Best Practices in the Management

of Vaginal Bleeding after Childbirth

Best Practices in Maternal and Newborn

Care

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Session Objectives

By end of session, participants will be able to:

 Describe the significance of PPH
 Discuss the causes of PPH
 Discuss the prevention of PPH
 Describe the management of PPH

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Vaginal Bleeding after Childbirth

WARNING: Rapid action in response to PPH is

critical!

 More than half of all maternal deaths occur within 24

hours of childbirth, mostly due to excessive bleeding.
 Uterine atony is the major factor of PPH, which causes
more than one-quarter of all maternal deaths worldwide.

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Hematological Changes in Pregnancy
 40% expansion of blood volume by 30 weeks
 600 ml/min of blood flows through intervillous space
 Appreciable increase in concentration of Factors I
(fibrinogen), VII, VIII, IX, X
 Plasminogen appreciably increased
 Plasmin activity decreased
 Decreased colloid oncotic pressure secondary to 25%
reduction in serum albumin

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Definition of PPH
 Vaginal bleeding in excess of 500 mL or any amount
sufficient enough to cause cardiovascular compromise
 The mean blood loss in a
 > 500 ml vaginal delivery is

 >1000ml after C/S

 >1400ml for elective Cesarean-hyst

 >3000-3500ml for emergent Cesarean-hyst

 Another proposed definition for PPH is a 10% drop in

Hct.

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Types of PPH
 Early /Primary postpartum hemorrhage. :- Excessive hHemorrhage
that occurs within the first 24 hours postpartum is termed
 Late/ secondary postpartum hemorrhage.:- While excessive
bleeding after 24 hours is referred to as
 In general, early PPH involves heavier bleeding & greater
morbidity.
 Facts:
 Estimated amounts of blood loss are notoriously low, often half

the actual loss

 The lower the Hb level, the poorer is the woman’s tolerance of

blood volume loss

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Cause of Primary PPH

 - Atonic uterus
 - Retained Placenta
 - Retained Cotyledon
 - Genital trauma
 - Coagulation failure =DIC
 - Acute Inversion of uterus

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

8
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Cause of secondary PPH

 - Chorioamnioitis
 - Retained products

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

9
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Predisposing factors- Intrapartum

 Operative delivery  Previous PPH or

 Prolonged or rapid manual removal
labour  Abruption/previa
 Induction or  Fetal demise
agumentation  Gestational
 Choriomnionitis hypertension
 Shoulder dystocia  Over distended uterus
 Internal podalic version  Bleeding disorder
 coagulopathy
BEmONC – LRP: Ethiopia Management of Headache, Convulsions,
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
Risk factors for PPH include the following:

  Placenta praevia
  Abruptio placentae
  Placenta accreta
  Maternal obesity
  Macrosomia/multiple pregnancy
  Advanced maternal age
  Previous post-partum haemorrhage
  Operative delivery

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Etiology PPH
 The etiologies of early PPH are most easily understood as abnormalities of one
or more of four basic processes.
 Bleeding will occur if for some reason the uterus is not able to contract well
enough to arrest the bleeding at the placental site.
 Retained products of conception may cause large blood losses postpartum
 Genital tract trauma may cause large blood losses postpartum
 Coagulation abnormalities can cause excessive blood loss alone or when
combined with one of the other processes.
 The four “T” processes.

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Etiology of PPH
The Four “T”

Tone Uterine atony 80-95%

Tissue Retained tissue/clots
Trauma laceration,
rupture,
inversion
Thrombin Coagulopathy
Infection (delayed PPH)

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 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

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal
PPH- and Newborn Care
Prof.S.N.panda & Loss of Consciousness or Elevated Blood
Dr.A.Patnaik 14
 Diagnosis ?

 Assess in the fundus

 Inspect the lower genital tract
 Explore the uterus
 Retained placental fragments
 Uterine rupture
 Uterine inversion
 Assess coagulation

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Management

 This is a life-threatening complication, which must

be managed promptly and effectively.
 Get all the help you can.
 Prevention is the best management.

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Question ?

What measures can we take to prevent PPH?

