NISHA JAYAN

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POST PARTUM HEMORRHAGE
Presented By NISHA JAYAN
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DEMOGRAPHIC PROFILE
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CASE NO 190
NAME G.X.
AGE 31 y/o
SEX FEMALE
DIAGNOSIS POST PARTUM HEMORRHAGE
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PHYSICAL ASSESSMENT
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GENERAL

• The patient is 31 y/o, FEMALE, weighs 67 kg.

• Vital Signs
• BP 110/60 mmHg
• PR76 bpm
• RR 22 /mt
• Temp37C O²Sat 98

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SKIN

• Fair complexion

• No palpable masses or lesions

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HEAD

• Maxillary, frontal, and ethmoid sinuses are not
  tender.

• No palpable masses and lesions

• No areas of deformity

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LOC ORIENTATION

• Awake and alert

• Oriented to persons, Place, Time

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EYES

• Pale conjunctivae but no dryness

• Pupils equally round and reactive to light

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EARS

• No unusual discharges noted

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NOSE

• Pink nasal mucosa

• No unusual nasal discharge

• No tenderness in sinuses

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MOUTH

• Pink and moist oral mucosa

• Free of swelling and lesions

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NECK AND THROAT

• No palpable lymph nodes

• No masses and lesions seen

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CHEST AND LUNGS

• Equal chest expansion

• No retraction

• Clear breath sounds

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HEART

• Regular rhythm

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ABDOMEN

• Not well contracted uterus after delivery

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GENITALS

• With moderate vaginal bleeding

• With vaginal laceration

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EXTREMITIES

• No lesions noted

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PATIENT HISTORY
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PAST MEDICAL HISTORY

• No past medical history

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OBSTETRICAL HISTORY
DATES OF PRIOR PREGNENCIES GESTATIONAL AGE ROUTE COMPLICATIONS
G1 TERM NSVD NONE
G2 TERM NSVD NONE
G3 TERM NSVD GDM ON DIET
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PRESENT MEDICAL HISTORY

• G4P3 39 weeks delivered normally with RMLE
  ,vaginal laceration with PPH.

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MEDICATIONS
DRUG DOSE ACTION
Inj.oxytocin 10units Oxytocin in 500ml of RL It stimulates uterine contraction.
Inj.methergin (ergometrine) 1amp(0.2mg) IM Increases motor activity of the uterus by direct stimulation of the smooth muscle ,shortening the third stage of labour and reducing blood loss
Tab.cytotec (misoprostol) 800mg (4tab)p/r To contracts the uterus and prevent uterine Atony
Inj.cefuroxime 1 gm I V TID Antibiotic
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INVESTIGATIONS
LABORATORY RESULT REFERANCE RANGE
CBC Hb Hb HCT PLT 12.5(BEFORE DELIVERY) 9.6 g/dl(AFTER DELIVERY) 26.2 292 11.2-15.7gdl 11.2-15.7g/dl 34.1-44.9 182-369/UL
PT 11.7 10.9-16.3 SEC
APTT 30 SEC 27-39 sec
BLOOD GROUP O POSITIVE
HBsAG NEGATIVE
RBS 6.8mmol/L
ANTIBODY SCRREN NEGATIVE
RUBELLA POSITIVE
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INTRODUCTION
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POST PARTUM HEMMORHAGE

• Post partum hemorrhage (PPH) is an obstetrical
  emergency that can follow vaginal or cesarean
  delivery.
• The average amount of blood loss after vaginal
  delivery is 500 ml ,and blood loss for cesarean
  birth is approximately 1000 ml .
• It is major cause of maternal morbidity .The most
  PPH occurs right after delivery but it can occur
  later as well.
• In most cases, PPH is due to bleeding from the
  placental site, which is due to uterine Atony.
  Because the flow of blood is high in the uterine
  arteries at the end of pregnancy.

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POST PARTUM HEMMORHAGE

• PRIMARY PPH
• There is greater risk of hemorrhage in the first
  24 hours after birth called.
• SECONDARY PPH
• Occurs after the first 24 hours of birth

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ANATOMY PHYSIOLOGY
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ANATOMY PHYSIOLOGY ON THIRD STAGE OF LABOR
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• The third stage is called the placental stage.
• It begins with the birth of the infant and ends
  with the delivery of the placenta. Two separate
  phases are involved placental separation and
  placental expulsion.
• After birth, the uterus can be palpated as a firm
  round mass just inferior to the level of the
  umbilicus. After a few minutes, the uterus begins
  to contract again and assumes a discoid shape. It
  retains this shape until placenta is separated,
  approximately 5 minutes after birth of the
  infant.

