CONTENTS
Introduction
Definition
Incidence
Types of PPH
Clinical manifestations Prevention
Management of 3rd stage bleeding
Management of true PPH
Secondary PPH
Clinical manifestations
Diagnosis
Management of sec PPH
Active management
Evaluation
Bibliography
INTRODUCTION
PPH is a condition in which excessive bleeding
from( or ) into genital tract at any time following
the baby's birth upto 6weeks after delivery.
Hemorrhage may occur before, during or after
delivery of the placenta.
The average blood loss following vaginal delivery,
cesarean delivery and cesarean hysterectomy is
sooml, loooml and 1500ml respectively.
DEFINITION
"Any amount of bleeding from or into genital tract following birth
of the baby up to the end of the puerperium, which adversly
affects the general condition of the patient, evidenced by rise in
pulse rate and falling blood pressure, is called postpartum
hemorrhage".
-DC DUTTA
INCIDENCE
The incidence widely varies mainly because of
lack of uniformity in the criteria used in
definition.
The incidence is about 4-6% of all deliveries.
TYPES OF PPH
PRIMARY PPH:
Hemorrhage occurs within 24hours
following the birth of the baby. In the majority,
hemorrhage occurs within two hours following
delivery.
SECONDARY PPH:
Hemorrhage occurs after 24hours of
the delivery of the placenta upto 6 weeks after the
delivery is called secondary postpartum hemorrhage.
PRIMARY PPH
Primary pph is divided into 2 types:
Third stage hemorrhage: This is primary
hemorrhage that occurs after the delivery of the
baby but before the expulsion of the placenta.
True primary PPH: This is hemorrhage that occurs
after the delivery ofthe placenta at any time
within 24hours of the delivery of the baby. The
majority of the cases of postpartum hemorrhage
fall in this category.
CAUSES OF PRIMARY PPH
Atonic
Traumatic
Mixed
Retained
Coagulopathy
ATONIC PPH
Atonic means lack of tone of the muscles of the
flabby muscles. Failure of the muscles of the uterus
to contract properly after the placenta has been
delivered.
It is the commonest cause of postpartum
hemorrhage.
Contributes for 80% of PPH
Uncontracted uterus placenta
cervix
ETIOLOGY
Grand multipara
Over- distension of UterUS
Anemia
Prolonqed labour
Anaest%esia
Uterine fibroid
Precipitate labour
Malformations of uterus
Ante partum hemorrhage
Initiation and augmentation of the delivery with
oxytocin.
TRAUMATIC
Trauma to the genital tract usually occurs following
operative delivery; even after spontaneous
delivery.
Trauma involves usually the cervix, vagina,
perinium(episiotomy wound and laceration).
While minor tears cause only a minimal bleeding
which is easily controlled, deep tears may need to
be examined and treated under anesthesia.
ETIOLOGY
Cervix: laceration
Vaginal laceration
Perinium injury
Paraurethral injury
Uterine rupture.
MIXED PPH
Postpartum hemorrhage is frequently a mixture of
both atonic as well as traumatic hemorrhage. Many of
the factors that contribute to the laxity of the uterine
muscles are also factors that contribute to injury of the
birth canal.
RETAINED PLACENTA
Bits of placenta, blood clots cause PPH due to
imperfect uterine retraction.
ETIOLOGY:
Placenta accreta, increta and percreta
Succentuirate placenta.
Retained
placenta after the
birth of the baby
COAGULOPATHY
Blood coagulation disorders, acquired or congenital,
are less common causes of postpartum hemorrhage.
The firmly retracted uterus can usually prevent
bleeding.
ETIOLOGY:
Abruptio placentae
Jaundice in pregnancy
Thrombocytopenic purpura
Severe pre-eclampsia
Hemophilia
Patient on anti-coagulant.
CLINICAL MANIFESTATIONS
Uncontrolled bleeding
Increased heart rate
Decreased in RBC count
Swelling and pain in the tissues in the vaginal and
perineal area.
An enlarged uterus as if it fills with blood or
blood clots. It is found on palpation
PREVENTION
Postpartum hemorrhage cannot always be prevented.
However, the incidence and especially its magnitude
can be reduced substantially by assessing the risk
factors.
ANTENATAL
Improvement of the health status of the women.
High-risk patients screening
Blood grouping
Placental localization
All women with prior cerarean delivery must have
their placental site determined by usg/MRl to
determine morbid adherent placenta.
women with morbid adherent placenta are at
high risk of PPH.
INTRANATAL
Active management of the third stage, for all women in labour
should be a routine as it reduces PPH by 60%.
Cases with induced or augmented labor by oxytocin the
infusion should be continued for at least one hour after
delivery,
Women delivered by cesarean section, oxytocin SIU slow IV is
to be given.
Examination of the placenta and membranes.
Exploration of the utero-vaginal canal for evidenced of
trauma.
During cesarean section spontaneous separation and delivery
of the placenta reduces blood loss 30%,
Expert obstetric anesthetist is needed when the delivery is
conducted under General anesthesia.
Observation fora out two hours after delivery.
MANAGEMENT OF THIRD STAGE BLEEDING
The principles in the management are:
To empty the uterus
To replace the blood
To ensure effective hemostasis
STEPS OF MANAGEMENT
Palpate the fundus and massage.
Start dextrose saline drip and blood transfusion if
necessary.
Oxytocin 10 IU 1M or merthergine 0.2mg is given
intravenously.
If features of placental separation are evident,
placenta is expressed by fundal pressure or
controlled cord traction
If placenta is not separated, manual removal of
the placenta under general anesthesia is to be
done.
