POSTPARTUM HAEMORRHAGE

DEFINITION QUANTITATIVE Postpartal haemorrhage has been defined as any blood loss from the uterus greater than 500ml within a 24hr period. CLINICAL Any amount of bleeding from or into the genital tract following birth of the baby upto the end of the puerparium which adversly affects the general condition of the patient evidenced by rise in pulse rate and falling blood pressure is called postpartum haemorrhage.

INCIDENCE It varies. It is about 1% among hospital deliveries.

CLASSIFICATION PRIMARY ⁄ EARLY Haemorrhage occurs within 24hrs following the birth of the baby. In majority of cases haemorrhage occurs within two hours following delivery. TYPE Third stage haemorrhage. True postpartum haemorrhage. SECONDARY ⁄ LATE Haemorrhage occur beyond 24hrs and within puerperium is called

PRIMARY POSTPARTUM HAEMORRHAGE CAUSES Atonic uterus. Traumatic. Mixed. Blood coagulopathy.

ATONIC UTERUS Failure of myometrium at the placental site to contract and retract and to compress torn blood vessels and control blood loss by living ligature action. ☺CAUSES FOR ATONIC UTERUS Grand multipara. Overdistension of the uterus. Malnutrition and anaemia. Antepartum haemorrhage. Prolonged labour. Anaesthesia. Initiation or augmentation of delivery by oxytocin. Persistent uterine distension.

☺TRAUMATIC ☺COMBINATION OF ATONIC AND TRAUMATIC CAUSE Malformation of the uterus. Uterine fibroid. Mismanaged third stage of labour. Constriction ring. Precipitate labour. ☺TRAUMATIC Trauma to the genital tract. Bleeding is usually revealed but can be concealed. ☺COMBINATION OF ATONIC AND TRAUMATIC CAUSE ☺BLOOD COAGULATION DISORDER Abruptioplacenta. Jaundice in pregnancy. Thrombocytopenic purpura. HELLP syndrome or in IUD.

CLINICAL MANIFESTATION TRAUMATIC HAEMORRHAGE Uterus is found well contracted. UTERINE ATONY Uterine fundus is difficult to locate. Uterine fundus feels soft and boggy. Uterus becomes firm when massaged and loses its tone when massage is removed. Fundus is located above the expected level. Excessive lochia which is bright red. Excessive clots expelled.

SIGNS OF POST PARTUM HAEMORRHAGE Vaginal bleeding. Pallor. Rising pulse rate. Falling blood pressure. Altered level of conciousness. Patient becomes restless or drowsy. Enlarged uterus and feels boggy. Maternal collapse.

PROPHYLATIC MANAGEMENT ANTENATAL Improvement in health status of women. Screening high risk women. Blood grouping and typing. INTRANATAL Judicious administration of sedatives and hypnotics. Hasty delivery of the baby is to be avoided. Local or epidural anaesthesia is preferable to GA. Service of an expert is ideal when GA is needed. Active management of third stage is a prophylaxis. Temptation of fiddling or kneading the uterus,pulling the cord or crede’s expression of the placenta to be avoided

Routine examination of the placenta and membrane. In all cases of accelerated labour continue oxytocin and administer prophylactic ergometrine with the delivey of anterior shoulder. In case of instrumental delivery or difficult labour explore utero vaginal for evidence of trauma. Observe the patient for two hours after labour.

MANAGEMENT OF THIRD STAGE BLEEDING PRINCIPLES To empty the uterus . To replace the blood. To ensure effective haemostasis in traumatic bleeding.

STEPS OF MANAGEMENT PLACENTAL SITE BLEEDING Palpate the fundus and massage the uterus to make it hard. Administer Ergometrine 0.25mg or Methergin 0.2mg intravenously. Sedation may be given with Morphine 15mg intramuscularly. Start Dextrose saline drip. Arrange for Blood Transfusion. Catheterise the bladder if it is full. If features of placental separation is present , deliver the placenta either by Fundal pressure or controlled cord traction.

If features of placental seperation is not evident Manual removal of the placenta under GA is to be done. If the patient is in shock ,Resucitate the patient before manual removal of placenta is done. Crede’s expression of the placenta is abandoned. TRAUMATIC BLEEDING Explore the utero – vaginal canal. Apply the hemostatic suture at the bleeding site.

MANUAL REMOVAL OF PLACENTA DIFFICULTIES Hour glass contractions Morbid adherent placenta

COMPLICATIONS Haemorrhage Shock Injury to the uterus Infection Inversion Thrombophlebitis Subinvolution Embolism

MANAGEMENT OF TRUE PPH PRINCIPLE To diagnose the cause of bleeding. To take prompt and effective measures to control bleeding. To correct hypovolemia.

MANAGEMENT Immediate measures Call for extra help. Put in one or two large bore IV cannula. Send blood for grouping and cross matching. Arrange for two units of blood. Administer IV fluids. Do all the needed observations.

Actual management Atonic uterus: Step 1 Massage the uterus. Methergin 0.2 mg IV. Morphine 15 mg. Oxytocin drip. Empty the bladder. Examine the expelled placenta. Step 2 The uterus is to be explored under GA. Step 3 Bimanual compression.

Step 4 Hot intrauterine douche. Step 5 Tight intrauterine packing. IF IT FAILS Bilateral ligation of arteries. Angiographic arterial embolisation. Shivkar Packing. B-lynch Operation. Hysterectomy. Traumatic : Identify the trauma. Repair under GA.

SECONDARY PPH CAUSES Retained bits of cotyledon or membrane. Seperation of slough over a deep cervico vaginal laceration. Subinvolution of the placental site. Secondary haemorrage from caesarian section.

DIAGNOSIS Bright red bleeding. Degree of anaemia. Evidence of sepsis. Piece of placenta inside uterine cavity on sonar examination.

MANAGEMENT Principles To asses the amount of blood loss. To replace the lost blood. To find out the cause. To take appropriate steps to treat. Supportive Therapy Resuscitative measures. Blood transfusion. Administer ergometrine 0.5mg IM. Administer antibiotic as routine.

Conservative treatement A careful watch for a period of 24hrs. Put the patient on bed rest. Active treatement Explore the uterus under GA. Ergometrine 0.5mg is given IM. Haemostatic suturing. Laparotomy . Ligation of internal iliac arteries. Hysterectomy .

NURSING MANAGEMENT Massage the uterus to make it firm. Express the clots. Empty the bladder. Check the pads and linen to measure the amount of blood loss. Monitor vital signs and general condition. Haemoglobin estimation . Iron rich food and iron treatment. Help breast feeding mothers to save milk for the baby.