3. Definition
WHO defines PPH as blood loss of more than 500
ml following vaginal delivery or more than 1000 ml
after caesarean section. In Asian women even loss
of 300 ml can have sinister effect due to smaller
built, lesser blood volume, lower Hb & poor
nutrition. However, various authors suggest that
PPH should be diagnosed with any amount of
blood loss that threatens the hemodynamic
stability of the woman.
4.
5. Causes of Maternal Death
Haemorrhage
24.8%
Infection
14.9%
Haemorrhage
Indirect
is the biggest
causes
and fastest
19.8%
killer
Eclampsia
12.9%
Other direct
causes Obstructed labour
Unsafe
7.9% 6.9%
abortion
12.9%
6. Postpartum Hemorrhage
PPH is a serious, Life-threatening obstetric problem.
One of the leading causes of maternal morbidity and
mortality.
In developing countries mainly due to three delays: -
1. Delay in seeking care.
2. Delay in reaching care.
3. Delay in receiving care.
7. Maternal Mortality following PPH
WHO estimated
5,29,000 maternal death / year in world
1,36,000 maternal death/ year in India i.e.
30%
29.6% maternal deaths due of PPH.
In India, about 15.15% - 25.8% mothers die
due to PPH.
8. Additional burden of PPH
• > 50% of births in India take place at
home without the help of trained/
qualified Birth attendant .
• 83% of rural deliveries occur at home
• 80% of women are anaemic
9. Incidence of PPH
• 11% women with live birth i.e. 14 million
women / year
• 3.9% in vaginal deliveries
• 6.4% in Cesarean section .
• Higher with high risk factor
• 10% overall.
• Mismanagement of III stage results in
higher incidence of PPH
10. The Four Ts Mnemonic – Causes of PPH
Four Ts Causes Incidence (%)
1st Tone Atonic uterus 70
2nd Lacerations, hematomas, 20
Trauma inversion, rupture
3rd Tissue Retained tissue, 10
Invasive placenta
4th Coagulopathies 1
Thrombin
Am Fam Physician 2007;75:875-82.
13. Prevention of PPH ???
It can be achieved
by
Active management
of
3 rd stage of labour
14. Active Management – Why?
30
20
Percent
10
0
Transfusion Prolonged 3rd Therapeutic Low Retained
Stage Uterotonic Hemoglobin Placenta
Active Management Physiological Management McMormick, Sanghvi,
Kinzie, McIntosh,
IJGO2003
1. Reduces length of time of 3rd stage
2. Reduces amount of blood loss
3. Reduces need for blood transfusions
15. Prevention
Universalization of Spancer’s
Modification of Brand- Andrew’s
technique of placental delivery e.g.
prophylactic injection of uterotonics at
the time of delivery of anterior shoulder
followed by traction and counter
traction maneuver for placental
delivery.
Prompt recognition and aggressive
management according to the cause of
PPH.
16. Prevention (contd)
Shout for help
1. Blood bank , relative, donors, blood and
blood components.
2. Anesthetist
3. Prepare Operation Theater.
4. Immediate Communication with nearest/
dependent Tertiary center,
5. Quick transportation to Tertiary Centre
(summon obstetrical flying squad /108
Ambulance)
18. “No matter where a woman delivers, giving birth
should be a moment of joy, not a sentence to
death”
19. “While managing PPH
Time lapsed should not
be counted in a minute-
--one has not lost one
minute ,but 60 seconds”
Ian Donald
20. “No amount of Blood from any
blood bank is safer and better
than Her own blood.”
Hence be prompt in
saving each second and every
drop of blood of bleeding woman
in her 3rd stage of labour,
23. Treatment Protocol Of Primary Atonic PPH
(1st T)
Management Management of
of Shock Uterine atonicity
Replacement of blood * Conservative medical or its
component management
* Surgical management
- Conservative surgery
- Radical surgery
24. Stepwise Management of Atonic PPH
Step I - Bleeding continues
- 15 methyl PGF2 250g every 15-30 mint.
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
25. Conservative Surgical Management
Mode of Actions:
Controls PPH
Preserves reproductive functions
Avoids hysterectomy and related
complications and consequences
31. Balloon Tamponade
Two-way catheter - temporary
control of PPH
Feasible in a scenario of atonic
PPH following a vaginal delivery,
unresponsive to medical
management & before
interventional radiological
procedures or surgical
interventions
Simple, cheap, easy to use &
effective measure
32. Procedure
Balloon portion is placed directly into uterus [entire balloon
(500ml capacity) has to be inserted past the cervical canal &
internal os].
Gentle traction on balloon shaft ensures proper contact
between balloon & tissue surface & enhances tamponade
effect
Success is judged by a declining loss of blood from cervix &
that seen through drainage port
Mean time for leaving the tamponade balloon - 8 to 48 hours
Gradual deflation of the balloon is advised to reduce the
potential risk of further bleeding
33. Step-Wise Devascularisation Of The Uterus
1st reported from Egypt
Effective in controlling PPH in 80% of cases
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
34.
