Obstetric emergency part 2
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Transcript of Obstetric emergency part 2
Obstetric emergency cont…
6. Managing third stage complications
1. Postpartum hemorrhage (PPH)
BY MUKEREM.A 2007
Objeonobctiv Objectify Objectives veObjeooctives
objectivesDefine PPH
Be familiar with clinical features of blood loss
Understand risk factors for PPH
Be able to take measures to prevent PPH
Be familiar with immediate management of PPH
BY MUKEREM.A 2007
Obstetric emergency cont…
Definition: . No single definition for PPHIs a bleeding from the genital tract during the third stage of labor or any time following the baby’s birth up to 6 weeks (some authors say 12 weeks) after delivery:1. to the amount of 500ml or more following
vaginal birth or2. to the amomnt of 1000 ml or more following c/s
or3. Fall in Hct of > 10 % or 4. Any amount bleeding which affects women
condition. BY MUKEREM.A 2007
Blood loss (mls) Vital signs Other features Level of Shock500-1000 PR Dizziness
Palpitations
Compensated
1000-1500 PR
BP (80-90 systolic)
RR (21-30)
Pale
Sweaty
Weakness
Mild
1500 – 2000 PR
BP (60-80 systolic)
RR (>30)
Cold clammy skin
Restlessness
Anxiety, confusion
Decrease urine output
Moderate
2000 – 3000 BP (< 50 systolic)
Peripheral cyanosis
Air hunger
Confusion, Anuria
Unconscious, Collapse
Severe
BY MUKEREM.A 2007
Obstetric emergency cont…
Classification of PPH according to time of occurrence
A. Primary post partum hemorrhage
This is called when bleeding occurs with in 24 hours of birth. This is usually a consequence of hypotonic uterine action or trauma
BY MUKEREM.A 2007
Obstetric emergency cont…
B. Secondary post partum hemorrhage
•Is bleeding from the genital tract more than 24 hours after delivery of the placenta and may occur up to 6 weeks later.
• It is most likely to occur between 10 and 14 days after delivery.
• Bleeding is usually due to retention of a fragment of the placenta or membranes or the presence of a large uterine blood clot
BY MUKEREM.A 2007
Risk factors for PPH
• Antepartum haemorrhage• Macrosomia **• Precipitate labour• Polyhydramnios **• Operative vaginal delivery• Anaemia ***• Previous PPH ****
Morbidly adherent placentaInduction of labour
• Pre eclampsia• Use of oxytocin• Previous caesarean section *• Prolonged first stage of labour• Multiple pregnancy **• Prolonged second stage of labour
BY MUKEREM.A 2007
Obstetric emergency cont…
Types of PPH
1. Atonic PPH
2. Traumatic PPH
3. Hypofibrinogenaemia
BY MUKEREM.A 2007
QUESTION ???
• What are the first things you should do when you encounter a woman with bleeding after third stage (postpartum hemorrhage)?
BY MUKEREM.A 2007
Immediate Management
• CALL FOR HELP
• Rapid assessment– ABC
– Vital signs -
– High flow oxygen
– Large bore IV access and fluid resuscitation
– Catheterise
– Aortal compression
BY MUKEREM.A 2007
Immediate management
• Investigations– Bloods: Hb or HCT
– Cross match
– Clotting studies
• Identify cause– 4 T’s
TreatUterine atony >
uterine massage, drugs, bimanual compression, surgery
genital tract trauma> repair tears
retained placenta > manual removal of placenta
BY MUKEREM.A 2007
Obstetric emergency cont…
Managing Atonic PPH
Atonic PPH
Defn – This is bleeding from the placental site when the uterus is not well contracted, or this is a failure of the myometrium at the placental site to contract and retract and to compress torn blood vessels and control blood loss by a living ligature action.
BY MUKEREM.A 2007
Obstetric emergency cont…
Causes of atonic PPH
A. Incomplete placental separation.
If once separation has begum maternal vessels are torn. If placental tissue remains partially embedded in the spongy deciduas efficient contraction and retraction is interrupted.
BY MUKEREM.A 2007
Obstetric emergency cont…
B. Retained placenta or products like retained cotyledon, placental fragment or membranes. This is the common cause of atonic PPH.
C. Precipitate labor: When the uterus has contracted vigorously during the first and second stages of labor (Hypertonic action) then the muscle has insufficient opportunity to retract.
