Postpartum Hemorrhage

POSTPARTUM HEMORRHAGE (PPH)

Women Health (MFD 3122)

Diploma of Physiotherapy

Universiti Industri Selangor

Definition

• PPH is defined as an excessive bleeding following the birth of the baby.

• May occur before or after delivery of the placenta.• About 4% women with postpartum hemorrhage and

it’s likely with a Cesarean birth. • Average amount blood loss in vaginal delivery is

500mL • Average amount blood loss in Cesarean birth is

1000mL

Epidemiology

• PPH can cause severe mortality and morbidity• According to CDC data, 17% of maternal mortality

is due to hemorrhage. • It though to be one third to one half cases • PPH occur in women childbearing age

Causes

• PPH can be causes by 4 T’s:1. Tone/uterine atony

- Failure of uterus to contract and retraction - Over distension of the uterus major risk for atony- Poor contraction result from fatigue due to

prolonged labor / rapid forceful labor (if stimulated)

- It also can result from inhibition of contractions by drugs

Normal postpartum with contracted uterus preventing

from bleeding

Uterine atony allows hemorrhage to flow into the

uterus

Cont.

2. Trauma- Delivery may tear tissue and vessels to significant

postpartum hemorrhage.- Cesarean delivery results in twice average blood

loss of vaginal delivery - It may occur during prolonged labor or vigorous

labor (uterus stimulated by the oxytocin and prostaglandin)

- It also may occur during remove the retained placenta manually or instrumentally that lead to cervix laceration.

Cont.

3. Thrombosis- fibrin deposition over placenta site and clots within

supplying vessels play a significant role in hour and days following delivery and lead to late PPH.

4. Tissue- Retention of placenta is more common.- It likely to retained at extreme preterm gestation (<

24weeks) and significant bleeding may occur. - Failure complete separation of placenta can occur in

placenta accreta- Placenta implanted over a previous scar tissue especially

if associated with placenta previa

Pathology

• Over period of pregnancy, maternal blood volume increase approximately 50%(4L – 6L).

• Plasma volume increase than total RBC volume cause fall in hemoglobin concentration and hematocrit volume.

• Increase blood volume serves to fulfill the perfusion demand of low-resistance utero-placenta and provide a reserve for blood loss that occurs at delivery

• Estimated blood flow to the uterus 500-800mL/min, which constitutes 10-15% CO. most of this flow traverses to the low-resistance placental bed

Cont.

• The uterine blood vessels that supply placental site traverse a weave of myometril fibers. As these fibers contract during delivery, retraction occurs.

• Characteristics of retraction is to maintain its shortened length following each successive contraction.

• Then the blood vessels is compressed and kinked by crisscross latticework and normally blood flow is quickly occluded.

• This arrangement of muscle bundles has been referred as living ligatures or physiologic sutures.

Classifications

1. Primary Postpartum Hemorrhage• Also known as early PPH• Defined as bleeding from genital tract during the 1st 24 hours

after birth• May occur before or after the third stage of labor is

completed.

2. Secondary Postpartum Hemorrhage• Also known as delayed PPH• Defined as excessive bleeding from the genital tract with a

blood loss of 400mL / more • Occur after the first 24 hours following delivery until 6th week

puerperium.

Sign and symptoms • Uncontrolled bleeding (>2pad/30min)• Decrease BP• Increase heart rate• Decrease in the RBC count• Swelling and pain • Lightheadedness, nausea and visual disturbance• Anxiety, pale and clammy skin• Increase pulse rate and respiratory rate

Risk factor

• Multiple gestation• Large baby• Polyhydramnias • Nulliparity or multiparity (multiple pregnancy)• Prolonged labor• Asian or Hispanic women• Placenta previa• Placenta accreta• Previous PPH• Forcep and vacum delivery

Complications

• Associated with blood transfusion• Consumptive coagulopathy• Disseminated intravascular coagulation• Bleeding disorder• Shock • Collapse• Multiple organ failure associated with circulatory

collapse and decreased organ perfusion

Diagnosis

• Doctor will do physical examination by checking:1. Temperature – elevated temperature indicate

endometritis that can lead second postpartum hemorrhage

2. Pulse rate and blood test – help to determine presence shock

3. Vaginal examination to determine if opening of the cervix is open or closed and vaginal discharge is offensive.

4. Examine genital area to look any lacerations, tears or episiotomy that may lead to PPH

Doctor management

• There are 2 doctor management: 1. Non-conservative

2. Conservative

• Non-conservative 1. Oxytocin – IM administered where it can stimulate

upper segment of myometrium to contract rhythmically

2. Ergometrine and methylergonovine (methergine) - generalized smooth muscle contraction in

upper and lower segment of the uterus to contract tetanically. Administered by IM

Cont.

3. Prostaglandin - enhances uterus contractility and causing vasoconstriction. The most common of prostaglandin such as 15-methyl prostaglandin F, or carboprost (Hemabate). Administered IM.

4. Misoprostol - another type of the prostaglandin that increases uterine tone and decreases postpartum bleeding. Administered by orally, vaginally and rectally.

5. Syntometrine - combination with oxytocin and ergometrine. Injection is given just after the birth of the child to stimulate the womb to contract.

Cont.

• Conservative1. Uterovaginal packing – packing the uterus with sponges

and sterile materials

2. Uterine curettage – also known as dilation and curettage (D&C). To remove remaining tissue in uterus. Doctor will use dilator to open cervix and insert hollow tube through cervix. Then suction performed to removed retain tissue.

3. Laporotomy – an incision to gain access to abdominal cavity before hysterectomy take place

Cont. 4. Hysterectomy – surgical removal of uterus. Types of

hysterectomy such as radial hysterectomy (complete removal of the uterus, upper vagina, and parametrium), subtotal hysterectomy (removal of the fundus of the uterus, leaving the cervix in situ) and total hysterectomy (Complete removal of the uterus including the corpus and cervix)

5. Bakri balloon catheter – used for temporary control or reduction PPH. Used with guidance of ultrasound

6. Sengstaken-Blakemore tube - used to tampon the uterus it reduced need for surgery or embolization in most patients and was also useful for controlling bleeding while patients waited for such procedures.

7. Foley catheter - type of catheters with a 30 mL balloon that use to tampon the uterus. It’s inserted behind the cervical wall and inflated

Bakri balloon catheter

Foley catheter

Physiotherapy management

• Bimanual Examination / Speculum Examination• Bimanual / Uterine massage

1. Johnson method

2. Internal bimanual massage

3. External bimanual massage

Cont.

• Breathing / relaxation technique – to control or slowing down patient’s heart rate.

• Patient education

1. breastfeeding. It allow patient to secrete their own oxytocin to help contract the uterus and expel the placenta.

2. warned patient not to do exercise that can

cause excessive stress to the uterus.

Cont. • Bimanual or uterine massage technique .

Internal Bimanual massage technique for the uterine atony

Cont.

1

2

3Johnson’s Method

Cont.

External bimanual/uterine massage

Cont. • Exercise for postpartum

1. Day 1 – pelvic tilt, abdominal breathing, ankle circles (where to enhance circulation

2. Day 2-7 – leg sliding exercise, arm and upper back stretch

3. After 1st week – straight curl-up, sits-up, diagonal sits-up, gentle aerobic exercise (walking)

• Patient’s education 1. Lifting and moving2. Bending 3. Protect posture