit dada/ susah nafas/ betis Ya / Tidak Jika ya, minta ibu untuk ke
bengkak/ sakit / kemerahan hospital dengan segera
10. Pemakanan - selera makan Normal/ Jika kurang selera makan, beri
kurang selera nasihat mengenai pemakanan
atau nasihat untuk datang ke
klinik jika perlu
11. Pergerakan janin ● Ya, cukup Jika kurang pergerakan,
● Bilangan - 10 kali dalam tempoh bilangan nasihat ibu untuk datang
12 jam dan segera ke klinik
● Kekuatan kekuatan
gerakan
● Tidak cukup
bilangan
dan
kekuatan
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KONSULTASI VIRTUAL KEDUA PADA 32-34 MINGGU
gerakan
12. Contractions Ya / Tidak Jika ya, minta ibu untuk ke
13. Pecah air ketuban / leaking Ya / Tidak Jika ya, minta ibu untuk ke
14. Pendarahan per-vagina Ya / Tidak Jika ya, minta ibu untuk ke
15. Kesihatan mental Ya / Tidak Jika ya kepada salah satu,
o Sejak kebelakangan ini, nasihat ibu untuk datang ke
adakah anda sering diganggui klinik.
perasaan murung atau sedih?
o Sejak kebelakangan ini,
adakah anda sering kehilangan
minat atau keseronokan dalam
melakukan kerja harian?
16. Kepatuhan pengambilan ubat / Ya / Tidak Jika tidak patuh, nasihat ibu
suplemen dan tekankan mengenai
kepentingan kepatuhan kepada
pengambilan ubat / suplemen
tersebut
17. Adakah terdapat sebarang Ya / Tidak Jika ya, jururawat perlu ambil
perubahan kepada perancangan maklum dan ambil tindakan
kelahiran yang telah dibincangkan sewajarnya
pada temujanji sebelum ini?
18. Soalan umum : Ya / Tidak Jururawat nasihat ibu apa yang
o Adakah mempunyai masalah perlu dilakukan dan jika perlu,
lain? – contohnya masalah berbincang dengan doktor.
kencing, buang air besar, corak
tidur terganggu
19. Adakah ibu tahu temujanji Ya / Tidak Jika tidak, maklumkan tarikh
seterusnya ? temujanji.
Nasihat ibu untuk hubungi
klinik/hospital atau datang ke
klinik/hospital jika mempunyai
sebarang masalah.
Nota:
mengenai kes kepada pihak hospital/ PAC dan memaklumkan status ibu jika terdapat
sebarang perubahan (Rujuk Garis panduan Perkhidmatan Kecemasan dan Ambulans
di Fasiliti Kesihatan Primer).
penjagaan ibu.
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APPENDIX 2-3
SISTEM KOD WARNA DAN SENARAI SEMAK PENJAGAAN ANTENATAL
Sistem ini menggunakan empat kod warna. Penentuan kod warna ini adalah
berdasarkan kepada penilaian faktor risiko ibu semasa sesi konsultasi di klinik/
rumah. Penjagaan ibu adalah berdasarkan kepada kod warna seperti berikut:
KOD
TAHAP PENJAGAAN
WARNA
Rujukan segera ke Hospital dan pengendalian selanjutnya
Merah adalah bersama (shared care) Pakar O&G dan/atau Pakar
Perubatan Keluarga
Rujukan untuk pengendalian oleh Pakar O&G Hospital/Pakar

Perubatan Keluarga, dan penjagaan selanjutnya boleh
Kuning
dilakukan bersama (shared care) Pegawai Perubatan dan
Jururawat Kesihatan
Pengendalian di Klinik Kesihatan oleh Pegawai Perubatan

dan Kesihatan dan pengendalian selanjutnya boleh dilakukan
Hijau
bersama (shared care) Jururawat Kesihatan/Jururawat
Masyarakat di bawah pengawasan Pegawai Perubatan
Penjagaan oleh Jururawat Kesihatan/Jururawat Masyarakat di

Klinik Kesihatan dan Klinik Desa (sekiranya tiada terdapat
Putih
faktor risiko yang disenaraikan dalam kod merah, kuning dan
hijau, ibu diberi kod warna putih)
Sistem kod warna ini adalah panduan bagi menentukan peringkat penjagaan ibu
hamil berdasarkan faktor risiko yang dikenalpasti. Senarai semak risiko
menyenaraikan situasi/ faktor risiko yang KERAP ditemui dalam kalangan ibu
hamil. Sekiranya terdapat situasi/ faktor risiko lain yang tidak tersenarai, bincang
dengan Pegawai Perubatan/ Pakar Perubatan Keluarga bagi menentukan kod
warna.
Di dalam situasi yang tertentu khususnya di kawasan pedalaman, di mana tidak

terdapat Pegawai Perubatan, pengendalian boleh dilakukan oleh Jururawat
Kesihatan/ Jururawat Masyarakat dengan pengawasan dari Pegawai Perubatan
yang terdekat atau mudah dihubungi.
Pakar O&G/ Pakar Perubatan Keluarga boleh menurunkan kod warna mengikut
penilaian tahap risiko semasa ibu hamil. Kod warna terkini, dilekatkan dengan
menampakkan sebahagian kecil pelekat warna yang terdahulu.
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SENARAI SEMAK PENGENDALIAN IBU HAMIL
KOD MERAH - Rujukan segera ke Hospital dan pengendalian selanjutnya adalah bersama (shared
care) Pakar O&G dan/ atau Pakar Perubatan Keluarga.
FAKTOR RISIKO Tandakan ( √ ) dalam ruangan jika ada faktor
Post
TRIMESTER 1 2 3 -
date
KEKERAPAN PENILAIAN RISIKO ≤12 13-22 23-27 28-32 33-36 37-40 >40
TARIKH
Jangkamasa tidak datang haid
(POA/POG)
1 Eclampsia
2 Pre-eclampsia (tekanan darah
tinggi dengan urin protein) -
sistolik ≥160mmHg atau
diastolik ≥100mmHg tanpa/
dengan urin protein ≥2+
3 Hypertensive crisis - Tekanan
darah tinggi ≥160/110mmHg
4 Penyakit jantung semasa
mengandung, dengan tanda
dan gejala (sesak nafas,
berdebar-debar)
5 Sesak nafas dan/ atau kadar
pernafasan ≥22/min
6 Diabetes ketoasidosis (paras
glukos dextrostix >11mmol/L
dan urin ketone ≥ 2+)
7 Pendarahan antepartum
(termasuk keguguran)
8 Denyutan jantung janin yang
abnormal
• FHR <110/min selepas 22/52
• FHR >160/min selepas 32/52
9 Anemia dengan simptom pada
mana-mana gestasi atau Hb
≤7g/dL
10 Kontraksi rahim pramatang
11 Keluar air ketuban tanpa

kontraksi
12 Sawan
13 Demam dengan tanda-tanda
sepsis (lesu, dehidrasi,
tachycardia)
14 Kes disyaki denggi (demam
berserta sakit kepala, sakit
sendi, sakit perut, muntah, cirit
birit dan sebagainya)
15 Gejala deep vein thrombosis
(DVT) dan/ atau Pulmonary
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KOD MERAH - Rujukan segera ke Hospital dan pengendalian selanjutnya adalah bersama (shared
care) Pakar O&G dan/ atau Pakar Perubatan Keluarga.
Post
TRIMESTER 1 2 3 -
date
TARIKH
(POA/POG)
Embolism
16 Keinginan mencederakan/
bunuh diri
NAMA & JAWATAN
PEMERIKSA
KOD KUNING -Rujukan untuk pengendalian oleh Pakar O&G Hospital/ Pakar Perubatan Keluarga, dan
penjagaan selanjutnya boleh dilakukan bersama (shared care) Pegawai Perubatan dan Jururawat
Kesihatan
Post-
TRIMESTER 1 2 3
Date
TARIKH
(POA/POG)
1 Ibu HIV positif
2 Ibu Hepatitis B positif
3 Ibu Tuberkulosis/ Malaria/
Syphilis
4 Tekanan darah >140/90 -
<160/100mmHg tanpa/ dengan
urin protein
5 Tekanan darah tinggi
(140/90mmHg) dengan urin
protein
6 Ibu diabetes dengan rawatan
dan/ atau komplikasi
7 **Pergerakan janin kurang
semasa kandungan ≥32
minggu dengan faktor risiko
8 Kandungan melebihi 7 hari
dari EDD
9 Ibu dengan masalah perubatan
yang memerlukan rawatan
bersama di hospital
10 Ibu tunggal atau ibu remaja
(<20 tahun)
11 Ibu berumur ≥40 tahun
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KOD KUNING -Rujukan untuk pengendalian oleh Pakar O&G Hospital/ Pakar Perubatan Keluarga, dan
penjagaan selanjutnya boleh dilakukan bersama (shared care) Pegawai Perubatan dan Jururawat
Kesihatan
Post-
TRIMESTER 1 2 3
Date
TARIKH
(POA/POG)
12 Hemoglobin 7 - <9g/dL dan
asymptomatic
13 Placenta previa tanpa
pendarahan
14 Maternal pyrexia ≥38˚C atau
>3 hari
15 Penyakit jantung tanpa gejala
16 *Ketagihan dadah/ rokok/
alkohol
17 Skor risiko antenatal Venous
Thromboembolism (VTE) ≥3
18 Kandungan kembar
19 Masalah kesihatan mental
20 BMI ≥ 40 kg/m²
NAMA & JAWATAN PEMERIKSA
*Penilaian sekali sahaja.

**Rujukan segera ke hospital untuk penilaian
Nota: Ibu mesti diperiksa oleh Pegawai Perubatan pada hari yang sama tarikh booking
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KOD HIJAU - Pengendalian di Klinik Kesihatan oleh Pegawai Perubatandan Kesihatan dan
pengendalian selanjutnya boleh dilakukan bersama (sharedcare) Jururawat Kesihatan/ Jururawat
Masyarakat dibawah pengawasan Pegawai Perubatan
Post-
TRIMESTER 1 2 3
Date
KEKERAPAN PENILAIAN
≤12 13-22 23-27 28-32 33-36 37-40 >40
RISIKO
TARIKH
(POA/POG)
1 *Rh negatif
2 *Berat badan ibu sebelum
mengandung atau ketika
booking <45kg
3 Obes (≥30.0kg/m²)
4 Pertambahan berat badan
yang mendadak (>2 kg
dalam seminggu)
5 Berat badan statik atau
menurun (dalam tempoh
sebulan)
6 *Masalah perubatan semasa
7 *Masalah ginekologi yang
lalu (fibroid, cyst,
pembedahan)
8 *LNMP yang tidak pasti
9 *≥3 kali keguguran yang
berturutan
10 *Sejarah obstetrik yang lalu:
• Pembedahan cesarean
• PIH/ eclampsia/ diabetes
• Kematian perinatal
• Bayi dengan berat lahir
<2.5kg atau >4kg
rd
• Luka perineum 3 degree
th
dan 4 degree
• Retained placenta
• Postpartum haemorrhage
• Kelahiran instrumental
11 **Pergerakan janin kurang
semasa kandungan ≥32
minggu
12 Tekanan darah
(140/90mmHg) tanpa urin
protein
13 Hemoglobin 9 - <11g/dL
14 Glukosuria 2 kali
15 Air kencing mempunyai
protein ≥1+
16 Tinggi rahim (SFH) tidak
sejajar dengan jangkamasa
kandungan +/- 3cm
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KOD HIJAU - Pengendalian di Klinik Kesihatan oleh Pegawai Perubatandan Kesihatan dan
pengendalian selanjutnya boleh dilakukan bersama (sharedcare) Jururawat Kesihatan/ Jururawat
Masyarakat dibawah pengawasan Pegawai Perubatan
Post-
TRIMESTER 1 2 3
Date
KEKERAPAN PENILAIAN
≤12 13-22 23-27 28-32 33-36 37-40 >40
RISIKO
TARIKH
(POA/POG)
17 Breech/ oblique/ tranverse
dengan tiada tanda sakit
bersalin pada 36 minggu
kehamilan
18 Kepala bayi tinggi (head
not engaged) semasa
kandungan 37 minggu
bagi primigravida
19 Ibu GDM dengan kawalan
diet tanpa komplikasi
20 *Ibu berumur 36 - 39 tahun
21 *Primigravida/
pseudoprimigravida
22 *Grandmultipara ≥5
23 *Jarak kelahiran <2 tahun
atau melebihi 5 tahun
24 *Ketinggian ibu <145cm
NAMA & JAWATAN

PEMERIKSA
*Penilaian sekali sahaja.

**Rujukan segera ke hospital untuk penilaian
Nota: Ibu mesti diperiksa oleh Pegawai Perubatan dalam tempoh 2 minggu dari tarikh booking
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KOD PUTIH -Penjagaan oleh Jururawat Kesihatan/ Masyarakat di Klinik Kesihatan dan Klinik
Desa. Ibu akan hanya diberi kod berwarna putih setelah ia tidak mempunyai sebarang faktor risiko
yang tersenarai dalam kod merah/ kuning/ hijau DAN menepati kriteria dibawah.
TANDAKAN (√) DALAM RUANG

KRITERIA
BERKENAAN
TARIKH
Jangkamasa tidak datang haid (POA/POG)
1 Gravida 2 – 5 (tidak termasuk pseudoprimigravida)
2 Tiada masalah obstetrik lalu dan semasa
3 Tiada masalah perubatan yang lalu dan semasa
4 Ibu berumur 20 - 35 tahun
5 Ibu berkahwin dan mempunyai sokongan keluarga

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APPENDIX 2-4
OPTIONAL VACCINATIONS FOR PREGNANT WOMEN
For pregnant women:
i. Influenza (flu) vaccination
Pregnant mothers are susceptible to severe illness if they acquire influenza

(flu) infections, especially in the third trimester.
Hence, all pregnant mothers are recommended to be vaccinated for

influenza (flu) in pregnancy, unless they have been vaccinated in the last
12 months.
There are two vaccines which are available, the trivalent and quadrivalent
and both are safe in pregnancy. Although there is no teratogenicity
associated with the use of the vaccine, it’s generally recommended beyond
20 weeks of pregnancy.
Influenza vaccine is contraindicated if patient had severe egg protein

allergy.
ii. Tdap vaccination
Although all babies are vaccinated for pertussis (whooping cough),

newborn babies aged 2 months and below remain susceptible.
Current recommendations is to vaccinate all pregnant mothers between 28

weeks to 36 weeks of pregnancy for pertussis (Tdap vaccination) which
triggers maternal immunoglobulin transfer via the placenta and offers some
immunity. These babies still require routine pertussis vaccination at the age
of 2 months.
For pregnant women in specific population
i. Asplenia (post splenectomy patients)

These patients will benefit from additional vaccines, which are:
● Haemophilus influenza (Hib)
● Meningococcal (2 doses) – 5 yearly booster
● Pneumococcal (2 doses) – 5 yearly booster
These vaccines are not contraindicated in pregnancy
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ii. Travelling
Additional vaccines may be essential, depending on the area of travel.
Diseases which are endemic in certain countries should be checked with
the local authorities prior to making travel arrangements. These includes:
● Yellow fever
● Typhoid
● Meningococcal
iii. Hepatitis A vaccine
This may be beneficial for patients with liver diseases, sewage workers,
intravenous drug abusers and haemophilia patients.
For breastfeeding mothers
Life vaccines that are safe during breastfeeding and are not contraindicated,
including:
● MMR
● Rubella
● Varicella
● BCG
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APPENDIX 2-5
PROTOCOLS ON HOME VISIT
▪ Enter the house only after obtaining permission

▪ Respect the mother and her family
▪ Communicate well with the mother in order to develop rapport
▪ Describe clearly the objectives of the visit to the mother
▪ Avoid making any unfavourable comment or judgement about the patient and
family
▪ Educate the mother and family about personal hygiene and sanitation
▪ Refer to relevant units, if basic facilities are not available (e.g. environmental
sanitation unit, if there is no toilet)
▪ If the mother prefers home delivery and meets all the criteria, the health worker
should check the intended birth site and advise the mother regarding necessary
preparation.
▪ If the mother requires delivery at a hospital or Alternative Birthing Centre, she
should be advised with regards to the facility and its locality
▪ A history and physical examination can be done after you have developed a
rapport with the mother. First ascertain the progress of the pregnancy and the
well being of the mother. The mother’s antenatal book should be updated.
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CHAPTER 3
INTRAPARTUM CARE
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CHAPTER 3: PROCESSES AND PROCEDURES OF INTRAPARTUM CARE
This chapter is a guide for health personnel attending to mothers in labour. The content is
developed in such a manner to provide an appropriate assessment of safety and birth
outcomes at different levels of health care.
3.1 NORMAL LABOUR AND SAFE DELIVERY
3.1.1 Definition of labour
Labour is a process where there is a presence of regular uterine

contractions of increasing intensity and frequency that is associated with
progressive dilatation and effacement of the cervix and descent of the
presenting part. It may or may not be associated with rupture of membranes
and leaking liquor.
3.1.2 Care in Labour
Care of a mother in labour starts with an accurate and legible

documentation of the date and time of consultation and signature of the
attending doctor or nurse with the name printed.
One must ensure that the mother is managed in an appropriate centre.

(Refer to Appendix 3-1 – Intrapartum Care Flow Chart). In any situation
whereby referral to hospital is required, consider the practical points in
Appendix 3-2.
A checklist for risk assessment for ABC / LRBC (Appendix 3-3) and
hospital (Appendix 3-4) should be completed by the nurse upon admission
of the mother in labour.
● Psychological support
o As most labour is spontaneous and ends with a normal delivery,
the main role of the birth attendant (usually a midwife) is to
provide support for the mother and her companion and to monitor
the progress of labour.
o Companionship to the labouring mother should be encouraged.
However, all companions are encouraged to undergo an
orientation programme when it is available.
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o A detailed and systematic examination should be carried out on
the labouring mother upon admission. All findings must be
accurately documented. Vaginal examinations should be done
every four hours, unless contraindicated, or sooner if indicated.
3.1.3 Abdominal Examination
Abdominal examination which includes inspection and palpation should be

carried out and documented including:
● Inspection
o Foetal movements
o Scars
o Skin changes
▪ Linea nigra
▪ Striae gravidarum
▪ Striae albicans
● Palpation
o Fundal height
o Lie
o Presentation
▪ if cephalic, head engagement
o Liquor volume
3.1.4 Vaginal Assessment
This should be done systematically and with adequate explanation to the

mother. The findings should include the nature of:
● Vulva and vagina
● Cervical length (effacement)
● Dilatation of the cervical os
● Presenting part/position
● Station of presenting part
● Membranes (intact/ruptured)
● Blood vessel on the membrane
● Cord (felt/not felt)
● Placenta (felt/not felt)
● Liquor colour and volume drained
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3.1.5 Amniotomy
Amniotomy is a process where the amniotic membranes are ruptured either

spontaneously or artificially.
Amniotomy is performed in certain conditions:

i Poor progress of labour
ii Induction of labour
Artificial rupture of membranes can be performed when all these criteria are
fulfilled.
i. Fetal head is two-fifths palpable per abdomen with regular uterine
contractions
ii. 2 contractions in 10 minutes and the cervical dilatation is more than 4
cm.
Trained staff nurses may do artificial rupture of the membranes if it is still

intact in advanced labour.
3.1.6 Analgesia
Choice of appropriate and available analgesia should be offered to all

mothers in labour:
● Intramuscular narcotics with anti-emetic.
o Pethidine 1mg/kg, with Metoclopramide 10 mg or Promethazine
25mg. This can be repeated 4 to 6 hourly.
o Pethidine should not be given when cervical dilatation is more
than 6 cm.
o Nalbuphine (Nubain) 10 -20mg, repeat 4 to 6 hourly.
● Entonox – Inhalation agent with 50:50 oxygen and nitrous oxide (can be
ordered by nurses).
● Epidural analgesia – available in hospital with anaesthetic service
● Non-pharmacological method of pain relief include – companionship,
warm bath, music, massage, Transcutaneous Electrical Nerve
Stimulation (TENS) etc
● The above methods may not be applicable in birth centres at rural
clinics. Companionship, ambulation and family support is important to
alleviate pain in the absence of medication
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3.2 INTRAPARTUM MONITORING
Intrapartum risk assessment and monitoring of the mother and foetus are
essential because complications can arise without warning.
Methods for intrapartum monitoring based on level of care are as below

(Table 3.1)
Table 3.1: Methods and appropriate technology for intrapartum monitoring

by level of care
Hospital
Community Health Low risk Hospital
with
Level health clinic and birth without
specialist
clinic ABC centre specialist
Medical
Medical
Person Community Doctor / Doctor / team
team with
health nurse nurse nurse without
Equipment specialist
specialist
Early labour
monitoring Yes Yes Yes Yes Yes
record/LPC
Partograph Yes Yes Yes Yes Yes
Foetal
stethoscope/ Yes Yes Yes Yes Yes
daptone
Cardiotocography No No Yes Yes Yes
Ultrasound No Optional Yes Yes Yes
3.2.1 When to document labour observation?
Nurses should commence documentation of contractions and foetal heart

rate upon admission by using Labour Progress Chart (LPC) / early labour
monitoring record
3.2.2 What is a Partograph?
A partograph is a diagrammatic representation of the progress of labour. It

is where all observations of the mother and her feotus are charted in a
manner which facilitates monitoring of the progress of labour by the health
care worker (Figure 3.2)
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Figure 3.2: Partograph
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The main components that need to be monitored and plotted on the
partograph are:
o Foetal condition
o The progress of labour
o Maternal condition
All mothers in labour should be monitored using partograph adapted by

Jawatankuasa Pengurusan dan Perkembangan Obstetrik & Ginekologi
(JKPPOG)
(The modified WHO partograph commences at 4 cm cervical dilatation
and dispenses with the recording of the latent phase of labour)
When to start a partograph?
When a patient is planned for delivery, with cervical dilatation of ≥ 4 cm or

contraction > 2 in 10 minute.
The information charted on a partograph includes:
i. Mother information
o Name
o Gravida
o Para
o registration number
o Diagnosis/problem list
o Date and time of admission
o Time of ruptured membrane
ii. Foetal heart rate

This is recorded every half an hour
iii. Membranes and amniotic fluid (Liquor)

The state of the membranes and amniotic fluid (liquor) should be
documented as follows:
I : Membranes intact
C : Membranes ruptured, clear liquor
M : Meconium-stained liquor
B : Blood-stained liquor
iv. Moulding
Moulding of the foetal skull is recorded as follows:
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o No moulding – parietal bones (sagittal suture) are not
apposed.
o +1 moulding – parietal bones are touching but not
overlapping.
o +2 moulding – parietal bones are overlapped but easily
reduced.
o +3 moulding – parietal bones have overlapped and are
irreducible.
v. Cervical dilatation
This is marked with a cross (X), and begin to plot the partograph
when cervical dilatation is 4 cm or more
vi. Descent of foetal head

This is assessed as fifths of the head palpable per abdomen, and
marked with an (O)
vii. Alert line

The Alert Line starts at 4 cm cervical dilatation, and increases to the
point of expected full dilatation at a rate of 1 cm per hour. If the
progress of labour is normal, this progress line (cervicogram) on the
partograph will correspond to the Alert Line or lie to the left of it
viii. Action line

The Action Line is parallel and 4 hours to the right of the Alert Line
ix. Hours
This charts the time (in hours) elapsed since the onset of the active
phase of labour
x. Time
The actual time of the clock is recorded
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xi. Contractions
Uterine contractions are assessed every half an hour and charted
as the number of contractions in 10 minutes and duration of
contraction in seconds. The duration of contraction reflects the
strength of contraction (Figure 3.1).
Figure 3.1: Duration of Contraction
Duration of contraction
Less than 20 seconds (weak)

20 to 40 seconds (moderate)
More than 40 seconds (strong)
xii. Oxytocin
The amount of oxytocin added per volume of intravenous fluids and
the rate of infusion must be recorded every half an hour
xiii. Additional drugs

Any additional drugs given such as Pethidine and Metoclopramide
must be recorded at the time of administration
xiv. Maternal pulse rate

This is documented every half an hour with a dot ( • )
xv. Maternal blood pressure

This is recorded every 4 hours (unless more frequently indicated) and
marked with arrows ( )
xvi. Maternal temperature

This is recorded every 4 hours
xvii. Urine protein, ketone and volume

Each time the mother passes urine or is catheterized, measure her
urine volume and record. Test the urine for protein and ketone and
record the result
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3.2.3 Foetal monitoring methods in labour
a. Intermittent auscultation with a pinard fetoscope/ Doppler Foetal

Monitor detector (Daptone)
Auscultation must be done after a contraction. This should be practised

every 15 – 30 minutes for mothers who are in labour. In the majority of ABC,
this is the only method to detect and monitor foetal heart.
b. Electronic Foetal Monitoring with CTG
CTG should be done on every woman in labour for 20 minutes on

admission. If the CTG is suspicious or abnormal, it should be continued and
immediate consultation should be done with the specialist.
CTG can be faxed or shared via smartphone to the covering hospital for
interpretation and advise if the facilities are available.
● Admission CTG
With a suspicious or abnormal admission CTG, there are higher
rates of meconium staining of liquor, intrapartum CTG decelerations
and other subsequent ominous patterns. A normal admission CTG is
reassuring.
● Indications for close monitoring of intrapartum CTG

Mothers requiring close monitoring of intrapartum CTG should ideally
be managed in the hospital with a specialist. Some of the indications
for are as follows:
o Maternal medical conditions :
▪ Gestational diabetes mellitus
▪ Hypertensive disorders in pregnancy
o Obstetric conditions:
▪ Multiple pregnancies
▪ Previous caesarean section
▪ Intrauterine growth restriction
▪ Prelabour rupture of membranes
▪ Preterm labour
▪ Meconium-stained amniotic fluid
▪ Third trimester bleeding
▪ Oxytocin induction/augmentation of labour
▪ Post-date
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Intermittent CTG monitoring every 2 to 4 hourly should be reviewed
by a medical officer. A specialist should be consulted if there is any
doubt.
Table 3.2: Interpretation of Cardiotocography (CTG)
Normal Suspicious Pathological

Baseline 110-160 bpm Lacking at least one < 100 bpm
Variability 5-25 bpm characteristic of Reduced variability for > 50
normality, but with no min,
pathological features increased variability for > 30
min,
or sinusoidal pattern for > 30
min
Decelerations No repetitive Repetitive* late or prolonged

decelerations decelerations during > 30 min,
* or 20 min if reduced variability,
or one prolonged deceleration
with > 5 min
Interpretation Feotus with Feotus with a low Feotus with a high probability of
no hypoxia/ probability of having having hypoxia/ acidosis
acidosis hypoxia/ acidosis
Clinical No Action to correct Immediate action to correct

Management intervention reversible causes if reversible causes, additional
necessary to identified, closed methods to evaluate foetal
improve monitoring or oxygenation, or if this is not
foetal additional methods to possible expedite delivery. In
oxygenation evaluate foetal acute situations (cord prolapse,
state oxygenation uterine rupture or placental
abruption) immediate delivery
should be accomplished.
* Decelerations are repetitive if they occur at >50% of uterine contractions
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Intrapartum indications for ultrasonography
The role of ultrasonography in the intrapartum period is limited to the

following:
● Antepartum haemorrhage – for placental localization and
retroplacental clots
● To ascertain lie/ presentation for multiple pregnancies, maternal
obesity, malpresentation, and polyhydramnios
● To confirm intrauterine death
● Presence of pelvic masses obstructing labour, when indicated
3.3 NORMAL STAGES OF DELIVERY
3.3.1 Stage 1
It starts from the onset of labour to full dilatation (commonly lasts 8-24 hours
in first labour including the latent phase and 3-12 hours in subsequent
labour). The first stage is further divided into two phases:
● Latent phase (0 – 4 cm cervical dilatation)
● Active phase (≥ 4 cm of cervical dilatation)
Mother presenting in latent phase should be managed by using

Labour Progress Chart (LPC) [Appendix 3-5]:
● Monitor temperature, pulse, blood pressure 4 hourly and urinalysis on

admission and when mother passes urine
● Monitor nature of contractions (length, strength and frequency) 4
hourly
● Abdominal examination finding – fundal height, lie, presentation and
engagement on admission
● Vaginal examination finding – vulva, vagina, cervical effacement and
dilation, station, position, membrane (if absent nature of the liquor)
and to rule out cord presentation.
● Pain assessment and offer pain relief if possible
● Auscultate/ listen for FHR for a minimum of 1 minute immediately after
a contraction and every four hourly
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● Encourage frequent drinks and eating light meals to maintain
hydration and energy
● Encourage mobilisation and mother should adopt whatever position
they find most comfortable
● 2 - 6 hourly passing of urine
● If the labour progresses, transfer patient to labour room
Mother presenting in active phase of labour:
● Partograph should be started.

● Drinking water and eating light meals may be given if the labour is
progressing normally in low risk mothers. This might be
contraindicated if they have received opioids or they develop risk
factors that make a general anaesthetic more likely.
● Mother may become more comfortable by changing position in bed or
by ambulation.
3.3.2 Stage 2
It starts from full dilatation of the cervix to delivery of the baby (commonly
ends within 1 hour). The start of the second stage is not clear but a vaginal
examination is indicated when the mother has a sensation of bearing down.
● During the second stage mother should be informed that they should
be guided by their own urge to push.
● Strategies to assist birth with effective pushing;
o Change of mother’s position
o Empty her bladder
o Support and encouragement
Intrapartum intervention to reduce perineal trauma include:
a. Either the ‘hands-on’ (guarding the perineum and flexing the baby’s
head) or the ‘hands poised’ (with hands off the perineum and baby’s
head but in readiness) technique can be used to facilitate
spontaneous birth.
b. Episiotomy may be considered at this time if indicated. Episiotomy is
an incision performed medio-laterally in the perineum during
crowning of the presenting part in order to prevent extensive perineal
tearing. It should be performed selectively and not routinely.
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● Episiotomy should be considered only in the case of
complicated vaginal deliveries (breech, shoulder dystocia,
forceps and vacuum) and for previous third or fourth degree
tears.
● Episiotomy should not be performed too early as excessive
bleeding will result.
● Local anaesthesia should be provided to the mother before
episiotomy repair.
● A rectal examination should be done on completion of
episiotomy repair.
● If a third or fourth degree tear is suspected, the mother
should be referred to a hospital with a specialist.
Haemostasis should be secured before referral. This may be
either by:
i. Suturing the bleeder
ii. Pack the wound to ensure pressure
Antibiotic therapy should be initiated at the earliest
opportunity
● The episiotomy rate should ideally not exceed 30% in any
centre (according to the Director General of Health’s circular
1/2008).
3.3.3 Stage 3
It starts from delivery of the baby to delivery of the placenta (usually lasts 15
– 30 minutes). Active management of the third stage helps to prevent
postpartum haemorrhage. Active management of the third stage of labour
includes:
● Immediate oxytocin
● Controlled cord traction, and
● Uterine massage
a) Oxytocin
● Within 1 minute of delivery of the baby, give IM oxytocin 10 units or IM
Syntometrine (5 units oxytocin plus 0.5mg ergometrine) or IM/IV
Carbetocin 100 mcg (oxytocin analogue) after palpating the abdomen
to rule out the presence of an additional feotus.
● Oxytocin/oxytocin analogue are drugs of choice because they are
effective 2 to 3 minutes after injection, has minimal side effects and
can be used in all mothers.
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● Do not give syntometrine to mother with hypertension and heart
disease because it increases the risk of convulsions and
cerebrovascular accidents.
b) Controlled cord traction

● Clamp the cord close to the perineum using Spencer Wells artery
forceps. Hold the clamped cord at the end of forceps with one hand.
● Place the other hand just above the woman’s pubic bone and stabilise
the uterus by applying counter traction during controlled cord traction.
This helps prevent inversion of the uterus.
● Wait for signs of placental separation i.e.
o Lengthening of the cord
o Gushing of blood
o Uterus raised and hard
● Gently pull downward the cord to deliver the placenta.
● Continue to apply counter traction to the uterus with the other hand.
● If the placenta does not descend during 30–40 seconds of controlled
cord traction (i.e. there are no signs of placental separation), do not
continue to pull on the cord.
● After delivery of the placenta, hold the placenta in two hands and
gently turn it until the membranes are twisted.
● Slowly pull to complete the delivery of placenta.
● Examine the placenta to be sure it is complete. If suspected to be
incomplete, refer to the hospital.
● If the cord is pulled off (cord snapped), manual removal of the
placenta may be necessary.
● If uterine inversion occurs, replace immediately (Refer to Chapter 9 –
Obstetric Emergencies).
c) Uterine Massage
● Immediately massage the fundus of the uterus through the woman’s
abdomen until the uterus is contracted.
● If the uterus is not contracted and ongoing bleeding, actions in Table
3.3 can be followed.
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Table 3.3: Actions during uterine atony and ongoing bleeding
Health Clinics / ABC /

District Hospital
Actions without Specialist / Hospital With Specialist
Low-risk Birthing
Centre
1. Initiate oxytocic
drugs and Yes Yes
bleeding stops
2. Uterine massage
every 15 minutes
for the first 1 hour Yes Yes
and bleeding
stops
3. Other uterotonic
drugs and Refer to hospital with
bleeding still specialist
continues and ● Uterine
*If uterine tamponade Uterine
uterus remain not tamponade
technique is available, conservation
contracted ● B-Lynch suture
(e.g.; Bakri balloon), to
insert before transfer
patient ● Hysterectomy
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3.4 LEVEL OF CARE FOR INTRAPARTUM MANAGEMENT
Apart from hospitals, other public health facilities which provide intrapartum services are
Alternative Birthing Centre (ABC) and Low-Risk Birthing Centre (LRBC). The
descriptions are as below:-
ALTERNATIVE LOW-RISK
HOME DELIVERY BIRTHING BIRTHING CENTRE
CENTRE (ABC) (LRBC)
DEFINITION Mothers delivering at A centre run by A centre run by
home, conducted by trained staff nurses trained staff nurses
trained medical where mothers can where mothers can
personnel deliver in a safe deliver under
medical setting supervision of
medical officers /
specialists (if
required) in a safe
medical setting.
CRITERIA White-coded White-coded White-code

Green-coded (after
assessment by
specialist)
FACILITY Delivery bag (List of Following current Following current

items in Appendix specification for ABC specification for
3-6) centre LRBC
Current Reference: Garis Refer Appendix 3-7

recommendation panduan Pusat and Appendix 3.8
does not favour Bersalin Alternatif di
usage of ravin Klinik Kesihatan,
enema before KKM, 2013
delivery process
To bring along the

eclampsia kit if
patient has
symptoms of
impending pre-
eclampsia
Reference: Manual
Perkhidmatan
Kesihatan Ibu dan
Anak Bagi Anggota
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ALTERNATIVE LOW-RISK
HOME DELIVERY BIRTHING BIRTHING CENTRE
CENTRE (ABC) (LRBC)
Kejururawatan di
Perkhidmatan
Kesihatan Awam,
KKM, 2016
MONITORING Minimum 1 hour Mothers will be Mothers will be

observation by admitted and admitted and
attending medical observed in the ABC observed in the
personnel after for 6 hours before postnatal ward for 6
delivery. Monitoring being discharged hours before
of BP, PR and uterus home. Vital signs allowing discharged
contraction to be should be monitored home. Vital signs
done every 15 every 15 minutes for should be
minutes. the first 1 hour. Then monitored every 15
2 – 4 hourly minutes for the first
depending on 1 hour. Then 2 – 4
mother’s condition hourly depending
on the mother’s
condition.
Discharge only after
assessment by
medical officer
References:
● FIGO Classification of Intrapartum Cardiotocography, 2015
● NICE Guideline Intrapartum care for healthy women and babies, 2017
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APPENDIX 3-1
INTRAPARTUM CARE FLOWCHART (ABC / LRBC)
Mother in
Labour
CHECKLIST
Appendix 3-3 for ABC
Appendix 3-8 for LRBC
Yes No
Risk
Factors?
Refer to hospital with specialist ABC or

LRBC
Abnormal Intrapartum Checklist

(Appendix 3-4)
+ Partograph / Foetal
Monitoring
Normal
Allow delivery at ABC

or LRBC
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APPENDIX 3-2
PRACTICAL POINTS DURING TRANSFER OF MOTHERS
Practical points to be noted during transfer of mothers:

Pre-transfer:
● Meticulous planning and coordination to identify personnel and mode of
transport
● Resuscitate and stabilise the mother
● Coordinate safe embarkation on to vehicle
During transfer:
● Maintain stability of mother
● Constant monitoring and documentation of vital signs, treatment and incidents
during transfer
● If acute problems arise, stop vehicle to carry out resuscitative measures or
divert to nearest health facility
On arrival:
● Hand over to appropriate person
● Ensure safe disembarkation
Steps to be taken prior to transfer to hospital in certain conditions :
RISK FACTORS PLAN OF ACTION

Leaking liquor or i. Check foetal heart rate and give mother oxygen if there is sign
rupture of of foetal distress
membrane > 6 ii. Rule out cord prolapse
hours
Cord Prolapse i. Elevate the perineum by putting two pillows under the
mother’s buttock
ii. Give oxygen to the mother
iii. If the cord is protruding through the vagina, cover it with a pad
or gauze which has been soaked with warm water and push it
back into the vagina if possible.
iv. Distend bladder with 500-750 mls of saline/water
v. If cord is within the vagina, push the presenting part away
from the cord
Gestation less IM Dexamethasone 12 mg stat. Can be given by trained Staff
than 36 weeks Nurse according to Garis panduan Pemberian Suntikan
Kortikosteroid (IM Dexamethasone) bagi Ibu Mengandung Berisiko
Kelahiran Pramatang di Klinik Kesihatan 2013
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APPENDIX 3-3
SENARAI SEMAK BAGI KELAYAKAN IBU UNTUK BERSALIN DI ABC/RUMAH
KRITERIA UNTUK BERSALIN DI ABC/ RUMAH
IBU DIBENARKAN BERSALIN DI PUSAT BERSALIN ALTERNATIF (ABC) /

RUMAH SEKIRANYA MEMENUHI SYARAT BERIKUT :-
TANDAKAN (√)
KRITERIA DALAM RUANG
BERKENAAN
TARIKH
Jangkamasa tidak datang haid (POA/POG)
1 Gravida 2 – 5 (tidak termasuk

pseudoprimigravida)
2 Tiada masalah obstetrik lalu dan semasa
3 Tiada masalah perubatan yang lalu dan semasa
4 Ibu berumur 20 - 35 tahun
5 Ibu berkahwin dan mempunyai sokongan
keluarga
6 POA 37- 40 minggu
7 Anggaran berat bayi 2.5-3.5kg
8 Persekitaran rumah ibu sesuai (jika ingin
bersalin di rumah)
*Ibu dibenarkan bersalin di ABC/ rumah sekiranya semua kriteria di atas dipenuhi.
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APPENDIX 3-4
SENARAI SEMAK JAGAAN INTRAPARTUM DI ABC/ RUMAH
Nota: Jika terdapat faktor risiko, ibu perlu dirujuk kepada Pegawai Perubatan di klinik/
hospital berhampiran.
Tarikh : ……………………….………….
Nama : ……………………………...……
No.K/P : ……………………………………
Tandakan (√ )
No. Faktor risiko pada ruang
berkenaan
PERINGKAT PERTAMA KELAHIRAN
1. Demam ≥ 37.5°C
2. Proteinuria (1+ atau lebih)
3. Tekanan darah tinggi ( ≥140/90 mmHg)
4. Kedudukan janin yang abnormal (menyongsang, menyerong,
melintang)
5. Masalah perubatan semasa seperti sakit jantung, asma, diabetes,
hipertensi, sawan, anemia, TB, HIV positif, Hepatitis B positif dan
syphilis.
6. Kandungan lebih 40 minggu
7. Kandungan kurang 37 minggu
8. Keluar air ketuban lebih 6 jam dan masih dalam peringkat latent
phase
9. Air ketuban mengandungi najis janin (meconium)
10. Kadar denyutan jantung bayi <110/min atau>160/min
11. Sakit bersalin >12 jam untuk primigravida, >8 jam untuk
multigravida
12. Dilatasi serviks yang statik selama 4 jam
13. Tali pusat terkeluar
14. Pendarahan (intrapartum haemorrhage)
15. Kontraksi rahim tidak tetap (irregular/incoordinated) > 4jam
PERINGKAT KEDUA KELAHIRAN
1. Peringkat kedua >1 jam untuk primigravida, >30 minit untuk
multigravida
2. Ibu mengalami pendarahan, sesak nafas, denyutan nadi >100/min
atau cyanosis
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Tandakan (√ )
No. Faktor risiko pada ruang
berkenaan
3. Kadar denyutan jantung bayi <110/min atau
>160/min
4. Shoulder dystocia
PERINGKAT KETIGA KELAHIRAN

1. Retained placenta
2. Cebisan uri / placenta / membrane (POC) tertinggal di dalam
rahim
3. Luka perineum (tear) tahap kedua atau ketiga
4. Pendarahan postpartum (PPH) ≥ 500ml, contohnya disebabkan
oleh uterine atony, uterine inversion atau masalah pembekuan
darah (clotting defect).
5. Ibu mengalami sesak nafas, denyutan nadi >100/min atau
cyanosis
Nama anggota : …………………………………………………………………...........…

Jawatan :…………………………………………………………………………………….
Klinik Kesihatan/ Klinik Desa : ……………………………………………………………
Nota: Sila kepilkan Senarai Semak Jagaan Intrapartum ini jika ibu dirujuk ke
klinik/hospital
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APPENDIX 3-5
MINISTRY OF HEALTH MALAYSIA

LABOUR PROGRESS CHART
NAME: RN:
WARD: BED NO:
HEIGHT: WEIGHT:
Foetal Uterine Contraction:

Blood Pulse Respiratory
Date Time Heart SpO2 strength/ frequency/ Pad Chart Remarks Name of
Pressure Rate Rate
Rate duration Staff
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APPENDIX 3-6
SENARAI KEPERLUAN PERALATAN UNTUK MENYAMBUT KELAHIRAN
A Delivery Set Kuantiti
1. Kidney dish (10 inci) 2

2. Kidney dish (6 inci) 1
3. Gallipot 2-3
4. Artery forceps (Spencer Wells forcep) 2
5. Dissecting forceps 1
6. Cord scissor 1
B Losen dan Krim Kuantiti
1. Hibitane in spirit 1:200 (Chlorhexidine 0.5% Alcohol) untuk cord

1 botol
dressing
2. Hibitane in spirit 1:2000 1 botol
3. Flavin 0.1% (Acriflavine lotion 0.1%) untuk ubat luka 1 botol
4. Alcohol 70% 1 botol
5. Swab hibitane (Swab soaked in hibitane in spirit) untuk membersihkan
1 botol
peralatan
C VE Set Kuantiti
1. Bowl 1
2. Gallipot 2
D Peralatan Sterile Loose Pack Kuantiti
1. Dressing towel 1
2. Stitch scissor 1
3. Needle holder 1
4. Artery forcep 2
5. Jug 1
6. Swab
7. Pad
8. Gauze
9. Paper hand towel
10. Linen paper
11. Syringe 2ml
12. Needle
13. Cord clamp
14. Cat gut
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E Peralatan Mengambil Pemeriksaan Vital Kuantiti
1. BP Set 1
2. Stethoscope 1
3. Daptone / Fetoscope 1
4. Penimbang bayi 1
5. Pita pengukur 1
6. Clinical thermometer 1
7. Disposable lancet dan glass slide – untuk kes yang mengalami demam*
F Set Infusi Intravena
1. IV Fluid
2. IV Drip set
3. Branula size 16G, 18G, 20G
4. Plaster
5. Gunting
G Ubatan
1. Syntometrine (4 ampoules)
2. Syntocinon (2 ampoules)
3. Carboprost
4. Tranexamic acid
5. Vitamin K
6. Hepatitis B
7. Tablet Paracetamol
H Lain-lain Peralatan
1. Mucus extractor/sucker
2. Kertas turas saringan G6PD
3. Tiub botol untuk saringan congenital hypothyroidism
4. Beg plastik kecil
5. Glove
6. Apron
7. Mask
8. Paddle pad soap/hand rub dan paper hand towel
I Kad dan Borang-borang
1. Buku Rekod Kesihatan Bayi dan Kanak-kanak 0-6 tahun

2. Borang Partogram
3. Senarai Semak Intrapartum
4. Stiker Kod Warna
5. Borang Makmal
6. Borang Rujukan Intrapartum (IP-1)
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APPENDIX 3-7
LOW-RISK BIRTHING CENTRE (LRBC)
Low-risk birthing centre is a mother friendly facility. The objective of LRBC is to conduct
low-risk deliveries. The choice of low risk deliveries will include patients tagged as white
and green. For green-coded mothers, O&G specialists need to assess and decide the
suitability for delivery in LRBC.
Objective of Low-risk Birth Centre (LRBC)

a. To provide an alternative high-quality care and safe delivery to low risk mothers.
b. To enable mothers to experience positive and satisfactory birth with minimal medical
and surgical intervention
c. To reduce congestion in the main labour room and obstetric ward, therefore reducing
overcrowding and optimising patient care.
Services Provided
1. Observation wards (antenatal observation and postnatal observation)
- Admission
- History taking and examination
- Maternal vital sign monitoring/ postpartum care
- Foetal monitoring/ care of newborn
2. Delivery bay
- Admission CTG
- Partogram
- Active management of labour
- Mother Friendly Care Policy during active labour will be practiced in LRBC,
promoting breastfeeding
- Vaccination
3. CTG assessment
- Admission CTG
- When indicated during labour
4. Ultrasound assessment
- If indicated
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APPENDIX 3-8
Kriteria Pemilihan untuk bersalin di Pusat Bersalin Berisiko Rendah
BIL KRITERIA KEMASUKAN

1. Warganegara Malaysia
2. Berumur 18 – 40 tahun
3. Perkahwinan yang sah
4. Ketinggian ibu melebihi 145 cm
5. BMI < 40 kg/m2 pada usia kandungan 36 minggu
6. Gravida 2 hingga 6 atau jumlah kelahiran tidak melebihi 5 kali
7. Telah dipastikan tarikh jangka bersalin
8. Kehamilan tunggal (singleton)
9. Usia kandungan ≥37 minggu dan ≤41 minggu
10. Kepala bayi berkedudukan di bawah (cephalic)
11. Anggaran berat bayi 2.2- 3.5 kg pada usia kandungan 36 minggu
12. Bersetuju mematuhi Program Imunisasi Kebangsaan
13. TIADA sejarah lampau seperti berikut:
i. Lahir mati atau kecederaan bayi ketika bersalin
ii. Anak dengan masalah perkembangan otak/ mengidap penyakit metabolik
iii. Kelahiran secara pembedahan atau pembedahan pada rahim
iv. Uri melekat selepas kelahiran bayi
v. Tumpah darah selepas kelahiran bayi (postpartum haemorrhage)
vi. Koyakan perineum tahap 3 atau 4 selepas kelahiran bayi
vii. Kelahiran instrumental
14. TIADA masalah kandungan semasa seperti berikut:
i. Tumpah darah sebelum kelahiran (antepartum haemorrhage)
ii. Kekurangan atau terlebih air ketuban (oligohydramnios/ polyhydramnios)
iii. Darah tinggi ketika mengandung
iv. Kencing manis ketika mengandung
v. Masalah perubatan, kardiovaskular
vi. Pecah air ketuban melebihi 12 jam
vii. Jangkitan GBS
viii. Ibu berstatus Rhesus negatif
ix. Hepatitis/ HIV/ penyakit kelamin
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BIL KRITERIA KEMASUKAN
x. Pengambilan dadah/ merokok
xi. Anaemia (paras haemoglobin <9g/dL pada usia kandungan 36 minggu)
xii. Masalah psikiatri
xiii. Kecacatan fizikal yang mengganggu proses kelahiran
xiv. Ketidaksuburan > 5 tahun (involuntary)
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Puerperium 2018.
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18. Royal College of Obstetricians and Gynaecologist. Green Top Guideline No 56.
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Umbilical Cord Prolapse, November 2014
22. Manual Perkhidmatan Kesihatan Ibu & Anak bagi Anggota Kejururawatan di
Perkhidmatan Kesihatan Awam MOH/K/ASA/65.15 (HB) 2015
23. Revised FIGO Guidelines on Intrapartum Foetal Monitoring 2015
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CHAPTER 4
POSTNATAL CARE
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CHAPTER 4: PROCESSES AND PROCEDURES OF POSTNATAL CARE
4.1 INTRODUCTION
● A significant number of maternal deaths as well as morbidity occur

during the postpartum period. About two-thirds of maternal deaths occur
during this phase.
● Postpartum complications can be grouped into acute life threatening,
mid- and long-term chronic conditions. Increased awareness of warning
signs and appropriate intervention is needed at all levels.
● Skilled care and early identification of problems can reduce the
incidence of death and disability.
● Postpartum period (puerperium) is from the end of labour until the
reproductive organs return to their original non-pregnant condition. It
lasts for 42 days. The postpartum period is a critical transitional time for
a woman, her newborn and her family, on a physiological, emotional and
social level. Inadequate postnatal care can reduce opportunities for early
detection and management of problems and disease.
● The aims of care in the postpartum period are:
1. Support of the mother and her family in the transition period for
the new family member and respond to their needs
2. Prevention, early diagnosis and treatment of complications of
mother and neonate, including the prevention of vertical
transmission of diseases from mother to neonate
3. Referral of mother and neonate for specialist care when
necessary
4. Counselling on baby care and immunisation of the infant
5. Support for breastfeeding
6. Counselling on maternal nutrition and exercise
7. Counselling and service provision for contraception and the
resumption of sexual activity
8. Provision of emotional and psychological support in particularly in
special circumstances
4.2 POSTNATAL CONTACTS
● Postnatal care starts immediately after the mother gives birth. Optimal
postnatal care should be carried out soon after delivery both in hospital
and health clinic. For continuous medical care, all deliveries must be
notified to the respective health clinic. The staff in the health clinic must
take action within 24 hours of reception of notification.
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● According to WHO Recommendations on Antenatal Care for a Positive
Pregnancy Experience (2016), ‘contact’ implies an active encounter
between the women and the healthcare provider that is not implicit with
the word ‘visit’. ‘Contact’ can be adapted to local contexts either through
home visits, clinic visits, phone calls or mobile phone-based contacts. All
mothers should be informed about the importance of postnatal contacts,
service and schedule from the antenatal period.
● In the event of a baby being admitted in the hospital, but the mother has
been discharged and continues to accompany the baby, postnatal care
should be provided in accordance with KKM policy as outlined in
Garispanduan Perawatan Ibu Postnatal di Hospital 2015. The provision
of this care must be documented in the Buku Rekod Kesihatan Ibu.
● In the event of a mother being admitted in the hospital but the baby has
been discharged, and continues to stay with the mother, neonatal care
should be provided. This care should be provided by the nursing staff
either from the obstetrics or paediatric department in the hospital. The
provision of this care must be documented in the Buku Rekod Kesihatan
Bayi dan Kanak-kanak.
4.3 FREQUENCY OF CONTACTS
● The schedule of postnatal home visits is determined by the condition of

mother and baby upon discharge and assessment of their health status
throughout postnatal contacts. For mothers with uneventful pregnancy
and delivery, it is recommended that home visits should be at least 5
times (Refer Table 4.1). As for high risk mothers and babies or any
abnormalities detected, the number of contacts should be more frequent.
Please refer to the postnatal checklist and flowchart. Any abnormality
observed during these visits may require more visits with appropriate
referral to be made.
● Postnatal mothers who give birth at the alternative birthing centre (ABC)
or at home and attended by trained health personnel must have
postnatal care via home visit within 24 hours after delivery (Day 1 of
baby’s life).
● WHO recommends at least four (4) postnatal contacts as below (WHO
Recommendations on Postnatal care of the Mother and Newborn 2013):
o If birth is in a health facility, mothers and newborns should
receive postnatal care in the facility for at least 24 hours after
birth.
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o If birth is at home, the first postnatal contact should be as
early as possible within 24 hours of birth.
o At least three additional postnatal contacts are recommended
for all mothers and newborns, on day 3 (48–72 hours),
between days 7–14 after birth, and six weeks after birth.
● For Malaysia, the minimum postnatal home visits are 5 times with 1 clinic
visit. The additional postnatal home visits on day 5 and between day 14-
16 are based on consensus from the expert committee.
● Postnatal contacts through virtual consultation can also be offered to
low-risk mothers and newborns if virtual requirement is fulfilled as
outlined in Garis panduan Peluasan Pelaksanaan Klinik Virtual (Virtual
Clinic), Bahagian Pembangunan Kesihatan Keluarga 2020.
Table 4.1: Schedule for minimum postnatal contacts
Days Contacts
(according to age of (home visit / virtual consultation /
baby) clinic visit)
Day 1 Home visit for mother who had safe
delivery at home
Day 2 Home visit
Day 3 Home visit
Day 5 Home visit
*assessment for suitability of virtual
consultation
Day 8 to 10 Home visit or Virtual (1 visit)
Day 14 to 16 Home visit (1 visit)
Day 30 Clinic visit
Note:
1. Weigh baby on day 5 and day 14-16. For babies with jaundice weigh
babies according to Clinical Practice Guidelines Management of
Neonatal Jaundice, MOH, 2014.
2. Consent for virtual consultation will be taken during postnatal contacts
on day 5 by nurses during home visit.
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High-risk postnatal mother and baby
● The postnatal contacts for high-risk mother and/or baby should be

carried out more frequently. The urgency, frequency, mode and number
of contacts are determined by the condition of mother and baby upon
discharge and assessment of their health status throughout postnatal
contacts.
● Upon discharge of a high-risk postnatal mother and/or baby, the medical
personnel / physician must identify and notify the health clinic
immediately by phone / email / fax or existing online system. This is to
ensure timely postnatal home visit is done. A documented management
plan should be attached to the mother’s copy of Buku Rekod Kesihatan
Ibu.
● Below are the criteria for high-risk postnatal mother and baby (Table
4.2). Mothers and babies under this category are not suitable for virtual
consultation.
Table 4.2: Postnatal mother and baby in the high risk criteria
High risk postnatal mother High risk baby

1. Maternal collapse 1. History of prolonged labour
2. Moderate/ severe PIH / pre-eclampsia/ 2. Baby to an obese mother
eclampsia / HELLP Syndrome 3. Small for gestation (SGA)
3. Diabetes on treatment 4. Large for gestation (LGA)
4. Maternal obesity, BMI ≥ 40 kg/m2 5. Baby to GDM mother
5. Medical disorders in pregnancy (i.e; 6. At risk of severe NNJ
cardiac disease, renal disease, 7. Preterm
autoimmune diseases, epilepsy, any 8. Under the management and
chronic diseases eg: active follow-up for neonatal jaundice,
tuberculosis, HIV, hepatitis B/C etc) poor weight gain /weight loss >
6. Malignancy 7%, or other conditions.
7. Mental health
a. Pre-existing : eg: suicidal ideation,
major depression disorder, bipolar ,
schizophrenia, previous history of
postpartum depression
b. At risk of perinatal mental health
issues including adverse foetal
outcome/ traumatic birth
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High risk postnatal mother High risk baby
8. Sepsis / infection
9. Current VTE
10. Massive postpartum haemorrhage and
obstetric anal sphincter injury (OASIS)
11. Social issue: teenage pregnancy,
substance abuse, domestic violence,
low socioeconomic status, lack of family
support (including single mother).
12. Mothers of vulnerable group (eg: Orang
Asli, mothers under custodial care,
immigrants)
13. Mothers with postpartum VTE score ≥ 3
14. AOR discharge
Note:
● This risk stratification is to be done before discharge.
● Any postnatal readmission should be re-triaged prior to discharge.
● This list is also applicable following management of miscarriage or termination
of pregnancy.
● This list is not exhaustive, if any mother or newborn out of this list requires a
higher level of care, tag as high-risk
4.4 COMPONENTS OF POSTNATAL CARE
4.4.1 Home visits

● For detailed procedure and checklist of postnatal home visit, refer
Manual Perkhidmatan Kesihatan Ibu & Anak bagi Anggota
Kejururawatan di Perkhidmatan Kesihatan Awam 2016, Buku Rekod
Kesihatan Ibu (KIK/1(a)/96 Pind. 2020) and Buku Rekod Kesihatan
Kanak-kanak.
● At each postnatal contact, enquiries should be made about general well-
being and assessments of mother’s vital signs, lochia, urinary and bowel
function, healing of wound, fatigue, perineal pain and perineal hygiene,
breast pain, abdominal tenderness, calf pain and other relevant signs
and symptoms. Mothers should also be given information about the
physiological process of recovery after birth, nutrition, hygiene and
contraceptives.
● Basic care for all newborns should include promoting and supporting
early and exclusive breastfeeding, keeping the baby warm, providing
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hygienic umbilical cord and skin care, identifying conditions requiring
additional care (e.g: jaundice) and counselling on when to take a
newborn to a health facility.
● Breastfeeding progress should be assessed at each postnatal contact.
At each postnatal contact, women should be asked about their emotional
wellbeing, what family and social support they have and their usual
coping strategies for dealing with day-to-day matters.
● All mothers and their families/partners should be encouraged to tell their
health care professional about any changes in mood, emotional state
and behaviour that are outside of the woman’s normal pattern.
● After day 10 postnatal, mothers should be asked about resolution or
symptoms of baby blues. If symptoms have not resolved the health staff
should arrange further support and communicate with the medical officer
regarding assessment for postnatal depression and further evaluation.
● If any abnormality is detected in mothers or babies, referral to the
hospital or clinic must be made. Mothers should be advised of the signs
and symptoms of potentially life-threatening conditions in themselves or
babies, to contact health staff immediately or call for emergency help.
4.4.2 Clinic visits
● Indications for clinic visits for postnatal mothers can be either a

scheduled visit at 1 month or various conditions requiring medical review
at clinic.
● For deliveries at home, both mother and baby need to be reviewed by a
medical officer at least within 24 hours after delivery.
● Among common situations which require clinic visits during the postnatal
phase are blood pressure review, laboratory investigations, referral to
medical officers or mother having complaints related to herself/baby.
● During the scheduled visit at 1 month, enquiries are made about general
well-being of the mother and other relevant signs and symptoms
including pervaginal bleeding/discharge, urinary and bowel function and
healing of the wound.
● Assessment of vital signs, physical examinations and laboratory
investigations i.e.; haemoglobin level and urine analysis for sugar and
albumin, are conducted and managed accordingly.
● They should be counselled on birth spacing and family planning ideally
before discharge following delivery. Contraceptive options should be
discussed and provided if agreeable. Sexual intercourse may be
resumed after the mother’s vaginal bleeding has stopped and perineal
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wound stitches has healed. Usually, this would have recovered within
four to six weeks following delivery.
● For babies, enquiries about feeding, urinary and bowel activities and
general conditions are made in addition to anthropometry
measurements, physical examinations and developmental assessments.
Immunisation is given as scheduled.
● For detailed procedure and checklist of postnatal home visit, refer
Manual Perkhidmatan Kesihatan Ibu & Anak bagi Anggota
Kejururawatan di Perkhidmatan Kesihatan Awam KKM 2016, Buku
Rekod Kesihatan Ibu (KIK/1(a)/96 Pind 2020) and Buku Rekod
Kesihatan Kanak-kanak.
● Specific conditions for clinic visits:
o For mothers with gestational diabetes (GDM), OGTT should
be repeated during the postnatal phase between 42 days until
3 months.
o Mothers with medical conditions, appropriate management
and follow-up must be arranged.
4.4.3 Virtual Consultations
● Virtual consultation is an option for eligible postnatal mothers when all

requirements are fulfilled.
● Mothers and newborns should be assessed for suitability of virtual
consultations on day 5 by nurses during home visit. Mothers with the
condition as below are not eligible for virtual consultation:
o High risk mothers and babies as in Table 4.2. If either mother
or newborns is high-risk, they are not suitable for virtual
consultations.
o Mothers with yellow or red postnatal coding based on Garis
panduan Senarai Semak bagi Penjagaan Kesihatan Ibu
Mengikut Sistem Kod Warna (2020).
o Mothers with social issues e.g.: poor social support
o Mothers with previous history of poor compliance to advise or
missed appointments
● Refer Garis panduan Peluasan Pelaksanaan Klinik Virtual (Virtual
Clinic), Bahagian Pembangunan Kesihatan Keluarga, 2020 on the
details for requirement of virtual consultation.
● Refer Appendix 4-1 – Consent form for postnatal virtual consultations
and Appendix 4-2 – Checklist for postnatal virtual consultations (mother
and baby).
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4.5 RISK STRATIFICATION IN POSTNATAL PERIOD
● During the postnatal contacts, any abnormalities detected should be

referred for further management in health clinic or hospital according to
the risk checklist (Refer Garispanduan Senarai Semak bagi Penjagaan
Kesihatan Ibu mengikut Sistem Kod Warna, KKM 2020). Mothers with
risk factors are stratified to either red code or yellow code which
determines the promptness of management. Figure 4.1 illustrates the
flow for action during postnatal contacts.
Figure 4.1: Flow of action during postnatal contacts
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4.6 POST-MISCARRIAGE / ABORTION CARE
Post-miscarriage home visit is not a routine care. It is only carried out at the
discretion of the attending doctor. Post-miscarriage women need to be
advised on:
● Next menses
Most women will resume menses within 4 to 6 weeks post-miscarriage/
abortion. However it may not be of the normal volume or duration of her
previous cycles. It is advisable for the patient to record her menses to
ensure the regularity of the menstrual cycle before planning to conceive.
● Physical activities
There is no restriction to resume normal physical activities following a
miscarriage. However it is advisable to avoid strenuous activities such as
jogging and lifting heavy weight during the immediate post miscarriage
period.
● Diet
A well-balanced diet with appropriate amount of fluid intake will assist the
body to return to its normal form. There is no particular restriction with
regards to the types of food that may be or may not be consumed during the
post miscarriage period.
● Sexual relationship
It may be appropriate for the couple to resume sexual intercourse only after
vaginal bleeding has stopped.
● Contraception
It is advisable for a woman to avoid a pregnancy soon after the miscarriage.
This is likely to happen in the event of unprotected intercourse.
Contraception advise should be offered in order to space her pregnancy.
This advise should be based on WHO Medical Eligibility Criteria for
Contraceptive Use 2015 or Garis panduan Kriteria Kelayakan Perubatan &
Soal Jawab Amalan Penggunaan Kaedah Kontraseptif, MOH 2017.
● Emotional support
Following miscarriage, a proportion of women may experience various
levels of emotional changes. At times, these changes may be similar to that
of a woman who has lost a baby at term. These reactions may be attributed
to abrupt changes in hormonal levels or due to the loss of a wanted
pregnancy. Counselling in the form of emotional support should be offered
to women who experience these changes.
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● Advise on next pregnancy
Next pregnancy can take place as long as the mother has no medical illness
or constraint. Mothers are encouraged to embark on their next pregnancy
once they are ready.
4.7 POSTPARTUM PRE PREGNANCY CARE
Identification of patients who require referral to the pre pregnancy service

should be done at postnatal visit at 1 month (Refer to pre pregnancy risk
factors – Chapter 1).
a. Women who should avoid future pregnancy:

This refers to a mother with serious medical conditions which may be
detrimental to her life if she embarks on another pregnancy. The woman
and partner should be counselled and provided with appropriate
contraceptives.
b. Women who are likely to be high-risk in future pregnancies:

They should be advised on the risk during pregnancy in relation to her
current health conditions. Other important information is the need to
attend pre pregnancy care and use of contraceptives. They must be
enrolled to the pre pregnancy care either in hospital or health clinic at the
earliest possible after postnatal period.
4.8 CONTRACEPTIVES
● Discussions on birth spacing and family planning should be initiated
early from the antenatal phase. Contraceptive options should be
discussed and provided if agreeable.
● Postpartum mothers can become pregnant again even before they have
their first menses. Breastfeeding is not a reliable form of birth control.
● Refer Garispanduan Kriteria Kelayakan Perubatan & Soal Jawab
Amalan Penggunaan Kaedah Kontraseptif, BPKK, KKM 2017, Buku
Panduan Latihan Pemasangan dan Pengeluaran Alat Dalam Rahim,
BPKK, KKM 2019, and WHO’s Four Cornerstones of Family Planning
Guidance, WHO.
4.9 RESUMING SEXUAL INTIMACY

● Among the needs of women in the postpartum period are information
and counselling on sexual life.
● Sexual intercourse may be resumed after the mother’s vaginal bleeding
has stopped and perineal wound stitches has healed. Usually, recovery
is within four to six weeks following delivery.
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● The couple should decide together, with the advise of their health care
provider, when to resume sexual intimacy. Initially, sex following birth
may be painful. Advise to use a lubricant or trying different positions that
allow the woman to be in control of penetration may help.
4.10 POSTNATAL EXERCISES

● All women should be encouraged to mobilize as soon as possible
following the birth. They should be encouraged to take gentle exercise
and make time to rest during the postnatal period.
Refer to Manual Senaman Antenatal dan Postnatal di Klinik Kesihatan,

BPKK, KKM 2014.
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APPENDIX 4-1
BORANG KEIZINAN KONSULTASI POSTNATAL SECARA MAYA
Konsultasi postnatal secara maya adalah penyampaian perkhidmatan kesihatan secara

maya (virtual), langsung (live) dan interaktif yang merangkumi konsultasi klinikal dan
pelan rawatan pelanggan di antara anggota kesihatan dan pelanggan. Konsultasi
postnatal secara maya merupakan satu inisiatif yang dilaksanakan bagi memastikan
penjarakan sosial dan menyediakan perkhidmatan kesihatan yang berterusan setaraf
dengan kemajuan teknologi.
Saya telah diberi penerangan oleh anggota kesihatan tentang pelaksanaan konsultasi
postnatal secara maya dan bersetuju:
1. Untuk menyertai sesi konsultasi postnatal secara maya.

