1. PPH may result from failure of the uterus to contract adequately (atony), genital
tract trauma (i.e. vaginal or cervical lacerations), uterine rupture, retained placental tissue, or maternal bleeding disorders. Uterine atony is the most common cause and consequently the leading cause of maternal mortality worldwide.
WHO 2009

2. Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main
Zentrum für Frauenheilkunde
Abteilung für Geburtshilfe und Pränatalmedizin / Perinatalzentrum Level I

3. You have the facilities to treat?
You have the possibilities to treat?
You shouldn´t waste time!
Maternal vaginal bleeding:
Placenta complete?
Uterus contracted?
Birth trauma?
Do you know the patient?
Do you have assistence?
Do you have interdisciplinary help?

4. Recommendation WHO 2009
Tranexamic acid may be offered as a treatment for PPH if: (i) administration of
oxytocin, followed by second-line treatment options and prostaglandins, has failed to stop the bleeding; or (ii) it is thought that the bleeding may be partly due to trauma.
(Quality of evidence: very low. Strength of recommendation: weak.)

6. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial 
Haleema Shakur, et al.; The Lancet (2017) (17)
Between March, 2010, and April, 2016, 20 060 women were enrolled and randomly assigned to receive tranexamic acid (n=10 051) or placebo (n=10 009), of whom 10 036 and 9985, respectively, were included in the analysis.
Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00; p=0·045), especially in women given treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the placebo group, RR 0·69, 95% CI 0·52–0·91; p=0·008). All other causes of death did not differ significantly by group. Hysterectomy was not reduced with tranexamic acid (358 [3·6%] patients in the tranexamic acid group vs 351 [3·5%] in the placebo group, RR 1·02, 95% CI 0·88–1·07; p=0·84). The composite primary endpoint of death from all causes or hysterectomy was not reduced with tranexamic acid (534 [5·3%] deaths or hysterectomies in the tranexamic acid group vs 546 [5·5%] in the placebo group, RR 0·97, 95% CI 0·87-1·09; p=0·65). Adverse events (including thromboembolic events) did not differ significantly in the tranexamic acid versus placebo group.
Interpretation: Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.

7. Figure 1
Trial profile
*Patients for whom there is no information about the primary endpoint.

8. Figure 2 The Lancet DOI: (10.1016/S0140-6736(17)30638-4)
Cause of death by hours since randomisation (A) and cause of hysterectomy by hours since randomisation (B)
*Excludes data for 311 women who had a hysterectomy before randomisation.
The Lancet DOI: ( /S (17) )

9. Death from bleeding by subgroup
Figure 3
Death from bleeding by subgroup
Death from bleeding by subgroup
*Heterogeneity p value. †One patient excluded from subgroup analysis because of missing baseline data.
The Lancet DOI: ( /S (17) )

10. Laparotomy for bleeding by subgroup
Figure 4
Laparotomy for bleeding by subgroup
Laparotomy for bleeding by subgroup
*Heterogeneity p value.
The Lancet DOI: ( /S (17) )
Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license Terms and Conditions

11. Time to treatment Figure 5
*Heterogeneity p value.
The Lancet DOI: ( /S (17) )
Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license Terms and Conditions

12. PPH – what else?

13. Treatment of birth canal injuries, placental retention and other causes of PPH

14. C. Management of retained placenta
1. Should uterotonics be offered as treatment for retained placenta?
2. Should intra-umbilical vein injection of oxytocin with or without saline be offered
as treatment for retained placenta?
3. Should antibiotics be offered after manual extraction of the placenta as part of the
treatment of retained placenta?
D. Choice of fluid for replacement or resuscitation
1. Should crystalloids be offered for fluid replacement in women with PPH?
E. Health systems and organizational interventions
1. Should health care facilities have a protocol for management of PPH?
2. Should health care facilities have a formal protocol for referral of women
diagnosed as having PPH?
3. Should simulation of PPH treatment be part of training programmes forhealth care providers?
WHO guidelines
for the management of
postpartum haemorrhage
and retained placenta
1.Placenta, Retained - therapy. 2.Postpartum hemorrhage - diagnosis. 3.Postpartum hemorrhage - therapy.
4.Obstetric labor complications. 5.Guidelines. I.World Health Organization.
ISBN (NLM classification: WQ 330)
© World Health Organization 2009

15. Diagnose and Definition
Therapy of Atonia
Management of retained placenta
1. Should uterotonics be offered as treatment for retained placenta?
Summary of evidence
One double-blind RCT was found that compared sulprostone with placebo in 50 women with retained placenta (187).
Recommendations
▪ If the placenta is not expelled spontaneously, clinicians may offer 10 IU of oxytocin in combination with controlled cord traction. (No formal scientific evidence of benefit or harm. Strength of recommendation: weak.)
▪ Ergometrine is not recommended, as it may cause tetanic uterine contractions, which may delay expulsion of the placenta. (Quality of evidence: very low. Strength of recommendation: weak.)
▪ The use of prostaglandin E2 (dinoprostone or sulprostone) is not recommended.
(Quality of evidence: very low. Strength of recommendation: strong.)
Remarks
▪ The Consultation found no empirical evidence to support recommendation of uterotonics for the management of retained placenta in the absence of haemorrhage. The above recommendation was reached by consensus.
▪ The WHO guide, Managing complications in pregnancy and childbirth , states that if the placenta is not expelled within 30 minutes after delivery of the baby, the woman should be diagnosed as having retained placenta. Since there is no
evidence for or against this definition, the delay used to diagnose this condition is left to the judgement of the clinician.
▪ The same guide also recommends that, in the absence of haemorrhage, the woman should be observed for a further 30 minutes following the initial 30 minutes, before manual removal of the placenta is attempted. The Consultation noted that, in the absence of bleeding, spontaneous expulsion of the placenta can still occur; thus, a conservative approach is advised and the timing of manual removal as the definitive treatment is left to the judgement of the clinician.
▪ The recommendation about prostaglandin E2 is based on the lack of evidence, as well as concerns regarding adverse events, notably cardiac events.

