Obstetric emergency part 2

Obstetric emergency cont…

6. Managing third stage complications

1. Postpartum hemorrhage (PPH)

BY MUKEREM.A 2007

Objeonobctiv Objectify Objectives veObjeooctives

objectivesDefine PPH

Be familiar with clinical features of blood loss

Understand risk factors for PPH

Be able to take measures to prevent PPH

Be familiar with immediate management of PPH

BY MUKEREM.A 2007


Definition: . No single definition for PPHIs a bleeding from the genital tract during the third stage of labor or any time following the baby’s birth up to 6 weeks (some authors say 12 weeks) after delivery:1. to the amount of 500ml or more following

vaginal birth or2. to the amomnt of 1000 ml or more following c/s

or3. Fall in Hct of > 10 % or 4. Any amount bleeding which affects women

condition. BY MUKEREM.A 2007

Blood loss (mls) Vital signs Other features Level of Shock500-1000 PR Dizziness

Palpitations

Compensated

1000-1500 PR

BP (80-90 systolic)

RR (21-30)

Pale

Sweaty

Weakness

Mild

1500 – 2000 PR

BP (60-80 systolic)

RR (>30)

Cold clammy skin

Restlessness

Anxiety, confusion

Decrease urine output

Moderate

2000 – 3000 BP (< 50 systolic)

Peripheral cyanosis

Air hunger

Confusion, Anuria

Unconscious, Collapse

Severe

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Classification of PPH according to time of occurrence

A. Primary post partum hemorrhage

This is called when bleeding occurs with in 24 hours of birth. This is usually a consequence of hypotonic uterine action or trauma

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B. Secondary post partum hemorrhage

•Is bleeding from the genital tract more than 24 hours after delivery of the placenta and may occur up to 6 weeks later.

• It is most likely to occur between 10 and 14 days after delivery.

• Bleeding is usually due to retention of a fragment of the placenta or membranes or the presence of a large uterine blood clot

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Risk factors for PPH

• Antepartum haemorrhage• Macrosomia **• Precipitate labour• Polyhydramnios **• Operative vaginal delivery• Anaemia ***• Previous PPH ****

Morbidly adherent placentaInduction of labour

• Pre eclampsia• Use of oxytocin• Previous caesarean section *• Prolonged first stage of labour• Multiple pregnancy **• Prolonged second stage of labour

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Types of PPH

1. Atonic PPH

2. Traumatic PPH

3. Hypofibrinogenaemia

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QUESTION ???

• What are the first things you should do when you encounter a woman with bleeding after third stage (postpartum hemorrhage)?

BY MUKEREM.A 2007

Immediate Management

• CALL FOR HELP

• Rapid assessment– ABC

– Vital signs -

– High flow oxygen

– Large bore IV access and fluid resuscitation

– Catheterise

– Aortal compression

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Immediate management

• Investigations– Bloods: Hb or HCT

– Cross match

– Clotting studies

• Identify cause– 4 T’s

TreatUterine atony >

uterine massage, drugs, bimanual compression, surgery

genital tract trauma> repair tears

retained placenta > manual removal of placenta

BY MUKEREM.A 2007


Managing Atonic PPH

Atonic PPH

Defn – This is bleeding from the placental site when the uterus is not well contracted, or this is a failure of the myometrium at the placental site to contract and retract and to compress torn blood vessels and control blood loss by a living ligature action.

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Causes of atonic PPH

A. Incomplete placental separation.

If once separation has begum maternal vessels are torn. If placental tissue remains partially embedded in the spongy deciduas efficient contraction and retraction is interrupted.

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B. Retained placenta or products like retained cotyledon, placental fragment or membranes. This is the common cause of atonic PPH.

C. Precipitate labor: When the uterus has contracted vigorously during the first and second stages of labor (Hypertonic action) then the muscle has insufficient opportunity to retract.

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D. Prolonged labor: May result in uterine inertia due to muscle exhaustion.

E. Over distention as in multiple pregnancy polyhydramnios, large baby

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Sign and Symptoms of atonic PPH Visible bleeding Maternal collapse Pallor Rising pulse rate (weak and irregular) Falling blood pressure Altered level of consciousness may become restless or drowsy Enlarged uterus as it fills with blood or blood clotUterus feels boggy on palpation i.e soft and distended and lacking tone.

BY MUKEREM.A 2007


Treatment of Atonic PPH

Three basic principles apply

1. Call for help

2. Stop the bleeding

3. Resuscitate the mother

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1. Call for help

This is an important initial step so that help is on the way whatever transpires.

2. Stop the bleeding

The initial action is always the same regardless of whatever bleeding occurs with the placental site or not. Steps to stop a bleeding are

a. Rub up a contraction

b. Give oxytocin drug

c. Empty the uterus BY MUKEREM.A 2007


a. Rub up a contraction or massage the uterus to stimulate contraction. The fundus is first 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.

b. Giving an oxygocin drug Oxytocic agent may be given to sustain the contraction. In many instances ergometrine or syntometrine 1ml has already been administered and this may be repeated intravenously.

BY MUKEREM.A 2007


c. Empty the uterus

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.

The placenta and membranes must be re –examined for completeness since retained fragments are often responsible for uterine atony.

Empty the bladder. BY MUKEREM.A 2007


3. Resuscitate the mother

A. Intravenous infusion

B. As an emergency measure the mother’s legs may be lifted up in order to allow blood to drain from them in to the central circulation. The foot of the bed should not be raised as this encourages pooling of blood in the uterus which prevents the uterus contracting.

