POST PARTUM HEMORRHAGE (HEAVY MENSTRUAL BLEEDING)
GENERALIZED
DEFINITION  Early – Blood loss is greater than 500ml
in the first 24 hours after a vaginal
delivery or greater than 1000ml after a
caesarean birth
 Late – Hemorrhage that occurs between
24 hours and 6 weeks following delivery
(e.g. RETAINED PLACENTAL TISSUE)
RISK FACTORS   overdistended uterus – twin, macrosomia, polyhydramnios
CLINICAL MANIFESTATIONS
MANAGEMENT
4Ts (TONE)
UTERINE ATONY
Contraction of the myometrium that mechanically compresses the blood vessels supplying the placental bed provides the principal
mechanism uterine hemostasis after delivery of the fetus, and the placenta is concluded. The process is complemented by local
decidual hemostatic factors such as tissue factor type-1 plasminogen activator inhibitor as well as by systemic coagulation factors
such as platelets, circulating clotting factors.
 failure of the uterus to contract properly following delivery
 Mismanagement of the 3rd stage of labor ( from delivery of the baby to delivery of the placenta) – 3rd stage haemorrhage
 After the delivery, some would tend to stimulate the fundus, impedes normal separation.
 Leads to incomplete separation of placenta
 Uterine muscle fatigue/relaxation – labor induction, prolonged labor
 chorioamnionitis
 uterine distortion
 uterine relaxing drugs
Direct palpation at cesarean delivery (typically after the closure of the uterine incision) or indirect examination at
bimanual examination after a vaginal delivery reveals a boggy, soft, and an unusually enlarged uterus, typically with
co-existent bleeding from the cervical os.
With focal localized atony, the fundal region may be well contracted while the lower uterine segment is dilated and
atonic, which may difficult to appreciate on abdominal examination, but may be detected on vaginal examination. A
digital exploration of the uterine cavity (if adequate anesthesia is available), or bedside obstetric ultrasound imaging to
reveal an echogenic endometrial stripe is an essential examination, as is a timely examination with adequate lighting
to exclude an obstetric laceration.
Administration of oxytocin soon after the baby’s birth is associated with reduced maternal blood loss and decreased trend for
therapeutic oxytocin.
Uterine massage is associated with reduced mean blood loss at 30 and 60 minutes and a reduced need for additional oxytocics.
(Grade A)
Hemostatics are adjunctive forms of management for uterine atony. (Grade C)
An antifibrinolytic agent, tranexamic acid, may be useful in emergencies. A dose of 1 gm is given intravenously and can be repeated
every 4-6 hours. Recombinant Activated Factor VII, on the other hand, is used for the prevention and treatment of hemorrhage in
patients with hematologic disorders. Although not generally used in obstetrics, there are numerous reports of its successful use in
cases of intractable hemorrhage from uterine atony.
PRODUCT EFFECT IN OBSTETRICAL HEMORRHAGE

