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R.C. Jordias, MD
POSTPARTUM HEMORRHAGE
(ung nakahighlight ung nasa lecture) Bleeding of atleast 500 cc after the 3rd stage of labor
o 1st stage of labor – from regular uterine contraction to full
“triad” of causes of maternal deaths: cervical dilatation (10cm)
Obstetrical hemorrhage o 2nd stage of labor – from full cervical dilatation to expulsion of
hypertension fetus
infections o 3rd stage of labor – from delivery of fetus to deliver of placenta
(accounts the majority of postpartum hemorrhages)
Any form of bleeding is considered to be dangerous o 4th stage of labor - 1-2hrs after the deliver of placenta
leading reason for admission of pregnant women to intensive care units Postpartum Hemorrhages
hemorrhage is the single most important cause of maternal death o Early or Primary
worldwide Anything that occurs within 24 hrs after the delivery of
responsible for half of all postpartum deaths in developing countries placenta, or 2 hrs after the delivery of the product of
conception.
Different Causes Of Bleeding: o Late or Secondary
Antepartum After 24hrs of the delivery of the placenta even up to 1
o 1st trimester week after the delivery.
Abortion – M/C
Expulsion of products of conception before Obstetrical Hemorrhage: Causes, Predisposing Factors, and Vulnerable
reaching 20 weeks AOG Patients
o 2nd trimester and early 3rd trimester
Abruption placenta
Premature separation of a normally implanted
placenta
Placenta previa
Premature separation of an abnormally implanted
placenta
Postpartum
o Leading cause of maternal mortality aside from hypertensive
disorders of pregnancy and infection
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Trans by: CharmingRNMSNMD Edited by- Dhezai & E. Ilano & 46ers nomlamlav
Hemorrhage from laceration Persistent bleeding despite a firm, well-
contracted uterus Thus, if blood loss is less than the amount added by pregnancy, the
Bright red blood arterial bleeding hematocrit stays the same acutely and during the first several days. It
To confirm that lacerations are a source of bleeding, careful inspection eventually increases as normal plasma volume shrinks postpartum.
of the vagina, cervix, and uterus is essential. Any time the postpartum hematocrit is lower than one obtained on
If with persistent supracervical bleedingmanual exploration of the admission for delivery, blood loss can be estimatedas the sum of the
uterus is done to exclude a uterine tear. It is also completed routinely calculated pregnancy hypervolemia plus 500mL for each 3 volumes
after internal podalic version and breech extraction. percent drop in the hematocrit.
Special Consideration
Woman with blood volume expansion is less than expected.
o Small women with normal pregnancy-induced hypervolemia.
(most common)
o Severe preeclampsia or eclampsia - because they frequently do
not have a normally expanded blood volume. Only 10% mean
increase in blood volume
o Women with chronic renal insufficiency
*When excessive hemorrhage is suspected inthese high-risk women,
crystalloid and blood are promptly administered for suspectedhypovolemia.
Treacherous feature of postpartum hemorrhage is the failure of the
pulse and blood pressure to undergo more than moderate alterations Hemostasis at the Placental Site
until large amounts of blood have been lost. Prevents blood loss during deliveries
Normotensive woman initially become hypertensive from Near term, it is estimated that at least 600 mL/min of blood flows
catecholamine release in response to hemorrhage through the intervillous space
Women with preeclampsia become “normotensive” despite This flow is carried by the spiral arteries—which average 120 in
remarkable hypovolemia. number—andtheir accompanying veins.
Traditionally postpartum hemorrhage defined as loss of 500 mL of With separation of the placenta, these vessels are avulsed
blood or more after completion of the third stage of labor. Hemostasis at the placental implantation site is achieved first by
o Blood loss: (if exceeds the number then problematic) contraction and retraction of the myometrium that compresses this
Normal spontaneous delivery – 500mL formidable number of relativelylarge vessels (occurs after delivery of
1000ml in CS placenta)
1500ml in CS with hysterectomy (elective) o Before the completion of the delivery of the placenta, the uterus
3000-4000ml for emergency CS with hysterectomy needs must be well contracting and periods of relaxation.
But, approximately 5 percent of women delivering vaginally lost more Followed by subsequent clotting and obliteration of their lumens.
than 1000 mL of blood. Thus, adhered pieces of placenta or large blood clots prevent
Estimated blood loss is commonly only approximately half the effective myometrial contraction (like in cases of uterine atony)
actual loss. impair hemostasis at the implantation site.
