PPH

⚫ TAJMAHAL-world`s most beautiful tomb,dedicated

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to the memory of “Queen Mumtaz” by her husband
“Emperor Sahajahan”, who died after her last child
birth due to PPH, is a testimony and a grim reminder

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of the tragedy
of maternal mortality, that can befall any women in
childbirth. PPH today living in the shadow of
TAJMAHAL
 Incidence
⚫ PPH is one of the commonest cause of maternal
mortality & accounts for 1/4th of all maternal death

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worldwide.(WHO 2005)
In developing countries it accounts over 1/3rd of all

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maternal death.(Khan KS 2006)
Widely variable 4% to 6% of all delivery
 Definition
❑ According to ACOG /WHO
⚫ PPH is defined as blood loss of greater than 500
mL with a vaginal delivery or greater than 1000
mL with a cesarean section or a 10% drop in the
hematocrit.
❑ Clinically :
⚫ 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.
 Pitfalls in definition:

⚫ Arbitrary, subjective & based on visual estimation

⚫ Change in hematocrit depends upon timing of
which underestimate actual loss

test & amount of fluid resuscitation given & on

⚫
post partum hemoconcentration
Ability to tolerate amount of blood loss without
any significant effect on health depends upon not
only antepartum Hb% but also on amount of
pregnancy hypervolumia Eg- preeclampsia,
eclampsia.
 Pitfalls in definition:

⚫
Conclusion :
Reliance on classification solely based on the amount
of blood loss, without considering clinical signs &
symptoms may lead to inconsistency with
management. So we need a clinical & prognostic
classification.
 Types of PPH
1. Primary PPH- occurs within 24 hrs of delivery

⚫ Third stage hemorrhage : before placental

⚫ True PPH : Occurs subsequent to placental
expulsion

expulsion

2. Late/secondary PPH-
occurs after 24 hrs & within 6 wks
 Causes & Predisposing factors of primary PPH

1. Tone : Uterine atony

2. Tissue : Retained placental tissue
3. Trauma:
▪ Large episiotomy
▪ Laceration perineum,vagina,cervix
▪ Ruptured uterus
4. Thrombine
 Pathophysiology
⚫ Blood vessels(spiral arteries) supplying placental
bed pass through an interlacing network of
muscle fibres of myometrium. Myometrial
contraction is main driving force for placental
separation & constriction of blood vessels. This
hemostasic mechanism is known as “physiological

⚫
sutures” or “living ligatures

⚫ So bleeding occures from placental beds due to

Uterine atony(myometrium fails to contract)
Retained products(that interferes contraction)
 Predisposing factors

⚫
Uterine atony is responsible for upto 80% of primary PPH.

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Grand Multipara
Over distended uterus(large fetus ,twins,

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hydroamnios

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Malnutrition

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APH

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Anesthesia (general anesthesia)

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Malformed uterus

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Tumor(fibroid uterus)
Abnormal uterine contraction(Precipitate/prolonged

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labor)
Induced/augmented labor
 Predisposing factors
⚫ Retention of placenta tissue
⚫ Placenta adhesion
⚫ Placenta implant
⚫ Retained placenta and membrane tissue
 Trauma
▪ Large episiotomy
▪ Laceration : perineum,vagina,cervix
▪ Ruptured uterus
Coagulation defects

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Congenital :Von Willebrand`s disease

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Acquired

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DIC(placental abruption,IUFD, sepsis)
Dilusional coagulopathy(fluid resuscitation/massive

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BT) Hypoxia & acidosis
Severe PET/Eclampsia
 Secondary PPH

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Retained bits of placenta

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Placental polyp

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Subinvolution of placental site

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Endometritis

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Infected sloughing from cervicovaginal wound
Puerperal inversion of uterus
 Prevention of PPH
⚫
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Ante natal screening of high risk pregnancy

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Timing of delivery –

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proper labor management –

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exploration of cervicovaginal canal –

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intense monitoring upto 1 hr –
increased post partum/ postoperative surveillance of
patients at risk
 Ante natal

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Improvement of health status of women
Screening of high risk pregnancy & hospital delivery :

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twin,hydromnios,grand multipara,APH, severe anaemia

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Blood grouping
Placental localization
 Timing of Delivery

❖ Elective C/S after completion of 37 weeks

Prevention of PPH

⚫ Placenta previa
⚫ Previous classical C/S , prev. 2 C/S
⚫ Previous myomectomy
⚫ Fibroid uterus
 Intra natal / Proper labor management

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Management of prolonged labour

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Slow delivery of baby

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Active management of 3rd stage of labour

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Placental delivery by controlled cord traction
Administration of utero tonics (oxytocin 10U/

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Ergometrine 0.2mg IM)
Oxytocin should cont. at least 1 hr. after delivery in

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induced / augmented cases
Uterine massage after placental delivery
 Intra natal / Proper labor management

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⚫
Exploration of cervico-vaginal canal

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Intense monitoring upto 2 hr after delivery
During C/S spontaneous separation & delivery of the

