Professional Documents
Culture Documents
1. Haemorrhagic Shock.
2. Consumptive Coagulopathy.
3. Multiple organ failure ( Renal failure).
4. Death.
5. Need for internal iliac ligation and its complications.
6. Need for hystrectomy and loss of child bearing potential.
7. Complications of Blood transfusion.
8. Need for other emergency surgical interventions.
DEFINITION
• There is no single satisfactory definition of PPH
• An estimated blood loss of 500ml following delivery
( either Vg or C.section )
• Decline in hematocrit level of 10% from admission to post partum
period or nee for erythrocyte transfusion.
• But Blood loss estimates at delivery are always notoriously
inaccurate with significant underreporting.
• Asian women with poor socio economic status and Poor nutrition and
lower Haemoglobin, small built and lesser blood volume. Collapse
even with less than 500 ml of Blood loss.
• Therefore patients vital parameters and general condition are taken as
the guidelines for the management rather than amount of blood loss.
PHYSIOLOGICAL CHANGE THAT
OCCURS IN ANTICIPATION OF BLOOD
LOSS AT DELIVERY
• Tone - Atonicity
• Tissue - Abnormal ut content
• Trauma - Accidental injury
• Thrombosis - Abnormal Coagulation
TONE
Atonicity or 70% of PPH Abnormal Contraction
1. Sepsis - Chorioamnionitis
2. Overdistension - TWINS
Polyhydramnius
Macrosomia
Hydrocepahalous
3. Muscle Exhaustion - Mulliparity
Precipitate Labour
Prolonged Labour
4. Uterine anamolies - Fibroid uterus
Congenital malformations
Induced labour associated with more blood loss than
non induced labour
TONE
Atonicity or 70% of PPH Abnormal Contraction
5. Drugs
Halogenated anesthetic agents
Nitrates
NSAID’S
MgSo4
B Sympathomimetics ( Tocolysis)
Nifidipine
6. Antepartum Haemorrahage
Couvelaire uterus Exhastion of Muscle
7. Mismanagement of III Stage
a. No attempts to deliver the placenta until it is separated
and the fundus is firmly retracted.
b. Squeezing of the uterus should be avoid.
c. A III stage > 18 mins. risk of PPH 6 times
TISSUE
Abnormal Uterine Content
Retained blood clots- Atonic uterus
Retained placenta or Products
Accreta
a. Abnormal Placentation Increta
Percreta
b. Multiparity
c. Placental anomalies
d. Previous Uterus surgery
Prevention of PPH
•Universal
ACTIVE MANAGEMENT OF III STAGE
1. Atonicity - Tone
2. Abnormal uterine - Tissue Content
3. Accidental - TRAUMA Injury
4. Abnormal - Thrombus
Coagulation
IDENTIFICATION OF WOMAN AT RISK FOR PPH
Risk Aetiology Clinical factors
Process Process
Manual removal
TONE
•Uterine Atony
•Bimanual compression
•IM Carboprost tromethamine 0.25mg IM repeat
after 15 min after I dose
•IV Methyl Ergometrine 0.2 mg, IV\ ( III Uterotonic
drug )
•Aortic Compression
•Uterine packing Uterine tamponade sengstaken
tude / foley’s catheter / Condom
UTERINE ATONY
BIMANUAL COMPRESSION
Squeeze the
uterus firmly
between the
hands. Continue
compression until
bleeding stops
AORTIC CMPRESSIO
Apply pressure
above umbilicus,
compressing the
aorta to stop uterine
bleeding until
femoral pulse is not
felt. Continue
pressure till further
help.
UTERINE PACKING
• Packing the uterus is
ineffective and wastes
precious time.
• This can be used before
woman is shifted from
prerophery to hospital Insert image page no 226 b
failure to respond to
oxytocics ( under proper
antibiotic cover )
UTERINE TAMPONADE
Technique Comments
Foley catheter - 4 inch gauze; can soak
with 5,000 units of
thrombin in 5mL of sterile
saline
Sengstaten- Blakemore -Insert balloon: instill 300-
tube 500 mL.
SOS Bakri tamponade
balloon
Condom
• Evacuate clots
• Manual removal of placenta if not
separated
• If placental tissue piecemeal removal
by sponge holder gently & gentle
curettage
TRAUMA
Modified from Marti SR, Strong TH Jr Transfusion of blood components and derivatives in the obstetric intensive care
patients ………………..
BLOOD COMPONENT THERAPY
Surgical Management of PPH
Uterine artery ligation Bilateral; also can ligate uteroovaria vessels
B-Lynch suture
Repair of rupture
Hysterectomy
ATONIC PPH
• Bimanual massage
and compression –
Elevation
• Ulerotonic agents
• Aortic Compression
Remove slide
UTEROTONIC AGENTS
Drug* Dose/Route Frequency Comment
Oxytocin(Pitocin) IV:10-40 units in 1 liter normal Continuos Avoid undiluted rapid IV infusion
saline or lactated Which causes hyotension
Ringer’s solution
IM: 10 units
ALERT LINE
1 500-1000 15 Minimal
ACTION LINE
2 1200-1500 20-25 ↓ urine output
↑ pulse rate
↑respiratory rate
Postural hypotension
Narrow pulse pressure