Post partum haemorrhage and its management. good for nursing students

1. POST-PARTUM
HARMORRHAGE
MR SANDWE T.K.
MR SANDWE T.K. 1

2. INTRODUCTION
•Providing good care include treating the woman
and her family with kindness and respect.
•In some parts of the world almost every woman
knows someone has died in child birth.
•This can make pregnancy a time of worry for
her and her family.
MR SANDWE T.K. 2

3. Cont’..d
•It is important to be aware of her concern.
•Postpartum haemorrhage is one of the most
alarming and serious emergencies
• especially terrifying when it occurs
immediately following a straight forward
delivery.
MR SANDWE T.K. 3

4. Cont’..d
•In more severe cases of PPH the woman’s life will
depend upon the prompt and efficient management
from the midwife.
• Postpartum haemorrhage accounts for 25% of
maternal morbidity in Zambia and is one of the
leading obstetrical emergences.
MR SANDWE T.K. 4

5. Cont’..d
•According to 2013-14 Zambia demographic health
survey (ZDHS) there is evidence that a large
proportion of maternal and neonatal deaths occur
during the postpartum period
•with postpartum haemorrhage being an important
cause of maternal mortality .
MR SANDWE T.K. 5

6. Definitions
•Post partum haemorrhage is excessive bleeding from
the genital tract any time from the birth of the child
to the end of puerperium (Mayers 1997)
•Postpartum haemorrhage is excessive haemorrhage
from the genital tract after birth of the baby ( Sellers
1994)
MR SANDWE T.K. 6

7. Cont’..d
•Vaginal bleeding in excess of 500ml or any amount
sufficient enough to cause cardiovascular
compromise.
• In practice it is any amount of Vaginal Blood loss
post delivery which threatens the life of the woman
MR SANDWE T.K. 7

8. Types
Primary post partum haemorrhage
•Is excessive loss of blood of more than 500 mls
from the genital tract
•during the third stage of labour or within 24
hours of delivery.
MR SANDWE T.K. 8

9. Primary post partum haemorrhage
•It is more common than secondary PPH
•When severe its one of the most urgent
emergencies in obstetrics.
•The woman’s life is dependent upon the prompt and
efficient management
MR SANDWE T.K. 9

10. Secondary post partum haemorrhage
• Excessive bleeding from the genital tract of more than 500
mls of blood
• occurs subsequent to the first 24 hours following birth up
until the 6th week postpartum.
MR SANDWE T.K. 10

11. Predisposing factors
•Prolonged or obstructed labour
( uterine inertia due to muscle exhaustion).
• overstretching of the uterus.
(Multiple pregnancy, Polyhydramnious).
•Anaemia (as the woman is unable to withstand
haemorrhage so any small loss may alter condition
of woman).
MR SANDWE T.K. 11

12. Cont’..d
•Grand multiparity (tired and fibrosed uterus)
•Induction and augmentation of labour for
hypotonic uterine action
•Placenta preavia because the thinner muscle
layer contains few oblique fibres to control
bleeding effectively.
MR SANDWE T.K. 12

13. Cont’..d
•Precipitate labour resulting to muscles having
insufficient opportunity to retract.
•General anaesthetic agents such as halothane cause
uterine relaxation
•Mismanagement ( fiddling with the fundus or
manipulation of he uterus may precipitate arrhythmic
contractions resulting in only partial separation of
the placenta
MR SANDWE T.K. 13

14. Cont’..d
•Previous history of PPH for there is a risk of
recurrence in subsequent pregnancies.
•Fibroids normally benign tumours consisting of
muscle fibrous tissue which may interfere with
uterine action.
•Retained products of conception will simply impede
uterine contraction.
MR SANDWE T.K. 14

15. Cont’..d
•Women who have HIV/AIDS usually have low
platelete count
MR SANDWE T.K. 15

16. Causes of PPH
The 4Ts
•Tone
•Tissue
•Trauma
•Thrombosis
MR SANDWE T.K. 16

17. Atonic uterus
•is failure of the relaxed myometrium at the placental
site
•To contract and retract and to compress torn blood
vessels and control blood loss by a living ligature
action.
•the commonest cause of primary postpartum
hemorrhage
• causes about 75 - 90% Primary PPH
MR SANDWE T.K. 17

