and Jyothi G Seshadri2
Traumatic PPH can occur following vaginal or caesarean delivery. Following vaginal delivery, it can occur as a result of precipitate labor, injudicious instrumental delivery, injudicious use of prostaglandins for induction of labor, injudicious use of oxytocin for augmentation of labor, malpresentations, macrosomia, and shoulder dystocia. It can occur even following a preterm vaginal delivery.
It can occur following caesarean section when the patient is taken up for caesarean section after considerable delay—when there is obstructed labor, deep transverse arrest, or when the patient is in second stage with a deeply engaged presenting part, and in cases of malpresentation when the obstetrician is unable to extract the baby without tears and extensions of the uterus.
Traumatic PPH as opposed to atonic PPH and PPH due to coagulopathy is almost always due to bad obstetric practices and lapses in judgment, unless it is a case of the patient being referred very late in the day, and there has been no further delay on the part of the attending obstetrician. Traumatic PPH is a condition that has to be prevented and rarely dealt with.
In teaching institutions, residents are taught that every primipara should be given a trial unless there is an obvious contraindication like malpresentation, placenta previa, etc., and every patient with one previous LSCS should be considered for TOLAC unless contraindicated. However, one must assess the pelvis at the onset of labor and determine if the pelvis is favorable with respect to baby size. With good uterine contractions, majority of the fetuses have good flexion and the vertex undergoes rotation. There is the “give of the pelvis” due to hormones like relaxin, because of which minor degrees of cephalopelvic disproportion can be overcome. However, what is not taken into consideration is that many women are under a lot of stress due to complications like PIH, being referred to a tertiary center in a state of emergency, and possible domestic issues. Also most Indian women have osteopenia [1]. Therefore though trail should be the norm, one must be vigilant and take findings like appearance of meconium, increasing caput, and FHR decelerations seriously.
Applying ventouse when the fetal head is still high can successfully deliver head out but can lead to shoulder dystocia. This is because the baby has been forcefully pulled down, but the head and shoulders have not undergone internal rotation [2]. Shoulder dystocia when encountered requires the obstetrician to deliver the baby by extending the episiotomy and by releasing the posterior shoulder. Thus one can expect multiple tears in the vaginal and paraurethral region and perineum.
To highlight the fact that one has a very high rate of successful vaginal deliveries, one must not create a record of having the maximum vaginal deliveries with disastrous results. Which means that the baby is in NICU for birth asphyxia and birth injuries, and the mother is having second/third/fourth-degree perineal tears with traumatic PPH, and needs multiple transfusions with prolonged ICU and hospital stay. Given such an outcome, the medical expenses are going to be huge and the baby’s development might also be compromised.
When the baby’s head is not coming out despite the cervix being fully dilated and good uterine contractions present, one must consider possibilities like cord around neck, true cord knot, constriction ring, occipito-posterior presentation, impending scar dehiscence in cases of previous LSCS, and CPD. One must review – is the head truly descended or is it the caput which is increasing? The decision to take the patient for an LSCS must be taken well in time. The mere fact that FHR is not showing significant decelerations should not be the sole criterion to continue giving a trial. Prolonged labor especially in second stage, where the mother has been bearing down for quite some time, is associated with multiple problems (e.g., risk of future prolapse), and performing an LSCS in such a patient is not always easy. The lower segment will be thinned out, the fetal presenting part could be deeply engaged, or there could be DTA. Difficulty in delivery is associated with tears extending down into the lower segment and laterally into the uterine arteries.
In case of prolonged trial in a patient with one previous LSCS, there is a risk of impending rupture, or even complete uterine rupture. The patient may have bled significantly by the time the abdomen is opened. The tissues can be very friable and can bleed wherever a bite is taken, and suturing can be very difficult. And if the membranes have been ruptured for a long time, there could be ascending infection, and very little liquor. The uterus would have gripped the baby, making delivery difficult.
Traumatic PPH following a vaginal delivery can be due to extension of episiotomy, perineal tears, paraurethral tears, vaginal lacerations, and rarely colporrhexis. When more than the usual bleeding is noted, the obstetrician must immediately put a mop in the vagina and ensure that there are two patent IV lines present. Oxytocin infusion must be started; methylergometrine should be given IV if not contraindicated; bladder catheterized to monitor urine output—this is an indicator of organ perfusion, and call for help. Blood sample should be sent for crossmatch if not sent earlier. An assistant should continuously monitor the vitals and must reassure the patient, keeping an eye if the patient is getting drowsy or disoriented. The obstetrician must check if the placenta and membranes are fully expelled. If the placenta and membranes have not been expelled fully, then they should be removed by controlled cord traction. Clots should be removed and uterine massage be done to contract the uterus. If the bleeding is manageable, then the suturing can be done in the labor room itself, with patient being given IM sedation and local infiltration.