2. Maklumat klinikal semasa sesi konsultasi boleh dikongsi dengan anggota
kesihatan lain untuk tujuan rujukan sekiranya perlu, bagi kesinambungan
perawatan.
3. Sebarang rakaman video atau audio sepanjang sesi konsultasi postnatal secara
maya tidak boleh ditular/ dikongsi/ disebar kepada pihak luar oleh kedua-dua pihak
4. Rakaman tidak boleh digunakan sebagai bukti untuk tindakan undang-undang
terhadap KKM
5. Anggota kesihatan yang bertugas boleh memberhentikan konsultasi jika:
a. berlaku gangguan akses capaian internet atau sebarang masalah teknikal.
b. jenis perbualan tiada berkaitan dengan tujuan konsultasi kesihatan saya
6. Saya berhak untuk tidak meneruskan konsultasi postnatal secara maya atas
pilihan saya sendiri.
7. Saya akan hadir ke klinik sekiranya terdapat keperluan untuk pemeriksaan
lanjutan.
8. Konsultasi secara maya boleh menyebabkan kelewatan dalam rawatan
berbanding konsultasi bersemuka.
Ditandatangani:
-------------------------------------- ---------------------------------------
(Ibu) (Saksi*)
Nama : Nama :
No. Kad pengenalan: No. Kad pengenalan:
Tarikh: Jawatan :
Tarikh :
Cop jawatan:
** Saksi boleh terdiri dari Pakar Perubatan Keluarga/ Pegawai Perubatan/ Jururawat/Penolong Pegawai
Perubatan
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APPENDIX 4-2
SENARAI SEMAK PEMANTAUAN IBU POSTNATAL SECARA VIRTUAL UNTUK

ANGGOTA KESIHATAN
KONSULTASI POSTNATAL SECARA VIRTUAL (HARI 8-10)

membolehkan anggota kesihatan dapat melihat penampilan ibu secara
keseluruhan.
2. Bertanya khabar ibu? Sihat / tidak sihat Jika ibu tidak sihat,
nasihat ibu untuk
datang klinik
3. Setuju untuk teruskan konsultasi Ya / Tidak Jika ibu tidak
secara virtual bersetuju untuk
teruskan konsultasi
secara virtual, beri
temujanji klinik
4. Demam Ya / Tidak Jika ya, nasihat ibu
untuk datang ke klinik
dan maklumkan
kepada doktor
5. Masalah pernafasan Ya / Tidak Jika ya, nasihat ibu
untuk datang ke klinik
dan maklumkan
kepada doktor
6. Pening/ pitam/ letih / lesu / berdebar- Ya / Tidak Jika ya, nasihat ibu
debar untuk datang ke klinik
dan maklumkan
kepada doktor
7. Sakit dada Ya / Tidak Jika ya, minta ibu
Sesak nafas Ya / Tidak untuk segera ke
Kesukaran bernafas ketika baring Ya / Tidak hospital
Cepat penat Ya / Tidak
8. Sakit kepala/ pening / loya/ muntah/ Ya / Tidak Jika ya kepada salah
mata kabur satu, nasihat ibu
untuk datang ke
klinik.
9. Pendarahan / lochia yang banyak / Normal / tidak Jika tidak normal,
normal nasihat ibu untuk
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berbau / discaj vagina / sakit perut datang ke klinik
10. Payudara dan penyusuan o Bengkak Jika terdapat

payudara masalah, nasihat ibu
o Sakit untuk datang ke klinik
payudara
o Masalah
penyusuan
11. Bagaimana keadaan luka perineum/ Jika ya kepada salah
pembedahan? satu, nasihat ibu
o Sangat sakit Ya / Tidak untuk datang ke
o Kemerahan Ya / Tidak klinik.
o Bengkak Ya / Tidak
o Jahitan terbuka Ya / Tidak
o Lelehan/ discaj Ya / Tidak
12. Edema di kaki/ tangan/ muka secara Ya / Tidak Jika edema di kaki,
mendadak tanya lebih lanjut
sehingga tahap
mana. Jika sehingga
lutut, nasihat ibu
untuk datang ke
klinik.
Jika edema di tangan
atau muka, nasihat
ibu untuk datang ke
klinik
13. Betis bengkak/ sakit / kemerahan Ya / Tidak Jika ya, minta ibu
untuk segera ke
hospital
14. Adakah ibu mempunyai tanda-tanda Ya / Tidak Jika tidak, nasihat ibu
dehidrasi/kurang minum air: kepentingan hidrasi
- kering bibir dan minum air yang
- kurang kencing, atau kencing cukup
berwarna gelap
15. Kesihatan mental Ya / Tidak Jika ya kepada salah
o Sejak kebelakangan ini, adakah satu, nasihat ibu
anda sering diganggui perasaan untuk datang ke
murung atau sedih? klinik.
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o Sejak kebelakangan ini, adakah
anda sering kehilangan minat atau
keseronokan dalam melakukan
kerja harian?
16. Kepatuhan pengambilan ubat / Ya / Tidak Jika tidak patuh,

suplemen nasihat ibu dan
tekankan mengenai
kepentingan
kepatuhan kepada
pengambilan ubat /
suplemen tersebut
17. Soalan umum : Ya / Tidak Jururawat nasihat ibu
o Adakah mempunyai masalah lain? apa yang perlu
– contohnya masalah kencing, dilakukan dan jika
buang air besar, corak tidur perlu, berbincang
terganggu
dengan doktor.
18. Adakah ibu tahu temujanji ke klinik Ya / Tidak Jika tidak,
pada 1 bulan selepas bersalin? maklumkan tarikh
temujanji.
Nasihat ibu untuk
hubungi
klinik/hospital atau
datang ke
klinik/hospital jika
mempunyai sebarang
masalah.
Nota:
mengenai kes kepada pihak hospital/ PAC dan memaklumkan status ibu jika
terdapat sebarang perubahan (Rujuk Garis panduan Perkhidmatan Kecemasan dan
Ambulans di Fasiliti Kesihatan Primer).
penjagaan ibu.
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SENARAI SEMAK PEMANTAUAN BAYI SECARA VIRTUAL UNTUK ANGGOTA
KESIHATAN
KONSULTASI POSTNATAL SECARA VIRTUAL UNTUK BAYI (HARI 8-10)

No. Perkara Soalan Penerangan Jawapan Tindakan
1. Tindakbalas Adakah bayi Tanda-tanda Ya/Tidak Sekiranya
bayi aktif? tidak aktif: tidak aktif,
- Tidur lama sila segera
- Susah bawa ke
dikejutkan klinik atau
- Kurang hospital
pergerakan terdekat
- Kurang
menyusu
2. Demam Adakah bayi Sentuhan yang Ya/Tidak Sekiranya

demam? panas atau rasa demam,
direkodkan > sila segera
37.50C bawa ke
klinik atau
hospital
terdekat
3. Jaundis Adakah bayi Blanching test Ya/Tidak Sekiranya
kelihatan sekiranya pernah jaundis yang
kuning? diajar. pernah
menerima
rawatan, sila
semak TSB
yang terakhir
dan rujuk
kepada
doktor untuk
tindakan
seterusnya.
Sekiranya
jaundis kes
baru, jaundis
bertambah,
ataupun ada
keraguan,
nasihat ibu
untuk bawa
ke klinik hari
yang sama.
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4. Kekerapan Berapa kali bayi Sekurang- Ya/Tidak Sekiranya
Penyusuan menyusu? kurangnya 8-12 Tidak,
kali dalam lawatan
tempoh 24 jam rumah/ klinik
perlu
dilakukan.
5. Kencing Berapa kali bayi Menukar lampin Ya/Tidak Sekiranya
kencing? basah sekurang- Tidak,
kurangnya 5-6 lawatan
kali dalam rumah/klinik
tempoh 24 jam perlu
dilakukan.
6. Membuang Berapa kali bayi Sekurang- Ya/Tidak Sekiranya
air besar membuang air kurangnya 2 kali Tidak,
besar? dalam tempoh 24 lawatan
jam rumah/klinik
perlu
dilakukan.
7. Pernafasan Adakah bayi Tanda-tanda Ya/Tidak Sekiranya
bernafas seperti pernafasan yang tidak
biasa? tidak normal: normal, sila
segera bawa
-Sesak nafas ke klinik
-Nafas laju atau hospital
-Lekuk di dada terdekat
8. Abdomen Adakah perut Tanda-tanda Ya/Tidak Sekiranya

dan tali pusat yang tidak
bayi kelihatan membimbangkan: normal, sila
biasa? segera bawa
-Perut kembung ke klinik
-Tali pusat merah atau hospital
ataupun terdekat
bernanah
9. Lain-lain Adakah Nyatakan: Ya/Tidak Tindakan

mempunyai ___________ bergantung
kebimbangan kepada
yang lain? penilaian.
Jika perlu,
sila rujuk
doktor
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Tanda-tanda bahaya (warning signs) yang menandakan bayi memerlukan
tindakan segera:
● kelihatan pucat dan kebiruan
● muntah kerap/hijau
● sawan
● tidak aktif
● demam
● tidak menyusu dengan baik
Nota:
1. Jika dinasihatkan untuk ke hospital, jururawat / pegawai perubatan perlu beritahu
mengenai kes kepada pihak hospital dan memaklumkan status bayi jika terdapat
sebarang perubahan (Rujuk Garis panduan Perkhidmatan Kecemasan dan
Ambulans di Fasiliti Kesihatan Primer).
2. Jururawat perlu melakukan tindaksusul ke atas perancangan pengendalian/
penjagaan bayi.
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CHAPTER 5
MEDICAL COMPLICATIONS IN PREGNANCY
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CHAPTER 5: MEDICAL COMPLICATIONS IN PREGNANCY
5.1 HAEMATOLOGICAL DISORDER IN PREGNANCY
5.1.1 Anaemia in Pregnancy
PHASE PLAN OF ACTION

Pre ● Women with known anaemia need to have her anaemia corrected
pregnancy before embarking on pregnancy
● Effective communication with women about diet and healthy eating
is essential.
At diagnosis ● FBC must be done at booking
in pregnancy ● Anaemia : Hb <11g/dL – investigate for the cause.
● The most common cause is iron-deficiency anaemia (IDA).
Hemoglobinopathy should be screened especially after IDA has
been ruled out. IDA & hemoglobinopathy may co-exist.
● Hematinics should be continued while investigation is on-going. An
improvement after a course of oral iron supplementation indicates
IDA.
● Anaemia workout includes:
o Serum ferritin
o Transferrin saturation (if serum ferritin is not conclusive) - send
for TIBC & Serum Iron
o FBP
o BFMP
o Stool for ova & cyst
● Role of serum ferritin:
o Routine antenatal serum ferritin testing along with FBC at
booking would detect iron depletion before a patient becomes
anaemic. Therefore allowing better opportunity to replenish iron
store to prevent maternal or neonatal complications.
o If routine antenatal serum ferritin is not feasible (e.g. cost
constraint), it should then be performed in patients at increased
risk of iron deficiency (ID) or bleeding (e.g. multiparity, previous
IDA, multiple pregnancy, placenta previa, previous scars,
history of PPH, etc).
o Iron deficiency is already advanced by the time anaemia is
detected. The deficiency has consequences even when no
anaemia is clinically apparent.
o Point-of-care test (POCT) ferritin would potentially lower the
cost of the test and facilitate earlier management of ID/ IDA.
● Oral Iron therapy:
o For prevention of anaemia (normal Hb):
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▪ Daily oral iron with 30-60 mg of elemental iron (higher dose
of 60mg elemental iron is preferred in view of high
prevalence of anaemia in pregnancy such as in Malaysia)
▪ Every other day (EOD) dosing of 30-60 mg elemental iron
(e.g. Mon/Wed/Fri) to reduce gastrointestinal side effects
▪ Weekly oral iron with 120 mg elemental iron if daily iron is
not acceptable due to side effects
o For treatment of anaemia (Hb <11.0 g/dL):
▪ Daily oral iron with 120 mg elemental iron
▪ Resume the standard daily antenatal iron dose once her
anaemia has been corrected.
▪ Include Folic Acid 400 µg (0.4 mg) with iron supplement
(daily or every other day dosing) or 2800 µg (2.8 mg) with
weekly iron supplement. Folic acid should be commenced
as early as possible, ideally before conception to prevent
neural tube defects.
● IV Iron therapy:
o IV Iron should be administered if oral iron is not tolerated, not-
compliant or if response is poor (i.e. <1 g/L in 2 weeks or <2 g/L
in 4 weeks)
o Do not use IM route
o DO NOT administer IV Iron in first trimester
o Use of Erythropoietin Stimulating Agent (ESA) may be
considered if poor response after IV Iron, after consultation with
haematologist.
● Transfusion is not a treatment for anaemia. It is only for bleeding,
unstable patients. Use non-blood alternatives instead of
transfusion whenever possible.
● Asymptomatic anaemia
o Hb 7-11 g/dL irrespective of gestational age – follow up at
health clinic.
o Try a course of oral iron. If there is poor / no response after 1 or
2 types of oral iron, switch to IV Iron unless contraindicated. If
gestational age is advanced, use IV Iron sooner. The response
time to IV Iron is the same, though faster response may be
seen, hence timing of treatment is important.
o Hb <7 g/dL and POA <34weeks – refer FMS
o Hb <7 g/dL and >34weeks – refer O&G
o Asymptomatic patients may be referred to FMS for IV Iron in
health clinics if available.
● Symptomatic anaemia – irrespective of Hb level or gestational age,
refer to O&G specialist.
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Subsequent ● Monitor monthly Hb level at health clinic
antenatal ● There may be a need to repeat serum ferritin especially after a
follow-up course of IV Iron.
● Foetal growth monitoring at health clinic
Delivery plan ● Hospital delivery for anaemic patients, with GSH on standby.
● PPH prophylaxis
● Generally may allow postdates, unless specified otherwise.
● There is no indication to transfuse just to top up a patient’s Hb level
as long as the patient is stable and asymptomatic.
Postpartum ● Discuss options of contraception with patient / couple (Refer
Medical Eligibility Criteria for Contraceptive)
● Continue iron supplementation for 3 to 6 months postpartum
● Use iron supplementation to improve Hb if the patient had PPH – IV
Iron if a faster increment in Hb and better replenishment of iron
stores are needed (e.g. after massive PPH, severe postpartum
anaemia).
● Blood transfusion is required if evidence of active bleeding or sign
and symptoms of heart failure
Upon ● Routine discharge procedure
discharge ● High risk postnatal notification if a patient had PPH and awaiting for
from Hb to increase with iron supplementation (oral or IV).
hospital
REMARKS:
1. WHO defines anaemia in pregnancy as Hb < 11 g/dL.
Trimester-specific Hb thresholds for diagnosing anaemia are:
● 1st & 3rd trimester: Hb 11.0 g/dL
● 2nd trimester: Hb 10.5 g/dL
● Postpartum: Hb 10 g/dL
WHO further defines the severity of anaemia in pregnancy as below:
● Mild: Hb 10.0-10.9 g/dL
● Moderate: 7.0-9.9 g/dL
● Severe: <7.0 g/dL
Mild anaemia is a misnomer: iron deficiency is already advanced by the time
anaemia is detected. The deficiency has consequences even when no anaemia is
clinically apparent.
Prevalence of anaemia among pregnant women >40% denotes severe public
health significance.
2. If anaemia (Hb <11 g/dL) – investigate for the cause
● Iron deficiency anaemia (IDA):
⮚ If FBC shows hypochromic microcytic anaemia, to send for Serum Ferritin.
⮚ Serum Ferritin <30µg/l indicates iron depletion (sensitivity of 90%, specificity
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of 85%)
⮚ If Serum Ferritin between 30-100µg/l, proceed to calculate Transferrin
Saturation (TSat) by sending for TIBC and Serum Iron. TSat <20% indicates
iron depletion.
● Hemoglobinopathy
⮚ If IDA is ruled out, send for Hb analysis to screen for hemoglobinopathy.
3. Indications for assessment of Serum Ferritin:
● Anaemic women when estimation of iron stores is necessary:
⮚ Known hemoglobinopathy (to rule out concomitant IDA)
● Non-anaemic women with high risk of iron depletion:
⮚ Previous anaemia
⮚ Multiparity
⮚ Short pregnancy interval of <1yr
⮚ Vegetarians
⮚ Teenage pregnancies
⮚ Recent history of bleeding
● Non-anaemic women where estimation of iron stores is necessary:
⮚ High risk of bleeding
⮚ Jehovah’s witness / women who refuse blood or blood product
4. Referral to hospital when:
● Significant symptoms
● Severe anaemia (Hb <7.0 g/dL)
● Anaemia in late gestation (>34weeks)
● Failure to respond to oral iron (this can be managed in health clinic if IV Iron is
available)
Asymptomatic patients may be referred to FMS for IV Iron in health clinic if
available.
5. Oral Iron preparation containing 60 mg elemental iron:
● Ferrous Gluconate 500 mg
● Ferrous Sulphate 300 mg
● Ferrous Fumarate 180 mg
6. IV Iron – examples:
● Iron sucrose such as Iron (III) hydroxide sucrose complex (Venofer)
● Low Molecular Weight Iron Dextran such as Iron (III hydroxide dextran complex
(Cosmofer)
● Iron (III) carboxymaltose (Ferinject)
● Iron (III) isomaltoside (Monofer)
The latter two are examples of single high-dose preparation.
● Do not use Iron Sucrose Similars (ISS) as they are associated with more side
effects and are less efficacious.
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● Do not use IM route for parenteral iron administration.
● Avoid parenteral Iron during 1st trimester.
7. Patient Blood Management (PBM) has three pillars:

● 1st Pillar – optimising erythropoiesis
● 2nd Pillar – minimise bleeding and blood loss
● 3rd Pillar – harness and optimise physiologic tolerance of anaemia
Early identification and treatment of iron deficiency and iron deficiency anaemia is
an important component of PBM which includes diagnosis and use of iron therapy
including IV Iron. IV Iron should be considered for stable postpartum anaemia
patients.
Reference:
1. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience,
2016.
2. UK Guidelines on the Management of Iron Deficiency in Pregnancy, British Committee
for Standards in Heamatology, 2012
3. Flores CJ, Sethna F, Stephens B, et al. Improving Patient Blood Management in
Obstetrics: snapshots of a practice improvement partnership. BMJ Quality
Improvement Reports 2017; 6:e000009. DOI:10.1136/bmjquality-2017-000009
4. Moretti D, Goede JS, Seder C, et al. Oral iron supplements increase hepcidin and
decrease iron absorption from daily or twice-daily doses in iron-depleted young
women. Blood, 22 October 2015
5. Holm C, Thomsen LL, Norgaard A, Langhoff-Roos J. Single-dose intravenous iron
infusion versus red blood cell transfusion for the treatment of severe postpartum
anaemia: a randomised controlled pilot study.
The International Journal of Transfusion Medicine 2016; DOI: 10.1111/vox.12475
6. Auerbach M. Commentary: Iron deficiency of pregnancy – a new approach involving
intravenous iron. Reproductive Health 2018, 15 (Suppl 1):96;
https://doi.org/10.1186/s12978-018-0536-1
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5.1.2 Thalassaemia in Pregnancy

Pre ● If either partner or the couple is a thalassaemia carrier, refer to
pregnancy FMS / O&G for counselling, including information regarding
prenatal diagnosis
● Screen untested partner
● Advise for early booking before 12 weeks of gestation
At diagnosis ● All antenatal women should be offered screening if they have a

family history of haemoglobinopathy
● All women who have MCV ≤ 80Fl and MCH ≤ 27pg and a normal
ferritin level (e.g. > 30µg/L) should be offered Hb analysis
● If confirmed carrier, screen partner for thalassaemia
● If the couple is carrier, refer to O&G Clinic for counselling + prenatal
diagnosis
Subsequent ● Monitor Hb level. If anaemic, check serum ferritin and for iron
antenatal supplement if serum ferritin <30 ng/ml
follow-up ● Folic acid should be given throughout pregnancy
● Referral to O&G if Hb <7 g/dL or symptomatic of anaemia
Delivery plan ● Keep Hb > 7.0 g/dL

● Generally may allow post date, unless specified otherwise
● If moderate or severe anaemia, deliver at specialist hospital and
give PPH prophylaxis
Postpartum ● If both parents are carriers – refer baby to paediatrics at delivery

● If only the mother is a carrier – baby to be seen at 6 months in
health clinics
● Discuss contraception options with couple
Upon ● Pre pregnancy counselling appointment for newly diagnosed

discharge thalassaemic couple
from
hospital
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5.1.3 Thrombocytopenia in Pregnancy

Pre ● Known thrombocytopenia in pregnancy need to be seen in pre
pregnancy pregnancy clinic and under specialist care
(if known ● Screen for thrombocytopenia at booking by performing FBC
pre-existing ● Repeat FBC is required if FBC is thrombocytopenic
case) or at ● Referral to medical / O&G if the repeated FBC remain
booking / thrombocytopenic
diagnosis ● Look for bleeding tendencies, immediate referral is required if
present clinically
● Tests to be done:
⮚ FBP
⮚ LFT
⮚ RP
⮚ Viral screening (HIV, HCV, HBV)
⮚ ANA
● Refer patient with asymptomatic thrombocytopenia in pregnancy
with platelet <100 x109/L or symptomatic thrombocytopenia to O&G
clinic / Medical clinic
● Patient with mild asymptomatic thrombocytopenia (100-150 x109/L)
can be monitored at Health Clinic
Subsequent ● Follow plan laid out by O&G / medical / haematology clinic
antenatal ● Follow up of mild asymptomatic thrombocytopenia in pregnancy at
follow-up health clinic with monthly FBC monitoring
Delivery ● For hospital delivery
plan ● Give PPH prophylaxis
● Consider anaesthetic referral for moderate to severe
thrombocytopenia
● Medical / heamatology input if severe thrombocytopenia for possible
need of intervention (steroid / azathioprine / IV IgG or platelet
transfusion)
● Avoid traumatic delivery / foetal scalp sampling / foetal scalp
electrode
● Refer baby to Paediatrics to rule out neonatal thrombocytopenia
● Avoid Vit K injection for the baby until thrombocytopenia is ruled out
(to discuss with Paediatric team)
Postpartum ● Discuss options of contraception with patient / couple (Refer WHO
Medical Eligibility Criteria for Contraceptive Use, 2015)
Upon ● Repeat FBC at 6 weeks postpartum for gestational
discharge thrombocytopenia
from ● For other causes of thrombocytopenia, follow medical/ heamatology
hospital plan
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REMARKS:
● Definition of thrombocytopenia in pregnancy: Platelet <150 x109/L
⮚ Mild: 100-150 x109/L
⮚ Moderate: 50-100 x109/L
⮚ Severe: <50 x109/L
● Thrombocytopenia occurs in 7-8% of all pregnancy:
⮚ 70-80% are gestational thrombocytopenia
⮚ 15-20% are severe pre-eclampsia
⮚ <1% are HELLP syndrome and APS
● Differential diagnosis:
⮚ Hereditary
⮚ Autoimmune disease (SLE, APS)
⮚ Pre-eclampsia
⮚ HELLP syndrome
⮚ DIVC
⮚ Drug-induced
⮚ Viral Infection (HIV, Dengue, HCV)
⮚ Hypersplenism due to chronic liver disease
⮚ Haematological malignancy
⮚ Gestational thrombocytopenia
⮚ Spurious-platelet clumping
● In gestational thrombocytopenia, platelet should have normalised by 6 weeks
postpartum
Reference:
1. Myers B. Thrombocytopenia in pregnancy, Royal College of Obstetrics and

Gynaecology guidelines, 2009
2. Clinical Practice Guidelines on Management of Immune Thrombocytopenic Purpura,
MOH 2006
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5.1.4 Rhesus Isoimmunisation in Pregnancy

At booking / ● Blood group & Rh status at first antenatal visit
diagnosis ● Check husband’s blood group & Rh status if patient is Rh
Negative
● Indirect Coomb’s test / indirect agglutination test are required to
detect prior sensitization
⮚ At first antenatal visit for known case of Rhesus negative
⮚ After diagnosis of new cases
Subsequent ● If Indirect Coomb’s test / indirect agglutination test is positive,
antenatal refer to MFM or O&G
follow-up ● If initial Indirect Coomb’s test / indirect agglutination is negative,
repeat test is required at 24-26 weeks
● Routine Antenatal Anti-D Prophylaxis (RAADP) for non-sensitised
patient, either one of these regimes:
⮚ 2-dose regime: IM Anti-D Immunoglobulin 500iu at 28 weeks
and 34 weeks
⮚ Single dose regime: IM Anti-D Immunoglobulin 1500iu
between 28-34 weeks
● RAADP may be administered in a health clinic if Anti-D
immunoglobulin is available.
Delivery plan ● Hospital delivery
● Mode and timing of delivery as per obstetric indications
Postpartum ● Refer baby to Paediatrics
● Administer IM Anti-D immunoglobulin 500iu within 72 hours if
baby is Rh positive
● IM Anti-D immunoglobulin 500iu is also required for IUD >20
weeks at diagnosis and again after delivery, unless delivery is
soon after IUD is diagnosed
● If baby’s direct Coomb’s test / direct agglutination test is positive,
baby is at risk of haemolytic disease of newborn (HDN) and
Kleihauer test for the mother should be performed to quantify the
foetal maternal haemorrhage (FMH). Further Anti-D required if
FMH >4ml.
Upon ● Contraceptive advise
discharge
from hospital
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Remarks:
Direct Coomb’s/ agglutination test is performed to detect anti-globulins attached to red
blood cell surfaces and their interactions in-vivo. Direct Coomb’s test is important to
diagnose autoimmune haemolytic anaemia.
Indirect Coomb’s / agglutination test is performed to detect the presence of antiglobulins
in the serum in an unbound state and to detect their interactions in-vitro with Coombs’
anti-human globulins. Indirect Coomb’s test is important for prenatal testing for pregnant
women prior to blood transfusion.
Anti-D Prophylaxis:
1) Routine – Routine Antenatal Anti-D Prophylaxis (RAADP) & postnatal prophylaxis
2) Any potentially sensitising events
GESTATIONAL POTENTIALLY SENSITISING EVENTS ANTI-D PROPHYLAXIS

WEEK
<12 weeks Vaginal bleeding + severe pain 250iu Anti-D
ERPOC/ instrumentation of uterus Immunoglobulin within 72
Medical / Surgical TOP hours of event
Ectopic / Molar pregnancy
12-20 weeks Amniocentesis, CVS, cordocentesis 250iu Anti-D
PV bleeding in pregnancy Immunoglobulin within 72
Abdominal trauma (sharp/blunt, hours of event
open/closed)
Ectopic pregnancy
Miscrarriages, threatened miscarriage
ERPOC / TOP
In-utero therapeutic interventions
20weeks to APH Regardless of whether
term ECV RAADP has been given,
Abdominal trauma (sharp/blunt, 500iu Anti-D
open/closed) Immunoglobulin to be
Delivery given within 72 hours of
Intraoperative cell salvage event
IUD
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5.2 HYPERTENSIVE DISORDER IN PREGNANCY
5.2.1 Gestational Hypertension / Pre-eclampsia
PHASE DEFINITION PLAN OF ACTION

At booking Gestational ● Identify patient at risk
Hypertension is ● Offer women with high risk of pre-eclampsia for
detected after 20 screening (i.e.; prior pre-eclampsia, chronic
week. hypertension, pregestational diabetes, BMI >30,
antiphospholipid syndrome, receipt of assisted
Hypertension in reproduction)
pregnancy is ● If fulfil criteria as high risk for pre-eclampsia:
defined as BP ⮚ To start Cardipirin 100mg ON or Aspirin
140/90 on 2 150mg ON once foetal heart activity is seen
occasions 4 to 6 (not recommended after 20 weeks).
hours apart. ⮚ Recommended dose of calcium is 1.5 – 2g
elemental calcium after 20 weeks until
Pre-eclampsia is delivery. (Calcium Carbonate 1g BD or
defined as Calcium Lactate 600mg TDS. Calcium
gestational Carbonate is preferred due to better
hypertension absorption).
with proteinuria.
At diagnosis ● Assess severity:
of Mild: ⮚ Blood pressure
gestational - SBP 140 – ⮚ Urine albumin
hypertension 149 mmHg ⮚ SFH
- DBP 90 – 99 ⮚ Hb and platelet (baseline)
mmHg ⮚ Renal function (baseline)
- without ⮚ Liver function test (baseline)
proteinuria ⮚ Uric acid (as a screening for referral)
Results should be reviewed by medical officer
Moderate: within 1 week
- SBP 150 – ● Choice of anti-HPT:
159 mmHg ⮚ Methyldopa
- DBP 100 – ⮚ Labetalol
109 mmHg ⮚ Nifedipine
● Treatment target:
Severe: ⮚ SBP: 140-149 mmHg
- SBP ⮚ DBP: 90-99 mmHg
≥160mmHg ● Consider reducing anti-HPT if BP < 140/90
- DBP ≥110 mmHg
At diagnosis mmHg ● Refer for admission and specialist assessment
of pre-
clampsia
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At diagnosis ● Management
of severe ⮚ Inform O&G specialist on-call
pre-clampsia ⮚ If BP is not controlled, consider IV Labetolol
/ eclampsia 20mg/ IV Hydralazine 5mg or oral Nifedipine
10mg.
⮚ Give loading dose of IM MgSO4 5g (with
Lignocaine 2%) before transfer (after
discussing with O&G specialist on-call
/FMS).
⮚ Maintenance dose of 5g every 4 hours (at
alternate buttocks) as per Garis panduan
Pemberian Suntikan Intramuscular MgSO4
di Peringkat Penjagaan Kesihatan Primer
bagi Kes Severe Pre-eclampsia / Eclampsia,
2014
● May request for Obstetrics Emergency Retrieval
Team (OERT) if available
Subsequent ● Educate and advise mother to return
antenatal immediately if develop symptoms of impending
follow-up eclampsia
● Mild gestational hypertension - manage at
health clinic
- weekly BP monitoring
● If BP well controlled, case can be managed by
MO and refer to FMS for assessment at 20-24
weeks and 32-34 week
● Moderate gestational hypertension
- refer to FMS/O&G
- biweekly BP monitoring
● Any hypertension with proteinuria or severe
gestational hypertension - to refer for admission
● Foetal surveillance with SFH, FKC, foetal
growth monitoring by serial ultrasound starting
at 28 weeks, at 4-weekly interval
Delivery plan ● Delivery plan to be outlined by O&G specialist
at about 36 weeks
● Hospital delivery
Postpartum ● Continue to monitor BP after delivery until 6
weeks postpartum (the frequency should be
individualised)
● Wean down treatment dose of anti-HPT and do
not stop abruptly
● Discuss options of contraception with couple
● Please note that persistent hypertension in
young women need to be investigated for the
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secondary causes and managed accordingly
Upon ● Notification of high-risk discharge from hospital

discharge to respective health clinics as per guideline.
from ● Respective health clinic will continue with
hospital follow-up care (unless specified otherwise on
high risk discharge summary).
● Home visit: BP monitoring, signs & symptoms of
pre-eclampsia (frequency individualised).
● Two weeks review at health clinic by MO.
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5.2.2 Chronic Hypertension In Pregnancy

Pre ● Refer FMS for assessment & counselling
pregnancy ● Screen for secondary causes of hypertension
● Need to rule out secondary complications of hypertension
● Review safety of medication
● Discuss pre-eclampsia prophylaxis
At booking / ● Dating scan
diagnosis ● Start aspirin once foetal heart activity is seen and calcium after 20
weeks
● Recommended monitoring:
⮚ Blood pressure
⮚ Body weight
⮚ Urine albumin
⮚ SFH
⮚ Hb and platelet (baseline)
⮚ Renal function (baseline)
⮚ Liver function test (baseline)
⮚ Uric acid (as a screening for referral)
⮚ ECG. If it is suggestive of left ventricular hypertrophy (LVH), for
echocardiography.
Results should be reviewed by medical officer within 1 week
● Choice of anti HPT:
⮚ <20 weeks: Methyldopa is preferred.
⮚ >20 weeks: Methyldopa, Labetalol and Nifedipine can be used
● Treatment target:
⮚ SBP: 140-149 mmHg
⮚ DBP: 90-99 mmHg
● Consider reducing anti-HPT if BP < 140/90 mmHg
Subsequent ● Educate and advise mother to return immediately if develop
antenatal symptoms of impending eclampsia
follow-up ● Nutritional intervention or advise by dietitian/ nurse
● Mild hypertension – manage at a health clinic. Weekly BP monitoring
● If BP is well-controlled, the case can be managed by MO.
● First assessment by FMS at around 20 weeks of gestation, refer to
O&G for further management if required. Subsequent assessment to
be decided by FMS based on patient’s condition
● Moderate hypertension refers to FMS/O&G. Biweekly BP monitoring.
● Any hypertension with proteinuria or severe hypertension to refer for
admission
● Foetal surveillance with SFH, FKC, foetal growth monitoring by serial
ultrasound, starting at 28 weeks, at 4-weekly interval
Delivery ● Delivery plan to be outlined by O&G specialist at about 36 weeks
plan ● Hospital delivery
Postpartum ● Continue antenatal anti-HPT after delivery
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⮚ Aim for BP <140/90 mmHg.
● Continue to monitor BP after delivery (frequency of monitoring should
be individualised)
● Discuss options of contraception with couples and reinforce the

importance of contraception and planned pregnancy.
● Restart old medication, as most hypertensive medication is safe for
breastfeeding
Upon ● Notification of high-risk discharge from hospital to respective health
discharge clinics as per guideline
from ● Respective health clinics will continue with follow-up care (unless
hospital specified otherwise on high-risk discharge summary).
● Home visit: BP monitoring, signs & symptoms of pre-eclampsia
(frequency of visit and monitoring is individualised)
● Review by MO at a health clinic in two weeks.
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5.3 DIABETES IN PREGNANCY
5.3.1 Gestational Diabetes Mellitus
Refer Clinical Practice Guidelines – Management of Diabetes in Pregnancy,

Ministry of Health, 2017
5.3.2 Pre-existing Diabetes in Pregnancy
Refer Clinical Practice Guidelines – Management of Diabetes in Pregnancy,

Ministry of Health, 2017
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5.4 THYROID DISORDER IN PREGNANCY
5.4.1 Hyperthyroidism in Pregnancy

Pre Clinical hyperthyroidism is ● Refer for counselling by FMS / O&G
pregnancy confirmed in the presence (pre pregnancy clinic)
of a suppressed (<0.1mU/L) ● Thyrotoxic women should be
or undetected (<0.01mU/L) rendered euthyroid before
TSH and an elevated FT4 attempting pregnancy
● The treatment of thyrotoxicosis
Tri - TSH FT4 should be optimised with the lowest
mester (mU/L) (pmol/L) dose of effective treatment
First 0-5.5 10 -16
At booking / Secon 0.5-3.5 9-15.5● Refer FMS for assessment / consult
diagnosis d O&G specialists for clinics without
Third 0.5-4 8-14.5 FMS.
(Reference: Oxford ● Combined Clinic appointment after
Handbook of Obstetrics and seen by FMS / after commencement
Gynaecology, 2013) of anti-thyroid drugs (ATD).
● Monitor:
⮚ FT4 and TSH level to be done 4
weekly after initiation of therapy
and then 4-6 weekly after
achieving the target value
⮚ Aim of treatment is to maintain
the FT4 levels at, or just above
upper limit of normal
⮚ Check FBC, LFT and TFT 4
weeks after commencement of
ATD
Treatment of hyperthyroidism in
pregnancy:
● PTU is the preferred ATD during first
trimester and can be continued up to
16 weeks of gestation
● Patients, who are already on
carbimazole pre pregnancy can
continue with the current regime
without switching to PTU.
● After first trimester, carbimazole is
recommended
● Propranolol is for symptomatic
control usually only for 2-4 weeks
and should not be continued without
review.
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● Treatment of subclinical
hyperthyroidism is not recommended
as it is usually transient in first
trimester & gradually improves in
later gestation
Subsequent ● Shared care between FMS and
antenatal Combined Clinic team every
follow-up trimester.
● Detail scan by fetomaternal team at
24 weeks.
● Urgent consultation with
endocrinologist if hyperthyroidism is
difficult to control
Delivery ● May allow postdate, unless specified
plan otherwise.
Postpartum ● Refer all babies born to mothers with
hyperthyroidism to Paediatric team
● It is important to trace and review
TFT for the babies
● Discuss options of contraception
Upon ● Arrange FMS appointment for

discharge postnatal review
from ● Pre pregnancy Clinic appointment
hospital postnatal (if future pregnancy
possible)
REMARKS:
● Important to distinguish Grave’s disease from gestational transient thyrotoxicosis
(GTT)
● GTT is defined as transient hyperthyroidism, limited to the first half of pregnancy,
characterised by elevated serum FT4 and suppressed or undetectable serum TSH, in
the absence of thyroid autoimmunity.
● The usual presentation is hyperemesis gravidarum (due to high levels of HCG).
● The presence of autoimmunity, goitre, ophthalmopathy, family history, would suggest
Grave’s, therefore recommended to treat with ATD
● Management of GTT: supportive treatment, treat dehydration, ATDs are not
recommended, low-dose short-term beta-blockers may be considered
● TSH receptor autoantibodies (TRAb): Measuring TRAb can help to assess foetal risk
o TRAb –ve : No antithyroid drugs needed as very low risk of foetal / neonatal
thyrotoxicosis
o TRAb +ve : Follow up foetal growth and monitor TFTs
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● 1-5% of neonates born to women with Graves’ disease have foetal hyperthyroidism/
thyrotoxicosis due to transplacental transfer of TRAb
● Uncontrolled hyperthyroidism can cause:
Mother Foetal / Neonatal

⮚ Miscarriage ⮚ Prematurity
⮚ Pre-eclampsia ⮚ Small size for gestational age
⮚ Preterm delivery ⮚ Intrauterine foetal death
⮚ Congestive heart failure (CHF) ⮚ Goitre
⮚ Thyroid storm ⮚ Thyrotoxicosis
⮚ Placental abruption ⮚ Transient hyperthyroidism
(neonates)
⮚ Hydrops fetalis
● Adverse effects of drugs used in hyperthyroidism:
Propylthiouracil (PTU) Carbimazole Propranolol

Rash, fever, Rash, fever, Bronchospasm, intrauterine
agranulocytosis, risk of liver agranulocytosis, aplasia growth restriction, neonatal
toxicity cutis, methimazole hypoglycaemia
embryopathy
● If patient is allergic to carbimazole, change to PTU
● Maintaining FT4 levels in the upper normal of non-pregnant reference range usually
protects the feotus from hypothyroidism
● Carbimazole is safe for lactating mothers and infants up to 20mg/day.
● Administer ATDs following a feeding, in divided doses to reduce excretion in breast milk.
● Subtotal thyroidectomy may be indicated if:
o Patient has severe reaction to ATD
o Persistent high doses of ATD are required (Carbimazole> 30mg or PTU >
450mg/day)
o Non-adherence or uncontrolled hyperthyroidism
● The optimal timing of surgery is in the second trimester
● Refer Medical Eligibility Criteria for Contraception Use, WHO 2015 for contraception
counselling
● Women with history of Postpartum Thyroiditis (PPT) have a markedly increased risk of
developing permanent primary hypothyroidism in the five-to-ten year’s period after the
episode of PPT. An annual TSH level should be performed in these women
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Reference:
1. The American Thyroid Association Taskforce on Thyroid Disease during Pregnancy

and Postpartum, Stagnaro-Green, A., Abalovich, M., Alexander, E., Azizi, F.,
Mestman, J. Wiersinga, W. (2011). Guidelines of the American Thyroid Association
for the Diagnosis and Management of Thyroid Disease during Pregnancy and
Postpartum. Thyroid, 21(10), 1081–1125. http://doi.org/10.1089/thy.2011.0087
2. 2017 Guidelines of the American Thyroid Association for the Diagnosis and
Management of Thyroid Disease during Pregnancy and the Postpartum. Erik K.
Alexander, Elizabeth N. Pearce, Gregory A. Brent, Rosalind S. Brown, Herbert Chen,
Chrysoula Dosiou, William A. Grobman, Peter Laurberg,John H. Lazarus, Susan J.
Mandel, Robin P. Peeters,11 and Scott Sullivan. THYROID, Volume 27, Number 3,
2017 ª American Thyroid Association ª Mary Ann Liebert, Inc. DOI:
10.1089/thy.2016.0457
3. 2015 American Thyroid Association Management Guidelines for Adult Patients with
Thyroid Nodules and Differentiated Thyroid Cancer. Bryan R. Haugen, Erik K.
Alexander, Keith C. Bible, et al. The American Thyroid Association Guidelines Task
Force on Thyroid Nodules and Differentiated Thyroid Cancer.
4. Oxford Handbook of Obstetric and Gynaecology 3rd edition (2013)
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5.4.2 Hypothyroidism in Pregnancy

Pre Overt ● Refer FMS for counselling- pre pregnancy care
pregnancy hypothyroidism ● If already on L-Thyroxine, maintain TSH < 2.5
: mIU/L
Booking ● An elevated ● Overt and subclinical hypothyroidism case should
TSH (>2.5 be referred to FMS/ combined clinic as it should be
mIU/L) in treated
conjunction ● As soon as pregnancy is confirmed, the dose of L-
with a Thyroxine should be increased by 25%-30%
decreased ● Target TSH differs according to each trimester as
FT4 stated below
concentrati ● To screen for hypothyroidism in pregnant women
on or with risk factors including history of thyroid
● Women disease, type 1 diabetes mellitus, or other
with TSH autoimmune diseases; current or past use of
level >10 thyroid therapy; or a family history of autoimmune
mIU/L, thyroid disease (American Academy of Family
irrespective Physician – Thyroid disease in Pregnancy, 2016).
with their ● Take blood for serum TSH in women with:
FT4 level ⮚ History of thyroid dysfunction or thyroid surgery
Subclinical ⮚ Symptoms of thyroid dysfunction or presence of
hypothyroidism goitre
● Serum TSH ⮚ History of head or neck radiation
above the ⮚ Use of amiodarone or lithium, or recent
upper limit administration of iodinated radiologic contrast
of the
Subsequen trimester- ● Dose of L-Thyroxine should be adjusted according
t antenatal specific to target TSH as below
follow up reference ● Target TSH
range with ⮚ 1st trimester: 0.1-2.5 mIU/L
a normal ⮚ 2nd trimester: 0.2-3.0 mIU/L
FT4 ⮚ 3rd trimester: 0.3-3.0 mIU/L
● TFT should be measured every 4- 6 weeks
● Shared care between FMS and Combined Clinic
team
Delivery ● May allow post-date unless there is other obstetric
indications for earlier delivery
● For hospital delivery
Post ● After deliver, most patients need to reduce the
partum dose of L-Thyroxine to the dose before pregnant
● L-Thyroxine can be continued in breastfeeding
mother
● Repeat serum TSH at 6 weeks postpartum
● The newborn babies should be referred to
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paediatric team for assessment
● Discuss options of contraception (Refer Medical
Eligibility Criteria for Contraception Use, WHO
2015)
Upon ● Refer FMS/MO at 2 month postpartum to review
discharge TSH result and contraception advise
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5.5 BRONCHIAL ASTHMA IN PREGNANCY

Pre Asthma ● Establish diagnosis of asthma accurately
pregnancy diagnosed ● Preferably every asthma patient need to have
before spirometry test
pregnancy ● Check the best baseline peak flow
● Assess level of asthma control as per CPG
Management of Asthma in Adults 2017 or GINA
guideline
● Optimise treatment before getting pregnant
● Address trigger factors
● Check inhaler techniques
● Educate patient on the stepwise approach
● Refer to FMS if asthma is partially controlled
● Refer to Medication Therapy Adherence Clinic
(MTAC) to optimise treatment
● Advise on smoking cessation in women who smokes
At booking ● Assess level of asthma control
● If asthma is well-controlled, mothers can be followed
up by MO
● If asthma is partially controlled (Step 2-3) follow-up
by FMS
● Refer to Combined Clinic if indicated
● Educate patients on stepwise approach
● Patient should have a written asthma action plan
Subsequent ● Assess level of asthma control
antenatal ● Monitor PEFR at every visit
follow-up ● Optimise treatment
● 2-4 weekly review depending on level of asthma
control
● Foetal surveillance with SFH, FKC, foetal growth
monitoring by serial ultrasound, starting at 28 weeks
till 36 weeks.
● Admit if indicated during exacerbations
● Refer to O&G specialist for further management if
required
plan ● May allow post-date unless there is other obstetric
indications for delivery
Postpartum ● Continue asthma medications

● Discharge patient once stable
● Emphasise on contraception
● Continue stepwise approach
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Upon ● Notify to health clinics prior to discharge
discharge ● In mild asthma, mothers should be reviewed by MO
from ● For moderate asthma, follow-up by FMS
hospital
Reference:
1. Global Strategy for Asthma Management and Prevention (2017 update) by Global
Initiative for Asthma (GINA)
2. Clinical Practice Guidelines Management of Asthma in Adults 2017, Ministry of
Health Malaysia
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5.6 CARDIAC DISEASE IN PREGNANCY
5.6.1 Heart Disease in Pregnancy
Refer Clinical Practice Guidelines – Heart Disease in Pregnancy, Ministry of

Health, 2nd Edition 2016
5.6.2 Peripartum Cardiomyopathy
Refer Clinical Practice Guidelines – Heart Disease in Pregnancy, Ministry of

Health, 2nd Edition 2016
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5.7 INFECTIOUS DISEASE IN PREGNANCY
5.7.1 Retroviral Disease
a. HIV in pregnancy
Refer Garis Panduan Pengukuhan Program Pencegahan Jangkitan HIV dan

Sifilis dari Ibu-ke-Anak, Kementerian Kesihatan Malaysia, 2021
b. Serodiscordant Couple (Positive Male, Negative Female)

Pre ● Refer couple for pre pregnancy counselling
pregnancy ● Pregnancy must be well-planned
● Husband should be on HAART and is virally suppressed before
attempting conception
● Plan for timed unprotected intercourse during fertile period
● Advise on protected sexual intercourse other than that timed period
● Advise for early antenatal booking
● Recommend wife to have pre-exposure prophylaxis (PrEP) if
husband is not on treatment/ non-compliant /unknown viral load/
unsuppressed viral load
● Wife does not have to be on PrEP if husband is virally suppressed,
but need proper counselling and close monitoring
At diagnosis ● Early booking if UPT positive
● To do HIV screening each trimester
● Emphasize on safe sex or abstinence
Subsequent ● Mother must be closely monitored
antenatal ● If HIV screening is reactive, to refer to FMS
follow-up
Delivery ● Mode of delivery as per obstetric indication
plan
Postpartum ● Closely monitor mother and child
● Discuss options for contraception. BTL can be offered if patient/
couple had completed family
discharge ● Repeat rapid test
from
hospital
Reference:
1. Management of HIV Infection in Pregnant Women, Ministry of Health, 2008
2. Malaysian Consensus Guidelines on Antiretroviral Therapy, Ministry of Health, 2017
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5.7.2 Syphilis in Pregnancy
Refer Garis Panduan Pengukuhan Program Pencegahan Jangkitan HIV dan

Sifilis dari Ibu-ke-Anak, Kementerian Kesihatan Malaysia, 2021
5.7.3 Hepatitis B in Pregnancy

At booking/ ● Screen for Hepatitis C co-infection if not done previously
diagnosis ● Screen husband and family
● Counsel on high-risk behaviours
● Determine infectivity
● Notify for newly diagnosed as required under the Infectious
Disease Prevention and Control Act 1988
Subsequent ● To do HBe antigen and Hbe antibody
antenatal ● Monitor liver functions every trimester
follow-up ● Look for hepatic flares and admit if indicated
● Refer to combined clinic / O&G if indicated
● If positive HBe antigen, arrange for ultrasound of hepatobiliary
system
● Admit if patient is jaundiced
● Look for other comorbidities
● If low infectivity (antibody Hbe reactive), for MO follow up
● Stable high infectivity can be followed up by FMS
● If available, measure HBV viral load at 28 weeks. If Hep B DNA is
high in third trimester (>200,000 IU/ml, refer gastroenterologist or
MFM for antiviral therapy)
Delivery plan ● Refer to O&G & decide mode of delivery
● Universal precaution
● Hep B immunoglobulin and Hepatitis B vaccination (1st dose) to
be given at birth or no later than 12 hours after delivery
● Refer baby to paediatric team
● Allow breastfeeding
Postpartum ● Advise on contraception (Refer Medical Eligibility Criteria for
Contraception Use, WHO 2015)
Upon ● Arrange for pre pregnancy care

discharge ● Ensure mother has follow up with gastroenterology/medical team
from hospital ● Advise patient on importance of early booking in next pregnancy
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Reference:
1. Asian-Pacific Clinical Practice Guidelines on the Management of Hepatitis B: a 2015

update
2. Management of Hepatitis B in Pregnancy: The Royal Australian and New Zealand
College of Obstetricians and Gynaecologists July 2016
3. South Australian Perinatal Practice Guidelines: Hepatitis B in Pregnancy
4. Chronic Hepatitis B in Pregnancy A Workshop Consensus Statement on Screening,
Evaluation, and Management
5. Sabah Obstetric Shared Care Guidelines 2018
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FLOW CHART FOR CHRONIC HEPATITIS B IN PREGNANCY MANAGEMENT APPROACH
HBsAg and anti-HBs tests Recommended screening of all household

and sexual contacts
HBsAg (-) HBsAg (+) HBsAg (-) HBsAg (-) HBsAg (+)
Anti-HBs (-) Anti-HBs (+)
If anti-HBs (-) and at high risk Order additional tests :

consider vaccination of the pregnant ALT Vaccinate Immune (No Primary care
woman during pregnancy or HBeAg, anti-HBe follow-up provider to
postpartum HBV DNA level required) evaluate and
monitor
HBeAg (+) HBeAg (-)

