Postpartum hemorrhage (PPH) is excessive bleeding following childbirth. It can be primary (within 24 hours) or secondary (24 hours to 6 weeks). The main causes are uterine atony (70%), trauma (20%), and retained tissue (10%). Signs include visible bleeding, pallor, tachycardia, and a boggy uterus. Treatment involves uterine massage, bimanual compression, fluid resuscitation, medications like oxytocin and misoprostol, and monitoring of vital signs. Prevention strategies include risk identification, active management of the third stage of labor, and treatment of any lacerations. PPH is a leading cause of maternal mortality worldwide.

1. Postpartum hemorrhage
Anju Bista
M.Sc. Nursing 2nd year
Maternal health nursing
1

2. Objectives:
• At the end of this session, participants will be
able to explain PPH
2

3. OUTLINES
• Introduction
• Types
• Causes
• Sign and symptoms.
• Diagnosis
• Medical Management
• Nursing Management
3

4. Introduction
• Globally every year 14 million women suffer
from postpartum hemorrhage.
• The most recent maternal mortality ratio was
estimated to be 281 per 100,000 live births
about 25% of which has been attributed to
postpartum hemorrhage (PPH).(DHS-2016)
4

5. Introduction
• Immediate PPH occurs during the first 24
hours after delivery.
• It most commonly is the result of uterine atony
caused by over distention during pregnancy or
factors complicating labor and delivery.
5

6. Contd…
• Hemorrhage also may be delayed, occurring
more than 24 hours after delivery.
• Most frequently occurs between the 5th and
15th postpartum day, but it can occur as long
as 6 weeks after delivery.
• Hemorrhage usually occur suddenly and may
be so massive that they produce hypovolemia.
6

7. Contd…
• The most frequent causes of delayed and late
postpartum hemorrhage are sub-involution of
the placental site, retained placental tissue, and
infection.
• Regeneration of the placental site takes longer
than the rest of the endometrium.
• Until the site is firmly epithelialized, sloughing
of clots may cause bleeding.
7

8. PPH
• 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
evidence by rise pulse and falling blood
pressure, is called Post partum hemorrhage.
8

9. Contd…
• Clinical definition is vaginal blood loss
irrespective of its amount post delivery up to
end of puerperium making patient
hemodynamically unstable or hematocrit drop
of 10% or hemorrhage requiring immediate
transfusion.
• If occur in 1st 24 hrs- primary PPH
• Occurs aftr 24 hrs- secondary PPH
9

10. Contd…
• The average blood loss after vaginal delivery,
cesarean delivery and cesarean hysterectomy is
500 mL,1 L and 1.5 L respectively.
• Some authors classify PPH depending on blood
loss as minor PPH (blood loss 500 mL to 1 L)
major PPH (blood loss 1 L-2 L) and severe PPH
(blood loss > 2 L).
• Other authors consider blood loss of > 1 L as
massive PPH.
• Incidence: varies
10

11. Incidence
• Occurs about 1% amongst hospital deliveries.
• More than half of all maternal death occurs
within 24 hrs of childbirth, mostly due to
excessive bleeding.
• PPH causes more than 1/4th of all maternal
deaths worldwide, with uterine atony being the
major factor.
• Tears of the birth canal are the 2nd most
frequent causes of PPH.
11

12. 12

13. Classification/ type
1. Primary PPH:
• Prior hemorrhage occurs within 24 hours
following the birth of baby is known as
primary PPH In the majority, hemorrhage
occurs within 2 hours following delivery.
• Primary PPH is defined as blood loss of more
than 500 mL (1 L for cesarean section) from or
into the genital tract in the first 24 hours of
childbirth (World Health Organization, 1990)
13

14. These are of two types
• 3rd stage hemorrhage: bleeding occurs
before expulsion of placenta
• True PPH: bleeding occurs subsequent to
expulsion of placenta up to 24 hours of
delivery. (majority).
14

