Day 2 Review DME 21 - Midwives Revision

DAY 2 📅 Nov 11 (Mon)

🩸 Postpartum Hemorrhage (PPH)

DME 211: #1 Killer of Mothers

🚨 EMERGENCY STATUS

PPH is a MEDICAL EMERGENCY requiring IMMEDIATE intervention!

Every minute of delay increases maternal mortality by 10%. Act within 5 minutes!

DEFINITION

Primary PPH: Blood loss >500ml within 24 hours of vaginal delivery, or >1000ml after cesarean section
Severe PPH: Blood loss >1000ml within 24 hours
Secondary PPH: Excessive bleeding between 24 hours and 6 weeks postpartum
Clinical significance: Any amount causing hemodynamic instability is PPH!

📏 REMEMBER: 500ml = 2 cups, 1000ml = 1 liter. Visual estimation underestimates by 30-50%!

THE 4 Ts - CAUSES OF PPH

1. Tone (70-80% cases): Uterine atony - failure of uterus to contract effectively

Overdistended uterus (twins, polyhydramnios, macrosomic baby)
Prolonged labour (>12 hours)
Grand multiparity (>5 deliveries)
Chorioamnionitis
Uterine fatigue from oxytocin use

2. Tissue (5-10%): Retained placental tissue or membranes
3. Trauma (20%): Genital tract lacerations, uterine rupture, hematoma
4. Thrombin (1%): Coagulation disorders - DIC, abruptio placentae, pre-eclampsia

🎯 KEY MNEMONIC: 4 Ts = Tone, Tissue, Trauma, Thrombin. Tone is COMMONEST!

RISK FACTORS

Multiple pregnancy, polyhydramnios, macrosomia
Prolonged or augmented labour
Grand multiparity (>5 deliveries)
Previous PPH history
Placenta previa or abruption
Chorioamnionitis
Prolonged third stage (>30 minutes)
Maternal anemia, hypertension, obesity
Operative delivery (forceps, vacuum)

⚠️ REMEMBER: Risk factors mean HIGH ALERT. Prepare oxytocin BEFORE delivery!

CLINICAL FEATURES

Visible bleeding: Bright red, continuous or trickling
Signs of shock: Pallor, tachycardia (>100/min), hypotension (<90/60)
Soft, boggy uterus: Failure to contract (atony)
Distended bladder: Contributing to atony
Oliguria: <30ml/hr (kidney hypoperfusion)

🚨 CRITICAL: Blood loss may be CONCEALED (e.g., intrauterine, hematoma). Assess for shock symptoms!

AIMS OF MANAGEMENT

Immediate Objectives:

✅ Stop the bleeding within 5 minutes
✅ Restore circulating blood volume
✅ Prevent hypovolemic shock and organ damage
✅ Identify and treat the underlying cause
✅ Prevent complications (DIC, organ failure, death)

FIRST AID & INITIAL MANAGEMENT

⏱️ THE FIRST 5 MINUTES - CRITICAL!

CALL FOR HELP: Activate obstetric emergency team immediately
MONITOR VITALS: BP, pulse, respiration, SpO2 every 2 minutes
IV ACCESS: Two large-bore IV cannulas (16G or 18G)
BLOOD TAKING: Cross-match 4 units, FBC, clotting profile
OXYGEN: 10-15L/min via non-rebreather mask
CATHETERIZE: Empty bladder (reduces uterine displacement)

NURSING CARE & INTERVENTIONS

1. Uterine Massage: Rub fundus firmly in circular motion to stimulate contraction
2. Pharmacologic measures:
- Inj. Oxytocin 10 IU IM immediately after baby
- Continue 20 IU oxytocin in 1L NS @ 60 drops/min
- Inj. Ergometrine 0.2mg IM (if not hypertensive)
- Misoprostol 800-1000mcg PR if oxytocin unavailable
3. Bimanual Compression: Insert one hand into vagina, other on abdomen, compress uterus
4. Aortic Compression: Apply pressure on abdominal aorta if massive bleeding
5. Fluid resuscitation: Crystalloids (NS, RL) 1L in 15 min, repeat if needed
6. Blood transfusion: If no response after 2L crystalloids
7. Positioning: Elevate legs (shock position), keep warm
8. Continuous monitoring: Output, bleeding, mental status
9. Psychological support: Stay with patient, reassure, explain actions
10. Documentation: Record every intervention, time, response

👐 REMEMBER: Uterine massage is the FIRST and MOST IMPORTANT nursing action for atony!

