《妇幼保健学 Maternal and Child Health》课程教学资源（文献资料）Integrated Management of Pregnancy and Childbirth（IMPC）孕产妇保健指南 Pregnancy, Childbirth, Postpartum and Newborn Care：A guide for essential practice.pdf_P16-P20

Standard precautions and cleanliness A4 38V0 STANDARD PRECAUTIONS AND CLEANLINESS 8 Observe these precautions to protect the Protect yourself from blood and Practice safe waste disposal Clean and woman and her baby,and you as the health other body fluids during deliveries disinfect gloves provider.from infections with bacteria and Dispose of placenta or blood,or body fluid 超 Wear gloves;cover any cuts,abrasions or contaminated items,in leak-proof containers. viruses,including HIV. Wash the gloves in soap and water. broken skin with a waterproof bandage; Bum or bury contaminated solid waste. Check for damage:Blow gloves full of air,twist Wash hands take care when handling any sharp Wash hands,gloves and containers after the cuff closed,then hold under clean water disposal of infectious waste. 石 instruments(use good light);and practice and look for air leaks.Discard if damaged. Wash hands with soap and water: safe sharps disposal. Pour liquid waste down a drain or flushable toilet. Soak ovemight in bleach solution with 0.5% Before and after caring for a woman .Wear a long apron made from plastic or Wash hands after disposal of infectious waste available chlorine (made by adding 90 ml or newbom,and before any treatment other fluid resistant material,and shoes. water to 10 ml bleach containing 5%available procedure If possible,protect your eyes from splashes Deal with contaminated chlorine) Whenever the hands(or any other skin of blood. laundry Dry away from direct sunlight. area)are contaminated with blood or other Dust inside with talcum powder or starch. body fluids Practice safe sharps disposal Collect clothing or sheets stained with blood After removing the gloves,because they or body fluids and keep them separately from This produces disinfected gloves.They are not may have holes Keep a puncture resistant container nearby. other laundry,wearing gloves or use a plastic sterile. After changing soiled bedsheets or clothing. Use each needle and syringe only once. bag.DO NOT touch them directly. ■Keep nails short Do not recap,bend or break needles after Rinse off blood or other body fluids before Good quality latex gloves can be disinfected 5 or giving an injection. washing with soap. more times. Wear gloves Drop all used (disposable)needles,plastic syringes and blades directly into this Wear sterile or highly disinfected gloves when Sterilize and clean contaminated container,without recapping.and without Sterilize gloves perfomming vaginal examination,delivery,cord equipment passing to another person. Sterilize by autoclaving or highly disinfect by cutting.repair of episiotomy or tear,blood Empty or send for incineration when the Make sure that instruments which penetrate steaming or boiling. drawing. container is three-quarters full. the skin(such as needles)are adequately Wear long sterile or highly disinfected gloves for sterilized,or that single-use instruments are manual removal of placenta. disposed of after one use. Wear clean gloves when: Thoroughly clean or disinfect amy equipment -Handling and cleaning instruments which comes into contact with intact skin Handling contaminated waste (according to instructions). Cleaning blood and body fluid spills Use bleach for cleaning bowls and buckets, ■Drawing blood and for blood or body fluid spills

Standard precautions and cleanliness PRINCIPLES OF GOOD CARE A4 Observe these precautions to protect the woman and her baby, and you as the health provider, from infections with bacteria and viruses, including HIV. Wash hands N Wash hands with soap and water: ¡ Before and after caring for a woman or newborn, and before any treatment procedure ¡ Whenever the hands (or any other skin area) are contaminated with blood or other body fluids ¡ After removing the gloves, because they may have holes ¡ After changing soiled bedsheets or clothing. N Keep nails short. Wear gloves N Wear sterile or highly disinfected gloves when performing vaginal examination, delivery, cord cutting, repair of episiotomy or tear, blood drawing. N Wear long sterile or highly disinfected gloves for manual removal of placenta. N Wear clean gloves when: ¡ Handling and cleaning instruments ¡ Handling contaminated waste ¡ Cleaning blood and body fluid spills N Drawing blood. Protect yourself from blood and other body fluids during deliveries ¡ Wear gloves; cover any cuts, abrasions or broken skin with a waterproof bandage; take