POSTPARTAL OBSTETRIC

EMERGENCIES

BY

TARSIS HENITA .H.J

ASSOCIATE PROFESSOR
DEPARTMENT OF OBSTETRIC AND
GYNAECOLOGIC NURSING
Dr.S.M.C.S.I.COLLEGE OF NURSING
KARAKONAM
POST PARTUM HAEMORRHAGE

ACUTE UTERINE INVERSION

POST PARTUM SHOCK

POST PARTUM
HAEMORRHAGE
 DEFINITION

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 patient
as evidenced by rise in pulse rate and fall in
blood pressure is called post partum
haemorrhage
 INCIDENCE

1% among hospital deliveries

 TYPES

Primary post partum haemorrhage

Secondary post partum haemorrhage

 PRIMARY
POSTPARTUM
HAEMORRHAGE
Haemorrhage with in 24 hours
following birth of the baby
Third stage haemorrhage – Bleeding
before expulsion of placenta
True post partum haemorrhage –
Bleeding subsequent to expulsion of
placenta
SECONDARY POST PARTUM
HAEMORRHAGE

Haemorrhage beyond 24
hours and with in
puerperium
 ETIOLOGY
PRIMARY POST PARTUM
HAEMORRHAGE
 Atonic uterus
 Trauma
 Mixed(Atonic & Traumatic)
 Blood coagulopathy
SECONDARY POST PARTUM
HAEMORRHAGE
 Retained bits of cotyledon or membrane
 Separation of slough over a deep cervico-
vaginal laceration following infection
 Subinvolution of the placental site
 Secondary haemorrhage from caesarean
section wound
 Withdrawal bleeding following oestrogen
therapy for suppression of lactation
 Rare causes - Carcinoma cervix
- Placental polyp
- Infected fibroid / polyp
- Inversion of uterus
PREDISPOSING FACTORS OF
ATONICITY OF UTERUS
 Grand multipara
 Over distention of the uterus
 Malnutrition and anaemia
 Antepartum haemorrhage
 Prolonged labour
 Anaesthesia
 Initiation or augmentation of delivery by
oxytocin
 Persistent uterine distention
 Malformation of the uterus
 Uterine fibroid
 Mismanaged third stage of labour
 Constriction ring
 Precipitate labour
 DIAGNOSIS
 Postpartum haemorrhage is usually external
 It may, however, be partly concealed from
distension of the uterus or the vagina with
blood clots
 Concealed haemorrhage is confirmed by
squeezing the uterus firmly, when the blood
will be forced out with a gush
 PREVENTION
ANTEPARTUM
Improvement of the health
 analgesics
status
 Screening mothers at risk for
PPH and conducting delivery
in well equiped hospital
INTRAPARTUM
Judicious administration of sedatives and

Avoid hasty delivery of baby

 Prefer local or caudal anaesthesia for
instrumental vaginal delivery
 Active management of the third stage
 Avoid fiddling or kneading the uterus
 Avoid pulling the cord
 Routine examination of the placenta and
membranes for completeness
 Continue IV oxytocin for atleast 1hour after
delivery
 Administer ergometrine with the delivery of
anterior shoulder
 Routine exploration of utero-vaginal canal for
evidence of trauma
 Close monitoring of mother for atleast 2 hours
following delivery
 COMPLICATIONS

 Haemorrhage
 Shock
 Injury to the uterus
 Infection
 Inversion
 Subinvolution
 Thrombophlebitis
 Embolism
 SCHEME OF MANAGEMENT OF THIRD STAGE
HAEMORRHAGE
 Massage the uterus and make it hard
 Inj.Ergometrine 0.25 mg IV
 Inj.Morphine 15 mg IM
 Start 5% dextrose
 Arrange for blood transfusion
 Catheterise the bladder

Placenta separated Not separated

Normal placental Morbid adhesion
attachment
Express the placenta Manual removal if
out by controlled cord Manual removal separation possible /
traction under Hysterectomy
general anaesthesia
 SCHEME OF MANAGEMENT OF TRUE PPH
TO FEEL THE UTERUS BY ABDOMINAL PALPATION

