TRAUMATIC PPH

• The incidence of tr.pph is 20%

• Trauma to the genital tract usually occurs
following operative delivery.
• Blood loss from episiotomy wound
• Blood loss in cesarean section- 800 to
1000 ml.
• Trauma usually involves cervix, vagina,
perineum, paraurethral region and rarely
rupture of uterus.
• Concealed – vulvovaginal or broad
ligament hematoma
 Prevention
• Good perinial support during second
stage.
• Episiotomy
• Utero vaginal canal is to be explored after
placenta is expelled and hemostatic
sutures placed against offending sites.
• Vulva : Lacerations of vulval skin
posteriorly and paraurethral tear on inner
aspect of labia minora are common sites –
should be repaired by interrupted catgut
sutures after introduction of rubber
catheter into bladder.
 Perineum
• Causes :
– Overstretching due to large baby, face to
pubis or face delivery, outlet contraction with
narrow pubic arch, shoulder delivery and
forceps delivery.
– Rapid stretching of the perineum due to rapid
delivery of head during uterine contraction,
ppt labour and delivery of aftercoming head in
breech.
– Inelastic perineum as in rigid perineum in
elderly primi, scar, previous operations.
• Degrees :
– First degree – lacerations of remnants of
hymen, fourchette, lower part of vagina but
perineal body remains intact.
– Second degree – lacerations of post vaginal
wall and perineal body excluding anal
sphincter.
– Third degree – posterior vaginal wall and
perineal body tear including anal sphincter
complex without involvement of anal canal or
rectum.

– Fourth degree – involving anal sphincter

complex and rectal mucosa.
• Management :
– Recent tear should be repaired immediately. In case of delay
beyond 24hrs repair withheld antibiotics should be started.
Complete tear repaired after 3 months.
– Incomplete :
• First degree : Continuous locked or interrupted sutures
• Second degree : interrupted sutures with catgut including
torn ends of lev.ani
– Complete :
• Third degree : Torn ends of ext. anal sph. Identified and
sutured by interrupted sutures. Levator ani aproximated
infront of rectum vagina sup. Muscles of perineum.
• Fourth degree : rectal wall sutured by two layers of inverted
interrupted catgut including mucosa.
 Post op care
• Iv fluids for 48hrs
• Clear fluids for next 24hrs
• Soft low residue diet for 48hrs
• Regular diet after that
• Laxative not used for 4-5 days
• Proph. antibiotics should be given
 Vagina
• Tears are repaired by interrupted or
continuous sutures using chromic catgut
number O.
• Colporrhexis – rupture of vault of vagina.
• Primary - only vault involved.
• Secondary – with cervical tear.
 Cervix
• Commonest cause of traumatic pph
• Causes :
– Iatrogenic – attempted forceps delivery or
breech extraction through incompletely dilated
cervix.
– Rigid cervix.
– Strong uterine contractions.
– Detachment.
– Manual dilatation of cx
• Types :
– Unilateral :
• Dextrorotation of uterus
• Lot
– Lateral
– Stellate multiple tears extending radially from
ext. os
– Annular detachment
• Diagnosis :
– Excessive bleeding immediately following
delivery in presence of hard and contracted
uterus.
• Complications :
– Early –
• 1.Deep cervical tears involving major vessels.
• 2.Broad ligament hematoma.
• 3.Pelvic hematoma
• 4.Pelvic cellulitis
• 5.Thrombophlebitis.
• 6.Rupture uterus due to upward extension
 – Late –
• 1.Ectropion
• 2.Cervical incompetence

• Treatment :
– Repair under GA.
 Pelvic Hematoma
• Collection of blood anywhere in the area
between pelvic peritoneum and perineal
skin is called pelvic hematoma.
• Types –
– 1. Infra levator hematoma.
– 2. Supra levator hematoma.
 ILH
• Etiology
– 1.Improper hemostasis during repair of tears
or epi wound
– 2.Failure to take precaution while suturing
apex of tear.
– 3.Rupture of para vaginal venous plexous
following instrumental delivery
• Symptoms :
– Appear 12-48hrs later
– Collection of blood limited by lev. Ani above
but laterally may extend to fill ischiorectal
fossa
– Persistent,severe pain on perineal region
– Rectal tenesmus
• Management :
– Small hematoma managed conservatively
– Large – incised longitudinally evacuation of
clotted blood bleeding points ligated gap
closed in layers
 SLH
• Causes :
• 1.Extension of cervical laceration
• 2.Lus rupture
• 3.Spontaneous rupture of para vaginal venous
plexus.
• Diagnosis :
• Unexplained shock with features of internal
hemorrhage following delivery.
• Vaginal examination reveals occlusion of vaginal
canal by a bulge or boggy swelling.
 Broad ligament hematoma
• Causes :
– Upper vaginal, cervical or uterine tears may lead
• Clinical symptoms:
– Hypovolimia, shock
– Swelling on one side of uterus increasing over period
of days may reach upto lower pole of kidney or upto
diaphragm
– Uterus is felt seperately and deviated to opposite side
– Fever ilius and uni lateral leg edima
– Upper vaginal, cervical or uterine tears may lead
 Rupture of uterus

