Management Normal Post Partum ( Revisi ) - Dr Jeno.pdf

Postpartum Hemorrhage Prevention with Active Management of the Third Stage of Labor

Dr. J. Jeno Wibisono, Sp OG

FAKULTAS KEDOKTERAN UNIVERSITAS PELITA HARAPAN This teaching material is copyrighted. No part of this work may be reproduced, including photocopied, without written permission of Universitas Pelita Harapan .

INTRODUCTION

Healthy Indonesian Vision 2010 Mission : 1.To increase individual, family, society and environmental health 2.To increase the quality of health service, and make it accessible to all society 3.To encourage society’s independency

Main Program : To decrease the maternal mortality rate

September 2000 189 countries of United Nation Organization agree to support the Millenium Development Goals

GOALS 1.  2.  3.  4.    5.  6.  7. 

Maternal Mortality Rate 1998  125 / 100.000 Antenatal Care : 80%  90% (including exclusive breastfeeding) Labor with competent person : 60%  90% Anemia rate in pregnant woman : 64% - 35% Anemia rate in children : 55% - 40% Anemia rate in working woman : 30%  20% Referral rate of high risk patients : 20%  50% Immunization of TT2 : 64%  80% Low birth weight cases : 7.9%  5%

Contraception Aspect 1.  New Acceptor : 4.5 million  4.9 million 2.  Active acceptor : 21.5 million  25.2 million Youth Reproductive Health Service  Anemia prevalence in youth <20%

PROBLEMS

1. Barometer of a country is : Maternal mortality rate and infant mortality rate 2. Causes of maternal mortality rate : - Hemorrhage 40 – 60 % - Eclampsia 20 – 30% - Infection 20% 3. Causes of infant mortality rate (Java, Bali 1995) - Perinatal Disorder 33.5% - Respiratory Disorder 32.1% - Diarrhea 9.6% - Parasite 4.1% - Tetanus 2.3%

Research (Evidence Based) It is shown that the Active Management of the Third Stage of Labor is able to reduce the mortality and morbidity maternal rate in the world.

Active Management of Third Stage of Labor

The active evacuation of placenta is helpful to avoid any postpartum hemorrhage, including: 1.Give oxytocin as soon as the baby has been delivered 2.Umbilical cord controlled-traction 3.Uterus massage as soon as the placenta has been delivered

Oxytocin Trigger the uterus to contract and also to increase the likelihood of placental separation : 1. Oxytocin is given in 2 minutes 10 U, IM after the baby is delivered 2. If oxytocin is not available  stimulate the mother’s nipple to produce the natural oxytocin 3. If available  Ergometrine 0.2 mg IM

Controlled Cord Traction (Penegangan Tali Pusat Terkendali) 1. One hand is placed upon the uterus right above the pubic bone 2. When the contraction occurs, push the uterus with our hand (DORSO cranially towards mother’s head) 3. The other hand is holding the cord about 5-6cm in front of the vulva 4. Maintain a steady resistance on the cord and wait until there is a strong contraction (2 – 3 minutes) 5. Whenever the contraction occurs, do the controlled cord traction with the same resistance and power • •

•

Controlled cord traction is only conducted when the uterus is having contraction When the uterus is relaxed, our hand is still located above the uters, but not doing the controlled cord traction Repeat the procedure in every contraction until all the placenta is separated

Do uterus fundus massage after the placenta is delivered

3 Important steps in Active Management of the Third Stage of Labor: 1.Give Oxytocin 10 U IM  2 minutes after the baby is delivered 2.Do the controlled cord traction 3.Right after the placenta is delivered  do the massage upon the uterus fundus

Uterus massage soon after the placenta is delivered •

• • •

As soon as the placenta is separated, take it out with a hand movement approaching the placenta Move it with a “up and down” movement, just like the anatomy of the birth canal Both of our hands hold the placenta, and slowly turn the placenta around in a clockwise direction  take out the amniotic sac too After the placenta and sac is delivered, massage the uterus to make them contract  to avoid any hemorrhage

