PPH.pptx obstetrics and gynecology in nursing
- 2. INTRODUCTION • Postpartum hemorrhage (PPH) is an obstetric emergency. • Post-partum haemorrhage (PPH) remains a major cause of maternal mortality and morbidity worldwide. • Approximately, half a million women die annually from causes related to pregnancy and childbirth.
- 3. QUANTITATIVE DEFINITION • The amount of blood loss in excess of 500 mL following birth of the baby (WHO).
- 4. CLINICAL DEFINITION Any amount of bleeding from or into the genital tract following birth of the baby up to the end of the puerperium, which adversely affects the general condition of the patient, evidenced by rise in pulse rate and falling blood pressure is called postpartum hemorrhage.
- 5. The average blood loss following • Vaginal delivery- 500 ml • Cesarean delivery- 1000 ml • Cesarean hysterectomy-1500 ml
- 6. • Depending upon the amount of blood loss, PPH can be • Minor (< 1L), • Major (> 1L), • Severe (> 2L).
- 7. INCIDENCE: • The incidence is about 4–6% of all deliveries. • 2% - 4% after vaginal delivery. • 6% after cesarean section. • Every year about 14 million women around the world suffer from PPH.
- 8. TYPES: Types Primary Third stage True PPH Secondary
- 9. PRIMARY: • Haemorrhage occurs within 24 hours following the birth of the baby. These are of two types: • Third stage haemorrhage Bleeding occurs before expulsion of placenta. • True postpartum haemorrhage Bleeding occurs subsequent to expulsion of placenta (majority).
- 10. SECONDARY • Haemorrhage occurs beyond 24 hours and within puerperium(6 weeks), also called delayed or late puerperal haemorrhage.
- 11. PRIMARY POSTPARTUM HEMORRHAGE Causes Four basic pathologies are expressed as the 4 Ts’ • Tone (atonicity), • Tissue (retained bits, blood clots), • Trauma (genital tract injury) and • Thrombin (coagulopathy).
- 12. Atonic uterus (80%): • It is the commonest cause of PPH • The conditions, which often interfere with the retraction of the uterus as a whole and of the placental site in particular are.
- 13. Grand multipara • Inadequate retraction and frequent adherent placenta leads to PPH. • The women may have Associated anemia due to PPH.
- 14. OVERDISTENSION OF THE UTERUS • Multiple-pregnancy polyhydroamnios and big baby (>4 kg) causes over distension of uterus. • Imperfect retraction and a large placental site are responsible for excessive bleeding.
- 15. • Malnutrition and anemia • Antepartum hemorrhage (Both placenta previa and abruption) • Prolonged labor (>12 hours): Poor retraction, infection (amnionitis), dehydration are important factors (Tone).
- 16. • Anesthesia: Depth of anesthesia and the anesthetic agents (ether, halothane) may cause atonicity. • Initiation or augmentation of delivery by oxytocin: Postdelivery uterine atonicity is likely unless the oxytocin is continued for at least one hour following delivery.
- 17. • Malformation of the uterus: Implantation of the placenta in the uterine septum of a septate uterus or in the cornual region of a bicornuate uterus may cause excessive bleeding.
- 18. • Uterine fibroid causes imperfect retraction mechanically. • Placenta: Morbidly adherent (accreta, percreta), partially or completely separated and/or retained • Precipitate labor: In rapid delivery, separation of the placenta occurs following the birth of the baby. Bleeding continues before the onset of uterine retraction. Bleeding may be due to genital tract trauma also
- 19. • Mismanaged third stage of labor: This includes— (a) Too rapid delivery of the baby preventing the uterine wall to adapt to the diminishing contents, (b) Premature attempt to deliver the placenta before it is separated,
- 20. (d)Pulling the cord. All these produce irregular uterine contractions leading to partial separation of placenta and haemorrhage, (e)Manual separation of the placenta increases blood loss during caesarean delivery
- 21. • Other causes of atonic hemorrhage are: • Obesity (BMI > 35) • Previous PPH • Age (>40 yrs) • Drugs: Use of tocolytic drugs (ritodrine), MgSO4 , Nifedipine.
