POST PARTUM HEMORRHAGE

POSTPARTUM HEMORRHAGE

Refers to excessive blood loss during or after the third stage of labor.

500 ml

Normal blood loss for vaginal delivery

1000 ml

Normal blood loss for cs

first hour postpartum

Most dangerous time at which hemorrhage is likely to occur is during the

POSTPARTUM HEMORRHAGE

Leading cause of maternal mortality.

EARLY OR PRIMARY

PPH in the1st 24 hours after delivery.

LATE OR SECONDARY

PPH from 1st 24 hours to 6 weeks postpartum.

Tone

Refers to failure of the uterine myometrial muscle fiber to contract and retract.

Tissue

Presence of retained placental tissues prevents uterine contractions resulting to failure to seal off bleeding vessels.

Tissue

a. Presence of a succenturiate or accessory lobe

b. Preterm gestation especially in less than 24 weeks gestation

c. Abnormal adhesion such as accrete, increta and percreta.

Trauma

20% of postpartum hemorrhage is due to ________ anywhere in the genital tract.

− Lacerations and episiotomy, Hematoma, Cesarean section

Thrombosis

Clot formation on placental site stops oozing of blood from uterine blood vessels.

− Disorders of the coagulation system and platelets, whether preexistent or acquired, can result in bleeding or aggravate bleeding.

Dilutional coagulopathy

in which clotting factors are significantly reduced with aggressive transfusion of crystalloid and Packed Red Blood Cells (PRBC)

Preexistent coagulation disorder

thrombocytopenic purpura.

UTZ

– to detect causes of hemorrhage (retained placental fragments and occult hematoma)

Angiography

– done when embolization of bleeding vessels is to be performed.

Uterine packing

• Packing prevents bleeding by tamponade effect.

24-36 hours

Packing is removed after

UTERINE ATONY

− Refers to the failure of the uterus to contract continuously after delivery.

− Most common cause of PPH.

Massage uterine fundus

to stimulate uterine contractions and to express clots that have accumulated in the uterus or vagina.

Oxytocin

– 1st drug of choice for postpartum uterine atony

Methylergonovine Maleate

Administer uterotonics – to stimulate uterine contractions. (UTERINE ATONY)

External bimanual compression

-Place left hand on the fundus and make it go down as far as possible behind the uterus.

• Place right hand flat on the abdomen between the umbilicus and the symphysis pubis.

• Press hands toward each other to compress uterus, thereby sealing blood vessels at the placental site.

Internal bimanual compression and massage

to stimulate and sustain uterine contractions in

an atonic uterus.

LACERATIONS

− Results from over stretching / too rapid stretching of tissues, especially if poorly extensile & rigid

− Can occur anywhere in the cervix, vagina and perineum.

− Irregular tearing caused by blunt object.

First Degree Laceration

– limited to vaginal mucosa and skin of the introitus.

Second Degree Laceration

– extends to the fascia and muscles of the perineal body

Third Degree Laceration

trauma involves the anal spincter

Fourth Degree Laceration

– extends to the rectal lumen, through the rectal mucosa

HEMATOMAS

Collection of blood under the skin due to injury to blood vessels during instrumental delivery or during repair of episiotomy by needle prick.

Genital Hematomas

Retroperitoneal Hematomas

Types of Hematoma

RETAINED PLACENTAL FRAGMENTS

Most common cause of late postpartum hemorrhage.

Accreta

– the placenta adheres to the myometrium without invasion into the muscle.

Increta

– the placenta adheres into the myometrium

Percreta

– the placenta invades the full thickness of the uterine wall and possibly other pelvic structures, most frequently the bladder.

SUBINVOLUTION OF THE UTERUS

Occurs when there is a delay in the return of the uterus to its pre-pregnant size, shape and function.