LESSON PLAN ON

POST PARTUM HAEMORRHAGE

SUBJECT: Obstetrics and Gynaecological Nursing CLASS: 4TH year BSc Nursing

UNIT: DURATION: 1Hr

TOPIC: Post-partum hemorrhage

METHOD OF TEACHING: Lecture cum discussion

AV AIDS: Black board, LCD, OHP

PREVIOUS KNOWLEDGE OF THE STUDENTS: Students have not exposed to the topic before

GENERAL OBJECTIVE

At the end of the class, the students will be able to gain adequate knowledge regarding postpartum heamorrhage and utilize this
knowledge in caring the patients with PPH with a favorable attitude

SPECIFIC OBJECTIVE

At the end of the class students will:

● define PPH
● describe the types of PPH
● lists down the causes of PPH
● explain diagnosis and investigations of PPH
● enlist the preventive measures of PPH
● describe the management of third stage bleeding and true postpartum hemorrhage
 ● enumerate the secondary postpartum hemorrhage

SL TIME SPECIFIC CONTENT TEACHING AV EVALUATION

NO OBJECTIVE LEARNING aids
ACTIVITY
1 2min To introduce Introduction Teacher
the topic All women lose some blood as the placenta separates introduces the
from the uterus and immediately afterward. And women topic and
who have c-sections generally lose more than those who students listens
give birth vaginally. Unfortunately, some women bleed
too much after birth and require special treatment. This
excessive blood loss is called a postpartum hemorrhage
(PPH) and it happens in up to 6 percent of births.

Definitions Teacher defines

2 2min To define PPH Quantitative definition Postpartum
Amount of blood loss in excess of 500 mi following birth hemorrhage and LCD Define PPH
of the baby students
understands
Clinical definition
Any amount of bleeding from or in to the genital tract
following birth of baby up to the end of puerperium
which adversely affect the general condition of the

Types Teacher
3 4min To describe describes about
the types of
● Primary the types and Black What are the
PPH Haemorrhage occurs within 24 hours following the birth students takes board types of PPH?
of the baby. In the majority , haemorrhage occurs within 2 down the notes
hours following delivery . these are of two types
⮚ Third stage haemorrhage – bleeding occurs
before expulsion of placenta
⮚ True postpartum haemorrhage – bleeding
occurs subsequent to expulsion of placenta.
● Secondary
 Haemorrhage occurs beyond 24 hours and within
puerperium ,also called delayed or ate puerperal
4 10min To lists down hemorrhage Teacher lists
the causes of downs and
PPH Causes explain about OHP What are the
1. Primary postpartum haemorrhage each causes causes of PPH?
,students
Atonic causes comprehend
● Grand multi para and takes down
the notes
● Over distention of the uterus eg: multiple
pregnancy ,hydramnios and large baby
● Malnutrition and anemia
● Antepartum haemorrhage
● Prolonged labour
● Anesthesia
● Augmentation of delivery by oxytocin
● Persistent uterine distention eg: retention of
partially separated placenta or bits of placenta or
blood clots
● Malformation of uterus
● Uterine fibroid
● Miss managed third stage of labour –includes too
rapid delivery of the baby ,premature attempt to
expel the placenta before it is separated ,kneading
and fiddling of the uterus ,pulling the cord bladder
not being evacuated
● Constriction ring
● Precipitate labour

Traumatic cause
● Following operative delivery
● Blood loss from episiotomy wound
 ● Excess Blood loss in caesarian section

5 3min Combination of traumatic and atonic cause Teacher Black How will
● Blood coagulation disorders ,acquired or discusses the board postpartum
To explain congenital methods of hemorrhage is
diagnosis and diagnosis of diagnosed?
investigations PPH and
of PPH students
participates in
discussion
Diagnosis & investigations
Postpartum haemorrhage is diagnosed clinically when
significant blood loss (>500mL) is observed. While
managing the blood loss, several key examinations need
6 10mni to be performed in an attempt to identify the cause and Teacher LCDD How can you
control the haemorrhage. These include: explains the prevent post
To Enlist the preventive partum
preventive ● Examination of uterine size; measures and haemorrhage?
measures of ● Examination of the placenta for completeness; and students listens
PPH ● Examination of the birth canal for trauma .

Prevention
Antenatal
● Improvement of health status
● High risk group are to be screened and
delivered in a well equipped hospital
● Blood grouping and typing should be done
specially in the vulnerable groups so that no
time is lost during emergency

Intranatal
● Judicious administration of sedative and analgesic
drugs
 ● Hasty delivery of baby should be avoided
● Local or epidural analgesia preferred in forceps,
ventouse, breech deliveries
● Services of an expert anesthetist while delivery is
conducted
● Judicious administration of oxytoccic
● Temptation of fiddling and kneading with uterus
or pulling the cord should be avoided
● Examination of placenta and membrane should be
7 15min a routine Teacher LCD Explain the steps
explains the of mannual
● In all cases of induced or accelerated labour by
management of removal Of
To describe oxytocin, infusion should be continued for at least third stage placenta
the one hour after delivery and prophylactic bleeding PPH
management ergometrine should be given with the delivery of and students
of third stage anterior shoulder listens
bleeding ● Exploration of utero vaginal canal for evidence of
postpartum trauma following difficult labour
haemorrhage
● Observe patient about for two hours after delivery

