Postpartum Hemorrhage (PPH)

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It is abnormal uterine bleeding following delivery through 6 weeks (42 days). It is sub classified in to  Primary and Secondary PPH 

Primary PPH 

It is typically loss of more than 500 ml of blood from the genital tract after vaginal delivery or more  than 1000 ml after Caesarean section in the first 24 hours. OR it is any amount of blood loss after  delivery that would result in to haemodynamic instability. 

Management of PPH at Dispensary and Health centre 

  • Insert 2 large bore cannula IV line, start rapid infusion with compound sodium lactate or sodium chloride 
  • Start oxytocin (IV) 20IU in 500mls NS at a rate for 20drops per minute 
  • Ensure no retained placental tissues 
  • Clamp or ligate bleeding perineal tears if any. 
  • Massage the uterus 
  • Insert Urethral catheter 

Referral:  If bleeding continues, immediately refer the patient to the hospital an escort of a skilled  health attendant.  Maintain IV infusion during transfer. 

Management of PPH at the hospital 

  • Shout for help and mobilize resources 
  • Obtain blood samples for Hb, blood grouping and cross matching 
  • Insert  2  large  bore  cannulas  and  start  infusing  compound  sodium  chloride  or  sodium chloride (IV) rapidly 
  • Blood Transfusion depending on amount of blood loss 
  • Start  oxytocin  (IV)  20IU  in  500mls  compound  sodium  lactate/0.9%  sodium  chloride  (IV) titrate at 20 drops per minute OR misoprostol (PO) 1000mcg or per rectal 
  • Perform other manoeuvres (balloon tamponade, TAH, Illiac artery ligation, B-Lych suture) including surgical interventions depending on patient condition and available expertise. 

Prevention of PPH –Active management of Third Stage of Labour (AMSTL) 

Ensure no remaining second twin 

A: oxytocin (IM)10IU  

OR  

A: misoprostol (PO) 600mcg  

Controlled cord traction (CCT) is recommended for vaginal births. Sustained uterine massage is not  recommended  as  an  intervention  to  prevent  PPH  in  women  who  have  received  prophylactic  oxytocin. 

Prevention of PPH in Caesarean sections 

A: oxytocin (IV/IM) 10IU is the recommended uterotonic drug for the prevention of PPH in Caesarean section 

Cord traction is the recommended method for the removal of the placenta in Caesarean  section