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PART I

OVERVIEW
Bleeding is a very important issue in the field of obstetrics and gynecology. In
the field of obstetrics, bleeding is almost always fatal to both mother and
fetus. 1.2Postpartum hemorrhage is the leading cause of maternal death in the
world wide and is the sole cause of both maternal death, ranking behind
preeclampsia or eclampsia. Bleeding in obstetrics can occur either during
pregnancy, childbirth, and the postpartum period. Thus, the bleeding that occurs in
these periods should be regarded as a state of acute and serious. Every woman is
pregnant and postpartum bleeding should be treated immediately and determined
the cause, so it can then be given the right help, it is expected to indirectly reduce
maternal mortality. 1,2,3,4
In this world every minute a woman dies from complications related to
pregnancy and childbirth. Where in 1400 women die every day or more than
500,000 women die each year due to pregnancy and childbirth. Based on
Indonesia's health profile, the maternal mortality rate (MMR) in Indonesia still
stands at 228 per 100,000 live births and the birth rate of 17 births per 1000
population then every hour is 1 maternal death due to various causes. 6
Recognizing these conditions, the Ministry of Health since 1990 has
developed a Strategic Plan for long-term efforts to reduce maternal mortality and
neonatal mortality. In this Strategic Plan focused on activities that build on a solid
health system to ensure the implementation of cost-effective interventions based
on scientific evidence that is known as the Safe Motherhood. This movement is
followed by Mothers movement in 1996, and in 2000 the Ministry of Health
launched the "Making Pregnancy Safer (MPS)" through three key messages. The
three key messages that MPS is any births assisted by skilled health personnel,
every obstetric and neonatal complications receive adequate care and every
woman of childbearing age have access to prevention of unwanted pregnancy and
treatment of complications of miscarriage. Then in 2012, the Ministry of Health
launched a program Expanding Maternal and Neonatal Survival (EMAS) 6
Because of its importance in the treatment of bleeding in obstetrics, then this
will be discussed further on the importance of addressing bleeding, especially in
this case the treatment of postpartum hemorrhage.
CHAPTER II
LITERATURE REVIEW
2.1. Definition
Postpartum hemorraghe is blood loss> 500 ml through the birth canal after the
third stage (the placenta) and> 1000 by caesarean section in the first 24 hours after
birth (1).Actually, in normal pregnant women who will have additional blood
volume of about 30-60%, it causes intolerance in women experiencing postpartum
hemorraghe.Additionally approximately 5% of women who give birth with
normal birth bleeding> 1000ml. 1,4,7 Therefore, as a benchmark, after the delivery
is completed, the state is called "safe" when consciousness and vital signs of
mother is good , uterine contractions well, and there is no active bleeding from the
vagina. 1

2.2. classification 1,2,4,7


1. The primary postpartum hemorraghe (early postpartum
hemorrhage) which occur up to 24 hours after birth.
2. Further postpartum hemorraghe (late postpartum hemorrhage) that
occurs after 24 hours up to 1-2 week during childbirth.

2.3 etiology 17

A. Hypotonia - Atonia uteri


Atonic uterus is a condition where the uterus fails to maintain
normal contraction and retraction. This often causes the occurrence
of postpartum hemorraghe (incidence rates between 75- 90%). In a
normal birth, after birth will be obtained before the bleeding as
much as 200-600 ml wall attraction due to contraction of the uterine
myometrium. This causes the blood vessels will undergo shortening
so it will be followed by the release of a placental attachment. So if
obtained uterine contractions that are not good will cause blood
vessels to stay open, so the bleeding continues. 1,8,9,10

Factors that increase the risk for atonic are: 1,2,7,10

1. general anesthesia
2. The uterus is very stretched
3. Myometrium poor perfusion
4. prolonged labor
5. Childbirth is too fast
6. Labor induction / augmentation
7. multiparity
8. History atonic
9. abnormalities of the uterus
10. Preeklampsi - eclampsia
11. Khorioamnionitis

B. retained placenta
Is a condition in which the placenta has not been born within half an
hour after the baby is born. 1.17
Things that cause it are:

