BULE HORA UNIVERSITY

DEPARTMENT OF PUBLIC HEALTH

MANAGEMENT OF POSTPARTUM HEMORRHAGE

AND FAMILY PLANNING
PREPARED BY
1 Ahmed Mohamed ID 2099/12
2 Gashaw takele 0299/12
Moderator
Dr.Abel
 OUTLINES
 Objectives
 Definition , classification, ethiology,diagnosis and
management of PPH
 Definition of Family planning
 choosing method of contraception
Post partum hemorrhage
1. Excessive bleeding following delivery (>500 ml in vaginal delivery,
>1000 ml in CD and twin vaginal deliveries, >1500 ml following
cesarean hysterectomy)
2. A drop in Hct > 10% from baseline
3. Bleeding that makes a patient symptomatic and/or results in signs
of hypovolemia ( best definition)
4. Blood loss of > 15% of the total estimated blood volume
 CLASSIFICATION:
1. Primary PPH: PPH occurring within 24 hrs.
2. Secondary PPH: PPH occurring from 24 hrs until 6 wks
after delivery
1.Primary PPH
 Blood loss during the first 24hrs after delivery.
 Account for 98% PPH cases
Etiology
 Its etiologes easly remembered as 5Ts;
a. Tone
b. Trauma
c. Tissue
d. Thrombin
e. Traction
1. Uterine atony (80%)
• Uterine atony -Is failure of the uterus to contract
sufficiently
 Risk factors:
 uterine over distention (MG, polyhydramnios, fetal
macrosomia),
 induction or augmentation of labor,
 rapid or prolonged labor,
 grand multiparity,
 uterine infection,
 Cont.sis:
Diagno ..
 Hypotonic (boggy) uterus with brisk bleeding and expression
of clots when the uterus is massaged.

Managment
Principles
• Resuscitation of the mother
• Identification of the specific cause of PPH
• Call for help
 Uterine massage
 Bimanual uterine compression
 Cont...
Oxytocin
 IV oxytocin is the recommended first line uterotonic drug
 Dose: 20 – 40 units in 1-liter of NS or RL solution infuse
IV at fastest flow rate possible. or Give oxytocin 10 units
IM in women without IV access.
 Maintenance: infuse 20 units in 1 L IV fluids at 40
drops/min
 Cont...
 When oxtocin fails to produce adequate uterine tone,
second-line therapy must be initiated.
 The choice of a second-line agent depends on its side-
effect profile as well as its contraindications.
Cont...
Intrauterine tamponade balloons

