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MS.SASIKALA.N
MSC (N),OBSTETRICS AND GYNECOLOGICAL NURSING
LECTURER
GANGA COLLEGE OF NURSING
COIMBATORE
Post Partum Haemorrhage
Content Overview
• Introduction
• Definition Of PPH
• Risk factors
• Causative factors
• Pathophysiology
• Clinical symptoms
• Diagnostic evaluation
• Management
• Complications
Introduction
• Postpartum Haemorrhage (PPH) is an obstetric
Emergency. It is one of the top five causes of
maternal mortality in both high and low per capita
income countries.
• Any blood loss than has potential to produce
hemodynamic instability after delivery.
Definition - PPH
• 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 Mother, evidenced by
Increase in Pulse rate and Falling in blood
pressure is called Postpartum Haemorrhage.
Types
Primary
PPH
Secondary
PPH
Haemorrhage occurs within
24hours following the birth
of the baby
Haemorrhage occurs beyond
24hours and within
puerperium
Predisposing Factors
Antepartum
• Previous PPH or Manual Removal
• Abruption or praevia
• Fetal demise
• Gestational hypertension
• Over distended uterus
• Bleeding disorder
Cont..
Intrapartum
• Operative delivery
• Prolonged or rapid labour
• Induction or augmentation
• Chorio amnionitis
• Shoulder dystocia
• Internal podalic version
• Coagulopathy
Cont..
Postpartum
• Lacerations or episiotomy
• Retained placental/placental abnormalities
• Uterine rupture/inversion
• coagulopathy
Risk Factors
Antenatal
• Pre Eclampsia
• Gestational hypertension
• Previous PPH
• Abruption
• Placenta praevia
• Multiple pregnancy
• Obesity (BMI : >30)
• Anaemia
• Uterine anomalies
• Uterine fibroids
Intranatal
• Retained placenta
• Episiotomy
• Instrumental
• Prolonged labour
• >4kg baby
• Pyrexia
Etiology Factors
4T’s
• Tone : Uterine Atony
• Tissue : Retained
Placenta
• Trauma : Lacerations,
Uterine Rupture
• CloTTing (Thrombin):
Coagulopathy
Tone (abnormality of uterine
contraction)
• Over distended uterus
• Uterine muscle exhaustion
• Intra amniotic infection
• Functional/anatomical
distortion of uterus
Tissue (retained product of
conception)
• Retained products
• Abnormal placenta
• Placenta praevia/abruptio
placenta
• Blood clots and cotyledons
Thrombin (abnormality of
coagulation)
• Coagulopathy
• Therapeutic
Trauma (at genital tract)
• Cervix, vagina,perineal
lacerations
• Caesarean section laceration
• Uterine rupture
• Uterine inversion
4T’s aetiology of
primary PPH
Clinical Manifestation
Vaginal bleeding – Slow trickle or rarely Copious discharge
Uterus –Feels soft and Poorly contracted(boggy uterus)
Altered Level of Consciousness
Restlessness, and Drowsiness
Irritable, Pallor
Hypovolemic shock and Oliguria
Tachycardia, Narrow Pulse Pressure
Diagnosis
• State of uterus :
In Traumatic Haemorrhage – Uterus found
well contracted
In Atonic Haemorrhage – Uterus becomes
Flabby and Hard on massaging
• Estimation of blood loss
• Laboratory Investigation – Complete Blood Count
• Exploration of Birth canal to rule out extension of
injury to remove the Placental bits.
Prevention
Improve health
status of women Identify High
risk Mother
Blood Grouping
to be done
Placental Localisation to
be done Women with
previous C-Section
Exclude Morbid
Adherent
Placenta
Antenatally
Cont…
Women deliverd
by C-Section
Expert obstetric
anaesthetist is
needed
Cases with induced or
augmented by
oxytocin continued 1
hr after delivery
Examination of
placenta and
membrane should
be a routine
AMTSL for all
women in labour
reduces PPH
Intranatally
Management of 3rd stage bleeding
Principles
 To empty the uterus of its contents and to make it
concern
 To replace the blood
 To ensure effective haemostasis in traumatic
bleeding
 Steps of management
Placental site bleeding
Traumatic bleeding
Placental site bleeding
• To palpate the fundus and massage the
uterus to make it hard. If bleeding continues
even after the massaging then suggest the
presence of Genital Tract Injury.
• To start Crystalloid solution
• Start oxytocin 10units IM or IV Methergin
0.2mg
• To Catheterise the bladder
Cont..
