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 Loss
Mild
Hypovolemia
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
• Tissue
• Trauma
• Thrombopathy
- Uterine tone
- Retained tissue / clots
- Laceration, rupture,
uterine inversion
- 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 – Tissue
Examine placenta for completeness
Examine maternal side of placenta
Examine fetal side of
placenta
PPH Management – Tissue
Manual removal of placenta – if incomplete placenta
2
1
3
4
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 Management
Consider 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.