postpartum haemorrhage, dr jeevan

7/31/2019 Postpartum Haemorrhage, Dr Jeevan

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Definition

Qualitative definition:

Vaginal bleeding in excess of 500 ml after child birth.

But practically it is difficult to assess.

Clinical definition:Any amount of bleeding from or into the genital tract following child

birth which adversely affect the general condition of patient

evidenced by rise in pulse rate and falling blood pressure.

(Systolic BP < 90 mmHg and pulse > 110/min.)


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Epidemiology

According to the data of 1998, PPH found to

be major culprit for maternal death in Nepal.

About 47% of the maternal death was caused

by PPH.

A recent survey done in 10 districts of Nepalshows that PPH causes 19% of the maternal

death


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Types of PPH

Primary:

Bleeding within 24 hrs postpartum

Secondary:

Bleeding beyond 24 hrs till puerperium(6

weeks).


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Note:

Every healthy non anaemic women canhave catastrophic blood loss

Bleeding may occur at a slow rate overseveral hours and condition may not be

recognised until the woman suddenly enters

shock


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Causes of primary PPH

4 Ts

Tone

Trauma

Tissue Remnant

Thrombin


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A. Reduced Tone (70%)

With separation of placenta uterine sinuses

which are torn cannot be compressed

effectively due to imperfect contraction and

retraction of uterus

Risks: Grand Multipara

Over distension of uterus

Malnutrition and anaemia

Prolonged labour

Malformed uterus

Uterine fibroid

precipitate labour ( reduced adaptation / genital trauma)


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B. Trauma (20%)

Trauma to genital tract.

Cervix , vaginal wall, perineal tear can occur

Occurs more often with increased

instrumentation, difficult labour


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C. Tissue Retained (10%)

Bits of placenta / membrane

Blood clots

Primarily interfere in uterine contraction


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D. Thrombin (


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Prevention of PPH

PPH cannot always be prevented . However

incidence and its magnitude can be reduced

substantially.

Antenatal:

Improvement of health status

High risk patient screening and counselling

Blood grouping


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Intranatal:

Slow delivery of baby. Baby should be pushed out not pulled out Active management of third stage of labour which includes: inj.

oxytocin 10U IM stat, CCT to be done after placental separationonly and fundal massage

Examination of placenta and membrane should be routinely done

Oxytocin infusion should be continued at least one hour after

delivery in those cases in which labour is induced or augmented by

oxytocin

Exploration of birth canal especially following difficult labour or

instrumental delivery

Observation of patient for about 2 hours before sending her to

ward.


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Management of PPH

Shout for extra help. urgently mobilise all

personnel available

Counsel mother and her relatives about the

condition gravity

Rapid evalutation of general condition bymeasuring pulse, BP, Temperature and

respiratory rate


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Management of PPH

If patient has following features, the patient is

considered to have gone into shock:

Systolic BP: < 90 mmHg

Pulse: > 100/min

Pallor

Unconciousness

Cold clammy Periphery


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Management of PPH

Management of shock:

Basic principles of shock are: Maintain Airway , Breathing and circulation

Oxygen

positioning

Open IV line ( 2 lines) by large bore canula

and infuse fluid (NS or RL) fast.

Catheterisation and input/output charting

Send blood for Hb%, Blood grouping and cross

matching


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Management of PPH

Uterine massage should be done

if well contracted

Examine cervix, vagina and perinium for traumaif present repair.


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Management of PPH

If uterine atony is there then following steps

have to be carried out

Step 1.

Uterine massage

Inj. Oxytocin 10 U IM stat if not given earlier

and Inj. Oxytocin 10-20 U in 500ml Rl/NS @

40-60 drops/min Examine expelled placenta and membrane

Bladder catheterisation if not done earlier


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Management of PPH

Step 2.

Exclude coexisting injured/traumatic site in the

birth canal

Continue Oxytocin drip

Misoprostol 600 microgram per rectally


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Management of PPH

Step 3.

Bimanual compression / Aortic compression

Tight intrauterine packing under anaesthesia

Step 4.

Surgery


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Continuous care following

control of PPH

Vitals should be monitored every 15 min in 1st hour then

every 30 min in 2nd hour and 4 hourly in next 24 hours.

Breast feeding

Hb. done after 24 hours If haemoglobin is below 7 gm/dl and vitals of the patient is

unstable, blood transfusion should be done or referred.

Iron tablet should be given for 6 months

Albendazole given if was not given earlier. Nutritional counselling

Discharged only after 24 hours of control of PPH

During discharge counselling to be done regarding FP

and danger signs.


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Secondary PPH

Bleeding usually occurs between 8th and 14th

day of delivery

The causes of late post partum are

Retained bits of cotyledon or membrane(commonest)

Infection and separation of slough over a

deep cervico vaginal tear Endometritis and subinvolution of placental

site due to delay healing process


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Conclusion:

The commonest cause of PPH is uterine atony

Tone of the uterus can be regained by simple

measures like fundal massage and oxytocin

infusion primarily.All said and done to prevent from catastrophe

the essentials are:

Intelligent anticipation Skilled supervision

Prompt detection

Effective institution of therapy


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postpartum haemorrhage, dr jeevan

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