2. Specific Objectives: At the end of the session, the participants must be able to 1. Demonstrate the proper conduct of referrals 2. Recognize referral institutions/hospitals in their respective areas.

3.  Referral must be TIMELY  Referral includes :  Arranging for transport and care during transport  Preparing referral form/letter  Communicating with referral institution with emergency care facilities

4. 1) Give emergency treatment. 2) Discuss decision with woman, partner/spouse and relatives. Explain why patient is advised to transfer. 3) Help arrange transport of patient. 4) Inform the referral center by mobile phone, landline or radio. 5) Ensure support.

5. 6) Always send a referral letter with the patient. The referral must state the following: ◦ Date and time; Emergency or Non-emergency ◦ Problems identified ◦ Findings and action taken.

6. 7) If the hospital is far away (> 1 hour trip), ◦ Give appropriate treatment on the way. ◦ Continue to monitor patient ◦ Record all findings & treatment given. ◦ Keep mother and baby warm.  A relative or friend should accompany the patient → help look after the woman during the journey.  Do not delay. Go straight to the hospital.

7.  The physician  Woman with chronic medical condition  When physician’s opinion is needed  In case of uncertainty  The hospital  Severely ill pregnant woman  Needs operation or blood transfusion

8. BEMOC CEMOC 1. Administer PARENTERAL ANTIBIOTIC 2. Administer OXYTOCIN; 3. Administer Magnesium sulfate for pre-eclampsia; 4. Perform manual removal of placenta; 5. Perform removal of retained placental products; 6. Perform assisted vaginal delivery 7. Perform ESSENTIAL NEWBORN CARE  Perform the functions of a BEmOC facility  Give safe blood transfusion  Perform caesarean section & hysterectomy

9. Refer to M.D. Poor OB history: previous stillbirth; 3 consecutive abortions Poor OB history: previous stillbirth; 3 consecutive abortions Goiter Goiter UTI, Fever > 38° UTI, Fever > 38° Vaginal Infection Vaginal Infection Fever Fever Foul smelling discharge Foul smelling discharge Pallor Pallor Abdominal pain Abdominal pain Refer to M.D.; Hospital delivery recommended Parity > 4 Parity > 4 Previous CS Previous CS Hx of heart disease, asthma, diabetes, Hx of heart disease, asthma, diabetes, Vaginal bleeding Vaginal bleeding BP > 140/90 BP > 140/90 Abnormal presentation Abnormal presentation Preterm labor Preterm labor BOW ruptured > 12 hrs BOW ruptured > 12 hrs Labor > 12 ° Labor > 12 ° Some conditions that need to be referred

10. Try to clear the airway and dislodge obstruction. Help the woman to find the best position for breathing. Urgently refer the woman to the hospital with EmOC capabilities

11. Keep her on her back, arms at the side. Tilt head backwards (unless trauma is suspected). Lift chin to open airway. Inspect mouth for foreign body; remove if found. Clear secretions from throat.

12. Wash hands with soap and water. Clean woman’s skin with alcohol at site for IV line Insert IV line using a G16-18 needle Attach Ringer’s lactate or normal saline, ensure infusion is running well.  Do not administer IVF if you are not trained to do so.

13. Give fluids at RAPID RATE Systolic BP < 90 mm Hg PR > 110/minute Heavy vaginal bleeding Give fluids at MODERATE RATE Severe abdominal pain Obstructed labor Ectopic pregnancy Dangerous fever Dehydration. 1 L in 15-20 min (1 liter in 2-3 hours) If IV access is not possible, give oral rehydration solution (ORS) if able to drink at 300-500 ml in one hour.

14.  If postpartum bleeding persists after placenta is delivered: ◦ Check placenta for completeness ◦ Give oxytocin 10 IU IM ◦ Massage fundus and expel clots ◦ Insert IV fluids ◦ Measure or estimate blood loss, and record ◦ Give ergometrine 0.2 mg IM (except if woman is hypertensive) First Aid for the woman with danger signs Postpartum bleeding

15.  Endogenous hormone with uterine stimulant properties and vasopressive and antidiuretic effects.  Control of Postpartum Uterine Bleeding ◦ IV infusion (drip method) 10 to 40 units in 1L IVF at rate necessary to control uterine atony. ◦ IM 10 units (1 mL). Not given as IV bolus  Onset of uterine contraction: ◦ IV form: almost immediately; IM form: between 3 to 5 min.  Store in refrigerator (36° to 46°F). Discard after 30 days if stored at room temperature.

16.  Cardiovascular: cardiac arrhythmias, premature ventricular contractions, hypertensive episodes;  GI: Maternal nausea and vomiting.  Genitourinary: uterine rupture, uterine hypertonicity.  Metabolic-Nutritional: Severe water intoxication with convulsion, coma, and death.  Miscellaneous: Maternal anaphylactic reaction, pelvic hematoma, postpartum hemorrhage, subarachnoid hemorrhage

17.  CVS: bradycardia, premature ventricular contractions, other arrhythmias.  CNS: permanent CNS or brain damage and seizures  EENT: Retinal hemorrhage.  Hepatic: Fetal or neonatal jaundice.  Others: fetal death, low Apgar scores at 5 min.

18.  a semi-synthetic ergot alkaloid used for the prevention and control of postpartum hemorrhage.  Available in sterile ampuls of 1 mL, containing 0.2 mg methylergonovine maleate for IM or IV injection and in tablets for oral ingestion containing 0.2 mg methylergonovine maleate.

19.  acts directly on the smooth muscle of the uterus and increases the tone, rate, and amplitude of rhythmic contractions.  It induces a rapid and sustained tetanic uterotonic effect  The onset of action after I.V. administration is immediate; after I.M. administration, 2-5 minutes, and after oral administration, 5-10 minutes.

20.  Hypertension; toxemia; pregnancy; and hypersensitivity.  This drug should not be administered I.V. routinely because of the possibility of inducing sudden hypertensive and cerebrovascular accidents

21.  The most common adverse reaction is hypertension associated with seizure and/or headache.  Hypotension has also been reported.  Nausea and vomiting occasionally.  Rarely: acute myocardial infarction, transient chest pains, arterial spasm (coronary and peripheral), bradycardia, tachycardia, dyspnea, hematuria, thrombophlebitis, water intoxication, hallucinations, leg cramps, dizziness, tinnitus, nasal congestion, diarrhea, diaphoresis, palpitation

22.  If postpartum bleeding persists ….. apply bimanual uterine compression.  Check for other causes of postpartum bleeding (i.e. genital tract injury) First Aid for the woman with danger signs Postpartum bleeding

24.  Recognize conditions that require referral  Give emergency treatment before referral.  Inform the patient and her family that she needs to be referred to another hospital.  Arrange for transport