POSTPARTUM

HAEMORRHAGE
Introduction

Post-partum haemorrhage (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.
What is Postpartum Haemorrhage ?
Postpartum haemo-
rrhage refers to any
amount of bleeding
from or into the
genital tract following
birth of the baby upto
the end of
puerperium.
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.
Types
 Primary postpartum hemorrhage is the
hemorrhage occurring during the third stage of
labor and within 24 hours of delivery.

 Secondary postopartum hemorrhage is

hemorrhage occurring after 24hours of
delivery and within 6weeks of delivery. It is
also referred to as puerperal hemorrhage.
Causes
Primary postpartum hemorrhage are:
 Atonic uterus
 Trauma
 Mixed ( combination of both atonic and trauma)
 Retained product of conception
 Uterine rupture
 Uterine inversion
 Blood coagulopathy
2.Secondary postpartum haemorrhage include:
 Retained bits of cotyledon or membranes.
 Infection
 Cervico-vaginal laceration
 Endometritis
 Subinvolution of the placental site
 Secondary hemorrhage from caesarean section
 Other rare causes – chorion epithelioma, carcinoma

cervix, placental polyp, fibroid polyp and puerperal

inversion of uterus.
Risk factors
 Prolonged third stage of labor
 Multiple delivery
 Episiotomy
 Fetal macrosomia
 History of postpartum hemorrhage.
 Grandmultiparity
 Placenta previa
 Placental abruption
 Pregnancy induced hypertension
 Infection
Symptoms
 massive blood loss
 passing large clots
 dizziness
 lightheadedness or fatigue.
 Decreased blood pressure.
 Increased heart rate
 Swelling and pain in tissues in the vaginal and

perineal area
“Four Ts” mnemonic of PPH”
 Tone – Atonic uterus 70%
 Trauma – laceration, hematoma,

inversion, rupture 20%

 Tissue – Retained tissue, invasive

placenta 10%
 Thrombin – Coagulopathies 1%
Prevention of PPH
Antenatal
 Improvement of the health status.
 High risk patients.
 Blood grouping
 Intranatal
 Slow delivery of the baby.
 Expert obstetric anesthetist needed.
 Spontaneous separation and delivery of

placenta during caesarean section.

 Active management of third stage of labor.
 Examination of placenta.
 Induced or accelerated labor by oxytocin.
 Exploration of utero-vaginal canal.
 To observe the patient for about two hours

after delivery.
Active Treatment of Postpartum Haemorrhage

 Rub up the uterus to stimulate contraction and

retraction.
 Administer ergometrine(0.2mg) intramuscularly .

Syntometrine (1ml) intramuscularly may be given

instead of ergometrine.
 Expel the placenta with the next uterine contraction by

fundal pressure or controlled cord traction.

 Empty the urinary bladder by catheterization.
 A second dose of syntometrine or ergometrine may be

given in ten minutes if bleeding is not controlled.

Management of true PPH
Tone
 Uterine massage - If the uterus is soft,

massage is performed by placing one hand in

the vagina and pushing against the body of the
uterus while the other hand compresses the
fundus from above through the abdominal
wall. The posterior aspect of the uterus is
massaged with the abdominal hand and the
anterior aspect with the vaginal hand.
Uterotonic agents - Uterotonic agents include
oxytocin, ergot alkaloids, and prostaglandins.
 Oxytocin - 10 international units (IU) should be

injected intramuscularly, or 20 IU in 1 L of saline

may be infused at a rate of 250 mL per hour. As much
as 500 mL can be infused over 10 minutes without
complications.
 Methylergonovine (Methergine) and ergometrine,

a typical dose of methylergo-novine, 0.2 mg

administered intramuscularly, may be repeated as
required at intervals of two to four hours.
Prostaglandins –
 Carboprost can be administered intra-

myometrially or intramuscularly in a dose of

0.25 mg; this dose can be repeated every 15
minutes for a total dose of 2 mg.
 Misoprostol is another prostaglandin; It can

be administered sublingually, orally, vaginally,

and rectally. Doses range from 200 to 1,000
mcg; the dose recommended by FIGO is 1,000
mcg administered rectally.
Trauma
 Lacerations and hematomas resulting from

birth trauma can cause significant blood loss

that can be lessened by hemostasis and timely
repair.
 Uterine Rupture - Symptomatic uterine

rupture requires surgical repair of the defect or

hysterectomy.
 Uterine inversion is rare.
Tissue
Classic signs of placental
separation include a small
gush of blood with
lengthening of the umbilical
cord and a slight rise of the
uterus in the pelvis.
Placental delivery can be
achieved by use of the
Brandt-Andrews maneuver,
which involves applying
firm traction on the
umbilical cord with one
hand while the other applies
suprapubic counter-pressure.
Thrombin
Coagulation disorders, a rare cause of
post-partum hemorrhage, are unlikely to
respond to the measures described above.
Most coagulopathies are identified before
delivery, allowing for advance planning
preventing postpartum hemorrhage.
Surgical management of PPH

 Transvaginal uterine packing

 Conservative surgical approach - Uterine

Artery Ligation, Ovarian Artery Ligation,

Vaginal Artery Ligation, Internal Iliac
Ligation, Angiographic Arterial Embolization,
Hysterectomy.
Complication

 Blood loss
 Shock
 Death
 Septicemia
 Orthostatic hypotension
 Anemia
 Fatigue
Conclusion

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.