The document discusses the management of post-partum haemorrhage (PPH). It defines PPH as blood loss greater than 1000 ml within 24 hours of birth. The main causes of PPH are uterine atony (70%), trauma (20%), retained tissue (10%), and coagulopathy (1%). Active management of the third stage of labour (AMTSL) including uterotonics, controlled cord traction, and uterine massage is recommended for prevention. For treatment, a haemostasis algorithm is followed involving assessment of blood loss, establishing etiology, massaging the uterus, administering oxytocics, and potential surgical interventions if needed. Urgent resuscitation and monitoring of vital signs is crucial for

1. MANAGEMENT OF
POST-PARTUM HAEMORRHAGE
MODERATOR
DR SEEMA
UNIT 2

2. INTRODUCTION
• PPH is the most common cause of maternal
death worldwide.
• Responsible for half of all postpartum deaths in
developing countries.
• ACOG defines PPH as-
 Cumulative blood loss > or = 1000 ml
Or
 Blood loss accompanied by signs or symptoms of
hypovolumia
 Within 24 hrs of birth process
 including intrapartum loss
 regardless of route of delivery.

3. DEFINITIONS
• Primary PPH- occur in the first 24 hours following
delivery.
• Secondary PPH- occur between 24 hours and 12 weeks
postpartum.
• Minor (500 -1000 ml)
• Moderate (1000 -2000 ml) and
• Severe (more than 2000 ml)
• Massive haemorrhage is variably defined as blood loss
from uterus or genital tract >1500 ml / a decrease in
haemoglobin of >4 gm/dl / acute loss requiring
transfusion of >4 units of packed cell transfusion / any
haemorrhage associated with haemodynamic
instability.

4. CAUSES
4 “T”s:
• Tone: uterine atony (70%), distended bladder.
• Trauma: (20%) uterine, cervical, or vaginal
injury.
• Tissue: retained placenta or clots.(10%)
• Thrombin: pre-existing or acquired
coagulopathy.(1%)

5. The most common and important cause of PPH is
uterine atony. Myometrial blood vessels pass between
the muscle cells of the uterus; the primary mechanism
of immediate hemostasis following delivery is
myometrial contraction causing occlusion of uterine
blood vessels—“living ligatures” of the uterus

6. CAUSES
Primary PPH-
1) Uterine atony
2) Laceration
3) Retained placenta
4) Abnornally adherent placenta (Accreta/Percreta)
5) Defects of coagulation (eg. DIC)
6) Uterine inversion
Secondary PPH-
1) Subinvolution of placental site
2) Retained products of conception
3) Infection
4) Inherited coagulation defects (eg. Factor deficiency as von
Willebrand disease)

7. RISK FACTORS
ANTEPARTUM RISK FACTORS-
1) Grand Multiparity
2) Previous PPH
3) Age > 40 yrs
4) Obesity
5) Previous uterine surgery
6) Malnutrition/ anemia
7) Overdistended uterus (large
baby, polyhydramnios, multiple
gestation)
8) Antepartum haemorrhage
9) Uterine malformations
10) Uterine fibroids
11) Amnionitis
12) Use of drugs (MgSO4, Nifedipin,
anticoagulants)
13) Coagulation disorders
(Congenital/ acquired)
INTRAPARTUM RISK FACTORS-
1) Prolonged labor
2) Precipitate labor
3) Morbidly adherent placenta
4) Retained placenta/ Placenta
succenturiata
5) Abnormal uterine
contractions
6) Premature attempt to deliver
placenta
7) Operative delivery
8) Uterine inversion
9) Prolonged use of oxytocin

8. RISK ASSESSMENT TOOL
LOW RISK MODERATE
RISK
HIGH RISK
• SINGLETON
PREGNANCY
• < 4 PREVIOUS
DELIVERIES
• UNSCARRED UTERUS
• ABSENCE OF HISTORY
OF PPH
• PRIOR CESAREAN OR
UTERINE SURGERY
• >4 PREVIOUS
DELIVERIES
• MULTIPLE GESTATION
• LARGE UTERINE
FIBROIDS
• CHORIOAMNIONITIS
• MgSO4 USE
• PROLONGED USE OF
OXYTOCIN
• PREVIA, ACCRETA,
INCRETA, PERCRETA
• HCT<30
• BLEEDING AT
ADMISSION
• KNOWN COAGULATION
DEFECT
• H/O PPH
•ABNORMAL VITAL
SIGNS (TACHYCARDIA
AND HYPOTENSION)

9. ASSESSMENT OF BLOOD LOSS
Methods such as -
1) Visual estimation- most common method of quantifying
blood loss worldwide; however, this method
underestimates the blood loss.
2) Blood collection drapes for vaginal deliveries
3) Weighing of soaked swabs
4) Active periodic estimation, a written and pictorial guide.
5) The gold standard for blood loss estimation -,
photospectrometry or colorimetric measurement of
alkaline hematin, is impractical for many clinical settings.
6) Viscoelastic test like, Thromboelastography (TEG) and
Thromboelastometry (ROTEM) can test whole blood
coagulation, clot strength, stability and lysis with a
particular reference range

