Postpatrum Hemorrhage and
Third Stage Emergencies
Postpartum Hemorrhage
• 3-5% of vaginal deliveries
• Definition: >500ml blood loss
• Potentially serious complications for
mother
• Common cause of maternal morbidity
and mortality worldwide
PPH Risk Factors
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Antepartum
Pre-eclampsia
Multiparity
Multiple gestation
Previous
postpartum
hemorrhage
Previous cesarean
section
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Intrapartum
Prolonged third stage
(>30 mins)
Arrest of descent
Episiotomy
Lacerations: cervical,
vaginal, perineal
Assisted delivery:
forceps, vacuum
Augmented labour
Causes of PPH:
The Four “Ts”
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Tone (70%)
Trauma (20%)
Tissue (10%)
Thrombin (1%)
PPH:
Resuscitative Measures
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Call for help
Airways, Breathing, Circulation
Two large-bore IVs
Oxygen
Stat labs: type & cross, hb, coags
Consider transfusion
Treatment Approach for
PPH
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Catheterise bladder
Uterine massage
Oxytocics
Inspect for lacerations
Surgical intervention
Tone – Uterine Atony
• Most common cause of PPH
• Initial step = bimanual uterine
massage and compression
• Oxytocic agents
– Oxytocin
– Methylergometrine
– Prostaglandins
Oxytocin
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Drug of choice
10 – 40 units in 1 litre at 250 cc/hr
1M (10 units) or IV infusion
No contraindications
Hypotension with IV push
Ergot Alkaloide
• Ergometrine 0.25 mg
• IM only
• Contraindicated in hypertension
Prostaglandins
• 15-methyl prostaglandin F2a
– carboprost, Hemabate®
• 0.25 mg IM or intramyometrial
• Side effects: nausea, diarrhea,
flushing, headache
• Contraindication: hypersensitivity
• Caution: asthma, HTN, cardiopulmonary disease
Trauma
• Uterine inversion
• Uterine rupture
• Vaginal or cervical lacerations
• Perineal tears
• Hematoma
Uterine Rupture
• Associated with uterine surgery
• Suspect if:
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vaginal bleeding
abdominal tenderness
maternal tachycardia
signs of shock are out of proportion to
viable blood loss
Uterine Inversion
• Rare, but important to recognize quickly
• Suspect if shock disproportionate to
blood loss
• Replace uterus immediately or after
resuscitation
• Watch for vasovagal reflex
Tissue
• Retained placenta
– Not delivered within 30 minutes
– 3% of deliveries
• Retained placental fragments
• Invasive placenta
Manual Placental Removal
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Cease uterine massage
Identify cleavage plane
Cup cotyledons in palm
Explore uterine cavity
Give oxytocin
Thrombin - Coagulopathy
• Pre-existing conditions
– ITP, von Willebrands
• Coagulaopthic: Obstetric-related
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Hypertension disorders, HELLP
Abruption
Fetal demise
Sepsis
• Drugs (e.g. asprin)
Coagulation Lab Studies
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FBC with platelet count
PT-INR, aPPT
Fibrinogen level
FDP / D-dimer
PPH Summary
• Unpredictable – be prepared
• Uterine atony is the main cause
• Remember 4-Ts:
Tone, Trauma, Tissue, Thrombin
• Consider active management of the
third term