Postpartum

Hemorrhage
Every minute….,
Everyday…..,
some where in the
world …….
and most often in a
Developing country,
….a woman dies from
complications of
pregnancy.

1
 Postpartum Hemorrhage Magnitude of
the problem
WHO
MMR IN INDIA
25.7% Of maternal
deaths in world
occur in India.
25.7
1
India
2
MMR 353/lakh live
births .(2004-2005) Rest of the
world

Hemorrhage is the
leading cause.

2
 POSTPARTUM
HAEMORRAGE
Incidence of PPH
 About 5% of all
deliveries.
1
2
60%
 60% of all postpartum
maternal
death occur post
partum.
45% 1
2
 45% 0f this occur <24hrs
in 1st 24 hrs of
delivery.
3
 Postpartum Hemorrhage 3 Ds causing the
4th D(eath)
 1. Delay in recognizing & seeking help.
How to diagnose

 2. Delay in transport & reaching

medical facility.
When to shift?

 3. Delay in receiving an adequate &

comprehensive care upon arrival
What & how to give early & appropriate treatment
4 ?
 Postpartum Hemorrhage OBJECTIVES

PRACTICAL TEACHING
& STRUCTURED APPROACH

 Anticipate PPH.
 Identify PPH / Recognize PPH.
 Manage PPH efficiently without
delay.
 Prevent maternal death. 5
 Skilled
Postpartum Hemorrhage
attendants,
2000
only 42.6 %
Maternal deaths per 1000000 live births

1800
2
R = 0.74
1600 Y Log. (Y)

1400

1200

1000

800 INDIA
600

400

200

0
0 10 20 30 40 50 60 70 80 90 100

% skilled attendant at delivery

6
 Postpartum Hemorrhage

AIM OF THE MODULE

To create preparedness & skill to tackle PPH .

To Ensure correct technique and correct

sequence of events in response to PPH.

To create confidence in tackling PPH.

7
 Postpartum Hemorrhage
Assess risk
factors
Ante partum Intrapartum Post Partum
APH/ Operative Genital tract
Previous delivery, injury
PPH / MRP Manipulations

Over Prolonged Retained

distended labor placenta
uterus
Adherent Infection Uterine
placenta inversion
Congenital or Acquired 8
 Postpartum Hemorrhage REMEMBER

Every woman in labor is at risk

of PPH.

2/3 of those with PPH –have no

Be prepared in all labors
identifiable risk factors.

Active management of third

stage of labor should
It prevents be
60% of atonic PPH
practiced on ALL women in labor.
9
 Postpartum Hemorrhage PREVENTION

ACTIVE MANAGEMENT OF LABOUR

OXYTOCIN
<1 min of delivery of
baby,
Controlled cord traction with
5 units IV bolus/
Counter traction during uterin
10 units IM /
contraction
10 units / 500ml
NS
( 30 – 40 drops 10
 Postpartum Hemorrhage DIAGNOSI
S
Traditional Definition of PPH
 Blood loss of >500ml following child
birth.
Functional Definition
 Blood loss of <500ml can be fatal in
anemic and in those with
contracted intravascular volume as
in PIH. REMEMBER
Blood loss is consistently underestimated

11
Postpartum Hemorrhage
Even healthy, non anemic
women
can have catastrophic
blood loss.

Continuous slow
bleeding/sudden bleeding
is an emergency

Intervene early and 12

 Postpartum Hemorrhage General
Management
 Shout for help.
 Rapid evaluation of vitals.
 Oxygen by mask.
 Uterine massage.
 Oxytocin 10 U IM. lab test
 Draw & Send
Site 2 large bore (16G-gray color) IV cannula,
for
The blood for lab tes
Save blood
 Infuse IV fluid – NS / RL- run it fast.
 Catheterize bladder.
 Check the placenta –
 If it has been expelled
 If it is expelled , re examine & make
sure it is complete.
 Examine vagina, perineum and cervix for tears.

