This document discusses postpartum hemorrhage (PPH), including definitions, causes, risk factors, diagnosis, and management approaches. PPH can be primary (occurring within 24 hours of delivery) or secondary (occurring beyond 24 hours). The main causes are uterine atony, trauma, retained placenta or uterine fragments. Management involves emptying the uterus, replacing blood loss, arresting bleeding through medical or surgical interventions like uterine massage, medications, and in severe cases, hysterectomy. Complications of PPH like placenta accreta, uterine inversion are also summarized.

2.  Postpartum hemorrhage
 Retention of placenta
 Shock
 Pulmonary embolism
 Uterine inversion

4. 1. Quantitative – It is realted to amount of
blood loss in excess of 500ml following birth
of baby
2. Clinical- any amount of bleeding from or
into the genital tract following birth of the
baby up to the end of puerperium,which
adversly affects the general condition of the
patient evidenced by rise in pulse rate and
falling BP is called PPH.

5.  Minor <1L
 Major >1L
 Sever >2L
 Incidence: 4-6% of all deliveries.
 Types: Primary
Secondary

6. Primary: Hemorrhage occurs within 24
hours following the birth of the baby.
In the majority, hemorrhage occurs within
two hours following delivery.
Two types:
Third stage hemorrhage—Bleeding occurs
before expulsion of placenta.
True postpartum hemorrhage —Bleeding
occurs subsequent to expulsion of
placenta .
Secondary: Hemorrhage occurs beyond 24
hours and within puerperium, also called
delayed or late puerperal hemorrhage.

7. 4Ts
Tone: atonicity of uterus
 grand multipara
 Over distension of uterus
 Malnutrition and anemia
 APH
 Prolonged labor
 Malformation of uterus
 Uterine fibroid
 Precipitate labor
 Placenta acreta placenta percreta

8. 2.Traumatic:
Operative delivery
Episiotomy
Cesarean section
3.Tissue
Bites of placenta
Blood clots
4.Thrombin
Thrombocytopenic purpura
Sever preeclampsia

9. Diagnosis:
State of uterus, as felt per abdomen, gives
reliable clue as regards the cause of bleeding.
In traumatic hemorrhage: uterus is well
contracted.
In atonic hemorrhage: uterus is flabby
becomes hard on massaging.
both the atonic and traumatic cause may
coexist.

10. Prevention
Antenatal:
 Improvement of the health status of the
woman .
 High-risk patients are to be screened and
delivered in a well-equipped hospital.
 Blood grouping should be done .
 Placental localization
 Women with morbid adherent placenta are
should be delivered by a senior obstetrician

11. Intranatal:
 Active management of the third stage labor.
 Cases with induced or augmented labor,( 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 100 µg is
very useful to prevent PPH)
 Exploration of the uterovaginal canal .
 Expert obstetric anesthetist is needed .
 During cesarean section spontaneous separation and
delivery of the placenta reduces blood loss (30%).
 Examination of the placenta and membranes should be a
routine to detect at the earliest any missing part.

12. Management of third stage bleeding
principles of management :
 To empty the uterus
 To replace the blood.
 To ensure effective hemostasis
 STEPS OF MANAGEMENT:
 Placental site bleeding
 Traumatic bleeding

13. Placental site bleeding
 To palpate the fundus and massage the uterus to
make it hard.
 To start crystalloid solution (Normal saline or
Ringer’s solution) with oxytocin (1 L with 20 units)
at 60 drops per minute and to arrange for blood
transfusion if necessary.
 Oxytocin 10 units IM or methergine 0.2 mg IV.
Carbetocin, 100 µg as effective as oxytocin
infusion.
 To catheterize the bladder.
 Antibiotics (Ampicillin 2 g and Metronidazole 500
mg IV

14. Traumatic bleeding
 uterovaginal canal is to be explored under
general anesthesia after the placenta is
expelled and hemostatic sutures are placed
on the offending sites

15. Management of true PPH
PRINCIPLES: Simultaneous approach
1.Communication 2. Resuscitation
3.Monitoring 4. Arrest of bleeding
MANAGEMENT
 Call for extra help—involve the obstetric registrar (senior
staff) on call.
 Put in two large bore (14-gauge) intravenous cannulas.
 Keep patient flat and warm.
 Send blood for full blood count, group, cross matching,
diagnostic tests (RFT, LFT), coagulation screen including
fibrinogen and ask for 2 units (at least) of blood