C. Blood transfusion BY MUKEREM.A 2007


Bimanual compression of the uterus

If bleeding continues bimanual compression of the uterus may be necessary in order to apply pressure to the placental site.

BY MUKEREM.A 2007

Bimanual Compression of the Uterus

• Wearing HLD gloves, insert hand into vagina; form fist.

• Place fist into anterior fornix and apply pressure against anterior wall of uterus.

• With other hand, press deeply into abdomen behind uterus, applying pressure against posterior wall of uterus.

• Maintain compression for 20-30 min or until bleeding is controlled and uterus contracts.

BY MUKEREM.A 2007


External aortic compression

Transabdominal compression of the aorta.

done in preparation for laparotomy if required.

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Compression of Abdominal Aorta

• Apply downward pressure with closed fist over abdominal aorta through abdominal wall (just above umbilicus slightly to patient’s left)

• With other hand, palpate femoral pulse to check adequacy of compression

– Pulse palpable = inadequate

– Pulse not palpable = adequate

• Maintain compression until bleeding is controlled or until she reaches the operation theatre

BY MUKEREM.A 2007

QUESTION ???

If a woman with postpartum hemorrhage has no signs of atonic uterus, what should you do?

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Traumatic PPH

Defn:- This is bleeding from a laceration of the cervix, vaginal wall, episiotomy, or even from ruptured uterus or a combination of all.

This may occurs in:

Delivery through partially dilated cervix

Instrumental delivery

Difficult delivery. eg. Face to pubis or after coming head of a breech

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Management

1. When bleeding is from a tear you will suspect it because of the history of the labor.

2. Clamp the bleeding point if possible or suture it.

3. Make sure the uterus is not ruptured

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4. If you can suture the laceration and the bleeding stops your problem is over just make sure that the uterus is well contracted.

5. If the bleeding is from a bruised cervix then place a pack against it for a few minutes.

6. If bleeding is from ruptured uterus transfer to the hospital as soon as possible go with patient or send a full written report.

BY MUKEREM.A 2007


Differential point between atonic and traumatic PPHAtonic PPH

1. Uterus feels lax or soft (not contracted) traumatic PPH 2. Bleeding start after a few minutes 1. Uterus is contracted firmly

2. Starts immediately

3. Bleeding from injured part

4. Blood is bright red colour .

5. Not treated

3. Bleeding is from the placental site 4. The blood is dark red colour5. May be treated with oxytocic drug

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PPH due to Hypofibroinogenemia

Defn - This is bleeding from a clotting defect and the patient continues to bleed in spite of treatment for the other types of PPH

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Causes of hypofibrinogenaemia PPH

Placenta abruption

Intrauterine fetal death (which is prolonged)

Pre eclampsia

Amniotic fluid embolism

Hepatitis

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Management of hypofibrinogenaemia

1. Fresh blood transfusion

2. Fibrinogen

3. Doctor may order a special drug to clot the blood if available

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Management of a severe PPH in a health centre (in remote areas) 1. Massage the uterus and expel the placenta if

possible 2. Stay with your patient and shout for help 3. Give ergometrine 0.5mg IV 4. Put up a drip 5. Empty bladder 6. If placenta is not out. Try to expel it by fundal

pressure with the contraction caused by the ergometrine

BY MUKEREM.A 2007


7. If not expel do manual removal

8. Continue to massage the uterus

9. Examine the placenta to see if it is complete

10. Check if the uterus is contracted

11. If still lax put 5 units of oxytocin in to drip. If still is not contracted another 5 unit may be added.

12. If bleeding is still not controlled bimanual compression method is done.

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Management of Secondary PPH The following steps should be taken

Call for help Rub up a contraction by massaging the uterus if it is still palpable Express any clots Encourage mother to empty her bladder Give an oxytocic drug

- Ergometrine 0.5mg IV Keep all pads to assess the volume of blood lost If bleeding persists prepare mother for OR.

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Complications of PPH •Hemorrhagic shock •Consumptive coagulopathy•Multiple organ failure (Renal failure)•Death•Need for internal iliac artery ligation and its complications•Need of hysterectomy and its complications (loss of more children)•Complications of blood transfusion•Sheehan’s Syndrome

BY MUKEREM.A 2007

QUESTION ???

• What measures can we take to prevent postpartum hemorrhage?

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PREVENTION

CLIENT CARE

– Prevent Prolonged Labor

– Active Management of the Third Stage of Labor (AMTSL)

– Avoid perineal/vaginal trauma

– Monitor closely

EMERGENCY PREPAREDNESS

– Have emergency PPH pack ready

Summary

• ALL women in labor are at risk of PPH!

• Atonic uterus is the most common cause of primary PPH.

• Rapid action in response to PPH is critical!

• PPH is a life threatening complication which must be managed promptly and effectively.

• Prevention is the best management – AMTSL has been proven to reduce the incidence

of PPH

BY MUKEREM.A 2007

Case Study

• Adisa Mohammed was reched to your clinic by her family. She delivered at home 2 hrs ago and has since been bleeding profusely. She is now very weak. You are the health providers at the clinic:

– What first steps will you take and why?

– What rapid assessments will you undertake (history and examination) and why?

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Case Study (cont.)

• You note that she is very pale and barely alive. Her BP is 80/50 mmHg and Pulse 110/ min. Her uterus is lax and she is still bleeding actively PV. You are told that the placenta was delivered after the baby was born.

– What next resuscitative actions and assessments will you undertake and why?

BY MUKEREM.A 2007

BY MUKEREM.A 2007

Health & Medicine

Obstetric emergency part 2