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Obstetrical Hemorrhage

R.C. Jordias, MD
(ung nakahighlight ung nasa lecture)  Bleeding of atleast 500 cc after the 3rd stage of labor
o 1st stage of labor – from regular uterine contraction to full
“triad” of causes of maternal deaths: cervical dilatation (10cm)
 Obstetrical hemorrhage o 2nd stage of labor – from full cervical dilatation to expulsion of
 hypertension fetus
 infections o 3rd stage of labor – from delivery of fetus to deliver of placenta
(accounts the majority of postpartum hemorrhages)
 Any form of bleeding is considered to be dangerous o 4th stage of labor - 1-2hrs after the deliver of placenta
 leading reason for admission of pregnant women to intensive care units  Postpartum Hemorrhages
 hemorrhage is the single most important cause of maternal death o Early or Primary
worldwide  Anything that occurs within 24 hrs after the delivery of
 responsible for half of all postpartum deaths in developing countries placenta, or 2 hrs after the delivery of the product of
Different Causes Of Bleeding: o Late or Secondary
 Antepartum  After 24hrs of the delivery of the placenta even up to 1
o 1st trimester week after the delivery.
 Abortion – M/C
 Expulsion of products of conception before Obstetrical Hemorrhage: Causes, Predisposing Factors, and Vulnerable
reaching 20 weeks AOG Patients
o 2nd trimester and early 3rd trimester
 Abruption placenta
 Premature separation of a normally implanted
 Placenta previa
 Premature separation of an abnormally implanted
 Postpartum
o Leading cause of maternal mortality aside from hypertensive
disorders of pregnancy and infection

Classification: Timing of Hemorrhage

Antepartem Hemorrhage Placenta previa
Placental abruption
Postpartum Uterine atony
Hemorrhage Genital tract laceration
Uterine inversion
Puerperal hematomas
Rupture of the uterus
Placenta accrete syndromes
Rupture of scarred uterus
Hemorrhage retained placental

Incidence and predisposing condition:

Older studies:
 incidence of postpartum hemorrhage was cited to be 3.9 percent in Postpartum Hemorrhage and Blood Loss Estimation
women delivered vaginally and 6 to 8 percent in those undergoing  Postpartum hemorrhagedescribes an event rather than a diagnosis
cesarean delivery  When encountered, its etiology must be determined.
 from year 2000, 529,000 died because of bleeding  Diagnosis is usually reserved for pregnancy that has progressed beyond
 highest incidence is seen in ASIA and AFRICA 20 weeks AOG (before 20 weeks is called abortion)
 in developed countries, incidence is only 2,500/100,000 live births.  Ability to cope with blood loss depends
 Serious hemorrhage may occur at any time throughout pregnancy and o Previous health
the puerperium.  Give supplemental iron (ferrous sulfate and fumarate) to
 Causes of maternal death increase Hgb conc. of mother
o Hemorrhages – 25% o The presence or absence of anemia
o Infection o The presence or absence of volume contraction d/t hydration or
o Hypertension/eclampsia preeclampsia
o Abortion – 30%  Common causes:
o Vascular embolus o Bleeding from the placental implantation site
o Obstructed labor (dysfunctional labor/dystocia) – 8% o Trauma to the genital tract and adjacent structures
 Postpartum Hemorrhage is usually obvious, except:
o Unrecognized intrauterine and intravaginal blood accumulation
o Uterine rupture with intraperitoneal bleeding
 Initial assessment should attempt to differentiate uterine atony from
genital tract lacerations.
o Atony is identified by a boggy, soft uterus during bimanual
examination and by expression of clots and hemorrhage during
uterine massage.

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 Hemorrhage from laceration Persistent bleeding despite a firm, well-
contracted uterus  Thus, if blood loss is less than the amount added by pregnancy, the
 Bright red blood arterial bleeding hematocrit stays the same acutely and during the first several days. It
 To confirm that lacerations are a source of bleeding, careful inspection eventually increases as normal plasma volume shrinks postpartum.
of the vagina, cervix, and uterus is essential.  Any time the postpartum hematocrit is lower than one obtained on
 If with persistent supracervical bleedingmanual exploration of the admission for delivery, blood loss can be estimatedas the sum of the
uterus is done to exclude a uterine tear. It is also completed routinely calculated pregnancy hypervolemia plus 500mL for each 3 volumes
after internal podalic version and breech extraction. percent drop in the hematocrit.

 Methods In Estimating Excessive Blood Loss

o Measuring loss directly
o Using a predetermined decline in hematocrit or hemoglobin
o Counting the number of women transfused
 6% volume decrease in the postpartum hematocrit to define clinically
significant blood loss with vaginal delivery. This decrease easily
signifies >1000-mL blood loss in the averaged-sized women.
 A final marker used to estimate the hemorrhage incidence is the
transfusion rate.
 Thus, it is apparent that significant blood loss accompanies about a
fourth (40%) of vaginal deliveries.

Late Postpartum Hemorrhage

 Bleeding after the first 24hours

Special Consideration
 Woman with blood volume expansion is less than expected.
o Small women with normal pregnancy-induced hypervolemia.
(most common)
o Severe preeclampsia or eclampsia - because they frequently do
not have a normally expanded blood volume. Only 10% mean
increase in blood volume
o Women with chronic renal insufficiency
*When excessive hemorrhage is suspected inthese high-risk women,
crystalloid and blood are promptly administered for suspectedhypovolemia.
 Treacherous feature of postpartum hemorrhage is the failure of the
pulse and blood pressure to undergo more than moderate alterations Hemostasis at the Placental Site
until large amounts of blood have been lost.  Prevents blood loss during deliveries
 Normotensive woman initially become hypertensive from  Near term, it is estimated that at least 600 mL/min of blood flows
catecholamine release in response to hemorrhage through the intervillous space
 Women with preeclampsia become “normotensive” despite  This flow is carried by the spiral arteries—which average 120 in
remarkable hypovolemia. number—andtheir accompanying veins.
 Traditionally postpartum hemorrhage defined as loss of 500 mL of  With separation of the placenta, these vessels are avulsed
blood or more after completion of the third stage of labor.  Hemostasis at the placental implantation site is achieved first by
o Blood loss: (if exceeds the number then problematic) contraction and retraction of the myometrium that compresses this
 Normal spontaneous delivery – 500mL formidable number of relativelylarge vessels (occurs after delivery of
 1000ml in CS placenta)
 1500ml in CS with hysterectomy (elective) o Before the completion of the delivery of the placenta, the uterus
 3000-4000ml for emergency CS with hysterectomy needs must be well contracting and periods of relaxation.
 But, approximately 5 percent of women delivering vaginally lost more  Followed by subsequent clotting and obliteration of their lumens.
than 1000 mL of blood.  Thus, adhered pieces of placenta or large blood clots prevent
 Estimated blood loss is commonly only approximately half the effective myometrial contraction (like in cases of uterine atony)
actual loss. impair hemostasis at the implantation site.
 However, the blood volume of a pregnant woman with normal  Hypotonic uterus may cause fetal hemorrhages and blood
pregnancy-induced hypervolemia usually increases by 50%, but coagulation mechanisms are impaired. Thus take note the
increases range of 30 to 60%, amounts to 1500 to 2000 mL for an consistency of the uterus after the delivery of the products of
average-sized woman. (during pregnancy there is an increase in plasma conception.
volume)  Importantly, an intact coagulation system is not necessary for
 Equation to calculate maternal blood volume: postpartum hemostasis unless there are lacerations in the uterus, birth
canal, or perineum

