dr. alongkone phengsavanhlaoshealth.org/assets/english-post-partum... · – placenta previa /...
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Postpartum Hemorrhage
Dr. Alongkone Phengsavanh
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Objectives
• Define and discuss risk factors and causes• Describe management and prevention
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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
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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
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Clinical Findings & Blood LossMildHypovolemia
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
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PPH Etiology
• Tone - Uterine tone• Tissue - Retained tissue / clots• Trauma - Laceration, rupture,
uterine inversion• Thrombopathy - Coagulopathy
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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
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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
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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
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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
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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
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Controlled Cord Traction
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PPH Management
• Prevention– Active management of the third stage of labor– Identify patients at potential risk of PPH
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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)
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PPH Management – Tone• Determine source of
bleeding– Assess the uterine
fundus– Do Internal Bimanual
Massage of uterus
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PPH Management – TissueExamine placenta for completeness
Examine maternal side of placenta Examine fetal side of placenta
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PPH Management – Tissue1 2
3 4
Manual removal of placenta – if incomplete placenta
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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
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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
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PPH Management
• Consider transfer to center with additional resources– Surgery
• B-Lynch Stitch• Hysterectomy
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PPH ManagementConsider aortic compression
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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
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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
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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
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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
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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.