35. Ovarian Artery Ligation
Ovarian artery directly arises from the aorta
Anastomosis with the uterine artery in the region of
the uterine aspect of the utero-ovarian ligament
36. Uterine Artery Ligation
90% blood supply of uterus in pregnancy
is from uterine vessels
Ligation of uterine arteries result into
significant reduction in blood flow to the
uterus
39. Vaginal Route for
Uterine Artery Ligation
Indicated in
atonic PPH
following
vaginal
delivery
40. B-Lynch Suture
Exerts continuous vertical compression on uterine
vascular system
Before proceeding to place the suture into uterus,
potential efficacy of B-Lynch suture should be tested for
by performing open bimanual compression to see if
bleeding stops
The assistant performs compression & maintains it with
2 hands during the placement of the suture by the
surgeon
Monocryl suture or Vicryl number 2 should be used
48. Cho Multiple Square
Compression Sutures
Multiple square sutures
are used to cover the
whole body of uterus using
a straight 10-cm needle
May be useful in placenta
previa
52. Internal Iliac Artery Ligation
Conditions indicating ligation –
Atonic uterus refractory to
other measures
Abruptio placentae with uterine
atony
Abdominal pregnancy with
pelvic implantation of the
placenta & placenta accreta
53. Internal Iliac Artery Ligation
T Therapeutic indications
Before or after hysterectomy for PPH
Continuous bleeding from the broad ligament base;
profuse bleeding from pelvic side-wall or vaginal angle
Diffuse bleeding without , clearly identifiable vascular
bed
Ruptured uterus in which uterine artery may be torn at
its origin from internal iliac artery
Where extensive lacerations of cervix have occurred
following difficult instrumental delivery
56. Uterine Artery Embolization
Highly feasible, safe & beneficial procedure,
possibly precluding further laparotomy &
hysterectomy
If successful, not only saves the patient’s life,
but also preserves the functions of uterus
,tubes and ovaries.
Should be the procedure of choice for PPH
prior to surgical intervention
59. Hysterectomy
Best immediate option
When uterine atony is unresponsive to uterotonics
Where facilities for embolization are not available
Obstetrician not well versed with technical aspects of
conservative surgical procedures or iliac artery ligation
Indications
Uterine rupture secondary to obstructed labor
Previous Caesarean section
If rupture is extensive & hemorrhage cannot be contained by
suture of ruptured area
60. PPH in CASE of ABRUPTIO PLACENTA ( Covouliare Uterus)
61. 2nd T Surgical Treatment of
Traumatic PPH
Causes
1.CervicalTear-Lateral, annular, bucket handle type
detachment.
2. Vaginal Tear - Circular / Vertical, colporrhaxis.
3. Extended Episiotomy — upwards towards
posterior fornix, downwards involving anus
and rectum.
4. Vulval Hematoma .
5. Perineal lacerations.
6. Para Urethral tear , clitoral tear.
7. Uterine Rupture – complete / incomplete
8. Broad Ligament hematoma
62.
63. Cervical Tear Repair
Recognition - unilateral / bilateral
Stitching under good light,
68. 3rd T - TISSUE FACTOR
Retained Placenta
1. With Active Bleeding---MRP
- Partially Separated.-----MRP
- Retained Cotyledons.----Uterine Exploration and E&C
- Retained piece of Membranes.—Uterine Exploration and
E&C
2. With No Bleeding.
- Active Retention ( Hour Glass Contraction)-G.A., Placental
Delivery.
- Placenta Accreta
- Placenta Inccreta
-Placenta Perccreta.
Acute inversion of Uterus--Protocol
69. Retention of Placenta
Retention of Retention of
Detached Placenta Adherent Placenta
Uterine Hour glass contraction Simple Adhesion Morbid Adhesion
Inertia ( constriction ring ) Placenta Accreta
Placenta Inccreta
Placenta Perccreta
70. Morbid Adherent Placenta
Placenta Accreta Rare occurs in 1: 500 to
1: 700 deliveries. Placenta adhers to uterine
wall because the Decidua and the Nitabuch
layer , the physiological cleavage in decidua is
lacking or incomplete.
Inccreta placenta penetrates the uterine
myometrium to variable3 depth.
Perccreta Very rare occurring in1 : 6,000 to
1: 40,000 deliveries. Placenta perforates the
entire thickness of uterine wall and serosa
even., -- entire placenta or part of it maybe
morbidly adherent.
76. Rx of Morbid Adherent Placenta
Once the diagnosis is made , counseling the woman
and her relatives regarding possible need of Hystere
ctomy will avoid psychological and medicolegal
problems.
Medical Management Umbilical cord is cut close
to placenta and left in situ. A course of 6 doses of
Methotrexate is given orally or parenterly in a dose
of 50 mg Methotrexate and 6mg Folinic acid on
alternate days.
Follow up with USG and Beta HCG estimation
weekly indicates the need for further courses of the
medicine.
Woman can have normal Delivery in future.
77. Inversion Of Uterus
“Turning inside out of the uterus”
Acute Inversion is extremely rare ---In India its incidence
is reported ----1: 23,0000 deliveries.
Management
1. Resuscitation measures must be promptly instituted ,
Blood transfusion , I.V.fluids and sedation given.
2.Immediate manual reposition in labour room under
sedation ( 2- 4.gm MgSo4 in 10ml iv or Terbutalin o.25
in5ml saline iv.)without administration of utero -tonics .
3.O “ Sullivan ‘s technique of intra vaginal hydrostatic
pressure.
4. Surgical Technique---usually required in chronic
case3s.