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Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice. 3rd edition. Geneva: World Health Organization; 2015.

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Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice. 3rd edition.

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BQUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE

  • 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.
  • 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.

B2. QUICK CHECK

A person responsible for initial reception of women of childbearing age and newborns seeking care should:

  • assess the general condition of the careseeker(s) immediately on arrival
  • periodically repeat this procedure if the line is long.

If a woman is very sick, talk to her companion.

ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT
  • Why did you come?
    →

    for yourself?

    →

    for the baby?

  • How old is the baby?
  • What is the concern?
Is the woman being wheeled or carried in or:
  • bleeding vaginally
  • convulsing
  • looking very ill
  • unconscious
  • in severe pain
  • in labour
  • delivery is imminent
  • If the woman is or has:
  • unconscious (does not answer)
  • convulsing
  • bleeding
  • severe abdominal pain or looks very ill
  • headache and visual disturbance
  • severe difficulty breathing
  • fever
  • severe vomiting.
EMERGENCY FOR WOMAN
  • Transfer woman to a treatment room for Rapid assessment and management B3-B7.
  • Call for help if needed.
  • Reassure the woman that she will be taken care of immediately.
  • Ask her companion to stay.
Check if baby is or has:
  • very small
  • convulsing
  • breathing difficulty
  • Imminent delivery or
  • Labour
LABOUR
  • Transfer the woman to the labour ward.
  • Call for immediate assessment.
If the baby is or has:
  • very small
  • convulsions
  • difficult breathing
  • just born
  • any maternal concern.
EMERGENCY FOR BABY
  • Transfer the baby to the treatment room for immediate Newborn care J1-J11.
  • Ask the mother to stay.
  • Pregnant woman, or after delivery, with no danger signs
  • A newborn with no danger signs or maternal complaints.
ROUTINE CARE
  • Keep the woman and baby in the waiting room for routine care.

Image quickcheckfu2.jpgIF emergency for woman or baby or labour, go to B3.

IF no emergency, go to relevant section

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

B3. Airway and breathing, circulation (shock)

EMERGENCY SIGNSMEASURETREATMENT
Do all emergency steps before referral
AIRWAY AND BREATHING
  • Very difficult breathing or
  • Central cyanosis
  • Manage airway and breathing B9.
  • Refer woman urgently to hospital* B17.
This may be pneumonia, severe anaemia with heart failure, obstructed breathing, asthma.
CIRCULATION (SHOCK)
  • Cold moist skin or
  • Weak and fast pulse
  • Measure blood pressure
  • Count pulse
If systolic BP < 90 mmHg or pulse >110 per minute:
  • Position the woman on her left side with legs higher than chest.
  • Insert an IV line B9.
  • Give fluids rapidly B9.
  • If not able to insert peripheral IV, use alternative B9.
  • Keep her warm (cover her).
  • Refer her urgently to hospital* B17.
This may be haemorrhagic shock, septic shock.
*

But if birth is imminent (bulging, thin perineum during contractions, visible fetal head), transfer woman to labour room and proceed as on D1-D28.

Image quickcheckfu2.jpg Next: Vaginal bleeding

B4. VAGINAL BLEEDING

  • Assess pregnancy status
  • Assess amount of bleeding
PREGNANCY STATUSBLEEDINGTREATMENT
EARLY PREGNANCY
not aware of pregnancy, or not pregnant (uterus NOT above umbilicus)		HEAVY BLEEDING
Pad or cloth soaked in < 5 minutes.
  • Insert an IV line B9.
  • Give fluids rapidly B9.
  • Give 0.2 mg ergometrine IM B10.
  • Repeat 0.2 mg ergometrine IM/IV if bleeding continues.
  • If suspect possible complicated abortion, give appropriate IM/IV antibiotics B15.
  • Refer woman urgently to hospital B17.
This may be abortion, menorrhagia, ectopic pregnancy.
LIGHT BLEEDING
  • Examine woman as on B19.
  • If pregnancy not likely, refer to other clinical guidelines.
LATE PREGNANCY
(uterus above umbilicus)		ANY BLEEDING IS DANGEROUSDO NOT do vaginal examination, but:
  • Insert an IV line B9.
  • Give fluids rapidly if heavy bleeding or shock B3.
  • Refer woman urgently to hospital* B17.
This may be placenta previa, abruptio placentae, ruptured uterus.
DURING LABOUR
before delivery of baby		BLEEDING MORE THAN 100 ML SINCE LABOUR BEGANDO NOT do vaginal examination, but:
  • Insert an IV line B9.
  • Give fluids rapidly if heavy bleeding or shock B3.
  • Refer woman urgently to hospital* B17.
This may be placenta previa, abruptio placenta, ruptured uterus.
*

But if birth is imminent (bulging, thin perineum during contractions, visible fetal head), transfer woman to labour room and proceed as on D1-D28.

