Vaginal Bleeding after Childbirth

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Vaginal Bleeding after Childbirth

• Managing Complications in Pregnancy and Childbirth

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Session Objectives

• To discuss best practices for postpartum
  hemorrhage
• To describe strategies for prevention of
  postpartum hemorrhage

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Definition

• Vaginal bleeding of more than 500 mL after
  childbirth
• Bleeding underestimated because visual
  quantification is difficult
• Blood is mixed with other fluids (amniotic fluid,
  urine) and therefore underestimated
• Bleeding may occur slowly over several hours and
  condition may not be recognized until woman
  suddenly enters shock

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Initial Assessment and Management

• Shout for help mobilize personnel
• Evaluate womans condition including vital signs
• If shock suspected, immediately begin treatment
• Massage uterus to expel clots and feel to see
  that it is contracted recheck intermittently
• Give oxytocin 10 units IM

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Initial Assessment and Management (contd)

• Infuse IV fluids
• Catheterize bladder, if needed
• Check to see that placenta has been expelled
  examine for completeness
• Examine the cervix, vagina and perineum for tears
• After bleeding is controlled, check for anemia

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Differential Diagnosis of Postpartum Hemorrhage

• Atonic uterus
• Retained placenta
• Tears of cervix, vagina or perineum
• Retained placental fragments
• Ruptured uterus
• Inverted uterus

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Management of Atonic Uterus

• Continue IV fluids
• Continue to massage uterus
• Continue oxytocic drugs
• Perform bimanual compression or perform aortic
  compression
• Consider uterine and utero-ovarian artery
  ligation or hysterectomy

• All the while
• Transfuse blood as needed
• Consider other diagnoses
• Do not pack uterus

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Oxytocic Drugs
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Management of Retained Placenta

• If placenta is seen, ask woman to push if in
  vagina, remove
• Ensure bladder is empty catheterize if necessary
• Give oxytocin 10 units IM if not already done
• Attempt controlled cord traction
• Manually remove placenta
• Assess clotting status if bleeding continues

• All the while
• Transfuse blood as needed
• Give oxytocin if not already done
• Give antibiotics if manual removal of placenta
• Ampicillin 2 g IV one dose

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Management of Genital Tract Tears

• Inspect cervix, vagina and perineum
• Repair tears that are
• Bleeding
• More than first degree
• Away from urethra
• Place catheter if necessary

• All the while
• Transfuse blood as needed
• Consider concurrent diagnoses if bleeding still
  heavy

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Management of Retained Placental Fragments

• Feel inside uterus for placental fragments
• Remove placental fragments by hand, ovum forceps
  or large curette
• Assess clotting status if bleeding continues

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Management of Ruptured Uterus

• Repair uterus if it can be repaired with less
  operative risk than hysterectomy would entail and
  edges of tear are not necrotic
• Perform subtotal hysterectomy if uterus cannot be
  repaired or total hysterectomy if tear extends
  through cervix and vagina

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Management of Inverted Uterus

• Act quickly
• Assess clotting status
• Reposition uterus
• Hold oxytocics until uterus is repositioned
• Give antibiotics as for metritis if signs of
  infection are present
• Perform vaginal hysterectomy if necrosis is
  suspected

• All the while
• Give IV fluids
• Transfuse blood as needed
• Give pain medication and antibiotics
• Ampicillin 2 g IV one dose and metronidazole 500
  mg IV OR
• Cefazolin 1 g IV and metronidazole 500 mg IV

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Delayed Postpartum Hemorrhage

• If severe anemia, arrange for transfusion and
  provide oral iron and folic acid
• If signs of infection are present, give
  antibiotics as for metritis
• Give oxytocics
• Remove large clots and placental fragments if
  cervix is dilated
• Evacuate uterus if cervix is not dilated
• Consider uterine and utero-ovarian artery
  ligation if bleeding continues

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Prevention Strategies

• Birth preparedness
• Skilled provider at childbirth
• Treatment of anemia
• Active management of third stage of labor
• Avoid unnecessary procedures (e.g., episiotomy)

• Oxytocin 10 units IM within 2 min. of childbirth
• Controlled cord traction
• Fundal massage after delivery of placenta

Active management of third stage of labor
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Oxytocic Drugs

• Oxytocin posterior pituitary extract
• Ergometrine preparation of ergot
• Syntometrine combination of oxytocin and
  ergometrine

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Oxytocic Drugs Misoprostol

• Misoprostol prostoglandin E1 analogue

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Oxytocic Drugs Oxytocin

• Advantages
• Causes uterus to contract
• Acts within 2 1/2 min. when given IM
• Generally does not cause side effects
• Disadvantages
• More expensive than ergometrine
• IM or IV preparations only
• Not heat stable

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Oxytocic Drugs Ergometrine

• Advantages
• Low price
• Effect lasts 24 hours
• Disadvantages
• Takes 67 minutes to become effective when given
  IM oral form insufficiently effective
• Causes tonic uterine contraction
• Increased risk of hypertension, vomiting,
  headache
• Contraindicated in women with hypertension or
  heart disease
• Not heat stable

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Oxytocic Drugs Syntometrine

• Advantages
• Combined effect of rapid action of oxytocin and
  sustained action of ergometrine
• Disadvantages
• Increased risk of hypertension, nausea and
  vomiting
• Not heat stable

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Summary

• Postpartum hemorrhage is a leading cause of death
  in mothers
• Stop bleeding
• Uterine massage
• Examine perineum, vagina and cervix
• Oxytocics (first choice oxytocin)
• Empty bladder
• Examine placenta
• Begin resuscitation immediately