Post Partum Hemorrhage
Uterine Rupture
Women’s Hospital School of Medicine
Zhejiang University
Wang Zhengping
Post partum hemorrhage
Post partum hemorrhage
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Past partum hemorrhage denotes excessive
bleeding (≥500ml in vaginal delivery) during the
first 24 hours after delivery
Common cause of death and diseases in pregnant
women globally
Leading cause of death in pregnant women in
China
Incidence 2%-3% of total number of deliveries
Etiology
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Uterine atony: 70%
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Obstetric lacerations: 20%
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Retained placental tissue: 10%
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Coagulation:1%
Uterine atony
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General factors: extreme nervousness, sedative,
anesthesia, tocolytics, weak
Obstetric factors: prolonged labour, fatigue,
placenta previa, placenta abruptio, severe anemia
Uterine factors: uterine muscular fiber
underdevelopment, such as uterine deformity or
myoma; uterine overstretched, such as
macrosomia, multiple pregnancy, polyhydramnios
Placental factors
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Incomplete placental separation
Retained placenta
Placental incarceration（嵌顿 ）
Placental adhesion
Placental implantation (accreta, increta,
percreta)
Residual placenta and amniotic membrane
Implantation of placenta
Birth canal injury
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Laceration during labour are usually
associated with:
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Poor vulval elasticity
Strong labour force, emergency delivery,
macrosomia
Inadequate skills at assisted vaginal delivery
Inadequate cessation of bleeding during
episiotomy repair, missing out tears at cervix or
fornices
Coagulation disorder
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Complications associated with obstetric: amniotic
fluid embolism, pregnancy induced hypertensive
diseases, placenta abruptio and intrauterine demise
Pregnancy liver disease: acute fatty liver, severe
hepatitis
Hematology diseases: primary thrombocytopenic
purpura, aplastic anemia etc
Clinical presentation

Vaginal bleeding:
 If bleeding occurs immediately after delivery of baby,
consider birth canal injury
 If bleeding occurs minutes after delivery of baby,
consider placenta factors
 If bleeding occurs minutes after delivery of placenta,
main reasons are uterine atony or retained products of
conception
 Persistent bleeding and blood do not coagulate,
consider coagulation disorder causing PPH
Clinical presentation
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Vaginal hematoma
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Shock: dizziness, paleness, weak pulse, low
blood pressure etc
Diagnosis
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Estimation of blood loss
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Ascertain cause of post partum hemorrhage
Estimation of blood loss
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Visual observation: only 50%-70% of blood loss
Container: kidney dish, measuring cup
Surface area: blood stained 10cmx10cm = 10ml
Weighing: 1.05g = 1ml
Hct<=30%, Hb50-70g/L, blood loss >1000ml
Hourly urine output <25ml, blood loss >2500ml
Shock index = pulse rate/systolic pressure
Shock index (SI)
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SI <=0.5, normal blood volume
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SI = 0.5-1, blood loss <20%, 500-750ml
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SI = 1, blood loss 20-30%, 1000-1500ml
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SI = 1.5, blood loss 30-50%, 1500-2500ml
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SI = 2, blood loss 50-70%, 2500-3500ml
Ascertain cause
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Uterine atony
 Fundus goes up
 Uterine consistency soft, water bag like
 After uterine massage or using oxytocin, uterus
harden, per vaginal bleeding lessen
 Categorize into primary and secondary, with
direct and indirect causes
Ascertain cause
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Placental factors:
 Placenta not delivered within 10 minutes of
delivery of baby, with massive per vaginal
bleed, consider placental factors
 Residual placenta is a common cause of post
partum hemorrhage
 Must examine the placenta and membrane
carefully
Ascertain cause
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Birth canal injury
 Cervical tear
 Vaginal tear
 Vulval tear
Degree of vulval tear
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Degree I: vulval skin and vaginal opening mucosa
tear, not reaching muscular layer
Degree II: tear into perineal body muscular layer,
involving posterior vaginal wall mucosa, may
extend up on both sides, making it hard to recognise
original anatomy
Degree III: external anal sphincter tear, may involve
vaginal rectal septum and anterior rectal wall
Degree of vulval tear
Ascertain cause
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Coagulation disorder:
 Patients with blood disorder or DIC caused by
delivery etc
 Sustained per vaginal bleeding, non-clotting,
difficulty in hemostasis
 May have bleeding at any parts of the body
 Diagnose based on history, bleeding
characteristics, platelet count, prothrombin time,
fibrinogen etc tests
Management
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Principal of management for post partum
hemorrhage is:
 Rapid hemostasis according to the cause
 Replenish volume, correct shock
 Prevent infection
Management of uterine atony
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Remove cause
Uterine massage:
Abdominal fundus massage
Abdominal-vaginal bimanual uterine massage
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Uterotonic agents:
oxytocin/ ergot derivatives/prostaglandins
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Uterine packing
Pelvis vessel ligation
B-Lynch suture
Arterial embolism
Hysterectomy
Uterine massage
Management of uterine atony
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Remove cause
Uterine massage:
Abdominal fundus massage
Abdominal-vaginal bimanual uterine massage
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Uterotonic agents:
oxytocin/ ergot derivatives/prostaglandins
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Uterine packing
Pelvis vessel ligation
B-Lynch suture
Arterial embolism
Hysterectomy
Management of uterine atony


