OBSTETRICS 2

o Bimanual compression- may induce tonic contraction

P.10 OBSTETRIC HEMORRHAGE (Part 2)
Dr. Ursua | February 7, 2019

OUTLINE:
I. CAUSES OF POST PARTUM HEMORRHAGE: 4 T’S
II. UTERINE ATONY
III. PLACENTA ACCRETA
IV. UTERINE RUPTURE
V. UTERINE INJURY ABNORMALITY DURING CURRENT
PREGNANCY
VI. UTERINE INVERSION
VII. BLEEDING WITH FIRM UTERUS
VIII. GENITAL TRACT LACERATIONS
IX. VULVAR HEMATOMA o Ice packs, sand bag
X. CONTINUED UTERINE BLEEDING o Uterine packing or balloon tamponade
XI. MANAGEMENT OF PPH: ABC’S
XII. SUMMARY
XIII. CONCLUSIONS

I. CAUSES OF POST PARTUM HEMORRHAGE: 4 T’S

1. Tone diminished – Uterine Atony
2. Tissue
a. Retained placenta
b. Placenta accreta
3. Trauma
a. Uterine rupture – previous CS  Insert FC Fr 24 into uterine cavity
b. Uterine inversion  Inflate with 60-80 ml of saline
c. Lacerations  May remove after 12-24 hrs.
d. Hematomas
4. Thrombin – Coagulopathy INVASIVE MEASURES
 Compression sutures
EARLY PPH  Arterial embolization
 Atony  Vaso-occlusive procedures
 Genital tract lacerations o Uterine artery ligation
 Uterine rupture o Hypogastric artery ligation
 Dissecting hematomas  Hysterectomy
 Uterine inversion
 Coagulation defects OTHER MEASURES
 Uterine massage
LATE PPH o Empty bladder
 Retained placental secundines or accrete o Bi-manual massage
 Placental polyp  Drugs
 Infection o Methylergonavine Maleate (Methergin) 0.2 mg IM
 Uterine subinvolution q 6h
- aside from oxytocin, we now give this
II. UTERINE ATONY - please check first the BP of the patient
 Factors associated with Uterine Atony: - contraindicated in hypertensive patients because
o Prolonged labor it’s a potent vasoconstrictor
o Oxytocin o Misoprostol 600 mcg. Rectally
o General anesthetics (Halothane) o Oxytocin
o Multiple gestation o Tranexamic acid: anti-plasminogen
o Polyhydramnios
o Fetal macrosomia III. PLACENTA ACCRETA
o Grand multiparity  Risk factors:
o Couvelaire uterus o Age (low risk when < 30 y.o)
o Infection o Parity (high risk: 2-3)
o Previa/ prior CS- trauma
A. MANAGEMENT (UTERINE ATONY) o Prior Curettage
 Keep the uterus well contracted. o Prior retained placenta
o Infection
CONSERVATIVE MEASURES
o Uterine stimulants  Associations:
 Oxytocin o 1/3 of cases: Placenta Previa
 Methergine o 1/4 of cases: prior CS delivery
 Misoprostol o 1/4 of cases: prior curettage
o 1/4 of cases: Gravida 6 or more

Transcribers: RIMANDO, SMITH, HIDALGO Page 1 of 4

 OBSTETRICS 2
 Presentation: o CS, myomectomy
o Postpartum hemorrhage o Operative vaginal delivery: internal podalic version,
o Prolonged 3rd stage labor breech extraction, midforceps
o placenta should be delivered in not more than 30 mins. o Obstructed labor
after delivery of the fetus (primipara) o Abnormal fetal lie- transverse lie, breech
o in multiparas- not more than 15 mins. o High parity- thin uterine lining

 Symptomatology
o Asymptomatic
o Sudden cessation of uterine contractions during labor
o Hemodynamic instability
o Fetal heart rate abnormalities
o Hypogastric pain and tenderness
o Shock

 Clinical Signs
o Severe abdominal pain
o Shock
o Vaginal bleeding
o Cessation of labor
o Recession of presenting part
o Fetal distress

V. UTERINE INJURY ABNORMALITY DURING CURRENT

PREGNANCY
 Before delivery
o Intense uterine contractions
o External trauma
o External version
o Uterine over distention
o Placement of internal catheters

 Acquired (uterine injuries)

o Placenta increta or percreta
A. MANAGEMENT (PLACENTA ACCRETA)
o Gestational trophoblastic neoplasia
 Avoid attempts to separate placenta!
o Adenomyosis
 Transfer and refer patients to hospital immediately
 Hysterectomy
 During delivery
o Internal version
B. DIAGNOSIS (PLACENTA ACCRETA)
o Difficult forceps delivery
 High index of suspicion
o Breech extraction
 Mostly discovered only during the 3rd stage
o Vigorous uterine pressure
 Imaging modalities
o Manual extraction of placenta
 Ultrasonography with Doppler
o Fetal anomalies
 CT Scan
 MRI
VI. UTERINE INVERSION
IV. UTERINE RUPTURE

 Risk Factors
o Fundal placentation
o Cord traction
o Fundal pressure (Crede’s maneuver)
 Risk factors
-should be executed with caution
o Previous uterine surgery- indication to do CS, no
o Manual extraction
questions asked
o Uterine atony
o The most common cause of uterine rupture is
separation of a previous cesarean hysterotomy
scar.

