Management of Post-Partum Haemorrhag - Essay Example

Running head: MANAGEMENT OF POST-PARTUM HAEMORRHAGE (PPH) Management of PPH Place March 12, 2006 The article Management of Post-Partum Haemorrhage starts off defining postpartum haemorrhage followed by a brief description of third stage haemorrhage, primary postpartum haemorrhage and secondary postpartum haemorrhage. The article describes the steps to be taken for management of postpartum haemorrhage. The article concludes with references. Management of Post-Partum Haemorrhage (PPH) According to Dawn Postpartum Haemorrhage (PPH) is the term denoting "excessive haemorrhage from the genital tract at any time after the birth of the baby up to the end of puerperium amounting to a degree affecting the general condition of the patient. Statistically, haemorrhage of more than 500ml is defined as Postpartum Haemorrhage." Post partum haemorrhage can be clinically classified into following three types: 1. Third Stage Haemorrhage: The third stage haemorrhage is due to non-expulsion of placenta. 2. Primary Postpartum Haemorrhage: This type of haemorrhage occurs within 24 hours after third stage haemorrhage. 3. Secondary Postpartum or Puerperal Haemorrhage: This type of haemorrhage takes place after 24 hours during puerperium (2004). According to Jones the placental remains in the uterus and poor retraction of muscle may lead to inefficient constriction of vessels resulting into bleeding. An important point to remember is that an "empty contracted uninjured uterus does not bleed."(1990) According to Bennett and Brown some signs of Postpartum Haemorrhage are as follows: i. Collapse of the patient ii. Bleeding visible iii. Pallor iv. Fall in blood pressure v. Rise in pulse rate vi. Altered level of consciousness: restless or drowsy vii. Enlargement of uterus due to filling of blood or blood clot. Management of postpartum haemorrhage involves the following three basic steps: 1. Call the doctor 2. Try to stop bleeding and 3. Resuscitate the patient. First step would be calling a doctor immediately or summon the emergency obstetric unit on observation of postpartum haemorrhage. Under no circumstances should a collapsed patient be moved without resuscitation. In the second step the midwife should try to stop bleeding by adhering to the following three steps: a. Rubbing up a contraction. b. Administering oxytocic c. Emptying the uterus. A skilled midwife is expected to feel the fundus with finger tips which if found to be soft and relaxed is massaged with a smooth, circular motion applying no undue pressure resulting into contraction. Once the contraction occurs the hand is held still. To sustain the contraction an oxytocic agent such as Syntometrine 1 ml is administered. Intravenously 0.25 to 0.5 mg Ergometrine is also injected as an alternative which is effective in 45 seconds time. Utmost care should be exercised in limiting the dosage of Ergometrine to two, including any dosage of Syntometrine to avoid pulmonary hypertension. A very important point to be noted is that "Physiological secretion of oxytocin from the posterior lobe of the pituitary gland" may be enhanced by putting the baby to the breast of the patient. It is the duty of midwife to ensure that the uterus is emptied or the placenta has to be delivered. Then the clots if any may be expelled by applying firm and gentle pressure on the fundus. In emergency cases the patient's legs should be lifted to allow the blood to drain from them into central circulation, but the foot of the bed should not be raised to avoid the pooling of blood into uterus, thus preventing its contraction. If the bleeding stops with the above measures, 10 ml blood may be collected for haemoglobin estimation and for cross-matching compatible blood. Then 40units of Syntocinon in one litre of dextrose/saline may be infused over a period of 8-12 hours to ensure continued uterine contraction and minimise the risk of recurrence. If the placenta remains undelivered manual removal of placenta may be performed with full aseptic precautions. The midwife is expected to carry out manual placental removal if the doctor is not available and a postpartum haemorrhage is diagnosed (1993). According to Jones manual removal of placenta may be carried out by Crede's method. "A firm uterine contraction is obtained by fundal massage, and at its height the uterus is compressed grimly with the fingers reaching far down behind the fundus and the thumb in front. In some cases this leads to placental separation and descent which can be felt as the uterus appears empty between the fingers. Further descent is helped by fundal pressure during the next uterine contraction or by controlled cord traction." Manual removal may be carried out under mild general anaesthesia. The vulval area is cleaned and well lubricated with chlorhexidine cream. A lubricated gloved hand is introduced into the uterine cavity and the other hand is used for controlling the fundus per abdomen. "If a constriction ring is present it is slowly dilated with the intrauterine fingers shaped into a cone" and if the cord is present then it is followed to the placenta and the placental edge is identified. "The palm of the hand facing the cavity, the placenta is sheared from its attachments by a sawing motion, mainly using the ulnar border of the hand; meanwhile the external hand keeps constant control over the fundus during manipulation." Once the placenta lies freely in the uterine cavity, the cavity is palpated gently to ensure that the entire placenta and membranes are separated. Then the hand is withdrawn grasping the placenta and the external hand simultaneously massaging the uterus to obtain contraction (1990). According to Dawn immediately after removal of the placenta Inj. methergin 0.2 mgm I.V. is administered and repeated after 3-4 hours. Inj. glucose and oxytocin drip and blood are continued, further Inj. cefazolin 1 gm. is administered in drip tube for prophylaxis. Bimanual compression of the uterus is done if the bleeding continues from an empty uterus. If atonic uterine bleeding continues Inj. prostodin 25 g is administered every 15-60 minutes (about 3-4 injections). Hysterectomy is considered as a last resort provided the patient can withstand the operation and massive amounts of blood transfusions are made available (2004). According to studies conducted by Magann et al., placenta not delivered by 18 minutes should be removed immediately to reduce the incidence of postpartum haemorrhage (2005). Postpartum haemorrhages remains a major cause for maternal deaths, hence utmost care should be exercised by the midwife in diagnosing it and remain alert by strictly adhering to the above mentioned steps to minimise bleeding. The medications etc., may be kept handy to face emergency situations. References C.S. Dawn. Textbook of Obstetrics, Neonatology & Reproductive & Child Health Education. (2004). Publisher Dawn Books Publications. Kolkata. India. V.Ruth Bennett and Linda K.Brown. Myles Textbook for Midwives. (1993). Publisher Churchill Livinstone (UK). Derek Llewellyn-Jones. Fundamentals of obstetrics and Gynaecology Vol. I .(1990). Publisher Faber and Faber (UK). Everett F. Magann, Sharon Evans, Suneet P. Chauhan, Grainger Lanneau, Andrea D. Fisk, and John C. Morrison. The Length of the Third Stage of Labor and the Risk of Postpartum Hemorrhage. VOL. 105, NO. 2.(2005). The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. Read More