BY MUKEREM.A 2007
Obstetric emergency cont…
D. Prolonged labor: May result in uterine inertia due to muscle exhaustion.
E. Over distention as in multiple pregnancy polyhydramnios, large baby
BY MUKEREM.A 2007
Obstetric emergency cont…
Sign and Symptoms of atonic PPH Visible bleeding Maternal collapse Pallor Rising pulse rate (weak and irregular) Falling blood pressure Altered level of consciousness may become restless or drowsy Enlarged uterus as it fills with blood or blood clotUterus feels boggy on palpation i.e soft and distended and lacking tone.
BY MUKEREM.A 2007
Obstetric emergency cont…
Treatment of Atonic PPH
Three basic principles apply
1. Call for help
2. Stop the bleeding
3. Resuscitate the mother
BY MUKEREM.A 2007
Obstetric emergency cont…
1. Call for help
This is an important initial step so that help is on the way whatever transpires.
2. Stop the bleeding
The initial action is always the same regardless of whatever bleeding occurs with the placental site or not. Steps to stop a bleeding are
a. Rub up a contraction
b. Give oxytocin drug
c. Empty the uterus BY MUKEREM.A 2007
Obstetric emergency cont…
a. Rub up a contraction or massage the uterus to stimulate contraction. The fundus is first felt gently with the fingertips to assess its consistency if it is soft and relaxed the fundus is massaged with a smooth circular motion applying no undue pressure. When a contraction occurs the hand is held still.
b. Giving an oxygocin drug Oxytocic agent may be given to sustain the contraction. In many instances ergometrine or syntometrine 1ml has already been administered and this may be repeated intravenously.
BY MUKEREM.A 2007
Obstetric emergency cont…
c. Empty the uterus
If the uterus is atonic following delivery of the placenta light fundal pressure may be used to expel residual clots whilst a contraction is stimulated.
The placenta and membranes must be re –examined for completeness since retained fragments are often responsible for uterine atony.
Empty the bladder. BY MUKEREM.A 2007
Obstetric emergency cont…
3. Resuscitate the mother
A. Intravenous infusion
B. As an emergency measure the mother’s legs may be lifted up in order to allow blood to drain from them in to the central circulation. The foot of the bed should not be raised as this encourages pooling of blood in the uterus which prevents the uterus contracting.
C. Blood transfusion BY MUKEREM.A 2007
Obstetric emergency cont…
Bimanual compression of the uterus
If bleeding continues bimanual compression of the uterus may be necessary in order to apply pressure to the placental site.
BY MUKEREM.A 2007
Bimanual Compression of the Uterus
• Wearing HLD gloves, insert hand into vagina; form fist.
• Place fist into anterior fornix and apply pressure against anterior wall of uterus.
• With other hand, press deeply into abdomen behind uterus, applying pressure against posterior wall of uterus.
• Maintain compression for 20-30 min or until bleeding is controlled and uterus contracts.
BY MUKEREM.A 2007
Obstetric emergency cont…
External aortic compression
Transabdominal compression of the aorta.
done in preparation for laparotomy if required.
BY MUKEREM.A 2007
Compression of Abdominal Aorta
• Apply downward pressure with closed fist over abdominal aorta through abdominal wall (just above umbilicus slightly to patient’s left)
• With other hand, palpate femoral pulse to check adequacy of compression
– Pulse palpable = inadequate
– Pulse not palpable = adequate
• Maintain compression until bleeding is controlled or until she reaches the operation theatre
BY MUKEREM.A 2007
QUESTION ???
If a woman with postpartum hemorrhage has no signs of atonic uterus, what should you do?
BY MUKEREM.A 2007
Obstetric emergency cont…
Traumatic PPH
Defn:- This is bleeding from a laceration of the cervix, vaginal wall, episiotomy, or even from ruptured uterus or a combination of all.
This may occurs in:
Delivery through partially dilated cervix
Instrumental delivery
Difficult delivery. eg. Face to pubis or after coming head of a breech
BY MUKEREM.A 2007
Obstetric emergency cont…
Management
1. When bleeding is from a tear you will suspect it because of the history of the labor.
2. Clamp the bleeding point if possible or suture it.
3. Make sure the uterus is not ruptured
BY MUKEREM.A 2007
Obstetric emergency cont…
4. If you can suture the laceration and the bleeding stops your problem is over just make sure that the uterus is well contracted.
