Definition

Postpartum hemorrhage has been defined as blood loss in excess of 500 ml in a vaginal birth and in excess of 1 L (1000 ml) in a cesarean delivery

•           Haemoglobin: 10% fall from antenatal level

•           For clinical purposes, any blood loss that has the potential to produce hemodynamic instability should be considered a PPH

Incidence

1 to 5% of deliveries (14 million cases / year)

Single most imp. Cause of maternal deaths worldwide 88% deaths due to PPH occur within 4 hours

Deaths from haemorrhage could often beavoided

Thus the need for set protocols and emergency drills for PPH management

Types

1.      Primary PPH (immediate)

2.      Secondary PPH (late)

Primary Postpartum Hemorrhage -

Primary (immediate) PPH occurs within the first 24 hours after delivery.

Approximately 70% of immediate PPH are due to uterine atony.

Atony of uterus is defined as failure of the uterus to retract afterthe child is born It is of 2 types

•           Third stage hemorrhage- Bleeding occurs before expulsion of the placenta

•           True PPH -Bleeding occurs subsequent to expulsion of placenta

Secondary Postpartum Hemorrhage –

Secondary (late) PPH occurs between 24 hours after delivery of infant and 6 weeks postpartum. Most late PPH is due to retained products of conception, infection or both.

Aetiology

•           Retained placenta

•           Failure to progress in 2nd stage

•           Placenta accreta

•           Lacerations

•           Instrumental delivery

•           Large for gest. age baby (>4000 g)

•           Hypertensive disorders

•           Induction of labor

•           Augmentation of labor with oxytocin

•           Placenta praevia.

•           Previous history of PPH

•           Obesity

•           High parity

•           Asian or Hispanic race

•           Precipitous labour

•           Pre-eclampsia

•           Only a fewwomen with riskfactors develop PPH

•           Manywomen without risk factors have PPH

Prevention of PPH

The incidence of PPH has shown a falling trend with the routine use of active management of third stage of labor (AMTSL)

AMTSL has 3 main components:

•           Uterotonic(most important component)

•           Oxytocin 10 IU I/M (First choice drug -recommended by WHO)

•           Ergometrine/Methylergometrine 0.2 mg l/M

•           Misoprostol 600 µg orally

•           Controlled cord traction (CCI)

•           Uterine massage after delivery of the placenta

AMTSL reduces:

•           Incidence of PPH by 60%

•           Quantity of blood loss—thereby decreasing incidence & severity of anemia (100-150 ml)

•           Emergencies & related cost

•           The use of blood transfusion

PRIMARY POSTPARTUM HEMORRHAGE

Incidence

•           Primary PPH occurs in 2-3% of all deliveries. About 15% of these are associated with retained placenta requiring manual removal

Aetiology

4Ts:                                         Cause                                     Incidence(%age)

Tone                          Atonic uterus                                                         70

Trauma                     Perineal, vaginal, cervical lacerations                    20

Haematoma, Rupture uterus

Tissue Retained placenta or retained clots                                                 10

Thrombin                 Coagulation disorder                                             01

Diagnosis.

•           PPH is usually external. It may partly be concealed from distention of uterus or vagina with blood clots. Concealed hemorrhage is confirmed by squeezing the uterus firmly, when the blood will be forced out with gush

•           Blood loss is underestimated because in pregnancy signs of hypovolaemia do not show until the losses are large and visual quantification is difficult

•           S Mother can lose up to 30-35% of circulating blood volume (2000 ml) before showing signs of hypovolaemia

•           Blood is mixed with other fluids (amniotic fluid, urine) and therefore underestimated

•           Bleeding may occur slowly over several hours and condition may not be recognized until woman suddenly enters shock

We mostly have to depend on clinical competence to assess blood loss

Degree of blood loss & features

Blood loss in ml (%)                         Systolic Blood Pressure                  Signs & Symptoms

1500-2000(25-35)                70-80                                                  Restless, Pallor, Oliguria

2000-3000(35-45)             50-70                                                Collapse,                                            Air       hunger, Anuria

Atonic uterus:

Most common cause of Primary PPH is uterine atony Causes of uterine atony are:

