Pph

PPH for medical students, Paramedicals and midwifery

1. Post Partum
Haemorrhage
Dr. UmaGupta *Head & Prof. Obstetrics &
Gynecology
*M.D, MARD, FAIMER (CMCL 2012), PGDHHM,MHPE.
[email protected]
5/10/2021 Uma Gupta 1

2. 5/10/2021 Uma Gupta 2
MumtazMahal
died
frompostpartum
hemorrhagein
Burhanpuron 17
June 1631 while
giving birth to
her fourteenth
child, after a
prolonged labor
of approximately
30 hours.

3. Learning Objectives
1.Define postpartum hemorrhage
2.Differentiate between primary and secondary postpartum
hemorrhage.
2. Describe prevention(active management of the third stage
of labour) and treatmentof postpartum hemorrhage.
3. Recall the four Ts as causes of postpartum hemorrhage.
4. Identify risk factors for PPH.
5. Describe the implications of postpartum hemorrhage on
the health of the mother and baby.
6. Prevention and management of PPH
5/10/2021 Uma Gupta 3

4. Postpartum hemorrhage (PPH) is leading
cause of maternal mortality, accounting for
one-third of all maternal deaths worldwide
PPH causes up to 60% of all maternal deaths
in developing countries.
The majority of these deaths -within 4
hours of delivery, indicating they are a
consequence of third stage of labour.
5/10/2021 Uma Gupta 4

5. •Primary (immediate) postpartum hemorrhage is
defined as excessive bleeding that occurs within the
first 24 hours after delivery.
•About 70% of immediate PPH cases are due to uterine
atony.
•Atonyof the uterus is defined as the failure of the
uterus to contract adequately after the child is born.
5/10/2021 Uma Gupta 5