However, the blood volume of a pregnant woman with normal Hypotonic uterus may cause fetal hemorrhages and blood
pregnancy-induced hypervolemia usually increases by 50%, but coagulation mechanisms are impaired. Thus take note the
increases range of 30 to 60%, amounts to 1500 to 2000 mL for an consistency of the uterus after the delivery of the products of
average-sized woman. (during pregnancy there is an increase in plasma conception.
volume) Importantly, an intact coagulation system is not necessary for
Equation to calculate maternal blood volume: postpartum hemostasis unless there are lacerations in the uterus, birth
canal, or perineum
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Trans by: CharmingRNMSNMD Edited by- Dhezai & E. Ilano & 46ers nomlamlav
o With persistent bleeding
Weakness
Dizziness
Palpitations
Tachycardia
Pallor
Oliguria
And other signs of hypovolemia
Exact measurement of blood loss may not be possible b/c it may be on
the pail/basin mixed with amniotic fluid or urine, in her beddings or
splattered on the floor.
Separation and delivery of the placenta by cord traction, especially
when the uterus is atonicuterine inversion
Bleeding during the third stagemassage
Uterine atony management
o Bimanual uterine compression (at LOWER UTERINE
SEGMENT where lower uterine artery is located wherein it
Postpartum Hemorrhage originates from the iliac artery)
1. UTERINE ATONY o Get help
Failure of the uterus to contract effectively after the delivery of the o Begin blood transfusion
placenta causing significant bleeding o Manual exploration of uterine cavity
The uterus is normally stony hard after the delivery of the products of o Thorough inspection of cervix and vagina (presence of
conception. If it is not hard then you might be dealing with uterine lacerations)
atony. o Second IV route so blood and oxytocin can be given at the same
Prevalence time (large bore IV catheter)
o WHO – about 13,000 bleed to death per year while giving birth o Insert foley catheter to assess urine output
about 80% of these is due to uterine atony o Surgical: Internal Iliac Artery Ligation
o POGS (2002-2006) - 2 to 3 cases per 1000 deliveries Reduces hemorrhage, 85% reduction in pulse pressure in
Most frequent cause of obstetrical hemorrhage those arteries distal to the ligation
Mechanism of placental separation: BS of uterus: 80% comes from Uterine Arteries while 10-
o Duncan mechanism Blood from the implantation site escape 20% comes from ovarian arteries located above the
into the vagina immediately uterine arteries
o Schultze mechanismremains concealed behind the placenta Technically difficult and is successful in less than half of
and membranes until the placenta is delivered the patients
Causes Bilateral ligation doesn’t interfere sith subsequent
o Excessively halogenated anesthetics are employed reproduction
o Overdistention of uterus is present o Surgical: Uterine Compression Sutures (B-Lynch)
Multiple pregnancy Giving the appearance of suspenders to compress together
Large baby the anterior and posterior walls
Polyhydramnios Use absorbable kind of suture
o Remarkably vigorous or barely effective uterine contractions
o In oxytocin induced or augmented labor Third-Stage Bleeding
Use PG for induction Manual placental removalindicated if with significant bleeding
Oxytocin for augmentation persists after delivery of the infant and while the placenta remains
o High parity partially or totally attached
If >7 parity o Placenta is peeled off by a motion similar to that used in
o Chorioamnionitis separating the pages of a book.
o History of atony in a previous pregnancy
Palpate the fundus to determine of uterus is well-contracted Bleeding with Prolonged Third Stage
Vigorous massage if not Prolonged third stage of labor more than 30mins
Oxytocin infusion maybe given (not bolus) – active management (2
ways of management: active and expectant management) Management after Placental Delivery
Potent drugs that can cause contraction of uterus Fundus should always be palpated following delivery to confirm that
o Methylergonovine (IM/IV) the uterus is well contracted.
o PG F2a If not firm do vigorous fundal massage
4 signs of placental separation: 20 U of oxytocin in 1000 mL of lactated Ringer or normal saline infuse
o Round and globular uterus by 10 mL/min—200 mU of oxytocin per minute
o Sudden gosh of blood o Simultaneously effective uterine massage
o Uterus rises upto abdomen Oxytocin should never be given as an undiluted bolus doseserious
o Lengthening of the cord hypotension or cardiac arrhythmias
Risk factors
o Overdistended uterus Risk Factors
o Prolonged Labor Primiparity
o Very rapid Labor (precipitate labor) – 5-10cm/hr High parity
o Placenta previa Overdistended uterus
o Myoma o Prone to hypotonia after delivery, and thus women with a large
o Induced or augmented labor fetus, multiple fetuses, or hydramnios are at greater risk.
