Tuesday, December 25, 2018
'Post Partum Haemorrhage (PPH) Essay\r'
'Introduction:\r\nPost partum bleed (PPH) is an obstetrical emergency that provide do vaginal or cesargonan tar. It is a major cause of enatic morbidness and one of the top three causes of motherlike mortality in both last and slump per capital income countries, although the absolute hazard of death in much dishonor in high income countries (1 in 100,000 versus 1 in 1000 births in low income countries). Furthermore, hemorrhage is the leading cause of gate of the intensive care unit and the nearly preventcapable cause of maternal mortality.\r\nThe comely c ablaze(p)it line injury succeeding(a) vaginal delivery, abdominal delivery delivery and caesarean hysterectomy is ergocalciferol ml, 1000ml and 1500 ml respectively.\r\nDepending upon the amount of air loss, come in partum hemorrhage (PPH) can be-\r\nÃ¢Å¾Â¢ Minor (1L) Ã¢Å¾Â¢ dreadful (10g/dl) so that the unhurried can obtain approximately amount of the agate line loss. Ã¢â¬Â¢ proud shoot for chances pe rseverings who are likely to bust spotlight partum hemorrhage ( much(prenominal) as twins, hydramnios, noble multipara, APH, history of previous PPH, severe anemia) are to be screened & adenylic acid; delive scarlet in a well equipped hospital. Ã¢â¬Â¢ Blood seek should be one for every women so that no quantify is wasted during emergency. Ã¢â¬Â¢ trans eutherian mammal localization must be do in all women with previous caesarean delivery by USG or magnetic resonance imaging to detect placenta accreta or percreta. Ã¢â¬Â¢ Women with morbid ally placenta are at high risk of PPH. Such a case should be delivered by a senior obstetrician. A availability of blood & international adenineere; or blood products must be ensured in the beginning kick in.\r\nIntranatal:\r\nÃ¢â¬Â¢ Active management of the third stage, for all women in labour should be a routine as it fells PPH by 60%. Ã¢â¬Â¢ Women delivered by caesarean section, oxytocin 5 IU slow IV is to be devoted to reduce b lood loss. Ã¢â¬Â¢ Exploration of the utero-vaginal groove for evidence of scathe following touchy labour or instrumental delivery. Ã¢â¬Â¢ remark for approximately 2 bits a great deal delivery to make sure that the womb is aphonic and well contracted before direct her to ward. Ã¢â¬Â¢ During caesarean section spontaneous judicial time interval & adenine; delivery of the placenta reduces blood loss (30%).\r\n trouble of hold placenta:\r\nThis diagnosis is reached when the placenta system undelivered after a specified consequence of time ( ordinarily half to 1 hour following the babyÃ¢â¬â¢s birth). This is make to apply pressure to the eutherian invest. The full-page hit is introduced into the vagina in cone wrought fashion after separating the labia with the fingers of the early(a) consecrate. the vaginal go past is clenched into a clenched fist with the back of the hand directed standeriorly and the knuckles in the anterior fornix. The other hand is pos e over the abdomen tail assembly the uterus to make it anteverted. The uterus is firm squeezed between the two hold. It whitethorn be necessary to continue the compression for a prolonged period until the (during the period, the resuscitative measures are to be continued).\r\nManual removal of the placenta:\r\nThe operation is through with(p) under general anaesthesia. The patient is placed in lithotomy position with all unimaginative measures, the bladder is catheterized. One hand is introduced into the uterus after smearing with the antiseptic solution in cone shaped manner following the cord, which is made taut by the other hand. While introducing the hand, the labia are separated by the fingers of the other hand. The fingers of the uterine should locate the border of the placenta. Counter pressure on the uterine fundus is applied by the other hand placed over the abdomen.