POSTPARTUM

HAEMORRHAGE
Presented by Dr. Jeevan Adhikari Medical Officer Salyan Hosital 2069/1/15

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.)

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 Nepal shows that PPH causes 19% of the maternal death

Types of PPH

Primary: Bleeding within 24 hrs postpartum

Secondary: Bleeding beyond 24 hrs till puerperium(6 weeks).

Note:

Every healthy non anaemic women can have catastrophic blood loss Bleeding may occur at a slow rate over several hours and condition may not be recognised until the woman suddenly enters shock

Causes of primary PPH

4 Ts

Tone Trauma

Tissue Remnant
Thrombin

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)

B. Trauma (20%)
Trauma to genital tract. Cervix , vaginal wall, perineal tear can occur Occurs more often with increased instrumentation, difficult labour

C. Tissue Retained (10%)

Bits of placenta / membrane Blood clots

Primarily interfere in uterine contraction

D. Thrombin (<1%)
Interfere in blood coagulation

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

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 separation only 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.

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 by measuring pulse, BP, Temperature and respiratory rate

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

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

Management of PPH
Uterine massage should be done
if well contracted Examine cervix, vagina and perinium for trauma if present repair.

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

Management of PPH
Step 2. Exclude coexisting injured/traumatic site in the birth canal

Continue Oxytocin drip Misoprostol 600 microgram per rectally

Management of PPH
Step 3. Bimanual compression / Aortic compression Tight intrauterine packing under anaesthesia Step 4. Surgery

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.

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

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