36. Postpartum hemorrhage -before and after the delivery of the placenta.

Question 1

what is postpartum hemorrhage ?

Answer 1

blood loss in excess of 500 mL following birth of the baby

but clinical definition better

bleeding following the birth to the end of puerperium, which adversely affects the general condition of the patient evidenced by rise in pulse rate and falling blood pressure

Question 2

depending on the amount of blood loss PPH divided into ?

Answer 2

Minor (< 1L), ♦ Major (> 1L) or ♦ Severe (> 2L).

Question 3

what are the types of PPH?

Answer 3

primary -Hemorrhage occurs within 24 hours following the birth of the baby (usually first 2 ) , these are two types

these are two types :

Third stage hemorrhage—Bleeding occurs before expulsion of placenta.

True postpartum hemorrhage—Bleeding following expulsion of placenta (majority).

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Secondary: Hemorrhage occurs beyond 24 hours and within puerperium

Question 4

cause of primary PPH ?

Answer 4

atonic uterus -
grand multipara 
hydromaonois and big baby - over extension of uterus 
malnutrition and anemia 
prolonged labour >12hrs
anaesthesia 

trauma - Blood loss from the episiotomy
or laceration of genital tract

blood coagulopathy

Question 5

diagnosis of primary ph ?

Answer 5

State of uterus, as felt per abdomen, gives a reliable clue as regards the cause of bleeding.

In traumatic hemorrhage, the uterus is found well contracted.

In atonic hemorrhage, the uterus is found flabby and becomes hard on massaging

Alteration of pulse, blood pressure and pulse

Question 6

prevention of primary PPH ?

Answer 6

intranatal
Active management of the third stage, for all women in labor should be a routine as it reduces PPH by
60%

Cases with induced or augmented labor by oxytocin, the infusion should be continued for at least one
hour after the delivery.

Women delivered by cesarean section,oxytocin slow IV is to be given to reduce blood loss

Exploration of the utero vaginal canal for evidence of trauma following difficult labor or instrumental
delivery.

Observation for about two hours after delivery to make sure that the uterus is hard and well contracted

Question 7

what is the management of third stage placental site bleeding ?

Answer 7

Placental site bleeding
— To palpate the fundus and massage the uterus to make it hard. The massage is to be done by placing four fingers behind the uterus and thumb in front.

-start crystalloid solution (Normal saline or Ringer’ssolution)

Oxytocin 10 units IM or methergine 0.2 mg is given intravenously.

arrange for blood transfusion if necessary.

— To catheterize the bladder.

— To give antibiotics

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If the placenta is not separated and the patient is resuscitated , manual removal of placenta under general anesthesia is to be done

Question 8

STEPS Of MAnUAl REMOvAl Of PlACEnTA?

Answer 8

done under general anesthesia.

aseptic measures, the bladder is catheterized.

cups the fundus with one hand and hold it down by assistant

1)One hand is introduced into the uterus in cone shaped manner pronated following the cord, which is made taut by the other hand

fingers of the uterine hand should locate the margin of the placenta.
fingers are insinuated between the placenta and the uterine wall with the back of the hand in contact with the uterine wall. e fingers.

When the placenta is completely separated, bring it out

The hand immediate goes inside the uterus for exploration of the cavity to be sure that nothing is left behind

Intravenous methergine given and then uterine hand is gradually removed while massaging the uterus by the external hand to make it hard.

After the completion of manual removal, inspection of the cervicovaginal canal is to be made to exclude any injury

the placenta and membranes are inspected for completeness

Question 9

what is the general management of true post partum hemorrhage ?

Answer 9

rapidly 2 liters of normal saline(crystalloids) or plasma substitutes like Haemaccel(colloids)

Give oxygen by mask

Start 20 units of oxytocin in 1 L

Question 10

what is the management of atonic uterus in true post partum hemorrhage ?

Answer 10

Massage the uterus to make it hard
Methergine 0.2 mg is given intravenously,
IV oxytocin -10 U
Foley catheter to keep bladder empty and to monitor urine output,

always examine the expelled placenta and membranes, If the uterus fails to contract, proceed to the next step

iv saline or ringer
blood transfusion

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Step—II: The uterus is to be explored under general anesthesia. Simultaneous inspection of the cervix, vagina especially the paraurethral region

In refractory cases:
 Injection 15 methyl PGF2α IM in the deltoid muscle every 15 minutes
OR
 Misoprostol (PGE1) per rectum is effective.
 When uterine atony due to tocolytic drugs,calcium gluconate (1gIVslowly) should be given

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step 3 -Uterine bimanual compression

whole hand is introduced into the vagina in cone shaped fashion separating the labia

vaginal hand is clenched into a fist in the anterioir fornix

The other hand is placed over the abdomen behind the uterus to make it anteverted, (d) The uterus is firmly squeezed between the two hands

continue the compression for a prolonged period until the tone of the uterus is regained

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in rare cases, when the uterus fails to contract, the following may be tried desperately as an alternative to hysterectomy

Uterine tamponades:

Tight intrauterine packing by sterile gauze is done uniformly under general anesthesia

packed so that no empty space is left behind starting from the fundus and abdominal hand steadying the uterus. A separate pack is used to fill the vagina. An abdominal binder is placed

antibiotics are given

or

Balloon tamponade
bakri balloon catheter,is inserted into the uterine cavity and the balloon is inflated with normal saline (200–500 mL). It is kept for 4–6 hours

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Surgical methods
Ligation of uterine arteries

B-Lynch compression suture (1997) and multiple square sutures

Question 11

causes of secondary post partum hemorrhage ?

Answer 11

Retained bits of cotyledon or membranes (most common),

(2) Infection and separation of slough over a deep cervicovaginal laceration,
(3) Endometritis and subinvolution of the placental site
(4) Secondary hemorrhage from cesarean section wound usually occur between 10–14 days.

Question 12

what is the diagnosis of secondary post partum hemorrhage

Answer 12

trauma - bleeding is bright red and of varying amount
speculum and colpspscopy

uterine subinvoltuion -
sue to retained products - Ultrasonography is useful in detecting the bits of placenta inside the uterine cavity

endometritis - high cervical and vaginal culture

blood - leukocytosis and increased crp

scant lochia- ecoli
or persistent and prolonged lochia

Question 13

management of secondary post partum hemorrhage?

Answer 13

saline or ringer IV

Blood transfusion, if necessary,

administer antibiotics (clindamycin and metronidazole) as a routine.

If the bleeding is slight and no apparent cause is detected, a careful watch for a period of 24 hours.

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retained bits of cotyledon or membranes, it is preferable to explore

under general anesthesia and prophylactic antibiotics

dilation and suction evacuation followed by currtegae ..

Methergine 0.2 mg is given intramuscularly.

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Presence of bleeding from the sloughing wound of cervicovaginal canal should be controlled by hemostatic sutures.

Question 14

other than oxytocin what other drugs are given if uterine hypotonic CAUSING PPH ?

Answer 14

methergine - 0.2mg - IM/IV

CARBOPROST (PGF2a) - IM 250mg, (if not responsive to methergine and oxytocin)

misoprostol PGE1
700mcg per rectum

Dinoprostone

PROSTIN (PGE2)