This document provides an update on new technologies for managing postpartum haemorrhage (PPH). It discusses challenges in PPH management and definitions. Risk factors and types of PPH are outlined. New methods for accurately estimating blood loss are presented, including the BRASSS-V drape. Causes and clinical manifestations of PPH are described. Diagnosis involves assessing the 4 T's: Tone, Tissue, Trauma, Thrombin. Conservative and surgical management options are discussed, as well as complications of PPH. Newer techniques like uterine tamponade balloons and compression sutures aim to control bleeding without hysterectomy.

1. UPDATE OF NEW TECHNOLOGIES
IN MANAGEMENT of
POSTPARTUM HAEMORRHAGE
Dr. Abd El Naser Abd El Gaber Ali
Assistant professor of obstetrics & Gynecology
South valley university

2. Challenges in Management of PPH
Prediction of PPH occurrence is difficult on the
basis of risk factors.
The estimation of blood loss amount is not easily
Rapid deterioration of patient up to death in short
time from start of a bleeding.
Need Rapid, Aggressive and Skilled
interventions action that are critical for survival.

3. Definitions
Definition of PPH
• An excessive bleeding from the genital tract occurring at any time
from the birth of the baby up to 6 or 12 weeks postnatal.
Traditional Definition
• blood loss of > 500 mL after vaginal delivery
• blood loss of > 1000 mL after cesarean delivery
Functional Definition
• Any blood loss that has the potential to produce or
produces hemodynamic instability (manifestations of
hypovolemia)
woman with normal pregnancy-induced hypervolemia increases blood-volume by 30-60% = 1-
2L . Therefore, tolerates similar amount of blood loss at delivery. Women may lose up to a
third of their blood volume (1500-1800mls) without showing signs of shock

4. Types
Early or primary: Occurs in the first 24 hours after delivery
of the fetus
Late or secondary: Hemorrhage that occurs after the first 24
hours after delivery of the fetus and up to the end of puerperium (6
weeks) (nowadays up to12 weeks ).
Degree
◦ A minor or mild PPH: 500-1000ml in VD and 1000-1500ml
in CS
◦ A major or severe PPH: > 1000mL in VD and >1500ml in
CS

5. • Postpartum hemorrhage is the first cause of maternal death
in developing countries and the third cause of in developed
countries.
 Incidence of 1ry postpartum hemorrhage is
about 5% (1-8%)
 Incidence of 2ry postpartum hemorrhage is
about 0.5%

6.  Visual estimation of blood loss amounts has fallacies
of 30-50%
 Old methods for estimating blood loss:
 Weighing method (They include weighing
soaked clothes and pads, collection into pans etc.,)
 Acid hematin techniques, Spectrophotometric
techniques and measuring plasma volume changes
 New methods as using THE BRASSS-V DRAPE

7. THE BRASSS-V DRAPE

9. Simple and practical
Low cost: ( Plastic)
Accurate:
Objective
Used in a wide range of
settings
Provides a hygienic
delivery surface

10.  Most important factor for control of bleeding from
placenta site:
Contraction and retraction of myometrium to
compress the vessels served with placental
separation so Incomplete placental separation will
prevent good uterine contraction
 Activation of coagulation system

15. Tone
Trauma
Tissue
Thrombin

16. Tone Uterine atony 95%
Tissue Retained
tissue/clots
Trauma laceration, rupture,
inversion
Thrombin coagulopathy

17. Thrombin
Tissue
Trauma
Tone
Pre-eclampsia
HELLP
Syndrome
Placental
abruption
Amniotic Fluid
Embolism
Sepsis
Bleeding
disorders
Drugs (aspirin /
heparin)
Retained
placental
tissue
Abnormal
placentation
Placenta
accreta
Operative
delivery
Cervical /
vaginal
lacerations
Prolonged labour
Precipitate labour
Grand Multiparity
Multiple pregnancy
Polyhydramnios
Macrosomia
Abnormalities:
fibroids
Intrauterine infection
Uterine relaxing
agents such
as general
anaesthetic/
tocolytics

18.  Over distended uterus
 Instrumental delivery
 Prolonged or precepitate labor
 Induction or augmentation of labor
 Choriomnionitis and IUFD
 Shoulder dystocia
 Internal podalic version
 Coagulopathy and bleeding disorder
 Placental Abruption or previa
 Gestational hypertension and PET

19.  Assess in the fundus for (Tone)
 Inspect the lower genital tract for (Trauma)
 Explore the uterine cavity for (Tissue)
 Assess coagulation for (Thrombin)

