It is ridiculous to hear that man from Peru complaining about America’s poverty. Peru has twice as much poverty

1. 1
POST PARTUM HEMORRHAGE
(PPH)
BY: Andualem Gezahegn (BSc, MSc, MRHN)
Lecturer, SLU
May,2022

2. Presentation outline
2
Objectives
Introduction
Types of PPH
Causes of PPH
management
prevention

3. 3
Objective
At the end of this session you will be able to:
Define Post partum hemorrhage
Describe types of PPH
Identify the possible causes and risk factors for PPH
Manage PPH properly

4. Introduction
4
Obstetrics is a "bloody business!!!"
 Death from hemorrhage still remains a leading cause of
maternal mortality.
 Over half a million women die during pregnancy and
childbirth each year
 Worldwide 25% - 60% of maternal death is due to PPH
 PPH is the most common cause of hemorrhage related
maternal deaths

5. Cont…
5
 PPH affects 10% of all live births
 The incidence of PPH is approximately 3% - 5%
 In countries with fewer resources, the contribution of
hemorrhage to maternal mortality is even more striking

6. Cont…
6
Maternal mortality:
 Death of women during pregnancy, childbirth, or
with in 42 days after delivery, remains a major
challenge to health systems worldwide.

7. Causes
7
Direct:
 Which results from obstetric complications of the
pregnancy state from interventions, omissions,
incorrect treatment or from chain of events.
Indirect:
 those resulting from previous existing diseases or
diseases that developed during pregnancy, which are
aggravated by the physiologic effects of pregnancy.

8. Maternal Mortality: A Global Tragedy
8
 Annually, 529,000
women die of pregnancy
related complications:
 99% in developing world
 ~ 1% in developed
countries

9. 9
Leading causes of maternal death globally

10. Leading causes of Maternal Mortality in Ethiopia
10
Hemorrhage
10%
Sepsis
12%
Hypertension
9%
Obstructed
labour
22%
Abortion
<10%
Others
15%

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Definition:
PPH:- a loss of excess blood exceeding 500ml following SVD or
1000ml following CS delivery respectively till post partum period.
Can be defined based on;
 Volume of blood loss
- > 500ml following vaginal delivery to 12 wks PP
- > 1000 ml following C/S and some times in twin
vaginal delivery
Is a reason for 10% decline in postpartum % hct/hgb.

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Challenges related to definitions:
 Estimation of blood loss is usually not practical
 The lower the Hgb level, the poorer is the woman’s
tolerance of blood volume loss.
 Bleeding rate is most important than volume!!!

13. Classifications of PPH
13
Based on time
 Primary PPH:- PPH that occurs in the first 24 hours
after delivery.
 Secondary PPH:- happened after 24 hours of delivery.
 More than half of all maternal deaths occurs within 24
hours of childbirth, mostly due to excessive bleeding.
 Uterine atony is the major factor of postpartum
hemorrhage (PPH), accounting about 75%.

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Based on source
 Placental site
 Trauma to genital tract
Causes of PPH:
The 5 T’s of post partum hemorrhage- primary
 TONE- Atonic uterus 70-75%
 TRAUMA- Genital trauma 20%
 TISSUE- Retained placenta 10%
 TROMBIN- Coagulation failure 1%
 TRACTION- Acute inversion of uterus (rare)

15. Cont…
15
Cause for secondary PPH
 Infection
 Sub-involution of placental site
 Retention of placental fragments (undergoes necrosis and
retention of fibrins)
N.B: Generally PPH is a DESCRIPTION OF AN EVENT NOT A
DIAGNOSIS; therefore, one should identify the cause before giving
specific treatment.
N.B: Generally PPH is a DESCRIPTION OF AN EVENT NOT A
DIAGNOSIS; therefore, one should identify the cause before giving
specific treatment.

16. Cont.
16
 Caesarean section may be associated with blood loss
greater than 500 ml and therefore constitutes a risk of
PPH.
 Additional bleeding will occur if the uterine incision
extends laterally to the uterine artery or down towards the
cervix.
 Caesarean section for an anterior placenta previa is
highly likely to be associated with excessive blood loss,
particularly in the presence of a previous caesarean section
scar as placenta accreta or percreta may have occurred.

