Post Partum H haemorrhage presentation.ppt

Post Partum H haemorrhage

1. POST PARTUM HEMORRHAGE

2. Session Objectives
2
By the end of this session, the students will be able to:

Explain the Pathophysiology of postpartum
haemorrhage(PPH)

Identify the Risk factors and causes of PPH

Discuss the Classifications of PPH

Describe the Clinical manifestations and management
of PPH
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3. Defnition
3

Post partum Hemorrhage:- Is vaginal bleeding in excess of
500mls following vaginal delivery and 1000mls following c/s or
any amount sufficient enough to cause cardiovascular
compromise/hemodynamic instability.
Estimated amounts of blood loss are notoriously low, often half
the actual loss.
The lower the Hb level the poorer is the woman’s tolerance of
blood volume loss.
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4. Cont….
4

More than half of all maternal deaths occur within
24 hours of childbirth, mostly due to excessive
bleeding.

Uterine atony is the major factor of postpartum
haemorrhage (PPH) which causes more than one-
quarter of all maternal deaths worldwide

It is unpredictable – be prepared!
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5. Pathophysiology

Physiologic changes during pregnancy, including:-

An increase in uterine blood flow from approximately 100
mL/min in a nonpregnant uterus to 700 mL/min

Coagulation changes resulting in a hypercoagulable state

Postpartum changes (eg, myometrial contraction and local
decidual hemostatic factors)

Therefore, conditions that lead to a failure of these
mechanisms can result in PPH.
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6. RISK FACTORS

Preeclampsia.

Nulliparity.

Multiple gestation.

Previous Caesarean section

Prolonged third stage (>30min)

Assisted delivery.

Grand multiparty.

Placenta previa.

Polyhydramnious.

Episiotomy.
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7. THE CAUSES
7

Atonic uterus(Tone)

Retained placenta or fragments(Tissue)

Tears of uterus, cervix, vagina, perineum(Trauma)

Thrombin(Coagulation defects)

Inversion of uterus

Infection (delayed PPH)
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8. Classifications of PPH

Primary postpartum haemorrhage:- includes all
occurrences of PPH within 24 hours after delivery.

Secondary postpartum haemorrhage:- includes all cases of
PPH occurring between 24 hours and six weeks postpartum.

Secondary PPH can occur at any time from 24 hours after
delivery up to the sixth postnatal week, but the most common
time is between 7 and 12 days after delivery
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9. Primary PPH

Bleeding can occur at any time from the birth of the baby up to 24
hours after delivery.

A warning sign is that the uterus is not well contracted.

Sometimes the bleeding is not entirely visible, in which
case the uterus will feel bulky and the fundus will be higher than
normal and rising.

In these cases signs of hypovolemic shock may be the first
indications of a problem.
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10. Primary PPH Cont…
The causes of primary PPH include:

Atonic uterus (due to retained placenta or membranes);

Genital trauma (including both spontaneous trauma and trauma
caused by treatment or

Interference, e.g. instrumental delivery including Caesarean
section, episiotomy);

Primary haematological disorders (e.g. von Willebrand’s or
other clotting factor deficiency);

Disseminated intravascular coagulation (rare);

Inversion of the uterus (rare)
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11. Secondary PPH
Is bleeding from the genital tract, in excess of that expected
from normal lochia, after 24 hours and during the first six
weeks following delivery.
The uterus does not involute properly.
Puerperal sepsis makes the danger of secondary PPH greater.
Signs of infection may include:
a, Offensive lochia
b, Fever
c, Tachycardia
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12. Secondary PPH Cont….
The causes of secondary PPH are:-

Retained fragments of placenta or membranes;

Shedding of dead tissues following obstructed labour (this may
involve cervix, bladder, rectum);

Breakdown of uterine wound (after Caesarean section or
ruptured uterus).
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13. Why is PPH such a problem?

Postpartum haemorrhage can be a very serious emergency.

The condition of the mother can deteriorate alarmingly in a matter
of seconds.

Because haemorrhage can follow the most normal of
deliveries, midwives and other health professionals must be
prepared both to diagnose and to expedite treatment without
sophisticated medical aids.

