Clinical Management of Abortion Complications: A practical Guide (WHO - OMS, 1994, 86 p.): ANNEX 2 - EXAMPLE OF A REFERRAL FORM FOR COMPLICATIONS OF ABORTION CASES

Clinical Management of Abortion Complications: A practical Guide (WHO - OMS, 1994, 86 p.)

		(introduction...)
		ABSTRACT
		ACKNOWLEDGEMENTS
		PREFACE
		INTRODUCTION
		CHAPTER 1 - INITIAL ASSESSMENT: DETERMINING THE WOMAN'S NEEDS FOR IMMEDIATE TREATMENT
		CHAPTER 2 - MANAGEMENT OF SHOCK
		CHAPTER 3 - MANAGEMENT OF MODERATE TO LIGHT VAGINAL BLEEDING
		CHAPTER 4 - MANAGEMENT OF SEVERE VAGINAL BLEEDING
		CHAPTER 5 - MANAGEMENT OF INTRA-ABDOMINAL INJURY
		CHAPTER 6 - MANAGEMENT OF SEPSIS
		CHAPTER 7 - GENERAL PRINCIPLES OF EMERGENCY ABORTION CARE
		ANNEX 1 - EQUIPMENT AND FACILITIES FOR ABORTION CARE
		ANNEX 2 - EXAMPLE OF A REFERRAL FORM FOR COMPLICATIONS OF ABORTION CASES
		ANNEX 3 - EMERGENCY RESUSCITATION MATERIALS
		ANNEX 4 - ESSENTIAL DRUGS FOR EMERGENCY ABORTION CARE
		ANNEX 5 - SUPPLIES FOR SURGICAL UTERINE EVACUATION PROCEDURES
		ANNEX 6 - INSTRUMENTS AND EQUIPMENT FOR FIRST TRIMESTER UTERINE EVACUATION
		ANNEX 7 - INSTRUMENTS AND EQUIPMENT FOR SECOND TRIMESTER UTERINE EVACUATION
		ANNEX 8 - INSTRUMENTS AND SUPPLIES FOR LAPAROTOMY
		ANNEX 9 - LABORATORY AND BLOOD MATERIALS
		ANNEX 10 - MANUFACTURERS, SUPPLIERS AND SOURCES OF PROCUREMENT OF EMERGENCY GYNAECOLOGIC EQUIPMENT
		ANNEX 11 - MANUAL VACUUM ASPIRATION (MVA)
		ANNEX 12 - DILATION AND CURETTAGE (D&C)
		SAFE MOTHERHOOD RESOURCE LIST
		BACK COVER

ANNEX 2 - EXAMPLE OF A REFERRAL FORM FOR COMPLICATIONS OF ABORTION CASES

The attending health worker should complete this form for any patient who is referred for treatment of abortion complications. The form should accompany the patient to the referral centre.

Patient Information

	Name:
	Date of Admission:	Time of Admission:
	Diagnosis:

History

Describe the patient's relevant history

Patient's Clinical Condition

Describe the patient's condition (vital signs, physical/pelvic exam findings)

Initial Treatment

Describe treatment (fluids, drugs given, action to control bleeding, any other medical steps taken)

Assessment of Patient's Condition/Other Information

______________________________	____________________
Health worker reporting (print name)	Location (hospital, clinic)

______________________________	Date: ___________________
Signature