Pregnancy >20 weeks + 2 BP readings 15 min apart if severe (≥160/110) or 4 h apart if mild (140-159/90-109) + evidence of end-organ damage (clinical: headache, visual changes, right upper quadrant pain, pulmonary edema; laboratory: AST/ALT≥70, LDH≥600, platelets<100,000, bilirubin≥1.2) OR proteinuria (≥300 mg/24h, protein/creatinine ratio≥0.3, albumin/creatinine ratio≥0.8, dipstick≥2+) OR angiogenic tests sFlt1/PlGF>38.

Proteinuria is NOT required for the diagnosis of severe preeclampsia.

Prevention: calcium 1-2 g/day in all pregnant patients; aspirin 150 mg/day based on risk factors (1 high-risk factor or 2 moderate-risk factors).

Code activation: SBP>160 or DBP>110 or eclamptic seizures.

Team: Coordinator, Assistant, Circulating Nurse.

Post-target monitoring: every 10 min for the 1st hour, every 15 min for the 2nd hour, every 30 min for the 3rd hour, every hour from the 4th hour for an additional 4 h.

Sustained severe-range BP for >15 min = life-threatening emergency.

SSSAO mnemonic: Support, Safety, magnesium sulfate (loading dose 4-6 g IV, maintenance 1-2 g/h until 24 h postpartum), Antihypertensives (reduce by 20-25% over 24-48 h, target 135/85 per NICE), Obstetric management (fetal maturation at 24-34 weeks, fetal well-being, delivery: non-severe PE at 37 weeks, severe PE at 34 weeks).

Stepwise hypertensive emergency algorithm: IV labetalol 20→40 mg / oral nifedipine 10→20→20 mg / IV hydralazine 10 mg, reassessing every 10-20 min.

Fluid management: no bolus, total 80 mL/h or 1 mL/kg/h, max 125 mL/h.

Eclampsia: seizure control with a 4-6 g IV MgSO4 bolus (or 2 g IV if already receiving it), maintenance 2 g/h, second 2 g IV bolus if seizures recur. Intubate if: unconscious after seizure, status epilepticus, aspiration, hypoxia. Continue MgSO4 for at least 24 h postpartum or from the last seizure.

All patients with severe PE receive MgSO4; mode of delivery is determined by obstetric factors, NOT automatic cesarean delivery.

Chronic hypertension with superimposed preeclampsia: new-onset proteinuria, or sudden loss of blood pressure control, or end-organ dysfunction after 20 weeks of gestation in a patient with hypertension predating pregnancy.

Additional severity criterion — Progressive renal insufficiency: serum creatinine >1.1 mg/dL or doubling of baseline creatinine (not previously included alongside LDH/bilirubin — added as an independent laboratory criterion).

Urine output — alternative weight-based threshold: <0.5 mL/kg/h, as an alternative to the absolute threshold of <30 mL/h already used for MgSO4 toxicity monitoring.

CaVeSal® proprietary algorithm · Based on: ACOG PB 222 (2020) · NICE NG133 · FIGO 2019 · ISSHP 2021.

CaVeSal® proprietary algorithm · Based on: FIGO 2019 · USPSTF 2021 · ACOG PB 222.

High-risk indications (warrant initiation of aspirin): history of preeclampsia, chronic hypertension, type 1 or 2 diabetes, kidney disease, SLE/APS, multiple pregnancy.

Calcium: 1.5-2.0g/day in populations with low dietary calcium intake (<800mg/day) — same FIGO caveat used in Prevention (subcard 1).

• Nifedipine in hypertensive crisis: swallow with water; DO NOT administer sublingually.
• MgSO4 antidote: Calcium gluconate 10% 1g (10mL) slow IV. Two administration-rate options: 3-5 min (MSPBS/CaVeSal regimen) or 10 min (ACOG/WHO).
• Monitoring for MgSO4 toxicity: discontinue if RR <12 breaths/min; some guidelines use <12-16 breaths/min (CaVeSal regimen) and others <12-14 breaths/min (ACOG). Patellar reflex present and urine output ≥30 mL/h in all regimens.

The Calculator uses the Pritchard/MSPBS regimen by default. The Zuspan IV regimen is the intravenous alternative and is preferred for neuroprotection; the University of Antioquia uses a larger dilution volume with the same total dose.

IM maintenance — how to administer (clarification to prevent underdosing): each dose is 5 g PER SCHEDULED DOSE (10 cc total). Option 1 (official text): 10 cc in one buttock, alternating buttocks at each scheduled dose. Option 2 (administration variant proposed by CaVeSal®): 5 cc (2.5 g) in each buttock at the same scheduled dose, repeated at the next scheduled dose (every 4 h). The frequent error is to administer a TOTAL of 5 cc per scheduled dose (2.5 g): the full dose is 10 cc (5 g).

Typical sequence of toxicity: 1st, decreased urine output (<30 mL/h, risk of accumulation); 2nd, loss of the patellar reflex; 3rd, respiratory depression (RR <12-16 breaths/min). Rescue: calcium gluconate 10%, 1 g (10 cc) slow IV over 3-5 min, in the event of respiratory depression or instability (this is not gram-for-gram neutralization). The regimen may be repeated (repeat regimen) according to clinical course.

CaVeSal® proprietary algorithm · Based on: MSPBS Paraguay, Guía de Código Rojo Materno Neonatal 2ª ed. 2022 (pág. 71) · MSPBS, Manual Nacional de Normas 2018 (neuroprotección) · Universidad de Antioquia/UNFPA.

Definition (WHO 2017): "maternal sepsis is a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, postabortion, or the postpartum period."

Suspected or confirmed infection + organ dysfunction = maternal sepsis. Sepsis-3 framework adapted to obstetrics: the focus shifts from the inflammatory response (SIRS) to organ dysfunction. WHO calls for two sets of criteria: early identification ("presumed maternal sepsis") to enable immediate action, and diagnostic confirmation for epidemiological purposes.

Prevention: handwashing, universal urine culture, clean birthing areas, sterile instruments, vector protection, disposal of contaminated materials, vaccination, education, STI screening/treatment.

Criteria for suspected sepsis (WHO GLOSS 2020; labeled "OTAS" in the reference handout, but not the OTAS triage scale): temperature>38°C or <35°C, SpO2<95%, SBP<90, HR>100, RR>25, altered mental status, uterine tenderness with suspected source.

Suspected infection + 2 of 4: temp<36 or >38°C, HR>110, RR>24, WBC>15,000 or <4,000 or 10% bands = SEPSIS → start 1-2 L crystalloids + antibiotics + monitoring.

If MAP remains <65 after a 30 mL/kg bolus = SEPTIC SHOCK.

MSPBS, Code Red Guide, 2nd ed. 2022 (p. 76): septic shock = need for vasopressors to maintain MAP ≥65 mmHg with lactate ≥2 mmol/L (18 mg/dL) despite adequate fluid resuscitation.

This set (T, HR>110, RR>24, WBC with >10% bands) is the one used in the UdeA/UNFPA workshop, adapted from the CMQCC Toolkit. It is stricter than classic SIRS (HR>90, RR>20, WBC >12,000; see subcard 10). A slide from the same workshop states "MAP <60"; this is excluded because it lacks its own citation: the current cutoff is 65 (MSPBS + CMQCC + SOMANZ).

Adapted EAPO (MEOWS, reference from the handout): 7 parameters (temp, SBP, DBP, pulse, RR, SpO2, mental status, urine output). Score: 0=routine; 1-3=observation every 4h + notify charge nurse; ≥4 with a single "red 3" or total≥4="THINK SEPSIS" (observation every 4h + urgent notification); ≥6="THINK SEPSIS" (continuous monitoring + emergency notification).

Note: this reference EAPO-MEOWS differs from the official MSPBS EAPO used in the Full module — shown here only as an additional reference; do not confuse them.

Take 4: cultures, laboratory tests for organ dysfunction + lactate, vital signs, imaging.

Give 5: O2 FiO2≥50%, crystalloids 20-30 mL/kg bolus + maintenance 1-2 mL/kg/h, broad-spectrum antibiotics, treatment of hyper/hypothermia, vasopressors if MAP<65 after bolus.

Consider 3: fetal well-being if >26 weeks, infection source control, thromboprophylaxis.

Targets: urine output>0.5 mL/kg/h or >30 mL/h, MAP ≥65 (MSPBS 2022; Surviving Sepsis Campaign 2021), PaO2>60 or SpO2>95%, Glasgow Coma Scale 15.

UdeA/UNFPA variant (slide "Therapeutic targets"): MAP >60 or SBP >85 mmHg, urine output >0.5 mL/kg/h or >30 mL/h, SpO2 >95%, normal mental status.

Stabilize and refer: review at 3 h (diagnosis/treatment/labs, repeat lactate, reassess source) and at 6 h (review diagnosis/treatment, close monitoring; ideally transfer to a tertiary care center by 6 h).

Urinary: piperacillin-tazobactam 4.5 g q8h or gentamicin 3-5 mg/kg q24h.

Respiratory: ampicillin-sulbactam 3g q6h + clarithromycin 500mg q12h (+ oseltamivir if at risk for influenza).

Puerperal infection: clindamycin 900mg q8h + gentamicin 240mg q24h or amikacin 1g q24h; or ampicillin-sulbactam 3g q6h; or crystalline penicillin + metronidazole + gentamicin regimen.

Vasopressor: norepinephrine 0.05 µg/kg/min until MAP ≥65, via central line or 14-16G access. UdeA: dopamine 5 µg/kg/min via peripheral line as an alternative, only after volume repletion.

CaVeSal® proprietary algorithm · Based on: SOMANZ.

≥ 2 points = High Risk (high suspicion of sepsis) — apply the complete Obstetric SOFA. <2 = Low Risk.

Consistent with the SOMANZ omqSOFA (SBP<90, RR≥ 25, mentation not alert) — dual source support. Improves sensitivity from 37.5%→81.2% and specificity from 72.2%→75% compared with standard non-obstetric qSOFA (SBP≤100, RR≥ 22, GCS<15).

Interpretation: score ≥ 2 = Organ Dysfunction (confirmed sepsis). Increase >2 points from baseline also confirms sepsis (SOMANZ/MFB criterion, same logic in µmol/L).

CaVeSal® proprietary algorithm · Based on: SOMANZ.

Point ladder for: temperature, systolic BP/vasopressor use, heart rate, ventilation/RR/SpO₂, leukocytes, lactate ≥ 4, bands ≥ 10%.

Positive if ≥ 6 points — obstetric sepsis alert.

9 variables, each scored from 0 to 3 (0 = normal). Apply every 4 h to all pregnant and postpartum patients.

CaVeSal® proprietary algorithm · Based on: Ministry of Public Health of Ecuador. “MAMÁ Score and Obstetric Codes.” Protocol. Quito: MSP; 2025 (Ministerial Agreement 00042-2025)The colors are from CaVeSal®; the protocol does not assign colors to the levels. In the Full calculator, it can be used alone or in combination with EAPO (CaVeSal® Obstetric Alert, see Code Red, card 23).

Includes embedded sub-calculations for the shock index and preeclampsia screening by BP — does not replace the existing specific modules (Shock Index, HDP); it is an integrated early warning view.

CaVeSal® proprietary algorithm · Based on: MD Antonio Heras G. — Obstetric Coagulopathy and Sepsis Calculator · SOMANZ Sepsis Guidelines 2017 · MDCalc — Diastolic Shock Index.

DSI: general sepsis literature more commonly cites the rounded cutoff ≥2.0; 2.2 is used as the primary cutoff (Heras source), with this note on the variant most cited in the non-obstetric literature. VDI: the classic intensive care formula uses MAP in the denominator (VIS/MAP); the variant recorded here (DBP ÷ dose × HR) is specific to the Heras source.

