CLINICAL SCENARIO

A 24 year-old woman, gravida-2, para-1, was admitted to labour

room after 2 hours of labor. On admission, she was having strong
contractions 2 minutes apart, and delivered a 3500 gm baby girl
at 01:20 hrs. She delivered the placenta 15 minutes later. Her BP
at 01:45 hrs. was 90/70mm of Hg and pulse was 130beats/min.
Her estimated blood loss at the time of delivery was 550cc. Over
the past 10 minutes, the nurse says she has soaked an entire pad.
She has been bleeding heavily and showing signs of shock.
How much bleeding is ‘excessive’ during
delivery?
 POSTPARTUM
HAEMORRHAGE-
ASSESSMENT AND
MANAGEMENT

Presented By:
Mrs.Santhanalakshmi.G
Asst.Professor
Maternity Nursing Department
 Postpartum haemorrhage is a significant contributor to maternal
morbidity & mortality .Obstetric hemorrhage accounts for 38%
of maternal deaths, of which PPH accounts for
25%.(Maharastra,2018)

PSG HOSPITAL: (JUNE 2018-MAY 2019)-Coimbatore

 37 cases were identified

How Hemorrhage Causes Shock,
Morbidity, and Death
 Severe blood loss

Decrease in circulating blood volume

Interruption in oxygen supply to tissues

Tendency of blood to accumulate in lower

abdomen & legs

Brain, heart, lungs deprived of oxygen

Damage to vital organs

Death
Mechanism of control of
bleeding
 CLINICAL DEFINITION OF PPH

Any amount of bleeding from or into

the genital tract following birth of

the baby up to the end of puerperium

which adversely affects the general

condition of the patient evidenced by

rise in pulse rate and falling blood

pressure.
 Traditional definition

• Blood loss of >500ml following vaginal

delivery

• Blood loss of >1000ml following cesarean

section

• Blood loss of >1500ml following cesarean

Hysterectomy
 CLASSIFICATION

According to the amount of blood loss

• Minor PPH is estimated blood loss of up to 1000 ml.

• Major PPH is any estimated blood loss over 1000ml.

• Severe : more than 2000ml

 Types

a)Primary PPH (99%): hemorrhage occurs within 24

hrs following birth of the baby.

 Third stage hemorrhage- bleeding occurs before

expulsion of placenta

 True PPH-bleeding occurs subsequent to expulsion of

placenta

b)Secondary PPH: hemorrhage occurs beyond 24 hrs and

within puerperium.
PRIMARY POSTPARTUM
HAEMORRHAGE
 Reason for PPH

Delay Lack of prompt

diagnosis treatment
 The 4 Ts of PPH
S.N Causes Incidence
o
1 Uterine atony 70%
2 Trauma 20%
3 Retained tissue 10%
4 Blood coagulapathy 1%
 1T-Atonic Uterus

• Grand multipara

• Over distension of the uterus

• Malnutrition and anemia

• APH

• Prolonged labor
Continue ….
• Over dose of oxytocin

• Malformation of the
uterus

• Uterine fibroid

• Mismanaged third stage

of labor

• Precipitate labor
 Trauma

• Laceration in cervix, vagina, perinium.

• Rupture of the uterus

• Inversion
 Tissue

• Retained tissue

• Blood clots
 Thrombin

• Less common cause of PPH

• May be due to diminished procoagulants or increased

fibrinolytic activity.
 Diagnosis and clinical effects
State of uterus as felt per abdomen, gives a reliable clue as
regards the cause of bleeding.

