1. Postpartum Hemorrhage (PPH)
Family Medicine Specialist CME
University of Health Sciences

2. Clinical Case
25 year-old G7P2 female presents for delivery, which occurs very rapidly after arriving at the District Hospital. Her baby was delivered without difficulty but then the placenta was retained and she began to hemorrhage. What is your definition of a postpartum hemorrhage? What are the risk factors this patient has for a postpartum hemorrhage? What are you going to do to manage this patient?

3. Objectives Define postpartum hemorrhage (PPH)
Discuss the risk factors and possible causes for PPH
Describe the preventative measures to take to prevent a PPH
Discuss the management of PPH
Explain the risks to maternal morbidity and mortality of PPH

4. Definitions Primary/immediate PPH Secondary/late PPH
Excessive bleeding during the 24 hours after a delivery
Most often due to uterine atony
Secondary/late PPH
Excessive bleeding between 24 hours and up to 6 weeks after delivery
Most often due to retain products of conception, infection or both

5. What is excessive bleeding or a PPH?
Vaginal delivery
>500 cc of blood loss
Cesarean section
>1000 cc of blood loss
Clinically
Any blood loss that causes the patient to be hemodynamically unstable

6. Hypovolemia Clinical Presentation
Mild (<20% of blood volume)
Heart rate - mild tachycardia
Skin – mottled, cool extremities due to increased systemic vascular resistance and prolonged capillary refilling
Urinary output - decreased
Neurologic status – may report dizziness but usually remains normal
Moderate (20–40% of blood volume)
Heart rate - >110 bpm
Tachycardia - >30 rpm
BP – Normal in supine position/significant postural hypotension
Skin - marked pallor; conjuntiva, palms and mucous
Neurologic status – increasingly anxious
Severe (>40% of blood volume)
Heart rate - marked tachycardia
BP – declines/unstable even in supine position
oliguria or anuria
Neurologic status – agitation, confusion, possible loss of consciousness

7. Estimating blood loss Usually underestimated
Ongoing trickling can cause significant blood loss
Underestimation can lead to delayed or inadequate treatment
If patient is anemic, then the ability to compensate for blood loss may not be possible and patient cannot tolerate any blood loss

8. PPH Etiology Tone – uterine atony Tissue – retained placenta
Trauma – vaginal/cervical lacerations, rupture, inversion of uterus
Thrombin - coagulopathy

9. Tone: Risk Factors Etiologic process Clinical risk factors
Overdistended uterus Polyhydramnios
Multiple gestation
Macrosomia
Uterine muscle Rapid labour
exhaustion Prolonged labour
High parity
Intraamniotic infection Fever
Prolonged rupture of membranes (PROM)

10. Tone – Risk Factors (2) Etiologic process Clinical risk factors
Functional or anatomic Fibroid uterus
distortion of the uterus Placenta previa or abruptio
Uterine anomalies
Uterine-relaxing Halogenated medications anesthetics nitroglycerin, magnesium sulphate

11. Tissue – Risk Factors Retained Placental tissue
Etiologic process Clinical risk factors Retained products, Incomplete delivery of placenta abnormal placentation, Previous uterine surgery retained cotyledon or High Parity succinuriate lobe Abnormal placenta on ultrasound Retained blood clots Atonic uterus

12. Trauma (Genital Tract) – Risk Factors
Etiologic process Clinical risk factors
Tears (lacerations) of the Precipitous delivery
cervix, vagina, or perineum Operative delivery
Ruptured vulvar varicosities Mistimed or inappropriate use of episiotomy
Extensions, lacerations Malposition
at cesarean section Deep engagement
Uterine rupture Previous uterine surgery
Uterine inversion High parity
Fundal placenta

13. Thrombin (Abnormalities of Coagulation) – Risk Factors
Etiologic process Clinical risk factors Pre-existing states History of hereditary coagulopathies History of liver disease Therapeutic History of thrombotic anticoagulation disease

14. Thrombin (Abnormalities of Coagulation) – Risk Factors (2)
Etiologic process Clinical risk factors
States acquired in pregnancy
idiopathic thrombocytopenic bruising
purpura elevated blood pressure
thrombocytopenia with fetal demise
preeclampsia fever
disseminated intravascular elevated white blood cells
coagulation antepartum hemorrhage
preeclampsia sudden collapse
dead fetus in utero
severe infection/sepsis
placental abruption
amniotic fluid embolus

