POSTPARTUM HAEMORRHAGE (PPH)Ilala crest lodge Training12-06-2009Marla

GOAL

To equip midwives and other skilled birth attendants with knowledge, skills and attitude in the management of women with postpartum haemorrhage

OBJECTIVES

At the end of the session midwives and other skilled births attendants will be able to:Define postpartum haemorrhageExplain the types of post-partum haemorrhageExplain causes of postpartum haemorrhage

OBJECTIVES CONT

Explain the complications of postpartum haemorrhageDemonstrate competence in caring for women who develop post partum haemorrhageDemonstrate positive attitudes in managing patients with PPH

LEARNING ACTIVITIES

History takingExamination of placenta and membranesVaginal examinationMeasuring of blood lossBimanual compression of the uterusManual removal of placenta

Definition

Postpartum haemorrhage is excessive bleeding of 500 mls and above from the genital tract after delivery of the baby and before the end of puerperium.Any amount of blood loss that threatens the life of the mother can also be regarded as PPH

Types of Postpartum Haemorrhage

Primary postpartum haemorrhageThis is excessive bleeding from the genital tract within 24 hrs of delivery. This is the most common type of post partum haemorrhage.Secondary postpartum haemorrhage It is excessive bleeding from the genital tract after 24 hours of delivery up to 6 weeks postpartum.

Causes of Postpartum Haemorrhage: The 3 Ts

First T: TONEBleeding due to lack of TONE of the uterine muscles or any condition interfering with contraction of the uterus. This includes:Retained placenta Retained placental tissue or membranes Incomplete separation of placenta

Causes of Postpartum Haemorrhage: The 3 Ts cont

Full bladderAnte-partum haemorrhage like in placenta praevia (less oblique muscle fibres in the lower uterine segment) or placenta abruptio (muscle fibres are damaged due to concealed uterine haemorrhage

Causes of Postpartum Haemorrhage: The 3 TscontSecond T: TRAUMA Lacerations to birth canal including cervical, perineum, and vagina tears, ruptured uterus, uterine inversion, too early episiotomiesThird T: THROMBINCoagulation failure interfering with blood clotting mechanism

Examples of causes of Coagulation failureAbruptio placentae Amniotic fluid embolism Retained dead fetus Inherited coagulopathy

Factors predisposing to postpartum uterine atonyOverdistention of the uterus Multiple gestations Polyhydramnios Fetal macrosomia Prolonged labor Oxytocic augmentation of labor Grand multiparity (a parity of 5 or more) Precipitous labor (one lasting

Management of primary PPH (according to cause)

a)ToneManagement will depend on whether the placenta is delivered or retainedi)Placenta deliveredCall for help and never leave the patient alone till the bleeding has stopped and the patient is stableExplain calmly to the mother about her condition and what interventions will be done

Placenta not delivered contRub up a contraction and expel clots if anyGive Oxytocin (10 units IM stat)Empty the bladder and maintain an indwelling catheterPut up two large bore cannula and take blood for grouping, X-matching and haemoglobin and check clotting time

Placenta not delivered contInfuse Normal Saline or crystalloids with 20-40 units of Oxytocin. Maintain the infusion at 40 drops per minute to keep the uterus well contracted (or run the infusion fast).Arrange blood donors. If at a health centre, donors should accompany the patient to the Central Hospital/District Hospital.

Placenta not delivered contAssess patients condition (pulse, BP, colour of mucus membranes, consciousness level, uterine tone) and estimate how much blood has been lost already. Start resuscitating the patient immediately: airway to be patent, oxygen therapy 6-8 litres per minute.

Placenta not delivered contQuickly examine placenta and membranes for completeness.Inform the doctor about the condition of the patient and about the interventions that you have carried out.If bleeding persists and the uterus keeps relaxing, use bimanual compression of the uterus. (see Annex 6)

Placenta not delivered contIf bleeding persists and the uterus is well contracted, examine the vagina and cervix for lacerations/tears.In case of severe shock use plasma expanders or blood transfusion if available.In case of infection commence antibiotics

Placenta not delivered contKeep the woman warm throughout the procedure.Record intake and outputDocument all interventions done and keep accurate records

Management of PPH -TONE contii)Placenta not deliveredCall for helpExplain to the patient the condition and plan of care.Rub up the fundus of the uterus for a contractionEmpty the bladder.Give Oxytocin 10 units IM.

Placenta not delivered cont

Apply controlled cord traction with the next contractions.If placenta still not delivered, commence intravenous infusion of saline with 20-40 units of Oxytocin (If at the health centre refer).A second attempt at controlled cord traction should be tried.

Placenta not delivered cont

If controlled cord traction is not successful proceed to manual removal of the placenta. (see Annex 5).If manual removal is not successful, refer immediately

Management of PPH-TRAUMAb)TraumaCall for helpExplain the condition to the mother and plan of carePlace the woman in lithotomy position and use good lighting Find the bleeding point if visible, clamp it, and suture the tear.

Management of PPH-TRAUMA contTake blood for grouping, X-matching and haemoglobin estimation.Set up an intravenous infusion, give saline or sodium lactate followed by plasma expander if available and if shock is severe.Estimate the blood loss

Management of PPH-TRAUMA contCheck pulse and blood pressure, and observe general condition.Start the woman on broad spectrum antibioticsKeep accurate records.

Management of PPH- THROMBINc)ThrombinCheck blood at the bed side for clotting time The rest of management is the same with that for TONE but transfuse fresh blood.

Management of secondary PPHAdmit the woman to hospital as an emergency and assess the condition.

Rub up uterine contraction by massaging the uterus if it is still palpable.

Give Oxytocin 10 units IM.

Management of secondary PPHTake blood for Hb grouping and X-matching.Put up intravenous infusion of normal salineIf bleeding is severe add 40 units IV Oxytocin per litre to run at 40 drops per minute.Inform doctor or clinical officer

Management of secondary PPHIn case of severe shock use plasma expanders or transfuse blood if available.Start the woman on broad spectrum antibiotics in high doses.Prepare the patient for EUA and possible re-suturing.Monitor the patients condition, blood pressure, pulse, temperature, respiration and blood loss.

Management of secondary PPHAssess lochia for colour, amount, odour and consistencyObserve colour on the conjunctiva, tongue Observe level of consciousnessObserve intake and output and keep accurate records

Management of secondary PPHPalpate uterus for tenderness

Provide good nursing care by assisting mother with activities of daily living e.g. nutrition, hygiene, rest and sleep.

Encourage exclusive breast feeding.

Complications of PPH

InfectionHypovolaemic shockSevere anaemia Sheehans syndromeRenal failureMaternal death

Required competencies

History takingPhysical examinationManual removal of placentaExamination of placenta and membranesSuturing skills of episiotomy and tears

Required competencies contBimanual compressionActive management of 3rd stage of labourInserting and monitoring intravenous infusions including bloodCheck blood for bedside clotting time

YEBO CHOMENE!

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