care when handling any sharp instruments (use good light); and practice safe sharps disposal. ¡ Wear a long apron made from plastic or other fluid resistant material, and shoes. ¡ If possible, protect your eyes from splashes of blood. Practice safe sharps disposal N Keep a puncture resistant container nearby. N Use each needle and syringe only once. N Do not recap, bend or break needles after giving an injection. N Drop all used (disposable) needles, plastic syringes and blades directly into this container, without recapping, and without passing to another person. N Empty or send for incineration when the container is three-quarters full. Practice safe waste disposal N Dispose of placenta or blood, or body fluid contaminated items, in leak-proof containers. N Burn or bury contaminated solid waste. N Wash hands, gloves and containers after disposal of infectious waste. N Pour liquid waste down a drain or flushable toilet. N Wash hands after disposal of infectious waste. Deal with contaminated laundry N Collect clothing or sheets stained with blood or body fluids and keep them separately from other laundry, wearing gloves or use a plastic bag. DO NOT touch them directly. N Rinse off blood or other body fluids before washing with soap. Sterilize and clean contaminated equipment N Make sure that instruments which penetrate the skin (such as needles) are adequately sterilized, or that single-use instruments are disposed of after one use. N Thoroughly clean or disinfect any equipment which comes into contact with intact skin (according to instructions). N Use bleach for cleaning bowls and buckets, and for blood or body fluid spills. Clean and disinfect gloves N Wash the gloves in soap and water. N Check for damage: Blow gloves full of air, twist the cuff closed, then hold under clean water and look for air leaks. Discard if damaged. N Soak overnight in bleach solution with 0.5% available chlorine (made by adding 90 ml water to 10 ml bleach containing 5% available chlorine). N Dry away from direct sunlight. N Dust inside with talcum powder or starch. This produces disinfected gloves. They are not sterile. Good quality latex gloves can be disinfected 5 or more times. Sterilize gloves N Sterilize by autoclaving or highly disinfect by steaming or boiling. STANDARD PRECAUTIONS AND CLEANLINESS

ORGANIZING A VISIT Receive and you can about what you are doing.If she is Begin each routine visit If follow-up visit is within a week,and if no respond immediately unconscious,talk to the companion. (for the woman and/or the baby) other complaints: Ensure and respect privacy during Assess the woman for the specific condition Receive every woman and newborn baby examination and discussion. Greet the woman and offer her a seat. requinng follow-up only seeking care immediately after arrival(or If she came with a baby and the baby is ■Introduce yourself -Compare with earlier assessment and organize reception by another provider). well,ask the companion to take care of the Ask her name(and the name of the baby). re-classify. Perform Ouick Check on all new incoming baby during the maternal examination and ■Ask her: If a follow-up visit is more than a week after women and babies and those in the waiting treatment -Why did you come?For yourself or for your the initial examination(but not the next room,especially if no-one is receiving themE2 baby? scheduled visit): At the first emergency sign on Quick Care of woman or baby referred for For a scheduled (routine)visit? Repeat the whole assessment as required Check,begin emergency assessment and For specificcomplaints about you or your special care to secondary level facility for an antenatal,post-abortion,postpartum management(RAM)EE for the woman,or baby? or newborn visit according to the schedule examine the newborn When a woman or baby is referred to a First or follow-up visit? If antenatal visit,revise the birth plan. If she is in labour,accompany her to an secondary level care facility because of Do you want to include your companion or appropriate place and follow the steps as in a specific problem or complications,the other family member(parent if adolescent) Childbirth:labour,delivery and immediate During the visit underlying assumption of the Guide is that. in the examination and discussion? postpartum care Dib2s at referral level,the woman/baby will be If the woman is recently delivered,assess the Explain all procedures, If she has priority signs,examine her assessed.treated,counselled and advised baby or ask to see the baby if not with the mother. Ask permission before undertaking an immediately