1. Postpartum hemorrhage

2. Postpartum hemorrhage
Blood loss
> 500 ml for vaginal delivery
>1000 ml for caesarean section (Pritchard et al, 1962) (WHO)
After completion of the third stage of labor
Inaccurate estimated blood loss, underreporting
** However, this is not a clinically useful definition for several reasons: and antepartum hemoconcentration (eg, from preeclampsia or dehydration) may cause a large fall in serum hemoglobin concentration following delivery in the absence of excessive intrapartum blood loss
Michael A Belfort, MBBCH, MD, PhD, FRCSC, FRCOG. Overview of postpartum hemorrhage.

3. Postpartum hemorrhage
>10% change in hematocrit (Combs et al, 1991)
Need for blood transfusion (Combs et al, 1991)
Excessive bleeding that makes the patient symptomatic
Potential to produce hemodynamic instability (>10% of total blood volume)
** However, this is not a clinically useful definition for several reasons: and antepartum hemoconcentration (eg, from preeclampsia or dehydration) may cause a large fall in serum hemoglobin concentration following delivery in the absence of excessive intrapartum blood loss
Michael A Belfort, MBBCH, MD, PhD, FRCSC, FRCOG. Overview of postpartum hemorrhage.

4. Symptom related to blood loss with postpartum hemorrhage

5. Postpartum hemorrhage
Primary PPH
4–6% of pregnancies
Occurring within first 24 hours of delivery
Secondary PPH
Occurring between 24 hours and 6–12 weeks postpartum
Michael A Belfort, MBBCH, MD, PhD, FRCSC, FRCOG.Overview of postpartum hemorrhage
ACOG Practice Bulletin No.76: Postpartum Hemorrhage . Obstet Gynecol ; 108(4):

6. 80% or more of cases
Primary postpartum hemorrhage, which occurs in 4–6% of pregnancies, is caused by uterine atony in 80% or more of cases

8. Etiology of PPH Tone Tissue Trauma Thrombin
Hereditary coagulopathies or liver disease
Acquired in pregnancy
HEELP syndrome
DFIU
Amniotic fluid embolus
Lacerations of the cervix, vagina, perineum
Extensions, lacerations at cesarean section
Uterine rupture
Uterine inversion
Retained products of conception
Retained blood clots
Overdistension of uterus
Uterine muscle exhaustion
Intra-amniotic infection
Anatomic distortion of uterus
Uterine-relaxing medications
Bladder distension
Tone
Tissue
Thrombin
Trauma
SOGC clinical practice guideline : Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage. JOCG. 2009; 235:

9. แนวทางการวินิจฉัยเพื่อหาสาเหตุของภาวะตกเลือดหลังคลอดระยะแรก

10. แนวทางการวินิจฉัยเพื่อหาสาเหตุของภาวะตกเลือดหลังคลอดระยะแรก

11. Management

12. Step 1 Initial Assessment and treatment Step 2 : Directed Therapy
Resuscitation
Call for help
Large bore IV
ABC
O2 supplement
Vital sign, I/O
Foley catheter
Assess Etiology
- Explore uterus (tone,tissue)
- Explore LGT (trauma)
- Review Hx (thrombin)
- Observed bleeding
Laboratory test
- CBC
- Coagulation
- Group and cross
Step 2 : Directed Therapy
Tone
- Massage
- Uterotonic Drugs
Tissue
- Manual removal
- Curettage
Trauma
- Correct inversion
- Repair laceration
- Repair hematoma
Thrombin
- Anticoagulation
- Replace factor
Adapted from : WHO guidelines for the management of postpartum haemorrhage and retained placenta, 2009.

13. Step 5 : Post Hysterectomy Bleeding Angiographic Embolization
Step 3 : Intractable PPH
Get Help
- Large bore iv
- Anesthesiologist
- Lab and ICU
Local Control
- Manual compression
+/- pack uterus
+/- uterine tamponade
+/- embolization
BP & Coagulation
- Crystalloid
- Blood product
Step 4 : Surgery
Repair laceration
Ligate vessels
- Uterine/ ovarian vessel
- Internal iliac artery
Hysterectomy
Step 5 : Post Hysterectomy Bleeding
Abdominal packing
Angiographic Embolization
Adapted from : WHO guidelines for the management of postpartum haemorrhage and retained placenta, 2009.

