pph in obstrectric for UG

1. POST PARTUM
HEMORRHAGE
(PPH)
NUR FARRA NAJWA BINTI ABDUL
AZIM
082015100035

2. LEARNING OBJECTIVE
By the end of seminar student should be able to
discuss
1. What is post-partum haemorrhage (PPH)
2. Classification
3. Type of PPH
4. Causes of PPH
5. Risk factor of PPH
6. Diagnosis of PPH
7. Clinical effect of PPH
8. Prognosis of PPH
9. Prevention of PPH
10. Management of PPH

3. INTRODUCTION
 3rd stage of labour is most important to
mother
 Fatal complication may appear
 Important complication
◦ Postpartum haemorrhage
◦ Retention of placenta
◦ Shock (haemorrhagic /non-haemorrhagic)
◦ Pulmonary embolism
◦ Uterine inversion

5. DEFINITION
QUANTITATIVE DEFINITION :
 Blood loss of ≥500ml following delivery
(both Spontaneous Vaginal Delivery or
Caesarean section).

6. CLINICAL DEFINITION
 Any amount of bleeding from or into the
genital tract following birth of the baby up to
the end of the puerperium which adversely
affect the general condition of the patient
evidence by
◦ rise in pulse rate
◦ falling in blood pressure.

8. NORMAL AVERAGE BLOOD LOSS :
1. Vaginal delivery = 500ml
2. Caesarean section = 1000ml
3. Caesarean hysterectomy = 2000 ml

9. TYPES OF PPH

10. Further Classification Of Primary
PPH
Classification based on
amount of blood loss
MINOR
<1L
MAJOR
>1L
SEVERE
>2L

11. PRIMARY SECONDARY
• Occurs within 24 hours following
the birth of the baby.
• Occurs beyond
24 hours and
within
puerperium.
3RD STAGE
HAEMORRHAGE
TRUE PPH
• Bleeding occurs
before
expulsion of
placenta.
• Bleeding
occurs
subsequent to
expulsion of
placenta.

12. PRIMARY
POST PARTUM
HAEMORRHAGES
a) Definition
b) Causes
c) Risk factor
d) Diagnosis and clinical effect
e) Prognosis
f) Prevention
g) Management

13. PRIMARY
• Occurs within 24 hours following the
birth of the baby.
3RD STAGE
HAEMORRHAGE
TRUE PPH
• Bleeding occurs
before expulsion
of placenta.
• Bleeding
occurs
subsequent to
expulsion of
placenta.
A)

14. B)

15. 1. Tone - Uterine Atony - 80%
• After separation of placenta, bleeding will continue at
placental site as the uterine sinuses that have been torn
cannot be compressed effectively.
• Failure of uterus to contract & retract.
Open uterine sinuses

16. Presented with:
a) Excessive bright red bleeding
b) Boggy uterus
c) High fundus with non-contracting uterus
d) Abnormal clot
e) Unusual pelvic discomfort or backache

18. C) RISK FACTORS
• Grand multipara
• Over-distention of uterus
• Malnutrition and anemia
• Antepartum hemorrhage
• Prolonged labor
• Anaethesia usage
• Initiation or augmentation of delivery by oxytocin
• Uterus malformation
• Uterine fibroid

19. • Placenta abnormalities
• Precipitate labour
• Mismanaged 3rd stage of labor
● Too rapid delivery of baby,
● Premature attempt to separate placenta before it is
separated
● Pulling the cord
● Kneading and fiddling the uterus
● Manual separation of placenta

20. 2. Trauma – Traumatic Delivery- 20%
• Usually occurs following operative delivery.
• Underestimated blood loss from episiotomy wound and
lacerations.
• Blood loss in casaerean section of 800-1000ml.
• In rare cases, uterine rupture occur if delivery happened
before the cervix is fully dilated.

21. • Trauma sites :
● Vulva
● Vagina
● Cervix
● Perineum
● Paraurethral region
● Rupture uterus
*Bleeding is usually revealed but can rarely be
concealed in case of vulvovaginal or broad ligament
hematoma.

22. 3. Retained Tissues
 Bit of placenta
 Blood clot
4. Thrombin – Coagulation Disorders
 Congenital or acquired
 May be due to diminished pro coagulants
(washout effect) or increased fibrinolytic activity.

23. Condition leading to thrombosis :
● Placental abruption
● Jaundice in pregnancy
● Prolonged retention of dead fetus
● Thrombocytopenic purpura
● HELLP syndrome
● Any congenital coagulation disorders

24. D) DIAGNOSIS
 Vaginal bleeding
● Visible as a slow trickle.
● May be concealed as in broad ligament
hematoma or vulvo-vaginal
 Effect of blood loss depends on :
● Pre delivery hemoglobin level.
● Degree of pregnancy induced hypervolemia.
● Speed at which blood loss occur.
● Alteration of vitals appear after Class 2
haemorrhage

25. • State of uterus as felt per abdomen
● Traumatic hemorrhage : Well contracted
● Atonic hemorrhage : Flabby and becomes hard on
massaging
*Both atonic and traumatic cause may coexist.
Traumatic hemorrhage causes a state of low general
condition hence making the uterus atonic.

