The document summarizes the third stage of labor and postpartum hemorrhage (PPH). It defines PPH, describes the causes including uterine atony, retained tissues, trauma, and coagulopathy. It outlines prevention strategies, signs and symptoms, management which includes emptying the uterus, replacing blood loss, achieving hemostasis, and surgical procedures like hysterectomy if needed. PPH is a leading cause of maternal mortality and this document provides guidance on diagnosing and treating both primary and secondary PPH.

1. Mrs. U SREEVIDYA
Msc. NURSING,
Associate Professor,
Apollo college of nursing, CHITTOOR

3. Time from the birth of the
baby to the expulsion of the
placenta and its membrane
Events:
– Placental separation
– Descent to lower segment
– Expulsion with membrane.
3rd STAGE OF LABOR

4. Important 3rd stage complication
Postpartum
hemorrhage
Retention of
placenta
Shock
Pulmonary
embolism
Uterine inversion

5. AVERAGE BLOOD
Vaginal
delivery
500mL
Cesarean
delivery
1000mL
Cesarean
hysterectomy
1500mL

6. POSTPARTUM
HEMORRHAGE

7. DEFINITION
• Quantitative (WHO):
Amount of blood loss in
excess of 500mL
following birth of baby.

8. DEFINITION
• Clinical :
Any amount of bleeding,
from or into genital tract,
following birth of baby  the end of puerperium,
which adversely affect the condition of patient,
evidenced by rise in PR, and falling BP.

9. • Any amount of bleeding from and into the
genital tract following the birth of the baby
up to the end of the pueperium which
adversely affects the general condition of
the patient evidenced by rise in pulse rate
and falling BP is called post partum
haemorrhage”.
• Incidence
4-6% of all deliveries.

10. CLASSIFICATION
AMOUNT OF
BLOOD LOSS TYPES
Minor (< 1L)
Severe (> 2L)
Major (> 1L)
SECONDARYPRIMARY

11. beyond 24
hours
and within
puerperium
within 24
hours
followingthe
birth of baby
Third stage hemorrhage:
Bleeding occurs before
expulsion of placenta
True PPH:
Bleeding occurs subsequent
to expulsion of placenta

12. Primary
Postpartum
Hemorrhage

13. Primary post partum haemorrhage
Causes
• 4 T’s
• Tone
• Tissue
• Trauma
• Thrombin( blood coagulopathy)

14. Atonic
uterus
Blood
coagulopathy
Combined
(atonic uterus
+trauma)
CAUSES
Retained
tissues
Traumatic
Drugs
Tone
Thrombus Trauma
Tissues

15. COMMONEST CAUSE OF PPH
80%
1. Atonic
uterus

17. Separation of placenta
Torn uterine sinuses
Cannot be compressed
effectively
Imperfect contraction & retraction of
uterine musculature
Bleeding continues

19. C
A
U
S
E
S
GRAND
MULTIPARA
OVERDISTENDED
UTERUS
MALNUTRITION &
ANEMIA
ANTEPARTUM
HEMORRHAGE
PROLONGED OR
RAPID LABOUR
ANESTHESIAINDUCTION OR
AUGMENTATION
UTERUS
MALFORMATION
MISMANAGED 3RD
STAGE OFLABOR

20. Uterine atony
• High parity
• Over-distension of the uterus
• Malnutrition and anemia
• Antepartum hemorrhage
• General anesthesia
• Poorly perfused myometrium
• Prolonged labour
• Following augmented labour

21. • Uterine atony in previous labour
• Chorioamnionitis
• Malformation of uterus
• Uterine fibroid
• Very rapid labour
• Mismanaged third stage of labour

22. • Constriction ring:
• Avulsed cotyledon, succenturiate lobe
• Placenta previa
• Placental abruption
• A full bladder

23. CONTRIBUTES OF ALL PPH
10- 20%
2.Traumatic
Trauma to genital tract usually occurs following
operative delivery and even after spontaneous delivery

