THE MANAGEMENT AND PREVENTION OF POST PARTUM HAEMORRHAGE IN A CLINIC

Classification of Post-Partum Haemorrhage According to Cause In considering the management of post-partum haemorrhage, it is much more valuable to classify ex­ cessive blood loss according to its cause. Hypotonic post-partum haemorrhage occurs because the uterus fails to undergo adequate contraction and retraction following the delivery of the baby. This type of post-partum haemorrhage can be torrential and terri­ fying and usually occurs within half an hour of delivery. Traumatic post-partum haemorrhage occurs as a result of traum a to the genital tract at any level from the uterus to the vulva. The am ount and duration of bleeding will depend upon such factors as what struc­ ture has been damaged, and whether there is any supervening sepsis. Haemorrhage caused by retained products of concep­ tion can occur immediately as in the case o f post-abortal bleeding, or may be delayed as long as 10 days as in the case of a retained placental cotyledon. Bleeding associated with coagulation defects almost always occurs within the first half hour of delivery. Because a fully developed post-partum haemorrhage can be such a serious and terrifying condition, its prevention under each o f these headings is discussed before the management o f the bleeding patient in a clinic.

P OST-PARTUM haem orrhage is best defined as ex cessive blood loss from the genital tract following the birth o f the fetus.For statistical purposes, the definition o f excessive blood loss is 600 ml or more.Traditionally, post-partum haem orrhage is divided into prim ary P P H which is bleeding ocurring within 24 hours o f delivery, and secondary P P H which is bleeding occurring after that time.

Classification of Post-Partum Haemorrhage According to Cause
In considering the managem ent of post-partum haem orrhage, it is much m ore valuable to classify ex cessive blood loss according to its cause.
Hypotonic post-partum haem orrhage occurs because the uterus fails to undergo adequate contraction and retraction following the delivery o f the baby.This type of post-partum haem orrhage can be torrential and terri fying and usually occurs within half an hour o f delivery.
Traum atic post-partum haem orrhage occurs as a result o f traum a to the genital tract at any level from the uterus to the vulva.The am ount and duration o f bleeding will depend upon such factors as what struc ture has been dam aged, and whether there is any supervening sepsis.
H aem orrhage caused by retained products o f concep tion can occur immediately as in the case o f post-abortal bleeding, or may be delayed as long as 10 days as in the case o f a retained placental cotyledon.
Bleeding associated with coagulation defects almost always occurs within the first half hour o f delivery.
Because a fully developed post-partum haem orrhage can be such a serious and terrifying condition, its prevention under each o f these headings is discussed before the managem ent o f the bleeding patient in a clinic.

H YPOTO NIC POST-PARTUM H A EM O RR H A G E
H ypotonic post-partum haem orrhage should be ex pected in any patient who is suffering from hypotonic uterine inertia.This pattern o f labour can occur in any patient during labour, although it is m ost com m only found in grande m ultiparae, patients with multiple pregnancy, and patients with hydram nios.It is characterised by weak contractions occurring at long in tervals during the active phase o f labour, i.e. after 4 cm dilatation o f the cervix.Strictly speaking, post-partum haem orrhage associated with placenta praevia is due to hypotonic post-partum haem orrhage because the lower uterine segment in which the abnorm ally situated placenta has em bedded, does not norm ally undergo good contraction and retraction.Occasionally the Couvelaire uterus o f an accidental haem orrhage will fail to contract properly in the third stage because of damage done to its fibres by dissecting blood and kinin release.
Prevention o f hypotonic post-partum haem orrhage at the clinic level can therefore largely be achieved by selec ting all patients with m ultiple pregnancy, hydram nios, and ante-partum haem orrhage for hospital delivery, and by adm itting them to the waiting m others' area before the onset o f labour.In a rural situation with poor com m unications, grande multiparae should be added to this list.
Both at the base hospital and at the clinic, hypotonic patterns o f labour should always be corrected before the second stage com m ences.This is best done in the clinic by rupturing the m em branes provided the cervix is m ore than 4 cm dilated and having the patient walk about in the labour w ard.The patient should then be re-assessed two hours later and, if the pattern o f labour has not been corrected, she should be transferred to the hospital for an oxytocic infusion.If the patient is already m ore than 7 cm dilated when the diagnosis o f hypotonic iner tia is m ade, she should be transferred because an oxytocic infusion should be com m enced at the time o f artificial rupture o f m em branes.In the case o f twin labour, it is always valuable to have an intravenous in fusion running before the onset o f second stage.Weak contractions which persist longer than 10 m inutes after the birth o f the first twin should then usually be cor rected with an oxytocic infusion before the second twin is delivered, provided the lie is longitudinal, and presen tation not a brow or face.Some older midwives would add a large enem a to this sequence o f m anagem ent, but this is o f doubtful value.
In order to prevent hypotonic post-partum haem or rhage occuring in patients in whom the diagnosis o f hypotonic inertia has been missed, it is recom m ended th at the third stage o f labour should always be m anaged by giving Syntom etrine (ergom etrine tartrate 0,5 mg, oxytocin 5 i.u.: Sandoz) with the birth o f the anterior shoulder and following this with B randt-A ndrew 's m anoeuvre.If the patient is seriously hypertensive and the Ergom etrine p art o f Syntom etrine is contrain dicated, an alternative regime is to give 10 units o f oxy tocin intram uscularly followed by a 20 units per litre oxytocic infusion.