11. CALIBERATED BLOOD DRAPE

12. BLOOD COLLECTION MAT

13. Calculation of Maternal Total Blood Volume
• Blood volume depends on the body weight. Approximate
blood volume (in liters) equals body weight in kilograms
divided by 12.
• Non-pregnant blood volume:
{[Height (inches) × 50] + [Weight (pounds) × 25]}/2
= Blood volume (ml)
Pregnancy blood volume:
• Average increase is 30 to 60 percent of calculated
nonpregnant volume
• Increases across gestational age and plateaus at
approximately 34 weeks
• Usually larger with low normal-range hematocrit (∼30) and
smaller with high normal-range hematocrit (∼40)
• Average increase is 40 to 80 percent with multifetal
gestation
• Average increase is less with preeclampsia—volumes vary
inversely with severity

15. PREVENTION OF PPH
Active management of the third stage of
labor (AMTSL)
• Active management of the third stage of labor by
all skilled birth attendants reduces the incidence
of PPH, the quantity of blood loss, and the need
for blood transfusion.
• The usual components of AMTSL include:
 Administration of oxytocin
Late cord clamping and Controlled cord traction.
Uterine massage after delivery of the placenta.

16. Comparison of expectant (physiologic) versus AMTSL
Physiologic (expectant)
management
Active management
Uterotonics Uterotonic is not given before the
placenta delivered
Uterotonic is given within one
minute of the baby's birth
(after ruling out the presence
of a second baby)
Signs of
placental
separation
Wait for signs of separation:
1) Gush of blood
2) Lengthening of cord
3) Uterus becomes rounder and
smaller as the placenta descends
Do not wait for signs of
placental separation. Instead:
palpate
the uterus for a contraction
Wait for the uterus to contract
Apply CCT with counter
traction
Delivery of
the placenta
Placenta delivered by gravity
assisted by maternal effort
Placenta delivered by CCT
while supporting and
stabilizing
the uterus by applying counter
traction

17. Uterine
massage
Massage the uterus after the
placenta is delivered
Massage the uterus after
the placenta is delivered
Advantages Does not interfere with normal labor
process
Does not require special
drugs/supplies
May be appropriate when immediate
care is needed for the baby (such as
resuscitation) and no trained
assistant is available
May not require a birth attendant
with injection skills
Decreases length of third
stage
Decrease likelihood of
prolonged third stage
Decreases average blood
loss
Decreases the number of
PPH cases
Decreases need for blood
transfusion
Disadvant-
ages
Length of third stage is longer
compared to AMTSL
Requires uterotonic and
items needed for injection
safety

18. AMTSL
Administration of uterotonics-
(A) Oxytocin-
1) preferred uterotonic.
2) stimulates the smooth muscle tissue of the upper segment of the
uterus—causing it to contract rhythmically, constricting blood
vessels, and decreasing blood flow through the uterus.
3) For a sustained effect, IV infusion is preferred because it provides
a steady flow of the drug. Uterine response subsides within 1 hour
of cessation of IV administration.
4) Dose- 10 IU I/M or 5 IU slow I/V push within 1 min of delivery.
5) Side effect- Prolonged use can cause water intoxication. IV push
dosing may cause hypotension.
6) preferred storage of oxytocin is refrigeration but it may be stored
at temperatures up to 30 °C for up to 3 months without significant
loss of potency.
7) In women with major cardiovascular disorders low-dose oxytocin
infusion is recommended as a safer alternative.

19. Second line uterotonics for prophylaxis-
A) Ergot derivatives-
1. Include methylergonovine (Methergine) and ergonovine. Only
methylergonovine is currently manufactured in the United States.
2. rapidly stimulate tetanic uterine contractions and act for
approximately 60-120 minutes.
3. 0.2 mg of either drug given I/M or slow I/V within 1 min of
delivery.
4. C/I- Pre-eclampsia, eclampsia, cardiac disease, concomitant use of
protease inhibitors given HIV infection. as Intravenous use may
cause dangerous hypertension.
5. superior therapeutic effects of ergot derivatives compared with
oxytocin, but more incidence of retained placenta.
6. Side effect- nausea, vomiting,
7. SYNTOMETRINE- Fixed dose combination of Oxytocin 5 IU and
Ergometrine 0.5 mg.
B) Misoprostol- Prostaglandin E1
- If oxytocin is not available or can not be used safely.
- 600 mcg orally within 1 min of delivery

20. Other Uterotonics
A) Carboprost - is the 15-methyl derivative of prostaglandin F2α.
• Dose - 250 μg (0.25 mg) I/M.
• can be repeated if necessary at 15- to 90-minute intervals up to a
maximum of eight doses.
• Side effects - diarrhea, hypertension, vomiting, fever, flushing, and
tachycardia.
• C/I- asthmatics and suspected amniotic fluid embolism as it
causes pulmonary airway and vascular constriction, occasionally
severe hypertension when given with preeclampsia.
B) Dinoprostone—Prostaglandin E2
• Dose- 20-mg suppository per rectum or per vaginum every 2 hours.
• Side effect- diarrhea, which is problematic for the rectal route,
whereas vigorous vaginal bleeding may preclude its use per
vaginum.
C) Sulprostone - Intravenous prostaglandin E2— used in Europe, but
it is not available in India.
D) Carbetocin- Carbetocin is a longer-acting oxytocin derivative.
• It is not currently recommended for routine use because it is
relatively expensive.

