AREA: PREGNANCY COMPLICATION MANAGEMENT
(HYPOVOLEMIC SHOCK, SEVERE PRE-ECLAMPSIA/ECLAMPSIA, ABDOMINAL PAIN)
FACILITY: ________________________________________________________________________________________________________________
ASSESSOR: ____________________________________________________________ DATE:
PERFORMANCE
STANDARDS
__________________________________________
VERIFICATION CRITERIA
Y, N
COMMENTS
Hypovolemic shock
Instructions to the assessor: Interview a provider who is likely to manage a client with hypovolemic shock.
1. The provider can
describe signs of shock.
Ask the provider: “What are the signs of shock?”
 Pulse weak and equal to or greater than 110
 Systolic BP less than 90mm Hg
 Rapid breathing (30 breaths per minute or above)
 Pale, skin feels cold and clammy (cold perspiration)
 Confusion or unconsciousness
2. The provider can
describe the steps of
rapid initial assessment
of a woman with
hypovolemic shock.
Ask the provider: “How do you conduct a rapid initial assessment and management
of a woman in hypovolemic shock?”
 Request assistance and immediately mobilize all available personnel
 Quickly shift the woman to an examining table
 Rapidly evaluate vital signs
o Pulse
o Blood pressure
o Breathing
 Place the woman on her side to prevent aspiration
 Cover the woman with a blanket
 Raise the foot-end of the bed or elevate legs
EOC Standards—March 2009
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Pregnancy Complications – 18
PERFORMANCE
STANDARDS
3. The provider describes
the management of
shock.
4. The provider can
describe the steps to
identify the specific
causes of shock.
EOC Standards—March 2009
VERIFICATION CRITERIA
Ask the provider to describe how to manage shock:
 Ensure client’s head is down and the foot-end of the bed is raised
 Place the client on her side to prevent aspiration
 Administer oxygen by mask at 6–8L/minute
 Extract blood for haemoglobin, coagulation, blood group and Rh (cross-matching)
tests
 Request blood from donor
 Start two IV lines using a 16- or 18-gauge cannula
 Label IV bags with medications added, if any
 Replace fluids with:
o Saline or Ringer’s solution
o 1L over a 15–20 minute period (wide open rate)
o Give 2 additional litres during the first hour over and above fluid replacement
for continuing blood loss
 Continue to replace volume IV in accordance with the loss of blood (two or three
times the estimated loss)
 Assess woman’s need for transfusion based upon signs and symptoms of shock or
impending shock due to amount of blood lost
 Catheterize bladder and take baseline urine output
 Keep the patient warm
Ask the provider: “How do you identify the causes of shock?”
 Take history (from patient or accompanying person)
 Perform an abdominal and pelvic examination as needed
 Assess findings to list possible causes of bleeding
Y, N
COMMENTS
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Pregnancy Complications – 19
PERFORMANCE
STANDARDS
5. The provider can
describe monitoring
and evaluation of
patient's response to the
intervention and plan
for the next step.
6. The provider records
on the clinical history
the information related
to findings and
procedures performed.
EOC Standards—March 2009
VERIFICATION CRITERIA
Ask the provider:
 How do you evaluate the women’s response to the immediate treatment?
o Monitor every 15 minutes:
 Pulse
 BP
 Mental state (confusion)
 Urine output
 What would you do if the vital signs stabilize (pulse 90 or less, systolic BP
100mmHg or more, at least 30ml of urine per hour and less anxiety/confusion)?
o Continue management of underlying cause of bleeding
o Adjust IV infusion to 1L over a 6-hour period
(60 drops/minute)
o Continue to monitor vital signs
 What would you do if the conditions do not improve?
o Continue IV solution 1L over a 6-hour period (60 drops/minute)
o Continue to administer oxygen 6–8L/minute
o Continue monitoring
Observe whether the provider records:
 Admission condition
 Cause of shock
 Solutions, fluids, and drugs given (doses, time)
 Procedures performed
 Progress
Y, N
COMMENTS
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Pregnancy Complications – 20
PERFORMANCE
STANDARDS
7. The provider shows the
equipment and drugs to
be used for
management of shock.
VERIFICATION CRITERIA
Ask the provider to show the interviewer the following:
 Supplies for starting an IV line:
o 16- or 18-gauge needle or cannula
o IV equipment
o Saline or Ringer’s lactate solution
 Equipment and supplies for administering oxygen:
o Functioning oxygen cylinder and regulator
o Nasal piece or oro-nasal mask
 Supplies for bladder catheterization:
o Foley catheter
o Urine collection bag
 Supplies for blood extraction
o 10cc syringe and gauge 21 needle
o Citrated and non-citrated test tube
Y, N
COMMENTS
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Bleeding in Early Pregnancy
Instructions to the assessor: Interview a provider that usually works in the emergency room or in the maternity ward and that is likely to manage an incomplete abortion.
