SALSO - Po

1. POSTPARTUM
HAEMORRHAGE
DR SUKANDA JAILI
O&G DEPARTMENT
SGH

2. Major cause of death
 PPH is still the largest cause of
maternal death, responsible for 24% in
1995 and 20.0% in 1996.
 Over the last 6 report PPH account for
25% of all maternal death.

3. Postpartum Haemorrhage
 50% associated with substandard care
 3 main factors involved;
1. Home deliveries (46.7%)
2. Delay in resuscitating the mother
3. Delay in transportation to GH

4. National MMR by Ratio 1950-2000
220 PPH
200
180 HDP
160
No. of Deaths
140 Obst.
120 Embolism
100 Medical
80 Condition
60 Obst. Trauma
40
20
Puerperal
0 Sepsis
1991 - 1993 1994 - 1996 1997 - 1999 2000 - 2002 2003 - 2005 2006-2008

5. DEFINITION
 1 PPH
 BLOOD LOSS FROM THE GENITAL TRACT IN
EXCESS OF 500 ML IN THE FIRST 24 HOURS OF
DELIVERY
 2 PPH
 EXCESSIVE BLEEDING FROM THE GENITAL TRACT
AFTER THE FIRST 24 HOURS POST PARTUM UNTIL 6
WEEKS AFTER DELIVERY.

6. Causes of maternal Deaths, 1997 & 2007
Causes 1997 2007
No. % No. %
PPH 31 19.6 23 16.9
PIH/PE 24 15.2 25 18.4
Obstetric Embolism 18 11.4 24 17.7
Associated Medical conditions 36 22.7 20 14.7
Obstetric Trauma 9 5.7 6 4.4
APH 3 1.9 2 1.5
Puerperal sepsis 3 1.9 3 2.2
Abortion 5 3.2 6 4.4
Ectopic Pregnancy 2 1.3 7 5.1
Associated with Anaesthesia 5 3.2 1 0.7
Others 22 13.9 19 15.0
TOTAL 158 100 136 100

7. Postpartum Haemorrhage:
Etiology
 Uterine atony (80-90%)
 Retained placenta or parts of placenta
 Genital tract lacerations / uterine
tears
 Coagulation disorder (DIVC)
 Ruptured uterus/Uterine inversion
 LSCS

8. RISKS
 Previous PPH
 Maternal obesity
 Multiple pregnancy
 Retained placenta
 Operative vaginal dellivery
 Prolong labor
 Big baby
 Maternal Haemorrhagic condition

9. Postpartum Haemorrhage:
‘Risk Management’
 ‘At risk’ patients should deliver in hospital
 Active management of 3rd stage
 20 - 40 units oxytocin in 500mls of Hartman’s
soln. at 30 dpm
 Closer post-natal observation for 2-3 hours
 Cases of ragged membranes need at least 24
hours monitoring in hospital and given proper
counseling and appropriate antibiotics

10. CAUSES OF 1 PPH
A. UTERINE ATONY
B. RETAINED PLACENTA
C. TRAUMA
D. COAGULATION DEFECT

11. CAUSES OF 2 PPH
A. RETAINED POC
B. ENDOMETRITIS
C. PLACENTAL SITE TROPHOBLASTIC TUMOUR

12. ESTIMATION OF BLOOD LOSS
 1 TAMPON FULLY SOAKED – 30 ML
 1 SANITARY PAD FULLY SOAKED – 120 ML
 1 SARONG FULLY SOAKED – 500 ML

13. Blood loss,ml Up to 750 750-1500 1500-2000 2000 or more
(Blood loss, %BV) (Up to 15%) (15-30%) (30-40%) (40% or
more)
Pulse rate <100 >100 >120 >140
Blood pressure Normal Normal Decreased Decreased
Respiratory rate 14-20 20-30 30-40 >35
Urine output (ml/hr) >30 20-30 5-15 Negative
Slightly Lethargic, Confusion,
CNS-mental status anxious Mildly confusion lethargy,
anxious coma
Anorexia Anorexia, Ileus
Gastrointestinal vomiting
Fluid replacement Crystalloid Crystalloid Crystalloid Crystalloid
(3:1 rule) + blood + blood

14. MANAGEMENT
I. RECOGNISE PPH
II. CALL FOR HELP(CODE BLUE)
 O & G SPECIALIST
 ANAESTHETIST
 SISTER ON CALL
 BLOOD BANK/HAEMATOLOGIST
III. RESUSCITATION !
IV. IDENTIFY AND TREAT SPECIFIC CAUSE

