QUICK CHECK,RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE 口B2 QUICK CHECK Perform Quick check immediately after the woman arrives If amy danger sign is seen,help the woman and send her quickly to the emergency room. Always begin a clinical visit with Rapid assessment and management(RAM) Check for emergency signs first EG EE RAPID ASSESSMENT AND If present,provide emergency treatment and refer the woman urgently to hospital. MANAGEMENT(RAM)(1) Complete the referral form Airway and breathing Check for priority signs.If present,manage according to charts Circulation and shock If no emergency or prority signs,allow the woman to wait in line for routine care,according to pregnancy status. E RAPID ASSESSMENT AND MANAGEMENT(RAM)(2) Vaginal bleeding E5 RAPID ASSESSMENT AND MANAGEMENT(RAM)(3) Vaginal bleeding:postpartum EB RAPID ASSESSMENT AND MANAGEMENT(RAM)(4) Convulsions Severe abdominal pain Dangerous fever E RAPID ASSESSMENT AND MANAGEMENT(RAM)(5) priority signs Labour Other danger signs or symptoms Non-urgent Quick check,rapid assessment and management of women of childbearing age B1Quick 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 post￾abortion 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