Primary Postpartum Hemorrhage - Term Paper Example

Postpartum Hemorrhage in Childbirth Introduction Postpartum hemorrhage is a form of obstetric haemorrhage. This is a condition that occurs because of the loss of over 500 ml of blood within a day after birth through the genital tract (Alfirevic, 2008). The condition can be major or minor depending on the volume of blood loss i.e. either loss of less that 500ml or over 1000ml after the birth of a child. In severe cases, patients can lose up to 2000ml of blood hours after the birth. The postpartum hemorrhage is divided into two primary and secondary forms. Primary postpartum hemorrhage is the most common form with secondary postpartum hemorrhage defines a situation is which excessive bleeding from genital tract occurs twelve weeks during the postnatal period. Besides dealing with obstetric hemorrhage, this essay addresses with physiological, pathological and psychosocial care for victims of PPH. The paper also discusses hypovolemic shock. Obstetric hemorrhage is a major cause of maternal death in developing and developed countries (Lombaard & Pattinson, 2009). Physical care for post partum hemorrhage Active caution is the final stages of the labor lowers the changes of blood loss which can end up reducing the cases of PPH. The third stage of labor calls for active use of prophylactic oxytocins (Alfirevic, 2008). This can reduce the risk of PPH by up to 60 percent. The uterus contains unique networks of muscles that interlace. The muscles are known as myometrium. Some of the blood vessels supply placental bed (Ayers et al, 2006). This means that have to cross the uterine muscle latticework. Constriction of the blood vessels is the major force that drives homeostasis and placental separation. The physiological process of the PPH is enhanced by the level of care and active management in the third stage of pregnancy (Lynch et al, 1997). For instance, physiological enhancing of clotting factors at the final stages of labor is helpful in controlling the loss of blood especially when the placenta is separated. Research shows that a blood loss of 500ml during birth is perceived to be a physiological norm. The cases of secondary postpartum hemorrhage are known to be caused by infection or retention of conception products (Ayers et al, 2006). The most common cause is the uterine atony (Alfirevic, 2008). Myometrial contraction in the uterus causes the uterus blood vessels to occlude (Chandraharan & Arulkumaran, 2012). It is imperative to consider the resultant implications of PPH to the patients. A casing point could include hypovolemic shock. Hypovolemic shock Hypovolemic shock refers to a medical condition in which hemorrhage and consequent inadequate perfusion leads to multiple organ failure. A rise is the pulse rate and a subsequent drop is blood pressure is signs of hypovolemia. The symptoms can be accompanied by sweating, cold extremities and poor capillaries refill. Continuous assessment of blood pressure, temperature, respiration and pulse is essential. The woman can show signs of thirst, dizziness and nausea (Alfirevic, 2008). The woman should be placed on a flat surface. Her feet are supposed to be placed slightly higher than the level of her head. The midwife can consider placing hands onto the uterine fundus (Lynch et al, 1997). This should be followed by gentle massages. This physiological response helps in ensuring that the contraction of uterus happens. The process can also express out clots of blood. The bladder should be emptied through catheterization process or the woman can do it (Butterfield et al, 2002). The midwife should check for coagulation disorders, vaginal tears, uterine rapture and inversion (Ayers et al, 2006). The pathophysiological process of dealing with post partum hemorrhage involves placing on hand into the vagina while clenching it to a fist. The other hand should be placed on the uterine fundus (Lombaard & Pattinson, 2009). The midwife is expected to bring both hands together with the aim of squeezing the uterus (Alfirevic, 2008). This can either slow bleeding or stop it. The position should be maintained until medical help is obtained. The other alternative for controlling heavy post partum hemorrhage is to use aortic compression (Chandraharan & Arulkumaran, 2012). This physiological process involves cutting off blood supply to the pelvis through compression. The role of skilled midwives and birth attendant is central to the success of the birth process (Hofmeyr et al, 2008). Intervention in the process of birth reduces death from the condition especially among pregnant women (Butterfield et al, 2002). The midwives are expected to have skills in the process of administration of oxytocin. Controlled cord traction and uterine massage should be carefully administered after the delivery of the placenta (Lynch et al, 1997). Within a minute after the infant delivery, the midwives are expected to palpate the abdomen. This can be used to rule out the presence of additional infants. The oxytocin drug is then administered because of its effectiveness (Lombaard & Pattinson, 2009). Midwives are expected to have proper skills on the administration of misoprostol (Alfirevic, 2008). This prevents primary postpartum hemorrhage. The process should be accompanied by placing one hand over the public bone of the woman giving birth (Hofmeyr et al, 2008). This helps in stabilizing the uterus. Counter-pressure is necessary when controlling cord traction (Gülmezoglu & WHO, 2009). In case of pathological conditions in the process of delivery of the infant or the