Introduction Definition Incidence Types of PPH Causes of Primary PPH Clinical manifestations Prevention Management of 3rd stage bleeding Management of true PPH Secondary PPH Clinical manifestations Diagnosis Management of sec PPH Active management Evaluation Bibliography

1.  SUBMITTEDTO:
Mrs. Pushpa Kerketta
ClinicalTutor
College of Nrsing RIMS,
Ranchi
 Submitted by:
ChandraTamang
Roll no. 05
Basic bsc nursing
4th year
College of Nursing
RIMS,Ranchi

2.  Introduction
 Definition
 Incidence
 Types of PPH
 Causes of Primary PPH
 Clinical manifestations
 Prevention
 Management of 3rd stage bleeding
 Management of true PPH
 Secondary PPH
 Clinical manifestations
 Diagnosis
 Management of sec PPH
 Active management
 Evaluation
 Bibliography

3.  PPH is a condition in which excessive
bleeding from or into genital tract at any time
following the baby’s birth upto 6weeks after
delivery.
 Hemorrhage may occur before, during or
after delivery of the placenta.
 The average blood loss following vaginal
delivery, cesarean delivery and cesarean
hysterectomy is 500ml, 1000ml and 1500ml
respectively

4.  “Any amount of bleeding from or into genital
tract following birth of the baby up to the end
of the puerperium, which adversly affects the
general condition of the patient, evidenced
by rise in pulse rate and falling blood
pressure, is called postpartum hemorrhage”.
-DC DUTTA

5.  The incidence widely varies mainly because
of lack of uniformity in the criteria used in
definition.
 The incidence is about 4-6% of all deliveries.

6. PRIMARY PPH
 Hemorrhage occurs within
24hours following the
birth of the baby. In the
majority, hemorrhage
occurs within two hours
following delivery.
SECONDARY PPH
 Hemorrhage occurs after
24hours of the delivery of
the placenta upto 6 weeks
after the delivery is called
secondary postpartum
hemorrhage.

7.  Primary pph is divided into 2 types:
1.Third stage hemorrhage:This is primary
hemorrhage that occurs after the delivery of the
baby but before the expulsion of the placenta.
2.True primary PPH:This is hemorrhage that
occurs after the delivery of the placenta at any
time within 24hours of the delivery of the baby.
The majority of the cases of postpartum
hemorrhage fall in this category.

8.  Atonic
 Traumatic
 Mixed
 Retained
 Coagulopathy

9.  Atonic means lack of tone of the muscles of
the flabby muscles. Failure of the muscles of
the uterus to contract properly after the
placenta has been delivered.
 It is the commonest cause of postpartum
hemorrhage.
 Contributes for 80% of PPH

11.  Grand multipara
 Over- distension of uterus
 Anemia
 Prolonged labour
 Anaesthesia
 Uterine fibroid
 Precipitate labour
 Malformations of uterus
 Ante partum hemorrhage
 Initiation and augmentation of the delivery with
oxytocin.

12.  Trauma to the genital tract usually occurs
following operative delivery; even after
spontaneous delivery.
 Trauma involves usually the cervix, vagina,
perinium(episiotomy wound and laceration).
While minor tears cause only a minimal
bleeding which is easily controlled, deep tears
may need to be examined and treated under
anesthesia.

14.  Cervix: laceration
 Vaginal laceration
 Perinium injury
 Paraurethral injury
 Uterine rupture.

15.  Postpartum hemorrhage is frequently a
mixture of both atonic as well as traumatic
hemorrhage. Many of the factors that
contribute to the laxity of the uterine muscles
are also factors that contribute to injury of
the birth canal.

16.  Bits of placenta, blood clots cause PPH due to
imperfect uterine retraction.
ETIOLOGY
1.Placenta accreta, increta and percreta
2.Succentuirate placenta.

