Postpartum Hemorrhage
HEE HEE That’s the only fake
blood I could manage!!! Too
messy.
Jessi Goldstein MD
MCH Fellow
September 7, 2011
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Objectives
We will discuss:
• Prevention of PPH.
• Causes of PPH.
• Initial and secondary interventions in PPH in both
vaginal and Cesarean delivery.
• Causes and treatment of secondary PPH.
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Advanced Techniques for
PPH
 Initial Interventions should include fundal massage , IV
access, lab tests and uterotonic drugs and fluid
resuscitation.
 Secondary interventions for vaginal delivery include
checking for lacerations, removing retained products
(sweeping, suction curettage), uterine tamponade
(ballons, packing) , arterial embolization, and
laparotomy and ultimate hysterectomy if needed.
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Advanced Techniques for
PPH
 Initial Interventions for C/S should include fundal massage ,
IV access, lab tests and uterotonic drugs and fluid
resuscitation. Controlling incisional bleeding with suture
ligation
 Intraoperative interventions for Cesarean delivery include
uterine and ovarian artery ligation (O’Leary stitch), Uterine
compression sutures (The most popular technique is the BLynch suture), balloon tamponade, and hysterectomy as last
resort.
 Uterine artery embolization and Bakri balloon management
can be considered postoperatively as well.
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©2011 UpToDate® Anterior uterine wall with B-Lynch
suture in place and an enlarged drawing (box) of lower
uterine segment with B-Lynch suture in place
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Sutures are placed to ligate the ascending uterine artery
and the anastomotic branch of the ovarian artery. Uterine
vessel ligation is known as the O’leary stitch. ( Taken from
Up to date)
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Uterine Artery Embolization: Right uterine angiogram reveals
occlusion of the right uterine artery (arrow) after superselective
uterine artery embolization. The procedure successfully stopped the
bleeding ( Taken from Up to date).
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Bakri Balloon is a tamponade technique
that can be used for PPH.
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Secondary PPH
 Defined as excessive bleeding 24 hrs to 12 weeks
postpartum.
 Incidence is about 1 percent of women.
 Theory is that thought to be atony or subinvolution of
placental site from retained products or infection.
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Management of Secondary
PPH
 Evaluate for underlying disorders (coagulopathies).
 For atony give uterotonics.
 If large amount of bleeding, fever uterine tenderness, or
foul smelling discharge treat for endometritis.
 Consider suction currettage.
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Case 1
 A 22y/o G1P0 was delivered by vaccum assisted
vaginal delivery approximately 2 hours ago. She was
induced for mild preeclampsia at 37 weeks and
required pitocin augmentation for several hours prior to
needing an operative vaginal delivery for fetal distress.
She had a second degree laceration that was repaired,
but she has soaked a whole pad in the last 15 minutes
and the nurse would like you to evaluate her.
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Case 2
 A 22 yo G4P3 approximately 4 days s/p delivery
presents at OB triage and mentions to you that she
feels lightheaded and has been having bleeding at
about a pad an hour for the last 2 days.
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Thank you!!!
 Questions?
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