POSTPARTUM
HEMORRHAGE
(PPH)
SERUNGA BRUHAN
Learning Objectives
Define and diagnose PPH.
Understand the risk factors and causes of
PPH.
Learn to prevent PPH and manage a
woman with PPH.
Describe the implications of PPH on mother
and newborn.
Introduction
Most common form of major obstetric
haemorrhage
Bleeding of 500 ml or more after vaginal
delivery and
1000 ml or more after caesarean section
OR
Any amount that causes deterioration of
the maternal condition (systolic BP,
<90mmHg, pulse rate>100bpm, urine
output <30mls/hr and altered level of
consciousness)
Prevalence of PPH
Globally PPH prevalence stands at 6% and it
remains the leading cause of maternal death.
In sub-Saharan Africa PPH prevalence is at
10.5% while for Uganda is 9.0%
In Uganda PPH is the leading cause of
maternal deaths accounting for about 34% of
the causes(2021/22).
Causes of maternal deaths across four
years FY18/19 – FY21/22
45%
40%
39%
39%
35%
35%
34%
30%
25%
20%
15%
15%
13% 14% 13% 12% 13%
10% 11% 11% 12% 11% 12%
9%10%9%
5% 7%6%8%7% 6% 6% 6%
8%
5% 5%
0% 2%1%3%2% 2%2%2%2% 2%2%2%3%
18/19 [N= 447 ] 19/20 [N=779] 20/21[N=811] 21/22 [N=1096]
TYPES OF PPH
Primary PPH
Bleeding that occurs within the first 24 hours after delivery.
Secondary PPH
Bleeding that occurs 24 hours after delivery of the baby up to 6
weeks postpartum.
The basic principles and management for primary and secondary
PPH remain the same
Risk factors
All pregnant women are at risk of PPH
Uterine Atony
Trauma to the genital tract (Uterus, Cervix &
Vagina)
• Obstructed labour
(60-70%) • Precipitate labour
• Caesarean section (difficult/inadequate skill)
H/O PPH • Assisted vaginal delivery
Retained placenta or membranes • Big baby
Tissue
Prolonged labour - Retained placenta
Over-distended uterus (e.g., - Placenta accreta
- Retained membranes
polyhydramnios or multiple
- Blood clots
pregnancy, big baby)
Full bladder
Thrombotic disorders (Coagulopathy)
Grand multiparity Note: Prolonged haemorrhage from all those
Anaesthetics agents (e.g., halothane) causes listed above can lead to coagulation
disorder. Others include;
Uterine fibroids • Intrauterine foetal death
Induction and augmentation of labour • Preeclampsia and eclampsia
• Uterine infections (chorioamnionitis)
with oxytocin • Use of anticoagulants
Chorioamnionitis • Amniotic fluid embolism
• Hypovolemic shock
Risk factors (cont)
Risk factors may present antenatally or intrapartum;
care plans must be modified as and when risk factors
arise.
Providers must be aware of risk factors for PPH and
should take these into account when counselling
women about place of delivery.
Women with known risk factors for PPH should only be
delivered in a facility with a blood bank on site.
MANAGEMENT OF PPH
[Link] of Anaemia during ANC
• Provide daily iron and folate
• Intermittent presumptive treatment of Malaria
(IPTx3)
• Sleep under ITN
• Screen for Anaemia in pregnancy
• HB measurement at 1st trimester, 26 wks
• Women with HB less than 8 gm/dl refer for
further investigations &Tx
Prevention of Anaemia during ANC
Re-check HB for all women at
36 weeks and onset of labour
If HB <10gm/dl at onset of
labour refer to CEmONC facility
Antenatal anaemia should be
investigated and treated
appropriately as this may reduce
the morbidity associated with PPH.
Support: Draw a Birth plan for all Women 1st visit (1st
trimester)
MECHANISMS OF CONTROLLING BLEEDING
AFTER DELIVERY OF THE BABY
Blood flow through the placental site is 500-800ml per minute at term.
• The tortuous uterine blood vessels pass
between the crisscrossing muscle fibers in
the upper uterine segment. After childbirth,
muscle fibers contract and act like living
ligatures to stop the bleeding by pressing
the blood vessels.
• Uterotonics (oxytocin, carbetocin,
misoprostol, and ergometrine) enhance the
contraction of the uterus.
• After delivery, a thin blood clot forms at the
placental site, further helping to stop the
bleeding.
