Postpartum Hemorrhage

Postpartum Hemorrhage
Postpartum Hemorrhage
Learning Objectives
 Define and differentiate between early and late
 Identify causes and risk factors of PPH.
 Identify symptoms and signs of PPH and list
the laboratory investigations.
 Manage PPH immediately after delivery of the
baby and before delivery of the placenta.
 Manage PPH immediately after delivery of the
 Manage PPH 24 hours after delivery.
Postpartum Hemorrhage
Postpartum Hemorrhage
Problem in Egypt
 Postpartum hemorrhage is the single
greatest cause of maternal death in Egypt.
 Postpartum hemorrhage was responsible for
34% of all maternal deaths.
 The most important avoidable factors were:
– Substandard care by obstetricians(50%)
– Lack of blood (31%)
– Substandard care by dayas (14%)
Postpartum Hemorrhage
 Postpartum hemorrhage is excessive
blood loss after delivery sufficient to
affect the general condition of the mother
as shown by tachycardia and/or
 The traditional definition, based on a
blood loss  500 mL from or within the
reproductive tract after delivery, is
difficult to estimate in clinical practice.
Postpartum Hemorrhage
Average Blood Loss and
Complexity of Delivery
Vaginal delivery–500 ml
Cesarean section–1000 ml
Repeat cesarean section & TAH–1500 ml
Emergency hysterectomy–3500 ml.
Pritchard AJOB 1961
Clark Obstet Gynecol 1984
Postpartum Hemorrhage
Classification of Hemorrhage in the
Pregnant Patient *
Hemorrhage Acute Blood
Loss (ml)
Postpartum Hemorrhage
Classification of Hemorrhage in the
Pregnant Patient
Hemorrhage Signs and Symptoms
Usually none
Tachycardia, tachypnea orthostatic
changes, prolonged hypothenar blanching,
narrowing of pulse pressure
Overt hypotension, marked tachycardia
(120-160 bpm), marked tachypnea (3040/mln, cold, clammy skin
No discernible blood pressure, oliguria or
anuria, absent peripheral pulses
Postpartum Hemorrhage
Types of PPH
 Primary:
–within the first 24 hours
 Secondary:
–after the first 24 hours up to the
42nd day
Postpartum Hemorrhage
Postpartum Hemorrhage
Causes of PPH
 Uterine atony
 Genital tract trauma
 Third stage complications:
– Mismanagement of the third stage of labor
– Acute inversion of the uterus
– Abnormal or incomplete placental
 Coagulation disorders
Postpartum Hemorrhage
Factors Predisposing To Uterine Atony
 Overdistended uterus
 Uterine muscle exhaustion
 Amniotic infection
 Functional or anatomic distortion of the
uterus due to a fibroid uterus, placenta
previa or uterine anomalies
 Certain general anesthetics (e.g. halothane)
 History of previous PPH
Postpartum Hemorrhage
Factors Predisposing To Genital Tract Trauma
 Precipitate delivery
 Operative or manipulative delivery
 Malposition or deep engagement of the
fetal head predisposes the genital tract to
extensions and/or lacerations during a CS
 Previous uterine surgery predisposes to a
uterine rupture
Postpartum Hemorrhage
Factors predisposing to retained
products of conception
An incomplete placenta at delivery
Previous uterine surgery (morbid adhesions)
High parity
An abnormal placenta on ultrasound
– Placenta previa
– Placenta implanted on a scar
– Placenta increta,percreta, accreta
– Accessory placental lobe
– Placental Abruption
Postpartum Hemorrhage
Abnormalities of Coagulation
 Pre-existing coagulation disorders such as:
– Hemophilia A or Von Willebrand’s disease
– Idiopathic thrombocytopenic purpura (ITP)
– History of liver disease
– Use of anticoagulants
 Acquired in pregnancy:
– Thrombocytopenia with pre-eclampsia (HELLP
– DIC caused by:
• Abruptio placentae
• Chorioamnionitis
Postpartum Hemorrhage
In a woman with excessive PPH, begin first aid
management while simultaneously taking a
history and performing a physical examination.
 History.
 General examination:
– Tachycardia and hypotension
 Abdominal examination
– Consistency of the uterus (lax or firm)
– Uterine fundal level.
– Any abdominal tenderness or rigidity
– Scars from previous operations
Postpartum Hemorrhage
Diagnosis - (Cont.)
 Local examination:
– Assess the amount of vaginal bleeding
– Look for lacerations (perineal, vulvar, vaginal
or cervical)
– Determine whether the placenta has been
 Tachycardia and hypotension may be
present without evidence of excessive blood
loss in cases of uterine rupture.
