EOC Module: Postpartum Hemorrhage - Session 2

Session 2: Management of
Postpartum Hemorrhage
Overview
Purpose
The purpose of this session is to introduce
participants to the prophylactic measures
that should be followed to decrease the
incidence of postpartum hemorrhage,
provide first aid management and active
management for cases of postpartum
hemorrhage whether primary or secondary.
Postpartum Hemorrhage - Session Overview Slide 1
EOC Module: Postpartum Hemorrhage - Session 2

Session 2: Management of
Postpartum Hemorrhage

Purpose (cont.)
With early and accurate management,
maternal and fetal morbidity and
mortality from postpartum hemorrhage
will be reduced.

Postpartum Hemorrhage - Session Overview Slide 2

EOC Module: Postpartum Hemorrhage - Session 2

Session 2: Management of
Postpartum Hemorrhage
Story
A healthy 38-year old G7 P6 woman with
unremarkable prenatal histories, except for a
single postpartum bleeding episode,
presented to a private clinic near term, with
spontaneous rupture of membranes two days
ago. The obstetrician started augmentation
of labor. When labor prolonged for 12 hours
she was transferred to a hospital where she
delivered after another 12 hours a 4 Kg
neonate .
Postpartum Hemorrhage - Session Overview Slide 3
EOC Module: Postpartum Hemorrhage - Session 2

Session 2: Management of
Postpartum Hemorrhage

Story (cont.)
Following the delivery massive bleeding
began. The blood supply was insufficient to
complete an adequate transfusion; she
received 1000cc and the bleeding continued.
The following morning a hysterectomy was
performed, but the patient went into
irreversible shock and died.

Postpartum Hemorrhage - Session Overview Slide 4

EOC Module: Postpartum Hemorrhage - Session 2

Learning Objectives
By the end of this session each
participant
should be able to:
1. Recognize the prophylactic measures
to decrease the incidence of
postpartum hemorrhage.
2. Provide first aid management for cases
of postpartum hemorrhage.

Postpartum Hemorrhage - Learning Objectives Slide 5

EOC Module: Postpartum Hemorrhage - Session 2

Learning Objectives (cont.)

3. Manage cases of postpartum hemorrhage
before delivery of the placenta.
4. Manage cases of postpartum hemorrhage
after delivery of the placenta.
5. Manage cases of secondary postpartum
hemorrhage.
6. Monitor cases of postpartum hemorrhage
during their hospital stay.

Postpartum Hemorrhage - Learning Objectives Slide 6

EOC Module: Postpartum Hemorrhage - Session 2

Prophylactic Measures
Preventive care during the
antenatal period
Recognize risk factors.
Perform routine laboratory investigations
to diagnose anemia at an early stage.
Ensure iron and folic acid
supplementation.
Provide health education.

Postpartum Hemorrhage - Prophylactic Measur Slide 7

EOC Module: Postpartum Hemorrhage - Session 2

Prophylactic Measures
(Cont.)
Preventive care during labor and
delivery
Order routine laboratory investigations. If
the hemoglobin level is 8 gm/dL,
crossmatch at least one unit of whole
blood even if the delivery is normal, or two
units if it is CS, to be used if needed.
Identify patients at risk of developing PPH.
Avoid abuse of Oxytocin.
Actively manage the third stage of labor

Postpartum Hemorrhage - Prophylactic Measur Slide 8

EOC Module: Postpartum Hemorrhage - Session 2

Emergency Rules
First, the obstetrician should SHOUT FOR
HELP to mobilize all available personnel
(senior obstetrician, nurses, anesthesiologist,
and laboratory and blood bank technicians).
Remember that two patients, the mother and
the neonate, require evaluation and
intervention as needed so proper delegation
of responsibilities is necessary.

Postpartum Hemorrhage - Emergency Rules Slide 9

EOC Module: Postpartum Hemorrhage - Session 2

First Aid Management

Insert two wide bore IV cannulae
(size 16 or 18), and withdraw 20
mL of blood for crossmatching and
required investigations before
starting any IV fluids.
Administer an IV crystalloid
solution (saline or Ringers lactate)
at a fast drip (1 L/hour) and start
ecbolic drugs

Postpartum Hemorrhage - First Aid Manageme Slide 10

EOC Module: Postpartum Hemorrhage - Session 2

First Aid Management

(cont.)
Continuously monitor pulse and
BP every five minutes.
Insert a Foley catheter.
Monitor urine output.
Massage the uterine fundus.

