INTRODUCTION

People move through several predictable stages during transition first is

the act of ending old ways of thinking or believing next. There is a neutral zone

during fortable and finally, there is new beginning during which new ideas and

concepts are put into action.

The postpartum period is a time of transition during which a people gives

up concepts. Such as childless or parents of one and moves of the beginning of

new parenthood. The immediate postnatal period is neutral time during which a

couple tries out the new role and attempts to fit their expectation for that role.

The nurses can help couples acknowledge the extent of the change. So that they

can gain closure on their process life style opening channels for communication

anticipating new needs and high lighting potential gain that will occur because

by changes are important action.

 DEMOGRAPHICAL DATA

Name : Mrs.Guna

Age : 28 years

Educational status : +2

Husband’s name : Mr.Munusamy

Age : 35 years

Educational level : +2

Religion : Hindu

I.P. No. : 30736

Occupation : Coolie

Income : Rs.2,000/-p.m.

Admitted on : 15.12.1át3:00a.m.

Ward : Postnatal ward

Unit : I unit

Address : No.50/13, North Street,

Melur, Madurai.

Diagnosis : Postpartum Hemorrhage

Reason for hospitalization : Safe confinement

Obstetrical score : G1P1L1

Biological Environment History

Socio Economical History

She is living in a rented house at the rent of Rs.1000/- per month. She is home
maker. She has the facility of closed drainage system, using metro water for
drinking purpose. She is using well water for washing. Living in a single room
it consists of one light, fan and Television set.

Recreation activity : Watching Television

Hobby : Reading magazines and listening music.

She is a non vegetarian. She cooks non-vegetation meal for 2 days in a week.
Takes meal 2 times and Tiffin once.

Rest:

Takes 2 hours rest during day time and 6 hours during night. She
continuous sleeps. No disturbance.

Hygiene:

Takes bath daily and she is clean and neat.

Exercise:

House hold work

Chief Complaints:

Increased blood loss through vagina, giddiness, lower abdominal pain

since 2 days.
Present History:

Admitted with the history of increased blood loss through vagina,

giddiness, lower abdominal pain since 2 days.

Past History:

She underwent appendicectomy 5 years back. She used to get cough and
cold on and off. No history of communicable disease in the past.

Family pedigree
Past Familial History

There is no past familial history of multiple pregnancy, communicable

disease, genetic disorder or mental illness. There is no familial history of GDM
or PIH in the family.

Personal Medical history

There is no previous illness of HT /DM! Asthma / epilepsy! CAD

Menstrual History

She attained menarche at the age of 14 years. No menstrual flow is

normal 5/30 days, regular in cycle, Dysmenorrhoea present.

Past Obstetrical History

Primi

Present Obstetrical History

LMP: 11.3.11

EDD: 18.12.11

Had 2 doses of TT V2 cc and totally 8 visits she had at Government

Rajaji Hospital, Madurai.

Physical assessment

Temperature : 98.4o F

Pulse : 72beats/mt

Respiration : 16beats/mt

Height : 156cms

Weight : 52kgs
General appearance:

Conscious oriented under nourished, thin, oriented to place, Neat and

clean.

Head:

Uniform distribution of hair. No dandruff. Pediculosis or fungal infection

no hair falls.

Eyes:

No discharge/ redness/ orbital swelling/ blurred vision / refractory error /

pallor / icterus

Noses:

No septal deviation, Rhinorrhoea, congestion polyp / Epistaxis

Ear:

No swelling / No pain / No hard of hearing ceruman accumulation present

Mouth:

Dryness of mouth, No halitosis/ angular stomatitis/ no coating tongue/

pallor / dental caries

Neck:

No cericallymphadenopathy/ no thyroid swelling.

Chest:

Moves equally on respiration no scar or deviation or pain / palpitation.

Breast

Enlarged, soft, primary and secondary aerolar present, Montgomery

tubercele present, Nipple moist, No cracks, colostrums present.

Upper extremities:

Normal – No shortens/ Swelling of the joint/ pain normal Range of

movement.

Abdomen

Bowel sound heard. No constipation. No pain or bladder distension. No

organomegally.

Lower extremities

Normal range of movement present

Genertalia

Clean, No vulval swelling / foul smelling discharge present, increased

blood discharge.

Review of system

Central Nervous System

Conscious oriented happy mood

Respiratory System:

Bilateral air entry present. No crepitus or ronchi / pleural rub.

Cardio vascular system:

S1 S2 heard No palpitation, No murmur gallop.

Gastro intestinal system:

No constipation. Bowel sound heard vomiting nausea / heard burn.

Musculo skeletal system:

No cramps/ numbness / pain

Genitourinary system:

No burning of micturation / dribbling frequency.

