POSTPARTUM HAEMORRHAGE IN MIDWIFERY .ppt

Midwifery care

1. Postpartum Hemorrhage
Presenters;
ALLY ABDUL
MARCH,2019.
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2. OBJECTIVES
At the end of this session each student will be able to;
•Define the term post-partum hemorrhage(PPH)
•Identify the causes of PPH
•List the risk factors for PPH
•Mention signs and symptoms of PPH
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3. OBJECTIVES CONT`
•Explain the complications of PPH
•Explain the prevention of PPH
•Describe the management of PPH
•Analyze the midwifery roles
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4. INTRODUCTION
•Postpartum hemorrhage (PPH) continues to be a leading
cause of maternal morbidity and mortality worldwide (WHO,
2016).
•It is a life-threatening event that can occur with little warning
and is often unrecognized until the mother has profound
symptoms.
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5. Introduction cont.
•PPH can be reduced by 60% through active
management of third stage of labour (AMSTL) for
all women if done routinely (WHO, 2016).
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6. DEFINITION OF TERMS
Postpartum hemorrhage
Is the loss of more than 500 ml of blood after vaginal birth and
1000 ml after cesarean birth.
OR
•Is 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.
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7. TYPES OF PPH
1. Primary PPH
2. Secondary PPH
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8. Primary Hemorrhage-occurs within 24 hours
following the birth of the baby.
Secondary Hemorrhage-occurs beyond 24 hours
and within puerperium, also called delayed or late
puerperal hemorrhage.
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9. CAUSES OF PPH
There are four basic pathologies which are expressed
as the 4 Ts’ as the main causes of PPH
•Tone
•Tissue
•Trauma
•Thrombin
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10. TONE
Accounts for an estimated 70% of PPH cases
Abnormalities of uterine contractionClinical risk factors
Exhaustion of the uterine
muscles
• Precipitous labour
• Prolonged labour
• Augmentation of labour
• Induction of labour
• Prior PPH
Over-distended uterus
• Polyhydramnios
• Multiple gestation
• Fetalmacrosomia
Chorioamnionitis • Earlier rupture of membranes
Anatomic distortion of the
uterus
• Fibroids
• Placenta previa/low-lying placenta
• Uterine anomalies
• Bladder distention
Uterine-relaxing agents
• Tocolytics
• Halogenated anesthetics(inhaledethers)
• MgSO4

11. TISSUE
Accounts for an estimated 10% of PPH cases
Retained placental tissue or
clots prevent occlusion of
uterine blood vessels
Clinical risk factors
Retained placenta, placental
fragments, clots, lobe or
membranes
• Manual removal of placenta
• Prolonged augmentation of
labour
Retained placenta, placental
fragments,clots, lobe or
membranes
Abnormal placentation:
placenta
accreta/increta/percreta
• Previous uterine surgery
• Placenta Previa
• Preeclampsia

12. TRAUMA
Accounts for an estimated 20% of PPH cases
Blood loss due to genital tract
trauma
Clinical risk factors
Lacerations and hematomas
of vagina, perineum or cervix
• Precipitous labour
• Episiotomy
• Operative delivery
• Shoulder dystocia
Laceration at CS, extension of
incision
Malposition, malpresentation,
deep engagement
Uterine rupture •Previous uterine surgery
Uterine inversion • Fundal placenta
• Excessive cord traction
• Grand multiparty

13. CONT.
Thrombin
•Abruption
•PET
•Pyrexia
•Intrauterine death
•Amniotic fluid embolism
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14. Complications of PPH
•Shock
•Hysterectomy
•Cardiovascular problems
•Anaemia
•Transfusion reaction
•Failing lactation
•Pulmonary embolism
•Thrombosis
•Thrombophlebitis
•Puerperal sepsis
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15. Signs of PPH
Obvious signs
•Visible bleeding
•Maternal collapse
(shock)
Other signs
•Pallor
•Rise in pulse rate
•Hypotension
•Altered level of
consciousness
•Enlarged uterus
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16. Severity of blood loss depends on,
•Pre-delivery hemoglobin level
•Degree of pregnancy induced hypervolemia
•Speed at which blood loss occur. On incidence the
blood loss is so rapid and brisk that death may occur
within fiveminutes.
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17. Management of PPH
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Management
principles
Communication
Resuscitation
Monitoring
Arrest of
bleeding

18. Communication
•Shout for help to manage the woman collaboratively
and give clear instructions and explanations
•Provide clear information to the woman
•Document all assessments concurrently or as soon as
possible and assign someone to record critical
information if needed.
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19. Resuscitation
•Observe airway/breathing/circulation (ABC)
•Put in two large bore intravenous cannulas (14-18 gauge)
•Place a woman in recumbent position with legs elevated
•Send quickly blood for cross matching, grouping and
other diagnostic test and ask for at least 2 units of blood
•Infuse rapidly 2 litres of NS and provide oxygen (8-10
L/min)
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20. Monitoring
•Talk with the mother and monitor vitals (BP, PR,RR and
O2)
•Monitor type and amount of intravenous fluid the mother
has received
•Monitor fluid input and output (continuous catheterization)
•Monitor drugs given (type, dose and time) 20

