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Post partum haemorrhage

MIDWIFERY NURSING

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Post partum haemorrhage

  1. 1. POST PARTUM HAEMORRHAGE - A Challenge To Safe Motherhood
  2. 2. WEL COME TO Taj Mahal Taj Mahal-One of the seven wonders of the world, One of the Greatest monuments, dedicated to the memory of “Queen Mumtaz” who died in child birth, by her husband “Emperor Sahajahan”, is a testimony and a grim reminder of the tragedy of maternal mortality, that can befall any women in childbirth. Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 2
  3. 3. Obstetric Haemorrhage --- Ranks as the First cause of maternal mortality accounting for 25 – 50 % of maternal deaths POST ARTUM HAEMORRHAGE though preventable, accounts for the majority of the cases of obstetric haemorrhage, the other causes being – antepartum haemorrhage, abortion, ectopic pregnancy and ruptured uterus. Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 3
  4. 4. POST PARTUM HAEMORRHAGE . . . the most common and severe type of obstetric haemmorrhage, is an enigma even to the present day obstetrician as it is sudden, often unpredicted, assessed subjectively and can be catastrophic. The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period. Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 4
  5. 5. MAGNITUDE OF THE PROBLEM Direct Causes (%) of Mat.Mort. in selected countries* Country +MMR Haemorrhage Sepsis Toxaemia Abortion Obstructed Labour INDIA 874 18 14 16 14 03 Bangladesh 600 22 03 19 31 09 Ethiopia 566 6 2 6 25 4 Tanzania 678 18 15 03 17 -- Zambia 118 17 15 20 17 -- USA 15 10 08 17 06 03 *World watch paper 102Jacobson JL ed, 1991 Mar 5, 2014 +MMR – Maternal Mortality Rate / 100000 live births PPH- Prof.S.N.panda & Dr.A.Patnaik 5
  6. 6. MAGNITUDE OF THE PROBLEM Causes of Mat.Mort. In India Cause Reg.Gen. India (1992) FOGSI (1982) 23.7% 22.3% Toxaemia 15.2 10.7 Puerperal Sepsis 08.1 28.4 Anaemia 19.4 - Obstructed Labour 07.1 - Abortion 11.8 - Others 14.7 - Haemorrhage Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 6
  7. 7. MAGNITUDE OF THE PROBLEM CAUSES OF 110 MATERNAL DEATHS AT OUR HOSPITAL FROM 1/1996-7/2000 120 NUMBER 100 80 11 OTHERS 4 5 7 MALARIA 12 ANAEMIA 60 17 40 23 RUPTURED UERUS UNSAFE ABORTION VIAL HEPATIIS PIH 20 0 Mar 5, 2014 31 HAEMORRHAGE CAUSES PPH- Prof.S.N.panda & Dr.A.Patnaik 7
  8. 8. MAGNITUDE OF THE PROBLEM PPH - A world of difference Year Developing Countries 1930 1:3000 Births Not Available 1950 1:20,000 Not Available 1980 1:60,000 1:1000 2000 Mar 5, 2014 Developed Countries 1:100,000 1:5000 PPH- Prof.S.N.panda & Dr.A.Patnaik 8
  9. 9. POST PARTUM HAEMORRHAGE DEFINITION: - Blood loss of 500ml or more per vaginum during the first 24hrs after the delivery of the baby. Risk of Maternal Mortality & Morbidity are 50 times more after PPH Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 9
  10. 10. ASSESSMENT OF BLOOD LOSS AFTER DELIVERY  Difficult  Mostly Visual estimation (So, Subjective & Inaccurate)  Underestimation is likely  Clinical picture -Misleading  Our Mothers-Malnourished, Anaemic, Small built, Less blood volume Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 10
  11. 11. MECHANISM OF HAEMOSTASIS AFTER DELIVERY • Uterine contraction & retraction • Platelet aggregation → clot formation Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 11
  12. 12. Why PPH ? 1. Uterine atony (80%) 2. Retained Placenta 3. Trauma to genital tract 4. Coagulation disorders 5. Uterine inversion Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 12
  13. 13. 1. UTERINE ATONY RISK FACTORS  Over distension of uterus  Induction of labour  Prolonged / precipitate labour  Anaesthesia (halogeneted) & analgesia  Tocolytics (Tocolytics (also called anti-contraction medications or labor repressants) are medications used to suppress premature labor )  APH  Grand multiparity  Mismanagement of 3rd stage of Labour  Full bladder Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 13
  14. 14. 2. RETAINED PLACENTA Simple adhesion Morbid adhesion>Accreta, Increta & Percreta 3. TRAUMATIC  Large episiotomy & extensions  Tears & lacerations of perineum, vagina or cervix  Haematoma  Uterine rupture Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 14
  15. 15. Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 15
  16. 16. 4. COAGULATION DISORDERS Abruptio placentae Sepsis :IUD,PROM(premature rupture of membrane) Massive blood loss Massive blood transfusion Severe PET (Pre-eclamptic Toxemia)/ Eclampsia Amniotic fluid embolism Hepatitis Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 16