Postpartum Hemorrhage - First Aid Manageme Slide 11

EOC Module: Postpartum Hemorrhage - Session 2
Hemorrhage after delivery of
the neonate, before delivery of
the placenta
(retained placenta)
Determine the cause of the retained
placenta (hourglass contraction versus
partial separation).
Administer Oxytocin 10 IU (1 ampule) IM
stat, or give misoprostol 200 g (one tablet)
rectally, followed by controlled cord traction
to deliver the placenta. Avoid forceful cord
traction and fundal pressure as they may
cause uterine inversion.
Postpartum Hemorrhage - Retained Placenta Slide 12
EOC Module: Postpartum Hemorrhage - Session 2

Hemorrhage after delivery of

the neonate, before delivery of
the placenta
(retained placenta) (cont.)
Quickly explore the perineum, vagina, and
cervix, looking for lacerations if the
bleeding persists without delivery of the
placenta.
Call the anesthesiologist.
Manually remove the placenta with
adequate sedation (e.g., Valium or
Pethidine) or anesthesia.
Postpartum Hemorrhage - Retained Placenta Slide 13
EOC Module: Postpartum Hemorrhage - Session 2

Hemorrhage Immediately after

Delivery of The Placenta

Examination under anesthesia:

Explore the perineum, vagina,
cervix and uterus looking for
lacerations and repair as needed.
Explore the uterine cavity for
retained placental fragments.

Postpartum Hemorrhage - Hemorrhage after Del Slide 14

EOC Module: Postpartum Hemorrhage - Session 2

Hemorrhage Immediately after

Delivery of The Placenta (cont.)
If there are retained placental
fragments, remove them manually
or with ring forceps, and if needed,
use curettage (suction curettage) or
a large blunt curette.
If there is a cervical tear, repair

Postpartum Hemorrhage - Hemorrhage after Del Slide 15

EOC Module: Postpartum Hemorrhage - Session 2

Hemorrhage Immediately after

Delivery of The Placenta (cont.)
If bleeding continues in spite of
the above management, perform
bimanual compression of the uterus
Perform an emergency Laparotomy
if the above measures failed or
there is uterine rupture

Postpartum Hemorrhage - Hemorrhage after Del Slide 16

EOC Module: Postpartum Hemorrhage - Session 2

Procedures at Laparotomy
Surgical compression suture (B-Lynch
suture) technique
Uterine packing (balloon tamponade)
Ligation of the uterine and utero-ovarian
arteries
Supravaginal hysterectomy

Postpartum Hemorrhage - Procedures at Lapar Slide 17

EOC Module: Postpartum Hemorrhage - Session 2

Secondary PPH
If bleeding is severe (as manifested by
the passage of blood clots, continuous
bleeding, tachycardia or hypotension)
start first aid management immediately
as previously mentioned.
Administer IV broad spectrum antibiotics
If the cervix is dilated, explore by hand
to remove large clots and placental
fragments.

Postpartum Hemorrhage - Secondary PPH Slide 18

EOC Module: Postpartum Hemorrhage - Session 2

Secondary PPH (cont.)

If the cervix is not dilated, evacuate the
uterus to remove placental fragments.
In rare cases, if bleeding continues, consider
performing a uterine and utero-ovarian artery
ligation or a hysterectomy.
Perform a histological investigation of the
products of the curetting or hysterectomy
specimen, if possible, to rule out a trophoblastic
tumor.

Postpartum Hemorrhage - Secondary PPH Slide 19

EOC Module: Postpartum Hemorrhage - Session 2

Secondary PPH (cont.)

If bleeding is mild, check the cervix:
If the cervix is open, perform curettage
and perform a histological investigation of
the products of the curetting.
If the cervix is closed give broad spectrum
antibiotics for one week and reassess the
condition.
If bleeding continues perform curettage
and perform a histological investigation of
the products of the curetting.

Postpartum Hemorrhage - Secondary PPH Slide 20

EOC Module: Postpartum Hemorrhage - Session 2

Monitoring during Stay in

Hospital
Check the patients blood pressure and
pulse every 30 minutes for the first two
hours, then hourly for six hours, and then
every four hours.
Perform gentle uterine massage every 30
minutes.
Check for vaginal bleeding every hour.
Check urine output every two hours.

Postpartum Hemorrhage - Monitoring Slide 21

EOC Module: Postpartum Hemorrhage - Session 2

Conditions That Should Be

Met before Discharge:
No active bleeding
No fever
Stable general condition (pulse 90 and
systolic Bp 90 mmHg)
Open bowel
Satisfactory urine output ( 30 cc/hour)
No wound complications ( C.S or
Episiotomy)
Postpartum Hemorrhage - Conditions Met befo Slide 22
EOC Module: Postpartum Hemorrhage - Session 2

Summary
At the end of this session each
participant is
able to:
1. Recognize the prophylactic measures to
decrease the incidence of postpartum
hemorrhage.
2. Provide first aid management for cases of
postpartum hemorrhage.
3. Manage cases of postpartum hemorrhage
before delivery of the placenta.

Postpartum Hemorrhage - Summary Slide 23

EOC Module: Postpartum Hemorrhage - Session 2

Summary (cont.)
4. Manage cases of postpartum
hemorrhage after delivery of the
placenta.
5. Manage cases of secondary
postpartum hemorrhage.
6. Monitor cases of postpartum
hemorrhage during their hospital stay.

Postpartum Hemorrhage - Summary Slide 24