1. Presented By: NISHA JAYAN Presented By: NISHA JAYAN POST PARTUM HEMORRHAGE

3. CASE NO: 190*** NAME: G.X. DIAGNOSIS: POST PARTUM HEMORRHAGE DIAGNOSIS: POST PARTUM HEMORRHAGE AGE: 31 y/o SEX: FEMALE

5. GENERAL  The patient is 31 y/o, FEMALE, weighs 67 kg.  Vital Signs: BP= 110/60 mmHg PR=76 bpm RR= 22 /mt Temp=37 ⁰ C O²Sat= 98%  Vital Signs: BP= 110/60 mmHg PR=76 bpm RR= 22 /mt Temp=37 ⁰ C O²Sat= 98%

6.  Fair complexion  No palpable masses or lesions SKIN

7.  Maxillary, frontal, and ethmoid sinuses are not tender.  No palpable masses and lesions  No areas of deformity HEAD

8.  Awake and alert LOC & ORIENTATION  Oriented to persons, Place, Time

9.  Pale conjunctivae but no dryness  Pupils equally round and reactive to light EYES

10. EARS  No unusual discharges noted

11.  Pink nasal mucosa  No unusual nasal discharge  No tenderness in sinuses NOSE

12.  Pink and moist oral mucosa  Free of swelling and lesions MOUTH

13.  No palpable lymph nodes  No masses and lesions seen NECK AND THROAT

14.  Equal chest expansion  No retraction  Clear breath sounds CHEST AND LUNGS

15.  Regular rhythm HEART

16.  Not well contracted uterus after delivery ABDOMEN

17.  With moderate vaginal bleeding GENITALS  With vaginal laceration

18.  No lesions noted EXTREMITIES

20. PAST MEDICAL HISTORY  No past medical history

21. OBSTETRICAL HISTORY DATES OF PRIOR PREGNENCIES GESTATIONAL AGE ROUTE COMPLICATIONS G1 TERM NSVDNONE G2TERMNSVDNONE G3 TERMNSVDGDM ON DIET

22. PRESENT MEDICAL HISTORY  G4P3 39 weeks delivered normally with RMLE,vaginal laceration with PPH.

23. MEDICATIONS

24. INVESTIGATIONS LABORATORYRESULTREFERANCE RANGE CBC  Hb  HCT  PLT 12.5(BEFORE DELIVERY) 9.6 g/dl(AFTER DELIVERY) 26.2% 292 11.2-15.7gdl 11.2-15.7g/dl 34.1-44.9% 182-369/UL PT11.710.9-16.3 SEC APTT30 SEC27-39 sec BLOOD GROUP“O” POSITIVE HBsAGNEGATIVE RBS6.8mmol/L ANTIBODY SCRRENNEGATIVE RUBELLAPOSITIVE

26. POST PARTUM HEMMORHAGE o Post partum hemorrhage (PPH) is an obstetrical emergency that can follow vaginal or cesarean delivery. o The average amount of blood loss after vaginal delivery is 500 ml,and blood loss for cesarean birth is approximately 1000 ml. o It is major cause of maternal morbidity.The most PPH occurs right after delivery but it can occur later as well. o In most cases, PPH is due to bleeding from the placental site, which is due to uterine Atony. Because the flow of blood is high in the uterine arteries at the end of pregnancy. o Post partum hemorrhage (PPH) is an obstetrical emergency that can follow vaginal or cesarean delivery. o The average amount of blood loss after vaginal delivery is 500 ml,and blood loss for cesarean birth is approximately 1000 ml. o It is major cause of maternal morbidity.The most PPH occurs right after delivery but it can occur later as well. o In most cases, PPH is due to bleeding from the placental site, which is due to uterine Atony. Because the flow of blood is high in the uterine arteries at the end of pregnancy.

