SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Reproductive Morbidity and Maternal Mortality

Maternal deaths and reproductive illness are largely preventable. This guide covers definitions and burden, causes and prevention, reproductive morbidity, near misses, health-system delays and programmes, and death review, using the MOTHER approach.

🎯 AT A GLANCE — REPRODUCTIVE MORBIDITY AND MATERNAL MORTALITY

Maternal death is the tip of the iceberg: for each woman who dies, many more survive severe illness, injury, or lasting disability (reproductive morbidity)

About 260,000 women died worldwide in 2023 (maternal mortality ratio 197 per 100,000 live births), about 40% lower than in 2000; around 87% of these deaths were in sub-Saharan Africa and southern Asia (World Health Organization, WHO)

India's ratio was 88 per 100,000 live births in 2021–23 (Sample Registration System, SRS) — far below 1998 (398) but still above the Sustainable Development Goal target of under 70 by 2030

Most deaths are preventable: severe bleeding, hypertensive disorders, infection, obstructed labour, and unsafe abortion respond to well-known, low-cost care delivered on time

Reviewing every death and near miss turns tragedy into local action — the core of Maternal Death Surveillance and Response (MDSR)

Every maternal death has a cause and a delay behind it — find both, fix the system, and do not blame the individual

🚨 DANGER SIGNS — REFER IMMEDIATELY

Vaginal bleeding in pregnancy, heavy bleeding after delivery, or a bleeding woman who is pale, faint, or drowsy

Severe headache, blurred vision, upper abdominal pain, convulsions, or blood pressure 160/110 mmHg or more

Fever, foul-smelling discharge, or severe lower abdominal pain after delivery, miscarriage, or abortion

Difficulty breathing, chest pain, calf swelling, or severe anaemia (haemoglobin below 7 g/dL)

Labour over 12 hours, absent fetal movements, or leaking fluid before labour

🗺️ THE PATHWAY AT A GLANCE

1 · PreventContraception, safe abortion, folic acid, anaemia correction, vaccination

2 · Detect earlyAntenatal contacts, risk screening, blood pressure, haemoglobin, danger-sign teaching

3 · PlanBirth preparedness, a delivery site matched to risk, transport, blood

4 · Deliver safelySkilled attendance, partograph, active management of the third stage, respectful care

5 · RespondEmergency obstetric care, high-dependency care, referral without delay

6 · ReviewNotify, review, act: deaths and near misses feed back into care

STEP 1 · DEFINITIONS AND BURDEN — know what is being counted

📖 KEY DEFINITIONS

Term	Meaning
Maternal death	Death of a woman while pregnant or within 42 days of the end of pregnancy, from any cause related to or made worse by the pregnancy or its management, but not from accidental or incidental causes (WHO, International Classification of Diseases)
Late maternal death	Death from direct or indirect obstetric causes more than 42 days but less than 1 year after the end of pregnancy
Pregnancy-related death	Death during pregnancy or within 42 days whatever the cause
Direct and indirect causes	Direct: obstetric complications, interventions, omissions, or incorrect treatment; indirect: pre-existing or new disease made worse by pregnancy (heart disease, anaemia, malaria, HIV, tuberculosis, hepatitis)
Maternal mortality ratio (MMR)	Maternal deaths per 100,000 live births; maternal mortality rate uses women of reproductive age as the denominator; lifetime risk combines fertility and the ratio
Severe maternal morbidity	Life-threatening complications (for example haemorrhage needing transfusion, eclampsia, sepsis, hysterectomy, ventilation) in a woman who survives
Maternal near miss	A woman who nearly died but survived a complication in pregnancy, childbirth, or within 42 days (WHO criteria: clinical signs, laboratory markers, or life-saving management)
Reproductive morbidity	Any illness or disability of the reproductive system or from reproduction, obstetric or gynaecological, physical, sexual, or mental

🌍 HOW BIG IS THE PROBLEM?

Measure	Figure
Global (2023, WHO)	About 260,000 maternal deaths; ratio 197 per 100,000 live births; about 40% decline since 2000; about 87% of deaths in sub-Saharan Africa and southern Asia; Sustainable Development Goal 3.1: under 70 by 2030
India (Sample Registration System)	88 per 100,000 live births in 2021–23 (about 22,500 deaths in a year); 398 in 1998; states differ widely — check the latest bulletin for Odisha and for your district
Leading global causes	Severe bleeding (mostly after delivery), infection (usually after delivery), hypertensive disorders (pre-eclampsia and eclampsia), delivery complications, and unsafe abortion account for about 75% of deaths; the rest are mainly indirect causes
Approximate shares (from memory)	Haemorrhage about 27%, hypertensive disorders about 14%, sepsis about 11%, abortion about 8%, embolism about 3%, indirect causes about 28% (WHO systematic analysis)
India — unsafe abortion	About 5% of maternal deaths in the Million Death Study (2007–2014); haemorrhage was the leading cause nationally
When deaths occur	Most during labour, delivery, and the first 24 hours after birth, and many in the first week — so care must not stop at delivery

STEP 2 · CAUSES AND PREVENTION — target the main killers

🩸 DIRECT CAUSES AND WHAT WORKS

Cause	Prevention and early action
Obstetric haemorrhage	Treat anaemia; oxytocin 10 IU intramuscularly after birth and active management of the third stage; tranexamic acid 1 g intravenously within 3 hours of birth for bleeding; uterine massage, balloon tamponade, compression sutures; blood and a protocol ready (see the haemorrhage sheet)
Hypertensive disorders	Check blood pressure and urine at every visit; low-dose aspirin (about 75–150 mg nightly from 12–16 weeks) for women at high risk; calcium supplement where dietary intake is low; magnesium sulfate for severe pre-eclampsia and eclampsia; treat severe hypertension quickly; deliver at the right time
Sepsis	Clean delivery and hand hygiene; antibiotics for prolonged rupture of membranes and for caesarean; recognise early (fever, tachycardia, foul discharge); sepsis bundle within the first hour
Obstructed labour and ruptured uterus	Plot the partograph; act at the alert and action lines; refer early; caesarean in a facility with a trained team
Unsafe abortion	Contraception, comprehensive abortion care within the law, and post-abortion care; treat incomplete abortion and septic abortion urgently
Embolism	Prevent venous thrombosis (mobilise, assess risk, give prophylaxis); consider amniotic fluid embolism in sudden collapse
Anaesthesia and surgical complications	Skilled anaesthesia, airway equipment, safe surgical checklist, postoperative monitoring

