Cairo University

1. Group : 3
2016 / 2017
Dr. Walaa
Dr. Basma Dr. Heba
Under Supervision of :
Cairo University
Faculty of Nursing
Obstetric Department

2. Outlines:
• Introduction
• Definition
• Incidences
• Types bleeding (according to time of it)
• Primary PPH
• causes (4 Ts)
• tone
• tissue
• trauma
• thrombin
• risky factors and management of each type
• secondary PPH
• Puerperal sepsis
• Postpartum blues (adjustment reaction with depressed

3. A-PPH:
• Introduction
 Obstetrical emergency that can follow vaginal or
cesarean delivery.
 Postpartum hemorrhage is a significant cause of
maternal morbidity and mortality.
 Postpartum hemorrhage, the loss of more than
500 mL of blood after delivery, occurs in up to 18
percent of births and is the most common
maternal morbidity in developed countries.
Although risk factors and preventive strategies
are clearly documented, not all cases are
expected or avoidable.

4. •Definition
• loss of more than 500 ml or 1,000 ml of blood
within the first 24 hours following childbirth
.that makes the patient symptomatic
(lightheaded, syncope) and/or results in signs
of hypovolemia (hypotension, tachycardia,
oliguria)

5. • Why do we care?
• Major obstetric haemorrhage – more
than 1000ml
• Very rapidly lead to maternal
death

6. Incidences :
• 3% of births
• 3rd most common cause of maternal death.
• PPH is the leading cause of maternal
mortality in low-income countries and the
primary cause of nearly one quarter of all
maternal deaths globally.

7. •Types bleeding (according to time
of it)
• 1-Primary post partum hemorrhage: occur during
the first 24 hrs after delivery – blood loss of
500ml or more .
• 2-Secondary post partum hemorrhage: occurring
more than 24 hrs after delivery.
It can occur along 6 weeks after delivery

8. 1. Primary PPH causes (4
Ts)
1-Tone: uterine atony, distended bladder
defined as the lack of efficient uterine contractility after placental
separation, is the most common cause of PPH and
complicates ∼1 in 20 deliveries.
Risk Factors : Risk factors for uterine atony include
conditions in which the uterus is overdistended
(polyhydramnios, multiple gestation, and
macrosomia), fatigued (prolonged labour,
chorioamnionitis), or unable to contract due to
tocolytics or general anaesthesia

9. Management :
• the uterus may be stimulated to contract with
use of massage and intravenous oxytocin.
• Many studies show this technique reduces
postpartum hemorrhage and the need for blood
transfusions.
• If heavy bleeding from atony occurs despite the
use of oxytocin after delivery, then two additional
medications may be used to help control
hemorrhage
• Methylergonovine, a strong vasoconstrictor
derived from ergot, is injected into a muscle.
• It is not given to patients with preeclampsia or a
history of high blood pressure because it can
cause high blood pressure.

10. Cont..
• Prostaglandin F-2-alpha (Hemabate) is injected
under the skin and also directly into the uterus.
• Frequent side effects include diarrhea and
vomiting. It can cause bronchial constriction and
is usually avoided in patients with asthma.
• Emergency surgery should be performed if atony
persists despite these measures to control the
bleeding
• If bleeding persists in spite of all conservative
measures to control it, a hysterectomy (removal
of the uterus) may be necessary.

11. Primary PPH causes (4 Ts)
• 2-Tissue:
• retained placenta or clots
• a placenta that has not undergone placental
expulsion within 30 minutes of the baby’s birth
where the third stage of labor has been managed
actively.