• If separation of placenta is evident, then the
expression of placenta is done by fundal pressure
or control cord traction.
• If features, are not evident go with the procedure
i.e Manual Removal of placenta
Traumatic site bleeding
• Utero Vaginal Canal to be explored under General
Anaesthesia after the placenta is expelled and
Haemostatic sutures are placed on the offending
sites.
Management of True PPH
Principles
• Communication
• Resuscitation
• Monitoring
• Arrest of Bleeding
Cont..
• Identify and treat the cause of blood loss
• Call for help
• Resuscitation
• Assess the “ABC”
• Monitor BP,PR and RR
• Empty Bladder and Monitor Urine output
• IV line – Crystalloid
• Fluid replacement – Isotonic and Crystalloid
• Oxygen by mask
How much time do we have?
 2 hours from Postpartum Haemorrhage
 12 hours from Antepartum Haemorrhage
 2 days from Obstructed Labour
 6 days from Infection
Pitfalls in Assessing Quality of Blood Loss
Medical Therapies
General Practice
Active Management of 3rd Stage of
Labour
Active Management of 3rd Stage of
Labour
Administer a uterus contracting drug – e.g
Oxytocin, Misoprostol within one minute.
Applying controlled cord traction and
counter Traction to the uterus.
Massaging the fundus of the uterus through
the abdomen.
Monitoring for further signs of bleeding.
Mangement of PPH
First Line of Therapy
 Oxytocin
 Ergometrine
 Misoprostol
Second line of therapy
 Fundal Massage and Uterine Tamponade
 Surgical management
 Radiological embolization
 Haemostatic drugs e.g. Tranexaminc acid
First Line of Therapy
Uterotonic agents
• Oxytocin : 5 units IV bolus
20units/lit in NS
10units Intra Myometrial, Transabdominally
• Ergometrine : 0.25mg IM or 1.25mg IV
Maximum dose is 1.25mg
• Cytotec(misprostol )PG E1
800 – 1000mcg PR
Second Line of Therapy
Fundal massage and Compression
Fundal Massage
Bimanual
Compression
Uterine Tamponade Intra Uterine Packing
Surgical Intervention
Ligation of Uterine
Arteries
Ligation of Utero
Ovarian Arteries
B-Lynch Compression and
Multiple Square Sutures
Ligation of Anterior
division of Internal
iliac Artery
Hysterectomy
Radiological Embolization
Angiographic arterial
embolization(bleeding vessel)
Post Partum Haemorrhage

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Post Partum Haemorrhage

  • 1. MS.SASIKALA.N MSC (N),OBSTETRICS AND GYNECOLOGICAL NURSING LECTURER GANGA COLLEGE OF NURSING COIMBATORE
  • 3. Content Overview • Introduction • Definition Of PPH • Risk factors • Causative factors • Pathophysiology • Clinical symptoms • Diagnostic evaluation • Management • Complications
  • 4. Introduction • Postpartum Haemorrhage (PPH) is an obstetric Emergency. It is one of the top five causes of maternal mortality in both high and low per capita income countries. • Any blood loss than has potential to produce hemodynamic instability after delivery.
  • 5. Definition - PPH • 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 Mother, evidenced by Increase in Pulse rate and Falling in blood pressure is called Postpartum Haemorrhage.
  • 6. Types Primary PPH Secondary PPH Haemorrhage occurs within 24hours following the birth of the baby Haemorrhage occurs beyond 24hours and within puerperium
  • 7. Predisposing Factors Antepartum • Previous PPH or Manual Removal • Abruption or praevia • Fetal demise • Gestational hypertension • Over distended uterus • Bleeding disorder
  • 8. Cont.. Intrapartum • Operative delivery • Prolonged or rapid labour • Induction or augmentation • Chorio amnionitis • Shoulder dystocia • Internal podalic version • Coagulopathy
  • 9. Cont.. Postpartum • Lacerations or episiotomy • Retained placental/placental abnormalities • Uterine rupture/inversion • coagulopathy
  • 10. Risk Factors Antenatal • Pre Eclampsia • Gestational hypertension • Previous PPH • Abruption • Placenta praevia • Multiple pregnancy • Obesity (BMI : >30) • Anaemia • Uterine anomalies • Uterine fibroids Intranatal • Retained placenta • Episiotomy • Instrumental • Prolonged labour • >4kg baby • Pyrexia
  • 11. Etiology Factors 4T’s • Tone : Uterine Atony • Tissue : Retained Placenta • Trauma : Lacerations, Uterine Rupture • CloTTing (Thrombin): Coagulopathy
  • 12. Tone (abnormality of uterine contraction) • Over distended uterus • Uterine muscle exhaustion • Intra amniotic infection • Functional/anatomical distortion of uterus Tissue (retained product of conception) • Retained products • Abnormal placenta • Placenta praevia/abruptio placenta • Blood clots and cotyledons Thrombin (abnormality of coagulation) • Coagulopathy • Therapeutic Trauma (at genital tract) • Cervix, vagina,perineal lacerations • Caesarean section laceration • Uterine rupture • Uterine inversion 4T’s aetiology of primary PPH
  • 13. Clinical Manifestation Vaginal bleeding – Slow trickle or rarely Copious discharge Uterus –Feels soft and Poorly contracted(boggy uterus) Altered Level of Consciousness Restlessness, and Drowsiness Irritable, Pallor Hypovolemic shock and Oliguria Tachycardia, Narrow Pulse Pressure
  • 14. Diagnosis • State of uterus : In Traumatic Haemorrhage – Uterus found well contracted In Atonic Haemorrhage – Uterus becomes Flabby and Hard on massaging • Estimation of blood loss • Laboratory Investigation – Complete Blood Count • Exploration of Birth canal to rule out extension of injury to remove the Placental bits.