🫀 INDIRECT CAUSES AND UNDERLYING FACTORS

Factor	What to do
Anaemia	Screen early and repeat; iron and folic acid (India: 100 mg elemental iron and 500 µg folic acid daily for at least 180 days from the second trimester; WHO: 30–60 mg iron and 400 µg folic acid daily); treat severe anaemia in a facility
Heart disease	Pre-pregnancy counselling; shared antenatal and delivery planning; deliver in a centre with a cardiology team
Infections	Malaria, HIV, tuberculosis, hepatitis E, influenza, and COVID-19: screening, vaccination, treatment, and prevention (see the infection sheets)
Mental health	Screen for depression and anxiety in pregnancy and after birth; suicide is a leading cause of late maternal death in many countries
Social determinants	Adolescent pregnancy, poverty, low education, distance, domestic violence, and discrimination — address them with community and family support
Family planning	Birth spacing of at least 2 years and access to contraception reduce risk and unsafe abortion

STEP 3 · REPRODUCTIVE MORBIDITY — the burden beyond death

🩺 TYPES OF REPRODUCTIVE MORBIDITY

Group	Examples
Obstetric	Anaemia, severe maternal morbidity, hypertensive disease, postpartum haemorrhage, puerperal sepsis, perineal tears, obstetric fistula (an estimated 50,000 to 100,000 new cases each year worldwide), third- and fourth-degree tears, incontinence
Gynaecological	Genital prolapse, menstrual disorders, chronic pelvic pain, fibroids, endometriosis, cervical and breast cancer, and infertility
Infections	Reproductive tract and sexually transmitted infections, pelvic inflammatory disease, HIV, hepatitis B — with long-term effects such as infertility and ectopic pregnancy
Abortion and contraception-related	Unintended pregnancy, unsafe abortion complications, contraceptive failure or side effects
Sexual and mental health	Postpartum depression and anxiety, post-traumatic stress after traumatic birth, sexual dysfunction, fear of childbirth
Violence	Intimate-partner violence, sexual violence, and harmful practices cause injury, miscarriage, and chronic illness

Reproductive morbidity is often silent and unreported: ask about incontinence, pain, discharge, mood, and violence at antenatal, postnatal, and gynaecology visits — screen and treat, not just record

🔎 SEVERE MORBIDITY AND NEAR MISS

Topic	Details
WHO near-miss criteria (examples)	Clinical: shock, cardiac arrest, convulsions, loss of consciousness, severe respiratory distress, cyanosis, jaundice with pre-eclampsia, stroke; laboratory: severe acidosis, hypoxaemia, acute renal failure markers, severe thrombocytopenia; management: hysterectomy, transfusion of 5 or more units, intubation and ventilation over 60 minutes, dialysis, cardiopulmonary resuscitation, vasoactive drugs
Why review near misses?	They are far commoner than deaths, the woman can tell her story, and they reveal the same system weaknesses
Useful indicators	Maternal near-miss ratio (near misses per 1,000 live births); mortality index = maternal deaths ÷ (deaths + near misses), showing the quality of care
Scale	For every maternal death, many women suffer severe morbidity or lasting disability (WHO estimates about 20 to 30, in some settings more)

STEP 4 · THE HEALTH SYSTEM — delays, emergency care and programmes

⏱️ THE THREE DELAYS AND SYSTEM RESPONSES

Delay	Causes and remedies
Delay 1 — in deciding to seek care	Not recognising danger signs, family decision-makers, cost fears, distrust → community education, birth preparedness, danger-sign teaching, empowerment of the woman
Delay 2 — in reaching a facility	Distance, roads, no transport, no money → ambulance (108 or 102), community transport funds, birth waiting homes, early referral
Delay 3 — in receiving adequate care	No staff, drugs, blood, or theatre; poor skills; delay in decision; disrespect → trained teams, emergency obstetric care, blood storage, drill and protocols, stabilise and refer
Emergency obstetric care	Basic: parenteral antibiotics, uterotonics, anticonvulsants, manual removal of placenta, removal of retained products, assisted vaginal birth, newborn resuscitation; comprehensive: these plus caesarean section and blood transfusion
Respectful maternity care	No abuse, privacy, consent, birth companion, and clear communication — women avoid facilities that disrespect them

🇮🇳 INDIAN PROGRAMMES (FROM MEMORY)

Programme	Purpose
Janani Suraksha Yojana and Janani Shishu Suraksha Karyakram	Promote institutional delivery; free delivery, drugs, diagnostics, diet, blood, and transport for mothers and sick newborns
Pradhan Mantri Surakshit Matritva Abhiyan	Free, assured antenatal check by a specialist on the 9th of every month; identifies and follows up high-risk pregnancies
LaQshya	Quality improvement in labour rooms and maternity operation theatres (reduce haemorrhage, hypertension, sepsis, and avoid unnecessary caesareans)
Surakshit Matritva Aashwasan (SUMAN)	Zero denial of assured, respectful, free care to every woman and newborn
Maternal Death Surveillance and Response (2017)	Notify every maternal death, review at facility and community level, act on findings
Obstetric high-dependency and intensive care units	Dedicated critical care for the sickest women (see the Obstetric ICU sheet)
Anaemia Mukt Bharat	Prevent and treat anaemia with iron and folic acid, deworming, testing, and diet

STEP 5 · REVIEW AND AUDIT — learn from every death

📑 MATERNAL DEATH SURVEILLANCE AND RESPONSE

Step	What happens
1 · Identify and notify	Every maternal death is reported within 24 hours to the district health authority (timelines from memory)
2 · Review at the facility	Facility-based maternal death review: case summary, timeline, root causes, by the treating team and a facilitator
3 · Community review	Verbal autopsy and a home visit to learn about delays and social factors
4 · District and State review	The committee classifies the cause, finds avoidable factors, and assigns actions with owners and dates
5 · Act and follow up	Training, protocols, drugs and blood supply, transport, referral systems; check that actions were completed
Classification (WHO ICD-MM)	Abortive outcome; hypertensive disorders; obstetric haemorrhage; pregnancy-related infection; other obstetric complications; complications of management; non-obstetric complications; unknown; coincidental

Reviews are confidential and blame-free: the aim is to find what in the system failed, not who to punish — staff must feel safe to tell the truth

🛠️ HOW TO RUN A GOOD REVIEW

Use a timeline: arrival, assessment, decisions, treatments, and escalation — with exact times

Ask 'why' repeatedly until you reach a root cause (no blood in the unit, no senior called, no protocol)

Judge avoidability across patient, community, provider, and system factors

Write actions that are specific, owned, dated, and measurable; feed back to the whole team and the community

Review near misses and good outcomes too — learn what went right

⚠️ COMMON PITFALLS

Late recognition and late escalation: a worsening woman is not called to a senior in time

Referral without stabilisation (no magnesium sulfate, no oxytocin, no IV access, no escort, no call ahead)

Blood or drugs not available, or anaemia left untreated before delivery

Under-reporting and misclassification of deaths (particularly after abortion and at home)

Blaming individuals instead of fixing systems

Ignoring the postpartum period — including mental health and family planning

Memory Aid

MOTHER

Six actions to save mothers and prevent morbidity.