1. The placenta can not be detached from the wall of the


uterus as it grows attached on the inside, which is then
divided into:
a. Placenta adhesiva, namely the decidua
endometrium deeper
b. Increta placental villi khorialis grow deeper
and decidua to penetrate the myometrium
c. Placenta accreta, deeper penetrating
myometrium but haven’t yet to penetrate serous
d. Placenta perkreta and pierced serous or
peritoneal lining of the uterus.
C. Laseration
Generally, birth canal laceration occurred in delivery with
trauma. Deliveries are increasingly manipulative and will facilitate the
traumatic birth canal laceration and therefore inevitably lead labor at the
time of the opening is not yet complete. Rips through the birth canal is
usually due to an episiotomy, spontaneous perineal laceration, trauma
forceps or vacuum extraction, or by extraction version.
Rips that occur can be mild (abrasions, lacerations), episiotomy,
perineal tears spontaneous mild to rupture perineal totalis (anal
sphincter disconnected), a tear in the wall of the vagina, fornix of the
uterus, cervix, the area around the clitoris and urethra and in fact, the
heaviest, uterine rupture.Therefore, at every birth should do a thorough
inspection for possible tear this. Bleeding which occurred uterine
contractions well, usually, because there is a tear or retained placenta,
checks can be done by inspection of the vulva, vagina, and cervix using
a speculum transform and find the source of bleeding with the
characteristic color of blood is red fresh and pulsatif corresponding
pulse , Bleeding because of uterine rupture can be expected in
obstructed labor / cassette, or uterus with minoris resistencia loci and
their atonic and mark-free intra-abdominal fluid. All point source of
bleeding must be clamped, bound and sewn with catgut layer by layer
until the bleeding stops. 17
D. Inversio uteri 2, 17
Is a state where the fundus reversed partially or completely into the
uterine cavity. This is usually caused by the withdrawal of the strong
against the umbilical cord when the placenta attached to the fundus,
atonic uterus, the cervix is still open, under pressure from above or
intra-abdominal pressure that is loud and sudden (coughing or
sneezing). This event is actually rare, and occurs suddenly in the third
stage or soon after the placenta comes out.According to its
development, inversio uteri are divided into:

1. Inversio light uteri


Fundus inverted stand in the cavum uteri, but not yet out of the
uterine cavity
2. Inversio uteri were
Fundus upside down and have entered the vagina
3. Inversio uterine weight
The uterus and vagina all upside down and some have been out
of the vagina.

Inversio uteri are marked with signs: the shock of pain, bleeding a
lot clotted, in inverted vulva looks endometrium with or without
placenta attached.When a new case, then the prognosis is good, but it
was long enough that narrowed cervical tongs will make the uterus
ischemia, necrosis, and infection.

E. Defect coagulopathies 1.3


According DeLee, women with placenta detached will experience a
temporary hemophilia. This is associated with hypofibrinogenemia,
which can lead to intravascular coagulation. It is ultimately often
referred to as consumptive coagulopathy or disseminated intravascular
coagulation.
When there solutio placenta, a small amount of amniotic fluid can
leak into the blood vessels and thromboplastin in the amniotic fluid
would trigger a consumptive coagulopathy. And in patients who have a
tendency purpura idiopathic thrombocytopenia have abnormal platelet
function ddengan or shortening of life span. This will cause bleeding.

For ease in considering the etiology of this postpartum hemorraghe, can be


summed up with "4T" ie tone, tissue, trauma, and thrombosis. 3

TONUS
Causes of acute hemorrhage and severe postnatal often caused by a weak
force of contraction of the myometrium, which can lead to more severe
complications which occur hypovolemic shock. Atonic occur for reasons noted
previously.
Lack of muscle contractions of the uterus can also be caused by muscle
fatigue as a result of labor too long or can also be due to stimulation. Can also be
due to medications that can decrease the strength of contraction like; halogen,
nitrate, NSAIDs, MgSO4, and nifedipine. 3
TISSUE
On the basis of the placenta are usually obtained fibrinoid layer of material
called "layer nitabuch". This relates to the release of the placenta uterine
contraction.But the separation of the placenta from this layer can be disturbed
when engaging villous placenta develops downwards into the myometrium that
interfere with the layer. Such as placenta accreta, in which there are these layers
so that the placenta will be attached to the myometrium, so that if despite some
will cause bleeding very much. This is because the myometrium can not contract
properly to stop the bleeding because it is part of the placenta still attached. 3