o Chorioamnionitis Labor abnormalities
o Halogenated Anesthetics Labor induction or augmentation
Clinical Manifestations Prior postpartum hemorrhage
o Heavy or moderate vaginal bleeding that persists after the
delivery of placenta
o Uterus is soft, boggy, distended and lacks tone
o Uterus has repeated periods of contractions and relaxations
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Trans by: CharmingRNMSNMD Edited by- Dhezai & E. Ilano & 46ers nomlamlav
Evaluation and Management 2. Immediately mobilize the emergent-care obstetrical team to the
Immediate postpartum hemorrhage inspect to exclude birth canal delivery room and call for whole blood or packed red cells.
laceration. 3. Request urgent help from the anesthesia team.
Inspect also for retained placental fragments 4. Secure at least two large-bore intravenous catheters so that
If with defect manual exploration of the uterus crystalloid with oxytocin is continued simultaneously with blood
During examination for laceration and causes of atony uterus should products. Insert an indwelling Foley catheter for continuous
be massage and uterotonic agents are administered urine output monitoring.
5. Begin volume resuscitation with rapid intravenous infusion of
Uterotonic Agents (read) crystalloid
Oxytocin 6. With sedation, analgesia, or anesthesia established and now with
Ergot derivatives optimal exposure, once again manually explore the uterine cavity
o Used for second line treatment for retained placental fragments and for uterine abnormalities,
o Methylergonovine (methergine) including lacerations or rupture.
o Ergonovine 7. Thoroughly inspect the cervix and vagina again for lacerations
o Given parenterally it rapidly stimulate tetanic uterine that may have escaped attention.
contractions and act for approximately 45 minutes 8. If the woman is still unstable or if there is persistent hemorrhage,
o Caveat in using ergot agent then blood transfusions are given
May cause dangerous hypertension
Uterine Packing or Balloon Tamponade (read)
E- and F-series prostaglandins
o CARBOPROSTTROMETHAMINE (Hemabate) Techniques:
15-methyl derivative of prostaglandinf2α. Foley catheter
Approved more than 25 years ago for uterine atony o Tip of a 24F Foley catheter with a 30-ml balloon is guided into
treatment the uterine cavity and filled with 60 to 80 ml of saline.
Dose250 μg (0.25 mg) IM o Open tip permits continuous drainage of blood from the uterus.
Can be repeated if necessary at 15- to 90-minute intervals o If bleeding subsides, typically removed after 12 to 24 hours.
maximum of 8 doses o Also used for tamponadeSegstaken-Blakemore and Rusch
Side effects (in descending order) balloons and condom catheters
Diarrhea Packed directly with gauze
Hypertension Bakri postpartum Balloon or BTCath
Vomiting o Specially constructed intrauterine balloons
Fever o Inserted and inflated to tamponade the endometrial cavity and
Flushing stop bleeding
Tachycardia o Need 2-3 members
Also can cause: pulmonary airway and vascular First memberwill do sonography during procedure
constriction Second memberwill deflate the balloon and stabilize it
*should not be used for asthmatics and those with suspected amnionic-fluid Third memberwill instill 150ml of fluid to inflate the
embolism balloon
o DINOPROSTONE Failures will require surgical methods (including
o ProstaglandinE2 hysterectomy)
o given as a 20-mg suppository per rectum or per vagina every 2
hours Adjunctive Surgical Procedures
o typically causesdiarrhea if given per rectal UTERINE ARTERY LIGATION
o SULPROSTONE Either unilateral or bilateral is used primarily for lacerations at the
o Intravenous prostaglandin E2 lateral part of a hysterotomy incision
o MISOPROSTOL(Cytotec) Less helpful lfor hemorrhage from uterine atony.
o synthetic prostaglandin E1 analogue
o evaluated for both prevention and treatment of atony and UTERINE COMPRESSION SUTURES
postpartum hemorrhage B-Lynch technique or braces
o Procedure involve splacement of a No. 2-chromic suture to
Bleeding Unresponsive to Uterotonic Agents compress the anterior and posterior uterine walls together.
