PPH PRESENTASI GLOBAL.ppt

8/16/2019 PPH PRESENTASI GLOBAL.ppt

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Managing Complications inManaging Complications in

Pregnancy and ChildbirthPregnancy and Childbirth

A guide for midwives and doctorsA guide for midwives and doctors

Department of Reproductive Health and ResearchDepartment of Reproductive Health and Research(RHR)(RHR)

!orld Health "rgani#ation!orld Health "rgani#ation


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"ng $%andra"n

g $%andra

&agian 'ebidanan dan 'andungan&a

gian 'ebidanan dan 'andungan

$imia * Maret +,,-$imia

* Maret +,,-


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.ven healthy non/anaemic women can.ven healthy non/anaemic women can

have catastrophic blood losshave catastrophic blood loss

Bleeding may occurBleeding may occur

at a slow rate overat a slow rate overseveral hours and theseveral hours and the

condition may not becondition may not be

recognized until therecognized until the

woman suddenlywoman suddenlyenters shock.enters shock.


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"b%ectives"b%ectives

Review risk factors and causes of PPHReview risk factors and causes of PPH

Review Management StrategiesReview Management Strategies

The T!sThe T!sH"#P"RRH"#P"RR

Review active Management of third stageReview active Management of third stage


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$"%&'&T&('S$"%&'&T&('S

MiscarriageMiscarriage ) *+ to , weeks of gestation) *+ to , weeks of gestationor less than - gms /0H( 1 , weeks2or less than - gms /0H( 1 , weeks2

Ante/partum haemorrhageAnte/partum haemorrhage ) %rom ,) %rom ,

weeks gestation until the onset of labour weeks gestation until the onset of labour 0ntra/partum haemorrhage0ntra/partum haemorrhage ) %rom onset) %rom onset

of labour until the end of second stageof labour until the end of second stage

Post/partum HaemorrhagePost/partum Haemorrhage ) from third) from thirdstage of labour until the end of thestage of labour until the end of the+uer+erium+uer+erium


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Postpartum HemorrhagePostpartum Hemorrhage

$efinition) 3 4 ml blood loss w5in , hours$efinition) 3 4 ml blood loss w5in , hoursafter delivery /avg loss 6 -ml2after delivery /avg loss 6 -ml2

""+idemiology 4 +er 4 deliveries7 in+idemiology 4 +er 4 deliveries7 in

develo+ing countries 89- times more.develo+ing countries 89- times more.(ne of the main causes of maternal mortality(ne of the main causes of maternal mortality

8 9 - : of vaginal deliveries8 9 - : of vaginal deliveries

Potentially serious com+lications for mother Potentially serious com+lications for mother Third leading cause of maternal deathsThird leading cause of maternal deaths

worldwideworldwide


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1aginal bleeding after childbirth1aginal bleeding after childbirth

;aginal bleeding in e


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$here are however some problems$here are however some problems

with this definition2with this definition2"stimates of blood loss are notoriously"stimates of blood loss are notoriously

low7 often half the actual loss.low7 often half the actual loss.

Blood is mi


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Risk assessment in the antenatal +eriodRisk assessment in the antenatal +eriod

does not effectively +redict those womendoes not effectively +redict those womenwho will have PPH.who will have PPH.

Active management of the third stageActive management of the third stage

should be practiced on all women inshould be practiced on all women inlabour since it reduces the incidence oflabour since it reduces the incidence of

PPH due to uterine atonyPPH due to uterine atony ..

=ll +ost+artum women must be closely =ll +ost+artum women must be closelymonitored to determine those that havemonitored to determine those that have

PPH.PPH.


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$hird 3tage Management$hird 3tage Management

"


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ProblemProblem

&ncreased vaginal bleeding within the first&ncreased vaginal bleeding within the first, hours after childbirth /immediate PPH2., hours after childbirth /immediate PPH2.

&ncreased vaginal bleeding following the&ncreased vaginal bleeding following the

first , hours after childbirth /delayedfirst , hours after childbirth /delayedPPH2.PPH2.


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Ris 4actorsRis 4actors

='T"P=RT*M ='T"P=RT*M RRRR Preeclam+siaPreeclam+sia -.-.

