Emergency treatments for the woman B8 EMERGENCY TREATMENTS FOR THE WOMAN E ECLAMPSIAAND This section has details on emergency treatments identified PRE-ECLAMPSIA(2) during Rapid assessment and management(RAM)B3-36 to be Give diazepam given before referral. Give appropriate antihypertensive Give the treatment and refer the woman urgently to hospital 17 E AIRWAY,BREATHING AND CIRCULATION EE INFECTION Give appropriate IV/IM antibiotics If drug treatment,give the first dose of the drugs before referral. Manage the airway and breathing Insert IV line and give fluids Do not delay referral by giving non-urgent treatments. E0 BLEEDING(1) EG MALARIA Massage uterus and expel clots Give artemether or quinine IM Apply bimanual uterine compression Give glucose I Apply aortic compression Give oxytocin Give ergometrine E REFER THE WOMAN URGENTLY 311 BLEEDING(2) TO THE HOSPITAL Remove placenta and fragments manually Refer the woman urgently to the hospital After manual removal of the placenta Essential emergency drugs and supplies for transport and home delivery B12 BLEEDING(3) Repair the tear Empty bladder B1图 ECLAMPSIAAND PRE-ECLAMPSIA(1) Important considerations in caring for a woman with eclampsia and pre-eclampsia Give magnesium sulphate
Emergency treatments for the woman EMERGENCY TREATMENTS FOR THE WOMAN B8 EMERGENCY TREATMENTS FOR THE WOMAN AIRWAY, BREATHING AND CIRCULA TION Airway, breathing and circulation EMERGENCY TREA TMENTS FOR THE WOMAN B9 Manage the airwa y nd breathing If the woman has g reat difficulty breathing and: N If you suspect obstr uction: ¡ Try to clear the airwa y and dislodg e obstruction ¡ Help the woman to find the best position for breathing ¡ Urgently refer the woman to hospital. N If the woman is unconscious: ¡ Keep her on her back, arms at the side ¡ Tilt her head backwards (unless trauma is suspected) ¡ Lift her chin to open airwa y ¡ Inspect her mouth for foreign bod y; remove if found ¡ Clear secretions from throat. N If the woman is not breathing: ¡ Ventilate with bag and mask until she star ts breathing spontaneously N If woman still has g reat difficulty breathing , keep her propped up, and N Refer the woman urg ently to hospital. Insert IV line and giv e fluids N Wash hands with s oap and water and put on glo ves. N Clean woman’s skin with spirit at site for IV line. N Insert an intravenous line (IV line) using a 16-18 g auge needle. N Attach Ring er’s lactate or nor mal sali ne. Ensure infusion is r unning well. Give fluids at rapid rate if shock, systolic BP<90 mmHg , pulse>110/minute, or heavy vaginal bleeding: N Infuse 1 litre in 15-20 min utes (as rapid as possible). N Infuse 1 litre in 30 minut es at 30 ml/minute. Repat if necessar y. N Monitor e very 15 minutes for: ¡blood pressure (BP) a nd pulse ¡shortness of breath orpuffiness. N Reduce the infusion r ate to 3 ml/mi nute (1 litre in 6-8 hours) w hen pulse slo ws to less than 100/ minute, systolic BP increases to 100 mmHg or higher . N Reduce the infusion r ate to 0.5 ml/inute if breathing difficulty or puffiness develops. N Monitor urine output. N Record time and amou nt of fluids giv en. Give fluids at moderate rate if severe abdominal pain, obstructed labour, ectopic pregnancy , dangerous fever or dehydration: N Infuse 1 litre in 2-3 hou rs. Give fluids at slow rate if severe anaemia/se ver pre-eclampsia or eclampsia: N Infuse 1 litre in 6-8 hou rs. If intravenous access not possible N Give oral rehydration solution (ORS) b y mouth if able to drink, or by nasogastric (NG) tube. N Quantity of ORS: 300 to 500 mlin 1 hour. DO NOT give ORS to a woman who is unconscious or has con vulsions. BLEEDING Bleeding (1) EMERGENCY TREA TMENTS FOR THE WOMAN B10 Massage uterus and expel clots If heavy postpar tum bleeding persists after placenta is deliv ered, or uter us is not well contrac ted (is soft): N Place cupped palm on uterine fundus and feel for state of contraction . N Massage fundus in a circular motion with cupped palm until uter us is well contracted. N When well contracted, place fingers behind fundus and push do wn in one s wift action to expel clots. N Collect blood in a container placed close to the vulv a. Measure or estimate blood loss, and record. Apply bimanual uterine compression If heavy postpar tum bleeding persists despite uterine massag e, oxytocin/erg ometrine treatment and removal of placenta: N Wear sterile or clean glo ves. N Introduce the right hand into the v agina, clenched fist, with the back of the hand directe d posterior ly and the knuckles in the anterior for nix. N Place the other hand on the abdomen behind the uter us and squeeze the uter us firmly between the two hands. N Continue compression until bleeding stops (no bleeding if the compres sion is released). N If bleeding persists, apply aor tic compression and transpor t woman to hospital. Apply aor tic compression If heavy postpar tum bleeding persists despite uterine massag e, oxytocin/ergometrine treatment and removal of placenta: N Feel for