1. Nahida Chakhtoura, M.D.

2.  Postpartum hemorrhage (PPH): leading cause of maternal mortality worldwide  Prevalence rate: 6%  Africa has highest prevalence rate: 10.5%  In Africa and Asia PPH accounts for more than 30% of all maternal deaths  Maternal death rates attributable to PPH vary considerably between developed and developing countries, suggesting that deaths from PPH are preventable

3.  Uterine Atony  Placenta: retained placenta, placental tissue or membrane, incomplete separation  Full bladder  Antepartum hemorrhage: placenta previa or placental abruption  Overstretched uterus: high parity, multiple pregnancy, polyhydramnios, macrosomia, fibroids

4.  Uterine Atony  Prolonged active phase  Medical factors: anemia, coagulopathy  Others: severe pre-eclampsia and eclampsia, precipitate labor, induction/ augmentation, IUFD, h/o PPH, c/s, gen. anesthesia, chorioamnionitis or endometritis

5.  Genital Trauma  Perineum  Vaginal walls  Cervix  Uterus  Risk Factors  Mistimed episiotomy  Induced labor  Precipitate labor  C/S  Forceps Delivery  Prolonged labor  Previous uterine surgery  Anemia  Delay in Tx

7.  Priorities  Call for Help!  Rapid assessment of patient’s condition  Identify source of bleeding  Stop the bleeding  Stabilize/resuscitate  Prevent further bleeding

8.  Atonic PPH  Massage the uterus to promote contraction and expel clots  Oxytocin 10 IU IM  Assess EBL  Type and cross, CBC, coagulation profile  Start IVF: if shock  1L NS or LR in 15min up to 3L  Foley catheter  Check placenta and membranes. If placenta cannot be delivered, manually extract  Examine cervix, vagina, and perineum

9.  If bleeding persists…  Oxytocin 20 units in 1L of IVF @ 60 drops per min  Add other IV access  Continue uterine massage  Assess clotting status and transfuse if necessary  Consider transferring to higher level  Uterine or utero-ovarian ligation; hypogastric artery ligation  Uterine balloon  B-lynch suture  Hysterectomy  Document properly

10.  Traumatic PPH  Lithotomy position  Identify site of bleeding and repair

11.  Close monitoring over next 24-48hrs  Uterine tone  VS; Ins and Outs  Blood loss  Serial CBC

12.  Developing Countries  Active management of labor  Uterine massage  Draining the bladder  10 U oxytocin IM  Misoprostol  Uterine packing  Hysterectomy

13.  Fausto Astudillo-Davalos, M.D.  Mabel Marotta  Danielle Kramer  Nahida Chakhtoura, M.D.