Emergency Treatment Module 2 – Session 1 Preparation and Client Assessment

Module 2 - Session 1 Session Objectives At the end of this session, participants will be able to: Describe emergency treatment Define how to reorganize patient service areas to ensure confidentiality, privacy and the ability to counsel a male partner or other companion with the client (objectives continued on next slide)

Session Objectives (2) Perform client assessment and examination according to standards, including: A rapid assessment to rule out life-threatening conditions: Include immediate management as needed A complete history A physical examination including: Abdominal examination Assessment of uterine size and position Determination of whether cervix is dilated (and how much) Speculum examination Appropriate laboratory tests Explain the different types of miscarriage and abortion, including major signs and symptoms Demonstrate during practice sessions the ability to integrate appropriate counseling in emergency treatment as indicated

What Is Emergency Treatment? The prompt management of potentially life-threatening abortion complications including hemorrhage and/or infection from retained products of conception, injury to internal organs and other related problems such as shock.

Emergency Treatment Emergency treatment includes: Client assessment Pain management Uterine evacuation Treatment for complications Counseling Referral or transfer as appropriate Follow-up Related treatment such as antibiotics

Why Emergency Treatment? “Emergency treatment” does not mean all PAC is urgent: Incomplete/unsafe abortions do not always involve complications and are not always life-threatening Treatment is not always needed on an emergency basis Majority of PAC clients are clinically stable and present with minor symptoms Timely evaluation, treatment and referral are needed since delays in care could result in eventual complications.

Emergency Treatment Remember: Emergency treatment alone is not PAC! Postabortion care is incomplete without appropriate FP counseling and services.

Level of Emergency Treatment The extent of emergency treatment provided depends on: Level of care Staff skills Available equipment Referral system

Aspects of Emergency Treatment Complete client assessment/evaluation including: Rapid assessment: Evaluation for shock, other life-threatening conditions Resuscitation/stabilization Preparation for treatment or transfer Continuing assessment and diagnosis: Recognition of signs and symptoms of abortion Recognition of signs and symptoms of postabortion complications

Aspects of Emergency Treatment (2) Preparation for treatment and care as needed: Pain management Uterine evacuation and related treatment (if needed) Treatment for complications Counseling (throughout this and all phases of care) Referral or transfer as appropriate Follow-up

Aspects of Emergency Treatment (3) All care should include: Responding to questions or concerns about future pregnancy, incomplete abortion, treatment and fertility Emotional support throughout the visit Counseling for family planning methods: Initiate as soon as possible to facilitate integration of contraceptive and reproductive health services

Rapid Assessment Immediate recognition of the specific problem and taking of quick action When a woman presents with a pregnancy-related problem: Quickly assess her condition to determine appropriate level of treatment For life-threatening conditions such as shock or severe hemorrhage, delay complete assessment until client is stabilized and no longer in danger

Rapid Assessment (2) Conditions and postabortion complications that require immediate attention and treatment include: Shock Severe vaginal bleeding (hemorrhage) Signs of intra-abdominal injury (e.g., uterine perforation) Sepsis or septic shock

Rapid Assessment Steps History of presenting problem Rapid evaluation of the woman’s general condition: Vital signs Level of consciousness Assessment of color If shock is suspected, begin treatment IMMEDIATELY Shock can develop at any time, so careful monitoring throughout PAC is important Once shock is ruled out, assess quickly for other serious problems

Rapid Assessment Steps (2) Initial assessment of vaginal bleeding: Amount of bleeding Presence of clots or products of conception (POC) Pallor Presence or history of blood-soaked clothing, pads or bedding Assessment for intra-abdominal injury Assessment for sepsis

Rapid Assessment Steps (3) Steps must be taken quickly and some can be done simultaneously: Example: while obtaining the history, assess color and level of consciousness

Rapid Initial Assessment Summary Airway and breathing Circulation Vaginal bleeding Level of consciousness Dangerous fever Abdominal pain Then: If needed, stabilize and refer or proceed with full assessment and treatment

Integrating Counseling Before emergency treatment: Assess the client’s capacity to receive information Explore the client’s needs and feelings Examine the client’s values and reproductive plans

Integrating Counseling (2) Based on the client’s condition, provide information about the following as appropriate: Exams and findings Treatment/procedures/pain management Possible side effects, complications and risks Human reproductive processes Available FP methods Adapted from: EngenderHealth 2003.