MANAGEMENT OF THIRD STAGE BLEEDING

STEPS OF MANAGEMENT
● Placental site bleeding
● Traumatic bleeding

Placental site bleeding

⮚ To palpate the fundus and massage :the massage is
to be done by placing four fingers behind the
uterus and thumb in front . however ,if bleeding
continues even after the uterus becomes hard
,suggest presence of genital tract injury
⮚ Ergometrine 0.25mg or methergine 0.2 mg is
given IV
⮚ Sedation may be given with morphine 15 mg IM
⮚ To start a dextrose saline drip and arrange for
blood transfusion, if necessary
⮚ To catheterize the bladder ,if it is found to be full
⮚ During this procedure ,if if features of placental
separation are evident ,expression of the placenta
is to be done either by controlled cord traction
method .if features of controlled cord traction are
not evident ,manual removal of placenta under
general anesthesia is to be done

Traumatic bleeding
The utero vaginal canal is to be explored under
general anesthesia after the placenta is expelled and
haemostatic sutures are placed on the offensing sites
Manual removal of placenta –steps
❖ Step 1: the operation is done under general
anesthesia. In extreme emergency, where
anesthesia is not available, the operation may
have to be done under deep sedation with 10 mg
diazepam given IV. The patient is placed in
lithotomy position. Antiseptic precautions are
meticulously taken. The vulva and vagina
swabbed with antiseptic solutions and sterile
leggings are placed as in other vaginal
operations. The bladder is catheterized
❖ Step 2: one hand is introduced in to the uterus
after smearing with the anti septic solution in
cone shaped manner following the cord, which is
made taut by the other hand . While introducing
the other hand, the labia are separated by the
fingers of the other hand. the fingers of the
uterine hand should locate the margin of the
 placenta

❖ 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 movement of the fingers
inside the uterine cavity till the placenta is
completely separated

❖ Step 4 : as soon as the placental margins are

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

Teacher Explain the

8 10 min explains the LCD management of
management of true postpartum
true haemorrhage
To explain the postpartum
management haemorrhage
of t true
postpartum ❖ Step V When placenta is completely separated, it
bleeding is extracted by 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
❖ Step V I Intravenous ergometrine 0.25 mg 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, inspiration of the utero vaginal canal is
to be made to exclude any injury
❖ Step V II The placenta and membrane are to be
 inspected for completeness and be sure that the
uterus remains hard and complete

MANAGEMENT OF TRUE POST

PARTUM HAEMORRHAGE

Immediate measures
● Call for extra help
● Put in one or more large bore IV cannulas
● Keep patient flat and warm
● Send blood for group, cross matching diagnostic
test and and ask for 2 units of blood
● Infuse rapidly 2 litters of normal saline or plasma
substitute like haermocele ,an urea linked gelatin,
to re expand the vascular bed . it does not interfere
with cross matching
● Give oxygen by mask 10-15L/min
● Start 20 units of oxytocin in 1 L of normal saline
IV at the rate of 60 drops per minute . transfuse
blood as soon as possible
● One midwife or/ rotating house man should be
assigned to monitor the following 1)pulse 2)blood
pressure 3) respiratory rate and oxymeter 4)type
and amount of fluid the patient has received
5)urine output 6)drugs type 7)CVP

Actual management
First step is to control the fundus and to note the feel of
the uterus . if the uterus is flabby ,the bleeding is likely to
be from the atonic uterus . if the uterus is firm and
contracted ,the bleeding is is likely of traumatic origin
Atonic uterus :step 1
a. Massage the uterus to make it hard and express
the blood clot
b. Methergin 0.2 mg is given IV
c. Inj. Oxytocin drip is started (10 units in 500 ml of
normal saline)at the rate of 40-60 drops / minute
d. Foley catheter to keep the bladder empty and to
monitor urine out put
e. To examine the expelled placenta and membrane
for missed cotyledon or piece of membrane if the
uterus failed to contract , proceed to the next step
Step 2
The uterus is to be explored under general
anaesthesia, simultaneous inspection of the cervix,
vagina specially the para ureteral region is to be done to
exclude co- existing bleeding sites from the injured area.
In refractory cases :
● Inj. 15 methyl PGF2α,250µg IM in deltoid
muscle every 15 minute (up to maximum
of 2mg ) OR
● Misoprostol (PGE1)1000µg per rectum is
effective
● When uterine atony is due to tocolytic
drugs, calcium gluconate 1 g IV slowly
should be given to neutralize the calcium
blocking effect of these drugs