Causeunrecognized genital tract laceration (uterine rupture) Complication:
If bleeding persists after initial measures for atony have been o Uterine ischemic necrosis with peritonitis (MC)
implemented, then the following management steps are performed o Defects in the uterine wall
immediately and simultaneously: o Uterine cavity synechiae
1. Begin bimanual uterine compression.
Posterior uterine wall is massaged by one hand on the INTERNAL ILIAC ARTERY LIGATION
abdomen, while the other hand is made into a fist and Ligation of one or both internal iliac arteries has to reduce hemorrhage
placed into the vagina. This fist kneads the anterior from pelvic vessels
uterine wall through the anterior vaginal wall. Drawbacks technically difficult
not particularly helpful to abate hemorrhage with postpartum atony
most important mechanism of action 85% reduction in pulse pressure
in arteries distal to the ligation
converts an arterial pressure system into one with pressures
approaching those in the venous circulation.
creates vessels more amenable to hemostasis via pressure and clot
formation.
Does not interfere subsequent reproduction(even in bilateral)
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Trans by: CharmingRNMSNMD Edited by- Dhezai & E. Ilano & 46ers nomlamlav
ANGIOGRAPHIC EMBOLIZATION o Cord traction applied before placental separation
Used for many causes of intractable hemorrhage when surgical access o Accrete syndromes (placenta accreta)
is difficult
90% effective Ayon naman sa powerpoint ni doc:
Can be used to arrest refractory postpartum hemorrhage, but, less Fundal pressure
effective with placenta percreta or with concurrent coagulopathy Relaxed uterus, lower segment and cervix (check ung difference nya sa
ACOG describes its efficacy as “unclear.” uterine atony)
Also used for renal hemorrhage Tough cord that does not readily break away from the placenta
Complications (uncommon but can be severe): Placenta accreta
o Uterine ischemic necrosis Complete inversion is d/t strong traction on the umbilical cord
o Uterine infection attached to a placenta implanted in the fundus
o Massive buttock necrosis and paraplegia Classifications:
o Complete inversion – corpus passes through the cervix
PREOPERATIVE PELVIC ARTERIAL CATHETER PLACEMENT o Incomplete inversion - corpus does not pass through the cervix
balloon-tipped catheters inserted into the iliac or uterine arteries o Prolapsed – corpus extends through the vaginal intro itus(1st
preoperatively. structure to come out of vagina:normally is cervix but in
Used commonlyaccrete syndromes prolapsed inversion the 1st structure to come out is fundus, body
Adverse effects uncommon, but postoperative iliac and popliteal then cervix)
artery thrombosis and stenosis have been reported Clinical Course:
o Most often there is immediate life-threatening hemmorhage and
PELVIC UMBRELLA PACK is fatal w/o prompt treatment
umbrella or parachute pack used to arrest intractable pelvic o Shock tends to disproportionate to blood loss
hemorrhage following hysterectomy Manifestations
pack is constructed of a sterile x-ray cassette bag that is filled with o Acute abdominal pain with sudden profuse hemorrhage followed
gauze rolls knotted together to provide enough volume to fill the pelvis by shock
removed vaginally after 24 hours. Diagnosis
Recommended as “last-ditch” attempt when exsanguination is o Fleshy mass protruding out of the cervix or vagina
inevitable, especially in “low-resource” areas. o Abdominal palpation of crater-like depression
Transfer patient to hospital immediately
Signs of placental separation (expectant management or passive management Do not attempt to repose the uterus w/o anethesia b/c this may result in
– means that we have to wait for the placenta to go down passively without neurogenic shock
introducing any drugs. In this management, oxytocin is given only after the Treatment
placenta has been delivered.) o Immediate assistance including anesthesiologist
Uterus contracts (uterus becomes globular and rounded) – 1st sign o Freshly inverted uterus with placenta already separated maybe
Sudden gush of blood – 2nd sign replaced by pushing up on the fundus with the palm and fingers
The fundus of the uterus rises up to the abdomen- when there is already in the direction of the long axis of the vagina
separation of placenta and placenta starts to go down – 2nd sign o Two IV infusion systems LR and blood
Lengthening of umbilical cord – 4th sign o If the placenta is attached, it is NOT removed until there is
already ongoing fluids and halothane or enflurane is already
For active management of placental delivery, you do not wait for the signs of administered terbutaline, ritodrine, or mgso4 maybe used to
placental separation but you do UMBILICAL CORD/GENITAL TRACTION effect and uterine relaxation and repositioning.
