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Postpartum Hemorrhage Management: Essential Guidelines

Understand the definition, incidence, etiology, prevention, and management of postpartum hemorrhage. Learn about predisposing factors, diagnosis, and effective interventions to control bleeding after delivery. This comprehensive course covers essential techniques and approaches to successfully manage postpartum hemorrhage situations.

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Postpartum Hemorrhage Management: Essential Guidelines

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  1. King Khalid University Hospital Department of Obstetrics & Gynecology Course 481 Postpartum Haemorrhage Haitham A A Badr, MD Security Forces Hospital

  2. Definition Any blood loss than has potential to produce or produces hemodynamic instability About 5% of all deliveries Incidence

  3. Definition >500ml after completion of the third stage, 5% women loose >1000ml at vag delivery >1000ml after C/S >1400ml for elective Cesarean-hyst >3000-3500ml for emergent Cesarean-hyst

  4. woman with normal pregnancy-induced hypervolemia increases blood-volume by 30-60% = 1-2L therfore, tolerates similar amount of blood loss at delivery hemorrhage after 24hrs = late PPH

  5. Hemostasis at placental site At term, 600ml/min of blood flows through intervillous space Most important factor for control of bleeding from placenta site = contraction and retraction of myometrium to compress the vessels severed with placental separation Incomplete separation will prevent appropriate contraction

  6. Etiology of Postpartum Haemorrhage

  7. Predisposing factors- Intrapartum • Operative delivery • Prolonged or rapid labour • Induction or agumentation • Choriomnionitis • Shoulder dystocia • Internal podalic version • coagulopathy

  8. Predisposing Factors- Antepartum • Previous PPH or manual removal • Abruption/previa • Fetal demise • Gestational hypertension • Over distended uterus • Bleeding disorder

  9. Postpartum causes • Lacerations or episiotomy • Retained placental/ placental abnormalities • Uterine rupture / inversion • Coagulopathy

  10. Prevention • Be prepared • Active management of third stage • Prophylactic oxytocin • 10 U IM • 5 U IV bolus • 10-20 U/L N/S IV @ 100-150 ml/hr • Early cord clamping and cutting • Gentle cord traction with surapubic countertraction

  11. Remember! • Blood loss is often underestimated • Ongoing trickling can lead to significant blood loss • Blood loss is generally well tolerated to a point

  12. Management- • talk to and assess patient • Get HELP! • Large bore IV access • Crystalloid-lots! • CBC/cross-match and type • Foley catheter

  13. Diagnosis ? • Assess in the fundus • Inspect the lower genital tract • Explore the uterus • Retained placental fragments • Uterine rupture • Uterine inversion • Assess coagulation

  14. Management- Assess the fundus • Simultaneous with ABC’s • Atony is the leading case of PPH • Bimanual massage • Rules out uterine inversion • May feel lower tract injury • Evacuate clot from vagina and/ or cervix • May consider manual exploration at this time

  15. Management- Bimanual Massage

  16. Management- Manual Exploration • Manual exploration will: • Rule out the uterine inversion • Palpate cervical injury • Remove retained placenta or clot from uterus • Rule out uterine rupture or dehiscence

  17. Replacement of Inverted Uterus

  18. Management- Oxytocin • 5 units IV bolus • 20 units per L N/S IV wide open • 10 units intramyometrial given transabdominally

  19. Replacement of Inverted Uterus

  20. Replacement of Inverted Uterus

  21. Management- Additional Uterotonics • Ergometrine (caution in hypertension) • .25 mg IM 0r .125 mg IV • Maximum dose 1.25 mg • Hemabate (asthma is a relative contraindication) • 15 methyl-prostaglandin F2 alfa • O.25mg IM or intramyometrial • Maximum dose 2 mg (Q 15 min- total 8 doses) • Cytotec (misoprostol) PG E1 • 800-1000 mcg pr

  22. Management- Bleeding with Firm Uterus • Explore the lower genital tract • Requirements • Appropriate analgesia • Good exposure and lighting • Appropriate surgical repair • May temporize with packing

  23. Management – ABC’s ENSURETHAT YOU ARE ALWAYS AHEAD WITH YOUR RESUSCITATION!!!! • Consider need for Foley catheter, CVP, arterial line, etc. • Consider need for more expert help

  24. Management- Evolution • Panic • Panic • Hysterectomy • Pitocin • Prostaglandins • Happiness

  25. MANAGEMENT OF PPH

  26. Management- Continued Uterine Bleeding • Consider coagulopathy • Correct coagulopathy • FFP, cryoprecipitate, platelets • If coagulation is normal • Consider embolization • Prepare for O.R.

  27. Surgical Approaches • Uterine vessel ligation • Internal iliac vessel ligation • Hysterectomy

  28. Conclusions • Be prepared • Practice prevention • Assess the loss • Assess the maternal status • Resuscitate vigorously and appropriately • Diagnose the cause • Treat the cause

  29. Summary: Remember 4 Ts • Tone • Tissue • Trauma • Thrombin

  30. “TONE” Rule out Uterine Atony Palpate fundus. Massage uterus. Oxytocin Methergine Hemabate Summary: remember 4 Ts

  31. “Tissue” R/O retained placenta Inspect placenta for missing cotyledons. Explore uterus. Treat abnormal implantation. Summary: remember 4 Ts

  32. “TRAUMA” R/O cervical or vaginal lacerations. Obtain good exposure. Inspect cervix and vagina. Worry about slow bleeders. Treat hematomas. Summary: remember 4 Ts

  33. “THROMBIN” Check labs if suspicious. Summary: remember 4 Ts

  34. Thank You ! ! !

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