CaVeSal® proprietary algorithm · Based on: Bauer ME et al. Risk Factors, Etiologies, and Screening Tools for Sepsis in Pregnant Women: A Multicenter Case-Control Study. Anesth Analg 2019;129(6):1613-1620

Most useful individual criteria: HR >90 is almost always present (sensitivity 96 %) but has low specificity (45 %); by contrast, RR >30 and altered mental status are virtually absent in controls (specificity close to 100 %), although they are absent in more than half of sepsis cases.

Clinical interpretation: Use SIRS or maternal early warning criteria for screening; qSOFA to stratify severity; SOFA and lactate to confirm. The operational scores remain those in subcards 5-9.

CaVeSal® proprietary algorithm · Analysis based on Bauer ME et al. Anesth Analg 2019;129(6):1613-1620 (multicenter case-control study: 82 cases, 328 controls). Rounded values; confidence intervals and details by criterion are in the original article. Original definitions: Bone RC et al. Chest 1992;101:1644-55 · Singer M et al. JAMA 2016;315:801-10 · Mhyre JM et al. Obstet Gynecol 2014;124:782-6. The UdeA/UNFPA workshop cites this study for obstetric qSOFA (sensitivity 36-50 %, specificity 70-95 %).

• Most common causes: chorioamnionitis 24.4%; endometritis 23.2%; pneumonia 11.0%.
• Most common pathogens: E. coli 14.6%; other gram-negative bacilli 9.8%; group A Streptococcus 7.3%.
• Mortality: 12.2% overall; 8.3% if antibiotics are started in <1 h versus 20% if >1 h.

CaVeSal® proprietary algorithm · Based on: Bauer ME et al., Anesth Analg 2019;129(6):1613-1620 · WHO Statement on Maternal Sepsis (WHO/RHR/17.02)Delivery variables exclude cases of sepsis prior to delivery (reverse causality).

CaVeSal® proprietary algorithm · Analysis based on Bauer ME et al., Anesth Analg 2019;129(6):1613-1620 (rounded ORs; confidence intervals in the original) · WHO Statement on Maternal Sepsis (WHO/RHR/17.02)Delivery variables exclude cases of sepsis prior to delivery (reverse causality).

Interpretation: an increase ≥2 points above baseline defines organ dysfunction (Sepsis-3). The UdeA/UNFPA workshop expresses it as «> 2».

Cardiovascular 0 points = MAP ≥70 mmHg without vasopressors (Vincent 1996). Subcard 6 shows the modified 3-level obstetric version (0-2) used by Heras/SOMANZ; MSPBS (p. 75) reproduces the same 5-level table. CaVeSal® proprietary algorithm · Based on: Vincent JL et al. Intensive Care Med 1996;22:707-10 · Singer M et al. JAMA 2016 (Sepsis-3) · UdeA/UNFPA «Sepsis» workshop.

CaVeSal® proprietary algorithm · Based on: Bauer ME et al. Anesth Analg 2019 (see subcard 10) · UdeA/UNFPA «Sepsis» workshop · SOMANZ 2017.

Suggested sequence: SIRS/MEOWS for screening → qSOFA to stratify severity → SOFA and lactate to confirm. Sources: Bauer ME et al. Anesth Analg 2019 (see subcard 10) · UdeA/UNFPA «Sepsis» workshop · SOMANZ 2017.

Cumulative score (0-3 per parameter) for early detection of maternal physiological deterioration — does not diagnose sepsis by itself, but identifies deterioration that warrants escalation of the response, whatever the cause. Complements SIRS/qSOFA/SOFA (subcards 5-13).

Sensitivity 89%, specificity 79% for severe maternal morbidity (not specific to sepsis). Available as a mini-calculator in the Calculator mode.

CaVeSal® proprietary algorithm · Based on : Norfolk and Norwich University Hospital NHS Trust, MEOWS Development Group, 2022 (scoring table, taken from Universidad de Antioquia/UNFPA, “Sepsis” workshop, p. 17) · Singh S, McGlennan A, England A, Simons R. A validation study of the CEMACH recommended modified early obstetric warning system (MEOWS). Anaesthesia. 2012 Jan;67(1):12-18.

The current designation «Triple I» (NICHD 2015, ACOG CO 712) is detailed in the PROM tab, subcard 8.

CaVeSal® proprietary algorithm · Based on: Chorioamnionitis: An Update on Diagnostic Evaluation (Gibbs 1982, J Infect Dis 145:1-8) · Management of Clinical Chorioamnionitis — PMC8315154 · ACOG Committee Opinion No. 712 (2017).

Mnemonic (Knapp C & Bhatia K, Br J Hosp Med 2022): Accidents/anesthetic complications/asthma; Bleeding (hemorrhages); Cardiovascular; Drugs/medications (magnesium sulfate); Embolic (amniotic fluid, pulmonary); Fever (sepsis, septic shock); General (6Ts and 6Hs); Hypertension (HDP, HELLP).

“Perpetuates cardiac arrest” — 6Hs: Hypoxia, hypo-/hyperkalemia, H+ acidosis, hypothermia, hypovolemia, hypoglycemia.

6Ts: Cardiac tamponade, pulmonary thrombosis, coronary thrombosis, tablets/toxins, pneumothorax, trauma.

Unresponsive/unconscious patient → activate Obstetric Code Blue → check pulse for 10 seconds → if no pulse, initiate CABD (Circulation: compressions; Airway: open; Breathing: positive-pressure ventilation; Defibrillate if shockable rhythm).

Chest compressions 30:2, ventilations every 2 min or 5 cycles → aortocaval decompression (left uterine displacement) → open the airway → epinephrine 1mg IV every 3-5 min.

Modifications in pregnancy: deeper chest compressions, left uterine displacement, early endotracheal intubation + cricoid pressure.

Airway: O2 100% at 15L/min → intubation attempt 1 and 2 → if unsuccessful, supraglottic airway device attempt 1 and 2 → if unsuccessful, bag-mask ventilation → if ineffective, cricothyrotomy. 8-10 ventilations/min, monitor CO2, minimize time without compressions, 6.0-7.0mm tube.

VF/pulseless VT: initial shock 150J biphasic or 360J monophasic + 2 min CPR (30:2); if there is no response, another shock + amiodarone 300mg IV (150mg additional if VT persists).

Asystole/PEA: continue compressions and ventilation, verification protocol.

Epinephrine 1mg IV every 3-5 min: for a nonshockable rhythm, administer immediately once IV access is obtained; for a shockable rhythm, after the 2nd shock.

4-minute rule: preparation for hysterotomy begins when cardiac arrest is recognized. If there is no return of spontaneous circulation by minute 4, initiate resuscitative hysterotomy (perimortem cesarean delivery) on site, without transferring the patient or stopping CPR, to achieve delivery by minute 5 → alert the neonatal team if GA>24 weeks. Timer on the calculator, Obstetric Code Blue.

Perimortem cesarean delivery: <20 weeks NO; 20-24 weeks depending on suspected aortocaval compression; >24 weeks ALWAYS.

Magnesium sulfate toxicity: calcium gluconate 10% 30mL, or calcium chloride 10% 10mL (1g).

• A dilated RV does not distinguish PE from AFE. Severe early coagulopathy points to AFE; its absence points to PE.
• No laboratory test confirms AFE: it is a clinical diagnosis of exclusion.

Practice the three cases in the simulator: Septic shock · Massive PE · Amniotic fluid embolism.

CaVeSal® proprietary algorithm · Based on: SMFM Clinical Guideline #9, Pacheco LD et al. Am J Obstet Gynecol 2016 · APSF Newsletter, amniotic fluid embolism · StatPearls, Amniotic Fluid Embolism · POCUS + ROTEM in amniotic fluid embolism (case report, PMC11800665) · Iba T et al. ISTH SSC 2025, J Thromb Haemost 2025;23:2356-62.

For all patients (pregnancy, labor or postpartum): adequate hydration and early ambulation.

Mandatory anticoagulation (regardless of the risk scale) if there is: active venous thromboembolic disease (DVT, PE, cerebral venous sinus thrombosis), high-risk cardiac conditions (arrhythmias, prosthetic valves, cardiomyopathy with reduced LVEF, intracardiac thrombi, pulmonary hypertension), or known thrombophilia.

CaVeSal® proprietary algorithm · Based on: Grillo-Ardila CF et al. Rev Colomb Obstet Ginecol 2017;68(4):285-304 (rounded values; confidence intervals in the original).

Rule: the most severe level applies when at least one factor is present (factors are not added across levels).

CaVeSal® proprietary algorithm · Based on: Grillo-Ardila CF et al. Rev Colomb Obstet Ginecol 2017 · MSPBS.

Weight >170 kg — two alternatives: not included in the Colombian CPG table (specialist assessment) · enoxaparin 0.6 mg/kg/day according to the MSPBS Thromboprophylaxis draft (corrected, unpublished version). In the absence of LMWH: unfractionated heparin.

Known bleeding disorder (hemophilia, von Willebrand disease, acquired coagulopathies), active antepartum or postpartum bleeding, risk factors for major obstetric hemorrhage (e.g., placenta previa), thrombocytopenia (<75,000/µL), recent cerebrovascular event (within the last 4 weeks), severe renal disease (GFR<30 mL/min/1.73m²).

Fondaparinux, dabigatran and rivaroxaban are not approved for use during pregnancy. Warfarin and heparins are safe during breastfeeding.

Incidence of VTE during pregnancy/postpartum: 0.76-1.72 per 1000 (4× the risk in the general population). Accounts for 14.9% of global maternal mortality.

CaVeSal® proprietary algorithm · Based on: Grillo-Ardila CF et al. Rev Colomb Obstet Ginecol 2017;68(4):285-304 (rounded values; confidence intervals in the original).

CaVeSal® proprietary algorithm · Based on: Grillo-Ardila CF et al. Rev Colomb Obstet Ginecol 2017;68(4):285-304 (rounded values; confidence intervals in the original).

CaVeSal® proprietary algorithm · Based on: Grillo-Ardila CF et al. Rev Colomb Obstet Ginecol 2017;68(4):285-304 (rounded values; confidence intervals in the original).

CaVeSal® proprietary algorithm · Based on: Grillo-Ardila CF et al. Rev Colomb Obstet Ginecol 2017;68(4):285-304 (rounded values; confidence intervals in the original).

Homozygous Factor V Leiden and Prothrombin G20210A correspond to the “very high-risk” category of the traffic-light system (subcard 2).

• LMWH: strong recommendation in favor, low-quality evidence — no preference for a specific type.
• Unfractionated heparin: alternative when LMWH is not feasible (strong recommendation in favor).
• Fondaparinux: consider only if heparins are contraindicated (good practice point).
• Antiplatelet agents: weak recommendation against use for VTE prevention (very low-quality evidence).
• Intermittent pneumatic compression + pharmacological prophylaxis: weak recommendation against — no clear additional benefit and more bleeding.
• Regional anesthesia preferred over general anesthesia: weak recommendation in favor, associated with lower VTE risk (RR 0.66, 95% CI 0.55-0.79 for DVT).
• Graduated compression stockings: reduce DVT OR 0.33 (0.26-0.41), proximal DVT OR 0.26, PE OR 0.38 — strong recommendation in favor, very low-quality evidence.
• Hydration: “avoid dehydration” is a weak recommendation in favor, with very low-quality evidence. Vigorous hydration/hemodilution increased the risk of postoperative DVT in a controlled trial (RR 4.50, 95% CI 1.06-19.11) — never recommend “aggressive hydration” as a thromboprophylaxis measure.

Last dose before the procedure: 12h before induction/cesarean (prophylactic dose); 24h before if very high risk and receiving anticoagulation doses (therapeutic).

Postpartum restart: 12h after delivery/cesarean if not contraindicated (non-pharmacological measures in the meantime). In patients at high risk of postpartum hemorrhage: non-pharmacological measures only until the bleeding risk is minimal.

CaVeSal® proprietary algorithm · Based on: Grillo-Ardila CF et al. Rev Colomb Obstet Ginecol 2017;68(4):285-304 (rounded values; confidence intervals in the original).