•       Grand multipara

•       Overdistension of uterus as in hydramnios, twins

•       Malnutrition and anaemia

•       APH

•       Prolonged labor

•       Anesthesia

•       Initiation or augmentation of delivery by oxytocin

•       Malformation of uterus

•       Uterine fibroid

•       Mismanaged third stage of labor

•       Precipitate labor

•       Full bladder

Initial Assessment and Management (If at periphery ,refer if bleeding is not controlled after giving uterotonic drugs and uterine massage)

•           Shout for help—mobilize personnel

•           Evaluate woman's condition including vital signs

•           Place the woman on a flat surface, such as delivery table or birthing bed, with her feet higher than her head

•           Massage uterus to expel clots and feel to see that it is contracted— recheck intermittently

•           Start oxygen

•           Give uterotonics

•           Infuse IV fluids

•           Catheterize bladder, if needed

•           Check to see that placenta has been expelled—examine for completeness

•           Examine the cervix, vagina and perineum for tears

•           After bleeding is controlled, check for anemia

Management of Atonic Uterus

•           Continue IVfluids

•           Continue to massage uterus (per abdomen)

•           Continue oxytocic drugs

•           Perform bimanual compression or perform aortic compression

•           Hydrostatic intrauterine ballontamponade

•           Arterial embolization

•           Laparotomy

-            B-Lynch suture

-            Consider stepwise devascularisation

-            Hysterectomy

Uterotonic Drugs

•           OXYTOCIN –FIRST CHOICE

•           101Ul/M(if not already given)

•           IV: Infuse 20 units in 1 L(nOrmal saline) at 60 drop/mm.

•           Continuimg Dose: Infuse 20 units in 1 1 at 40 drop/mm.

•           Maximum Dose: Not more than 3 LoflVfluids

•           Precautions/Contraindications: Do not give as IV bolus

ERGOMETRINE or METHYLERGOMETRINE ( used if oxytocin is not available or bleeding continues despite having used oxytocin)

•               Repeat 0.2 mg IM every 2-4 hours for a maximum of 5 doses

•               Max. Dose: 5 doses or 1 mg

•               Precautions/Contraindications: Pre-eclampsia, hypertension, heart disease

•       

MISOPROSTOL

•               800 g sublingually ( 4x 200        g tablets)

•        PGF2 alpha

•               IM: 0.25mg

•               Continuing Dose: IM: 0.25 mg every 15 mm

•               Max. Dose: 8 doses or 2 mg             -

•               Precautions/Contraindications: Asthma

If bleeding persists after administration of uterotonics, these life saving measures are to be considered: Bimanual Compression of Uterus

•           Wearing sterile gloves, insert hand into vagina; form fist

•           Place fist into anterior fornix and apply pressure against anterior wall of uterus

•           With other hand, press deeply into abdomen behind uterus, applying pressure against posterior wall of uterus

•           Maintain compression until bleeding is controlled and uterus contracts

o    Apply downward pressure with closed fist over abdominal aorta directly through abdominal wall just above the umbilicus slightly to be save

o    With other hand, palpate femoral pulse to check adequacy of compression

Pulse palpable = inadequate Pulse not palpable = adequate

Maintain compression until bleeding is controlled

1 LAPAROTOMY

1.   B-Lynch sutures

Haemostatic sutures applied with No. 2 Chromic catgut as shown in diagram

Anterior and posterior wall of uterus are compressed to see if bleeding stops, that means the sutures will be beneficial

1.                Stepwise pelvic devascularization

•           Ligation of ascending branch of uterine artery

•           Ligation of uterine and ovarian artery anastomosis

•           Ligation of ant. Division of internal iliac a tier

2.                Hysterectomy (Subtotal or Total)

•           If conservative measures have failed, then hysterectomy is the final option.

•           Subtotal hysterectomy may not beeffective when source of bleeding is in lower segment, cervix or vaginal fornices.

•           There is belief that both operating time and blood loss are significantly lower with the subtotal technique but some studies have reported no such differences.

Continued care of the woman

•           Once bleeding is controlled and woman is stable careful monitoring for next 24-48

•           hours is needed               -

•           A rising BP and stabilizing heart rate is reassuring

•           Keep checking that uterus is well retracted &remains so

•           Carefully estimate blood loss

•           Assess vital signs

•           Ensure proper fluid intake

•           Monitor blood transfusion

•           Monitor urinary output

Finally

Before discharging the woman from health facility:

•           Check the hemoglobin

•           Give iron and folate supplementation as indicated by her condition