placenta, the midwives are expected to have the skills necessary to perform the pathophysiological processes that bring stability (Butterfield et al, 2002). The physiological role of the midwives involves keeping relative tension on the cord while awaiting significant uterine contraction for about three minutes (Ayers et al, 2006). During the process of uterine constructions, the midwives are expected to encourage the mother to push (Chandraharan & Arulkumaran, 2012). The process is accompanied by pulling one cord gently downwards. Delivery of the placenta involves application of the counter-pressure to the uterine muscles to ensure that the process manages postpartum hemorrhage (Lynch et al, 1997). In case the placenta fails to descend, the midwives are expected stop pulling one cord. The attendant must wait until the uterine contraction is strong again. The physiological process should be repeated again together with the controlled cord traction (Ruprai et al, 2011). Counter-pressure should also be applied. The counter traction should be applied simultaneously with cord traction (Alfirevic, 2008). The process should be performed above the pubic bone. The physiological process should only be done when the uterus is well contracted (Van der Walt, 2005). The process of placenta delivery should involve gentle pulling with both hands to ensure the twisting of the membranes (Ayers et al, 2006). They are also expected to have the knowledge of using sponge forceps to ensure the pieces of membranes present are removed incase the membranes tears up. The midwives should have the knowledge to ensure they look carefully at the placenta and find out the missing parts (Butterfield et al, 2002). In case of the pathological occurrences like the tearing of the placenta, that can lead to increased postpartum hemorrhage (Hofmeyr et al, 2008). Therefore, the pathophysiological process involved includes taking the appropriate actions to restore normalcy (Alfirevic, 2008). The physiological process of correcting or managing post partum hemorrhage includes massaging the fundus of the uterine war after the removal of placenta (Ayers et al, 2006). This should continue until the uterus is contracted. The uterine massage should be repeated as need arises during the first 2 hours to ensure palpation for a contracted uterus (Van der Walt, 2005). The midwives are supposed to ensure the uterus is not extremely soft by the time the uterine massage stops (Lynch et al, 1997). The role of midwives should be consistent with the pathology and physiological solutions to be offered to PPH victims. Pathophysiology in postpartum hemorrhage The speed of the blood flow through the intervillous space can be estimated to be about 600ml per minute. The blood is carried through veins and spiral arteries (Hofmeyr et al, 2008). The removal of the placenta means that the blood vessels become avulsed. There are chances of fatal postpartum hemorrhage in case of uterine atony. This can occur despite normalcy in coagulation. Vigorous contraction of myometrium adjacent to denuded implantation ensures that fatal hemorrhage remains unlikely (Lombaard & Pattinson, 2009). Physiological management is vital in controlling post partum hemorrhage. The midwives must ensure that birth is conducted in a semi-sitting position (Ayers et al, 2006). The mother is generally expected to have a comfortable sitting position (Alfirevic, 2008). The midwives and birth attendants are expected to place the infant on the chest of the mother. This ensures there is skin contact which is necessary for warmth. The process also ensures that breastfeeding starts as soon as possible (Butterfield et al, 2002). Physiological care involves monitoring to ensure that pathological signs are controlled or responded to in a timely and effective manner (Van der Walt, 2005). The midwives are expected to understand the physiologic signs in the delivery and management of infant and placenta (Chandraharan & Arulkumaran, 2012). This includes visually observing the change is size, position and shape of the uterine muscles. This includes ensuring avoidance of the palpation of the uterus (Lynch et al, 1997). The midwives should also observe a relatively small gush of blood as part of the physiologic process is post partum hemorrhage management. At vaginal introitus, the cord is expected to lengthen. At this point, the birth attendant is likely to observe discomfort and contractions coming from the mother. This can cause the mother to change the sitting position or show signs of vaginal heaviness. The uterine massage is known to decrease post partum hemorrhage and consequently reduce PPH incidents (Ayers et al, 2006). The process also ensures that the need for blood transfusion is decreased. The midwife is expected to take the right sitting position. The birth attendant is expected to wait until the placenta is expelled (Van der Walt, 2005). The process can either be by encouraging contractions in the process of delivering placenta or it can be spontaneous (Lombaard & Pattinson, 2009). The former should only be practiced after signs of separation have been observed (Alfirevic, 2008). The midwives are expected to either hold the placenta using a bowl or two hands and ensure that the membranes are twisted through turning its gently (Ayers et al, 2006). The alternative is easing the membranes from the vagina gently through an up and down movement (Lynch et al, 1997). Research shows that despite the advanced case, there are cases that require treatment. The midwives must give professional care through ensuring