“ Management of postpartum haemorrhage ”

Post partum haemorrhage

1. SEMINAR ON POST PARTUM HAEMORRHAGE PRESENTED BY- Ms Priyashree Pal 4 th yr B.Sc Nursing

2. INTRODUCTION Third stage is the most crucial stage for the mother. Fatal complications may appear unexpectedly in an otherwise uneventful first / second stage.

3. Complications of third stage of labour:- POSTPARTUM HAEMORRHAGE RETENTION OF PLACENTA SHOCK-HAEMORRHAGIC OR NON-HAEMORRHAGIC PULMONARY EMBOLISM UTERINE INVERSION

4. DEFINITION QUANTITATIVE DEFINITION- It refers to the amount of blood loss in excess of 500ml following birth of the baby. CLINICAL DEFINITION- Any amount of bleeding from or into the genital tract following birth of the baby up to the end of the puerperium which adversely affects the general condition of the patient evidenced by rise in pulse rate and falling blood pressure

5. Depending upon the amount of blood loss, PPH can be:- MINOR (<1 L) SEVERE (>2L) MAJOR (>1L)

6. INCIDENCE The incidence widely varies mainly because of lack of uniformity in criteria used in definition and the extent of use of prophylactic ergometrine. 1-5% amongst hospital deliveries.

7. CLASSIFICATION

8. 1. PRIMARY POST PARTUM HAEMORRHAGE It is the haemorrhage occurring during the third stage of labour and within 24 hrs of delivery. Third stage haemorrhage- bleeding occurs before expulsion of placenta. True PPH- bleeding occurs subsequent to expulsion of placenta

9. CAUSES

10. a. ATONIC UTERUS(80%) Refers to imperfect contraction and retraction of the uterus which cannot compress the torn sinuses after separation of placenta leading to bleeding@ 500-800ml/min.

11. ATONIC UTERUS

12. CAUSES OF UTERINE ATONICITY

13. 1. Grand multipara 2. Over distension of the uterus

14. 3.Incomplete separation of the placenta 4.Mismanaged third stage of labour

15. 5.Malnutrition and anemia

16. 6.Precipitated labour 7.Prolonged labour

17. 8.Anesthesia

18. 9.Malformation of the uterus

19. 10.Uterine fibroid

20. 11.Constriction ring

21. 12.Placenta praevia

22. 13.Placental abruption

23. 14.A full bladder

24. b. TRAUMATIC HAEMORRHAGE(20%) Trauma involves usually the cervix, vagina, perineum (episiotomy wound and lacerations), para-urethral region and rarely uterine rupture. CAUSES Perineal, vaginal and cervical tears Lower segment tears Uterine rupture Vulval injuries

25. 1.Perineal, vaginal and cervical tears 2.Vulval injuries

26. 3.Cervical tear

27. 4. Uterine rupture 5.Lower segment tears

28. c. BLOOD COAGULATION DISORDERS It may be due to diminished procoagulants or increased fibrinolytic activity. The firmly retracted uterus can usually prevent bleeding even if serious clotting disorders are present. CAUSES:-

29. Abruptio placentae

30. Jaundice in pregnancy

31. Thrombocytopenic purpura

32. Intra uterine death

33. HELLP Syndrome

34. Disseminated intravascular coagulation

35. Excessive fibrinolysis

36. Combination of Atonic and traumatic causes. d. Mixed

37. CLINICAL FEATURES Vaginal bleeding- slow or copious flow Pallor Rising pulse rate Falling blood pressure Altered level of consciousness-restless or drowsy Enlarged uterus- boggy on palpation Maternal collapse

38. Anxiety Complaint of thirst Sinking quickly into a condition of syncope with shallow respiration Death The effect of blood loss depends on:- Pre –delivery hemoglobin level Degree of pregnancy induced hypervolemia Speed of blood loss

39. DIAGNOSIS State of uterus as felt per abdomen Traumatic hemorrhage- uterus well contracted Atonic hemorrhage- uterus flabby , becomes hard on massaging

40. PREVENTION ANTENATAL Improvement of the health status Hemoglobin level>10 gm/dl Screening of high risk patients (twins, polyhydramnios, grand multipara, APH, severe anemia) Delivery of high risk patients in well equipped hospitals Blood grouping

41. 2.INTRANATAL Slow delivery of baby- push rather than pull Expert obstetric anesthetist -local or epidural in case of forceps, ventouse or breech delivery Spontaneous separation and delivery of placenta even during caesarean section. Active management of third stage of labour. Avoid the temptation of fiddling/ kneading with the uterus or pulling the cord.

