Postpartum Bleeding And Childbirth Injuries

POSTPARTUM HAEMORRHAGE (PPH)

• Vaginal bleeding in excess of 500 ml after childbirth
• Causes one in four maternal deaths worldwide
• Most common cause of maternal death in low income countries
• Assessment in antenatal period does not effectively predict who will have post-partum haemorrhage
• Closely monitor all postpartum women to early diagnose PPH

BLEEDING: Atonic Uterus

• Bleeding occurs from the placental site after delivery
• Blood vessels in the placental site are surrounded by uterine muscles, which normally contract after delivery and close off vessels
• Failure of uterus to contract (atonic uterus) results in excessive bleeding; commonest cause of bleeding after childbirth

PREVENTION OF POSTPARTUM HEMORRHAGE

• Bleeding may occur at slow rate over several hours; condition may not be recognized until woman suddenly enters shock
• Practice active management of third stage of labour in all cases to prevent PPH, including
  - Give oxytocin to mother when baby is born, 10 IU IM/IV
  - Assess uterus tone through repeated abdominal palpation to early identify cases of uterine atony
  - Placenta delivery by controlled cord traction (CCT) is only indicated if performed by skilled birth attendant
  - Uterine massage is not indicated for prevention if oxytocin has been given.

TREATMENT OF PPH

• Intravenous oxytocin alone is the recommended uterotonic drug
• If intravenous oxytocin is unavailable, or if bleeding does not respond to oxytocin, use:
  - Intravenous ergometrine
  - Oxytocin-ergometrine fixed dose, or
  - A prostaglandin drug, including sublingual misoprostol, 800 μg).
  
• The use of non-pneumatic anti-shock garments is recommended as a temporizing measure until appropriate care is available.

REPAIR OF VAGINAL AND PERINEAL TEARS

Four degrees of tear can occur during delivery:
First degree		Vaginal mucosa + connective tissue
Second degree		Vaginal mucosa + connective tissue + muscles
Third degree		Complete transection of anal sphincter
Fourth degree		Rectal mucosa also involved

REPAIR OF CERVICAL TEARS

Gently grasp cervix with ring or sponge forceps, apply on both sides of tear Gently pull in various directions to see entire cervix, tear Close tears with continuous 0-chromic non-absorbable suture

Repair of First and Second Degree Tears

Use local anaesthesia Carefully examine vagina, perineum, cervix Make sure there are no 3rd or 4th degree tears Most first degree tears heal spontaneously Repair vaginal mucosa with 2-0 suture, begin at apex of tear Repair perineal muscles Close skin with subcuticular stitch

Repair of Third and Fourth Degree Tears

If you cannot see edges, use general anesthesia If you can see edges, use local or block Repair rectal mucosa with 3-0 or 4-0 interrupted sutures Close fascial layer Close sphincter with interrupted 2-0 During repair, use multiple rounds of antiseptic wash Change gloves Repair vaginal mucosa, perineal muscles, skin

FEMALE GENITAL INJURY

• Obtain information regarding nature of injury
• Conduct local examination of genitalia
• Check for tears of hymen, vaginal walls, fornices, cervix
• Irrigate with saline
• Ligate bleeding vessels
• Excise only devitalized tissues
• Repair deep lacerations with absorbable suture; skin with non-absorbable suture
• Catheterize bladder if urinary retention