堂 RAPID ASSESSMENT AND MANAGEMENT(RAM) Use this chart for rapid assessment and management(RAM)of all women of childbearing age,and also for women in labour,on first arrival and periodically throughout labour,delivery and the postpartum period.Assess for all emergency and priority signs and give appropriate treatments,then refer the woman to hospital.- FIRSTASSESS EMERGENCY SIGNS MEASURE TREATMENT Do all emergency steps before referral N3WOM AIRWAY AND BREATHING Very difficult breathing or Manage airway and breathing Es This may be pneumonia,severe ■Central cyanosis Refer woman urgently to hospital* anaemia with heart failure. 告 obstructed breathing,asthma. CIRCULATION(SHOCK)） If systolic BP<90 mmHg or pulse >110 per minute: ■Cold moist skin or This may be haemorrhagic shock Measure blood pressure Position the woman on her left side with legs higher than chest. septic shock. ■Neak and fast pulse ■Count pulse ■Insert an IV line BS ■Give fluids rapidlyB If not able to insert peripheral IV,use alterativeE Keep her wamm(cover her). Refer her urgently to hospital*E But if birth is imminent(bulging.thin perineum during contractions,visible fetal head),transfer woman to labour room and proceed as on D2. NEXT:Vaginal bleeding Rapid assessment and management (RAM)Airway and breathing,circulation(shock) B3
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 heart failure, obstructed breathing, asthma. This may be haemorrhagic shock, septic shock. TREATMENT N Manage airway and breathing B9 . N Refer woman urgently to hospital* B17 . If systolic BP < 90 mmHg or pulse >110 per minute: N Position the woman on her left side with legs higher than chest. N Insert an IV line B9 . N Give fluids rapidly B9 . N If not able to insert peripheral IV, use alternative B9 . N Keep her warm (cover her). N Refer her urgently to hospital* B17 . * But if birth is imminent (bulging, thin perineum during contractions, visible fetal head), transfer woman to labour room and proceed as on D1-D28 . RAPID ASSESSMENT AND MANAGEMENT (RAM) Use this chart for rapid assessment and management (RAM) of all women of childbearing age, and also for women in labour, on first arrival and periodically throughout labour, delivery and the postpartum period. Assess for all emergency and priority signs and give appropriate treatments, then refer the woman to hospital.- FIRST ASSESS EMERGENCY SIGNS Do all emergency steps before referral 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 T
Rapid assessment and management(RAM)Vaginal bleeding B4 学 VAGINAL BLEEDING Assess pregnancy status Assess amount of bleeding PREGNANCY STATUS BLEEDING TREATMENT EARLY PREGNANCY HEAVY BLEEDING ■Insert an IV line E9 This may be abortion, not aware of pregnancy,or not pregnant Pad or cloth soaked in <5 minutes. Give fluids rapidlyES menorrhagia,ectopic pregnancy (uterus NOT above umbilicus) Give 0.2 mg ergometrine IM EO N3WOM Repeat 0.2 mg ergometrine IM/IV if bleeding continues If suspect possible complicated abortion,give appropriate IM/IV antibiotics Refer woman urgently to hospitalE LIGHT BLEEDING Examine woman as on E If pregnancy not likely,refer to other clinical guidelines. LATE PREGNANCY ANY BLEEDING IS DANGEROUS DO NOT do vaginal examination,but This may be placenta previa, (uterus above umbilicus) ■Insert an IV line BS abruptio placentae,ruptured Give fluids rapidly if heavy bleeding or shock uterus. Refer woman urgently to hospital*E DURING LABOUR BLEEDING DO NOT do vaginal examination,but: This may be before delivery of baby MORE THAN 100 ML ■Insert an IV line B9 placenta previa,abruptio SINCE LABOUR BEGAN Give fluids rapidly if heavy bleeding or shock placenta,ruptured utens. Refer woman urgently to hospital* But if birth is imminent(bulging,thin perineum during contractions,visible fetal head),transfer woman to labour room and proceed as on NEXT:Vaginal bleeding in postpartum
Rapid assessment and management (RAM) Vaginal bleeding QUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE B4 PREGNANCY STATUS EARLY PREGNANCY not aware of pregnancy, or not pregnant (uterus NOT above umbilicus) LATE PREGNANCY (uterus above umbilicus) DURING LABOUR before delivery of baby BLEEDING HEAVY BLEEDING Pad or cloth soaked in < 5 minutes. LIGHT BLEEDING ANY BLEEDING IS DANGEROUS BLEEDING MORE THAN 100 ML SINCE LABOUR BEGAN This may be abortion, menorrhagia, ectopic pregnancy. This may be placenta previa, abruptio placentae, ruptured uterus. This may be placenta previa, abruptio placenta, ruptured uterus. TREATMENT N Insert an IV line B9 . N Give fluids rapidly B9 . N Give 0.2 mg ergometrine IM B10 . N Repeat 0.2 mg ergometrine IM/IV if bleeding continues. N If suspect possible complicated abortion, give appropriate IM/IV antibiotics B15 . N Refer woman urgently to hospital B17 . N Examine woman as on B19 . N If pregnancy not likely, refer to other clinical guidelines. DO NOT do vaginal examination, but: N Insert an IV line B9 . N Give fluids rapidly if heavy bleeding or shock B3 . N Refer woman urgently to hospital* B17 . DO NOT do vaginal examination, but: N Insert an IV line B9 . N Give fluids rapidly if heavy bleeding or shock B3 . N Refer woman urgently to hospital* B17 . * But if birth is imminent (bulging, thin perineum during contractions, 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 TNEXT: Vaginal bleeding in postpartum
