POSTPARTUM

HEMORRHAGE

CCH
DEFINITION:
Blood loss of more than 500 ml after vaginal delivery
and more than 1,000 ml after cesarean delivery
Decrease in hematocrit of more than 10% from before
to after delivery

CLASIFICATION
Primary Hemorrhage on the first 24 hours
Secondary Hemorrhage after the first 24 hours

CCH
Normal, pada partus biasa darah hilang 500mL.
Klasifikasi postpartum hemorarge itu :
a. Early postpartum hemorarge :<24 jam
b. Late postpartum hemorarge :>24 jam

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Causes of postpartum hemorrhage:

The 4 Ts
Tone (atonic uterus)
Trauma (tears in birth canal.berupa
laserasi)
Tissue (retained placental
fragments.placenta tertinggal)
Thrombi (blood coagulation disorders)
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UTERINE ATONY
Postpartum uterine contraction inadequate for
hemostasis (failure of the uterus to contract) most
common cause of PPH
Risk factor :
Uterine overdistended (Fetal macrosomia,
polyhydramnious, Multiple gestation)
Prolonged, augmented, precipitous labor
Chroriomanionitis
Grandmultiparity
Use of tocolytic agent

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Yang dimaksud dengan augmented adalah uterus telah
matang dan terbuka lalu diberi oksitosin untuk kontraksi.
Bedakan dengan induced yaitu cervix belum matang.
Precipitous labor: jadi dia melahirkan sebelum dari
perkiraan. Misal harusnya 8 jam lagi tapi 2jam kemudian
lahir
Tocolitic agent: dia mencegah kelahiran
Laserasi umumnya berada di vagina,perineum dan servix
Pada epiostomi kalau terlalu dalam guntingnya bisa laserasi
Kalau dr umum boleh menjahit laserasi perineum, tetapi
kalau kena anal sfingter harus di rujuk

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Bishop score

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 GENITAL TRACT LACERATIONS
Suspect of lacerations : perineum, vaginal or cervical laceration
Before you perform your inspection administer adequate
analgesia(untuk cegah shock neurogenik) and prepare excellent
light
The perineal trauma may occur spontaneously or arise from
episiotomy during vaginal delivery
Anterior perineal trauma involves the labia, ant vagina, urethra or
clitoris
Posterior perineal trauma involves posterior vaginal wall, perineal
muscles or anal sphincters and may extend through the rectum

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Classificationof spontaneous
tears acc to the degree or depth
1st degree involves the fourchette, perineal skin and
vaginal mucous membrane but not yet underlying
fascia and muscle

2nd degree aside from the skin and mucous membrane,

the fascia and muscles of the perineal body are
involved. This stage is most common in clinical.
Perineal body adalah bagian vagina, diantara anus dan
vagina.
RT untuk mengecek tonus sfingter. Dia kenyal.
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3rd degree lacerations extend through skin, mucous
membrane, perneal body and anal sphincter
3a : <50% of ext anal sphincter thickness torn
3b : >50% of ext anal sphincter thickness torn
3c : internal anal sphincter torn

4th degree there is extension of laceration through the rectal

mucosal to expose lumen of the rectum
Grade 4 bisa terjadi rectovaginal fistula. Ini biasanya karena
epiostomi median.
Epistomi median memiliki estetika baik.
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GENITAL TRACT HEMATOMA
The pregnant uterus, vagina and vulva have rich vascular
supplies that are at risk of trauma during birth process
and may result in formation of a hematoma
The most common location : vulva, vagina/paravaginal,
and retroparitoneum/subperitoneal
Risk factor :nulliparity, prolonged 2nd stage of labor,
instrumental delivery(vacum, forcep. Forcep lebih
beresiko.), baby > 4000gr sehingga dinding lateral
robek, genital tract varicosities, preeclampsia, multifetal
pregnancy, cloting disorders

