postpartum hemorrhage

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1. DATE

2. POSTPARTUM HEAMORHAGE DR SABA BAJWA

3. Postpartum heamorrhage Definition Loss of blood more than 500ml from the genital tract post delivery of the baby. Clinically the amount of blood loss will adversely affect the general condition of the patient. Incident is 1-4 percent. Prognosis: 3% risk of death.

4. Classical Clinical Picture Low bp Rapid weak pulse Pallor cold clammy sweat cyanosis of fingers dimness of vission restlessness oliguria /anuria

5. TYPES Primary PPH Secondary PPH

6. Primary PPH: Bleeding occurs following delivery of the baby up to 24 hours SECONDARY/DELAYED PPH: Bleeding occurs following delivery of the baby after 24 hours upto 6 weeks

7. Causes of PPH The FOUR “T” to Remember: Tone Tissue Trauma Thrombin

8. TONE – UTERINE ATONY 70 - 90% of cases Uterine hyper distension - Macrosomic baby -Multiple pregnancies - Polyhydromnios -Grand Multipara Anemia Previous PPH Prolonged labor

9. TISSUE Retained placenta Retained Blood clots

10. THROMBIN Pyrexia in labor Pre –existing bleeding disorder like haemophilia Patient already on anti – coagulant Disseminated Intravascular Coagulation (DIC)

11. TRAUMATIC PPH 5 -10% of cases CERVIX- lacerations VAGINAL-Lacerations Uterine rupture Perineum- injury Operative vaginal delivery vaccum / forcep

12. Preventions Identify the risk factors that may present antenatally or intrapartum will help us to plan the delivery. However ,most cases of PPH have no identifiable risk factors . Active management of 3rd stage of labour lower maternal blood loss and reduce risk of PPH.

13. Active managemnt of 3rd stage -use of uterotonic -uterine massage -control cord traction for delivery of placenta

14. According to the guidelines, 40IU of Synto in 500ml R/L IV slowly should be given to all the women to reduce the risk of PPH. As it reduce the risk of PPH by -60%

15. DIAGNOSIS OF PPH Profuse bleeding at the time of delivery . Sign and symptoms of hypovolemic shock.

16. Management 1 . COMMUNICATION 2 .RESUSCITATION 3 .MONITORING AND INVESTIGATIONS 4 . ARREST THE BLEEDING

17. Communication Alert all relevant professionals. For major PPH , call for help. Red Alert -Call consultant obstetrician -Call experienced Midwife -Alert Anesthetist -Alert blood transfusion laboratory

18. RESUSCITATION - Airway - breathing -circulation The measurement for resuscitation depends on condition and degree of shock. - Asses Airway and Breathing - Give oxygen via face mask -Fluid balance - Blood transfusion - Blood products , FFPS, Platelets , Cryoprecipitate should be given

19. MONITORING AND INVESTIGATION Monitor Blood pressure/Pulse Rate every 15 min in minor PPH Monitor urine out put . Transfer to ICU or HDU once bleeding is controlled .

20. Arrest the bleeding Depend on the cause of massive bleeding Common causes –uterine Atony - Mechanical - Pharmacological - Surgical

21. Mechanical Uterine packing Bimanual uterine compression to stimulate uterus to contract.

22. PHARMACOLOGICAL High dose intravenous syntocinon should be given as per protocols 10 to 20 IU stat dose. Prostaglandins may be injected systemically or directly into myometrium through the anterior abdominal wall . Misoprostol 800mg (4 pessaries ).

23. PHARMACOLOGICAL WHO now strongly recommends early use of IV tranexamic acid (within 3 hours of birth) in addition to standard care for women with clinically-diagnosed PPH following vaginal birth or caesarean section. Tranexamic acid should be used in all cases of PPH, regardless of whether the bleeding is thought to be due to genital tract trauma or other causes, including uterine atony

24. SURGERY Baloon temponade

25. THE B –LYNCH SUTURING

26. Bilateral internal iliac artery ligation Bilateral uterine arteries ligation

27. T hank Y ou!