Additional information: COVID-19 requiring hospitalization → LMWH during hospitalization + for up to 14 days post-discharge (moderate cases) or up to 1 month post-discharge (severe/critical cases).

VTE risk: pregnancy ×10 vs nonpregnant individuals; postpartum period (6 weeks) ×5, peak in the first week; cesarean delivery ×4 vs vaginal delivery.

CaVeSal® proprietary algorithm · Based on: Grillo-Ardila CF et al. Rev Colomb Obstet Ginecol 2017;68(4):285-304 (rounded values; confidence intervals in the original).

Anatomic predilection: left lower extremity and proximal iliofemoral veins (May-Thurner phenomenon: compression of the left iliac vein by the right iliac artery, combined with compression of the inferior vena cava by the gravid uterus).

Clinical presentation: pain along the course of the vein, unilateral edema, increased local temperature, difference in limb circumference, superficial collateral circulation.

Test of choice: venous Doppler ultrasound of the lower extremities (loss of compressibility or absence of flow). If negative and suspicion persists (especially for iliac vein thrombosis): repeat at 3 and 7 days or consider MRI.

Management: confirmed DVT → therapeutic-dose LMWH (enoxaparin 1 mg/kg every 12 h).

Clinical presentation: sudden or progressive dyspnea, pleuritic chest pain, cough, hemoptysis, tachypnea, tachycardia, cyanosis, syncope.

If leg symptoms are present: Doppler ultrasound first; if DVT is confirmed → anticoagulate without further testing.

CaVeSal® proprietary algorithm · Based on: van der Pol LM et al. NEJM 2019;380:1139-49 (Artemis) · Medicina Fetal Barcelona (2021).

The D-dimer cutoff differs by branch (1000 vs 500 ng/mL); it is not simplified to a single value. This algorithm avoided CT pulmonary angiography in 32-65% of pregnant patients, depending on trimester. Source: van der Pol LM et al. NEJM 2019;380:1139-49 (Artemis) · Medicina Fetal Barcelona (2021).

Indication for testing: Personal history of VTE or adverse obstetric history (≥3 miscarriages <10 weeks, fetal death ≥10 weeks with a morphologically normal fetus, severe FGR <34 weeks, severe preeclampsia <34 weeks).

Hereditary: factor V Leiden, prothrombin G20210A, protein C, protein S, or antithrombin III deficiency, factor XII mutation. Acquired/mixed: hyperhomocysteinemia, APS.

CaVeSal® proprietary algorithm · Based on: Medicina Fetal Barcelona 2021 · ACOG PB 196 and 197 (2018) · RCOG GTG 37a.

Treatment during pregnancy: Aspirin 100 mg/night from preconception or diagnosis until week 36 + prophylactic LMWH from ultrasound confirmation of fetal heartbeat until delivery. Postpartum: aspirin + prophylactic LMWH for 42 days.

Do not confuse with aspirin 150 mg/night for preeclampsia prevention (HDP tab): these are different indications and doses. Sources: Medicina Fetal Barcelona 2021 · ACOG PB 196 and 197 (2018) · RCOG GTG 37a.

• Normal risk (1/6000): no antepartum thromboprophylaxis, except if hospitalized with ≥4 of: BMI >30 kg/m², age ≥35 years, smoking, preeclampsia, multiple pregnancy, significant varicose veins.
• High risk (>3/1000): rule out APS and thrombophilias; multidisciplinary management.
• COVID-19: thromboprophylaxis if hospitalized for moderate, severe, or critical illness; continue for 14 days after discharge (moderate) or 1 month (severe/critical).
• Postpartum: according to the postpartum score (previous section); continue during hospitalization and decide with hematology whether to continue.

Source: MSPBS draft «Thromboembolism and pregnancy. Thromboprophylaxis» (corrected, unpublished version).

1. Triage: identity, gestational age/postpartum status, reason for presentation, and warning signs (sudden dyspnea, chest pain, tachypnea, cyanosis, syncope, tachycardia, painful and swollen lower limb).
2. Assess hemodynamic stability; if there is severe compromise or suspected PE: oxygen, monitoring, and transfer to a higher level of care with referral form and perinatal record.
3. Complete the perinatal medical history, with emphasis on thromboembolic risk factors.
4. Clear information and emotional support throughout the process.
5. Vital signs: BP, HR, RR, temperature, SpO₂.
6. Determine gestational age or postpartum day (LMP, delivery date, perinatal record).
7. Obstetric assessment: fundal height, FHR, uterine activity, fetal movements.
8. Focused history: symptoms, dyspnea, pleuritic pain, cough/hemoptysis, leg pain/swelling, personal or family history of VTE/thrombophilia, immobilization, surgery, cesarean delivery, trauma, obesity.
9. Focused physical examination: respiratory and cardiovascular systems, and lower extremities (unilateral edema, pain, warmth, difference in circumference, collateral veins).
10. Studies as available: venous duplex ultrasound, ECG, blood gas analysis, chest radiograph with abdominal shielding, CT pulmonary angiography or V/Q scan.
11. Presumptive or confirmed diagnosis of DVT/PE.
12. Weight-adjusted LMWH (subcard 3 of block 1), unless contraindicated.
13. Additional measures: early mobilization, compression stockings >20 mmHg, intermittent pneumatic compression (if LMWH is contraindicated, cesarean delivery/high risk, prior VTE, travel >4 h).
14. Education for the patient and family: adherence, warning signs, seek immediate care if symptoms worsen.
15. Detailed documentation in the medical record and follow-up scheduling.

Risk factors for dystocic labor — maternal: maternal age <18 or >35 years, multiparity/nulliparity, non-gynecoid pelvis, concomitant uterine injury, congenital pelvic defects, maternal history of dystocia, prior cesarean delivery, post-term pregnancy, prior stillbirth, prolonged or instrumented labor, induction with prostaglandins, weight gain >12kg, height <155cm. Fetal: weight >4000g, non-cephalic presentation.

CaVeSal® proprietary algorithm · Based on: Valenti EA, Andina E, Rey A, et al. Clinical practice guidelines: Shoulder dystocia. Rev Hosp Mat Inf Ramón Sardá 2007;26(1):37-41 · Magnin G, Pierre F. Distocia de hombros. EMC Ginecología-Obstetricia 1999;5-067-A-10 · Romero Gutiérrez G, Ríos López JC, Cortés Salim P, Ponce Ponce de León AL. Risk factors associated with dystocic labor. Ginecol Obstet Mex 2007;75(9):533-8.

Definition: inability of one or both shoulders to pass through the pelvic inlet. It is the obstetric condition most strongly associated with birth trauma (20-50%). Obstetric emergency.

Mechanism: the biparietal diameter exceeds the diameter of the pelvic inlet; pressure at the level of the pubic symphysis from endogenous forces 4-9 times greater than exogenous forces.

CaVeSal® proprietary algorithm · Based on: Valenti EA, Andina E, Rey A, et al. Clinical practice guidelines: Shoulder dystocia. Rev Hosp Mat Inf Ramón Sardá 2007;26(1):37-41 · Magnin G, Pierre F. Distocia de hombros. EMC Ginecología-Obstetricia 1999;5-067-A-10 · Romero Gutiérrez G, Ríos López JC, Cortés Salim P, Ponce Ponce de León AL. Risk factors associated with dystocic labor. Ginecol Obstet Mex 2007;75(9):533-8.

⚠️ 50% of cases occur in fetuses with normal weight — macrosomia alone is not predictive; the team must be prepared for every delivery.

CaVeSal® proprietary algorithm · Based on: Valenti EA, Andina E, Rey A, et al. Clinical practice guidelines: Shoulder dystocia. Rev Hosp Mat Inf Ramón Sardá 2007;26(1):37-41 · Magnin G, Pierre F. Distocia de hombros. EMC Ginecología-Obstetricia 1999;5-067-A-10 · Romero Gutiérrez G, Ríos López JC, Cortés Salim P, Ponce Ponce de León AL. Risk factors associated with dystocic labor. Ginecol Obstet Mex 2007;75(9):533-8.

Turtle sign: retraction of the fetal head toward the perineum after delivery — diagnostic sign.

CaVeSal® proprietary algorithm · Based on: Valenti EA, Andina E, Rey A, et al. Clinical practice guidelines: Shoulder dystocia. Rev Hosp Mat Inf Ramón Sardá 2007;26(1):37-41 · Magnin G, Pierre F. Distocia de hombros. EMC Ginecología-Obstetricia 1999;5-067-A-10 · Romero Gutiérrez G, Ríos López JC, Cortés Salim P, Ponce Ponce de León AL. Risk factors associated with dystocic labor. Ginecol Obstet Mex 2007;75(9):533-8.

• Act in less than 60 seconds.
• Wide prophylactic episiotomy.
• McRoberts maneuver (see subcard 6).
• Call for help: obstetrician, pediatrician, anesthesiologist.

CaVeSal® proprietary algorithm · Based on: Valenti EA, Andina E, Rey A, et al. Clinical practice guidelines: Shoulder dystocia. Rev Hosp Mat Inf Ramón Sardá 2007;26(1):37-41 · Magnin G, Pierre F. Distocia de hombros. EMC Ginecología-Obstetricia 1999;5-067-A-10 · Romero Gutiérrez G, Ríos López JC, Cortés Salim P, Ponce Ponce de León AL. Risk factors associated with dystocic labor. Ginecol Obstet Mex 2007;75(9):533-8.

External maneuvers, without additional anesthesia.

CaVeSal® proprietary algorithm · Based on: Valenti EA, Andina E, Rey A, et al. Clinical practice guidelines: Shoulder dystocia. Rev Hosp Mat Inf Ramón Sardá 2007;26(1):37-41 · Magnin G, Pierre F. Distocia de hombros. EMC Ginecología-Obstetricia 1999;5-067-A-10 · Romero Gutiérrez G, Ríos López JC, Cortés Salim P, Ponce Ponce de León AL. Risk factors associated with dystocic labor. Ginecol Obstet Mex 2007;75(9):533-8.

Internal fetal manipulation, requires regional anesthesia.

• Woods maneuver ("corkscrew" — screw-like rotation of the posterior shoulder, 180°, to an anterior position).
• Rubin maneuver (rotation of the more accessible shoulder toward the oblique diameter, adducting the shoulders).
• Jacquemier maneuver (delivery of the posterior shoulder: the posterior arm is moved backward, the forearm is flexed over the arm, the hand is grasped, and the posterior shoulder is disengaged).
• Posterior axillary traction.
• Gaskin maneuver (maternal position on all fours — changes pelvic geometry without direct fetal manipulation).

Greater fetal morbidity and mortality — use only if the above maneuvers fail.

• Deliberate clavicular fracture (reduces the biacromial diameter).
• Zavanelli maneuver (cephalic replacement and emergency cesarean delivery).
• Abdominal rescue (hysterotomy with disimpaction of the shoulder from the abdomen, followed by assisted vaginal delivery).
• Symphysiotomy (surgical division of the pubic symphysis).

If all the above fail: downward traction on the head + moderate suprapubic pressure, under general anesthesia.

Document (medicolegal): explanation to the patient, severity/complexity, procedures and possible sequelae, maneuvers and timing.

CaVeSal® proprietary algorithm · Based on: Valenti EA, Andina E, Rey A, et al. Clinical practice guidelines: Shoulder dystocia. Rev Hosp Mat Inf Ramón Sardá 2007;26(1):37-41 · Magnin G, Pierre F. Distocia de hombros. EMC Ginecología-Obstetricia 1999;5-067-A-10 · Romero Gutiérrez G, Ríos López JC, Cortés Salim P, Ponce Ponce de León AL. Risk factors associated with dystocic labor. Ginecol Obstet Mex 2007;75(9):533-8.

Incidence: 3-4% of births. The frequency increases at lower gestational ages (more common in preterm infants).

Risk factors: prematurity, uterine relaxation/multiparity, pelvic tumor, pelvic narrowing, hydramnios, oligohydramnios, hydrocephalus and anencephaly, history of prior breech delivery, uterine anomalies.

