Post Partum Haemorrhage

M1, FMBS
Dr DOHBIT SAMA
HGOPY - FMBS
Objectives
At the end of this lecture, the student should be able to:
1. Define PPH and discuss 5 complications
2. State 5 major causes of PPH and their management
3. Describe the various steps of the AMSTL (GATPA)
Plan
Definition
Incidence
Morbidity and Mortality (complications)
Aetiology
Management
The AMSTL (GATPA)
Management of delayed PPH
Conclusion
Definition
PPH denotes excessive bleeding following delivery; 500mls
for vaginal delivery and 1000mls for caesarean delivery
Blood loss may be before, during or after the delivery of the
placenta.
A major problem of underestimation
Early (primary) PPH is within the 1st 24 hours and from 24
hours to 6 weeks is known as late (secondary) PPH
Incidence
An estimated 58% women would have excessive blood loss
following delivery
PPH is main cause of pregnancy related bleeding and blood
transfusions.
Leading cause of maternal mortality worldwide
Morbidity and mortality
Women with anaemia or intercurrent diseases would suffer
more deterioration of condition following PPH
More puerperal sepsis would ensure: antibiotherapy
Risks associated with transfusions; reactions, infections with
HIV, hepatitis
Sterility from emergency hysterectomy
Postpartum panhypopituitarism
Panhypopituitarism or Sheehan
Sheehans syndrome resulting from partial or complete
necrosis of the anterior pituitary, characterised by:
Failure to lactate, Decreased breast size,
Amenorrhea,
Loss of pubic and axillary hair,
Hypothyroidism, and adrenal insufficiency.
Rare condition, 1/10,000 deliveries
Aetiology of Primary PPH
1. Uterine atony
2. Obstetric lacerations
3. Retained placental tissue
4. Coagulation defects
5. Uterine inversion
Aetiology secondary PPH
1. Retained membranes,
blood clots
2. Infectionof retained parts,
c/s wounds, lacerations,
placental site
3. Fibroid polyp,
4. Subinvolution of the
uterus.
5. Local gynaecological
lesions: e.g. cervical
ectropion, carcinoma.
6. Choriocarcinoma.
7. Puerperal inversion of the
uterus.
8. Oestrogen withdrawal
bleeding if it was given for
suppression of lactation
The Aetiologies

Which are the main causes?

1. Uterine Atony
Most common cause of PPH, 50% cases
Postpartum bleeding is physiologically controlled by
constriction of interlacing myometrial fibers that surround
the blood vessels supplying the placental implantation site.
Uterine atony exists when the myometrium cannot contract
Atony 2
Atony is the most common cause of PPH, >50% of cases
Predisposing factors include;
1. Uterine overdistension (twins, polyhydramnios,
macrosomias)
Dg: Dark blood, uterus larger than expected and soft,
squeezing will send out clots of blood
Predisposing factors for atony
1. Uterine overdistension (twins, macrosomias)
2. Prolonged labour
3. Grand multiparity
4. Uterine myomas
5. Excessive manipulation of the uterus
6. General anaesthesia (halogenated compounds) during
caesarean section
7. Operative delivery
8. Full bladder and rectum
Predisposing factors for atony 2
9. Wrong oxytocin usage
10. A past history
11. Uterine infection
12. Couvelaire uterus as in abruptio
13. Intrinsic myometrial dysfunction