15. Prevention of PPH – Active Management of the Third Stage of Labor
prophylactic administration of oxytocin with delivery of anterior shoulder or immediately after delivery
10 U IM OR 5 U IV bolus
clamp and cut cord after pulsating has stopped
palpate the uterine fundus and confirm the uterus is contracted
perform controlled cord traction with suprapubic counter traction with next strong contraction
perform uterine massage after delivery of the placenta, as appropriate
examine placenta for completeness

16. Controlled cord Traction

17. Uterotonics - Oxytocin
stimulates smooth muscle tissue of the upper segment of the uterus causing it to contract rhythmically, constricting blood vessels, and decreasing blood
safe and effective first choice for prevention and treatment
acts almost immediately for IV injections, and within 3 to 5 minutes for IM injections
should be stored in a cool, dry place
uncommon side effects: nausea, vomiting, and headache

18. Uterotonics – Ergot Alkaloids “Ergometrine”
causes the smooth muscle of both the upper and lower uterus to contract tetanically
takes 5 to 7 minutes to take effect when given intramuscularly
effects last approximately 2 to 4 hours
should be stored in a refrigerator between 2°C – 8°C and away from light
adverse effects include nausea and vomiting

19. Uterotonics – Prostaglandins “Misoprostol”
causes vasoconstriction and enhances contractibility of the uterine muscles
administered orally or sublingually (rapid action), or rectally (acts fir greater period of time) for prevention or treatment of PPH
relatively inexpensive, easy to store, stable at room temperature
side effects: shivering and fever are generally mild

20. Management of Postpartum Hemorrhage
Prevention is the key!
Identify and manage risk factors identified for potential PPH
Active management of the third stage of labor

21. Management of Postpartum Hemorrhage
Active management of the Third Stage of Labor
REMEMBER the ABCs
Call for HELP
Estimate blood loss.
Ask the woman to urinate or catheterize
Put the baby to the breast
Give Oxygen
Assess the uterus using external or internal bimanual massage
Give uterotonic - Oxytocin, Misoprostol, ergotamine
Observe the woman, and consider transport if unstable or bleeding continues

22. Management of PPH
ABC
A = airway
B = breathing
C = circulation

23. External Bimanual Uterine Massage

24. Internal Bimanual Uterine Massage

25. Examine the placenta for completeness
Examination of fetal side
Examination of maternal side

26. Manual removal of placenta1. 2. 3. 4.

27. Management of Postpartum Hemorrhage
Examine the genitals for trauma and repair as required ie. vulva, vagina, cervix
If bleeding continues may require uterine tamponade or aortic compression
Ensure no uterine inversion or rupture
Manage possible coagulopathy with blood transfusion (if possible)
Consider transfer to facility for surgical management of PPH

28. Aortic Compression

29. Uterine Tamponade

30. Management of secondary PPH
Associated with:
retained placental fragments or membranes
infection
shedding of dead tissue following an obstructed labour
breakdown of a uterine wound after a cesarean section or ruptured uterus

31. Management of secondary PPH (2)
assess the woman’s condition carefully
control blood loss
treat for shock, if necessary
administer antibiotics prophylactically for infection
provide anti-tetanus prophylaxis, if necessary
if there is no improvement with the above treatments, refer the woman promptly for further assessment and treatment

32. Continued care of 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 vital signs
estimating ongoing blood loss
ensuring adequate fluid intake
monitoring blood transfusions
monitoring urinary output
ensuring the continuous presence of a skilled attendant, who maintains good documentation

33. Before discharge from hospital
check hemoglobin, and provide supplements as required
examine for hookworm infestation, malaria, HIV/AIDS or other co-existing conditions, provide treatment as required
provide the mother and her family with information about her experience of PPH
ensure that lactation has been established, and that a well baby care plan is in place

34. Conclusion Assess patient for PPH risk factors and manage accordingly
Prevention is the key: Active management of the third stage of labor
Management of bleeding is essential for saving a woman’s life
Refer to center as required for advanced care