POST PARTUM

HEMORRHAGE
(PPH)
INTRODUCTION
• Postpartum hemorrhage (also
called PPH) is when a woman
has heavy bleeding after giving
birth.
• It's a serious but rare condition.
• It usually happens within 1 day
of giving birth, but it can happen
up to 12 weeks after having a
baby.
 DEFINITION

QUANTITATIVE DEFINITION :

Blood loss of ≥500ml following

delivery

(both Spontaneous Vaginal

Delivery or Caesarean
section).
CLINICAL DEFINITION

Any amount of bleeding from or
into the genital tract following birth
of the baby up to the end of the
puerperium which adversely affect
the general condition of the patient
evidence by

◦ rise in pulse rate

◦ falling in blood pressure.
NORMAL AVERAGE BLOOD LOSS :

1. Vaginal delivery = 500ml

2. Caesarean section = 1000ml
3. Caesarean hysterectomy = 2000 ml
TYPES OF PPH
Further Classification Of
Primary PPH

Classification based on
amount of blood loss

MINOR MAJOR SEVERE

<1L >1L >2L
 PRIMARY SECONDARY

• Occurs within 24 hours following • Occurs

the birth of the baby. beyond 24
hours and
within
puerperium.
3RD STAGE TRUE PPH
HAEMORRHAGE

• Bleeding occurs • Bleeding

before occurs
expulsion of subsequent to
placenta. expulsion of
placenta.
PRIMARY
POST PARTUM
HAEMORRHA
GES
a) Definition
b) Causes
c) Risk factor
d) Diagnosis and clinical effect
e) Prognosis
f) Prevention
g) Management
A) PRIMARY

• Occurs within 24 hours following the

birth of the baby.

3RD STAGE TRUE PPH

HAEMORRHAGE

• Bleeding occurs • Bleeding

before expulsion occurs
of placenta. subsequent to
expulsion of
placenta.
B)
1. Tone - Uterine Atony - 80%
• After separation of placenta, bleeding will continue at
placental site as the uterine sinuses that have been
torn cannot be compressed effectively.
• Failure of uterus to contract & retract.

Open uterine sinuses

Presented with:

a) Excessive bright red bleeding

b) Boggy uterus
c) High fundus with non-contracting uterus
d) Abnormal clot
e) Unusual pelvic discomfort or backache
C) RISK
FACTORS
• Grand multipara
• Over-distention of uterus
• Malnutrition and anemia
• Antepartum hemorrhage
• Prolonged labor
• Anaethesia usage
• Initiation or augmentation of delivery by
oxytocin
• Uterus malformation
• Uterine fibroid
• Placenta abnormalities
• Precipitate labour
• Mismanaged 3rd stage of labor

● Too rapid delivery of baby,

● Premature attempt to separate placenta
before it is separated
● Pulling the cord
● Kneading and fiddling the uterus
● Manual separation of placenta
2. Trauma – Traumatic Delivery- 20%

• Usually occurs following operative delivery.

• Underestimated blood loss from episiotomy wound
and lacerations.
• Blood loss in casaerean section of 800-1000ml.
• In rare cases, uterine rupture occur if delivery
happened before the cervix is fully dilated.
• Trauma sites :
● Vulva
● Vagina
● Cervix
● Perineum
● Paraurethral region
● Rupture uterus

*Bleeding is usually revealed but can

rarely be concealed in case of
vulvovaginal or broad ligament
hematoma.
3.Retained Tissues-10%

retention of tissue from the placenta or fetus as well as

placental abnormalities such as placenta accreta and
percreta may lead to bleeding.

4. Thrombin– Coagulation Disorders 1%

 Congenital or acquired
 May be due to diminished pro coagulants (washout

effect) or increased fibrinolytic activity.

Condition leading to thrombosis
:

● Placental abruption
● Jaundice in pregnancy
● Prolonged retention of dead
fetus
● Thrombocytopenic purpura
● HELLP syndrome
● Any congenital coagulation
disorders
 D)
DIAGNOSIS
 Vaginal bleeding
● Visible as a slow trickle.
● May be concealed as in broad ligament
hematoma or vulvo-vaginal

 Effect of blood loss depends on :

● Pre delivery hemoglobin level.
● Degree of pregnancy induced
hypervolemia.
● Speed at which blood loss occur.

