4. 1. Quantitative – It is realted to amount of
blood loss in excess of 500ml following birth
of baby
2. Clinical- any amount of bleeding from or
into the genital tract following birth of the
baby up to the end of puerperium,which
adversly affects the general condition of the
patient evidenced by rise in pulse rate and
falling BP is called PPH.
5. Minor <1L
Major >1L
Sever >2L
Incidence: 4-6% of all deliveries.
Types: Primary
Secondary
6. Primary: Hemorrhage occurs within 24
hours following the birth of the baby.
In the majority, hemorrhage occurs within
two hours following delivery.
Two types:
Third stage hemorrhage—Bleeding occurs
before expulsion of placenta.
True postpartum hemorrhage —Bleeding
occurs subsequent to expulsion of
placenta .
Secondary: Hemorrhage occurs beyond 24
hours and within puerperium, also called
delayed or late puerperal hemorrhage.
7. 4Ts
Tone: atonicity of uterus
grand multipara
Over distension of uterus
Malnutrition and anemia
APH
Prolonged labor
Malformation of uterus
Uterine fibroid
Precipitate labor
Placenta acreta placenta percreta
9. Diagnosis:
State of uterus, as felt per abdomen, gives
reliable clue as regards the cause of bleeding.
In traumatic hemorrhage: uterus is well
contracted.
In atonic hemorrhage: uterus is flabby
becomes hard on massaging.
both the atonic and traumatic cause may
coexist.
10. Prevention
Antenatal:
Improvement of the health status of the
woman .
High-risk patients are to be screened and
delivered in a well-equipped hospital.
Blood grouping should be done .
Placental localization
Women with morbid adherent placenta are
should be delivered by a senior obstetrician
11. Intranatal:
Active management of the third stage labor.
Cases with induced or augmented labor,( oxytocin, the
infusion should be continued for at least one hour after the
delivery)
Women delivered by cesarean section (oxytocin 5 IU slow
IV is to be given to reduce blood loss. Carbetocin 100 µg is
very useful to prevent PPH)
Exploration of the uterovaginal canal .
Expert obstetric anesthetist is needed .
During cesarean section spontaneous separation and
delivery of the placenta reduces blood loss (30%).
Examination of the placenta and membranes should be a
routine to detect at the earliest any missing part.
12. Management of third stage bleeding
principles of management :
To empty the uterus
To replace the blood.
To ensure effective hemostasis
STEPS OF MANAGEMENT:
Placental site bleeding
Traumatic bleeding
13. Placental site bleeding
To palpate the fundus and massage the uterus to
make it hard.
To start crystalloid solution (Normal saline or
Ringer’s solution) with oxytocin (1 L with 20 units)
at 60 drops per minute and to arrange for blood
transfusion if necessary.
Oxytocin 10 units IM or methergine 0.2 mg IV.
Carbetocin, 100 µg as effective as oxytocin
infusion.
To catheterize the bladder.
Antibiotics (Ampicillin 2 g and Metronidazole 500
mg IV
14. Traumatic bleeding
uterovaginal canal is to be explored under
general anesthesia after the placenta is
expelled and hemostatic sutures are placed
on the offending sites
15. Management of true PPH
PRINCIPLES: Simultaneous approach
1.Communication 2. Resuscitation
3.Monitoring 4. Arrest of bleeding
MANAGEMENT
Call for extra help—involve the obstetric registrar (senior
staff) on call.
Put in two large bore (14-gauge) intravenous cannulas.
Keep patient flat and warm.
