07/10/2025
Nurses ⚕️💉💊🏥 home 👩⚕️👨⚕️🤱
BY NTS MUTALE FREDRICK CHILESHE
COURSE IRH
POSTPARTUM HAEMORRHA
QUESTIONS PPH
A.Define primary postpartum haemorrhage. 5%
B. i) Outline five (5) causes of postpartum haemorrhage. 20% ii) List five (5) signs and symptoms that Mrs. MWEENE will
present with. 5%
C. Describe in detail the management you will give to Mrs MWEENE under the following headings
I. Immediate management 25%
II. Subsequent management 25%
D. Explain five (5) complications that Mrs. Mweene is likely to develop. 20%
ANSWERS
DEFINITION
A. Define primary postpartum haemorrhage (5%)
👩⚕️Primary postpartum haemorrhage is severe/ excessive bleeding from the ge***al tract within the first 24 hours after delivery of the baby with blood loss of more than 500 mls following va**nal delivery and more than 1000 mls following caesarean section.
B.CAUSES OF PPH
i) Outline five (5) causes of postpartum haemorrhage. (20%)
1. VAGINAL TEARS /LACERATIONS
⚕️These may be related to trauma to the birth canal during delivery which can lead to excessive bleeding
2 UTERINE ATONY
📖The myometrium fail to contract and retract and to compress the torn blood vessels and control blood loss by a living ligature action. This may be due to prolonged labour, retained products of conception or a full bladder.
3. RETAINED COTYLEDON, PLACENTAL FRAGMENTS or MEMBRANES:
👩⚕️These will impede efficient uterine action leading to failure of the uterus to contact hence causing bleeding
4. HIGH PARITY
✍️With each successful pregnancy fibrous tissue replaces muscle fibers in the uterus. This reduces its contractility and blood vessels become more difficult to compress. Women who have had five or more deliveries are at increased risk.
5. CLOTTING DISORDER/COAGULOPATHY
⚕️Failure of blood to clot after delivery especially in women with conge***al coagulation problems can lead to continuous bleeding leading to postpartum hemorrhage.
II. SIGNS AND SYMPTOMS OF PPH
List five (5) signs and symptoms that Mrs. Mweene will present with. (5%)
1. Visible bleeding
2. Maternal collapse
3. Pallor
4. Tachycardia/Rising pulse rate
5. Hypotension
6. Altered level of consciousness, that is, the woman may become restless and drowsy.
C. MANAGEMENT OF PPH
I. IMMEDIATE MANAGEMENT
Aims of management
To call for help
To identify the cause of bleeding
To treat the cause of bleeding
To resuscitate the woman
NOTIFICATION
Regardless of whether the patient is at the hospital or clinic, the following are the steps that should be taken, unless the circumstances dictate otherwise; though the sequence may not be rigid but determined by the patient’s presentation.
✍️ CALL FOR HELP
📌Shout for help to organize human resource.
📌Immediately you notice that the woman is bleeding profusely, Call for help by shouting “PPH PPH”.
📌Be calm and work skilfully
📌Care is effectively instituted by a team of medical and none-medical staff (emergency team) comprising;
📌The midwife caring for the woman, other midwives, obstetrician, anaesthetist and pottering staff.
📌This team should be summoned immediately excessive PV bleeding is observed.
📌Place her in bed for comfort and to facilitate further assessment and care provision.
PSYCHOLOGICAL CARE
📌Meanwhile, ensure the mother is kept informed of the events and provided an opportunity to verbalize.
📌Reassure her and explain the need for support from other members of staff.
📌This is important to allay anxiety and ensure she cooperates with you.
QUICK ASSESSMENT
📌Make a quick assessment of the general condition of the patient;
level of consciousness
📌Air way-any signs of obstruction
📌Breathing- Respiratory rate and pattern, cyanosis
📌Circulation- Blood pressure, pulse, temperature
RESUSCITATION
Air way
📌Ensure the patient is breathing well but if signs of obstruction, ensure that the air way is clear and patient well positioned.
Breathing
📌If the patient has challenged breath; hungry for air or cyanosed;
Provide oxygen by mask
📌Open window to ensure good air circulation
📌Position
Circulation
📌Put up an IV line of normal saline/R/lactate on one hand and one for oxytocin on the other hand
📌IV lines should be commenced when veins are still easy to access.
📌This provides access port for oxytocic drugs and fluid
QUICK SUPPORTIVE CARE
Done during resuscitation
📌At the same time, collect blood samples for Hb, grouping and cross match.
📌Ensure the laboratory keeps units of ready blood in case of need for transfusion
📌Keep IV access for drugs and blood transfusion
📌Whole fresh blood may be transfused if the Hb is less than 10g/dl or severe bleeding.
📌The following may also be given depending on the condition of the patient and availability;
Fresh frozen plasma
Colloid solution i.e hemaccel)
Fibrinogen
📌Elevate the legs of the patient to allow enough blood flow to the vital centres in the brain.
📌Do not lift the foot end of the bed as this will lead to pooling of blood in the uterus there by preventing its contraction.