24. • Trauma involves usually the cervix, vagina,
perineum, paraurethral region (episiotomy
wound or lacerations)
• Rupture of uterus (rare)
• Broad ligament haematoma
• Vulvo-vaginal
haematoma
• Uterine inversion

25. Cause PPH due to
imperfect uterine
contraction
• Bits of placenta
• Blood clots
3. Retained
tissues

26. • Rare causes of PPH
• Blood coagulopathy
may be due to
diminished pro-
coagulants or increased
fibrinolytic activity
• Conditions :
– Abruptio placentae
– Jaundice in pregnancy
– Thrombocytopenic purpura
– HELLP syndrome
– IUD
• Specific therapy following
coagulation screen
including recombinant
activated factor VII may
be given
4. Blood
coagulopathy
(THROMBUS)

27. Drugs
Use of
tocolytic
drugs
Ritodrine
Nifedipine
Magnesium
sulphate
• Combination of atonic and traumatic causes

28. Clinical Features
• Visible bleeding
• Maternal collapse
• Pallor
• Rising pulse rate
• Falling BP
• Altered level of consciousness
• May restless/drowsy
• Enlarged uterus, boggy on palpation

29. Diagnosis
• Direct observation in open hemorrhage.
• In concealed case, diagnosis is based on
clinical effects.
• In traumatic hemorrhage- uterus is
contracted.
• In atonic hemorrhage-uterus is flabby and
becomes hard on massaging.

30. A) GENERAL EXAMINATION
• The general examination of the patient correspond to
the amount of blood loss
• In excessive blood loss, manifestation of shock appear
as hypotension, rapid pulse, cold sweaty skin, pallor,
restlessness, air hunger & syncope
B) ABDOMINAL EXAMINATION
• In atonic PPH: Uterus is larger than expected, soft, &
squeezing it lead to gush of clotted blood PV.
• In traumatic PPH: Uterus is contracted

31. C) VAGINAL EXAMINATION
• In atony: Bleeding is usually started few minutes after
delivery of the fetus
• It is dark red in colour
• Placenta may not be delivered
• In trauma: Bleeding starts immediately after delivery of
fetus
• It is bright red in colour
• Lacerations can be detected by local
examination

32. Investigations
• Thorough examination of the lower genital
tract. This may require theatre/anaesthesia.
• CBC, clotting screen, cross match, Coagulation
studies
• Hourly urine output
• Continuous pulse/blood pressure or central
venous pressure monitoring
• ECG, pulse oximetry

33. PREVENTION-
ANTENATAL
•Improvement of the
health status of the
women & to keep the
haemoglobin level
normal (>10g/dl).
•High risk patients who
are likely to develop PPH (
such as twins, hydramnios
etc.) are to be screened &
delivered in a well
equipped hospital
•Blood grouping should be
done for all women so that
no time is wasted during
pregnancy.
•Placental localization must
be done in all women with
previous caesarean 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 senior obstetrician.

34. PREVENTION- INTRANATAL
•Active management of the third stage,
for all women in labour should be routine as it reduces PPH by 60%.
•Cases with induced or
augmented labour by
oxytocin, the infusion
should be continued for
at least 1 hour after the
delivery.
•Women delivered by
caesarean section:
- Oxytocin 5 IU slow IV is to
be given to reduce blood
loss (Carbetocin 100mcg)
- Spontaneous separation
& delivery of the placenta
reduces blood loss (30%)
•Exploration of the utero-
vaginal canal for evidence
of trauma following
difficult labour or
instrumental delivery.
•Expert obstetric
anaesthesist is needed
when the delivery is
conducted under general
anaesthesia
•Examination of the
placenta & the membranes
should be a routine so as to
detect at the earliest any
missing part.

