POSTPARTUM

HEMORRHAGE

DEFINITION:
Blood loss of more than 500 ml after vaginal
delivery and more than 1,000 ml after cesarean
delivery
Decrease in hematocrit of more than 10% from
before to after delivery
CLASIFICATION
Primary Hemorrhage on the first 24 hours
Secondary Hemorrhage after the first 24 hours

Causes of postpartum hemorrhage:

The 4 Ts
Tone (atonic uterus)
Trauma (tears in birth canal)
Tissue (retained placental
fragments)
Thrombi (blood coagulation
disorders)

UTERINE ATONY
Postpartum uterine contraction inadequate for

hemostasis (failure of the uterus to contract)

most common cause of PPH
Risk factor :
Uterine overdistended (Fetal macrosomia,

polyhydramnious, Multiple gestation)

Prolonged, augmented, precipitous labor
Chroriomanionitis
Grandmultiparity
Use of tocolytic agent

GENITAL TRACT
LACERATIONS
Suspect of lacerations : perineum, vaginal or
cervical laceration
Before you perform your inspection administer
adequate analgesia and prepare excellent light
The perineal trauma may occur spontaneously or
arise from episiotomy during vaginal delivery
Anterior perineal trauma involves the labia, ant
vagina, urethra or clitoris
Posterior perineal trauma involves posterior vaginal
wall, perineal muscles or anal sphincters and may
extend through the rectum

Classificationof
spontaneous
tears acc to
1 degree involves the fourchette, perineal
skin and
vaginal mucous
membrane but not
the
degree
or
depth
yet underlying fascia and muscle
st

2nd degree aside from the skin and mucous

membrane, the fascia and muscles of the

perineal body are involved

3rd degree lacerations extend through skin,

mucous membrane, perneal body and anal

sphincter
3a : <50% of ext anal sphincter thickness torn
3b : >50% of ext anal sphincter thickness torn
3c : internal anal sphincter torn

4th degree there is extension of laceration

through the rectal mucosal to expose lumen of

the rectum

GENITAL TRACT
HEMATOMA
The pregnant uterus, vagina and vulva have rich
vascular supplies that are at risk of trauma
during birth process and may result in formation
of a hematoma
The most common location : vulva,
vagina/paravaginal, and
retroparitoneum/subperitoneal
Risk factor :nulliparity, prolonged 2 nd stage of
labor, indtrumental delivery, baby > 4000gr,
genital tract varicosities, preeclampsia, multifetal
pregnancy, cloting disorders

Excessive perineal pain is a hallmark

symptom
Imaging (UTZ, CT, MRI) may be helpful to
confirm the diagnosis (location, size, progress
or resolution)

Stable hematomas may be managed

conservatively
Expanding hematoma should be evacuated
performa generous incision, irrigate copiously
and ligate the bleeding vessels. Layered
clossure is recommended to assist
hemostasis and eliminate dead space
Vaginal packing for 12-24 hours
Antibiotic broad spectrum should be
administered

RETAINED PLACENTA
Risk factor : abnormal placentation, placenta

acreta, chorioamnionitis and very preterm

labor
If the 3rd stage of labor last longer than 30
minutes consider abnormal placentation
Manual extraction and uterine exploration are
performed
Blunt curettage may be required
If bleeding is control by uterotonic agent,
conservative management may be sufficient

UTERINE INVERSION
The uterus is turned inside out, with the fundus

protruding through the cervical os into or out of the

vagina
Risk factor : multiparity, long labor, short umbilical
cord, abnormal placentation, connective tissue
disorders, excessive traction of the cord
Classification :
Incomplete corpus travel partially through the cervix
Complete corpus travel entirely through the cervix
Prolapse corpus travel beyond the vaginal introitus

Diagnosed ???
Hemorhage
Shock
Severe pelvic pain

Management ???
The immidiate treatment of the hemorrhagic

shock and replacement of the uterus

Occasionaly administration of smooth muscle
relaxant, such as :
-adrenergic agonist (terbutaline) 0.25mg
Nitroglycerine
Magnesium Sulfate IV dose of 4 grams