TRAUMA
At birth the birth canal damage may occur spontaneously or be caused by
the actions in labor. And the labor per abdominal bleeding risk two times greater
than vaginally.
In the former cesarean section, there is increased risk of uterine
rupture. Uterine rupture can also be obtained when previously had a history of rips
or tears in total. The tears are included as a result of fibroidektomi, uteroplasti,
resection of the cervix and uterine perforation caused by stretching, curettage,
biopsy, hysteroscopy, laparoscopy or intra-uterine contraceptive use.
Trauma can also occur in a long labor, especially in patients with
disproportion cephalopelvic relative or absolute and the uterus was stimulated by
oxytocin or prostaglandins. 3

THROMBIN
In the postpartum period abnormalities in coagulation and clotting system
is not always the case in a lot of bleeding, it is emphasized the efficacy of
contraction and retraction to prevent bleeding. The precipitate fibrin at the site of
the placenta, blood clots and supply of blood vessels plays an important role in the
hours and days after delivery in which abnormalities in this area can trigger
secondary postpartum hemorraghe or exacerbation of bleeding due to other causes
which are most often traumatized. The symptoms of a blood clotting disorder can
be hereditary diseases or acquired. Blood clotting disorder can include:
 Hypofibrinogenemia, can lead to increased intravascular coagulation.
 Disseminated Intravascular Coagulation / consumptive coagulopathy
 Thrombocytopenia
 Idiopathic Thrombocytopenic Purpura
 HELLP syndrome (hemolysis, Elevated Liver enzymes, and Low
Platelet Count)

2.4. Clinical symptoms


Although postpartum hemorraghe caused by various factors, but found
common clinical symptoms are:

1. Vaginal bleeding, which continuously after birth


2. When the weight can be obtained signs of shock such as, weakness,
anxiety, blood pressure is difficult to assess, rapid and weak pulse, and
decreased levels of Hb (8gr%)
3. Other symptoms such as pallor, cold extremities, nausea. 1 2

2.5.Diagnosis
Diagnosis on postpartum hemorraghe to look for the underlying
cause. Diagnosis can be made: 12

1. Based on clinical symptoms


a. Bleeding after birth, but the placenta has not been born, the
blood that comes out is usually fresh red. This is commonly
caused by tearing of the birth canal.
b. Bleeding after delivery of the placenta, usually caused by an
atonic.
2. Inspekulo: tear in the vagina, cervix or varicose rupture.
3. Palpation of the uterus: the uterus flabby, still above the center,
contraction is not good, the usual sign of an atonic
4. Checking the placenta, whether complete or not kotiledonnya and
amniotic membrane.
5. Exploration of the uterine cavity, to look for blood clots or retained
placenta and membranes, uterine tear.
6. Lab tests:
a. Complete blood count: hemoglobin, hematocrit, Tc
b. Prothrombin Time (PT) and activated partial thromboplastin
time (aPTT): to see coagulation disorders
c. Fibrinogen: coagulopathy (N = 300-600)

Monitoring the state of postnatal mother is very important, because the


bleeding may be rapid and severe, but it can also occur slowly and continuously
so that it can also cause the mother fell in a state of shock and pre
shock. Therefore it is vital that we monitor every birth mother's blood levels
regularly, in addition to the need to measure blood pressure, pulse, respiration,
and the mother's contractions of the uterus and bleeding for 1 hour. 12

Table 2.1 Assessment Clinic 13

Presenting Symptom and Symptoms and Signs Probable


Other Symptoms and Signs Sometimes Present Diagnosis
Typically Present

• Immediate PPHa • Shock

• Uterus soft and not contracted Atonic uterus

• Immediate PPHa • Complete placenta

• Uterus contracted Tears of cervix,


vagina or
perineum

• Placenta not delivered within • Immediate PPHa


30 minutes after delivery • Uterus contracted Retained
placenta

• Portion of maternal surface of • Immediate PPHa


placenta missing or torn • Uterus contracted Retained
membranes with vessels placental
fragments

• Uterine fundus not felt on • Inverted uterus apparent at


abdominal palpation vulva Inverted uterus
• Slight or intense pain • Immediate PPHb

• Bleeding occurs more than 24 • Bleeding is variable (light or


hours after delivery heavy, continuous or irregular) Delayed PPH

• Uterus softer and larger than and foul-smelling

expected for elapsed time since • Anaemia


delivery

• Immediate PPHa (bleeding is • Shock


intra-abdominal and/or vaginal) • Tender abdomen Ruptured uterus
• Severe abdominal pain (may • Rapid maternal pulse
decrease after rupture)

