postpartum hemorrhage , a part of it

1. NUR AMALINA AMINUDDIN BAKI
082012100067
COMPLICATION
OF 3RD STAGE
OF LABOR

2.  Time from the birth of
the baby to the
expulsion of the
placenta and its
membrane
Placental separation
Descent to lower segment
Expulsion with membrane.
INTRODUCTION

3. IMPORTANT 3RD STAGE COMPLICATION
Postpartum
hemorrhage
Retention of
placenta
Shock
Pulmonary
embolism
Uterine inversion

4. POSTPARTUM
HEMORRHAGE

5. Vaginal delivery
500mL
Cesarean delivery
1000mL
Cesarean hysterectomy
1500mL
AVERAGE BLOOD LOSS

6.  Quantitative (WHO) :
 Amount of blood loss in excess of 500mL following birth of
baby.
 Clinical :
 Any amount of bleeding, from or into genital tract , following
birth of baby up to the end of puerperium, which adversely
affect the condition of patient, evidenced by rise in PR, and
falling BP.
 4-6% of all deliveries
DEFINITION

7. Amount of blood loss
 Minor (< 1L)
 Major (> 1L)
 Severe (> 2L)
Types
 Primary (< 24 hours)
 3rd stage hemorrhage:
before placental expulsion
 True postpartum
hemorrhage : after
placental expulsion
(common)
 Secondary/Delayed/
Late puerperal (>24
hours but within
puerperium)
CLASSIFICATION

8. PRIMARY
POSTPARTUM
HEMORRHAGE

9. Atonic
uterus
Blood
coagulopathy
Combined
(atonic uterus
+trauma)
CAUSES
Drugs
Retained
tissues
Traumatic
Tone
Thrombus
Trauma
Tissues

10.  Maternal
 Grand multipara : inadequate retraction, anemia
 Uterine malformation : septate/ bicornuate
 Uterine fibroid : imperfect mechanical retraction
 Malnutrition and anaemia: more pronounced manifestation
 Pregnancy complications
 APH
 Overdistension : imperfect retraction, large placental site
 Placenta
 Placenta : adherent, separated, retained
 Drugs
 Anesthesia : ether, halothane cause atonicity
 Augmentation of delivery by oxytocin : if not continued > 1
hour following delivery
ATONIC UTERUS (80%)

11. Labour
Prolonged labor : poor retraction, infection,
dehydration
Precipitate labor : bleeding before uterine retraction
Mismanaged 3rd stage of labor
 Too rapid delivery
 Premature attempt of placental delivery
 Kneading and fiddling with uterus
 Pulling cord
 Manual placental separation

12.  Revealed bleeding :
 Cervix, vagina, perineum
(laceration, episiotomy),
paraurethral region ,
uterus (rupture)
 Concealed bleeding :
 vulvovaginal / broad
ligament hematoma
TRAUMATIC (20%)

13.  Washout phenomenon ( decreased pro-coagulant) or increased
fibrinolytic activity
 Jaundice in pregnancy
 Abruptio placenta
 HELLP syndrome
 IUD
 Thrombocytopenic purpura
BLOOD COAGULOPATHY

14.  Combined ( atonic uterus + trauma)
 Drugs
 Tocolytic drugs, magnesium sulphate , nifedipine
 Retained tissue

15.  Visible bleeding (slow trickle)
 Rare: Concealed bleeding ( vulvo-vaginal/ broad ligament
hematoma)
 Differentiate atonic and traumatic hemorrhage as felt per
abdomen,
 Atonic : flabby uterus becomes hard on massaging
 Traumatic: well- contracted uterus
DIAGNOSIS

16.  Depend on :
 Predelivery Hb level
 Degree of pregnancy-induced hypervolemia
 Rate of blood loss
 After 20-25% loss of blood volume (class 2 hemorrhage),
appears alteration of:
 Pulse
 Blood pressure
 Pulse pressure
CLINICAL EFFECTS

17.  Major cause of maternal deaths
 Increased morbidity
 Shock, transfusion reaction, puerperal sepsis, failing lactation,
pulmonary embolism, thrombosis and thrombophlebitis.
 Late sequelae:
 Sheehan’s syndrome, diabetes insipidious
PROGNOSIS

18.  Antenatal
 Improve health of woman and keep Hb level normal
 Screening of high risk patients
 Blood grouping
 Placental localization
PREVENTION

19.  Intranatal
 Routine active management of third stage
 IOL:
 Continue oxytocin infusion for at least an hour after delivery
 CS :
 Oxytocin 5 IU slow IV/ Carbetocin 100µg
 Spontaneous separation and delivery of placenta
 Placenta and membrane examination
 Uterovaginal canal exploration
 2 hours observation after delivery
 Expert obstretic anesthetist

20. MANAGEMENT

21. 3rd stage
hemorrhage
Placental site
bleeding
Traumatic
bleeding
True PPH
Immediate Actual
Atonic Traumatic Retained
tissue
Coagulopathy
MANAGEMENT

22.  Principles:
 To empty uterus
 To replace blood
 To ensure effective hemostasis
 Steps of management :
 Placental site bleeding
 Traumatic bleeding
3RD STAGE HEMORRHAGE

23.  Palpate fundus and uterus ( place 4 fingers behind uterus and
thumb in front)
 Bleeding continues = genital tract injury
 Start crystalloid solution (normal saline/ Ringer’s solution) +
oxytocin (1L with 20 units) at 60 dpm
 Arrange for blood transfusion
 Oxytocin 10 units IM or methergin 0.2mg IV
 Catheterize bladder
 Antibiotics ( Ampicillin 2g and Metronidazole 500mg IV)
PLACENTAL SITE BLEEDING

24.  Per abdomen
 Uterus – globular,firm,ballottable.
 Increased fundal height
 Slight suprapubic bulge
 Per vaginum
 Slight gush of vaginal bleeding
 Permanent lengthening of cord
FEATURES OF PLACENTA SEPARATION

25. Evident placental
separation
Fundal pressure/
controlled cord traction
Failed twice (if oxytocin
10 units IM used)
Manual removal of
placenta
Not separated
placenta
If shock,
resuscitate
Under general
anesthesia
Manual removal
of placenta

26.  Abandoned.
 Thumb on posterior surface of the fundus uteri
 The flat of the hand on the anterior surface,
 The pressure being applied in the direction of the birth canal.
 If done properly, cause inversion of the uterus.
CREDE’S MANEUVER

27.  Uterovaginal canal is explored
 Under general anesthesia
 After placenta is expelled
 Hemostatic sutures placed on bleeding site
TRAUMATIC BLEEDING

28.  Principles:
 Simultaneous approach
 Communication
 Monitoring
 Resuscitation
 Arrest of bleeding
 Essential for all cases of major PPH
TRUE POSTPARTUM HEMORRHAGE

29.  Call for extra help
 Put 2 large bore ( 14 gauge) IV cannula
 Keep patient flat and warm
 Send blood for group, cross-match and diagnostic tests
 Ask for 2 units of blood
 Infuse rapidly 2L of normal saline/ plasma substitute
 Give oxygen by mask 10-15L/min
IMMEDIATE

30.  Start 20 units of oxytocin in 1L normal saline IV at 60 dpm
 Transfuse blood immediately
 Monitor
 Pulse
 BP
 Respiratory rate and oxymeter
 Type and amount of fluids patient had received
 Urine output
 Drugs – type, dose, time
 Central venous pressure

31.  To control fundus
 To note the feel of uterus
 Flabby = atonic uterus
 Firm = trauma
ACTUAL MANAGEMENT
Atonic Traumatic
Retained
tissues
Coagulo
pathy

32. STEP 1
 Massage uterus to make it hard and express blood clot
 Methergin 0.2 mg IV
 Injection oxytocin 20 units in 1L normal saline at 40-60 dpm
 Foley catheter – empty bladder and monitor urine output
 Examine expelled placenta and membranes
ATONIC UTERUS

33. STEP 2
 Uterus explored under GA
 Simultaneous cervix, vagina, paraurethral region inspection
 Refractory cases:
 Inj. 15 methyl PGF2α 250µg IM (deltoid muscle) every 15 mins ( max.
2mg)
OR
 Misoprostol ( PGF1) 1000µg per rectum
 If due to tocolytic drugs
 Calcium gluconate (1g IV slowly)

34.  STEP 3: BIMANUAL
COMPRESSION
 Whole hand introduced
into vagina in cone-shaped
manner after separating
labia with other hand
 Vaginal hand clenched into
a fist with back of hand
directed posteriorly and
knuckles in anterior fornix
 Other hand is placed over
abdomen behind uterus –
anteverted
 Uterus is firmly squeezed
in between

35.  Continue till tone of uterus regained – bleeding stopped if
released ( most cases)
 If bleeding continues,
 Blood coagulation disorders are suspected
 Blood transfusion is given

36.  STEP 4: UTERINE TAMPONADE
i. Tight intrauterine packing
 Under GA, 5m long, 8 cm wide gauze folded twice
(soaked in antiseptic cream) packed into fundus
while uterus is steadied by external hand
 Rest of cavity is packed – no empty space is left
 Separate pack to fill vagina
 Abdominal binder is placed
 Stimulate contraction and direct hemostatic
pressure
 Give antibiotics
 Removed after 24 hours

37. ii. Balloon tamponade
 Hydrostatic balloon catheter
with similar mechanism to
uterine packing
 Eg. Foley catheter, Bakri
balloon, Condom catheter or
Sengtaken-Blakemore tube
 Inserted into uterine cavity and
inflated with 200-500mL
normal saline for 4-6 hours
 Can avoid hysterectomy by 78%

38. STEP 5 : SURGICAL METHOD
1. Ligation of uterine arteries (ascending branch)
 At lateral border between upper and lower uterine segment
 No.1 chromic suture ia passed into myometrium 2cm medial to
artery
 75% effective in atonic hemorrhage
2. Ligation of ovarian and uterine artery anastomosis
 below ovarian ligament
 Temporary occlusion by rubber sleeved clamps at
infundibulopelvic ligament

39. 3. Ligation of ant.division of internal illiac artery
 Uni/bilateral
 Reduces distal blood flow
 Help clot formation by reducing 85% of pulse pressure
 No pelvic tissue necrosis-
 Avoid hysterectomy by 50%
4. B-Lynch suture and multiple square sutures
 work by tamponade of uterus
 80% success rate

40. 5. Angiographic arterial embolization
 Under fluoroscopy using gel foam
 > 90% success rate

41. STEP 6: HYSTERECTOMY
 Rare
 Has to be considered involving a
second consultant
 May be subtotal or total

42.  Search under good light by speculum examination
 Hemostasis by appropriate catgut sutures
 Under general anesthesia, if necessary
TRAUMATIC

43.  To identify and correct underlying pathology
 To achieve
 Platelet count > 50,000/µL
 Fibrinogen level > 100 mg/dL
 Volume replacement by crsytalloid or colloids
 Blood component therapy
 Whole blood transfusion
 Fresh frozen plasma / Cryoprecipitate- coagulation factors
 Platelet concentrates ABO and Rh specific
 Packed red blood cell- increased oxygen carrying capacity
 Recombinant activated factor VIIA- reverse DIC
COAGULOPATHY

44.  Heparin if vascular compartment is intact
 Fibrinolytic inhibitors
 Eg. EACA, Aprotinin
 PPH in abruptio placentae

45. 3rd stage
hemorrhage
Placental site
bleeding
Fundal
pressure
Controlled
cord traction
Manual
removal
Traumatic
bleeding
True PPH
Immediate Actual
Atonic
Oxytocics
Bimanual compression
Uterine tamponade
Surgery
Hysterectomy
Traumatic Retained
tissue
Coagulopathy
Volume replacement
Blood componenet
therapy
Heparin
Fibrinolytic inhibitors
CONCLUSION

46. REFERENCE