Pre by:- Naol Abdi &Raji

MANAGEMENT PROTOCOL FOR Beyene CII

Mudulato: Dr. Shewangizawu
POST PARTUM HAEMORRHAGE HMC department of Gyn/Obs
OUTLINE
I. Introduction
II. Classification
III.Incidence and Significance
IV.pathophysiology
V. Cause
VI.Risk Factor
VII.Diagnosis
VIII.
Management
IX.Late PPH
X. Prevention
XI.Referance
I. INTRODUCTION
DEFINATION
Blood loss in excess of 500ml following vaginal delivery and
1000ml following
cesarean section or
10% drop in Hct secondary to blood loss after delivery. Or
Clinically it may be evidenced by change in vital signs, pallor and
the need for
blood transfusion.
II. CLASSIFICATION:
Primary PPH: hemorrhage occurring with in the first 24hrs of
delivery.
Secondary PPH is vaginal bleeding occurring 24hrs after delivery
through 6
weeks postpartum.
III. INCIDENCE AND
SIGNIFICANCE:
PPH complicates approximately 5-8% of vaginal deliveries.
Hemorrhage is one of the five major causes of maternal death
and accounts for about 25% of this death worldwide.
IV. PATHOPHYSIOLOGY

At term, the uterus and placenta receive 500-800 mL of blood per minute through their low
resistance network of vessels.
The high circulatory exchange predisposes a gravid uterus to significant bleedingif not well
physiologically or medicallycontrolled.
Maternal blood volume increases by 50% the third trimester (increases the bodys tolerance
of blood loss during delivery).
The gravid uteruscontracts downsignificantlyafter deliverygiven the reduction in
volume.This allows the placenta to separate from the uterine interface, exposing maternal
blood vessels that interface with the placental surface.
After separation and delivery of the placenta, the uterus initiates a process of contraction and
retraction, shortening its fiber and kinking the supplying blood vessels, like physiologic sutures
or living ligatures.
If the uterus fails to contract, or the placenta fails to separate or deliver, then significant
hemorrhage may ensue.
V. CAUSES OF PPH

Early or primary PPH

Uterine atony
Retained placenta
Genital tract lacerations
Uterine rupture
Uterine inversion
Coagulopathy
Late/ Secondary PPH
Endometritis
Placental site sub involution
Retained placental fragments
Coagulopathy
Gestational choriocarcinoma
Others (submucous myoma, cervical cancer, Placental polyp)
 VI. RISK FACTORS FOR
PPH
1. Uterine atony:
Uterine over distention
Polyhydramnios
Multifetal gestation
Macrosomia
Grande multiparity
 General anesthesia (halothane)
Previous history of PPH
Obstructed or prolonged labor
Chorioamnionitis
Induction / augmentation of labor(Use of oxytocin)
Couvellairs uterus (uterine apoplexy)
Retained placenta
2. Lower genital tract laceration
Instrumental delivery
Episiotomy
Fetal macrosomia
Precipitate labor
Breech extraction
Delivery through undilated cervix
3. Retained placental tissue
Mismanagement of the third stage
Succenturiate lobe
Morbidly adherent placenta
Uterine anomalies
4. Uterine inversion
Faulty cord traction
Fetal macrosomia
Fundal placentation
Morbidly adherent placenta
Uterine anomalies
5. Coagulopathy
Abruptio placentae
Preeclampsia/eclampsia
Sepsis
Amniotic fluid embolism
IUFD
Excessive blood loss
Drugs
Hereditory disorders
DIAGNOSIS AND By Naol Abdi
MANAGEMENT
VII. DIAGNOSIS
Is mainly clinical
Excessive bleeding
Hypotension, Tachycardia,/ hypovolemic shock.
Atonic uterus with /without placental expulsion
Post partum drop of Hct by 10%
Bleeding could be
Massive (external or concealed as much as 1000ml of blood in
distended uterine cavity) or
Moderate over a prolonged period resulting in excess blood
loss in few hrs.
Hence close observation in the Fourth stage of labor with
serial monitoring of vital signs, uterine palpation and assessment of
vaginal blood loss is very essential.
VIII. MANAGEMENT
General
1. Assess risk factors for PPH antepartum or early intrapartum
2. High risk patients should have blood group typed and possibly
cross-matched
upon arrival.
3. Shout for HELP! Once PPH has set in. Treatment of PPH is
teamwork
4. Palpate the uterus and massage if atonic
5. Open at least two intravenous lines for fluid replacement
6. Take blood sample for group and Rh determination and cross
match.
7. Evacuate the bladder.
8. Supplement oxygen administration (5 l/min of 100% oxygen) and
placement of
an indwelling urinary catheter
9. Careful documentation of vital signs, input-output and drugs
used
10. Further management depending on the cause
PROTOCOL