M

Measure and review — notify every death, review every near miss, act on findings

O

Obstetric emergencies — treat bleeding, high blood pressure, and sepsis fast

T

Timely referral and transport — beat the three delays; stabilise before moving

H

Health before pregnancy — contraception, anaemia, vaccines, safe abortion access

E

Educate and screen — danger signs, risk assessment, birth preparedness

R

Respectful, skilled care — at birth and in the first week after

Remember: prevent, detect early, respond fast, and learn from every death.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. The global figures (about 260,000 deaths, ratio 197, about 40% decline, about 87% in sub-Saharan Africa and southern Asia, and the Sustainable Development Goal target) were read from the World Health Organization fact sheet on maternal mortality (2023 estimates). India's 88 per 100,000 (2021–23) and 398 (1998) come from a secondary summary of the Sample Registration System; the unsafe-abortion share is from the Million Death Study as summarised there; check the latest Registrar General bulletin for state figures. No Government of India document was read directly: the Indian programmes, Maternal Death Surveillance and Response steps and timelines, the cause-wise percentages, near-miss criteria, supplement doses, and clinical details are from memory. Figures and guidance change, so confirm with current sources; thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and involve a senior obstetrician in any high-risk case.

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Biomedical Waste Management

Safe disposal of biomedical waste protects patients, staff, waste handlers, and the environment. This guide covers the Indian rules, the colour code, obstetric and gynaecological waste, safe handling, needle-stick response, and records, using the SORTING approach.

🎯 AT A GLANCE — BIOMEDICAL WASTE MANAGEMENT

Biomedical waste is any waste produced in diagnosing, treating, or immunising humans or animals, or in related research; in India the Bio-Medical Waste Management Rules, 2016 (Ministry of Environment, Forest and Climate Change, notified 28 March 2016, amended since) govern it

The rules apply to everyone who generates, collects, stores, transports, treats, or disposes of it — including vaccination, blood donation, and surgical camps, not only hospitals

Most health-care waste is harmless (about 85% is general waste), but about 15% is infectious, toxic, or otherwise hazardous (World Health Organization) — mixing it all turns everything into expensive hazardous waste

Four colour-coded categories: yellow, red, white (translucent), and blue — segregate at the point of generation

Untreated waste must not be stored beyond 48 hours; staff must be trained and immunised; bar-coded bags go to an authorised common treatment facility; records are kept for 5 years

Segregation at the bedside is the whole system — if the wrong bin is used, no later step can fix it safely

🚨 NEVER

Recap, bend, break, or hand over a used needle — drop it straight into the white puncture-proof container

Mix sharps, plastics, glass, and soft waste or put infectious waste into the general (black) bag

Overfill a bag or container (seal at about three-quarters full) or reach into a bin or compress waste by hand

Keep untreated waste more than 48 hours, burn it in the open, or dump it in a landfill or drain

After a needle-stick or splash: do not delay — wash, report, and start post-exposure prophylaxis within hours

🗺️ THE WASTE PATHWAY AT A GLANCE

1 · SegregateAt the point of generation, into the right coloured bin

2 · CollectClosed trolleys, sealed bags, labelled, bar-coded

3 · StoreSecure, ventilated, signed store; no more than 48 hours

4 · TransportAuthorised vehicle of the common treatment facility

5 · Treat and disposeIncineration, autoclave, shredding, recycling, or approved burial

6 · Record and reportDaily register, accident report, annual report by 30 June

STEP 1 · THE RULES — what the law requires

📜 BIO-MEDICAL WASTE MANAGEMENT RULES, 2016

Topic	Details
Who is covered	Hospitals, nursing homes, clinics, laboratories, blood banks, camps, research and veterinary institutions, and anyone who handles the waste; excluded: radioactive waste, municipal solid waste, lead-acid batteries, e-waste, and hazardous microorganisms (other rules apply)
The occupier (hospital head or owner)	Responsible for all duties: segregate, store, hand over to the common facility, train staff, immunise staff, and keep records
Authorisation	From the State Pollution Control Board (in Odisha, the Odisha State Pollution Control Board); one-time for non-bedded facilities; for bedded facilities, validity is linked to the consent order
Common treatment facility	No on-site treatment if a common bio-medical waste treatment facility exists within 75 km; the operator collects waste on time, treats it, reports accidents, and helps with training
Storage limit	No untreated waste kept beyond 48 hours; if unavoidable, inform the Pollution Control Board with reasons
Pre-treatment of laboratory waste	Disinfect or sterilise laboratory and microbiological waste on site, by WHO or National AIDS Control Organisation methods, before it leaves the premises
Bar code	Bags and containers sent out carry bar codes; common facilities track vehicles with GPS
Plastics	Chlorinated plastic bags, gloves, and blood bags are phased out (they release dioxins and furans when burned); the 2018 amendment adjusted the deadlines
Annual report	Occupier to the prescribed authority by 30 June each year; the authority to the Central Pollution Control Board by 31 July; published on websites
Records and accidents	Keep records of generation, storage, transport, treatment, and disposal for 5 years; report major accidents at once and submit a report within 24 hours
Penalties	Under the Environment (Protection) Act, 1986 (penalties and compensation have been revised, so check the current provision) (from memory)

STEP 2 · THE COLOUR CODE — four categories, four containers

🎨 SEGREGATION, CONTAINERS AND TREATMENT

Colour	What goes in	Container and treatment
🟡 Yellow	Human anatomical waste (placenta, tissues, organs, fetus); soiled waste (dressings, swabs, pads, items contaminated with blood or body fluids); expired and discarded medicines and cytotoxic drugs; chemical waste; contaminated linen and bedding; laboratory and microbiology waste, blood bags (after on-site pre-treatment)	Non-chlorinated yellow plastic bag (chemical liquids: separate collection to effluent treatment); incineration or plasma pyrolysis at the common facility; deep burial only in remote areas without a facility and with approval; expired medicines: return to the manufacturer or incinerate; soiled waste may be autoclaved and shredded where incineration is unavailable
🔴 Red	Contaminated recyclable plastics: tubing, IV sets, catheters, urine bags, suction tubing, bottles, syringes without needles, and gloves	Non-chlorinated red plastic bag or container; autoclave, microwave, or hydroclave, then shred or mutilate; sent to authorised recyclers; never landfilled or incinerated
⚪ White (translucent)	Sharps: needles, syringes with fixed needles, scalpel and surgical blades, suture needles, and any contaminated sharp metal object	Puncture-proof, leak-proof, tamper-proof container; autoclave or dry-heat sterilise, then shred, mutilate, or encapsulate; sent to authorised recyclers or foundries
🔵 Blue	Glassware: broken or discarded contaminated glass, vials, and ampoules (except those contaminated with cytotoxic drugs); metallic body implants	Cardboard box with blue marking; disinfect (wash with detergent, then sodium hypochlorite soak) or autoclave, then recycle