  17. 17. 5. UTERINE INVERSION ←Incomplete InversionFundus felt through the Cx Complete Inversion with placenta accreta attached to the fundus→ Mostly iatrogenic due to mismanagement of 3rd stage - strong traction on the cord with a relaxed uterus / adherent placenta. Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 17
  18. 18. SYMPTOMS & SIGNS Blood loss Systolic BP Signs & Symptoms (% B Vol) ( mm of Hg) 10-15 Normal postural hypotension 15-30 slight fall ↑PR, thirst, weakness 30-40 60-80 pallor,oliguria, confusion 40+ 40-60 anuria, air hunger, coma, death Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 18
  19. 19. PREVENTION Regular ANC Correction of anaemia Identification of high risk cases Delivery in hospital with facility for Emergency Obstetric Care.  Otherwise transport to the nearest such hospital at the earliest.      Keep speedy transport available  Local / Regional anaesthesia  ACTIVE MANAGEMENT OF 3RD STAGE OF LABOUR  4th Stage of labour - Observation, Oxytocin Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 19
  20. 20. ACTIVE MANAGEMENT OF 3RD STAGE OF LABOUR (WHO-1989)  Oxytocics - Routine use in third stage → blood loss ↓ by 30-40%  10 Units Oxytocin IV bolus  Syntometrine 1 Amp IV  Ergometrine 1 Amp IV  Carboprost ( better than Ergometrine) 0.125 – 0.25 Mg IM  Early cord clamping  Controlled cord traction  Inspection of placenta & lower genital tract Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 20
  21. 21. MANAGEMENT OF PPH  TEAM- Obstetrician, Anesthesiologist, Haematologist and Blood Bank  Correction of hypovolaemia  Ascertain origin of bleeding  Ensure uterine contraction  Surgical management  Management of special situation Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 21
  22. 22. MANAGEMENT OF PPH CORRECTION OF HYPOVOLEMIA  Large bore IV line (two)  Crystalloids (RL)-3ml / ml of blood loss  Urine output (desired) –30ml / hr  Whole blood / pack cell Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 22
  23. 23. MANAGEMENT OF PPH ENSURE UTERINE CONTRACTION  Palpate fundus  Uterine massage  Bimanual compression  Compression of Aorta against sacral promontory  Foleys catheters Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 23
  24. 24. MANAGEMENT OF PPH OXYTOCICS  Oxytocin:  Bolus of 10 units IV followed by Continuous Infusion 100 mu / min  Ergometrine 0.2 - 0.5mg IV  Prostaglandins Carboprost- 0.25mg start, Rpt.15-30 min, Maximum 2.0mg, Route-IM / intramyometrial  Sulprostone- 400-600 micro gm Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 24
  25. 25. MANAGEMENT OF PPH OTHER MODES  M.A.S.T (Military Anti Shock Treatment)  UTERINE PACKING  UTERINE TAMPONADE • Large bulb Foleys • Sangstaken blakemole tube Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 25
  26. 26. MANAGEMENT OF PPH SURGICAL TREATMENT Depends on  Extent & cause of haemorrhage  General condition of patient  Future reproduction  Experience & skill Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 26
  27. 27. MANAGEMENT OF PPH SURGICAL TREATMENT        Mar 5, 2014 Repair of trauma if any Uterine Artery ligation Utero ovarian A. Ligation Internal Iliac A. Ligation Brace suturing of Uterus Hysterectomy Angiographic embolisation PPH- Prof.S.N.panda & Dr.A.Patnaik 27
  28. 28. MANAGEMENT OF PPH RETAINED PLACENTA  EUA(examination Under Anaesthesia & Manual Removal  If Placenta accretaObservation Cytotoxic drugs- Methotrexate Hysterectomy Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 28
  29. 29. MANAGEMENT OF PPH ACUTE INVERSION OF UTERUS  Manual replacementUnder GA / Uterine relaxant  Hydrostatic method  Surgical method ( Usually delayed procedure) Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 29
  30. 30. MANAGEMENT OF PPH MANAGEMENT OF DIC  Fresh blood transfusion  Blood products Cryoprecipitate Fresh frozen plasma Platelet concentrate Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 30
  31. 31. MORBIDITY & MORTALITY from PPH  Shock & DIC  Renal Failure  Puerperal sepsis  Lactation failure  Blood transfusion reaction  Thromboembolism  Sheehan’s syndrome  >25% Maternal deaths are due to PPH Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 31
  32. 32. Intelligent anticipation, skilled supervision, prompt detection and effective institution of therapy can prevent disastrous consequences of PPH. Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 32
  33. 33. Mar 5, 2014 PPH- Prof.S.N.panda & Dr.A.Patnaik 33

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