Dr. Sunita Singal discusses postpartum hemorrhage (PPH) and shock. PPH is a leading cause of maternal death worldwide. Early recognition and treatment is important to prevent shock. The document outlines strategies for prevention of PPH through active management of the third stage of labor. It describes the signs and causes of PPH and shock, including the four T's (tone, tissue, trauma, thrombin). Treatment involves following ABCs - airway, breathing, circulation. Circulatory support includes IV fluids and blood transfusion as needed. Management depends on the identified cause, and may involve uterotonic drugs, bimanual compression, aortic compression, or uterine tamponade. Referral

1. PPH & Shock
Dr Sunita Singal,SJH ND

2. Objectives
 To detect PPH & assess degree of shock
 Identify types of PPH
 To develop skills and best practices for
management of postpartum hemorrhage
 To describe strategies for prevention of
postpartum hemorrhage

3. Haemorrhage is common
 Most common cause of maternal death
worldwide
 Probably accounts for more than 30-38% of
all maternal deaths
 Deaths from haemorrhage could often be
avoided

4. Haemorrhage is often not recognized
 Blood loss is underestimated because in
pregnancy signs of hypovolaemia do not show
until the losses are large
 Mother can lose up to 30-35% of circulating
blood volume (2000 mls) before showing signs
of hypovolaemia

5. PREVENTION STRATEGY
FOR PPH

6. AMTSL: ACTIVE
MANAGEMENT OF THIRD
STAGE OF LABOUR

7. The classical expectant management
• Wait for the natural forces of labor to bring
about 3rd stage contraction and placental
separation
• Look for the signs of placental separation
• Controlled cord traction to expel the placenta
and membranes
• Optional administration of Oxytocics

8. WHAT IS AMTSL :Active management
of 3rd stage
• Oxytocic administration immediately after
delivery of the baby so that the uterine
contractions & placental separation is not
left to the natural uncertain forces of labor
• Controlled cord traction on perception of a
strong uterine contraction with out waiting
for the actual signs of placental separation
• Uterine massage to maintain the contraction

9. Benefits of AMTSL
• Uterine atony accounts for 70-90% of all PPH cases
• AMTSL reduces:
Incidence of PPH by 60%
Quantity of blood loss—thereby decreasing incidence &
severity of anemia
Emergencies & related cost, transport
The use of blood transfusion

10. PPHaemorrhage - causes
4Ts:
 Tone: uterine atony,
 Tissue: retained placenta or retained products,
 Tears: cervical or perineal, or ruptured uterus),
 Thrombin: coagulation disorder
 Coagulation disorders may also be associated with
haemorrhage

11. Symptoms
& signs
Associated
findings
Probable
diagnosis
Immediate PPH
Uterus soft &
not contracted
Bleeding may
be continuous
or Intermittent,
Shock
Atonic uterus
Immediate PPH
Uterus
contracted
Bleeding is
bright red and
continuous
(Complete
placenta
expelled)
Traumatic PPH-
tears in the
cervix or vagina
Placenta not
delivered
within 30 min
of delivery
PPH may or
may not be
present
Retained
placenta

12. Diagnosing the cause of PPH
Portion of placenta
missing or
membranes torn
Uterus relaxed
PPH
Retained
placental
fragments
Uterine fundus not
felt on abdominal
palpation
Inverted uterus
apparent at
vulva
Immediate PPH
Inverted uterus

13. Shock due to Haemorrhage
 Shock is a life threatening condition that
requires immediate, intensive treatment
 The presence of shock mean that there is an
inadequate perfusion of organs & cells with
oxygenated blood. There is some form of
cardiovascular compromise

14. Signs Present?
 When signs are there they are SIGNIFICANT
 Have a high suspicion and ACT QUICKLY!

15. Shock due to Haemorrhage –Signs
 Pale
 Confused
 Increased HR
 Reduced BP (late sign)
 Reduced urine output
 Obvious or hidden bleeding

16. Signs of shock
 Brain -unconscious, anxious, agitated and
confused, drowsy
 Skin - sweaty or cold and clammy
 Breathing - rapid
 Conjunctivae - pale
 Pulse - weak and fast >100/minute
(sometimes “bounding pulse”)
 BP - low systolic < 90 mmHg
(late sign)
 Kidney - poor urine output

17. Haemorrhage - management
 Follow the protocol
 ABCs
 C - replace the volume
- stop the bleeding

18. Haemorrhage
 ABCs
 Circulation
 IV access by 2 large bore cannulae
 Send off blood samples
 Give iv fluids
16G – GREY: 1 litre in 5 mins
18G – GREEN: 1 litre in 10 mins
20G – PINK: 1 litre in 15 mins
22G – BLUE: litre in 30 mins

19. Shock- immediate action
Circulation
 Get iv access and send blood samples
 If pulse>100 / minute or BP< 90 mm Hg or heavy vaginal
bleeding
 Give 1 l iv fluid over 20 minutes
 Give further 1 l over 30 minutes
 Review the situation and repeat if necessary
 Beware – if underlying anaemia or severe pre-eclampsia

20. How much fluid, How fast?
• Volume of 3x the estimated loss as crystalloids
(up to 4L) then as colloids
• Give blood early – mistake often is too little
too late! (So REFER to FRU early)
• Replace as quickly as you can if patient
shocked
• Be guided by the patients signs and response
(e.g. Pulse rate, level of consciousness)

21. Be aware of blood lost!
Signs Blood lost Action
Mild increase in
pulse-
700 mls Give iv fluids
Increase in pulse
and respiratory rate
1500 mls Give iv fluids
Fall in BP 2000 mls Give fluids and
blood
Cold, drowsy, very
high pulse, very low
BP
2500 mls Large transfusion
required

