Postpartum hemorrhage is excessive bleeding from the genital tract after childbirth, defined as blood loss over 500ml. It can be immediate or occur more than 24 hours later. The main causes are problems with uterine contraction leading to bleeding from the placental site, or lacerations during childbirth. Prevention focuses on correcting anemia during pregnancy and using oxytocin or ergometrine to aid uterine contraction after birth. Treatment seeks to stop the bleeding through massaging the uterus or medications, and replace lost blood volume through transfusions or fluids while the cause is addressed.

1. Definition
• Excessive bleeding from the genital tract
after the birth of the child
• Conventionally defined as a loss of more
than 500ml of blood
• May be immediate (or primary) or if it
occurs more than 24 hours after delivery it
is described as secondary

2. Primary Postpartum Hemorrhage
• Two sources: the placental site and
lacerations of the genital tract.
• Incidence is reported to be between 1-2% of
deliveries, although PPH accounted for over
60% of all maternal death from hemorrhage.

3. PPH from placental site – causes:
• Ineffective uterine contraction and retraction may occur
• After a long labor caused by weak and uncoordinated
uterine action
• If prolonged deep anesthesia has been administered
• In multipara with an atonic uterus
• If the uterus has been over distended (big child,
polyhydromnios, twin pregnancy)
• In a case of antepartum hemorrhage – placenta praevia and
abruptio placentae

4. PPH from placental site – causes:
continuation
• Mismanagement of the 3rd stage (if the uterus is manipulated during
the interval after a normal delivery and before complete separation has
occurred, the placenta may be partly separated and bleeding may
begin)
• Abnormally adherent placenta ( placenta accreta – villi penetrate
through the decidua and placenta increta – villi penetrate into
myometrium
• Disseminated intravascular coagulation (DIC) and other clotting
disorders – concealed abruptio placentae, amniotic embolism, after
dead fetus has been retained in the uterus for some weeks – rapid
depletion of coagulation factors and platelets resulting in catastrophic
bleeding
• Inversion of the uterus and hourglass constriction and placental
retention

5. Clinical events
• The escape of blood
• In rare instances severe bleeding occurs into the
cavity of an atonic uterus, with only some of the
blood appearing externally. This should be
suspected if the patient becomes shocked, the
fundus of the uterus appears to be abnormally high
in the abdomen and the uterus feels larger and
softer than normal
• If hemorrhage continues, the blood pressure falls,
the pulse rate rises, and in severs cases pallor and
air-hunger occurs.

6. Clinical events
continuation
• Circulatory collapse caused by hemorrhage
(immediate blood transfusion is essential to restore
the blood volume, and an infusion of plasma or
saline may be started while the transfusion is
being arranged)
• Postpartum necrosis of the anterior love of the
pituitary gland as a sequel of PPH in which the
blood pressure has remained at a low level of
some hours.

7. Prevention
• Anemia must be corrected during pregnancy
because an anemic patient tolarates
hemorrhage badly
• Prolonged labor can lead to uterine
exhaustion – the second stage of labor
should be short
• The correct management of the third stage
is using OXYTOCIN or ERGOMETRINE

8. Treatment
Two principles govern the treatment of PPH:
1. The bleeding must be arrested
2. The blood volume must be restored

9. Treatment continuation
• Treatment if the placenta has already been
delivered (rubbing the uterus with the hand,
ergometrine injections, other causes of
bleeding – a laceration of the cervix or
vagina)
• Treatment if the placenta is not delivered –
if the placenta has separated or if it has not
separated

10. Secondary Postpartum
Hemorrhage
• This occurs more than 24 hours after
delivery of the child
• It is usually caused by the retention of a
piece of the placenta or membranes, and
frequently complicated by intrauterine
infections with pyrexia
• Ultrasound examination will show whether
there is retained placental tissue.