1. Tell the woman (and her support person) what is going to be done.  Listen to her. Respond attentively to her questions and concerns.

2. Provide continual emotional support and reassurance, as possible.

3. (If able to give IV at your facility) Ask an assistant to start Ringer’s Lactate or Normal Saline IV with 20 IU oxytocin and run it quickly.

4. Put on personal protective equipment.

EXTERNAL BIMANUAL COMPRESSION

5. Put one hand on the abdomen behind the top of the uterus and the other hand just above the pubic bone.

6. Press hands together firmly, making sure the uterus is directly between your 2 hands.

7. Look to see if bleeding slows or stops. If after 1 minute the bleeding is not stopped, proceed to internal bimanual compression

8. If bleeding slows to a small amount or stops, continue to give external bimanual compression for at least 5 minutes.

9. If continuing to internal bimanual compression; instruct an assistant or the support person to continue external bimanual compression while preparing for internal bimanual compression.

 

INTERNAL BIMANUAL COMPRESSION

11. Put high-level disinfected or sterile surgical gloves on both hands.

12. Clean the vulva and perineum with antiseptic solution.

13. Do digital evacuation of clots:

14. Gently slide index and middle fingers into the cervix through the vagina.

a. Gather all clots and tissue

b. Remove hand from cervix with clots

15. Reinsert gloved hand into vagina, feel for anterior vaginal fornix.

16. Form hand into fist.

17. If the cervix is in the way, move it posteriorly

18. Put the fist into the anterior vaginal fornix and apply pressure against the anterior wall of the uterus, not on the cervix.

19. Put the external hand on the abdomen behind the fundus of the uterus.

20. Press the abdominal hand deeply into the abdomen and apply pressure against the posterior wall of the uterus.

21. Press internal and external hands together firmly, making sure pressure is put on the uterus between your 2 hands.

POST PROCEDURE TASKS

1. Dispose of waste materials (e.g. blood-contaminated swabs) in a leak proof container or plastic bag.

2. Decontaminate open instruments by placing in a plastic container filled with 0.5% Chlorine (Chlorine (Jik)) solution for 10 minutes.

3. Dispose of needles and syringes in a puncture proof container.

4. Dispose of gloves

a. Remove gloves by slowly pulling them down from the cuff, turning them inside out, being careful not to splash.

b. Note: If waste disposal system not effective in facility, first rinse gloves while on hands in Chlorine (Jik) 0.5% decontamination solution before removing.

Put gloves in plastic waste container or plastic bag.

5. Wash hands thoroughly with soap and water and dry with a clean cloth or air dry.

6. Teach the woman (and support person) how to feel and massage the uterus and to call a health care provider if the uterus does not stay hard or if she feels bleeding.

7. Monitor vaginal bleeding and take the woman’s vital signs:

• Every 15 minutes for 2 hours

• Then every 30 minutes for 1 hour.

8. Make sure that the uterus is firmly contracted.

9. Record information about estimated blood loss, medicines given and what procedures you did (i.e. IV with oxytocin, bimanual compression).

10. Immediately refer once on bleeding. It’s stable for further investigations for anaemia and IV antibiotics.