Prompt treatment may be lifesaving.
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14. Cont…..

PPH remains one of the most common causes of maternal
death in all countries.

Deaths usually occur as a result of lack of appropriate care
and skills in recognizing the signs of haemorrhage and
failure to take prompt and appropriate action.
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15. Effects of severe blood loss on the body

Women can lose up to 500 ml of blood in one minute.
The effects of severe blood loss are:

General effects of loss of blood in the circulation:

Effects on vital organs:
– kidneys: renal shutdown and cortical necrosis
– Lungs: air hunger
– Brain: loss of consciousness, nausea, pituitary necrosis
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16. Cont….

The long-term effects of severe blood loss include Sheehan’s
syndrome, caused by hypovolaemia, which causes necrosis
of the pituitary gland

This condition affects endocrine function and there will be
failure of lactation and premature ageing.
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17. Clinical Manifestations of PPH

Heavy vaginal bleeding

Drop in blood pressure or signs of shock ( blurred vision;
chills, cold clammy skin, fast heartbeat; feeling confused,
dizziness, sleepy or weak; or feeling faint)

Nausea

Pale skin

Swelling and pain around the vagina or perineum.
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18. MANAGEMENT
18
This is a life threatening complication which must be managed
promptly and effectively

Get all the help you can.

Prevention is the best management.

The management of PPH depends on the cause.

However, the main priority of management is to recognize
that haemorrhage is occurring and institute prompt action.

It is vital that all midwives promptly recognize the signs of
hypovolaemia (reduced blood volume) and shock
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19. Signs of Early hypovolemic shock

Awake, aware, anxious

Feeble and fast pulse (110 per minute or more)

Slightly fast breathing (30 respirations per minute or more)

Pale

Relatively low blood pressure (systolic less than 90 mmHg)

Reduced urine output, but >30cc per hour
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20. Signs of Late hypovolemic shock

Confused or unconscious

Very fast and weak pulse

Extremely fast and shallow breathing

Pale and cold

Very low blood pressure (systolic less than 60 mmHg) Urine
output <30cc per hour
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21. Cont….
21

It is vital that everyone concerned with women in
labour is able to recognize the signs of hypovolemic
shock as not all causes of haemorrhage in labour can
be predicted

Good management of hypovolaemic shock is
essential if the woman is to survive
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22. Treatment of primary PPH
The six priorities in treatment are:

Call for help (to assist in controlling the bleeding)

Assess the patient’s condition

Find the cause of the bleeding

Stop the bleeding

Stabilize or resuscitate the woman

Prevent further bleeding.
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23. Treatment of secondary PPH
Priorities in treating secondary PPH

The priorities in treating secondary PPH are similar to those in treating
primary PPH, but the woman will usually be at home.
1. Admit the woman to hospital urgently or – if necessary – as an emergency.
2. Assess her condition and, if in a remote area, start treatment if possible
before transfer.
3. Give ergometrine 0.5 mg or methergyn IM or IV (where there is no
contraindication).
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24. Cont….
4. Take blood for haemoglobin check, blood grouping and
cross-matching.
5. Put up an IV. Use normal saline or Ringer’s lactate initially.

If the woman is in shock, run it fast (1 litre in 15 minutes) until
she stabilizes (you may need to infuse up to 3 litres to correct the
shock
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25. Cont…
6. If bleeding is severe, add 40 units oxytocin per litre to the IV
and run it at 40 drops per minute (the health care provider may
need to set up a second IV line)
7. In cases of severe shock use plasma expanders or blood
transfusion if available
8. Start broad-spectrum antibiotics in high doses.
9. If possible, prepare the patient for immediate examination
under anaesthetic
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26. GENERAL MANAGEMENT
STEPS
26

Call for help

Perform Rapid Evaluation (Vital Signs, Pallor & Cause)

Massage Uterus

If shock is present start Immediate Resuscitation
Start IV Infusion, establish two IV lines if necessary.
Give Oxygen
Elevate foot end and Keep woman warm.

Massage the uterus to expel blood and blood clots.

Give oxytocin 10 units IM.
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27. GENERAL MANAGEMENT
STEPS; contd…
27

Take blood (5 mL) for hemoglobin/ hematocrit, etc

Catheterize the bladder.

