CHRISTIAN COLLEGE OF NURSING, NEYYOOR

CLINICAL TEACHING
ON
POST PARTUM
HAEMORRHAGE

Guided By Submitted By
Dr. Jeba Nesa Mahiba S.T. Anne Jakuline Princy .P
Associate Professor Ist year MSC Nursing
OBG Department OBG Department

SUBMITTED ON:
07-06-2023
 POST PARTUM HAEMORRHAGE

Name of the student : Anne JakulinePrincy .P

Year of study : M.Sc (N) I year

Name of the Subject : OBG

Topic : POST PARTUM HAEMORRHAGE

Time :

Duration : 1 hour

Method of Teaching : Lecture cum discussion

Date :
General Objectives:
The student will be able to adequate knowledge regarding post partum

haemorrhage and develop positive skill and attitude towards post partum

haemorrhage and able to apply their day to day life

Specific objectives :

The students will be able to

1. Introduce about post partum haemorrhage

2. define the term of post partum haemorrhage

3. enlist the types of post partum haemorrhage

4. determine the causes of the post partum haemorrhage

5. enlist the signs and symptoms of post partum haemorrhage

6. enumerate the prevention of post partum haemorrhage

7. illustrate the management of post partum haemorrhage

 Specific Teacher’s Learner’s Evalu
Time Content
Objectives Activity Activity -ation

POSTPARTUM

HAEMORRHAGE

INTRODUCTION:

Postpartum haemorrhage (PPH)

Introduce remains a major cause of maternal

about mortality and morbidity worldwide.

post Approximately, half a million

partum women die annually from causes

haemorrha related to pregnancy and child

ge birth. All pregnancies are at risk of

PPH even if no predisposing

factors are present The average

blood loss flowing vaginal

delivery, cesarean delivery and

cesarean hysterectomy is 500ml,

1000ml and 1500ml respectively.

 DEFINITION:

Any amount of bleeding from or

into the genital tract following birth

of the baby up to the puerperium,

which adversely affects the general

Define condition of the patient evidenced

the term by rise in pulse rate and blood

of post pressure is called Postpartum

partum haemorrhage. What

Teaching Listening
haemorrh - Dutta is PPH

age

PPH is generally defined as blood

loss greater than or equal to 500ml

with 24 hours after birth, while

severe PPH is blood loss greater

than or equal to 1000ml within 24

hours.

– WHO
 TYPES OF PPH:

 PrimaryPostpartum haemorrhage

 Secondary Postpartum

haemorrhage

Primary Postpartum

haemorrhage:

It is defined as excessive
Enlist the
bleeding that occurs within the first What
types of
24 hours after delivery. In the are the
post
majority, haemorrhage occurs Teaching Listening types
partum
within two hours following of
haemorrha
delivery. PPH
ge

These are of two types:

Third stage haemorrhage:

Bleeding occurs before expulsion

of placenta.

True Postpartum haemorrhage:

Bleeding occurs subsequent to

expulsion of placenta.
Secondary Postpartum

haemorrhage:

It is defined as excessive bleeding

that occurring between 24 hours

after delivery of the baby and 6

weeks postpartum.

Most of the PPH is due to retained

product of conception or inflection

or both combined. This condition

of Postpartum haemorrhage causes

hemorrhagic shock.

CAUSES:
What
 4T’s
are the
 Tone
Teaching Listening causes
 Tissue
of
 Trauma
PPH
 Thrombin
 Tone (Uterine Atony):

 The most common and

important cause of PPH

uterine atony.

 75-90% of cases

 Incomplete separation of
Determine
placenta
the causes
 Uterine hyper distention-
of post
o Macro semi baby
partum
o Multiple pregnancy
haemorrha
o Polyhydramnios
ge
 Previous PPH

 Placenta Previa

 Precipitated labour- less than

1 hour

 Prolonged labour- active

phase lasts more than 12

hours.

 Fibroids

 Obesity

 Age> 40 years old

Tissue

 Retained products of

conception, most often a

retained placental fragments

must be removed to stop

bleeding.

 Abruption placenta

 Blood clots

Trauma:

 5-10% cases

 Operative vaginal delivery

(vacuum/forceps)

 Perineal, vaginal and cervical

tears

 Lower segment tears

 Uterine rupture

 Trauma resulting from the

birth process can result in

significant blood loss.

 Thrombin:

 Disseninated intravascular

coagulation.