- 22. TRAUMATIC (20%) • Trauma to the genital tract usually occurs following operative delivery, even after spontaneous delivery. • Trauma involves usually the cervix, vagina, perineum (episiotomy wound and lacerations), paraurethral region and rarely uterine rupture occurs. • The bleeding is usually revealed but can rarely be concealed (vulvovaginal or broad ligament hematoma).
- 23. RETAINED TISSUES: Bits of placenta, blood clots cause PPH due to imperfect uterine retraction.
- 24. THROMBIN • Blood coagulation disorders, acquired or congenital, are less common causes of postpartum haemorrhage. • The blood coagulopathy may be due to diminished procoagulants (washout phenomenon) or increased fibrinolytic activity
- 25. It can occur following • Preeclampsia • HELLP syndrome • Abruptio placenta • Jaundice in pregnancy, • Thrombocytopenic purpura
- 26. PATHOPHYSIOLOGY • Atonic Placental separation and torn uterine sinuses Imperfect uterine contractions and retractions Uterine muscles cannot compress effectively Bleeding
- 27. • Traumatic genital tract Trauma to genital tract Significant disruption of blood vessels and tearing of blood vessels Torrential blood loss(revealed/concealed) PPH
- 28. CLINICAL FEATURES • Vaginal bleeding • Pallor • Tachycardia • Hypotension • Altered level of consciousness • Drowsy • Enlarged uterus • Maternal collapse • Rarely Vulvovaginal/broad ligament hematoma
- 29. • The effect of blood loss depends on— (a)Predelivery hemoglobin level, (b)degree of pregnancy induced hypervolemia and (c) speed at which blood loss occurs. (d)If the blood loss is so rapid and brisk that death may occur within a few minutes.
- 30. • The state of the uterus reveals the cause of bleeding • In traumatic hemorrhage, the uterus is well contracted • In atonic hemorrhage,the uterus is flabby and becomes hard on massaging
- 31. PROGNOSIS: Postpartum hemorrhage is one of the life-threatening emergencies. It is one of the major causes of maternal deaths both in the developing and developed countries
- 32. CONTRIBUTING FACTORS. • Malnutrition and anemia, • Inadequate antenatal and intranatal care • Lack of blood transfusion facilities,
- 33. • There is also increased co-morbidity. These include • Shock, • Transfusion reaction, • Puerperal sepsis, • Failing lactation, • Pulmonary embolism, • Thrombosis and thrombophlebitis.
- 34. DIAGNOSIS • speculum examination - visible bleeding - rarely the bleeding is concealed as vulvovaginal or broad ligament hematoma • Abdominal examination • Traumatic haemorrhage- well contracted • Atonic haemorrhage- uterus is flabby and become hard on massaging.
- 35. PREVENTION • The PPH cannot be prevented always but the incidence and magnitude can be reduced to some extent
- 36. Antenatal • Improvement of the health status of the woman (keep the hemoglobin level normal (> 10 g/dL),that the mother can withstand blood loss.) • Screening of high risk mothers (multiple pregnancy,previous third stage complications,APH and severe anemia)
- 37. • Blood grouping • Placental localization(All women with prior cesarean delivery must have their placental site determined by ultrasound/MRI to determine morbid adherent placenta)
- 38. • Women with morbid adherent placenta • Availability of blood and or blood products must be ensured beforehand. • Multidisciplinary team approach should be made in such a case.
- 39. INTRANATAL • Active management of third stage of labour • Continuation of oxytocin for 1 hour after delivery • baby should be pushed out by retracted uterus, Do not pull the baby.
- 40. • Women delivered by cesarean section, oxytocin 5 IU slow IV is to be given to reduce blood loss. Carbetocin (long-acting oxytocin) 100 µg is very useful to prevent PPH.
