Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide, accounting for 25-50% of deaths. PPH is defined as blood loss of 500ml or more within 24 hours of delivery. Uterine atony is the most common cause, occurring in 80% of cases. Other causes include retained placenta, genital tract trauma, and coagulation disorders. Prevention strategies include active management of the third stage of labour and treatment involves restoring blood volume, ensuring uterine contraction, and potential surgical interventions if bleeding cannot be controlled. Without timely treatment, PPH can lead to complications like shock and death within a short period.

1. POST PARTUM HAEMORRHAGE
- A Challenge To Safe Motherhood

2. WEL COME TO
Taj Mahal
Taj Mahal-One of the seven wonders of the world, One
of the Greatest monuments, dedicated to the memory of
“Queen Mumtaz” who died in child birth, by her
husband “Emperor Sahajahan”, is a testimony and a
grim reminder of the tragedy of maternal mortality, that
can befall any women in childbirth.
Mar 5, 2014
PPH- Prof.S.N.panda & Dr.A.Patnaik
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3. Obstetric Haemorrhage
--- Ranks as the First cause of maternal mortality
accounting for 25 – 50 % of maternal deaths
POST ARTUM HAEMORRHAGE
though preventable, accounts for the
majority of the cases of obstetric
haemorrhage, the other causes being
– antepartum haemorrhage, abortion,
ectopic pregnancy and ruptured
uterus.
Mar 5, 2014
PPH- Prof.S.N.panda & Dr.A.Patnaik
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4. POST PARTUM HAEMORRHAGE
. . . the most common and severe type of
obstetric haemmorrhage, is an enigma
even to the present day obstetrician as it
is sudden, often unpredicted, assessed
subjectively and can be catastrophic.
The clinical picture changes so rapidly
that unless timely action is taken
maternal death occurs within a short
period.
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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5. MAGNITUDE OF THE PROBLEM
Direct Causes (%) of Mat.Mort. in selected countries*
Country
+MMR
Haemorrhage Sepsis
Toxaemia Abortion Obstructed
Labour
INDIA
874
18
14
16
14
03
Bangladesh
600
22
03
19
31
09
Ethiopia
566
6
2
6
25
4
Tanzania
678
18
15
03
17
--
Zambia
118
17
15
20
17
--
USA
15
10
08
17
06
03
*World watch paper 102Jacobson JL ed, 1991
Mar 5, 2014
+MMR – Maternal Mortality Rate / 100000 live births
PPH- Prof.S.N.panda & Dr.A.Patnaik
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6. MAGNITUDE OF THE PROBLEM
Causes of Mat.Mort. In India
Cause
Reg.Gen. India (1992)
FOGSI (1982)
23.7%
22.3%
Toxaemia
15.2
10.7
Puerperal Sepsis
08.1
28.4
Anaemia
19.4
-
Obstructed Labour
07.1
-
Abortion
11.8
-
Others
14.7
-
Haemorrhage
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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7. MAGNITUDE OF THE PROBLEM
CAUSES OF 110 MATERNAL DEATHS AT
OUR HOSPITAL FROM 1/1996-7/2000
120
NUMBER
100
80
11
OTHERS
4
5
7
MALARIA
12
ANAEMIA
60
17
40
23
RUPTURED UERUS
UNSAFE ABORTION
VIAL HEPATIIS
PIH
20
0
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31
HAEMORRHAGE
CAUSES
PPH- Prof.S.N.panda & Dr.A.Patnaik
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8. MAGNITUDE OF THE PROBLEM
PPH - A world of difference
Year
Developing
Countries
1930
1:3000 Births
Not Available
1950
1:20,000
Not Available
1980
1:60,000
1:1000
2000
Mar 5, 2014
Developed
Countries
1:100,000
1:5000
PPH- Prof.S.N.panda & Dr.A.Patnaik
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9. POST PARTUM HAEMORRHAGE
DEFINITION: -
Blood loss of 500ml or more per vaginum
during the first 24hrs after the delivery of
the baby.
Risk of Maternal Mortality & Morbidity
are 50 times more after PPH
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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10. ASSESSMENT OF BLOOD LOSS
AFTER DELIVERY
 Difficult
 Mostly Visual estimation (So, Subjective &
Inaccurate)
 Underestimation is likely
 Clinical picture -Misleading
 Our Mothers-Malnourished, Anaemic,
Small built, Less blood volume
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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11. MECHANISM OF HAEMOSTASIS
AFTER DELIVERY
• Uterine contraction & retraction
• Platelet aggregation → clot
formation
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12. Why PPH ?
1. Uterine atony (80%)
2. Retained Placenta
3. Trauma to genital tract
4. Coagulation disorders
5. Uterine inversion
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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13. 1. UTERINE ATONY
RISK FACTORS
 Over distension of uterus
 Induction of labour
 Prolonged / precipitate labour
 Anaesthesia (halogeneted) & analgesia
 Tocolytics (Tocolytics (also called anti-contraction medications or
labor repressants) are medications used to suppress premature labor )
 APH
 Grand multiparity
 Mismanagement of 3rd stage of Labour
 Full bladder
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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14. 2. RETAINED PLACENTA
Simple adhesion
Morbid adhesion>Accreta, Increta &
Percreta
3. TRAUMATIC
 Large episiotomy & extensions
 Tears & lacerations of perineum, vagina
or cervix
 Haematoma
 Uterine rupture
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15. Mar 5, 2014
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16. 4. COAGULATION DISORDERS
Abruptio placentae
Sepsis :IUD,PROM(premature
rupture of membrane)
Massive blood loss
Massive blood transfusion
Severe PET (Pre-eclamptic
Toxemia)/ Eclampsia
Amniotic fluid embolism
Hepatitis
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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17. 5. UTERINE INVERSION
←Incomplete InversionFundus felt through the Cx
Complete Inversion with
placenta accreta attached to the
fundus→
Mostly iatrogenic due to
mismanagement of 3rd stage - strong
traction on the cord with a relaxed
uterus / adherent placenta.
Mar 5, 2014
PPH- Prof.S.N.panda & Dr.A.Patnaik
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18. SYMPTOMS & SIGNS
Blood loss Systolic BP Signs & Symptoms
(% B Vol)
( mm of Hg)
10-15
Normal
postural hypotension
15-30
slight fall
↑PR, thirst, weakness
30-40
60-80
pallor,oliguria,
confusion
40+
40-60
anuria, air hunger,
coma, death
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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19. PREVENTION
Regular ANC
Correction of anaemia
Identification of high risk cases
Delivery in hospital with facility for Emergency
Obstetric Care.
 Otherwise transport to the nearest such hospital at
the earliest.