Table. 2.2 Symptoms in obstetric haemorrhage 14

Blood Volume Blood Pressure Symptoms and Degree of


Loss (systolic) Signs Shock

Palpitations,
500-1000 mL
Normal tachycardia, Compensated
(10-15%)
dizziness

Weakness,
1000-1500 mL Slight fall (80-100
tachycardia, Mild
(15-25%) mm Hg)
sweating
1500-2000 mL Moderate fall (70- Restlessness,
Moderate
(25-35%) 80 mm Hg) pallor, oliguria

2000-3000 mL Marked fall (50-70 Collapse, air


Severe
(35-50%) mm Hg) hunger, anuria

2.6. Prevention and management


Active treatment of bleeding when in stage 3 is a combination of 3:
1. Giving uterotonic (ex oxytocin) immediately after the baby is
born
2. Cutting the umbilical cord quickly
3. Withdrawal cord gently when the uterus contracts well.

A. Management 13.14
Handling on postpartum hemorraghe intended to restore normal
blood circulation, it is necessary to act quickly and appropriately. The
best treatment is prevention.Therefore we need to do:

1. Rate the patient's condition appropriately


2. Lead delivery refers to the delivery of clean and safe
3. Make observations are strictly for 2 hours postnatal, and continued for
four hours postpartum.
4. Perform clinical assessment and prepare for emergency rescue purposes
and for the preparation in the face complications
5. overcome shock
6. Ensure good contractions (remove blood clots, uterine massage,
uterotonic 10 IU IM, continue in the 500cc RL 20 IU / NS 40 drops /
minute)
7. Make sure the placenta was born complete and check for rips through
the birth canal
8. If the bleeding continues, clotting time test
9. Catheterization for monitoring fluid output
10. Find the cause and resolve the problem.
11. After the bleeding is resolved (24 hours after the bleeding stops),
check Hb:
a. If the hemoglobin is less than 7g / dL or hematocrit less than 20%
(severe anemia). Give blood transfusion and ferrous sulfate or
ferrous fumarate 120 mg plus 400 mcg of folic acid orally once a
day for 3 months
b. After 3 months, continue with ferrous sulfate or ferrous fumarate
60 mg plus 400 mcg of folic acid orally once daily for 6 months.
c. If the Hb 7-11g / dL, give ferrous sulfate or ferrous fumarate 60
mg plus 400 mcg of folic acid orally once daily for 6 months.
d. If roundworms in endemic areas (prevalence of 20% or more),
give albendazole 400 mg orally once or mebendazole 500 mg
orally once or 100 mg twice daily for 3 days, or levamisole 2.5
mg / kg orally once daily for 3 days, or pyrantel 10 mg / kg orally
once a day for 3 days.
e. In highly endemic areas (prevalence of 50% or more) provide
dose therapy for 12 weeks after the first dose.

Table 2.3 uterotonic type and mode of administration of 13,14

Oxytocin Ergometrine/ 15-methyl


Methyl-ergometrine Prostaglandin
F2α

Dose and IV: Infuse 20 units IM or IV (slowly): 0.2 IM: 0.25 mg


route in 1 L IV fluids at mg
60 drops per
minute
IM: 10 units

Continuing IV: Infuse 20 units Repeat 0.2 mg IM 0.25 mg every 15


dose in 1 L IV fluids at after 15 minutes minutes
40 drops per minute If required, give 0.2
mg IM or IV (slowly)
every 4 hours

Maximum Not more than 3 L 5 doses (Total 1.0 mg) 8 doses (Total 2
dose of IV fluids mg)
containing oxytocin

