management of postpartum hemorrhage in obstetrics and gynecology,bleeding can lead to death of mother after delivery. it is a very serious problem that need immediate interventions

1. THIRD STAGE
COMPLICATIONS
Third stage complications
Sreya Paul ,118

2.  About half a million women die every year across the world due to
reasons related to pregnancy and childbirth.
 Approximately one quarter of them succumb to third stage
complications, primarily Postpartum haemorrhage

3.  The complications encountered in the third stage of labour include:
1. Postpartum haemorrhage
2. Retained placenta
3. Morbidly adherent placenta
4. Inversion of uterus
5. Amniotic fluid embolism

4. Postpartum haemorrhage
 Primary postpartum haemorrhage is defined as
1. a blood loss of more than 500 ml from the genital tract in the first 24
hours of child birth
2. in caesarean section-blood loss more than 1000 ml is considered
significant
 Bleeding before the delivery of placenta is called third stage
haemorrhage.
 Secondary postpartum haemorrhage – bleeding occurring after 24 hours
and up to 6 weeks postpartum

5.  A more practical definition of postpartum haemorrhage is a haematocrit
drop of 10% or a haemorrhage that requires immediate transfusion
 Significant postpartum haemorrhage - amount of blood loss that
produces significant signs and symptoms of haemodynamic instability or
bleeding to a degree that will result in haemodynamic changes if left
untreated.
 Primary haemorrhage complicates about 5% of all deliveries

6. Causes
1) Atonic postpartum haemorrhage
2) Traumatic postpartum haemorrhage
3) Coagulopathy
4) Retained placenta and placental fragments
5) Morbidly adherent placenta
6) Uterine inversion
Remember 4 T’s – Tone,Trauma,Tissue,Thrombin

7. Atonic postpartum haemorrhage
 Most common cause – 90%
 It is the failure of the uterus to contract adequately after the child is
born.
 Blood vessels have not been obliterated by contraction and retraction of
the uterine muscle fibres
 Living ligatures

9.  Grand multiparity—Inadequate retraction and adherent placenta
 Over distended uterus – multiple pregnancy,hydramnios,macrosomia
 Previous history of atonic postpartum haemorrhage
 Rapid and prolonged labour.( uterus, which had contracted very strongly or
feebly is more likely to bleed, dehydration in prolonged labour)
 Antepartum haemorrhage
 Oxytocin induced or augmented labour
 Chorioamnionitis
 Uterine abnormalities or fibroids- placenta attachment and inadequate
retraction
 Retained placental fragments
 General anaesthesia (halothane)
 Mismanagement of third stage of labour – premature attempts to express
placenta before separation is complete, rapid delivery of baby ,pulling cord
 Constriction ring

11. Traumatic postpartum haemorrhage
 Genital tract injuries – laceration of cervix,vagina,perineum
 Vulvovaginal haematomas – concealed cause
 Colporrhexis and ruptured uterus.
Predisposing factors:
 Instrumental delivery
 Vaginal birth after caesarean
 Face to pubis delivery
 Precipitate labour
 Macrosomia

12. Coagulopathy
 Disseminated intra vascular coagulation and hypofibrinogenemia –rare
- Considered in all patients at risk for coagulopathy
Predisposing factors:
 Abruption
 Sepsis
 Intra uterine death
 Severe preeclampsia with HELLP syndrome
 Amniotic fluid embolism

13. Retained placenta and its fragments
 Third stage haemorrhage
 Rule out placental lobes and fragments being retained and causing
bleeding
 Remove using sponge holding forceps

14. management
Active management of third stage of labour :
1. Reduces incidence of PPH
2. Quantity of blood loss
3. Need for blood transfusion
Components :
1. Administration of oxytocin within 1 min after delivery of baby
2. Controlled cord traction
3. Uterine massage after the delivery of placenta

15. Symptoms and signs
 Rising pulse rate
 Drop of blood pressure
 Pallor
 Sweating
 Poor capillary refill
 Cold extremities
 Faintness/dizziness ,nausea ,thirst

16. What to do??
Call for help --A multidisciplinary team is formed
1.General measures
 Resuscitative measures
 Investigations
 Monitoring
 Confirm the cause of postpartum haemorrhage
2.Medical methods
3.Mechanical methods
4.Surrgical methods
5.Radiological arterial embolisation