15. Medical Management

16. ACOG Practice Bulletin No. 76: Postpartum Hemorrhage. Obstet Gynecol

17. RTCOG Guideline October 2011
RTCOG Guideline October Management of atonic postpartum hemorrhage

18. RTCOG Guideline October 2011
RTCOG Guideline October Management of atonic postpartum hemorrhage

19. ยาที่ใช้รักษาภาวะมดลูกไม่หดรัดตัว

20. ยาที่ใช้รักษาภาวะมดลูกไม่หดรัดตัว

21. ยาที่ใช้รักษาภาวะมดลูกไม่หดรัดตัว

22. ยาที่ใช้รักษาภาวะมดลูกไม่หดรัดตัว

23. Bimanual uterine compression

24. Compression of abdominal aorta

25. Tamponade and Surgical Management

26. Uterine tamponade
Temporarily control active PPH due to uterine atony which not responded to medical treatment
Prophylactic ATB
ACOG Practice Bulletin No.76: Postpartum Hemorrhage . Obstet Gynecol ; 108(4):

27. Tamponade balloon

28. Bakri Balloon Tamponade
ใส่น้ำได้ มิลลิลิตร

29. Surgical Management
Uterine a ligatation โดยต้องผูกทั้ง2ข้าง โดยอาจจะรวมผูก uteroovarian vss ด้วย
ทำ เย็บ b lych
การทำ hypogastric a ligation – เป็นหัตถการที่ไม่เลือกใช้เป็นหัตถการแรก และเป็นหัถตการที่ยากต้องมีประสบการณ์
การ repaired rupture ในกรณีที่มดลูกแตก
การทำ hystercotmy

30. B-lynch Technique Compression suture

31. B-lynch Technique Compression suture

32. Cho technique Compression suture

33. Uterine artery ligation

34. Umbrella packing

35. Uterine artery embolization

36. Birth canal laceration

37. Birth canal laceration
Perineal tear
Vaginal tear
Cervical tear

38. Perineal tear repair
Principle : ensure that first stitch suture inserted above apex of the tear or episiotomy wound
Continous polyglactin/ polyglycolic acid suture on tapercut needle
Obliterated dead space and taking care that sutures not too tightly
If dead spaces cannot be closed securely : Vg packing
B-Lynch C et al. A textbook of postpartum hemorrhage: bleeding from the lower genital tract. Sapiens Publishing, 2006.

39. Vaginal tear repair Superficial tear : similar to perineal tear
Deeper tear :
Identified bleeding vessel and ligated it
Any significant dead space or tear too friable to accept suturing >> packing
Repaired should be done under adequate anesthesia
B-Lynch C et al. A textbook of postpartum hemorrhage: bleeding from the lower genital tract. Sapiens Publishing, 2006.

40. Vaginal tear repair
Vaginal packing using gauze : common method to achieve temponade
Vaginal packing with thrombinsoaked pack : closure of all laceration has not been possible
Risk of raw surface will rebleeding when removed packing : using sterile plastic bag inserted with providoneiodine-soaked pack
Left packing for hr with retained Foley’s catheter and ATB prophylaxis
B-Lynch C et al. A textbook of postpartum hemorrhage: bleeding from the lower genital tract. Sapiens Publishing, 2006.

41. Cervical tear
Superficial lacerations of the cervix can be seen on close inspection in more than half of all vaginal deliveries.
Most of these are less than 0.5 cm and seldom require repair (Fahmy, 1991).
Deeper lacerations are less frequent, but even these may be unnoticed.
Due to ascertainment bias, variable incidences are described.
Williams Obstetrics, 24th Edition - Cunningham, Leveno, Bloom et al

42. Cervical tear not usually problematic unless
hemorrhage
extend to the upper third of the vagina.
Rarely, the cervix may be entirely or partially avulsed from the vagina —colporrhexis—in the anterior, posterior, or lateral fornices.
sometimes follow
difficult forceps rotations
forceps blades applied over the cervix.
Williams Obstetrics, 24th Edition - Cunningham, Leveno, Bloom et al

43. Cervical tear
In some women, cervical tears reach into lower uterine segment and involve the uterine artery and its major branches.
They occasionally extend into the peritoneal cavity.
The more severe lacerations usually manifest as external hemorrhage or as a hematoma, however, they may occasionally be unsuspected.
Williams Obstetrics, 24th Edition - Cunningham, Leveno, Bloom et al

44. Cervical tear
Melamed N et al. Intrapartum cervical lacerations: characteristics, risk factors, and effects on subsequent pregnancies. AJOG ;200: 388e1-4.

45. Cervical tear repair Laparotomy : tear extending above internal os
Packing with pressure : small, or non bleeding laceration
Cervical tear with active bleeding or longer than 2 cm may be repaired
Absorbable suture material

46. Gasp edges of most caudal part of laceration with ring forceps
B-Lynch C et al. A textbook of postpartum hemorrhage: bleeding from the lower genital tract. Sapiens Publishing, 2006.