21. Arrest of Bleeding
•Recognize excessive bleeding
•Identify the cause
•Act according to the cause
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22. Arrest bleeding cont.
Atonic uterus
•Massage the uterus
•Give uterotonic drug 10 IU of oxytocin in 500 mlsof NS
•Catheterize to keep bladder empty
•Examine expelled placenta and membranes to exclude retained tissue.
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23. Atonic uterus cont.
•If the uterus fails to contract proceed with,
•Inspection of cervix and vagina to exclude co-
existent bleeding sites from the injury areas.
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24. Uterine massage and bimanual
compression
•Massage the atonic uterus when placenta is
delivered to stimulate myometrium contractions to
diminish excessive bleeding and expel blood and
retained clots.
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25. Bimanual compression
•The whole hand is introduced into the vagina in cone
shaped fashion after separating the labia with the
fingers of the other hand
•The vaginal hand is clenched into a fist with the back
of the hand directed posteriorly and the knuckles in
the anterior fornix
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26. CONT.
•The other hand is placed over the abdomen behind the
uterus to make it un inverted
•The uterus is firmly squeezed between the two hands.
•It may be necessary to continue the compression for a
prolonged period until the tone of the uterus is
regained.
Endocrine disorders 26

27. Bimanual compression
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28. Balloon (uterine) Tamponade
•Tamponade is done by using hydrostatic balloon catheter into the
uterine cavity i.e. Foley catheter, Bakri balloon or Condom
catheter.
•The balloon is inflated with normal saline (200–500 mls) and kept
for 4–6 hours.
•It is successful in atonic PPH and this can avoid hysterectomy in
78% cases.
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29. Balloon tamponade using Bakri
balloon
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30. Aortic compression
•Palpate the femoral pulse using left four fingers
•Close the fist with the thumb outside the fingers to create
90 degrees angle between metacarpal and digital bones.
•Place the fist on the umbilicus with the forearm
perpendicular to the skin and compress downward while
left hand palpating femoral pulsations.
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31. Aortic compression cont.
•Slowly force the fist downwards to feel the aorta
pulsations.
•Move the fist downward until it reaches bone
surfaces of vertebral column.
•When successful there will be no more femoral
pulsations and bleeding will stop.
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32. Aortic Compression
•It is a temporary and effective
measure to control bleeding
•This allows time for
resuscitation and volume
replacement before any
surgical intervention is done
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33. Hysterectomy
•Rarely uterus fails to contract and bleeding continues in spite of
the all other measures.
•Hysterectomy has to be considered involving a second
consultant.
•Decision of hysterectomy should be taken earlier in a parous
woman.
•Depending on the case, it may be subtotal or total.
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34. Traumatic PPH
•Inspect for the trauma to the perineum, vagina and the
cervix under good light by speculum examination if
bleeding continues despite firm uterus.
•Bleeding from genital tract lacerations may occur
simultaneously as bleeding from an atonic uterus.
•With severe lacerations that are bleeding consider repairing
to stop bleeding 34

35. Retained Tissue
•Examine placenta to see if it is complete.
•Massage uterus and expel clots.
•Determine if there are clots sitting in cervix or posterior
fornix and attempt to remove them.
•If the are remained tissue or retained placenta consider
manual removal of placenta
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36. Retained placenta
The placenta is said to be retained when it is not
expelled out even 30 minutes after the birth of the
baby.
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37. Causes of placenta retention
•Poor voluntary expulsive efforts
•Uterine atonicityin grand multipara, over distension of
uterus and uterine malformation
•Morbid adherence placenta (placenta accrete, increta
•Premature attempts to deliver placenta before its
separation
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38. Manual Removal of Placenta
•With a clamp on the cord to assist with traction, use the
non-dominant hand to hold the cord and with the
dominant hand follow it up to the uterus.
•Move non-dominant hand to apply firm fundal pressure in
order to stabilize the uterus while the dominant hand
separates the placenta from the uterine wall.
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39. •Keeping the hand flat, peel the placenta off the wall of the
uterus using the side or back of the hand with a side-to-side
sweeping motion.
•If an assistant is available the assistant can apply fundal
pressure or maintain traction on cord.
•If the placenta does not detach and it seems adherent, do not
continue with manual removal, consider placenta accrete. 39

40. 40

41. Thrombin
•Blood coagulation disorders, acquired or congenital,
are less common causes of postpartum haemorrhage.
•The blood coagulopathy may be due to diminished
procoagulants or increased fibrinolytic activity
•When all other measures are done but the woman is
still bleeding assess coagulation Problems.
•Severe blood loss can lead to consumption of
clotting factors.
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42. •Potential coagulation problems may be assessed at the bedside by
the clot observation test:
•Obtain 2 to 5 mlsof woman’s blood in a red top tube and set aside
to observe.
•Blood will normally clot and stay clotted within 8 to 10 minutes.
•If a clot does not form within 8 minutes or if it breaks down easily
this suggests coagulopathy.
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43. Midwifery roles
•Proper history taking during antenatal to identify women
with increased risk for PPH.
•Competence in proper assessment and management during
labour.
•Conduct active management of third stage of labour for every
woman to prevent PPH.
•Competence in assessment of causes and management of
PPH according to its cause.
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44. References
•Dutta D. C (2015). Textbook of Obstetrics including
perinatology and contraception, 8
th
Edition
•Lowdermilk L. D., Perry, S.E. , Cashion , K. & Alden, K.R
(2012). Maternity &Women's Health Care (10
th
Ed)
Elsevier Inc.
•Bennet. R.V & Brown .K.L(2006). Myles text book for
Midwives African ed ,Churchill Living stone
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