POST PARTUM HEMORRHAGE IS A CONDITION WHERE A EXCESS BLOOD LOSS FROM THE GENITAL TRACT MORE THEN 500 ML AFTER DELIVERY.

1. PPH (POST-PARTUM
HEMORRHAGE)

2. Introduction
PPH is defined as blood loss of 500 ml or more
within 24 hours after birth, whereas severe PPH
is defined as blood loss of 1000 ml or more at the
same time, according to the World Health
Organization (WHO).

3. DEFINITION
QUANTITATIVE PPH- “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”.

4. Cont.
CLINICAL DEFINITION- “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”
The average blood loss following vaginal
delivery, cesarean delivery and cesarean
hysterectomy is 500 mL, 1000 mL and 1500 mL
respectively.

5. Cont.
Depending upon the amount of blood loss, PPH
can be-
• Minor (< 1L)
• Major (> 1L)
• Severe (> 2L)

6. INCIDENCES
Severe bleeding after childbirth - postpartum
haemorrhage (PPH) - is the leading cause of maternal
mortality world-wide. Each year, about 14 million
women experience PPH resulting in about 70,000
maternal deaths globally.
(WHO)

7. TYPES
1. Primary
2. Secondary

8. Primary Postpartum
Hemorrhage
Hemorrhage occurring during the third
stage of labor and within 24 hours of
delivery.

9. Four basic pathologies are
expressed as the four Ts’ (RCOG)-
• Atonic PPH: TONE – Atonic (70%)
• Traumatic PPH :TRAUMA- Traumatic (20%)
• Mixed PPH :TISSUE- Mixed (10%) Increased
• THROMBIN: Blood Coagulopathy (1%)

10. Prevention
• Active Management of Third stage of Labour.
• Examination of Placenta
• Induced or accelarate Labour by Oxytocin.

11. 1) ATONICITY
Causes
• Grand multipara
• Overdistension of uterus
• Malnutrition

12. Management
• Massaging the uterus, PV examination.
• Oxytocin up to IV/500 ml.
• Tranexamic acid 1 gm.
• Methergin 0.2 mg
• Prostaglandins
 Mesoprostol (80 g Anal)
 Carbaprostol
• Bimanual compression
• IU Packing
• Surgical sutures
• Hysterectomy
• Uterine embolization/artery ligation
• JADA system

13. 2) TRAUMATIC PPH
PPH resulting from injury to genital tract.
Causes
A. Perineal tear.
B. Cervical
C. Hematoma
D. Rupture of uterus

14. A. Perineal Tear
A tear which involves perineum.
Causes
• Over stretching of the perineum (fuse to
pubic delivery)
• Rapid stretching of the perineum
(Precipitate Labour)
• Inelastic perineum- elderly Primi
(perineal scar)

15. Classification of tear
1 Tear
When vaginal mucosa/skin are tom
Injury to confined to vaginal mucosa and
skin

16. 2 Tear
1 + perineal muscles are tom

17. 3 Tear
Injury to perineum and sphincter involved
50 % ≥ 50 % External
of external of external Anal
anal sphincter anal sphincter Sphincter+
Tear tear Internal Anal
Sphincter Tear

18. 3 and 4 Tear- Complete Perineal Tear

19. Management
– Repairing of 3 and 4 Tear-
• If recognized within 24 hrs of delivery
 Immediate Repair
• If recognized>24 hrs of delivery
 wait for 2 weeks
 Repair after infection and inflammation
subsides

20. Techniques of Repair
• 1 and 2 Tear
To be Done in Labour Room
Sutures vaginal mucosa (Continuous
suture- using vicryl/polyglactin)
Suture muscles (Interrupted sutures)
Vaginal skin (mattress sutures)

21. • 3 and 4 Tear
• Done under OT under General
Anesthesia Local Anesthesia
Repair rectal mucosa
Internal anal Sphincter
External anal sphincter

22. 4 Tear
Repairing 1 and 2 Tear
Vaginal mucosa
Mucosa
Vaginal skin

23. • Most common
End to end Anastomosis
• Best
Over lapping Techniques

24. Important point after
repairing
• Pregnancy should be avoided for a year
(Ideally)but at-least 6 months after 3rd/4th
degree repairs.
• In future these finalized can have vaginal
delivery.
• ACOG recommended a single shot of
antibiotics at the time of repairs.