(one hand). The other hand is over the symphysis pubis while pushing the o After removal of placenta, the palm is placed on the center of the
uterus upward. (Brandt-Andrews Method) fundus with the fingers extended to identify the margins of the
cervix. Upward pressure is applied.
2. RETAINED PLACENTAL FRAGMENTS o Bimanual compression
The most important is the maternal surface o Surgical intervention is done if the uterus cannot be reinverted
vaginally.
Look for the completeness of cotyledons in the placenta (usually
20-24 cotyledons) Progressive severity of inversion
o After the fundus begins and continues to invert (Nos. 1 and 2),
Seldom causes immediate postpartum hemorrhages
usually not visible
Usually causes LATE POSTPARTUM HEMORRHAGES
o At the level of the introitus (No. 3), already visible externally
o Completely inverted (No. 4)
Hemorrhages From Retained Fragments Of Placenta
Incidences from approximately 1 in 2000 to 1 in 20,000 deliveries
Seldom causes immediate postpartum hemorrhage but is a common
cause of late postpartum hemorrhage
Placental inspection after delivery is mandatory
Succenturiate lobes: Placental polyps
Pregnancy Outcomes
Can have disastrous outcomes for both mother and fetus
Recognition and Management
Subsequent Pregnancy Immediate recognition improves the chances of a quick resolution
Increased risks for recurrence, uterine rupture, hysterectomy, and and good outcome
previa Continued hemorrhage likely will prompt closer examination of the
birth canal
3. UTERINE INVERSION partially inverted uterus can be mistaken for a uterine myoma, and this
Risk factors include alone or in combination: can be resolved by sonography
o Fundal placental implantation Once any degree of uterine inversion is recognized, several steps must
o Delayed-onset or in uterine atony, be implemented urgently and simultaneously:
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1. Immediate assistance is summoned, including obstetrical and o Note: bleeding in the presence of firmly contracted uterus is
anesthesia personnel. evidence of genital tract laceration, retained fragments of
2. Blood is brought to the delivery suite placenta or both.
3. The woman is evaluated for emergency general anesthesia. INJURIES TO THE CERVIX
Large-bore intravenous infusion systems are secured to begin o Laparotomy is mandatory if concomitant peritoneal perforation,
rapid crystalloid infusion to treat hypovolemia while awaiting retroperitoneal and intraperitoneal bleeding is suspected
arrival of blood for transfusion. o Cervical lacerations must be suspected when there is profuse
4. If the recently inverted uterus has not contracted and retracted bleeding during and after the third stage especially if uterus is
completely and if the placenta has already separated, then the well contracted.
uterus may often be replaced simply by pushing up on the o Entails adequate exposure and not jist digital examination and
inverted fundus with the palm of the hand and fingers in the proper suturing
direction of the long axis of the vagina. Care is taken not to o Cervical inspectionmust be routinely done especially after
apply so much pressure as to perforate the uterus with the forceps delivery.
fingertips.
Vulvovaginal Lacerations
Small tears of the anterior vaginal wall near the urethra
o Relatively common
o Superficial with little to no bleeding
o Repair is not indicated
Minor superficial perineal and vaginal lacerations occasionally
require sutures for hemostasis
Frequency of third- or fourth-degree perineal lacerations5.7% in
5. If the placenta is still attached, it is not removed until infusion nulliparas and 0.6% in multiparas
systems are operational and a uterine relaxant drug administered. Bleeding in firmly contracted uterusstrong evidence of genital tract
If these fail will administer rapidly acting halogenated laceration
inhalational agent. o Usually result from injuries sustained during operative vaginal
6. After removing the placenta, steady pressure with the fist, palm, delivery with forceps or vacuum extractor
or fingers is applied to the inverted fundus in an attempt to push Extensive vaginal or cervical tearslook for evidence of
it up into and through the dilated cervix as described in Step4. retroperitoneal hemorrhage or peritoneal perforation or hemorrhage
7. Once the uterus is restored to its normal configuration, tocolysis Extensive vulvovaginal lacerationsneed to do intrauterine exploration
is stopped. Oxytocin is the ninfused, and other uterotonics may for possible uterine tears or rupture
be given. Meanwhile, the operator maintains the fundus in its For deep vulvovaginal lacerationssuture repair is usually required,
normal anatomical position while applying bimanual and effective analgesia or anesthesia, vigorous blood replacement, and
compression to control further hemorrhage until the uterus is capable assistance are mandatory
well contracted. The operator continues to monitor the uterus
transvaginally for evidence of subsequent inversion. Levator Sling Injuries
Levatorani muscle
Surgical Intervention o Usually involved with deep vaginal vault lacerations
Done if manual replacement fails. o Sustain stretch injuries that result from over distention of the
Caused bydense myometrial constriction ring birth canal
To reposition the uterusTocolysis agents + combined effortby Muscle fibers are torn and separatedwill interfere pelvic diaphragm
simultaneously pushing upward from below and pulling upward from functioncause pelvic relaxation.
