INTRODUCTION

PPH is commonly defined as blood loss exceeding 500 milliliters following vaginal birth and
1000 mL following caesarean In addition, pph may be described as third or fourth stage
depending of the placenta, respectively.

Causes of postpartum bleeding include loss of tone in the uterine muscles, a bleeding disorder
or the placenta failing to come out completely or tearing.

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 affects the general condition of the patient evidenced
by rise in pulse rate and falling blood pressure is called postpartum hemorrhage”.

The average blood loss following vaginal delivery, cesarean delivery and cesarean
hysterectomy is 500 mL, 1000 mL and 1500 mL respectively.

Depending upon the amount of blood loss, PPH can be:

♦ Minor (< 1L)

♦Major (> 1L)

♦ Severe (> 2L)

INCIDENCE: The incidence is about 4–6% of all deliveries.

TYPES-

 Primary pph
 Secondary pph
PRIMARY POST PARTUM HEMORRHAGE

Hemorrhage occurs within 24 hours following the birth of the baby. In the majority,
hemorrhage occurs within two hours following delivery.

 These are of two types:

a) Third stage hemorrhage: Bleeding occurs before expulsion of placenta.
b) True postpartum hemorrhage: Bleeding occurs subsequent to expulsion of placenta
(majority).

Causes: Four basic pathologies are expressed as the four Ts’: Tone (atonicity), Tissue
(retained bits, blood clots), Trauma (genital tract injury) and Thrombin (coagulopathy).

Atonic uterus (80%): Atonicity of the uterus is the commonest cause of postpartum
hemorrhage.
With the separation of the placenta, the uterine sinuses, which are torn, cannot be compressed
effectively due to imperfect contraction and retraction of the uterine musculature and
bleeding continues. The following are the conditions, which often interfere with the retraction
of the uterus as a whole and of the placental site in particular.

Traumatic (20%): Trauma to the genital tract usually occurs following operative delivery
even after spontaneous delivery. Blood loss from the episiotomy wound is often
underestimated. Similarly, blood loss in cesarean section amounting to 800-100 mL is most
often ignored.

Trauma involves usually the cervix, vagina, perineum (episiotomy wound and lacerations),
paraurethral region and rarely, rupture of the uterus occurs. The bleeding is usually revealed
but can rarely be concealed (vulvovaginal or broad ligament hematoma).

Retained tissues: Bits of placenta, blood clots cause PPH due to imperfect uterine retraction.

Thrombin: Blood coagulation disorders, acquired or congenital, are less common causes of
postpartum hemorrhage. The blood coagulopathy may be due to diminished procoagulants
(washout phenomenon) or increased fibrinolytic activity. The firmly retracted uterus can
usually prevent bleeding.

Diagnosis and clinical effects of primary post partum hemorrhage:

In the majority, the vaginal bleeding is visible outside, as a slow trickle. Rarely, the bleeding
is totally concealed as either vulvovaginal or broad ligament hematoma. The effect of blood
loss depend on:

a) Predelivery hemoglobin level,

b) Degree of pregnancy induced hypervolemia.
c) Speed at which blood loss occurs. Alteration of pulse, blood pressure and pulse
Pressure appears only after class 2 hemorrhage (20–25% loss of blood volume). On
occasion, blood loss is so rapid and brisk that death may occur within a few minutes.

Prognosis of primary post partum hemorrhage : It is one of the major causes of maternal
deaths both in the developing and developed countries. Prevalence of malnutrition and
anemia, inadequate antenatal and intranatal care and lack of blood transfusion facilities,
substandard care are some of the important contributing factors. There is also increased
morbidity. These include shock, transfusion reaction, puerperal sepsis, failing lactation,
pulmonary embolism, thrombosis and thrombophlebitis. Late sequelae include Sheehan’s
syndrome (selective hypopituitarism) or rarely diabetes insipidus.