📌If patient is in shock apply Non pneumatic anti shock garment
STOP THE BLEEDING
⚕️This is done Simultaneously with resuscitation, ensure measures to attend to the identified cause of bleeding are immediately instituted as follows;
Bleeding is stopped/ arrested according to the cause...
1. UTERINE ATONY
✍️If bleeding is due to uterine atony
✍️Check the bladder and if full, empty it by catheterization to aid uterine contraction.
✍️Rub up a contraction: Feel the uterine fundus for contraction and if not contracted, massage it with smooth circular motions without applying undue pressure.
✍️Give oxytocin 10 International Units (IU) Intra-muscular (IM)
✍️Ensure that the uterus is emptied i.e. examine the placenta for completeness
✍️The baby may be put to the breast to enhance the physiological secretion of oxytocin from the posterior lobe of pituitary gland.
✍️This will help contract the uterus.
✍️If bleeding is not controlled within 5 minutes, give oxytocin 20 units in 1 litre of a normal saline IV at a rate of 60 drops per minute.
🤞Follow this up with another 20IU to run at 40 drops/min.
BIMANUAL COMPRESSION
📌If bleeding is not controlled and retained placenta is ruled out, bimanual compression is performed as follows:
📌Place the patient in dorsal
📌Ensure asepsis and use sterile gloves
📌Remove clots from lower part of uterus & cervix
📌Con fingers of the right hand, slip them into the va**na and them make a fist
📌Place the fist into the anterior fornix and apply pressure on the anterior wall of the uterus
📌Place the left hand on the abdomen with fingers directed downwards, behind the fundus.
📌Press the upper portion of the uterus forward onto the fist there by compressing the placenta site.
📌Maintain compression until bleeding is controlled and the uterus contracts
NOTE:
📌That Drugs and uterine compression may be combined.
📌If all fails in the absence of retained products and trauma, a decision may be made to perform hysterectomy in theatre.
📌The patient needs to be moved quickly to a facility where advanced procedures can be performed.
📌Compression may be maintained during transfer.
EXTERNAL AORTIC COMPRESSION
📌It is a temporal measure until appropriate care is available
📌Apply downward pressure with a closed fist over the abdominal aorta directly through the abdominal wall
📌Point of compression is just above the umbilicus slightly to the left
📌With the other hand palpate the femoral pulse
📌If femoral pulse is not palpable, pressure exerted is adequate
📌Maintain pressure until bleeding is controlled or alternative measure can be taken
UTERINE BALLOON (CONDOM) TAMPONADE
📌Indicated for women not responding to uterotonics and uterine massage
📌Provide temporary control or reduction of postpartum uterine bleeding when conservative management is being warranted.
📌Application of UBTs should be concomitant with close monitoring for signs of arterial bleeding and/or (DIC).
Procedure
📌Catheterise patient
📌Secure a balloon catheter or use a condom attached to the catheter
📌Give emotional support
📌Observe infection prevention techniques
📌Insert speculum and grasp the anterior lip of cervix with sponge forcep
📌Insert catheter with balloon or condom(deflated)
📌Inflate catheter beyond internal cervical os with 300-500mls of warm saline until balloon is visible in the cervix
📌Observe bleeding if not present then tamponade test is positive. If bleeding continues surgical intervention
📌Pack va**na to prevent expulsion
📌Palpate uterine fundus and mark with pen to note any uterine distension
📌Give 20IU oxytocin IV in normal saline at 60 drops/min
📌Single dose of antibiotics ampicillin 2g
📌Continue monitoring-bleeding and fundal height.
📌After 6-24hrs if no bleeding and fundal height still the same, deflate balloon by removing saline 50-100ml every hour
(you connected with nurses home)
2. TRAUMA
📌If bleeding is due to trauma
📌Repair of tears and lacerations
📌Inspect the perineum, v***a and va**na for lacerations.
📌Suture any tears if present
📌Tears of the cervix should be done by an experienced midwife of obstetrician
📌If bleeding is due to uterine tears, repair should be done in theatre with urgency.
📌Hysterectomy may be performed in severe cases.
3. RETAINED PRODUCTS OF CONCEPTION
📌If bleeding is due to retained membranes or cotyledons
📌If there are any retained membrane or cotyledons, expel them by applying firm but gentle pressure on the uterine fundus and then stimulate a contraction of the uterus by massaging.
📌Or manually remove them
📌If not curette or manual vacuum aspiration
📌If bleeding is due to retained placenta
📌If bleeding is due to retained placenta and membrane, follow these steps to remove it;
📌Explain to the patient that the placenta will need to be removed manually and that the procedure will be uncomfortable but necessary.
📌Give antibiotic single dose Ampicillicin 2g IV
📌Give pethidine 100mg and diazepam 10mg IV or ketamin
📌Ensure the bladder is empty
MANUAL REMOVAL OF THE PLACENTA
📌Put on sterile gloves
📌Hold cord with a clamp until parallel to the floor
📌Insert the other hand into the va**na up into uterus following the cord to locate the placenta
📌Locate the lateral edges to identify line of cleavage
📌Provide counter traction to fundus to prevent inversion
📌Detach the placenta by keeping fingers tight together and using the edge of the hand until the whole placenta is detached
📌Palpate area for any placental tissue
📌Withdraw hand with placenta in the palms
📌Continue with counter traction
📌N.B if placenta is very adherent suspect placenta accreta
📌The Give oxytocin 20 IU IV infusion of saline
📌Massage uterus
📌Examine placenta for completeness
📌Examine ge***al tract for tears
📌Monitor vital signs 1/4hrly for 2hrs, 1/2hrly for 6hrs.