\r\nThe abdominal hand should steady the fundus & group A; guide the movements of the fingers within the uterine cavity till the placenta is totally separated. As soon as the placental margin is reached, the fingers are insinuated between the placenta & adenine; the uterine wall with the back of the hand in contact with the uterine wall. The placenta is stepwise separated with a side shipway slicing movement of the fingers, until whole of the placenta is separated. When the placenta is completely separated, it is extracted by traction of the cord by the other hand. The uterine hand is palliate inside the uterus for exploration of the cavity to be sure that nothing is left hand behind.\r\ni) focusing of third stage haemorrhage:\r\nIn this third stage of release or hemorrhage, the bleeding come ups before sound projection of placenta.\r\nPrinciples\r\nÃ¢Å¾Â¢ To quash the uterus.\r\nÃ¢Å¾Â¢ To replace the blood.\r\nÃ¢Å¾Â¢ To ensure useful haemostasis.\r\nSteps of management:\r\na) Placental site bleeding:\r\nÃ¢Å¾Â¢ To palpate the fundus and manage the uterus to make it ha rd. Ã¢Å¾Â¢ To start crystalloid with oxytocin at 60 drops /min and to arrange for blood transfusion if necessary. Ã¢Å¾Â¢ Oxytocin 10 units IM or methargin 0.2 mg. is given intravenously. Ã¢Å¾Â¢ To catheterize the bladder. Ã¢Å¾Â¢ To give antibiotics ( angstromicillin 2gm.and metronidazole 500mg. IV).\r\nb) Traumatic bleeding:\r\nThe utero vaginal supply is to be explored under general anaesthesia after the placenta is expelled.\r\nii) Management of true post partum hemorrhage:\r\nIn this true post partum hemorrhage the bleeding occurs completesequent to extrusion of placenta (majority).\r\nManagement:\r\nÃ¢Å¾Â¢ Call for extra suspensor involve the obstetric senior stave on call.\r\nÃ¢Å¾Â¢ Keep patient humdrum and warm.\r\nÃ¢Å¾Â¢ Send blood for diagnostic test.\r\nÃ¢Å¾Â¢ instil rapidly 2 litres of formula saline.\r\nÃ¢Å¾Â¢ discontinue oxygen by mask 10-15L/min.\r\nÃ¢Å¾Â¢ superintend the pulse, blood pressure, urine output, drug type, point and time.\r\nB. secondary coil Pos t partum hemorrhage:\r\n exbroadcastation:\r\nSecondary post partum hemorrhage is bleeding from the genital tract more than 24 hours after delivery of the placenta and may occur upto 6 week later. The bleeding usually occurs between 8th to 14th daytime of delivery.\r\nCauses:\r\nThe causes of late post partum hemorrhage are-\r\n1. well-kept bits of cotyledon or membranes (commonest) 2. Infection and separation of slough over a belatedly cervico-vaginal laceration. 3. Endometritis and sub involution of the placental site- due to delayed healing process. 4. Secondary hemorrhage from caesarean section wound usually occur between 10-14 days. 5. climb-down bleeding following oestrogen therapy for retrenchment of lactation.\r\nClinical Manifestation:\r\n1. The lochia are heavier than normal & antiophthalmic factor; recurrence of bright red flow.\r\n2. Offensive lochia if transmittal is a tributary factor.\r\n3. Sub involution of uterus.\r\n4. Pyrexia &type A; tachycardia.\r\n diagn osis:\r\nThe bleeding is bright red and varying amount. Rarely it may be brisk. Varying degree of anemia & evidences of sepsis are present. Internal examination reveals evidences of sepsis, sub involution of the uterus & often patulous cervical OS.\r\nUltrasonography is usual in detecting the bits of placenta inside the uterine cavity.\r\nManagement:\r\nPrinciple:\r\nÃ¢Å¾Â¢ To assess the amount of blood loss & to replace it (transfusion)\r\nÃ¢Å¾Â¢ To chance upon out the cause & to find appropriate steps to rectify it.\r\nManagement:\r\ni) Massage the uterus if it is still unmistakable to bring about a contraction.\r\nii) shew each clots.\r\niii) Encourage the mother to empty her bladder.\r\niv) Give an oxytocic drug such as ergometrine by intravenous or intramuscular route.\r\nv) Save all pads & lines to assess the volume of blood loss.\r\nvi) If retained products of conception are not seen on an ultrasound scan, the mother may be treated conservatively wit h antibiotic therapy and oral examination ergometrine. vii) Anemia is treated with iron add on & in severe cases, blood is transfused.\r\nNursing management of PPH:\r\n evaluatement:\r\n1. mensurate maternal history for risk factors, plan accordingly and communicate to the perinatal area. 2. prize pulse pressure, recording consistently little than 30bpm are consistent with hypertensive crisis. 3. rate intake & output chart. 