femoral pulse. N Apply pressure abo ve the umbilicus to stop bleeding . Apply sufficient pr essue until femoral pulse is not felt. N After finding cor ret site, show assistant or relativ how to apply pressure, if necessary. N Continue pressure until bleeding stops. If bleeding persists, keep applying pressure w hile transpor ting woman to hospital. Give oxytocin If heavy postpar tum bleeding Initial dose Continuing dose Maximum dose IM/IV: 10 IU IM/IV: repeat 10 IU after 20 minu tes Not more than 3 litres if heavy bleeding persists of IV fluids containing IV infusion: IV infusion: oxytocin 20 IU in 1 litre 10 IU in 1 litre at 60 drops/min at 30 drops/min Give ergometrine If heavy bleeding in ear ly pregnancy or postpartum bleeding (after oxytocin) but DO NOT give if eclampsia, pre-eclampsia, or hypertension Initial dose Continuing dose Maximum dose IM/IV:0.2 mg IM: repeat 0.2 mg Not more than slowly IM after 15 minutes if hea vy 5 doses (total 1.0 mg) bleeding persists Bleeding (2) EMERGENCY TREA TMENTS FOR THE WOMAN B11 Remove placenta and fragments manually N If placenta not deliv ered 1 hour after deliv ery of the baby, OR N If heavy vaginal bleeding continues despite massag e and oxytocin and placenta cannot be deliv ered by controlled cord traction, or if placenta is incomplete and bleeding c ontinues. Preparation N Explain to the w oman the need for manual remo val of the placenta and obtain her consent. N Insert an IV line. If bleeding, give fluids rapidly . If not bleeding , give fluids slowly B9. N Assist woman to g et onto her back. N Give diazepam (10-mg IM/IV). N Clean vulva and perineal area. N Ensure the bladder is empty . Catheterize if necessar y B12. N Wash hands and forear ms well and put on long sterile glo ves (and an apron or g ownif available). Technique N With the left hand, hol the umbilical cord with the clamp. Then pull the cord g ently until it is horizontal. N Insert right hand into the v agina and up into the uter us. N Leave the cord and hold the fundus with the left hand in order to supp ort the fundus of the uter us and to pro vide counter-traction during remo val. N Move the fingers of the right hand side ways until edge of the placenta is located. N Detach the placenta from the implantation site b y keeping the fing ers tightly tog eher and using the edge of the hand to g radually mak e a space betw een the placenta and the uterine wall. N Proceed gradually all around the placental bed until the w hole placenta is detached from the uterine wall. N Withdraw the right hand from the uter us gradually, bringing the placenta w ith it. N Explore the inside of the uterine ca vity to ensure all placental tissue has been remo ved. N With the left hand, provide counter-traction to the fundus through the abdomen b y pushing it in the opposite direction of the hand that is being withdra wn. This pre vents inversion of the uter us. N Examine the uterine surface of the placenta to ensure that lobes and membranes are complete. If any placental lobe or tissue fragments are missing , explore ag ain the uterine ca vity to remo ve them. If hours or da ys have passed since deliver y, or if the placenta is retaine d due to constrictio n rng or closed cer vix, it may not be possible to put the hand into the uter us. DO NOT persist. Refer urgently to hospital B17. If the placenta does not separ ate from the uterine surface b y gentle sideways movement of the fingertips at the line of clea vage, suspect placenta accreta. DO NOT persist in effor ts to remove placenta. Refer urgently to hospital B17. After manual remo val of the placenta N Repeat oxytocin 10-I U IM/IV. N Massage the fundus of the uter us to encourag e tonic uterine contraction. N Give ampicillin 2 g IV/IM B15. N If fever >38.5°C, foul-smelling lochia or histor y of rupture of membranes for 18 or more hour also s give gentamicin 80 mg IM B15. N If bleeding stops: ¡ give fluids slowly for at least 1 hour after remo val of placenta. N If heavy bleeding continues: ¡ give ergometrine 0.2mg IM ¡ give 20 IU oxytocin in each litre of IV f luids and infuse rapidly ¡ Refer urgently to ho spitalB17. N During transpor tation, feel continuously w hether uterus is well contracted (hard and roun d). If not, massage and repeat oxytocin 10 IU IM/IV . N Provide bimanual or aor tic compression if se vere bleeding before and during transpor tation B10. REPAIR THE TEAR AND EMPTY BLADDER Bleeding (3) EMERGENCY TREA TMENTS FOR THE WOMAN B12 Repair the tear or episiotomy N Examine the tear and deter mine the deg ree: ¡ The tear is small and in volved only vaginal mucosa and connectiv e tissues and und erlying muscles (first or second deg ree tear). If the tear is not bleeding , leave the wound open. ¡ The tear is long and deep through the perineum and in volves the anal sphincte r and rectal muco sa (third and four th degree tear). Cover it with a clean pad and refer the woman urg ently to hospital B17. N If first or second deg ree tear and hea vy bleeding persists