Prevention of primary post partum hemorrhage: Postpartum hemorrhage cannot always

be prevented. However, the incidence and especially its magnitude can be reduced
substantially by assessing the risk factors and following the guidelines as mentioned below:

Antenatal
  Improvement of the health status of the woman and to keep the hemoglobin level
normal (> 10 g/dl) so that the patient can withstand some amount of the blood loss.
 High risk patient who are likely to develop postpartum hemorrhage (such as twins,
hydramnios, grandmultipara, APH, history of previous PPH, severe anemia) are to be
screened and delivered in a well-equipped hospital.
 Blood grouping should be done for all women so that no time is wasted during
emergency.
 Placental localization must be done in all women with previous cesarean delivery by
USG or MRI to detect placenta accreta or percreta.
 All women with prior cesarean delivery must have their placental site determined by
ultrasound/MRI to determine morbid adherent placenta.
 Women with morbid adherent placenta are at high risk of PPH. Such a case should be
delivered by a senior obstetrician. Availability of blood and or blood products must be
ensured beforehand. Multidisciplinary team approach should be made in such a case.

Intranatal:

 Active management of the third stage , for all women in labor should be a routine as it
reduces pph by 60%.
 Cases with induced or augmented labor by oxytocin, the infusion should be continued
for at least one hour after the delivery.
 Women delivered by caesarian section, oxytocin 5 IU slow IV are to be given to
reduce blood loss. Carbetocin (long-acting oxytocin) 100 μg is very useful to prevent
PPH.
 Exploration of the uterovaginal canal for evidence of trauma following difficult labor
or instrumental delivery.
 Observation for about two hours after delivery to make sure that the uterus is hard and
well contracted before sending her to ward.
 Expert obstetric anesthetist is needed when the delivery is conducted under general
anesthesia.
 Local or epidural anesthesia is preferable to general anesthesia, in forceps, ventouse
or breech delivery.
 During cesarean section spontaneous separation and delivery of the placenta reduces
blood loss (30%).
 Examination of the placenta and membranes should be a routine to detect at the
earliest any missing part.

Management of third stage bleeding

Steps of management:

 Placental site bleeding.

 Traumatic bleeding
Placental site bleeding To palpate the fundus and massage the uterus to make it hard. The
massage is to be done by placing four fingers behind the uterus and thumb in front. However,
if bleeding continues even after the uterus becomes hard, suggests, the presence of genital
tract injury.

 To start crystalloid solution (Normal saline or Ringer’s solution) with oxytocin (1 L

with 20 units) at 60 drops per minute and to arrange for blood transfusion if
necessary.
 Oxytocin 10 units IM or methergine 0.2 mg is given intravenously. Carbetocin, a
longer acting oxytocin derivative is found (100 μg) as effective as oxytocin infusion.
 To catheterize the bladder.
 To give antibiotics (Ampicillin 2 g and Metronidazole 500 mg IV).

During this procedure, if features of placental separation are evident, expression of the
placenta is to be done either by fundal pressure or controlled cord traction method. If the
placenta is not separated, manual removal of placenta under general anesthesia is to be done.
However, if the patient is in shock, she is resuscitated first before undertaking manual
removal.

Traumatic bleeding:

 The uterovaginal canal is to be explored under general anesthesia after the placenta is
expelled and hemostatic sutures are placed on the offending sites.

Steps of manual removal of placenta

Step I: The operation is done under general anesthesia. In extreme urgency where anesthetist
is not available, the operation may have to be done under deep sedation with 10 mg diazepam
given intravenously. The patient is placed in lithotomy position. With all aseptic measures,
the bladder is catheterized.

Step II: One hand is introduced into the uterus after smearing with the antiseptic solution in
cone shaped manner following the cord, which is made taut by the other hand. While
introducing the hand, the labia are separated by the fingers of the other hand. The fingers of
the uterine hand should locate the margin of the placenta.

Step III: Counter pressure on the uterine fundus is applied by the other hand placed over the
abdomen. The abdominal hand should steady the fundus and guide the movements of the
fingers inside the uterine cavity until the placenta is completely separated.

Step IV: As soon as the placental margin is reached, the fingers are insinuated between the
placenta and the uterine wall with the back of the hand in contact with the uterine wall. The
placenta is gradually separated with a sideways slicing movement of the fingers, until whole
of the placenta is separated.
Step V: When the placenta is completely separated, it is extracted by traction of the cord by
the other hand. The uterine hand is still inside the uterus for exploration of the cavity to be
sure that nothing is left behind.

Step VI: Intravenous methergine 0.2 mg is given and the uterine hand is gradually removed
while massaging the uterus by the external hand to make it hard. After the completion of
manual removal, inspection of the cervicovaginal is to be made to exclude any injury.

Step VII: The placenta and membranes are inspected for completeness and be sure that the
uterus remains hard and contracted.