Uterus flabby Uterus hard

. Massage the uerus and
. Inj.Ergometrine 0.25 Hysterectomy contracted
mg IV (Traumatic)
. Inj.Morphine 15mg IM Fails
. Start 5% dextrose
. Arrange for blood Conservative surgery Exploration
. Examine placenta
. Catheterise bladder
Intra uterine plugging / Haemostatic sutures
Uterus remains flabby Balloon tamponade on the
tear sites
Exploration of the uterus
Fails

Remains flabby
Bimanual compression
Repeat ergometrine
start oxytocin drip
Fails
Uterus flabby

Administration of PGE1
Administration of suppository
15 methyl PGF2alpha
20 IU in 500 ml Fails
ACUTE UTERINE INVERSION
 DEFINITION

Inversion is a condition where the uterus

becomes turned inside out; the fundus
prolapsing through the cervix
INCIDENCE

1 in 17000 to 1 in 200000 deliveries

 TYPES
COMPLETE INVERSION INCOMPLETE INVERSION

Fundus herniates completely Fundus is inverted but does

through the cervix and is not herniate through the
found lying in the vagina or cervix
seen out at the vulva
DEGREES
 FIRST DEGREE – Fundus is depressed and bulges into
the uterine cavity, fundus reaches the internal OS
 SECOND DEGREE – Fundus protrudes through the
external OS so as to enter the vaginal canal
 THIRD DEGREE – Uterus, cervix and vagina are
inverted and are visible
ETIOLOGY
 Excessive cord traction to manage the delivery of
placenta actively
 Combining fundal pressure and cord traction to
deliver the placenta
 Use of fundal pressure while the uterus is atonic to
deliver the placenta
 Pathologically adherent placenta
 Short umbilical cord
 Sudden emptying of a distended uterus
 CLINICAL MANIFESTATIONS
SYMPTOM
Acute lower abdominal pain with bearing
down sensation
SIGNS
 Varying degree of neurogenic and hypovolaemic shock
 Abdominal examination
 I Degree - Cupping or dimpling of the fundal surface
 II & III Degree – Fundus cannot be made out but a ring formed
by the neck of the inverted organ may sometimes be felt with
the fingers
 Vaginal examination
 I Degree – Mass felt at the level of internal OS
 II Degree – A polypoidal mass is felt in the vagina
 III Degree – A pear shaped mass protrudes outside the vulva
with the broad end pointing downwards and looking reddish
purple in colour
 DANGERS

 Shock
 Neurogenic
 Hypovolaemic
 Pulmonary embolism
 URGENT MANUAL REPLACEMENT
Principal steps:
 To replace that part first which is inverted last with the placenta
attached to the uterus by steady firm pressure exerted by the fingers
 To apply counter support by the other hand placed on the abdomen
 After replacement the hand should remain inside the uterus until the
uterus becomes contracted by parenteral oxytocics
 The placenta is to be removed manually only after the uterus becomes
contracted
 Gradually withdraw the hand
 Maintain uterine tone with the help of an oxytocic like
inj.methergine/prostaglandin F2 alpha
 Keep an infusion of oxytocin going for the next 8 to 12 hours to ensure
against recurrence of inversion
 MANAGEMENT AFTER SHOCK
PRINCIPAL STEPS
 The treatment of shock should be instituted vigorously
 Sedative analgesic to allay anxiety
 Infusion of crystalloid solution like 5% DNS
 Send the blood for cross-matching and start transfusion in time
 To push the uterus inside the vagina if possible and pack the vagina with
antiseptic roller gauze
 Foot end of the bed is raised
 Replacement of the uterus:
 Manual replacement
 Hydrostatic method (O’Sullivan’s method)
 Tocolytic agents like magnesium sulphate 2-4 mg administered slow
intravenously over 3-5 minutes often helps to relax the constricting cervical ring
to allow successful reposition
 HYDROSTATIC METHOD

