Hesperian Health Guides
Emergency care for problems after miscarriage or abortion
HealthWiki > A Book for Midwives > Chapter 22: Helping a woman after a pregnancy ends early > Emergency care for problems after miscarriage or abortion
Infection can happen when:
- tissue from the pregnancy is still in the woman’s womb after the miscarriage or abortion.
- germs get into the womb during an abortion, when something that was not sterilized is used in the womb.
Bleeding too much can happen when:
- tissue from the pregnancy is still inside the woman’s womb after the miscarriage or abortion.
- the womb or vagina has been cut with a tool during an abortion.
- the womb becomes infected.
WARNING! If a woman has heavy bleeding or a serious infection, she can go into shock or even die. Get medical help fast.
If you have been trained to help a woman after an unsafe abortion or
miscarriage, you can help her yourself.
Incomplete abortion (tissue left inside the womb)
Incomplete abortion is a common cause of bleeding or infection. The bleeding or infection will not stop until all the tissue has been removed from the womb.
- Tissue coming out of the womb. If you do a pelvic exam you might see pieces of tissue coming out of the cervix or you might feel that the womb is still enlarged because of tissue inside it.
- Infection. The woman might have a fever, a bad smell coming from her vagina, or pain in her belly.
- Heavy bleeding from the vagina.
Treating incomplete abortion
There are several ways to empty the womb after an incomplete abortion. In this book, we explain how to use:
- MVA
- medicines
- forceps or other ways to remove tissue from the cervix, if you cannot use the first 2 methods
MVA
manual vacuum aspiration
The best treatment for incomplete abortion is to empty the womb using manual vacuum aspiration. Even though MVA is usually only safe in the first 3 months of pregnancy, it is worth trying after 3 months for a woman who has an incomplete abortion.
Treating incomplete abortion with medicines
Two medicines can help empty the womb after an incomplete abortion — misoprostol and ergometrine. Misoprostol can be given by mouth or inserted in the vagina — it makes the womb contract and pushes out any tissue. It is best to use this medicine when you have access to emergency care, including MVA, because it can cause heavy bleeding and does not always empty the womb completely. Ergometrine is another medicine that causes contractions and can be given by mouth or injection.
| To empty the womb |  |
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| After an incomplete abortion for a pregnancy less than 14 weeks | |||||
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by mouth, 1 time only | ||||
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to dissolve slowly under the tongue or in the vagina, 1 time only | ||||
| After an incomplete abortion for a pregnancy of 14 weeks or more | |||||
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to dissolve slowly under the tongue or in the vagina, every 3 hours until the abortion is complete | ||||
| For a retained miscarriage of less than 14 weeks | |||||
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to dissolve slowly under the tongue or in the vagina, every 3 hours until the abortion is complete | ||||
| For a retained miscarriage of 14 weeks or more | |||||
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to dissolve slowly under the tongue or in the vagina, every 4 to 6 hours until the abortion is complete. | ||||
| Do not use misoprostol in the vagina if the woman is bleeding from her vagina. If she is bleeding, give misoprostol by mouth or under the tongue. | |||||
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When misoprostol is used to end a pregnancy
It is important to have access to emergency care when using misoprostol to end a pregnancy. While it is very safe, on rare occasions it causes too much bleeding or an incomplete abortion. Emptying the womb using misoprostol alone may take many hours. If the womb does not empty completely, it must be emptied another way, such as with MVA (see Chapter 23). | |||||
Removing tissue from the cervix If you cannot do MVA, cannot give medicines, and you cannot find someone else to empty the womb, do a speculum exam and look for tissue or clots of blood coming out of the cervix. Use a sterilized forceps or long tweezers to remove the tissue or clots. This does not always work, but it is better than doing nothing.
If you do not have a speculum but you do know how to do a bimanual exam, wash yourhands well and put on sterile plastic gloves. Put 2 fingers into the woman’s vagina to feel her womb. Move your fingers across the opening of the cervix. If you feel tissue coming from inside the cervix, gently try to remove it. If it is too slippery to hold, wrap two fingers with sterile gauze or a thin piece of sterilized cloth and try again to remove the tissue. This might be painful for the woman, so be very gentle. This method is rarely helpful, but it is better than doing nothing.
WARNING! If you are not able to remove the tissue from an incomplete abortion, you must get medical help immediately so the tissue can be removed. On the way to the medical center, treat the woman for infection, and watch for shock.
After you remove the tissue:
- Feel the womb from the outside to see if it is soft. Rub the womb every few hours to keep it hard.
- Watch for signs of infection.
Infection
A woman with an infection in the womb is in serious danger. The infection can cause injury to the womb, and can spread into the blood (sepsis). Sepsis is very dangerous and can quickly cause shock or death. Women mainly get infections after abortions when unsterile tools were used, or after miscarriages and abortions that were not complete, but even an abortion that was done safely can sometimes cause an infection.
- Temperature, above 38°C (100.4°F).
- Fast pulse, over 100 beats a minute.
- Feeling chills and shivering.
- Swollen, hard, or painful belly.
- Bad-smelling fluid coming from the vagina.
- Feeling ill or weak.
