Postpartum

hemorrhage
PREPARED BY:
BANDE, KYLA MARIE
O.
LORENTE, ALFIE
JOHN C.
Introduction
 Post-partum Hemorrhage (PPH) remains a major
cause of maternal mortality and morbidity
worldwide. Approximately, half million women die
annually from causes related to pregnancy and
childbirth.

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 What is postpartum
hemorrhage?
Postpartum hemorrhage
refers to any amount of
bleeding from or into the
genital tract following birth
of the baby up to the end of
puerperium

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 Types of postpartum
hemorrhage
 PRIMARY POSTPARTUM HEMORRHAGE
Is the hemorrhage occurring during the third stage of labor and within
24 hours of delivery

 SECONDARY POSTPARTUM HEMORRHAGE

Is hemorrhage occurring after 24 hours of delivery and within
6 weeks of delivery. It is also referred to as puerperal
hemorrhage.

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CAUSES
PRIMARY POSTPARTUM HEMORRHAGE ARE:

 Atonic Uterus
 Trauma
 Mixed ( combination of both atonic and trauma)
 Retained product of conception
 Uterine rupture
 Uterine inversion
 Blood coagulopathy

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Secondary postpartum hemorrhage
include
 Retained bits of cotyledon :
or membranes
 Infection
 Cervico – vaginal laceration
 Endometritis
 Subinvolution of the placental site
 Secondary hemorrhage from caesarean section
 Other rare causes – chorion epithelioma, carcinoma cervix, placental polyp,
fibroid polyp and puerperal inversion of uterus.

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RISK FACTORS
 Prolonged third stage of labor
 Multiple delivery
 Episiotomy
 Fetal macrosomia
 History of postpartum hemorrhage
 Grandmultiparity
 Placental Previa
 Placental abruption
 Pregnancy induced hypertension
 Infection

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SYMPTOMS
 Massive blood loss
 Passing large clots
 Dizziness
 Lightheadedness or fatigue
 Decreased blood pressure
 Increased heart rate
 Swelling and pain in tissues in the vaginal and perineal
area

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“Four Ts” mnemonic of PPH
 TONE – Uterine atony (relaxed uterus)
 TRAUMA – Uterine rupture cervical and vaginal lacerations;
uterine inversion
 TISSUE – Retained placental fragments
 THROMBIN – Coagulation disorders

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Prevention of PPH
ANTENATAL
 Improvement of the health status
 High risk patients
 Blood grouping

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INTRANATAL
 Slow delivery of the body
 Expert obstetric anesthetist needed
 Spontaneous separation and delivery of placenta during caesarean section
 Active management of third stage of labor
 Examination of placenta
 Induced or accelerated labor by oxytocin
 Exploration of utero-vaginal canal
 To observe the patient for about two hours after delivery

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ACTIVE TREATMENT OF POSTPARTUM
HEMORRHAGE
 Rub up the uterus to stimulate contraction and retraction
 Administer ergometrine (0.2mg) intramuscularly
Syntometric (1ml) intramuscularly may be given instead of ergometrine
 Expel the placenta with the next uterine contraction by fundal pressure or
controlled cord traction.
 Empty the urinary bladder by catheterization
 A second dose of syntometrine or ergometrine may be given in ten minutes if
bleeding is not controlled

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 MANAGEMENT OF
PPH
TONE
 UTERINE MASSAGE - If the uterus is soft,
massage is performed by placing one hand in
the vagina and pushing against the body of the
uterus while the other hand compresses the
fundus from above through the abdominal
wall. The posterior aspect of the uterus is
massaged with the abdominal hand and the
anterior aspect with the vaginal hand

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UTEROTONIC AGENTS - Uterine agents include oxytocin, ergot alkaloids, and
prostaglandins.
 OXYTOCIN – 10 international units (IU) should be injected intramuscularly,
or 20 IU in 1 L of saline may be infused at a rate of 250 mL per hour. As
much as 500 mL can be infused over 10 minutes without complications.
 METHYLERGONOVINE (Methergine) AND ERGOMETRINE – a
typical dose of methylergo- noving, 0.2 mg administered intramuscularly,
may be repeated as required at intervals of two to four hours.

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PROSTAGLANDINS
 CARBOPROST- can be administered intramyometrially or
intramuscularly in a dose of 0.25 mg; this doe can be repeated every
15 minutes for a total dose of 2 mg
 MISOPROSTOL – is another prostaglandin; It can be administered
sublingually, orally, vaginally, and rectally. Does range from 200 to
1,000 mcg; the dose recommended by FIGO is 1,000 mcg
administered rectally

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 TRAUMA
 LACERATIONS AND
HEMATOMAS – resulting from
birth trauma can cause significant
blood loss that can be lessened by
hemostasis and timely repair
 UTERINE RUPTURE –
Symptomatic uterine rupture requires
surgical repair of the defect or
hysterectomy.
 UTERINE INVERSION is rare

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TISSUE
 Classical signs of placental
separation include a small gush of
blood with lengthening of the
umbilical cord and a slight rise of
the uterus in the pelvis. Placental
delivery can be achieved by the
use of the Brandt-Andrews
maneuver, which involves
applying firm traction on the
umbilical cord with one hand
while the other applies
suprapubic counter- pressure

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THROMBIN
Coagulation disorders, a rare cause of post-partum
hemorrhage, are unlikely to respond to the measures
described above. Most coagulopathies are identified
before delivery, allowing for advance planning
preventing postpartum hemorrhage.

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SURGICAL MANAGEMENT
OFPPH
Transvaginal uterine packing
 Conservative surgical approach – Uterine
Artery Ligation, Ovarian Artery Ligation,
Vaginal Artery Ligation, Internal Iliac
Ligation, Angiographic Arterial Embolization,
Hysterectomy.

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COMPLICATION
 Blood Loss
 Shock
 Death
 Septicemia
 Orthostatic hypotension
 Anemia
 Fatigue

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CONCLUSION
Postpartum hemorrhage defined as the loss of more than 500 mL
of blood after delivery, occurs in up to 18 percent of births. 1,2
Blood loss exceeding 1,000 mL is considered physiologically
significant and can result in hemodynamic instability. Uterine
atony is responsible for most cases and can be managed with
uterine massage in conjunction with oxytocin, prostaglandins, and
ergot alkaloids.

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THANK YOU !

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