 The Bakri tamponade balloon

 the BT-Cath
 the Belfort-Dildy Obstetrical Tamponade
System
Intrauterine tamponade balloons
Uterine packing
 safe, simple, and effective way to control PPH
 The pack should be made of long, continuous gauze (e.g.,
Kerlix) rather than multiple small sponges.
 When packing the uterus, placement should begin at the
fundus and progress downward in a side-to-side fashion to
avoid dead space for blood accumulation.
 Insert urinary catheter and give prophylactic antibiotic to
prevent urinary retention and infection
 Avoid prolonged packing (not more than 12 to 24 hours), and
 Follow vital signs and blood indices while the pack is in place
to minimize unrecognized ongoing bleeding.
 This method is currently being replaced by balloon
tamponade
 Surgical intervention
arterial ligation,
 The goal is to decrease uterine perfusion and subsequent bleeding.
 Success rates have varied from 40% to 95% depending on which vessels are
legated.
 Arterial ligation may be performed on
 the ascending uterine arteries,
 the uteroovarian arteries,
 the infundibulopelvic ligament vessels, and
 the internal iliac (hypogastric) arteries
Uterine comprassion sutures
.B-lynch sutures
.Hyman vertical sutures
. Pereira stitch
. Cho stitch
Hysterectomy
 The final surgical intervention for refractory bleeding due
to atony is hysterectomy, which provides definitive
therapy
 2.Trauma /Genital tract Laceration
 The second leading cause of postpartum hemorrhage
 Lowe genital tract laceration: perineal, valvular, vaginal,
and cervical
▶ upper genital tract: broad ligament and retroperitoneal
hematomas.
 Cont...
a. Uterine rupture
 Complete nonsurgical disruption of all uterine layers
 Uterine rupture is most common in women with a scarred
uterus, including those with prior cesarean delivery and
myomectomy
Risk factors
 Precipitate labour
 High parity
 Uterine anomaly
 Previous uterine rupture
 Previous fundal or high vertical hysterotomy
 Patients with a previous low vertical hysterotomy
 Macrosomia.
 Multiple gestation
 Clinical manifestations
 Fetal
 Fetal bradycardia with or without preceding variable or late
decelerations-most common(33-70%),Loss of fetal station in labor
Maternal:
 acute vaginal bleeding
 constant abdominal pain or uterine tenderness
 change in uterine shape
 cessation of contractions
 hematuria (if extension into the bladder has occurred )
Diagnosis
 Uterine rupture is suspected clinically but confirmed surgically.
 Laparotomy-complete disruption of the uterine wall with
hemoperitoneum and partial or complete extravasation of the
fetus into the maternal abdomen
 Cont...
 Management of patients in whom rupture is suspected before
delivery
 Stabilize patients with hemodynamic instability.
 Secure IV lines bilaterally with large bore cannulae.
 Resuscitation with IV fluids and blood products
 Prepare for operative interventions (e.g. determine HCT, BG and
RH, avail cross-matched blood and organize the OR)
Management of patients with uterine rupture at
laparotomy;
a. Repair
b. Hysterectomy
Cont...

Uterine Repair
 The goals of conservative surgery are
 to repair the uterine defect,
 control hemorrhage,
 identify damage to other organs (eg, urinary tract),
 minimize early postsurgical morbidity
 reduce the risk of complications in future pregnancies
 Hysterectomy
 It is the procedure of life saving
b. Genital tract Laceration
 The most common lower genital tract lacerations are perineal,
vulvar, vaginal, and cervical.
 Risk factors:
 Episiotomy extension
 instrumental deliveries
 precipitate labor
 fetal malpresentation or macrosomia
 delivery through undilated cervix
 shoulder dystocia
 Clinical manifestations
 Bright red (arterial) bleeding
 Large amounts of blood loss may occur in an unrecognized
hematoma
 Pain and hemodynamic instability are often the primary
presenting symptoms
Classification of perineal lacerations
a. First-degree lacerations involve injury to the skin and
subcutaneous tissue of the perineum
b. Second-degree lacerations extend into the fascia and
musculature of the perineal body
c. Third-degree lacerations extend through the fascia and
musculature of the perineal body and involve some or all of the
fibers of the external anal sphincter (EAS) and/or the internal
anal sphincter (IAS)
 Cont...
4. Fourth-degree lacerations – Injury to the perineum that involves
both the anal sphincter complex (EAS and IAS) and anal mucosa
 Episiotomy is a type of second degree perineal tear
 Third- and fourth-degree perineal lacerations are called Obstetric
anal sphincter injuries (OASIS)
 Management
 Repair the laceration with adequate exposure
 Perineal repairs are the most common types of genital
tract lacerations
3 Tissue (Retained products of conception)
 Retained products of conception-->uterine atony-->PPH
Diagnosis;
 when spontaneous expulsion of the tissue has not occurred
within 30 to 60 minutes of delivery
 Risk factors:
 retained placenta
 mismanagement of third stage of labor
 untimely use of uterotonics
 chorioamnionitis
Clinical manifestations
 It present with uterine bleeding and associated atony
 Manual exploration is both diagnostic and therapeutic.
 If manual access to the uterine cavity is difficult or limited owing to
maternal body habitus or inadequate pain relief, transabdominal
or transvaginal ultrasound may be used to determine whether
retained placental fragments are present
Diagnosis:
when spontaneous expulsion of the tissue has not occurred
within 30 to 60 minutes of delivery.
 Management
 Manual extraction
 Nitroglycerin (50 to 200 µg IV) provides rapid uterine relaxation to
assist with removal of the retained tissue
Uterine curettage.