• Atonic – Flabby and becomes hard on massaging

• Traumatic – well contracted uterus

Effect of blood loss depend on

• Pre delivery HB level

• Degree of pregnancy induced hypervolemia

• Speed at which blood loss occurs

 ASSESSMENT OF PPH
• Recognizing High Risk Situations

• Recognizing Bleeding Associated with PPH

• Recognizing Accessory Symptoms

• Creating a Nurse Care Plan (For Nurses and

Doctors
 1. Recognizing High Risk Situations
A)Know which conditions can cause a
PPH.
• Placenta Previa, placental abruption, retained placenta, and
other placental abnormalities
• Multiple pregnancies
• History of PPH in a previous delivery
• Obesity
• Uterine abnormalities
• Anemia
• Emergency caesarean section
• Bleeding during pregnancy
• Long lasting labour more than 12 hours
• Baby’s birth weight above 4 kgs
B)Understand that uterine atony is a
cause of major blood loss.
C)Know that trauma during childbirth can
lead to a postpartum hemorrhage.
2.Recognizing Bleeding
Associated with PPH
A) Keep track of the quantity of blood
loss.
B)Look at the flow and texture of the
blood.
C) Know that the blood’s odor may
help you determine whether or not
there is a PPH.
 3.Recognizing
Accessory Symptoms
 1
A)Seek medical help if you recognize any
severe symptoms.
B)Watch for signs that occur a few days
after delivery.
C)Contact your OB immediately, as you could be
developing shock.
 Low blood pressure
• Low pulse rate
• Oliguria or reduced urine
• Sudden and continuous vaginal bleeding or
passing of large clots
• Fainting
• Rigors
• Fever
• Abdominal pain
4.Creating a Nurse Care
Plan (For Nurses and
Doctors)
A)Pay close attention to mothers who are
predisposed to developing a postpartum
hemorrhage
B) Evaluate the mother’s condition
frequently
C) Monitor the fundus
D)Look at the bladder
E)Assess the lochia
F)Check the mother’s vital signs.
G)Understand that trauma could lead
to excessive bleeding.
H)Massage the mother’s uterus and
keep track of blood loss.
I)Regulate the mother’s blood levels.
J)Put the mother in the
Trendelenburg position.
K)Give the mother medications
M)Evaluate the mother when the
mother is in a safer state.
N)Check on any open wounds the
mother may have sustained.
O)Check for side effects of the
medications.
Prevention
 ANTENATAL
• Improve the general health of the mother
(hb>10gms/dl)

• High risk cases screened and delivered in well equipped

hospital by senior obstetricians

• Blood grouping done for all pregnant women

• Localization of the placenta by USG or MRI

• High risk cases delivered

 INTRANATAL
• Slow delivery of the baby is done.

• During C.S spontaneous separation and delivery of the placenta reduces blood
loss.

• Active management of third stage of labor

• Induced or augmented labor by oxytocin , the infusion ,at least one hour after
delivery

• Women delivered by C.S, Oxytocin 5 IU slow IV is to be given to reduce

blood loss. Carbetocin (long acting oxytocin) 100 micro gms is very useful
to prevent PPH.

• Exploration of the uterovaginal canal for trauma

 Continue….
• Observation of the uterus for two hours following delivery

• Expert obstetricians is needed when delivery is conducted

under GA.

• Allow for spontaneous separation and delivery of the placenta

during cesarean section

• Routine placental examination after the delivery to at the

earliest any missing part.
 Goals of pph
management

Early recognition

Supportive care

Treat the etiology and stop the bleeding

 Management of third stage bleeding

Principle of management
– Empty the uterus to make it contract

– To replace the blood

– To ensure effective haemostasis in traumatic

bleeding
 Measuring Blood Loss
A key step to EFFECTIVE TREATMENT

• The Diagnosis of PPH is based on the amount of

blood loss (>500ml). Underestimation leads to
delayed intervention.

• Visual estimated amounts of blood loss are

notoriously far from accurate by as much as 30-50%:
especially for very large amounts.
 Old methods for estimating blood loss
more accurately tend to be complex

• weighing soaked clothes and pads,

• collection into pans etc., are very complex.

