Presented By:

NISHA JAYANPresented By:

NISHA JAYAN

POST PARTUM HEMORRHAGE

CASE NO: 190***NAME: G.X.

DIAGNOSIS:

POST PARTUM HEMORRHAGE

AGE: 31 y/oSEX: FEMALE

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

Vital Signs:BP= 110/60 mmHgPR=76 bpm RR= 22 /mtTemp=37⁰C O²Sat= 98%

Vital Signs:BP= 110/60 mmHgPR=76 bpm RR= 22 /mtTemp=37⁰C O²Sat= 98%

Fair complexionFair complexion

No palpable masses or lesions

No palpable masses or lesions

SKIN

Maxillary, frontal, and ethmoid sinuses are not tender.

Maxillary, frontal, and ethmoid sinuses are not tender.

No palpable masses and lesionsNo palpable masses and lesionsNo areas of deformityNo areas of deformity

HEAD

Awake and alertAwake and alert

LOC & ORIENTATION

Oriented to persons, Place, Time

Oriented to persons, Place, Time

Pale conjunctivae but no dryness

Pale conjunctivae but no drynessPupils equally round and reactive to light

Pupils equally round and reactive to light

EYES

EARS

No unusual discharges noted

No unusual discharges noted

Pink nasal mucosaPink nasal mucosa

No unusual nasal dischargeNo unusual nasal discharge

No tenderness in sinusesNo tenderness in sinuses

NOSE

Pink and moist oral mucosaPink and moist oral mucosa

Free of swelling and lesionsFree of swelling and lesions

MOUTH

No palpable lymph nodesNo palpable lymph nodes

No masses and lesions seenNo masses and lesions seen

NECK AND THROAT

Equal chest expansionEqual chest expansionNo retractionNo retraction

Clear breath soundsClear breath sounds

CHEST AND LUNGS

Regular rhythmRegular rhythm

HEART

Not well contracted uterus after delivery

Not well contracted uterus after delivery

ABDOMEN

With moderate vaginal bleeding With moderate vaginal bleeding

GENITALS

With vaginal lacerationWith vaginal laceration

No lesions notedNo lesions noted

EXTREMITIES

PAST MEDICAL HISTORY

OBSTETRICAL HISTORY

DATES OF PRIOR

PREGNENCIES

GESTATIONAL AGE

ROUTE COMPLICATIONS

G1

TERM

NSVD NONE

G2 TERM NSVD NONE

G3

TERM NSVD GDM ON DIET

PRESENT MEDICAL HISTORY

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

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

MEDICATIONS

INVESTIGATIONSLABORATORY RESULT REFERANCE RANGE

CBC

HbHbHCTPLT

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

POST PARTUM HEMMORHAGE

o Post partum hemorrhage (PPH) is an obstetrical emergency that can follow vaginal or cesarean

delivery.o The average amount of blood

loss after vaginal delivery is 500 ml ,and blood loss for cesarean

birth is approximately 1000 ml .o It is major cause of maternal

morbidity .The most PPH occurs right after delivery but it can

occur later as well.o 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.

o Post partum hemorrhage (PPH) is an obstetrical emergency that can follow vaginal or cesarean

delivery.o The average amount of blood

loss after vaginal delivery is 500 ml ,and blood loss for cesarean

birth is approximately 1000 ml .o It is major cause of maternal

morbidity .The most PPH occurs right after delivery but it can

occur later as well.o 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.

POST PARTUM HEMMORHAGE

PRIMARY PPHoThere is greater

risk of hemorrhage in the first 24 hours after

birth called.SECONDARY PPHoOccurs after the

first 24 hours of birth

PRIMARY PPHoThere is greater

risk of hemorrhage in the first 24 hours after

birth called.SECONDARY PPHoOccurs after the

first 24 hours of birth

ANATOMY & PHYSIOLOGY ON ANATOMY & PHYSIOLOGY ON THIRD STAGE OF LABORTHIRD STAGE OF LABOR

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.

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.

 

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 (Crede’s 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 10–12 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

ETIOLOGY

Remember the 4 Ts:ToneTissueTraumaThrombin

Remember the 4 Ts:ToneTissueTraumaThrombin

TONE• Uterine Atony• “Boggy” uterus•Most common cause of PPH• 70% of all PPH

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

RISK FACTOR FOR UTERINE ATONY

o Risk Factors for Uterine Atonyo Uterine over distension (Polyhydramnios,

large baby, multiples)o Uterine exhaustion (precipitous labour,

prolonged/augmented labour, high parity)o Infection (prolonged rupture of membranes,

fever)o Anatomical distortion of the uterus (uterine

abnormality, fibroids, placenta Previa)o Exposure to specific drugs (NTG, Volatile

agents, Beta agonist)

o Risk Factors for Uterine Atonyo Uterine over distension (Polyhydramnios,

large baby, multiples)o Uterine exhaustion (precipitous labour,

prolonged/augmented labour, high parity)o Infection (prolonged rupture of membranes,

fever)o Anatomical distortion of the uterus (uterine

abnormality, fibroids, placenta Previa)o Exposure to specific drugs (NTG, Volatile

agents, Beta agonist)

