This document defines and describes postpartum haemorrhage (PPH). PPH is classified as primary (occurring within 24 hours of delivery) or secondary (occurring between 24 hours and 12 weeks post delivery). The main causes of PPH are uterine atony, retained placenta, genital tract lacerations, coagulation disorders, and acute inversion of the uterus. Risk factors include multiparity, overdistension of the uterus, prolonged labour, and uterine fibroids. Management involves ABCs, fluid resuscitation, uterotonic drugs, bimanual compression, exploration for retained tissue, and in severe cases surgical interventions like hysterectomy. Secondary PPH is usually caused by retained products of conception or

1. Postpartum Haemorrhage (PPH)
By Ezmeer Emiral

2. PRIMARY PPH
• Loss of MORE than or
EQUAL to 500mL blood
from the genital tract
within 24 hours of
delivery
• Loss of MORE than or
EQUAL to 500mL blood
from the genital tract
between 24 hours and
12 weeks post delivery
SECONDARY PPH
•Postpartum Haemorrhage (PPH)
Classification

3. •Aetiology
5 “T”s
Uterine atony
Retained placenta and/or membranes
Clotting disorder
Uterine inversion
Tone
Tissue
Trauma
Thrombin
Injury to vagina, perineum ad uterine tears
at Caesarean section
Traction

4. 3.Genital tract laceration
•Causes
1.Uterine atony
2.Retained placenta
4.Coagulopathy
5.Acute inversion of uterus

5. • Can be predict.
• Predisposing conditions:
• Multiparity(Fibrosis of uterine
muscle)
• Over distension of uterus(eg:
Macrosomia,polyhydramnios)
• Prolong labour (uterine inertia)
• Fibroid
• Placenta previa
• Oxytocin induce labour
•Uterine Atony
Uterus fails to contract following delivery of placenta.

6. 3.Genital tract laceration
•Causes
1.Uterine atony
2.Retained placenta
4.Coagulopathy
5.Acute inversion of uterus

7. • Causes:
• Placenta separated but undelivered
• Placenta partly or wholly attached
• Placenta accreta
•Retained Placenta
Prevent a uterus from contracting efficiently

8. 3.Genital tract laceration
•Causes
1.Uterine atony
2.Retained placenta
4.Coagulopathy
5.Acute inversion of uterus

9. • Causes:
• Intsrumental delivery (Cervical
tears)
• Episiotomy can extend upwards
• Uterine rupture
•Genital Tract Lacerations
Perineal or vaginal tears.

10. 3.Genital tract laceration
•Causes
1.Uterine atony
2.Retained placenta
4.Coagulopathy
5.Acute inversion of uterus

11. • Causes:
• Von Willebrand's Disease, Platelet
disorder
• Placenta Abruptio-Retroplacental
clot leads to consumptive
coagulopathy
• Unidentified dead fetus
• Amniotic fluid embolus-amniotic
fluid entering maternal circulation
•Clotting disorder

12. 3.Genital tract laceration
•Causes
1.Uterine atony
2.Retained placenta
4.Coagulopathy
5.Acute inversion of uterus

13. • Caused by traction on the
umbilical cord before
placenta has separated.
• Associated factors:
-Fundal placenta
-Short cord
-Morbidly adherent placenta
• Cardiovascular collapse &
shock.
•Acute Inversion of Uterus
Uterus is pulled ‘inside out’ and the fundus at the introitus.
Third Degree Uterine Inversion

14. •Uterine Inversion
Stages/Classification
• First Degree (Incomplete)-inverted fundus
reached the external os.
• Second Degree (Complete)-whole body of the
uterus is inverted and protrudes into the
vagina
• Third Degree – prolapse of inverted uterus,
cervix and vagina outside the vulva

15. • (A)The protruding fundus is
grasped with fingers directed
toward the posterior fornix.
• (B, C) The uterus is returned to
position by pushing it through
the pelvis and into the abdomen
with steady pressure towards
the umbilicus.
• Acute inversion of uterus-
reduced manually or O’Sullivan
(hydrostatic pressure) or
surgery.
•Johnson’s Method

16. • Circulatory collapse ► shock,
organ failure, stroke,death
• Sheehan’s syndrome –
damage to pituitary –
pituitary necrosis
• Puerperal anaemia
• Fear of further pregnancies
•Complications of PPH

17. • ABC,fluid resuscitation
• Feel abdomen-uterus poorly
contracted
• Rub the fundus gently –see
wether uterus contract and
bleeding arrested
• Set up IV line & IV infusion of 40
units of syntocinon/B.C*/
intramyometrial injection of
ergometrine or PG
• Send blood for group and cross
matching
• Examine placenta to see if it is
complete-If uncompleted, sent
to OT for manual exploration
• If complete-Examine vagina and
cervix in lithotomy position for
laceration
•Management
Diagnosis & management occur simultaneously
Bimanual Compression*

18. • No laceration?-Examination
under anaesthesia(allow
further measures eg:uterine
tamponade,radioloical
occlusion)
• Exploratory Laporotomy(iliac
artery ligation,sutures)
• Hysterectomy
• B lynch -sutures are placed in
double loop that surround the
uterus & aim to squeeze
whole uterus by tightening
them
•Management
B lynch suture
Uterine Balloons

19. PRIMARY PPH
• Loss of MORE than or
EQUAL to 500mL blood
from the genital tract
within 24 hours of
delivery
• Loss of MORE than or
EQUAL to 500mL blood
from the genital tract
between 24 hours and
12 weeks post delivery
SECONDARY PPH
•Postpartum Haemorrhage (PPH)
Classification

20. • It is usually the result of:
• Retained product of conception
• Uterine infection
Rare cause of massive bleeding.
•Secondary PPH
Management
•Broad spectrum antibiotic
•Gentle evacuation of uterus
Clinical Sign
•Crampy abdominal pain
•Delayed uterine involution
•Signs of infection

21. Thank You for Your Attention
Questions?