PPH, Definition, types and management

1. POSTPARTUM
HAEMORRHAGE (PPH)

2. PPH
• Definition- Haemorrhage occurring after the delivery of the baby is termed as
PPH.
• In quantitative terms- Blood loss >500ml in vaginal deliveries or 1000ml in
caesarean deliveries or 10% fall in hematocrit compared to pre labour values.

3. CLASSIFICATION OF PPH
Primary PPH Secondary PPH
Definition -Blood loss of >500 ml occurring
within 24hrs of delivery
Any sudden loss of blood from the genital tract
after the first 24hrs postpartum and within
6weeks of delivery
Etiology- 4T’s
Tone (uterine atony)/
Trauma(genital tract) /
Tissue(Retained placental fragments)/
Thrombus( Coagulation disorders)
Retained placental bits or membranes which may
be infected
Rarely, it may be due to submucous fibromyoma/
choriocarcinoma

4. PRIMARY PPH
• Classification based on volume of blood loss
Type Volume of blood loss (ml)
Minor 500-1000
Major 1000-2000
Major- moderate 1000-2000
Major- severe >2000

5. PRIMARY PPH
Atonic PPH Traumatic PPH
Any factor which prevents proper contraction
and retraction of the uterus
Traumatic cause leads to persistent bleeding
despite adequate uterine retraction
Causes
Maternal- multiparity/ prev h/o PPH/ maternal
anemia/ fibroids complicating pregnancy /
APH/ Polyhydraminos / Macrosomia
Labour- prolonged labour/ precipitate labour/
Induced labour
Drugs – Magnesium sulfate/ Nifidepine/
Anaesthetic drugs
Instrumental deliveries
Perineal lacerations
Cervical lacerations

6. ATONIC PPH
• During the normal process of third stage of labour , the separation, descent and
expulsion of the placenta are not associated with or followed by severe bleeding.
• Due to the contraction and retraction of uterus which results in shortening of
fibre and kinking of feeder vessels – Living ligatures.
• Atonic PPH is a placental site haemorrhage ,which sets in due to failure of the
above mechanism and failure of process to control bleeding due to 1)uterine
inertia or exhaustion 11) retained placental bits

7. ATONIC PPH
• AMTSL- reduces 60% chances of PPH
• Components of AMTSL-
• Inj Oxytocin 10units (I.m ) after the delivery of baby
• Cord clamping after cessation of cord populations,followed by removal of
placenta by traction and counter traction during uterine contractions
• Uterine massage

8. CLINICAL FEATURES
• Based on patient’s general condition and amount of blood loss
• Signs of haemorrhage- tachycardia, hypotension, restlessness, sweating, fainting
attacks, air hunger, syncope with shallow respiration
Blood volume (ml) BP(Systolic) Signs and symptoms Degree of shock
500-1000(10-15%) Normal Palpitation, tachycardia,
dizziness
Compensated
1000-1500(15-25%) Slight fall 80-100 Weakness,
tachycardia,sweating
Mild
1500-2000(25-35%) Moderate fall 70-80 Restlessness,
pallor,oliguria
Moderate
2000-3000(35-50%) Marked fall 50-70 Collapse, air
hunger,anuria
Severe

9. DIAGNOSIS
Atonic PPH Traumatic PPH
Uterus- flabby,large Contracted and appropriate for
postpartum uterus
Blood- dark in colour Fresh, bright red
No lacerations/injuries On speculum examination-
lacerations/injuries to the genital tract

10. MANAGEMENT
• Every attempt must be made to prevent or anticipate PPH.
Prophylaxis Curative treatment
Antenatal care- good nutrition,
anemia correction
Correct hypovolemia
Intranatal care- blood transfusion Correct atonicity- medical or surgical
methods

11. MANAGEMENT
• Replacement of lost blood: CALL FOR HELP
1. At least 2 large bore I.v cannula(16gauge)
2. Blood Samples - crossmatching, Hb, PCV,Coagulation tests, baseline Urea,
electrolytes
3. Fluid replacement- Crystalloid solutions- 0.9% saline should be rapidly infused
(500ml in 15 min)to restore systolic blood pressure .
4. Bladder should be catheterized and strict I/O chart should be maintained.
5. Check for PR, BP, RR and other vitals.

12. 6. Palpate the uterus and ensure it is atonic PPH.
7. Once atonicity is confirmed , start 20 units of inj.Oxytocin in 500ml NS or RL at
the rate of 20-40 drops per min.
8. Blood transfusion should be started as soon as possible ideally within 30 mins.
9. Oxygen should be given by face mask at the rate of 8-10 liters per minute.

