• Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice
• Berek & Novak's Gynecology

Postpartum Hemorrhage (PPH) - as per DC Dutta's Textbook of Obstetrics

Definition

• Traditional definition: Blood loss ≥500 mL within 24 hours of delivery (vaginal or cesarean)
• Practical/clinical definition (Dutta): Any bleeding from the genital tract following delivery of the baby that adversely affects the general condition of the patient (pulse, BP)
• Primary PPH: Within 24 hours of delivery
• Secondary PPH: Between 24 hours and 6 weeks postpartum

Incidence

• Occurs in approximately 2-4% of vaginal deliveries
• Leading cause of maternal mortality, especially in developing countries
• Accounts for 25-30% of all maternal deaths globally

Etiology - The "4 T's"

Causes in Detail

1. Uterine Atony (Most Common ~70%)

• Over-distension: polyhydramnios, multiple pregnancy, macrosomia
• Over-worked: prolonged/obstructed labor
• Over-relaxed: general anesthesia, MgSO4, tocolytics
• Multiparity (grandmultipara)
• Placenta previa (lower segment poorly contracts)
• Fibromyoma (interferes with uterine retraction)
• Full urinary bladder
• Intrauterine infection (chorioamnionitis)
• Mismanaged 3rd stage

2. Retained Placenta / Membranes

• Partial separation with retained cotyledons
• Placenta accreta / increta / percreta
• Succenturiate lobe retention

3. Genital Tract Trauma

• Cervical tears (especially with precipitate/instrumental delivery)
• Vaginal tears, perineal tears
• Uterine rupture
• Broad ligament hematoma
• Uterine inversion

4. Coagulation Failure

• Pre-existing: ITP, von Willebrand's disease, hemophilia
• Acquired: placental abruption, IUFD, AFE, severe pre-eclampsia leading to DIC

Clinical Features

Signs of PPH:

• Excessive vaginal bleeding (overt) OR
• Patient in shock without visible external bleeding (concealed/internal)
• Uterus: Boggy, flabby, not felt per abdomen (atony)
• Tachycardia, hypotension, pallor, cold clammy skin
• Syncope, oliguria in severe cases

Diagnosis

1. Feel the uterus - tone? Contracted or boggy?
2. Inspect the placenta and membranes - complete?
3. Inspect the cervix and vagina - any lacerations?
4. Check coagulation - clotting at bedside (blood fails to clot in 7-10 min = DIC)

Management

Principle: Resuscitate + Find Cause + Treat Cause Simultaneously

Step 1: Immediate Resuscitation (CALL FOR HELP)

• Call senior obstetrician, anesthetist, blood bank
• 2 wide-bore IV cannulas
• Rapid IV crystalloid (Normal saline/Ringer's lactate)
• Blood for CBC, coagulation profile, group & cross-match
• Foley catheter - empty bladder, monitor urine output
• Oxygen by mask
• Prepare blood / FFP / platelets

Step 2: Management of Uterine Atony

A. Bimanual Uterine Compression and Massage

• Most immediate step
• One hand in vagina (anterior fornix), other hand over fundus abdominally
• Compress uterus between both hands
• Continued until uterus contracts

B. Uterotonic Drugs (Dutta's sequence)

Step 3: If Bleeding Persists - Surgical / Interventional Options

Intrauterine Balloon Tamponade

• Bakri balloon or condom catheter (Condom Tamponade - affordable option described by Dutta for resource-poor settings)
• Filled with 300-500 mL saline
• "Positive tamponade test" = bleeding stops after balloon inflation (avoids surgery)

Compression Sutures

• B-Lynch suture: Brace suture applied to compress the uterus like a brace; uterus-conserving
• Hayman suture: Simpler vertical compression sutures

Stepwise Devascularization

1. Bilateral uterine artery ligation (O'Leary's stitch)
2. Bilateral utero-ovarian artery ligation
3. Bilateral internal iliac (hypogastric) artery ligation

Uterine Artery Embolization

• Interventional radiology; preserves fertility
• Requires facility availability

Peripartum Hysterectomy (Last Resort)

• Life-saving procedure
• Subtotal hysterectomy preferred (faster)
• Done when all conservative measures fail

Step 4: Retained Placenta Management

• Manual removal of placenta under GA/spinal
• Oxytocics given after removal
• Placenta accreta: may need hysterectomy

Step 5: Genital Tract Trauma

• Repair lacerations under adequate anesthesia
• Systematic inspection: cervix → vagina → perineum

Step 6: Coagulopathy

• DIC: Fresh Whole Blood / FFP / Cryoprecipitate / Platelet transfusion
• Treat underlying cause (e.g., retained dead fetus, abruption)

Prevention of PPH

1. Oxytocin 10 IU IM within 1 minute of baby's birth (drug of choice)
2. Controlled cord traction (CCT) - Brandt-Andrews maneuver
3. Uterine massage after placenta delivery

• Correct anemia in antenatal period
• Identify and correct risk factors antenatally
• Conduct deliveries in facilities with blood bank
• Skilled birth attendants for all deliveries

Secondary PPH

• Occurs 24 hours to 6 weeks after delivery
• Causes: Sub-involution of placental site, retained placental fragments, uterine infection (endometritis)
• Management: Antibiotics + Ergometrine + if retained products - evacuation under ultrasound guidance

Key Dutta Points to Remember

1. Uterine atony = 70% of PPH cases - always rule out first
2. AMTSL reduces PPH by 60% - must be done routinely
3. Bimanual compression is the most immediate mechanical measure
4. Oxytocin IV drip (not bolus) is drug of choice
5. Ergometrine is contraindicated in hypertension
6. Carboprost is contraindicated in asthma
7. Tranexamic acid should be given early (within 3 hours)
8. Condom catheter tamponade is a cost-effective alternative to Bakri balloon
9. Peripartum hysterectomy = last resort, life-saving

Note: DC Dutta's Textbook of Obstetrics is not available in our institutional library database, so the above is synthesized from my training knowledge of Dutta's content. The core content is well-established and consistent across editions. For exam preparation, always verify drug doses and contraindications against your own edition of Dutta (currently 9th edition by Hiralal Konar).