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 doesnt 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 PPH
S.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)
Hypertension
Cardiac disease
3. 15 methyl PGF
2

0.25 mg
Repeat every 15 mins
(max. 8 doses)
Hepatic insufficiency
Asthmatic patients
Cardiac and renal problems
4. Misoprostol 400- 600 g PO
800 1000 g per rectal
Uterine scar
Stepwise Management of Atonic PPH
Step I - Bleeding continues
- 15 methyl PGF
2
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 anaesthesia
Useful in cases of uncontrolled PPH where medical
treatment has failed and the patient is prepared
for transport to tertiary care centre.
Balloon tamponade
This 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 suture
Ligature 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 treatment
Abruptio placenta with
atonic uterus
For 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