POSTPARTUM

HAEMORRHAGE (PPH)

Dr.Shameem R. ALaasam
 PPH: Excessive bleeding from genital tract after delivery of the
baby.

Definition Loss of more than 500 ml from the genital tract post delivery of a
baby (WHO)
Excessive PVB that cause haematocrit drop more than 10% that
require immediate transfusion (ACOG)
PRIMARY PPH
– Loss of 500 ml or more of blood from the genital tract within 24
hours of the birth of a baby
 Minor : 500-1000 ml with no clinical shock
 Major : > 1000 ml

 SECONDARY PPH
– Abnormal or excessive bleeding from the birth canal between 24
hours and 12 weeks postnatally
Primary PPH is a major & important cause of maternal
mortality & morbidity in both developed & developing countries. it
account for 28% of pregnancy related deaths worldwide.
There are differing capacities of individual patients to cope with
blood loss. A healthy woman has a 30-50% increase in blood
volume in a normal singleton pregnancy and is much more
tolerant of blood loss than a woman who has *preexisting anemia,
*an underlying cardiac condition, *or a volume-contracted
condition secondary to dehydration or preeclampsia.
For these reasons, various authors have suggested that PPH
should be diagnosed with any amount of blood loss that threatens
the hemodynamic stability of the woman.
  At term, 600ml/min of blood flows through intervillous space
 Most important factor for control of bleeding from placenta site =
Hemostasis at contraction and retraction of myometrium to compress the
vessels severed with placental separation
placental site  Incomplete separation will prevent appropriate contraction
Primary PPH 1. A traumatic (from placental site )
classification: 2. Traumatic type
 4T
– Tone (abnormality of uterine contraction – UTERINE ATONY)

Causes of PPH – Tissue (retained products of conception)

– Trauma (of genital tract)

– Thrombin (abnormality of coagulation)

  Operative delivery
 Prolonged or rapid labour
 Induction or agumentation
Predisposing  Choriomnionitis
factors-  Shoulder dystocia
Intrapartum  Internal podalic version
 coagulopathy
  Previous PPH or manual removal
 Abruption/previa
Predisposing  Fetal demise

Factors-  Gestational hypertension

 Over distended uterus
Antepartum
 Bleeding disorder
  Lacerations or episiotomy
 Retained placental/ placental abnormalities
Postpartum  Uterine rupture / inversion
causes  Coagulopathy
  Contributes for 80 % of PPH
 Commonest cause of PPH
 Cause – Faulty retraction of the uterus
Tone Etiology:
(UTERINE  1] Grand Multipara

ATONY )  2] Over- distension of uterus – Multiple pregnancy, Hydramnios,

big baby
 3] Anemia
 4] Prolonged Labor
 5] Anaesthesia – Halothane. Ether,
 Cyclopropane
 6] Uterine fibroid
 7] Precipitate labor
 8] Malformations of uterus – septate uterus, bicornuate uterus
 9] Ante partum hemorrhage
 10] Initiation & augmentation of delivery with oxytocin
TISSUE Retained placenta
  5-10% of cases

 1] Cervical lacerations
TRAUMA  2] Vaginal laceration
( Traumatic  3] Perineum injury
PPH)  4] Paraurethral injury
 5] Uterine rupture
  Blood coagulation Disorders:
THROMBIN  Abruptio Placenta, Jaundice, Thrombocytopenic purpura, HELLP
syndrome
  Visual blood loss estimation often underestimates

Remember! More accurate method

– Blood collection drapes
– Weighing swabs
 Identify the risk factors that may present antenatally or
intrapartum will help us to plan the delivery
Correction of anemia during pregnancy because anemic patient will
not tolerate blood loss & shock will develop rapidly
PREVENTION Anticipation , that there are certain risk factors which are associated
with PPH. Those with previous history of PPH have 2 – 4 times
more risk for PPH than those with no previous history
However, most cases of PPH have no identifiable risk factors
Active management of 3rd stage of labour lowers maternal blood
loss and reduce risk of PPH
 Active management of 3rd stage
– Use of uterotonic
– Uterine massage
– Control cord traction for delivery of placenta
Prophylactic oxytocics should be given routinely to all women
As it reduce the risk of PPH by ≈60%
Syntometrine (oxytocin + ergometrine) may be used in absence of
hypertension
 For cases with no risk factors and delivering vaginally, give IM
Oxytocin 5 iu or 10 iu
 For cases of Caesarean section, IV Oxytocin 5 iu by slow infusion

Syntometrine and Oxytocin have similar efficacy in prevention of

PPH
However major difference in the side effect.
Syntometrine : 5-fold increase of nausea, vomiting, elevation of BP
 Patient with placenta accreta that diagnosed antenatally should
be managed by consultant (O&G, Anaest) at tertiary centre

 Reduce the blood loss by leaving the placenta in the uterus after
delivery of the baby by fundal classical uterine incision . Followed
by hysterectomy / treatment with methotrexate.
 Role of prophylactic interventional radiology in case of antenatally
diagnosed placenta accreata
 – Balloon occlusion
 – Embolization of pelvic arteries

 Studies done show the procedure have value in control of primary

PPH and secondary PPH
MANAGEMENT
 It is a team work that correction of blood loss & arrest of bleeding
should be don at the same time.