above. If pubococcygeus muscle is involve urinary incontinence
Huntington procedureApplication of atraumatic clamps to each
round ligament and upward traction Cervical Lacerations
Haultain incision longitudinal surgical cut made posteriorly through Most are less than 0.5 cm seldom require repair
the ring to expose the fundus and permit. Not usually problematic unless they cause hemorrhage or extend to the
o Done if the constriction ring still prohibits repositioning upper third of the vagina.
Colporrhexis cervix is totally or partially avulsed from the vagina in
the anterior, posterior, or lateral fornices.
2. INJURIES TO THE BIRTH CANAL (GENITAL TRACT o These injuries sometimes follow difficult forceps rotations or
LACERATION) deliveries performed through an incompletely dilated cervix with
2 TYPES OF EPISIOTOMY the forceps blades applied over the cervix.
o Median – all advantages are seen compared to lateral; o Rare case
disadvantages are that incision is made on the center and If cervical injury reached lower uterine segment involve the uterine
involvement of rectal mucosa and sphincter. artery and its major branches.
o Lateral Annular or circular detachment of the cervixwhen the entire vaginal
REVIEW THE DEGREES IN LACERATIONS portion of the cervix is avulsed.
PERINEAL LACERATIONS o Seen with difficult deliveries, especially forceps deliveries
o Must be appropriately repaired including the underlying perineal
and vaginal fascia and muscle to prevent subsequent outlet Diagnosis
relaxation, cystorectocele and uterine prolapse Deep cervical tear should always be suspected in profuse hemorrhage
LEVATOR ANI INJURIES during and after third-stage labor, particularly if the uterus is firmly
o Results from the overdistention of birth canal separation of contracted.
muscle fibers, dimunition of tonicity pelvic diaphragm o If upon inspection flabby cervix interferes digital
dysfunction pelvic relaxation and incontinence examinationan assistant applies firm downward pressure on
VAGINAL LACERATIONS the uterus while the operator exerts traction on the lips of the
o Middle or upper third vaginal isolated lacerations more often cervix with ring forceps.
result from forceps or vacuum extraction
o Lacerations of the anterior vaginal wall close to the urethra are Management
often minor and need no repair; however if they are extensive, Cervical lacerations of 1 and even 2 cm not repaired unless they are
repair is indicated, and indwelling catheter is placed. bleeding
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Usually will result to irregular, sometime stellate appearance of the If bleeding ceasessmall- to moderate-sized hematomas will be
external cervical os that indicates previous delivery of a viable-size absorbed. But it can rebled in up to 2 weeks or tissues may rupture
fetus. secondary to pressure necrosis.
Deep cervical tears surgical repair If paravaginal space are affected and extend above the levator sling
If limited to the cervix or extends somewhat into the vaginal fornix massive retroperitoneal bleeding
need suturing of the cervix after bringing it into view at the vulva
First suture laced above the angle Diagnosis
o Because hemorrhage usually comes from the upper angle of the Readily diagnosed by presence of severe perineal pain
wound Rapidly develops and covered by discolored skin
In lacerations involving lateral vaginal sulcus, attempts to restore the symptoms of pelvic pressure pain, or inability to void should prompt
normal cervical appearance may lead to subsequent stenosis. evaluation usually due to round, fluctuant mass encroaching the
If with uterine involvement and continued hemorrhage adjunctive vaginal fault
surgical procedure supralevator hematomashematoma extends into the paravaginal
o ex. Angiographic embolization for a high cervical tear after space and between the leaves of the broad ligament.
failed surgical repair. o Worrisome b/c it can lead to hypovolemic shock and
death
3. PUERPERAL HEMATOMAS sonography or computed tomographic (CT) scanning
Mostly associated with a laceration, episiotomy, or an operative o useful to assess location and extent
delivery
Most common symptom is seen after discharge of patient. Management
Associated risk: managed according to their size, duration since delivery, and expansion
o Nulliparity smaller vulvar hematomasexpectant management
o Episiotomy if pain is severe or the hematoma continues toenlargesurgical
o Forceps delivery exploration
laparotomy if there is continued hemorrhage
Classification: Blood loss with large puerperal hematomas is nearly always
o Vulvar considerably more than the clinical estimate.