Whole blood Restores blood volume and fibrinogen

Packed RBC Increases Hct 3-4 volume percent per unit

Fresh Frozen Plasma Restores circulating volume and fibrinogen

 POST PARTUM HEMORRHAGE (HEAVY MENSTRUAL BLEEDING)
4Ts (TRAUMA) 4Ts (TISSUE)
LACERATION AND PUERPERAL HEMATOMA RETAINED PLACENTA
DEFINITION Lacerations can occur within the genital tract during childbirth. This often occurs at the Following delivery of the baby, the retro-placental myometrium is initially relaxed. It is only
vaginal vault as the fetal head passes through. Lacerations can involve the when it contracts that the placenta shears away from the placental bed and is
perineum, vagina, and the cervix. Perineal trauma may occur spontaneously or detached. This leads to its spontaneous expulsion. Retained placenta occurs when
arise from episiotomy during vaginal delivery. There are several classifications of the retro-placental myometrium fails to contract leading to dysfunctional labour.
spontaneous perineal trauma. It can be classified according to location or depth of the
perineal tissue involved. Anterior perineal trauma is described as an injury Placenta Adherens occurs when the contractions of the womb are not robust enough to
involving the labia, anterior vagina, urethra or clitoris. Posterior perineal trauma completely expel the placenta. This results in the placenta remaining loosely attached to
involves injury to the posterior vaginal wall, perineal muscles or anal sphincters the wall of the uterus. This is the most common type of retained placenta.
and may extend through the rectum.
Trapped Placenta
 First Degree involves the fourchette, perineal skin, and vaginal mucous membrane When the placenta successfully detaches from the uterine wall but fails to be expelled
but not the underlying fascia and muscle from the woman’s body it is considered a trapped placenta. This usually happens as a
 Second Degree aside from the skin and mucous membrane, the fascia and muscles result of the cervix closing before the placenta has been expelled. The Trapped Placenta
of the perineal body are involved is left inside the uterus.
 Third Degree lacerations extend through skin, mucous membrane, perineal body,
and anal sphincter Placenta Accreta
 3a: less than 50% of external anal sphincter thickness torn When the placenta attaches to the muscular walls of the uterus instead of the lining of the
 3b: more than 50% of external anal sphincter thickness torn uterine walls, delivery becomes harder and often results in severe bleeding. Blood
 3c: internal anal sphincter torn transfusions and even a hysterectomy may be required. This complication is called
 Fourth Degree there is extension of laceration through the rectal mucosal to expose Placenta Accreta.
lumen of the rectum
PUERPERAL HEMATOMAS FROM PPT:
 Vulvar Hematoma  retention of the placenta in utero for more than 30 minutes
 involves pudendal artery  wait 30 minutes for signs of placental separation, then do controlled traction
 branches include post. rectal, transverse perineal and post. Labial arteries.  Give oxytocin, if there is bleeding
 Paravaginal Hematomas  If still not delivered, attempt manual extraction
 associated with forceps delivery
 complain of rectal pressure
 involves the descending branch of uterine artery/vein (blood accumulates
above the pelvic diaphragm)
Subperitoneal (Retroperitoneal) Hematoma
Least common, most dangerous
asysmptomatic until hypotension
involved vessel from the hypogastric artery
this may results from uterine rupture, placental abruption and extension of vaginal
hematomas
RISK FACTORS 
CLINICAL MANIFESTATIONS 1.) Symptoms PUERPERAL HEMATOMA that in these women blood flow continues through the myometrium to the placenta
 excruciating pain irrespective of whether the cause is placenta accreta or prolongation of the latent phase.
 Often mistaken as pain of episiorrhaphy This provides a scientific explanation for the increased rates of haemorrhage during
2.) Physical Exam manual removal of placenta when compared with spontaneous delivery10. It also
 tense, fluctuant tender mass with discoloration of the skin on examination explains why partial or forced detachment of the placenta prior to onset of the contraction
phase is associated with high rates of haemorrhage.

Ultrasound is typically the first-line investigation in suspected retained products of

conception:
• a variable amount of echogenic or heterogeneous material within the
endometrial cavity
• in some instances, this may present like an endometrial or intrauterine
mass
• presence of vascularity within the echogenic material supports the
diagnosis but the absence of color Doppler flow has a low negative predictive
value because retained products of conception may be avascular 9
• calcification may be present
Retained products of conception can be suspected on ultrasound if the endometrial
thickness is >10 mm following dilatation and curettage or spontaneous abortion
(80% sensitive).
PATHOPHYSIOLOGY Retained placenta is generally attributed to one of three pathophysiologies. First, an
atonic uterus with poor contraction may prevent normal separation and contractile
expulsion of the placenta.Second, an abnormally adherent or invasive placenta, as
seen with placenta accreta spectrum (PAS), may be incapable of normal separation.
Finally, a separated placenta may be trapped or incarcerated due to closure of the
cervix prior to delivery of the placenta Placental hypoperfusion disorders, such as with
preeclampsia, and infection have also been proposed as mechanisms for retained
placenta, although little is known about the specific mechanism.
MANAGEMENT Expectant management Manual removal of the placenta is warranted if the other maneuvers have failed to
Incision and evacuation deliver the placenta and significant bleeding occurs. This followed by
severe pain, rapidly enlarging administration of antibiotics.
Ligation of bleeding points
obliteration of potential space The retained or partially detached placenta interferes with uterine contraction and
Compression 12-24 hrs. retraction and leads to bleeding. Perform manual removal with a level of analgesia that
 <3 cm – treated conservatively (e.g. ice packs) matches the clinical urgency of the situation. The cessation of an oxytocin infusion or the
 >3 cm and rapidly expanding – administration of uterine relaxants to promote uterine exploration and manual removal is
of questionable value and may lead to increased bleeding. Ultrasound may be useful
inselect cases.

