PROTOCOL FOR MANAGEMENT OF POST – PARTUM HAEMORRHAGE.

INTRODUCTION

Post – partum haemorrhage is one of the commonest causes of maternal deaths globally, consequently, securing the post - partum period has been recognized as the key to all efforts aimed at reducing the burden of maternal mortality especially in developing countries where inadequacy of skilled birth attendants at delivery and poor health status of women combine frequently to increase the risk of morbidity and mortality from delivery.

Definition

Traditionally, Post – partum haemorrhage (PPH) said to occur if a patient loses 500ml or more of blood from the birth canal after complete delivery of the baby.

If this occurs within 24Hours of delivery, it is termed primary PPH and if it occurs after 24Hours but within 6weeks of delivery, it is termed secondary Post – Partum haemorrhage (20 PPH)

However, any bleeding from the genital tract after delivery, that compromises the patient’s clinical state after delivery, is significant, irrespective of quantity. This is influenced by the patient’s clinical state before delivery. This rider to the definition of PPH (especially 10 PPH) is particularly important in patients with anaemia and sickle cell disease and those with contracted blood volume as in pre-eclampsia and dehydration.

Management of PPH

Post-partum haemorrhage is an important obstetric emergency and demands prompt diagnosis and treatment.

Estimation of blood loss

It is often difficult to accurately quantify blood loss at delivery. Most midwives / accoucheurs rely on their experiences to make estimates and under-estimation is often the rule than the exception. Practitioners should beware of this fact, and where there is doubt, rely more on the clinical features exhibited by each patient as useful indicators of the volume of blood loss as at the time of assessment.

STEPS IN THE MANAGEMENT OF PPH

Due to the emergency nature of post-partum haemorrhage and the fact that its cause is best determined by exclusion, it is useful to adopt a flow chart approach for its management.

This has the advantage of a step-ladder process that integrates investigation, treatment and monitoring of the patient, with minimal loss of time. And this is very crucial in the management of PPH.

VITAL STEPS / ACTIONS

Successful management of a patient with PPH stands on a tripod of 3 basic actions.

1. Identify patient with PPH.

2. Resuscitate patient.

3. Determine the cause of PPH and treat the cause.

Step 1

Identify patient with PPH by using the above defined criteria or the following clinical features

 Profuse bleeding per vaginam

 Pallor.

 Rapid and thready pulse.

 Low blood pressure.

 Uterus may or may not be well contracted.

Step 2

Upon suspicion of excessive bleeding in a patient, in the third stage of labour, it is advocated that the uterine cornua be massaged in order to stimulate an efficient contraction.

Step 3

The urinary bladder should be emptied by voiding or catheterization.

Step 4

An intravenous access should be established quickly and administration of intravenous fluids commenced.

Step 5

Ergometrine 0.5mg should be given intravenously or same dose repeated if this has been given at delivery. This should be followed by intravenous administration of high concentration Oxytocin infution constituted by adding 40 international units of oxytocin to 500ml of normal saline. This should be given, preferably, through a second intravenous access secured with a wide bore I.V. cannula or connected via a Y- connection to the first I.V. line.

Step 6

Further bleeding will necessitate a blood cross-match, verification of the patient’s clotting profile and commencement of blood transfusion when blood is available.

Step 7

At this stage, if the placenta has not been delivered, controlled cord traction should be performing to do so, failing which a manual removal should be instituted under general anaesthesia. Accumulated evidence now suggests that injection of 0.9% saline solution plus oxytocin into the umbilical vein of a retained placenta is a more effective, safer and simpler means of treatment than the manual removal.

Step 8

Where the placenta has been previously delivered, it should be carefully inspected for completeness. In the event on an uncertainty of the completeness of the placenta, an ultrasound scan may be perform to detect residual placenta tissue, which will necessitate a uterine evacuation.

Step 9

Persistence of bleeding will require the attention of an obstetrician who is expected to examine for and repair any genital tract laceration.