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 PREVENTION
 Regular ANC
 Correction of anemia
 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

 AMTSL
 4th Stage of labour – Observation/Monitor, Oxytocin
BEmONC – LRP: Ethiopia Management of Headache, Convulsions,
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 PREVENTION
 Although any woman can experience a PPH, the
presence of risk factors makes it more likely.
 For women with such risk factors, consideration should
be given to extra precautions such as:
 IV access

 Coagulation studies

 Crossmatching of blood

 Anaesthesia backup

 Referral to a tertiary centre

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Prevention
CLIENT CARE
 Prevent prolonged labor

 AMTSL

 Avoid perineal/vaginal

trauma
 Monitor closely

EMERGENCY
PREPAREDNESS
 Have emergency PPH pack

BEmONC – LRP: Ethiopia

Best Practices in Maternal and Newborn Care
readyManagement of Headache, Convulsions,
Loss of Consciousness or Elevated Blood
 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

 Early cord clamping

 Controlled cord traction
 Inspection of placenta & lower genital tract

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
21
 ICM/FIGO Joint Statement on AMTSL

 AMSTL has been proven to reduce the incidence of

postpartum hemorrhage, reduce the quantity of blood
loss and reduce the use of transfusion

 AMSTL should be offered to all women who are giving

birth

 Every attendant at birth needs to have the knowledge,

skills and critical judgment needed to carry out AMSTL

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Prevention: Be Prepared

ALL women are at risk of PPH!

Women who are predisposed to fatal consequences of PPH include
women with:
 Over-distended uterus (twins, big baby,
polyhydraminios)
 Prolonged labor
 Severe pre-eclampsia/eclampsia
 Prolonged intrauterine death
 APH ( weakens)
 Anemia (weakens)
BEmONC – LRP: Ethiopia Management of Headache, Convulsions,
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Question ??

What are the first things you should do when you

encounter a woman with bleeding after third stage
(PPH)?

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 General Management Steps
 CALL FOR HELP
 Perform rapid evaluation (V/S= B/P, P/R, R/R, pallor & cause)
 Massage uterus
 If shock is present, start immediate resuscitation:
 Start IV infusion 1 liter/15 min.
 Take blood for grouping and cross-matching
 Give oxygen
 Elevate foot end and keep woman warm

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 IV Fluid Replacement: In Shock
 Start resuscitation with intravenous fluids (normal saline or Ringer’s
lactate)
 Use large-bore cannula (16 or bigger)
 Volume to give:
 First 1,000 mL ( 500 ml x 2) rapidly in 15–20 min.
 GIVE AT LEAST 2000 mL ( 500 X 4 ) IN FIRST HOUR
 Aim to replace 2–3x the volume of estimated blood loss
 If condition stabilizes, then adjust rate to 1,000 mL/6 hrly
 Monitor BP, pulse every 15 min. and urine output hourly
(> 30 mL/hr)
 Avoid dextrans; they interfere with grouping and cross- matching as well
as with coagulation of blood

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Management: Rapid Assessment

Assess for s/s of following conditions and perform

appropriate action before proceeding with additional
care:
 Uterine atony (uterus soft/not contracted)
 Tears of perineum, vagina, cervix
 Retained placenta or placental fragments
 Ruptured or inverted uterus
 Delayed postpartum hemorrhage (PPH)

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 PPH Risk Factors

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 1. UTERINE ATONY
RISK FACTORS
 Over distension of uterus
 Induction of labour
 Prolonged / precipitate labour
 Anaesthesia (halogeneted) & analgesia
 Tocolytics
 APH
 Grand multiparity
 Mismanagement of 3rd stage of Labour
 Full bladder

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
29
 Vaginal Bleeding after Childbirth (cont):
Management
 If s/s of uterine atony:
 Atonic uterus is the most common cause of primary
PPH.
 Continue to massage the uterus.
 Use oxytocic drugs which can be given together or
sequentially (See table). /AMTSL
 Start IV infusion (plus oxytocin 20 units/liter IV
fluids)/ORS
 Give oxytocin 10 units IM*
 Ensure urination (catheterize if needed)
BEmONC – LRP: Ethiopia Management of Headache, Convulsions,
30
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Atonic Uterus!
First action is to massage uterus
DOSE & CONT. CONTRA-
DRUG MAX DOSE
ROUTE DOSE INDICATION

OXYTOCIN IM 10 U OR IV 20 u in Not > 40 U No IV admin.,

IV 20 U in 1,000 mL infused at not even slow
1000 ml NS at 40 rate of IV push unless
at >60 drps/min. 0.02–0.04 IV fluids are
drp/min OR 5- U/min. running
10 U slow IV
push
ERGO- IM OR IV Repeat 0.2 Five doses High BP
METRINE Slowly 0.2 mg after 15 (Total 1.0 Heart disease
mg min. if mg)
required
every 4
hours
BEmONC – LRP: Ethiopia Management of Headache, Convulsions,
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Atonic Uterus (cont.)

