All pregnancies are at risk of PPH even if no predisposing factors are present.

2. Postpartum Hemorrhage
Prepared By:
Reena Bhagat
Senior Nursing Instructor
Maternal Health Nursing
BPKIHS

3. Introduction:
• Puerperium, the period of adjustment after childbirth
during which the mother‘s reproductive system returns
to its normal prepregnant state. triggered by a sharp
drop in the levels of estrogen and progesterone
produced by the placenta during pregnancy.
• The uterus shrinks back to its normal size and resumes
its pre-birth position by the sixth week.
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4. Contd..
Definition:
It is the period following child birth during which all
the body tissue especially pelvic organs revert back to
their pre pregnant stage both anatomically and
physiologically.
It has 3 types:
• Immediate- within 24 hrs
• Recent- within 7 days
• Remote- up to the end of 6 weeks
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5. Contd..
• Of all the stages of labor, third stage is the most
crucial one for the mother.
• Fatal complications may appear unexpectedly in an
otherwise uneventful first or second stage.
• The following are the important complications:
(1) Postpartum hemorrhage
(2) Retention of placenta
(3) Shock—hemorrhagic or non-hemorrhagic
(4) Pulmonary embolism either by amniotic fluid or by
air
(5) Uterine inversion (rare).
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6. All pregnancies are at risk of PPH
even if no predisposing factors are
present.
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7. Postpartum Hemorrhage
• PPH is the leading cause of maternal morbidity
and mortality.
• It accounts for a quarter of maternal deaths
worldwide and its incidence in developed world is
increasing.
• Worldwide, PPH continues to contribute to
significant maternal morbidity and mortality
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8. Introduction
• PPH is a condition in which excessive bleeding from the
genital tract at any time following the baby‘s birth up to
6 weeks after delivery.
• Hemorrhage may occur before, during, or after delivery
of the placenta.
• The average blood loss following
- vaginal delivery : 500ml
- cesarean delivery: 1000ml and
- cesarean hysterectomy: 1500 ml.
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9. Definition
Quantitative definition is arbitrary and is related to the
amount of blood loss in excess of 500 mL following
birth of the baby (WHO). It may be useful for statistical
purposes.
Clinical definition which is more practical states,
―Any amount of 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 patient evidenced by rise in pulse rate
and falling blood pressure is called postpartum
hemorrhage‖.
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10. Contd..
Depending upon the amount of blood loss, PPH can be
♦ Minor (< 1L),
♦ Major (> 1L) or
♦ Severe (> 2L).
Incidence:
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.
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11. Types of PPH
Acute or Primary PPH
• Hemorrhage occurs within 24 hours following the
birth of the baby
• In the majority, hemorrhage occurs within two
hours following delivery.
Late or Secondary PPH
• Hemorrhage occurs beyond 24 hours and within
puerperium, also called delayed or late puerperal
hemorrhage
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13. Primary PPH
These are of two types:
Third stage hemorrhage: Bleeding occurs before
expulsion of placenta.
True postpartum hemorrhage: Bleeding occurs
subsequent to expulsion of placenta (majority).
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14. Causes of PPH
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15. Causes of PPH
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16. Contd..
 Atonic uterus (80%):
• Atonicity of the uterus is the commonest cause of
postpartum hemorrhage.
• With the separation of the placenta, the uterine sinuses
which are torn, cannot be compressed effectively due
to imperfect contraction and retraction of the uterine
musculature and bleeding continues.
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17. Risk factors
Grand multipara Inadequate retraction and frequent adherent
placenta contribute to it
Over-distension of the
uterus
multiple pregnancy, hydramnios and large baby
Malnutrition and anemia Even slight amount of blood loss can cause
hemorrhage
Antepartum hemorrhage
Prolonged labor: Poor retraction, infection (amnionitis),
dehydration are important factors.
Anesthesia: Depth of anesthesia and the anesthetic agents
(ether, halothane) may cause atonicity.
Initiation or augmentation
of delivery by oxytocin:
Post-delivery uterine atonicity is likely unless the
oxytocin is continued for at least one hour
following delivery.
