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EOC Module: Postpartum Hemorrhage - Session 1

Essential Obstetric Care


Module:
Postpartum
Hemorrhage

Anemia during pregnancy Slide 1


EOC Module: Postpartum Hemorrhage - Session 1

Module Overview: Purpose


The purpose of this module is to
provide facilitators with a sound,
competency-based training (CBT)
methodology which, if implemented
as designed, will result in
participants attaining mastery in the
knowledge, competencies and skills
required to prevent, diagnose and
manage postpartum hemorrhage.
Postpartum Hemorrhage - Module Overview Slide 2
EOC Module: Postpartum Hemorrhage - Session 1

Module Overview: Story


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.

Postpartum Hemorrhage - Module Overview Slide 3


EOC Module: Postpartum Hemorrhage - Session 1

Module Overview: Story


(cont.)

The most important avoidable


factors were:
Substandard care by obstetricians
(85.5%)
Delay in seeking care (71.5%)
Transportation problems (28.6%)

Postpartum Hemorrhage - Module Overview Slide 4


EOC Module: Postpartum Hemorrhage - Session 1

Task Analysis

Task:
Diagnose and Manage Cases
of Postpartum Hemorrhage

Postpartum Hemorrhage - Task Analysis Slide 5


EOC Module: Postpartum Hemorrhage - Session 1

Task Analysis: Competency


1
Competency 1:
Diagnose cases of postpartum hemorrhage.
Skills:
1.1 Define postpartum hemorrhage
according to the guidelines.
1.2 Identify the magnitude of the problem
in Jordan.
1.3 Distinguish between primary and
secondary postpartum hemorrhage
according to the guidelines.

Postpartum Hemorrhage - Task Analysis Slide 6


EOC Module: Postpartum Hemorrhage - Session 1

Task Analysis: Competency


1 (cont.)
1.4 Identify the causes of postpartum
hemorrhage, according to the
guidelines.
1.5 Identify the predisposing factors of
postpartum hemorrhage, according to
the guidelines.
1.6 Perform clinical assessment for cases
of postpartum hemorrhage, according
to the guidelines.

Postpartum Hemorrhage - Task Analysis Slide 7


EOC Module: Postpartum Hemorrhage - Session 1

Task Analysis: Competency


1 (cont.)
1.7 Order and interpret the investigations
required for cases of postpartum
hemorrhage, according to the
guidelines.
1.8 Diagnose the cause of postpartum
hemorrhage according to the
guidelines.

Postpartum Hemorrhage - Task Analysis Slide 8


EOC Module: Postpartum Hemorrhage - Session 1

Task Analysis: Competency


2
Competency 2:
Manage cases of postpartum hemorrhage.
Skills:
2.1 Recognize the prophylactic measures to
decrease the incidence of postpartum
hemorrhage according to the guidelines.
2.2 Provide first aid management for cases
of postpartum hemorrhage according to
the guidelines.

Postpartum Hemorrhage - Task Analysis Slide 9


EOC Module: Postpartum Hemorrhage - Session 1

Task Analysis: Competency


2 (cont.)
2.3 Manage cases of postpartum
hemorrhage before delivery of the
placenta, according to the guidelines.
2.4 Manage cases of postpartum
hemorrhage after delivery of the
placenta, according to the guidelines.
2.5 Manage cases of secondary postpartum
hemorrhage according to the guidelines.
2.6 Monitor cases of postpartum
hemorrhage during their hospital stay
according to the guidelines.

Postpartum Hemorrhage - Task Analysis Slide 10


EOC Module: Postpartum Hemorrhage - Session 1

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.

Postpartum Hemorrhage - Session Overview Slide 11


EOC Module: Postpartum Hemorrhage - Session 1

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.

Postpartum Hemorrhage - Session Overview Slide 12


EOC Module: Postpartum Hemorrhage - Session 1

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.

Postpartum Hemorrhage - Session Overview Slide 13


EOC Module: Postpartum Hemorrhage - Session 1

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.

Postpartum Hemorrhage - Session Overview Slide 14


EOC Module: Postpartum Hemorrhage - Session 1

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.

Postpartum Hemorrhage - Learning Objectives Slide 15


EOC Module: Postpartum Hemorrhage - Session 1

Learning Objectives (cont.)

