3. 1. INTRODUCTION
Of all stages of labour, the 3rd stage is the most crucial for the mother. Fatal
complications may appear unexpectedly in otherwise normal 1st and 2nd stages.
Postpartum haemorrhage is one among the important complications. Others
include:
Retention of placenta
Shock
Obstructed labour
Infections, etc……………….
Postpartum haemorrhage is one of the commonest cause of maternal death in
our hospitals. It accounts for large proportion of maternal death in Tanzania.
4.
5. 2. DEFINITION
PPH is a loss of 500 mls or more blood from the
genital tract after delivery (WHO).
CLINICALLY it is defined as “any amount of bleeding from or
into the genital tract following birth of the baby up to the
end of pueperium which adversely affects the general
condition of the patient evidenced by rise in pulse rate and
falling blood pressure”
6. The average blood loss following vaginal delivery and
caesarian delivery is 500mls and 1000mls respectively.
Depending upon the amount of blood loss PPH can be:
Minor (<1L)
Major (>1L)
Severe (>2L)
Blood loss <500mls can also cause death in:
Severely anaemic women
Women with severe pre-eclampsia and eclampsia since they have
contracted blood volume.
7. 3. TYPES
1. PRIMARY: if the haemorrhage occurs within 24 hrs.
following delivery (in majority of cases it occurs 2
hrs. following delivery).
- primary PPH is further divided into:
Third stage haemorrhage: bleeding occurs before
expulsion of placenta.
True postpartum haemorrhage: bleeding occurs
subsequent to expulsion of placenta (majority)
8. 2. SECONDARY: Haemorrhage occurs beyond
24 hrs. and within pueperium.
Also known as DELAYED or LATE PUPERAL
HAEMORRHAGE
9. 4. CAUSES OF PRIMARY
PPH
a) ATONIC UTERUS
b) TRAUMA
c) RETAINED TISSUES
d) BLOOD COAGULOPATHY
THE 4 Ts
TONE
TISSUE
TRAUMA
THROMBIN
10. a) ATONIC UTERUS
This is the commonest cause of PPH (80%)
Accounts for about 60% of maternal death
Commonly seen in association with:
Over-distension of the uterus: (large foetus, multiple pregnancies,
polyhaydromnious)
Prolonged labour: poor retraction, infection and dehydration are important
factors.
Anaesthesia: depth of anaesthesia and anaesthetic agents (ether, halothane) may
cause atonicity.
Malformation of the uterus: e.g. Septate uterus may cause excessive bleeding.
11. Mismanaged third stage of labour: this includes:
i. Too rapid delivery of the baby preventing the uterine wall
to adapt to the diminishing contents.
ii. Premature attempt to deliver the placenta before it is
separated.
iii. Pulling the cord.
iv. Manual separation of the placenta (increases blood loss
during caesarean delivery)
Grand multipara: inadequate retraction and frequent
adherent placenta contribute to it.
12. Drugs: use of tocolytic drugs e.g. Mg.SO4 ,
nifedipine, etc…
Initiation or augmentation of delivery by
oxytocin: post-delivery uterine atonicity is
likely unless the oxytocin is continued for at
least one hour following delivery.
Full bladder
13. b) TRAUMATIC
Accounts 20% of PPH
trauma to the genital tract usually occurs following operative delivery
and even after spontaneous delivery.
Trauma usually involves:
Uterus (laceration/ rupture)
Cervix (lacerations)
Vagina (laceration)
Perineum (episiotomy wound and lacerations)
Para-urethral region
14. C) RETAINED TISSUES
Retained products of conception including bits of
placenta and blood clots may cause PPH due to
imperfect uterine retraction.
This is mostly associated with:
• Mismanagement of third stage of labour
• Incomplete separation of placenta
• Abnormally adherent placenta ( accreta, Increta,
pancreta)
15. D) BLOOD COAGULOPATHY
Blood coagulation disorders are less common causes of
postpartum haemorrhage. They include:
Disseminated intravascular coagulopathy (DIC)
Thrombocytopenia.