Previous +ost+artum hemorrhagePrevious +ost+artum hemorrhage 8.?8.?

Multi+le gestationMulti+le gestation 8.88.8 Previous cesarean sectionPrevious cesarean section 4.@4.@

=sian5His+anic =sian5His+anic 4.@4.@

Multi+arityMulti+arity 4.-4.- PolyhydramniosPolyhydramnios

MacrosomiaMacrosomia >ombs7 (bstet Aynecol @@7 44>ombs7 (bstet Aynecol @@7 44


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Preeclam+sia "clam+siaPreeclam+sia "clam+sia


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(verdisted due to +olihidramnion(verdisted due to +olihidramnion


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(verdistended due to macrosomia(verdistended due to macrosomia


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Multi+arityMulti+arity


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Ris 4actorsRis 4actors

&'TR=P=RT*M&'TR=P=RT*M RR RR Prolonged third stageProlonged third stage @[email protected]

#eft mediolateral e+isiotomy#eft mediolateral e+isiotomy .@.@

Midline e+isiotomyMidline e+isiotomy 4.?4.? =rrest of descent =rrest of descent 8.8.

#acerations) vaginal7 +erineal#acerations) vaginal7 +erineal ,.,.

=ssisted delivery) force+s7 vacuum =ssisted delivery) force+s7 vacuum 4.@4.@

=ugmented labor =ugmented labor 4.@4.@

>horioamnionitis>horioamnionitis

MgS( during labor MgS( during labor >ombs7 (bstet Aynecol @@7 44>ombs7 (bstet Aynecol @@7 44


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Causes5Ris factors

=nte +artum

C =ge 3 8- year

C*terine fibroids

CPreci+itate labor

C*se of o


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%ibroid%ibroid


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Posterior succenturiate +lacental lobe.Posterior succenturiate +lacental lobe.


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Continuous slow bleeding or suddenContinuous slow bleeding or sudden

bleeding is an emergency6 intervenebleeding is an emergency6 intervene

early and aggressively7early and aggressively7


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A"'"R=# M='=A"M"'TA"'"R=# M='=A"M"'T

3H"8$ 4"R H.9P3H"8$ 4"R H.9P. *rgently mobilize all. *rgently mobilize all

available +ersonnel.available +ersonnel.

Make a ra+id evaluation of the generalMake a ra+id evaluation of the general

condition of the woman including vitalcondition of the woman including vital

signs /+ulse7 blood +ressure7 res+iration7signs /+ulse7 blood +ressure7 res+iration7

tem+erature2.tem+erature2.


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A"'"R=# M='=A"M"'TA"'"R=# M='=A"M"'T

&f shock is sus+ected7 immediately begin&f shock is sus+ected7 immediately begin

treatment. "ven if sign of shock are nottreatment. "ven if sign of shock are not+resent7 kee+ shock in mind as you+resent7 kee+ shock in mind as youevaluate the woman further because herevaluate the woman further because herstatus may worsen ra+idly.status may worsen ra+idly.

&f shock develo+s7 it is im+ortan to begin&f shock develo+s7 it is im+ortan to begintreatment immediatelytreatment immediately


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A"'"R=# M='=A"M"'TA"'"R=# M='=A"M"'T

Massage the uterus to e


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A"'"R=# M='=A"M"'TA"'"R=# M='=A"M"'T

>atheterize the bladder.>atheterize the bladder.

>heck to see if the +lacenta has been>heck to see if the +lacenta has been

e


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After bleeding isAfter bleeding is

controlledcontrolled /, hours/, hours

after bleeding sto+s27after bleeding sto+s27

determinedeterminehaemoglobin orhaemoglobin or

haematocrit to checkhaematocrit to check

for anaemia)for anaemia)


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&f&f haemoglobin is below : g5d9haemoglobin is below : g5d9 oror

haematocrit is below +,;haematocrit is below +,; /severe/severe

anaemia2)anaemia2)

Aive ferrous sulfate or ferrous fumerateAive ferrous sulfate or ferrous fumerate

4, mg by mouth P#*S folic acid 4, mg by mouth P#*S folic acid mcg by mouth once daily for 8 monthsmcg by mouth once daily for 8 months


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=fter 8 months7 continue su++lementation =fter 8 months7 continue su++lementation

with ferrous sulfate or ferrous fumerate ?with ferrous sulfate or ferrous fumerate ?

mg by Mouth P#*S folic acid mcg bymg by Mouth P#*S folic acid mcg bymouth once daily for ? months.mouth once daily for ? months.


