post partum haemorrhage.ppt how to access

Manage and medical diagnosis

1. Postpartum Haemorrhage
PRESENTED
BY
Dr Bellington Vwalika

2. THE PROBLEM
•More than half of all maternal deaths occur
within 24 hours of childbirth, mostly due to
severe bleeding.
•PPH accounts for about 25% of maternal
deaths world wide.
•Rapid action is critical for survival.
•Incidence varies from 2 to 8% among
hospitals

3. CAUSES OF DEATH FROM AUDITED REPORTS9.4
3.8
3.1
12.5
21.3
18.7
8.8
5.6
16.8
ABORTION
APH
AMN EMB
PIH/ECL
PPH
SEPSIS
ANEMIA
RUPTURED
UTERUS
OTHERS

4. Definition
•Vaginal bleeding in excess of 500ml or any
amount sufficient enough to cause cardiovascular
compromise.
•Primary and secondary PPH
•FACT
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.

5. THE CAUSES
•Atonic uterus
•Retained placenta or fragments
•Tears of uterus, cervix, vagina,
perineum
•Coagulation defects
•Inversion of uterus
•Infection (delayed PPH)

6. Risk factors
•Maternal age 35 0r over
•Delivery after APH
•Multiple pregnancy
•Polyhydramnios
•Past history of PPH

7. MANAGEMENT
•This is a life threatening complication
which must be managed promptly and
effectively.
•Get all the help you can.
•Prevention is the best management.

8. PREVENTION: Be prepared
•WHO IS AT RISK!
–Client with over distended uterus (Twins, big baby,
Polyhydraminios)
–Prolonged labour
–APH ( weakens)
–Severe Pre-eclampsia/Eclampsia
–Prolonged IUD
–Anaemia

9. BE PREPARED
CLIENT CARE
–Have IV access line in place -2
large bore cannulae
–Active Management of the third
stage
–Start Oxytocin infusion for 4
th
Stage
–Monitor closely
EMERGENCY PREPAREDNESS
–Have emergency PPH pack ready

10. GENERAL MANAGEMENT STEPS 1
•Have protocol in labour ward
•Callfor help
•Perform Rapid Evaluation(Vital Signs& cause
BP, pulse, RR, Pallor)
•Massage Uterus
•If shock is present start Immediate Resuscitation
Start IV Infusion 1 litre/15 min
Give Oxytocin 10Units IM ff 20u in 1litre NS
Take Blood for G& XM –20ml blood for XM and coagulation
studies
Give Oxygen
Elevate foot end

11. GENERAL MANAGEMENT 2
•Catheterize to monitor urine output
(<30ml/hr)
•Check Placenta for completeness
•Examine Birth canal for tears (EUA)
•Monitor closely for further bleeding
•When client stabilized Check HB
•Treat anaemia

12. IV FLUID REPLACEMENT : IN SHOCK
•START RESUSCITATION WITH CYSTALLOIDS FLUIDS :
NORMAL SALINE OR RINGERS LACTATE
•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 2-3X THE VOLUME OF ESTIMATED BLOOD LOSS.
–IF CONDITION STABILIZES THEN ADJUST RATE TO 1000 mls / 6 HRLY
•MONITOR BP PULSE EVERY 15 MINS AND URINE OUT PUT
HOURLY (> 30 ML /HR)
•AVOID DEXTRANS THEY INTERFERE WITH GROUPING
AND X MATCHING AS WELL AS WITH COAGULATION OF
BLOOD

13. •In massive haemorrhage order a minimum 6
units whole blood
•Do not give FFP or platelets until
haemorrhage has stopped or at least 5 units
of stored blood have been given

14. ATONIC UTERUS!
FIRST ACTION IS MASSAGE UTERUS
DRUG DOSE &
ROUTE
CONT.
DOSE
MAX
DOSE
PRECAU&
CI
OXYTOCIN IM 10 U
IV 20 U in
1000 ml NS
at 60drp/min
IV 20 u in
1000ml at 40
drps /min
NOT more
than 3 litres
of IV fluids
containing
Oxytocin
DO NOT
Give IV
Bolus
ERGOT 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

15. ATONIC UTERUS cont
DRUG DOSE &
ROUTE
CONT.
DOSE
MAX
DOSE
CAUTIONS
& CI
MISOPROSTOL
(CYTOTEC)
ORAL/SL
INTRAVAG
RECTAL
200-800mcg
(600mcg)
200mg
Every 4
hours
2000mg Asthma
Heart Dis*
PROST
F2a
IM only
0.25mg
0.25mg
Every 15
Minutes
Total 8
Doses=2 mg
Asthma
Heart Dis*

16. ATONIC UTERUS OTHER MEASURES
•BIMANUAL COMPRESSION
•AORTIC COMPRESSION
•CONDOM TAMPONADE
•SURGERY
Uterine artery ligation, catheter tamponade of both
uterine arteries
Utero-ovarian artery branch ligation
Hysterectomy

17. CONDOM TAMPONADE
N/S
INFLATE
CONDOM with
300-350MLS
Water
UTERUS
CONDOM
FOLEYS CATHETER
WATER
clamp
Big syringe

18. Treat cont..
--Other measures include
–Hyserectomy (subtotal)
–Ligation of internal iliac arteries
–Compression of the uterus –B-Lynch brace sutures
i) Trauma
–Repair lacerations
–Hysterectomy (a repair) for ruptured uterus.
ii) Retained Products
–Evacuation
–Manual removal of placenta or placental pieces

19. MANAGING RETAINED PLACENTA
•Ensure Bladder is Empty
•Apply Controlled Cord Traction: If fails
•Repeat Oxytocin 10u IM: If no success in 30 min
•Attempt 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

20. Secondary PPH
•Occurs after 24 hours to 6 weeks
postpartum
•Mainly due to infection (endometritis)
•Look out for RPOC and mlignancies such
as cancer or cervix and choriocarcinoma
•Perform vaginal swabs and scan

21. Anaesthesia and Anaelgesia
for short procedures <30 mins
•Pethidine 1mg/kg BW
IM or IV slowly
(max 100mg dose )
Give Promethaxine(Phenergan) if vomiting
occurs)
Plus
•Diazepam10mg 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
•Ketaminefor procedures < 60 mins
–Dose 6-10 mg/ kg BW by IM or
IV bolus or IV Infusion
–2 mg/Kg BW IV slowly last for 15
mins
–200mg in 1 litre D/S at 20 dpm
infusion for longer procedures.
–Give Atropine 0.6 mg IM as pre-
medication
–Give O2 6-8l/min by mask
–Add Diazepam 10 mg IV to avoid
hallucinations
Contraindicated in HIGH BP
and Heart Disease

22. Treat cont..
iv) Coagulopathy (DIC)
•Fresh whole blood
•Fresh frozen plasma
•Platelets if indicated (thrombocytopenia )
v)Uterine inversion
-manual reposition.
vi)Full bladder
-empty it.

23. preparedness
1. Antenatal Care
• Correct anaemia
• Maintain good health
2. During labour
-look out for visit factors such as polyhyaramnios, multiple pregnancy
-Active management of labour
-avoid prolonged labour
-active management fo the 3rd stage labour.
-Be prepared
• Availabity in labour ward and
-IV fluids, cannulas, laboratory bottles
-oxytocics
• Senior staff reachable/contactable
• Supportive blood bank.

24. THANK YOU