POST PARTUM HAEMORRHAGE IS THE MAJOR CAUSE OF MATERNAL MORTALITY RATE

1. PPH
Prepared by
Parbati Chouhan

3. Post-partum haemorrhage
(PPH) remains a major
cause of maternal mortality
and morbidity worldwide.
Approximately, half a
million women die
annually from causes
related to pregnancy and
childbirth.
INTRODUCTION

4. DEFINE
•Blood loss of more
than 500ml following
vaginal delivery
PPH
•Blood loss more than
1000ml following
caesarean section

5. Clinical definition
PPH can be defined as any amount of bleeding from the
genital tract following birth of the baby up to 6 weeks after
delivery, which adversely affects the general condition of the
patients evidenced by rise in pulse rate and falling blood
pressure
Quantitative definition
It is arbitrary and is related to the amount of blood loss
in excess of 500ml following birth of the baby. It is
useful for statistical purpose. But the effects of blood
loss is rather than the amount of blood loss so more
than 300ml blood loss in anaemic patient is also called
PPH

6. b
In the developing world, several
countries have maternal mortality rates
in excess of 1000 women per 100,000
live births, and
 World Health Organization statistics
suggest that 25% of maternal deaths are
due to PPH, accounting for more than
100,000 maternal deaths per year.
The incidence is about 1%amongst
hospital deliveries in developing
countries. In Nepal the first cause of
MMR is PPH.
INCIDENCE

7. In Nepal, 46.3% deaths of women occur due
to post-partum haemorrhage and most
leading cause of maternal mortality
rate(MMR)

9. TYPES
• Primary PPH
Within 24 hrs
after delivery
• Secondary PPH
after 24hrs of
delivery
99% cases of PPH occurs with
in 24 hrs

10. PRIMARY PPH
Third stage haemorrhage: bleeding occurs before
expulsion of placenta
True post partum haemorrhage: bleeding occurs
subsequent to expulsion of placenta up to 24 hours of
delivery
SECONDARY PPH
It is bleeding from the genital tract more
than 24 hours after delivery of the
placenta and may occur up to 6 weeks
later. It is also called delayed or late
puerperal haemorrhage. It is most likely
occur between 10-14 days after delivery

11. 4
CAUSES
TRAUMA
20%TONE 80%
TISSUE
THROMBOS
IS

12. TONE
80%
Grand
multipara
Over distention
of the uterus
Anaemia ,
Precipitate
labour
Prolonged
labour
Anaesthesia
and APH
Mismanagement
of 3rd stage of
labour

13. ATONY UTERUS 80%
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 and bleeding
continues. Its also called as living
ligature action. The following are
conditions which often interfere with
retraction if the uterus as a whole and
the placental site in particular.

15. Grand Multipara - Inadequate retraction
and frequent adherent placenta contribute to
it. Associated anaemia may also probably
play a role. In multipara the muscle fibers in
the uterus are replaced by fibrous tissue.
Over-distension of the uterus - as in
multiple pregnancy, hydramnios and large
baby. Imperfect retraction and a large
placental site are responsible for excessive
bleeding.

16. Malnutrition and anaemia - Even slight
amount of blood loss may develop clinical
manifestations of postpartum haemorrhage.
Antepartum haemorrhage – The cause of
excessive bleeding are mentioned
Prolonged labour - Poor retraction,
infection (amnionitis), dehydration and
analgesic drugs used during labor are
responsible factors.
Anaesthesia - It is the depth of anaesthesia
and also the anaesthetic agents (either,
halothane or cyclopropane) which cause
atonicity.

17. • Malformation of the uterus – Implantation of the
placenta in the uterine septum of a septate uterus or in
the corneal region of a bicornuate uterus may cause
excessive bleeding.

18. Mismanaged third stage of labour -
This includes:
(a) Too rapid delivery of the baby
preventing the uterine wall to adapt to
the diminishing contents.
(b) Premature attempt to deliver the
placenta before it is separated
(c) Kneading and fidding the uterus.
(d) Pulling the cord. All these produce
irregular uterine contraction leading to
partial separation of placenta and
haemorrhage
(e) Manual separation of the placenta
increases blood loss during caesarean
delivery.

19. • Constriction ring - Hour- glass contraction formed
in the upper segment across the partially separated
palcenta or at the junction of the upper and lower
segment with the fully separated placenta trapped in
the upper segment may produce excessive bleeding.