The author would like to point out that many seniors with years of experience are very quick and efficient. They suture a small episiotomy or a small tear in one continuous layer, sometimes before the placenta is expelled. This should not be a problem given the years of experience of some consultants. Episiotomy rarely gapes despite being subjected to constant friction and movement due to limb ambulation. Perineum is a naturally contaminated region of the human body. Despite these factors, episiotomy rarely gapes probably because of good blood supply.
However, this is not what the younger obstetricians and gynecologists should practice. One must wait for the placenta and membranes to be expelled and remove all clots and membrane remnants. The placenta needs to be examined for any missing lobe or abnormalities. One must remember that missing cotyledons can cause profuse vaginal bleeding later, and some placental abnormalities are associated with fetal anomalies [3]. If any placental abnormality is found, the neonatologist has to be informed. After suturing the episiotomy, one is reluctant to explore the vagina since one would not want to disturb the sutures. The practice of tightly packing the vagina is strongly discouraged. If the bleeding is significant and hinders good visualization, a mop must be inserted only till the patient is shifted to the OT for exploration and suturing under GA. For these reasons, it is prudent to wait till the placenta and membranes are fully expelled, the vagina is explored with good illumination before beginning to suture the episiotomy. The separation of placenta should not take more than a few minutes.
After the placenta and membranes are expelled fully and the uterus well contracted, the patient must be given lithotomy with IM sedation given, and bladder catheter in situ. The lips of the cervix should be held with two sponge holders side by side. The assistant should expose the vagina with two Sims speculums. The obstetrician can explore clockwise or counterclockwise and check for any cervical tears and colporrhexis. As the obstetrician moves from one point to another, the sponge holders are released and reapplied further along the cervix, while the assistant moves the two Sims speculums in the direction of the exploration. Any tear should be sutured taking care to go a little beyond the apex of the tear. Should there be colporrhexis or profuse bleeding which obstructs visualization, the patient must be quickly shifted to the OT for exploration and repair under GA.
After the cervical tears are sutured, one must begin suturing the episiotomy and the vaginal tears. Come from above downward. One can visualize the lower tears only after the bleeding from the upper most tear has been controlled. Care must be taken to go beyond the apex of each tear, lest the tear continues to bleed from the point above the highest stitch. If the apex cannot be visualized, then one can insert a tampon or a small mop in the vagina. This will apply pressure on the other tears and may help in locating the apex of the episiotomy/tear that is being sutured. If the apex is still not visualized, take a stitch as high as possible and apply gentle traction to the suture material. This should help is lowering and bringing out the part of the episiotomy/tear above the point of the stitch. One can then take stitches above this point. If the episiotomy is very big due to extension, sometimes the ischiorectal pad of fat is exposed, then one has to close this space with interrupted sutures after securing the apex. It will be very difficult to close the middle layer between the mucosa and the perineal skin once the entire mucosa is sutured. Unsecured bleeding vessels in this layer can result in vulval hematoma. This space can accommodate a large volume of blood. The patient can silently bleed and can land in hypovolemic shock and severe anemia. Thus severe pain and discomfort at the episiotomy site should be checked promptly, never dismissed. There could be a huge vulval hematoma, which can deceptively look small due to tight skin sutures. It is only after the sutures are opened that a huge clot is revealed.
An obstetrician must make a liberal episiotomy, especially for preterm births (contrary to what one might think that small babies do not need so much of space. But then excessive compression of the head has to be avoided in preterm babies). When the head is on perineum and is stretching it, one may be reluctant to give a 5–8 cm long episiotomy, fearing that it may be very big! But once the baby is delivered, a big episiotomy will not appear so big! Taking a small episiotomy and then applying ventouse or forceps is another disastrous step. A single 5–8 cm long mediolateral episiotomy is easy to suture than multiple tears and lacerations caused due to delivery of a big baby through narrow birth canal as a result of a small episiotomy. If the ischiorectal pad of fat is seen, then it indicates extension of the episiotomy.
Small paraurethral tears can be left alone if there is no bleeding, but if they need to be sutured, then a per urethral catheter is a must. Not only does it help is monitoring urine output, but more importantly it prevents a stitch being taken through the urethral lumen during suturing of a paraurethral tear. The catheter has to be left in situ for a few days if a paraurethral tear is present. This is an extremely pain-sensitive area, and the patient may not feel bladder fullness when there are sutures in this area. Also it prevents the burning pain when urine drops come in contact with the sutures.
Third-degree perineal tears involving the edge of the anal sphincter can be sutured in labor room with good local infiltration provided the patient is stable and cooperative. But all fourth-degree perineal tears involving the rectum, all tears where the patient is bleeding profusely, those patients in severe pain, and hemodynamically unstable patients should be sutured in the OT under GA. It is always advisable to call a surgeon if there are rectal injuries.
