Postpartum Hemorrhage Prevention

with Active Management of the Third

Stage of Labor

Dr. J. Jeno Wibisono, Sp OG

FAKULTAS KEDOKTERAN
UNIVERSITAS PELITA HARAPAN

This teaching material is copyrighted.

No part of this work may be reproduced, including photocopied, without written permission of Universitas Pelita Harapan .
 INTRODUCTION

Healthy Indonesian Vision 2010

Mission :
1.To increase individual, family, society and environmental health
2.To increase the quality of health service, and make it accessible to all society
3.To encourage society’s independency

Main Program :
To decrease the maternal mortality rate
September 2000

189 countries of United Nation Organization agree

to support the Millenium Development Goals
 GOALS

1.  Maternal Mortality Rate 1998  125 / 100.000

2.  Antenatal Care : 80%  90% (including exclusive breastfeeding)
3.  Labor with competent person : 60%  90%
4.  Anemia rate in pregnant woman : 64% - 35%
 Anemia rate in children : 55% - 40%
 Anemia rate in working woman : 30%  20%
5.  Referral rate of high risk patients : 20%  50%
6.  Immunization of TT2 : 64%  80%
7.  Low birth weight cases : 7.9%  5%
Contraception Aspect
1.  New Acceptor : 4.5 million  4.9 million
2.  Active acceptor : 21.5 million  25.2 million

Youth Reproductive Health Service

 Anemia prevalence in youth <20%
PROBLEMS

1. Barometer of a country is : Maternal mortality rate and infant mortality rate

2. Causes of maternal mortality rate :

- Hemorrhage 40 – 60 %
- Eclampsia 20 – 30%
- Infection 20%

3. Causes of infant mortality rate (Java, Bali 1995)

- Perinatal Disorder 33.5%
- Respiratory Disorder 32.1%
- Diarrhea 9.6%
- Parasite 4.1%
- Tetanus 2.3%
Research (Evidence Based)

It is shown that the Active Management of the Third Stage of Labor

is able to reduce the mortality and morbidity maternal rate in the
world.
 Active Management of Third Stage of Labor

The active evacuation of placenta is helpful to avoid any postpartum

hemorrhage, including:
1.Give oxytocin as soon as the baby has been delivered
2.Umbilical cord controlled-traction
3.Uterus massage as soon as the placenta has been delivered
 Oxytocin

Trigger the uterus to contract and also to increase the likelihood of placental
separation :
1. Oxytocin is given in 2 minutes 10 U, IM after the baby is delivered
2. If oxytocin is not available  stimulate the mother’s nipple to produce
the natural oxytocin
3. If available  Ergometrine 0.2 mg IM
 Controlled Cord Traction
(Penegangan Tali Pusat Terkendali)

1. One hand is placed upon the uterus right above the pubic bone
2. When the contraction occurs, push the uterus with our hand (DORSO cranially
towards mother’s head)
3. The other hand is holding the cord about 5-6cm in front of the vulva
4. Maintain a steady resistance on the cord and wait until there is a strong
contraction (2 – 3 minutes)
5. Whenever the contraction occurs, do the controlled cord traction with the same
resistance and power

• Controlled cord traction is only conducted when the uterus is having

contraction
• When the uterus is relaxed, our hand is still located above the uters, but not
doing the controlled cord traction
• Repeat the procedure in every contraction until all the placenta is separated
Do uterus fundus massage after the placenta is delivered

3 Important steps in Active Management of the Third Stage of Labor:

1.Give Oxytocin 10 U IM  2 minutes after the baby is delivered
2.Do the controlled cord traction
3.Right after the placenta is delivered  do the massage upon the uterus
fundus
 Uterus massage soon after the placenta is delivered

• As soon as the placenta is separated, take it out with a hand movement

approaching the placenta
• Move it with a “up and down” movement, just like the anatomy of the
birth canal
• Both of our hands hold the placenta, and slowly turn the placenta
around in a clockwise direction  take out the amniotic sac too
• After the placenta and sac is delivered, massage the uterus to make
them contract  to avoid any hemorrhage

