1.

Definition

PPH is termed as excessive bleeding in the first 24 hours post birth. In an emergent situation, diagnosis most
commonly occurs through estimation of blood loss volume and changes in the haemodynamic state. After
vaginal birth: 500 mL or more, After caesarean section (CS) : 1000 mL or more.

The World Health Organization (WHO) defines PPH as “blood loss greater than or equal to
500 ml within 24 hours after birth”, and severe PPH as “blood loss greater than or equal to 1
000 ml within 24 hours”

2. Aetiology

The common causes of PPH are referred to as the ‘Four T’s

Tone(70%) : Atonic uterus

Trauma (20%) : Lacerations of the cervix, vagina and perineum

· Extension lacerations at CS
· Uterine rupture or inversion
· Non-genital tract trauma (e.g.sub capsular liver rupture)

Tissue (10%) : Retained products, placenta(cotyledon or succenturiate lobe), membranes or clots, abnormal
placenta

Thrombin (<1%) : Coagulation abnormalities

3. Classification

Postpartum haemorrhage (PPH) can be classified as primary (early) or secondary (late).

- Primary PPH, the most common and severe, occurs within the first 24 hours after
delivery. Most cases of morbidity and mortality due to PPH are the result of primary
PPH.

- Secondary PPH occurs 24 hours to 12 weeks after delivery, while secondary PPH
results from retained placental fragments, subinvolution of the placental site,
infection, and coagulation defects (bleeding diatheses) which cause abnormal
excessive bleeding.

4. Complications

Most patients with PPH are quickly identified and successfully treated before
major complications develop. The most common problem is anemia and loss
of iron stores, which results in fatigue in the postpartum period. Many of the
complications of severe PPH are related to massive blood loss and
hypovolemic shock. Damage to all major organs is possible; respiratory (adult
respiratory distress syndrome) and renal (acute tubular necrosis) damage are
the most common but are rare. Hemorrhagic shock may lead to anterior
pituitary ischemia with delay or failure of lactation (i.e., postpartum pituitary
necrosis).
5. Talak non-farma

The 2012 WHO recommendations for the management of PPH recommends the
following non pharmacological interventions for managing PPH.9

- Uterine massage: A safe and inexpensive intervention to be initiated once

PPH has been diagnosed.

- Bimanual uterine compression: Could be offered as a temporary measure in

the treatment of PPH due to uterine atony after vaginal delivery.

- Intrauterine balloon or condom tamponade: May be used in the treatment of

PPH due to uterine atony when other uterotonics fail or if uterotonics are not
available. Possible infection is the risk associated with this intervention. The
WHO identifies the use of uterine balloon or condom tamponade in the
treatment of PPH as a research priority. 1

- External aortic compression: May be provided as a temporary measure to

slow down blood loss in treatment of PPH due to uterine atony after vaginal
delivery, until appropriate care is available.

- Uterine artery embolization: May be offered as a treatment for PPH due to

uterine atony if other measures have failed and resources are available.

- Non-pneumatic anti-shock garments: Recommended as a temporary measure

until appropriate care is available.