The document outlines the management of postpartum hemorrhage (PPH). It discusses forming a multidisciplinary team and performing general resuscitative measures like fluid replacement, blood transfusion, and monitoring vital signs. It also describes evaluating for causes of PPH and various medical, mechanical, surgical, and radiological methods to control bleeding, such as uterine massage, uterine packing, sutures, and arterial embolization. The principles of evaluating and treating secondary PPH related to infection are also covered.

1. MANAGEMENT
OF PPH

2.  Multidisciplinary team consisting of obstetrician ,
anaesthetist, haemotologist, theatre staff and nursing staff
is ideal.
 The patients general condition is evaluated and if he/she
is in shock immediate resuscitative measures are
instituted.
 A hand on uterus will confirm atonicity and enable
uterine massage which should be done continuously.

3. PRINCIPLES OF MANAGEMENT
1. GENERAL MEASURES
* Resuscitative measures
* Investigations
* Monitoring
* Confirm the cause of PPH
2. MEDICAL METHODS
3. MECHANICAL METHODS
4. SURGICAL METHODS
5. RADIOLOGICAL ARTERIAL EMBOLISATION

4. GENERAL MEASURES
RESUSCITATIVE MEASURES
FLUID REPLACEMENT
 Two intravenous infusions with large 14 gauge cannulae
are started
 Aim is to replace 2-3 times the estimated blood lose
 Crystalloids (normal saline or Ringer lactate) infused at
the rate of 1L in 15-20 min
 Colloids can be given until blood is available (1-2L)
 Crossmatch blood should be given as rapidly as possible
 A central venous pressure line can be introduced

5. BLOOD COMPONENTTHEORY
 Correction of RBC deficit is guided by the rule that each
unit of packed cells will restore Hb concentration by
1gm/dl
 If there is evidence of coagulation defects fresh frozen
plasma, platelet concentrates, and cryoprecipitate are
made available

6.  For every 6 units of red cells , 4 units of fresh frozen
plasma can be given
 Each adult dose of cryoprecipitate will raise fibrinogen
level by 100mg/dl
 Each adult dose of platelet concentrates will raise the
platelet count by 20000/L

7. OTHER MEASURES
 Oxygen can be given by a mask or nasal cannula at rate
of 10-15L/min
 Patients leg may be elevated in order to increase venous
return
 If unconscious patient should be turned to one side to
minimise aspiration in case of vomiting
 Important to keep patient warm as hypothermia will
exacerbate poor peripheral circulation

8. INVESTIGATIONS
LABORATORYTESTS
 Hb, haematocrit, bloodgrouping and crossmatching must
be done
 Platelet count, fibrinogen assay, partial thromboplastin
time, prothrombin time should be measured .
 Electrolytes, urea and creatinine needed in severe
hemorrhage
 Bedside tests like clot observation test or clotting time
can be done

9. MONITORING
 Pulse and Blood pressure
 Heart rate by ECG monitor
 Oxygen saturation by pulse oximetry
 Central venous pressure line- to assess adequacy of fluid
replacement
 Hourly urine output
 Fluids and drugs given

10. CONFIRMATION OF DIAGNOSIS
 Genital tract injuries are looked for and if present,
sutured
 If placenta is not yet expelled signs of seperation are
looked for
 If there are retained placental fragments , they are
removed
 Succenturiate lobe should not be missed
 Coagulopathy is checked

11. MEDICAL METHODS
Oxytocin
20-40 units in 500ml of normal saline
Ergometrine
Ergometrine 0.25mg or methergin 0.2mg given
Prostaglandin derivatives
15 methyl analogue of prostodin- 250microgram given.

12. MECHANICAL METHODS
BIMANUAL COMPRESSION
 Abdominal hand massages the posterior aspect of uterus
and the vaginal hand made into a fist presses the anterior
uterine aspect through anterior fornix.
 Should be done continuously to promote uterine
contraction
 Aortic compression against sacral promontory to reduce
bleeding.

13.  Other mechanical methods include uterine packing and
balloon tamponade
BIMANUAL COMPRESSION

14. SURGICAL METHODS
 UNDER SEWING
 CHO’s MULTIPLE BLOCK SUTURES
 B LYNCH OR BRACE SUTURE
 MODIFIED B LYNCH (HAYMAN)
 SYSTEMIC PELVIC DEVASCULARISATION-
 HYSTERECTOMY

15. UNDERSEWING
 Undersewing the placental bed with figure of eight or
purse string sutures
 Done at caesarean section for placenta praevia
MULTIPLE BLOCK SUTURES
 Involve approximation of anterior and posterior uterine
walls with multiple squares until no space is left in uterine
cavity

16. MULTIPLE BLOCK
SUTURES

17. BRACE SUTURE
 Involves use of vertical brace sutures
 Very easy to perform
 Commonly performed at caesarean section but can also
be done after vaginal delivery.
MODIFIED B LYNCH(HAYMAN)
 Involves use of two vertical compression sutures placed
on either side of fundus
 Quicker than brace suture.
 Does not require a low transverse incision . Hence it is
useful following a vaginal delivery

18. BRACE SUTURE

19. SYSTEMIC PELVIC DEVASCULARISATION
 Involve laparotomy and progressive stepwise
devascularisation
 Uterine , ovarian and finally the internal iliac arteries are
ligated
 Absorbable sutures should be used always
 The ascending branch of uterine artery or the anterior
division of internal iliac artery are usually ligated.

20. UTERINE ARTERY LIGATION

21. HYSTERECTOMY
 Considered as a last resort
 Indications include severe atonic hemorrhage, placenta
accreta , placenta praevia and uterine rupture
 Subttotal hysterectomy may be easier and quicker but is
inadequate in cases where bleeding is in the lower
segment as in placenta praevia and adherent placenta
 Ovaries should be retained

22. RADIOLOGICAL ARTERIAL
EMBOLISATION
 The patient shoud be hemodynamically stable
 Under angiographic guidance and percutaneous
transcatheter technique , femoral artery catheterisation is
done
 Bleeding vessels are identified
 Embolisation carried out with gel foam or microspheres

23. Management of secondary PPH
 High vaginal swab should be taken for culture
 Broad spectrum antibiotics should be started
 If the ultrasound scan reveals retained products , uterus
should be evacuated
 The tissues obtained should be sent for culture and
histopathological studies
 If there is evidence of sepsis , evacuation should be
delayed by 12-24 hours to reduce risk of septicemia
 If bleeding is severe uterine artery ligation or
hysterectomy is done

24. THANKYOU