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    26a. Post Partum Hemorrhage

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    Aubrey
    This document provides guidance on managing postpartum haemorrhage (PPH) for midwives and birth attendants. The goal is to equip them with the knowledge, skills, and attitudes to manage women experiencing PPH. It defines PPH, describes the types and causes using the "three Ts" framework of tone, trauma, and thrombin. It outlines objectives, learning activities, and detailed steps for managing primary and secondary PPH depending on the underlying cause. Complications of PPH and the competencies required to properly treat PPH are also reviewed.

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    © All Rights Reserved
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    26a. Post Partum Hemorrhage

    Uploaded by

    Aubrey
    432 views35 pages
    This document provides guidance on managing postpartum haemorrhage (PPH) for midwives and birth attendants. The goal is to equip them with the knowledge, skills, and attitudes to manage women experiencing PPH. It defines PPH, describes the types and causes using the "three Ts" framework of tone, trauma, and thrombin. It outlines objectives, learning activities, and detailed steps for managing primary and secondary PPH depending on the underlying cause. Complications of PPH and the competencies required to properly treat PPH are also reviewed.

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    This document provides guidance on managing postpartum haemorrhage (PPH) for midwives and birth attendants. The goal is to equip them with the knowledge, skills, and attitudes to manage women experiencing PPH. It defines PPH, describes the types and causes using the "three Ts" framework of tone, trauma, and thrombin. It outlines objectives, learning activities, and detailed steps for managing primary and secondary PPH depending on the underlying cause. Complications of PPH and the competencies required to properly treat PPH are also reviewed.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    432 views35 pages

    26a. Post Partum Hemorrhage

    Uploaded by

    Aubrey
    This document provides guidance on managing postpartum haemorrhage (PPH) for midwives and birth attendants. The goal is to equip them with the knowledge, skills, and attitudes to manage women experiencing PPH. It defines PPH, describes the types and causes using the "three Ts" framework of tone, trauma, and thrombin. It outlines objectives, learning activities, and detailed steps for managing primary and secondary PPH depending on the underlying cause. Complications of PPH and the competencies required to properly treat PPH are also reviewed.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 35

    POSTPARTUM

    HAEMORRHAGE (PPH)
    Ilala crest lodge Training
    12-06-2009
    Marla

    GOAL

    To equip midwives and other skilled birth


    attendants with knowledge, skills and
    attitude in the management of women with
    postpartum haemorrhage

    OBJECTIVES
    At the end of the session midwives and
    other skilled births attendants will be able to:
    Define postpartum haemorrhage
    Explain the types of post-partum
    haemorrhage
    Explain causes of postpartum haemorrhage

    OBJECTIVES CONT
    Explain the complications of postpartum
    haemorrhage
    Demonstrate competence in caring for
    women who develop post partum
    haemorrhage
    Demonstrate positive attitudes in managing
    patients with PPH

    LEARNING ACTIVITIES

    History taking
    Examination of placenta and membranes
    Vaginal examination
    Measuring of blood loss
    Bimanual compression of the uterus
    Manual removal of placenta

    Definition
    Postpartum haemorrhage is excessive
    bleeding of 500 mls and above from the
    genital tract after delivery of the baby and
    before the end of puerperium.
    Any amount of blood loss that
    threatens the life of the mother can also
    be regarded as PPH

    Types of Postpartum
    Haemorrhage
    1. Primary postpartum haemorrhage

    This is excessive bleeding from the genital tract


    within 24 hrs of delivery. This is the most
    common type of post partum haemorrhage.
    2. Secondary postpartum haemorrhage

    It is excessive bleeding from the genital tract after


    24 hours of delivery up to 6 weeks postpartum.

    Causes of Postpartum Haemorrhage: The


    3 Ts
    First T: TONE
    Bleeding due to lack of TONE of the uterine
    muscles or any condition interfering with
    contraction of the uterus.
    This includes:
    Retained placenta
    Retained placental tissue or membranes
    Incomplete separation of placenta

    Causes of Postpartum Haemorrhage: The


    3 Ts cont
    Full bladder
    Ante-partum haemorrhage like in placenta
    praevia (less oblique muscle fibres in the
    lower uterine segment) or placenta abruptio
    (muscle fibres are damaged due to
    concealed uterine haemorrhage

    Causes of Postpartum Haemorrhage:


    The 3 Tscont
    Second T: TRAUMA

    Lacerations to birth canal including


    cervical, perineum, and vagina tears,
    ruptured uterus, uterine inversion, too
    early episiotomies
    Third T: THROMBIN
    Coagulation failure interfering with blood
    clotting mechanism

    Examples of causes of Coagulation failure


    Abruptio placentae
    Amniotic fluid embolism
    Retained dead fetus
    Inherited coagulopathy

    Factors predisposing to postpartum


    uterine atony

    Overdistention of the uterus


    Multiple gestations
    Polyhydramnios
    Fetal macrosomia
    Prolonged labor
    Oxytocic augmentation of labor
    Grand multiparity (a parity of 5 or more)
    Precipitous labor (one lasting <3 hr)
    Magnesium sulfate treatment of preeclampsia
    Chorioamnionitis
    Halogenated anesthetics
    Uterine leiomyomata

