a ppt on post partum hemorhage

1. A case study on PPH
Presented by
Dr Mayuri Mane
PG scholar

2. Post partum haemorrhage

3. Definition
1) “The amount of blood loss in excess of 500 ml following
birth of the baby” (WHO)
2) "Any amount of bleeding from or into the genital tract
following birth of the baby up to the end of puerperium
which adversely affect the general condition of the
patient evidence by rising pulse rate and falling blood
pressure is called postpartum haemorrhage.

4. Average blood loss
Vaginal delivery = 500ml
cesarean delivery = 1000ml
cesarean hysterectomy = 1500ml

5. Depending upon the amount of blood loss pph can be
classified
● Minor = less than 1 litre
● Major = more than 1 litre
● Severe =more than 2 litre

6. Types
1) Primary PPH
Haemorrhage occurs within 24 hours following the birth of
the baby. These are of two types
● 3rd stage haemorrhage
Bleeding occurs before expulsion of placenta
● True postpartum haemorrhage
Bleeding occurs at subsequent to expulsion of placenta

7. 2) Secondary PPH
Haemorrhage occurs beyond 24 hours and within your
puerperium also called delayed or late puerperal
haemorrhage.
Cause =retained bits, infection, endometritis
Diagnoses= bleeding is bright red , varying degree of anaemia
, evidence of sepsis are present.
Management = blood replacement(transfusion) , find out the
cause and take appropriate steps to rectify it .

8. Causes
Tone Trauma
Tissue Thrombin

9. 1)Tone
Atonic uterus : Imperfect contraction and retraction of the
uterine musculature so bleeding continues. This can be due to
● Grand multipara
● Overdistension of the uterus
● Malnutrition and anaemia
● Antepartum haemorrhage
● Prolonged labour
● Augmentation of delivery by oxytocin
● Malformation of the uterus
● Uterine fibroid
● Miss managed third stage of labour
● placenta

10. 2)Trauma
○ Operative vaginal delivery (vacuum / forceps
delivery)
○ Caesarean section
● Trauma involves usually the -cervix , vagina ,
perineum , para ureteral region and rarely rupture of the
uterus occurs

11. Tissues
● Retain product of conception(tissue)
● Bits of placenta, blood clots cause PPH due to imperfect
uterine retraction

12. Thrombin
blood coagulopathy disorders
Abruptio placenta,
Thrombocytopenic purpura,
HELLP syndrome

13. Diagnosis and clinical effects
 In traumatic haemorrhage the uterus is found well
contracted.
 In atonic haemorrhage the uterus is found flabby and
becomes hard on massaging
 However both the atonic and traumatic cause may co-exist
 Vaginal bleeding may be revealed or concealed
 Alteration in pulse , BP

14. Prognosis
One of the life threatening emergencies
One of the major causes of maternal deaths
Prevalence of malnutrition and anaemia, inadequate
antenatal and intranatal care and lack of blood transfusion
facilities are some of the important contribution factors

15. Prevention in antenatal care
● Improvement of the health status
● High risk patients
● Blood grouping
● Placental localisation
● Women with morbid adherent placenta

16. Prevention in Intranatal care
● Active management of the third stage for all women in
labour should be a routine as it reduces PPH by 60%
● Cases with induced or augmented labour by oxytocin
● Women delivered by cesarean section
● Exploration of the utero vaginal canal
● Observation for about 2 hours
● Examination of the placenta

17. Management of 3rd stage
bleeding
The principles in the management our
● To empty the uterus of its contents and to make it
contract
● To replace the blood patient may be in shock , in that
case patient is manage for shock first
● To ensure effective haemostasis in traumatic bleeding

18. Steps of Management
1)Placental site bleeding
To palpate the fundus and massage the uterus to make it
hard. If bleeding continuous possibility of presence of genital
tract injury
To start crystalloid solution with Oxytocin at 60 drops per
minute and to arrange for blood transfusion if necessary
Catheterise the bladder
Give antibiotics

20. Steps of manual removal of
placenta (MRP)

21. Management of true PPH
Principles
• Communication
• Resuscitation
• Monitoring
• Arrest of bleeding

22. Actual management
Atonic uterus
• Massage the uterus to make it hard and Express the
blood clot out
• The uterus is to be explored under general
anaesthesia
• Uterine massage and bimanual compression
• Uterine tamponade - tight intrauterine packing, balloon
tamponade
• Surgical methods to control PPH

24. Surgical methods
Ligation of uterine arteries
Ligation of the ovarian and uterine artery anastomosis
Ligation of anterior division of internal iliac artery
B Lynch compression suture and multiple square
suture
Angiographic arterial embolization
Obstetric Hysterectomy

26. Ligation of uterine vessels

29. Angiographic arterial embolisation

30. Obstetric hysterectomy

31. Summary
TONE TISSUE TRAUMA THROMBIN
• Palpate fundus
• Massage
uterus
• Oxytocin
• methargin
• Inspect
placenta for
missing
placenta
• Explore uterus
• Treat abnormal
implantation
• Obtain good
exposure
• Inspect Cx &
vagina
• Treat
hematoma
• Replacement
with blood or
fresh frozen
plasma or
platelet rich
plasma

33. Thank you