Secondary postpartum haemorrhageSecondary postpartum haemorrhage

-Secondary postpartum hemorrhage is any -Secondary postpartum hemorrhage is any abnormal or excessive bleeding from the abnormal or excessive bleeding from the genital tract occurring between 24 hrs and 12 genital tract occurring between 24 hrs and 12 weeks postnatally. weeks postnatally.

-It is most likely to occur between 10 and 14 -It is most likely to occur between 10 and 14 days after birth. days after birth.

-Bleeding is usually due to retention of a -Bleeding is usually due to retention of a fragment of the placenta or membranes, or the fragment of the placenta or membranes, or the presence of a large uterine blood clot. presence of a large uterine blood clot.

--TypicallyTypically: : -occurring during the second week-occurring during the second week - the lochia is heavier than normal- the lochia is heavier than normal - and will have changed from a serous pink or - and will have changed from a serous pink or

brownish loss to a bright red blood loss.brownish loss to a bright red blood loss. - The lochia may also be offensive if infection - The lochia may also be offensive if infection

is a contributory factor.is a contributory factor.

- Sub involution- Sub involution - pyrexia- pyrexia - tachycardia . - tachycardia . ManagementManagement •• call a doctorcall a doctor •• reassure the woman and her support person(s)reassure the woman and her support person(s) •• rub up a contraction by massaging the uterus if rub up a contraction by massaging the uterus if

it is still palpableit is still palpable •• express any clotsexpress any clots

encourage the mother to empty her bladderencourage the mother to empty her bladder •• give a uterotonic drug such as give a uterotonic drug such as

ergometrine maleate by the intravenous or ergometrine maleate by the intravenous or intramuscular routeintramuscular route

•• keep all pads and linen to assess the keep all pads and linen to assess the volume of blood lost.volume of blood lost.

-The doctor, midwife or paramedic who -The doctor, midwife or paramedic who attends will start an intravenous infusion and attends will start an intravenous infusion and ensure that the mother's condition is stable first ensure that the mother's condition is stable first

-Careful assessment is usually undertaken prior to the -Careful assessment is usually undertaken prior to the uterus being explored under general anaesthetic.uterus being explored under general anaesthetic.

- The use of ultrasound as a diagnostic tool.- The use of ultrasound as a diagnostic tool. - If retained products of conception cannot be seen on - If retained products of conception cannot be seen on

a scan, the mother may be treated conservatively with a scan, the mother may be treated conservatively with antibiotic therapy and oral ergometrine. antibiotic therapy and oral ergometrine.

-The hemoglobin should be estimated prior to -The hemoglobin should be estimated prior to discharge.discharge.

- If it is below 9 g/dL, options for iron replacement - If it is below 9 g/dL, options for iron replacement should be discussed with the woman. should be discussed with the woman.

-increased intake of iron-rich foods, iron -increased intake of iron-rich foods, iron supplements or, in extreme cases, blood supplements or, in extreme cases, blood transfusion. transfusion.

-It is also important to discuss the common -It is also important to discuss the common symptoms that may be experienced as a result symptoms that may be experienced as a result of anaemia following PPH, including extreme of anaemia following PPH, including extreme tiredness and general malaise. tiredness and general malaise.

-hemoglobin levels checked & monitored.-hemoglobin levels checked & monitored.

Haematoma formationHaematoma formation -PPH may also be concealed as the result of progressive -PPH may also be concealed as the result of progressive

haematoma formation.haematoma formation. - sites : - sites : -the perineum -the perineum - lower vagina- lower vagina -broad ligament -broad ligament - vault of the vagina. - vault of the vagina. -A large volume of blood may collect insidiously (up to 1 L).-A large volume of blood may collect insidiously (up to 1 L). - Involution and lochia are usually normal- Involution and lochia are usually normal - the haematoma has to be drained in theatre under a general - the haematoma has to be drained in theatre under a general

anaesthetic.anaesthetic. -Secondary infection may occur.-Secondary infection may occur.

Care after a postpartum Care after a postpartum haemorrhagehaemorrhage -continues support -continues support -partner reassurance. -partner reassurance. -encourage breast-feeding -encourage breast-feeding