15. RESUSCITATION
 DONE SIMULTANEOUSLY
 ASSESS VITAL SIGNS AND CONSCIOUS LEVEL
(IF UNCONSCIOUS, FOLLOW BLS)
 2 X 14/16 G CANNULA

16. RESUSCITATION
 TAKE 20 ML OF BLOOD FOR
 GXM 4 UNITS PC
 FBC
 COAGULATION SCREENING
 ELECTROLYTES

17. RESUSCITATION
 INFUSE FLUIDS (COLLOID/CRYSTALLOID)
 MAINTAIN CIRCULATORY VOLUME WHILE
WAITING FOR BLOOD
 IN DIRE STATES, USE GROUP SPECIFIC
BLOOD OR UNMATCHED O RH –VE BLOOD

18. RESUSCITATION
 RUNNERS – SN/ HO/ MO
 CONSIDER CENTRAL LINES
 CBD FOR HOURLY MONITORING
 OXYGEN

19. RESUSCITATION
 GIVE WARM BLOOD
 CORRECT
COAGULATION

20.  STABILIZING AND
INITIAL
RESUSCITATION MUST
BE DONE FIRST 1
GOLDEN HOUR
 IN DH DECISION FOR
REFERRAL MUST BE
MADE EARLY

21.  DURING
TRANSPORTATION
 MONITORING
 RESUSCITATION
 TEMPORARY MEASURE
 COMMUNICATION

22. UTERINE ATONY
 MASSAGE UTERUS
 OXYTOCIN INFUSION (40 UNITS IN 500 ML NS
AT 20 – 30 DPM)
 ERGOMETRINE IV/IM 0.5 MG
 CARBOPROST (HAEMABATE) IM 250 UG

24. UTERINE ATONY
 BIMANUAL COMPRESSION
 UTERINE PACKING
 AORTIC COMPRESSION

25. RETAINED PLACENTA
 RESUSCITATION!
 DO NOT CONTINUE WITH CCT WITH SUCH
PATIENT
 OXYTOCIN SHOULD BE GIVEN
 MRP IN OT UNDER GA WITH ANAESTHETIC
BACK UP FOR RESUSCITATION
 LOOK FOR GENITAL TRACT TRAUMA
 START OXYTOCIN INFUSION AFTER MRP
 ANTIBIOTICS

26. UTERINE ATONY
SURGICAL TREATMENT
 CONSERVATIVE MEASURES
 BRACE SUTURING – B LYNCH
 INTERNAL ILIAC LIGATION
 HYSTERECTOMY

27. MORBIDLY ADHERENT
PLACENTA
 IN CASES OF ACCRETA, IF NO BLEEDING, MAY
TREAT CONSERVATIVELY WITH MEDICATION
 OTHERWISE, REQUIRE LAPAROTOMY 
HYSTERECTOMY

28. GENITAL TRACT INJURY
 INJURY TO
 EPISIOTOMY
 VAGINA
 CERVIX
 UTERUS
 EXTENSION TO BROAD LIGAMENTS

29. GENITAL TRACT INJURY
 RISK FACTORS
 INSTRUMENTAL DELIVERY
 BIG BABY
 SHOULDER DYSTOCIA
 PRECIPITATE LABOUR

30. GENITAL TRACT INJURY
 EXAMINATION – BEST UNDER ANAESTHESIA IN
OT
 ‘WALK THE CERVIX’
 HIGH INDEX OF SUSPICION OF EXTENSION TO
BROAD LIGAMENTS AND UTERUS IF
LACERATION INVOLVING CERVIX AND
FORNICES
 ANTIBIOTICS

31. GENITAL TRACT INJURY
- UTERINE RUPTURE
 HIGH INDEX OF SUSPICION
 PREVIOUS SCAR
 DIFFICULT DELIVERY (INTERNAL PODALIC VERSION)
 GRANDMULTIPARA
 OBSTRUCTED LABOUR

32. GENITAL TRACT INJURY
- UTERINE RUPTURE
 WHAT ARE THE SIGNS?
 CTG CHANGES
 MATERNAL TACHYCARDIA
 PER VAGINAL BLEEDING
 SCAR TENDERNESS
 DECREASE UTERINE CONTRACTION
 HAEMATURIA

