Primary postpartum hemorrhage is a leading cause of maternal mortality. This presentation defines PPH as blood loss exceeding 500mL after vaginal delivery or 1000mL after c-section within 24 hours of delivery. The main causes are uterine atony, retained placenta or clots, genital tract trauma, and coagulopathy. Risk factors include previous c-sections, multiple gestation, and medical disorders. Prevention focuses on active management of the third stage of labor and treatment involves addressing the underlying cause, fluid resuscitation, blood transfusion, and potentially hysterectomy for uncontrolled bleeding.

1. Presentation
on
Primary Postpartum Hemorrhage
by
Dr. Ahmed H. Yakubu (H.O.)
DEPARTMENT OF O & G
FEDERAL MEDICAL CENTRE, KATSINA
presented on 6TH January, 2018
supervised by Dr. Kundil

2. Outline
• Introduction
• Definition
• Classification
• Epidemiology
• Etiology/Risk factors
• Pathophysiology
• Prevention
• Management
• Conclusion
• References

3. Introduction
• Primary PPH is a frequently encountered obstetric emergency.
• Systemic reviews suggest that the burden of the condition
varies from region to region however it is agreed among
respected colleges that its attendant mortality and morbidity
is significant both in developed and developing countries.
• WHO statistics suggest that 25% of maternal deaths in
developing countries are due to PPH.
• Unpredictable and relatively common, it is pertinent at the
very least identify women at risk and take appropriate
measures to limit the prevalence of the emergency.

4. Definition of Primary Postpartum hemorrhage
1. Blood loss in excess of 500mls following vaginal delivery or In
excess of 1000mls following caesarean section or in excess of
1500mls following caesarean hysterectomy…
2. Blood loss that is significant enough to cause hemodynamic
instability…
3. Decline in hematocrit value by up to 10% or more from the
premorbid value…
*Any of the above occurring after the age of viability (28weeks)
and within the first 24hours after delivery.

5. Classification
Minor:
Estimated blood loss is 500mls – 1000mls
Major:
Estimated blood loss is in excess of 1000mls or clinical shock or
presence of ongoing or continuous hemorrhage.
• Moderate: 1000 – 2000mls
• Severe: >2000mls

6. Epidemiology
A systematic review and meta-analysis by Clara Calvert et al in
2012 reported the highest rates of PPH in Africa (27.5%), and the
lowest in Oceania (7.2%), with an overall rate globally of 10.8%.
Both Europe and North America was around 13%.
High rates:
• Multiple pregnancies (32.4% compared with 10.6% for
singletons)
• The overall rate of major PPH (>1000mls) was much lower at
an overall rate of 2.8%, again with highest rate in Africa
(5.1%).

7. Etiology/Risk factors (The 4T’s)
1. Tone (Uterine atony):
a. Over distension:
i. Multifetal Gestation
ii. Grandmultiparity
iii. Fetal Macrosomia
iv. Fetal Abnormalities
v. Polyhydramnios
vi. Retained Placenta
vii. Retained blood clots
viii. Uterine Structural Abnormalities

8. Etiology/Risk factors (The 5 T’s)
1. Tone (Uterine atony):
b. Poor myometrial activity:
i. Prolong labour
ii. Precipitous labour
iii. Placenta implantation in lower uterine segment
iv. Drugs
v. chorioamnionitis
vi. Hypoxia
vii. Hypothermia
viii. Uterine anomalies
ix. Uterine inversion

9. Etiology/Risk factors (The 5 T’s)
2. Tissue:
a. Retained placenta
b. Retained blood clots
3. Trauma: Spontaneous or Iatrogenic:
a. Uterine Rupture
b. Cervical, vaginal or perineal lacerations

10. Etiology/Risk factors (The 5 T’s)
4. Thrombi (Coagulopathy):
a. Consumptive coagulopathy
DIC
Dilutional coagulopathy
Thrombocytopenia: ITP, TTP
b. Pharmacological inhibition
Warfarin
Heparin
Dextran infusion
c. Hereditary coagulation Disorders
Familial Hypofibroginaemia
Von Wille Brand disease

11. Risk assessment:
Low risk Moderate risk High risk
Singleton pregnancy Prior C/S or uterine
surgery
Previa, accreta,
percreta, increta
< 4 previous
deliveries
> 4 previous deliveries PCV <30%
Unscarred uterus Multiple gestation Bleeding at presentation
No previous Hx Large uterine fibroids Known Coagulation
defects
Chorioamnionitis Positive Previous Hx
MgSo4 use Abnormal vital signs
Prolonged us of oxytocin