Check to see if the placenta has been expelled and
examine the placenta to be certain it is complete.

Examine the cervix, vagina and perineum for tears.

Provide specific treatment for the specific cause
identified.

After bleeding is controlled (24 hours after bleeding
stops), determine haemoglobin or haematocrit to check
for anaemia:
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28. IV FLUID REPLACEMENT:
IN SHOCK
28

Start resuscitation with intravenous fluids (N/S or R/L)

Use large bore cannula (16 or bigger)

Volume to give
First 1000 ml ( 500 ml x 2) rapidly in 15-20 mins
GIVE AT LEAST 2000 ml ( 500 X 4 ) IN FIRST HOUR
Aim to replace 3x the volume of estimated blood loss.
If condition stabilizes adjust rate to 1000 mls / 6 hrly

Monitor BP, Pulse every 15 mins and Urine output hourly
(> 30 ml /hr)

If the cause is not known or bleeding continues despite
treatment, refer her urgently continuing supportive care.
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29. MANAGEMENT:
Rapid Assessment
29
Assess for s/s of following conditions and perform
appropriate action before proceeding with additional care:
Uterine atony (uterus soft/not contracted)
Tears of perineum, vagina, cervix
Retained placenta or placental fragments
Ruptured or inverted uterus
Delayed postpartum hemorrhage (PPH)
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30. Atonic Postpartum Haemorrhage

This is bleeding from the placental site when the uterus
is not well contracted.

This is a failure of a myometrium at the placental site
to contract and retract and to compress torn blood
vessels and control blood loss by a living ligature action

Atonic uterus is the most common cause of primary PPH
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31. Causes of Atonic PPH

Incomplete separation of placenta

Retained cotyledon, placental fragments or
membranes

Prolonged labour & obstructed labour resulting in
uterine inertia

Multiple pregnancy, over stretching of the uterus
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32. Cont….

Adherent placenta that has partially separated

Precipitate labour

Full bladder

Fibroids

Grand multiparty
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33. Management of atonic PPH

ATONIC UTERUS! first action is massage uterus

Continue massage uterus and expel clots if there is.

Give oxytocin 10 IU, or ergometrine 0.2mg IM/IV

If bleeding continues , check other causes

Open IV line and add oxytocin 20IU in 1L and run
60drop/min
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34. 34
Oxytocic Drugs Dosage, Routes and Contraindications
DRUG DOSE &
ROUTE
CONT.
DOSE
MAX
DOSE
CONTRA-
INDICATION
OXY-TOCIN IM 10 U OR
IV 20 U in 1000 ml
NS at >60 drp/min
OR 5-10 U slow IV
push
IV 20 u in
1000ml at 40
drps /min
Not > 40 U
infused at
rate of 0.02-
0.04 U/min.
No IV admin.,
not even slow IV
push unless IV
fluids are
running
ERGO-
METRINE
IM OR IV
Slowly 0.2mg
Repeat 0.2mg
after 15 mins if
required every
four hours
Five doses
(Total 1.0
mg)
High BP
Heart Disease
MISOPROS
TOL
(CYTOTEC)
ORAL/SL
INTRAVAG
RECTAL
800mcg
200mg
Every 4 hours
2000mg Asthma
Heart Dis*
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35. Cont….

If bleeding continues: Perform bimanual compression of
uterus OR

Compression of abdominal aorta (compress for 5min and
then check bleeding and continue for 20 min)
Method for Bimanual compression

Insert hand into vagina; form fist.

Place fist into anterior fornix and apply pressure against
anterior wall of uterus.
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36. Cont….

With other hand, press deeply into abdomen behind uterus,
applying pressure against posterior wall of uterus.

Maintain compression until bleeding is controlled and
uterus contracts

Give additional oxytocics if available.
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37. Bimanual Compression
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38. 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
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39. Compression of Abdominal Aorta
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40. Cont…

After bimanual or aortic compression ,if bleeding
continues ,facilitate urgent referral.

