Managing the Postpartum Hemorrhage

This study material from Desklib discusses interventions for managing postpartum hemorrhage, a leading cause of maternal mortality. The article covers medication, uterine massage, removal of placenta remains, pelvic tissue repair, intrauterine balloon, surgery, and sealing bleeding vessels. The study also highlights the advantages and limitations of these interventions and their relevance in reducing maternal deaths worldwide.

MANAGING THE POSTPARTUM HEMORRHAGE1
MANAGING THE POST-PARTUM HEMORRHAGE
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MANAGING THE POSTPARTUM HEMORRHAGE2
Interventions of the antenatal health education that can influence on an antenatal mother
for managing the post-partum hemorrhage.
1. Significant of study
In the developing world, maternal death rates have reduced but postpartum hemorrhage
remains to be the main trauma and it is the main reason for high maternal mortality rates. It is
common among those women who incur gestation period of more than 8 months. The year 2013,
17 deaths in each group of one thousand live births occurred in united states and eleven percent
of this deaths were caused by postpartum hemorrhage. Research by World Health Organization
shows that sixty percent of one thousand deaths per hundred thousand live births is due to
postpartum hemorrhage. This results in a large number of deaths per year and may result in the
death of one woman in a duration of four minutes. From the year 1999 to 2009 the rate of
postpartum deaths increased from 1.5% to 4.1%. this failure is brought by lack of good
caregivers with the needed knowledge, giving same medication for early postpartum hemorrhage
and late postpartum hemorrhage, lack of blood transfusion facilities, reduction of pain operations
and presence of disorders. Postpartum hemorrhage is a situation where vaginal delivery cause
blood loss of more than 500ml and cesarean delivery cause blood loss of more than 100ml in 24
hours.
2. Question for literature review
What are the interventions of the antenatal health education that can influence on an
antenatal mother for managing the post-partum hemorrhage?
3. Search strategy

MANAGING THE POSTPARTUM HEMORRHAGE3
Pieces of evidence were conducted online used COCHRANE, CINNAL and UOW
database systems which are available from the University of Wollongong Library. Based on the
search question, the concepts of the search strategy are postpartum, hemorrhage, management
and antenatal. The term education was not highlighted in the search because many of the articles
addressed of managing the problem of postpartum hemorrhage and the ways to control it. The
article also concentrated much on the causes of postpartum hemorrhage.
The research was done purely in the English language in articles ranging from the year
2008 and 2018, ten article were found and all were included in the review and well analyzed.
They were all focusing on how to reduce the rate of deaths due to postpartum hemorrhage.
4. Summary of evidence
The studies were conducted and examined based under several interventions of antenatal
health education for managing postpartum hemorrhage: (a) medication (b) uterine massage (c)
removing remains of the placenta in the uterus (d) pelvic tissue repair (e) Foley balloon (f) use of
surgery (g) sealing bleeding vessels (Evensen and Anderson, 2018 pp 445).
4.1 Medication
The medicines used for management of postpartum hemorrhage management are
syntometrine, oxytocin, carbetocin, hemabate, misoprostol, carboprost, and ergotamine.
Oxytocin is used when there is a failure in the contraction of uterine walls, it enhances
the contraction and it does it in a way that it will last, in case there is no oxytocin misoprostol
can be used in small amounts as it can lead to high blood temperatures (Abdel-Aleem and El-
Sonoosy, 2006). The third stage of labour is managed by combining syntocinon and ergometrine
in a process called syntometrine. Each can work alone but the combination is more effective.

MANAGING THE POSTPARTUM HEMORRHAGE4
Ergometrine can also be used for tone uterine wall but with caution as it can cause high
blood pressure and excessive pain after use. Carbetocin is also used in cases of vaginal deliveries
and caesarean sections for women who need a uterine massage. It has fewer effects compared to
the other medications (Attilakos and Psaroudakis, 2010). Methylergometrine and tranexamic acid
can be used to reduce bleeding a day aft6er birth or during blood transfusion. They are effective
when given in a range of three hours after birth (Abdel-Aleem and Alhusaini, 2013).
4.2 Uterine massage
Uterine massage is the gently rubbing the uterus from the outer part of abdomen until
bleeding ceases. After delivery of placenta uterine massage is done to improve the contraction of
the uterine wall during the third stage of labour. It also softens the walls making it easy for the
placenta to detach from the wall of the uterus. Uterine massage also improves the flow of blood
in the uterine wall (Abdel-Aleem and Singata, 2010).
4.3 Removal of placenta remains from the uterus
If the placenta is not delivered within the first thirty minutes after birth, the uterine wall
will not be free to contract and this may lead to excessive loss of blood. Bleeding may also occur
from the part where the placenta is attached. The removing is done in two ways, one, the whole
placenta is removed, two, removal of some parts which remain attached to the uterine wall
(Jongkolsiri and Manotaya, 2009).
There several ways in which placenta can be removed, one, removal of placenta using the
doctor's hand, this may lead to infections. Two, use of medicine to make the uterine wall contract
and relax and this will help to get rid of the placenta. Three, breastfeeding. This help in the
release of hormones which help the uterine wall contract hence detaching the placenta from the

