THIRD STAGE COMPLICATIONS:

ATONIC PPH

DR SWETA SINGH
ADDITIONAL PROFESSOR
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
AIIMS BHUBANESWAR
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POSTPARTUM HAEMORRHAGE

DR SWETA SINGH
ADDITIONAL PROFESSOR
OBSTETRICS AND GYNAECOLOGY
AIIMS BHUBANESWAR
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LEARNING OBJECTIVES
1. Define postpartum hemorrhage, differentiate between primary and
secondary postpartum haemorrhage

2. Describe appropriate prevention (active management of the third stage

of labour)

3. Recall the four Ts as causes of postpartum haemorrhage

4. Identify possible risk factors for postpartum hemorrhage

5. Treatment of postpartum haemorrhage (medical and surgical)

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DEFINITION OF PPH
• Postpartum haemorrhage is defined as a blood loss of more than 500ml
from the genital tract in the first 24 hours of childbirth (primary PPH)

• For caesarean section, a blood loss more than 1000ml is significant

• Bleeding before delivery of the placenta is termed third stage

haemorrhage

• Secondary PPH is bleeding occurring after 24 hours and upto 12 weeks

postpartum

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DEFINITIONS OF PPH
Organization Definition of PPH
World Health Organization (WHO) • Blood loss >/= 500ml within 24 hours after birth
• Severe PPH: Blood loss >/= 1000 ml within the same time frame

American College of Obstetricians Cumulative blood loss >/= 1000 ml or blood loss accompanied by signs and
and Gynecologists (ACOG) 2017 symptoms of hypovolemia within 24 hours after the birth process ( includes
intrapartum blood loss) regardless of route of delivery

Royal College of Obstetricians and Minor PPH (500 to 1000 ml) and major PPH (>1000ml). Sub-divisions of
Gynaecologists (RCOG) major PPH include moderate PPH ( 1001 to 2000ml) and severe PPH
(>2000ml)

Society of Obstetricians and Any amount of bleeding that threatens the patients hemodynamic stability
Gynaecologists of Canada (SOGC)

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GLOBAL BURDEN OF PPH
• Every year,14 million women around the world suffer from PPH

• Incidence=1-3% of deliveries

• 52% of maternal deaths are attributable to three leading preventable

causes- haemorrhage, sepsis, and hypertensive disorders

• WHO:25% of maternal deaths are due to PPH

• Postpartum bleeding is the quickest of maternal killers; can kill even a

healthy woman within two hours, if not treated

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PATHOPHYSIOLOGY OF ARRESTING BLEEDING
POST DELIVERY
• Blood flow through intervillous space= 600 ml/min; this circulates
through the spiral arteries (n=120 )

• The spiral arteries have no muscular layer because of their remodeling

by trophoblasts, which creates a low-pressure system

• With placental separation, the vessels at the implantation site are

avulsed, and hemostasis is achieved first by myometrial contraction,
which compresses these vessels (living ligatures). This is followed by
clotting and obliteration of vessel lumens

• Importantly, an intact coagulation system is not necessary for

postpartum hemostasis unless there are lacerations in the uterus, birth
canal, or perineum

• At the same time, fatal postpartum hemorrhage can result from

uterine atony despite normal coagulation
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CAUSES OF PPH

PRIMARY CAUSES (4 Ts) SECONDARY CAUSES

• Uterine atony (Tone)
• Lacerations (Trauma)
• Retained placenta(Tissue)
• Defects of coagulation
(Thrombin)
• Abnormally adherent placenta
(placenta accreta spectrum)
• Uterine inversion
• Subinvolution of placental site
• Retained products of
conception
• Infection
• Inherited coagulation defects
(vWF deficiency)

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 RISK FACTORS
Antenatal and Intrapartum Risk Factors for Postpartum Hemorrhage
Etiology Primary Problem Risk Factors, Signs
Abnormalities of uterine Atonic uterus Prolonged use of oxytocin
contraction—atony High parity
(Tone) Chorioamnionitis
General anesthesia
Over-distended uterus Twins or multiple gestation
Polyhydramnios
Macrosomia
Fibroid uterus Multiple uterine fibroids
Uterine inversion Excessive umbilical cord traction
Short umbilical cord
Fundal implantation of the placenta

Genital tract trauma Episiotomy Operative vaginal delivery

(Trauma) Cervical, vaginal, and perineal lacerations Precipitous delivery
Uterine rupture

Retained placental tissue Retained placenta Succenturiate placenta

(Tissue) Placenta accreta Previous uterine surgery
Incomplete placenta at delivery
Abnormalities of coagulation Preeclampsia Abnormal bruising Petechia
(Thrombin) Inherited clotting factor deficiency Fetal death
(von Willebrand, hemophilia) Placental abruption
Severe infection Fever, sepsis
Amniotic fluid embolism Hemorrhage
Excessive crystalloid replacement Current thromboembolism treatment
Therapeutic anticoagulation 9
DRUGS USED IN MEDICAL MANAGEMENT OF PPH

(Methergin) Max 6 doses

(Prostodin)

Tranexamic acid 1g IV One time

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ASSESSING BLOOD LOSS IN PPH:PICTORIAL GUIDE

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ASSESSINGH BLOOD LOSS IN PPH:GRADUATED
DRAPES

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ASSESSING BLOOD LOSS WITH CLINICAL
FEATURES IN PPH

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FAQ: WHAT IS THE RULE OF 30 IN PPH?
• If >30% of a woman’s blood volume is lost→ Moderate shock

• PR increased by 30 bpm
• SBP drops by 30 mmHg
• Respiratory rate becomes >30/min
• Haematocrit/Hb drops by 30%
• Urinary output <30ml/hr

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FAQ: WHAT IS SHOCK INDEX?

