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Postpartum Hemorrhage (PPH): A Detailed Clinical Note for OBG Residents

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1. DEFINITION

WHO (2012) revised the definition: any blood loss that causes haemodynamic instability should be treated as PPH, regardless of volume.

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2. INCIDENCE & SIGNIFICANCE

• Affects approximately 1–5% of all deliveries
• Leading cause of maternal mortality worldwide (accounts for ~27% of maternal deaths globally)
• In India, PPH accounts for ~38% of maternal deaths
• Most deaths are preventable with timely intervention

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3. AETIOLOGY — THE "4 Ts"

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4. RISK FACTORS

Antepartum

• Previous PPH (recurrence risk 10–15%)
• Grand multiparity (≥5 deliveries)
• Uterine overdistension: multiple gestation, polyhydramnios, macrosomia
• Fibroids
• Placenta praevia / abruption / accreta spectrum
• Pre-eclampsia / gestational hypertension
• Anaemia
• Bleeding disorder or anticoagulant therapy

Intrapartum

• Prolonged labour (any stage)
• Augmented or precipitate labour
• Instrumental delivery (forceps/ventouse)
• Caesarean delivery (emergency > elective)
• General anaesthesia
• Episiotomy, perineal tears
• Chorioamnionitis
• Shoulder dystocia

Postpartum

• Uterine inversion
• Postpartum infection

Note: Anticoagulants like LMWH do not predispose to atonic bleeding (since haemostasis at the placental bed depends on myometrial contraction, not the clotting cascade), but do worsen traumatic bleeding. (Venous Thromboembolism in Pregnancy, p. 15)

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5. PATHOPHYSIOLOGY

1. Uterine muscle fibres contract → mechanical compression of uterine spiral arteries ("living ligature")
2. Platelet plug formation
3. Coagulation cascade activation

• Atony: Failure of myometrial contraction → open sinusoids → continuous bleeding
• Trauma: Mechanical disruption of vessels
• Tissue: Retained products prevent uterine contraction (mechanical obstruction)
• Thrombin/DIC: Consumption of clotting factors, fibrinogen, platelets → failure of coagulation

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6. CLINICAL FEATURES

Signs of PPH

• Excessive visible blood loss (may be underestimated by up to 50% clinically)
• Soft, "boggy," enlarged uterus (atony)
• Uterus well-contracted but continued bleeding → suspect trauma or retained tissue
• Signs of haemodynamic compromise: tachycardia, hypotension, pallor, cold extremities, reduced urine output, altered consciousness

Shock Index (SI) = Heart Rate / Systolic BP

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7. PREVENTION (Active Management of Third Stage of Labour — AMTSL)

1. Uterotonic drug immediately after delivery of the baby (before or at cord clamping)
   • Oxytocin 10 IU IM — first-line (FIGO/WHO)
   • Misoprostol 600 mcg sublingual — where oxytocin unavailable
   • Carbetocin 100 mcg IM/IV — single dose, sustained action (especially post-CS)
2. Controlled cord traction (Brandt-Andrews method) — after uterine contraction confirmed
3. Uterine massage after placental delivery (controversial — not recommended routinely by WHO 2012, but widely practised)

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8. MANAGEMENT

Immediate Resuscitation ("HAEMOSTASIS" or "ABCDE")

Step 1 — Resuscitation (Simultaneous with assessment)

• Two large-bore IV cannulas (14–16 G)
• IV crystalloids (Normal saline / Ringer's lactate) to maintain perfusion
• Warm IV fluids
• Oxygen via face mask (10–15 L/min)
• Foley catheter (monitor urine output ≥30 mL/hr)
• Cross-match blood; send: FBC, coagulation screen (PT, aPTT, fibrinogen), U&E, LFT, ABG
• Keep patient warm (prevent hypothermia — worsens coagulopathy)

Step 2 — Identify and Treat the Cause (4Ts)

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TONE (Uterine Atony) Management

• One hand in vagina (anterior fornix), one on abdomen — compress uterus between both hands
• Stimulates uterine contraction mechanically

Methylergonovine maleate and misoprostol are commonly used first-line uterotonics and effect a rapid response. If hemorrhage is severe or doesn't resolve with single agent, additional doses or additional agents should be given. (Management of Hemorrhage at Time of Abortion, p. 7)

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TRAUMA Management

• Inspect birth canal systematically: perineum → vagina → cervix → uterus (under good light and exposure)
• Repair all lacerations (suture promptly)
• Cervical tears: visualise fully; suture from the apex down
• Broad ligament / retroperitoneal haematoma: conservative if stable; surgical drainage if expanding
• Uterine rupture: exploratory laparotomy, repair or hysterectomy

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TISSUE Management

• Inspect placenta for completeness after every delivery
• If retained placenta: manual removal under anaesthesia
• Retained products: exploration of uterine cavity + curettage (blunt curette preferred postpartum to avoid perforation)
• Placenta accreta spectrum (PAS):
  • Accreta (superficial): manual removal may be attempted
  • Increta/Percreta: caesarean hysterectomy is usually definitive; conservative management (leaving placenta in situ + methotrexate) only in selected centres

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THROMBIN (Coagulopathy) Management

• Treat the underlying cause (e.g., abruption, sepsis, AFE, HELLP)
• Fresh Frozen Plasma (FFP): 4 units (15 mL/kg) — replaces all clotting factors; target INR <1.5
• Cryoprecipitate: 10 units — rich in fibrinogen (target fibrinogen >2 g/L), factor VIII, vWF
• Platelet transfusion: target >50 × 10⁹/L (>100 × 10⁹/L if ongoing bleeding)
• Packed Red Blood Cells (PRBC): maintain Hb >8 g/dL in active bleeding; use 1:1:1 ratio (PRBC:FFP:platelets) in massive transfusion
• Calcium gluconate: 10 mL of 10% solution IV — for hypocalcaemia from massive transfusion (citrate toxicity)
• Recombinant Factor VIIa (rFVIIa/NovoSeven): last resort in refractory coagulopathy