-or- HBV DNA < 200,000 IU/mL
HBV DNA > 200,000 IU/mL ALT normal
-or-
ALT elevated* *New norms establish elevated ALT as
≥ 19 IU/L for women, ≥ 30 IU/L for men
Abbreviations: ALT, alanine aminotransferase;
Refer to specialist Refer to specialist or HBsAg, hepatitis B surface antigen;
immediately during primary care provider anti-HBs, antibody to HBsAg;
pregnancy postpartum HBeAg, hepatitis B e-antigen;
anti-HBe, antibody to HBeAg.
Recommended Approach for Hepatitis B Virus (HBV) Screening, Evaluation, Vaccination, and Referral of Pregnant Women
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5.7.4 Tuberculosis in Pregnancy

Pre ● Women with tuberculosis (TB) on treatment must be advised for
pregnancy contraception until she has completed treatment
At booking / ● To screen all pregnant mothers according to the guideline by asking

diagnosis whether she has prolonged cough more than 2 weeks
● For patient with suspected tuberculosis based on history and
physical examination, investigations including:
⮚ Sputum AFB direct smear X 3
(Induce sputum if unable to produce sputum)
⮚ CXR with abdominal shield (preferably after 12 weeks gestation)
⮚ Biopsy if indicated (extrapulmonary tuberculosis)
● For newly diagnosed tuberculosis:
⮚ Refer Pusat Rawatan 1 (PR 1) and FMS once for follow up
⮚ Notify and contact tracing as per protocol
⮚ Baseline investigations (FBC, RBS, BUSE, creatinine, LFT,
sputum MTB C&S, HIV rapid test)
⮚ Refer combined clinic/ visiting O&G specialist in district hospital
● For relapsed pulmonary TB (PTB):
⮚ may start re-treatment and refer to respiratory team if suspected
MDR TB
● Treatment regime:
1. For pulmonary tuberculosis – 2 EHRZ / 4HR
(Pyridoxine 30 mg OD to be given with Isoniazid)
2. For extrapulmonary tuberculosis – refer to respective team
3. For drug-resistance TB (DR-TB) – refer to chest physician
Streptomycin can cause foetal ototoxicity and should not be used
during pregnancy
Subsequent ● Check on directly observed therapy (DOT)
antenatal ● Continue anti-TB treatment
follow-up ● Monitor patient as per guidelines.
● Ultrasound monthly after 24 weeks to look for IUGR
Postpartum ● Refer baby to Paediatric team to initiate isoniazid prophylaxis
● Defer giving BCG if baby is symptomatic
● Inform health clinic upon discharge to ensure continuity of TB
treatment
● Allow breastfeeding
● Advise on contraception (Refer Medical Eligibility Criteria for
Contraception Use, WHO 2015). Rifamycin drugs such as rifampicin
or rifabutin reduce contraceptive efficacy of both OCP and POP.
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Remarks:
1. Diagnosing TB in pregnancy can be difficult as it is masked by pregnancy changes.
2. TB in pregnancy has been associated with increased risk of maternal and perinatal
morbidity namely premature delivery, SGA and LBW
3. Mantoux test is considered safe and valid for use in pregnancy
4. Chest X-ray must not be delayed in diagnosis of PTB even before 12 weeks
because the risk of ionizing radiation is so low for one with an abdominal shield
5. First-line anti-TB drugs are safe in pregnancy and breastfeeding
6. Breastfeeding should be continued – use 3-ply surgical mask of the mother is still
infectious
Reference:
1. Garis Panduan Kawalan Dan Pencegahan Tibi Dalam Kalangan Ibu Mengandung,
Programme Kawalan Tibi Kebangsaan, Kementerian Kesihatan Malaysia, 2018
2. Clinical Practice Guidelines Management of Tuberculosis (3rd edition ), Ministry of
Health, 2012
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5.7.5 Chickenpox in Pregnancy

At diagnosis ● Pregnancy with significant exposure:
⮚ Administer VZIg (ideal to be administered within 96 hours to 10
days of exposure)
▪ If VZIg is given – pregnant women should be managed as
potentially infectious from 8 to 28 days (8 to 21 days if no VZIg
is given)
⮚ A second dose of VZIg may be require if further exposure is
reported and 3 weeks have elapsed since the last dose
● Assess for complications (i.e,.: pneumonia, hepatitis and encephalitis)
⮚ If complications developed, to refer O&G and medical team
⮚ In the absence of complication but the mother has risk factors † or
co
⮚ morbidities, to refer O&G for assessment
⮚ If no complications, to manage as outpatient
● Onset of symptoms:
⮚ If onset within 72 hours and >20 weeks POG, to treat with oral
Acyclovir 800mg 5 times daily for 7 days. Intravenous acyclovir
may be required for severe disease
⮚ if <20 weeks POG, need to discuss risk and benefit of acyclovir
● Refer immediately to hospital for severe presentation (refer O&G and
medical team)
● Isolate either at home or ward (if admission is required)
● Educate mothers on prevention of spread of disease – infectious state
until the lesions have crusted (usually about 5 days after the onset of
rash)
● Symptomatic treatment and emphasise on hygiene to prevent
secondary bacterial infection of the lesions
Subsequent ● If infection occurred ≤ 20 weeks POG, refer to O&G for detail scan at
antenatal follow- 24 weeks POG
up
Delivery plan ● Preferably to delay delivery 7 days after onset of symptoms
Delivery ● Hospital delivery
● Timing of delivery as per obstetric indications
Postpartum ● Breastfeeding is encouraged
● Baby should be referred to paediatric team after delivery, irrespective
of the gestation when maternal varicella zoster infection developed
Contraception Use, WHO 2015).
Pre pregnancy & ● Varicella vaccination can be considered for seronegative patient
Postpartum ⮚ To avoid pregnancy in the next 4 weeks after the completing the
vaccine schedule
⮚ To continue breastfeeding after vaccination
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†
Risk factor and comorbid that requires the mother to be assessed by specialist even
though without complications:
⮚ Smoker
⮚ Chronic lung disease
⮚ Corticosteroids use in the preceding 3 months
⮚ In the second half of pregnancy
REMARKS:
● Causative agent: Varicella zoster virus
● Mode of transmission: Direct contact with vesicle fluid & respiratory droplets (2 days
before appearance of rash up to the healing of active rash).
● Incidence: uncommon for primary varicella infection.
● Maternal complication**
⮚ Pneumonia (40% risk of death)
⮚ Hepatitis
⮚ Encephalitis
● Foetal complications
⮚ Congenital Varicella Syndrome (0.4 to 2%) early 2nd trimester (< 20 week)
▪ Skin scarring in dermatomal distribution
▪ Eye defects (microphthalmia, chorioretinitis, cataracts)
▪ Limb hypoplasia
▪ Neurological abnormalities (microcephaly, cerebral cortical atrophy, mental
retardation or dysfunction of bowel and bladder sphincters)
● Neonatal complication
⮚ Neonatal varicella (within first ten days of life) – if mother developed rash 5 days
before or 2 days after delivery
▪ If maternal infection occurs 1-4 weeks before delivery, up to 50% of infants are
infected and up to 23% develop clinical varicella
▪ Severe chickenpox may occur if infants are born within 7 days of onset of
mother’s rash or if mother develops rash up to 7 days after delivery
⮚ Risk of death – 30%
● Severe presentations that need immediate referral including:
⮚ Dense rash
⮚ Respiratory symptoms
⮚ Neurological symptoms
⮚ Haemorrhagic rashes
⮚ Immunosuppressive drugs use
● Aim of treatment is to reduce maternal complication
⮚ Significant varicella infection such as pneumonitis should be treated
● Side effects of acyclovir – cardiovascular effect, polydactyly, limb reduction &
hypospadias
● Varicella Zoster vaccination(attenuated live-virus vaccine) in pregnant women is NOT
recommended
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Reference:
1. Chickenpox in Pregnancy (Green-top Guideline No. 13), Royal College of
Obstetricians & Gynaecologists (RCOG), 2015
2. Clinical Practice Guideline No. 274-Management of Varicella Infection
(Chickenpox) in Pregnancy, Society of Obstetricians & Gynaecologists of Canada
(SOGC), 2012
5.7.6 Group B Streptococcus in Pregnancy

At booking ● Routine universal screening for GBS is currently not
recommended.
● High risk screening by identifying clinical risk factors:
⮚ History of previously affected baby (GBS sepsis, both early &
late onset)
▪ intrapartum antimicrobial prophylaxis (IAP) will be required,
repeat test is not necessary
⮚ History of maternal GBS carriage but baby did not contract
GBS sepsis
▪ to screen for GBS at 35-37 weeks (singleton) or 32-34
weeks (twins)
● HVS (high vaginal swab) C&S is the usual test, especially for
symptomatic woman (diagnostic).
● LVS (low vaginal swab) and/ or rectal swab or VRS (vaginal-
rectal swab) may be used for screening of asymptomatic women.
However, confirmation with the laboratory is needed for LVS /
rectal swab / VRS (regarding transport media). If LVS / rectal
swab / VRS cannot be sent, then resort to HVS.
Antenatal Care ● In mothers with history of maternal GBS carriage, but baby did
not contract GBS sepsis:
⮚ Screen for GBS C&S at 35-37 weeks (singleton) or 32-34
weeks (twins):
▪ If positive – for IAP
▪ If negative – IAP is not required
● In mothers with proven GBS during this pregnancy
⮚ GBS bacteriuria / UTI  treat and will require IAP even if
GBS has been eradicated from urine as evidenced from
repeat urine C&S 2 weeks after treatment.
⮚ GBS cultured from vaginal / rectal swab for symptomatic
patients  treat and repeat swab 2 weeks after treatment. If it
has been eradicated, IAP would not be required
⮚ GBS cultured from vaginal / rectal swab (incidentally and
asymptomatic)  no need antenatal treatment but IAP would
be required.
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Intrapartum ● Clinical factors that are associated with increased risk of baby
care contracting GBS sepsis:
⮚ Previous baby affected with GBS sepsis
⮚ Maternal GBS carriage from bacteriological investigation e.g.
urine or vaginal C&S
⮚ Preterm birth
⮚ Prolonged rupture of membranes
⮚ Suspected intrapartum maternal infection including
chorioamnionitis
● Therefore, IAP would be required for:
⮚ Mother with history of previously affected baby with GBS
sepsis
⮚ Mother with history of GBS UTI, even after it has been treated
/ eradicated
⮚ Mother whose latest vaginal / rectal swabs was GBS positive
(intentional swabs e.g. 35-37 weeks screening, or incidental
swabs)
⮚ Mother with history of GBS carriage but no repeat swab was
done – counsel patient that the likelihood of maternal GBS
carriage in this pregnancy is 50% and offer IAP
⮚ Preterm labour (PTL)
⮚ Preterm prelabour rupture of membranes (PPROM):
▪ PPROM >34+0 weeks: start IAP and expedite delivery
▪ PPROM <34+0 weeks: start antibiotic and conservative
management with close monitoring as perinatal risks
associated with prematurity will likely outweigh perinatal
infection. Deliver when indicated.
⮚ Prelabour rupture of membranes (PROM):
▪ If known GBS carrier – start immediate IAP and induce for
delivery
▪ If not a GBS carrier – start IAP at 18hr of PROM and
induce for delivery as per protocol (not later than 24hr of
PROM)
● In suspected intrapartum maternal infection (maternal pyrexia
>380C) – start broad spectrum antibiotic which covers for GBS.
● IAP is not required for women undergoing planned caesarean
section in the absence of labour and with intact membranes. The
routine prophylactic antibiotics for surgery is necessary and
adequate.
● IAP regimens:
⮚ IV Penicillin G 5million units, followed by 2.5 million units 4-
hourly until delivery (after test dose)
⮚ OR
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⮚ IV Ampicillin 2g followed by 1g 4-hourly until delivery
⮚ Consider Vancomycin for patients with suspected penicillin
allergy
Postpartum ● Refer baby to Paediatric team
care ● Counsel patient for all future pregnancies / deliveries:
⮚ IAP if baby has GBS sepsis
⮚ Screen for GBS 35-37 weeks if she has GBS this / past
pregnancy and baby is not affected
● Document the above instruction in patient’s antenatal (red) book
● Advise on contraception
Reference:
1. Hughes RG, Brocklehurst P, Steer PJ, Heath P, Stenson BM on behalf of the
Royal College of Obstetricians and Gynaecologists. Prevention of early-onset
neonatal group B streptococcal disease. Green-top Guideline No.36. BJOG
2017;124:e280-e305
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5.7.7 Dengue in Pregnancy
Refer Clinical Practice Guidelines – Management of Dengue Infection in

Adults, Ministry of Health, 3rd Edition 2015
5.7.8 Malaria in Pregnancy
Refer to Management Guidelines of Malaria in Malaysia 2013
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5.8 KIDNEY DISEASE IN PREGNANCY
5.8.1 Urinary Tract Infection
Refer Consensus Guidelines on the Management of Urinary Tract Infections

in Pregnancy, MOH 2021
5.8.2 Chronic Kidney Disease

Pre ● All women in the reproductive age group with renal impairment
pregnancy should be referred for pre pregnancy counselling by O&G and
nephrologist (multidisciplinary team)
● Pregnancy may be considered in women having mild renal
impairment (serum creatinine < 125µmol/L) and well-controlled
blood pressure
● Women with moderate to severe renal impairment should be
counselled to avoid pregnancy due to greater adverse maternal and
foetal outcomes
● Rule out relative contraindication to pregnancy:
⮚ ESRF
⮚ Renal replacement therapy / haemodialysis
⮚ Recent transplant < 1-2 years
⮚ Transplant with recent rejection
● Baseline investigations: Pre-eclampsia profile
Antenatal ● Shared care between health clinic and O&G team
● First trimester dating scan
● For Aspirin 150mg OD and Calcium Carbonate 1g BD at booking
● At every visit, women should be screened for complications,
hypertension, proteinuria and pre-eclampsia
● UTI screening for asymptomatic bacteriuria at each visit
● Renal function monitoring at each trimester or more frequent if
needed.
● Anomaly scan at 24 weeks (Indication: drug exposure in pregnancy)
● Ultrasound for foetal growth every 4 weeks starting from 24 weeks
POA till delivery

● Timing of delivery as per obstetric indications
Postpartum ● Encourage breastfeeding
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REMARKS:
● Severity grading in chronic kidney disease follows serum creatinine level
Severity Serum Creatinine Level (µmol/L)
Mild 90-124
Moderate 125-225
Severe >225
● Pregnancy in women with moderate to severe renal impairment (serum creatinine>

125µmol/L) results in increased risk of adverse maternal and foetal outcomes
● Common maternal complications include accelerated decline in renal function,
hypertension, proteinuria and pre-eclampsia
● Common foetal complications include spontaneous abortion/ neonatal death,
prematurity, low birth weight/ SGA baby
Reference:
1. Clinical Practice Guidelines, Management of Chronic Kidney Disease (2 nd edition),
Ministry of Health, Malaysia 2018
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5.9 CONNECTIVE TISSUE DISEASE IN PREGNANCY
5.9.1 Rheumatoid Arthritis

Pre pregnancy ● Refer to pre pregnancy clinic (FMS/ O&G/ Rheumatologist/
Physician)
● Avoid unplanned pregnancy
● Pregnancy should be deferred until disease is under good
control on medications compatible with pregnancy
● Folic acid 5mg daily
● Majority will achieve disease control in pregnancy
● NSAIDs should be discontinued during periconception period
and used sparingly during the first trimester
● Medications that can generally be used throughout pregnancy
are hydroxychloroquine (HCQ), sulfasalazine (SSZ) and
azathioprine (AZA)
● Pregnancy is contraindicated for patients on methotrexate,
leflunomide, JAK-2 inhibitors and biological agents due to its
teratogenicity
At booking/ ● Continue calcium supplementation during pregnancy
diagnosis ● For patients already on medical / rheumatology follow-up 
refer Combined Clinic
● For patients not on medical / rheumatology follow-up  refer
medical / rheumatology AND Combined Clinic
● OGTT for patients on prednisolone
● Foetal detail scan
Delivery plan ● Timing and mode of delivery as per obstetric indications
Postpartum ● Monitor for flares.
● Refer rheumatologist for follow-up
Lactation ● Safe to continue: NSAIDS (but aspirin should be avoided),
corticosteroids, HCQ, SSZ, TNF inhibitors, AZA
● Inadequate data: JAK inhibitors (tofacitinib)
● Contraindicated: methotrexate, leflunomide, cyclosporine,
cyclophosphamide, chlorambucil and other biologics
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5.9.2 Systemic Lupus Erythematosus

Pre pregnancy ● Refer to pre pregnancy clinic (FMS/ O&G/Rheumatologist/Physician)
● Pregnancy should be deferred until disease is under good control on
medications compatible with pregnancy, whenever possible
● Folic acid 5mg daily
● Pregnancy may increase the risk of disease flares
● Assess disease activity, major organ involvement, hypercoagulability
and concurrent medical conditions
● Pregnancy is allowed if:
⮚ Disease in remission for ≥ 6 months
⮚ BP is well-controlled
⮚ eGFR >60ml/min
⮚ Proteinuria <1g/day (proteinuria 2+)
● Test for anti‐Ro and anti‐La is recommended if available, as
determining the status of these autoantibodies improves counselling
regarding pregnancy and foetal risk
At booking/ ● Refer for rheumatology clinic assessment
diagnosis ● Early combined clinic appointment after assessment by rheumatologist
● Assessment to detect disease flares:
⮚ Symptoms:
▪ Joint pain
▪ Cutaneous manifestations
▪ Serositis
● Blood pressure should be monitor closely
● Investigations:
▪ FBC, RP, LFT, ESR, uric acid
▪ Red cell cast in urine (UFEME)
▪ Urine 24hour protein (if proteinuria present)
▪ Reduction in complement (C3, C4) values
▪ Increase in dsDNA antibody titer
Subsequent ● T. Aspirin 150mg daily from 12 weeks until delivery
antenatal follow- ● Calcium supplementation starts at 20 weeks until delivery
up ● During antenatal follow up, look out for signs and symptoms of disease
flares, anaemia, pre-eclampsia, foetal growth restriction and other
disease complications
Delivery plan ● Hospital delivery
● Timing and mode of delivery as per obstetric indications
Post-partum ● Monitor for flares
● If antiphospholipid syndrome is present, continue pharmacological
thromboprophylaxis for 6 weeks after delivery
● Advise patient regarding contraception (Refer Medical Eligibility
Criteria for Contraceptive Use, WHO 2015)
Lactation ● Generally safe
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5.9.3 Antiphospholipid Syndrome (APS)

Pre pregnancy ● Assessment of past thrombotic event (arterial or venous)
● Assessment of any associated condition (e.g. SLE) and
thrombotic risk (e.g. obesity, smoking)
● APS patients on oral anticoagulation should be informed about
the potential teratogenic effects of warfarin
● Oral anticoagulation should be switched to a therapeutic dose
of low-molecular-weight heparin (LMWH) either before or very
shortly after conception.
● Defer pregnancy in order to improve general health and reduce
risk, such as the need for weight loss, following an acute
thrombotic event or treatment of active SLE
● Pregnancy should be actively discouraged in certain condition
e.g; in pulmonary hypertension, the risk of maternal death is
estimated at 35%
At booking/ ● Refer specialist for assessment / initiation of VTE prophylaxis
diagnosis ● Start low-dose aspirin (150mg OD) on confirmation of
pregnancy
Subsequent ● Refer hospital for combined care
antenatal follow- ● Foetal growth should be monitored monthly from 24 weeks of
up gestation
Delivery plan ● Timing and mode of delivery as per obstetric indication

● Delivery should be planned for thrombotic APS
● There is no contraindication for vaginal delivery for patients on
LMWH, but vigilance for PPH is recommended
● LMWH should be discontinued at least 12 hours prior to
planned delivery / IOL
Postpartum ● Continue VTE prophylaxis for 6 weeks for those with history of
thrombosis
● Avoid oestrogen-containing contraception pills. Refer Medical
Eligibility Criteria for Contraceptive Use by WHO 2015
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5.10 NEUROLOGICAL DISORDER IN PREGNANCY – EPILEPSY

Pre pregnancy ● Refer all women with epilepsy in the reproductive age and
planning to conceive to the pre pregnancy clinic
● Emphasise on compliance to antiepileptic drug (AED)
● Counsel patient on the risk of treatment (teratogenicity) vs risk of
defaulting treatment (seizure risk to mother and feotus)
● Advise to take folic acid 5mg daily
● Aim for seizure control at least 6 months before conception
● Aim to use the lowest effective dose of a single anticonvulsant
whenever possible
● Advise early booking once pregnant
At diagnosis in ● Perform first trimester dating scan and anomaly scan (i.e.NTD)
pregnancy ● Refer combined clinic
● Folic acid 5mg daily till delivery
● Maintain the pre-existing AED if seizure is well-controlled
Subsequent ● Shared care between FMS and combined clinic
antenatal ● For detailed scan at 18 to 24 weeks gestation
follow-up ● Watch out for signs of depression, anxiety and neuropsychiatric
symptoms in all mothers on AED
● Advise compliance to AED
● Advise to avoid triggers of seizures such as sleep deprivation
and stress
● Perform serial growth scans monthly from 24 weeks of gestation
● Routine serum AED level monitoring during pregnancy is not
recommended
Delivery Plan ● Generally may allow postdate unless specified
otherwise/compounded by other factors
Delivery ● Timing and mode of delivery as per obstetric indications
● Provide adequate analgesia
● Continue AED in labour
Postpartum ● Reinforce the importance of contraception and planned
pregnancy. Advise on contraception according to Medical
Eligibility Criteria for Contraceptive Use, WHO 2015
● Adjustment of AED dose (if required) need further discussion
with treating physician/neurologist
● Breastfeeding is encouraged
● Neonates need to be monitored for side effects of AEDs e.g.:
drowsiness, jitteriness and hypotonia
● Monitor the mother for at least 24 hours postpartum
● Screen mothers for depression
● Advise on safety issues and strategies to prevent accidental
injury while caring of newborns with involvement of family
members
●
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Upon ● Notification of high-risk discharge from hospital to respective
discharge from health clinics as per guideline.
hospital ● Arrange appointment with FMS at 1 month postpartum
● Provide neurology / medical clinic appointment
● To give pre pregnancy clinic appointment with FMS at 3 months
postpartum (if future pregnancy is possible / anticipated)
REMARKS:
● Seizure frequency in pregnant women with epilepsy: 60% no change, 30%
increase, 10% decrease
● Pregnancies in women with epilepsy should be planned, when possible
● Give women a clear understanding of the risks of uncontrolled seizures and the
possible teratogenicity of AED. Where possible, avoid sodium valproate and AED
polytherapy. Phenytoin, carbamazepine, sodium valproate, lamotrigine and
levetiracetam can cross the placenta
● In-utero exposure to carbamazepine, lamotrigine, levetiracetam and phenytoin
does not appear to adversely affect neurodevelopment of the child
● Major malformation: NTD (valproate), orofacial clefts (phenobarbitone), heart
disease (phenytoin and valproate).
● Minor malformation: Foetal anticonvulsant syndrome - also need to be ruled out
Safety strategies to prevent accidental injury while caring of newborns:

● Nurse the baby on the floor
● Use very shallow baby baths and do not bathe the baby unaccompanied
● Lay the baby down if there is a warning aura
● Avoid sleep deprivation and alcohol
Contraception:
● IUCD is a preferred choice of contraception
● If opting for hormonal contraception, higher dose is required
Reference:
1. Epilepsy in Pregnancy (Green-top Guideline No. 68) , Royal College of Obstetricians
& Gynecologists (RCOG), 2016
2. Diagnosis and management of epilepsy in adults (SIGN 143), Scottish Intercollegiate
Guidelines Network (SIGN) 2015
3. Consensus Guidelines on the Management of Epilepsy, Malaysian Society of
Neurosciences, 2017
4. Women and Epilepsy, Edmonton Epilepsy Association, 2011
5. Clinical Guideline Epilepsy and Pregnancy Management, South Australian Maternal
and Neonatal Clinical Network, 2014
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5.11 THROMBOEMBOLISM IN PREGNANCY
Refer Training Manual on Prevention and Treatment of Thromboembolism

in Pregnancy and Puerperium, Ministry of Health 2018
5.12 OBESITY IN PREGNANCY
Refer Consensus Clinical Guideline on Obesity in Pregnancy, Ministry of

Health 2022
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5.13 SMOKING IN PREGNANCY

Pre ● Offer quit smoking services and pre pregnancy care to all
pregnancy reproductive women who are smoking
At booking ● Smoking history should be elicited in all pregnant women

/ diagnosis ● If the woman is an active smoker, assess:
⮚ Stage of her willingness to quit
▪ Pre-contemplation - No quit plan in next 6 months
▪ Contemplation - Quit plan in next 6 months. Seriously
considering
▪ Preparation - Quit plan for next month.
▪ Action - Quit. Day 1-6 months tobacco free
▪ Maintenance - Quit. More than 6 months
⮚ Level of addiction using Fagerstrom’s score for nicotine
dependence (Table 5.1)
⮚ Analyse level of carbon monoxide (CO) in blood by breath test
▪ Level >3 ppm (suspect smoking), (usually smoker >7ppm)
▪ Test is available at Quit Smoking Clinic
Subsequen ● No safe smoking level in pregnancy

t antenatal ● Stopping smoking at any time during pregnancy is beneficial to
follow-up mother and baby
● Advise all pregnant women to avoid cigarette smokes during
pregnancy including secondhand smokes
● Refer O&G if complications develop
● Refer quit smoking programme (need support to cope with
withdrawal and craving)
● Treatment:
⮚ Non-pharmacological - Psychosocial intervention is effective in
supporting pregnant smokers to quit :
▪ Advise regarding smoking-related risks
▪ Pregnancy-specific self-help materials counselling session
with a health educator.
▪ Counsellor provided counselling session and telephone follow
up calls during pregnancy and after delivery
▪ Quit plan : set date for quit smoking
▪ Counselling
● Motivation – 5R
♦ Relevance – Why quitting is important to them
♦ Risks – Negative consequences of ongoing habit
♦ Rewards – Benefits of tobacco cessation
♦ Roadblock – Identify impediments to quitting (eg:
withdrawal symptom, fear, weight gain)
♦ Repetition – Repeat every time the patient comes to the
clinic
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⮚ Pharmacological
▪ Indicated when non-pharmacological treatment failed
▪ Nicotine replacement therapy (NRT) – Safer than smoking (no
tar and carbon monoxide)
▪ NRT helps to manage craving
▪ Risks & benefits should be discussed
▪ Only prescribe NRT once quit date is set
♦ Prescribe NRT for 2 weeks then reassess
♦ Continue NRT if they have quit smoking
▪ Be cautious of NRT use in CVD
● Bupropion and Vareniciline should not be offered to pregnant or
breastfeeding women.
● Electronic cigarettes are not recommended in pregnancy because
long term risk to baby is unknown
Delivery ●
Mode and timing of delivery as per obstetric indications
plan ●
Hospital delivery
●
Refer baby to paediatric team
●
Advise on contraception. Refer Medical Eligibility Criteria for
Contraceptive Use, WHO 2015
Postpartum ● If still smoking – advise for quit smoking for better quality of breast
milk
● Refer pre pregnancy care
discharge
from
hospital
REMARKS:
● Risk of active smoking in pregnancy:
⮚ Miscarriage
⮚ Ectopic pregnancy
⮚ Stillbirth (one-third of stillbirth are related to smoking)
⮚ Congenital abnormalities (cleft lips & palate)
⮚ IUGR
⮚ Abruptio placenta
⮚ Premature birth
⮚ Risk of sudden infant death syndrome (SIDS)
⮚ Asthma, chest infection & ear infection
⮚ Risk of ADHD
⮚ Poor performance at school in children
● Risk of passive smoking in pregnancy:
⮚ Stillbirth
⮚ Premature birth
⮚ IUGR
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Table 5.1: Fagerstrom’ Test for Nicotine Dependence
PLEASE TICK (✔) ONE BOX FOR EACH QUESTION

Within 5 minutes  3
How soon after waking do you smoke your first 5-30 minutes  2
cigarette? 3-60 minutes
1
Do you find it difficult to refrain from smoking in places Yes  1
where it is forbidden? E.g. church, library, etc No  0
Which cigarette would you hate to give up? The first in the morning  1
Any other  0
How many cigarettes a day do you smoke? 10 or less  0
11-20  1
21-30
2
31 or more
3
Do you smoke more frequently in the morning? Yes  1
No  0
Do you smoke even if you are sick in bed most of the Yes  1
day? No  0
Total score
1- 2 = low dependance 5-7 = moderate dependance
SCORE
3 – 4 = low to moderate dependance 8+ = high dependance
Reference:
1. MIMS Stop Smoking Cessation Guidelines 2014.
2. Smoking: Stopping in Pregnancy and After Childbirth, National Institute for Health and
Care Excellence (PH 26) June 2010.
3. Health & Care Information, Royal College of Obstetricians & Gynaecologists, 2015
4. Clinical Practice Guideline, Treatment of Tobacco Use Disorder, Ministry of Health
Malaysia, 2016
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5.14 TEENAGE PREGNANCY

Pre ●Refer FMS for assessment & counselling
pregnancy ●Folic acid pre-conception
●Rule out anaemia and pre-existing medical condition
At booking Teenage ●Use HEADSS framework to establish rapport and
/ diagnosis mothers: assess psycho-social- economic status
aged 10–19 ● Implement Verbal Confidentiality Contract (VCC) and
years old apply CRET (Confidentiality, Rapport, Empathy,
(WHO) Trust)
● Identify risk factors for
⮚ Infection (UTI, STIs, pneumonia etc.)
⮚ Medical condition (DM, HPT, heart disease,
asthma, anaemia etc.)
⮚ Malnutrition (underweight, overweight, obese,
micronutrient deficiencies)
Dating scan
● Screening for HIV, VDRL, Hepatitis B, blood group
● Routine monitoring of :
⮚ Blood pressure
⮚ Body weight
⮚ Urine albumin
⮚ SFH
⮚ Haemoglobin
● Assess mental health
● Explore condition/ situation surrounding conception :
⮚ Marital status/ teenager’s age at conception
⮚ Wanted/ unwanted pregnancy
⮚ Victim of abuse/ rape (statutory /coercion)
⮚ Alcohol/ substance abuse
⮚ Domestic violence
⮚ Spouse/ partner’s history
▪ Substance use/abuse
▪ Occupation
▪ Sexual history (STI/ multiple partner)
⮚ Family/ social support
● Consider involving the police/ medical social worker/
child protector/ other disciplines in accordance to
relevant act eg. the Child Act 2001 / Penal Code (Act
574) / Sexual Offences Against Children Act (Act
792)/ Control of Infectious Diseases Act 2020 (Act
342)/ etc (Refer Garispanduan Pengendalian
Masalah Kesihatan Seksual dan Reproduktif Remaja
di Klinik Kesihatan or other relevant acts and
guidelines)
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Subsequent ● Routine monitoring of :
antenatal ▪ Blood pressure
follow-up ▪ Body weight
▪ Urine protein
▪ SFH
▪ Hb
▪ Foetal kick chart
● Routine and repeated screening of mood disorders,
alcohol/ substance abuse
● Hematinics to reduce anaemia
● Aspirin and calcium to reduce pre-eclampsia risk
● Advise on balanced diet
● Ultrasound for foetal growth to look for SGA or IUGR
● High Vaginal Swab if STIs suspected
● Screening for diabetes mellitus / other common
medical conditions in pregnancy as per guideline
● Educate patients and caregivers on
⮚ signs and symptoms of preterm labour
⮚ physiological changes of pregnancy
⮚ early warning symptoms and signs of
▪ fever
▪ headache/ blurring of vision
▪ abnormal PV discharge and/or foul smelling
discharge
▪ abdominal pain
▪ dysuria
▪ palpitation/dyspnoea/reduce effort tolerance
⮚ basic personal hygiene
⮚ sexual history and safe sex /contraception
⮚ unmarried teenagers (in particular)
▪ afterbirth childcare (adoption/ keep baby/
abortion in special cases of harm to mother’s
life or physical or mental health )
▪ education/ life skills & employment

plan ● Legal guardian should accompany patients to delivery
suites for teenage <18 years old
Postpartum ● Refer to medical social worker/ social worker as per
hospital policy or to facilitate adoption process (if
indicated)
● Refer school counsellor / educator for continuation of
education if applicable
● Contact police if indicated / there is an on-going
investigations
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● Discuss contraception and spacing
● Facilitate breastfeeding
● Assess for postpartum blues / depression
● Reinforce on personal hygiene, wound care, perineal
care and early warning symptoms of puerperal sepsis
(fever, pelvic pain, abnormal PV discharge and/or foul
smelling)
Upon ● Inform nearest health clinic for home visit

discharge ● Physical and mental well-being of patient
from ● Eat balanced diet and do appropriate exercise/
hospital physical activity
● Ensure well-being of baby
● Breastfeeding support
● Pre pregnancy care before next conception
● Further reinforce personal hygiene, perineal care and
early warning symptoms
● TCA early if any complication arises (e.g. fever,

abnormal PV bleeding and/or abnormal foul smelling
PV discharge)
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5.15 MENTAL DISORDER IN PREGNANCY

Pre pregnancy ● If known case of mental illnesses, refer to FMS/ psychiatrist for
assessment and preparation for pregnancy
At booking/ ● Screening for depression may be done for high-risk group, e.g those
diagnosis with health problems causing disability, past history of depression, a
family history of depression and those with other mental health
problems.
● Screening tool to be used is the Two-Question Case-Finding
Instrument
⮚ Patient Health Questionnaire-4 (PHQ-4)
⮚ Edinburgh Postnatal Depression Scale (EPDS)
● Consult psychiatrist for assessment
● Assess:
⮚ symptoms related to mental health problem
⮚ social support (family, housing, employment)
⮚ preparedness towards the pregnancy and acceptance of pregnancy
(planned / unplanned pregnancy)
⮚ mental health status during previous pregnancy
⮚ possibility of self-harm or suicide
● Screen for substance abuse, e.g. alcohol, smoking, drugs
Subsequent ● Shared care between FMS / psychiatrist / O&G

antenatal follow- ● Detailed scan at 24 weeks if indicated
up ● OGTT for patient on antipsychotic medication
● Monitor for excessive weight gain in women taking antipsychotic
● Monitor regularly for symptoms of relapse throughout pregnancy
● Provide ongoing social support with referral to social workers if needed.
● Advise for sleep hygiene.
Delivery plan ● Generally may allow postdate unless specified otherwise

Postpartum ● Look for symptoms of postpartum psychosis / depression

● Look for symptoms of relapse
● Advise on contraception according to Medical Eligibility Criteria for
● Encourage breastfeeding. Advise to take psychotropic medication just
after breastfeeding
● Monitor the baby for adverse effects such as drowsiness, hypotonia,
rigidity, tremor and withdrawal symptoms
● Review family support
Upon discharge ● Notification of high-risk discharge from hospital to respective health

from hospital clinics as per guideline.
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● Family planning counselling before discharged
● Follow-up within two weeks in health clinic for possible symptoms of
postpartum psychosis/ depression after childbirth
● Follow up in psychiatry clinic
● Pre pregnancy clinic appointment
REMARKS:
1. Depression and Anxiety in Pregnancy
● Perinatal depression and anxiety are common. In the perinatal period, 1 in 10

women develop depression. The prevalence of anxiety disorders is 10-15%.
● Untreated depression and anxiety lead to adverse effects to feotus/child, mother
and family e.g. low birth weight, poor antenatal care, interpersonal difficulties and
impaired children’s neurobehavioural development.
● Depression and anxiety are underrecognized and undertreated due to multiple
barriers eg lack of awareness or knowledge, stigma, time constraints.
● If patients are screened positive for depression or anxiety:
⮚ Proceed for further assessment to establish diagnosis
⮚ Assess psychosocial risks
o socioeconomic status
o unintended pregnancy
o unmarried
o intimate partner violence
o insufficient emotional and practical support
⮚ Assess suicidal risk
● Diagnosis of depression or anxiety is based on the criteria from Diagnostic and
Statistical Manual 5th Edition (DSM-5) or International Statistical Classification of
Diseases and Related Health Problems (ICD-10)
● Counsel on risk-benefit analysis of treatment options (psychological intervention vs
medication vs combination).
● Take note that access to psychological interventions depends on availability of the
services and require logistic arrangement to attend several sessions.
● For mild to moderate depression or anxiety:
⮚ Provide brief psychosocial intervention in primary care or O&G setting (e.g.
supportive psychotherapy, counselling, problem solving therapy or relaxation
therapy)
⮚ Arrange for brief psychological intervention by trained personnel in primary care
e.g. brief cognitive behaviour therapy (CBT)
⮚ Refer to tertiary centre for intensive psychological interventions e.g.CBT,
interpersonal psychotherapy (IPT).
● For moderate to severe depression or anxiety:
⮚ Counsel on risk-benefit of medication.
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o Risks of medication, i.e.; Selective Serotonin Reuptake Inhibitors (SSRI):
no risk of teratogenicity, low absolute risks of miscarriage, premature
delivery, neonatal adaptation syndrome and primary pulmonary
hypertension.
o Risk of untreated depression: miscarriage, premature delivery, low birth
weight, poor antenatal self-care, interpersonal conflict, functional
impairment, mother-baby bonding/attachment difficulties, low breastfeeding
initiation, long-term behavioural problems in offsprings, suicide and
infanticide.
o Based on risk-benefit ratio, start SSRI (e.g.; Sertraline 50-100 mg OD)
o Avoid benzodiazepines in pregnancy.
o Offer psychological intervention when medications have taken effect.
o If medication is indicated but the patient refused, offer adequate support,
refer to FMS or psychiatrist, and expedite intensive psychotherapy (CBT or
IPT)
2. Severe Mental Illness in Pregnancy
● Manage under a multi-disciplinary team of family medicine, psychiatry and

obstetrics.
● Medication:
⮚ If a patient is stable on antipsychotic, to continue on the same medication.
Refer as soon as possible for patients on Clozapine
⮚ Patients on mood stabilizers (sodium valproate, carbamazepine, lamotrigine
and lithium) need to have their medication withheld immediately. Consult a
psychiatrist immediately for switching.
● Monitoring for early signs of relapse.
● If a patient has chosen not to be on medication or has defaulted, close monitoring
is required. Structured individual, group and family therapy can be offered to
patients to prevent relapse.
● If patient has become pregnant while on a known teratogenic medication,
⮚ explain that stopping or switching the medication after pregnancy is confirmed
may not remove the risk of foetal malformations
⮚ refer for foetal abnormality screening and neonatology consultation
⮚ explain the need for additional monitoring and the risks to the feotus if
medication is continued
⮚ sodium valproate is associated with major malformation, cardiac malformation
and adverse cognitive outcomes
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5.16 ALCOHOL ABUSE IN PREGNANCY

Pre ● Counsel about the adverse effects of alcohol on pregnancy
pregnancy outcomes
● Promote alcohol abstinence if planning for pregnancy
At booking/ ● SCREENING – Need to ask all women for alcohol use

diagnosis ⮚ If positive, need to screen with ‘AUDIT-10’ questionnaire
Score Risk Zone

0–7 Low risk 1
8 – 15 Hazardous drinker 2
16 – 19 Harmful & dependency 3
0 – 40 High risk for alcohol related 4
harm
● ASSESSMENT during first contact;

⮚ History should include alcohol pattern, complication, comorbid,
MSE & social support
⮚ Physical examination including general signs of chronic alcohol,
gastrointestinal/abdomen & CNS.
⮚ Investigation including; FBC-Hb, MCV, LFT (GGT, AST, ALT),
(Ultrasound hepatobiliary system, OGDS, x-ray & EEG if
indicated)
● COUNSEL those who screened positive women regarding risks of
alcohol use
⮚ Advise maternal cessation of alcohol intake to reduce
complications to mother and foetus
● INTERVENTION involving multidisciplinary team approach,
depending on zone as per Malaysian guideline.
Zone Intervention
1 Health education
2 Simple advise
3 Extended intervention (MO / FMS)
4 Refer specialist in addiction (Psychiatrist
or FMS with subspecialty in addiction)
Subsequent ● Frequent antenatal follow up to monitor maternal and foetal status
antenatal (maternal alcohol consumption habits and complications such as
follow-up withdrawals, foetal surveillance for pregnancy complications)
● Emphasise on maternal cessation of alcohol intake
● Refer O&G for detailed scan (at 24 weeks) for women with alcohol
exposure in first trimester
Delivery ● Similar with normal pregnancy
plan ● Hospital delivery
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Post-partum ● Refer baby of women with heavy drinking to paediatric team
(possibility of neonatal withdrawal)
● Encourage breastfeeding and advise to avoid alcohol
● Advise on contraception. Refer Medical Eligibility Criteria for
Upon ● Notification of high-risk discharge from hospital to respective health
discharge clinics as per guideline.
from
hospital
REMARKS:
● Alcohol – contains ethanol (depressant drug)

⮚ 1 unit = 10 ml @ 10 gm ethanol (Malaysia)
● 13.5% aged 13 years and above ever consumed alcoholic beverages in year 2019
in Malaysia. In general, most of the current drinkers aged 18 years and above,
were categorised as low risk drinkers with a proportion of 81.5% (95% CI: 75.32,
86.36). The proportion of risky drinkers was 17.6% (95% CI: 12.79, 23.71) while
the proportion of drinkers with probable alcohol dependence was 0.9% (NHMS
2019)
● There is NO safe level of alcohol consumption during pregnancy. It is best to

abstain from alcohol during pregnancy & breastfeeding
● Recommendations on alcohol consumption:
⮚ Pregnant women / women planning a pregnancy should be advised to avoid
alcohol in the first 3 months in pregnancy
⮚ If women choose to drink alcohol during pregnancy, they should be advised to
drink no more than 2 units and not more than twice per week (after 3 months of
gestation)
⮚ Avoid binge drinking (>6 unit per occasion)
● Complications of alcohol to the mother & baby:

⮚ Spontaneous miscarriage
⮚ Stillbirth
⮚ IUGR
⮚ Low birth weight
⮚ Foetal alcohol spectrum disorder (FASD), which includes foetal alcohol
syndrome (FAS), partial foetal alcohol syndrome, alcohol-related
neurodevelopmental disorder, alcohol-related birth defects
** Risk is progressively increased with greater alcohol consumption
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Reference:
1. Royal College of Obstetricians & Gynaecologist – Health & Care Information

(February 2015)
2. NICE Antenatal Care- Routine Care for the Healthy Pregnant Woman (March 2008)
3. Nykjaer.C, et al. J.Epidemiol Community Health 2014;0:1-8, doi:10.1136/jech-2013-
202934
4. Garis Panduan Penilaian Risiko dan Intervensi Primer Kemudaratan Alkohol,
Cawangan Penyakit Tidak Berjangkit, Bahagian Kawalan Penyakit, KKM 2010
5. Maklumat Kesihatan- Intervensi, Pencegahan dan Pengurangan Kemudaratan
Alkohol, Unit Alkohol & Substans, NCD, KKM (2013)
6. Alcohol Use Disorder: A Comparison Between DSM–IV and DSM–5, National Institute
on Alcohol Abuse and Alcoholism, www.niaaa.nih.gov • 301.443.3860
7. SOGC Alcohol Use and Pregnancy Consensus Clinical Guidelines 2010
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Table 5.2 Alcohol Use Disorders Identification Test (AUDIT)
The Alcohol Use Disorders Identification Test : Interview Version

Read questions as written. Record answers carefully. Begin the AUDIT by saying ‘Now I am going to ask you some
questions about your alcoholic beverages during this past year’. Explain what is meant by ‘alcoholic beverages’ by
using local examples of beer, wine, vodka etc. Code answers in terms of ‘standard drinks’. Place the correct
answer number in the box at the right.
1. How often do you have a drink containing 6. How often during the last year have you
alcohol? needed a first drink in the morning to get
(1) Never (skip to Questions 9-10) yourself going after a heavy drinking session?
(2) Monthly or less (1) Never
(3) 2 to 4 times a month (2) Less than monthly
(4) 2 to 3 times a week (3) Monthly
(5) 4 or more times a week (4) Weekly
(5) Daily or almost daily
2. How many drinks containing alcohol do you 7. How often during the last year have you had a
have on a typical day when you are drinking? feeling of guilt or remorse after drinking?
(1) 1 or 2 (1) Never
(2) 3 or 4 (2) Less than monthly
(3) 5 or 6 (3) Monthly
(4) 7, 8 or 9 (4) Weekly
(5) 10 or more (5) Daily or almost daily
3. How often do you have six or more drinks on 8. How often during the last year have you been
one occasion? unable to remember what happened the
(1) Never night before because you had been drinking?
(2) Less than monthly (1) Never
(3) Monthly (2) Less than monthly
(4) Weekly (3) Monthly
(5) Daily or almost daily (4) Weekly
Skip to Question 9 – 10 if Total Score for Questions 2
and 3 is 0
4. How often during the last year have you 9. Have you or someone else been injured as a
found that you were not able to stop drinking result of your drinking?
once you had started? (1) No
(1) Never (2) Yes, but not in the last year
(2) Less than monthly (3) Yes, during the last year
(3) Monthly
(4) Weekly
5. How often during the last year have you 10. Has a relative or friend or a doctor or another
failed to do what was normally expected from health worker been concerned about your
you because of drinking? drinking or suggested you cut down?
(1) Never (1) No
(2) Less than monthly (2) Yes, but not in the last year
(3) Monthly (3) Yes, during the last year
(4) Weekly
RECORD TOTAL OF SPECIFIC ITEMS HERE
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Table 5.3 : A comparison between DSM-IV and DSM-5
DSM-IV DSM-5
In the past year, have you: In the past year, have you:
Found that drinking – or being sick from drinking –
often interfered with taking care of your home or Had times when you ended up drinking more,
1
family? Or caused job troubles? Or school or longer, than you intended?
problems?
Any 1 = ALCOHOL ABUSE
More than once gotten into situations while or

after drinking that increased your chances of
More than once wanted to cut down or stop
getting hurt (such as driving, swimming, using 2
drinking, or tried to, but couldn’t?
machinery, walking in a dangerous area, or having
unsafe sex?) The
More than once gotten arrested, been held at a presence of
police station, or had other legal problems because Spent a lot of time drinking? Or being sick or at least 2 of
3 these
of your drinking? getting over other aftereffects?
**This is not included in DSM-5 symptoms
indicates an
Wanted a drink so badly you couldn’t think of
Continued to drink even though it was causing Alcohol Use
4 anything else?
trouble with your family or friends? Disorder
**This is new to DSM-5
(AUD).
Had to drink much more than you once did to get Found that drinking – or being sick from
the effect you want? Or found that your usual drinking – often interfered with taking care of
5 The severity
number of drinks had much less effect than your home or family? Or caused job troubles?
of AUD is
before? Or school problems?
defined as:
Found that when effects of alcohol were wearing
off, you had withdrawal symptoms, such as trouble
Continued to drink even though it was Mild:
sleeping, shakiness, restlessness, nausea, sweating, 6
causing trouble with your family or friends? The
a racing heart, or a seizure? Or sensed things that
presence of
were not there?
2 to 3
Given up or cut back on activities that were
Had times when you ended drinking more, or symptoms
7 important or interesting to you, or gave you
Any 3 = ALCOHOL DEPENDENCE
longer, than you intended?

pleasure, in order to drink?
Moderate:
More than once gotten into situations while
The
or after drinking that increased your chances
More than once wanted to cut down or stop presence of
8 of getting hurt (such as driving, swimming,
drinking, or tried to, but couldn’t? 4 to 5
using machinery, walking in a dangerous area,
symptoms
or having unsafe sex)?
Continued to drink even though it was making Severe:
Spent a lot of time drinking? Or being sick or you feel depressed or anxious or adding to The
9
getting over other aftereffects? another health problem? Or after having had presence of
a memory blackout? 6 or more
Had to drink much more than you once did to symptoms
Given up or cut back on activities that were
get the effect you want? Or found that you
important or interesting to you, or gave you 10
usual number of drinks had much less effect
pleasure, in order to drink?
than before?
Found that when the effects of alcohol were
Continued to drink even though it was making you wearing off, you had withdrawal symptoms,
feel depressed or anxious or adding to another such as trouble sleeping, shakiness,
11
health problem? Or after having had a memory restlessness, nausea, sweating, a racing heart,
blackout? or a seizure? Or sensed things that were not
there?
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5.17 SUBSTANCE ABUSE IN PREGNANCY

1 Pre ● Assess:
pregnancy ➢ types of substance abuse
➢ duration of substance abuse
➢ status – withdrawal, intoxication
➢ psychosocial support
➢ associated infectious diseases
● Inform National Anti-Drugs Agency (AADK)
● Psychiatric referral for management
● Defer pregnancy until remission with contraception
2 At booking/ ● Assess:
diagnosis ➢ Status of substance use disorder
➢ Screening for STIs
● If patient on medication-assisted therapy, continuation of
therapy is advised
● Refer FMS
● Combined care with psychiatrist, FMS and O&G team for
pregnancy care
3 Subsequent ● Detailed scan at 24 weeks
antenatal ● Monthly growth scan after 28 weeks
follow-up ● Admission is required for following cases:
➢ Develop withdrawal symptoms during pregnancy
➢ Psychological implication
4 Delivery plan ● May consider to taper down opioid-agonist

● Pain management during intrapartum
5 Postpartum ● Neonatal assessment by paediatrics team for Neonatal

Abstinence Syndrome
● Breastfeeding is not contraindicated
● Psychiatric assessment before discharge
● Advise on contraception. Refer Medical Eligibility Criteria for
6 Upon ● Notification of high-risk discharge from hospital to respective
discharge health clinics as per guideline.
from hospital
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REMARKS:
1. Assessment during first contact:
a) History
▪ Patterns of substance use (The ASSIST [Alcohol, Smoking and Substance
Involvement Screening Test] helps identify current or potential problems
resulting from substance use and motivate those at risk to change their
substance use behaviour).
▪ Medical or psychiatric comorbidity
▪ Blood-borne and other infectious diseases
▪ Psychosocial problems such as relationship with a partner/ other people
living in the same household, homelessness, poverty and violence
b) Physical examination
▪ Including general, sign of chronic substance use (Difficulty caring for self,
poor dentition, parasitic skin infections such as lice or scabies, malnutrition),
injection marks, GI/abdomen & CNS
c) Investigation
▪ Urine drug screen: whenever intoxication, withdrawal, or overdose is
suspected
▪ HIV, Hepatitis B and C screening if the person has been injecting drugs
▪ Testing for sexually transmitted infections, including HIV, syphilis,
chlamydia, gonorrhoea, and human papilloma virus (HPV)
▪ Obtain a tuberculosis test, sputum sample, and a chest x-ray if tuberculosis
is suspected
2. Substance use disorders during the perinatal period have been identified as critical
to the health of mothers and babies.
3. Substance use contributes to obstetrics, paediatrics and mental health
complications.
4. Women with perinatal substance use disorder presented with extremely
complicated issues:
● unplanned pregnancy
● late or no antenatal booking
● low socio-economic background
● poor living condition complicated with issues of estrangement from family
● involvement with other high-risk behaviors.
5. They presented with a high rate of mental health comorbidities and risks of self-
neglect, self-harm as well as posing a risk of neglect and abuse to the babies.
6. In addition, they might be victims of interpersonal violence. Frequently there were
histories of child abuse, neglect or sexual abuse.
7. There were lots of gaps in providing intervention which include lack of multi-agency
coordination, unavailability of case management, lack of skills to provide
specialised care and lack of human resources.
8. To some women, the prospect of becoming a mother turned out to be a golden
opportunity for a life changing decision of abstinence but they need intensive
support.
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9. Outlining a comprehensive individual care plan covering issues in pregnancy,
childbirth, postpartum and mother-baby relationship was a daunting task, given the
complexity of issues faced by these women.
10. For professionals in perinatal mental health, addiction, obstetrics, paediatrics,
social welfare and the National Anti-Drug Agency; the ability to coordinate
responsibilities and share information in monitoring and delivering interventions
required lots of effort.
11. Early identification in antenatal care may be the first step towards engaging women
with substance use disorder into treatment but the high prevalence of unintended
pregnancy made this a big challenge.
12. Fine tuning the integrated care is crucial and the way forward; where a policy,
guidelines, standard operational procedures and training will ensure an effective
and coordinated service delivery.
13. Case-management approach with regular multidisciplinary discussion is postulated
to be a good strategy to start with; although working within lots of limitations, this
will build up the experience and collaboration among the team member
Reference:
1. Guidelines for the identification and management of substance use and substance
use disorders in pregnancy (WHO 2014)
2. Mental Health Gap Action Programme Intervention Guide Version 2.0 (WHO 2016)
3. Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid
Dependence (WHO 2009)
4. The ASSIST Project-Alcohol, Smoking and Substance Involvement Screening Test
(World Health Organization 2009
5. Antenatal and Perinatal Mental Health: Clinical Management and Service
Guidance (NICE)
6. Laura P .M, Madeleine B., Nehama D. Guidelines for management of pregnant
women with substance use disorder. The Journal of Consultation-Liaison
Psychiatry (Psychosomatic) Dec 3, 2015
7. Grella CE. Background and overview of mental health and substance abuse
treatment system: meeting the needs of women who are pregnant or parenting. J
Psychoactive Drugs 1996 Oct-Dec
8. Grella CE. Services for perinatal women with substance abuse and mental health
disorders: the unmet need. J Psychoactive Drugs. 1997 Jan-Mar
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Table 5.4: Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)
1. In your life, which of the following substances have you ever tried? (non-medical use
only)
a. Tobacco products  Yes  No f. Inhalants  Yes  No

b. Alcoholic beverages  Yes  No g. Sedatives or sleeping pills  Yes  No
c. Cannabis  Yes  No h. Hallucinogens  Yes  No
d. Cocaine  Yes  No i. Opioids  Yes  No
e. Amphetamine-type  Yes  No j. Others  Yes  No
stimulants
2. During the past 3 months, how often have you used the substances you mentioned (first
drug, second drug, etc)?
 Never (0)  Once/ twice (2)  Monthly (3)  Weekly (4)  Daily/almost daily
(6)
3. During the past 3 months, how often have you had a strong desire or urge to use (first
(6)
4. During the past 3 months, how often has your use of (first drug, second drug, etc) led to
health, social, legal or financial problems?
(7)
5. During the past 3 months, how often have you failed to do what was normally expected of
you because of you use of (first drug, second drug, etc)?
 Never (0)  Once/ twice (5)  Monthly (6)  Weekly (7)  Daily/almost daily (8)
6. Has a friend or relative or anyone else ever expressed concern about your use of first
 No, never (0)  Yes, in the past 3 months (6)  Yes, but not in the past 3 months (3)
7. Have you ever tried and failed to control, cut down, or stop using (first drug, second drug,
etc)?
8. Have you ever used any drug by injection? (non-medical use only)
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ASSIST risk score and associated risk level and intervention
All other
Alcohol Risk level Intervention
substances
0 – 10 0–3 Lower risk ▪ General health advise
▪ Brief intervention
11 – 26 4 – 26 Moderate risk ▪ Take home booklet & information
▪ Take home booklet & information
27 + 27 + High risk
▪ Referral to specialist assessment
and treatment
▪ Risk of injecting card

▪ Take home booklet & information
Injected drugs in last 3 months
Moderate and
high risk
▪ Referral for testing for blood-borne
virus (BBV)
▪ Referral to specialist assessment
and treatment
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CHAPTER 6
ANTENATAL COMPLICATIONS
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CHAPTER 6: ANTENATAL COMPLICATIONS
6.1 UNSURE OF DATE
Signs & Symptoms Symptoms :

● Asymptomatic
Signs:
● Uterus larger or smaller than date
Investigations Differential Care Plan

Diagnosis Level of Level of
Management
Personnel Care
● Perform - ● History: FMS/MO HC
ultrasound o Detail menstrual
scan for history
dating as o Date of UPT
soon as o Early scan
possible ● Measure SFH
(within 1 ● Foetal growth by scan FMS/MO HC
week) and plot foetal
parameters chart FMS/MO HC
● If foetal parameters
from scan < 22 weeks
o REDD from the
scan can be used
● If parameters measure
>22 weeks,
o Do not rely on the
given REDD.
o Scan must be
repeated every 3-4
weeks later to
support the working O&G HC/
gestational age Hospital
o Given concern that
a suboptimally-
dated pregnancy
could actually be O&G HC/
weeks further along Hospital
than it is believed to
be, initiate foetal
surveillance at 39-
40 weeks of
gestation
● The timing of delivery
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Management
Personnel Care
should be based on
the best clinical
estimate of gestational
age
● If foetal parameters
and SFH are not
corresponding, to refer
O&G
6.2 PRETERM LABOUR
Signs & Symptoms Symptoms:

● Contraction pain before 37 completed weeks
● PV bleeding
Signs:
● Contractions felt
● Cervical / os changes on digital vaginal examination

