Post Partum Hemorrhage

 Definition 

Excessive bleeding from the genital tract of 500mls or more after the birth of the baby, or with less but deterioration in the patient’s condition.

 

Classification

1.           Primary Post Partum haemorrhage

 

2.           Secondary post Partum haemorrhage.

 

Primary Post Partum heamorrhage when it occurs within 24 hours after delivery. 

There are two types of PPH

1.           Atonic Haemorrhage – Bleeding from the placenta sit e.

 

2.           Traumatic PPH – Bleeding from laceration of the gen ital tract.

 

3.           Blood dyscracia. (Developmental disorder of the blood)

 

Atonic Haemorrhage

 

Bleeding is due to inability of the uterine muscle to contract effectively causes.

 

1. Atonic uterus: leading to incomplete separation of placenta 30 prevent effective retraction of the placental site.

 

·              Common with prolonged labour

 

·              Prolonged and deep anaesthesia.

 

·              Overstretching of the uterus – e.g. Polyhydramnios, multiple pregnancy.

 

·              Multipara with laxed uterine muscle.

 

·              Concealed Ante Partum haemorrhage.

 

·              Rapid explusion of a large baby (Precipitate labour)

 

2. Mismanagement of the 3rd stage of labour. This is about the commonest cause of post partum haemorrhage and under the control of the midwife. This management includes:

 

·              Conducting labour with full bladder.

 

·              Massaging, kneading, squeezing and pushing of the uterus

 

o     These over stimulate the uterus and cause irregul ar contraction and partial separation of the placenta and inadequate control of haemorrhage.

 

3. Subendomentrial Fibroids; This interferes with uterine contraction.

 

4. Blood dyscrasica: clothing disorders – Hypofibrinog enaemia.

 

i.                  It is associated with concealed Accidental haemorrhage.

 

ii.                  Amniotic fluid embolism

 

iii.                  Mixed abortion for many weeks.

 

If in addition the uterus is atonic uncontrollable bleeding occurs

 

5. Placental abnormalities

i.                  Placenta chorionic villi penetrate more deeply than usual – (Placental accrete) leading to inseperation .

 

ii.                  Placenta Praevia – partial separation.

 

6. Anaemia ketosis – Induction or augmentation of labo ur with oxytocin

 

Sign & Symptoms

 

1.           Bleeding – May start a few minute after delivery of the baby and comes out in gush.

 

2.           Big uterus – Higher than umbilical level or feels l arge

 

3.           Boggy: soft and flabby, distended with no definite outline

 

4.           Rapid Pulse: Above 90 beats

 

5.           Pallor – on the face

 

6.           Collapse.

 

Management

Prevention: 

1.           Treat anaemia in Pregnancy.

 

2.           High Risk women should be delivered in Hospital – P revious PPH, Placenta accrete, Grandmultiparity, APH, and Fibroids.

 

3.           Good management of second stage of labour.

 

o     Empty bladder at the end of first stage.

 

o     Slow delivery of the baby.

4.           Good management of 3rd stage – Control Cord traction (CCT)

 

5.  Anticipation of blood coagulation disorders.

 

6.  The use of oxytocic drugs.

 

o  Suspected cases

 

o  Oxytocin drip – To run for 1hr after delivery (Induction).

 

Active Management

 

(Before the delivery of the placenta) To control the bleeding the uterus must be strongly contracted and empty.

 

Principle of Management

o     Stop the bleeding

 

o     Replace lost fluid

 

o     Treat circulatory failure – Shock

 

o     Massage and kneed the uterus to contract.

o     Deliver the placenta by CCT or Brandt Andrews method and remove blood clots.

 

o     Give injection ergometrine 0.5mg or syntometrine 1ml i.m.

 

o     Send for medical Aid or transfer to a Hospital.

 

o     If palcenta can not be expeclled give syntometrine 1ml (syntocinon 5 unit + Erg+ 0.5mg) check for contraction and deliver by CCT. If placenta does not separate completely repeat after 10min. that alone will control haemorrhage.

 

o     If all fail manual removal of the placenta have to be performed.

 

Bleeding after the Birth of the placenta:

 

o     Message the uterus until it contracts.

 

o     Empty the bladder

 

o     Expel blood clots

 

o     Send for medical Aid

 

o     Give Oxytocin drugs – syntometrine, it acts fast or Ergtometrine i.v. (45sec) by Dr. Dext at 40 drops per minute.

 

o     If bleeding continues – Apply bimanaual compression on the placenta site to control bleeding until oxytocin drugs take effect – Do clotting time.

 

o     Exploration of the uterus under G.A. – for retained product and trauma.

 

o     Hysterectomy for uncontrollable and severe cases.

 

o     Blood transfusion if necessary.

 

o     The uterus should not be packed.

 

o     Raise the foot of the bed if in shock.

 

o     Insert indwelling catheter to monitor urinary output.

 

o     Keep all records of observations meticulously pulse ¼ hourly, B/P respirations

 

o     Give analgesic to relief pains.

 

 

Traumatic Post Partum Haemorrhage.

 

Is due to laceration of the cervix or upper vaginal wall. Bleeding from the perineum is readily controlled but when from clitoris bleeding may be profused. It may occur in abnormal presentation and instrumental delivery.