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Excessive perineal pain is a hallmark symptom. Jadi
kemaluan sangat sakit dam hemodinamik ibu
berubah.
Imaging (UTZ, CT, MRI) may be helpful to confirm
the diagnosis (location, size, progress or resolution)
Usg dapat menentukan lokasi,ukuran dan sejauh
mana progresivitasnya.
Kalau jahitan tidak adekuat maka sectio bisa
menyebabkan hematom sehingga untuk mengetahui
ada yang bocor atau tidak, dilakukan abdominal wash
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Stable hematomas may be managed
conservatively(monitor dan beri antibiotik. Kalau diluar
hematomnya bisa diberi tampon)
Expanding hematoma should be evacuated performa
generous incision, irrigate copiously and ligate the
bleeding vessels. Layered clossure is recommended to
assist hemostasis and eliminate dead space. Jadi dibuka
lagi lalu di abdominal wash dan jahit layer. Tapi keadaan
harus stabil.
Vaginal packing for 12-24 hours
Antibiotic broad spectrum should be administered
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 RETAINED PLACENTA(tertinggal
segmennya)
Risk factor : abnormal placentation, placenta acreta,
chorioamnionitis and very preterm labor
If the 3rd stage of labor last longer than 30 minutes consider
abnormal placentation
Manual extraction and uterine exploration are performed.kalau bisa
dialkukan yang manual maka lakukan. indikasi:>30menit placenta
belum lahir maka tangan masuk,cari plasenta seperti membuka
lebaran buku. Kalau kecil dikuret saja lalu beri antibiotik single dose
Blunt curettage may be required
If bleeding is control by uterotonic agent, conservative management
may be sufficient

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UTERINE INVERSION
The uterus is turned inside out, with the fundus protruding
through the cervical os into or out of the vagina
Risk factor : multiparity, long labor, short umbilical cord,
abnormal placentation, connective tissue disorders, excessive
traction of the cord
Makadari itu kalau melahirkan placenta dengan kontrol
traksi untuk mencegah ini
Classification :
Incomplete corpus travel partially through the cervix
Complete corpus travel entirely through the cervix
Prolapse corpus travel beyond the vaginal introitus

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Delayed cord clumping tidak mempengaruhi uterus
tapi mempengaruhi cadangan FE pada bayi

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Diagnosed ???
Hemorhage
Shock
Severe pelvic pain

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Management ???
The immidiate treatment of the hemorrhagic shock
and replacement of the uterus
Occasionaly administration of smooth muscle
relaxant, such as :
-adrenergic agonist (terbutaline) 0.25mg.KI hipertensi
Nitroglycerine
Magnesium Sulfate slowIV dose of 4 grams

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Uterotonics(oksitosin) drugs should only be given
immediately after repositioning of the uterus. Sebelum balik
ke posisi asal jangan diberi uterotonic!!
Antibiotic prophylaxis (WHO) :
Ampicilline 2 gr IV or Cefazolin 1 gr IV, plus
Metronidazole 500mg IV
With sign of infection (+fever)
Ampicilline 2 gr IV every 6 hours, Gentamycin 5 mg/kg
body weight every 24 hours and Metronidazole 500mg IV
every 8 hours
AB untill afebrile 48 hours
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Repositioning
Repositioning
Method of hydrostatic reduction (OSullivans hydrostatic
maneuver):dimasukin air infus hangat di cervical dengan
kateter dengan cepat untuk mendorong
Johnson maneuver: masukin tangan seperti meminta lalu
korek placenta, setelah tidak nempel lagi tangan seperti
posisi meninju untuk menghentikan pendarahan lalu
masukin packing
Huntington maneuver: dioperasi
Hultain maneuver: dioperasi dari perut ke vagina
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COAGULOPATHY
Risk factors : severe pre-eclampsia, abruptio placenta,
idiopathic/autoimune thrombocytopenia, amniotic
fluid embolism, DIC, heredity coagulopathy (von
willebrands disease)
Surgical treatment will only increase the hemorrhage
Replace coagulation factors and platelets as needed

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PPH DRILL
HAEMOSTASIS

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MANAGEMENT
Uterine massage and or bimanual uterine
compression.
Advantages of bimanual uterine compression :
Prevents increase in radius of the uterus
Uterus is pushed cephalad
Uterine arteries under tension
Reduces blood flow
Beri tahu pasien untuk memassage uterusnya. Jika
malah jadi atoni maka lakukan bimanual.