Management
Personnel Care
● FBC ● UTI ● Refer to the nearest O&G Hospital
● UFEME ● Abruptio hospital doctor
● HVS C+S Placenta ● IM Dexamethasone HC/
● Predictors of ● Braxton 12mg, 2 doses 12 hours MO/MS Hospital
preterm hicks apart, if POA between
labour if Contraction 24 to 36 weeks (1st
available dose can be given in the
(e.g.; Actim clinic)
Partus, foetal ● Tocolysis if indicated.
Fibronectin ● If delivery is imminent,
etc) prepare for delivery
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6.3 PRETERM PRELABOUR RUPTURE OF MEMBRANE (PPROM)

● Leaking without contraction before 37 completed weeks
● vaginal discharge may be present
Signs:
● Fever
● Uterus < dates
● Leakage of fluid seen in speculum examination

Management
Personnel Care
● FBC ● Vaginal ● Refer to the nearest O&G Hospital
● UFEME discharge hospital doctor
● HVS C&S secondary to ● IM Dexamethasone 12
● Amnicator or vaginal mg, 2 doses 12 hours HC/
litmus paper infection apart, if POA between MO/FMS hospital
showing ● Urinary 24 to 36 weeks. First
alkali or incontinence dose can be given in
other point- the clinic after
of-care test if discussion with
available, specialist (FMS or
e.g.; Actim O&G)
PROM ● Erythromycin 400mg
BD for 10 days
6.4 PRELABOUR RUPTURE OF MEMBRANES (PROM)

● Leaking without contraction after 37 completed weeks
● vaginal discharge may be present
Signs:
● Fever
● Uterus< dates
● Leakage of fluid seen in speculum examination

Management
Personnel Care
● FBC ● Vaginal ● Refer to the nearest MO / HC/
● UFEME discharge hospital O&G Hospital
● HVS C&S secondary to doctor
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Management
Personnel Care
● Amnicator vaginal
test or litmus infections
paper ● Urinary
indicate incontinence
alkali
reaction or
other point-
of-care test if
available,
e.g.; Actim
PROM
6.5 UTERUS LARGER THAN DATES

● Distended abdomen
● Compressive symptoms
● Asymptomatic
Signs:
● Uterus > dates (≥3cm discrepancy between the SFH and
POA)
● Shifting dullness
● Abnormal lie
● Multiple foetal pole
● Excessive maternal weight gain

Diagnosis Level of Level
Management
Personnel of Care
● Plot growth ● Multiple Refer hospital for FMS/MO/ HC /
chart pregnancy further management O&G Hospital
● Pelvic tumour
● Ultrasound ● Polyhydramnio
scan: s
o Amniotic ● Wrong dates
fluid index ● Foetal anomaly
(AFI) ● Placenta previa
o Estimated
foetal
weight
(EFW)
o Multiple
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Management
Personnel of Care
pregnancy
o Pelvic
tumour
o Foetal
anomaly
● OGTT if
indicated
6.6 UTERUS SMALLER THAN DATES

● Small abdomen
● Unsure of dates
● Leaking liquor
Signs:
● Uterus < dates (≤3cm discrepancy between the SFH and
POA)
● Clinically reduced liquor
● Easily felt parts
● Poor maternal weight gain

Management
Personnel Care
● Plot growth ● Oligohydramnio Refer hospital for FMS / Hospital
chart s further management MO/
● Ultrasound ● IUGR O&G
scan: ● Intrauterine
o AFI death
o Foetal ● Wrong dates
paramete ● Foetal
rs abnormality
o Foetal ● Normal feotus
anomaly
● Serial
ultrasound if
correspondi
ng
to dates and
AFI is normal
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6.7 BREECH AT TERM

● Asymptomatic
Signs:
● Breech presentation from palpation

Management
Personnel of Care
● Ultrasound ● Foetal Refer to the nearest MO/FMS HC
scan: anomalies hospital at about 36
o Parameters ● Wrong dates weeks for further
o AFI ● Polyhydramnio management.
o Placental s Possible options: O&G/MO Hospital
localization ● Presence of ● ECV
o Foetal pelvic mass ● Elective LSCS
anomalies ● Placenta ● Vaginal breech
o Pelvic mass Praevia delivery
6.8 MALPRESENTATION (AT 36 WEEKS AND BEYOND)

● Asymptomatic
Signs:
● Transverse/ oblique lie
Management
Personnel Care
● Ultrasound ● Foetal Refer hospital for O&G Hospital
scan: anomalies further management
o Parameters ● Wrong
o AFI dates
o Placental ● Poly
localization hydramnios
o Foetal ● Presence of
anomalies pelvic mass
o Pelvic mass ● Placenta
Praevia
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6.9 MULTIPLE PREGNANCY

● excessive nausea and vomiting
● uterus larger than date
Signs:
● SFH > POA/POG
● multiple foetal pole

Diagnosis Level of
Level of
Management Personn
Care
el
● First 1st ● MCDA ● When to refer: FMS/ HC/
ultrasound is ● DCDA o KD to refer MO/ Hospital
recommended ● Triplet immediately to KK O&G
, (best at 14 ● Molar o KK to be seen
weeks) to pregnancy by MO/ FMS
determine with normal ● Refer O&G within 1
chorionicity ongoing week to determine
o If mono- pregnancy chorionicity,
chorionic, ● Pelvic counselling and
screen for tumour outline of antenatal
Twin to twin ● Polyhydram follow-up plan
transfusion nios ● Refer fetomaternal
syndrome ● Wrong dates specialist as soon
(TTTS) as chorionicity is
● serial determined for
ultrasound further antenatal
care plan
● URGENT
REFERRAL IF:
o Monoamniotic
o Suspected twin-
to-twin
transfusion
syndrome
(TTTS)
o Foetal structural
abnormality
o Suspected
discordance in
weight >18%
(weight)
o High order
multiple
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Diagnosis Level of
Level of
Management Personn
Care
el
gestation (≥ 3)
o Single foetal
demise
● If monochorionic
(MC) twins or high
order multiple
pregnancy (≥3), to
follow up in
fetomaternal clinic/
general O&G clinic
of hospital (high
risk pregnancy)
● If dichorionic (DC)
twins, patient will
be followed-up both
at health clinic and
hospital (general
O&G clinic)
● All multiple
pregnancies
require monthly
growth scan
● Delivery plan to be
outlined by O&G:
o High order
multiple
pregnancy: soon
after diagnosis is
confirmed
o Twins: depend
on chorionicity,
presentation and
any other
associated
factors. Plan by
third trimester
o Uncomplicated
monochorionic
twins: to deliver
by 36 weeks
o Uncomplicated
dichorionic
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Diagnosis Level of
Level of
Management Personn
Care
el
twins: deliver by
38 weeks
● Mode of delivery
should be
individualised -
based on
gestational age, co
morbidity,
availability of
expertise in
management of
vaginal twin birth
and mothers’
preference.
6.10 PREVIOUS CAESAREAN SECTION

● Asymptomatic
Signs:
● Scar at the lower abdomen (suprapubic / sub-umbilical)

Management
Personnel Care
● Ultrasound ● Review indication & MO/FMS HC/
for placental complications of the hospital
localization previous caesarean MO/FMS/
section hospital
● Refer hospital
immediately if pain
o if upper ● Refer hospital at 32 - 34 O&G MO/

segment weeks specialist
o if placenta ● Refer hospital

praevia immediately if placenta
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Management
Personnel Care
praevia with previous O&G MO/
scar specialist
6.11 REDUCED FOETAL MOVEMENT

● Reduced foetal movement
● <10 movements within 12 hours
● Progressively longer in a day to reach 10 kicks
● Any subjective feeling of reduced foetal movement (frequent ±
intensity)
Signs:
● Foetal heart rate :
o Normal
o Bradycardia
o Tachycardia
o Irregular
o Absent

Management
Personnel Care
● CTG (CTG ● Intrauterine ● Refer to hospital for FMS / HC /
prior to 28 Death further assessment and MO Hospital
weeks is ● IUGR management
difficult to ● Foetal ● Repeat CTG & USG if
interpret in anomaly required
view of ● Normal
foetal foetus
immaturity)
● Ultrasound
scan:
o AFI
o foetal
biometry
±
morpholo
gy
● Doppler
studies
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6.12 POSTDATES (EDD + 7 DAYS)
Signs & Symptoms Asymptomatic

Management
Personnel Care
● Reassess ● Wrong ● If wrong dates FMS/ MO HC /
the dates dates with a o Correct the date Hospital
● Ultrasound healthy o Continue follow up
● CTG feotus
● If postdates (EDD+ 7
days) FMS/ MO HC/
o Refer to hospital for Hospital
further management
o KIV IOL (depending
on individual hospital
protocol)
6.13 HYPEREMESIS GRAVIDARUM

● intractable vomiting
● unable to tolerate orally
● hypersalivation and spitting
● retching
Signs:
● dehydration
● weight loss greater than 5% of body weight
● signs of muscle wasting

Management
Personnel of Care
● Urinalysis ● UTI ● PUQE score FMS/MO/&G Hospital
● Urea & ● hyperthyroidis ● Refer hospital for
electrolytes m assessment and
● FBC ● multiple inpatient management
● Ultrasound pregnancy based on severity
to rule out ● molar ● Aims of treatment:
multiple pregnancy o Alleviate symptoms
pregnancy ● peptic ulcer of nausea/vomiting
and molar ● cholecystitis o Rehydration
pregnancy ● pyelonephritis o Correction of
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Management
Personnel of Care
● hepatitis electrolyte
If indicated: ● pancreatitis imbalance
● thyroid o Prevention of
function complications
test
● liver
function
test
● blood
glucose
6.14 RECURRENT MISCARRIAGES (LOSS OF 3 OR MORE CONSECUTIVE

PREGNANCIES)

Management
Personnel Care
● Lupus anticoagulant ● Anti- ● Low dose aspirin ● FMS/ HC /
and anticardiolipin phospholipid once pregnancy Physician/ Hospital
antibodies 6 weeks syndrome is confirmed and O&G
apart low molecular Specialist
● OGTT ● Diabetes weight heparin
Mellitus (LMWH) after 1st
If indicated: trimester
● Parental test for ● Genetic
peripheral Factor ● Refer CPG ● FMS / MO HC /
karyotyping Diabetes in Hospital
● Pelvic ultrasound ● Uterine Pregnancy (2018)
(2D or 3D)/ anomaly ● Genetic
hysteroscopy/ counselling/
hysterosalpingogra referral to ● FMS/ HC /
m (HSG) / MRI geneticist if O&G / Hospital
● Serial transvaginal ● Cervical available MFM /
sonography (TVS) incompetenc Geneticist
in early trimester to e ● Offer early
detect cervical prenatal
shortening / diagnostic test ● MO / O&G HC /
funnelling Specialist Hospital
● Thyroid Function ● Thyroid ● Hysteroscopic
Test / Thyroid Disorder resection of ● MO / O&G
antibodies uterine septa Specialist HC /
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Management
Personnel Care
● Serum prolactin ● Hyperprolactin could be Hospital
emia performed
● Thrombophilic ● Inherited ● Cervical cerclage
screening including Thrombophilia / cervical pessary
Factor V Leiden, / transabdominal
Prothrombin, Protein cerclage
S&C ● MO /
● Vaginal swab C&S ● Infection (eg ● Anti-thyroxine for FMS/
● STD workout TORCHES, hyperthyroidism / Physician
Bacterial L-thyroxine for / HC /
Vaginosis) hypothyroidism Endocrinol Hospital
ogist/
● Treatment with O&G
bromocriptine Specialist
before pregnancy
● LMWH ● MO /
throughout Physician/
antenatal period O&G
● Treatment ● MO/ FMS/ HC /

accordingly to O&G / Hospital
known and Genitourin
treatable ary
organism medicine
specialist HC /
(if Hospital
available)
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6.15 PREVIOUS HISTORY OF UNEXPLAINED INTRAUTERINE DEATH (IUD)

Management
Personnel Care
● OGTT ● Poorly ● Refer O&G for shared FMS/ HC/
● Growth chart controlled DM care MO/O&G Hospital
● Detail scan at ● Genetic
18-24 weeks if disorder
available ● Undiagnose
d infection
6.16 HISTORY OF FOETAL ABNORMALITY

● Asymptomatic
Signs:
● Uterus may be smaller or larger than dates

Management
Personnel Care
● Ultrasound - Refer O&G or MFM for FMS/ MO / HC/
scan: assessment that could O&G Hospital
o for dating include blood
o anomaly investigations, cell-free
foetal DNA (cffDNA) (if
available) and detailed
scan
6.17 SYMPTOMATIC VAGINAL DISCHARGE

● vaginal discharge more than normal
● with or without:
- itchiness
- dysuria
- lower
- abdominal
- discomfort
- dyspareunia
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● fever
Signs:
● abdominal tenderness
● discharge seen in the vagina
● redness and swelling of the cervix, vagina and vulva

Management
Personnel Care
● If cervicitis: ● Neisseria ● Vaginal candidiasis – MO MO/FMS
o endocervical gonorrhoea – clotrimazole pessary
swab gram stain 500mg ON stat dose or
i. gram stain for shows pus clotrimazole pessary
pus cells, cells, 200mg ON for 3 days or
intracellular intracellular Nystatin pessary
gram-negative gram 100,000 unit daily for 14
diplococci negative days
ii. culture for diplococci
Neisseria ● Bacterial vaginosis - oral
gonorrhoea ● Chlamydia metronidazole 400mg
(Thayer-Martin trachomatis - OD for 5-7 days
culture antigen/
medium) NAAT ● Trichomonas vaginalis –
iii. Antigen/ NAAT positive oral metronidazole
test for 400mg OD for 5-7 days
Chlamydia ● Trichomonas
trachomatis vaginalis - ● Neisseria gonorrhoea -
iv. Pap smear wet mount IM ceftriaxone 500mg
slide stat and T.azithromycin
● If vaginitis: microscopy 1g stat (single dose) or
o Vaginal Swab shows motile IM spectinomycin 2g as
i. Wet mount flagellates, a single dose
from posterior oval or pear
fornix for shaped ● Chlamydia trachomatis -
trichomonas organism erythromycin stearate
vaginalis with jerky 500mg QID for 7 days
ii. gram stain for movement or erythromycin ethyl
pus cells, clue succinate 800mg QID
cells and yeast for 7 days or amoxycillin
iii. candida 500mg tds for 7 days or
culture - swab azithromycin 1g PO stat
from lateral
fornix ● In areas where
laboratory facilities and
investigations are
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Management
Personnel Care
limited, a modified
syndromic approach
may be used.
o if cervicitis is noted
on speculum
examination:
▪ oral azithromycin
1 g stat dose and
IM ceftriaxone
500mg stat
▪ OR IM
ceftriaxone
500mg stat and
oral erythromycin
ethyl succinate
800mg for 10-14
days
o if vaginitis is noted
in speculum
examination,
▪ oral
metronidazole 2g
stat dose and
nystatin pessary
100,000 unit
dose for 14 days
▪ OR clotrimazole
pessary 500mg
stat
▪ OR clotrimazole
pessary 200mg
ON for 3 nights
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6.18 ADVANCED MATERNAL AGE (≥ 40 YRS OLD)

● Asymptomatic

Management
Personnel Care
● First trimester - Refer FMS and/or O&G if MO/ FMS/ HC/
ultrasound suspected foetal anomaly O&G Hospital
● Offer prenatal
screening for
chromosomal
abnormality (if
available)
● OGTT
6.19 MATERNAL SEPSIS
Signs & Sepsis

Symptoms ● Infection plus systemic manifestations of infection
Clinical signs:
● Temp ≥ 380C or < 360C
● HR >100bpm
● RR>20/min or PaCO2 <32mmHg
● Leukophilia >12x109/L or Leucopenia <4x109/L
Systemic Inflammatory Reponse Syndrome (SIRS) =

Presence of > 2 of above signs
Severe Sepsis
● Sepsis is associated with organ dysfunction or tissue
hypoperfusion (hypotension, arterial hypoxemia, lactic
acidosis, renal failure, liver dysfunction, coagulation
abnormalities and mental status changes).
Septic Shock
● Sepsis associated with hypotension despite IV fluid
resuscitation leading to cell dysfunction and, if prolonged,
cell death
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Management
Personnel of Care
● FBC ● UTI Hospital care according to Specialist Hospital
● Blood C&S ● Pyelonephritis causes, consider:
● Other cultures ● Pneumonia ● Antibiotic – IV broad-
as guided by ● Chorioamnionitis spectrum antibiotics are
clinical ● Wound infection recommended within 1
suspicion of ● Endometritis hour of suspicion of
the focus of ● Puerperal sepsis severe sepsis, with or
infection e.g. ● Dengue without septic shock.
throat swabs, ● Malaria ● Wound care
mid-stream ● Influenza-like ● Supportive management
urine, high Illness (ILI)* ● Manage according to
vaginal swab, causes
CSF, sputum, * ILI is an o Dengue – as per
wound swab acute Management of
● UFEME respiratory Dengue Infection in
● Serum lactate infection with Adults CPG
– to be taken fever >380C o Malaria – as per
within 6 hours and cough. WHO Guidelines for
of suspicion of Pregnant the Treatment of
severe sepsis women are Malaria
to guide one of the o ILI – start Tamiflu as
management. high risk per guidelines, dose
Serum lactate categories. depends on severity.
>4mml/l is
indicative of
tissue
hypoperfusion
.
● Any relevant
imaging
studies
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CHAPTER 7
INTRAPARTUM COMPLICATIONS
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CHAPTER 7: INTRAPARTUM COMPLICATIONS
7.1 FALSE LABOUR
In false labour, the cervix remains undilated, and uterine contractions

remain impalpable or infrequent. No further action needs to be taken in the
absence of other complications.
Misdiagnosis of false labour or prolonged latent phase

leads to unnecessary induction of labour or
augmentation, which may fail. This may lead to
unnecessary caesarean section or chorioamnionitis.
7.2 ABNORMAL LABOUR PROGRESS CHART (LPC) / EARLY LABOUR

MONITORING RECORD
● Abnormal latent phase

o Cervical dilatation remains less than 4 cm despite 8 hours of
regular contractions
o The duration may be longer for primigravidae
● Any abnormal LPC/ early labour monitoring record at the hospital without
specialist or at lower levels should be referred and transferred to a
hospital with specialist for further action.
7.3 ABNORMAL PARTOGRAPH
The following features in a partograph indicate poor progress of labour:

o Cervical dilatation to the right of Alert Line
o Cervical dilatation at or beyond the Action Line
7.3.1 Diagnosis of poor progress of labour
a. Primary dysfunctional labour

The rate of cervical dilatation is less than 1 cm/hour in the active
phase of labour due to ineffective uterine contractions of less than 3
in 10 minutes, each lasting less than 40 seconds.
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b. Cephalopelvic Disproportion (CPD)
Secondary arrest of cervical dilatation and descent of the presenting
part occurs despite good uterine contractions. This can be either:
o Absolute – due to big feotus or small pelvis
o Relative – due to foetal malposition
7.3.2 Management of abnormal partograph

Management of abnormal partograph at the hospital without specialist or at
lower level
a. Moving to the right of the alert line

In the active phase of labour, plotting of cervical dilatation will
normally remain on, or to the left of the alert line. However, some will
cross to the right of the alert line and this warns that labour may be
prolonged.
When this occurs in the absence of adequate facilities for obstetric

emergencies and operative delivery, the woman must be transferred
to a hospital where such facilities are available after consultation with
the Specialist
b. At or beyond the action line

Mothers who are at or beyond the action line should ideally be
managed in a hospital with a specialist. If a woman’s labour reaches
or crosses this line, a decision must be made about the cause of
poor progress, and appropriate action taken.
This decision and action must be taken in a hospital with facilities to

deal with obstetric emergencies and operative delivery
Inefficient contractions are less common in multigravida than in

primigravidae.
Hence, every effort should be made to rule out CPD in multigravidae
before augmenting with oxytocin.
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Figure 7.1: Abnormal Partograph
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7.4 OBSTRUCTED LABOUR
Obstructed labour means that, in spite of strong contractions of the uterus,

the feotus cannot descend through the pelvis because there is an
insurmountable barrier preventing its descent. Obstruction usually occurs at
pelvic brim, but occasionally it may occur in the cavity or at the outlet of the
pelvis.
7.4.1 Evidence of obstructed labour

● Secondary arrest of cervical dilatation and descent of presenting part
● Large caput
● Third degree moulding
● Oedematous cervix
● Maternal/foetal distress
7.4.2 Management of obstructed labour

● Rehydrate the mother
● Give supportive care
● Refer mother to the nearest higher level of care or for a caesarean
section in hospital with a specialist.
7.5 MANAGEMENT OF ABNORMAL FOETAL HEART RATE (FHR)

PATTERNS
● Prop up and turn patient to the left lateral position to alleviate vena caval
compression
● Discontinue intravenous oxytocin if any evidence of hyperstimulation
● Perform vaginal examination to rule out cord presentation/prolapse
● Transfer mother immediately to a hospital with facilities for operative
delivery
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APPENDIX 7-1
STANDARD OPERATING PROCEDURES
Diagnostic Care of Plan

Laboratory
Signs & Criteria and
SOP Condition Investigation Level of Level of
Symptoms Differential Management
& Findings Personnel Care
Diagnosis
1 Meconium- Greenish/ ● FBC Breech ● Initiate MO/Specialist Hospital with
stained yellowish ● GXM presentation continuous ● O&G Specialist
liquor discolouration of ● CTG electronic ● Anaesthetist
liquor foetal heart ● Paediatrician
activity
monitoring
● May be
necessary to
expedite
delivery
● May need
operative
delivery
● MO/
Paediatrician
on standby
2 Abnormal Refer to Foetal ● FBC Refer to Foetal ● Initial MO/Specialist Hospital with
foetal Monitoring ● GXM Monitoring section management: ● O&G Specialist
heart rate section ● CTG o Left ● Anaesthetist
lateral ● Paediatrician
position
o Stop
oxytocin
o VE to rule
out cord
presentati
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Diagnostic Care of Plan
Laboratory
Signs & Criteria and
SOP Condition Investigation Level of Level of
Symptoms Differential Management
& Findings Personnel Care
Diagnosis
on/ cord
prolapse
o IV
infusion
● Expedite
delivery as
appropriate
● MO/
Paediatrician
on standby
● May need
operative
delivery
3 Prolonged ● Latent phase ● FBC ● Exclude MO/Specialist Hospital with

first stage > 8 hours ● GXM cephalopelvic ● O&G specialist
of labour ● Crossed alert ● CTG disproportion ● Anaesthetist
line on ● Augmentation ● Peadiatrician
partograph if appropriate
● May need
caesarean
section
● Augmentation
if appropriate
4 Prolonged ● Primigravida > ● FBC ● Instrumental MO/Specialist Hospital with

second 60 mins ● GXM delivery ● O&G specialist
stage ● Multigravida > ● CTG ● Caesarean ● Anaesthetist
30 mins section ● Peadiatrician
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APPENDIX 7-2
GUIDELINES FOR PERFORMING LOWER SEGMENT CAESAREAN

SECTION (LSCS) AT DISTRICT HOSPITALS WITHOUT SPECIALIST
Caesarean section in district hospitals can only be performed by medical officers who
have been credentialed and certified competent.
General criteria for LSCS that can be performed in district
All caesarean sections to be performed in district hospitals must be decided by the

specialist who provides the coverage for the hospital, having taken into consideration the
availability of appropriate staff and resources.
1. Maternal:
i. BMI < 30
ii. Parity ≤ 4
iii. No midline or Pfannenstiel scar on abdomen. Laparoscopy or Lanz incision
are permissible
iv. Upper segment placenta
v. No significant uterine fibroids or ovarian cyst
vi. Blood available
2. Fetal:
i. Able to be supported by district paediatrics team
ii. No known abnormality that needs tertiary paediatrics support
3. Anaesthetic factors:
i. ASA 1 or 2
ii. BMI <30
iii. Non-difficult airway
iv. No history of CVS diseases
v. No history of bleeding disorders
vi. No spine abnormalities
vii. No eventful anaesthetic history
Potentially difficult LSCS that has to be performed in the district will need the most
experienced MO to perform, after discussing with specialist
● Second stage LSCS
● Failed instrumental delivery
● Obstructed labour that cannot be transferred to a specialist hospital in time
● Presence of foetal compromise
● Abruptio / APH
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Elective LSCS at district hospital
● For cases that fulfil the above criteria, to arrange LSCS for 38-39 weeks gestation.
● If LSCS is done before 39 weeks, offer IM Dexamethasone 12 mg x 2 doses at 12
or 24 hours apart.
Drugs
1. Premedication
● IV Ranitidine 50mg
● Sodium citrate 15mls
2. Prophylactic antibiotics up to 1 hour before incision
● IV Unasyn 1.5g
● alternatively IV Cefuroxime 1.5g and IV Metronidazole 500mg
3. PPH prophylaxis/ treatment medications
● Oxytocin 5 IU by slow intravenous injection (may repeat dose)
● Oxytocin infusion (40 IU in 500 ml isotonic crystalloids at 125 ml/hour) unless
fluid restriction is necessary
● Cases of PPH should be referred to a specialist on phone cover for advise for
plan of management
● Carboprost 0.25 mg by intramuscular injection repeated at intervals of not less
than 15 minutes to a maximum of eight doses (use with caution in women with
asthma)
● IV Tranexamic acid 2g and followed by 1g/hour for 6 hours
4. Thromboprophylaxis
● Clexane or heparin as per protocol (Prevention & Treatment of
Thromboembolism in Pregnancy and Puerperium 2018)
Staffing for LSCS

● 2 O&G MO for each LSCS where possible
● 1 Paediatric MO on standby
● 1 Anaesthetic medical officer and or medical assistant
● 1 Anaesthetic assistant (medical assistant or nurse)
● 1 scrub nurse
● 1 circulating nurse
● 1 recovery nurse
● 1 counter nurse
● 1 Pembantu Perubatan Kesihatan
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Instruments and Equipment for LSCS
Ensure that the LSCS set is complete as listed below:
No. Instrument Unit
1. Instrument tray 540x325x64mm 1
2. Kidney dish 12” (SH533) 2
3. Kidney dish 10”(JG50R) 1
4. Bowl 6" (JG524R) 1
5. Gallipot 10oz,6oz 2
6. Standard tooth dissecting forceps (BD560R) 1
7. Standard plain dissecting forceps (BD050R) 1
8. Mcindoe dissecting forceps (BD236R) 1
9. Gillies dissecting forceps (BD 660R) 1
10. Waugh plain dissecting forceps (BD049R) 1
11. Waugh plain dissecting forceps (BD559R) 1
12. B/P scalpel handle no.3 ( BB073R) 1
13. B/P scalpel handle no.4 (BB084R) 2
14. Mayo scissors (C) 6 3/4" (BC557R) 2
15. Mayo scissors (STR) 6" (BC545R) 1
16. Metzenbaum scissors (C) 7" (BC606R) 1
17. Mayo needle holder 7 ½” golden handle (BN065R) 1
20. Babcock tissue forceps (EA031R) 2
21. Allis tissue forceps (EA015R) 2
22. Kocher artery forceps (S) (BH642) 2
23. Spencer wells artery forceps (str) 7 ½” (BH336R) 4
24. Halstead artery forceps (C) 7 ½ ” (BH203R) 6
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No. Instrument Unit
25. Spencer wells artery forceps (C) 7 ½ ” (BH337R) 4
26. Allis Thomas toothed (EA020R) 2
27. Green Armytage forceps (FT269R) 4
28. Towel clips (BF432R) 6
29. Sponge holders (BF122R) 6
30. Doyen retractor 48x90mm (BT723R) 1
31. Sinus forceps (C) (BF006R) 1
32. Canny Ryall retractor Medium (BT048R) 2
33. Canny Ryall retractor Small (BT047R) 2
34. Wrigley’s obstetric forceps 1 pair
35. Yankauer sucker 1
36. Instrument pins 2
37. Silicone tubing 3m
Ensure other essential medical and non-medical equipment needed to perform LSCS is
available and functioning well e.g. anaesthetic machine, diathermy machine, resuscitation
trolley and defibrillator.
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General Anaesthesia Service in the Operating Theatre
1. All patients shall be assessed pre-operatively by the anaesthetising doctor.

2. Pre-operative fasting practice shall be in accordance with the Guidelines on
Preoperative Fasting, College of Anaesthesiologists, Academy of Medicine
Malaysia, revised 2008.
3. In OT, the correct identification of the patients are verified by the nurse and doctor
by using SSSL checklist which also includes valid informed consent for surgery
and anaesthesia (refer to Consent for Treatment of Patients by Registered Medical
Practitioner: Malaysian Medical Council, 2013).
4. Separation of children or intellectually challenged patients from parents or
guardians prior to anaesthesia is to be discouraged.
5. The minimum standards for the safe conduct of anaesthesia in the OT shall be
strictly adhered to (refer to Recommendations on Minimum Facilities for Safe
Anaesthesia Practice in Operating Suites and Other Anaesthetising Locations:
Australia and New Zealand College of Anaesthesiologists. P255. 2012).
6. A skilled assistant shall be available in every operating room to assist in the
administration of anaesthesia.
7. Formal hand-over of patient information shall take place whenever there is a
change of caregivers during anaesthesia even temporarily e.g. during relief for
breaks or permanently.
8. The assistant medical officer (AMO) shall be responsible for the regular preventive
maintenance of the equipment in the unit through the hospital’s concession
company.
9. Monitoring of patients under anaesthesia shall comply with the recommended
standards (refer to Recommendations for Safety Standards and Monitoring during
Anaesthesia and Recovery: College of Anaesthesiologists Malaysia, 2008).
10. All anaesthetic locations shall be equipped with anaesthetic gas scavenging
system.
11. Post-anaesthesia patients shall be monitored in the recovery room according to the
level of care determined by the physiologic status of the patient.
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Anaesthetic Equipments in OT
1. Anaesthesia machine, ventilator, physiologic monitor

2. Emergency trolley with cardiac pacing and defibrillation device
3. Airway adjuncts: Guedel airways, LMA, endotracheal tubes, bougies
4. Laryngoscope with various blades sizes (+/- McCoy Blades)
5. Suction apparatus, Yankauers, suction catheters
6. Infusion syringe pump
7. Warming blanket/mattress
8. Patient transport trolley
9. Patient transfer device
10. Blood warming device
11. Blood refrigerator
12. Drugs refrigerator
13. Equipment drying cabinet
14. Anaesthesia trolley
Recovery room
1. Recovery room monitor
2. Oxygen
3. Suction apparatus
4. Patient recovery trolley
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List of medications
No. Types of medication Medications
1. IV induction agents ▪ Propofol

▪ Thiopentone
▪ Ketamine
▪ Midazolam
2. Muscle relaxants ▪ Atracurium

▪ Rocuronium
▪ Suxamethonium
3. Reversal drugs ▪ Atropine

▪ Neostigmine
4. DDA drugs ▪ Morphine

▪ Fentanyl
▪ Ketamine
5. Volatile agents ▪ Sevoflurane
6. Emergency drugs ▪ Adrenaline

▪ Atropine
▪ Calcium gluconate
▪ Dextrose 50%
▪ Ephedrine
▪ Hydrocortisone
▪ Chlorpheniramine
▪ Dexamethasone
▪ Dopamine
▪ Flumazenil
▪ Frusemide
▪ Metoclopramide
▪ Naloxone
6. Local anaesthetics ▪ Lignocaine

▪ 0.5% Hyperbaric bupivacaine
▪ Plain Marcaine
7. Lubricants ▪ K-Y jelly
8. Suppositories ▪ Diclofenac sodium

▪ Paracetamol
9. Inhalational drugs ▪ Salbutamol metered dose inhaler
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LOGBOOK FOR LSCS FOR DISTRICT MEDICAL OFFICER
Name of Indication of Assist/ Initial of

No. NRIC. Date
patient LSCS Performed supervisor
COMPETENCY ASSESSMENT : LOWER SEGMENT CAESAREAN SECTION
Supervisor signs when

Expected
Target competence level
competence level
achieved
1 2 3 4 5 Signature Date
Uncomplicated lower segment

caesarean sections including those
without previous scars
Signature to confirm completion:

Name of the Supervisor/ Specialist:
Date:
Hospital:
General Information:
The level of competence ranges from observation (Level 1) to independent practice (Level 4 or 5).
The officer should achieve at least level 4 to be credentialed to be able to perform uncomplicated
LSCS independently. The officer should keep a logbook of the cases of LSCS assisted or
performed. Minimum of 5 LSCS needs to be performed before a competency assessment is
carried out. When you feel ready for competency assessment, it is your responsibility to organise
with your supervisor.
SCORING SYSTEM: 1: Passive attendance, assistance

2: Needs close supervision
3: Able to carry out procedure under some supervision
4: Able to carry out procedure without supervision
5: Able to supervise and teach the procedure
*The general aim is to get at least mark 4.
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CHAPTER 8
POSTNATAL COMPLICATIONS
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CHAPTER 8: POSTNATAL COMPLICATIONS
8.1 MENTAL HEALTH IN POSTNATAL PERIOD
8.1.1 Postnatal blues

● Postnatal blues is common, affecting around 8 in 10 postnatal mothers
and considered as a normal situation after childbirth.
● It is a mild and transient condition where mothers may experience a
range of feelings: being tearful, overwhelmed, irritable and emotionally
fragile with sadness, loneliness, anxiety and insomnia
● It may occur immediately after childbirth, commonly within the first few
days of delivery, peak around one week and resolve by the end of the
second week of postpartum.
● It may be associated with sudden hormonal changes, discomfort from
breast engorgement and birth pain, stress of parenthood and childcare,
isolation, sleep deprivation and exhaustion.
● It normally resolves as mothers learn to adjust to her new life and with
understanding and support.
8.1.2 Postnatal depression
● Postnatal depression is a major depressive disorder with onset in the

postnatal period, up to 1 year. It is considered as a common psychiatric
disorder affecting 1 in 10 postnatal women.
● In postnatal depression, women experience symptoms of depression for
more than 2 weeks:
o depressed mood
o loss of interest and pleasure in activities they usually enjoy
o loss of appetite or eating much more than usual
o inability to sleep or sleeping too much
o fatigue
o diminished ability to concentrate or make decisions
o restlessness or becoming slow
o feeling worthless
o recurrent thoughts of death and suicide
● It may also be associated with
o irritability
o anxiety and panic attacks
o difficulty in bonding with baby
o feeling like they are not a good mother
o thoughts of harming baby
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● It is commonly underrecognized and underdiagnosed due to multiple
barriers such as ignorance or not having awareness and fear of stigma
on women’s side; time constraint and unwillingness to explore on health
providers’ side.
● It may not be easily diagnosed as there is overlap between depressive
symptoms and what women commonly experience in perinatal period
such as feeling fatigue, having changes in sleep and appetite.
● Screening for postnatal depression will be useful and can be done from
6 to 12 weeks postnatal and be repeated once in later postnatal years.
Useful tools include: Whooley Two-Question Screen, Patient Health
Questionnaire-2 (PHQ-2) or Edinburgh Postnatal Depression Scale
(EPDS).
● Management:
o Mild depression: provide psychosocial intervention (e.g.
counselling, peer-support) and provide or arrange psychological
intervention (e.g. cognitive behavioural therapy, interpersonal
psychotherapy).
o Moderate depression: consider risk-benefit of antidepressant in
combination of psychosocial and psychological intervention as
above.
o Severe depression: antidepressant is most likely indicated.
Consider SSRI, e.g. Sertraline 50-100 mg daily.
o Consult/refer to FMS or psychiatrist particularly for severe
functional impairment, high risk of suicide or depression with
psychosis.
o Assess mother-baby interaction and address difficulties in
parenting and childcare.
8.1.3 Severe mental illness (for postpartum psychosis refer to obstetric

emergency)
● Mental disorders have a high risk of relapse during the postpartum
period.
● Management during the postnatal period will involve multidisciplinary
teams eg: O&G, paediatrics, psychiatry and social worker.
● Close monitoring is crucial for the first six weeks and may be required for
up to one year postnatal in women with severe mental illness. Home visit
by maternal child health teams and community psychiatry services may
be required.
● Ask about change in behaviour, agitation, suspiciousness, confusion and
hallucinations during the postnatal follow-up. Obtain collaborative history
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from family and partners regarding emotional lability and abnormal
behaviour.
● Observe difficulties in mother-baby interaction as well as parenting and
child-care abilities and offer appropriate support.
● Address psychosocial problems such as poor support, financial
difficulties, housing problems and unemployment
● Breastfeeding
o Breastfeeding is encouraged for most patients on psychotropics.
o Aim for antipsychotic that has an infant plasma level of less than
10%
o Olanzapine is antipsychotic of choice (infant plasma level 1.6%)
o Patients on Lithium and Clozapine are not recommended to
breastfeed.
o Mothers who are too heavily sedated should not sleep with the
baby
o Breastfeeding might need to cease if patient is too unwell, to avoid
sleep disruption or requires night time sedation
● Sleep preservation is important for prevention of relapse.
● Admission during a relapse in the postpartum period
o Admission is necessary if there is danger to patient and infant.
o As much as possible, mother and infant should be kept together by
mobilising social support or activating community mental health
care.
8.1.4 Substance abuse in postpartum period

● Women with perinatal substance use disorder presented with extremely
complicated issues and they may present in labour with no antenatal
check-up.
● Ask about history of substance use, withdrawal symptoms, psychosocial
issues as well as comorbid psychiatric and medical conditions.
● Management during the postnatal period must involve a multidisciplinary
team eg: O&G, Paediatrics, Psychiatry and Social worker.
● Address the needs of the care of the baby that may involve parenting
capacity issues, social support or adoption.
● Provide support for women to meet needs such as shelter, food and
safety plan
● Arrange follow-up (collaboration of hospital and health clinic).
● For women on methadone replacement therapy,
o relevant information includes confirmation of identification, last
dose and current prescription
o observe signs and symptoms of withdrawal
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o Arrangements for short-course of directly observed treatment
(DOTS)
o The client’s next of kin is allowed to take on behalf of the client
during confinement period (around 2 weeks) then the client needs
to attend methadone clinic on her own
o Arrangements for take away depend on the client’s drug history
and recent opioid use as well as the client’s stability - urine drug
test result (negative in 1-2 years)
● Breastfeeding:
o For individual risk-benefit analysis
o Breast-feeding is not contraindicated in patients on methadone
replacement therapy
o For patients still taking substance, generally breastfeeding is not
contraindicated unless the woman is a polysubstance user. She
may require advice regarding time from substance use to
breastfeeding or expressing breast milk for baby.
● Do not breastfeed for 72 hours after using amphetamines. To express
and discard milk after drug use.
● To limit alcohol to two standard drinks in a day. Not to consume
immediately before feeding. Consider expressing breast milk in advance
● Short acting benzodiazepines may be used for a limited time but long
acting should be avoided. Advise not to breastfeed immediately after
taking short acting benzodiazepines
8.2 COPING WITH DEATHS
8.2.1 Grief and bereavement

● Grief is the process of experiencing psychological, behavioural, social
and physical reactions to loss that may evolve over time. It is a normal
reaction, and its absence may be abnormal and indicative of pathology.
● Bereavement is the entire experience of family members and friends in
the anticipation of death and subsequent adjustment to living following
the death of a loved one.
● The emotional and somatic responses to death differ from person to
person. The grief response will be more intense if the death occurs in a
person who is closely related. The process of grief involves a few
stages.
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Table 8.1: Normal grief reaction
● Denial and disbelief

Stage 1 ● Numbness
Hours to days
● Sadness, weeping, waves of grief

● Somatic symptoms of anxiety
● Restlessness
Stage 2 ● Poor sleep
Weeks to 6 months ● Diminished appetite
● Guilt, blame of others
● Symptoms resolve
● Social activities resumed
Stage 3 ● Memories of good times
Weeks to months ● Symptoms may recur at anniversaries
● Abnormal or pathological grief:

o Symptoms are more intense than usual
o Symptoms prolonged beyond 6 months
o Symptoms delayed in onset
a. Abnormally intense grief:

▪ Up to 35% of bereaved people meet the criteria for a
depressive disorder at some time during grieving.
▪ Most of these depressive disorders resolve within six
months but about 20 % persist for longer periods.
▪ These persons are more likely:
▪ to have poor social adjustment
▪ visit doctors frequently
▪ to use alcohol
▪ Suicidal thoughts may occur when grief is
intense. The rate of suicides is increased most in
the year after bereavement, but continues to be
high for five years after the death of a spouse or
parent.
▪ Elderly widowers are at higher risk than other
bereaved people.
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▪ The presence of suicidal ideas should prompt
appropriate assessment of suicide risk.
b. Prolonged grief:
▪ Defined as grief lasting for more than 6 months. However, it
is difficult to set such a defined limit to normal grief and
complete resolution may take much longer.
▪ Instead of the normal progression, symptoms of the first and
second stage persist.
▪ Such prolongation may be associated with a depressive
disorder but can occur without such a disorder.
c. Delayed grief:
▪ It is said to occur when the first stage of grief does not
appear until more than two weeks after the death.
▪ It is said to be more frequent after sudden traumatic or
unexpected deaths.
d. Inhibited and distorted grief:

▪ Absence of grief is a pathological variant of grieving.
▪ Inhibited grief refers to a reaction that lacks some normal
features.
▪ Distorted grief refers to features (other than depressive
symptoms) that are either unusual in degree, for example
marked hostility, over – activity, and extreme social
withdrawal, or else unusual in kind, for example expression
of physical symptoms that were part of the last illness of the
deceased.
● The mortality of bereavement

o Several studies have shown an increased rate of mortality among
bereaved spouses and other closed relatives, with the greatest
increase being in the first 6 months after bereavement.
● Abnormal grief reactions are more likely in the following circumstances:
▪ When the death was sudden and unexpected,
▪ When the bereaved person had a very close, or
dependent, or ambivalent relationship with the deceased
▪ When the survivor is insecure, or has difficulty in
expressing, feelings, or has suffered a previous psychiatric
disorder
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▪ When the survivor has to care for dependent children and
so cannot show grief easily.
8.2.2 Management of grief and bereavement

● In planning the management it is important to take into account the
individual circumstances of the patient as well as the general guidelines
outlined below:
i. Counselling
The bereaved person needs:

▪ To talk about the loss
▪ To express feelings of sadness, guilt or anger
▪ To understand the normal course of grieving.
It is helpful to forewarn a bereaved person about unusual experience

such as feeling as if the dead person were present, illusions, and
hallucinations, otherwise these experiences may be alarming.
Help may be needed :

▪ to accept that loss is real
▪ to work through stages of grief
▪ to adjust to life without the deceased
Viewing the dead body and putting away the dead person’s
belonging help this transition, and a bereaved person should be
encouraged to perform the actions.
Practical problems may need to be discussed, including funeral

arrangements and financial difficulties.
As time passes, the bereaved person should be encouraged to

resume social contacts, to talk to other people about the loss, to
remember happy and fulfilling experiences that were shared with the
deceased, and to consider positive activities that the latter would
have wanted survivors to undertake.
ii. Drug treatment
Cannot remove the distress of normal grief, but it can relieve severe
anxiety.
In the second stage, antidepressant drugs may be beneficial if the

criteria for depressive disorder are met, though such usage has not
been evaluated in this special group.
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iii. Support groups
Can be useful, however, it may be difficult to sustain effective

functioning.
iv. Psychotherapy
It is not practical, nor it is there evidence that it is helpful, to provide

psychotherapy for all bereaved persons
Best Practice Guide:

● Provide an environment and circumstances for feeling hurt, guilty, angry or
other strongly negative feelings.
● Allow the spouse and relatives to ventilate
● Validate the extent of grief
● Facilitate procedures for removal of the body to the home for last rites.
● Be sensitive for the need for postmortem in cases of sudden death
● Do home visit to explore feelings of guilt or blame and explain /reinforce
circumstances of death.
● Encouraging the spouse to build a support network of family, friends and
professional-bereavement clinics are useful.
● Consider the needs of the children and refer to the appropriate welfare
authorities where appropriate.
● Be alert for suicidal intention or behaviour
● Remember that grief takes time
● Stages of grief are not always predictable
For health workers handling death among their patients:

Do
● Direct expression of sympathy
● Talk about deceased by name
● Elicit question about circumstances of the death
● Elicit question about feeling and about how the death has affected the
person
Don’t
● Have a casual or passive attitude
● Give statements that death is for the best
● Assume that the bereaved is strong and will get through this
● Avoid discussing the death
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To help remember grief work: Remember TEAR
● T - To accept the reality of the loss
● E - Experience the pain of the loss
● A - Adjust to the new environment without the lost object
● R - Reinvest in the new reality
8.3 MATERNAL DEATH

● The death of a pregnant woman in the antepartum, intrapartum or
postpartum period up to 42 days after the delivery.
● Special characteristics of a maternal death:
o Sudden, may be totally unexpected
o May occur in a healthy woman in the prime of her life
o Sudden end to hope of going home with a healthy wife and infant
after a pregnancy that was full of great expectations
● A maternal death is a great loss as the mother has multiple roles :
o Mother-newborn child, previous children
o Wife
o Wage earner
o Role model
o Member of the family
o Member of the community.
● After a maternal death:
1. Provide an accurate diagnosis. (Medical Officers/
Specialists)
o International Statistical Classification of Diseases and Related
Health Problems 10th Revision (ICD-10) is used.
o The cause of death should be discussed with the obstetrician
covering the district before release of the body.
o All maternal deaths where the cause of death is not known
including home deaths should be reported to the police. Once
a postmortem order has been issued, a detailed post-mortem
should be carried out. In the event where a post-mortem order
cannot be obtained, consent for a clinical post-mortem
examination should be requested. This request could be for a
limited postmortem examination or permission to carry out
needle biopsies.
2. Documentation and report:
o Events leading to the death must be completely documented.
o All investigations done must be documented and the results
traced.
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o The burial permit and death certificate should be completed by
the medical officer.
o The maternal death coordinator (Health Matron/Sister in the
case of a home/private sector death or labour ward sister for a
hospital death) should be notified within 24 hours using KIK/KI
– 1 form.
o The antenatal record should be summarised in the Maternal
Mortality Report. All maternal death cases need to be reported
and notified using the standard Maternal Mortality Report form.
The report should be filled and sent to the District Health
Officer for further action.
o All health facilities providing antenatal care should be stated in
the report.
o The Maternal Mortality Report (KIK/KI-2) should be promptly
filled within two weeks and sent to the state health department
for further action. This format should bear no indication of the
place or the persons involved in the death.
3. Provision of spousal support and bereavement counselling (Nurse/
Medical Officers/Specialist)
8.4 PERINATAL LOSS
● Perinatal loss is all types of loss which include early neonatal death,
intrauterine death, stillbirth, spontaneous miscarriages and medical
terminations.
● Refer Guideline for Stillbirth and Under Five Mortality Reporting System,
Ministry of Health 2018 for detailed procedures on the notification,
investigation of all stillbirths and Under -5 mortality.
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Reference:
1. David M. Taylor, Thomas R. E. Barnes, Allan H. Young. (2018). The Maudsley

Prescribing Guidelines, 13th Edition
2. Royal Australian and New Zealand College of Obstetricians and Gynaecologists.
Substance use in pregnancy. College Statement- C-Obs 55. 2013.
3. Queensland Clinical Guidelines. Perinatal substance use: neonatal. Guideline No.
MN16.38-V1-R21. Queensland Health. 2016.
4. World Health Organisation. Guidelines for the identification and management of
substance use and substance use disorders in pregnancy. 2014.
5. Commonwealth of Australia. National clinical guidelines for the management of drug
use during pregnancy, birth and the early development years of the newborn. 2006.
6. Guideline for Stillbirth and Under Five Mortality Reporting System, Ministry of Health
2018
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APPENDIX 8-1

Laboratory
Care of Plan
Signs & Investigati Diagnostic Criteria &
SOP Conditions
Symptoms ons & Differential Diagnosis Level of Level of
Management
Findings Personnel Care
1 Perineal ● Pain at wound site ● Swab N/A ● Wound care Nurses/ MO/ HC/
wound ● Swelling around C&S ● Antibiotics Specialist Hospital
problem the site ● FBC
● Bleeding from When required to
wound site consider:-
● Abnormal ● Incision & drainage
discharge ● Secondary suturing
● Wound
breakdown
2 Post
caesarean
care:
● Wound ● Gaping wound Wound a. Superficial and ● Dressing & Toilet MO HC
break down ● serous discharge swab C&S small size < 4cm ● Antibiotics oral
± foul smell and involve skin and cloxacillin 500mg QID
fat layer for 5 days
● Review C&S result and
treat accordingly
b. Deep and size >4cm MO / Specialist Hospital
involved rectus ● Refer to hospital with or
sheath and below ● Wound toilet without
● Antibiotic specialist
c. Result of ● Suturing after wound is
examination and clean
investigation
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Laboratory
Care of Plan
SOP Conditions
Management
● Infected ● Pus Wound Result of examination ● Refer to hospital MO/ O&G Hospital
wound ● Redness swab C&S and investigation ● Wound toilet Specialist with or
● Pain FBC if ● Antibiotic without
● Fever ± foul smell indicated ● Suturing after wound is specialist
clean
● Wound ● Swelling FBC Result of examination ● Conservative if small MO / Specialist Hospital

haematoma ● Redness (<4 cm), not increasing with or
● Pain in size and minimal pain without
● Require evacuation if specialist
increasing in size or
expanding or with pain
3 Heart ● Dyspnoea Any or all of ● Pulmonary oedema ● More frequent postnatal MO/ FMS/ Hospitals
diseases ● Cyanosis the ● CCF visit Specialist with
● Cardiac murmur following ● Embolism ● Assessment of cardiac specialist
● Signs of cardiac investigatio status during postnatal
failure n as visit
required: ● Any worsening
- FBC symptoms or inter-
- ECG current symptoms to
- CXR refer to hospital
- ECHO ● Ensure cardiology
appointment and follow
up
● Continue medication
● Avoid aggravating
factors
● Advise contraceptives
according to MEC
Pre pregnancy clinic

(PPC) referral:
● Patients who are not fit
for pregnancy, to be
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Laboratory
Care of Plan
SOP Conditions
Management
referred to PPC during
the postpartum period
● Patient to be informed to
attend PPC when plan
for next pregnancy in
view of might need
cardiac assessment
prior to conception
4 Urinary ● Unable to pass ● Urine ● UTI ● Intermittent or Nurses / MO / HC/

retention urine FEME ● Neurogenic Bladder continuous bladder Specialist Hospital
● Distended bladder ● Urine catheterisation
● Lower abdominal C&S ● Antibiotic for infection
discomfort ● Ultrasoun
● Fever d may be
considere
d
5 Urinary Intermittent or ● Urine Need to rule out any Management according to MO/Specialist HC/
incontinence continuous FEME urinary fistula cause Hospital
incontinence ● Urine ● Treatment of UTI
C&S ● Pelvic floor exercise
● Referral to
gynaecologist/ uro-
gynaecology
6 Subinvolutio ● Uterus does not Ultrasound Need to rule out ● Reassurance if MO/ FMS/ O&G HC/
n of uterus involute as to rule out: retained placenta or ultrasound normal and Specialist Hospital
expected ● retained POC asymptomatic
● Severe pain POC ● If abnormal USG or
● Abnormal ● uterine or sever pain to refer
bleeding ovarian hospital
mass
7 Secondary Excessive bleeding ● FBC ● Uterine atony Refer to training manual MO/ FMS/ O&G Hospital
postpartum from the genital ● GXM ● Retained POC on management of PPH Specialist
haemorrhage tract after 24 hours ● Coagulati ● Coagulations disorder
post delivery on profile ● Endometritis
● Ultrasoun ● Pelvic arteriovenous
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Laboratory
Care of Plan
SOP Conditions
Management
d malformation (AVM) –
if all of the above have
been ruled out
o
8 Puerperal ● Temp > 38 C ● FBC ● Genital tract infection According to causes, MO/ FMS/ O&G Hospital
pyrexia ● Abnormal vagina ● Blood ● Wound infection – consider: Specialist
discharge C&S episiotomy & LSCS ● Antibiotic
● Urine ● UTI ● Wound care
FEME ● Other intercurrent ● Supportive management
● Urine infections such as ● Admission to hospital
C&S URTI, malaria,
● HVS C&S pneumonia, dengue
● Wound ● DVT
swab
C&S
● Lower
limb
ultrasoun
d doppler
9 Breast ● Pain ● Mastitis ● Cold and warm Nurses / MO/ All level
engorgement ● Swelling ● Abscess compression Specialist
● Express breast milk
● Antibiotics and
analgesics
● If unresolved, for
incision & drainage
10 Deep Vein ● Unilateral calf Lower limb ● Redness of calf ● Inform medical officer/ Specialist Hospital
Thrombosis swelling ultrasound ● Tenderness on FMS with
● Tenderness doppler palpation ● Refer to hospital specialist
● Pain on walking ● Decrease peripheral urgently
● Low grade fever pulsation
11 Pulmonary ● Difficulty in ● Chest X ● Resuscitation Specialist and Hospital

embolism breathing ray ● Inform medical multidisciplinary with
● Sudden onset ● Abnormal officer/FMS team specialist
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Laboratory
Care of Plan
SOP Conditions
Management
chest pain ECG ● Refer to hospital
● Non- productive changes urgently
cough ● Arterial
● Tachypnoea blood
● Tachycardia gases
● Hypotension ● CTPA
● Low O2 saturation ● V/Q scan
● Maternal collapse
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CHAPTER 9
OBSTETRIC EMERGENCIES
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CHAPTER 9: OBSTETRIC EMERGENCIES
9.1 RED ALERT SYSTEM
The Red Alert System is described in the Report on Confidential

Enquiries into Maternal Mortality in Malaysia for the year 1992. It should
be operational in all hospitals dealing with obstetric cases where it helps
to improve emergency response time and reduces maternal morbidity
and mortality. This system should also be implemented in other health
facilities, but amended to suit the facility concerned.
9.1.1 How the Red Alert System Functions

● Red Alert code is triggered in the presence of an obstetric emergency
case in any health facility.
● The nurse or doctor in charge of the area activates the system by calling
the telephone operator of the hospital or in the case of health clinics to
call their colleagues for assistance by saying “Red Alert”
● The operator will immediately initiate a ‘call system’ to get staff involved
to attend to this emergency.
● Each health facility is to establish its own system
● The doctors involved (see below) will go to the area of concern
9.1.2 Staff involved in Red Alert (hospital)

● Medical officers on call From O&G, Medical and
● Specialist on call Anaesthesiology
● Consultant on call Departments
● Blood bank
● Sister on-call
9.1.3 Staff involved in Red Alert (health clinic)

● Staff attending the patient to trigger red alert (nurse or doctor)
● To call FMS / Medical officer in charge
● Ambulance driver if available
● Medical assistant
● The person in charge (nurse or doctor) must consult the specialist on call
in the nearest specialist hospital
● Preparation for transfer of patients by clinic ambulance or by an
obstetrics retrieval team should be prompted
● The aim is to get as many staff as possible to assist simultaneously to
stabilise the patient and facilitate the transfer to a specialist hospital
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9.1.4 Indications to activate Red Alert (but not limited only to these
conditions)
● Severe antepartum haemorrhage
● Postpartum haemorrhage
● Eclampsia
● Uterine inversion
● Cord prolapse
● Shoulder dystocia
9.2 REFERRAL SYSTEMS AND RETRIEVAL & RESUSCITATION TEAM
9.2.1 When should a nurse or medical officer refer or consult a higher level
of care?
● Abnormalities of the foetal heart rate
● Delay in the first or second stage of labour.
● Any meconium-stained liquor
● Obstetric emergency – antepartum haemorrhage, cord presentation or
prolapse, postpartum haemorrhage, uterine inversion, shoulder dystocia,
eclampsia, maternal collapse or a need for advanced neonatal
resuscitation is anticipated.
● Retained placenta
● Maternal pyrexia in labour (38°C once or 37.5.°C on two occasions 2
hours apart)
● Malpresentation or breech presentation diagnosed for the first time at the
onset of labour
● Either raised diastolic blood pressure (over 90 mmHg) and or systolic
blood pressure (over 140 mmHg) on two consecutive readings taken 30
minutes apart
● Uncertainty about the presence of a foetal heart activity
● Third or fourth degree tears or other complicated perineal trauma
requiring repair.
● Any other medical conditions in which the medical officer is unable to
manage
9.2.2 Referral System
Inter-hospital / inter-centre transfer should be considered if the

necessary resources or personnel for optimal maternal care are not
available at the facility providing the care. The resources available at the
referring and the receiving centres/hospitals should be considered. The
risks and benefits of transporting or not transporting the mother, should
be assessed.
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9.2.3 In-utero transfer
All conditions potentially requiring specialised care for the neonate

(medical/ surgical) e.g. preterm labour, foetal growth restriction and
congenital anomaly requiring surgical intervention may benefit from in-
utero transfer. This has proven to result in a better neonatal outcome
compared to neonatal transfer after delivery.
9.2.4 Retrieval and Resuscitation Team
A system should be available to transport trained medical personnel

from higher level centres to provide assistance in the referring
centre/home. In some hospitals, the team is called the “Flying Squad”.
Team members
● Medical officer / specialist
● Assistant medical officer (optional)
● Staff nurse from labour ward
● Ambulance driver
● Male attendant from Emergency Department
Indications for mobilisation of the Retrieval Team

● Antepartum haemorrhage
● Postpartum haemorrhage
● Eclampsia
● Severe pre-eclampsia
● Mother in labour
● Cord prolapse
● Uterine inversion
How the team functions

● A telephone call is received from a peripheral or private maternity centre
● Staff in Labour Ward triggers the operation of the team by calling the
person in-charge from the Emergency Department
● The team assembles at the Emergency Department and sets out to the
referring centre as soon as possible preferably within 10 minutes of the
initial call
● The team retrieves the mother at the referring centre and brings her to
the hospital
● The referring centre needs to perform initial resuscitation
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Resuscitative equipment
It is dependent on the nature of the cases being retrieved. A complete
set of medical equipment should be brought in the ambulance:
● Defibrillator
● Mobile vital sign monitors including pulse oximetry
● Non-pneumatic anti-shock garments (if available)
● Infusion pumps
● IV fluids/volume expanders
● Matched or unmatched blood and blood products
9.2.5 Referral letter

● A standard Intrapartum Referral Form (IP-1) should be used to refer a
mother in labour.
● The intrapartum checklist of the mother (Appendix 3-4) should be
updated and attached to the referral form.
● The receiving hospital should likewise reply using a standard reply form
(IP-2) when the mother is discharged from their care.
● Effective communication between the centres involved will help maintain
good working relationships and understanding and ensure continuity of
care for the mother.
● As suggested under “Level of Care” – (SOP – Intrapartum
Management), apart from mother in normal labour, mother with all other
conditions as stated in the Checklist of Intrapartum Risk Factors
(Appendix 3-4) should be managed in a hospital and not in a health
centre/ community health clinic or home.
9.3 CORD PROLAPSE
Cord prolapse has been defined as the descent of the umbilical cord
through the cervix alongside (occult) or past the presenting part (overt)
in the presence of ruptured membranes.
Cord presentation is the presence of the umbilical cord between the

foetal presenting part and the cervix, with or without rupture of
membranes.
Risk factors for cord prolapse include:

● Multiparity
● Prematurity less than 37 weeks
● Artificial rupture of membranes
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● External cephalic version (during procedure)
● Low birth weight, less than 2.5 kg
● Foetal congenital anomalies
● Vaginal manipulation of the feotus with ruptured membranes
● Internal podalic version
● Breech presentation
● Stabilising induction of labour
● Second twin
● Insertion of uterine pressure transducer
● Unengaged presenting part
● Polyhydramnios
● Transverse, oblique and unstable lie (when the longitudinal axis of the
feotus is changing repeatedly)
● Low-lying placenta or other abnormal placentation
Note: Refer to Appendix 3-2 for measures to be taken before transfer to

the tertiary centre.
9.4 UTERINE RUPTURE
Uterine rupture is defined as a disruption of the uterine muscle

extending to and involving the uterine serosa or disruption of the uterine
muscle with extension to the bladder or broad ligament.
Signs and symptoms of uterine rupture:

● Shock
● Rapid maternal pulses
● Abdominal distension
● Free fluid present in the abdominal cavity
● Abnormal uterine contour
● Tender abdomen
● Easily palpable foetal parts
● Absent foetal movements and foetal heart sounds
● Abnormal CTG
What actions need to be taken?

