Dr. Ahmed Al Harbi Consultant Obstetrician & Gynecologist

1. POSTPARTUM HAEMORRHAGE Dr. Ahmed Al Harbi Consultant Obstetrician & Gynecologist

2. POSTPARTUM HAEMORRHAGE Definition Excess blood loss after delivery (>500ml ) Types - Primary PPH in the first 24 hours Secondary PPH up to 6 weeks. Massive PPh may be truly terrifying and its management requires experience and a clam sense of purpose that is best obtained by a thorough knowledge of protocols and participation in obstetric haemorrhage practice drills.

3. POSTPARTUM HAEMORRHAGE Aetiology and management The most important cause of massive PPH is uterine atony when the uterus is not contracted. Steps to stop bleeding 1. Massaging the uterus to cause it to contract 2. Bimanual compression 3. Uterine contraction is maintained by ergometrine and high dose intravenous Syntocinon 4. The bladder should be emptied 5. Prostaglandin F2-alpha (Haemabate) may be injected systemically or directly into the myometrium through the anterior abdominal wall.

4. POSTPARTUM HAEMORRHAGE Fibrin degradation products, which are increased in disseminated intravascular coagulation, may themselves act to relax the uterus. When bleeding persists despite uterine contraction, look for genital tract trauma and repair it. If the patient's haemodynamic status is not improving, or is deteriorating despite apparent control of revealed bleeding, consider hidden bleeding such as broad ligament or paravaginal bleeding or even uterine rupture. If conservative measures are not succeeding, move to surgical solutions sooner rather than later. Is the uterus empty? Can tamponade be effected by the use of intrauterine balloons such as the Rusch urological catheter? Rarely, bilateral internal iliac artery ligation or hysterectomy may be necessary.

5. POSTPARTUM HAEMORRHAGE Secondary PPH 1. Retained products or conception 2. Uterine infection Massive haemorrhage - Summon senior multidisciplinary help - Resuscitate - Replace and maintain fluid volume - Investigate status and cause of bleeding - Arrest blood loss

6. RETAINED PLACENTA Incidence Retained placenta is found in 2% of deliveries. The frequency of retained placenta is markedly increased (twenty-fold) at gestation <26 weeks, and even up to 37 weeks it remains tree times more common than at term. At term, 90% of placentas will be delivered within 15 minutes. Once the third stage exceeds 30 minutes, there is a ten-fold increase in the risk of haemorrhage.

7. RETAINED PLACENTA Management When the placenta is delivered, it should be inspected for completeness. Manual exploration of the uterine cavity is required. This will need to be undertaken under anaesthesia. If the placenta is retained as a whole, if it is within the uterus, the operator (wearing a gauntlet glove) should use the fingers of one hand, held as a 'spatula' to lift the placenta, whilst the hand on the abdomen balances these movements with downward pressure on the uterus. A gauze swab around the exploring fingers. Curettage with a blunt instrument. Antibiotics should be routinely administered.

8. PLACENTA ACCRETA Definition Placenta accreta is a retained placenta that is morbidly adherent to the uterine wall. Epidemiology Placenta accreta is a serious cause of haemorrhage. Lower segment Caesarean section appears to increase the risk of subsequent placenta praevia, and there is a well-documented associated between placenta praevia and previous Caesarean section and placenta accreta.

9. PLACENTA ACCRETA Management 1. Hysterectomy 2. Simple excision of the site of trophoblast invasion with over sewing of the area to the uterine 3. Internal iliac artery ligation

10. RETAINED PLACENTA Key points Anticipate haemorrhage, insert an intravenous infusion line, take blood for full count, group, save and catheterize Check that the placenta is not in the cervical canal or vagina prior to giving anaesthetic - Give prophylactic antibiotics Carry out manual removal – call senior help if there is accrete and/or heavy bleeding

11. HAEMATOMAS Vulval and paravaginalhaematomas Definition 1. Infralevatorhaematomas include those of the vulva and perineum, as well as paravaginalhaematomas and those occurring in the ischiorectalfossa 2. Supralevatorhaematomas spread upwards and outwards beneath the broad ligament or partly downwards to bulge into the walls of the upper vagina. These haematomas can also track backwards into the retroperitoneal space.

