POST PARTUM

HEMORRHAGE
dr. Munizar. Sp.OG
DEFINITION:
It is bleeding in excess of 500cc in the first
24hours after vaginal delivery.
>1000cc blood loss after cesarean section.
>1500cc blood loss after CS hysterectomy
ACOG 10% drop in hematocrit value between
admission & PP period,or a need for blood
transfusion.
CLASSIFICATION OF PPH:
1ry : PPH within 1st 24 hours of delivery.

2ry :PPH after this time ;up to 6 weeks

postpartum.
MATERNAL MORTALITY OF PPH;
The risk of dying from PPH is about 1 in
100,000 deliveries in UK.

This is 100 times higher in developing

countries .

Globally > 130,000 women die every year

from PPH.
ETIOLOGY OF PPH
The causes of postpartum hemorrhage can
be thought of as the
tone,
tissue,
trauma,
thrombin
ETIOLOGY OF PPH
1. Uterine atony (80%)
2. Retained Placenta
3. Trauma to genital tract
4. Coagulation disorders
5. Uterine inversion
 TEAM- Obstetrician, Anesthesiologist,
Hematologist and Blood Bank
Correction of hypovolemia
Ascertain origin of bleeding
Ensure uterine contraction
Surgical management
Management of special situation
MANAGEMENT PPH
CORRECTION OF HYPOVOLEMIA
talk to and assess patient
Get HELP!
Large bore IV line (two)
Crystalloids (RL)
Monitor Urine output
Whole blood / pack cell
 ENSURE UTERINE CONTRACTION
Palpate fundus
Uterine massage
Bimanual compression
Compression of Aorta against sacral
promontory
Foleys catheters
STEP 1 INITIAL ASSESSMENT
Resuscitation:-Ensure IV access& Restore
circulating volume .-O2 by mask Monitor
BP,P,R,?CVP. Urine output (>30ml/hr ) .

Assess etiology:-Palpate uterine fundus

( atony , uterine inversion ). Explore birth
canal & uterine cavity .

Laboratory tests : CBC ; Coagulation

screen ;Group & X-match .
STEP 2 DIRECTED THERAPY
ATONY : -Massage , -Compression,-Drugs ,-
Surgery.
RETAINED TISSUE: -Manual removal
,Curettage,-Manage accreta .
TRAUMA:-Repair laceration,-Identify
rupture; repair VS hysterectomy.
UTERINE INVERSION: -Correct inversion.
DIC:-Transfuse:crystalloids;blood.-Replace
clotting factors.
UTERINE CONTRACTION-FIRST
LINE DRUGS
Oxytocin 5IU
Oxtocin infusion 40IU in 500mls
Ergometrine 0.2 mg
Carboprost (Haemabate) 0.25mg IM every
15 minutes x 8 doses
Misoprostol 600 mcg sublingually/oral, 400
mcg rectal
STEP 3 INTRACTABLE PPH
Get Help :- Most experienced OBGYN ,
-Anaesthesiologist,-Lab & ICU .

Local Control :- Manual compression +/-

pack uterus,+/- Hydrostatic tamponade .
STEP 4 SURGERY;
Repair Lacerations: - Vaginally & if needed
Laparotomy.

Ligate Vessels : - Uterine & Ovarians, -

Internal iliacs.

HYSTERECTOMY .
LACERATION CANAL BIRTH
Vaginal examination soon after delivery

repair:

cervical laceration >2cm in length and be

actively bleeding

laceration of vaginal and perineum

Give Sedation First, Diazepam , Prepare Vagal
Reflex, Atropin
UTERINE INVERSION
Manual
replacement-
Under GA /
Uterine relaxant
Hydrostatic
method
Surgical method (
Usually delayed
procedure)
UTERINE INVERSION
Resucitation, two IV line,
General Anesthesia

Give Tocolytic : MgSo4,

Terbutaline

Separate Plasenta

Restore Uterus

Stop Tocolytic, Give

Uterotonic : Oxytocin
ATONIA UTERUS
ATONIA UTERUS
Under GA uterus is firmly
compressed for 5-30 min
between closed fist of
Rt hand in anterior
vaginal fornix & Lt hand
on abdomen behind
body of uterus .
The compression is
maintained until uterus
is firmly contracted.
During this period, blood
transfusion , oxytocin and
ergometrine are given .
ATONIA UTERUS
Foley catheter
Filled
with 60-80ml saline
Remove after 12-24h
Segstaken blakemore,
Rusch balloons
Condom catheters
Bakri postpartum
balloon/BT cath
Insertion requires 2-3
persons
Succes rate 85%
Failuresurgical method
ATONIA UTERUS
Step V Surgical
Procedure B lynch
MANAGEMENT OF DIC
Fresh blood transfusion
Blood products
Cryoprecipitate
Fresh frozen plasma
Platelet concentrate
MORBIDITY & MORTALITY FROM
PPH
Shock & DIC
Renal Failure
Puerperal sepsis
Lactation failure
Blood transfusion reaction
Thromboembolism
Sheehans syndrome
>25% Maternal deaths are due to PPH
CONCLUSION
Most maternal deaths are avoidable & are
due to underestimation of blood loss,
inadequate volume replacement , & delay in
operative intervention.
Any delay in achieving haemostasis results in
terminal coagulopathy & later DIC .
At this stage even surgery may be too
late.Hence rapid & quick action is
mandatory.
THANK YOU