T R A U M A T IC P O ST -PA R T U M H A E M O R R H A G E
T raum atic post-partum haem orrhage occurs m ost com m only in patients requiring operative vaginal delivery, in those unco-operative patients who provoke a precipitate delivery by pushing uncontrollably against an incom pletely dilated cervix, in patients with cephalopelvic d isproportion (be it surm ountable or in surm ountable), and in patients who undergo crim inal abortion.

P o st-p a rtu m h a e m o rrh ag e follow ing operative
vaginal delivery is usually due to lacerations o f the vulva and vagina.It is im portant to point out th at lacerations near the clitoris m ay bleed very profusely and m ay only be seen if specifically looked for by separating the labia m inora.Similarly, longitudinal lacerations closely related to the labia m inora are easily missed unless the labia are carefully separated and inspected.M ost o f these lacerations on the anterior and lateral vaginal walls can be prevented by the use o f well-timed adequate episiotomies.
The unco-operative patient who pushes her baby through her cervix and perineum , can sustain m ultiple lacerations o f this sort, and also-tear her cervix.Cervical lacerations can o f course also occur when the vacuum extractor is em ployed before full dilatation.Lacerations o f the vaginal fornices and o f the cervix are frequently found after attem pts at crim inal abortion.
W hen there is cephalopelvic disproportio n , lacera tions o f the lower genital tract are com m on when the d isproportion is worst at the m id-cavity and outlet o f the pelvis.T raum a to, or rupture o f the uterus occurs when there is serious disproportion at any level in the pelvis, but m ost com m only at the pelvic brim .This is particularly so if the uterus has been dam aged at a previous C aesarean section, or by a previous long and difficult labour, or perforated accidentally at the tim e o f dilatation and curettage or evacuation.
T raum atic post-partum haem orrhage at the clinic level can largely be prevented by the selection o f all p a tients who have small pelves, very big babies, or a scar red uterus for whatever reason, for hospital delivery.Such patients in a rural area would ideally be adm itted to a waiting m others' area well before the onset o f labour, i.e. usually at 37 weeks gestation.A dequate sedation in labour (and this m eans clinic midwives m ust be perm itted to give Pethidine for pain relief) and ad e quate psychological preparation o f the patient in the antenatal clinic in the form o f health education and possibly relaxation exercises, should elim inate p o st partum haem orrhage due to uncontrolled delivery.