Uterine massage is a simple first line treatment as it helps the uterus to contract to
reduce bleeding.
A detailed stepwise management protocol has been introduced by the California
Maternity Quality Care Collaborative.
It describes 4 stages of obstetrical hemorrhage after childbirth and its application
reduces maternal mortality.
Stage 0: normal - treated with fundal massage andoxytocin.
Stage 1: more than normal bleeding - establish large-bore intravenous access, assemble personnel, increase
oxytocin, consider use ofmethergine, perform fundal massage, prepare 2 units ofpacked red blood cells.
Stage 2: bleeding continues - check coagulation status, assemble response team, move tooperating room,
placeintrauterine balloon, administer additionaluterotonics(misoprostol,carboprost tromethamine),
consider:uterine artery embolization,dilatation and curettage, andlaparotomywith uterine compression
stitches or hysterectomy.
Stage 3: bleeding continues - activatemassive transfusion protocol, mobilize additional personnel, recheck
laboratory tests, perform laparotomy, consider hysterectomy.
FLUID ADMINISTRATION
Three (3ml) of crystalloid solution is infused for each ml of estimated
blood loss
Attempt should be made to keep systolic blood pressure above
90mmHg and
urine out put over 0.5ml/kg/hr.
When available colloids such as Dextran or Hemacel can as well be
used.
Since colloids can influence blood typing specimen should be
collected before
starting infusion.
BLOOD TRANSFUSION
Blood transfusion is indicated If no improvement or only transient
improvement in vital signs and urine output occurs with the initial
infusion of 3000ml of crystalloids.
FINAL TREATMENT
DEPENDS ON THE
UNDERLYING CAUSE
A. Uterine atony
I. Massage the uterus.
I. Evacuate the bladder
II. Medical therapy with the following drugs
DRUGS
Oxytocin:
Methods of Administration
20units/ in 1000ml of N/S or R/L
60drops/min(>125ml/hr) IV
Not more than 3lits
Given IV at 10ml/unit For a dose of 200mU/min
Contra-indications: none
Methylergometrine
Methods of Administration
0.2mg repeated Q Or
Ergometrine 2-4 hrs im or iv
Maximum 5 doses
Act for 45 minute
Contra-indications
Hypertension
Cardiac disease
15-MPGF2
Methods of Administration
0.25mg im every 15-90 min
Can be repeated every 15 90 minute at Maximum of 8 doses.
Can be given in combination with oxytocine
Contra-indications
Active cardiac,
Renal disease
Hepatic disease
Bronchial asthma
Side effect
Vomiting
Diarrhea
Hypertension
Fever
Flushing
Tachycardia
Atria O2 desaturation
Dinoprostone
20mg suppository per vagina or rectum
Every 2hr

