PostPartum haemorrhage
By
Dr. Oliver Chukwuemeka Onwube
(mbbs,fwacs,afmcog,fics)
Postpartum haemorrhage
Outline
1. Introdcution
2. Definition
3. Causes
4. Managemen
5. The WHO PPH bundle
6. Conclusion
Introduction
Postpartum haemorrhage remains a leading cause
of maternal mortality. In fact it contributes to
25-30% of maternal mortality
The wife of the Shah Jahan of India, the Empress
Mumtaz had 14 children and died after her last
chidbirth of a postpartum haemorrhage in 1630.
So great was the Shah Jahan’s love for his wife
that he built the world’s most beautiful tomb in
her memory- the TAJ MAHAL
Today maternal mortality from postpartum
haemorrhage is still ever present with us. We must
find answers to this turn in the flesh
Definition
 Postpartum haemorrhage is defined as loss of
greater than 500mls of blood after a vaginal delivery
or loss of greater than 1000mls of blood after a
caesarean section…… WHO
 Or any bleeding after delivery leading to
haemodynamic imbalance as evidenced by weakness,
dizziness, tachycardia and hypotension.
 It is Primary postpartum haemorrhage if the bleeding
occurs within 24hours of birth.
 Secondary postpartum haemorrhage is defined as any
vaginal bleeding in excess of normal lochia occurring
greater than 24 hours but less than 6weeks
postpartum
Aetiology
Causes (The 4Ts)
A. Atony (60-70%)
1.Uterine Overdistension(Multiparity,
polyhydramnios,Macrosomia)
2. Uterine relaxants(Nifedipine,magnesium,betamimetics,indomethacin, Nitric oxide donors)
3. Rapid or prolonged labour
4. Oxytoxics to induce labour
5. Chorioamnionitis
6. Halogenated Anaesthesia
7. Fibroid Uterus
B. Tissue(5-10%)
1.Retained placenta
2. Morbidly adherent placenta eg, placenta
acreta/percreta/increta, succenturiate lobe
3. Prior Uterine Surgery eg, myomectomy,
caesarean Section
4. Obstructed labour
 C. Trauma (20%)
1. Vulvovaginal injury
2. Episiotomy
3. Cervical tears
D. Thrombin (1-2%)
1. HELLP syndrome
2. DIC (Eclampsia, IUFD, Septicemia, placenta
Abruption, Amniotic fluid embolism)
3.Hereditary eg, Von Willebrand’s disease
4. Anticoagulant therapy
 This is not the time for time wasting history taking
 The key strategies in management are as follows:
1. Call for help
2. Resuscitation (A B C)
3. Secure a double i.v. access with a wide bore canula
4. Commence fluid replacement with crystallooids eg,
n/s, Ringers lactate, Hartman solution or colloids eg,
haemacele and Isoplasma
5. Urgently take blood for grouping and crossmatching
6. Insert an indwelling urethral catheter to commence
monitoring of urine output.
Management of PPH..
6. A CVP can be inserted in centres with the
capability to monitor and manage fluid replacement
After these, the cause of the bleeding can be quickly
assessed by examining the uterus for atony and a
gentle and gradual genital tract examination for
injuries or retained products
Medical
1. Forty i.u. of oxytocin added to 500mls of N/s at
20dpm
2. Insert 1000micrograms of misoprostol rectally
3. IM ergot 0.5ml stat
4. IM/ I.V. Carbetocin 100mcg start
5. I.V. Tranexamic acid 1000mg start
Management of PPH
Surgical
1. Rubbing up uterine contraction
2. Repair of episiotomy (Episiorrhaphy)
3. Cervical tear repairs
4. Vaginal tear repairs
5. Uterine Tamponade(bimanual uterine compression,
Bakri balloon, uterine packing, foley’s catheter,
condom catheter, Sengstaken Blakemore tube)
6. B-lynch procedure
7. Hayman suture
8. Cho suture
9. Stepwise devascularization
10. Internal iliac artery ligation
11. Uterine artery embolization/ligation
12. Esike’s Procedure
13. Peripartum hysterectomy
The WHO PPH care bundle
 Care bundles are described by the Institute for
Healthcare Improvement (IHI) as a structured way
of improving processes of care and patient
outcomes (1). Care bundles typically consist of a
set of evidence-based practices (generally three to
five) that, when performed consistently, can
improve outcomes. While the IHI definition does
not mention a specific time frame to implement
these practices, many care bundles are designed in
such a manner that component interventions are
meant to be initiated concurrently, collectively or
otherwise rapidly.
 A care bundle approach might help improve PPH-
related outcomes through one or more of the
following pathways. • Help optimize the coverage of
multiple effective interventions simultaneously. • Place
an emphasis on collective, rather than sequential, use
of interventions. This can shorten the time to initiating
an intervention (such as a uterotonic or antifibrinolytic
drug), which can optimize their effects. Reducing
delays in treatment could prevent ensuing
complications. • The concurrent use of multiple
effective interventions may confer other synergistic
effects. The use of a care bundle for PPH treatment is
conceptually linked to the accurate diagnosis of PPH.
 The bundle includes early detection and trigger
criteria (based on the measurement of blood loss
using a calibrated blood loss collection drape, and
assessment of clinical signs) and a first response
PPH treatment package (uterine massage,
oxytocic agents and uterotonics, tranexamic acid,
intravenous fluid infusion and examination.