POSTPARTUM
HEMORRHAGE (PPH)
Causes, Management & Prevention
CLINICAL GROUP 03 – 42ND BATCH
DEFINITION OF PPH
• Primary PPH:
Blood loss >500 mL (vaginal) or >1000 mL
(C-
section) within 24 hours
• Secondary PPH:
Excessive bleeding 24 hours to 6 weeks
postpartum
MODIFIED CLINICAL CLASSIFICATION OF
PPH
Haemorrhage EBL (ml) SBP Blood Signs & Symptoms
Class (mmHg) Volume Loss
(%)
0 < 500 - < 10 None
1 500- 1000 Normal 10 – 15 Minimal
2 1000 – 1500 90 - 100 15 – 25 Tachycardia, Narrow pulse
pressure, Tachypnoea, Oliguria
3 1500 – 2000 75 – 90 25 – 35 Restless, Pallor, Cold &
Clammy
4 > 2000 < 75 > 35 Collapsed, Air Hunger, Anuria,
Profound shock
CLINICAL IMPORTANCE
• Leading cause of maternal mortality worldwide
• Rapid onset: requires prompt recognition and
action
• Can lead to shock, coagulopathy, organ failure,
death
RISK FACTORS
Antenatal Intrapartum
• Abruptio placentae/ Placenta Previa • Prolonged Labour
• Pregnancy Induced Hypertension • Induction / Augmentation of labour
• Previous C. Section • Instrumental deliveries
• Placenta accreta / increta / percreta • Retained placenta / Placental
• Multiple pregnancies / Hydramnios / fragments
Macrosomia • Chorioamnionitis / pyrexia in labour
• Grand Multiparity / Obesity • C. Section
• Fibroids
• Chorioamnionitis
• Hemorrhagic disease / Anticoagulant
therapy
• Previous PPH or retained placenta
CAUSES OF PPH
• Main Causes – “The 4 Ts”
1. Tone – Uterine atony (most common cause)
2. Tissue – Retained placenta or clots
3. Trauma – Lacerations, uterine rupture, inversion
4. Thrombin – Coagulopathy (e.g., DIC)
CAUSES OF PPH
• Other Causes –
Eclampsia
Death in Utero
Abruptio placentae
Sepsis
Amniotic fluid embolism
Pulmonary embolism
Other coagulopathy / hemorrhagic state
Viral hepatitis
HELLP Syndrome
MANAGEMENT OF PPH
Identification of the Severity of Haemorrhage
• Visual estimation of blood loss is inaccurate; clinical signs and
symptoms should be included in PPH assessment.
• Blood collection drapes and weighing of swabs can improve
accuracy, but not significantly reduce severe PPH risk.
• Clinical reconstructions, written, and pictorial guidelines may
help in early diagnosis and management.
• Physiological adaptations in pregnancy may delay signs of
hypovolaemic shock:
• 1000 ml loss: Mild tachycardia, tachypnoea, slight BP
drop.
• 1000 –1500 ml loss: More pronounced tachycardia,
tachypnoea.
• 1500 ml loss: SBP <80 mmHg, worsening tachycardia,
altered mental state.
< 0.9 - Provide reassurance
> 1.7 - Indicates need of urgent intervention
Shock Index = HR
SBP
Identifies women at risk of adverse outcomes.
Communication with Mother.
Maintain a calm atmosphere and reassure the Mother
regularly where feasible.
Initial Management of Major PPH
• Call for help
• Resuscitation
• Airway & Breathing :
- Ensure open airway, administer high-flow oxygen (15 L/min).
• Circulation :
- Position patient flat and keep warm to prevent
hypothermia.
- Establish two large-bore (14G) IV cannulas.
• Take blood samples for FBC, coagulation profile, fibrinogen, cross-
match (4 units minimum).
Management of Minor PPH without Clinical
Shock
• IV access: One 14G cannula.
• Urgent blood tests for blood grouping and , Full Blood Count
(FBC) , Coagulation screen (including fibrinogen).
• Monitor vitals: Pulse, respiratory rate, and BP every 15 minutes.
• Start warmed crystalloid infusion.
• Fluid Resuscitation:
– Up to 2L isotonic crystalloid (Hartmann’s or saline) rapidly.
– Up to 1.5L colloid if needed while awaiting blood.
• Blood Transfusion: Start O-negative or type-specific blood if
unstable
• Monitor urine output with a Foley catheter.
Assess and Control Bleeding (“4T’s Approach”):
1. Tone (Uterine Atony) – Most Common Cause
• Uterine massage.
• Empty bladder (catheterize if needed).
