This document discusses postpartum haemorrhage (PPH), defined as blood loss exceeding 500 ml following childbirth. It notes that PPH has various causes including an atonic uterus, trauma during delivery, retained placental tissues, and coagulation disorders. The primary types are those occurring within 24 hours of delivery. Management involves controlling blood loss, administering oxytocics, and may require interventions like uterine packing or hysterectomy in severe cases. Prevention strategies include active management of the third stage of labour and being prepared to treat PPH as a potential complication of childbirth.

2. POST PARTUM
HAEMORRHAGE

3. INTRODUCTION-
PPH is one of the most alarming and serious
emergencies a midwife may face and is
especially terrifying if it occurs immediately
following a birth.

4. DEFINITION
 The amount of blood loses in excess of 500
ml following birth of the baby (WHO).
 Clinical definition “Any amount of bleeding
from or into genital tract following birth of the
baby up to the end of the puerperium, which
adversely affects the general condition of the
patient evidence by rise in pulse rate and
falling blood pressure, is called post partum
hemorrhage.”

5.  The incidence is about 4-6% of all deliveries.
TYPES
 Primary – hemorrhage occurs within 24 hours
following the birth of the baby.
Third stage hemorrhage – bleeding occurs
before expulsion of placenta.
True stage hemorrhage – bleeding occurs
subsequent to expulsion of placenta
(majority).
 Secondary- hemorrhage occurs beyond 24
hours within puerperium.

6. PRIMARY PPH-
CAUSES-
1.ATONIC UTERUSES (80%)
Atonicity of the uterus is the commonest cause of
post partum hemorrhage. This is a failure of the
myometrium at the placental site to contract and
retract and to compress blood vessel and control
blood loss by living ligature action. Following are
the conditions
 Grand multipara – inadequate retraction and
frequent adherent placenta.
 Over-distension of the uterus- as in multiple
pregnancy, hydramnious and large baby.
Imperfect retraction.
 Malnutrition and anemia – even slight blood
loss can develop PPH.

7.  APH
 Prolonged labour – poor retraction, infection
(amnionitis), dehydration are important factors.
 Anesthesia – depth of anesthesia and the
analgesic may cause atonicity.
 Initiation or augmentation of delivery by oxytocin.
 Malformation of the uterus – implantation of the
placenta in the uterine septum of a septate
uterus.
 Uterine fibroid
 Mismanaged third stage of labour.
 Precipitate labour.

8. 2.Traumatic (20%)
Trauma to the genital tract usually occurs
following operative delivery, even after
spontaneous delivery. Trauma involves
usually the cervix, vagina, perineum
(episiotomy wound and lacerations) and Para
urethral region.
3.Retained tissues-Bits of placenta, blood
clots cause PPH due to imperfect uterine
retraction.

9. 4.Drugs
Use of Tocolytic drugs (ritodrine), MgSO4,
Nifedipine
5.Blood coagulation disorders, acquired or
congenital
Blood coagulation disorder is less common
cause of PPH.

10. CLINICAL FEATURE-

11. MANAGEMENT OF PPH-
 Management of 3rd stage bleeding
 Actual management
 MANAGEMENT OF 3RD STAGE BLEEDING
Steps of management
1. Placental site bleeding-
 To palpate the fundus and massage the uterus to
make it hard. The massage is to be done by
placing four fingers behind the uterus and thumb
in front.
 To start crystalloid solution (NS or RL) with
oxytocin (1L with 20 units) at 60 drops per minute
and to arrange for blood transfusion if necessary.

13.  Oxytocin 10 unit IM or methergine 0.2 mg is given
intravenously.
 To catheterize the bladder.
 To give antibiotics (Ampicillin 2gm and
Metronidazole 500mg IV)
2. Management of traumatic bleed
 The uterovaginal canal is to be explored under
general anesthesia after the placenta is expelled
and haemostatic sutures are placed on the
offending sites.

14. STEPS OF MANUAL REMOVAL OF PLACENTA
 The patient is placed in lithotomy position. With
all aseptic measures, the bladder is catheterized.
 One hand is introduced into the uterus in cone
shaped manner following the cord. While
introducing the hand, the labia are separated by
the fingers at the other hand.
 Counter pressure on the uterine fundus is applied
by the hand placed over the abdomens. The
abdominal hand should steady the fundus and
guide the movement of the fingers inside the
uterine cavity till the placenta is completely
separated.

15.  As soon as the placenta margin is reached, the
fingers are inserted between the placenta and the
uterine wall with the back of the hand in contact
with the uterine wall.
 When the placenta is completely separated, it is
extracted by traction of the cord by the other
hand. The uterine hand is still inside the uterus for
exploration of the cavity to be sure that nothing is
left behind.

17. MANAGEMENT OF TRUE PPH
 Immediate measures are to be taken by the
attending House officer (Doctor/ Midwife).
 Call for extra help.
 Send blood for group, cross matching, diagnostic
test
 Infuse rapidly 2 liters of normal saline.
 Give O2 by mask 10-15 L/min.
 Start 20 units of oxytocin in 1 L of NS IV at the
rate of 60drop per min.

18. ACTUAL MANAGEMENT
The first step is to control the fundus and to note
the feel of the uterus. If the uterus is flabby, the
bleeding is likely to be from the atonic uterus. If
the uterus is firm and contracted, the bleeding is
likely to traumatic origin.

