Post Partum Hemorrhage

Sapti Djula, S.Kep., MPH

Fakultas Keperawatan
UNAI

3/9/2019 shwdjula@yahoo.com
Definition of PPH

• Blood loss > 500ml in the first

24 hours after delivery (with
average blood loss at Cesarean
delivery of 1000ml)

• drop in hematocrit of 10 points

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Epidemiology of PPH

• PPH occurs in approximately 4% of

vaginal deliveries

• 25% of 430 maternal deaths/100,000

births worldwide

• Major cause of U.S. maternal

mortality at 7.5/100,000

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Complications
• Hemodynamic instability
• Hemorrhagic shock – Coma, Death
• Risks of transfusion
• Iron deficiency anemia (with its
fatigue and newborn care
difficulties)
• Prolongation of hospital stay
• Pituitary affects on lactation, or
infarction

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Risk Factors -
Antepartum
• Pre-eclampsia
• Nulliparity
• Multiple gestation
• Previous PPH
• Previous Cesarean Section

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Risk Factors -
Postpartum

• Augmented labor
• Arrest of descent
• Assisted delivery (forceps/vacuum)
• Third Stage longer than 30 minutes
• Episiotomy, mediolateral or midline
• Laceration (cervical/vaginal/perineal)

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 • from Williams, 20th Ed. p. 762
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Key Management Issues

• Prevention
• Early Recognition
• Immediate Appropriate
Intervention
 Blood Loss Signs &
Symptoms
Blood Loss (%) Blood Signs & Symptoms
Pressure
500-1000ml (10-15) normal Palpitations,
dizziness, tachycardia
1000-1500ml (15-25) Slightly low Weakness, sweating,
tachycardia
1500-2000ml (25-35) 70-80 Restlessness, pallor,
oliguria
2000-3000ml (35-45) 50-70 Collapse, air hunger,
anuria
>2500cc blood loss – 50% mortality if not managed urgently &
appropriately
 Initial Management
• ABC’s
• Call for help
• Mobilize team (staff, anesthesia, blood
bank etc)
• IV access
• Fluid resuscitation
• Examine patient including fundal
massage, dx trauma/ inversion/ other
etiologies, and fundal massage
• Foley catheter
• Blood work (CBC, coag profile, cross
match)
• Reverse coagulation abnormality
 Uterotonic Medications

• Oxytocin
• Ergot
• Hemabate
• Misoprostol
• Vasopressin
 Drug Therapy For PPH
Drug Dose Side Effects Contraindications
Oxytocin 10 IU IM/IMM -Usually none -hypersensitivity
5 IU iv bolus -ctx
10-40 IU/L -N&V
-water intoxication
Ergot 0.25mg IM -peripheral -HTN
0.125 mg IV vasospasm -peripheral disease
Q5mins X 5 doses -HTN -Raynauld’s
-N&V -hypersensitivity
Hemabate 0.25 mg IM/IMM -flushing -hypersensitivity
(PGF2α) Q15mins X 8 doses -diarrhea/N&V -asthma
-O2 desats -active cardiac,
-bronchospasm pulmonary, renal, or
-restlessness hepatic disease

Misoprostol 400-1000mcg -pyrexia/flushing -hypersensitivity

(PGE1) PR/PV/PO X 1 dose -N&V/diarrhea -pregnancy
-abd pain
-HA
Vasopressin 20U/100ml saline -acute HTN -coronary artery disease
Inject 1ml at bleeding -bronchospasm -hypersensitivity
Prevention of PPH
• ACTIVE not expectant management of
third stage of labor (Cat. A a la Cochrane)
to reduce PPH by 2/3
• The third stage of labor refers to the interval
from the delivery of the baby to the separation
and expulsion of the placenta
• The average length of 3rd stage is five to six
minutes, 90 percent of placentas are delivered
within 15 minutes and 97 percent are delivered
within 30 minutes of birth.
• Oxytocin given at time of delivery of the anterior
shoulder
• Early cord clamping and cutting and controlled
cord traction