after applying pressure over the wound: ¡ Suture the tear or refer for suturing if no one is a vailable with suturing s klls. ¡ Suture the tear using univ ersal precautions, aseptic technique and sterile equipment. ¡ Use a needle holder and a 21 g auge, 4 cm, curved needle. ¡ Use absorbable polyglycon suture material. ¡ Make sure that the apex of the tear is reached before y ou begin suturing . ¡ Ensure that edgs of the tear match up w ell. DO NOT suture if more than 12 hours since deliv ery. Refer woman to hospital. Empty bladder If bladder is distended an the woman is unable to passurine: N Encourage the woman to urinate. N If she is unable to ur inate, catheterize the bladder : ¡ Wash hands ¡ Clean urethral ar ea with antiseptic ¡ Put on clean glo ves ¡ Spread labia. Clean area again ¡ Insert catheter up to 4 cm ¡ Measure urine and r ecord amount ¡ Remove catheter . ECLAMPSIA AND PRE-ECLAMPSIA (1) Eclampsia and pre-eclampsia (1) EMERGENCY TREA TMENTS FOR THE WOMAN B13 Give magnesium sulphate If severe pre-eclampsia and eclampsia IV/IM combined dose (loading dose) NInsert IV line and giv e fluids slo wly (nor mal saline or Ring er’s lactate) — 1 litre in 6-8 hours (3-ml/minute) B9. NGive 4-g of magnesium sulphate (20 ml of 20% solution) IV slo wly over 20 minutes (woman may feel war m during injection). AND: NGive 10 g of magnesium sulphate IM: giv e 5 g (10 ml of 50% solution) IM deep in upper outer quadrant of each buttock with 1 ml of 2% lignocaine in the same syri nge. If unable to give IV , give IM only (loading dose) NGive 10 g of magnesium sulphate IM: giv e 5 g (10 ml of 50% solution) IM deep in upper outer quadrant of each buttock with 1 ml of 2% lignocaine in the same syri nge. If convulsions recur NAfter 15 minutes, give an additional 2 g of magnesium sulphate (10 m l of 20% solution) IV over 20 minutes. If convulsions still continue, give diazepam B14. If referral delayed for long, or the woman is in late labour , continue treatment: NGive 5 g of 50% magnesium sulphate solution IM with 1 ml of 2% l ignocaine e very 4 hours in alternate buttocks until 24 hours after bir th or after last con vulsion (whichever is later). NMonitor urine output: collect urine and measure the quantity . NBefore giving the next dose of magnesium sulphate, ensure: ¡ knee jerk is present ¡ urine output >100 ml/4 hrs ¡ respirator y rate >16/min. NDO NOT give the next dose if an y of these signs: ¡knee jerk absent ¡urine output <100 ml/4 hrs ¡respirator y rate <16/min. NRecord findings and dr ugs given. Important considerations in caring for a woman with eclampsia or pre -eclampsia N Do not leave the woman on her o wn. ¡ Help her into the le ft side position and protec t her fr om fall and injur y ¡ Place padded tong ue blades betw een her teeth to pre vent a tongue bite, and secure it to pre vent aspiration ( DO NOT atempt this during a con vulsion). N Give IV 20% magnesi um sulphate slo wly over 20 minutes. Rapid injection can cause respirator y failure or death. ¡ If respirator y depression (breathi ng less than 16/minute) occurs after magnesium sulp do h not give any more magnesium sulphate. Give the antidote: calcium gluconate 1 g IV (10 ml 10% solution) o ver10 minutes. N DO NOT give intravenous flui ds rapidly . N DO NOT give intravenously 50% magnesium sulphate without dilluting it to 20%. N Refer urgently to hospit al unless delivery is imminent. ¡ If delivery imminent, manage as in Childbir th D1-D29 and accompany the woman duri ng transpor t ¡ Keep her in the lef t side position ¡ If a convulsion occurs during the jour ney, give magnesium sulphate and protect her from f all and injury. Formulation of magnesiu m sulphat e 50% solution: 20% solution: to make 10 ml of 20% sol ution, vial contain ing 5 g in 10 ml (1g/2ml) add 4 ml of 50% solution to 6 ml sterile water IM 5 g 10 ml and 1 ml 2% lignocaine Not applicable IV 4 g 8 ml 20 ml 2 g 4 ml 10 ml After receiving magnes ium sulphate a w oman feel flushing , thirst, headache, nausea or may vomit. B9 AIRWAY, BREATHING AND CIRCULATION Manage the airway and breathing Insert IV line and give fluids B10 BLEEDING (1) Massage uterus and expel clots Apply bimanual uterine compression Apply aortic compression Give oxytocin Give ergometrine B11 BLEEDING (2) Remove placenta and fragments manually After manual removal of the placenta B12 BLEEDING (3) Repair the tear Empty bladder B13 ECLAMPSIA AND PRE-ECLAMPSIA (1) Important considerations in caring for a woman with eclampsia and pre-eclampsia Give magnesium sulphate ECLAMPSIA AND PRE-ECLAMPSIA (2) Eclampsia and pre-eclampsia (2) EMERGENCY TREA TMENTS FOR THE WOMAN B14 Give diazepam If convulsions occur in ear ly pregnancy or If magnesium sulphate toxicity occurs or magnesium sulphate is not a vailable. Loading dose IV N Give diazepam 10 mg IV slo wly over 2 minutes. N If convulsions recur , repeat 10 mg . Maintenance dose N Give diazepam 40 mg in 500 ml IV fluids (nor mal saline or Ring er’s lactate) titrated o ver 6-8 hours