12. •risk factors :
• The mean time from delivery until
placental expulsion is eight to nine
minutes.
• Longer intervals are associated with
an increased risk of postpartum
hemorrhage, with rates doubling
after 10 minutes.
• Retained placenta (i.e., failure of the
placenta to deliver within 30 minutes
after birth) occurs in less than 3
percent of vaginal deliveries

13. •Management :
• option is to inject the umbilical vein with 20 mL of a
solution of 0.9 percent saline and 20 units of
oxytocin.
• This significantly reduces the need for manual
removal of the placenta compared with injecting
saline alone.
• Alternatively, physicians may proceed directly to
manual removal of the placenta, using appropriate
analgesia.
• If the tissue plane between the uterine wall and
placenta cannot be developed through blunt
dissection with the edge of the gloved hand, invasive
placenta should be considered.

15. •Primary PPH causes (4
Ts)
• 3-Trauma:
• lacerations of the uterus, cervix, or vagina.
• The most common injuries at delivery are
lacerations and hecatombs of the perineum,
vagina, and cervix.
• A majority of the cases are minor, but some
injuries are associated with significant,
immediate, or delayed hemorrhage

16. •Risk factors :
1. null parity.
2. Episiotomy.
3. advanced maternal age.
4. operative delivery.
5. breech presentation.
6. multiple gestation.
7. high birth weight.

17. •Management :
• involving observation, ice, pressure, and analgesics
should be limited to those patients
• small pelvic haematomata that are stable in size,
with no evidence of homodynamic
compromise, Otherwise, surgical exploration,
evacuation, and legation of vessels should be
performed in a controlled setting
• avoid the known severe complications of infection,
septicemia, pressure necrosis, profuse
hemorrhage, and death.
• The choice of anesthetic technique depends on
the affected area, surgical requirements, physical
status of the patient, and urgency of the
procedure.

18. Primary PPH causes (4 Ts)
4-Thrombin:
1-pre-existing or acquired coagulopathy.
Coagulation disorders, a rare cause of post-partum
hemorrhage, are unlikely to respond to the measures
described above.
2- Most coagulopathies are identified before delivery,
allowing for advance planning to prevent postpartum
hemorrhage.
3- These disorders include idiopathic thrombocytopenic
purpura, thrombotic thrombocytopenic purpura, von
Willebrand's disease, and hemophilia.
4-Patients also can develop HELLP (hemolysis, elevated
liver enzyme levels, and low platelet levels) syndrome
or disseminated intravascular coagulation

19. •Risk factors :
1. severe pre-eclampsia
2. amniotic fluid embolism
3. Sepsis
4. placental abruption
5. prolonged retention of fetal demise.
6. Abruption is associated with cocaine use and
hypertensive disorders

20. Management :
• should include a platelet count and measurement
of prothrombin time, partial thromboplastin time,
fibrinogen level, and fibrin split products (i.e., D-
dimer).
• Management consists of treating the underlying
disease process, supporting intravascular volume,
serially evaluating coagulation status, and
replacing appropriate blood components.
• Administration of recombinant factor VII a or
clot-promoting medications (e.g., tranexamic acid
[Cyklokapron]) may be considered.

21. 2-secondary PPH :
• A secondary postpartum hemorrhage is defined as
abnormal or excessive bleeding from the birth
canal between 24 hours and 12 weeks of the
postnatal period.

22. •risk factors :
1. retained bit of cotyledon
2. Separation of slough exposing a blood vessels
3. Sub involution at the placental sit.
• Management:
1. Reassurance.
2. Monitor TPR (temp ,pulse ,resp, bp).
3. IV, empty bladder, give medication.

23. Uterine Contraction
non - pharm
• Empty uterus
• Foley catheter
• Rub up a contraction
• Bimanual compression
• Balloon tamponade
• Brace suture
• Uterine artery legation
• Internal iliac artery legation
• Interventional radiology

24. B-Lynch Suture

25. Balloon Tamponade

26. B-Puerperal sepsis
• puerperal sepsis, is a condition that occurs
when a new mom experiences an infection
related to giving birth.
• puerperal sepsis are the sixth-leading cause of
death among new mothers, according to the
World Health Organization (WHO).
• While fatalities are rare in the United States,
puerperal infections affect about 6 percent of
new mothers.