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o With persistent bleeding
 Weakness
 Dizziness
 Palpitations
 Tachycardia
 Pallor
 Oliguria
 And other signs of hypovolemia
 Exact measurement of blood loss may not be possible b/c it may be on
the pail/basin mixed with amniotic fluid or urine, in her beddings or
splattered on the floor.
 Separation and delivery of the placenta by cord traction, especially
when the uterus is atonicuterine inversion
 Bleeding during the third stagemassage
 Uterine atony management
o Bimanual uterine compression (at LOWER UTERINE
SEGMENT where lower uterine artery is located wherein it
Postpartum Hemorrhage originates from the iliac artery)
1. UTERINE ATONY o Get help
 Failure of the uterus to contract effectively after the delivery of the o Begin blood transfusion
placenta causing significant bleeding o Manual exploration of uterine cavity
 The uterus is normally stony hard after the delivery of the products of o Thorough inspection of cervix and vagina (presence of
conception. If it is not hard then you might be dealing with uterine lacerations)
atony. o Second IV route so blood and oxytocin can be given at the same
 Prevalence time (large bore IV catheter)
o WHO – about 13,000 bleed to death per year while giving birth o Insert foley catheter to assess urine output
about 80% of these is due to uterine atony o Surgical: Internal Iliac Artery Ligation
o POGS (2002-2006) - 2 to 3 cases per 1000 deliveries  Reduces hemorrhage, 85% reduction in pulse pressure in
 Most frequent cause of obstetrical hemorrhage those arteries distal to the ligation
 Mechanism of placental separation:  BS of uterus: 80% comes from Uterine Arteries while 10-
o Duncan mechanism Blood from the implantation site escape 20% comes from ovarian arteries located above the
into the vagina immediately uterine arteries
o Schultze mechanismremains concealed behind the placenta  Technically difficult and is successful in less than half of
and membranes until the placenta is delivered the patients
 Causes  Bilateral ligation doesn’t interfere sith subsequent
o Excessively halogenated anesthetics are employed reproduction
o Overdistention of uterus is present o Surgical: Uterine Compression Sutures (B-Lynch)
 Multiple pregnancy  Giving the appearance of suspenders to compress together
 Large baby the anterior and posterior walls
 Polyhydramnios  Use absorbable kind of suture
o Remarkably vigorous or barely effective uterine contractions
o In oxytocin induced or augmented labor Third-Stage Bleeding
 Use PG for induction  Manual placental removalindicated if with significant bleeding
 Oxytocin for augmentation persists after delivery of the infant and while the placenta remains
o High parity partially or totally attached
 If >7 parity o Placenta is peeled off by a motion similar to that used in
o Chorioamnionitis separating the pages of a book.
o History of atony in a previous pregnancy
 Palpate the fundus to determine of uterus is well-contracted Bleeding with Prolonged Third Stage
 Vigorous massage if not  Prolonged third stage of labor more than 30mins
 Oxytocin infusion maybe given (not bolus) – active management (2
ways of management: active and expectant management) Management after Placental Delivery
 Potent drugs that can cause contraction of uterus  Fundus should always be palpated following delivery to confirm that
o Methylergonovine (IM/IV) the uterus is well contracted.
o PG F2a  If not firm do vigorous fundal massage
 4 signs of placental separation:  20 U of oxytocin in 1000 mL of lactated Ringer or normal saline infuse
o Round and globular uterus by 10 mL/min—200 mU of oxytocin per minute
o Sudden gosh of blood o Simultaneously effective uterine massage
o Uterus rises upto abdomen  Oxytocin should never be given as an undiluted bolus doseserious
o Lengthening of the cord hypotension or cardiac arrhythmias
 Risk factors
o Overdistended uterus Risk Factors
o Prolonged Labor  Primiparity
o Very rapid Labor (precipitate labor) – 5-10cm/hr  High parity
o Placenta previa  Overdistended uterus
o Myoma o Prone to hypotonia after delivery, and thus women with a large
o Induced or augmented labor fetus, multiple fetuses, or hydramnios are at greater risk.
o Chorioamnionitis  Labor abnormalities
o Halogenated Anesthetics  Labor induction or augmentation
 Clinical Manifestations  Prior postpartum hemorrhage
o Heavy or moderate vaginal bleeding that persists after the
delivery of placenta
o Uterus is soft, boggy, distended and lacks tone
o Uterus has repeated periods of contractions and relaxations
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Evaluation and Management 2. Immediately mobilize the emergent-care obstetrical team to the