● If a patient is unstable, call for help. Start resuscitation immediately.
Refer to O&G specialist on call at the nearest hospital and arrange for
transfer.
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● If uterine rupture is suspected and the patient is stable, for the medical
officer to refer to O&G specialist on call in the nearest hospital and
arrange for transfer.
9.5 SHOULDER DYSTOCIA
Shoulder dystocia is defined as a delivery that requires additional

obstetric manoeuvres to release the shoulders after gentle downward
traction to deliver the feotus has failed. Shoulder dystocia occurs when
either the anterior or less commonly, the posterior foetal shoulder
impacts on the maternal symphysis or sacral promontory.
Table 9.1 : Factors Associated with Shoulder Dystocia
Pre-labour Intrapartum
● Short stature ● Prolonged first stage of labour
● Previous shoulder dystocia ● Secondary arrest
● Macrosomia ● Prolonged second stage of
● Diabetes mellitus/ GDM labour
● Maternal BMI > 30 kg/m2 ● Oxytocin augmentation
● Induction of labour ● Assisted vaginal delivery
Note:
● Health care providers in clinics should undergo obstetric emergency
drills such as for shoulder dystocia on a regular basis.
● One should refer immediately to a tertiary centre if shoulder dystocia is
anticipated. However, if delivery occurs at your centre refer to Standard
Operating Procedure for Cord Prolapse and Figure 9.1 for measures to
overcome this complication.
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Figure 9.1 : Algorithm for Management of Shoulder Dystocia
Discourage
CALL FOR HELP pushing
Midwife coordinator, additional midwifery help, experienced
obstetrician, neonatal team and anaesthetist Lie flat and move
buttocks to edge
of bed
McROBERTS’ MANOEUVRE
(Thighs to abdomen)
SUPRAPUBIC PRESSURE
(and routine axial traction)
Consider episiotomy if it will make

internal manoeuvres easier
Try either manoeuvres first

depending on clinical
circumstances and
operator experience
INTERNAL ROTATIONAL
DELIVER POSTERIOR ARM
MANOEUVRES
Inform consultant obstetrician

and anaesthetist
If above manoeuvres fail to release impacted shoulders,

consider ALL FOURS POSITION (if appropriate)
OR
Repeat all the above again
Consider cleidotomy, Zanaveli manoeuvre or

symphysiotomy
Baby to be reviewed by neonate team after birth and referred for specialist review if any
concerns
DOCUMENT ALL ACTIONS AND COMPLETE INCIDENT REPORTING FORM
Adapted from Royal College of Obstetricians and Gynaecologists Green-top Guideline No.42,
nd
2Released
edition, 2012
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9.6 MATERNAL COLLAPSE
Maternal collapse is defined as an acute event involving the

cardiorespiratory systems and/or brain, resulting in a reduced or absent
conscious level (and potentially death), at any stage in pregnancy and
up to six weeks after delivery. The common reversible causes of
collapse in any woman can be remembered using the well known 4Ts
and the 4Hs employed by the Resuscitation Council (UK).
Table 9.2 : Causes of maternal collapse
Reversible cause Cause in Pregnancy

Bleeding (may be concealed) (obstetric/
other) or relative hypovolaemia of
Hypovolaemia
dense spinal block; septic or neurogenic
shock.
Pregnant mother can become hypoxic
more quickly
4H’s Hypoxia Cardiac events: peripartum
cardiomyopathy, myocardial infarction,
aortic dissection, large-vessel
aneurysms
Hypo/ hyperkalaemia and other No more likely
electrolyte disturbances
Hypothermia No more likely
Amniotic fluid embolus,
Thromboembolism pulmonary embolus, air embolus,
myocardial infarction.
4T’s Tension pneumothorax Following trauma/suicide attempt
Toxicity Local anaesthetic, magnesium, other
Tamponade (cardiac) Following trauma/suicide attempt
Eclampsia and pre-eclampsia Includes intracranial haemorrhage
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9.7 UTERINE INVERSION
● This is an obstetric emergency (Red Alert)

● Sign and symptoms of uterine inversion include:
o Profuse bleeding
o Absence of uterine fundus on abdominal examination
o An obvious defect of the fundus on abdominal examination
o Visible uterus at the perineum in second and third degree inversion
o Evidence of shock
● Refer immediately to an O&G specialist in the nearest hospital, the
patient should ideally be transferred and managed in specialist hospital
● Any attempt to reduce the inversion should only be done by a trained
person and after getting approval from an O&G specialist.
● Replace the inverted uterus immediately (with placenta if still attached)
by slowly and steadily pushing upwards.
● The last part to come out should be the first part to go in.
● Do not attempt to remove the placenta as this can lead to severe
postpartum haemorrhage.
● With the passage of time, the constriction ring around the inverted uterus
becomes more rigid and the uterus more engorged with blood.
● If the attempt fails, refer to the nearest hospital after stabilising the
mother.
● In hospital if manual reduction failed, can proceed to the O’Sullivan
Method.
● If all the above fails, consider surgical reduction.
Risk factors for uterine inversion include:

● Short umbilical cord
● Excessive traction on the umbilical cord
● Excessive fundal pressure
● Fundal implantation of the placenta
● Retained placenta and abnormal adherence of the placenta
● Chronic endometritis
● Vaginal births after previous caesarean section
● Precipitous or prolonged labour
● Previous uterine inversion
9.8 SEVERE PRE-ECLAMPSIA
Patients who presents with the following signs and symptoms:

● Headache
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● Blurring of vision
● Epigastric pain
● Nausea and vomiting
● Hyperreflexia (ankle clonus)
Potential complications from severe pre-eclampsia :

● Eclampsia
● Shortness of breath – may indicate acute pulmonary oedema
● Per vaginal bleeding and abdominal pain to suggest placenta abruption
Management of severe pre-eclampsia:

● At KK level, refer to FMS or medical officer to attend urgently
● To set IV access
● To control blood pressure if there is hypertensive crisis by giving oral
Nifedipine 10mg stat
● To consult O&G specialist on-call in nearest specialist hospital
● To give bolus IM Magnesium sulphate injection + 2% lignocaine
● Transfer patient to a specialist hospital once blood pressure has been
stabilised but there should not be a delay to transfer the patient if blood
pressure is difficult to stabilise
● Obstetric retrieval team should be considered if available
● Refer to Training Manual on Hypertensive Disorders in Pregnancy
(2018)
9.9 ECLAMPSIA
● Eclampsia is an obstetric emergency.

● Any seizure occurring in pregnant women NOT due to other causes is
considered eclampsia until proven otherwise.
9.9.1 Management of Eclampsia
Management of eclampsia is essentially similar to that of severe pre-

eclampsia. In addition, resuscitation and control of seizure should be of
priority.
1. Call for help! (INITIATE RED ALERT)

2. Resuscitation
a. Ictal phase: left lateral position and oxygen supplementation.
b. Post-ictal: assessment of response, protect airway, assess
breathing and circulation (may need maternal
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cardiorespiratory resuscitation if there is absence of normal
breathing).
3. Secure at least 2 intravenous lines.
4. Prevent recurrent seizure with loading dose of IV MgSO4 4g slow
bolus over 10-15 mins or IM MgSO4 5g + 1ml 2% lignocaine in each
buttock followed by maintenance dose.
5. For maintenance dose, IM MgSO4 5g every 4 hours in alternate
buttocks (without lignocaine)
6. If the woman develops another fit after 1 hour of loading dose or
maintenance dose, administer another 5g of IM MgSO4. Refer Garis
panduan Pemberian Suntikan Intramuscular Magnesium Sulphate di
Peringkat Penjagaan Kesihatan Primer bagi Kes Severe Pre-
eclampsia/Eclampsia, MOH, 2014.
7. Start parenteral anti-hypertensive if systolic BP ≥ 160 mmHg or
diastolic BP ≥ 110mmHg.
8. Monitor closely according to protocol while awaiting transfer to
specialist hospital.
9. Monitor the feotus accordingly.
10. Do not give too much fluid as the patient is at risk of acute pulmonary
oedema, total fluids should not exceed 2L in 24 hours.
11. Refer to Training Manual on Hypertensive Disorders in Pregnancy
(2018)
Table 9.3: Intravenous Magnesium Sulphate dosage
Loading dose
Dose 4g
Concentration 1 ampoule = 2.47g / 5 ml
Preparation Withdraw 8 ml (4g) of MgSO4 + 12 ml of normal saline = 20 ml
Administration To give 4g MgSO4 in slow bolus for 15 – 20 minutes.
In cases where seizure occurs after administration of MgSO4, a further bolus of 2 g
MgSO4 can be given with close monitoring of Mg level. Serum magnesium can be
taken before the repeated MgSO4 bolus if the situation allows.
Maintenance dose
Infusion pump Syringe pump
Dose 1 g/hour
Concentration 1 ampoule = 2.47g / 5 ml
Preparation Withdraw 10 ampoules (50 ml) Withdraw 2 ampoules (5 g/10
of MgSO4 + 450 ml of normal ml) of MgSO4 + 40 ml of normal
saline = 25g/500ml saline = 5 g/50 ml (1 g/10 ml)
Infusion Infusion rate: 21 ml/hour (1 g/ Infusion rate: 10 ml/hour (1 g/
hour) hour)
Continue infusion of MgSO4 for Continue infusion of MgSO4 for
24 hours after delivery or last 24 hours after delivery or last
seizure, whichever occurs later. seizure, whichever occurs later.
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Table 9.4: Intramuscular Magnesium Sulphate dosage
Loading dose
Dose Total of 10 g (5 g each buttock)
Concentration 1 ampoule = 2.47 g/5 ml
Preparation Withdraw 2 ampoules (5 g/10 ml) of MgSO4 + 1ml of local
anaesthesia (2% lignocaine)
Administration Deep intramuscular injections into each buttock.
In cases where seizure occurs after administration of MgSO4, a further bolus of 5 g
intramuscular MgSO4 can be given with close monitoring of Mg level. Serum
magnesium can be taken before the repeated MgSO4 bolus if the situation allows.
Maintenance Doses
Dose 5 g every 4 hours
Concentration 1 ampoule = 2.47 g/5 ml
Preparation Withdraw 2 ampoules (5 g/10 ml) of MgSO4 + 1ml of local
anaesthesia
Administration Deep intramuscular injection into alternate buttock every 4 hourly
until 24 hours after delivery or last seizure, whichever occurs later.
9.9.2 Maternal and Foetal Monitoring in Eclampsia
Magnesium sulphate can potentially cause cardiorespiratory depression.

Therefore, the woman needs to be monitored for signs and symptoms of
MgSO4 toxicity.
Table 9.5: Maternal monitoring for Magnesium Sulphate toxicity
Parameters Interval of monitoring Target

Blood pressure Every 15 minutes 140 – 150/ 90 – 109
mmHg
Pulse rate Every 15 minutes  60 bpm
Respiratory rate Hourly  16 breaths per minute
Urine output Hourly  30 mls/H or  100 mls/4
hours or 0.5 ml/kg/H
Deep tendon reflex Hourly Presence of reflexes
of knee
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9.10 OBSTETRIC HAEMORRHAGE
Obstetric haemorrhage can be divided into bleeding while the feotus is still
in-utero which is antepartum haemorrhage (APH), or bleeding after delivery
of the feotus which is defined as postpartum haemorrhage (PPH). The
causes for APH and PPH are very different. However, the principles of
management and good communication remain the same.
Principles of Managing Obstetric Haemorrhage
1. Recognition of obstetric haemorrhage and assessment of severity

2. Communication and call for help
3. Resuscitation
4. Identification and treatment of the cause of haemorrhage
5. Monitoring and documentation
Communication, Resuscitation, Treatment & Monitoring should occur

simultaneously.
● Timing is critical in the management of obstetric haemorrhage
● Early involvement & intervention by specialist/consultant can be
lifesaving
Recognition and Assessment of Haemorrhage
Ability to recognise APH/PPH early and to appreciate the severity is the

most crucial aspect of management.
The three commonest shortfalls identified in maternal deaths due to
massive PPH are delay to diagnose, failure to appreciate severity and the
delay, inadequate and/or inappropriate therapy.
A systemic assessment is essential in obstetric haemorrhage to

establish:
● The severity of her condition based on:

o Visual estimation of blood loss
o Clinical signs and symptoms of hypovolaemic shock
o Obstetric Shock Index
o Cause of bleeding
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Table 9.6 : Clinical Signs and Symptoms of Hypovolaemic Shock
Blood loss
Pulse
(ml) Urine
Classification Shock Rate Blood Respiratory Mental
(% of output
of shock Index (beats Pressure Rate Status
blood (ml/hour)
per min)
volume) **
Class I <0.6 Up to 750 < 100 Normal 14 – 20 Normal > 30
(No shock) ml
(< 15%)
Class II ≥ 0.6 to 750 – 1500 > 120 Normal but 20 – 30 Anxious 20 – 30

(Mild shock) <1 ml may have
(15 – 30%) narrow pulse
pressure
Class III ≥ 1 to < 1500 – > 120 Reduced 30 – 40 Confused 5 – 15

(Moderate 1.4 2000 ml
shock) (30 – 40%)
Class IV ≥ 1.4 > 2000 ml > 140 Very low, > 35 Lethargic Nil
(Severe (> 40%) can be
shock) unrecordable
** based on body weight of 50kg
Source: Gutierrez G, Wulf-Gutierrez M & Reines D, Clinical
review: Hemorrhagic shock; Critical Care (2004)
Obstetric Shock Index (SI)
Visual estimation of blood loss is usually inaccurate and blood loss is often
underestimated. Physiological compensatory mechanisms of pregnancy and
the puerperium may also mask decompensation until late in hypovolaemic
shock. Abnormality in vital signs is a late sign of hypovolaemic shock. This
will lead to late recognition of hypovolaemic shock, and delay in
resuscitation.
Obstetric Shock Index (SI) is defined as HR/SBP. It is a useful tool as an

early marker of compromise and thus should be practiced to improve the
management of all obstetric haemorrhages. For the pregnant population,
normal SI ranges from 0.7- 0.9; SI  1 predicts adverse clinical outcome.
OBSTETRIC SHOCK INDEX = HR/SBP

(NORMAL = 0.7 – 0.9)
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Minor Obstetric Haemorrhage
1. Identify early and call for help
2. Set 1 large bore intravenous cannula of at least 18 G or 16 G.
3. Fluid resuscitation with crystalloids
4. Monitor vital signs every 15 minutes until bleeding stops
5. Continue to assess blood loss and Shock Index periodically if there is
ongoing loss.
6. Monitor foetal heart if it is antepartum haemorrhage
7. Refer early to O&G specialist on-call from the nearest hospital and
transfer patient
Major Obstetric Haemorrhage
1. Activate RED ALERT

2. Refer stat to O&G specialist on-call
3. Place the woman flat and keep her warm.
4. Supplementation of oxygen up to the rate of 15 L/min via facemask.
5. Set 2 large bore intravenous cannulas – 16G or 18G.
6. Fluid resuscitation with crystalloids first and then colloids at the
recommended ratio while waiting for transfer to a hospital or for an
obstetric retrieval team to arrive.
7. Monitor vital signs every 15 minutes or more often until patient is
transferred
8. Continue to assess blood loss and Shock Index periodically until the
patient arrives in a specialist hospital
9. Monitor foetal heart if it is antepartum haemorrhage
9.10.1 ANTEPARTUM HAEMORRHAGE
Antepartum haemorrhage (APH) is defined as any pervaginal bleeding

occurring after 22 weeks of pregnancy. Prior to 22 weeks, any pervaginal
bleeding is categorized under threatened miscarriage.
Two main causes of APH are:
1. Abruptio placenta
2. Placenta praevia
Abruptio placenta
Defined as the premature separation of a normally located placenta from the
uterus prior to the delivery of the feotus.
● Bleeding in placenta abruptio is usually accompanied by severe
abdominal pain
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● Bleeding in placenta abruptio may be REVEALED / CONCEALED /
MIXED
● Do not treat patient based on the amount of bleeding seen. Include
Obstetric Shock Index in assessment.
Placenta praevia
Placenta praevia is defined as a placenta which is implanted partially or

entirely in the lower segment of the uterus. Bleeding is usually painless but
can be life-threatening.
Table 9.7: Classification of Antepartum Haemorrhage
Classification Definition
Spotting Staining, streaking or blood spotting noted
on underwear or sanitary protection
Minor Blood loss is less than 500ml and has
haemorrhage stopped
Major Blood loss of 500-1000ml, with no signs of
haemorrhage clinical shock
Massive Blood loss is more than 1000ml and/or signs
haemorrhage of clinical shock
9.10.2 POSTPARTUM HAEMORRHAGE
Postpartum haemorrhage (PPH) is the second commonest cause of direct

maternal deaths in Malaysia.
Table 9.8: Classifications of Postpartum Haemorrhage
Classification Definitions
Primary Blood loss of 500 ml or more from the genital
tract within 24 hours after vaginal delivery and
1000ml following operative delivery
Secondary Any abnormal or excessive bleeding from the
genital tract after 24 hours to 6 weeks
postpartum
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Table 9.9: Severity of Postpartum Haemorrhage
Severity Amount of blood loss (ml)

Minor 500 – 1000
Major > 1000
Massive > 1500
*RCOG defined severe PPH as blood loss of
≥2000 ml; however, with the logistic issues,
we have lowered the threshold to prevent
potential delays in resuscitation.
Risk Identification and Prevention
Assessment of risk for PPH should be done for all pregnant women
throughout their antenatal care. Risk identification allows a safe delivery
plan to be outlined and documented in the woman’s antenatal card.
Care should be taken to optimise high-risk women before delivery. A safe

delivery plan includes delivery in hospital with specialists and support from
blood banks.
Risk Factors Associated with PPH (Antenatal)

● Grandmultipara
● Anaemia in pregnancy
● Previous history of PPH
● Previous history of retained placenta
● Previous history of caesarean section
● Previous history of myomectomy
● Multiple pregnancies
● Macrosomia
● Placenta praevia
● Any bleeding disorder
● Women on anticoagulant
● Presence of uterine fibroid
● Overdistended uterus
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Prevention of PPH (Antenatal)
● Optimization of haemoglobin level by 36 weeks
● Identification of high risk women
● Women who are high risk for PPH from remote area may need to stay
near a hospital with O&G specialist from 36 weeks onwards (e.g.: transit
home, relatives’ house)
● Women with placenta praevia should be managed accordingly
● Women with previous caesarean section and placenta praevia should be
referred to rule out morbidly adherent placenta
General Principles in Managing of PPH

● Recognition and assessment of severity
● Communication and call for help
● Resuscitation as necessary
● Treatment to arrest the bleeding
● Monitoring and documentation
● Early referral and prompt transfer
● Refer to the Training Manual on Management of Postpartum
Haemorrhage (PPH), 2016
Causes of Bleeding
The causes of bleeding – 4 T’s
● Tone (70%) – uterine atony
● Trauma (20%) – genital tract trauma including uterine rupture
● Tissue (10%) – retained placenta or product of conception
● Thrombin (<1%) – pre-existing or acquired coagulopathy (DIVC from
placenta abruption or severe pre-eclampsia)
Management of common causes of PPH
a. UTERINE ATONY
1. Uterine massage
2. Empty urinary bladder with continuous bladder drainage
3. Oxytocics – oxytocin or syntometrine
● Oxytocin (Pitocin) – IM Pitocin bolus 10 units/IV Pitocin
bolus 5 units slow bolus over 1 – 2 minutes.
o Dose may be repeated after 5 minutes – up to a total
dose of 10 units.
o Start IV infusion of oxytocin infusion 40 units in 1 pint
normal saline for 4 hours (125 mls/H).
● Syntometrine – IM 1 ampule stat (5 units oxytocin and 0.5
mg ergometrine)
o Contraindicated in hypertension and cardiac disease.
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● If the mother is unbooked or unsure of medical or
antenatal history, use oxytocin.
● IM Carboprost 0.25 microgram stat. This can be repeated
every 15 minutes up to 8 doses
● IV Tranexamic acid 1g stat
b. GENITAL TRACT TRAUMA
Vulval/Vaginal/Cervical Tears:
1. Attempt repair if possible but do not delay transfer.

2. If repair is not feasible or bleeding continues, control the
bleeding temporarily with vaginal packing (either using a roller
gauze or 2-3 rolled sanitary pads) while awaiting transfer (if it
happens in the district hospital) or definitive management.
c. RETAINED PLACENTA
1. Retained placenta is diagnosed after 30 minutes if active

management of the third stage is practiced (controlled cord
traction). Otherwise, it is diagnosed after 1 hour.
2. MRP should not be attempted in a health clinic unless in
certain circumstances and only with the approval of an O&G
specialist
3. IV oxytocin infusion 40 units should be started while awaiting
transfer.
SECONDARY PPH
Defined as abnormal or excessive bleeding from the genital tract after 24

hours and up to 6 weeks post-delivery.
● Causes of Secondary PPH

o Infection (most common)
o Retained product of conception
o Unrecognised lower genital tract trauma
o Bleeding disorder
o Persistent trophoblastic disease (uncommon)
o Others – chronic sub-involution of uterus (uncommon), uterine AV
malformation (rare)
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● Management of Secondary PPH
General principles of management are essentially similar to

management of primary PPH.
1. Recognition and assessment of the severity

2. Resuscitation if required
3. Initiate treatment based on the cause:
● Intravenous broad-spectrum antibiotic should be initiated
● Uterotonics to be given if indicated
4. Refer and transfer patient accordingly
5. Refer to the Training Manual on Management of Postpartum
Haemorrhage (2016)
9.11 PUERPERAL SEPSIS
World Health Organisation (WHO) defined puerperal sepsis as “an infection

of the genital tract is occurring at any time between the rupture of
membranes or labour and the 42nd day postpartum”, in which, two or more
of the following are present:
● pelvic pain
● fever (oral temperature 38.5°C or higher on any occasion)
● abnormal vaginal discharge, for example, presence of pus
● abnormal smell/foul odour of discharge
● delay in the rate of reduction of the size of the uterus
Diagnosis of sepsis in pregnant women has been made difficult as the signs
and symptoms may not be present or less distinctive compared to the non-
pregnant population due to physiological changes in pregnancy. This
causes a delay in diagnosis of puerperal sepsis, often until it is too late for
intervention. Disease progression may be rapid, hence early recognition
leading to diagnosis of puerperial sepsis and commencement of appropriate
treatment play crucial roles in improving the outcome.
Common pathogens causing sepsis in the puerperium are:
● Group A streptococcus (e.g.; Streptococcus pyogenes), Group B

streptococcus (Streptococcus agalactiae)
● Escherichia coli
● Staphylococcus aureus
● Methicillin resistant Staphylococcus aureus, clostridium septicum and
morganella morganii
Puerperal sepsis carries a significant preventable maternal morbidity and

mortality risk. The diagnosis of sepsis is clinical. Early diagnosis and
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treatment of sepsis may improve outcomes of those unfortunate maternal
deaths secondary to sepsis.
The National CEMD report commonly identify the following shortfalls
● Delay and suboptimal treatment

● Delay in referring to specialist hospitals
● Failure to appreciate severity
Management plan:
● Early identification during clinic or home visits

● Patients need to be assessed by medical officer
● To initiate IV or oral antibiotics
o Broad spectrum antibiotics (cephalosporins, clavulanic acid,
sulbactam)
o Metronidazole
● Patients suspected of puerperal sepsis should be referred to an O&G
specialist and should be transferred
9.12 POSTPARTUM PSYCHOSIS
● Postpartum psychosis is a psychiatric emergency that affects about one

in every 1000 new mothers.
● Postpartum psychosis presents as rapid onset of:
o frank psychosis such as hallucinations or delusions
o cognitive impairment and confusion
o mood swings
o disorganised behaviours
● Postpartum psychosis carries the risk of maternal harm and infanticide
and must be intervened urgently. It has been estimated that untreated
postnatal psychosis carries a four percent risk of infanticide and a five
percent risk of suicide
● Factors that increase risk for postpartum psychosis includes:
o primiparous mothers who are single
o women who are older
o women with a past psychiatric history and family history of
schizophrenia or bipolar disorder
o prenatal depression
o past history of postpartum psychosis (recurrence 25 % to 75%)
● Acute management for a patient who present with postpartum psychosis
o Ensure safety of mother and infant
o Locate the patient and infant if the family came by proxy. If mother
came alone, locate the infant
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o Urgent referral to tertiary centre for review by psychiatrist
o Admission will be decided by the psychiatry team
● There is no clear prevention for postnatal psychosis but identification of
risk factors and lowering of aggravating factors may help. Encourage
social support, sleep hygiene and mobilise help for new mothers.
● The overall prognosis is positive, especially when symptoms emerge
less than 1 month after delivery. Among patients who develop
postpartum psychosis immediately after childbirth, 72%–88% have
bipolar illness or schizoaffective disorder and 12% have schizophrenia.
9.13 PERINATAL SUICIDE AND PARASUICIDE
● Perinatal suicides are suicides that occur during pregnancy and up to six
weeks postpartum, but often expanded to the entire first postpartum year
(as maternal psychiatric illness most often persists beyond six weeks
postpartum).
● Suicide accounted for about 5–20% of maternal deaths during
pregnancy and the first postnatal year in high-income countries and 1–
5% in low-income and middle-income countries.
● Parasuicide (self-harm) is self-poisoning or self-injury, irrespective of the
apparent purpose of the act. Self-harm ideation is more common than
suicide attempts or deaths, with the prevalence of 5 to 14%. These are
often associated with Borderline Personality Disorder or trauma
syndromes.
● Risk factors for perinatal suicide:
o Younger age
o Being unmarried
o Previous history of psychiatric disorders (e.g. mood disorders,
substance use disorder)
o Previous history of suicidal attempt or suicidal ideation
o Psychiatric comorbidity
o Shorter illness duration
o Family history of psychiatric disorders
o Family history of suicidal attempt or suicidal ideation
o Family conflict
o Exposure to domestic violence
o Loneliness and lack of support
o Partner who rejected paternity
o Unintended pregnancy
● Protective factors
o Support and connectedness
o Engagement to health services
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o Life skills (eg coping strategies)
o Sense of purpose or meaning of life
o Faith, cultural and religious beliefs that discourage suicide
9.13.1 Assessment
● Assess suicidal thought

o Do you have any suicidal thoughts?’
o How frequent and persistent are they?
● Assess suicidal plan
o Do you have a plan?
● Assess mental state, e.g.
o Are you depressed?
o Are you feeling hopeless?
o Commanding hallucinations
● Assess risk factors
● Assess protective factors
o What is stopping you?
o Do you have people to support you?
9.13.2 Triaging of patients with suicide risks
● Low Risk of Suicide

o Some mild or passive suicide ideation, with no intent or plan
o No history of suicide attempt
o Available social support
● Moderate Risks
o Suicidal ideation with some level of suicide intent, but who have
taken no action on the plan
o No other acute risk factors
o History of psychiatric illness & receiving treatment
● High risks
o Made a serious or nearly lethal suicide attempt
o Persistent suicide ideation or intermittent ideation with intent and/or
planning
o Psychosis, including command hallucinations
o Other signs of acute risk
o Recent onset of major psychiatric syndromes, especially
depression
o Been recently discharged from a psychiatric inpatient unit
o History of acts/threats of aggression or impulsivity
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9.13.3 Management
● Risk of suicide can be reduced by recognising past history and taking
proactive management
● Screen during antenatal care for a personal or family history of mental
illness. If there is history of mental illness:
o Document clearly in the antenatal book and clinical case notes
o Counsel the patient regarding risks and plan of care
● Activate a plan for multidisciplinary monitoring and support:
o maternal and child health care service
o high-risk pregnancy care
o psychiatry and mental health service
o social worker
● At each visit, assess for suicide risk especially if there are mood
changes
● Manage suicide risks by mitigating risk factors and strengthening
protective factors.
● Prepare plan of care during antenatal, intrapartum, discharge and
postnatal.
● Admit when there is high suicidal risk.
9.14 POSTPARTUM MOTHERS WITH INFANTICIDE RISK
● Thoughts of harming one’s child is not uncommon but are considered so

taboo that most mothers will not voice it out.
● There are many factors that lead to infanticide such as unintended
pregnancies, substance use, domestic violence, poverty, marital conflict
and mental illness.
● Untreated postpartum psychosis carries a four percent risk of infanticide,
usually resulting from a psychotic belief about the infant or negative
maternal reaction to separation.
● Infanticide may also occur in severe postpartum depression causing
neglect and abuse
● Empathetic questioning of at risk patients regarding such thoughts is
mandatory. If risk to the safety of the infant is present, actions must be
taken. Alternative caregivers such as family members must be identified
or admission of the infant while the mother undergoes treatment.
● Referral to social worker and child protector is mandatory if the infant is
in immediate risk
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APPENDIX 9-1
Diagnostic Care of plan

Laboratory
Condition Symptoms/ criteria and
SOP Investigation Level of Level of
signs differential Management
& findings personnel care
diagnosis
1 Maternal Temperature ≥ ● TWBC ● Chorio- ● Broad spectrum MO/Specialist Hospital with
Pyrexia 38oC ● Septic work up, amnioniti antibiotic (Medical/ Specialist
including s ● Expedite delivery if Surgical/
Blood C&S if ● Intercurre chorioamnionitis Peadiatric)
maternal nt ● Assessment of baby
temperature ≥ infection; at delivery
380C UTI,
● UFEME URTI
● Urine C&S ● DVT
● HVS C&S
● CXR (if
indicated)
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Laboratory
diagnosis
2 Cord ● Presence ● FBC Initial management: MO/Specialist Hospital with
Prolapse of cord ● GXM ● Elevate mother’s (O&G / Specialist
outside the buttocks Anaesthesia /
cervix ● Oxygen to mother Peadiatric)
● Membranes ● Replace cord into
absent the vagina with
warm gauze/pad
● Inflate bladder with
normal saline
● Expedite delivery as
appropriate
3 Shoulder Delay in ● FBC ● Call for the most All levels All levels
Dystocia delivery of ● GXM senior staff available
shoulder at the centre.
● IV line
● The mother must be
in lithotomy position,
legs up in stirrups
with buttock at the
edge of the bed.
● Empty the bladder
● Extend episiotomy
● McRobert
manoeuvre:
Hyperflex hips and
knees and abducts
hips.
● Suprapubic
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Laboratory
diagnosis
pressure to dislodge
anterior shoulder.
● Downward axial
traction on feotus.
● Failing the above,
deliver the posterior
shoulder followed by
the anterior
shoulder.
● Failing the above,
activate referral/
retrieval system
4 Postpartum Bleeding from ● FBC ● Uterine ● TRIGGER RED All levels All levels
Haemorrhage the ● GXM atony ALERT
genital tract ● Coagulation ● Retained ● IV line with 16-18G
>500mls profile placenta cannula
in vaginal ● Trauma: ● Resuscitation
delivery Cervical ● Oxytocics/
and > 1000mls tear, Prostaglandins
in vaginal Refer Training Manual
Caesarean wall tear/ on Management of PPH
section
haemato
Or enough
ma
blood loss to
● Uterine
cause
hypotension or inversion
shock ● Coagulati
on
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Laboratory
diagnosis
disorder
5 Antepartum PV bleed ● FBC ● Bleeding ● IV line MO/Specialist Hospital with

Haemorrhage during ● GXM Placenta ● Resuscitation (O&G / Specialist
antepartum ● Coagulation Praevia ● Refer hospital with Anesthesia /
period profile ● Abruptio specialist Peadiatric)
● CTG placenta ● Expedite delivery
● Ultrasound ● Uterine
rupture
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References:
1. Royal College of Obstetricians and Gynaecologists Green-top Guideline No.42, 2nd

edition, 2012
2. Susan Hatters Friedman, Renée Sorrentino. Commentary: Postpartum Psychosis,
Infanticide, and Insanity—Implications for Forensic Psychiatry Journal of the
American Academy of Psychiatry and the Law Online Sep 2012, 40 (3) 326-332
3. Essali, A., Alabed, S., Guul, A., & Essali, N. (2013). Preventive interventions for
postnatal psychosis. Schizophrenia bulletin, 39(4), 748–750.
https://doi.org/10.1093/schbul/sbt073.
4. Khalifeh, H., Hunt, I. M., Appleby, L., & Howard, L. M. (2016). Suicide in perinatal
and non-perinatal women in contact with psychiatric services: 15 year findings from
a UK national inquiry. The lancet. Psychiatry, 3(3), 233–242.
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TABLE OF CONTENTS
PAGE

INTRODUCTION TO NEONATAL CARE SECTION
CHAPTER 10 : Overview of Newborn Care 315
10.1 At Birth
10.2 After birth
10.3 Discharge of Term Baby
10.4 Discharge of Newborn with Special Needs
10.5 Home Visits
10.6 Work Process for Home/Low-Risk Birth Centre (LRBC)
Deliveries
10.7 Work Process in Labour Room
10.8 Work Process After Birth and Just Before Discharge
10.9 Work Process During Home Visit
Appendices 326-335
Appendix 10-1 Newborn Physical Examination as in Buku Rekod
Kesihatan Bayi dan Kanak-Kanak ( 0- 6 Tahun)
Appendix 10-2 Garis Panduan Pemeriksaan Bayi Baru Lahir Mengikut
Buku Rekod Kesihatan Bayi dan Kanak-Kanak (0 – 6
Tahun)
Appendix 10-3 Rawatan Postnatal (Home Visit)
Appendix 10-4 Garis Panduan Pemeriksaan Rawatan Postnatal
Mengikut Buku Rekod Kesihatan Bayi dan Kanak-
Kanak (0 – 6 Tahun)
Appendix 10-5 Role of Traditional Practice among Mothers and The
Newborn
CHAPTER 11 : Resuscitation and Stabilisation 337

11.1 Resuscitation of The Newborn
11.2 Thermal Protection
11.3 Stabilisation and Transportation of The Newborn
11.4 Criteria for Various Levels of Neonatal Care
11.5 Normal care
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PAGE
CHAPTER 12 : Early Newborn Care 357
12.1 Overview of Newborn Examination

12.2 Common Findings in Newborn Examination
12.3 Screening for Congenital Hypothyroidism

12.4 Administration of Hepatitis B Prophylaxis, BCG
Vaccination and Vitamin K in The Newborn
12.5 Common Neonatal Issues/Conditions
Appendices 391-393
Appendix 12-1 Warning Signs for Babies
CHAPTER 13 : Breastfeeding and Weight Monitoring 395

13.1 Breastfeeding
13.2 Acceptable Medical Reasons for Supplementation to
Babies Below Six Months of Age
13.3 Weight Monitoring in Newborn Term Infants
CHAPTER 14 : Specific Perinatal Conditions Related To Maternal 407

Comorbidities
14.1 Infant of Mother with Diabetes
14.2 Infant of Mother with Thalassaemia
14.3 Infant of Mother with Autoimmune Diseases
14.4 Infant of Mother with other Blood Disorders
14.5 Infant of Mother with Thyroid Disease
14.6 Infant of Mother with Syphilis
14.7 Infant of Mother with HIV
14.8 Infant of Mother with Active Tuberculosis
14.9 Infant of Mother with Mental Disorders
14.10 Infant of Teenage or Single Mother
14.11 Infant of Mother with Substance Abuse
14.12 Infant of Mother with Group B Streptococcal Infection
or Risk of GBS Ascending Infection
14.13 Infant of Mother with Recent Varicella Zoster Infection
14.14 Infant of Family History of Neonatal Death
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INTRODUCTION TO NEONATAL CARE SECTION
This neonatal section outlines the care plans and work processes for a baby at birth, the
immediate period after birth and thereafter at home. Routine care for most babies who are
healthy is as laid out in the flow charts and complications necessitating other interventions
and management will be discussed in the relevant chapters. Existing Ministry of Health
documents e.g. Integrated Plan for the Detection and Management of Neonatal Jaundice
(2017), National Screening Programme for Congenital Hypothyroidism (2018), Paediatric
Protocols for Malaysian Hospital 4th edition (2018), Garispanduan Sistem Kawalan
Keselamatan Bayi (2007) are intended to be used in conjunction with this manual and will
be referenced in the relevant sections. Common neonatal health problems such as skin
rashes and feeding problems will be addressed but specific management of serious
neonatal medical conditions are not included in the manual except for highlighting the
recognition of signs of the seriously ill child and how he/ she should be referred and or
transported. We encourage reference to other resources where information is lacking in
the manual.
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CHAPTER 10
OVERVIEW OF NEWBORN CARE
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CHAPTER 10: OVERVIEW OF NEWBORN CARE
10.1 AT BIRTH
a. Identify high-risk factors and request for Paediatric Unit doctor’s
standby if necessary (Chapter 11)
b. Resuscitate if necessary (Chapter 11)
c. Facilitate skin-to-skin contact immediately and initiate breastfeeding
within first hour of birth (Chapter 11)
d. Check vital signs (Chapter 12) for range of normal neonatal vital
signs and ensure thermal protection (Chapter 11)
e. Perform physical examination to exclude congenital anomalies such
as abnormal facies, cleft palate and lips, abdominal wall defects,
neural tube defects, imperforate anus etc (Chapter 12)
f. Ensure cord blood is sent for G6PD and TSH screening (Chapter 12)
g. Administer Vitamin K and Hepatitis B vaccination (Chapter 12)
h. Transfer the baby to relevant level of care as necessary (Chapter 11)
10.2 AFTER BIRTH
a. Perform physical examination, and chart findings on newborn

physical examination findings in Child Health Record Book
(Appendix 10-1)
b. Ensure thermal protection (Chapter 11)
c. If baby is nursed in postnatal or neonatal wards, regular observations
and vital signs must be taken
d. Check for hypoglycaemia in high risk cases (Chapter 12)
e. Check for jaundice and monitor severity (Chapter 12)
f. Encourage breastfeeding and bonding (Chapter 13)
g. Administer BCG vaccination (Chapter 12)
h. Document results of G6PD, TSH screening, universal hearing
screening (if available), and pulse oximetry screening (if available) in
the child health card. If abnormal, appropriate action is to be taken
i. Promote education on bathing, cleanliness, skin and cord care,
postnatal follow-up, immunisation, and warning signs (Chapter 10)
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10.3 DISCHARGE OF TERM BABY [Hospital/Low-Risk Birth Centre (LRBC)]
Purpose
To ensure newborn babies are safely discharged, they should meet basic
criteria and have appropriate arrangements for continuous care.
The baby should be healthy in the clinical judgement of the health care
provider and the mother should have demonstrated a reasonable ability to
care for the baby.
Criteria for Discharge of Term Baby

i. Assessment of baby
● Feeding well - at least two successful feedings
● Size appropriate for gestational age
● If small-for-gestational age
o no (further) hypoglycaemia
o and has been discharged by the paediatric doctor
● If large-for-gestational age
o no (further) hypoglycaemia
o and has been discharged by the paediatric doctor
● Passed checklist (Chapter 13) for breastfeeding technique, and
adequacy (observation and health education)
● Normal body temperature (axillary temperature of 36.5°C to
37.5°C)
● Pink and has no breathing difficulties
● No evidence of sepsis. If there is risk of sepsis -observe for at
least 24-48 hours
● Minimal neonatal jaundice (except for Day 1 jaundice)
● Passed urine
● Passed meconium
● Cord is dry and clean
● No significant eye discharge
● Physical examination done by doctor and baby discharged from
additional observation and treatment
ii. Immunisation and others

● Received BCG, Hepatitis B & Vitamin K
● G6PD and TSH, results documented in Home Based Child Health
Record.
● Document results of G6PD, TSH screening, universal newborn
hearing screening (if available), and pulse oximetry screening (if
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available) in the child health card. If abnormal, appropriate action
is to be taken.
● If results are not available yet, arrangements MUST be made to
trace results and document in the Home Based Child Health
Record.
● Health education on bathing, cleanliness, skin and cord care,
postnatal follow-up, immunisation, and warning signs.
● Mother is able to provide routine baby care and recognise signs of
illness and other problems related to newborn.
iii. Follow-up appointments

● Home Based Child Health Record to be filled and given to mother
● Notify the health clinic once the baby is discharged so that
arrangements for follow-up by community health nurse can be
done (preferably within 24 hours of discharge).
● Outpatient appointment to see doctor if necessary.
● Follow-up appointment for baby in Paediatric clinic, if required.
10.4 DISCHARGE OF NEWBORN WITH SPECIAL NEEDS
Five critical components must be looked into when providing post-

discharge care:
i. Parent education
● General care plans and health education on bathing, cleanliness,
skin and cord care, postnatal follow-up, immunisation, and
warning signs.
● Specific care plans as below.
ii. Primary care implementation

● Timely immunisation
● Regular hearing and vision tests
● Nutritional support and monitoring
● Growth and development assessment
iii. Evaluate current medical problems

● Physical handicap
● Psychomotor development
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iv. Develop home care plan
● Identify parent/caregiver
● Identify equipments needed
● Identify community support
● Have emergency plan
v. Follow up care – coordination between the specialists
Specific Care Plans:
i. Preterm
● care with thermal protection
● more patience with feeding – ensure appropriate weight gain
● avoid overcrowded places and URTI contact – to reduce risk of
respiratory tract infection
● follow immunisation schedule according to chronological age
● to nurse in a supine position to reduce risk of SIDS (Sudden
Infant Death Syndrome).
● avoid cigarette smoke
● educate on hand hygiene
● close supervision at all times
● follow up for weight at health clinic
● follow up for myopia, hearing and neurodevelopment
● Basic Life Support (BLS) training for parents/caregivers.
ii. At risk families due to family issues

e.g. single or young parents, marital problems, lack of social support,
poverty, domestic violence or substance abuse
● review family’s coping skills – advise on handling crying baby

● if any financial assistance required – refer Jabatan Kebajikan
Masyarakat (JKM)
● mobilise extended family support and supervision especially in
drug addiction
● more frequent home/health clinic visits
● alternative care placement of baby may be required – refer JKM
iii. Baby with special health care needs

● Cleft palate – feeding technique, growth, care with aspiration,
hearing tests
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● Nasogastric feeding – regular change of nasogastric tube, mother
to know
● Oxygen dependence – avoid cigarette smoke, avoid URTI contact
● Tracheostomy – parents to learn suctioning and tracheal care
● Colostomy care
● Basic Life Support (BLS) training for parents/caregivers.
iv. Babies with multiple problems

● Multiple congenital abnormalities – multi-disciplinary assessment
and follow-up, early intervention programme
● Motor/ sensory disability - multi-disciplinary assessment and
follow-up, early intervention programme
For further management of children with special needs, health care providers are
required to refer to the following documents developed by the Division of Family
Health Development, MOH :
 A series of six manuals on Management of Children with Disabilities
 Care of Children with Special Needs: Manual on Management of
Children with:
o Fine Motor Delay
o Visual Impairment
o Communication problems
o Personal & Social problems
10.5 HOME VISITS
Postnatal home visits are done for mothers and babies according to
schedule and whenever necessary (Chapter 4)
● Re-examine baby and chart findings on in Child Health Record Book

(both mother’s and clinic’s copy)
● Ensure thermal protection.
● Weigh baby and check for normal weight gain pattern (Chapter 13)
● Assess adequacy of feeding and technique (Chapter 13)
● Check for jaundice and monitor severity
● Promote education on bathing, cleanliness, skin and cord care, postnatal
follow-up, immunisation and warning signs.
● Educate on the role of traditional practice after delivery (mother and
newborn) (Appendix 10-5)
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10.6 WORK PROCESS FOR HOME/LOW-RISK BIRTH CENTRE (LRBC)
DELIVERIES
Nurse standby
(nurse with post-basic midwife)
Determine baby’s condition

Collect and send cord blood for TSH
and G6PD screening
Resuscitate as necessary
Put tag on baby

Initiate breastfeeding, skin-to-skin
contact, & bonding with mother
Stabilise vital signs, ensure thermal

protection and monitor for
hypogylcemia
Examine baby using newborn

checklist
Normal baby Baby with abnormal Emergency

findings but stable (hospital admission)
Refer to Health Clinic

for vaccination* and
medical examination
Newborn home visits Refer early to Stabilise and transfer to

(same time as health clinic for referral hospital
postnatal visit) review
Hepatitis B and Vitamin K injections:

st
Home delivery- Refer to Health Clinic for Hepatitis B 1 Dose
st
LRBC Delivery – Give Hepatitis B 1 Dose and IM Vitamin K after birth
BCG:
Home delivery- Refer to Health Clinic/hospital for BCG
LRBC Delivery – Give BCG in Health Clinic/hospital
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10.7 WORK PROCESS IN LABOUR ROOM
Identify high-risk factors and request for Paediatric unit

doctor standby if necessary
Resuscitate as necessary
Stabilise vital signs, ensure thermal protection and

monitor for hypogylcemia
Put tag on the baby

Facilitate skin-to-skin and initiate breast feeding
Ensure cord blood is sent for G6PD and TSH screening
Perform physical examination using newborn checklist and

exclude congenital anomalies
To determine appropriate level of neonatal care

(refer to Chapter 11)
Normal care Special Care or Neonatal Intensive and Semi-Intensive

Care (Level IIa or I) Care (Level III and II b)
Give Vit K
Can baby be SCN/NICU

nursed with No available in
mother in the same
obstetric ward? hospital?
Yes
Hepatitis B
immunisation
No
Yes
Nurse with Nurse with mother in

Stabilise and transfer to
mother in obstetric ward and
referral hospital
obstetric ward paediatric team to continue
monitoring
Admit to SCN/NICU
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10.8 WORK PROCESS AFTER BIRTH AND JUST BEFORE DISCHARGE
Perform newborn examination with checklist
No Yes
Any problems?
Nurse in postnatal/neonatal ward

Refer to Paediatrics Unit
Ensure thermal protection
Check for hypoglycaemia in high

risk cases, check for jaundice, and
monitor vital signs. No Require
admission to
SCN/NICU?
Encourage breastfeeding and
bonding
Yes
Administer BCG vaccination
Admit and manage in SCN/NICU
Trace and document G6PD & TSH

screening results, universal hearing
screening (if available), pulse Discharge to No Discharge
oximetry screening (if available) in postnatal/neonatal home
the Child Health Card and take ward
appropriate actions
Yes
Discharge:
Discharge with notification form to

be given within 24 hours to health No
Baby with
clinic for follow up special needs?
Complete documentation of
delivery and newborn checklist in
Home Based mother and Child
Yes
Health Card
Paediatric hospital or Outpatient
appointment if necessary Discharge:
Hospital to inform health clinic upon patient
discharge
Discharge with special care plan and
notification form to be given within 24 hours
to health clinic for follow up
Complete documentation of delivery and
newborn checklist in Home-based mother
and Child Health Card
Paediatric hospital or Outpatient
appointment if necessary
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WORK PROCESS DURING HOME VISIT
Home visit
Examine baby and chart findings in Child Health Record Book (mother’s
and clinic’s copy)
Any
problem?
Yes No
 Check and update documentation

on BCG, Hep B vaccination and
Give Vit K status
appropriate  Check and update G6PD and
Referral No TSH test result in Child Health
needed home treatment
according to Record Book
guideline
Yes
Advise on:
Follow up visit.  Thermal protection
Refer
Refer if no  Breastfeeding and bonding
clinic/hospital
improvement  Hygiene and cleanliness
 Skin and cord care
 Jaundice
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APPENDIX 10-1
NEWBORN PHYSICAL EXAMINATION AS IN BUKU REKOD KESIHATAN BAYI DAN

KANAK-KANAK (0- 6 TAHUN)
SARINGAN BAYI BARU LAHIR
PEMERIKSAAN FIZIKAL: (Diisi oleh Pegawai Perubatan)

Vital sign:
Suhu Badan:………........ °C Kadar respiratori:……......……/min
Kadar denyutan jantung: ……… /min
Buang air besar dalam masa 24 jam : Ya Tidak
Buang air kecil dalam masa 24 jam : Ya Tidak
Memulakan penyusuan susu ibu : Ya Tidak
Pemeriksaan Am : Tanda ( √ ) di ruangan berkenaan
Pemeriksaan Normal Abnormal Catatan
Pemeriksaan Am
Wajah bayi
Keadaan Kulit
Kepala/Kulit
Telinga/Hidung
Mata (termasuk red light
reflex)
Mulut
Gusi
Lelangit
Dada
Jantung
Abdomen
Spine
Anus
Genitalia
Nadi Femoral
Pinggul (Hips)
Tangan
Kaki
Reflexes
Maklumat Tambahan (jika ada):
....................................................................................................................................................
....................................................................................................................................................
..........................................................................................................................................
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APPENDIX 10-2
GARIS PANDUAN PEMERIKSAAN BAYI BARU LAHIR MENGIKUT BUKU REKOD

KESIHATAN BAYI DAN KANAK-KANAK (0 – 6 TAHUN)
Kelahiran di hospital:
● Pemeriksaan dijalankan oleh doktor di wad postnatal sebelum discaj.
● Tanda (√ ) pada ruang berkaitan.
● Tulis di ruangan catatan jika berkenaan
.
Kelahiran di rumah:
● Pemeriksaan dijalankan oleh doktor di klinik kesihatan berhampiran semasa
lawatan pertama ke klinik.
● Tanda (√ ) pada ruang berkaitan.
● Tulis di ruangan catatan jika berkenaan.
Pemeriksaan Penemuan
Vital signs ● Ambil suhu badan, kadar respiratori dan kadar denyutan
jantung dan rekodkan.
● Kadar pernafasan normal: 40-60/min
● Kadar denyutan jantung normal: 120-160/min
● Rujuk kepada pegawai perubatan sekiranya kadar
pernafasan/denyutan jantung luar daripada julat normal
Buang air besar dalam • Tanya ibu atau penjaga sama ada bayi ada buang air
masa 24 jam besar atau tidak dalam masa 24 jam yang lalu.
• Tanda (√ ) di petak berkenaan.
Buang air kecil dalam • Tanya ibu atau penjaga sama ada bayi ada buang air
masa 24 jam kecil atau tidak dalam masa 24 jam yang lalu.
• Tanda (√ ) di petak berkenaan.
Penyusuan susu ibu di • Tanda (√ ) di petak berkenaan.
mulakan
1. Pemerhatian Am
Perhatikan secara am keadaan dan kecergasan bayi. Bayi yang tidak aktif/kurang
cergas, tangisan lemah atau ‘irritable’ perlu dirujuk
2. Wajah Bayi
Rupa bayi yang luar biasa sama ada asymmetry atau mempunyai ciri-ciri
dysmorphic seperti Down Syndrome.
3. Keadaan Kulit
Warna Kulit: perhatikan warna kulit bayi sama ada pucat, cyanosis atau jaundis
Keadaan Kulit: periksa sama ada terdapat sebarang masalah seperti ruam, septic
spot yang meluas (extensive), petechiae dan lain-lain. Periksa status hidrasi.
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4. Kepala/Leher
Periksa kepala untuk:
● Bonjol atau lekuk pada ubun-ubun (bulging or depressed fontanelle).
● Caput succedaneum – ialah benjolan yang bukan hematoma. Akan susut
selepas beberapa hari.
● Cephalhaematoma – keadaan di mana hematoma tidak merentasi garis
sutures di kepala.
● Subaponeurotic haemorrhage – hematoma yang merentasi garis sutures
yang boleh menyebabkan renjatan hipovolemik. Ini perlu dirujuk segera
Periksa leher untuk:

● Sternomastoid tumor yang boleh menyebabkan teleng (torticollis)
● Pembengkakan seperti cystic hygroma
5. Telinga/ Hidung
Perhatikan posisi dan rupa bentuk telinga seperti low-set ear menunjukkan ciri
Down Syndrome.
Perhatikan untuk nasal flaring jika ada.
6. Mata
Jika terdapat keadaan seperti merah, bertahi, bernanah, congenital cataract,
pendarahan bahagian sclera ‘subconjunctival haemorrhage), congenital ptosis,
atau juling.
Gunakan ophthalmoscope untuk memeriksa red light reflex.
7. Mulut/ Gusi/ Lelangit

Periksa untuk sumbing bibir (cleft lip), sumbing lelangit (cleft palate), tongue tie,
macroglossia atau terdapat natal teeth (berisiko mengalami aspirasi jika gigi
longgar). Periksa juga untuk oral thrush (tompokan putih pada lidah atau gusi)
8. Dada
Periksa untuk bentuk dada yang tidak normal, kadar dan cara pernafasan. Kadar
pernafasan yang normal adalah 40 – 60 / minit dan tiada grunting atau stridor’
9. Jantung
Periksa kadar dan bunyi denyutan jantung. Kadar denyutan normal adalah 120 –
160/ minit.
10. Abdomen
Jika terdapat keadaan abdomen yang kembung berserta dengan muntah, cirit atau
tidak membuang air besar, perlu dirujuk segera. Periksa juga keadaan tali pusat
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11. Spine
Perhatikan untuk skoliosis, Spina Bifida atau tanda kulit seperti lipoma,
haemangioma atau tuft of hair.
12. Anus
Periksa untuk patensi dan kehadiran fistula.
13. Genitalia
Lelaki:
● Periksa kedudukan pembukaan urethra. Keadaan seperti hypospadias,
epispadias adalah luar biasa.
● Keadaan undescended testes perlu dirujuk.
● Pembesaran pada kerandut zakar mungkin disebabkan hydrocele, inguinal
hernia, tumour
Perempuan:
● Perhati untuk labia minora dan labia majora, clitoris, urethral dan vaginal
orifice.
● Jika terdapat discaj dari vagina berwarna putih atau sedikit perdarahan dalam
minggu pertama adalah normal.
Sekiranya jantina tidak dapat dikenalpasti, perlu rujukan segera untuk memastikan
bukan disebabkan oleh gejala merbahaya seperti Congenital Adrenal Hyperplasia
14. Nadi Femoral

Periksa nadi femoral, jika tiada atau lemah perlu dirujuk (kemungkinan coartation
of aorta)
15. Pinggul (Hips)

Perhati pergerakan di kedua belah sendi pinggul adakah seimbang (symmetrical).
Rujuk kepada pakar ortopedik sekiranya Ortolani atau Barlow test adalah positif
(clunk sensation)
16. Kaki
Periksa untuk congenital talipes equinovarus (CTEV), panjang kedua belah kaki
dan tapak kaki adalah sama
17. Tangan
Boleh menggerakkan tangan dengan bebas. Periksa untuk webbed fingers,
polydactyly, syndactyly dan warna kuku jari.
18. Reflexes
Grasp dan moro reflex.
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Unilateral moro reflex menunjukkan kecederaan brachial plexus, Erb’s palsy atau
fracture clavicle/humerus.
Sucking reflex tidak perlu dilakukan jika bayi telah menyusu dengan baik.
Catatan:
1. Sila rujuk bayi kepada Pegawai Perubatan/Pakar Perubatan Keluarga/Pakar Pediatrik di

klinik atau hospital berdekatan dengan segera jika perlu.
2. Sila rujuk Perinatal Care Manual: Neonatal Care, Chapter 12, Ministry of Health, 4th
Edition, 2020.
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APPENDIX 10-3
Rawatan Postnatal (Home Visit)
AKTIVITI PENEMUAN
Tarikh
Umur semasa lawatan
Berat badan (kg),
Panjang (cm),
Lilitan kepada (cm)
Suhu (Suhu normal
ketiak 36.5 - 37.00C)
Tindakbalas
(Aktif/Tidak Aktif)
Keadaan kulit
(warna, hidrasi)
Penilaian penyusuan
Buang air kecil
Buang air besar
Sistem Kardiovaskular
(Kadar denyutan
jantung normal: 120-
160/min)
Sistem Pernafasan
(kadar pernafasan
normal: 40-60/min)
Pemeriksaan fizikal
lain: kepala, leher,
mata, mulut, telinga,
abdomen, sistem
tulang
Alat kelamin
Sistem neurologi (reflex
dan muscle tone)
Bimbingan awal ibu
bapa
Catatan
Tandatangan & Nama
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APPENDIX 10-4
GARIS PANDUAN PEMERIKSAAN RAWATAN POSTNATAL MENGIKUT BUKU