pathophysiological checks. The uterus must be firm upon touching and should remain in the navel region (White et al, 2006). This is the essence of massage. Research shows before that post partum hemorrhage can lead to post traumatic stress disorder. Therefore, midwives need skills on the kind of psychological processes for dealing with PPH victims. Psychosocial care after post partum hemorrhage (PTSD) Child birth is a traumatic experience from many women. The rate of prevalence of PTSD can be as high as 6 percent on the upper limit. This means that if the condition is left untreated, it can lead to the psychological health of a woman. The midwives have a critical role to play in ensuring the psychosocial care is delivered after post partum hemorrhage experience (Hofmeyr et al, 2008). Women are particularly sensitive to the comments by the midwives and birth attends. Post traumatic stress disorder (PTSD) after child birth causes mothers to feel increasingly isolated and detached (WHO, 2007). The symptoms for the condition include fear of child birth and lose of interest in sex. Some of the mothers have problems bonding with the babies after extreme post partum experiences (Ayers et al, 2006). Mothers suffering from PTSD experience flashbacks and nightmares (Chandraharan & Arulkumaran, 2012). The flashbacks and nightmares affect their relationships with both the husband and the children (Hofmeyr et al, 2008). Women who suffer from post partum hemorrhage tend to become numb and shadows of their former selves. The midwives are expected to offer increased obstetric interventions to ensure that mothers stop being hypersensitive to stimuli associated with the trauma (Butterfield et al, 2002). The midwives can use routine assessment of infant-mother interactions at the postpartum stage to identify cases of PTSD and deal offer psychosocial care. The best intervention from the midwives is the prevention of PTSD arising from postpartum hemorrhage (Lombaard & Pattinson, 2009). The birth attendants are expected to be caring and to have effective communication with the mothers in addition to providing physiological care (Lynch et al, 1997). This may include debriefing sessions to minimize the effects of trauma. The process of studying the attitude and response of a mother should be intentional for the midwives (Alfirevic, 2008). In some cases, apologies from midwives and healthcare providers can reduce cases of depression and anxiety. The psychosocial care should include deliberate and consistent follow-ups by the midwives and exposure to other mothers who share the same experiences. Conclusion The post partum hemorrhage is a condition that leads to blood loss through genital tract. The condition can lead to hypovolemic shock and consequent maternal death in extreme cases. There are several processes that aim at controlling the impact of PPH. The physiological processes of managing PPH demand that the midwives have the skills to examine cervix and the upper vagina while wearing sterile gloves. The midwives also are expected to be in a position to handle placenta while still performing physiological management procedures postpartum hemorrhage. This can only happen when the appropriate pathological and physiological processes are followed accurately. The midwives are expected to have the skills to offer the psychosocial care to the women suffering to childbirth post traumatic stress disorder. Trauma counseling and support by the midwives are central to be delivery of psychosocial care after the traumatic process. References Alfirevic, Z. (2008). Postpartum Haemorrhage. Kidlington, Oxford: Elsevier. Ayers, S., Eagle, A., & Waring, H. (2006). The effects of childbirth-related post-traumatic stress disorder on women and their relationships: A qualitative study. Psychology Health & Medicine, 8(1), 5-12. B-Lynch, C., Coker, A., Lawal, A. H., Abu, J., & Cowen, M. J. (1997). The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Bjog-an International Journal of Obstetrics and Gynaecology, 2(1), 6-11. Butterfield, M. I., Becker, M., & Marx, C. E. (2002). Post-traumatic stress disorder in women: Current concepts and treatments. Current Psychiatry Reports, 2(2), 6-8. Chandraharan, E., & Arulkumaran, S. (2012). Obstetric and intrapartum emergencies: A practical guide to management. Cambridge, UK: Cambridge University Press. Gülmezoglu, A. M., & WHO (2009). WHO guidelines for the management of postpartum haemorrhage and retained placenta. Geneva: World Health Organization. Hofmeyr, J., Neilson, J., Alfirevic, Z., Crowther, C., Duley, L., Gulmezoglu, A. M., . . . Hodnett, E. (2008). Pregnancy and childbirth. Wiley-Blackwell (an imprint of John Wiley & Sons Ltd. Lombaard, H., & Pattinson, R. C. (2009). Common errors and remedies in managing postpartum haemorrhage. Best Practice & Research in Clinical Obstetrics & Gynaecology, 9(2), 4-7. Ruprai, C. K., Jha, R., Robinson, G., & Kanwar, S. (2011). Pelvic artery embolisation for severe post partum haemorrhage in a tertiary care centre in the UK. Archives of Disease in Childhood-fetal and Neonatal Edition, 4(1), 7-12. Van der Walt, P. (2005). A comparison between four midwife obstretic units in the Pretoria region. University of Pretoria. White, T., Matthey, S., Boyd, K., & Barnett, B. (2006). Postnatal depression and post‐traumatic stress after childbirth: Prevalence, course and co‐occurrence. Journal of Reproductive and Infant Psychology, 5(2), 10-14. WHO (2007). Midwifery education modules: Education for safe motherhood. Geneva: Department of Making Pregnancy Safer, World Health Organization. Read More