CaVeSal® proprietary algorithm · Based on: Williams Obstetrics (Breech Delivery) · ACOG CO 745 (2018) · MSF — Breech presentation.

Only frank or complete breech presentations are candidates for vaginal delivery (see subcard 4); footling breech is excluded.

CaVeSal® proprietary algorithm · Based on: Williams Obstetrics (Breech Delivery) · ACOG CO 745 (2018) · MSF — Breech presentation.

All criteria must be met — failure to meet any one indicates cesarean delivery:

• Estimated fetal weight <3,500 g.
• Biparietal diameter <96 mm (range 90-100mm, Williams Obstetrics citing Giuliani 2002 and Roman 2008 — not a specific ACOG cutoff).
• Clinically adequate pelvis.
• Frank or complete breech (footling breech excluded).
• Flexed fetal head.
• Absence of fetal anomalies.
• No contraindications to vaginal delivery.
• Absence of concomitant pathology.

This checklist is available as a binary (yes/no) mini-calculator in the Calculator mode.

General management of breech labor, not a specific maneuver: the infant should be delivered by maternal pushing, supported only by the bony parts (hips and sacrum), without traction, without pulling on the legs, without touching the infant until the scapulae appear (to avoid triggering the respiratory reflex before the head is delivered).

⏱️ Once the umbilicus is out: complete delivery within a maximum of 3 minutes (risk of cord compression). Ensure the back does not rotate to a posterior position.

CaVeSal® proprietary algorithm · Based on: Williams Obstetrics (Breech Delivery) · ACOG CO 745 (2018) · MSF — Breech presentation.

Pinard: insert two fingers into the vagina and “hook” the leg from medial to lateral just above the knee; flex at the hip and abduct to release the foot. Repeat with the other leg if the breech is complete.

Lovset: place the thumbs over the sacrum, grasp the hips, and rotate 90°; release the anterior arm; counter-rotate 180° and release the posterior arm.

Bracht: hold the hips and lift with both hands toward the maternal abdomen without traction; the neck pivots over the symphysis. An assistant applies suprapubic pressure.

Mauriceau-Smellie-Veit (modified): kneel at a 45° downward angle; support the infant on the hand and forearm; place the index and middle fingers on the maxilla (NOT inside the mouth — risk of mandibular fracture); place the other hand on either side of the neck; lower the head, bringing the subocciput beneath the symphysis; use a sweeping motion, bringing the back toward the maternal abdomen. Apply suprapubic pressure along the pelvic axis.

Suzor: rotate the back 90°; pull downward; insert one hand along the back to locate the anterior arm; place the thumb in the axilla and the middle finger along the arm; lower the anterior arm; lift by the feet to release the posterior shoulder.

1. Verify the criteria for vaginal delivery (subcard 4) — if not met, cesarean delivery.
2. Confirm the type of presentation (subcard 2) — frank/complete breech are candidates; footling breech is highly unfavorable.
3. Delivery: hands off — allow descent with maternal pushing.
4. Legs (if not delivered spontaneously): Pinard.
5. Arms: Lovset (or Suzor if it fails).
6. Head: Bracht → if unsuccessful, Mauriceau-Smellie-Veit → if unsuccessful, forceps for the aftercoming head.
7. Timer: from delivery of the umbilicus, a maximum of 3 minutes to deliver the head.
8. Document maneuvers and times (medicolegal).

Clinical: clear fluid leaking from the vagina — reliability >90% if visualized at the external cervical os on speculum examination.

Confirmatory tests:

• Fern test.
• Nitrazine test (pH>6.5 turns blue).
• Commercial biomarkers (PAMG-1/AmniSure, IGFBP-1/Actim PROM).
• Measurement of urea and creatinine in vaginal secretions — urea 94%/82% and creatinine 98%/90% (sensitivity/specificity, Alao 2023); low cost, useful in resource-limited settings. See comparative table in subcard 7.

Diagnostic amniocentesis (gold standard in equivocal cases): ultrasound-guided instillation of indigo carmine, vaginal tampon, confirmation of staining at 20-30 min.

CaVeSal® proprietary algorithm · Based on: Alao AI et al. Arch Gynecol Obstet 2023;307(2):447-452.

Microbiological analysis of amniotic fluid: Gram stain, culture (aerobes/anaerobes/Mycoplasma/Ureaplasma), amniotic fluid glucose (<14 mg/dL suggests intra-amniotic infection), leukocyte count.

CaVeSal® proprietary algorithm · Based on: ACOG · FIGO.

Standard ACOG/NICHD regimen (7 days):

• Days 1-2 IV: Ampicillin 2g q6h + erythromycin 250mg q6h (or azithromycin 1g PO as a single dose).
• Days 3-7 PO: Amoxicillin 250mg q8h + erythromycin base 333mg q8h (MSPBS 2018 uses amoxicillin 500mg; see card 17).

Alternative regimen (with azithromycin, widely used):

• Ampicillin 2g IV q6h x48h → amoxicillin 250mg PO q8h x5 days + azithromycin 1g PO as a single dose at admission (ACOG: an appropriate substitute for erythromycin).

CaVeSal® proprietary algorithm · Based on: ACOG.

Contraindicate expectant management at any gestational age:

• Clinical chorioamnionitis / confirmed intra-amniotic infection (Gibbs criteria).
• Placental abruption.
• Acute fetal compromise (non-reassuring FHR / abnormal biophysical profile).
• Established labor.
• Fetal death.

These therapies are shared with the Threatened Preterm Labor (TPL) module — same regimen, same table of recommendations by guideline:

Regimens: Betamethasone 12mg IM every 24h (2 doses total); Dexamethasone 6mg IM every 12h (4 doses total). Rescue dose: a single dose or repeat course if >14 days since the initial course, GA<34 weeks, and imminent risk of delivery within 7 days.

CaVeSal® proprietary algorithm · Based on: ACOG · FIGO · WHO · NICE.

Regimen: loading dose 4g IV over 20-30min; maintenance 1g/h IV until delivery or for a total of 24h; antidote: Calcium Gluconate 10% 1g IV.

In the Calculator, the single cutoff used is that of MSPBS Paraguay (corticosteroids: 24⁰/⁷ to 34⁰/⁷ weeks, not from 34¹/⁷ onward · MgSO4: less than 32 weeks); ACOG/FIGO/NICE variations are listed in this guide — see Calculator Mode.

• PROM: rupture of membranes occurring at least 2 hours before the onset of labor, regardless of GA (FASGO 2018 consensus).
• Latency period: time between rupture and onset of labor; inversely proportional to GA (longer when rupture occurs earlier).

CaVeSal® proprietary algorithm · Based on: FASGO. 2018 Obstetrics Consensus: Premature rupture of membranes.

These subtypes are not included in the 2018 FASGO Consensus and are presented without specific attribution to that source.

CaVeSal® proprietary algorithm · Based on: Chalurkar U, Andallu R. Int J Contemp Med Res 2017;4(5):1118-21 (IGFBP-1 vs. ferning) · Khooshideh M et al. Iran J Reprod Med 2015;13(6):355-60 (PAMG-1) · Abdelazim IA, Makhlouf HH. Arch Gynecol Obstet 2012;285(4):985-9 (AmniSure®) · Alao AI et al. Arch Gynecol Obstet 2023;307(2):447-452.

“Triple I” (Intrauterine Inflammation, Infection or both) is the modern term proposed by the 2015 NICHD workshop and adopted by ACOG/SMFM; it replaces “clinical chorioamnionitis” (classic Gibbs 1982 criteria: fever ≥37.8 °C + ≥2 signs; many guidelines use ≥38.0 °C).

CaVeSal® proprietary algorithm · Based on: ACOG Committee Opinion No. 712 (2017) · Medicina Fetal Barcelona — Chorioamnionitis or Triple I.

Patient at risk of MDR = 1 major criterion or 2 or more minor criteria (comorbidities count as one criterion).

• Major criterion: previous infection or colonization with MDR bacteria.
• Minor criterion 1: comorbidity (CKD, pregestational diabetes, heart disease, COPD) or immunosuppression (neutropenia, transplant, corticosteroids >20 mg/day of prednisone or equivalent for >2 weeks, immunosuppressants/cytotoxic agents, HIV with CD4 <200, primary immunodeficiencies).
• Minor criterion 2: indwelling urinary catheter.
• Minor criterion 3: hospital admission in the previous 3 months, regardless of duration.
• Minor criterion 4: systemic antibiotic (oral or IV) in the previous 3 months, regardless of duration (common in recurrent UTIs).
• Minor criterion 5: origin from an endemic area (Latin America, the Caribbean, Asia, non-EU Mediterranean) and <6 months in the country, or >6 months in the country but travel to or visits from family from that country in the previous 6 months.

CaVeSal® proprietary algorithm · Based on: Medicina Fetal Barcelona protocol, preterm and term PROM (09/2025).

In the absence of suspected multidrug-resistant bacteria, the standard regimen in subcard 3 is maintained. Source: Medicina Fetal Barcelona protocol, preterm and term PROM (09/2025).

Seaman et al., AJOG 2022 (5 studies, 1289 patients):

• Latency: no difference (6.6 vs 6.7 days; mean difference 0.07 days, 95% CI −0.45 to 0.60).
• Clinical chorioamnionitis: OR 0.53 (95% CI 0.39-0.71) with azithromycin; median prevalence 14% vs 25% with erythromycin (approximately 47% relative reduction).

Azithromycin is not intended to achieve longer latency: it aims for equal efficacy with better tolerability and less chorioamnionitis (FLASOG 2026 pearl). Source: Seaman AN et al. Am J Obstet Gynecol 2022;226(6):794-801.

References: FIGO 2023 (Ubom et al., Int J Gynecol Obstet 163 Suppl 2:40-50) · SMFM Consult Series #71 (2024) · NICE NG25 (2022) · ACOG PB 217 (2020) · RCOG Green-top No. 73 (2022) · FASGO Consensus 2018 · Manual of Obstetric Standards and Procedures 2021, INPer Mexico (generic attribution) · Ghafoor S. Malays J Med Sci 2021;28(3):5-17.

CaVeSal® proprietary algorithm · Based on: RCOG Green-top No. 73 · StatPearls (NBK537123).

RCOG: biophysical profile and Doppler are not first-line tests for diagnosing fetal infection. ACOG: there is no consensus on the optimal frequency of assessment during expectant management. Sources: RCOG Green-top No. 73 · StatPearls (NBK537123).

CaVeSal® proprietary algorithm · Based on: RCOG · ACOG · NICE.

Outpatient management should only be considered if all these requirements are met:

• Patient at low risk of infection, strictly selected.
• Guaranteed maternal adherence and stable connectivity.
• 24/7 monitoring by a specialized team.
• Immediate access to obstetric and neonatal ICU care.
• Response in <15 min to a critical alarm.

Recommendation to use regional clinical judgment, consistent with RCOG #73, ACOG, and NICE NG25 (inpatient expectant management by default).

CaVeSal® proprietary algorithm · Based on: Cochrane 2020 (corticosteroids) · Kenyon, Cochrane 2013 · SciELO Argentina (MgSO4) · Universiteit Leiden (GBS).

Low-cost, high-evidence interventions (corticosteroids, antibiotics, MgSO4, GBS prophylaxis) provide greater benefit than costly technology without infrastructure. Sources: Cochrane 2020 (corticosteroids) · Kenyon, Cochrane 2013 · SciELO Argentina (MgSO4) · Universiteit Leiden (GBS).

• Emerging molecular biomarkers: proteomics, metabolomics, microRNA, IL-6, IL-8, TNF-α; detect intra-amniotic inflammation before clinical manifestations.
• QuantusFLM® (AI-based fetal lung texture analysis) in PROM: sensitivity 60%, specificity 79.5%, negative predictive value 89.7% (Palacio M et al. Fetal Diagn Ther 2020).
• Cervical elastography and amniotic sludge as emerging risk markers.

Not an acute management protocol. AI does not replace clinical judgment; it enhances its analytical capacity to support better decision-making (FLASOG 2026).