To help a woman with an infection
- If she still has tissue in her womb, the infection will not get better until the tissue is removed. See about methods to empty the womb.
- Give antibiotics.
- Prevent tetanus infection.
- Help the woman drink lots of fluids. This will help the body fight infection. If she has a hard time drinking, give her rehydration drink, rectal fluids, or an IV.
- Help the woman eat nutritious food. Some fresh fruits like oranges, guava, papaya, mangos, and breadfruit have vitamin C, which helps promote healing.
- If you know how to use plant medicines to stop infections, the woman can take them, but do not put any plant medicines into the womb. (See about how to decide if plant medicines are useful or harmful.)
| To treat womb infection |  |
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| Get medical help. On the way, give these medicines. For complete information on these medicines, see the Medicines Pages. | |||||||
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in the muscle, then reduce the dose to 1g, 4 times a day | ||||||
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in the muscle, 2 times a day | ||||||
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by mouth, 3 times a day | ||||||
| Stop giving these antibiotics when the person has had no fever for 48 hours. Then start giving the antibiotics below. | |||||||
| When fever has been gone for 48 hours | |||||||
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by mouth, 2 times a day for 10 days | ||||||
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by mouth, 3 times a day for 10 days | ||||||
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by mouth, 3 times a day for 10 days | ||||||
Tetanus (lockjaw)
Tetanus is a type of infection that can be caused by unsafe abortion.
Women who have not been vaccinated against tetanus face a high risk of becoming sick or even dying from tetanus if anything that was not sterilized was put into their womb during an abortion.
If a woman had an unsafe abortion and she may not have been vaccinated against tetanus in the last 10 years, give her tetanus immune globulin immediately.
| To protect against a tetanus infection |  | ||||
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in the muscle, 1 time only | ||||
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in the muscle, 1 time only, but in a different place than the tetanus immune globulin injection | ||||
Signs of tetanus
- headache
- difficulty swallowing
- stiff neck
- jaw spasms
- tense or rigid body
- painful muscle contractions or spasms
- convulsions
Signs of a tetanus infection might start weeks after the infection happened.
If a woman is sick with tetanus, get medical help right away. On the way, help her lie down on her side, keep her calm, and protect her from light.
All women should receive vaccinations to prevent them from getting tetanus.
Bleeding
Most women bleed about the same amount as regular monthly bleeding for a few days after a miscarriage or abortion. Some women keep bleeding a small amount for up to 2 weeks. After a couple of days, the blood should be dark, not bright red. More bleeding than this could be dangerous and is a warning sign. If a woman is bleeding a lot after an abortion, especially if the blood is bright red and has few clots, it means the blood is fresh and flowing. She is in danger and the bleeding must be stopped. If she keeps bleeding she could go into shock or even die.
Women bleed too much after an abortion or miscarriage when:
- the womb does not contract.
- tissue is left inside the womb.
- there is an injury inside the body.
A woman can help herself if she is bleeding heavily
If a woman is bleeding and she is by herself with no one to help her, she can try to stop the bleeding herself. This method is probably not enough to stop the bleeding, but it may slow it down.
Help the womb contract by rubbing the lower belly very hard while lying down or squatting. If there is tissue in the womb, a woman may be able to push it out by bearing down as if she is having a bowel movement or pushing a baby out.
To help a woman who is bleeding
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Help stop the bleeding by emptying the womb.
I need to empty your womb to make the bleeding stop. It will not take long. - Rub her womb every few hours until it is hard to help it push out the blood and tissue inside of it.
- Check the woman for infection.
- Watch the woman for signs of shock.
Internal injury (injury inside the body)
An internal injury from an abortion is most often caused by a sharp tool making a hole in the womb. The object may also cause harm to other organs inside the body such as the ovaries, intestines, or bladder.
When a woman has internal injuries she may have bleeding inside her belly that you cannot see. Or she may have bleeding from her vagina that you can see.
- Belly feels stiff and hard with no sounds or gurgles inside.
- Very bad pain or cramps in the belly.
- Fever with chills or shivering.
- Nausea and vomiting.
- Pain in one or both shoulders.
- Shock.
WARNING! Immediately take any woman with an internal injury to a hospital or medical center to have surgery. Without surgery she could die.
On the way to a medical center, treat the woman as you would for shock, but do not give her any food or drink by mouth. (It is OK to give medicines by mouth and a little water so the woman can swallow the medicine.)
Shock
If a woman has a serious infection or bleeds heavily, she may go into shock.
- She feels faint, dizzy, weak, or confused.
- She is pale and has a cold sweat.
- Fast pulse, over 100 beats a minute.
- Fast breathing.
- Dropping blood pressure.
- Sometimes loss of consciousness.
Get medical help fast. You must treat the shock first to save her life. Then follow the directions earlier in this chapter to stop her bleeding or infection.
On the way to a medical center:
- Have the woman lie with her feet higher than her head, and her head turned to one side.
- Give her fluids. If she is conscious, she can drink water or rehydration drink. If she is not conscious, you can give her rectal fluids, or an IV if you know how.
- If she is unconscious, do not give her anything by mouth — no medicines, drink, or food.
Note: See information about how to get and use an Anti-Shock Garment which helps you treat and save the life of a woman with shock.