18. Causes of uterine atony
•Incomplete placental separation such that
If the placental tissue remains partially embedded in
the spongy decidual, efficient contraction and
retraction are interrupted.
MR SANDWE T.K. 18

19. Cont’..d
•Retained cotyledon, placenta fragment or
membranes (similarly impede efficient uterine
action)
•Precipitate labour as the muscle may have
insufficient opportunity to retract
•Prolonged labour(uterine inertia or sluggishness may
result from muscle exhaustion.
MR SANDWE T.K. 19

20. Cont’..d
•Over distension of the uterus in conditions such as
multiple pregnancy and polyhydramnious.
•This causes it to fail to contract effectively after
delivery.
•The myometrium become excessively stretched and
there is less efficient.
MR SANDWE T.K. 20

21. Cont’..d
•Mismanagement of the third stage of labour
(Fundus fiddling or manipulation of the uterus
may precipitate arrhythmic contractions causing
partial placenta partially separation)
MR SANDWE T.K. 21

22. Cont’..d
•A full bladder may interfere with uterine action
•Placenta preavia causes couvalaire uterus
•General anaesthesia may cause uterine relaxation
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23. Tissue
•Partial separation of the placenta prevents the
uterus from contracting due to
•Retention of placental fragments e.g.
membranes or placenta lobe.
MR SANDWE T.K. 23

24. Trauma
•Lacerations of the birth canal, including the vulva
, perineum and a badly performed episiotomy.
MR SANDWE T.K. 24

25. Causes of lacerations
•Premature bearing down
•Delivery of the after coming head of a breech is
indicated.
•Forceps deliveries and especially rotational forceps
delivery
•Internal version (these lacerations can extend up to
the uterus causing uterine rupture).
MR SANDWE T.K. 25

26. Cont’..d
• Delivering of babies with large presenting diameters of the
head, large babies, persistent occipital- posterior position,
face presentation
• precipitate labour and uncontrolled patient
• Manipulations and forces delivery.
• Rigid perineum.
MR SANDWE T.K. 26

27. Coagulation failure
•Coagulation defects related to hypertensive disorders
and other conditions.
•may be preexisting or may develop in the second
stage of labour
MR SANDWE T.K. 27

28. Causes of Coagulation failure
•Any condition interfering with the maternal blood
clotting mechanism can cause coagulation failure.
•DIC or hypofibrinogenaemia due to hypertension in
pregnancy, placenta abruption, intra uterine death
and amniotic fluid embolism.
MR SANDWE T.K. 28

29. Cont’..d
• Congenital blood clotting defects (lack of clotting factors).
• physiological processes of third stage of labour due to
Previous history, Congenital and acquired clotting
abnormalities
• Placenta accreta
MR SANDWE T.K. 29

30. Clinical manifestation of PPH ( signs)
•Uterus Feels large and soft and high in the
abdomen
• The fundus of the uterus will be felt near the
umbilicus or above
• it is also displaced to the right or left.
•Vaginal bleeding
•usually visible at the introitus, if the placenta
has delivered
MR SANDWE T.K. 30

31. Cont’..d
•If the placenta remains in situ, then a significant
amount of blood can be retained in the uterus behind
a partially separated placenta, the membranes, or
both. Gushes of blood coming out- when the fundus
of the uterus is rubbed up or massaged.
MR SANDWE T.K. 31

32. Cont’..d
•Blood from any part of the birth canal will
appear as:
•Venus blood and the flow is dark red
•Arterial bleeding spurts of bright red blood
corresponding to pulse rate
•In Coagulation failure there is Prolonged clotting
time (normal 6-8 minutes) and
generalized bleeding
MR SANDWE T.K. 32

33. Cont’..d
•Other signs are those of hypervolemia which include:
•Heart palpitations and tachycardia which are due to
cardiac overload.
•Dizziness caused by reduced blood volume.
•oliguria in moderate state and anuria
MR SANDWE T.K. 33

34. Cont’..d
•Depending on the extent of the blood loss, the blood
pressure fall may range from being mild to moderate
or severe.
•A cold sweat which is a sign of shock appears on the
forehead.
•Restlessness and air hunger occurs due to
hypervolaemia which reduces the circulating red
blood cells and oxygen.
MR SANDWE T.K. 34

35. Diagnosis
MR SANDWE T.K. 35

36. Cont’..d
•look for vaginal and cervical lacerations,
Re-examine placenta ,Look for other
bleeding sites.
Other Investigations include;
•FBC
•Blood cultures
•Midstream Urine
•High vaginal swab
MR SANDWE T.K. 36