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Placental Separation

• As the uterus further contracts down on an almost
  empty interior causing disproportion between the
  placenta and the contracting wall of the uterus
  ultimately causing separation of the placenta.
• The following are the signs indicating that
  placenta has loosened and is ready to deliver
• Lengthening of the umbilical cord
• Sudden gush of vaginal blood
• Change in the shape of the uterus
• Firm contraction of the uterus
• Appearance of the placenta at the vaginal opening
  
• Bleeding occurs as a normal consequence of
  placental separation. The normal blood loss is
  500mL.
•  

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Placental Expulsion

• After separation, the placenta is delivered
  either by the natural bearing-down effort of the
  mother or by gentle pressure on the contracted
  uterine fundus by the physician or nurse-midwife
  (Credes maneuver).
• Pressure must never be applied to post-partal
  uterus in a non-contracted state, because doing
  so would cause uterus to evert and maternal blood
  sinuses are open and gross hemorrhage could
  occur.
• If the placenta does not deliver spontaneously,
  it can be removed manually.
• The average time from delivery of the baby until
  complete expulsion of the placenta is estimated
  to be 1012 minutes dependent on whether active
  or expectant management is employed. In as many
  as 3 of all vaginal deliveries, the duration of
  the third stage is longer than 30 minutes and
  raises concern for retained placenta

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ETIOLOGY

• Remember the 4 Ts
• Tone
• Tissue
• Trauma
• Thrombin

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TONE

• Uterine Atony
• Boggy uterus
• Most common cause of PPH
• 70 of all PPH

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RISK FACTOR FOR UTERINE ATONY

• Risk Factors for Uterine Atony
• Uterine over distension (Polyhydramnios, large
  baby, multiples)
• Uterine exhaustion (precipitous labour,
  prolonged/augmented labour, high parity)
• Infection (prolonged rupture of membranes, fever)
• Anatomical distortion of the uterus (uterine
  abnormality, fibroids, placenta Previa)
• Exposure to specific drugs (NTG, Volatile agents,
  Beta agonist)

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TISSUE

• Retained products
• Abnormal placenta (placenta accrete, increta or
  percreta)
• Previous uterine surgery

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TRAUMA

• Lacerations of cervix, vagina, perineum or C/S
  incision site
• Hematomas
• Uterine Rupture
• Uterine inversion

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RISK FACTOR FOR TRAUMA

• Precipitous delivery
• Operative delivery
• Assisted delivery (forceps, vacuum)
• Previous uterine surgery
• Fundal placenta

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THROMBIN

• Abnormal coagulation
• Very rare
• Usually identified before delivery

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RISK FACTOR FOR THROMBIN

• Pre-existing
• Hemophilia
• Idiopathic thrombocytopenia (ITP)
• History of blood clots
• Acquired in pregnancy
• Pre-eclampsia
• HELLP
• Amniotic fluid embolus
• Medication (aspirin, heparin)
• Antepartum Hemorrhage

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PREVENTATIVE MEASURES

• Active management of the third stage of labour
• Oxytocin with delivery of baby
• Prophylactic Oxytocin decreases PPH by 40
• Deliver placenta with controlled cord traction
  and inspect for completeness
• Palpate uterus and inspect lower genital tract

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SIGNS SYMPTOMS

• With uterine Atony ,uterus is soft or boggy
  difficult to palpate
• Uncontrolled bleeding
• Decreased blood pressure, dizziness and decreased
  urine output occur late
• Increased heart rate
• Laceration of the vagina, cervix can cause
  continuous bleeding even when the funds is firm
• Decrease in the red blood cell count
• Abdominal pain

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COMPLICATIONS

• Significant blood loss
• Hysterectomy
• Death

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HOW IS POST PARTUM HAEMORRHAGE DIAGNOSED?

• Estimation of blood loss(this may be done by
  counting the number of saturated pads ,or by
  weighing of pads and sponges used to absorb blood
  )
• Pulse rate and blood pressure measurement
• Hematocrit red blood cell count
• Clotting factors in the blood

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NURSING MANAGEMENT
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NURSING MANAGEMENT

• Maintain I. V. access with normal saline infusion
  and add a secondary line with 16g catheter for
  sever loss.
• Monitor vital signs every 15 minutes
• Make sure that cross matched blood is available
• Provide supplemental oxygen by face mask ,
  monitor oxygen saturation with pulse oximeter
• Administer medications as order

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NURSING MANAGEMENT

• Use proper technique ( with two hands ,gentile
  Fundal pressure) during uterine massage
• Prevent infection by maintaining sterile techniqu
• Maintain adequate rest and nutrition
• Provide emotional support
• Documentation

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MEDICAL MANAGEMENT

• Medication
• Manual massage of the uterus-to stimulate
  contraction
• Removal of placental pieces that remain in the
  uterus
• Examination of the uterus and pelvic tissues
• Packing the uterus with sponges and sterile
  materials(to compress the bleeding area in the
  uterus )

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MEDICAL MANAGEMENT

• Tying off of bleeding blood vessels
• Laparotomy- surgery to open the abdomen to find
  the causes of the bleeding
• Hysterectomy- (surgical removal of the uterus) in
  most cases this is a last resort.