6. •Secondary (late) postpartum hemorrhage is
defined as excessive bleeding occurring between 24
hours after delivery of the baby and 6 weeks
postpartum. Most late PPH is due to retained
products of conception, or infection, or both
combined.
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7. Quantified
PPH has been defined as blood loss in excess of 500
cc in vaginal deliveries and in excess of 1,000 cc in
cesarean section deliveries. For clinical purposes,
any blood loss that has the potential to produce
hemodynamic compromise should be considered a
PPH.
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8. The amount of blood loss required to cause
hemodynamic compromise will depend on the pre-
existing condition of the woman.
Hemodynamic compromise is more likely to occur in
conditions such as anemia (e.g. iron deficiency, sickle
cell, and thalassemia) or volume contracted states
(e.g. dehydration, gestational hypertension with
proteinuria).
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9. Classification
•Primary : Loss within 1
st
24 hours after delivery
•Secondary : 24 hours till 12 weeks postnatally
•Minor : 500-1000 ml
•Moderate : 1000-2000 ml
•Severe : > 2000 ml
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10. Clinical Findings With Varying
Amounts of Blood Loss
Blood loss will result in changes to the state of
consciousness, the pulse rate, the respiratory rate,
the temperature, the blood pressure, the status of
the skin and mucous membranes, capillary refilling,
and urine output.
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11. Estimating Blood Loss
•Accurate estimation of blood loss is essential in the
recognition and management of obstetric
hemorrhage. Underestimation of blood loss may
result in lack of recognition of PPH, and inadequate
or inappropriate management
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12. Direct Measurement
PAD 120 CC
TAMOPNE 50 CC
GUAZE 30 CC
SMALLABDOMINAL PACK 250 CC
LARGE ABDOMINAL PACK 450 CC
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13. •Mild hypovolemia, loss of <20% of the blood
volume,
•mild tachycardia,
•mottled skin,
•cool extremities due to increased systemic vascular
resistance and prolonged capillary refilling,
•urinary output may be decreased.
•The woman may report dizziness, although her
neurologic status usually remains normal.
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14. •With moderate hypovolemia, i.e. loss of 20% to 40%
of the blood volume,
•woman will become increasingly anxious.
•pulse will become very fast and weak, >110/bpm
(tachycardia).
•Her respiratory rate will increase to a rate of
>30/bpm.
•will exhibit marked pallor; her eyelids, palms, and
mucous membranes will be very pale.
•Her blood pressure may be normal when she is in the
supine position. However, there may be significant
postural hypotension
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15. •When blood loss is severe, i.e. >40% of the blood
volume,
•the classic signs of shock will appear.
•The blood pressure declines and becomes unstable
even in the supine position.
•The woman will develop marked tachycardia,
oliguriaor anuria, and agitation or confusion.
•Loss of consciousness is an ominous sign.
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16. Rule of 30
This rule is used to measure severity of shock
resulting from at least 30% of blood loss –
•Increase in HR by >30 beats/min
• Fall in Systolic BP >30 mmHg
• RR >30/min
• Hematocritdrops by >30%
• Urine output <30ml/min
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17. 3.SHOCK INDEX (S.I)
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18. •Frequent measuring of birth fluids may help health
care providers become more skilled in assessing
blood loss. Health care providers should become
familiar with the absorbency of maternity pads,
under pads, and other surfaces on which maternal
blood may accumulate during delivery in their
practice location
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19. ➢REMEMBER
➢Blood loss is consistently underestimated.
➢Underestimation may result in inadequate treatment
resulting in complications or death.
➢Ongoing trickling can lead to significant blood loss.
➢Blood loss is generally well tolerated by healthy
women, to a point.
➢Anemia and other underlying health conditions may
profoundly affect a woman‘s ability to tolerate any
amount of blood loss.
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20. •Complications Associated With Postpartum
Hemorrhage
•Significant blood loss can occur very quickly. Women
can lose up to 500 ml of blood in 1 minute during a
PPH.
•The average woman has approximately 5 litresof
blood in her circulation. At this rate, it is possible for a
woman to become exsanguinated(lose all of her
blood) within 10 minutes. Rapid, efficient action must
be taken to save the woman‘s life and to prevent
complications related to significant blood loss
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21. Effects of PPH
•PPH is associated with orthostatic hypotension,
anemia, and fatigue.
•Postpartum anemia is associated with lactation failure
placing the health of the newly born infant at risk.
•It is also associated with postpartum depression that
may in turn affect maternal bonding with the
newborn. Maternal attachment to the newborn is
essential for the long-term well-being of the infant.
•Extreme fatigue resulting from anemia may make
maternal care of the newborn and other siblings more
difficult
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22. Etiology
•Causes of PPH in terms of the Four T‘s:
•Tone -uterine atony
•Tissue -retained placenta or clots
•Trauma -uterine, cervical, or vaginal injury
•Thrombin -pre-existing or acquired coagulopathy
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23. CAUSES -THE ‘FOUR Ts’ OF PPH
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CAUSE INCIDENCE (% )
TONE–atonic uterus 80
TRAUMA -
lacerations, rupture
10 –15
TISSUE –retained
tissue
3–5
THROMBIN 1-2

