Based on the ALSO (Advanced Life Support in Obstetrics), American Academy of Family Physicians, 4th edition (revised), 2006.

 

 

All the medical procedures and drug administration mentioned in this text should be followed only under a senior doctor’s consultancy.

Some of the above information is empirical.

 

·         Prolapsed cord: First stop ocytocin infusion. Then press the head of the baby into the uterus in order to avoid pressing the cord from the head. Don’t touch the cord because its vessels may vasoconstrict and the baby die from asphyxia. Perhaps you can cover the cord with a wet (tepid water) towel.  Maintain pressing the head of the baby into the uterus until the woman is transferred to an operating room for C section.

 

Position the woman to a knee – elbow position (kneeling on the bed, so rump to be higher than the head). Fill the bladder with water (using a Foley). Use a tocolytic drug such as terbutalin. Arrange an emergency C - section (if there is a complete cervical dilation, then you may do a vaginal delivery with forceps).

 

Polyhydramnios (increased amniotic fluid) increases the risk for prolapsed cord. Other risk factors are prematurity, fetus weight < 2.5 kg, multiple pregnancy, abnormal presentations (e.g. breech presentation),  transverse lie, and multiparity. 

 

 

·        The commoner reasons that women die during pregnancy are (on order of more to less frequent causes) psychiatric problems (including suicide and abuse), cardiac problems (exclude cardiomyopathy, prevent ischemic heart disease if obese and if hypertensive), thromboembolism, trauma/ haemorrhage, hypertensive disease/ preeclampsia and sepsis. 

 

·        Puerperium sepsis may occur without fever (!), and also the WCC may not increase (and this increase may be because of the pregnancy or puerperium). Ask if the woman had a C section and also ask for the surgery records. Make sure that the placenta was fully delivered and also that the delivered placenta, when checked,  contained all its lobes. Consider surgical complications. Check calf for tenderness. Exclude a respiratory infection (CXR chest X’ Ray).

 

Check HR, RR (respiratory rate), BP, T (temperature), SpO2 (oxygen saturation). Perform physical examination including cardiac and lung auscultation, abdominal palpation and bowel sounds.  

 

·        Sepsis examination: blood/ urine culture, culture of the wound of the C section, vaginal smears, sputum and feces culture, cervical smear.

 

Sepsis complications: thrombopenia, DIC, ARDS/ALI, ARF (acute renal failure), liver failure, multiorgan failure.

 

Sepsis and antibiotics: you may try e.g. IV clindamycin plus IV meropenem plus IV gentamycin. Also fluids and CVP measurement to control fluids.

 

 

·        Chest pain in pregnancy. You need to exclude upper respiratory infection, pneumothorax, dilated cardiomyopathy/ heart failure, MI (heart attack), aortic dissection (tearing pain, it may radiate to the back, check for hypertension & Marfan’s), aortic aneurysm rapture, and PE (pulmonary embolus). Consult early a cardiologist.

 

·        Pregnancy increases the risk for aortic dissection (especially if uncontrolled BP), aortic aneurysm rupture, other aneurysms (e.g. splenic or hypogastric artery) rupture.

 

·        Pregnancy also increases the risk for ITP (idiopathic thrombopenic porphyra) or TTP (thrombotic thrombopenic porphyra) or autoimmune haemolytic anaemia and these may cause uterine bleeding. Consult a senior haematologist.  

 

·        Pregnancy increases the risk for pyelonephritis and UTIs (urinary tract infections), however on the ultrasound a dilation of the ureters (especially the right) may be normal because of the pregnancy.

 

·        PE (pulmonary embolism): Symptoms may be respiratory distress, increased respiratory rate, tachycardia, pleuritic pain and may have hemoptysis. Massive pulmonary embolism may manifest with cardiac arrest. Consider thrombolytics or surgical embolectomy in massive PE.

 

Check D’ Dimmers, ECG (may have just tachycardia), CXR (Chest X’ Ray, changes are not specific), CBC (FBC Full Blood Count), ABGs (Arterial Blood Gases: decreased PO2, PCO2, PH, bicarbonate, also metabolic acidosis), Doppler of legs and pelvis, Spiral CT or V/Q lung scan. The gold standard test is pulmonary angiography.  

