POST PARTUM HEMORRHAGE

POST PARTUM HEMORRHAGE

Postpartum Hemorrhage (PPH)
According to the United Nations
Population Fund (UNFPA)
“In the Philippines - three major
causes of maternal mortality.
• Hypertension (27%),
• Hemorrhage (18%)
• Unsafe abortion (11%)
All of these problems are preventable
and can be addressed through adequate
medical care such as the presence of
skilled birth attendants, emergency
obstetric care (EmOC), when necessary,
and access to family planning services.”
(Seehttp://philippines.unfpa.org/read_m
ore.php?id=14)
 PPH
• All pregnancies are at risk of PPH even if no
predisposing factors are present
• Postpartum hemorrhage (PPH) remains a
major cause of maternal mortality and
morbidity worldwide. Approximately, half a
million women die annually from causes
related to pregnancy and child birth
 WHAT IS PPH?
• Post partum hemorrhage refers to any amount
of bleeding from or into the genital tract
following birth of the baby up to the end of
puerperium or 6 weeks after delivery
• Hemorrhage may occur before, during or after
delivery of the placenta
• Any blood loss of more than 500ml of blood
with in 24 hrs after vaginal delivery and more
than 1000ml with in 24 hrs
• Normal blood loss – 300 to 500ml
 TYPES/ classification
1. Primary postpartum hemorrhage - hemorrhage
occurring during the third stage of labor and within
24 hours of delivery
CAUSES
• Uterine atony
• Lacerations
• Retained placenta
• Coagulation problems
• Uterine inversion
 Types / classification
2. Secondary or late
occurs after 24 hrs of delivery and with in 6
weeks of delivery. Referred to as puerperal
hemorrhage.
Causes
Retained placenta
Subinvolution of the placenta site
 RISK FACTORS
• Previous history PPH
• Antepartum haemorrhage
• Grand multiparity
• Multiple pregnancy
• Polyhydramnios
• Fibroids
• Placenta previa
• Prolonged labour
• Labor augmentation with oxytocin
 SYMPTOMS
• Massive blood loss
• Passing large clots
• Dizziness
• Lightheadedness or fatigue
• Decreased blood pressure
• Increased heart rate
• Swelling and pain in tissues in the vaginal and
perineal area
Causes: ( 5 T’s)
1. TONE -Uterine Atony
2. TISSUE -Retained placenta or
membranes, subinvolution
3. TRUAMA -Injury to vagina, perineum
and uterine tears, hematoma
4. TROMBIN – Clotting disorders
5. TRACTION – Uterine inversion
TONE: Uterine Atony
- relaxation of the uterus
- most common cause of PPH
- Inability of the uterus to
contract and retract effectively.
• Normally
placental
separation and
expulsion are
facilitated by
uterine
contraction, which
also prevents
hemorrhage from
the placental site.
(A) UTERINE ATONY -
The uterine Muscle fibers did not
contract sufficiently to compress
the blood vessels and so there’s
continuous Bleeding .

(B) Normally, with the uterus

contracting after delivery of the
placenta the vessels of the
placental bed are compressed
by the contracted muscle fibers
and so no bleeding occurs .
UTERINE ATONY PREDISPOSING FACTORS

• Precipitate labour - When the uterus has contracted vigorously

and frequently resulting in a duration of labour that is less than 1
hr, then the muscle may have insufficient opportunity to retract.
• Prolonged labour - In a labour where the active phase lasts >12
hrs uterine inertia (sluggishness) may result from muscle
exhaustion.
• Polyhydramnios or multiple pregnancy
• The myometrium becomes excessively stretched and therefore
less efficient
• Anaesthetic agents may cause uterine relaxation, in particular the
volatile inhalational agents, for example halothane.
Management
•Assess and document bleeding
•Fundal massage and express clots
•Bimanual compression
•Put baby to breast
•Assess V/S and signs of shock
•Give meds
- oxytocin
- methylergometrine (Methergin)
- Carboprost tromethamine (hemabate)
- Misoprostol per rectum
Replace blood/fluids
D & C/ Hysterectomy
TISSUE: Retained placenta
Definition: Failure of placental delivery 30 minutes after
the birth of the fetus.
• Normally the placenta is expelled within 15-20 minutes
Signs:
- boggy, relaxed uterus
- Dark red bleeding

