Tuesday, February 14, 2012

POSTPARTUM HAEMORRHAGE


Postpartum haemorrhage(PPH) is a condition whereby a woman starts bleeding immediately or 4-6wks after delivery. It is an excessive loss of >500mls of blood after vaginal delivery, or 1000mls of blood following ceaserean section or any blood loss that will affect the general condition of the woman even if it is not upto 500mls.
Fluid loss is extremely difficult to measure with any degree of accuracy, especially when a mixture of blood and fluid has soaked into delivery couch and spilled onto the floor. It should also be taken into consideration that measurable solid clots represents only half the total fluid loss,therefore the best way to diagnose PPH is by watching out for any blood loss that adversely affects the mother’s general wellbeing. In addition, if the blood loss is upto 500mls,it must be treated as PPH, irrespective of the maternal condition.
Postpartum haemmorrhage as we all know is one of the complications of third stage of labour and a leading causes of maternal mortality(ie one quarter of maternal death) and may occur in any woman especially those already compromised by anaemia or other illnesses during pregnancy.

INCIDENCE:
The incidence of postpartum haemorrhage is 5-8%.It is the most commonest cause of maternal death in the developed countries and a major cause of maternal morbidity worldwide.

CAUSES:
There are so many causes of PPH which include uterine atony, vaginal/cervical lacerations, retained placental tissue, coagulation defects.The causes of postpartum haemorrhage has been grouped into 4T’s +1 which are:

A.Tone
a.Uterine atony :-is the inability of the uterus to contract and may lead to continuous bleeding. Postpartum haemorrhage is physiologically controlled by constriction of the living ligatures that surround the blood vessels supplying the placenta site. This atony occurs when the myometrium refuses to contract after the delivery of the placenta. This atony causes about 50% of PPH.

Predisposing factors to uterine atony
This can be classified into:
i.fatigued uterus which can be caused by
*excessive manipulation of the uterus during operative delivery/
mismanagement of the third stage of labour (fundus fiddling) may
trigger contractions which are retraction.
*general anaesthesia( especially with halogenated compounds or
cyclopropane causes relaxation of the uterine muscles)
*prolonged labour resulting to uterine inertia due to muscle
exhaustion
*precipitate labour – causes insufficiency of the uterine muscles
to contract
ii.obstructed uterus caused by
* presence of uterine leiomyoma
*full bladder
*incomplete seperation of placenta –interrupts efficient
contraction and retraction but an adherent placenta may not
cause bleeding
*retained cotyledon, placenta fragments or membranes – impedes
efficient uterine action.
*placenta praevia/abruption
iii.induction and augumentation of labour with oxytocin –causes
uterine inertia which inhibits uterine muscles from providing
strong and sustained contraction and retraction of the empty
uterus.
iv.other causes:
*previous history of PPH –detailed history is necessary because
there may be risk of recurrence in subsequent pregnancies.
*intrinsic myometrial dysfuntion
*uterine infections
*keto-acidosis
v.overdistension of the uterus caused by
*high parity /grand multiparity(5 or more birth)-there is
formation of fibrous tissue which replaces muscle fibres with
each successive pregnancy and this reduces the contratilityof
the uterus and makes the blood vessels more difficult to compress.

B.Trauma
i.Vaginal/cervical lacerations and haematoma
This may occur as a result of precipitous or uncontrolled delivery. Bleeding from episiotomy and laceration is the 2nd most frequent cause of over 20% of PPH. Laceration of the vagina, cervix and uterus most commonly occurs in assisted or surgical delivery due to the fact that these parts of the body are highly vascularised.
Predisposing factors are :-
*delivery of a macrosomic baby.
*vaginal birth after caeserean section
*instrumental delivery or intrauterine manipulation
*episiotomy

C.Tissue (retained placenta)
This occurs in cases where the placenta has an accessory lobe, in preterm delivery or where there is placenta accreta.
Predisposing factors:-
*previous uterine surgeries
*premature delivery
*difficult or prolonged placenta delivery

D.Thrombosis(clotting disorder)
This occurs when there is failure of blood to clot and this occurs when there is delay in uterine contractions which gives room for liqour to enter into the blood stream causing coagulopathy.
Predisposing factors:-
*platelet dysfunction eg thrombocytopenia.This may be as a result of HELLP syndrome( haemolysis, elevated liver enzymes and low platelet count).
*inherited coagulopathy
*Hiv/Aids (immunosupression lowers platelet count)
*use of anticoagulants
*disseminated intravascular coagulation(DIC)-occurs from intrauterine fetal death,placenta abruption, amniotic fluid embolism.
*physiologic factors eg hypocalcemia acidemia and hypothermia.

E.Traction(uterine inversion)
This occurs when the weight of a partially seperated placenta pulls on an atonic uterus or excessive traction of the cord during controlled cord traction.

SIGNS AND SYMPTOMS OF POSTPARTUM HAEMORRHAGE
Obvious signs:-
-visible bleeding.
-maternal collapse.
Other subtle signs
-pallor
-rising pulse rate
-falling blood pressure.
-altered level of consciousness with restlesnes or drowsiness.
-fundal height above the umblicus ie enlarged uterus as it is filled with blood
clots(it feels boggy on palpation).Uterus is soft and distended due to lack of
tone and there may be no visible bleeding.