37. Cont’..d
•Ultrasound to detect retained products of conception
•Group B Streptococcus (gram +ve) organisms often
cause endometritis.
MR SANDWE T.K. 37

38. Oxytocic drugs
DRUG DOSE &
ROUTE
CONTINUATIO
N
DOSE
MAXIMUM
DOSE
PRECAUTIO
N AND C/I
OXYTOCIN IM 10 IU
IV 20 IU IN 1000
MIS NS AT 60
DROPS/MIN
IV 20 u in
1000ml at
40 drps
/min
NOT MORE
THAN 3 LITERS
OF IV FLUIDS
CONTAINING
OXYTOCIN
DO NOT
GIVE IV
BOLUS
EROMETRIN IM OR IV
SLOWLY
0.2MG
REPEAT 0.2MG
AFTER 15 MINS
IF REQUIRED
EVERY FOUR
HOURS
FIVE DOSES
(TOTAL 1.0 MG)
HIGHG BP
MISOPROSTAL ORAL ,SUB/L
INTRAVAGINAL
Y
200-800
Mcg
200 Mcg
every 4
hours
ASTHMA
,HEART
DISEASE
MR SANDWE T.K. 38

39. CONDOM TAMPONADE
N/S
INFLATE
CONDOM with
300-350MLS
Water
UTERUS
CONDOM
FOLEYS CATHETER
WATER
clamp
Big syringe
MR SANDWE T.K. 39

40. MANAGEMENT OF PPH
IMMEDIATE MANAGEMENT
• Aims
- To identify the cause of PPH
- To control or stop the bleeding
MR SANDWE T.K. 40

41. IMMEDIATE MGT cont’
- To resuscitate the woman
- To prevent infection
- To prevent complications
MR SANDWE T.K. 41

42. IMMEDIATE MGT cont’
Once you are confronted by a woman with PPH you need to act fast
enough to ensure that the mother receives the required care without
delay.
MR SANDWE T.K. 42

43. IMMEDIATE MGT cont’
Regardless of whether the patient is at the hospital or clinic, the
following are the steps that should be taken, unless the circumstances
dictate otherwise; though the sequence may not be rigid but determined
by the patient’s presentation.
MR SANDWE T.K. 43

44. Call for help
 Immediately you notice that the woman is bleeding profusely, Call for
help by shouting “PPH PPH”. Be calm and work skilfully
 Care is effectively instituted by a team of medical and none-medical
staff (emergency team) comprising;
MR SANDWE T.K. 44

45. Call for help cont’
 the midwife caring for the woman, other midwives, obstetrician,
anaesthetist and pottering staff. This team should be summoned
immediately excessive PV bleeding is observed.
MR SANDWE T.K. 45

46. Call for help cont’
 Place her in bed for comfort and to facilitate further assessment and
care provision.
MR SANDWE T.K. 46

47. Psychological support
 Meanwhile, ensure the mother is kept informed of the events and
provide for an opportunity to verbalize.
 Reassure her and explain the need for support from other members of
staff. This is important to allay anxiety and ensure she cooperates with
you.
MR SANDWE T.K. 47

48. 1. QUICK ASSESSMENT
• Make a quick assessment of the general condition of the patient;
• level of consciousness
• Air way-any signs of obstruction
• Breathing- Respiratory pattern, cyanosis
• Circulation- Bp, pulse, temperature
MR SANDWE T.K. 48

49. Quick assessment cont’
• Check amount of PV loss by;
• checking the vulva for blood flow
• If blood was collected, measure and record
• checking the used pads or any soiled material and estimate blood loss.
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50. Assessment cont’
• Determine the possible cause of bleeding from history (if she
delivered at home, find out when this was, how long labour was,
whether the placenta was complete, any possibility of trauma etc)
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51. Assessment cont’
• Examine the uterus to rule out sub-involution.
• Check the state of the bladder- not full?
• Examine the birth canal for tears or lacerations.
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52. • Concurrent with and following determination of the
cause of PPH, the rest of the care proceeds and
encompasses the steps in the summary below;
• Resuscitate (A,B,C,D)
• Stop the bleeding
• Atony
• Trauma
• Retained products
• Subsequent care
MR SANDWE T.K. 52

