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%

Welcome back Bashi — been a while! Let's pick up where you left off. a) Primary postpartum hemorrhage (PPH) is defined as blood loss of 500\,mL or more following a vaginal birth, or 1000\,mL or more following a Cesarean section, occurring within the first 24 hours after delivery. 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. c) The management of Mrs. Bupe Phiri until discharge involves several steps: Step 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. Step 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. Step 3: Pharmacological Management • Administer oxytocin (10-40\,IU in 500-1000\,mL IV fluid, infused rapidly, then 20\,IU in 1\,L at 125\,mL/hour for 4 hours). • If oxytocin is insufficient, consider other uterotonics: • Ergometrine (0.2\,mg IM or IV slowly, contraindicated in hypertension). • Misoprostol (800-1000\, rectally). • Carboprost (250\, IM, contraindicated in asthma). Step 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. Step 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. Step 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. 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. Send me the next one 📸