Category: POST PARTUM HEMORRHAGE (PPH)

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Causes:

• Atony of the uterus
• Retained placental parts
• Uterine rupture
• Cervical and/or vaginal tears
• DIC (HELLP)

Treatment:

• Resuscitate with fluids
• Massage the uterus manually
• Apply firm and continuous pressure suprapubically with a closed fist for a full 10 minutes
  • Eyes on the watch!
• Oxytocin infusion i.v. (preferred)
  • 30 units in 500 cc in Normal Saline
  • Infused over 2 to 4 hours
• Misostoprol (Cytotec) tablets (if oxytocin is not available)
  • 2 – 4 tablets
    • Oral or rectal adminstration

Bleeding does not subside:

• Bring patient to operating theater
• Place legs in stirrups
• Examine by intracavitary palpation
  • Placental parts present:
    • Remove
  • Uterine rupture present:
    • Laparotomy and repair
  • Neither retained placenta nor rupture of the uterus is present:
    • Pack firmly with gauze
    • Remove gauze pack in the operating theater after 24 hours

• Transfuse one or two units of fresh blood

• Perform hysterectomy as a last resort

Speculum Examination:

• It is usually difficult and messy to identify bleeding site(s) from cervical tears
• Attempts to suture the friable tissue results in further tearing and bleeding
• Proceed directly with gauze packing in the absence of retained placental parts or ruptured uterus.