2. POSTPARTUM HEMORRHAGE
Any amount of bleeding from and into the genital tract
following the birth of the baby up to the end of the
pueperium which adversely affects the general
condition of the patient evidenced by rise in pulse rate
and falling BP is called post partum haemorrhage
4. ⚫Calculation of maternal blood volume
⚫ Non pregnancy TBV=
⚫Pregnancy TBV=add 50% to non pregnancy
⚫In serious PPH, acute return of pregnancy TBV to non
11. Clinical Features
May beobvioussuch as,
⚫Altered level of consciousness
⚫Enlarged uterus, boggy on palpation
⚫Directobservation in open hemorrhage.
⚫In concealed case, diagnosis is based on clinical
⚫In traumatic hemorrhage- uterus is contracted.
⚫In atonic hemorrhage-uterus is relaxed.
⚫Improvement in health status, keep Hb level >10gm/dl.
⚫Screen high risk clients.
⚫Women considered at high risk of thromboembolism may
be receiving prophylaxis in the form of Unfractionated
Heparin (UH) or Low Molecular Weight Heparin (LMWH)
⚫Women with a lower level of increased risk of
thromboembolism may be receiving aspirin (75mg daily)
antenatally and may begin intrapartum prophylaxis with
⚫In theeventof a womancoming todeliverywhile
receiving therapeutic heparin, the infusion should be
stopped. Heparin activity will fall to safe levels within
an hour. Protaminesulphatewill reverseactivity more
rapidly, if required.
⚫Active managementof 3rd stageof labour.
16. ⚫Following delivery, administering a uterotonic
⚫Avoiding pulling thecord, avoid fiddling and kneading
the uterus, avoid Crede’sexpression
⚫Examine placentaand membranes for intactness.
⚫Continueoxytocin foratleast 1 hrafter
⚫Check forgenital tract trauma.
⚫Observe the patient forabout 2hrs after thedelivery
17. Immediate care in PPH
⚫MONITOR / INVESTIGATE.
18. Management of 3rd stage
The principles in the managementare:
⚫Toempty the uterusof its contentand to make it
⚫Toreplace the blood. If in shock, then manage shock.
⚫Toensureeffective hemostasis in traumatic bleeding.
19. Placental site bleeding
⚫Palpate the fundusand massage the uterus to make it
⚫Ergometrine 0.25mg or methergine 0.2mg is given
⚫Startadextrosesalinedripand arrange for blood
transfusion, if necessary.
⚫Catheterise the bladder, if it is found to be full.
⚫Sedation may begiven with morphine 15mg
22. ⚫Complications :
⚫ Haemorrhage due to incomplete removal
⚫ injury to the uterus (rare)
23. Management of true post partum
⚫To diagnose thecauseof bleeding.
⚫To take promptand effective measures tocontrol
⚫To correct hypovolemia.
⚫Call for help.
⚫Head down tilt
⚫Oxygen by mask, 8 litres / min
⚫Put in two large bore,14 gauge, cannula.
⚫Send blood forgrouping and cross matching and ask for 2
⚫ Infuserapidly 2 litres of NS (crystalloids) orplasmasubstitutes
⚫ Use awarming deviceand a pressurecuff.
⚫Monitor BP and pulseevery 25min, tem. every 4 hr.
⚫Monitor type and amount of fluids the patient has
received, urineoutput, drugs- type, dose and time, CVP.
25. Actual Management:
⚫ note the feel of the uterus.
⚫Step 1: Massage the uterus to make it hard.
⚫Step 2: Explore the uterusunder GA
⚫Ligation of uterinearteries
⚫Ligation of theovarian and uterineartery anostomasis.
⚫Ligation of theanteriordivision of internal iliacartery
(unilateral or bilateral).
⚫B- Lynch brace sutureand haemostaticsuturing
⚫Angiographic arterial embolisation under fluoroscopy
28. Secondary PPH
⚫Retained bitsof placenta or membranes.
