RAPID ASSESSMENT AND MANAGEMENT (RAM)

OF MOTHER
contents
 Introduction
 Importance
 Areas to be assessed
 More signs needing immediate management
 Immediate and specific management of
shock
 Management of shock due to bleeding
 Reassessment
 Management of bleeding in early& late
pregnancy, during labour and after birth
 Management of severe pre-eclampsia and
eclampsia
Rapid initial assessment of the mother:
The survival of women experiencing an
obstetric emergency is determined by the
amount of time it takes for care to be
delivered and by the level and quantity of
care provided.
 Importance of RAM:
To determine the extent of women’s and
newborn’s illness.

To deliver the essential care as soon as

possible.
To save the life of mother and baby
Rapid assessment should be
done on
1.Assess airway and breathing:
Look for cyanosis (blueness), respiratory
distress.
Examine skin for pallor; auscultate lungs for
wheezing or rales.
 Woman may suffer from severe anemia,
heart failure, pneumonia, asthma, etc.
 2. Assess circulation (signs of
shock):
Low blood pressure (systolic less
than 90mm of Hg.),
fast and weak pulse rate,>110
/min
pallor
sweatiness or cold, calmly skin
rapid breathing(>30 or more)
anxious, confusion or
unconsciousness
scanty urine output(<30ml/hour)
3.Assess for vaginal bleeding(early or
late pregnancy & after child birth)

Ask if pregnant, length of gestation, recently given

birth, placenta delivered.
Examine vulva for amount of bleeding, retained
placenta, obvious tears, atonic uterus and full
bladder.
 May be due to abortion, ectopic pregnancy, molar
pregnancy(in early preg ,before 22 wog), abruptio
placenta, ruptured uterus, placenta previa (in late
preg and labour),atonic uterus, tears of cervix and
vagina, retained placenta, inverted uterus,
postpartum hemorrhage(after child birth)etc.
4.Assess for unconsciousness or
convulsion:
Ask if pregnant, length of gestation.
Examine BP: high (systolic
BP>=140,DBP>= 90 mmHg),
temperature: >=38˚c
 Woman may suffer from eclampsia,
malaria, epilepsy, tetanus, etc.
.
 5.Assess for dangerous fever:
Ask about fever, weakness, lethargic,
frequent and painful micturition, etc.
Examine temp 38˚c or more, check
unconsciousness, neck stiffness, lungs
for slow breathing and consolidation,
abdomen for severe tenderness, vulva
for purulent discharge, breast for
tenderness.
 Above S/S indicates UTI, malaria,
endometritis, pelvic abscess, peritonitis,
breast infection, complication of
abortion, pneumonia, etc.
6.Assess for abdominal pain:
Ask if pregnant, length of gestation.
Examine woman for blood pressure (low;
systolic less than 90mmof Hg), pulse fast
(110/min or more), temperature 38˚c or
more, uterus for state of pregnancy.
 Woman may be suffering from ovarian
cyst, appendicitis, ectopic pregnancy(in
early pregnancy), possible term or preterm
labor, amnionitis, abruptio placenta,
ruptured uterus(in late pregnancy) etc.
Additional signs that may need
immediate management
• Blood stained mucus discharge (show)