using Antenatal care, on follow-up for that particular condition/ If antenatal care,always revise the birth plan at examination or test. Postpartum or Post-abortion care charts complication. the end of the visit after completing the chart. Keep the woman informed throughout. C1-C19E1E10B18-822 Follow-up for that specific condition will be For a postpartum visit,if she came with the Discuss findings with her (and her partner) If no emergency or priority sign on RAM or not either: baby,also examine the baby: Ensure privacy during the examination and in labour,invite her to wait in the waiting room. organized by the referral facility or Follow the appropriate charts according discussion. If baby is newly born,looks small,examine written instructions will be given to the to pregnancy status/age of the baby and immediately.Do not let the mother wait in the woman/baby for the skilled attendant at purpose of visit. At the end of the visit queue. the primary level who referred the woman/ Follow all steps on the chart and in relevant Ask the woman if she has any questions. 告 baby. boxes. Summarize the most important messages with her. Begin each emergency care visit the woman/baby will be advised to go for a Unless the condition of the woman or the Encourage her to return for a routine visit(tell ■Introduce yourself.. follow-up visit within 2 weeks according to baby requires urgent referral to hospital,give her when)and if she has any concerns. severity of the condition. Ask the name of the woman. preventive measures if due even if the woman Fill the Home-Based Maternal Record(HBMR) Routine care continues at the primary care has a condition"in yellow"that requires and give her the approprate information sheet 5 Encourage the companion to stay with the woman Explain all procedures,ask permission, level where it was initiated. special treatment. Ask her if there are any points which need to be and keep the woman informed as much as discussed and would she like support for this A5

A5 PRINCIPLES OF GOOD CARE Receive and respond immediately Receive every woman and newborn baby seeking care immediately after arrival (or organize reception by another provider). N Perform Quick Check on all new incoming women and babies and those in the waiting room, especially if no-one is receiving them B2 . N At the first emergency sign on Quick Check, begin emergency assessment and management (RAM) B1-B7 for the woman, or examine the newborn J1-J11 . N If she is in labour, accompany her to an appropriate place and follow the steps as in Childbirth: labour, delivery and immediate postpartum care D1-D29 . N If she has priority signs, examine her immediately using Antenatal care, Postpartum or Post-abortion care charts C1-C19 E1-E10 B18-B22. N If no emergency or priority sign on RAM or not in labour, invite her to wait in the waiting room. N If baby is newly born, looks small, examine immediately. Do not let the mother wait in the queue. Begin each emergency care visit N Introduce yourself. N Ask the name of the woman. N Encourage the companion to stay with the woman. N Explain all procedures, ask permission, and keep the woman informed as much as you can about what you are doing. If she is unconscious, talk to the companion. N Ensure and respect privacy during examination and discussion. N If she came with a baby and the baby is well, ask the companion to take care of the baby during the maternal examination and treatment. Care of woman or baby referred for special care to secondary level facility N When a woman or baby is referred to a secondary level care facility because of a specific problem or complications, the underlying assumption of the Guide is that, at referral level, the woman/baby will be assessed, treated, counselled and advised on follow-up for that particular condition/ complication. N Follow-up for that specific condition will be either: ¡ organized by the referral facility or ¡ written instructions will be given to the woman/baby for the skilled attendant at the primary level who referred the woman/ baby. ¡ the woman/baby will be advised to go for a follow-up visit within 2 weeks according to severity of the condition. N Routine care continues at the primary care level where it was initiated. Begin each routine visit (for the woman and/or the baby) N Greet the woman and offer her a seat. N Introduce yourself. N Ask her name (and the name of the baby). N Ask her: ¡ Why did you come? For yourself or for your baby? ¡ For a scheduled (routine) visit? ¡ For specific complaints about you or your baby? ¡ First or follow-up visit? ¡ Do you want to include