POSTPARTUM HEMORRHAGE

Dr : Einas
Mustafa
Assistant professor
 OBJECTIVES
At the end of this lecture, participants will be able to:
1. List the important causes of postpartum hemorrhage.

2. Describe methods for preventing postpartum

hemorrhage.

3. Describe the initial approach to treating postpartum

hemorrhage.

Dr : Einas
Mustafa
Assistant professor
 Definition
Excessive bleeding from the genital tract after the birth of
the child (both Vaginal Delivery or Caesarean section).

Conventionally defined as a loss of more than 500ml of

blood after Vaginal delivery
or more than 1000ml after Caesarean section
or more than2000 ml after Caesarean hysterectomy

Dr : Einas
Mustafa
Assistant professor
• Clinically, postpartum hemorrhage defined as
blood loss sufficient to cause hemodynamic
instability.
• 2/3 of women with PPH have no identifiable
risk factors
• 90% of cases of PPH are due to uterine atony
 TYPES:
May be immediate ( primary)
or late (secondary)

Dr : Einas
Mustafa
Assistant professor
PRIMARY :
Occurs within 24 hours following the birth of the baby.
Bleeding occurs before expulsion of placenta or
subsequent to expulsion of placenta.
Secondary Postpartum Hemorrhage:

• This occurs more than 24 hours after delivery of the

child
• It is usually caused by the retention of a piece of the
placenta or membranes, and frequently complicated
by intrauterine infections with pyrexia
• Ultrasound examination will show whether there is
retained placental tissue.
 Risk Factors:
.
Pre-eclampsia
.Prolonged Third Stage of labour
.Mulltiparity
.Episiotomy
.Over distention of the uterus:Multiple gestation and
poly hydramnious
.Arrest of descent of the fetus
.Precipitate labour
. Mismanaged 3rd stage of labor

Dr : Einas
Mustafa
Assistant professor
 .Previous cesarean delivery
.Assisted delivery (forceps/vacuum)
.Augmented labour
. antepartum hemorrhage – placenta praevia and
abruptio placentae
.Abnormally adherent placenta ( placenta accreta –
and increta )
.Malnutrition and anemia
. Anaethesia usage
.Uterus malformation
. Uterine fibroid
Dr : Einas
Mustafa
Assistant professor
 Major causes and Specific Approach:
specific causes of postpartum hemorrhage
may be remembered by the mnemonic, “THE 4 T’S”
Tone Atonic uterus 70 percent
Trauma Cervical, vaginal & perineal uterine inversion;
ruptured uterus 20 percent
Tissue Retained tissue 10 percent
Thrombin coagulopathies 1 percent

Dr : Einas
Mustafa
Assistant professor
PREVENTION
● 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 risk PPH
delivered by senior consultant
● 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 5IU slow IV
● Exploration of uterovaginal canal for evidence of trauma.
● 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
 Principles that govern the treatment of PPH:
1.Resuscitation

2. Communication

3. Monitoring

4.Arrest of bleeding

5.Restoring Blood volume

Dr : Einas
Mustafa
Assistant professor
• Steps:

• Call for help (obs-anaeth-nurse-midwife-H.O)

• Put the patient on left lateral position
• Check airway for breathing ,patency &give oxygen
by mask 10–15 L/min.
• .Put 2 I.V wide pore canulae
• Start 20 units of oxytocin in 1L of normal saline IV at
the rate of 60 drops per minute
• Take blood sample for CBC,RFT,LFT and coagulation
profile
• Cros match
• Prepair blood
• Fixed urinary catheter
• 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)
TONE:
atonic uterus or Uterine Atony 80-90% of causes
After separation of placenta, bleeding will continue at
placental site as the uterine sinuses that have been torn
cannot be compressed effectively.

Uterine Massaging
Uterotonic agents
Presented with:
.Excessive bright red bleeding
.Boggy uterus
. High fundus with non-contracting uterus
.Abnormal clot
.pelvic discomfort or backache
 Oxytocic agent
Oxytocin Pitocin 10 IU IM
10 to 40 IU in IV 1L of fluid

Methyl Methergine 0.2 mg IM

Contraindicated in pre-eclampsia or PIH

15-methyl prostaglandine F2α

0.25 mg, Intramyometrial
up to 2.0 mg
Dr : Einas
Mustafa
Assistant professor
IF medical treatment failed:

Laprotomy
B lynch
Internal iliac artry embolization
hysterectomy
Uterotonic Drugs

Oxytocin Ergometrine
• Advantages • Advantages
. Acts within 2 1/2 minutes • Low price
when given IM • Effect lasts 2-4 hours
. Safe in hypertension • Disadvantages
• Disadvantages • Takes 6-7 minutes to become
effective when given IM; oral form
. More expensive than insufficiently effective
ergometrine • Causes tonic uterine contraction
. IM or IV preparations only • Increased risk of hypertension,
. Not heat stable vomiting, headache
• Contraindicated in women with
hypertension or heart disease
• Not heat stable
Trauma:
Cervical, vaginal , perineal, Vulvar, Paraurethral
region, uterine inversion and pupture uterus

exploration and Surgical repair

• Uterine invertion:
Uterine replacement
• ruptured uterus:
Laprotomy
Surgical repair
Internal iliac artry embolization
hysterectomy
Tissue :
• the placenta may be partly separated and bleeding may
begin
• Abnormally adherent placenta ( placenta accreta and
placenta increta )

Retained tissue: evacuation

Retained placenta: manual removal of placenta

under general anathaesia

•Thrombin coagulopathies:
causes
Disseminated intravascular coagulation (DIC) ,concealed abruptio
placentae, amniotic embolism, after IUFD, Jaundice in
pregnancy ,Thrombocytopenic purpura, HELLP syndrome ,Any congenital
coagulation disorders
rapid depletion of coagulation factors and platelets resulting in
catastrophic bleeding

•
Selective blood product replacement
 PROGNOSIS
It is Life threatning emergency, Major cause of mother
death in developed and developing countries Increase
morbidity due to shock, transfusion reaction,
pueperal sepsis, failing lactation, pulmonary embolism
Late sequaele :
Postpartum infection
Anemia
Transfusion hepatitis,
Sheehan’s syndrome
Asherman’s syndrome

Dr : Einas
Mustafa
Assistant professor
 The best management of PPH is prevention

Dr : Einas
Mustafa
Assistant professor
 THANK YOU

Dr : Einas
Mustafa
Assistant professor