This document discusses two situations involving postpartum hemorrhage: 1) Excessive bleeding from the vagina or perineal area, which can be due to tears in the perineal region, vagina, cervix, or uterus. Risk factors include iatrogenic causes like episiotomy. 2) Excessive pain in the episiotomy site with no frank bleeding, but low vitals indicating hemorrhage. The cause here is likely a vulval or cervical hematoma that needs to be drained and the source of bleeding ligated and repaired. Management may involve repairing tears, draining hematomas, and identifying and ligating the source of bleeding.

1. Postpartum Hemorrhage
Supritha JP, 104

2. Case Scenario
• A 35 year old Primigravida who is a known case of Gestational
diabetes mellitus delivered a baby weighing 4.2 kgs through forceps
delivery . After the delivery it is noted that the mother’s BP falls to
90/60 mm Hg and the heart rate is found to be 120 bpm .
• On palpation , the Uterus is not flabby and is well contracted .
• What do you suspect ?

3. Let us consider these 2 situations
• Situation 1 : Excessive bleeding either from the vagina or in the
perineal area .
• Situation 2: Excessive pain in the episiotomy site after 1 hour of
delivery but there is no complaints of excessive bleeding although the
vitals are showing signs of hemorrhage.
Think of traumatic PPH

4. Situation 1 : Excessive bleeding
• Can be due to
1) Tear in the Perineal region or vagina
2) Tear in the cervix or Uterus
Why was this seen in our patient ? What were the risk factors ?

6. Vaginal and perineal tear
1. Iatrogenic – Episiotomy

8. CERVICAL TEARS

9. Situation 2 : Excessive pain but no frank
excessive bleeding
Local examination finding

10. • It is a vulval hematoma
• Beware that the hematoma need not always be a frankly visible
hematoma. It can be concealed if it is present in the cervix or Broad
ligament .

11. How do we manage this patient ?
What are the investigations ?

12. Managing the tear
• Perineal tear :
Repair done under 1% lignocaine or general anesthesia . Repair by
using interrupted vicryl sutures

13. • For cervical tears we use chromic or catgut sutures
• Hematoma treatment : If hematoma <5 cm – cold compress
If hematoma > 5cm – Drain the hematoma .
Clear clots , identify bleeder and ligate
and suture the wound.
Uterine Rupture : Subtotal hysterectomy or repair and sterilization .

14. THANKYOU