Uterine fibroid Causes imperfect retraction mechanically.
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18. Malformation
of the uterus
Implantation of the placenta in the uterine septum of a septate
uterus or in the cornual region of a bicornuate uterus
Mismanaged
third stage of
labor
(a)Too rapid delivery of the baby preventing the uterine wall to
adapt to the diminishing contents
(b)Premature attempt to deliver the placenta before it is
separated
(c)Kneading and fiddling the uterus
(d)Pulling the cord. All these produce irregular uterine
contractions leading to partial separation of placenta and
hemorrhage
(e)Manual separation of the placenta increases blood loss
during cesarean delivery.
Placenta: Morbidly adherent (accreta, percreta), partially or completely
separated and/or retained.
Precipitate
labor
In rapid delivery, separation of the placenta occurs following
the birth of the baby. Bleeding continues before the onset of
uterine retraction. Bleeding may be due to genital tract trauma
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19.  Traumatic (20%):
• Trauma to the genital tract usually occurs following
operative delivery; even after spontaneous delivery.
• Trauma involves usually the cervix, vagina, perineum
(episiotomy wound and lacerations), paraurethral
region and rarely, rupture of the uterus occurs.
• The bleeding is usually revealed but can rarely be
concealed (vulvovaginal or broad ligament hematoma).
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20.  Retained tissues:
Bits of placenta, blood clots cause PPH due to
imperfect uterine retraction.
 Drugs: Use of tocolytic drugs (ritodrine), MgSO4 ,
Nifedipine.
 Combination of atonic and traumatic causes.
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21. Contd..
Blood coagulation disorders, acquired or congenital:
 The blood coagulopathy may be due to diminished pro-
coagulants (washout phenomenon) or increased
fibrinolytic activity.
 The conditions where such disorders may occur are
abruptio placentae, jaundice in pregnancy,
thrombocytopenic purpura, HELLP syndrome or in
IUD.
 Specific therapy following coagulation screen including
recombinant activated factor VII (rF VIIa) may be
given.
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23. Diagnosis
1. Visual Estimation of Blood Loss
2. Direct Measurement: It is one of the oldest methods
of accurately determining blood loss.
3. Shock index (SI) has been used in intensive
treatment units (ITU) and trauma centres. It refers to
heart rate (HR) divided by systolic blood pressure
(SBP). The normal value is 0.5–0.7.
It has been reported that if it increases above 0.9–1.1,
intensive resuscitation may be required.
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24. Contd..
4. Golden First hour and The Rule of 30
• Severe PPH can lead to cardiovascular compromise,
aggressive resuscitative measures should be deployed
before the estimated blood loss is more than one-third of
the woman‘s blood volume (blood volume [mL] 5 weight
[kg] 3 90 during pregnancy) or more than 1000 mL or a
change in hemodynamic status.
• The ‗golden first hour‘ is the time at which resuscitation
must begin to achieve maximum survival before
metabolic acidosis sets in.
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25. Contd..
• Rule of 30 is used to measure severity of shock
resulting from at least the loss of 30% of blood
volume leading to moderate shock.
• It is based on the fact that when a woman loses 30%
of her blood volume, her systolic blood pressure
(SBP) is likely to fall by 30 mmHg, her heart rate
(HR) is likely to increase by 30 beats/min, her
respiratory rate is likely to be 30 breaths/min and her
haemoglobin or haematocrit is likely to drop by 30%.
As a result of peripheral shut down, her urinary output
is likely to fall , 30 mL/hour.
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26. Signs and Symptoms
• In the majority, the vaginal bleeding is visible
outside, as a slow trickle. Rarely, the bleeding is
totally concealed either as vulvo-vaginal or broad
ligament hematoma.
• The effect of blood loss depends on:
(a) Predelivery hemoglobin level
(b) degree of pregnancy induced hypervolemia and
(c) speed at which blood loss occurs.
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27. Contd..
• On occasion, blood loss is so rapid and brisk that
death may occur within a few minutes.
