POSTPARTUM HEMORRHAGE

INTRODUCTION: -
Post-partum hemorrhage (PPH) remains a major cause of maternal mortality and morbidity
worldwide. Approximately, half a million women die annually from causes related to pregnancy
and childbirth.

DEFINITIONS: -
 "any amount of bleeding from or into the genital tract following birth of the baby up to the
end of the puerperium which adversely affects the general condition of the patient evidenced
by rise in pulse rate and falling blood pressure is called postpartum haemorrhage."
 "Postpartum Hemorrhage is defined "as excessive bleeding from the genital tract at any time
following the baby's birth up to 6 weeks after delivery".

INCIDENCE: -

 In the developing world, several countries have maternal mortality rates in excess of 1000
women per 100,000 live births, and World Health Organization statistics suggest that 25%
of maternal deaths are due to PPH, accounting for more than 100,000 maternal deaths per
year.
 The incidence is 1% among the hospital deliveries.

TYPES: -

 Primary postpartum hemorrhage: - is the hemorrhage occurring during the third

stage of labour and within 24 hours of delivery.
1. Third stage hemorrhage: - Bleeding occurs before expulsion of placenta.
2. True postpartum haemorrhage-Bleeding occurs subsequent to expulsion of placenta
(majority).
 Secondary postpartum hemorrhage: - Hemorrhage occurring after 24hours of
delivery and within 6weeks of delivery. It is also referred to as puerperal hemorrhage.

PRIMARY POSTPARTUM HAEMORRHAGE-

Primary haemorrhage occurs within 24 hours following the birth of the baby. It is of two types:
1. Third stage haemorrhage: Bleeding occurs before expulsion of placenta

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2. True postpartum haemorrhage: Bleeding occurs subsequent to expulsion of placenta

CAUSES:
1. Atonic uterus (70%)
2 Traumatic
3.Tissue
3. Mixed
4 Blood coagulopathies

1. Atonic Uterus (70%):

Atonicity of the uterus is the commonest cause of Post Partum Haemorrhage. As long as
placenta remains unseparated, bleeding does not occur With the separation of placenta, the
uterine sinuses which are torn cannot be compressed effectively due to imperfect contraction
and retraction of the uterus and bleeding continues.
The following are the causes of atonic uterine action:
A. Grand multipara: Grand multipara causes laxity of the uterine and abdominal mascles
which contract ineffectively i.e. fibrous tissue replaces muscle fibers in the uterus reducing
its contractility and the blood vessels become more difficult to compress. Hence, women
who have had five or more deliveries are at increased risk.
B. Over distension of the uterus: In multiple pregnancy, hydramnious and large baby, the
myometrium becomes excessively stretched and therefore less efficient.
C. Malnutrition and anemia: Malnourished women or anemic mothers (haemoglobin
concentration below 10g/dl) may be at risk.
D. Antepartum haemorrhage: It includes: Placenta praevia and abruption placenta:
Placenta praevia predisposes to postpartum haemorrhage because the lower uterine segment
on which the placenta is implanted does not contract and retract as efficiently as the upper
uterine segment. In concealed accidental haemorrhage, retained large blood clots over
distend the uterus and sometimes seeps into the uterine muscle wall. All these factors
prevent adequate contractions and retractions of the uterus.
E. Prolonged labour: In labour where the active phase lasts for more than 12 hours uterine
inertia (sluggishness) may occur due to muscle exhaustion
F. Anesthesia: Anesthetic agents may cause uterine relaxation, particularly in inhalational
agents like halothane.
G. Initiation or augmentation of delivery by oxytocin: Post-delivery uterine atonicity is
likely to develop as oxytocin will increase the power of contraction without improving the
retraction power of uterine muscles.
H. Persistent uterine distension: This may cause PPH due to over distension.
I. Malformation of the uterus: This may also lead to PPH
J. Uterine fibroid: A number of interstitial fibroids may interfere with good uterine action.

