Post -Partum Hemorrhage

Subject: Midwifery II (Theory)

Overview

Post-partum hemorrhage is defined as any quantity of bleeding from the vaginal tract following the birth of the baby up to 6 weeks after delivery, which has an adverse effect on the patient's general state as demonstrated by an increase in pulse rate and a fall in blood pressure. It is arbitrary and is associated with blood loss in excess of 500 ml following the birth of the infant. It is beneficial for statistical purposes. Primary PPH and Secondary PPH are the two types of PPH. The four Ts of PPH are Tone, Trauma, Tissue, and Thrombin. Inversion implies "turning inside out." Uterine inversion occurs when the uterus is partially or totally turned inside out.

Post-partum hemorrhage is defined as any quantity of bleeding from the vaginal tract following the birth of the baby up to 6 weeks after delivery that has an adverse effect on the patient's general condition as demonstrated by an increase in pulse rate and a decrease in blood pressure.

It is arbitrary and is related to blood loss in excess of 500 ml following the baby's birth. It is beneficial for statistical purposes. However, the consequence of blood loss is more important than the amount of blood loss, hence more than 300ml of blood loss in an anemic patient is referred to as PPH.

Types

  • Primary PPH
  • Secondary PPH

Causes

PPH causes are frequently referred to as "four T4".

  • Tone: Uterine atony is the inability of the uterus to contract, which can result in continuous bleeding. Retained placental tissue and infection may both play a role in uterine atony.
  • Trauma: The delivery trauma may tear tissue and arteries, resulting in severe post-partum bleeding.
  • Tissue: Retention of placental or fetal tissue may result in bleeding.
  • Thrombin: A bleeding disorder arises when there is a clotting failure, such as with coagulopathies.

Management

  • Stage 0: Normal 3rd stage management – treated with fundal massage and oxytocin
  • Stage 1: More than normal bleeding – set up large-bore intravenous access, gather personnel, boost oxytocin, consider methergine, do fundal massage, and prepare 2 units of packed red cells.
  • Stage 2: Check coagulation status, gather response team, proceed to operating room, place intrauterine balloon, administer additional uterotonics (misoprostol, carboprost tromethamine), consider uterine artery embolization, dilatation, and curettage, laparotomy with uterine compression stitches, or hysterectomy.
  • Stage 3: Bleeding persists – initiate a major transfusion regimen, mobilize extra personnel, reassess laboratory tests, conduct a laparotomy, and consider a hysterectomy.

Uterine Inversion

Inversion means to turn inside out. Uterine inversion is a condition in which the uterus is partially or entirely turned inside out. It is a very unusual and dangerous third-stage labor complication.

Classification of Inversion

  • First degree: The fundus is dimpling, although it is still above the level of the internal os.
  • Second degree: The fundus travels through the cervix but is contained within the vagina.
  • Third degree: Outside the vulva, the endometrium, with or without the associated placenta, is visible. This process may also involve the cervix and a portion of the vagina.

Causes

  • Spontaneous
  • Short cord
  • Placenta accrete
  • Induced
  • CCT with fundal pressure
  • Fundal pressure with the uterus is a tonic
  • Sudden emptying of the distended uterus
  • Pathologically adherent placenta etc

Sign and Symptoms

  • The shock that occurs suddenly as a result of extreme pain
  • Anemia can range from mild to severe.
  • In an acute inversion, extreme shock out of proportion to blood loss
  • Chronic inversion symptoms include prolonged vaginal bleeding, pelvic pain, something coming from the vagina, and difficulties with micturition.

Management

  • Review standard infection prevention precautions and begin an IV I/V infusion.
  • Compress the inverted uterus with a moist, warm sterile towel until the surgery is ready.
  • Wearing sterile gloves, hold the inverted uterus and push it through the cervix in the direction of the umbilicus, stabilizing the uterus with the other hand. If the placenta remains attached after repair, manually remove it.
  • Following replacement, the hand should remain inside the uterus until the uterus is constricted by parenteral oxytocin.
  • Only after the uterus has constricted should the placenta be physically removed.
  • Hemorrhages cannot be controlled if the uterus is inverted; an inverted uterus cannot contract or retract.
  • If a totally inverted uterus cannot be placed, hydrostatic correction is used. Manage any shock that occurs (see in obstetrical emergencies)
  • Hydrostatic adjustment
  • Put the ladies in a deep Trendelenburg position (lower head about 0.5m below the level of the perineum)
  • Set up the high-level disinfected or sterile douche system, which should have a large nozzle, lung tubing (3m), and a warm water reservoir (3-5liters).
  • Determine the posterior fornix. When the inverted uterus is still in the vagina, this is a simple procedure. In other circumstances, the posterior fornix is identified by the transition of the rugose vagina to the smooth vagina.
  • Insert the douche nozzle into the posterior fornix.
  • At the same time, using the other hand, place the labia scaled over the nozzle and support it with the forearm.
  • As a helper, request that the douche be started with maximum force. Water progressively dilates the posterior fornix of the vagina, causing it to extend. This increases the circumference of the opening, relieves cervical tightness, and corrects the inversion.