25. B. Cervical Tear
• Is the most common cause of traumatic PPH.
Cause
• Iatrogenic
• Attempted forceps delivery trough incomplete
dilated delivery.
• Strong uterine contraction right Cervix.

26. Complication
– Hematoma
– Pelvic cellulitis
– Thrombophlebitis
– Cervical atropia
– Mid-Tri abortion in next pregnancy
– Colporrhexis – rupture of the vaginal wall

27. Management
– Most common site- 3’O Clock> 9’ O Clock
– Repairing the Tear

28. C. PELVIC HEMATOMA
• Collection of blood anywhere in the
areas between the pelvic peritoneum and
the perineal skin is called pelvic
hematoma.

29. Uncommon
– Serious morbidity
– Localized blood collection of blood
outside of blood vessels >2.5cm.

30. Incidence
1: 1000 deliveries
 >4cm: 1/1000 deliveries
 Supralevatorinfralevator
 Surgical intervention 1/1000 deliveries

31. Secondary postpartum
hemorrhage
Hemorrhage occurring after 24 hours of
delivery and within 6weeks of delivery.
It is also referred to as puerperal
hemorrhage.

32. Causes: Bleeding usually occurs between the 8th and
14th day of birth. Causes of late postpartum
hemorrhage are:
Stored pieces of cotyledon or membrane (most
common)
Infection and slough separation over deep laceration
of the cervix.
Endometritis and transplantation of the placenta -
due to delayed healing process.
Second hemorrhage from a surgical wound usually
occurs within 10-14 days. Probably because
1) Slough separation reveals a bleeding vessel
2) From granulation tissue

33. Bleeding withdrawal follows estrogen
treatment for breastfeeding suppression.
Other common causes are:
chorionepithelioma- occurs 4 weeks after
birth; cervical carcinoma; placental poly,
infected fibroid or fibroid polyp and puerperal
remodeling of the uterus.

34. Management
Supportive treatment:
• Blood transfusions, if necessary.
• Administration of 0.2 mg methergine
intramuscularly, if bleeding is the root of the
uterus.
• Prescribe antibiotics (clindamycin and
metronidazole) as usual.
Conservative: If bleeding is minimal and no
apparent cause has been found, a vigilant watch
for 24 hours or more is performed at the
hospital.

36. Prevention
Postpartum bleeding cannot always be
prevented. However, the incidence and
especially its magnitude can be greatly reduced
by assessing risk factors and following the
guidelines as set out below: However, most PPH
cases do not have significant risk factors.

37. Antenatal
• Improvement of the health status of the woman and to
keep the hemoglobin level normal (> 10 g/dL).
• High-risk patients, such as twins, hydramnios, grand
multipara, APH, history of previous PPH, severe
anemia).
• Blood grouping should be done for all women.
• Placental localization must be done in all women with
previous cesarean delivery (see p. 286) by USG or
MRI to detect placenta accreta or percretal.
• All women with prior cesarean delivery.
• Women with morbid adherent placenta are at high
risk of PPH.

38. Intra-natal
• 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.
• During cesarean section spontaneous separation and
delivery of the placenta reduces blood loss (30%).
• Examination of the placenta and membranes.

39. Conclusion
Around the world everyday About 830 women
die from pregnancy or childbirth-related
complications. Low and middle socio-economic
status countries are having more PPH cases
compared with 1% of industrialized nation.

40. SUMMARY

41. Thank you