Outofhospital Delivery And Postpartum Hemorrhage

Our group14 compared maternal and neonatal outcomes in out-of-hospital vs. in-hospital deliveries in a prospective study. Unplanned out-of-hospital deliveries resulted in a statistically significant higher rate of postpartum hemorrhage (OR 8.4 95 CI 1.1-181.1 p 0.018) (Table 4). Postpartum hemorrhage due to uterine atony is the primary direct cause35 of maternal mortality globally. Management strategies in developed countries involve crystalloid fluid replacement, blood transfusions, and...

Treatment

The majority of cases of secondary postpartum hemorrhage are due to subinvolution of the uterus caused by uterine infection and or retained placental tissue. Initial management Table 1 Causes of secondary postpartum hemorrhage Subinvolution of the uterus - retained placental tissue and or endometritis, fibroid uterus Lower genital tract lacerations hematoma Surgical injury Vascular abnormality - arteriovenous malformation Placental abnormality - placenta accreta, percreta Coagulapathies,...

References

Out of hospital deliveries incidence, obstetrical characteristics and perinatal outcome. Harefuah 2003 142 38-41 2. Burnett CA 3rd, Jones JA, Rooks J, Chen CH, Tyler CW Jr, Miller CA. Home delivery and neonatal mortality in North Carolina. JAMA 1980 244 2741-5 3. Bateman DA, O'Bryan L, Nicholas SW, Heagarty MC. Outcome of unattended out-of-hospital births in Harlem. Arch Pediatr Adolesc Med 1994 148 147-52 4. Hinds MW, Bergeisen GH, Allen DT. Neonatal outcome...

Consequences to the mother

The problem is more than one of mortality. Little doubt exists that for every woman who dies, there are at least 20-30 who suffer (1) Failure of or impaired lactation leading to an undernourished child prone to infections, especially if born preterm (2) Anemia leading to susceptibility to post-partum infections, ranging from simple endometritis to severe puerperal sepsis, which in itself can be a cause of maternal death later in the puerperium (3) Deterioration of existent diseases, especially...

Incidence

Abdominal pregnancies are rare events. In the United States, it is estimated that it occurs once in 10 000 live births and once also for every 1000 ectopic pregnancies1. A more recent African report provides a much higher estimate of 4.3 of ectopic pregnancies, which is probably a reflection of referral patterns in that region as well as a higher baseline rate of inherent tubal disease in the patient base of the hospital catchment area2. However, it also may be reasonable to presume that the...

Blunt Abdominal Trauma

The three main causes of serious blunt abdominal trauma in pregnancy are motor vehicle accidents, falls and domestic or intimate partner physical abuse. In the developed world, the most common cause of blunt abdominal trauma is motor vehicle accidents27,28. In the less developed countries, the incidence of domestic physical abuse or intimate partner physical abuse can be as high as 13.5 29. Developed countries are not immune from this problem, however, and a large review of the prevalence of...

Uterine abnormalities

Fibroids are associated with primary postpartum hemorrhage. They cause uterine enlargement and prevent involution of the uterus, therefore leading to prolonged bleeding from the placental bed. More rarely, they can be associated with secondary postpartum hemorrhage. Fibroids have usually been identified by ultrasound in the antenatal period. Abnormalities of uterine vasculature such as arteriovenous malformations and false aneurysms may also lead to secondary postpartum hemorrhage....

Special clinical considerations

The major pitfall associated with ligation of the hypogastric artery is delay. When hemorrhagic shock is irreversible, this operation will not overcome it. Inadequate transfusion is another pitfall in the therapy of patients with severe hemorrhage. Blood loss is often seriously underestimated. Failure to remember that the vaginal artery is a separate branch of the hypogastric artery, rather than a branch of the uterine artery, may lead the surgeon into the pitfall of an unnecessary and...

Conclusion

Midwives are central to the effective prevention, recognition and treatment of postpartum hemorrhage. They need to be aware of the risk factors for postpartum hemorrhage and take appropriate action when they are identified. They should also be skilled in basic life support and have an understanding of the pathophysio-logy of hypovolemic shock. This knowledge must be used in conjunction with an understanding of women's social, cultural and psychological well-being. Training as multidisciplinary...

Resuscitation

The key feature of all resuscitation efforts is the early recognition and management of hypovolemic shock with an overall objective of restoring the circulating blood volume to maintain normal tissue perfusion and oxygenation. The reason for the high mortality associated with obstetric hemorrhage is simple, i.e. the delayed recognition of hypovolemia and failure to provide adequate volume resuscitation. Common problems include the failure to recognize risk factors, frequent under-estimation of...

Embolic material

Practical embolic materials are summarized in Table 1. Gelatine particles are the most commonly used embolic material in embolization for postpartum hemorrhage as they are expected to dissolve in several weeks' time, leading to recanalization of the embolized artery. However, these are not free from embolic complica-tions2,11. Other advantages of gelatine particles include that they are economical and easily available. Where the particle form of gelatine is unavailable, gelatine plate or sponge...

