O&G Postpartum haemorrhage

1. Postpartum
Haemorrhage
Siti Aishah, Lee Cun Han, Najib

2. CONTENTS
DEFINITION
PRIMARY POSTPARTUM SECONDARY POSTPARTUM
HAEMORRHAGE HAEMORRHAGE
•CAUSES •CAUSES
•DIAGNOSIS & CLINICAL •DIAGNOSIS
EFFECTS
•PREVENTION •MANAGEMENT
•MANAGEMENT

3. Introduction
 Obstetric haemorrhage remains one of the major causes of maternal death
in both developed and developing countries.
 PPH is still the largest cause of maternal death, responsible for 24% in 1995
and 20.0% in 1996
 50% associated with substandard care
 3 main factors involved;
- 1. Home deliveries (46.7%)
- 2. Delay in resuscitating the mother
- 3. Delay in transportation to GH

4. •Primary postpartum haemorrhage (PPH) is the most common form of major obstetric
haemorrhage. The traditional definition of primary PPH is the loss of 500 ml or more of blood
from the genital tract within 24 hours of the birth of a baby. PPH can be minor (500–1000 ml) or
major (more than 1000 ml). Major could be divided to moderate (1000–2000 ml) or severe
(more than 2000 ml).
•Secondary PPH is defined as abnormal or excessive bleeding from the birth canal between
24 hours and 12 weeks postnatally.
•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 affects the
general condition of the patient evidenced by rise in pulse rate & falling
blood pressure is called postpartum hemorrhage.
*definitions from RCOG guideline (greentop guideline 52)
DEFINITION

5. PRIMARY PPH
Haemorrhage occurs within 24
hrs following the birth of baby
Primary PPH involving an estimated
blood loss of 500–1000 ml (and in the
absence of clinical signs of shock)
should prompt basic measures (close
monitoring, intravenous access, full
blood count, group and screen) to
facilitate resuscitation should it
become necessary
SECONDARY PPH
Haemorrhage occurs beyond 24 hrs and
within puerperium also called delayed or late
puerperal haemorrhage

6. Risk Factors
Most cases have no risk factors
 Previous PPH
 Antepartum haemorrhage
 Grand multiparity
 Multiple pregnancy
 Polyhydramnios
 Fibroids
 Placenta praevia
 Prolonged labour (& oxytocin)
 There is also some evidence that iron deficiency anaemia can contribute to atony
because of depleted uterine myoglobin levels necessary for muscle action.

8. PPH : “Risk” management
 ‘At risk’ patients should deliver in hospital
 Active management of 3rd stage
20 - 40 units oxytocin in 500mls of Hartman’s
solution at 30 dpm
Closer post-natal observation for 2-3 hours
 Cases of ragged membranes need at least 24
hours monitoring in hospital and given proper
counselling and appropriate antibiotics

9. ETIOLOGY OF
POSTPARTUM HAEMORRHAGE
4 Ts
TONE UTERINE ATONY
TISSUE RETAINED TISSUE/CLOTS
TRAUMA LACERATION/RUPTURE
THROMBIN COAGULATION

10. Causes
Tone (70%)
o Previous PPH
o Prolonged labour
o Age > 40 years
o Big baby
o Multiple pregnancy
o Placenta praevia
o Obesity
o Asian ethnicity
Tissue(10%)
o Retained placenta/
membrane/clot

11. Thrombin(1%)
o Abruption
o Pre-eclamptic Toxemia
o Pyrexia
o Intrauterine death
o Amniotic fluid
embolism
o DIC
Trauma (20%)
o Caesarean section
(emergency > elective)
o Perineal trauma
o Operative delivery
o Vaginal and cervical tears
o Uterine rupture

12. PRIMARY AND SECONDARY PPH
CAUSES
PRIMARY PPH SECONDARY PPH
UTERINE ATONY RETAINED POC
TRAUMA ENDOMETRITIS
RETAINED PLACENTA PLACENTAL SITE THROPHOBLASTIC
TUMOUR
COAGULATION DEFECT