to keep the woman sedated but rousable. N Stop the maintenance dose if breathing <16 breaths/minute. N Assist ventilation if necessar y with mask and bag . N Do not give more than 100 mg in 24 hours. N If IV access is not possible (e.g . during con vulsion), give diazepam rectally . Loading dose rectally N Give 20 mg (4 ml) in a 10 ml syring e (or urinar y catheter): ¡ Remove the needle, lubricate the bar rel and inser t the syring e into the rectu m o half its lengt h. ¡ Discharge the contents and lea ve the syring e in place, holding the buttocks tog ether for 10 minutes to pre vent expulsion of the dr ug. N If convulsions recur , repeat 10 mg . Maintenance dose N Give additional 10 mg (2 ml) e very hour during transpor t. Diazepam: vial containing 10 mg in 2 ml IV Rectally Initial dose 10 mg = 2 ml 20 mg = 4 ml Second dose 10 mg = 2 ml 10 mg = 2 ml Give appropriatentihyper tnsive drug If diastolic blood pres sure is > 110-mmHg: N Give hydralazine 5 mg IV slowly (3-4 minutes). If IV not possible giv e IM. N If diastolic blood press ure remains > 90 mmHg , repeat the dose at 30 minute inter vals until diastolic BP is around 90 mmHg . N Do not give more tha n 20 mg in total. INFECTION Infection EMERGENCY TREA TMENTS FOR THE WOMAN B15 Give appropriate IV/IM antibiotics N Give the first dose of antibiotic(s) before refer ral. If refer ral is dela yed or not possible, continue antibiotics IM/IV for 48 hours after w oman is fe ver free. Then giv e amoxicillin ora lly 500 mg 3 times daily until 7 da ys of treatment completed. N If signs persist or mother becomes w eak or has abdominal pain postpar tum, refer urgently to hospital B17. CONDITION ANTIBIO TICS N Severe abdominal pain 3 antibiotics N Dangerous fever/very severe febrile disease N Ampicillin N Complicated abor tion N Gentamicin N Uterine and fetal infection N Metronidazole N Postpartum bleeding 2 antibiotics : ¡ lasting > 24 hours N Ampicillin ¡ occurring > 24 hours after deliv ery N Gentamicin N Upper urinar y tract infection N Pneumonia N Manual remo val of placenta/fragments 1 antibiotic : N Risk of uterine and fetal infection N Ampicillin N In labour > 24 hours Antibiotic Prepar ation Dosag e/route Frequency Ampicillin Vial containing 500 mg as po wder: First 2 g IV/IM then 1 g every 6 hours to be mixed with 2.5 ml sterile water Gentamicin Vial containing 40 mg/ml in 2 ml 80 mg IM every 8 hours Metronidazole Vial containing 500 mg in 100 ml 500 mg or 100 ml IV infusion e very 8 hours DO NOT GIVE IM Erythromycin Vial containing 500 mg as po wder 500 mg IV/IM every 6 hours (if allergy to ampicillin) MALARIA Malaria EMERGENCY TREA TMENTS FOR THE WOMAN B16 Give arthemeter or quinine IM If dangerous fevr or very severe febrile disease Arthemeter Quinine* 1ml vial containing 80 mg/ml 2 ml vial containing 300 mg/ml Leading dose for 3.2 mg/kg 20 mg/kg assumed weight 50-60 kg 2 ml 4 ml Continue treatment 1.6 mg/kg 10 mg/kg if unable to refer 1 ml once daily for 3 da ys** 2 ml/8 hours for a total of 7 da ys** N Give the loading dose of the most effectiv e drug, according to the national policy . N If quinine: ¡ divide the required dose equally into 2 injections and giv e 1 in each anteri or thigh ¡ always give glucose with quinine. N Refer urgently to hospital B17. N If delivery imminent or unable to refer immediately , continue treatment as abo ve and refer after delivery. * These dosages are for quinine dih ydrochloride. If quinine base, give 8.2 mg/kg e very 8 hours. ** Discontinue parenteral treatment as soon as w oman is conscious and able to swallow. Begin oral treatment according to national guidelines. Give glucose IV If dangerous fevr or very severe febrile disease treated with quinine 50% glucose solution* 25% glucose soluti on 10% glucose solution (5 ml/kg) 25-50 ml 50-10 ml 125-250 ml N Make sure IV drip is r unning well. Give glucose by slow IV push. N If no IV glucose is available, give sugar water by mouth or nasogastr ic tube. N To make sugar water, dissolve 4 level teaspoons of sug ar (20 g) in a 200 ml cup of clean water . * 50% glucose solution is the same as 50% dextrose solution or D50. This solution is irritating to veins. Dilute it with an equa lquantity of sterile water or saline to produce 25% glucose REFER THE WOMAN URGENTL Y TO THE HOSPITAL Refer the woman urgently to hospital EMERGENCY TREA TMENTS FOR THE WOMAN B17 Refer the woman urg ently to hospital N After emerg ency manag ement, discuss decision with w oman and relativ es. N Quickly org anize transpor t and possible financial aid. N Inform the refer ral centre if possible b y radio or phone. N Accompany the woman if at all possible, or send: ¡ a health worker trained in deliv ery care ¡ a relative who can donate blood ¡ baby with the mother , if possible ¡ essential emerg ency dr ugs and supplies B17. ¡ referral note N2. N During jour ney: ¡ watch IV infusion ¡ if journey is long, give appropriate treatment on the wa y ¡ keep record of all IV fluids, medications giv en, time of