15. Incidence
• Primary PPH: Approximately 2 to 5 % and is
higher in areas where active management of
the 3rd stage of labour is not practiced.
• Secondary PPH: bleeding or haemorrhage
occurs beyond 24 hours and within puerperium
also called delay / late puerperal haemorrhage.
15

16. Acc To Helping Mothers Survive
Bleeding after Birth Complete
16

17. Causes of Primary PPH:
• Any factor that causes the uterus to relax after
birth will cause bleeding.
• A helpful way to remember the causes of PPH
is by using the “4Ts":
• Tone (70%), trauma (20%), tissue retain
product (10%), and thrombosis (1%). Among
three T', the thrombin will be occurred as 1%)
17

18. I. Bleeding from Placental
Implantation Site (Tone)
1. Uterine atony (80% cases):Atonicity of the
uterus is the commonest cause of PPH. With the
separation of the placenta, the uterine sinuses,
which are torn, cannot be compressed effectively
due to imperfect contraction and retraction of the
uterine musculature and bleeding continues.
 Some general anesthetics-halogenated
hydrocarbons or conduction analgesia uterine
inertia results uterine muscle exhaustion
 Poorly perfused myometrium--hypotension
18

19. Contd…
 Over distended uterus-_twins, large fetus,
polyhydramnios- imperfect retraction, large
placental site cause excessive bleeding.
Prolonged labor due to poor retraction ,
infection, dehydration and analgesic drugs
Precipitate labor – contracted vigorously then
muscle may have insufficient opportunity to
retract or bleeding from genital lacerations
19

20. Contd…
Induction or augmentation with prostaglandins
and oxytocin excessive use can cause
oxytocin receptor desensitization.
High parity due to inadequate retraction, more
chances of adherent placenta
Chorio amnionitis bacterial infection
could enter in uterus too.
Full bladder – interfere with good uterine
contraction
20

21. II. Tissues
1.Retained placental tissue
2.Avulsed cotyledon,
succenturiate lobe
3.Morbidly adherent
placenta (placenta accreta,
increta, percreta)
21

22. III. Trauma to the Genital
Tract(20%)
1. Large episiotomy and extensions
2. Lacerations of perineum, vagina or cervix
3. Rupture uterus
22

23. IV. Combined Factors (Tone +
Trauma)
• Atonicity and traumatic cause
23

24. V. Thrombosis (Coagulation Defects)
• Congenital or acquired bleeding or coagulation
disorders, thrombocytopenic purpura, severe
preeclampsia, HELLP syndrome or in IUD.
24

25. Clinical Features(1/4):
• In majority:- visible
bleeding from vagina,
rarely, concealed either as
vulvo-vaginal or broad
ligament hematoma.
• The effect of blood loss
depends on: pre-delivery
Hb% level, blood volume
& speed of blood loss.
25

26. Clinical Features(2/4):
• However, more subtle signs present (after 20-
25% blood loss) (Initial)
Pallor
Rising pulse rate
Raised ,normal or slightly Falling BP
Enlarged uterus- fills with blood cause “boggy
on palpation.
26

27. Clinical Features(3/4):
• Late features:
Tachycardia, hypotension, severe pallor, cold
clammy skin, air hunger, per abdomen – uterus
is soft and flaccid, fundal height is air higher
level.
Altered level of consciousness: may become
restless or drowsy
27

28. Clinical Features(4/4):
State of uterus, as felt per abdomen, gives a
reliable clue for cause of bleeding- contracted /
not
In traumatic hemorrhage, the uterus is found
well contracted.
In atonic hemorrhage, the uterus is found
flabby and become hard on massaging.
However, both atonic and traumatic cause may
co-exist.
28

29. Diagnosis and Clinical Effects
• In majority, diagnosis is obvious as the vaginal
bleeding is visible outside.
• Occasionally hemorrhage may be totally
concealed like in vulvo-vaginal or broad
ligament hematoma.
29

