Post Partum hemorrhage

DR. NAZNEEN RASHID

Definitions
Blood loss : if, > 500 ml at vaginal delivery
: if, > 1000 ml at Cesarean Section
ACOG :10% reduce in hematocrit>Need for blood transfusion
Severe PPH : > 1000ml loss at vaginal delivery

• Immediate or Primary PPH: increased vaginal bleeding within first

24 hours after childbirth
• Delayed or Secondary PPH: following the first 24 hours after
childbirth upt0 6 weeks
Etiology
1.Early PPH: 2.Late PPH:
• Endometritis
• Uterine atony • Retained placental fragments
• Retained placental fragments • Disorders of coagulation
• Retained placenta
• Genital tract laceration
• Placental adherence
• Uterine inversion
Specific management of PPH
Specific management of PPH
General management of PPH:
• Shout for help and assess ABC and start resuscitation
• Massage fundus to expel blood clot
• Give 10 unit of oxytocin I/M
• I/V access with wide bore cannula rapidly infuse N/S or Hartman`s
solution with 20 unit oxytocin in 1 liter infuse in 15 min and next
1litre within 30 minutes and then regulate the rate of infusion
according to response. (pulse settle down <100/min and systolic BP
>100mmHg)
• Catheterization, initiate and encourage breast feeding
Continue….

• Assess pulse/BP/monitor blood loss/urine output until stable

• Inj. Ergometrine 02mg IM and Tab. Misoprostol 800-1000 micro gm
PR
• Send blood for Hb%, blood grouping and Rh typing and arrange blood
transfusion
• Reassure the mother and keep the family informed
Prevention of PPH by Active Management of Third Stage
of Labor (AMTSL)
• After delivery of baby palpate the uterus to make sure no other baby is present

• If no other baby is present, administer Inj. Oxytocin 10 unit IM within one minute of
delivery

• Clamp the cord by artery forceps near woman’s perineum

• Wait for uterine contraction (2-3 minutes)

• When there is uterine contraction, apply counter traction to the uterus and firm, steady
traction to the cord cautiously
Continue….
• If the placenta doesn’t descend during 30-40 seconds of CCT, STOP
CONTROLLED CORD TRACTION. Hold the cord & wait until the uterus is
well contracted again. When there is another contraction, repeat the procedure

• Immediately message the uterus after delivery of placenta. And teach the
mother how to message the uterus

• Check for completeness of placenta and membranes

• Monitor the woman at least every 15 minutes during the first 2 hours after
delivery of placenta for vital signs, uterine contraction and excessive bleeding
Examination of Placenta
Examination of placenta
• Examine the fetal and maternal sides of the placenta and membranes to ensure
they are complete. A small amount of placental tissue or membranes remaining
in the woman can prevent uterine contractions and cause PPH.
• To examine the placenta for completeness;
• Hold the placenta in the palms of the hands with the maternal side facing
upward and make sure that all lobules are present and fit together.
• Hold the cord with one hand, allowing the placenta and membranes to hang
down. Place the other hand inside the membranes, spreading your fingers to
ensure that membranes are complete and dispose of the placenta as appropriate.
Fig 12: Examining Maternal Side
THANK YOU