16. -

17.  One midwife/rotating houseman should be
assigned to monitor the following—(i) Pulse
(ii) Blood pressure (iii) Temperature (iv) Respiratory
rate and oximeter (v) Type and amount of fluids
(blood, blood products) the patient has received (vi)
Urine output (continuous catheterization) (vii)
Drugs-type, dose and time (viii) Central venous
pressure (when sited

18. Management of true PPH
 Control the fundus and note the feel of uterus
 ATONIC UTERUS
Step 1:
 message the uterus
 Methergine 0.2mg IV
 Oxytocin drip
 Examine the expelled placenta membranes
Step 2:
 Uterus is explored under general anesthesia
 Injection 15 methyl PGF2α 250 µg IM in the
deltoid muscle every 15 min (up to max of 2 mg).
 Misoprostol (PGE1) 1000 µg per rectum
 When uterine atony is due to tocolytic drugs,
calcium gluconate (1 g IV slowly)

19.  Step 3: Uterine massage and bimanual
compression

20. Step 4:Uterine tamponade
 Tight uterine packing
 Balloon tamponade
Foleys catheter ,bakri balloon,condom catheter

21. Other measures
 Non pneumatic antishock garment
 Compression of abdominal aorta

22. Step 5: surgical methods to control PPH
 B-lynch compression suture and multiple
square sutures

23.  Ligation of uterine arteries
 Ligation of the ovarian and uterine artery
anastomosis

24.  Ligation of anterior division of internal iliac
artery
 Angiographic selective aeterial embolization
Step 5:
 Hysterectomy
TRAUMATIC PPH
Catgut sutures

26. Causes
 (1) Retained bits of cotyledon or membranes
 (2) Infection and separation of slough over a
deep cervicovaginal laceration,
 (3) Endometritis and subinvolution of the
placental site—due to delayed healing
process,
 (4) Secondary hemorrhage from cesarean
section wound usually occur between 10–14
days.
(a) separation of slough exposing a bleeding
vessel or
(b) from granulation tissue,

27.  (5) Withdrawal bleeding following estrogen
therapy for suppression of lactation,
 6) Other rare causes are:
chorionepithelioma—occurs usually beyond 4
weeks of delivery
 carcinoma cervix
 placental polyp
 infected fibroid or fibroid polyp
 puerperal inversion of uterus

28. Diagnosis
 bleeding is bright red and of varying amount.
Rarely it may be brisk.
 Varying degree of anemia and evidences of
sepsis are present.
 Internal examination reveals evidences of
sepsis, subinvolution of the uterus and often a
patulous cervical os.
 Ultrasonography is useful in detecting the
bits of placenta inside the uterine cavity.

29.  Management
 Principles:
 To assess the amount of blood loss and to
replace it (blood transfusion).
 To find out the cause and to take appropriate
steps to rectify it.
 Supportive therapy: (1) Blood transfusion,
 (2) administer methergine 0.2 mg IM, if the
bleeding is uterine in origin,
 (3) administer antibiotics (clindamycin and
metronidazole) as a routine.
 Conservative: If the bleeding is slight and no
apparent cause is detected, a careful watch for a
period of 24 hours or so is done in the hospital.

30. ACTIVE TREATMENT
 Retained bits
explore uterus under general anesthesia
Methergine 0.2mg IM
 Bleeding from cervicovaginal canal uterus
Hemostatic stures
 Hemorrhage following cesarean
laproptomy

33. DEFINITION
The placenta is said to be retained when it is
not expelled out even 30 minutes after the
birth of the baby (WHO 15 minutes).
CAUSES: There are three phases involved in
the normal expulsion of placenta
 (1) Separation through the spongy layer of
the decidua
 (2) Descent into the lower segment and
vagina
 (3) Finally its expulsion to outside.

34. Interference in any of these physiological
processes, results in its retention.
 Placenta completely separated but retained is
due to poor voluntary expulsive eff orts.
 Simple adherent placenta
 Morbid adherent placenta
 Incarcerated placenta

35.  DIAGNISIS
 diagnosis of retained placenta is made by an
arbitrary time (15 minutes) spent following
delivery of the baby.
 Features of placental separation are
assessed
 The hourglass contraction or the nature of
adherent placenta (simple or morbid) can
only be diagnosed during manual removal.

36.  DANGERS
 (1) Hemorrhage
 (2) Shock is due to—(a) blood loss, (b) at
times unrelated to blood loss, especially when
retained more than one hour and (c) frequent
attempts of abdominal manipulation to
express the placenta out
 (3) Puerperal sepsis
 (4) Risk of its recurrence in next pregnancy.