30. The effect of blood loss depends
on(1/2):
• Rate of blood loss. Alteration of pulse, Blood
pressure and pulse pressure appears only after
20-25% loss of blood volume as these are
young women. Rarely, brisk hemorrhage may
cause death quickly.
• Antenatal hematocrit, Lab. Investigation:
CBC, Group & Rh factor,
30

31. The effect of blood loss depends
on(2/2):
• Uterine tonicity is a clinically useful and
reliable indicator for the etiology of bleeding.
• In traumatic PPH, the uterus is well contracted;
while in atonic PPH, the uterine tone is
decreased, feels soft becoming hard only on
manual massaging.
• Excessive hemorrhage in traumatic PH may
jeopardize her general condition and may
make the uterus atonic.
31

32. Prevention
• It is not always possible to prevent PPH.
However, the incidence and severity of PPH
can be significantly reduced by using the
following guidelines.
Antepartum Care
• Improvement of the health status and the
hemoglobin of the patient.
• The high risk patients should have their
delivery in a well-equipped hospital.
32

33. Contd…
• Blood grouping should be done for all women and
blood should be cross-matched and arranged for
high-risk women.
• Placental localization should be done by
ultrasound for all cases to diagnose placenta
previa.
• Morbidly adherent placenta should be ruled out in
previous cesarean cases. If present they need
management in tertiary hospital with facilities for
blood and cesarean hysterectomy.
33

34. Intrapartum Care
• Delivery should be slow and gentle and by
pushing from the retracted uterus.
Pulling of the baby should be avoided.
As women with anemia and pre-eclampsia do
not have a reserve, quick replacement of blood
loss should be carried out.
Adequate hydration of all women in labor is
recommended and any dehydration should be
quickly treated by intravenous hydration.
34

35. Intrapartum Care
• Local or epidural analgesia should be used
instead of general anesthesia.
Even for cesarean delivery, spinal anesthesia is
preferred.
Expert obstetric anesthetist should give
anesthesia
35

36. Intrapartum Care
• To minimize blood loss during cesarean
delivery, spontaneous separation and delivery
of the placenta should be allowed.
Experienced surgeon should perform cesarean
delivery for conditions associated with high
prevalence of PPH like placenta previa.
36

37. Intrapartum Care
• It has been proven that active management of the
third stage of labor decreases the incidence and
severity of PPH.
Thus, active management of the third stage should
be universally adopted.
• Undue compression of uterus, pulling the cord
and Crede's method of placental delivery should
be abandoned.
Placenta should be delivered by controlled cord
traction method.
37

38. Intrapartum Care
• Examination of the placenta and membranes
should be a routine so as to detect missing part or
lobe of placenta at the earliest.
• For women who are on oxytocin drip for
induction or augmentation of labor, the oxytocin
drip should be given for an hour after the delivery.
• Routine exploration of the genital tract should be
done for any lacerations after difficult labor or
forceps delivery.
38

39. Intrapartum Care
• The woman should be monitored for about two
hours after the child birth.
If the uterus remains hard and contracted for 2
hours, she can be transferred to the ward.
Every hospital should have a documented
protocol for PPH and all doctors, including
residents and nursing staff should be sensitized
to PPH drills to ensure adequate treatment in
event of an eventuality.
39

40. 40

41. 41

42. Management of True PPH
Principles:
• Simultaneous approach: communication
• Resuscitation
• Monitoring
• Arrest of bleeding
42

43. Management of True PPH
Immediate management
1. Call senior midwife, doctor, and extra help.
Massage the uterus abdominally to make it
hard
43

44. 2. Massage uterus and expel
clots(Acc IMPAC)
• If heavy postpartum bleeding persists after
placenta is delivered, or uterus is not well
contracted (is soft): Place cupped palm on uterine
fundus and feel for state of contraction.
• Massage fundus in a circular motion with cupped
palm until uterus is well contracted.
• When well contracted, place fingers behind
fundus and push down in one swift action to expel
clots.
• Collect blood in a container placed close to the
vulva. Measure or estimate blood loss, and record.
44

