ABNORMAL MIDWIFERY cc
Prepared by: c
ALEX DECHE
c
Senior lecturer
c
Kenya Medical Training College
c c c
1 Promotingcsafecmotherhood
,OBSTETRICAL EMERGENCIES c
POST PARTUM HEAMORRHAGE (PPH)
c c c
Def:cIt’scthecbleedingcaftercdeliverycofcthecbabycamountingctoc500cmlscorcmorecpercvaginallycorc1clitr
ecthroughcceaseriancsectioncorcaycamountcaffectingcthecmother’sccondition.
TYPEScOFcPPH;
TherecarectwoctypescofcPPH;
1. PrimarycPPH
2. SecondarycPPH
PRIMARYcPPH
Def:cIt’scthecbleedingcaftercdeliverycofcthecbabycamountingctoc500cmlscorcmorecvaginalcorc1clitrecthr
oughcceaseriancsectioncorcaycamountcaffectingcthecmother’scconditioncoccurringcwithinc24choursca
ftercbirth
CausescofcPPH
Therecarecfourccauses:c(4Ts)
1. T-cTonec(Atoniccuterus)c–cmostccommon
2. T-Traumac(e.g.ctear,crupturedcuterus)
3. T-Tissue(Retainedcproductscofcconception)
4. T-Thrombinc(thrombocytopenia-c clottingcdisorders)
1. Atonic uterus c
Def:cThisciscacsituationcwherecthecuteruscfailsctoccontractcaftercdeliverycofcthecbab
y.
NB/c Thec commonestc causec ofc primaryc PPH
PredisposingcfactorsctocAtoniccuterus
a. Multiplecpregnancy
Thisciscascacresultcofcovercdistensioncofcthecuterus
b. Polyhydromnous
2 Promotingcsafecmotherhood
,Thiscisc acconditioncwherecisc excessivecamnioticcfluidc incthec uterusceithercorcequ
alctoc1500ml.cthisccontributesctocovercdistensioncofcuteruscleadingctocatoniccuter
us
c. Bigc baby
ThisccausescovercdistensioncofcthecuteruscleadingctocuteruscAtomy.
d. Prolongedc labour
Itcexposescuterinecmusclesctocfatiguecreducingcthecabilityctoccontractcaftercthecde
liveryc ofc thec babyc causingc uterinec atony
e. Fibroids
Itc reducesc thec abilityc ofc thec uterusc toc contractc (beingc anc abnormalc growth/massci
nc thec uterus)c afterc thec deliveryc ofc thec baby
f. Fullcbladder
Acfullcbladderccompetescforcspacecwithctheccontractingcuteruscwhichcpreventscth
ec uterusc fromc contractingc fullyc thusc causingc atonicc uterus.
g. Previousc caesareanc sectionc CCS
Thec previousc asc scarc usuallyc healsc withc ac formationc ofc ac fibrousc tissues;c thecfibr
osisc reducesc thec abilityc ofc thec uterusc toc contractc leadingc toc uterusc atony.
h. Multiplyc parity
Everyctimecyoucconceivecthecplacentacsitecchangescforcconvenience.
Everycpreviouscplacentalcsitechealscwithcfibrosis.cThecmorecplacentalccsiteccthecmore
c thec myometriumc isc replacedc withc fibrousc tissuec andc thisc resultc toc uterinecatonyc
afterc thec deliveryc ofc thec baby
i. Placentac previa
Thisciscacplacentaconctheclowercuterinecsegment;cthecabilitycofcthecuterusctoccontr
actc andc closec thec placentalc sitec ofc thec uteruscsegmentc isc lowc Itc isc asc acresultcofcfe
wercmyometriumconctheclowercuterinecsegmentcleadingctochaemorrhage.
j. Placentacabruption
Withc placentac abruptionc therec isc ac formationc ofc rectc ro-
placentalc dot.c Bloodcfromcthecdotcleakscorcitscabsorbedcintocthecmyometrium,cres
ultingcintocaccouvelewrcuteruscorcuterinecmyometra.cThiscwillcleadctocinabilitycofc
myometriumc toc contractc resultingc toc uterinec atony.