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&f&f haemoglobin is between :


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8terine Atony

%ailure of the uterus to contract after

delivery of the +lacenta.

Most common cause of +rimary

+ost+artum hemorrhage.


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$rauma$rauma

*terine inversion*terine inversion

*terine ru+ture*terine ru+ture

;aginal or cervical lacerations;aginal or cervical lacerations

HematomaHematoma


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$0338.$0338.

Retained +lacentaRetained +lacenta'ot delivered within 8 minutes'ot delivered within 8 minutes

8 : of deliveries8 : of deliveriesRetained +lacental fragmentsRetained +lacental fragments

&nvasive +lacenta&nvasive +lacenta


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$hrombin5Coagulopathy$hrombin5Coagulopathy

Pre9e


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Coagulation 9ab 3tudiesCoagulation 9ab 3tudies

>B> with +latelet count>B> with +latelet count

PT9&'R7 aPTTPT9&'R7 aPTT%ibrinogen level%ibrinogen level

%ibrin s+lit +roducts 5 $9dimer %ibrin s+lit +roducts 5 $9dimer


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Prostaglandins should not be given intravenously7 $hey may be fatal


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0f bleeding continues0f bleeding continues))

>heck +lacenta again for>heck +lacenta again for

com+letenessDcom+letenessD &f there are&f there are signs of retainesigns of retaine

placental fragmentsplacental fragments

/absence of a +ortion of/absence of a +ortion of

maternal surface or tornmaternal surface or torn

membranes with vessels27membranes with vessels27

remove remaining +lacentalremove remaining +lacental

tissuetissue

DD


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=ssess clotting status using a bedside =ssess clotting status using a bedside

clotting testclotting test..

%ailure of a clot to form after @ minutes or%ailure of a clot to form after @ minutes or

a soft clot that breaks down easilya soft clot that breaks down easily

suggestssuggests coagulo+athycoagulo+athy..


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&f&f bleeding continuesbleeding continues in s+ite of mangement abovein s+ite of mangement above

Perform bimanual com+ression of the uterusPerform bimanual com+ression of the uterus


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Perform bimanual com+ression of the uterusPerform bimanual com+ression of the uterus ))

0earing high9level0earing high9level

disinfected gloves7 insert adisinfected gloves7 insert a

hand into the vagina andhand into the vagina and

form a fistDform a fistD

Place the fist into thePlace the fist into the

anterior forni< and a++lyanterior forni< and a++ly

+ressure against the+ressure against theanterior wall of the uterusDanterior wall of the uterusD


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=lt ti l th t=lt ti l th t


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=lternatively7 com+ress the aorta =lternatively7 com+ress the aorta

Compression of abdominal aorta and palpation of femoral pulseCompression of abdominal aorta and palpation of femoral pulse


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=++ly downward +ressure with a closed fist over =++ly downward +ressure with a closed fist over

the abdominal aorta directly through thethe abdominal aorta directly through the

abdominal wall)abdominal wall)


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The +oint of com+ression is Gust above theThe +oint of com+ression is Gust above theumbilicus and slightly to the leftDumbilicus and slightly to the leftD =ortic +ulsations can be felt easily through the =ortic +ulsations can be felt easily through the

anterior abdominal wall in the immediateanterior abdominal wall in the immediate

+ost+artum +eriod.+ost+artum +eriod.