45. 3. Apply bimanual uterine
compression
• If heavy postpartum bleeding persists despite uterine
massage, oxytocin/Methyl Ergometrine treatment and
removal of placenta:
 Wear sterile or clean gloves.
 Introduce the right hand into the vagina, clenched fist, with
the back of the hand directed posteriorly and the knuckles in
the anterior fornix.
 Place the other hand on the abdomen behind the uterus and
squeeze the uterus firmly between the two hands.
 Continue compression until bleeding stops (no bleeding if
the compression is released).
 If bleeding persists, apply aortic compression and transport
woman to hospital.
45

46. 4. Apply aortic compression
• If heavy postpartum bleeding persists despite uterine
massage oxytocin/Methyl Ergometrine treatment and
removal of placenta:
 Feel for femoral pulse.
 Apply pressure above the umbilicus to stop
bleeding.Apply sufficient pressure until femoral pulse
is not felt.
 After finding correct site, show assistant or relative
how to apply pressure, if necessary.
 Continue pressure until bleeding stops. If bleeding
persists, keep applying pressure while transporting
woman to hospital.
46

47. Management of True PPH
5. Administer oxygen at 6-8 liter per min by
mask or nasal cannula
• Attain intravenous access by using two large
bore cannula (size 14,16).
47

48. Management of True PPH
6. Quick infusion of crystalloids (normal saline, Ringer
lactate, dextrose saline) 1-2 L and colloids
(Hemaccel) or other plasma substitutes should be
given to expand vascular bed.
 Initialy One litre of fluid per 15-20 minutes should be
given.- 2litre in 1st one hr
 At least two units of blood should be arranged after
grouping and cross matching the blood.
48

49. Management of True PPH
 Blood should also be tested for coagulation
profile.
• Investigations
(i) Hemogram, PCV, blood group, cross
matching
(ii) Electrolytes, urea and creatinine
(iii) Clot observation test.
49

50. 7. Monitoring of vital signs and maintenance
of airways and intravenous access (rate on
ECG monitor)
Pulse
Blood pressure
Heart rate
Respiratory rate
Oxygen saturation by pulse oximetry
Temperature
Urine output hourly -30ml/hr
Record of type and amount of fluids transfused
 Record of all drugs given
Central venous pressure by anesthetist for major and
severe hemorrhage.
50

51. 8. Confirmation of diagnosis
• It is made and cause of PPH should be
elucidated (e.g. atonicity, trauma or
coagulopathy).
51

52. 6. Medical methods.
1. Oxytocin
• Initial dose: iv/im 10 units, iv infusion 20 units
in one lit of Ringer lactate or normal saline at
the rate of 60 drops per minute.
• Continuous dose: IM/IV: repeat 10 IU after 20
minutes if heavy bleeding persists
Iv infusion: 10 IU in 1 litre at 30 drops/min
Iv fluid not more than 3lit with oxytocin
52

53. 6. Medical methods.
• Misoprostol : If IV oxytocin not available or
if bleeding does not respond to oxytocin.
Misoprostol 1 tablet = 200µg 4 tablets (800µg)
under the tongue
53

54. 6. Medical methods.
2. Methyl Ergometrine : If heavy bleeding in early
pregnancy or postpartum bleeding (after oxytocin)
DO NOT give if eclampsia, pre-eclampsia,
hypertension or retained placenta (placenta not
delivered).
• Initial dose : Ergometrine 0.25 mg or methyl
ergometrine (Methergin) 0.2 mg IM or IV slow
• Continuous dose: repeated after 15 minutes if
heavy bleeding persists. The same may be
repeated every 2-4 hours.
• Not more than 5 doses (total 1.0 mg)
54

55. 6. Medical methods.
3. Prostaglandin (15-methyl PGF,a
[Carboprost]) 250 μg can be given both
intramuscularly and intra myometrially and
repeated after 15 minutes for a maximum of
eight doses.
Prostaglandins may cause diarrhea, vomiting,
tachycardia, pyrexia and bronchospasm in
asthmatic patients.
55