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Resuscitative measures

• Call for help (eg Surgery)

• Airway, Breathing, Circulation
• Two large bore IVs
• Oxygen
• Stat labs: type and cross, h/h,
coags
• Consider transfusion
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 Surgical Management

• Curettage
• Embolization
• Tamponade (Balloon, packing
etc…)
• Compression sutures
• Vessel ligation
• Hysterectomy
 Tamponade

• Bakri Balloon
- Silicone balloon - 500cc
capacity
• Foley catheter with 30cc
balloon
• Sengstaken-Blakemore Balloon
• Vaginal packing
• Saline filled glove
B-Lynch Suture
Vessel Ligation
 Vessel Ligation
• Uterine
- O’Leary Stitch
- Chromic 0 passed through lateral aspect of lower
segment as close to cervix as possible and then through
broad ligament lateral to vessels

• Ovarian
- distal to cornua by passing suture through
myometrium medial to vessels
Causes of PPH – THE
FOUR T’s
• TONE (70 %)
• TRAUMA (20 %)
• TISSUE (10 %)
• THROMBIN (1 %)

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TONE - Treatment

• Atonic Uterus – (70%)

• Bimanual Uterine massage

• Oxytocic agents

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 Bimanual Uterine
Massage
1)Insert one hand into the
vagina and push up agianst
the body of the uterus
2)Place the other hand above
the uterus and compress the
uterus against the hand in the
vagina
3)Massage the posterior aspect
of the uterus with the
abdominal hand and, at the
same time, massage the
anterior aspect with the
vaginal hand

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Oxytocic Agents
• Oxytocin (Pitocin)
• Stimulates upper uterine segment
contraction, decreasing blood flow
through uterus
• Physiologic
• Once receptors saturated, higher doses
only lead to water intoxication
• DOSE: 10-40 units/1000ml IVF (eg
Ringers Lactate), which is approx.
80milliunits/minute if choose 20
units/1000ml IVF
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Oxytocic Agents (#2) –
Ergot Alkaloids
• Methylergonovine (Methergine)
• Causes generalized smooth mm
contraction in both upper and
lower uterine segments
• placental entrapment more at risk
• Contraindicated in Htn: Increases
chance of Htn and peripheral
vasoconstriction
• DOSE: .2 mg IM
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Oxytocic Agents (#3) -
Prostaglandins
• Carboprost (Hemabate)
• 86% of PPH controlled when other
means (uterine massage, oxytocin or
ergots) have failed
• Use with caution in pts c asthma, htn,
active cardiac, pulmonary, renal or
hepatic disease
• Side effects of n/v, diarrhea, htn, ha,
flushing or pyrexia
• DOSE: .25mg IM or Intramyometrially
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Oxytocic Agents for
Uterine Atony Summary

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ALSO,
shwdjula@yahoo.com 2006, p.6
Causes of PPH
– THE FOUR T’s

• TONE
• TRAUMA
• TISSUE
• THROMBIN

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TRAUMA - Treatment
• UTERINE INVERSION
• Appears as bluish grey mass protruding from
vagina
• Disproportionate Vasovagal shock as clue
• BEFORE CERVICAL CONTRACTION RING HAS
DEVELOPED: grasp fundus with one hand,
fingers directed toward posterior fornix, lift
uterus out of the pelvis forcefully holding the
uterus in the abdominal cavity above the level of
the umbilicus (this hand and 2/3 of forearm may
therefore be in vagina). Allow uterine ligaments
to pull the uterus back into position
• Promote uterine tone as above
• If symptomatic bradycardia/hypotension
develops, consider atropine .5mg IV and fluid
bolus

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TRAUMA – Treatment (2)
• UTERINE RUPTURE
• Signs:
• prolonged fetal bradycardia,
• non-reassuring fetal heart tracing,
• vaginal bleeding,
• abdominal tenderness,
• maternal tachycardia,
• circulatory collapse out of proportion to
amount of external blood loss,
• increasing abdominal girth
• TO SURGERY!!!!

