Mrs. Shwetha Rani C.M.

Associate Professor & H.O.D.

Department of Obstetrics & Gynecological Nursing
SCPM College of Nursing & Paramedical Sciences,
Gonda. U.P.
▪ 200,000 women die from PPH each year.

▪ All pregnancies are at risk of PPH even if no predisposing factors are

present.

▪ Important cause of maternal mortality.

▪ Accounting for nearly one quarter of all maternal deaths worldwide.

▪ India -The maternal mortality rate 35-56%, 560/100,000 live births &

PPH accounts for 35- 56% of Maternal deaths in India.

▪ PPH is a condition in which excessive bleeding from the genital tract at any

time following the baby’s birth up to 6 weeks after delivery.

▪ Hemorrhage may occur before, during, or after delivery of the placenta.

▪ The average blood loss following vaginal delivery, cesarean delivery and

cesarean hysterectomy is 500 ml, 1000 ml and 1500 ml respectively.

▪ Any amount of bleeding from or into the genital tract following birth

of the baby up to the end of the puerperium, which adversely affects

the general condition of the mother, evidenced by increase in pulse

rate and falling blood pressure is called postpartum hemorrhage”

-Dutta, 2001
1. Primary (immediate) postpartum
Hemorrhage
IT 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.
• Atony of the uterus is defined as
the failure of the uterus to contract
adequately after the child is born.
2. Secondary (late) postpartum
hemorrhage
IT 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. This condition of
postpartum hemorrhage causes
hemorrhagic shock.
▪ • The most common and important cause of PPH is uterine atony.

▪ • 75-90% of cases

▪ • Uterine atony can often be effectively managed with uterine

massage in conjunction with administration of uterotonics.

1. Incomplete separation of placenta 2. Uterine hyperdistention –
Macrosomia baby –Multiple
pregnancy- polyhydramnios
3. Previous PPH 4. Placenta previa

5. General anesthesia- in inhalational 6. High parity

agents like halothane

7. Precipitated labour- less than 1 hour 8. Prolonged labour – active phase lasts more
than 12 hours

9. Fibroids 10. Obesity (BMI > 35), Age > 40 years old
▪ Retained products of conception, most often a retained placenta or

retained placental fragments, must be removed to stop bleeding.

▪ Rarely, an invasive placenta may be present.

▪ Hysterectomy is the most common treatment.

▪ 5-10% of cases
▪ Operative vaginal delivery (vacuum / forceps)
▪ Perineal, vaginal and cervical tears
▪ Lower segment tears
▪ Uterine rupture
▪ Caesarean section
▪ Mediolateral episiotomy
▪ Trauma resulting from the birth process can result in significant blood loss.
▪ The source of trauma must be quickly identified and treated.
▪ Disseminated intravascular coagulation

▪ Placental abruption

▪ Pre-existing bleeding disorder like hemophilia

▪ Patient on anti-coagulant

▪ Fresh blood is usually the best treatment, as this will contain platelets

and the coagulation factors V and VIII.

▪ Fresh frozen plasma may also be infused.

▪ Vaginal bleeding is visible outside, either as slow trickle or
rarely a copious flow. Rarely, the bleeding is concealed either
remaining inside the uterovesical canal or in the surrounding
tissue space resulting in hematoma.

▪ Enlarged uterus, as it fills with blood or blood clot. It feels

boggy on palpation, i.e., soft and distended lacking tone.
Pallor

Tachycardia

Hypotension

Altered level of consciousness

Restlessness

Drowsiness

Maternal collapse
▪ • PPH cannot always be prevented.

▪ • However, the incidence and especially its magnitude

can be reduced substantially by assessing the risk

factors and following the guidelines as mentioned
below:
▪ • Improvement of the health status.

▪ • High risk patients (twins, hydramnios, grand multipara,

APH, history of previous PPH, severe anemia)

▪ • Blood grouping

▪ • Placental localization by USG or MRI to detect placenta

accreta or percreta.
▪ • Active management of the third stage.
▪ • Cases with induced or augmented labor by oxytocin.
▪ • Women delivered by cesarean section.
▪ • Exploration of the uterovaginal canal for evidence of trauma.
▪ • Observation for about two hours after delivery to make sure that the
uterus is hard and well contracted before sending women to ward.
▪ • Expert obstetric anesthetist.
▪ • During cesarean section spontaneous separation and delivery of the
▪ placenta reduces blood loss.
▪ • Examination of the placenta.
▪ TRANSVAGINAL UTERINE PACKING
▪ A surgical operation to remove all or part of the
uterus in case of life threatening condition of the
women i.e., menorrhagia, post-menopausal period.

▪ Most common surgical treatment done in India.

▪ • Abdominal hysterectomy
▪ • Vaginal hysterectomy
▪ • Laparoscopic-assisted
vaginal hysterectomy
▪ • Laparoscopic-assisted
supracervical hysterectomy
▪ • Total laparoscopic
hysterectomy
The
End