56. 6. Medical methods.
4. Misoprostol or PGE, 1000 mcg can be
inserted rectally or taken orally.
5.Inj Tranexamic acid 500 mg IV has also
been tried.
56

57. 7. Blood component therapy
One unit of fresh frozen plasma (FFP) should be
given for every five packed RBC transfusions.
 Cryoprecipitate is useful along with FFP as it has
more concentration of fibrinogen and other
clotting factors especially in massive PPH or
where disseminated intravascular coagulation
(DIC) is suspected.
 Recently recombinant activated factor VII (F
VIIa) has been used successfully in intractable
PPH not responding to traditional treatment but is
expensive.
57

58. 58

59. 8. The uterus is to be explored
Simultaneous inspection of cervix and vagina,
especially para-urethral region, is to be done to
exclude lacerations.
9. Intrauterine packing (uterine tamponade)
using a 5 metres long and 8 cm wide folded strip
of gauze soaked in antiseptic cream or betadine
lotion.
Antibiotics should be given and the pack should
be removed after 24 hours.
59

60. 60

61. 10. Use of Sengstaken-Blakemore esophageal catheter
(SBEC) into the uterine cavity with gastric balloon of the
catheter filled with about 200-500 mL of warm saline to
cause effective tamponade.
• The catheter should be removed in 12-24 hours. If
significant bleeding continues through cervix or gastric
lumen of the tube, tamponade has failed and laparotomy is
required.
• In rural areas No. 24 Foley's catheter (30 mL balloon) is
inflated with 60-80 mL saline. Alternatively Rush urological
hydrostatic balloon or Bakri balloon can be used for the
tamponade. Even condom catheter pack can be used for the
same purpose.
61

62. 11.The military anti-shock garment or
treatment(MAST). MAST is a giant blood
pressure cuff that applies external counter
pressure to legs and abdomen to return blood
to the vital organs and stabilize blood
pressure until the patient reaches hospital,
thus reducing mortality.
62

63. 63

64. • Surgical management of uterine atony should be
considered when the above conservative measures
fail and are as follows:
i. Compression sutures
• B lynch sutures :B Lynch sutures is a pair of
vertical braces catgut suture around the uterus,
apposing anterior and posterior walls, resulting in
continuous compression to reduce blood flow to
uterus.
It is easy to perform and may avoid a
hysterectomy.
 It is commonly performed at cesarean section but
can also be done after vaginal delivery
64

65. Contd…
ii. Stepwise uterine revascularization
1. Bilateral uterine artery ligation
2. Unilateral or bilateral tubal branch of ovarian
vessel ligation
3. Bilateral internal iliac artery
(anterior division)ligation .
65

66. 66

67. 67

68. Contd…
iii. Selective arterial embolization
• Selective arterial embolization of internal iliac,
uterine and ovarian arteries is performed with
polyurethane foam or polyvinyl alcohol particles.
iv. Hysterectomy
• Emergency subtotal or total hysterectomy may
have to be performed by senior (doctors) as the
last resort when all medical and surgical
interventions have failed in all cases of PPH
68

69. Traumatic PPH
• When uterus is contracted, but still patient is
bleeding; perineum, vagina and cervix should
be inspected under good light for tears.
• Repair is done under general anesthesia.
69

70. SECONDARY POSTPARTUM
HEMORRHAGE
• The bleeding occurring after 24 hours of delivery
is termed as secondary PPH. It usually manifests
between eighth and fourteenth day.
Causes
1. Abnormalities of placentation
I. Retained products of conception (placental bits
or membranes)
II. Subinvolution of the placental site
III. Placenta accrete
70

71. Contd…
2. Infections
I. Endometritis
II. Myometritis
III. Parametritis
IV.Infection at vulvovaginal lacerations
V. Infection and dehiscence of cesarean scar
(usually occurs between 10-14 days due to
separation of slough)
71