20. Precipitate labour : In rapid
delivery, separation of the
placenta occurs following the
birth of the baby. Bleeding
continues before the onset of
uterine retracton. Bleeding may
be due to genital tract trauma
also.
Previous history of PPH or
retained placenta.
Placenta:-
Adherent placenta (accreta)
 partially separated and
retained placenta.

21. TRAUMA
20%
Episiotomy
Cesarean
section
Tear and laceration

22. Traumatic (20%):
Blood loss from :
ocaesarean section amounting to 800-
1000 ml is most often ignored.
oTrauma involves usually the cervix,
vagina, perineum (episiotomy wound
and lacerations), para-urethral region
and rarely, rupture of the uterus occurs.
The bleeding is usually revealed but
can rarely be concealed (vulvo-vaginal
or broad ligament haematoma).

23. Traumatic (20%):
Blood loss from caesarean section
amounting to 800-1000 ml is most
often ignored.
oTrauma involves usually the cervix,
vagina, perineum (episiotomy wound
and lacerations), para-urethral region
and rarely, rupture of the uterus
occurs.
The bleeding is usually revealed but
can rarely be concealed (vulvo-
vaginal or broad ligament
haematoma).

24. TISSUE
Retained
tissue
Retained
lobes ,
blood clots

25. THROMBIN
Blood coagulation
disorder
It may occur in
Abruptio placenta
 jaundice in pregnancy
Thrombocytopenia purpura
HELLP syndrome

26. • Blood coagulation disorders, acquired or
congenital: -
The firmly retracted uterus can usually
prevent bleeding even if serious disorders of
clotting mechanism are present. The conditions
where such disorders may occur are abrupio
placenta, jaundice in pregnancy,
throumbocytopenic purpura, DIC(disseminated
intravascular coagulation), etc.

27. How much time do we have ?
It is estimated that, if untreated, Death occurs on
average in:
2 hours from Postpartum Hemorrhage
 12 hours from Antepartum Hemorrhage
2 days from Obstructed Labor
6 days from Infection

28. Sign and Symptoms
Vaginal bleeding is occur
The uterus is flabby in atony uterus
Patient looks pale
 Hypotension and tachycardia
 Enlarge uterus
Air hunger
Uterus is soft and flaccid
Fundal height is greater than normal

29. • Prevention
What Can Be Done?
• Management
Photocredit:LaurenGoldsmith
Photocredit:???POPPHI

30. PREVENTION
COMMUNITY
Improvement of the health
status of the women.
Community awareness
programme
Antenatal care including birth
preparedness/complication
readiness.
Promotion of skilled attendace
at birth
Family planning and birth
space.

31. PREVENTION
ANTENATAL
Improvement of the health
status.
High risk patient
 Blood grouping and HB
Localization of placenta
Regular ANC check up
Diet
Coagulation study

32. INTRANATAL
Active management of
third stage of labour
Avoid fundal pressure
Cases with induced or
augmented labor by oxytocin
Women delivered by
caesarean section
Exploration of the utero
vaginal canal
 observation for about 2 hrs
Examination of the
placenta

33. After
delivery
 Examination of placenta and
membrane carefully
 Routinely inspect the vulva,
vagina, perineum and anus.
 Evaluate the uterus is contracted
or not
 Encourage women to empty her
bladder

34. Principle of management
• To diagnosis the causes of bleeding atony or trauma
• To take prompt and effective measures to control
bleeding
• To empty the uterus of its content and to make it
contract.
• To correct hypovolemia/replace blood
• To ensure effective hemostasis in traumatic
bleeding.

35. General Management

36. •Even if signs of shock are not present, keep
shock in mind as you evaluate the woman
further because her status may worsen rapidly.
•Massage the uterus to expel blood and blood
clots. Blood clots trapped in the uterus will
inhibit effective uterine contractions.

37. •Breast feeding and nipple stimulation is done
to stimulate oxytocin secretion
•. Check for anaemia after bleeding has been
stopped for 24 hours;
a. If hemoglobin is less than 7 g/dL (severe
anemia), arrange for a transfusion and :
•Give ferrous sulfate or ferrous fumerate 120
mg PLUS folic acid 400 mcg by mouth OD
for three months;

38. Give oxytocin 10 units IM
Start an IV infusion with 20 unit
oxytocin at 60 drops per minute and
infuse another plain fluid to replace
blood volume.
Catheterize the bladder
Check to see if the placenta has been
expelled, and examine the placenta
to be certain it is complete
Examine the cervix, vagina and
perineum for tears.

