Postpartum hemorrhage (PPH) is excessive bleeding following childbirth. It is a leading cause of maternal mortality, accounting for nearly one quarter of maternal deaths worldwide. The most common cause is uterine atony, or failure of the uterus to contract after delivery. Other causes include retained placenta, trauma during delivery, coagulation disorders, and issues like placenta previa. Risk factors include previous PPH, macrosomia, multiple pregnancy, and uterine overdistention. Prevention focuses on risk assessment and active management of the third stage of labor. Treatment depends on the severity but may include uterine massage, uterotonic drugs, uterine packing, arterial ligation, embolization, compression sutures,

1. POST PARTUM
HEMORRHAGE
ANAMIKA RAMAWAT
M.Sc. Nursing Prev.
Batch 2017-18
GCON, Jodhpur

3. OUR BEST ESTIMATE IS A GROSS UNDERESTIMATE
200,000 women die from
PPH each year.

4. All pregnancies are at risk of PPH
even if no predisposing factors are
present.

5. • Important cause of maternal
mortality.
• Accounting for nearly one
quarter of all maternal deaths
worldwide.
• India -The maternal mortality
rate 35-56%, 560/100,000 live
births & PPH accounts for 35-
56% of Maternal deaths in
India.
35-56%

6. INTRODUCTION
• PPH is a condition in which excessive bleeding from the
genital tract at any time following the baby’s birth up to
6 weeks after delivery.
• Hemorrhage may occur before, during, or after delivery
of the placenta.
• The average blood loss following vaginal delivery,
cesarean delivery and cesarean hysterectomy is 500 ml,
1000 ml and 1500 ml respectively.

8. 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 mother, evidenced by increase in pulse
rate and falling blood pressure is called postpartum
hemorrhage”
-Dutta, 2001

10. 1. Primary (immediate) postpartum
hemorrhage is defined as excessive
bleeding that occurs within the first 24
hours after delivery.
• About 70% of immediate PPH cases
are due to uterine atony.
• Atony of the uterus is defined as the
failure of the uterus to contract
adequately after the child is born.
2. Secondary (late) postpartum
hemorrhage is defined as excessive
bleeding occurring between 24 hours
after delivery of the baby and 6 weeks
postpartum.
• Most late PPH is due to retained
products of conception, or infection,
or both combined. This condition of
postpartum hemorrhage causes
hemorrhagic shock.

11. ETIOLOGY

13. TONE (UTERINE ATONY)
• The most common and important cause of PPH is uterine
atony.
• 75-90% of cases
• Uterine atony can often be effectively managed with uterine
massage in conjunction with administration of uterotonics.

14. 1. Incomplete separation of placenta 2. Uterine hyperdistention –
Macrosomia baby –Multiple
pregnancy- polyhydramnios
3. Previous PPH 4. Placenta previa
5. General anesthesia- in inhalational
agents like halothane
6. High parity
7. Precipitated labour- less than 1 hour 8. Prolonged labour – active phase
lasts more than 12 hours
9. Fibroids 10. Obesity (BMI > 35), Age > 40 years
old

15. TISSUE
• Retained products of conception, most often a retained
placenta or retained placental fragments, must be removed
to stop bleeding.
• Rarely, an invasive placenta may be present.
• Hysterectomy is the most common treatment.

16. TRAUMA
• 5-10% of cases
• Operative vaginal delivery (vacuum / forceps)
• Perineal, vaginal and cervical tears
• Lower segment tears
• Uterine rupture
• Caesarean section
• Mediolateral episiotomy
• Trauma resulting from the birth process can result in significant blood loss.
• The source of trauma must be quickly identified and treated.

17. THROMBIN
• Disseminated intravascular coagulation
• Placental abruption
• Pre-existing bleeding disorder like hemophilia
• Patient on anti-coagulant
• Fresh blood is usually the best treatment, as this will contain
platelets and the coagulation factors V and VIII.
• Fresh frozen plasma may also be infused.

18. SIGNS & SYMPTOMS OF PPH
 Vaginal bleeding is visible outside, either as slow trickle
or rarely a copious flow. Rarely, the bleeding is
concealed either remaining inside the uterovesical canal
or in the surrounding tissue space resulting in
hematoma.
 Enlarged uterus, as it fills with blood or blood clot. It
feels boggy on palpation, i.e., soft and distended
lacking tone.

19. Pallor
Tachycardia
Hypotension
Altered level of consciousness
Restlessness
Drowsiness
Maternal collapse

20. PREVENTION
• PPH cannot always be prevented.
• However, the incidence and especially its
magnitude can be reduced substantially by
assessing the risk factors and following the
guidelines as mentioned below:

21. ANTENATAL
• Improvement of the health status.
• High risk patients (twins, hydramnios, grand
multipara, APH, history of previous PPH, severe
anemia)
• Blood grouping
• Placental localization by USG or MRI to detect
placenta accreta or percreta.

22. INTRANATAL
• Active management of the third stage.
• Cases with induced or augmented labor by oxytocin.
• Women delivered by cesarean section.
• Exploration of the uterovaginal canal for evidence of trauma.
• Observation for about two hours after delivery to make sure that the
uterus is hard and well contracted before sending women to ward.
• Expert obstetric anesthetist.
• During cesarean section spontaneous separation and delivery of the
placenta reduces blood loss.
• Examination of the placenta.

27. UTERINE INVERSION

29. SURGICAL
MANAGEMENT

30. TRANSVAGINAL UTERINE PACKING

31. UTERINE TAMPONADE

33. PELVIC ARTERY LIGATION- UTERINE, OVARIAN,
VAGINAL & INTERNAL ILIAC ARTERY

34. ANGIOGRAPHIC ARTERIAL EMBOLIZATION OR UTERINE
ARTERY EMBOLIZATION

35. B-LYNCH SUTURE (DESCRIBE IN 1997)

36. HAYMAN SUTURE, DESCRIBE IN 2002 WITH MODIFIED
COMPRESSIVE SUTURE WHICH DOES NOT REQUIRE
HYSTEROTOMY

37. HYSTERECTOMY
A surgical operation to remove all or part
of the uterus in case of life threatening
condition of the women i.e., menorrhagia,
post-menopausal period.
Most common surgical treatment done in
India.

39. SUB-TOTAL HYSTERECTOMY WILL BE NECESSARY IN
SOME CASES.

40. TECHNIQUES OF HYSTERECTOMY
• Abdominal hysterectomy
• Vaginal hysterectomy
• Laparoscopic-assisted vaginal
hysterectomy
• Laparoscopic-assisted
supracervical hysterectomy
• Total laparoscopic hysterectomy

42. SUMMARY…

43. THANK YOU