Midwifery & Obstetrical Nursing B.Sc (N) IV yr

1. POSTPARTUM
HAEMORRHAGE
M. NIRMALA, M.Sc (N), MBA,
ASSOCIATE PROFESSOR,
GRT COLLEGE OF NURSING,
TIRUTTANI

2. Postpartum Hemorrhage
• Postpartum bleeding or postpartum
hemorrhage (PPH) is often defined as the loss of
more than 500 ml or 1,000 ml of blood within
the first 24 hours following child birth. The
condition can occur up to six weeks following
delivery.
• Hemorrhage most commonly occurs after the placenta
is delivered. The average amount of blood loss after the
birth of a single baby in vaginal delivery is about 500
ml.
• The average amount of blood loss for a cesarean birth
is approximately 1,000 ml. Most postpartum
hemorrhage occurs right after delivery, but it can occur
later as well.

3. Definition
• Postpartum haemorrhage refers to any amount
of bleeding from or into the genital tract
following birth of the baby upto the end of
puerperium.

4. Definition
• Postpartum hemorrhage, defined as the loss of
more than 500 ml of blood after delivery, occurs
in upto 18 percent of births.
• Blood loss exceeding 1,000 ml is considered
physiologically significant and can result in
hemodynamic instability.
• Even with appropriate management,
approximately 3% of vaginal deliveries will result
in severe post-partum hemorrhage.
• It is the most common maternal morbidity in
developed countries and a major cause of death
worldwide.

5. Background
• Postpartum hemorrhage (PPH) is the leading cause of
maternal mortality.
• All women who carry a pregnancy beyond 20 weeks’
gestation are at risk for PPH and its sequelae.
• Although maternal mortality rates have declined greatly
in the developed world, PPH remains a leading cause of
maternal mortality elsewhere.
• The pregnancy-related mortality ratio in the United
States was 17. 3 deaths per 100,000 live births in 2013
• About 1 to 5 percent of women have postpartum
hemorrhage and it is more likely with a cesarean birth.

6. Incidence
• The most common cause is poor contraction of the
uterus following childbirth.
• Not all of the placenta being delivered, a tear of the
uterus, or poor blood clotting are other possible causes.
• It occurs more commonly in those who: already have a
low amount of red blood, are Asian, with bigger or more
than one baby, are obese or are older than 40 years of
age.
• It also occurs more commonly following caesarean
sections, those in whom medications are used to start
labor, those requiring the use of a vacuum or
forceps, and those who have an episiotomy.

7. Incidence
 In the developing world about 1.2% of deliveries are
associated with PPH and when PPH occurred about 3%
of women died.
 World Health Organization statistics suggest that 25%
of maternal deaths are due to PPH, accounting for
more than 100,000 maternal deaths per year.
 Globally it occurs about 8.7 million times and
results in 44,000 to 86,000 deaths per year making
it the leading cause of death during pregnancy.
 About 0.4 women per 100,000 deliveries die from PPH
in the United Kingdom while about 150 women per
100,000 deliveries die in Sub-Saharan Africa.

8. Contd…
• PPH is a leading cause of maternal mortality and morbidity
worldwide and accounts for nearly one-quarter of all maternal
pregnancy-related deaths.
• Multiple studies have suggested that many deaths associated
with PPH could be prevented with prompt recognition and
more timely and aggressive treatment.
• Morbidity from PPH can be severe with sequelae including
organ failure, shock, edema, compartment syndrome,
transfusion complications, thrombosis, acute respiratory
distress syndrome, sepsis, anemia, intensive care, and
prolonged hospitalization.

9. Contd…
• The most common etiology of PPH is uterine atony
(impaired uterine contraction after birth), which occurs
in about 80 percent of cases.
• Atony may be related to over distention of the uterus,
infection, placental abnormalities, or bladder distention.
• Though the majority of women who develop PPH have
no identifiable risk factors, clinical factors associated
with uterine atony, such as multiple gestation,
polyhydramnios, high parity, and prolonged labor, may
lead to a higher index of suspicion.
• Other causes of PPH include retained placenta or clots,
lacerations, uterine rupture or inversion, and inherited
or acquired coagulation abnormalities.

10. Postpartum Hemorrhage

11. Types
• Primary postpartum hemorrhage is the
hemorrhage occurring during the third stage of
labor and within 24 hours of delivery.
• Secondary postopartum hemorrhage is
hemorrhage occurring after 24 hours of
delivery and within 6weeks of delivery. It is
also referred to as puerperal hemorrhage.

