Dr.

Irene Maria Elena

Departemen Kebidanan dan Kandungan
FK UKRIDA

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

Causes of postpartum hemorrhage:

The 4 Ts
Tone (atonic uterus)
Trauma (tears in birth canal)
Tissue (retained
placental/placental fragments)
Thrombi (blood coagulation
disorders)

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

Penanganan Aktif Kala III

(PONED ed.2008)

Menyuntikan Oksitosin
Memeriksa fundus uteri untuk memastikan
kehamilan tunggal
Menyuntikan oksitosin 10 UI im pada bagian luar
paha kanan 1/3 atas
Peregangan tali pusat
Memindahkan klem tali pusat hingga berjarak 5-

10cm dari vulva atau menggulung tali pusat

Meletakan tangan kiri diatas simpisis menahan
bagian bawah uterus, sementara tangan kanan
memegang tali pusat

Saat uterus kontraksi, meregangkan tali pusat

dengan tangan kanan sementara tangan kiri

menekan uterus dengan hati-hati ke arah dorsokranial

Mengeluarkan plasenta
Jika dengan penegangan tali pusat terkendali, tali
pusat terlihat bertambah panjang dan terasa
adanya pelepasan plasenta, minta ibu untuk
meneran sedikit sementara tangan kanan menarik
tali pusat ke arah bawah kemudian ke atas sesuai
dengan kurve jalan lahir hingga plasenta tampak
pada vulva

Bila tali pusat bertambah panjang tetapi

plasenta belum lahir, pindahkan kembali klem

hingga berjarak 5-10 cm dari vulva
Bila plasenta belum lepas setelah melakukan
langkah tersebut selama 15 menit, suntikan
ulang 10 IU im oksitosin
Periksa ulang kandung kemih, lakukan
kateterisasi bila penuh
Tunggu 15 menit bila belum lahir, lakukan
plasenta manual

Bila plasenta sudah tampak pada vulva, lahirkan

secara hati-hati
Segera setelah plasenta lahir, lakukan massage
pada fundus uteri, secara sirkuler menggunakan
bagian palmar 4 jari hingga fundus teraba keras
Memeriksa kemungkinan adanya perdarahan
pasca persalinan:
Kelengkapan plasenta dan ketuban
Kontraksi uterus
Perlukaan jalan lahir

Langkah-langkah
penatalaksanaan
Atonia
Lakukan massage fundus uteri segera
setelah
plasenta dilahirkan
Uteri
Bersihkan kavum uteri dari selaput ketuban dan
(PONED ed.2008)

gumpalan darah
Mulai lakukan kompresi bimanual interna
jika uterus berkontraksi keluarkan tangan setelah
1-2 menit.
Jika uterus tetap tidak berkontraksi teruskan
kompresi bimanual interna hingga 5 menit
Minta kelurga lakukan kompresi bimanual eksterna

Berikan metil-ergometrin 0,2mg im/iv

Berikan infus cairan larutan RL dan oksitosin 20

IU/500 cc
Mulai lagi kompresi bimanual interna atau pasang
tampon uterovagina
Buat persiapan untuk rujuk segera
Teruskan cairan IV hingga ibu mencapai tepat
rujukan
Infus 500cc cairan pertama dalam 10 menit
Cairan tambahan setidaknya 500cc/jam pada jam

pertama, dan 500cc/4 jam pada jam-jam berikutnya

Lakukan laparotomi ligasi arteri

uterina/hipogastrika atau histerektomi

GENITAL TRACT
LACERATIONS
Suspect of lacerations : perineum, vaginal or
cervical laceration
Before you perform your inspection administer
adequate analgesia 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

Classification of spontaneous
perineal tears acc to the degree or
1 degree involves the fourchette, perineal skin
depth
st

and vaginal mucous membrane but not yet

underlying fascia and muscle (selaput lendir
vagina dengan atau tanpa mengenai kulit
perineum)

2nd degree aside from the skin and mucous

membrane, the fascia and muscles of the

perineal body are involved (selaput lendir vagina
dan otot perinei transversalis, tetapi tidak
mengenai sfingter ani)

3rd degree lacerations extend through skin,

mucous membrane, perineal body and anal

sphincter (seluruh perineum dan otot sfingter ani)
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 (sampai mukosa rektum)

Robekan Dinding Vagina

Robekan dinding vagina harus dijahit
Kolporeksis : suatu keadaan dimana terjadi

robekan di vagina bagian atas sehingga

sebagian serviks uteri dan sebagian uterus
terlepas dari vagina. Robekan dapat
memanjang atau sirkular
Pada kolporeksis dan fistula vesicovaginal
harus dirujuk ke RS

Robekan Serviks
Paling sering terjadi pada jam 3 dan 9
Robekan dijahit dengan catgut kromik

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 2 nd stage of
labor, indtrumental delivery, baby > 4000gr,
genital tract varicosities, preeclampsia, multifetal
pregnancy, cloting disorders