- 41. • Exploration of the uterovaginal canal for evidence of trauma following difficult labor or instrumental delivery
- 42. • Observation for about two hours after delivery to make sure that the uterus is hard and well contracted before sending her to ward
- 43. • An expert obstetric anesthetist is needed when the delivery is conducted under general anesthesia. • Local or epidural anesthesia is preferable to general anesthesia, in forceps, ventouse or breech delivery.
- 44. • During cesarean section spontaneous separation and delivery of the placenta reduces blood loss (30%).
- 45. • Examination of the placenta and membranes should be a routine to detect at the earliest any missing part.
- 46. MANAGEMENT OF THIRD STAGE BLEEDING
- 47. • The principles in the management are: • To empty the uterus • To replace the blood. • To ensure effective hemostasis in traumatic bleeding.
- 48. STEPS OF MANAGEMENT • Placental site bleeding • Traumatic bleeding
- 49. Placental site bleeding • Palpate the fundus and massage • The massage is to be done by placing four fingers behind the uterus and thumb in front.
- 50. • Start crystalloid solution • Normal saline or Ringer’s solution with oxytocin (1 L with 20 units) at 60 drops per minute.
- 51. • Oxytocin 10 units IM or methergine 0.2 mg is given intravenously. Carbetocin, a longer acting oxytocin derivative is found (100 µg) as effective as oxytocin infusion
- 52. • Catheterize the bladder • Give antibiotics (ampicillin 2 g and metronidazole 500 mg IV).
- 53. • if features of placental separation are evident, expression of the placenta can be done either by fundal pressure or controlled cord traction method. • If it is not separated, manual removal of placenta under general anesthesia is to be done
- 54. • If she is in shock, she is resuscitated first before undertaking manual removal • If the patient is delivered under general anesthesia, quick manual removal of the placenta solves the problem.
- 55. • In cases where oxytocin 10 units is given IM with the delivery of the anterior shoulder, manual removal is done promptly when two attempts of controlled cord traction fail.
- 56. Management of traumatic bleeding: • The uterovaginal canal is to be explored under general anesthesia after the placenta is expelled and hemostatic sutures are placed on the offending sites.
- 57. STEPS OF MANUAL REMOVAL OF PLACENTA • Step–I: • The operation is done under general anesthesia • In the absence of an anesthetist, the operation may be performed under deep sedation, by administering diazepam(10mg) intravenously.
- 58. • Place the patient in lithotomy position • Catheterize the bladder
- 59. • Step–II: • 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 hand should locate the margin of the placenta.
- 61. • 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 until the placenta is completely separated.
- 62. • Step–IV: As soon as the placental margin is reached, the fingers are insinuated between the placenta and the uterine wall with the back of the hand in contact with the uterine wall. • The placenta is gradually separated with a sideways slicing movement of the fingers, until whole of the placenta is separated
- 64. 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.
- 65. Step–VI: • Intravenous methergine 0.2 mg is given and the uterine hand can be removed while massaging the uterus by the external hand to make it hard. • After the completion of manual removal, inspect the cervicovaginal canal,to exclude any injury.
- 66. Step–VII: • The placenta and membranes are inspected for completeness and make sure that the uterus remains hard and contracted.
- 67. Difficulties: • Hour-glass contraction leading to difficulty in introducing the hand. • Morbid adherent placenta which may cause difficulty in getting to the plane of cleavage of placental separation. • In such difficulties placenta is removed gently in fragments using an ovum forceps
- 68. Complications: • Hemorrhage due to incomplete removal • Shock • Injury to the uterus • Inversion(rare cases) • Subinvolution • Thrombophlebitis • Embolism • If complications persist, the placenta can be removed by using ovum forceps or flushing curette
- 69. • Schematic representation of management • • 1. Massage the fundus and make it hard 2. Inj.methergine 0.2 mg/iv 3. Oxytocin with NS 4. catheterization Placenta separated Placenta not separated Expulsion of cord by controlled cord traction MROP traumatic haemorrhage can be ceased by suture
- 70. MANAGEMENT OF TRUE PPH • PRINCIPLES: Communication Resuscitation Monitoring
- 71. MANAGEMENT • Immediate measures • Call for extra help • Put in two large bore (14-gauge) intravenous cannulas. • Keep patient flat and warm
- 72. • Send blood for full blood count, group, cross matching, diagnostic tests (RFT, LFT), coagulation screen including fibrinogen and arrange 2 units (at least) of blood. • Infuse rapidly 2 litters of normal saline (crystalloid) It does not interfere with cross matching
- 73. • Give oxygen by mask 10–15 L/min. • Start 20 units of oxytocin in 1 L of normal saline IV at the rate of 60 drops per minute. • Transfuse blood as soon as possible.