27. POST PARTUM HEMMORHAGE  PRIMARY PPH o There is greater risk of hemorrhage in the first 24 hours after birth called.  SECONDARY PPH o Occurs after the first 24 hours of birth  PRIMARY PPH o There is greater risk of hemorrhage in the first 24 hours after birth called.  SECONDARY PPH o Occurs after the first 24 hours of birth

29. ANATOMY & PHYSIOLOGY ON THIRD STAGE OF LABOR

30. The third stage is called the placental stage. It begins with the birth of the infant and ends with the delivery of the placenta. Two separate phases are involved: placental separation and placental expulsion. After birth, the uterus can be palpated as a firm round mass just inferior to the level of the umbilicus. After a few minutes, the uterus begins to contract again and assumes a discoid shape. It retains this shape until placenta is separated, approximately 5 minutes after birth of the infant.

31. Placental Separation As the uterus further contracts down on an almost empty interior causing disproportion between the placenta and the contracting wall of the uterus ultimately causing separation of the placenta. The following are the signs indicating that placenta has loosened and is ready to deliver: –Lengthening of the umbilical cord –Sudden gush of vaginal blood –Change in the shape of the uterus –Firm contraction of the uterus –Appearance of the placenta at the vaginal opening –Bleeding occurs as a normal consequence of placental separation. The normal blood loss is 500mL.

32. Placental Expulsion After separation, the placenta is delivered either by the natural bearing-down effort of the mother or by gentle pressure on the contracted uterine fundus by the physician or nurse-midwife (Crede’s maneuver). Pressure must never be applied to post-partal uterus in a non- contracted state, because doing so would cause uterus to evert and maternal blood sinuses are open and gross hemorrhage could occur. If the placenta does not deliver spontaneously, it can be removed manually. –The average time from delivery of the baby until complete expulsion of the placenta is estimated to be 10–12 minutes dependent on whether active or expectant management is employed. In as many as 3% of all vaginal deliveries, the duration of the third stage is longer than 30 minutes and raises concern for retained placenta

33. ETIOLOGY Remember the 4 Ts:  Tone  Tissue  Trauma  Thrombin Remember the 4 Ts:  Tone  Tissue  Trauma  Thrombin

34. TONE Uterine Atony “Boggy” uterus Most common cause of PPH 70% of all PPH Uterine Atony “Boggy” uterus Most common cause of PPH 70% of all PPH

35. RISK FACTOR FOR UTERINE ATONY o Risk Factors for Uterine Atony o Uterine over distension (Polyhydramnios, large baby, multiples) o Uterine exhaustion (precipitous labour, prolonged/augmented labour, high parity) o Infection (prolonged rupture of membranes, fever) o Anatomical distortion of the uterus (uterine abnormality, fibroids, placenta Previa) o Exposure to specific drugs (NTG, Volatile agents, Beta agonist) o Risk Factors for Uterine Atony o Uterine over distension (Polyhydramnios, large baby, multiples) o Uterine exhaustion (precipitous labour, prolonged/augmented labour, high parity) o Infection (prolonged rupture of membranes, fever) o Anatomical distortion of the uterus (uterine abnormality, fibroids, placenta Previa) o Exposure to specific drugs (NTG, Volatile agents, Beta agonist)

36. TISSUE Retained products Abnormal placenta (placenta accrete, increta or percreta) Previous uterine surgery Retained products Abnormal placenta (placenta accrete, increta or percreta) Previous uterine surgery

37. TRAUMA Lacerations of cervix, vagina, perineum or C/S incision site Hematomas Uterine Rupture Uterine inversion Lacerations of cervix, vagina, perineum or C/S incision site Hematomas Uterine Rupture Uterine inversion

38. RISK FACTOR FOR TRAUMA o Precipitous delivery o Operative delivery o Assisted delivery (forceps, vacuum) o Previous uterine surgery o Fundal placenta o Precipitous delivery o Operative delivery o Assisted delivery (forceps, vacuum) o Previous uterine surgery o Fundal placenta