Intugumentory:

No itching / burning / no papules redness

Labour summary:

Type of Delivery : Full term normal vaginal delivery

Mode of delivery : Spontaneous vaginal delivery

Baby born at : 12.12.11 at 8.30am

Uterus : Flabby, soft, Not contracted well.

Conduction during puerperium : Looks dull and tired conscious

oriented. Undue bleeding P.V

Baby chart

Name : B/o Guna

Sex : Male baby

Date of birth : 15.12.11 at 8.30am

Length : 48cms
 Birth weight : 3.2kg

Head circumference : 33cms

Anus : Patent

Congenital Anamalis : Nil

Birth injury : Nil

Apgar scoring : 7/10-5 min. 8/10 – 10min

Medication:

Cap. Amoxycillin 500mg.tds

T Metronidazole 400mg.tds

T Paracetamol 1 tds

T Calcium 1 OD

T FST 1 OD

Blood transfusion 1 bottle given.

Present obstetrical history

S.NO Type of Mode Term / Weigh Sex Apga Remark

delivery of abortio t r s
deliver n
y
1. Spontaneou Vaginal Term 3.2kg Mal 1min Alive,
s delivery e 6/10 healthy,
5min breathing
8/10 normal
sucking
well on
breast
feed.
INVESTIGATION:
BLOOD PATIENT NORMAL
REMARKS
PICTURE VALUE VALUE

Haemoglobin 6 grams 12-14grams Slightly

Urine – Alb Nil Nil Normal

Sugar Nil

Blood group O +ve

HIV Negative

Hbs As Negative

VDRL Non reaction

OBJECTIVES:

 To understand detail about the disease condition.

 To educate the client regarding the care of child.
 To detect complication and take preventive measures.
 To reduce anxiety and fear associated with pregnancy.
 To reduce the maternal and infant mortality and morbidity rate.
 To sensitize the mother to the need of family planning.
POSTPARTUM HAEMORRHAGE RETAINED PLACENTA, MANUAL
REMOVAL OF PLACENTA

INTRODUCTION:

While constricting the house the basement will be constricted by the

maison. The pit has to be made by them properly. Ex: If any root is penetrating
the walls whole building will be disturbed so the maison must properly clean
the while surrounding likewise after the birth of the baby. The placenta has to
be delivered completely if not the mother has to face the problems. Which will
cause the very fetal if not identified early?

DEFINITION:

PPH has been defined as the loss of more than 500ml of blood after
vaginal birth and 1000ml after caesarean birth.

- Lowder milk

The amount of blood loss in excess of 500ml of following birth of the baby.

- D.C.Dutta

Of all the stages of labour, third stage is the most crucial one for the mother.

Following are the important complications.

1. Postpartum hemorrhage

2. Retention of placenta

3. Shock - Haemorrhage non hemorrhagic

4. Pulmonary embolism either by amniotic fluid (or) by ais.

5. Uterine inversion (Rare)

INCIDENCE

Is about 1% amongst hospital deliveries.

TYPES:

 Primary

 Secondary

Primary:

Occurs within 24hurs of the birth

Secondary:

Occurs more than 24hours but less than 6weeks postpartum.

IN PRIMARY:

Third stage hemorrhage -Bleeding occurs before expulsion of placenta

True postpartum hemorrhage: Bleeding occurs subsequent to expulsion of

placenta (majority)
 PRIMARY POSTPARTUM HAEMORRHAGE

Causes:
1. Atonic
2. Traumatic
3. Mixed
4. Blood coagutopathy.
Atonic uterus (80%)

The separation of the placenta. The Uterine sinuses which are turn cannot
be compressed effectively due to imperfect contraction and retraction of the
uterus and bleeding continues.

Grand multipara

In adequate retraction and frequent adherent placenta contribute to it.

Anemia may also probably play a role.

Over distension of the uterus:

Multiple pregnancy
Hydramnios
Large baby
Imperfect retraction and a large placental site are responsible for excessive
bleeding.

Malnutrition and anemia

Slight amount of blood loss may develop clinical manifestation of

postpartum haemorrhage

ANTEPARTUM HAEMORRHAGE:

 Faculty diabetic habit, Faculty

 Absorption mechanism
PROLONGED LABOUR:
Poor retraction
Infection, (aminonitis)
Dehydration.
ANAETHESIA
Halothane (or) Magnesium sulfate

INITIATION (OR) AUGMENTATION OF DELIVERY BY OXYTOCIN

Post delivery uterine atomicity is likely unless the oxytain is continued

for at least one hour following delivery.

PERSISTENT UTERINE DISTENSION

Retension of partially separated placenta (or) bits of placenta (or) blood

clots interfere with effective retraction.

MALFORMATION OF THE UTERUS:

Implantation of the placenta in the uterine septum of a septate uterus (or)

in the corneal region of a bicarbonate uterus may cause excessive bleeding.

