Post Partum Hemorrhage
Excessive
bleeding from the genital tract of 500mls or more after the birth of the baby,
or with less but deterioration in the patient’s condition.
1.
Primary Post Partum haemorrhage
2.
Secondary post Partum haemorrhage.
Primary Post Partum heamorrhage when it occurs within 24 hours after delivery.
There
are two types of PPH
1.
Atonic Haemorrhage – Bleeding from the placenta sit
e.
2.
Traumatic PPH – Bleeding from laceration of the gen
ital tract.
3.
Blood dyscracia. (Developmental disorder of the
blood)
Bleeding
is due to inability of the uterine muscle to contract effectively causes.
1. Atonic
uterus: leading to incomplete separation of placenta 30 prevent effective
retraction of the placental site.
·
Common with prolonged labour
·
Prolonged and deep anaesthesia.
·
Overstretching of the uterus – e.g. Polyhydramnios,
multiple pregnancy.
·
Multipara with laxed uterine muscle.
·
Concealed Ante Partum haemorrhage.
·
Rapid explusion of a large baby (Precipitate
labour)
2. Mismanagement
of the 3rd stage of labour. This is about the commonest cause of
post partum haemorrhage and under the control of the midwife. This management
includes:
·
Conducting labour with full bladder.
·
Massaging, kneading, squeezing and pushing of the
uterus
o
These over stimulate the uterus and cause irregul
ar contraction and partial separation of the placenta and inadequate control of
haemorrhage.
3. Subendomentrial
Fibroids; This interferes with uterine contraction.
4. Blood
dyscrasica: clothing disorders – Hypofibrinog enaemia.
i.
It is associated with concealed Accidental
haemorrhage.
ii.
Amniotic fluid embolism
iii.
Mixed abortion for many weeks.
If in
addition the uterus is atonic uncontrollable bleeding occurs
5. Placental
abnormalities
i.
Placenta chorionic villi penetrate more deeply than
usual – (Placental accrete) leading to inseperation .
ii.
Placenta Praevia – partial separation.
6. Anaemia
ketosis – Induction or augmentation of labo ur with oxytocin
1.
Bleeding – May start a few minute after delivery of
the baby and comes out in gush.
2.
Big uterus – Higher than umbilical level or feels l
arge
3.
Boggy: soft and flabby, distended with no definite
outline
4.
Rapid Pulse: Above 90 beats
5.
Pallor – on the face
6.
Collapse.
1.
Treat anaemia in Pregnancy.
2.
High Risk women should be delivered in Hospital – P
revious PPH, Placenta accrete, Grandmultiparity, APH, and Fibroids.
3.
Good management of second stage of labour.
o
Empty bladder at the end of first stage.
o
Slow delivery of the baby.
4.
Good management of 3rd stage – Control
Cord traction (CCT)
5. Anticipation
of blood coagulation disorders.
6. The use
of oxytocic drugs.
o
Suspected cases
o
Oxytocin drip – To run for 1hr after delivery
(Induction).
(Before
the delivery of the placenta) To control the bleeding the uterus must be
strongly contracted and empty.
o
Stop the bleeding
o
Replace lost fluid
o
Treat circulatory failure – Shock
o
Massage and kneed the uterus to contract.
o
Deliver the placenta by CCT or Brandt Andrews
method and remove blood clots.
o
Give injection ergometrine 0.5mg or syntometrine
1ml i.m.
o
Send for medical Aid or transfer to a Hospital.
o
If palcenta can not be expeclled give syntometrine
1ml (syntocinon 5 unit + Erg+ 0.5mg) check for contraction and deliver by CCT.
If placenta does not separate completely repeat after 10min. that alone will
control haemorrhage.
o
If all fail manual removal of the placenta have to
be performed.
Bleeding
after the Birth of the placenta:
o
Message the uterus until it contracts.
o
Empty the bladder
o
Expel blood clots
o
Send for medical Aid
o
Give Oxytocin drugs – syntometrine, it acts fast or
Ergtometrine i.v. (45sec) by Dr. Dext at 40 drops per minute.
o
If bleeding continues – Apply bimanaual compression
on the placenta site to control bleeding until oxytocin drugs take effect – Do
clotting time.
o
Exploration of the uterus under G.A. – for retained
product and trauma.
o
Hysterectomy for uncontrollable and severe cases.
o
Blood transfusion if necessary.
o
The uterus should not be packed.
o
Raise the foot of the bed if in shock.
o
Insert indwelling catheter to monitor urinary
output.
o
Keep all records of observations meticulously pulse
¼ hourly, B/P respirations
o
Give analgesic to relief pains.
Is due to
laceration of the cervix or upper vaginal wall. Bleeding from the perineum is
readily controlled but when from clitoris bleeding may be profused. It may
occur in abnormal presentation and instrumental delivery.