Shock index= Pulse rate/Systolic BP

Changes by 30%
Normal =0.5 to 0.7

If >0.9: Indicates shock that

requires urgent resuscitation

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FLUID THERAPY AND BLOOD PRODUCT
TRANSFUSION

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MANAGEMENT OF PPH:INITIAL RESUSCITATION

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MANAGEMENT OF PPH: INVESTIGATIONS AND
MANAGEMENT

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FAQ: WHAT IS ‘HAEMOSTASIS’ IN THE
MANAGEMENT OF PPH?
Medical Management of PPH (HAEMO)
• Help (Ask for help)
• Assess (Vitals, blood loss &
resuscitate)
• Etiology, ensure availability of
blood
• Massage uterus
• Oxytocics
Surgical management of PPH (STASIS)
• Shift to OT
• Trauma (to exclude), tamponade
• Apply compression sutures
• Stepwise pelvic
devascularisation
• Intervention radiology
• Subtotal hysterectomy
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FAQ: WHAT IS THE GOLDEN HOUR IN
MANAGEMENT OF PPH?

• The 1st hour of PPH is taken as the golden hour, as the patient has
the best chances of survival if management is started within 1st hour
of onset of PPH.

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BIMANUAL COMPRESSION

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UTERINE TAMPONADE

Bakri balloon:
Maximum
capacity 500ml

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INDIAN INNOVATIONS IN MANAGEMENT OF
PPH

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INDIAN INNOVATIONS IN MANAGEMENT OF
PPH: SUCTION CANNULA

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NON-PNEUMATIC ANTISHOCK GARMENT
(NASG)

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AIMS OF SURGICAL MANAGEMENT IN ATONIC
PPH
▪ Providing “Tone” through internal or external tamponade
▪ Compression sutures or

▪ Balloon tamponade

▪ Decreasing blood loss

▪ Vascular ligation

▪ Interventional radiology

▪ Hysterectomy becomes the final method if the above techniques fail

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SURGICAL TECHNIQUES IN ATONIC PPH
Conservative procedures:
• Uterine compression sutures
• Stepwise pelvic devascularisation
• Uterine Artery embolization(UAE)
Definitive procedures:
• Hysterectomy (total/subtotal)

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INTERVENTIONS DECREASING THE BLOOD LOSS
Stepwise devascularisation of uterus:
UTERINE ARTERY LIGATION (O’Leary) :
• Uterus is grasped and elevated anteriorly and
suture is passed through the myometrium
(ant to post) approximately 2 cm medial to
the uterine artery brought out through an
avascular plane broad ligament, and tied to
create compression
UTERO OVARIAN ANASTOMOSIS :
• Suture placement should be done 2 cm
lateral to the cornua at the junction of
ovarian and anterior branch of uterine artery
INTERNAL ILIAC ARTERY LIGATION :
• Reduces pelvic blood flow by 49%
and pulse pressure by
85%,resulting in venous pressures
in arterial circuit thus causing
coagulation and arrest bleeding
• Anterior division should be ligated
2cm from the division and 5 cm
from the bifurcation and should be
done from lateral to medial
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SURGICAL LIGATION LOCATIONS

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 INTERVENTIONS IMPROVING THE TONE
EXTERNAL UTERINE COMPRESSION (compression sutures ) INTRA UTERINE BALLOON TAMPONADE

-Haemodynamically stable patient Haemodynamically stable patient

-Fertility sparing surgery Decreases the need for invasive procedures,

including uterine artery embolization
-B-Lynch sutures, CHO sutures, Hayman
sutures

- A balloon tamponade device can be

applied concurrently if needed.

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 UTERINE COMPRESSION SUTURES
B-LYNCH SUTURES HAYMAN SUTURES CHO SUTURES

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UTERINE ARTERY EMBOLISATION FOR PPH

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DEFINITIVE SURGICAL MANAGEMENT-HYSTERECTOMY
FOR PPH

• Either supracervical (subtotal) or total

hysterectomy

• Frequently, it is easier to perform a subtotal

hysterectomy

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UTERINE BLEEDING DURING CAESAREAN SECTION

• Uterine extensions into the lower

uterine segment or vagina: Repaired
with running locked sutures

▪ Areas of bleeding in the placental

bed can be sutured with box type
sutures

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 PREVENTION OF PPH
• Regular ANC
• Correction of anaemia during
antenatal period
• Identification of high risk cases
• Delivery in hospital with facility for
emergency obstetric care or
• Quick transport to nearest such
hospital (108 ambulance /air
ambulance)
• Active management of third stage
of labour (AMTSL)
• Oxytocin 10 U IM
• Controlled cord traction
• Delayed cord clamping
• Uterine massage after delivery of
placenta
• Observation for 2 hours post
delivery for early diagnosis
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 SUMMARY
1. Definition of postpartum haemorrhage

2. Primary and secondary postpartum haemorrhage

3. Appropriate prevention (active management of the third stage of labour)

4. Four Ts as causes of postpartum haemorrhage

5. Risk factors for postpartum hemorrhage

6. Treatment of postpartum haemorrhage (medical and surgical)

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THANK YOU !

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