1. Postpartum Hemorrhage
Dr. Alongkone Phengsavanh

2. Objectives Define and discuss risk factors and causes
Describe management and prevention

3. Postpartum Hemorrhage
Leading cause of maternal deaths worldwide
Responsible for 1/3 of maternal deaths worldwide and 60% in developing countries
Majority of deaths within 4 hours of delivery

4. Postpartum Hemorrhage (PPH)
Primary (immediate)
Hemorrhage in first 24 hours after delivery
70% due to uterine atony
Secondary (delayed)
Hemorrhage after 24 hours up to 6 weeks postpartum
Caused by
Retained placental tissue
Infection
Definitions – Volume loss (Traditional)
Spontaneous vaginal delivery
>500 cc blood
C/Section
>1000 cc blood
Clinical
Any blood loss that has the potential to produce hemodynamic instability

5. Clinical Findings & Blood Loss
Mild
Hypovolemia
Moderate Hypovolemia
Severe Hypovolemia
Definition
(blood volume)
<20% %
>40% HR
Mild tachycardia
>110 bpm
 tachycardia RR
Normal
>30 rpm
 tachypnea
Clinical
Cool extremities, decreased urine output, dizziness, normal neuro status
Marked pallor, hypotension with sitting, anxious state
Oliguria / anuria, agitation, confusion, loss of consciousness, BP unstable

6. PPH Etiology Tone - Uterine tone Tissue - Retained tissue / clots
Trauma - Laceration, rupture,
uterine inversion
Thrombopathy - Coagulopathy

7. PPH Risk Factors - Tone Overdistended uterus Uterine muscle exhaustion
Polyhydramnios
Multiple gestation
Macrosomia
Uterine muscle exhaustion
Rapid labor
Prolonged labor
High parity
Intra-amniotic infection
Fever
Prolonged Rupture of Membranes
Uterine abnormalities
Fibroid uterus
Congenital uterine abnormalities
Placenta previa / placental abruption
Uterine relaxing agents
Magnesium sulfate
Halogenated anesthetics
Nitroglycerin

8. PPH Risk Factors - Tissue
Retained tissue, abnormal placentation (succinuriate lobe, retained cotyledon)
Incomplete placental delivery
Previous uterine surgery
High parity
Retained blood clots
Atonic uterus

9. PPH Risk Factors - Trauma
Lower genital tract lacerations (cervix, vaginal wall, perineum)
Precipitous delivery
Operative delivery
Poorly timed or inappropriate episiotomy
Caesarean section – extensions / lacerations
Deep engagement of head
Malposition
Uterine rupture
Prior uterine surgery
Uterine inversion
High parity
Fundal placenta

10. PPH Risk Factors - Thrombin
Pre-existing states
Hereditary conditions
History of liver disease
Therapeutic anticoagulation
History of thrombotic disease
Other (DIC, ITP, Pre-eclampsia, placental abruption, severe infection)
Intrauterine fetal demise
Bruising
Elevated blood pressure
Fever
Elevated WBC
Antepartum hemorrhage
Sudden collapse

11. PPH Prevention Active management of the Third Stage of Labor
Administer oxytocin with delivery of anterior shoulder or immediately after delivery of baby
Oxytocin 10 units IM or 5 units IV
Clamp and cut cord
Palpate uterine fundus & confirm uterus contracting
Perform controlled cord traction with suprapubic counter traction with next strong contraction
Perform uterine massage after delivery of placenta
Examine placenta for completeness

12. Controlled Cord Traction

13. PPH Management Prevention
Active management of the third stage of labor
Identify patients at potential risk of PPH

14. PPH Management Primary PPH Active management of third stage of labor
Call for HELP
ABC (Airway, Breathing, Circulation)
Estimate / measure blood loss
Closely monitor vital signs
Catheterize bladder (urine volume)
Give oxygen
Give oxytocin (IV/IM) or misoprostil (PR)

15. PPH Management – Tone Determine source of bleeding
Assess the uterine fundus
Do Internal Bimanual Massage of uterus

16. PPH Management – Tissue
Examine placenta for completeness
Examine maternal side of placenta
Examine fetal side of
placenta

17. PPH Management – Tissue
Manual removal of placenta – if incomplete placenta 2 1 4 3

18. PPH Management - Trauma
If fundus firm & placenta complete, then examine for trauma
Upper vaginal tract - identify and repair tears
Lower & external genital tract – apply pressure and repair tears

19. PPH Management If bleeding continues consider IV oxytocin Misoprostil
Oxytocin 40 units/1 liter Normal Saline run wide open
Misoprostil
800 ug pr (4 tablets per rectum)
Correct hypovolemia
Normal Saline
Ringers Lactate
Blood products – RBC transfusion

20. PPH Management Consider transfer to center with additional resources
Surgery
B-Lynch Stitch
Hysterectomy

21. PPH Management
Consider aortic compression

22. Uterine inversion Rare Caused by over vigorous cord traction
More common in grand multiparous women
Treatment
Replace uterus promptly
Replacement is “last out” is “first in”
Consider uterine relaxation with nitroglycerin

23. Uterine rupture Can occur with: Management
Prolonged or obstructed labor
Prior uterine surgery – caesarean section
Grand multiparous women being induced or augmented
Management
Vigorous resuscitation
Emergency laparotomy
Delivery of fetus / repair of uterus
Hysterectomy
Prophylactic antibiotics

24. Secondary PPH Cause Management Retained tissue Infection
Breakdown of uterine wound following C/S
Management
ABC – treat for shock
Antibiotics
Assess patient carefully for source of bleeding

25. Secondary PPH After bleeding controlled monitor woman for:
24 – 48 hours for further bleeding
Urine output
Vital signs
Uterine tone
CBC
Educate patient and family about PPH and when to return to hospital

26. Conclusion – Key message
PPH is a serious obstetrical emergency requiring urgent diagnosis and treatment.
PPH is prevented with Active Management of the Third Stage of Labor.
Patient may need to be transferred to referral hospital if local resources inadequate.