 Immediate postpartum hemorrhage inspect to exclude birth canal delivery room and call for whole blood or packed red cells.
laceration. 3. Request urgent help from the anesthesia team.
 Inspect also for retained placental fragments 4. Secure at least two large-bore intravenous catheters so that
 If with defect  manual exploration of the uterus crystalloid with oxytocin is continued simultaneously with blood
 During examination for laceration and causes of atony uterus should products. Insert an indwelling Foley catheter for continuous
be massage and uterotonic agents are administered urine output monitoring.
5. Begin volume resuscitation with rapid intravenous infusion of
Uterotonic Agents (read) crystalloid
 Oxytocin 6. With sedation, analgesia, or anesthesia established and now with
 Ergot derivatives optimal exposure, once again manually explore the uterine cavity
o Used for second line treatment for retained placental fragments and for uterine abnormalities,
o Methylergonovine (methergine) including lacerations or rupture.
o Ergonovine 7. Thoroughly inspect the cervix and vagina again for lacerations
o Given parenterally it rapidly stimulate tetanic uterine that may have escaped attention.
contractions and act for approximately 45 minutes 8. If the woman is still unstable or if there is persistent hemorrhage,
o Caveat in using ergot agent then blood transfusions are given
 May cause dangerous hypertension
Uterine Packing or Balloon Tamponade (read)
 E- and F-series prostaglandins
 15-methyl derivative of prostaglandinf2α.  Foley catheter
 Approved more than 25 years ago for uterine atony o Tip of a 24F Foley catheter with a 30-ml balloon is guided into
treatment the uterine cavity and filled with 60 to 80 ml of saline.
 Dose250 μg (0.25 mg) IM o Open tip permits continuous drainage of blood from the uterus.
 Can be repeated if necessary at 15- to 90-minute intervals o If bleeding subsides, typically removed after 12 to 24 hours.
maximum of 8 doses o Also used for tamponadeSegstaken-Blakemore and Rusch
 Side effects (in descending order) balloons and condom catheters
 Diarrhea  Packed directly with gauze
 Hypertension  Bakri postpartum Balloon or BTCath
 Vomiting o Specially constructed intrauterine balloons
 Fever o Inserted and inflated to tamponade the endometrial cavity and
 Flushing stop bleeding
 Tachycardia o Need 2-3 members
 Also can cause: pulmonary airway and vascular  First memberwill do sonography during procedure
constriction  Second memberwill deflate the balloon and stabilize it
*should not be used for asthmatics and those with suspected amnionic-fluid  Third memberwill instill 150ml of fluid to inflate the
embolism balloon
o DINOPROSTONE  Failures will require surgical methods (including
o ProstaglandinE2 hysterectomy)
o given as a 20-mg suppository per rectum or per vagina every 2
hours Adjunctive Surgical Procedures
o typically causesdiarrhea if given per rectal UTERINE ARTERY LIGATION
o SULPROSTONE  Either unilateral or bilateral is used primarily for lacerations at the
o Intravenous prostaglandin E2 lateral part of a hysterotomy incision
o MISOPROSTOL(Cytotec)  Less helpful lfor hemorrhage from uterine atony.
o synthetic prostaglandin E1 analogue
o evaluated for both prevention and treatment of atony and UTERINE COMPRESSION SUTURES
postpartum hemorrhage  B-Lynch technique or braces
o Procedure involve splacement of a No. 2-chromic suture to
Bleeding Unresponsive to Uterotonic Agents compress the anterior and posterior uterine walls together.
 Causeunrecognized genital tract laceration (uterine rupture)  Complication:
 If bleeding persists after initial measures for atony have been o Uterine ischemic necrosis with peritonitis (MC)
implemented, then the following management steps are performed o Defects in the uterine wall
immediately and simultaneously: o Uterine cavity synechiae
1. Begin bimanual uterine compression.
 Posterior uterine wall is massaged by one hand on the INTERNAL ILIAC ARTERY LIGATION
abdomen, while the other hand is made into a fist and  Ligation of one or both internal iliac arteries has to reduce hemorrhage
placed into the vagina. This fist kneads the anterior from pelvic vessels
uterine wall through the anterior vaginal wall.  Drawbacks technically difficult
 not particularly helpful to abate hemorrhage with postpartum atony
 most important mechanism of action 85% reduction in pulse pressure
in arteries distal to the ligation
 converts an arterial pressure system into one with pressures
approaching those in the venous circulation.
 creates vessels more amenable to hemostasis via pressure and clot
 Does not interfere subsequent reproduction(even in bilateral)