** If the placenta has not been delivered yet in 15 minutes  give the second dose of Oxytocin 10 U IM (15 minutes after the 1st dose)

Active Management of the Third Stage of Labor – 30 min but the placenta still not delivered yet • • • •

Check the bladder  do the catheterization if needed Check the signs of placental separation Give the third dose of Oxytocin 10 U IM Prepare for referral

WARNING: - If the uterus is moving to inferior when we try to pull the cord; but the placenta is not separated yet  STOP it, perhaps it is the UTERUS INVERSION - If the mother is in pain or the uterus is not having contraction  STOP ! Risk of hemorrhaging - Wait for few minutes, and re-check

Dangerous Routine Procedure

Description

•

Push the uterus before the placenta is delivered

•

•

Push the fundus towards the inferior directing the vagina Catheter the bladder

•

Traction of the cord is too powerful Keep the placenta inside the uterus partly

• •

• • •

•

Can cause incomplete separation of placenta and post partum hemorrhage Can cause the uterus inversion

Increase the risk of urinary tract infection Can cause the cord to break Can cause the postpartum hemorrhage  the uterus is not fully contracted until the placenta is completely delivered

Uterine Atony If any bleeding occurs  FIND THE SOURCES!!

• Situation when the uterus is failed to have adequate contraction after the labor – Continue the uterus massage for 15 seconds and do: – 1. Internal Bimanual Compression (Kompresi Bimanual Internal – KBI) • Push the uterus with both hand powerfully to give direct pressure towards the blood vessels in the uterus wall, also to stimulate the myometrium to contract

2. If the uterus still not having contraction within 1 – 2 minutes  prepare for referral (this is not a usual uterine atony) 3. Accompany the mother to the referral destination, and keep doing the internal bimanual compression, then do : a. IV line (16 – 18) 500ml RL that contains Oxytocin 20 U  within 10 minutes b. Then 500ml/hour until the referral place or 1.5L fluids and then 125ml/hour c. If the infusion fluid is not adequate, then the second infusion bottle is 500ml but with slower rate

• This can also be done when we’re on the way to the referral place • • •

1. Place one hand upon abdomen in front of the uterus, right above the pubic bone 2. Put the other hand on the abdominal wall (behind the uterus body), try to hold the back part of the uterus 3. Try to compress between the two hands to compress the blood vessel of the uterine wall. This is to help the uterus to contract and constrict the blood vessel

External Bimanual Compression

Placental Retention • This can be happening without any sign of bleeding • Placenta or parts of it can still be within the uterus after the baby is delivered. • If the placenta is seen on the vagina, ask the mother to push. If we can feel the placenta, try to take them out • Make sure the bladder is empty. Do catheterization if needed • If the placenta is not yet delivered, give Oxytocin 10 U IM if the active management of the third stage of labor is not yet performed.

• Don’t give Ergometrine because it can cause a TONIC contraction of uterus  delay the placenta delivery • If the placenta still cant be delivered (after 30 min Oxytocin) and the uterus is contracting  do the controlled cord traction

• Avoid doing the controlled cord traction powerfully and push the uterine fundus too strong  can cause uterine inversion

If the controlled cord traction is not succesful  do the manual separation of placenta

Placental Retention • The bleeding is caused by the placental retention  the cotyledon is not completely delivered • If the cervix is still opened  explore digitally to take out the blood clots and any tissue • Some patients come with late postpartum hemorrhage (after 6-10 days) and uterus subinvolution • Give wide spectrum antibiotic  Ampicillin • Check Hb level  if <8gr%  refer – If >8gr% : give Ferrous Sulfate 600mg (3x1 tab) for 10 days

Do not leave the mother (at least) 2 hours after the labor process. Before leaving the mother : 1. Make sure the mother is in a stable condition and normal vital signs; adequate uterine contraction, firm consistency and normal position. Normal bleeding and the mother can urinate without any help 2. Teach the mother or the family how to evaluate the uterine tonus and do massage of the uterus. 3. Do the first management of the newborn 4. Make sure that breastfeeding start soon after the baby is born 5. Teach the mother and the family to find any help if the following dangerous signs are found : - fever - active bleeding - blood clots >> - dizzy - difficulty in breastfeeding - pain in pelvic or abdomen area that is more severe than the usual cramp

