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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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BBLEEDING IN EARLY PREGNANCY AND POST-ABORTION CARE

  • Always begin with Rapid assessment and management (RAM) B3-B7.
  • Next use the Bleeding in early pregnancy/post abortion care B19 to assess the woman with light vaginal bleeding or a history of missed periods.
  • Use chart on Preventive measures B20 to provide preventive measures due to all women.
  • Use Advise and Counsel on post-abortion care B21 to advise on self care, danger signs, follow-up visit, family planning.
  • Record all treatment given, positive findings, and the scheduled next visit in the home-based and clinic recording forms.
  • If the woman is HIV positive, adolescent or has special needs, use G1-G11 H1-H4.

B19. EXAMINATION OF THE WOMAN WITH BLEEDING IN EARLY PREGNANCY, AND POST-ABORTION CARE

Use this chart if a woman has vaginal bleeding in early pregnancy or a history of missed periods

ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT
  • When did bleeding start?
  • How much blood have you lost?
  • Are you still bleeding?
  • Is the bleeding increasing or decreasing?
  • Could you be pregnant?
  • When was your last period?
  • Have you had a recent abortion?
  • Did you or anyone else do anything to induce an abortion?
  • Have you fainted recently?
  • Do you have abdominal pain?
  • Do you have any other concerns to discuss?
  • Look at amount of bleeding.
  • Note if there is foul-smelling vaginal discharge.
  • Feel for lower abdominal pain.
  • Feel for fever. If hot, measure temperature.
  • Look for pallor.
  • Vaginal bleeding and any of:
    →

    Foul-smelling vaginal discharge

    →

    Abortion with uterine manipulation

    →

    Abdominal pain/tenderness

    →

    Temperature >38°C

COMPLICATED ABORTION
  • Insert an IV line and give fluids B9.
  • Give paracetamol for pain F4.
  • Give appropriate IM/IV antibiotics B15.
  • Refer urgently to hospital B17.
  • Light vaginal bleeding
THREATENED ABORTION
  • Observe bleeding for 4-6 hours:
    →

    If no decrease, refer to hospital.

    →

    If decrease, let the woman go home.

    →

    Advise the woman to return immediately if bleeding increases.

  • Follow up in 2 days B21.
  • History of heavy bleeding but:
    →

    now decreasing, or

    →

    no bleeding at present

COMPLETE ABORTION
  • Check preventive measures B20.
  • Advise on self-care B21.
  • Advise and counsel on family planning B21.
  • Advise to return if bleeding does not stop within 2 days.
  • Two or more of the following signs:
    →

    abdominal pain

    →

    fainting

    →

    pale

    →

    very weak

ECTOPIC PREGNANCY
  • Insert an IV line and give fluids B9.
  • Refer urgently to hospital B17.

Image bleedingfu1.jpg Next: Give preventive measures

B20. GIVE PREVENTIVE MEASURES

ASSESS, CHECK RECORDSTREAT AND ADVISE
  • Check tetanus toxoid (TT) immunization status.
  • Give tetanus toxoid if due F2.
  • Check woman's supply of the prescribed dose of iron/folate.
  • Give 3 month's supply of iron and counsel on compliance F3.
  • Check HIV status C6.
  • If HIV status is unknown, counsel on HIV testing G3.
  • If HIV-infected:
    refer to HIV services for further assessment and treatment
    →

    give support G4

    →

    advise on opportunistic infection and need to seek medical help C10

    →

    counsel on safer sex including use of condoms G2.

  • If HIV-negative, counsel on safer sex including use of condoms G4.
  • Check RPR status in records C5.
  • If no RPR results, do the RPR test L5.
If Rapid plasma reagin (RPR) positive:
  • Treat the woman for syphilis with benzathine penicillin F6.
  • Advise on treating her partner.
  • Encourage HIV testing and counselling G3.
  • Reinforce use of condoms G2.
  • Record the findings (including the immunization card).

B21. ADVISE AND COUNSEL ON POST-ABORTION CARE

Advise on self-care

  • Rest for a few days, especially if feeling tired.
  • Advise on hygiene
    →

    change pads every 4 to 6 hours

    →

    wash the perineum daily

    →

    avoid sexual relations until bleeding stops.

  • Advise woman to return immediately if she has any of the following danger signs:
    →

    increased bleeding

    →

    continued bleeding for 2 days

    →

    foul-smelling vaginal discharge

    →

    abdominal pain

    →

    fever, feeling ill, weakness

    →

    dizziness or fainting.

  • Advise woman to return in if delay (6 weeks or more) in resuming menstrual periods.

Advise and counsel on family planning

  • Explain to the woman that she can become pregnant soon after the abortion - as soon as she has sexual intercourse — if she does not use a contraceptive:
    →

    Any family planning method can be used immediately after an uncomplicated first trimester abortion.

    →

    If the woman has an infection or injury: delay IUD insertion or female sterilization until healed. For information on options, see Methods for non-breastfeeding women on D27.

  • Make arrangements for her to see a family planning counsellor as soon as possible, or counsel her directly. (see The decision-making tool for family planning clients and providers for information on methods and on the counselling process).
  • Counsel on safer sex including use of condom if she or her partner are at risk of sexually transmitted infection (STI) or HIV G2.

Provide information and support after abortion

  • A woman may experience different emotions after an abortion, and may benefit from support:
  • Allow the woman to talk about her worries, feelings, health and personal situation. Ask if she has any questions or concerns.
  • Facilitate family and community support, if she is interested (depending on the circumstances, she may not wish to involve others).
    →

    Speak to them about how they can best support her, by sharing or reducing her workload, helping out with children, or simply being available to listen.

    →

    Inform them that post-abortion complications can have grave consequences for the woman's health. Inform them of the danger signs and the importance of the woman returning to the health worker if she experiences any.

    →

    Inform them about the importance of family planning if another pregnancy is not desired.

  • If the woman is interested, link her to a peer support group or other women's groups or community services which can provide her with additional support.
  • If the woman discloses violence or you see unexplained bruises and other injuries which make you suspect she may be suffering abuse, see H4.
  • Counsel on safer sex including use of condoms if she or her partner are at risk for STI or HIV G2.

Advise and counsel during follow-up visits

  • If threatened abortion and bleeding stops:
  • Reassure the woman that it is safe to continue pregnancy.
  • Provide antenatal care C1-C18.
  • If bleeding continues:
  • Assess and manage as in Bleeding in early pregnancy/post-abortion care B18-B22.
    →

    If fever, foul-smelling vaginal discharge, or abdominal pain, give first dose of appropriate IV/IM antibiotics B15.

    →

    Refer woman to hospital.

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).

Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html).

Bookshelf ID: NBK326684
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