Image quickcheckfu2.jpg Next: Vaginal bleeding in postpartum

B5. Vaginal bleeding: postpartum

PREGNANCY STATUSBLEEDINGTREATMENT
POSTPARTUM
(baby is born)		HEAVY BLEEDING
  • Pad or cloth soaked in < 5 minutes
  • Constant trickling of blood
  • Bleeding >250 ml or delivered outside health centre and still bleeding
  • Call for extra help.
  • Massage uterus until it is hard and give oxytocin 10 IU IM B10.
  • Insert an IV line B9 and give IV fluids with 20 IU oxytocin at 60 drops/minute.
  • Empty bladder. Catheterize if necessary B12.
  • Check and record BP and pulse every 15 minutes and treat as on B3.
This may be uterine atony, retained placenta, ruptured uterus, vaginal or cervical tear.
Image quickcheckfu1.jpg Check and ask if placenta is deliveredPLACENTA NOT DELIVERED
  • When uterus is hard, deliver placenta by controlled cord traction D12.
  • If unsuccessful and bleeding continues, remove placenta manually and check placenta B11.
  • Give appropriate IM/IV antibiotics B15.
  • 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.
PLACENTA DELIVERED
Image quickcheckfu1.jpg CHECK PLACENTA B11		If placenta is complete:
  • Massage uterus to express any clots B10.
  • If uterus remains soft, give ergometrine 0.2 mg IV B10.
    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 B11.
  • Give appropriate IM/IV antibiotics B15.
  • If unable to remove, refer woman urgently to hospital B17.
Image quickcheckfu1.jpg Check for perineal and lower vaginal tearsIF PRESENT
  • Examine the tear and determine the degree B12.
    If third degree tear (involving rectum or anus), refer woman urgently to hospital B17.
  • For other tears: apply pressure over the tear with a sterile pad or gauze and put legs together.
  • Check after 5 minutes, if bleeding persists repair the tear B12.
Image quickcheckfu1.jpg Check if still bleedingHEAVY BLEEDING
  • Continue IV fluids with 20 units of oxytocin at 30 drops/minute. Insert second IV line.
  • If IV oxytocin not available or if bleeding does not respond to oxytocin, give misoprostol, 4 tablets of 200µg (800µg) under the tongue B10.
  • Apply bimanual uterine or aortic compression B10.
  • Give appropriate IM/IV antibiotics B15.
  • Refer woman urgently to hospital B17.
CONTROLLED BLEEDING
  • Continue oxytocin infusion with 20 IU/litre of IV fluids at 20 drops/min for at least one hour after bleeding stops B10.
  • Observe closely (every 30 minutes) for 4 hours. Keep nearby for 24 hours. If severe pallor, refer to health centre.
  • Examine the woman using Assess the mother after delivery D12.

Image quickcheckfu2.jpg Next: Convulsions or unconscious

B6. Emergency signs

EMERGENCY SIGNSMEASURETREATMENT
CONVULSIONS OR UNCONSCIOUS
  • Convulsing (now or recently), or
  • Unconscious
    If unconscious, ask relative “has there been a recent convulsion?”
  • Measure blood pressure
  • Measure temperature
  • Assess pregnancy status
  • Protect woman from fall and injury. Get help.
  • Manage airway B9.
  • After convulsion ends, help woman onto her left side.
  • Insert an IV line and give fluids slowly (30 drops/min) B9.
  • Give magnesium sulphate B13.
  • If early pregnancy, give diazepam IV or rectally B14.
  • If diastolic BP >110 mm of Hg, give antihypertensive B14.
  • If temperature >38ºC, or history of fever, also give treatment for dangerous fever (below).
  • Refer woman urgently to hospital* B17.
This may be eclampsia.
  • Measure BP and temperature
  • If diastolic BP >110 mm of Hg, give antihypertensive B14.
  • If temperature >38ºC, or history of fever, also give treatment for dangerous fever (below).
  • Refer woman urgently to hospital* B17.
SEVERE ABDOMINAL PAIN
  • Severe abdominal pain (not normal labour)
  • Measure blood pressure
  • Measure temperature
  • Insert an IV line and give fluids B9.
  • If temperature more than 38ºC, give first dose of appropriate IM/IV antiobiotics B15.
  • Refer woman urgently to hospital* B17.
  • If systolic BP <90 mm Hg see B3.
This may be ruptured uterus, obstructed labour, abruptio placenta, puerperal or post-abortion sepsis, ectopic pregnancy.
DANGEROUS FEVER
Fever (temperature more than 38ºC) and any of:
  • Very fast breathing
  • Stiff neck
  • Lethargy
  • Very weak/not able to stand
  • Measure temperature
  • Insert an IV line B9.
  • Give fluids slowly B9.
  • Give first dose of appropriate IM/IV antibiotics B15.
  • Give artesunate IM (if not available, give artemether or quinine IM) and glucose B16.
  • Refer woman urgently to hospital* B17.
This may be malaria, meningitis, pneumonia, septicemia.
*

But if birth is imminent (bulging, thin perineum during contractions, visible fetal head), transfer woman to labour room and proceed as on D1-D28.

Image quickcheckfu2.jpg Next: Priority signs

B7. Priority signs

PRIORITY SIGNSMEASURETREATMENT
LABOUR
  • Labour pains or
  • Ruptured membranes
  • Manage as for Childbirth D1-D28.
OTHER DANGER SIGNS OR SYMPTOMS
If any of:
  • Severe pallor
  • Epigastric or abdominal pain
  • Severe headache
  • Blurred vision
  • Fever (temperature more than 38ºC)
  • Breathing difficulty
  • Measure blood pressure
  • Measure temperature
  • If pregnant (and not in labour), provide antenatal care C1-C19.
  • If recently given birth, provide postpartum care D21. and E1-E10.
  • If recent abortion, provide post-abortion care B20-B21.
  • If early pregnancy, or not aware of pregnancy, check for ectopic pregnancy B19.
IF NO EMERGENCY OR PRIORITY SIGNS, NON URGENT
  • No emergency signs or
  • No priority signs
  • If pregnant (and not in labour), provide antenatal care C1-C19.
  • If recently given birth, provide postpartum care E1-E10.
Copyright © World Health Organization 2015.

All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob).

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Bookshelf ID: NBK326676
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