20. Manifestations
Excessive
dark Red
Bleeding
Abnormal
Clots
Lax uterus enlarged filled
with blood
Unusual pelvic discomfort or backache

21. Manifestations
1. Bright red bleeding
2- Uterus in contracted
3- Continuous trickling of blood
4- Presence of tear (s) in lower genital tract

22.  This occurs when there is incomplete
separation of the placenta and fragments of
placental tissue retained
(simple or morbid adhesion).
 Signs
◦ Relaxed uterus
◦ Dark red bleeding
◦ U/S can confirm

23. The uterus inverts or turns inside out after
delivery.
Complete inversion - a large red rounded mass
protrudes from the vagina
Incomplete inversion - uterus can not be seen, but felt
Predisposing Factors:
 Traction applied on the cord before the placenta has
separated.
 Incorrect traction and pressure applied to the fundus,
especially when the uterus is flaccid

24. Inverted Uterus

25.  Retained placental tissue or piece of membranes
 Uterine infection
 Subinvolution of uterus
 Necrosis of submucous fibroid or polyp
 Inversion of uterus
 Gestational trophoblastic neoplasia
 Hemorrhagic blood diseases
 Local gynecological lesions as cervical erosion or
carcinoma

26.  Maternal mortality
 Long term morbidity includes
 Renal impairment
 Sheehan Syndrome
 Risk of blood-borne infections from blood
transfusions

27. 27
 Poor access to skilled providers (‫)االمدادات‬
 Poor transport systems
 Poor emergency services
- Lack of blood/products

28. Prevention of PPH
• Preconception: optimal health to begin
pregnancy, correct anaemia ….
• Pregnancy: identify risk factors, diagnosis and
treatment of anaemia
• Labour: policy guidelines, good management 1st
and2nd 3rd stage of labour and Active
management of 3rd stage (RCOG, 2009)
• After delivery: careful monitoring in 1st hour
after delivery

29.  Oxytocin with delivery of anterior shoulder
– 10 U IM or 5 U IV bolus
– 20 U/L N/S IV run rapidly
 Early cord clamping and cutting (One to three
minute delay in cord clamping does not increase risk of
PPH )
 Continuous, controlled cord traction
 Uterine tone is assessed after placenta delivery
(continuous massage is not useful, WHO 2012)
29

30. 30
30
30

32. Assess patient
2 Large bore IV access
Fluids (Crystalloid-lots!)
CALL FOR HELP!
CBC/cross-matching and typing
Foley catheter

33. Is a simple device that
counteracts shock and
decreases blood loss by
applying direct counter
pressure to the lower parts
of the body.
Useful as a first aid

34. • Rapidly applied. Need only 2
minutes
• Need minimal training
• Within 2-5 minutes of
application most patients with
severe shock regain
consciousness and vital signs
begin to stabilize
• less expensive

35.  Senior persons notifications and immediately
be present
 Anesthesia consultant
 Blood transfusion
 From donor or
 Cell savers – blood lost at operation is centrifuged and washed
then returned to patient as packed RBC so transfused with own
blood not someone else’s (has no platelet – may be contaminated
with fetal red cells (Rh isoimmunisation)- Amniotic fluid embolism
 Haematologist
 Arrange for a bed at Intensive Care Unit

36.  Medical treatment as Oxytocin, Ergometrine ,
misoprostol, carbitocin
 Uterine massage, bimanual uterine compression
and external aortic compression (places a fist on the
mother’s abdomen, above the fundus and below the level
of the renal arteries (Lumbar 1/2) )
 Non medical maneuvers as intrauterine balloon
 Surgical treatment, compression sutures, devascularization,
hysterectomy
 Interventional radiology (uterine artery embolization)

37. Oxytocin
 5 units IV bolus and 20 units per Liter N/S IV rapidly
 10 units intramyometrial given transabdominally
Additional Uterotonics
 Ergotamine - caution in hypertension
 – 0.25 mg IM or 0.125 mg IV
 – maximum dose 1.25 mg
 Carboprost– 15 methyl-prostaglandin F2α
 – 0.25 mg IM or intramyometrial – Maximum dose 2 mg
 Misoprostol – 400 mg orally or per rectal
 Carbetocin 100 ug (Pabal)

39.  Digital exploration of
the uterus
 Removal of retained
membranes and
placental fragments
 Use analgesia

40. Uterine Massage and Bimanual
compression

41. Balloon Tamponade
• A balloon (inflated with saline/water) exerts pressure
to stop bleeding from uterine cavity in 5-15 minutes.
• Is very effective (≥85%) when uterotonics fail. Can
prevent need for laparotomy and hysterectomy.
(Reported success rates range between 70-100%.)
• Easy to use
• Can effectively be used in low resource settings
• Safer alternative to uterine packing