-Uterine curettage may be performed in a delivery room;

however, excessive bleeding mandates that an OR be used
for
the procedure.
Either a large blunt (Banjo or Hunter) curette or vacuum
suction curette can be used.
 Transabdominal ultrasound guidance is helpful in
determining when tissue evacuation is complete.
4. Thrombin(coagulopathy)
Can be: Acquired or Hereditary
Acquired
 Idiopathic thrombocytopenic purpura
 Thrombocytopenia with preeclampsia
 HELLP syndrome
 Sepsis
 Placental abruption
 Amniotic fluid embolus
 Severe hemorrhage
 Hereditary
 Hypotension out of proportion to blood loss
 Micro angiopathic hemolytic anemia,
 Acute lung injury,
 Acute renal failure, and
 Ischemic end-organ tissue damage
Diagnosis:
 Consumptive coagulopathy is a clinical diagnosis that is
confirmed with laboratory data
 coagulopathy should be suspected in patients with one or
more of the following:
 low fibrinogen level (1.5), and/or aPTT
 Cont...
Management
 Identify and correct the underlying etiology- the most important.
 Rapid replacement of blood products and clotting factors.
 Maintain adequate oxygenation and normothermia
5. Traction(uterine inversion)
Collapse of the fundus in to the uterine cavity
 It is classified it to:
Three, based on timing:-
 Acute (within 24 hours of delivery)
 Sub-acute (>24 hours postpartum but<4 weeks)
 Chronic(> 1 month postpartum)
 Four, based on degree of inversion:-
 First degree (incomplete)
 Second degree (complete)
 Third degree (prolapsed)
 Fourth degree (total)
Cont....
Risk factors include:-
 uterine over-distention
 fetal macrosomia
 rapid labor and delivery
 congenital uterine malformations
 retained placenta
 short umbilical cord
Clinical manifestation
 Incomplete-subtle in its clinical findings,
 Complete-brisk vaginal bleeding- inability to palpate the
fundus abdominally, and maternal hemodynamic
instability
Dignosis

Clinically with bimanual examination, during which the

uterine fundus
is palpated in the lower uterine segment or within the
vagina.
o Sonography-to confirm the diagnosis if the clinical
examination is unclear
Management
o fluid resuscitation
o The uterus must be replaced to its proper orientation to
resolve the
hemorrhage, this best accomplished in an OR with the
assistance of an anesthesiologist.
manual repositioning
 the uterus and cervix should initially be relaxed with
nitroglycerin (50 to 500 µg), a tocolytic agent (magnesium sulfate
or β-mimetic), or an inhaled anesthetic
 gentle manual pressure is applied to the uterine fundus to return
it to its proper abdominal location
 Uterotonic therapy should then be given to assist with uterine
contraction and to prevent recurrence of the inversion
surgical correction- includes:
 The Huntington procedure: a laparotomy with serial
clamping
and upward traction of the round ligaments to restore the
uterus
to its proper position.
 The Haultain procedure: can be attempted, if the above
technique fails
 vertical incision within the inversion and subsequent
repositioning of the fundus
 Laparoscopic assisted repositioning, and
 Cervical incisions with manual uterine repositioning.
Late PPH

 PPH occurring from 24 hours to 12 weeks after

delivery
 Unlike primary PPH, bleeding usually is not
catastrophic
Etiology
Common causes of secondary PPH are:
 Retained products of conception-most common cause
secondary PPH
 Sub involution of the placental bed
 Infection
Rare causes include:
 Inherited or acquired bleeding diatheses
 Pseudoaneurysm of the uterine artery, internal pudendal
artery, vaginal artery, or vulvar labial artery
 Arteriovenous malformations
 Choriocarcinoma
 Undiagnosed carcinoma of the cervix
Management