Send blood for full blood count, group, cross matching,
diagnostic tests (RFT, LFT), coagulation screen including
fibrinogen and ask for 2 units (at least) of blood
17. One midwife/rotating houseman should be
assigned to monitor the following—(i) Pulse
(ii) Blood pressure (iii) Temperature (iv) Respiratory
rate and oximeter (v) Type and amount of fluids
(blood, blood products) the patient has received (vi)
Urine output (continuous catheterization) (vii)
Drugs-type, dose and time (viii) Central venous
pressure (when sited
18. Management of true PPH
Control the fundus and note the feel of uterus
ATONIC UTERUS
Step 1:
message the uterus
Methergine 0.2mg IV
Oxytocin drip
Examine the expelled placenta membranes
Step 2:
Uterus is explored under general anesthesia
Injection 15 methyl PGF2α 250 µg IM in the
deltoid muscle every 15 min (up to max of 2 mg).
Misoprostol (PGE1) 1000 µg per rectum
When uterine atony is due to tocolytic drugs,
calcium gluconate (1 g IV slowly)
19. Step 3: Uterine massage and bimanual
compression
26. Causes
(1) Retained bits of cotyledon or membranes
(2) Infection and separation of slough over a
deep cervicovaginal laceration,
(3) Endometritis and subinvolution of the
placental site—due to delayed healing
process,
(4) Secondary hemorrhage from cesarean
section wound usually occur between 10–14
days.
(a) separation of slough exposing a bleeding
vessel or
(b) from granulation tissue,
27. (5) Withdrawal bleeding following estrogen
therapy for suppression of lactation,
6) Other rare causes are:
chorionepithelioma—occurs usually beyond 4
weeks of delivery
carcinoma cervix
placental polyp
infected fibroid or fibroid polyp
puerperal inversion of uterus
28. Diagnosis
bleeding is bright red and of varying amount.
Rarely it may be brisk.
Varying degree of anemia and evidences of
sepsis are present.
Internal examination reveals evidences of
sepsis, subinvolution of the uterus and often a
patulous cervical os.
Ultrasonography is useful in detecting the
bits of placenta inside the uterine cavity.
29. Management
Principles:
To assess the amount of blood loss and to
replace it (blood transfusion).
To find out the cause and to take appropriate
steps to rectify it.
Supportive therapy: (1) Blood transfusion,
(2) administer methergine 0.2 mg IM, if the
bleeding is uterine in origin,
(3) administer antibiotics (clindamycin and
metronidazole) as a routine.
Conservative: If the bleeding is slight and no
apparent cause is detected, a careful watch for a
period of 24 hours or so is done in the hospital.
30. ACTIVE TREATMENT
Retained bits
explore uterus under general anesthesia
Methergine 0.2mg IM
Bleeding from cervicovaginal canal uterus
Hemostatic stures
Hemorrhage following cesarean
laproptomy
31.
32.
33. DEFINITION
The placenta is said to be retained when it is
not expelled out even 30 minutes after the
birth of the baby (WHO 15 minutes).
CAUSES: There are three phases involved in
the normal expulsion of placenta
(1) Separation through the spongy layer of
the decidua
(2) Descent into the lower segment and
vagina
(3) Finally its expulsion to outside.
34. Interference in any of these physiological
processes, results in its retention.
Placenta completely separated but retained is
due to poor voluntary expulsive eff orts.
Simple adherent placenta
Morbid adherent placenta
Incarcerated placenta
35. DIAGNISIS
diagnosis of retained placenta is made by an
arbitrary time (15 minutes) spent following
delivery of the baby.
Features of placental separation are
assessed
The hourglass contraction or the nature of
adherent placenta (simple or morbid) can
only be diagnosed during manual removal.
36. DANGERS
(1) Hemorrhage
(2) Shock is due to—(a) blood loss, (b) at
times unrelated to blood loss, especially when
retained more than one hour and (c) frequent
attempts of abdominal manipulation to
express the placenta out
(3) Puerperal sepsis
(4) Risk of its recurrence in next pregnancy.
37. MANAGEMENT
PERIOD OF WATCHFUL EXPECTANCY
During the period of arbitrary time limit of
half an hour, the patient is to be watched
carefully for evidence of any bleeding,
revealed or concealed and to note the signs
of separation of placenta. The bladder should
be emptied using a rubber catheter.