⚫Infection and separation of slough overadeepcervico-
⚫Endometritisand subinvolution of the placental site
⚫Withdrawal bleeding following oestrogen therapy for
⚫Otherrarecausesare—chorion epithelioma; carcinoma of
cervix, infected fibroid or fibroid polypand puerperal
⚫The bleeding site is usually brightred. Varying degree
of anaemia and evidences of sepsis are present.
Internal examination reveals evidences of sepsis,
subinvolution and often a patulous cervical os. USG
helps in detecting retained bits of placenta inside the
⚫Blood transfusion, if necessary; Inj Ergometrine 0.5mg
IM, if the bleeding is uterine in origin, antibiotics as
⚫ If the bleeding is slight and no apparent cause is
detected, a careful watch fora period of 24hrsorso is
done in hospital.
32. Active treatment:
⚫As thecommonestcause is due to retained bitsof
placentaor membranes, it is preferable toexplore the
uterusurgently under GA. The productsare removed
byovum forceps. Gentlecurettage is done by using
flushing curette. Ergometrine 0.5mg is given IM.If
bleed is from sloughing of wound of cervico- vaginal
canal, control it by suturing.
34. Nursing Management
⚫Deficient fluid volume r/t excessive blood loss
secondary to uterine atony, lacerations, incisions,
coagulation defects, retained placental fragments,
⚫Fearand anxiety r/t threat to physical being, deficient
knowledgeof treatment .
⚫Pain r/t uterinecontractions, distention from blood
between uterinewall and placenta.
⚫Risk forcomplication, shock related toexcessive
35. ⚫Interrupted breast feeding r/t mother’s health state
during the PPH.
⚫Risk for impaired parent/ infant bonding r/t lack of
early parent/ infantcontact.
⚫Interrupted family process r/t change in family roles,
inability to assume usual role and prolonged recovery
⚫Placentacompletelyseparated but retained is due to
⚫Simpleadherent placenta is due touterineatonicity in
casesof grand multipara, overdistension of the uterus,
prolonged labour, uterine malformation or due to
bigger placental surfacearea. The commonestcauseof
retention of non-separated placenta is atonic uterus.
⚫Morbid adherentplacenta- partial orrarely
⚫Placenta incarcerated following partial orcomplete
separation due toconstriction ring, premature
attempts todeliverplacenta before it is separated
⚫It is made byan arbitrary timespent following delivery
of the baby.
⚫Featuresof placental separation is assessed.
⚫The hourglass contraction or the natureof adherent
placenta can only be diagnosed during manual
Period of watchful expectancy:
⚫During the period of arbitrary time limit of an half an
hour, the patient is to be watched carefully for the
evidenceof any bleeding, revealed orconcealed and to
note the signs of separation of placenta.
⚫The bladdershould beemptied using a rubber
⚫Any bleeding during the period should be managed as
outlined in third stage bleeding
41. Unseparated retained placenta:
⚫ Manual removal of placenta is to bedone under GA.
Complicated retained placenta:
⚫Retained placenta complicated with haemorrhage or shock.
⚫Retained placenta with shock no haemorrhage.
⚫Retained placenta with haemorrhage
⚫Retained placenta with sepsis
⚫Intrauterine swabs are taken forculture and sensitivitytest
and broad spectrum antibiotics is usuallygiven.
⚫Blood transfusion is helpful.
⚫ Manual removal of placenta.
⚫Retained placenta with an episiotomywound
⚫Shock is due to blood loss, at times unrelated blood
loss, specially when retained more than one hour,
Frequentattemptsof abdominal manipulation to
express the placentaout
⚫Risk of recurrence in next pregnancy.
43. PLACENTA ACCRETA
⚫It is defined as an extreme rare form in which the
placenta is directly anchored to the myometrium
partially or completely without any intervening
deciduas. The abnormal adherence may involve all
lobules—total placenta accreta. Or, it may involve
onlya few toseveral lobules— partial placenta
accreta. All or part of a single lobule may be
attached— focal placenta accreta.
⚫Thediagnosis is madeonlyduring attempted manual
removal when the plane of cleavage between the
placentaand the uterinewallscannot be madeout.