17. Causes of PPH
17

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1. Uterine atony:-
Normal Physiology of haemostasis
Oblique fibers constriction & shortening
contraction and retraction
kinking the supplying blood vessels
“living ligatures”
 blood clots
Uterine inertia
 The most typical causes in the 1st 4 hours
 The uterus unable to contract adequately
 Occurring a few hrs after delivery or lately
 Uterus not well contracted
 Soft & Lax uterus
 Distended and lacking tone uterus

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Risk factors for atonic PPH:
Interference with ability of uterus to contract
Over distended uterus(multiple gestation,
polyhydramnions)
 Fatigue uterus
 Wrong practice
 Tumors like fibroids
 Repeated pregnancy

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2. Trauma:-
 Is the second frequent causes for PPH
 Spontaneous or profuse type
Mgt or interference will based on:
 Firm & well contracted Uterus
 Bright red persistent bleeding
 Careful inspection of vagina, cervix & Uterus
 Common site for trauma:-
 Perineum
 Vaginal wall
 Cervix
 Uterus
 Degree of tears can be :- 1st degree, 2nd degree, 3rd degree and
4th degree.

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Risk factors:-
 Mistimed episiotomy
 Induced labor
 Instrumental delivery
 Delivery of large infant
 Intrauterine manipulation
 Vaginal birth after cesarean section(VBAC)
 Prolonged or vigorous labour,( CPD)

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3. Tissue:
 The normal uterine contraction and retraction leads to
detachment and expulsion of the placenta.
 the placenta, Parts of the placenta/ lobes can adhere to
the uterus and
 prevent/ inhibits the myometrium contraction and
retraction result in continuous bleeding.

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Risk factors for retained products:
 Prior uterine surgery or procedures
 Difficult or prolonged placental delivery
 Multi lobed placenta
 Manipulation & squeezing of uterus

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4. Thrombin factors:
 Fibrin deposition over the placental site
 Clots within supplying vessels
 any condition that prevents blood clotting can result in pph.
 It can be a result or a cause of bleeding.
 Abnormalities in this area can lead to late PPH or
exacerbate bleeding from other causes, mostly trauma.

25. Cont…
25
 Potential causes:
 Platelet dysfunction
 Inherited coagulopathy
 Use of anticoagulants
 DIC
Managing coagulopathy:
 Treating the cause
 Blood transfusion
Study suggested that to reduce the risk of PPH, aspirin
therapy (used in pre-eclampsia) should cease at least 3
days prior to delivery.
Study suggested that to reduce the risk of PPH, aspirin
therapy (used in pre-eclampsia) should cease at least 3
days prior to delivery.

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5. Traction:
 Traction on the cord when placenta is still attached will
result in Uterine inversion, which in turn Prevents
myometrium from contracting and retracting.
Diagnosis:
 Hemorrhage
 A dark red- blue bleeding mass at the
cervix, vagina, or out side the vagina
 A depression in the fundus/ absent on
abdomenal palpation
 Shock

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Inversion of uterus
Types
Based on protrusion
1. Incomplete
2. Complete
Based on duration:
I. Acute- before the cervix constricts
II. Sub acute- once the cervix constricts
III. Chronic- > 4wks after delivery

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General management of PPH
 The approach to treatment of postpartum hemorrhage
(PPH) differs some what depending on the cause and
whether hemorrhage occurs after a vaginal birth or after
a cesarean delivery.
 Avoidance of laparotomy, when possible, is a goal in
patients who have had a vaginal birth, whereas this is not
a major consideration at cesarean delivery.

29. Cont…
29
 Regardless of the method of delivery, there are many
potentially effective actions and interventions for
management of PPH,
 Principles of managing PPH involves:
 Speed
 Skill
 Priorities
 team work

30. General Management Steps
30
 CALL FOR HELP!!! CALL FOR HELP!!!
 Perform rapid evaluation (vital signs BP, pulse, RR, pallor
and cause)
 Massage uterus
 If shock is present, start immediate resuscitation:
• Start IV infusion 1 liter/15 min.
• Take blood for grouping and cross-matching
• Give oxygen
• Elevate foot end and keep woman warm

31. I. Fluid Replacement: In Shock
31
 Start resuscitation with intravenous fluids (NS/ RL)
 Use large-bore cannula (16 or bigger)
 Volume to give:
 First 1,000 mL ( 500 ml x 2) rapidly in 15–20 min.
 GIVE AT LEAST 2000 mL ( 500 X 4 ) IN FIRST
HOUR
 Aim to replace 2-3x the volume of estimated blood loss
 If condition stabilizes, adjust rate to 1,000 mL/6 hrly
 Monitor BP, pulse every 15 min. and urine output hourly
(> 30 mL/hr)

