POST-PARTUM

HEMORRHAGE
DR . R AV EENDRA M V
DN B - F M 3 RD YEA R R ES I DENT
DE PT. OF OBG , CI HS R
Definition

Quantitative definition: The amount of blood loss in excess of 500ml

following birth of the baby (WHO)

Clinical definition : “Any amount of bleeding from or into the genital tract
following birth of the baby up to the end of puerperium, which adversely
affects the general condition of the patient evidenced by rise in pulse rate
and falling blood pressure is called postpartum hemorrhage”
Incidence : 4 – 6% of all deliveries.
Types:

Primary PPH Secondary PPH

Within 24 hours Beyond 24 hours
Third stage hemorrhage: Also k/a- delayed or late
Before expulsion of puerperal hemorrhage
placenta
True PPH: Subsequent to
expulsion of placenta
Causes
ATONIC TRAUMATIC

RETAINED TISSUE BLOOD

COAGULOPATHY
ATONIC UTERUS ( 80% )
Grand multipara Over distension of the uterus
Antepartum hemorrhage Prolonged labor (>12Hrs)

Initiation or augmentation delivery by Obesity

OXYTOCIN
Mismanaged third stage of labor(Too rapid, Morbidly adherent placenta(accrete,
Premature attempt, pulling the cord) percreta)

Malnutrition and anemia Anesthesia( ether, Halothane )

Malformation of the uterus Uterine fibroid

H/o – Previous PPH Use of tocolytics
TRAUMATIC(20%)
Usually following operative delivery

Blood loss from episiotomy and cesarean are underestimated

Bleeding is usually Revealed but can rarely be concealed ( Vulvovaginal or broad ligament

hematoma )

COMBINATION OF ATONIC AND TRAUMATIC CAUSES

Retained tissues: Bits of placenta and clots cause PPH due to imperfect uterine
retraction.

Thrombin: Both Congenital and Acquired.

( Diminished procoagulopathy or increased fibrinolytic activity)
-> Abruptio placentae, jaundice in pregnancy, TTP, Severe preeclampsia, HEELP Syndrome or in
IUD.
Prevention
ANTENATAL
I. Improvement of health status
II. High risk patients are screened and delivered
in a well-equipped hospital
III. Blood grouping should be done in all patients
IV. Prior Placental localization
V. Morbid adherent placenta should be ruled out V. Observation for about 2 hours post delivery
prior to delivery
VI. In case of woman with morbid adherent
placenta, delivery should be conducted by Sr.
Obstetrician.
INTRANATAL
I. Active management of 3rd stage of labor
II. Cases with Induced or Augmented labor by
oxytocin, it should be continued at least one
hour after delivery.
III. In case of Caesarean delivery, Oxytocin 5 IU
slow iv
IV. Exploration of Uterovaginal canal
VI. To allow spontaneous separation and delivery
of placenta during cesarean section
VII. Examination of placenta as a routine
MANAGEMENT OF 3RD STAGE BLEEDING
Principles:

1.To empty the uterus

2.To replace the blood

3.To ensure effective hemostasis in traumatic bleeding

MANAGEMENT OF 3RD STAGE BLEEDING
Placental site bleeding:
To palpate the fundus and massage
To start the crystalloid solution
Oxytocin 10 IU IM or Methergine 0.2mg IV
To catheterize the bladder
To give antibiotics ( Ampicillin 2g and metronidazole 500mg IV )
If patient is in shock, Address it first.

Traumatic bleeding: Exploration of uterovaginal canal and apply hemostatic sutures on

offending sites.
Scheme of management of 3rd stage of hemorrhage
Steps of Manual removal of placenta
Step-I: General anesthesia or under deep
sedation
Step-II: Introduction of one hand into the
uterus in a cone shaped manner following the
taut umbilical cord
Step-III: Counter pressure with opposite hand
Step-IV: As soon as the placental margin is
reached, the fingers are insinuated between
the placenta and uterine wall and placenta is
separated with a sideways slicing movement
of fingers.
Steps of Manual removal of placenta
Step V: When placenta is completely
separated, it is extracted by traction of the
cord by other hand.
Step VI: IV Methergine 0.2mg is given and
uterine hand is gradually removed while
massaging the uterus by external hand.
Step VII: Inspection of Cervicovaginal canal is
to be made.
Step VIII: The placenta and membranes are
inspected.
Management of True PPH
Simultaneous approach

COMMUNICATION RESUSCITATION MONITORING ARREST OF BLEEDING

Immediate measures
Call for extra help

Put in 2 large bore iv cannulas

Keep patient flat and warm

Send Blood investigations

Oxygen by mask @ 10-15L/min

Start 20 IU OXYTOCIN in 1L NS @ 60 drops/min

One person should be assigned to monitor her

ACTUAL MANAGEMENT
First step is to control the fundus and to note the feel of
uterus.

