External uterine massage technique

Evaluation sheets for emergency medical care for bleeding in early and late pregnancy, postpartum hemorrhage, preeclampsia, eclampsia, septic conditions, sepsis

1. Scorecard for bleeding in early pregnancy

(prehospital care at the PHC level)

Components of actions of medical personnel Criteria for assessing the condition and therapeutic measures Time (min) Actual time spent (min) Volume completed. medical measures Points
Passed (+) 1 point; not done (-) 0 points
Assessment of obstetric history 1. Date of the last menstruation 5 minutes
2. The nature of the menstrual cycle
3. Presence of likely pregnancy symptoms
4. Whether a pregnancy test was performed and its result
Assessment of the degree of blood loss 1. Amount of blood on the pad
2. Blood on clothes, legs, etc.
Assessment and monitoring of general condition 1. Respiration rate
2. Heart rate and BP filling
3. The nature of abdominal pain
4. Symptoms of peritoneal irritation
Actions of medical personnel 1. Catheterization of a peripheral vein (catheter No. 14 or 16) 10 minutes
2.Infusion of isotonic sodium solution
Treatment of symptoms of shock (if present) 1. Catheterization of 2 peripheral veins (catheter No. 14,16)
2. Infusion of isotonic sodium solution at a rate of 1 liter in 15 minutes
3. Maintain blood pressure > 100 mm Hg.
4. Humidified oxygen
Informing the relevant hospital about the transfer of the patient 5 minutes
Transportation to the nearest specialized care hospital (if symptoms of shock are present – with flashing beacons and siren on) 15-20 min
The total amount of time before admission to the hospital 35-40 min

16-19 points : the volume of diagnostic and treatment measures was completed in full (excellent)

10-15 points : the volume of diagnostic and treatment measures was not completed in full (good)

3-9 points : the volume of medical and diagnostic measures was partially completed (satisfactory)

0-3 : the volume of diagnostic and treatment measures has not been completed (unsatisfactory)

Note:

The main causes of bleeding during pregnancy up to 22 weeks of gestation are spontaneous abortion; ectopic pregnancy (up to 14 weeks); other causes (trophoblastic disease, trauma, pathology of the cervix).

Spontaneous abortion (miscarriage) is accompanied by 2 main clinical symptoms: bleeding from the vagina, pain in the lower abdomen.

Differential diagnosis of spontaneous abortion

Threatened abortion 1. Insignificant bleeding from the vagina 2. Pain in the lower abdomen of varying intensity
Started abortion 1. Abundant bleeding from the vagina 2. Pain in the lower abdomen of varying intensity
Complete abortion 1. Reducing bleeding from the vagina 2. Spontaneously subsiding pain in the lower abdomen

Symptoms of an ectopic pregnancy

Main clinical symptoms Other common symptoms
1. Delayed menstruation 2. Pain in the abdomen more often on one side 3. Bleeding from the vagina 1. Symptoms of peritoneal irritation 2. Decrease in blood pressure (systolic below 100 mm Hg) 3. Fainting 4. Tachycardia 5. Pain under the shoulder blade

Regardless of the cause of bleeding, it is necessary to assess the condition, establish a presumptive diagnosis, provide emergency care, inform the hospital and hospitalize.

When providing emergency medical care for bleeding, adhere to the “4 T” principle of the Algorithm for actions in case of emergency (Order of the Minister of Health of the Republic of Kazakhstan dated September 1, 2010 No. 691).

1) Tone – violation of the tone of the uterus (atony of the uterus):

a) external massage of the uterus

b) uterotonics – repeated administration of oxytocin 10 IU IM or 5 IU IV at slow dilution (the dose of administered oxytocin is 50-60 IU) and the introduction of group E prostaglandins (misoprostol at a dose of 800-1000 mg) or the F2a prostaglandin group

c) bimanual compression of the uterus

2) Tissue – with a delay in parts of the placenta, manual examination of the uterine cavity (curettage of the uterus);

3) Injury – with ruptures of the soft birth canal, uterine rupture, uterine inversion:

a) suturing ruptures of the soft birth canal

b) laparotomy for uterine rupture

c) correction of uterine inversion

4) Thrombin – hereditary or acquired coagulopathy – antifibrinolytic therapy, transfusion of FFP, cryoprecipitate, thrombus mass, recombinant blood factors

In critical situations, women should follow the notification scheme in accordance with the order of the Minister of Health of the Republic of Kazakhstan dated May 28, 2010 No. 389 “On approval of the Instructions for monitoring critical conditions in pregnant women, women in labor, puerperas.”

2. Evaluation sheet for bleeding in the late

terms of pregnancy

(prehospital care at the PHC level)

Components of actions of medical personnel Criteria for assessing the condition and therapeutic measures Time (min) Actual time spent (min) Volume completed. medical measures Points
Passed (+) 1 point; not done (-) 0 points
Assessment of obstetric history 1.Term of pregnancy 5 minutes
2. Parity of childbirth
3.Number of abortions in anamnesis
4.Operations on the uterus
5. Congenital anomalies of the uterus
Assessment of risk factors 1. Multiple pregnancy
2. Placenta previa
3. Preeclampsia
4. Ultrasound data during pregnancy
Assessment of the degree of blood loss 1. Amount of blood on the pad
2. Blood on clothes, legs, etc.
Assessment and monitoring of general condition 1. Respiration rate
2. Heart rate and BP filling
3. The nature of abdominal pain
4. Symptoms of peritoneal irritation
5. Shape of the uterus
6.Fetal condition
Actions of medical personnel 1. Catheterization of a peripheral vein (catheter No. 14 or 16) 10 minutes
2. Infusion of isotonic sodium solution
Treatment of symptoms of shock (if present) 1. Catheterization of 2 peripheral veins (catheter No. 14,16)
2. Infusion of isotonic sodium solution at a rate of 1 liter in 15 minutes
3. Maintain blood pressure > 100 mm Hg.
4. Humidified oxygen
Informing the relevant hospital about the transfer of the patient 5 minutes
Transportation to the nearest specialized care hospital (if symptoms of shock are present – with flashing beacons and siren turned on) 15-20 min
The total amount of time before admission to the hospital 35-40 min

