POST PARTUM

HAEMORRHAGE
 DEFINITION

PPH is defined as a blood

loss in excess of 500 c.c.
after vaginal delivery,
and more than 1000 c.c.
following C.S
 TYPES OF PPH
 Primary PPH: Immediate bleeding, or
within first 24 hours, after delivery. It is
the most important variety as it is
associated with acute blood loss that
may be life threatening.
 Secondary PPH: Bleeding which is
delayed > 24 hours, and till the end of
puerperium. It is uncommon, the
bleeding tends to be mild and chronic,
and may even present as a
gynaecological problem.
 PRIMARY POST PARTUM
HAEMORRHAGE
 INCIDENCE: The incidence of PPH
varies from 0.5 - 4 % depending on
the proper management of labour.
 AETIOLOGY:
1. Placental site haemorrhage (atonic
PPH)
2. Traumatic laceration of the genital
tract (traumatic PPH).
3. Disseminated Intravascular
Coagulation (DIC)
PLACENTAL SITE HAEMORRHAGE (Atonic PPH)

1. Over distension of the uterus (e.g. over sized

baby, polyhydramnios and twins).
2. Prolonged labour (maternal exhaustion and
dehydration)
3. Antepartum haemorrhage (placenta praevia and
accidental haemorrhage).
4. Grand multiparity (lax and weak uterine muscles).
5. Precipitate labour (rapid delivery gives no time for
efficient uterine retraction).
6. Nervous shock & full bladder lead to reflex atony
of the uterus.
7. Retained separated placenta (partial or
complete). In these cases the myometrium cannot
contract and retract sufficiently due to presence
of retained placental tissue
 LACERATIONS OF THE GENITAL
TRACT (Traumatic PPH)

1. Perineal, vaginal, or cervical

lacerations
2. Rupture of the uterus
 DISSEMINATED INTRAVASCULAR
COAGULOPATHY (DIC)

1. Abruptio placenta
2. Retained IUFD
3. Amniotic fluid embolism
(AFE).
 CLINICAL PICTURE
 History: Ask for the presence of a
risk factor
– Atonic PPH: over distended uterus,
multifetal pregnancy, polyhydramnios,
etc.
– Traumatic PPH: traumatic or
instrumental delivery.
 General Examination: Check for
signs of hypovolaemic shock
Pallor, rapid weak pulse, low B.P.,
subnormal temperature, and oliguria.
 CLINICAL PICTURE
 Abdominal Examination: To check
the size and consistency of the
uterus.
– Atonic PPH is usually revealed, but may
be partially or entirely concealed.
– In atonic PPH, palpation of the uterus
reveals a soft consistency. The fundal
level may be higher than expected if
bleeding is partially concealed.
– In traumatic PPH, the uterus is firm, and
vaginal bleeding continues in spite of a
well contracted uterus. The cause of
traumatic PPH should be confirmed by
PV examination.
 CLINICAL PICTURE
 Vaginal Examination:
Preferably done under
anaesthesia
– To detcetd bleeding from a
perineal, vaginal, or cervical
laceration.
– To explore digitally the uterine
cavity for retained parts, and
for exclusion of uterine
rupture.
 COMPLICATIONS OF PPH
1. Maternal mortality (PPH represents about
34% of MMR in egypt).
2. Haemorrhagic shock (due to exessive
rapid blood loss, and possible DIC)
3. Acute renal failure (2ry to hypovolaemic
shock).
4. Puerperal sepsis (2ry to low immunity
and possible manipulations and retained
products)
5. Sheehan's syndrome (hypopituitrism
leading to 2ry amenorrhea due to
hypovolaemic shock)
 MANAGEMENT OF PPH
 Prevention:
1. Proper antenatal care (ANC):
 Previous history of PPH
 Grand multiparity (uterine muscle atony)
 Hydramnios, twins, oversized fetus (over
distension of uterine muscle).
 Placenta praevia and abruptio placenta
(causes of APH).
 Correction of anaemia during pregnnacy
 MANAGEMENT OF PPH
 Prevention:
1. Proper management of the 1st and 2nd
stages of labour:
 Avoid difficult and prolonged labour.
 Avoid difficult and unnecessary
instrumental delivery, especially if
conditions are not suitable for safe
applications
 MANAGEMENT OF PPH
 Prevention:
1. Proper management of the 3rd stage of
labour:
 Active management of the 3rd stage; reduces the
occurrence of PPH by nearly 50%.
 Wait for signs of separation before delivery of the
placenta. Attempts to express the placenta before
its separation are dangerous.
 Routine use of ecbolics after delivery, especially in
high risk cases.
 Intermittent uterine massage every 15 minutes,
and continuous observation for the pulse,
temperature, B.P., and vaginal bleeding, throughout
the first two hours after delivery
 MANAGEMENT OF PPH
 Treatment:
– Antishock measures and blood
transfusion, whenever necessary.
– Gentle uterine massage: done by
placing the thumb abdominally on the
uterine fundus and the four fingers of
the same hand behind to stimulate the
uterus to contract
 MANAGEMENT OF PPH
 Treatment:
– Ecbolics: must be given with uterine
massage. These include:
 Oxytocin given as an I.V. drip (syntocinon); to
increase the frequency and strength of uterine
contraction. (It should never be given as direct I.V.
bolus, as it may cause serious hypotension and
arrythmias.
 Methyl ergometrin (methergin); 0.2–0.5 mg, I.M. or
I.V., causes tetanic uterine contractions.
 Mesoprostol (synthetic prostaglandin); given by
rectal route, in a dose of 800 – 1000 ug
 MANAGEMENT OF PPH
 Treatment:
– If bleeding persists the following steps
are activated:
 If the placenta was retained; it should be delivered
immediately by controlled cord traction or manual
removal.
 If the placenta was already delivered, then perform
a vaginal exploration under anaesthesia to reveal:
 Undiagnosed retained placenta fragments which
should be removed, or
 Vaginal or cervical lacerations that should be
sutured and repaired.
 Bimanual compression of the uterus may be life
saving until a laparotomy is performed
Bimanual Compression
 MANAGEMENT OF PPH
 Treatment:
– If bleeding persists a Laparotomy
is mandatory:
 Subtotal hysterectomy: is the standard
procedure if bleeding is uncontrollable.
 Internal iliac artery ligation: may be
attempted if the patient's general
condition allows in an attempt to preserve
the uterus, if the patient is young and
desirous of further fertility. If this
procedure fails to control the bleeding,
hysterectomy is performed without
hesitation
SECONDARY POST PARTUM
HAEMORRHAGE
Definition: Bleeding
which is delayed > 24
hours, and till the end of
puerperium
 Causes
 Retained placental fragments; diagnosed
by U.S., and treated by ecbolics and/or
D&C.
 Separation of an infected slough from a
laceration in the lower genital tract; give
antibiotics.
 Sloughing of an infected submucous
fibroid polyp.
 Undiagnosed chronic uterine inversion.
 Rarely choriocarcinoma.
 Treatment

Treatment is that of the

cause.
 KEY POINTS IN PPH
 PPH is an important mostly preventable cause of
maternal mortality
 Uterine atony is the commonest cause for PPH
.Genital tract lacerations or DIC are other possible
causes.
 Abdominal palpation of the uterus can
differentiate atonic from traumatic PPH.
 Proper management of the third stage of labour is
very important in prevention of PPH.
 First aid treatment of 1ry PPH is massage and
ecbolics, with exclusion of retained placental
fragments. If bleeding is severe and
uncontrollable, subtotal hysterectomy may be life
saving.
 PPH cannot always be prevented for it
occasionally occurs when conditions are in all