REKOD KESIHATAN BAYI DAN KANAK-KANAK (0 – 6 TAHUN)
RAWATAN POSTNATAL (Hari ke 2, 3, 5, 8-10 dan 14-16)
Aktiviti Penemuan
Tarikh Tulis tarikh dan masa lawatan ke rumah dibuat.
Umur semasa lawatan Umur bayi semasa lawatan.
Parameter Ukur berat badan (kg), panjang (cm) dan lilitan kepala.
Suhu Badan Ambil suhu badan bayi dan catat bacaan (°C)
Tindakbalas • Lihat secara am keadaan bayi sama ada aktif atau tidak.
• Tanya ibu keadaan bayi.
Warna dan keadaan • Perhatikan warna bayi sama ada normal, biru (cyanose)
kulit bayi atau pucat (pale) dan catat di ruang penemuan.
• Ambil tindakan yang sewajarnya dan rujuk jika perlu.
• Periksa sama ada kulit baik atau mempunyai masalah
seperti ruam, septic spot dan lain-lain.
• Periksa untuk jaundis. Sekiranya jaundis ambil tindakan
seterusnya mengikut garis panduan pengendalian jaundis
dan di isi di dalam borang yang telah disediakan
(MMN/NNJ2016)
Penilaian penyusuan Tanya ibu sama ada mempunyai masalah penyusuan seperti:
• Bengkak buah dada.
• Puting buah dada pecah (cracked nipples).
• Bayi tak mahu menyusu.
• Tiada susu ibu /tidak cukup susu ibu dan lain-lain.
• Beri nasihat mengenai penyusuan susu ibu.
• Pantau cara ibu menyusukan anak
Tanya ibu sama ada bayi buang air besar dengan baik
Buang air besar
(kekerapan dan warna). Sekurang-kurangnya 2 kali sehari.
Tanya ibu sama ada bayi buang air kecil dengan baik
Buang air kecil
(kekerapan dan warna). Sekurang-kurangnya 5-6 kali sehari.
Sistem Kardiovaskular • Kira pernafasan dalam satu minit,
(Kadar denyutan • Ulangi perkiraan dan rujuk ke klinik atau hospital
jantung normal: 120- berdekatan jika kadar di luar julat normal
160/min)
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Aktiviti Penemuan
Sistem Pernafasan • Kira pernafasan dalam satu minit
(kadar pernafasan • Ulangi perkiraan dan rujuk ke klinik atau hospital
normal: 40-60/min) berdekatan jika kadar denyutan jantung di luar julat normal
Pemeriksaan fizikal • Rujuk kepada pemeriksaan fizikal bayi baru lahir

lain: kepala, leher,
mata, mulut, telinga,
abdomen, sistem
tulang
Alat kelamin • Periksa rupa bentuk genitalia dan catit penemuan
• Periksa keadaan testis, ‘undescended testes’ perlu dirujuk.
• Rujuk kepada pemeriksaan fizikal bayi baru lahir
Sistem neurologi • Periksa grasp dan moro reflex bayi (rujuk pemeriksaan bayi
(reflex dan muscle baru lahir)
tone)
Bimbingan awal ibu • Baca dan terangkan kepada ibubapa/penjaga mengenai
bapa Panduan Ibubapa
• Tanya ibu jika ada masalah dan catat di ruang yang
disediakan.
• Beri nasihat yang bersesuaian dan catitkan
Catatan
Catatkan sebarang maklumat tambahan sekiranya ada
Tandatangan & Nama • Tandatangan dan tulis nama (cop) pegawai yang
melakukan pemeriksaan kesihatan bayi setiap kali lawatan
ke rumah dijalankan.
• Pada lawatan antara hari ke 10, 15 dan ke 20, ingatkan
ibubapa/penjaga lawatan ke klinik pada umur 1 bulan.
Catatan:
1. Sila rujuk bayi kepada Pegawai Perubatan/Pakar Perubatan Keluarga/Pakar Pediatrik

di klinik atau hospital berdekatan dengan segera jika perlu.
2. Sila rujuk Perinatal Care Manual : Neonatal Care, Section 14 dan Appendix 10-2,
Ministry of Health, 2nd Edition, 2010.
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APPENDIX 10-5
ROLE OF TRADITIONAL PRACTICE AMONG MOTHERS AND THE NEWBORN

Good Practice Harmful Practice Unsure Benefit
● Breastfeeding ● Too early weaning e.g. ● Feeding of gripe water
exclusively mashed bananas, rice for relief of abdominal
● Using coconut oil to porridge, glucose water distension/ colic
remove cradle cap etc ● Use of herbs and jamu
● Frequent breastfeeding ● Goat’s milk for jaundiced by mother during
to encourage production baby postnatal period
of milk ● Bathing jaundiced
● Baby sleeping with babies with herbs. This
mother in same room may mask jaundice and
sometimes trigger an
acute haemolysis in
G6PD deficient babies
● Applying ash, ‘celak
mata’ to the umbilical
stump
● Using knitted cap when
there is cradle cap
(aggravates the cradle
cap )
● Restriction of fluids in
postnatal mothers
(especially among
Malays), certain food,
vegetables, fruits,
chickens, egg and
seafood
● Discarding colostrum
● Application of irritant on
baby’s skin
● Application of heated
object to abdomen and
scrotum after bath
● Using breastmilk to wash
eyes
● Baby sleeping with
mother on the same bed
● Baby sleeping prone (on
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Good Practice Harmful Practice Unsure Benefit
his stomach)
● Application of medicated
oil/ ointment on the
baby’s stomach ie Yu
Yee oil
● Exposing jaundiced
babies to direct sunlight
● Feeding plain water or
glucose water to
jaundiced babies
● Feeding pearl powder to
babies
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CHAPTER 11
RESUSCITATION AND STABILISATION
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CHAPTER 11: RESUSCITATION AND STABILISATION
11.1 RESUSCITATION OF NEWBORN:
● Should be done by trained health care personnel

● Resuscitation equipment should be in working order
● Standard precautions should be observed
11.1.1 Perinatal risk factors increasing the likelihood for neonatal

resuscitation
Antepartum factors Intrapartum Factors

o Maternal age >35 years o Emergency Caesarean section
o Maternal diabetes o Breech or other abnormal
o Pregnancy induced hypertension presentation
o Chronic hypertension o Forceps or vacuum assisted
o Maternal cardiac, renal, delivery
pulmonary, thyroid or neurologic o Premature labour
disease o Precipitous labour
o Maternal infection o Shoulder dystocia
o Maternal substance abuse o Chorioamnionitis
o Drug therapy o Prolonged rupture of membrane
(e.g.magnesium,adrenergic (>18 hours before delivery)
agonists) o Prolonged labour (>24 hours)
o No prenatal care o Macrosomia
o Foetal Anaemia or Rhesus- o Non-reassuring foetal heart rate
isoimmunisation pattern or persistent foetal
o Previous foetal or neonatal death bradycardia
o Bleeding in second or third o Use of general anaesthesia
trimester o Maternal magnesium therapy
o Oligo/polyhydramnios o Uterine hyperstimulation/ uterine
o Premature rupture of membranes tachysystole with foetal heart rate
o Foetal hydrops changes
o Post-term gestation o Narcotics to mother within 4
o Multiple gestation hours of delivery
o Size-dates discrepancy o Meconium stained liquor
o Foetal Malformation or anomalies o Prolapsed cord
o Diminished foetal activity o Abruptio placenta
o Placenta praevia/ Vasa praevia
o Significant intrapartum bleeding
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Stand-by for High-Risk Deliveries
A medical officer trained in neonatal resuscitation should ideally be present

at all high-risk deliveries. It is recommended that the following situations
warrant to standby:
● Preterm infants < 35 weeks
● Severe IUGR (weight ≤ 1.8kg)
● Meconium stained liquor
● Abnormal CTG or scalp pH < 7.20 or other indications of
foetal distress
● Cord prolapse
● Antepartum haemorrhage
● Multiple births with anticipated problems
● Breech or other abnormal presentations
● Instrumental delivery (not for uncomplicated low forceps or
vacuum lift- out)
● Caesarean section under general anaesthesia
● Emergency caesarean section
● Infants with significant congenital malformations diagnosed
antenatally
11.1.2 Neonatal resuscitation equipments
1. Suction equipment
● Mechanical suction and tubing
● Suction catheters 5F, or 6F, 8F, 10F, 12F or 14F
2. Bag and mask equipment/ T-Piece resuscitator and mask

● Device for delivering positive pressure ventilation
● Face masks : newborn & premature sizes, cushioned rim mask
preferred
● Wall oxygen and air with flowmeters & tubing
3. Intubation equipment
● Laryngoscope with straight blades, No. 00, 0 and 1
● Endotracheal tubes, 2.5, 3.0 and 3.5mm internal diameter and
stylets
4. Cardiorespiratory monitor
● Stethoscope
● Pulse oximeter
● Electronic cardiac monitor
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5. Medications
● Adrenaline 1:10 000 (0.1mg/ml)
● Normal Saline
● Dextrose 10%
6. Catheters
● Umbilical catheters 3.5F and 5F
7. Miscellaneous
● Radiant warmer or other heat source
● Pre warmed linens
● Plastic wrap or cling film
8. Home delivery (uncommon) for resuscitation for babies

● Manual suction apparatus
11.1.3 Thermal protection and ABC’s of resuscitation

1. Provide Warmth
● Preheat radiant warmer, warm the linens, dry baby.
● Plastic wrap or cling film if indicated.
2. Establish an open Airway
● Position the head, suction mouth and nose if necessary
3. Initiate Breathing
● Tactile stimulation
● Positive pressure ventilation with bag and mask or ET if needed
4. Maintain Circulation
● Chest compressions
5. Administer Drugs
● Adrenaline as you continue PPV and chest compression
● Normal saline for volume expansion as indicated
Note :
 Refer Figure 11.1 for Overview of Resuscitation in the Delivery Room
 The neonatal resuscitation process will follow the current NRP guideline in use
in each local facility and is dependent on the resources available.
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Table 11.1 : Guidelines for ETT size (NRP 7th edition)
Gestational age
Infant weight Tube size (mm)
(weeks)
<1000g < 28 2.5
1000-2000g 28-34 3.0
>2000g > 34 3.5
Table 11.2: Guidelines for ETT position (NRP 6th edition)

Oral intubation – weight in kg + 6 cm
Infant weight
(Tip to lip distance)
1 kg 7 cm
2 kg 8 cm
3 kg 9 cm
11.1.4 Apgar scoring
● Mechanism for documenting newborn's condition at specific intervals

after birth
● Should not be used to determine need for resuscitation.
● Resuscitative efforts should be initiated promptly after birth, if required
Table 11.3: Apgar Score

Sign 0 1 2
Heart rate Absent < 100/min >100/min
Respiration Absent Slow, irregular Good, crying
Muscle tone Limp Some flexion Active
Reflex irritability No response Grimace Crying
Colour Blue Pink centrally Pink all over
Extremities blue
Cessation of Cardiopulmonary Resuscitation
● Decision should be based on cause of arrest, response to resuscitation

and remedial factors
● Death or severe neurological abnormality is predicted by a failure to
obtain a heart rate by 10 minutes despite adequate resuscitation and
failure to respond to adrenaline
*The adherence to the above guideline shall depend on the local facilities and the
availability of resources.
Reference: "Textbook of Neonatal Resuscitation" by American Heart Association

& American Academy of Paediatrics, 6th and 7th Edition.
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Figure 11.1 : Neonatal Resuscitation Flow Diagram
Antenatal counselling.
Team briefing and equipment check
Birth
Yes Stay with mother for routine care: Warm and

Term? Tone? Breathing or maintain normal temperature, position airway,
crying? clear secretions if needed, dry, ongoing
evaluation.
No
Warm and maintain normal temperature, position

1 airway, clear secretions if needed, dry, stimulate.
minute
No
Apnea, gasping, or HR Labored breathing or
below 100 bpm? persistent cyanosis?
Yes
PPV. Position and clear airway.

*Spo2 monitor. *Spo2 monitor.
*Consider ECG monitor. Supplemental O2 as needed.
Consider CPAP.
No Post-resuscitation care.
HR below 100 bpm? Team debriefing.
Yes
Check chest movement. Pre-ductal SpO2 Target

Ventilation corrective steps if needed.
ETT or laryngeal mask if needed. 1 min 60% - 65%
2 min 65% - 70%
3 min 70% - 75%
No 4 min 75% - 80%
HR below 60 bpm? 5 min 80% - 85%
10 min 85% - 95%
Yes
Intubate if not already done.

Chest compressions.
Coordinate with PPV.
100% O2.
*ECG monitor
HR below 60 bpm?
Source : Weiner, G.M, &Zaichkin, J (2016) Textbook of Neonatal

Yes
Resuscitation 7th edition. Elk Grove Village, IL: American Academy of
Paediatrics
IV epinephrine.
If HR persistently below 60 bpm:

Consider hypovolemia,
Consider pneumothorax.
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11.2 THERMAL PROTECTION
Thermal protection of the newborn is a series of measures taken at birth and in the first
days of life to ensure that the newborn maintains a normal body temperature.
How the newborn loses heat
The temperature inside the mother’s womb is 38°C. Leaving the warmth of the womb at
birth, the wet newborn finds itself in a much colder environment and immediately starts
losing heat.
The newborn loses heat in 4 different ways:
● Evaporation ( amniotic fluid from the baby’s body)
● Conduction (naked baby on a cold surface)
● Convection (naked baby exposed to cooler surrounding, draught )
● Radiation (baby to cooler objects)
Table 11.4 : The 10 steps of “Warm Chain” to minimise heat loss in newborn
(Adapted from WHO 1997, for well, term babies)
Steps Procedure
1. Warm delivery ● The delivery room temperature should be at least
room 25°C, free from the draughts from open windows &
doors, or fans.
2. Immediate drying ● Immediately dry the newborn after birth with a
warm towel.
● Discard the wet towel and wrap the newborn with
another dry towel and cap
3. Warm ● Newborn that needs resuscitation, should be kept
resuscitation warm by putting the newborn under an additional
source of heat ie radiant warmer
● Preterm ≤ 32 weeks should be wrapped in
polyethylene plastic bag
4. Skin-to-skin ● The stable newborn can be placed on the mother’s
contact chest or abdomen while being dried.
● Newborns can be maintained in skin-to-skin
contact with the mother:
o while she is being attended to (placenta
delivery, suturing)
o during transfer to the postnatal unit,
recovery room
o during assessments and initial interventions
o for the first hours after birth
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Steps Procedure
5. Breastfeeding ● Breastfeeding should begin as soon as possible
after delivery, preferably within an hour
● Baby should breastfeed on demand
6. Bathing and ● Bathing should not be done before 6 hours after
weighing birth, preferably on the 2nd or 3rd day of life so
postponed long as the newborn is healthy and the
temperature is normal
● Bathe newborn in a warm room, using warm water.
After bathing, immediately wrap the newborn in a
dry warm towel, dry thoroughly, dress quickly and
place near the mother
7. Appropriate ● Newborn’s clothing should be appropriate for the
clothing and environmental temperature
bathing
8. Mother and ● Keep mother and newborn together 24 hours a day
newborn rooming (rooming-in), in a warm room
in together
9. Warm ● Keep newborn warm during transport
transportation ● Use a transport incubator, where available
10. Training and ● All healthcare personnel involved in the process on
awareness raising birth and care of the newborn should be aware of
the risks of hypothermia and hyperthermia
● They should be taught the principle of thermal
protection of the newborn.
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11.2.1 Hypothermia in The Newborn
Hypothermia is defined as body temperature below 36.5°C
Figure 11.2 : Body Temperature in the newborn infant
Infants at risk for hypothermia

● Preterm, low birth weight babies
● Small-for-gestational age babies
● Infants who require prolonged resuscitation
● Infants who become acutely ill with infectious, cardiac, neurologic, and
endocrine problems
● Infants with surgical problems – especially infants with open body wall
defect (gastroschisis, omphalocele, exposed spinal defect), where heat
loss is more rapid
● Infants who have decreased activity or are hypotonic from sedatives,
analgesics, paralytics or anaesthetics
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Figure 11.3 : Effects of Cold Stress on Newborn
Other harmful effects of hypothermia include impaired immune function,

impaired coagulation and impaired surfactant production. If not treated,
severe hypothermia can lead to cell damage and even death.
Signs of Hypothermia
● Pale, mottled skin that is cool to touch

● Acrocyanosis
● Respiratory distress
● Apnoea, bradycardia, central cyanosis
● Irritability then lethargy as hypothermia worsens
● Hypotonia
● Weak cry and suck
● Abdominal distension, vomiting, feeding intolerance
● Shivering in more mature babies
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Treatment of Hypothermia
● Rewarm at a rate of 0.5 – 1°C/ hour.

● Rapid warming has been associated with apnoea, hypotension and rapid
electrolyte (Ca++, K+) shifts.
● During the rewarming process, monitor and record temperatures (skin,
axillary and environmental) every 30 minutes. Heart rate, blood pressure
and respiratory rate should also be monitored.
Additional Considerations
● Other methods to reduce heat loss include using double-walled
incubators, humidifying the incubators, or using radiant warmers.
● Avoid hot water bottles, gloves filled with hot water or heat lamps
because they may cause burns.
● Avoid warming linen in the microwave oven.
11.2.2 Hyperthermia
Hyperthermia is defined as body temperature more than 37.5°C
Causes of hyperthermia
● Environmental causes: excessive environmental temperature,
overwrapping of the baby, loose skin temperature probe with an
incubator or radiant warmer in servo-controlled mode, or a servo-
controlled temperature set too high
● Infection
● Dehydration
● Maternal fever in labour
● Maternal epidural analgesia
● Drug withdrawal
Signs of Hyperthermia
● Reddened skin that is warm to touch
● Tachycardia
● Tachypnoea
● Irritability, lethargy, hypotonia, weak cry
● Poor feeding
● Apnoea
● Sweating in more mature babies
● Dehydration
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Treatment of Hyperthermia
● Determine the cause of the hyperthermia.The most common cause in
NICU is iatrogenic (remove external heat sources,check incubator and
radiant warmers for appropriate functioning, assess temperature probe
position for appropriate location on baby)
● Non-environmental causes of hypothermia (infection, dehydration or
CNS disorder) should be considered and treated accordingly
● During the cooling process, monitor and record temperatures (skin,
axillary and environmental) every 30 minutes
Reference
1. World Health Organization. (1997). Safe Motherhood: Thermal Protection of the

Newborn: A Practical Guide.
2. Gomella TL, et al .Gomella’s Neonatology : Management, Procedures, On-Call
Problems, Diseases, and Drugs 8th ed. McGraw Hill: 2020 p.92-95
3. Gardner SL and Hernandez JA. Heat Balance : Merenstein & Gardner’s Handbook of
Neonatal Intensive Care 8th ed. Elsevier; 2016.p.105 -25
4. Karlsen K. The S.T.A.B.L.E programme 6th ed.
11.3 STABILISATION AND TRANSPORTATION OF THE NEWBORN
11.3.1 Cases Requiring Transport
● For neonatal or surgical care not available at the referring centre

● For transfer from labour room to NICU/SCN
● For transfer from one neonatal ward to another
● Health clinic to hospital
The principles of initial stabilisation of the neonate:

● Airway
● Breathing
● Circulation, Communication
● Drugs, Documentation
● Environment, Equipment
● Fluids – electrolytes, glucose
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11.3.2 Approach to Neonatal Transfer
COMMUNICATION
● Contact referral hospital and discuss with receiving staff about the case
and request for advise
● Record time and details of discussion
STABILISATION
Airway
● Airway suctioning and maintenance of clear airway
o Administer oxygen via cannula, headbox, bag and mask, or
endotracheal tube
o Monitor oxygen saturation with oximeter
Breathing
● Observe breathing effort and rate
● Support breathing by bagging
● Note effectiveness of manual respiratory support
● Monitor oxygen saturation with pulse oximeter
● Obtain a blood gas if available
Circulation
● Observe colour especially central area
● Suction airway and administer oxygen effectively
Drugs
● Administer drugs as required
● Correct hypoglycaemia after capillary blood sugar sampling
● Administer Vitamin K (if not given)
Environment
● Prewarm transport incubator setting at 35°C using mains power supply
● Place necessary articles inside
● Monitor temperature of baby closely
● Warm baby up to normal body temperature under the radiant warmer
then place baby in the transport incubator
Fluids
● Set up intravenous infusion of dextrose 10%.
● Use a syringe pump if available and set the correct flow rate.
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● If a syringe pump is unavailable, use paediatric chambers to deliver IV
fluid at a correct drip rate. The maximum volume in a chamber is 40 mls
only.
● Set up blood transfusion or plasma expander when required.
11.3.3 PREPARATION FOR NEONATAL TRANSFER
Transport team
● Inform team members: doctor, staff nurse, attendant, driver
● Inform team members of neonate’s condition and stabilisation activities
Equipment
● The transport incubator temperature will be set at 35°C (or appropriate
temperature according to the baby’s gestation)
● When there is no incubator, wrap the neonate in warm towels/linen.
However, it is impossible to observe abnormal respiratory functions
without disturbing the neonate. This method prevents heat loss but will
not warm up a low birth weight baby.
● Portable ventilator and adequate oxygen.
● Resuscitation equipment and drugs i.e. bag and mask, suctioning
equipment, intubation equipment, drugs, syringes, and others (refer to
“resuscitation equipment” and “medications”).
● Intravenous fluids e.g. dextrose 10%.
● Monitoring equipment: appropriate equipments such as cardiorespiratory
monitor, pulse oximeter, thermometer, and stethoscope.
Vehicle
● The ambulance should be in functioning order and have adequate
equipments
● Secure the incubator and other equipments in place during the transfer
Parents
● Inform parents the need for transfer of the neonate
● Encourage one parent to accompany neonate
● Obtain written consent from parents for blood transfusion or emergency
surgery
● Obtain mother’s blood sample if she is not accompanying her child
● Allow neonate’s mother to see and touch her baby
● Referral letter:
o should include a complete and detailed history of maternal factors
and neonatal problems
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o treatment already carried out should be listed such as antibiotics,
resuscitation given, immunisation, Vitamin K
o events that have occurred should be written in sequence
o date, time and name of the doctor should be written clearly
Records
● State the date and time of events in the progress notes
● Record a brief but concise account of the events before the transfer of
the neonate.
● Record in admission book, census book and 24-hour report book
Checklist before departure

● The following should be ready to be sent with the baby:
o cord blood specimen or baby’s blood specimen
o mother’s blood specimen (10 ml clotted blood) labelled correctly
with mother’s full name and identity card number
o referral letter
o all X-rays and other investigation results
o written consent of parent for the appropriate procedures
● Ensure the endotracheal tube, if required, is properly secured and at the
appropriate level.
● The baby’s condition should be reviewed just before transport and
referral hospital should be reinformed if the general condition has
changed.
● Check that all equipment in the ambulance is functioning and has
adequate power supply to last the journey.
During transport
● Connect ventilator or oxygen delivery system to ambulance supply, if
available.
● Any electrical equipment should be plugged into the AC-DC converter in
the ambulance.
● Monitor vital signs, IV fluids, and medication, and chart in the Neonatal
Transport Chart.
● Where possible, observations should be done without disturbing the
baby. Use monitoring equipment if available.
● Stop at the nearest health clinic or in a safe area if the condition of the
neonate deteriorates or needs further resuscitation.
● Ensure airway is maintained by neutral neck position, suctioning as
required, and correct position of the endotracheal tube.
● Check on adequacy of chest expansion, colour, and oxygen saturation,
especially in the baby who is receiving assisted ventilation.
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At the receiving hospital
● Hand over to the receiving nurse/medical officer the following information
& records:
1. Name and identity card number and full name of the mother
2. Name of the baby, if available
3. Sex of the baby
4. Referral letter and other documents
5. Records and observations during transport
6. Medications and immunisation given
7. Blood and other specimens
8. Imagings e.g. x-ray films
9. Introduce parents/relatives to the receiving staff
● Account for all equipment before leaving.
After returning from the referring hospital

● If parent(s) have not accompanied the baby, inform them about the
condition of the child the ward/ hospital he or she is placed in, the
contact number and the name of the doctor-in-charge.
Reference:
1. Protocol of Neonatal Nursing Procedure Pub. Ipoh Postgraduate Medical Society
Ed. J.Ho, 1995
2. Paediatric Protocol for Malaysian Hospitals 4th edition 2018 (pp.74-81)
11.4 CRITERIA FOR VARIOUS LEVELS OF NEONATAL CARE
11.4.1 Levels of Neonatal Care
LEVEL III – Intensive Care: For babies with problems requiring intensive
care such as endotracheal intubation for assisted ventilation, intra- arterial
blood pressure monitoring, continuous cardiorespiratory monitoring,
parenteral nutrition, central venous catheterisation, transcutaneous blood
gas and oxygen saturation monitoring and neonates requiring stabilisation
following major surgery.
LEVEL IIb – Semi-intensive or High Dependency Unit: For babies with

problems requiring close observation and intervention but not requiring
intensive care. These babies may require peripheral intravenous therapy,
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simplified cardiorespiratory monitoring, apnoea monitoring, oxygen not
usually in excess of 40%, chronic oxygen dependency and surgical nursing.
LEVEL IIa – Special Care or Low Dependency Unit: For babies who
could not be cared for at home. These babies include convalescent preterm
neonates, or neonates requiring observation for transient problems,
phototherapy, investigatory procedures and frequent feeding.
LEVEL I – Neonatal Care In Postnatal Wards: For uncomplicated

maternal and neonatal cases where routine nursing care is provided and
close observation is not required. Normally, these babies are placed
together with their mothers in the postnatal wards and regarded as an
inpatient.
Reference
Appendix II of Paediatric Services Operational Policy, Ministry of Health, 2012.
11.4.2 Indications for Admission to Various Levels of Care
LEVEL III - Intensive Care

1. Respiratory distress requiring ventilatory support or CPAP
2. Very low birth weight (VLBW) babies of birthweight (BW) < 1000 gm.
3. Moderate to severe neonatal encephalopathy
4. Severe birth trauma - intracranial haemorrhage
5. Duct dependent congenital heart disease which may be cyanotic or
acyanotic; congestive heart failure; supraventricular tachycardia,
arrhythmia.
6. Hypotension, shock
7. Need for resuscitation and inotropic support
8. Disseminated intravascular coagulation
9. Immediate post-op surgical patients
10. Necrotising Enterocolitis (> Grade 1)
11. Hydrops foetalis
12. Intractable hypoglycaemia
13. Persistent metabolic acidosis
14. Neonatal seizures
15. Any other baby whose clinical condition is considered to be unstable
or require very close observation
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LEVEL IIb - Semi-Intensive Care
1. Receiving NCPAP for some part of the day and ≥ 1000 gm in weight
2. Receiving parenteral nutrition and not fulfilling criteria for intensive
care
3. Requiring monitoring for seizures
4. Requiring oxygen > FiO2 40%
5. Requiring continuous cardiorespiratory monitoring
6. Requiring frequent stimulation for apnoea
7. Requiring treatment for neonatal abstinence syndrome in acute
period
8. Acute surgical cases
LEVEL IIa - Special Care

1. Babies >1500gm to 2000gm birth weight
2. Babies < 35 weeks gestation
3. Large babies ie birth weight > 4.2kg
4. Large for gestational age (LGA) babies ie BW>90th centile
5. Small for gestational age (SGA) babies ie BW<10th centile
6. Babies with respiratory distress requiring < 40% oxygen
7. Babies with risk of meconium aspiration without respiratory distress
on admission
8. Babies with Rhesus or ABO incompatibility
9. Babies with significant jaundice.
10. Babies with mild asphyxia or Apgar Score < 7 at 5 mins
11. Babies born to mothers with chorioamnionitis or pyrexia > 38 oC or
leaking liquor of more than 18 hours
12. Sepsis (fever, umbilical discharge, severe eye discharge) and
congenital infection (e.g.maternal chickenpox)
13. Babies of diabetic mothers
14. Babies with more than one episode of hypoglycaemia (blood sugar <
2.6mmol/L)
15. Babies with birth trauma – mild subaponeurotic haemorrhage, Erb’s
palsy and fractures
16. Babies of drug addict mothers with no further withdrawal symptoms
17. Babies with multiple or serious congenital anomalies
18. Babies requiring IV drip
19. Babies requiring surgery and do not require intensive care
20. Unwell babies (e.g. poor feeding, lethargy, vomiting)
21. Babies born to HIV mothers and symptomatic babies of VDRL
positive mothers
22. Stable babies with cardiac conditions
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Note:
In conditions other than those listed above and if unsure, please consult
Registrar or Specialist
LEVEL I - Neonatal Care in Postnatal Wards (these are babies that may be considered
for nursing in the obstetric ward depending on local factors. The baby has to be monitored
and transferred to appropriate level of care depending on the progress)
1. Borderline low birthweight (ie between 1.8 and 2.5 kg) babies who
are otherwise well
2. Well babies of 35 to 37 weeks gestation who are 1.8 kg. and above
3. Large babies between 4 and 4.5 kg
4. LGA and SGA babies
5. Babies with meconium below cords during resuscitation with no
respiratory distress or hyperinflation of the chest.
6. Babies with G6PD deficiency, Rhesus or ABO incompatibility and
moderate jaundice (SB < 300 µmol/L except for babies with jaundice
on day one of life) – phototherapy with monitoring
7. Asymptomatic babies with presumed sepsis needing antibiotic
therapy
8. Asymptomatic babies born to VDRL positive mother
9. Babies with glucose 6-phosphate dehydrogenase (G6PD) deficiency
10. Babies of thyrotoxic mothers
11.5 Normal care
Normal care is the routine care of the healthy term baby who requires only
the maintenance of body temperature, the establishment of feeding and
hygiene care. This is usually provided in the obstetric ward or at home with
the mother.
Infant’s progress at every level should be monitored and transferred to the

appropriate level as indicated by the patient’s condition
Disclaimer : The adherence to the above guidelines shall depend on the local facilities
and the availability of resources
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CHAPTER 12
EARLY NEWBORN CARE
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CHAPTER 12: EARLY NEWBORN CARE
12.1 OVERVIEW OF NEWBORN EXAMINATION
● The aims of newborn examination should be fully explained and the

results shared with the parents and recorded in the baby’s home-based
card.
● A complete examination of the baby should be done within 72 hours of
birth.
● This examination should include a review of :
o parental concerns
o baby's medical history: family, maternal, antenatal and perinatal
history
o any previously plotted birth weight and head circumference
o feeding adequacy
o whether the baby has passed meconium and urine (and urine
stream in a boy)
o vitamin K and immunisation status
o results of G6PD and cord TSH, if available
● A physical examination should also be carried out. This should include

checking the baby's:
o appearance including colour, breathing, behaviour, activity and
posture
o head (including fontanelles), face, nose, mouth including palate,
ears, neck and general symmetry of head and facial features.
Measure and plot head circumference
o eyes; check opacities and red reflex
o neck and clavicles, limbs, hands, feet and digits; assess proportions
and symmetry
o heart; check position, heart rate, rhythm and sounds, murmurs and
femoral pulse volume, check oxygen saturation over lower limbs (if
available)
o lungs; listen for noisy breathing, check effort, rate and lung sounds
o abdomen; check shape and palpate to identify any organomegaly;
also check condition of umbilical cord
o genitalia and anus; check for appearance of genitalia, undescended
testes in males and anal patency
o spine; inspect and palpate bony structures and check integrity of
the skin
o skin; note colour and texture as well as any birthmarks or rashes
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o central nervous system; observe tone, behaviour, movements and
posture. Elicit newborn reflexes ie Moro’s reflex
o hips; check symmetry of the limbs and skin folds (perform Barlow
and Ortolani's manoeuvres)
o cry; note sound
o weight and length; measure and plot
o gestational age; assess using Ballard Score (Figure 12.1) if the
baby is of low birth weight or if gestation is uncertain
● Vital signs : normal range for newborn

o Respiratory rate : 40- 60/min
o Heart rate : 120 – 160 / min
o Capillary refill time : < 3 seconds
o Oxygen saturation : > 95% ( for Term babies), 90-95% ( for Preterm
babies)
o Blood pressure:
Figure 12.1 : Normal Range of Vital Signs for Newborn
Source: Blood pressure by birth weight (From Versmold HT,

Kitterman JA, Phibbs RH et al:Paediatrics 67(5):607, 1981
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Figure 12.2: Expanded New Ballard Score for determining gestational age by
assessment of neuromuscular and physical maturity
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12.2 COMMON FINDINGS IN NEWBORN EXAMINATION
Below are some of the conditions that may be found during routine newborn
examination. The list, however, is far from complete. Please refer if in doubt.
12.2.1 Colour
● Pallor - associated with shock or low haemoglobin
● Cyanosis - It is important to distinguish between central cyanosis due to
hypoxaemia (lips, buccal mucosa and peripheries are bluish) and
peripheral cyanosis due to cold (only the feet and fingers are bluish).
Circumoral cyanosis is common among newborn babies and has no
diagnostic significance. Facial congestion may be due to a tight umbilical
cord around the neck and parents should be reassured if the baby is
pink centrally.
● Mottling – may be a response to hypothermia or associated with sepsis.
If the baby is well, it may be a feature of cutis marmorata.
● Plethora - associated with polycythemia
● Jaundice - babies who are visibly jaundiced should have their bilirubin
levels checked (TSB or TcB measurement) If the jaundice is detected
within 24 hours of life, urgent referral is needed to rule out haemolysis or
sepsis.
12.2.2 Skin
The following skin conditions are benign and self-limiting:
● Erythema toxicum - Most common newborn rash. Variable, irregular
macular papular patches and sometimes vesicular lesions. Appears
soon after birth and persists for a few days.
● Milia - pinpoint white papules of keratogenous material usually on nose,
cheeks and forehead, last several weeks.
● Miliaria - obstructed eccrine sweat ducts. Pinpoint vesicles on forehead
scalp and skinfolds. Clears within 1 week.
● Transient neonatal pustular melanosis - small vesiculopustules,
generally present at birth, containing WBCs and no organisms. The
intact vesicle ruptures to reveal a pigmented macule surrounded by a
thin skin ring.
● Mongolian blue spots - Bluish discolouration commonly seen on lower
back, buttocks or lower limbs. Can be mistaken for a bruise but unlike a
bruise, it does not change in colour over a period of days. May persist for
years.
● Capillary naevi - Pink macular discolouration over upper eyelids or
forehead (salmon patch) or on back of neck (stork mark).
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The following skin conditions may need referral for further assessments:
● Septic spots – these are yellow pus-filled spots with or without
inflammation of the surrounding skin. May need antibiotic treatment.
● Petechiae or Purpura – this may indicate a bleeding disorder i.e.
thrombocytopaenia or platelet dysfunction. Need urgent referral.
● Cafe au lait spots - suspect neurofibromatosis if there are many large
spots.
● Haemangioma (capillary, venous, arteriovenous) - Large or multiple
haemangiomas may cause circulatory problems or thrombocytopaenia
and need urgent referral. Multiple haemangiomas may have visceral
involvement. Haemangiomas on the face and neck, lumbosacral spine,
axilla and perineum need referral for further assessment. Capillary
haemangiomas usually increase in size in the first few months of life but
will involute spontaneously.
● Oedema - generally unusual in the newborn. If generalised, may be
associated with causes of hydrops fetalis. If oedema is localised to the
neck, consider Turner syndrome or Down syndrome. Non-pitting
oedema over the dorsum of both feet is suggestive of Turner or Noonan
syndrome.
12.2.3 Head
● Moulding
● Caput succedaneum – should resolve in 2-3 days
● Chignon – commonly follows vacuum extraction
● Cephalohaematoma- a collection of blood between the periosteum and
the bone and does not cross suture lines. Usually resolves in 2-3
months. Massaging should be avoided.
● Subaponeurotic haemorrhage (subgaleal bleed) -a boggy swelling of
the head which may cross suture lines. The scalp appears diffusely
swollen and the ears may be lifted forward. This requires urgent referral
because the baby can bleed insidiously and rapidly go into hypovolaemic
shock.
● Other swellings (i.e.; encephalocaele) may need referral for further
assessment.
12.2.4 Eyes
● Eye discharge – common organisms causing eye discharge or
conjunctivitis are staphylococci, chlamydia and gonococci. Bilateral
copious purulent discharge with or without haemorrhage with
accompanying oedema of the eyelids is typical of gonococcal
conjunctivitis and should be urgently treated.
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● Cloudy cornea - may indicate congenital glaucoma and needs urgent
referral.
● Subconjunctival haemorrhage - commonly seen in normal babies.
● Absent red reflex - Hold the ophthalmoscope 6-8” from the eye. Use
the +10 diopter lens. The normal newborn transmits a clear red colour
back to the observer. Black dots may represent cataracts. The absence
of a clear red reflex is indicative of cataract, glaucoma or retinoblastoma.
12.2.5 Ear and Nose

● Pre-auricular skin tags – benign, fairly common and usually inherited
● Pre-auricular pit – is a small opening near the front of the ear,which can
be a blind- ended opening or have a sinus tract. If persistent or
recurrent infection occurs, surgical excision may be indicated
● Choanal atresia may be manifested by respiratory distress or cyanosis
(neonates are obligate nose breathers). To confirm patency, gently insert
a soft NG tube through each nostril.
12.2.6 Mouth
● Cleft lip and/or cleft palate: may occur in isolation or in association with
a syndrome
● Epstein pearls - small white papules found on the midline of the hard
palate. These are benign and will eventually resolve.
● Ranula - small bluish white swelling on the floor of the mouth
representing benign mucous gland retention cyst. This will resolve with
time and is benign.
● Tongue-tie due to a short frenulum does not usually cause problems.
Refer only if feeding difficulty or speech problems
● Natal teeth occur in 1/2,000 births and are mostly lower incisors. There
is risk of aspiration and should be extracted if loosely attached.
● Oral thrush is a fungal infection of the mouth or throat caused by
Candida Albicans. It is seen as white patches scattered over the tongue
and the buccal mucosa, which cannot be easily wiped away. Treatment
is with oral Nystatin.
12.2.7 Neck
● Cystic hygroma – a congenital malformation of the lymphatic system
which may cause airway obstruction and need early surgical referral
● Sternomastoid ‘tumour’ - a firm fibrous mass in the sternomastoid
muscle which may be associated with torticollis and can be treated with
early physiotherapy.
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12.2.8 Chest
● Signs of Respiratory Distress include:
o Grunting – expiratory sound much like a short cry, occurs when
glottis is closed during expiration
o Nasal flaring – widening of the nostrils on inspiration
o Retractions –muscles sucked in between the ribs to increase air
flow, can be subcostal or intercostal
● Stridor - a high-pitched cry heard on inspiration. Laryngomalacia is the
most common cause but may be due to other upper airway
abnormalities
● Breasts in the newborn may be enlarged due to the effects of maternal
oestrogen. A white discharge may be present and is normal
12.2.9 Heart
● Murmur – may be associated with congenital heart lesions, need referral
for further assessment.
● Cyanosis – may be associated with congenital cyanotic heart disorders,
pulmonary disorders or PPHN (persistent pulmonary hypertension of
Newborn). Need to consult the Paediatric team urgently
● Heart failure - tachypnoeic, tachycardic, hepatomegaly, gallop rhythm,
weak pulses – may be due to structural heart lesion, myocardial
diseases, arrhythmia or extracardiac cause’s i.e. severe anemia,
neonatal thyrotoxicosis, fulminant sepsis. Need to consult the Paediatric
team urgently
12.2.10 Abdominal Wall and Umbilicus

● Omphalocoele and Gastrochisis - An omphalocoele has a membrane
covering (unless it has been ruptured during the delivery) whereas
gastroschisis does not. Place cling wrap over exposed intestines and
refer to a hospital with surgical facilities as soon as possible
● Diasthesis recti – a gap between the two recti abdominis muscle and
usually presents as a midline epigastric swelling which becomes more
prominent during straining. In the newborn, the muscles are not fully
developed and may not be sealed together at midline. This condition
heals on its own and does not require treatment.
● Single umbilical artery – may be associated with other abnormalities
● Omphalitis – infection of the umbilicus and/ or surrounding tissues. It is
characterised by tenderness, erythema, and induration of the umbilicus
and surrounding tissues. If untreated, it may progress to systemic
infection and death
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● Patent urachus – is a communication between the bladder and the
umbilicus, resulting in the urine coming from the umbilicus. Paediatric
surgical referral is needed.
● Umbilical hernia – results from the weakness in the muscles of the
abdominal wall or umbilical ring. Usually resolves in the first year of life,
without treatment
● Umbilical granuloma - is composed of granulation tissue at the base of
the umbilical cord, appearing after the umbilical cord has separated. It
may be associated with serous or serosanguinous drainage and a
tendency for easy bleeding with trauma. Treatment options include
topical applications of silver nitrate, excision and cryosurgery.
12.2.11 Genitalia
Male genitalia
● Micropenis – penile length that is ≤2.5 cm in a term newborn (Term
normal penis is 3.6 ± 0.7 cm stretched length).
● Hypospadias is abnormal location of the urethral meatus on the ventral
surface of the penis, Epispadias is abnormal location of the urethral
meatus on the ventral surface of the penis
● Phimosis - the inability to retract the foreskin or prepuce covering the
glans of the penis. It can be normal in newborn and usually resolves
around 5-7 years of age
● Undescended testis – can be unilateral or bilateral. Early referral to the
Paediatric surgical team is recommended.
● Hydrocoeles are collections of fluids in the scrotum. They are common
and usually disappear by 1 year old
● Inguinal hernias are more common in preterm babies. The bowel enters
the scrotal sac through the patent processus vaginalis. Early referral to
the Paediatric surgical team is recommended.
Female genitalia
● Mucosal/vaginal tag – commonly attached to the wall of the vagina
and is of no clinical significance
● Vaginal discharge – whitish or blood tinged discharge is common due
to maternal hormones and lasts for a few days, bloody discharge may be
normal and secondary to maternal oestrogen withdrawal.
Indeterminate sex
● If the sex of the baby cannot be determined from physical examination,
urgent referral is required to determine the sex early and to exclude
medical emergencies such as congenital adrenal hyperplasia.
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12.2.12 Spine
● Skin stigmata of neural tube defects : such as lipoma, haemangioma,
pilonidal skin dimples with tufts of hair or no visible floor - should be
referred for ultrasound.
● Dermal sinuses in the posterior midline area - usually communicates
with the spinal canal and can lead to meningitis. Need urgent referral
● Sacral dimples are common and are of no consequence. Referral for
ultrasound is required only for sacral dimple > 5 mm in diameter or > 2.5
cm from the anus.
● Meningocoele – a neural tube defect in which there is incomplete
closure of the posterior spine; the lumbar spine is the most common
location. There is a risk of meningitis, especially if there is cerebrospinal
fluid leakage.
12.2.13 Lower Limbs

● Developmental Dysplasia of the Hips – check for asymmetry of the
thigh or gluteal creases and limb length discrepancy. Refer to the
orthopaedic team if the Ortolani or Barlow test is positive (“clunk”
sensation).
● Congenital Talipes Equinovarus (CTEV) - the foot is turned downward
and inward, and the sole is directed medially. If this problem can be
corrected with gentle force, it will resolve spontaneously. If not,
orthopaedic treatment and follow up are necessary.
References
1. Gomella TL, et al .Gomella’s Neonatology : Management, Procedures, On-Call
Problems, Diseases, and Drugs 8th ed. McGraw Hill: 2020
2. Public Health England, Newborn and infant physical examination (NIPE) screening
programme handbook https://www.gov.uk/government/publications/newborn-and-
infant-physical-examination-programme-handbook/newborn-and-infant-physical-
examination-screening-programme-handbook
3. Hj Muhammad Ismail et al., (2019) Paediatric Protocol for Malaysian Hospital 4 th
edition, Ministry of Health Malaysia
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12.3 SCREENING FOR CONGENITAL HYPOTHYROIDISM
Congenital hypothyroidism is an uncommon but clearly identified and

preventable cause of mental retardation. In Malaysia, the incidence is
1:2200 to 3000.
Infants born with congenital hypothyroidism usually lack clinical features in

the first weeks or months of life and are usually discovered to have
congenital hypothyroidism around the age of 2 – 6 months. Studies have
shown that if detected and treated within the first week of life, it will result in
average, normal or near-normal intellectual performance and growth.
Table 12.1: Causes and Birth Prevalence of Neonatal Thyroid Dysfunction
Disorder Prevalence
Permanent disorder
1. Thyroid dysgenesis (agenesis, hypoplasia, ectopia) 1: 4,500
2. Thyroid dyshormonogenesis 1: 30,000
3. Hypothalamic-pituitary hypothyroidism 1: 100,000
4. Generalised resistance to thyroid hormone Very rare
Transient disorder
1. Transient hypothyroxinemia (mainly premature infants) 1:2000
2. Transient primary hypothyroidism (common in areas of Variable
iodine deficiency
3. Transient hyperthyrotropinemia (predominantly seen in Very rare
Japanese population)
Often babies with congenital hypothyroidism appear normal at birth. However, the early
features include :
● umbilical hernia,
● constipation,
● prolonged jaundice,
● poor feeding,
● inactivity and delayed bone age.
Late features of untreated congenital hypothyroidism
● macroglossia,
● coarse features,
● dry skin and hair,
● hoarse cry,
● delayed development,
● poor growth and mental retardation.
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12.3.1 Newborn Screening for Congenital Hypothyroidism
Immediately after delivery, blood from the umbilical cord is collected and
sent to the laboratory to screen for cord blood TSH (Refer to Figure 12.3).
Babies with high TSH (> 60mIU/L) or borderline TSH (20-60mIU/L) with low
FT4 (< 15pmol/l) will need to be retested.
Blood samples for confirmation (retesting) should be venous samples and

should be taken from the baby after the third day of life. This is to avoid the
TSH surge that occurs from half an hour after birth to 72 hours of age.
Babies for retesting are those with high TSH (> 60mIU/L) or borderline TSH
(20-60mIU/L) with low FT4 (< 15pmol/l).
12.3.2 Treatment
Treatment should begin immediately after diagnosis, and within 2 weeks of

life. If features of hypothyroidism are present, treatment is to be started
urgently. L-thyroxine is started at a dose of 10 – 15 mcg/kg/dose daily.
The goal of therapy is to restore euthyroid state by maintaining a serum FT4

level at the upper half of the normal age-related reference range. Ideally
serum TSH levels should be between 0.5 – 2.0 mIU/L after the first month of
life.
Table 12.2: Time interval for follow-up and thyroid function test
Age of patient Intervals for Thyroid Function Test

After initiation of L-thyroxine 1 - 2 weeks (until normalization of
results)
1 - 6 months 1 - 2 monthly
6 months – 3 years 3 – 4 monthly
>3 years until growth is complete 5 – 12 monthly
Note : More frequent intervals is needed if compliance is questionable or abnormal

TFT values are obtained, and 4 – 6 weeks after any change in L-thyroxine
dose/formulation
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Figure 12.3: Flowchart for Congenital Hypothyroidism Screening at Hospital with
T4/TSH Screening Facilities
1
Cord blood sample collected at birth in labour room
Sent to screening hospital lab for TSH
2 2, 3 2, 3
Normal Borderline High Missed
(<20mIU/L) (20-60mIU/L) (>60mIU/L) cases
FT4 analysis (on

card blood)
3
FT4 Normal FT4 Low
(> 15pmol/l) (≤ 15pmol/l)
Babies not Babies

discharged discharged
1
Blood taken by staff who conducts
the delivery. Investigation form for Recall babies urgently
screening of TSH to be filled up by - By phone
attending staff. - Through nearest
4
2
Result to be sent to paediatric clinic - Health clinic/office
and compiled by staff in charge.
3
Lab to inform relevant officer/staff at
Paediatric Clinic to recall for cases
either by phone or to inform Refer baby to Paediatric Clinic
sisters/PHN at health districts/
clinics. 6
4 Take blood for FT4/TSH
Sister/PHN to recall babies.
5
Urgent referral and appointment to
pediatric clinic.
6 Blood to lab for Se FT4/TSH
Blood to be taken at Paediatric
Clinic
Result sent to Paediatric Clinic
* For asphyxiated neonates, repeat
screening test should be done after
rd
3 day of life when
Further management by Paediatrician
hemodynamically stable.
For further information, please refer to National Screening Programmeme for Congenital
Hypothyroidism 2018, Family Health Development Division, MOH.
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12.4 ADMINISTRATION OF HEPATITIS B PROPHYLAXIS, BCG
VACCINATION AND VITAMIN K IN THE NEWBORN
12.4.1 Recommendations For Hepatitis B Vaccination And Hepatitis B

Immunoglobulin In Newborns
● Hepatitis B vaccination is the mainstay effort in the prevention of HBV

transmission.
● ALL infants weighing > 2 kg should be given 5mcg (0.5ml) (IM) Hep B
vaccination at 0, 1, 6 months of life.
● Infants born to HBsAg-positive mother should receive Hepatitis B
vaccine and 100iU (0.5ml) IM HepB immunoglobulin (HBIG) within 12
hours of birth, administered at different injection sites (e.g., anterolateral
aspects of opposite thighs).Thereafter, to give Hepatitis B vaccination at
1, 6 months according to schedule. HBsAg and anti-HBs should be
performed after completion of the vaccine series at age 9–12 months.
● For infants weighing <2kg, the birth dose should be given, but should not
be counted as part of the vaccine series because of the potentially
reduced immunogenicity of HepB vaccine in these infants; 3 additional
doses of vaccine (for a total of 4 doses) should be administered
beginning when the infant reaches age 1 month.
● Infants who are born to HBsAg-positive mothers and receive post-
exposure prophylaxis may be breastfed beginning immediately after
birth.
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Figure 12.4 : Management of infant HBsAg positive mothers
MOTHER WITH HBsAg POSITIVE
INFANT WITH BIRTH WEIGHT INFANT WITH BIRTH WEIGHT  2000 GM

MONTH
 2000 GM (INCLUDING PREMATURE INFANTS)
INTRAMUSCULAR injection within 12 hours of
life at different site:
INTRAMUSCULAR injection within 12 hours of
● Hepatitis B vaccine (0.5 mls)
life at different site : a
0 ● Hepatitis B Immunoglobulins (100 iu)
● Hepatitis B vaccine (0.5 mls)
a
● Hepatitis B Immunoglobulins (100 iu)
There is increased risk of apnoea in this group of
babies
2 2
Continue Hepatitis B vaccination according to
Continue Hepatitis B vaccination according to
national immunisation schedule
3 3 national immunisation schedule 0, 2, 3 and 5
(0, 2,3,5 months) –according to updated
months
immunization schedule
5 5
b b
Check Anti-HBs and HBsAg Check Anti-HBs and HBsAg
9 to 12
Review in Paediatric Clinic Review in Paediatric Clinic
HBsAg Negative HBsAg Positive
Anti HBs Anti HBs

> 10 mIU/mL <10 mIU/mL Referral to Paediatric
Infectious Specialist/
Paediatric Gastroenterologist
th for adequate follow up &
Protected; Re-immunisation with a 4 dose of medical evaluation for chronic
no further Hepatitis B vaccine; retest Anti- Hepatitis B carrier
c
medical HBs
management
Anti HBs Anti HBs

>10 mIU/mL <10 mIU/mL
Re-immunisation with 2 additional

d
doses of Hepatitis B vaccine ;
c
retest Anti-HBs
Anti HBs Anti HBs

10 mIU/mL 10 mIU/mL
No further vaccine required; Discussion with Paediatric Infectious

Disease Specialist / Paediatric Gastroenterologist required
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a
Given at same limb as Vitamin K but at different area
b
Test at 9 to 12 months of age, generally at the next well child visit after completion of the primary series
c
Retest Anti-HBs 4 to 8 weeks after re-immunisation
d
Additional 2 doses given 1 to 2 months apart
Source: Redbook 2018 (Prevention of Hepatitis B Virus Infection in the United States:
Recommendations of the Advisory Committee on Immunization Practices
Recommendations and Reports / January 12, 2018 / 67(1);1–31)
Notes:
o All babies delivered at home should receive the above recommended regime from
the nearest health facility.
o Presently it is not the MOH’s policy to routinely screen all mothers for their
Hepatitis B status.
12.4.2 Recommendations for BCG Vaccination in Newborns
● All newborns are to be given BCG soon after birth. This is usually carried
out in well babies on the second day or just before discharge.
● For babies who are admitted directly to the neonatal ward after birth,
BCG is often not given until the baby is due for discharge from the
special care nursery. Being a live vaccine it is not recommended to be
given within a neonatal intensive care unit where babies are ill or
immature.
● There are no specific weight criteria for BCG vaccination. It has been
shown that babies of 34-35 weeks post-conceptual age can be
effectively vaccinated and comparable to vaccination at term.
12.4.3 Recommendations for Vitamin K Administration in The Newborn
● All newborns should receive a single intramuscular dose of Vitamin K

within 1 hour of birth. Administer 0.5 mg if the baby weighs less than 1.5
kg or 1mg if the baby weighs more than 1.5 kg.
● If the injection has not been given in the labour room or other location of
birth it must be given as soon as possible in the neonatal ward.
● For home deliveries, Vitamin K can also be given at the health clinics if
the attending nurse has not given it immediately at birth.
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Table 12.3 : National Immunisation Schedule
Age of Child Vaccinations

First BCG injection
At Birth
Birth dose: Hepatitis B
2 months First dose: DTaP, IPV, Hib, Hepatitis B
Second dose: DTaP, IPV, Hib,
3 months
Hepatitis B
4 months First dose : Pneumococcal
Third dose : DTaP, IPV, Hib, Hepatitis
5 months
B
Hepatitis B Measles (Sabah)
6 months
Second dose: Pneumococcal
First dose MMR
9 months
First dose: JE (Sarawak)
12 months Second dose of MMR
15 months Booster dose Pneumococcal
Booster dose: DTaP, IPV, Hib,
18 months
Hepatitis B
21 months Booster dose: JE (Sarawak)
In the cases of vaccine refusal, refer “Garis panduan Imunisasi Kebangsaan Bayi
dan Kanak-Kanak 2016” by Ministry of Health.
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12.5 COMMON NEONATAL ISSUES/CONDITIONS
12.5.1 Neonatal Jaundice
Excerpts from Malaysian CPG on Management of Neonatal Jaundice 2 nd

edition 2015 and the Integrated Plan for Management of Neonatal Jaundice
2nd Revision 2017.
Key messages:
● Neonatal jaundice (NNJ) is common in newborn babies. Severe NNJ can

lead to acute & chronic bilirubin encephalopathy.
● NNJ within 24 hours of life is abnormal and needs urgent attention.
● Assess all babies for jaundice at every opportunity. Methods include
visual assessment, transcutaneous bilirubinometer (TcB) or total serum
bilirubin (TSB)
● The adequacy of breastfeeding, weight & hydration status of all babies
should be assessed during the first week of life. Refer babies with weight
loss ≥7% of birth weight for further evaluation. See Chapter 13 on
weight monitoring
● Screen all babies for Glucose-6-phosphate dehydrogenase (G6PD)
deficiency. Babies with G6PD deficiency should be admitted for the first
five days of life.
● Start phototherapy when TSB reaches the phototherapy threshold. See
Table 12.4 below. The threshold is lower in preterm & low birth weight
babies.
● Consider exchange transfusion (ET) when TSB reaches the ET
threshold. This should follow a standardised protocol & be supervised by
experienced personnel.
● Babies discharged <48 hours after birth should be seen by a health care
provider in an ambulatory setting or at home within 24 hours of
discharge.
● Continue breastfeeding in babies with jaundice. Provide adequate
lactation support to all mothers, particularly those with preterm babies.
● Babies with acute bilirubin encephalopathy (ABE) should have long-term
follow-up to  monitor for neurodevelopmental sequelae. Auditory
Brainstem Response testing should be done within the first three months
of life.  
Prevention of severe neonatal jaundice (antenatal and postnatal visits):
● Health education to parents on NNJ: prevention, detection and treatment

● Identification of risk factors for severe NNJ
● Early detection of NNJ
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● Early referral for further assessment or treatment
● Breastfeeding should be encouraged. Supportive measures should be
present to promote successful breastfeeding. Supplementation may be
needed temporarily to ensure adequate hydration. Supplementing with
water or dextrose water does not lower bilirubin level in healthy, jaundice
and breastfeeding babies. See Chapter 13 on weight monitoring
● All babies should be screened for G6PD deficiency. Ideally G6PD status
should be known before discharge. If G6PD deficient/ intermediate, it is
recommended that the babies are observed for at least 5 days. If they
are discharged earlier, they should be followed-up closely.
● Babies of mothers with blood group “O” with a sibling who had severe
neonatal jaundice should be observed for at least the first 24 hours of
life.
● Predischarge screening in hospitals using TcB or narrowing down to
specific groups e.g. blood group “O” mother may be considered.
Risk factors for severe NNJ
Risk factors for severe NNJ should be identified during antenatal or

postnatal as a guide to decide which group of babies to monitor closely,
rather than to decide for treatment:
● Prematurity
● Sepsis
● Baby of diabetic mother
● Onset of jaundice before 24 hours of life
● A sibling with severe neonatal jaundice or exchange transfusion
● Inadequate breastfeeding/ dehydration (as shown by ≥10% weight loss)
● Mothers with blood group O/ Rhesus negative
● G6PD deficiency
● Asphyxia
● Rapid rise of total serum bilirubin
● Cephalohaematoma or bruises
Indications for referral to hospital
1. Onset of jaundice within 24 hours of life  

2. TSB reaches the phototherapy threshold according to the TSB level
for phototherapy (Table 12.4).
3. Rapidly rising TSB:
a. More than 103µmol/L/day (> 6mg/dL/day) – indication for
phototherapy
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b. More than 8.5µmol/L/hour (> 0.4mg/dL/hour) – indication for
exchange transfusion
4. Clinical jaundice below umbilicus (if till the soles of the feet - urgent
referral for possibility of ET)
5. G6PD deficiency (if not previously hospitalised)
6. Clinical symptoms/signs suggestive of sepsis
Effective phototherapy consists of:
● Phototherapy in the blue light range (wavelengths of about 400-500nm)

● A minimum irradiance of 15uW/cm2/nm for conventional phototherapy
● A minimum irradiance of 30uW/cm2/nm for intensive phototherapy
● A distance of light source not more than 30-50cm from top surface of the
baby
● An adequately exposed baby.
Care of babies during phototherapy:

● Babies should be regularly monitored for vital signs including
temperature, hydration status and urine output.
● Babies’ eyes should be covered to prevent retinal damage
● Breastfeeding should be continued.
Discontinue phototherapy when:

● TSB is below the conventional phototherapy level. For healthy term
babies who are 96 hours of life and older, discontinue phototherapy if
only serum bilirubin is below 280umol/L.
Follow-up
● All babies discharged less than 48 hours after birth should as far as
possible be seen by a healthcare provider in an ambulatory setting or at
home within 24 hours of discharge. On discharge, the local health
worker should be informed and the parents advised accordingly.
● Babies with severe/ pathological jaundice who are discharged in the first
5 days of life, early follow-up is needed to detect rebound jaundice.
● Babies with acute bilirubin encephalopathy should have long-term follow-
up to monitor for neurodevelopmental sequelae.
● Term and late preterm babies with TSB > 20mg/dL(342 µmol/L) and
those who require exchange transfusion should have Auditory Brainstem
Response (ABR) testing done, preferably before discharge or within the
first month of life. They should continue the Audiology follow-up until 3
years old, to monitor for any development/ progression of hearing
impairment.
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● Healthy term and late preterm babies with non-haemolytic
hyperbilirubinemia, normal hearing assessment, and TSB < 25mg/dL
(428µmol/L) may be followed-up at the primary care level.
Postnatal Home visit

● Home visit for all newborns should be as schedule for postnatal care.
Special attention for jaundice must be taken for the first five days of life.
● If the jaundice is detected but not indicated for admission or
phototherapy, daily visits should be conducted to monitor the severity of
jaundice, especially if a risk factor is present (see above).
Table 12.4: TSB levels for phototherapy & ET in babies’ ≥35 weeks’ gestation
Age LOW RISK MEDIUM RISK HIGH RISK

> 38 weeks & well >38 weeks with risk factors 35-37 weeks + 6 days with
or 35-37 weeks + 6 days & risk factors
well
Hours Conventional ET – TSB in Conventional ET – TSB in Conventional ET – TSB in
of life Phototherapy mg/dL Phototherapy mg/dL Phototherapy mg/dL
– TSB in (µmol/L) – TSB in (µmol/L) – TSB in (µmol/L)
mg/dL mg/dL mg/dL
(µmol/L) (µmol/L) (µmol/L)
24 9 (154) 19 (325) 7 (120) 17 (291) 5 (86) 15 (257)
48 12 (205) 22 (376) 10 (171) 19 (325) 8 (137) 17 (291)
72 15 (257) 24 (410) 12 (205) 21 (359) 10 (171) 18.5 (316)
96 17 (291) 25 (428) 14 (239) 22.5 (385) 11 (188) 19 (325)
>96 18 (308) 25 (428) 15 (257) 22.5 (385) 12 (205) 19 (325)
a. Start intensive phototherapy at a TSB level of 3 mg/dL (51 µmol/L) above

the level for conventional phototherapy or when TSB increasing (increment
rate) at >0.5 mg/dL/hour (8.5 µmol/L/hour).
b. Risk factors are isoimmune haemolytic disease, G6PD deficiency, asphyxia
& sepsis.
12.5.2 Prolonged Neonatal Jaundice
All babies with prolonged neonatal jaundice need to be clinically assessed

and investigated. Infants with suspected biliary atresia have to be referred to
the paediatric surgeon before 2 months of age for surgery. Below are the
excerpts from the Integrated Plan for Management of Neonatal Jaundice 3 rd
edition and Paediatric Protocols for Malaysian Hospital 4th edition.
Definition
Visible jaundice (SB >85 μmol/L or 5 mg/dL) that persists beyond 14 days of
life in a term baby (≥ 37 weeks) or 21 days in a preterm baby (≥35 weeks to
< 37 weeks).
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Causes of prolonged neonatal jaundice
● It may be unconjugated or conjugated hyperbilirubinaemia.