MANAGING THE POSTPARTUM HEMORRHAGE5
walls. Four, the full bladder may be the reason for the failure of removal of placenta so emptying
it through urinating may help (Badhwar and Singh, 1991).
4.4 Pelvic, vagina tissue repair
If any rapture occurs during birth a surgical repair is needed to prevent excessive
bleeding. People who are at high risk of vaginal tears are those who are delivering for the first
time, those with babies of high weight, those who take long to give birth and those who were
assisted by midwives by use of forceps of other methods (Andersen and Andersen, 1998). There
are home ways which can be used to deal with vaginal tears. These include the use of ice packs,
placing the ice on the affected area for about 15 minutes can help in reducing bleeding and the
rate of swelling (Patwardhan and Sawant, 2018 pp 349).
Use of stool softeners such as Colace which make it easy for a bowel movement.
Observing cleanness and staying dry, using warm water in a squeeze bottle of filling the birth
with warm water and sitting there for few minutes to free your skin from dirt. Resting to avoid
strenuous activities may help in quick healing.
There several ways to prevent vaginal tears although some are unavoidable, vaginal tears
can be avoided through practicing Kegel exercises before giving to strengthen the pelvic tissue,
prenatal vitamins may also be used, taking balanced diet, keeping good health status and doing
exercises. Softening muscles through warming up the perineum to increase blooding circulation.
To avoid worsening of the tears one should avoid salt water for baths, perfumes, using hot water
in squeezing bottles, strenuous activities such as squatting, sexual activities, avoid tampons and
vaginal cleansers.
4.5 Intrauterine balloon

MANAGING THE POSTPARTUM HEMORRHAGE6
Because all this other method of dealing with postpartum hemorrhage, intrauterine
balloon tamponade remains as the only safe suggestion to deal with post hemorrhage. It is easy
to use and give the mother guarantee to bear other children later. There are multiple of these
balloons, they include BT-Cath balloon tamponade, Bakri balloon, Foley balloon, condom
balloon, Bakri balloon and the Rusch balloon catheter. Experts approve the use of Bakri and the
BT-Cath postpartum balloon catheter and in case these are not available then the others can be
useful (Revert and Rozenberg, 2018).
These balloons help to exert pressure inwards and outwards to reduce blood loss from the
myometrium and the endometrium. The pressure presses on the bleeding parts preventing the
pouring of blooding and fastening clotting.
4.6 Use of surgery
There are two types of surgery when it comes postpartum hemorrhage. These are
laparotomy and hysterectomy. Laparotomy is the surgery to find the cause of bleeding by
opening the abdomen while hysterectomy is the surgery done to remove the uterine wall and is
done as the last option. These two operations are done when there is a uterine rupture, trauma
issues, and cervical lacerations. Surgery can only be done by experts to avoid causing
unnecessary deaths. This is also the last option if only the other practices fail to work out the
problem (Wilcox and Ramprasad, 2018 pp 520).
4.7 Sealing bleeding vessels
Sealing of walls and bleeding vessels is done by use of compression sutures, use of gel,
coils, and specific glues. This is done by experts to avoid contamination and transmission of
infections from dirty objects and hands. They are easy to use and they are not expensive

