1. ABSTRACT
• The third stage of the labour usually eclipsed by the excitement of the birth of a baby and of all the
stages of labour it is the most crucial one for the mother. Various complications may occur
unexpectedly or if accurate preventive measures not taken such as postpartum haemorrhage,
retention of placenta, shock, uterine inversion etc. Here the light is mainly focused on the
postpartum haemorrhage. Its etiology, types, clinical effects, diagnoses, preventive measures are the
main part of discussion. The most important part that is the management which play a major role in
protecting the life of the patient is also elaborated here according to the respecting etiology. As the
clinical examination, ultrasound scanning were carried out in each case and there are various
methods used to treat postpartum haemorrhage but homoeopathy can also be an effective method
for prophylaxis of disturbance of uterine contractile function in delivery and at the postnatal stage
for pregnant women at higher risk of complications. Here some homoeopathic therapeutics also
mentioned which play a good role in the management of postpartum haemorrhage.

2. POSTPARTUM
HAEMORRHAGE
(PPH)
PRESENTED BY: KANCHAN SINGH

3. CONTENTS
DEFINITION
PRIMARY POSTPARTUM SECONDARY POSTPARTUM
HAEMORRHAGE HAEMORRHAGE
•CAUSES •CAUSES
•DIAGNOSIS & CLINICAL •DIAGNOSIS
EFFECTS
•PREVENTION •MANAGEMENT
•MANAGEMENT

4. •Amount of blood loss in excess of 500ml following birth of the baby.
•Clinical 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 & falling
blood pressure is called postpartum haemorrhage.
•Depending upon the amount of blood loss it can be minor(<1l), major(>1l) or severe (>2l).
•The incidence is about 4-6% of all deliveries
DEFINITION

5. PRIMARY PPH
Haemorrhage occurs within 24 hrs
following the birth of baby
Third Stage Haemorrhage:
bleeding occurs before the
expulsion of placenta.
True Postpartum Haemorrhage:
Bleeding occurs subsequent to
expulsion of placenta
SECONDARY PPH
Haemorrhage occurs beyond 24 hrs and
within puerperium also called delayed
or late puerperal haemorrhage

6. ETIOLOGY OF
POSTPARTUM HAEMORRHAGE
4 Ts
Tone Uterine atony 95%
Tissue Retained tissue/clots
Trauma Lacerations, rupture,
inversion
Thrombin Coagulopathy

7. ATONIC UTERUS
Normal postpartum condition
with contracted uterus
preventing haemorrhage
Uterine atony allows haemorrhage
to flow into the uterus
•It is the commonest cause of postpartum
haemorrhage.
•With the separation of placenta, the uterine
sinuses which are torn, cannot be compressed
effectively due to imperfect contraction and
retraction of the uterine musculature & the
bleeding continues.

8. PREDISPOSING FACTORS- INTRAPARTUM
PROLONGED AND RAPID LABOUR
OPERATIVE DELIVERY INTERNAL PODALIC
VERSION
CHORIOMNIONITIS
SHOULDER DYSTOCIA
COAGULOPATHY
INDUCTION OR AUGMENTATION

9. PREDISPOSING FACTORS- ANTEPARTUM
•ABRUPTIO PLACENTA/ PLACENTA PREVIA •FETAL DEMISE
•BLEEDING DISORDER •GESTATIONAL HYPERTENTION •OVER DISTENDED UTERUS

10. POSTPARTUM CAUSES
•Lacerations or episiotomy
•Retained placental / placental abnormalities
•Uterine rupture / inversion
•Coagulopathy

11. LACERATIONS OR EPISIOTOMY
•Trauma involves usually the cervix, vagina, perineum, paraurethral
region and rarely the rupture of the uterus occurs.
•Blood loss from the episiotomy wound is most often
underestimated.