53. 1. RESUSCITATE THE WOMAN
Note:
Measures instituted in the resuscitation of the woman with PPH follow
the Airway, Breathing, Circulation and Drugs (A,B,C,D) standard.
However, the actual implementation of care is not rigid but determined
by the assessment findings and priority setting.
MR SANDWE T.K. 53

54. Resuscitation cont’
Air way
• Ensure the patient is breathing well but if signs of obstruction ensure
that the air way is clear and patient well positioned.
Breathing
• If the patient has challenged breath; hungry for air or cyanosed;
• Provide oxygen by mask
• Open window to ensure good air circulation
• Position
MR SANDWE T.K. 54

55. Resuscitation cont’
Circulation
• Put up an IV line of normal saline/R/lactate on one hand and one for
oxytocin on the other hand
• IV lines should be commenced when veins are still easy to access. This
provides access port for oxytocic drugs and fluid
MR SANDWE T.K. 55

56. Resuscitation cont’
• At the same time, collect blood samples for Hb, grouping and cross
match. Ensure the laboratory keeps units of ready blood in case of
need for transfusion
• Keep IV access for drugs and BT
MR SANDWE T.K. 56

57. Resuscitation cont’
• Whole fresh blood may be transfused if the Hb is less than 10g/dl or
severe bleeding.
• The following may also be given depending on the condition of the
patient and availability;
• Fresh frozen plasma
• Colloid solution i.e hemaccel)
• Fibrinogen
MR SANDWE T.K. 57

58. Resuscitation cont’
• Elevate the legs of the patient to allow enough blood flow to the vital
centres in the brain.
• Do not lift the foot end of the bed as this will lead to pooling of blood
in the uterus there by preventing its contraction.
Drugs (Oxytocin, ergometrin, cyntometrin, prostaglandins and
antibiotics - discussed under control of bleeding)
MR SANDWE T.K. 58

59. 2. CONTROL OF BLEEDING
Simultaneous with resuscitation, ensure measures to attend to the
identified cause of bleeding are immediately instituted as follows;
MR SANDWE T.K. 59

60. cont’d
If bleeding is due to uterine atony
• Check the blander and if full, empty it by catheterization to aid
uterine contraction.
MR SANDWE T.K. 60

61. cont’
• Rub up a contraction: Feel the uterine fundus for contraction and if
not contracted, massage it with smooth circular motions without
applying undue pressure.
• Give oxytocin 10 International Units (IU) Intra-muscular (IM)
MR SANDWE T.K. 61

62. cont’
• Ensure that the uterus is emptied i.e examine the placenta for
completeness
• The baby may be put to the breast to enhance the physiological
secretion of oxytocin from the posterior lobe of pituitary gland. This
will help contract the uterus.
MR SANDWE T.K. 62

63. Stop the bleeding cont’
• If bleeding is not controlled within 5 minutes, give oxytocin 20 units in
1 litre of a crystalloid IV at a rate of 60 drops per minute.
• Follow this up with another 20 iu to run at 40 drops/min.
MR SANDWE T.K. 63

64. Stop the bleeding cont’
• The following alternative drugs may be administered depending on
the severity of the condition;
• Syntometrine (Syntocinone 5mg + ergometrine 0.5mg) IM 1ml
MR SANDWE T.K. 64

65. Stop the bleeding cont’
• Alternatively, in severe atonic haemorrhage, ergometrin 0.25-0.5mg IV/IM
may be given (effective within 45 seconds). No more than two doses should be
given as it may cause pulmonary hypertension.
MR SANDWE T.K. 65

66. Stop the bleeding cont’
• Prostaglandins F2 Aipha: 5mg (1ml) directly into the uterine muscle through
the abdomen by the obstetrician.
MR SANDWE T.K. 66

67. Stop the bleeding cont’
Bimanual compression
If bleeding is not controlled and retained placenta is ruled out, bimanual
compression is performed as follows:
 Place the patient in dorsal
MR SANDWE T.K. 67

68. Stop the bleeding cont’
 Ensure asepsis and use sterile gloves
 Con fingers of the right hand, slip them into the vagina and them make
a fist
 Place the fist into the anterior fornix, palm uppermost. Rest the elbow
on the bed.
MR SANDWE T.K. 68