35. Immediate care in PPH
• COMMUNICATE.
• RESUSCITATE.
• MONITOR / INVESTIGATE.
• STOP THE BLEEDING.

36. Communicate to clinical team
• Call experienced midwife
• Call obstetric registrar & alert consultant
• Call anaesthetic registrar, alert consultant
• Alert haematologist
• Alert Blood Transfusion Service
• Call porters for delivery of specimens / blood

37. Resuscitate
• IV access with 14 G cannula X 2
• Head down tilt
• Oxygen by mask, 8 litres / min
• Transfuse
• Crystalloid
• Colloid

38. Management of 3rd stage hemorrhage
The principles in the management are:
 To empty the uterus of its contents & to make
it contract
 Toreplace the blood
 To ensure effective haemostasis in traumatic
bleeding

39. Steps of management:
Placental site bleeding
• Palpate the fundus and massage the uterus to make it
hard.
• To start crystalloid solution (NS or RL) with oxytocin
(1L with 20 units) at 60 drops per minute and to
arrange for blood transfusion
• Oxytocin 10U IM or Ergometrine 0.25mg or
methergine 0.2mg is given intravenously.
• Catheterise the bladder
• Sedation with morphine 15mg intramuscularly.
• To give antibiotics

40. MANAGEMENT OF THIRD STAGE BLEEDING
 Palpate the fundus & massage the uterus
to make it hard
 Tostart normal saline drip with oxytocin
& arrange for blood transfusion
 Oxytocin 10 units IM/ Methergin 0.2mg IV
 Catheterize the bladder
 Antibiotics (Ampicillin 2g & Metronidazole
500mg IV)
Placenta separated Not separated
Express the placenta out by
fundal pressure or controlled
cord traction method
Manual removal
under GA
** Traumatic haemorrhage should be
tackled by sutures

41. Manual Removal of Placenta
 Step 1
 Step2
 Step3
 Step4
 Step5
 Step6
 Step7

42. STEPS OF MANUAL REMOVAL OF
PLACENTA
1.PREPARATION- General anesthesia, Lithotomy
position, Catheterization
2.INTRODUCTION of one hand into the uterus
- after smearing with antiseptic solution
- in cone shaped manner
-fingers of the other hand separate the labia
majora
- fingers of uterine hand should locate the
placenta

43. 3.COUNTER PRESSURE on uterine fundus
-by the hand placed on abdomen (abdominal
hand)
-it should steady the fundus & guide the
movements of fingers inside the uterine cavity
till the placenta is completely separated
4.INSINUATION of fingers between the placenta
and the uterine wall
- back of the hand in contact with the uterine
wall

45. 5.EXTRACTION of placenta
- traction of the cord by the other hand
-uterine hand is still inside the uterus for
exploration of the cavity (to be sure that nothing
is left behind)
6.COMPLETION
- IV Methergin 0.2mg is given
-uterine hand is gradually removed while
massaging the uterus by the external hand to
make it hard

46. 7.INSPECTION
-inspection of cervicovaginal canal to exclude
any injury
-placenta and membranes is checked for
completeness
-be sure that uterus remains hard and
contracted

47. Difficulties:
 Hour – glasscontraction
 Morbid adherentplacenta
constriction of an organ at its centre as a result of
abnormal muscular contraction. ...
Hourglass contraction is the complication of labour,
tending to trap the placenta in the upper part of the
constricted uterus and possibly leading to excessive
blood loss after delivery.

48. Complications
• Haemorrhage due to incomplete removal
• Shock
• Injury to the uterus
• Infection
• Inversion
• Subinvolution
• Thrombophlebitis
• Embolism.

49. Management of true post partum
haemorrhage
Principles
• Todiagnose the cause of bleeding.
• To take prompt and effective measures to
control bleeding.
• Tocorrect hypovolemia.

50. Management
General measures
• Call for help.
• Put in two large bore, 14 gauge, cannulas.
• Keep patient flat and warm.
• Send blood for grouping and cross matching and ask
for 2 units of blood.
• Oxygen by mask, 10-15 litres / min
• Start 20 units of oxytocin in 1 L of NS at the rate of 60
drops/mt.
• Monitor vital signs
• Monitor type and amount of fluids the patient has
received, urine output, drugs- type, dose and time,
CVP.

