Complications of the third stage Postpartum haemorrhage

1. Complications of the third stagePostpartum haemorrhage

2. Primary postpartum haemorrhage: bleeding from the genital tract in excess of 500 ml at any time following the baby's birth up to 24 hours postpartum a mild PPH : A loss of 500–999 ml in a healthy woman

3. severe hemorrhage : is deemed to be a loss of greater than 1000 ml

4. (PPH) is one of the most alarming and serious emergencies a midwife may face and can occur following both traumatic and straightforward births. a stressful experience for the woman and any support persons present undermine her confidence, influence her afitude to future childbearing delay her recovery. A significant causes of direct maternal death due to PPH, often in the absence of a trained health professional.

5. The midwife is often the first, and may be the only, professional person present when a hemorrhage occurs • , so her prompt, competent action will be crucial l in controlling blood loss and reducing the risk of maternal morbidity or even death.

6. Primary postpartum hemorrhage • Fluid loss is extremely difficult to measure Because blood and fluid has soaked into the bed linen and spilled onto the floor. • measurable solidified clots represent only about half the total fluid loss. • small blood loss , may adversely affects the mother's condition constitutes a PPH. • depend upon the woman's general wellbeing

7. Causes • atonic uterus • retained placenta • trauma • blood coagulation disorder.

8. *Atonic uterus • a failure of the myometrium at the placental site to contract and retract and to compress torn blood vessels and control blood loss by a living ligature action.

9. Box 18.1 • Causes of atonic uterine action ; • Incomplete separation of the placenta • Retained cotyledon, placental fragment or membranes • Precipitate labour • Prolonged labour resulting in uterine inertia • Polyhydramnios or multiple pregnancy causing overdistension of uterine muscle • Placenta praevia • Placental abruption

10. General anesthesia especially halothane or cyclopropane • Episiotomy or perineal trauma • Induction or augmentation of labour with oxytocin • A full bladder • Aetiology unknown

11. *Incomplete placental separation • When separation of placenta partially has begun, maternal vessels are torn. & placental tissue remains embedded in the spongy decidua,no efficient contraction and retractionso bleeding occur . • Retained placenta, cotyledon, placental fragment or membranes • impede efficient utérine action

12. Precipitate laborWhen the uterus has contracted vigorously and frequently, resulting in a duration of labour that is less than 1 hour, then the muscle may have insufficient opportunity to retract. • Prolonged labour • In a labour where the active phase lasts more than 12 hours uterine inertia (sluggishness) may result from muscle exhaustion

13. Polyhydramnios, macrosomia or multiple pregnancy • The myometrium becomes excessively stretched and therefore less efficient ). • Placenta praevia • The placental site is partly or wholly in the lower segment where the thinner muscle layer contains few oblique fibres: this results in poor control of bleeding. • Placental abruption • Blood may have seeped between the muscle fibres, interfering with effective action. At its most severe this results in a Couvelaire uterus

15. Induction or augmentation of labor with oxytocin • -some case , the use of oxytocin during labour may result in hyperstimulation of the uterus and cause a precipitate, expulsive birth of the baby • - the uterus may still be responding in a stimulated, but ineffective manner in terms of contracting the empty uterus. • -In the case of induction or augmentation of labor, that continues over a prolonged period without establishing efficient uterine contractions, :

16. The result will be : • @physical and emotional fatigue of the mother • @ uterine fatigue or inertia may occur. • @ inertia inhibits the uterine muscle from providing strong, sustained contraction and retraction of the empty uterus that aids in the prevention of a postpartum haemorrhage

17. Episiotomy, and need for perineal sutures • -Blood loss from perineal trauma, in addition to even a normal blood loss from the uterus, can together equal a mild PPH , an episiotomy can cause up to 30% of postpartum blood loss. • General anaesthesia • Anaesthetic agents may cause uterine relaxation, especially inhalational agents, for example halothane.

18. Mismanagement of the third stage of labour • -‘Fundus fiddling’ or manipulation of the uterus may precipitate arrhythmic contractions so that the placenta only partially separates and retraction is lost. • A full bladder • -If the bladder is full, in the abdomen on completion of the second stage may interfere with uterine action. • Etiology unknown

19. Box 18.2 • Pr e dispo sing f a ct o r s t ha t m ig ht incr e a se t he r isks o f po st pa r t um ha e m o r r ha g e • Previous history of postpartum haemorrhage or retained placenta • Presence of fibroids • Maternal anaemia • Ketoacidosis • Multiple pregnancy • HIV/AIDS • Caesarean section

21. Previous history of PPH or retained placenta • -a risk of recurrence in subsequent pregnancies, depending on the cause of the PPH in the previous birth. • A detailed obstetric history taken at the first antenatal visit will ensure that optimum care can be given. • Fibroids (fibromyomata) • These are normally benign tumors consisting of muscle and fibrous tissue, which may impede efficient uterine action.

22. Anemia • Women who enter labor with reduced hemoglobin concentration (below 10 g/dl) may feel a greater effect of any subsequent blood loss, however small. Moderate to severe anemia (<9 g/dl) is associated with an increase in third stage blood loss and risk of postpartum hemorrhage • HIV/AIDS • Women who have HIV/AIDS are often in a state of severe immunosuppressant, which lowers the platelet count to such a degree so minor blood loss may cause severe morbidity or death.

23. Ketosis • The influence of ketosis upon uterine action is still unclear. • ketonuria at some time during labour,if labor progressed well or not , this did not appear to jeopardize either the fetal or maternal condition. • -a significant relationship between ketosis: • 1- the need for oxytocin augmentation • 2- instrumental delivery • 3- PPH

24. Time for occurrence of ketoacidosis when labor lasted more than 12 hours. • Correction of ketosis by ; • ensuring women have an adequate intake of fluids and light solid nourishment as tolerated throughout labor. • There is no evidence to suggest restriction of food or fluids is necessary during the normal course of labour

25. Caesarean section • a lack of routine observation of vital signs in the postoperative period, or failure on the part of staff to notice that bleeding was occurring, were key failures in care. • Postoperative observations need to be recorded regularly, using a modified early obstetric warning score (MEOWS) chart, and abnormal findings acted upon