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 B5Rapid 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