Sulprotone
Misoporostel For prevention and treatment
have approved
BLEEDING CONTINUES:
Explore the
uterine cavity,
check placenta again for completeness,
inspect the cervix and the lower genitalia for laceration and
manage accordingly
Perform
Bimanual compression of the uterus.
Alternatively, compress the abdominal aorta until surgical
intervention is amenable.
These procedures will buy time for surgical intervention and might
be life saving.
INDICATIONS FOR
SURGICAL INTERVENTION
Uterine atony when medical therapy is unsuccessful
Uterine rupture
Factors to be considered include:
Patients desire for future fertility
Parity
The degree of hemorrhage
Homodynamic stability of the patient
Skill and experience of the surgeon
SURGICAL MANAGEMENT
1.Uterine artery ligation or/and utero- ovarian artery
ligation:
In the absence of uterine rupture and/or broad
ligament hematoma
2.Hypogastric artery ligation:
Experienced surgeon
Uterine rupture and broad ligament hematoma.
Hemodynamically stable patient
3.Emergency Hysterectomy
When conservative measures fail or future fertility is not
considered
Pelvic pressure pack in persistent post hysterectomy hemorrhage
B. Lower genital tract laceration
Bleeding continues despite a well-contracted uterus.
Explore the
Cervix,
Vagina,
Perineum and
episiotomy site and manage accordingly.
Vulvar hematomas (vulvar, vaginal and episiotomy site)
If small (<5cm diametre)
Observation, Ice pack, Analgesic

Larger in size
Evacuation, ligate the bleeding vessel

N.B: The cervix should be inspected routinely in all difficult

(instrumental,
destructive, difficult breech) deliveries.
C. Uterine inversion
Is a rare cause of PPH but associated with high rate of
maternal mortality and morbidity
Diagnosis: Clinical
oComplete inversion: the uterus is inverted inside out and
can easily be seen.
oIncomplete inversion: depression or defect of the uterine
fundus on abdominal
examination and easily palpable fundus vaginally
Treament
Resuscitation with fluids/blood
Replace the uterus manually immediately if it fails replace it under
anesthesia
Start oxytocin drip and discontinue relaxing agent as soon as the uterus is
Replaced
If placenta is undelivered, replace the uterus first and remove the placenta
manually with IV infusion in situ.
Surgical intervention may rarely be indicated, if manual replacement fails
D. Abnormal placentation
Diagnosis:
The placenta doesn't have cleavage line from the decidual
plate
The placenta will be retained and there may not be
bleeding unless has already been manipulated
The abnormality may involve all of the cotyledons (total), a
few to severalcotyledons (partial) or a single cotyledon (focal)
Treatment

Generally, up on attempting removal of a

retained placenta if there is no cleavage line
the procedure has to be abandoned not to
inflict severe hemorrhage
Emergency hysterectomy is the safest
treatment
Curettage and/or hemostatic sutures may be
E. Coagulopathy
Continuous bleeding from multiple sites with deranged coagulation profile
Can cause or exacerbate PPH or coagulopathy may be a result of PPH
Lab investigations: platelet count, PT, PTT, fibrinogen level, clotting time
The main stay of treatment is the resolution of the primary disorder
Give fresh whole blood or blood products (fresh frozen plasma, packed
RBC,
cryoprecipitate or platelet concentrate based on the major disorder
recognized)
IX. LATE PPH
oThe commonest cause is Infection
oPeak occurrence in first through second postpartum week
oUltrasonography to rule out retained placental tissue
oTissue specimen retrieved from curettage should be subjected for
histopathology
Treatment should include:

oUterotonic agents
oBroad-spectrum antibiotics if infection is
suspected
oUterine curettage if retained tissue
X. PREVENTIVE
MEASURES FOR PPH
Identify high risk factors for PPH
Iron supplementation during pregnancy to build up iron store in all pregnant
women and treat anemia in pregnancy
Active management of third stage of labor (see protocol on laborand delivery)
Careful management of the third stage and avoid unnecessary interventions at
delivery
Family planning/child spacing
XI. REFERENCE
Williams Obs 24th Edition
Management Guideline on Selected Topics in Obstetrics and
Gynecology First edition First edition 2004
WWW.wikipidia.com
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