Posted at 12.16.2018
Post-partum haemorrhage (PPH) identifies an estimated loss of blood in excess of 500 ml carrying out a vaginal birth and a damage greater than 1000 ml during a Caesarean section. Major haemorrhage is defined as an estimated blood loss greater than 2500 ml or the transfusion of 5 or even more units of blood vessels or treatment of coagulopathy.
These worth are arbitrary as visual estimation of loss of blood is not reliable. Patients with a low body mass index have less blood level of 70 ml/kg and anaemic women have fewer reserves to resist blood loss and therefore will decompensate earlier. Thus, a useful definition considers any blood loss that causes a significant physiological change just like a fall in blood pressure, as the risk of dying from PPH will depend on the total amount and rate of loss of blood and the girl health.
PPH is categorised as main and secondary. Main PPH occurs within 24 hours of delivery and extra PPH after 24 hours and within 6-12 weeks post-partum.
PPH is often due to one or a combo of four processes referred to in the '4Ts' mnemonic:
tone (post-delivery poor uterine contraction)
muscle (bloodstream clots and/or retained products of conception)
trauma (genital tract)
thrombin (coagulation abnormalities).
Common risk factors for PPH are an over-distended uterus credited to fetal macrosomia, multiple motherhood and polyhydramnios. Antepartum haemorrhage, chorio-amnionitis, coagulation disorders, fibroid uterus, induction of labour, instrumental delivery, excess weight, pre-eclampsia, prior Caesarean section delivery, previous background of PPH, primigravidity, extended rupture of membranes and/or labour are also regarded as risk factors.
There is a trend in the UK towards delaying child-bearing. Increased maternal age, Caesarean and instrumental deliveries and placenta praevia increase the incidence of PPH. A growing number of multiple pregnancies due to assisted duplication can also bring about an increased incidence of PPH.
PPH may appear in women without identifiable risk factors. In complete volumes, more women without risk factors have atonic PPH in comparison with those with risk factors.
The blood vessels providing the placental foundation pass through an interlacing network of muscle fibres of the myometrium. Myometrial contraction triggers placental parting and causes blood vessels to constrict. This haemostatic mechanism or 'living ligatures' control the bleeding from the placental bed when the placenta separates. Uterine atony brings about a failure of the 'living ligatures' to avoid the bleeding. The dynamic management of the 3rd stage of labour is associated with a decrease in the chance of PPH and less dependence on bloodstream transfusion by improving the above physiological process.
Mild surprise occurs when 20% of the bloodstream size is lost, resulting in decreased perfusion of non-vital organs and tissues (i. e. bone, fats, skeletal muscle) with pale and cool pores and skin. When 20-40% of the blood amount is lost, average surprise occurs with reduced perfusion of essential organs (i. e. gut, kidneys, liver), oliguria and/or anuria, a drop in blood pressure, and mottling of the skin in the feet. When 40% or more of the blood vessels amount is lost, severe surprise occurs resulting in decreased perfusion of the center and brain, agitation, restlessness, coma, echocardiogram and electroencephalogram abnormalities, and lastly cardiac arrest.
Only 40% of women who develop PPH offer an identifiable risk factor. Women with risk factors should be shipped in centres with transfusion and rigorous care product facilities. The Royal College or university of Obstetricians and Gynaecologists (RCOG) urges early on or prophylactic interventional radiology for the elimination and management of PPH in high-risk situations and recommends approaches for the management of unpredicted PPH.
Prevention of PPH includes antenatal risk evaluation and treatment of anaemia or other health problems so that ladies are healthy enough to tolerate PPH, as well as appropriate intra-partum and post-partum management. The International Confederation of Midwives and the International Federation of Gynecology and Obstetrics (FIGO) have together launched a world-wide programme to promote energetic management of the third level of labour for any women. Effective management involves interventions made to accomplish placental delivery by improving uterine contractions and protecting against PPH by averting uterine atony. These measures include supervision of uterotonic realtors, controlled cord grip and uterine massage therapy after delivery of the placenta, as deemed appropriate. This process reduces the risks of PPH, anaemia, requirement for blood transfusion, prolonged third stage of labour and use of healing drugs for PPH. It is strongly recommended that dynamic management should be tedious for women in maternity hospitals and there is no evidence to suggest that this recommendation should not include low-risk births at home or in birth centres.
Oxytocin is used routinely in the active management of the third level of labour. It is routinely administered for the avoidance and treatment of PPH as a first-line agent as it works well within 2-3 minutes after injections and, as it has minimal side results, it can be found in all women. If oxytocin is unavailable, ergometrine maleate 0. 5 mg intramuscularly, ergometrine with oxytocin 5 IU/ml (syntometrine) or misoprostol 0. 4 mg orally can be utilized.
Misoprostol - which really is a prostaglandin E1 analogue - can be given by dental, sublingual and rectal routes. The primary side results are diarrhoea, nausea and vomiting. Rectal misoprostol causes less shivering and pyrexia, than oral misoprostol. A recently available Cochrane review on the utilization of prostaglandins for preventing PPH figured neither intramuscular prostaglandins nor misoprostol are preferred to regular injectable uterotonics as part of the management of the third level of labour specifically for low-risk women.
Carbetocin is a long-acting oxytocin agonist and has been used for the prevention of PPH. The good thing about intramuscular carbetocin over intramuscular oxytocin is its longer duration of action. It induces an extended uterine response post-partum, both in amplitude and consistency of contraction. Carbetocin is associated with reduced dependence on other uterotonic providers and uterine rub, and there are no dissimilarities in side effects between carbetocin and oxytocin.
FIGO recommends that skilled delivery attendants should use physiological (or expectant) management of the 3rd stage if oxytocin or misoprostol are unavailable.
In 2006, the World Health Organization placed a technical appointment on the prevention of post-partum haemorrhage and it advises the following.
Lively management of the third level of labour should include: administration of the uterotonic immediately after the labor and birth of the baby; delayed cable clamping; and delivery of the placenta by manipulated cord traction followed by uterine massage.
Productive management of the 3rd level of labour should be provided by skilled attendants, as potential dangers such as uterine inversion, may result from inappropriate cord traction force.
Oxytocin should be offered for the prevention of PPH in preference to oral, sublingual or rectal misoprostol.
Within the absence of dynamic management of the third level of labour, an uterotonic medication (oxytocin or misoprostol) should be offered.
PPH is a major cause of maternal morbidity and mortality. Recognition of risk factors antenatally and intra-partum is useful in the avoidance and treatment of PPH. Catastrophic and life-threatening haemorrhage is often unpredictable. Prompt resuscitation of the patient with effective recovery of the circulating blood volume and identification of the cause of bleeding should be performed in a multidisciplinary team arranging. Rapid and fast treatment steps should be instituted in a step-wise manner using the algorithm 'HAEMOSTASIS' and examination tools like the 'rule of 30' and the 'impact index'. Protocols for the avoidance and management of PPH should be constantly updated in every maternity unit. The training of all participants of personnel in the management of the common obstetric disaster should include regular 'hearth drills'.
Specific management of controlling PPH should go together with fluid, bloodstream and clotting factor resuscitation
Every device should have a protocol to control PPH in a stepwise manner
Medical management should precede operative management
Simple operative management (tamponade, brace sutures) is less time-consuming, can be done with minimal training and works well in more than 80% of cases