● Conjugated hyperbilirubinaemia is defined as the direct (conjugated)
fraction of bilirubin more than 34 μmol/L (2mg/dL), or more than 15% of
the total bilirubin.
Table 12.5: Causes of Unconjugated and Conjugated Hyperbilirubinemia
Unconjugated Hyperbilirubinemia Conjugated Hyperbilirubinemia*

Septicaemia/ Urinary Tract Infection Biliary Atresia
Hypothyroidism Neonatal hepatitis syndrome
Haemolysis Choledochal Cyst
Breast milk jaundice (most common, benign Septicaemia/ Urinary Tract Infection
condition) Congenital Infection (TORCHES)
Inborn Error of Metabolism
TPN-induced cholestasis
*All babies with conjugated hyperbilirubinemia must be referred to a paediatric
department urgently to exclude biliary atresia.
Initial Approach and Management
● All babies MUST be assessed or screened for prolonged neonatal

jaundice (PNNJ) at day 14 for term babies and day 21 for preterm
babies.
● Even if the baby has resolved neonatal jaundice and reducing trend of
serum bilirubin (SB), the baby must be reassessed for jaundice again at
Day 14 of life.
● In the presence of prolonged neonatal jaundice (regardless of SB level),
the baby must be referred to a medical officer (in any hospital or health
clinic) the same day or the next working day for clinical assessment and
further laboratory workup, using the PNNJ clerking sheet as a guide.
● Risk stratification into high, moderate or low risk groups are
recommended (Figure 12.5). This is done by:
a. Clinical assessment
e.g. feeding method, weight, STOOL COLOUR and presence of
hepatosplenomegaly AND
b. Important laboratory investigations 
i.e. serum bilirubin with direct and indirect bilirubin.
● Subsequent management of these babies will depend on the risk
groups.
● Refer to Paediatric Team if conjugated hyperbilirubinaemia, signs of
obstructive jaundice (pale stool, dark urine and hepatosplenomegaly)
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SB> 300µmol/L, abnormal lab results, jaundice more than 2 months or
any other features in the high or moderate risk category.
Figure 12.5: Flowchart for the Management of Prolonged Neonatal Jaundice in

Babies ≥ 35 Weeks
Clinical Jaundice (SB>85μmol/L) at D14 for babies ≥ 38 weeks or
+6
D21 for babies 35 to 37 weeks
WARNING SIGNS for
Parents (at any stage):
TCA STAT if
REFER MO same day or next working day (KK or Hospital) Unwell/Pale Stool/ Dark
Yellow Urine/ New
Onset of Jaundice/
INITIAL ASSESSMENT using ‘Clerking and Referral Sheet for Persistent Jaundice > 2
Prolonged Neonatal Jaundice’ months
RISK STRATIFICATION
MODERATE RISK
HIGH RISK LOW RISK
*Conjugated
Lethargic/ septic Hyperbilirubinemia DO Serum Bilirubin
poor perfusion TSB > 300 μmol/L with Differential
respiratory New Onset of (Direct + Indirect)
distress Jaundice (especially Review results within
poor feeding after D7) 72 hours
Pale Stool DISCHARGE +
Dark Yellow Urine Warning Signs
(stains the diapers) Unconjugated Hyperbilirubinemia
Follow up at
Pallor RME 1 & 2
Poor Weight Gain months
REFER TCA 1 WEEK to No
Hepatosplenomegaly
PAEDIATRICIAN review baby & results
FOR ADMISSION Jaundice LOOK OUT
Others: FOR Warning
STAT Jaundice > 1 month Signs or New
not investigated before Baby still jaundice Concerns
significant family BUT WELL, do
history jaundiced & SB with differential
bottle fed > 50% urine dipstick +
Microscopy
Free T4 & TSH
Full Blood Count
Note: TCA 1-2 WEEKS to Normal Results

REFER PAEDITRIC
TEAM review baby & results & Child Well
*Conjugated
Hyperbilirubinemia (To be reviewed the
= Direct Bilirubin > same day, or if child
15% or > 34 μmol/L relatively well, the next
working day) Abnormal Results or
of TSB New Concerns
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Table 12.6 : Management of Prolonged Neonatal Jaundice for Babies ≥ 35 weeks
Gestation by Risk Groups at the point of diagnosis in any health facilities
HIGH RISK MODERATE RISK LOW RISK

Positive Clinical Features/ Positive Clinical Features/ Positive Clinical Features/
Lab Results Lab Results Lab Results
● Ill/ Septic Looking ● Conjugated ● None
● Respiratory distress Hyperbilirubinaemia ● Well babies with good
● Poor feeding ● Severe Jaundice- weight gain, exclusively
● Lethargy TSB>300 μmol/L breast fed (or > 50%),
● Poor perfusion ● New Onset Jaundice bright yellow stool with
(esp after Day 7) normal physical
● Pale Stools examination
● Dark Yellow Urine ● Breast milk jaundice
(stains diapers)
● Poor Weight Gain Management
● Hepatosplenomegaly Can be managed and
followed up at primary care
To also consider: level or hospitals without
● Bottle fed > 50% specialists.
● Jaundice > 1 month not
investigated before Term babies > 37 wks
● Other suspected medical Day 14:
condition ● S. Bilirubin with Direct/
● Significant family history Indirect bilirubin,
● Full Blood Count
Management Management ● UFEME + microscopy
● Stabilise Airway, ● Refer to Paediatric Team ● Free T4, TSH
Breathing, Circulation ● Same day or next
● Refer to Paediatrician working day Preterm babies ≥ 35 < 37
immediately weeks
To work up 1 week later
than term babies.
Well, low risk babies DO NOT need heel prick capillary bilirubin till jaundice resolves.
Warning signs* for parents and RME (routine medical examination) at 1 month and 2
months in health clinics, looking at the same clinical features will serve as a good safety
net.
Refer to Paediatric Team if conjugated hyperbilirubinaemia, warning signs*, SB>
300 μmol/L, abnormal lab results, jaundice more than 2 months or any features in
the high or moderate risk category.
*Unwell, pale stool, dark yellow urine, new onset of jaundice, persistent jaundice > 2
months
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12.5.3 Neonatal Hypoglycaemia
There is no single plasma glucose concentration or duration of

hypoglycaemia that can predict permanent neurologic injury in high-risk
infants. Clinical hypoglycaemia is defined as a plasma glucose
concentration low enough to cause symptoms and/or signs of impaired brain
function, commonly accepted at <2.6 mmol/L in a term or preterm
infant.
● In term infants < 4 hours old, plasma glucose > 1.5 mmol/L is acceptable
if the infant is well, asymptomatic and tolerating feeds and repeat
glucose is > 2.6 mmol/L
● For infants > 48 hours old, it is recommended to keep plasma glucose
level > 3.3 mmol/L to be above the threshold for neuroglycopaenic
symptoms.
● For infants with suspected congenital hypoglycaemia disorder or
symptomatic infants, keep plasma glucose > 3.9mmol/L.
Infants who are at high risk of hypoglycaemia and require glucose

screening:
● Symptoms of hypoglycaemia
● Large-for-gestational age (LGA) - even without maternal diabetes
● Intrauterine growth retardation/ small-for-gestational age (SGA)
● Perinatal stress: birth asphyxia, meconium aspiration syndrome,
hypothermia, polycythaemia, sepsis
● Premature or postmature delivery
● Family history of a genetic form of hypoglycaemia
● Congenital syndromes (e.g.; Beckwith-Wiedemann), or abnormal
physical features (e.g.; Midline facial malformations, microphallus).
Clinical signs of hypoglycaemia

● Jitteriness
● Cyanosis
● Seizures
● Apneoic episodes
● Tachypnoea
● Weak or high-pitched cry
● Floppiness or lethargy
● Eye-rolling
● Poor feeding
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Indications for Referral to Paediatric Team
● Babies of diabetic mothers on insulin treatment (or metformin)
● LGA (birth weight ≥ 4.2kg) or SGA (birth weight < 2kg) babies
● Sick babies
● Symptomatic babies
● Blood glucose < 1.5 mmol/L
● Blood glucose persistently low (< 2.6 mmol/L)
Management of High Risk Infants

Blood glucose concentration should only be measured in symptomatic
babies, or who are known to be at risk of hypoglycaemia.
1. Identify at risk babies 
2. Well babies who are at risk
● Immediate feeding within 1 hour of birth - first feed can be given in
the labour room.
● Supplement feeding until breastfeeding is established
● Initial blood glucose should be done 30 minutes after the first feed.
3. Any sick babies:
● Refer to Paediatric Team
● Check blood glucose on admission
● Set up IV dextrose 10% drip at the rate of 60ml/kg/day
4. Regular glucometer monitoring:
● 3 - 6 hourly pre-feeding for 12 -24 hours
Management of Hypoglycaemia
1. Repeat blood glucose (glucometer, dextrostix) and send for plasma
glucose levels (RBS) stat.
2. Examine and document any symptoms.
3. Note when last feeding was given.
4. If on IV drip, check that IV infusion of glucose is adequate and running
well.
5. If blood glucose is < 1.5 mmol/L in the first 4 hours of life or if the infant
is symptomatic:
● Inform Paediatric team stat
● Quickly set up a peripheral intravenous line or umbilical venous line
● Give IV Dextrose 10% at 2-3ml/kg bolus
● Followed by IV Dextrose 10% drip at 60-90ml/kg/day (for day 1 of
life).
● If the infant is already on IV Dextrose 10% drip, consider increasing
the rate or the glucose concentration (usually require 6-8mg/kg/min
of glucose delivery load)
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● Calculation of dextrose/ glucose load (or delivery rate):
Rate (ml/hr) x Dextrose concentration (%)

------------------------------------------------------
Weight x 6
6. Within the first 4 hours of life, if blood glucose is 1.5 - 2.5mmol/L and
asymptomatic:
● Give supplementary feed [expressed breast milk (EBM) or formula]
as soon as possible.
● If blood glucose remains < 2.6 mmol/L and the infant refuses feeds,
start IV dextrose 10% drip and refer to the paediatric team.
● If the infant is already on IV Dextrose 10% drip, consider a stepwise
increment of glucose infusion rate by 2 mg/kg/min until blood sugar
is > 2.6 mmol/L.
● If blood glucose is below target level, recheck blood glucose every
30 minutes.
● Once blood glucose is above target level for 2 readings, monitor
hourly x 2, then 2 hourly x 2, then to 3-6 hourly pre feeding, if blood
glucose remains normal.
7. Start feeding when blood glucose remains stable and increase as
tolerated. Reduce the IV Dextrose infusion rate 1 hour after the feeding
increment.
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Figure 12.7: Management of Persistent Hypoglycaemia
Hypoglycaemia
Blood glucose (BG) < 2.6mmol/L or
< target glucose
- BG < 1.5mmol/L in first 4 - BG 1.5 - < 2.6 mmol/L and

hours of life asymptomatic (0-4 hours of
- Symptomatic, or life)
- After 48 hours of life, BG < 3.3
mmol/L
Send RBS Give supplement feeding ASAP

IV Dextrose 10% 2-3 ml/kg bolus Send RBS
IV Dextrose 10% drip at If refuses to feed:
60-90ml/kg/day IV Dextrose 10% drip 60ml/kg/day
Repeat BG in 30 minutes
If still hypoglycaemia:
- Re-evaluate * see below

- Give an initial IV Dextrose 10% 2-3
ml/kg bolus followed by increase in
glucose delivery
- Refer Paediatric team if not done yet
Further management by Paediatric team
*NOTES
 Once BG achieves >2.6mmol/L or target BG for 2 readings, monitor hourly twice , then 2
hourly twice, then 3-4 hourly
 If BG <2.6mmol/L or symptomatic, do critical sampling
 For those with risk of congenital hypoglycaemia disorders of symptomatic, aim for target BG >
3.9mmol/L
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12.5.4 Common Skin Lesions
a. Diaper rash (ammoniacal dermatitis)

b. Candida diaper rash
c. Seborrheic dermatitis
Diaper rash (ammoniacal dermatitis)

May be caused by prolonged contact with urine or faeces. It can also be an
allergic reaction to the diaper material, creams, powders, wipes or
detergents used in laundering cloth diapers.
The best treatment is prevention, by frequent diaper changes and by

protection of the skin with a barrier product containing zinc oxide. The skin
should be cleansed with warm water after voiding or passing motion. Avoid
diaper wipes that contain alcohol. Cornstarch and baby powder should not
be used as they provide a media for growth of bacteria and yeast. Don’t use
creams that contain steroids (cortisone or hydrocortisone).
Candida diaper rash

A fungal infection of skin in the diaper area may include buttocks, groins,
thighs and abdomen. It is caused by the organism Candida albicans. It
appears as a moist erythematous eruption often with white or yellow satellite
pustules.
Treatment consists of antifungal cream or ointment such as nystatin applied

to the rashes several times per day.
Seborrhoeic dermatitis
Seborrheic dermatitis affects the scalp, central face, and anterior chest.
Seborrheic dermatitis also may cause mild to marked erythema of the
nasolabial fold, often with scaling.The scales are greasy, not dry, as
commonly thought. This rash has an erythematous background and a
greasy yellow scale. It is common in hair-bearing areas of the body,
especially the scalp and eyebrows. It is usually absent in the flexures.
Scaling is prominent on the scalp producing the so-called ‘cradle-cap’. It has
a tendency to recur throughout infancy.
Treatment is with topical application of 1% sulphur + 1% salicylic acid in

cream applied overnight and washed off the next day with a mild shampoo,
used 3 times a week. Milder cases of cradle cap can be treated with topical
olive oil. If severe, the whole body may be affected and should be referred
to hospital.
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12.5.5 Feeding Problems
Vomiting
Regurgitation or reflux
One of the most common symptoms in the neonatal period is regurgitation

of milk during or shortly after feeding. It is usually seen soon after feeding.
Unlike vomiting, the amounts are small and the baby does not seem to be in
any distress, of normal hydration and thriving. Regurgitation begins in the
first weeks of life and clears by one year of age. The cause is incomplete
closure of the valve at the upper end of the stomach in the first few months
of life. Causes include overfeeding, frequent change of formula, early use of
supplementary food, improper feeding technique and posture.
The following tips can be given to the mother, if the regurgitation causes
distress to the parents:
● Do not overfeed baby, especially if you are bottle-feeding

● Avoid pressure on the abdomen because it ‘squeezes’ the stomach.
Check that the diapers are not tight when the baby is in a sitting position
● After feeding, try to hold or keep your baby in an upright position for 30-
60 minutes
● If you think the regurgitation does not improve over time or the baby has
other symptoms as given below, refer to hospital
Signs and symptoms of vomiting where baby must be referred to hospital:

● baby is lethargic, tachypnea
● not feeding well
● having a fever
● vomiting out greenish-coloured fluid (bile) or has a distended abdomen
● looks dehydrated or reduced urine output
● not putting on weight
Colic
Colic is a common problem, affecting 10-25% of all newborns. Colic

describes episodes of crying that continuous for hours at times. It is quite
common in babies below 3 months of age and the cause is not known. It
may be associated with hunger, swallowing large amounts of air,
overfeeding or inadequate carbohydrate intake. Colic usually begins at
about 2 weeks of age and should resolve by 4 months of age. Breastfed
babies are not as likely to get colic as babies who are formula-fed.
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Parents are usually stressed and upset when the baby does not stop crying,
no matter what they do. Provide reassurance after checking that the baby is
healthy.
Some things that parents can do:

● Hold the baby in an upright position during feeding
● If being bottle fed, holding the bottle so that the milk covers the entire
opening of the teat
● Burp the baby after feeding to reduce air in the stomach
● Try swaddling (wrapping) the baby in a blanket. Walking with the baby
on the shoulder,or rocking the baby sometimes helps to quieten the baby
● A ride in the car, with the baby in a safety car seat, usually works well
IF YOU FEEL THE PARENTS ARE UNABLE TO COPE WITH THE STRESS OR
IF THE BABY CANNOT BE COMFORTED IN A REASONABLE AMOUNT OF
TIME, REFER TO HOSPITAL
12.5.6 Eye Problem
Nasolacrimal duct obstruction
Term and preterm newborn infants have the capacity to secrete tears (reflex
tearing to irritants) but usually do not secrete emotional tears until 2-3
months of age.
Congenital obstruction is usually caused by an imperforate membrane at the

distal end of the nasolacrimal duct.
Congenital nasolacrimal obstruction is the most common abnormality of the

neonate’s lacrimal apparatus. Incidence of this condition ranges between
2% and 6% of all newborn infants. The majority of nasolacrimal obstruction
resolves spontaneously or with massage by 1 year of age.
Clinical presentation (usually with the first few weeks of life) :
● Persistent tearing. Need to rule out congenital glaucoma.

● Crusting or matting of the eyelashes (sticky eyes)
● Spilling of tears over the lower lid and cheek (a wet look in the involved
eyes)
● Absence of conjunctival infection.
● Mucopurulent discharge
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Complications
● Acute dacryocystitis
● Fistula formation
● Orbital or facial cellulitis
Management
● Conservative management – daily massage of nasolacrimal sac to
rupture the membrane at the lower end of the duct. Technique – place
index finger over common canaliculus and stroke downwards firmly.
● If mucopurulent discharge, antibiotic eye drops or ointment may be
required.
● Eye should be cleaned with moist compresses.
Conjunctivitis
Inflammatory reactions resulting from infection of the conjunctiva by
pathogenic organisms – e.g. Neisseria gonorrhoea, Chlamydia trachomatis,
Staphylococcus aureus, enteric pathogen.
1. Neisseria Gonorrhoeal Conjunctivitis

Bilateral purulent conjunctival discharge within a few days of life. Onset of
symptoms usually between the second and fifth day of life. Eye discharge
on the first day of life is usually due to gonococcal infection.
Clinical presentation
Oedema of the eyelids, purulent discharge, redness of the conjunctiva.
Diagnostic findings
● Maternal history of sexually transmitted infections
● Physical examination – clinical signs of inflammation, purulent
discharge.
● Laboratory – Gram negative diplococci on Gram stain of direct
smear.
● Culture positive for Neisseria gonorrhoea from conjunctival
surface or exudates.
Management
● Isolate baby
● Irrigate eyes with sterile normal saline solution hourly. Refer
patient promptly to the hospital for further treatment
● Notify to health authorities concerned
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2. Chlamydia Trachomatis Conjunctivitis
Unilateral or bilateral conjunctivitis onset between 5 and 14 days of age.
Clinical presentation - vary from mild conjunctivitis to intense oedema of the

lids with purulent discharge.
Diagnostic findings - identification of Chlamydia antigen.
Management - Refer patients to the hospital for treatment.
12.5.7 Umbilical Cord Care
The cord stump remains the major means of entry of infections after birth.
The umbilical cord stump usually drops off in 1-2 weeks. Until then, keep it
clean and dry.
● The stump will dry and mummify if exposed to air without any
dressing, binding or bandage
● Gently clean the area where the cord and the tummy meet at
least once a day or when the area is damp.
● It will remain clean if it is protected with clean clothes and is kept
from urine and soiling.
● If soiled, the cord can be washed with clean water and dried with
clean cotton or gauze. If there is redness or the umbilical area is
moist or smells, dip a cotton swab with the alcohol preparation
provided by the staff at the time of discharge.
● There may be a spot of blood on the diaper when the stump falls
off. If bleeding persists for more than a few days or is more than
just spots, bring baby to see a doctor
● If you see pus, redness, or the baby cries when you touch the
area, refer to the doctor.
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APPENDIX 12-1
WARNING SIGNS FOR BABIES
The following are warning signs of an ill baby who needs immediate attention by the
doctor.
1. Central cyanosis
Table 12.8: Differentiating between central cyanosis from peripheral cyanosis
Central cyanosis Peripheral cyanosis

Site Tongue, lips, extremities Extremities only. Tongue is
pink.
Causes Cardiac, pulmonary, Mainly hypothermia causing
profound peripheral vasoconstriction
sepsis
Action required Check SpO2 Check Temperature
Immediate referral Warm up the baby as
necessary
2. Signs of respiratory distress

● Tachypnoea > 60/min.
● Grunting or stridor
● Intercostal and or subcostal recession
● Flaring of the nostrils
● Cyanosis
● Reduced air entry
3. Signs of sepsis
Table 12.9: Signs of sepsis
Systems Signs
Respiratory Apnoea
Tachypnoea
Grunting, nasal flaring
Recession
Cardiovascular Tachycardia*
Hypotension
Bradycardia
Poor perfusion
Central nervous Temperature instability – hypothermia or fever*
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Systems Signs
Lethargy*
Hypotonia
Irritability*
Seizures
GIT Feeding intolerance/ poor feeding*
Abdominal distension
Vomiting*
Diarrhoea
Others Jaundice
Pallor
Petechiae
*Early signs of sepsis
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Reference: Training Manual on Approach to Unwell Children under 5 years
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CHAPTER 13
BREASTFEEDING AND WEIGHT MONITORING
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CHAPTER 13: BREASTFEEDING AND WEIGHT MONITORING
13.1 BREASTFEEDING
13.1.1 Promoting Breastfeeding
WHO/UNICEF Global Strategy for Infants and Young Child Feeding (2003)
recommended that infants should be exclusively breastfed for six months to
achieve optimal growth development and health. This recommendation is in
line with the Ministry of Health Malaysia Breastfeeding Policy.
All hospitals under the Ministry of Health have achieved the Baby Friendly
Hospital Initiative (BFHI) Status. It is recognised that there is a need to
ensure continuity of practises as listed in the 10 steps plus 3 items to
successful Breastfeeding. To ensure the sustainability of this programme, all
hospitals will be assessed every 2 to 3 years by the accredited BFHI
assessors.
13.1.2 Early Initiation of Breastfeeding
Immediate and uninterrupted skin-to-skin contact and initiation of

breastfeeding within the first hour after birth are important for the
establishment of breastfeeding. Early suckling is important for stimulating
milk production and establishing the maternal milk supply. All mothers
should be supported to initiate breastfeeding as early as possible after birth.
Early initiation of breastfeeding will ensure the success of breastfeeding for
6 months and also will ensure the baby gets enough colostrum.
Initiation of breastfeeding at birth checklist for normal and full term

delivery
● Put to breast as soon as possible after birth for skin-to-skin
contact
● Initiate breastfeeding in the first hour of life
● Check baby’s positioning and attachment
● Keep baby warm
13.1.3 Support with Breastfeeding
Mothers should receive practical support which includes providing emotional

and motivational support, imparting information and teaching concrete skills
to enable them to initiate and maintain breastfeeding and manage common
breastfeeding difficulties.
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13.1.4 Breastfeeding Problems and Management
Problems Remedial Measures

Sore nipple • Help mother to improve attachment and positioning
• Show the mother how to feed in different feeding position
• Treat skin condition or remove source of irritation
• Treat candida both on mother’s nipple and baby’s mouth
Breast engorgement • Warm compress or warm shower

• Massage neck and back
• Light massage of breast
• Help mother to relax
• Provide supportive atmosphere
• Cold compress on the breast if oedema present
• If baby is able to suckle :
- Feed frequently, help with positioning
• If baby is not able to suckle :
- Express the breast
Block duct and • Advise mother :

Mastitis - Breastfeeding frequently
- Proper attachment
- Gentle massage the blocked and tender area down
toward the nipple before and during the feeds
- Apply a moist, warm cloth to the area before a
breastfeed
- Check that her clothing especially her bra, does not have
a tight fit
• Analgesia to reduce pain
• Antibiotic therapy if indicated
Breast abscess • Needs surgical incision and antibiotic
• Continue breastfeeding if:
- Incision far enough from areola and does not interfere
- Mother tolerate pain
- Otherwise express milk from affected side
- Continue breastfeeding from unaffected breast
Insufficient milk • Start early feeding

• Frequent demand feeding
• Good breastfeeding technique – good attachment
• Express breast milk every two to three hourly if baby is not
able to suck well
• Not to use pacifier or bottle feeding
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13.1.5 Checklist for Initiation of Breastfeeding at Birth (Normal, Full Term
Delivery)
● Put to breast as soon as possible after birth for skin to skin

contact
● Initiate latching to the breast within half to 1 hour
● Check baby’s attachment and suckling
● Keep baby warm
13.1.6 Checklist for Assessing Progress of Breastfeeding (Prior to Discharge)
● Correct body position

● Correct attachment and sucking
● Feeding on demand
o No limits on frequency or duration
o Night feeding
● Emotional bonding
o Secure, confident hold
o Face to face attention from mother
o Close contact with mother
● Breastfeeding problems are attended to:
o E.g. inverted nipples; breast engorgement
13.1.7 Checklist for Indicators of Sufficient Breast Milk Intake (At Second
Week of Life)
● Weight gain :
o Good weight gain according to growth chart, or 25 gram/day
o In the first 7 - 10 days of life, babies lose weight. Babies regain
their birth weight by the second week, double this by 5 months of
age, and triple the birth weight by 1 year of age
o At day 5-6, if weight loss is more than 10% - refer to hospital for
possible hypernatraemic dehydration
o if weight loss is between 5 – 10 % - refer baby to medical officer
at nearest health clinic for review. Baby to be monitored until
weight gain is obtained
● Stools: 5 to 10 yellow milk stools per day
● Urine: 6 to 8 wet diapers per day, urine looks clear, not dark or
concentrated
● Baby’s behaviour: Baby acts hungry at times and appears
satisfied after feeding, and generally calm and relaxed during
feeding.
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● Baby’s general condition: Baby has normal skin colour, mucous
membrane wet with good skin turgor, alert, and good tone.
● Number of feeds: At least 8-12 feeds per day.
● Length of feeds: Feeding for 5-40 minutes at most feeds
● End of feeds: Baby lets go spontaneously, or does so when
breast is gently lifted.
● Sucking pattern: Initial rapid sucks changing to slower sucks with
pauses and soft swallowing.
13.1.8 Care for Mothers at Discharge
Mothers need sustained support to continue breastfeeding. Coordinate

discharge so that parents and their babies have timely access to ongoing
support and care
● Reevaluate mothers’s knowledge and skills on breastfeeding
o Correct body position
o Correct attachment and sucking
o Breastfeeding on cues or baby-led feeding
● Understand the importance of breastfeeding exclusively for six
months
● Breastfeeding problems addressed to, e.g. inverted nipples;
breast engorgement
● Inform mother where to get help if she has breastfeeding problem
– Healthcare Facilities, NGO & Breastfeeding Support Group
● Notification to health staff of all hospital discharges especially
high-risk cases
13.2 ACCEPTABLE MEDICAL REASONS FOR SUPPLEMENTATION TO

BABIES BELOW SIX MONTHS OF AGE
13.2.1 Infant’s conditions

i. Infants who should not receive breast milk or any other milk except
specialised formula. This applies to babies with inborn errors of
metabolism eg:
● Classic galactosemia : a special galactose-free formula is
needed
● Maple syrup urine disease : a special formula free of leucine,
isoleucine and valine is needed
● Phenylketonuria : a special phenylalanine-free formula is
needed (some breastfeeding is possible, under careful
monitoring)
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ii. Infants for whom breast milk remains the breastfeeding options but who
may need other food in addition to breast milk for a limited period
● Very low birth weight infants (those born weighing less than
1500g)
● Very preterm infants, i.e. those born less than 32 week
gestational age
● Newborn infants who are at risk of hypoglycaemia by virtue of
impaired metabolic adaptation or increased glucose demand
(such as those who are preterm, small for gestational age or
who have experienced significant intrapartum hypoxic/
ischaemic stress, those who are ill and those whose mothers
are diabetic) if their blood sugar fails to respond to optimal
breastfeeding or breast milk feeding;
● Infants younger than 6 months who, in spite of frequent and
effective sucking and in the absence of illness, show
persistent growth faltering (as demonstrated by a flat or
downward growth curve).
The mothers of the above babies must be encouraged to establish early

bonding with their babies and given more support with breastfeeding.
13.2.2 Maternal Conditions

The mother who is affected by any of the conditions mentioned below
should receive treatment according to standard guidelines.
i. Mother who should avoid breastfeeding PERMANENTLY

● HIV infection
● HTLV-I (Human T-cell Leukaemia virus)
ii. Mother who should avoid breastfeeding TEMPORARILY
● Severe illness that prevents a mother from caring for her
infant, for example septicaemia
● Herpes simplex virus type 1 (HSV-1): direct contact between
lesions on the mother’s breasts and the infant’s mouth should
be avoided until all active lesions have resolved
iii. Mother who CAN CONTINUE BREASTFEEDING, although the

health problems may be of concern
● Breast abscess: breastfeeding should continue on the
unaffected breast; feeding from the affected breast can
resume once the abscess has been drained and antibiotic
treatment has started
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● Mother with Hepatitis B : infants should be given hepatitis B
vaccine, within the first 48 hours or as soon as possible
thereafter
● Hepatitis C infection in the mother is not a contraindication to
breastfeeding. There is no current data to suggest that HCV is
transmitted by human breast milk.
● Mastitis : If breastfeeding is very painful, milk must be
removed by expression to prevent progression of the
condition;
● Tuberculosis : If active pulmonary disease or miliary TB has
been recently diagnosed, it has been recommended that
mother and baby be separated until mother is sputum negative
or mother has been given anti TB therapy (usually at least two
completed weeks) then mother can breastfeed. The newborn
should receive isoniazid prophylaxis for 6 months followed by
BCG
When breastfeeding has to be temporarily delayed or interrupted, mothers

should be helped to establish or maintain lactation e.g through hand
expression of milk, in preparation for breastfeeding to be resumed.
13.2.3 Medications and other substances that can adversely affect the
breastfed infant
Maternal medication
Risks are greater during the first 2 months on high dosages of medications
(as therapy or with abuse). Monitor infants for adverse effects. The use of
low doses usually requires no special precautions in older infants.
● Sedating psychotherapeutic drugs, anti-epileptic drugs and

opioids and the combinations may cause side effects such as
drowsiness and respiratory depression in neonates; use less
sedating alternative and low dosages whenever possible;
● Sulphonamides,chloramphenicol, tetracyclines – small risk of side
effects : use alternative drugs if possible
● Oestrogen (including oestrogen containing contraceptives),
thiazide diuretics, - may reduce milk supply, use alternative
drugs.
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● Mothers on antithyroid drugs e.g. propylthiouracil can be allowed
to breastfeed but monitor babies closely with thyroid function
tests.
● Radioactive iodine (RAI) in therapeutic doses should be avoided
given that safer alternatives are available; a mother may resume
breastfeeding about two months after receiving this substance
with measured low milk radioactivity;
● Excessive use of topical iodine or iodophors (e.g., povidone-
iodine), especially on open wounds or mucous membranes, can
result in thyroid suppression or electrolyte abnormalities in the
breastfed newborn and should be avoided;
● Cytotoxic chemotherapy requires that a mother stop
breastfeeding during therapy.
Substance use
Mother should be advised not to use these substances and given

opportunities and support to abstain. Mothers who choose not to cease their
use of these substances or who are unable to do so, should seek individual
advice on the risks and benefits of breastfeeding, depending on their
individual circumstances. For the mother who uses these substances in
short episodes, consideration may be given to avoiding breastfeeding
temporarily during this time.
● Maternal use of nicotine often decreases the duration of
breastfeeding, and can adversely affect the infant, but
breastfeeding is preferable to formula feeding in mothers who
smoke. Infants should not be exposed to tobacco smoke.
● Alcohol taken before breastfeeding can cause infant sedation and
reduced milk intake.
● Abuse of amphetamines, cocaine and related stimulants may
produce harmful effects on babies who are breastfed especially if
the infant is additionally exposed to inhalation of smoked drugs.
The following are usually safe in usual dosage:
● Analgesics – short courses of paracetamol, acetylsalicylic acid,

ibuprofen, occasional doses of morphine and pethidine
● Antibiotics – penicillin, cloxacillin and related drugs, erythromycin,
● metronidazole
● Antihistamines, antacids, digoxin, insulin, bronchodilators,
corticosteroids, antihelmintics, chloroquine, antituberculous
drugs.
● Nutritional supplements e.g. iron, iodine and vitamins.
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Adapted from UNICEF/ WHO (January 2008) Section 4: Hospital Self-
Appraisal and Monitoring, Baby Friendly-Friendly Hospital Initiative.
Revised, updated and expanded for integrated care.
References:
1. Implementation Guidance. Protecting, Promoting And Supporting Breastfeeding In
Facilities Providing Maternity And Newborn Services: The Revised Baby-Friendly
Hospital Initiative. WHO/UNICEF 2018
2. Acceptable medical reasons for use of breast-milk substitutes, WHO/UNICEF 2009
3. BABY-FRIENDLY HOSPITAL INITIATIVE Revised, Updated and Expandedfor
Integrated Care. Section 3. Breastfeeding Promotion and Support in a Baby
Friendly Hospital. A 20-Hour Course for Maternity Staff. WHO/UNICEF 2009
13.3 WEIGHT MONITORING IN NEWBORN TERM INFANTS
1. A term baby loses weight in the first 7-10 days of life.

2. After day 7-10, the expected rate of weight gain is 15-25g/day.
3. The baby should regain birth weight by Day 14 of life.
4. A baby who loses more than 10% of their birth weight must be referred
to a medical officer immediately.
5. Although it is the current practice to weigh the baby on day 5 and day
14-16, it is recommended that a baby is also weighed at any opportunity
and especially when there is a concern with weight or feeding. This is
because weight is the only objective measure for adequacy of feeding
and we also could detect earlier if a baby is not doing well or not feeding
well. Studies have also shown that a baby that lost more than 7% of
birth weight in the first few days of life has a higher risk of severe
neonatal jaundice.
6. Breastfeeding education and assessment on the adequacy of feeding
should be carried out at every encounter.
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Table 13.1: Management Plan related to Weight Monitoring of Newborn
Babies
Group of babies Management Plan

All babies To weigh at 1st visit, Day 5, Day 15, Day 20 and
when there is a concern with weight or feeding.
Babies with weight loss > To reinforce on breastfeeding education
7% To assess breastfeeding technique, supplement if
needed.
If the baby is generally well, to review the baby
again in 1-2 days.
To refer to a medical officer if there any concerns.
Babies with weight loss > To refer to amedical officer on the same day
10% of birth weight
Table 13.2: Assessment of Adequacy of Feeding in Newborn Babies
Parameter Normal
Urine output At least 5-6 heavy wet nappies in 24 hours
Appearance and frequency of At least 2 in 24 hours; normal appearance
stools
Baby’s colour, alertness and tone
Normal skin colour, alert, good tone
Weight Weight loss not more than 10% of birth
weight
Number of feeds in the last 24 At least 8-12 feeds
hours
Baby’s behaviour during feeds Generally calm and relaxed
Sucking pattern during feeds Initial rapid sucks changing to slower suck
with pauses and soft swallowing
Length of feed Feeding for 5-40 minutes at most feeds
End of the feed Baby lets go spontaneously, or does so
when breast is gently lifted
Baby’s behaviour after feeds Content after most feeds
Source: Breastfeeding assessment form, UNICEF.
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CHAPTER 14
SPECIFIC PERINATAL CONDITIONS RELATED TO
MATERNAL COMORBIDITIES
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CHAPTER 14: SPECIFIC PERINATAL CONDITIONS RELATED TO MATERNAL
COMORBIDITIES
14.1 INFANT OF MOTHER WITH DIABETES

● Infant of mother with DM/GDM may have many of the morbidities
or complications as below:
System Conditions
Prenatal risks ▪ Sudden foetal death in third trimester

▪ Premature birth with or without caesarean
delivery
▪ Intrapartum asphyxia
▪ Birth trauma secondary to macrosomia
Growth ▪ Macrosomia
▪ Intrauterine growth retardation
Cardiac ▪ Restrictive cardiomyopathy

▪ Congenital heart disease e.g.; VSD
Central nervous ▪ Anencephaly,

system ▪ Spina bifida
▪ Microcephaly
▪ Sacral agenesis and/ or caudal regression
syndrome
Gastrointestinal ▪ Atresias
▪ Small left colon syndrome
▪ Hirschsprung disease
Urinary tract ▪ Urinary tract abnormalities
Hematologic ▪ Hyperviscosity or polycythaemia
Metabolic ▪ Hypoglycaemia
▪ Hypocalcemia
▪ Hypomagnesemia
▪ Hyperbilirubinemia
Respiratory ▪ Respiratory Distress Syndrome (RDS)
Source: PediatricEducation.org
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● Refer to paediatric team at birth.
● At birth, assess for congenital anomalies, birth injuries and
respiratory distress.
● Initiate early feeding and monitor for hypoglycaemia and observe
vital signs (Refer Chapter 12 - Management of Neonatal
Hypoglycaemia).
14.2 INFANT OF MOTHER WITH THALASSAEMIA

● If both parents are thalassaemia carriers, to refer to Paediatric
team postnatally for further management and follow-up plans
● If only one parent is thalassaemia carrier, for Paediatric clinic
review at 6-12 months of age.
14.3 INFANT OF MOTHER WITH AUTOIMMUNE DISEASE (eg: SLE)

● To refer to paediatric team at birth.
● Infants of mother with autoimmune disease, especially if mother
has anti-SSA/Ro or anti-SSB/La antibodies, may present with
congenital complete heart block or other conduction problem, and
neonatal lupus erythematosus.
● At birth, assess heart rate, ECG for conduction problems, and
take FBC, KIV FBP.
14.4 INFANT OF MOTHER WITH OTHER BLOOD DISORDER (eg: ITP,

THROMBOCYTOPENIA etc)
● To refer to the paediatric team at birth. Assess the baby, send
FBC and KIV FBP.
14.5 INFANT OF MOTHER WITH THYROID DISEASE

● To refer to the paediatric team at birth.
● Several conditions could arise in the newborn, depending on the
type of maternal thyroid disease: neonatal thyrotoxicosis
(tachycardia and goitre), congenital hypothyroidism, transient
neonatal hypothyroidism or hyperthyroidism.
● Trace cord TSH before discharge and repeat T4TSH after 72
hours of life, and Day 10-14 of life if needed.
● Refer to Paediatric Protocols for Malaysian Hospitals 4th Edition
(2019) for further information and the references as below.
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14.6 INFANT OF MOTHER WITH SYPHILIS
● Take baby’s blood for VDRL or RPR at birth.
● Assess for clinical features of congenital syphilis at birth: non-
immune hydrops, IUGR, jaundice, hepatosplenomegaly, rhinitis,
skin rash, pseudoparalysis of extremity.
● Management of the baby will depend on the mother’s VDRL or
RPR status (to be labelled as having recent infection, it must be
reactive), timing of maternal treatment and stage of maternal
infection, and the clinical condition of the baby.
● Refer to Paediatric Protocols for Malaysian Hospitals 4th edition
(2019) for further information.
14.7 INFANT OF MOTHER WITH HIV

● To refer to the paediatric team before birth, to assess the
mother’s condition and to arrange for the antiretroviral (ARV)
prophylaxis and care of the newborn.
● After assessing at birth for other evidence of congenital infections
and symptoms of drug withdrawal (if maternal history suggestive),
babies must receive ARV prophylaxis as soon as possible after
birth, and also to undergo blood tests and further counselling on
feeding and follow-up.
● Standard precautions must be observed in the care of the baby.
● All routine vaccinations can be given according to schedule.
● Several interventions have proven effective in reducing vertical
transmission: a) total substitution of breastfeeding with infant
formula, b) elective caesarean section, c) ARV prophylaxis.
● To follow BFHI procedures (AFASS) if infant formula is opted for
baby.
● Refer to Paediatric Protocols for Malaysian Hospitals 4 th edition
(2019)
14.8 INFANT OF MOTHER WITH ACTIVE TUBERCULOSIS

● To refer the paediatric team at birth and to isolate and admit the
baby to special care nursery.
● Defer BCG immunisation.
● The infant should be evaluated for congenital TB. Prophylactic TB
treatment should be given to babies born to mothers with active
pulmonary TB (except those diagnosed more than two months
before delivery who have documented smear negative before
delivery) once congenital TB is ruled out.
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● BCG is only given months later once prophylaxis has been
completed and the tuberculin test is negative.
● Congenital TB is rare but should be suspected if the infant born to
a tuberculous mother fails to thrive or is symptomatic.
● Baby can receive expressed breast milk from mother even on
medication as the amount of drug ingested by the baby is
minimal.
● If the mother is already on treatment (preferably after 2 weeks)
and is non-infective, the baby can be breastfed.
● Women who are receiving isoniazid and are breastfeeding should
receive pyridoxine.
● Symptomatic mothers can hold and be with their baby with double
masks.
● To refer to CPG Management of Tuberculosis 2012 3rd edition
(Table 14.1 below) and Paediatric Protocols for Malaysian
Hospitals 4th edition for further information.
Table 14.1: Prophylaxis for infants with maternal TB
Active PTB diagnosed after

Active PTB diagnosed before delivery
delivery
< 2 months <2 months > 2 months
> 2 months before
before after after
Smear Smear
negative just positive just
- - -
before before
delivery delivery
Give prophylaxis : Isoniazid for 6 Give prophylaxis : Isoniazid for 6
No prophylaxis
months OR isoniazid for 3 months OR isoniazid + rifampicin
for infant
months followed by TST for 3 months
Reimmunised If BCG given
Defer BCG at birth, give after with BCG after at birth, no
BCG at birth
stopping isoniazid stopping need to
isoniazid immunise
Recommendations:
o BCG should not be given to babies on prophylactic tuberculosis (TB) treatment.
o Prophylactic TB treatment should be given to babies born to mothers with active
pulmonary TB except those diagnosed more than two months before delivery who
have documented smear negative before delivery.
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14.9 INFANT OF MOTHER WITH MENTAL DISORDERS
● Assess the stability of the mother’s psychiatric condition and her
social or family support. Refer to the social worker or child
protector if the welfare of the baby is of concern.
● If possible, proper rooming in with mother for a few days before
discharge.
● Another family member needs to be briefed on the condition and
management or follow-up of the newborn before discharged.
14.10 INFANT OF TEENAGE OR SINGLE MOTHER

● Assess the social or family support of the mother.
● Refer to a social worker if not done yet.
● Settle placement of baby before discharge.
● Another family member needs to be briefed on the condition and
management or follow-up of the newborn before discharged.
14.11 INFANT OF MOTHER WITH SUBSTANCE ABUSE

● To refer to Paediatric team at birth for risk of neonatal withdrawal/
abstinence syndrome
● Assess the social or family support of the mother.
● Refer to a social worker if not done yet.
● Babies may be born to opiate-dependent mothers OR mothers on
drugs associated with withdrawal symptoms (generally milder).
● Further information by Neonatal Guidelines 2017-2019, NHS:
a) Timescale of withdrawal symptoms in babies:
i. Signs of withdrawal from opiates (e.g.; heroine) can occur <

24 hours after birth
ii. Signs of withdrawal from opioids (prescribed drugs eg
methadone) can occur 3-4 days to 2 weeks after birth.
iii. Multiple drug use can delay, confuse and intensify
withdrawal signs.
b)Minor signs: tremors when disturbed, tachypnoea, pyrexia,
sweating, yawning, sneezing, nasal stuffiness, poor feeding,
regurgitation, loose stools, sleeping < 3 hrs after feed.
c) Major signs: convulsions, profuse vomiting or diarrhoea, inability to

coordinate sucking, baby inconsolable after 2 feeds
● Usual management:
o Do NOT give naloxone to babies
o Care of baby as any other baby
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o Assess for signs of withdrawal (e.g. with Modified
Finnegan Neonatal Abstinence Score), other risk of infection,
child protection issues, social history etc.
o Babies with signs of withdrawal will need close observation
and may need treatment e.g. morphine/ phenobarbital (mother
on other drugs as well)/ chlorpromazine (mother on
benzodiazepines) etc.
14.12 INFANT OF MOTHER WITH GROUP B STREPTOCOCCAL (GBS)

INFECTION OR RISK OF GBS ASCENDING INFECTION

● GBS systemic infection in the newborn carries high mortality.
Early onset GBS (EOGBS) infection is defined as isolation of
GBS from blood, cerebrospinal fluid (CSF), or another normally
sterile site from birth through 6 days of age. EOGBS infections
are acquired vertically through exposure to GBS from the
maternal gastro-intestinal and genito-urinary tract.
● The use of intravenous intrapartum antibiotic prophylaxis to
prevent early-onset GBS disease in infants has been proven
through clinical trials and well-designed observational studies.
● Late-onset infections occur in infants aged > 1 week, with most
infections evident during the first 3 months of life (Prevention of
Perinatal Group B Streptococcal Disease Revised Guidelines
from CDC, 2010)
● Infected infants become symptomatic shortly after birth, majority
by 12 to 24 hours of age. Signs and symptoms of neonatal
infection can be non-specific and include: temperature instability,
lethargy, irritability, poor peripheral perfusion, mottling, pallor,
jaundice, sclerema, tachypnoea, respiratory distress,apnoea,
tachycardia, hypotension, hypoglycaemia, hyperglycaemia,
metabolic acidosis
● Refer section 5.7.6 for indication for intrapartum antibiotic
prophylaxis (IAP) and its regimen
● Neonatal management of baby with risk of GBS infection:
i. If baby is unwell at birth, shows any signs of sepsis or
maternal chorioamnionitis, for septic workup (FBC and blood
culture. CXR and LP if necessary) and start IV antibiotics (IV
C-Penicillin and Gentamicin) immediately. This will fall under
Paediatric care.
ii. If baby is born term and stable without maternal
chorioamnionitis (regardless of whether had completed at
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least 2 doses of antibiotics) to observe for 24-48 hours and to
give warning signs especially on sepsis before discharge.
Baby could be monitored either in SCN or postnatal ward with
paediatric review and blood tests or empirical antibiotics may
be needed.
iii. If baby is born preterm (<37 weeks), to refer to the paediatric
team, may need full septic workup and IV antibiotics.
14.13 INFANT OF MOTHER WITH RECENT VARICELLA ZOSTER INFECTION

● Infants born to mothers who develop varicella zoster infection
between 7 days before delivery or 7 days after delivery should
receive prophylaxis.
● Infants in this group need to be referred to the paediatric team
immediately to receive Varicella Zoster immunoglobulin (VZIG) as
soon as possible, after delivery or within 96 hours of initial
exposure. Attenuation of disease might still be achieved with
administration of VZIG up to 10 days after exposure.
● This is because infants who develop varicella within this time
frame have mortality as high as 20% as they have not acquired
maternal protecting antibodies.
● For infants born to mothers who develop varicella between 5 days
before and 2 days post-delivery, add IV acyclovir 15 mg/kg/dose
over 1 hour every 8hrly (total 45 mg/kg/day) for 5 days.
● On sending home, warn parents to look out for new vesicles or
babies being unwell, for 28 days after exposure. If so, parents to
bring the infant to the nearest hospital as soon as possible (62%
of healthy such neonates given VZIG after birth)
● If vesicles develop, give Acyclovir 15 mg/kg/dose over 1 hour
every 8hrly (total 30-45 mg /kg/day) for 7-10 days.
● Women with varicella at time of delivery should be isolated from
their newborns, breastfeeding is contraindicated. The newborn
baby can receive expressed breast milk in the meantime and
breastfeeding commences when all the mother’s lesions have
crusted.
● Neonates with varicella lesions should be isolated from other
infants but not from their mothers.
● Refer to Paediatric Protocols for Malaysian Hospitals 4 th edition
(2019) for further information.
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14.14 INFANT OF FAMILY HISTORY OF NEONATAL DEATH
To refer to the paediatric team at birth for further assessment, especially if
there is a history of inborn error of metabolism, primary immunodeficiencies
disorders or other serious hereditary disease.
Reference:
1. Paediatric Protocol for Malaysian Hospitals 4th edition (2019)

2. Neonatal Guidelines 2017-2019, by the Bedside Clinical Guidelines Partnership,
Staffordshire, Shropshire and Black Country Neonatal Operational Delivery
Network and Southern West Midlands Neonatal Operational Delivery Network,
NHS.
3. Health Technology Assessment, Childhood Immunization 2001
4. Centers for Disease Control and Prevention (CDC): Prevention of Hepatitis B
infection 2018
5. Prevention of Perinatal Group B Streptococcal Disease. Revised Guidelines from
CDC, 2010
6. Malaysian CPG on Management of Tuberculosis 3rd Edition, 2012
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SECTION C: PERINATAL NUTRITION
CARE
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TABLE OF CONTENTS
PAGE
SECTION C: PERINATAL NUTRITION CARE

CHAPTER 15 :Perinatal Nutrition Care 419
15.1 Introduction to Perinatal Nutrition Care (PNC)
15.2 Promoting Healthy Eating for Pregnancy
15.3 Managing Gestational Weight Gain
15.4 Nutrition Care for Specific Conditions in Pregnancy
15.5 Breastfeeding
Appendices 451-456
Appendix 15-1 Carta alir Pemantauan Berat Badan Wanita Hamil
semasa Pemeriksaan Antenatal Pertama
Appendix 15-2 Carta alir Pemantauan Berat Badan Wanita Hamil
semsa Pemeriksaan Antenatal Ulangan
Appendix 15-3 Pemantauan Peningkatan Berat Badan Ibu Antenatal
Appendix 15-4 Panduan Pemakanan bagi Ibu Hamil yang Mengalami
Anemia kekurangan zat besi (Iron deficiency anaemia)
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CHAPTER 15
PERINATAL NUTRITION CARE
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CHAPTER 15: PERINATAL NUTRITION CARE
15.1 INTRODUCTION TO PERINATAL NUTRITION CARE (PNC)
The Perinatal Nutrition Care (PNC) section outlines nutrition advice as a

guide for health professionals to educate mothers starting from pre
pregnancy up to postpartum period. Management of PNC are accustomed
towards a holistic approach in which nutrition advice for mothers should
consist of comprehensive information to support optimal nutrient intake
according to mother health conditions.
These include basic advice on pre pregnancy nutrition as it is vital to have

an optimal nutrition status before getting pregnant as it will give impact to
the health of the mother and feotus in various stages of pregnancy. Any
women with chronic diseases must have an optimal control of the diseases
and in optimal nutritional status to undergo pregnancy. It must be a well-
planned pregnancy. This may require a referral to a dietitian for medical
nutrition therapy (MNT) intervention for optimal nutritional status and
disease control.
To undergo pregnancy, any woman with chronic conditions must have

excellent disease control and an optimal nutritional status. It has to be a
meticulously planned pregnancy. For optimal nutritional status and illness
control, a referral to a dietitian for medical nutrition treatment (MNT)
intervention is necessary. A dietitian will need to perform a detailed nutrition
assessment including past and current medical history; social history;
anthropometric measurement; biochemical and clinical evaluation; dietary
intake in order to prescribe proper MNT. It will be dealt with on a one-to-one
basis.
Dietetic referral may be necessary at any stages of perinatal care for any
chronic or acute disease in order to achieve or maintain optimal nutrition
and health.
Pregnant women have an increased nutrient requirement throughout the

pregnancy to achieve optimal maternal and foetal health. There is an
increased need for energy, protein and micronutrients such as iron, iodine,
folate, and vitamins such as A and C intake. The increased nutrient intake
extends to the postpartum mothers.
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PNC also includes the management of Gestational Weight Gain (GWG)
which uses the pre pregnancy BMI categories to determine the GWG range
according to the Institute of Medicine, IOM 2009 guidelines. Certain
pregnancy conditions such as anaemia, diabetes and hypertension that
need specific nutrient recommendation have been added in this topic.
Special consideration must be made for women with chronic or acute

illness, any kind of malnutrition (excess or deficient macro or
micronutrients), any electrolyte imbalance, adolescent pregnancy should be
given special attention because they are at risk for poor maternal and foetal
outcomes.
Existing Ministry of Health document e.g. Recommended Nutrition Intake