12. RETAINED PLACENTA / PLACENTAL ABNORMALITIES
PLACENTA ACCRETA
PLACENTA PRAEVIA
ABRUPTIO PLACENTA BATTELDORE PLACENTA VASA PREVIA
SUCCENTURIATE PLACENTA
CIRCUMVALLATE PLACENTA
RETAINED PLACENTA- When it is not
expelled out even 30 minutes after the
birth of the baby

13. INVERSION OF THE UTERUS
It is an extremely rare but a
life threatening complication
in third stage in which uterus
is turned inside out partially
or completely
ETIOLOGY
•Pulling the cord while uterus is atonic esp. when combined with fundal pressure.
•Fundal pressure while uterus is relaxed-faulty technique in manual removal.
DANGERS
•Shock
•Haemorrhage
•Pulmonary embolism
•If left uncared for, it may lead to-infection, uterine slough & a chronic one
UTERINE RUPTURE
•It is potentially catastrophic event
during childbirth by which the integrity
of myometrial wall is breached
•Life threatning event for mother +
baby

14. DIAGNOSIS OF UTERINE INVERSION
SIGNS SYMPTOMS
•Acute lower abdominal
pain with bearing down
sensation
•Bimanual examination not only
confirm the diagnosis but also the
degree
COMPLETE
INVERTED
UTERUS
•Sonography can confirm
the diagnosis when clinical
examination is not clear
•In complete variety, a pear shaped
mass protrudes outside the vulva with
the broad end pointing downwards and
looking reddish purple in colour

15. MANAGEMENT - UTERINE INVERSION
1)To replace that first part which is
inverted last with the placenta
attach to the uterus by steady
firm pressure exerted by fingers.
2) To apply counter support by the other
hand placed on the abdomen.
3) After replacement, the hand should
remain inside the uterus until the
uterus becomes contracted by
parenteral oxytocin or PGF2α
4) The placenta is to be removed
manually only after the uterus
become contracted
Usual treatment of shock including blood
transfusion should be arranged simultaneously

16. COAGULOPATHY
•Blood coagulation disorders are less common causes of
postpartum
haemorrhage.
•The blood coagulopathy may be due to diminished
procoagulants or increased fibrinolytic activity.
•The conditions where such disorders may occur are
abruption
placentae, jaundice in pregnancy, thrombocytopenic purpura
etc.
•Speciifc therapy following coagulation screen
includingrecombinant
activated factor VII may be given.

17. DIAGNOSIS AND CLINICAL EFFECTS
PELVIC HEMATOMA POSTERIOR ASPECT OF UTERUS
SHOWING LEFT BROAD LIGAMENT
HEMATOMA
VAGINAL BLEEDING
•In the majority, the vaginal
bleeding is visible outside,
as a slow trickle.
•Rarely, the bleeding is totally
concealed either as vulvo-vaginal
or broad ligament hematoma.
CLINICAL EFFECTS :- • Alteration of pulse, blood pressure & pulse pressure .
•On occasion, blood loss is so rapid & brisk that death may occur with in a few minutes.
-State of uterus as felt per abdomen, gives a reliable clue as regards the cause of bleeding.
•In traumatic haemorrhage, the uterus is found well contracted.
•In atonic haemorrhage, the uterus is found flabby and becomes hard on massaging

18. PROGNOSIS
Postpartum haemorrhage is one of the life threatening emergencies.
It is one of the major cause of maternal deaths both in developing & developed countries.
CONTRIBUTING FACTORS
•Prevalence of malnutrition & anaemia.
•Inadequate antenatal & intranatal care.
•Lack of blood transfusion facilities.
•Substandard care.
THERE IS ALSO INCREASED MORBIDITY
THESE INCLUDE:
•Shock
•Transfusion reaction
•Puerperal sepsis
•Failing lactation
•Pulmonary embolism
•Thrombosis & thrombophlebitis
LATE SEQUALE INCLUDES:
•Sheehan's syndrome( selective hypopituitarism)
•Rarely diabetess incipidus.

19. PREVENTION-ANTENATAL
•Improvement of the health status of
the women & to keep the haemoglobin
level normal (>10g/dl).
•High risk patients who are likely to
develop PPH ( such as twins, hydramnios
etc.) are to be screened & delivered in a
well equipped hospital
•Blood grouping should be done for all
women so that no time is wasted during
pregnancy.
•Placental localization must be done in all
women with previous caesarean delivery by
USG or MRI to detect placenta accrete or
percreta
•Women with morbid adherent placenta are at high risk of PPH. Such a case should be
delivered by senior obstetrician.