with palpable contraction

• Ruptured membranes
• Blurred vision
• Vomiting
• Weakness
• Fainting
• Respiratory distress
 1. Management of shock:
Immediate management
 Shout for help: urgently mobilize all available
personnel.
 Monitor vital signs: BP, pulse, respiration, temp.
 If the woman is unconscious, turn her onto her
side to minimize the risk of aspiration is she
vomits and to ensure that an airway is open.
 Keep the woman warm but do not overheat her
as this will increase peripheral circulation and
reduce blood supply to the vital centers.
 Elevate the legs to increase return of blood to
the heart ( if possible, raise the foot end of the
bed)
 Specific management of shock:
 Start an IV infusion with large bore (16 gauge or
largest available) cannula or needle.
 Collect blood for estimation of Hb%, cross-match
and bedside clotting test just before infusion of
fluids.
 Rapidly infuse IV fluids (NS or RL) initially at the rate
of 1 litre in 15-20 minutes.
 Give at least 2 litres of these fluids in the first hour.
 If a peripheral vein can’t be cannulated, perform a
venous cut down.
 Continue to monitor vital signs (every 15 minutes)
and blood loss.
 Catheterize the bladder and monitor fluids intake
and urine output.
 Give oxygen at the rate of 6-8 litres per minute by
mask or nasal cannula.
Determine and manage the cause of shock:
 If shock is due to heavy bleeding:
 Take steps to stop bleeding e.g.. oxytocin, uterine
massage, bimanual compression, aortic compression,
preparation for surgical intervention.
 Transfuse as soon as possible to replace blood loss.
 Determine the cause of bleeding and manage
accordingly.
 If bleeding occurs before 22 WOG=abortion, ectopic or
molar pregnancy
 If bleeding occurs after 22 WOG=placenta praevia,
abruptio placenta, or ruptured uterus.
 If bleeding occurs after child birth=ruptured uterus,
uterine atony, tear of genital tract, retained placenta
or placental fragments.
 Reassess the woman’s condition for sign of
improvement.
REASSESSMENT
 Reassess within 30 minutes to determine if her
condition is improving. :
 Stabilizing pulse ( rate of 90 /min or less)
 Increasing BP( systolic100mmHg or more)
 Improving mental status ( less confusion or
anxiety)
 Increasing urine output (30 ml/hr or more)

If the woman’s condition improves:

 Adjust the rate of infusion of IV fluids to 1 litre in
six hours.
 Continue management for the underlying cause of
shock.
 If the woman’s condition fails to improve or
stabilize, provide further management.
Further management
Continue to infuse IV fluids, adjusting
the rate of infusion to 1 litre in six
hours and maintain oxygen at 6-8 litres
per minute.
Closely monitor the woman’s condition.
Perform laboratory tests, including
repeat haemoglobin determination,
blood grouping and Rh typing. If
facilities are available, check serum
electrolytes, serum creatinine and
blood pH.
 Management of Vaginal
Bleeding
In early pregnancy
Immediate management
rapid evaluation of the woman’s general
condition, vital signs(P,BP,R),level of
consciousness, presence of anxiety and/or
confusion, blood loss, color and temp of the
skin.
If shock is suspected ,immediately begin
treatment, even if no sign of shock ,keep shock
in mind as you evaluate the woman further
because her status may worsen rapidly.
If woman is in shock, suspect, consider
ruptured ectopic pregnancy and immediately
manage accordingly.
Depending upon gestational age, check the
FHR and ask for perceiving fetal movement.
If FHR <100 or >180,suspect fetal distress.
If no fetal movement and FHR can’t be heard,
suspect fetal death and manage accordingly.
Start an IV fluid infusion, send blood sample
for Hb% or hematocrit and type and screen
before infusing fluids.
After the general management, go for specific
management like management of abortion.
In Late Pregnancy and labor
General management:
Shout for help. Urgently mobilize all
available personnel.
Perform a rapid evaluation of the general
condition of the woman, including vital
signs (pulse, blood pressure, respiration,
temperature).
If shock is suspected, immediately begin
treatment. Even if no signs of shock,
keep in mind as shock.
 If shock develops, it is important to
begin treatment immediately.
Check the fetal heart sound and ask for
fetal movements
If FHR <100 and >180b/min, suspect
fetal distress.
If FHR and fetal movement can’t be felt
suspect for intrauterine fetal death.
Start an IV infusion and infuse IV fluids.
After the general management, go for
specific management like, management
of placenta praevia, management of
abruptio placenta or accordingly etc.
Vaginal bleeding after childbirth
 Postpartum hemorrhage(PPH)=blood loss in excess
of 500 ml within 24 hours afterbirth .
 severe PPH =blood loss of 1000ml or more within
the same time frame work.
Rapid management
 Shout for help. Urgently mobilize all available
personnel.
 Perform a rapid evaluation of the general condition,
including vital signs (pulse, BP, resp, temp.)
 If shock is suspected, immediately begin
treatment. Even if signs no of shock, keep shock in
mind.
 If shock develops, it is important to begin
treatment immediately.
Massage the uterus to expel blood and
blood clots. Blood clots trapped in the
uterus: will inhibit effective uterine
contractions.
Give inj. Oxytocin 10 units IM(or IV as an
infusion if an IV infusion line is already in
place.)
Start an IV infusion and infuse IV fluids.
Send blood sample for Hb% or
hematocrit ,blood typing and arranging
blood for possible order of blood
transfusion before fluid infusion.
Anticipate early need of blood transfusion
and transfuse as necessary.
 Catheterize the bladder.
 Rapidly apply non-pneumatic anti shock
garment (NASG) if available, if not ,cover the
patient and keep her warm and elevate the legs.
 Check to see if the placenta has been expelled
and examine the placenta to be certain it is
complete.
 Examine the cervix, vagina and perineum for
tears.
 Determine the cause of PPH and manage
accordingly.(atonic uterus, retained placenta,
tears of vagina, cervix or perineum, ruptured
uterus, inverted uterus)
NASG(NON PNEUMANIC ANTI SHOCK GARMENT)
If bleeding continues in spite of above
management ,
Perform bimanual compression of the
uterus.
Alternatively, compress the aorta.
Intrauterine balloon tamponade.
If bleeding continues in spite of
compression
Perform uterine and utero-ovarian artery
ligation.
If life-threatening bleeding continues after
ligation, perform subtotal hysterectomy.
BIMANUAL AORTIC COMPRESSION
Balloon
tamponade
Management of Severe Pre-
eclampsia and Eclampsia
Sign and symptoms of severe pre-
eclampsia
Severe headache
Difficulty in breathing
Blurr vision
Epigastric pain or pain in hypochondrium
Nausea and vomiting
Systolic BP160mmHg or more and Diastolic
BP 110 or more
Albumin in urine 2+ or more
Hyperreflexia
 Eclampsia
Sign and symptoms of severe pre
eclampsia +convulsions, coma
 Severe pre-eclampsia and
eclampsia are managed similarly,
 except that birth must occur
within 12 hours of onset of
convulsions in eclampsia.
General management

Start an IV infusion and infuse IV

fluids.
Administer anticonvulsant drugs,
MgSo4.
Position the woman on her left
side to reduce risk of aspiration
of secretions, vomits and blood.
Suction the mouth and throat as
necessary.
Monitor vital signs, reflexes and
If systolic blood pressure remains
160mmHg or higher and/or if diastolic
blood pressure remains above 110 mmHg,
give antihypertensive drugs. Reduce the
diastolic blood pressure to less than 100
mmHg but not below 90 mmHg.
Catheterize the bladder to monitor urine
output and proteinuria.
Maintain strict fluid balance chart to
prevent fluid overload.
If urine output is less than 30 ml per hour,
withhold magnesium sulfate and infuse IV
fluids at1 litre in 8 hours.
 Never leave the woman alone. A convulsion
followed by aspiration of vomit may cause
death of the woman and fetus.
 Auscultate the lungs bases hourly for rales
(crackling noises) indicating pulmonary
edema. If rales are heard, withhold fluids and
give frusemide 40 mg IV once.
 Assess clotting status with a bedside clotting
test. Failure of a clot to form after seven
minutes or a soft clot that breaks down easily
suggests coagulopathy.
 Delivery should take place as soon as the
woman’s condition has stabilized.
 In severe pre-eclampsia, delivery should occur
with 24 hours of the onset of symptoms.
 In eclampsia, delivery should occur within 12
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