CLASSIFICATION OF POSTPARTUM HAEMORRHAGE
A. PRIMARY POSTPARTUM HAEMORRHAGE
This type of haemorrhage occurs immediately after the delivery of the placenta.
The patient bleeds abnormally and looses blood that may affects the general condition of the patient.

B.SECONDARY POSTPARTUM HAEMORRHAGE
This is a bleeding from the vaginal occuring between 24hrs and12weeks postnatally. This occurs due to retention of some products of conception like pieces of placenta, membrane or even blood clots. When it occurs the lochia is usually heavy and will change from a serous pink or brownish to a bright red blood loss, the lochia may even be offensive if the patient has infection.There may be subinvolution, pyrexia, and tachycardia etc.


MANAGEMENT OF POSTPARTUM HAEMORRHAGE

A.ANTENATALLY:-
Management of postpartum haemorrhage starts from the day a pregnant mother books in the hospital. The midwife that books the pregnant mother applies some
preventive screening so as to identify those who are at greater risk and recognise causative factors.Thorough and accurate history taking of previous obstetric
experience will identify risk factors eg previous PPH or precipitate labour. This will also help in planning for the delivery of the index pregnancy in a hospital that has facilities for dealing with emergencies. All mothers who are identified as being at risk
should be advised to do series of blood test eg blood typing and cross-matching.Mothers at risk should provide a pint of blood that will be reserved in the blood bank till 24hrs after delivery.
Early detection and treatment of anaemia will help the woman enter into labour with haemoglobin that is greater than 10g/dl.The midwife should make sure that the patient’s blood test is done regularly,results recorded and explained to the woman.If the woman’s haemoglobin is less than normal, arrangement should be made to restore it before birth by transfusion with 1pint of blood.
Autologous blood donation has also been advocated mainly for patients who has been identified to be at risk of postpartum haemorrhage.

B.DURING LABOUR

i.First and second stage
During labour, good pratices should be applied in the first and second stage of labour to prevent prolonged labour (by the use of partogragh) and ketoacidosis. A woman should not go into second stage with full bladder. Intramuscular or intravenous administration of uterotonic as prophylaxis is recommended.
After the delivery of the baby,the uterus is massaged in a circular or back-and-forth motion for contractions until the myometrium becomes firm and well contracted. Remember that excessive massage of the uterus will also cause PPH by interferring with normal contraction of the myometrium.

ii.Third stage of labour
The placenta is usually delivered 5mins after the delivery of the baby. Do not be in a hurry to force it out because it is of no benefit and may succeed in causing more harm.Before delivering the placenta, make sure that the signs of placenta seperation(gush of blood from the vagina,lenghtening of the cord, uterus becomes firm and rises in the abdomen)are there.
The placenta can be delivered by a gentle traction on the umblical cord ie using controlled cord traction (CCT) or by using Brandt-Andrews manoeuver ie applying a gentle steady traction on the cord combined with an upward pressure on the lower uterine segment. Placenta is thoroughly inspected to check for completeness.
Adherent membrane can be removed by manual removal or by using a gloved hand wrapped with sterile gauze to sweep the myometrium.
If the bleeding continues, suture the episiotomy if there is any and check clotting time give inj VIT K 1 ampoule stat if clotting time is more than normal ie over 8seconds.

MANAGEMENT OF A PATIENT WITH POSTPARTUM HAEMORRHAGE WHO DELIVERED IN A PRIMARY HEALTH CENTRE.

PRE-HOSPITAL CARE
After the delivery of a baby, there are two patients to observe ie the mother and baby. These two should be observed closely using the ABC of acute life support ie airway,breathing and circulation.

Midwife’s responsibility:-
It is an emergency condition therefore it requires immediate and prompt attension.
*reassure the woman and her support person.
*check the patient’s vital signs.
*do a general examination using ABC.
*do perineal examination to check for source of bleeding.
*rub up uterine contraction ie rubbing the fundus to increase contractions and reduce bleeding.
*encourage the woman to empty her bladder.
*keep all pads and linen so as to assess the volume of blood loss.
*set up an IV infusion with crystalloids + oxytocin.
*pack any visible tear with sterile gauze.
*transfer the patient to the hospital where there are facilities for emergency care.

EMERGENCY DEPARTMENT CARE
*start resuscitation measure with taking of history, physical examination
according to acute life support algorithm.
*do ABC emergency care ie primary survey:-
-place patient in a recumbent position(patient will lie on her back with her head
turned to one side and with one pillow under her head)
-monitor her vital signs.
-set up IV infusions ie 1L 0.9% normal saline + 40iu oxytocin.
-laboratory investigations
*secondary survey:-
Address the 4T’s plus 1
i.Tone :-if the cause of the bleeding is atonic uterine contraction, do
-uterine massage
-empty the bladder with a sterile urinary catheter.
-remove blood clots from the uterus
-reduce excessive uterine manipulation especially the fundus.
-give uterotonics eg oxytocin [(bolus(im or iv)or added in a crystalloid )], ergometrine ( 0.5mg if BP is not high) or misoprostol (400mcg sublingually or 800mcg rectally)
-if bleeding continues do bimanual compression for 20-30mins

ii.Trauma:-
-repair episiotomy or lacerations of the vagina or cervix.
-pack uterine cavity with sterile gauze.
-put blakemore(barkri) balloon in the uterus and fill it with normal
saline to act as tamponade.
-disrupt any haematoma
-resuscitate patient if bleeding has stopped.