General (non-infectious) waste — paper, packaging, kitchen waste, and clean items — goes to the municipal stream in a separate black or other general bag; it must not enter the coloured bins (colour of general bins varies locally)

STEP 3 · OBSTETRICS AND GYNAECOLOGY — where the waste arises

🤰 WHICH BIN FOR WHICH ITEM

Item	Bin and notes
Placenta, membranes, products of conception, fetus, tissue from surgery	Yellow (human anatomical waste); do not hand them over to families (follow the facility policy and local permission if a family requests it)
Blood-soaked swabs, mops, pads, drapes, and lochia pads	Yellow (soiled waste)
Used gloves, IV sets, catheters, urine bags, suction tubing, and cord-blood or amnio sets	Red
Needles, blades, suture needles, scalpel handles with blades, and cannula stylets	White; use a needle destroyer or hub cutter where provided
Empty oxytocin, methylergometrine, and magnesium sulfate ampoules or vials; broken glass	Blue
Expired or unused drugs	Yellow (return to the manufacturer or common facility); cytotoxic drugs such as methotrexate in labelled cytotoxic yellow containers
Blood and body-fluid specimens, blood bags, and culture plates	Yellow, after on-site disinfection or sterilisation
Amniotic fluid, blood in suction bottles, and washings	Disinfect with sodium hypochlorite before drain disposal (per local sewage rules), or follow the facility's liquid waste protocol
Contaminated linen and gowns	Disinfect and launder or treat as yellow waste if heavily soiled and disposable
Mercury thermometers and blood pressure instruments	Hazardous mercury: do not use bins; use a mercury spill kit and a mercury-free alternative (from memory)
Disposable speculums, scissors, and instruments	Reusable ones: decontaminate and sterilise; disposable plastic parts: red; metal blades: white

STEP 4 · SAFE HANDLING — protect staff and patients

🧤 HANDLING, STORAGE AND TRANSPORT

Step	Details
At the bedside and in the labour room	Place the correct bins within reach, with the colour and a poster of what goes in; segregate immediately after the procedure; do not carry waste across the ward
Bags and sharps boxes	Use non-chlorinated plastic bags; fill no more than about three-quarters; seal with a tie or lock; do not re-open; close and replace sharps containers when three-quarters full; label with date, ward, and bar code
Personal protective equipment	Gloves, apron, mask, eye protection, and closed shoes for waste handlers; hand hygiene after removing gloves
Internal transport	Covered, wheeled trolleys on fixed routes and at fixed times, kept away from patients, food, and clean supplies; clean and disinfect them daily
Storage room	Within the premises, secure, ventilated, shaded, with a floor drain and a biohazard symbol; locked and accessible only to authorised staff; untreated waste out within 48 hours
Spills	Cover with absorbent material, apply disinfectant (about 1% sodium hypochlorite, 10,000 ppm, for blood), wait about 10 minutes, then clean up wearing gloves; discard the cleaning materials as yellow waste (from memory)
Training and immunisation	Train all staff and cleaners at joining and every year; immunise everyone who handles waste against hepatitis B and tetanus (rules require both)

STEP 5 · INJURY AND EXPOSURE — needle-stick and splash

🩹 FIRST RESPONSE TO A NEEDLE-STICK OR SPLASH

Step	What to do
1 · Wash at once	Skin: wash with soap and running water, do not squeeze or scrub; eyes: irrigate with water or saline; mouth: rinse with water
2 · Report and assess	Inform the infection control officer or designated doctor immediately; record the source, type of exposure, and depth; fill the accident or exposure register
3 · Test	Source patient (with consent) and the exposed worker: HIV, hepatitis B surface antigen, and hepatitis C antibody
4 · Prophylaxis	HIV post-exposure prophylaxis as early as possible (ideally within 2 hours and not later than 72 hours) for a 28-day course per the National AIDS Control Organisation protocol; hepatitis B vaccine, plus immunoglobulin if non-immune, ideally within 24 hours; tetanus booster if needed (from memory)
5 · Follow up	Repeat tests at 6 weeks, 3 months, and 6 months (per protocol); counsel; safe sex advice during follow-up; review how it happened and fix it

STEP 6 · RECORDS AND COMPLIANCE — show that it is done

🗂️ ACCOUNTABILITY

Item	Details
Daily register	Quantity of waste by colour category, handed to the common facility with date and signature; keep for 5 years
Committee and nodal officer	A bio-medical waste management committee (meets regularly) and a named officer to monitor, train, and report incidents
Annual report	By 30 June each year, covering waste handled, training, immunisation, accidents, and treatment
Accident reporting	Report major accidents immediately and submit a report within 24 hours
Audit and quality schemes	Regular audits of segregation and storage; biomedical waste is part of the national Kayakalp and quality assessment checklists (from memory)
Reduce and reuse	Buy less single-use plastic where safe, replace mercury devices, send recyclables for authorised recycling

⚠️ COMMON PITFALLS

Throwing everything into one bag or putting sharps in soft bags

Overfilled sharps containers and needles recapped or left on trays

Storage rooms that are open, dirty, or hold waste beyond 48 hours

Staff not immunised or not trained, especially cleaners and new nurses

Delayed reporting after a needle-stick

No daily register or annual report, or non-chlorinated bags not used

Giving the placenta away or putting it in the general bin

Memory Aid

SORTING

Seven habits for safe biomedical waste management.

S

Segregate at the source — right bin, right time, no mixing

O

One colour, one rule — yellow soft and anatomical, red plastics, white sharps, blue glass

R

Reduce and recycle — non-chlorinated bags, mercury-free devices, authorised recycling

T

Time limit — treated or collected within 48 hours; bar-coded bags to the common facility

I

Immunise and protect staff — hepatitis B, tetanus, gloves, and training

N

Needle-stick plan — wash, report, test, prophylaxis within hours

G

Give proof — daily register, accident report, annual report by 30 June

Remember: segregate, store safely, hand over in time, protect staff, and keep records.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. The scope, 48-hour limit, 75 km rule, authorisation, training and immunisation duties, bar code, annual report dates, 5-year records, 24-hour accident report, pre-treatment of laboratory waste, and chlorinated-plastic phase-out were read from published summaries of the Bio-Medical Waste Management Rules, 2016 (Ministry of Environment, Forest and Climate Change). The 2018 amendment text could not be opened. The container colours and treatment for each category, the obstetric bin guide, the needle-stick and spill protocols, and the penalties are from memory of Schedule I of the Rules, Central Pollution Control Board guidance, World Health Organization, and National AIDS Control Organisation advice. Rules and guidelines change, so check the current Rules, Central Pollution Control Board guidelines, and the Odisha State Pollution Control Board; thresholds, intervals and regimens vary between guidelines — follow your hospital's infection control and waste policy.