When possible, an elbow-length glove is worn and attention is paid to asepsis.

The perineum and vagina must be prepared. The vaginal hand may be immersed in
povidone-iodine solution to facilitate easier entry. The hand is passed into the vagina
through the cervix and into the lower segment following the umbilical cord. Care is taken
 to minimize the profile of the hand as it enters, keeping the thumb and fingers together in
the shape of a cone to avoid damage.

Control of the uterine fundus with the nonvaginal hand is essential. If the placenta is
encountered in the lower segment, it is removed. If the placenta is not encountered, the
placental edge is sought. Once found, the fingers gently develop the space between the
placenta and uterus and shear off the placenta. The placenta is pushed to the palmar
aspect of the hand and wrist; when it is entirely separated, the hand is withdrawn. Ensure
that an oxytocin infusion is running rapidly as the hand is withdrawn in order to encourage
strong uterine contraction, and then perform uterine massage. Care must be taken to
tease out the membranes. Once uterine contraction is established, examine the placenta
and membranes to determine whether further exploration or curettage is necessary. The
administration of antibiotics following manual removal is sometimes advocated.

POST PARTUM HEMORRHAGE (HEAVY MENSTRUAL BLEEDING)

4Ts (TISSUE) 4Ts (TISSUE)
UTERINE INVERSION UTERINE RUPTURE
DEFINITION Complete uterine inversion after delivery of the infant is almost always the consequence Symptomatic or complete uterine rupture is defined as separation of the entire thickness
of strong traction on an umbilical cord attached to a placenta implanted in the fundus. of the uterine wall, with extrusion of fetal parts and intra-amniotic contents into the
Incomplete uterine inversion may also occur. Contributing to uterine inversion is a peritoneal cavity.1
sturdy cord that does not readily break away from the placenta, combined with fundal
pressure and a relaxed uterus, including the lower segment and cervix. Placenta Uterine rupture is associated with clinically significant uterine bleeding; fetal distress;
accreta may be implicated, although uterine inversion can occur without a firmly expulsion or protrusion of the fetus, placenta, or both into the abdominal cavity; and the
adhered placenta. need for prompt CS, uterine repair, or hysterectomy.

Puerperal uterine inversion is due to displacement of the fundus of the uterus, usually Complete Rupture – direct communication between the uterine and peritoneal cavity
occurring during the third stage of labor. It is a complication of childbirth that occurs
between 1 in 2148 and 1 in 6407 births Incomplete Rupture – 2 cavities are separated by the uterine serosa or the broad
ligament