 

Normal D’ Dimmers exclude tromboembolism. Increasing D’ Dimmers is not specific (it may be ought to pregnancy!).  However, many doctors order a spiral CT or a V/Q lung scan in case the D’ Dimmers are increased. I strongly suggest this too. In case you give heparin, then don’t perform spinal epidural anaesthesia 12 hours before (12 h if you gave prophylactic dose and 24 h if you gave therapeutic dose) and 4 hours after the heparin administration (notify the anaesthetist!).

 

·        The risk for thromboembolism (TE) is big during whole pregnancy and puerperum. 75% of thromboembilisms occur before the labour, but pulmonary embolism happens more often after the delivery! Risk factors for TE are: history of TE (personal or family history), obesity (>80 kg), > 35 years old (!), after a C section, the pregnancy its self (!), hyperemesis gravitarum (prevent dehydration!), immobility, long trips (>3 hours), varicose veins, multiparus, thrombophilia (V Leiden mutation, protein C or S deficiency, lupus anticoagulant, homocysteinaemia, antithrombin III deficiency, cardiolipin antibody, G20210A mutation of the prothrombin gene and dysfibrinogenaemia).  

 

Prevention of TE is with LMWH (low molecular weight heparin) Sc, compressive stocking and hydration (especially in hyperemesis gravitarum). In case the woman has pain on the calf exclude DVT (deep vein thrombosis). The calf may be warm, with oedema, tender, red, and the patient may have increase in temperature. Perform leg & pelvis to check the iliacofemoral veins) Doppler and plythismography and check D’ Dimmers.

 

The gold standard test is venography. WBCs may be increased. Avoid Homan’s manoeuvre (passive dorsal flexion of the foot) because it may detach the clot! The left calf is affected more frequently. A deference of > 2 cm perimeter on measuring the legs with a measure tape indicates DVT.

 

The pregnant may have DVT deep vein thrombosis also on her pelvis veins, so perform a leg Doppler as well as a pelvis Doppler (to check the iliacofemoral veins) in case you suspect DVT/ TE/ PE.

 

·        Shock in pregnancy. Exclude haemorrhage, anaphylaxis (!), infection/ sepsis, MI (myocardial infarction), PE (pulmonary embolus), amniotic fluid embolism and pneumothorax.

 

 

·        Spinal epidural anaesthesia may cause dystokia (difficulty in labour) on a primiparous woman (it’s her 1^st baby) and increase the 1^st and 2^nd stage of the labour. As well as C- section, this intervention has side effects for the mother and the baby.

 

C – Section has many complications to the woman as well as to the baby in which can cause ARDS type II because of not absorbance of the alveolar fluid. Also increases the risk for allergy (the baby doesn’t pass thru the vaginal flora). Avoid C – section without a clear medical indication.

 

·        Dystokia is difficulty in labour. Normally the minimum cervical dilation on the active phase of labour is 1.2 cm/hour for a primiparous and 1.5 cm/h for a multiparous. The labour time is prolonged when the cervical dilation is slow or the baby’s descent is slow. 

 

Reasons for dystokia (delay in delivery) are UMB, Uterus (inadequate contractions), Mother (pelvis anatomy), Baby (big baby, abnormal presentation, foetal genetic abnormalities, analgesia).

 

Prolonged 2^nd stadium of the labour occurs if it lasts more than 2 hours (or more than 3 hours with regional anaesthesia) on a nulliparous, or more than 1 hour (or more than 2 hours with regional anaesthesia on a multiparous). 

 

 

 

·        Respiratory distress in pregnancy: exclude respiratory infection, PE (pulmonary embolus), sepsis, anemia, MI (heart attack), pneumothorax, anaphylaxis, asthma, cardiomyopathy/heart failure, thyreotoxicosis, amniotic fluid embolism.  

 

·        Gestation (weeks)  abdominal USS β-HCG vaginal USS

 

Less than 5 weeks normal 1800 may show

 gestational sac

5 – 6 weeks gestational sac 1800 – 3500 gest. sac plus  

 yolk sac

7 weeks foetus 5 – 10 mm >20.000 cardiac function

 

A baby is about 23 – 24 weeks if the uterine fundus is 3 – 4 fingers above the umbilicus. In case the fundus is on the umbilicus height then the baby is about 20 – 22 weeks. 

 

 

 

·        Mendelson syndrome includes cyanosis, bronchospasm, pulmonary oedema and tachycardia that develop after inhalation of gastric contents during general anaesthesia. It may be prevented by preoperative H2 antagonists, sodium citrate, gastric emptying, cricoids pressure and cuffed ET (endotracheal) tube and pre-extubation emptying of stomach.

