postpartum hemorrhage

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Clinical featuresdiagnosisprevention OF PPH & manual removal of placenta : 

Clinical featuresdiagnosisprevention OF PPH & manual removal of placenta harikrishna

Why tajmahal overhere??? : 

Why tajmahal overhere??? ANY GUESS??????

HERE’S THE REASON……….. : 

HERE’S THE REASON……….. TAJMAHAL, THE SYMBOL OF LOVE WAS BUILT BY MUGHAL EMPEROR , SHAHJAHAN IN MEMORY OF HIS WIFE MUMTAZ WHO DIED DUE TO POSTPARTUM HEMORRHAGE AFTER THE BIRTH OF HER LAST CHILD.

Slide 4: 

In the majority, the vaginal bleeding is visible outside as a slow trickle Rarely, bleeding is concealed either as vulvo-vaginal or broad ligament hematoma The effect of blood loss depends upon a) predelivery hemoglobin level b) degree of pregnancy induced hypervolaemia c) speed at which blood loss occurs

Clinical features : 

Clinical features Bleeding from the vagina followed by Pulse rate Blood pressure ( they appear only after class 2 hemorrhage ) Swelling and pain in the tissues in vaginal and perineal area State of uterus * atonic hemorrhage * traumatic hemorrhage

Diagnosis of pph : 

Diagnosis of pph Diagnosis of PPH mainly depends upon clinical features In addition to a complete medical history and physical examination, diagnosis is based on symptoms , with laboratory tests often helping with the diagnosis. Tests used to diagnose PPH may include a) estimation of blood loss ( this may be done by counting the no. of saturated pads or by weighing of packs & sponges used to absorb blood: 1ml of blood weighs approximately 1 gm) b)pulse rate & B.P. measurement c)hematocrit d)clotting factors in blood

prevention : 

prevention

Slide 9: 

ANTENATAL a)improvement of the health status of the patient & keep the Hb level normal b)high risk patients c)blood grouping should be done

intranatal : 

intranatal Slow delivery of the baby General anaesthesia- expert obstetric anaesthetist * Local or epidural anaesthesia Spontaneous separation and delivery of placenta during caesarean section Active management of third stage labor Examination of placenta and membranes Infusion of oxytocin for atleast 1 hr in case of induced or accelerated labor

Slide 11: 

Exploration of utero-vaginal canal for evidence of trauma following difficult labor or instrumental delivery Observation of the patient for about 2 hours after delivery and if the uterus remains hard &contracted only then she should be sent to the ward

Slide 12: 

ALL SAID AND DONE, IT IS THE INTELLIGENT ANTICIPATION, SKILLED SUPERVISION, PROMPT DETECTION AND EFFECTIVE INSTITUTION OF THERAPY THAT CAN PREVENT AN OTHERWISE NORMAL CASE FROM UNDERGOING A DISASTROUS CONSEQUENCES

STEPS OF MANUAL REMOVAL OF PLACENTA : 

STEPS OF MANUAL REMOVAL OF PLACENTA

Slide 14: 

STEP -1 : The operation is done under general anaesthesia. In extreme urgency where anaesthetist is not available ,the operation may have to be done under deep sedation with 10mg diazepam given i.v. The patient is placed in lithotomy position.

Slide 15: 

STEP-2 : One hand is introduced into uterus after smearing with the aseptic solution in cone shaped manner following the cord, which is made taut by the other hand. While introducing the hand, labia are separated by the fingers of the other hand. The fingers of the uterine hand should locate the margins of the placenta.

Slide 17: 

STEP-3 : Counter pressure on the uterine fundus is applied by the other hand placed over the abdomen. The abdominal hand should steady the fundus and guide the movements of the fingers inside the uterine cavity till the placenta is completely separated.

Slide 19: 

STEP-4 : As soon as the placental margin is reached ,the fingers are insinuated between the placenta and the uterine wall with the back of the hand in contact with the uterine wall. The placenta is gradually separated with a sideways slicing movement of the fingers ,until whole of the placenta is separated .

Slide 21: 

STEP-5 : When the placenta is completely separated,it is extracted by the traction of the cord by the other hand. The uterine hand is still inside the uterus for exploration of the cavity to be sure that nothing is left behind .

Slide 22: 

STEP-6 : Intravenous ergometrine 0.25mg is given and the uterine hand is gradually removed while massaging the uterus by the external hand to make it hard. After the completion of manual removal, inspection of the cervico-vaginal canal is to be made to exclude any injury .

Slide 23: 

STEP-7 : The placenta and membranes are to be inspected for completeness and be sure that the uterus remains hard and contracted.

DIFFICULTIES : 

DIFFICULTIES Hour- glass contraction leading to difficulty in introducing the hand Morbid adherent placenta which may cause difficulty in getting to the plane of cleavage of placental separation

COMPLICATIONS : 

COMPLICATIONS HEMORRHAGE DUE TO INCOMPLETE REMOVAL SHOCK INJURY TO UTERUS INFECTION INVERSION (RARE) SUBINVOLUTION THROMBOPHLEBITIS EMBOLISM

THANK : 

THANK Y O U

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