🩸 KEY POINT: Each unit of blood = 500ml. Aim to restore hemoglobin >7g/dl

MEDICAL MANAGEMENT

Pharmacological Treatment:

Oxytocin: First-line agent. 10 IU IM/IV, then infusion
Ergometrine: 0.2mg IM. Contraindicated in hypertension, cardiac disease
Misoprostol: 800-1000mcg PR. Useful when IV unavailable
Carboprost: 0.25mg IM. For refractory cases (asthma contraindication)
Tranexamic Acid: 1g IV over 10 min. Reduces bleeding by 30%
Antibiotics: Broad-spectrum if infection suspected

SURGICAL MANAGEMENT

1. Manual Removal of Placenta: Under anesthesia if retained
2. Uterine Exploration: Remove retained tissue with sponge forceps/curette
3. Repair of Tears: Cervical, vaginal, perineal lacerations
4. Uterine Balloon Tamponade: Condom catheter or Bakri balloon
5. Uterine Artery Embolization: Radiological intervention (if available)
6. Laparotomy & Devascularization: Uterine/ilio-uterine artery ligation
7. B-Lynch Suture: Compression suture for atony
8. Hysterectomy: Last resort to save life (subtotal or total)

🔪 REMEMBER: Surgical management = Stepwise escalation. Start least invasive!

COMPLICATIONS OF PPH

Immediate:
- Hypovolemic shock (commonest)
- Disseminated Intravascular Coagulation (DIC)
- Acute Kidney Injury (AKI) from hypoperfusion
- Multi-organ failure
- Maternal death (leading cause globally)
Long-term:
- Sheehan's syndrome (pituitary necrosis)
- Anemia and fatigue
- Secondary infertility
- Psychological trauma (PTSD)

💔 REMEMBER: Sheehan's syndrome = Delayed lactation, amenorrhea, hypothyroidism months/years later!

PREVENTION OF PPH

Active Management of Third Stage Labour (AMTSL):

Oxytocin: 10 IU IM immediately after baby delivery (within 1 min)
Controlled Cord Traction (CCT): After uterus contracts, deliver placenta
Uterine Massage: Immediately after placenta, rub fundus until contracted

Effectiveness: Reduces PPH by 60%, severe PPH by 70%

🛡️ REMEMBER: AMTSL should be routine for EVERY delivery. No exceptions!

"PPH is PREVENTABLE and TREATABLE. Your rapid response is the difference between life and death!"

"Rescue those being led away to death; hold back those staggering toward slaughter." - Proverbs 24:11

LIKELY EXAM QUESTIONS FOR DAY 2

1. DEFINITION (2 marks)

Define postpartum hemorrhage according to WHO.

ANSWER: Blood loss >500ml within 24 hours of vaginal delivery or >1000ml after cesarean section.

2. MNEMONIC QUESTION (3 marks)

List the 4 Ts causes of PPH.

ANSWER: Tone (uterine atony), Tissue (retained), Trauma (lacerations), Thrombin (coagulopathy)

3. SHORT ANSWER (5 marks)

Explain the first aid management of PPH in the first 5 minutes.

ANSWER: Call for help, massage uterus, give oxytocin 10 IU IM, establish 2 IV lines, catheterize bladder, monitor vitals, start fluid resuscitation.

4. NURSING CARE (5 marks)

Describe nursing interventions for a patient with uterine atony.

ANSWER: Fundal massage, administer uterotonics, bimanual compression, monitor bleeding, empty bladder, position for shock, emotional support, documentation.

5. DRUG CALCULATION (3 marks)

Calculate the infusion rate for 20 IU oxytocin in 1L NS at 60 drops/min (20 drops = 1ml).

ANSWER: 60 drops/min = 3ml/min. 1000ml ÷ 3ml/min = 333 minutes (5.5 hours) for full infusion.

6. COMPLICATION (2 marks)

State one long-term complication of severe PPH.

ANSWER: Sheehan's syndrome (postpartum pituitary necrosis leading to lactation failure, amenorrhea, hypothyroidism).

🚨 EXAM TIP: PPH appears in 95% of DME 211 exams! Master every detail!