• State of uterus, as felt per abdomen, gives a reliable
clue as regards the cause of bleeding. In traumatic
hemorrhage, the uterus is found well contracted. In
atonic hemorrhage, the uterus is found flabby and
becomes hard on massaging. However, both the
atonic and traumatic cause may co-exist.
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28. Degree of Blood Loss and Clinical Findings in Obstetric Hemorrhage:
The ‘Urgency Grid’
Loss of
Blood
Volume
Amount /
% Blood
volume
Blood Pressure
Systolic (SBP)
Symptoms and
Signs
Obstet
ric
Shock
Index
Degree of
Shock/
Urgency
500–1000
ml
10–15%
Normal SBP Palpitation, mild
tachycardia,
dizziness
<1 Compensate
d Grade 4
1000–1500
ml
15–30%
Slight Fall in SBP
(SBP=80–100
mmHg) A rise in
diastolic blood
pressure leading to
increased pulse
pressure
Weakness,
marked
tachycardia,
sweating
>1 Mild Grade
3
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29. Contd..
1500–
2000ml
30–40%
Moderate
Fall in SBP
(70–80
mmHg
Restlessnes
s, marked
tachycardia,
pallor,
oliguria
>1.5 Moderate
Grade 2
>2000
>40%
Marked fall
in SBP
(50–70
mmHg
Collapse,
air hunger,
anuria
>2 Severe
Grade 1
Note: It is recommend that women scoring Grade 1 and Grade 2 (Shock Index
>1.5 indicating a fall in SBP in association with increasing pulse rate) should
have immediate senior input.
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30. Prognosis
• Postpartum hemorrhage is one of the life-threatening
emergencies. It is one of the major causes of maternal
deaths both in the developing and developed countries.
• Prevalence of malnutrition and anemia, inadequate
antenatal and intranatal care and lack of blood transfusion
facilities, substandard care are some of the important
contributing factors.
• There is also increased morbidity. These include shock,
transfusion reaction, puerperal sepsis, failing lactation,
pulmonary embolism, thrombosis and thrombophlebitis.
Late sequelae includes Sheehan‘s syndrome (selective
hypopituitarism) or rarely diabetes insipidus.
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31. Prevention
• Postpartum hemorrhage cannot always be prevented.
However, the incidence and especially its magnitude
can be reduced substantially by assessing the risk
factors.
• However, most cases of PPH have no identifiable
risk factors.
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32. Contd..
Antenatal
• Improvement of the health status of the woman and to keep the
hemoglobin level normal (> 10 g/dL) so that the patient can
withstand some amount of the blood loss.
• High risk patients who are likely to develop postpartum
hemorrhage (such as twins, hydramnios, grand multipara, APH,
history of previous PPH, severe anemia) are to be screened and
delivered in a well equipped hospital.
• Blood grouping should be done for all women so that no time is
wasted during emergency.
• Placental localization must be done in all women with previous
cesarean delivery by USG or MRI to detect placenta accreta or
percreta.
• Women with morbid adherent placenta are at high risk of PPH.
Such a case should be delivered by a senior obstetrician.
Availability of blood and or blood products must be ensured
before hand.
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33. Contd..
Intranatal
 Active management of the third stage, for all women in
labor 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
the delivery.
 Women delivered by cesarean section, Oxytocin 5 IU
slow IV is to be given to reduce blood loss. Carbetocin
(long-acting oxytocin) 100 µg is very useful to prevent
PPH.
 Exploration of the uterovaginal canal for evidence of
trauma following difficult labor or instrumental delivery.
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34. Contd..
• Observation for about two hours after delivery to make
sure that the uterus is hard and well contracted before
sending her to ward.
• Expert obstetric anesthetist is needed when the delivery is
conducted under general anesthesia. Local or epidural
anesthesia is preferable to general anesthesia, in forceps,
ventouse or breech delivery.
• During cesarean section spontaneous separation and
delivery of the placenta reduces blood loss (30%).
• Examination of the placenta and membranes should be a
routine so as to detect at the earliest any missing part.
