Post Partum Haemorrhage (PPH) Essay Example for Free

Post Partum Haemorrhage (PPH) EssayIntroductionPost partum haemorrhage (PPH) is an obstetrical emergency that can check vaginal or ces arean delivery. It is a major cause of maternal morbidity and one of the top three causes of maternal mortality in some(prenominal) high and low per capital income countries, although the absolute risk of death in much lower in high income countries (1 in 100,000 versus 1 in super acid births in low income countries). Furthermore, haemorrhage is the leading cause of admission of the intensive care unit and the most preventable cause of maternal mortality. The average daub loss following vaginal delivery, caesarean delivery and caesarean hysterectomy is 500 ml, 1000ml and 1500 ml respectively.Depending upon the amount of rent loss, post partum hemorrhage (PPH) can be- Minor (1L) concentrated (10g/dl) so that the persevering can withstand some amount of the descent loss. High risk patients who are likely to develop post partum hemorrhage (such as twins, hydramnios, grand multipara, APH, biography of previous PPH, severe anemia) are to be screened delivered in a well equipped hospital. Blood groping should be one for completely women so that no time is wasted during emergency. Placental localization must be done in all women with previous caesarean delivery by USG or MRI to detect placenta accreta or percreta. Women with morbid adherent placenta are at high risk of PPH. Such a case should be delivered by a senior obstetrician. A availability of blood or blood products must be ensured before mickle.Intranatal Active management of the third stage, for all women in labour should be a routine as it reduces PPH by 60%. Women delivered by caesarean section, oxytocin 5 IU slow IV is to be inclined to reduce blood loss. Exploration of the utero-vaginal canal for evidence of trauma following difficult labour or instrumental delivery. Observation for about 2 hours a good deal delivery to feed sure that the womb is hard and well contracted before sending her to ward. During caesarean section spontaneous separation delivery of the placenta reduces blood loss (30%).Management of retained placentaThis diagnosis is reached when the placenta remains undelivered after a specified period of time (usually half to 1 hour following the rapes birth). This is done to apply pressure to the transplacental site. The whole delve is introduced into the vagina in cone shaped fashion after separating the labia with the fingers of the other hand. the vaginal hand is clenched into a fist with the back of the hand directed posteriorly and the knuckles in the anterior fornix. The other hand is placed over the abdomen behind(predicate) the uterus to make it anteverted. The uterus is firmly squeezed between the two hands. It may be necessary to continue the compression for a prolonged period until the (during the period, the resuscitative measures are to be continued).Manual removal of the placentaThe operati on is done under general anaesthesia. The patient is placed in lithotomy position with all aseptic measures, the bladder is catheterized. star hand is introduced into the uterus after smearing with the antiseptic solution in cone shaped manner following the cord, which is made taut by the other hand. magic spell introducing the hand, the labia are separated by the fingers of the other hand. The fingers of the uterine should locate the margin of the placenta. Counter pressure on the uterine fundus is applied by the other hand placed over the abdomen.The abdominal hand should steady the fundus guide the movements of the fingers inside the uterine cavity till the placenta is completely separated. As soon as the placental margin is reached, the fingers are insinuated between the placenta the uterine wall with the back of the hand in contact with the uterine wall. The placenta is gradually separated with a side slipway slicing movement of the fingers, until whole of the placenta is separated. When the placenta is completely separated, it is extracted by 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.i) Management of third stage dischargeIn this third stage of hemorrhage or hemorrhage, the bleeding occurs before expulsion of placenta.Principles To empty the uterus. To set back the blood. To ensure effective haemostasis.Steps of managementa) Placental site bleeding To palpate the fundus and manage the uterus to make it hard. To start crystalloid with oxytocin at 60 drops /min and to arrange for blood transfusion if necessary. Oxytocin 10 units IM or methargin 0.2 mg. is given intravenously. To catheterize the bladder. To give antibiotics (ampicillin 2gm.and metronidazole 500mg. IV).b) Traumatic bleedingThe utero vaginal canal is to be explored under general anaesthesia after the placenta is expelled.ii) Management of trustworthy post partum hemorrhage In this true post partum hemorrhage the bleeding occurs subsequent to expulsion of placenta (majority).Management Call for extra help involve the obstetric senior staff on call. entertain patient flat and warm. Send blood for diagnostic test. Infuse rapidly 2 litres of normal saline. Give oxygen by mask 10-15L/min. Monitor the pulse, blood pressure, urine output, drug type, dose and time.B. Secondary Post partum hemorrhageDefinitionSecondary post partum hemorrhage is bleeding from the genital tract more than 24 hours after delivery of the placenta and may occur upto 6 week later. The bleeding usually occurs between 8th to 14th day of delivery.CausesThe causes of late post partum hemorrhage are-1. Retained bits of cotyledon or membranes (commonest) 2. Infection and separation of slough over a deep cervico-vaginal laceration. 