Post partum Hemorrhage

Definition:-Post partum hemorrhage is bleeding from thegenital tract during the 3rd stage of labour, or with in 24 hours after delivery of the placenta to the amount of 500ml or any amount that will change the patient’s condition

It is responsible for maternal deaths and is one of the emergencies in which if the Nurse/ mid wife does not know how or fails to play the part the doctor may be Unable to save the mother’s life as shock gets in quickly and can become irreversible.

The rate of flow that is more important than the amount Anaemia is a predisposing cause.

It is occurs within 24 hours at delivery it is caused primary while after 24 hrs of Delivery is secondary PPH.

Cause of Primary PPH

· Retained Placenta

· Retained Cotyledon

· Genital trauma

· Disseminated intramuscular coagulation (DIC)

· Inversion of uterus

Cause of secondary PPH

· Chorioamnioitis

· Retained products

Type of PPH

· Atonic postpartum hemorrhage

· Traumatic postpartum hemorrhage

· Hypofibrinogenaemia

Management of PPH

Three basic principle are applied

· Call an obstetrician

· Stop the bleeding

· Resuscitate the mother

1. Atonic Postpartum Hemorrhage (80% of PPH)

This is bleeding from the placental site when the uterus is not well contracted. This is a failure of a myometrium at the placental site to contract and retract and to compress torn blood vessels and control blood loss by a living ligature action.

Cause

· Incomplete separation of placenta

· Retained cotyledon, placental fragments or membranes

· Prolonged labour & obstructed labour resulting in uterine inertia

· Rapid expulsion of large body

· Poly hydraminous, multiple pregnancy-over stretnig of the uterus

· Anteportum hemorrhage

· Adherent placenta that has partially separated

· Precipitate labour

· Full bladder

· Mismanagement of the ill state of labour

· Prolonged anesthesia

· Fibroids

· Grand mult

Management of atonic PPH

· Massage uterus

· Give pitocin or ergometrine

· Baby to breast

· Empty bladder

· Empty uterus

· Bimanual compression

Bimanual Compression

It can be done externally or internally

Method

Place one hand on the fundus and the other above the Symphsis pubis (external) or in anterior fornix (internally) and squeeze until clotting occurs usually clotting takes place 7-10 minutes later. Remove the external hand to check whether the bleeding is stopped or not

Dangers: -

Hemorrhage

Shock

Infection

2. Traumatic Post Partum Hemorrhage (20% of PPH)

This is bleeding from a laceration of the cervix, vaginal wall, and perineum episiotomy or even from ruptured uterus.

Cause

· Delivery through partially dilated cervix

· Instrumental delivery-bruised

· Difficult delivery- Face to pubes, after coming head of breech

Management of traumatic PPH

When bleeding is due to the tear, explore the area for the tear, clamp the bleeding point and suture. Make sure that the uterus is not ruptured. If the laceration is sutured and bleeding stop make sure that the uterus is well contacted.

If bleeding is from bruised cervix place a pack against it for a few minutes to an hour, if so leave catheter in situ.

If bleeding is from ruptured uterus, transfer to the hospital as soon as possible; go with patient or send a full written report with date, time of departure and Signature.

3. Hypo Fibrinogenaemia

This is bleeding due to a clothing defect and the patient continuous to bleeding in spite of treatment for the other types of postpartum hemorrhage.

Causes

· Placental abraption

· Intrauterine death which is prolonged

· Amniotic fluid embolism

· Pre- eclampsia, eclampsia

· Intra uterine infection

· Hepatitis

Management of hypofibrinogenaemia (DIC)

The best treatment is

· Fresh blood transfusion

· Fibrinogen or triple strength plasma transfusion

· Give oxygen and resuscitate with IV dirp

· Drugs as prescribed

· IV syntocinic if uterus is lax

The patient will respond quickly to this treatment if given quickly. Advice Hospital delivery for the next time and warm her to explain to doctor or nurse.

It is important to be able to differentiate between a tonic and traumatic psot part hemorrhage.

Management of Severe PPH in a Health Center

· Massage the uterus to stimulate contraction and expel the placenta if possible

· Stay with your patient and shout for help

· Give ergometrine 0.5 ml I.V and put up a drip

· Empty bladder

· If placenta is already expelled, expel clots if not try to expel it with the contraction caused by ergometrine. If not and she is still bleeding severely in order to save the patient’s life manual removal is done.

· If still the uterus is lax as a last reason, bimanual compression method is done.

Consequences of PPH

· Shock and collapse- death

· Puerperal anemia – weakness & low resistance to infection

· Fear of the further pregnancy

· Sheehan’s syndrome- due to anterior pituitary necrosis

· Infection

Prevention of PPH

Good antenatal care

· Careful history taking to find out if she had PPH in previous delivery.

· Bring hemoglobin as high as possible and treat anemia. Book high risk for hospital delivery. Group & cross match high-risk mother in labour

· Try to prevent prolonged or obstructed labour

· Make sure that the mother rests as much as possible during 1st stage and prevent dehydration.

· Keep bladder empty

· Delivery head slowly and control it

· Active management of third stage