DOSE & CONT. MAX CAUTIONS

DRUG
ROUTE DOSE DOSE & CI

MISOPROSTOL ORAL/SL 200 mg 2000 mg Asthma

(CYTOTEC) INTRAVAG Every 4 Heart Dis*
RECTAL hours

200–800 mcg
(600mcg)

PROSTAGLANDI IM only 0.25 mg Total 8 Asthma

N 0.25mg Every 15 Doses=2 Heart Dis*
F2a minutes mg

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Vaginal Bleeding after Childbirth:
Management (cont.)
 If bleeding continues:
 Perform bimanual compression of uterus OR compression
of abdominal aorta (per next two slides)
 Give additional oxytocics e.g. Misoprostol, Ergometrine,
Prostaglandins if available.
 If bleeding continues, facilitate urgent referral/transfer
 If bleeding stops, proceed with additional care plus
measure woman’s hemoglobin in 4 and 24 hours

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

33
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Bimanual compression of
the uterus
BEmONC – LRP: Ethiopia
34
Best Practices in Maternal and Newborn Care
Abdominal Aortic
compression
Management of Headache, Convulsions,
Loss of Consciousness or Elevated Blood
 Internal Bimanual Compression of
the Uterus
 Wearing HLD gloves, insert hand
into vagina; form fist
 Place fist into anterior fornix and
apply pressure against anterior
wall of uterus
 With other hand, press deeply into
abdomen behind uterus, applying
pressure against posterior wall of
uterus
 Maintain compression until
bleeding is controlled and uterus
contracts

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Compression of Abdominal Aorta
 Apply downward pressure with
closed fist over abdominal aorta
through abdominal wall (just
above umbilicus slightly to pt’s
left)
 With other hand, palpate femoral
pulse to check adequacy of
compression:
 Pulse palpable =
inadequate
 Pulse not palpable =
adequate
 Maintain compression until
BEmONC – LRP: Ethiopia Management of Headache, Convulsions,
bleeding is controlled or until
Best Practices in Maternal and Newborn Care she Loss of Consciousness or Elevated Blood
Non Pneumatic Anti-Shock
Garment (NASG)

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

37
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Non-Pneumatic Anti-Shock Garment
(NASG)
 NASG is a first aid device that can reverse shock,
decrease blood loss and stabilize women suffering
hypovolemic shock secondary to severe obstetric
hemorrhage, by compressing the uterus and pelvic area
and shunting blood from the peripheral parts of the body
to the central part.
 Helps to buy time while she is being transported to
emergency obstetric care center for definitive treatment.

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

38
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 BEmONC – LRP: Ethiopia Management of Headache, Convulsions,
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 THERAPEUTIC EFFECTS OF ANTISHOCK
GARMENT

Efficient, simple and safe means to apply external

counter pressure to the lower body.

RESUSCITATION OF CENTRAL CIRCULATION

 Results in translocation of 1.5-2.0 liters of blood

from the lower body to the head and chest.

REDUCES HEMORRHAGE IN LOWER BODY

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 INDICATIONS FOR NASG

 INITIAL CONTROL OF HEMORRHAGE

 SHOCK
 Postpartum hemorrhage - any cause

 Ectopic Pregnancy

 Post cesarean hemorrhage

 Trauma with injury/hemorrhage below the

diaphragm
 RECOMMEND: Apply the NASG after 500 - 750 ml
of blood loss, before signs of shock occur!

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 STRATEGY FOR USE OF NASG FOR
POSTPARTUM HEMORRHAGE

 Stabilizes patient while evaluating, transporting or

preparing for definitive surgical treatment.
 With proper monitoring for adverse effects, can be
safely and comfortably used for 24 - 48 hours.
 On occasion may arrest bleeding and avoid surgical
intervention.
 May decrease need for blood transfusions.