 

It is treated with suction (tilt down the woman’s head and turn to one side), 100%O2 (oxygen), aminophyline, hydrocortisone, antibiotics (e.g. ampicillin and netilmicin), assisted ventilation and suction with a bronchoscope.

 

·        Some non obstetric/ gynaecological causes of abdominal pain in pregnancy: appendicitis, cholecystitis, rectus sheath haematoma (from coughing or spontaneous, ultrasound may be helpful), pancreatitis (rare, in 1^st trimester check urinary diastase, because amylase may be low!), pyelonephritis, aortic aneurysm rapture or splenic or hypogastric artery aneurysm rapture.  

 

·        Some obstetric/ gynaecological causes of abdominal pain in pregnancy: abruption of placenta (abdominal pain, uterine rigidity and vaginal bleeding), uterine rupture, uterine fibroids, uterine torsion (!), ovarian tumours (torsion or rupture), pre-eclampsia with liver congestion (HELLP syndrome), symphysis pubis strain and ligament stretching.  In early pregnancy exclude ectopic pregnancy and miscarriage.

 

·        Progesterone less than 5 ng/ml shows ominous prognosis. If progesterone is > 25 ng/ml you may have a live foetus or ectopic pregnancy.

 

·        On an ectopic pregnancy we may have a pseudo – gestational sac on the ultrasound that we mustn’t confuse it with a live foetus.

 

·        Premature labour. Preterm (premature) is a newborn of < 37 weeks. Ask how many weeks is the gestation, if it is the 1^st pregnancy, if there is history of premature labour. Ask also if history of UTI (urinary tract infection), trauma, abuse. Ask about the membrane’s rupture, how much was the amniotic fluid (e.g. how much liquid on the serviette), if she feels pain or a tender uterus or if the uterus is stony hard. Ask if previous ultrasounds. Check the uterus height (with a measure tape). With an ultrasound estimate the length of the cervix. Check vitals and temperature, exclude vaginal or urinary infection, ask if she has dysury. With a vaginal speculum check the posterior fornix for liquor (liquid) (ask the pregnant to cough and check for liquid leakage).

 

Do not perform a vaginal digital examination! Check if the woman has contractions, Use a nitrazine stick or the fern test to make sure that the liquid is amniotic liquor. Check also for abnormal presentation (it increases the risk for premature labour). Perform urine culture and culture of the vaginal and anal region smear.

 

If temperature is higher than 37 degrees C ( 98.6 degrees F) then give antibiotics. If the foetus is 24 – 34 weeks give steroids (to make the lungs mature). Tokolytic agents that may be considered for 2 days therapy are atociban (most used today), terbutaline and ritodrine.

 

·       On trauma give Td (tetanus immunization). Consider also Anti D immunoglobulin on a Rh negative woman after a Kleihauer test (see below).

 

·        Emergency ultrasound should be performed with initially empty bladder and next with the bladder full. Perform abdominal, transvaginal and perineal ultrasound.

 

·        Don’t forget to give anti D immunoglobulin to Rh negative mothers in hemorrhage, chorionic villus sampling, external cephalic version, antepartum hemorrhage, amniocentesis (and other uterine procedures such as fetal blood sampling), abdominal trauma, ectopic pregnancy, intrauterine death and stillbirth, spontaneous abortion followed with instrumentation, spontaneous complete abortion after 12 weeks gestation, threatened abortion after 12 weeks, threatened miscarriage before 12 weeks (if viable fetus, heavy or repeated bleeding and abdominal pain) and all surgical or medical terminations of pregnancy. In all the above cases perform a Kleihauer test on a Rh negative pregnant! In case of ABO incompatibility the Kleihauer test may be negative! 

 

·        In case of difficulty in separation of placenta you can separate the placenta manually under general anesthesia in the OR (operating room).

 

Oxytocin must be given diluted in RL (Ringers Lactated solution). Its side effects include fluid retention with hyponatraemia and uterine hypertonicity! Don’t give it with dextrose. Also, give it slowly! Contraindication: rule out multiple fetuses before the administration.

 

·        Large amounts of dextrose IV (with no saline fluids administration) may cause hyponatraemia.

