Postpartum Hemorrhage

Dr. Alongkone Phengsavanh

Objectives

• Define and discuss risk factors and causes• Describe management and prevention

Postpartum Hemorrhage

• Leading cause of maternal deaths worldwide

• Responsible for 1/3 of maternal deaths worldwide and 60% in developing countries

• Majority of deaths within 4 hours of delivery

Postpartum Hemorrhage(PPH)

• Primary (immediate)– Hemorrhage in first 24

hours after delivery– 70% due to uterine atony

• Secondary (delayed)– Hemorrhage after 24 hours

up to 6 weeks postpartum– Caused by

• Retained placental tissue• Infection

• Definitions – Volume loss (Traditional)– Spontaneous vaginal

delivery• >500 cc blood

– C/Section• >1000 cc blood

• Clinical– Any blood loss that has the

potential to produce hemodynamic instability

Clinical Findings & Blood LossMildHypovolemia

Moderate Hypovolemia

Severe Hypovolemia

Definition(blood volume)

<20% 20 - 40% >40%

HR Mild tachycardia >110 bpm tachycardia

RR Normal >30 rpm tachypnea

Clinical Cool extremities, decreased urine output, dizziness, normal neuro status

Marked pallor, hypotension with sitting, anxious state

Oliguria / anuria, agitation, confusion, loss of consciousness, BP unstable

PPH Etiology

• Tone - Uterine tone• Tissue - Retained tissue / clots• Trauma - Laceration, rupture,

uterine inversion• Thrombopathy - Coagulopathy

PPH Risk Factors - Tone• Overdistended uterus

– Polyhydramnios– Multiple gestation– Macrosomia

• Uterine muscle exhaustion– Rapid labor– Prolonged labor– High parity

• Intra-amniotic infection– Fever– Prolonged Rupture of

Membranes• Uterine abnormalities

– Fibroid uterus– Congenital uterine

abnormalities– Placenta previa / placental

abruption• Uterine relaxing agents

– Magnesium sulfate– Halogenated anesthetics– Nitroglycerin

PPH Risk Factors - Tissue

• Retained tissue, abnormal placentation (succinuriate lobe, retained cotyledon)– Incomplete placental delivery– Previous uterine surgery– High parity

• Retained blood clots– Atonic uterus

PPH Risk Factors - Trauma• Lower genital tract lacerations (cervix, vaginal wall,

perineum)– Precipitous delivery– Operative delivery– Poorly timed or inappropriate episiotomy

• Caesarean section – extensions / lacerations– Deep engagement of head– Malposition

• Uterine rupture– Prior uterine surgery

• Uterine inversion– High parity– Fundal placenta

PPH Risk Factors - Thrombin• Pre-existing states

– Hereditary conditions– History of liver disease

• Therapeutic anticoagulation– History of thrombotic disease

• Other (DIC, ITP, Pre-eclampsia, placental abruption, severe infection)– Intrauterine fetal demise– Bruising– Elevated blood pressure– Fever– Elevated WBC– Antepartum hemorrhage– Sudden collapse

PPH Prevention• Active management of the Third Stage of

Labor– Administer oxytocin with delivery of anterior shoulder

or immediately after delivery of baby• Oxytocin 10 units IM or 5 units IV

– Clamp and cut cord– Palpate uterine fundus & confirm uterus contracting– Perform controlled cord traction with suprapubic

counter traction with next strong contraction– Perform uterine massage after delivery of placenta– Examine placenta for completeness

Controlled Cord Traction

PPH Management

• Prevention– Active management of the third stage of labor– Identify patients at potential risk of PPH

PPH Management• Primary PPH

– Active management of third stage of labor– Call for HELP– ABC (Airway, Breathing, Circulation)– Estimate / measure blood loss– Closely monitor vital signs– Catheterize bladder (urine volume)– Give oxygen– Give oxytocin (IV/IM) or misoprostil (PR)

PPH Management – Tone• Determine source of

bleeding– Assess the uterine

fundus– Do Internal Bimanual

Massage of uterus

PPH Management – TissueExamine placenta for completeness

Examine maternal side of placenta Examine fetal side of placenta

PPH Management – Tissue1 2

3 4

Manual removal of placenta – if incomplete placenta

PPH Management - Trauma

• If fundus firm & placenta complete, then examine for trauma– Upper vaginal tract - identify and repair tears– Lower & external genital tract – apply

pressure and repair tears

PPH Management• If bleeding continues consider

– IV oxytocin• Oxytocin 40 units/1 liter Normal Saline run wide

open– Misoprostil

• 800 ug pr (4 tablets per rectum)– Correct hypovolemia

• Normal Saline• Ringers Lactate• Blood products – RBC transfusion

PPH Management

• Consider transfer to center with additional resources– Surgery

• B-Lynch Stitch• Hysterectomy

PPH ManagementConsider aortic compression

Uterine inversion• Rare• Caused by over vigorous

cord traction• More common in grand

multiparous women• Treatment

– Replace uterus promptly– Replacement is “last out” is

“first in”– Consider uterine relaxation

with nitroglycerin

Uterine rupture• Can occur with:

– Prolonged or obstructed labor– Prior uterine surgery – caesarean section– Grand multiparous women being induced or

augmented• Management

– Vigorous resuscitation– Emergency laparotomy

• Delivery of fetus / repair of uterus• Hysterectomy

– Prophylactic antibiotics

Secondary PPH

• Cause– Retained tissue– Infection– Breakdown of uterine wound following C/S

• Management– ABC – treat for shock– Antibiotics– Assess patient carefully for source of bleeding

Secondary PPH

• After bleeding controlled monitor woman for:– 24 – 48 hours for further bleeding

• Urine output• Vital signs• Uterine tone• CBC

• Educate patient and family about PPH and when to return to hospital

Conclusion – Key message

• PPH is a serious obstetrical emergency requiring urgent diagnosis and treatment.

• PPH is prevented with Active Management of the Third Stage of Labor.

• Patient may need to be transferred to referral hospital if local resources inadequate.