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 STRATEGY FOR USE OF NASG

HOWEVER, use of anti shock garment does not

avert the necessity for evaluation to identify cause
of shock, management of fluid and blood
replacement, and appropriate therapy for
coagulopathy.

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
≈ 2000 mL
 BEmONC – LRP: Ethiopia Management of Headache, Convulsions,
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 BENEFITS OF NASG

 It stabilizes the patient while trying to look for the cause of

bleeding.
 It keep patient alive while transporting to a referral centres
 It may stop bleeding and thus prevent surgery.
 It may reduce or prevent blood transfusion and its associated
problems.
 It can be applied by any trained health care personnel

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 CONTRAINDICATIONS FOR USE OF
THE NASG
 Viable fetus in-utero
 Pulmonary edema
 Bleeding above the diaphragm
 Congestive heart failure due to mitral stenosis
 A major cause of morbidity and mortality when using
the NASG is the premature and inappropriate release
of external counter pressure.

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 WHO can APPLY the NASG?

 Midwives
 Doctors
 Nurses
 CHEW
 Health Attendants
 Ambulance drivers
 Etc

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 When to remove the NASG??

 Intravascular volume re-expanded with blood and

saline
 Vital signs stable and systolic >100/
pulse <100
 Hb>7.0 or Hct (PCV) >20
 Remove one segment every 15 minutes starting
below with #1 - check pulse/BP
BEmONC – LRP: Ethiopia Management of Headache, Convulsions,
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Cleaning

 NASG should be cleaned with 0.05% Chlorine

solution
 Show how to prepare the solution

Referral
 If a mother is referred with the NASG the receiving

health facility (Hospital)must replace with the new

one

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Question ??

If a woman with PPH has no signs of atonic uterus,

what should you do?

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Management of PPH

 If no s/s of uterine atony:

 Examine vagina, perineum, cervix for tears
 Start IV infusion or oral rehydration solution
(ORS) – if woman is conscious
 Keep woman warm; elevate legs
 Ensure urination (catheterize if needed)
 Proceed with assessment

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Additional Management (cont.)

 If s/s of tears:
 If extensive tears (3rd or 4th degree), facilitate urgent
referral/transfer
 If 1st or 2nd degree tears, perform repairs
 If s/s of retained placenta, perform appropriate
management to deliver placenta
 If s/s of retained placental fragments, perform
appropriate management to remove fragments

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 2. TRAUMATIC


Large episiotomy & extensions

Tears & lacerations of perineum, vagina or cx

Haematoma

Uterine rupture

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
54
 PPH Risk Factors

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Local Anesthesia
Lidocaine:
 Only use in concentration of 0.5% (drug is usually
available in 1% and 2% preparations)
 If more than 40 mL is required, add adrenaline to delay
dispersion
 MAX safe dose is 4mg/kg BW for plain and 7mg/kg
BW with adrenaline
 Anesthetic effect can last for 2 hrs
 Dose can be repeated after 2 hr PRN
 Avoid injecting into vessel

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Retained Placenta
&
Adherent Placenta

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Retained Placenta

Definition: - When the placenta remains undelivered after

a specified period of time usually half to one hour
following the baby’s birth having left the upper uterine
segment.

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
Cause
- Poor uterine contraction
- Hours glass contraction: a contraction ring in the third
stage caused by giving ergometrine and not expelling
the placenta in time
- Full bladder
- Mismanagement of third stage of labour.

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Management of retained placenta

1. Careful observation - check pulse

- Vaginal bleeding
- Check bladder
2. Gently try to deliver by controlled cord traction
3. If not manual removal followed by antibiotics

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Manual removal of Placenta

 Method:-Place one hand on the fundus to support the

uterus, let the other hand follow the cord until it reaches
the placenta move hand up to the edge of placenta
and find where it is partiality separated (remember it
would not be bleed if it is not separated) then move your
hand up and down, until you have it, completely
separated then bring it out in your hand, examine it.