• Dissolution in the continuity of uterine wall

antime beyond 28 weeks of pregnancy is
called rupture of the uterus.
 causes
• Spontaneous : usually complete involves upper
segment
– During pregnancy
• Previous damage thereby weakening of uterine walls
following dnc or manual removal of placenta
• grand multi para
• Conganital malformation of uterus(bicornuate)
• Couvelaire uterus
– During labour :
• Obsturcted labour
• Grand multi para
• Iatrogenic :
– During pregnancy :
• Injudicious administration of oxytocin.
• Use of PG for induction of abortion or labour.
• Forcible external version under GA.
• Fall or blow on abdomen.

– During labour :
• Internal podalic version.
• Distructive operation.
• Manual removal of placenta.
• Application of forceps or breech extraction through
incompletely dilated cervix.
• Scar rupture :
– During pregnancy :
• Weekening of scar due to implantation of placenta
over scar
• Classical or hysterotomy scar
– During labour :
• Classical or hysterotomy scar
 Pathology
• Types :
– Complete
• Peritoneal coat involved usually occurs following
disruption of scar in upper segment
– Incomplete
• Peritoneal coat not involved results from rupture of
lower segment
– Rupture over previous scar is almost always
located at the site of scar
• Dehiscence :
– Disruption of part of scar and not the entire length
– Fetal membranes remain intact
– Bleeding is almost nil or minimal
• Rupture includes
– Disruption of the entire length of scar
– Rupture of the membranes with
– Varying amount of bleeding from the margin or from
its extension
– In incomplete rupture both fetus and placenta remain
inside uterine cavity
– In complete rupture fetus with or without placenta
escapes out of uterus
 Diagnosis
• During pregnancy :
– Scar rupture :
• Classical or hysterotomy – dull abdominal pain
over scar with slight vaginal bleeding varying
degrees of tenderness on uterine palpation FHS
may be irregular or absent sense of something
giving way accompanied by acute abdominal pain
and collapse
• Spontaneuos :
– rupture usually confined to high parous women onset
usually acute with acute pain abdomen with fainting
attacks and may collapse. Features of shock acute
tenderness on abdominal examination, palpation of
superficial fetal parts, if rupture is complete and
absence of FHS
• Iatrogenic :
– Acute pain abdomen, slight vaginal bleeding, rapid
pulse and tender uterus
– rupture usually confined to high parous women onset
usually acute with acute pain abdomen with fainting
attacks and may collapse. Features of shock acute
tenderness on abdominal examination, palpation of
superficial fetal parts, if rupture is complete and
absence of FHS
• During Labour :
– Scar rupture :
• Classical or hysterotomy
• Lower segment scar rupture – onset insidious. There is no
classical feature of LS scar rupture hence called silent
rupture.
– Spontaneous obstructive rupture :
• Usually in multi para.
• Pain becomes severe, comes at quick intervals may be
continuous confined to supra pubic region. The patient is
dehydrated and exhausted. Evidence of fetal distress or FSH
may be absent on P/V presenting part is found jammed in
pelvis and vagina becomes dry and edematous.
• Sense of something giving way, constant pain is changed to
dull aching pain with cessation of uterine contractions
• P/A reveals superficial fetal parts, absence of FHS, absence
of uterine contoure, two separate swellings,one contracted
uterus and other fetal ovoid.
• Spontaneous non obstructive rupture:
– Usually in high parus. Patient at height of
uterine contraction is suddenly seized with
agonizing worsting pain followed by relief with
cessation of uterine contraction
– Presence of shock, evidence of interanl
hemmorage, tenderness over uterus varying
amoutn of vaginal bleeding
• Iatrogenic :
– Sudden deterioration of general condition of
patient following instrumental delivery
 Prophylaxis
• At risk mothers should have hospital delivery,
these are a)contracted pelvis, previous CS,
hysterotomy or myomectomy b)uncorrected
transverse lie c)multiparity with pendulous
abdomen d)grand multi parity
• GA not to be given in external version
• Undue delay in progress of labour in multipara
should be weaved with caution
• Judicious selection of cases with previous
history of CS for vaginal delivery
• Avoiding forceps delivery or breech through
incompletely dilated cervix
 Treatment
• Resuscitation
• Laparotomy
– Hysterectomy : Indicated in spontaneous
obstructive rupture
– Repair : applicable to scar rupture where
margins are clear
– Repair and steralization