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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 

 


Section 1 - Clinical Principles


Rapid initial assessment

When a woman of childbearing age presents with a problem, rapidly assess her condition to determine her degree of illness.

 Table C 1 Rapid initial assessment a

Access

Danger signs

Consider

Airway and breathing

LOOK FOR

• cyanosis (blueness)

• respiratory distress

EXAMINE:

• skin: pallor

• lungs: wheezing or rales

• severe anaemia

• heart failure

• pneumonia

• asthma

See Difficulty in breathing

Circulation

(signs of shock)

EXAMINE:

• skin: cool and clammy

• pulse: fast (110 or more) and weak

• blood pressure: low (systolic less than 90 mm Hg)

Shock

Vaginal bleeding

(early or late pregnancy or after childbirth)

ASK IF:

• pregnant, length of gestation

• recently given birth

• placenta delivered

EXAMINE:

• vulva: amount of bleeding, placenta retained, obvious tears

• uterus: atony

• bladder: full 

DO NOT DO A VAGINAL EXAM AT THIS STAGE

• abortion

• ectopic pregnancy

• molar pregnancy

See Vaginal bleeding in early pregancy

• abruptio placentae

• ruptured uterus

• placenta praevia

See Vaginal bleeding in later pregnancy and labour

• atonic uterus

• tears of cervix and vagina

• retained placenta

• inverted uterus

See Vaginal bleeding after childbirth

Unconscious or convulsing

ASK IF:

• pregnant, length of gestation

EXAMINE:

• blood pressure: high (diastolic 90 mm Hg or more)

• temperature: 38�C or more

• eclampsia

• malaria

• epilepsy

• tetanus

See Convulsions or loss of consciousness

Dangerous fever 

ASK IF:

• weak, lethargic

• frequent, painful urination

EXAMINE:

• temperature: 38�C or more

• unconscious

• neck: stiffness

• lungs: shallow breathing, consolidation

• abdomen: severe tenderness

• vulva: purulent discharge

• breasts: tender

• urinary tract infection

• malaria

See Fever during pregnancy and labour

• metritis

• pelvic abscess

• peritonitis

• breast infection

See Fever after childbirth

• complications of abortion

See Vaginal bleeding in early pregnancy

• pneumonia

See Difficulty in breathing

Abdominal pain

ASK IF:

• pregnant, length of gestation

EXAMINE:

• blood pressure: low (systolic less than 90 mm Hg)

• pulse: fast (110 or more)

• temperature: 38�C or more

• uterus: state of pregnancy

• ovarian cyst

• appendicitis

• ectopic pregnancy

See Abdominal pain in early pregnancy

• possible term or preterm labour

• amnionitis

• abruptio placentae

• ruptured uterus

See Abdominal pain in later pregnancy and after childbirth

a This list does not include all the possible problems that a woman may face in a pregnancy or the puerperal period. It is meant to identify those problems that put the woman at greater risk of maternal morbidity and mortality.

The woman also needs prompt attention if she has any of the following signs: 

 

  • blood-stained mucus discharge (show) with palpable contractions;
  • ruptured membranes;
  • pallor;
  • weakness;
  • fainting;
  • severe headaches;
  • blurred vision;
  • vomiting;
  • fever;
  • respiratory distress.

The woman should be sent to the front of the queue and promptly treated.

 

IMPLEMENTING A RAPID INITIAL ASSESSMENT SCHEME

Rapid initiation of treatment requires immediate recognition of the specific problem and quick action. This can be done by:

  • training all staff—including clerks, guards, door-keepers or switchboard operators—to react in an agreed upon fashion (“sound the alarm”, call for help) when a woman arrives at the facility with an obstetric emergency or pregnancy complication or when the facility is notified that a woman is being referred;
  • clinical or emergency drills with staff to ensure their readiness at all levels;
  • ensuring that access is not blocked (keys are available) and equipment is in working order (daily checks) and staff are properly trained to use it; 
  • having norms and protocols (and knowing how to use them) to recognize a genuine emergency and know how to react immediately;
  • clearly identifying which women in the waiting room—even those waiting for routine consultations—warrant prompt or immediate attention from the health worker and should therefore pass to the front of the queue (agreeing that women in labour or pregnant women who have any of the problems noted in Table C-1 should immediately be seen by a health worker);• agreeing on schemes by which women with emergencies can be exempted from payment, at least temporarily (local insurance schemes, healthcommittee emergency funds).

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Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support

Emergencies

General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages

Symptoms

Shock

Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems

Procedures

Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia

Ketamine

External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section

Symphysontomy

Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy

Episiotomy

Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy

Appendix

 

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