Postpatrum Hemorrhage and Third Stage Emergencies

Postpartum Hemorrhage 3-5% of vaginal deliveries Definition: >500ml blood loss Potentially serious complications for mother Common cause of maternal morbidity and mortality worldwide

PPH Risk Factors Antepartum Pre-eclampsia Multiparity Multiple gestation Previous postpartum hemorrhage Previous cesarean section Intrapartum Prolonged third stage (>30 mins) Arrest of descent Episiotomy Lacerations: cervical, vaginal, perineal Assisted delivery: forceps, vacuum Augmented labour

Causes of PPH: The Four “Ts” Tone (70%) Trauma (20%) Tissue (10%) Thrombin (1%)

PPH: Resuscitative Measures Call for help Airways, Breathing, Circulation Two large-bore IVs Oxygen Stat labs: type & cross, hb, coags Consider transfusion

Treatment Approach for PPH Catheterise bladder Uterine massage Oxytocics Inspect for lacerations Surgical intervention

Tone – Uterine Atony Most common cause of PPH Initial step = bimanual uterine massage and compression Oxytocic agents Oxytocin Methylergometrine Prostaglandins

Oxytocin Drug of choice 10 – 40 units in 1 litre at 250 cc/hr 1M (10 units) or IV infusion No contraindications Hypotension with IV push

Ergot Alkaloide Ergometrine 0.25 mg IM only Contraindicated in hypertension

Prostaglandins 15-methyl prostaglandin F2a carboprost, Hemabate® 0.25 mg IM or intramyometrial Side effects: nausea, diarrhea, flushing, headache Contraindication: hypersensitivity Caution: asthma, HTN, cardio- pulmonary disease

Trauma Uterine inversion Uterine rupture Vaginal or cervical lacerations Hematoma Perineal tears

Uterine Rupture Associated with uterine surgery Suspect if: vaginal bleeding abdominal tenderness maternal tachycardia signs of shock are out of proportion to viable blood loss

Uterine Inversion Rare, but important to recognize quickly Suspect if shock disproportionate to blood loss Replace uterus immediately or after resuscitation Watch for vasovagal reflex

Tissue Retained placenta Retained placental fragments Not delivered within 30 minutes 3% of deliveries Retained placental fragments Invasive placenta

Manual Placental Removal Cease uterine massage Identify cleavage plane Cup cotyledons in palm Explore uterine cavity Give oxytocin

Thrombin - Coagulopathy Pre-existing conditions ITP, von Willebrands Coagulaopthic: Obstetric-related Hypertension disorders, HELLP Abruption Fetal demise Sepsis Drugs (e.g. asprin)

Coagulation Lab Studies FBC with platelet count PT-INR, aPPT Fibrinogen level FDP / D-dimer

Tone, Trauma, Tissue, Thrombin PPH Summary Unpredictable – be prepared Uterine atony is the main cause Remember 4-Ts: Tone, Trauma, Tissue, Thrombin Consider active management of the third term