 

·        Don’t use halothane in obstetric procedures because it may cause uterine muscle relaxation and increase bleeding.

 

·        AFI is amniotic fluid index on the ultrasound. Normally is 8 – 20 cm. If <5 then we have oligohydramnios. If > 20 we have polyhydramnios and increased risk for congenital abnormalities, gestational DM (diabetes mellitus) and prolapsed cord.  

 

·        Foetal cardiotocography. Normal foetal HR (heart rate) is 110 – 160 bpm. An abnormal cardiotocorgram is not an ominous outcome because its low positive prognostic value (that means that a C section performed only because of an abnormal cardiotocography may be useless).

 

NST (non stress test) is the cardiotocography (CTG) without oxytocin stimulation

 

Follow the algorithm DRC BRAVADO

 

Determine Risk (high or low risk pregnancy?)

 

Contractions. Normally we have max 5 contractions in 10 min. If more than 5 contractions exclude uterus hypertonicity and stop oxytocin administration.

 

Baseline RAte. Normally the fetus has HR (heart rate) 110 – 160 bpm. Decreased HR may indicate prolapsed cord or a > 40 weeks gestation.

Increased HR may indicate a gestation of <32 weeks, infection, maternal fever etc.

 

Variability. Normal HR variability is 10 – 15 bpm. Lower limit is 5 bpm. Variability may be low or absent on foetal distress, opioids, hypoxia, on a gestation < 28 weeks and when the baby is sleeping.

 

Accelerations. They are HR increase from the baseline equal or more than 15 bpm for equal or more than 15 sec. It shows a good embryonic condition. Differential diagnosis from ‘shoulders’ on variable decelerations.

 

Decelerations. Early decelerations are indicated by HR decreasing > than 60 bpm, from the baseline.  They show that the baby’s head is compressed and it is a good sign for the foetal condition.

 

Late deceleration show fetal hypoxia on 50 – 60%.

 

Variable decelerations are characterized by variable shape, depth and initiation.  They show compressed cord or hypoxia if they are late or if they last long. However the ‘shoulders’ are good prognostic sign. The shoulders occur at the beginning and the end of a contraction.

 

Overall assessment & Plan.

 

·        On a non reassuring NST (non stress test cardiotocography): estimate fetal PH (take blood from its head), oxygen administration (100%, high flow), turn the uterus to left  15 – 30 degrees (place a pillow below the woman’s pelvis or if on a stretcher put a wedge below it), stop all drugs (especially oxytocin).

 

Also check fetal position & presentation, exclude compression of the cord, prolapsed cord, check for contractions, stop ocytocin, reassess after 30 sec

 

·        Vaginal bleeding in 1^st trimester: the 3 main reasons are ectopic pregnancy, gestational trophoblastic disease and abortion  (miscarriage).

 

 

·        vaginal bleeding in 2^nd and 3^rd trimester: exclude uterus rapture (pain, contractions stop, ask if previous C Section, check for scar),  placenta praevia (painless hemorrhage, sentinel hemorrhage – small on 26^th – 28^th week), (placenta) vasa praevia (rare, bleeding begins with the membranes rupture), placenta abruption (pain/ uterine rigidity, clinical diagnosis, the negative ultrasound shouldn’t exclude it/ increased risk if increased aFP alpha fetoprotein during pregnancy/ may have posterior placental haematoma – Couvelaire uterus/ danger for DIC and uterus atony).

 

Other causes are rapture/haematoma of vagina, cervix, perineum, cervical ectropion, vaginal polyps, coagulation disorders (!), cervical or vaginal cancer and abuse (check previous visits to the hospital).

 

·        The 4 Ts of vaginal hemorrhage: Tone (uterus atony), Trauma (rupture or hematoma of cervix, vagina, perineum, uterus rapture after C section or previous scar of C section, and uterine inversion), Tissue (retained placenta), Thrombin (coagulation disorders). In case of uterus atony, perform uterine massage. In case the uterus is contracted, it has no atony.

 

 

·        Postpartum severe hemorrhage: we need a team of 3 doctors. Call experts to help.

 

1^st doctor: head. Airway, breathing, 100% high flow oxygen administration, supine position, time record.

 

2^nd doctor: upper extremities. Check vitals: temperature, HR (heart rate), BP, RR (respiratory rate) SpO2 (Oxygen saturation), ABGs (arterial blood gases). Establish 2 wide IVI lines (grey or orange), take blood for CBC/ FBC (complete/ full blood count), biochemistry, coagulation studies, toxicology, type & crossmatch of 4 – 6 units, fluid administration (initially 2 L crystalloids).

