Professional Documents
Culture Documents
High parity
Overdistended uterus
General anesthesia
Poorly perfused myometrium
Prolonged labour
Following augmented labour
Uterine atony in previous labour
Chorioamnionitis
Malformation of uterus
Uterine fibroid
Very rapid labour
Mismanaged third stage of labour
Constriction ring:
Incomplete separation of placenta
Retained placenta
Abnormally adherent
Avulsed cotyledon, succenturiate lobe
Placenta previa
Placental abruption
A full bladder
Traumatic( 20%):
Combination of atonic and traumatic causes
Blood coagulation disorders, acquired or congenital:
Other risk factors are;
Antepartum hemorrhage
History of PPH or retained placenta
Anaemia
Ketoacidosis
HIV/AIDS
Clinical Features
COMMUNICATE.
RESUSCITATE.
MONITOR / INVESTIGATE.
STOP THE BLEEDING.
Management of 3rd stage
hemorrhage
The principles in the management are:
To empty the uterus of its content and to make it
contract.
To replace the blood. If in shock, then manage shock.
To ensure effective hemostasis in traumatic bleeding.
Placental site bleeding
Palpate the fundus and massage the uterus to make it
hard.
Ergometrine 0.25mg or methergine 0.2mg is given
intravenously.
Start a dextrose saline drip and arrange for blood
transfusion, if necessary.
Catheterise the bladder, if it is found to be full.
Sedation may be given with morphine 15mg
intramuscularly.
Manual Removal of Placenta
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
Difficulties:
Hour – glass contraction
Morbid adherent placenta
Complications :
Haemorrhage due to incomplete removal
Shock
injury to the uterus (rare)
infection
inversion
Subinvolution
Thrombophlebitis
Embolism.
Management of true post partum
haemorrhage
Principles
To diagnose the cause of bleeding.
To take prompt and effective measures to control
bleeding.
To correct hypovolemia.
Management
Immediate measures:
Call for help.
Head down tilt
Oxygen by mask, 8 litres / min
Put in two large bore,14 gauge, cannula.
Send blood for grouping and cross matching and ask for 2
units of blood.
Infuse rapidly 2 litres of NS (crystalloids) or plasma substitutes
Use a warming device and a pressure cuff.
Monitor BP and pulse every 25min, tem. every 4 hr.
Monitor type and amount of fluids the patient has
received, urine output, drugs- type, dose and time, CVP.
Actual Management:
note the feel of the uterus.
Atonic uterus
Step 1: Massage the uterus to make it hard.
Step 2: Explore the uterus under GA
Step 3: Uterine massage and bimanual compression.
Step 4: Uterine tamponade
Step 5: Surgical methods
Step 6: hystrectomy
surgery
Ligation of uterine arteries
Ligation of the ovarian and uterine artery anostomasis.
Ligation of the anterior division of internal iliac artery
(unilateral or bilateral).
B- Lynch brace suture and haemostatic suturing
Angiographic arterial embolisation under fluoroscopy
Secondary PPH
Causes:
The causes are,
Retained bits of placenta or membranes.
Infection and separation of slough over a deep cervico-
vaginal laceration.
Endometritis and subinvolution of the placental site
Withdrawal bleeding following oestrogen therapy for
suppression of lactation.
Other rare causes are—chorion epithelioma; carcinoma of
cervix, infected fibroid or fibroid polyp and puerperal
Diagnosis:
Principles—
(1) To assess the amount of blood loss and to replace
the lost blood.
(2) To find out the cause and to take appropriate steps
to rectify it.
Supportive therapy:
Blood transfusion, if necessary; Inj Ergometrine 0.5mg
IM, if the bleeding is uterine in origin, antibiotics as
routine.
Conservative:
If the bleeding is slight and no apparent cause is
detected, a careful watch for a period of 24hrs or so is
done in hospital.
Active treatment:
As the commonest cause is due to retained bits of
placenta or membranes, it is preferable to explore the
uterus urgently under GA. The products are removed
by ovum forceps. Gentle curettage is done by using
flushing curette. Ergometrine 0.5mg is given IM.If
bleed is from sloughing of wound of cervico- vaginal
canal, control it by suturing.
Complications
Shock
Collapse
Disseminated intravascular coagulation
Nursing Management
Deficient fluid volume r/t excessive blood loss
secondary to uterine atony, lacerations, incisions,
coagulation defects, retained placental fragments,
hematomas
Fear and anxiety r/t threat to physical being, deficient
knowledge of treatment .
Pain r/t uterine contractions, distention from blood
between uterine wall and placenta.
Risk for complication, shock related to excessive
bleeding
Interrupted breast feeding r/t mother’s health state
during the PPH.
Risk for impaired parent/ infant bonding r/t lack of
early parent/ infant contact.
Interrupted family process r/t change in family roles,
inability to assume usual role and prolonged recovery
period.
RETAINED PLACENTA
placenta is said to retained when it is not expelled out
even 30 minutes after the birth of the baby.
Causes:
Placenta completely separated but retained is due to
poor voluntary expulsive efforts.
Simple adherent placenta is due to uterine atonicity in
cases of grand multipara, over distension of the uterus,
prolonged labour, uterine malformation or due to
bigger placental surface area. The commonest cause of
retention of non-separated placenta is atonic uterus.
Morbid adherent placenta- partial or rarely
incomplete.
Placenta incarcerated following partial or complete
separation due to constriction ring, premature
attempts to deliver placenta before it is separated
Diagnosis:
Haemorrhage
Shock is due to blood loss, at times unrelated blood
loss, specially when retained more than one hour,
Frequent attempts of abdominal manipulation to
express the placenta out
Puerperal sepsis
Risk of recurrence in next pregnancy.
PLACENTA ACCRETA
It is defined as an extreme rare form in which the
placenta is directly anchored to the myometrium
partially or completely without any intervening
deciduas. The abnormal adherence may involve all
lobules—total placenta accreta. Or, it may involve
only a few to several lobules— partial placenta
accreta. All or part of a single lobule may be
attached— focal placenta accreta.
PLACENTA INCRETA
placenta increta, villi actually invade into the
myometrium and anchored into the muscle bundles.
PLACENTA PERCRETA
with placenta percreta, villi penetrate through the
myometrium upto the serosal layer.
Associated Conditions
placenta previa,
prior cesarean delivery,
previously undergone curettage
gravida 6 or more.
MSAFP levels exceeded 2.5 MoM;
Diagnosis
Haemorrhage
Shock
Infection
Inversion of uterus
INVERSION OF THE UTERUS
Definition:
It is extremely rare but a life threatening complication
in third stage in which the uterus is turned inside out
partially or completely.
Varieties:
Spontaneous: 40%
Iatrogenic:
Diagnosis:
Symptoms:
Acute lower abdominal pain with bearing down
sensation
Signs:
Varying degree of shock is a constant feature
Abdominal examination
Bimanual examination
In complete variety pear shaped mass protrudes
outside the vulva with broad end pointing downwards
and looking reddish purple in colour
Prevention: