This document discusses complications of the third stage of labor, specifically postpartum hemorrhage. It defines postpartum hemorrhage, classifies it by severity and timing, and identifies the main causes as being an atonic uterus, trauma, retained placental tissues, and coagulation disorders. The management of postpartum hemorrhage is described in stages from immediate resuscitation through bimanual compression, uterine tamponade, surgery such as ligation of arteries, and hysterectomy if needed. Specific approaches are provided for addressing atonic, traumatic, or coagulation-related causes of bleeding.
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
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
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
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
Dec in contraction n retraction of uterus uterine sinuses not compressed bleeding cont.
HELLP : Hemolysis Elevated Liver enzymes Low Platelet count
general activation of the coagulation cascade. Fibrin forms crosslinked networks in small blood vessels. leads to a microangiopathic hemolytic anemia destruction of red blood cells as if were being forced through a strainer.
Increased with malnutrition, anaemia, lack of facilities
Normal Hb > 10g/dL
Carbetocin : long acting oxytocin
Bulge- distended LUS by separated placenta
Lenghtening- no indrawing of cord
MAJOR ppH >1L . Clinical shock
N saline= crystalloid
Plsma sub= hemaccel ( colloid), urea linked gelatin to re expand vascular bed , x intrfere w cross match
DIC – as it is precursor for extrinsic clotting cascade