PR E V E N T IO N O F P O ST -PA R T U M H A E M O R R H A G E IN T H E C LIN IC
In spite o f all her attem pts to prevent the condition occurring in her clinic, the m idwife will still occasionally be faced with a post-partum haem orrhage when she is far from the assistance o f a m edical officer.The cause o f such a post-partum haem orrhage is seldom im m ediately ap p aren t, and the following sequence o f m anagem ent is therefore suggested: (1) React to excessive bleeding before the statutory 600 ml has been lost.(3) While this is being done review the nature o f the labour.If contractions were weak at the time o f full dilatation, bleeding is probably due to a hypotonic uterus.If the bab y 's head was exces sively m oulded the bleeding is alm ost certainly traum atic in origin.W hile the nature o f the labour is being reviewed, re-examine the placenta to en sure th a t a cotyledon is not retained.
(4) If the placenta is still retained when bleeding begins, rem ove it by repeated B randt-A ndrew 's m anoeuvres.If the placenta does not com e or the cord breaks o ff, do a gentle vaginal exam ination.
If the placenta can be felt protruding through the cervix it should be grasped with the fingers and steadily w ithdraw n from the uterus which is sup ported through the abdom inal wall with the left han d .Only when haem orrhage is severe should a midwife in a peripheral clinic undertake a form al m anual removal o f a placenta that is still wholly in the uterus.C ontrol o f haem orrhage can be achieved if the placenta cannot be removed by bi m anual com pression o f the uterus.
(5) W hen the placenta has been rem oved, rub up the uterus to achieve a sustained contraction.Should bleeding persist, place the patient in lithotom y position and with the aid o f a good light examine the vulva and vagina for lacerations which are bleeding.Pressure upon each bleeding point will establish w hether this is the chief source o f haem orrhage.
(6) Should a visible bleeding laceration prove to be the chief source o f haem orrhage, it should be sutured im m ediately under local anaesthesia.
(7) If there is no local source o f bleeding on the vulva or vagina, and the review o f the pattern o f labour suggests th at it was hypotonic, persistent bleeding m ay be due to an accum ulation o f blood clot inside the uterus.This can be simply removed by doing a gentle vaginal exam ination and passing two fingers through into the cervix into the uterus.If the fu n dus o f the uterus is then controlled with the left hand and brought dow n on to these two fingers, clots within the uterus can be gently and effectively scraped out.Bleeding will then cease. (

M A N A G E M E N T O F A SECO N D A RY P O S T P A R T U M H A E M O R R H A G E IN A C L IN IC
P ost-partum haem orrhage occurring later th an 24 hours after delivery is nearly always due to retained p ro ducts o f conception, sepsis or trau m a. N one o f these conditions can be satisfactorily m anaged in a clinic.The clinic m idw ife's duty to these patients is therefore fairly simple: to resuscitate the patient with intravenous fluids if she is shocked and to m ove the patient as rapidly as is necessary to hospital.Only in the case o f late bleeding from an unrecognised ru p tu re o f the cervix and uterus will bleeding be so heavy th at it m ust be stopped in order to im prove the p atien t's condition during tran sfer.Bi-m anual com pression o f the uterus can be em ployed here as well.
It is relevant to point ou t th at a light bleed m ay precede heavy vaginal bleeding from separation o f a re tained placental cotyledon.T herefore recurrence o f m oderate vaginal bleeding after the fourth or fifth day in the puerperium deserves investigation at the base hospital.
It is o f course true th at even when selection o f p a tients for clinic delivery is excellent, som e will still develop cephalopelvic disproportion in labour at the clinic.The disciplined use o f the P hilpott L abour G raph enabling tim eous transfer o f all patients m aking inade quate progress should lead to early recognition and hospital m anagem ent o f all such p atients'.At the base hospital level, it is o f course im p o rtan t to the prevention o f traum atic post-partum haem orrhage th at all staff undertaking operative delivery have an adequate level o f technical skill.R ET A IN E D PR O D U C TS O F C O N C E P T IO NThis condition can be expected in all patients in whom separation and evacuation o f the placenta is incom plete.It is therefore very com m on in patients who ab o rt under 20 weeks gestation, and possibly m ore com m on in p a tients who have a scarred uterus because the decidua overlying the scar is frequently abnorm ally thin.As a cause o f post-partum haem orrhage, it is best detected by disciplined exam ination o f the placenta and m em branes after delivery.Any patient in w hom the placenta appears incom plete should be referred from the clinic to the base hospital where digital exploration o f the uterus under general anaesthesia will confirm the diagnosis.Evacuation o f the uterus can then be p er form ed. Retained products o f conception not dealt with in this way will usually declare themselves later at the tim e o f a secondary post-partum haem orrhage or o f puerperal sepsis, when the presence o f subinvolution o f the uterus and an open cervix will suggest the correct d ia g n o s is .P re v e n tio n o f s e c o n d a ry p o s t-p a r tu m haem orrhage due to retained products o f conception therefore dem ands careful exam ination o f the placenta in all patients and the exam ination o f every patient on the th ird and fifth post-partum days in order to detect pyrexia and subinvolution.Every m idw ife rem em bers from her training th at prevention o f prim ary p o st-p artu m haem orrhage due to a partially separated retained placenta involves correct m anagem ent o f the third stage o f lab o u r, and the avoidance o f the habit o f fiddling with the fundus.A c tive m anagem ent involving the giving o f Syntom etrine with the birth o f the an terio r shoulder followed by B randt-A ndrew 's m anoeuvre rem oves the tem ptation to fiddle.C O A G U L A T IO N D EFEC TS P o st-p artu m haem orrhage due to defects in the m echanism s o f coagulation can occur in m any patients who suffer a large accidental haem orrhage2, and in those pregnancies com plicated by intra-uterine death or missed second trim ester ab o rtio n in whom the fetus is retained for m ore th an three weeks3.In these tw o groups o f patients, the m echanism o f the d e f e c t is t h a t o f a d is s e m in a te d i n t r a v a s c u l a r coagulopathy due to the release into the general circula tion o f blood and tissue throm boplastins.H aem orrhage due to blood dyscrasias such as idiopathic thro m b o cy to p aen ia and acute leukaem ia are very rare in pregnancy.E arly an d aggressive m an ag e m en t o f accid en tal haem orrhage, aim ing at em ptying the uterus within 8 to 12 h o urs o f the onset o f bleeding, undoubtedly reduces th e in c id e n c e o f d is s e m in a te d i n tr a v a s c u la r coagulopathy in this condition.H ealth education at a clinic m ust always therefore include the advice th at the patient should retu rn to the clinic im m ediately should she develop vaginal bleeding o r unexplained abdom inal pain.Localised uterine tenderness o f recent onset with or w ithout vaginal bleeding should be an indication for urgent tran sfer o f the patient by am bulance from the clinic to the base hospital.T here, free use should be m ade o f C aesarean section if the baby is still alive, or if clinical signs suggest th a t th e prospect o f vaginal delivery within this tim e interval is rem ote.A coagulation defect can usually be prevented in the case o f intra-uterine death and m issed ab o rtio n if the uterus is em ptied within 3 to 4 weeks o f the death o f the baby.Every patient suspected o f having an intra-uterine death or missed ab o rtion should therefore be referred to the base hospital for assessm ent im m ediately.W hen patients present late in the course o f their disease, the diagnosis o f dissem inated intravascular coagulopathy can be m ade by doing a crude clotting tim e.The defect should always be corrected if possible before the uterus is em ptied.A sum m ary o f the im p o rtan t steps in preventing the occurrence o f post-partum haem orrhage at the clinic is set out below.