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ANGIOGRAPHIC EMBOLIZATION o Cord traction applied before placental separation
 Used for many causes of intractable hemorrhage when surgical access o Accrete syndromes (placenta accreta)
is difficult
 90% effective Ayon naman sa powerpoint ni doc:
 Can be used to arrest refractory postpartum hemorrhage, but, less  Fundal pressure
effective with placenta percreta or with concurrent coagulopathy  Relaxed uterus, lower segment and cervix (check ung difference nya sa
 ACOG describes its efficacy as “unclear.” uterine atony)
 Also used for renal hemorrhage  Tough cord that does not readily break away from the placenta
 Complications (uncommon but can be severe):  Placenta accreta
o Uterine ischemic necrosis  Complete inversion is d/t strong traction on the umbilical cord
o Uterine infection attached to a placenta implanted in the fundus
o Massive buttock necrosis and paraplegia  Classifications:
o Complete inversion – corpus passes through the cervix
PREOPERATIVE PELVIC ARTERIAL CATHETER PLACEMENT o Incomplete inversion - corpus does not pass through the cervix
 balloon-tipped catheters inserted into the iliac or uterine arteries o Prolapsed – corpus extends through the vaginal intro itus(1st
preoperatively. structure to come out of vagina:normally is cervix but in
 Used commonlyaccrete syndromes prolapsed inversion the 1st structure to come out is fundus, body
 Adverse effects uncommon, but postoperative iliac and popliteal then cervix)
artery thrombosis and stenosis have been reported  Clinical Course:
o Most often there is immediate life-threatening hemmorhage and
PELVIC UMBRELLA PACK is fatal w/o prompt treatment
 umbrella or parachute pack  used to arrest intractable pelvic o Shock tends to disproportionate to blood loss
hemorrhage following hysterectomy  Manifestations
 pack is constructed of a sterile x-ray cassette bag that is filled with o Acute abdominal pain with sudden profuse hemorrhage followed
gauze rolls knotted together to provide enough volume to fill the pelvis by shock
 removed vaginally after 24 hours.  Diagnosis
 Recommended as “last-ditch” attempt when exsanguination is o Fleshy mass protruding out of the cervix or vagina
inevitable, especially in “low-resource” areas. o Abdominal palpation of crater-like depression
 Transfer patient to hospital immediately
Signs of placental separation (expectant management or passive management  Do not attempt to repose the uterus w/o anethesia b/c this may result in
– means that we have to wait for the placenta to go down passively without neurogenic shock
introducing any drugs. In this management, oxytocin is given only after the  Treatment
placenta has been delivered.) o Immediate assistance including anesthesiologist
 Uterus contracts (uterus becomes globular and rounded) – 1st sign o Freshly inverted uterus with placenta already separated maybe
 Sudden gush of blood – 2nd sign replaced by pushing up on the fundus with the palm and fingers
 The fundus of the uterus rises up to the abdomen- when there is already in the direction of the long axis of the vagina
separation of placenta and placenta starts to go down – 2nd sign o Two IV infusion systems  LR and blood
 Lengthening of umbilical cord – 4th sign o If the placenta is attached, it is NOT removed until there is
already ongoing fluids and halothane or enflurane is already
For active management of placental delivery, you do not wait for the signs of administered terbutaline, ritodrine, or mgso4 maybe used to
placental separation but you do UMBILICAL CORD/GENITAL TRACTION effect and uterine relaxation and repositioning.
(one hand). The other hand is over the symphysis pubis while pushing the o After removal of placenta, the palm is placed on the center of the
uterus upward. (Brandt-Andrews Method) fundus with the fingers extended to identify the margins of the
cervix. Upward pressure is applied.
2. RETAINED PLACENTAL FRAGMENTS o Bimanual compression
 The most important is the maternal surface o Surgical intervention is done if the uterus cannot be reinverted
 Look for the completeness of cotyledons in the placenta (usually
20-24 cotyledons)  Progressive severity of inversion
o After the fundus begins and continues to invert (Nos. 1 and 2),
 Seldom causes immediate postpartum hemorrhages
usually not visible
o At the level of the introitus (No. 3), already visible externally
o Completely inverted (No. 4)
Hemorrhages From Retained Fragments Of Placenta
 Incidences from approximately 1 in 2000 to 1 in 20,000 deliveries
 Seldom causes immediate postpartum hemorrhage but is a common
cause of late postpartum hemorrhage
 Placental inspection after delivery is mandatory
 Succenturiate lobes: Placental polyps