** If the placenta has not been delivered yet in 15 minutes  give the
second dose of Oxytocin 10 U IM (15 minutes after the 1st dose)
Active Management of the Third Stage of Labor – 30 min but the
placenta still not delivered yet
• Check the bladder  do the catheterization if needed
• Check the signs of placental separation
• Give the third dose of Oxytocin 10 U IM
• Prepare for referral

WARNING:
- If the uterus is moving to inferior when we try to pull the cord; but
the placenta is not separated yet  STOP it, perhaps it is the
UTERUS INVERSION
- If the mother is in pain or the uterus is not having contraction 
STOP ! Risk of hemorrhaging
- Wait for few minutes, and re-check
 Dangerous Routine
Procedure
• Push the uterus before the
placenta is delivered
• Push the fundus towards the
inferior directing the vagina
• Catheter the bladder
• Traction of the cord is too
powerful
• Keep the placenta inside the
uterus partly
Description
• Can cause incomplete separation
of placenta and post partum
hemorrhage
• Can cause the uterus inversion
• Increase the risk of urinary tract
infection
• Can cause the cord to break
• Can cause the postpartum
hemorrhage  the uterus is not
fully contracted until the placenta
is completely delivered
 Uterine Atony
If any bleeding occurs  FIND THE SOURCES!!
• Situation when the uterus is failed to have
adequate contraction after the labor
– Continue the uterus massage for 15 seconds and do:

– 1. Internal Bimanual Compression (Kompresi

Bimanual Internal – KBI)
• Push the uterus with both hand powerfully to give direct
pressure towards the blood vessels in the uterus wall, also to
stimulate the myometrium to contract
2. If the uterus still not having contraction within 1 – 2 minutes  prepare
for referral (this is not a usual uterine atony)

3. Accompany the mother to the referral destination, and keep doing the
internal bimanual compression, then do :
a. IV line (16 – 18) 500ml RL that contains Oxytocin 20 U 
within 10 minutes
b. Then 500ml/hour until the referral place or 1.5L fluids and
then 125ml/hour
c. If the infusion fluid is not adequate, then the second infusion
bottle is 500ml but with slower rate
 • This can also be done when we’re on the way to the referral place

• 1. Place one hand upon abdomen in front of the uterus, right above the
pubic bone
• 2. Put the other hand on the abdominal wall (behind the uterus body),
try to hold the back part of the uterus
• 3. Try to compress between the two hands to compress the blood vessel
of the uterine wall. This is to help the uterus to contract and constrict
the blood vessel

External Bimanual Compression

 Placental Retention

• This can be happening without any sign of bleeding

• Placenta or parts of it can still be within the uterus after the
baby is delivered.
• If the placenta is seen on the vagina, ask the mother to
push. If we can feel the placenta, try to take them out
• Make sure the bladder is empty. Do catheterization if
needed
• If the placenta is not yet delivered, give Oxytocin 10 U IM if
the active management of the third stage of labor is not yet
performed.
• Don’t give Ergometrine because it can cause a
TONIC contraction of uterus  delay the placenta
delivery
• If the placenta still cant be delivered (after 30 min
Oxytocin) and the uterus is contracting  do the
controlled cord traction

• Avoid doing the controlled cord traction

powerfully and push the uterine fundus too strong
 can cause uterine inversion
If the controlled cord
traction is not
succesful  do the
manual separation of
placenta
 Placental Retention

• The bleeding is caused by the placental retention

 the cotyledon is not completely delivered
• If the cervix is still opened  explore digitally to
take out the blood clots and any tissue
• Some patients come with late postpartum
hemorrhage (after 6-10 days) and uterus sub-
involution
• Give wide spectrum antibiotic  Ampicillin
• Check Hb level  if <8gr%  refer
– If >8gr% : give Ferrous Sulfate 600mg (3x1 tab) for 10
days
Do not leave the mother (at least) 2 hours after the labor process. Before leaving
the mother :
1. Make sure the mother is in a stable condition and normal vital signs;
adequate uterine contraction, firm consistency and normal position. Normal
bleeding and the mother can urinate without any help
2. Teach the mother or the family how to evaluate the uterine tonus and do
massage of the uterus.
3. Do the first management of the newborn
4. Make sure that breastfeeding start soon after the baby is born
5. Teach the mother and the family to find any help if the following dangerous
signs are found :
- fever
- active bleeding
- blood clots >>
- dizzy
- difficulty in breastfeeding
- pain in pelvic or abdomen area that is more severe than the usual cramp
 Conclusion and Suggestion