RISK FACTORS Excessive umbilical cord traction with a fundal attachment of placenta and fundal (UNSCARRED UTERUS) SCARRED UTERUS
pressure in the setting of a relaxed uterus are the 2 most common proposed  Grand multiparity – more than 5  Oxytocin induction/augmentation
aetiologies for uterine inversion.  Neglected labor  Cervical ripening
Other possible risk factors for uterine inversion include rapid labor, invasive  Breech extraction  Shorter inter-delivery interval
placentation, manual removal of placenta, short umbilical cord, use of uterine-  Uterine instrumentation  One layer closure
relaxing agents, uterine overdistension, fetal macrosomia, nulliparity, placenta  Congenital uterine relaxing drugs  Lower uterine wall thickness <3-3.5mm
previa, connective tissue disorders (Marfan syndrome and Ehlers-Danlos syndrome),  Malpresentation – transverse lie
and history of uterine inversion in the previous pregnancy. However, in the majority of
cases, no risk factors are identified, thus making this condition unpredictable
CLINICAL MANIFESTATIONS Hemorrhage, shock and severe pelvic pain mainly support the diagnosis of the uterine
inversion. Bimanual examination will confirm the diagnosis and also reveal the degree
of inversion.
The completely inverted uterus usually appears as a bluish-gray mass protruding from
the vagina. In incomplete inversion, palpating the fundal wall in the lower uterine
segment and cervix might be required for diagnosis. Profuse bleeding, absence of
uterine fundus, or an obvious defect of the fundus on abdominal examination, as
well as evidence of shock with severe hypotension, will further provide the clinician
diagnostic clues for uterine inversion.
PATHOPHYSIOLOGY suspected when fundus is not palpable abdominally along with the sudden onset
of brisk vaginal bleeding, which leads to hemodynamic instability in the mother.
Traditionally, the shock has been considered disproportionate to blood loss, which is
possibly mediated by parasympathetic stimulation caused by stretching of tissues.
However, careful evaluation of the need for the blood transfusion should be made
because blood loss is massive and is greatly underestimated. The other symptoms are
mainly severe lower abdominal pain with a strong bearing down sensation, though most
women may not be able to complain due to severe shock. It may occur before or after
placental detachment.[1][6]
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Evaluation
The diagnosis is often made clinically with a bimanual examination, during which the
uterine fundus is palpated in the lower uterine segment or within the vagina. If a clinical
examination is equivocal, then ultrasound can be used to confirm the diagnosis
MANAGEMENT • replacement of the uterus
• anaesthetics
• tocolytic agents
• oxytocin/bimanual compression
• Once uterus returns to normal, stop tocolytics and give oxytocin
• Laparotomy
• Reduction of uterine inversion
• The protruding fundus is grasped with fingers directed toward the
posterior fornix.
• The uterus us returned to position by pushing it through the pelvis
and into the abdomen with steady pressure towards the umbilicus.
 abnormal fetal heart rate pattern
 most common abnormal presentation
 There is no reliable sign for impending rupture, need to have high index of suspicion.
 Patient would often have fetal distress
 Would complain that there is sudden tenderness in hypogastric area.
 Loss of fetal station in IE
The most common cause (>90%) of uterine rupture is an old Cesarean section scar.
Uterine rupture may be limited to dehiscence of the ends of the Cesarean scar with
an intact overlying serosal layer. A full-thickness uterine rupture with direct
communication of the uterine and peritoneal cavities results in massive
hemoperitoneum, and carries high fetal and maternal morbidity and mortality. Classic
scars are more likely to rupture before labor, whereas lower uterine segment scars tend
to rupture after labor
Fortunately, a uterine rupture from a prior cesarean with a low-transverse scar is a rare
event and occurs in less than 1% of women laboring for a VBAC. With this type of scar
less than 5 out of 1,000 women laboring for a VBAC will be at risk for a uterine rupture.
Uterine ruptures have also been known to occur in some women who have never had a
cesarean. This type of rupture can be caused by weak uterine muscles after several
pregnancies, excessive use of labor inducing agents, a prior surgical procedure on the
uterus, or mid-pelvic use of forceps.
Hysterectomy
 intractable bleeding
 multiple uterine rupture sites
Wound can be repaired if:
 small wound, bleeding minimal, 1-time cS

THROMBIN: COAGULOPATHIES

 Least common
 When bleeding continues with no identifiable source, an acquired coagulopathy must be considered
 Coagulation status must be assessed quickly and continuously
 Abnormal results:
 correct with FFP, cryoprecipitate, platelets and PRBC’s