Leaving the Placenta in Situ

 In few cases if this may be wise for women in whom abnormal
placentation was not suspected before cesarean delivery and inwhom
uterine closure stops bleeding

Pregnancy Outcomes
 Can have disastrous outcomes for both mother and fetus
Recognition and Management
Subsequent Pregnancy  Immediate recognition improves the chances of a quick resolution
 Increased risks for recurrence, uterine rupture, hysterectomy, and and good outcome
previa  Continued hemorrhage likely will prompt closer examination of the
birth canal
3. UTERINE INVERSION  partially inverted uterus can be mistaken for a uterine myoma, and this
 Risk factors include alone or in combination: can be resolved by sonography
o Fundal placental implantation  Once any degree of uterine inversion is recognized, several steps must
o Delayed-onset or in uterine atony, be implemented urgently and simultaneously:
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1. Immediate assistance is summoned, including obstetrical and o Note: bleeding in the presence of firmly contracted uterus is
anesthesia personnel. evidence of genital tract laceration, retained fragments of
2. Blood is brought to the delivery suite placenta or both.
3. The woman is evaluated for emergency general anesthesia.  INJURIES TO THE CERVIX
Large-bore intravenous infusion systems are secured to begin o Laparotomy is mandatory if concomitant peritoneal perforation,
rapid crystalloid infusion to treat hypovolemia while awaiting retroperitoneal and intraperitoneal bleeding is suspected
arrival of blood for transfusion. o Cervical lacerations must be suspected when there is profuse
4. If the recently inverted uterus has not contracted and retracted bleeding during and after the third stage especially if uterus is
completely and if the placenta has already separated, then the well contracted.
uterus may often be replaced simply by pushing up on the o Entails adequate exposure and not jist digital examination and
inverted fundus with the palm of the hand and fingers in the proper suturing
direction of the long axis of the vagina. Care is taken not to o Cervical inspectionmust be routinely done especially after
apply so much pressure as to perforate the uterus with the forceps delivery.
Vulvovaginal Lacerations
 Small tears of the anterior vaginal wall near the urethra
o Relatively common
o Superficial with little to no bleeding
o Repair is not indicated
 Minor superficial perineal and vaginal lacerations occasionally
require sutures for hemostasis
 Frequency of third- or fourth-degree perineal lacerations5.7% in
5. If the placenta is still attached, it is not removed until infusion nulliparas and 0.6% in multiparas
systems are operational and a uterine relaxant drug administered.  Bleeding in firmly contracted uterusstrong evidence of genital tract
If these fail will administer rapidly acting halogenated laceration
inhalational agent. o Usually result from injuries sustained during operative vaginal
6. After removing the placenta, steady pressure with the fist, palm, delivery with forceps or vacuum extractor
or fingers is applied to the inverted fundus in an attempt to push  Extensive vaginal or cervical tearslook for evidence of
it up into and through the dilated cervix as described in Step4. retroperitoneal hemorrhage or peritoneal perforation or hemorrhage
7. Once the uterus is restored to its normal configuration, tocolysis  Extensive vulvovaginal lacerationsneed to do intrauterine exploration
is stopped. Oxytocin is the ninfused, and other uterotonics may for possible uterine tears or rupture
be given. Meanwhile, the operator maintains the fundus in its  For deep vulvovaginal lacerationssuture repair is usually required,
normal anatomical position while applying bimanual and effective analgesia or anesthesia, vigorous blood replacement, and
compression to control further hemorrhage until the uterus is capable assistance are mandatory
well contracted. The operator continues to monitor the uterus
transvaginally for evidence of subsequent inversion. Levator Sling Injuries
 Levatorani muscle
Surgical Intervention o Usually involved with deep vaginal vault lacerations
 Done if manual replacement fails. o Sustain stretch injuries that result from over distention of the
 Caused bydense myometrial constriction ring birth canal
 To reposition the uterusTocolysis agents + combined effortby  Muscle fibers are torn and separatedwill interfere pelvic diaphragm
simultaneously pushing upward from below and pulling upward from functioncause pelvic relaxation.
above.  If pubococcygeus muscle is involve urinary incontinence
 Huntington procedureApplication of atraumatic clamps to each
round ligament and upward traction Cervical Lacerations
 Haultain incision longitudinal surgical cut made posteriorly through  Most are less than 0.5 cm seldom require repair
the ring to expose the fundus and permit.  Not usually problematic unless they cause hemorrhage or extend to the
o Done if the constriction ring still prohibits repositioning upper third of the vagina.
 Colporrhexis cervix is totally or partially avulsed from the vagina in
the anterior, posterior, or lateral fornices.
2. INJURIES TO THE BIRTH CANAL (GENITAL TRACT o These injuries sometimes follow difficult forceps rotations or
LACERATION) deliveries performed through an incompletely dilated cervix with
 2 TYPES OF EPISIOTOMY the forceps blades applied over the cervix.
o Median – all advantages are seen compared to lateral; o Rare case
disadvantages are that incision is made on the center and  If cervical injury reached lower uterine segment involve the uterine
involvement of rectal mucosa and sphincter. artery and its major branches.
o Lateral  Annular or circular detachment of the cervixwhen the entire vaginal
 REVIEW THE DEGREES IN LACERATIONS portion of the cervix is avulsed.
 PERINEAL LACERATIONS o Seen with difficult deliveries, especially forceps deliveries
o Must be appropriately repaired including the underlying perineal
and vaginal fascia and muscle to prevent subsequent outlet Diagnosis
relaxation, cystorectocele and uterine prolapse  Deep cervical tear should always be suspected in profuse hemorrhage
 LEVATOR ANI INJURIES during and after third-stage labor, particularly if the uterus is firmly
o Results from the overdistention of birth canal separation of contracted.
muscle fibers, dimunition of tonicity  pelvic diaphragm o If upon inspection flabby cervix interferes digital
dysfunction  pelvic relaxation and incontinence examinationan assistant applies firm downward pressure on
 VAGINAL LACERATIONS the uterus while the operator exerts traction on the lips of the
o Middle or upper third vaginal isolated lacerations more often cervix with ring forceps.
result from forceps or vacuum extraction
o Lacerations of the anterior vaginal wall close to the urethra are Management
often minor and need no repair; however if they are extensive,  Cervical lacerations of 1 and even 2 cm not repaired unless they are
repair is indicated, and indwelling catheter is placed. bleeding