 Placental abruption

 Patient on anticoagulant

 Pre-existing bleeding

disorder like hemophilia

SIGNS AND SYMPTOMS OF

PPH:
Enlist the
 Vaginal bleeding is visible
signs and What
outside, either as slow trickle
symptoms are the
or rarely a copious flow.
of post signs
Rarely, the bleeding is
partum Teaching Listening and
concealed either remaining
haemorrha sympt
inside uterovesical canal or
ge oms of
in the surrounding tissue
PPH
space resulting in hematoma.

 Enlarged uterus, s it fills with

blood or blood clot. It feels

 boggy on palpation.

 Pallor

 Tachycardia

 Hypotension

 Altered level of

consciousness

 Restlessness

 Drowsiness

 Maternal collapse

PREVENTION:

PH cannot always be prevented.

Enumerate
However the incidence and
the
especially its magnitude can be
prevention What
reduced substantially by assessing
of post are the
the risk factors and following the
partum Teaching Listening preven
guidelines as mentioned below:
haemorrha tion of

ge PPH
ANTENATAL

Improvement of the health

status:

Improvement of the health status of

the women and to keep the

hemoglobin level normal

(>10gm/dl)

High risk patients:

Who are likely to develop

Postpartum haemorrhage (such as

twins, hydramnios, grand

multipare, APH, history of previous

PPH, severe anemia) are to be

screened and delivered in a well-

equipped hospital.

Blood grouping:

It should be done for all women so

that time is wasted during

emergency.

Placental localization:

It must be done in all women with

previous cesarean delivery by USG

or MRI to detect placenta accrete

orpercrete.

All women with prior cesarean

delivery:

All women with prior cesarean

delivery must have their placental

site determined by USG/MRI to

determine morbid adherent

placenta.

Intrenatal:

Active management of the third

stage of labor, for all women in

labor should be a routine as it

reduces PPH by 60%.

Cases with induced or augmented

labor by oxytocin, the infusion

should be continued for at least one

hour after the delivery.

Women delivered by cesarean

section, oxytocin 5IU slow IV is to

be given to reduce blood loss.

Exploration of the uterovaginal

canal for evidence of trauma

following difficult labor or

instrumental delivery.

Observation for about two hours:

after the delivery to make sure that

the uterus is hard and well

contracted before sending her to

delivery.

Expert obstetric anesthetist is

needed when the delivery is

conducted under general

anesthesia.

During cesarean section,

pontaneous separation and delivery

of the placenta reduces blood loss.

 Examination of the placenta and

membranes should be a routine to

detect at the earliest and the

missing part.

Management during third stage

labor:

Principles in the management:

 To remove the uterus of its

Illustrate contents (removal of placenta)

the and to make its contract. What

managae  To replace the blood. On are the

ment of occasion, patient may be in manag

Teaching Listening
post shock. In that case patient is ement

partum managed for shock first. of

haemorrha  To ensure effective hemostasis PPH

ge in traumatic bleeding.

Steps of management:

Placental site bleeding:

To palpate the fundus and

massage: the uterus to make it

hard. However, if bleeding

continues even after the uterus

becomes hard, suggests the

presence of genital tract injury.

To start crystalloids solution

(normal saline or Ringer’s lactate

solution) with sytous (1l with 20

units) at 60 drops per minute and to

arrange for blood transfusion, if

necessary.

Oxytocin 10 units IM or

methargine 0.2mg is given

intravenously. Carboetoceu, a

longer acting oxytocin derivative is

found (100mg) as effective as

oxytocin infusion.

To catherize the bladder.

To give antibiotics: (Ampicillin

2gm and metronidazole

500mgIV).

During this procedure, if

features of placental separation are

evident, expression of the placenta

is done by fundal pressure or

controlled contradiction method. If

the placenta under general

anesthesia is to be done.

Management of traumatic

bleeding:

The uterovaginal canal is to be

explored under general anesthesia

after the placenta is expelled and

hemostatic sutures are placed on

the offending sites.

Steps of manual removal of

placenta:

Step 1: The operation is done

under general anesthesia. In

extreme urgency where anesthetist

is not available, the operation may

have to be done under deep

sedation with 10mg diazepam

given intravenously. The patient is

placed in lithotomy position. With

all aseptic measures, the bladder is

catheterized.

Step 2: One hand is introduced into

the uterus after smearing with the

antiseptic solution in cone-shaped

manner following the chord, which

is made taut by the other hand.

While introducing the hand, the

labia are separated by the fingers of

the other hand. The fingers of the

uterine hand should locate the

margin of the placenta.

Step 3: Counter pressure on the

uterine fundus is applied by the

other hand placed over the

abdomen. The abdominal hand

should steady the fundus and guide

the movement of the fingers inside

uterine cavity until the placenta is

completely separated.