42. Examination of the placenta and membranes as routine. Oxytocin infusion should be continued at least 1 hr after delivery. Exploration of uterovaginal canal for evidence of trauma Observation of patient for about two hours after delivery Send patient to ward only when uterus becomes hard and contracted.

43. MANAGEMENT PRINCIPLES OF MANAGEMENT To empty the uterus of its contents and to make it contract. To replace the blood loss , on occasions patient may be in shock, in that case patient is managed for shock first. To ensure effective haemostasis in traumatic bleeding.

44. STEPS OF MANAGEMENT PLACENTAL SITE BLEEDING Palpate the fundus and massage the uterus to make it hard. Ergometrine 0.25mg or Methergin 0.2mg IV or Oxytocin 10 units IM. Start a normal saline/RL drip Arrange for blood transfusion if necessary

45. To catheterize the bladder if full. to give antibiotics (Ampicillin 2 gm and Metronidazole 500mg) Signs of placental separation Placenta not separated Shock Fundal pressure Cord traction Manual removal Resuscitation

46. 2. TRAUMATIC BLEEDING Exploration of utero -vaginal canal under general anesthesia after the placenta is expelled and haemostatic sutures are applied on the offending sites.

47. STEPS OF MANUAL REMOVAL OF PLACENTA Step 1- General anesthesia or deep sedation with 10mg Diazepam IM. Lithotomy position Step 2- One hand is introduced into the uterus after smearing with antiseptic solution in cone shaped manner. Other hand making the cord taut. Fingers of uterine hand locate the margin of the placenta.

48. Step 3- Counter pressure on uterine fundus by the hand placed over the abdomen till complete separation of placenta. Step 4- When placenta margin is reached , fingers are insinuated between the placenta and the uterine wall with back of hand in contact with the uterine wall.

49. Step 5- Extraction of placenta by cord traction by other hand. Uterine hand still inside to explore cavity to find any residual bits or cotyledons of placenta. Step 6- IV Ergometrine 0.25 mg is given Uterine hand gradually removed Massage with external hand Inspection of cervico-vaginal canal Step 7- Inspection of placenta and membranes for completeness Make sure uterus is hard and contracted.

50. MANAGEMENT OF TRUE POST PARTUM HAEMORRHAGE PRINCIPLES:- simultaneous approach Communication Resuscitation Monitoring Arrest of bleeding

51. MANAGEMENT IMMEDIATE MEASURES Call for extra help Put in 2 large bore IV cannula Keep patient flat and warm. Send blood for group and cross-matching and ask for 2 units of blood. Infuse rapidly 2L of NS / hemaccel Give oxygen by mask 10-15 L/min.

52. Start 20 units of Oxytocin in 1L of NS IV @60 drops/min Monitor- Pulse Blood pressure Urine output Drugs- type, dose and time Type and amount of fluid patient has received Central venous pressure

53. ACTUAL MANAGEMENT A- ATONIC Step 1- Massage the uterus to make it hard and express the blood clot

54. Methergin 0.2mg is given IV Morphine 15mg may be given IM Inj. Oxytocin drip is started at the rate of 30-40 drops per min. Empty the bladder Examine expelled placenta and membranes.

55. Step 2-In refractory cases:- Inj. 15 methyl PGF2 α 250 μ g IM in the deltoid muscle every 1-2 hrs. Misoprostol 1000 μ g per rectum is effective

56. Step 3- Uterine massage and bimanual compression.

57. Step 4- Uterine tamponade Tight intrauterine packing Insertion of Sengstaken Blakemore tube into uterine cavity and inflating balloon with 200ml of NS

58. Tight intrauterine packing

59. Sengstaken Blakemore tube and inflating balloon

60. Step 5- Surgical methods to control PPH are many:- Ligation of uterine arteries Ligation of ovarian and uterine artery anastomosis Ligation of anterior division of internal iliac artery(unilateral or bilateral)

61. B-Lynch brace suture and haemostatic suturing

62. Angiographic arterial embolisation

63. Step 6- Hysterectomy

64. TRAUMATIC POST PARTUM HEMORRHAGE The trauma to perineum, vagina and the cervix is to be searched under good light by speculum examination and haemostasis is achieved by appropriate catgut sutures. The repair is done under general anesthesia .

