15.PPH

Obstetrics                                                             Lec 15                                                          Dr. Aseil 

1 

PPH 

DEFINTION 

Postpartum Hemorrhage: bleeding from genital tract in excess of 500 ml after 
delivery. Types:-  
  *Primary pph occur within first 24 h 
  * Secondary pph occur between24h  and 6-12w postpartum 
 

ASSESSMENT OF BLOOD LOSS AFTER DELIVERY 

  Difficult, mostly visual & subjective. 
  For this reason it is more important to take into account any blood loss 

that causes a haemodynamic change 

  As the risk of dying from pph depend not only on the amount and rate of 

blood loss but also on the health of women.  

Physiology of 3

rd

 stage 

  Once the baby is born myometrial contraction is the main driving force for 

placental separation &blood v.constriction .This hamostatic mechanism is 
known as  

  Physiological suture or livinig ligature. 
  If the uterus does not contract normally, the blood vessels at the placental 

site stay open & hemorrhage results. 

  Because the estimated blood flow to the uterus is 500 – 800 ml/min at 

term a  severe postpartum hemorrhage can happen within just a few 
minutes.  

Etiology of PPH 

The causes of postpartum hemorrhage can be thought of as the four Ts: 

 tone,  
 tissue,  
 trauma,  
 thrombin 

Obstetrics                                                             Lec 15                                                          Dr. Aseil 

2 

Tone 

Uterine atony 

 Multiple gestation , polyhydramnios  
 high parity,  
 prolonged labor 
 chorioamnionitis,  
 augmented, instrumental delivery 

Tissue 

1-Retained uterine contents 

 Placenta &products of conception,  
 blood clots 

2-Placental abnormalities 

 Location : Placenta previa 
 Attachment : Accreta (Leiomyoa, previous surgery) 
 Peripartum  : Placental abruption 

Trauma 

Lacerations and trauma 

 Planned: Cesarean section, episiotomy 
 Unplanned: Vaginal/cervical tear, Uterine rupture, Haematoma 

Thrombin 

Coagulation disorders 

 Congenital: Von Willebrand's disease 
 Acquired: DIC(AP,IUD,PET,AFE) , Heparin, Massive transfusion 

PREVENTION 



Regular ANC 



Correction of anaemia 



Identification of high risk cases,who should  deliver  



in hospital with facility for Emergency Obstetric Care. 

ACTIVE MANAGEMENT OF 3

RD

 STAGE :- 

Obstetrics                                                             Lec 15                                                          Dr. Aseil 

3 

• Placenta delivered by controlled cord traction (CCT) with counter-traction to 
the fundus. 
• Fundal massage. 
 
Prophylactic oxytocics should be offered routinely in the management of the 
third stage of labour 
Oxytocin  5 u iv, 10 u im  
Syentometrin (5 u syentocinon+0.5 mg ergometrin) 
 
 

SYMPTOMS & SIGNS 

Blood loss  
(% B Vol) 

Systolic BP 
(mm of Hg) 

Signs & Symptoms 

10-15 

Normal 

postural hypotension 

15-30     

slight fall 



PR, thirst, weakness 

30-40 

60-80 

pallor,oliguria, confusion 

40+ 

40-60 

anuria, air hunger, coma, 

death

Management 

A-RESUSCITATE 

  TEAM(call for help)- Obstetrician, Anaesthetist ,midwife Haematologist 

and Blood Bank 

  IV access with 14 G cannula X 2,Oxygen, head down  
Transfuse 
  Crystalloid (eg Hartmann’s)  
  Colloid (eg Gelofusine)  
 GIVE ‘O NEG’ OR  uncross-matched own-group If no cross-matched blood 
available .  

Obstetrics                                                             Lec 15                                                          Dr. Aseil 

4 

Monitor 
  PR,BP,Foley catheter for UOP,CVP,oximeter 
Investigate 
  Cross match 6 units of blood 
  FBC  ,Clotting screen 
  RFT,LFT  

B-STOP THE BLEEDING

First step(if placenta delivered) 
 Examine uterus for atonia,  or inversion 
 ENSURE UTERINE CONTRACTION.  
1- Ensure empty bladder        
2-Give uterotonics)                 
*IV oxytocin 10 units bolus followed by 40U in500ml NS infusion 125ml/hr  
*IV ergometrine 0.2-0.5 mg  
*IV Syntometrine (5 unit oxytocin +ergometrine)  
*IM or inramyometrial Carboprost or haemabate(PG F2 * 
*Misoprostol (PG E1).(800 Mcg rectally or orally) 
bronchoconstrive C.I. in asthma SE diarrhea,v omiting ,fever ,headache & 
flushing  
3-(uterine massage, Bimanual compression)

Second step 

Exclude causes  other than uterine atony 

Obstetrics                                                             Lec 15                                                          Dr. Aseil 

5 

  Explore the uterine cavity for integrity , placenta debris and exclude clot 

retention 

  *Examine lower genital tract for possible cervical,vaginal and perineal 

tears. 

  *Exclude coagulopathies: bed side clotting test, clotting profile,fibrinogen 

and FDP 

Third step 



EUA 



SURGICAL TREATMENT 



Repair of trauma if any 



UTERINE PACKING 



UTERINE TAMPONADE 



Uterine A. ligation 



Internal Iliac A. Ligation  



Brace suturing of Uterus(B- Lynch) 



Angiographic embolisation of U.A. 



Hysterectomy 

IF Placenta not delivered 
EUA & MANUAL REMOVAL OF PLACENTA 

Placenta Accreta 

(1) Accreta vera, 

in which the placenta adheres to the myometrium without invasion . 

(2) Increta, in which it invades into the myometrium.  

Obstetrics                                                             Lec 15                                                          Dr. Aseil 

6 

(3) Percreta, in which it invades the full thickness of the uterine wall and 
possibly other pelvic structures, most frequently the bladder.  
 

UTERINE RUPTURE

Rupture of the uterus is described as complete or incomplete and  dehiscence 
of a cesarean section scar.  
Management of Rupture Uterus 

 At this point, a decision must be made to perform hysterectomy or to 

repair the rupture site. In most cases, hysterectomy should be performed. 

   repair of the rupture can be attempted (in dehiscent scar following C/S). 

MORBIDITY & MORTALITY from PPH 

  Shock & DIC 
  Renal Failure 
  Puerperal sepsis 
  Blood transfusion reaction 
  Thrombo-embolism 
  Sheehan’s syndrome 
  >25% Maternal deaths are due to PPH 

 
EDITED BY :TWANA NAWZAD