Any bleeding during the period should be
managed as outlined in third stage bleeding.
RETAINED PLACENTA:
Separated
Unseparated
Complicated
38. Placenta is separated and retained
To express the placenta out by controlled
cord traction.
Unseparated retained placenta
Manual removal of placenta is to be done
under general anesthesia as described earlier
39.
40. DEFINITION
Placenta accreta is an extremely rare form in
which the placenta is directly anchored to
the myometrium partially or completely
without any intervening decidua
41. RISK FACTORS
Placenta previa
Prior cesarean delivery
Prior uterine surgery
DIAGNOSIS
During manual removal
Ultrasound, color dopler, MRI
(i) loss of normal hypoechoic retroplacental myometrial zone
(ii) thinning and disruption of the uterine serosa-bladder interface and
focal exophytic masses invading the bladder.
Color flow Doppler study shows hypervascularity of serosa bladder
interface.
MRI reveals detour vessels and dark intraplacental bands on T2-
weighted imaging.
Unexplained rise of maternal serum αFP is observed with placenta
accreta
42. PATHOLOGICAL CONFIRMATION
absence of decidua basalis
absence of Nitabuch’s fibrinoid layer and
varying degree of penetration of the villi into
the muscle bundles (increta) or up to the
serosal layer (percreta).
RISKS
hemorrhage, shock, infection ,inversion of
the uterus.
43. MANAGEMENT
Partial placenta accreta
Remove placental tissue
Oxytocin and intra uterine plugning
Hysterectomy
Total placenta accreta
Hysterectomy
Rare cases
Placenta accreta invading bladder
Hysterectomy and partial cystectomy
44.
45. It is an extremely rare but a life-threatening
complication in third stage in which the
uterus is turned inside out partially or
completely
46. incidence: 1 in 20,000 deliveries.
VARIETIES
First degree: dimpling of the fundus, which
still remains above the level of internal os.
Second degree:fundus passes through the
cervix but lies inside the vagina.
Third degree (complete):endometrium with or
without the attached placenta is visible
outside the vulva. cervix and part of the
vagina may also be involved in the process .
47. ETIOLOGY
Spontaneous :
Localised atony
Short cord
Placenta accreta
IATROGENIC
Pulling of cord when uterus is atonic
Fundal pressure: faulty technique in manual
removal
48. RISK FACTORS
uterine oveR enlargement
prolonged labor
fetal macrosomia
uterine malformations
morbid adherent placenta
short umbilical cord
tocolysis and manual removal of placenta.
common in women with collagen disease like
Ehler-Danlos syndrome
49. DANGERS
Shock
Hemorrhage
Pulmonary embolism
If untreated: infection uterine sloughing
SYMPTOMS
Acute lower abdomen pain with bearing
down sensation
50. SIGNS
Varying degree of shock
Abdominal examination
Cupping or dimpling of the fundal surface
Bimanual examination: pear-shaped mass
protrudes outside the vulva with the broad
end pointing downward and looking reddish
purple
(c) Sonography : confirm the diagnosis
51. MANAGEMENT
Call for extra help
Before the shock develops: urgent manual
replacement even without anesthesia, if it is
not readily available, is the essence of
treatment for a skilled accoucheur
52. PRINCIPAL STEPS
Patient is under general anesthesia.
Replace that part first, which is inverted last with the
placenta attached to the uterus by steady firm
pressure exerted by the fingers.
Apply counter support by the other hand placed on
the abdomen.
After replacement, the hand should remain inside
the uterus until the uterus becomes contracted by
parenteral oxytocin or PGF2α.
The placenta is to be removed manually only after
the uterus becomes contracted. The placenta may
however be removed prior to replacement
(a) to reduce the bulk which facilitates replacement or
(b) if partially separated to minimize the blood loss,
Usual treatment of shock including blood transfusion
should be arranged simultaneously.
