Postpartum haemorrhage (PPH) is defined as blood loss exceeding 500 mL following childbirth. It can be primary (within 24 hours) or secondary (24 hours to 12 weeks). The main causes are atonic uterus, trauma, retained tissues, and coagulopathy. Clinical features include vaginal bleeding, pallor, tachycardia, hypotension, restlessness, and drowsiness. Diagnosis is based on clinical examination and lab tests. Management involves uterine massage, uterotonics like oxytocin, ergometrine, misoprostol, aortic compression, uterine tamponade, and surgery if needed. Prevention strategies include identifying high-risk women and active management of

1. POSTPARTUM
HAEMORRHAGE (PPH)
SWECHCHHA POKHAREL
SWETA SHRESTHA
RASHMI GHISING
SUNITA GURUNG
SMITA PANDEY
MSC. NURSING 2ND YEAR
BATCH OF 2019

2. Content
Definitions
Types
Causes of PPH
Clinical Features of PPH:
Diagnosis of vaginal bleeding after childbirth (IMPAC)
Management of Primary PPH
Treatment in Low Resource Settings
Prevention
Complications
2

3. Introduction [1/2]
 Obstetric haemorrhage remains a
leading cause of maternal mortality.
 The average blood loss for a vaginal
delivery- 500 ml
caesarean delivery- 1000 ml
caesarean hysterectomy- 1500 ml
3

4. Introduction [2/2]
 Depending upon the amount of blood
loss, PPH can be:
Minor (< 1L),
Major (> 1L) or
Severe (> 2L).
4

5. Definitions [1/2]
 Amount of blood loss in excess of 500
mL following birth of the baby (WHO).
5

6. Definitions [2/2]
 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.
6

7. Types [1/2]
1. Primary Haemorrhage occurs within 24
hours following the birth of the baby. It’s of two
types:
- Third stage haemorrhage: bleeding occurs
before expulsion of placenta.
- True postpartum haemorrhage: bleeding
occurs subsequent to expulsion of placenta
(majority).
7

8. Types [2/2]
2. Secondary Haemorrhage:
Occurs beyond 24 hours and within
puerperium. It is also called as delayed or late
puerperal haemorrhage.
8

9. Causes of PPH
Primary PPH:
i. Atonic uterus
ii. Traumatic
iii. Retained tissue
iv. Blood coagulopathy
9

10. i. Atonic uterus (80%) [1/4]
 Commonest cause
 Cause due to imperfect
contraction and retraction of
the uterine musculature and
bleeding continues.
10

11. i. Atonic uterus (80%) [2/4]
Risks Factors
Grand multipara
Over distension of the uterus
Malnutrition and anaemia
Antepartum haemorrhage
Prolonged labour
11

12. i. Atonic uterus (80%) [3/4]
Initiation or augmentation of delivery by
oxytocin
Malformation of uterus
Uterine fibroid
Mismanaged third stage of labour
Placenta
12

13. i. Atonic uterus (80%) [4/4]
Precipitate labour
Other causes are:
• Obesity (BMI > 35)
• Previous PPH
• Age (>40 yrs.)
• Drugs: Ritodrine, MgSO4, Nifedipine
13

14. ii. Traumatic (20%)
 Operative delivery or even after
spontaneous delivery.
 Trauma to: cervix, vagina, perineum,
paraurethral region and rarely, rupture of the
uterus occurs.
 Usually revealed but can rarely be
concealed.
14

15. iii. Retained tissues
Bits of placenta, blood clots cause PPH due to
imperfect uterine retraction. Combination of
atonic and traumatic causes.
15

16. iv. Thrombin
 Less common
 Diminished procoagulants or increased
fibrinolytic activity
 Abruptio placentae, jaundice in pregnancy,
thrombocytopenic purpura, severe
preeclampsia, HELLP syndrome or in IUD.
16

17. Clinical Features [1/2]
 Bleeding from vagina, rarely, concealed.
 Pre-delivery Hb% level, blood volume &
speed of blood loss
 Pallor
 Rising pulse rate
17

18. Clinical Features[2/2]
 Falling BP
 Restless or drowsy
 State of uterus for cause of bleeding-
contracted / not
18

19. Diagnosis [1/2]
o Clinical features: visible outside.
o Examination: general physical, per vaginal.
The uterus as felt per abdomen gives clue as
regards the cause of bleeding.
19