1.
Start immediately the baby is born.
2.
The flow is a continuous heavy trickle.
3.
Uterus is firm and well contracted.
1.
Suture the laceration under Generaaal anaesthesia
(G.A). – Cervical laceration
o
Use Sims Ferguson’s speculum for inspection.
o
Sponge holding forceps is used to hold the cervix
as tenaculum will tear the cervix the more.
2.
Tie bleeding points and suture with catgut.
3.
In remote area, pack the vagina to compress the
bleeding points
o
using gauze plug.
4.
Remove clots from the vagina, empty the bladder.
Usually
done under G.A. The vulva is cleaned and gloved hand is lubricated with an
obstetric cream and introduced into the uterine cavity. The left hand controls
the fundus per abdomen. The hand follows the cord if present up to the placenta
and identifies edge. Using the ulner border the placenta is separated from the
uterine wall. The external hand keeps constant manipulation. Ensure that all
the placenta tissues have been removed before the hand is withdrawn. The
external hand massages the uterus for contraction, ergometrine 0.5mg is given
i.v. or i.m. The placenta is examined for completeness.
This is
used to control bleeding until oxytocic drugs take effect method:
Place
patient in a dorsal position. Clean the vulva. Scrup the hands and wear glove.
Insert the right hand into the vagina like a cone, make it into a fist. Place
the flat part of the fist in the Anterior vaginal fornix against the uterine
wall. Rest the elbow on the bed between the woman’s thighs place the left hand
over the uterus abdominally with fingers directed towards the cervix. Bring the
uterus forward and compress it on to the fist in the vagina. In this way the
uterus is compressed between the two hands and haemorrhage is controlled. It
should be maintained until the uterus is well contracted. Early compression is
very effective, though it is a tiring procedure – Ergometrine may be repeated
i. m to maintain contraction.
Bleeding
that occurs after 24 hrs hours or more after delivery, within 6 weeks of
delivery, usually about the 10th day.
Usually
due to retained fragment of placenta tissue, chronic membranes, chorionic
membranes or blood clots. Frequently complicated by intrauterine infection and
pyrexia – myometritis.
1.
Separation of septic slough from the cervical or
vaginal tear or placenta site or Caesarean Section wound.
2.
Rarely from infected and slough from a
subendometrial fibromyoma (Fibroid)
3.
Some times may not be associated with sepsis.
If
associated with sepsis there is usually fever, offensive lochia, or other
evidence of infection. The cervice usually remains opened when something is
remained in the uterus.
o
Persistent red lochia – evacuation
o
Retained succenturate lobe
·
Ergometrine 0.5mg i.m is repeated.
·
Digital exploration of the uterus
·
Broad spectrum antibiotic
·
Careful light curettage to prevent uterine
perforation – if bleeding persists.
·
In profuse bleeding – do bimanual compressions.
·
Call a Doctor
·
Empty bladder, save all linens.
It may
give rise to traumatic haemorrhage . It is caused by ruptured leading to
collection of blood in the connective tissue of the vulva and vaginal wall. A
small haematoma may be associated with repair of medio lateral episiotomy or
laceration. Sign manifest a few hours after delivery and the woman complains of
discomfort and pain in the perineum and/or labia. The skin of the labia becomes
thin and haematoma may bulge into the vagina.
·
Apply a hot saline pack
·
Incision and drainage
·
Tie the bleeding vessel
·
Blood transfusion if bleeding is severe.
If
placenta does not leave the upper segment after 30mins of delivery. This is
suspected, usually no bleeding. The midwife should not make attempt to separate
the placenta as partial separation will result in bleeding. Doctor will do
manual removal under general anaesthesia.
Placenta
has separated but not expelled.
·
Faulty technique
·
Full bladder
Empty the
bladder, rub up for contractions and deliver the placenta.
Check
that the uterus is firm, if placenta is palpable in the vaginal
separated
use material effort or fundal pressure to deliver the placenta – with care to
avoid invention of the uter us. If possible under anaesthesia – Epidural, to
avoid shock.
Blood
coagulation disorders may occur following severe pre-clampsia,APH, Amniotic
fluid embolisim, IUD or sepsis.
Fresh
blood , platelets, factor v, x, vii, fresh plasma and fibrinogen could be
given.
Observation
of mother following APH
Estimate
lost volume of blood, Vital signs e.g. pulse, BP ¼ hourly temperature.
Palpate
uterus to ensure contraction, observe lochia for normalcy, replace i.v loss –
avoid circulatory over leading. Acurate intake and out put chart to assess renal
functions, Woman to remain in labour ward until condition is satisfactory, in a
comfortable room for 24 – 48hr. she should not be discharged home un til Hb is
normal, Reasure the woman as necessary.
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