Excessive perineal pain is a hallmark

symptom
Imaging (UTZ, CT, MRI) may be helpful to
confirm the diagnosis (location, size, progress
or resolution)

Stable hematomas may be managed

conservatively kompres
Expanding hematoma should be evacuated
performa generous incision, evacuation of blodd
clots, irrigate copiously and ligate the bleeding
vessels. Layered clossure is recommended to
assist hemostasis and eliminate dead space
Vaginal packing for 12-24 hours
Antibiotic broad spectrum should be
administered

RETENSIO PLASENTA
Plasenta yang belum lahir dalam 30 menit setelah janin lahir
Risk factor : abnormal placentation, placenta acreta,

chorioamnionitis and very preterm labor

Plasenta adhesive : plasenta yang belum lahir dan masih
melekat di dinding rahim oleh karena kontraksi rahim
kurang kuat untuk melepaskan plasenta
Plasenta akreta : plasenta yang belum lahir dan masih
melekat di dinding rahim oleh karena villi korialisnya
menembus desidua sampai miometrium
Plasenta inkarserata : plasenta yang sudah lepas seluruhnya
tetapi belum lahir karena terhalang oleh lingkaran konstriksi
di bagian bawah rahim tersebut

Prosedur Manual Plasenta

(PONED ed.2008)

Sebaiknya dalam narkosis

Dipasang infus NaCl 0.9%
Asepsis andtiseptik tangan dan daerah vulva

dan sekitarnya
Tangan kanan masuk kedalam vagina secara
obstetriks; tangan kiri menahan fundus untuk
mencegah terjadinya kolporeksis
Tangan kanan menuju ke ostium uteri dan
terus ke lokasi plasenta, menyusuri tali pusat
agar tidak terjadi false route

Setelah sampai ke plasenta, tangan kanan ke sisi

plasenta yang sudah lepas

Dengan sisi tangan kanan sebelah kelingking plasenta
dilepaskan dengan gerakan sejajar dinding rahim
Setelah plasenta terlepas, plesenta dipegang dan
perlahan-lahan ditarik keluar
Setelah plasenta lahir dan diperiksa bahwa plasenta

lengkap, lakukan kompresi bimanual uterus dan

suntikan Ergometrin 0.2mg im atau iv sampai
kontraksi baik

Sisa Plasenta
Dapat menimbulkab perdarah post partum dini atau

lambat (6-10 hari)

Pada umumnya perdarahan dari rongga rahim setelah
plasenta lahir dan kontraksi rahim baik dianggap
sebagai sisa plasenta yang tertinggal
Untuk memastikan adanya sisa plasenta yang
tertinggal dapat ditentukan dengan eksplorasi dengan
tangan, kuret atau alat bantu diagnostik yaitu USG
Pada PPH lambat gejala sama dengan subinvolusi
rahim
Perdarahan ini jarang menimbulkan syok

Pengelolaan
Pada umumnya dengan kuretase; pada kondisi

tertentu dapat dilakukan secara manual

Berikan uterotonika melalui suntikan atau oral
Berikan antibiotika dalam dosis pencegahan

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
Classification :
Incomplete corpus travel partially through the cervix
Complete corpus travel entirely through the cervix
Prolapse corpus travel beyond the vaginal introitus

Diagnosed ???
Hemorhage
Shock
Severe pelvic pain

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
Nitroglycerine
Magnesium Sulfate IV dose of 4 grams

Uterotonics drugs should only be given

immediately after repositioning of the uterus

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

Repositioning
Method of hydrostatic reduction (OSullivans

hydrostatic maneuver)
Johnson maneuver
Huntington maneuver
Hultain maneuver

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

GEJALA DAN TANDA

TANDA DAN GEJALA

LAIN

DIAGNOSIS KERJA

Syok
Bekuan darah pada
serviks atau posisi
terlentang akan
menghambat aliran
darah keluar

Atonia uteri

(
Uterus tidak
berkontraksi dan
lembek, perdarah
segera setelah anak
lahir

Darah segar yang

Pucat
mengalir segera setelah Lemah
bayi lahir
menggigil
Uterus kontraksi dan
keras
Plasenta lengkap

Robekan jalan lahir

Plasenta belum lahir

setelah 30 mnt
Perdarahan segera
Uterus berkontraksi dan
keras

Retensio plasenta

Tali pusat putus akibat

traksi berlabihan
Inversio uteri akibat
tarikan
Perdarahan lanjut

GEJALA DAN TANDA

TANDA DAN GEJALA

LAIN

DIAGNOSIS KERJA

Plasenta atau sebagian

selaput tidak lengkap
Perdarahan segera

Uterus berkontraksi
tetapi tinggi fundus
tidak berkurang

Tertinggal sebagian
plasenta atau selaput
ketuban

Uterus tidak teraba

Lumen vagina terisi
masa
Tampak tali pusat (bila
plasenta belum lahir)