Conclusion and Suggestion 1. The priority to achieve the 2010 Healthy Indonesian Goal is by achieving a decreasing number in infant mortality rate and maternal mortality ratio 2. The most common causes of the maternal death is the post partum hemorrhage (40 – 60%) 3. Active management of the 3rd stage of labor is proved to be effective as the main method to prevent the post partum hemorrhage 4. The mother should be monitored and should not be left in the first 2 hours 1. As the result, a midwife must be able to do the active management of the 3rd stage of labor and prioritize : - Give oxytocin in the first 2 minutes after the baby is delivered - Do the controlled cord traction - Do uterine massage after the placenta is delivered

REFERENCES

Puerperal Infection

Puerperal Infection Definition: The postpartum infection that usually origin from the endometrium, the insersion area of placenta Symptoms: Temperature >38˚C for 2 consecutive days after 24hours of labor in the first 10 days of post partum periods

The puerperal infection can be  with: - Antibiotic - Less surgery (severe trauma) - Minimize the operative duration - Asepsis - Blood transfusion - Improvement of general health

Etiology: Exogenous (outside) Endogenous (the woman’s own birth canal) → the most common The most common bacteria: Streptococcus, bacil coli, Staphylococcus rarely: basil welchii, Gonococcus, bacil thypus, C. tetani

Transmission: - Bimanual internal exam - Tools that are used during the procedures - The sexual intercourse during the last month

Predisposing factors: - Bleeding ( immune) - Labor trauma * port d’ entree * necrotic tissue - Mother’s condition (anemia, malnutrition →immune)

Pathology: From the wound infection a. Limited to the wound itself (perineum, vaginal, cervix or endometrium infection) b. Spread to the surroundings tissue (thrombophlebitis, parametritis, salpingitis, peritonitis)

Prognosis: depend on the bacterial virulence and the patient’s immunity

Transmission of infection : I. II. III. IV.

Spread out to the surface : endometritis, salpingitis, pelvicoperitonitis, general peritonitis Spread out to inner layer : endometritis, myometritis, perimetritis, peritonitis Spread out via lymphatic : lymphangitis, perilymphangitis, parametritis, perimetritis Spread out via vein : phlebitis (→ sepsis), periphlebitis, parametritis

Sapraemia (retention fever): fever that is caused by blood clots retention or amniotic sac retention. Blood is suddenly gushing out and also amniotic sac can be seen. Blood usually >>

Perineal wound infection: The wound is painful, erythema, and edema  open wound, infected, abscess + fever Cervical wound infection : In depth wound  parametrium : parametritis

Endometritis (most common): After the incubation period, the organism is invading the endometrium (ex-placental implantation) The fever occurs within 48 hours postpartum When contraction occurs  pain (+), longer Lochia >>, red / brownish, foul smell Subinvolution Leukocyte 15000 – 30000/mm³ Headache, lack of sleep, appetite  Temperature  on day 7-10

Thrombophlebitis: Transmission via venous system

•

Most common, the most important causes of death

Involve the veins : a. Uterine wall veins and latum ligament (vena ovarica, vena uterina & vena hypogastrica) → pelvic thrombophlebitis a. Veins of extremity (Femoral v., popliteal v., saphena v.) → thrombophlebitis femoral

Pelvic Thrombophlebitis The most common: Ovarian v. Left ovarian v.→ Renal v. Right ovarian v.→ Inferior v. cavae Thrombosis (+) → emboli/sepsis → pyemia (if the thrombosis contains pus) → lungs (sudden death / lungs abscess) → kidney → heart valve

Pelvic Thrombophlebitis Occur in the 2nd week: - Fever - Complication: lung abscess, pleuritis, pneumonia, kidney abscess - Occur for 1 – 3 months - High mortality rate (usually if lung abscess (+)

