POSTPARTUM

HEMORRHAGE
Parul
Yudi
Shanro
Ayu
Helen

Aishah
Padma
Stesy
Dneska
Fajar

DEFINITION
The

loss of 500 ml of blood or more after

completion of the third stage of labor

Is

a description of an event rather than

diagnosis
About

5 % of women delivering vaginally

lost more than 1000 ml of blood

CLASSIFICATION
Early

postpartum hemorrhage
hemorrhage in the first 24 hours
after delivery

Late

postpartum hemorrhage after

the first 24 hours

ETIOLOGY
Bleeding

Site

from Placental Implantation

Hypotonic myometrium uterine atony

Retained placental tissues
Trauma

to the Genital Tract

Large episiotomy
Lacerations of perineum, vagina, or cervix
Ruptured uterus

Coagulation

defects

CLINICAL CHARACTERISTICS
There

may be no sudden massive

hemorrhage, but steady rather
bleeding
The effects of hemorrhage blood
volume, pregnancy inducedhypervolemia, degree of anemia
Women with severe preeclampsia vs.
normotensive women

DIAGNOSIS
Bleeding

from uterine atony or from

laceration?
Can be differentiated predisposing
risk factor and the condition of the
uterus
Sometimes may be caused by both
INSPECTION !

THIRD STAGE BLEEDING

As

the result of transient partial

separation of the placenta
Duncan mechanism
Schultze mechanism
Delivery of placenta by cord traction,
especially when the uterus is atonic,
may cause uterine inversion !

THIRD STAGE BLEEDING (2)

When

do we decide to do manual
placenta?
When is exactly the prolonged third
stage bleeding?

TECHNIQUE OF MANUAL
REMOVAL
Adequate

analgesia, anesthesia,

aseptic !
After grasping the fundus through the
abdominal wall with one hand, the
other hand is introduced into the
vagina and passed into the uterus
As soon as the placenta is reached
ulnar border of the hand insinuated
between it and the uterine wall

UTERINE ATONY
Failure

of the uterus to contract

properly following delivery
Overdistended uterus women with
large fetus, multi fetus, hydramnios,
high parity, or with general anesthesia
May happen in the third stage or four
stage

UTERINE ATONY (2)

How to diagnose ?
Soft

consistency of uterus
Massive bleeding
High fundus
No laceration of the vagina or cervix
No part of placenta
Can be accompanied by hypovolemic
shock

RETENTIO PLACENTA
If

the placenta is not yet delivered

after 30 minutes
Caused by :
a. Functional
- Contraction

- Placenta
b. Patology
Placenta accreta, increta, percreta

GENITAL TRACT
LACERATION

Characteristic :

Good contraction
Continuous bleeding

According to the location :

Perineal
Vaginal
Levator ani
Cervix
Ruptured of utery

INVERSION OF THE UTERY

Complete

uterine inversion uterine

fundus in vagina
Incomplete uterine inversion
uterine fundus does not come out of
ostium
Prolaps inversion uterine fundus
can be seen out of vulva

INVERSION OF THE UTERINE

(2)
Caused by :
1. tonus otot rahim yang lemah
2. tekanan atau tarikan pada fundus
(tekanan intraabdominal, tekanan
dengan tangan, dan tarikan pada
tali pusat)
3. kanalis cervikalis yang longgar

INVERSION OF THE UTERINE

(2)
Characteristic

Life threatening hemorrhage

Signs of shock
Unpalpable uterine fundus
Reddish tumor out of the vulva or
in the vagina

GENERAL MANAGEMENT
Obtain

help !
Quick examination vital signs
Management of shock
Make sure the contraction of uterus is
adequate massage, oxitocyn
Intravenous line
Cathetherization
Check the placenta and the genital tract
If the bleeding is continue Bedside
Clot Test !