A short, comprehensive and informative lecture on PPH which will help the UG students to understand PPH and prepare for the exams.

1. Post Partum Hemorrhage (PPH)
class for undergradutes
Dr. Debraj Mondal
MBBS, MS, DNB, MRCOG (1)-UK
Asst. Professor, Dept. of OBGY
GIMSH, Durgapur, WB, India

2. Clinical Definition
 Any bleeding from or into the
genital tract following birth of
the baby up to the end of
puerperium which adversely
affects the general condition of
the patient evidenced by rise in
pulse rate and falling blood pressure
is called “Post Partum Hemorrhage
(PPH)”.

3. End of puerperium
 Previously it was considered as 6
wk.
 Now it has extended up to 12 wk
following birth of the child.

4. Quantitative definition
 Blood loss >500 ml following
vaginal birth of the baby
 Or >1000 ml after CS (WHO).
 ACOG: Either a 10% drop of
Hematocrit of need for Packed RBC
transfusion following birth of the
baby.

5. How much time do we have ?
It is estimated that, if untreated,
Death occurs on average in:
2 hours from Postpartum Hemorrhage
12 hours from Antepartum Hemorrhage
2 days from Obstructed Labor
6 days from Infection

6. Types
Primary PPH
 Within 1st 24 hour of
delivery of baby. Two
types:
1. Third stage
bleeding: bleeding
during separation of
placenta.
2. True primary PPH:
After delivery of the
placenta.
Secondary PPH
 Beyond first 24 hours
and upto 12 wk (or
some say 6 wk).

7. Causes of PPH
4 ‘T’s
 Tonicity- Atonic PPH- most
common (75-90%).
 Trauma- Traumatic PPH (10-20%)
 Tissue- Retained tissues related
PPH (Placenta, membranes).
 Thromboplastin- Coagulation
defect related PPH.

8. Atonic PPH- Risk Factors
1. Over distended uterus: Multiple
pregnancy, hydramnios.
2. Mismanaged third stage of labour.
3. Multi parity
4. Anemia & malnutrition
5. Prolonged labour, precipitate labour
6. APH
7. Abnormal Uterine anatomy- malformation,
fibroids.
8. Obesity
9. Drugs- Halothane, tocolytics
10. Prior history of atonic PPH.

9. Traumatic PPH
1. Laceration of the cervix, vagina,
perineum and peri-urethral tear-
mostly in instrumental delivery,
complicated vaginal delivery.
2. Ruptured uterus
3. Extension of the cesarean
section incision- Uterine artery tear.
4. Broad ligament hematoma.
5. Uterine inversion.

10. Management of PPH
1. Prevention
2. Treatment

11. Prevention
1. Regular antenatal care
2. Correction of anemia & malnutrition
3. Identify at risk women and deliver them
in a hospital where emergency Obstetric
care (EmOC) facility available.
4. Emergency referral facility to a tertiary
care hospital should be available.
&
5. Routine AMTSL

12. Active Management of Third Stage of
Labour (AMTSL)
 It is recommended by WHO that
AMTSL should be done in all cases.
Because:
1. It minimizes the blood loss
2. Cut short the third stage of labour.

13. WHO Recommendations for Active
Management of the Third Stage of Labour
(AMTSL), 2012
1. Check the uterus for presence of twin.
2. Uterotonic immediately after the
delivery of the baby in all births.
3. Delayed cord clamping.
4. Controlled Cord traction (CCT): is not
mandatory. Perform CCT, if required.
5. Postpartum vigilance for uterine
tonus.

14. Uterotonic immediately after the
delivery of the baby in all births
 The use of uterotonics for the
prevention of postpartum haemorrhage
(PPH) during the third stage of labour is
recommended for all births.
 Oxytocin (10 IU, IV/IM) is the
recommended uterotonic drug for the
prevention of PPH.
 Other option is misoprostol.
 Ensure a continuous supply of high-quality
Oxytocin by maintaining the cool chain.

15. Delayed cord clamping
 Delay clamping the cord for at least
1-3 minutes to reduce rates of
infant anaemia.
The only indication for Early cord
clamping in modern day obstetrics:
 Asphyxiated baby who needs
immediate neonatal resuscitation.

16. CCT: is not mandatory.
Perform CCT, if required
 In settings where skilled birth
attendants (SBA) are available,
controlled cord traction (CCT) is
recommended for vaginal births
 In settings where SBA are
unavailable, CCT is not
recommended.
 CCT is the recommended method for
removal of the placenta in
caesarean section.