Blood coagulation disorders are associated with
Abruptio placenta
Jaundice in pregnancy
Thrombocytopenic purpura
In IUD
Etc………..
16. 5. CAUSES OF SECONDARY PPH
1. RETAINED PRODUCTS OF CONCEPTION
2. INFECTION (esp. over lacerations)
3. ENDOMETRITIS
4. SECONDARY BLEEDING FROM CAESSARIAN SECTION
WOUND
5. PUPERAL SEPSIS
6. RUPTURED UTERUS
17. 6. SYMPTOMS AND OBJECTIVE
FINDINGS
Vaginal bleeding
Light headness
Weakness
Palpitations
Change in vital signs
Oliguria
hemoglobin and hematocrit
18. 7. DIAGNOSIS OF PRIMARY PPH
In the majority, the vaginal bleeding is visible outside (but rarely the bleeding is
totally concealed as vulvo-vaginal or broad ligament haematoma).
Weak pulse, rise in pulse rate.
Raised RR
Low blood pressure
On occasion, blood loss is so rapid and death may occur within few minutes.
In traumatic haemorrhage, the uterus is found well contracted
In atonic haemorrhage, uterus becomes flabby and becomes hard on messaging
Change in vital signs
19. 8. DIAGNOSIS OF
SECONDARY PPH
The bleeding is bright red and of varying amount.
There is varying degree of anaemia
Evidence of sepsis is present
Ultrasonography is useful in detecting the bits of
placenta inside the uterine cavity.
20. 9. MANAGEMENT OF PRIMARY PPH
The principles of management are:
A. To empty the uterus of its contents and
make it contract
B. To replace the blood
C. To ensure effective haemostasis
21. IMMEDIATE MEASURES
Call for help!!! Involve the senior staff on call
put in 2 large bore (14 gauge) IV cannulas.
Keep patient flat and worm.
Send blood for group, cross matching diagnostic tests and
ask for at least 2 units of blood
Infuse rapidly 2 litres of normal saline (crystalloids) to re-
expand the vascular bed.
Give oxygen by mask 10 – 15L/min
22. Insert Foley catheter to empty the bladder and
monitor urine output.
Start 20 units of oxytocin in 1L of normal saline IV
at the rate of 60 drops/min.
Transfuse blood as soon as possible.
Monitor the following:
PULSE
BP
RR
URINE OUTPUT (CONTINUOUS CATHETARIZATION)
TYPE AND AMOUNT OF FLUID THE PATIENT RECEIVED
23. IF PLACENTA IS ALREADY DELIVERED AND UTERUS
ATONIC
Rub the uterus to make it contract, hard and express the blood clot
If contraction is not coming compress the uterus intermittently
bimanually. IT MAY BE NECESSARY TO CONTINUE THE COMPRESSION FOR
A PROLONGED PERIOD UNTILL THE TONE OF THE UTERUS IS REGAINED
IF THE UTERUS IS STILL NOT CONTRACTING PERFORM UTERINE TAMPONADE
METHODS:
TIGHT INTRAUTERINE PACKING
BALOON TEMPONADE
Injection oxytocin drip is started (10 units in 500ml of NS) at the rate of 40-60
drops/min.
24. If the uterus is contracted, check the cause and site of
bleeding.
Explore the uterus to exclude retained products of
conception and coexistent bleeding sites AND REPAIR
THEM IF FOUND.
EXPLORE THE UTERINE CAVITY FOR RETAINED POC
AND EVACUATE THEM IF FOUND.
25. rarely if bleeding is uncontrollable SURGICAL METHODS are
implemented. these include:
ligation of uterine arteries: the ascending branch of the uterine
artery is ligated at its lateral border btw upper and lower uterine
segment. in atonic haemorrhage it is effective in abt. 75% of cases.
ligation of ovarian & uterine artery anastomoses if bleeding
continues, is done just below the ovarian ligament
ligation (uni / bilateral) of anterior division of internal iliac artery:
reduces distal blood flow. bilateral ligation can avoid hysterectomy in
abt. 50% of cases.