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 Usually will result to irregular, sometime stellate appearance of the  If bleeding ceasessmall- to moderate-sized hematomas will be
external cervical os that indicates previous delivery of a viable-size absorbed. But it can rebled in up to 2 weeks or tissues may rupture
fetus. secondary to pressure necrosis.
 Deep cervical tears surgical repair  If paravaginal space are affected and extend above the levator sling
 If limited to the cervix or extends somewhat into the vaginal fornix massive retroperitoneal bleeding
need suturing of the cervix after bringing it into view at the vulva
 First suture  laced above the angle Diagnosis
o Because hemorrhage usually comes from the upper angle of the  Readily diagnosed by presence of severe perineal pain
wound  Rapidly develops and covered by discolored skin
 In lacerations involving lateral vaginal sulcus, attempts to restore the  symptoms of pelvic pressure pain, or inability to void should prompt
normal cervical appearance may lead to subsequent stenosis. evaluation usually due to round, fluctuant mass encroaching the
 If with uterine involvement and continued hemorrhage adjunctive vaginal fault
surgical procedure  supralevator hematomashematoma extends into the paravaginal
o ex. Angiographic embolization for a high cervical tear after space and between the leaves of the broad ligament.
failed surgical repair. o Worrisome b/c it can lead to hypovolemic shock and
3. PUERPERAL HEMATOMAS  sonography or computed tomographic (CT) scanning
 Mostly associated with a laceration, episiotomy, or an operative o useful to assess location and extent
 Most common symptom is seen after discharge of patient. Management
 Associated risk:  managed according to their size, duration since delivery, and expansion
o Nulliparity  smaller vulvar hematomasexpectant management
o Episiotomy  if pain is severe or the hematoma continues toenlargesurgical
o Forceps delivery exploration
 laparotomy if there is continued hemorrhage
 Classification:  Blood loss with large puerperal hematomas is nearly always
o Vulvar considerably more than the clinical estimate.
 Involves branches of pudendal arteries, including  Blood transfusion is almost always . Pt. is at risk for hypovolemia
posterior rectal, transverse perineal or posterior labial  Angiographic embolization popular for management of some
artery puerperal hematomas
o Paravaginal o Can be used primarily or secondarily, if surgical attempts at
 Involves descending branch of uterine artery hemostasis have failed or if the hematoma is difficult to access
o Vulvovaginal surgically
o Retroperitoneal  Bakri balloon for a paracervical hematoma has also been described
o Severe pain – 1st symptom
o If moderate in size  spontaneous absorption 4. RUPTURE OF THE UTERUS
o May cause overlying in tissue necrosis  profuse hemorrhage  Primary uterine rupture
o Dx: o Occur in a previously intact or unscarred uterus
 Severe perineal pain  secondary
 Tense, fluctuant, discolored tender mass o Associated with a preexisting myometrial incision, injury, or
 Inability to void anomaly
 Pressure symptoms
 a catastrophic obstetric event accompanied by adverse maternal and
 Extension of the hematomas into the leaves of the broad
neonatal complication (both mother and fetus)
 Incidence
o Treatment:
o Spontaneous – unknown, exceedingly rare
 Expectant
o 1 previous low transverse scar – 0.2-1.5%
 Severe pain, enlarging  incision and evacuation of
o 2 or more prior CS – 3-9%
clots + ligation of bleeders
 Angiographic embolization  Complete
o Rupture of uterus in which there is direct communication with
 Hematomas of the genital tracts often involves more
bleeding than is estimated  blood transfusion the peritoneal cavity
o Defect in the uterine wall leads to a direct communication
between the peritoneal and intrauterine cavities
o A true emergency
o More difficult to treat
o Potentially life-threatening for both the mother and the fetus
o Laparotomy is advisable
 Incomplete
 One classification of puerperal hematomas includes vulvar,
o Uterine cavity is separated from the peritoneal cavity by the
vulvovaginal, paravaginal, andretroperitoneal hematomas.
visceral peritoneum over the uterus or over the broad ligament
 Vulvar hematomas involve the vestibular bulb or branches of the
o Typically presents as asymptomatic DEHISCENCE of a
pudendal artery(inferior rectal, perineal, and clitoral arteries) previous uterine scar
 Paravaginal hematomasinvolve the descending branch of the o The peritoneal and intra-uterine cavities are separated by the
uterine artery uterine serosa
 supralevator hematoma  develops when a torn vessel lies above the o Usually uncomplicated
pelvic fascia  Rupture of the CS scar
 retroperitoneal hematomas when a continuing bleeding dissect o Separation of old uterine incision throughout its length, with
retroperitoneally and form a mass palpable above the inguinal rupture of the fetal membranes so that the uterine and peritoneal
ligament cavity communicate and parts of the fetus are extruded into the
 it may also dissect behind the ascending colon or in hepatic flexure at latter; bleeding is significant from scar edges or from extension
the lower margin of the diaphragm into previously uninvolved parts of the uterus
 Dehiscence of CS Scar
Vulvovaginal Hematomas o Fetal membranes are not ruptured; the entire length of scar is not
 develop rapidly and frequently cause excruciating pain involved; overlying peritoneum is intact; absent or scanty