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 BEmONC – LRP: Ethiopia Management of Headache, Convulsions,
62
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 BEmONC – LRP: Ethiopia Management of Headache, Convulsions,
63
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 3. RETAINED PLACENTA
 Simple adhesion
 Morbid adhesion>Accreta, Increta & Percreta

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
64
 PPH Risk Factors

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Retained Placenta
 If you can see the placenta, ask the woman to push it
out
 If you can feel the placenta in the vagina, remove it
 If the placenta is still not delivered:
 Give oxytocin 10 units IM (if not already given for

AMTSL) and attempt CCT with the next contraction

 Catheterize the bladder using aseptic technique if not

already done
 If CCT unsuccessful, attempt manual removal of the

placenta
BEmONC – LRP: Ethiopia Management of Headache, Convulsions,
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Managing Retained Placenta
 Ensure bladder is empty
 Apply controlled cord traction; If it fails,

Repeat oxytocin 10u IM: If no success of CCT in 30 min:
 Attempt manual removal of placenta:
 Give Pethidine and diazepam or Ketamine
 Give antibiotics: (Ampicillin 2g + Metronidazole 500 mg)
 Perform procedure and examine placenta for completeness
 Give Oxytocin 20 U/1,000 mL NS or RL at 60 dpm
 Monitor BP, pulse, pad and urine output closely
 Add ergot or prostaglandin if bleeding continues
 Transfuse PRN and treat for anemia
BEmONC – LRP: Ethiopia Management of Headache, Convulsions,
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Anesthesia and Analgesia
for Short Procedures < 30 Minutes
 Pethidine 1mg/kg BW IM or
 IV slowly (max 100 mg dose)

 Give Promethaxine (Phenergan) if vomiting occurs)

Plus
 Diazepam 10mg IV at rate of 1mg every 2 min.

 Monitor RR closely; stop if RR<10/min

DO NOT MIX THE TWO

DRUGS IN SAME SYRINGE
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 Ketamine for procedures < 60 min:
 Dose 6-10 mg/kg BW by IM or IV bolus or IV Infusion
 2 mg/kg BW IV slowly last for 15 min
 200 mg in 1 liter D/S at 20 dpm infusion for longer
procedures
 Give atropine 0.6 mg IM as pre-medication
 Give O2 6-8l/min by mask
 Add diazepam 10 mg IV to avoid hallucinations
 CONTRAINDICATED IN HIGH BP AND HEART DISEASE

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Retained Placenta (cont.)
 If bleeding continues, ACT NOW! Facilitate urgent
referral/transfer
 If bleeding stops, continue with basic care
 4 hrs after bleeding stops, measure the woman’s Hgb:
 If Hgb less than 7g/dL, facilitate urgent transfer
 If Hgb is 7–11g/dL, treat anemia with iron/folate
 DO NOT give Ergot. as it causes tonic contractions
 AVOID forceful CCT and fundal pressure as they may cause
uterine inversion

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Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Vaginal Bleeding after Childbirth:
Management (cont.)
If s/s of retained placental fragments:
 Give uterotonic drug according to guidelines
 Assess cervix for dilation

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Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Vaginal Bleeding after Childbirth:
Management (cont.)
 If cervix is not dilated, facilitate urgent referral/transfer
 If cervix is dilated, perform appropriate management to
remove fragments/tissue:
 If bleeding continues, perform bimanual compression

of uterus OR compression of abdominal aorta

 NOTE: Very adherent tissue may be placenta accreta.

Efforts to extract fragments that do not separate easily

may result in heavy bleeding or uterine perforation,
which usually requires hysterectomy.

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Adherent Placenta

 When the placenta one-hour after delivery still has

not speared and left the upper uterine segment. This
occurs when the placenta has grown into the uterine
muscle.

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
Types:-
1 Placenta accreta- into muscles
2 Placenta increata- deep in muscle
3 Placenta percrata- through muscle

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Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Management

- Is usually hysterectomy
- Some times doctors can remove it as a piecemeal
under general anesthesia or leave it to be absorbed.

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Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Vaginal Bleeding after Childbirth:
Management (cont.)
 If s/s of ruptured uterus, facilitate urgent
referral/transfer
 If s/s of inverted uterus, perform manual correction
of inverted uterus

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Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Vaginal Bleeding after Childbirth:
Additional Management
 If bleeding continues, facilitate urgent referral/transfer
 If bleeding stops, proceed with additional care, plus
measure woman’s Hgb in 4 hours:
 If Hgb is less than 7g/dL, facilitate urgent referral
 If Hgb is 7–11g/dL, treat anemia with iron/folate

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Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 4. Acute UTERINE INVERSION
 Incomplete Inversion- Fundus felt through the Cx
 Complete Inversion with placenta accreta attached to the
fundus
 Mostly iatrogenic due to mis-mgt of 3rd stage -
strong traction on the cord with a relaxed uterus /
adherent placenta.