18.  Blood coagulation disorders, acquired or
congenital, are less common causes of
postpartum hemorrhage.The firmly retracted
uterus can usually prevent bleeding.

19.  Abruptio placentae
 Jaundice in pregnancy
 Thrombocytopenic purpura
 Severe pre-eclampsia
 Hemophilia
 Patient on anti-coagulant

21.  Uncontrolled bleeding
 Increased heart rate
 Decreased in RBC count
 Swelling and pain in the tissues in the vaginal
and perineal area.
 An enlarged uterus as if it fills with blood or
blood clots. It is found on palpation

22.  Postpartum hemorrhage cannot always be
prevented. However, the incidence and
especially its magnitude can be reduced
substantially by assessing the risk factors.

23.  Improvement of the health status of the women.
 High-risk patients screening
 Blood grouping
 Placental localization
 All women with prior cerarean delivery must
have their placental site determined by usg/MRI
to determine morbid adherent placenta.
 Women with morbid adherent placenta are at
high risk of PPH.

24.  Active management of the third stage, for all women in
labour should be a routine as it reduces PPH by 60%.
 Cases with induced or augmented labor by oxytocin, the
infusion should be continued for at least one hour after
delivery.
 Women delivered by cesarean section, oxytocin 5IU slow IV
is to be given.
 Examination of the placenta and membranes.
 Exploration of the utero-vaginal canal for evidenced of
trauma.
 During cesarean section spontaneous separation and
delivery of the placenta reduces blood loss 30%.
 Expert obstetric anesthetist is needed when the delivery is
conducted under general anesthesia.
 Observation for about two hours after delivery.

25. The principles in the management are:
 To empty the uterus
 To replace the blood
 To ensure effective hemostasis

26.  Palpate the fundus and massage.
 Start dextrose saline drip and blood transfusion if
necessary.
 Oxytocin 10IU IM or merthergine 0.2mg is given
intravenously.
 If features of placental separation are evident,
placenta is expressed by fundal pressure or controlled
cord traction .
 If placenta is not separated, manual removal of the
placenta under general anesthesia is to be done.
 If patient is in shock, resuscitate the mother before
manual removal of the placenta.

28.  STEP 1.The operation is done under general anesthesia. In extreme
urgency where anesthesia is not available, the operation may have to
be done under deep sedation with 10mg diazepam given
intravenously.The patient is placed in lithotomy position.with all
aseptic measures, the bladder is catheterized.
 STEP 2. One hand is introduced into the uterus after smearing with
the antiseptic solution in cone shaped manner following the cord,
which is made taut by the other hand. While introducing the hand,
the labia are separated by the fingers of the other hand.
 STEP 3. Counter pressure on the uterine fundus is applied by the other
hand placed over the abdomen.The abdominal hand should steady
the fundus and guide the movements of the fingers inside the uterine
cavity until the placenta is compeletly separated.

29.  STEP 4. As soon as the placenta margin is
reached, the fingers are insinuated between
the placenta and the uterine wall with back of
the hand in contact with the uterine wall.
 STEP 5. when the placenta is completely
separated, it is extracted by traction of the
cord by the other hand.
 STEP 6. IV methergine 0.2mg is given and the
uterine hand is gradually removed.
 STEP 7.The placenta and membranes are
inspected for completeness and be sure that
the uterus remains hard and contracted.

31.  ACTIVE MANAGEMENT:
STEP1.
• Palpate the fundus and massage the
uterus to make it hard and to express the
clot.
• Methergine 0.2mg is given IM.
• Inj oxytocin drip is started 10IU in 500ml of normal
saline at 30-40 drops per min.
• Examine the expelled placenta and membranes.
• Oxygen administration.
STEP2.
• The uterus is to be explored under general anesthesia.