The third stage of labor is the interval from delivery of the infant to
expulsion of the placenta. Delayed separation and expulsion of the
placenta is a potentially life-threatening event because it interferes
with normal postpartum contraction of the uterus, which can lead to
hemorrhage.
Causes:
• Morbid Adherence of the placenta
- Placenta Acreta (into the decidua)
- Placenta Increta (into the myometrium)
- Placenta Percreta (through the
myometrium to the peritoneal)
• Uterine Abnormality
• Full bladder
• adherence of placenta (previous cesarean
delivery,prior uterine curettage)
• succenturiate placenta
Succenturiate placenta
Complicated retained placenta
• Hemorrhage, shock or sepsis
 TISSUE: Subinvolution
– Uterus remains large, does not involute
Causes: retained placental fragments,
infection
Symptoms:
– Lochia fails to progress,
– Prolonged lochial flow
– Large flabby uterus
– backache and infection
– Profuse vaginal bleeding
Treatment:
– methergine
– curretage
– antibiotics
TRAUMA: Lacerations, Hematoma
• Cervical, Vaginal or perineal, uterine
• Is suspected if bleeding continues despite a firm
and contracted uterine fundus..
• Bleeding is slow trickle, an oozing or frank
hemorrhage
• Occur in the ff:
- in primigravida
- difficult or precipitate birth
- use of lithotomy position (It increases tension
in the perineum.
- instrumental delivery: forceps, Ventouse or CS
 PERINEAL LACERATION
• Vaginal tear or perineal laceration – an injury
to the tissue around the vagina and the
rectum that can happen during childbirth
 Degrees of Laceration
• First Degree – laceration extends through the
skin and structures superficial to muscles
• Second Degree – laceration extends through
muscles of perineal body
• Third Degree – laceration continues through
anal sphincter muscle
• Fourth degree – laceration also involves the
anterior rectal wall.
Degrees of Laceration
 Management
1. Immediate repair promotes healing, limits residual
damage, and decreases the possibility of infection
2. Continue to monitor lochial discharges and other
symptoms to identify any previously missed damage.
3. Promote soft stools (roughage, fluid, activity, and
stool softeners) for a few days to increase woman’s
comfort and to foster healing.
• NOTE: ENEMAS AND SUPPOSITORIES ARE
CONTRAINDICATED FOR THESE WOMEN.
Hematomas

• a collection of blood under the

surface of the skin at the edge of the
anal opening.
• are caused by a traumatic rupture of a
small blood vessel in vagina or vulva.
• develop rapidly
• may contain 300-500ml blood
Symptoms
• Severe pain
• Difficulty voiding
• Mass felt on vaginal exam
• Flank pain
• Abdominal distension
• Shock
Treatment
• Ice
• I & D (incision and
drainage)
• Packing
THROMBIN: CLOTTING DISORDER

• Disorders of the clotting system

• This should be suspected when
bleeding persists without an
identifiable cause.

• These blood clots can reduce or block blood

flow through the blood vessels, which can
damage the body's organs.
DIC (Disseminated intravascular
coagulation)
- is a condition in which blood clots
form throughout the body's small blood
vessels.
- It is associated with abruptio
placenta, septic abortion, Fetal
death in utero.
Disseminated intravascular
coagulation (DIC)
-Von Willebrand’s disease
- inability to form a stable blood
clot in the placental site and
susceptible to immediate
hemorrhage
TRACTION
Nursing intervention:
Assess the fundus
 Initiate uterine massage
 Weigh perineal pads (1gm of
weight = 1ml of fluid)
 Turn patient to her side to inspect
buttocks for pooling of blood
 Facilitate voiding every 4 hours to
empty the bladder.
Nursing intervention:
Assess vital signs every 5 to 15
minutes
 Prepare for IV infusion of oxytocin &
blood transfusion if needed.
 Administer Methergin IM as ordered.
 Administer oxygen per face mask.
 Measure & record fluid intake and
output
 Be prepared for a possible D &C
(Postpartum curettage),
Hysterectomy, bimanual fundal
massage
 Management
TONE
• Massage – manual
fundal massage
• Compress
• Drugs
 Management
TISSUE
• Manual removal
of the placenta
• Curettage
 Management
TRAUMA
• Repair or suturing
of the laceration
• Incision & drainage
(I & D)
• Identify the rupture
 Management
TRACTION
• Repositioning of the
uterus
• Correction of uterine
inversion
• Oxytocin
• Antibiotics
 Management
THROMBIN
• Blood
replacement
Prevention: Active Management of the Third Stage
(AMTSL)
1. Administration of uterotonic within one
minute of delivery of the baby.
2. Controlled cord traction with counter
traction on the uterus
3. Uterine massage
 Uterine Contraction-First Line
Drugs
• Oxytocin 5IU
• Oxtocin infusion – 40IU in 500mls
• Ergometrine 0.5mg
• Carboprost (Haemabate©) 0.25mg IM every
15 minutes x 8 doses
• Misoprostol 600 mcg
SURGICAL INTERVENTION