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placenta reduces blood loss
Examination of the placenta & membranes should be
routine
 Prepare for PPH management
⚫ Nursing -Anesthesia - Surgical assistance

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Drugs/Equipment

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Oxytocin ,Methergine ,Prostaglandins

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Crystalloids
Blood/Bl.products

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Surg. Instruments –
Hemostatic ballons ( Cook, S-B, Foley)
Diagnosis & Management
Clinical assessment of bl loss

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⚫
PPH BOWL AND BAG
Soakage characteristics of 10×10cm pads. It is used for

⚫
rough estimation of blood loss in rural area
Blood drained into an fixed container for measurement
⚫ Retained placenta tissue
manual exploration of the uterus
curretage
⚫ Soft tissue laceration
repair the laceration
Clear the haematoma
⚫ Coagulation defect
blood replacement
 Retained placenta
Incidence

Retained placenta is found in 2% of deliveries. The

frequency of retained placenta is markedly increased
(twenty-fold) at gestation <26 weeks, and even up to 37
weeks it remains tree times more common than at term.
At term, 90% of placentas will be delivered within 15
minutes. Once the third stage exceeds 30 minutes, there
is a ten-fold increase in the risk of haemorrhage.
 Retained placenta
Management

When the placenta is delivered, it should be inspected for

completeness. Manual exploration of the uterine cavity is
required.This will need to be undertaken under
anaesthesia.

If the placenta is retained as a whole, if it is within the

uterus, the operator (wearing a gauntlet glove) should use
the fingers of one hand, held as a 'spatula' to lift the
placenta, whilst the hand on the abdomen balances these
movements with downward pressure on the uterus. A
gauze swab around the exploring fingers. Curettage with a
blunt instrument. Antibiotics should be routinely
administered
 rd
3 stage bleeding mgt
⚫
⚫
Anticipate haemorrhage

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insert an intravenous infusion line,

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take blood for full count, group,

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catheterize

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Give prophylactic antibiotics
oxytocin drip
 3rd stage bleeding mgt
Check that the placenta is seperated or not or in
the cervical canal or in vagina
If seperated :
removal by fundal pressure or by controlled cord
traction
If retained:
Carry out manual removal under G/A – call
senior help if there is accrete and/or heavy
bleeding
 3rd stage bleeding mgt
⚫ Retained placenta tissue
manual exploration of the uterine
curretage
⚫ Soft tissue laceration
repair the laceration
⚫ Clear the haematoma
⚫ Coagulation defect
blood replacement
 Management of true PPH
⚫
⚫
HAEMOSTASIS algorithm

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H- ask for help
A- assess (vitals, blood loss) & resuscitate
2 wide bore cannula, infussion N/S ( crystalloid),
Haemaccele ( colloid)
An indwelling catheterisation

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Blood grouping
E - Establish etiology(tone,tissue,trauma,thrombine)
Ecbolics (syntometrine,ergometrine)
Ensure availability of blood
 HAEMOSTASIS algorithm

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M - massage the uterus ,

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O – oxytocin infusion & prostaglandin

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S- shift to operating theatre
T- Tissue & trauma to be excluded,Bimanual compression
Tamponade : intra uterine packing

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Balloon tamponade

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A-apply compression sutures

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S-systematic pelvic devascularisation
I -interventional radiology – angiographic arterial

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embolisation by gelatin sponge
S-subtotal/total hysterectomy
 The golden hour” of resuscitation
⚫ Golden hour is the time by which resuscitation
must be initiated to ensure better survival.

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“Rule of 30”-
If SBP falls by 30mmHg,HR rises by 30beats/min,

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RR to 30breaths/min,

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Hct drop by 30%,

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Urine output <30ml/hr
She is likely to have lost at least 30% of her bl vol & is
in moderate shock leading to severe shock.
 Blood replacement in PPH
⚫
⚫
Continuing bleeding, loss of >30% bl vol,

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Hemodynamic instability,hct <30 vol%

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Compatible whole bl is ideal for Ac.hge
Platelet transfusion is considered in a bleeding

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patient with PL<50,000/μL 1lt
FFP sh be transfused wth every 6U of bl to prevent
dilutional coagulopathy/when fibrinogen
level<100mg/dl.
 Blood replacement in PPH

⚫ Blood products commonly transfused in

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coagulopathies
Coagulopathies are rare. Suspect if oozing from

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puncture sites noted.
Work up with platelets, PT, PTT, fibrinogen level,
fibrin split products, and possibly antithrombin III.
 Management of secondary PPH
⚫
⚫
Assess blood loss

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Find out cause & take steps to rectify it
Supporting therapy
B.T

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Antibiotic
Active management
Retained bits : Explore uterus & remove products
Sloughing wound of cervico vaginal canal :
Haemostatic suture
 Management of secondary PPH
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⚫
Blood : CBC, grouping ,CRP,

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Urine : R/M/E, C/S

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Blood C/S

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S. creatinin

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HVSfor C/S

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sonographic evaluation if retained product
If bleeding continues for prolonged period without

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definite cause-
ß HCG estimation to rule out chorioCa