UTERINE FIBROID:

Causes imperfect retraction mechanically

MISMANAGED THIRD STAGE OF LABOUR

a. Too rapid delivery of the baby preventing the uterine wall to adapt to the
diminished contents

b. Premature attempt to deliver the placenta before it is separated.

c. Kneading and fiddling the uterus.

d. Pulling the cord. All these produce irregular uterine contractions leading
to partial separation of placenta and haemorrhage

e. Manual separation of the placenta increases blood loss during caesarean

delivery.

CONSTRICTION RING

Hour glass contraction formed in the upper segment across the partially
separated placenter (or)

Junction of the upper and lower segment with the fully separated placenta
trapped in the upper segment may produce excessive bleeding.

PRECIPITATE LABOUR:
 In rapid delivery, separation of the placenta occurs following the birth of
the baby.

Bleeding continues before the onset to the uterine retraction.

Bleeding may be due to genital tract trauma.

TRAUMATIC (20%)

Even after spontaneous delivery

Blood loss from the episiotomy wound

Trauma - cervix, vagina, perineum (Laceration)

Para uretheral region, rupture of the uterus.

COMBINATION OF ATONICAND TRAUMATIC CAUSES

BLOOD COAGULATION DISORDERS

Acquired (or) congenital

The blood coagulopathy - increased fibrinolytic activity abruption

placental. Jaundice in pregnancy. Thrombocytopenic purpura. HELP syndrome
(or) IN IUD.

RISK FACTORS

۞ UTERINE ATOMY

 over distended uterus

 Large fetus

 Multiple fetuses

 Hydramnios

 Distention with clots

ANAESTHESIA AND ANALGESIA

Conduction anesthesia

۞ PREVIOUS HISTORY OF UTERINE ATOMY

 ۞ HIGH PARITY

۞ PROLONGED LABOUR, OXYTOCIN, INDUCED LABOUR

۞ TRAUMA DURING LABOUR AND BIRTH

 Forceps assisted birth

 Vaccum assisted birth

 Caesarean birth

LACREATIONS OF THE BIRTH CANAL

RETAINED PLACENTAL FRAGMENTS

RUPTURED UTERUS

INVERSION OF THE UTERUS

PLACENTA ACCRETA

COAGULATION DISORDERS

PLACENTAL ABRUPTION

ENDOMETRTITIS

UTERINE SUBINVOLUTION

DIAGNOSIS

The vaginal bleeding is visible outside. The bleeding is totally concealed

either as valvovaginal (or) broad ligament haemotoma.

THE EFFECT OF BLOOD DEPENDS ON:

Pre delivery hemoglobin level

Degree of pregnancy induced hypervolemia

Speed at which blood loss occurs

Alteration of pulse, blood pressure and pulse pressure.

State of uterus as felt per abdomen

Traumatic haemorrhage - The uterus is found well contracted.

ATONIC HAEMORHAGE:

Uterus found flabby and becomes hard on massaging

PROGNOSIS

PPH is life threatening emergencies

Maternal death is about 10%

Prevalence of malnutrition and anemia

Inadequate antenatal and intranatal care

Lack of blood transfusion facilities

Morbidity

Shock, transfusion reaction, puerperal sepsis. Failing lactation,

Pulmonary embolism, thrombosis and thrombophlebitis.

Sheetan’s syndrome - selective hypopituitarism rarely diabetes insipidus.

PREVENTION:

 Antenatal

 Intranatal

ANTENATAL

Improvement of the health status

To keep the haemoglobin level normal >10gm/dl so that the patient some
amount of the blood loss.

HIGH RISK PATIENT

Twins, hydraminiuos, grand multipara, APH, H/O Previous third stage

complications. Severe anaemia are to be screened and delivered in a well
equipped hospital.

BLOOD GROUPING

Done for all women so that no time is wasted during emergency.

INTRANATAL
 Slow during of the baby

Expert obstetric anesthetist - Local (or) epidural anesthesia

During caesarean section - Spontaneous separation and delivery of the placenta

reduced blood loss.

Active management of 3rd stage - At risk patient

Temptation of fiddling (or) kneading

Examination of the placenta:

All causes of labour - Induced by Oxytocin.

Infusion should continue at least one hour after delivery.

Exploration of the utero - vaginal canal

Difficult labour

for evidence of trauma

Instrumental delivery

To observe the patient for about two hairs

It is the intelligent anticipation, skilled supervision, prompt detection and

effective institution of therapy.
MANAGEMENT:

NURSING ASSESSMENTS FOR POSTPARTUM BLEEDING

POST BIRTH HAEMORRHAGE

ASSESSMENT TO DETERMINE SOURCE OF BLEEDING AND SIGNS OF

SHOCK

CBC, Blood typing and cross match, coagulations studies.