 The inverted uterus is replaced into the vagina

 Warm sterile fluid (upto 5 litres) is gradually instilled
into the vagina through a douche nozzle
 The vaginal orifice is blocked by operator’s palms
supplemented by labial apposition around the palm by
an assistant
 The douche can be placed at a height of about 3 feet
above the uterus
 Water distends the vagina and the consequent increased
intra vaginal pressure leads to replacement of the uterus
 SURGICAL REPAIR

 Haultain’s operation:
 Laparotomy
 Dividing the posterior cervical rim
 Repositioning the uterine fundus
 Repair of posterior cervical rim
 Hysterectomy – as the last resort
Shock is defined as a state of circulatory
inadequacy with poor tissue perfusion resulting
in generalized cellular hypoxia
CLASSIFICATION

 Hypovolaemic shock
 Neurogenic shock
 Septic shock
 Cardiogenic shock
ETIOLOGY

HYPOVOLAEMIC SHOCK
 Postpartum haemorrhage

 Rupture of uterus

 Excessive fluid loss (associated with excessive

vomiting, diarrhoea, diuresis, too rapid removal
of amniotic fluid, etc)
ETIOLOGY

NEUROGENIC SHOCK
 Acute inversion of uterus

 Pulmonary embolism

 Aspiration of gastrointestinal contents during

general anaesthesia specially in caesarean
section
 Drug induced – associated with spinal
anaesthesia
 SCHEMATIC REPRESENTATION OF VARIOUS CLINICAL
FACTORS LEADING TO THE BASIC PATHOLOGICAL CHANGES
OF SHOCK
Stagnation of blood at Reduced venous
microcirculatory unit return
*Neurogenic *Stagnation of blood
*Late phase of at M.C.U
hypovolaemic *Pressure on I.V.C

*Fluid loss Failure of ventricular

*Blood loss INADEQUATE TISSUE PERFUSION filling
*Pulmonary embolism

METABOLIC ACIDOSIS

DIC CELLULAR DEATH

CLINICAL FEATURES OF SHOCK

CLINICAL FEATURES
EARLY PHASE(Compensatory phase)
 Tachycardia
 Diaphoresis
 Restlessness
 Anxious
CLINICAL FEATURES
INTERMEDIATE PHASE(Reversible phase)
 Hypotension
 Progressive paleness
 Tachycardia
 Diaphoresis
 Cold periphery
CLINICAL FEATURES
LATE PHASE(Irreversible phase)
 Hypotension
 Cold and clammy extremities
 Ashen grey skin
 Tachypnoea
 Feeble pulse
 Oliguria
 Mental confusion
 MANAGEMENT

BASIC MANAGEMENT OF SHOCK IS TO STOP THE

BLEEDING AND REPLACE THE VOLUME WHICH
HAS BEEN LOST
 Infusion and transfusion
 Maintenance of cardiac efficiency
 Administration of oxygen to avoid metabolic acidosis
 Pharmacologic therapy
 Control of haemorrhage
 INFUSION AND TRANSFUSION

 Blood
 Crystalloids (NS, DNS)

 Colloids (Haemaccel, Gelofusion)

MAINTENANCE OF CARDIAC EFFICIENCY

In a patient with border-line C.V.P.(12-16cm of

Water) 500 ml fluid at a rate of 20 ml/mt is
infused to maintain cardiac efficiency
 ADMINISTRATION OF OXYGEN TO AVOID
METABOLIC ACIDOSIS

 Early phase – Administration of oxygen by face

mask at a rate of 6-8 litres/minute
 Intermediate &late phase – Ventilation by
endotracheal intubation
PHARMACOLOGIC THERAPY

 Ionotropics:
 Adrenaline
 Noradrenaline
 Dopamine
 Dobutamine
 Vasodilators:
 Sodium nitro prusside
 Nitroglycerine
 corticosteroids:
 Hydrocortisone
 CONTROL OF HAEMORRHAGE

Specific surgical and medical treatment for

control of haemorrhage should start along with
the general management of shock