12. VULVAL & PARAVAGINAL HAEMATOMAS (a) Vulval (b) Para vaginal haematomas

13. VULVAL & PARAVAGINAL HAEMATOMAS Incidence and associations An acceptable definition would be any haematoma >4cm in diameter. The incidence of these is approximately 1:1000 deliveries.  The injury if frequently related to episiotomy  Intact perineum

14. VULVAL & PARAVAGINAL HAEMATOMAS Diagnosis Although a vulvalhaematoma is usually obvious, a paravaginalhaematoma may be missed, with no symptoms until shock develops. In general, the symptoms depend upon the size and rate of haematoma formation. Some genital haematomas may be up to 15cm in diameter. Management 1. Resuscitative measure 2. Surgical evacuation of the haematoma - haematoma is <5cm in diameter - not expanding

15. VULVAL & PARAVAGINAL HAEMATOMAS Observation to limit haematomas 1. Ice packs 2. Pressure dressings 3. Appropriate analgesia Need for surgical interventions 1. Haematomas >5cm in diameter 2. Rapidly expanding

16. VULVAL & PARAVAGINAL HAEMATOMAS Technique The incision should be made via the vagina. If a figure of eight suture does not achieve haemostasis, either a drain or a pack can be used.

17. MANAGEMENT OF HAEMATOMAS A trap for the unwary – beware occult haemorrhage in a 'collapsed' postpartum patient Large vulvalhaematomas benefit from drainage: - leave the wound open - leave a drain Broad ligament haematomas are usually managed conservatively

18. SUBPERITONEAL HAEMATOMAS Incidence and associations Subperitonealhaematomas (broad ligament) are much less common than genital haematomas: 1 in 20,000 deliveries. Spontaneous vaginal delivery, Caesarean section or forceps operations. Patients presenting immediately tend to show signs of lower abdominal pain and haemorrhage. Management A conservative approach is recommended. If It is not possible to maintain a stable haemodynamic state, prompt surgical exploration is recommended and a hysterectomy may be indicated.

19. INJURIES TO THE CERVIX After a vaginal delivery, the majority of women will have lacerations and/or bruising of the cervix.  Bleeding does not appear to be arising from the vagina or perineum and which continues despite a well-contracted uterus is an indication for examining the cervix.  Deep lacerations, and particularly those that involve the vaginal vault, need to be managed in theatre under anaesthesia. A laceration into the vault could extend forward to the bladder or laterally towards the uterine artery at the base of the broad ligament.

20. INJURIES TO THE CERVIX Management Repair For repairing a cervical tear, good visibility using right-angle retractors is essential. Using two pairs of ring forceps applied to the cervix at any one time, it is possible to inspect the whole circumference accurately. Identification of the apex of the tear is essential before commencing repair. Prompt recognition of the injury and action to control the bleeding are essential

21. INJURIES TO THE CERVIX Key Points The cervix often looks damaged but is very rarely associated with bleeding Ventouse prior to full dilation has been implicated in injury to the cervix

22. UTERINE RUPTURE Rupture, or tearing, of the uterus occurs most commonly in association with a previous scar, uterus, typically previous Caesarean section. Unrecognized perforation of the uterus in a previous termination of pregnancy. Almost all cases occur in labour. Patients Complain 1. Continuous abdominal pain 2. Vaginal blood loss 3. Contractions cease 4. The fetal heart rate pattern becomes abnormal

23. UTERINE RUPTURE  If rupture occurs in the second stage of labour, it is frequently not recognized. The fetus is usually delivered by ventouse or forceps for 'fetal distress'. The mother will bleed internally and start to show signs of circulatory collapse whilst complaining of abdominal discomfort.  Immediate laparotomy is necessary when uterine rupture is suspected. Sometimes it is possible to repair the uterus, but frequently the only safe way forward is hysterectomy.

24. UTERINE INVERSION

25. UTERINE INVERSION Descent of the uterine fundus into the cavity, through the cervix or even though the vulva – is a very rare event. The inverted uterus may be seen at the vulva, felt in the vagina or in lesser cases, identified as a dimpling of the uterine fundus on abdominal examination. The patient may be shocked out of all proportion to visible blood loss. Do not remove the placenta if it is still attached; this will increase the bleeding. Immediately replace the uterus through the cervix by manual compression.

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