POST PARTUM

HEMORRHAGE
(PPH)
Nasheel Kaur Gill
Supervisor : Dr Kosilla
Definition
- Primary PPH: Loss of 500ml or more of blood from the genital tract
within 24 hours of birth of a baby

- Secondary PPH: Abnormal / excessive bleeding from birth canal

between 24 hours to 6weeks postnatally

- Minor: 500-1000ml Moderate:

1001 – 2000ml
- Major: >1000
Severe: > 2000 ml
Cause and Risk Factors
1. TONE
2. TISSUE

3. TRAUMA
4. THROMBIN
Estimate
Blood
Loss
Management
-Measures for minor PPH (blood loss 500–1000 ml) without clinical
shock:
- Call for help
-intravenous access (one 14-gauge cannula)
-group and screen, full blood count, coagulation screen,
-pulse, respiratory rate and blood pressure recording every 15
minutes
- insert CBD to monitor urine output
-commence warmed crystalloid infusion
Major PPH
RED ALERT
INDICATIONS

DECISION FOR RED ALERT BY MO/SPECIALIST

CALL 5888
STATE THE PLACE

OPERATOR WILL INFORM RESPECTIVE TEAM MEMBERS

AND INDICATING THE PLACE CLEAR
O&G, ANAEST, SISTER ONCALL, LAB

PATIENT ATTENDED
 Types of Fluids
1. Crystalloid
- Volume expanders
- Isotonic
- 1/4th remains intravascular
- Ratio of blood loss to fluid 1:3
- Initial resuscitation need to replace depleted intravascular volume
- Eg NS/HM/D5

2. Colloids
- Plasma expanders
- Contains large molecules (proteins)  high osmolarity  increases oncotic P and draws fluid
from interstitial and intracellular to vascular compartment
- Ratio of blood loss to fluid 1: 1.5
- Eg Gelafundin

3. Blood products
- Ratio 1:1
BAKRI BALLOON
- Used as tamponade to
decrease hemorrhage
secondary to uterine atony
- Temporary control or
reduction of PPH when
conservative management is
desired and uterotonics fail to
cause sustained uterine
contractions and satisfactory
control of haemorrhage
Bakri balloon placement after SVD
- Empty bladder and inspect uterine cavity
(clear from placental fragment)
- Clean surgical field
- Insert the balloon digitally into the
uterus under US guidance, ensure entire
balloon passes the cervical canal above
the internal os
- Inflate with 500ml sterile saline
- Pack vagina with iodine soaked vaginal
pack to maintain correct balloon
placement
- Apply gentle traction to shaft of balloon,
to maximize effect of tamponade to
lower uterine segment. Secure ballon
shaft to patient leg.
- Connect drainage port to fluid collecting bag to monitor bleeding.
- Monitor I/O balance, PR, BP, pallor, active bleeding, cramping.
- Ensure adequate analgesia and give prophylactic antibiotic.
- Remove after 24 H (infection and tissue necrosis)
- If bleeding recur, do not re-insert the balloon. Proceed with other
treatment option.
Contraindications
• Retained POC
• Heavy arterial bleeding requiring surgical exploration or angiographic
embolization
• Cervical cancer
• Congenital uterine anomaly
• Uterine distorting pathology (leiomyoma)
• Suspected uterine ruptured
• Purulent infection of the vagina, cervix, or uterus
• Allergy to balloon material (Silicone)
• DIVC
 Retained Placenta

• Diagnosed after 30 min (CCT applied), if not after 1 H. Book patient for
MRP within 30 min after diagnosis.
• Done under spinal/ GA in the OT
• Start IV pitocin infusion (40 units) if patient bleeding
• If unable to find plane between the placenta and uterus, think of
morbidly adherent placenta. Abandon the procedure if patient is not
bleeding.
• Start oxytocin IV pitocin drip 40 units after MRP
Perineal Tears

