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HEMORRHAGE
DEFINITION:
Blood loss of more than 500 ml after vaginal
delivery and more than 1,000 ml after cesarean
delivery
Decrease in hematocrit of more than 10% from
before to after delivery
CLASIFICATION
Primary Hemorrhage on the first 24 hours
Secondary Hemorrhage after the first 24 hours
The 4 Ts
Tone (atonic uterus)
Trauma (tears in birth canal)
Tissue (retained placental
fragments)
Thrombi (blood coagulation
disorders)
UTERINE ATONY
Postpartum uterine contraction inadequate for
GENITAL TRACT
LACERATIONS
Suspect of lacerations : perineum, vaginal or
cervical laceration
Before you perform your inspection administer
adequate analgesia and prepare excellent light
The perineal trauma may occur spontaneously or
arise from episiotomy during vaginal delivery
Anterior perineal trauma involves the labia, ant
vagina, urethra or clitoris
Posterior perineal trauma involves posterior vaginal
wall, perineal muscles or anal sphincters and may
extend through the rectum
Classificationof
spontaneous
tears acc to
1 degree involves the fourchette, perineal
skin and
vaginal mucous
membrane but not
the
degree
or
depth
yet underlying fascia and muscle
st
GENITAL TRACT
HEMATOMA
The pregnant uterus, vagina and vulva have rich
vascular supplies that are at risk of trauma
during birth process and may result in formation
of a hematoma
The most common location : vulva,
vagina/paravaginal, and
retroparitoneum/subperitoneal
Risk factor :nulliparity, prolonged 2 nd stage of
labor, indtrumental delivery, baby > 4000gr,
genital tract varicosities, preeclampsia, multifetal
pregnancy, cloting disorders
symptom
Imaging (UTZ, CT, MRI) may be helpful to
confirm the diagnosis (location, size, progress
or resolution)
conservatively
Expanding hematoma should be evacuated
performa generous incision, irrigate copiously
and ligate the bleeding vessels. Layered
clossure is recommended to assist
hemostasis and eliminate dead space
Vaginal packing for 12-24 hours
Antibiotic broad spectrum should be
administered
RETAINED PLACENTA
Risk factor : abnormal placentation, placenta
UTERINE INVERSION
The uterus is turned inside out, with the fundus
Diagnosed ???
Hemorhage
Shock
Severe pelvic pain
Management ???
The immidiate treatment of the hemorrhagic
Repositioning
Repositioning
Method of hydrostatic reduction (OSullivans
hydrostatic maneuver)
Johnson maneuver
Huntington maneuver
Hultain maneuver
COAGULOPATHY
Risk factors : severe pre-eclampsia, abruptio
placenta, idiopathic/autoimune
thrombocytopenia, amniotic fluid embolism,
DIC, heredity coagulopathy (von willebrands
disease)
Surgical treatment will only increase the
hemorrhage
Replace coagulation factors and platelets as
needed
PPH DRILL
HAEMOSTASIS
MANAGEMENT
Uterine massage and or bimanual uterine
compression
compression :
Uterotonic therapy
Agent
Dose
Route
Dosing
frequency
Side
effects
Contraindications
Oxytocin
(Pitocin)
10-80
IV (1st)
units in IM / IU
1L soln
Continuous
Nausea,
emesis, water
intoxicaton
None
Methylergonovine
(Methergin)
0.2mg
IM (1st)
IU / PO
Q 2-4 hr
Hypertension,
hypotension,
nausea,
emesis
Hypertension
preeclampsia
Misoprostol
(Cytotec)
6001000ug
PR (1st)
PO
Single
dose
Nausea,
None
emesis,
diarrhea, fever,
chills
Uterotonic therapy
Agent
Dose
Route
Dosing
frequency
Side
effects
Contraindications
15-methyl
prostaglandin F2
(Hemabate)
0.25mg
IM (1st)
IU
Q15-90min
(8 dose max)
Nausea,
emesis,
diarrhea,
flushing,
chills
Active cardiac,
pulmonary,
renal or
hepatic
disease
Prostaglandin E2
20mg
PR
Q 2 hr
Nausea,
emesis,
diarrhea,
fever, chills,
headache
Hypotension
(Dinoprostone)
Hospital
Tamponade
Balloon
Gloves
Condoms
Urterine Packing
Uterine packing controls postpartum bleeding
Baloon Tamponade
The technique is simple
A foley catheter with a 30-ml balloon capacity is easy
Condom Catheter
Tamponade
This simple technique uses a 500 cc infusion
bag connected to a Nelaton catheter which is
in turn connected to a condom.
Compression suture
B-Lynch
operation
Cho operation
Pereire operation
B-Lynch technique
Uterus remains
exteriorized
A 70-80 mm round
needle, 2-0 chromic
or plain
With the bladder
displaced inferiorly
1st stitch placed 3 cm
below the lower
cesarean incision
A. Rebarber, A. Roman. Seven ways to control postpartum hemorrhage. Contemporary
Ob/Gyn 2003
30
B-Lynch technique
B-Lynch technique
Carry suture on
the top and
posterior side
Suture is vertical
and 4 cm from
cornua
B-Lynch technique
The suture is placed
same way as the left
side
3 cm above the
incision, 4 cm from
the lateral side of
the uterus
3 cm below the
incision
A. Rebarber, A. Roman. Seven ways to control postpartum hemorrhage. Contemporary
Ob/Gyn 2003
33
B-Lynch technique
Maintains
compression
Two ends of
suture put
under
tension
Double
throw knot
placed
Closure of
C/S incision
A. Rebarber, A. Roman. Seven ways to control postpartum hemorrhage.
Contemporary
Ob/Gyn 2003
34
Selective pelvic
devascularization
Bilateral
uterine sources
Hypogastric Artery
Ligation
Decrease bleeding
Decreased arterial pulse pressure
Clot forms
Too long to perform
Surgical repertoire of well-trained gynecologic
surgeon
INDICATION
Placenta accreta
Abdominal pregnancy
Uterine atony
Couvelaire uterus
Ruptured uterus
COMPLICATIONS
Waiting too long
Easy to ligate the external iliac artery instead of
Interventional radiology
Selective
(SAE)
arterial embolization
Advantages
Control hemorrhage
Effective in the management
Postpartum hemorrhage
Ectopic pregnancy
Postabortal hemorrhage
Malignancy
Post-conization hemorrhage
Technique
Interventional radiologist under flouroscopic
guidance
Regional anesthesia or conscious sedation
Introduces a catheter via the femoral artery
Directs it into the target vessel
Target artery is occluded
Patients respond immediately
Menses returns in 3 months
Normal pregnancies
risk of PPH
Complications
Fever
Buttock ischemia
Hematoma
Vascular perforation
Infection
Uterine necrosis
Hysterectomy
Should only be used for persistent and
Remember
Help from MDs / RNs
Assess maternal condition
Etiology of bleeding
Massage the uterus
Oxytocin infusion
48
hospital
Tamponade (Balloon /
Packing / Condom)
Apply Compression Sutures
Systemic Pelvic
devascularization
Interventional Radiology
Subtotal / Total Hysterectomy
49
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