17. 1.General methods
 Resuscitation measures
1. Fluid replacement
- two iv infusions with large 14 gauge cannula are started
- crystalloids (normal saline or ringer lactate) are rapidly infused at the
rate of 1l in 15-20min
-amount of crystalloid required will be three times the volume of blood
lost
- up to 2l crystalloids and 1-2l colloids can be given while awaiting blood
- cross matched blood should be given as soon as possible
- a cvp line can be introduced and after resuscitation the cvp should rise
btw 10 and 12mm hg

18. 2. Blood component therapy
- each unit of packed cell restore haemoglobin by 1gm/dl
- if coagulation defect—fresh frozen plalsma,platelet
concentrates,cryoprecipitates
-for 6 units red cells , 4 units ffp
-each unit ffp restore pro coagulant activity by 10% and fibrinogen level
raised by 25mg/dl
-if fibrinogen level is below 100 mg/l—cryoprecipitate containing factor
viii,fibrinogen,von wille brand factor is indicated

19. -each adult dose of cryoprecipitate raise fibrinogen level by 100 mg/dl
-if platelet count is <50000/l—platelet concentrates
- each adult dose of platelet concentrate raise the platelet count by
20000/l
-recombinant factor VIIa –severe cases –common protocols failed
3. Oxygen delivery
-10 to 15 l/min
4. Other methods--- leg elevation, turn patient to one side, keep patient
warm

20. Investigations
 Laboratory test
- HB ,Haematocrit, blood grouping and cross matching
- platelet count, fibrinogen assay, partial thromboplastin
time,prothrombin time, fibrin degradation products
-electrolytes , urea ,creatine
 Bed side tests
-clotting time---- < 10 min – fibrinogen level > 100 mg/dl
- after 1 hour if good clot retraction – platelet normal
- clot instability –fibrinolysis due to fibrin degradation products

21. Monitoring
Done initially and repeated at least 4th hourly
 Pulse and BP
 Heart rate by ECG monitor
 Pulse oximetry
 Central venous pressure line (to assess adequacy of fluid replacement)
 Hourly urine output
 Fluids and drugs given

22. Confirmation of diagnosis
 First note the feel of uterus
- if flabby , boggy ,soft ,enlarged --atonic uterus
-firm and contracted– traumatic origin
 Genital tract injuries are looked for and sutured
 If placenta is not expelled , signs of expulsion are looked for??
 If placenta is not separated and heavy bleeding –manual separation under
GA and oxytocin to promote uterine contraction
 Inspect for the presence of succenturiate lobe
 Inversion checked and corrected

23. Medical methods
 Oxytocin
-20 to 40 units in 500 ml normal saline ,infusion rate –60 drops/min
-oxytocin 5 units can be given as slow IV bolus
- smooth muscles of upper segment of uterus contracts rhythmically
 Ergometrine
-upper and lower smooth muscles contract tetanically
-ergometrine—0.25 mg IM or
-methergin –0.2 mg IV and repeated after 15 min
the same may be repeated every 4 hours (max 5 doses in 24 hrs.)
-careful in hypertensive– IV use can lead to dangerous hypertension

24.  Prostaglandin derivatives
-prostodin ( 15 methyl analogue of PGF2 alpha) 250 microgram given
both IM and intra murally into uterine musculature and repeated after15
min for a max 3 doses
- severe bronchospasm ,so use with caution in asthmatic ( relatively CI)
- Misoprostol or PGE1 analogue 200 microgram can be inserted vaginally
or rectally up to max 800 microgram– low cost and ease of administration

25. Mechanical methods
1. Bimanual compression
the abdominal hand massages the posterior aspect of the uterus and
vaginal hand made in to a fist ,presses the anterior uterine aspect through
the anterior fornix. Bring both hands together to squeeze the uterus.
it is done continuously to promote contraction of uterus

26.  Aortic compression
Blood flow is restricted to the upper body and vital organs
Bleeding in lower area is reduced and hence volume is conserved

27. 2. Uterine packing
before transporting to a tertiary centre
but it can mask the bleeding
not recommended today
3. Balloon tamponade
hydrostatic balloon catheters are used— Sengstaken Blakemore tube,bakri
balloon

28. 4. Condom tamponade
before transporting patient to a
tertiary centre
replaced packing
oxytocin continued
can be retained for 24 – 48 hours
and deflated slowly
it can avoid a hysterectomy in
many cases

