Post Partum Haemorrhage

Question 1

Full meaning if PPH

PPH) : is commonly defined as

Answer 1

Postpartum hemorrhage

(PPH) : is commonly defined as Severe bleeding after childbirth
Or
blood loss exceeding 500 milliliters (mL) following vaginal birth and 1000 mL following cesarean. 1.

Question 2

Post-partum haemorrhage may be ?

Answer 2

Post-partum haemorrhage may be
— primary or
— secondary.

Question 3

Primary postpartum haemorrhage refers to ?

Primary postpartum hemorrhage usually occurs?

Secondary post-partum haemorrhage is defined as

In Secondary post-partum haemorrhage the bleeding may occur with?

Postpartum haemorrhage becomes life threatening if ?

Blood loss of more than …… ml may lead to…..?

Answer 3

Primary postpartum haemorrhage refers to bleeding of more than 500 ml from the genital tract within the first twenty-four hours of delivery or any amount of blood loss that result in haemodynamic compromise of the patient.

It usually occurs during or immediately after the third stage of labour.

Secondary post-partum haemorrhage is defined as excessive vaginal bleeding occurring from twenty-four hours to six weeks after delivery.

The bleeding may occur with the placenta retained or after its expulsion from the uterus.

Postpartum haemorrhage becomes life threatening if the mother is already anaemic.

Blood loss of more than 500 ml may lead to shock.

Question 4

Causes Of PPH?

Answer 4

Causes

— Uterine atony (70-90% of cases): means lack of normal tone or tension, as in muscles; abnormal relaxation of a muscle.
— Retention of all or part of placental tissue within the uterine cavity
— Infection within the uterine cavity (endo-myometritis)
— Genital tract trauma
— Clotting disorders

Question 5

Symptoms

Signs

Answer 5

Symptoms
— Excessive or prolonged vaginal bleeding after delivery
— Lower abdominal pains

Signs
— Active bleeding from the genital tract
— Conjunctival pallor
— Rapid pulse
— Blood pressure may be low or normal
— Deterioration of maternal levels of consciousness
— Flabby poorly contracted uterus
— Obvious tears in birth canal and/or perineum
— Obvious retained placenta
— Suprapubic tenderness

Question 6

Investigations

Answer 6

Investigations

— FBC, sickling status
— Bedside clotting test
— Blood grouping and cross-matching
— Ultrasound scan (if patient is stable to check for retained placenta
tissue)

Question 7

Treatment refer to page 345 to 348

Answer 7

Treatment
Treatment objectives
y To identify the cause and stop bleeding as quickly as possible y To correct hypotension
y To correct resulting anaemia
Non-pharmacological treatment
Due to uterine atony (70-90% of cases), with no placental retention
y Massage fundus of uterus to stimulate contraction
y Encourage woman to empty bladder or pass a urethral catheter to
empty the bladder and monitor urine output
y Bimanual compression of the uterus and balloon tamponade if
uterus fails to contract with massage
Due to retained placenta
y Attempt removal of the placenta by controlled cord traction as soon as a contraction is felt. If not successful await the next contraction and repeat the procedure
y If the placenta cannot be expelled in this fashion, manual removal under anaesthesia is indicated
y Iftheplacentahasbeendeliveredandisincomplete,explorationthe uterus and manual removal under anaesthesia is indicated
y Ifthefacilitiesformanualremovalofplacentaunderanaesthesiaare not immediately available refer to hospital
Bleeding with uterus well contracted and placenta completely delivered
y Examine the patient in the lithotomy position with adequate analgesia and/or anaesthesia, good lighting to identify and suture perineal, vaginal and cervical tears
y Ifthetear(s)extendsintotheuterinebody,effectivesuturingcannot be performed and repair will involve a laparotomy
y For ruptured uterus, repair or hysterectomy is required
Bleeding associated with coagulopathy
y Bedsideclottingtest-5mlofbloodplacedina10mlroundbottomed glass tube should clot in 6 minutes
Pharmacological treatment
A. If the uterus is poorly contracted (Atony)
1st Line Treatment
Evidence Rating: [A]
y Oxytocin, IM, 10 units stat. Then
y Oxytocin, IV, infusion, 10-40 units in 500 ml Dextrose saline or 0.9% or Normal saline
Dose not to exceed 40 units
2nd Line Treatment
y Misoprostol, sublingual, 600 microgram (for PPH prophylaxis within 1 minute of delivery)
Evidence Rating: [B]
y Misoprostol, sublingual, 800 microgram stat if patient is conscious (for PPH treatment)
Or
3rd Line Treatment
Evidence Rating: [B]
y Ergometrine, IV, 500 microgram stat. Or
Evidence Rating: [B]
y Oxytocin-ergometrine, IM, (Oxytocin 10 units and Ergometrine 500 microgram) stat.
Or
y Oxytocin-misoprostol,(Oxytocin,IV,10unitsandMisoprostol,rectal, 600 micrograms) stat.
Evidence Rating: [B]
346
Note 13-6
If intravenous oxytocin is unavailable, or if the bleeding does not respond to oxytocin, the following second line drugs are recommended.
— Post-Partum Haemorrhage —
Note 13-7
High rates of adverse effects (nausea, vomiting, and high blood pressure) occur in women treated with ergometrine.
They should not be given to women with hypertension in pregnancy or heart disease.