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35. Management of Third Stage Bleeding
The principles in the management are:
 To empty the uterus of its contents and to make it
contract.
 To replace the blood. On occasion, patient may be in
shock. In that case patient is managed for shock first.
 To ensure effective hemostasis in traumatic bleeding.
Steps of Management:
♦ Placental site bleeding ♦ Traumatic bleeding
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36. Placental site bleeding
To catheterize the bladder.
Oxytocin 10 units IM or methergin 0.2 mg is given
intravenously.
To start crystalloid solution (Normal saline or Ringer‘s solution) with
oxytocin (1 L with 20 units) at 60 drops per minute and to arrange for blood
transfusion if necessary.
To palpate the fundus and massage the uterus to make it hard.
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37. If the patient is in shock,
She is resuscitated first!
If features of placental separation are evident
Expression of the placenta is to be done by
controlled cord traction method
If the placenta is not separated, manual removal
of placenta under general anesthesia is to be
done.
Give antibiotics( ampicillin 2gm and metronidazole 500gm iv).
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38. Manual Removal of Placenta
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39. Contd.
Management of traumatic bleeding:
• The uterovaginal canal is to be explored under general
anesthesia after the placenta is expelled and
hemostatic sutures are placed on the offending sites.
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41. Management of True PPH
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42. Principles
Simultaneous approach
Communication
Resuscitation
Monitoring and
Arrest of bleeding
It is essential in all cases of major PPH (blood loss >
1000 mL or clinical shock). (RCOG - 2009).
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43. Management
Immediate measures are to be taken by the attending
Doctor/Midwife.
 Call for extra help.
 Put in two large bore (14 gauge) intravenous cannulas.
 Keep patient flat and warm.
 Send blood for group, cross matching, diagnostic tests
and ask for 2 units (at least) of blood.
 Infuse rapidly 2 liters of normal saline (crystalloids) or
plasma substitutes like hemaccel (colloids), an urea
linked gelatin, to re-expand the vascular bed.
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44. Contd..
 Give oxygen by mask 10–15 L/min.
 Start 20 units of oxytocin in 1 L of normal saline IV at
the rate of 60 drops per minute. Transfuse blood as
soon as possible.
 One midwife should be assigned to monitor the
following:
(i) Pulse
(ii) Blood pressure
(iii)Respiratory rate and oxymeter
(iv) Type and amount of fluids the patient has received
(v) Urine output (continuous catheterization)
(vi) Drugs-type, dose and time
(vii)Central venous pressure (when sited).
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45. Actual Management
♦ Atonic
♦ Traumatic
♦ Retained tissues
♦ Coagulopathy
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46. Contd..
• The first step is to control the fundus and to note
the feel of the uterus.
• If the uterus is flabby, the bleeding is likely to be
from the atonic uterus. If the uterus is firm and
contracted, the bleeding is likely of traumatic
origin.
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47. Atonic Uterus
Step—I:
a. Massage the uterus to make it hard and express the
blood clot.
b. Methergin 0.2 mg is given intravenously.
c. Injection oxytocin drip is started (10 units in 500 mL
of normal saline) at the rate of 40–60 drops per minute
d. Foley catheter to keep bladder empty and to monitor
urine output
e. To examine the expelled placenta and membranes, for
evidence of missing cotyledon or piece of
membranes.If the uterus fails to contract, proceed to
the next step.
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48. Contd..
Step—II:
The uterus is to be explored under general anesthesia.
Simultaneous inspection of the cervix, vagina especially
the paraurethral region is to be done to exclude co-
existent bleeding sites from the injured area.
In refractory cases:
• Injection 15 methyl PGF2α 250 µg IM in the deltoid
muscle every 15 minutes (up to maximum of 2 mg). OR
• Misoprostol (PGE1 ) 1000 µg per rectum is effective.
• When uterine atony is due to tocolytic drugs, calcium
gluconate (1 g IV slowly) should be given to neutralize
the calcium blocking effect of these drugs.
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49. Contd..
Step—III: Uterine massage and bimanual compression.