22. Shock- immediate action
 Ascertain the cause of haemorrhage
 Cover her and keep her warm
 Keep a careful record of input and output and drugs
given
 If at a lower level facility, Prompt Referral to FRU
after resuscutation

23. Diagnosing the cause of PPH
The most important step in making a diagnosis
of the cause of PPH is to keep a hand on the
lower abdomen of the woman and feel for
the uterine tone

24. PPH – How to manage
Stepwise approach in case of uterine
atony

25. Uterine atony
 Empty bladder
 Give Oxytocics
 Check for
 placenta completeness
 genital tract injury
 Rub uterus
 Bimanual compression
 Aortic compression
 Uterine tamponade

26. Management (Contd.)
 Massage uterus to expel clots and feel to
see that it is contracted—recheck
intermittently
 Give oxytocin 10 units IM
 Give iv fluids
 Oxygen @6-8 L/ minute by mask

27. Oxytocic Drugs
Oxytocin Ergometrine/ 15-methyl
prostaglandin F2
Dose and Route IV: Infuse 20
units in 1 L at
60 drop/min.
IM: 10 units
IM 0.2 mg IM: 0.25 mg
Continuing
Dose
IV: Infuse 20
units in 1 L at
40 drop/min.
Repeat 0.2 mg
IM after 15 min.
If required, give
0.2 mg IM every
4 hours
IM: 0.25 mg
every 15 min.
Maximum Dose Not more than
3 L of IV
fluids
5 doses 8 doses
Precautions/
Contraindicatio
ns
Do not give
as IV bolus
Pre-eclampsia,
hypertension,
heart disease
Asthma

28. Bimanual Compression of Uterus
 Wearing sterile gloves,
insert hand into vagina;
form fist
 Place fist into anterior
fornix and apply pressure
against anterior wall of
uterus

29. Bimanual Compression of Uterus
(contd.)
 With other hand, press deeply into abdomen
behind uterus, applying pressure against
posterior wall of
uterus
 Maintain
compression until
bleeding is controlled
and uterus contracts

30. Compression of Abdominal Aorta
 Apply downward pressure with
closed fist over abdominal aorta
directly through abdominal wall
 With other hand, palpate femoral
pulse to check adequacy of
compression
Pulse palpable = inadequate
Pulse not palpable =
adequate

31. Compression of Abdominal Aorta
(Contd.)
• Maintain compression
until bleeding is
controlled

32. Uterine Tamponade (1)

33. Uterine Tamponade (2)
Up to 500mls or until the uterus is contracted

34. RETAINED PLACENTA: MRP
•IV oxytocin, oxygen, Empty bladder, CCT
•If CCT not successful, on PV it can be felt in
cervix, grasp & remove.
•If still cannot be removed, & Cx is
dilated,MRP should be attempted give
plasma expanders, additionally
•If placenta is retained & no bleeding refer
to FRU.

35. Traumatic PPH
 Episiotomy
 Perineal tears and lacerations
 Vaginal tears
 Cervical tears
 Uterine rupture
 Broad ligament hematoma
 Para-vaginal & Vulval hematoma

36. Follow-up care in atonic PPH
• Monitor the vital signs( pulse, BP, RR)
• every 10 min. for the first 30 mins,
• every 15 mins. for the next 30 mins. & then
• every 30mins. for the next 3-6 hours or until stable.
• Palpate the uterine fundus to ensure that the uterus
remains contracted.
• Continue oxytocin infusion
• Monitor the urinary output - should be more than 30
ml/ hour

37.  Not a common condition
 Pulling on the umbilical cord in the
absence of a uterine contraction in an
effort to deliver the placenta can cause
inversion of uterus
Acute Uterine Inversion

38. Manual replacement of uterus
 Give the woman IV sedation with Inj.
Pentazocine (Fortwin) 30mg, and Inj.
Phenergan 25 mg.
 Ensure aseptic precautions
 Insert a hand into the vagina. Feel for the
cervical rim.
 Reposit the uterus back, starting with the part
that comes out last (the fundus comes out first
and the portion of the uterus just above the
cervix comes out last)

39. Uterine Inversion
 ‘O’ Sullivan’s hydrostatic pressure method
can be attempted (?) if service provider is
experienced
 Do not remove the placenta, if attached to
uterus, before vaginal replacement of the
uterus as it can lead to severe hemorrhage

40. Prevention
 Do not pull on the cord in the absence of a
uterine contraction.
 Always apply "counter-traction" with the
other hand while carrying out controlled cord
traction.
 Do not apply fundal pressure to deliver the
baby or the placenta.

41. DELAYED PPH
Management
• Give Inj. Oxytocin 10 IU I/M stat
• Start IV infusion of 20 IU Oxytocin in 500 ml of
Ringer Lactate / Normal saline at rate of 40-60
drops / min
• Suspect infection if fever and / or foul smelling
vaginal discharge
• Give first dose of antibiotics
Cap. Ampicillin 1 gm oral
Tab. Metronidazole 400 mg oral
Inj. Gentamycin 80 mg IM stat
• Refer to FRU

42. KEYPOINTS
• Prevent PPH Practice AMTSL
• Diagnose & treat PPH promptly if it occurs
• Quick assessment of mother’s condition &
Tx of shock.
• Identify the cause of PPH and manage
accordingly.
• Timely referral to FRU where blood is
available (after immediate management)

43. THANK YOU

44. Dr Sunita Singal,SJH ND

45. Dr Sunita Singal,SJH ND