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 Postpartum Hemorrhage
Step 1
A = Airway
B = Breathing
C = Circulation
A
A B
B C
Assess
Assess Big C
Big bore
bore CBC
the
the shock
shock cannula CBC
cannula Cross
Assess
Assess (16g) Cross
(16g) match
the
the match
cause.
cause. Coagulatio
Coagulatio
Arrange
Arrange nn screen
screen
for
for 14
 Postpartum Hemorrhage AETIOLOGY

REMEMBER - 4Ts
Tone - Uterine atony. (Commonest)

Tissue - Retained tissue/ clots.

Trauma - Laceration, rupture, inversion.

Thrombin - Coagulopathy.

15
 Postpartum Hemorrhage Assessment
of Shock

CompensatioMild Moderate Severe

n
Symptoms Palpitation, Weakness, Restlessnes Collapse,
& signs dizziness, sweating, s, pallor, air-hunger,
tachycardia tachycardia oliguria anuria

BP Slight fall Marked fall Profound

(Systolic) Normal 80- 70- fall
100mmHg 80mmHg 50-
70mmHg
Blood loss 500-1000ml 1000- 1500- 2000-
Blood 10-15% 1500ml 2000ml 3000ml
volume 15-25% 25-35% 35-45%
16
 Postpartum Hemorrhage
Step 2
STEP 2- DIRECTED THRPAPY

IMMEDIATE PPH- PALPATE

UTERUS
SOFT CONTRACTED
UTERUS UTERUS

Placenta Fundus
Placent retained not felt Comple
a / +Shock
Expelle Partially te
+Pain
d expelled placent
complet a
ely TRAUMA
ATONIC TISSUE INVERSION

Massage MRP/ Immediate Cervical/

Ut Evacuat Reposition Vaginal/
Oxytocics e Of uterus Perineal 17
 Postpartum Hemorrhage Oxytocics
Dose & Maintenan Max frequency Precautio
route ce dose dose n /CI
Oxytocin IV IV infuse Not -
infusion 10U/500ml more
10U/500 40dpm than 3lt
ml
60dpm
Ergometri IM / 0.2mg 5 4th hourly PIH, HT,
ne / slow IV ofafter 15 doses. Heart
Methergin 0.2mg min. (1mg) disease.

15methyl IM 250μg 250μg 8 doses 15 - Asthma,

PGF2α ** after (2mg) 90mnts heart
15mnts disease.

** NEVER GIVE PROSTAGLANDIN INTRAVENOUSLY

18
 Bleeding
Postpartum Hemorrhage
continues
Think :
THROMBIN
Coagulopath
y
Cause/result
of PPH

COAGULOPATHY ----- Replace factors

THINK OF SHIFTING THE
PATIENT
19
 Postpartum Hemorrhage STEP 3
INTRACTABLE PPH

BP Local
Local Control
Control
BP &
& --Manual
Coagulation Manual
Coagulation compression
compression
-- Crystalloids
Crystalloids +/-
-- blood +/- pack
pack uterus
uterus
blood products
products +/-
+/- vasopressin
vasopressin
+/-
+/- embolisation
embolisation

Get
Get more
more help
help
-- Obstetrician
Obstetrician // Time to shift
surgeon
surgeon
-- Anaesthesiologist
Anaesthesiologist
--Haematologist-BT
Haematologist-BT 20
-- Lab & ICU
 WHERE TO
Postpartum Hemorrhage
SHIFT?
 Delay in shifting is an important
cause of Death
 Think of shifting as early as possible.
 Shift as quickly as possible.
 Communicate- to patient /attendant
 - to the tertiary care personnel

 Shift to a tertiary care centre with:

 OT
 ICU
 Blood bank
 Personnel
21
 Postpartum Hemorrhage HOW TO
SHIFT?
 Shift preferably in an ambulance,
 With nasal oxygen on flow
 With 2 IV lines with fluid on flow (it can be
lifeline)
 Document
 The events in sequence
 IV fluids given
 Drugs administered
 Communicate to personnel at tertiary care
centre.
22
 Postpartum Hemorrhage
Step 4
Surgery-donot hesitate

Repair Ligate Hysterect

laceratio Vessels omy
ns Stepwise ( life
saving )

23
 Postpartum Hemorrhage
Step 5

Debriefing

Discussions

Documentation

24
Postpartum Hemorrhage

Management – Bimanual
massage

25
Postpartum Hemorrhage

Replacement of Inverted Uterus

26