Step 3
Uterine massage and bimanual compression
a)The whole hand is introduced in to vagina in cone
shaped fashion after separating the labia with the fingers
of the other hand
b) the vaginal hand is clenched in to fist with the back of
 the hand directed posteriorly and the knuckles in the
anterior fornix
c) other hand is placed over the abdomen behind the
uterus to make it anteverted
d) the uterus is firmly squeezed between the two hands . it
may be necessary to continue the compression for a
prolonged period untill the tone of the uterus is regained .
this is evidenced by absence of bleeding if the
compression is released
step 4
uterine tamponade
Tight intra uterine packing done uniformly under general
anaesthesia.
A 5 meters long strip of gauze ,8cm wide folded twice is
required. The gauze should be soaked in anti septic cream
before introduction. The gauze is placed high up and
packed in to the fundal area first while the uterus is
steadied by the external hand . gradually the rest of the
cavity is packed so that no empty space is left behind. A
separate pack is used to fill the vagina. An abdominal
binder is placed . intra uterine plugging acts not only by Teacher discuss Explain about
9 10min stimulating uterine contraction but excerts direct regarding LCD secondary
haemostatic pressure to the open uterine sinuses. Anti secondary post postpartum
biotic should be given and the plug should be removed partum hemorrhage
To enumerate after 24 hours hemorrhage and
the secondary Intra uterine packing is useful in a case of uncontrolled students
postpartum postpartum haemorrhage where other methods have failed participate in
haemorrahage and the patient is being prepared for transport to a tertiary discussion
care unit

Balloon tamponade
Tamponnade using various type of hydrostatic balloon
catheter has mostly replaced uterine paking. Mechanism
of action is similar to uterine packing. Foley catheter
,bakri balloon ,condom catheter or sengstaken –
blakemore tube is inserted in to uterine cavity and the
balloon is inflated with normal saline it is kept for 4-6
 hours . it is success ful in atonic PPH
Step V: Surgical methods to control PPH are many. An
outline of step wise uterine devascularisation procedures
are given below
● Ligation of uterine artery –the ascending branch
of the uterine artery is ligated at the lateral boarder
between upper and lower uterine segment
● Ligation of the ovarian and uterine artery
anastomosis
● Ligation of anterior devision of internal ileac
artery
● Angiographic arterial embolisation

Step VI
Hysterectomy rarely uterus fails to contract and bleeding
continues in spite of the above measures

SECONDARY POST PARTUM HEMORRHAGE

Causes
The bleeding usually occurs between 8th 14 th day of
delivery. The cause of late postpartum haemorrhage are
● Retained bits of cotyledon or membranes
● Infection and separation due to delayed healing
process
● Secondary haemorrhage from caesarean section
wound usually occur in 10-14 days
● Withdrawal bleeding following oestrogen therapy
for suppression of lactation
10 1min ● Other rare causes are :chorion epithelioma, Teacher
carcinoma of cervix, placental polyp, infected summarize the
topic and
To summarize students listens
 the topic fibroid and puerperal inversion of uterus

Diagnosis
11 1min 1. Signs and symptoms Teacher
● The bleeding is bright red and of varying amount . concludes the
rarely it may be brisk topic and
To conclude ● Varying degree of anaemia and and evidence of students listens
the topic
sepsis
2. Internal examination –reveals evidence of sepsis,
sub involution of the uterus and often pattulus
cervical os
3. Ultrasonography-is useful in detecting the bits of
placenta inside the uterine cavity

Management
Supportive therapy
1. Blood transfusion if necessary
2. To administer methergine 0.2mg IM if bleeding is
uterine in origin Teacher asks
12 2min questions and
3. To administer anti biotics as a routine
students gives
answers
Conservative
To obtain feed If the bleeding is slight and no apparent cause is detected,
back from the a care full watch for a period of 24 hours or so is done in
students the hospital
Active treatment
As the commonest cause is due to retained bits of
13 1min cotyledon or membranes, it is preferable to explore the
uterus urgently under general anaesthesia. The products
are removed by ovum forceps. Gentle curettage is done
To encourage by using flushing curette. Methergine 0.2 mg is given IM.
students for The material s removed are to be sent for histological
self directed examination
learning
 SUMMARY

Postpartum hemorrhage is a significant cause of maternal

morbidity and mortality. Most postpartum hemorrhages
are caused by uterine atony and occur in the immediate
postpartum period. The class dealt with definition, types,
causes, diagnosis and management measures for PPH.

CONCLUSION

Postpartum haemorrhage (PPH) remains an important

complication of childbirth and contributes significantly to
maternal mortality. Care was adjudged to be substandard
in most cases. Significant blood loss from any cause
requires standard maternal resuscitation measures Blood
loss of more than 1,000 mL requires quick action and an
interdisciplinary team approach. Hysterectomy is the
definitive treatment in women with severe, intractable
hemorrhage. In patients who desire future fertility, uterus-
conserving treatments include uterine packing or
tamponade procedures, B-lynch uterine compression
sutures, artery ligation, and uterine artery embolization.

RECAPITULATION QUESTIONS

● Define PPH
● What are the types of PPH?
● What are the causes of PPH
● Explain the steps of manual removal Of placenta
● Explain about secondary postpartum hemorrhage
 Assignment

Write Down the nursing management of patients of

patients with post partum hemorrhage

BIBLIOGRAPHY

1. Dutta DC.Text book of obstetrics .London:New Central Book Agency(P)Ltd;2013.

2. Bennett V. R, Brown.K.L, Myles Text Book for Midwives.London: ChurchilLivingstone; 2013.