1. Darling .B.Jiji
Lecturer in nursing
Sebha CON , Libya.

2. 
Of all the stages of labour, third
stage is the most crucial one for the
mother. The important complications are :-
Postpartum haemorrhage
Retention of placenta
Haemorrhagic shock
Pulmonary embolism
Uterine inversion


3. Definition:
It means any amount of bleeding from or into the
genital tract following the birth of baby up to the end of
puerperium which affects the general condition of the patient
evidenced by raise in pulse rate and falling blood pressure.

It is an excessive blood loss following the birth of baby. It
may be more than 500 ml. It is specially occurs in the third stage
or fourth stage.
( normal blood loss during delivery is 150 - 250 ml ).


4. Primary Postpartum Haemorrhage :- the
haemorrhage occurs within 24 hours
following the birth of baby.
Secondary Postpartum Haemorrhage :- the
haemorrhage occurs beyond 24 hours
following the birth of baby and within
puerperium , also called delayed or late
puerperal haemorrhage .


5. Atonic uterus ( 80 % - common cause )
Grand multipara
Chronic anaemia and malnutrition
Inadequate retraction and frequent adherent placenta
Over – distension of the uterus  multiple pregnancy, poly hydramnios, large baby
Antepartum haemorrhage
Prolonged labour
Excessive use of Anaesthesia
Excessive use of oxytocin
Retained placental bits or blood clots
Malformation of uterus ( septate uterus or bicornuate uterus)
Uterine fibroid
Rapid delivery of baby
Premature attempt to expel the placenta
Kneading and fiddling of the uterus
Premature pulling of the umbilical cord
Full bladder
Precipitate labour
Trauma to the genital tract
Blood coagulation disorders

6.  Improve the health status ( correct the anaemia )
 High risk patients such as twins , hydramnios, grand multipara
, severe anaemia,
antepartum haemorrhage ( APH ) and past history of third stage
complications are
screened and delivered in a well equipped hospital.
 Blood grouping and typing and all blood investigations ( Hb )
should be done early.
 Empty the bladder before delivery
 Avoid excessive use of oxytocin and vigorous delivery of the
baby
 Avoid fundal pressure, kneading and fiddling during delivery
 Wait for placental separation and deliver the placenta by
controlled cord traction method
 Examine the placenta after delivery
 Check the vital signs and constant observation in the fourth
stage of labour
 Encourage the patient to have hospital delivery.

7. Empty the uterus
Identify the site of bleeding
Check the vital signs
Palpate and massage the uterus ( the massage is to be done by placing four
fingers behind the uterus and thumb in front. This temporarily stop the bleeding
)
Administer Inj –Ergometrine 0.25 mg or Methergin 0.2 mg by IM or IV
Administer sedation Inj - Morphine 15 mg by IM
Start 5% dextrose drip
Arrange for blood transfusion
Catheterise the bladder
Do placental examination
In retained placenta, do manual removal of placenta ( give anaesthesia . keep the
patient in lithotomy position. The bladder is catheterised . Follow aseptic
technique. One hand is introduced into the uterus in cone shaped following the
cord . Locate the margin of the placenta. Separate the placenta with a side ways
slicing movement of the fingers. When the placenta is completely separated
deliver the placenta. The placenta and membranes are to be inspected for
completeness).

8.  Do bimanual compression of the uterus. ( the whole hand is
introduced into the vagina in cone shaped . The vaginal hand
is clenched into a fist with the back of the hand. The other
hand is placed over the abdomen. The uterus is firmly
squeezed between the two hands ) .
Hot intra uterine douche ( it stimulate the uterus to attain
its tone. The temperature of the fluid should be about 1180 F
( 47. 80C ) and some antiseptic lotion are mixed. The can
should not placed more than 2 feet above the level of
uterus ).
Tight intra – uterine packing ( it should be done under
general anaesthesia. A 5 metres long strip of gauze , 8 cm
wide folded twice is required. The gauze is socked in
antiseptic cream. The gauze is placed high up and packed .
The plug should be removed after 24 hours ).
Hysterectomy ( removal of uterus ).
Traumatic haemorrhage should be tackled by sutures

9. MANAGEMENT OF POSTPARTUM HAEMORRHAGE

To fell the uterus by abdominal palpation

Uterus flabby uterus hard and contracted
( Traumatic)
-Massage the uterus to make it hard
-Inj – Ergometrine 0.25 mg IV or IM
-Inj – Morphine 15 mg IM
-To start 5% dextrose drip / arrange for blood
-To examine the expelled placenta Exploration
-To catheterise the bladder

Uterus remains flabby

Exploration of the uterus
Remains flabby
Manual removal of placenta
Fails Haemostatic sutures
Repeat ergometrine & oxytocin drip on the tear sites
Uterus flabby
Administration of 15 methyl PGF 2α
Fails
Bimanual compression
Fails
Hot intra uterine douche
Fails
Intra uterine plugging
Fails

Hysterectomy
