Postpartum Haemorrhage: Overview, Causes, Management by Nurses Note

 POSTPARTUM HEMORRHAGE 

OVERVIEW: POSTPARTUM HEMORRHAGE 

 • Postpartum Haemorrhage is an obstetrical emergency and is a major cause of maternal morbidity and one of the top three causes of maternal mortality. 

• The incidence varies between 1-5% of deliveries.

 • PPH is either primary occurring within 24 hours after delivery and secondary occurs 24 hours-12 weeks after delivery. 

• Defined clinically as excessive bleeding after delivery that makes the patient symptomatic (e.g pallor, palpitation, weakness, restlessness, hypotension, tachycardia, oxygen saturation < 95%). 

• Another classic definition is a 10 percent decline in postpartum hemoglobin concentration from antepartum levels 

• A less useful definition of estimated blood loss ≥ 500 ml after vaginal birth or ≥ 1000 ml after cesarean delivery.

WORK UP: 

• It is a teamwork. 

• Detect the risk factors for postpartum haemorrhage, counseling and planning for delivery. 

• Consultant on call or Specialist should be informed to assess the case if needed. 

• All patients with risk factors for postpartum haemorrhage should have blood cross-match and ready. 

• Most risk factors are unpredictable but can be preventable, the majority of cases of PPH have no identifiable risk factor: 

➤  Suspected abruption of placenta 

➤  Placenta previa 

➤  Multiple pregnancy 

➤  Multiparity 

➤  PET 

➤  Retained placenta 

➤  Operative vaginal delivery 

➤ Over-distended uterus

Causes of PPH:

Uterine atony 80% 

• Trauma of cervix, vagina or ruptured uterus 20% - 30% 

• Retained placenta 10% 

• Coagulation defect 1% 

Prediction & prevention of postpartum haemorrhage:

 Active management of 3rd stage of labour by: 

• oxytocin (5 international unit I.V or 10 iu by intramuscularly “ STAT ” with 0.2 mg. of Methergin ( if no contraindication) 

• Control cord traction will reduce blood loss 

• Alert about the patient with risk factors 

• Activate the Protocol of Postpartum haemorrhage 

• Postpartum Cart with medication and instrument

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MANAGEMENT: POSTPARTUM HEMORRHAGE 

It is team work. 

- Multidisciplinary approach: 

• Experienced midwife 

• Senior Obstetrician 

• Alert Consultant obstetrician on call. 

• Alert Anesthesiologist 

• Alert the Blood Bank 

• Alert the Haematologist as needed 

• Alert one member of the team to record events, fluids, drugs and vital signs.

Resuscitation by :

1. Assess airway , breathing. 

      Give oxygen mask at 10 – 15 L/minute. 

2. Evaluate circulation. 

a) Assess the vital signs every 10 – 15 minutes 

b) Oxygen saturation 

c) Foley’s catheter 

d) I.V. line with 2 big cannula, infuse crystalloid solution (Ringer Lactate) – 3 Liters: for every 

    1 liter of blood loss. 

    2 Liters Crystolloid + 1 -2 colloid ( Plasma Protein) until blood arrive. 

e ) Cross match 4 units of PRBC and 2 units of Fresh Frozen Plasma.

_ Recombinant factor VIIa therapy should be based on the results of coagulation.

3. If the patient is in hypovolemic shock: 

   3.1 Head tilt down. 

   3.2 Keep patient warm. 

   3.3 Check for Coagulation Profile ( PT, PTT, Fibrinogen, FDP, D- Dimer) 

    3.4 Send for CBC, LFT, RFT, ABG as baseline every 30 minutes 

    3.5 Consider central, arterial line 

    3.6 ECG

4. Commence Record Chart. Blood transfusion: 

1. Blood transfusion is the volume replacement best and should be started as soon as possible.

 Preparation of blood products should be as: 

• 6 units of PRBC 

• 6 units of Fresh Frozen Plasma 

• 6 units of Platelets 

• 10 units of cryoprecipitate 

 2. Aim to maintain: 

• Hb> 8 g/dl • Platelet > 75 x 10 9 

• Prothrombin < 1.5 

• Fibrinogen > 1 gm. Identify the causes of postpartum haemorrhage

 A. If uterine atony is suspected : 

         • Bimanual uterine massage 

         •  Empty the bladder

• Insert 2 large bore I.V. cannula 

• Start syntocinon drip 40 units in 500 cc. LR 

• Methergin 0.2 mg. IM, if there is no contraindications, repeat it as needed.

• If still no response, start Carboprost Protocol - 0.25 mg(- contraindicated in women with 

• asthma ) IM every 15 minutes for maximum 8 doses 

 • Misoprostol 1000 microgram per rectal ( 1 Tablet = 200 microgram)Total of 5 tabs. 

If patient is still bleeding, initiate subsequent intervention.

1. Uterine Balloon Tamponade ( Bakri Ballon) after ensuring if no placental remnants. 

   - Insert either post vaginal delivery or during caesarean section.

2. Or intrauterine packing during caesarean section to control lower segment uterine bleeding. 

• If the patient is still bleeding and/or is haemodynamically unstable, proceed for laparotomy. 

 Procedure during laparotomy to control haemorrhage of atonic uterus:

1. External uterine compression suture: B- lynch

2. Uterine artery ligation 

3. Internal iliac artery ligation 

. Arterial embolization (If available and arranged before) 

5. Hysterectomy, the last resort but it should be decided for patients who are unstable with persistent heamorrhage to prevent DIC and death.It has to be decided after the opinion of two Consultants and informing the husband.

B. In case of retained product:

    1. Manual removal of placenta under Ultrasound guidance. 

    2. Suction and evacuation.

C. In case of vaginal or cervical laceration or uterine rupture:

1. Patient should be taken for laparotomy for repair of the injury and control of bleeding. Once the bleeding has been controlled, continuous monitoring and observation in ICU.

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ALERT: POSTPARTUM HEMORRHAGE 

 1. Vaginal bleeding after delivery may not appear abnormal in the symptomatic patients were physician must role out intra-abdominal bleeding relate to cesarean section or broad ligament or vaginal hematomas. 

 2. Management of PPH is a teamwork and depend on the cause of bleeding, therefore early involvement of the most senior obstetrician is essential. 

 3. Activate the massive blood loss > 2.5 liter protocol as early as possible to ensure proper and volume replacement. 

 4. Hysterectomy is the last resort method for controlling haemorrhage and must be decided by two consultants after explaining to the husband. 

 5. Documentation: It is important to record:

 _ the staff in attendance and the time they arrived

 _ the sequence of events 

_ the time of administration of different pharmacological agents given, their timing and sequence 

_ the time of surgical intervention, where relevant 

_ the condition of the mother throughout the different steps 

 _ the timing of the fluid and blood products given.