  • 15. Prevention Improve health status of women Identify High risk Mother Blood Grouping to be done Placental Localisation to be done Women with previous C-Section Exclude Morbid Adherent Placenta Antenatally
  • 16. Cont… Women deliverd by C-Section Expert obstetric anaesthetist is needed Cases with induced or augmented by oxytocin continued 1 hr after delivery Examination of placenta and membrane should be a routine AMTSL for all women in labour reduces PPH Intranatally
  • 17. Management of 3rd stage bleeding Principles  To empty the uterus of its contents and to make it concern  To replace the blood  To ensure effective haemostasis in traumatic bleeding  Steps of management Placental site bleeding Traumatic bleeding
  • 18. Placental site bleeding • To palpate the fundus and massage the uterus to make it hard. If bleeding continues even after the massaging then suggest the presence of Genital Tract Injury. • To start Crystalloid solution • Start oxytocin 10units IM or IV Methergin 0.2mg • To Catheterise the bladder
  • 19. Cont.. • If separation of placenta is evident, then the expression of placenta is done by fundal pressure or control cord traction. • If features, are not evident go with the procedure i.e Manual Removal of placenta
  • 20. Traumatic site bleeding • Utero Vaginal Canal to be explored under General Anaesthesia after the placenta is expelled and Haemostatic sutures are placed on the offending sites.
  • 21. Management of True PPH Principles • Communication • Resuscitation • Monitoring • Arrest of Bleeding
  • 22. Cont.. • Identify and treat the cause of blood loss • Call for help • Resuscitation • Assess the “ABC” • Monitor BP,PR and RR • Empty Bladder and Monitor Urine output • IV line – Crystalloid • Fluid replacement – Isotonic and Crystalloid • Oxygen by mask
  • 23. How much time do we have?  2 hours from Postpartum Haemorrhage  12 hours from Antepartum Haemorrhage  2 days from Obstructed Labour  6 days from Infection
  • 24. Pitfalls in Assessing Quality of Blood Loss
  • 26. General Practice Active Management of 3rd Stage of Labour
  • 27. Active Management of 3rd Stage of Labour Administer a uterus contracting drug – e.g Oxytocin, Misoprostol within one minute. Applying controlled cord traction and counter Traction to the uterus. Massaging the fundus of the uterus through the abdomen. Monitoring for further signs of bleeding.
  • 28. Mangement of PPH First Line of Therapy  Oxytocin  Ergometrine  Misoprostol Second line of therapy  Fundal Massage and Uterine Tamponade  Surgical management  Radiological embolization  Haemostatic drugs e.g. Tranexaminc acid
  • 29. First Line of Therapy Uterotonic agents • Oxytocin : 5 units IV bolus 20units/lit in NS 10units Intra Myometrial, Transabdominally • Ergometrine : 0.25mg IM or 1.25mg IV Maximum dose is 1.25mg • Cytotec(misprostol )PG E1 800 – 1000mcg PR
  • 30. Second Line of Therapy Fundal massage and Compression Fundal Massage Bimanual Compression
  • 31. Uterine Tamponade Intra Uterine Packing
  • 32. Surgical Intervention Ligation of Uterine Arteries Ligation of Utero Ovarian Arteries
  • 33. B-Lynch Compression and Multiple Square Sutures Ligation of Anterior division of Internal iliac Artery