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9. SURGICAL MANAGEMENT (Stepwise)

1. Intrauterine Balloon Tamponade

• Bakri balloon (500 mL capacity) — specifically designed for uterine tamponade
• Sengstaken-Blakemore tube (adapted), Foley catheter (less effective)
• Insert, inflate with 250–500 mL saline, apply gentle traction
• "Tamponade test": if bleeding stops after inflation → surgical exploration may be deferred
• Leave in situ for 12–24 hours

2. Uterine Compression Sutures

• B-Lynch suture (1997): brace suture placed over uterus to mimic bimanual compression; uses #1 or #2 absorbable suture (e.g., Vicryl/PDS)
• Hayman suture: simpler, parallel vertical sutures through full thickness of uterus
• Cho suture: square sutures for localised bleeding (e.g., lower segment)
• Preserve uterus; future fertility possible

3. Uterine Devascularisation

• Uterine artery ligation (O'Leary suture): bilateral ligation of uterine arteries at the level of lower uterine segment; reduces uterine blood flow by ~90%
• Utero-ovarian ligament ligation
• Internal iliac (hypogastric) artery ligation: technically demanding; reduces pulse pressure; reduces blood flow by 48%

4. Interventional Radiology

• Uterine artery embolisation (UAE): highly effective (85–95% success); fertility-preserving; requires haemodynamic stability and interventional radiology availability
• Bilateral embolisation under fluoroscopy

5. Peripartum Hysterectomy

• Last resort — definitive management when all else fails
• Subtotal (supracervical) hysterectomy is faster and preferred in emergency
• Total hysterectomy if bleeding from cervical/lower segment (e.g., accreta, cervical tear)
• Complications: bladder/ureter injury (especially in emergency setting), infection, thrombosis

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10. SPECIAL SITUATIONS

Uterine Inversion

• Degrees: 1st (fundus inverts, not beyond cervix) → 4th (uterus inverted and outside vagina)
• Do NOT remove placenta before replacing uterus
• Johnson's manoeuvre: push fundus back through cervical ring with fist
• Hydrostatic method (O'Sullivan): 3–5 L warm saline infused into posterior fornix (seal vulva with hand)
• If manual replacement fails → Huntington's (laparotomy) or Haultain's procedure

Amniotic Fluid Embolism (AFE)

• Sudden cardiovascular collapse + DIC after delivery
• Triad: hypoxia, hypotension, coagulopathy
• Supportive management; treat DIC aggressively

Abnormal Placentation (Accreta Spectrum)

• Risk factors: prior CS, placenta praevia, prior uterine surgery
• Diagnosed antenatally by USS (loss of retroplacental clear zone, placental lacunae) ± MRI
• Management: planned caesarean hysterectomy at 34–36 weeks at a centre with multidisciplinary team (obstetrics, urology, vascular, blood bank, IR)

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11. HAEMOSTASIS MNEMONIC

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12. BLOOD TRANSFUSION IN PPH

1. Hypothermia (<35°C)
2. Acidosis (pH <7.35)
3. Coagulopathy

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13. MONITORING & DOCUMENTATION

• Vital signs every 5 minutes during active PPH
• Urine output (target ≥30 mL/hr)
• Blood loss estimation: weigh swabs/pads (1 g = 1 mL), calibrated drapes, pictorial estimation charts
• Serial labs: FBC, coagulation, fibrinogen, ABG, lactate, ionised calcium every 30–60 minutes in active bleeding
• Maintain a PPH trolley/kit in every labour ward

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14. SECONDARY PPH

• Definition: excessive uterine bleeding 24 hours to 12 weeks postpartum (peak at 1–2 weeks)
• Causes: sub-involution of placental bed, retained RPOC, endometritis, gestational trophoblastic disease
• Assessment: USS (RPOC), endometrial swab (culture), beta-hCG
• Management:
  • Antibiotics (amoxicillin-clavulanate or co-amoxiclav ± metronidazole)
  • Uterine evacuation under USS guidance (increased risk of perforation)
  • Uterotonics (misoprostol/ergometrine)
  • Hysteroscopy if conservative management fails

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15. KEY TRIALS & EVIDENCE

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16. QUICK SUMMARY ALGORITHM

Delivery → Assess blood loss
     ↓
Blood loss ≥500 mL (vaginal) / ≥1000 mL (CS)
     ↓
CALL FOR HELP | IV access ×2 | Labs | Oxygen | Catheter
     ↓
IDENTIFY CAUSE — 4Ts
     ↓
TONE?
  → Bimanual compression + Oxytocin → Ergometrine → Carboprost → Misoprostol + TXA
     ↓ (if failing)
  → Balloon tamponade → B-Lynch suture → Devascularisation → UAE → Hysterectomy
     ↓
TRAUMA? → Repair lacerations/tears | Explore uterus
TISSUE?  → Manual removal of placenta | Curettage
THROMBIN? → FFP + Cryoprecipitate + Platelets + Calcium

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KEY POINTS TO REMEMBER

• Most PPH is preventable — AMTSL is the single most effective intervention
• Don't underestimate blood loss — clinical estimation is 30–50% inaccurate
• Act early, escalate quickly — delay is the most common cause of death
• TXA within 3 hours — do not forget; it saves lives
• Maintain the "warm, alkaline, normocoagulable" patient — prevent the lethal triad
• Balloon tamponade test before proceeding to open surgery where appropriate
• PAS disorders require planned, multidisciplinary management — never attempt manual removal of a suspected accreta placenta without preparation

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