A.
Hypotonic post-partum haemorrhage: Prevent by: C orrect hypotonic patterns o f labour before se cond stage: ?E nem a ?A rtificial ru p tu re o f m em branes Up and about O xytocic infusion R outine Syntom etrine with anterior shoulder com bined with B randt-A ndrew 's m anoeuvre.B. Traumatic post-partum haemorrhage: Prevent by: A dequate psychological preparation in antenatal clinic A dequate sedation Early recognition and m anagem ent o f cephalopelvic disproportion G ood technical skill.C. Retained products o f conception: Detect by: Disciplined exam ination o f placenta and m em branes Subinvolution with an open cervix Prevent by early evacuation o f the uterus.D. Coagulation defects: Prevent by: Aggressive m anagem ent o f accidental haem or rhage Em pty uterus in patients with I.U .D .or missed abo rtio n under 4 weeks.

( 2 )
R e p e a t S y n to m e tr in e in tr a m u s c u la r ly .I f E rg o m etrin e is co n tra in d ic ated because o f hypertension, start an intravenous infusion o f 20 units o f oxytocin per litre at 40 drops per m inute.
Provided the m idwife has acted rapidly in accordance with this sequence, the p a tient should not be shocked.If she has becom e shocked, however, the drip should always be co m m enced as soon as this is noticed, preferably by a colleague, while bi-m anual com pression o f the uterus is com m enced in order to prevent fu rth er blood loss.A shocked patient should always receive at least 1 litre o f R inger's L actate fast before she is moved.(10)The patient should then be transferred as speedily as possible to hospital.W hen the am bulance is ready at the clinic, the m idwife should rem ove her fist and the pad from the vagina and observe w hether bleeding has ceased.If heavy bleeding recom m ences, bi-m anual com pression o f the uterus should be continued in the am bulance and into theatre at the base hospital, where the d o cto r in charge can perform an exam ination under anaesthesia and plan definitive m anagem ent.