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NISHA JAYAN

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POST PARTUM HEMORRHAGE Presented By: NISHA JAYAN TONE Uterine Atony Boggy uterus Most common cause of PPH 70% of all PPH RISK FACTOR FOR UTERINE ATONY Risk ... – PowerPoint PPT presentation

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Title: NISHA JAYAN


1
POST PARTUM HEMORRHAGE
Presented By NISHA JAYAN
2
DEMOGRAPHIC PROFILE
3
CASE NO 190
NAME G.X.
AGE 31 y/o
SEX FEMALE
DIAGNOSIS POST PARTUM HEMORRHAGE
4
PHYSICAL ASSESSMENT
5
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

6
SKIN
  • Fair complexion
  • No palpable masses or lesions

7
HEAD
  • Maxillary, frontal, and ethmoid sinuses are not
    tender.
  • No palpable masses and lesions
  • No areas of deformity

8
LOC ORIENTATION
  • Awake and alert
  • Oriented to persons, Place, Time

9
EYES
  • Pale conjunctivae but no dryness
  • Pupils equally round and reactive to light

10
EARS
  • No unusual discharges noted

11
NOSE
  • Pink nasal mucosa
  • No unusual nasal discharge
  • No tenderness in sinuses

12
MOUTH
  • Pink and moist oral mucosa
  • Free of swelling and lesions

13
NECK AND THROAT
  • No palpable lymph nodes
  • No masses and lesions seen

14
CHEST AND LUNGS
  • Equal chest expansion
  • No retraction
  • Clear breath sounds

15
HEART
  • Regular rhythm

16
ABDOMEN
  • Not well contracted uterus after delivery

17
GENITALS
  • With moderate vaginal bleeding
  • With vaginal laceration

18
EXTREMITIES
  • No lesions noted

19
PATIENT HISTORY
20
PAST MEDICAL HISTORY
  • No past medical history

21
OBSTETRICAL HISTORY
DATES OF PRIOR PREGNENCIES GESTATIONAL AGE ROUTE COMPLICATIONS
G1 TERM NSVD NONE
G2 TERM NSVD NONE
G3 TERM NSVD GDM ON DIET
22
PRESENT MEDICAL HISTORY
  • G4P3 39 weeks delivered normally with RMLE
    ,vaginal laceration with PPH.

23
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
24
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
25
INTRODUCTION
26
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.

27
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

28
ANATOMY PHYSIOLOGY
29
ANATOMY PHYSIOLOGY ON THIRD STAGE OF LABOR
30
  • 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.

31
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.
  •  

32
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

33
ETIOLOGY
  • Remember the 4 Ts
  • Tone
  • Tissue
  • Trauma
  • Thrombin

34
TONE
  • Uterine Atony
  • Boggy uterus
  • Most common cause of PPH
  • 70 of all PPH

35
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)

36
TISSUE
  • Retained products
  • Abnormal placenta (placenta accrete, increta or
    percreta)
  • Previous uterine surgery

37
TRAUMA
  • Lacerations of cervix, vagina, perineum or C/S
    incision site
  • Hematomas
  • Uterine Rupture
  • Uterine inversion

38
RISK FACTOR FOR TRAUMA
  • Precipitous delivery
  • Operative delivery
  • Assisted delivery (forceps, vacuum)
  • Previous uterine surgery
  • Fundal placenta

39
THROMBIN
  • Abnormal coagulation
  • Very rare
  • Usually identified before delivery

40
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

41
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

42
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

43
COMPLICATIONS
  • Significant blood loss
  • Hysterectomy
  • Death

44
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

45
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46
NURSING MANAGEMENT
47
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

48
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

49
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 )

50
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.

51
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
52
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
53
NURSING CARE PLAN
54
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.
55
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.

56
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

57
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.
58
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