Femoral thrombophlebitis Origin: - Saphena magna thrombophlebitis / Femoral v. - Thrombophlebitis v. uterina, v. hypogastrica, v. iliaca ext, v. femoralis - Parametritis Congested veins  edema of extremity (1 or both legs) “Phlegmasia alba dolens”

Femoral thrombophlebitis Occur on day 10 – 20 Temp is increasing Pain on extremity (usually on left) Extremity : flexion and pronated, pain on movement Palpation : pain along the veins area, rigid, edema

Puerperalis Sepsis • Port d’ entrée: placental insertion place • Originally from: thrombophlebitis V. uterina / v. ovarica • Can also be secondary to (metastases): lungs, heart valves, kidney, liver, spleen, brain, etc

Puerperalis Sepsis Signs : Temp >40˚C, remittens, shivering Physical appearance: severe, resp.rate >>, anxious Hb due to hemolysis, leukocytosis

Peritonitis Spread through lymphatic  Peritoneum (Peritonitis) → Parametrium (Parametritis) Peritonitis that is limited in pelvic area  Pelveoperitonitis If generally affected: General peritonitis (worse prognosis)

Peritonitis Signs: Sudden pain in all abdomen region Shivering, fever Distended abdomen, sometimes diarrhea Vomit Anxious Before death : delirium, coma

Parametritis (Pelvis cellulitis) Occurs in 3 ways: - Deep cervix laceration - Endometritis transmission / infected cervix laceration transmitted via lymph - Continously from pelvis thrombophlebitis

Parametritis (Pelvic cellulitis) Postpartum temp is high for >1 week Unilateral or bilateral lower abdominal pain, radiating to leg Toucher : infiltrate is palpated in parametrium, sometimes spread out to pelvic wall The infiltrate can also be infected (abscess)

Salphyngitis

Commonly affected by Gonorrhea infection Occur in the 2nd week Fever, bilateral lower abdominal pain Can be healed in 2 weeks Can cause infertility

Prognosis - HR <100x/min → good - HR >130x/min, HR not ↓ even though the temp is ↓  not so good - Continous fever, shivering, insomnia, jaundice, Hb level , leukocyte↓ or very ↑ → bad Peritonitis, thrombophlebitis pelvis→ bad

Prophylaxis

Pregnancy: - Give Fe for anemic patients - Maximize the nutrition - Stop sexual intercourse within last 1 – 2 months of pregnancy

Prophylaxis During the labor: 1. Minimize the any contamination inside the birth canal (asepsis, bimanual examination only if any indication) 2. Minimize any trauma 3. Minimize the bleeding (>500cc→transfusion) 4. Minimize the labor period

Prophylaxis Postpartum: Do not open vulva or insert fingers inside the vulva to clean the perineum Do not irrigate for the first 2 weeks Infectious patient should be isolated

Treatment

Antibiotic Penicilline G: 5.000.000 S every 4 hours IV Ampicillin 3-4 gram IV/IM If penicilline resistant: Oxacilline, Dicloxacilline, Methicilline

Treatment Special treatment Perineal, vulva, vagina laceration : if there is infection  take out the suture  drainage Endometritis: Fowler, Uterotonic, educate the mother to drink >>, isolate, but the baby still allowed to breastfeed

Treatment Special treatment Thrombophlebitis pelvis - Avoid lungs embolism - Reduce the complication of thrombophlebitis (edema, pain) - Anticoagulant (heparin, dicumarol)

Treatment Special management Thrombophlebitis femoral - Lift the leg - Bedrest for a week after the fever resides - Don’t stand too long, use elastic socks

Treatment

Special management Peritonitis - High dose antibiotic - Abot Miller Tube → reduce epigastric fullness - IVFD, blood transfusion, O2 - Sedatives - Eat and drink  if flatus (+)

Medication Special management Parametritis - Antibiotic - If fluctuation + → incision Location of incision : above the thigh area or on douglas cavity

THANK YOU