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0ith the other hand7 +al+ate the femoral +ulse to check0ith the other hand7 +al+ate the femoral +ulse to checkthe adeFuacy of com+ression)the adeFuacy of com+ression)

&f the&f the pulse is palpable during compressionpulse is palpable during compression7 the7 the+ressure e


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0f bleeding continues in spite of compression0f bleeding continues in spite of compression

Perform uterine and utero9ovarian arteryPerform uterine and utero9ovarian artery

ligationDligationD

&f&f life/threatening bleeding continueslife/threatening bleeding continues afterafter

ligation7 +erform subtotal hligation7 +erform subtotal hysterectomyysterectomy

Pacing the uterus is ineffective andPacing the uterus is ineffective and

wastes precious time7wastes precious time7


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$.AR3 "4 C.R10 1A@0>A "R P.R0>.8M$.AR3 "4 C.R10 1A@0>A "R P.R0>.8M

Tears of the birth canal are the secondTears of the birth canal are the second

most freFuent cause of PPH. Tears maymost freFuent cause of PPH. Tears may

coe


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"


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Re+airing tear of vaginaRe+airing tear of vagina


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R.$A0>.D P9AC.>$A


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R.$A0>.D P9AC.>$AR.$A0>.D P9AC.>$A

There may be no bleeding with retainedThere may be no bleeding with retained

+lacenta.+lacenta.

&f&f you can see the placentayou can see the placenta7 ask the7 ask the

woman to +ush it out. &f you can feel thewoman to +ush it out. &f you can feel the

+lacenta in the vagina7 remove it.+lacenta in the vagina7 remove it.

"nsure that the bladder is em+ty."nsure that the bladder is em+ty.

>atheterize the bladder7 if necessary.>atheterize the bladder7 if necessary.


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&f the&f the placenta is not eBpelledplacenta is not eBpelled7 give7 give

o


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&f the&f the placenta is undelivered after , minutesplacenta is undelivered after , minutesof oBytocinof oBytocin stimulation and thestimulation and the uterus isuterus is

contractedcontracted77 attem+t controlled cordattem+t controlled cord

tractiontraction..

>ote>ote) =void forceful cord traction and fundal) =void forceful cord traction and fundal

+ressure as they may cause uterine inversion.+ressure as they may cause uterine inversion.


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&f&f controlled cord traction iscontrolled cord traction isunsuccessfulunsuccessful77 attem+t manual removalattem+t manual removalof +lacentaof +lacenta..

>ote>ote) ;ery adherent tissue may be +lacenta) ;ery adherent tissue may be +lacentaaccreta. "fforts to e


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&f&f bleeding continuesbleeding continues assess clotting statusassess clotting status

using a bedsideusing a bedside clotting testclotting test..%ailure of a clot to form after @ minutes or a soft%ailure of a clot to form after @ minutes or a soft

clot that breaks down easily suggestsclot that breaks down easily suggests

coagulo+athycoagulo+athy..

&f&f there are signs of infectionthere are signs of infection /fever7/fever7

foul9smelling vaginal discharge27foul9smelling vaginal discharge27 give antibioticsgive antibiotics

as for metritisas for metritis..

R.$A0>.D P9AC.>$A9 4RA@M.>$3R.$A0>.D P9AC.>$A9 4RA@M.>$3


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There may be no bleeding with retainedThere may be no bleeding with retained+lacental fragments+lacental fragments

0hen a +ortion of the +lacentaone or0hen a +ortion of the +lacentaone or

more lobesis retained7 it +revents themore lobesis retained7 it +revents the

uterus from contracting effectively.uterus from contracting effectively.


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%eel inside the uterus for +lacenta%eel inside the uterus for +lacentafragments. Manual e


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>ote>ote) ;ery adherent tissue may be +lacenta accreta) ;ery adherent tissue may be +lacenta accreta

"fforts to e


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&nverted *terus&nverted *terus

The uterus is said to be inverted if it turnsThe uterus is said to be inverted if it turnsinside9out during delivery of the +lacenta.inside9out during delivery of the +lacenta.

Re+ositioning the uterus should beRe+ositioning the uterus should be

+erformed immediately+erformed immediately. 0ith the +assage. 0ith the +assageof time the constricting ring around theof time the constricting ring around the

inverted uterus becomes more rigid andinverted uterus becomes more rigid and

the uterus more engorged with bloodthe uterus more engorged with blood


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&nverted uterus&nverted uterus


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&f&f bleeding continuesbleeding continues7 assess clotting status7 assess clotting statususing a bedsideusing a bedside clotting testclotting test. %ailure of a clot to. %ailure of a clot to

form after @ minutes or a soft clot that breaksform after @ minutes or a soft clot that breaks

down easily suggestsdown easily suggests coagulo+athycoagulo+athy..

