Postpartum Hemorrhage
(PPH)
Family Medicine Specialist CME
University of Health Sciences
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?
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
Definitions
• Primary/immediate 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
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
Hypovolemia Clinical Presentation
Mild (<20% of blood
volume)
•
•
•
•
Moderate (20–40% of
blood volume)
•Heart rate - >110 bpm
Heart rate - mild
tachycardia
•Tachycardia - >30 rpm
Skin – mottled, cool •BP – Normal in supine
extremities due to
position/significant
increased systemic
vascular resistance
postural hypotension
and prolonged
•Skin - marked pallor;
capillary refilling
conjuntiva, palms and
Urinary output mucous
decreased
Neurologic status – •Neurologic status –
may report dizziness increasingly anxious
but usually remains
normal
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
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
PPH Etiology
• Tone – uterine atony
• Tissue – retained placenta
• Trauma – vaginal/cervical lacerations, rupture,
inversion of uterus
• Thrombin - coagulopathy
Tone: Risk Factors
Etiologic process
Clinical risk factors
Overdistended uterus
Polyhydramnios
Multiple gestation
Macrosomia
Uterine muscle
exhaustion
Rapid labour
Prolonged labour
High parity
Intraamniotic infection
Fever
Prolonged rupture of
membranes
(PROM)
Tone – Risk Factors (2)
Etiologic process
Clinical risk factors
Functional or anatomic
distortion of the uterus
Fibroid uterus
Placenta previa or
abruptio
Uterine anomalies
Uterine-relaxing
medications
Halogenated
anesthetics
nitroglycerin,
magnesium
sulphate
Tissue – Risk Factors
Retained Placental tissue
Etiologic process
Retained products,
abnormal placentation,
retained cotyledon or
succinuriate lobe
Clinical risk factors
Incomplete delivery of placenta
Previous uterine surgery
High Parity
Abnormal placenta on
ultrasound
Retained blood clots
Atonic uterus
Trauma (Genital Tract) – Risk Factors
Etiologic process
Clinical risk factors
Tears (lacerations) of the
cervix, vagina, or perineum
Ruptured vulvar varicosities
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
Fundal placenta
Thrombin (Abnormalities of
Coagulation) – Risk Factors
Etiologic process
Clinical risk factors
Pre-existing states
History of hereditary
coagulopathies
History of liver disease
Therapeutic
anticoagulation
History of thrombotic
disease
Thrombin (Abnormalities of
Coagulation) – Risk Factors (2)
Etiologic process
States acquired in pregnancy
• idiopathic thrombocytopenic
purpura
• thrombocytopenia with
preeclampsia
• disseminated intravascular
coagulation
• preeclampsia
• dead fetus in utero
• severe infection/sepsis
• placental abruption
• amniotic fluid embolus
Clinical risk factors
bruising
elevated blood pressure
fetal demise
fever
elevated white blood cells
antepartum hemorrhage
sudden collapse
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
Controlled cord Traction
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
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
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
Management of Postpartum
Hemorrhage
• Prevention is the key!
1. Identify and manage risk factors identified for
potential PPH
2. Active management of the third stage of labor
Management of Postpartum
Hemorrhage
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
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
Management of PPH
A
B
C
= airway
= breathing
= circulation
External Bimanual Uterine Massage
Internal Bimanual Uterine Massage
Examine the placenta for
completeness
Examination of maternal side
Examination of fetal side
Manual removal of placenta
1.
3.
2.
4.
Management of Postpartum
Hemorrhage
11.Examine the genitals for trauma and repair as
required ie. vulva, vagina, cervix
12. If bleeding continues may require uterine
tamponade or aortic compression
13.Ensure no uterine inversion or rupture
14.Manage possible coagulopathy with blood
transfusion (if possible)
15.Consider transfer to facility for surgical
management of PPH
Aortic Compression
Uterine Tamponade
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
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
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
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
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