Obstetric Haemorrhage
Obstetric Emergencies
Empangeni Hospital
28th July 2000
Obstetric Haemorrhage
Causes of ANTEPARTUM haemorrhage
• Abruptio Placentae
• Placenta praevia
• Local causes
• Unknown origin
ABRUPTIO PLACENTAE
Underlying pathology
• Hypertensive Disease
• Multiple pregnancy
• Trauma
• Anaemia
• Polyhydramnios
PLACENTA PRAEVIA
Predisposing factors
• Previous Caesarean
Section
• Most have no known
cause – presumed late
implantation
Local & Unknown Causes of
APH
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Rupture of uterus
Carcinoma of cervix
Trauma
Cervical polyp
Bilharzia of cervix
• ? Edge bleed
• ? Haemorrhoids
Obstetric Haemorrhage
• Induction of labour with oxytocin is
associated with an increased rate of uterine
rupture in gravid women with 1 prior
uterine scar, in comparison with the rate in
spontaneously labouring women.
Abruptio Placentae
Features
• Pain and tenderness
• Often I.U.F.D
• “Hypotension on
hypertension”
• Clotting defects
• Renal impairment
Antepartum Haemorrhage
• Exclude abruption, uterine rupture, placenta
praevia with labour
• Is she stable? - ?BP, pulse
• Check Abdomen - previous C/S scar, fundal
height and uterine tenderness
• Check FH
• Vaginal examination and ARM
Abruptio placentae
Abruptio Placentae
• Resuscitate - FDP, whole blood
• Monitor BP and urine output
• Give oxytocin infusion or prostaglandin if
necessary to induce contractions
• Avoid Caesarean Section unless salvageable
baby, or no progress
• Watch out for PPH
Placenta Praevia
• Diagnose by Ultrasound
• Resuscitate, monitor BP and amount
of bleeding
• Persistent bleeding requires delivery
whatever the gestation
•  34 weeks - buy time for steroids
• prevent contractions with indocid
Placenta Praevia
• Transfer anterior placenta
praevia
• Elective caesarean if  37
weeks
• Never cut through the
placenta
• Lower segment may need to
be packed
Post Partum Haemorrhage
Predisposing factors
• Antepartum haemorrhage
• Multiple pregnancy
• Prolonged labour
• Caesarean Section
Post Partum Haemorrhage
Causes
* Uterine atony
* Obstetric trauma
Post Partum Haemorrhage
Atonic uterus (soft uterus)
* Compression - bimanual
is best
* Oxytocin - 10 units IV
* Syntometrine 1 amp IM
* PgF2α 5mg in 500 ml IV
* Misoprostol (PgE1) 1mg
(5 tabs) rectally
Trauma (hard uterus)
* Vaginal tears are most
common
* Cervical tears rare
unless instrumental
* Remember the ruptured
uterus
* Uterine inversion
Post Partum Haemorrhage
Other causes
• Instrumental Delivery
• After Caesarean Section
• Infection - 2° PPH
• Retained placental
fragments
Post Partum Haemorrhage
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Rub up a contraction
Get help
Insert two large bore IV lines - Haes-Steril
Give an oxytocic
Explore digitally for fragments and tears
Explore with speculum for tears - especially
cervix
• Evacuate under GA
Rupture of Uterus
Two types
• True rupture
• Dehiscence of scar
Rupture of Uterus
True Rupture
• Contractions stop
• Continuous pain
• Tender abdomen
• Fundus ill-defined
• PV Bleeding
• Fetal heart dips or absent
fetal heart
Scar Dehiscence
• Dehiscence may be
silent – no bleeding
• Fetal distress
• Haematuria
• Vague uterine outline
• Failed induction
Rupture of Uterus
• High Index of suspicion in grande multips and in
scarred uteri
• All cases of Ante and Intra partum haemorrhage
must exclude rupture
• Laparotomy if suspected
• Repair or Hysterectomy?
Surgical Management
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Direct suture
Stepwise devascularisation
Internal iliac artery ligation
Hysterectomy
B-Lynch, “foley
tourniquet”, packing
Stepwise Devascularisation