39. After three months, continue
supplementation with ferrous sulfate or
ferrous fumerate 60 mg PLUS folic acid
400 mcg by mouth OD for six months.
b. If haemoglobin is 7-11 gm/dL, give
ferrous sulfate or ferrous fumerate 60 mg
by mouth PLUS folic acid 400 mcg by
mouth once daily for six months;

40. Specific Management
ATONIC UTERUS
An atonic uterus fails to contract
after delivery
Continue to massage the uterus
Use oxytocic drugs which can be
given together or sequentially

41. Dose and
Route
Continuing Dose Maximum
Dose
Precautions
and Contra-
Indications
Oxytocin IV: infuse 20
units in 1 L IV
fluids at 60
drops per
minute
IV: infuse 20 units
in 1 L IV fluids at
40 drops per
minute
Not more than
3 L of IV
fluids
containing
oxytocin
Do not give as
an IV bolus
IM: 10 units
Ergometri
ne/ Methyl-
ergometrin
e
IM or IV
(slowly): 0.2
mg
Repeat 0.2 mg IM
after 15 minutes, If
required, give 0.2
mg IM or IV
(slowly) every four
hours
Five doses
(Total 1.0 Mg)
High blood
pressure, pre-
eclampsia,
heart disease
15-Methyl
Prostaglan
din F2α
IM: 0.25mg 0.25 mg every 15
minutes
Eight doses
(Total 2 mg
Asthma

42. If bleeding continues:
-Check placenta again for completeness;
-If there are signs of retained placental
fragments (absence of a portion of maternal
surface or torn membranes with vessels),
remove remaining placental tissue;
-Assess clotting status using a bedside
clotting test. Failure of a clot to form after
seven minutes or a soft clot that breaks down
easily suggests coagulopathy.

43. b

44. If bleeding continues in spite of
management above:
-Perform bimanual compression of the
uterus:
-Wearing high-level disinfected or
sterile gloves, insert a hand into the
vagina and remove any blood clots
from the lower part of the uterus or
cervix,
-Form a fist;

45. -Place the first into the anterior fornix
and apply pressure against the anterior
wall of the uterus;
-With the other hand, press deeply into
the abdomen behind the uterus,
applying pressure against the posterior
wall of the uterus;
-Maintain compression until bleeding
is controlled and the uterus contracts

46. Bimanual compression of the uterus

47. Alternatively, aortic compression
Apply downward pressure with a
closed fist over the abdominal aorta
directly through the abdominal wall:
-The Point of compression is just
above the umbilicus and slightly to the
left;
-Aortic pulsations can be felt easily
through the anterior abdominal wall in
the immediate postpartum period.

48. With the other hand, palpate the
femoral pulse to check the adequacy
of compression:
-If the pulse is palpable during
compression, the pressure exerted by
the fist is inadequate;
-if the femoral pulse is not palpable,
the pressure exerted is adequate;
Maintain compression until bleeding
is controlled.

49. Compression of abdominal aorta and palpation
of femoral pulse:-

50. If bleeding continues in spite of
compression:
-perform uterine and utero-ovarian
artery ligation.
-If life-threatening bleeding continues
after ligation, perform subtotal
hysterectomy.

51. Condom temponade
The WHO recommends the use of
intrauterine ballon tamonade as a second
line treatment for PPH due to uterine
atony when uterotonic drugs and
bimanual compression fail.
IBT success rate are as high as 97%
If bleeding continuous in spite of
bimanual and aortic compression,
perform IBT.
When a ballon catheter designed
specially for treatment of PPH is not
available, low cost adaptation such as a
condo ballon temponade can function as
a substitute

53. If bleeding continuous in spite of
bimanual and aortic compression,
perform IBT.
When a ballon catheter designed
specially for treatment of PPH is
not available, low cost adaptation
such as a condom ballon
temponade can function as a
substitute

55. Mechanism of Action
1. Increased intrauterine pressure,
which becomes superior to
capillary blood vessels pressure.
2. Compression of the bleeding site by
the inflated condom.
3.Contractions induced by the
presence of the condom inside the
uterus.