3 Promotingcsafecmotherhood
, k. Precipitatec labour
Thisciscabnormalcshortclabourccharacterizedcbyccontractionscwithcnocretractions,
c afterc deliveryc ofc thec babyc thec uterusc failsc toc contractc duec toc poorcmusclec co-
ordinationc duringc labourc toc uterinec atony.
l. Drugs
Usec ofc drugsc thatc affectc thec contractilityc ofc thec uterusc e.g.c Anestheticc drug,
Anticonvulsantc e.g.c MgSo4
m. Mismanagementc ofc 3rdc stagec ofc labour
Thiscincludescevencthecfailurecorcdelayctocadministercsyntocinoncaftercthecbirthcof
c thec babyc asc required.
n. Overcmassagingcofcthecabdomen.c
Massagec bringsc musclec confusion.
o. Overc usec ofc oxygenc willc leadc toc failurec ofc oxytonicc toc causec contractionc of
thecuterus.
Oncec thec uterusc isc exposedc toc sintocinonc severalc timesc thec effectivenessc ofc thec
drugc goesc down.c Thec oxytocinc receptorsc onc thec uterusc failc toc workc effectively.
p. Retainedcplacenta
Thisciscwhencretainedcproductscofcconceptionc e.g.cplacenta,cclots,cmembranescha
vecnotcbeencdelivered.cThiscisconecofcthecmostccommonccausescofcuterinecatony.
Diagnosisc ofc anc Atonicc uterus
a. Excessc bleedingc afterc thec deliveryc ofc thec body
b. Uteruscfeelscsoftlycandcboggy,cdistended.
NB
Allcwomencwithcriskcfactorsctocatoniccuteruscshouldcreceivecprophylacticcmanage
mentc toc thec motherc aboutc anc atonicc uterus.
Managementc ofc postpartumc hemorrhagec withc Atonicc uterus
1. Shoutcforchelp,cDrcABC
2. Reassurec thec mother.
3. Massagec thec uterusc toc expelc clots
4. Emptycbladder
5. Removec clotsc ifc any
6. Givec oxytocinc ifc notc givenc orc repeatc 10ru
7. Fixc anc ivc accessc preferablyc withc largec bonec cannulac gaugec 16-18.
8. Collectcbloodcsamplecforcinvestigation,cGXM,cdottingctimecplateletccountc
Hb
4 Promotingcsafecmotherhood
Prepared by: c
ALEX DECHE
c
Senior lecturer
c
Kenya Medical Training College
c c c
1 Promotingcsafecmotherhood
,OBSTETRICAL EMERGENCIES c
POST PARTUM HEAMORRHAGE (PPH)
c c c
Def:cIt’scthecbleedingcaftercdeliverycofcthecbabycamountingctoc500cmlscorcmorecpercvaginallycorc1clitr
ecthroughcceaseriancsectioncorcaycamountcaffectingcthecmother’sccondition.
TYPEScOFcPPH;
TherecarectwoctypescofcPPH;
1. PrimarycPPH
2. SecondarycPPH
PRIMARYcPPH
Def:cIt’scthecbleedingcaftercdeliverycofcthecbabycamountingctoc500cmlscorcmorecvaginalcorc1clitrecthr
oughcceaseriancsectioncorcaycamountcaffectingcthecmother’scconditioncoccurringcwithinc24choursca
ftercbirth
CausescofcPPH
Therecarecfourccauses:c(4Ts)
1. T-cTonec(Atoniccuterus)c–cmostccommon
2. T-Traumac(e.g.ctear,crupturedcuterus)
3. T-Tissue(Retainedcproductscofcconception)
4. T-Thrombinc(thrombocytopenia-c clottingcdisorders)
1. Atonic uterus c
Def:cThisciscacsituationcwherecthecuteruscfailsctoccontractcaftercdeliverycofcthecbab
y.
NB/c Thec commonestc causec ofc primaryc PPH
PredisposingcfactorsctocAtoniccuterus
a. Multiplecpregnancy
Thisciscascacresultcofcovercdistensioncofcthecuterus
b. Polyhydromnous
2 Promotingcsafecmotherhood
,Thiscisc acconditioncwherecisc excessivecamnioticcfluidc incthec uterusceithercorcequ
alctoc1500ml.cthisccontributesctocovercdistensioncofcuteruscleadingctocatoniccuter
us
c. Bigc baby
ThisccausescovercdistensioncofcthecuteruscleadingctocuteruscAtomy.