Vaginal urea and creatinine: the reference study (Alao 2023) was conducted in Nigeria as an inexpensive alternative to AmniSure®; it is not standard practice in the UK, where NICE recommends IGFBP-1 or PAMG-1. Ultrasound: oligohydramnios cutoffs are the same as those in the prenatal calculator (AIUM/ACOG/SMFM).

CaVeSal® proprietary algorithm · Based on: MSPBS Paraguay 2018, chapter 29 · NICE NG25, section 1.3 · Alao AI et al. Arch Gynecol Obstet 2023.

Difference from ACOG PB 217 (2020): amoxicillin 250 mg q8 h + erythromycin 333 mg q8 h during the oral phase, and no latency antibiotics from 34⁰/⁷ onward (only Group B streptococcus prophylaxis). The calculator uses ACOG as the preferred regimen at 24-33⁶/⁷ and allows selection of the MSPBS and NICE regimens.

CaVeSal® proprietary algorithm · Based on: MSPBS Paraguay, National Manual of Standards for Care of Major Obstetric Conditions 2018, ch. 29, pp. 217-224.

If corticosteroids are given after 34 weeks: neonatal glucose monitoring. Chorioamnionitis: ALPS showed no increase in chorioamnionitis or sepsis, and neither did a meta-analysis (RR 0.86) (WAPM, J Perinat Med 2022). The citation "Li G et al. Lancet Neurol 2022;21:948-962" (>16,000 women) does not exist in PubMed or Lancet Neurology; the title corresponds to Aviram 2022, whose data are shown above.

CaVeSal® proprietary algorithm · Based on: Gyamfi-Bannerman C et al. NEJM 2016;374:1311-20 · Gyamfi-Bannerman C et al. JAMA 2024;331:1629-37 · Ninan K et al. JAMA Pediatr 2022;176:e220483 · Aviram A et al. Arch Dis Child Fetal Neonatal Ed 2022;107:250-255 · Daskalakis G et al. J Matern Fetal Neonatal Med 2023 (European guideline) · WAPM, J Perinat Med 2022 · ACOG CO 713 · NICE NG25.

If used: no signs of infection, maximum 48 h, discontinue if fever or tachycardia occurs. Drugs and timer in the calculator (Tocolysis card).

CaVeSal® proprietary algorithm · Based on: MSPBS 2018 · Mackeen AD et al. Cochrane 2014 (CD007062) · RCOG Green-top No. 73.

All predict maturity well and immaturity poorly. If delivery is indicated, the result does not change management (2011 consensus). In PROM before 34 weeks, it may guide the decision.

CaVeSal® proprietary algorithm · Based on: Varner S et al. Rev Obstet Gynecol 2013;6(3-4):126-134 · Palacio M et al. Am J Obstet Gynecol 2017 · Palacio M et al. Fetal Diagn Ther 2020.

Definition: regular uterine activity (≥4 contractions/20min or ≥8/60min) + cervical changes, between 22⁰/⁷ and 36⁶/⁷ weeks.

Transvaginal cervical ultrasound (TVUS):

• Cervical length (CL) >30mm → high negative predictive value (rules out active preterm labor).
• CL <25mm (or <20mm) → short cervix / elevated risk.

Biomarkers if CL 20-30mm: fetal fibronectin (fFN) or PAMG-1 (PartoSure) — if negative, avoids unnecessary tocolysis.

Objective: delay delivery 48-72h to complete fetal lung maturation, provide neuroprotection, and transfer to a Level III center. Use: weeks 22/24 to 33⁶/⁷.

Progesterone (prevention, not acute tocolysis): micronized vaginal progesterone 200 mg/day, started between 16-24 weeks and continued until at least 34 weeks, for a short cervix (≤25 mm) or history of preterm birth (NICE NG25 · SOGC 398).

CaVeSal® proprietary algorithm · Based on: ACOG · FIGO · NICE · RCOG.

The Calculator includes a single timer, reusable for all 3 drugs, with an internal cadence parameterized according to the active drug:

• Manual trigger: starts when “tocolysis initiated” is selected — not assumed automatically.
• Active alerts at dose milestones: alert at each hour corresponding to the next maintenance dose for the drug (see table above).
• Pause/stop button: preserves the accumulated time (e.g., “tocolysis stopped at 18h 40min”) without resetting to zero.
• End of window: alert at 48h (or 72h) — “tocolysis target reached; reassess continuation/transfer.”
• Joint display with the uterine activity record (contractions/20-60min) to assess clinical response.

Submodule shared with PROM — same 3 guideline positions:

CaVeSal® proprietary algorithm · Based on: ACOG · FIGO · WHO · NICE.

Regimens: Betamethasone 12mg IM every 24h (2 doses); dexamethasone 6mg IM every 12h (4 doses).

Single cutoff in Calculator: NICE.

Submodule shared with PROM — same 3 guideline positions:

CaVeSal® proprietary algorithm · Based on: ACOG · NICE · FIGO · WHO.

Regimen: loading dose 4g IV over 20-30min; maintenance 1g/h IV until delivery or for a total of 24h; antidote: Calcium Gluconate 10% 1g IV.

Single cutoff in Calculator: FIGO/WHO.

Table adapted (translated) from Wynne K et al. F1000Research 2020;9:F1000 Faculty Rev-219 (Table 1) · CC BY 4.0 License (use permitted with attribution). Single cutoff in Calculator: NICE.

• Do not repeat routinely. Single rescue course if risk of delivery recurs, the previous course was >14 days ago, and gestational age is <34 weeks (risk of delivery within 7 days).
• Benefits: reduces neonatal RDS by 34%, neonatal mortality by 31%, intraventricular hemorrhage by 46%, and necrotizing enterocolitis by 54%.
• Betamethasone vs dexamethasone (ASTEROID, Crowther 2019): no difference in the primary outcome (death or neurodevelopmental disability at 2 years: 33% vs 32%; RR 0.97). With dexamethasone: fewer cesarean deliveries (43% vs 52%; RR 0.84) and less hypertension at 2 years (32% vs 41%; RR 0.78). Intraventricular hemorrhage did not differ (RR 1.09; p=0.72).

CaVeSal® proprietary algorithm · Based on: Crowther CA et al. ASTEROID, Lancet Child Adolesc Health 2019;3(11):769-780 · Ninan K et al. JAMA Pediatr 2022;176(6):e220483.

Supports the rule against routine use of corticosteroids in late preterm/term infants or repeating courses. Räikkönen et al., JAMA 2020 (670,097 children): HR 1.33 (1.26-1.41) for any mental/behavioral disorder.

CaVeSal® proprietary algorithm · Based on: Petrini JR et al. Increased risk of adverse neurological development for late preterm infants. J Pediatr 2009;154(2):169-76 · Stanley FJ. Survival and cerebral palsy in low birthweight infants: implications for perinatal care. Paediatr Perinat Epidemiol 1992;6:298-310 · Moster D et al. NEJM 2008;359(3):262-273.

Prevalence of cerebral palsy: 2-2.5/1000 live births, inversely proportional to gestational age. Prematurity accounts for 75% of perinatal deaths and 50% of neurological abnormalities (excluding malformations).

Justifies prioritizing neuroprotection at the earliest gestational ages. Citation chain: Petrini 2009 (J Pediatr; HR 3.39 at 34-36 weeks), Stanley 1992 (Paediatr Perinat Epidemiol), Moster 2008 (NEJM; RR 78.9 at 23-27 weeks). The 8× value has no specific primary reference identified.

CaVeSal® proprietary algorithm · Based on: Doyle, Cochrane 2007 · SOGC · FIGO 2021 · SOGC 2019 · NICE · Martínez Gallegos 2024.

The sequence “4 h before, 12 h, repeat at 6 h” mixes the two regimens. Alternative dose (Martínez Gallegos 2024): loading dose 5 g IV in 100-200 cc of 5% dextrose over 30 min; maintenance 20 g in 500 cc of 5% dextrose at 7 drops/min.

Hourly monitoring: blood pressure and pulse, respiratory rate, deep tendon reflexes, and urine output. Antidote: calcium gluconate 1 g IV slowly (over 3-4 min; some sources indicate up to 10 min).

Serum magnesium measurement is optional, depending on availability; clinical monitoring remains the mainstay. Thresholds vary slightly between sources (e.g., StatPearls places respiratory paralysis at 12-15 mg/dL).

NVP (Nausea and Vomiting of Pregnancy): physiological/mild, affecting up to 80% of pregnant patients, onset at weeks 4-9, resolution at weeks 16-20.

HG (Hyperemesis Gravidarum): severe and intractable form, 0.3-2% of pregnancies. Classic triad:

• Intractable vomiting.
• Weight loss >5% of prepregnancy weight.
• Ketonuria/ketonemia + electrolyte abnormalities (hypokalemia, hypochloremia, metabolic alkalosis).

CaVeSal® proprietary algorithm · Based on: Koren G et al. 2002 y 2005 (PUQE scale) · ACOG PB 189 (2018).

CaVeSal® proprietary algorithm · Based on: ACOG PB 189 (2018, reaffirmed 2021) · RCOG GTG 69 (2016).

0.9% Normal Saline or Lactated Ringer’s solution.

KCl replacement according to the electrolyte panel.

CaVeSal® proprietary algorithm · Based on: MSPBS · WHO · CLAP · FIGO · Labour Care Guide 2018 · ACOG.

The three sources are shown separately, without merging. The Calculator’s dynamic partograph (Childbirth tab) lets you choose the model: Ministry CLAP (default), WHO 2020 or ACOG 2024. How to use each: cards 9 to 12.

• Prolonged latent phase (>20h nulliparous, >14h multiparous in the 2014 consensus; ACOG 2024: >16 h in nulliparous patients) should NOT be an indication for cesarean delivery on its own.
• Slow but progressive active phase (not arrested) should not be an indication for cesarean delivery.
• Operative vaginal delivery (forceps/vacuum) in the 2nd stage by trained personnel: a reasonable alternative to cesarean delivery — training should be encouraged.
• Fetal monitoring: appropriate use of CTG categories (ACOG/NICHD classification) to reduce unnecessary cesarean deliveries for suspected fetal compromise, including intrauterine resuscitation measures before cesarean delivery.
• External cephalic version for breech presentation from 36 0/7 weeks, when there is no contraindication.
• Elective induction only with a favorable cervix, or after considering the risk of failure if the cervix is unfavorable.
• Fetal macrosomia: elective cesarean delivery for suspected macrosomia should be limited to an estimated fetal weight ≥ 5000g (or ≥ 4500g if diabetes is present) — do not perform routine cesarean delivery for suspected macrosomia without reaching that threshold (weak recommendation, lower-quality evidence).

Diagnose only if:

• Dilation ≥ 6 cm, AND
• Ruptured membranes, AND
• No cervical progress despite ≥ 4 h of adequate uterine activity (more than 200 MVUs with an intrauterine pressure catheter), or ≥ 6 h of inadequate activity with oxytocin

Source: ACOG CPG 8 (2024). Detail and flowchart in sheet 11.

CaVeSal® proprietary algorithm · Based on: ACOG CPG 8 (2024) · ACOG/SMFM Obstetric Care Consensus No. 1 (2014).

Beyond these time limits, ACOG recommends an individualized approach (progress of descent, epidural, occiput posterior position, patient preference) before diagnosing arrest. The traditional definition is shown for historical reference only.

CaVeSal® proprietary algorithm · Based on: MSPBS — Standards for Preconception, Prenatal, Labor, Birth and Postpartum Care · WHO partograph, Lancet 1994;343:1399-404 · CLAP/SMR 1577 (2011).

Recording frequency: FHR, contractions and maternal pulse every 30 min · temperature every 2 h · BP every 4 h · at each vaginal examination: dilatation, descent and molding. Amniotomy: not routine; only for abnormal progress.