69. Stop the bleeding cont’
 Place the left hand on the abdomen with fingers directed downwards,
behind the fundus.
 Press the upper portion of the uterus forward onto the fist there by
compressing the placenta site.
• An assistant may help by applying pressure on the abdomen
MR SANDWE T.K. 69

70. Bimanual compression of the uterus
MR SANDWE T.K. 70

71. Note:
• Drugs and uterine compression may be combined.
• If all fails in the absence of retained products and trauma, a decision
may be made to perform hysterectomy in theatre.
• The patient needs to be moved quickly to a facility where advanced
procedures can be performed. Compression may be maintained
during transfer.
MR SANDWE T.K. 71

72. Stop the bleeding cont’
If bleeding is due to trauma
Repair of tears and lacerations
• Inspect the perineum, vulva and vagina for lacerations.
 Suture any tears if present
MR SANDWE T.K. 72

73. Stop the bleeding cont’
• Tears of the cervix should be done by an experienced midwife of
obstetrician
• If bleeding is due to uterine tears, repair should be done in theatre
with urgency.
• Hysterectomy may be performed in severe cases.
MR SANDWE T.K. 73

74. Stop the bleeding cont’
If bleeding is due to retained membrane or cotyledons
• If there are any retained membrane or cotyledons,
expel them by applying firm but gentle pressure on
the uterine fundus and then stimulate a contraction
of the uterus by massaging.
• Assess clotting time regularly
MR SANDWE T.K. 74

75. Stop the bleeding cont’
If bleeding is due to retained placenta
If bleeding is due to retained placenta and membrane, follow these
steps to remove it;
MR SANDWE T.K. 75

76. Stop the bleeding cont’
• Explain to the patient that the placenta will need to be removed
manually and that the procedure be uncomfortable but necessary.
MR SANDWE T.K. 76

77. Stop the bleeding cont’
• Ensure the bladder is empty
• Give oxytocin 10 IU IM immediately and rub the uterus again (The
type and dose of oxytocin is given according to local policy).
• Apply Controlled cord traction (CCT) with the next uterine contraction
MR SANDWE T.K. 77

78. Stop the bleeding cont’
• If this is not successful and bleeding continues attempt CCT again.
• If it fails again perform manual removal of the placenta as follows:
MR SANDWE T.K. 78

79. Stop the bleeding cont’
Method for manual removal of placenta
• Place the woman in lithotomy
• Ensure the vulva area is aseptically cleansed and don sterile gloves as
quickly as possible. Apply antiseptic solution on the right glove.
MR SANDWE T.K. 79

80. Stop the bleeding cont’
• With the cord in the left hand, cone the fingers of the right hand
around and run them up the cord into the uterus till you reach the
placenta.
• Steady the uterus with the left hand while the right finds the area of
placenta separation.
MR SANDWE T.K. 80

81. Stop the bleeding cont’
• Gently place fingers into the separated area with the palm facing the
placenta and with gentle sideways sweeping movements, gently and
methodically strip the placenta off the uterine wall
MR SANDWE T.K. 81

82. Stop the bleeding cont’
• Grasp the placenta while the left rubs up a contraction. Remove the
placenta from the uterus.
MR SANDWE T.K. 82

83. Stop the bleeding cont’
Bleeding may be due to coagulation failure
• Frozen plasma
• Platelet transfusion
or
• Fresh whole blood
MR SANDWE T.K. 83

84. SUBSEQUENT CARE OF PPH (After bleeding
has been controlled)
Aims
 To improve the Hb levels
 To prevent infection
 To promote good lactation
MR SANDWE T.K. 84

85. SUBSEQUENT CARE CONT’
The following care, in addition to the standard postpartum care, should
be provided:
Environment
 Keep the mother in the labour ward or resuscitation site for at least an
hour for close observation.
MR SANDWE T.K. 85

86.  Nurse her in the postnatal ward, quiet and well ventilated room, clean
to prevent infection as her immunity may be lowered.
 She should be close enough to the nurses’ area for easy monitoring and
observation.
MR SANDWE T.K. 86

87. SUBSEQUENT CARE CONT’
Position
 When stable, she can take any position comfortable. Sitting position
may aid in the drainage of the lochia hence it enhances involution of
the uterus.
MR SANDWE T.K. 87

88. SUBSEQUENT CARE CONT’
Psychological care
Explain to the patient the cause of bleeding, what has been
done or is still being done to help her and possible out come
of her condition.
Encourage her to ask questions and give appropriate
responses.
MR SANDWE T.K. 88