Remove cause
Uterine massage:
Abdominal fundus massage
Abdominal-vaginal bimanual uterine massage

Uterotonic agents:
oxytocin/ ergot derivatives/prostaglandins





Uterine packing
Pelvis vessel ligation
B-Lynch suture
Arterial embolism
Hysterectomy
Uterine packing
Management of uterine atony


Remove cause
Uterine massage:
Abdominal fundus massage
Abdominal-vaginal bimanual uterine massage

Uterotonic agents:
oxytocin/ ergot derivatives/prostaglandins





Uterine packing
Pelvis vessel ligation
B-Lynch suture
Arterial embolism
Hysterectomy
Pelvis vessel ligation
Management of uterine atony


Remove cause
Uterine massage:
Abdominal fundus massage
Abdominal-vaginal bimanual uterine massage

Uterotonic agents:
oxytocin/ ergot derivatives/prostaglandins





Uterine packing
Pelvis vessel ligation
B-Lynch suture
Arterial embolism
Hysterectomy
B-Lynch suture
Management of uterine atony


Remove cause
Uterine massage:
Abdominal fundus massage
Abdominal-vaginal bimanual uterine massage

Uterotonic agents:
oxytocin/ ergot derivatives/prostaglandins





Uterine packing
Pelvis vessel ligation
B-Lynch suture
Arterial embolism
Hysterectomy
Arterial embolism
Management of uterine atony


Remove cause
Uterine massage:
Abdominal fundus massage
Abdominal-vaginal bimanual uterine massage