Obstetric ICU

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Obstetric ICU — Care of the Critically Ill Mother

The obstetric ICU and HDU bring skilled, early care to women with life-threatening complications. This guide follows the Government of India (MoHFW) guidelines on unit design, staffing, admission, monitoring, protocols, discharge, and referral, with organ support in pregnancy and the CRITICAL approach.

🎯 AT A GLANCE — THE OBSTETRIC ICU

An obstetric high-dependency unit (HDU) and intensive care unit (ICU) care for women with life-threatening complications of pregnancy, childbirth, or the puerperium — "when things go wrong in obstetrics, they go wrong fast"

HDU = step-up and step-down care for single-organ or no-organ support; ICU = multi-organ failure or advanced support (ventilation, inotropes, dialysis), led by an intensivist

The main reasons for admission are haemorrhage, hypertensive disorders (eclampsia, HELLP), sepsis, heart disease, respiratory failure, and acute kidney or liver failure

Pregnancy changes everything: airway, oxygenation, blood pressure targets, drug choice, and the fetus — treat the mother first, because a stable mother is the best treatment for the baby

Early transfer saves lives: do not wait for the woman to deteriorate; the right level of care, at the right time, by trained staff

🚨 MOVE FROM HDU TO ICU IF (MoHFW)

Pulmonary oedema, acute respiratory distress syndrome (ARDS), or oxygen need that rises despite treatment

Systemic inflammatory response (SIRS), septic shock, or poor cardiac output despite fluids

Disseminated intravascular coagulation (DIC) or multi-organ failure

Need for ventilation, inotropes, or dialysis, or a falling level of consciousness

🗺️ THE PATHWAY AT A GLANCE

1 · RecogniseEarly-warning score triggers; senior review without delay

2 · TriageWard, HDU, or ICU; obstetrician and intensivist decide together

3 · StabiliseAirway, oxygen, circulation, left tilt, treat the cause

4 · SupportOrgan support, fetal plan, thromboprophylaxis, nutrition

5 · MonitorHourly observations in the acute phase; protocols and records

6 · Step downDischarge criteria, follow-up, counselling, case review

STEP 1 · THE UNIT — design, staff, and equipment (MoHFW guidelines)

🏥 HDU AND ICU — SPACE, STAFF AND EQUIPMENT

Topic	Details (Ministry of Health and Family Welfare)
HDU versus ICU	HDU: between the labour ward and the ICU; single-organ or no-organ support; usually not for ventilated or multi-organ failure patients; ICU: multi-organ failure or advanced support, led by an intensivist
Number of beds	Up to 250 deliveries a month: 4 beds; 250–500: 8 beds; over 500: increase in proportion; one isolation room (about 150 sq ft) for infectious cases
Space and location	About 120–130 sq ft per HDU bed and 130–150 per ICU bed; next to the labour room and theatre, near the ICU, laboratory, radiology, and blood bank; one entry, emergency exits
Staff	Nurse-to-patient ratio 1:2 in HDU and 1:1 in ICU; HDU headed by a full-time obstetrician; 8-bed HDU: 4 nurses and 2 emergency obstetric care medical officers per shift; 4-bed ICU: 4 nurses and an intensivist; anaesthetist present 24 hours; on-call physician, paediatrician, surgeon, radiologist
Equipment	Bedside monitors (oxygen saturation, blood pressure, ECG, respiration, temperature), infusion and syringe pumps, ultrasound with colour Doppler, cardiotocography, defibrillator and crash cart, transport and non-invasive ventilators, arterial blood gas machine, blood warmer, eclampsia box, Bakri balloon, intubation equipment
Per bed	At least 2 oxygen, 1 air, and 2 suction outlets and about 10 power points; backup power, fire safety, biomedical waste management, ambulance with newborn transport support
Training	Orientation for nurses and medical officers; 3 months of ICU posting for medical officers; emergency drills every 3 months; emergency trolley checked daily; everyone trained in CPR

STEP 2 · ADMISSION AND TRIAGE — who needs which level of care

🚪 WHO SHOULD BE ADMITTED

Level	Typical conditions
HDU (MoHFW list)	Severe anaemia, haemorrhage, pre-eclampsia, eclampsia, HELLP syndrome (haemolysis, elevated liver enzymes, low platelets), sepsis, DIC, placental problems; cardiac disease, thyroid disorders, diabetic complications, dengue, malaria, asthma; surgical or trauma cases; or clinical judgement
ICU (physiological thresholds)	Very low or very high blood pressure, low Glasgow coma score, abnormal electrolytes or pH, low oxygen despite oxygen therapy, need for ventilation or inotropes, DIC, ARDS, multi-organ failure (use the national tables for exact values)
Common triggers (general)	Respiratory rate over 30 or under 10, saturation under 90% on oxygen, systolic pressure under 90, urine under 0.5 mL/kg/hour for 2 hours, lactate over 4, seizures or coma, platelets under 50,000 with bleeding
Who decides	Obstetrician with the intensivist or anaesthetist; ICU referral only after ICU admission is assured; a mother's baby moves with her if already delivered

STEP 3 · ORGAN SUPPORT IN PREGNANCY — what changes at the bedside

🫁 SUPPORT BY SYSTEM — SPECIAL POINTS IN PREGNANCY AND AFTER BIRTH

System	Advice
Airway	Difficult and failed intubation are commoner (oedema, large breasts, obesity); aspiration risk; pre-oxygenate well (desaturates quickly); senior operator, video laryngoscope, smaller tube
Breathing	Target saturation of 95% or more and PaO₂ of 70 or more; lung-protective ventilation (6 mL/kg ideal body weight); avoid high PaCO₂ (above about 45–50) because it acidifies the fetus; normal pregnant PaCO₂ is 28–32 (see the ABG sheet)
Circulation	Left lateral tilt (about 15°) if over 20 weeks; mean arterial pressure of 65 or more; noradrenaline first for septic shock; restrict fluids in pre-eclampsia (pulmonary oedema risk)
Kidney	Hourly urine output; avoid nephrotoxic drugs (NSAIDs, aminoglycosides); dialysis for refractory acidosis, hyperkalaemia, overload, or uraemia
Brain	Seizures: magnesium sulfate for eclampsia (see the neurology sheet); exclude other causes (stroke, cerebral venous thrombosis, hypoglycaemia)
Blood	Massive haemorrhage protocol, tranexamic acid 1 g, correct DIC (fibrinogen above 2 g/L, platelets above 50,000 if bleeding); Bakri balloon for atony
Infection	Cultures and broad-spectrum antibiotics within the first hour; find and remove the source (retained products, abscess, hysterectomy)
Metabolic and nutrition	Avoid hypoglycaemia; early enteral feeding; correct electrolytes; treat ketoacidosis with insulin infusion
Thromboprophylaxis	Low molecular weight heparin (weight-based) and stockings unless bleeding or very low platelets
Analgesia and sedation	Adequate pain relief; avoid over-sedation; check drug safety for breastfeeding