19.  ATONIC UTERUS
STEP I
 Massage the uterus to make it hard and express
the blood clot.
 Inject oxytocin drip is started (10 units in 500 ml
of NS) at the rate of 40-60 drops/ min.
 FC to keep bladder empty and to monitor urine
output.
 To examine the expelled placenta and
membranes for evidence of missing cotyledon or
piece of membranes.
 If the uterus fails to contract, proceed to next

20. STEP II
 Simultaneous inspection of the cervix and vagina
is to be done.
 T. Misoprostol 1000 mg per rectum is effective.
 When uterus atony is due to Tocolytic drug,
calcium gluconate (1g IV slowly) should be given
to neutralize the calcium blocking effect of the
drug.

21.  STEP III
 UTERINE MASSAGE AND BIMANUAL
COMPRESION
 The whole hand is introduced into the vaginal in
cone shaped fashion after separating the labia with
the finger of the other hand.
 The vaginal hand is clenched into a fist with the
back at the hand directed posteriosly and the
knuckles in the anterior fornix.
 The other hand is placed over the abdomen behind
the uterus to make it anteverted.
 The uterus is firmly squeezed between the two
hands.
 It may be necessary to continue the compression
for a prolonged period until the tone of the uterus is

23.  STEP IV
 UTERINE TAMPONADE
 Tight intrauterine packing is done
 A 5 meter long strip of gauze, 8cm wide folded twice
is required.
 The gauge is soaked in antiseptic cream before
introduction. The gauge is placed high up and
packed into the fundal area first while the uterus is
steadied by the external hand.
 Gradually the rest of the cavity is packed so that no
empty space is left behind.
 Antibiotic should be given and the plug should be
removed after 24 hours.

25. BALOON TAMPONADE
Tamponade using various types of
hydrostatic balloon catheter has mostly
replaced uterine packing.
STEP V
 Surgical methods to control PPH
 Ligation of uterine arteries-. The ascending
branch of the uterine artery is ligated at the lateral
border between upper and lower uterine segment..

26.  Ligation of the ovarian and uterine artery
anastomosis- If bleeding continue is done just
below the ovarian ligament.
 Ligation of anterior division of internal iliac
artery – reduced distal blood flow.
STEP VI
 Hysterectomy – rarely uterus fails to contract and
bleeding continues in spite of the above
measures.

29.  MANAGEMENT OF 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.

30. SECONDARY PPH
CAUSES
 The bleeding usually occurs 8th – 14th day of
delivery.
 Retained bits of cotyledon or membrane.
 Infection and separation of slough over a deep
cervico –viganal laceration.
 Endometritis and subinvolutionof the placental
site due to delayed healing process.

31. DIAGNOSIS
 The bleeding is bright red in color and of
varying amount.
 Degree of anemia and evidence of sepsis.
 Sub involution.
 USG
MANAGEMENT
 SUPPORTIVE THERAPY
 Blood transfusion
 Administer antibiotic as routine.

32.  CONSERVATIVE
 If the bleeding is slight and no apparent
cause is detected, a careful watch for a
period of 24 hrs or so is done in the hospital.
 ACTIVE MANAGEMENT
 The retained bits are removed by ovum
forceps.
 Gentle curettage is done by using flushing
curette.
 Methargin 0.2 mg is given IM.

33. PREVENTION-
1.Antenatal
 Improvement of the health status.
 High risk patients who are likely developing
PPH are to be screened and delivered in a
well equipped hospital.
 Blood grouping should be done for all women
so that no time is wasted during emergency.
 High risk cases should be delivered by a
senior obstetrician.

34. 2. Intranatal
 Active management of the third stage for all
women in labour should be a routine as it reduces
PPH by 60%.
 Cases with induced or augmented labour by
oxytocin, the infusion should be continued for at
least one hour after the delivery.
 Woman delivered by caesarean sections,
oxytocin 5IU slow IV is to be given to reduce
blood loss.
 Exploration of the utero-vaginal canal for
evidence of trauma following difficult labour or
instrumental delivery.
 Observation for about two hours of the delivery to
make sure that the uterus is hard and well
contracted before sending her .

35.  Expert- obstetric anesthetist is needed when
the delivery is conducted under general
anesthesia.
 Examination of the placenta and membranes
should be a routine so as to detect at the
earliest any missing part.

36. NURSING MANAGEMENT-
ASSESSMENT
1.Determine that normal third stage progress is
occurring.
 Rhythmic contraction until the placenta is born.
 Birth of placenta occurs 5 -30 min after birth of
the baby.
 Signs of placental separation is seen
 Fundus rises slightly in abdomen.
 Umbilical cord lengthens.
 Slight gush of blood noted.
 Placenta separation
 The mother may experience chills or shivering.

37.  Assess maternal blood pressure following birth of
baby.
 Assess the status of the uterus – contraction will
continue until birth of the placenta.
 Examine placenta to document that all cotyledons
and membrane are present.
NURSING DIAGNOSIS
 Anxiety related to knowledge deficit.
 Risk of infection
 Pain
 Fatigue
 Impaired skin integrity.

38. PLANNING
 Monitor maternal and newborn status.
 Provide support in parental newborn
interactions.
 Provide support and comfort measure during
third stage.
IMPLEMENTATION
 Observe and record birth of placenta.
 Monitor maternal blood pressure.

39.  Dry the baby completely.
 Administer oxytocics drugs as per physician’s
order.
EVALUATION
 Be sure that mother and newborn maintain
normal physical parameter.
 Monitor mother – baby attachment/ bonding.
 Make sure that mother feels comfortable and
supported during the third stage.