堂 PREGNANCY STATUS BLEEDING TREATMENT POSTPARTUM HEAVY BLEEDING ■Call for extra help. This may be uterine atony. (baby is bor) Pad or cloth soaked in <5 minutes Massage uterus until it is hard and give oxytocin 10 IU IME retained placenta,ruptured Constant trickling of blood Insert an IV lineE and give IV fluids with 20 IU oxytocin at 60 drops/minute. uterus,vaginal or cervical tear. Bleeding>250 ml ordelivered outside Empty bladder.Catheterize if necessary health centre and sti bleeding Check and record BP and pulse every 15 minutes and treat as on Check and ask if placenta is delivered PLACENTA NOT DELIVERED When uterus is hard,deliver placenta by controlled cord traction If unsuccessful and bleeding continues,remove placenta manually and check placenta Give appropriate IM/IV antibiotics. If unable to remove placenta,refer woman urgently to hospital During transfer,continue IV fluids with 20 IU of oxytocin at 30 drops/minute. PLACENTA DELIVERED If placenta is complete: Massage uterus to express any clots Check placentaE If uterus remains soft,give ergometrine 0.2 mg IV DO NOT give ergometrine to women with eclampsia,pre-eclampsia or known hypertension. Continue IV fluids with 20 IU oxytocin/litre at 30 drops/minute. Continue massaging uterus till it is hard. If placenta is incomplete(or not available for inspection): Remove placental fragments Give appropriate IM/IV antibioticsB. If unable to remove,refer woman urgently to hospital Check for perineal and lower IF PRESENT Examine the tear and determine the degree vaginal tears If third degree tear(involving rectum or anus).refer woman urgently to hospital For other tears apply pressure over the tear with a sterle pad or gauze and put legs together.Do not cross ankles. Check after 5 minutes,if bleeding persists repair the tear HEAVY BLEEDING Continue IV fluids with 20 units of oxytocin at 30 drops/minute.Insert second IV line. Check if still bleeding Apply bimanual uterine or aortic compression Give appropriate IM/IV antibioticsE15 Refer woman urgently to hospital CONTROLLED BLEEDING Continue oxytocin infusion with 20lU/ltre of IVfluids at 20 drops/min for at least one hour after bleeding stops Observe closely (every 30 minutes)for 4 hours.Keep nearby for 24 hours.If severe pallor,referto health centre. Examine the woman using Assess the mother after delivery NEXT:Convulsions or unconscious Rapid assessment and management(RAM)Vaginal bleeding:postpartum B5
Rapid assessment and management (RAM) Vaginal bleeding: postpartum NEXT: Convulsions or unconscious QUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE B5 PREGNANCY STATUS POSTPARTUM (baby is born) 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 soaked in < 5 minutes N Constant trickling of blood N Bleeding >250 ml or delivered outside health centre and still bleeding PLACENTA NOT DELIVERED PLACENTA DELIVERED Check placenta B11 IF PRESENT HEAVY BLEEDING CONTROLLED BLEEDING This may be uterine atony, retained placenta, ruptured uterus, vaginal or cervical tear. TREATMENT N Call for extra help. N Massage uterus until it is hard and give oxytocin 10 IU IM B10 . N Insert an IV line B9 and give IV fluids with 20 IU oxytocin at 60 drops/minute. N Empty bladder. Catheterize if necessary B12 . N Check and record BP and pulse every 15 minutes and treat as on B3 . N When uterus is hard, deliver placenta by controlled cord traction 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 remove placenta, refer woman urgently to hospital B17 . During transfer, continue IV fluids with 20 IU of oxytocin at 30 drops/minute. If placenta is complete: N Massage uterus to express any clots B10 . N If uterus remains soft, give ergometrine 0.2 mg IV B10 . DO NOT give ergometrine to women with eclampsia, pre-eclampsia or known hypertension. N Continue IV fluids with 20 IU oxytocin/litre at 30 drops/minute. N Continue massaging uterus till it is hard. If placenta is incomplete (or not available for inspection): N Remove placental fragments B11 . N Give appropriate IM/IV antibiotics B15 . N If unable to remove, refer woman urgently to hospital B17 . N Examine the tear and determine the degree B12 . If third degree tear (involving rectum or anus), refer woman urgently to hospital B17 . N For other tears: apply pressure over the tear with a sterile pad or gauze and put legs together. 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 or aortic compression B10 . N Give appropriate IM/IV antibiotics B15 . N Refer woman urgently 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 (every 30 minutes) for 4 hours. Keep nearby for 24 hours. If severe pallor, refer to health centre. N Examine the woman using Assess the mother after delivery D12 . T