89. SUBSEQUENT CARE CONT’
Allow her spouse to visit and participate in the
provision of care. Explain to the spouse what ever
relates to the condition and measures being instituted.
MR SANDWE T.K. 89

90. SUBSEQUENT CARE CONT’
Bring the baby for her to see and if she is able,
allow her to handle the baby and possibly to
breast feed. She may be allowed to stay with her
baby with assistance.
MR SANDWE T.K. 90

91. SUBSEQUENT CARE CONT’
Observations
Observe the general condition to assess;
• improvement or deterioration.
MR SANDWE T.K. 91

92. SUBSEQUENT CARE CONT’
•Check temperature 4 hourly to rule out
hypothermia which could be due to blood loss or
hyperthermia due to infection.
MR SANDWE T.K. 92

93. SUBSEQUENT CARE CONT’
Check pulse and BP ¼, ½ and as she stabilises, 4
hourly to rule out shock or assess bleeding.
MR SANDWE T.K. 93

94. Assess the amount of PV bleeding. Check the
vulva, pads for blood loss. Ask the mother to
report excessive bleeding
Palpate the uterus for contraction. Ensure it is
well contracted.
MR SANDWE T.K. 94

95. SUBSEQUENT CARE CONT’
Check the bladder and ensure it is emptied
regularly.
Check the eyes, lips and palms for pallor
MR SANDWE T.K. 95

96. SUBSEQUENT CARE CONT’
Observe the mental status of the woman. Rule
out anxiety, depression, disorientation. Observe
her reaction towards her baby.
Observe urine output to rule out oliguria or
anuria which could be indicative of renal failure
MR SANDWE T.K. 96

97. SUBSEQUENT CARE CONT’
Nutrition
When the condition is stable the woman may be
allowed to take food rich in protein, vitamins and
iron to help replenish the lost blood.
MR SANDWE T.K. 97

98. SUBSEQUENT CARE CONT’
Encourage enough roughage (vegetable) and
fluids to prevent constipation hence help reduce
discomfort and pain during defecation.
Meals should be small and frequent to ensure
tolerance
MR SANDWE T.K. 98

99. SUBSEQUENT CARE CONT’
Infection prevention/hygiene
• Encourage frequent change of pants and pads
to prevent infection and bad odour.
MR SANDWE T.K. 99

100. SUBSEQUENT CARE CONT’
Assisted bath or shower is encouraged
Encourage hand washing after changing pads and
pants, after toilet, before handling the baby.
Regular change of soiled linen to prevent
infection and discomfort
MR SANDWE T.K. 100

101. SUBSEQUENT CARE CONT’
Sitz baths at least three times daily using
previously boiled cooled water if the woman has
perineal lacerations or tears to aid quick healing.
Dump dust the room, lockers and other surfaces
in the room with jik 1;6 to prevent infections.
MR SANDWE T.K. 101

102. SUBSEQUENT CARE CONT’
Elimination
Encourage her to empty the bladder regularly to
aid in the involution of the uterus. A full bladder
may hinder effective uterine contraction.
If the patient is not able to pass urine you should
catheterize to empty the bladder.
MR SANDWE T.K. 102

103. SUBSEQUENT CARE CONT’
Encourage bowel opening whenever she feels the
urge to prevent constipation and discomfort.
If the patient is not ambulant provide a bed pan.
Encourage adequate fluid intake and high
roughage diet to prevent constipation.
MR SANDWE T.K. 103

104. SUBSEQUENT CARE CONT’
Exercise
In the initial or critical phase provide passive
exercises of the limbs to prevent deep vein
thrombosis.
Encourage deep breathing exercises to prevent
hypostatic pneumonia.
MR SANDWE T.K. 104

105. SUBSEQUENT CARE CONT’
Later, encourage the patient out of bed or to be
ambulant to aid in drainage of the uterus and
hence, aid in the involution of the uterus.
MR SANDWE T.K. 105

106. SUBSEQUENT CARE CONT’
Medication
The patient should be commenced on prophylactic
antibiotics if the woman was exposed to invasive
procedure such as manual removal of the placenta.
oX-pen and Gentamycin IV/IM OR
oAmoxyl, Flagyl if she is able to take orally
MR SANDWE T.K. 106

