Beruflich Dokumente
Kultur Dokumente
HEMORRHAGE
Definition :
UTERINE
TENDERNESS
*tense woody-hard CONTRACTIONS
abdomen more frequents
*difficult to appreciate
fetal movement
FETAL HEART
ABSENT
fetal death is likely
INVESTIGATION
1. FULL BLOOD COUNT
. Determine current hemoydnamic status , to anticipate bleeding
during emergency caesarean section
3. ULTRASONOGRAPHY
. Shows retroplacental clot but not all are detectable . +ve in
only 25% cases .
. Types of abruption : concealed or revealed
. Exclude other causes of antepartum hemorrhage
INITIAL MANAGEMENT
CAESAREAN SECTION
resuscitation Patient in
labour Not in labour
+
Pregnancy <37
ARM ARM
Pt improve
No fetal No fetal
distress Continue until
distress term
Normal Normal
delivery delivery
Does not
Fetal distress Fetal distress improve
LSCS LSCS Proceed with
delivery
INDETERMINATE APH
* diagnosis of exclusion
Postpartum
Haemorrhage
Definition
1. Loss of blood of 500ml or more during
vaginal delivery
2. Loss of blood of 1000ml or more during
caeserean section
3. Blood loss significant enough to cause
haemodynamic instability
. Primary PPH : within 24hours of delivery
. Secondary PPH : from 24 hours to
12weeks after delivery
In Practice (Vaginal
delivery), we consider:
500-1000ML (MINOR)
>1000 ML (MAJOR)
should trigger emergency
PPH protocols
However, estimation of
blood loss is notoriously
inaccurate, thus if a woman
demonstrates evidence of
CVS compromise or
continued bleeding,
protocols should be
instituted even if EBL are
<1000ml.
Pathogenesis
In late pregnancy uterine artery
blood flow is 500 to 700mL/minand
accounts for about 15 percent of
cardiac output.
Hemostasis is mediated by two
mechanism:
1. Contraction of the myometrium,
which compresses the blood vessels
supplying the placental bed and
causes mechanical hemostasis.
2. Local decidual hemostatic factors
(tissue factor , type-1 plasminogen
activator inhibitor, systemic
coagulation factors [eg, platelets,
circulating clotting factors]), which
cause clotting.
RISK FACTORS (MATERNAL)
Pre-existing : Intrapartum :
Raised maternal age Prolonged labour
Primiparity Operative delivery
Grandmultiparity Instrumental delivery
Uterine Fibroids Pyrexia in Labour
Previous CS Chorioamnionitis
Bleeding Augmented/induced
Obesity Labour
APH Precipitated (rapid)
Previous PPH Labour
Placenta praevia Episiotomy
Abruptio placenta Internal podalic version
PIH
RISK FACTORS (FETAL)
Large baby (macrosomia)
Multiple Pregnancy
Polyhydramnios
Shoulder dystocia - Obstructed labour whereby
after the delivery of the head, the anterior
shoulder of the infant cannot pass below, or
requires significant manipulation to pass below,
the pubic symphysis. Maternal complications of
shoulder dystocia include post-partum
hemorrhage, vaginal lacerations, anal tears, and
uterine rupture.
CAUSES
4Ts
1. TONE
2. TISSUE
3. TRAUMA
4. THROMBIN
PRIMARY PPH
TONE : UTERINE ATONY
UTERINE ATONY-DIAGNOSIS
Feel abdomen for poorly contracting
uterus.
Presenting signs:
Excessive vaginal bleeding
A large, soft, relaxed uterus
Examine placenta-complete?
Provide AMTSL.
Do not use fundal pressure (apply pressure
on a woman's abdomen to help expel the
placenta) to assist the delivery of the
placenta.
Do not perform controlled cord traction
without administering a uterotonic drug.
Do not perform controlled cord traction
without providing countertraction to
support the uterus.
Prevention strategies
after placenta delivery
Routinely inspect the vulva, vagina, perineum, and
anus to identify genital lacerations. Inspect the
placenta and membranes.
Massage the uterus at regular intervals after placental
delivery to keep the uterus well contracted and firm (at
least every 15 minutes for the first two hours after
birth).
Teach the woman to massage her own uterus to keep it
firm. Instruct her on how to check her uterus and to call
for assistance if her uterus is soft or if she experiences
increased vaginal bleeding.
Encourage the woman to keep her bladder empty
during the immediate postpartum period.
SECONDARY PPH
SECONDARY PPH-CAUSES
RARE CAUSE OF MASSIVE BLEEDING
USUALLY DUE TO:
1. RETAINED PRODUCTS OF
CONCEPTION
2. UTERINE INFECTION
3. INHERITED COAGULATION DEFECT
. Clinical signs:
. delayed uterine involution
. Signs of infection : febrile, tachycardia
SECONDARY PPH-
DIAGNOSIS
SECONDARY PPH-
MANAGEMENT
PPH-PROGNOSIS