POST PARTUM HEMORRHAGE

 Significant blood lost after giving birth

Could cause internal bleeding
 Decrease of >10% Hematocrit
 Changes in Mother’s:
 HR
 BP
 Oxygen Saturation
 No.1 reason for maternal morbidity=death
 Losing:
 500 mL of blood after vaginal delivery
 1000 mL of blood after cesarean section delivery
 Primary PPH- within 24hrs
 Secondary PPH- after 24 hrs

CAUSES: Tone, Trauma, Tissue, Thrombin

1.Lack of Uterine Tone (a.k.a UTERINE ATONY)
 Soft, spongy, boggy uterus which results to slow & steady loss of blood
 Most common cause of morbidity & mortality
 Myometrium (smooth muscle):
o Normal condition:
Contractions placental arteries clamped shut reduced bleeding

o Uterine Atony:
No contraction excessive bleeding PPH

 Causes:
 REPEATED DISTENTION
- Multiple pregnancies
- Overstretching from twins/triplets
 MUSCLES FATIGUE from DELIVERY
 UNABLE to EMPTY BLADDER (pushes on uterus & interfere on
uterine contraction)
 OBSTETRIC MEDICATIONS
- Anesthetics (e.g. halothane)
- Magnesium sulfate, nifedipine, terbutaline
-
 Medications:
 Fundal Massage = Smooth Muscle Contract
 Urination (or catheter placed)
 Medications
 Surgery

2.Trauma or Damage to Genital Structure

 Uterus, cervix, vagina, perineum
 INCISION from CESAREAN

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  From BABY coming through VAGINAL CANAL
 From MEDICAL INSTRUMENTS
- Forceps
- Vacuum Extraction
- Episiotomy
 Hematoma – mass or collection of blood could form, could go unnoticed
after delivery
- Severe pain
- Persistent bleeding
 Trauma/damage site = *EMERGENCY* - site must be repaired right
away by:
-apply pressure
-stitch lacerations

3. Tissue or Placental Fragments retained in uterine cavity

 Placenta Accreta – placenta invades myometrium
- Doesn’t easily separate
 Traction or umbilical Cord

Retained Placenta Prevents Contraction Uterine Atony

 Prevention:
 Make sure placenta comes out intact
 Remove retained tissue ASAP

4. Thrombin or Blood Clotting Condition

 Genetic disease like Von Willebrand ds.
 Obstetric: (which clotting disorder)
-Eclampsia
-Placental Abruption
 Can lead to Disseminated Intravascular Coagulation (DIC) –
prevents clot formation

POSTPARTUM HEMMORRHAGE

OBSTETRIC EMERGENCY
 Maintaining Adequate
Circulating Vol.
- Intravenous Fluids
- Blood Products

PLACENTA PREVIA
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 Means placenta first in the uterine cavity
 Placenta implants in the lower uterus, close to or covers the internal cervical
OS
 Causes bleeding after 20 weeks gestation

 Causes:
 Unclear
 (Hypotheses) Upper uterus Endometrium is NOT well vascularized
- Damage from:
- Previous Cesarean,
- Abortion,
- Uterine Surgery, or
- Multiparity
Could increase risk of placenta previa.
 Risk Factors:
 Having multiple placentas
from twins or triplets
 Placenta larger than normal surface area
 Maternal age >35
 Intrauterine fibroids
 Maternal Smoking

 Classified as:
1.Complete/ completely covered
2.Partial
3.Marginal - or the edge of placental extends within 2cm of the cervical os

Lower uterine segment GROWS

Disrupts Placental Vessels

Bleeding
- typically happens after 20 wks gestation
- could be intermittent or continuous
- painless & bright red
- can increase during labor due to contractions & cervical dilation

COMPLICATIONS
 Maternal – related to blood loss
 Fetal - include hypoxia and preterm delivery

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 Placenta Previa is associated with Placenta Accreta - placenta invades
myometrium

 DIAGNOSIS
 Prenatal Ultrasound
 (Sometimes) during labor

 Tx/Mngt:
 Corticosteroids – enhance fetal development
 Minor Bleeding – Bed Rest
 Major Bleeding – Blood Products & IVF
 Severe Cases – Immediate CS

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