107. SUBSEQUENT CARE CONT’
Analgesic i.e pethidine 50-100mg IM if there is severe
pain exhibited or in cases where invasive procures are
performed.
MR SANDWE T.K. 107

108. Information education and communication
•Hygiene
oTo take regular bath
oChange pads and pants regularly or when soiled
oHand washing after change of pad/pants and before
breast feeding.
MR SANDWE T.K. 108

109. IEC
Nutrition
oTo take food rich in iron for replenishment of lost
RBC
oFood rich in roughage and plenty fluids to prevent
constipation.
o Food rich in protein, vitamins and carbohydrates
MR SANDWE T.K. 109

110. IEC
Family planning
oTo commence preferred and appropriate
family planning method soon so as to prevent
unplanned pregnancy which, if it occurs, may
result in complications due to depleted iron
stores
MR SANDWE T.K. 110

111. IEC
Post natal review
oTo return for post natal review at 6 days and 6
weeks for assessment of general recovery and
uterine involution.
MR SANDWE T.K. 111

112. IEC
Danger signs
oTo watch out for danger signs such as; excessive or
heavy lochia, fowl smelling lichia, fever, distended
abdomen, severe abdominal tenderness.
MR SANDWE T.K. 112

113. IEC
Drug compliance
oTo strictly observe and adhere to directives given on
discharge on taking of medication, especially antibiotics
and haematinics
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114. Complications of PPH
•Hypovolemic shock due to severe haemorrhage
•Disseminated intravascular coagulation leading
to shock
•Anaemia and general weakness due to severe
blood loss
•Secondary haemorrhage due to infection
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115. Cont’...d
•Poor lactaction due to anaemia, lowered immunity
and chronic ill health
•Infection introduced by high rate of interference in the
course and treatment of primary postpartum
haemorrhage leading to puerperal sepsis
•Also due to retained product of conception with sub
involution of the uterus.
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116. Cont’...d
•Multiple organ failure for example
brain,kidney,liver,lung and retinal damage due to
severe haemorrhage
•Sheehan syndrome or Simmond’s
diseases(pituitary necrosis) due to severe
haemorrhage
•Development of cardiac complications
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117. Cont’...d
•Secondary PPH due to retained products of
conception,
•Fear of further pregnancies. This leads to
reluctance on mothers to conceive after such
experiences.
•Puerperal sepsis may occur secondary to anaemia
•Maternal death due to excessive loss of blood
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118. Summary
• PPH is bleeding from the birth canal after delivery of the
baby
•PPH is one of the highest causes of maternal mortality
among women in the world
• worse in developing countries
• It can occur within 24 hours of labour (Primary PPH) or
any time after 24hours of delivery up to the end of
puerperium.
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119. Cont’...d
•The most critical being within the first 24hours
after labour.
•It is a life threatening complication which
must be managed promptly and effectively.
•Prevention is the best management.
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120. Cont’...d
•The signs of PPH are;
• excessive loss of blood, restlessness,
•weakness, dizziness, tachycardia,
• lowered blood pressure and fainting.
•Early detection of PPH helps in management
and saving of life.
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121. Cont’...d
•Women at risk include;
•Maternal age 35 or over
•Delivery after APH
•Multiple pregnancy
•Polyhydramnios
•Past history of PPH
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122. Cont’...d
• Prolonged labour
• Severe pre-eclampsia/eclampsia
• Prolonged IUD
• Anaemia
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123. Cont’...d
• SERVE MOTHERS GIVING LIFE, THEREFORE,NO WOMAN SHOULD DIE
WHILE GIVING LIFE.
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124. References
• Sellers P.M (1994), Midwifery Text book and reference, Juta and
company Ltd, South Africa.
• Sweet B.M. (1997), Mayer’s Midwifery A Textbook for Midwives
London New York
• Hanretty Kelvin P. (2003), Obstetrics Illustrated, 6th Edition, Churchill
Livingstone, UK.
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125. Cont’...d
•Myles, F.M. (1985), Text Book for Midwives, 14th
edition, Churchill Livingstone, London.
•Pauline McCall Sellers, (1997), Midwifery,
Volume 2, third impression, Creda Press (pty)
Eliot avenue , Cape Town, South Africa.
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126. Cont’...d
•Henderson .C. and MacDonald’s. (2004), Mayes’s
Midwifery (a text book for midwives), Elsevier
ltd, London
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127. THE END
127
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