Involves branches of pudendal arteries, including Blood transfusion is almost always . Pt. is at risk for hypovolemia
posterior rectal, transverse perineal or posterior labial Angiographic embolization popular for management of some
artery puerperal hematomas
o Paravaginal o Can be used primarily or secondarily, if surgical attempts at
Involves descending branch of uterine artery hemostasis have failed or if the hematoma is difficult to access
o Vulvovaginal surgically
o Retroperitoneal Bakri balloon for a paracervical hematoma has also been described
VULVAR HEMATOMAS
o Severe pain – 1st symptom
o If moderate in size spontaneous absorption 4. RUPTURE OF THE UTERUS
o May cause overlying in tissue necrosis profuse hemorrhage Primary uterine rupture
o Dx: o Occur in a previously intact or unscarred uterus
Severe perineal pain secondary
Tense, fluctuant, discolored tender mass o Associated with a preexisting myometrial incision, injury, or
Inability to void anomaly
Pressure symptoms
a catastrophic obstetric event accompanied by adverse maternal and
Extension of the hematomas into the leaves of the broad
neonatal complication (both mother and fetus)
ligament
Incidence
o Treatment:
o Spontaneous – unknown, exceedingly rare
Expectant
o 1 previous low transverse scar – 0.2-1.5%
Severe pain, enlarging incision and evacuation of
o 2 or more prior CS – 3-9%
clots + ligation of bleeders
Angiographic embolization Complete
o Rupture of uterus in which there is direct communication with
Hematomas of the genital tracts often involves more
bleeding than is estimated blood transfusion the peritoneal cavity
o Defect in the uterine wall leads to a direct communication
between the peritoneal and intrauterine cavities
SUBPERITONEAL/SUPRAVAGINAL HEMATOMAS
o A true emergency
o More difficult to treat
o Potentially life-threatening for both the mother and the fetus
o Laparotomy is advisable
Incomplete
One classification of puerperal hematomas includes vulvar,
o Uterine cavity is separated from the peritoneal cavity by the
vulvovaginal, paravaginal, andretroperitoneal hematomas.
visceral peritoneum over the uterus or over the broad ligament
Vulvar hematomas involve the vestibular bulb or branches of the
o Typically presents as asymptomatic DEHISCENCE of a
pudendal artery(inferior rectal, perineal, and clitoral arteries) previous uterine scar
Paravaginal hematomasinvolve the descending branch of the o The peritoneal and intra-uterine cavities are separated by the
uterine artery uterine serosa
supralevator hematoma develops when a torn vessel lies above the o Usually uncomplicated
pelvic fascia Rupture of the CS scar
retroperitoneal hematomas when a continuing bleeding dissect o Separation of old uterine incision throughout its length, with
retroperitoneally and form a mass palpable above the inguinal rupture of the fetal membranes so that the uterine and peritoneal
ligament cavity communicate and parts of the fetus are extruded into the
it may also dissect behind the ascending colon or in hepatic flexure at latter; bleeding is significant from scar edges or from extension
the lower margin of the diaphragm into previously uninvolved parts of the uterus
Dehiscence of CS Scar
Vulvovaginal Hematomas o Fetal membranes are not ruptured; the entire length of scar is not
develop rapidly and frequently cause excruciating pain involved; overlying peritoneum is intact; absent or scanty
bleeding
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Uterine Injury or anomaly sustained pregnancy Clinical Course
o Surgery involving myometrium o Sudden severe FHT decelerations – MC finding (80%)
CS delivery (well-formed lower uterine segment) or o Chest pain – referred from hemoperitoneum and irritation of
hysterotomy (not well-formed lower uterine segment) diaphragm
Previously repaired uterine rupture o Cessation of contractions
Myomectomy incision through or to the endometrium o Loss of station - presenting part
Deep cornual resection of interstitial oviduct o Fetal parts are more easily palpable abdominally
Metroplasty o Vaginal exam may reveal the rupture site (BUT NOT