39. THROMBIN Abnormal coagulation Very rare Usually identified before delivery Abnormal coagulation Very rare Usually identified before delivery

40. RISK FACTOR FOR THROMBIN  Pre-existing –Hemophilia –Idiopathic thrombocytopenia (ITP) –History of blood clots  Acquired in pregnancy –Pre-eclampsia –HELLP –Amniotic fluid embolus  Medication (aspirin, heparin)  Antepartum Hemorrhage  Pre-existing –Hemophilia –Idiopathic thrombocytopenia (ITP) –History of blood clots  Acquired in pregnancy –Pre-eclampsia –HELLP –Amniotic fluid embolus  Medication (aspirin, heparin)  Antepartum Hemorrhage

41. PREVENTATIVE MEASURES Active management of the third stage of labour Oxytocin with delivery of baby Prophylactic Oxytocin decreases PPH by 40% Deliver placenta with controlled cord traction and inspect for completeness Palpate uterus and inspect lower genital tract Active management of the third stage of labour Oxytocin with delivery of baby Prophylactic Oxytocin decreases PPH by 40% Deliver placenta with controlled cord traction and inspect for completeness Palpate uterus and inspect lower genital tract

42. SIGNS & SYMPTOMS With uterine Atony,uterus is soft or boggy difficult to palpate Uncontrolled bleeding Decreased blood pressure, dizziness and decreased urine output occur late Increased heart rate Laceration of the vagina, cervix can cause continuous bleeding even when the funds is firm Decrease in the red blood cell count Abdominal pain With uterine Atony,uterus is soft or boggy difficult to palpate Uncontrolled bleeding Decreased blood pressure, dizziness and decreased urine output occur late Increased heart rate Laceration of the vagina, cervix can cause continuous bleeding even when the funds is firm Decrease in the red blood cell count Abdominal pain

43. COMPLICATIONS Significant blood loss Hysterectomy Death Significant blood loss Hysterectomy Death

44. HOW IS POST PARTUM HAEMORRHAGE DIAGNOSED? Estimation of blood loss(this may be done by counting the number of saturated pads,or by weighing of pads and sponges used to absorb blood ) Pulse rate and blood pressure measurement Hematocrit red blood cell count Clotting factors in the blood Estimation of blood loss(this may be done by counting the number of saturated pads,or by weighing of pads and sponges used to absorb blood ) Pulse rate and blood pressure measurement Hematocrit red blood cell count Clotting factors in the blood

46. NURSING MANAGEMENT

47. Maintain I. V. access with normal saline infusion and add a secondary line with 16g catheter for sever loss. Monitor vital signs every 15 minutes Make sure that cross matched blood is available Provide supplemental oxygen by face mask, monitor oxygen saturation with pulse oximeter Administer medications as order Maintain I. V. access with normal saline infusion and add a secondary line with 16g catheter for sever loss. Monitor vital signs every 15 minutes Make sure that cross matched blood is available Provide supplemental oxygen by face mask, monitor oxygen saturation with pulse oximeter Administer medications as order

48. NURSING MANAGEMENT Use proper technique ( with two hands,gentile Fundal pressure) during uterine massage Prevent infection by maintaining sterile techniqu Maintain adequate rest and nutrition Provide emotional support Documentation Use proper technique ( with two hands,gentile Fundal pressure) during uterine massage Prevent infection by maintaining sterile techniqu Maintain adequate rest and nutrition Provide emotional support Documentation

49. MEDICAL MANAGEMENT Medication Manual massage of the uterus-to stimulate contraction Removal of placental pieces that remain in the uterus Examination of the uterus and pelvic tissues Packing the uterus with sponges and sterile materials(to compress the bleeding area in the uterus ) Medication Manual massage of the uterus-to stimulate contraction Removal of placental pieces that remain in the uterus Examination of the uterus and pelvic tissues Packing the uterus with sponges and sterile materials(to compress the bleeding area in the uterus )

50. MEDICAL MANAGEMENT Tying –off of bleeding blood vessels Laparotomy- surgery to open the abdomen to find the causes of the bleeding Hysterectomy- (surgical removal of the uterus) in most cases this is a last resort. Tying –off of bleeding blood vessels Laparotomy- surgery to open the abdomen to find the causes of the bleeding Hysterectomy- (surgical removal of the uterus) in most cases this is a last resort.

