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 Any amount of bleeding from or into the

genital tract following birth of the baby up to


the end of the puerperium, which adversely
affects the general condition of the patient
evidenced by rise in pulse rate and falling
blood pressure.
 500 ml-vaginal delivery
 1000 ml- caesarean delivery
 1500 ml- caesarean hysterectomy
 Depending upon the amount of blood loss
 minor (less than 1 litre)
 Major(greater than 1 litre)
 Severe(greater than 2 litre)
 Primary-Loss of MORE than or EQUAL to 500mL
blood from the genital tract within 24 hours of
delivery.
2 types- third stage haemorrhage(bleeding occurs
before expulsion of placenta)
- true postpartum haemorrhage (bleeding
occurs subsequent to expulsion of placenta).
 Secondary- Loss of MORE than or EQUAL to
500mL blood from the genital tract between 24
hours and 12 weeks post delivery(within
puerperium).
 Tone- Uterine atony 95%
 Tissue- Retained tissue/clots
 Trauma- laceration, rupture
 Thrombin- coagulopathy
 Traction- uterine inversion
 ATONIC
 TRAUMATIC
 RETAINED TISSUES
 BLOOD COAGULOPATHY
 Multiparity(Fibrosis of uterine muscle)
 Over distension of uterus
(eg: Macrosomia, polyhydramnios)
 Prolong labour (uterine inertia),precipitate labour
 Fibroid
 APH (Placenta praevia,abruptio placenta)
 Oxytocin induce labour
 Malformation of uterus(septate uterus,bicornuate)
 Uterine fibroid
 Anaesthesia(ether, halothane) contractility of gravid
uterus
 Mismanaged 3rd stage of labour
 Malnutrition and anemia
 Blood loss from episiotomy wound,cesarean
section.
 Trauma – cervix, vagina, perineum, rupture of
uterus
 Intsrumental delivery
RETAINED TISSUES
THROMBIN
 Bits of placenta, blood  Blood coagulation
clots disorders
 Thrombocytopenic purpura
 HELLP Syndrome
 Jaundice
 Unidentified dead fetus
 Amniotic fluid embolus-
amniotic fluid entering
maternal circulation
 Acute Inversion of Uterus
Uterus is pulled ‘inside out’ and
the fundus at the introitus.
 Caused by traction on the
umbilical cord before
placenta has separated.
• Associated factors:
 -Fundal placenta
 -Short cord
 -Morbidly adherent placenta
 Cardiovascular collapse &
shock.
 Vaginal bleeding
 Effect of blood loss depends on- pre delivery
Hb level
 Speed of blood loss.
 Consistency of uterus.
ANTENATAL INTRANATAL

 Improvement of health  Active management of 3rd stage


status of labour
 Screening of high risk  In case of augmentation or
patients induction of labour, infusion
should be continued for atleast 1
 Blood grouping
hour after delivery
 Placental localization in all
 Exploration of uterovaginal canal
women prior  Observe uterine consistency for 2
hours.
 Examination of completion of
placenta and membranes
 INTELLIGENT ANTICIPATION

 SKILLED SUPERVISION

 PROMPT DETECTION

 EFFECTIVE INSTITUTION OF
THERAPY.
 Placental site bleeding
Palpate the fundus and massage(placing four fingers
behind the uterus and thumb infront)

( if bleeding continues)

suggests presence of genital injury

-Start crystalloid solution (NS/RL) with oxytocin (1 L with 20 units) at 60


drops/minute, arrange for blood transfusion if necessary.

-Oxytocin 10 units im or methergin 0.2mg is given intravenously.

- catheterize the bladder

- Give antibiotics
- If Features of placental separation

Expression of placenta either by fundal pressure


or CCT.

- If not, manual removal of placenta.


- -If delivered under GA ,quick manual removal
of placenta
- If the patient is in shock, resuscitation ,then
manual removal
 Traumatic bleeding
After placental expulsion

Uterovaginal canal is explored under GA

Hemostatic sutures are applied on the sites.


Immediate measures
 Call for extra help
 IV cannula(14G)
 Flat and warm
 Blood crossmatching
 Rapid infusion of 2ltr NS/plasma substitutes
 O2
 Catheterise
 20units oxytocin+1L NS(60drops/mt)
 Monitor vital signs, urine output
Assess uterine consistency

flabby uterus firm and contracted uterus

Atonic uterus traumatic bleeding


Massage the uterus
If uterus
Methergine 0.2mg iv remains atonic
Oxytocin drip (10 units in 500
STEP
ml NS)
2
Foleys catheterisation
Examine expelled placenta and
membranes

If remains atonic
STEP 2
Exploration of uterus under GA
Blood transfusion
continue oxytocin drip
still atonic
15 methyl PGF2α 250 µg im
Or
Misoprost 1000 µg per rectum
If bleeding continues

Possibility of blood coagulation disorders


should be kept in mind
 If pt is hemodynamiclly stable they are transferred to
the radiology suite where under fluoroscopy.
 A femoral catheter is placed and threaded to the
hypogastric artery and then embolized.
 The material that is used for the embolization are
pledgets of gelatin sponge or gelatin sponge slurry –
these agents are used because they cause a temporary
occlusion that allows recannualization of the vessel
within a few weeks.
 The use of non-resorbable materials has been
associated with ischemia and necrosis.
 Inspect perineum, vagina and the cervix
under good light by speculum examination
 Haemostasis is achieved by catgut sutures
Commonly occurs between 8th and 14th day of
delivery
Causes:
 Retained bits of cotyledon or membranes
 Infection and separation of slough over a
deep cervicovaginal laceration.
 Endometritis and subinvolution
 Secondary haemorrhage from caesarean
section wound.
 Bright red bleeding
 Varying degree of anemia and evidences of
sepsis
 Internal examination
 Ultrasonography
Supportive therapy
 Blood transfusion
 Methergine 0.2mg im, bleeding is uterine in
original
 Antibiotics
Conservative treatment
If bleeding is slight and no apparent cause is
detected, a careful watch for 24 hours
Explore the uterus under GA
Products are removed by ovum forceps.
Gentle curettage
Methergin 0.2mg im
Materials collected- histological examination.
Bleeding from sloughing wound-hemostatic
sutures
Bleeding following CS- laprotomy
Hysterectomy