Cumulative 1 gm weight = 1 ml of blood loss

 THE BRASSS-V DRAPE

• A low cost calibrated plastic blood collection

drape.
Direct measurement of blood
loss (PPH)
 STEPS OF MANAGEMENT
Placental site bleeding
• To palpate the fundus and massage the uterus to
make it hard – if bleeding continues even after
the uterus becomes hard suggest, the presence
of genital tract injury
 Continue….
• To start crystalloid solution (NS or RL ) with oxytocin (1
L with 20 Units) at 60 drops/mint and to arrange for
blood transfusion if necessary
• Oxytocin 10 Units IM or methergin 0.2mg IV is given
• To catheterize the bladder
• Give antibiotics
– Ampicillin 2gms and metronidazole 500mg IV
 Above the treatment

Placenta is separated Placenta is not separated

Delivered by controlled Manual removal of

cord traction or placenta under GA
fundal pressure
• If the patient is in shock, she is resuscitated first before
undertaking manual removal.
• If she is delivered under GA, quick manual removal of placenta
solves the problem.
 STEPS OF MANUAL REMOVAL OF
PLACENTA

Step-1 :

• The operation is done under GA.

• The patient is placed in lithotomy position.

• With all aseptic measures the bladder is

catheterised.
Step: II

• One hand is introduced into the

uterus after smearing with the
antiseptic solution in cone shaped
manner following 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 hand

should locate the margin of the
placenta.
Step: III

• Counter pressure on the uterine fundus

is applied by the other hand placed over
the abdomen.

• The abdominal hand should steady the

fundus and guide the movements of the
fingers inside the uterine cavity till the
placenta is completely separated.
Step: IV
Step:v

• 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.
Step: VI

• Ergometrine 0.25 mg IV is given

and the uterine hand is removed
gradually while massaging the
uterus by the external hand to
make it hard.

• inspection of the cervico- vaginal

canal is to be made to exclude
any injury.
Step: VII

• The placenta and membranes are to be inspected for

completeness and be sure that uterus is hard and
contracted.
 Complications

1. Haemorrhage due to
incomplete removal
2. Shock
3. Injury to the uterus
4. Infection
5. Inversion (rare)
6. Subinvolution
7. Thrombophlebitis
8. Embolism
 Resuscitation
Resuscitation of both blood volume and oxygen carrying is important

• Compromise of airway and breathing must be assessed and

corrected

• BP and pulse rate must be monitored continuously

• O2 may be administered by mask at 10-15 liters/minutes

• Keep the mother in flat position

• Keep the mother warm

 ACTUAL MANAGEMENT

• to note the feel of uterus.

• If the uterus is flabby, the bleeding is

from atonic uterus.

• If the uterus is firm, the bleeding is

from traumatic origin.
• Call for extra help

• Put in two large bore (14 gauge) IV cannula.

• Infuse rapidly 2 liters of normal saline or

plasma substitutes
• Administer O2
• Empty the bladder
• Blood for grouping and cross matching
ATONIC UTERUS. TRAUMATIC ORIGIN

Uterine Massage

Uterotonic Agents
Hemostatsis achieved catgut suture
Uterine Massgae And Bimanual
Compression

Uterine Tamponade

Surgical Management

Hysterectomy
 Atonic Uterus
Step-1:
a) Massage the uterus and make it
hard and express the blood clots

b) Empty the bladder

c) Examine the expelled placenta

and membranes
 Step-II:
Uterotonic agents(oxytocin, ergot alkaloids, and
prostaglandins)
• Oxytocin stimulates the upper segment of the
myometrium to contract rhythmically, which
constricts spiral arteries and decreases blood
flow through the uterus.
• effective first-line treatment for postpartum
hemorrhage
• 10 international units (IU) should be injected
intramuscularly, or 20 IU in 1 L of saline may be
infused at a rate of 250 mL per hour
Ergot alkaloids(Methergine and Ergometrine )

• It cause generalized smooth muscle contraction

in which the upper and lower segments of the

uterus contract tetanically.

• A typical dose of Methergine, 0.2 mg

administered intramuscularly, may be repeated as

required at intervals of two to four hours.

• Prostaglandins enhance uterine
contractility and cause
vasoconstriction.
• The prostaglandin most
commonly used is 15-methyl
prostaglandin F2a or carboprost .
• Carboprost can be administered
intramyometrially or
intramuscularly in a dose of 0.25
mg; this dose can be repeated
every 15 minutes for a total dose
of 2 mg.
Misoprostol

• Misoprostol is another
prostaglandin that increases
uterine tone and decreases
postpartum bleeding.