51. Actual Management:
 note the feel of theuterus.
Atonicuterus
 Step 1: Massage the uterus to make it hard.
 Step 2: Explore the uterus under GA

52.  Step 3: Uterine massage and bimanualcompression.
 Step 4: Uterinetamponade
 Step 5: Surgical methods
 Step 6: hystrectomy

53. Actual Management:
Atonic uterus
Step 1:
• Massage the uterus to make it hard and express
the blood clot.
• Inj. Methergin 0.2mg IV.
• Start Inj.oxytocin drip (10 units in 500ml of NS) at
the rate of 40- 60 drops per min.
• Catheterise the bladder
• Examine the expelled placenta and membranes
for completeness. If the uterus fails to contract,
proceed to the next step.

54. Step 2:
• Explore the uterus under GA. Simultaneous
inspection of the cervix, vagina specially the
para- urethral region is to be done to exclude
co- existent bleeding sites from the injured
area.
• Blood transfusion
• Continue oxytocin drip.

55. In refractory cases:
• Inj. 15 methyl PGF2α 250micro gram IM in the
deltoid muscle every 15 minutes ( upto
maximum of 2 mg) or Misoprostol (PGE1) 1000
microgram per rectum.
• When uterine atony is due to tocolytic drugs,
calcium gluconate (1 gm IV slowly)

56. • Step 3: Uterine massage and bimanual
compression.
• Step 4: Uterine tamponade
(i) Tight intra uterine packing done uniformly
under GA.
(ii) Balloon tamponade

57. Step 5: Surgical methods
• Ligation of uterine arteries
• Ligation of the ovarian and uterine artery
anastomosis
• Ligation of the anterior division of internal iliac
artery (unilateral or bilateral).

58. • Step 6: Hysterectomy

59. Protocol
• Stage 0: normal - treated with fundal
massage and oxytocin.
• Stage 1: more than normal bleeding - establish
large-bore intravenous access, assemble
personnel, increase oxytocin, consider use of
methergine, perform fundal massage, prepare 2
units of packed red cells.

60. • Stage 2: bleeding continues - check coagulation status,
assemble response team, move to operating room,
place intrauterine balloon, administer additional
uterotonics (misoprostol, carboprost tromethamine),
consider: uterine artery embolization, dilatation and
curettage, and laparotomy with uterine compression
stitches or hysterectomy.

61. • Stage 3: bleeding continues - activate massive transfusion
protocol, mobilize additional personnel, recheck laboratory
tests, perform laparotomy, consider hysterectomy
• Following PPH keep the patient in labour room and observe
for 24-48 hrs.
Traumatic PPH
• The trauma to the perineum, vagina and the cervix is to be
searched under good light by speculum examination and
haemostasis is achieved by appropriate catgut sutures. The
repair is done under GA, if necessary.

62. Secondary PPH
Causes:
The causesare,
 Retained bits of placenta ormembranes.
 Infection and separation of slough over a deep cervico-
vaginal laceration.
 Endometritis and subinvolution of the placentalsite
 Withdrawal bleeding following oestrogen therapyfor
suppression of lactation.
 Other rare causes are—chorion epithelioma; carcinoma of
cervix, infected fibroids or fibroid polyps and puerperal
sepsis.

63. Diagnosis
 The bleeding site is usually brightred.
 Varying degree of anaemia and evidences of sepsis
are present.
 Internal examination reveals evidences of sepsis,
subinvolution and often a patulous cervical os.
 USG helps in detecting retained bits of placenta
inside the uterinecavity.

64. Management
 Principles—
 (1) To assess the amount of blood loss and to replace
the lost blood.
 (2) To find out the cause and to take appropriate steps
to rectify it.

65. • Call doctor
• Reassure woman and support person
• Rub up contraction by massaging uterus if it is still
palpable
• Express any clots
• Encourage to empty bladder
• Give an uterotonic drug
• Keep all pads and linen to assess blood loss
• If bleeding persists transfer women to the high
facilitated hospital.