In case of traumatic PPH encountered during LSCS, one has to exteriorize the uterus and quickly secure the angles of the uterine incision. If there is an extension into the uterine arteries, then one has to first secure the angle and may have to do the uterine artery ligation just below the level of the uterine incision. If there are extensions into the lower segment, then they should be sutured separately. One should not try to suture the upper and lower incisions in a straight line, since the length of the lower margin will be longer than the length of the upper margin of the incision. The thickness of myometrium at the upper and lower margins of the incision will also be different. The thickness of the upper margin will be more than that of the lower margin. The myometrium of the lower segment may be very much thinned out and the tissue integrity poor. The tissue may cut through and can bleed wherever a bite is taken. It may require very gentle suturing, and the sutures should not be tightened by pulling. Instead a mop should be used to gently pull the suture material against the tissue to tighten it.
There could be tears or extensions which could be intentional, like an inverted T incision, or a J-shaped incision, taken to deliver a baby in transverse lie, or with deeply engaged head. Even in such a scenario, each angle has to be secured separately and sutured. No attempt should be made to suture the entire length in a straight line.
If there are tears which have extended deep down or laterally, one must trace the ureters to rule out the possibility of a stitch being taken through it. One must look transperitoneally through the pouch of Douglas and locate the ureters, and check if the stitches are well above the level of the ureters. It would be advisable to call the urologist if ureteric and bladder injuries are suspected/found. Bladder injuries in a case of obstructed labor and those due to prolonged trial in a case of previous LSCS may involve the trigone or the posterior wall of bladder. It may require ureteric stenting and an extensive repair. Only a small rent in the dome of bladder can be sutured by the obstetrician [4, 5].
A Pfannenstiel incision for an LSCS for a patient in second stage is perfectly fine, even if there are other problems like uterine rupture. Even if internal iliac artery ligation becomes necessary, one can convert the incision to a Maylard incision and ask the anesthetist for GA.
The decision to go for internal iliac artery ligation and/or obstetric hysterectomy should never be deferred till it is too late to save the patient. It is better to operate when the patient is still stable, than when in a state of DIC and irreversible shock due to profuse hemorrhage.
Lastly, all patients who have delivered by an LSCS done in second stage of labor are poor candidates for TOLAC, and one must not subject them to a trail in next pregnancy just for sake of following a protocol. Those with tears, extensions, inverted T-shaped and J-shaped scars are not to be subjected to labor in subsequent pregnancies, even if it is a case of preterm labor or a case of IUD. They have to be taken up for elective repeat LSCS. The risks of uterine rupture are far too high.
Also, those patients who have suffered a third- or fourth-degree perineal tear in a previous pregnancy should be taken for elective repeat LSCS, though the perineal trauma could have been due to bad judgment and vaginal delivery in the present pregnancy might be safe.
Let us now study some photographs taken when traumatic PPH was encountered following vaginal delivery followed by photographs taken when traumatic PPH was encountered during LSCS.
Traumatic PPH following Vaginal Delivery (Figs. 10.1, 10.2a–c, 10.3a, b, 10.4, 10.5a–c, and 10.6)
Badly Sutured Episiotomy
Badly sutured episiotomy
There are clots in the episiotomy incision (Fig. 10.1). The patient was complaining of severe pain at the episiotomy site. The sutures have been opened. The arrow is pointing at a catgut remnant. On close inspection of the skin edges, the suture bite marks can be appreciated along the skin margins. At the upper end of the episiotomy, there is a swelling, and the finger is inserted into the vagina, inside that part of the episiotomy where the mucosa has not been sutured. This is because of the tearing hurry on part of the obstetrician. It is now advisable to remove all sutures and close the episiotomy in layers with the patient in lithotomy position, and with careful inspection of the entire vagina under good illumination. The patient will require IM sedation, and repeat local infiltration prior to suturing.
Fortunately, the condition is discovered before a large vulval hematoma was formed.
Suturing Cervical Tears (Fig. 10.2a–c)
Figure 10.2a shows the anterior and posterior lip of the cervix being held by sponge holders. The assistant has inserted a Sims speculum in the 11 o’clock and the 6 o’clock positions. There are two cervical tears as shown by the two straight arrows. The assistant should rotate the two Sims speculums either clockwise or counter clockwise as shown by the curved arrows, so that the obstetrician can inspect the entire cervix and vagina all around. Each tear should be sutured. Should there be profuse bleeding, multiple tears, or if the patient is in severe pain, suturing should be done in the OT under GA. If the tears are just one or two and if the patient is not bleeding heavily and is cooperative, then the suturing can be done in the labor room under IM sedation and local infiltration.