27. •Causes :
1. While a hospital is a place of healing, it is also a location
where many different types of bacteria grow. After giving
birth, women are more vulnerable to infections of the genital
tract. Bacteria are opportunistic and thrive in warm, moist
environments, like the genital and urinary tracts.
2. Bacteria known to cause a puerperal infection include:
A-chlamydia B-Clostridium tetani C-Clostridium welchii D-
Escherichia coli (E.coli) E-gonococci F-staphylococci G-
streptococci
3. These bacteria can enter the body via pelvic examinations
during labor. This can be because of trauma during labor or
because of prolonged delivery that gives more time for
bacteria to enter the vaginal tract. Use of non-sterile
instruments or unclean hands during dilation checks can also
introduce bacteria into the body.

28. Symptoms :
1. Chills.
2. drainage from the uterus that contains pus or is
foul-smelling.
3. fever greater than 100.4° Fahrenheit.
4. lower stomach pain.
5. Malaise.
6. pain or tenderness in the uterus.
7. uterus does not return to its normal size.
(Symptoms of puerperal sepsis typically begin
anywhere between 24 hours to 10 days after
infection occurs.)

29. •Puerperal sepsis Diagnosed
• check the vagina and uterus for signs of swelling
and tenderness.
• He or she may test for the presence of bacteria
by taking a urine or blood sample or swabbing any
wounds.
• Until the specific bacteria type is determined, a
physician will likely prescribe a broad-spectrum
antibiotic to keep the infection from spreading.

30. •Management :
• Because a blood culture can take time, a
physician may prescribe a broad-spectrum
antibiotic.
• These can kill a range of bacterial types and
prevent an infection from spreading.
• If a surgical site infection is the cause, the
area must be kept clean and dry to prevent
further bacteria from invading.
• Anti-fever medications and cold compresses
may also help keep a patient’s fever as minimal
as possible.

31. C-Postpartum blues :
• A common temporary psychological state right after
childbirth when a new mother may have sudden mood swings,
feeling very happy, then very sad, cry for no apparent
reason, feel impatient, unusually irritable, restless, anxious,
lonely and sad.
• The baby blues may last only a few hours or as long as 1 to 2
weeks after delivery.
• The baby blues in this sense are less severe than
a postpartum depression. The baby blues do not always
require treatment from a health care provider. Often,
joining a support group of new mothers or talking with other
mothers helps.

32. •symptoms
1. crying for no apparent reason
2. Impatience
3. Irritability
4. Restlessness
5. Anxiety
6. Fatigue
7. Insomnia (even when the baby is sleeping)
8. Sadness
9. Mood changes
10. Poor concentration

33. •causes :
• The exact cause of the “baby blues” is unknown at
this time.
• It is thought to be related to the hormone
changes that occur during pregnancy and again
after a baby is born.
• These hormonal changes may produce chemical
changes in the brain that result in depression.
• Also, the amount of adjustment that comes after
the birth of a baby, along with sleep disturbance,
disruption of “routine”, and emotions from the
childbirth experience itself can all contribute to
how a new mom feels.

34. •Management
• Taking care of mom is the best way to decrease the symptoms
of the “baby blues.” There are several different ways that you
can care of moms if they are having the “baby blues.”
• Should Tell moms to :
1. Talk with someone that you trust about how you are feeling.
2. Maintain a well balanced diet. Having a new baby may cause
you not to eat correctly, and too many simple carbohydrates
can make mood swings more pronounced.
3. Keep a journal of all your thoughts and feelings.

35. Cont..
1. Get outside to enjoy fresh air and life outside the
confines of diapers, feedings, and spit up.
Sometimes just a different view for a few moments
can make a huge difference.
2. Ask for help with meals, other children, getting into
a “routine”, or any help that allows you to focus on
the joy of having a new baby and not just the
pressure of juggling it all.
3. Don’t expect perfection in the first few weeks. Give
yourself time to heal from birth, to adjust to your
new “job,” and for feeding and sleeping routines to
settle in.