POSTPARTUM

HAEMORRHAGE (PPH)
Ilala crest lodge Training
12-06-2009
Marla

GOAL

To equip midwives and other skilled birth

attendants with knowledge, skills and
attitude in the management of women with
postpartum haemorrhage

OBJECTIVES
At the end of the session midwives and
other skilled births attendants will be able to:
Define postpartum haemorrhage
Explain the types of post-partum
haemorrhage
Explain causes of postpartum haemorrhage

OBJECTIVES CONT
Explain the complications of postpartum
haemorrhage
Demonstrate competence in caring for
women who develop post partum
haemorrhage
Demonstrate positive attitudes in managing
patients with PPH

LEARNING ACTIVITIES

History taking
Examination of placenta and membranes
Vaginal examination
Measuring of blood loss
Bimanual compression of the uterus
Manual removal of placenta

Definition
Postpartum haemorrhage is excessive
bleeding of 500 mls and above from the
genital tract after delivery of the baby and
before the end of puerperium.
Any amount of blood loss that
threatens the life of the mother can also
be regarded as PPH

Types of Postpartum
Haemorrhage
1. Primary postpartum haemorrhage

This is excessive bleeding from the genital tract

within 24 hrs of delivery. This is the most
common type of post partum haemorrhage.
2. Secondary postpartum haemorrhage

It is excessive bleeding from the genital tract after

24 hours of delivery up to 6 weeks postpartum.

Causes of Postpartum Haemorrhage: The

3 Ts
First T: TONE
Bleeding due to lack of TONE of the uterine
muscles or any condition interfering with
contraction of the uterus.
This includes:
Retained placenta
Retained placental tissue or membranes
Incomplete separation of placenta

Causes of Postpartum Haemorrhage: The

3 Ts cont
Full bladder
Ante-partum haemorrhage like in placenta
praevia (less oblique muscle fibres in the
lower uterine segment) or placenta abruptio
(muscle fibres are damaged due to
concealed uterine haemorrhage

Causes of Postpartum Haemorrhage:

The 3 Tscont
Second T: TRAUMA

Lacerations to birth canal including

cervical, perineum, and vagina tears,
ruptured uterus, uterine inversion, too
early episiotomies
Third T: THROMBIN
Coagulation failure interfering with blood
clotting mechanism

 Examples of causes of Coagulation failure

Abruptio placentae
Amniotic fluid embolism
Retained dead fetus
Inherited coagulopathy

Factors predisposing to postpartum

uterine atony

Overdistention of the uterus

Multiple gestations
Polyhydramnios
Fetal macrosomia
Prolonged labor
Oxytocic augmentation of labor
Grand multiparity (a parity of 5 or more)
Precipitous labor (one lasting <3 hr)
Magnesium sulfate treatment of preeclampsia
Chorioamnionitis
Halogenated anesthetics
Uterine leiomyomata

Management of primary PPH (according to

cause)
a) Tone
Management will depend on whether the placenta
is delivered or retained
i) Placenta delivered
Call for help and never leave the patient alone till
the bleeding has stopped and the patient is stable
Explain calmly to the mother about her condition
and what interventions will be done

Placenta not delivered cont

Rub up a contraction and expel clots if any
Give Oxytocin (10 units IM stat)
Empty the bladder and maintain an
indwelling catheter
Put up two large bore cannula and take
blood for grouping, X-matching and
haemoglobin and check clotting time

Placenta not delivered cont

Infuse Normal Saline or crystalloids with 2040 units of Oxytocin. Maintain the infusion at
40 drops per minute to keep the uterus well
contracted (or run the infusion fast).
Arrange blood donors. If at a health centre,
donors should accompany the patient to the
Central Hospital/District Hospital.

Placenta not delivered cont

Assess patients condition (pulse, BP, colour
of mucus membranes, consciousness level,
uterine tone) and estimate how much blood
has been lost already.
Start resuscitating the patient immediately:
airway to be patent, oxygen therapy 6-8
litres per minute.

Placenta not delivered cont

Quickly examine placenta and membranes
for completeness.
Inform the doctor about the condition of the
patient and about the interventions that you
have carried out.
If bleeding persists and the uterus keeps
relaxing, use bimanual compression of the
uterus. (see Annex 6)

Placenta not delivered cont

If bleeding persists and the uterus is well
contracted, examine the vagina and cervix
for lacerations/tears.
In case of severe shock use plasma
expanders or blood transfusion if available.
In case of infection commence antibiotics

Placenta not delivered cont

Keep the woman warm throughout the
procedure.
Record intake and output
Document all interventions done and keep
accurate records

Management of PPH -TONE cont

ii) Placenta not delivered
Call for help
Explain to the patient the condition and plan
of care.
Rub up the fundus of the uterus for a
contraction
Empty the bladder.
Give Oxytocin 10 units IM.

Placenta not delivered cont

Apply controlled cord traction with the next
contractions.
If placenta still not delivered, commence
intravenous infusion of saline with 20-40
units of Oxytocin (If at the health centre
refer).
A second attempt at controlled cord traction
should be tried.

Placenta not delivered cont

If controlled cord traction is not successful
proceed to manual removal of the placenta.
(see Annex 5).
If manual removal is not successful, refer
immediately

Management of PPH-TRAUMA
b) Trauma
Call for help
Explain the condition to the mother and plan
of care
Place the woman in lithotomy position and
use good lighting
Find the bleeding point if visible, clamp it,
and suture the tear.

Management of PPH-TRAUMA cont

Take blood for grouping, X-matching and
haemoglobin estimation.
Set up an intravenous infusion, give saline
or sodium lactate followed by plasma
expander if available and if shock is severe.
Estimate the blood loss

Management of PPH-TRAUMA cont

Check pulse and blood pressure, and
observe general condition.
Start the woman on broad spectrum
antibiotics
Keep accurate records.

Management of PPH- THROMBIN

c) Thrombin
Check blood at the bed side for clotting time
The rest of management is the same with
that for TONE but transfuse fresh blood.

Management of secondary PPH

Admit the woman to hospital as an
emergency and assess the condition.
Rub up uterine contraction by massaging
the uterus if it is still palpable.
Give Oxytocin 10 units IM.

Management of secondary PPH

Take blood for Hb grouping and X-matching.
Put up intravenous infusion of normal saline
If bleeding is severe add 40 units IV
Oxytocin per litre to run at 40 drops per
minute.
Inform doctor or clinical officer

Management of secondary PPH

In case of severe shock use plasma
expanders or transfuse blood if available.
Start the woman on broad spectrum
antibiotics in high doses.
Prepare the patient for EUA and possible resuturing.
Monitor the patients condition, blood
pressure, pulse, temperature, respiration
and blood loss.

Management of secondary PPH

Assess lochia for colour, amount, odour and
consistency
Observe colour on the conjunctiva, tongue
Observe level of consciousness
Observe intake and output and keep
accurate records

Management of secondary PPH

Palpate uterus for tenderness
Provide good nursing care by assisting
mother with activities of daily living e.g.
nutrition, hygiene, rest and sleep.
Encourage exclusive breast feeding.

Complications of PPH

Infection
Hypovolaemic shock
Severe anaemia
Sheehans syndrome
Renal failure
Maternal death

Required competencies

History taking
Physical examination
Manual removal of placenta
Examination of placenta and membranes
Suturing skills of episiotomy and tears

Required competencies cont

Bimanual compression
Active management of 3rd stage of labour
Inserting and monitoring intravenous
infusions including blood
Check blood for bedside clotting time

YEBO
CHOMENE!