Postpartum hemorrhage denotes excessive bleeding (more than 500 ml in vaginal bleeding) following delivery. Hemorrhage may occur during or after delivery of the placenta.
As retained placenta tissue constitutes the main cause in majority of cases of PPH, the patient is managed in following steps.
- Predelivery preparation
- Postdelivery measures
- Active management of 3rd stage of labor
- Measures to control bleeding
- Management of delayed PPH.
- Blood typing
- Anemia correction
- I.V catheter should be securely taped into place.
Post delivery measures
Uterus is massaged in back and forth motion until the myometrium becomes firm and well contracted.
Active management of 3rd stage of labor.
Gentle traction is maintained on umbilical cord until separation of the placenta occurs. The placenta may then be removed by more vigorous means and adherent membranes grasped with ring forceps and gently striped from uterine cavity.
If bleeding s excessive before placental removal then manual removal of the placenta is indicated.
Oxytocin 10-20 units per litre of isotonic saline or other intravenous infusion solution are slowly infused.
The vagina and cervix are carefully inspected immediately after delivery of the placenta.
The episiotomy is quickly repaired.
Measures to control bleeding
If bleeding persists after the management of the 3rd stage of labor, following measures are carried out.
- Manual exploration of uterus to ensure that the uterus is entirely empty and no placental tissue left in the cavity.
- Bimanual compression and massage continued for 20-30 mi.
- fluid replacement
- Uterine packing is carried out.
- If bleeding still persists, embolization of pelvic and uterine vessels by angiographic technique is tried.
- Prostaglandins to attain uterine contractions.
- Operative techniques include
- pressure occlusion of aorta
- internal iliac artery ligation
- uterine artery ligation and lastly
Management of delayed PPH.
Delayed PPH is due to subinvolution of the placental bed. Uterine massage and bimanual compression will control it.
Broad spectrum antibiotics should be started when resuscitation allows. Oxytocin 10 units IV every 4hrs for at least 48hrs.