32. STEP3.
• Uterine massage and bimanual compression.

33.  The whole hand is introduced into the vagina in cone-
shaped fashion after separating the labia with the
fingers of the other hand.
 The vaginal hand is clenched into a fist with the back
of the hand directed posteriorly and the knuckles in
the anterior fornix.
 The other hand is placed over the abdomen behind
the uterus to make it anteverted.
 The uterus is firmly squeezed between the two hands.
It may be necessary to continue the compression for a
prolonged period until the tone of the uterus is
regained.

34. STEP4.
• Uterine temponade
• Tight intrauterine plugging done uniformly
under general anesthesia.
• Insertion of a senstaken Blackmore tube into
the uterine cavity and inflating ballon with
200ml of normal saline.

36. STEP5.
• SURGICAL METHOD
• Ligation of uterine arteries: The ascending
branch of the uterine artery is ligated at the
lateral border between upper and lower uterine
segment.
 Ligation of anterior division of internal iliac
artery:Reduces the distal blood flow.
 Ligation of ovarian and uterine artery
anastomosis: If bleeding continues, is done just
below the ovarian legament.

37.  B- Lynch brace suture and haemostatic
suture: Both these surgical methods work by
temponade (like bimanual compression) of
the uterus . Success rate is about 80%.
 Angiographic arterial embolisation: Under
fluoroscopy can be done using gel foam.
Success rate is more than 90%.

38. LIGATION OF UTERINE
ARTERIES
B- LYNCH BRACE SUTURE

39. LIGATION OF INTERNAL ILIAC
ARTERY
ANGIOGRAPHIC SELECTIVE
ARTERIAL EMBOLIZATION

40. STEP 6.
• HYSTERECTOMY:A surgical procedure to
remove all or some parts of the uterus In case of
life threatening conditions. Rarely uterus fails to
contract and bleeding continues in spite of the
above measures.
• Hysterectomy has to be considered involving a
second consultant.
• Decision of hysterectomy should be taken earlier
in a parous woman. Depending on the case, it
may be subtotal or total.

43.  The bleeding occurs after the delivery usually
between 8th to 14th days of delivery.
ETIOLOGY:
 Retained bits of cotyledon and membranes.
 Sepsis
 Secondary hemorrhage from cesarean section
wound.
 Endometritis
Other: carcinoma cervix, placenta polyp, fibroids
etc.

44.  The lochia are heavier then normal and is
bright red in color.
 Lochia is offensive if associated with
infection.
 Sub involution of the uterus.
 Pyrexia and tachycardia.
 Anemia proportionate to blood loss.

45.  The bleeding is bright red and of varing
amount.
 Varying degree of anaemia and evidenced of
sepsis, subinvolution of the uterus and often
a patulous cervical os.
 Ultrasound is usefull in detecting the bits of
placenta inside the uterine cavity.

46.  SUPPORTIVETHERAPY
• Blood transfusion if necessary.
• Ergometrine 0.5mg IM if bleeding is uterine in
origin.
• Antibiotics as routine.
CONSERVATIVETHERAPY
• Bed rest and observation for 24hrs if bleeding
is mild.

47.  Exploration of uterus is to be done under general
anesthesia.
 Gentle curettage is done by flushing curette and
sent materials for histological examination.
 Ergometrine 0.5mg IM .
 Secondary hemorrhage following cesarean
section may at times require laparotomy.
 The bleeding from uterine wound can be
controlled by haemostatic sutures, may rarely
require ligation of the internal iliac artery or
hysterectomy.

48. 1.What is PPH?
2.What is the Commonest cause of pph?
3.What is the difference between pri and sec
pph?
4. what are the clinical manifestation of pri
pph?

49.  Dutta Parul, Konar Hiralal; D.C Dutta’sTextbook of
Obstetrics; Jaypee Publication, 9th Edition;
Page No.-385-392 .
 Bhasker Neema; Midwifery and Obstetrical Nursing;
Emmess Publishers; 3rd Edition; Page No.-
492-495.
 www.webmed.com
 www.slideshare.com
 www.wikipedia.com