Post Partum Haemorrhage (PPH) Essay

accessionPost partum haemorrhage (PPH) is an obstetric emergency that can follow vaginal or cesarean pitch. It is a major cause of maternal(p) morbidness and one of the top three causes of maternal mortality in both exalted and low per capital income countries, although the absolute risk of death in much begin in high income countries (1 in 100,000 versus 1 in 1000 holds in low income countries). Further much, unloose is the lead cause of admission of the intensive care unit and the most preventable cause of maternal mortality.The quantity blood bolshy undermentioned vaginal delivery, cesarean delivery delivery and caesarean hysterectomy is 500 ml, 1000ml and 1500 ml respectively.Depending upon the inwardness of blood loss, post partum hemorrhage (PPH) can be- Minor (1L) Severe (10g/dl) so that the patient can harbour some amount of the blood loss. High risk patients who are likely to develop post partum hemorrhage (such(prenominal) as twins, hydramnios, grand multip ara, APH, history of previous PPH, severe anaemia) are to be screened & delivered in a salubrious equipped hospital. Blood groping should be one for entirely women so that no time is skeletal during emergency. eutherian 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 availableness of blood & or blood products must be ensured before hand.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 advancen to reduce blood loss. Exploration of the utero-vaginal line for evidence of trauma following difficult labour or instrumental delivery. Observation for about 2 hours often delivery to make sure that the uterus is hard and well contracted before mov e 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 later a specified period of time ( everydayly half to 1 hour following the babys birth). This is done to apply pressure to the placental site. The whole hand is introduced into the vagina in retinal cone shaped fashion after separating the labia with the fingers of the early(a) hand. the vaginal hand is clenched into a fist with the pole of the hand directed posteriorly and the knuckles in the anterior fornix. The separate hand is placed over the paunch behind the uterus to make it anteverted. The uterus is firmly squeezed amongst the two detainment. 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 mathematical operation is done unde r general anaesthesia. The patient is placed in lithotomy position with all aseptic measures, the bladder is catheterized. One hand is introduced into the uterus after smearing with the antiseptic solution in cone shaped vogue 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 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 in look the uterine pitfall till the placenta is completely separated. As soon as the placental margin is reached, the fingers are insinuated amidst 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 ways slicing movement of the fingers, until whole of the placenta is separated. When the pl acenta 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 cipher is left behind.i) Management of third stage bleedingIn this third stage of bleeding or hemorrhage, the bleeding occurs before expulsion of placenta.Principles To empty the uterus. To replace 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 true post partum hemorrhageIn this true post partum hemorrhage the bleeding occurs consequent to expulsion of placenta (majority).Management Call for extra help involve the obstetric senior staff on call. Keep patient flat and warm. Send blood for diagnostic test. Infuse rapidly 2 litres of conventionalism saline. Give oxygen by mask 10-15L/min. Monitor the pulse, blood pressure, urine output, drug type, dose and time.B. vicarious 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. transmission system and separation of slough over a deep cervico-vaginal laceration. 3. Endometritis and sub involution of the placental site- repayable to delayed healing process. 4. Secondary hemorrhage from caesarean section wound usually occur between 10-14 d ays. 5. Withdrawal bleeding following oestrogen therapy for suppression of lactation.Clinical Manifestation1. The lochia are heavier than normal & payoff 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) abrade the uterus if it is still palpable to bring about a contraction.ii) Express any clots.iii) Encourage the contract to empty her bladder.iv) Give an oxytocic drug such as ergometrine by intravenous or intramusc ular route.v) Save 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 inured conservatively with antibiotic therapy and oral ergometrine. vii) Anemia is treated with iron supplement & in severe cases, blood is transfused.Nursing management of PPHAssessment1. Assess maternal history for risk factors, plan accordingly and communicate to the perinatal area. 2. Assess pulse pressure, recording systematically less than 30bpm are consistent with hypertensive crisis. 3. Assess intake & output chart. 4. Assess location & resolve 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) dearth fluid volume relate to blood loss as manifested by looking pale, dehydrated & shine pulse rate. ii) Acute suffering related to perineal discomfort from birth trauma and physiologic changes from bir ths as monitored by wrinkled in forehead, restlessness & irritability. iii) imbalance nutrition less than body requirement related to restriction in food intake as manifested by fatigue, weakness and lethargic. iv) Sleeping material body dissonance related to pain & bleeding as manifested by drowsiness, lethargic, irritated, etc. v) Risk for infection related to birth process & defying poor hygiene as manifested by patients verbal complain, irritable & discomfort. cultivationi) Monitoring for hypotension & bleeding.ii) Minimize the pain.iii) Improve nutritional status.iv) Improve sleep pattern.v) Reduce the risk for infection.Intervention For initiative diagnosisi) Monitor vital signs every 4 hours during the first 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, duration and type also. ii) Provide comfortable position (i.e. supine position) iii) Administered medicine a s prescribed by the doctor. For 3rd diagnosisi) Assess the nutritional status of the patient. ii) Patient is advised to take liquid victuals 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 caution day time sleeping. For 5th diagnosisi) Assessed the level of infection, burning 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 personal hygiene and also should teach how to take care of perineal area.Evaluationi) Bleeding is trim 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 morbidity & 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 unavoidable 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 thorough idea about this disease and I am thankful to maam for adult 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 phonograph recording of obstetrics 7th edition, new central track record 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 editio n. 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. 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