This document defines and describes postpartum hemorrhage (PPH). PPH is bleeding after childbirth within 24 hours (primary) or anytime after 24 hours (secondary). Primary PPH is blood loss over 500ml vaginally or 1000ml for c-section. The main causes are atonic PPH from the uterus failing to contract (90% of cases), traumatic due to birth injuries, coagulopathy, and retained placenta. Risk factors include prior PPH, macrosomia, and prolonged labor. Prevention focuses on risk assessment, monitoring for complete placenta removal, and having protocols for rapid response to hemorrhage. Secondary PPH can be caused by infection, retained fragments, or uterine inc

1. POSTPARTUM
HEMORRHAGE

2. DEFINITION
 Hemorrhage occurring after the
delivery of the baby
 Hemorrhage occurring within 24
hours of delivery – Primary
postpartum hemorrhage
 Hemorrhage occurring anytime
after 24 hours of delivery- Secondary
postpartum hemorrhage

3. PRIMARY POSTPARTUM HEMORRHAGE
 Blood loss of more than 500ml from the genital
tract in the first 24 hours of childbirth.
 For caesarean section, a blood loss more than
1000ml is considered significant.
Incidence of about 5% of all deliveries.
 A more practical definition is a haematocrit drop of
10% or a hemorrhage that requires immediate
transfusion.

4. CAUSES
1 . Atonic postpartum hemorrhage
2 . Traumatic postpartum hemorrhage
3 . Coagulopathy
4 . Retained placenta and placental fragments
5 . Morbidly adherent placenta
6 . Uterine inversion

5. ATONIC POSTPARTUM HEMORRHAGE
 Most common cause (90%)
 Bleeding occurs because the blood vessels have
not been obliterated by contraction and
retraction of the uterine muscle fibres.

6. PREDISPOSING FACTORS
 Grand multiparity
 Over distended uterus due to multiple
pregnancy hydramnios or macrosomia
 Previous history of postpartum hemorrhage
 Antepartum hemorrhage
 Fibroids of uterus
 General malnutrition
 Prolonged labour leading to uterine exhustion
 Precipitate labour

7. TRAUMATIC POSTPARTUM
HEMORRHAGE
 It occurs due to genital tract injuries.
 Include lacerations of the cervix , vagina and
perineum
 Vulvovaginal hematomas may be a concealed
cause

8. PREDISPOSING FACTORS
 Instrumental delivery
 Vaginal birth after caesarian
 Face to pubis delivery
 Precipitate labour
 Macrosomia

9. COAGULOPATHY
 Disseminated intravascular coagulation and
hypofibrinogenemia should be considered in all
patients at high risk for coagulopathy.
PREDISPOSING FACTORS
• Abruption
• Sepsis
• Intrauterine death
• Amniotic fluid embolism

10. PREVENTION OF PPH
 Anemia should be corrected in the antenatal
period.
 In high risk patients PPH should be anticipated
and institutional delivery should be arranged.
 Blood should be arranged in high risk patients
 Use of partogram during labour will help to
avoid prolonged labour.
 Dehydration should be promptly corrected
 Premature attempts to express a placenta that
has not yet seperated are to be avoided.

11.  After delivery completeness of placenta is
checked for.
 The genital tract should be exposed in case of
instrumental delivery.
 Oxytocin infusion can be continued and vital
signs monitored closely
 Every hospital should have a protocol for
managing PPH

12. SECONDARY POSTPARTUM
HEMORRHAGE
• Hemorrhage occurring after the first 24 hours of
delivery and within 6 weeks
AETIOLOGY
• Sepsis
• Retained placental fragments
• Poor healing of the uterine incisions in previous
caesarian section.
• Choriocarcinoma

13. SHEEHAN SYNDROME
• Described by Sheehan and colleagues in 1983
• Rare consequence of severe PPH
• There is anterior pituitary necrosis and pituitary
failure
• There is failure of lactation, amenorrhoea,
hypothyroidism and adrenocorticalinsufficiency.