8. The provider can list
the different conditions
causing early bleeding
in pregnancy.
EOC Standards—March 2009
Ask the provider to list conditions that cause early bleeding in pregnancy:
 Ectopic pregnancy
 Abortion or miscarriage
 Molar pregnancy
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Pregnancy Complications – 21
PERFORMANCE
STANDARDS
9. The provider can
describe the initial
management of
bleeding in early
pregnancy.
EOC Standards—March 2009
VERIFICATION CRITERIA
Ask the provider: “What is the initial management of bleeding in early pregnancy?”
 Rapid evaluation of condition:
o Check vital signs
o Assess for hypovolemic shock
o If in shock, manage accordingly (see above)
 Collect information to make presumptive diagnosis:
o History
o Abdominal examination
o Pelvic examination
 Manage according to diagnosis:
o Ectopic pregnancy
o Threatened abortion
o Incomplete abortion
o Completed abortion
o Molar pregnancy
Y, N
COMMENTS
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Pregnancy Complications – 22
PERFORMANCE
STANDARDS
10. The provider describes
the sign and symptoms
of abortion.
EOC Standards—March 2009
VERIFICATION CRITERIA
Ask the provider: “What are the sign and symptoms of abortion?”
 Threatened abortion:
o Light bleeding
o Closed cervix
o Uterus corresponds to dates
 Inevitable abortion:
o Heavy bleeding
o Dilated cervix
o Uterus corresponds to dates
 Incomplete abortion:
o Heavy bleeding
o Dilated cervix
o Uterus is smaller than dates
 Complete abortion:
o Light bleeding
o Closed cervix
o Uterus is smaller than dates and softer than normal
 Molar pregnancy:
o Heavy bleeding
o Dilated cervix
o Uterus larger than dates
o Uterus softer than normal
o Partial expulsion of product of conception resembling grapes
Y, N
COMMENTS
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Pregnancy Complications – 23
PERFORMANCE
STANDARDS
11. The provider describes
the management of
abortions.
EOC Standards—March 2009
VERIFICATION CRITERIA
Ask the provider: “What is the correct management of abortions?”
 Threatened abortion:
o Medical treatment is usually not necessary
o Avoid strenuous activity and intercourse but bed-rest is not necessary
o If bleeding persists assess for fetal viability (PT or US) or ectopic pregnancy.
Persistent bleeding, particularly in the presence of a uterus larger than
expected, may indicate twins or molar pregnancy
 Inevitable abortion:
o If pregnancy is less than 16 weeks, plan for evacuation of uterine contents
 If immediate evacuation is not possible, give ergometrine 0.2mg IM and
repeat after 15 min if necessary; or misoprostol 400 mcg by mouth (repeat
once after 4 hours, if necessary)
o If pregnancy is greater than 16 weeks, await spontaneous expulsion of POC
and then evacuate the uterus to remove any remaining POC
o If necessary, infuse oxytocin 40 units in 1L IV fluid (normal saline or Ringers
lactate) at 40 drops per minute to help achieve expulsion of POC
o Ensure follow-up of the woman after treatment
 Incomplete abortion:
o If bleeding is mild to moderate and pregnancy is less than 16 weeks, use
finger or sponge forceps to remove the POC
o If bleeding is heavy and pregnancy is less than 16 weeks evacuate the uterus
(MVA is preferred method)
o If pregnancy is greater than 16 weeks infuse oxytocin 40 units in 1L IV fluids
at the rate of 40 drops /min until the expulsion of POC
o If necessary give misoprostol 200 mcg vaginally every 4 hours until expulsion
and evacuate any remaining POC from the uterus
 Complete abortion:
o Observe for heavy bleeding and ensure follow-up of woman
Y, N
COMMENTS
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Pregnancy Complications – 24
PERFORMANCE
STANDARDS
VERIFICATION CRITERIA

12. The provider can
describe sign and
symptoms of ectopic
pregnancy.
Molar Pregnancy
o If diagnosis of molar pregnancy is certain, evacuate the uterus
o Use vacuum aspiration
o Infuse oxytocin 20 units in 1L IV fluids at 60 drops/min to prevent
haemorrhage
o Recommend hormonal FP method for at least one year
o Follow-up every 8 weeks for at least one year with urine pregnancy tests:
 If urine pregnancy test is not negative after 8 weeks or becomes positive
again, refer to a tertiary facility for follow-up
Ask the provider: “What are the signs and symptoms of ectopic pregnancy?”
 History of amenorrhea
 Slight vaginal bleeding
 Abdominal pain
 Fainting
 Closed cervix
 Uterus slightly larger than normal
13. The provider can
describe the
management of ectopic
pregnancy.
Ask the provider: “What is the correct management of ectopic pregnancy?”
 Cross-match blood and prepare and perform laparotomy
14. The provider can
describe post-abortion
care steps.
Ask the provider, “What would be the post-abortion steps to take before a woman is
discharged?”
