This document defines postpartum hemorrhage and discusses its causes and management. It states that postpartum hemorrhage is defined as blood loss of over 500 ml following vaginal delivery or 1000 ml following c-section. The main causes discussed are atonic (80% of cases), traumatic, and coagulopathy. It recommends the use of uterotonic drugs like oxytocin to reduce the risk of PPH by over 40% and outlines the mnemonic "tone, tissue, trauma, thrombin" for evaluating and treating postpartum hemorrhage. Early recognition and having an established management plan are important for treating PPH once preventive measures fail.

1. Dr.Suresh Babu Chaduvula
Professor
Dept. of Obstetrics & Gynecology
College of Medicine, Abha, KKU, Saudi Arabia

2.  Definition:
 More than 500 ml of blood loss following
normal vaginal delivery of the fetus or
1000ml following Cesarean section.
 Clinically the amount of blood loss from or
into the genital tract which will adversely
affect the general condition of the patient
 Hemorrhage leading to fall in hematocrit by
10 %.
 Incidence – 1 %

3.  1] Primary 2] Secondary
 Primary – bleeding occurs following delivery
of the baby up to 24 hours
 Primary is two types:
 A] Third Stage hemorrhage
 B] True Post Partum hemorrhage

4.  Third Stage hemorrhage:
 Bleeding occurs before the expulsion of
placenta
 Example- Placenta accreta, retained
placenta
 True Postpartum hemorrhage:
 Occurs after the expulsion of placenta

5.  Secondary or Delayed or Late Postpartum
hemorrhage:
 Bleeding occurs following delivery of the
baby after 24 hours up to 6 weeks.

6.  Causes:
 1] Atonic
 2] Traumaic
 3] Mixed
 4] Coagulopathy

7.  Contributes for 80 % of PPH
 Commonest cause of PPH
 Cause – Faulty retraction of the uterus
 Etiology:
 1] Grand Multipara
 2] Over- distension of uterus – Multiple
pregnancy, Hydramnios, big baby
 3] Anemia

8.  4] Prolonged Labor
 5] Anaesthesia – Halothane. Ether,
 Cyclopropane
 6] Uterine fibroid
 7] Precipitate labor
 8] Malformations of uterus – septate uterus,
bicornuate uterus
 9] Ante partum hemorrhage
 10] Initiation & augmentation of delivery
with oxytocin

9.  1] Cervix – lacerations
 2] Vaginal laceration
 3] Perineum injury
 4] Paraurethral injury
 5] Uterine rupture

10.  Combination of Atonic and Traumatic:
 Blood coagulation Disorders:
 Abruptio Placenta, Jaundice,
Thrombocytopenic purpura, HELLP syndrome

11. Tone
Tissue
Trauma
Thrombin

16.  Vaginal bleeding may be revealed or
concealed
 Alteration in pulse, Blood pressure and Pulse
pressure
 Flabby uterus in atonic uterus

18.  UTEROTONIC DRUGS
 Routine oxytocic administration in the third
stage of labour can reduce the risk of PPH by
more than 40%
 The routine prophylaxis with oxytocics results
in a reduced need to use these drugs
therapeutically
 Management of the third stage of labour should
therefore include the administration of
oxytocin after the delivery of the anterior
shoulder.

19.  Early recognition of PPH is a very important
factor in management.
 An established plan of action for the
management of PPH is of great value when
the preventive measures have failed.

28. Description of technique

29.  Tone
 Tissue
 Trauma
 Thrombin

30.  “TONE”
 Rule out Uterine
Atony
 Palpate fundus.
 Massage uterus.
 Oxytocin
 Methergine

31.  “Tissue”
 R/O retained placenta
 Inspect placenta for
missing cotyledons.
 Explore uterus.
 Treat abnormal
implantation.

32.  “TRAUMA”
 R/O cervical or
vaginal lacerations.
 Obtain good
exposure.
 Inspect cervix and
vagina.
 Worry about slow
bleeders.
 Treat hematomas.

33.  “THROMBIN”  Replacement with
blood or Fresh frozen
plasma or Platelet
rich plasma.

34. THANK YOU