administratio n and the woman’s condition. Essential emerg ency dr ugs and supplies for transpor t and home delivery Emergency drugs Strength and Form Quantity for car ry Oxytocin 10 IU vial 6 Ergometrine 0.2 mg vial 2 Magnesium sulphate 5 g vials (20 g) 4 Diazepam (parenteral ) 10 mg vial 3 Calcium gluconate 1 g vial 1 Ampicillin 500 mg vial 4 Gentamicin 80 mg vial 3 Metronidazole 500 mg vial 2 Ringer’ s lactate 1 litre bottle 4 (if distant refer ral) Emergency supplies IV catheters and tubin g 2 sets Gloves 2 pairs, at least, one pair sterile Sterile syring es and needles 5 sets Urinary catheter 1 Antiseptic solution 1 small bottle Container for sharps 1 Bag for trash 1 Torch and extra batter y 1 If deliver y is anticipated on the way Soap, towels 2 sets Disposable deliv ery kit (blade, 3 ties) 2 sets Clean cloths (3) for recei ving, drying and wrapping the bab y 1 set Clean clothes for the bab y 1 set Plastic bag for placenta 1 set Resuscitation bag and mask for the bab y 1set B14 ECLAMPSIA AND PRE-ECLAMPSIA (2) Give diazepam Give appropriate antihypertensive B15 INFECTION Give appropriate IV/IM antibiotics B16 MALARIA Give artemether or quinine IM Give glucose IV B17 REFER THE WOMAN URGENTLY TO THE HOSPITAL Refer the woman urgently to the hospital Essential emergency drugs and supplies for transport and home delivery N This section has details on emergency treatments identified during Rapid assessment and management (RAM) B3-B6 to be given before referral. N Give the treatment and refer the woman urgently to hospital B17. N If drug treatment, give the first dose of the drugs before referral. Do not delay referral by giving non-urgent treatments
AIRWAY,BREATHING AND CIRCULATION Manage the airway and breathing Insert IV line and give fluids If the woman has great difficulty breathing and: Wash hands with soap and water and put on gloves If you suspect obstruction: Clean woman's skin with spirit at site for IV line. Try to clear the ainway and dislodge obstruction Insert an intravenous line (IV line)using a 16-18 gauge needle Help the woman to find the best position for breathing Attach Ringer's lactate or normal saline.Ensure infusion is running well. -Urgently refer the woman to hospital. Give fluids at rapid rate if shock,systolic BP<90 mmHg,pulse>110/minute,or heavy vaginal bleeding If the woman is unconscious: Infuse 1 litre in 15-20 minutes (as rapid as possible). Keep her on her back,arms at the side Infuse 1 litre in 30 minutes at 30 ml/minute.Repeat if necessary. -Tilt her head backwards(unless trauma is suspected) Monitor every 15 minutes for: Lift her chin to open airway blood pressure (BP)and pulse Inspect her mouth for foreign body;remove if found shortness of breath or puffiness. NVW Clear secretions from throat Reduce the infusion rate to 3 ml/minute(1 litre in 6-8 hours)when pulse slows to less than 100/ minute,systolic BP increases to 100 mmHg or higher. If the woman is not breathing: Reduce the infusion rate to 0.5 ml/minute if breathing difficulty or puffiness develops. Ventilate with bag and mask until she starts breathing spontaneously ■Monitor urine output If woman still has great difficulty breathing,keep her propped up,and Record time and amount of fluids given. Refer the woman urgently to hospital. Give fluids at moderate rate if severe abdominal pain,obstructed labour,ectopic pregnancy,dangerous fever or dehydration: Infuse 1 litre in 2-3 hours. Give fluids at slow rate if severe anaemia/severe pre-eclampsia or eclampsia: Infuse 1 litre in 6-8 hours. If intravenous access not possible Give oral rehydration solution(ORS)by mouth if able to drink,or by nasogastric(NG)tube. Quantity of ORS:300 to 500 ml in 1 hour. DO NOT give ORS to a woman who is unconscious or has convulsions. Airway,breathing and circulation B9
AIRWAY, BREATHING AND CIRCULATION Airway, breathing and circulation EMERGENCY TREATMENTS FOR THE WOMAN B9 Manage the airway and breathing If the woman has great difficulty breathing and: N If you suspect obstruction: ¡ Try to clear the airway and dislodge obstruction ¡ Help the woman to find the best position for breathing ¡Urgently refer the woman to hospital. N If the woman is unconscious: ¡ Keep her on her back, arms at the side ¡ Tilt her head backwards (unless trauma is suspected) ¡ Lift her chin to open airway ¡ Inspect her mouth for foreign body; remove if found ¡ Clear secretions from throat. N If the woman is not breathing: ¡ Ventilate with bag and mask until she starts breathing spontaneously N If woman still has great difficulty breathing, keep her propped up, and N Refer the woman urgently to hospital. Insert IV line and give fluids N Wash hands with soap and water and put on gloves. N Clean woman’s skin with spirit at site for IV line. N Insert an intravenous line (IV line) using a 16-18 gauge needle. N Attach Ringer’s lactate or normal saline. Ensure infusion is running well. Give fluids at rapid rate if shock, systolic BP<90 mmHg, pulse>110/minute, or heavy vaginal