 

Signs & Symptom

1.           Start immediately the baby is born.

 

2.           The flow is a continuous heavy trickle.

 

3.           Uterus is firm and well contracted.

 

Treatment

 

1.           Suture the laceration under Generaaal anaesthesia (G.A). – Cervical laceration

 

o     Use Sims Ferguson’s speculum for inspection.

 

o     Sponge holding forceps is used to hold the cervix as tenaculum will tear the cervix the more.

 

2.           Tie bleeding points and suture with catgut.

 

3.           In remote area, pack the vagina to compress the bleeding points

 

o     using gauze plug.

 

4.           Remove clots from the vagina, empty the bladder.

 

Manual Removal of Placenta

 

Usually done under G.A. The vulva is cleaned and gloved hand is lubricated with an obstetric cream and introduced into the uterine cavity. The left hand controls the fundus per abdomen. The hand follows the cord if present up to the placenta and identifies edge. Using the ulner border the placenta is separated from the uterine wall. The external hand keeps constant manipulation. Ensure that all the placenta tissues have been removed before the hand is withdrawn. The external hand massages the uterus for contraction, ergometrine 0.5mg is given i.v. or i.m. The placenta is examined for completeness.

 

Bimanual Compression

 

This is used to control bleeding until oxytocic drugs take effect method:

 

Place patient in a dorsal position. Clean the vulva. Scrup the hands and wear glove. Insert the right hand into the vagina like a cone, make it into a fist. Place the flat part of the fist in the Anterior vaginal fornix against the uterine wall. Rest the elbow on the bed between the woman’s thighs place the left hand over the uterus abdominally with fingers directed towards the cervix. Bring the uterus forward and compress it on to the fist in the vagina. In this way the uterus is compressed between the two hands and haemorrhage is controlled. It should be maintained until the uterus is well contracted. Early compression is very effective, though it is a tiring procedure – Ergometrine may be repeated i. m to maintain contraction.

 

Secondary Post Partum Haemorrhage

 

Bleeding that occurs after 24 hrs hours or more after delivery, within 6 weeks of delivery, usually about the 10th day.

 

Causes:

 

Usually due to retained fragment of placenta tissue, chronic membranes, chorionic membranes or blood clots. Frequently complicated by intrauterine infection and pyrexia – myometritis.

 

1.           Separation of septic slough from the cervical or vaginal tear or placenta site or Caesarean Section wound.

 

2.           Rarely from infected and slough from a subendometrial fibromyoma (Fibroid)

 

3.           Some times may not be associated with sepsis.

 

If associated with sepsis there is usually fever, offensive lochia, or other evidence of infection. The cervice usually remains opened when something is remained in the uterus.

 

Warning signs

o     Persistent red lochia – evacuation

 

o     Retained succenturate lobe

 

Management

·              Ergometrine 0.5mg i.m is repeated.

 

·              Digital exploration of the uterus

 

·              Broad spectrum antibiotic

 

·              Careful light curettage to prevent uterine perforation – if bleeding persists.

 

·              In profuse bleeding – do bimanual compressions.

 

·              Call a Doctor

 

·              Empty bladder, save all linens.

 

Vulva Haematoma

 

It may give rise to traumatic haemorrhage . It is caused by ruptured leading to collection of blood in the connective tissue of the vulva and vaginal wall. A small haematoma may be associated with repair of medio lateral episiotomy or laceration. Sign manifest a few hours after delivery and the woman complains of discomfort and pain in the perineum and/or labia. The skin of the labia becomes thin and haematoma may bulge into the vagina.

 

Management

·              Apply a hot saline pack

 

·              Incision and drainage

 

·              Tie the bleeding vessel

 

·              Blood transfusion if bleeding is severe.

 

Adherent Placenta

 

If placenta does not leave the upper segment after 30mins of delivery. This is suspected, usually no bleeding. The midwife should not make attempt to separate the placenta as partial separation will result in bleeding. Doctor will do manual removal under general anaesthesia.

 

Retained Placenta

Placenta has separated but not expelled.

 

Causes:

·              Faulty technique

 

·              Full bladder

 

Treatment

 

Empty the bladder, rub up for contractions and deliver the placenta.

 

Breaking of the cord:

Check that the uterus is firm, if placenta is palpable in the vaginal

 

separated use material effort or fundal pressure to deliver the placenta – with care to avoid invention of the uter us. If possible under anaesthesia – Epidural, to avoid shock.

 

Blood coagulation disorders may occur following severe pre-clampsia,APH, Amniotic fluid embolisim, IUD or sepsis.

 

Management

 

Fresh blood , platelets, factor v, x, vii, fresh plasma and fibrinogen could be given.

 

Observation of mother following APH

 

Estimate lost volume of blood, Vital signs e.g. pulse, BP ¼ hourly temperature.

 

Palpate uterus to ensure contraction, observe lochia for normalcy, replace i.v loss – avoid circulatory over leading. Acurate intake and out put chart to assess renal functions, Woman to remain in labour ward until condition is satisfactory, in a comfortable room for 24 – 48hr. she should not be discharged home un til Hb is normal, Reasure the woman as necessary.