STEP 4 · CONDITION-SPECIFIC CARE — the commonest reasons for admission

🩺 KEY ICU ACTIONS BY CONDITION

Condition	Key actions
Severe pre-eclampsia, eclampsia, HELLP	Treat severe hypertension within 30–60 minutes (labetalol, nifedipine, hydralazine); magnesium sulfate with monitoring of reflexes, respiration, and urine; restrict fluids; deliver after stabilisation; watch for pulmonary oedema, renal failure, liver haematoma
Obstetric haemorrhage and DIC	Haemostatic resuscitation (red cells, plasma, platelets, fibrinogen), tranexamic acid, surgical control, warm the patient, correct calcium
Sepsis and septic shock	Antibiotics within an hour, fluids with caution, noradrenaline for a mean pressure under 65, source control; influenza in pregnancy: oseltamivir at once without waiting for a test
Heart disease	Peripartum cardiomyopathy and valve disease: echocardiography, diuretics, rate control, anticoagulation as indicated; avoid fluid overload
Amniotic fluid embolism	Supportive care, manage the coagulopathy, consider extracorporeal support
ARDS and pneumonia	Lung-protective ventilation, prone positioning is possible, treat the infection, extracorporeal support if refractory
Acute fatty liver and acute liver failure	Deliver, glucose monitoring, correct coagulopathy, liver unit referral (see the liver sheet)
Diabetic ketoacidosis	Insulin infusion, fluids, potassium; can occur at near-normal glucose in pregnancy (see the diabetes sheet)

STEP 5 · MONITORING, FETUS AND DISCHARGE — the whole picture

📈 MONITORING, THE FETUS AND STEP-DOWN

Topic	Details
Monitoring (MoHFW)	Temperature, blood pressure, heart rate, respiratory rate, oxygen saturation, and urine output at least hourly in the acute phase; fluid and electrolyte balance; treat the cause
The fetus	Continuous cardiotocography when viable; left lateral tilt about 15° and oxygen; corticosteroids if under 34 weeks; magnesium for neuroprotection before 32 weeks; deliver when it helps the mother (pre-eclampsia, chorioamnionitis, abruption, fatty liver) — not simply to improve a mother's lungs or heart
Protocols (MoHFW)	Written SOPs for admission and discharge, resuscitation, major haemorrhage, pre-eclampsia and eclampsia, severe blood pressure disorders, diabetic ketoacidosis, sepsis, difficult intubation, anaesthesia and analgesia, post-dural puncture headache, thromboprophylaxis
Discharge from HDU (MoHFW)	Stable circulation, no need for intensive monitoring, no continuous intravenous drugs or frequent blood tests, no active bleeding or oxygen need, walking; HDU stay is usually 24–72 hours
Records and referral (MoHFW)	History, diagnosis, tests, operative notes, summary, dated and signed entries, consent and family counselling documented; referral slip, emergency drugs, escort with infusions, monitoring, secure airway
Family and follow-up	Daily, honest communication; support for the woman's mental health (depression and post-traumatic stress are common); breastfeeding, contraception, and counselling for future pregnancy; near-miss review of every ICU admission (see the collapse sheet)

⚠️ COMMON PITFALLS

Late recognition and late transfer; treating on the ward what needs the HDU

Using non-pregnant targets (PaCO₂, blood pressure, oxygen) or forgetting left tilt

Fluid overload in pre-eclampsia, or too little fluid in haemorrhage and sepsis

Delivering a very sick mother for the baby's sake before she is stabilised

No thromboprophylaxis, no hourly chart, poor handover, or no record of consent

Forgetting the baby, the family, and the woman's mind after she leaves the unit

Memory Aid

CRITICAL

Eight rules for the critically ill mother.

C

Choose the right level — ward, HDU, or ICU; obstetrician and intensivist together

R

Recognise early — early-warning score and hourly observations

I

Intervene on the cause — bleeding, blood pressure, sepsis, heart, lungs

T

Tilt and oxygen — left lateral tilt, saturation 95% or more

I

Involve the team — obstetrician, intensivist, anaesthetist, neonatologist, nurse

C

Care for the fetus — monitor, steroids under 34 weeks, deliver when it helps her

A

Audit and record — protocols, signed notes, near-miss review

L

Look after family and follow-up — mental health, contraception, next pregnancy

Remember: recognise early, choose the right level, treat the cause, and care for the whole family.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Unit design, bed numbers, staffing, equipment, admission lists, transfer triggers, hourly monitoring, protocols, training, discharge criteria, and referral and records follow the Ministry of Health and Family Welfare (MoHFW) Guidelines for Obstetric HDU and ICU (nhm.gov.in), as summarised from the document; the exact physiological admission thresholds in its tables were not extracted. The organ-support advice, general triggers, and condition-specific actions are from memory of the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine (SMFM), and the Surviving Sepsis Campaign guidance. Check the full national guideline and local protocols before use; thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and involve a senior obstetrician in any high-risk case.

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Placenta and Fetal Nutrition

Fetal growth depends on the placenta, the mother's nutrition, and the fetus's own potential. This guide covers placental function, maternal nutrition, placental disorders, growth surveillance and Doppler, management of growth restriction and large babies, and care after birth, using the PLACENTA approach.

🎯 AT A GLANCE — PLACENTA AND FETAL NUTRITION

The placenta is the fetus's lung, gut, kidney, liver, and endocrine gland — it delivers oxygen and nutrients, removes waste, makes hormones, and filters some harmful substances

Fetal growth depends on three things: the mother's nutrition and health, placental function, and the fetus's own genetic potential

Small-for-gestational-age: estimated weight or abdominal circumference below the 10th centile; fetal growth restriction (FGR) is a small fetus that is failing to reach its potential (usually from placental insufficiency) — many small babies are healthy, and some normal-sized fetuses are restricted

Large-for-gestational-age (above the 90th centile) and macrosomia (birth weight 4000 g or more) mostly reflect maternal diabetes, obesity, and excess weight gain

Good nutrition before and during pregnancy, early detection of growth problems, and well-timed delivery reduce stillbirth, neonatal death, and lifelong disease

Check growth, not just size: serial measurements and Doppler separate constitutionally small babies from those at risk

🚨 ACT NOW IF

Reduced fetal movements — assess the same day with cardiotocography and ultrasound; never reassure by phone alone