24. Risk factors for postpartum hemorrhage
Etiologic Process (Cause) Clinical Risk Factors
Abnormalities
of Uterine
Contraction
(Tone)
Over-distended uterus
•Polyhydramnios
• Multiple gestation
• Macrosomia
Uterine muscle exhaustion
• Rapid labour
• Prolonged labour
• High parity
Intraamnioticinfection • Fever
• Prolonged rupture of membranes
(ROM)
Functional or anatomic
distortion of the uterus, i.e.
distended bladder may
prevent contraction of the
uterus
• Fibroid uterus
• Placenta previaor abruptio
• Uterine anomalies
Uterine-relaxing
medications
• Halogenated anesthetics,
nitroglycerin, magnesium sulphate
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25. Living ligature
•Failure of this living ligature leads to atonicity of
uterus leading to PPH .
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26. Etiologic Process (Cause) Clinical Risk Factors
Retained
Products of
Conception
(Tissue)
Retained products
abnormal placentation
retained cotyledon or
succinturiatelobe
• Incomplete placenta at
delivery
• previous uterine surgery
• High parity
• Abnormal placenta on
ultrasound
• Retained blood clots •Atonicuterus
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27. Etiologic Process (Cause) Clinical Risk Factors
Genital Tract
Trauma
(Trauma)
• Tears (lacerations) of the cervix,
vagina, or perineum
• Ruptured vulvalvaricosities
• Precipitous delivery
• Operative delivery
• Mistimed or inappropriate
use of episiotomy
• Extensions, lacerations at cesarean
section • Malposition
• Deep engagement
Uterine rupture Previous uterine surgery
• Uterine inversion • High parity
• Fundalplacenta
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28. Etiologic Process (Cause) Clinical Risk Factors
Abnormalities
of
Coagulation
(Thrombin)
• Pre-existing states
-hemophilia A
-von Willebrand‘sdisease1
History of hereditary
coagulopathies
• History of liver disease
• Acquired in pregnancy
-idiopathic thrombocytopenic purpura2
-thrombocytopenia with preeclampsia
-disseminated intravascular coagulation
-preeclampsia
-dead fetus in utero
-severe infection/sepsis
-placental abruption
-amniotic fluid embolus
• bruising
• elevated BP
• elevated BP
• fetal demise
• fever
• elevated white blood
cells
• antepartumhemorrhage
• sudden collapse
Therapeutic anticoagulation history of thrombotic
disease
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29. Prevention
•Compared to expectant management, active
management of the third stage of labour(AMTSL)is
associated with
•↓ maternal blood loss,
•↓ postpartum hemorrhage,
•↓ postpartum anemia,
•↓ need for blood transfusions
•and a ↓ e in the incidence of prolonged third stage
of labour.
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30. What is active management of 3rd stage of labour?
Active management of 3
rd
stage of labour(AMTSL)
involves 3 steps after delivery of baby:
1. Uterotonicdrug given immediately after birth of baby
2. Placenta delivered by controlled cord tractionwith
counter-traction on the fundusduring contraction
3. Fundalmassage after delivery of the placenta
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31. 5/10/2021 Uma Gupta 31

32. What are the oxytocicdrugs used in AMTSL?
There are 4 kinds of drugs used in third stage of labor
• Oxytocin-posterior pituitary extract
• Ergometrine-preparation of ergot
• Syntometrine-combination of oxytocinand
ergometrine
• Misoprostol-prostaglandin E1 analogue
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33. Drugs Advantage Disadvantage
Oxytocin Causes uterus to contract
• Acts within 2.5 minutes when
given IM
• Generally does not cause side
effects
• Safe in hypertension
• IM or IV preparations only
• Not heat stable
ErgometrineLow price
• Effect lasts 2–4 hours
• Takes 6–7 minutes to
become effective when
given IM; oral form
insufficiently effective
• Causes tonic uterine
contraction
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34. Drugs Advantage Disadvantage
Syntometrine Combined effect of
rapid action of oxytocin
and sustained action of
ergometrine
Increased risk of
hypertension, nausea
and vomiting
• Not heat stable
Misoprostol
• Effective orally,
buccally, vaginally and
rectally
• Rapid absorption after
oral 3 minutes
T1/2 life = 20-40
minutes
• Predictable side
effects: shivering,
pyrexia, nausea,
vomiting and diarrhea
• Rate of PPH is higher
with misoprostol
compared to oxytocin.
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35. Management
of third stage
of labor
Blood Loss (>
1000 ml)
Physiologic13-18%
Active
(oxytocin)
2.9%
Misoprostol4%
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36. Management of PPH
Principles of management -
To replace the blood
To empty the uterus
To ensure effective hemostasis
For systematic management of PPH there is algorithm
known as
‘ HEMOSTASIS ’
5/10/2021 Uma Gupta 36

37. HEMOSTASIS
H: Ask forhelp
A: Assess (vitals, blood loss) &resuscitate
E: Establish etiology &check Ecbolics
(syntometrine, ergometrine)Ensure availability
of blood
M: Massage uterus
O: Oxytocin infusion, prostaglandins
S: Shift to operating room, exclude retained
products &trauma5/10/2021 Uma Gupta 37