57. Advantage
1. Simple procedure can be
performed even with minimal
facilities and skill.
2. Therapeutic as well as
diagnostic in management of
postpartum haemorrhage.
3. Bleeding can be controlled
until the patient is transferred
to a major hospital.

58. Disadvantage
The CBT has two main disadvantage
1. First is not having a drainage port
and therefore not letting the clinician
assess the actual blood loss.
2. second is that the thread or suture is
used to tie the condom to the
catheter which often causes leakage
of saline.
3. Other: risk of infection, prolonged
intensive monitoring is needed.

59. Indication
1. Postpartum hemorrhage due to
atony, when uterine massage,
uterotonics and bimanual
compression have failed to
stop the bleeding .
2. When temporary control of
PPH is needed before
referring the client to a higher
level of care.

60. Contraindication
Arterial bleeding
Cases requiring hysterectomy
Untreated uterine anomaly , cervical
or uterine cancer.
Infection in vagina, cervix or uterus
DIC
Retained placenta
Lack of trained provider

61. Complications
Uterine rupture/perforation/scar
rupture
 migration of balloon following
perforation

62. Articles and supplies
Pair of sterile gloves
Male condom 1 pck
Ring forcep
Sims speculum
Iv set 1
Foleys catheter no 16 or 18 ( 2)
Scciossor and suture thread
Perineal pad 2
Kidney tray
 sponge holder
20 or 50 ml syringe
Clamp 2
500 ml bottle of normal saline/ distilled water

65. PROCEDURE
Step 1: preparation
Call for help. Obtain a UBT kit or prepare the
necessary equipments.
Explain to the woman what her condition is
and why you are going to do
Provide emotional support and encouragement
Insert an indwelling foleys catheter into the
bladder.

66. Administer prophylatic antibiotics : 1 gm
ampicillin or 1 gm cephalosporin IV
Put on personnel protective barriers
Hand wash and put on HDL or sterile gloves. Use elbow
length gloves if available.
 place the condom over the foley catheter, leaving a small
porton of the condom beyond the catheter.
With sterile suture or string , tie lower end of the condom on
the foleys catheter
Tie should be enough to prevent leakage of saline solution
but should not strangulate catheter and prevent inflow of

68. Step 2 : transvaginal placement
Gently insert a HDL or sterile speculum into
the vagina.
Gently grasp the anterior lip of the cervix
with a ring or sponge feocep. A ring or sponge
forces is preferable, as it is less likely than
tenacullum to tear the cervix.
Hold the catheter with a sterile forcep and gently introduce it
through the cervix. Ensure that the inflatable bulb or catheter
is beyond the internal cervical os
Place the condom into the uterine cavity. Make sure that the
position of the condom ballon temponade remains in the
uterine cavity

71. Step 3: inflation
Connecting outlet of foley’s catheter to an IV set connected
to infusion bottle of saline
Once the balloon end has been in the uterine cavity, inflate
the condom with 300-500 ml of saline solution. Inflate the
condom until it is visible in the cervix. Beware of overfilling
the balloon as this might cause the ballon to bulge out of the
cervix and expelled.
Clamp catheter when desired volume is achieved and
bleeding is controlled
If there is no bleeding through the cervix, the temponade test
is positive. No further fluid is added and further surgery is not
required at this stage.

73. The catheter was strapped to the thigh with a
small piece of adhesive tape to prevent an
accidental pull and inadvertent expulsion of
balloon.
Maintain in situ for 12-24 hours if bleeding
is controlled and mother is stable.
Continue uterotonics infusion 20 IU
oxytocin in 1000ml saline solution 60d/m for
6-8 hours

74. Continue to monitor client closely,
resuscitate or treat shock if necessary.
Place pen mark on the abdomen at the
level of the uterine fundus. Monitor for
rise in fundus du to concealed
haemorrhage
 if bleeding is not controlled within 15
minutes of initial inflation of UBT,
abandon procedure and seek for surgical
intervention immediately

75. Step 4: deflection
 when mother is stable , if the uterus fundus
remains at the same level and there is no
active vaginal bleeding deflate the balloon 50-
100 ml every hour as long as there is no
further bleeding at each interval
If there is no further vaginal bleeding 30
minutes after the balloon is totally deflate,
remove the balloon and stop oxytocin.

