SECTION III: INTRANATAL CARE
POST PARTUM HAEMORRHAGE
Post Partum Haemorrhage is bleeding after delivery and is defined as a blood loss of 500 ml or more during or after the third stage of labour.
The main cause is uterine atony (lax uterus), which may be due to:
- Multiple-pregnancy / grand-multiparity
- Fetal macrosomia
- Placenta abruption
Patients with the conditions listed above should have the following done before delivery:
- Hb grouping and cross matching
- Setting up an intravenous infusion.
General Management in the Health Facility/Hospital
- SHOUT FOR HELP. Urgently mobilize all available personnel
- Make a rapid evaluation of the general condition of the woman including vital signs (pulse, blood pressure, respiration, temperature)
- If shock is suspected, immediately begin treatment
- Massage the uterus to expel blood and blood clots. Blood clots trapped in the uterus will inhibit effective uterine contractions and cause more bleeding.
- Give oxytocin 10 units IM.
- Start an IV 500 ml Ringers Lactate solution
- Take blood for Hb grouping and cross matching
- Catheterize the bladder
- Check to see if the placenta has been expelled and examine the placenta to be certain it is complete
- Examine the cervix, vagina and perineum for tears
- Call the doctor
Uterus soft – Massage Uterus and Expel Clots
- Place cupped palm on uterine fundus and feel for state of contraction.
- Massage fundus in a circular motion with cupped palm until uterus is well contracted. When well contracted, place fingers behind fundus and push down in one swift action to expel clots.
- Collect blood in a container placed close to the vulva. Measure or estimate blood loss, and record.
Bleeding Continues – Apply Bimanual Uterine Compression
(This can be done by doctor or midwife)
- Wear sterile or clean gloves
- Introduce the right hand into the vagina, clenched fist, with the back of the hand directed posteriorly and the knuckles in the anterior fornix.
- Place the other hand on the abdomen behind the uterus and squeeze the uterus firmly between the two hands
- Continue compression until bleeding stops (no bleeding if the compression is released)
- If bleeding persists, apply aortic compression; transfuse blood as soon as it becomes available
Apply Aortic Compression
If heavy postpartum bleeding persists despite uterine massage, oxytocin/ergometrine treatment and removal of placenta:
- Feel for femoral pulse
- Apply pressure above the umbilicus to stop bleeding. Apply sufficient pressure until femoral pulse is not felt
- After finding correct site, show assistant or relative how to apply pressure, if necessary
- Continue pressure until bleeding stops. If bleeding persists, keep applying pressure while transporting woman to hospital.
|Oxytocin doses for heavy bleeding:|
|Initial dose||Continuing dose||Maximum dose|
|IM/IV: 10 IU||IM/IV: repeat 10 IU after 20 minutes if heavy bleeding persists||Not more than 3 litres of IV fluids containg oxytocin|
|IV infusion: 20 IU in 1 litre at 60 drops/min||IV infusion: 20 IU in 1 litre at 30 drops/min|
Give ergometrine or carbetocin (Duratocin®) - If heavy bleeding in the postpartum (after oxytocin).
- DO NOT give ergometrine if eclampsia, pre-eclampsia or hypertension. Syntocinon or carbetocin can be used in these situations.
- Carbetocin is a long-acting oxytocin which has the advantage of a single I.V bolus of 100mcg. The need for monitoring of an oxytocin infusion or an additional bolus dose is not necessary. Only occasionally would an additional syntocinon dose be needed.
|Ergometrine doses for PPH|
|Initial dose||Continuing dose||Maximum dose|
|IM/lV:0.2 mg slowly||IM: repeat 0.2 mg IM after 15 minutes if heavy bleeding persists||Not more than 5 doses (total 1.0mg)|
Remove Placenta and Fragments Manually
(This can be done by skilled, trained staff)
- If placenta is not delivered 1 hour after delivery of the baby, OR
- If heavy vaginal bleeding continues despite massage and oxytocin and placenta cannot be delivered by controlled cord traction or if placenta is incomplete and bleeding continues.
- Explain to the woman the need for manual removal of the placenta and obtain her consent.
- Insert an IV line. If bleeding, give fluids rapidly. If not bleeding, give fluids slowly.
- Assist woman to get onto her back.
- Give diazepam 10 mgs IM/IV.
- Clean vulva and perineal area.
- Ensure the bladder is empty. Catheterize if necessary.
- With the left hand, hold the umbilical cord with the clamp. Then pull the cord gently until it is horizontal.
- Insert right hand into the vagina and up into the uterus.
- Leave the cord and hold the fundus with the left hand in order to support the fundus of the uterus and to provide counter-traction during removal.
- Move the fingers of the right hand sideways until edge of the placenta is located.
- Detach the placenta from the implantation site by keeping the fingers tightly together and using the edge of the hand to gradually make a space between the placenta and the uterine wall.
- Proceed gradually all around the placental bed until the whole placenta is detached from the uterine wall.
- Withdraw the right hand from the uterus gradually, bringing the placenta with it.
- Explore the inside of the uterine cavity to ensure all placental tissue has been removed
- With the left hand, provide counter-traction to the fundus through the abdomen by pushing it in the opposite direction of the hand that is being withdrawn. This prevents inversion of the uterus.
- Examine the uterine surface of the placenta to ensure that lobes and membranes are complete. If any placental lobe or tissue fragments are missing, explore again the uterine cavity to remove them.
If hours or days have passed since delivery, or if the placenta is retained due to constriction ring or closed; cervix, it may not be possible to put the hand into the uterus. DO NOT persist. Refer urgently to hospital.
If the placenta does not separate from the uterine surface by gentle sideways movement of the fingertips at the line of cleavage, suspect placenta accreta. DO NOT persist in efforts to remove placenta. Refer urgently to hospital.
After Manual Removal of the Placenta
- Repeat oxytocin 10 IU IM/IV
- Massage the fundus of the uterus to encourage a tonic uterine contraction.
- Give ampicillin 2 grams IV/IM as indicated by the physician.
- If fever is 38.5°C, foul-smelling lochia or history of rupture of membranes for 6 or more hours, give gentamicin 80 mg IM.
- If bleeding stops: o Give fluids slowly for at least 1 hour after removal of placenta.
- If heavy bleeding continues:
- Give ergometrine 0.2 mg IM stat o Give 20 IU oxytocin in a litre of IV fluid at 20 drops per minute. o In addition, infuse IV fluids to resuscitate as needed.
- Feel continuously whether uterus is well contracted (hard and round). If not, massage and repeat oxytocin 10 IU IM/IV.
Note: If there is postpartum haemorrhage after the placenta is delivered and the woman is on an oxytocin infusion, continue infusion for at least one hour.
Repair the Tear or Episiotomy
Examine the tear and determine the degree
- If the tear is small and involves only vaginal mucosa and connective tissues and underlying muscles (first or second degree tear). If the tear is not bleeding, leave the wound open.
- If the tear is long and deep through the perineum and involves the anal sphincter and rectal mucosa (third and fourth degree tear). Cover it with a clean pad and refer the woman urgently to hospital.
If first or second degrees tear and heavy bleeding persists after applying pressure over the wound:
- Suture the tear or refer for suturing if no one is available with suturing skills
- Suture the tear using universal precautions, aseptic technique and sterile equipment
- Use a needle holder and a 21 gauge, 4 cm, curved needle
- Use absorbable suture material
- Make sure that the apex of the tear is reached before you begin suturing
- Ensure that edges of the tear match up well
DO NOT suture if more than 12 hours since delivery but refer the patient to hospital.