5. If the bleeding is from a bruised cervix then place a pack against it for a few minutes.
6. If bleeding is from ruptured uterus transfer to the hospital as soon as possible go with patient or send a full written report.
BY MUKEREM.A 2007
Obstetric emergency cont…
Differential point between atonic and traumatic PPHAtonic PPH
1. Uterus feels lax or soft (not contracted) traumatic PPH 2. Bleeding start after a few minutes 1. Uterus is contracted firmly
2. Starts immediately
3. Bleeding from injured part
4. Blood is bright red colour .
5. Not treated
3. Bleeding is from the placental site 4. The blood is dark red colour5. May be treated with oxytocic drug
BY MUKEREM.A 2007
PPH due to Hypofibroinogenemia
Defn - This is bleeding from a clotting defect and the patient continues to bleed in spite of treatment for the other types of PPH
BY MUKEREM.A 2007
Obstetric emergency cont…
Causes of hypofibrinogenaemia PPH
Placenta abruption
Intrauterine fetal death (which is prolonged)
Pre eclampsia
Amniotic fluid embolism
Hepatitis
BY MUKEREM.A 2007
Obstetric emergency cont…
Management of hypofibrinogenaemia
1. Fresh blood transfusion
2. Fibrinogen
3. Doctor may order a special drug to clot the blood if available
BY MUKEREM.A 2007
Obstetric emergency cont…
Management of a severe PPH in a health centre (in remote areas) 1. Massage the uterus and expel the placenta if
possible 2. Stay with your patient and shout for help 3. Give ergometrine 0.5mg IV 4. Put up a drip 5. Empty bladder 6. If placenta is not out. Try to expel it by fundal
pressure with the contraction caused by the ergometrine
BY MUKEREM.A 2007
Obstetric emergency cont…
7. If not expel do manual removal
8. Continue to massage the uterus
9. Examine the placenta to see if it is complete
10. Check if the uterus is contracted
11. If still lax put 5 units of oxytocin in to drip. If still is not contracted another 5 unit may be added.
12. If bleeding is still not controlled bimanual compression method is done.
BY MUKEREM.A 2007
Obstetric emergency cont…
Management of Secondary PPH The following steps should be taken
Call for help Rub up a contraction by massaging the uterus if it is still palpable Express any clots Encourage mother to empty her bladder Give an oxytocic drug
- Ergometrine 0.5mg IV Keep all pads to assess the volume of blood lost If bleeding persists prepare mother for OR.
BY MUKEREM.A 2007
Obstetric emergency cont…
Complications of PPH •Hemorrhagic shock •Consumptive coagulopathy•Multiple organ failure (Renal failure)•Death•Need for internal iliac artery ligation and its complications•Need of hysterectomy and its complications (loss of more children)•Complications of blood transfusion•Sheehan’s Syndrome
BY MUKEREM.A 2007
QUESTION ???
• What measures can we take to prevent postpartum hemorrhage?
BY MUKEREM.A 2007
PREVENTION
CLIENT CARE
– Prevent Prolonged Labor
– Active Management of the Third Stage of Labor (AMTSL)
– Avoid perineal/vaginal trauma
– Monitor closely
EMERGENCY PREPAREDNESS
– Have emergency PPH pack ready
Summary
• ALL women in labor are at risk of PPH!
• Atonic uterus is the most common cause of primary PPH.
• Rapid action in response to PPH is critical!
• PPH is a life threatening complication which must be managed promptly and effectively.
• Prevention is the best management – AMTSL has been proven to reduce the incidence
of PPH
BY MUKEREM.A 2007
Case Study
• Adisa Mohammed was reched to your clinic by her family. She delivered at home 2 hrs ago and has since been bleeding profusely. She is now very weak. You are the health providers at the clinic:
– What first steps will you take and why?
– What rapid assessments will you undertake (history and examination) and why?
BY MUKEREM.A 2007
Case Study (cont.)
• You note that she is very pale and barely alive. Her BP is 80/50 mmHg and Pulse 110/ min. Her uterus is lax and she is still bleeding actively PV. You are told that the placenta was delivered after the baby was born.
– What next resuscitative actions and assessments will you undertake and why?
BY MUKEREM.A 2007
BY MUKEREM.A 2007