 Tell the woman that her fertility will return as early as 2 weeks after the event
 Provide counselling on healthy timing and spacing of pregnancy
 Assist her to choose a contraceptive method
 Provide method of choice before discharge
EOC Standards—March 2009
Y, N
COMMENTS
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Pregnancy Complications – 25
PERFORMANCE
STANDARDS
VERIFICATION CRITERIA
Y, N
COMMENTS
Preeclampsia and eclampsia
15. The provider can
correctly describe the
signs and symptoms of
severe pre-eclampsia
and eclampsia.
16. The provider can
describe the correct
management of severe
pre-eclampsia and/or
eclampsia.
Ask the provider: “What are the signs and symptoms of severe pre-eclampsia and
eclampsia?”
 Severe pre-eclampsia:
o Diastolic BP 110mmHg or more
o 20 weeks or more of gestation
o Proteinuria 3+
 Eclampsia:
o Convulsions
o Diastolic BP 90mmHg or more
o 20 weeks or more of gestation
o Proteinuria 2+ or more
Ask the provider: “What is the correct management of severe preeclampsia/eclampsia?”
 Take vital signs including FHS every 15 minutes
 Insert catheter to start measuring urine output
 Give magnesium sulfate:
Loading dose:
o Administer 4g of 20% solution of magnesium sulphate in IV solution (20ml)
slowly over a 5-minute period
o Administer 5g of 50% magnesium sulphate solution (20ml), with 1ml of 2%
lidocaine IM deep in each buttock (total 10g)
o If convulsions reoccur after 15 min, give 2g 50% magnesium sulphate
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slowly in IV over 5 min.
EOC Standards—March 2009
Pregnancy Complications – 26
PERFORMANCE
STANDARDS
VERIFICATION CRITERIA

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Maintenance Dose
o Administer 5g of 50% magnesium sulphate solution (20ml), with 1ml of 2%
lidocaine IM deep every 4 hours into alternate buttocks
o Continue treatment with magnesium sulphate for 24 hours after delivery or
the last convulsion, whichever occurs last.
Start IV line with saline or Ringer’s lactate solution
Give antihypertensive to maintain diastolic pressure at 90-100mm Hg:
o Plan 1: Hydralazine 5mg IV slowly every 5 min or 12.5mg IM every 2 hours,
until diastolic BP stabilizes between 90 and 100mmHg, or
o Plan 2: Nifedipine 5mg orally, repeating the dose if the diastolic BP is still
more than 110 after 10 min
Deliver within 24 hours of onset of severe pre-eclampsia and within 12 hours for
eclampsia
Monitor vital signs, FHS, reflexes and urine output
Management of eclampsia
o Give anticonvulsive – as above
o Give antihypertensive-as above
o Passively restrain for protection
o Place on left side to minimize aspiration
o Aspirate mouth and throat as needed post convulsion
o Gather equipment (airway, suction, mask and bag, oxygen)
o Deliver within 12 hours of start of convulsion
Withhold or delay drug if:
 Respiratory rate falls below 16/min
 Patellar reflexes are absent
 Urinary output falls below 30ml per hour over preceding 4 hours
Keep antidote ready:
 Assist ventilation (mask and bag, anaesthesia apparatus, intubation), and give
oxygen at 4-6L per minute.
 Give calcium gluconate 1g (10mL of 10 % solution), in IV slowly until respiration
begins to antagonize the effects of magnesium sulphate
EOC Standards—March 2009
Y, N
COMMENTS
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Pregnancy Complications – 27
PERFORMANCE
STANDARDS
VERIFICATION CRITERIA
Y, N
COMMENTS
Abdominal Pain in Early Pregnancy
Instructions to the assessor: Interview a provider who usually works in the emergency room or in the maternity ward who is likely to manage abdominal pain in early
pregnancy
17. The provider can list
the different conditions
causing pain in early
pregnancy.
18. The provider can
describe the initial
management of
abdominal pain in early
pregnancy.
EOC Standards—March 2009
Ask the provider to list conditions that cause pain in early pregnancy:
 Ovarian cyst – torsion
 Appendicitis
 Cystitis
 Acute pyelonephritis
 Peritonitis
 Ectopic pregnancy
 Abortion
Ask the provider: “How do you initially manage abdominal pain in early pregnancy?”
 Rapid evaluation of condition:
o Check vital signs
o Assess for hypovolemic shock
o If in shock, manage accordingly (see above)
 Collect information to make presumptive diagnosis:
o History
o Abdominal
o Pelvic examination
 Manage according to diagnosis:
o Ovarian cyst – torsion
o Appendicitis
o Cystitis
o Acute pyelonephritis
o Peritonitis
o Ectopic pregnancy
o Abortion
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Pregnancy Complications – 28
Total of standards
18
Total observed
Total achieved
EOC Standards—March 2009
Pregnancy Complications – 29