29. Surgical methods
1. Undersewing
- undersewing the placental bed with figure of eight sutures or purse
string suture can be done at caesarean section for placenta previa
2. Cho's multiple block sutures
- approximation of anterior and posterior uterine walls with multiple
squares until no space is left in uterine cavity
- useful in atonic and placental site bleeding

30. 3. B-Lynch or brace sutures
B Lynch in 1977
vertical brace sutures, which will appose the anterior and posterior walls
of uterus
compress the fundus and lower uterine segments
very easy to perform and hysterectomy can be avoided many a time
commonly done after caesarean section but can be done after vaginal
delivery also

31. 4. Modified B Lynch
By Hayman and colleagues
Two vertical compression sutures placed on either side of the fundus,
Its quicker than B Lynch and doesn't require a low transverse incision –
useful in vaginal delivery
Also two horizontal compression sutures ( passing anterior and posterior
through uterus and tied anteriorly one on each side
Multiple interrupted sutures are also put .they are first placed anteriorly
and then posteriorly if necessary

34.  5.systematic pelvic devascularisation
Laprotomy and stepwise devascularisation
Uterine artery—ovarian artery—internal iliac are ligated
Absorbable sutures are used

35.  Uterine and ovarian artery ligation
The ascending branch of uterine artery is ligated at the lateral border of the upper
and lower segments.
A no.1 absorbable suture is passed into the myometrium,2cm medial to the artery
and then through an avascular space in the broad ligament and then tied.
Ovarian artery is ligated just below the ovarian ligament

36.  Internal iliac artery ligation
The ligation of anterior division internal iliac artery is another option and is done
combined with ovarian artery ligation.
In nulliparous as the uterus can be conserved
Reduces pulse pressure by 85% and thereby reduces bleeding
Retroperitoneal space is entered and artery is ligated about 3 cm from the division
of common iliac artery –ensure that posterior division is not included
Artery as a whole can also be ligated
Dorsalis pedis and femoral pulsations are looked to ensure external iliac is not tied –
loss of entire limb
Disadvantage---requires high degree of surgical skill

38.  Hysterectomy
as a last life saving resort
Indications:
1.Severe atonic haemorrhage
2.Placenta accrete
3.Placenta praevia
4.Uterine rupture
Total hysterectomy /subtotal hysterectomy can be done
Ovaries should be retained

39.  Radiological arterial embolization
If the patient is haemodynamically stable and if there is a good
interventional radiology team
Under angiographic guidance and a percutaneous trans catheter technique-
femoral artery catheterisation is performed—bleeding vessels are identified
and embolization is carried out with gel foam or microspheres.

41. Secondary post partum haemorrhage
 Aetiology
1. Sepsis
2. Retained placental fragments
3. Poor wound healing in previous caesarean section
4. Placental site trophoblastic tumour or choriocarcinoma

42. Management
 Broad spectrum antibiotics – infection control
 Oxytocics also given
 Trans vaginal ultrasound-placental fragments—evacuated—perforation
can occur in puerperal uterus---send for histopathology----trophoblastic
malignancy
 Indiscriminate curettage avoided—esp. in prev CS --injure the scar—
bleeding
 Other methods –angiographic embolization of bleeding vessel
 b/l internal iliac artery ligation, hysterectomy

43. Sheehan syndrome
 Rare consequence of severe post partum haemorrhage
 Anterior pituitary necrosis and pituitary failure
 Failure of lactation,amenorrhea,hypothyroidism,adrenocortical
insufficiency
 CT scan –partially or totally empty sella tursica

45. Prevention
 It is not always possible to prevent PPH but certain general measures are
prophylactic
 Anaemia – corrected in antenatal period
 PPH is anticipated in all high risk patients and institutional delivery is
arranged
 Blood arranged
 In preeclampsia and anaemia – prompt replacement is mandatory as a
small blood loss is detrimental
 Partogram during labour- prevent prolonged labour

46.  Dehydration should be corrected and all patient should have an IV line in
second stage
 Active management of third stage of labour –uterine massage, prophylactic
oxytocics before placental delivery, controlled cord traction
 Completeness of placenta is checked for after delivery. Genital tract
examined in case of instrumental delivery, oxytocin infusion continued, vital
signs monitored closely. Patient not left unattended for 1 hour following
delivery
 Placenta previa especially in presence of a previous caesarean – experienced
obstetrician needed
 Protocol for PPH management in every hospital. Drills carried out at intervals
– for prompt management when emergency occurs