Establish venous access - start IV fluids

Placenta delivered

Fundal massage

Fundus boggy Uterus firm

Empty urinary bladder Assess for cervical (or)

vaginal lacerations/ haematoma

Giver uterotonics as ordered Anticipate and assist with repair

Uterus firms Atony persists Bleeding continues

Continue assessments for maternal Start supplemental O2

hemodynamic status. Repeat laboratory studies

Anticipate fluid / blood

replacement therapy

Anticipate surgical intervention.

POST BIRTH HAEMORRHAGE

 Assessment to determine source of bleeding and signs of shock

Anticipate laboratory studies, CBC, blood typing and cross match,

coagulation studies

Establish venous access verify patency of venous access and start IV fluid

Placenta retained
Anticipate need for anesthesia

Give tocolytic as or dered

Anticipate and assist with manual removal of placenta

Give uterotonics as ordered

If bleeding continues s/s of shock

Start supplement oxygen

Repeat laboratory studies

Anticipate fluid / blood replacement therapy

Anticipate surgical intervention

POST BIRTH HAEMORRHAGE

Assessment to determine source of bleeding and signs of stock

Anticipate libratory studies - CBC, Blood typing and cross match coagulation
studies

Establish venous access start IV fluids

Suspected coagulopathy

Assess for understanding cause and start supplemental O2

Continuous assessment of maternal hemodynamic status

Anticipate fluid / blood replacement therapy

Anticipate pharmacologic management, antibiotics vasoactive drugs, and

uterotonic agents.

Anticipate surgical intervention.

MANUAL REMOVAL OF PLACENTA

Step - I

Is done under general anesthesia (or) to be done under deep sedation with
10mg Iv diazepam placed in lithotomy position, bladder in authorized .

Step - II

One hand is introduced in to the uterus in care shaped manner.

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 - III

Counter pressure on the uterine fundus, the other hand placed over the
abdomen.

The abdominal hand should study the fundus and guide the movements of
the fingers inside the uterine cavity fill the placenta is completely separated.

Step - IV

As soon as the placental margin is a reached. The placenta is gradually

separated with a sideways slicing movement of the fingers until whole of the
placenta is separated.

Step - V
 When the placenta is completely separated. The uterine hand is still inside
the uterus for exploration of the cavity to be sure that nothing is left behind.

Step - VI

Ergometrine 0.25 mg IV

Uterine hand is gradually removed

Massaging the uterus by the external hand to make it have after the completion
of manual removal, inspection of the cervico vaginal canal is to be made to
exclude any injury.

Step - VII

The placenta and membranes are to be inspected for completeness.

Be sure that the uterus remains hard and contracted.

DIFFICULTIES

1. Hour - glass contraction - Difficulty in introducing the hand

2. Morbid adherent placenta - difficulty is getting to the plane of cleavage of

placental separation.

COMPLICATIONS:

Haemorrhage due to incomplete removal

Shock

Injury to the uterus, embolism

Infection, inversion, sub involution, thrombophlebitis

SCHEME OF MANAGEMENT OF THIRD STAGE HAEMORRHAGE

 Control the fundus, massage and make it hard

 Inj.Methergin 0.2mg IV

 To start normal saline drip and arrange for blood transfusion.

 Catheterize the bladder

Placenta separated Not separated

Express the placenta out by controlled Manual removal

by controlled cord traction under G.A

Traumatic haemorrhage should be tackled by sutures.

MANAGEMENT OF TRUE PPH

PRINCIPLES:

 To diagnose the cause of bleeding, atonic (or) traumatic

 To take prompt and effective measures to control bleeding

 To correct hypovolemia

ATONIC UTERUS:

Massage the uterus. express the blood clot

Methergin 0.2mg IV

Morphine 15mg Im

In.oxytocin 10 units with 500ml NS. 30-40drops / min

To empty the bladder

To examine the expelled placenta and membranes

Step II

The uterus is to be explored under general anesthesia

Inspection of cervix, vagina

Inj.Methyl PGF2 250mg - Im deltoid 1-2 hours ( upto maximum five doses)
or

Misoprostol (PGE1) 1000 mg per rectum is effective.

Step - III

Uterine massage and bio manual compression. Evidenced by absence of

bleeding if the compression is released.

Resuscitative measures are to be continued possibility of blood

coagulation disorder should be rolled out fresh whole blood transfusion should
be given. When the uterus fails to contract Hysterectomy.

Step - IV

Uterine tamponade - Tight intrauterine packing done uniformly under

general anesthetists.

A separate pack is used to fill the vagina

Intrauterine plugging acts not only by stimulating uterine contraction but exerts
direct haemostatic pressure to the open uterine sinuses.

The plug should be removed after 24hours.

Insertion of a sends taken Blake more tube in to the uterine cavity and inflating
the balloon with 200ml of N.S.