Aive a single dose of +ro+hylactic antibioticsAive a single dose of +ro+hylactic antibiotics afterafter

correcting the inverted uterus)correcting the inverted uterus)

9am+icillin , g &; P#*S metronidazole - mg &;D9am+icillin , g &; P#*S metronidazole - mg &;D

9(R9(R

cefazolin 4 g &; P#*S metronidazole - mg &;.cefazolin 4 g &; P#*S metronidazole - mg &;.



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&f&f there are signs of infectionthere are signs of infection /fever7 foul9/fever7 foul9

smelling vaginal discharge27smelling vaginal discharge27 give antibioticsgive antibiotics

as for metritisas for metritis..

&f&f necrosis is suspectednecrosis is suspected7 +erform vaginal7 +erform vaginal

hysterectomy. This may reFuire referral to ahysterectomy. This may reFuire referral to a

tertiary care centre.tertiary care centre.

$$.9A?.D (3.C">DAR?E) P"3$PAR$8M.9A?.D (3.C">DAR?E) P"3$PAR$8M


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$$.9A?.D (3.C">DAR?E) P"3$PAR$8M.9A?.D (3.C">DAR?E) P"3$PAR$8M

HA.M"[email protected]"RRHA@.

&f&f anaemia is severeanaemia is severe /haemoglobin less/haemoglobin lessthan @ g5d# or haematocrit less than ,:27than @ g5d# or haematocrit less than ,:27arrange for a transfusion and +rovide oralarrange for a transfusion and +rovide oral

iron and folic acid.iron and folic acid.

&f&f there are signs of infectionthere are signs of infection /fever7 foul9/fever7 foul9

smelling vaginal discharge27 give antibioticssmelling vaginal discharge27 give antibioticsas for metritis.as for metritis.


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Prolonged or delayed PPH may be a signProlonged or delayed PPH may be a signof metritis7of metritis7

Aive o


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&f the&f the cerviB is not dilatedcerviB is not dilated7 evacuate the7 evacuate theuterus to remove +lacental fragments.uterus to remove +lacental fragments.

Rarely7 ifRarely7 if bleeding continuesbleeding continues7 consider7 consider

uterine and utero9ovarian artery ligation oruterine and utero9ovarian artery ligation orhysterectomy.hysterectomy.

Perform histologic e


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&ntrauterine Hydrostatic Ballooning by a&ntrauterine Hydrostatic Ballooning by a


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condom is a method for control ofcondom is a method for control of

Post+artum HemorrhagePost+artum Hemorrhage

Brief descri+tion of method


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+

= sterile +lain rubber catheter attached to = sterile +lain rubber catheter attached to

a condom is inserted into the uterus.a condom is inserted into the uterus.

>ondom is inflated with isotonic saline of>ondom is inflated with isotonic saline of

,- 1 - ml /sometime 3- ml 1 4 #2,- 1 - ml /sometime 3- ml 1 4 #20hen the bleeding is reduced0hen the bleeding is reduced

considerably7 further inflation is sto++ed.considerably7 further inflation is sto++ed.

then outer end of the catheter is foldedthen outer end of the catheter is folded

and tied to fi< it with the thigh.and tied to fi< it with the thigh.



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To kee+ the inflated balloon within the uterus7To kee+ the inflated balloon within the uterus7

the +ost vagina is +acked with sterile +ack.the +ost vagina is +acked with sterile +ack.

*terine contraction maintained with o


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>ecessary 9ogistics

3"33"3 &ari&ari $amponade$amponade &alloon&alloon


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Bakri, et al, Int J Gyne Obstet,Bakri, et al, Int J Gyne Obstet,

20012001 Designed specifically forDesigned specifically for

obstetrical hemorrhageobstetrical hemorrhage

maximm capacity !00cc ofmaximm capacity !00cc of

balloon "recommended 2#0 toballoon "recommended 2#0 to

#00c$#00c$

%ider caliber drainage shaft%ider caliber drainage shaft

article describes # sccessflarticle describes # sccessflcases %ith pre&iascases %ith pre&ias

It can be placedIt can be placed from abo&efrom abo&e atat

time of '()time of '() / not from below 2/ not from below 2


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ProcedureProcedure


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Condom inflated

ProcedureProcedure


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Cervical lips hold by sponge forceps