If bleeding stops, proceed with additional care plus
measure woman’s hemoglobin in 4 and 24 hours

If no s/s of uterine atony: Examine vagina, perineum,
cervix for tears
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41. Traumatic Post Partum Haemorrhage

This causes 20% of primary PPH

It includes bleeding from a laceration of the cervix, vaginal
wall tears, episiotomy extensions and uterine rupture.
Risk factors are:-

Precipitate labour, instrumental delivery

Macrosomia, shoulder dystocia, manual removal of placenta
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42. Management of traumatic PPH

When bleeding is due to the tear, explore the area for the
tear, clamp the bleeding point and suture.
If extensive tears (3
rd
or 4
th
degree), facilitate urgent
referral/transfer
If 1
st
or 2
nd
degree tears, perform repairs

Make sure that the uterus is not ruptured.

If the tear is sutured and bleeding stop make sure that the
uterus is well contacted.
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43. Cont…..

If bleeding is from bruised cervix place a pack against it
for a few minutes to an hour, if so leave catheter in situ.

If bleeding is from ruptured uterus, It depends on the
condition to determine mode of management either repair
or removal of the uterus.
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44. Hypofibrinogenaemia

This is bleeding due to a clothing defect and the patient continues to bleed
in spite of treatment for the other causes of PPH.
Causes

Placental abruption

Intrauterine death which is prolonged

Amniotic fluid embolism

Pre- eclampsia, eclampsia

Intra uterine infection
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45. Management of Hypofibrinogenaemia
The best treatment is:

Fresh blood transfusion

Give oxygen and resuscitate with IV drip

IV syntocinon if uterus is lax
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46. Retained Placenta
Definition: - When the placenta remains undelivered
after a Specified period of time usually half to one hour
following the delivery of fetus it lefts in the upper uterine
segment.
Cause

Poor uterine contraction

Mismanagement of third stage of labour
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47. Management of Retained placenta
1. Careful observation – watch the patient and note signs
of separation of placenta like Vaginal bleeding, bladder
should be emptied, bleeding should be controlled
2. Gently try to deliver by controlled cord traction

Repeat Oxytocin 10u IV: If no success of CCT in 30’
3. If not manual removal followed by antibiotics
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48. Manual removal of Placenta

Give Pethidine and diazepam or Ketamine

Give antibiotics: (Ampicillin 2g + Metronidazole 500mg)

Perform procedure and examine placenta for completeness

Give Oxytocin 20 U/1000 mls NS or RL at 60 dpm

Monitor BP, Pulse, Pad and Urine output closely

Add Ergot or Prostaglandin if bleeding continues

Transfuse PRN and treat for anaemia
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49. Manual removal of Placenta
Method:-Place one hand on the fundus to support the uterus

let the other hand follow the cord until it reaches the placenta

Move hand up to the edge of placenta and find where it is
partiality separated (remember it would not be bleed if it is not
separated) then move your hand up and down,

Until you have it, completely separated then bring it out in
your hand, examine it
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50. Anesthesia and Analgesia
for short procedures <30 mins

Pethidine 1mg/kg BW
IM (max 100mg dose )
Give Promethaxine (Phenergan) if vomiting occurs)
Plus

Diazepam 10mg IV at rate of 1mg every two
mins.
Monitor RR closely Stop if
RR<10/min

DO NOT MIX THE TWO DRUGS IN SAME
SYRINGE
50
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51. Cont…

If bleeding continued facilitate urgent referral/transfer

If bleeding stops, continue with basic care

Two to three hours after bleeding stops, measure the
woman’s hemoglobin

If Hgb less than 7g/dL, facilitate urgent transfer

If Hgb is 7-11g/dL, treat anemia with iron/folate

DO NOT give ergometrine as it causes tonic contractions

AVOID forceful CCT and fundal pressure as they may cause
uterine inversion
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52. Cont….

If s/s of retained placental fragments:

Give uterotonic drug according to guidelines

Assess cervix for dilation

If cervix is not dilated, facilitate urgent referral/transfer

If cervix is dilated, perform appropriate management to remove
fragments/tissue

If bleeding continues, perform bimanual compression of uterus OR
compression of abdominal aorta
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53. Adherent Placenta

When the placenta has still not speared and left the
upper uterine segment one-hour after delivery .