Step - V

Surgical methods to central PPH

a. Ligation of uterine arteries - the ascending branch of the uterine artery is

ligated.

b. Ligation of the ovarian and uterine artery anostomosis

c. Ligation of anterior division of internal iliae artery

d. B - Lynch brace suture and haemostatic suturing

e. Angiographic arterial embolization

Step - VI

Hysterectomy - Depending on the case it may be subtotal (or) total

TRAUMATIC PPH:

The trauma to the perineum, vagina and the cervix is to be searched under
good light by speculum examination and homeostasis is achieved by appropriate
utergut satures. The repar is done under general anesthesia.

SECONDARY POSTPARTUM HAEMORRHAGE

CAUSES:

The bleeding usually occurs between 8th to 14th day of delivery.

1. Retained bits of cotyledon (or) membranes (commonest)

2. Infection and separation of slough over a deep cervico - vaginal

laceration.

3. Endometritis and subinvolution of the placental site due to delayed

healing process.

4. Secondary hemorrhage from caesarean section wound usually occurs

between 10 -14 days, due to separation of slough exposing a bleeding
vessel 9or) from grantuation tissue.

5. Withdrawal bleeding following oestrogen therapy for suppression of

lactation.

OTHER RARE CAUSES:

Carcinoma cervix, placental polyp, infected fibroid puerperal inversion of

uterus.

DIAGNOSIS:

The bleeding is bright red and of varying amount varying degree of anemia an
evidence of sepsis are present.

Internal examination reveals evidences of sepsis.

Subinvolution of the uterus and often a patulous cervical OS.

Ultra sonography is useful in detecting the bits placenta inside the uterine
cavity.

MANAGEMENT:
Principles:

To assess the amount of blood loss and to replace the lost blood.

To find out the cause and to take appropriate steps to rectify it.

Supportive therapy

Conservative

Active treatment

SUPPORTIVE THERAPY

 Blood transfusion if necessary

 Ergometrine 0.5mg Im - Bleeding is uterine is origin

 Antibiotics as a routine.

CONSERVATIVE

 Bleeding is slight

 No apparent cause is detected

 Careful watch for a period of 24 hours.

ACTIVE TREATMENT:

It is preferable to explore the uterus urgently under general

anesthesia. Should not ignore the small amount of bleeding.

The products are removed by ovum forceps.

The material removed are to be sent for histological examination.

Presence of bleeding from the sloughing wound of cervico vaginal canal

should be controlled by haemostatic sutures.

Secondary haemorrhage following caesarean section may at times require

laboratory.

The bleeding from uterine wound can be controlled by haemostatic

sutures. May rarely require ligation of the internal iliae artery.

RETAINED PLACENTA
 The placenta is said to be retained when it is not expelled out even 30
minutes after the birth of the baby.

Retained placenta may result from partial separation of a normal

placenta, partially (or) completely separated placenta by an hour glass
constriction ring of the uterus. Mismanagement of the third stage of labour.

Placenta retention because of poor separation is common in

preterm births.

Management of non adherent retained placenta is by manual separation

an removal.

Supplementary anesthesia is not usually needed for women who have had
regional anesthesia for birth.

Intravenous thiopental facilitates uterine exploration and placenta

removal. After this removal the women is at continued risk for PPH and for
infection.

ADHERENT RETAINED PLACENTA

Abnormal adherence of the placenta occurs for reasons unknown; result

from zygotic implantation in an area of defective endometrium so that there is
no zone of separation between the placenta and the decidua.

Attempts to remove the placenta in the usual manner are unsuccessful and
laceration (or) perforation of the uterine wall may result, the woman at great
risk for severe PPA and infection.

Unusual placental adherence may be partial (or) complete.

PLACENTA ACCRETA:

Slight penetration of myometrium by placental trophoblast.

PLACENTA INCRETA:

Deep penetration of myometrium by placenta

PLACENTA PERCRETA:

Perforation of uterus by placenta. Bleeding with complete (or) total

placenta accrete may not occur unless separation of the placenta is attempted.
 With more extensive involvement, bleeding will become profuse when
delivery of the placenta is attempted. Treatment includes blood component
replacement therapy, and hysterectomy may indicated.

Separation through the spongy layers of the decidua Descent into the
lower segment and vagina finally its expulsion to outside.

INTERFERENCE IN ANY OF THESE PHYSIOLOGY PROCESS

RESULTS IN ITS RETENTION

 Placenta completely separated but retained - due to poor voluntary

expulsive efforts.

 Simple adherent placenta is due to uterine atoxicity, grand multipara, over

distension of uterus. Prolonged labour

uterine malformation

Bigger placental surface area.

The commonest cause of retention of non separated placenta is atonic uterus.

Morbid adherent placenta.