16. 2. Should intra-umbilical vein injection of oxytocin with or without saline be offered as treatment for retained placenta?
Summary of evidence
One systematic review on umbilical vein injection for the management of retained placenta has been published (188). RCTs comparing the use of intraumbilical vein injection of saline with expectant management (four studies, 413 women), intraumbilical vein injection of saline+oxytocin with expectant management (five studies, 454 women), and intraumbilical vein injection of saline+oxytocin with saline (ten studies, 649 women) were identified.
The results of one unpublished study (189) were made available to the Consultation by the investigators.
Recommendations
▪ Intraumbilical vein injection of oxytocin with saline may be offered for the management of retained placenta.
(Quality of evidence: moderate. Strength of recommendation: weak.)
▪ If, in spite of controlled cord traction, administration of uterotonics and intraumbilical vein injection of oxytocin+saline, the placenta is not delivered, manual extraction of the placenta should be offered as the definitive treatment.
(No formal assessment of quality of evidence. Strength of recommendation: strong.)
Remarks
▪ During the discussion on this topic, a new meta-analysis of the available data was performed, by including data from the recent large unpublished study with the existing published meta-analysis. Sensitivity analyses by quality of data and a fixed-versus-random-effects analysis were also conducted. In all these secondary analyses, the summary estimate reflected a modest effect, with the relative risk of manual removal being 0.89 (95%CI 0.81–0.98) with a fixed-effect model and 0.82 (95%CI 0.68–0.98) with a random-effect model. The Consultation was concerned about the possibility of publication bias in the meta-analysis, and was split between making a weak recommendation and not recommending intra-umbilical vein injection of oxytocin+saline.
▪ The Consultation recommended by a majority the use of umbilical vein injection of oxytocin+saline for retained placenta. In making the recommendation, the Consultation considered the advantages of avoiding an invasive intervention, such as manual removal of the placenta, and the low cost and absence of any sideeffects with umbilical vein injection. It was noted that a potential disadvantage was that this intervention may delay the administration of other effective interventions. These considerations should be taken into account in the local adaptation of these guidelines. …

17. E. Health systems and organizational interventions
1. Should health care facilities have a protocol for management of PPH?
Summary of evidence
The literature search did not reveal any research evidence for or against the use of PPH management protocols. Although no systematic review was carried out, the Consultation considered that management protocols are generally useful and unlikely to be harmful.
Recommendation
Health care facilities should adopt a formal protocol for the management of PPH.
(Quality of evidence: no formal evidence reviewed; consensus. Strength: strong.)
Remark
The Consultation acknowledged that the implementation of formal protocols is a
complex process, which will require local adaptation of general guidelines.

20. Cervical tear
- Minor degree of cervical tear is during 1st delivery is common.
- It is commonest cause of traumatic PPH
- Cervical tear or vaginal tear should be suspected when PPH is there in-spite of well contracted uterus.
Recommendation
- Explore the cervix and vagina for tear under good light.
- With all aseptic precaution
- Evacuation of bladder if full
- Place the patient in lithotomy position
- Insert speculum and retract the posterior
- Ask the assistant to push down the fundus of uterus gently.

21. - Hold the anterior lip of cervix with sponge holder and trace whole of the cervix with another sponge holder forceps in clock wise manner and identify the cervical tear
- Now grasped the both margin of the tear of cervix by the sponge holder.
- Stitch the cervical tear by interrupted mattress suture by taking the whole thickness of cervix, suture material is 1-0 chromic catgut with round body needle.
The repair should be started 1 cm above the apex of the tear. Mattress suture prevents rolling of the edges.
- If the cervical tear is extending to the lower segment or vault with broad ligament haematoma needs laparotomy.
After the proper exposure haemostatic suture and vaginal tear suturing to be done if multiple laceration, then pack the vagina for 24 hrs. after removing the packing see for bleeding
Vulva injuries- vulval laceration, perineal laceration and hematoma needs to be drained and proper haemostatic suture should be given

22. You have the facilities to treat?
You have the possibilities to treat?
You shouldn´t waste time!
Maternal vaginal bleeding:
Placenta complete?
Uterus contracted?
Birth trauma?
Do you know the patient?
Do you have assistence?
Do you have interdisciplinary help?
Create consensus in your team, establish a common treatment.

23. Thank you for your attention
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