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K. Mismanaged 3rd stage of labour: Fundus fiddling or manipulation of the uterus may
precipitate arrhythmic contractions, so that the placenta only partially separates and
retraction is lost.
L. Constriction ring: Hour glass constriction formed in the upper segment across the partially
separated placenta or at the junction of upper and lower segments with the fully separated
placenta trapped in the upper segment, may produce excessive bleeding.
M. Precipitate labour: When the uterus has contracted vigorously and frequently resulting in
duration of labour, that is less than one hour, then the uterine muscles may have in sufficient
opportunity to retract.
N. Incomplete separation of placenta: If the placenta remains fully adhered to the unseen
wall, it is unlikely to cause bleeding. However, once separation has begun, maternal vessels
are torn. If placental tissue remains partially embedded in the spongy decades, efficient
contraction and refraction is interrupted.
O. Retained cotyledons: Placental fragments or membranes will similarly impede efficient
uterine action.
P. A full bladder: A full urinary bladder impairs the efficiency of uterine action.
Q. Unknown etiology: These include the factors that might increase the risk of atonic
postpartum haemorrhage.
R. Previous history of postpartum haemorrhage or retained placenta-In such woman, there
is risk in subsequent pregnancies.
2. Traumatic (20%): It includes:
A. Trauma to genital tract usually following operative delivery. It may occur even after
spontaneous delivery, lower segment tears, valval injuries.
B. Blood loss from the episiotomy wound is often underestimated especially in cases of delay
in repairing the episiotomy wound.
C. Similarly, blood loss in caesarean section occurs up to 800-1000 ml. (It is most often
ignored).
D. Trauma sites involving the
 Vulva
 cervix
 vagina,
 perineum
 para-urethral region.
E. The bleeding is usually revealed but rarely concealed
F. It can be due to uterine rupture.

3.Tissues-
A. Bit of placenta
B. Blood clot
4.Drugs-

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 Use of tocolytic drug(ritodrine), mgso4, nifedipine.
5. Mixed: Combination of atonic and traumatic cases.
6. blood coagulation disorders: It may be:
a. Acquired
b. Congenital

The conditions where disorders may operate are:

i. Abruptio placenta.
ii. Jaundice in pregnancy.
iii. Thromobocytopenic purpura.
iv. Pre-eclampsia.
v. Amniotic fluid embolism.
vi. HELLP syndrome.
vii. Intrauterine death or sepsis.
Causes of blood coagulation disorders: It can be as a result of coagulation failure (increased
fibrinolytic activity). Blood coagulation defect may cause hypofibrinogenemia and leads to
reduction in the fibrinogen content of blood resulting in clotting defect.
The causes of blood coagulation are:
a. Excessive fibrinolysis.
b. Disseminated intravascular coagulation
c. Inherited coagulation disorder
d. Idiopathic thrombocytopenic purpura.
SIGNS OF PPH:
The signs of PPH are based on the effect of blood loss and also depend on pre-delivery
hemoglobin level, degree of pregnancy-induced hypervolemia and the speed at which blood loss
occurs. Hence, these are listed below:
Atonic Hemorrhage:
1. Here, the bleeding occurs a few minutes after the birth of the baby and tends to come in
gushes.
2. Uterus is soft, flabby, big and does not contract.
3. It fills up easily with blood and the fundus rises above the umbilicus.
Traumatic Haemorrhage: Here, the blood comes in a steady flow but the uterus is usually
hard and well contracted and retracted.

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Hypofibrinogenemia: In this, the blood just pours out through the vagina and does not clot.
The uterus is soft and flabby but at times, it is contracted and retracted.
Severe Blood Loss:
1. Pallor of:
a) Conjunctiva
b) Palms of the hand
c) Tongue
d) Soles of feet
2. Vaginal bleeding is visible outside as a slow trickle or copious flow.
3. Rising pulse rate.
4. Falling blood pressure.
5. Altered level of consciousness and the mother may become restless and drowsy.
6. Uterus is enlarged (if fills with blood or blood clot).
7. Uterus feels boggy on palpation that is soft and distended lacking tone.
8. Maternal collapse (shock).
9. If blood loss is rapid and brisk, it may cause death within a few minutes.
DIAGNOSIS: It is diagnosed by:
a. In majority of cases, vaginal bleeding is visible outside as slow trickle.
b. Rarely bleeding is totally concealed.
c. There may be systemic effect of hypovolemia due to blood loss
d. Initially the pulse rate becomes slow.
e. In late features, there may be features of shock, i.e. tachycardia, hypotension, severe pallor,
cold clammy skin, air hunger.
f. Per abdomen, uterus is felt soft and flaccid.
PROPHYLAXIS or PREVENTION
Postpartum hemorrhage cannot always be prevented. However, the incidence and magnitude
can be reduced substantially if following guidelines are followed.

