Postpartum hemorrhage (PPH) is excessive bleeding from the genital tract following childbirth up to 42 days post-delivery. It is classified as primary (occurring within 24 hours of delivery) or secondary. Primary PPH is most often caused by uterine atony due to factors like multiparity, prolonged labor, or large placenta. Its management involves uterine massage, medication to induce contractions, fluid resuscitation, and potential surgical interventions if bleeding cannot be stopped. Preventing anemia prior to delivery and identifying risk factors for uterine atony can help reduce cases of primary PPH.

1. Postpartum Hemorrhage
Aleena Bukhari (41)

2. Definition
• Postpartum Hemorrhage or PPH is defined as the excessive bleeding
from the genital tract from the time of delivery till the completion of
the puerperium i.e. 42 days after delivery.

3. Types
• It is further classified into
Primary Postpartum Hemorrhage
Secondary Postpartum Hemorrhage

4. Primary Postpartum Hemorrhage
• Excessive bleeding from the genital tract occurring during the third
stage of labor within 24 hours of delivery.
• WHO defined as blood loss exceeding 500ml
after normal delivery and 1000ml after c-section.
• Suggested definitions of primary PPH include a hemorrhage resulting
in a hematocrit drop of 10% or a hemorrhage that requires immediate
blood transfusion.

5. Causes
• These result from
• Uterine atony (90%)
Multiparity
Increase in fibrous tissue due to recurrent trauma resulting in reduction
of myometrial contractile tissue as well as increase in uterine
vascularity.
Prolonged labor
Associated with incoordinate uterine activity requiring large doses of
oxytocin which later responds poorly to bolus

6. Incoordinate uterine activity
Due to uterine over distention (twins, polyhydramnios, large baby),
chorioamnionitis, uterine fibroids and uterine inversion.
Drugs
Halothane in anesthesia, tocolytics like beta sympathomimetics,
mgSO4 and nifedipine
Retained placental tissue
Placental abruption (infiltration of blood into myometrium)
Placenta previa (low muscle content)
Large placental site (multiple pregnancies, macrosomia, hydrops
fetalis)
Placenta accreta

7. • Genital Tract Trauma
Vulval/perineal tears
Episiotomy
Vaginal/cervical tear
Uterine rupture
• Coagulation disorder
Disseminated intravascular coagulation (may be associated with
hypertension, retained dead fetus, chorioamnionitis, placental abruption and
amniotic fluid embolism)
ITP
Leukemia
VonWillerbrand's disease

8. Management
• History
Biodata, blood group, previous pregnancies, iron folic acid use, history
of PIH and GDM, previous c-sections, infections, PV bleeds, family
history of coagulopathies etc
• Examination
PS- rule out infections/tears, examine cervical lips for tears
PV-check cervical dilatation in case of prolonged labor, retained
placental tissue etc

9. Investigations
• Hemoglobin monitoring
• Blood sugar monitoring
• Blood pressure monitoring
• Clotting factors
• Ultrasound/anomaly scan for structural and functional abnormalities

10. Approach
• After the diagnosis of PPH has been made a senior should be called
for help and proper documentation of timings for events should be
initiated along with the following step wise approach should be taken
Uterine compression/rub up contractions
Empty uterus and vagina of clots and tissue
Empty bladder
Uterotonic agents like Oxytocin and misoprostol

11. Bimanual uterine compression
Intravenous access x2 large bore
cannulae
Full blood count/group/cross match
and coagulation profile e.g PT aPTT
Fluid replacement

12. • Step wise approach to uterotonic agents:
5-10 units IV/IM Oxytocin
40 units oxytocin in 1000ml normal saline/ringer's over 4 hrs
800-1000μg rectal misoprostol
Syntometrine (ergometrine 500μg and Syntocinon 5units) contraindicated in PIH
Repeat ergometrine 500μg IM slow or IV push
Carbaprost 0.25 mg by IM repeated at >15min intervals and maximum of 8 doses
(contraindicated in asthmatics)

13. Ongoing bleeding
• Consider DIC and replacement of clotting agents
• Call senior for help
• Transfer to operating room
• Surgical intervention:
Uterine balloon insertion
Iliac ligation
Uterine artery embolization
Hysterectomy

14. Prevention
• Hemoglobin levels below normal range of pregnancy should be
investigated.
• Iron supplementation is indicated to optimize hemoglobin prior to
delivery.
• Prophylactic use of oxytocin in high risk patients.
• Risk factors for uterine atony should be timely identified
e.g macrosomia, multiple pregnancies, prolonged labor, oxytocin use,
polyhydramnios etc

15. Thank You