72. Contd…
3. Miscellaneous causes:
I. Choriocarcinoma usually occurs beyond 4
weeks of delivery
II. Infected fibroid
III. Leiomyomatous or placental polyp
IV.Cervical cancer
V. Uterine inversion
72

73. Diagnosis
• Hemorrhage is usually variable in quantity.
• General physical examination shows pallor
and signs of sepsis.
• Vaginal examination demonstrate open OS,
poor involution of uterus and evidence of
infection.
• Ultrasound scan can demonstrate retained
placental bits or membranes in uterus.
73

74. Sign/symptoms/Diagnosis
• Signs: Bright red bleeding varying in amount
• Blood test:CBC, haematocrit – there can be
anaemia and sepsis.
• Internal examination reveals evidence of
sepsis,subinvolution of the uterus and often a
patulous cervical os.
• Ultrasound: to detect the remaining bits of
clots inside the uterine cavity
74

75. Management
• Principles:
To assess the amount of blood loss & replace
the lost blood.
To find out the cause & to take appropriate
steps to rectify it.
75

76. 1. Supportive therapy
i. Intravenous hydration and blood transfusion
ii. To administer ergometrine 0.25-0.5 mg or
methylergometrine (methergin) 0.2-0.4mg
intramuscularly, if the bleeding is uterine in
origin.
iii. Broad spectrum gentamicin and antibiotics
metronidazole(ampicillin,for any infection.
iv. For mild bleeding without retained bits
conservative treatment is offered.
76

77. Contd…
v. Active treatment: Evacuation of retained bits
of placenta and membranes from uterus is done
under antibiotic cover.
 Gentle curettage may be done to ensure complete
evacuation. However, excessive curettage is
avoided as it may cause Asherman's syndrome.
• Ergometrine0.25 mg is given intramuscularly.
• The products must be sent for histological
examination (to rule out choriocarcinoma).
77

78. Contd…
• For excessive or continuous bleeding,
surgical treatment should be undertaken using
hemostatic sutures.
Secondary continuous PH from cesarean site
may necessitate laparotomy needing
hemostatic sutures, ligation of the internal iliac
artery or even hysterectomy for intractable
cases.
78

79. Complications
• Maternal death.
• Acute renal failure.
• Sheehan‘s syndrome.
• Sepsis.
• Anaemia.
• Failure of lactation.
79

80. Nursing management
80

81. Nursing Assessment
• Assess the case profile, high risk identify
• Assess the amount of bleeding.
• Assess maternal vital signs to establish
baseline data.
• Assess for signs of shock.
• Assess the condition of the uterus.
81

82. Nursing Assessment
• The characteristics and quantity of blood passed can
suggest excessive bleeding.
• For example, bright red blood is arterial and can
indicate lacerations of the genital tract; meanwhile,
dark red blood is likely of venous origin and may
indicate superficial lacerations or varices of the birth
canal.
• Spurts of blood with clots can indicate partial placental
separation, excessive traction on the cord, and failure of
the blood to clot or remain clotted may indicate
coagulopathy, such as disseminated intravascular
coagulation
82

83. Nursing Diagnosis
1. Deficient Fluid Volume related excessive
fluid loss following / after delivery as
evidenced by decreased blood pressure.
2. Ineffective Tissue Perfusion related to acute
and massive blood loss as evidenced by
changes in the mental status.
3. Anxiety related to present health status as
evidenced by increasing heart rate.
83

84. Nursing Diagnosis
4. Risk for Infection related to weak immunity
due to blood loss and selfcare deficit
5. Risk for Altered Parent-Infant Attachment
related to maternal ill-health.
84

85. Nursing Intervention
1. Assess vital signs and monitor for signs of
shock: Decreased fluid volume will cause blood
pressure to drop and patient will go into shock
2. Monitor blood loss: Amount of blood loss and
presence of blood clots can help determine
treatment.
3. Assess for vaginal hematoma: If bleeding is due
to vaginal hematoma, rest and application of an
ice pack may be sufficient treatment.
85