32. Management: Rapid Assessment
32
Assess for signs and symptoms of the following
conditions and perform appropriate action before
proceeding with additional care:
 Uterine atony (uterus soft/not contracted)
 Tears of perineum, vagina, cervix
 Retained placenta or placental fragments
 Ruptured or inverted uterus
 Delayed postpartum hemorrhage (PPH)

33. Cont…
33
 If sign/symptoms of uterine atony:
 Massage uterus
 Start IV infusion (plus oxytocin 20 units/liter IV fluids)
 Or give oxytocin 10 units IM*
 Ensure urination (catheterize if needed)
*If not able to start IV

34. Management (cont…)
34
 If bleeding continues:
 Perform bimanual compression of uterus OR
compression of abdominal aorta
 Give additional oxytocics e.g., misoprostol,
ergometrine, prostaglandins if available.
 If bleeding stops, proceed with additional care, plus
measure woman’s hemoglobin in 2 or 3 hours.

35. Bimanual Compression of the Uterus
 Wearing HLD gloves, insert
hand into vagina; form fist
 Place fist into anterior fornix
and apply pressure against
anterior wall of uterus
 With other hand, press deeply
into abdomen behind uterus,
applying pressure against
posterior wall of uterus
 Maintain compression until
bleeding is controlled and
uterus contracts
35

36. Compression of Abdominal Aorta
 Apply downward pressure with
closed fist over abdominal aorta
through abdominal wall (just
above umbilicus slightly to
patient’s left)
 With other hand, palpate femoral
pulse to check adequacy of
compression:
 Pulse palpable = inadequate
 Pulse not palpable = adequate
 Maintain compression until
bleeding is controlled
36

37. Atonic Uterus!
First action is to massage uterus
DRUG DOSE & ROUTE CONT. DOSE MAX DOSE
CONTRA-
INDICATION
OXYTOCIN IM 10 U OR
IV 20 U in 1000 ml
NS at >60 drp/min
OR 5-10 U slow IV
push
IV 20 u in 1,000
mL at 40
drps/min.
Not > 40 U
infused at rate
of 0.02–0.04
U/min.
No IV admin., not
even slow IV push
unless IV fluids are
running
ERGO-
METRINE
IM OR IV
Slowly 0.2 mg
Repeat 0.2 mg
after 15 min. if
required every 4
hours
Five doses (Total
1.0 mg)
High BP
Heart disease
37

38. Atonic Uterus (cont.)
DRUG DOSE & ROUTE CONT. DOSE
MAX
DOSE
CAUTIONS &
CI
MISOPROSTOL
(CYTOTEC)
ORAL/SL
INTRAVAG
RECTAL
200–800 mcg
(600mcg)
200 mg
Every 4 hours
2000 mg Asthma
Heart Dis
PROSTAGLANDIN
F2a
IM only
0.25mg
0.25 mg
Every 15
minutes
Total 8
Doses=2 mg
Asthma
Heart Dis
38

39. Management (cont…)
39
If sign/symptoms of tears:
 If extensive tears (3rd or 4th degree), facilitate
urgent referral/transfer
 If 1st or 2nd degree tears, perform repairs
 If s/s of retained placenta, perform appropriate
management to deliver placenta with AMTSL
 If s/s of retained placental fragments, perform
appropriate management to remove fragments

40. Local Anesthesia
40
Lidocaine:
 Only use in concentration of 0.5% (drug is usually
available in 1% and 2% preparations)
 If more than 40 ml is required, add adrenaline to delay
dispersion
 Anesthetic effect can last for 2 hrs
 Dose can be repeated after 2 hr PRN
 Avoid injecting into vessel

41. Retained placenta:
41
 When the placenta is not expelled from the uterus even 30
minutes after the delivery of the baby.
 Stages of placental expulsion:
i. Separation from the uterine muscle
ii. Descends in to the lower segment & vagina
iii. Expelled.

