Primary Postpartum Haemorrhage

2. Definition
A blood loss in excess of 500ml after a vaginal
delivery, occurring in the first 24 hrs post-
partum

3. Background
PPH is a leading cause of maternal mortality
in resource-poor settings
Uterine blood flow (UBF) at term is 500-700
ml/min
Approx. 85% of UBF goes to the placental
cotyledons

4. Aetiology
Uterine atony - common
Obstetric lacerations
Retained placental tissue
Inverted uterus
Ruptured uterus
Defective coagulation

5. Risk Factors
Polyhydramnios, multiple gestation, macrosomia
Prolonged labour, grandmultiparity
Fibroid, placenta praevia
Previous surgery
Precipitous or instrumental delivery
Pregnancy induced hypertension
Bleeding diasthesis, liver disease

6. Management
All available personnel should be mobilized.
Inform Obstetrician/anaeshetist.
Resuscitate: iv access, O
2
by mask, monitor
vital signs, catheterize
assess uterine contraction; explore uterus &
LGT; expel & observe blood clots
FBC, clotting profile, Group & Xmatch

7. Management contd…
Atony – massage, compress, oxytocics
Placental causes – remove manually or do a
gentle curretage (if not morbidly adherent)
Obstetric trauma – repair lacerations, correct
inversion (under analgesia); identify rupture
Reverse Coag. Defect – desmopressin,
replace factors…

8. Controlling bleeding
Uterine exploration
Bimanual compression &massage
Abdominal aorta compression
Curretage
Oxytocics
Operative management

9. Use of oxytocics
Useful in uterine atony
Oxytocin – im 10units, follow iv infusion 20 U
in 1 L (max. 3L)
Ergometrine – im/iv 0.5 mg bolus. Can repeat
after 15 min, then q4hrs (max 5 doses). Not used
in hypertensive or heart disease
Prostaglandins

10. Prevention
Risk assessment not reliable in predicting PPH
Active management of the third stage of labour –
give oxytocic at the delivery of the anterior
shoulder
Antenatal care – women with normal Hb levels are
more likely to tolerate blood loss
- Thank you

11. References
1.Managing complications in pregnancy and Childbirth. WHO;
http://www.who.int/reproductive-
health/inpac/Symptoms/Vaginal_bleeding_after_S25_S34.html
2.Prevention and Management of Postpartum Haemorrhage. SOGC.
http://sogc.medical.org/SOGCnetsogc_docs/common/guide/pdfs/ps88
.pdf