The manual does not name Friedman: it is cited as the WHO/CLAP partograph (alert/action line, 1994). Sources: MSPBS — Standards for Preconception, Prenatal, Labor, Birth and Postpartum Care · WHO partograph, Lancet 1994;343:1399-404 · CLAP/SMR 1577 (2011).

• Active phase from 5 cm; do not apply the 1 cm/h rule to justify interventions if the mother and fetus are stable.
• Companion of choice and freedom of position.
• Vaginal examination every 4 h in uncomplicated active labor.
• Intermittent auscultation (Pinard/Doppler): every 15-30 min during dilatation, every 5 min or after each contraction during the second stage.
• Second stage: non-supine positions, spontaneous pushing, perineal protection or warm compresses, restrictive episiotomy.
• Third stage: oxytocin 10 IU IM/IV, controlled cord traction, cord clamping at 1-3 min.
• Newborn: skin-to-skin contact for 60-90 min, breastfeeding in the first hour; defer anthropometric measurements, eye prophylaxis and vitamin K; bathing after 24 h.

Practices NOT routinely recommended: enema, pubic shaving, admission pelvimetry, prophylactic IV access in low-risk patients, early amniotomy, oxytocin to shorten labor, routine episiotomy, Kristeller maneuver (prohibited).

Sources: WHO Intrapartum care for a positive childbirth experience (2018) · WHO Labour Care Guide (2020) · FIGO 2019 (third stage, IJGO 145:256-8) · Lalonde A. IJGO 2012;119:84-7.

CaVeSal® proprietary algorithm · Based on: Lugones Botell M, Ramírez Bermúdez M. El parto en diferentes posiciones a través de la ciencia, la historia y la cultura. Rev Cubana Obstet Ginecol 2012;38(1):134-45 (cited in the UdeA/UNFPA workshop).

WHO recommends free choice of position, not one mandatory position. Source: Lugones MB. Rev Cubana Obstet Ginecol 2012;38(1) (UdeA workshop).

• Labor pain is physiological; nonpharmacological pain relief: warm water, movement, breathing, massage, and continuous support.
• In the absence of contraindications, maternal request alone is a sufficient indication for an epidural.
• Delayed cord clamping (1-3 min): less neonatal anemia and fewer transfusions, improved transition, and placental blood transfer (Edmonds 2013).
• Skin-to-skin contact: warmth, bonding and attachment, greater breastfeeding success; requires continuous support from the team.

Sources: WHO 2018 · Edmonds P. Midwifery Today 2013;(108):58-62 · UdeA workshop.

CaVeSal® proprietary algorithm · Based on: MSPBS — Care Standards (PAHO/WHO-CLAP partograph) · MSPBS — Safe Birth Protocol · shading by duration: Bettercare — Maternal Care y J Obstet Gynecol India.

Descent: the calculator allows it to be recorded in Hodge planes (default) or in palpable fifths by abdominal examination. In the calculator: Labor → Dynamic partograph → “Ministry CLAP” model.

CaVeSal® proprietary algorithm · Based on: WHO Labour Care Guide (2020) · Jhpiego — LCG Participant ManualOriginal design; does not reproduce the form (CC BY-NC-SA).

Variable decelerations (V) are recorded but are not alerts. The guide has no alert or action lines. In the calculator: Labor → Dynamic partograph → “WHO 2020” model (dynamic table with alerts marked).

CaVeSal® proprietary algorithm · Based on: ACOG Clinical Practice Guideline No. 8 — First and Second Stage Labor Management (2024).

In the calculator the “ACOG 2024” model has a selector: with a catheter (textual criterion, MVU >200) or without a catheter, with a contraction counter (clinical adaptation: strong contractions every 3 min or less, according to FPQC/USF PROVIDE). Intensity is marked as mild, moderate, or strong by palpation.

CaVeSal® original table · sources in cards 9, 10, and 11.

Variant (reference only, not in the calculator): the partograph with CLAP alert curves (Schwarcz et al.) uses five curves according to parity, maternal position (upright or horizontal), and membrane status, constructed using the 10th percentile of 1188 normal births. Source: Ministry of Health of Argentina — Resolution 647/2003, Chapter 2. The Ministry of Paraguay uses the alert and action line model described in card 9.

CaVeSal® proprietary algorithm · Based on: ACOG PB 200 (2018) · NICE NG126 (2019/2023).

General measures: relative rest, sexual abstinence, avoid repeated vaginal examinations.

Progesterone — CaVeSal recommends: micronized progesterone 400 mg vaginally every 12 h until week 16, even without a history of miscarriage.

Variants: MSPBS 2018 not routinely indicated · NICE NG126 only with ≥1 prior miscarriage (PRISM trial) · in favor: RANZCOG, FOGSI 2024, Cochrane 2018 y Cochrane 2021.

• Micronized progesterone 400mg vaginally every 12h until week 16.
• Alternative: Dydrogesterone 40mg orally initially, then 10mg every 8h.

Anti-D prophylaxis: if Rh-negative, unsensitized, with clinically significant bleeding → anti-D immunoglobulin 120-300mcg IM within the first 72h.

Definition: inability of the cervix to retain the pregnancy in the absence of contractions/clinical abruption, with painless dilation/effacement in the 2nd trimester (16-24 weeks) → recurrent fetal loss or extreme preterm birth.

Types:

• History-indicated (prophylactic/elective): ≥2-3 prior unexplained painless 2nd-trimester losses or preterm births. Timing: week 12⁺⁰-14⁺⁶ (after confirming viability and ruling out aneuploidy).
• Ultrasound-indicated (therapeutic): prior spontaneous preterm birth <34 weeks + cervical length <25mm on transvaginal ultrasound surveillance before week 24.
• Emergency/rescue: painless dilation with membranes protruding into the vagina/external cervical os between weeks 16-24, without active labor, chorioamnionitis, or placental abruption.

Classification: primary (congenital, malformations, collagen disorders) or secondary (conization, dilations, lacerations). Prophylactic cerclage (based on history), therapeutic cerclage (based on ultrasound), or emergency cerclage (based on physical examination) (Ginecol Obstet Méx 2020).

By history — variants: RCOG GTG 75: ≥3 losses or preterm births in the 2nd trimester; with 1-2, serial ultrasound at 16-24 weeks and cerclage if ≤25 mm. ACOG: may be offered after 1 typical loss.

Short cervix without prior history (≤20 mm): vaginal progesterone; cerclage is not indicated.

CaVeSal® proprietary algorithm · Based on: GPC IMSS 539 · UNAM (Espinosa Flores) · FASGO 2021 · ACOG PB 142.

Contraindications: active labor, intra-amniotic infection, active bleeding, PROM, placental abruption, lethal fetal anomaly, or fetal demise.

Fetal fibronectin: does not diagnose cervical insufficiency; predicts preterm birth in preterm labor (high negative predictive value).

Cerclage removal: scheduled electively at 36-37 weeks (or immediately if active labor/chorioamnionitis).

CaVeSal® proprietary algorithm · Based on: MSPBS 2018 (p. 63) · WHO 2022 · NICE NG126.

Evacuation: WHO recommends aspiration and advises against sharp curettage before 14 weeks; MSPBS uses MVA before 13 and D&C from 13 to 22. The calculator ends at 13 weeks.

• With sepsis or septic shock: IV antibiotics within the 1st hour + immediate evacuation for source control (Code Yellow — Sepsis, Rule 4-5-3; SSC 2021).
• Without sepsis: IV antibiotics and evacuation 6-8 h after initiation (Clinical Practice Guideline IMSS-088, Ecuador Clinical Practice Guideline). Other guidelines: 12 h or 24-48 h.
• MSPBS regimens (72 h): ampicillin + metronidazole · cefazolin + metronidazole · ceftriaxone + metronidazole · gentamicin + metronidazole · gentamicin + clindamycin · ampicillin/sulbactam + clindamycin · ampicillin 2 g + gentamicin 5 mg/kg + metronidazole.

• WHO / RCOG GTG 17: 3 consecutive losses.
• ESHRE 2022 / ASRM: ≥2, not necessarily consecutive.
• National literature (Acosta, Paraguay): 3 consecutive or 5 nonconsecutive losses.

Management: genetic counseling and gynecologic-obstetric and reproductive evaluation.

PUL: do not treat without ultrasound confirmation; βhCG at 48 h with a minimum rise of 49 % (<1500), 40 % (1500-3000) or 33 % (>3000) (AAFP 2020).

Complicated (free fluid, severe pain, instability): emergency surgery + Code Red; salpingectomy is preferred.

CaVeSal® proprietary algorithm · Based on: MSPBS 2018 · NICE NG126 (ectopic pregnancy).

Methotrexate follow-up: β-hCG on days 4 and 7; decline ≥15 % → weekly until negative; otherwise, second dose or surgery. Anti-D if Rh(-).

Non-tubal ectopics (RCOG GTG 21): cervical → methotrexate; for evacuation, uterine artery embolization or vaginal uterine artery clamping (Zea technique) · cesarean scar → neither expectant management nor systemic methotrexate alone; aspiration or resection · interstitial/cornual → methotrexate or cornual resection · abdominal → early laparoscopy; advanced, laparotomy with the placenta left in situ.

Diagnosis: complete (snowstorm appearance, enlarged uterus, very high β-hCG, diploid) vs. partial (fetus, placenta with cysts, triploid). Chest X-ray in all cases.

Treatment: suction evacuation with oxytocin started at the time of aspiration; histopathology in all cases; contraception.

CaVeSal® proprietary algorithm · Based on: MSPBS 2018 · RCOG 2020.

CaVeSal® proprietary algorithm · Based on: ACOG PB 183 (2017) · RCOG GTG 63 · MSPBS/SPGO 2018 · MSPBS Code Red 2022.

Placenta previa: Diagnosis by transvaginal ultrasound — placenta previa if it covers the internal os; low-lying placenta if <20mm from the internal os.

• Stable/no active bleeding: fetal lung maturation at 34-36⁺⁶ weeks; elective cesarean delivery at 36⁺⁰-37⁺⁶.
• Severe active hemorrhage: stabilization + immediate emergency cesarean delivery, regardless of gestational age.

Placental abruption: immediate delivery.

• Emergency cesarean delivery: general rule if the fetus is alive with compromise or the mother is unstable.
• Fetal demise: MSPBS recommends cesarean delivery for grades II and III; RCOG GTG 63 and the 2013 Colombian CPG accept vaginal delivery with a stable mother, early amniotomy, and oxytocin (see card 9).

Timing definition: bleeding in the second half of pregnancy = vaginal bleeding from 22.0 weeks until before birth.

Initial stabilization protocol:

• O2 via non-rebreather mask at 10 L/min, target SpO2 >95%.
• 2 large-bore peripheral IV lines (14G or 16G).
• Tube color code: blue (coagulation: PT/aPTT/fibrinogen), red/brown (chemistry), lavender (CBC + crossmatch/blood bank).
• Warm crystalloids at 37-39°C in 250-500 mL boluses, target SBP ≥90 mmHg while avoiding fluid overload.
• Check vital signs every 15 min with EAPO + Foley catheter, target urine output ≥30 mL/h.

Expectant management (placenta previa only) — eligibility: GA <34 weeks + scant/self-limited bleeding + stable mother + normal fetal well-being.

• Strict bed rest in the left lateral position.
• Lung maturation: Betamethasone 12mg IM every 24h ×2 doses or dexamethasone 6mg IM every 12h ×4 doses (if <34 weeks).
• Neuroprotection with MgSO4 if preterm labor is threatened at <32 weeks.
• Serial CBCs + strict monitoring of blood loss.

Indications for emergency cesarean delivery (regardless of GA): active moderate-to-severe bleeding unresponsive to conservative measures; hemodynamic instability/shock; acute fetal distress; confirmed placental abruption or uterine rupture/strong suspicion; complete placenta previa at term ≥37.0 weeks.

CaVeSal® proprietary algorithm · Based on: MSPBS/SPGO · Code Red 2021 · ACOG · RCOG · SPGO.