13. PREDISPOSING FACTORS- INTRAPARTUM
PROLONGED AND RAPID
LABOUR
OPERATIVE
DELIVERY
INTERNAL
PODALIC
VERSION
CHORIOMNIONITIS
SHOULDER
DYSTOCIA
COAGULOPATHY
INDUCTION OR AUGMENTATION

14. ESTIMATION OF BLOOD LOSS
1 TAMPON FULLY SOAKED – 30 ML
 1 SANITARY PAD FULLY SOAKED – 120 ML
1 SARONG FULLY SOAKED – 500 ML
LINEN: 300-500 ML
GAUZE: 30-50ML
KIDNEY DISH: (PORTEX)-700ML
GULLY POT:100ML

15. MANAGEMENT
 RECOGNISE PPH
 CALL FOR HELP(RED ALERT)
- O & G SPECIALIST
- ANAESTHETIST
- SISTER ON CALL
- BLOOD BANK/HAEMATOLOGIST
 RESUSCITATION
 IDENTIFY AND TREAT SPECIFIC CAUSE

16. RESUSCITATION
 DONE SIMULTANEOUSLY- ASSESS VITAL SIGNS AND CONSCIOUS
LEVEL (IF UNCONSCIOUS, FOLLOW BLS), 2 X 14/16 G CANNULA
 TAKE 20 ML OF BLOOD FOR * GXM 4 UNITS PC * FBC *
COAGULATION SCREENING * ELECTROLYTES
 INFUSE FLUIDS (COLLOID/CRYSTALLOID)+ MAINTAIN CIRCULATORY
VOLUME WHILE WAITING FOR BLOOD * IN DIRE STATES, USE GROUP
SPECIFIC BLOOD OR UNMATCHED O RH –VE BLOOD
 RUNNERS – SN/ HO/ MO- CONSIDER CENTRAL LINES + CBD FOR
HOURLY MONITORING & OXYGEN, MONITOR TEMP EVERY 15MINUTES
 GIVE WARM BLOOD & CORRECT COAGULATION
 STABILIZING AND INITIAL RESUSCITATION MUST BE DONE FIRST 1
GOLDEN HOUR- IN DISTRICT HOSPITAL DECISION FOR REFERRAL MUST
BE MADE EARLY

18. ATONIC UTERUS
Normal postpartum
condition with contracted
uterus preventing
haemorrhage
Uterine atony allows
haemorrhage to flow into the
uterus
•It is the commonest cause of postpartum
haemorrhage.
•With the separation of placenta, the
uterine sinuses which are torn, cannot be
compressed effectively due to imperfect
contraction and retraction of the uterine
musculature & the bleeding continues.

19. The first step is to control the fundus and to note the feel of the
uterus. ATONIC UTERUS
Step 1 :
a) Massage the uterus to make it hard and express the blood clot.
b) Ergometrine 0.5mg is given intravenously. (MAX 3 TIMES)
c) IV syntocinon infusion 40 units in 500ml of normal saline at the rate of 125mls/hr
d) Foley catheter to keep bladder empty and to monitor urine output.
e) To examine the expelled placenta and membranes , for evidence of missing
cotyledon or piece of membranes .
f) Misoprostol 100mcg rectally
If the uterus fails to contract, proceed to the next step.
Step 2 :
The uterus is to be explored under general anaesthesia.
-if traumatic lesions or retained placenta have been excluded, give IM Carboprost
(Hemabate) 250mcg. This dose can be repeated after 15min up to max 3 doses , if
bleeding persist, prepare for surgical intervention.
ACTUAL MANAGEMENT
MASSAGE THE
FUNDUS

20. Step 3 : Uterine massage
and bimanual
compression.
Step 4 :
UTERINE TAMPONADE
1.Tight intrauterine packing
Intrauterine packing is useful in case of uncontrolled
postpartum haemorrhage where other methods
have failed and the patient is being prepared for
transport to a tertiary care centre. Intrauterine
balloon tamponade is an appropriate firstline
‘surgical’ intervention for most women where uterine
atony is the only or main cause of haemorrhage.
2.Balloon tamponade:
Bakri
balloon Balloon tamponade
Sangstaken-blakemore
tube

21. Step 5 :
Surgical methods to control PPH
a) Ligations of uterine arteries-
the ascending branch of the uterine artery is ligated at
the lateral border between upper and lower uterine
segment.