Complications:

(1) Hemorrhage due to incomplete removal

(2) Shock

(3) Injury to the uterus

(4) Infection

(5) Inversion (rare)

(6) Subinvolution

(7) Thrombophlebitis

(8) Embolism

In such cases placenta is removed in fragments using an ovum forceps or a flushing curette.

Management of true postpartum hemorrhage

Principles:

 Communication
 Resuscitation
 Monitoring
 arrest of bleeding

Management: Immediate measure is to be taken by the attending house officer

(doctor/midwife).

 Involve the obstetric registrar (senior staff) on call.

 Put in two large bore (14-gauge) intravenous cannulas.
 Keep patient flat and warm.
 Send blood for full blood count, group, cross matching, diagnostic tests (RFT, LFT),
coagulation Screen including fibrinogen and ask for 2 units (at least) of blood.
  Infuse rapidly 2 liters of normal saline (crystalloids) or plasma substitutes like
haemaccel (colloids), an urea-linked gelatin, to reexpand the vascular bed. It does not
interfere with cross matching.
 Give oxygen by mask 10–15 L/min.
 Start 20 units of oxytocin in 1 L of normal saline IV at the rate of 60 drops per
minute. Transfuse blood as soon as possible.
 One midwife/rotating houseman should be assigned to monitor the following—(i)
Pulse (ii) Blood pressure (iii) Temperature (iv) Respiratory rate and oximeter (v) Type
and amount of fluids (blood, blood products) the patient has received (vi) Urine
output (continuous catheterization) (vii) Drugs-type, dose and time (viii) Central
venous pressure (when sited).

Actual management

The first step is to control the fundus and to note the feel of the uterus. If the uterus is flabby,
The bleeding is likely to be from the atonic uterus. If the uterus is firm and contracted, the
bleeding is likely of traumatic origin.

Atonic uterus:

Step I:

 Massage the uterus to make it hard and express the blood clot,
 Methergine 0.2 mg is given iv
 Injection oxytocin drip is started (10 units in 500mL 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. If the uterus fail to contract, proceed the next step.

Step II:

 The uterus is to be explored under general anesthesia. Simultaneous inspection of the

cervix, vagina especially the paraurethral region is to be done to exclude coexistent
bleeding sited from the injured area. In refractory cases:
 Injection 15 methyl PGF2α 250 μg IM in the deltoid muscle every 15 minutes (up to
maximum of 2 mg).
Or

Misoprostol (PGE1) 1000 μg per rectum is effective.

- When uterine atony is due to tocolytic drugs, calcium gluconate (1 g IV slowly) should be
given to neutralize the calcium blocking effect of these drugs.

Step III:

 Uterine massage and bimanual compression.

Procedures:

- 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. It may be necessary to continue the
compression for a prolonged period until the tone of the uterus is regained. This is evidenced
by absence of bleeding if the compression is released. But in rare cases, when the uterus fails
to contract, the following may be tried desperately as an alternative to hysterectomy.

Step IV:

Uterine tamponade:

a. Tight intrauterine packing is done uniformly under general anesthesia.

Procedure: 5 meters long strip of gauze, 8 cm wide folded twice is required. The gauze
should be soaked in antiseptic cream before introduction. The gauze is placed high up and
packed into the fundal area first while the uterus is steadied by the external hand. Gradually,
the rest of the cavity is packed so that no empty space is left behind. A separate pack is used
to fill the vagina. An abdominal binder is placed. Intrauterine plugging acts not only by
stimulating uterine contraction but exerts direct hemostatic pressure (tamponade effect) to the
open uterine sinuses. Antibiotic should be given and the plug should be removed after 24 hrs.

b. Ballon tamponade :
Tamponade using various types of hydrostatic balloon catheter has mostly replaced
uterine packing. Mechanism of action is similar to uterine packing. Foley catheter,
Bakri balloon, Condom catheter or Sengstaken-Blakemore tube is inserted into the
uterine cavity and the balloon is inflated with normal saline (200–500 mL). It is kept
for 4–6 hours. It is successful in atonic pph. This can avoid hysterectomy in 78%
cases. It is considered the first line surgical intervention for most women with atonic
pph.