Uterotonics drugs should only be given

immediately after repositioning of the uterus

Antibiotic prophylaxis (WHO) :
Ampicilline 2 gr IV or Cefazolin 1 gr IV, plus
Metronidazole 500mg IV

With sign of infection (+fever)

Ampicilline 2 gr IV every 6 hours, Gentamycin
5 mg/kg body weight every 24 hours and
Metronidazole 500mg IV every 8 hours
AB untill afebrile 48 hours

Repositioning
Repositioning
Method of hydrostatic reduction (OSullivans

hydrostatic maneuver)
Johnson maneuver
Huntington maneuver
Hultain maneuver

COAGULOPATHY
Risk factors : severe pre-eclampsia, abruptio

placenta, idiopathic/autoimune
thrombocytopenia, amniotic fluid embolism,
DIC, heredity coagulopathy (von willebrands
disease)
Surgical treatment will only increase the
hemorrhage
Replace coagulation factors and platelets as
needed

PPH DRILL

HAEMOSTASIS

MANAGEMENT
Uterine massage and or bimanual uterine

compression

Advantages of bimanual uterine

compression :

Prevents increase in radius of the uterus

Uterus is pushed cephalad
Uterine arteries under tension
Reduces blood flow

Bimanual uterine compression

Massage the
posterior
aspect of the
uterus with the
abdominal
hand and
massage
through the
vagina of the
anterior uterine
aspect with the
other fist
Cunningham, G, et al. Williams Obstetrics 22 nd edition 2005.
20

Uterotonic therapy
Agent

Dose

Route

Dosing
frequency

Side
effects

Contraindications

Oxytocin
(Pitocin)

10-80
IV (1st)
units in IM / IU
1L soln

Continuous

Nausea,
emesis, water
intoxicaton

None

Methylergonovine
(Methergin)

0.2mg

IM (1st)
IU / PO

Q 2-4 hr

Hypertension,
hypotension,
nausea,
emesis

Hypertension
preeclampsia

Misoprostol
(Cytotec)

6001000ug

PR (1st)
PO

Single
dose

Nausea,
None
emesis,
diarrhea, fever,
chills

Uterotonic therapy
Agent

Dose

Route

Dosing
frequency

Side
effects

Contraindications

15-methyl
prostaglandin F2
(Hemabate)

0.25mg

IM (1st)
IU

Q15-90min
(8 dose max)

Nausea,
emesis,
diarrhea,
flushing,
chills

Active cardiac,
pulmonary,
renal or
hepatic
disease

Prostaglandin E2

20mg

PR

Q 2 hr

Nausea,
emesis,
diarrhea,
fever, chills,
headache

Hypotension

(Dinoprostone)

Shock Garment & Shift to

Hospital

Tamponade
Balloon
Gloves
Condoms

Urterine Packing
Uterine packing controls postpartum bleeding

and may be useful in several settings (uterine

atony, retained placental tissue, and placenta
accreta)
Although uterine packing was advocated for
treating PPH in the past, it fell out of use
largely due to concerns of concealed
hemorrhage and uterine overdistention
It is usually left inside the abdomen for 48
hours or until the patient is stable.

Baloon Tamponade
The technique is simple
A foley catheter with a 30-ml balloon capacity is easy

to acquire and may be stocked on labor and delivery

rooms
Using a french 24 foley catheter, the tip is guided into
the uterine cavity and inflated with 60 to 80 ml of
saline
Additional foley catheters can be inserted if necessary
If bleeding stops, the patient can be observed with the
catheters in place and then removed after 12 to 24
hours.

Condom Catheter
Tamponade
This simple technique uses a 500 cc infusion
bag connected to a Nelaton catheter which is
in turn connected to a condom.