21. Immediately following the birth of the
placenta
The birth attendant should -
• Monitor the mother's vital signs every 5–10 minutes
during the first 30 minutes, then every 15 minutes for
the next 30 minutes and then every 30 minutes for the
next 2 hours.
◆ Blood pressure, pulse, level of the uterine fundus.
◆ Massages the uterus, look for bleeding, and make
sure the uterus is contracted (the uterus will be found
in the area around the navel and should feel firm to the
touch).
• Observe the infant's color, respiration, and heart rate
every 15 minutes for the first 2 hours.
• Examine the placenta for completeness.

22. WHO Recommendations for Active Management of the Third
Stage of Labour (AMTSL), 2012
• The use of uterotonics for the prevention of postpartum
haemorrhage (PPH) during the third stage of labour is
recommended for all births.
• Oxytocin (10 IU, IV/IM) is the recommended uterotonic drug for the
prevention of PPH.
• In settings where skilled birth attendants are available, controlled
cord traction (CCT) is recommended for vaginal births if the care
provider and the parturient woman regard a small reduction in
blood loss and a small reduction in the duration of the third stage of
labour as important.
• In settings where skilled birth attendants are unavailable, CCT is not
recommended.
• Sustained uterine massage is not recommended as an intervention
to prevent PPH in women who have received prophylactic oxytocin.
• Postpartum abdominal uterine tonus assessment for early
identification of uterine atony is recommended for all women.
• CCT is the recommended method for removal of the placenta in
caesarean section.

23. • Oxygen 10-15 liters/min, intubate if necessary
• Two large bore IV canulae (no. 14 or 16)
• Draw 22ml of blood
2ml EDTA vial – CBC
5ml citrate vial – coagulation profile
10ml (5ml EDTA, 5ml plain) – blood & blood products
5ml plain vial – KFT, LFT
• Start NS or RL, infuse 2 liter rapid
• Catheterize
PPH tray should contain all of these items

24. MANAGEMENT

25. PPH Management
The Haemostasis Algorithm
General medical management
• H – Ask for help
• A – Assess (vital parameters, blood loss) & resuscitate
• E – Establish etiology, ensure availability of blood
• M – Massage the uterus
• O – Oxytocics
Varatharajan L. Int J Obstet Gynecol, 2011, 113; 152-54

26. Specific surgical management
• S – Shift to operating theatre
bimanual compression
anti shock garment, especially if transfer is
required
• T – Tissue & trauma to be exclude and proceed to
tamponade, balloon, uterine packing
• A – Apply compression sutures
• S – Systematic pelvic devascularization (uterine,
ovarian, quadruple, internal iliac)
• I – Interventional radiology, uterine artery
embolisation
• S – Subtotal or total abdominal hysterectomy

27. A – Assess blood loss & resuscitate
• Rule of 30 – heart rate ⇧ by 30, SBP ⇩30, RR >30,
Hb or haematocrit ⇩30%, ur output <30ml/hr
30% of blood volume is lost – moderate shock
• Shock index – HR ÷ SBP
Normal (0.5-0.7)
Significant hemorrhage (0.9-1.1)
• Obstetric shock index
Normal (0.7-0.8)
>1 massive hemorrhage requiring blood in 80%
Cont..

28. • Obstetric Shock Index (HR / SBP) (normal = 0.5
–0.7)
• Modified Shock Index ( HR / MAP) (normal
<1.3 ) has been found to have clinical utility
for early diagnosis of haemorrhage.
(from AOGD January 2019)

29. Urgency Grid based on OSI
Loss of blood
volume
amount/ %
blood volume
Blood pressure systolic (SBP) Symptoms and signs Obstetric
shock
index
Degree of
shock/
urgency
500-1000ml
10-15%
Normal SBP Palpitation, mild
tachycardia, dizziness
<1 Compensated
Grade 4
1000-1500ml
15-30%
Slight fall in SBP (SBP=80-
100mmHg)
A rise in diastolic blood
pressure leading to increased
pulse pressure
Weakness, marked
tachycardia, sweating
>1 Mild
Grade 3
1500-2000ml
30-40%
Moderate fall in SBP (70-80
mmHg)
Restlessness, marked
tachycardia, pallor,
oliguria
>1.5 Moderate
Grade 2
>2000ml
>40%
Marked fall in SBP (50-70
mmHg)
Collapse, air hunger,
anuria
>2 Severe
Grade 1

30. MANAGEMENT
Principles:
A) Minor PPH-
1. Close monitoring
2. Intravenous access
3. Full blood count
4 Group and screen (full blood count and
coagulation factor screen including fibrinogen)
B) Major PPH-
1) Communication
2) Resuscitation
3) Monitoring
4) Arrest of bleeding

31. Initial assessment and basic treatment
1. Call for help
2. Assess airway, breathing and circulation (ABC)
3. Provide supplementary oxygen
4. Obtain an intravenous line
5. Start fluid replacement with intravenous crystalloid fluid
6. Monitor blood pressure, pulse and respiration
7. Catheterize bladder and monitor urinary output
8. Assess need for blood transfusion
9. Order laboratory tests-complete blood count, coagulation
screen, blood grouping and cross-match.
10. Start intravenous oxytocin infusion.