3. Endometritis and sub involution of the placental site- due to hold up healing process. 4. Secondary hemorrhage from caesarean section wound usually occur be tween 10-14 days. 5. Withdrawal bleeding following oestrogen therapy for suppression of lactation.clinical Manifestation1. The lochia are heavier than normal recurrence of bright red flow.2. Offensive lochia if infection is a contributory factor.3. Sub involution of uterus.4. Pyrexia tachycardia.DiagnosisThe bleeding is bright red and varying amount. Rarely it may be brisk. Varying degree of anemia evidences of sepsis are present. Internal examination reveals evidences of sepsis, sub involution of the uterus often patulous cervical OS.Ultrasonography is usual in detecting the bits of placenta inside the uterine cavity.ManagementPrinciple To assess the amount of blood loss to replace it (transfusion) To find out the cause to take appropriate steps to rectify it.Managementi) Massage the uterus if it is still palpable to bring about a contraction.ii) Express any clots.iii) Encourage the mother to empty her bladder.iv) Give an oxytocic drug such as ergometrine by intravenous or in tramuscular route.v) turn in all pads lines to assess the volume of blood loss.vi) If retained products of conception are not seen on an ultrasound scan, the mother may be treated guardedly with antibiotic therapy and oral ergometrine. vii) Anemia is treated with iron supplement in severe cases, blood is transfused. treat management of PPHAssessment1. Assess maternal history for risk factors, plan accordingly and communicate to the perinatal area. 2. Assess pulse pressure, recording consistently less than 30bpm are consistent with hypertensive crisis. 3. Assess inhalation output chart. 4. Assess location firmness of uterine fundus. 5. Palpate the bladder distension, which may interfere with contracting of the uterus. 6. Inspect for intactness of any parineal area.Diagnosisi) Deficit legato volume related to blood loss as manifested by looking pale, dehydrated decrease pulse rate. ii) Acute pain related to perineal innervation from birth trauma and physiologic changes from births as monitored by wrinkled in forehead, restlessness irritability. iii) imbalance nutrition less than body requirement related to parapet in food intake as manifested by fatigue, weakness and lethargic. iv) Sleeping pattern disturbance related to pain bleeding as manifested by drowsiness, lethargic, irritated, and so on v) Risk for infection related to birth process maintaining poor hygiene as manifested by patients verbal complain, irritable discomfort.Goali) supervise for hypotension bleeding.ii) Minimize the pain.iii) Improve nutritional circumstance.iv) Improve sleep pattern.v) Reduce the risk for infection.Intervention For 1st diagnosisi) Monitor vital signs every 4 hours during the root 24 hours. ii) Assess vaginal discharge for clots and amount. iii) Maintained IV line as ordered by the doctor. For 2nd diagnosisi) Assess pain level, location, date and type also. ii) admit comfortable position (i.e. supine position) iii) Administered medicine as prescribed by the doctor. For 3rd diagnosisi) Assess the nutritional status of the patient. ii) diligent is advised to take liquid diet from 3rd day solid from 4th day. iii) Weight in monitored daily. For 4th diagnosisi) Sleep pattern is assessed.ii) Provide a neat and tidy bed to the patient.iii) Unnecessary procedures avoided during sleeping period.iv) Patient is advised to discourage day time sleeping. For 5th diagnosisi) Assessed the level of infection, keen sensation and frequency of urination. ii) Washing hands wearing gloves can reduce the risk for infection before doing any procedure. iii) Advised the patient to maintain the face-to-face hygiene and also should teach how to take care of perineal area.Evaluationi) Bleeding is reduced than before.ii) Patients pain level might be minimized.iii) Nutritional status of the patient is improved.iv) Patients sleep pattern is improved.v) Infection is controlled.ConclusionPost Partum hemorrhage continued to be a leading cause of maternal morbid ity mortality. In this patient despite identification and attempt at correction of an identified clotting disorder, major obstetric hemorrhage was not avoided.However, these factors may be needful and early surgical intervention as per local protocol is recommended to minimize maternal morbidity. After studying presenting the seminar on the topic of PPH, I got a positive idea about this disease and I am thankful to maam for giving me opportunity of presenting this topic. I think I can be able to import some amount of knowledge to the group I will be able to provide proper care to such patient if I got in future.Bibliography1. C.D. Dutta text book of obstetrics 7th edition, new central book agency, page no- 410-418 2. Annamma Jacob A comprehensive textbook of midwifery gynecological Nursing, 3rd edition, Joypee brothers medical publishers (p) Ltd. 3. Myhes Tex book for midwives, edited by V. Rith Bennett Linda K. Brown, 12th edition. Page No- 462-4704. Dr. Parulekar Shashank V ., Text book for midwives, 2nd edition, voramidical publication. Page No- 351-356.5. B. Basavanthappa T. Essentials of midwifery obstetrical Nursing, 1st edition, Jaypee Brothers medical publishers. Page No- 544-555.6. w.w.w.urmc.rochester.eduURMCHealth Encyclopedia w.w.w.birth.com.auLabour Birth. w.w.w.rcog.org.ukHomewomenshealth idelinessearch for a guideline. Bmb.oxford journals.org/..205full. w.w.w.ncbi.nlm.nih.gov journal listcases J/V.J2008