bleeding: N Infuse 1 litre in 15-20 minutes (as rapid as possible). N Infuse 1 litre in 30 minutes at 30 ml/minute. Repeat if necessary. N Monitor every 15 minutes for: ¡blood pressure (BP) and pulse ¡shortness of breath or puffiness. N Reduce the infusion rate to 3 ml/minute (1 litre in 6-8 hours) when pulse slows to less than 100/ minute, systolic BP increases to 100 mmHg or higher. N Reduce the infusion rate to 0.5 ml/minute if breathing difficulty or puffiness develops. N Monitor urine output. N Record time and amount of fluids given. Give fluids at moderate rate if severe abdominal pain, obstructed labour, ectopic pregnancy, dangerous fever or dehydration: N Infuse 1 litre in 2-3 hours. Give fluids at slow rate if severe anaemia/severe pre-eclampsia or eclampsia: N Infuse 1 litre in 6-8 hours. If intravenous access not possible N Give oral rehydration solution (ORS) by mouth if able to drink, or by nasogastric (NG) tube. N Quantity of ORS: 300 to 500 ml in 1 hour. DO NOT give ORS to a woman who is unconscious or has convulsions
Bleeding(1) B10 BLEEDING Massage uterus and expel clots Give oxytocin If heavy postpartum bleeding persists after placenta is delivered,or uterus is not well contracted(is soft): If heavy postpartum bleeding Place cupped palm on uterine fundus and feel for state of contraction. Massage fundus in a circular motion with cupped palm until uterus is well contracted. Initial dose Continuing dose Maximum dose When well contracted,place fingers behind fundus and push down in one swift action to expel clots IM/IV:10 IU IM/IV:repeat 10 IU Collect blood in a container placed close to the vulva.Measure or estimate blood loss,and record. after 20 minutes Not more than 3 litres SIN3 if heavy bleeding persists of IV fluids containing Apply bimanual uterine compression IV infusion: IV infusion: oxytocin 20 IU in 1 litre 10 IU in 1 litre If heavy postpartum bleeding persists despite uterine massage,oxytocin/ergometrine treatment and at 60 drops/min at 30 drops/min removal of placenta: Wear sterile or clean gloves. Introduce the right hand into the vagina.clenched fist,with the back of the hand directed posteriorly and the knuckles in the anterior fornix. Give ergometrine Place the other hand on the abdomen behind the uterus and squeeze the uterus firmly between the If heavy bleeding in early pregnancy or postpartum bleeding(after oxytocin)but two hands. DO NOT give if eclampsia,pre-eclampsia,or hypertension Continue compression until bleeding stops(no bleeding if the compression is released). 岳 If bleeding persists,apply aortic compression and transport woman to hospital. Initial dose Continuing dose Maximum dose IM/IV:0.2 mg IM:repeat 0.2 mg Not more than Apply aortic compression slowly IM after 15 minutes if heavy 5 doses(total 1.0 mg) bleeding persists If heavy postpartum bleeding persists despite uterine massage,oxytocin/ergometrine treatment and removal of placenta: Feel for femoral pulse. Apply pressure above the umbilicus to stop bleeding Apply sufficient pressure until femoral pulse is not felt. After finding correct site,show assistant or relative how to apply pressure,if necessary. Continue pressure until bleeding stops.If bleeding persists,keep applying pressure while transporting woman to hospital
BLEEDING Bleeding (1) EMERGENCY TREATMENTS FOR THE WOMAN B10 Massage uterus and expel clots If heavy postpartum bleeding persists after placenta is delivered, or uterus is not well contracted (is soft): N Place cupped palm on uterine fundus and feel for state of contraction. N Massage fundus in a circular motion with cupped palm until uterus is well contracted. N When well contracted, place fingers behind fundus and push down in one swift action to expel clots. N Collect blood in a container placed close to the vulva. Measure or estimate blood loss, and record. Apply bimanual uterine compression If heavy postpartum bleeding persists despite uterine massage, oxytocin/ergometrine treatment and removal of placenta: N Wear sterile or clean gloves. N Introduce the right hand into the vagina, clenched fist, with the back of the hand directed posteriorly and the knuckles in the anterior fornix. N Place the other hand on the abdomen behind the uterus and squeeze the uterus firmly between the two hands. N Continue compression until bleeding stops (no bleeding if the compression is released). N If bleeding persists, apply aortic compression and transport woman to hospital. Apply aortic compression If heavy postpartum bleeding persists despite uterine massage, oxytocin/ergometrine treatment and removal of placenta: N Feel for femoral pulse. N Apply pressure above the umbilicus to stop bleeding. Apply sufficient pressure until femoral pulse is not felt. N After finding correct site, show assistant or relative how to apply pressure, if necessary. N Continue pressure until bleeding stops. If bleeding persists, keep applying pressure while transporting woman to hospital. Give oxytocin If heavy postpartum bleeding Initial dose Continuing dose Maximum dose IM/IV: 10 IU IM/IV: repeat 10 IU after 20 minutes Not more than 3 litres if heavy bleeding persists of IV fluids containing IV infusion: IV infusion: oxytocin 20 IU in 1 litre 10 IU in 1 litre at 60 drops/min at 30 drops/min Give ergometrine If heavy bleeding in early pregnancy or postpartum bleeding (after oxytocin) but DO NOT give if eclampsia, pre-eclampsia, or hypertension Initial dose Continuing dose Maximum dose IM/IV:0.2 mg IM: repeat 0.2 mg Not more than slowly IM after 15 minutes if heavy 5 doses (total 1.0 mg) bleeding persists