42. Insertion of Uterine Tamponade Balloon

43. Commercially Available Balloon
Tamponades in Use
Bakri
$250 per device
Sengstaken–Blakemore
$220 for two devices Rusch hydrostatic
$77 (quoted £50)
BT-CATH
$200 per device

44. The Condom /Catheters Unit
can be assembled in a few
minutes and has low cost
Condom Tamponade Unit
Developed in
Bangladesh
by Ashkter and Team

45. Inflate Condom with
water till no further
bleeding is occuring
(usually about 300-500
mls )
UTERUS
Foleys Catheter
Condom
String
Apply clamp to keep water within
Condom after inflation
Giving set
Water/NS
OR
syringe
THE CONDOM TAMPONADE
Clean
water

46. The Condom Tamponade Emergency Pack

47. The Condom Tamponade Emergency Pack

48. Steps in using the Condom Tamponade
1. Place condom over balloon end of Foleys catheter
2. Using suture / string tie lower end of condom below level of the
balloon as shown. Tie should be tight enough to prevent leakage of
water but should not strangulate catheter and prevent inflow of
water into condom. Check for leakage by inflating balloon with
about 20cc water.
3. Using an aseptic technique place the condom end high into uterine
cavity by digital manipulation or with aid of speculum and forceps
4. Inflate CT by connecting open/outlet end of catheter to giving set
connected to infusion bag or use clean water with aid of large
syringe.
5. Inflate condom with water or saline to about 300- 400 mls (or to
amount at which no further bleeding is observed).
6. Maintain In-situ for 6-12 hours if bleeding controlled and patient is
stable.
7. Give Broad spectrum antibiotic cover

49. Contraindications To Use
• Active arterial bleeding requiring exploration and
ligation or angiographic embolization.
• Cases indicating hysterectomy.
• Where uterine rupture is suspected
• Cervical cancer.
• Disseminated Intravascular Coagulation (DIC)

50. Intra-Operative Surgical Techniques
A variety of intra-operative techniques are available to effectively control bleeding
from the uterus: They either act to produce tamponade by compressing the uterus
and apposing its anterior and posterior walls or to effectively reduce blood flow to
the uterus.
• Uterine Compression sutures :e.g.
– B-Lynch Brace Sutures
– Modified B-Lynch Brace Sutures
– Square sutures
– Transverse compression suture of lower segment
• Reduced blood flow to the uterus
– Arterial ligation/pelvic devascularization
– Selective Arterial embolization (Uterine Artery)

51. UTERINE COMPRESSION SUTURES
• SQUARE VERTICAL
Cho JH, Jun HS, Lee CN: Haemostatic Suturing Technique For uterine Bleeding during Cesarean
Section delivery. Obstet Gynecol 200 0 96:129-131
A Straight needle is passed anterior to
posterior and passed over fundus
and ligated anteriorly.
Multiple square sutures are
Passed intramurally and tied at
Various points.

54. Modified B-Lynch Brace Sutures

55. SQUARE sutures

56. The B-Lynch surgical technique: clinical points
• User-friendly suture material monocryl No.1 mounted on 90-cm
• rapidly absorbable sutures may be used according to the surgeon.
• Basic surgical competence required
• Uterine cavity checked, explored and evacuated
• Suture bends maintain even and adequate tension without uterine
trauma or ‘shouldering’
• Allows free drainage of blood, debris
• Simple, effective and cost-saving
• Fertility preserved and proven
• Mortality avoided
• Potential for prophylactic application at cesarean section when signs
of imminent postpartum hemorrhage develop, e.g. placenta accreta, or
overdistended uterus

57. Modified B-Lynch
brace suture
B-Lynch
brace suture
Easy to perform
Requires expertise
1
LUS incision not
required
Transverse LUS
incision required
2
Less time consuming
Time consuming
3
No cervical stenosis
Cervical stenosis
4
No haematometra
formation
Haematometra
formation
5
No bleeding from LUS
Bleeding from LUS
6

58. • In a patient with placenta previa, a figure of-
eight or transverse compression suture to the
lower anterior or posterior compartment or both
is applied to control bleeding.
• If this is not completely successful, then, in
addition, the longitudinal Brace suture may be
applied for complete hemostasis.
Transverse compression sutures of lower
segment

60. The Compression Sutures
Advantages :
• Preserves future fertility and menstrual
function
• Simple and quick to perform
Disadvantages
• Uterine wall ischaemia /Necrosis