MANAGING THE POSTPARTUM HEMORRHAGE7
compared to the other practices in this paper. Keeping the tone services dry may also help
because clotting will not long to take place.
5. The critical review of evidence
In the modern developing world, the deaths caused by postpartum hemorrhage have
reduced from 4% to 1.3% due to use of all ways discussed above. Some of these ways are
invasive but they save lives of large numbers. Many people may decide not to use these ways as
they lack knowledge on their benefits. In areas where postpartum hemorrhage is not dealt well
with, high rate of deaths is experienced. Each country is fighting to have facilities which will
save lives of mothers. Postpartum care gives the mother another chance to give birth to other
babies in her lifetime. It also improves the health of the mothers by reducing the rate at which
they lose blood. Almost all health centers have knowledge of using these advanced ways of
dealing with excessive bleeding after birth and governments are trying to empower the plan by
introducing medicinal devices for the same service.
6. Advantages and limitations of the above ways
The main advantage of using this way of managing postpartum hemorrhage is that they
save lives. They are time-saving and others are easy to use. They give mothers courage to give
birth because they are sure that no sequelae will hit them. Some of this ways reduce the rate of
blood transfusion avoiding chances of other infections.
There are also limitations to these ways of fighting postpartum hemorrhage, first, they are
all expensive so they need a lot of money to be used. In cases where the government offers the
support, they are the best. They also need experts because if carelessly used they may cause
death. Not all health centers can afford to carry out the above practices because of their
expensiveness. Some people may fear to be introduced to these ways because of bad rumors.

MANAGING THE POSTPARTUM HEMORRHAGE8
Some of this practices also have negative effects which cannot be avoided by the victims in
hand.
7. The relevance of introducing these practices and the impact they have.
Each government from each country in all corners of the world is fighting against
unnecessary deaths. Fighting postpartum hemorrhage is one of the burning issues and putting
more effort to reduce deaths caused by it becomes more relevant to the society. The population
of mothers in the world is rising up because fewer deaths are experienced during delivery.
Offering education on antenatal health give people hope and they create a health-
promoting environment for the mothers. Traditional ways of dealing with postpartum
hemorrhage are now not used because they not able to deal with the current complex situations.
8. Conclusion
In this paper, by using online search from COCHRANE, CINNAL and UOW database
systems which are available from the University of Wollongong Library, there were 10 articles
which were chosen to analyze ways of managing postpartum hemorrhage. Despite of all
challenges experienced in all corners of the world people are trying to their level best to access
this practices in order to save lives. people should also be educated on the trending ways of
dealing with delivery problems in order to be on the safe side. World Health Organization should
also promote the less developed countries to catch up to these levels of standards.

MANAGING THE POSTPARTUM HEMORRHAGE9
Appendix 1: the critical analysis of the chosen articles
Description Research design outcomes
Reference
details
Objectives Nature
Of
intervention
Study
population
Researc
h type
Data
Collection
methods
results conclusion limitations
Article:
Journal of the
Medical
Association of
Thailand
Cited by
(CrossRef): 7
articles Publisher
name Cochrane
Pregnancy and
Childbirth Group
DOI:
10.1002/14651858
.
CD004665.pub3
Authors:
Attilakos
G,
Psaroudakis
D, Ash J,
Buchanan
R and
Winter C,
Year: 2011
Assess the
specific effects
of placental cord
drainage on the
third stage of
labour following
vaginal birth,
with or without
prophylactic use
of uterotonics in
the management
of the third stage
of labour.
Randomized
controlled
trials
comparing
placental cord
draining with
no placental
cord drainage
as part of the
management
of the third
stage of
labour.
All
women
who had a
vaginal
delivery.
Practices Filling Data
forms
Cord drainage reduced
the length of the third
stage of labour (mean
difference (MD) -2.85
minutes, 95% confidence
interval (CI) -4.04 to -
1.66; three trials, 1257
women (heterogeneity:
T² = 0.87; Chi²P=17.19,
I² = 88%)) and reduced
the average amount of
blood loss (MD -77.00
ml, 95% CI -113.73 to -
40.27; one trial, 200
women).
There was a
small
reduction in
the length of
the third stage
of labour and
also in the
amount of
blood loss
when cord
drainage was
applied
compared with
no cord
drainage.
Description Research design outcomes
Reference
details
Objectives Nature
Of
intervention
Study
population
Research
type
Data
Collection
methods
results conclusion limitations
Article
Title:
International
Journal of
Gynecology
& Obstetrics
Source:
trials
Publisher
name:
Cochrane
Pregnancy
and
Childbirth
Group
Authors:
Shakur H,
Roberts I,
Edwards
P,
Elbourne
D,
Alfirevic
Z,
Ronsmans
C
Year:2013
To determine
the effectiveness
of prophylactic
oxytocin at any
dose to prevent
PPH and other
adverse
maternal
outcomes
related to the
third stage of
labour.
This
updated
review
included
20 trials
(involving
10,806
women)
Primary and
secondary
research
observation Prophylactic oxytocin
compared with placebo
reduced the risk of PPH
greater than 500 mL,
(risk ratio (RR) 0.53;
95% confidence interval
(CI) 0.38 to 0.74; six
trials, 4203 women; T² =
0.11, I² = 78%) and the
need for therapeutic
uterotonics (RR 0.56;
95% CI 0.36 to 0.87,
four trials, 3174 women;
T² = 0.10, I² = 58%).
Prophylactic
oxytocin at any
dose decreases
both PPH
greater than
500 mL and
the need for
therapeutic
uterotonics
compared to
placebo alone.