Compression suture
B-Lynch

operation
Cho operation
Pereire operation

The theory behind each technique is the

same: the mechanical compression of uterine

vascular sinuses prevents further
engorgement with blood and continued
hemorrhage. When used to treat atony and
hemorrhage that does not respond to
pharmacologic intervention, the B-Lynch
appears to be very effective

B-Lynch technique
Uterus remains
exteriorized
A 70-80 mm round
needle, 2-0 chromic
or plain
With the bladder
displaced inferiorly
1st stitch placed 3 cm
below the lower
cesarean incision
A. Rebarber, A. Roman. Seven ways to control postpartum hemorrhage. Contemporary
Ob/Gyn 2003
30

B-Lynch technique

The first stitch is placed 3 cm below the lower cesarean incision on

the patients left side and threaded thru the uterine cavity to
emerge 3 cm above the upper incision margins, approx. 4 cm from
the lateral border of the uterus
A. Rebarber, A. Roman. Seven ways to control postpartum hemorrhage. Contemporary
Ob/Gyn 2003
31

B-Lynch technique
Carry suture on
the top and
posterior side

Suture is vertical
and 4 cm from
cornua

A. Rebarber, A. Roman. Seven ways to control postpartum hemorrhage. Contemporary

Ob/Gyn 2003
32

B-Lynch technique
The suture is placed
same way as the left
side
3 cm above the
incision, 4 cm from
the lateral side of
the uterus
3 cm below the
incision
A. Rebarber, A. Roman. Seven ways to control postpartum hemorrhage. Contemporary
Ob/Gyn 2003
33

B-Lynch technique
Maintains
compression
Two ends of
suture put
under
tension
Double
throw knot
placed
Closure of
C/S incision
A. Rebarber, A. Roman. Seven ways to control postpartum hemorrhage.
Contemporary
Ob/Gyn 2003
34

Selective pelvic

devascularization
Bilateral

uterine artery ligation

Bilateral ovarian artery ligation
Bilateral Hypogastric Artery
ligation

Advantages of uterine artery ligation :

Relatively simple and safe procedure
Provide future childbearing
Highly effective in controlling bleeding from

uterine sources

Cuts off 90% of uterine blood flow

Uterine Artery Ligation

Uterus grasped and tilted
Place stitch 2 cm below level of transverse

lower uterine incision site

Include full thickness of myometrium
Ensure uterine artery and veins are completely
included
Needle passed thru avascular portion of broad
ligament; tied anteriorly
Opening broad ligament is unnecessary

Ovarian Artery Ligation

Arises directly from aorta
Anastomose with uterine artery at the uterine

aspect of uteroovarian ligament

Ligation just inferior to uteroovarian ligament
Similar to that of uterine artery ligation
Amount of uterine blood flow supplied by these
vessels increase after uterine artery ligation

Hypogastric Artery
Ligation
Decrease bleeding
Decreased arterial pulse pressure
Clot forms
Too long to perform
Surgical repertoire of well-trained gynecologic

surgeon

INDICATION
Placenta accreta
Abdominal pregnancy
Uterine atony
Couvelaire uterus
Ruptured uterus

COMPLICATIONS
Waiting too long
Easy to ligate the external iliac artery instead of

the hypogastric artery

Puncture of the hypogastric vein
Necrosis of the gluteus maximus

Interventional radiology
Selective

(SAE)

arterial embolization

Advantages
Control hemorrhage
Effective in the management
Postpartum hemorrhage
Ectopic pregnancy
Postabortal hemorrhage
Malignancy
Post-conization hemorrhage

97% success rates

Technique
Interventional radiologist under flouroscopic

guidance
Regional anesthesia or conscious sedation
Introduces a catheter via the femoral artery
Directs it into the target vessel
Target artery is occluded
Patients respond immediately
Menses returns in 3 months
Normal pregnancies

Can be used for women with

risk of PPH

Catheters placed prophylactically

Prior to planned CS delivery
Reduced total blood loss
Reduced incidence of coagulopathy

Complications
Fever
Buttock ischemia
Hematoma
Vascular perforation
Infection
Uterine necrosis

Hysterectomy
Should only be used for persistent and

severe bleeding after all medical and

other surgical therapy has failed

Remember
Help from MDs / RNs
Assess maternal condition
Etiology of bleeding
Massage the uterus
Oxytocin infusion
48

Shock garment Shift to

hospital
Tamponade (Balloon /
Packing / Condom)
Apply Compression Sutures
Systemic Pelvic
devascularization
Interventional Radiology
Subtotal / Total Hysterectomy
49

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