obstetrics and gynaecology

2. •Blood loss >500ml from the genital tract in the first
24 hours of child birth or >1000 ml in case of
caesarean section deliveries
Primary
postpartum
hemorrhage
• Bleeding before delivery of placenta
Third stage
hemorrhage
• Bleeding after 24 hours and upto 12 weeks
postpartum
Secondary
postpartum
hemorrhage

3. Atonic postpartum haemorrhage
Traumatic postpartum haemorrhage
Coagulopathy
Retained placenta and placental fragments
Morbidly adherent placenta
Uterine inversion

4. Most common cause.
Bleeding occurs because the blood vessels have not
been obliterated by contraction and retraction of
uterine fibres.

5.  Grand multiparity
 Overdistended uterus due to multiple pregnancy, hydramnios or macrosomia
 Previous history
 Rapid and prolonged labour
 Antepartum haemorrhage
 Oxytocin induced or augmented labour
 Chorioamnionitis
 Uterine abnormalities or fibroids
 Retained placental fragments
 General anaesthesia(especially halothane)
 Mismanagement of third stage of labour

6. Predisposing factors
 Instrumental delivery
 Vaginal birth after caesarean section
 Face to pubis delivery
 Precipitate labour
 Macrosomia

7. Predisposing factors
 Abruption
 Sepsis
 Intrauterine death
 Severe preeclampsia with HELLP syndrome
 Amniotic fluid embolism

8.  Correction of anemia
 It should be anticipated in all high
risk patients and institutional
delivery must be arranged
 Blood should be arranged
 Preeclampsia and anemic patients –
replacement
 Partogram [avoid prolonged labour]
 Correction of Dehydration
 Prolonged postpartum oxytocin
infusion
 AMTSL –uterine massage,
prophylactic oxytocics before delivery
of placenta by controlled cord
traction. Attempts to express
placenta before separation must be
avoided
 After delivery completeness of
placenta must be looked for
 Placenta previa
 Train the ward staff
 Wait for spontaneous placental
separation during caesarean section

9. Fundal massage is the simplest and immediate treatment for atonic haemorrhage
and should be performed simultaneously with resuscitation and administration of
uterotonic drugs.
General measures
 Resuscitative measures
 Investigations
 Monitoring
 Confirm the cause of postpartum haemorrhage
Medical methods
Mechanical methods
Surgical methods
Radiological arterial embolisation

10.  Fluid replacement
AIM : Replace 2-3 times the estimated blood loss
Two intravenous infusions with large 14 gauge cannulae are started.
Crystalloids (normal saline or ringer lactate) are rapidly infused at the rate of 1L in
15-20 min.
Amount of crystalloid required =3 x volume of blood loss
Upto 2L of crystalloid or 1-2 L of colloid can be given.
CVP line can be introduced. After resuscitation the CVP should rise to between 10
and 12 mm of Hg

11.  Blood component therapy
 1 unit of packed cell – Hb by 1gm/dl
 If coagulation defects + fresh frozen plasma,
platelet concentrates, cryoprecipitate.
[for every 6 unit of red cells, 4 units of fresh frozen plasma]

12. Fresh frozen
plasma
• Restore procoagulant
activity by about 10% ;
fibrinogen by 25 mg/dl.
Cryoprecipitate
• FactorVIII, fibrinogen
and von willebrand
factor.
• Restore fibrinogen by
100mg/dl.
Platelet
concentrate
• Indication : platelet
<50,000/L
• Restore platelet count
by 20,000/L

13.  Oxygen delivery : at the rate of 10-15 L/min(mask or nasal cannula)
 Others:
 Elevation of leg
 If unconscious turn to one side to minimise aspiration in case of
vomiting.
 Keep the patient warm – to avoid hypothermia which in turn
would exacerbate poor peripheral circulation.

14.  Performed every 4th hourly
 lab tests: Hb, HCT, blood grouping ,cross matching, platelet count, fibrinogen
assay,partial thromboplastin time,prothrombin time and measurement of fibrin
degradation products, electrolytes, urea and creatinine.
 Bedside tests :
 clotting time: clot formed in <10 min fibrinogen >100mg /dl
 At the end of hour, good clot retraction normal platelet function
 Fragility/instability of clot fibrinolysis (normally stable for 24 hrs)

15.  Temperature every 15 min
 Pulse
 Blood pressure
 Heart rate by ECG monitor
 Oxygen saturation by pulse oximetry
 Central venous pressure line(to check adequacy of fluid replacement)
 Hourly urine output
 Fluids and drugs given

16.  Confirm atonicity and rule out other causes
 Look for genital injuries
 Signs of separation of placenta are looked for
 If not separated, but bleeding is excessive, manual removal of placenta under
general anaesthesia and oxytocics.
 Retained fragments are removed if any using sponge holding forceps.
 Look out for coagulopathy
 Inversion must be corrected if present