Management of postpartum haemorrhage

OBSTETRICS

1. MANAGEMENT
OF PPH

2. Multidisciplinary team consisting of obstetrician ,
anaesthetist, haemotologist, theatre staff and nursing staff
is ideal.
The patients general condition is evaluated and if he/she
is in shock immediate resuscitative measures are
instituted.
A hand on uterus will confirm atonicityand enable
uterine massage which should be done continuously.

3. PRINCIPLES OF MANAGEMENT
1. GENERAL MEASURES
* Resuscitative measures
* Investigations
* Monitoring
* Confirm the cause of PPH
2. MEDICAL METHODS
3. MECHANICAL METHODS
4. SURGICAL METHODS
5. RADIOLOGICAL ARTERIAL EMBOLISATION

4. GENERAL MEASURES
RESUSCITATIVEMEASURES
FLUID REPLACEMENT
Two intravenous infusions with large 14 gauge cannulae
are started
Aim is to replace 2-3 times the estimated blood lose
Crystalloids (normal saline or Ringer lactate) infused at
the rate of 1L in 15-20 min
Colloids can be given until blood is available (1-2L)
Crossmatchblood should be given as rapidly as possible
A central venous pressure line can be introduced

5. BLOOD COMPONENT THEORY
Correction of RBC deficit is guided by the rule that each
unit of packed cells will restore Hbconcentration by
1gm/dl
If there is evidence of coagulation defects fresh frozen
plasma, platelet concentrates, and cryoprecipitate are
made available

6. For every 6 units of red cells , 4 units of fresh frozen
plasma can be given
Each adult dose of cryoprecipitate will raise fibrinogen
level by 100mg/dl
Each adult dose of platelet concentrates will raise the
platelet count by 20000/L

7. OTHER MEASURES
Oxygen can be given by a mask or nasal cannulaat rate
of 10-15L/min
Patients leg may be elevated in order to increase venous
return
If unconscious patient should be turned to one side to
minimiseaspiration in case of vomiting
Important to keep patient warm as hypothermia will
exacerbate poor peripheral circulation

8. INVESTIGATIONS
LABORATORY TESTS
Hb, haematocrit, bloodgroupingand crossmatchingmust
be done
Platelet count, fibrinogen assay, partial thromboplastin
time, prothrombintime should be measured .
Electrolytes, urea and creatinineneeded in severe
hemorrhage
Bedside tests like clot observation test or clotting time
can be done

9. MONITORING
Pulse and Blood pressure
Heart rate by ECG monitor
Oxygen saturation by pulse oximetry
Central venous pressure line-to assess adequacy of fluid
replacement
Hourly urine output
Fluids and drugs given

10. CONFIRMATION OF DIAGNOSIS
Genital tract injuries are looked for and if present,
sutured
If placenta is not yet expelled signs of seperationare
looked for
If there are retained placental fragments , they are
removed
Succenturiatelobe should not be missed
Coagulopathyis checked

11. MEDICAL METHODS
Oxytocin
20-40 units in 500ml of normal saline
Ergometrine
Ergometrine0.25mg or methergin0.2mg given
Prostaglandin derivatives
15 methyl analogue of prostodin-250microgram given.

12. MECHANICAL METHODS
BIMANUAL COMPRESSION
Abdominal hand massages the posterior aspect of uterus
and the vaginal hand made into a fist presses the anterior
uterine aspect through anterior fornix.
Should be done continuously to promote uterine
contraction
Aortic compression against sacral promontory to reduce
bleeding.

13. Other mechanical methods include uterine packing and
balloon tamponade
BIMANUAL COMPRESSION

14. SURGICAL METHODS
UNDER SEWING
CHO’s MULTIPLE BLOCK SUTURES
B LYNCH OR BRACE SUTURE
MODIFIED B LYNCH (HAYMAN)
SYSTEMIC PELVIC DEVASCULARISATION-
HYSTERECTOMY

15. UNDERSEWING
Undersewingthe placental bed with figure of eight or
purse string sutures
Done at caesarean section for placenta praevia
MULTIPLE BLOCK SUTURES
Involve approximation of anterior and posterior uterine
walls with multiple squares until no space is left in uterine
cavity

16. MULTIPLE BLOCK
SUTURES

17. BRACE SUTURE
Involves use of vertical brace sutures
Very easy to perform
Commonly performed at caesarean section but can also
be done after vaginal delivery.
MODIFIED B LYNCH(HAYMAN)
Involves use of two vertical compression sutures placed
on either side of fundus
Quicker than brace suture.
Does not require a low transverse incision . Hence it is
useful following a vaginal delivery

18. BRACE SUTURE

19. SYSTEMIC PELVIC DEVASCULARISATION
Involve laparotomyand progressive stepwise
devascularisation
Uterine , ovarian and finally the internal iliac arteries are
ligated
Absorbable sutures should be used always
The ascending branch of uterine artery or the anterior
division of internal iliac artery are usually ligated.

20. UTERINE ARTERY LIGATION

21. HYSTERECTOMY
Considered as a last resort
Indications include severe atonichemorrhage, placenta
accreta, placenta praeviaand uterine rupture
Subttotalhysterectomy may be easier and quicker but is
inadequate in cases where bleeding is in the lower
segment as in placenta praeviaand adherent placenta
Ovaries should be retained

22. RADIOLOGICAL ARTERIAL
EMBOLISATION
The patient shoudbe hemodynamicallystable
Under angiographic guidance and percutaneous
transcathetertechnique , femoral artery catheterisationis
done
Bleeding vessels are identified
Embolisationcarried out with gel foam or microspheres

23. Management of secondary PPH
High vaginal swab should be taken for culture
Broad spectrum antibiotics should be started
If the ultrasound scan reveals retained products , uterus
should be evacuated
The tissues obtained should be sent for culture and
histopathologicalstudies
If there is evidence of sepsis , evacuation should be
delayed by 12-24 hours to reduce risk of septicemia
If bleeding is severe uterine artery ligation or
hysterectomy is done

24. THANK YOU