4. COAGULATION FAILURE
Bleeding may be due to coagulation failure
📌Transfuse using ;
📌frozen plasma
📌Platelet
📌or Fresh whole blood
END/
II. SUBSEQUENT MANAGEMENT
AIMS
✍️To improve the Hb levels
✍️To prevent infection
✍️To promote good lactation
The following care, in addition to the standard postpartum care, should be provided:
ENVIRONMENT
📌Keep the mother in the labour ward or resuscitation site for at least an hour for close observation.
📌Nurse her in the postnatal ward, quiet and well ventilated room, clean to prevent infection as her immunity may be lowered.
📌She should be close enough to the nurses’ area for easy monitoring and observation.
POSITION
📌When stable, she can take any position comfortable.
📌Sitting position may aid in the drainage of the lochia hence it enhances involution of the uterus.
PSYCHOLOGICAL CARE
📌Explain to the patient the cause of bleeding, what has been done or is still being done to help her and possible out come of her condition.
📌Encourage her to ask questions and give appropriate responses.
📌Allow her spouse to visit and participate in the provision of care.
📌Explain to the spouse what ever relates to the condition and measures being instituted.
📌Bring the baby for her to see and if she is able, allow her to handle the baby and possibly to breast feed.
📌She may be allowed to stay with her baby with assistance.
OBSERVATIONS
📌Observe the general condition to assess;
📌 improvement or deterioration.
📌Check temperature 4 hourly to rule out hypothermia which could be due to blood loss or hyperthermia due to infection.
📌Check pulse and BP ¼, ½ and as she stabilises, 4 hourly to rule out shock or assess bleeding.
📌Assess the amount of PV bleeding. Check the v***a, pads for blood loss. As the mother to report excessive bleeding
📌Palpate the uterus for contraction. Ensure it is well contracted.
📌Check the bladder and ensure it is emptied regularly.
📌Check the eyes, lips and palms for pallor
📌Observe the mental status of the woman. Rule out anxiety, depression, disorientation.
📌Observe her reaction towards her baby.
📌Observe urine output to rule out oliguria or anuria which could be indicative of renal failure
NUTRITION
📌When the condition is stable the woman may be allowed to take food rich in protein, vitamins and iron to help replenish the lost blood.
📌Encourage enough roughage (vegetable) and fluids to prevent constipation hence help reduce discomfort and pain during defecation.
📌Meals should be small and frequent to ensure tolerance
INFECTION PREVENTION/HYGIENE
📌Encourage frequent change of pants and pads to prevent infection and bad odour.
📌Assisted bath or shower is encouraged
📌Encourage hand washing after changing pads and pants, after toilet, before handling the baby.
📌Regular change of soiled linen to prevent infection and discomfort
📌Sitz baths at least three times daily using previously boiled cool water if the woman has perineal lacerations or tears to aid quick healing.
📌Dump dust the room, lockers and other surfaces in the room with jik 1;6 to prevent infections.
ELIMINATION
📌Encourage her to empty the bladder regularly to aid in the involution of the uterus.
📌A full bladder may hinder effective uterine contraction.
📌If the patient is not able to pass urine you should catheterize to empty the bladder.
📌Encourage bowel opening whenever she feels the urge to prevent constipation and discomfort.
📌If the patient is not ambulant provide a bed pan.
📌Encourage adequate fluid intake and high roughage diet to prevent constipation.
EXERCISE
📌In the initial or critical phase provide passive exercises of the limbs to prevent deep vein thrombosis.
📌Encourage deep breathing exercises to prevent hypostatic pneumonia.
📌Later, encourage the patient out of bed or to be ambulant to aid in drainage of the uterus and hence, aid in the involution of the uterus.
MEDICATION
📌The patient should be commenced on prophylactic antibiotics if she was exposed to invasive procedure such as manual removal of the placenta.
📌X-pen and Gentamycin IV/IM OR
📌Amoxyl, Flagyl if she is able to take orally
Analgesics.
D. COMPLICATIONS OF PPH
1. RENAL FAILURE
📌Renal failure due to reduced supply of blood to the kidneys
2. SHOCK
📌Shock can be due to excessive blood loss that causes circulatory failure
3. ANAEMIA
📌Due to excessive bleeding that reduces the oxygen carrying capacity (haemoglobin) levels
4. DISSEMINATED COAGULATION FAILURE (DIC)
📌Due to abnormal coagulation process leading to depletion of platelets eventually causing uncontrollable bleeding
5. MATERNAL DEATH
📌Due to circulatory failure resulting into damage to the vital organs
THE END
BY NTS MUTALE FREDRICK CHILESHE
KNOWLEDGE IS GREAT SUCCESS & POWER 📚