67. Supportive therapy:
 Blood transfusion, if necessary; Inj Ergometrine 0.5mg
IM, if the bleeding is uterine in origin, antibiotics as
routine.
Conservative treatment:
 If the bleeding is slight and no apparent cause is
detected, a careful watch for a period of 24hrs or so is
done in hospital.

68. Active treatment:
 As the commonest cause is due to retained bits of
placenta or membranes, it is preferable to explore the
uterusurgently under GA.
 The productsare removed byovum forceps.
 Gentlecurettage is done by using flushing curette.
 Ergometrine 0.5mg is given IM.
 If bleed is from sloughing of wound of cervico-
vaginal canal, control it bysuturing.

69. Complications
• Shock
• Collapse
• Disseminated intravascular coagulation

70. Nursing Management

71. NursingAssessment
1. Assess for hypotension, tachycardia, change in
respiratory rate, decrease in urine output, and
change in mental status—may indicate hypovolemic
shock.
2. Assess location and firmness of uterine fundus.
3. Percuss and palpate for bladder distention, which may
interfere with contracting of the uterus.
4. Monitor amount and type of bleeding or lochia
present and the presence of clots.
5. Inspect for intactness of any perineal repair

72. Nursing Management
 Deficient fluid volume r/t excessive blood loss
secondary to uterine atony, lacerations, incisions,
coagulation defects, retained placental fragments,
hematomas
 Fear and anxiety r/t threat to physical being, deficient
knowledge of treatment.
 Pain r/t uterine contractions, distention from blood
between uterine wall andplacenta.
 Risk for complication, shock related to excessive
bleeding

73.  Interrupted breast feeding r/t mother’s health state
during the PPH.
 Risk for impaired parent/ infant bonding r/t lack of
early parent/ infantcontact.
 Risk for Infection related to blood loss and vaginal
examinations

74. Nursing Interventions
A. DecreasingAnxiety
1. Maintain a quiet and calm atmosphere.
2.Provide information about the situation and
explain everything as it is done; answer
questions that the woman and her family ask.
3.Encourage the presence of a support
person.

75. B. Maintaining Fluid Volume
1.Maintain or start a large-bore IV line if
vaginal bleeding becomes heavy.
2.Ensure that crossmatched blood is
available.
3.Infuse oxytocin, IV fluids, and blood
products at prescribed rate.
4. Monitor CBC for anemia.

76. C. Preventing Infection
1. Maintain aseptic technique.
2.Evaluate for symptoms of infection, chilling, and
elevated temperature, changes in white blood
cell count, uterine tenderness, and odor of
lochia.
3. Administer antibiotics as prescribed.

77. Patient Education/Health
Maintenance
1. Educate the woman about the cause of the
hemorrhage.
2. Teach the woman the importance of eating a balanced
diet and taking vitamin supplements.
3. Advise the woman that she may feel tired and
fatigued and to schedule daily rest periods.
4. Advise the woman to notify her health care provider
of increased bleeding or other changes in her status.

78. Evaluation
A. Verbalizes concerns about her well-being
B.Vital signs stable, urine output adequate,
hematocrit stable
C.Remains afebrile, WBC count within
normal limits

79. RETAINED PLACENTA
The placenta is said to be retained when it is not
expelled out even 30 minutes after the birth of
the baby.(WHO 15mnts)

80. PLACENTA ACCRETA, INCRETA,
AND PERCRETA

81. INVERSION OF THE UTERUS
• It is extremely rare but a life threatening
complication in third stage in which the uterus
is turned inside out partially or completely.

82. OBSTETRIC SHOCK
 Shock is a critical condition and a life threatening
medical emergency.
 Shock results from acute, generalized,
inadequate perfusion of tissues, below that
needed to deliver the oxygen and nutrients for
normal function

83. AMNIOTIC
FLUID
EMBOLISM
Definition
 An amniotic fluid embolism is rare
but serious condition that occur
when amniotic fluid, fetal material,
such as hair, enters the maternal
bloodstream

85. Thank
You 