Uterotonic agents:
oxytocin/ ergot derivatives/prostaglandins





Uterine packing
Pelvis vessel ligation
B-Lynch suture
Arterial embolism
Hysterectomy
Management of placental factors
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Retained placenta – remove separated placenta
quickly
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Residual placenta or membrane – curettage
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Placental adhesion – manual removal of placenta
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Placental implantation – never separate forcefully,
usually hysterectomy
Management of laceration
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Thorough hemostasis
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Stitch according to anatomical layering
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First stitch must be 0.5cm above top end
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When stitching do not leave dead space
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Avoid stitching through rectal mucosa
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Manage cervical tear
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Manage birth canal hematoma
Manage cervical tear
Management of coagulation disorder
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First exclude bleeding caused by uterine
atony, placental factors and birth canal
injury
Actively transfuse fresh whole blood,
platelets, fibrinogen or prothrombin
complex, clotting factors etc
If DIC set in, manage DIC
Prevention
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Comprehensive antenatal care, screen for high risk
factors, intervene accordingly
Appropriate labour management
Aggressive post partum monitoring: 2 hours post
partum is the peak of post partum hemorrhage,
patient must be monitored in labour room for 2
hours
Rupture of uterus
Definition
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The body uterine or lower uterine segment
happens to rupture during late pregnancy or
labor
Rupture of the pregnant uterus is a obstetric
catastrophe and major cause of maternal
death
Etiology
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Descending of presenting part obstruction: narrow
pelvis, cephalo-pelvic disproportion, soft tissue
obstruction, fetal malposition, fetal abnormality
Inappropriate use of oxytocin、prostaglandin etc
Uterine scar: fibroidectomy, caesarean section
Surgical trauma
Clinical presentation
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Happens at late pregnancy or during labour,
more during labour
Complete rupture and incomplete rupture
Spontaneous rupture or traumatic rupture
Body rupture or lower segment rupture
It is usually a progressive process, separated
into 2 stages, impending rupture and uterine
rupture
Threatened uterine rupture
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Obstructed descend of fetal presenting part,
prolong labor
Appearance of pathologic retraction ring
Mother shows distress, rapid breathing and
heart rate, unbearable pain
Urination difficulty, hematuria
Fetal heart rate change or unclear
Complete uterine rupture
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At the point rupture, patient experiences sudden
abdominal tearing pain, uterine contraction ceases,
temporary relieve of abdominal pain
Following blood, amniotic fluid, fetus going into
the abdominal cavity, abdominal pain
progressively worsen
Patient presents with rapid breathing, paleness,
weak pulse, decreasing blood pressure etc shock
manifestations
Complete uterine rupture
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Tenderness and rebound tenderness throughout
abdomen
Fetal parts and small uterine body may be easily
palpable under abdominal wall, disappearing of
fetal movement and fetal heart
Vaginal examination: may have fresh bleeding,
originally dilated cervix becomes smaller, ascend
of fetal presenting part, if site of rupture is low,
may be able to palpate uterine wall rupture per
vaginal
Complete uterine rupture
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Uterine body scar rupture, usually complete
rupture, no obvious impending rupture
presentations
As the scar tear progressive widens, pain
and other presentations progressively
worsen, but might not have typical tearing
pain
Incomplete uterine rupture
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Usually seen in lower segment caesarean section scar
Usual pain symptoms and signs are not obvious, may have
obvious tenderness at the site of incomplete rupture
Incomplete rupture involving uterine artery, may lead to
acute massive bleeding
Rupture occurring in lateral uterine walls within the broad
ligaments, may cause broad ligament hematoma, during
which a tender mass is palpable one side of the uterine
body and progressively enlarges
Irregular fetal heart
Diagnosis
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Typical uterine rupture is easily diagnose
based in the history, symptoms and signs
Incomplete uterine rupture, as signs and
symptoms are not obvious, diagnosis is
difficult.
Ultrasound examination: may show position
between fetus and uterus, confirming site of
rupture
Differential diagnosis
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1. Severe placenta abruptio
 Unbearable abdominal pain, uterine tenderness
 Disproportion between bleeding volume and
degree of anemia
 Ultrasound may shows retro-placental
hematoma, fetus is intrauterine
 Usually associated with pregnancy induced
hypertensive diseases or trauma
Differential diagnosis
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2. Intrauterine infection
 Usually seen in premature rupture of membrane,
prolonged labour, multiple vaginal examination
 May have abdominal pain and uterine tenderness
etc
 Temperature rise
 Abdominal examination: fetus is intrauterine
 White blood cell and neutrophil counts rise
Management of impending uterine rupture
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Suppress uterine contraction: give inhaled
anesthesia or intravenous generalized anesthesia,
intramuscular pethidine 100mg etc to relieve
uterine contraction
Oxygen
Prepare for emergency surgery
Immediate caesarean section, prevent uterine
rupture
Management of uterine rupture
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Regardless whether fetus is alive, actively manage
shock and operate soonest possible
Type of surgery: decided based on maternal
condition, degree of uterine rupture, duration of
rupture and degree of infection
Tear repair: neat tear, no obvious infection
Hysterectomy: big tear, irregular tear or obvious
infection, perform subtotal hysterectomy. If tear
extends to cervix, perform total hysterectomy
Management of uterine rupture
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During surgery carefully inspect cervix,
vagina, bladder, urethra, rectum and all
neighboring structures, repair accordingly if
damage found
Give high dose broad spectrum antibiotics
perioperatively to prevent infection
Transfer
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Uterine rupture presenting with shock,
resuscitate immediately on site
If transfer is necessary, it must be done
under the condition where blood transfusion,
fluid infusion, resuscitation. abdomen must
be bandaged before transporting
Prevention
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Build more efficient and comprehensive antenatal care
Patients of high risk should admit 1-2 weeks before
expected date of delivery
Strengthen observation ability of doctors and midwives,
pick up abnormality during labour promptly
Strict indication for caesarean section and all vaginal
surgery, strict surgical steps, avoid careless surgery, pick
up surgical damage promptly
Strict indication of usage of oxytocin