Precautions/ Do not give as an Pre-eclampsia, Asthma


Contrain- IV bolus hypertension, heart
dications disease

Actions of supporters: 1

1. In a state of excessive bleeding, immediate expulsion of the


placenta by hand rather than waiting for spontaneous
birth. While it was prepared for the possibility of blood
transfusion.
2. Inspection carefully into the genital tract with adequate lighting.
3. Discontinue administration of general anesthesia, oxygen is
administered with a face mask
4. Until blood is available, plasma expanders such as RL should be
used, a minimum of 1 liter of PRC or fresh blood should be
transfused.
5. Calculate the risks of transfusion of blood components adult.
6. If the blood pressure drops, elevate legs
7. In an atonic, are encouraged to massage the uterus and
compression of the aorta
8. Platelet transfusions are rarely needed cryoprecipitate or fresh
frozen plasma. Coagulation function test (PTT, PT, platelet
count) should be performed after administration of each of 5-10
units of blood. If there hypofibrinogenemia, should be given
fibrinogen in the cryoprecipitate or fresh frozen plasma IV. If
there is severe thrombocytopenia (20,000 / mm 3 or less), should
be given 6-10 pack of platelets to increase the platelet count of
15,000 -60 000 / mm 3
9. Ultrasound examination to determine the rest of retained
placenta in the uterus in postpartum hemorrhage acute or
delayed very useful.
B. Special Treatment based on etiology
Management of uterine atony 1.2

 Perform clinical assessment


 While the infusion and administration performed a uterine tonic, do
uterine massage
 Derivatives oxytocin
20-40 units of oxytocin in a liter of IV fluids at a rate sufficient to
maintain the uterus in a state of contraction. 2
 ergot derivatives
If the administration of oxytocin infusion quickly ineffective,
methylergonovine given 0.2 mg IM or IV. This will stimulate the uterus
to contract properly to control bleeding. With IV administration may
cause hypertension, especially in women with preeklampsi. 1.

1. External bimanual compression


Pressing the uterus through the abdominal wall to the road juxtapose
each other both palms surrounding the uterus. Monitor blood flow
out. If the bleeding is reduced, compression continues, keep up the
uterus can return to contract or brought to the referral health
facility. When you do not succeed, try with internal bimanual
compression.
2. Internal bimanual compression
Uterus is pressed between the palms in the abdominal wall and a fist
in to clamp blood vessels in the myometrium (instead of the
contraction mechanism).Note the bleeding that occurs. Maintain this
condition when measuring or stop bleeding, wait until the uterus
contracts back. If bleeding persists, try the compression of the
abdominal aorta.

3. Compression of the abdominal aorta


Raba femoral artery with a left hand finger tips, keep the
position. Grasp your right hand and then emphasize the umbilicus
area, perpendicular to the axis of the body, reaching up to the vertebral
column. Emphasis is right, it will stop or greatly reduce the femoral
arterial pulse. See the results of compression with regard bleeding
occurs.
OPERATIVE ACTION
Done if the above procedure is still unable to stop the bleeding
a) Ligation of the uterine artery
The abdomen is opened, the uterus is magnified in the operator's
hands, and local uterine blood vessels in the lower part of the broad
ligament is opened. By using a large needle and thread chromic catgut or
vicryl no.1, made a suture through the biggest part of the lower segment of
the uterus muscle, 2-3 cm medial of the blood vessels. The blood vessels
were tied up but not cut. Menstruation and pregnancy are not affected. 13

Figure 2.3 Ligation a.uterina

b) hypogastric artery ligation


Iliaca communis artery and its branches are iliaca externa arteries and
arteries iliaca interna (hypogastrica) palpable and visible through the
posterior peritoneum. Ureter crosses in front of a branch. Iliaca communis,
and need to be identified in order to prevent potential damage. Posterior
peritoneum tensed and slashed in a longitudinal direction of the internal
a.iliaca tall origin. Two stitches of silk thread is placed around the 2-0 no
internal a.iliaca within 1 cm and then tied on each side. 13
Figure 2.4 a ligation. iliaca interna
c) Hysterectomy
If the above procedures are not effective or if time does not permit,
must do a hysterectomy. Death after or when a hysterectomy is usually
performed as a result of the delay surgery until the patient's condition is
very heavy. 13

d) Uterine compression suture (B-Lynch)


That did chromic suture around the uterus to suppress the anterior and
posterior wall of the uterus.