1. The priority to achieve the 2010 Healthy Indonesian Goal is by achieving a

decreasing number in infant mortality rate and maternal mortality ratio
2. The most common causes of the maternal death is the post partum hemorrhage
(40 – 60%)
3. Active management of the 3rd stage of labor is proved to be effective as the main
method to prevent the post partum hemorrhage
4. The mother should be monitored and should not be left in the first 2 hours
1. As the result, a midwife must be able to do the active management of the 3rd stage
of labor and prioritize :
- Give oxytocin in the first 2 minutes after the baby is delivered
- Do the controlled cord traction
- Do uterine massage after the placenta is delivered
REFERENCES
Puerperal Infection
 Puerperal Infection
Definition:
The postpartum infection that usually origin from
the endometrium, the insersion area of placenta

Symptoms:
Temperature >38˚C for 2 consecutive days after
24hours of labor in the first 10 days of post partum
periods
The puerperal infection can be  with:
- Antibiotic
- Less surgery (severe trauma)
- Minimize the operative duration
- Asepsis
- Blood transfusion
- Improvement of general health
 Etiology:

Exogenous (outside)
Endogenous (the woman’s own birth canal)
→ the most common

The most common bacteria: Streptococcus, bacil

coli, Staphylococcus
rarely: basil welchii, Gonococcus, bacil thypus, C.
tetani
Transmission:
- Bimanual internal exam
- Tools that are used during the procedures
- The sexual intercourse during the last month

Predisposing factors:
- Bleeding ( immune)
- Labor trauma
* port d’ entree
* necrotic tissue
- Mother’s condition (anemia, malnutrition
→immune)
 Pathology:
From the wound infection
a. Limited to the wound itself (perineum, vaginal,
cervix or endometrium
infection)
b. Spread to the surroundings tissue (thrombophlebitis,
parametritis, salpingitis, peritonitis)

Prognosis: depend on the bacterial virulence and

the patient’s immunity
 Transmission of infection :
I. Spread out to the surface : endometritis,
salpingitis, pelvicoperitonitis, general peritonitis
II. Spread out to inner layer : endometritis,
myometritis, perimetritis, peritonitis
III. Spread out via lymphatic : lymphangitis,
perilymphangitis, parametritis, perimetritis
IV. Spread out via vein :
phlebitis (→ sepsis), periphlebitis,
parametritis
Sapraemia (retention fever): fever that is caused by
blood clots retention or amniotic sac retention.
Blood is suddenly gushing out and also amniotic sac
can be seen. Blood usually >>

Perineal wound infection:

The wound is painful, erythema, and edema  open
wound, infected, abscess + fever

Cervical wound infection :

In depth wound  parametrium : parametritis
Endometritis (most common):
After the incubation period, the organism is
invading the endometrium (ex-placental
implantation)
The fever occurs within 48 hours postpartum
When contraction occurs  pain (+), longer
Lochia >>, red / brownish, foul smell
Subinvolution
Leukocyte 15000 – 30000/mm³
Headache, lack of sleep, appetite 
Temperature  on day 7-10
 Thrombophlebitis: Transmission via venous system

• Most common, the most important causes of

death

Involve the veins :

a. Uterine wall veins and latum ligament (vena
ovarica, vena uterina & vena hypogastrica)
→ pelvic thrombophlebitis
a. Veins of extremity (Femoral v., popliteal v.,
saphena v.) → thrombophlebitis femoral
 Pelvic Thrombophlebitis

The most common: Ovarian v.

