POST PARTUM HEMORRHAGE

Recognition Referral

General Measures

• Call for extra help.• Start resuscitation.• Two bore wide I.V. canula must be sited• Blood grouping and cross matching• Investigation like Hb estimation(usually normal),

PCV, coagulation profile carried out by the side• Urinary catheterization is started• Monitoring of the vitals every 15 mins

Management of Third Stage

• Inj methergin 0.2mg IV• Oxytocin infusion with normal saline• Delivery of placenta by modified Brandt –

Andrews technique• Separation of placenta occurs• By controlled cord traction the placenta is

expressed out.

• If placenta doesn’t separate out , manual removal of placenta under GA is done.

• If still bleeding continues, cause for PPH is diagnosed and managed accordingly

Manual Removal of Placenta

Prevention of PPH• Improvement of health status during antenatal

period• High risk patients are screened and delivered in

hospital • Active management of third stage of labour reduces

PPH by 60%• Oxytocin infusion for women delivered by caesaren

section and cases with augmented labour• Examination of placenta• Active management of fourth stage of labour and

careful observation.

Management of Atonic Uterus

Medical management• Uterotonic agents are the first line of

management in PPHS.No Drugs Dosage Contraindications

1. Oxytocin 10 units I M, 20 – 40 units / L

Do not give as I V bolus

2. Methyl ergometrine 0.25 mg I.M./I.V.Repeat every 5 – 15 mins(max. 5 doses)

HypertensionCardiac disease

3. 15 methyl PGF2α0.25 mgRepeat every 15 mins(max. 8 doses)

Hepatic insufficiencyAsthmatic patientsCardiac and renal problems

4. Misoprostol 400- 600 µg PO800 – 1000 µg per rectal

Uterine scar

Stepwise Management of Atonic PPHStep I - Bleeding continues

- 15 methyl PGF2 250g every 15-30 mins

Step II - a) Bimanual compression

b) Aortic compression

Step III - Transvaginal options

- Uterine packing

- Tamponade

Step IV - Compression sutures

B.Lynch, Hayman, Cho Square

Step V -Other surgical measures

- stepwise uterine devascularisation

Step VI - Hysterectomy

Transvaginal options• Uterine tamponade by tight intrauterine packing

with gauze under general anaesthesiaUseful in cases of uncontrolled PPH where medical

treatment has failed and the patient is prepared for transport to tertiary care centre.

• Balloon tamponadeThis is feasible in atonic PPH following vaginal

delivery which is unresponsive to medical treatment and before surgical interventions

Simple, easy and cost effective measure

SURGICAL METHODS

Step-Wise Devascularisation Of The Uterus

• Effective in controlling PPH in 80% of cases

Steps:• Unilateral uterine artery ligation • Bilateral uterine artery ligation at the upper part of the lower

uterine segment• Low uterine vessels ligation after mobilization of the bladder • Unilateral ovarian vessel ligation • Bilateral ovarian vessel ligation

• 90% of the blood supply for uterus comes from uterine artery

• Ligation of uterine arteries result into significant reduction in blood flow to the uterus

• But complete devascularization would not be achieved.

• Can be done for both vaginal delivery and LSCS

Following vaginal delivery – ligation of uterine artery

B – lynch sutureLigature material:chromic catgut 2.0

Hayman suture – modified B lynch suture

Transverse compression suture

Cho suture

Multiple square sutures are used to cover the whole body of uterus

Internal iliac artery - anatomy

Internal iliac artery ligation• INDICATIONS:Atonic uterus refractory

to other treatmentAbruptio placenta with

atonic uterusFor therapeutic purposes,

before or after hystrectomy for PPH

• Reducing the blood supply to the uterus decreases the pulse pressure of the artery, thus PPH is controlled

• Internal iliac artery ligation also used in patients with traumatic causes of PPH – more beneficial than atonic PPH.

Uterine artery embolization

• Highly feasible, safe & beneficial procedure• Done under USG guidance• can avoid hystrectomy surgery in uncontrolled

PPH patients• Preserves the function of uterus, tubes and

ovaries

Hystrectomy

Indications:• Uterine rupture secondary to obstructed labor• Previous Caesarean section• If rupture is extensive & hemorrhage cannot

be contained by suture of ruptured area

• Saving life of the one giving birth to a new life…