• Administer uterotonics:
– Oxytocin 5–10 IU IV or oxytocin infusion 40 IU in 500mL
saline over 4 hours.
– Ergometrine 0.5mg IM/IV (if no hypertension).
– Misoprostol 800–1000 mcg rectally/sublingually.
• Tranexamic Acid 1g IV within 3 hours, repeat if
bleeding continues after 30 minutes
2. Tissue (Retained Placenta/Clots)
• Inspect placenta for completeness.
• Perform manual removal under anesthesia if necessary.
• Consider ultrasound for retained products.
3. Trauma (Genital Tract Lacerations, Uterine Rupture,
Inversion)
• Inspect and repair perineal, vaginal, cervical tears.
• Reposition uterus if inverted.
• Consider laparotomy for uterine rupture
4. Thrombin (Coagulopathy – DIC, HELLP, Sepsis,
Abruption)
• Monitor PT, APTT, fibrinogen, platelets.
• Replace clotting factors:
• Fresh frozen plasma (FFP) 12–15 mL/kg if PT/APTT
>1.5× normal.
• Platelets if <75×10⁹/L.
• Cryoprecipitate if fibrinogen <2 g/L
Mechanical Compression
• 300–500 ml saline into balloon, left for 12–24 hours .
• Bimanual Uterine Compression – While waiting for
definitive measures.
Surgical Management
• Suturing genital tract tears
• Balloon tamponade (Bakri Balloon)
• Compressive uterine stitches
• Bilateral uterine & ovarian artery ligation
• Internal iliac artery ligation
• Uterine artery embolization
• Total Abdominal Hysterectomy (TAH) if
unresponsive
Surgical Interventions
• Uterine Compression Sutures
B Lynch Sutures
• Ligation of Uterine Arteries.
• Internal Iliac Artery Ligation (requires experienced
surgeon).
• Uterine Artery Embolization – If interventional radiology
is available.
• Definitive Surgery (Last Resort)
• Subtotal or Total Hysterectomy – If all other measures
fail, especially in placenta accreta or uterine rupture.
Post-PPH Care
• Monitor in HDU/ICU for continued bleeding or
complications.
• Thromboprophylaxis (LMWH, TED stockings)
when stable.
• Psychological support – Debrief patient and
family.
Management of Secondary Postpartum
Haemorrhage
Clinical Assessment
– Evaluate hemodynamic stability (heart rate,
blood pressure, signs of shock).
– Assess the extent of bleeding (amount,
duration, and pattern).
– Consider the patient’s concerns, including the
inconvenience and impact of prolonged
bleeding.
Investigations
Microbiological Testing:
– Perform high vaginal and endocervical swabs to check
for infection, especially endometritis.
– Although the yield from vaginal swabs is often low, a
significant proportion of women may have abnormal
microbiology results.
Pelvic Ultrasound:
– Helps identify retained products of conception (RPOC).
– Sensitivity and specificity vary widely (44–94% and
16–92%, respectively).
Treatment
• Antibiotic Therapy (if endometritis is suspected):
• First-line treatment: Intravenous clindamycin +
gentamicin.
• Surgical Evacuation for RPOC
PREVENTION OF PPH
Adopt corrective measures for antenatal risk
factors
In labour ward -
– Check Blood Group & Rh
– Check Hb level
– IV cannula (DT SOS)
– Consider intrapartum risk factors
PREVENTION OF PPH
Active Management of Third Stage of Labour -
– Oxytocin 5 -10 IU IV, after delivery of baby
– Delay clamping of cord and cutting > 2 min
– Controlled cord traction (CCT) with uterine
contraction
– no waiting for signs of placental separation
– Uterine massage
– Examine placenta and confirm complete removal
If placenta not expelled within 30 min. ( Retained
Placenta)
• Intra umbilical vein oxytocin: 50 IU in 30ml N. Saline
• Repeat CCT intermittently
• If successful : inspect placenta & confirm it is complete
• If still retained :
– Manual Removal of Placenta under IV Pethidine 75mg &
Atropine 0.5 mg IM
– IV Ampicillin 1g , Gentamycin 160mg & Metronidazole 500mg
• After removal of placenta :
– Ergometrine 0.5mg IV + Oxytocin 20 IU in 500ml N. Saline IV
infusion
Summary
• PPH is a major obstetric emergency.
• Timely recognition and multidisciplinary
approach are key.
• Prevention with AMTSL and risk assessment is
critical.
Thank You
UNDER DIRECT SUPERVISION OF
Dr.J.A.P. DHAMMIKA
MBBS(Ruhuna),MS Obs/Gyn(Colombo),MRCOG(Gt.Brit.),FSLCOG