 

Drug administration:

1) Ergometrine 0.5 mgIV/IM.

2) Oxytocin 10 – 40 Units/hour, IV (diluted in 1 L RL Ringers – Lactated), titrated to controle uterine bleeding.

Contraindication: rule out multiple fetuses before the administration.

3) Carboprost (PGF2a, Hemabate) 0.25 mg IM, repeat every 15 minutes, max 8 doses. If you need more than 2 doses, this is an indication for emergency surgery.

4) Misoprostol 0.8 mg per rectum.

 

Before the separation of the placenta give 5 units oxytocin (diluted in RL) slowly IV, or give 10 units IM for PPH (post partum hemorrhage).

 

3^rd doctor: Uterus massage to make it contact. Bladder catheterization (Foley). Send urine for urinalysis (check glucose and protein). Bimanual compression (abdomen & vagina) if uterine’s  atony persists.

 

Consider the 4 Ts for hemorrhage: Tone (uterus atony), Trauma (rupture or hematoma of cervix, vagina, perineum, uterus rapture after C section or previous scar of C section, and uterine inversion), Tissue (retained placenta), Thrombin (coagulation disorders).

 

If the hemorrhage persists, transfer to the OR (operating room) for surgery.

 

·       On vaginal hemorrhage don’t perform digital vaginal examination.

 

·        Obstetric emergencies: check for contractions, cervical dilation (Bishop score 0 if 0 cm, 1 if 1-–2 cm and 2 if 3–4 cm, a satisfactory rate of dilation from 3 cm dilated is 1cm/hour), length of cervix (ultrasound), rapture of membranes, cardiotocography and emergency ultrasound (abdominal and transvaginal, foetal position and presentation, is the baby engaged?).

 

Check the uterus height (with a measure tape). A viable baby is >_ 23 – 24 weeks (uterine fundus 3 – 4 fingers above the umbilicus). In case the fundus is on the umbilicus height then the baby is about 20 – 22 weeks.

 

If the pregnancy is > 24 weeks, put a pillow under the pregnant’s pelvis (or if on a stretcher, put a wedge below the stretcher) in order to move the uterus to a left position on an incline of 15 – 30 degrees. This maneuver decompresses the aorta and the inferior vena cava from the uterus.

 

In case of BLS/ CPR, a EMS member may put his legs like a wedge below the pregnant’s pelvis in order to move the uterus on a left position. In case of suspected spinal trauma, don’t move the uterus left, but instead place a wedge below the stretcher. 

 

Give oxygen. Do not put the pregnant on a boom.

 

Stop all drugs (consider that oxytocin may cause uterine hypertonicity and hyponatraemia, opioids may cause decreased variability on the NST non stress test).

 

Check vitals: temperature, HR (heart rate), BP, RR (respiratory rate), temperature, SpO2 (Oxygen saturation) & ABGs (arterial blood gases).

 

In case of hemorrhage the woman can lose more than 30% of her volume until the BP falls. PaCO2 35 – 40 mmHg may indicate respiratory insufficiency! BUN (blood urea nitrogen) may be decreased because of the pregnancy, so in case BUN is on the upper normal limits, this may be ubnormal!

 

Do not hesitate to take all the necessary emergency X’ Rays!

 

Don’t forget Kleihauer test, Td (tetanus immunization) to trauma,  and to give anti D immunoglobulin on a Rh negative woman.

 

Emergency cardiotocorgaphy. Decreased variability or late decelerations or variable decelerations without shoulders. ?

 

ABCs, oxygen administration (100% high flow), time record.

 

 

Put  2 wide IVI lines (grey or orange), take blood for CBC (FBC), biochemistry, coagulation studies, toxicology, type & crossmatch of 4 – 6 units, fluid & drug administration (as indicated).

 

Call experts to help. Bladder catheterization (Foley). Sends urine for urinalysis (check glucose and protein).

 

·        Uterine inversion may cause shock that is disproportional with the bleeding. The uterus appears as a blue /gray mass outside the vagina. Therapy is with manual replacement (we put our fist in the vagina and replace the uterus) and may be helped with the administration of drugs such as magnesium sulphate, terbutaline, or nitroglycerine. The procedure, if not successful, may be done under anesthesia. After the replacement give ocytocin!

