1. DR. SUGUNA. R. KUMAR. MD
(OBG)
Suguna Maternity Hospital
Sastri nagar Bijapur

2. • Post partum hemorrhage (PPH) is the leading cause of
maternal mortality (35-38%)
• If PPH is untreated death occurs in 2 hrs
• MMR in Karnataka is 144 / 1L birth . And of India is 178/
1L birth
• ALL WOMEN who carry a pregnancy beyond 20 weeks
gestation at risk of PPH

3. • Defined a blood loss of >500ml in vaginal and
1000ml in caesarean, within 24 hours of delivery is
primary , if occurs after 24 hours is secondary.
• Definition is arbitrary and problematic
• A woman with anemia, cardiac disease, volume
contracted in preeclampsia cannot cope up .
• Blood loss assessment done by visual assessment

4. • Visual assessment of blood loss – requires no
expenditure, should be correlate with the clinical signs.
Inaccurate, Underestimated, small “trickle” neglected
• Direct collection of blood
bedpan and standard measuring jar, rubberized blood
mat ,
Kelly’s Pad (India) funnels blood into a calibrated
collection
bowl, Kangas (large piece of African cloth), Blood drape
plastic
sheet into a calibrated measuring pocket , Gravimetric
method
dry and wet sponges weighed.
• Laboratory based methods – Alkaline hematin / acid

5. 4 TS - Tone, tissue, trauma, thrombus.
• Tone – 70% Atonic uterus major cause - over
distended polyhydramnios, multiple pregnancy , big
baby, grandmulti, prolonged labour (>12hr),
precipitated labour,
placenta previa, abruptio placentae, Inversion uterus
• Tissue- Retained placenta, Clots, fibroid uterus
• Trauma- Uterine rupture, cervical tears, vaginal
tears.
• Thrombosis- Thrombhocytopenia due to HELLP
syndrome, abruptio, DIC, Sepsis. Coagulation failure
disorders
• Most cases don’t have risk factors.

6. • ACTIVE MANAGEMENT OF III STAGE OF LABOUR (AMTSL) IN
ALL DELIVERING WOMEN
• Oxytocin 10 IU IV/IM is the recommended uterotonic drug at the
anterior shoulder delivery or immediately following delivery of
the baby.
• Oxytocin unavailable / skilled birth attendants are not present
then 600ug of oral misoprostol recommended.
• Cord clamping after 1-3min.
• Controlled cord traction (CCT) if skilled birth attendant are
available.
• Sustained uterine massage not recommended
• Postpartum abdominal uterine tonus assessment up to 4hours
recommended
• In CS Oxytocin 10 IU IV/IM and CCT is recommended.

7. • 60% reduction in the occurrence of PPH and Blood
transfusion
• 80% reduction in the need for therapeutic uterotonic
agents
• No increase in the incidence of retained placenta.
• Following delivery ideal to continue uterotonic for 2-
3hrs - 10IU of oxytocin 500ml of IV fluid or 200 mcg
of methylergometrine, 250mcg of carboprost, 600ug
of misoprostol PR.

8. • Clinical assessment of obstetric hemorrhage
Blood
volume
loss
BP
(systolic)
S/S Degree of
shock
500-1000ml
(10-15%)
normal Palpitation,
tachycardia,
dizziness
compensate
d
1000-1500ml
(15-25%)
Slight fall (
80-
100mmHg)
Weakness ,
tachycardia,
sweating
mild
1500-2000ml
(25-35%)
Moderate fall
(70-
80mmHg)
Restlessnes
s, pallor,
oliguria
moderate
2000-3000ml
(35-50%)
Marked fall
(50-
70mmHg)
Collapse , air
hunger,
anuria
severe

9. • Antenatal CBC and Blood grouping and typing.
• Hb <10gm% promptly treated
• During labour recent CBC
• Identification of at risk and thrombhocytopenia
in whom 2-6 U of blood ideally reserved, require
multidisciplinary approach.
• IV line large gauge 16 G in at risk pt.

10. Management
• Has the placenta been delivered and is
complete?
• Is the uterus well contracted?
• Is the bleeding due to trauma?

11. • IV cannula 16 G -2 with easyfix/ plaster,
• Blood sample bottles
• Syringes 10ml- 4, 5ml- 2, 2ml- 4
• Foleys cathetar 16 no, urosac, distilled water
10ml
• Drip set, blood set, RL, NS, 3 way cannula
• O2 face mask,
• Cotton swabs, scissors

12. • Uterotonics-
Oxytocin 5 amp
Methergin 2 amp,
Prostodin 2 amp,
Misoprostol 600mcg
• Instruments –
large speculum 3,
sponge holder 4,
condom tamponed.

13. LOW RECOURSE SETTINGS
• IV oxytocin is the recommended drug 20IU in 500ml NS
• Oxytocin is not available or bleeding not responding then IV
ergometrine, syntometrine, IM Prostagladin , 800ug SL
misoprostol.
• IV fluids isotonic crystalloids NS is prefered over colloids.
• Tranexamic acid used if the bleeding doesnot stop with
uterotonics or sure of traumatic PPH.
• Not responding to uterotonic or uterotonic not available then
intrauterine balloon tamponed recommended
• There is no response to uterotonic and tamponed measure
then surgical intervention
• The use of uterine pack not recommended
• IV /IM oxytocin 10 IU with CCT recommended in retained
placenta
• Ergometrine not recommended in retained placenta
• Single dose of amphicillin or cephalosporin recommended if
MRP is practised

14. • Bimanual compression, external aortic compression, non
pneumatic anti shock garment, intrauterine balloon tamponed
are temporary measures until appropriate surgical treatment ,
while shifting.

15. Organisation
• Call for help (experienced Obstetrician and anesthetists)
• Alert the blood bank and hematologist
• Designate a doctor or nurse to record the vitals, UOP ,
fluids and drug administration
• OT ready.
Resuscitation
• Administer O2 mask
• Place 2 large bore (16 G ) IV lines
• Take blood for crossmatching 4-6 PRBCs, for CBC
count, coagulation screen, RFT, and electrolyte status.
• Rapid fluid replacement with NS or RL 2litres.
• Blood transfusion PRBCs

16. Uterine contraction – first line drugs
 Oxytocin 10IU IM/IV
 Oxytocin 20IU in 500ml NS
 Methyl ergometrine 0.2mg (max 5 doses 4th
hourly
 Carboprost 0.25mg IM every 15min to 90min x 8
doses
 Misoprostol 800mcg SL/PR.

17. • Empty the uterus.
• Foley catheter UOP
• Uterine massage, bimanual compression
• Balloon tamponed
• Brace Sutures
• Uterine artery ligation, stepwise revascularization
• Internal iliac artery ligation
• Interventional radiology
• Hysterectomy before too late.

18. • Retained placenta
• Infection endometritis
• Infection of the cervical and vaginal tears
• Puerperal uterine inversion
• Uterine polyp, fibroids
• Undiagnosed Ca Cx
• chorioepithelioma

19. • PPH remains the number one killer of women in
developing country.
• Access to well stocked and well staffed facilities capable
of rapid response in PPH are lacking in lower resource
settings.
• A formal protocol for the prevention and treatment PPH
and also for referral to higher center recommended
• Frequent use of stimulation and drills in the PPH
treatment of the health personal.
• A prepared mind, a prepared team, a full range of therapy
is required to avert maternal death.

20. Thank you