To understand the importance of prompt and appropriate management in saving lives from PPH◦ Define PPH◦ List the causes and risk factors for PPH◦ Discuss the steps taken in managing PPH

Bleeding >500 ml after childbirth Pad or cloth soaked in less than 5

minutes Constant trickling of blood

OR

Delivered outside health center and still bleeding

Call for extra help Massage uterus until it is hard and give

OXYTOCIN 10 units IM

Place cupped palm on uterine fundus and feel for state of contraction

Massage fundus in a circular motion with cupped palm until uterus is well contracted

When well contracted, place fingers behind fundus and push down in one swift action to expel clots

Measure/estimate blood loss and record

Give IV fluids with 20 units oxytocin at 60 drops per minute

Empty the bladder: catheterize if necessary Check and record BP and pulse every 15

minutes Establish cause of bleeding

Uterine atony Tears of the cervix, vagina, or perineum Retained placenta Retained placental fragments Inverted uterus Ruptured uterus

When uterus is hard, deliver placenta by controlled cord traction

If unsuccessful and bleeding continues – perform vaginal examination (check if placenta is in the cervix). Remove placenta carefully and check if complete.

Massage uterus

If unable to remove placenta – REFER urgently to hospital

During transfer, continue IV fluids with 20 units oxytocin at 30 drops/minute

Check placenta If placenta complete

◦ Massage uterus to express any clot◦ If uterus remains soft, give OXYTOCIN 10 units IM◦ Continue IV fluids with 20 units Oxytocin at 30

drops/min◦ Continue uterine massage until it is hard

Placenta is not complete or not available for inspection◦ Remove placental fragments by hand. ◦ If bleeding continues after fragments removed,

refer woman urgently to hospital Placenta is complete and vaginal bleeding

continuous: ◦ Check for uterine atony◦ Check for trauma

Massage the uterus until it is well contracted

Give oxytocin◦ Initial dose: 10 IU IM/IV or 20 IU IV infusion in 1

liter saline, 60 drops per minute Continuing Dose

◦ IM/IV repeat 10 IU after 20 minutes if heavy bleeding persists OR

◦ 10 IU IV infusion in 1000 ml of saline, 30 drops per minute.

ERGOMETRINE – 1st line treatment of uterine atony not responsive to oxytocin

Rapid onset of action (2-5 min) after IM injection

Clinical effect persists for approximately 3 hours

Initial dose: 0.2 mg IM/IV slowly Continuing dose: 0.2 mg IM after 15

minutes if bleeding persists (up to 5 doses=1.0 mg)

DO NOT GIVE IF PATIENT IS HYPERTENSIVE, or has heart disease

Monitor BP and PR Common side effects: nausea, vomiting,

dizziness Store at temperatures below 8°C and

away from light

Bimanual compression of uterus

AORTIC COMPRESSION

Point of compression is just above the umbilicus and to the left

If uterus contracted and still bleeding:

Look for perineal, vaginal or cervical lacerations

Determine degree and extent of tear If 3rd degree tear – REFER to CEMONC facility

For other tears – apply pressure over tear with sterile pad or gauze and put legs together. Do not cross the ankles.

Check after 5 minutes. If bleeding persists – repair the tear.

Giving birth should be about giving life not giving up a life.