27. E) PROGNOSIS
 Life threatning emergencies
 Major cause of mother death in developed and
developing country
 Increase morbidity due to
◦ shock,
◦ transfusion reaction,
◦ pueperal sepsis,
◦ failing lactation,
◦ pulmonary embolism
 Late sequaele : sheehan syndrome

28. SHEEHAN SYNDROME
 Postpartum necrosis of posterior pituitary gland
causing hypopituitarism
 Due to severe haemorrhage or shock as blood loss
during or after labour
 Present as anterior pituitary hormone deficiency
 Evolve slowly and diagnose late

29. F) PREVENTION
 Cannot always be prevented
 But incidence and magnitude can be reduced by
assessing risk factor and follow the guideline
stated
*however, most cases have no identifiable risk factor

30. PREVENTION GUIDLINE
ANTENATAL
● Improvement of the health status (keep the Hb
level normal, >10g/dl).
● High risk patient need to be screened and
delivered in a well equipped hospital.
● Blood grouping
● Placental localization must be done
● Women with morbid adherent placenta with high
risk PPH delivered by senior consultant

31. INTRANATAL
● Active management of 3rd stage of labor.
● For cases with induced or augmented labor by
oxytocin, the infusion should be continued for at least
1 hour after delivery.
● Women delivered by caesarean given oxytocin 5IU
slow IV
● Exploration of uterovaginal canal for evidence of
trauma.

33. Cont
● Observation for about 2hours after delivery.
● For caesarean section, spontaneous separation
and delivery of placenta will reduce blood loss.
● Examination of placenta and membranes should
be done as a routine to detect any missing part.
● Local or epidural anaethesia is preferable,
general anaesthesia requires expert obstetric
anaethetist

34. G) MANAGEMENT OF 3RD
STAGE BLEEDING

35. Principle:
1. Empty uterus from its content and
make its contract
2. Replace blood
3. Ensure effective hemostasis
STEPS
Placenta
site
bleeding
Traumatic
bleeding

36. A) Placenta Site Bleeding
Catheterize the bladder
Oxytocin 10 units IM or methergine 0.2 mg is given
IV
Start crystalloid solution with oxytocin (1 L with 20
units) at 60 drops per minute and arrange for blood
transfusion.
Palpate fundus and uterus to make it hard

37. Resuscitated first!
If the patient is in shock, she is
If features of placental separation are evident,
Expression of the placenta is
to be done either by fundal
pressure or controlled cord
traction method.
If the placenta is not
separated, manual removal
of placenta under general
anesthesia is to be done.
Give antibiotics (ampicillin 2 g and metronidazole
500 mg IV).

38. Manual removal is done promptly when two attempts
of controlled cord traction fail.
Oxytocin 10 units is given IM with the delivery of
the anterior shoulder,
Quick manual removal of the placenta
Delivered under general anesthesia,

39. B) Traumatic Site Bleeding
 The uterovaginal
canal is to be
explored under
general anesthesia
after the placenta is
expelled and
hemostatic sutures
are placed on the
offending sites.

40. STEPS OF MANUAL
REMOVAL OF
PLACENTA

41. Step 1
 Under general anesthesia.
 OR deep sedation with 10 mg
diazepam given intravenously.
 Lithotomy position.
 With all aseptic measures,
 The bladder is catheterized.

43. Step 2
 One hand is introduced into the uterus
after smearing with the antiseptic
solution in cone shaped manner
following the cord, which is made taut
by the other hand
 The labia are separated by the fingers
of the other hand.
 The fingers of the uterine hand should
locate the margin of the placenta

45. Step 3
 Counter pressure on the uterine
fundus is applied by the other hand
placed over the abdomen.
 The abdominal hand should steady
the fundus and guide the movements
of the fingers inside the uterine cavity
until the placenta is completely
separated.

47. Step 4
 As soon as the placental margin is
reached, the fingers are insinuated
between the placenta and the uterine
wall with the back of the hand in
contact with the uterine wall.
 The placenta is gradually separated
with a sideways by
slicing movement of the fingers, unt
il whole of the placenta is separated

49. Step 5
 When the placenta is completely
separated, it is extracted by traction of
the cord by the other hand.
 The uterine hand is still inside the
uterus for exploration of the cavity to
be sure that nothing is left behind

51. Step 6
 Intravenous methergine 0.2 mg is
given and
 Uterine hand is gradually removed
while massaging the uterus by the exter
nal hand to make it hard.
 After the completion of manual removal,
inspection of the cervicovaginal canal is to
be made to exclude any injury.