 Antenatal
 Improvement of the health status of women, especially to raise their hemoglobin level as
near to normal as possible, so that they can withstand the blood loss.
 Screening of high-risk women, such as those with twins, Hydramnios, grand multipara,
antepartum hemorrhage (APH), history of previous third stage complications and severe
anemia for delivery in a well-equipped hospital.
 Blood grouping and typing should be done for the high-risk mothers, so that no time is
lost during an emergency.
 Intranatal or During Labor

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 Prevent prolonged labor and ketoacidosis by following good management practices:
 Prophylactic administration of oxytocic drugs for the third stage.
 Baby should be pushed out by the retracted uterus and not be pulled out. One should take 2-
3 minutes to deliver the trunk after the head is born.
 Temptation of fiddling with or kneading the uterus, pulling the cord or Crede's expression of
placenta to be avoided.
 In all cases of induced or accelerated labor by oxytocin, the infusion should be continued for
at least 1 hour after the delivery and prophylactic ergometrine should be given with the
delivery of the anterior shoulder.
 For any woman known to have placenta previa, two units of crossmatched blood should be
kept available.
 The woman should be observed for about 2 hours after the delivery and after being satisfied
that the uterus is hard and contracted. The pulse and blood pressure should be within normal
limits before transferring the woman to the ward/postpartum floor.

MANAGEMENT OF THIRD STAGE BLEEDING: -

Principles-
 To empty the uterus of its contents and to make it contract.
 To replace the blood. On occasion, patient may be in shock. In that case patient is managed
for shock first
 To ensure effective hemostasis in traumatic bleeding.

STEPS OF MANAGEMENT:
* Placental site bleeding * Traumatic bleeding
Placental site bleeding
The following procedures are to be followed:
 To palpate the fundus and massage the uterus to make it hard. The massage is to be
done by placing four fingers behind the uterus and thumb in front. However, if bleeding
continues even after the uterus becomes hard, suggests, the presence of genital tract
injury.
 Ergometrine 0.25 mg or methergine 0.2 mg is given intravenously.
 To start a dextrose saline drip and arrange for blood transfusion, if necessary
 To catheterize the bladder if it is found to be full.
 Sedation may be given with morphine 15 mg intramuscularly.
During this procedure, if features of placental separation are evident, expressions of the
placenta is to be done either by fundal pressure or controlled cord traction method.
If the placenta is not separated, manual removal of placenta under general anesthesia is to
be done. However, if the patient is in shock, she is resuscitated first before undertaking

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manual removal. If the patient is delivered under general anesthesia, quick manual
removal of the placenta solves the problem. In cases where oxytocine10 units is given IM.,
with the delivery of the anterior shoulder, manual removal is done promptly when no
attempts of controlled cord traction fail. Crede's expression of the placenta is abandoned
as it is not only ineffective, but produces shock and rarely inversion
Management of traumatic blending: 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 MANUAL REMOVAL OF PLACENTA

Step-1: The option is done under general anesthesia. In extreme urgency where
anesthetist is not available, the operation may have to be done under deep sedation with 10
mg diazepam given intravenously. The patient is placed in lithotomy position. with all
aseptic measures the bladder is catheterized.
Step-II: One hand is introduced into the times after smearing with the antiseptic solution in
cone shaped manner following the cord, which is made taut by the other hand. While
introducing the hand, the labia are separated by the fingers of the other hand. The fingers of
the uterine hand should locate the margin of the placenta.

Step III: 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 till the placenta is completely separated.
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 Step - IV: 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 slicing movement of the fingers, until whole
of the placenta is separated.
Step-V: 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-VI: Intravenous ergometrine 0.2 mg is given and the uterine hand is gradually
removed while massaging the uterus by the external hand to make it hand. After the
completion of manual removal, inspection of the cervicovaginal canal is to be made to
exclude any injury.
Step-VII: The placenta and membranes are to be inspected for completeness and be sure that
the uterus remains hard and contracted.
Difficulties:
(1) Hour-glass contraction leading to difficulty in introducing the hand
(2) Morbid adherent placenta which may cause difficulty in getting to the plane of cleavage
of placental separation
Complications:
(1) Haemorrhage due to incomplete removal
(2) Shock
(3) Injury to the uterus
(4) Inflection
(5) Inversion (rare)
(6) Subinvolution Thrombophlebitis
(5) Embolism.