20. Diagnosis [2/2]
o In traumatic the uterus is well contracted.
o In atonic haemorrhage it is found flabby
and becomes hard on massaging.
o Lab. Investigation: CBC, Group & Rh factor
20

21. Presenting symptoms May present Probable
diagnosis
 Immediate PPH
 Uterus soft and not contracted
 Shock Atonic uterus
 Immediate PPH  Complete
placenta
 Uterus
contracted
Tear of cervix,
vagina or
perineum
 Placenta not delivered within 30
minutes after delivery
 Immediate PPH
 Uterus
contracted
Retained placenta
 Portion of maternal surface of
placenta missing or torn
membranes with vessels
 Immediate PPH
 Uterus
contracted
Retained placental
fragments
21

22.  Fundus not palpable on
abdominal palpation
 Slight or intense pain
 Inverted uterus
seen at vagina
 Immediate PPH
Inverted uterus
 Bleeding >24 hrs. After delivery
 Uterus softer and larger than
expected
 Bleeding
variable
 Anemia
Delayed PPH
Immediate PPH (intraabdominal
or vaginal)
 Severe abdominal pain
 Shock
 Tender
abdomen
 Rapid maternal
pulse
Ruptured uterus
22

23. Management[1/6]
Principles
o Simultaneous approach: communication
o Resuscitation
o Monitoring
o Arrest of bleeding
23

24. Management[2/6]
 Shout for help
 Perform a rapid evaluation of G/C: vital signs
 Start IV line with wide bore cannula.
 Send blood for grouping, X-matching & ask
to arrange for blood.
24

25. Management[3/6]
 If shock is suspected, immediately begin
resuscitation & treatment. Rapidly infuse 2 L.
of N/S to expand the fluid volume.
 Massage the uterus to expel blood & blood
clots to bring effective uterine contractions.
25

26. Management[4/6]
 Give Oxytocin 10 units IM
 Catheterize the bladder
 Check for completeness of placenta &
membranes.
 Shock treatment: If shock is suspected,
immediately begin resuscitation & treatment.
26

27. Management[5/6]
Sign of shock:
 fast, weak pulse (110 per minute or more);
 low blood pressure (systolic less than 90 mm
Hg).
 Pallor
 sweatiness or cold clammy skin;
27

28. Management[6/6]
 rapid breathing (rate of 30 breaths per minute
or more);
 anxiousness, confusion or unconsciousness;
 scanty urine output (less than 30 mL per
hour).
28

29. Actual Management [1/10]
Step 1:
 Uterine massage
 Inj. Syntocin 10 units IM
 Inj. Oxytocin drip is started
 Catherization to empty the bladder.
 Examine the placenta & membrane.
 If failed then proceed to next step.
29

30. Actual Management [2/10]
Step 2:
 Uterus explore under G.A.
 Inspect cervix, vagina, & perineum,
paraurethral region for any injuries
 Continue oxytocin drip
 Injection 15methyl PGF2 @50 micro gm IM
every 15 minutes (up to maximum of 2 gm)
30

31. Actual Management [3/10]
 Misoprostol 600-1000mcg per rectum is
effective.
 Inj tranexamic acid 0.5gm or 1gm Iv may be
given in addition to oxytocin
 Due to tocolytic drugs, calcium gluconate (1g
IV slowly) given to neutralize these drugs.
31

32. Actual Management [4/10]
Step 3:Uterine massage and bimanual compression
Introduce whole hand into the vagina
in cone shaped, clenched fist with the
back of hand directed posteriorly.
The other hand is placed over the
abdomen behind the uterus to
make anteverted. The uterus is
squeezed firmly between two hands.
32

33. Actual Management [5/10]
Step 4:
- Compression of
abdominal aorta and
palpation of femoral
pulse
-Uterine tamponade
33

34. Actual Management [6/10]
Balloon tamponade
- Condom tamponade
 Sterile rubber catheter is
inserted within the condom and
tied near the mouth of the
condom by a silk thread.
 Urinary bladder was kept empty
by catheterisation.
34

