Post partum haemorrhage (PPH) is an obstetrical emergency that can follow vaginal or cesarean delivery. It is a major cause of maternal morbidity and one of the top three causes of maternal mortality in both high and low per capital income countries, although the absolute risk of death in much lower in high income countries (1 in 100,000 versus 1 in 1000 births in low income countries). Furthermore, hemorrhage is the leading cause of admission of the intensive care unit and the most preventable cause of maternal mortality.
The average blood loss following vaginal delivery, caesarean delivery and caesarean hysterectomy is 500 ml, 1000ml and 1500 ml respectively.
Depending upon the amount of blood loss, post partum hemorrhage (PPH) can be-
âž¢ Minor (1L) âž¢ Severe (10g/dl) so that the patient can withstand some amount of the blood loss. ¢ High risk patients who are likely to develop post partum hemorrhage (such as twins, hydramnios, grand multipara, APH, history of previous PPH, severe anemia) are to be screened & delivered in a well equipped hospital. ¢ Blood groping should be one for all women so that no time is wasted during emergency. ¢ Placental localization must be done in all women with previous caesarean delivery by USG or MRI to detect placenta accreta or percreta. ¢ Women with morbid adherent placenta are at high risk of PPH. Such a case should be delivered by a senior obstetrician. A availability of blood & or blood products must be ensured before hand.
¢ Active management of the third stage, for all women in labour should be a routine as it reduces PPH by 60%. ¢ Women delivered by caesarean section, oxytocin 5 IU slow IV is to be given to reduce blood loss. ¢ Exploration of the utero-vaginal canal for evidence of trauma following difficult labour or instrumental delivery. ¢ Observation for about 2 hours often delivery to make sure that the uterus is hard and well contracted before sending her to ward. ¢ During caesarean section spontaneous separation & delivery of the placenta reduces blood loss (30%).
Management of retained placenta:
This diagnosis is reached when the placenta remains undelivered after a specified period of time (usually half to 1 hour following the babys birth). This is done to apply pressure to the placental site. The whole hand is introduced into the vagina in cone shaped fashion after separating the labia with the fingers of the other hand. the vaginal hand is clenched into a fist with the back of the hand directed posteriorly and the knuckles in the anterior fornix. The other hand is placed over the abdomen behind the uterus to make it anteverted. The uterus is firmly squeezed between the two hands. It may be necessary to continue the compression for a prolonged period until the (during the period, the resuscitative measures are to be continued).
Manual removal of the placenta:
The operation is done under general anaesthesia. The patient is placed in lithotomy position with all aseptic measures, the bladder is catheterized. One hand is introduced into the uterus after smearing with the antiseptic solution in cone shaped manner following the cord, which is made taut by the other hand. While introducing the hand, the labia are separated by the fingers of the other hand. The fingers of the uterine should locate the margin of the placenta. Counter pressure on the uterine fundus is applied by the other hand placed over the abdomen.
The abdominal hand should steady the fundus & guide the movements of the fingers inside the uterine cavity till the placenta is completely separated. As soon as the placental margin is reached, the fingers are insinuated between the placenta & the uterine wall with the back of the hand in contact with the uterine wall. The placenta is gradually separated with a side ways slicing movement of the fingers, until whole of the placenta is separated. When the placenta is completely separated, it is extracted by traction of the cord by the other hand. The uterine hand is still inside the uterus for exploration of the cavity to be sure that nothing is left behind.
i) Management of third stage bleeding:
In this third stage of bleeding or hemorrhage, the bleeding occurs before expulsion of placenta.
âž¢ To empty the uterus.
âž¢ To replace the blood.
âž¢ To ensure effective haemostasis.
Steps of management:
a) Placental site bleeding:
âž¢ To palpate the fundus and manage the uterus to make it hard. âž¢ To start crystalloid with oxytocin at 60 drops /min and to arrange for blood transfusion if necessary. âž¢ Oxytocin 10 units IM or methargin 0.2 mg. is given intravenously. âž¢ To catheterize the bladder. âž¢ To give antibiotics (ampicillin 2gm.and Metronidazole 500mg. IV).
b) Traumatic bleeding:
The utero vaginal canal is to be explored under general anaesthesia after the placenta is expelled.
ii) Management of true post partum hemorrhage:
In this true post partum hemorrhage the bleeding occurs subsequent to expulsion of placenta (majority).
âž¢ Call for extra help involve the obstetric senior staff on call.
âž¢ Keep patient flat and warm.
âž¢ Send blood for diagnostic test.
âž¢ Infuse rapidly 2 litres of normal saline.
âž¢ Give oxygen by mask 10-15L/min.
âž¢ Monitor the pulse, blood pressure, urine output, drug type, dose and time.
B. Secondary Post partum hemorrhage:
Secondary post partum hemorrhage is bleeding from the genital tract more than 24 hours after delivery of the placenta and may occur upto 6 week later. The bleeding usually occurs between 8th to 14th day of delivery.
The causes of late post partum hemorrhage are-
1. Retained bits of cotyledon or membranes (commonest) 2. Infection and separation of slough over a deep cervico-vaginal laceration. 3. Endometritis and sub involution of the placental site- due to delayed healing process. 4. Secondary hemorrhage from caesarean section wound usually occur between 10-14 days. 5. Withdrawal bleeding following oestrogen therapy for suppression of lactation.