d. Prolongedc labour
Itcexposescuterinecmusclesctocfatiguecreducingcthecabilityctoccontractcaftercthecde
liveryc ofc thec babyc causingc uterinec atony
e. Fibroids
Itc reducesc thec abilityc ofc thec uterusc toc contractc (beingc anc abnormalc growth/massci
nc thec uterus)c afterc thec deliveryc ofc thec baby
f. Fullcbladder
Acfullcbladderccompetescforcspacecwithctheccontractingcuteruscwhichcpreventscth
ec uterusc fromc contractingc fullyc thusc causingc atonicc uterus.
g. Previousc caesareanc sectionc CCS
Thec previousc asc scarc usuallyc healsc withc ac formationc ofc ac fibrousc tissues;c thecfibr
osisc reducesc thec abilityc ofc thec uterusc toc contractc leadingc toc uterusc atony.
h. Multiplyc parity
Everyctimecyoucconceivecthecplacentacsitecchangescforcconvenience.
Everycpreviouscplacentalcsitechealscwithcfibrosis.cThecmorecplacentalccsiteccthecmore
c thec myometriumc isc replacedc withc fibrousc tissuec andc thisc resultc toc uterinecatonyc
afterc thec deliveryc ofc thec baby
i. Placentac previa
Thisciscacplacentaconctheclowercuterinecsegment;cthecabilitycofcthecuterusctoccontr
actc andc closec thec placentalc sitec ofc thec uteruscsegmentc isc lowc Itc isc asc acresultcofcfe
wercmyometriumconctheclowercuterinecsegmentcleadingctochaemorrhage.
j. Placentacabruption
Withc placentac abruptionc therec isc ac formationc ofc rectc ro-
placentalc dot.c Bloodcfromcthecdotcleakscorcitscabsorbedcintocthecmyometrium,cres
ultingcintocaccouvelewrcuteruscorcuterinecmyometra.cThiscwillcleadctocinabilitycofc
myometriumc toc contractc resultingc toc uterinec atony.
3 Promotingcsafecmotherhood
, k. Precipitatec labour
Thisciscabnormalcshortclabourccharacterizedcbyccontractionscwithcnocretractions,
c afterc deliveryc ofc thec babyc thec uterusc failsc toc contractc duec toc poorcmusclec co-
ordinationc duringc labourc toc uterinec atony.
l. Drugs
Usec ofc drugsc thatc affectc thec contractilityc ofc thec uterusc e.g.c Anestheticc drug,
Anticonvulsantc e.g.c MgSo4
m. Mismanagementc ofc 3rdc stagec ofc labour
Thiscincludescevencthecfailurecorcdelayctocadministercsyntocinoncaftercthecbirthcof
c thec babyc asc required.
n. Overcmassagingcofcthecabdomen.c
Massagec bringsc musclec confusion.
o. Overc usec ofc oxygenc willc leadc toc failurec ofc oxytonicc toc causec contractionc of
thecuterus.
Oncec thec uterusc isc exposedc toc sintocinonc severalc timesc thec effectivenessc ofc thec
drugc goesc down.c Thec oxytocinc receptorsc onc thec uterusc failc toc workc effectively.
p. Retainedcplacenta
Thisciscwhencretainedcproductscofcconceptionc e.g.cplacenta,cclots,cmembranescha
vecnotcbeencdelivered.cThiscisconecofcthecmostccommonccausescofcuterinecatony.
Diagnosisc ofc anc Atonicc uterus
a. Excessc bleedingc afterc thec deliveryc ofc thec body
b. Uteruscfeelscsoftlycandcboggy,cdistended.
NB
Allcwomencwithcriskcfactorsctocatoniccuteruscshouldcreceivecprophylacticcmanage
mentc toc thec motherc aboutc anc atonicc uterus.
Managementc ofc postpartumc hemorrhagec withc Atonicc uterus
1. Shoutcforchelp,cDrcABC
2. Reassurec thec mother.
3. Massagec thec uterusc toc expelc clots
4. Emptycbladder
5. Removec clotsc ifc any
6. Givec oxytocinc ifc notc givenc orc repeatc 10ru
7. Fixc anc ivc accessc preferablyc withc largec bonec cannulac gaugec 16-18.
8. Collectcbloodcsamplecforcinvestigation,cGXM,cdottingctimecplateletccountc
Hb
4 Promotingcsafecmotherhood
