1. POSTPARTUM HAEMORRHAGE

2. DEFINITION:-
Any amount of bleeding from or into the genital tract following birth of the baby upto the end of the puerperium which adversely affects the general condition of the patient evidenced by rise in pulse rate and falling blood pressure is called postpartum haemorrhage”

3. INCIDENCE:-
1% amongst hospital deliveries.

4. TYPES:-
(1)primary
Haemorrhage occurs within 24 hr following the birth of the baby.
3rd stage haemorrhage :- bleeding occurs before expulsion of placenta.
True postpartum hemorrhage :- bleeding occurs subsequent to expulsion of placenta.
(2)secondary.
Hemorrhage occurs beyond 24 hr and within puerperium

5. CAUSES:- (1)atonic . Grand multipara. Over –distension of uterus.
Malnutrition and anaemia.
Prolong lobar.
Precipitate labor.
(2)traumatic.
(3)mixed.
Combination of atonic and traumatic.
(4)blood coagulopathy.

6. DIAGNOSIS AND CLINICAL EFFECTS:-
In the majority, the vaginal bleeding is visible outside. Rarely, the bleeding is totally concealed either as vulvo-vaginal or broad ligament haematoma.
THE EFFECT OF BLOOD LOSS DEPENDS ON
Pre-delivery Hb level.
Degree of pregnancy induced hypervolaemia.
Speed at which blood loss occurs.

7. PREVENTION ANTENATAL Improvement of health status.
High risk patients are to be screened.
Blood grouping should be done.

8. INTRANATAL Slow delivery of the baby. Expert obstetric anaesthetist.
During caesarean section spontaneous separation and delivery of placenta.
Active management of 3rd stage.
Examination of placenta.
If induced labour than by oxytocin.
Exploration of the utero-vaginal canal.
Observe the patient for about two hours.

9. MANAGEMENT OF 3rd STAGE HAEMORRHAGE
-Control the fundus, massage and make it hard
-Inj. Methergin 0.2 mg I.V.
-Start normal saline drip and arrange for B.T.
-Catheterize the bladder
Placenta separated Not seperated
Expressed the placenta out manual removal under G.A.
by controlled cord traction
Traumatic haemorrhage should be tackled by suture.

10. MANAGEMENT OF TRUE P.P.H Immediate measure
-Call for extra help.
-I.V. line with a wide bore cannula.
-Send blood for cross matching.
-rapidly infuse normal saline or colloids liters blood is available.
Feel the uterus by abdominal palpation
Uterus atonic Uterus hard & contracted
-Massage the uterus to make it hard (Traumatic)
-Inj. Methergin 0.2 mg I.V.
-Add oxytocin 10 units in 500 ml of N. saline, Exploration
at the rate of 40 drops per minute.
Suture on tear sites
Examine the expelled placenta.
Catheterize the bladder

11. Stepwise uterine devascularisation procedure
Uterus remains atonic
Exploration of the uterus.
Blood transfusion
Continue oxytocin drip
Uterus atonic
Inj. 15 methyl PGF2α 250 µg IM
Misoprostol 1000 µg per rectum
Uterine temponade
Bimanual compression
Tight intrauterine packing under anasthesia
Insertion of a Sengstaken – Blakemore tube and inflation
Surgical methods
Stepwise uterine devascularisation procedure
Ligation of uterine artery and utero-ovarian anastomosis vessels unilateral or bilateral
Ligation of anterior division of internal iliac artery
B-Lynch brace suture
Angiographic arterial embolization with gelatin sponge.
Hysterectomy (rarely)

12. SECONDARY POSTPARTUM HAEMORRHAGE.
CAUSES:
Retained bits of membrane.
Infection and separation of slough over a deep cervico-vaginal laceration.
Endometritis and subinvolutoin of the placental site.
Secondary haemorrhage from caesarean section wound.
Withdrawal bleeding following oestrogen therapy for suppression of lactation
Others like carcinoma of cervix, infected fibroid and puerperal inversion of uterus.

13. DIAGNOSIS: The bleeding is bright red and of varying amount.
Ultrasonography

14. MANAGEMENT: Supportive therapy: Blood transfusion
Ergometrine 0.5 mg I.M. if bleeding is uterine in origin.
Antibiotics.
Conservative: A careful watch for a period of 24 hours.

15. Active treatment: Explore the uterus urgently under G.A.
The product is removed by ovum forceps.
Ergometrine o.5 mg I.M.
Bleeding from cervico-vaginal canal controlled by sutures. Suture may require ligation of the internal iliac artery and may end in hysterectomy.
Bleeding following caesarean section may at times require laprotomy.

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