TISSUE• Retained products• Abnormal

placenta (placenta accrete, increta or percreta)• Previous uterine

surgery

• Retained products• Abnormal

placenta (placenta accrete, increta or percreta)• Previous uterine

surgery

TRAUMA• Lacerations of

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

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

RISK FACTOR FOR TRAUMA

oPrecipitous deliveryoOperative deliveryoAssisted delivery (forceps, vacuum)

oPrevious uterine surgeryoFundal placenta

oPrecipitous deliveryoOperative deliveryoAssisted delivery (forceps, vacuum)

oPrevious uterine surgeryoFundal placenta

THROMBIN• Abnormal coagulation• Very rare• Usually identified before delivery

• Abnormal coagulation• Very rare• Usually identified before delivery

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

Pre-existing – Hemophilia– Idiopathic thrombocytopenia (ITP)– History of blood clots

Acquired in pregnancy– Pre-eclampsia– HELLP– Amniotic fluid embolus

Medication (aspirin, heparin)Antepartum Hemorrhage

PREVENTATIVE MEASURES

Active management of the third stage of labourOxytocin with delivery of babyProphylactic Oxytocin decreases PPH by 40%Deliver placenta with controlled cord traction and inspect for completenessPalpate uterus and inspect lower genital tract

Active management of the third stage of labourOxytocin with delivery of babyProphylactic Oxytocin decreases PPH by 40%Deliver placenta with controlled cord traction and inspect for completenessPalpate uterus and inspect lower genital tract

SIGNS & SYMPTOMS

With uterine Atony ,uterus is soft or boggy difficult to palpateUncontrolled bleedingDecreased blood pressure, dizziness and decreased urine output occur lateIncreased heart rateLaceration of the vagina, cervix can cause continuous bleeding even when the funds is firmDecrease in the red blood cell countAbdominal pain

With uterine Atony ,uterus is soft or boggy difficult to palpateUncontrolled bleedingDecreased blood pressure, dizziness and decreased urine output occur lateIncreased heart rateLaceration of the vagina, cervix can cause continuous bleeding even when the funds is firmDecrease in the red blood cell countAbdominal pain

COMPLICATIONS

Significant blood lossHysterectomyDeath

Significant blood lossHysterectomyDeath

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 measurementHematocrit red blood cell countClotting factors in the blood

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 measurementHematocrit red blood cell countClotting factors in the blood

NURSING MANAGEMENT

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 minutesMake sure that cross matched blood is available Provide supplemental oxygen by face mask , monitor oxygen saturation with pulse oximeterAdminister medications as order

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

NURSING MANAGEMENT

Use proper technique ( with two hands ,gentile Fundal pressure) during uterine massage Prevent infection by maintaining sterile techniquMaintain adequate rest and nutritionProvide emotional supportDocumentation

Use proper technique ( with two hands ,gentile Fundal pressure) during uterine massage Prevent infection by maintaining sterile techniquMaintain adequate rest and nutritionProvide emotional supportDocumentation

MEDICAL MANAGEMENT

MedicationManual massage of the uterus-to stimulate contractionRemoval of placental pieces that remain in the uterusExamination of the uterus and pelvic tissuesPacking the uterus with sponges and sterile materials(to compress the bleeding area in the uterus )

MedicationManual massage of the uterus-to stimulate contractionRemoval of placental pieces that remain in the uterusExamination of the uterus and pelvic tissuesPacking the uterus with sponges and sterile materials(to compress the bleeding area in the uterus )

MEDICAL MANAGEMENT

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

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

DRUG DOSES FOR MANAGEMENT OF PPH

DRUG DOSES FOR MANAGEMENT OF PPH

PRIORITIZATION OF NURSING PROBLEMS

1. Risk for ineffective tissue perfusion related to hemorrhage.

1. Risk for ineffective tissue perfusion related to hemorrhage.

4. Anxiety related to unexpected blood loss and uncertainty of outcome 4. Anxiety related to unexpected blood loss and uncertainty of outcome

2. Deficient Fluid Volume related to blood loss2. Deficient Fluid Volume related to blood loss3. Health seeking behaviors related to special care necessary for healthy pregnancy

3. Health seeking behaviors related to special care necessary for healthy pregnancy

5. Risk for infection related to blood loss and vaginal examinations5. Risk for infection related to blood loss and vaginal examinations

ASSESSMENTNURSING

DIAGNOSISGOALS & DESIRED

OUTCOME

NURSING INTERVENTION RATIONALE EVALUATI

ON

SUBJECTIVE:“I’m still bleeding heavily” as verbalized by the mother

OBJECTIVE:1.Restlessness2.Irritability3.Fall BP

V/S taken as follows:BP:80/60mmHgPR: 110 bpmRR: 16 cpmTemp.: 36.9◦C

Risk for ineffective tissue perfusion related to hemorrhage.

After12hours of nursing interventions patient will demonstrate adequate perfusion and stable vital signs.

1.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.

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.

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

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

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

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

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

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.

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.

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.