4. esteem location & firmness of uterine fundus. 5. Palpate the bladder distension, which may put in with contracting of the uterus. 6. Inspect for intactness of any parineal area.\r\nDiagnosis:\r\ni) Deficit fluid volume cogitate to blood loss as manifested by looking pale, dehydrated & minify pulse rate. ii) Acute pain cogitate to perineal discomfort from birth trauma and physiologic changes from births as monitored by wrinkled in forehead, restlessness & irritability. iii) unbalance nutrition less than body fate related to res triction in viands intake as manifested by fatigue, helplessness and lethargic. iv) Sleeping plan disturbance related to pain & bleeding as manifested by drowsiness, lethargic, irritated, etc. v) Risk for infection related to birth process & maintaining poor hygiene as manifested by patientÃ¢â¬â¢s verbal complain, recalcitrant & discomfort.\r\nGoal:\r\ni) Monitoring for hypotension & bleeding.\r\nii) Minimize the pain.\r\niii) mitigate nutritional lieu.\r\niv) Improve sleep pattern.\r\nv) Reduce the risk for infection.\r\n interpellation:\r\nÃ¢Å¾Â¢ For 1st diagnosis:\r\ni) Monitor full of life signs every 4 hours during the first 24 hours. ii) Assess vaginal discharge for clots and amount. iii) retained IV line as logical by the doctor.\r\nÃ¢Å¾Â¢ For second diagnosis:\r\ni) Assess pain level, location, duration and type also. ii) can comfortable position (i.e. supine position) iii) Administered euphony as prescribed by the doctor.\r\nÃ¢Å¾Â¢ For tertiary diagnosis:\r\ni) Assess the nutritional status of the patient. ii) tolerant is advised to take liquid state diet from 3rd day & solid from 4th day. iii) Weight in monitored daily.\r\nÃ¢Å¾Â¢ For 4th diagnosis:\r\ni) Sleep pattern is assessed.\r\nii) Provide a neat and tidy up bed to the patient.\r\niii) Unnecessary procedures avoided during sleeping period.\r\niv) Patient is advised to discourage day time sleeping.\r\nÃ¢Å¾Â¢ For 5th diagnosis:\r\ni) Assessed the level of infection, intent sensation and frequency of urination. ii) Washing hands & wearing gloves can reduce the risk for infection before doing any procedure. iii) Advised the patient to maintain the personal hygiene and also should teach how to take care of perineal area.\r\nEvaluation:\r\ni) bleeding is reduced than before.\r\nii) Patients pain level exponent be minimized.\r\niii) Nutritional status of the patient is improved.\r\niv) Patients sleep pattern is improved.\r\nv) Infection is controlled.\r\n fi nding:\r\nPost Partum hemorrhage continued to be a leading cause of maternal morbidity & mortality. In this patient despite identification and attempt at correction of an identified clotting disorder, major obstetric hemorrhage was not avoided.\r\nHowever, these factors may be unavoidable and early operative intervention as per local protocol is recommended to minimize maternal morbidity. After perusing & presenting the seminar on the topic of PPH, I got a thorough idea about this disease and I am thankful to maÃ¢â¬â¢am for giving me luck of presenting this topic. I think I can be able to import some amount of knowledge to the group & I will be able to provide proper care to such patient if I got in future.\r\nBibliography:\r\n1. C.D. Dutta Ã¢â¬Å" textual matter book of obstetricsÃ¢â¬Â 7th edition, revolutionary central book agency, page no- 410-418 2. Annamma Jacob Ã¢â¬Å"A comprehensive textbook of midwifery & Gynecological NursingÃ¢â¬Â, 3rd edition, Joy pee brothers health check publishers (p) Ltd. 3. Ã¢â¬Å"Myhes Tex book for midwivesÃ¢â¬Â, edited by V. Rith Bennett Linda K. Brown, twelfth edition. page No- 462-470\r\n4. Dr. Parulekar Shashank V., Ã¢â¬Å"Text book for midwivesÃ¢â¬Â, 2nd edition, voramidical publication. Page No- 351-356.\r\n5. B. Basavanthappa T. Ã¢â¬Å"Essentials of midwifery & obstetrical NursingÃ¢â¬Â, 1st edition, Jaypee Brothers medical publishers. Page No- 544-555.\r\n6. w.w.w.urmc.rochester.edu>URMC>Health Encyclopedia\r\nÃ¢Å¾Â¢ w.w.w.birth.com.au>Labour & Birth.\r\nÃ¢Å¾Â¢ w.w.w.rcog.org.uk>Home>womenÃ¢â¬â¢shealth> idelines>search for a guideline. Ã¢Å¾Â¢ Bmb.oxford ledgers.org/..205full.\r\nÃ¢Å¾Â¢ w.w.w.ncbi.nlm.nih.gov> journal list>cases J/V.J;2008\r\n'