⚫USG and colourdoppler:
two factorswere highly predictiveof myometrial
invasion: (1) a distance less than 1 mm between the
uterineserosa-bladder interfaceand the retroplacental
vessels, and (2) identification of large intraplacental
(1) uterine bulging, (2) heterogeneous signal
intensitywithin the placenta, and (3) presenceof dark
intraplacental bandson T2-weighted imaging.
In the focal placentaaccrete
⚫Remove the placental tissue as much as possible.
Effective uterine contraction and hemostasis are
achieved by oxytocics and if necessary by intrauterine
plugging. In cases of caesarean section the bleeding
areas are over sewed. If the uterus fails to contract
hysterectomy may have to be taken and this preferable
52. In the total placentaaccrete:
⚫Hysterectomy is indicated in the parouswomen, while
in patientsdesiring to haveachild conservative
attitude may be taken. This consists of cutting the
umbilical cord as close to its base as possible and
leaving behind the placenta which is expected to be
autolysed during the course of time. Appropriate
antibiotics should be given. Methotrexate also is used
53. ⚫In rarecases:
⚫Placentaaccrete may invade bladder. In thatcase try to
avoid placental removal. It may need hysterectomy
and partial cystectomy. Methotrexate therapy may be
⚫Deliveryof the Placenta.
55. INVERSION OF THE UTERUS
⚫It is extremely rare but a life threatening complication
in third stage in which the uterus is turned inside out
⚫Firstdegree: there is dimpling of the funduswhich still
remains above the level of internal os
⚫Second degree: the fundus passes through thecervix
but lies inside thevagina.
⚫Third degree: the endometriumwith orwithout the
attached placenta is visible outside the vulva. The
cervix and partof vagina may be also involved in the
⚫Acute lowerabdominal pain with bearing down
⚫Varying degree of shock is a constant feature
⚫In complete variety pear shaped mass protrudes
outside thevulvawith broad end pointing downwards
and looking reddish purple in colour
⚫Do notemployany method toexpel placentaoutwhen
the uterus is relaxed.
⚫Puling thecord simultaneouslywith fundal pressure
⚫Manual removal in a safe manner
⚫Immediateassistance is summoned to include
anesthesia personnel and otherphysicians
⚫The recently inverted uteruswith placentaalready
separated from it mayoften be replaced
⚫Adequate large-bore intravenous infusion systems
⚫If still attached, the placenta is not removed until
infusion systems are operational, fluids are being
given, and a uterine-relaxing anesthetic such as a
halogenated inhalation agent has been administered.
62. ⚫Other tocolytic drugs such as terbutaline, ritodrine,
magnesium sulfate, and nitroglycerin have been used
successfully foruterine relaxation and repositioning
⚫Afterremoving the placenta, steady pressurewith the
fist is applied to the inverted fundus in an attempt to
push it up into thedilated cervix.
⚫Care is taken not to apply so much pressure as to
perforate the uterus with the fingertips
64. Beforeshock develops:
⚫To replace the part firstwhich is inverted last with the
placenta attached to the uterus by steady firm pressure
exerted by the fingers.
⚫To applycounter support by theother hand placed on the
⚫Afterreplacement the hand should remain inside the until
the uterus become contracted by parentral oxytocin or
⚫The placenta is to be removed manually after the uterus
⚫Usual treatmentof shock including blood transfusion
65. Aftershock develops:
⚫urgentdextrosesaline dripand blood transfusion
⚫topush the uterus inside thevagina if possibleand
pack thevagina with antiseptic rollergauze.
⚫Footend of the bed is raised.
⚫Replacement of uterus either manually or hydrostatic
method (O Sullivan’s) under GA. Hydrostatic method
is less shock producing.
⚫Tension on the nerves due to stretching of the infundibulo-
⚫Pressure on theovaries as theydragged with the fundus
through cervical ring.
⚫Haemorrhage, speciallyafterdetachmentof placenta
If left uncared it leads to:
⚫A chronic one