26. angiographic arterial embolism under
fluoroscopy can be done using gel foam.
success rate is greater than 90% and it avoid
hysterectomy
hysterectomy: if the uterus fails to contract
and bleeding continues inspite of the above
measures
27. Keep accurate records
Give Fe and Folic acid for 6 wks.
Check Hb and discharge if Hb is above 8g/dl
See her at follow up postnatal clinic at 2, 4
and 6 wks.
28. IF PLACENTA IS UNDELIVERED AND
BLEEDING
It implies that the placenta is partially or wholly separated but
retained in the uterus
Attempt delivery of placenta by controlled cord traction
If this fails maintain uterine contraction by oxytocics and conduct
manual removal of placenta on the delivery bed immediately.
After manual removal give 0.5 mg ergometrine IM/IV
Massage the uterus
29. Give antibiotics of Ampicillin and
metronidazole for 5 days
Give Fe and Folic acid for 6 wks.
Check Hb and discharge if Hb is above 8g/dl
See her at follow up postnatal clinic at 2, 4 and
6 wks.
30. IF PLACENTA IS UNDELIVERED AND NOT BLEEDING
Implies that the placenta is not separated at all and may be
abnormally adherent
Perform the immediate measures as described above then
council the patient for manual removal of the placenta and
get informed consent.
Send the patient to the theatre and conduct manual
removal of the placenta.
Get ready for possible hysterectomy in abnormally adherent
placenta with uncontrolled bleeding after manual removal
and evacuation.
31. Give antibiotics
Give Fe and Folic acid for 6 wks.
Check Hb and discharge if Hb is above
8g/dl
See her at follow up postnatal clinic at 2, 4
and 6 wks.
32. IF UTERUS IS WELL CONTRACTED, PLAENTA
IS DELIVERD AND BLEEDING CONTINUES
Implies that there are genital tract injuries.
Explore for the possibility of rupture of the uterus, tears of the cervix,
lacerations of vagina or perineum.
Place woman in lithotomy position and use good light.
Find bleeding point and clump it to ensure haemostasis.
Suture perineal and vaginal lacerations under local anaesthesia.
33. If the apex of the cervical tear is high up into the uterus and
can not be reached from below or if rupture of the uterus is
suspected or diagnosed, a laparotomy is indicated for repair
or hysterectomy.
Check general condition.
Give Fe and Folic acid for 6 wks.
Check Hb and discharge if Hb is above 8g/dl
See her at follow up postnatal clinic at 2, 4 and 6 wks.
34. 10. MANAGEMENT OF
SECONDARY PPH
PRINCIPLES:
to access the amount of blood loss and
replace it
to find out the cause and take appropriate
steps to rectify it
35. SUPPORTIVE THERAPY:
blood transfusion, if necessary
Administer Methergin 0.2mg IM if bleeding is uterine in
origin.
Administer antibiotics
CONSERVATIVE:
If bleeding is slight and no apparent cause is detected, a
careful watch for a period of 24 hrs.
36. ACTIVE TREATMENT:
Preferable to explore the uterus urgently under general
anaesthesia (as the commonest cause is retained POC)
If present the POC are removed.
Material removed are to be sent for histological examination.
Bleeding from uterine wounds can be controlled by
haemostatic sutures, but may rarely require ligation of internal
iliac arteries or may end in hysterectomy.
37. COMPLICATIONS OF PPH
EARLY COMPLICATIONS
Shock
Renal failure
Coagulation disorders
Death
LATE
COMLICATIONS
Hepatitis B
Syphilis
HIV
38. 11. PREVENTON OF PPH
ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR.
CORRECTING PRENATAL ANAEMIA.
ASESSING THE MOTHERS BELIEF AND ACCEPTANCE OF BLOOD
TRNSFUSION.
AVOID EPISIOTOMY.
AVOID ASSISTED DELIVERY or CAESARREAN SECTION.
MANAGING AND IDENTIFYING RISK FACTORS.
39. MEDICINE IS NOT CONGENITAL!!
IT IS ACCUIRED
SLOWLY U WILL UNDERSTAND!!
Thank you for listening
