{"id":1769,"date":"2010-12-14T07:38:17","date_gmt":"2010-12-14T07:38:17","guid":{"rendered":"https:\/\/cloverock.info\/mockosce23\/new\/postpartum-haemorrhage\/"},"modified":"2023-09-20T09:43:36","modified_gmt":"2023-09-20T08:43:36","slug":"postpartum-haemorrhage","status":"publish","type":"post","link":"https:\/\/www.qpercom.com\/sim\/index.php\/obstetrics\/management-of-childbirth\/postpartum-haemorrhage\/","title":{"rendered":"Postpartum Haemorrhage"},"content":{"rendered":"
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Introduction<\/strong><\/span><\/h3>\n

During parturition, postpartum blood loss<\/strong><\/span> should be measured as accurately<\/span> as possible. There is no standardly-accepted definition of postpartum haemorrhage. In the Netherlands, postpartum haemorrhage is defined as 1000 ml or more<\/strong><\/span> of blood loss. Internationally, this boundary is set at 500 ml<\/strong><\/span>.<\/span><\/p>\n

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Causes<\/strong><\/span><\/h3>\n

The most important causes<\/strong><\/span> of postpartum haemorrhage:<\/span><\/p>\n

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  • Uterine atony (reduced contractility of the uterus<\/em>).<\/span><\/li>\n
  • Marked uterine distension (multiple pregnancies, polyhydramnios, macrosomia<\/em>).<\/span><\/li>\n
  • High parity.<\/span><\/li>\n
  • Prolonged birth.<\/span><\/li>\n
  • Uterine fibroids.<\/span><\/li>\n
  • Congenital uterine anomaly.<\/span><\/li>\n
  • Damage to the soft birth canal.<\/span><\/li>\n
  • Coagulation disorders.<\/span><\/li>\n<\/ul>\n
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    Management<\/strong><\/span><\/h3>\n

    It is important to distinguish between a haemorrhage that occurs prior to the birth of the placenta<\/strong><\/span> (third stage of labour<\/em>) and one that occurs after the birth of the placenta<\/strong><\/span> (post placental stage<\/em>). Any haemorrhage greater than 1000 ml<\/span> is reason to admit a new mother to hospital. The means of transport depends on a number of factors such as:<\/span><\/p>\n

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    • Whether or not the bleeding has stopped.<\/span><\/li>\n
    • Amount of blood lost.<\/span><\/li>\n
    • Clinical condition of the woman.<\/span><\/li>\n<\/ul>\n
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      Procedure<\/strong><\/span><\/h3>\n
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      • Determine the height of the fundus<\/strong><\/span> and check whether the uterus is well contracted.<\/span><\/li>\n
      • Determine as quickly as possible the origin<\/strong><\/span> of the blood loss (from the uterus, episiotomy wound, tears in the cervix, vaginal wall, perineum<\/em>).<\/span><\/li>\n
      • Empty the bladder<\/strong><\/span>.<\/span><\/li>\n
      • Have a drip<\/strong><\/span> inserted as soon as possible (if necessary, by ambulance personnel<\/em>).<\/span><\/li>\n<\/ul>\n
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        If the uterus is well contracted:<\/em><\/span><\/p>\n

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        • Assess whether the placenta is detached<\/strong><\/span> in the lowest uterine segment. Use K\u00fcstner\u2019s manoeuvre<\/strong><\/span> to determine this.<\/span><\/li>\n
        • If the placenta is detached<\/strong><\/span>:<\/span>\n
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          • Stimulate the birth of the placenta by means of Bar\u2019s manoeuvre<\/strong><\/span>.<\/span><\/li>\n
          • Check whether the placenta is complete.<\/span><\/li>\n
          • If the blood loss persists, determine its origin once more, administer a uterotonic agent<\/strong><\/span> (oxytocin or Methylergometrine<\/em>) and while waiting for the ambulance, suture<\/strong><\/span> the bleeding vessels, tears and\/or episiotomy, if necessary.<\/span><\/li>\n
          • Refer the woman for hospital admission.<\/span><\/li>\n<\/ul>\n<\/li>\n
          • If the placenta is not detached<\/strong><\/span>, refer the woman immediately for clinical treatment<\/strong><\/span>.<\/span><\/li>\n<\/ul>\n
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            If the uterus is not<\/span> well contracted:<\/em><\/span><\/p>\n

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            • Administer oxytocin<\/strong><\/span> (e.g. 5 IU i.m.<\/em>).<\/span><\/li>\n
            • Stimulate the uterus to contract by means of gentle fundal massage<\/strong><\/span>.<\/span><\/li>\n
            • As soon as the uterus contracts, assess whether the placenta is detached and in the lowest uterine segment. Use K\u00fcstner\u2019s manoeuvre<\/strong><\/span> to determine this.<\/span><\/li>\n
            • If the placenta is detached<\/strong><\/span>:<\/span>\n
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              • Stimulate the placenta to be born using Bar\u2019s manoeuvre<\/strong><\/span>.<\/span><\/li>\n
              • Check whether the placenta is complete.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n
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                If the placenta is complete:<\/em><\/span><\/p>\n

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                • Administer Methylergometrine (e.g. 0.2 mg i.m.<\/em>). Important:<\/strong><\/span> Methylergometrine is contraindicated in the case of hypertension<\/strong><\/span> and uterine fibroids<\/strong><\/span>. While waiting for the ambulance, suture any bleeding vessels, tears and\/or episiotomy, as necessary. Refer the woman for hospital admission.<\/span><\/li>\n<\/ul>\n
                  \n

                  If the placenta is not<\/span> complete:<\/em><\/span><\/p>\n

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                  • Administer oxytocin i.m. and refer the woman for clinical treatment (evacuation of the uterus<\/em>).<\/span><\/li>\n
                  • If the placenta is not detached<\/strong><\/span>,\u00a0refer the woman immediately for clinical treatment<\/strong>.<\/span><\/span><\/li>\n<\/ul>\n
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                    \u2018Controlled Cord Traction\u2019 (Brandt-Andrews Method<\/em>)<\/strong><\/span><\/h3>\n

                    If in the event of heavy blood loss postpartum<\/strong><\/span>, the placenta is not born<\/span> after the administration of oxytocin and the use of the Bar\u2019s manoeuvre<\/em>;\u00a0the Brandt-Andrews Method<\/strong><\/span> can also be used. For this method, the uterus must be contracted<\/strong><\/span>.<\/span><\/p>\n

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