ProcedureProcedure


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1agina paced F catheter connected with saline set


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p gp g

3ummary3ummary

*n+redictable 9 be +re+aredJ*n+redictable 9 be +re+aredJ

*terine atony is the main cause*terine atony is the main cause

Remember 9Ts)Remember 9Ts)>onsider active management of third>onsider active management of third

stagestage



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3ummary3ummary$">.$">. 1 sterine hy+otony due to) Multi+le 1 sterine hy+otony due to) Multi+le

+regnancy7 multi+arity7 +rotracted delivery7+regnancy7 multi+arity7 +rotracted delivery7

tocolysistocolysis

$0338.$0338. 1 +lacenta retention7 amniotic 1 +lacenta retention7 amnioticretention7 coagules of bloodretention7 coagules of blood

$RA8MA$RA8MA 1 e7 big blood loss7 overdosage of he+arin

P i


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PreventionPrevention

Treat anemia during +renatal careTreat anemia during +renatal care

=void routine e+isiotomy =void routine e+isiotomy

Actively manage third stageActively manage third stageRe9e


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Treatment &. Suttures and ligatures7 uterotonics7Treatment &. Suttures and ligatures7 uterotonics7crystaloids7 +lasma7blood7 laboratory testing7crystaloids7 +lasma7blood7 laboratory testing7

o


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Risk assessment in the antenatal +eriodRisk assessment in the antenatal +eriod

does not effectively +redict those womendoes not effectively +redict those womenwho will have PPH.who will have PPH.

Active management of the third stageActive management of the third stage

should be practiced on all women inshould be practiced on all women inlabour since it reduces the incidence oflabour since it reduces the incidence of

PPH due to uterine atonyPPH due to uterine atony ..

=ll +ost+artum women must be closely =ll +ost+artum women must be closelymonitored to determine those that havemonitored to determine those that have

PPH.PPH.

$hi d 3 M$hi d 3t M t


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$hird 3tage Management$hird 3tage Management

"


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H"! $" 83. 8$.R"$">0C A@.>$3H"! $" 83. 8$.R"$">0C A@.>$3


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0ithin one minute of the delivery of the0ithin one minute of the delivery of thebaby7 +al+ate the abdomen to rule out thebaby7 +al+ate the abdomen to rule out the+resence of an additional baby or babies+resence of an additional baby or babies

and give o


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uterotonics can be used7 such asuterotonics can be used7 such as

"rgometrine ., mg &M7"rgometrine ., mg &M7Syntometrine /4 am+oule2 &M7 orSyntometrine /4 am+oule2 &M7 or

Miso+rostol 1? Ng orallyMiso+rostol 1? Ng orally..

(ral administration of ? Ng miso+rostol(ral administration of ? Ng miso+rostol

should be reserved for situations whenshould be reserved for situations when

safe administration and a++ro+riatesafe administration and a++ro+riatestorage conditions for inGectable o


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*terotonics reFuire*terotonics reFuire

+ro+er storage)+ro+er storage)

4.4. ergometrine) kee+ at ,1IO> and +rotectergometrine) kee+ at ,1IO> and +rotect

from light and freezingfrom light and freezing,.,. miso+rostol) kee+ at room tem+erature7miso+rostol) kee+ at room tem+erature7

in a closed container in a closed container

8.8. o7 +rotect fromo7 +rotect fromfreezingfreezing

>ounselling on the side effects of these>ounselling on the side effects of these

drugs should be givendrugs should be given

H"! $" D" C">$R"99.D C"RD $RAC$0">H"! $" D" C">$R"99.D C"RD $RAC$0">


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4. >lam+ the cord close to the +erineum4. >lam+ the cord close to the +erineum

/once +ulsation sto+s in a healthy/once +ulsation sto+s in a healthynewborn2 and hold in one hand.newborn2 and hold in one hand.

,. Place the other hand Gust above the,. Place the other hand Gust above the

woman!s +ubic bone and stabilize thewoman!s +ubic bone and stabilize theuterus by a++lying counter9+ressureuterus by a++lying counter9+ressure

during controlled cord traction.during controlled cord traction.