65. TRAUMATIC POST PARTUM HEMORRHAGE

66. Secondary Post- Partum hemorrhage Any sudden loss of blood from the genital tract after the first 24 hrs postpartum and within 6 weeks of delivery. It is most likely to occur between 8 th and 14 th day after delivery

67. CAUSES

68. Caesarean section wound

69. Infection and separation of slough over a deep cervico-vaginal laceration.

70. Retained bits of cotyledon or membranes.

71. Endometritis and Subinvolution.

72. Withdrawal bleeding following estrogen therapy

73. Carcinoma cervix

74. Uterine inversion

75. Others-epithelioma, placental polyp, infected fibroid or fibroid polyp,.

76. CLINICAL FEATURES Lochia are heavier than normal Bright red loss Offensive if infection occurs Subinvolution of uterus Pyrexia and tachycardia Anemia

77. DIAGNOSIS Clinical features Laboratory examinations Ultrasonography

78. MANAGEMENT PRINCIPLES To assess the amount of blood loss and to replace the lost blood. To find out the cause and to take appropriate steps to rectify it. SUPPORTIVE THERAPY Blood transfusion, if necessary To administer ergometrine 0.5mg IM To administer antibiotics

79. CONSERVATIVE Careful watch for 24 hrs in hospital if bleeding is slight and no apparent cause is detected. ACTIVE TREATMENT Do not ignore small amount of bleeding. Remove the products by ovum forceps General curettage is done by using flushing curette. Ergometrine 0.5mg is given IM. Materials removed are to be sent for histological examination

80. Presence of bleeding from the sloughing wound of cervico-vaginal canal should be controlled by haemostatic sutures. May require laparotomy. Ligation of internal iliac artery. Hysterectomy

81. NURSING MANAGEMENT

82. NURSING ASSESSMENT Maternal history for risk factors. Evaluate for presence of clots expelled during voiding. Vital signs periodically Pulse pressure Intake and output Location and firmness of uterine fundus Palpate and percuss for bladder distension

83. Inspect for intactness of any perineal repair Breath sounds for signs of pulmonary edema Abdominal girth Effective hemostasis

84. NURSING DIAGNOSES Deficient fluid volume related to blood loss Anxiety related to unexpected blood loss and uncertainty of outcome Risk for infection related to blood loss and vaginal examination

85. PATIENT EDUCATION Educate about cause of hemorrhage. Importance of eating a balanced diet and taking vitamin supplements. Advise the women regarding feeling of tiredness and fatigue and to schedule daily rest periods. Sign and symptoms of hemorrhage for homecare. Ensure she has emergency numbers readily available. Follow up.

86. RECENT ADVANCEMENTS Prophylactic oxytocics reduce the risk of PPH by about 60% and the need for extra oxytocics by about 70%. O’Brien et al reported in a pilot study that Misoprostol 1000 μ g given rectally is an effective intervention in women with sever PPH unresponsive to standard uterotonic agents. The latter trials also concluded that Misoprostol is more effective than a combination of IM Syntometrine injection and Oxytocin infusion.

87. A recent survey from Norway has shown that 20% of obstetricians now use Misoprostol in the treatment of PPH. This is despite the fact that, until recently, no pharmacokinetic study had shown that Misoprostol is absorbed from the rectum. Within the last decade there has been renewed interest in new uterine tamponade procedures such as balloon compression and other procedures e.g. B- Lynch suture.

88. The easy-to-use, injection-ready format of Uniject ensures an accurate dose of Oxytocin in a nonreusable, sterile injection system with minimal preparation and minimum waste. The features and benefits of Oxytocin in Uniject will help programs launch innovative approaches to expand prevention and treatment of postpartum hemorrhage such as: Administration by skilled midwives, auxiliary nurses, or other trained lay providers. Use in areas of limited health facility infrastructure and/or health worker shortages. Overcoming acceptability concerns, including fear of injections, and safety concerns, regarding reuse of needles.

89. Uniject Oxytocin injection

90. CONCLUSION PPH is an Important cause of maternal morbidity. We now have new pharmacological and technical developments for prevention and treatment which can greatly reduce its incidence and sequelae. Wider use of thermostable prostaglandins like Misoprostol and dissemination of knowledge about new tamponade procedures can minimize its incidence and limit its serious sequelae.

91. The safety of the third stage of labour, and the incidence of PPH and its complications will remain linked however to the wider issues of reproductive health in general and more specifically to the funding and training needed to raise the standard of care offered to women in labour in many parts of the world.

92. THANK YOU