This occurs when the placenta has grown into the
uterine muscle
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54. Types
1. Placenta accreta- into muscles
2. Placenta increata- deep in muscle
3. Placenta percreta- through muscle
Management

Is usually hysterectomy

Some times removed under general anesthesia.
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55. Uterine Inversion

Refers to the collapse of the fundus into the uterine
cavity.

Is uncommon but potentially life-threatening obstetric
complication.
.
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56. Causes

Atony of placental site over the fundus

Mismanagement of 3rd stage of labour

Combined fundal pressure with cord traction

Use of fundal pressure while uterus is atonic
Common risk factors: - Prolonged labour,fetal macrosomia,
uterine malformations, short umbilical cord, Placenta accreta,
increta, or percreta, Chronic endometritis


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57. Classification of uterine Inversion

Puerperal uterine inversion

Acute, with in 24 hours

Sub acute, 24hours to 30days

Chronic, > 30 days after delivery

Gynecologic uterine inversion
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58. Degree of Uterine Inversion

First degree: -Fundus reaches internal OS but it
remains above the level of internal OS

Second degree: -The body of the uterus passes
through the Cx but remains in the vagina

Third degree: -The body, fundus,Cx all are visible
at the vulva.
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59. Conn…
Other method of classification:

Incomplete – fundus in uterine cavity

Complete – fundus in the vagina

Prolapse – fundus outside the vagina
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60. Clinical presentation
Acute & Subacute uterine inversion

Early PPH( in 94% of cases)

Mass per vagina

Shock(in 40% of cases)

Inability to palpate uterine fundus

Inability to visualize the cervix
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61. Conn…
Chronic uterine inversion

Persistent vaginal bleeding

Vaginal discharge

Low back pain

Pelvic pressure

Low grade fever
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62. Diagnosis

Mainly clinical: by sign and symptoms

U/S
Management of uterine inversion

Manage shock

Uterine replacement

Administration of utero-tonic agents
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63. Manage shock

Call for help

IV fluid resuscitation, on both hands

Hct, blood group & Rh, X- matched blood

Administer oxygen, Insert a Foley catheter
Replace the uterus

Administer tocolytics to promote uterine relaxation
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64. Conn…

Nitroglycerine 0.25 - 0.5mg IV

Terbutaline 0.1- 0.25mg IV

MgSO4 4 – 6g IV over 20minutes
Techniques to replace the inversion

Manual replacement

Hydrostatic correction

Lapratomy
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65. Administration of uterotonic
agents

Administer one of the uterotonics

Ergometrine 0.2mg IM

Oxytocin drip 40 – 60IU/1000ml Ringers

Misoprostol 0.4mg PO
If s/s of ruptured uterus, facilitate urgent
referral/transfer
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66. PREVENTION
CLIENT CARE
Prevent Prolonged Labor
Active Management of the Third Stage of Labor
Avoid perineal/vaginal trauma
Monitor closely
EMERGENCY PREPAREDNESS
Have emergency PPH pack ready
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67. ICM/FIGO Joint Statement on Active Management
of the Third Stage of Labor (AMTSL)
67

AMSTL has been proven to reduce the incidence of
postpartum hemorrhage, reduce the quantity of blood loss
and reduce the use of transfusion

AMSTL should be offered to all women who are giving
birth

Every attendant at birth needs to have the knowledge,
skills, and critical judgement needed to carry out AMSTL
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68. Components of AMTSL
AMTSL as a prophylactic intervention is composed of a
package of three components or steps:
1)Administration of a uterotonic, preferably oxytocin,
immediately after birth of the baby;
2)Controlled cord traction (CCT) to deliver the placenta;
3) Massage of the uterine fundus after the placenta is
delivered
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69. PREVENTION: Be prepared
69
ALL women are at risk of PPH!
Women who are predisposed to fatal consequences of PPH include
women with:
Over distended uterus (Twins, big baby, Polyhydraminios)
Prolonged labour
Severe Pre-eclampsia/Eclampsia
Prolonged Intrauterine Death
APH ( weakens)
Anemia (weakens)
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