Following are useful in Rx of PPH in women with Rheumatic heart disease except: (AIPG 2011)
a. Postpartum hemorrhage has been defined as a blood loss of greater than 500 mL during or after the third stage of labor. This definition is somewhat paradoxical, as careful measures of blood loss following delivery indicate that the average is approximately 500 mL.
b. After hypertensive disorders and embolism, postpartum hemorrhage is the major cause of maternal mortality for women who reach the second trimester.
c. The major cause of postpartum hemorrhage is uterine atony or failure of the uterus to contract sufficiently after delivery. This failure inhibits the major hemostatic mechanism of the postpartum uterus—myometrial contraction with constriction of placental bed arteries and veins.
d. Risk factors for uterine atony include prolonged or oxytocin-augmented labor, uterine overdistension (as with polyhydramnios, fetal macrosomia, or multiple gestations), chorioamnionitis, grand multiparity, and a history of postpartum hemorrhage. Halogenated anesthetic agents also inhibit uterine contractility, and very rapid labors have been associated with failure of the uterus to contract adequately after delivery.
e. Additional causes of postpartum hemorrhage are vaginal or cervical lacerations, and retained products of conception.
f. Most serious hemorrhages occur within the first 24 hours after delivery but may occur even weeks after delivery.
1. If uterus flabby
a. Massage uterus
b. IV methargin
d. Bladder catheterization
e. Examine expelled placenta
2. If still flabby, explore the uterus.
3. If still flabby, Blood transfusions, continue oxytocin, and add 15-methyl PgF2αIM.
4. If still flabby, bimanual compression.
5. If still flabby i.e. if contractions cannot be stimulated in a refractory atonic uterus, Hot uterine douche and intrauterine packing and if this fails, either hysterectomy or bilateral ligation of anterior division of internal iliac arteries (in exceptional cases as an alternative to hysterectomy).
Injection ergometrine 0.25mg or Methargin 0.2mg is given intravenously following the birth of anterior shoulder. It should not be used in cardiac cases or severe preeclampsia for fear of precipitating cardiac overload in the former and aggravation of blood pressure in the latter.