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78
 Replacement of Inverted Uterus

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Part II: Inversion of the Uterus

 Uterine inversion may occur immediately postpartum

or, much less frequently, during the puerperium.

 Inversions are usually described as acute (<30 d after

delivery) or chronic (>30 d after delivery).

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Inversion of Ux…

 In first-degree inversion, the inverted wall extends to

but not through the cervix.
 In second-degree inversion, the inverted wall
protrudes through the cervix but remains within the
vagina.
 In third-degree inversion, the inverted fundus
extends outside the vagina.
 In fourth degree or total inversion, both the vagina
and uterus are inverted.

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Possible etiology/ Predisposing factors

 Reported associations/risks for uterine inversion

include the following:
 Idiopathic
 Excessive cord traction or a short umbilical cord
 Credé (fundal) pressure
 Placenta accreta or increta or percreta
 Fundal implantation of the placenta
 Chronic endometritis

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/2004

Possible etiology …

 Fetal macrosomia
 Trials of vaginal birth following cesarean delivery
 Myometrial weakness
 Precipitate labor
 drugs, including magnesium sulfate

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/2004

Possible etiology …

 Uterine anomalies and cancers

 Protracted labor
 Fundal pressure

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/2004

Possible etiology …

 Many cases of uterine inversion are due to

mismanagement of the third stage of labor
 To prevent uterine inversion, maneuvers like
 excessive traction on the umbilical cord,
 excessive fundal pressure,
 excessive intra-abdominal pressure, and
 excessively vigorous manual removal of the placenta
should be avoided

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/2004

Signs & Symptoms

The classic observations include :
 postpartum hemorrhage,

 the sudden appearance of a vaginal mass, and

 varying degrees of cardiovascular collapse—all

usually occurring in the immediate puerperium.

 The postpartum hemorrhage is usually the most

striking of the symptoms and initially commands the

attention of the clinician.

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Signs & Symptoms…

 In other cases, the sudden and disconcerting
protrusion of a large, dark red, polypoid mass
through the vagina either accompanying or
following the placenta is noted.
 The characteristic appearance of the inverted
uterus either retained within the vagina or
protruding externally is both surprising and
startling and usually immediately establishes the
correct diagnosis

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Diagnosis of uterine inversion

 Hx
 P/E
 Shock and hemorrhage are prominent with considerable
pain.
 A dark red–blue bleeding mass is palpable and often
visible at the cervix, in the vagina, or outside the vagina.
 A depression in the uterine fundus or even an absent
fundus is noted on abdominal examination.
 DDx for chronic uterine inversion are fibroid polyp, UVP,
prolapsed hypertrophied cervix and cervical malignancy

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Management of Uterine inversion

 Successful management of patients with uterine

inversion depends on;
 prompt recognition
 Definitive treatment

 vigorous resuscitation

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Management of Uterine inversion…

Manual Repositioning of the Uterus

 Treatment should begin as soon as the diagnosis of uterine
inversion is made. Assistance is vital.
Trial 1; to reduce possibility of hemorrhage
 Reposition the uterus as quickly as possible

 Resuscitation(iv fluid to reduce hypovolumia, shock )

 Attempt to separate the placenta is forbidden if it is not separate

 Grasp and push up ward the uterine fundus in the uterine axis

 oxytocin administration along repositioning

 In successful repositioning administer antibiotics

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Management of Uterine inversion…

If the initial attempt fails, induce general anesthesia

(halothane) and tocolytics (iv magnesium sulfate or
terbutaline);
 Then the operator's fist is placed on the uterine

fundus, and the fundus is gradually pushed back into

the pelvis through the dilated cervix

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Management of Uterine inversion…

 It is important that the part of the uterus that

came out last (the part closest to the cervix) goes
in first.

