Undergraduate course lectures in Obstetrics&Gynecology ,Faculty of medicine,Zagazig University ,Prepared by DR Manal Behery

1. Postpartum
Hemorrhage

2. Definition
Blood loss > 500 ml at vaginal delivery
> 1000 ml at Cesarean
ACOG 10% drop in hematocrit
Need for blood transfusion
Severe PPH > 1000 ml loss at vaginal delivery
Any amount of blood loss causes
S/O Hypovolemic Hemorrhagic Shock
- Tachycardia - Hypotension - Reduced urine out put

3. Why it is important?
 PPH remained one of the top 3 causes of
direct maternal deaths.
 Incidence 4% after vaginal delivery
 6,5% after CS delivery

4. We have 4 problems
 Problem 1: almost 50% of deliveries lose >500
ml of blood.
 Problem 2: estimated blood loss is often less
than half the actual blood loss.
 Problem 3: Most of the serious causes of
“PPH” have origins prior to the end of the 3rd
Stage of labor.
 Problem 4: PPH, as defined, is technically
misdiagnosed and clinically irrelevant.

5. Measuring Blood Loss
A key step to EFFECTIVE
TREATMENT…..
 Underestimation leads to delayed intervention.
 Visual estimated amounts of blood loss are far from accurate
by as much as 30-50%: especially for very large amounts.
 Old methods for estimating blood loss tend to be complex.
 (include weighing soaked clothes and pads, collection into
pans etc., Acid haematin techniques, Spectrophometric
technics and measuring plasma volume changes)

6. Measuring Blood Loss in PPH
THE BRASSS-V DRAPE

7. Advantages of Brasss-V
 Simple and practical
 Low cost: ( Plastic)
 Accurate:
 Objective
 Can be used in a wide
range of settings
 Provides a hygienic delivery surface

8. CAUSES OF PPH
FOUR “ T”s
TONE
TRUAMA
TISSUE RETENSION
THROMBIN
BUT MOST IMPORTANT IS

9. Tone”Uterine Atony”90%of
causes
 - Uterine over distension
 Polyhydramnios, Multiple gestations,
Macrosomia
 Prolonged labor: “uterine fatigue”
 Precipitory labor
 High parity
 Chorioamnionitis
 Retained product of conception
 Halogenated anesthetic

10. TRUMA “Obstetric OR OPERATIVE”
“7% of causes”
 7% of causes
 Obstetric Trauma
- Uterine Rupture
- Lacerations of the Birth Canal
- Operative Trauma
Cesarean sections
Episiotomies
Forceps, Vacuums, Rotations

11. Tissue retension “Abnormal
placentaion”
 - PlacentaPrevia
- Abruptio Placentae
- Accreta, increta, percreta
- Vasa previa

12. Thrombin “Coagulation
Defects
- Sepsis
- Amniotic Fluid Embolism
- Abruptio Placentae associated
coagulopathy
- HELLP Syndrome
- Dilutional Coagulopathy
- Inherited Clotting Disorders
- Anticoagulant Therapy

13. Thrombin “Coagulation
Defects
2-3% of causes
- Sepsis
- Amniotic Fluid Embolism
- Abruptio Placentae associated
coagulopathy
- HELLP Syndrome
- Dilutional Coagulopathy
- Inherited Clotting Disorders
- Anticoagulant Therapy

14. Prevention of Postpartum
Hemorrhage
 Oxytocin
 With or soon after delivery
 Cord traction
Continues tension
 Gentle pull with contraction
 Uterine massage after placental delivery

15. Goals of Therapy
•Maintain the following:
Systolic pressure >90mm Hg
Urine output >0.5 mL/kg/hr
Normal mental status
•Eliminate the source of hemorrhage
•Avoid overzealous volume replacement
that may contribute to pulmonary edema

16. Management Protocol
• Examine the uterus to rule out atony
• Examine the vagina and cervix to rule
out lacerations; repair if present
• Explore the uterus and perform
curettage to rule out retained placenta

17. On recognition of
Hemorrhage
1. Initiate volume replacement with
lactated ringers or normal saline.
2. Alert blood bank and surgical team.
3. Control the blood loss.
4. Initiate decisive therapy.
5. Monitor for complications.

18. MANAGEMENT of Uterine
atony uterus for retained placental
1. Explore
tissue.
2. Uterine massage
3Firm bimanual compression

19. management of uterine
atony Cont’
4-Ecobolics “uterotonic agents”
• Oxytocin infusion, 40 units in 1 liter of D5RL
• Methergine 0.2 mg IM
• 15-methyl prostglandin F2a, 0.25 to 0.50 mg
intramuscularly; may be repeated
• , PGE1 200 mg, or PGE2 20 mg are second
line drugs in appropriate patients

20. Vaginal exploration
 General anesthesia usually best
 Uterine cavity manual exploration for retained
placenta / uterine rupture