Step V:

Surgical methods to control PPH are many. An outline of stepwise uterine devascularization
procedures are given below:

a) B-Lynch compression suture and multiple square suture: Both these surgical methods
work by tamponade (like bimanual compression) of the uterus. Success rate is about
80% and it can avoid hysterectomy.
Ligation of uterus arteries: The ascending branch of the uterine artery is ligated at the
lateral border between upper and lower uterine segment. The suture (No. 1 chromic)
 is passed into the myometrium 2 cm medial to the artery. In atonic hrmorrhage,
bilateralligation is effective in about 75% of cases.
b) Ligation of the ovarian and uterine artery anastomosis, if bleeding continues, is done
just below the ovarian ligament (Fig. 28.5). Rarely temporary occlusion of the ovarian
vessels at the infundibulopelvic ligament may be done by rubber-sleeved clamps.
c) Ligation of anterior division of internal iliac artery (unilateral or bilateral)- reduces
the distal blood flow. It helps stable clot formation by reducing the pulse pressure up
to 85%. Due to extensive collateral circulation, there is no pelvic tissue necrosis.
Bilateral ligation (not division) can avoid hysterectomy in about 50% of the cases.
d) Angiographic selective arterial embolization (bleeding vessel) under fluoroscopy
(interventional radiology) can be done using gel foam. Success rate is more than 90%
and it avoids hysterectomy.

Step VI:

Hysterectomy: Rarely uterus fails to contract and bleeding continues in spite of the above
measures. Hysterectomy has to be considered involving a second consultant. Decision of
hysterectomy should be taken earlier in a parous woman. Depending on the case, it may be
subtotal or total.

Traumatic PPH: The trauma to the perineum, vagina and the cervix is to be searched under
good light by speculum examination and hemostasis is achieved by appropriate catgut
sutures.

SECONDARY POSTPARTUM HEMORRHAGE

Hemorrhage occurs beyond 24 hours and within puerperium, also called delayed or late
puerperal hemorrhage.

Causes:

The bleeding usually occurs between 8th and 14th day of delivery.

Causes of late pph are:

(1) Retained bits of cotyledon or membranes (most common)

(2) Infection and separation of slough over a deep cervicovaginal laceration

(3) Endometritis and subinvolution of the placental site—due to delayed healing process

(4) Secondary hemorrhage from cesarean section wound usually occur between 10–14 days.

(5) Withdrawal bleeding following estrogen therapy for suppression of lactation,

(6) Other rare causes are: chorionepithelioma—occurs usually beyond 4 weeks of delivery;
carcinoma cervix; placental polyp; infected fibroid or fibroid polyp and puerperal inversion
of uterus.
Diagnosis :

The bleeding is bright red and of varying amount. Rarely it may be brisk. Varying degree of
anemia and evidences of sepsis are present. Internal examination reveals evidences of sepsis,
subinvolution of the uterus and often a patulous cervical os. Ultrasonography is useful in
detecting the bits of placenta inside the uterine cavity.

Management :

-To assess the amount of blood loss and to replace it (blood transfusion).

- To find out the cause and to take appropriate steps to rectify it.

Supportive therapy:

(1) Blood transfusion, if necessary

(2) To administer methergine 0.2 mg intramuscularly, if the bleeding is uterine in origin.

(3) To administer antibiotics (clindamycin and metronidazole) as a routine

Conservative :

If the bleeding is slight and no apparent cause is detected, a careful watch for a period of 24
hours or so is done in the hospital.

Active treatment :

As the most common cause is due to retained bits of cotyledon or membranes, it is preferable
to explore the uterus urgently under general anesthesia. One should not ignore the small
amount of bleeding, as unexpected alarming hemorrhage may follow sooner or later. The
products are removed by ovum forceps. Gentle curettage is done by using flushing curette.
Methergine 0.2 mg is given intramuscularly.

Presence of bleeding from the sloughing wound of cervicovaginal canal should be controlled
by hemostatic sutures. Secondary hemorrhage following cesarean section may at times
require laparotomy. The bleeding from uterine wound can be controlled by hemostatic
sutures; may rarely require ligation of the internal iliac artery or may end in hysterectomy.
SUMMARY
We discussed about the introduction of pph, definition of pph, classification of pph, types of
pph, causes of pph, diagnosis of pph, clinical effect of pph, prognosis of pph, prevention of
pph, and management of pph.

CONCLUSION
Post partum hemorrhage is important cause of morbidity. We now have new pharmacological
and technical developments for prevention and treatment which can greatly reduce its
incidence and sequelae.
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