Postpartum hemorrhage

Fitria Siswi Utami, S.Si.T., MNS

Definition
 Blood loss > 500 ml
after 3rd stage of labor
after vaginal delivery

Blood loss > 1000 ml

after cesarean section
Classification
 Early PPH

Uterine atony

Retained placental fragment

Retained Placenta

G Genital tract laceration

P Placenta adherence

Uterine inversion

Saksiriwuttho.P
 Late PPH

Endometritis

Retained placental fragment

Coagulopathy

Saksiriwuttho.P
Uterine atony
 Uterine atony

The most common cause

of early PPH
Uterine atony
 Uterine atony

contraction of the
uterine muscle
Normally compresses the
vessels and
reduces flow
 Uterine atony

A condition in which the

uterine corpus does not
constrict properly

Continued blood loss

from the placental site
 Uterine atony

Risk factors

Overdistended uterus  multiple

pregnancy, macrosomia

Fatiqued uterus  prolonged labor, oxytocin

Intrauterine infection  prolonged PROM

Abnormal uterus  myoma uteri,

 Uterine atony

Can’t palpate Uterine

globular uterus atony
Uterine atony

Management

1. Uterine massage

2. Medical treatment
 Uterine atony

3. Can not control bleeding

1. Call for help!!!!!!!
2. Crystalloid intravenous fluid plus oxytocin
3. If anemia blood transfusion
4. Birth canalinjury repaired
5. Retained piece of placenta curettage
6. Retained Foley catheter record input and
output
 Uterine atony
4. Resuscitation
5. Bimanual uterine compression
6. Surgery
Definition: Retained placental tissue
in endometrial cavity

Normally after the placenta

is delivered, uterus
contracts down to close off
all the blood vessels inside
the uterus.
But in retained placenta, the
uterus cannot contract
properly, so the blood
vessels inside will continue
to bleed
 Retained Retained placenta
placenta

Retained placental fragment

Etiology

1.Retained placental fragments

- Placenta succenturiata

- Placenta adherence
2.Retained placenta

- Placenta adherence
- Constriction Ring ,
cervical clamp
Diagnosis

- Placental examination after birth

- Ultrasound

Treatment

- Uterine curettage
 Diagnosis
No placental delivery
in 30 minutes

Treatment

- Manual removing
Manual removing

- Blood,Fluid
- Empty bladder
- Antibiotic
(Ampicillin +Metronidazole)
- Manual removal
under anaesthetic
Genital tract lacerations
 Genital tract lacerations

Etiology

- Precipitated labor

- Face precentation

- Breech delivery

- Inappropriate episiotomy
 Genital tract lacerations

Diagnosis

– No uterine atony
– Seen genital tract lacerations
Genital tract lacerations

Types

1.Perineal tear
2.Vaginal tear
3.Cervical tear
 Genital tract lacerations
Vaginal tear

•Usually longitudinal

•Forceps or vacuum operation, but

they may even develop with
spontaneous delivery

•Lacerations of the anterior vaginal

wall in close proximity to the urethra
are relatively common
 Genital tract lacerations
Management

-They are often superficial with

little to no bleeding, and repair is
usually not indicated

-If lacerations are large enough to

require extensive repair, difficulty
in voiding can be anticipated and
an indwelling catheter placed
 Genital tract lacerations

Cervical tear

-Usually, less than 0.5 cm. and

upper third of the vagina  no
need for repair

-Deep cervical tears require

surgical repair
Genital tract lacerations
Genital tract lacerations
Placenta adherence
Placenta adherence

Classification

- Placenta accreta
- Placenta increta
- Placenta percreta
Placenta adherence
 Placenta adherence

Risk factors

- Placenta previa
- Previous cesarean section
- Previous curettage
- Multiparity
Placenta adherence

Diagnosis

-Ultrasound
-MRI
Placenta adherence
 Placenta adherence

Management

1. Supportive therapy
- Blood replacement therapy
- Intravenous fluid

2. If placenta accreta occurred

try to separate it from uterine wall

3. Hysterectomy
Uterine inversion
 Uterine inversion

Definition

Uterine fundus is pulled

down through cervix
Uterine inversion
Uterine inversion
Uterine inversion
 Uterine inversion

Diagnosis

1. Seen uterus from vulva

2. Cup-like defect from uterine
fundus
3. Per vaginal examination
4. Ultrasound
 Uterine inversion
Management

Conservative treatment
1.IV fluid , blood transfusion
2.Anesthesia (halothane) and push
back the uterus
3.Oxytocin and stop halothane
immediately
4.Observation for hemorrhage and
recurrent uterine inversion
5.If failed conservative treatment,
surgery may be indicated
Uterine inversion
Late postpartum hemorrhage
Late postpartum hemorrhage

Etiology

- Endometritis

- Retained placental
fragments

- Disorders of coagulation
Late postpartum hemorrhage

Initial treatment

1. IV or bloodtransfusion
2. Oxytocin
 Endometritis

-Gram-negative enteric bacteria :

E.coli,Klebsiella,Enterobacter,Pseudomo
nas,Serratia

-Gram-negative anaerobes : Bacteroides

-Gram-positive bacteria : S. pyogenes

-Viruses : Varicella

-Fungal infection
 Endometritis
Risk factors

•Cesarean delivery

•Prolonged rupture of membrane >24 hrs.

•Prolonged labor with multiple vaginal

examinations

•Prolonged internal fetal monitoring

•Maternal anemia
 Endometritis
Sign and symptom

- Foul smell vaginal discharge

- Bleeding per vagina
- Anemia
- Fever
Endometritis

Lab investigation

- Increased WBC
 Endometritis

Management

1.Ampicillin 2 gm iv q 6 hrs + Gentamicin 5

mg/kg iv q 24 hrs + Metronidazole 500 mg iv q 8
hrs
2.Clindamycin 600 mg iv q 6 hrs +
Gentamicin 5 mg/kg iv q 24 hrs
 Endometritis

Indication for surgery

- Abscess accumulation

- Gas gangrene at uterus

- Uterine infection with

surgical wound seperation
Retained placental fragments

- Curettage