MANAGING THE POSTPARTUM HEMORRHAGE10
Description Research design outcomes
Reference
details
Objectives Nature
Of
interventio
n
Study
population
Research
type
Data
Collection
methods
results conclusion limitations
Article
Title:
Publisher
name:
Cochrane
Pregnancy
and
Childbirth
Group
Authors:
Nermeen
SEB, Aly
K, Sameh
SED, Amr
AEN
Editors:
Nermeen
SEB, Aly
K, Sameh
SED, Amr
AEN
Year:2013
To determine
the
effectiveness of
uterine massage
after birth and
before or after
delivery of the
placenta, or
both, to reduce
postpartum
blood loss and
associated
morbidity and
mortality.
200
women
Primary
research
observation The numbers of
women with blood
loss more than 500
mL was small, with
no statistically
significant difference
(risk ratio (RR) 0.52,
95% confidence
interval (CI) 0.16 to
1.67). There were no
cases of retained
placenta in either
group
The joint statement of
ICM/FIGO 2004 on
management of the
third stage of labour,
advises uterine
massage after delivery
of the placenta to
prevent postpartum
hemorrhage.

MANAGING THE POSTPARTUM HEMORRHAGE11
References
Badhwar L, Singh K, Sethi N, Gupta I, Aggarwal N. The value of nipple stimulation in the
management of third stage of labour. International Journal of Gynecology and
Obstetrics 1991;36 Suppl:16.
EVENSEN, A, ANDERSON, J, & FONTAINE, P 2017, 'Postpartum Hemorrhage:
Prevention and Treatment', American Family Physician, 95, 7, pp. 442-449, CINAHL
Plus with Full Text, EBSCOhost, viewed 1 June 2018.
Wilcox, L, Ramprasad, Abdel-Aleem H, Alhusaini TK, Abdel-Aleem MA, Menoufy
M, Gulmezoglu AM. Effectiveness of tranexamic acid on blood loss in patients
undergoing elective cesarean section: randomized clinical trial. Journal of Maternal-
Fetal & Neonatal Medicine2013;26(17):1705-9.
Andersen B, Andersen LLT, Sorensen T. Methylergometrine during the early puerperium; a
prospective randomized double blind study. Acta Obstetricia et Gynecologica
Scandinavica 1998;77:54-7.
Attilakos G, Psaroudakis D, Ash J, Buchanan R, Winter C, Donald F, et al. Carbetocin versus
oxytocin for the prevention of postpartum haemorrhage following caesarean section:
the results of a double-blind randomised trial. BJOG: an international journal of
obstetrics and gynaecology2010;117(8):929-36.
Abdel-Aleem H, Singata M, Abdel-Aleem M, Mshweshwe N, Williams X, Hofmeyr
GJ. Uterine massage to reduce postpartum hemorrhage after vaginal
delivery. International Journal of Gynecology & Obstetrics2010;111(1):32-6.
Jongkolsiri P, Manotaya S. Placental cord drainage and the effect on the duration of third
stage labour, a randomized controlled trial. Journal of the Medical Association of
Thailand 2009;92(4):457-60.

MANAGING THE POSTPARTUM HEMORRHAGE12
Abdel-Aleem H, Hofmeyr GJ, Shokry M, El-Sonoosy E. Uterine massage and postpartum
blood loss. International Journal of Gynecology & Obstetrics2006;93(3):238-9.
Revert, M, Rozenberg, P, Cottenet, J, & Quantin, C 2018, 'Intrauterine Balloon Tamponade
for Severe Postpartum Hemorrhage', Obstetrics & Gynecology, 131, 1, pp. 143-149,
CINAHL Plus with Full Text, EBSCOhost, viewed 1 June 2018.
Patwardhan, S, Sawant, A, Ismail, M, Nagabhushana, M, & Varma, R 2008, 'Simultaneous
bladder and vaginal reconstruction using ileum in complicated vesicovaginal fistula',
Indian Journal of Urology, 24, 3, pp. 348-351, CINAHL Plus with Full Text,
EBSCOhost, viewed 1 June 2018.