21-26 points : the volume of diagnostic and treatment measures was completed completely (excellent)

15-20 points : the volume of diagnostic and treatment measures was not completed in full (good)

3-14 points : the volume of diagnostic and treatment measures was partially completed (satisfactory)

0-3 : the volume of diagnostic and treatment measures has not been completed (unsatisfactory)

Note:

The main causes of bleeding after 22 weeks of pregnancy are placenta previa, placental abruption, uterine rupture.

Differential diagnosis of bleeding in late pregnancy

placenta previa 1. Bleeding from the vagina of varying intensity, bright red, occurs suddenly
Placental abruption 1. Abdominal pain of varying intensity. 2. Bleeding from the vagina of varying intensity, dark in color, does not always reflect the amount of blood loss (due to possible imbibition of the walls of the uterus) 3. Possible deterioration of the fetus
Rupture of the uterus 1. Bleeding from the vagina of varying intensity 2. Pain in the abdomen, especially in the area of the scar on the uterus 3. Deterioration of the fetus 4. Easily palpable parts of the fetus through the abdomen 5. Tachycardia 6. Decrease in blood pressure (systolic below 100 ml Hg) 7 .Lack of fetal heartbeat

Regardless of the cause of bleeding, it is necessary to assess the condition, establish a presumptive diagnosis, provide emergency care, inform the hospital and hospitalize.

It must be remembered that external bleeding does not always correspond to the true volume of blood loss. If the volume of bleeding from the vagina is small, but there are signs of shock, internal bleeding associated with placental abruption or uterine rupture should be considered.

3. Scorecard for postpartum hemorrhage

(prehospital care at the PHC level)

Components of actions of medical personnel Criteria for assessing the condition and therapeutic measures Time (min) Elapsed time in fact (min) Volume completed. medical measures Points
Passed (+) 1 point; not done (-) 0 points
Assessment of obstetric history 1. Date and time of delivery 5 minutes
2. In the case of home birth, has the placenta separated?
Assessment of the degree of blood loss 1. Amount of blood on the pad
2. Blood on clothes, legs, etc.
Assessment and monitoring of general condition 1. Respiration rate
2. Heart rate and pulse filling
3. AD
4. The nature of abdominal pain
5.Status of the uterus
Actions of medical personnel 1. Catheterization of a peripheral vein (catheter No. 14 or 16) 10 minutes
2. Infusion of isotonic sodium solution
3. For home births and the presence of an afterbirth in the uterine cavity, clamp the umbilical cord, inject 10 IU of oxytocin intramuscularly and try to isolate it. After separation of the placenta, make an external massage of the uterus. Deliver the afterbirth to the hospital.
4. If it is impossible to separate the afterbirth – transport with the afterbirth into the uterine cavity
5. If the bleeding continues – perform methods of temporary stopping the bleeding and in this state transport to the hospital
Treatment of symptoms of shock (if present) 1. Catheterization of 2 peripheral veins (catheter No. 14,16)
2. Infusion of isotonic sodium solution at a rate of 1 liter in 15 minutes
3. Maintain blood pressure > 100 mm Hg.
4. Humidified oxygen
Informing the relevant hospital about the transfer of the patient 5 minutes
Transportation to the nearest specialized care hospital (if symptoms of shock are present – with flashing beacons and siren turned on) 15-20 min
The total amount of time before admission to the hospital 35-40 min

17-21 points : the volume of diagnostic and treatment measures was completed completely (excellent)

12-16 points : the volume of diagnostic and treatment measures was not completed in full (good)

3-11 points : the volume of diagnostic and treatment measures was partially completed (satisfactory)

0-3 : the volume of diagnostic and treatment measures has not been completed (unsatisfactory)

Note:

Postpartum haemorrhage ( PPH) is a clinically significant blood loss of 500.0 ml or more during vaginal delivery.

Distinguish early postpartum bleeding – in the first 24 hours after childbirth. Late postpartum hemorrhage – after 24 hours to 6 weeks postpartum

Causes of early postpartum hemorrhage:

• The remaining fragments of the placenta

• Uterine atony

• Rupture of the uterus and birth canal, inversion of the uterus

• Pre-existing or acquired bleeding disorders

The most common cause is uterine atony.

Causes of late postpartum hemorrhage

Remains of placental tissue

Metroendometritis

Regardless of the cause of bleeding, it is necessary to assess the amount of blood loss, the general condition, establish a presumptive diagnosis, provide emergency care, inform the hospital and hospitalize.

External uterine massage technique

1. Grasp the fundus of the uterus through the abdominal wall with the palm of your hand 2. Lightly massage and squeeze the uterus so that it begins to contract 3. During this, blood clots may be released 4. If the massage is effective, the uterus will become dense and decrease in size 5. It may be necessary to continue the massage for several minutes

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