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Task Analysis
Task:
Diagnose and Manage Cases
of Postpartum Hemorrhage
Session 1 Diagnosis of
Postpartum Hemorrhage
Overview
Purpose
The purpose of this session is to introduce
participants to the correct definitions of
early and late postpartum hemorrhage
and emphasize the importance of certain
risk factors that must be taken into
consideration during antenatal visits.
Session 1: Diagnosis of
Postpartum Hemorrhage
Overview
Purpose (cont.)
With early and accurate assessment,
diagnosis of postpartum hemorrhage can
be achieved early; consequently maternal
and fetal morbidity and mortality will be
reduced.
Session 1: Diagnosis of
Postpartum Hemorrhage
Story
A healthy 35-year old G9 P8 woman with
unremarkable prenatal histories, presented to a
private clinic near term, with acute abdominal
pain and bleeding. The obstetrician gave her an
injection to stop the bleeding. Labor began six
hours later and she was transferred to a
hospital where she delivered a dead neonate.
Session 1: Diagnosis of
Postpartum Hemorrhage
Story (cont.)
Following the delivery massive bleeding
began. The blood supply was insufficient to
complete an adequate transfusion; she
received 1000cc and the bleeding continued.
The following morning a hysterectomy was
performed, but the patient went into
irreversible shock and died.
Learning Objectives:
By the end of this classroom session,
each
participant should be able to:
1. Define and distinguish between early and
late postpartum hemorrhage.
2. Identify the magnitude of the problem in
Jordan.
3. Identify the causes of postpartum
hemorrhage.
Definition
Postpartum hemorrhage is
excessive blood loss after
delivery sufficient to affect the
general condition of the mother
as shown by tachycardia and/or
hypotension.
Types
There are two types of postpartum
hemorrhage:
Primary: within the first 24
Hours
Secondary: after the first 24
hours up to the 42nd day
Problem in Jordan
Postpartum hemorrhage is the second
greatest cause of maternal death in
Jordan. The JNMMS 1995/1996
reported PPH to be responsible for 7
maternal deaths with a MMR of
5.55/100,000. Postpartum
hemorrhage was responsible for 13%
of all maternal deaths.
Causes
Uterine atony: poor or ineffective uterine
contractions and retraction
Genital tract trauma, e.g., vaginal, and
cervical tears or uterine rupture
Third stage complications:
Mismanagement of the third stage of
labor
Acute inversion of the uterus
Abnormal or incomplete placental
separation
Coagulation disorders
Predisposing Factors
Factors predisposed to uterine atony
Overdistended uterus
Uterine muscle exhaustion
Intrauterine infection
Functional or anatomic distortion of the
uterus
Certain general anesthetics (e.g.,
halothane)
History of previous PPH
Diagnosis
History taking
Surgical history including previous
uterine surgery
History of previous blood transfusion(s)
History of any of the previously
mentioned risk factors
History of the events of the current
delivery (including where it took place
and if uterine stimulants were used; was
delivery obstructed or instrumental)
Had the placenta been delivered
Diagnosis (cont.)
Physical examination
General examination
Abdominal examination
Local examination:
1. Assess the amount of vaginal bleeding
2. Look for lacerations
3. Determine whether the placenta has
been delivered
Diagnosis (cont.)
Rule
In a woman with excessive
postpartum hemorrhage, begin first
aid management while simultaneously
taking a history, either from the
patient or her relatives in case of
shock, and performing physical
examination
Diagnosis (cont.)
Investigations
ABO grouping and Rh type
Crossmatch at least two units of whole
blood or as needed for the clinical
situation.
CBC (Hb, Hct, differential, platelet count)
Bleeding time
Coagulation time
Diagnosis (cont.)
Diagnosis (cont.)
Diagnosis (cont.)
Presenting Symptoms Probable
symptom and and signs diagnosis
other symptoms sometimes
and signs present
typically present
Primary PPH Complete Genital
placenta tract
Contracted trauma
uterus
Diagnosis (cont.)
Presenting Symptoms Probable
symptom and and signs diagnosis
other symptoms sometimes
and signs present
typically present
Placenta not Primary PPH Retained
delivered within Uterus placent
30 minutes after contracted a
delivery
Diagnosis (cont.)
Presenting Symptoms Probable
symptom and and signs diagnosis
other symptoms sometimes
and signs present
typically present
Portion of the Immediate Retained
maternal PPH placental
surface of the Uterus fragment
placenta missing contracted s
or torn
membranes with
vessels
Postpartum Hemorrhage - Diagnosis Slide 35
EOC Module: Postpartum Hemorrhage - Session 1
Diagnosis (cont.)
Presenting Symptoms Probable
symptom and and signs diagnosis
other symptoms sometimes
and signs present
typically present
Uterine fundus Inverted Inverted
not felt on uterus uterus
abdominal apparent at
palpation vulva
Slight or Primary PPH
intense pain
Postpartum Hemorrhage - Diagnosis Slide 36
EOC Module: Postpartum Hemorrhage - Session 1
Diagnosis (cont.)
Presenting Symptoms Probable
symptom and and signs diagnosi
other symptoms sometimes s
and signs present
typically present
Primary PPH Shock Rupture
(bleeding is Tender d uteru
intra-abdominal abdomen s
and/or vaginal) Rapid
Severe
maternal
abdominal pain pulse
(may decrease
Postpartum Hemorrhage - Diagnosis Slide 37
after rupture)
EOC Module: Postpartum Hemorrhage - Session 1
Diagnosis (cont.)
Presenting Symptoms and Probable
symptom and signs diagnosi
other symptoms sometimes s
and signs present
typically
present
Bleeding occurs Bleeding is Seconda
more than 24 variable (light ry PPH
hours after or heavy,
delivery continuous or
irregular) and
foul-smelling
Postpartum Hemorrhage - Diagnosis Slide 38