7|O B S T E T R I C S , 2 0 1 4
Trans by: CharmingRNMSNMD Edited by- Dhezai & E. Ilano & 46ers nomlamlav
 Uterine Injury or anomaly sustained pregnancy  Clinical Course
o Surgery involving myometrium o Sudden severe FHT decelerations – MC finding (80%)
 CS delivery (well-formed lower uterine segment) or o Chest pain – referred from hemoperitoneum and irritation of
hysterotomy (not well-formed lower uterine segment) diaphragm
 Previously repaired uterine rupture o Cessation of contractions
 Myomectomy incision through or to the endometrium o Loss of station - presenting part
 Deep cornual resection of interstitial oviduct o Fetal parts are more easily palpable abdominally
 Metroplasty o Vaginal exam may reveal the rupture site (BUT NOT
o Coincidental Uterine Trauma ALWAYS)
 Abortion with instrumentation – curette, sounds  Prognosis
 Sharp or blunt trauma – accidents, bullets, knives o If fetus is expelled into peritoneal cavity, its chance for survival
 Silent rupture in previous pregnancy is dismal
o Congenital Anomaly o If fetus is alive at time of rupture, survival depends on prompt
 Pregnancy in undeveloped uterine horn delivery – usually by CS
 Uterine Injury or abnormality pregnancy o Causes of maternal death
o Before delivery  Hemorrhage
 Persistent, intense, spontaneous contractions  Infection
 Labor stimulation – oxytocin or PGs o Important:
 Intra-amnionic instillation – saline or PGs  Prompt diagnosis
 Perforation by internal uterine pressure catheter  Immediate operation
 External trauma – sharp or blunt  Availability of blood and antimicrobial therapy
 External version  Hysterectomy vs Repair
 Uterine overdistention – hydramnios, multiple pregnancy o Laparotomy is not indicated if there is asymptomatic dehiscence
o During Delivery after VDAC
 Internal version, Difficult forceps o Spontaneous or frank rupture  hysterectomy
 Breech extraction o Repair is reserved only in selected cases
 Fetal anomaly distending lower segment  Internal Iliac Artery Ligation
 Vigorous uterine pressure during delivery o Can reduce bleeding appreciably and does not appear to
 Difficult manual removal of placenta compromise the patient’s subsequent reproductive capacity
o Acquired  Uterine rupture through the cesarean hysterotomy scar became
 Placenta increta or percreta preeminent d/t increased number of CS delivery
 Adenomyosis
 Gestational Trophoblastic Neoplasia Causes of Uterine Rupture
 Sacculation of entrapped retroverted uterus  Primary  occurring in a previously intact or unscarred uterus
 Classic Scar  Secondary  associated with a preexisting myometrial incision, injury,
o Greater probability of rupture or anomaly
o Rupture before labor in 30%
 LSCS Scar
o Less likely to rupture
o Rarely ruptures antepartum

 Rupture of CS Scar
o VBAC is encouraged and is not significantly associated with
rupture provided that:
 Only one previous LSCS Scar
 Indication for CS then is no longer present
 Avoidance of Oxytocin Augmentation
 Uterine rupture (TYPES)
o Rupture of a CS Scar
 Classical or vertical
 CS scar has a higher risk of rupture compared to a low
segment transverse incision
 Maternal mortality: LOW
 Fetal mortality: 32%
o Rupture of an intact uterus
 Spontaneous
 Oxytocin or PG induction of labor in women with
high parity, big babies, or malpresentation
 Almost always occurs in the Lower Uterine
 Traumatic
 Internal Podalic Version
 Difficult forceps delivery
 Breech Extraction
 Forceful fundal pressure
 Hydrocephaly
 Maternal Mortality: 13.5%
 Fetal Mortality: 76%

8|O B S T E T R I C S , 2 0 1 4
Trans by: CharmingRNMSNMD Edited by- Dhezai & E. Ilano & 46ers nomlamlav
"I'm more than what your naked brain can comprehend"

Predisposing Factors and Causes

 Prior cesarean hysterotomy incision
 Other previous operations or manipulations that traumatize the
o Uterine curettage or perforation, endometrial ablation,
myomectomy, or hysteroscopy
 Excessive or inappropriate uterine stimulation with oxytocin
 Incidence rate in developed countries 1in 4800 deliveries
 Frequency of primary rupture approx.. 1 in 10,000 to 15,000 births

 Involves thinned-out of lower uterine segment
 When the rent is in the immediate vicinity of the cervix extends
transversely or obliquely
 When the rent is in the portion of the uterus adjacent to the broad
ligamenttear is longitudinal
 It is usual for the tear to extend upward into the active segment or
downward through the cervix and into the vagina
 If the rupture is of sufficient sizeuterine contents will escape into the
peritoneal cavity
 Fetal prognosis is largely dependent on the degree of placental
separation and magnitude of maternal hemorrhage and hypovolemia
 In some there is an inherent weakness in the myometrium in which the
rupture takes place
o Ex. anatomical anomalies, adenomyosis, and connective-tissue
defects such as Ehlers-Danlos syndrome

Management and Outcomes

 14% of deaths caused by hemorrhage.
 Major concern surviving infants develop severe neurological

*Postpartum hemorrhages are the major cause of maternal mortality and
*Recognizing patient at risk is the basic fundamental step to minimize and
prevent its occurence.
*Early recognition and prompt referral are the key notes to prevent
detrimental outcome of this complication.

"I'm more than what your naked eyes can see"


9|O B S T E T R I C S , 2 0 1 4
Trans by: CharmingRNMSNMD Edited by- Dhezai & E. Ilano & 46ers nomlamlav