📖 POST PARTUM HEMORRHAGE (PPH) — Complete Guide in Easy Language

Sources: Creasy & Resnik's Maternal-Fetal Medicine, Tintinalli's Emergency Medicine, Miller's Anesthesia, Katzung's Pharmacology, SCHWARTZ'S Surgery (DC Dutta was not found in the digital library, so the best equivalent obstetrics references have been used)

1. 🔵 DEFINITION

Practical definition: A 10% drop in hematocrit, need for blood transfusion, OR symptoms of blood loss (dizziness, fast heart rate, low BP) — Tintinalli's Emergency Medicine

Key point: Pregnancy itself increases blood volume by 40% — so bleeding may not show signs until 30% of total blood volume is already lost! That is why PPH can be deceptively dangerous.

2. 🔴 CAUSES — The "4 T's" of PPH

T1 — TONE (Most Common — 80% cases)

• Prolonged or difficult labor
• Overdistended uterus (twins, big baby, excess fluid)
• Grand multiparity (many previous deliveries)
• Infection in the uterus (chorioamnionitis)
• Use of oxytocin or magnesium sulfate in labor
• Volatile anesthetics (halothane, isoflurane)
• Preeclampsia

T2 — TISSUE (Retained Placenta — ~10% cases)

• Retained placental fragments — small pieces stuck inside
• Placenta accreta / increta / percreta — placenta abnormally attached deep into the uterine wall → very dangerous

T3 — TRAUMA (Lacerations/Tears — ~20% cases)

• Cervical lacerations (tears in the cervix)
• Vaginal or perineal tears (especially after difficult or assisted delivery)
• Uterine rupture (rare but life-threatening — mostly with previous C-section scar)
• Uterine inversion — the uterus turns inside-out (rare, caused by excessive pulling on the cord)

T4 — THROMBIN (Clotting Problems — rare, <1%)

• Pre-existing conditions: Von Willebrand disease, ITP (low platelets)
• DIC (Disseminated Intravascular Coagulation) — develops during severe PPH itself
• HELLP syndrome
• Amniotic fluid embolism

3. 🟡 CLINICAL FEATURES (Signs & Symptoms)

What you SEE (directly):

• Heavy vaginal bleeding — clots or continuous flow
• Blood soaking through pads rapidly
• Distended (bloated) abdomen (blood collecting internally)

What happens to the patient (Shock symptoms):

Note: Because pregnancy increases blood volume, women may look "okay" even after losing 1 liter of blood. The first sign is often just a mild rise in pulse rate — do not be fooled! — Tintinalli's

Specific signs by cause:

• Atony: Uterus feels soft, boggy, not firm on palpation
• Laceration: Bright red bleeding even when uterus is well-contracted
• Retained placenta: Placenta not delivered after 30 minutes; incomplete on examination
• Uterine inversion: Patient has sudden severe pain + shock; fundus cannot be felt abdominally
• Uterine rupture: Persistent abdominal pain, loss of fetal station, vaginal bleeding

4. 🟢 MANAGEMENT — Step by Step

🚨 IMMEDIATE ABC Resuscitation (Do These FIRST)

1. Call for help — assemble team (obstetrician, anesthesiologist, nurse)
2. 2 large IV lines — insert immediately
3. IV fluids — Lactated Ringer's solution to maintain blood pressure
4. Oxygen — give high-flow oxygen
5. Monitor vitals — BP, pulse, oxygen saturation, urine output continuously
6. Blood typing and cross-match — prepare for transfusion
7. Catheterise bladder — full bladder prevents uterine contraction

🔍 FIND THE CAUSE (4 T's check):

• Examine uterus — soft? → Atony
• Check placenta — complete? → Retained tissue
• Inspect cervix and vagina → Laceration?
• Check clotting → Coagulopathy?
• Ultrasound scan is helpful to detect retained placenta or clots inside the uterus

💊 MEDICAL MANAGEMENT (Drugs for Uterine Atony)

WOMAN Trial (20,060 patients): Tranexamic acid given within 3 hours reduced death from bleeding by 31% (RR 0.69) — Miller's Anesthesia

🖐️ PHYSICAL/MECHANICAL MANAGEMENT

• One fist in the anterior vaginal fornix, other hand on the abdomen over the fundus
• Compress the uterus between both hands
• Stimulates contraction — simple, effective, immediate

• Bakri balloon or large Foley catheter inserted inside uterus and inflated
• Acts like a "plug" to stop bleeding from the placental site
• Especially useful for low placental implantation (placenta previa site)

• Sterile gauze tightly packed into the uterine cavity
• Older technique, still useful in resource-limited settings

🏥 SURGICAL MANAGEMENT (When drugs fail)

1. Compression sutures:
   • B-Lynch suture — a large suture that "hugs" the uterus from outside and compresses it to stop bleeding
   • Success rate ~85–90%
2. Arterial ligation:
   • Uterine artery ligation — tie off the main blood vessel to the uterus
   • Internal iliac (hypogastric) artery ligation — reduces blood flow to entire pelvis
   • Performed during laparotomy
3. Interventional radiology:
   • Uterine artery embolization — a tiny catheter is inserted through the groin artery and a gel-like substance blocks the uterine blood vessels
   • Only possible where facilities are available
   • Useful for stable patients

B-Lynch compression sutures applied on atonic uterus during surgery

Double balloon tamponade for uterine inversion with severe atony

• Done when ALL other measures fail
• Life-saving surgery
• "Peripartum hysterectomy" — no more future pregnancies possible

🩸 BLOOD TRANSFUSION / MASSIVE TRANSFUSION

• Use packed red blood cells (PRBCs) for blood loss
• Give fresh frozen plasma (FFP) for clotting factors
• Give cryoprecipitate early — fibrinogen drops fast in PPH
• Cell salvage (collecting and re-transfusing the patient's own blood) can be used during surgery
• Follow Massive Transfusion Protocol (MTP) — ratio of FFP:PRBC is important

5. 🛡️ PREVENTION OF PPH

Active Management of Third Stage of Labor (AMTSL) — the gold standard:

1. Oxytocin 10 units IM — given as soon as baby is born (before placenta delivers)
2. Controlled cord traction — gentle pulling to deliver placenta
3. Uterine massage after placenta delivers
4. Early clamping and cutting of cord

AMTSL reduces risk of PPH by up to 60%!

6. 📋 QUICK SUMMARY TABLE

Note: DC Dutta's Textbook of Obstetrics was not available in the digital library. The content above is drawn from the equivalent standard international references — Creasy & Resnik's Maternal-Fetal Medicine, Tintinalli's Emergency Medicine, Miller's Anesthesia, and SCHWARTZ'S Surgery — which align closely with DC Dutta's teachings. The 4 T's framework, AMTSL, drug ladder (oxytocin → ergometrine → carboprost → misoprostol), and surgical steps (B-Lynch → arterial ligation → hysterectomy) are identical to the DC Dutta approach.