● Alteration of vitals appear after Class 2

• State of uterus as felt per abdomen

● Traumatic hemorrhage : Well

contracted
● Atonic hemorrhage : Flabby and
becomes hard on massaging

*Both atonic and traumatic cause may

coexist. Traumatic hemorrhage causes
a state of low general condition hence
making the uterus atonic.
E)
PROGNOSIS
 Life threatning emergencies
 Major cause of mother death in
developed and
developing country
 Increase morbidity due to

◦ shock,
◦ transfusion reaction,
◦ pueperal sepsis,
◦ failing lactation,
◦ pulmonary embolism


SHEEHAN
SYNDROME
 Postpartum necrosis of posterior pituitary
gland causing hypopituitarism
 Due to severe haemorrhage or shock as blood
loss during or after labour
 Present as anterior pituitary hormone deficiency
 Evolve slowly and diagnose late
F)
PREVENTION
Cannot always be prevented
But incidence and magnitude can be
reduced by assessing risk factor and
follow the guideline stated

*however, most cases have no identifiable

risk factor
PREVENTION
GUIDLINE
ANTENATAL

● Improvement of the health status (keep

the Hb level normal, >10g/dl).
● High risk patient need to be screened
and
delivered in a well equipped hospital.
● Blood grouping
● Placental localization must be done
● Women with morbid adherent
placenta with high
INTRANATAL

● Active management of 3rd stage of labor.

● For cases with induced or augmented
labor by oxytocin, the infusion should be
continued for at least 1 hour after
delivery.
● Women delivered by caesarean given
oxytocin 5 IU slow IV
● Exploration of uterovaginal canal for
evidence of trauma.
Cont
● Observation for about 2hours after
delivery.
● For caesarean section, spontaneous
separation and delivery of placenta will
reduce blood loss.
● Examination of placenta and membranes
should be done as a routine to detect any
missing part.
● Local or epidural anaethesia is
preferable, general anaesthesia
requires expert obstetric anaethetist
G) MANAGEMENT OF
3 RD STAGE BLEEDING
Principle
:
1. Empty uterus from its content
and make its contract
2. Replace blood
3. Ensure effective hemostasis
STEPS

Placenta
Traumatic
site
bleeding
bleeding
A) Placenta Site Bleeding
Palpate fundus and uterus to make it hard

Start crystalloid solution with oxytocin (1 L with 20

units) at 60 drops per minute and arrange for blood
transfusion.

Oxytocin 10 units IM or methergine 0.2 mg is

given IV

Catheterize the bladder

 Give antibiotics (ampicillin 2 g and
metronidazole 500 mg IV).

If features of placental separation are evident,

Expression of the placenta If the placenta is not

is to be done either by fundal separated, manual removal
pressure or controlled cord of placenta under
traction method. general anesthesia is to be
done.

If the patient is in shock, she is

Resuscitated first!
 Delivered under general anesthesia,

Quick manual removal of the placenta

Oxytocin 10 units is given IM with the

delivery of the anterior shoulder,

Manual removal is done promptly when two attempts

of controlled cord traction fail.
 B) Traumatic Site Bleeding

The uterovaginal
canal is to be
explored under
general anesthesia
after the placenta is
expelled and
hemostatic sutures
are placed on the
offending sites.
STEPS OF
REMOVAL
MANUAL
OF
PLACENTA
Step 1
Under general anesthesia.
OR deep sedation with 10 mg
diazepam given
intravenously.
Lithotomy position.
With all aseptic measures,
The bladder is catheterized.
Step 2
One hand is introduced into the
uterus after smearing with the
antiseptic solution in cone shaped
manner following the cord, which is
made taut by the other
hand
The labia are separated by the
fingers of the other hand.
The fingers of the uterine hand
should locate the margin of the
Step 3
Counter pressure on the uterine
fundus is applied by the other hand
placed over the abdomen.
The abdominal hand should steady
the fundus and guide the movements
of the fingers inside the uterine
cavity until the placenta is
completely separated.
Step 4
As soon as the placental margin is
reached, the fingers are insinuated
between the placenta and the uterine
wall with the back of the hand in
contact with the uterine wall.
The placenta is gradually
separated with a sideways by
slicing movement of the fingers,
unt il whole of the placenta is
separated
Step 5
When the placenta is completely
separated, it is extracted by traction of
the cord by the other hand.
The uterine hand is still inside the
uterus for exploration of the cavity to
be sure that nothing is left behind
Step 6
Intravenous methergine 0.2 mg is
given and
Uterine hand is gradually
removed
while massaging the uterus by the
exter nal hand to make it hard.