4. Identify the risk factors of


postpartum hemorrhage.
5. Perform clinical assessment for cases
of postpartum hemorrhage.
6. Order and interpret the
investigations required for cases of
postpartum hemorrhage.
7. Diagnose the cause of postpartum
hemorrhage.

Postpartum Hemorrhage - Learning Objectives Slide 16


EOC Module: Postpartum Hemorrhage - Session 1

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.

Postpartum Hemorrhage - Definition Slide 17


EOC Module: Postpartum Hemorrhage - Session 1

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

Postpartum Hemorrhage - Types Slide 18


EOC Module: Postpartum Hemorrhage - Session 1

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.

Postpartum Hemorrhage - Problem in Jordan Slide 19


EOC Module: Postpartum Hemorrhage - Session 1

Problem in Jordan (cont.)


Avoidable factors:
Substandard care by obstetricians (85.5%)
Delay in seeking care (71.5%)
Transportation problems (28.6%)

Among the deaths due to PPH, lack of


antenatal care and poor quality antenatal
care were avoidable factors in 42% and 14%
of cases respectively. All of the 7 women,
who died from PPH, were seen by a physician
at some point around the time of death.

Postpartum Hemorrhage - Problem in Jordan Slide 20


EOC Module: Postpartum Hemorrhage - Session 1

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

Postpartum Hemorrhage - Causes Slide 21


EOC Module: Postpartum Hemorrhage - Session 1

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

Postpartum Hemorrhage - Predisposing Factors Slide 22


EOC Module: Postpartum Hemorrhage - Session 1

Predisposing Factors (cont.)


Factors predisposed to genital tract
trauma
A precipitate delivery or an operative
or manipulative delivery
Malposition or deep engagement of
the fetal head
Previous uterine surgery
Abuse of Oxytocin.

Postpartum Hemorrhage - Predisposing Factors Slide 23


EOC Module: Postpartum Hemorrhage - Session 1

Predisposing Factors (cont.)


Factors predisposed to retained products
of
conception:
An incomplete placenta at delivery
Previous uterine surgery
High parity
An abnormal placenta on ultrasound
Intrauterine infections may lead to
adherent placenta

Postpartum Hemorrhage - Predisposing Factors Slide 24


EOC Module: Postpartum Hemorrhage - Session 1

Predisposing Factors (cont.)


Abnormalities of coagulation
Preexisting coagulation disorders:
Hemophilia A or von Willebrands disease
Idiopathic thrombocytopenic purpura
(ITP)
History of liver disease
Use of anticoagulants

Postpartum Hemorrhage - Predisposing Factors Slide 25


EOC Module: Postpartum Hemorrhage - Session 1

Predisposing Factors (cont.)


Abnormalities of coagulation
Acquired in pregnancy:
Thrombocytopenia with pre-
eclampsia (HELLP syndrome)
DIC caused by:
1. Abruptio placentae
2. Chorioamnionitis
3. IUFD

Postpartum Hemorrhage - Predisposing Factors Slide 26


EOC Module: Postpartum Hemorrhage - Session 1

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

Postpartum Hemorrhage - Diagnosis Slide 27


EOC Module: Postpartum Hemorrhage - Session 1

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

Postpartum Hemorrhage - Diagnosis Slide 28


EOC Module: Postpartum Hemorrhage - Session 1

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

Postpartum Hemorrhage - Diagnosis Slide 29


EOC Module: Postpartum Hemorrhage - Session 1

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

Postpartum Hemorrhage - Diagnosis Slide 30


EOC Module: Postpartum Hemorrhage - Session 1

Diagnosis (cont.)

Ultrasound, only required in


cases of secondary postpartum
hemorrhage if bleeding is not
severe to exclude the presence of
retained products of conception.

Postpartum Hemorrhage - Diagnosis Slide 31


EOC Module: Postpartum Hemorrhage - Session 1

Diagnosis (cont.)

Presenting Symptoms Probable


symptom and and signs diagnosis
other symptoms sometimes
and signs present
typically present
Primary PPH Shock Atonic
Uterus soft and uterus
not contracted

Postpartum Hemorrhage - Diagnosis Slide 32


EOC Module: Postpartum Hemorrhage - Session 1

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

Postpartum Hemorrhage - Diagnosis Slide 33


EOC Module: Postpartum Hemorrhage - Session 1

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

Postpartum Hemorrhage - Diagnosis Slide 34


EOC Module: Postpartum Hemorrhage - Session 1

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