Estimated weight or abdominal circumference below the 10th centile with abnormal umbilical artery Doppler, or absent or reversed end-diastolic flow

Fundal height lagging by 3 cm or more, oligohydramnios, or early severe pre-eclampsia with a small fetus

Third-trimester bleeding (painless: think placenta previa; with pain and a hard uterus: abruption)

Previous caesarean with an anterior low placenta — exclude placenta accreta

🗺️ THE PATHWAY AT A GLANCE

1 · Before pregnancyNutrition, folic acid, weight, diabetes and anaemia control, stop smoking

2 · First trimesterDating scan, risk assessment, aspirin if high risk

3 · Mid-pregnancyAnomaly scan, placental site, uterine artery Doppler in at-risk women

4 · Third trimesterFundal height, growth scans, fetal movements, Doppler if small

5 · DiagnoseGrowth restriction or overgrowth, find the cause

6 · Deliver and feedTimed delivery, placental examination, early feeding, glucose checks

STEP 1 · THE PLACENTA — structure, transport and hormones

🫘 HOW THE PLACENTA WORKS

Topic	Details
Development	Trophoblast invades the uterine wall and remodels the spiral arteries into wide, low-resistance vessels (complete by about 18–20 weeks); full maternal blood flow into the intervillous space from about 10–12 weeks; poor remodelling underlies pre-eclampsia and growth restriction
At term	Weight about 500 g (about one-sixth of the baby's weight), diameter 15–20 cm; cord about 50–60 cm with 2 arteries and 1 vein
Gas and water	Oxygen and carbon dioxide cross by simple diffusion; fetal haemoglobin binds oxygen more tightly than adult haemoglobin; flow depends on maternal perfusion and fetal circulation
Glucose	Crosses by facilitated diffusion (GLUT1 transporters); the main fetal fuel; fetal glucose follows maternal levels, so maternal hyperglycaemia drives fetal insulin and fat deposition
Amino acids and minerals	Active transport: fetal amino acid levels exceed maternal levels; iron, calcium, and vitamins are transferred actively; calcium transfer peaks in the third trimester
Fats	Free fatty acids and long-chain polyunsaturated fats (including DHA) cross selectively; most fetal fat is laid down in the third trimester
Antibodies	IgG crosses actively (mostly from about 28 weeks), giving passive immunity; preterm babies receive less
Hormones	Human chorionic gonadotrophin, progesterone, oestrogen, human placental lactogen (raises maternal insulin resistance so glucose reaches the fetus), placental growth hormone, corticotrophin-releasing hormone, placental growth factor
Barrier	Not complete: alcohol, nicotine, many drugs, and several infections cross (see the TORCH sheet); the placenta also inactivates some maternal cortisol

STEP 2 · FETAL NUTRITION — what the baby needs and how to supply it

🥗 MATERNAL NUTRITION IN PREGNANCY

Topic	Details
Weight gain (Institute of Medicine)	Underweight (BMI under 18.5): 12.5–18 kg; normal (18.5–24.9): 11.5–16 kg; overweight (25–29.9): 7–11.5 kg; obese (30 or more): 5–9 kg; twins: larger ranges
Energy	No extra energy in the first trimester; about 350 kcal a day more in the second and third trimesters (ICMR–NIN and Institute of Medicine figures differ slightly)
Protein	Extra protein in the second half (about 10–25 g a day more): pulses, milk, eggs, fish, and meat
Folic acid	400 µg daily before conception and in the first 12 weeks; 4–5 mg for a previous neural tube defect, epilepsy drugs, diabetes, or obesity
Iron and folic acid	WHO: 30–60 mg elemental iron daily; India: 100 mg elemental iron with 500 µg folic acid daily for at least 180 days from the second trimester; treat anaemia early
Calcium	WHO: 1.5–2 g daily in populations with low calcium intake to lower pre-eclampsia risk; India recommends about 1 g daily
Other micronutrients	Iodine (about 250 µg daily), vitamin D, vitamin B12 (vegetarians), zinc; avoid excess vitamin A
Balanced energy and protein supplements	WHO suggests them for undernourished women to reduce stillbirth and small babies; not for well-nourished women
Avoid	Alcohol, smoking and smokeless tobacco, caffeine above about 200 mg daily, unpasteurised dairy and undercooked meat or eggs (listeria, toxoplasma), high-mercury fish

The first 1,000 days (conception to age 2) shape adult health: low birth weight is linked to later diabetes, hypertension, and heart disease — nutrition and growth are long-term investments

🔗 WHAT AFFECTS FETAL GROWTH

Group	Examples
Maternal	Undernutrition, short stature, low pre-pregnancy weight, anaemia, hypertension, diabetes, renal or cardiac disease, antiphospholipid syndrome, smoking, alcohol, drug use, high altitude, young or older age
Placental and cord	Poor placentation, infarcts, abruption, placenta previa, accreta, abnormal cord insertion, single umbilical artery, twin-to-twin transfusion
Fetal	Chromosomal and genetic conditions, structural anomalies, and congenital infection (cytomegalovirus, toxoplasma, rubella, syphilis, malaria)
Large babies	Maternal diabetes, obesity, excess weight gain, previous macrosomia, post-dates, male sex, and genetic factors

STEP 3 · PLACENTAL DISORDERS — recognise and act

⚠️ PLACENTAL AND CORD PROBLEMS

Disorder	Key points and action
Placental insufficiency and growth restriction	Small fetus with abnormal Doppler, often with oligohydramnios; see Step 4
Pre-eclampsia	Shallow trophoblast invasion, raised soluble fms-like tyrosine kinase, and low placental growth factor; often with fetal growth restriction; aspirin prevention for high-risk women
Placenta previa	Placenta covering or near the internal os; painless bleeding; no vaginal examination; caesarean at 36–37 weeks if uncomplicated; a low placenta at the anomaly scan needs a repeat scan at about 32 weeks
Placenta accreta spectrum	Risk rises with previous caesareans and previa; plan delivery in a centre with blood, interventional radiology, and a surgical team
Placental abruption	Painful bleeding, tender hard uterus, fetal distress; resuscitate and deliver; watch for coagulopathy (see the haemorrhage sheet)
Vasa praevia and velamentous cord	Fetal vessels over the cervix; bleeding with membrane rupture and fetal bradycardia; elective caesarean at 34–36 weeks when diagnosed
Single umbilical artery	Look for other anomalies and monitor growth
Placental infection and infarcts	Malaria and other infections damage the placenta and cause low birth weight (see the malaria sheet)

