Post partum haemorrhage is defined as excessive bleeding following childbirth up to 6 weeks post-delivery. The main causes are an atonic uterus which fails to contract properly (80% of cases) and trauma to the genital tract during delivery (20% of cases). Management involves resuscitation with fluids and blood transfusions, massaging the uterus to help it contract, administering uterotonic drugs like oxytocin and methylergonovine, and potentially more invasive procedures like uterine artery ligation if bleeding cannot be controlled. Prevention efforts include risk assessment and management during pregnancy and delivery to minimize postpartum bleeding risk factors.

1. POST PARTUMHaemorrhage

2. INTRODUCTION
Post partum
haemorrhage is
defined as
excessive bleeding
from the genital
tract at any time
following the birth
up to 6 week after
delivery.

3. DEFINITION
“Any amount of the bleeding from or into the
genital tract following birth of the baby up to
the end of the puerperium which adversely
affects the general condition of the patients
evidenced by rise in pulse rate and falling
blood pressure is called postpartum
haemorrhage”
.................ACCO. TO WHO

4. CONT.......
Average blood loss following
Vaginal delivery- 500ml
Caesarean delivery- 1000ml
Caesarean hysterectomy is 1500ml.
Depending upon the amount of blood loss
PPH can be :-
1. Minor(less than 1L)
2. Major (more than 1L)
3. Severe (more than 2L)

5. incidence

6. types

7. PRIMARY HAEMORRHAGE
Haemorrhage occurs within 24 hrs
following the birth of the baby. In the
majority, haemorrhage occurs within two
hours following delivery these are of 2
types:-
Third stage haemorrhage
True postpartum
haemorrhage

8. CAUSES OF PRIMARY PPH

9. ATONIC UTERUS (80%)
This is the failure of the myometrium at
the placental site to contract and retract
and to compressed tone blood vessels
ligature action.
The following are the conditions which
often interfere with the retraction of the
uterus as a whole and of the placental
site in particular.

11. CAUSES

12. TRAUMATIC(20%)
Trauma to the genital tract usually occurs
following operative delivery even after
spontaneous delivery. Blood loss from the
episiotomy wound is of undestimated.
similarly blood loss in caesarean section
amounting to 800-1000ml is most often
ignored.

13. RETAINED TISSUES
Bits of placenta, blood clot cause PPH
due to imperfect uterine retraction.

14. BLOOD COAGULATION DISORDERS
1. The blood coagulopathy may be due to
diminished pro-coagulant or increased
fibrinolytic activity, the firmly retracted
uterine can usually prevents bleeding.
2. The condition where such disorders may
occurs are abruptio placenta, jaundice in
pregnancy, thrombocytopenia, HELLP
syndrome on in IUD.
3. Screening and recumbent activated factor VII
may be given.

15. CLINICAL FEATURES
The majority the vaginal bleeding is visible
Rarely the bleeding is totally concealed
either as vulva, vagina or broad ligaments
haematoma the effect of blood loss depends
on:-
• Pre –delivery haemoglobin level estimation.
• Degree of pregnancy induced
hypervolaemia.
• Speed at which blood loss occurs

16. CONT......
• Alteration of pulse, blood pressure and pulse
pressure
• Altered level of consciousness may become
drowsy or restless
• Metabolic acidosis and shock.

17. Management of PPPH
Primary postpartum haemorrhage is an
emergency which requires prompt and efficient
management.
Principles: simultaneous approaches
1. Communication
2. Resuscitation
3. Monitoring
4. Arrest of bleeding
It is essential in all cases of major PPH (blood
loss more than 1000ml or clinical shock)

18. IMMEDIATE MANAGEMENT
•Immediate measures are to be taken by
the attending house official
(doctormidwife)
•Call for extra help-involve the obstetric
registrar (senior staff)on call.
•Put in two large bore (14 gauze)
intravenous cannula.
•Keep patient flat and warm.

19. CONT....
•Send blood for group cross matching
diagnostic tests and ask for 2 unit (at
least) of blood
•Infuse rapidly 2 litres of normal saline
(crystalloids) or plasma substitutes like
haemaccel (colloids) an urea linked
gelatin to re-expand the vascular bed. It
does not interfere with cross matching.

20. CONT......
•Give oxygen by mask 10-15Lmin
•Start 20 unit of oxytocin in 1L of
normal saline IV at the rate of 60
drops per minute.
•Transfuse blood as soon as
possible.

21. VIDEO

22. ACTUAL /MEDICAL MANAGEMENT

23. ATONIC UTERUS
STEP – 1
Massage the uterus:-To make it hard
and express the blood clot
Methergin 0.2mg is given intravenously
Inj. Oxytocin drip is started (10 units in
500ml of normal saline) at the rate of 40-
60drops of normal minute.