- 74. • One midwife/rotating houseman should be assigned to monitor the following— • Pulse • Blood pressure • Temperature • Respiratory rate and oximeter • Type and amount of fluids (blood, blood products) the patient has received • Urine output (continuous catheterization) • Drugs-type, dose and time • Central venous pressure (when sited).
- 75. ACTUAL MANAGEMENT • To control bleeding, asses the uterus whether the bleeding is because of atonicity(uterus will be flabby) or trauma( it is firm and contracted)
- 76. • Atonic uterus- • STEP—I: • massage the uterus and make it hard • Removal/expulsion of blood clots • Administer Methergine 0.2 mg/IV • Inj oxytocin((10 units in 500 mL of NS/RL)
- 77. • Examine the placenta for any missing lobes/cotyledon.
- 78. • Step—II: • The uterus is to be explored under general anesthesia • Check for bleeding from other sites in the genital tract.
- 79. • In refractory cases, • Injection 15 methyl PGF2α(dinoprost) 250 µg IM in the deltoid muscle every 15 minutes (up to maximum of 2 mg). • Misoprostol (PGE1 ) 1000 µg per rectum is effective. • Inj tranexamic acid 0.5gm or 1 gm/IV
- 80. • When uterine atony is due to tocolytic drugs, calcium gluconate (1 g IV slowly) should be given to neutralize the calcium blocking eff ect of these drugs.
- 81. Step—III: • Uterine massage and bimanual compression Procedures: • Spread the labia with non dominant hand • Introduce the dominant hand in to the vagina in a cone shape manner. • The vaginal hand is clenched into a fist with the back of the hand directed posteriorly and the knuckles in the anterior fornix.
- 82. • The other hand is placed over the abdomen behind the uterus to make it anteverted. • The uterus is firmly squeezed between the two hands. • Continue the massage until the uterus regains it’s tone.(it can be identified by absence of bleeding)
- 83. • oxytocics and blood transfusion can be effective in almost all cases. • If still the uterus fails to contract proceed to the 4th step.
- 84. Step—IV: • Uterine tamponade; • Tight intrauterine packing • Balloon tamponade
- 85. TIGHT INTRAUTERINE PACKING • It can be done under general anesthesia • Procedure: • A 5 meters long strip of gauze, 8 cm wide folded twice is required for intrauterine packing.
- 86. • Soak the gauze in antiseptic lotion before introduction • Steady the uterus and Place/pack the fundal region first with the gauze • Pack the entire uterine cavity with gauze without any empty space • Use separate gauze pack to fill the vagina
- 87. • Place an abdominal binder also • Intrauterine packing not only acts by stimulation of uterine contraction, it also exerts direct hemostatic pressure (tamponade effect) to the open uterine sinuses.
- 88. • Antibiotic should be given and the plug should be removed after 24 hours. • Intrauterine packing is more helpful in severe bleeding, where the other methods fails.
- 90. Balloon tamponade • Tamponade using various types of hydrostatic balloon catheter has mostly replaced uterine packing. • Its Mechanism of action is similar to uterine packing.
- 91. • Foley catheter, bakri balloon, condom catheter or sengstaken-blakemore tube is inserted into the uterine cavity • The balloon is inflated with normal saline (200–500 ml).
- 92. • It can be kept for 4-6 hours • This can avoid hysterectomy in 78% cases. • It is considered the first line surgical intervention for most women with atonic PPH.