1. Activate the obstetric emergency team + notify the obstetrician on call.
2. Left lateral position + supplemental oxygen by face mask; stop oxytocin infusion if running.
3. 2 large-bore IV lines (16G), samples for CBC + coagulation studies + crossmatch for 6 units.
4. Crystalloids/blood products as needed; continuous monitoring of vital signs + CTG.
5. Prepare the operating room for emergency cesarean delivery — birth within 30 minutes of the decision (Category 1), anticipating neonatal resuscitation.
6. In hemodynamic instability: fluid resuscitation/transfusion in parallel with surgical preparation, without waiting for complete stabilization before operating.

Incision: Pfannenstiel incision provides good exposure of the lower uterine segment/pelvis; a vertical midline incision provides better exposure for exploring the entire abdominal cavity (including the uterine fundus)—preferred when fetal distress and maternal instability coexist.

Repair vs. hysterectomy: depends on the extent of the injury, patient stability, desire for future fertility, and surgeon experience — if adequate closure and hemostasis cannot be achieved → hysterectomy (usually subtotal).

Complications to manage: concomitant uterine atony (uterotonics + hemostatic sutures + intrauterine balloon); bladder injury if the laceration extends to the bladder, or suspected ureteral injury → consult urology.

Hemorrhage control after delivery if bleeding persists: abdominal packing, uterine artery ligation, internal iliac artery ligation, topical hemostatic agents, cesarean hysterectomy as a last resort.

General anesthesia is usual; regional/spinal anesthesia is contraindicated in cases of severe bleeding diathesis.

Antenatal diagnosis by ultrasound (color Doppler along the cervical route) allows elective cesarean delivery to be scheduled before the onset of labor — fetal survival >95% with antenatal diagnosis + planned cesarean delivery, vs. fetal mortality ≥60% when diagnosed intrapartum.

• Timing of elective cesarean delivery: SMFM Consult Series #37 recommends scheduled cesarean delivery between 34⁺⁰ and 37⁺⁶ weeks (GRADE 2C).
• Antenatal corticosteroids: consider between 28-32 weeks if there is a risk of urgent preterm delivery (GRADE 2C), not routinely in asymptomatic patients; a 2023 review suggests administering them within the 7 days before scheduled delivery.
• Antenatal hospitalization: proposed from 30-34 weeks in some series (GRADE 2C), but evidence is insufficient to make it a mandatory standard — individualized decision.

CaVeSal® proprietary algorithm · Based on: SMFM.

Without placenta previa, risk ranges from 0.24% to 6.74% according to the number of cesarean deliveries.

Ultrasound signs (ISUOG 2016): loss of the retroplacental clear zone, placental lacunae, myometrial thinning <1 mm, disruption of the bladder line, placental bulge, focal exophytic mass; Doppler: uterovesical or subplacental hypervascularity and bridging vessels.

Management: level III-IV center with a multidisciplinary team and blood bank; corticosteroids if <37 weeks; tranexamic acid at onset; uterine incision away from the placenta and cesarean hysterectomy with the placenta in situ (do not attempt placental separation). Activate Code Red in the event of bleeding.

CaVeSal® proprietary algorithm · Based on: Jauniaux E et al. FIGO classification, Int J Gynaecol Obstet 2019 · FIGO — Classification of PAS disorders · Silver RM et al. Obstet Gynecol 2006;107:1226-32 · ACOG/SMFM OCC No. 7 · RCOG GTG 27b · ISUOG/EW-AIP 2016.

• Classification: complete, partial, marginal, lateral (>2 cm from the internal os). Definitive diagnosis from 32 weeks.
• Expectant management <34+0 weeks with mild bleeding; from 34+0, cesarean delivery with recurrent bleeding. MSPBS mentions 35 weeks in one chapter; CaVeSal uses 34+0 for consistency.
• Asymptomatic complete previa: admission at 36 and cesarean at 37 (ACOG/SMFM: 36+0-37+6).
• Marginal previa in labor: amniotomy and trial of vaginal birth with the operating room ready; lateral previa: vaginal delivery may be possible.
• Tocolysis (hybrid): nifedipine only with preterm labor, light bleeding, and stability; avoid with heavy bleeding, instability, or fetal compromise (RCOG GTG 63).
• Prior cesarean: rule out placenta accreta (calculation in the CaVeSal prenatal calculator).

CaVeSal® proprietary algorithm · Based on: MSPBS 2018 (p. 83).

• Fetal death — expectant management: RCOG GTG 63, Colombia CPG 2013 y Universidad Nacional de Colombia: vaginal delivery if the mother is stable, with early amniotomy and oxytocin.
• Tocolysis: optional in mild abruption <34 weeks with a stable mother and no fetal compromise, at the discretion of the senior obstetrician, to complete fetal maturation (observational studies).
• ≥34 weeks in advanced labor: vaginal delivery may be possible with amniotomy and continuous monitoring (NHS Worcestershire).

CaVeSal® proprietary algorithm · Based on: Clínica Universidad de Navarra · Medway.

Impending: discontinue uterotonics, initiate acute uterine inhibition, and perform urgent cesarean delivery. Established: laparotomy; uterine repair if the rupture is not extensive and the patient is stable, hysterectomy if irreparable; evaluate the bladder if hematuria occurred.

CaVeSal® proprietary algorithm · Based on: MSPBS 2018 · ACOG/SMFM · SMFM CS 44 · FIGO 2018.

• Planned PAS: TXA 1 g, incision away from the placenta, no traction or uterotonics, cesarean hysterectomy with the placenta left in situ.
• Conservative (focal, in centers with experience): placenta in situ, one-stage resection, arterial embolization (FIGO 2018 conservative management). MSPBS includes methotrexate; FIGO does not recommend it. Prophylactic iliac balloons: not routinely.
• Vasa previa with bleeding after PROM or a sinusoidal pattern: immediate cesarean delivery.

• Immediate (first 24h): highest risk of PPH/4Ts — monitor vital signs, uterine tone (Pinard’s safety globe) and bleeding every 15 min for the first 2 h (MSPBS), then every 6 h — see flowchart in sheet 5.
• Early (day 2 to 7-10): onset of lactogenesis II, progressive intra-pelvic uterine involution (~1cm/day), red/serous lochia.
• Late (day 11 to 42/6 weeks): return of the genital organs to the pre-pregnancy state, resolution of lochia (alba), resumption of ovulation if not exclusively breastfeeding.

Uterine involution: the uterine fundus should not be palpable above the pubic symphysis from postpartum day 10-12.

CaVeSal® proprietary algorithm · Based on: WHO 2022 (postnatal care) · ACOG CO 736 (2018).

Perineal/surgical wound care: wash with water and mild soap, pat dry, monitor for infection/dehiscence of episiotomy repair or cesarean incision.

Definition (MSPBS): from the birth of the newborn until expulsion of the placenta. A period with potential risk of hemorrhage.

Signs of placental separation: lengthening of the cord · sudden gush of blood · the uterus rises and becomes globular (Schröder) · the cord does not retract with suprapubic pressure (Küstner). Both signs were positive in 98 % of placentas with ultrasound-confirmed separation.

Ultrasound shows that separation usually begins at the lower pole; the observed mechanism is determined as the placenta exits through the vulva.

CaVeSal® original table · Based on: MSPBS, Normas de Cuidados 2022, p. 69 · WHO/FIGO/ICM 2025, rec. 16, 30 and 31 · NICE NG235 (2023) · Herman et al., ultrasound and clinical findings in the third stage · El-Mowafi, GFMER — Schultze 80 % / Duncan 20 %. Third-stage timer in the calculator →

CaVeSal® proprietary algorithm · Based on: MSPBS, Normas de Cuidados 2022, pp. 69-71 · WHO 2018, intrapartum care, rec. 52, 55 and 56 · WHO/FIGO/ICM 2025, rec. 22. Dynamic 2 h monitoring in the calculator →

Hormonal axis: prolactin (production through suckling) + oxytocin (milk ejection through myoepithelial contraction).

Correct latch: mouth wide open, lower lip everted, covering most of the lower areola, chin against the breast, nose unobstructed.

Physiological breast engorgement: manually express a few drops beforehand to soften the areola, frequent on-demand feeds, brief warm compresses before feeding + local cold after feeding.

Etiology: milk stasis + bacterial superinfection; most common pathogen Staphylococcus aureus (and S. epidermidis).

Clinical presentation: severe unilateral breast pain, wedge-shaped/well-demarcated erythema, local warmth, induration, fever ≥38.5°C, flu-like symptoms.

1. Initial management (ALL cases):
   • NEVER stop breastfeeding — frequent and effective emptying of the affected breast is the mainstay; breast milk poses no infectious risk to a term infant.
   • Warm compresses before feeding + cold after feeding.
   • Analgesia: Ibuprofen 400-600mg orally every 8h or acetaminophen 500-1000mg orally every 6-8h.
   • Maternal hydration and rest.
2. Reassess at 12-24h — start antibiotics ONLY IF there are systemic symptoms (fever >38.5°C, chills, myalgia) OR there is no clinical improvement after 12-24h of optimized nonpharmacological management.
3. Antibiotic regimen (10-14 days) if the above criterion is met:

   Scenario	Medications and doses
   1st line (methicillin-susceptible, outpatient)	Cephalexin 500mg orally every 6h; Cloxacillin/Dicloxacillin 500mg orally every 6h; Amoxicillin + Clavulanic acid 875/125mg orally every 8-12h
   Penicillin/beta-lactam allergy	Clindamycin 300mg orally every 6h; Erythromycin 500mg orally every 6h
   Suspected MRSA	Trimethoprim/sulfamethoxazole 160/800mg orally every 12h (avoid if infant is <1 month old with jaundice) or IV vancomycin if hospitalization is required

   CaVeSal® proprietary algorithm · Based on: ABM Clinical Protocol #36 (2022) · WHO — Mastitis.

Clinical suspicion: persistent painful fluctuant mass with erythema that does not resolve after 48-72h of antibiotics.

Criteria for referral to the emergency department/surgery:

• Treatment failure (persistence/worsening after 48-72h of appropriate antibiotics + effective milk drainage).
• Signs of a collection (fluctuant mass, induration, overlying skin thinned/shiny).
• Severe systemic involvement (refractory fever >38.5°C, tachycardia, hypotension, marked leukocytosis, suspected sepsis/SIRS).
• Local complications (ischemia, skin necrosis, rapid spread of erythema, suspected granulomatous mastitis/inflammatory breast cancer — oncologic red flag).
• Technical difficulty (image-guided percutaneous drainage not feasible at the facility).

Ultrasound diagnosis (gold standard): hypoechoic/anechoic collection, irregular/microlobulated margins, thickened wall with Doppler hypervascularity; heterogeneous contents with mobile internal echoes, septa, sometimes fluid-fluid levels or gas bubbles; posterior acoustic enhancement; color Doppler shows no flow in the center with increased peripheral vascularity (inflammatory halo); perilesional edema.

1. Ultrasound-guided fine-/large-bore needle aspiration (first line): collections <3-5cm, intact skin without necrosis. 16G-18G needle + 10-20mL syringe under ultrasound guidance, complete aspiration + saline irrigation. May be repeated every 48-72h if recurrence (success rate >85-90%). Always send for culture (aerobes, anaerobes, susceptibility testing).
2. Percutaneous catheter drainage: abscesses ≥3-5cm or rapid recurrence after simple aspiration. Ultrasound-guided 8-12Fr pigtail catheter, daily irrigation, removal when output is <10-15mL/24h and the cavity has collapsed.
3. Open surgical incision and drainage: failure of percutaneous drainage/repeated aspiration, extensive multiloculated abscesses, or skin compromise with necrosis/ischemia. Curvilinear incision respecting Langer’s lines (or periareolar), gentle digital debridement, irrigation + passive drainage (Penrose drain or iodoform gauze) for healing by secondary intention.

Do not stop breastfeeding; continue emptying the affected breast.

