POSTPARTUM HEMORRHAGE Question Mrs. Bupe Phiri aged 38 para 9, has just delivered a baby boy with Apgar score 9/10 at 1 and 5 minutes, weighing 3.8kg. As you were doing observations on her, she complained of feeling dizzy and you realized she is bleeding profusely. A diagnosis of postpartum hemorrhage due to atonic uterus has been made. a) Define Primary postpartum hemorrhage 5% b) Outline five (5) causes of atonic uterus 20% c) Describe the management of Mrs. Bupe Phiri until discharge 50% d) State five (5) preventive measures of postpartum hemorrhage 25%

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a) Primary postpartum hemorrhage (PPH) is defined as blood loss of 500 mL500\,\text{mL} or more following a vaginal birth, or 1000 mL1000\,\text{mL} or more following a Cesarean section, occurring within the first 24 hours after delivery.

Part b

Five causes of atonic uterus are

  • Uterine overdistension: Due to multiple gestation, polyhydramnios, or a macrosomic baby.
  • Prolonged or rapid labor: Exhaustion of uterine muscles or insufficient time for muscle fiber retraction.
  • Grand multiparity: Uterine muscle fibers lose tone after multiple pregnancies.
  • Retained placental fragments or membranes: Prevents complete uterine contraction.
  • Uterine infection (chorioamnionitis): Inflammation can impair uterine contractility.

Part c· 6 steps

The management of Mrs. Bupe Phiri until discharge involves several steps

  1. Immediate Assessment and Resuscitation

    • Call for help and activate the PPH protocol.
    • Assess vital signs (blood pressure, pulse, respiratory rate, oxygen saturation) and level of consciousness.
    • Establish two large-bore intravenous (IV) lines and rapidly infuse crystalloids (e.g., normal saline or Ringer's lactate) to restore circulating volume.
    • Send blood samples for complete blood count, coagulation profile, blood group, and cross-match.
    • Administer supplemental oxygen.

  2. Identify and Address the Cause

    • Perform vigorous uterine massage to stimulate contractions and expel clots.
    • Insert a urinary catheter to monitor urine output and ensure the bladder is empty, as a full bladder can inhibit uterine contraction.
    • If bleeding persists, perform bimanual uterine compression while awaiting pharmacological agents.
    • Inspect the placenta for completeness and check for any retained fragments.

  3. Pharmacological Management

    • Administer oxytocin (10−40 IU10-40\,\text{IU} in 500−1000 mL500-1000\,\text{mL} IV fluid, infused rapidly, then 20 IU20\,\text{IU} in 1 L1\,\text{L} at 125 mL/hour125\,\text{mL/hour} for 4 hours).
    • If oxytocin is insufficient, consider other uterotonics:
      • Ergometrine (0.2 mg0.2\,\text{mg} IM or IV slowly, contraindicated in hypertension).
      • Misoprostol (800−1000 μg800-1000\,\mu\text{g} rectally).
      • Carboprost (250 μg250\,\mu\text{g} IM, contraindicated in asthma).

  4. Advanced Interventions (if bleeding continues)

    • Consider intrauterine balloon tamponade (e.g., Bakri balloon) to apply pressure to the uterine walls.
    • If medical and balloon measures fail, prepare for surgical interventions such as B-Lynch suture, uterine artery ligation, or hysterectomy as a last resort.
    • Administer blood products (packed red blood cells, fresh frozen plasma, platelets) as indicated by blood loss and coagulation studies.

  5. Post-Stabilization Care and Monitoring

    • Continuously monitor vital signs, blood loss, uterine tone, and urine output.
    • Monitor for signs of complications such as disseminated intravascular coagulation (DIC), acute kidney injury, or infection.
    • Administer prophylactic antibiotics if there is a risk of infection.
    • Provide pain relief and emotional support.

  6. Discharge Planning

    • Ensure Mrs. Phiri is hemodynamically stable, with a stable hemoglobin level.
    • Prescribe oral iron supplements for anemia.
    • Educate her on signs of infection, anemia, and when to seek urgent medical attention.
    • Schedule a follow-up appointment for postpartum check-up and counseling on future pregnancies, including the risk of recurrent PPH.

Part d

Five preventive measures of postpartum hemorrhage are

  • Active Management of Third Stage of Labor (AMTSL): Involves administering a uterotonic (e.g., oxytocin) immediately after birth, controlled cord traction, and uterine massage after placental delivery.
  • Early identification and management of risk factors: Screening for conditions like anemia, multiple gestation, or previous PPH during antenatal care.
  • Correction of anemia during pregnancy: Ensuring adequate iron and folate intake to optimize hemoglobin levels before delivery.
  • Careful management of labor: Avoiding prolonged labor, judicious use of oxytocin for augmentation, and preventing uterine overdistension.
  • Thorough inspection of the placenta and birth canal: Ensuring complete placental delivery and identifying/repairing any lacerations or trauma immediately after birth.
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