Active Management of the
Third Stage of Labor (AMTSL)
1. Administration of a
uterotonic agent within
one minute after the
baby is born (Oxytocin
10 IU IV/IM, heat stable
carbetocin 100 mcg
IV/IM ergometrine 0.2mg
or Misoprostol 400-
600mcg oral)
2. Controlled cord traction
while supporting and
stabilizing the uterus by
applying counter
traction
3. Uterine massage every
15 minutes for 2 hrs
Start post delivery monitoring and documentation
after delivery of the
Monitoring after childbirth (first 2 hours)
Early detection of PPH before it has
become massive is key to reduction
of mortality & morbidity
Initiate early resuscitation &
treatment
Done in labour ward
Monitor
– Blood loss
– Blood pressure
– Pulse
– Uterine tone
Management of 3rd stage of labour
Diagnosis of PPH
Its often dramatic with the main feature being
heavy vaginal bleeding
The patient may present with signs and
symptoms of hypovolemic shock(rapid pulse of
>110, low blood pressure, sweating, cold clammy skin)
Sometimes the bleeding might be slower and
ultimately results in critical loss and shock
Treatment of PPH
Facility readiness is very
critical (emergency
preparedness)
Teamwork is important (call
for help)
Communication with woman
or relative
Emergency Preparedness for PPH
Note: Every facility delivery suite
MUST have a PPH emergency box
Call for help and assess
severity
First response PPH care
bundle M=Massage
Massage the uterus O=Oxytocic
Give an oxytocic agent T=Tranexamic acid
IV= IV fluids
Oxytocin 10 IU IV then 20IU in
E= Explore for tear
1litre of N/S
Misoprostol sublingual 800 mcg
Ergometrine IV 0.2mg If atony is not
Give tranexamic acid 1 gm IV over 10 responding to above
and Carboprost is
minutes available, give 250
Set up two large bore IV lines and mcg (IM) every 15
mins for 90 mins
run normal saline (IV fluids)
First Response Bundle
Manage the underlying cause
Retained placenta (1
hour after childbirth)
- Attempt controlled cord traction (CCT)
- If CCT fails, perform a gentle vaginal examination and if the
placenta is felt protruding through the cervix, grasp with the fingers
and steadily withdraw from the uterus while the other hand
supports it through the abdominal wall.
- If the placenta cannot be delivered, manual removal of the
placenta is performed under general anaesthesia if available or
refer to CEmONC facility.
- Give oxytocin after removal
- Broad spectrum antibiotics
- Continue monitoring vital signs and PV bleeding
Manage the underlying
cause
Uterine atony
Give oxytocin IV if not given
Massage the uterine fundus.
Empty the bladder, as needed.
Set up drip and allow to run fast and add
Oxytocin 20 IU in 1000ml of normal
saline.
Perform bimanual compression of uterus
Insert uterine balloon tamponade
Apply non-pneumonic anti-shock
garments
Bleeding persist refer to CEmONC
facility
Manage the underlying
cause
Tears
• Continue IV fluids
• Have good lighting for inspection
• Use sterile speculum to visualize the vaginal
wall
• Cervical tear: apply ring forceps, and repair in
theatre
• If at BeMONC facility cervix is torn and
bleeding, hold the bleeding edges with ring
forceps and refer to higher facility
Refractory
PPH
Interventions
1. Abdominal Aortic Compression
2. Bimanual compression of uterus
3. Uterine balloon Tamponade
4. Application of Anti-shock Garments
5. Give Oxygen
Coagulopathy
Suspected when there is profuse bleeding from the site of
– Trauma
– oozing from venepuncture
– intravenous line insertions
Laboratory
– Activated partial thromboplastin time and prothrombin time
(aPTT/PT) ratio
– Fibrinogen
– Platelet count
Coagulopathy
Transfusion with Fresh Frozen Plasma (FFP) as wait for lab result
Administer FFP 12-15 ml/kg to aPPT/PT less than 1:5
Transfuse with platelets to maintain level above 75x109 /L
If no lab results transfuse with 4 units of whole blood maximum 8
units (FFP:RBC 1:1)
Continued care of the
woman
Once the bleeding is controlled, and the woman is stable, careful
monitoring over the next 24–48 hours is required, including:
• Monitoring uterine tone
• Monitoring blood
transfusions
• Monitoring vital signs • Monitoring urinary output
• Ensuring the continuous
• Estimating ongoing blood loss presence of a skilled
attendant, who maintains
• Ensuring adequate fluid intake good documentation
Golden hour for PPH
Management
Direct relationship between the time taken to control the bleeding and a poor
maternal outcome
Time What you should have done
1st 20 mins Offer 1st response bundle MOTIVE
• Massage, oxytocic, TXA, IV fluid replacement and identification and
examine for the main cause bleeding, taking into account the
context of the 4 Ts: Tone, Trauma, Tissue, Thrombin
20-40 mins Perform mechanical maneuvers, Aortic compression, intrauterine
tamponade balloon, Bimanual compression of the uterus and non-
pneumatic anti-shock garment (NASG)
40-60 Perform uterine compressive sutures, pelvic vascular ligatures or
minutes hysterectomy
Key to successful management of
PPH and best outcome
Difficult to predict women at risk of PPH “Every pregnant woman is at
risk”
Majority of PPH-associated deaths could be avoided by prophylactic
uterotonics during the third stage of labour.
Immediate postnatal care and monitoring
Teamwork and communication is critical
Emergency preparedness “PPH Emergency Box”
Early identification and Use PPH Care Bundle
Early decision to use a surgical intervention eg B-Lynch
Key to successful management of
PPH and best outcome (cont)
Identify and manage the cause of PPH accordingly
Resuscitate promptly and adequately. Always use wide bore
needles for infusions.
Prevent infection with use of prophylactic antibiotics.
Ensure a good communication system and adequate transport
facilities for referral.
Always keep your emergency resuscitation tray replenished,
ready and accessible.
Ensure accurate and complete documentation
Ensure timely referral or consultation.
Refractory PPH Interventions
