Pph

1. POST-PARTUM
HAEMORRHAGE

3. PPH constitutes of
 Definition
 Types
 Causes
 Diagnosis
 Prevention
 Management

4. DEFINITION
■ QUANTITATIVE DEFINITION :
 Blood loss of ≥500ml following
delivery (both Spontaneous
Vaginal Delivery or Caesarean
section).

5. CLINICAL DEFINITION
■ Any amount of bleeding from or
into the genital tract following
birth of the baby up to the end of
the puerperium which adversely
affect the general condition of the
patient evidence by:
Rise in pulse rate
Falling in blood pressure

6. NORMAL AVERAGE BLOOD LOSS :
■ Vaginal delivery = 500ml
■ Caesarean section = 1000ml
■ Caesarean hysterectomy = 2000 ml

7. TYPES OF PPH
PPH
Primary
Third stage
hemorrhage
True PPH
Secondary

8. 1. PRIMARY PPH:
It occurs within 24hrs following the birth of the
baby.
a) 3rd stage Hemorrhage: Bleeding occurs before
expulsion of placenta.
b) True PPH: Bleeding occurs subsequent to
expulsion of placenta.
2. SECONDARY PPH:
It occurs beyond 24hrs and within puerperium.

9. PRIMARY PPH
CAUSES
■ The Four T’s
 Tone: Uterine atony
 Tissue: Retained placenta, invasive
placenta
 Trauma: To any part of the genital
tract, inverted uterus
 Thrombin: Coagulopathy

10. ■ Tone:
 After separation of placenta,
bleeding will continue at placental
site as the uterine sinuses that have
been torn cannot be compressed
effectively.
 Failure of uterus to contract &
retract.

11. ■ Trauma:
 Usually occurs following operative
delivery.
 Underestimated blood loss from
episiotomy wound and lacerations.
 Blood loss in caesarean section of
800-1000ml.
 In rare cases, uterine rupture occur if
delivery happened before the cervix
is fully dilated.

12. ■ Retained tissue:
 Bit of placenta
 Blood clot
■ Thrombin-coagulation Disorders
 Congenital or acquired
 May be due to diminished pro
coagulants or increased
fibrinolytic activity.

13. DIAGNOSIS
■ Vaginal bleeding:
 Visible as a slow trickle.
■ Effect of blood loss depends on :
 Pre delivery hemoglobin level.
 Degree of pregnancy induced
hypervolemia.
 Speed at which blood loss occur.

14. State of uterus as felt per abdomen
■ Traumatic hemorrhage : Well
contracted
■ Atonic hemorrhage : Flabby and
becomes hard on massaging

15. PREVENTION
■ Cannot always be prevented.
■ But incidence and magnitude can be
reduced by assessing risk factor and
follow the guideline stated.

16. PREVENTION OF PPH
■ Antenatal:
 Improvement of the health status
(keep the Hb level normal, >10g/dl).
 High risk patient need to be screened
and delivered in a well equipped
hospital.
 Blood grouping.

17. ■ Intranatal:
 Active management of 3rd stage of
labor.
 Slow delivery of the baby.
 Women delivered by caesarean given
oxytocin 5IU slow IV
 Exploration of Uterovaginal canal for
evidence of trauma.
 To observe the patient for about 2hrs
after delivery.

18. MANAGEMENT OF 3rd STAGE
BLEEDING
■ Principle:
Empty uterus from its content
and make its contract
Replace blood
Ensure effective hemostasis

19. PLACENTAL SITE BLEEDING
Palpate fundus
and uterus to
make it hard
Start crystalloid
solution with
oxytocin (1L with
20 units) at 60
drops/min.
Oxytocin 10
units IMor
methargine 0.2
mg is given IV
Catheterize the
bladder
Give antibiotics
(ampicillin 2g
and
metronidazole
500 mg IV).

20. ■ If the patient is in shock,
?

21. Delivered under
general anesthesia
Quick manual
removal of the
placenta
Oxytocin10 units is
given IM with
the delivery of the
anterior shoulder
Manual removal is
done promptly
when two attempts
of controlled cord
traction fail.

22. TRAUMATIC SITE BLEEDING
■ The exploration of the utero-
vaginal canal to be done under
general anesthesia after the
expulsion of the placenta.

23. MANAGEMENT OF TRUE PPH
■ PRINCIPLES:
 Communication
 Resuscitation
 Monitoring
 Arrest of bleeding
■ It is essential in all cases of major
PPH (blood loss > 1000 mL or
clinical shock)

24. IMMEDIATE MEASURES
Call
for
extra
help
Put in
two
large
bore
(14-
gauge
)
intrav
enous
cannu
las.
„
Keep
patien
t flat
and
warm.
„
Send
blood
for
full
blood
count,
group,
cross
match
ing
ask
for 2
units
(at
least)
of
blood.
„
Infuse
rapidl
y 2
liters
of
norma
l
saline
Give
oxyge
n by
mask
10–15
L/min
.
„
Start
20
units
of
oxyto
cin in
1 L of
norma
l
saline
IV
Transf
use
blood
as
soon
as
possib
le.

25. ACTUAL MANAGEMENT
■ Atonic uterus:
 Massage the uterus to make it hard and
express the blood clot
 Methergine 0.2 mg is given intravenously
 Injection oxytocin drip is started (10 units
in 500 mL of normal saline) at the rate of
40–60 drops per minute
 Foley catheter to keep bladder empty and
to monitor urine output
 To examine the expelled placenta and
membranes, for evidence of missing
cotyledon or piece of membranes.

26. ■ If the uterus fails to contract, it should
be explored under general anesthesia.
■ When uterine atony is due to tocolytic
drugs, calcium gluconate (1 g IV slowly)
should be given.

27. Uterine massage and bimanual compression.
 The whole hand is introduced into the vagina in
cone shaped fashion after separating the labia
with the fingers of the other hand
 The vaginal hand is clenched into a fist with the
back of the hand directed posteriorly and the
knuckles in the anterior fornix
 The other hand is placed over the abdomen
behind the uterus to make it Anteverted
 The uterus is firmly squeezed between the two
hands .

29. SURGICAL MANAGEMENT
1. Uterine tamponade/ Balloon Tamponade
 Tight intrauterine packing is done
uniformly under general anesthesia.
 Balloon tamponed: Tamponed using
various types of hydrostatic balloon
catheter has mostly replaced uterine
packing.

30. 2. Ligation of uterine arteries.
3.Hysterectomy: It is a surgical
operation to remove all or part of the
uterus in case of PPH.

31. CONCLUSION
 PPH is unavoidable
 PPH is an important cause of maternal
morbidity and mortality. It should be
diagnosed early and properly managed
by the obstetrical team.
 A good referral system, transfusion
services and well trained personnel
should therefore be put in place if
deaths associated with complication
after delivery are to be avoided.