STEP 4 · ASSESSING GROWTH — find the baby who needs help

📏 SURVEILLANCE AND DOPPLER

Tool	Details
Symphysis–fundal height	From 24 weeks, measure at each visit and plot on a growth chart; a lag of 3 cm or more, or a static or falling plot, needs a scan; fundal height alone misses many small babies
Ultrasound growth	Estimated fetal weight from head, abdomen, and femur measurements; abdominal circumference is the most sensitive; repeat no sooner than about 2 weeks; accurate dating matters
Umbilical artery Doppler	Pulsatility index above the 95th centile suggests placental resistance; absent or reversed end-diastolic flow signals severe disease
Middle cerebral artery Doppler	Low pulsatility index ('brain sparing') and a low cerebroplacental ratio indicate fetal redistribution, especially in late-onset growth restriction
Uterine artery Doppler	At 20–24 weeks, a high mean pulsatility index or notching identifies women at risk of pre-eclampsia and growth restriction
Ductus venosus	Absent or reversed a-wave is a late sign of cardiac compromise in early-onset growth restriction
Amniotic fluid	Deepest vertical pocket under 2 cm, or amniotic fluid index under 5, is oligohydramnios; often a sign of placental insufficiency
Cardiotocography and biophysical profile	Reduced variation on computerised cardiotocography, a low biophysical score, or decelerations indicate fetal compromise
Placental biomarkers	Placental growth factor and the soluble fms-like tyrosine kinase-1 to placental growth factor ratio help in suspected pre-eclampsia

STEP 5 · MANAGEMENT — fetal growth restriction and large babies

🛡️ FETAL GROWTH RESTRICTION

Topic	Details
Definition	Consensus (Delphi 2016): estimated weight or abdominal circumference below the 3rd centile, or below the 10th with abnormal Doppler or a crossing of centiles; early-onset: under 32 weeks, late-onset: 32 weeks or more
Find the cause	Detailed anomaly scan; consider invasive testing or karyotype if early-onset or with anomalies (see the prenatal diagnosis sheet); test for infection (cytomegalovirus, toxoplasma, syphilis, malaria); look for maternal hypertension, renal, or autoimmune disease
What helps	Stop smoking; treat hypertension, anaemia, and infection; improve nutrition; low-dose aspirin (75–150 mg nightly from 12–16 weeks) lowers the risk in high-risk women; bed rest, extra supplements, and sildenafil are not proven
Monitoring	Growth every 2 weeks, Doppler weekly to twice weekly if abnormal, cardiotocography as indicated; daily fetal movement awareness
Timing of delivery (varies by guideline)	Reversed end-diastolic flow: about 30–32 weeks; absent end-diastolic flow: about 34 weeks; abnormal middle cerebral or uterine Doppler with growth restriction: about 36–37 weeks; small with normal Doppler: about 37–39 weeks; earlier for fetal compromise
Before preterm birth	Antenatal corticosteroids (under 34 weeks), magnesium sulfate under 32 weeks, delivery in a unit with newborn intensive care, continuous fetal monitoring in labour and a low threshold for caesarean

📈 LARGE BABIES AND DIABETES

Topic	Details
Screening for diabetes	India (DIPSI test): 75 g oral glucose, non-fasting, with a 2-hour plasma glucose of 140 mg/dL or more diagnostic (test at the first contact and again at 24–28 weeks); WHO and other criteria are also in use
Control	Diet and activity, glucose monitoring, insulin or metformin when targets are missed (fasting about 95 mg/dL or less and 2-hour after meals about 120 mg/dL or less); tight control lowers macrosomia
Suspected macrosomia	Ultrasound weight estimates are imprecise (error up to 15–20%); discuss the risks of shoulder dystocia, birth injury, and caesarean; caesarean is considered for estimated weight of 4500 g or more in diabetes and 5000 g or more without diabetes
Timing	Induction at 38–39 weeks may be offered for diabetes with a large baby; prepare for shoulder dystocia
The baby	Check blood glucose early and feed promptly; watch for hypoglycaemia, polycythaemia, jaundice, and respiratory distress

STEP 6 · AFTER BIRTH — the placenta and the baby

🔬 EXAMINE THE PLACENTA AND FEED THE BABY

Topic	Details
Examine every placenta	Complete? (cotyledons and membranes), weight, size, shape, infarcts, clots, calcification, cord insertion, length, and 3 vessels; placental weight to birth weight is about 1 to 6 at term
Send for histopathology	Stillbirth or neonatal death, fetal growth restriction, severe pre-eclampsia, abruption, preterm birth, severe anaemia in the baby, maternal sepsis, twin discordance, and abnormal placenta or cord
Small-for-gestational-age babies	Early skin-to-skin contact and breastfeeding; keep warm; check glucose in the first hours; watch for polycythaemia; fortify feeds if very small (see the premature newborn sheet)
Catch-up growth	Support exclusive breastfeeding for 6 months; avoid forced overfeeding; monitor weight, length, and head circumference
Mother	Counsel on diet, iron, interpregnancy interval of at least 2 years, and cardiometabolic follow-up after pre-eclampsia, diabetes, or a growth-restricted birth

⚠️ COMMON PITFALLS

Relying on fundal height or palpation alone and missing growth restriction

Labelling every small baby as restricted, or reassuring a restricted baby because the weight is above the 10th centile

Reassuring about reduced movements without cardiotocography and ultrasound

Scanning too often (growth intervals under 2 weeks give unreliable results) or without accurate dating

Not looking for a cause (infection, anomaly, maternal disease) or not using aspirin in high-risk women

Overlooking diabetes and anaemia, or forgetting the newborn's glucose

Discarding the placenta without examining it

Memory Aid

PLACENTA

Eight steps for placental health and fetal nutrition.

P

Perfusion first — aspirin if high risk, treat hypertension, stop smoking

L

Look at growth — fundal height each visit; scans if at risk, 2 weeks apart

A

Assess with Doppler — umbilical, middle cerebral, uterine arteries

C

Counsel on nutrition — energy, protein, iron, folate, calcium, iodine

E

Evaluate the cause — infection, anomaly, maternal disease, diabetes

N

Notice reduced movements — assess the same day

T

Time the delivery — by Doppler, gestation, and fetal state

A

After birth — examine the placenta, feed early, check glucose

Remember: healthy placenta, well-fed mother, measured growth, timely delivery.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary drawn from memory of Royal College of Obstetricians and Gynaecologists (RCOG), American College of Obstetricians and Gynecologists (ACOG), International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), Institute of Medicine, World Health Organization (WHO), and Indian Council of Medical Research–National Institute of Nutrition (ICMR–NIN) guidance; no source was read for this sheet. No Government of India document was read: the Indian iron, folic acid, calcium, and gestational diabetes (DIPSI) recommendations are from memory, so check the Ministry of Health and Family Welfare guidelines. Centile thresholds, Doppler cut-offs, supplement doses, weight-gain ranges, and delivery timing vary between guidelines and units; thresholds, intervals and regimens vary between guidelines — follow local protocol and involve a senior obstetrician in any high-risk case.