32. RESUSCITATION
Aim-
• Restoration of blood volume
• Restoration of oxygen-carrying capacity
Therapeutic goals of management of massive
blood loss is to maintain:
1) Haemoglobin > 8g/dL
2) Platelet count > 75 x109 / L
3) Prothrombin time < 1.5 x mean control
4) Activated prothrombin times <1.5 x mean control
5) Fibrinogen >1.0 g/L

34. Medications Dose Contraindication
s
Or cautions
Side effects/
Comments
Oxytocin 5 IU slow IV X 2
(may repeat dose)
Or
40 IU /500 ml Hartmann’s
solution at 125 ml/hour
Overdose or
prolonged use can
cause water
intoxication.
IV push dosing may
cause hypotension
Rare
Ergometrine 0.2 mg IM, can repeat
every 2-4 hrs with max 5
doses (1 mg) per 24 hrs
period
Hypertension/
toxemia, patients with
HIV taking protease
inhibitors, patient with
vascular disease,
hepatic or renal
disease or sepis
Nausea, vomiting and
increased B/P
MEDICAL TREATMENT (Uterotonics)

35. Syntometrine Combination of Oxytocin
5 IU and Ergometrine 0.5
mg,
Give 1 ampoule I/M
Carboprost 250 μg IM every 15
minutes up to 8 times
Direct Intra myometrial
0.5 μg
Active or history of
pulmonary disease
(asthma), renal
hepatic or cardiac
disease
Nausea, vomiting,
and diarrhea
Mispoprostol 800 μg sub-lingually Cardiovascular
disease
Nausea, vomiting,
diarrhea, pyrexia,
shivering

36. MECHANICAL METHODS

37. Bimanual compression of uterus
The uterus is positioned
with the fist of one
hand in the anterior
fornix pushing against
the anterior wall, which
is held in place by the
other hand on the
abdomen. The
abdominal hand is also
used for uterine
massage.

38. Balloon tamponade
• WHO, the International Federation of Gynecology and
Obstetrics, and the Royal College of Obstetricians and
Gynaecologists, all recommend a uterine balloon
tamponade (UBT) if uterotonics and uterine massage
fail to control bleeding.
• Various types of balloons used are
a) Bakri balloon
b) Foley’s catheter,
c) Rusch balloon,
d) Sengstaken-Blackmore oesophageal catheter
e) sterile glove
f) condom.
• The only contraindication - suspected or diagnosed
uterine rupture.

39. Various Tamponade Balloons

40. ‘Tamponade test’.
• A ‘positive test’ (control of PPH following
inflation of the balloon) indicates that
laparotomy is not required
• A ‘negative test’ (continued PPH following
inflation of the balloon) is an indication to
proceed to laparotomy.

41. Bakri Tamponade Balloon
• Developed by Bakri et al in
2001
• Designed specifically for
obstetrical hemorrhage
• maximum capacity 800cc of
balloon (recommended 250
to 500cc
• wider caliber drainage shaft
• It can be placed from above
at time of C/S ( not from
below )

42. How to insert Bakri balloon
• Insert Foley catheter prior to the procedure.
• Clean cervix and vagina with betadine..
• Insert the catheter transvaginally under ultrasound guidance to
assure that the uterus is clear of any retained placental fragments,
arterial bleeding, or lacerations.
• Determine approximate uterine volume by ultrasound or direct
Examination
• Insert the proximal end of the balloon catheter through the cervix
into the uterus.
• The balloon catheter should be gently inserted with a long forceps
(Do not use a tenaculum).
• The entire balloon should be inserted past the cervical canal and
internal os.
• Avoid excessive force when inserting the balloon into the uterus. If
resistance occurs during insertion, remove the catheter.
• Fill the balloon with 250- 300 ml sterile saline through the stopcock.
• Do not over inflate the balloon. Maximum inflation volume is 500
ml.
• Always inflate the balloon with sterile normal saline.

43. • NEVER inflate the balloon with air, carbon dioxide, or any
other gas.
• Insert X-Ray detectable sponges. Soak sponges with
betadine and insert around shaft of the catheter to
maintain correct catheter placement and maximize
tamponade effect.
• Count sponges prior to insertion and document on the
Intraoperative Record/ Nursing flowsheet..
• Apply gentle traction to the balloon shaft and secure it to
the patient’s inner thigh to maintain tension.
• Connect the drainage port to a fluid collection bag (e.g.
small Foley leg bag) to monitor hemostasis after the
balloon is inflated.
• Flush balloon drainage port and tubing with 15-30 mL
sterile normal saline if there is no drainage and/or the
fundus is increasing in height.
• If the balloon catheter becomes dislodged due to shaft
tension, deflate the balloon,