Remove placenta and fragments manually After manual removal of the placenta If placenta not delivered 1 hour after delivery of the baby,OR Repeat oxytocin 10-IU IM/IV. If heavy vaginal bleeding continues despite massage and oxytocin and placenta cannot be delivered Massage the fundus of the uterus to encourage a tonic uterine contraction. by controlled cord traction,or if placenta is incomplete and bleeding continues. Give ampicillin 2 g IV/IM E15. If fever>38.5C,foul-smelling lochia or history of rupture of membranes for 18 or more hours,also Preparation give gentamicin 80 mg IM E5 Explain to the woman the need for manual removal of the placenta and obtain her consent ■If bleeding stops: Insert an IV line.If bleeding.give fluids rapidly.If not bleeding.give fluids slowly -give fluids slowly for at least 1 hour after removal of placenta. Assist woman to get onto her back. If heavy bleeding continues: Give diazepam (10-mg IM/IV). -give ergometrine 0.2 mg IM Clean vulva and perineal area. -give 20 IU oxytocin in each litre of IV fluids and infuse rapidly Ensure the bladder is empty.Catheterize if necessary Refer urgently to hospital Wash hands and forearms well and put on long sterile gloves (and an apron or gown if available) During transportation,feel continuously whether uterus is well contracted (hard and round).If not, massage and repeat oxytocin 10 IU IM/IV. Technique Provide bimanual or aortic compression if severe bleeding before and during transportation With the left hand,hold the umbilical cord with the clamp.Then pull the cord gently until it is horizontal. Insert right hand into the vagina and up into the uterus. Leave the cord and hold the fundus with the left hand in order to support the fundus of the uterus and to provide counter-traction during removal. 山 Move the fingers of the right hand sideways until edge of the placenta is located. Detach the placenta from the implantation site by keeping the fingers tightly together and using the edge of the hand to gradually make a space between the placenta and the uterine wall. 豆 Proceed gradually all around the placental bed until the whole placenta is detached from the uterine wall. Withdraw the right hand from the uterus gradually,bringing the placenta with it. Explore the inside of the uterine cavity to ensure all placental tissue has been removed. With the left hand,provide counter-traction to the fundus through the abdomen by pushing it in the opposite direction of the hand that is being withdrawn.This prevents inversion of the uterus. Examine the uterine surface of the placenta to ensure that lobes and membranes are complete.If any placental lobe or tissue fragments are missing.explore again the uterine cavity to remove them. E If hours or days have passed since delivery,or if the placenta is retained due to constriction ring or closed cervix,it may not be possible to put the hand into the uterus.DO NOT persist.Refer urgently to hospital If the placenta does not separate from the uterine surface by gentle sideways movement of the fingertips at the line of cleavage,suspect placenta accreta.DO NOT persist in efforts to remove placenta.Refer urgently to hospital Bleeding(2) B11
Bleeding (2) EMERGENCY TREATMENTS FOR THE WOMAN B11 Remove placenta and fragments manually N If placenta not delivered 1 hour after delivery of the baby, OR N If heavy vaginal bleeding continues despite massage and oxytocin and placenta cannot be delivered by controlled cord traction, or if placenta is incomplete and bleeding continues. Preparation N Explain to the woman the need for manual removal of the placenta and obtain her consent. N Insert an IV line. If bleeding, give fluids rapidly. If not bleeding, give fluids slowly B9 . N Assist woman to get onto her back. N Give diazepam (10-mg IM/IV). N Clean vulva and perineal area. N Ensure the bladder is empty. Catheterize if necessary B12 . N Wash hands and forearms well and put on long sterile gloves (and an apron or gown if available). Technique N With the left hand, hold the umbilical cord with the clamp. Then pull the cord gently until it is horizontal. N Insert right hand into the vagina and up into the uterus. N Leave the cord and hold the fundus with the left hand in order to support the fundus of the uterus and to provide counter-traction during removal. N Move the fingers of the right hand sideways until edge of the placenta is located. N