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Bimanual uterine compression
Massage the
posterior aspect
of the uterus with
the abdominal
hand and
massage through
the vagina of the
anterior uterine
aspect with the
other fist

Cunningham, G, et al. Williams Obstetrics 22 nd edition 2005.

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Uterotonic therapy
Agent Dose Route Dosing Side Contra-
frequency effects indications

Oxytocin 10-80 IV (1st) Continuous Nausea, None

(Pitocin) units in IM / IU emesis, water
1L soln intoxicaton

Methylergo- 0.2mg IM (1st) Q 2-4 hr Hypertension, Hypertension

novine IU / PO hypotension, preeclampsia
(Methergin) nausea,
emesis

Misoprostol 600- PR (1st) Single Nausea, None

(Cytotec) 1000ug PO dose emesis,
diarrhea, fever,
chills
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Uterotonic therapy
Agent Dose Route Dosing Side Contra-
frequency effects indications

15-methyl 0.25mg IM (1st) Q15-90min Nausea, Active cardiac,

prostaglan- IU (8 dose max) emesis, pulmonary,
din F2 diarrhea, renal or
(Hemabate) flushing, hepatic
chills disease

Prostaglan- 20mg PR Q 2 hr Nausea, Hypotension

din E2 emesis,
(Dinoprostone) diarrhea,
fever, chills,
headache

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Shock Garment & Shift to
Hospital
Shockgarment meruoakan
pakaian seperti korset dan stoking
untuk kompresi pembuluh darah.

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For life saving
Tamponade
Balloon

Gloves

Condoms

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Urterine Packing
Uterine packing controls postpartum bleeding and
may be useful in several settings (uterine atony,
retained placental tissue, and placenta accreta)
Although uterine packing was advocated for treating
PPH in the past, it fell out of use largely due to
concerns of concealed hemorrhage and uterine
overdistention
It is usually left inside the abdomen for 48 hours or
until the patient is stable.
Jadi beri dia kasa->diamkan 1-2 hari
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Baloon Tamponade
The technique is simple
A foley catheter with a 30-ml balloon capacity is easy to
acquire and may be stocked on labor and delivery rooms
Using a french 24 foley catheter, the tip is guided into
the uterine cavity and inflated with 60 to 80 ml of saline
Additional foley catheters can be inserted if necessary
If bleeding stops, the patient can be observed with the
catheters in place and then removed after 12 to 24 hours.
Pada praktek pake sarung tangan/kondom steril dulu
masukin baru pake kateter lalu masukin air.

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Condom Catheter Tamponade
This simple technique uses a 500 cc infusion bag
connected to a Nelaton catheter which is in turn
connected to a condom.

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Compression suture: dijait ke belakang->
kaya roti kasur
B-Lynch operation

Cho operation

Pereire operation

Penggunaan benang pakai catgut. Jika atoni tidak

dapat diatasi bisa pakai benang yang tidak
diserap. Tapi dia tidak bisa hamil lagi sampai
dibuka

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The theory behind each technique is the same: the
mechanical compression of uterine vascular sinuses
prevents further engorgement with blood and
continued hemorrhage. When used to treat atony and
hemorrhage that does not respond to pharmacologic
intervention, the B-Lynch appears to be very effective

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B-Lynch technique
Uterus remains
exteriorized
A 70-80 mm round
needle, 2-0 chromic or
plain
With the bladder
displaced inferiorly
1st stitch placed 3 cm
below the lower cesarean
incision
A. Rebarber, A. Roman. Seven ways to control postpartum hemorrhage. Contemporary
Ob/Gyn 2003
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B-Lynch technique