o Coincidental Uterine Trauma ALWAYS)
Abortion with instrumentation – curette, sounds Prognosis
Sharp or blunt trauma – accidents, bullets, knives o If fetus is expelled into peritoneal cavity, its chance for survival
Silent rupture in previous pregnancy is dismal
o Congenital Anomaly o If fetus is alive at time of rupture, survival depends on prompt
Pregnancy in undeveloped uterine horn delivery – usually by CS
Uterine Injury or abnormality pregnancy o Causes of maternal death
o Before delivery Hemorrhage
Persistent, intense, spontaneous contractions Infection
Labor stimulation – oxytocin or PGs o Important:
Intra-amnionic instillation – saline or PGs Prompt diagnosis
Perforation by internal uterine pressure catheter Immediate operation
External trauma – sharp or blunt Availability of blood and antimicrobial therapy
External version Hysterectomy vs Repair
Uterine overdistention – hydramnios, multiple pregnancy o Laparotomy is not indicated if there is asymptomatic dehiscence
o During Delivery after VDAC
Internal version, Difficult forceps o Spontaneous or frank rupture hysterectomy
Breech extraction o Repair is reserved only in selected cases
Fetal anomaly distending lower segment Internal Iliac Artery Ligation
Vigorous uterine pressure during delivery o Can reduce bleeding appreciably and does not appear to
Difficult manual removal of placenta compromise the patient’s subsequent reproductive capacity
o Acquired Uterine rupture through the cesarean hysterotomy scar became
Placenta increta or percreta preeminent d/t increased number of CS delivery
Adenomyosis
Gestational Trophoblastic Neoplasia Causes of Uterine Rupture
Sacculation of entrapped retroverted uterus Primary occurring in a previously intact or unscarred uterus
Classic Scar Secondary associated with a preexisting myometrial incision, injury,
o Greater probability of rupture or anomaly
o Rupture before labor in 30%
LSCS Scar
o Less likely to rupture
o Rarely ruptures antepartum
Rupture of CS Scar
o VBAC is encouraged and is not significantly associated with
rupture provided that:
Only one previous LSCS Scar
Indication for CS then is no longer present
Avoidance of Oxytocin Augmentation
Uterine rupture (TYPES)
o Rupture of a CS Scar
Classical or vertical
CS scar has a higher risk of rupture compared to a low
segment transverse incision
Maternal mortality: LOW
Fetal mortality: 32%
o Rupture of an intact uterus
Spontaneous
Oxytocin or PG induction of labor in women with
high parity, big babies, or malpresentation
Almost always occurs in the Lower Uterine
Segment
Traumatic
Internal Podalic Version
Difficult forceps delivery
Breech Extraction
Forceful fundal pressure
Hydrocephaly
Maternal Mortality: 13.5%
Fetal Mortality: 76%
8|O B S T E T R I C S , 2 0 1 4
Trans by: CharmingRNMSNMD Edited by- Dhezai & E. Ilano & 46ers nomlamlav
"I'm more than what your naked brain can comprehend"
-MADAMOT VS TALANGKA
Pathogenesis
Involves thinned-out of lower uterine segment
When the rent is in the immediate vicinity of the cervix extends
transversely or obliquely
When the rent is in the portion of the uterus adjacent to the broad
ligamenttear is longitudinal
It is usual for the tear to extend upward into the active segment or
downward through the cervix and into the vagina
If the rupture is of sufficient sizeuterine contents will escape into the
peritoneal cavity
Fetal prognosis is largely dependent on the degree of placental
separation and magnitude of maternal hemorrhage and hypovolemia
In some there is an inherent weakness in the myometrium in which the
rupture takes place
o Ex. anatomical anomalies, adenomyosis, and connective-tissue
defects such as Ehlers-Danlos syndrome
SUMMARY:
*Postpartum hemorrhages are the major cause of maternal mortality and
morbidity.
*Recognizing patient at risk is the basic fundamental step to minimize and
prevent its occurence.
*Early recognition and prompt referral are the key notes to prevent
detrimental outcome of this complication.
9|O B S T E T R I C S , 2 0 1 4
Trans by: CharmingRNMSNMD Edited by- Dhezai & E. Ilano & 46ers nomlamlav