76. If the woman starts to bleed
when the balloon is deflated or
the oxytocin has stopped,
reinflate the balloon and
recommence the oxytocin
infusion, prepare for surgical
intervention when her condition
become stable.
Remove the urinary catheter
once the woman is stable.

77. RECORD
The following information should be
recorded every 15 minutes for the first
2hours, then every 30 minutes for the
next 2 hours, and then every hour for
the next 2 hours:
Blood pressure, pulse, urine output,
pallor and active bleeding , uterine
tone.
Document the time of a uterine
balloon temponade is placed,
document the following in the client’s
chart.

78. Outcome of the placement , blood
loss before and after UBT placement,
volume of liquid used to fill the
condom , time from insertion to
cessation of bleeding , deflation start
time.
Time of complete removal, type of
provider( nurse, midwife, doctor)

79. SECONDARY PPH
Secondary PPH occuring
between 24 hours of delivery and
6 weeks postpartum

80. CAUSES
Retained fragments of placenta or
membranes
Shedding of dead tissue following
obstructed labour
Break down of uterine wound( after cs
or rupture uterus)
Endometritis and sub involution of the
placental side due to delayed healing
process
Secondary haemorrhage from CS
wound usually occurs between 10-14
days.

81. DIAGNOSIS
The bleeding is bright red and
varying amount of blood loss.
There is varying degree of anaemia
Evidence of sepsis is present
USG is useful in detecting the bits
of placenta inside the uterine cavity

82. Principles
To assess the amount od
blood loss and replace the lost
blood.
To find out the cause and to
take appropriate steps to
rectify it.


83. MNANAGEMENT OF SECONDARY PPH
Aim : to preserve the life and health of the
woman
Priorities in managing secondary PPH.
These are similar in managing primary PPH
Admit the woman to hospital as an
necessary
If bleeding is slight and no apparent cause
is detected, a careful watch for period of 24
hours.

84. Preferable to explore the uterus urgently under
general anaesthesia.
Bleeding from uterine wounds can controlled
by haemostatic suture, internal illiac arteries
sutures, but may rarely require ligation or may
end in hysterectomy.
Observe for sign and symptoms of secondary
PPH . Excessive bleeding from the vagina or
lochia after 24 hours to 42 days following
delivery is considered abnormal and required
prompt investigation and treatment.

86.  Rub up a contraction by massaging
the uterus if it is still palpable.
 Assess her condition and if in a
remote area, start management
before transfer.
 Take blood for haemoglobin,
grouping and cross match
 IV infusion start with normal saline
and RL

87. If the woman is in shock
oGive IV fluid (1 ltr fast within 15 minutes )
until the woman stabilize. The health care
provider may need to infuse up to 3 ltr to
correct shock.
oBlood transfussion if necessary
If bleeding is heavy add 20 units in 1 ltr IV
fluidsat 60 drops per minute. Give IM or IV
slowly ergometrine 0.2mg .
The health care provider may need set up a
second IV line.

88. Start broad spectrum antibiotics in high
doses. A suitable regimen ampicillin 1gm
IV start followed by 500 mg every 6 hourly
plus metronidazole 400 mg orallyevery 8
hours.
Explain to the mother and her family
what is hapenning.
If haemoglobin less than 7gm/dlarrange
for blood transfussion and provide oral iron
and folic acid.

89. Give ferrus sulphate or ferrous
fumerate 120mg by mouth plus folic
acid 400mcg orally once daily for
three months.
After three months , continue
supplementation with ferrus sulphate
of ferrus fumerate60 mg by mouth
plus folic acid 400mcg per oral once
daily

90. If HB is 7-11gm/dl, give ferrus
sulphate or ferrus fumerate 60 mg by
mouth plus folic acid 400 mcg per oral
once a day.
If the cervix is dilated, explore by
hand to remove clots and placental
fragments . Manual exploration of the
uterus

91. If the cervix is not dilated, evacuate
the uterus to remove placental
fragments.
Rarely, if bleeding continues,
consider uterine and utero-ovarian
ligation or hysterectomy

93. COMPLICATIONS
oShock
oRenal failure
oCoagulation disorder
infection
odeath

94. THANK
YOU