00:02
So let's talk about Tone
as we said this does account
for most of our postpartum
hemorrhages.
00:07
We attempt to prevent atony
by active management
of the third stage of labor
in each delivery.
00:13
This means giving oxytocin after
the delivery of the placenta.
00:16
And for the reasons mentioned
before, some patients
are prone to atony despite
the prophylactic treatment.
00:23
You want to manage that
with uterine massage.
00:25
And this is how it's performed
as you can see here.
00:28
One thing to know is important
to first empty the bladder to
make sure your uterine
massage is more effective.
00:34
Next you want to give
additional oxytocin.
00:38
And if you still have an atony
you want to consider using other
uterotonic agents.
00:43
Let's go through those
in a little detail.
00:46
So our first uterotonic agent to
talk about is Methlyergonivine.
00:50
So this is methrogen.
00:51
Now it is a very good medication
to help contract the uterus.
00:55
But it is contraindicated in
hypertension and can increase
the blood pressure .
01:00
Next is PGF2 Alpha or Hemabay.
01:03
This is also a great uterotonic
agent but it is contraindicated
in patients that have asthma.
01:08
And then third is misoprostol.
01:11
This can be given vaginally
or it can be given rectally
or orally.
01:15
Vaginally is less effective
because the patient is bleeding
and so usually they can't absorb
the misoprostol as effectively.
01:22
So you would want to consider
your oral or rectal route.
01:25
And there are no real
indications to give
a misoprostol.
01:30
So what's our direct therapy for
retained products of conception.
01:34
That's either be going to manual
exploration to remove
the placenta or D&C.
01:40
You should be suspicious for
retained products of conception.
01:43
If the placenta is
not removed intact.
01:45
Remember when we deliver our
placenta we give gentle downward
traction on the cord,
uterine massage,
and we expect the placenta
to deliver as one piece.
01:54
If you don't have a deliver
that way
or you have to manually
remove it,
you should be suspicious for
retained products of conception.
02:01
You want to make sure you
inspect your placenta
to make sure that no cotyledons
are missing as well.
02:08
Now when we have trauma meaning
lacerations to the cervix,
the perineum, the vaginal tract
we want to repair those.
02:17
You repair those just by as you
can see here in the picture.
02:21
Stitching them close.
02:22
You can either use
chromic or bicral.
02:24
And you want to do that
to stop the bleeding.
02:27
Now if you have a hematoma,
you want to just apply
pressure to that to help
the bleeding not to expand.
02:34
Hematomas can be particularly
dangerous because they are not
in a confined space so you can
actually lose a lot of blood
through extravagation
into hematoma.
02:45
Now for our thrombin disorder.
02:47
What's the therapy for that?
Well that's going to
be blood products.
02:50
Let's go through this
in a little detail.
02:52
Now, for packed red
blood cells we give that.
02:55
We expect after one unit,
the blood level will go up
1 gram per decalitre on
the hemoglobin.
03:00
Or if you looking at
her hematocrit
it should increase by 3%.
03:03
If you are given platelets,
1 unit should cause
the platelets to increase
by 5,000 to 10,000.
03:10
If you are given fresh frozen
plasma which has Fibrinogen,
antithrombin III,
factors V and VIII,
one unit cause of the Fibrinogen
to increase by 10 milligrams
per decalitre.
03:22
And with Cryoprecipitate which
is Fibrinogen, factors VIII
and factor XIII as well as von
Willebrand's factor,
one unit will also cause
the Fibrinogen
to increase by 10 milligrams
per decalitre.
03:34
This is important slide
to pay attention to.
03:37
Because even if we have a
thrombin disorder or if we have
someone that has bled to
the point that they've now
transition into DIC,
this is how we're going to
correct that problem.
03:49
So here's some other treatments
for postpartum hemorrhage.
03:52
Uterine artery embolization.
03:54
So this is a procedure
that's done by
interventional radiologist.
03:58
So a patient is taken to an
interventional radiologist
suite.
04:01
The uterine artery is located
on arteriogram and is embolize.
04:06
So patients are candidates
for this procedure.
04:09
If they are bleeding
but they are stable.
04:13
Another option is
uterine packing.
04:15
We can place belly balloons.
04:17
We can place lapse sponges.
04:18
We can place any type of
packing inside the uterus.
04:21
This works really well for our
patients that are having
subinvolution issues or if they
have retained products
that you've had to piecemeal
out.
04:30
Also manual compression
will help with bleeding.
04:33
This particular procedure here
is called the "B-Lynch suture."
This is going to send
the uterus down and cause manual
compression to help clear
our postpartum hemorrhage.
04:44
If a patient is continuing
to bleed then you may need
to consider take her to
the operating room
and doing an exploratory laparotomy.
04:52
When you do that the first thing
you are going to try to do is
arterial ligation.
04:56
So you at first try to
ligate the uterine arteries.
05:00
If this doesn't work you can
consider your ovarian arteries.
05:04
And finally if you've done all
of these measures that you can
that are conservative and our
patient continues to bleed,
then we need to do hysterectomy
to treat them.
05:12
Remember though, not only you
are going to correct the initial
cause of postpartum hemorrhage,
but you are also going to be
looking for that patient to
possibly to be going into DIC.
05:22
And that is only corrected
by given those correct blood products.