your companion or other family member (parent if adolescent) in the examination and discussion? N If the woman is recently delivered, assess the baby or ask to see the baby if not with the mother. N If antenatal care, always revise the birth plan at the end of the visit after completing the chart. N For a postpartum visit, if she came with the baby, also examine the baby: ¡ Follow the appropriate charts according to pregnancy status/age of the baby and purpose of visit. ¡ Follow all steps on the chart and in relevant boxes. N Unless the condition of the woman or the baby requires urgent referral to hospital, give preventive measures if due even if the woman has a condition "in yellow" that requires special treatment. N If follow-up visit is within a week, and if no other complaints: ¡ Assess the woman for the specific condition requiring follow-up only ¡ Compare with earlier assessment and re-classify. N If a follow-up visit is more than a week after the initial examination (but not the next scheduled visit): ¡ Repeat the whole assessment as required for an antenatal, post-abortion, postpartum or newborn visit according to the schedule ¡ If antenatal visit, revise the birth plan. During the visit N Explain all procedures, N Ask permission before undertaking an examination or test. N Keep the woman informed throughout. Discuss findings with her (and her partner). N Ensure privacy during the examination and discussion. At the end of the visit N Ask the woman if she has any questions. N Summarize the most important messages with her. N Encourage her to return for a routine visit (tell her when) and if she has any concerns. N Fill the Home-Based Maternal Record (HBMR) and give her the appropriate information sheet. N Ask her if there are any points which need to be discussed and would she like support for this. ORGANIZING A VISIT

Quick check, rapid assessment and management of women of childbearing age QUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE B1 QUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE Quick check QUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDB EARING AGE ASK, CHECK RECORD N Why did you come? ¡ for yourself? ¡ for the baby? N How old is the bab y? N What is the concer n? LOOK, LISTEN, FEEL Is the woman being wheeled or carried in or: N bleeding vaginally N convulsing N looking very ill N unconscious N in severe pain N in labour N delivery is imminent Check if bab y is or has: N very small N convulsing N breathing difficulty SIGNS If the woman is or has: N unconscious (does not ans wer) N convulsing N bleeding N severe abdominal pain or looks very ill N headache and visual disturbance N severe difficulty bre athing N fever N severe vomiting. N Imminent delivry or N Labour If the baby is or has: N very small N convulsions N difficult breathing N just born N any mater nal concer n. N Pregnant woman, or after deliv ery, with no dang er signs N A newbor n with no dang er signs or maternal complaints. TREAT N Transfer woman to a treatment room for Rapid assessment and manag ement B3-B7. N Call for help if needed. N Reassure the woman that she will be tak en care of immediately. N Ask her companion tostay. N Transfer the woman to the labour ward. N Call for immediate assessm ent. N Transfer the baby to the treatment room for immediate Ne wborn care J1-J11. N Ask the mother to sta y. N Keep the woman and bab y in the waiting room for routine care. CLASSIFY EMERGENCY FOR WOMAN LABOUR EMERGENCY FOR BABY ROUTINE CARE IF emergency for woman or bab y or labour , go to B3. IF no emergency, go to relevant section QUICK CHECK A person responsible for initial reception of women of childbearing ag e and newbor ns seeking care should: N assess the gneral condition of the careseek er(s) immediately on ar rival N periodically repeat this procedure if the line is long . If a woman is ver y sick, talk to her companion. B2 Rapid assessment and management (RAM) Airway and breathing , circulation (shock) NEXT: Vaginal bleeding QUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE B3 This may be pneumonia, severe anaemia with hear t failure, obstructed breathing, asthma. This may be haemor rhagic shock, septic shock. TREATMENT N Manage airway and breathing B9. N Refer woman urg ently to hospi tal* B17. Measure blood pressure. If systolic BP < 90 mmHg or pulse >110 per minute: N Position the woman on her lef t side with legs higher than chest. N Insert an IV line B9. N Give fluids rapidly B9. N If not able to inser t peripher al IV, use alternative B9. N Keep her war m (cover her). N Refer her urg ently to hospital * B17. * But if bir th is imminent (bul ging, thin peri neum during contractions, visible fetal head), transfer woman to labour room and proceed as on D1-D28. RAPID ASSESSMENT AND MANAGEMENT (RAM) Use this char t for rapid assessment and manag ement (RAM) of all women of childbearing ag e, and also for women in labour , on first arival and periodically throughout labour, delivery and the postpar tum period. Assess for all emerg ency and priority signs and give appropriate treatments, then refer the woman to hospital.