Good myometrial function will always reduce blood

loss (Young Laplace)
Young Laplace formula
F = 2T/r
F = the force of the myometrial fibers to contract and
occlude interlacing blood vessels
T = the tension in the myometrial fibers
R = is the radius of the uterus
Compression will empty the uterus of blood clots and
reduce its radius (r), thereby increasing F which occludes
the bleeding vessels
2. Obstetric Lacerations
About 20% of PPH
Excessive bleeding from episiotomy, lacerations or both
Lacerations can involve the uterus (grandmultips,
malpresentation, previous uterine surgery, oxytocin use),
cervix, vagina or vulva
Laceration of blood vessels underneath the vaginal or
vulvar epithelium cause haematomas
May become apparent only when shock occurs
2. Obstetric lacerations 2
Episiotomies may cause excessive bleeding if:
Involve arteries or large varicosities,
Too large
Delay between episiotomy and delivery
Delay between delivery and its repair
NB: persistent bright red bleeding despite a
contracted uterus, suggests a laceration or from the
episiotomy
3. Retained Placental Tissue
Retained placental tissue and membranes cause 5-10% of
PPH
Occurs in:
1. Placenta accreta
2. Manual removal of the placenta
3. Mismanagement of the 3rd stage of labour
4. Unrecognized succenturiate placenta
Ultrasound will show an echogenic uterine mass
4. Coagulation Defects
Coagulopathies in pregnancy may be acquired in several
obstetric disorders like:
1. Abruptio placenta
2. Excess thromboplastin from a retained dead foetus
3. Amniotic fluid embolism
4. Severe preeclampsia and eclampsia
5. Sepsis
4. Coagulation Defects 2
May present with:
1. Hypofibrinogenemia
2. Thrombocytopenia
3. Disseminated intravascular coagulation
Excessive transfusion may in itself induce dilutional
coagulopathy
5. Uterine inversion
Caused by wrong management of the 3rd stage, by
uncontrolled traction.
If untreated, may lead to uterine necrosis.
Requires immediate repositioning of the uterus, with the
placenta still attached to it.
Delayed cases may require hysterectomy.
Management of PPH
1. Predelivery preparation
2. Delivery and the third stage of normal labour
3. Treat every identified cause of haemorrhage
3. Evaluate any persistent bleeding
4. Manage delayed PPH
1. Predelivery preparation
Blood typed
Cross match blood for those at increased risk of PPH like
placenta praevias
Keep x-matched blood 24 hours after delivery
Large bore IV cannula in place
Transfuse severely anemic ones
The 3rd stage of labour: GATPA
1. Examine to verify 2nd foetus
2. Inject IM, 10 units of oxytocin
3. Enroll cord on forceps, wait a contraction
4. Wait for a contraction
5. Apply a controlled traction on the cord
6. Massage the uterus
7. Examine the placenta
8. Examine the genital tract
Step 1: Verify for a second baby
Step 2: Inject IM 10 units of oxytocin
Step 3: Wrap cord around forceps and
wait for a contraction
 Step 4

Wait for a contraction

Step 5: Controlled cord traction
Step 6: Massage the uterus
Step 7: Examine the placenta
Step 8:Examine the genital tract of the
woman
Repair of lacerations
Vagina and cervix repaired under good lighting and assistance
A pack placed above the episiotomy helps to keep the field
dry
Begin the repair at least 1cm above the highest extent of the
laceration in order to catch retracted vessels
Evaluation of persistent bleeding
Treatment should be aggressive, steps involve:
- Manually compress the uterus
- Obtain assistance
- Obtain blood for typing and x-match
- Rule out coagulopathy
- Begin fluid or blood replacement
- Carefully explore the uterine cavity
- Completely inspect cervix and vagina
- Insert a second IV cannula
Measures to control bleeding
I. Manual exploration of the uterus
II. Bimanual compression and massage (20-30 minutes) will
virtually control all cases of haemorrhage due to: atony,
retained products, coagulopathies and even bleeding from a
cervical tear
III. Curettage if adherent placenta fragments are felt
IV. Uterine packing (+/-)
Measures to control bleeding 2
V. Uterotonic agents:
1. Oxytocin in IV drips
2. Methylergometrine IM
3. Rectal or vaginal misoprostol
4. Injectable forms of prostaglandin F2

VI. Radiographic embolization of pelvic vessels

VII. Operative management; conservative or radical
surgery
Measures to control bleeding 3
Conservative operative management:
1. Pressure occlusion of aorta
2. Uterine artery ligation (95% effective)
3. Internal iliac artery ligation (40% effective)
4. B-lynch brace suture
Radical operative management: hysterectomy
Blood replacement very essential tool
Complications
Maternal death in 10% of postpartum haemorrhages.
Acute renal failure.
Embolism.
Sheehans syndrome.
Sepsis.
Anaemia.
Failure of lactation.
Management of delayed PPH
Almost always due to subinvolution of placental bed or
retained placental fragments
If ultrasound shows intracavitary tissue, curettage is
warranted
Uterine compression and bimanual massage will also control
such bleeding
Other causes of delayed PPH
Infection:
separation of infected retained parts.
infected C.S. wound.
infected genital tract lacerations.
infected placental site.
Fibroid polyp: necrosis and sloughing of its tip.
Subinvolution of the uterus.
Other causes of delayed PPH 2
Local gynaecological lesions: e.g. cervical ectropion or
carcinoma.
Choriocarcinoma.
Puerperal inversion of the uterus.
Oestrogen withdrawal bleeding: if oestrogen was given for
suppression of lactation.
Conclusion
PPH remains a leading cause of maternal mortality
worldwide
Active management of the third stage of labour (AMTSL /
GATPA) has been shown to be very effective in reducing
PPH
A careful evaluation to get the aetiology is paramount in the
management
Team work is always essential
References
1. Current Gynecologic and Obstetric Diagnosis and
Treatment. 9th edition, 2007
2. William Obstetrics, 22nd edition
3. www.gfmer.ch
4. www.thecochranelibrary.org
 Thank you

Merci, Danke, Njikaa, Nasom