53. Step 7
 The placenta and membranes are
inspected for completeness and be
sure that the uterus remains hard and
contracted

56. DIFFICULTIES
(1) Hour-glass contraction
leading to difficulty in introducing the
hand
(2) Morbid adherent placenta
which may cause difficulty in getting to
the plane of cleavage of placental
separation.
In such a case placenta is removed gently
in fragments using an ovum forceps.

57. COMPLICATIONS:
(1) Hemorrhage due to incomplete
removal
(2) Shock
(3) Injury to the uterus
(4) Infection
(5) Inversion
(6) Subinvolution
(7) Thrombophlebitis
(8) Embolism.
In such cases placenta is removed in
fragments using an ovum forceps or a
flushing curette.

58. MANAGEMENT OF TRUE
PPH

59. PRINCIPLE
1. Communication
2. Resuscitation
3. Monitoring
4. Arrest of bleeding

62. IMMEDIATE MEASURES :
• Call for extra help – involve a senior obstetrician.
• Put in two large bore (14 gauge) of intravenous
cannulas.
• Keep patient flat and warm.
• Send blood for group, cross matching, diagnostic
tests.
• Ask for 2 units of blood at least.
• Infuse rapidly 2L of normal saline or plasma
substitutes.

63. • Give oxygen by mask 10–15 L/min.
• Start 20 units of oxytocin in 1L of normal saline IV at the
rate of 60 drops per minute.
• Monitor the following :
● Pulse
● Blood pressure
● Respiratory rate and oxymeter
● Type and amount of fluids the patient has received
● Urine output (continuous catheterization)
● Drugs - type, dose and time
● Central venous pressure (when sited)

64. ACTUAL MANAGEMENT
• ATONIC UTERUS
Step 1
● Massage uterus to make it hard and express blood clot.
● Methergin 0.2mg IV
● Inj Oxytocin 10U in 500ml of normal saline, at a rate of
40-60 drops/min.
● Foley catheter to monitor urine output.
● Examine the expelled placenta for evidence of missing
cotyledons or membranes.
*If uterus fails to contract, proceed to step 2

65. Step 2
● Explore uterus under general anesthesia.
● In refractory cases :
• Inj 15-methyl PGF2α 250mcg IM in deltoid muscle
every 15 min (maximum dose : 2mg)
OR
• Misoprostol (PGE1) 1000mcg per rectum.
• If atony is due to tocolytic drug, Calcium gluconate
1g IV slowly is given.

67. Step 3
• Uterine massage and bimanual compression.
● Continue compression for a prolonged period of time
until the tone of uterus is regained.
● Absence of bleeding if the compression is released
indicates regaining of tone.

69. • Resuscitative measures are to be continued.
• If bleeding continues, there might be a possibility of
blood coagulation disorders.
• Massive fresh blood transfusion is to be given.

71. TIGHT INTRAUTERINE
PACKING
 Under GA.
 A 5-meters long strip of gauze, 8 cm wide folded twice is
required.
 The gauze should be soaked in antiseptic cream before
 The gauze is placed high up and packed into the f
undal area first
 Gradually, the rest of the cavity is packed so that no
empty space is left behind.
 A separate pack is used to fill the vagina.
 An abdominal binder is placed.

72. TIGHT INTRAUTERINE PACKING

73. CONT.
 Stimulate uterine contraction and direct
hemostatic pressure to the open uterine
sinuses.
 Antibiotic should be given and the plug
should be removed after 24 hours.
 Useful in a case of uncontrolled postpartum
hemorrhage where other methods have
failed and the patient is being prepared for
transport to a tertiary care center.

74. BALLOON TAMPONADE
 Various types of hydrostatic balloon
catheter
 Mechanism of action is similar to uterine
packing.
Foley catheter
Bakri balloon
Condom catheter
Sengstaken-Blakemore tube
 Inserted into the uterine cavity and
inflated with normal saline (200–
500 mL).
 Kept 4-6 hours.

75. BAKRI BALLON

76. CONDOM CATHETER

77. SENGSTAKEN-BLAKEMORE TUBE

78. B-LYNCH COMPRESSION SUTURE

79. SUMMARY
1. What is post-partum haemorrhage
(PPH)
2. Classification
3. Type of PPH
4. Causes of PPH
5. Risk factor of PPH
6. Diagnosis of PPH
7. Clinical effect of PPH
8. Prognosis of PPH
9. Prevention of PPH
10. Management of PPH*

80. REFERENCES
 Mudaliar and Menon’s Clinical
Obstetrics, 11th edition, Sarala Gopalan
and Vanita Jain, Complication in Third
Stage of Labour (pg: 422-428)
 DC Dutta’s Textbook of Obstetrics, 9th
edition, Hiralal Konar, Complication in
Third Stage of Labour (pg: 410-418)
 Essential Of Obstrectric, Lakshmi
Seshadri, Gita Arjun,complication Of
Third Stage Of Labour(pg: 641-661)