Step 4: As soon as the placental

margin is reached, the fingers are

insinuated between the placenta

and the uterine wall. The placenta

is gradually separated with a

sideways slicing movement of the

fingers, until whole of the placenta

is separated.
Step 5: When the placenta is

completely separated, it is extracted

by traction pf the land by the other

hand. The uterine hand is still

inside the uterus for exploration of

the cavity to be sure that nothing is

left behind.

Step 6: Intrevenousmethergin

0.2mg is given and the uterine hand

is gradually removed while

massaging the uterus by the

external hand to make it hard. After

the completion of manual removal,

inspection of the cervicovaginal

canal is to be made to exclude any

injury.

Step 7: The placenta and

membranes are inspected for

completeness and be sure that the

uterus remains hard and contracted.

Complications:

 Haemorrhage due to

incomplete removal.

 Shock Injury to the uterus

 Infection

 Inversion

 Sub involution

 Thrombophlebitis

 Embolism

Management of True Postpartum

haemorrhage:

It is essential in all cases of major

PPH. (Blood loss >1000ml or

clinical shock).

Management:

Immediate actions are to be taken

by the attending house officer.

(doctor/midwife).

 Call for extra help involve the

obstetric register on call.

 Patient flat and warm.

 Sand blood for full blood count,

group, cross matching,

diagnostic test (RFI/LFI)

coagulation screen, including

fibrinogen and ask for 2 units(at

least) of blood.

 Infuse rapidly 2 liters of normal

saline(crystalloids) an area

linked gelatin, to re expand the

vascular bed. It does not

interferewith cross matching.

 Give oxygen by mask 10-

15L/min.

 Start 20 units of oxytocin in 1L

normal saline IV at the rate of 60

drops per minute. Transfuse

 blood as soon as possible.

 One staff should be assigned to

monitor the following:

i. Pulse

ii. Blood pressure

iii. Temperature

iv. Respiratory rate and

oximeter

v. Type and amount of fluids

(blood, blood products) the

patient has received,

vi. Urine output (continuous

catheterization)

vii. Drugs-type, dose and time

viii. Central venous pressure

Actual Management

Step 1:

 Palpate the fundus and massage

the uterus to make it hard and to

express the clot.

 Methergine 0.2mg is given

intramuscularly

 Inj.Oxytocin drip is started

(10unts in 500ml of normal

saline at rate 30-40 drops per

minute)

 Examine the expelled placenta

and membranes.

 Oxygen is administered at the

rate of 8litres per minute

Step 2:

The uterus is to be explored under

general anesthesia.

Step 3:

Uterine massage and bimanual.

Procedure:

The whole hand is introduced in

to the vagina in cone shaped

manner after separating the labia

minor with other hand, the vaginal

hand is cleaned into a fist with back

of the hand directed posteriorly and

the knuckles in the anterior fornix.

The other hand is placed over the

abdomen behind the uterus to make

it auteverted. The uterus is firmly

squeezed between the two hands. It

may be necessary to continue the

compression for a prolonged period

until the tone of the uterus is

regained.

Step 4:

 Uterine tamponade

 Tight intrauterine plugging

done uniformly under

general anesthesia.

 Insertion of a sengstaken

Blackemore tube with 200ml

 of normal saline.

Step 5:

Surgical Methods:

 B-lynch compression suture

and multiple square sutures.

 Ligation of uterine arteries

 Ligation of the ovarian and

uterine artery anastomosis.

 Ligation of anterior division of

internal iliac artery.

 Angiographic selective arterial

embolization.

Step 6: Hysterectomy

Secondary PPH:

Causes:

 The bleeding usually8th 14th

day of delivery.

 Retained bits of membrane.

 Infection and separation of

slough over a deep cervico-

vaginal laceration.

 Endometritis and sub

involution of the placental site

due to delayed healing process.

Diagnosis:

 The bleeding is bright red in

color and of varying amount.

 Degree of anemia and

evidence of sepsis.

 Sub involution

 USG

Management:

Supportive therapy

 Blood transfusion

 Administer antibiotic or

routine.
Conservative:

 If the bleeding is slight and no

apparent cause is detected, a

careful watch for a period of 24

hours or so is dine in the

hospital.

Active Management

 The retained bits are removed

by ovum forceps.

 Gentle curettage is done by

using flushing curette.

 Methergine 0.2mg is given Im.

BIBLIOGRAPHY :

 Dutta Parul, Konar Hiralal, D.C Dutta's Textbook of Obstetrics, Jaypee

publications 9th edition Page No 385-392

 Bhasker Meema: Medwifery and obstetrical Nursing, Emmess Publishers,

3rd edition, Pg No. 492-420

 www.webmed.com

 www.sliideshare.com

 www.pubmed com