 Keep speedy transport available
 Local / Regional anaesthesia
 ACTIVE MANAGEMENT OF 3RD STAGE OF
LABOUR
 4th Stage of labour - Observation, Oxytocin
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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20. ACTIVE MANAGEMENT OF 3RD
STAGE OF LABOUR (WHO-1989)
 Oxytocics - Routine use in third stage → blood loss ↓
by 30-40%
 10 Units Oxytocin IV bolus
 Syntometrine 1 Amp IV
 Ergometrine 1 Amp IV
 Carboprost ( better than Ergometrine) 0.125 – 0.25 Mg IM
 Early cord clamping
 Controlled cord traction
 Inspection of placenta & lower genital tract
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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21. MANAGEMENT OF PPH
 TEAM- Obstetrician,
Anesthesiologist, Haematologist and
Blood Bank
 Correction of hypovolaemia
 Ascertain origin of bleeding
 Ensure uterine contraction
 Surgical management
 Management of special situation
Mar 5, 2014
PPH- Prof.S.N.panda & Dr.A.Patnaik
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22. MANAGEMENT OF PPH
CORRECTION OF HYPOVOLEMIA
 Large bore IV line (two)
 Crystalloids (RL)-3ml / ml of
blood loss
 Urine output (desired) –30ml / hr
 Whole blood / pack cell
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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23. MANAGEMENT OF PPH
ENSURE UTERINE CONTRACTION
 Palpate fundus
 Uterine massage
 Bimanual compression
 Compression of Aorta against
sacral promontory
 Foleys catheters
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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24. MANAGEMENT OF PPH
OXYTOCICS
 Oxytocin:
 Bolus of 10 units IV followed by Continuous
Infusion 100 mu / min
 Ergometrine 0.2 - 0.5mg IV
 Prostaglandins Carboprost- 0.25mg start, Rpt.15-30 min,
Maximum 2.0mg, Route-IM / intramyometrial
 Sulprostone- 400-600 micro gm
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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25. MANAGEMENT OF PPH
OTHER MODES
 M.A.S.T (Military Anti Shock Treatment)
 UTERINE PACKING
 UTERINE TAMPONADE
• Large bulb Foleys
• Sangstaken blakemole tube
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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26. MANAGEMENT OF PPH
SURGICAL TREATMENT
Depends on
 Extent & cause of haemorrhage
 General condition of patient
 Future reproduction
 Experience & skill
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27. MANAGEMENT OF PPH
SURGICAL TREATMENT







Mar 5, 2014
Repair of trauma if any
Uterine Artery ligation
Utero ovarian A. Ligation
Internal Iliac A. Ligation
Brace suturing of Uterus
Hysterectomy
Angiographic embolisation
PPH- Prof.S.N.panda & Dr.A.Patnaik
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28. MANAGEMENT OF PPH
RETAINED PLACENTA
 EUA(examination Under
Anaesthesia & Manual Removal
 If Placenta accretaObservation
Cytotoxic drugs- Methotrexate
Hysterectomy
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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29. MANAGEMENT OF PPH
ACUTE INVERSION OF UTERUS
 Manual replacementUnder GA / Uterine relaxant
 Hydrostatic method
 Surgical method ( Usually delayed
procedure)
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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30. MANAGEMENT OF PPH
MANAGEMENT OF DIC
 Fresh blood transfusion
 Blood products
Cryoprecipitate
Fresh frozen plasma
Platelet concentrate
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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31. MORBIDITY & MORTALITY from PPH
 Shock & DIC
 Renal Failure
 Puerperal sepsis
 Lactation failure
 Blood transfusion reaction
 Thromboembolism
 Sheehan’s syndrome
 >25% Maternal deaths are due to PPH
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PPH- Prof.S.N.panda & Dr.A.Patnaik
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32. Intelligent anticipation, skilled supervision,
prompt detection and effective institution
of therapy can prevent disastrous
consequences of PPH.
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33. Mar 5, 2014
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