20. PREVENTION- INTRANATAL
•Active management of the third stage, for all women in labour should be routine as it reduces PPH by
60%.
•Cases with induced or augmented
labour by oxytocin, the infusion should
be continued for at least 1 hour after the
delivery.
•Women delivered by caesarean
section, Oxytocin 5IU slow IV is to be
given to reduce blood loss
•Exploration of the utero-vaginal canal
for evidence of trauma following difficult
labour or instrumental delivery.
•Expert obstetric anaesthesist is needed
when the delivery is conducted under
general anaesthesia
•During caesarean section spontaneous separation & delivery of the placenta reduces blood loss (30%).
•Examination of the placenta & the membranes should be a routine so as to detect at the earliest any
missing part.

21. MANAGEMENT OF THIRD STAGE BLEEDING
•Control the fundus, massage & make it hard
•Inj. Methergin 0.2mg IV
•To start normal saline drip with oxytocin &
arrange for blood transfusion
•Catheterise the bladder
Placenta separated Not separated
Express the placenta out by
controlled cord traction
Manual removal under GA
Traumatic haemorrhage should be tackled by sutures

22. TRUE POSTPARTUM HAEMORRHAGE
(It is bleeding occurs subsequent to expulsion of placenta)
MANAGEMENT OF TRUE POSTPARTUM HAEMORRHAGE:-
Principles: Simultaneous approach
-Communication
-Resuscitation
-Monitoring and
-Arrest of bleeding
It is essential in all cases of major PPH (blood loss >1000ml or clinical shock).
Management
Immediate measures are to be taken by the attending House
officer(Doctor/Midwife)
-Call for extra help-involve the obstetric registrar on call.
-Put in two large bore (14 gauge) IV cannulas.
-Keep the patient flat and warm.
-Send blood for group, cross matching, diagnostic tests and ask for 2 units (at least) of
blood.

23. -Infuse rapidly 2 litres of normal saline (crystalloids) or plasma substitutes like
haemaccel(colloids), an urea linked gelatin, to re-expand the vascular bed. It does not
interfere with cross matching.
-Give oxygen by mask 10-15L/min.
-Start 20 units of oxytocin in 1L 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:-
1.Pulse
2.Blood pressure
3.Respiratory rate and oxymeter
4.Type and amount of fluids the patient has received
5.Urine output(continuous catheterisation)
6.Drugs-type, dose and time
7.Central venous pressure(when sited).

24. ACTUAL MANAGEMENT
The first step is to control the fundus and to note the
feel of the uterus.
ATONIC UTERUS
Step 1 :
a) Massage the uterus to make it hard and express the
blood clot.
b) Methegrin 0.2mg is given intravenously.
c) Inj oxytocin drip is started (10 units in 500ml of
normal saline) at the rate of 40-60 drops per minute.
d) Foley catheter to keep bladder empty and to monitor
urine output.
e) To examine the expelled placenta and membranes , for
evidence of missing cotyledon or piece of membranes .
If the uterus fails to contract, proceed to the next step.
Step 2 :
The uterus is to be explored under general anaesthesia.
MASSAGE THE FUNDUS

25. Step 3 : Uterine massage and
bimanual compression.
Step 4 :
UTERINE TAMPONADE
1.Tight intrauterine packing
Intrauterine packing is useful in case of
uncontrolled postpartum haemorrhage
where other methods have failed and the
patient is being prepared for transport to a
tertiary care centre.
2.Balloon tamponade:
Bakri balloon Balloon tamponade Sangstaken-blakemore tube

26. Step 5 :
Surgical methods to control PPH
a) Ligations of uterine arteries-
the ascending branch of the uterine artery is ligated at the lateral
border between upper and lower uterine segment.

27. b) Ligation of the ovarian
and uterine artery anastomosis-
if bleeding continues, it is done
just below the ovarian ligament
c) Ligation of anterior division
of internal iliac artery-
Reduces the distal blood flow

28. d) B-Lynch compression suture and multiple square sutures-

29. e) Angiographic arterial embolisation
(bleeding vessel) under fluoroscopy can be done using gel foam.
Outcome following unilateral uterine artery embolisation
-Success rate is more than 90% and it avoids hysterectomy.