22. b) Ligation of the ovarian
and uterine artery anastomosis-
if bleeding continues, it is done
just below the ovarian ligament
c) Ligation of anterior division
of internal iliac artery-
Reduces the distal blood flow

23. d) B-Lynch compression suture and multiple square
sutures-

24. e) Angiographic arterial embolisation
(bleeding vessel) under fluoroscopy can be done using gel foam.
Outcome following unilateral uterine artery embolisation
-Success rate is more than 90% and it avoids hysterectomy.

25. STEP 6:
Hysterectomy
It is done in cases where uterus fails to contracts and bleeding
continues in spite of the above measure. Resort to hysterectomy
SOONER RATHER THAN LATER (especially in cases of placenta
accreta or uterine rupture). A second consultant clinician should
be involved in the decision for hysterectomy

26. RETAINED PLACENTA
 RESUSCITATION!
 DO NOT CONTINUE WITH CCT WITH SUCH PATIENT
 OXYTOCIN SHOULD BE GIVEN
 MRP IN OT UNDER GA WITH ANAESTHETIC BACK UP FOR RESUSCITATION
LOOK FOR GENITAL TRACT TRAUMA
 START OXYTOCIN INFUSION AFTER MRP
 ANTIBIOTICS

27. MORBIDLY ADHERENT PLACENTA
IN CASES OF ACCRETA, IF NO BLEEDING,
MAY TREAT CONSERVATIVELY WITH
MEDICATION
OTHERWISE, REQUIRE LAPAROTOMY
 HYSTERECTOMY

28. RETAINED PLACENTA / PLACENTAL ABNORMALITIES
PLACENTA
ACCRETA
PLACENTA
PRAEVIA
ABRUPTIO
PLACENTA
BATTELDORE
PLACENTA
VASA PREVIA
SUCCENTURIATE
PLACENTA
CIRCUMVALLATE
PLACENTA
RETAINED PLACENTA- When it is
not expelled out even 30
minutes after the birth of the
baby

29. GENITAL TRACT INJURY
 INJURY TO :
o EPISIOTOMY
o VAGINA
o CERVIX
o UTERUS
o EXTENSION TO BROAD LIGAMENTS
 RISK FACTORS : (1) INSTRUMENTAL DELIVERY (2) BIG BABY (3) SHOULDER DYSTOCIA
(4) PRECIPITATE LABOUR
 EXAMINATION – BEST UNDER ANAESTHESIA IN OT
o ‘WALK THE CERVIX’
o HIGH INDEX OF SUSPICION OF EXTENSION TO BROAD LIGAMENTS AND UTERUS IF
LACERATION INVOLVING CERVIX AND FORNICES
o ANTIBIOTICS

30. LACERATIONS OR EPISIOTOMY
•Trauma involves usually the cervix, vagina, perineum,
paraurethral region and rarely the rupture of the uterus
occurs.
•Blood loss from the episiotomy wound is most often
underestimated.

31. GENITAL TRACT INJURY - UTERINE RUPTURE
 HIGH INDEX OF SUSPICION
 PREVIOUS SCAR
 DIFFICULT DELIVERY (INTERNAL PODALIC VERSION)
 GRANDMULTIPARA
 OBSTRUCTED LABOUR
 WHAT ARE THE SIGNS?
o CTG CHANGES
o MATERNAL TACHYCARDIA
o PER VAGINAL BLEEDING
o SCAR TENDERNESS
o DECREASE UTERINE CONTRACTION
o HAEMATURIA

