1. APH/PPH PPT BYAPH/PPH PPT BY
Dr Donald.Dr Donald.

2.  Bleeding that occurs between 28 weeks GA and term.
 CAUSES:
 Extra placental – cervical lesions e.g trauma,
polyps,tumors.
 Vaginal lesions e.g tears and lacerations.
 Infections.
 Uterine rapture.
 Placental causes e.g Abruptio placenta, placenta
praevia, vasa previa

3. 1. CBC
2. Urine analysis for haematuria and proteinuria
3. Bedside clotting time.
4. Bleeding time.
5. Obs scan.

4.  Take careful and comprehensive history.
 Do physical/ abdominal exam for peritonism, contractions and
FH presence.
 Do speculum exam to check bleeding points and assess cervical
dilatation.
 Catheterize for input/ output chart.
 Urgent GXM.
 IVF – DNS is the ideal.
 Monitor vitals and FH tones.
 Incase of AP start BT and do AROM, give IV 10 IU oxytocin in D5.
 Continue oxytocin drip upto 2 hours PP.
 Incase of PP 1 & 2 do vaginal delivery. 3 & 4 prepare for
emergency CS.
 For VP elective CS between 35 – 36 weeks GA. This is because we
want to deliver before spontaneous ROM.

5.  I – Low lying placenta and not encroaching the Os.
 II - Partially encroaches but not in labor.
 III – Partially encroaches and stays during labor.
 IV – Completely covers the Os and doesn’t change in
labor.

6.  Early
 Occurs when blood loss is greater than
500 ml. in the first 24 hours after a vaginal delivery
or greater than 1000 ml after a cesarean birth
*Normal blood loss is about 300 - 500 ml.)
 Late
 Hemorrhage that occurs after the first 24 hours

7.  Uterine Atony:
 Precipitate and/or prolonged labor.
 Uterine over distension e.g. multiple pregnancy, macrosomia, macrocephaly
( hydrocephalus), uterine myomas.
 Grand multiparity.
 GA/Halothane use.
 Couvelaires uterus – concealed bleeding during AP that eventually leads to
intramyometrial bleeding.
 Uterine sub involution.
 Tears and Lacerations:
 Cervical, vaginal or vulvoperineal tears.
 Uterine rapture due to previous scars – 2 or more, overuse of uterotonics e.g.
oxytocin, misoprostol, obstructed labor in multigravida, ecbolic herbal use,
grand multiparity.
 Retained Placental Fragments e.g. placenta accreta, increta, percreta.
 Thromboembolism:
 DIC secondary to IUFD, abortion, amniotic fluid embolism, APH, Eclampsia.

8. **The myometrium fails to contract and
the uterus fills with blood because of
the lack of pressure on the open
vessels of the placental site
The myometrium fails to contract and
the uterus fills with blood because of
the lack of pressure on the open blood
vessels of the placental site.

9. Prolonged
labor
Overdistention
of the
Uterus
Grandmultiparity
Excessive use of
Analgesia / Anesthesia
Intrapartum
Stimulation
with Pitocin
Trauma due
to Obstetrical
Procedures

10.  Most common cause of Hemorrhage:-
 Key to successful management is:
PREVENTION!
 Nurse many times can predict which women
are at risk for hemorrhaging.

11. Signs
and
Symptoms
Excessive
or
Bright Red
Bleeding
Abnormal
Clots
A boggy uterus that does not
respond to massage
Unusual pelvic discomfort or backache

12.  Document Vaginal Bleeding
 Fundal massage / Bimanual Compression
 Assess Vital Signs (shock)
 Give medications– Oxytocin, Ergometrine.
 D & C, Hysterotomy/ectomy, Replace blood /
fluids

13.  PREDISPOSING FACTORS
1. Spontaneous or Precipitous delivery
2. Size, Presentation, and Position of baby
3. Contracted Pelvis
4. Vulvar, cervical, perineal, uretheral area and vaginal
varices
 Signs and Symptoms
1. Bright red bleeding where there is a steady
trickle of blood and the uterus remains firm.
2. Hypovolemia

14.  Treatment and Nursing Care
1. Meticulous inspection of the entire
lower birth canal
2. Suture any bleeders
3. Vaginal pack-- nurse may remove and
assess bleeding after removal
4. Blood replacement

15.  You are assigned to Mrs. B. who
delivered vaginally. As you do your
post-partum assessment, you notice that
she has a large amount of lochia rubra.
 What would be the first measure to
determine if it is related to uterine atony or a
laceration?

16.  This occurs when there is incomplete
separation of the placenta and fragments of
placental tissue retained.
 Signs
 Boggy , relaxed uterus
 Dark red bleeding
 Treatment
 D & C
 Administration of Oxytocins
 Administration of Prophylactic antibiotics

17. Major Symptom: PAIN- deep, severe,
unrelieved, feelings of pressure
Many times bleeding is concealed. Major
symptom is rectal pain and tachycardia.
Treatment:
May have to be incised and drained.