8. ee+ slight tension on the cord and8. ee+ slight tension on the cord and


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g

await a strong uterine contractionawait a strong uterine contraction

/,18 minutes2./,18 minutes2.

*7*7 0ith the strong uterine contraction70ith the strong uterine contraction7encourage the mother to +ush andencourage the mother to +ush andvery gently +ull downward on thevery gently +ull downward on thecord to deliver the +lacenta.cord to deliver the +lacenta.>ontinue to a++ly counter9+ressure>ontinue to a++ly counter9+ressureto the uterus.to the uterus.


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-.&f the +lacenta does not descend-.&f the +lacenta does not descend

during 81 seconds of controlledduring 81 seconds of controlled

cord traction7 do not continue to +ullcord traction7 do not continue to +ull

on the cord) gently hold the cord andon the cord) gently hold the cord and

wait until the uterus is well contractedwait until the uterus is well contracted

again with the ne


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>ever apply cord traction (pull)>ever apply cord traction (pull)without applying counter tractionwithout applying counter traction

(push) above the pubic bone on a(push) above the pubic bone on a

wellcontracted uterus7wellcontracted uterus7

GG = th l t d li h ld th= th l t d li h ld th


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G7G7 =s the +lacenta delivers7 hold the =s the +lacenta delivers7 hold the

+lacenta in two hands and gently turn it+lacenta in two hands and gently turn ituntil the membranes are twisted. Slowlyuntil the membranes are twisted. Slowly

+ull to com+lete the delivery.+ull to com+lete the delivery.

:7:7 &f the membranes tear7 gently e


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-7-7 #ook carefully at the +lacenta to be sure#ook carefully at the +lacenta to be surenone of it is missing. &f a +ortion of thenone of it is missing. &f a +ortion of the

maternal surface is missing or there arematernal surface is missing or there are

torn membranes with vessels7 sus+ecttorn membranes with vessels7 sus+ectretained +lacenta fragments and takeretained +lacenta fragments and take

a++ro+riate action.a++ro+riate action.

H"! $" D" 8$.R0>. [email protected]"! $" D" 8$.R0>. MA33A@.


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77 &mmediately massage the fundus of the&mmediately massage the fundus of theuterus until the uterus is contracted.uterus until the uterus is contracted.

+7+7 Pal+ate for a contracted uterus every 4-Pal+ate for a contracted uterus every 4-

minutes and re+eat uterine massage asminutes and re+eat uterine massage asneeded during the first , hours.needed during the first , hours.

77 "nsure that the uterus does not become"nsure that the uterus does not become

rela


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g gg g


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M(R" QM(R" Q

>=P" $"H.>=P" $"H.

"H=*ST"$$$eh"H=*ST"$$$eh


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*+on review of the available evidence %&A(*+on review of the available evidence7 %&A(


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*+on review of the available evidence7 %&A(*+on review of the available evidence7 %&A(

and &>M agree that active management of theand &>M agree that active management of the

third stage of labour is +roven to reduce thethird stage of labour is +roven to reduce theincidence of +ost+artum hemorrhage /PPH27 theincidence of +ost+artum hemorrhage /PPH27 the

Fuantity of blood loss7 and the use of bloodFuantity of blood loss7 and the use of blood

transfusion.transfusion. Active management of the third stage ofActive management of the third stage of

labour should be offered to women since itlabour should be offered to women since it

reduces the incidence of postpartumreduces the incidence of postpartum

hemorrhage due to uterine atony7hemorrhage due to uterine atony7


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=ctive management of the third stage of =ctive management of the third stage oflabour consists of interventions designedlabour consists of interventions designed

to facilitate the delivery of the +lacenta byto facilitate the delivery of the +lacenta by

increasing uterine contractions and toincreasing uterine contractions and to+revent PPH by averting uterine atony.+revent PPH by averting uterine atony.


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The usual com+onents include)The usual com+onents include)administration of uterotonic agentsadministration of uterotonic agents

controlled cord tractioncontrolled cord traction

uterine massage after delivery of theuterine massage after delivery of the

+lacenta7 as a++ro+riate+lacenta7 as a++ro+riate


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PPH PRESENTASI GLOBAL.ppt

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