 In a patient with hypertension or preeclampsia, severe blood loss may cause a
misleading “normal” blood pressure reading.
Postpartum Hemorrhage
Laboratory Investigations
 ABO grouping and Rh type
– Cross-match at least two units of whole
blood or as needed for the clinical
 CBC (Hb, Hct, differential, platelet
 Bleeding time
 Coagulation time
Postpartum Hemorrhage
Prophylactic Measures
 During the antenatal period:
– Recognize risk factors
– Diagnose anemia at an early stage
– Ensure iron and folic acid supplementation
– Educate the patient regarding the following:
• Anemia prevention
• Going to the hospital early in labor
• Seeking immediate medical attention if
vaginal bleeding occurs
Postpartum Hemorrhage
Prophylactic Measures - (Cont.)
 During labor and delivery:
– Identify patients at risk of developing PPH
– If the hemoglobin level is  8 gm/dL, crossmatch at least one unit of whole blood even if
the delivery is normal, or two units if it is CS,
to be used if needed.
– Actively manage the third stage of labor.
• Administer 10 IU of oxytocin IM with the
delivery of the anterior shoulder.
• Perform controlled cord traction to
deliver the placenta.
• Perform uterine massage.
Postpartum Hemorrhage
First Aid Management
 Insert two wide bore IV cannulae (size 16 or 18),
and withdraw 20 mL of blood for cross-matching
and required investigations before starting any
IV fluids
 IV crystalloid solution at a fast drip (1 L/hour)
and start ecbolic drugs
 Continuously monitor pulse and BP every five
 Insert a Foley catheter.
 Monitor urine output.
 Massage the uterine fundus.
Postpartum Hemorrhage
Ecbolic Drugs
 Misoprostol:
– Rectal 1000 g tablets [200mcgX5]
 Oxytocin:
– IV Infusion 20 IU in 1 L IV fluids at 60 drops per
minute then infuse at 40 drops per minute
– Not more than 3 L of IV fluids containing oxytocin
– Do not give as an IV bolus
 Methyl ergometrine:
– IM or IV (slowly): 0.2 mg, repeat after 15 minutes.
– If required, give 0.2 mg IM or IV (slowly) every 4
hours, maximum 5 doses (Total 1.0 mg)
– Contraindications: pre-eclampsia, hypertension,
heart disease
Postpartum Hemorrhage
Active Management
 Hemorrhage after delivery of the neonate,
before delivery of the placenta (retained
– Determine the cause of the retained placenta
(hourglass contraction versus partial
– Administer Ergotrate 0.2 mg (1 ampule) IM , or
give misoprostol 200 µg (one tablet) rectally,
followed by controlled cord traction to deliver the
Postpartum Hemorrhage
Active Management – (Cont.)
 Hemorrhage after delivery of the neonate,
before delivery of the placenta (retained
– Avoid forceful cord traction and fundal pressure
as they may cause uterine inversion.
– Explore the perineum, vagina, and cervix,
looking for lacerations if the bleeding persists
without delivery of the placenta.
– Call the anesthesiologist.
– Manually remove the placenta with adequate
sedation (e.g., Valium or Pethidine) or
Postpartum Hemorrhage
Manual Removal of the Placenta
Introducing one hand into the vagina along the cord
Postpartum Hemorrhage
Manual Removal of the Placenta - (Cont.)
Supporting the fundus while detaching the placenta
Postpartum Hemorrhage
Manual Removal of the Placenta - (Cont.)
Withdrawing the hand from the uterus
Postpartum Hemorrhage
Manual Removal of the Placenta - (Cont.)
 Palpate the inside of the uterine cavity to ensure
that all placental tissue has been removed
 Give ecbolic drugs
 Massage the fundus of the uterus
 Examine the uterine surface of the placenta to
ensure that it is complete
 Examine the woman carefully and repair any
tears or episiotomy.
 If the placenta does not separate from the uterine
surface, suspect an adherent placenta and
proceed to perform a laparotomy and possibly a
subtotal hysterectomy.
Postpartum Hemorrhage
Hemorrhage Immediately After Delivery of
 First Aid Management
 Ecbolics
 EUA if bleeding persists
– Explore the perineum, vagina, cervix and uterus
looking for lacerations and repair as needed
– Explore the uterine cavity for retained placental
– If there are retained placental fragments,
remove them manually or with ring forceps
 If the cervical tear has extended deep beyond
the vaginal vault (incomplete uterine rupture),
a laparotomy may be required.