12. Pathophysiology
Physiological changes during pregnancy:
Hematological:
• Progressive decline in Platelet count, (5 – 10%) 100 – 150 x
109 cells/l
Cardiovascular:
• Blood flow to the uterus at term is 500 – 800mls/min (10 –
15% of cardiac output)

13. Pathophysiology
Physiological changes after delivery of placenta:
• Uterine contraction and retraction
• Activation of coagulation system (Factor)
Pathology:
• Uterine atony (80%)
• Trauma
• Retained tissue
• Coagulopathy (DIC)
“Living Ligatures”

14. Estimation of blood loss:
• Visual inspection
• Clinical signs
• Hematocrit
• Gravimetric method
• Maximum swab (gauze) capacity: small (10 x 10cm) – 60mls,
medium (30 x 30cm) – 140mls, Large (45 x 45cm): 350ml
• Photometric method

15. Clinical features correlation with estimated
blood loss:
Symptoms/Signs Systolic Blood
pressure
Estimated blood
loss
Degree of shock
Palpitations,
tachycardia,
dizziness.
Normal 500 – 1000mls
10 – 15%
Compensated
Tachycardia,
sweating,
weakness.
80 – 100mmhg 1 – 1.5L
15 – 25%
Mild
Restlessness,
Oliguria, pallor.
70 – 80mmhg 1.5 – 2L
25 – 35%
Moderate
Collapse, Anuria,
Air hunger.
<70mmhg >2L
>35 %
Severe

16. Prevention:
a. Pre-pregnancy: Health Education (men & women)
Primary Health care Services
Women Empowerment
b. Pregnancy: Antenatal care: Clinical Evaluation
Investigations

17. Labour:
a. Review patients obstetric history
b. Examine
c. Establish a diagnosis
d. Intravenous cannula
e. Investigations: Urgent Full Blood Count (Hematocrit)
GXM 2pints
Urinalysis
f. Use of Partograph (Active Phase)
g. Episiotomy???, There must be a clear indication based on the
experienced judgment

18. ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR:
Paramount in preventing primary PPH, it involve:
a. Administration of uterotonics, oxytocin, after delivery of the
fetus and exclusion of a 2nd twin.
b. Cord clamping & cutting after 1 – 3min after delivery of fetus
c. Delivery of the placenta by control cord traction after
resumption of uterine contraction (signs of separation)
d. Inspect placenta for completeness
e. Rub-up contraction and monitor uterine state every
15minutes for first 2hours.
f. Prophylactic measures for high risk patients should be
ensured.
Monitor patient up to 24hours before discharge.

19. Management:
• CALL FOR HELP (4 ASSISTANTS)
• Resuscitation: Airway
Breathing
Circulation: 2 wide-bore IV cannula in-situ,
investigation samples, normal saline.
Anti-shock garment
• Request for 2 – 4 pints of Fresh Whole blood
• Notify the theater to be on stand-bye and blood bank of the
possibility of the need for more blood within a short time.
• Document critical intervention/information and time, i.e. note
vital signs momentarily, drugs, fluids given and volume, SPo2
and chest auscultation.

20. Management:
3. Tertiary level continue:
Examination:
• Uterine palpation for atony, rupture or inversion
• Inspect placenta for completeness
• Inspect Genital tract for laceration
• Inspect for signs of coagulopathy
• Review of results

21. Treatment of underlying causes:
UTERINE ATONY:
• Mix 40IU Oxytocin + 1L Normal saline to over 4hours + empty
urinary bladder.
• Other uterotonic agents may be used:
Misoprostol (800ug – 1000ug), Ergometrine or Carboprost
• Bimanual compression
• Uterine tamponade:
SOS Bakri tamponade, Ebb uterine tamponade system, Condom or
Surgical gloves

22. Improvised condom Tamponade
Bakri Uterine Tamponade Baloon

23. UTERINE ATONY:
Laparotomy, ongoing hemorrhage 2o unresponsive-atonic uterus
Ancillary measures:
• Bimanual compression
• NASG
• Uterine tamponade
• External aortic compression
Bimanual Uterine Compression

24. OPTIONS INCLUDE:
• Uterine/Ovarian artery ligation or Selective Arterial
Embolization
• Uterine compression sutures
B-lynch, Modified B-lynch, vertical uterine, square
compression suture.
• Hysterectomy
OTHER TREATMENT:
• Use of tranexamic acid
• Use of antibiotic prophylaxis
Further care in the Intensive Care Unit!

