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Vaginal Bleeding After Childbirth

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To discuss best practices for postpartum hemorrhage ... Do not give as IV bolus. Precautions/ Contraindications. 8 doses. 5 doses ... – PowerPoint PPT presentation

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Title: Vaginal Bleeding After Childbirth


1
Vaginal Bleeding After Childbirth
  • Managing Complications in Pregnancy and Childbirth

2
Session Objectives
  • To discuss best practices for postpartum
    hemorrhage
  • To describe strategies for prevention of
    postpartum hemorrhage

3
Definition
  • Vaginal bleeding of more than 500 mL after
    childbirth
  • Bleeding underestimated because visual
    quantification is difficult
  • Blood is mixed with other fluids (amniotic fluid,
    urine) and therefore underestimated
  • Bleeding may occur slowly over several hours and
    condition may not be recognized until woman
    suddenly enters shock

4
Initial Assessment and Management
  • Shout for helpmobilize personnel
  • Evaluate womans condition including vital signs
  • If shock suspected, immediately begin treatment
  • Massage uterus to expel clots and feel to see
    that it is contractedrecheck intermittently
  • Give oxytocin 10 units IM

5
Initial Assessment and Management (continued)
  • Infuse IV fluids
  • Catheterize bladder, if needed
  • Check to see that placenta has been
    expelledexamine for completeness
  • Examine the cervix, vagina and perineum for tears
  • After bleeding is controlled, check for anemia

6
Differential Diagnosis of Postpartum Hemorrhage
  • Atonic uterus
  • Retained placenta
  • Tears of cervix, vagina or perineum
  • Retained placental fragments
  • Ruptured uterus
  • Inverted uterus

7
Management of Atonic Uterus
  • Continue IV fluids
  • Continue to massage uterus
  • Continue oxytocic drugs
  • Perform bimanual compression or perform aortic
    compression
  • Consider uterine and utero-ovarian artery
    ligation or hysterectomy
  • All the while
  • Transfuse blood as needed
  • Consider other diagnoses
  • Do not pack uterus

8
Oxytocic Drugs
9
Management of Retained Placenta
  • If placenta is seen, ask woman to push if in
    vagina, remove
  • Ensure bladder is empty catheterize if necessary
  • Give oxytocin 10 units IM if not already done
  • Attempt controlled cord traction
  • Manually remove placenta
  • Assess clotting status if bleeding continues
  • All the while
  • Transfuse blood as needed
  • Give oxytocin if not already done
  • Give antibiotics if manual removal of placenta
  • Ampicillin 2 g IV one dose

10
Management of Genital Tract Tears
  • Inspect cervix, vagina and perineum
  • Repair tears that are
  • Bleeding
  • More than first degree
  • Away from urethra
  • Place catheter if necessary
  • All the while
  • Transfuse blood as needed
  • Consider concurrent diagnoses if bleeding still
    heavy

11
Management of Retained Placental Fragments
  • Feel inside uterus for placental fragments.
  • Remove placental fragments by hand, ovum forceps
    or large curette
  • Assess clotting status if bleeding continues

12
Management of Ruptured Uterus
  • Repair uterus if it can be repaired with less
    operative risk than hysterectomy would entail and
    edges of tear are not necrotic
  • Perform subtotal hysterectomy if uterus cannot be
    repaired or total hysterectomy if tear extends
    through cervix and vagina

13
Management of Inverted Uterus
  • Act quickly
  • Assess clotting status
  • Reposition uterus
  • Hold oxytocics until uterus is repositioned
  • Give antibiotics as for metritis if signs of
    infection are present
  • Perform vaginal hysterectomy if necrosis is
    suspected
  • All the while
  • Give IV fluids
  • Transfuse blood as needed
  • Give pain medication and antibiotics
  • Ampicillin 2 g IV one dose and metronidazole 500
    mg IV OR
  • Cefazolin 1 g IV and metronidazole 500 mg IV

14
Delayed Postpartum Hemorrhage
  • If severe anemia, arrange for transfusion and
    provide oral iron and folic acid
  • If signs of infection are present, give
    antibiotics as for metritis
  • Give oxytocics
  • Remove large clots and placental fragments if
    cervix is dilated
  • Evacuate uterus if cervix is not dilated
  • Consider uterine and utero-ovarian artery
    ligation if bleeding continues

15
Prevention Strategies
  • Birth preparedness
  • Skilled provider at childbirth
  • Treatment of anemia
  • Active management of third stage of labor
  • Avoid unnecessary procedures (e.g., episiotomy)
  • Oxytocin 10 units IM within 2 min. of childbirth
  • Controlled cord traction
  • Fundal massage after delivery of placenta

Active management of third stage of labor
16
Oxytocic Drugs
  • Oxytocin - posterior pituitary extract
  • Ergometrine - preparation of ergot
  • Syntometrine - combination of oxytocin and
    ergometrine

17
Oxytocic Drugs Misoprostol
  • Misoprostol - prostoglandin E1 analogue

18
Oxytocic Drugs Oxytocin
  • Advantages
  • Causes uterus to contract
  • Acts within 2 1/2 min. when given IM
  • Generally does not cause side effects
  • Disadvantages
  • More expensive than ergometrine
  • IM or IV preparations only
  • Not heat stable

19
Oxytocic Drugs Ergometrine
  • Advantages
  • Low price
  • Effect lasts 24 hours
  • Disadvantages
  • Takes 67 minutes to become effective when given
    IM oral form insufficiently effective
  • Causes tonic uterine contraction
  • Increased risk of hypertension, vomiting,
    headache
  • Contraindicated in women with hypertension or
    heart disease
  • Not heat stable

20
Oxytocic Drugs Syntometrine
  • Advantages
  • Combined effect of rapid action of oxytocin and
    sustained action of ergometrine
  • Disadvantages
  • Increased risk of hypertension, nausea and
    vomiting
  • Not heat stable

21
Summary
  • Postpartum hemorrhage is a leading cause of death
    in mothers
  • Stop bleeding
  • Uterine massage
  • Examine perineum, vagina and cervix
  • Oxytocics (first choice oxytocin)
  • Empty bladder
  • Examine placenta
  • Begin resuscitation immediately
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