38. CONT…
T: Tissue & Trauma to be excluded , proceed for
Tamponade, bakriballoon, uterine packing
A : Apply compression sutures
S : Systematic pelvic devascularization(uterine,
ovarian, internal iliac artery ligation)
I : Intervention radiologist, uterine artery
embolization
S : Subtotal or total abdominal hysterectomy
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39. Assess
1.Assess Vital signs &Estimate Blood Loss
2.Adequate venous access : 2 large bore I/v
cannula(16-18G)
3. DrawBloodsample(~20ml)forhaemogram,
Blood Group,Cross Match, Coagulation
screen, RFT &LFT
4. Foley’scatheter:Monitoringadequaterenal
perfusion.
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40. Volume Replacement
5. Fluid ofChoice –Crystalloid over colloids
6. Crystalloid of choice –RingerLactate
7. Lossof1Litofbloodrequiresreplacement
with4-5Litof crystalloids (NS or RL) or
colloids until cross matched blood Is available
(1 ml of blood loss= 3 ml ofcrystalloids)
8. The recommended transfusion ratio for
PRBC:FFP:RDP IS1:1:1
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41. Medical management
1 . FIRST LINE DRUG
Oxytocin:
•Start with10 units imand Infusion of 20 units in 1L
@ 60 drops /min.
•Continue same dose @ 40 drops/min until bleeding
stops.
•Maximum dose of 3 liters of oxytocininfusion
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42. SECONDLINE DRUG
Ergometrine/ methyl ergometrine:
•Dose: 0.2 mg imor slow iv Repeat 0.2mg after 15
min.
•Maximum 5 doses (1 mg) can be given
•Syntometrineim
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43. Third line
Carboprost/ (PGF2alpha)
Dose: 0.25mg (250µgm) mg im.
Can be repeated every 15 min. Maximum
upto2 mg or8 doses can be given .
Misoprostol
•200-800 µg sublingually. Do not exceed 800 µg
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44. 3. Bimanual
Compression
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•
•
•
•
Form a fist.
Place the fistin anterior
fornix & apply pressure
against the anterior wall of
uterus.
With the other hand press
deeply into the abdomen
behind the uterus to make it
anteverted.
Pressure against the posterior
wall of uterus Maintain
pressure until bleeding is
controlled & uterus contracts.

45. 4. Shift to OT
•Patient is to be shifted to O.T
•By P/S examination rule out trauma to perineum ,
vagina, and cervix .
•If required then hemostasissutures are to be taken by
catgut suture.
•Also examine the placenta for its completeness.
•Exploration of uterus is done .
•Evacuation of any product of conception if retained.
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46. 5. Uterine tamponade
1.Tight uterine packing
2. Balloon tamponade
a. Bakriballoon
b. SengstakenBlakemore catheter
c. Condomcatheter
5/10/2021 Uma Gupta 46

47. Intrauterine packing
•A long gauze of 5 metresoaked in antiseptic cream
is introduced inside the uterus and placed in to the
fundalarea.
•Exerts direct haemostatic effect to open uterine
sinuses.
•Obseletenow days because of risk of intra uterine
sepsis .
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48. Balloon tamponade
•Balloon Inflate balloon with 200-500 ml warm 0.9 %
Sodium chloride.
•It adapts to shape of the uterine cavity and occludes
the venous sinus.
•If the bleeding is controlled it known as Positive
TamponadeTest.
•The catheter should not be removed within 12-
24hrs.
•Effectiveness –88%
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49. 5/10/2021 Uma Gupta 49

50. 5/10/2021 Uma Gupta 50

51. 6.Compression sutures
1.B -Lynch suture
2.Hayman suture
3.Cho suture
✓These suture causes bimanual compression of the
uterus.
✓Apposes anterior and posterior wall of uterus.
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52. Cho and haymansuture
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53. 5/10/2021 Uma Gupta 53
B-Lynch suture

