Postpartum Haemorrhage, Dr Jeevan
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Transcript of Postpartum Haemorrhage, Dr Jeevan
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Definition
Qualitative definition:
Vaginal bleeding in excess of 500 ml after child birth.
But practically it is difficult to assess.
Clinical definition:Any amount of bleeding from or into the genital tract following child
birth which adversely affect the general condition of patient
evidenced by rise in pulse rate and falling blood pressure.
(Systolic BP < 90 mmHg and pulse > 110/min.)
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Epidemiology
According to the data of 1998, PPH found to
be major culprit for maternal death in Nepal.
About 47% of the maternal death was caused
by PPH.
A recent survey done in 10 districts of Nepalshows that PPH causes 19% of the maternal
death
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Types of PPH
Primary:
Bleeding within 24 hrs postpartum
Secondary:
Bleeding beyond 24 hrs till puerperium(6
weeks).
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Note:
Every healthy non anaemic women canhave catastrophic blood loss
Bleeding may occur at a slow rate overseveral hours and condition may not be
recognised until the woman suddenly enters
shock
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Causes of primary PPH
4 Ts
Tone
Trauma
Tissue Remnant
Thrombin
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A. Reduced Tone (70%)
With separation of placenta uterine sinuses
which are torn cannot be compressed
effectively due to imperfect contraction and
retraction of uterus
Risks: Grand Multipara
Over distension of uterus
Malnutrition and anaemia
Prolonged labour
Malformed uterus
Uterine fibroid
precipitate labour ( reduced adaptation / genital trauma)
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B. Trauma (20%)
Trauma to genital tract.
Cervix , vaginal wall, perineal tear can occur
Occurs more often with increased
instrumentation, difficult labour
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C. Tissue Retained (10%)
Bits of placenta / membrane
Blood clots
Primarily interfere in uterine contraction
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D. Thrombin (
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Prevention of PPH
PPH cannot always be prevented . However
incidence and its magnitude can be reduced
substantially.
Antenatal:
Improvement of health status
High risk patient screening and counselling
Blood grouping
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Intranatal:
Slow delivery of baby. Baby should be pushed out not pulled out Active management of third stage of labour which includes: inj.
oxytocin 10U IM stat, CCT to be done after placental separationonly and fundal massage
Examination of placenta and membrane should be routinely done
Oxytocin infusion should be continued at least one hour after
delivery in those cases in which labour is induced or augmented by
oxytocin
Exploration of birth canal especially following difficult labour or
instrumental delivery
Observation of patient for about 2 hours before sending her to
ward.
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Management of PPH
Shout for extra help. urgently mobilise all
personnel available
Counsel mother and her relatives about the
condition gravity
Rapid evalutation of general condition bymeasuring pulse, BP, Temperature and
respiratory rate
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Management of PPH
If patient has following features, the patient is
considered to have gone into shock:
Systolic BP: < 90 mmHg
Pulse: > 100/min
Pallor
Unconciousness
Cold clammy Periphery
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Management of PPH
Management of shock:
Basic principles of shock are: Maintain Airway , Breathing and circulation
Oxygen
positioning
Open IV line ( 2 lines) by large bore canula
and infuse fluid (NS or RL) fast.
Catheterisation and input/output charting
Send blood for Hb%, Blood grouping and cross
matching
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Management of PPH
Uterine massage should be done
if well contracted
Examine cervix, vagina and perinium for traumaif present repair.
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Management of PPH
If uterine atony is there then following steps
have to be carried out
Step 1.
Uterine massage
Inj. Oxytocin 10 U IM stat if not given earlier
and Inj. Oxytocin 10-20 U in 500ml Rl/NS @
40-60 drops/min Examine expelled placenta and membrane
Bladder catheterisation if not done earlier
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Management of PPH
Step 2.
Exclude coexisting injured/traumatic site in the
birth canal
Continue Oxytocin drip
Misoprostol 600 microgram per rectally
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Management of PPH
Step 3.
Bimanual compression / Aortic compression
Tight intrauterine packing under anaesthesia
Step 4.
Surgery
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Continuous care following
control of PPH
Vitals should be monitored every 15 min in 1st hour then
every 30 min in 2nd hour and 4 hourly in next 24 hours.
Breast feeding
Hb. done after 24 hours If haemoglobin is below 7 gm/dl and vitals of the patient is
unstable, blood transfusion should be done or referred.
Iron tablet should be given for 6 months
Albendazole given if was not given earlier. Nutritional counselling
Discharged only after 24 hours of control of PPH
During discharge counselling to be done regarding FP
and danger signs.
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Secondary PPH
Bleeding usually occurs between 8th and 14th
day of delivery
The causes of late post partum are
Retained bits of cotyledon or membrane(commonest)
Infection and separation of slough over a
deep cervico vaginal tear Endometritis and subinvolution of placental
site due to delay healing process
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Conclusion:
The commonest cause of PPH is uterine atony
Tone of the uterus can be regained by simple
measures like fundal massage and oxytocin
infusion primarily.All said and done to prevent from catastrophe
the essentials are:
Intelligent anticipation Skilled supervision
Prompt detection
Effective institution of therapy
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