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MANAGEMENT OF TRUE POSTPARTUM HAEMORRHAGE
PRINCIPLES
 To diagnose the cause of bleeding: atonic or traumatic
 To take prompt and effective measures to control bleeding
 To correct hypovolemia
MANAGEMENT
Immediate Measures: The following immediate measures are to be taken by the attending
House Officer when the amount of blood loss is more than a liter).
 Call for extra help-involve the obstetric registrar (Senior Staff) on call
 Put in two large bore (14 gauge) intravenous cannula.
 Send blood for group (if not done before) and cross matching and ask for 2 units (at
least) of blood.
 Infuse rapidly 2 litters of normal saline (crystalloids) or plasma substitutes like
haemocoel (colloids), a urea linked gelatin, to re-expand the vascular bed. Haemocoel is
rich in potassium and calcium. It does not interfere with cross matching.
 Give oxygen by mask 10-15 L/min.
 START 20 UNITS OF OXYTOCINE IN 1 l of normal saline IV at the rate of 60 drops
per minute. Transfuse blood as soon as possible.
 One Midwife/Rotating Houseman should be assigned to monitor the following-

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 I. Pulse
II. Blood pressure
III. Respiratory rate and oximeter
IV. Type and amount of fluids the patient has received
V. Urine output (continuous catherization)
VI. Drugs-type, dose and time
VII. Central venous pressure (when sited).

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 SECONDARY POSTPARTUM HEMORRHAGE

Secondary postpartum hemorrhage is bleeding from the genital tract more than 24 hours
after delivery of the placenta and may occur up to 6 weeks after delivery. It is most likely to
occur between 8th and 14th day after delivery.

CAUSES
 Retained bits of cotyledons, membranes or a large uterine blood clot.
 Separation of slough over a deep cervicovaginal laceration.
 Subinvolution of the placental site due to delayed healing process because of low-
grade infection.
 Secondary hemorrhage from cesarean section wound
 Withdrawal bleeding following estrogen therapy for suppression of lactation
 Other causes are chorion epithelioma, carcinoma cervix, placental polyp or fibroid
polyp.

CLINICAL FEATURES
 The lochia are heavier than normal and will consist of a bright red loss
 The lochia may be offensive, if infection is a contributing factor.
 Subinvolution of uterus and often a patulous os .
 Pyrexia and tachycardia
 Varying degrees of anemia: Proportionate to the blood loss.
As this is an event most likely to occur at home, women should be alerted to the
possible signs of postpartum hemorrhage prior to discharge from the postnatal ward.

MANAGEMENT
The principles of management are:
 To assess the amount of loss and to replace the lost blood.
 To find out the cause and to take appropriate steps to rectify it.
Supportive Therapy
 Resuscitative measures including blood transfusion, if the bleeding is heavy
 Ergometrine 0.5 mg intramuscularly, if the bleeding is uterine in origin
 Antibiotics as a routine.

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 Conservative Therapy
Bedrest and observation for 24 hours, if the bleeding is mild.
Active Management
 Exploration of the uterus under general anesthesia, if retained bits of placenta or
membranes is the cause .
 Gentle curettage is done and the materials removed are to be sent for
histopathological examination
 Ergometrine 0.5 mg is given intramuscularly. Secondary bleeding following
cesarean section may at times require laparotomy for applying hemostatic sutures.
Rarely, ligation of internal iliac artery or hysterectomy may become necessary.

NURSING CONSIDERATIONS
 If the uterus is still palpable, massaging the uterus and expressing the clots may help
 The mother must be encouraged to empty her bladder
 All the pads and linen must be assessed for the volume of blood lost
 Vital signs and general condition must be monitored.
 Hemoglobin estimation, iron treatment and teaching about iron-rich foods
 Help to breastfeeding mothers to save the milk for the baby.

SUMMARY:-
Postpartum hemorrhage, defined as the loss of more than 500 mL of blood after delivery, occurs
in up to 18 percent of births.1,2 Blood loss exceeding 1,000 mL is considered physiologically
significant and can result in hemodynamic instability. Uterine atony is responsible for most
cases and can be managed with uterine massage in conjunction with oxytocin, prostaglandins,
and ergot alkaloids.

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 BIBLIOGRAPHY :-
 Jacob A. A Comprehensive Textbook of Midwifery And Gynaecological Nursing, 5th
ed. New Delhi; Jaypee Brothers (2019) page no.- 358-370.
 Dutta D.C. Text Book Of Obstetrics, 6 th ed. Calcutta; New Central Book Agency
(2009). page no.-411-422.
 Sira S and Magon S. Text Book of Midwifery and obstetrics, 3rd ed. New Delhi Lotus
Publishers (2015) page no.- 671-683.
 Linda S.D. PPH [Online]2013 feb 12 [cited on 2021 Oct 30]; [25 slideshare]available
from: URL: https://www.slideshare.net>mobile.
 Ramawat A postpartum haemorrhage [Online] 2018 august 03 [cited on 2021 Oct 30];
[43 screen] available from: URL: https://www.slidesharemobile.

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