18.  The uterus inverts or turns inside out after
delivery.
 Complete inversion - a large red rounded mass
protrudes from the vagina
 Incomplete inversion - uterus can not be seen, but felt
 Predisposing Factors:
 Traction applied on the cord before the placenta has
separated.
**Don’t pull on the cord unless the placenta has
separated.
 Incorrect traction and pressure applied to the fundus,
especially when the uterus is flaccid
**Don’t use the fundus to “push the placenta out”

19. Traction on
the cord
starts the
uterus to
invert
Uterus continues
to be pulled and
inverted
Uterus
Placenta

20. Vagina
Uterus
Inverted
Vagina
Uterus
Manually
pushed back
into place

21.  Replace the uterus--manually replace and pack uterus
 Combat shock, which is usually out of
proportion to the blood loss
 Blood and Fluid replacement
 Give Oxytocin
 Initiate broad spectrum antibiotics
 May need to insert a Nasogastric tube to
minimize a paralytic ileus
Notify the Recovery Nurse what has occurred!
Care must be taken when massaging

22. All or part of the decidua basalis is absent and the
Placenta grown directly into the uterine muscle.

23.  Signs:
 During the third stage of labor, the
placenta does not want to separate.
 Attempts to remove the placenta in
the usual manner are unsuccessful,
and lacerations or perforation of the
uterus may occur

24.  If it is only small portions that are
attached, then these may be removed
manually
 If large portion is attached--a
Hysterectomy is necessary!

25.  The following is a plan for managing massive
obstetric hemorrhage, adapted from Bonner.
[31]
The word order is a useful mnemonic for
remembering the basic outline.
 OrganizationCall experienced staff (including
obstetrician and anesthetist).
 Alert the blood bank and hematologist.
 Designate a nurse to record vital signs, urine
output, and fluids and drugs administered.
 Place operating theater on standby.
 ResuscitationAdminister oxygen by mask.

26.  ResuscitationAdminister oxygen by mask.
 Place 2 large-bore (14-gauge) intravenous lines.
 Take blood for crossmatch of 6 U PRBCs, and
obtain a CBC count, coagulation screen, urea
level, creatinine value, and electrolyte status.
 Begin immediate rapid fluid replacement with
NS or Ringer lactate solution.
 Transfuse with PRBCs as available and
appropriate

27.  Defective blood coagulationOrder coagulation
screen (International Normalized Ratio,
activated partial thromboplastin time) if
fibrinogen, thrombin time, blood film, and D-
dimer results are abnormal.
 Give FFP if coagulation test results are
abnormal and sites are oozing.
 Give cryoprecipitate if abnormal coagulation
test results are not corrected with FFP and
bleeding continues.
 Give platelet concentrates if the platelet count

28.  Evaluation of responseMonitor pulse, blood
pressure, blood gas status, and acid-base
status, and consider monitoring central venous
pressure.
 Measure urine output using an indwelling
catheter.
 Order regular CBC counts and coagulation
tests to guide blood component therapy.

29.  Remedy the cause of bleedingIf antepartum,
deliver the fetus and placenta.
 If postpartum, use oxytocin, prostaglandin, or
ergonovine.
 Explore and empty the uterine cavity, and
consider uterine packing.
 Examine the cervix and vagina, ligate any
bleeding vessels, and repair trauma.

30.  Ligate the uterine blood supply (ie, uterine,
ovarian, and/or internal iliac arteries).
 Consider arterial embolization.
 Consider hysterectomy.

31.  Uterine Atony
 Retained placental
fragments
 Lacerations
 Inversion of the uterus
 Placenta accreta
 Hematoma
 _________________
 _________________
 _________________
 _________________
 _________________
 _________________

33.  DefinitionDefinition
Infection of the genital tract that occurs
within 28 days after abortion or delivery
 Causes
Streptococcus Groups A and B
Clostridium, E. Coli

34.  Predisposing Factors
1. Trauma
2. Hemorrhage
3. Prolonged labor
4. Urinary Tract Infections
5. Anemia and Hematomas
6. Excessive vaginal exams
7. P R O M

35.  Signs and Symptoms of Postpartum
Infection
1.1.Temperature increase of 100.4 or higher
on any 2 consecutive days of the first
10 days post-partum, not including the
first 24 hours.
2.2. Foul smelling lochia, discharge
3.3. Malaise, Anorexia, Tachycardia, chills
4.4. Pelvic Pain
5.5. Elevated WBC

36. • Administer broad spectrum antibiotics
• Provide with warm sitz baths
• Promote drainage--have pt. lie in HIGH fowlers position
• Force fluids and hydrate with IV’s 3000 - 4000 cc. / day
• Keep uterus contracted, give Methergine
• Provide analgesics for alleviation of pain
• Nasogastric suction if peritonitis develops
TREATMENT AND NURSING CARE

37.  What is the classic sign of a
Postpartum Infection?
Test Yourself !

38. Pelvic Cellulitis
Peritonitis
Spiking a fever of 102 0
F to 104 0
F
Elevated WBC
Chills
Extreme Lethargy
Nausea and Vomiting
Abdominal Rigidity and Rebound Tenderness
Signs and Symptoms:

39.  Prompt treatment of anemia
 Well-balanced diet
 Avoidance of intercourse late in pregnancy
 Strict asepsis during labor and delivery
 Teaching of postpartum hygiene measures
 keep pads snug
 change pads frequently
 wipe front to back
 use peri bottle after each elimination

40.  Infection of the Episiotomy, Perineal
laceration, Vaginal or vulva lacerations
 Wound infection of incision site
 Signs:
Reddened, edematous, firm, tender edges of
skin
Edges seperate and purulent material drains
from the wound.
 Treatment
Antibiotics
Wound care

41.  Mrs. X. was admitted with endometritis
and Mrs. Y. was admitted with an infection
in her cesarean incision. Are both classified
as a postpartum Infection?
 What would be the major difference in
presenting symptoms you would note on
nursing assessment?

43. • Prevention:
• Monitor the patients urination diligently!
• Don’t allow to go longer than 3 - 4 hours before intervening.
• Treatment
• Antibiotics -- Ampicillin
• Urinary Tract Antispasmodics
• Causes:
• Stretching or Trauma to the base of the bladder results in
edema of the trigone that is great enough to obstruct the
urethra and to cause acute retention.
• Anesthesia

44. Marked Engorgement, Pain, Chills,
Fever, Tachycardia, Hardness and
Redness, Enlarged and tender lymph
nodes

46. Types:
Mammary Cellulitis - inflammation of the
connective tissue betweenbetween the lobes in the
breast
Mammary AdenitisMammary Adenitis - infection inin the ducts
and lobes of the breasts

47. P o o r
P o s it i o n in g
o f I n f a n t
Im p r o p e r
b r e a k in g o f
s u c t io n
S t r o n g
S u c k in g
In f a n t
F ir s t
N u r s i n g
E x p e r i e n c e
A b r u p t
W e a n i n g
S u p p le m e n t a l
F e e d i n g s
In t e r v a l
b e t w e e n
n u r s in g t o o l o n g
" L a z y F e e d e r "
D e v e lo p m e n t o f M a s t it is
Nipple Trauma Pain Impaired Engorgement
Let down
Cracked Stasis
nipples of milk
Entry for Bacteria Plugged ducts
Mastitis
Treatment, No Treatment
Problem will resolve Breast Abscess

48.  Rest
 Appropriate Antibiotics--Usually Cephalosporins
 Hot and / or Cold Packs
 Don’t Breast Feeding because:
 If the milk contains the bacteria, it also contains the
antibiotic
 Sudden cessation of lactation will cause severe
engorgement which will only complicate the
situation
 Breastfeeding stimulates circulation and moves the
bacteria containing milk out of the breast
StopStop

49. Preventive Measures
Meticulous
handwashing
Frequent feedings
and massage
distended area to
help emptying
Rotate position of
baby on the breast

50. Breast AbscessBreast Abscess
Breast Feeding is stopped on the affected side, but may feed on the
unaffected side.
Treatment: Incision and Drainage

51.  Predisposing Factors
Slowing of blood in the legs
Trauma to the veins
 Signs and Symptoms
Sudden onset of pain
Tenderness of the calf
Redness and an increase in skin temperature
Positive Homan’s Sign

52.  Treatment
Heparin --it does not cross into breast milk
Antidote: protamine sulfate
Teach patient to report any unusual bleeding, or
petchiae, bleeding gums, hematuria, epistaxis, etc.
 Complication
Pulmonary Emboli

53. Pregnancy alone is not a cause of a psychiatric
Illness; however, the psychological and physiological
stressors relating to pregnancy may bring on an
emotional crisis
Mental Health problems can complicate the
puerperium.
There are days when each new mother may feel
inadequate, but the mother who has a constant
feeling of inadequacy needs professional
counseling.

54.  The Most common Mood Disorders
are:
Baby Blues
Postpartum Depression
Bipolar Disorder

55.  50-80% of moms are affected
 Self-limiting (up to 10 days)
 Cause
 Seems to be related to changes in progesterone,
estrogen, and prolactin levels
 Symptoms
 Tearful yet happy
 overwhelmed
 Treatment

56. Risk factors:
Primiparity
History of postpartum depression
Lack of social and relational support
Clinical therapies
Counseling and support groups
Medication (usually SSRI’s)
Childcare assistance

57. Predisposing factors
Similar to those of postpartum depression
Assessments
Grandiosity
Decreased need for sleep (insomnia)
Flight of ideas
Psychomotor agitation/hyperactivity
Rejection of infant

58.  Drug therapy
 Psychotherapy
 Explain the importance of good nutrition and
rest
 Reintroduce the mother to the baby at the
mothers own pace

59.  How do the signs and symptoms of hematoma
differ from those of uterine atony or a laceration?
 What laboratory study should the nurse suspect
if the woman is on heparin anticoagulation?
 What is the significance of a board-like abdomen
in a woman who has endometritis?
 Why is it important that the breast-feeding
mother with mastitis empty her breasts
completely?
 What is the KEY difference between postpartum
blues and postpartum depression?