Title: NISHA JAYAN
1POST PARTUM HEMORRHAGE
Presented By NISHA JAYAN
2DEMOGRAPHIC PROFILE
3CASE NO 190
NAME G.X.
AGE 31 y/o
SEX FEMALE
DIAGNOSIS POST PARTUM HEMORRHAGE
4PHYSICAL ASSESSMENT
5GENERAL
- The patient is 31 y/o, FEMALE, weighs 67 kg.
- Vital Signs
- BP 110/60 mmHg
- PR76 bpm
- RR 22 /mt
- Temp37C O²Sat 98
6SKIN
- No palpable masses or lesions
7HEAD
- Maxillary, frontal, and ethmoid sinuses are not
tender.
- No palpable masses and lesions
8LOC ORIENTATION
- Oriented to persons, Place, Time
9EYES
- Pale conjunctivae but no dryness
- Pupils equally round and reactive to light
10EARS
- No unusual discharges noted
11NOSE
- No unusual nasal discharge
12MOUTH
- Pink and moist oral mucosa
- Free of swelling and lesions
13NECK AND THROAT
- No masses and lesions seen
14CHEST AND LUNGS
15HEART
16ABDOMEN
- Not well contracted uterus after delivery
17GENITALS
- With moderate vaginal bleeding
18EXTREMITIES
19PATIENT HISTORY
20PAST MEDICAL HISTORY
21OBSTETRICAL HISTORY
DATES OF PRIOR PREGNENCIES GESTATIONAL AGE ROUTE COMPLICATIONS
G1 TERM NSVD NONE
G2 TERM NSVD NONE
G3 TERM NSVD GDM ON DIET
22PRESENT MEDICAL HISTORY
- G4P3 39 weeks delivered normally with RMLE
,vaginal laceration with PPH.
23MEDICATIONS
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
24INVESTIGATIONS
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
25INTRODUCTION
26POST 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.
27POST 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
28ANATOMY PHYSIOLOGY
29ANATOMY 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.
31Placental 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. -
32Placental 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
33ETIOLOGY
- Remember the 4 Ts
- Tone
- Tissue
- Trauma
- Thrombin
34TONE
- Uterine Atony
- Boggy uterus
- Most common cause of PPH
- 70 of all PPH
35RISK 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)
36TISSUE
- Retained products
- Abnormal placenta (placenta accrete, increta or
percreta) - Previous uterine surgery
37TRAUMA
- Lacerations of cervix, vagina, perineum or C/S
incision site - Hematomas
- Uterine Rupture
- Uterine inversion
38RISK FACTOR FOR TRAUMA
- Precipitous delivery
- Operative delivery
- Assisted delivery (forceps, vacuum)
- Previous uterine surgery
- Fundal placenta
39THROMBIN
- Abnormal coagulation
- Very rare
- Usually identified before delivery
40RISK 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
41PREVENTATIVE 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
42SIGNS 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
43COMPLICATIONS
- Significant blood loss
- Hysterectomy
- Death
44HOW 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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46NURSING MANAGEMENT
47NURSING 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
48NURSING 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
49MEDICAL 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 )
50MEDICAL 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.
51DRUG 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
52PRIORITIZATION OF NURSING PROBLEMS
- 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
53NURSING 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.
55HEALTH 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.
56CONCLUSION
- 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
57BIBLIOGRAPHY
? 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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