Postpartum Hemorrhage
Hemorrhage Immediately After Delivery of Placenta
 If the hemorrhage still persists, assess the
patient’s clotting status using a bedside clotting
– Failure of a clot to form after 7 minutes or a soft clot
that breaks down easily suggests coagulopathy.
 If bleeding continues in spite of the above
management, perform bimanual compression of
the uterus.
 Perform an emergency laparotomy if the above
maneuver fails or if a ruptured uterus is found.
Do not waste valuable time trying to save
the uterus at the expense of the general
condition of the mother.
Postpartum Hemorrhage
Bimanual Compression of the Uterus
Postpartum Hemorrhage
Uterine Packing (Balloon Tamponade)
 Using either a Foley catheter or a
Sengstaken-Blakemore tube
 Useful for uterine atony, retained placental
tissue, and placenta accreta
 Both the Foley catheter and the
Sengstaken-Blakemore tube have open
tips, which permit continuous drainage
from the uterus
Postpartum Hemorrhage
Uterine Packing (Balloon Tamponade)
 Ultrasound can more effectively detect a
developing hematoma when the contrast is
a fluid-filled balloon as opposed to bloodsaturated gauze.
– Thus, this technique has the advantage of
being not only therapeutic but also diagnostic
when used in combination with ultrasound, in
differentiating the various etiologies described
Postpartum Hemorrhage
Uterine Packing (Balloon Tamponade)
 Foley catheter procedure:
– Using a 24 Fr Foley catheter, guide the tip
into the uterine cavity and inflate with 20 to
30 mL of saline.
 Sengstaken-Blakemore tube:
– Has an advantage due to the larger capacity
of its balloon tip
 If the bleeding stops, the patient can be
observed with the catheters in place and
then they are removed after 12 to 24 hours.
Postpartum Hemorrhage
 Inspect the uterus. If lacerated, repair
adequately and if it is atonic, perform
direct uterine massage
 Surgical compression suture (B-Lynch
suture) technique
 Uterine packing (balloon tamponade)
 Ligation of the uterine and utero-ovarian
 Bilateral internal iliac artery ligation
 Supravaginal hysterectomy
Postpartum Hemorrhage
Surgical Compression Suture
(B-Lynch suture) Technique
 Mechanical compression of the uterine vascular
sinuses prevents further engorgement with blood
and continued hemorrhage
 Used to treat atony and hemorrhage that does not
respond to pharmacologic interventions
 Used if bimanual compression decreases the
amount of uterine bleeding by abdominal and
perineal inspection
 Although originally described using No. 2-0
chromic catgut, variations using No. 0 Vicryl
suture have been equally successful
Postpartum Hemorrhage
Postpartum Hemorrhage
Postpartum Hemorrhage
Postpartum Hemorrhage
Postpartum Hemorrhage
Surgical Compression Suture (B-Lynch
suture) Technique - (Cont.)
Postpartum Hemorrhage
Ligation of Uterine , Utero-Ovarian and
Hypogastric Arteries
 The obstetrician should consider ligation
of the hypogastric arteries if trained in
this technique
Postpartum Hemorrhage
Secondary PPH (severe degree)
 First aid management
– Administer IV broad spectrum antibiotics
– Give ecbolic drugs
– If the cervix is dilated, explore by hand to
remove large clots and placental fragments,
plus manual exploration of the uterus
– If the cervix is not dilated, evacuate the
uterus to remove placental fragments
 In rare cases, if bleeding continues, consider
performing a uterine and utero-ovarian
artery ligation or a hysterectomy
Postpartum Hemorrhage
Secondary PPH (mild degree)
 Check the cervix:
– If the cervix is open, perform curettage and
perform a histological investigation of the
products of the curetting.
– If the cervix is closed give broad spectrum
antibiotics for one week and reassess the
 Perform a histological investigation of the
products of the curetting or hysterectomy
specimen, if possible, to rule out a gestational
trophoblastic tumor.
Postpartum Hemorrhage
Monitoring During Hospital Stay
 Check the patient’s blood pressure and
pulse every 30 minutes for the first two
hours, then hourly for six hours, and then
every four hours.
 Perform gentle uterine massage every 30
 Check for vaginal bleeding every hour.
 Check urine output every two hours.
Postpartum Hemorrhage
 Remember that a postpartum patient can lose a large
amount of blood in a very short time. You must act
promptly and anticipate complications.
 Assure adequate team coverage.
 A laparotomy for PPH is an extremely urgent situation
and need not be delayed while waiting for a blood
 Administer prophylactic antibiotics before and after the
 Do not give oxytocin as an undiluted IV push since the
patient may collapse.
Postpartum Hemorrhage
Thank You

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