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Topics: Childbirth, Obstetrics, Blood Pages: 47 (1047 words) Published: December 22, 2014
Postpartum Hemorrhage
Jorge Garcia, MD
December, 2001

Outline






Case History
Definition
Rapid diagnosis
Treatment
Review risks

Case History.













Healthy 32 yo G2P1+0.
Previous C/S 2 years back
Augmented vaginal delivery with vacuum extraction, with episiotomy On admission uterus will contracted. Lochia normal
Second day Patient complaining of continues sever pain prescribed as pressure on the rectum side which was not relieved by analgesia. Lochia was minimal, episiotomy site is clear.
Glycerin Suppository inserted
Patient called she started bleeding per vagina.
Upon fundal palpation; Atony in left lateral position
Speculum used to examine vagina, bleeding increase. Clots noted Tachycardiac, BP maintained. Syntocine 40 units plus Methergine injection given.
Patient fainted, crush call announced. IV fluids started sent to OT for laboratory

Postpartum Hemorrhage Definition






Mean blood loss with vaginal delivery:
500cc
> 1000cc is “hemorrhage”
Mean blood loss with C/S: 1000cc
>1500cc is “hemorrhage”
Seen in ~5% of deliveries.

Early vs. Late
Most authors define early as < 72h.
 ALSO defines it as 




Most patients with hemorrhage have none.
Pre-eclampsia (RR 5.0)
Previous postpartum hemorrhage (RR 3.6)
Multiple gestation (RR 3.3)
Previous C/S (RR 1.7)
Multiparity (RR1.5)

Intrapartum Risk Factors








Prolonged 3rd stage (>30 min) (RR7.5)
medio-lateral episiotomy (RR4.7)
midline episiotomy ( RR1.6)
Arrest of descent (RR 2.9)
Lacerations (RR 2.0)
Augmented labor ( RR1.7)
Forceps delivery (RR 1.7)

Easy to miss
Physicians underestimate blood loss by
50%
 Slow steady bleeding can be fatal
 Most deaths from hemorrhage seen after 5h
 Abdominal or pelvic bleeding can be
hidden


Always look for signs of bleeding








Estimate blood loss accurately.
Evaluate all bleeding, including slow bleeds.
Vital sign Changes (Tachycardia, hypotension,
breathing difficulty)
Abdominal Signs ( pain, flabby uterus, higher
fundal height, distended abdomen)
Pale, weakness, anxiety
Lochia
HB

Initial Assessment







Identify possible post partum hemorrhage.
Simultaneous evaluation and treatment.
Remember ABCs.
Use O2 4L/min.
If bleeding does not readily resolve, call for
help.
Start two 16g or 18g IVs.

ALSO’s 4 Ts
Tone (Uterine tone)
 Tissue (Retained tissue--placenta)
 Trauma (Lacerations and uterine rupture)
 Thrombin (Bleeding disorders)


“Tone: Think of Uterine Atony”
Uterine atony causes 70% of hemorrhage
 Assess and treat with uterine massage
 Use medication early
 Consider prophylactic medication...


Bimanual Uterine Exam
Confirms diagnosis of uterine atony.
 Massage is often adequate for stimulating
uterine involution.


Medications for Uterine Atony


1. Oxytocin promotes rhythmic

contractions.
 Give IM or IU, not IV. (Can cause  BP)
 40U/L at 250cc/h.

2. Methergine 0.2mg (1 amp) IM
 3. Hemabate 0.25mg IM q 15min (max


X8).

Medications: Methergine
Causes tetanic uterine contraction.
 May trap placenta.
 Can cause Hypertension, especially IV.
 Contraindicated in hypertensive patients
and those with pre-eclampsia.


Prostaglandin F2 15-methyl







Hemabate 0.25mg IM or IU.
Used to be called Prostin.
Controls hemorrhage in 86% when used
alone, and 95% in combination with above.
Can repeat up to eight times.
Contraindicated in active systemic diseases.
Can cause nausea/vomiting/diarrhea,  BP.

Rectocele

Results from a tear in the rectovaginal septum (which is normally a tough, fibrous, sheet-like divider between the rectum and vagina). Rectal tissue bulges through this tear and into the vagina as a hernia....
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