Neurogenik syok
pucat

Inversio uteri

Sub-involusi uterus
Anemia
Nyeri tekan perut bawah demam
pada uterus
Perdarahan
Lokhia mukopurulen dan
berbau

Endometritis atau sisa

fragmen plasenta
(terinfeksi)
Late PPH
Perdarahan post partum
sekunder

(PONED ed.2008)

PPH DRILL

HAEMOSTASIS

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

Bimanual uterine compression

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

Letakan satu
tangan pada
dinding perut
dan usahakan
menahan bag
belakang
uterus sejauh
mungkin,.
Letakan tangan
lain pada
korpus depan
dari dalam
vagina, tekan
kedua tangan
untuk kompresi
34

Hand positions
compression

for

external

External bimanual compression of the uterus: The

uterus is compressed externally between two hands to
constrict uterine blood vessels and stop bleeding.

Uterotonic therapy
Agent

Dose

Route

Dosing
frequency

Side
effects

Contraindications

Oxytocin
(Pitocin)

10-80
IV (1st)
units in IM / IU
1L soln

Continuous

Nausea,
emesis, water
intoxicaton

None

Methylergonovine
(Methergin)

0.2mg

IM (1st)
IU / PO

Q 2-4 hr

Hypertension,
hypotension,
nausea,
emesis

Hypertension
preeclampsia

Misoprostol
(Cytotec)

6001000ug

PR (1st)
PO

Single
dose

Nausea,
None
emesis,
diarrhea, fever,
chills

Uterotonic therapy
Agent

Dose

Route

Dosing
frequency

Side
effects

Contraindications

15-methyl
prostaglandin F2
(Hemabate)

0.25mg

IM (1st)
IU

Q15-90min
(8 dose max)

Nausea,
emesis,
diarrhea,
flushing,
chills

Active cardiac,
pulmonary,
renal or
hepatic
disease

Prostaglandin E2

20mg

PR

Q 2 hr

Nausea,
emesis,
diarrhea,
fever, chills,
headache

Hypotension

(Dinoprostone)

JENIS DAN CARA OKSITOSIN

ERGOMETRIN

MISOPROSTOL

Dosis dan cara

pemberian

IV : 20 IU dalam
1L lar garam
fisiologis dengan
tetesan cepat
IM : 10 IU

IM atau IV
(lambat) : 0.2 mg

Oral atau rektal

400 g dapat
diulang sampai
1200 g

Dosis lanjutan

IV : 20 IU dalam
Ulangi 0.2 mg IM
1L lar garam
setelah 15 menit
fisiolog is dengan
40 tts/mnt

400g 2-4 jam

setelah dosis awal

Dosis maksimal
per hari

Tidak lebih dari

3L lar dengan
oksitosin

Total 1200g
atau 3 dosis

Kontraindikasi

Pemberian IV
Preeklampsia,
secara cepat atau vitium cordis,
bolus
hipertensi

Total 1 mg atau 5
dosis

Nyeri kontraksi,
asma

(PONED ed.2008)

Shock Garment & Shift to

Hospital

Tamponade
Balloon
Gloves
Condoms

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.

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.

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.

Compression suture
B-Lynch

operation
Cho operation
Pereire operation

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

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
46

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
47

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
48

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
49

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
50

Selective pelvic

devascularization
Bilateral

uterine artery ligation

Bilateral ovarian artery ligation
Bilateral Hypogastric Artery
ligation

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

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

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

Hypogastric Artery
Ligation
Decrease bleeding
Decreased arterial pulse pressure
Clot forms
Too long to perform
Surgical repertoire of well-trained gynecologic

surgeon

INDICATION
Placenta accreta
Abdominal pregnancy
Uterine atony
Couvelaire uterus
Ruptured uterus

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

Interventional radiology
Selective

(SAE)

arterial embolization

Advantages
Control hemorrhage
Effective in the management
Postpartum hemorrhage
Ectopic pregnancy
Postabortal hemorrhage
Malignancy
Post-conization hemorrhage

97% success rates

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

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

Complications
Fever
Buttock ischemia
Hematoma
Vascular perforation
Infection
Uterine necrosis

Hysterectomy
Should only be used for persistent and

severe bleeding after all medical and

other surgical therapy has failed

Remember
Help from MDs / RNs
Assess maternal condition
Etiology of bleeding
Massage the uterus
Oxytocin infusion
64

Shock garment Shift to

hospital
Tamponade (Balloon /
Packing / Condom)
Apply Compression Sutures
Systemic Pelvic
devascularization
Interventional Radiology
Subtotal / Total Hysterectomy
65

Williams obstetrics
Williams gynecology
Pelayanan Obstetri & Neonatal Emergensi

Dasar (PONED) ed. 2008

PPH drill lecture of Prof. Walfrido W Sumpaico
(AOFOG secretary)

THANK YOU
GOD BLESS US