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TRAUMA – Treatment (3)

• BIRTH TRAUMA
• Repair lacerations c hemostasis
• Small hematomas can be managed
expectantly

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Causes of PPH
– THE FOUR T’s
• TONE
• TRAUMA
• TISSUE
• THROMBIN

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TISSUE - Treatment

• Retained Placenta - >30 minutes

(3% of vaginal deliveries)
• For entrapped placenta: apply
firm traction on the umbilical
cord with one hand, suprapubic
pressure with the other
• Manual removal

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Manual Removal of
Placenta
• O2, 2 large bore IV, adequate anesthesia,
surgical assist notified
• Relax uterus (cease massage, administer
subq terbutaline or other agent)
• ID cleavage plane, advance fingertips
along plane
• Ensure entire placenta removed, massage
uterus
• If no success, surgical removal or
hysterectomy

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Manual Removal of
Placenta

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• from Williams, 20th Ed. p. 264
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3/9/2019 ALSO, 2006 ed.
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Causes of PPH
– THE FOUR T’s
• TONE
• TRAUMA
• TISSUE
• THROMBIN

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THROMBIN -Treatment

• ID coagulopathy prior to
delivery
• Idopathic thromocytopenic
purpura
• Thrombotic thrombocytopenic
purpura
• Con Willebrand’s disease
• Hemophilia
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THROMBIN
–Treatment (2)
• DIC
• Pre-eclampsia
• Placental abruption
• Intrauterine fetal demise
• Amniotic fluid embolus
• Sepsis
• Depletion of coagulation factors
due to excessive bleed
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THROMBIN
–Treatment (3)
• Tests: Platelets, PT, INR, PTT,
fibrinogen level and fibrin split
products

• Management:
• Treat underlying cause
• Serially evaluate coags
• Replace fluids

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THROMBIN
–Treatment (4)
• Maintain Hct near 30 c PRBC
• FFP to increase fibrinogen by 10
mg/dL, aiming to more than 100
mg/dL
• Platelets to keep greater than
50,000
• Cryoprecipitate for coag factors
• DDAVP (Desmopressin acetate)
• For Von Willebrand’s

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SUMMARY on PPH

• Recognize early and prepare

• Evaluate and treat systematically
− Tone
− Trauma
− Tissue
− Thrombin

• Remember that uterine atony is

main cause of PPH
• Actively manage 3rd Stage of Labor

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 Step 1 – Initial Assessment
Resuscitat Dx Etiology Labs
-explore uterus (tone/tissue)
ion -explore genital tract (trauma)
-CBC
-coag
-Large bore iv’s -review history (thrombin) profile
-O2 -observe clots -cross
-Vitals
match
-±foley catheter
Step 2 – Directed Therapy
Tone Tissue Trauma Thrombin
- -manual -correct -reverse
massag removal inversion anticoagulation
e -curettage -repair -replace factors
- laceration
compre Step 3 – Intractable
-identify
ss rupture
Get Help
-drugs PPH
Local BP and
-OB/Surgery
-Anesthesia
Control Coagulation
-manual -crystalloids
-Lab/Blood
compression -blood products
Bank
-±pack uterus
-ICU
-±vasopressin
Step 4-
-±embolization

Repair Surgery
Ligate Hysterecto
Lacerations Vessels my
-uterines
-ovarian
-internal iliac
Step 5 – Post Hysterectomy
Bleeding
Abdominal Embolizati
Packing on
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Did we achieve our Objectives?

• Chief cause of PPH: ________________

• A method for prevention of
PPH:_________________________________
• Why is it difficult to recognize PPH?
• What is the initial approach to
treating postpartum hemorrhage?

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RESOURCES

• ALSO course syllabus. 2006 ed.

• Williams Obstetrics, 20th ed.
• Up to Date, accessed 7/20/07
• Active versus expectant
management in the third stage of
labour. Prendiville WJ; Elbourne D;
McDonald S, Cochrane Database
Syst Rev 2000;(3):CD000007.

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 THE
END
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