POSTPARTUM HAEMORRHAGE.pptx

nursing

1. POSTPARTUM HAEMORRHAGE Presented by Racquel Burrowes Blackwood (RN/M)

2. PICTURE SHOWING SEVERE PPH

3. OBJECTIVES By the end of the presentation, participants will be able to: Define Postpartum Haemorrhage ( PPH ) . List causes of PPH. List risk factors of PPH. Management of PPH PPH Prevent ion .

4. INTRODUCTION Postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality and morbidity worldwide. It accounts for nearly a quarter of all maternal deaths. Although maternal mortality rates have declined greatly, PPH remains a leading cause of maternal mortality in developing countries such as Jamaica . PPH is actually ranked in the top 3 causes of maternal mortality, along with embolism and hypertension i n the developing world .

5. What is Postpartum Haemorrhage (PPH)? Postpartum Ha emorrhage ( PPH) is an obstetric emergency that can result in death if not recognized and treated promptly by a knowledgeable and effective medical team. Multiple studies have suggested that many deaths associated with PPH could have be prevented with prompt recognition , more timely and adequate treatment.

6. What is Postpartum Haemorrhage (PPH)? cont.d PPH is defined as severe bleeding from or in the genital tract after childbirth : > 500 ml following vaginal delivery > 1000 ml following cesarean section Any amount of blood loss that cause haemodynamic instability after delivery. Inorder to diagnose PPH there must be a change in hematocrit, need for transfusion, rapidity of blood loss and changes in the patient’s vital signs.

7. C lassifi cation of PPH PPH is often classified as P rimary, occurring within 24 hours of birth, S econdary, occurring more than 24 hours post-birth to up to 12 weeks postpartum.

8. Adverse Outcomes Associated with PPH PPH is a n emergency , it is a serious and potentially fatal condition . L arge amounts of blood can be lost very quickly caus ing a sharp decline in the patient’s condition such as Decrease blood pressure, Hypoxia Hypovolemic shock B lood flow and oxygen will be restrict ed to the brain and other vital organs which can lead to disability or death.

9. How serious is postpartum hemorrhage? Morbidity from PPH can be severe with sequelae including organ failure, shock, edema, compartment syndrome, transfusion complications, thrombosis, acute respiratory distress syndrome, sepsis, anemia, intensive care , prolonged hospitalization and ultimately death .

10. Diagram showing the most common causes of PPH

11. Causes of P ostpartum H emorrhage T he re are four most common causes of PPH called the 4 Ts ( T one, T rauma, Ti ssue and T hrombin) . Uterine atony (70%) : The uterine muscles don’t contract enough to clamp the placental blood vessels shut.This leads to a steady loss of blood after delivery. Uterine trauma (20%) : Damage sustained to the reproductive tract during delivery such tears and hematoma ( form during instrumental deliveries) in a concealed area caus ing bleeding hours or days after delivery .

12. Illustration of Degree of Lacerations

13. Causes of PPH Cont.d Retained placental tissue (9%) : Th e entire or fragments of placenta doesn't separate from the uterine wall. This usually affects the uterus’s ability to contract after delivery. Blood clotting condition (thrombin) (1%) : Thrombin’ ( coagulopathies and vascular abnormalities ) interfere with the body’s clotting ability. This can make even a tiny bleed uncontrollable .

14. R isk F actors All women who carry a pregnancy beyond 20 weeks’ gestation are at risk for PPH, majority of women who develop PPH have no identifiable risk factors. Maternal profile: Age >40, BMI > 35, Asian ethnicity, previous PPH . Induction of labour : prolonged (>12 hours) “uterine fatigue” or precipitous labour and delivery. Large myoma ( uterine fibroid)

15. R isk F actors Uterine over-distension – multiple pregnancy and multiparity polyhydramnios, fetal macrosomia, Chorioamnionitis ( infection ) , large clots, bladder distention , r etained product of conception Halogenated anesthetic

16. R isk F actors cont.d Placental problems – placental abnormalities such as placenta praevia, placental abruption. Uterine rupture or inversion Instrumental vaginal deliveries (forceps or ventouse / vacuum extraction during delivery can increase your risk of uterine trauma. Episiotomy C-section

17. R isk F actors cont.d Vascular – Placental abruption, hypertension, pre-eclampsia , eclampsia . Coagulopathies – V on Willebrand’s disease, haemophilia A/B, ITP or acquired coagulopathy i.e. Disseminated intravascular coagulation ( DIC ) , HELLP. Unsupervised deliveries resulting in 2nd and 3rd degree lacerations to the vagina, cervi x, uter us or perineum .