Presenting Signs and Symptoms Regardless of the woman’s obstetric, menstrual or contraceptive history, consider the possibility of an abortion-related condition in anyone with symptoms of possible abortion (spontaneous or induced). A woman may be experiencing emotional as well as physical distress, so pay careful attention to all signs and symptoms.

Presenting Signs and Symptoms (2) Symptoms of possible miscarriage or induced abortion include the following in any woman of reproductive age with a history of: Amenorrhea: More than a month has passed since last menstrual period (LMP) Known or suspected pregnancy Onset of vaginal bleeding: May be heavy or light May be accompanied by passage of clots or tissue fragments Cramping or lower abdominal pain

Presenting Signs and Symptoms (3) Other ob/gyn conditions can cause vaginal bleeding, abdominal pain and/or similar signs and symptoms: Ectopic pregnancy Pelvic inflammatory disease (PID) Postpartum hemorrhage Shock/loss of consciousness during pregnancy may not be pregnancy-related: Cerebral malaria Trauma

Next Steps If vital signs are normal and client does not appear to be infected (temperature <38°C) or have intra-abdominal injury (non-rigid abdomen), the next step is to determine the cause of vaginal bleeding: Take reproductive history Perform physical and pelvic exam Obtain appropriate lab tests (when/if needed)

Types of Abortion or Miscarriage Threatened Inevitable Spontaneous Induced Incomplete Complete Septic Missed

History For personal, socio-cultural and/or legal reasons, women may be reluctant to provide information at first. Respect the woman’s needs and provide care without expressing judgment, either verbally or non-verbally. Always ensure privacy, confidentiality and dignity throughout all care and counseling. If woman is unconscious/unable to provide information, obtain basic history from the person who accompanied her.

Reproductive History First, review antenatal care records (if applicable). Then ask about or confirm: Date of last normal menstrual period Current contraceptive method Vaginal bleeding (duration and amount) Cramping (onset and severity) Fainting Fever, chills or general malaise Abdominal or shoulder pain (intra-abdominal injury) Tetanus vaccination status; possible exposure to tetanus: Insertion of unclean instruments/materials into the uterus

General Medical History Drug allergies (especially local anesthetics and antibiotics) Bleeding disorders: Sickle cell anemia or thalassemia Hemophilia or platelet disorder Current medications (e.g., corticosteroids) Recent ingestion of any herbs or medicine Other health conditions or problems: Malaria during this pregnancy Hypertension Diabetes Any other health concerns

Integrating Counseling: Addressing the Client’s Feelings… Remember: Clients may experience a wide range of feelings: Fear, pain before or during anticipated procedure Guilt, shame Fear that abortion may be discovered (by family, local authority or others) Women experiencing miscarriage may feel great sense of loss, disappointment, frustration or guilt over not having been able to carry pregnancy to term

Tips for Maintaining Privacy Fully close and secure doors or curtains Close curtains on windows Position exam table so that the client’s feet are not facing the door when lying down Keep the woman covered, exposing only what is needed for each part of the exam Knock before entering an exam room and wait for permission to enter

Physical Exam A careful physical examination, including a pelvic exam and laboratory tests, is essential in making an accurate diagnosis and treatment plan.

Physical Exam (2) During the physical exam: Provide visual and audio privacy Expose only the part of the body being examined Maintain infection prevention precautions Do not limit the exam to her presenting problem: Note the general appearance of the woman and be attentive to non-verbal clues

Abdomen Check for: Masses or gross abnormalities Distended abdomen with decreased bowel sounds Rebound tenderness with guarding Suprapubic or pelvic tenderness

Pelvic Exam Purpose To determine the size, consistency and position of uterus To check for uterine or adnexal tenderness To assess the vagina and cervix for tears and bleeding To determine the degree of cervical dilatation To rule out other conditions such as PID and ectopic pregnancy

Speculum Exam Before inserting the speculum: Inspect the genital area for blood/discharge: Amount, color, consistency, odor Next: Insert the speculum to look at the cervix Remove visible POC and keep for lab exam

Speculum Exam (2) Look for any: Bleeding (amount, color, clots) Discharge or pus: Color, odor and amount Cervical or vaginal tears or perforations

Speculum Exam (3) If infection suspected: Obtain samples for culture if possible Begin antibiotic treatment before performing uterine evacuation Cervical infection increases the chance of post-procedure uterine infection including acute PID

