Postpartum Haemorrhage
(PPH)
Dr. Godbless
Learning Objectives
• Define postpartum haemorrhage
• Describe the significance of postpartum
haemorrhage
• Describe the causes of postpartum
haemorrhage
• Describe clinical features of postpartum
haemorrhage
• Describe the management postpartum
haemorrhage
• Discuss the prevention of postpartum
haemorrhage
Postpartum Haemorrhage
• Blood loss of > 500 ml following vaginal
delivery or blood loss of > 1000 mL
following caesarean delivery.
• In anaemic patients it is any amount of
blood loss that produces cardiovascular
compromise.
Classification of Postpartum
Hemorrhage
• Primary postpartum haemorrhage (PPH) is
excess blood loss after delivery within the
first 24 hours.
• Secondary PPH is after 24 hours to six
weeks.
Significance of Postpartum
Haemorrhage (PPH)
• Globally PPH occurs in about 5% of all
deliveries.
• In Tanzania it accounts for >28% maternal
deaths are due to PPH. (See the current
data for maternal deaths due to PPH)
Causes of Postpartum Haemorrhage
• Remember the 4Ts
i. Tone
ii. Tear
iii. Tissue
iv. Thrombin
I. TONE
• Uterine Atony: Contributes ≈ 80% of PPH
(Tone)
Causes of uterine Atony
i. Over distension of uterus (twins, big
baby, polyhydromnious)
ii. Induction of labour
iii. Prolonged / precipitate labour
iv. Anaesthesia (halogeneted) and analgesia
v. Tocolytics
vi. Antepartum haemorrhage, esp. Abruptio
placenta
vii. Grand multiparity
viii.Mismanagement of third stage of labour
ix. Full bladder
II. TISSUE FACTORS
• Retained Placenta (Tissue Factors)
i. Morbid adhesion like accreta, increta and
percreta
ii. Retention of parts of the placenta
III. TEARS
• Tears of the Genital Tract (Tears)
i. Large episiotomy and extensions
ii. Tears and lacerations of perineum, vagina
or cervix
iii. Haematoma
iv. Uterine rupture
IV. THROMBIN FACTORS
• Coagulation Disorders (Thrombin Factors)
i. Abruptio placentae – consumptive
coagulopathy
ii. Sepsis: IUFD, PROM
iii. Massive blood loss - depleted platelets
and clotting factors
iv. Massive blood transfusion
v. Severe pre eclampsia – HELLP syndrome
vi. Amniotic fluid embolism
Secondary PPH
• The bleeding usually occurs between 8th to
14th day of delivery.
• The causes of late postpartum hemorrhage
are:
(1) Retained bits of cotyledon or membranes
(most common)
(2) Infection and separation of slough over a
deep cervicovaginal laceration
(3) Endometritis and subinvolution of the
placental site—due to delayed healing process
(4) Secondary hemorrhage from cesarean section wound
usually occur between 10–14 days. It is probably due to—
(a) separation of slough exposing a bleeding vessel or (b)
from granulation tissue
(5) Withdrawal bleeding following estrogen therapy for
suppression of lactation
(6) Other rare causes are:
• chorion-epithelioma—occurs usually beyond 4 weeks of
delivery; carcinoma cervix; placental polyp; infected
• fibroid or fibroid polyp and puerperal inversion of uterus.
Clinical Features
• Excessive blood loss after delivery
• Features of shock (thirst, weakness, cold
sweating, air hunger, pallor, oliguria/
anuria, confusion, reduced blood pressure,
coma).
The degree of shock will depend on the
amount of blood loss and haemoglobin
level before haemorrhage.
Management of Postpartum Haemorrhage
General Management Steps
1. Call for HELP
2. Perform Rapid assessment
Vital signs (BP, PR, pallor)
Assess the uterus whether is atonic or well
contracted
Inspect the genital tract to rule out tears/ lacerations
Explore the uterus for retained placental fragments,
uterine inversion
Empty the bladder (this can aid in uterine
contraction)
Assess coagulation
3. Resuscitation
Establish an IV line with a large bore
cannula and give fast fluid: Replace fluid
(RL or NS) two to three times the
estimated blood loss
Insert indwelling urethral catheter for urine
output monitoring
Collect blood specimen for blood grouping
and cross matching
Keep the woman warm
Management of Special Cases
Uterine atony
Massage the uterus
Start IV infusion (plus oxytocin 20units/litre
of NS or RL)
Give oxytocin 10 IM
Refer the patient immediately in case
bleeding persists
A nurse/midwife should accompany the
patient while massaging the uterus or
even bimanual compression.
If misoprostol is available, use 800mcg per
rectum.
If ergometrine is available, give 0.2mg IM.
Bimanual compression of the uterus
Retained Placenta
Give oxytocin 10 units IM and attempt
controlled cord traction (CCT)
Catheterize the bladder
If controlled cord traction is not successful,
attempt manual removal of the placenta.
• This is painful, and the patient may require
general anaesthesia in the hospital.
• Typically, unless we are doing curettage,
this is tried with IV narcotics alone first.
Manual removal of placenta
Retained but not bleeding:
It may be placenta accreta so refer
immediately to the hospital
Tears of the birth canal:
Repair accordingly.
Uterine inversion;
Perform manual correction of the inverted
uterus.
Ruptured uterus:
Resuscitate the patient, then, facilitate
urgent referral for laparotomy,
accompanied by blood donors.
Prevention of Postpartum
Haemorrhage
1. Regular antenatal care visits:
Correct anaemia. Anaemic patients are
vulnerable for PPH since they may not
tolerate even moderate blood loss.
Identification of high risk cases and plan
delivery in hospital with facility for
comprehensive Emergency Obstetric Care.
2. Active Management of the Third Stage of
Labour (AMTSL)
Gentle traction on the umbilical cord with
counter traction on the uterus
Fundal massage
IV or IM Oxytocin within 1 minute after
delivery of the infant
Key points
• PPH is one of the major causes of maternal
deaths in the world.
• It may cause maternal death within two to
three hours after onset.
• Management of PPH needs team work.
• PPH can be prevented by practising
AMTSL.
Evaluation
• What is the management approach to a
patient presenting with severe bleeding
immediately after delivery?
• What are the preventive measures for
postpartum haemorrhage?
References
• Baker, P. & Monga, A. (2006). Obstetrics by Ten Teachers (18th
Ed.). London: Hodder Arnold.
• DeCherney, A.H. & Nathan, L. (2002). Current Obstetrics and
Gynaecology (9th Ed.). McGraw Hill.
• Hanretty, K.P. (2003). Obstetrics Illustrated (6th Ed.). London:
Churchill Livingstone.
• MOHSW. (2005). Advanced Life Saving Skills. Dar es Salaam, vol 2.
• MOHSW. (2008). Emergency obstetric care. Job Aid
• Oats, J., Abraham, S. (2005) Llewellyn-Jones Fundamentals of
Obstetrics and Gynaecology. (8th Ed.). Edinburgh: Mosby.
• Parisaei, M., Shailendra, A., Dutta, R., Broadbent, J.A. (2008).
Crash Course: Obstetrics and Gynaecology. (2nd Ed.) Mosby.
• World Health Organization. (2005). Managing Complications in
Pregnancy and Childbirth: A Guide for Midwives and Doctors.
Geneva: WHO.