12. Contd..
• Primary postpartum hemorrhage are:
Atonic uterus
Trauma
Mixed ( combination of both atonic and
trauma)
Retained product of conception
Uterine rupture
Uterine inversion
Blood coagulopathy

13. Contd..
• Secondary postpartum haemorrhage include:
 Retained bits of cotyledon or membranes.
 Infection
 Cervico-vaginal laceration
 Endometritis
 Subinvolution of the placental site
 Secondary hemorrhage from caesarean section
 Other rare causes – chorion epithelioma,
carcinoma cervix, placental polyp, fibroid polyp
and puerperal inversion of uterus.

14. Risk factors
Normal
• Once a baby is delivered,
the uterus normally
continues to contract
(tightening of uterine
muscles) and expels the
placenta.
• After the placenta is
delivered, these contractions
help compress the bleeding
vessels in the area where the
placenta was attached.
Abnormal
• If the uterus does not
contract strongly enough,
called uterine atony, these
blood vessels bleed freely
and hemorrhage occurs.
This is the most common
cause of postpartum
hemorrhage.
• If small pieces of the
placenta remain attached,
bleeding is also likely.

15. Contd…
Some women are at greater risk for postpartum hemorrhage than
others.
• Placental abruption. The early detachment of the placenta
from the uterus.
• Placenta previa. The placenta covers or is near the cervical
opening.

16. Contd…
• Over distended uterus.
Excessive enlargement of the
uterus due to too much
amniotic fluid or a large baby,
especially with birth weight
over 4,000 grams (8.8
pounds).
• Multiple pregnancy. More
than one placenta and over
distention of the uterus.
• Gestational hypertension or
preeclampsia. High blood
pressure of pregnancy

17. • Postpartum hemorrhage may
also be due to other factors
including the following:
• Tear in the cervix or vaginal
tissues, Tear in a uterine
blood vessel
• Bleeding into a concealed
tissue area or space in the
pelvis which develops into a
hematoma, usually in the
vulva or vaginal area
• Blood clotting disorders,
such as disseminated
intravascular coagulation

18. Contd…
• Placenta accreta. The placenta
is abnormally attached to the
inside of the uterus (a condition
that occurs in one in 2,500 births
and is more common if the
placenta is attached over a prior
cesarean scar).
• Placenta increta. The placental
tissues invade the muscle of the
uterus.
• Placenta percreta. The
placental tissues go all the way
into the uterine muscle and may
break through (rupture).

19. Contd…
• Having many previous births
• Prolonged labor
• Infection
• Obesity
• Medications to induce labor
• Medications to stop contractions (for preterm
labor)
• Use of forceps or vacuum-assisted delivery
• General anesthesia

20. Major Causes
• Causes of postpartum hemorrhage are uterine
atony, trauma, retained placenta or placental
abnormalities and coagulopathy, commonly
referred as the “Four T’s”
Cause Incidence
Uterine Atony 70%
Trauma 20%
Retained Tissue 10%
Coagulopathy 1%

21. (Contd..)
• Tone: Uterine atony is the inability of the uterus to
contract and may lead to continuous bleeding.
Retained placental tissue and infection may
contribute to uterine atony. Uterine atony is the most
common cause of postpartum hemorrhage.

22. Contd…
• Predisposing factors for Uterine Atony:
• Prolonged labour
• Over distension of the uterus
• Multiple pregnancy
• Excessive stimulation of uterus by pitocin &
use of analgesics & anaesthesia
• Grand multiparity
• Trauma due to the obstetrical procedures

23. Contd…
• Trauma: Injury to the birth canal which includes the
uterus, cervix, vagina and the perineum which can
happen even if the delivery is monitored properly.
The bleeding is substantial as all these organs become
more vascular during pregnancy.

24. Contd…
Predisposing factors for Trauma
1. Spontaneous or Precipitous delivery
2. Size, Presentation, and Position of baby
3. Contracted Pelvis
4. Bleeding from or into genital tract due to trauma to uterus,
vulvar, cervical, perineal, uretheral area and vaginal varices

25. (Contd..)
• Tissue: Retention of tissue from the placenta
or fetus as well as placental abnormalities such
as placenta accreta and percreta may lead to
bleeding.