Rapid assessment and management(RAM)Emergency signs B6 EMERGENCY SIGNS MEASURE TREATMENT CONVULSIONS OR UNCONSCIOUS Convulsing (now or recently).or Measure blood pressure Protect woman from fall and injury.Get help This may be eclampsia ■Unconscious ■Measure temperature ■Manage airwayE If unconscious.ask relative Assess pregnancy status After convulsion ends,help woman onto her left side. "has there been a recent convulsion?" Insert an IV line and give fluids slowly (30 drops/min) Give magnesium sulphateE If early pregnancy,give diazepam IV or rectally N3WOM If diastolic BP>110mm of Hg.give antihypertensive If temperature>38C.or history of fever,also give treatment for dangerous fever(below). 芒 Refer woman urgently to hospital* Measure BP and temperature If diastolic BP>110mm of Hg.give antihypertensive If temperature >38C.or history of fever,also give treatment for dangerous fever(below). Refer woman urgently to hospital* SEVERE ABDOMINAL PAIN Severe abdominal pain (not normal labour) Measure blood pressure Insert an IV line and give fluidsE This may be ruptured uterus, ■Measure temperature If temperature more than 38C.give first dose of appropriate IM/IV obstructed labour,abruptio antiobiotics B5. placenta,puerperal or post- WSS3 Refer woman urgently to hospital* abortion sepsis,ectopic If systolic BP <90 mm Hg seeE pregnancy 妇 DANGEROUS FEVER e Fever(temperature more than 38C) Measure temperature ■Insert an IV line ES This may be malaria. and any of: ■Give fluids slowlyE meningitis,pneumonia. ■/ery fast breathing Give first dose of appropriate IM/IV antibiotics septicemia. ■Stiff neck Give artemether IM (if not available,give quinine IM)and glucoseG ■Lethargy Refer woman urgently to hospital*E Very weak/not able to stand *But if birth is imminent(bulging.thin perineum during contractions,visible fetal head).transfer woman to labour room and proceed as on NEXT:Priority signs
Rapid assessment and management (RAM) Emergency signs QUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE B6 EMERGENCY SIGNS N Convulsing (now or recently), or N Unconscious If unconscious, ask relative “has there been a recent convulsion?” N Severe abdominal pain (not normal 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 ruptured uterus, obstructed labour, abruptio placenta, puerperal 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 injury. Get help. N Manage airway B9 . N After convulsion ends, help woman onto her left side. N Insert an IV line and give 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 antihypertensive B14 . N If temperature >38ºC, or history of fever, also give treatment for dangerous fever (below). N Refer woman urgently to hospital* B17 . Measure BP and temperature N If diastolic BP >110mm of Hg, give antihypertensive B14 . N If temperature >38ºC, or history of fever, also give treatment for dangerous fever (below). N Refer woman urgently to hospital* B17 . N Insert an IV line and give fluids B9 . N If temperature more than 38ºC, give first dose of appropriate IM/IV antiobiotics B15 . N Refer woman urgently to hospital* 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 antibiotics B15 . N Give artemether IM (if not available, give quinine IM) and glucose B16 . N Refer woman urgently to hospital* B17 . * But if birth is imminent (bulging, thin perineum 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 TNEXT: Priority signs
PRIORITY SIGNS MEASURE TREATMENT LABOUR ■Labour pains or Manage as for Childbirth 2 ■Ruptured membranes OTHER DANGER SIGNS OR SYMPTOMS If any of: Measure blood pressure If pregnant(and not in labour).provide antenatal care N3WOM ■Severe pallor Measure temperature If recently given birth,provide postpartum care 2 and B3 Epigastric or abdominal pain If recent abortion,provide post-abortion care 20 ■Severe headache If early pregnancy,or not aware of pregnancy.check for ectopic pregnancy 告 ■Blurred vision Fever(temperature more than 38C) Breathing difficulty N3W35VNV IF NO EMERGENCY OR PRIORITY SIGNS,NON URGENT ■No emergency signs or If pregnant(and not in labour).provide antenatal care ■No priority signs If recently given birth,provide postpartum care Rapid assessment and management(RAM)Priority signs B7
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 Childbirth D1-D28 . N If pregnant (and not in labour), provide antenatal care C1-C19 . N If recently given birth, provide postpartum care D21 . and E1-E10 . N If recent abortion, provide post-abortion 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-C19 . N If recently given birth, provide postpartum care E1-E10 . LABOUR OTHER DANGER SIGNS OR SYMPTOMS IF NO EMERGENCY OR PRIORITY SIGNS, NON URGENT MEASURE N Measure blood pressure N Measure temperature