44. SOS Bakri Balloon Catheter Removal
• Remove tension from balloon shaft.
• Remove and count vaginal packing/sponges.
• Obtain X-ray if sponge count is incorrect.
• Deflate the catheter slowly prior to removal.
• Using an appropriate size syringe, aspirate the contents
of the balloon until fully deflated.
• Verify that the original volume inserted in the balloon
was removed.
• Gently retract the balloon from the uterus and vaginal
canal and discard.
• Continue to monitor the patient for signs of uterine
bleeding after removal of balloon catheter

45. Condom tamponade
• The idea of using a condom as a balloon
tamponade was first generated and evaluated
in Bangladesh in 2001 by Akther to fill a need
and in response to the high cost of
commercially available UBT devices.
• A quick, minimally invasive, easy procedure
and life saving if carried out in time; especially
in settings where blood transfusion and
surgical facilities may not be readily available.

46. How to use
• A size 16 rubber catheter (Foley’s catheter) was
inserted within the condom and tied near the
mouth of the condom by a silk thread.
• 200-500cc normal saline
• Triple Antibiotic coverage
• Removed after 24-48 hrs
• Vagina packed with gauze or another condom.
• Do not over-inflate the balloon.
• Maximum inflation volume is 500 ml

49. CG BALLOON

51. Glove balloon
• By Basket, 2004
• Technique
– straight catheter and
surgical glove
– tie at wrist with #1
vicryl
– insert and fill with
100cc

52. UTERINE PACKING
Indications
1. Uterotonics fail to cause sustained uterine contractions & satisfactory
control of bleeding after vaginal delivery.
2. Surgical treatment is unavailable at the current site.
3. Woman is too unstable to undergo surgery at that time. No prompt
response: exploratory laparotomy.
Steps:
• 4 inch gauze from one cornu to the other using a sponge stick, packing
back & forth, and ending with extension of the gauze through the
cervical os.
• Antibiotics
• Pack is left for 24 hr.
• Fluid and blood component replacement.
Complications: Trauma, Infection, Ineffective packing, concealed bleeding
increasing need for uterotonics
Effectiveness: 97% immediate control of bleeding.

53. Uterine packing

54. Temporary methods
•Temporizing measures recommended for intractable
atonic and non-atonic PPH.
• Include –
1) External aortic compression,
2) Bimanual uterine compression,
3) Non-pneumatic anti-shock garment (NASG)
•Arterial balloon occlusion and UAE are procedures
that can prevent major blood loss, obviating the need
for blood transfusion and hysterectomy.
• Recommended for trial prior to surgical intervention

55. External aortic compression
• Significantly reduces blood flow to the pelvic organs
while preserving blood supply to surrounding organs.
• It has traditionally been accomplished manually, with a
provider applying pressure with a closed fist on the
abdominal aorta slightly to the patient’s left and
immediately above the umbilicus.
• Recently, the external aortic compression device
(EACD), a hand-made spring device held in place by a
leather belt, was used as a first aid temporary
intervention.
• EACD use was associated with significantly reduced
time to cessation of uterine bleeding in one study;
however, additional research is necessary to determine
the effectiveness of this device.

58. NASG (non-pneumatic anti-shock garment)
• The NASG is a low-technology first-aid device for stabilizing women
suffering hypovolumic shock secondary to obstetric hemorrhage.
• Lightweight, re-usable lower-body compression garment made of
neoprene and Velcro TM.
• Anti-shock garments work through the application of counter-
pressure to the lower body, which may reverse shock by returning
blood to the vital organs. The garment is applied first to the lowest
possible extremity (the ankles), then upwards.
• NASG increases blood pressure by decreasing the vascular volume
and increasing vascular resistance within the compressed region of
the body, but does not exert pressure sufficient for tissue ischemia
like its predecessors.
• can be used for any etiology, applied by individuals with minimal
training, and does not compete with the use of other PPH
management interventions.
• Recommended as a temporary measure for PPH by the WHO and
FIGO.
• RCOG indicates role during transport of hemorrhaging women from
rural areas to urban treatment centers, or while awaiting
procedures or surgery.

59. Non-pneumatic anti-shock garment

60. Intravascular Aortic Balloon Occlusion
(IABO)
• Emerged as prophylactic, simple, safe and minimally invasive
method
• Performed by an experienced interventional radiology team.
• Indication-
1) Prophylactic for known placenta accreta by placement of occlusive
balloons in the internal iliac or uterine arteries, which are inflated in
the event of PPH.
2) In management of life threatening PPH and in the conservative
management of abnormal placentation (Placenta percreta).
• Similar results in terms of blood loss and absence of need of blood
products as internal lilac artery occlusion but requires further
research by using control group before regarding this method, as
an ancillary procedure of choice during scheduled cesarean
hysterectomy in known or suspected cases of abnormal
placentation.