Blood Products Acceptable For Jw

The JW Society demands that the 'primary components' of blood must be refused. These are red and white blood cells, platelets and plasma (fresh frozen plasma). Autologous blood collection and storage for later re-infusion (pre-deposit) is not acceptable to most JW as the blood is separated from the individual for a period of time by storage. In contrast, 'fractions' of plasma or cellular components such as albumin, immuno-globulins, non-recombinant clotting factors and hemoglobin-based oxygen...

Postoperative care

Internal Iliac Artery Branches Proviso

Intensive care is necessary because these women may be moribund and have required huge blood transfusion. Large hematomas or collections of serosanguineous fluid can be drained through separate stab wounds. Usually, this is unnecessary. Antibiotics are not indicated after ligation of the arteries. Their use is dictated only by the presence of infection. Early ambulation is advisable in all cases. An indwelling catheter may be necessary to facilitate adequate assessment of urinary output in...

Ruptured Uterus

Uterine rupture is a serious obstetric complication with high morbidity and mortality. In developed countries, the increasing number of Cesarean sections performed for minor degrees of disproportion, fetal distress or pre-eclampsia in primiparae is of considerable importance in calculating the long-term risks associated with Cesarean section, particularly in terms of the incidence and risk of uterine rupture. Both the short- and long-term risks are accentuated in resource-poor countries....

Postpartum Haemorrhage In Asia Japan

Japan has the largest and most sophisticated economy in Asia and a medical system that was substantially revised after World War II. Despite these advantages, the number of maternal deaths from postpartum hemorrhage increased in number from four to 17 between 1995 and 200311. More importantly, as a percentage of causes of maternal mortality, postpartum hemorrhage increased from 4.7 to 24.6 between 1995 and 2003 (Figure 2). During the same period of time, obstetric embolism (amniotic fluid, air...

Von Willebrand disease

Von Willebrand disease (vWD) is the most common of the inherited bleeding disorders, found in approximately 1 of the general population without ethnic variations. It is caused by a reduced plasma concentration of structurally normal von Willebrand factor (vWF) or the presence of a structurally abnormal molecule with reduced activity. vWF is the carrier protein in plasma for FVIII, and it also acts as a bridge between platelets and subendothelial collagen fibers. vWF is synthesized in...

Practical Use Of Cell Salvage In Obstetrics

There presently exists a substantial experience with the use of cell salvage in obstetrics in the UK cases include major hemorrhage due to placenta previa, placenta accreta, ruptured uterus, extrauterine placentation, massive fibroids and placental abruption, as well as routine use in Jehovah's Witnesses to avoid postoperative anemia14. The following guidelines are in use for cell salvage in obstetric use in the Swansea NHS Trust Hospitals, UK (1) It may be used for any situation in which...

Assessment Of Circulating Blood Volume

Young healthy adults can compensate for the loss of large volumes from the circulation with few obvious external signs. Accurate assessment of blood loss can be difficult for the experienced as well as the inexperienced examiner, as described in Chapter 4. In cases of hemorrhage symptoms often precede signs. These include unexplained anxiety and restlessness, the feeling of breathlessness (with or without an increased respiratory rate), and a sensation of being cold or generally unwell. For...

Acquired And Congenital Hemostatic Disorders In Pregnancy And The Puerperium

During normal pregnancy, a series of progressive changes in hemostasis occur that are overall procoagulant and help prevent excessive bleeding at the time of delivery. The concentrations of coagulation factors V, VII, VIII, IX, X, XII and von Willebrand factor (vWF) rise significantly (Table 1) and are accompanied by a pronounced increase in fibrinogen levels (up to two-fold from non-pregnant levels). Factor XIII levels tend to decrease in late pregnancy after an initial increase in the...

Visual Drape

Figure 6 Number of cases detected for specific blood loss (p < 0.01). The calibrated drape more accurately determined true blood loss when > 250 ml and more accurately estimated overall levels efficiently as gold-standard spectrophotometry (Pearson's correlation coefficient of 0.928 p 0.01, Table 3). Use of the drape diagnosed postpartum hemorrhage four times as often as the visual estimate. A larger validation study is presently underway at the University of Missouri at Kansas City School...

Section I

Demographic and logistical considerations POSTPARTUM HEMORRHAGE TODAY LIVING IN THE SHADOW OF THE TAJ MAHAL A. B. Lalonde, B.-A. Daviss, A. Acosta and K. Herschderfer 'Women are not dying because of a disease we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.' Mamoud Fathalla, President of the International Federation of Gynecology and Obstetrics (FIGO), The wife of the Shah Jahan of India, the Empress Mumtaz, had 14 children and...