- 93. Foley catheter
- 95. condom catheter
- 98. • Other Measures: • A non-pneumatic antishock garment may be used when patient is being transferred to a referral center. • Compression of the abdominal aorta may be a temporary but effective measure. • This allows time for resuscitation and volume replacement before any surgical intervention is done.
- 101. • Step V: Surgical methods to control PPH are many (a)B-Lynch compression suture (1997) and multiple square sutures: Both these surgical methods work by direct application of compression on the uterus. Success rate is about 80% and it can avoid hysterectomy.
- 104. • (b) Ligation of uterine arteries—the ascending branch of the uterine artery is ligated at the lateral border between upper and lower uterine segment. • The suture (No. 1 chromic) is passed into the myometrium 2 cm medial to the artery • In atonic hemorrhage, bilateral ligation is effective in about 75% of cases.
- 106. • Ligation of the ovarian and uterine artery anastomosis just below the ovarian ligament can be done if bleeding continues • Rarely temporary occlusion of the ovarian vessels at the infundibulo-pelvic ligament may be done by rubber-sleeved clamps.
- 107. • Ligation of anterior division of internal iliac artery (unilateral or bilateral)—reduces the distal blood flow. • It helps stable clot formation by reducing the pulse pressure up to 85%. • Bilateral ligation can avoid hysterectomy in about 50% of the cases.
- 108. • Angiographic selective arterial embolization (blocking of bleeding vessel) under fluoroscopy can be done. • Success rate is more than 90% and it avoids hysterectomy.
- 110. Step VI: • Hysterectomy—rarely uterus fails to contract and bleeding continues. • Hysterectomy has to be considered involving a second consultant. • Decision of hysterectomy should be taken earlier in a parous woman. • Depending on the case, it may be subtotal or total.
- 111. • Traumatic PPH: • The trauma to the perineum, vagina and the cervix is to be searched under good light by speculum examination • Hemostasis is achieved by appropriate catgut sutures. • The repair is done under general anesthesia, if necessary.
- 113. • CAUSES: • The bleeding usually occurs between 8th and 14th day of delivery • The causes of late postpartum hemorrhage are; • (1) Retained bits of cotyledon or membranes (most common), • (2) Infection and separation of slough over a deep cervicovaginal laceration,
- 114. • (3) Endometritis and subinvolution of the placental site—due to delayed healing process, • (4) Secondary hemorrhage from cesarean section wound (usually occur between 10–14 days.) • (It is probably due to— • separation of slough exposing a bleeding vessel or from granulation tissue,)
- 115. • (5) Withdrawal bleeding following estrogen therapy for suppression of lactation, • (6) Other rare causes are: • Chorionepithelioma(a tumour which arises from the trophoblast)—occurs usually beyond 4 weeks of delivery; • carcinoma cervix; • placental polyp; • infected fibroid or fibroid polyp and puerperal inversion of uterus.
- 116. SIGNS AND SYMPTOMS • Heavy vaginal bleeding • Sub-involution • Pyrexia and tachycardia • Anemia
- 117. DIAGNOSIS • Internal examination reveals evidences of sepsis, subinvolution of the uterus and often a patulous cervical os. • Ultrasonography is useful in detecting the bits of placenta inside the uterine cavity.
- 118. MANAGEMENT • Principles: • To assess the amount of blood loss and to replace it (blood transfusion). • To find out the cause and to take appropriate steps to rectify it.
- 119. • Supportive therapy: (1)Blood transfusion (2)Administer methergine 0.2 mg intramuscularly, if the bleeding is uterine in origin, (3)To administer antibiotics (clindamycin and metronidazole) as a routine.
- 120. • Conservative: If the 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.
- 121. Active treatment: • explore the uterus urgently under general anesthesia(in case of retained placenta) • Uterine curettage • Methergine 0.2 mg(IM) • Secondary hemorrhage following cesarean section may at times require laparotomy.
- 122. • The bleeding from uterine wound can be controlled by hemostatic sutures; • May rarely require ligation of the internal iliac artery or Hysterectomy