61. Uterine artery embolisation
• Recommended as a conservative management alternative for
multiple hemorrhage etiologies where resources are available.
Adv.-
1. High clinical success rates (95%),
2. low complication rates (4.5%)
3. preliminary evidence of fertility preservation
4. shorter operating time,
5. lower operating blood loss and
6. higher success rate in placenta accreta when compared with other
hemostatic surgeries.
Disadv. -
• techniques require sufficient expertise.
• performed by an experienced interventional radiology team
Complications -
a) uterine necrosis
b) thromboembolic events

62. • If bleeding continues
despite inflation,
embolization can be
performed via the balloon
catheters, or via
dedicated catheters
• UAE – done by placement
of microparticles,
polyvinyl alcohol, gel
foam or coils, which
occlude blood flow to the
uterine arteries.

63. Selective arterial occlusion or embolisation
• They have similar efficacy as uterine balloon
tamponade.
• The use of uterine artery embolisation is
recommended where other measures have failed
and the necessary resources are available.
• Interventional radiology may be considered in
cases of placenta praevia with accreta if
intraarterial balloons can be placed in the
radiology department before the woman goes to
OT for caesarean section.
• Not impair subsequent menstruation and fertility.

64. SURGICAL METHODS

65. Compression sutures
• Used as a first step in surgical management when
hemorrhage is a result of atony.
• B-Lynch procedure (described by B-Lynch in 1997)
or Cho suture if a hysterotomy has been
performed (delivery via cesarean section)
• Hayman suture (described by Hayman et al. in
2002) in the absence of a hysterotomy (vaginal
delivery)
• Technically less challenging than vessel ligation
and
• Less morbidity than a hysterectomy

66. • Suture material- Monocryl suture ( Dexon, Vicryl) is
recommended.
• Needle - Straight/ round shallow curve, round body,
atroumatic needle.
• Possible complications of the technique include
pyometra and partial uterine necrosis.
• The risk of potential complication appears to be higher
when non absorbable sutures are used.
• Uterine compression sutures irrespective of its type
should not prevent the blood drainage from the
uterine cavity and it should not affect the uterine
vascularity.
• Monofilament sutures with an absorption time of 90–
120 days can decrease complications.
• Subsequent hysteroscopic assessment should be done
especially after putting stepwise devascularization and
compression sutures.

67. B-LYNCH SUTURE

68. Technique of B-Lynch suture placement
A: The initial bite is placed anteriorly at one
angle of the uterine incision
B: After the anterior B-Lynch suture is placed,
the suture is passed over the fundus, a deep
transverse bite is taken in the posterior lower
uterine segment, and the suture is passed
back over the fundus.
C: The uterine incision is closed, and the B-Lynch
suture is tied down. An assistant manually
compresses the uterus while the suture is
tied.

70. Various compression sutures

71. Uterus sandwich Technique
• Compression sutures
and balloon tamponade
are applied
simultaneously.

72. Uterine artery ligation.
• A: Lateral view
demonstrating ligature
placement.
• B: Anatomic relation of
ligature to uterine wall
and vessels.

73. Internal iliac artery ligation
• The major blood supply to the uterus and pelvis comes from the
internal iliac artery
• Ligation of this artery controls bleeding by decreasing the pulse
pressure by as much as 85%.
• Important to perform bilaterally to adequately decrease pressure
to the uterus.
• This allows pressure and packing to produce clotting.
• Interferes little with subsequent pregnancies.
• The ureter should be identified and retracted medially, if necessary.
• A right-angle clamp is gently passed under the artery in the lateral
to medial direction to avoid injury to the vein by the tip of the
clamp.
• The ligation should be performed about 2 cm distal to the
bifurcation to avoid disrupting the posterior division, which can lead
to ischemia and necrosis of the skin and subcutaneous tissue of the
gluteal region.
• Two nonabsorbable sutures of 2-0 silk should be used for ligation.

75. Step-wise De-vascularisation
• Decrease blood flow to the uterus, in order to arrest
life threatening PPH before hysterectomy,when
medical therapy is unsuccessful.
1. Bilateral uterine artery ligation: 90% of the uterus
blood supply in pregnancy comes from these vessels. If
this measure fails to control bleeding, the next step is
ovarian artery ligation.
2. Bilateral ovarian artery ligation: Suture is placed on
the ovarian artery through a vascular area in
mesoovarium.
3. Internal iliac artery ligation: It causes almost 85%
reduction in pulse pressure in those arteries distal to
ligation thereby, causing arterial pressure system into
one with pressure approaching those in venous
circulation and provides haemostasis via clot
formation.

77. Triple P Procedure
• The Triple-P procedure is a three step
conservative treatment involving obstetricians,
anesthetists and interventional radiologists to
prevent significant haemorrhage and peripartum
hysterectomy. The three steps are:
1. Perioperative location of the placenta and
delivery of the fetus by an incision above the
upper border of the placenta.
2. Pelvic devascularisation by inflating radiologically
pre-placed occlusion balloons in both internal
iliac arteries.
3. Placental non-separation with myometrial
excision and reconstruction of the uterine wall.

78. Cesarean Hysterectomy
• In the event that compression sutures, vessel ligation
and stepwise de-vascularisation fail, definitive
management of PPH is hysterectomy.
• Early decision may be lifesaving especially where
bleeding is associated with placenta accreta or uterine
rupture.
• DO NOT delay until the woman is in extremes or while
less definitive procedures.
• Subtotal hysterectomy is the operation of choice unless
there is trauma to the cervix or lower segment in which
case total hysterectomy will be necessitated.