(2017), Dietary Guidelines for Pregnant and Lactating Mothers (2019), CPG
On Management of Diabetes in Pregnancy, Medical Nutrition Therapy
Guideline for Type 2 Diabetes Mellitus 2005, Medical Nutrition Therapy
Guideline for Type 2 Diabetes Mellitus Second Edition and other related
international guidelines and policy on nutrition such as WHO Nutritional
Anaemias; Tools For Effective Prevention And Control, Guidelines on
Weight Gain And Pregnancy, Institute of Medicine (IOM) 2009 and WHO
Recommendations on Antenatal Care for a Positive Pregnancy Experience
2016 are used as references.
15.2 PROMOTING HEALTHY EATING FOR PREGNANCY
This section outlines the key aspect of maternal nutrition for all women. All
women deserve to be healthy throughout their lifetime. Menstruation,
childbirth, entering menopause and aging pose challenges to women’s
nutrition and health.
Therefore, women need to be encouraged to prepare themselves first

specifically in the nutrition aspect and to have an optimum health status
before pregnancy. It is important for women to enter pregnancy with healthy
body weight (normal BMI range) and in good nutritional status.
15.2.1 The importance of pre pregnancy nutrition
Women who are well-nourished and healthy will have a higher chance of
having healthier offspring. Therefore, nutrition information should be
disseminated to women in reproductive age between 15-49 years old on
various platforms long before pregnancy takes place. Pre pregnancy
nutrition care should take into consideration their health condition,
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socioeconomic status, lifestyle habits, history of previous pregnancy, and
other history that might affect their pregnancy.
Table 15.1: Improving maternal nutrition with special nutrition care focus on three
critical stages of pregnancy
SUPPORTIVE ENVIRONMENTAL PRECONCEPTION PREGNANCY POSTPARTUM
CONDITIONS
▪ Appropriate provision of ▪ Dietary advise ▪ Dietary advise ▪ Dietary advise
healthcare services for ▪ Physical activity advise ▪ Physical activity advise ▪ Physical activity advise
optimum nutrition for ▪ Weight optimisation ▪ Assessment of ▪ Weight optimisation
maternal and infant health for women with a BMI micronutrient status for women with a BMI
▪ Appropriate education of ≤18.5 or ≥25.0 ▪ Appropriate GWG ≤18.5 or ≥25.0
health professionals on diet- ▪ Assessment of ▪ Appropriate education ▪ Support for exclusive
related issues micronutrient status of future parents breastfeeding for the
▪ Specific guidance on clinical (antenatal classes) first 6 months
care pathways to manage and ▪ Assessment of
prevent underweight, micronutrient status
overweight and obesity
▪ Incorporating of e-health with
shared access among the
different groups of health
care professionals
Source: WHO Good Maternal Nutrition, The Best Start In Life, 2016
Women need to start eating healthy and balanced meals as soon as they
plan to conceive or get married. Poor eating patterns and low intake of
protein, vegetables, fruit, legumes and milk or milk products could increase
the risk of having micronutrient deficiencies that might result in poor
pregnancy conditions and outcomes. Women should be advised on healthy
eating in pre pregnancy stage with other healthy lifestyle advice as below:
●
Know your health status once planning to get pregnant or married.
●
Aim to have a normal BMI before getting pregnant.
●
Start eating a balanced diet consists of a variety of food using
Malaysian Healthy Plate Concept #sukusukuseparuh for every meal.
●
Limit intake of high-sugar food, high-fat food, processed food, and
sugary drinks and beverages.
●
Limit intake of caffeinated drinks such as tea, coffee, carbonated
drinks, and cocoa drinks.
●
Start taking a folic acid pill three months before getting pregnant.
●
Take the initiative to check your haemoglobin status (Hb) and consult
a doctor if Hb level is below 12g/dL.
●
Incorporate a healthy lifestyle including staying active, stopping
smoking, and managing your stress.
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15.2.2 Nutritional requirements during pregnancy
The ability of pregnant women to provide nutrients and oxygen for her baby
is a critical factor for foetal health and its survival. Failure in supplying
adequate amounts of nutrients to meet foetal demand can lead to foetal
malnutrition. The feotus responds and adapts to undernutrition but by doing
so it permanently alters the structure and function of the body. Maternal
overnutrition also has long-lasting and detrimental effects on the health of
the offspring. There is growing evidence that maternal nutrition can induce
epigenetic modifications of the foetal genome (Martin-Gronert & Ozanne
2006).
Therefore, it is important to ensure pregnant women get all the nutrient

requirements through everyday meals. Recommendations for healthy eating
during pregnancy are based on the Dietary Guidelines for Pregnant and
Lactating Mothers (2021), Malaysia Dietary Guidelines (2020) and
Recommended Nutrition Intake (2017).
a. Pregnancy requirement on selected nutrients:
Below is the requirement of each selected nutrients:
Table 15.2: Pregnancy requirements on selected nutrients
NUTRIENTS REQUIREMENT
Total Energy Intake ● Meet energy requirement range for women from
1 (TEI) 1600kcal/day for sedentary lifestyle women or can up to
1800kcal/day for moderate-active women.
● Obtain additional energy requirement during pregnancy:
o First trimester: +80kcal/ day
o Second trimester: +280kcal/ day
o Third trimester: +470kcal/ day
2 Macronutrients: ● Recommended additional protein intake:
Protein o First trimester: +0.5g/day
o Second trimester: + 8g/day
o Third trimester: + 25 g/day
● Eat more protein from animal source such as fish,
poultry, egg and meat.
● Include legumes in daily meals or snacking.
3 Macronutrients: ● Eat 25-30% of total energy intake (TEI) based on dietary
fat during pregnancy.
Fat
● Eat according to fat distribution:
o Saturated fatty acids : < 10% TEI
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o Monosaturated fatty acids : 12% to 15% TEI
o n-6 polyunsaturated fatty acids: 5% to 7% TEI
o n-3 polyunsaturated fatty acids: 0.3% to 1.2% TEI
4 Macronutrients: ● Eat 50-65% of total energy intake (TEI) based on
Carbohydrate carbohydrate source during pregnancy
● Limit sugars intake to <10% from TEI (equal to 10
teaspoon based on 2,000 kcal)
● Eat 20-30g dietary fibre per day
● Choose food low Glycemic Index (GI)
5 Micronutrient: ● Diets alone could not provide enough iron as iron
requirement increased tremendously in pregnancy for the
Iron
formation of red blood cells.
● Take daily oral iron supplementation with 30mg to 60mg
of elemental iron to prevent maternal anaemia.
● Eat a variety of protein from animal sources that are
rich in heme-iron to support optimum iron needs by
the body (refer Nutritional Anaemia Section for more
info).
6 Micronutrient: ● Folic acid requirements for pregnancy are 600 µg/day.
● WHO suggested daily oral supplement of 400µg (0.4mg)
Folate
folic acid for at least four weeks before, and 12 weeks
after conception to reduce the risk of NTDs.
● Pregnant women who have high risk of NTDs are
recommended to take a 5000 µg (5 mg) folic acid
supplement for the same period of time.
● Precautions should be taken when giving high doses of
folic acid supplementation for healthy women as general
as there were growing evidences on excessive intake of
folic acid supplement during pregnancy and the effects
on offspring's NTDs, allergy/respiratory problems, cancer
and behaviour problems.Eat variety of food sources that
are rich in folate such as legumes, green leafy
vegetables and fortified food product daily.
7 Micronutrient: ● Iodine is an essential trace element required for the
synthesis of the thyroid hormones. Iodine requirement
Iodine
during pregnancy is increased to provide the needs of
the foetus and to compensate for the increased loss of
iodine in the urine.
● Increasing iodine intake up to 200µg/ day during
pregnancy reduces risk of pregnancy loss, infant
mortality, and irreversible cognitive impairment in
children.
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● Eat variety of food source that rich in iodine such as
seaweeds, seafood, seawater fish, egg, milk, milk
products and food enriched with iodine such as cereal
and iodized salt
● Store iodised salt in air tight containers and avoid
exposure to moisture, heat and sunlight.
● Put a small amount of iodised salt at the end of cooking
or after extinguishing the fire and cover the food to avoid
iodine from evaporating.
● Iodized salt needs to be used sparingly (less than 1
teaspoon flat /day).Increased intake of salt could lead to
other health problems.
8 Micronutrient: ● Women who chronically consume low amounts of
calcium (<500 mg/day) may be at risk for increased bone
Calcium
turnover during pregnancy. If a diet does not provide
enough calcium, then the body steals it from the bones.
Dietary calcium intake has a negative correlation with
bone resorption markers. High calcium intake is
associated with improved calcium balance, perhaps
providing a protective effect against bone loss during
pregnancy.
● The requirement for calcium is 1000mg/day for pregnant
and breastfeeding women aged 20 years and above.
Note:
This is only a selection of nutrients that has been highlighted for
pregnant women. For further readings on other nutrients that are equally
important, such as Vitamin C, Vitamin B1, B2, B6, B12, Vitamin A and
etc, do check Recommended Nutrient Intakes for Malaysia (2017) to get
more info.
b. How to achieve a sufficient nutrient intakes in pregnancy

● Eat moderate, variety and balanced meals everyday.
● Include all five (5) food groups in meals and use Malaysian
Food Pyramid as a guide on serving size which are:
o Group 1: Vegetables
o Group 2: Fruits
o Group 3: Cereal
o Group 4 : Fish, poultry, egg, meat and legume
o Group 5: Milk and milk product
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● Use Healthy Malaysia Plate Concept #sukusukuseparuh as a
guide to plan each meal for a day (Breakfast, Lunch & Dinner).
● Add nutrient-dense food as a snacking in between meals such
as baked bean, sandwiches, chicken salad etc.
● Take 2 servings of milk or milk products such as yoghurt,
cheese and other food high in calcium (green vegetables,
cereal, sardines, anchovies, beans and beans products
including yellow dhal, tofu, tempe and soybean milk every day.
● Limit intake of sugar, salt and fat
● Limit intake of high-sugar foods and beverages.
● Limit caffeinated drinks such as tea, coffee or cocoa.
● It is best not to drink alcohol during pregnancy.
● Use healthier cooking methods such as steaming, roasting,
grilling, boiling, and braising to reduce the fat intake.
● Use iodised salt less than 5g (1 teaspoon flat) per day.
● Limit intake of food high in salt such as sauces and processed
food.
● Drink plenty water (6 to 8 glasses daily)
c. Consume clean and safe foods and beverages

● Choose and purchase fresh foods
● Prepare foods using clean appliances
● Cook foods with the right temperature
● Store foods using appropriate, clean and safe containers to
ensure food safety
● Ensure pregnant women and lactating women are safe from
environmental pollution such as lead, mercury and cadmium
● Select restaurants/ out-of-home premises with a clean
environment within and outside the premise, those with clean
food handlers, as well as with sufficient facilities such as sinks
and toilets
d. WHO recommendation on micronutrient supplement for

pregnancy
These recommendations are applied to pregnant women and adolescent

girls within the context of routine ANC.
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Table 15.3 : WHO recommendations on micronutrient supplement for pregnancy
A. Nutritional Interventions
Type of
Recommendation
Recommendation
A.1.1: Counselling about healthy eating and Recommended
keeping physically active during pregnancy is
recommended for pregnant women to stay
healthy and to prevent excessive weight gain
during pregnancy
A.1.2: In undernourished populations, nutrition Context-specific
education on increasing daily energy and protein recommendation
intake is recommended for pregnant women to
Dietary reduce the risk of low-birth-weight neonates.
interventions A.1.3: In undernourished populations, balanced Context-specific
energy and protein dietary supplementation is recommendation
recommended for pregnant women to reduce the
risk of stillbirths and small-for-gestational-age
neonates.
A.1.4: In undernourished populations, high- Not recommended
protein supplementation is not recommended for
pregnant women to improve maternal and
perinatal outcomes.
A.2.1: Daily oral iron and folic acid Recommended
supplementation with 30 mg to 60 mg of
elemental iron and 400 mcg (0.4 mg) of folic acid
is recommended for pregnant women to prevent
maternal anaemia, puerperal sepsis, low birth
weight, and preterm birth.
Iron and folic
acid A.2.2: Intermittent oral iron and folic acid Context-specific
supplements supplementation with 120 mg of elemental iron recommendation
and 2800 mcg (2.8 mg) of folic acid once weekly
is recommended for pregnant women to improve
maternal and neonatal outcomes if daily iron is
not acceptable due to side-effects, and in
populations with an anaemia prevalence among
pregnant women of less than 20%.
Calcium A.3: In populations with low dietary calcium Context-specific
supplements intake, daily calcium supplementation (1.5–2.0 g recommendation
oral elemental calcium) is recommended for
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A. Nutritional Interventions
Type of
Recommendation
Recommendation
pregnant women to reduce the risk of pre-
eclampsia.
Vitamin A A.4: Vitamin A supplementation is only Context-specific
supplements recommended for pregnant women in areas recommendation
where vitamin A deficiency is a severe public
health problem to prevent night blindness.
Zinc Context-specific
A.5: Zinc supplementation for pregnant women is
supplements recommendation
only recommended in the context of rigorous
research. (research)
*Multiple A.6: Antenatal multiple micronutrient Context-specific
micronutrient supplements that include iron and folic acid are recommendation –
supplements recommended in the context of rigorous research
research.
*This recommendation updates in 2020 and
supersedes the WHO recommendation found in
the WHO ANC guideline issued in 2016.
Vitamin B6 A.7: Vitamin B6 (pyridoxine) supplementation is Not recommended
(pyridoxine) not recommended for pregnant women to
supplements improve maternal and perinatal outcomes.
Vitamin E A.8: Vitamin E and C supplementation is not Not recommended
and C recommended for pregnant women to improve
supplements maternal and perinatal outcomes.
Vitamin D A.9: Oral vitamin D supplementation is not Not recommended
supplements recommended for all pregnant women to improve
maternal and perinatal outcomes.
*This recommendation updates in 2020 and
supersedes the WHO recommendation found in
the WHO ANC guideline issued in 2016.
Restricting A.10: For pregnant women with high daily Context-specific
caffeine caffeine intake (more than 300 mg per day), recommendation
intake lowering daily caffeine intake during pregnancy is
recommended to reduce the risk of pregnancy
loss and low-birth-weight neonate.
Source: WHO Recommendations on Antenatal Care for A Positive Pregnancy Experience
2016 (update 2020)
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15.2.3 Postpartum nutrition for recovery and lactation
Giving birth may affect mothers’ health in every aspect. Therefore, optimum intake of
nutrients is critical for recovery of childbirth and also as preparation for lactation. Both of
actions require a good and various balance meal to provide all the important nutrients to
the body.
Table 15.4: Nutrition requirements for postpartum recovery and lactation
1 Total Energy Intake ● Meet energy requirements range for women from 1600
kcal/day for sedentary lifestyle women or can up to 1800
kcal/day for moderate-active women.
● Obtain additional energy needs of 500 kcal/day for the
first 6 month if exclusively breastfeeding.
2 Macronutrients: ● Add 19 g/day protein during the first 6 month and lower it
Protein to 13 g/day the subsequent 6 months respectively of
breastfeeding.
● Eat more lean meat such as fish and chicken.
● Include legumes, milk and milk product ini daily meal or
snacking.
3 Macronutrients: ● Eat 25-30% of total energy intake (TEI) based on dietary
Fat fat during pregnancy.
● Eat according to fat distribution:
o Saturated fatty acids : < 10% TEI
o Monosaturated fatty acids : 12% to 15% TEI
o n-6 polyunsaturated fatty acids: 5% to 7% TEI
o n-3 polyunsaturated fatty acids: 0.3% to 1.2% TEI
4 Micronutrient: ● Iron is a critical micronutrient that needs to be restored in
Iron postpartum stages due to the blood loss and is important
for lactation.
● Iron requirement for the first 12 months of postpartum
period should follow non-pregnant women needs as
below:
o 29mg/day with bioavailability of 10%
o 20mg/day if the bioavailability is 15%
● If the mother is lactating, an additional 1.1mg iron
requirement is needed everyday (WHO/FAO, 2004).
● Eat a variety of protein food sources that are rich in iron
to support optimum iron needs by the body.
5 Micronutrient: ● Iodine requirement in postpartum is 200 mg/day and
Iodine essential for proper function of mother thyroid hormones.
● At the same time, infants depend on breast milk as the
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main source of iodine to continue the development of
their brains and nervous system.
● Therefore, it is critical to have an optimum iodine intake
for the postpartum period to support iodine demands in
breastmilk in which the iodine level respectively also
highly depends on maternal iodine storage.
● Eat a variety of food sources that are rich in iodine such
as seaweeds, seafood, seawater fish, egg, milk, milk
products and food enriched with iodine such as cereal
and iodised salt.
● Use iodised salt properly (storage and cooking) in order
to get the benefits of iodine. Iodised salt needs to be
used sparingly (less than 1 teaspoon flat /day). Increased
intake of salt could lead to other health problems.
6 Micronutrient: ● Postpartum mothers who are lactating need to ensure
Calcium adequate calcium intake for their health and also
lactation.
● Eat calcium-rich food to achieve 1000mg/ day
requirement for women aged 20 years and above.
Notes:
● To achieve optimal intake of nutrients from foods, refer to pregnancy advice on
‘How to achieve sufficient nutrient intakes in pregnancy’.
● This is only a selection of nutrients that has been highlighted for postpartum
stages. For further readings on other nutrients that are equally important, refer
Recommended Nutrient Intakes for Malaysia (2017).
● Refer to Dietary Guidelines for Pregnant and Lactating Mothers (2019) for details.
15.3 MANAGING GESTATIONAL WEIGHT GAIN
15.3.1 Maternal obesity and underweight
Women of childbearing age living in Malaysia nowadays are significantly

heavier than in the past. The National Health and Morbidity Survey (NHMS)
2019 showed that 54.7% women aged 18 and above were overweight or
obese compared to 48.9% in 2015 and 46.0% in 2006.
This is alarming because overweight and obese women are more likely to
have health issue during pregnancy and may reflect of poor pregnancy
outcome. These women will have a higher risk of premature birth,
hypertension, diabetes during pregnancy and increased risk of developing
large-for-gestational age infants.
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Underweight women remain a concern as they also have a risk of having
micronutrient deficiency for certain nutrients such as iron, folate, calcium or
iodine that can affect their health and development of feotus. They also
have higher chances to have a preterm baby in which later on have a higher
risk of malnutrition episodes if their child’s nutrient intake is not being taken
care off.
15.3.2 Excessive or inadequate gestational weight gain (eGWG/iGWG)
All women tend to have the same risk to gain weight whether excessive or
inadequate than the recommended range during pregnancy regardless of
their pre pregnancy BMI status. This GWG rate is a guide to determine the
risk for health complications among pregnant mothers.
Range of gestational weight gain varies according to pre pregnancy BMI

status. Poor gestational weight gains, whether excessive (eGWG) or
inadequate (iGWG) than the recommended range can risk the mother to
develop complications throughout the pregnancy which can affect baby’s
health.
Physiologically, women will gain weight during pregnancy to cater energy

and nutrient requirements for the development of feotus and as well for
breastfeeding preparation. Distribution of the weight consists of placenta,
feotus and amniotic fluid account for approximately 35% of the total
pregnancy weight gain. The rest comes from increment of blood and fluids,
tissues of the breast and uterus and fat stores. Throughout pregnancy,
maternal body weight is used as a general indicator of the health of the
mother and development of a healthy feotus. Weight gain in pregnancy
normally occurs in the second and third trimesters with minimal weight gain
in the first trimester.
a. Risk of excessive gestational weight gain (eGWG):
● Mother: Increase the risk of gestational diabetes, pre-
eclampsia and postpartum weight retention (PPWR) which
further increases the risk of obesity.
● Infant: Increase risks of neonatal hypoglycaemia, low birth
weight or macrosomia in which increases the risk of other
infant and birth complications.
b. Risk of inadequate gestational weight gain (iGWG):
● Mother: Less likely to initiate breastfeeding.
● Infant: Increase risk of preterm birth, low birth weight and
foetal distress.
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Therefore, women who wish to get pregnant in any stages of pregnancy
should be educated about weight management as below:
● Pre pregnancy stage:
o Try to achieve optimum weight before getting pregnant.
● During pregnancy stage:
o Monitor weight gain by using the range that is specifically
according to pre pregnancy BMI status of the mother
according to the IOM 2009 indicator.
o Women should not avoid gaining weight or try to lose
weight.
o Eat a balanced diet with nutrient-dense meals everyday.
● Postpartum stage:
o Try to reduce postpartum weight retention (PPWR) by
proper weight and diet management.
● In any stage, physical activity should be routinely done
accordingly.
15.3.3 Gestational Weight Gain Range
Malaysia is using the standard range from Weight Gain during Pregnancy
Reexamining Guidelines, Institute of Medicine (IOM), United States, 2009.
There is no data available to establish a recommended range for the local
population. These ranges vary according to the pre pregnancy BMI status
and types of pregnancy.
a. Women with Single Pregnancy
Table 15.5: Gestational Weight Gain Range for Single Pregnancy

Total Weight Mean and range of weight
Pre pregnancy BMI Total Weight
Gain in (kg) in gain in second and third
(kg/m²) Gain (kg)
first trimester trimester
Underweight
0.5kg (0.44-0.58kg) per week 12.5 – 18.0
< 18.5
Normal
0.4kg (0.35-0.50kg) per week 11.5 – 16.0
18.5 – 24.9
0.5 – 2.0 kg
Overweight
0.3kg (0.23-0.33kg) per week 7.0 – 11.5
25.0 – 29.9
Obese
0.2kg (0.17-0.27kg) per week 5.0 – 9.0
≥ 30.0
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b. Women with Twin Pregnancy
Women carrying twins or multiple feotuses have more maternal tissue and
higher foetal weight, and should therefore gain more weight. There is a little
information on weight gain for women carrying 3 or more babies. Further
assessment should be done accordingly.
Table 15.6: Gestational Weight Gain Range for Twin Pregnancy

Pre pregnancy BMI
Total Weight Gain (kg)
(kg/m²)
Underweight
< 18.5
Normal
17.0 – 25.0
18.5 – 24.9
Overweight
14.0 – 23.0
25.0 – 29.9
Obese
11.0 – 19.0
≥ 30.0
Notes:
● There is insufficient information to develop guidelines for underweight
women carrying twins (IOM, 2009).
● Refer to Weight Gain During Pregnancy Reexamining the Guidelines,
Institute of Medicine (IOM), 2009 for more information (p: 76)
15.3.4 Monitoring of Gestational Weight Gain

a. At booking visit:
● Detailed prepregnancy weight, height and BMI status.
● Weigh the mother and record it in Pregnancy Weight
Monitoring Form (KIK (a) & (b)) (Appendix 15-3)
o If pre pregnancy weight could not be obtain, use
booking BMI status (≤12 weeks) as a proxy to select
appropriate GWG range.
o If booking visit > 12 weeks, ask the mother about their
pre pregnancy BMI or weight. If mother could not recall,
the nurse should estimate their BMI category.
Estimation BMI category purpose is to monitor the rate
of weight gain throughout the pregnancy is in the
appropriate range given. TheGWG graph is not suitable
to be used.
● For maternal underweight (BMI <18.5 kg/m2) and obese (BMI
> 30.0 kg/m2) mother, further assessment should routinely be
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done on history or family background with chronic diseases,
cancer due to obesity or thyroid problem. Clinical investigation
should consist of comorbid conditions due to obesity, sleep
apnea and the risk of VTE. Investigation such as OGTT, ECG,
renal profile and others should be done if needed.
● Referred to nutritionist for nutrition management for maternal
underweight (<18.5 kg/m2) and maternal obesity ( >30.0
kg/m2) without underlying causes.
● Referred to dietitian for counselling if poor GWG is due to
gestational diabetes and any other related diseases.
b. At subsequent visits:
● Weigh the mother and record it in Pregnancy Weight
Monitoring Form (KIK (a) & (b)).
● Calculate rate of GWG per week by looking at the differences
between current weight and weight during previous visit.
● Calculate total gestational weight gain by the differences of
current weight compared to pre pregnancy weight / booking
weight (POG < 12 weeks).
● Explain to mothers about the trend of their weight gain and
monitor their weight by eating a balanced diet and keep
physically active with appropriate antenatal exercise.
● Refer or discuss with a medical officer if there is excessive
GWG (eGWG) or inadequate GWG (iGWG) for further action.
● Nutrition management of GWG should be a holistic approach
and take into account all the underlying health problems such
as GDM, PIH etc and not to be managed separately.
Therefore refer to a dietitian if mother weight gain is due to this
factor.
● Refer to nutritionist if inappropriate GWG is solely due to
anemia or dietary pattern problem. (Use Borang Rujukan
Runding Cara Pemakanan di Klinik Kesihatan Pindaan 2019).
15.3.5 Postpartum Weight Management
Usually women will gain weight during the first four days after delivery, but
by the fifth postpartum day, most will have begun to lose weight. An above-
average rate of weight loss immediately will occur among women who
experienced hypertension or preeclampsia during pregnancy—probably
because of postpartum diuresis.
Women normally lose weight through the first 4 to 6 months; however, some
women gain weight, even if they are breastfeeding. After a period of rapid
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weight loss in the first few weeks, the average rate of weight loss by
lactating women is 0.5 to 1.0 kg per month through the first sixth month.
If weight loss is an appropriate goal, the woman should be encouraged to

set a reasonable body weight goal, and she should be assisted in
developing a healthy dietary plan for achieving that goal. For overweight
breastfeeding women, the maximum suggested rate of weight loss after the
first month postpartum is about 2 kg/month.
The total energy intake by these women should not be less than 1,600
kcal/day, to allow adequate intake of protein, vitamins and minerals.
Although this level of energy intake may seem high to some women who are
familiar with reducing diets, it takes into account the energy required for
breastfeeding. Liquid diets and weight loss medications are not
recommended (Institute of Medicine US Committee on Nutritional Status
during Pregnancy and Lactation, 1992)
15.4 NUTRITION CARE FOR SPECIFIC CONDITIONS IN PREGNANCY
An existing medical condition, or one that is acquired during pregnancy, is a

risk factor generally for both mother and infant. Medical nutrition therapy
(MNT) is often required for conditions that are associated with pregnancy.
Therefore, this section will highlight several conditions during pregnancy

such as nutritional anaemia, gestational diabetes mellitus and hypertension
as a basic guide for health professionals.
Usually, collaboration within health care providers (multidiscipline) is

required, and referral to other providers needed in some instances.
Nutrition management of pregnant mothers should be a holistic approach
and take into account all the underlying health problems. Dietary
intervention should be as one comprehensive nutrition message that caters
to all related health problems with a practical diet plan to follow.
15.4.1 Nutritional anaemia

● Anaemia is a condition in which the haemoglobin (Hb) concentration
in the blood is lower than normal. WHO defines anaemia in
pregnancy as a haemoglobin concentration of less than 11 g/dL at
any stage of pregnancy. Anaemia in pregnancy has adverse impact
on both maternal and foetal outcomes such as increased risk of
maternal / prenatal, low birth weight and preterm delivery. It also
affects everyday working productivity due to reduced oxygen
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transport in the body, which then translates to conditions such as
difficulties to concentrate and fatigue.
● Anaemia develops through three main mechanism which are:
o Ineffective erythropoiesis (when the blood makes too few
red blood cells)
o Haemolysis (when red blood cells are destroyed)
o Blood loss
● Root cause of anaemia:
o Nutrient insufficient – Iron, Vitamin A, B2, B6, Folate etc.
o Diseases – Infectious or chronic disease such as HIV,
malaria, TB & parasite infection.
o Genetic haemoglobin disorders (Sickle cell disorder/
thalassemia etc).
● Iron Deficiency Anaemia
Iron deficiency anaemia is a type of anaemia in which the supply of

iron to bone marrow is inadequate and total body iron is deficient to
support optimal erythropoiesis for the development of red cell mass.
It occurs following prolonged negative iron balance and is
characterised by a small pale erythrocyte.
During pregnancy, increased maternal iron is needed to provide the
demands of the growing foetus and placenta, increased erythrocyte
mass and expanded maternal blood volume especially in the third
trimester.
Iron deficiency anemia in pregnancy can be caused by many factors
including an iron-deficient diet, gastrointestinal issues affecting
absorption, or a short interpregnancy interval. Other causes of
anaemia include parasitic diseases, micronutrient deficiencies, and
genetically inherited hemoglobinopathies.
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Figure 15.1 : Indices for Assessing Iron Status at Various Stages of Pregnancy
Source: Nutritional anaemias: tools for effective prevention and control. Geneva: World Health Organization; 2017
● Iron Availability in Food

Several dietary factors have been identified which positively or
negatively influenced the absorption of the dietary iron. The
absorption of heme iron from animal sources such as meat, chicken,
egg, fish and other seafood are very effective compared to non-heme
iron from vegetable sources such as peria, kangkung, spinach and
legum. The absorption of non-haem iron from a meal depends upon
the net effect of factors enhancing iron absorption (ascorbic acid and
organic acids; meat, chicken, fish and other seafood; fermented
vegetables, fermented soy sauces). There are several foods
containing inhibiting factors for iron absorption such as phytates and
inositol phosphates; iron-binding polyphenols; calcium; soy proteins
and vegetable proteins.
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Table 15.7: Factors influencing dietary iron absorption:
CATEGORY FACTORS
a) Amount of dietary haem iron, especially from meat.
b) Content of calcium in meals (e.g. from milk,
Haem iron absorption
cheese).
c) Food preparation (i.e. time, temperature)
Non-haem iron Amount of potentially available non-haem iron (includes

absorption adjustment for fortification iron and contamination iron)
Enhancing factors:
a) Ascorbic acid (e.g. certain fruit juices, fruits,
potatoes, and certain vegetables)
b) Meat, fish and other seafood
c) Fermented vegetables (e.g. sauerkraut), fermented
soy sauces, etc.
Inhibiting factors:
Balance between the
a) Phytate and other lower inositol phosphates (e.g.
following enhancing
and inhibiting factors: bran products, bread made from high-extraction
flour, breakfast cereals, oats, rice — especially
unpolished rice, pasta products, cocoa, nuts, soya
beans, and peas)
b) Iron-binding phenolic compounds (e.g. tea, coffee,
cocoa, certain spices, certain vegetables, and most
red wines)
c) Calcium (e.g. from milk, cheese)
d) Soya
Source: WHO/FAO (2004)
15.4.2 Diabetes in pregnancy

● The recommendations for diabetes in pregnancy are based on CPG
Management of Diabetes in Pregnancy (2017) and Medical Nutrition
Therapy Guidelines for Type 2 Diabetes Mellitus 2nd Edition (2014).
● Pregnant women with the following conditions should be referred to a
dietitian for early initiation of Medical Nutrition Therapy (MNT):
o at risk for GDM
o pre-existing diabetes
o at diagnosis of GDM
o at initiation of insulin therapy
o postpartum care
● Medical nutrition therapy (MNT) consists of a nutritional diagnosis
and therapy, which includes dietary intervention and counselling.
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● Energy prescription should be individualised based on pre pregnancy
BMI, weight gain, foetal growth pattern, physical activity, food and
blood glucose records.
o For women with normal pre pregnancy BMI, energy
prescriptions (approximately ranges from 30-35 kcal/kg
body weight depending on activity level) should be given
as per normal pregnancy based on the Recommended
Nutrient Intakes for Malaysia.
o For obese women, a 30-33% of calorie restriction of their
estimated energy needs (approximately 25 kcal/kg body
weight) can be prescribed to reduce the rate of GWG
without inducing maternal ketosis and compromising foetal
growth or birth weight. The GWG must be closely
monitored, and the additional energy needs during
pregnancy should be modified accordingly.
● Main focus of MNT in diabetes during pregnancy is on carbohydrate
(CHO)-controlled meal plan. The aim is to achieve and maintain
optimum glycaemic levels and appropriate GWG, while meeting
essential nutrients to promote positive maternal and foetal outcomes.
● A minimum of 175 g CHO daily has been recommended.
● A general recommendation of macronutrients distribution to promote
a balanced diet and influence glycemic control would be:
o Carbohydrate : 45-60% of total energy requirement
o Protein : 15-20% of total energy requirement
o Fat : 25-35% of total energy requirement
The steps and sequence of carbohydrate prescription and distribution
are shown in Figure 15.2.
● Both the amount and type of CHO influence glycaemic control. The
type of CHO is best described using the glycaemic index (GI)
concept. A low-GI diet was more effective in reducing insulin
requirement compared with high-GI diet. The components of CHO-
meal plan include the following:
o Monitoring of total CHO intake using grams, exchange list,
household or hand measures as long as it is practical for
women to comprehend and follow. An example of
carbohydrate exchanges in food as illustrated in Figure
15.3 and Figure 15.4.
o Distributing total CHO exchanges according to SMBG,
lifestyle and medications.
o Choosing the appropriate type of CHO which is lower in
GI.
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o Sucrose (e.g. sugars) intake must be counted as part of
the total CHO intake; excess sucrose intake contributes to
calories and may cause excessive GWG.
o Non-nutritive sweeteners do not impact glycaemic level.
However, it should not exceed the acceptable
recommended daily intake.
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Figure 15.2 : Carbohydrate prescription and distribution steps and sequence
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Figure 15.3: Carbohydrate exchange for cereals, cereal products and starchy vegetable
Notes: Each photo represents 1 exchange carbohydrate equivalent to 15g carbohydrate.
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Figure 15.4: Carbohydrate exchange for fruits and milk
Notes: Each photo represent 1 exchange carbohydrate equivalent to 15g carbohydrate.
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15.4.3 Hypertension in pregnancy
a. Medical Nutrition Therapy and Nutrition-related Implications:

Assessment
Nutrition assessment consist of anthropometric, biochemical, clinical

and dietary. The nutrition goals for preeclampsia are the same as
those for a typical pregnancy. There are a few additional factors to
consider, however.
● Anthropometric: Rapid weight gain (e.g., >1kg/week or

3kg/month) may suggest preeclampsia
● Individual and diagnosis-specific biochemical and clinical
evaluation.
● Dietary:
o Fibre, vitamins & minerals (vegetable and fruits)
o Calcium (dairy, non-dairy, and supplements)
o Sodium
b. Medical Nutrition Therapy and Nutrition-related Implications:

Intervention
● Maternal weight gain is one of the important indicators for

monitoring. Rapid weight gain >2kg/week may suggest / increase
risk of preeclampsia.
● In general, nutrition interventions may be able to help prevent
preeclampsia (or its progression), and the dietitian can assist in
dietary interventions through the early detection of symptoms.
Once the condition has progressed, however, medical therapies
that are beyond the scope of nutrition practice are often needed.
● Patients with hypertension are encouraged to eat more fruits,
vegetables, whole grain and low-fat dairy foods. DASH (Dietary
Approaches to Stop Hypertension) recommends eating 4 to 5
servings of fruits, 4 to 5 servings of vegetables and 1 serving of
whole grain per day.
● Fat consumption should be limited to 30–35 percent of total
energy consumption. Limit consumptions of food high in saturated
fat, cholesterol, and trans-fats. Choose healthy source of protein,
fish, poultry, and nuts.
● The sodium needed is the same as for a normal person, which is
2000 mg per day. Restriction of sodium intake is sometimes
recommended to reduce risk of preeclampsia. However, a
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Cochrane Database Syst Rev. found no evidence to support this
recommendation (Arvizu M et.al, 2020).
● Low dietary calcium may increase risk of hypertension during
pregnancy. Pregnant mothers are encouraged to take adequate
dietary calcium intake 1000-1500mg per day. Dairy products are
rich sources of protein and calcium. Choose fat-free (skim) or low
fat (1%) liquid or powdered milk, fat free or low fat yoghurt and
low fat cheese. Condensed milk, evaporated milk and non-dairy
creamer are not recommended. Alternatively, for those individuals
with lactose intolerance, calcium enriched soy milk and other
calcium rich foods such as green leafy vegetables can be taken
as an alternative.
● In populations with low dietary calcium intake, WHO recommends
daily calcium supplementation (1.5 g–2.0 g oral elemental
calcium) is recommended for pregnant women to reduce the risk
of pre-eclampsia. Calcium intakes greater than 4000 mg per day
can cause calcium toxicity.
● Supplementation with vitamins C and E has also been suggested
to reduce the risk of pre-eclampsia but a recent study showed no
benefit. Another study showed a link between a food pattern high
in fibre, potassium, magnesium, and calcium and lower rates of
preeclampsia.
15.4.4 Adolescent pregnancy
● The growing adolescent has distinct nutritional needs. While no

longer experiencing the rapid changes associated with early
childhood, adolescents undergo a period of rapid growth and
maturation as the ability to reproduce is gained. Therefore
adolescents who become pregnant need to be given extra attention
on their nutrient intake.
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Table 15.8: Nutrient requirement for adolescent pregnancy
1 Total Energy Intake ● Meet energy requirement range for sedentary to
(TEI) moderate active lifestyle adolescent:
o Age 13-15 years old: 1580 – 1810 kcal/day
o Age 16-<18 years old:1660-1890 kcal/day
● Obtain additional energy requirement during pregnancy:
o First trimester: +80kcal/ day
o Second trimester: +280kcal/ day
o Third trimester: +470kcal/ day
2 Micronutrient: Adolescents pregnant and lactating age 13 to 19 years old

Calcium have to achieve calcium requirement 1300mg/ day.
3 Micronutrient: Adolescents pregnant and lactating age 13 to 19 years old
Iodine have an increased requirement of iodine up to 200mg
everyday. This is essential for proper function of mother
thyroid hormones and at the same time, infants depend on
breast milk as the main source of iodine to continue the
development of their brains and nervous system.
a. Gestational Weight Gain for Adolescent
Monitor adolescent GWG using the same standard range from

Weight Gain during Pregnancy Reexamining Guidelines, Institute of
Medicine (IOM), United States, 2009. The Pre pregnancy BMI for
adolescents should be determined by the usage of adult BMI. This
will result in a wider range of GWG for adolescents in pregnancy to
fulfil the requirement of energy and micronutrient intake.
b. Dietary advise for pregnant adolescent
General pregnancy dietary advice applies for adolescent pregnancy

with emphasis on calcium intake. Health practitioners need to
consider the developmental characteristics of adolescents in order to
ensure the adolescent could understand nutrition education that is
being given. Things to consider is as such:
● Simple use of word / message.
● Use visual / pictographic material.
● Focus on types of food to increase the intake of certain
micronutrients.
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● Individualise messages and work within the pregnant
adolescent's current eating habits.
● Consider to include family members in the discussion
● Highlight the negative impact on certain food to the pregnancy
and foetus such as fast food, high sugar food and beverages
and low nutrient snack food.
● Focus on weight gain patterns for optimal birth outcomes.
15.5 BREASTFEEDING
15.5.1 The importance of breastfeeding

● Breastfeeding is important to children, mothers and families.
Breastfeeding protects the infant’s health. Children who are not
breastfed are more likely to be:
o Ill or to die from infection such as diarrhoea and
gastrointestinal infections, and chest infection
o Underweight and not grow well, if they live in poor
circumstances
o Overweight and to have later heart problems, if they live in rich
circumstances
● Breastfeeding is important to mother, women who do not breastfeed
are more likely:
o To develop anaemia and to retain fat deposited during
pregnancy, which may result in later obesity
o To become pregnant soon after the baby’s birth
o To develop breast cancer
o To have hip fractures in older age
● In addition:
o Breastmilk is readily available and free. It needs no
preparation or storage
o Breastfeeding is simple, with no equipment or preparation
needed
o If a baby is not breastfed, the family will need to buy
replacement milk for the baby and find time to prepare feeds
and keep feeding equipment clean
o If a baby is not breastfed, there may be loss of income through
a parent’s absence from work to care for an ill child
● Mother’s milk is all a baby needs:
o Exclusive breastfeeding is strongly recommended for the first
six months. The baby does not need water, other fluids, or
foods during this time
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o Breastfeeding continues to be important after the first 6
months even when other foods are given to the baby
o A mother’s milk is especially suited for her own baby and
changes from day to day, month to month, and feed to feed to
meet the baby’s needs. The baby learns the tastes of the
family foods through the flavours of breastmilk
o Mother’s milk is unique (special). Human milk is a living fluid
that actively protects against infection. Artificial formula
provides no protection from infections
15.5.2 Practices that can help breastfeeding to go well

● Hospital practices can help breastfeeding to go well. These practices
include to:
o Have a companion with you during labour, which can help you
to be more comfortable and in control
o Avoid labour and birth interventions such as sedating pain
relief and caesarean sections unless they are medically
necessary
o Have skin-to-skin contact immediately after birth, which keeps
the baby warm and gives an early starts to breastfeeding
o Keep the baby beside you (rooming-in or bedding-in), so that
your baby is easy to fed as well as safe
o Learn feeding signs in your baby so that feeding is baby-led
rather than to a schedule
o Feeding frequently helps to develop good milk supply
o Breastfeeding exclusively with no supplements, bottles or
artificial teats
o It is important to learn how to position and attach the baby for
feeding. The hospital staff will teach the mother how to
breastfeed. Most women can breastfeed and help is available
if needed
15.5.3 Information for HIV positive mothers on breastfeeding

● All pregnant women are offered voluntary and confidential HIV
counselling and testing. If a woman is HIV-infected there is a risk of
transmission to the baby during the pregnancy and birth, as well as
during breastfeeding. If the pregnant woman knows that she is HIV-
positive then she can make informed decisions.
● About 5-15% of babies (one in 20 to one in seven) born to women
who are HIV infected will become HIV-positive through breastfeeding.
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This means most infants born to women who are HIV-positive will be
infected through breastfeeding.
● In some settings, the risk to the child of illness and death from not
exclusively breastfeeding is higher than the risk of HIV transmission
from breastfeeding. One of the reasons that individual counselling is
so important is that it gives the mother the information they need to
make the informed choices about how to feed their babies in their
own situations.
● The majority of women are not infected with HIV. Breastfeeding is
recommended for:
o Women who do not know their status, and
o Women who are HIV-negative
Reference:
1. Implementation Guidance – Protecting, promoting and supporting Breastfeeding in

facilities providing maternity and newborn services : the revised Baby-Friendly
Hospital Initiative – UNICEF/WHO2018
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APPENDIX 15-1
Carta Alir Pemantauan Berat Badan Wanita Hamil Semasa

Pemeriksaan Antenatal Pertama
NOTA:
* Sekiranya ibu berada dalam kategori BMI kurang berat badan, penilaian perlu dibuat untuk mengenalpasti punca /
penyakit berkaitan (contoh: TB, hipertiroidism, kanser dll) dan rawatan/ intervensi berdasarkan diagnosa semasa.
*Bagi kes ibu obes, peningkatan berat badan semasa hamil secara berlebihan perlu diberi perhatian. Penilaian teliti
perlu dilakukan bagi menentukan punca penyebab/ penyakit berkaitan seperti risiko pre-eklampsia, GDM dan
makrosomia/ polyhydramnios
** Penilaian oleh MO/FMS:

1 Sejarah
- tabiat pemakanan dan aktiviti fizikal
- perihal keluarga: obesiti, DM, HPT, dislipidaemia, penyakit kardiovaskular, kanser berkaitan obesiti,
tiroid
2. Pemeriksaan klinikal
- komorbid berkaitan obesiti, sleep apnea
- penilaian risiko VTE
3. Siasatan:
- OGTT
- ECG
- Lain-lain
*** Boleh melibatkan juga penglibatan oleh Pegawai Fisioterapi dll yang bersesuaian.
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APPENDIX 15-2
Carta Alir Pemantauan Berat Badan Wanita Hamil Semasa

Pemeriksaan Antenatal Ulangan
NOTA
* Penilaian oleh MO/FMS:
1. Sejarah
- tabiat pemakanan dan aktiviti fizikal.
- perihal keluarga: obesiti, DM, HPT, dislipidaemia, penyakit kardiovaskular, kanser berkaitan
obesiti, tiroid.
2. Pemeriksaan klinikal
- komorbid berkaitan obesiti, sleep apnea.
- penilaian risiko VTE.
3. Siasatan:
- OGTT,ECG atau lain-lain ujian jika perlu ( RP, LFT, TFT, Echo, dll).
4. Sekiranya berlaku eGWG, penilaian teliti perlu dilakukan bagi menentukan punca penyebab dan risiko
penyakit berkaitan sepert:
- Risiko pre-eklampsia.
- Kemungkinan gestational diabetes.
- Makrosomia/ polyhydramnios.
5. Sekiranya ibu mengalami iGWG penilaian perlu dilakukan untuk mengenalpasti punca penyebab dan
risiko penyakit berkaitan (ie TB, hipertiroidism, kanser dll) dan rawatan/ intervensi berdasarkan
diagnosa semasa.
**
1. Boleh melibatkan Pegawai Fisioterapi sekiranya bersesuaian.
2. Ibu mengalami iGWG boleh dirujuk kepada PSP untuk didaftarkan dalam program Makanan Tambahan Susu
Tepung Penuh Krim (STPK) sekiranya memenuhi kriteria kelayakan bantuan. APPENDIX 15-3
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APPENDIX 15-3
PEMANTAUAN PENINGKATAN BERAT BADAN IBU ANTENATAL

(GESTATIONAL WEIGHT GAIN - GWG)
Tinggi : . meter
Berat ibu sebelum hamil: . kg
Nota: Jika tiada maklumat berat ibu sebelum hamil, berat ibu semasa booking POG ≤12/52 boleh digunakan.
Jika POG > 12/52, kategori BMI boleh didapati secara anggaran berdasarkan maklumat ibu.
2
Nilai BMI sebelum hamil . kg/m
Status BMI sebelum hamil : Kurang Berat Badan / Normal / Lebih Berat Badan / Obes (Bulatkan yang
berkenaan)
Jadual Berat Badan Sepanjang Kehamilan
Kadar
Tarikh Minggu Berat Peningkatan Peningkatan
Bil
Lawatan Gestasi Badan (kg) Berat Badan (kg) Berat Badan
(a) kg/minggu
(b) (c) (d) (e)
(f)
10
11
12
13
14
15
Jumlah Peningkatan Berat Badan (kg) Sepanjang Kehamilan
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APPENDIX 15-4
PANDUAN PEMAKANAN BAGI IBU HAMIL YANG MENGALAMI ANEMIA

KEKURANGAN ZAT BESI (IRON DEFICIENCY ANAEMIA-IDA)
PERTANYAAN PENERANGAN
Anemia merupakan keadaan di mana kepekatan hemoglobin (Hb) dalam

sel darah merah adalah rendah. Terdapat pelbagai faktor yang boleh
menyebabkan kepekatan Hb ini menjadi rendah iaitu:
● Kekurangan mikronutrien terutama zat besi (IDA), folat atau
vitamin B6.
● Penyakit berjangkit atau kronik seperti HIV, malaria atau
jangkitan parasit.
Apakah anemia ● Gangguan genetik hemoglobin seperti talasemia atau sickle
dan bagaimana cell disorder.
ia boleh terjadi?
Anemia Kekurangan Zat Besi (IDA) berlaku akibat bekalan zat besi
yang kurang dalam tubuh badan untuk membentuk hemoglobin dalam sel
darah merah secukupnya. Anemia akan dikesan melalui paras
hemoglobin (Hb) dalam darah yang kurang daripada 11 gm% semasa
hamil. Pemeriksaan profil darah selanjutnya perlu dijalankan bagi
mengesahkan anemia yang berlaku berpunca daripada kekurangan zat
besi.
Sebelum hamil:
● Mudah penat, tidak bersemangat, cepat mengantuk, kurang
tumpuan dan fokus, dan mudah tercungap (breathless).
● Risiko untuk mendapat anemia semasa hamil lebih tinggi dan
boleh menjejaskan kesihatan bayi yang akan dikandung kelak.
Semasa hamil:
● Meningkatkan risiko kesihatan kepada ibu dan bayi yang
dikandung seperti kelahiran pra-matang dan bayi lahir kurang
Apakah kesan
berat.
anemia?
● Meningkatkan risiko kepada kematian ibu anak akibat pelbagai
komplikasi.
Semasa berpantang dan menyusu:

● Menyebabkan ibu menjadi terlalu penat, lemah, hilang fokus dan
tidak bertenaga untuk menguruskan diri dan anak.
● Ibu lebih cenderung mengalami tekanan perasaan.
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Untuk meningkatkan paras Hb dan seterusnya mengatasi masalah

IDA ini, ibu hamil boleh meningkatkan pengambilan zat besi melalui:
1. Pengambilan makanan kaya dengan sumber zat besi.
Bagaimana
2. Pengambilan pil zat besi dan vitamin C.
untuk
mencegah dan
merawat?
*Di Klinik Kesihatan, sekiranya kaedah di atas tidak dapat membantu
meningkatkan paras Hb ibu, pegawai perubatan mungkin akan
menyarankan rawatan lain contohnya seperti parenteral (IV/IM).
1. Tingkatkan kekerapan pengambilan makanan kaya zat besi

seperti:
Zat besi heme dari sumber haiwan seperti: Kerang, ikan bilis, hati ayam/
lembu, ayam, daging, telur, ikan seperti cencaru, kembung, tenggiri,
tongkol.
Zat besi non-heme dari sumber tumbuhan seperti: kacang kuda, kacang
hijau, pucuk maman, peria, pegaga gajah, ulam raja, bayam, kangkung,
pucuk paku, taugeh kasar, celery dan lain-lain
2. Tingkatkan kekerapan pengambilan makanan mengandungi

Apakah jenis Vitamin C untuk bantu tingkatkan penyerapan zat besi seperti:
makanan yang Buah - Jambu, limau, betik, limau kasturi, mangga, nanas, cempedak dan
perlu ibu ambil lain-lain buah-buahan. Sayur – Bunga kobis, brokoli, tomato, bayam dan
untuk bantu lain-lain sayuran hijau.
atasi masalah
ini?
3. Elakkan pengambilan makanan dan minuman yang tinggi
kandungan kafein dan tanin untuk mengelakkan gangguan
penyerapan zat besi kesan interaksi antara makanan/suplemen zat
besi seperti berikut: Kopi, teh, koko, wain merah.
4. Jarakkan pengambilan makanan dan minuman di bawah dengan

pengambilan pil atau makanan kaya zat besi bagi mengelakkan
gangguan penyerapan zat besi:
Susu, soya, keju, atau lain-lain produk makanan tinggi kalsium.
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1. Suplemen yang biasanya dibekalkan oleh Klinik Kesihatan kepada

semua ibu hamil anemia bagi membantu mengatasi masalah anemia zat
besi merangkumi empat jenis pil iaitu:
● Zat besi (ferrous fumarate), asid folik, Vitamin C, dan Vitamin B
Kompleks.
2. Makan pil zat besi sejam sebelum makan atau dua jam selepas makan
bagi penyerapan zat besi yang optima. Dapatkan nasihat lebih lanjut
Bagaimana cara daripada anggota kesihatan sekiranya mempunyai alahan atau masalah
pengambilan pil
dalam pengambilan pil zat besi.
zat besi?
3. Makan pil /supplemen tersebut bersama air kosong atau bersama jus
buah yang mengandungi Vit C membantu penyerapan zart besi.
4. Sekiranya pihak klinik kesihatan membekalkan suplemen zat besi

seperti Iberet, Zincofer, Obimin atau lain-lain, sila rujuk kepada arahan di
risalah produk atau dapatkan nasihat farmasi bagi pengambilan yang
betul.
Sumber:
1. WHO Nutritional anaemias: tools for effective prevention and control, 2016
2. Garis Panduan Pengurusan Pemakanan Ibu Hamil Anemia, 2006.
3. Buku Rekod Kesihatan Ibu Hamil, KKM (2019)
4. NCCFN (National Coordinating Committee on Food and Nutrition) (2017).
Recommended Nutrient Intakes for Malaysia. A Report of the Technical Working
Group on Nutritional Guidelines. Ministry of Health Malaysia, Putrajaya, Malaysia.
Released June 2022

456
Reference:
1. NCCFN (National Coordinating Committee on Food and Nutrition) (2017).

Recommended Nutrient Intakes for Malaysia. A Report of the Technical Working
Group on Nutritional Guidelines. Ministry of Health Malaysia, Putrajaya, Malaysia.
2. World Health Organization (WHO) (2016). WHO recommendations on Antenatal care
for a positive pregnancy experience. Geneva: World Health Organisation.
3. Martin-Gronert MS, Ozanne SE. Maternal nutrition during pregnancy and health of the
offspring. Biochem Soc Trans. 2006 Nov;34(Pt 5):779-82. doi: 10.1042/BST0340779.
PMID: 17052196.
4. Carla Silva, Elisa Keating, Elisabete Pinto. The impact of folic acid supplementation on
gestational and long term health: Critical temporal windows, benefits and risks,Porto
Biomedical Journal,Volume 2, Issue 6,2017.
5. A Nutrient in Pregnancy, Ashok Kumar, Simar Kaur, J Obstet Gynaecol India. 2017
Oct; 67(5): 313–318. Published online 2017 May 22. doi: 10.1007/s13224-017-1007-2
6. Institute of Medicine (US) Committee on Nutritional Status during Pregnancy and
Lactation. Nutrition Services in Perinatal Care: Second Edition. Washington (DC):
National Academies Press (US); 1992. 2, Nutritional Concerns of Women in the
Preconceptional, Prenatal, and Postpartum Periods.
7. Panduan Pemantauan Peningkatan Berat Badan Wanita Hamil Di Klinik Kesihatan
(GWG) Bahagian Pemakanan, KKM (2020)
8. World Health Organization (WHO) (2016). WHO recommendations on Antenatal care
for a positive pregnancy experience. Geneva: World Health Organisation.
9. World Health Organization (WHO) (2016). Good Maternal Nutrition: The Best Start in
Life. Denmark: World Health Organization.
10. Montgomery KS. Improving nutrition in pregnant adolescents: recommendations for
clinical practitioners. J Perinat Educ. 2003 Spring;12(2):22-30. doi:
10.1624/105812403X106801. PMID: 17273337; PMCID: PMC1595150.
11. Implementation Guidance – Protecting, promoting and supporting Breastfeeding in
facilities providing maternity and newborn services : the revised BABY-FRIENDLY
HOSPITAL INITIATIVE – UNICEF/WHO2018
12. Malaysian CPG on Management of Diabetes in Pregnancy (2017)
13. Medical Nutrition Therapy Guidelines for Type 2 Diabetes Mellitus 2 nd Edition (2014),
Malaysian Dietitian Association.
14. Arvizu M, Bjerregaard AA, Madsen MTB, et al. Sodium Intake during Pregnancy, but
Not Other Diet Recommendations Aimed at Preventing Cardiovascular Disease, Is
Positively Related to Risk of Hypertensive Disorders of Pregnancy [published
correction appears in J Nutr. 2020 Apr 1;150(4):970]. J Nutr. 2020;150(1):159-166.
doi:10.1093/jn/nxz197
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___________________

PERINATAL CARE MANUAL

MINISTRY OF HEALTH MALAYSIA

Released June 2022

Division of Family Health Development

Released June 2022

Dr. Faridah binti Abu Bakar

Released June 2022

(In Alphabetical Order)

Pn. Aleijjah bt. Ali Dr. Bong Yee Khiun

Released June 2022

Released June 2022

Dr. Norasiah bt. Hashim Dr. Radziah bt. Mohamad

Pn. Norasimah bt. Kassim Dr. Rafidah bt. Md Noor

Released June 2022

Released June 2022

Dr. Sharmini Diana Parampalan Dr. Tan Chew Khang

Dr. Zaharita bt. Bujang Dr. Suzaini bt Mat Daud

Dr. Majdah bt. Mohamed Dr. Tuty Aridzan Irdawati bt.

Released June 2022

NO. CONTENT PAGE

2 Members of Working Groups 6

4 Abbreviations & Acronyms 12

5 How to Use This Manual 16

7 SECTION A: MATERNAL CARE

CHAPTER 1 : Processes and Procedures of Pre pregnancy Care 27

CHAPTER 2 : Processes and Procedures of Antenatal Care 75

CHAPTER 3 : Processes and Procedures of Intrapartum Care 107

CHAPTER 4 : Processes and Procedures of Postnatal Care 139

CHAPTER 5 : Medical Complications in Pregnancy 159

CHAPTER 6 : Antenatal Complications 225

CHAPTER 7 : Intrapartum Complications 245

CHAPTER 8 : Postnatal Complications 261

CHAPTER 9 : Obstetric Emergencies 279

8 SECTION B: NEONATAL CARE

CHAPTER 10 : Overview of Newborn Care 315

CHAPTER 11 : Resuscitation and Stabilisation 337

CHAPTER 12 : Early Newborn Care 357

CHAPTER 13 : Breastfeeding and Weight Monitoring 395

CHAPTER 14 : Specific Perinatal Conditions Related To Maternal 407

9 SECTION C: PERINATAL NUTRITION CARE

CHAPTER 15 : Perinatal Nutrition Care 419

Released June 2022

ABC Alternative Birthing Centre CHF Congestive Heart Failure

ACE-I Angiotensin-converting enzyme inhibitor CKD Chronic Kidney Disease

ACR Albumin-to-Creatinine Ratio CNS Central Nervous System

ADHD Attention Deficit Hyperactivity Disorder CO Carbon Monoxide

AED Anti-Epileptic Drugs CPD Cephalopelvic Disproportion

AFI Amniotic Fluid Index CPG Clinical Practice Guidelines

AIDS Acquired Immunodeficiency Syndrome CTG Cardiotocography

AMO Assistant Medical Officer CTPA Computed Tomography Pulmonary

APH Antepartum Haemorrhage CVS Cerebrovascular Diseases

APS Antiphospholipid Syndrome CVT Cerebral Venous Thrombosis

ARB Angiotensin Receptor Blocker CXR Chest X-ray

ART Antiretroviral Therapy DBP Diastolic Blood Pressure

ATD Anti-Thyroid Drugs DCDA Dichorionic Diamniotic

ATT Anti Tetanus Toxoid DIVC Disseminated Intravascular

BD Bis in die (Latin) - Twice Daily DOT Directly Observed Treatment

BMI Body Mass Index DVT Deep Vein Thrombosis