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Manual repositioning of the inverted uterus

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Management of Uterine inversion…

 The general anesthetic or uterine relaxant is
discontinued after positioning the uterus and
continue oxytocin administration. Remove the
placenta ,compress the uterus bimanually and
massage until the uterus is well contracted.
 Administer antibiotics
 Apply O’sullivian’s technique; hydrostatic
positioning,i.e,
 Administering large amount of warm water or
N/S into the vagina and drain after time
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Management of Uterine inversion…

If both attempts failed;

 Surgical mgt:

 Surgical repositioning; a vertical incision through the

lower uterine segment directly posterior. Then the
uterus is repositioned by either pulling from above or,
very rarely, pushing from below (using a sterile glove)
 hysterectomy

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 Manual replacement

If fails
Resuscitate
Give tocolytics

Hydrostatic repositioning

If fails

laparatomy

99
/2004

Management of Uterine inversion…

Shock
1. Initiate fluid resuscitation with 2 large-bore
intravenous lines. Promptly administer 1 or more
liters of an isotonic salt solution such as lactated
Ringer parenterally.
2. Submit specimens to the laboratory for possible
transfusion and for determination of baseline values
of hemoglobin (Hgb), hematocrit (Hct), and
coagulation factors.
3. Insert a Foley catheter.

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Management of Uterine inversion…

4. Immediately summon an anesthesiologist.

5. Treat aggressively
6. Order appropriate surgical equipment and assistants
to ready the operating room for a possible
laparotomy.
7. Administer tocolytics to promote uterine relaxation.
These may include nitroglycerin , or magnesium
sulfate at 4-6 g IV over 20 minutes

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/2004

Nursing diagnosis

 Fluid volume deficit,

 Risk for infection,
 Urinary retention,
 Ineffective sexuality pattern,
 Sexual dysfunction,
 Social Isolation,
 Disturbed body image,…

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Management of Uterine inversion…

POST-PROCEDURE CARE:
 Once the inversion is corrected, infuse oxytocin 20
units in 500 mL IV fluids (normal saline or Ringer’s
lactate) at 10 drops per minute:
 If haemorrhage is suspected, increase the infusion
rate to 60 drops per minute;
 If the uterus does not contract after oxytocin, give
ergometrine 0.2 mg or prostaglandins

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/2004

Summary

 Uterine inversion may occur immediately postpartum or, much less

frequently, during the puerperium
 The postpartum hemorrhage is usually the most striking of the
symptoms and initially commands the attention of the clinician.
 Treatment should begin as soon as the diagnosis of uterine inversion is
made.
 Successful management of patients with uterine inversion depends on;
 prompt recognition

 Definitive treatment

 vigorous resuscitation

 It is important that the part of the uterus that came out last (the
part closest to the cervix) goes in first.

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/2004

Acknowledgement

I am especially grateful for our instructor, Sr. Hirut

(RN,BSc N.,MSc ) for her giving me this
opportunity to present on ‘prolapse of genital organs
and uterine inversion’.
I would like to extend my thanks to my classmate for
your attention.

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/2004

Reference

1. Myles text book for midwives,14th ED, Churchil Livengstoone 2003.

2. 4.Bar-Oz B Eur J Obstet Gynecol Reprod Biol, 2009 Apr;143(2):75-8
3. ACOG Committee Opinion No. 267: Exercise during pregnancy and the
postpartum period. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2002;99:171.
4. Bump RC et al: The standardization of terminology of female pelvic
organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol
1996;175(1):10. [PMID: 8694033]
5. Shull BL: Pelvic organ prolapse: Anterior, superior, and posterior vaginal
segment defects. Am J Obstet Gynecol 1999;181:6. [PMID: 10411783]
6. Sze EH, Karram MM: Transvaginal repair of vault prolapse: A review.
Obstet Gynecol 1997;89:466. [PMID: 9052607]

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 5. COAGULATION DISORDERS
 Abruptio placentae
 Sepsis :IUCD,PROM
 Massive blood loss
 Massive blood transfusion
 Severe PET/ Eclampsia
 Amniotic fluid embolism
 Hepatitis

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107
 PPH Risk Factors

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Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Summary: Remember 4 Ts

 Tone
 Tissue
 Trauma
 Thrombin

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Summary: remember 4 Ts

 “TONE”  Palpate fundus.

 Rule out Uterine Atony  Massage uterus.
 Oxytocin
 Methergine
 Hemabate

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Summary: remember 4 Ts

 “Tissue”  Inspect placenta for

 R/O retained placenta missing cotyledons.
 Explore uterus.
 Treat abnormal
implantation.