21. Vaginal exploration cont’

22. Uterine inversion restitution

23. Vaginal exploration cont’
Intrauterine balloon Cather

24. Bakri Balloon is a tamponade
technique that can be used for
PPH.
24

25. When medical managament fails
SURGICAL MANAGEMENT
 Uterus conserving : NEED OF TIME
 Definitive - Hysterectomy

26. MANAGEMENT”cont’”
 If Hemorrhage is not controlled by
medications, massage, manual uterine
exploration, or suturing lacerations in the
birth canal,
 then surgical or radiological options must
be considered. At this time, start:
1. Packed red blood cell transfusion
2. Foley catheter and monitor urine output

27. Selective Artertial Embolization
 If the patient is stable
 and bleeding is not “torrential”,
 and if interventional radiology is available,
 then pelvic arteriography may show the
site of blood loss and therapeutic arterial
embolization may suffice to stop the
bleeding.

28. Uterine artery embolization
 Real time X-Ray (Fluoroscopy)
 Gelatin Sponges are injected
 into the bleeding vessel until
 stasis of flow in target vessel is
 achieved.
 Acess via RTfemorals
 to internal iliac and
 subsequently the uterine arteries

29. Pre embolization vs. .post embolization
Pre Embolization Post Embolization

30. Laparotomy for Obstetric
Hemorrhage
:
- Bleeding at Cesarean section
- “Torrential” Hemorrhage
- Pelvic hematoma (expanding)
- Bleeding uncontroled by other
means

31. AT laparotomy
 Consider vertical abdominal incision
 General anesthesia usually best
 Get Help!
 Avoid compounding problems by making major
mistakes
 Direct manual uterine compression / uterotonics
 Direct aortic compression
 Modified B-Lynch Suture for atony: #2 chromic
 Ligation of uterine and utero-ovarian vessels: #1
chromic

32. B-Lynch suture vs Modified B-Lynch
Suture

33. Anterior view of posterior view of
uterus showing uterus showing
modified B-Lynch modified B-Lynch
Technique Technique

34. OTHER COMPRESSION SUTURES
 Hayman Uterine
Compression Suture Cho’s Multiple Square Suture
Global Stitch By
Dr. Gunasheela Bangalore

35. COMPLICATIONS
NIL - IF DONE PROPERLY
TOO TIGHT COMPRESSION --
CUT THROUGH STITCH
UTERINE NECROSIS
INTRAPERITONEAL BLEED

36. Uterine artery ligation
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37. Sutures are placed to ligate the
ascending uterine artery and the
anastomotic branch of the ovarian
artery.
37

38. Internal iliac (hypogastric) artery
ligation
 50% success rate
 Desirous of children
 Experience of surgeon
 Steps:
 Palpate common iliac
bifurcation
 Ligate at least 2-3 cm
from bifurcation
 #1 silk. Do not divide
vessel

39. Repaire of cervical laceration
 Palpate uterine cavity to assure its integrity
 Full thickness mucosal repair above the apex
 Contionous interlocking absorbable sutures
 Hematoma incised,clot removed,bleeding vessels
ligated ,oblitrate defect with interlocking sutures
 Antibiotics& vaginal pack for 24 hours .


40. 40

41. Uterine Rupture
Prior Cesarean section = 1-2%
Modern obstetrics = 1/10,000 to
1/20,000 in unscarred uterus
In “Neglected labors”, this accounts
for many maternal deaths where
modern obstetrical care is not available.

42. Classic Symptoms of Uterine
Rupture
 Fetal distress
 Vaginal bleeding
 Cessation of labor
 Shock
 Easily palpable fetal parts
 Loss of uterine catheter pressure

43. Management of Uterine Rupture
 Laparotomy
 Debride and repair in 2-3 layers
of Maxon/PDS
 Subtotal Hysterectomy
 Total Hysterectomy

44. Management of Abnormal Placentation
 Diagnosis of exclusion after adressing tone and
truma
 Curettage of uterine cavity
 Localized resection and uterine repair:
(Vasopressin 1cc/10cc N.S-sub endometrial)
 Leave placenta in situ
 If not bleeding: Methotrexate
 Uterus will not be normal size by 8 weeks
 Uterine, utero-ovarian, hypogastric artery
ligation
 Subtotal/ total abdominal hysterectomy

45. Post-Hysterectomy Bleeding
 Patient usually has DIC – Rx with whole blood,
FFP, platelets, etc.
 Transvaginal or transabdominal
 (pelvic) pressure pack
 Bowel bag with opening pulled through
vagina cuff/ abd. Wall
 Stuff with 4 inch gauze tied end-to-end until
pelvis packed tight

46. Military Anti-Shock Trousers
(MAST)
 Increases pelvic and abdominal pressure to
reduce bleeding
 Can use at any point in the procedure
 Used when exploration is to be avoided

47. 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.
47

48. 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.
48

49. 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.
49

50. 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.
50

51. Case3
A 34yo G6P6 patient at term has just delivered
a 4000gm infant after second stage of labor
lasting 3 ½ hours. The placenta delivered
spontaneously and the patient is bleeding
briskly.
 What is most probable cause?
 What the next step?