Sapiens

All the authors and editors have contributed to this publication on a strictly charitable basis and have received no remuneration of any kind for their contributions. The book, which is available through the normal commercial channels in the Western World, is being provided free to a large number of selected physicians in developing countries and at a special low price to members of all national obstetric and gynecological societies worldwide. The whole book is also available entirely free of...

Incidence and risk factors

Insertion Velamentosa

It occurs in about 1 in 200 pregnancies10, although higher incidences have been reported54. When placentas are examined routinely, the incidence is much higher at 4.5 55 suggesting that small episodes are more common than those diagnosed clinically. Placental abruption can be revealed or concealed (Figure 4), the former occurring in 65-80 of cases. The concealed type is clinically more dangerous as it is often associated with more severe complications. Risk factors for placental abruption...

D S Shah H Divakar and T Meghal

The World Health Organization (WHO) estimates that, of the 529 000 maternal deaths occurring every year, 136 000 or 25.7 take place in India, where two-thirds of maternal deaths occur after delivery, postpartum hemorrhage being the most commonly reported complication and the leading cause of death (29.6 )1. The unacceptably high maternal death ratio (540 100 000 live births)1 in India during the last few decades remains a major challenge for health systems. According to the same WHO estimates,...

Postpartum Hemorrhage Conclusions

The identification of'substandard care' in 71 of maternal deaths attributed to hemorrhage in the 2000-2002 Confidential Report (UK)34 underscores the need for a standard of care to be established in every unit where childbirth takes place and for all relevant health-care workers to be keenly familiar with that standard (see Chapter 22). Integral to any protocol on management of postpartum hemorrhage will be a stepwise approach to achieving effective uterine contractility. The successful...

Factor VII deficiency

Congenital FVII deficiency is the most common of the rare inherited coagulation disorders with an estimated prevalence of 1 in 500 000. It is inherited in an autosomal recessive manner and its frequency is significantly increased in countries where there are consanguineous marriages. FVII levels are usually less than 10 in homozygotes and around 50 in heterozygotes. Although there is a poor correlation between FVII levels and bleeding risk, hemorrhages occur in patients with factor VII levels...

Lower Uterine Segment

Important pathologies here involve implantation on a previous Cesarean section scar, with abnormal adherence or formation of a diverticulum. A Cesarean section results in chronic changes in the lower uterine segment, including distortion and widening, inflammation, giant cell reaction and adenomyosis3. In some cases, a distinctive V-shaped defect of the anterior wall ('tenting') may be present. An important cause of weakening of a Cesarean section scar is infection. Postoperative wound...

Results Clinical data

Of 28 patients diagnosed between 1951 and 1959, 16 died of cortisol insufficiency precipitated by concurrent illnesses. In contrast, only two patients died in the group diagnosed between 1960 and 1970. This marked decrease in mortality was secondary to a better and regular follow-up and an improvement in their education regarding the nature and life-endangering risks of the disease. Fifty of the 72 patients diagnosed between 1960 and 1970 were thoroughly studied (Table 1). Forty-three (86 ) had...

Bleeding From The Lower Genital Tract

In the first comprehensive English Language textbook on the subject, William Smellie, in his 1752 Treatise on the Theory and Practise of Midwifery1, correctly identifies the atonic uterus as a major cause of postpartum hemorrhage with his statement 'This dangerous efflux is occasioned by every thing that hinders the emptied uterus from contracting'. Although he refers to vaginal packing with Tow or linen rags (dipped in astringents such as oxycrate, red tart wine, alum or Sacchar-saturni), he...

Malignant Hypertension 1993

In 1993, Evelyn Dybongco-Rimando had an uneventful spontaneous vaginal delivery of a healthy daughter, and she went home shortly afterwards. Some 8 years later, a judge of the Superior Court of Justice of Ontario was to say that her case 'presents a puzzle with a thousand pieces'. The trial started in 1999, and it lasted for 33 days spread over 3 years. The judge described it as 'a challenge to bench and bar alike'. Although her delivery was normal, 7 days later she suffered a massive...

Guidelines for consent to elective surgery in JW patients

The fact that a JW patient requires an elective operation must be ascertained and communicated to the 'JW ad hoc team' (see below) at least 2 weeks (10 working days) before the operation date. Notification of less than 2 weeks before planned surgery may lead to cancellation. This consists of the consultant surgeon and consultant anesthetist (key participants) and the consultant hematologist or transfusion nurse specialist (facilitator). The consultant anesthetist is self-identified as prepared...

Congenital platelet disorders

Bernard-Soulier syndrome is a rare autosomal recessive platelet disorder due to a variety of mutations in membrane glycoproteins Ib, IX and V. Patients usually present early in life with spontaneous bruising, epistaxis or bleeding after minor trauma menorrhagia is a common presentation. Laboratory findings include thrombocytopenia, large platelets, prolonged bleeding time and poor platelet aggregation in vitro to ristocetin. Eleven cases of Bernard-Soulier syndrome in pregnant women have been...