Step 10

The persistence of bleeding at this stage should be managed with a bimanual compression of the uterus while oxygen is administered and prosuidandin F2α is injected into the uterine fundus.

Step 11

The suspicion of rupture of the uterus will indicate a laparotomy.

Step 12

The clotting profile should he repeated at this stage, in the absence of a coagulopathy a laparotomy should he performed, at which ligation of the ascending branches of the uterine arteries or the hypogustric artery or a hysterectomy may he performed.

Step 13

If disseminated intravascular coagulation is confirmed, a haematologist will have to be involved and the transfusion of fresh frozen plasma or cryoprecipitate and fibrinogen should be given.


Flow Chart For The Management Of Post – Partum Haemorrhage.

PPH

• Intravenous Access / fluid / oxytocics

• Cross match blood / clotting profile

• Head low position

• Oxygen by mask

• Crystalloids / Colloids

• Blood Transfusion

Uterus not well contracted Uterus well contracted

Uterus Atony Retained Placenta Examine placenta

More oxytocics C.C.T. / Manual Removal Complete Incomplete/uncertain

Examine for Genital tract trauma USS

Absent Present ERPC

Repeat clotting profile, USS Repair

Coagulation failure Normal coagulation

Fresh frozen plasma or cryoprecipitate Suspect uterine Rupture

Laparotomy

Atony Rupture

Intramyometrial Ligation of ascending BIIAL B-lynch Hysterectomy Repair

Oxytocics, PGF2 Uterine Artery suture

Prevention of Primary Post-Partum haemorrhage

The adage, prevention is better than cure, finds ready application in post-partum haemorrhage. The institution of preventive measures on patients who are prone to developing this disorder has been one of the major achievements of modern midwifery. It draws its strength from patient’s attendance to prenatal care where risks of post-partum haemorrhage are from the past and present obstetric history and the characteristics of the current pregnancy. These considerations include high parity, previous haemorrhage, existing anaemia, multiple gestation, polyhydramnios, and placenta praevia.

The At Risk Group

The prevention process starts with risk identification and proceeds to patient counseling, blood group determination, correction of anaemia before on set of labour, and patient’s assessment at 36 weeks of gestation to determine the best mode of delivery. The process continues in labour with its supervision being made by a skilled attendant (doctor, midwife or muse), early presentation in labour, request for a blood cross-match, and an intravenous infusion in the first stage of labour. An adherence 10 partographic ideal in the care of the first stage of labour serves to prevent prolonged labour, a predisposing factor to post-partum haemorrhage. The use of episiolomy or resort to instrumental delivery should be only when indicated.

Prophylactic Management of Post-Partum Haemorrhage

Recent analysis of accumulated evidences suggests that active management of third stage of labour is superior to “expectant management” in terms of blood loss, post-partum haemorrhage and other serious complications of the third stage and is recommended for use for all women expecting to deliver in a maternity hospital. Active management involves administration of a prophylactic oxytocic before delivery of the placenta, curly cord clamping and controlled cord traction of the umbilical cord. Syntometrine (combination of syntocinon and Ergometrine) is the most preferred oxytocic for this purpose because it has been shown to be associated with reduced risk of post-partum haemorrhage when compared to oxytocin use alone. Syntometrine is also associated with side effect of vomiting and hypertension, which accompany Ergometrine use. Expectant management of the third stage of labour involves allowing the placenta to deliver spontaneously or aiding by gravity or nipple stimulation. A thorough inspection of the placenta and membranes usually held under running water, SS very valuable for the earliest diagnosis of retained placenta! tissue. Prompt and skillful repair if episiotomies are always protective against post-partum haemorrhage. The strict observance of maternal rest in the fourth stage of labour, coupled with close monitoring of her vital signs and sanitary pad count during the period is reassuring and proraotive of early detection of a haemorrhage. Another preventive measure against post-partum i haemorrhage is the continuation of syntocinon infusion throughout the fourth static of labour.