51. DRUG DOSES FOR MANAGEMENT OF PPH

52. PRIORITIZATION OF NURSING PROBLEMS 1.Risk for ineffective tissue perfusion related to hemorrhage. 4. Anxiety related to unexpected blood loss and uncertainty of outcome 2. Deficient Fluid Volume related to blood loss 3. Health seeking behaviors related to special care necessary for healthy pregnancy 5. Risk for infection related to blood loss and vaginal examinations

54. ASSESSMENT NURSING DIAGNOSIS GOALS & DESIRED OUTCOME NURSING INTERVENTIONRATIONALEEVALUATIO N SUBJECTIVE: “I’m still bleeding heavily” as verbalized by the mother OBJECTIVE: 1. Restlessness 2. Irritability 3. Fall BP V/S taken as follows: BP:80/60mmHg PR: 110 bpm RR: 16 cpm Temp.: 36.9 ◦ C Risk for ineffective tissue perfusion related to hemorrhage. After12hours of nursing interventions patient will demonstrate adequate perfusion and stable vital signs. 1.Monitor amount of bleeding by weighing all pads 2. Frequently monitor vital signs. 3.Massage the uterus 4.Administer medications as advice (eg.pitocin, methargine) 5. Administer oxygen 6. Provide comfort. Like back rubs, deep breathing, instruct in relaxation. 1. To measure the amount of blood loss. 2. Early recognition of possible adverse effects allows for prompt intervention. 3. To help expel clots of blood and it is also used to check the tone of the uterus and ensure that it is clamping down to prevent excessive bleeding. 4. To promote contraction and prevents further bleeding. 5. To supply adequate oxygen to mother and to prevent further complication. 6. Promote relaxation may enhance patients coping abilities by refocusing attension. After 12hours of nursing intervention s, patient was able to demonstrate adequate perfusion and stable vital signs.

55. HEALTH EDUCATION Educate the women about the cause of hemorrhage Teach the women the importance of eating a balanced diet taking vitamin supplements Advice the women she may feel tired and fatigued and to schedule daily rest periods Teach women and family signs and symptoms of hemorrhage for home care Advise the women to notify her health care provider of increased bleeding or other changes in her status.

56. Presented a case of a 31 y/o Female patient who is a known case of Post Partum Hemorrhage On conservative management such as oxytocin 10units Oxytocin in 500ml of RL, methargin(ergometrine) 1amp(0.2mg) IM, cytotec(misoprostol) 800mg (4tab)p/r, cefuroxime 1 gm I V TID Patient was discharged on 07/02 /2013 in good condition with the baby Post partum hemorrhage (PPH) is an obstetrical emergency that can follow vaginal or cesarean delivery. The average amount of blood loss after vaginal delivery is 500 ml,and blood loss for cesarean birth is approximately 1000 ml. It is major cause of maternal morbidity.The most PPH occurs right after delivery but it can occur later as well. Post partum hemorrhage (PPH) is an obstetrical emergency that can follow vaginal or cesarean delivery. The average amount of blood loss after vaginal delivery is 500 ml,and blood loss for cesarean birth is approximately 1000 ml. It is major cause of maternal morbidity.The most PPH occurs right after delivery but it can occur later as well.

57.  Wolters Kluwer & Lippincot Williams & Wilkins. Lippincot Manual of Nursing Practice, 9 th edition, page 1330-1333, 2010.  Pillitteri, Adele. Maternal & Child Health Nursing, 3rd ed.Philadelphia: Lippincott, 1999.