35. Actual Management [7/10]
 After putting the patient in the lithotomy position,
the condom is inserted within the uterine cavity.
 Inner end of the catheter remained within the
condom.
 Outer end of the catheter is connected with a
saline set and the condom is inflated with 250-500
mL of running normal saline.
35

36. Actual Management [8/10]
 On an average, 350 ml of normal saline was
required to create adequate tamponade to
stop the bleeding.
 Bleeding is observed, and when it is reduced
considerably, further inflation is stopped and
the outer end of the catheter is folded and
tied with thread.
36

37. Actual Management [9/10]
 Oxytocin drip - 6 hrs after the procedure.
 Kept for 24-48 hrs and then is deflated
gradually over (10-15 m) and removed.
 Triple antibiotic coverage (amoxicillin [500 mg/6
h] + metronidazole [500 mg/8 h] + gentamicin
[80 mg/8 hrs]) for 7 day.
37

38. 38

39. Actual Management [10/10]
Surgical measures by skilled surgical staff:
 Uterine & utero-ovarian artery ligation
 Ligation of anterior division of internal iliac
artery.
 B Lynch compression suture
 Angiographic arterial embolization
 Subtotal hysterectomy
39

40. Drug Dose and
route
Dose
frequency
Side effects Contraindication
s
Oxytocin IV: 20 unit in
1 L of RL 60
drops/ min
IM: 10 units
Continuous
IV
Nausea
Water
intoxication
Not as IV bolus
(Not more than 3
L of IV fluids
containing
oxytocin)
Ergometrine
Methergine
IM or IV: 0.2
mg
Repeat after
15 minutes If
required give
0.2mg IM or
IV slowly
every 4
hours
Nausea
Vomiting
Hypertension
Hypertension
Preeclampsia
(Maximum 5
doses)

41. Drug Dose and
route
Dose
frequency
Side effects Contraindications
15 Methyl
PGF2α
IM: 0.25 mg 2nd line
intrauterine.
Every 15- 90
minutes
Nausea
Vomiting
Diarrhea
Chills
Bronchial asthma
Active cardiac,
renal and hepatic
disease (Maximum:
8 doses)
Misoprostol
PGE1
PR: 600-
1000mcg
PO Single
dose
Fever
Tachycardia
None

42. Treatment in Low Resource
Settings [1/2]
1. Uterine massage
2. Misoprostol
3. Aortic Compression
4. Non-Pneumatic Anti Shock Garment (NASG)
42

43. Treatment in Low Resource
Settings [2/2]
Non-Pneumatic Anti Shock Garment (NASG)
- treatment of hypovolemic shock for transfer to
higher center.
- reverses the shock by compressing the lower
body vessels.
- circulating blood is directed mainly to the core
organs.
43

44. Prevention [1/2]
Antenatal
 Improvement of the health status.
 High risk patients are to be screened.
 Blood grouping should be done for all women.
 Placental localization must be done prior to CS.
 Women with morbid adherent placenta.
44

45. Prevention [2/2]
Intranatal
 Active management of third stage of labour.
 Cases with induced or augmented labour
by oxytocin.
45

46. Complications
Maternal death
Acute renal failure
 Sheehan’s syndrome
 Sepsis
 Anaemia
 Failure of lactation
46

47. 47

48. Summary 48

49. Reference
1. Dutta D.C. Textbook of obstetrics. Sixth edition. Calcutta, India;
New Central Book agency (P) Ltd: 2015.
2. Cooper MA, Fraser DM: Myles Text book for midwives:16th
edition, Churchill Livingstone Elsevier publication,2014.
3. Tuitui Roshani, Manual of Midwifery C, Postnatal. Fourth
edition. Bhotahiti, Kathmandu, Vidyarthi Pustak Bhandar: 2016.
4. Hasabe R, Gupta K, Rathode P. Use of Condom Tamponade to
Manage Massive Obstetric Hemorrhage at a Tertiary Center in
Rajasthan. The Journal of Obstetrics and Gynecology of India.
2015;66(S1):88-93
5. Pradhan, B., RC, L., Sharma, P., & Singh, A. (2016). Uterovaginal
Packing as Treatment in Primary Postpartum Hemorrhage in Patan
Hospital. Nepal Journal of Obstetrics and Gynaecology, 11(1), 44-
46. Retrieved from
https://www.nepjol.info/index.php/NJOG/article/view/16282
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