1. Postpatrum Hemorrhage and Third Stage Emergencies

2. Postpartum Hemorrhage
3-5% of vaginal deliveries
Definition: >500ml blood loss
Potentially serious complications for mother
Common cause of maternal morbidity and mortality worldwide

3. PPH Risk Factors Antepartum Pre-eclampsia Multiparity
Multiple gestation
Previous postpartum hemorrhage
Previous cesarean section
Intrapartum
Prolonged third stage (>30 mins)
Arrest of descent
Episiotomy
Lacerations: cervical, vaginal, perineal
Assisted delivery: forceps, vacuum
Augmented labour

4. Causes of PPH: The Four “Ts”
Tone (70%)
Trauma (20%)
Tissue (10%)
Thrombin (1%)

5. PPH: Resuscitative Measures
Call for help
Airways, Breathing, Circulation
Two large-bore IVs
Oxygen
Stat labs: type & cross, hb, coags
Consider transfusion

6. Treatment Approach for PPH
Catheterise bladder
Uterine massage
Oxytocics
Inspect for lacerations
Surgical intervention

7. Tone – Uterine Atony Most common cause of PPH
Initial step = bimanual uterine massage and compression
Oxytocic agents
Oxytocin
Methylergometrine
Prostaglandins

8. Oxytocin Drug of choice 10 – 40 units in 1 litre at 250 cc/hr
1M (10 units) or IV infusion
No contraindications
Hypotension with IV push

9. Ergot Alkaloide Ergometrine 0.25 mg IM only
Contraindicated in hypertension

10. Prostaglandins 15-methyl prostaglandin F2a
carboprost, Hemabate®
0.25 mg IM or intramyometrial
Side effects: nausea, diarrhea, flushing, headache
Contraindication: hypersensitivity
Caution: asthma, HTN, cardio- pulmonary disease

11. Trauma Uterine inversion Uterine rupture
Vaginal or cervical lacerations
Hematoma
Perineal tears

12. Uterine Rupture Associated with uterine surgery Suspect if:
vaginal bleeding
abdominal tenderness
maternal tachycardia
signs of shock are out of proportion to viable blood loss

13. Uterine Inversion Rare, but important to recognize quickly
Suspect if shock disproportionate to blood loss
Replace uterus immediately or after resuscitation
Watch for vasovagal reflex

14. Tissue Retained placenta Retained placental fragments
Not delivered within 30 minutes
3% of deliveries
Retained placental fragments
Invasive placenta

15. Manual Placental Removal
Cease uterine massage
Identify cleavage plane
Cup cotyledons in palm
Explore uterine cavity
Give oxytocin

16. Thrombin - Coagulopathy
Pre-existing conditions
ITP, von Willebrands
Coagulaopthic: Obstetric-related
Hypertension disorders, HELLP
Abruption
Fetal demise
Sepsis
Drugs (e.g. asprin)

17. Coagulation Lab Studies
FBC with platelet count
PT-INR, aPPT
Fibrinogen level
FDP / D-dimer

18. Tone, Trauma, Tissue, Thrombin
PPH Summary
Unpredictable – be prepared
Uterine atony is the main cause
Remember 4-Ts:
Tone, Trauma, Tissue, Thrombin
Consider active management of the third term