Sessions @BULLET Programmatic Part – Session 1: Maternal Mortality on a Global Level – Session...

Sessions

• Programmatic Part – Session 1: Maternal Mortality on a Global Level

– Session 2: Postpartum Hemorrhage (PPH) on a Global Level

• Clinical Part – Session 3: Stages of Labor

– Session 4 Causes of Postpartum Hemorrhage ( PPH )

– Session 5: Active Management of Third Stage of Labor (AMTSL) with Misoprostol

– Session 6: Review using Common Scenarios

• Strategies and Policies – Session 7: Strategies and Policies

• Review – Session 8: Quiz

1 Bixby Program UC Berkeley School of Public Health

The Causes of Postpartum Hemorrhage (PPH)

Session 4


Causes of Postpartum Hemorrhage

• Uterine atony (uterus fails to contract)

• Retained placenta / fragments left inside

• Lacerations / tears

• Ruptured uterus

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Most cases of PPH occur

within 24 hours after birth

Bixby Program UC Berkeley School of Public Health

Uterine Atony

• Uterine atony: the failure of the uterus to contract properly after the baby is born

• Uterine atony is the most common cause of immediate PPH


Normal uterus

Atonic uterus

• If the placenta is not expelled within 30 minutes following the birth of the baby, it is dangerous for the mother • Retention prevents the uterus from proper contraction increased risk of PPH

Retained Placenta


Carefully inspect placenta

• Look for:

– Hole or rough edge on the placenta; or

– Blood vessels trailing off the edge of the placenta


Lacerations / Tears

• The second most common cause of PPH:

injury to the cervix, vagina, or perineum

• Tears usually occur during delivery

• Tears and an atonic uterus may occur at the same time

If severe, immediately refer


Ruptured Uterus

• If a woman has a ruptured uterus, the fetus frequently dies and the mother's life is in grave danger.

• Bleeding may be visible, • Or, the fetal head blocks the pelvis, the bleeding may occur inside the abdomen and will not be visible Immediately refer


Ruptured Uterus

• Whether the bleeding is visible or not, immediate surgery is necessary to save the woman's life

• After a ruptured uterus, a woman is at increased risk of rupture with future pregnancies

• After the emergency is over,

the option of voluntary permanent

contraception should be

discussed with the woman

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Can PPH be Avoided ?

• Remember: Up to 90% of women experiencing a PPH have NO identifiable risk factors.

• EVERY woman is at risk of developing a PPH.

• BUT certain practices during delivery can help avoid a PPH !


To Reduce Chances of PPH

1. Prevent anemia during pregnancy

2. Healthy practices during labor

3. Prevent prolonged labor

4. Early detection of vaginal bleeding problems

5. Avoid forceps (can cause trauma)

6. Avoid episiotomy (can cause trauma)

7. Administration of a uterotonic drug


Anemia Prevention

•Even healthy women are at risk of a PPH, but for severely anemic women, blood loss of even 200-300 ml could prove fatal. •Severe anemia is very common among girls and women in developing countries. •Iron tablets will not prevent PPH, but may help women survive a hemorrhage1

1USAID 2005


Healthy Practices During Labor

Practices during labor that help reduce the likelihood of PPH include:

• Preventing prolonged labor

• Preventing dehydration

• Early detection and management of vaginal bleeding problems

• Avoiding cervical, vaginal, and perineal trauma

– Avoiding routine use of forceps

– Avoiding episiotomy

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Prevent Prolonged Labor

• Prolonged labor can be the result of an obstruction

– the baby is too large or in an incorrect position for the pelvis and birth canal

• If not detected and treated, such an obstruction may result in a ruptured uterus, fistula, fetal distress or fetal death.


Prolonged Labor & Fistula

• Fistula: When the baby’s head presses on the mothers tissue for too long, causing the tissue weaken, leading to a passage between vagina and urethra, or between vagina and rectum.

• Fistula often occur in situations of obstructed labor: if the mother’s pelvis is too small, the baby’s head is too big, or if the baby’s position makes delivery difficult.


Risk of fistula is especially high for very young, first-time mothers

Prolonged Labor & Fistula (cont.)

• Fistula leads to extreme physical and emotional trauma– leakage, smell,

humiliation, disability

• Very expensive and difficult to treat.

Avoid pregnancy at young age

• Community Prevention:

Improve overall health of girls

• Physical maturity reduces chances of obstructed labor because the

female pelvis continues to grow 4-7 years after menarche –


Inform your community of the dangers of early childbearing!

Vaginal Bleeding Problems

Pre-partum

Post-partum

Placenta previa: placenta near or on the cervix X

Abruptio placenta: placenta detaches from uterine wall prior to the birth of the baby

X

Placenta accreta: placenta growing into the uterine wall and not detaching from it

X

Ruptured uterus: a ruptured uterus not repaired will continue to bleed after the birth of the baby

X X


Early detection is critical!

Avoiding Trauma to Vagina and Perineum

• Allow birth of the baby to be slow and controlled – to allow the vaginal and perineal tissue to stretch without

tearing

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Cervical, vaginal, and perineal tears are the second most significant cause of PPH !


Avoiding Forceps

• Forceps are associated with higher risk of trauma to cervix and perineum

• If instruments are needed, a vacuum extractor may result in less trauma than forceps

• Do not push with or without instruments, until the cervix is completely dilated -- to avoid lacerations of the cervix.


Avoiding Episiotomy • Episiotomy

– More blood loss with episiotomy than

natural lacerations and tears

• Should only be performed if there is a clear indication: – shoulder dystocia

– breech birth

– forceps or vacuum delivery


http://images.google.com/imgres?imgurl=http://www.moondragon.org/images/breech3.jpg&imgrefurl=http://id.wikipedia.org/wiki/Episiotomy&h=406&w=297&sz=34&tbnid=6ydNTG35y34D7M:&tbnh=121&tbnw=88&hl=en&start=6&prev=/images%3Fq%3Depisiotomy%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DG

Administration of a uterotonic drug

• We will discuss uterotonic drugs and their role in preventing PPH in the next session

• Next Session: Active Management of Third Stage of Labor (AMTSL): Procedures and Drugs


Sessions @BULLET Programmatic Part – Session 1: Maternal Mortality on a Global Level – Session...

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