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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

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  • 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

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  • 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
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Repair of Third and Fourth Degree Tears

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  • 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
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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
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