54. 7. Systematic pelvic devascularization
▪Ligation of Uterine arteries
▪Ligation of Tubal branch of ovarian artery
▪Ligation of Internal iliac artery
➢Ascending branch of uterine artery is ligatedat
lateral border b/w upper and lower segment.
➢And ovarian artery is ligatedjust below ovarian
ligament.
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55. Ligation of uterine and internal iliac
artery ( ascending branch)
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56. 8. Interventional radiology
•Angiographic selective arterial embolization
•Possible where facility of interventional radiology
available.
•Avoids hysterectomy
•Success rate of about 90 %
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57. 9. Hysterectomy
•If all procedures failed to control bleeding
Decision for hysterectomy is taken to
save mother life
•It may be subtotal or total hysterectomy.
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58. Transferring to referral centre
5/10/2021 Uma Gupta 58
As PPH precedes Death by 2 hours”
If initial medical therapy fails within Golden Hour, then
shift the patient to higher centre.
Two important life savior methods -;
➢Aortic compression by Skilled Birth Attendant
➢Non Pneumatic Anti Shock Garment

59. 5/10/2021 Uma Gupta 59

60. •
NASG is a simple device -
Neoprene
•Shunts blood to vital organs
(anti-shock)
•It can shunt about 500-1500
ml into central pool
NON–PNEUMATIC ANTI SHOCK GARMENT
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61. PREVENTION:
5/10/2021 Uma Gupta 61
PreventionofPPHisnotalwayspossiblebuthowever itsincidencecanbereduced
Bysubstantiallyassessingtheriskfactorsandfollowingguidelinesasmentioned:
•ANTENATAL:
1.Improvementofhealthstatusofwomenandtokeepthehaemoglobinlevel
normal(>10g/dl),sothatthepatientcanwithstandsomeamountofbloodloss.
2.HighriskpatientswhoarelikelytodevelopPPH(suchastwins,hydramnios,grand
multipara,historyofpreviouspph,severeanemia) aretobescreened.
3.Bloodgroupingshouldbedoneforallwomensothatnotimeiswastedduring
emergency.

62. 4.PlacentallocalizationshouldforallwomenwithpreviouscesareandeliverybyUSGor
MRItodetectplacentaaccretaorpercretaortodeterminemorbidadherentplacenta.
P.P
5.Womenwithmorbidadherentplacentaareathighriskofdevelopingpph.Suchacase
shouldbedeliveredbyseniorobstetrician.Availabilityofbloodandbloodproductsmust
ensuredbeforehand.
•INTRANATAL:
1.Activemanagementofthethirdstage,forallwomeninlaborshouldbearoutineasit
reducesPPhby60%
2.Womendeliveredbycesareansection,oxytoxin5IUslowIVistobegiventoreduce
bloodloss.Carbetocin100mcgisveryusefultopreventPPH.
3.Explorationoftheuterovaginalcanalforevidenceoftraumafollowingdifficult
labororinstrumentaldelivery.
4.Observationforabouttwohoursafterdeliverytomakesurethattheuterusishardand
wellcontractedbeforesendinghertoward.
5.Duringcesareansectionspontaneousseparationanddeliveryoftheplacentareduces
bloodlossby30%
6.Examinationoftheplacentaandmembranesshouldbearoutinetodetectatthe
earliestanymissingpart.
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63. ASSESSMENT
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64. Question 1
•To be considered a PPH, what would the estimated
blood loss have to be for a C-section?
A.< 550 ML
B.> 600 ML
C.> 1000 ML
D.< 900 ML
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65. Question 1
•To be considered a PPH, what would the estimated
blood loss have to be for a C-section?
A.< 550 ML
B.> 600 ML
C.> 1000 ML
D.< 900 ML
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66. Question 2
•What types of trauma during labour and birth
would lead to PPH risk?
A.Instrumental assisted birth (vacuum or forceps)
B.C-Section
C.Lacerations of the cervix or vaginal wall
D.All of the above
5/10/2021 Uma Gupta 66