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Summary: remember 4 Ts

 “TRAUMA”  Obtain good exposure.

 R/O cervical or vaginal  Inspect cervix and
lacerations. vagina.
 Worry about slow
bleeders.
 Treat hematomas.

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Summary: remember 4 Ts

 “THROMBIN”  Check labs if

suspicious.

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Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Intelligent anticipation, skilled supervision,
prompt detection and effective institution of
therapy can prevent disastrous consequences
of PPH.

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114
 Secondary Postpartum Hemorrhage

 Secondary PPH (2 0 PPH) is abnormal bleeding

occurring from the second day to the sixth week
postpartum.

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 Causes

 Bleeding in the first 3 weeks after the first day of

delivery is mainly due to:
 Sub-involution of the uterus

 Infection

 Retained pieces of placental tissue or clot

 Breakdown of the uterine wound after Cesarean

delivery or ruptured uterus

 After obstructed labor, bleeding may occur due

to sloughing of dead vaginal tissue (cervix, vagina,

bladder, and rectum).
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 Bleeding from the third week to sixth week is
mainly due to:
 Choriocarcinoma (rare)

 Local causes (vaginal or cervical) such as severe

infection, malignancies, trauma

 Early onset menstruation

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 Treatment Plan:

1. Usually sub-involution of the uterus, intrauterine

infection and retained pieces of placental tissue are
considered as a triad of causes for bleeding in the first
two weeks especially from the 5th - 10th day
postpartum.
 When reliable US is available, the decision to
evacuate the uterus or not can be made based on US
finding.
 Otherwise, all the three conditions are treated
together:
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 Oxitocics in drip or ergometerine (PO 1 tablet twice a day
for 2-3 day)
 Semi-sitting position to enhance drainage from the uterus
 Antibiotics against common organisms of the vagina
 Evacuate the uterus using ‘finger curettage’, vacuum
aspiration or large blunt curette
 Treat anemia and shock as appropriate (see section on
hemorrhagic shock
 Very rarely, bleeding persists and hysterectomy or other
surgical procedures might be needed

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Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
2. Incase of breakdown of the uterine wound after
Cesarean delivery or ruptured uterus, laparotomy is
done to re-suture the wound or hysterectomy.
3. Sloughing of dead tissue of the vaginal wall is treated
by removing dead tissue under light anesthesia; and
packing the bleeding areas tightly for 24-48 hours

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Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
4. When bleeding occurs late in the postpartum period,
(3 rd - 6th wk), pregnancy test has to be performed
to role out choriocarcinoma. Specimen of uterine
evacuation must be submitted for histological
examination. In non-breast feeding woman, it may be
the first menstrual bleeding postpartum. Local legion
of the vagina or cervix are excluded by speculum
examination.

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 Case Study
 Adisa Mohammed was rushed to your clinic by
her family. She delivered at home 2 hrs ago and
has since been bleeding profusely. She is now very
weak. You are the health worker at the clinic:
 What first steps will you take?
 What rapid assessments will you undertake
(history and examination)?

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Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Case Study (cont.)

 You note that she is very pale and barely alive. Her
BP is 80/50 mmHg and Pulse 110/ min. Her uterus is
lax and she is still bleeding actively PV. You are told
that the placenta was delivered after the baby was
born.
 What next resuscitative actions and assessments
will you undertake?

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Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 Group Work
 Participants will divide into groups of 3 or 4.
 Half of the groups will receive Case Study 1: Vaginal
Bleeding after Childbirth and the other groups will receive
Case Study 2: Vaginal Bleeding after Childbirth.
 Groups will read case studies and answer questions.
 Larger group will reassemble and discuss each case study.

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Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood
 References

Deganus S. 2006. Vaginal Bleeding after Childbirth, a presentation in

Accra, Ghana, Basic Maternal and Newborn Care Technical Update.
(April).
World Health Organization (WHO). 2006. Essential Medicines for
Reproductive Health. WHO: Geneva.
World Health Organization (WHO). 2000. Managing Complications in
Pregnancy and Childbirth: A Guide for Midwives and Doctors. WHO:
Geneva.
www.globalhealthlearning.org – course on Preventing Postpartum
Hemorrhage.

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 BEmONC – LRP: Ethiopia Management of Headache, Convulsions,
Best Practices in Maternal and Newborn Care Loss of Consciousness or Elevated Blood