• Doses range from 200 to 1,000

mcg;

• The dose recommended is 1,000

mcg administered rectally
Step-III

• Uterine massage and bimanual compression

Step-IV

• Uterine tamponade- Tight intrauterine

packing done uniformly under GA
Step-V

Surgical methods to control PPH

a. Ligation of uterine arteries
b. Ligation of ovarian and uterine
artery anostomasis
c. Ligation of anterior division of
internal iliac artery
d. B-Lynch brace suture and
haemostatic suturing
e. Angiographic arterial embolisation
• Ligation of uterine arteries
• Ligation of ovarian and uterine artery anastomasis
• Ligation of anterior division of internal iliac artery
• B-Lynch brace suture and haemostatic suturing
Step-VI
• Hysterectomy
 SECONDARY PPH

Causes :
• Retained bits of cotyledon or
membranes
• Infection and separation of slough
over a deep cervico-vaginal
laceration
• Endometritis and subinvolution of
the placenta site
 Diagnosis

• The bleeding is bright red and varying amount

• Varying degree of anaemia and evidence of sepsis are
present
• Internal examination
– Sepsis
– Subinvolution of the uterus
– Patulous cervical os
• Ultrasonography
– Bits of placenta
 Management

Principles
• To assess the amount of blood loss and to
replace the lost blood

• To find out the cause and to take appropriate

steps to rectify it
 Supportive therapy

• Blood transfusion if necessary

• To administer ergometrine 0.5mg IM, if

bleeding is uterine in origin

• To administer antibiotics as a routine

 Conservative therapy

• If bleeding is slight and no apparent cause is

detected, a careful watch for a period of 24

hours or so is done in the hospital

 Active treatment

• As the commonest cause is due to retained bits of

cotyledon or membranes, it is preferable to explore the
uterus urgently under general anesthesia. The products are
removed by ovum forceps
• Gentle curettage is done by flushing curette.
• Ergometrine 0.5mg is given IM
• The material removed are to be sent for histological
examination
• Presence of bleeding from the sloughing of cervico-vaginal
canal should be controlled by haemostatic sutures.

• May require ligation of the internal iliac artery or

• hysterectomy
 NURSING DIAGNOSIS

Ineffective tissue perfusion related to excessive

vaginal bleeding as evidenced by fluctuation of vital
signs

Fluid volume deficit related to uterine atony as

evidenced by excessive vaginal blood loss

Risk for infection related to excessive blood loss

• Anxiety related to Threat of change in the health status

evidenced by Restlessness and distressed

• Deficient Knowledge related to Lack of exposure to

information as evidenced by Inappropriate behaviors.

 Risk for Altered Parent-Infant Attachment related to Perceived

threat to own survival.

Nursing Interventions for PPH

Check Vital Signs

Pitocin, Methergine

Lochia, Pad count

Iv Line, Blood Transfusion

Empty bladder

Uterine massage

Patient teaching
JOURNALS
Duration of labor and the risk of severe postpartum
hemorrhage: A case-control study-PLOS
• To investigate the association between duration of
active labor and severe postpartum
hemorrhage( January 1, 2008 to December 31, 2011-
NORWAY)
• Prolonged active labor (duration >12 hours) was
associated with severe postpartum hemorrhage.
Increased vigilance seems required when the labor is
prolonged to reduce the risk of severe postpartum
hemorrhage
 IJRCOG-
• Clinical study of post partum haemorrhage from a teaching
hospital in Maharashtra, India(2017)

• In an era with availability of excellent uterotonics and active

management of 3rd stage of labour even today postpartum
haemorrhage stands first as the cause of maternal morbidity and
mortality. Even though with excellent medical and surgical
interventions, maternal mortality due to PPH has been
significantly reduced, the field still needs extensive research and
new modalities to prevent and manage post-partum
haemorrhage