32. INVERSION OF THE UTERUS
It is an extremely rare
but a life threatening
complication in third
stage in which uterus is
turned inside out partially
or completely
ETIOLOGY
•Pulling the cord while uterus is atonic esp. when combined with
fundal pressure.
•Fundal pressure while uterus is relaxed-faulty technique in manual
removal.
DANGERS
•Shock
•Haemorrhage
•Pulmonary embolism
•If left uncared for, it may lead to-infection, uterine slough & a
chronic one
UTERINE RUPTURE
•It is potentially catastrophic
event during childbirth by which
the integrity of myometrial wall is
breached
•Life threatening event for
mother + baby

33. DIAGNOSIS OF UTERINE INVERSION
SIGNS SYMPTOMS
•Acute lower
abdominal pain with
bearing down sensation
•Bimanual examination not only
confirm the diagnosis but also
the degree
COMPLETE
INVERTED
UTERUS
•Sonography can confirm
the diagnosis when clinical
examination is not clear
•In complete variety, a pear
shaped mass protrudes outside
the vulva with the broad end
pointing downwards and
looking reddish purple in colour

34. MANAGEMENT - UTERINE INVERSION
1)To replace that first part
which is inverted last with the
placenta attach to the uterus
by steadyfirm pressure exerted
by fingers.
2) To apply counter support by
the other hand placed on the
abdomen.
3) After replacement, the hand
should remain inside the uterus
until the uterus becomes
contracted by parenteral
oxytocin or PGF2α
4) The placenta is to be
removed manually only
after the uterus become
contracted
Usual treatment of shock including
blood transfusion should be arranged
simultaneously

35. COAGULOPATHY
•Blood coagulation disorders are less common
causes of postpartum
haemorrhage.
•The blood coagulopathy may be due to
diminished procoagulants or increased fibrinolytic
activity.
•The conditions where such disorders may occur
are abruption
placentae, jaundice in pregnancy,
thrombocytopenic purpura etc.
•Specific therapy following coagulation screen
including recombinant
activated factor VII may be given.

36. DIAGNOSIS AND CLINICAL EFFECTS
PELVIC HEMATOMA POSTERIOR ASPECT OF UTERUS
SHOWING LEFT BROAD
LIGAMENT HEMATOMA
VAGINAL BLEEDING
•In the majority, the vaginal
bleeding is visible outside,
as a slow trickle.
•Rarely, the bleeding is totally
concealed either as vulvo-
vaginal or broad ligament
hematoma.
CLINICAL EFFECTS :- • Alteration of pulse, blood pressure & pulse pressure .
•On occasion, blood loss is so rapid & brisk that death may occur with in
a few minutes.
-State of uterus as felt per abdomen, gives a reliable clue as regards the cause
of bleeding.
•In traumatic haemorrhage, the uterus is found well contracted.
•In atonic haemorrhage, the uterus is found flabby and becomes hard
on massaging

37. PROGNOSIS
Postpartum haemorrhage is one of the life threatening emergencies.
It is one of the major cause of maternal deaths both in developing &
developed countries.
CONTRIBUTING FACTORS
•Prevalence of malnutrition &
anaemia.
•Inadequate antenatal &
intranatal care.
•Lack of blood transfusion
facilities.
•Substandard care.
THERE IS ALSO INCREASED
MORBIDITY
THESE INCLUDE:
•Shock
•Transfusion reaction
•Puerperal sepsis
•Failing lactation
•Pulmonary embolism
•Thrombosis & thrombophlebitis
LATE SEQUALE INCLUDES:
•Sheehan's syndrome( selective
hypopituitarism)
•Rarely diabetes insipidus.

38. PREVENTION-ANTENATAL
•Improvement of the health
status of the women & to
keep the haemoglobin level
normal (>10g/dl).
•High risk patients who are
likely to develop PPH ( such
as twins, hydramnios etc.)
are to be screened &
delivered in a well equipped
hospital
•Blood grouping should be
done for all women so that no
time is wasted during
pregnancy.
•Placental localization must be
done in all women with previous
caesarean delivery by USG or
MRI to detect placenta accrete
or percreta
•Women with morbid adherent placenta are at high risk of
PPH. Such a case should be delivered by senior obstetrician.