Bimanual Exam Assess the size of the uterus Compare size with date of LMP: Size is usually smaller than dates with incomplete abortion Assess shape and position of uterus: This is critical to the safety and success of uterine evacuation Check adnexae and cervical motion tenderness (may indicate infection, ectopic pregnancy or other condition)

Bimanual Exam (2) If uterus larger than expected, may indicate: A more advanced pregnancy than estimated Multiple pregnancy Uterus filled with clots Molar pregnancy (rare) Presence of uterine fibroids

Uterine Sizing If uterine size difficult to assess: Uterine may be tilted backward (retroverted) or laterally placed Client may be overweight Client may have abdominal guarding: Not relaxing or tensing the abdomen so that uterus cannot be felt

Uterine Sizing (2) If having problems in determining size or position of uterus: Have a more experience clinician assess the uterus If in doubt, treat as if the pregnancy is more advanced than initially suspected

Bimanual Exam: Anteverted Uterus Most common uterine position Tilted forward If uterus excessively anteverted (or anteflexed): Risk of perforation may be increased when performing uterine evacuation (MVA)

Bimanual Exam: Retroverted Uterus Tilted backwards More easily felt in posterior vaginal wall or through recto-vaginal exam Perforation more likely if clinician unaware of retroverted/ retroflexed position

Palpating Retroverted Uterus Source: Yordy, Leonard and Winkler, 1993.

Laterally Displaced Uterus Laterally displaced uterus (not common): Tilted to one side If the uterus is pushed laterally to one side or the other, the clinician must be especially careful during evacuation procedures or the risk of perforation may be increased.

Post-Procedure Tasks After completing the pelvic examination, gloves should be immediately removed, decontaminated and discarded according to recommended infection prevention practices.

Laboratory Tests The following are some of the lab tests/investigations that may be needed as part of the physical exam, depending on the client presenting and medical condition, endemic problems in the region, etc.: Blood group and Rhesus status Give Rh (D) immune globulin if available for Rh-negative women Hemoglobin Malaria and/or relevant testing HIV counseling/testing (if applicable/client does not “opt out”) Any other relevant testing or preventive measures such as tetanus toxoid

Vaginal Bleeding in Early Pregnancy (First 20 Weeks of Pregnancy) Vaginal bleeding can be an important danger sign of pregnancy or postabortion. An accurate diagnosis will guide you in providing the appropriate care or treatment in a timely manner.

Vaginal Bleeding: General Management Rapid assessment is the first step in assessing the woman who presents with vaginal bleeding: If shock is suspected, immediately begin treatment.

Ectopic Pregnancy Consider ectopic pregnancy in anyone with: Shock History of PID or ectopic pregnancy Threatened abortion Unusual complaints about abdominal pain Smaller uterus than expected Cervical motion tenderness

Ectopic Pregnancy (2) Typically present: Light bleeding, abdominal pain Closed cervix Uterus slightly larger/softer than normal Sometimes present: Fainting Tender adnexal mass Cervical motion tenderness Amenorrhea

Caution If an ectopic pregnancy is suspected, perform a bimanual exam gently: An early ectopic pregnancy is easily ruptured. A bimanual exam in suspected ectopic pregnancy should be performed only by a provider trained in this skill and only when facilities for emergency surgery can be organized.

Management of Vaginal Bleeding Be sure to determine gestational age before performing a vaginal exam on a pregnant woman who presents with bleeding. A pelvic exam should NOT be performed on a woman after 20 weeks with vaginal bleeding. An IV infusion will be needed for severe vaginal bleeding, shock and any related condition that may be life-threatening.

Referral Guidelines Explain the reason for the referral to the woman: Include her family members or support person(s) as appropriate Arrange transport and notify the referral facility Prepare to transfer the woman

Referral Guidelines (2) Document the referral: Complete the required paperwork and include: Reason for the referral Findings of any examinations or lab tests All treatments given Time and date Name and signature of person completing the form(s)

Referral Guidelines (3) If the referral is delayed, not possible or the woman/family refuse: Be sure the mother is clinically stable: Start an IV if needed to maintain hydration and an open line for any medications Monitor for any signs of shock and manage accordingly Counsel and support the woman/family as appropriate: Integrate PAC counseling including FP and RH as appropriate