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DRUG DOSES FOR MANAGEMENT OF PPH
Oxytocin Methergin Methyl Prostaglandin f2 (prostodine) Misoprostol (cytotec) Carbatocin (pabal)
Dose Route I.V.infuse 20iu in 1LT I.V .fluid I.M.or I.V.(slowly) 0.2 mg I.M. only 0.25 mg 800mg- 1000mg IM/IV 100mcg
Continuing dose I.V.infuse 20iu in 500ml I.V fluid at 40 gtts/min Repeat 0.2mg IM after 15 mins. 0.25mg every 15 mins. 800mg- 1000mg Every 15-90 mins.
Maximum dose Not more than 3 L of IV fluid containing oxytocin 5 doses (total 1.0 mg) 8 doses ( total 2 mg) 800mg- 1000mg 2 mg
Contraindication /Precautions Do not give as an IV bolus Pre- eclampsia, hypertension, heart disease Asthma Pregnant woman Astham, Hypotension, anemia, jaundice and diabetes, seizure disorder, previous uterine surgery
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PRIORITIZATION OF NURSING PROBLEMS

1. Risk for ineffective tissue perfusion related to
   hemorrhage.

2. Deficient Fluid Volume related to blood loss
3. Health seeking behaviors related to special
care necessary for healthy pregnancy
4. Anxiety related to unexpected blood loss and
uncertainty of outcome
5. Risk for infection related to blood loss and
vaginal examinations
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NURSING CARE PLAN
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ASSESSMENT NURSING DIAGNOSIS GOALS DESIRED OUTCOME NURSING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE Im still bleeding heavily as verbalized by the mother OBJECTIVE Restlessness Irritability Fall BP V/S taken as follows BP80/60mmHg PR 110 bpm RR 16 cpm Temp. 36.9?C Risk for ineffective tissue perfusion related to hemorrhage. After12hours of nursing interventions patient will demonstrate adequate perfusion and stable vital signs. Monitor amount of bleeding by weighing all pads 2. Frequently monitor vital signs. 3.Massage the uterus 4.Administer medications as advice (eg.pitocin, methargine) 5. Administer oxygen 6. Provide comfort. Like back rubs, deep breathing, instruct in relaxation. 1. To measure the amount of blood loss. 2. Early recognition of possible adverse effects allows for prompt intervention. 3. To help expel clots of blood and it is also used to check the tone of the uterus and ensure that it is clamping down to prevent excessive bleeding. 4. To promote contraction and prevents further bleeding. 5. To supply adequate oxygen to mother and to prevent further complication. 6. Promote relaxation may enhance patients coping abilities by refocusing attension. After 12hours of nursing interventions, patient was able to demonstrate adequate perfusion and stable vital signs.
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HEALTH EDUCATION 

• Educate the women about the cause of hemorrhage
• Teach the women the importance of eating a
  balanced diet taking vitamin supplements
• Advice the women she may feel tired and fatigued
  and to schedule daily rest periods
• Teach women and family signs and symptoms of
  hemorrhage for home care
• Advise the women to notify her health care
  provider of increased bleeding or other changes
  in her status.

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CONCLUSION

• Presented a case of a 31 y/o Female patient who
  is a known case of Post Partum Hemorrhage

• Post partum hemorrhage (PPH) is an obstetrical
  emergency that can follow vaginal or cesarean
  delivery.
• The average amount of blood loss after vaginal
  delivery is 500 ml ,and blood loss for cesarean
  birth is approximately 1000 ml .
• It is major cause of maternal morbidity .The most
  PPH occurs right after delivery but it can occur
  later as well.

• On conservative management such as oxytocin
  10units Oxytocin in 500ml of RL,
  methargin(ergometrine) 1amp(0.2mg) IM,
  cytotec(misoprostol) 800mg (4tab)p/r, cefuroxime
  1 gm I V TID

• Patient was discharged on 07/02 /2013 in good
  condition with the baby

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BIBLIOGRAPHY
? Wolters Kluwer Lippincot Williams Wilkins.
Lippincot Manual of Nursing Practice, 9th
edition, page 1330-1333, 2010.
? Pillitteri, Adele. Maternal Child Health
Nursing, 3rd ed.Philadelphia Lippincott, 1999.
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