Postpartum Hemorrhage
Definition
Postpartum
hemorrhage (PPH) is excessive blood loss at delivery
sufficient to affect the general condition of the mother
as shown by rising pulse rate, falling blood pressure,
and poor peripheral perfusion.
The
traditional definition, based on blood loss of 500 ml or
more from within the reproductive tract after birth
within 24 hours of delivery, is difficult to estimate in
clinical practice.
There are
two types of PPH:
Postpartum hemorrhage is the leading cause of maternal
mortality
Risk Factors
-
Increasing maternal age >35
years
-
Increasing parity
-
Anemia and poor nutritional
status
-
Uterine overdistension
(multiple pregnancy, macrosomia, polyhydramnios)
-
Antepartum hemorrhage
-
Previous postpartum
hemoorhage
-
Prolonged labor
-
Traumatic delivery with
laceration of perineum, cervix, vagina or uterus
-
Complications of third stage
of labor
-
Previous cesarean section
-
Certinal general anesthetics
(e.g. halothane)
-
Uterine fibroid
-
Coagulation disorders:
Ø
Acquired
-
Pregnancy induced hyepertension
-
Amniotic fluid embolism
-
Placental abruption
-
Placenta praevia
-
Fetal demise
Ø
Inherited
Causes
Principal clinical signs
NB In patients with
hypertension or pre-eclampsia severe blood loss may
cause misleading “normal” blood pressure
Laboratory Examination
-
Complete blood count
(hemoglobin, hematocrit, differential, platelet count)
-
Bleeding time
-
Coagulation time
-
Blood grouping and Rh type
-
Cross match as many units as
needed for clinical situation
Laboratory Findings
-
Low hemoglobin or hematocrit
-
Increased bleeding time
-
Increased coagulation time
-
Decreased platelets
-
Decreased fibrinogen
-
Increased prothrombin time
-
Increased partial
thromboplastin time
-
Fibrin split products
positive
Management
Antenatal period
Ø
Routine laboratory
examinations
Ø
Iron and Folic acid
supplementation
Ø
Educate the patient to
come to the hospital early in labor, the importance of
iron supplementation, and the need to seek immediate
medical attention if vaginal bleeding occurs
Ø
Refer to a tertiary level
facility for antenatal management
Labor and Deliver
-
Order routine laboratory
examinations ( standard admission orders for labor
ward)
-
Actively manage the third
stage of labor. Add oxytocin to IV infusion or inject
IM with delivery of anterior shoulder or, if not
hypertensive or cardiac patient, use ergometrine (Methergine)
Hemorrhage after delivery of
baby, before delivery of the placenta:
-
Determine cause of retained
placenta (hour glass contraction vs partial
separation)
-
Continuous monitoring of
pulse, blood pressure, urine output, and blood
coagulation
-
Establish adequate IV access
(If not already in place)
-
Empty bladder with Foley
catheter
-
Massage uterine fundus
-
Administer Ergotrate 0.2
mg(1 ampule) M stat followed by controlled cord
traction to deliver the placenta (maximum dose should
not exceed 1 mg-5 amps) and watch for uterine
inversion
-
Administer rapid IV saline
solution and start 40 IU oxytocin/liter
> If bleeding persists without delivery of placenta,
rapidly explore the perineum, vagina, and cervix looking
for lacerations
Call the anesthesiologist and perform manual removal of
the placenta with adequate sedation (e.g. valium,
pethidine) or anesthesia
>
If bleeding persists after removal of placenta , see
below
Hemorrhage immediately after
delivery of placenta:
-
Establish adequate IV access
(if not already in place)
-
Prepare for blood
transfusion
-
Empty bladder with Foley
catheter
-
Administer Ergotrate 0.2 mg
IV stat
-
Administer Oxytocin 10-50 IU
in 500 ml of dextrose or mixed IV solution, rapid
infusion rate until the uterus contracts and the
hemorrhage stops
-
Put the baby to the breast
to suck or stimulate nipples manually
-
Massage uterine fundus
If bleeding
persists, explore the perineum, vagina, and cervix
looking for lacerations and repair as needed
-
Call the anesthesiologist
-
Call the senior specialist
-
Explore the uterine cavity
for retained placental fragments
-
If there are retained
placental fragments, remove manually or with ring
forceps, and if needed curettage (suction curettage)
or large blunt curette
If bleeding
still persists then a blood coagulation disorder must be
suspected and investigated
-
continue bimanual massage
-
Give Carboprost 250
micrograms intramyometrial (transabdominal), repeat/5
min until senior specialist and anesthesiologist
arrive
-
Perform an emergency
laparotomy if above fails or ruptured uterus is found
-
Laparotomy:
Ø
1st step:
Inspect uterus. If lacerated, repair adequately. If
atony give direct massage
Ø
2nd step:
Inject intramyometrial Carboprost
Ø
3rd step:
-
Ligation of uterine arteries
-
Consider ligation of
hypogastric arteries, if you are trained in this
technique
Ø
4th step:
subtotal hysterectomy
Late postpartum hemorrhage
(after 24 hours)
Follow the
steps above
Important considerations
-
Remember that a postpartum
patient can lose a large amount of blood in a very
short time. You must act promptly and anticipate
complications
-
Assure adequate team
coverage
-
A laparotomy for postpartum
hemorrhage need not be delayed while awaiting for
blood transfusion. This is an extremely urgent
situation
-
Administer antibiotic
prophylais, such as 1 gm ampicillin before and after
the procedure
-
D not give oxytocin as
undiluted IV push since the patient may collapse
send
to a friend
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