42. Cont…
42
 Placenta does not deliver after 30 minutes despite
controlled cord traction
 There may be no bleeding on the outside, but the woman
can bleed into the uterus!
 Make sure the bladder is empty
 Repeat administration of uterotonic drugs
DO NOT give ergometrine; it delays expulsion!!
 Attempt manual removal of placenta if necessary
 REFER TO HOSPITAL IMMEDIATELY!

43.  Done in the health facility
Requires antibiotics, possibly
anesthetics, sterile gloves,
catherized bladder
 Hold cord firmly downwards with
one hand
 Slowly insert other hand into
uterus
 With one hand in the uterus,
second hand moves from cord to
holding the fundus
 Carefully detach the placenta
Manual removal of placenta

44. Retained Placenta
44
 If placenta is present, ask the woman to push it out
 If you can feel the placenta in the vagina, remove it
 If the placenta is still not delivered:
• Give oxytocin 10 units IM (if not already given for
AMTSL) and attempt CCT with the next contraction
• Catheterize the bladder using aseptic technique if not
already done
• If CCT unsuccessful, attempt manual removal of the
placenta(MRP)

45. Managing Retained Placenta
45
 Ensure bladder is empty
 Apply controlled cord traction; If it fails,
 Repeat oxytocin 10u IM: If no success of CCT in 30 min:
 Attempt manual removal of placenta:
 Give Pethidine and diazepam or Ketamine
 Give antibiotics: (Ampicillin 2g + Metronidazole 500 mg)
 Perform procedure and examine placenta for completeness
 Give Oxytocin 20 U/1,000 mL NS or RL at 60 dpm
 Monitor BP, pulse, pad and urine output closely
 Add ergot or prostaglandin if bleeding continues
 Transfuse PRN and treat for anemia

46. Anesthesia and Analgesia for Short Procedures < 30min
46
 Pethidine 1mg/kg BW IM or
 IV slowly (max 100 mg )
 Give Promethaxine (Phenergan)
if vomiting occurs) Plus
 Diazepam 10mg IV at rate of
1mg every 2 min.
 Monitor RR closely; stop if
RR<10/min
 Ketamine for procedures < 60 min:
 Dose 6-10 mg/kg BW by IM
or IV bolus or IV Infusion
 2 mg/kg BW IV slowly last for
15 min
 200 mg in 1 liter D/S at 20
dpm infusion for longer
procedures
 Give atropine 0.6 mg IM as
pre-medication
 Give O2 6-8l/min by mask
 Add diazepam 10 mg IV to
avoid hallucinations
DO NOT MIXTHETWO DRUGS IN
SAME SYRINGE!!!
CONTRAINDICATED IN HIGH BP AND
HEART DISEASE

47. Retained Placenta (cont…)
47
 If bleeding stops, continue with basic care
 2 to 3 hours after bleeding stops, measure the woman’s
hemoglobin:
 If Hgb less than 7g/dL, facilitate urgent transfer
 If Hgb is 7–11g/dL, treat anemia with iron/folate
 DO NOT give ergometrine as it causes tonic contractions
 AVOID forceful CCT and fundal pressure as they may
cause uterine inversion

48. Cont…
48
Management of Inverted uterus:-
 Secure IV line
 Tocolytics
 Manual repositioning of the uterus
 Remove the placenta
 Surgical repositioning of the uterus

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 The priorities:
 Call for help
 Make a rapid assessment
 Stabilize or resuscitate the woman
 Find the cause of bleeding
 Stop the bleeding
 Prevent further bleeding

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Advanced Measures to control bleeding:
 Massage & bimanual compression
 Manual exploration of uterus
 Curettage
 Uterine package
 Uterotonic agents
 Operative management
o Pressure occlusion of Aorta
o Uterine artery ligation
o Internal iliac artery ligation
o Hysterectomy

51. Prevention of PPH:-
51
 Encouraging institutional delivery
 AMTSL
 Early referral and appropriate mgt of cases
By Using AMTSL
Reduce 60% PPH
Reduce need for blood transfusion
 Reduce 80% need for uteru tonic agents

52. SUMMARY
 Recognize early and prepare
 Evaluate and treat systematically
 Tone
 Trauma
 Tissue
 Thrombin
 Traction(un common)
 Remember that uterine atony is main cause of PPH
 Actively manage 3rd Stage of Labor

53. B.Moss 7/23/07

54. B.Moss 7/23/07

55. 55
.....Questions!!!
Thank you!!!
Thank you!!!