79. Use for antifibrinolytic drugs
• Evidence for the use of fibrinolytic inhibitors (such as
tranexamic acid) in the managment of obstetric
haemorrhage is conflicting.
Tranexamic acid is recommended for the treatment of PPH if:
• The use of oxytocin and other uterotonics fail to stop the
bleeding
• It is thought that the bleeding may be partly due to trauma.
Dose:
• 1 gram intravenously (administer in 1 min)
• If bleeding continues, repeat 1 g after 30 minutes

80. Indication Timing Dosing
WHO 2012 TXA
Recommendation
If oxytocin and other
uterotonics fail to stop
the bleeding or if
trauma is suspected
For atonic uterus, use
TXA if oxytocin and
other uterotonics fail
to stop the bleeding.
IV (slowly): 1 g,
Repeat after 30
minutes if bleeding
continues.
WHO 2017 TXA
Recommendation
(updated)
Use TXA in all cases of
PPH, regardless of
whether the bleeding
is due to genital tract
trauma or other
causes.
Use TXA within 3
hours and as early as
possible after onset of
PPH. Do not initiate
TXA more than 3
hours after birth,
unless being used for
bleeding that restarts
within 24 hours of
completing the first
dose (see dosing).
Fixed dose of 1 g in 10
mL (100 mg/mL) IV at
1 mL per minute (i.e.,
administered over 10
minutes)Second dose
of 1 g IV if bleeding
continues after 30
minutes or if bleeding
restarts within 24
hours of completing
the first dose
New about the use of tranexamic acid (TXA) to
treat PPH (2017 WHO recommendation)

81. OTHER CAUSES OF PPH

82. Retained Placenta
• Placenta not delivered should be treated as
for whole retained placenta/ adherent
placenta.
• Placenta delivered as incomplete is to be
treated as for retained placenta fragments.
• The woman should be diagnosed as having a
retained placenta if the placenta is not
expelled within 30 minutes after delivery of
the baby.

83. • In the absence of haemorrhage, the woman
should be observed for a further 30 minutes
following the initial 30 minutes, before manual
removal of the placenta is attempted.
• Spontaneous expulsion of the placenta can still
occur, therefore a conservative approach is
advised and the timing of the manual removal of
the placenta as a definitive treatment is left to
the judgment of the clinician.

84. • Treated with:
1) Oxytocin
2) Manual exploration to remove fragments
3) Gentle curettage or aspiration
4) If bleeding continues manage as uterine
atony.

85. • The use of additional oxytocin (10 IU IV/IM) in
combination with controlled cord traction is
recommended for retained placenta.
• No empirical evidence.
• Ergometrine may cause tetanic uterine
contractions, which may delay expulsion of
the placenta. Its use is not recommended.
• Prostaglandin E2 alpha (dinoprostone or
sulprostone) is not recommended. Evidence is
lacking and there are concerns related to
adverse events, particularly cardiac events.

86. • The manual removal of a retained placenta
should be expedited in the presence of
haemorrhage.
• A single dose of antibiotics (ampicillin or first-
generation cephalosporin) is recommended
following manual removal of the placenta.
• There is insufficient evidence to recommend
the use of intra-umbilical vein injection of
oxytocin as a treatment for retained placenta.

87. Lower genital tract trauma
There is excessive bleeding or shock with a
contracted uterus.
Treat for lower genital tract trauma with:
 Repair of tears
 Evacuation and repair of haematoma
 If bleeding continues administer tranexamic
acid.

88. Causes
1) Perineal tears
2) Vaginal lacerations
3) Cervical tears
4) Heamatoma-
vulval, vaginal,
supra-levator,
broad ligament,
ischiorectal.
5) Uterine rupture

89. Uterine rupture and dehiscence
There is excessive bleeding or shock.
Treat for uterine rupture or dehiscence:
• Laprotomy for primary repair of the uterus
• Hysterectomy if repair fails
If bleeding continues administer tranexemic
acid.

90. Uterine Inversion
• Uterine fundus is not felt abdominally and a firm mass
coming through cervix and visible in the vagina.
• Treatment for uterine inversion:
1) Immediate manual replacement
2) Hydrostatic correction,(Balloon tamponade)
3) Manual reverse inversion (use general anaesthesia or wait
for effect of any uterotonic to wear off)
4) Haultain procedure- incise cervix posteriorly, digital
reposition of corpus and subsequent repair of cervix.
5) If treatment is not successful, laparotomy to correct the
inversion.
6) Huntington procedure- progressive upward traction on
inverted corpus using Babcock or allies forcep.
7) If laparotomy correction is not successful, hysterectomy.