13. • Control of bleeding: Atonic uterus is very often noticed after the expulsion of
placenta
• PPH is an Absolute Emergency situation, we need a prompt and coordinated action.
1. Recheck the placenta to confirm all the placental lobes and membranes have been
expelled.
2. If there is no response to Oxytocin drip, inj.methylergometrine 0.25mg I.v can be
given, can be repeated up to 4 doses, but contraindicated in hypertension/ maternal
heart disease.
3. If bleeding continues , inj. Prostaglandins (PGF2a) 250mcg I.v ( max 8 doses) can be
given.
4. Rectal misoprostal tablets 800mcg can be used.

14. BIMANUAL COMPRESSION OF THE UTERUS
• A successful Life saving technique
1. Wearing a sterile gloves,insert a hand into the vagina and remove any blood clots from the
lower part of the uterus or cervix.
2. Form a fist and place it into the anterior fornix and apply pressure against the anterior wall of
the uterus.
3. With the other hand ,press deeply into the abdomen behind the uterus, applying pressure
against the posterior wall of the uterus.
4. Maintain compression until bleeding is controlled and the uterus contracts and becomes hard.
5. Care must be taken to avoid aggressive massage that can injure the large vessels of the broad
ligament.

16. COMPRESSION OF ABDOMINAL AORTA
• Apply downward pressure with a closed fist over the abdominal Aorta directly
through the abdominal wall
• Point of the compression is just above the umblicus and slightly to the left
• Aortic pulsation can be easily felt.
• Check femoral pulse with the other hand, if it is palpable during compression,
the pressure exerted by the fist is not adequate. If it is not palpable, pressure
exerted is adequate.

17. MANAGEMENT OPTIONS FOR UNRESPONSIVE
HAEMORRHAGE
1. Ultrasound of uterus- to rule out placental bits or membranes .
2. Traumatic factors should be considered
3. Coagulation failure- adequate blood, FFP, Cryoprecipitate, platelets
4. PPH with placenta insitu- Brandt – Andrew’s technique
Conservative techniques
Tamponade techniques- Foley’s catheter/ Condom/ Rusch urologic hydrostatic
balloon, Sengstaken – Blakemore tube, SOS Bakri tamponade balloon.

18. TAMPONADE TECHNIQUES
• Foley’s tamponade
1. 2 to 3 Foley’s catheters are inserted into the uterine cavity and the individual Foley’s
bulbs distended with 60-80ml of saline , depending upon the response, these can
be left insitu for 24 hours
2. A saline drip is connected to a condom and is inserted into the uterine cavity. The
condom is distended with 100 ml of saline and kept distended
3. Whenever a tamponade technique is used, there should be a counter pressure from
the uterus by starting a 20 unit Oxytocin drip and running it at a speed wherein
effective uterine contractions are established.

20. CONSERVATIVE SURGICAL TECHNIQUES
1. Vessel ligation- uterine,ovarian,internal iliac artery
2. Uterine vertical full thickness sutures- Compression sutures B-lynch,Modified
B-lynch , Cho sutures.
3. Uterine horizontal full thickness suture- square suture, figure of 8 suture.
4. Uterine artery emobilization
5. Hysterectomy

21. ASSESSMENT OF BLOOD LOSS
• Blood drape method – conical plastic sheath sutured over another broad plastic
sheath, placed under the buttocks of the mother after the placenta is delivered
and the blood loss from the uterine cavity collects in the conical bag. The
markings in the bag indicate the volume of blood loss.
• NASG garment- Non pneumatic anti shock garment- temporary method to
overcome shock and is not a treatment for PPH.

23. TRAUMATIC PPH- MANAGEMENT
• Suturing the lacerations can usually control the haemorrhage
• If bleeding from vaginal lacerations cannot be sutured,it can be controlled by
using a tight pack .
• In C- section, massage the uterus manually, give uterotonic agents.
• If bleeding persists, exteriorise the uterus, compress manually and flex it caudally,
compression sutures should be applied

24. SECONDARY PPH
Clinical features Diagnosis Management
Persistent, foul smelling
lochia,
Subinvolution of the uterus
Fever
Usg abdomen- to rule out
placental bits
High vaginal swab for culture
Broad spectrum antibiotics
Uterine evacuation- MVA
If there is Sepsis- MVA should
be delayed for 12-24 hours,
Rarely-Uterine artery ligation/
Hysterectomy