Procedures:
a. The whole hand is introduced into the vagina in cone
shaped fashion after separating the labia with the
fingers of the other hand
b. The vaginal hand is clenched into a fist with the back
of the hand directed posteriorly and the knuckles in
the anterior fornix
c. The other hand is placed over the abdomen behind
the uterus to make it anteverted.
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50. Bimanual Compression
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51. Contd..
• 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.
This is evidenced by absence of bleeding if the
compression is released.
• During the period, the resuscitative measures are to be
continued. If, in spite of therapy, the uterus remains
refractory and the bleeding continues, the possibility of
blood coagulation disorders should be kept in mind and
massive fresh whole blood transfusion should be given
until specific measures can be employed.
• In rare cases, when the uterus fails to contract, the
following may be tried desperately as an alternative to
hysterectomy.
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52. Contd..
• Step—IV: Uterine tamponade
1. Tight intrauterine packing done uniformly under
general anesthesia.
Procedure:
 A 5 meters long strip of gauze, 8 cm wide folded twice
is required. The gauze should be soaked in antiseptic
cream before introduction.
 The gauze is placed high up and packed into the fundal
area first while the uterus is steadied by the external
hand. Gradually, the rest of the cavity is packed so that
no empty space is left behind..
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53. Contd..
• A separate pack is used to fill the vagina.
• An abdominal binder is placed.
• Intrauterine plugging acts not only by stimulating uterine
contraction but exerts direct hemostatic pressure
(tamponade effect) to the open uterine sinuses.
• Antibiotic should be given and the plug should be
removed after 24 hours.
• Intrauterine packing is useful in a case of uncontrolled
postpartum hemorrhage where other methods have failed
and the patient is being prepared for transport to a
tertiary care center
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55. Contd..
2. Balloon tamponade:
Tamponade using various types of hydrostatic balloon
catheter has mostly replaced uterine packing.
Mechanism of action is similar to uterine packing.
oFoley catheter,
oBakri balloon,
oCondom catheter or
oSengstaken-Blakemore tube is inserted into the uterine
cavity and the balloon is inflated with normal saline
(200–500 mL).
It is kept for 4–6 hours. It is successful in atonic PPH.
This can avoid hysterectomy in 78% cases.
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58. Contd..
Step V:
Surgical methods to control PPH
are: An outline of stepwise
uterine devascularization
procedures are given below:
(a) Ligation of uterine arteries:
the ascending branch of the
uterine artery is ligated at the
lateral border between upper
and lower uterine segment.
The suture (No. 1 chromic) is
passed into the myometrium 2 cm
medial to the artery.
In atonic hemorrhage bilateral
ligation is effective in about 75% of
cases.
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59. Contd..
(b) Ligation of the ovarian and uterine artery
anastomosis if bleeding continues, is done just below
the ovarian ligament.
Rarely temporary occlusion of the ovarian vessels at
the infundibulopelvic ligament may be done by
rubber sleeved clamps.
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60. Contd..
(c) Ligation of anterior
division of internal iliac
artery (unilateral or
bilateral): reduces the distal
blood flow.
 It helps stable clot formation
by reducing the pulse pressure
up to 85%.
 Due to extensive collateral
circulation, there is no pelvic
tissue necrosis. Bilateral
ligation (not division) can
avoid hysterectomy in about
50% of the cases
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61. Contd..
(d) B-Lynch compression suture and multiple
square sutures:
Both these surgical methods work by tamponade (like
bimanual compression) of the uterus.
Success rate is about 80% and it can avoid
hysterectomy
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62. B-Lynch compression suture
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63. Multiple square sutures
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64. Contd…
(e)Angiographic
arterial embolization
(bleeding vessel) under
fluoroscopy can be
done using gel foam.
Success rate is more
than 90% and it avoids
hysterectomy.
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65. Stepwise de vascularisation (sites of vascular occlusion)
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66. Contd..
Step VI: Hysterectomy:
• 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.