 

References

  • emedicine.medscape.com/article/1916662-treatment
  • https://www.ncbi.nlm.nih.gov › NCBI › Literature › PubMed Central (PMC)
  • Pathak, Sumita and Sochana Sapkota. A Textbook of Leadership and Management. Bhotahity, Kathmandu: Vidyarthi Pustak Bhandar, 2014
  • https://www.mayfieldclinic.com/pe-sah.htm
  • https://www.uptodate.com/contents/hemorrhagic-stroke-treatment-beyond-the-basics
  • pedemmorsels.com/post-tonsillectomy-hemorrhage/
Things to remember
  • Post-partum hemorrhage is defined as any quantity of bleeding from the vaginal tract following the birth of the baby up to 6 weeks after delivery that has an adverse effect on the patient's general condition as demonstrated by a rise in pulse rate and a fall in blood pressure.
  • It is arbitrary and is related to blood loss in excess of 500 ml following the baby's birth.
  • It is beneficial for statistical purposes.
  • However, the consequence of blood loss is more important than the amount of blood loss, hence more than 300ml of blood loss in an anemic patient is referred to as PPH.
  • Primary and secondary PPH are the two types of PPH.
  • PPH causes are usually referred to as the "four T4", which are Tone, Trauma, Tissue, and Thrombin.
  • Inversion means to turn inside out. Uterine inversion is a condition in which the uterus is partially or entirely turned inside out.
  • It is a very unusual and dangerous third-stage labor complication.
  • Placenta accrete, CCT with fundal pressure, Fundal pressure with atonic uterus,
  • Sudden emptying of distended uterus, Pathologically adherent placenta, and other causes of uterine inversion Chronic inversion symptoms include prolonged vaginal bleeding, pelvic pain, something coming from the vagina, and difficulties micturition.
Questions and Answers

Any amount of bleeding from the genital tract following the birth of the baby up to 6 weeks after delivery is referred to as post-partum hemorrhage, and it can be identified by a rise in pulse rate and a drop in blood pressure.

Causes of PPH is commonly referred as" four T4"

  • Tone : Uterine atony is the inability of a uterus to a contract may lead to continuous bleeding. Retained placental tissue and infection may contribute to uterine atony.
  • Trauma : Trauma from the delivery may tear tissue and vessels leading to significant post-partum bleeding.
  • Tissue : Retention of tissue from the placenta or fetus may lead to bleeding.
  • Thrombin : A bleeding disorder occurs when there is a failure of clotting such as with diseases known as coagulopathies.

Management

  • Stage 0:  (normal management of 3rd stage) : Treated with fundal massage and oxytocin
  • Stage 1: More than normal bleeding: Establish large-bore intravenous access, assemble personnel , increase oxytocin, consider use of methergine , perform fundal massage, prepare 2 units of packed red cells
  • Stage 2: Bleeding continues: Check coagulation status, assemble response team, move to operating room, place intrauterine balloon, administer additional uterotonics (misoprostol, carboprost tromethamine), consider; uterine artery embolization, dilatation and curettage and laparotomy with uterine compression stitches or hysterectomy
  • Stage 3: Bleeding continues : Active massive transfusion protocol , mobilize additional personnel, recheck laboratory tests , perform laparotomy, consider hysterectomy

 

Inversion literally means to turn inside out. The uterus can be partially or entirely turned inside out, which is known as uterine inversion. It is a serious and extremely uncommon third stage of labor complication.

Classification of Inversion

  • First Degree: There is dimpling of the fundus which still remains above the level of the internal os.
  • Second Degree: The fundus passes through the cervix but lies inside the vagina
  • Third Degree: The endometrium with or without the attached placenta is visible outside the vulva. The cervix and part of the vagina may also be involved in this process.

Sign and Symptoms

  • Sudden shock brought caused by excruciating agony.
  • Moderate to severe anemia is prevalent.
  • Extreme shock out of proportion to acute inversion blood loss.
  • Persistent vaginal bleeding, pelvic pain, something coming out of the vagina, and difficulty urinating are all symptoms of chronic inversion.

Management

  • Start an IV I/V infusion while reviewing general precautions for infection prevention.
  • Until the procedure is ready, apply compression to the uterus inverted with a moist, warm sterile towel.
  • Put on sterile gloves, grasp the inverted uterus, and push it through the cervix toward the umbilicus to return it to its normal anatomic position while stabilizing it with the other hand. After making the necessary corrections, manually remove the placenta if it is still attached.
  • The hand should stay inside the uterus after replacement until parenteral oxytocin causes the uterus to contract.
  • Only once the uterus has become constricted should the placenta be physically removed. Without it, bleeding cannot be stopped because an inverted uterus is unable to retract.
  • Hydrostatic correction is used if it is not feasible to position the uterus entirely inverted. If shock occurs, control it (see in obstetrical emergencies)
  • Hydrostatic adjustment
  • The women should be in a deep Trendelenburg position.
  • Set up the high-level sterile or disinfected douche system with a large nozzle, lung tubing that extends three meters, and a warm water reservoir.
  • The posterior fornix should be noted. When the uterus is partially inverted and still inside the vagina, this is simple to perform. In some instances, the transition from the rugose vagina to the smooth vagina serves as a telltale sign of the posterior fornix.
  • Put the douche's nozzle in your posterior fornix.
  • Hold the labia scaled over the nozzle with the other hand while supporting the nozzle with the forearm at the same time.
  • Request an assistant to turn on the shower's maximum pressure. The posterior fornix of the vagina gradually stretches as a result of water distension. This results in an increase in the orifice's circumference, the release of cervical constriction, and the correction of the inversion.

© 2021 Saralmind. All Rights Reserved.