Postpartum Hemorrhage – >500ml blood lost
Early ( 1°) PPH – in 1st 24 hours
Late ( 2°) PPH – up to 6 m.o
Patients on coagulation therapy
Patients with anemia
1° PPH – uterine atony (90%), genital tract trauma, coagulopathy, uterine rupture, uterine inversion
2° PPH – retained product of conception, uterine infection
Clinical signs of PPH
- External hemarhage – visible vaginal bleeding + anemic syndrome, severe → HYPOVOLEMIC SHOCK!!
- Internal hemorrhage – x visible bllod lost, but present signs and symptoms of anemia
Determine the cause and treat it!!
- FBC + cross matching of blood group
- Massage the uterus
- Set 2 lines (large gauge – 14 – 16 Fr) on both wrist
- Empty bladder
- Check for trauma of the genital tract
According to cause:
- Genital tract trauma
- Cervical tear – stitch from apex
- Vaginal tear – s/f tear: stitch from the apex
Deep tear – EUA, packed –remove after 24 hours and stitching is done
- Paravaginal hematoma –
supralevator: laparotomy, CT, TAH (total abdominal hysterectomy)
infralevator: if <5cm and is not expanding → ice packed, vaginal packing and analgesics,
If >5cm and is expanding → xplore and evacuate hematoma, ligate vessels,
drain, packed and CBD for 24hours.
- Coagulopathy – correction by transfusion with O- blood, FFP, and anticoagulant therapy should be reversed: aspirin with platlets, LMW heparin with protamine and warfarin with vit K or FFP. In DIC – 6 cryopercipitate + 4 FFP + 2 platlet
- Uterine rupture – incomplete type: repair; complete type: TAH
- Uterine inversion – immediately replace the uterus through the cervix by manual compression using as much of the hand as possible and maintain uterine contraction with an oxytocin.
- Retained product of conception – early: manual extraction of the placenta under anaesthesia; late – blunt curettage
- Uterine infection – antibiotics, uterotonics and antipyretics.
List of drugs available for hamostasis in PPH
- Syntometrine (i/m) : oxytocin 5 units + ergometrine 0.5 mg (long acting)
c/i: HPT and cardiopathy
- Syntocinon (i/v) : oxytocin 10 units (short acting)
40 units in 1 pint over 4 hours, 125 ml/hr
- Hemabate (i/m) : PGF2α
If 3 times syntometrine (fail) → give hemabate up to max 8 times, every 15 min (fail) → tamponade or balckmore tube/rusch catheter (fail) → hysterectomy
ALWAYS MONITOR VITAL SIGNS & SIGNS INDICATING
Active 3rd stage management to prevent PPH
- Indentify risk factors.
- Early cord clamping.
- Control cord traction.
- Administration of syntometrine (i/m)
- i/v syntocinon.
- Massage uterus.
- Set 2 lines (large bore).