25. B lynch sutures
Uterine artery ligation

26. Treatment of underlying causes:
RETAINED TISSUE:
Require performing a manual/digital exploration,
Therapeutic indication:
• Uterine atony despite optimal use of uterotonics
• Incomplete Placenta
• Retained placenta due to avulsion of cord
• Retained blood clots.
Diagnostic values:
• Complete or partial uterine inversion
• Detects uterine rupture
• Genital tract lacerations
• Retained tissue

27. Treatment of underlying causes:
RETAINED TISSUE:
Require performing a manual/digital exploration…
• Done under anesthesia or adequate analgesic cover based on
the clinical urgency of the situation.
• Using elbow length surgical gloves*
• Continue uterotonic infusion during evacuation or delivery of
the placenta.
• Resume bimanual massage/compression after evacuation.
• Have an assistant examine the placenta for completeness
if/when retrieved.
• Short term broad spectrum antibiotics.

28. Treatment of underlying causes:
TRAUMA:
Uterine Rupture: Absence of contraction with abdominal
pain/tenderness. repair of laceration or hysterectomy .
Despite well contracted uterus bleeding persists “per vagina “…
Consider cervical, vaginal or perineal lacerations or a combination.
Repair immediately under
• Adequate analgesia
• Excellent lighting
• Good positioning & exposure: realize the full extent & proper
anatomy of the laceration before repair
• Extensive lacerations (cervical lacerations inclusive) are best
repaired in the theatre
• Observe laceration for bleeding after repair

29. Treatment of underlying causes:
COAGULOPATHY:
• History (risk factors)
• clinical signs (bleeding from puncture sites, mucous membranes or
into the skin, spontaneous bruising)
• Available Investigation results:
Bedside clotting time
Clotting profile (PT, aPTT, D-dimer)
Platelet count (<50 x 109/L)
• Transfuse with Fresh whole blood or
• Transfuse with relevant blood component:
FFP: requirement 5 pints of PRBC : 1 pint FFP (10-20ml/kg).
Platelet concentrate: 1 pint increase count by 10 x 109/L, maintain
count >50 x 109/L.
Cryoprecipitate in isolated deficiencies.

30. Treatment of underlying cause:
HEMATOMA:
An extravascular localized (progressive) collection or accumulation of
blood associated with intense pain and localized tender swelling. This
may be associated with significant deterioration in the hemodynamic
state of the patient. It may occur in relation to laceration or in
isolation.
Rx:
Vulva or vaginal hematoma: for large progressive hematomas +
tachycardia, hypotension or anemia. I & D, secure hemostasis, and
repair defect in layers
Retroperitoneal hematoma requires Laparotomy

31. COMPLICATIONS:
EARLY COMPLICATIONS:
• Postpartum anaemia
• Infections
• ATN
• Pulmonary edema
• Thromboembolic events
• Blood transfusion related (massive blood transfusion)
• Gastrointestinal ulceration
• Surgical related
• Anesthesia related

32. LATE COMPLICATIONS:
• Sheehans Syndrome
• Infertility
• Uterine synechiae
• Infections
• Child neglect
• Maternal depression
• Rh Isoimmunization

33. CONCLUSION:
AMTSL is paramount to preventing primary PPH.
It is necessary to have a protocol for its management which
should be communicated to medical staffs involved.
Conducting periodic reviews and practice drills will enhance the
efficiency of its management.

34. REFERENCES:
1. Textbook of Obstetrics and Gynecology for Medical Students, 2nd
Edition, Edited by Akin Agboola, 2006
2. WHO Recommendation for the prevention and treatment of
postpartum hemorrhage, 2012.
3. RCOG Guideline, Prevention and Management of Postpartum
Hemorrhage , December 2016.
4. ACOG Practice Bulletin, Postpartum hemorrhage, October 2017.
5. Medscape, Postpartum Hemorrhage, updated August 03, 2017.
6. Monroe Kerrs, Operative Obstetrics, 11th Edition.