Detach the placenta from the implantation site by keeping the fingers tightly together and using the edge of the hand to gradually make a space between the placenta and the uterine wall. N Proceed gradually all around the placental bed until the whole placenta is detached from the uterine wall. N Withdraw the right hand from the uterus gradually, bringing the placenta with it. N Explore the inside of the uterine cavity to ensure all placental tissue has been removed. N With the left hand, provide counter-traction to the fundus through the abdomen by pushing it in the opposite direction of the hand that is being withdrawn. This prevents inversion of the uterus. N Examine the uterine surface of the placenta to ensure that lobes and membranes are complete. If any placental lobe or tissue fragments are missing, explore again the uterine cavity to remove them. If hours or days have passed since delivery, or if the placenta is retained due to constriction ring or closed cervix, it may not be possible to put the hand into the uterus. DO NOT persist. Refer urgently to hospital B17 . If the placenta does not separate from the uterine surface by gentle sideways movement of the fingertips at the line of cleavage, suspect placenta accreta. DO NOT persist in efforts to remove placenta. Refer urgently to hospital B17 . After manual removal of the placenta N Repeat oxytocin 10-IU IM/IV. N Massage the fundus of the uterus to encourage a tonic uterine contraction. N Give ampicillin 2 g IV/IM B15 . N If fever >38.5°C, foul-smelling lochia or history of rupture of membranes for 18 or more hours, also give gentamicin 80 mg IM B15 . N If bleeding stops: ¡ give fluids slowly for at least 1 hour after removal of placenta. N If heavy bleeding continues: ¡ give ergometrine 0.2 mg IM ¡ give 20 IU oxytocin in each litre of IV fluids and infuse rapidly ¡ Refer urgently to hospital B17 . N During transportation, feel continuously whether uterus is well contracted (hard and round). If not, massage and repeat oxytocin 10 IU IM/IV. N Provide bimanual or aortic compression if severe bleeding before and during transportation B10
Bleeding(3) B12 REPAIR THE TEAR AND EMPTY BLADDER Repair the tear or episiotomy Empty bladder Examine the tear and determine the degree: If bladder is distended and the woman is unable to pass urine: The tear is small and involved only vaginal mucosa and connective tissues and underlying Encourage the woman to urinate. muscles(first or second degree tear).If the tear is not bleeding.leave the wound open. If she is unable to urinate,catheterize the bladder: The tear is long and deep through the perineum and involves the anal sphincter and rectal mucosa →Wash hands SIN3 (third and fourth degree tear).Cover it with a clean pad and refer the woman urgently to hospital Clean urethral area with antiseptic If first or second degree tear and heavy bleeding persists after applying pressure over the wound: Put on clean gloves Suture the tear or refer for suturing if no one is available with suturing skills. Spread labia.Clean area again Suture the tear using universal precautions,aseptic technique and sterile equipment. Insert catheter up to 4 cm Use a needle holder and a 21 gauge,4 cm,curved needle. Measure urine and record amount Use absorbable polyglycon suture material. Remove catheter. Make sure that the apex of the tear is reached before you begin suturing. Ensure that edges of the tear match up well. DO NOT suture if more than 12 hours since delivery.Refer woman to hospital
REPAIR THE TEAR AND EMPTY BLADDER Bleeding (3) EMERGENCY TREATMENTS FOR THE WOMAN B12 Repair the tear or episiotomy N Examine the tear and determine the degree: ¡ The tear is small and involved only vaginal mucosa and connective tissues and underlying muscles (first or second degree tear). If the tear is not bleeding, leave the wound open. ¡ The tear is long and deep through the perineum and involves the anal sphincter and rectal mucosa (third and fourth degree tear). Cover it with a clean pad and refer the woman urgently to hospital B17 . N If first or second degree tear and heavy bleeding persists after applying pressure over the wound: ¡ Suture the tear or refer for suturing if no one is available with suturing skills. ¡ Suture the tear using universal precautions, aseptic technique and sterile equipment. ¡ Use a needle holder and a 21 gauge, 4 cm, curved needle. ¡ Use absorbable polyglycon suture material. ¡ Make sure that the apex of the tear is reached before you begin suturing. ¡ Ensure that edges of the tear match up well. DO NOT suture if more than 12 hours since delivery. Refer woman to hospital. Empty bladder If bladder is distended and the woman is unable to pass urine: N Encourage the woman to urinate. N If she is unable to urinate, catheterize the bladder: ¡ Wash hands ¡ Clean urethral area with antiseptic ¡ Put on clean gloves ¡ Spread labia. Clean area again ¡ Insert catheter up to 4 cm ¡ Measure urine and record amount ¡ Remove catheter