POST PARTUM HAEMORRHAGE

 Definition: - Bleeding from the genital tract at any time after the birth of the baby     up to end of puerperium.

general condition of pt by rise in pulse rate BP 

Type :- (1) Primary PPH 

(2) Secondary PPH 

(1) Primary PPH :- Bleeding occurs within 24 hrs of delivery 

3rd stage bleeding :- Bleeding occurs before placental separation

True c PPH :- Bleeding occurs after  reparation placenta but with in 24 hrs of delivery 

(2) Secondary/delayed/late PPH :- Haemorrhage occurs after 24 hrs  with in  Puerperium

Causes of PPH :-

 Atonic Uterus:-  

Incomplete separation of placenta

Placental  fragments 

Membranes 

Pre cipitate labour 

Placenta previa & abruptio 

Prolonged labour 

Fibroid 

Multiple Pregnancy

Full Urinary bladder 

Anemia & Malnutrition 

(2)  Traumatic Causes :-

 Haemorrhage due to vaginal/cervical Tear Due to rupture of uterus

(3)  Mixed Causes :- 

Blood Coagulation disorders 

Predisposing factor 

Previous history of PPH

Multipara

Maternal anemia 

History of retained placenta

Clinical Features:-

Visible bleeding 

Shock 

Increase Pulse

Decrease BP

Pallor 

Altered level of consciousness 

Rest less ness 

Enlarged uterus 

Uterus filled c blood 

lack of tone 

Prevention:-

Antenatal Prevention 

Improve Health status

Keep HB level > 10 g/all 

High risk pt’s should be observed and  delivery must be hospitalized 

Blood group cross matching 

Intra natal Prevention:-

Slow delivery of baby 

active management of 3rd stage 

Avoid Pulling of cord 

Examined placenta membranes for completeness 

Expulse utero vaginal canal for any trauma

Management:-

3rd Stage bleeding management :-

Palpate fundus a massage uterus to musket hard 

Ergometrinc 0.25 ml/ Methargin 2 ml (iv)

Stast IV infusion blood transfusion 

Catheterize the bladder 

Methargin 15 mg in for sedation 

If Placenta is separated than expulsion of placenta is done by controlled card traction 

If not separated than manual removal of placenta is done.

Bi manual Compressional :-

Whole hand is introduced in vagina in a cone shaped form

Other hand separates the labia 

Than place this hand per abdominally 

Press the anti. and post walls of uterus by vaginal abdominal hand 

keep this pressure until uterus regaling its tone 

If uterus is still atonic than administer prostodin 250 y zm 

If still uterus fail to contract then perform bilateral ligature of uterine artery vein

If bleeding still continues than perform hysterectomy 

(2) True PPH Management 

Immediate measures 

Call for extra help 

IV line 

Send blood for grouping cross matching infuse NS 

To Feel the uterus by abdominal palpation 

Uterus atonic         Uterus Hard e Contracted 

Massage the uterus

Inj. methargin              Exploration 

Oxytocin 10 V in 500 ml NS

Examine the expelled placenta Sutures on the tear sites 

To catheterize the bladder 

Uterus remain atonic:-

Exploration of uterus 

Blood Transfusion 

To Continue oxytocin drip 

Uterus a tonic 

 15 methyl pg f2 Im 

Misoprostal 100/ return 

Uterus A tonic 

Uterine temponade 

Bi manual Compression 

Tight intra uterine packing 

Surgical Method 

Ligation of uterine artery 

Ligation of internal iliac artery 

(2) Secondary/delayed/late PPH:-

     Causes: - Retained bits of membrane

Infection 

Endometritis 

Sub involution of placental site 

Haemorrhage 

Clinical Features:-

Bring red a varying Amt. of bleeding 

anemia 

Evidences of sepsis 

Management:-

Ergometrine 0.5 mg IM

Antibiotics 

Active Treatment:-

Remove Products by ovum forceps under general anesthesia 

Gentle Curettage 

Laparotomy 

Traumatic PPH:- if any traumas in perineum Vagina and cervix is detected than repair under gen anesthesia