Left ovarian v.→ Renal v.
Right ovarian v.→ Inferior v. cavae
Thrombosis (+) → emboli/sepsis → pyemia (if the
thrombosis contains pus)
→ lungs (sudden death / lungs abscess)
→ kidney
→ heart valve
 Pelvic Thrombophlebitis

Occur in the 2nd week:

- Fever
- Complication: lung abscess, pleuritis, pneumonia,
kidney abscess
- Occur for 1 – 3 months
- High mortality rate (usually if lung abscess (+)
 Femoral thrombophlebitis
Origin:
- Saphena magna thrombophlebitis / Femoral v.
- Thrombophlebitis v. uterina, v. hypogastrica, v. iliaca
ext, v. femoralis
- Parametritis
Congested veins  edema of extremity (1 or both legs)
“Phlegmasia alba dolens”
 Femoral thrombophlebitis

Occur on day 10 – 20
Temp is increasing
Pain on extremity (usually on left)
Extremity : flexion and pronated, pain on movement
Palpation : pain along the veins area, rigid, edema
 Puerperalis Sepsis

• Port d’ entrée: placental insertion place

• Originally from: thrombophlebitis V. uterina / v.
ovarica
• Can also be secondary to (metastases): lungs, heart
valves, kidney, liver, spleen, brain, etc
 Puerperalis Sepsis

Signs :
Temp >40˚C, remittens, shivering
Physical appearance: severe, resp.rate >>, anxious
Hb due to hemolysis, leukocytosis
 Peritonitis

Spread through lymphatic

 Peritoneum (Peritonitis)
→ Parametrium (Parametritis)

Peritonitis that is limited in pelvic area 

Pelveoperitonitis
If generally affected: General peritonitis (worse
prognosis)
 Peritonitis
Signs:
Sudden pain in all abdomen region
Shivering, fever
Distended abdomen, sometimes diarrhea
Vomit
Anxious
Before death : delirium, coma
 Parametritis (Pelvis cellulitis)

Occurs in 3 ways:
- Deep cervix laceration
- Endometritis transmission / infected cervix
laceration transmitted via lymph
- Continously from pelvis thrombophlebitis
 Parametritis (Pelvic cellulitis)

Postpartum temp is high for >1 week

Unilateral or bilateral lower abdominal pain, radiating
to leg
Toucher : infiltrate is palpated in parametrium,
sometimes spread out to pelvic wall
The infiltrate can also be infected (abscess)
 Salphyngitis

Commonly affected by Gonorrhea infection

Occur in the 2nd week
Fever, bilateral lower abdominal pain
Can be healed in 2 weeks
Can cause infertility
 Prognosis

- HR <100x/min → good
- HR >130x/min, HR not ↓ even though the temp
is ↓  not so good
- Continous fever, shivering, insomnia, jaundice,
Hb level , leukocyte↓ or very ↑
→ bad
Peritonitis, thrombophlebitis pelvis→ bad
 Prophylaxis

Pregnancy:
- Give Fe for anemic patients
- Maximize the nutrition
- Stop sexual intercourse within last 1 – 2 months of
pregnancy
 Prophylaxis

During the labor:

1. Minimize the any contamination inside the
birth canal (asepsis, bimanual examination
only if any indication)
2. Minimize any trauma
3. Minimize the bleeding (>500cc→transfusion)
4. Minimize the labor period
 Prophylaxis

Postpartum:
Do not open vulva or insert fingers inside the
vulva to clean the perineum

Do not irrigate for the first 2 weeks

Infectious patient should be isolated

 Treatment

Antibiotic
Penicilline G: 5.000.000 S every 4 hours IV
Ampicillin 3-4 gram IV/IM
If penicilline resistant: Oxacilline, Dicloxacilline,
Methicilline
 Treatment

Special treatment
Perineal, vulva, vagina laceration : if there is
infection  take out the suture  drainage
Endometritis: Fowler, Uterotonic, educate the
mother to drink >>, isolate, but the baby still
allowed to breastfeed
 Treatment

Special treatment
Thrombophlebitis pelvis
- Avoid lungs embolism
- Reduce the complication of thrombophlebitis
(edema, pain)
- Anticoagulant (heparin, dicumarol)
 Treatment

Special management
Thrombophlebitis femoral
- Lift the leg
- Bedrest for a week after the fever resides
- Don’t stand too long, use elastic socks
 Treatment

Special management
Peritonitis
- High dose antibiotic
- Abot Miller Tube → reduce epigastric fullness
- IVFD, blood transfusion, O2
- Sedatives
- Eat and drink  if flatus (+)
 Medication

Special management
Parametritis
- Antibiotic
- If fluctuation + → incision
Location of incision : above the thigh area or on
douglas cavity
THANK YOU