Post partum haemorrhage (PPH) is an obstetrical emergency that can follow vaginal or cesarean delivery. It is a major cause of maternal morbidity and one of the top three causes of maternal mortality in both high and low per capital income countries, although the absolute risk of death in much lower in high income countries (1 in 100,000 versus 1 in 1000 births in low income countries). Furthermore, hemorrhage is the leading cause of admission of the intensive care unit and the most preventable cause of maternal mortality.
The average blood loss following vaginal delivery, caesarean delivery and caesarean hysterectomy is 500 ml, 1000ml and 1500 ml respectively.
Depending upon the amount of blood loss, post partum hemorrhage (PPH) can be- ➢ Minor (1L)
➢ Severe (10g/dl) so that the patient can withstand some amount of the blood loss. • High risk patients who are likely to develop post partum hemorrhage (such as twins, hydramnios, grand multipara, APH, history of previous PPH, severe anemia) are to be screened & delivered in a well equipped hospital. • Blood groping should be one for all women so that no time is wasted during emergency. • Placental localization must be done in all women with previous caesarean delivery by USG or MRI to detect placenta accreta or percreta. • Women with morbid adherent placenta are at high risk of PPH. Such a case should be delivered by a senior obstetrician. A availability of blood & or blood products must be ensured before hand.
• Active management of the third stage, for all women in labour should be a routine as it reduces PPH by 60%. • Women delivered by caesarean section, oxytocin 5 IU slow IV is to be given to reduce blood loss. • Exploration of the utero-vaginal canal for evidence of trauma following difficult labour or instrumental delivery. • Observation for about 2 hours often delivery to make sure that the uterus is hard and well contracted before sending her to ward. • During caesarean section spontaneous separation & delivery of the placenta reduces blood loss (30%).
Management of retained placenta:
This diagnosis is reached when the placenta remains undelivered after a specified period of time (usually half to 1 hour following the baby’s birth). This is done to apply pressure to the placental site. The whole hand is introduced into the vagina in cone shaped fashion after separating the labia with the fingers of the other hand. the vaginal hand is clenched into a fist with the back of the hand directed posteriorly and the knuckles in the anterior fornix. The other hand is placed over the abdomen behind the uterus to make it anteverted. The uterus is firmly squeezed between the two hands. It may be necessary to continue the compression for a prolonged period until the (during the period, the resuscitative measures are to be continued).
Manual removal of the placenta:
The operation is done under general anaesthesia. The patient is placed in lithotomy position with all aseptic measures, the bladder is catheterized. One hand is introduced into the uterus after smearing with the antiseptic solution in cone shaped manner following the cord, which is made taut by the other hand. While introducing the hand, the labia are separated by the fingers of the other hand. The fingers of the uterine should locate the margin of the placenta. Counter pressure on the uterine fundus is applied by the other hand placed over the abdomen. The abdominal hand should steady the fundus & guide the movements of the fingers inside the uterine cavity till the placenta is completely separated. As soon as the placental margin is reached, the fingers are insinuated between the placenta & the uterine wall with the back of the hand in contact with the uterine wall. The placenta is gradually...