POSTPARTUM HEMORRHAGE

Primary postpartum hemorrhage:

Definitions:
Blood loss at delivery within 24 hours
exceeding:
Vaginal delivery: > 500 ml ( 500 ml is
considered
physiological)
Cesarean delivery: > 1000 ml ( 1000 ml is
considered
physiological).

Secondary postpartum
hemorrhage:
Excessive blood loss > 24 hours
and < 12 weeks postpartum

Etiology:
Lack of efficient uterine contraction (uterine atony)
commonest cause of primary PPH.
Retained parts of the placenta.
Vaginal or cervical lacerations.
Uterine rupture rare.
Clotting disorders, uterine inversion, or rupture
extremely rare.
Risk

Risk factors:
Risk factors for primary PPH include first pregnancy,
maternal obesity, a large baby, twin pregnancy, prolonged
or
augmented labor, and antepartum hemorrhage. High
multiparity
does not appear to be a strong risk factor, either in
high- or low-income countries, even after controlling for
maternal age. Despite the identification of risk factors,
primary
PPH often occurs unpredictably in low-risk women.

Complications:
Hypovolemic shock, disseminated
intravascular coagulation
(DIC), renal failure, hepatic failure,
adult respiratory
distress syndrome, and death.

Management
Primary postpartum hemorrhage:
Obtain help (multidisciplinary approach).
Vigorous uterine massage until firm.
Identify and repair any vaginal and cervical lacerations.
Place initial suture above the apex. Ensure adequate
exposure; if necessary, transfer patient to surgical suite.
Manually explore the uterus; ensure adequate intravenous
(IV) access.
Laboratory tests: complete blood count with platelet
concentration,
blood type, antibody screen, fibrinogen, fibrin split
products, prothrombin time, and partial prothrombin time.

 Administer uterotonic drugs :

1. Oxytocin 2080 IU in 1000 ml of normal saline
(NS),
fast IV drip, and/or
2. Misoprostol 8001000 g rectally
3. Methergine 0.2 mg intramuscular (IM) (if
evidence of
hypertension do not administer) every 24 hours,
and/or
4. Carboprost tromethamine (Hemabate;
prostaglandin
F2 *PGF2+) 0.25 mg IM every 1590 minutes.
Maximum dose is 2 mg (do not administer if asthma

Rectal misoprostol is a useful first-line drug for

the treatment
of PPH. Compared with a combination of IM
syntometrine
injection and oxytocin infusion, rectal
misoprostol 800 g is associated with a
statistically significant
reduction in the number of women who
continued to
bleed after the intervention and those who
required medical
co-interventions to control the bleeding.

During the administration of

uterotonic agents, bimanual
compression may control
hemorrhage. The physician
places his or her fist in the
vagina and presses on the
anterior surface of the uterus
while an abdominal hand
placed above the fundus
presses on the posterior wall.
This while the Blood for
transfusion made available.

suture bleeding sites.

uterine artery ligation.
B-Lynch stitch for uterine compression.

Hysterectomy.

B-Lynch compressive sutures

Uterine Artery Ligation

RETAINED PLACENTA

Definition:
The placenta is undelivered at > 30 minutes
after delivery
despite active management of the third
stage.

Etiology:
Preterm birth: incidence is inversely
proportional to gestational
age.
Cord avulsion: incidence is 3% with controlled
cord traction.
Placenta accreta.

Complications:
Hemorrhage

infection,
genital tract trauma

Management:
Provide adequate anesthesia.
Attempt manual extraction.
Once placental margin is identified, gently peel the
placenta from the uterine wall and remove it.May
consider
ultrasound to ascertain if placental removal is
complete.
Palpate and massage the fundus until firm.
injection of oxytocin (10 or 20 IU in 1 or
2 ml) in NS (1819 ml) is effective in the management of
retained placenta at 2030 minutes by decreasing the
need for manual placental removal compared with NS
alone or expectant management.

Removal of Abnormal
Placenta

UTERINE INVERSION
Definition:

Collapse of the uterine fundus

into the endometrial cavity.

Risks:

Excess cord traction.

fundal pressure.
fundal cord insertions.
abnormal placentations.

Management
Summon anesthesia and nursing staff.
Provide large-bore access and IV fluid therapy.
Withhold uterotonic agents.
To decrease bleeding, avoid separating the
placenta.
Consider pharmacological uterine relaxation:
magnesium sulfate IV bolus
terbutaline IV 0.25 mg subcutaneously 1
nitroglycerin 50500 g orally or by anesthesia

 Manual manipulation of the uterus

Rare surgical intervention (laparotomy) if cannot

correct
by vaginal manipulation alone:
Huntington procedure clamps are placed on
the round ligaments 2 cm deep in the inversion and
gentle
upward traction applied. Repeat clamping as
necessary.
Haultain procedure an incision is made in the
posterior
portion of the inversion ring to increase its size
and to reposition the uterus.

 Uterotonic agents when uterus repositioned:

Oxytocin 2040 IU/L NS IV, Methergine 0.2 mg
IM
every 6 hours as needed, or Hemabate 0.25 mg
IM
repeated every 2560 minutes as needed.
Treat PPH or retained placenta as mentioned
above.