Figure 2.5 Uterine compression suture


e) Uterine Packing 1
No.24F foley catheter with 30ml balloon is inserted into the uterine
cavity and is filled as much fluid as 60-80ml. Once the bleeding stops
catheter is removed after 12-24 hours.
The management of retained placenta
* Retained placenta

 Determine the type of retention that occurs as it relates to actions to be


taken
 Stretch the cord and ask the patient to be straining. If the expulsion of the
placenta does not happen, try controlled cord traction
 Replace the infusion of oxytocin 20 units in 500 cc RL with 40 droplets
per minute. If necessary, combine with misoprostol 400 mg rectal
(ergometrin because you should not use tonic contraction arising can
cause the placenta trapped inside the uterine cavity)
 When traction control failed to deliver the placenta, placental do manual
carefully and finely (to release the placenta attached tightly enforced, can
cause bleeding or perforation)
 Restoration of fluid to overcome hypovolemia
 Make a blood transfusion if necessary
 Give prophylactic antibiotics (ampicillin 2 g IV / oral metronidazole + 1
suppository / oral)
 Soon overcome if there is severe bleeding complications, infection, and
neurogenic shock. 11
Figure 2.6 How Placenta Extract with Hand 1

Figure 2.7 Mechanical removal of placenta way of Brandt


* The rest of the placenta
Give antibiotics Ampicillin antibiotics chosen is an initial dose of 1 g IV
followed by 3x1 g oral metronidazole combined with 1 g suppository
continued 3x500 mg orally. With these antibiotics, explore digital (when the
cervix is open) and remove blood clots or tissue, when the cervix is only
accessible by the instrument, perform evacuation of retained placenta with
dilation and curettage. When Hb <8 g% give a blood transfusion if Hb> 8 g%
give ferrous sulfate 600 mg / day for 10 days. 12

Management Inversio uteri 1


Handling inversio uteri requires quick thinking. Patients with rapidly go into
shock and needed immediate restoration of intravascular volume with intravenous
crystalloid. Anesthesiologists must be called. Inversio experiencing uterine fundus
repositioned by pushing with the palms and fingers elongated in the direction of
the uterus. Better prepare two IV lines for transfusions and fluid resuscitation.If
the placenta has not separated, well placenta before the uterus removed should not
be repositioned, IV lines installed, and anesthesia is given, because it can cause a
lot of bleeding. After the placenta is released, palms placed in the middle of the
fundus with a finger is extended. Then pressurized with pushed upwards.
After repositioning successfully given pitocin drip and uterine tamponade can
also be done so that does not happen again inversio, kalu manual repositioning is
not successful repositioning operative.
Figure 2.8 How to manually reposition the uterus undergo inversion 16

Handling a clotting disorder


Patients with thrombocytopenia requiring platelet concentrates infusion,
patients with von Willebrand disease require fresh frozen plasma. The infusion of
red blood cells is compressed given to patients who have experienced bleeding
enough to reduce the population of circulating red blood cells, so it is quite
harmful to the delivery of oxygen to tissues. Typically, hematocrit more than 25%
is sufficient. Massive transfusion (more than 3 liters), especially with blood, will
aggravate the clotting system that has been troubled by the spending of platelets
and factors V and VIII. Because of that one unit of fresh frozen plasma should be
given for every 2 units of blood after 6 units have been in tranfusikan. 12
Tabel.2.4 results are used to correct blood clotting disorders.
blood products Volume (mL) in one unit effects transfusion
platelet concentrate 30-40 Increase the platelet
count by approximately
20000 to 25000
cryoprecipitate 15-25 Supplying fibrinogen,
factor VIII, and factor
XIII (3 to 10 times more
concentrated than an
equivalent volume of
fresh plasma)
Fresh frozen plasma 200 Supplying all factors
except platelets
Red blood cells 200 Raise the hematocrit of
incompressible 3 to 4%

2.8 Complications
Some of the complications that can occur in postpartum hemorraghe is a
patient can fall into a state:

 Shock
 Anemia
 Sheehan's syndrome

2.9 Prognosis
Post partum hemorraghe has recurrence rate of approximately 10% in future
pregnancies. There are limited data on outcome of pregnancies after uterine artery
embolization or B-Lynch suture. It is unknown if these procedures put future
pregnancies at increased risk of complication, although there are case report and
series of uneventful pregnancy outcomes after these procudures.
CHAPTER III

CONCLUSION
Postpartum hemorraghe is one of the important causes of the high
maternal morbidity and mortality. Therefore health professionals are expected to
know what things that can cause bleeding as well as ways of handling. Hopefully,
by the early detection, diagnosis accuracy and speed in the handling of postnatal
hemorrhage, the incidence of maternal hemorrhage can be derived.

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