Post partum hemorrhage
- Is define as excessive bleeding from the genital tract at any time following the baby up to 6 weeks after delivery.
- It occure during the third stage of labour or within 24 hours of delivery it is termed primary postpartum hemorrhage.
- If bleeding occure sup sequent to the first 24hours following birth up until sixth week post partum it is termed secondary PPH.
Uterine atony: Relaxation of the uterus secondary to:
- Multiple pregnancies
- Prolonged labour
- Deep anesthesia
- Fibromyomata – prevents uterus from contracting
Retained placenta fragments result from:
- Manual removal of placenta
- Succenturiate (additional) lobe
- Abnormal adherent placenta
Laceration of the vagina, cervix or perineum secondary to:
- Forceps delivery, especially rotation forceps
- Large infant
- Multiple pregnancies
Uterine atony: uterus is soft or boggy, often difficult to palpate, and will not -remain contracted, excessive vaginal bleeding.
Retained placental fragment: hemorrhage usually occure about the 10th postpartum day.
Laceration of the vagina, cervix, or perineum: bleeding is bright red; fundus is firm.
Marked fluctuation in blood pressure and pulse will not usually occure until a large amount of blood has been lost.
Excessive blood loss: pallor, restlessness, dyspnea, thready pulse, lowered blood pressure, chills, and air hunger
Previous history of postpartum hemorrhage or retained placenta. There is a risk of recurrence in subsequent pregnancies. A detailed obstetric history taken at the first antenatal visit will ensure that arrangements are made for such a mother to give birth in a consultant unit.
With each successive pregnancy fibrous tissue replaces muscle fiber in the uterus, reducing its contractility and the blood vessel become more difficult to compress, Women who have had five or more deliveries are at increased risk.
These are normally benign tumors consisting of muscle and fibrous tissue which may impede efficient uterine action.
Women who enter labour with reduced hemoglobin contraction below 10 g/dI)
may succumb more quickly to any subsequent blood loss, however small. Anemia is associated with debility which is a more direct cause of uterine atony.
The influence of ketosis upon uterine action is still unclear.
- Identity women who may be at greater risk and to recognize causative factor.
- During the antenatal period a thorough and accurate history of previous obstetric experiences will identify risk factor such as previous postpartum hemorrhage or precipitate labour.
- The early detection and treatment of anemia will help ensure the women enter labour with a hemoglobin level in excess of 10 g/dl
- During labour, good management practices during the first second stages are important to prevent prolonged labour and ketoacidosis
- A mother should be not enter the second or third stage with a full bladder
- Prophylactic administration of an oxytocic agent is recommended for the third stage, either by intramuscular injection or intravenous infusion.
Treatment of postpartum hemorrhage
Call a doctor: this is important initial step so that help is on the way whatever transpires
Stop the bleeding: the initial action is always the same; regardless of whether bleeding occurs with the placenta in situ or later
Rub up a contraction: the fundus is the fires felt gently with the fingertips to assess its consistency, if it is soft and relaxed, the fundus is massaged with a smooth, circular motion, applying no undue pressure, when a contraction occurs, the hand is held still.
Give an oxytocic it sustains the contraction: in many instances, syntocinon 5 units or 10 units or syntometrine 1ml has already been administered and this may be repeated.
Empty the uterus: the nurse should ensure that the uterus is emptied.
If the placenta is still in the uterus, it should be delivered,
– Resuscitate the mother: an intravenous infusion should be commenced while peripheral veins are easily negotiated, this will provide a route for syntocinon infusion or fluid replacement.
– Placenta delivered: if the uterus is atonic following delivery of the placenta; light fundal pressure may be used to expel residual clots whilst a contraction is stimulated
– Bimanual compression: of the bleeding continues, bimanual compression of the uterus may be necessary in order to apply pressure to the placental site.
Monitor changes in physiologic status
- monitor vital signs frequently.
- Describe number and saturation of perineal pads used per hour.
- Evaluate uterine firmness, height, and position
Restore fluid / blood volume.
- administer IV fluids as prescribe to restore fluid volume.
- administer blood as prescribed.
When cause has been determined, prepare the woman for further treatment.
- Laceration – prepare for return to delivery room for inspection and repair.
- Retained placental fragment – prepare for curettage of uterus.
- Uterine atony – administer oxytocic as prescribe “usually ergo ovine for sustained uterine contraction”.
Helps reduce anxiety
- Determine major source of the woman’s anxiety.
- Explain current status and prescribed treatment regimen.
- Correct misinformation regarding status or potential complications.
- Keep the woman / family informed of changes in physiologic status or treatment plan with emphasis on improvements in condition.