- First-degree tear: Injury to

perineal skin and/or vaginal
mucosa
- Second-degree tear: Injury to
perineum involving perineal
muscles but not involving the
anal sphincter.
Perineal Tears
- Third-degree tear: Injury to
perineum involving the anal
sphincter complex:
- Grade 3a tear: Less than 50% of
external anal sphincter (EAS)
thickness torn
- Grade 3b tear: More than 50% of
EAS thickness torn
- Grade 3c tear: Both EAS and
internal anal sphincter (IAS) torn
- Fourth-degree tear: Injury to
perineum involving the anal
sphincter complex (EAS and IAS)
and anorectal mucosa
Perineal Tears
- 3rd and 4th degree repair should take place in an operating theatre,
under regional or general anaesthesia, with good lighting and with
appropriate instruments
- If there is excessive bleeding, a vaginal pack should be inserted and
the woman should be taken to the theatre as soon as possible.
- A rectal examination should be performed after the repair to ensure
that sutures have not been inadvertently inserted through the
anorectal mucosa. If a suture is identified it should be removed.
Uterine Rupture
- An urgent laparotomy is required once uterine rupture is diagnosed
to examine and repair the uterine rupture.
- Simple tears can be repaired
- Hysterectomy maybe necessary
Antepartum Haemorrhage
(APH)
- Antepartum haemorrhage (APH) is defined as bleeding from or in to
the genital tract, occurring from 24+0 weeks of pregnancy and prior to
the birth of the baby
- Complicates 3–5% of pregnancies
- A leading cause of perinatal and maternal mortality worldwide
- Recurrent APH is the term used when there are episodes of APH on
more than one occasion
- Causes include
- Placental causes: placental abruption; placenta praevia
- Fetal cause: vasa praevia
- Maternal causes: vaginal trauma; cervical ectropion; cervical carcinoma;
vaginal infection and cervicitis
- It is not uncommon to fail to identify a cause for APH when it is then described
as ‘unexplained APH’
1. History
- How much bleeding?
- Triggering factors (e.g. postcoital bleed)
- Associated with pain or contractions?
- Is the baby moving?
- Last cervical smear (date/normal or abnormal)?
2. Examination
- Pulse, blood pressure
- Is the uterus soft or tender and firm?
- Fetal heart auscultation/CTG
- Speculum vaginal examination, with particular importance placed on visualizing the
cervix (having established that placenta is not a praevia, preferably using a portable
ultrasound machine).
3. Investigations Depending on the degree of bleeding
- full blood count, clotting
- if suspected praevia/abruption GXM
- Ultrasound (fetal size, presentation, amniotic fluid, placental position and
morphology).
Corticosteroid
- Clinicians should offer a single course of antenatal corticosteroids to
women between 24+0 and 34+6 weeks of gestation at risk of preterm
birth
Abruptio Placenta
- Placental abruption is the
premature separation of the
placenta from the uterine wall
- The bleeding is acutely dangerous
for both the mother and fetus
- Warning signs: maternal collapse,
feeling cold, light-headedness,
restlessness, distress and panic,
painful abdomen, vaginal
bleeding, absence or reduced fetal
movements and tense painful
abdomen. CTG may reveal
evidence of fetal distress.
 Abruptio in previous Drug misuse
Smoking
pregnancy
Maternal thrombophilias
First trimester bleeding
Pre-eclampsia
Abdominal trauma

IUGR

Intrauterine infection
RISK FACTORS
PROM/PPROM

Pregnancy following ART

Non- vertex presentation

Polyhydramnios Multiparity
Advanced maternal age
Placenta Previa
• This condition is known as Low-lying Placenta or Placenta Previa in
pregnancy at more than 16 weeks of gestation on TAS/TVS:
• Low-lying placenta if the placental edge is <20mm from the internal os
• Placenta Previa if placenta lies directly over the internal os (usually diagnosed
after 28 weeks as the lower segment fully developed)
Clinical Classifications

Low-lying placenta: lower edge of the placenta lies less than 2 cm from the internal cervical os
Marginal previa: placenta reaches the internal cervical os
Partial previa: placenta partially covers the internal cervical os
Complete previa (total previa): placenta completely covers the internal cervical os
Diagnosis
• The classic presentation of PP is painless PV bleed in a previously
normal pregnancy
• Mean gestational age at onset of bleeding – 30 weeks
• Between 4% - 6% of patients have some degree of PP on Ultrasound
scan before 20 weeks of gestation
• With the development of lower uterine segment, a relative upward
placental migration occurs – with 90% of these resolving by the 3rd
trimester
• Complete/Total Placenta Previa is the least likely to resolve, with only
10% of cases resolving by the 3rd trimester
Diagnosis
• TAS has an accuracy of 95% for placenta previa detection
• If the placenta is implanted posteriorly and the fetal vertex is low,
• the lower margin of the placenta is obscured
• then the diagnosis of the placenta previa may be missed
• TVS can accurately diagnose Placenta Previa in virtually all cases
• RCOG Guidelines recommended TVS approach more than TAS for the
diagnosis of Placenta Previa
Physical Examination
• A pelvic examination SHOULD NOT be performed until Placenta Previa
has been excluded by ultrasound
• Once excluded, a sterile speculum examination can be safely done to
rule out genital tears or lesions (e.g. cervical/vaginal erosions,
cervical/vaginal lesions including cancer)
Mode of Delivery
• If the bleeding is severe enough to be life threatening, then after immediate
resuscitation of the patient, an EMLSCS is done regardless of the gestational
age of the fetus
• If the bleeding is not life threatening, the patient can be managed
conservatively provided the fetus is still premature
• Vaginal delivery only attempted in minor Placenta Previa (Type 1 and Type 2
Anterior)
• In PP Type 2 Posterior, the placenta obstruct the fetal head from descent into
the pelvis
• Also, the fetal head may compress the placenta on its descent – may
compromise the fetal circulation
Vasa Previa
- Occurs when fetal vessels traverse the fetal membranes over the
internal cervical os
- These vessels may be from either a velamentous insertion of the
umbilical cord or may be joining an accessory (succenturiate) placental
lobe to the main disc of the placenta
- The diagnosis is usually suspected when either spontaneous or
artificial rupture of the membranes is accompanied by painless fresh
vaginal bleeding from rupture of the fetal vessels
- This condition is associated with a very high perinatal mortality
- If the baby is still alive, once the diagnosis is suspected the immediate
course of action is delivery by emergency caesarean section