The first stitch is placed 3 cm below the lower cesarean incision on the
patients left side and threaded thru the uterine cavity to emerge 3 cm above
the upper incision margins, approx. 4 cm from the lateral border of the
uterus
A. Rebarber, A. Roman. Seven ways to control postpartum hemorrhage. Contemporary
Ob/Gyn 2003
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B-Lynch technique
Carry suture on the
top and posterior
side

Suture is vertical and

4 cm from cornua

A. Rebarber, A. Roman. Seven ways to control postpartum hemorrhage. Contemporary

Ob/Gyn 2003
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B-Lynch technique
The suture is placed
same way as the left
side

3 cm above the
incision, 4 cm from the
lateral side of the
uterus

3 cm below the incision

A. Rebarber, A. Roman. Seven ways to control postpartum hemorrhage. Contemporary

Ob/Gyn 2003
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B-Lynch technique
Maintains
compression
Two ends of
suture put
under tension

Double throw
knot placed
Closure of C/S
incision
A. Rebarber, A. Roman. Seven ways to control postpartum hemorrhage. Contemporary
Ob/Gyn 2003
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Selective pelvic
devascularization
Bilateral uterine artery ligation
Bilateral ovarian artery ligation

Bilateral Hypogastric Artery ligation.

Pembuluh darah dekat servix

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Advantages of uterine artery ligation :
Relatively simple and safe procedure

Provide future childbearing

Highly effective in controlling bleeding from uterine

sources

Cuts off 90% of uterine blood flow

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Uterine Artery Ligation
Uterus grasped and tilted
Place stitch 2 cm below level of transverse lower uterine
incision site
Include full thickness of myometrium
Ensure uterine artery and veins are completely included
Needle passed thru avascular portion of broad ligament;
tied anteriorly
Opening broad ligament is unnecessary

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Ovarian Artery Ligation
Arises directly from aorta
Anastomose with uterine artery at the uterine aspect of
uteroovarian ligament
Ligation just inferior to uteroovarian ligament
Similar to that of uterine artery ligation
Amount of uterine blood flow supplied by these vessels
increase after uterine artery ligation

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Hypogastric Artery Ligation
Decrease bleeding
Decreased arterial pulse pressure
Clot forms
Too long to perform
Surgical repertoire of well-trained gynecologic surgeon
Biasa dilakukan pada operasi cancer karena pendarahan
pasti banyak

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INDICATION
Placenta accreta
Abdominal pregnancy
Uterine atony
Couvelaire uterus
Ruptured uterus

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COMPLICATIONS
Waiting too long
Easy to ligate the external iliac artery instead of the
hypogastric artery
Puncture of the hypogastric vein
Necrosis of the gluteus maximus

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Interventional radiology
Selective arterial embolization
(SAE)

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Advantages
Control hemorrhage
Effective in the management
Postpartum hemorrhage
Ectopic pregnancy
Postabortal hemorrhage
Malignancy
Post-conization hemorrhage
97% success rates
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Technique
Interventional radiologist under flouroscopic guidance
Regional anesthesia or conscious sedation
Introduces a catheter via the femoral artery
Directs it into the target vessel
Target artery is occluded
Patients respond immediately
Menses returns in 3 months
Normal pregnancies
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Can be used for women with risk
of PPH
Catheters placed prophylactically
Prior to planned CS delivery
Reduced total blood loss
Reduced incidence of coagulopathy

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Complications
Fever
Buttock ischemia
Hematoma
Vascular perforation
Infection
Uterine necrosis

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Hysterectomy
Should only be used for persistent and severe
bleeding after all medical and other surgical
therapy has failed
Ini merupakan lastchoice apalagi pada ibu-ibu dengan
1 anak.

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Remember
Help from MDs / RNs
Assess maternal condition
Etiology of bleeding
Massage the uterus
Oxytocin infusion

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Shock garment Shift to
hospital
Tamponade (Balloon / Packing /
Condom)
Apply Compression Sutures
Systemic Pelvic
devascularization
Interventional Radiology
Subtotal / Total Hysterectomy
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THANK YOU
GOD BLESS US

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