17. Postpartum vigilance for uterine
tonus
 Immediately assess uterine tone to
ensure a contracted uterus; continue to
check every 15 minutes for 2 hours.
 If there is uterine atony, perform fundal
massage and monitor more frequently.
 But sustained uterine massage is not
recommended as an intervention to prevent
PPH in women who have received prophylactic
oxytocin

18. Treatment of PPH
(HAEMOSTASIS)
 Medical
mangement.
Mnemonic:
 HAEMO
 Surgical
mangement.
Mnemonic:
 STASIS

19. HAEMOSTASIS
 H= Help-ask for help
 A= Asses (Vitals, Blood loss) &
resuscitate.
 E= Etiology, Ensure availability of
blood.
 M= Massage uterus
 O= Oxytocics.

20. HAEMOSTASIS
 S= Shift to OT,
 T= Trauma (to exclude),
Temponade
 A= Apply compression sutures
 S= Stepwise pelvic
devascularization
 I= Intervention radiology
 S= Subtotal Hysterectomy.

21. H= Help-ask for help
 Whenever there is PPH the 1st thing
to do is to shout for help.
 It is a team effort not a one man’s
job.

22. A= Asses (Vitals, Blood loss) &
resuscitate
 Monitor Vitals:
Pulse,
BP,
Temp,
Respiration & oxygen saturation
Put the patient on multi-parameter
monitor.

23. Resuscitate
 Make two intra-venous channel with
large bore cannula (18G) in both
hands.
 IV fluids: Crystalloids (RL) and
colloids (to be given till the blood is
available).
 Moist O2 @ 10-15 Lit/min.
 Catheterize to monitor urine output.

24. E= Establish the etiology
 Asses the uterus tone- Atonic?
 Local examination to exclude
Trauma?
 Examination of placenta &
membranes to exclude retained
bits?
 Investigations: Complete
hemogram, Coagulation profile,
electrolytes, blood grouping.

25. Ensure availability of blood.
 Immediately send blood for
grouping and cross-matching and
arrange for at least two units of
WHOLE BLOOD.

26. Oxytocics
 Start oxytocin infusion: 10 units in
500 ml NS @ 15-30 drops/min.
 Methergine (Methyle ergometrine):
0.2 mg may be given IV

27. Oxytocics
Drug Dosage Cant be given
Oxytocin
infusion
10 units in 500 ml NS @ 15-30
drops/min
If pt has heart
failure
Methergine
(Methyle
ergometrine)
0.2 mg may be given IV
Repeat after 15 min, Max 4
doses.
If pt has
hypertension
Carboprost
(PGF2α)
250 micro-gram IM
Repeat after 15 min, max 8
doses.
If pt has
asthma
Misoprostol Tablets 200 micro-gram
sublingual or Per-rectal. Usual
dose 600 micro-gram.
Nothing
significant
Tranexamic acid IV injections 500-1000 mg can
be repeated after 4 hr.
Nothing
significant

28. S= Shift to OT
While shifting the patient the
following things may be done:
 Bimanual compression of the
uterus,
 NASG: Non-pneumatic anti-shock
garments.

29. Bimanual compression of the
uterus

30. NASG: Non-pneumatic anti-shock
garments

31. NASG: Non-pneumatic anti-shock
garments

32. T= Trauma, Temponade
 If any trauma is noted it should be
immediately repaired.
Temponade:
 Bakri baloon
 Sengstaken-Blakemore tube
 Rusch balloon
 Foley's catheter.
 Or uterus can be packed with
Gauge.

33. Internal Uterine Tamponade-
Bakri baloon

34. Sengstaken-Blakemore tube

35. Rusch balloon & Foley's catheter

37. A= Apply compression sutures
 B-Lynch
 Modified B-Lynch
 Cho sutures

38. B-Lynch “Brace” Suture

39. Cho sutures

40. S= Stepwise pelvic
devascularization
1. Uterine artery ligation.
2. Ligation of round ligaments and
3. Internal iliac (Hypogastric) artery
ligation

41. S= Stepwise pelvic
devascularization

42. Hypogastric Artery Ligation

43. I= Intervention radiology
 Selective
 uterine artery or
 Internal iliac (Hypogastric) artery
 embolization with the help of
angiographycally guided techniques.

44. Embolisation

45. S= Subtotal Hysterectomy
 Last resort, if everything fails.
 Sometimes total hysterectomy is
also done
 Ovaries must be preserved at any
cost.

46. Golden Hour
 The 1st hour of PPH is taken as the
golden hour, coz if management
started within 1st hour of onset of
PPH, then the patient has the best
chance of survival.
 Chance of survival decrease sharply
after the 1st hour.

47. Rule of 30
1. SBP drops by 30mmHg
2. Heart rate falls by 30 bpm
3. Resp rate becomes >30/ min
4. Hematocrit/ Hb drops by 30%
5. Urine output becomes <30 ml/hr
 It means that the pt has lost >30%
of her blood and is in moderate
shock.