Department of Gynecology

The third hospital affiliated to

Zhengzhou university
LiHongyu
 INCIDENCE

USA : the third leading cause of maternal

mortality and is directly responsible for
about one-sixth of maternal death
developing countries: among the leading
obstetric causes of maternal death
CHINA: 2%~3% all maternal death
 PPH
1 、 DEFINITION
2 、 ETIOLOGY
3 、 CLINICAL FINDINGS
4 、 MANAGEMENT
5 、 PREVENTION
 DEFINITION
Postpartum hemorrhage denotes excessive
bleeding ( ＞ 500 ml in vaginal delivery)
following delivery. Hemorrhage may occur befor,
during, or after delivery of the placenta. Blood
loss may often be underestimated.

Blood lost during the first 24 hours after

delivery is early postpartum hemorrhage;
blood lost between 24 hours and 6 weeks
after delivery is late postpartum
hemorrhage.
 the source of PPH

 the blood vessels

supplying the placental
implantation site

 obstetric lacerations of
blood vessels
 Bleeding is physiologically
controlled
 uterine contract ： constriction of interlacing
myometrial fibers that surround the blood
vessels supplying the placental implantation site.

 coagulation ： During pregnancy, levels of

several essential coagulation factors increase.
 ETIOLOGY
1. Uterine Atony: 70-80%
2. Placental Factors

3. Obstetric Lacerations
4. Coagulation Defects
 Ⅰ. Uterine Atony

fornix
 Uterine Atony
Predisposing causes
Excessive manipulation of the uterus
General anesthesia (particularly with halogenated compounds)
Uterine overdistention (twins ， or polyhydramnios)
Prolonged labor ， Preeclampsia or eclampsia
Grand multiparity ， Placenta previa, abruption of placenta
Uterine leiomyomas ， congenital anomalies
Operative delivery and intrauterine manipulation
Oxytocin induction or augmentation of labor
 Uterine Atony
Predisposing causes
Previous hemorrhage in the third stage
Uterine infection
Extravasation of blood into the myometrium
(Couvelaire uterus—uteroplacental apoplexy,
a purplish and copper-colored, ecchymotic
indurated organ that all but loses its contractile
power because of disruption of the muscle bundles)
Intrinsic myometrial dysfunction
Twins in ultrasonography
 PLACENTA PREVIA

Normal placenta Partial placenta previa

Low implantation Complete placenta
 Clinical Findings

 prolonged lab
 placenta couldn’t detach or delay detach.
 intermittence bleeding, dark red, coagulum or blood clot
 The uterine fundus can’t be palpated through abdominal
examination. The uterus is soft.
 Notice
 The estimated blood loss commonly is far less than
actual loss.
 The blood may not escape vagina but may collect
instead within the uterus when the uterus can’t expel the
detached placenta.
 The patient with excessive hemorrhage may develop
into hypovolemic shock with the appearance of
palpitation, dizziness, weak pulse, hypotension and cold
sweating.
 The diagnosis depends on uterine atony, excessive
hemorrhage after placenta delivery and hypovolemic
symptoms of the patient. Pay attention to combination
of uterine atony with lacerations and placental factors.
Management

If bleeding persists, the following

management should be initiated
immediately.
Hemostasis
 Reinforce uterine Oxytocin
contraction

Packing the uterine Massage the

with gauze uterus
Hemostasis

Ligating uterine
artery

Arterial embolism

Hysterectomy
 1. strengthen uterine
contraction

 oxytocin

 massage
2 、填 塞 宫 腔
Packing the uterus with gauze
Ⅱ. 胎 盘 因 素
Placental Factors
正常协助胎盘娩出
Assisting placental delivery
 胎盘因素
Placental Factors
 incomplete placental
separation
 retained placental tissue
 placental incarceration
 placental adherence
 placental implantation
 remnants of placenta and
fetal membrane
 placenta previa and
abruption placenta
Placental implantation ： The placental villi
invade into uterine muscles
 Clinical Findings

 Bleeding occurs before the placenta delivery

because of incomplete placental separation,
retained placental tissue, placental incarceration,
placental adherence or placental implantation,
 Bleeding maybe occurs after the placenta delivery
because of the remnants of placenta and fetal
membrane.
 Constriction ring of uterus induce placental
incarceration
 Diagnose

 Clinical Findings
 Explore the uterus and be carefully to
examine placenta & fetal membranes
 Sonohysterography
Treatment
 Manual removal of the placenta when
placenta adheres is advisable;
 Cleaning the uterine cavity with gauze is used for
remnants of fetal membrane; curettage for
retained placental products
 Anesthesia should be used to relieve the spasm of
the uterus when the placenta is sequestered
above the uterine stenosed circle
 Hysteractomy for placental implantation
 Pay attention to the general condition of the
patient, immediately infuse blood, soluid whenever
necessary
Ⅲ. Obstetric lacerations
 Obstetric
lacerations
The passage
 Lower uterine segment
 Cervix
 Vagina
 Soft tissues of pelvis
 Obstetric
lacerations

 If the fetus is a very large, delivery has been

very rapid, or operative forceps deliveries
through an incompletely dilated cervix, the
cervix and vaginal wall are commonly
lacerated before the infant birth.
 Clinical Findings:

 *Bleeding persists despite a firm well-

contracted uterus
 * Bright red blood
 * To diagnosis lacerations as a cause of
bleeding, careful inspection of the vagina,
cervix and lower uterine segment is an
essential precaution to avoid overlooking a
serious laceration.
 Classification
Perineal laceration may be classified as:

anus
 Treatment
Immediately Suture
Ⅳ. Blood Coagulation Defects

Complications
Coagulatio
of Labor and n defects
peripartum
 Coagulation
Defects
 *Blood disease rarely causes postpartum hemorrhage,
which is one of the contraindications for pregnancy.
 *Others such as severe hepatitis, placental abruption,
PIH syndrome, amniotic fluid embolism, intrauterine fetal
death may all affect the coagulation state or even cause
disseminated intravascular coagulation （ DIC ） to
induce postpartum hemorrhage.
Clinical Findings
 Hemorrhagic tendency during gestational
period
 Well-contracted uterus ， without obstetric
laceration
 Massive bleeding ， without blood clot
 laboratory examination ： blood platelets
count 、 PT 、 KPTT(kaolin
KPTT( partial
thromboplastin time)
 Coagulation
Defects
Prevention & Treatment
*Early gestational examination is necessary.
*Induced abortion is advised for pregnant
women with contraindications such as
blood disease.
*Etiological treatment
*Management of DIC
 i o n probable infection
s f us
tr an
anaemia puerperal
infection
complications death
PPH get worse

hypovolemic Sheehan syndrome

shock
liver/kidney injure
necrosis
The delivery technique should be improved in order
to prevent the unnecessary soft birth canal injuries.
*Appropriate episiotomy is recommended whenever
necessary.
*Examine the fetus and fetal membrane carefully
after placenta delivery.
*Eighty percent of the total amount of postpartum
hemorrhage occurs during the first two hours when
the pregnant woman should be carefully observed,
but the hemorrhage later should not be ignored.
 PPH Summary
 Unpredictable – be prepared
 Uterine atony is the main cause
 Remember 4-Ts:
- Tone
- Trauma
- Tissue
- Thrombin
 Consider active management of third stage.