DANGERS:

The risk involved in prolonged retention of placenta are

1. Haemorrhage

2. Shock - blood loss, unrelated to blood loss, frequent attempts of

abdominal manipulation to express the placenta out

3. Puerperal sepsis

4. Risk of its recurrence in next pregnancy.

MANAGEMENT

Period of watchful EXPECTANCY

The patient is to be watched carefully for evidence of any bleeding revealed or

concealed and to note the signs of separation of placenta.

 The bladder should be emptied using a rubber catheter.

  Any bleeding during the period should be managed.

RETAINED PLACENTA:

 Separated

 Unseparated

 Complicated

Placenta is separated and retained - To express the placenta out by controlled

cord traction.

Unseparated retained placenta - Manual removal of placenta is to be done under

general anesthesia.

MANAGEMENT OF UNFORSEEN COMPLICATIONS DURING

MANUAL REMOVAL

Hair - glass contraction - The ring should be made to relax by

- deepening the plane of anesthesia then the cone shaped hand is introduced and
the separation of the placenta is preferably done from above downwards to
minimize bleeding.

Morbid adherent placenta

The diagnosis in made only during attempted manual removal.

COMPLICATED RETAINED PLACENTA:

Retained placenta complicated by haemorrhage shock (or) sepsis.

Retained placenta with shock but no haemorrhage

Treat the shock and when the condition improves manual removal of the
placenta is to be done.

Retained placenta with haemorrhage

Similar to that of management of 3rd stage haemorrhage.

Retained placenta with sepsis:

INVERSION OF THE UTERUS

 It is an extremely rare but a life threatening complications in third stage
in which the uterus is turned inside out partially (or) completely.

VARITIES:

FIRST DEGREE

There is dimpling of the fundus which still remains above the level of
intervals.

SECOND DEGREE

The fundus passes through the cervix but lies inside the vagina.

THIRD DEGREE (COMPLETE)

The endometrium with (or) without the attached placenta is visible

outside the vulva. The cervix and part of the vagina may also be the involved in
the process.

ETIOLOGY

Spontaneous

Commonly induced

Spontaneous 940%)

Localized atony on the placental site over the fundus associated with
sharp rise of intrac abdominal pressure as in coughing. Sneezing 9or) bearing
down effort.

Fundal attachment of the placenta 75% short cord and placenta accrete.

Iatrogenic:

Mismanagement of 3rd stage of labour. Pulling the cord when the uterus is
atonic when combined with fundal pressure.

Faculty technique in manual removal.

Crede’s expression while the uterus is relaxed.

DANGERS

SHOCK - mainly of neurogenic origin

 a. Tension on the nerves due to stretching of the infundibulo - pelvic
ligament

b. Pressure on the ovaries as they are dragged with the fundus through the
cervical ring

c. Peritoneal irritation.

HAEMORRHAGE: - After detachment of placenta

Pulmonary embolism.

Left uncared - Infection, Uterine, sloughing

DIAGNOSIS:

Symptoms :

Acute lower abdominal pain with bearing down sensation.

Signs:

Varying degree of shock is a constant feature

Abdominal examination upping (or) dimpling of the fundal surface.

Blimanual examination not only helps to confirm the diagnosis but also the
degree.

In complete variety a pear shaped mass protrudes outside the vulva with the
broad and pointing downwards and looking reddish purple in colour.

Prognosis: Death may occur quite suddenly due to shock, haemorrhage (or)
embolism.

Prevention: Do not employ any method to expel the placenta out when the
uterus is relaxed.

Pulling the cord simultaneous with fundal pressure should be avoided.

MANAGEMENT

Before the shock develops

Urgent manual replacement

Principle
 To replace that part which is inverted last

To apply counter support by the other hand placed on the abdomen

After replacement the hand should remain inside the uterus until the uterus
becomes contracted by parentral Oxytocin on P4F2 a

The placenta is to be removed manually only after the uterus

becomes contracted.

The placenta may however be removed prior to replacement

To reduce the bulk which facilitates replacement

If partially separated to minimize the blood loss.

Unusual treatment of shock including blood transfusion should be arranged as

and when required.

AFTER THE SHOCK DEVELOPS:

PRINCIPLE

The treatment of shock should be insitututed with an urgent destrose

saline drip and blood transfusion.

To push the uterus inside the vagina if possible and pack the vagina with
antiseptic roller guuze.

Foot end of the bed is raised

Replacement of the uterus either manually (or) hydrostatic method under

G.A.Hydrostatic method is quiet effective and less shock producing.

HYDROSTATIC METHOD

The inverted uterus is replaced in to the vagina. Warm sterile fluid ( upto
5 liters) in gradually instilled into the vagina through a douche nozzle. The
vaginal orifice is blocked by operator’s palms supplement by labial apposition
around the palm by an assistant. The douche can be placed at a height of about 3
feet above the uterus. The water distends the vagina and the consequent
increased intra vaginal pressure leads to replacement of the uterus.