24. CONT...
 Foley catheter to keep bladder
empty and to monitor urine output
 To examine the expelled placenta
and membranes for evidence of
missing pieces of membrane.

25. STEP - 2
•The uterus is to be explored under general
anaesthesia
•Misoprostol (PGE1) 1000µg per rectum is
effective.
•When uterine atone is due to tocolytic
drug calcium glyconate (1gm IV slowly)
should be given.

26. STEP -3
•Uterine massage and bimanual
compression.

27. STEP- 4
UTERINE TEMPONADE
•Tight intrauterine packing:-
Tight intrauterine packing is useful in a
case of unrolled postpartum
haemorrhage, where other method than
failed and the patient are being prepared
for transport to a tertiary care centre

28. BALLOON TEMPONADE
Temponade using various type of
hydrostatic balloon catheter has mostly
replace uterine packing mechanism of
action is similar to uterine packing.

29. STEP -5
SURGICAL METHODS OF CONTROL PPH:-
1. Ligation of uterine arteries
2. Ligation of the ovarian and uterine
artery anatomises
3. Ligation of anterior – division of internal
iliac artery
4. B-lynch compression suture and
multiple square suture
5. Angiographic arterial embolisation

31. STEP-6

32. PREVENTION
1. ANTENATAL
2. INTRANATAL

33. SECONDARY HAEMORRHAGES
DEFINITION:-
“Secondary PPH is bleeding
from genital tract more than 24
hours after delivery of the
placenta and May occurs up to 6
week later”

34. CAUSES

35. DIAGNOSIS

36. MANAGEMENT
Principles:-
•To assess the amount of blood
loss and to replace it
(transfusion)
•To find out the cause and to
take appropriate steps to rectify
it.

38. D I C-(DISSEMINATED
INTRAVASCULAR COAGULATION)
Definition:-
DIC is a condition of in appropriate
coagulation within the blood
vessels which leads to the
consumption of clotting factors as a
result clotting fails to occur at the
bleeding site.

39. PHYSIOLOGICAL CHANGS IN
PREGNANCY
1. During pregnancy there increase in
concentration of clotting factors II, V,
VII, VIII, IX, X and XII
2. Plasma fibrinogen factors are
significantly increased
3. There is small disease in platelet
count due to low gread intravascular
coagulation.

40. CONT....
1. Plasma fibrinolytic activies is
supressed during pregnancy and
labour.
2. It returns to normal within 1 hrs of
delivery of the placenta
3. This is due to libration of
plasminogen inhibitors of the
placenta.

41. INVESTIGATION
Bed side tests that may be done
are:-
•Bleeding time
•Coagulation time
•Clot observation test
•Peripheral smear
•Circulatory fibrinolysis test

42. ACTUAL MANGEMENT:-
•Volume replacement
•Blood component therapy
•Heparin
•Fibrinolytic inhibitors

43. SHOCK
DEFINATION:-
Shock is definition as state of
circulatory inadequacy with
poor tissue perfusion resulting
in generalized cellular
hypoxia.

44. CLASSIFICATION OF SHOCK
HYPOVOLAEMIC SHOCK:-
Circulating blood volume is
inadequate resulting from
acute depletion it may be
•Haemorrhagic shock
•Non-haemorrhagic shock

45. CLINICAL FEATURES OF
SHOCK
1. EARLY PHASE
(COMPENSATORY PHASE)
2. INTERMEDIATE PHASE
(REVERSIBLE PHASE)
3. LATE STAGE (IRREVERSIBLE)

46. MANAGEMENT
1.HAEMORRHAGIC SHOCK:-Basic
management of haemorrhagic shock
is to stop the bleeding and replace the
volume which has been lost.
•RESTORE CIRCULATING VOLUME
•MAINTAINANCE OF CARDIAC IFFICIENCY
•ADMINISTRATION OF OXYGEN TO AVOID
METABOLIC ACIDOSIS
•PHARMACOLOGICAL AGENTS:-

47. NURSING MANAGEMENT

48. CONCLUSION
Post partum haemorrhage is usually
defined as the loss of more than 500ml of
blood during or after delivery .it is one of
the leading causes of maternal mortality.
Haemorrhage may occur early within the
first 24 hours. After delivery or late up to 28
days postpartum.

49. VIDEO

51. ASSIGNMENT:
 Explain causes and
management of primary
post partum hemorrhage…
Submit on coming Monday
51

52. THANK YOU
Best of luck
for
doing good for
pregnant women.