67. Question 2
•What types of trauma during labour and birth
would lead to PPH risk?
A.Instrumental assisted birth (vacuum or forceps)
B.C-Section
C.Lacerations of the cervix or vaginal wall
D.All of the above
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68. Question 3
•In which of these cases could you diagnose PPH
following vaginal delivery:1. > 500 blood loss over
24 hrs2. hypotension3. tachycardia
A.1 & 3
B.2
C.3
D.1
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69. Question 3
•In which of these cases could you diagnose PPH
following vaginal delivery:1. > 500 blood loss over
24 hrs2. hypotension3. tachycardia
A.1 & 3
B.2
C.3
D.1
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70. Question 4
•The 4 “T’s” of PPH are:1. Trauma2. Toxins3.
Travel4. Tissue5. Threads6. Thrombin7.
Tears8. Tone
A.1, 4, 6 & 8
B.1, 5 7 & 8
C.1, 2, 3 & 6
D.3, 4, 5 & 6
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71. Question 4
•The 4 “T’s” of PPH are:1. Trauma2. Toxins3.
Travel4. Tissue5. Threads6. Thrombin7.
Tears8. Tone
A.1, 4, 6 & 8
B.1, 5 7 & 8
C.1, 2, 3 & 6
D.3, 4, 5 & 6
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72. Question 5
•The normal blood flow through the placental site
each minute is 500-800 mls per minute.
A.True
B.False
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73. Question 5
•The normal blood flow through the placental site
each minute is 500-800 mls per minute.
A.True
B.False
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74. Question 6
•Which of these implantations would most likely
cause excessive bleeding?
A.Increta & Percreta
B.Normal & Accreta
C.Accreta & Increta
D.None of the above
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75. Question 6
•Which of these implantations would most likely
cause excessive bleeding?
A.Increta & Percreta
B.Normal & Accreta
C.Accreta & Increta
D.None of the above
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76. Question 7
•_________________ and ________________ are
the two most common causes of primary PPH.
(Tissue, Tone, Trauma, Thrombin)
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77. Question 7
•_____Tone__ and _Trauma__________ are the two
most common causes of primary PPH. (Tissue,
Tone, Trauma, Thrombin)
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78. Question 8
Ergometrineto control post-partum hemorrhage :
A. Is contraindicated in patient with high blood
pressure
B. It will not act on the smooth muscle of the blood
vessels
C. Intravenous root is the only way to be given
D. It can be used for induction of labor
E. Is safe in cardiac patient
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79. Question 8
Ergometrineto control post-partum hemorrhage :
A. Is contraindicated in patient with high blood
pressure
B. It will not act on the smooth muscle of the blood
vessels
C. Intravenous root is the only way to be given
D. It can be used for induction of labor
E. Is safe in cardiac patient
5/10/2021 Uma Gupta 79

80. Question 9
All of the following are used in treatment of PPH
except:
a.Misoprostol
b.Mifepristone
c.Carbaprost
d.Methyl ergometrine
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81. Question 9
All of the following are used in treatment of PPH
except:
a.Misoprostol
b.Mifepristone
c.Carbaprost
d.Methyl ergometrine
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82. Question 10
Carbetocin dose for PPH:
a.100 mcg IV
b.50 mcg IV
c.150 mcg IV
d.250 mcg IV
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83. Question 10
Carbetocin dose for PPH:
a.100 mcg IV
b.50 mcg IV
c.150 mcg IV
d.250 mcg IV
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84. Question 11
B Lynch suture is applied on:
a.Cervix
b.Uterus
c.Fallopiantube
d.Ovaries
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85. Question 11
B Lynch suture is applied on:
a.Cervix
b.Uterus
c.Fallopiantube
d.Ovaries
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86. Save the lifeof theone who
gives birth to a new life
THANK YOU
5/10/2021 Uma Gupta 86

87. Reference
1. DC Dutta’sOBSTETRICS Including Perinatologyand Contraception. 9
th
Edition.
JaypeeNew Delhi
2. TectBook of Obstetrics Sheila Balakrishnan. ParasPublishers, Delhi
3. Self Assessment Review Obstetrics SakshiArora
4. Extracts from: http://www.commonhealth.in/pdf/8.pdf
5. World Health Organization. Managing complications in pregnancy and
childbirth: A
guide for midwives and doctors. . 2003.
5. Obstetrics by Ten Teachers. 20
th
Edition.CRC Press, Taylor and Francis group UK.
2017.
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88. Twosome
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