SUBACUTE STAGE:
To improve the general condition by blood transfusion

Antibodies are given to control sepsis

Reposition of the uterus either manually (or) by hydrostatic method may be

tried.

It fails reposition may be done by abdominal operation.

NURSING DIAGNOSIS:

1. Deficient fluid volume related to excessive blood loss secondary to

uterine atony, lacerations (or) uterine inversion.

2. Nutrition less than body requirement related in adequate intake of food

3. Risk for infection related to exposed placental attachment site.

4. Risk for injury related to attempted manual removal of retained

placental / operative procedures.

5. Anxiety / Fear related to deficient knowledge regarding procedures and

operative management.

6. Knowledge deficit related to diet pattern

7. Sleep pattern disturbance related to frequent awakening for baby care

8. Risk for impaired parenting related to separation from infant secondary to

treatment regimen.

9. Ineffective, peripheral tissue perfusion related to excessive blood loss and

shunting of blood to central circulation.
CONCLUSION:

So far we have discussed about postpartum hemorrhage,

Retained placenta, manual removal of placenta it type, signs and

symptom complications and it management. I thank our madam

Mrs.R.Amritha gowri M.Sc (N), Faculty in Nursing and

Mrs.V.Vijayalakshmi M.Sc (N), Faculty in Nursing for giving this

opportunity.
 TIME PLAN

DAILY CARE FOR POST NATAL MOTHER

From 17.12.2011 to 20.12.2011

DATE TIME CARE PARTICULARS

17.12.2011 7am to Introduced myself to the mother and family members
8am looking after warol cleanliness doing basic nursing,
Bed nursing, Vital signs checking.
8am to Cooring out instruction given by the doctor to the
10am mother.
Administering drugs.
Explaining the reason for hospitalization
10 am to Antenatal assessment done. Health education given
1pm regarding need of rest.
18.12.2011 7am to Greeting to the mother
8am Ward supervision - cleanliness
Bed making done, vital signs checked
8am to Accompaning with the mother for investigation (USG)
10am Administration of drugs
10am to Breast care ginerm and explained the need.
1pm Health education given regarding importance
nutrition’s diet (iron and protein rich)
19.12.2011 7am to Vital signs checked followed by Bed making.
8am
8am to Antenatal assessment alone.
10am Explained about DFMC care of new
10am to New born (Twin)
1pm Importance of high calorie intake.
20.12.2011 7am to Bed making done
8am Vitals signs checked.
Administration of drugs.
Caring out order
8 am to Explaining the availability of scientifically advanced
1pm equipments and experts giving psychological support
to the family members.
Subjective data : Mother said that she can’t eat properly aversion to eat

Objective data : As evidenced by refusing the food with was given by the care giver.

Nsg. Diagnosis : Nutrition less than body requirement related in adequate intake of food.

Goal :Maintain adequate intake of balanced diet

PLANNING IMPLEMENTATION RATIONALE EXPECTED OUTCOME

Assess the level of Assessed the nutritional Helps to know the nutritional
nutritional status. status by 24hrs recall demand and further plan.

Explain the importance of Explained need for the To understanding the reason
nutrition’s diet & need. growing fetus demand helps to take diet adequately.
Maintain adequate intake of a
Advice the caregiver to give Adviced to given in a look It stimulates appetite
balanced diet after
frequent and attractive warm serve small and
intervention.
manner frequent

Teach to eat high calorie, To take green leaf vegetables Provide adequate calories for
protein, rich and high and dates pulses and nuts. mother ward fetus to aid in
carbohydrate foods. healing and prevent wasting
(or) los of fetus well being.
Subjective data : Mother liked questions about her diet restriction, weed of treatment.

Objective data : Mother asked repeated question about her diet pattern.

Nursing diagnosis : Knowledge deficit related to diet pattern

Goal : To gain adequate knowledge regarding diet modification.

PLANNING INTERVENTION RATIONALE EVALUATION

Assess the level of diet Type of diet and frequency Helps to plan accordingly
pattern she used to have her diet
Explain with realExplained with chart high To meet adequate amount of
demonstration (or) with chartfibre - chapatti, and more of calorie 011 daily need.
vegetable greens. Mother states that she gained
Advice the mother to take Advice given to the mother To prevent hypoglycemia knowledge about her diet
have her diet frequently and to have small and frequent. pattern as evidenced by four.
small feeds
Advice the importance of Explained the reason if not it To prevent maternal and fetal
diet control will cause problem for complications
mother as well as fetus.

Subjective data : Mother says that she didn’t’ sleep properly last night
Objective data : As evidenced by looks dull, drowsy, and sleepy
Nsg. Diagnosis : Sleep pattern disturbance related to frequent awakening for baby care.

