Clinical Management of Abortion Complications: A practical Guide (WHO - OMS, 1994, 86 p.): CHAPTER 3 - MANAGEMENT OF MODERATE TO LIGHT VAGINAL BLEEDING: 3.3 INITIAL ASSESSMENT

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

CHAPTER 3 - MANAGEMENT OF MODERATE TO LIGHT VAGINAL BLEEDING

		3.1 INTRODUCTION
		3.2 PRESENTATION
		3.3 INITIAL ASSESSMENT
		3.4 INITIAL TREATMENT
		3.5 DEFINITIVE MANAGEMENT
		3.6 UTERINE EVACUATION TECHNIQUES
		3.7 EXAMINATION OF THE PRODUCTS OF CONCEPTION
		3.8 UTERINE PERFORATION
		3.9 CONTRACEPTION

3.3 INITIAL ASSESSMENT

A complete clinical assessment, history, physical and pelvic exam are necessary to assess the patient's general condition, the stage of abortion, uterine size, and the presence of complications in order to manage incomplete abortion.

Guidelines for a complete clinical assessment are given in Chapter 1 and repeated here, for convenience. If the examination suggests shock, sepsis, severe bleeding, or intra-abdominal injury, assess further and begin treatment according to the appropriate chapter(s). When these steps are taken, attention can be turned to management of the incomplete abortion.

Table 4 Complete Clinical Assessment
History	Ask about and record the following information: Amenorrhoea [how long ago did she have her last menstrual period (LMP⁷)] Bleeding (duration and amount) Cramping (duration and severity) Abdominal or shoulder pain Drug allergies
General Physical Exam	Check and record vital signs (temperature, pulse, respirations, blood pressure) Note general health of woman (malnourished, anaemic, general poor health) Examine lungs, heart, abdomen, extremities. [In examining the abdomen first check bowel sounds, then if the abdomen is distended or rigid (tense and hard), if there is rebound tenderness,⁸ abdominal masses, and presence, location, and severity of pain] If a patient's Rh status is a routinely assessed in pregnancy, it should be done during the clinical assessment in cases of abortion as well. If the patient is Rh(-), give a dose of anti-D globulin within 48 hours of uterine evacuation or complete abortion.
Pelvic Exam	Remove any visible products of conception from the vaginal canal or cervical os Note if there is a foul-smelling discharge Note the amount of bleeding and whether the cervix is open or closed (to determine the stage of abortion, see Section 3.5.1) Check for cervical lacerations Perform a bimanual exam: estimate the size of the uterus⁹, check for any pelvic masses and pelvic pain [note severity, location, and what causes the pain (at rest, with touch and pressure, movement of the cervix)]

⁷ LMP is dale of the first day of the last menstrual period.
⁸ To check for rebound tenderness, press the abdomen with a hand. Then suddenly remove your hand, rapidly releasing the pressure. If removal of the hand causes or worsens pain, there is rebound tenderness. Rebound tenderness is a sign of peritoneal inflammation.
⁹ In this document uterine size is measured by weeks LMP (uterine size equivalent to a pregnant uterus of a given number of weeks since the last menstrual period) rather than in gestational weeks.