• If the infant’s mouth does NOT come into direct contact with the wound/drain/infected area → direct breastfeeding is safe.
• If the incision/drainage involves the areola or nipple → express milk mechanically/by hand; breastfeed from the unaffected breast while visible pus contamination persists.

CaVeSal® proprietary algorithm · Based on: MSPBS/DGPS Paraguay, “Time is life” (ICT model, training material) · MSPBS Maternal and Neonatal Code Red Guide, 2nd ed. (2021).

CaVeSal® proprietary algorithm · Based on: Cresswell et al., Lancet Glob Health 2025 · WHO, Trends in Maternal Mortality 2000-2023

• Delay 1: in seeking help.
• Delay 2: in reaching care.
• Delay 3: in receiving appropriate treatment.
• They correspond to delays in identifying, stabilizing and treating/transferring, each associated with declining survival.
• Pathophysiology: hypovolemic shock with DIC and peripheral redistribution (cardiothoracic due to sympathetic activity; peripheral due to parasympathetic activity).

Global context: causes of maternal death — hemorrhage ~27%, hypertensive disorders ~14%, sepsis ~11% (Cresswell et al., Lancet Glob Health 2025). In 2023, there were ~260,000 maternal deaths (≈1 every 2 minutes), global MMR 197/100,000 live births, 40% lower than in 2000 (WHO, Trends in Maternal Mortality 2000-2023).

Three-delays model: Thaddeus & Maine 1994. Official graphic version, MSPBS/DGPS Paraguay.

• Apply the Early Obstetric Warning Score (EAPO) and start the timer.
• Look for signs of MODS (multiple organ dysfunction syndrome): severe, acquired functional abnormality of at least 2 organ systems; an early detection criterion for extreme maternal morbidity/near-miss.
• Determine the cause: hemorrhage (4 Ts), severe hypertensive disorder, or infection.

Definition of MODS adopted from the Latin American obstetric literature (Rev Méd IMSS).

5 basic steps: call for help · 2 peripheral IV lines · oxygen therapy · urinary catheterization · prevent hypothermia.

Detailed version (8 steps):

1. Call for help.
2. Ensure airway patency.
3. Administer oxygen.
4. Insert 2 intravenous catheters, No. 14, 16, or 18 gauge.
5. Parenteral hydration with normal saline: maintain systolic BP >90 mmHg and urine output >30 mL/h (or >0.5 mL/kg/h); in hypertension, maintain diastolic BP >90 mmHg.
6. Urinary catheter and urine output monitoring.
7. Cover with a blanket to prevent hypothermia.
8. Monitor vital signs using the Code Red Alert Scale every 5-10 min.

Urine output target: >0.5 mL/kg/h (international clinical standard, WHO/StatPearls) or >30 mL/h (MSPBS/DGPS); both are shown with their source.

CaVeSal® proprietary algorithm · Based on: ATLS · Plaat F (classification adapted to obstetrics) · WHO 2025.

Intervention according to response: sustained improvement → no further intervention; partial improvement → fluid challenges; no improvement → blood products + surgery; no response → immediate surgical control.

Do not administer predetermined 1-2 L fluid loads or use replacement formulas. IV isotonic crystalloid boluses of 500 mL at 39 °C; assess radial pulse and mental status. Isotonic crystalloids over colloids (WHO 2025, Rec. 28).

1. Continuous external uterine massage throughout management, until bleeding stops.
2. Bimanual massage for ≥20 min or until bleeding stops if external massage is ineffective; additional uterotonics, Pinard safety balloon, and tranexamic acid.
3. Continue bimanual compression until bleeding stops (no bleeding when compression is released and uterus is contracted).
4. Abdominal aortic compression: closed fist (thumb out), pressing downward just above the umbilicus and slightly to the left.
5. Immediate surgical intervention if uterine tone is not restored: B-Lynch compression suture or obstetric hysterectomy.

Technique consistent with WHO, Managing Complications in Pregnancy and Childbirth, 2nd ed. 2017.

• Oxytocin IM: 10 IU if no IV line is in place.
• Oxytocin IV: 5 IU slowly over 5 min; may be repeated after 5 min up to a maximum of 10 IU.
• IV maintenance: 20 IU in 500 cc of normal saline over 4 h (80 mIU/min = 42 drops/min = 126 cc/h by pump).
• Misoprostol 800 µg SL as a 3rd option if oxytocin or ergonovine is unavailable.

CaVeSal® proprietary algorithm · Based on: WHO · FIGO 2022 · ACOG.

Contraindicated in hypertension, preeclampsia/eclampsia, and heart disease. Indicated if oxytocin is unavailable or the response is insufficient after 30 min.

Antibiotic prophylaxis after correction (single dose, together with oxytocin to prevent recurrence):

• Ampicillin 2 g IV + metronidazole 500 mg IV, or
• Cefazolin 1 g IV + metronidazole 500 mg IV (penicillin allergy).

Vascular ligation: bilateral uterine artery ligation (O'Leary) is the first-choice conservative surgical option (simpler, faster, immediate efficacy ~80-90%); internal iliac artery ligation is more complex (ureteral/venous risk, efficacy ~65-70%) and is reserved for failure of the former. Variants: Posadas technique (posterior selective devascularization of the uterine and internal tubal arteries, Series of 750 cases) and Tsirulnikov (triple ligation of the round ligaments, utero-ovarian and uterine arteries). Vaginal bridge: Zea technique (INPer — Zea technique).

The hierarchy reflects technical ease and risk profile, not absolute superiority in efficacy (FIGO/WHO).

• 1:1:1 ratio — RBCs 6 U : FFP 6 U : 1 apheresis unit (or 6 U) of platelets.
• Cryoprecipitate 10-20 units.
• Fibrinogen concentrate 2 g.
• Tranexamic acid 1 g.
• Fibrinogen <2 g/L: independent risk factor for massive PPH, OR 12.0 (95% CI 2.6-56.1) (Cortet et al., Br J Anaesth 2012); between 2 and 3 g/L, OR 1.90 (1.16-3.09).

Supporting reviews: Butwick, Int J Obstet Anesth 2013;22:87-91 · Pacheco et al., AJOG 2011;205(6):526-532.

CaVeSal® original table · Original content by Dr. Carlos Vera Salerno (“Emergencias Obstétricas 2025”).

Original content: Dr. Carlos Vera Salerno, “Emergencias Obstétricas 2025”. Complements the allocation by body area.

Assess and treat in order; if the patient deteriorates, return to “x”. Tasks are carried out simultaneously by team members.

CaVeSal® proprietary algorithm · Based on: StatPearls — Trauma Assessment (xABCDE, ATLS 11th ed.) · ACS — ATLS 11 launch · Victorian State Trauma System — Obstetric Trauma Guideline v2.0, pp. 7-9 and 11 · Krywko DM et al. StatPearls — Pregnancy Trauma · Frimley Health — Maternal Collapse in Pregnancy and the Puerperium (ABCDE) · Heras A. — Preeclampsia Checklist.

• Positive FAST in an unstable pregnant patient = significant finding. If stable, it can be performed during the secondary survey, ideally by a second operator.
• Performance for free fluid: sensitivity 61 % and specificity 94 % in pregnant patients (compared with 71 % and 97 % in nonpregnant patients). A negative FAST does not rule out bleeding.
• Ultrasound has low sensitivity for placental abruption: it cannot be used to rule it out.
• Severe preeclampsia: B-pattern was associated with elevated filling pressures. Restrict fluids (pilot study, n = 20).
• Subcapsular hematoma: bedside ultrasound in the unstable patient; CT if stable.

CaVeSal® proprietary algorithm · Based on: Victorian Obstetric Trauma Guideline v2.0, pp. 8 and 15 · OpenAnesthesia — Obstetric Trauma · Zieleskiewicz L et al. Anesthesiology 2014;120(4):906-914 · Hepatic rupture in HELLP, case report (PMC) · Subcapsular hepatic hematoma in HELLP (PMC).

CaVeSal® proprietary algorithm · Based on: MSPBS Maternal and Neonatal Code Red Guide, 2nd ed. (2021), pp. 32-33, 39, 70 and 124-126 · WHO-PQ — magnesium sulfate technical information (RH086) · Victorian Obstetric Trauma Guideline v2.0, p. 11.

CaVeSal® proprietary algorithm · Based on: PAHO/WHO — Robson Classification: application manual (2018).

It is classified using 6 variables: parity, prior cesarean delivery, onset of labor, number of fetuses, presentation/lie, and GA. Groups are mutually exclusive. Groups 1, 2 and 5 usually account for most cesarean deliveries and are the target of reduction strategies. Source: PAHO/WHO — Robson Classification: application manual (2018).

CaVeSal® proprietary table · Based on: PAHO/WHO — Robson Classification: application manual (2018).

Classification at admission and real-time use

• It is applied to every woman admitted for birth, prospectively: each woman is assigned a group at admission and followed to the outcome (WHO — Robson Platform; WHO implementation manual).
• Real-time use is institutional: each birth is recorded as it happens to track the cesarean rate by group and plan actions (quality improvement experience). WHO provides a platform where hospitals upload these data (WHO Bulletin).
• Standard report by group: number of cesareans, number of women, group size, group cesarean rate, absolute and relative contribution to the overall rate (Robson report table).
• Robson does not assess whether a cesarean was appropriately indicated: that requires an audit of indications.
• In CaVeSal®: the Prenatal Calculator shows the probable group (prognosis); the Emergency calculator assigns the group at admission with intrapartum management (Labor tab).

CaVeSal® proprietary algorithm · Based on: sources listed for each group · PAHO/WHO — Robson Classification (2018).

Fetal lung maturation, magnesium sulfate neuroprotection, tocolysis and PROM follow the management already set in their cards in this guide and in the calculator. Does not replace clinical judgment.

CaVeSal® proprietary algorithm · Based on: StatPearls — Bishop Score.

Variant: the modified Bishop score (Calder) replaces effacement with cervical length (cm). Unfavorable cervix → cervical ripening (misoprostol, Foley balloon) before oxytocin. Source: StatPearls — Bishop Score.

CaVeSal® proprietary algorithm · Based on: Gordijn SJ et al. Consensus definition of fetal growth restriction: a Delphi procedure. Ultrasound Obstet Gynecol 2016;48(3):333-9 · Hospital Universitario Virgen de las Nieves — FGR Protocol (2025) · Valenti EA et al. 2017 FASGO Consensus Update: FGR · Sardá Maternity Hospital — Clinical Practice Guideline for Fetal Growth Restriction.

It is subdivided into early-onset (<32 weeks) and late-onset (≥32 weeks). Sources: Delphi consensus (Gordijn 2016) · HUVN FGR protocol · FASGO 2017 · SARDA.

CaVeSal® proprietary algorithm · Based on: ACOG PB 216 (2020) · RCOG GTG 42 (2018, shoulder dystocia).

Macrosomia: ≥4000 g (some guidelines reserve the term for ≥4500 g); LGA: EFW ≥p90. In our setting, consider a history of birth weight ≥4000 g. Sources: ACOG PB 216 (2020) · RCOG GTG 42 (2018, shoulder dystocia).

• Height <145-150 cm is not an indication for cesarean delivery (WHO 2018, FIGO, ACOG): it is a biomechanical risk factor; allow a trial of labor with a strict partograph and, if available, intrapartum ultrasound.
• MSPBS: height <145 cm → referral to orthopedics and genetics (possible skeletal dysplasia), not a criterion for mode of delivery.
• CPD is diagnosed intrapartum: adequate uterine activity (3-5/10 min, >2-4 h), dilation ≥5-6 cm, and lack of progress in dilation or descent. Signs: cervical edema, marked caput with overlapping sutures, persistent asynclitism. Once confirmed → cesarean delivery.
• Estimated fetal weight ≥4000 g + short stature → heightened alert for surveillance of CPD, not automatic cesarean delivery.

Sources: WHO Intrapartum care 2018 · MSPBS Manual Nacional Prenatal · ACOG PB 216 · Williams Obstetrics 26.ª ed. (2022) · Caldwell-Moloy 1933 (tipos de pelvis).