If the cause of bleeding is uterine rupture:
-do pelvic ultrasound to look for intra abdominal fluid.
-give broad spectrum antiboitics.
-plan for emergency laparatomy.

iii.Tissue:-
If there is breakage of cord, invite the doctor on call to:
manual removal of the placenta but if the placenta has separated it can
be removed by little maternal effort.
If the placenta is adherent;
-do manual removal of the placenta or wrap a sterile gauze around
one hand and sweep the inner wall and gently remove adherent
placenta.
-if bleeding continues, do manual exploration of the uterus.This will
help to find out if there is uterine rupture or abnormality.
If it is retained placenta( ie placenta stays 1hr following child birth)
-seperate the placenta from the uterine wall digitally.
-curretage can be done using BANJO CURRETE when manual
exploration has failed to control the bleeding.
-if it is accreta, laparatomy is done.

iv.Traction:-
If uterine inversion occurs, push the uterus in position with the hand.

v.Thrombosis:-
-evaluate the clotting time.
-if hb drops *for anaemia –transfuse with blood.
*for thrombocytopenia –transfuse packed cell of platelets.

DETAILS OF WHAT TO DO BEFORE PROPER INTERVENTION

HISTORY TAKING:-
When the patient arrives the hospital ,she will be attended to by the midwife in the ward who will inform the obstetrician on duty about the patient. For adequate intervention to be given, quality history and examination should be taken as thus:
A. collect initial vital signs ,this helps to find out the state of the patient on arrival that will help in managing potential circulatory collapse.
* identify cause of PPH.
*ask about severity of bleeding, initial post delivery bleeding and how long the
bleeding has lasted and how heavy it is.
*find out duration of 3rd stage, has placenta been delivered (whether complete or incomplete.
*find out if there is any feeling of dizziness, lightheadedness, palpitations or fainting attack.
B. Enquire of any intervention she has received.
-any history of transfusion, reason and if there is any transfusion reaction.
-take past medical history especially pulmonary, hematologic and cardiovascular history.
-any history of allergies.
C. Ask question about predisposing factors and even potential causes.
-history of PPH.
-parity, gestational age of pregnancy, history of twinning.
D. Any complications:-
-pueperal sepsis.
-postpartum haemorrhage.
-abnormalities of placenta eg praevia /abruption
*ask how placenta was delivered.
*history of vaginal delivery and caeserean section( if emergency or elective).
*other uterine surgeries eg uterine septum removal,myomectomy.
*family history of blood defect or bleeding disorder.
*if patient is on any medication especially platelet inhibitors,anticoagulants,uterine relaxants and antihypertensives.
*where and when delivery was conducted ,who did it.

PHYSICAL EXAMINATION
Postpartum haemorrhage is managed as an emergency and it is important to focus on the cause of the bleeding.There may not be haemodynamic changes
observed immediately due to physiologic maternal hypervolaemia. Examination should centre on some areas of the body. Check if there are:-
*pulmonary oedema.
*heart murmur ,tachycardia.
*check the volume /strenght of the pulse.
*assess mental status.
*check skin for bleeding from infusion sites.This indicates coagulopathy
*take note of the temperature of the skin.
*check for any abdominal,vaginal, uterine haematoma because there may be an internal bleeding which is not seen outside.
Do abdominal palpation. To check:
*for pains
*tenderness.
*height of fundus
*check bladder(if empty or full), it may inhibit uterine contractions.
Perineal examination.
*rule out vaginal/cervical lacerations by using speculum
*check for trickling of blood at the vaginal orifice.
*check out for height of fundus and look for haematoma by doing bimanual
examination.
*check if cervical os is closed or open.
Examine placenta to check for:
*completeness of placenta to rule out detatched/missing lobe or membrane.

LABORATORY INVESTIGATIONS
These are some of the investigations that will help in the management of this patient. They include:-
A. complete/full blood count.
*check haemoglobin level and haematocrit.
*do white blood cell count( if it is elevated)
*look for thrombocytopenia.
B. coagulation lab studies
*check raised prothrombin time.
C. check eletrolyte balance.
D. check biliribin level,urea and creatinin –this can identify renal failure
E. grouping and crossmatching.
F. check fibrinogen level
G. do liver funtion test.
H. Imaging studies
*ultrasonography.
*computed tomography.
*magnetic resonance imaging.

PROGNOSIS OF POSTPARTUM HAEMORRHAGE
The prognosis of postpartum haemorrhage depends on:
-cause of bleeding.
-duration of PPH.
-amount of blood loss
-co-morbid conditions.
-effectiveness of treatment

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