- FIRST ASSESS EMERGENCY SIGNS Do all emergncy steps before refer ral AIRWAY AND BREATHING N Very difficult breathing or N Central cyanosis CIRCULATION (SHOCK) N Cold moist skin or N Weak and fast pulse MEASURE N Measure blood pressure N Count pulse Rapid assessment and management (RAM) Vaginal bleeding QUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDB EARING AGE B4 PREGNANCY ST ATUS EARLY PREGNANCY not aware of pregnancy , or not pregnant (uterus NOT above umbilicus) LATE PREGNANCY (uterus above umbilicus) DURING LAB OUR before delivry of baby BLEEDING HEAVY BLEEDING Pad or cloth soaked in < 5 minutes. LIGHT BLEEDING ANY BLEEDING IS D ANGEROUS BLEEDING MORE THAN 100 ML SINCE LABOUR BEGAN This may be abor tion, menorr hagia, ectopic pr egnancy. This may be placenta pr evia, abruptio placentae, ruptured uterus. This may be placenta pr evia, abruptio placenta, ruptured uterus. TREATMENT N Insert an IV line B9. N Give fluids rapidly B9. N Give 0.2 mg erg ometrine IM B10. N Repeat 0.2 mg erg ometrine IM/IV if bleeding continues. N If suspect possible complicated abor tion, give appropria te IM/IV antibiotics B15. N Refer woman urg ently to hospit al B17. N Examine woman as on B19. N If pregnancy not lik ely, refer to other clinical guidelines. DO NOT do vaginal examination, but: N Insert an IV line B9. N Give fluids rapidly if hea vy bleeding or shock B3. N Refer woman urg ently to hospit al* B17. DO NOT do vaginal examination, but: N Insert an IV line B9. N Give fluids rapidly if hea vy bleeding or shock B3. N Refer woman urg ently to hospit al* B17. * But if bir th is imminent (bulging , thin perineum during con tractions, visible fetal head), transfer woman to labour room and proceed as on D1-D28. VAGINAL BLEEDING N Assess pregnancy status N Assess amount of bleeding NEXT: Vaginal bleeding in postpar tum Rapid assessment and management (RAM) Vaginal bleeding : postpar tum NEXT: Convulsion s or unconscious QUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE B5 PREGNANCY ST ATUS POSTPARTUM (baby is bor n) Check and ask if placenta is delivered Check for perineal and lower vaginal tears Check if still bleeding BLEEDING HEAVY BLEEDING N Pad or cloth soa ked in < 5 minutes N Constant trickling of blood N Bleeding >250 ml or deliv ered outside health centre and still bleeding PLACENTA NOT DELIVERED PLACENTA DELIVERED Check placenta B11 IF PRESENT HEAVY BLEEDING CONTROLLED BLEEDING This may be uterine aton y, retained placen ta, ruptured uterus, vaginal or cer vical tear . TREATMENT N Call for extra help. N Massage uterus until it is hard and giv e oxytocin 10 IU IM B10. N Insert an IV line B9 and give IV fluids w ith 20 IU oxytocin at 60 drops/minute. N Empty bladder . Catheterize if necessar y B12. N Check and record BP and pulse e very 15 minutes and treat as onB3. N When uterus is hard, deliver placenta by controlled cord tracti on D12. N If unsuccessful and bleeding continues, remove placenta manually and check placenta B11. N Give appropriate IM/IV antibiotics B15. N If unable to remo ve placenta, refer woman urg ently to hospital B17. During transfer , continue IV fluids with 20 IU of oxytocin at 30 drops/minute. If placenta is compl ete: N Massage uterus to express an y clots B10. N If uterus remains soft, give ergometrine 0.2mg IV B10. DO NOT give ergometrine to women with ec lampsia, pre-eclampsia or kno wn hypertension. N Continue IV fluids with 20 IU oxytocin/litr e at 30 drops/minute. N Continue massaging uter us till it is hard. If placenta is incom plete (or not a vailable for inspection) : N Remove placental frag ments B11. N Give appropriate IM/IV antibiotics B15. N If unable to remo ve, refer woman urg ently to hospital B17. N Examine the tear and deter mine the deg ree B12. If third deg ree tear (in volving rectum or anus), refer woman urg ently to hospital B17. N For other tears: apply pressure o ver the tear with a sterile pad or g auze and put legs tog ether. Do not cross ankles. N Check after 5 minutes, if bleeding persists repair the tear B12. N Continue IV fluids with 20 units of oxytocin at 30 