If uterus is Flabby => Atonic uterus

If uterus is firm and contracted => Traumatic origin

Atonic Uterus
STEP – I

A. Massage the uterus

B. Inj. Methergine 0.2mg iv

C. Inj.Oxytocin drip 10 IU in 500ml NS @ 40-60 drops/min

D. Foley’s catheter

E. To examine expelled placenta and membranes

If Step-I fails to stop bleeding move to next step =======>

STEP-II
The Uterus is explored under GA or Deep sedation

In Refractory cases,

- Inj. Carboprost 250 mcg IM in deltoid muscle

Or

Misoprostol (PGE1) – 1000mcg PR

When Uterine atony is due to tocolytic drugs, Inj. Calcium gluconate ( 1gram iv slow )
STEP - III
Uterine massage and Bimanual compression

a) Introduce the whole hand into vagina in cone shaped

manner

B) Clench the vaginal hand to a fist

C) Keep the other hand over the abdomen behind the uterus
to make it anteverted.

D) Uterus is firmly squeezed between the two hands.

If the Uterus fails to contract ………………………………………..

Move to the next step==
STEP-IV
Uterine tamponade:

a) Tight intrauterine packing

B) Balloon tamponade

C) Other measures-

Non-pneumatic antishock garment

Compression of the abdominal aorta

STEP V
Surgical methods to control PPH:
A) B-lynch compression suture and multiple square sutures
(Success rate is 80% )
Surgical methods to control PPH

B) Ligation of Uterine arteries

C) Ligation of Uterine and Ovarian artery

anastomosis

D) Ligation of anterior division of internal iliac

artery

E) Angiographic selective arterial embolization

STEP VI
Hysterectomy
- Rarely uterus fails to contract and bleeding
continues in spite of the above measures.
-Hysterectomy should be considered involving
a second consultant
- Decision should be taken early in parous
woman
Depending on the case, it may be subtotal or
total.
Traumatic PPH
Exploration of Utero vaginal canal under good
light by speculum examination.

Offending sites are sutured with catgut.

SECONDARY PPH
Bleeding usually occurs between 8th and 14th day of delivery
Causes
1. Retained bits of cotyledon or membranes

2. Infection or separation of slough over a deep cervicovaginal laceration

3.Endometritis and subinvolution of placental site

4. Secondary hemorrhage from cesarean section wound vessel between 10-14 days

(a) Separation of slough (b) from granulation tissue

5. Withdrawal bleeding following estrogen therapy for suppression of lactation

6. Others- Chorionepithelioma, carcinoma cervix, placental polyp, infected fibroid, puerperial

inversion of uterus.
Management of secondary PPH
Principles:
To assess the amount of blood loss and to replace it
To find out the cause and to take appropriate steps to rectify it.
Supportive therapy:
(1) Blood transfusion,if necessary
(2) Inj. Methergine 0.2mg IM ( If bleeding is uterine origin )
(3) To administer antibiotics – Inj. Clindamycin and metronidazole
Management of secondary PPH
Conservative: If bleeding is slight and no apparent cause is detected
A careful watch for a period of 24 hours.
Active treatment:
As the m/c cause retained bits of cotyledon or membranes- It is preferable to explore the uterus
urgently under GA.
If bleeding is from sloughing wound <- Apply hemostatic sutures
Secondary hemorrhage following a cesarean section may at times require laparotomy.
Key Points
Obstetric hemorrhage is the major cause of maternal death in both in developed and
developing countries.
Even though incidence is low, when it occurs it is fatal
Clinical definition of PPH is more important than quantitative definition
Prediction and prevention of PPH may be possible to some extent. Most of the cases of PPH are
unexpected.
Management Protocol : Communication,Resuscitation, Monitoring and Arrest of bleed.
Always call for help from senior obstretician
Reference
Thank you…