61. Stepwise Uterine Devascularization
• Bilateral ligation of UA ascending
branches
• Bilateral ligation of UA descending
branches
• Bilateral ovarian arteries ligation
• Ligation of anterior division of internal
iliac artery (unilateral or bilateral)

64. Internal iliac artery ligation
• Internal iliac artery ligation effective in control of PPH by
reducing arterial pulse pressure
• Requires :
1-more surgical skills
2-hemodynamically stable patient
3- Should be bilateral
• Results:
– 14% by contra lateral
– 77% by homolateral
– 85% by bilateral
• Complications: carry risk of internal iliac veins are injured.

65. Selective Artery Embolisation
• Evolved from other angiograpic embolisation
techniques
• Gelatin Sponges are injected into the bleeding
vessel until stasis of flow in target vessel is
achieved.
• Access is gained via femorals to internal iliac
and subsequently the uterine arteries

66. Selective Artery Embolisation
Advantages
Preserves Fertility
Useful in Haemorrhage associated with Placenta praevia
Disadvantages
• Requires 24hr availability of radiological expertise.
• Patients must be stable
• Complications include: Necrosis of uterine wall,
contrast adverse effects, local haematoma formation

67. Success rates of the new Technological
measures in the management of PPH
Method Number of
Cases
Success
Rates (%)
B-Lynch/compression sutures 108 91.7
Arterial embolization 193 90.7
Arterial ligation/pelvic
devascularization
501 84.6
Uterine balloon tamponade 162 84.0

68.  Emergency hysterectomy is life saving in severe cases not
respond to other regimen
 The incidence of emergency peripartum hysterectomy 7
to 13 per 10,000 births
 Subtotal hystrectomy
 Decision should not be late or early
 Indications of urgent hysterectomy
 Atony – 43%
 Placenta previa and or accreta – 30%
 Uterine rupture – 13%
 Extension of low transverse incision – 10%
 Fibroids preventing closure – 4%

69.  Definition : Persist bleeding from the pelvic
surfaces after hysterectomy
 Causes: Coagulation defects and DIC
 Manifestations of Intraperitoneal hemorrhage
detected by intraabdominal drain or U/S
 Management: ABDOMINAL PACKING which
are then removed 24 hours later after correction
of the coagulopathy

70.  Assessment of the entire genital tract is essential (The
perineum, vagina and cervix should all be visually
inspected for bleeding sources).
 Compression should be applied to bleeding areas and
repair attempted, either in the labor ward or the operating
theatre if required.
 Compare patient general condition and amount of
blood loss from laceration site (if patient is shocked
and the amount of vaginal bleeding is normal, consider
intra-abdominal sources such as ruptured uterus, broad
ligament haematoma, subcapsular liver rupture, ruptured
spleen)

71.  Treat underlying cause
 Evaluate coagulation status (Platelet count, PT, PTT, and
fibrinogen)
 Correction coagulation defect with (FFP,
cryoprecipitate, platelets)
 Recombinant Factor V11 (Novoseven©) and
Fibrinogen.
 Support intravascular volume by fresh blood
transfusion
 Additionally use of hemostatic drugs

72. Tranexamic acid
 1g of tranexamic acid iv slowely, the dose was repeated
after 30 minutes if bleeding was persistent.
 Tranexamic acid reduces death due to bleeding in women
with post-partum haemorrhage with no adverse effects
 Tranexamic acid should be given as soon as possible after
bleeding onset.
 Tranexamic acid should only be administered in the context
of overall patient management
(National Blood Authority. Patient Blood Management Guidelines: Module 5
Obstetrics and Maternity. 2015).

73.  AMTSL (Active management of 3rd stage
of labor) should be used in every delivery
 Intervention should be done before
patients have symptoms or altered vital
signs
 Initial response to PPH:
◦ Team approach, call for help
◦ Bimanual massage
◦ Two large bore IVs, oxytocin
 Remember 4 Ts causes of PPH: Tone,
Trauma, Tissue, Thrombin 73

74.  Practice prevention better than treatment
 Always be prepared and ready (physical and mental)
 Keep in mind Blood loss is often underestimated
 Assess the blood loss carefully
 Assess maternal status
 Resuscitation must be vigorous and optimum
 Find the cause rapidly
 Treat the cause
 Ongoing trickling can lead to significant blood loss
 Blood loss is generally well tolerated to a point?

75.  Panic
 Panic
 Hysterectomy
 Pitocin
 Prostaglandins
 Happiness