1. The lochia are heavier than normal & recurrence of bright red flow.
2. Offensive lochia if infection is a contributory factor.
3. Sub involution of uterus.
4. Pyrexia & tachycardia.
The bleeding is bright red and varying amount. Rarely it may be brisk. Varying degree of anemia & evidences of sepsis are present. Internal examination reveals evidences of sepsis, sub involution of the uterus & often patulous cervical OS.
Ultrasonography is usual in detecting the bits of placenta inside the uterine cavity.
âž¢ To assess the amount of blood loss & to replace it (transfusion)
âž¢ To find out the cause & to take appropriate steps to rectify it.
i) Massage the uterus if it is still palpable to bring about a contraction.
ii) Express any clots.
iii) Encourage the mother to empty her bladder.
iv) Give an oxytocic drug such as ergometrine by intravenous or intramuscular route.
v) Save all pads & lines to assess the volume of blood loss.
vi) If retained products of conception are not seen on an ultrasound scan, the mother may be treated conservatively with antibiotic therapy and oral ergometrine. vii) Anemia is treated with iron supplement & in severe cases, blood is transfused.
Nursing management of PPH:
1. Assess maternal history for risk factors, plan accordingly and communicate to the perinatal area. 2. Assess pulse pressure, recording consistently less than 30bpm are consistent with hypertensive crisis. 3. Assess intake & output chart. 4. Assess location & firmness of uterine fundus. 5. Palpate the bladder distension, which may interfere with contracting of the uterus. 6. Inspect for intactness of any parineal area.
i) Deficit fluid volume related to blood loss as manifested by looking pale, dehydrated & decrease pulse rate. ii) Acute pain related to perineal discomfort from birth trauma and physiologic changes from births as monitored by wrinkled in forehead, restlessness & irritability. iii) imbalance nutrition less than body requirement related to restriction in food intake as manifested by fatigue, weakness and lethargic. iv) Sleeping pattern disturbance related to pain & bleeding as manifested by drowsiness, lethargic, irritated, etc. v) Risk for infection related to birth process & maintaining poor hygiene as manifested by patients verbal complain, irritable & discomfort.
i) Monitoring for hypotension & bleeding.
ii) Minimize the pain.
iii) Improve nutritional status.
iv) Improve sleep pattern.
v) Reduce the risk for infection.
âž¢ For 1st diagnosis:
i) Monitor vital signs every 4 hours during the first 24 hours. ii) Assess vaginal discharge for clots and amount. iii) Maintained IV line as ordered by the doctor.
âž¢ For 2nd diagnosis:
i) Assess pain level, location, duration and type also. ii) Provide comfortable position (i.e. supine position) iii) Administered medicine as prescribed by the doctor.
âž¢ For 3rd diagnosis:
i) Assess the nutritional status of the patient. ii) Patient is advised to take liquid diet from 3rd day & solid from 4th day. iii) Weight in monitored daily.
âž¢ For 4th diagnosis:
i) Sleep pattern is assessed.
ii) Provide a neat and tidy bed to the patient.
iii) Unnecessary procedures avoided during sleeping period.
iv) Patient is advised to discourage day time sleeping.
âž¢ For 5th diagnosis:
i) Assessed the level of infection, burning sensation and frequency of urination. ii) Washing hands & wearing gloves can reduce the risk for infection before doing any procedure. iii) Advised the patient to maintain the personal hygiene and also should teach how to take care of perineal area.
i) Bleeding is reduced than before.
ii) Patients pain level might be minimized.
iii) Nutritional status of the patient is improved.
iv) Patients sleep pattern is improved.
v) Infection is controlled.
Post Partum hemorrhage continued to be a leading cause of maternal morbidity & mortality. In this patient despite identification and attempt at correction of an identified clotting disorder, major obstetric hemorrhage was not avoided.
However, these factors may be unavoidable and early surgical intervention as per local protocol is recommended to minimize maternal morbidity. After studying & presenting the seminar on the topic of PPH, I got a thorough idea about this disease and I am thankful to maam for giving me opportunity of presenting this topic. I think I can be able to import some amount of knowledge to the group & I will be able to provide proper care to such patient if I got in future.
1. C.D. Dutta text book of obstetrics 7th edition, new central book agency, page no- 410-418 2. Annamma Jacob A comprehensive textbook of midwifery & Gynecological Nursing, 3rd edition, Joypee brothers medical publishers (p) Ltd. 3. Myhes Tex book for midwives, edited by V. Rith Bennett Linda K. Brown, 12th edition. Page No- 462-470
4. Dr. Parulekar Shashank V., Text book for midwives, 2nd edition, voramidical publication. Page No- 351-356.
5. B. Basavanthappa T. Essentials of midwifery & obstetrical Nursing, 1st edition, Jaypee Brothers medical publishers. Page No- 544-555.
6. w.w.w.urmc.rochester.edu>URMC>Health Encyclopedia
âž¢ w.w.w.birth.com.au>Labour & Birth.
âž¢ w.w.w.rcog.org.uk>Home>womenshealth> idelines>search for a guideline. âž¢ Bmb.oxford journals.org/..205full.
âž¢ w.w.w.ncbi.nlm.nih.gov> journal list>cases J/V.J;2008