91. Clotting Disorder
• Bleeding in the absence of uterine atony and above
conditions
• Treat for clotting disorder as necessary with blood
products.
• Best marker for developing coagulopathy -fibrinogen levels
Fresh Frozen Plasma:
• Prothrombin time/activated partial thromboplastin time >
1.5 x normal (12-15 mL/kg or total 1 litre)
Platelets concentrates:
• If PLT count < 50 x 109/L
Cryoprecipitate: Cryoprecipitate contain approximately 10
times the concentration of fibrinogen as FFP. In order to
raise the fibrinogen level by 1 gm/l, 30 ml/kg of FFP needs
to be given compared with 3 ml/kg of cryoprecipitate
• Used If fibrinogen < 1 g/L

92. recombinant factor Vlla (rFVlla) therapy
Uses:
• Only FDA approved indication- Hemophilia A & B.
• Not recommended for the treatment of primary PPH.
• Its use should be limited to women with specific haematological
indications and should be based on the results of coagulation
profile.
• Potentially life-saving drug, may be used in a case of life-
threatening PPH as an adjuvant to massive blood transfusion, in
consultation with a haematologist.
Dose:
• 90 micrograms/kg body wt
• May be repeated in the absence of clinical response within 15-30
minutes.
Precaution:
• Side-effects of rFVlla include thrombotic events that are life-
threatening.
• rFVlla is expensive (NOVOSEVEN)

93. Risk of defibrination with rFVlla use:
• Especially in the most severe cases that will be
considered for rFVlla there may be defibrination
(severe hypofibrinogenaemia).
• rFVlla will not work if there is no fibrinogen and
its efficacy may also be suboptimal with severe
thrombocytopenia (less than 20000/µL).
• Give rFVlla only if - fibrinogen > 1g/L, platelets >
50x109/l, pH>7.2 and temperature >34C
• If there is a suboptimal clinical response to rFVlla,
check and correct fibrinogen and platelets (with
cryoprecipitate, fibrinogen concentrate or
platelet transfusion as appropriate).

94. Resuscitation: Blood transfusion
• The best fluid for blood volume resuscitation is
compatible blood transfusion
• Transfuse cross-matched blood as soon as possible.
• If cross-matched blood is unavailable, give uncross-
matched group-specific blood OR give O RhD negative
blood.
• DO NOT use special blood filters as they slow infusions.
• If fully cross-matched blood is unavailable by the time
that 3.5 litres of clear fluid have been infused, the best
available alternative should be given to restore oxygen-
carrying capacity.
• Group O RhD negative blood is the safest to avoid a
mismatched transfusion in an acute emergency.
• Women with known risk factors for PPH should not be
delivered in a hospital without a blood bank on site.

95. • Blood components should be given when the
blood loss reaches about 4.5 litres (80 % of blood
volume) and large volumes of replacement fluids
have been given as there will be clotting factor
defects.
• Results of coagulations studies and the advice of
a haematologist should be used to guide
transfusion of coagulation factors.
• If bleeding is relentless, up to 1 litre of fresh
frozen plasma (FFP) and 10 units of
cryoprecipitate (2 packs) may be given
empirically, while awaiting the results of
coagulation studies

96. Massive blood transfusion protocol
• Definition- Transfusion of = or > 10 units of
PRBC in 24 hrs / transfusion of 4 units of
PRBC in 1 hr with ongoing need for more
blood transfusion / replacement of complete
blood volume.
• Recommended transfusion ratio-
PRBC : FFP : Platelets= 1 : 1 : 1
• Critically low Fibrinogen levels are particularly
anticipated in cases of abruption or amniotic
fluid embolism, so early use of cryoprecipitate
is recommended.

97. • Complication-
1) Hyperkalemia
2) Hypocalcemia due to citrate toxicity
3) Acidosis
4) Hypothermia
5) Dilutional coagulopathy and pulmonary oedema with
overzealous use of crystalloids
6) Transfusion febrile non-hemolytic reaction
7) Acute transfusion reaction related lung injury
8) Transfusion associated infectons (as HIV, Malaria,
Hepatitis etc) - Rare

98. SECONDARY PPH
• Incidence- 1%
• Communication, resuscitation, monitoring and
investigations are the same as for primary PPH.
• Additional investigations include:
1) High and low vaginal swabs,
2) Blood cultures if pyrexia,
3) Full blood count,
4) C-reactive protein,
5) Pelvic ultrasound that might help to exclude the
presence of retained products of conception

99. • Secondary PPH is often associated with infection and
conventional treatment involves antibiotics and
uterotonics.
• The appropriate choice of antibiotics is a combination of
ampicillin (clindamycin if penicillin allergic) and
metronidazole. The addition of gentamicin is recommended
in cases of endomyometritis (tender uterus) or overt sepsis.
• In continuing haemorrhage, insertion of a balloon catheter
may be effective.
• Surgical measures should be undertaken if there is
excessive or continuing bleeding, irrespective of ultrasound
findings.
• A senior obstetrician should be involved in decisions and
performance of any evacuation of retained products of
conception as there is a high risk for uterine perforation in
these women.

100. Documentation
• Accurate documentation of a delivery with PPH is
essential.
• A structured proforma should be used to aid accurate
record keeping.
It is important to record:
1) The staff in attendance and the time they arrived
2) The sequence of events
3) The timing of the administration of different
pharmacological agents given, their timing and
sequence
4) The time of surgical intervention, where relevant
5) The condition of the mother throughout the different
steps (including vital signs documentation)
6) The timing of the fluid and blood products given