86. Nursing Intervention
4. Monitor intake and output for 30ml - 50 ml/hr
urine output; may require indwelling catheter
insertion for accurate measurement: Decreased
urine output may be a sign of hematomas that
put pressure on the urethra, or may be a late sign
of hypovolemic shock.
5. Monitor lab values to determine need for
transfusions or signs of complications: Watch
haematocrit and clotting levels to know if blood
transfusion is necessary and for signs and
severity of DIC.
86

87. Nursing Intervention
6. Administer IV fluids, medications and blood
products as necessary: watch haematocrit and
clotting levels to know if blood transfusion is
necessary and for signs and severity of DIC.
Fluid replacement may be necessary and,
depending on amount of blood lost and
haematocrit level, a blood transfusion may be
required.
Oxytocin is sometimes given to initiate
contractions that will help stop bleeding.
87

88. Contd…
7. Perform uterine massage to stimulate
contractions following delivery: Begin fundal
massage and educate patient on how to
massage abdomen to stimulate contractions.
These contractions may help stop bleeding.
8. Monitor and manage pain: Continued,
unrelieved pain may be due to hematomas or
lacerations within the vagina
88

89. Nursing Intervention
9. Place patient on bed rest with legs elevated
Rest and elevation of legs helps venous return
and slows bleeding.
10.Prepare patient for surgery if indicated;
remain on NPO status: If bleeding can‘t be
managed otherwise, surgery may be required.
89

90. Research Evidence
• Assessment of Postpartum Hemorrhage in a
University Hospital in Eastern Ethiopia: A
Cross-Sectional Study
• The objective of this study was to assess the
magnitude of PPH and its associated factors
among women who gave birth in a university
hospital in eastern Ethiopia
91

91. Research Evidence
• Results:
From a total of 642 (98.3%) women included in
this study, 83 (12.9%; 95% CI 10.4– 15.6) had
PPH. Maternal age > 35 years (aOR = 3.08; 95%
CI 1.56, 6.07), no antenatal care (aOR = 3.65;
95% CI 1.97, 6.76), history of PPH (aOR = 4.18;
95% CI 1.99, 8.82), and being grand multigravida
(aOR = 3.33; 95% CI 1.14, 9.74) were
significantly associated with having PPH.
92

92. Research Evidence
• Incidence and Risk Factors of Postpartum
Hemorrhage in China: A Multicenter
Retrospective Study.
• Results:
A total of 99,253 pregnant women ,804 (0.81%)
experienced PPH. The subgroup analysis revealed
that the incidence of PPH was 0.75, 2.65, 1.40,
and 0.31% in singletons, twin pregnancies,
cesarean sections, and vaginal deliveries,
respectively.
93

93. Research Evidence
• Placenta previa and placenta accreta were the
predominant risk factors of PPH in the overall
population and all subgroups.
• A twin pregnancy was a risk factor for PPH regardless
of the mode of delivery. Obesity, and multiparity were
risk factors for PPH in both singletons and cesarean
section cases, but the latter predicted a reduced
probability of PPH in vaginal deliveries.
• Macrosomia was associated with increased risk of PPH
in singletons or vaginal deliveries. In women who
delivered vaginally, preeclampsia was associated with a
higher risk of PPH.
94

94. References:
• Dutta D.C. Textbook of obstetrics. ninth edition.
Calcutta, India; New Central Book agency (P) Ltd:
2019
• Raman,AV.Reeder’s Maternity Nursing.20th
Edition.Wolters Kluwer(India) Pvt.Ltd,New delhi.2020
• Sharma,JB .Midwifery and Gynaecological
Nursing.Eltee Printmaster,New delhi.2018
• Integrated Management of Pregnancy and Childbirth,
World Health Organization Geneva Revised 2014
• https://www.unhcr.org/5e0f5fe54.pdf.Helping Mothers
Survive Bleeding after Birth Complete guideline.
95

95. THANK YOU
96