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67. Hysterectomy
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71. Management Algorithm for Postpartum Haemorrhage ‘HEMOSTASIS’
H Ask for Help and Hands on uterus (uterine massage)
E Establish etiology, Ensure ABC (Airway, Breathing & Circulation),
Ensure availability of blood and Ecbolics (drugs that contract the
uterus)
M Massage uterus
O Oxytocin infusion/prostaglandins IV/IM/per rectal
S Shift to theatre-aortic pressure or anti- shock garment if considering
transfer
T Tamponade balloon/uterine packing after exclusion of tissue and
trauma /Consider Tranexamic acid 1 g i.v.
A Apply compression sutures e.g. B-Lynch/modified
S Systematic pelvic devascularization-uterine/ovarian/quadruple/internal
iliac
I Interventional radiology and, if appropriate uterine artery embolization
S Subtotal/total abdominal hysterectomy
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72. Traumatic PPH
• The trauma to the perineum, vagina and the
cervix is to be searched under good light by
speculum examination and hemostasis is achieved
by appropriate catgut sutures.
• The repair is done under general anesthesia, if
necessary.
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73. Secondary PPH
Causes: The bleeding usually occurs between 8th to 14th day of
delivery. The causes of late postpartum hemorrhage are:
(1) Retained bits of cotyledon or membranes (most common)
(2) Infection and separation of slough over a deep cervicovaginal
laceration
(3) Endometritis and sub involution of the placental site due to
delayed healing process
(4) Secondary hemorrhage from cesarean section wound usually
occur between 10–14 days. It is probably due to
(a) separation of slough exposing a bleeding vessel or
(b) from granulation tissue
(5) Withdrawal bleeding following estrogen therapy for suppression
of lactation
(6) Other rare causes are: chorion-epithelioma: occurs usually
beyond 4 weeks of delivery; carcinoma cervix; placental polyp;
infected fibroid or fibroid polyp and puerperal inversion of uterus.
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74. Contd..
Diagnosis:
 The bleeding is bright red and of varying amount.
Rarely it may be brisk.
 Varying degree of anemia and evidences of sepsis are
present.
 Internal examination reveals evidences of sepsis, sub
involution of the uterus and often a patulous cervical
os.
 Ultrasonography is useful in detecting the bits of
placenta inside the uterine cavity.
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75. Contd..
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.
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76. Contd..
Supportive therapy:
(1) Blood transfusion, if necessary
(2) To administer methergin 0.2 mg intramuscularly, if
the bleeding is uterine in origin.
(3) To administer antibiotics as a routine.
Conservative:
If the bleeding is slight and no apparent cause is
detected, a careful watch for a period of 24 hours or so
is done in the hospital.
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77. Contd..
Active treatment:
 As the most common cause is due to retained bits of
cotyledon or membranes, it is preferable to explore
the uterus urgently under general anesthesia.
 One should not ignore the small amount of bleeding;
as unexpected alarming hemorrhage may follow
sooner or later.
 The products are removed by ovum forceps. Gentle
curettage is done by using flushing curette.
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78. Contd..
• Methergin 0.2 mg is given intramuscularly.
• The materials removed are to be sent for histological
examination.
• Presence of bleeding from the sloughing wound of
cervicovaginal canal should be controlled by
hemostatic sutures.
• Secondary hemorrhage following cesarean section
may at times require laparotomy.
• The bleeding from uterine wound can be controlled by
hemostatic sutures; may rarely require ligation of the
internal iliac artery or may end in hysterectomy.
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79. References:
 Dutta DC. Textbook of Obstetric including
Perinatology and Contraception. 7th ed. Jaypee
Brothers Medical Publishers (P) Ltd. New Delhi,
India: 2013; Page No.: 410-417.
 Bhide, Arulkumaran, Damania, Daftary. Arias‘
Practical Guide to High-Risk Pregnancy and Delivery:
A South Asian Perspective, 4th ed. Reed Elsevier India
Private Limited: 2015; Page No. 389-398
 Subedi DP. A Textbook of Midwifery
Nursing(Postpartum Care) Part III. First ed.
Reprint:2020. Akshav Publication Kathmandu; Page
No. 71-82
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