2. Major cause of death
PPH is still the largest cause of
maternal death, responsible for 24% in
1995 and 20.0% in 1996.
Over the last 6 report PPH account for
25% of all maternal death.
3. Postpartum Haemorrhage
50% associated with substandard care
3 main factors involved;
1. Home deliveries (46.7%)
2. Delay in resuscitating the mother
3. Delay in transportation to GH
4. National MMR by Ratio 1950-2000
220 PPH
200
180 HDP
160
No. of Deaths
140 Obst.
120 Embolism
100 Medical
80 Condition
60 Obst. Trauma
40
20
Puerperal
0 Sepsis
1991 - 1993 1994 - 1996 1997 - 1999 2000 - 2002 2003 - 2005 2006-2008
5. DEFINITION
1 PPH
BLOOD LOSS FROM THE GENITAL TRACT IN
EXCESS OF 500 ML IN THE FIRST 24 HOURS OF
DELIVERY
2 PPH
EXCESSIVE BLEEDING FROM THE GENITAL TRACT
AFTER THE FIRST 24 HOURS POST PARTUM UNTIL 6
WEEKS AFTER DELIVERY.
9. Postpartum Haemorrhage:
‘Risk Management’
‘At risk’ patients should deliver in hospital
Active management of 3rd stage
20 - 40 units oxytocin in 500mls of Hartman’s
soln. at 30 dpm
Closer post-natal observation for 2-3 hours
Cases of ragged membranes need at least 24
hours monitoring in hospital and given proper
counseling and appropriate antibiotics
10. CAUSES OF 1 PPH
A. UTERINE ATONY
B. RETAINED PLACENTA
C. TRAUMA
D. COAGULATION DEFECT
11. CAUSES OF 2 PPH
A. RETAINED POC
B. ENDOMETRITIS
C. PLACENTAL SITE TROPHOBLASTIC TUMOUR
12. ESTIMATION OF BLOOD LOSS
1 TAMPON FULLY SOAKED – 30 ML
1 SANITARY PAD FULLY SOAKED – 120 ML
1 SARONG FULLY SOAKED – 500 ML
13. Blood loss,ml Up to 750 750-1500 1500-2000 2000 or more
(Blood loss, %BV) (Up to 15%) (15-30%) (30-40%) (40% or
more)
Pulse rate <100 >100 >120 >140
Blood pressure Normal Normal Decreased Decreased
Respiratory rate 14-20 20-30 30-40 >35
Urine output (ml/hr) >30 20-30 5-15 Negative
Slightly Lethargic, Confusion,
CNS-mental status anxious Mildly confusion lethargy,
anxious coma
Anorexia Anorexia, Ileus
Gastrointestinal vomiting
Fluid replacement Crystalloid Crystalloid Crystalloid Crystalloid
(3:1 rule) + blood + blood
14. MANAGEMENT
I. RECOGNISE PPH
II. CALL FOR HELP(CODE BLUE)
O & G SPECIALIST
ANAESTHETIST
SISTER ON CALL
BLOOD BANK/HAEMATOLOGIST
III. RESUSCITATION !
IV. IDENTIFY AND TREAT SPECIFIC CAUSE
16. RESUSCITATION
TAKE 20 ML OF BLOOD FOR
GXM 4 UNITS PC
FBC
COAGULATION SCREENING
ELECTROLYTES
17. RESUSCITATION
INFUSE FLUIDS (COLLOID/CRYSTALLOID)
MAINTAIN CIRCULATORY VOLUME WHILE
WAITING FOR BLOOD
IN DIRE STATES, USE GROUP SPECIFIC
BLOOD OR UNMATCHED O RH –VE BLOOD
25. RETAINED PLACENTA
RESUSCITATION!
DO NOT CONTINUE WITH CCT WITH SUCH
PATIENT
OXYTOCIN SHOULD BE GIVEN
MRP IN OT UNDER GA WITH ANAESTHETIC
BACK UP FOR RESUSCITATION
LOOK FOR GENITAL TRACT TRAUMA
START OXYTOCIN INFUSION AFTER MRP
ANTIBIOTICS
27. MORBIDLY ADHERENT
PLACENTA
IN CASES OF ACCRETA, IF NO BLEEDING, MAY
TREAT CONSERVATIVELY WITH MEDICATION
OTHERWISE, REQUIRE LAPAROTOMY
HYSTERECTOMY
28. GENITAL TRACT INJURY
INJURY TO
EPISIOTOMY
VAGINA
CERVIX
UTERUS
EXTENSION TO BROAD LIGAMENTS
29. GENITAL TRACT INJURY
RISK FACTORS
INSTRUMENTAL DELIVERY
BIG BABY
SHOULDER DYSTOCIA
PRECIPITATE LABOUR
30. GENITAL TRACT INJURY
EXAMINATION – BEST UNDER ANAESTHESIA IN
OT
‘WALK THE CERVIX’
HIGH INDEX OF SUSPICION OF EXTENSION TO
BROAD LIGAMENTS AND UTERUS IF
LACERATION INVOLVING CERVIX AND
FORNICES
ANTIBIOTICS
31. GENITAL TRACT INJURY
- UTERINE RUPTURE
HIGH INDEX OF SUSPICION
PREVIOUS SCAR
DIFFICULT DELIVERY (INTERNAL PODALIC VERSION)
GRANDMULTIPARA
OBSTRUCTED LABOUR
32. GENITAL TRACT INJURY
- UTERINE RUPTURE
WHAT ARE THE SIGNS?