 

·        Prolonged Labor: check foetal position and presentation, estimate fetal PH (take blood from its head) if NST is not reassuring, oxygen administration (100%, high flow), turn the uterus to left 15 – 30 degrees (place a pillow below the woman’s pelvis). Exclude infection, if many hours since the membranes rapture. Consider C–section. 

 

A NST (non stress test, namely a cardiotocography without ocytocin stimulation) is not reassuring if there are variable decelerations (without shoulders), or late deceleration or loss of variability.

 

·        Eclampsia with seizures: Ask for help (senior doctor), check vitals (HR, BP, RR respiratory rate, Temperature, SpO2 oxygen saturation, ABGs arterial blood gases), administrate oxygen (100%, high flow), turn the uterus left at 15 – 30 degrees (place a pillow below the woman’s pelvis), take ABCs, place Foley. With a urine dip stick check for protein in urine!

 

Take blood for CBC/ FBC (full blood count), biochemistry, LFTs (liver function tests), urate, BUN (blood urea nitrogen), creatinine, electrolytes and coagulation studies. WCC (WBC) may increase due to the seizures. Send also blood for type & crossmatch.   Check for contractions, membrane rapture, cervical dilation, perform a NST and an USS (ultrasound). 

 

·        Preeclampsia is characterized by hypertension, proteinuria (> 1+ or > 0.3 gr/24h – on urine of 24 hours) and may include oedema. Severe preeclampsia is characterized by SBP (systolic BP) > 160, DBP (diastolic BP)> 110, increased BUN (blood urea nitrogen) & creatinine, pulmonary edema, proteinuria >_ 5 gr/24h (on 24 h urine), right hypochondrium tenderness (exclude HELLP), headache, visual defects, decreased Plts (platelets).

 

Give MgSO4 (magnesium sulphate) for seizures. Don’t give barbiturates. When you use magnesium check frequently for loss of reflexes, decreased respiratory rate, decreased urine and decreased conscious level. It can cause apnea and also may cause decreased variability on the NST. The antidote is calcium gluconate. 

 

Avoid abrupt reduction on BP. Perform C – Section as soon as the woman is stabilized. Exclude IUGR (intrauterine growth retardation) on SGA (small for gestational age) babies. If BP is high, you can decrease it with hydralazine or labetalol (it can have IUGR as side effect if used long term) or nifedipine (consult a senior doctor!), or Methylpopa in less serious cases. 

 

·        HELLP syndrome is Haemolysis, Elevated Liver enzymes, Low Platelets. Suspect it if epigastric pain or tenderness at the right hypochondrium, on the 2^nd or 3^rd trimester.

 

·        Elevated liver enzymes may also indicate fatty liver disease of pregnancy.

 

·        Transvaginal or perineal ultrasound may be useful to detect placenta praevia and premature labor.

 

 

 

APPENDIX: SIGNS OF HYPOVOLAEMIC SHOCK

Signs of hypovolaemic shock (haemorrhage - external or internal blood loss; or severe dehydration e.g. on severe diarrhea or vomiting) include: tachycardia (if not on β' blockers or pacemaker!), fast thready pulse, narrowed pulse pressure (Systolic BP - diastolic BP), weak peripheral pulses, tachypnea, decreased level of concioussness (LOC), decreased urine output (adults < 0.5 ml/kg/h, children 1ml/kg/h, infants 2 ml/kg/h), decreased capillary refill time (>2 sec), hypotension (late, with > 30% volume loss on adults and > 40% on children), cool pale skin, diaphoresis (not on dehydration); also decreased skin turgor (unreliable on the elderly) and dry mucus membranes (e.g. dry tongue) on dehydration.

NOTE

Some information in this text is empirical and its reliability can't be ascertained. It is suggested to search official medical articles, books and guidelines in order to ascertain the medical information of this text.

All the medical procedures and drug administration mentioned in this text should be done only under a senior doctor's consultancy.

 REFERENCE

 

1.      ALSO (Advanced Life Support in Obstetrics), American Academy of Family Physicians, 4th edition (revised), 2006.

 

2.      Collier J., Longmore M. , Brisden M. Oxford Handbook of Clinical Specialties, chapter (1) & (3), 7^th edition, Oxford university press, 2006. www.oup.com