1. Contact all the staff required (obstetrician,

anesthetist, hematologist & blood transfusion

services.
2. Ensure that at least 2 peripheral infusion lines are established using
a wide bore canola (gauge 14 ).
3. 20 ml of blood sample should be taken for blood grouping cross
matching &coagulation studies. 6 units of blood (preferably fresh
whole blood ) should be cross matched & prepared.
4. PR , BP , HR (by ECG) , CVP , UOP , amount & type of fluid
given & any drugs given should be observed & recorded.
5. Restoration of blood loss by iv fluids (Hartman’s or hemacel) till
cross matched blood is available & if group Oˉ blood is given till
preparation of the appropriate blood group.
6. Arrest the bleeding which mean that we have to identify the cause
of bleeding and then stop the bleeding
So when we receive a patient with primary PPH we should replace
the blood loss & arrest the bleeding after we have had identify the
cause of bleeding
the bleeding could be atraumatic (from placental site ) or traumatic
(injury at any site of the genital tract)
So while we are replacing blood loss we can palpate the uterus
for contraction and give utero-tonic drugs accordingly while
transferring the patient to the operation theater for examination
under anesthesia . So if placenta is delivered & the uterus is well
contracted & there is still bleeding we should suspect traumatic
lesion to the genital tract .
 first we have to palpate the uterus to see whether it is soft or
contracted
Arrest of If it is soft & lax , the contraction is stimulated by

atraumatc rubbing the uterus gently with the abdominal hand , placing the
thumb in the front & the fingers behind the fundus. Meanwhile an

bleeding oxytocic drug is given intravenously , usually ergometrin 0.5 mg

with infusion of 10 units oxytocin in iv infusion drip.
If the placenta If the uterus become firmly contracted we should exclude any
retained piece of placenta & if there is so it should be removed
had already manually under GA .
delivered If there is still bleeding in spite that the uterus is firmly
contracted & there is no retained placental tissue then we should
look for traumatic lesion of the genital tract.
If uterine atony persist in spite of oxytocic drugs then do bimanual
compression of the uterus :
the right hand is formed as a fist & inserted into the vagina at the
anterior fornix above the cervix while the left hand is placed on the
abdomen & pressed downward onto the posterior wall of the uterus
so that it is compressed between the 2 hands till it become firm &
contracted
In all cases of atraumatic PPH , if inspite of uterine massage,
oxytocic drugs & bimanual compression the bleeding is continuous
then we should shift to other procedures:
1.intra uterine baloon
2. uterine packing
3. surgical choice by laparatomy then:

*hysterectomy if the patient had completed her family.

* if the family is not completed then we can preserve the uterus &
decrease bleeding by internal iliac artery ligation or insertion of B
Lynch suture .
 1. First step is to see whether the uterus is contracted or not , if
not , then do fundal massage as mentioned to stimulate uterine
contraction
2. Second step is to determine whether the placenta is separated or
not.

If the placenta If the placenta had been separated

is not delivered If the placenta is separated , it is expelled from the upper to the
lower uterine segment & the signes of separation are:
1. The uterus will be felt as a firm , rounded mass at the level of the
umbilicus & it can be moved from one side to other.
2. The umbilical cord will have be elongated as the placenta is
separated
3. The lower part of the placenta can be felt per vagina through the
cervical oss
So if those signs of placental separation are present , the placenta
should be delivered by Brandt-Andreus method:
the left hand is placed over the anterior surface of the uterus just
above the symphasis pubis & an artery forceps is placed on the
umbilical cord which is held tight but without traction with the right
hand.
the uterus is pushed gently upward with the left hand & if this can
be don easily then this mean that the placenta is separated &
descended into the lower
segment or the vagina , then lifting is discontinued & pressure is
made with the same left hand in a downward direction while the
cord is held tight until the placenta is seen at the introits.
After the delivery of the placenta , if bleeding doesn’t stop give
oxytocic drugs.
 this mean that the placenta is still attached to the upper uterine
segment & there are no signs that indicate its separation. The
uterus is large & soft well below the umbilicus & is relatively
immobile.

If the placenta on vaginal examination the cord is felt passing up into the uterus
but the placenta cannot be reached.
is not separated In this situation the placenta should be removed manually under
GA after stabilization of the patient general condition & correction
of shock & we should avoid giving oxytocic drugs till after removal
of the placenta.
Under GA a catheter is passed to empty the bladder then the left
hand is placed on the abdominal wall to locate & steady the fundus
of uterus , the right hand is passed into the uterus following the
cord to reach to the placenta.
The edge of the placenta is identified & gradually separated from
the uterine wall, while the left hand serves as a guide & to reduce
the risk of tearing the uterus.
After removal of the placenta the uterine wall is explored
carefully to ensure that no placental piece is left then the placenta is
examined to be sure that it is compelete.
If bleeding doesn't stop then give oxytocic drugs with bimanual compression
 in cases of abnormally adherent placenta the safest method of
management is hysterectomy but if the family is not completed then
other choices include simple excision of the site of trophoblastic
invasion with oversewing of the area or uterine or internal iliac
artery ligation or non surgical management by methotrexate locally
& systemically.