 Treat anemia and shock


Specific management
 Sub-involution: Oxytocin in drip or ergometrine (1 tablet PO
twice a day for 2-
3day). If bleeding is not controlled with these drugs give
misoprostol 800 µg
sublingually or rectally
-Infection: Antibiotics
 NG
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INTRODUCTION
Family planning:
 is defined as the ability of individuals and couples to anticipate
and attain their desired number of children and the spacing and
timing of their births.
 It is achieved through use of contraceptive methods and the
treatment of involuntary infertility.
 Family planning is a key life-saving intervention for mothers and
their children by which it can avert more than 42% of maternal
deaths and 10% of child mortality if couples space their
pregnancies more than 2 years.
CHOOSING A METHOD OF CONTRACEPTION
 Providers need to consider the following factors while counselling clients for
contraceptive method choice:
 Availability of a given method
 Efficacy
 Convenience
 Safety
 Duration of action Reversibility and time to return of fertility
 Effect on uterine bleeding Frequency of side effects and
complications
 Protection against sexually transmitted diseases
 Medical contraindication
POSTPARTUM FAMILY PLANNING (PPFP)
Postpartum family planning (PPFP)
 is defined as the prevention of unintended pregnancy
and closely spaced pregnancies through the first 12
months following childbirth.
Timing could be:
 Post-placental– within10 minutes after delivery of placenta (e.g.
IUD, tubal ligation during CS).
 Immediate postpartum- within 48 hours after delivery (e.g. IUD,
bilateral tubal ligation with mini-laparotomy, vasectomy, implants ).
 Early postpartum – 48 hours up to 6 weeks (lactational
amenorrhea, condoms, implants, mini pills)
 Extended postpartum – 6 weeks up to one year after birth.
Unique considerations for providing PPFP (IUCD, implants, tubal
legation, vasectomy, condoms, lactational amenorrhea
COUNSELLING
 Clients can be counselled during:-
 Preconception
 Antenatal
 Intrapartum but not during active labor  Immediate post-partum
 During postpartum, immunization, under five and other visits
 During counselling the following issues need to be addressed:
 Ensure that clients have made their decision based on full, free
and informed choice
 Counsel on safer sex including use of condoms for dual
protection from sexually transmitted infections (STI) or HIV and
pregnancy, particularly for those clients who are at risk for STI /
HIV.
 Counsel clients regarding possible side effect, danger sign and
complications related to the contraception
 Postpartum Family planning
 Explain that she can become pregnant as early as four weeks
after delivery if she is not exclusively breastfeeding.
 If coupes want to have more children, advise them to wait at least
for 2 years after giving live birth and at least 6 month after failed
pregnancy (e.g. Abortion).
 Information on when to start a method after delivery varies
depending on whether a woman is breastfeeding or not
Post-abortion family planning
 All clients with post abortion and safe abortion should be
counselled on all contraception options before, during and after
the procedure as part of abortion care.
 In the post-abortion period, a woman should start using
contraceptives as soon as possible.
 All short acting contraceptives (COC, Depo-Provera, Condoms
etc.) can be initiated immediately after abortion.
 Cont...
 All long acting (IUCD / Implants) and permanent contraceptives
can be initiated immediately; but, if there is a suspicion of
incomplete uterine evacuation or any uterine infection IUCD
insertion or female sterilization by tubal ligation should delayed
until the woman is treated
Linkage and referral
 Family panning clients should be referred to other facility if:
 The chosen contraceptive method is not available in the facility
e.g. permanent contraceptives.
 The contraceptive related complication is beyond the health
center’s capacity
References
1 Obstetric management protocol (MAY 2021)
2 Medstar Obstetric and gynecology( second edition)
3 STG- Final fourth edition(2021)
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