47. Suture with interrupted or figure of eight stitch
Held with hemostat to bring down into view next part to repair
เย็บรั้งส่วนที่ลึกที่สามารถเย็บได้djvo เพื่อเป็นจุดรั้ง แล้วพยายาม traction ลงมา เพื่อ approach จนให้เห็นบริเวณส่วนของแผลที่ลึกที่สุด
B-Lynch C et al. A textbook of postpartum hemorrhage: bleeding from the lower genital tract. Sapiens Publishing, 2006.

48. Suture to the apex of the laceration
Observed of laceration for a few minutes to ensure secure hemostasis
B-Lynch C et al. A textbook of postpartum hemorrhage: bleeding from the lower genital tract. Sapiens Publishing, 2006.

49. Umbilical cord clamping Controlled cord traction
Prevention of PPH
Active management of third stage of labor
Assisted expulsion of placenta
Prevent of decrease blood loss
Uterotonic drugs
Umbilical cord clamping
Controlled cord traction
- Assisted expulsion of placenta
- Prevent of decrease blood loss
uterotonics, clamping of the umbilical cord, and controlled traction of the cord
reduces the risk of PPH -> recommended to all women
SOGC clinical practice guideline : Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage. JOCG. 2009; 235:

50. Active management of 3rd stage of labor
The Cochrane Review concluded that active management reduced risks of the following
maternal blood loss
postpartum hemorrhage exceeding 500 mL
prolonged third stage labor

51. Active management of 3rd stage of labor
Active management of third stage of labor for all vaginal births including
routine administration of oxytocin with shoulder delivery
cord traction
uterine massage. (I-A)
SOGC Clinical practice guideline.Active management of the third stage of labor : prevention and treatment of postpartum hemorrhage. October 2009.

52. Active management of 3rd stage of labor
Oxytocin (10 IU) IM is the preferred medication and route for the prevention of PPH in low-risk vaginal deliveries. (I-A)
Care providers should administer this medication after delivery of the anterior shoulder. (I-A)
SOGC Clinical practice guideline.Active management of the third stage of labor : prevention and treatment of postpartum hemorrhage. October 2009.

53. Active management of 3rd stage of labor
Intravenous infusion of oxytocin (20 to 40 IU in 1000 mL, 150 mL per hour) is an acceptable alternative for AMTSL. (I-B)
SOGC Clinical practice guideline.Active management of the third stage of labor : prevention and treatment of postpartum hemorrhage. October 2009.

54. Active management of 3rd stage of labor
An IV bolus of oxytocin, 5 to 10 IU (given over 1 to 2 minutes), can be used for PPH prevention after vaginal birth but is not recommended at this time with elective Caesarean section. (II-B)
SOGC Clinical practice guideline.Active management of the third stage of labor : prevention and treatment of postpartum hemorrhage. October 2009.

55. Active management of 3rd stage of labor
Ergonovine can be used for prevention of PPH but may be considered second choice to oxytocin
greater risk of maternal adverse effects
need for manual removal of a retained placenta.
Ergonovine is contraindicated in patients with hypertension. (I-A)
SOGC Clinical practice guideline.Active management of the third stage of labor : prevention and treatment of postpartum hemorrhage. October 2009.

56. Active management of 3rd stage of labor
Active management of third stage of labor
Carbetocin : long-acting oxytocin
100 mcg IV bolus over 1 minute should be used instead of continuous oxytocin infusion in elective caesarean section to decrease the need for therapeutic uterotonic (I-B)
100 mcg IM decreases the need for uterine massage for women compared with continuous infusion of oxytocin in woman who delivering vaginally with 1 risk factor for PPH (I-B)
SOGC clinical practice guideline : Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage. JOCG. 2009; 235:

57. Active management of 3rd stage of labor
Late cord clamping (performed after 1 to 3 minutes after birth) is recommended for all births while initiating simultaneous essential newborn care.
Early cord clamping (<1 minute after birth) is not recommended unless the neonate is asphyxiated and needs to be moved immediately for resuscitation.
ที่ต่างกับ SCOG
WHO recommendations for the prevention and treatment of postpartum haemorrhage 2012

58. Active management of 3rd stage of labor
Oxytocin (IV or IM) is the recommended uterotonic drug for the prevention of PPH in caesarean section. (Strong recommendation, moderate-quality evidence)
ที่ต่างกับ SCOG
WHO recommendations for the prevention and treatment of postpartum haemorrhage 2012

59. Thank you

60. Late PPH