26. Contd…
Predisposing Factors for tissue damage:
 Failure of placenta to be expelled within 30 mts after
expulsion of fetus.
 Bleeding continues at the separation site because the uterus
is unable to contract due to reained placenta.
 Traction applied on the cord before the placenta has
separated.
**Don’t pull on the cord unless the placenta has separated.
 Incorrect traction and pressure applied to the fundus,
especially when the uterus is flaccid
**Don’t use the fundus to “push the placenta out”

27. Contd…
• Thrombin: a bleeding disorder occurs when
there is a failure of clotting, such as with
diseases known as coagulopathies.

28. Contd…
• Predisposing factors for Thrombin:
• Amniotic fluid embolism
• Abruptio placenta
• Sepsis
• Massive blood loss & transfusion
• Severe Pulmonary Embolism
• Chorioamnitis
• Idiopathic thrombocytopenia

29. Prevention
• Compared to expectant management, active management of
the third stage of labour (AMTSL) is associated with reduced
maternal blood loss, reduced postpartum hemorrhage,
reduced postpartum anemia, reduced need for blood
transfusions and a decrease in the incidence of prolonged
third stage of labour.

30. AMTSL (Active management of
the third stage of labour)
• AMTSL includes the following procedures:
• 1. Following the delivery of the baby, palpate the abdomen to
rule out the presence of an additional baby, and give oxytocin
10 units IM. Never give an uterotonic before the delivery of
the anterior shoulder. Oxytocin may also be give by other
routes including 5 units IV push or 20-50 units in 1L of
normal saline at 60 drops/minute.
• 2. If oxytocin is not available, give: Ergometrine 0.2 mg IM OR
Syntometrine (1 ampoule) IM OR Misoprostol 400–600 µg
orally

31. AMTSL (Active management of the
third stage of labour)
• 3. After delivery of the baby, wait until pulsation has stopped (approximately
2 to 5 minutes) before clamping and dividing the cord. Clamp the cord close
to the perineum. If it is your institutional policy, take the cord blood samples
including blood gases.
• 4. Keep slight tension on the cord while waiting for a strong uterine
contraction (approximately 2–3 minutes)
• 5. With the strong uterine contraction, encourage the mother to push, and
very gently pull downward and outward on the cord to deliver the placenta
while applying suprapubic counter-pressure on the uterus with the other
hand. Pulling too hard on the cord may cause the cord to tear off the
placenta or cause uterine inversion—an acute obstetrical emergency.

32. AMTSL (Active management of the
third stage of labour)
• 6. If the placenta does not descend during 30-40 seconds
of controlled cord traction , do not continue to pull on the
cord: a. Continue to gently hold the cord, and wait until
there is another strong contraction. b. With the next
contraction, repeat controlled cord traction with counter-
pressure.
• 7. As the placenta delivers, hold the placenta in both
hands. Gently turn it until the membranes are twisted.
Gently pull to complete the delivery.

33. AMTSL (Active management of the
third stage of labour)
• 8. If the membranes tear, gently examine the
upper vagina and cervix wearing sterile gloves.
Use a ring (sponge) forceps to grasp and
remove any pieces of membranes.
• 9. Examine the placenta carefully to ensure
that it is complete.
• 10.Check the fundus to ensure that it is well
contracted. Palpate for a contracted uterus
every 15 minutes and repeat uterine massage
as needed during the first 2 hours.

34. Management
• External and internal bi-manual uterine massage
• Aortic compression
• Umbilical vein injection (injection of uterotonic into the
umbilical cord attached to the undelivered placenta)
• Manual exploration of the uterus and manual removal of the
placenta
• Repair of perineal trauma including repair of episiotomy
• Repair of cervical and high vaginal tears
• Use of an anti-shock garment to treat shock
• Use of a hydrostatic balloon tamponade
• Uterine compression sutures
• Systematic pelvic devascularization
• Uterine artery embolization
• Total or sub-total hysterectomy.

35. Review
• Uterine atony is responsible for most cases and can be managed
with uterine massage in conjunction with oxytocin, prostaglandins,
and ergot alkaloids.
• Traumatic causes include lacerations, uterine rupture, and uterine
inversion.
• Retained placenta is a less common cause and requires
examination of the placenta, exploration of the uterine cavity, and
manual removal of retained tissue. Rarely, an invasive placenta
causes postpartum hemorrhage and may require surgical
management.
• Coagulopathies require clotting factor replacement for the
identified deficiency. Early recognition, systematic evaluation and
treatment, and prompt fluid resuscitation minimize the potentially
serious outcomes associated with postpartum hemorrhage.

36. Any Queries?