PLANNING IMPLEMENTATION RATIONALE EXPECTED OUTCOME

Advice the care given not to Advice given by changing of Helps to have continuous
disturb while the mother in Napkins during mother is in sleep.
sleeping sleep

Control the visitors Advice them to care only Disturbance by the visitors
during visiting time 4- 6pm will be controlled.

Advice the mother to sleep Advice given to the mother To have quite sleep
Mother said that she had
along with the baby. to sleep along with baby
good sleep after the
intervention
Provide conducive Conducive environment To ensure adequate sleep
environment switch after bright lights and
television, radio and cell
phone.

Advice the mother to drink Advice given to drink cup of Tryphotophen will induce
cup of milk before going to milk before going to bed sleep.
bed.
Subjective data : Mother verbalizes that she is not willing to take care of herself.

Objective data : As evidenced by looks like blend affect

Nsg. Diagnosis : Ineffective individual coping related to unsatisfactory support system.

PLANNING IMPLEMENTATION RATIONALE EXPECTED OUTCOME

Assess clients affect personal Assessed by visitors and Provides information about
hygiene and interaction with phone calls. support system.
support system.

Establish trusting Spend time with mother Establishment of trust

Mother demonstrated
relationship with mother provide for privacy and promotes of sense of safety
positive attitude
remain nonjudgmental and support for the mother.

Assess mothers attachment Assessed by how mother in Poor attachment behaviour

behaviour towards her infant holding in the baby touch , may signatal a risk for
with talking to the baby neglect

Subjective data : Mother said that she is not interested in day to day and activities (Related to role dissatisfaction)

Objective data : As evidenced by failure to attend hygiene had oral hygiene.

Nsg. Diagnosis : Self care deficit related to role dissatisfaction.

Goal : Demonstrate self care and maintain hygiene /groomed well.
BIBLIOGRAPHY

1. Abdella, (1978). “Patient care through Nursing Research” 3rd edition, New
York’s The Macmillan Publications

2. Adele Pilliteri (2003). “Maternal and Child health Nursing” 4 th edition,

Philadelphia, Lippincott and Williams Publications.

3. B.O.Bak, Jensan (1993). “Maternity and Gynecologic care” 5th edition,

Chicago, Mosby publications.

4. Basavanthappa B.T. (2009). “Nursing Theories” 2nd edition, New Delhi,

Jaypee brothers

5. D.C. Dutta (2004) “Textbook of obstetrics” 6th edition, Calcutta, Central

publications.

6. Mudaliar and Menon (2005) “Clinical obstetrics” 10th edition, India, Orient
longmann publication. Annama Jacob (2005), A comprehensive textbook
of midwifery” Jaypee brothers Medical Publisher, 1st edition.

7. Basavanthappa .B.T. 2006, Textbook of midwifery and reproductive

health nursing Jaypee brothers, 1st edition.

8. Dutta D.C 2006 Textbook of obstetrics New textbook agency (p) ltd 6th
edition, PP : 411 - 422

9. Dawn C.S 2006 Textbook of gynaecology and contraceptive Dawn books.

10.Lowder milk Perry 2008, Maternity and women’s health care 8th edition.

Net reference;
www.google.com
www.pubmed.com
www.medscape.com
 Drug chart

S. NURSE’S
NAME OF DOS- ROUT FREQUENC CONTRA SIDE
NO INDICATION RESPONSIBILIT
DRUG AGE E Y INDUATION EFFECT
. Y

1. F.S.T 200 Oral 1-2 times a Prophylaxis Haemo Constipatio Client use of
Iron mg. / day and of iron siderosis peptic n gastric antacid and any
absorbed 500 deficiency ulcer enteritis irritation other drugs may
in the GI
tract mg. anemia and ulcerative nausea interact with their
through colitis abdominal. preparation.
the
mucosal Hemolytic Cramps
cell where anemia vomiting.
it
combines
with the
protein
transferrin.
This
complex is
transporte
d to bone
marrow to
produce
Hb.
S. NURSE’S
NAME OF DOS- ROUT FREQUENC CONTRA SIDE
NO INDICATION RESPONSIBILIT
DRUG AGE E Y INDUATION EFFECT
. Y

2. T. 500 Oral BD/ od Pregnancy, Cancer with GI irritation Monitor for

Calcium is mg Acute hypo metastasis constipation calcium level
necessary
700 calcaemia hyperglycaemi watch for fatigue
for
activation mg. tetancy, a ventricular nausea vomiting
of many per premature fibrillation CNS Depression
enzyme
day delivery renal disease
reaction
and is maternal D.M.
required
for rene
impulses
contractio
n of
cardiac
and
skeletal
muscles.

II units of blood transfusion