Transcribers: RIMANDO, SMITH, HIDALGO Page 2 of 4

 OBSTETRICS 2
 Almost always due to over traction on the umbilical
cord attached to the placenta implanted in the fundus: VII. BLEEDING WITH FIRM UTERUS
o Unusual adherence of the placenta A. MANAGEMENT (BLEEDING)
o Fundal pressure during 3rd stage  Explore the lower genital tract
o Relaxed uterus  Requirements
o Appropriate analgesia
 Complete vs. Incomplete o Good exposure and proper lighting
o Complete: fundus out of the introitus  Appropriate surgical repair
o Incomplete: fundus within the vaginal canal o Trachelorrhaphy- repairing a lacerated cervix
o May temporize with packing
 Incidence
o In foreign literature: 1 in 2100-6400 VIII. GENITAL TRACT LACERATIONS
o In the Philippines: usually among TBA

A. DIAGNOSIS (UTERINE INVERSION)

 Fleshy mass in the introitus
 Cupping of the uterine fundus

B. MANAGEMENT (UTERINE INVERSION)

 Transfer patient to hospital immediately
A. Placenta separated
o Administer GA &/or tocolytic
o Push up uterine fundus thru cervix
o While hand in uterine cavity, start oxytocin until A. Perineal lacerations
tone returns  Extensions from episiotomy
B. Placenta attached  Usually superficial an easily controlled with proper suturing
o Administer GA &/or tocolytic  Can be prevented by Ritgen’s maneuver and adequate
o Replace uterus w/o removing placenta episiotomy
o Manually extract placenta, start oxytocin until tone B. Vaginal laceration
returns  Involves the middle or upper third of the vagina
 Usually longitudinal
 If repositioning is not possible, perform laparotomy  Usually secondary to forceps and vacuum application and
(Haultain or Huntington) traction

MANUAL REPLACEMENT OF THE UTERUS A. MANAGEMENT (GENITAL TRACT LACERATIONS)

 Inspect vagina and cervix
o Adequate anesthesia required
o Visualize extent of laceration/s
o Repair lacerations with appropriate layer apposition
o Provide antibiotic coverage

IX. VULVAR HEMATOMA

FUNDAL REPOSITIONING

 Vulvar/ vaginal
o Conservative: packing and re-inspection
o Aggressive: evacuation and ligation of bleeding sited
X. CONTINUED UTERINE BLEEDING
A. MANAGEMENT (CONTINUED BLEEDING)
 Consider coagulopathy
 Correct coagulopathy
o FFP, cryoprecipitate, platelets
 If coagulation is normal
o Consider embolization
o Prepare for OR

Transcribers: RIMANDO, SMITH, HIDALGO Page 3 of 4

 OBSTETRICS 2
XI. MANAGEMENT OF PPH: ABC’S
 Ensure that you are always ahead with your resuscitation
 Consider need for Foley catheter, CVP, arterial line, etc.
 Consider need for more expert help
 Prevention and anticipation are essential
 Treat underlying cause
 Vaso-occlusive measures and hysterectomy are last options
 Prompt and adequate blood replacement
 Don’t hesitate to ask for assistance if needed

XII. SUMMARY
 General Management Principles
o Identify and manage the etiology of the hemorrhage
o Ensure IV access (multiple large-caliber IV lines are
usually necessary)
o Mobilize the OR team
 Anesthesiologist
 Internist/ intensivist
 Nursing staff
 Fluid Replacement
o Prompt and adequate refilling of intravascular
compartment
o Crystalloid solutions are first priority
 Rapidly equilibrate into the extravascular space
 Only 20% of crystalloid remains in the circulation
after 1 hour of infusion
 Infuse 3x more crystalloid to the EBL
 Blood Replacement
 Cardiac output does not substantively decrease until the
hemoglobin falls to about 7 g/dL
 Rapid blood transfusion if:
o Hematocrit is < 25% or hemoglobin < 8 g/dL
o Acute operative blood loss
o A surgical procedure is imminent
o Acute hypoxia
o Signs of vascular collapse
 Whole blood
o Treatment of hypovolemia from catastrophic acute
hemorrhage
o 1 unit raises hct by 3%-4%
o Replaces many coagulation factors and fibrinogen
 Present Trend in Blood Transfusion
o FWB only in acute massive hemorrhage
o Component therapy is preferred
 Less incidence of passage of infection
 Less incompatibility reactions
 Less incidence of fluid overload

XIII. CONCLUSIONS
 Be prepared
 Practice prevention
 Assess the loss
 Assess maternal status
 Resuscitate vigorously and appropriately
 Diagnose the cause
 Treat the cause

CHECKPOINT:
True or False
____1. Uterine atony is associated with multiple gestation.
____2. Methylergonovine Maleate is a potent vasodilator.
____3. The placenta should be delivered w/in 30 mins. after delivery
of the fetus in multiparas.
____4. When placenta accreta is diagnosed, one must immediately do
manual separation of the placenta.
____5. Previous uterine surgery is an indication to do CS.
T,F,F,F,T

Transcribers: RIMANDO, SMITH, HIDALGO Page 4 of 4