39. PREVENTION- INTRANATAL
•Active management of the third stage, for all women in labour should be
routine as it reduces PPH by 60%.
•Cases with induced or
augmented labour by
oxytocin, the infusion should
be continued for at least 1
hour after the delivery.
•Women delivered by
caesarean section,
Oxytocin 5IU slow IV is to be
given to reduce blood loss
•Exploration of the utero-
vaginal canal for evidence
of trauma following difficult
labour or instrumental
delivery.
•Expert obstetric anesthetist
is needed when the delivery
is conducted under general
anaesthesia
•During caesarean section spontaneous separation & delivery of the
placenta reduces blood loss (30%).
•Examination of the placenta & the membranes should be a routine so
as to detect at the earliest any missing part.

40. Hemorrhage occurs beyond 24 hours and within
puerperium,is called delayed or late puerperal
hemorrhage.
SECONDARY POSTPARTUM
HAEMORRHAGE

41. SECONDARY POSTPARTUM HAEMORRHAGE
 USUALLY PRESENTS IN THE 2ND AND 3RD WEEK POST PARTUM
 HVS FOR CULTURE
 START ANTIBIOTICS
 IF DIAGNOSIS OF RETAINED POC, FOR EXPERIENCED PERSONNEL TO
PERFORM EVACUATION – HIGH RISK OF PERFORATION
 DIFFICULT TO DIFFERENTIATE POC AND BLOOD CLOT BY US IN 1ST 2
WEEKS POSTPARTUM

42. •Infection and separation of
slough Over a deep cervico-
vaginal laceration
CAUSES
•Retained bits of cotyledons and
membranes

43. •Endometriosis and subinvolution of the placental site
•Secondary hemorrhage from caesarean
section
• Wound usually occur between 10-14 days

44. MONITORING
 ICU/ HDU MONITORING
 VITAL SIGN MONITORING EVERY 15 MINUTES - BP, PR, RR, SA O2,
CVP
 FLUID RESUSCITATION DOCUMENTED
 URINE OUTPUT
 ON GOING HAEMORRHAGE NOTED
 DRAIN, PAD
 RESULTS TRACED STAT
 INFORM PATIENT AND RELATIVES

45. PPH Flow chart
Red alert
Resuscitation, IV
access, blood Ix,GXM
Uterotonic drugs
If placenta is out consider:
Genital trauma(repair), atonic uterus,
Uterine inversion(replacement), Uterine
rupture(repair), Chorioamenitis
(abx&oxytocin), DIVC
Laparotomy
-Hysterectomy and/or
internal iliac artery
ligation (B-Lynch)
Yes
(observe)
No
(? Accreta)-
Laparotomy
If placenta is retained:
Proceed to MRP
(abx&oxytocin)
Bleeding controlled?

46. Uterine atony
Bleeding stops
-observe/monitor
-cont oxytocin 6-12 hrs
then off and observe
Persistent bleeding
1)PGE2-intrauterine, IM,
intrarectal
2) PGF-@a- IM carboprost
250ugm every 15 min
max 3 doses
If still persistent bleeding
-LAPAROTOMY
-uterine/internal iliac
artery ligation, B-lynch,
hysterectomy
IM Ergometrine (0.5mgX 2 doses)
IV oxytocin (40-80 units in 500mls saline)

47. MANAGEMENT OF PPH-SUMMARY
DIRECTED THERAPY
“TONE”
•Massage
•Compress
•Drugs
“TISSUE”
•Manual
removal
•Curettage
“TRAUMA”
•Correct
inversion
•Repair
laceration
•Identity
rupture
“THROMBIN”
•Reverse
•Anticoagulat
ion
•Replace
factors
MANUAL FUNDAL
MASSAGE
REMOVAL OF
PLACENTA
CORRECTION OF
UTERINE INVERSION

48. CONCLUSIONS
•Be prepared
•Practice prevention
•Assess the loss
•Assess the maternal status
•Resuscitate vigorously and appropriately
•Diagnose the cause
•Treat the cause