    Management of primary PPH (according to


    cause)
    a) Tone
    Management will depend on whether the placenta
    is delivered or retained
    i) Placenta delivered
    Call for help and never leave the patient alone till
    the bleeding has stopped and the patient is stable
    Explain calmly to the mother about her condition
    and what interventions will be done

    Placenta not delivered cont


    Rub up a contraction and expel clots if any
    Give Oxytocin (10 units IM stat)
    Empty the bladder and maintain an
    indwelling catheter
    Put up two large bore cannula and take
    blood for grouping, X-matching and
    haemoglobin and check clotting time

    Placenta not delivered cont


    Infuse Normal Saline or crystalloids with 2040 units of Oxytocin. Maintain the infusion at
    40 drops per minute to keep the uterus well
    contracted (or run the infusion fast).
    Arrange blood donors. If at a health centre,
    donors should accompany the patient to the
    Central Hospital/District Hospital.

    Placenta not delivered cont


    Assess patients condition (pulse, BP, colour
    of mucus membranes, consciousness level,
    uterine tone) and estimate how much blood
    has been lost already.
    Start resuscitating the patient immediately:
    airway to be patent, oxygen therapy 6-8
    litres per minute.

    Placenta not delivered cont


    Quickly examine placenta and membranes
    for completeness.
    Inform the doctor about the condition of the
    patient and about the interventions that you
    have carried out.
    If bleeding persists and the uterus keeps
    relaxing, use bimanual compression of the
    uterus. (see Annex 6)

    Placenta not delivered cont


    If bleeding persists and the uterus is well
    contracted, examine the vagina and cervix
    for lacerations/tears.
    In case of severe shock use plasma
    expanders or blood transfusion if available.
    In case of infection commence antibiotics

    Placenta not delivered cont


    Keep the woman warm throughout the
    procedure.
    Record intake and output
    Document all interventions done and keep
    accurate records

    Management of PPH -TONE cont


    ii) Placenta not delivered
    Call for help
    Explain to the patient the condition and plan
    of care.
    Rub up the fundus of the uterus for a
    contraction
    Empty the bladder.
    Give Oxytocin 10 units IM.

    Placenta not delivered cont


    Apply controlled cord traction with the next
    contractions.
    If placenta still not delivered, commence
    intravenous infusion of saline with 20-40
    units of Oxytocin (If at the health centre
    refer).
    A second attempt at controlled cord traction
    should be tried.

    Placenta not delivered cont


    If controlled cord traction is not successful
    proceed to manual removal of the placenta.
    (see Annex 5).
    If manual removal is not successful, refer
    immediately

    Management of PPH-TRAUMA
    b) Trauma
    Call for help
    Explain the condition to the mother and plan
    of care
    Place the woman in lithotomy position and
    use good lighting
    Find the bleeding point if visible, clamp it,
    and suture the tear.

    Management of PPH-TRAUMA cont


    Take blood for grouping, X-matching and
    haemoglobin estimation.
    Set up an intravenous infusion, give saline
    or sodium lactate followed by plasma
    expander if available and if shock is severe.
    Estimate the blood loss

    Management of PPH-TRAUMA cont


    Check pulse and blood pressure, and
    observe general condition.
    Start the woman on broad spectrum
    antibiotics
    Keep accurate records.

    Management of PPH- THROMBIN

    c) Thrombin
    Check blood at the bed side for clotting time
    The rest of management is the same with
    that for TONE but transfuse fresh blood.

    Management of secondary PPH


    Admit the woman to hospital as an
    emergency and assess the condition.
    Rub up uterine contraction by massaging
    the uterus if it is still palpable.
    Give Oxytocin 10 units IM.

    Management of secondary PPH


    Take blood for Hb grouping and X-matching.
    Put up intravenous infusion of normal saline
    If bleeding is severe add 40 units IV
    Oxytocin per litre to run at 40 drops per
    minute.
    Inform doctor or clinical officer

    Management of secondary PPH


    In case of severe shock use plasma
    expanders or transfuse blood if available.
    Start the woman on broad spectrum
    antibiotics in high doses.
    Prepare the patient for EUA and possible resuturing.
    Monitor the patients condition, blood
    pressure, pulse, temperature, respiration
    and blood loss.

    Management of secondary PPH


    Assess lochia for colour, amount, odour and
    consistency
    Observe colour on the conjunctiva, tongue
    Observe level of consciousness
    Observe intake and output and keep
    accurate records

    Management of secondary PPH


    Palpate uterus for tenderness
    Provide good nursing care by assisting
    mother with activities of daily living e.g.
    nutrition, hygiene, rest and sleep.
    Encourage exclusive breast feeding.

    Complications of PPH

    Infection
    Hypovolaemic shock
    Severe anaemia
    Sheehans syndrome
    Renal failure
    Maternal death

    Required competencies

    History taking
    Physical examination
    Manual removal of placenta
    Examination of placenta and membranes
    Suturing skills of episiotomy and tears

    Required competencies cont


    Bimanual compression
    Active management of 3rd stage of labour
    Inserting and monitoring intravenous
    infusions including blood
    Check blood for bedside clotting time

    YEBO
    CHOMENE!

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