33. RESUSCITATION
 WELL DOCUMENTED
 ORGANIZED
 EARY REFERRAL
 COMMUNICATION

34. SECONDARY PPH
 USUALLY PRESENTS IN THE 2ND AND 3RD WEEK POST
PARTUM
 HVS FOR CULTURE
 START ANTIBIOTICS
 IF DIAGNOSIS OF RETAINED POC, FOR EXPERIENCED
PERSONNEL TO PERFORM EVACUATION – HIGH RISK
OF PERFORATION
 DIFFICULT TO DIFFERENTIATE POC AND BLOOD
CLOT BY US IN 1ST 2 WEEKS POSTPARTUM

35. MONITORING
 ICU/ HDU MONITORING
 VITAL SIGN MONITORING EVERY 15 MINUTES
- BP, PR, RR, SA O2, CVP
 FLUID RESUSCITATION DOCUMENTED
 URINE OUTPUT
 ON GOING HAEMORRHAGE NOTED
 DRAIN, PAD
 RESULTS TRACED STAT
 INFORM PATIENT AND RELATIVES

36. Case illustration
 A 35 year old Malay lady in her 4th pregnancy, had
a history of PPH in her previous pregnancies. She
was diagnosed to have pre eclampsia during this
pregnancy and was on oral antihypertensive
medication. At 38 weeks of gestation she was
admitted to a private facility and was induced with
prostaglandins.

37.  The labour was uneventful and she delivered a 3.9kg
baby. There was massive bleeding after her delivery.
Exploration did not reveal any retained products.
The uterus remained atonic despite repeated
injections of ergometrine and an oxytocin infusion.
No blood or blood products were available.

38.  She was transferred to a general hospital for further
resuscitation but arrived in a moribund state and
succumbed soon after.

39. Case illustration
 A 30 year Malay lady in her third pregnancy at 38
weeks of gestation came in labour at a district
hospital. Her antenatal period had been uneventful.
She delivered vaginally at 7.02pm. Active
management of 3rd stage instituted and the placenta
was delivered via CCT. Her delivery was conducted
by a staff nurse.

40.  After the placenta was delivered it was noted that
there was active bleeding from the vagina. A green
branula was inserted and the on-call doctor was
informed. Over the phone the doctor ordered for
uterine massage to be done, to give patient iv
ergometrine 0.5mg and iv Pitocin 40 unit in
500mls NS started while awaiting for him to come.

41.  On examination, the patient was alert, the blood
pressure was normal but the pulse rate was 96b/min.
Abdominal examination done showed that the uterus
was contracted.Despite that the patient was still
actively bleeding. Another iv line was inserted and
blood was sent for FBC, GXM and PT/PTT. She was
given NS running fast.

42.  Another doctor was called to help manage the patient.
Further examination showed a cervical laceration which the
doctor tried to repair but failed. The patient continued to
bleed, so vaginal packing was done and she was planned for
transferred to the general hospital.The placenta was also
re-examine for it’s completeness. By this time, the patient’s
blood loss was about 1 L. the patient was conscious but
lethargic, her BP was 90/60mmHg and PR was 110b/min.

43.  While awaiting for arrangements for transfer to the referral
center to be made, another 2 iv lines inserted and she was
rapidly infused with NS and later transfused with blood. A
Foley’s catheter was inserted to monitor urine output and
her vital signs was monitored every 15 minutes.

44.  She arrived at the general hospital at 10.20pm
accompanied by a doctor and 2 staff. Upon arrival
the estimated blood loss was about 2L and she had
4 iv lines (all green). 2 unit of blood has already
been transfused plus the crystalloids and the 3rd
and 4th unit of blood transfusion was still in
progress.

45.  Examination upon arrival showed very pale patient,
drowsy but still responding to call, the BP was
80/40mmHg and the PR was 130b/min. The uterus
was contracted and she was still actively bleeding
from the vagina.

46.  EUA was done and the cervical laceration was
sutured. Despite that patient continued to bleed. A
laparotomy was done and it showed that there was
another cervical laceration which extended up to the
lower segment of the uterus. As it was not able to be
repaired, a hysterectomy was performed.

47.  Post operatively she was managed for 2 days in ICU.
The estimated blood loss through out was 5.4L and
she was transfused a total of 21 unit of blood and 4
cycles of DIVC regime. She was discharged well on
day 6 post delivery.

48. THANK YOU