If patient is in shock, resuscitate the mother
before manual removal of the placenta.
(A)
(C)
STEPS OF MANUAL REMOVAL OF PLACENTA
STEP 1. The operation is done under general
anesthesia. In extreme urgency where anesthesia is
not available, the operation may have to be done
under deep sedation with 10mg diazepam given
intravenously. The patient is placed in lithotomy
[Link] all aseptic measures, the bladder is
catheterized.
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. While introducing the hand, the labia are
separated by the fingers of the other hand.
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 theuterine
cavity until the placenta is compeletly separated
STEP 4. As soon as the placenta margin is reached,
the fingers are insinuated between the placenta and
the uterine wall with back of the hand in contact with
the uterine wall.
STEP 5. when the placenta is completely separated,
it is extracted by traction of the cord by the other
hand.
STEP 6. IV methergine 0.2mg is given and the uterine
hand is gradually removed.
STEP 7. The placenta and membranes are inspected
for completeness and be sure that the uterus
remains hard and contracted.
C
MANAGEMENT OF TRUE PPH
ACTIVE MANAGEMENT:
STEP 1:
Palpate the fundus and massage the uterus to
make it hard and to express the clot.
Methergine 0.2mg is given 1M.
Inj oxytocin drip is started 1011J in 500ml of
normal saline at 30-40 drops per min.
Examine the expelled placenta and membranes.
Oxygen administration.
STEP 2:
The uterus is to be explored under general
anesthesia.
STEP 3:
Uterine massage and bimanual compression.
PROCEDURE
The whole hand is introduced into the vagina in
coneshaped fashion after separating the labia
with the fingers of the other hand.
The vaginal hand is clenched into a fist with the
back of the hand directed posteriorly and the
knuckles in the anterior fornix.
The other hand is placed over the abdomen
behind the uterus to make it anteverted.
The uterus is firmly squeezed between the two
hands.
It may be necessary to continue the
compression for a prolonged period until the tone of
the uterus is regained.
STEP 4:
Uterine tamponade.
Tight intrauterine plugging done uniformly under
general anesthesia.
Insertion of a senstaken Blackmore tube into the
uterine cavity and inflating ballon with 200ml of
normal saline.
STEP 5:
Surgical method.
Ligation of uterine arteries: The ascending branch
of the uterine artery is ligated at the lateral border
between upper and lower uterine segment.
Ligation of anterior division of internal iliac
artery : Reduces the distal blood flow.
Ligation of ovarian and uterine artery
anastomosis: If bleeding continues, is done just
below the ovarian legament.
B- Lynch brace suture and haemostatic suture:
Both these surgical methods work by temponade
(like bimanual compression) of the uterus Success
rate is about 80%.
Anaiographic arterial embolisation: Under
fluoroscopy can be done using gel foam. Success
rate is more than 90%.
LIGATION OF UTERINE B- LYNCH BRACE SUTURE
ARTERIES
LIGATION OF INTERNAL ILIAC ANGIOGRAPHICSELECTIVE
ARTERY ARTERIAL EMBOLIZATION
STEP 6:
HYSTERECTOMY: A surgical procedure to remove all
or some parts of the Uterus In case of life
threatening conditions. Rarely Uterus fails to
contract and bleeding continues in spite of the
above measures.
Hysterectomy has to be considered involving a
second consultant.
Decision of hysterectomy should be taken earlier in
a parous woman. Depending on the case, it may be
subtotal or total.
SECONDARY PPH
The bleeding occurs after the delivery usually
between 8th to 14th days of delivery.
ETIOLOGY:
Retained bits of cotyledon and membranes.
Sepsis.
Secondary hemorrhage from cesarean section
wound.
Endometritis
Other: carcinoma cervix, placenta polyp, fibroids
etc.
CLINICAL MANIFESTATION
The lochia are heavier then normal and is bright red
in color.
Lochia is offensive if associated with infection.
Sub involution of the Utertus.
Pyrexia and tachycardia.
Anemia proportionate to blood loss.
DIAGNOSIS
The bleeding is bright red and of varing amount.
Varying degree of anaemia and evidenced of
sepsis, subinvolution of the Uterus and often a
patulous cervical os.
Ultrasound is usefull in detecting the bits of
placenta inside the uterine cavity.
MANAGEMENT
SUPPORTIVE THERAPY
Blood transfusion if necessary.
Ergometrine [Link] 1M if bleeding is uterine in
origin.
Antibiotics as routine.
CONSERVATIVETHERAPY
Bed rest and observation for 24hrs if bleeding is
mild.
ACTIVE MANAGEMENT
Exploration of uterus is to be done under general
anesthesia.
Gentle curettage is done by flushing curette and
sent materials tor histological examination.
Ergometrine 0.5mg 1M
Secondary hemorrhage following cesarean section
may at times require laparotomy.
The bleeding from uterine wound can be controlled
by haemostatic sutures, may rarely require ligation
of the internal iliac artery or hysterectomy.
EVALUATION
1. What is PPI-I?
[Link] is the Commonest cause of pph?
[Link] is the difference between pri and sec pph?
[Link] are the clinical manifestation of pri pph?
BIBLIOGRAPHY
Dutta Parul, Konar Hiralal; D.C Dutta's Textbook of
Obstetrics; Jaypee Publication, 9th Edition; Page
No.-385-392 .
Bhasker Neema; Midwifery and Obstetrical
Nursing; Emmess Publishers; 3rd Edition; Page No.-
492-495.
[Link].
[Link].
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