After the completion of manual removal,
inspection of the cervicovaginal canal is
to be made to exclude any injury.
Step 7
The placenta and membranes are
inspected for completeness and be
sure that the uterus remains hard and
contracted
COMPLICATIONS:
(1) Hemorrhage due to incomplete
removal
(2) Shock
(3) Injury to the uterus
(4) Infection
(5) Inversion
(6) Subinvolution
(7) Thrombophlebitis
(8) Embolism.

In such cases placenta is removed in

fragments using an ovum forceps or a
MANAGEMENT OF
PPH
TRUE
PRINCIPLE
1. Communication
2. Resuscitation
3. Monitoring
4. Arrest of bleeding
IMMEDIATE
MEASURES :
• Call for extra help – involve a senior

obstetrician.
• Put in two large bore (14 gauge) of

intravenous cannulas.
• Keep patient flat and warm.

• Send blood for group, cross matching,

diagnostic tests.
• Ask for 2 units of blood at least.

• Infuse rapidly 2L of normal saline or

plasma substitutes.
• Give oxygen by mask 10–15 L/min.
• Start 20 units of oxytocin in 1L of normal saline IV
at the rate of 60 drops per minute.
• Monitor the following :

● Pulse
● Blood pressure
● Respiratory rate and oxymeter
● Type and amount of fluids the patient
has received
● Urine output (continuous catheterization)
● Drugs - type, dose and time
● Central venous pressure (when sited)
ACTUAL MANAGEMENT
• ATONIC UTERUS

Step 1

● Massage uterus to make it hard and express

blood clot.
● Methergin 0.2mg IV
● Inj Oxytocin 10U in 500ml of normal saline, at
a rate of 40-60 drops/min.
● Foley catheter to monitor urine output.
● Examine the expelled placenta for evidence of
missing cotyledons or membranes.

*If uterus fails to contract, proceed to step 2

Step 2

● Explore uterus under general anesthesia.

● In refractory cases :
• Inj 15-methyl PGF2α 250mcg IM in deltoid

muscle every 15 min (maximum dose :

2mg)
OR
• Misoprostol (PGE1) 1000mcg per rectum.

• If atony is due to tocolytic drug, Calcium

gluconate 1g IV slowly is given.

Step 3

• Uterine massage and bimanual compression.

● Continue compression for a prolonged period of
time until the tone of uterus is regained.
● Absence of bleeding if the compression is
released
indicates regaining of tone.
• Resuscitative measures are to be
continued.
• If bleeding continues, there might be a
possibility of
blood coagulation disorders.
• Massive fresh blood transfusion is to be
given.
 TIGHT INTRAUTERINE
PACKING
 Under GA.

 A 5-meters long strip of gauze, 8 cm wide folded

twice is required.
 The gauze should be soaked in antiseptic cream
 The gauze is placedhigh up and packed into
the
fundal area first
 Gradually, the rest of the cavity is packed so
that no empty space is left behind.
 A separate pack is used to fill the vagina.
 An abdominal binder is placed.
TIGHT INTRAUTERINE PACKING
CONT
.Stimulate uterine contraction and direct
hemostatic pressure to the open uterine
sinuses.

Antibiotic should be given and the
plug should be removed after 24
hours.
Useful in a case of uncontrolled postpartum
hemorrhage where other methods have
failed and the patient is being prepared for
transport to a tertiary care center.
BALLOON TAMPONADE
Various types of hydrostatic balloon
catheter
Mechanism of action is similar to
uterine packing.
Foley catheter
Bakri balloon
Condom catheter
Sengstaken-
Blakemore tube

Inserted into the uterine cavity and

inflated with normal saline (200–
500 mL).
BAKRI
BALLON
CONDOM CATHETER
SENGSTAKEN-BLAKEMORE
TUBE
B-LYNCH COMPRESSION
SUTURE