SALAH M.OSMAN CLINICAL MD

* It is an excessive blood loss from the genital tract after delivery of the foetus exceeding 500 ml or affecting the general condition of the patient.

* Primary : Bleeding occurs during the 3 rd stage or within 24 hrs after childbirth. It is more common. * Secondary : Bleeding occurs after the 1 st 24 hrs until 6 weeks.

AETIOLOGY :- 1- Placental site haemorrhage : (a) Atony of the uterus :- (more than 90%) Predisposing factors include :- - Antipartum haemorrhage. - Severe anaemia. - Over distension of the uterus - Uterine myomas. - Prolonged labour exhausting the uterus. - Prolonged anaesthesia and analgesia. - Full bladder or rectum. - Idiopathic. (b) Retained placenta. (c) DIC. 2- Traumatic haemorrhage

1- General examination :- In excessive blood loss manifestations of shock appear as hypotension, rapid pulse, cold sweaty skin, pallor, restlessness, air hunger and syncope. 2- Abdominal examination : In atonic postpartum haemorrhage the uterus is larger than expected, soft and squeezing. In traumatic postpartum haemorrhage the uterus is contracted. Combination of the two causes may occur 3- Vaginal examintion :- In atony bleeding usually started few minutes after delivery, dark in colour and the placenta may nit be delivered. In trauma Bleeding starts immediately after delivery of the foetus, it’s bright in coloue and lacerations can be detected by local examination.

1- Prevention :- * During pregnancy : A- Detection and correction of anaemia. B- Hospital delivery with ready cross-matched blood for high risk patients as : antepartum haemorrhage, previous postpartum haemorrhage, polyhydroamnios and multiple pregnancy and grand multipara.

* During labour : A- Proper use of analgesia and anasthesia. B- Avoid prolonged labour by proper oxytocin. C- Avoid lacerations by proper management of 2 nd stage and following the instructions for instrumental delivery. D- Routine use of ecobolics in the 3 rd stage of labour. E- Routine examination of the placenta and membranes for completeness.

* Postpartum :- A- Exploration of the birth canal after difficult or instrumental delivery as well as precipitate labour. B- Careful observation in the 4 th stage of labour

2- Treatment :- * Restoration of blood volume. * Arrest of bleeding :- A- Placental site bleeding : - Before delivery of the placenta : The placenta should be delivered by ergometrine and massage with gental cord traction. If failed, Brandt-Andrews manoeuvre. If failed, do Crede’s method. If failed, do manual seperation of the placenta.

- After delivery of the placenta :- The following steps are done in succession if each previous one fails to arrest bleeding :- (I) Inspection of the placenta and membranes. (II) Massage of the uterus and ecbolics as Oxytocin drip, Ergometrin and Synometrin. (III) Prostaglandins. (IV) Bimanual compression of the uterus. (V) Bilateral uterine artery ligation. (VI) Bilateral ligation of ovarian supply to the uterus. (VII) Bilateral internal iliac artery ligation. (VIII) Hysterectomy,

Other less commonly used methods to arrest bleeding :- * Uterine packaging. * Foley’s balloon. * Aortic compression. * Radipgraphic trans-arterial embolization. B- Lacerations

1- Maternal death in 10% of postpartum haemorrhages. 2- Acute renal failure. 3- Emcolism. 4- Sheehan’s syndrome. 5- Sepsis. 6- Anaemia. 7- Failure of lactation.

Aetiology :- 1- Retained parts : of the placenta, membranes, blood clot or formation of a placental polyp. 2- Infection. 3- Fibroid polyp. 4- Subinvolution of the uterus. 5- Local gynaecological lesions : eg, cervical ectopy or carcinoma. 6- Choriocarcinoma. 7- Puerperal inversion of the uterus. 8- Oestrogen withdrawal bleeding ; if oestrogen was given for supression of lactation.

Depends on the cause. 1- Retained parts :- * Minimal bleeding can be spontaneously expelled using ergometrine and antibiotics. * Severe bleeding Vaginal evacuation under anaesthesia is indicated. - Infections : Antibiotics. - Other causes : Treatment of the cause