17. 1. Palpate the fundus and massage the uterus to make it
hard. the massage is to be done by placing four fingers
behind the uterus and thumb in front. however if
bleeding continues even after the uterus become hard
suggests the presence of genital tract injury.
2. To start crystalloid solution with oxytocin 20 units at 60
drops per minute and to arrange for blood transfusion if
necessary.
3. Oxytocin 10 unit IM is given IV
4. To catheterize the bladder.
5. To give antibiotics ampicillin 2 g and metronidazole
500 mg IV
18. The utero vaginal canal
is to be explored under
general anaesthesia
after the placenta is
expelled and
hemostatic sutures are
placed on the offending
sites.
23. 1. It is done under general anaesthesia but can also be done under deep
sedation with 10 MG diazepam IV. patient is placed in lithotomy position and
with all antiseptic measures it is done. The bladder is catheterized.
2. One has is introduced into the uterus after smearing with antiseptic solution
in cone shaped manner following the cord which is made taut by the other
hand. While introducing the hand, the labia are separated by the fingers of the
other hand. The fingers of the uterine hand should look at the margin of the
placenta.
3. counter pressure on the uterine fundus is supplied by the other hand placed
over the abdomen. The abdominal hand should study the funders and guide
the movement of the finger inside the uterine cavity till the placenta is
completely separated
24. 4. As soon as the placental margin is reached the fingers are insinuated between
the placenta and the uterine wall with the back of the hand in contact with the
uterine wall .the placenta is gradually separated with the sideways slicing
movement of the fingers until the whole of the placenta is separated.
5. when the placenta is completely separated it is extracted by the traction of the
cord by the other hand. The uterine hand is still inside the uterus for exploration of
the cavity to be sure that nothing is left behind.
6. IV oxytocin is given and the uterine hand is gradually removed while massaging
the uterus by external hard to make it hard. After the completion of manual removal
inspection of the cervical vaginal canal is to be made to exclude any injury.
7. the placenta and the membranes are separated for completeness and be sure
that the uterus remains hard and contracted.
25. Management of true postpartum
hemorrhage
Principles
1. Communication
2. Resuscitation
3. Monitoring
4. Arrest of bleeding
30. Step 1.
a) massage the uterus to make it hard and express the
blood clot
b) Injection oxytocin drip started 10 units in 500 ml of
normal saline at the rate of 40 to 60 drops per minute.
c) Foley catheter to keep bladder empty and monitor
urine output.
d) to examine the expelled placenta and membranes for
evidence of missing cotyledons or piece of membranes
of the uterus fails to contract proceed to the next step.
32. Step 2
the uterus is to be explored under general anaesthesia full
stops time simultaneous inspection of the cervix and
vagina especially the paraurethral region is to be done to
exclude coexistent bleeding sites from the injured area.
In refractory cases -
Inj. 15 methyl PGF2 alpha 250 micrograms IM in deltoid
muscle every 15 mins
Or
Misoprostol PGE1) 1000 microgram per rectum is effective.
34. Step 3 -Uterine massage and bi manual
compression
a) The whole hand is introduced into the vagina in cone shaped
fashion after separating the labia with the fingers of the other
hand.
b) The vaginal hand is cleanched into a fist with the back of the
hand directed posteriorly and knuckles in the anterior fornix.
c) The other hand is played over the abdomen behind the uterus to
make it anteverted.
d)The uterus is firmly squeezed is between the two hands. It may
be necessary to continue the compression for a prolonged period
until the tone of the uterus is regained. This is evidenced by
absence of bleeding if the compression is released.
35.
36.
37.
38. Step 4 - Uterine Tamponade
5 meters long strip of gauze, 8 cm wide and folded his is required for the
good should be soaked in antiseptic cream before introduction. The gauze
is placed hai up high and packed into the fundal area first while the uterus
is steadied by the external hand. Gradually, the rest of the cavity is placed
so that no empty space is left behind full stop a separate pack is used to fill
the vagina. An abdominal binder is placed. Intrauterine plunging acts not
only by stimulating uterine contraction but exerts direct hemostatic
pressure to open uterine sinuses. antibiotic should be given and the plan
should be removed after 24 hours.
Intrauterine packing is useful in a case of uncontrolled postpartum
hemorrhage where other methods have failed and the patient is being
prepared for transport to a tertiary care centre.
39.
40. Balloon
Tamponade
Tamponade using various types of hydrostatic
balloon catheter has mostly replaced by uterine
packing. Mechanism of action is similar to
uterine packing. Foley's catheter, bakri balloon,
condom catheter or sengstaken-Bla is inserted
into the uterine cavity and the balloon is inflated
with normal saline 200 to 500 ml. It is kept for 4 to
6 hours.
41.
42. Final Step - Surgical management
1. Uterine Arteries Ligation
50. Traumatic PPH
the trauma to the perineum vagina and cervix
is to be searched under good light by
speculum examination and haemostasis is
achieved by appropriate catgut sutures. The
repair is to be done under general
anaesthesia if necessary.
53. Nursing assessment
Assess the amount of bleeding.
Assess maternal vital signs to
establish baseline data
.Assess the signs for shock
.Assess the condition of the uterus.
57. Deficient fluid volume
related to excessive loss of
blood after giving birth as
evidenced by decrease in
blood pressure and
decrease capillary refill
58. Risk of excess fluid
volume as related to
excessive fluid
infusion
59. Risk for infection related
to excessive blood loss
and exposed placental
attachment site and
lacerations.
61. Risk for altered parent
infant attachment related
to persistent threat to own
survival
62. Anxiety related to knowledge deficit
regarding procedures,management
and threat to change in health
status as evidenced by restlessness
and distress.
65. Intranatal
Slow delivery of the baby.
Expert obstetric anesthetist needed.
Spontaneous separation and delivery of placenta during
caesarean sections.
Active management of third stage of labor.
Examination of placenta.
Induced or accelerated labor by oxytocin.
Exploration of utero-vaginal canal.
To observe the patient for about two hours after delivery
68. BACKGROUND:-- Postpartum hemorrhage(PPH) is globally one of the
most common causes of maternal death, espically in developing country
like India. Pregnancy and childbirth involve significant health risks, event
to women with no pre-existing health problems. The objective of this
study was to analise the role of various interventions in the management
of PPH an its complications.
METHODS:-- Data collected and analyzed in PPH patients with medical
and surgical management.
69. RESULTS:-- In present study, most of cases were
multigravida(60%) and more than 50% required blood and blood
products.This was possible due to arly identification and timely
interventions.
CONCLUSION:-- Active management of 3rd stage of labour is
recommended in all cases. 70% cases were managed by medical
methods while rest of the cases required surg. Management.
Among the medical management uterotonic drugs and bimanual
uterine compression was used while among surgical methods
repair of cervical and vaginal laeration was mostly required.