30. STEP 6:
Hysterectomy
It is done in cases where uterus fails to contracts and
bleeding continues in spite of the above measure

31. Hemorrhage occurs beyond 24 hours and within puerperium,
called delayed or late puerperal hemorrhage.
SECONDARY POSTPARTUM
HAEMORRHAGE

32. •Infection and separation of slough
Over a deep cervico-vaginal laceration
CAUSES
•Retained bits of cotyledons and membranes

33. •Endometriosis and subinvolution of the placental site
•Secondary hemorrhage from caesarean section
Wound usually occur between 10-14 days

34. •ULTRASONOGRAPHY
is useful in detecting
the bits of placenta
inside the uterine
cavity
•INTERNAL
EXAMINATION
shows
subinvolution
of the uterus
•INTERNAl
EXAMINATION
shows massive
bleeding
•INTERNAL
EXAMINATION
shows evidence
of sepsis
DIAGNOSIS
White fluid show
presence of pus

35. SUPPORTIVE
THEREPY
CONSERVATIVE ACTIVE
TREATMENT
-BLOOD TRANSFUSI-
ON
-METHERGIN 0.2 mg
INTRAMUSCULARLY
-ANTIBIOTIC AS A
ROUTINE
IF SLIGHT BLEEDING,
NO APPARENT CAUSE
CAREFFULL WATCH
FOR A PERIOD
OF 24 hrs.
-GENERAL
ANAESTHESIA
-AT TIMES REQUIRE
LAPAROTOMY
MANAGEMENT

36. MANAGEMENT – ABC’s
ENSURE THAT YOU ARE ALWAYS
AHEAD WITH YOUR
RESUSCITATION!!!
•Consider need for Foley catheter, CVP,
arterial line, etc.
•Consider need for more
expert help
FOLEY CATHETER CVP

37. MANAGEMENT OF PPH
DIRECTED THERAPY
“TONE”
•Massage
•Compress
•Drugs
“TISSUE”
•Manual removal
•Curettage
“TRAUMA”
•Correct inversion
•Repair laceration
•Identity rupture
“THROMBIN”
•Reverse
•Anticoagulation
•Replace factors
MANUAL FUNDAL
MASSAGE
REMOVAL OF
PLACENTA
CORRECTION OF
UTERINE INVERSION

38. THERAPEUTICS IN HOMOEOPATHY
• HAMAMELIS VIRGINIANA- Profuse discharges, which stimulates a haemorrhage, and form a drain upon system as severe as loss of
blood. Bad effects from loss of blood. Uterine haemorrhages active or passive.
• IPECACUANHA- Haemorrhages active or passive, bright red, from the uterus; profuse, clotted; heavy, oppressed breathing during;
stitches from navel to uterus.
• ERIGERON CANADENSE- Haemorrhages from the uterus with dysuria; bright red flow; pregnant women with a “week uterus”.
• SABINA- Retained placenta from atony of uterus; intense after, pains. Inflammation of ovaries or uterus after abortion or premature
labour. Haemorrhage from the uterus. Promotes expulsion of moles or foreign bodies from uterus.
• SECALE CORNUTUM- Women's of very lax muscular fibre; everything seems loose and open; no action; vessels flabby; passive
haemorrhages. Discharge of sanious liquid blood with a strong tendency to putrescence. After-pains: too long; too painful; hour glass
contraction.
• CANTHARIS VESICATORIA- Retained placenta,with dysuria. Expels moles, dead fetuses, membranes etc. Constant discharge from
uterus. Pain in os coccyx, lancinating and tearing.
• CARBO VEGETABILIS- Haemorrhages from any mucous outlet; in systems broken down, debilitated; blood oozes from weakened
tissues; vital force exhausted. In the last stages of disease, with copious cold sweat,cold breath, cold tongue, voice lost, this remedy may
save a life.
• CAULOPHYLLUM THALICTROIDES- Haemorrhage, after hasty labour; want of tonicity in the womb; passive, after abortion.
• USTILAGO MAYDIS- Flabby condition of uterus. Postpartum haemorrhage, bright red, partly clotted.
• BELLADONNA- Pressing downwards as if contents of abdomen would issue from the vulva; >standing & sitting erect; worse mornings.
• CINNAMONUM CEYLANICUM- Bearing down sensation. Uterine haemorrhages caused by overlifting during puerperal state.

39. CONCLUSIONS
•Be prepared
•Practice prevention
•Assess the loss
•Assess the maternal status
•Resuscitate vigorously and appropriately
•Diagnose the cause
•Treat the cause