drops/minute. Insert second IV line. N Apply bimanual uterine o aortic compression B10. N Give appropriate IM/IV antibiotics B15. N Refer woman urg ently to hospital B17. N Continue oxytocin infusion with 20 IU/litre of IV fluids at 20 drops/min for at least one hour after bleeding stops B10. N Observe closely (e very 30 minutes) for 4 hou rs. Keep nearb y for 24 hour s. If severe pallor , refer to health cen tre. N Examine the woman using Assess the mother aft er deliver y D12. Rapid assessment and management (RAM) Emergency signs QUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDB EARING AGE B6 EMERGENCY SIGNS N Convulsing (now or recently), or N Unconscious If unconscious, ask relativ e “has there been a recent con vulsion?” N Severe abdominal pain (not nor mal labour) Fever (temperature more than 38ºC) and any of: N Very fast breathing N Stiff neck N Lethargy N Very weak/not able to stand This may be eclampsia. This may be r uptured uterus, obstructed labour, abruptio placenta, puerper al or postabortion sepsis, ectopic pregnancy . This may be malaria, meningitis, pneumonia, septicemia. CONVULSIONS OR UNCONSCIOUS SEVERE ABDOMINAL PAIN DANGEROUS FEVER TREATMENT N Protect woman from fall and inj ury. Get help. N Manage airway B9. N After convulsion ends, help woman onto her left side. N Insert an IV line and giv e fluids slowly (30 drops/min) B9. N Give magnesium sulphate B13. N If early pregnancy, give diazepam IV or rectally B14. N If diastolic BP >110mm of Hg , give antihypertensiv e B14. N If temperature >38ºC, or history of fever, also give treatment for dang erous fever (below). N Refer woman urg ently to hospit al* B17. Measure BP and temper ature N If diastolic BP >110mm of Hg , give antihypertensiv e B14. N If temperature >38ºC, or history of fever, also give treatment for dang erous fever (below). N Refer woman urg ently to hospit al* B17. N Insert an IV line and giv e fluids B9. N If temperature more than 38ºC, give first dose of appropriate IM/IV antiobiotics B15. N Refer woman urg ently to hospit al* B17. N If systolic BP <90 mm Hg see B3. N Insert an IV line B9. N Give fluids slowly B9. N Give first dose of appropriate IM/IV anti biotics B15. N Give artemether IM (if not available, give quinine IM) and glucose B16. N Refer woman urg ently to hospit al* B17. * But if bir th is imminent (bul ging, thin peri neum during contractions, visible fetal head), transfer woman to labour room and proceed as on D1-D28. MEASURE N Measure blood pressure N Measure temperature N Assess pregnancy status N Measure blood pressure N Measure temperature N Measure temperature NEXT: Priority signs Rapid assessment and management (RAM) Priority signs QUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE B7 PRIORITY SIGNS N Labour pains or N Ruptured membranes If any of: N Severe pallor N Epigastric or abdominal pain N Severe headache N Blurred vision N Fever (temperature more than 38ºC) N Breathing difficulty N No emergency signs or N No priority signs TREATMENT N Manage as for Childbir th D1-D28. N If pregnant (and not in labour), provide antenatal care C1-C18. N If recently giv en birth, provide postpartum care D21. and E1-E10. N If recent abor tion, provide post-abor tion care B20-B21. N If early pregnancy, or not aware of pregnancy , check for ectopic pregnancy B19. N If pregnant (and not in labour), provide antenatal care C1-C18. N If recently giv en birth, provide postpartum care E1-E10. LABOUR OTHER DANGER SIGNS OR SYMPT OS IF NO EMERGENCY OR PRIORITY SIGNS , NON URGENT MEASURE N Measure blood pressure N Measure temperature B2 QUICK CHECK B3 RAPID ASSESSMENT AND MANAGEMENT (RAM) (1) Airway and breathing Circulation and shock B4 RAPID ASSESSMENT AND MANAGEMENT (RAM) (2) Vaginal bleeding B5 RAPID ASSESSMENT AND MANAGEMENT (RAM) (3) Vaginal bleeding: postpartum B6 RAPID ASSESSMENT AND MANAGEMENT (RAM) (4) Convulsions Severe abdominal pain Dangerous fever B7 RAPID ASSESSMENT AND MANAGEMENT (RAM) (5) priority signs Labour Other danger signs or symptoms Non-urgent N Perform Quick check immediately after the woman arrives B2 . If any danger sign is seen, help the woman and send her quickly to the emergency room. N Always begin a clinical visit with Rapid assessment and management (RAM) B3-B7 : ¡ Check for emergency signs first B3-B6 . If present, provide emergency treatment and refer the woman urgently to hospital. Complete the referral form N2 . ¡ Check for priority signs. If present, manage according to charts B7 . ¡ If no emergency or priority signs, allow the woman to wait in line for routine care, according to pregnancy status