37.  MANAGEMENT
 PERIOD OF WATCHFUL EXPECTANCY
 During the period of arbitrary time limit of
half an hour, the patient is to be watched
carefully for evidence of any bleeding,
revealed or concealed and to note the signs
of separation of placenta. The bladder should
be emptied using a rubber catheter.
 Any bleeding during the period should be
managed as outlined in third stage bleeding.
RETAINED PLACENTA:
Separated
Unseparated
Complicated

38.  Placenta is separated and retained
To express the placenta out by controlled
cord traction.
 Unseparated retained placenta
Manual removal of placenta is to be done
under general anesthesia as described earlier

40. DEFINITION
Placenta accreta is an extremely rare form in
which the placenta is directly anchored to
the myometrium partially or completely
without any intervening decidua

41. RISK FACTORS
 Placenta previa
 Prior cesarean delivery
 Prior uterine surgery
DIAGNOSIS
 During manual removal
 Ultrasound, color dopler, MRI
 (i) loss of normal hypoechoic retroplacental myometrial zone
 (ii) thinning and disruption of the uterine serosa-bladder interface and
focal exophytic masses invading the bladder.
 Color flow Doppler study shows hypervascularity of serosa bladder
interface.
 MRI reveals detour vessels and dark intraplacental bands on T2-
weighted imaging.
 Unexplained rise of maternal serum αFP is observed with placenta
accreta

42. PATHOLOGICAL CONFIRMATION
 absence of decidua basalis
 absence of Nitabuch’s fibrinoid layer and
 varying degree of penetration of the villi into
the muscle bundles (increta) or up to the
serosal layer (percreta).
RISKS
hemorrhage, shock, infection ,inversion of
the uterus.

43.  MANAGEMENT
Partial placenta accreta
Remove placental tissue
Oxytocin and intra uterine plugning
Hysterectomy
Total placenta accreta
Hysterectomy
Rare cases
Placenta accreta invading bladder
Hysterectomy and partial cystectomy

45.  It is an extremely rare but a life-threatening
complication in third stage in which the
uterus is turned inside out partially or
completely

46. incidence: 1 in 20,000 deliveries.
VARIETIES
 First degree: dimpling of the fundus, which
still remains above the level of internal os.
 Second degree:fundus passes through the
cervix but lies inside the vagina.
 Third degree (complete):endometrium with or
without the attached placenta is visible
outside the vulva. cervix and part of the
vagina may also be involved in the process .

47. ETIOLOGY
 Spontaneous :
 Localised atony
 Short cord
 Placenta accreta
 IATROGENIC
 Pulling of cord when uterus is atonic
 Fundal pressure: faulty technique in manual
removal

48. RISK FACTORS
 uterine oveR enlargement
 prolonged labor
 fetal macrosomia
 uterine malformations
 morbid adherent placenta
 short umbilical cord
 tocolysis and manual removal of placenta.
 common in women with collagen disease like
Ehler-Danlos syndrome

49.  DANGERS
 Shock
 Hemorrhage
 Pulmonary embolism
 If untreated: infection uterine sloughing
SYMPTOMS
Acute lower abdomen pain with bearing
down sensation

50. SIGNS
 Varying degree of shock
 Abdominal examination
 Cupping or dimpling of the fundal surface
 Bimanual examination: pear-shaped mass
protrudes outside the vulva with the broad
end pointing downward and looking reddish
purple
 (c) Sonography : confirm the diagnosis

51.  MANAGEMENT
 Call for extra help
 Before the shock develops: urgent manual
replacement even without anesthesia, if it is
not readily available, is the essence of
treatment for a skilled accoucheur

52.  PRINCIPAL STEPS
 Patient is under general anesthesia.
 Replace that part first, which is inverted last with the
placenta attached to the uterus by steady firm
pressure exerted by the fingers.
 Apply counter support by the other hand placed on
the abdomen.
 After replacement, the hand should remain inside
the uterus until the uterus becomes contracted by
parenteral oxytocin or PGF2α.
 The placenta is to be removed manually only after
the uterus becomes contracted. The placenta may
however be removed prior to replacement
(a) to reduce the bulk which facilitates replacement or
(b) if partially separated to minimize the blood loss,
 Usual treatment of shock including blood transfusion
should be arranged simultaneously.