CTG CHANGES
MATERNAL TACHYCARDIA
PER VAGINAL BLEEDING
SCAR TENDERNESS
DECREASE UTERINE CONTRACTION
HAEMATURIA
34. SECONDARY PPH
USUALLY PRESENTS IN THE 2ND AND 3RD WEEK POST
PARTUM
HVS FOR CULTURE
START ANTIBIOTICS
IF DIAGNOSIS OF RETAINED POC, FOR EXPERIENCED
PERSONNEL TO PERFORM EVACUATION – HIGH RISK
OF PERFORATION
DIFFICULT TO DIFFERENTIATE POC AND BLOOD
CLOT BY US IN 1ST 2 WEEKS POSTPARTUM
35. MONITORING
ICU/ HDU MONITORING
VITAL SIGN MONITORING EVERY 15 MINUTES
- BP, PR, RR, SA O2, CVP
FLUID RESUSCITATION DOCUMENTED
URINE OUTPUT
ON GOING HAEMORRHAGE NOTED
DRAIN, PAD
RESULTS TRACED STAT
INFORM PATIENT AND RELATIVES
36. Case illustration
A 35 year old Malay lady in her 4th pregnancy, had
a history of PPH in her previous pregnancies. She
was diagnosed to have pre eclampsia during this
pregnancy and was on oral antihypertensive
medication. At 38 weeks of gestation she was
admitted to a private facility and was induced with
prostaglandins.
37. The labour was uneventful and she delivered a 3.9kg
baby. There was massive bleeding after her delivery.
Exploration did not reveal any retained products.
The uterus remained atonic despite repeated
injections of ergometrine and an oxytocin infusion.
No blood or blood products were available.
38. She was transferred to a general hospital for further
resuscitation but arrived in a moribund state and
succumbed soon after.
39. Case illustration
A 30 year Malay lady in her third pregnancy at 38
weeks of gestation came in labour at a district
hospital. Her antenatal period had been uneventful.
She delivered vaginally at 7.02pm. Active
management of 3rd stage instituted and the placenta
was delivered via CCT. Her delivery was conducted
by a staff nurse.
40. After the placenta was delivered it was noted that
there was active bleeding from the vagina. A green
branula was inserted and the on-call doctor was
informed. Over the phone the doctor ordered for
uterine massage to be done, to give patient iv
ergometrine 0.5mg and iv Pitocin 40 unit in
500mls NS started while awaiting for him to come.
41. On examination, the patient was alert, the blood
pressure was normal but the pulse rate was 96b/min.
Abdominal examination done showed that the uterus
was contracted.Despite that the patient was still
actively bleeding. Another iv line was inserted and
blood was sent for FBC, GXM and PT/PTT. She was
given NS running fast.
42. Another doctor was called to help manage the patient.
Further examination showed a cervical laceration which the
doctor tried to repair but failed. The patient continued to
bleed, so vaginal packing was done and she was planned for
transferred to the general hospital.The placenta was also
re-examine for it’s completeness. By this time, the patient’s
blood loss was about 1 L. the patient was conscious but
lethargic, her BP was 90/60mmHg and PR was 110b/min.
43. While awaiting for arrangements for transfer to the referral
center to be made, another 2 iv lines inserted and she was
rapidly infused with NS and later transfused with blood. A
Foley’s catheter was inserted to monitor urine output and
her vital signs was monitored every 15 minutes.
44. She arrived at the general hospital at 10.20pm
accompanied by a doctor and 2 staff. Upon arrival
the estimated blood loss was about 2L and she had
4 iv lines (all green). 2 unit of blood has already
been transfused plus the crystalloids and the 3rd
and 4th unit of blood transfusion was still in
progress.
45. Examination upon arrival showed very pale patient,
drowsy but still responding to call, the BP was
80/40mmHg and the PR was 130b/min. The uterus
was contracted and she was still actively bleeding
from the vagina.
46. EUA was done and the cervical laceration was
sutured. Despite that patient continued to bleed. A
laparotomy was done and it showed that there was
another cervical laceration which extended up to the
lower segment of the uterus. As it was not able to be
repaired, a hysterectomy was performed.
47. Post operatively she was managed for 2 days in ICU.
The estimated blood loss through out was 5.4L and
she was transfused a total of 21 unit of blood and 4
cycles of DIVC regime. She was discharged well on
day 6 post delivery.