18. SIGNS AND SYMPTOMS OF PPH The most common signs and symptoms of PPH are Persistent, excessive bleeding from the vagina after delivery Decrease BP causing dizziness, blurred vision , feeling faint or excessive tiredness . C omplain of palpitations , heart ra cing and SOB Restlessness, confusion ( f eeling disoriented ) , alteration in level of consciousness

19. SIGNS AND SYMPTOMS OF PPH Pallor or clammy skin. Nausea or vomiting. Worsening abdominal or pelvic pain Fever chills intense ringing in the ears Loss of uterine contractions and excessive vaginal bleeding after delivery of the placenta

20. Investigations and Tests PPH may be diagnosed through P hysical examinations and a thorough review of the women past medical history. Estimation or m easuring the volume of blood collected and weighing blood-soaked pads or sponges after a C-section delivery . Monitoring for ↑ pulse rate and ↓ blood pressure. Blood tests - complete blood count ( CBC), liver function test (LFTs), group and c ross match , c oagulation profile and Urea and Electrolytes Detailed Ultrasound of the uterus and other organs .

21. Investigations and Tests cont.d General examination may reveal H aemodynamic instability with tachypnoea, prolonged capillary refill time, tachycardia, and hypotension. Soft, boggy uterus that is located above the umbilicus Speculum examination may reveal sites of local trauma Incomplete placenta,a missing cotyledon or ragged membranes could both cause a PPH.

22. M anagement of PPH The management of PPH must take a multidisciplinary approach. Communication between the team, and diligent documentation is vital. Initial management includes: Identifying PPH Determining its cause Implementing appropriate interventions based on the etiology. Close m onitoring , this should include RR, O2 sats, HR, BP, temperature every 15 mins.

23. M anagement of PPH Interventions to treat PPH generally proceed from less to more invasive . Stopping and t reat ing the blood loss are vital to prevent shock and organs failure . T he source of bleeding must be Identify and s top as fast as possible with compression techniques, medications, repair of laceration , and surgeries. R eplac e blood volume with a djunctive therapies, such as blood and fluid replacement . Catheterisation to decompress the bladder

24. Management and Treatment Some of the treatments used are: Uterine massage help the muscles of the uterus contract. Remov e retained placental tissue from the uterus by expressing and massaging until it is firmly contracted Medication to stimulate contractions such IV Oxytocin infusion. Repairing vaginal, cervical and uterine tears or lacerations. Packing the uterus with sterile gauze or tying off the blood vessels.

25. Management and Treatment Using a catheter or balloon (uterine tamponade) to help put pressure on your uterine walls. Uterine artery embolization. Insertion of a central venous line, blood transfusion. In rare cases, or when other methods fail, a laparotomy or a hysterectomy may be perform . A laparotomy is done to locate the source of bleeding site for repair . Hysterectomy removal of the uterus usually lifesaving anf final resource.

26. Management of PPH (a) Bi-manual compression, (b) Balloon tamponade.

27. Resuscitation Resuscitate the patient via an A-E approach: Airway Protect airway (may lose it with reduced levels of consciousness). Breathing 15L of 100% oxygen through non-rebreathe mask. Circulation: Assess circulatory compromise (Cap refill, HR, BP, ECG) Insert two large bore (14G) cannulas and take blood samples .

28. Resuscitation cont.d Start circulatory resuscitation , replace blood loss - transfuse with blood as soon as it is available, until then administer crystalloid and colloids. Additional blood productions such as fresh frozen plasma, platelets, fibrinogen. Disability Monitor patient’s Glasgow coma score (GCS). Exposure Expose patient to identify bleeding sources.

29. PPH P revention Active management of the 3rd stage of labour routinely reduces PPH risk by 60%: Women delivering vaginally should be administered 5-10 units of IM Oxytocin prophylactically. Women delivering via C-section should be administered 5 units of IV Oxytocin Treat anaemia during prenatal care. Avoid routine episiotomy

30. PPH P revention cont.d Re-examine after completing delivery paperwork (4th stage examination at 1hour after delivery of the placenta) . Give Misoprostol 600 mcg po to every woman with risk factor of PPH after the active management of third stage of labour

31. CONCLUSION PPH is the leading cause of maternal mortality worldwide, accounting for roughly a quarter of all maternal deaths. Excess maternal mortality requires a multidisciplinary team’s coordinated approach to prevention, for early detection, and intervention. Some women have PPH risk factors that can be identified during pregnancy, labor, or births. However, majority of women with severe PPH do not have any risk factor. As a result, all pregnant women should be considered at risk of PPH and monitored appropriately before, during and after birth.

32. References Kelly C. Wormer; Radia T. Jamil; Suzanne B. Bryant (2023). Acute Postpartum Hemorrhage https://www.ncbi.nlm.nih.gov/books/NBK499988/ Pazhaniappan , N ., (2016, December) Primary Post-Partum Haemorrhage. Teach Me ObGyn https://teachmeobgyn.com/labour/puerperium/primary- post-partum-haemorrhage/ Reveiw 12 Research Protocol: Management of Postpartum Hemorrhage . (2019). Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD. Management of Postpartum Hemorrhage https://effectivehealthcare.ahrq.gov/products/hemorrhage- postpartum/research-protocol

33. https://effectivehealthcare.ahrq.gov/products/hemorrhage-postp Methods Guide for Effectiveness and Comparative Effectiveness Reviews. AHRQ Publication No. 10(12)-EHC063-EF. Rockville, MD: Agency for Healthcare Research and Quality. April 2012 . Chapters available at: https://effectivehealthcare.ahrq.gov/products/cer-methods-guide/overview/artum/research-protocol