{"id":527,"date":"2026-05-08T19:44:25","date_gmt":"2026-05-08T19:44:25","guid":{"rendered":"https:\/\/mayhospitalshendam.com\/?p=527"},"modified":"2026-05-08T19:48:52","modified_gmt":"2026-05-08T19:48:52","slug":"management-of-postpartum-haemorrhage","status":"publish","type":"post","link":"https:\/\/mayhospitalshendam.com\/?p=527","title":{"rendered":"Management Of Postpartum Haemorrhage"},"content":{"rendered":"

Management Of Postpartum Haemorrhage<\/h1>\n
BY<\/b><\/em>\r\n\r\nDR AKPAN, UDORIMA    <\/b><\/em><\/pre>\n
INTRODUCTION<\/em><\/h4>\n
DEFINITIONS<\/em><\/h4>\n
PHYSIOLOGY OF THIRD STAGE OF LABOUR<\/em><\/h4>\n
ASSESSMENT OF BLOOD LOSS AT DELIVERY<\/em><\/h4>\n
CAUSES OF PRIMARY & SECONDARY PPH<\/em><\/h4>\n
CLINICAL FEATURES<\/em><\/h4>\n
TREATMENT<\/em><\/h4>\n
\u00a0COMPLICATIONS<\/em><\/h4>\n
PREVENTIVE MEASURES<\/em><\/h4>\n
REFERENCES<\/em><\/h4>\n
CONCLUSION<\/em><\/h4>\n
INTRODUCTION<\/b><\/h2>\n
Obstetric Haemorrhage ranks as the\u00a0 leading cause of maternal mortality accounting for approx. 25% of maternal deaths.<\/p>\n
POSTPARTUM HAEMORRHAGE though preventable, accounts for\u00a0 the majority of the cases of obstetric haemorrhage 20-50%.<\/p>\n
PPH is the most common and severe type of obstetric haemorrhage.<\/p>\n
It is an enigma(difficult to understand) even to the present day Obstetrician as it is sudden, often unpredicted, assessed subjectively and can be catastrophic.<\/p>\n
Risk of Maternal Mortality & Morbidity are 50 times more after PPH<\/p>\n
Accounts for approximately 25% of all maternal deaths.<\/p>\n
110000 maternal deaths per year are due to PPH<\/p>\n
Nigeria accounts for about 23% of global maternal morbidity burden<\/p>\n
DEFINITIONS & TYPES<\/h2>\n
Defined as bleeding from the genital tract in excess of 500mls after vaginal delivery (WHO 2012) or 1000mls after Caesarean delivery, a decrease of 10% or more in haematocrit (ACOG) between admission and postpartum period or any blood loss enough to cause cardiovascular instability<\/p>\n
>1500ml caesarean hysterectomy.<\/p>\n
Essentially 2 types of PPH.<\/p>\n
    \n
  • PRIMARY PPH: Occurs within the first 24 hours of delivery : Most common<\/li>\n
  • SECONDARY PPH Occurs after 24 hours to the end of 6 weeks after delivery<\/li>\n<\/ul>\n
    ASSESSMENT OF BLOOD LOSS AFTER DELIVERY<\/b><\/h2>\n
    Difficult<\/p>\n
    Mostly by Visual estimation (Subjective & Inaccurate)<\/p>\n
    Under-estimation very much likely<\/p>\n
    Clinical picture \u2013 Often manifest late & can be misleading<\/p>\n
    Our Mothers – Malnourished, Anaemic, Small built, Less blood volume.<\/p>\n
    MECHANISM OF HAEMOSTASIS AFTER DELIVERY<\/h2>\n
    Uterine contraction & retraction\u00a0 \u00a0 \u00a0 \u00a0 \u00a0\"\"\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Occlusion of the sinuses<\/p>\n
    Platelet aggregation\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \"\"\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Clots formation<\/p>\n
      \n
    • Shortest stage, but carries great risk.<\/li>\n
    • During pregnancy, myometrial fibres are stretched to accommodate fetus.<\/li>\n
    • After delivery, uterus undergoes contraction and retraction.<\/li>\n
    • Contraction is a temporary reduction in length of the fibers, which attain their full-length during relaxation. In contrast, retraction results in permanent shortening of the fibers once and for all.<\/li>\n
    • This culminates in reduction of the surface area of the uterus favoring separation of placenta and effective hemostasis after the separation of the placenta (PHYSIOLOGICAL SUTURE OR LIVING LIGATURE).<\/b><\/li>\n<\/ul>\n
      PHYSIOLOGY OF THIRD STAGE<\/b><\/h2>\n
      \"\"<\/p>\n
      LIVING LIGATURE<\/h2>\n
      \"\"<\/p>\n
      CAUSES OF PRIMARY PPH<\/h2>\n
      4 Ts plus uterine inversion<\/b><\/p>\n
        \n
      • Tone<\/b>:\u00a0 (Atonic uterus)<\/li>\n<\/ul>\n
        Most common cause, up to 80% Polyhydramnios; AF>1500-2000ml or AFI 24-35cm or SDP >\/=8-16cm, Fetal macrosomia, Multiple gestation, Co-existing Uterine mass, Previous history of uterine atony, Grandmultiparity, Prolonged\/Precipitate labour, oxytocin driven labour, Halogenated Anaesthetic agents,, Tocolytics use, History of APH, Full bladder etc<\/p>\n
          \n
        • Tissue<\/b>: (Retained products of conception)<\/li>\n<\/ul>\n
            \n
          1. Accounts for about 10%<\/li>\n
          2. Simple adhesion<\/li>\n
          3. Morbid adhesion – Accreta, Increta & Percreta<\/li>\n<\/ol>\n
              \n
            • Trauma<\/b>: Genital tract trauma<\/li>\n<\/ul>\n
              Forms about 20% Genital lacerations\/tears, Large episiotomy & extensions, Haematoma<\/p>\n
                \n
              • Thrombin<\/b>: Coagulopathy, e.g. DIC Less than 1% – Consumptive coagulopathy (Abruptio placentae, Sepsis from IUFD & PPROM, Massive blood loss, Massive blood transfusion, Preeclampsia with Severe features\/Eclampsia, Amniotic fluid embolism, Hepatitis<\/li>\n<\/ul>\n
                COMMON CAUSES OF SECONDARY PPH<\/b><\/h2>\n
                  \n
                1. Retention of placenta tissue<\/li>\n
                2. Endometritis<\/li>\n
                3. Delayed placental bed involution<\/li>\n<\/ol>\n
                  Other less common etiologies:<\/p>\n
                    \n
                  • Congenital coagulopathies<\/li>\n
                  • Submucous fibroids,<\/li>\n
                  • Adherent Placenta<\/li>\n
                  • Ceaesarean scar dehiscence<\/li>\n
                  • Ruptured uterine pseudoaneurysm<\/li>\n<\/ul>\n
                    CLINICAL FINDING IN PPH: DEGREE OF SHOCK<\/h2>\n
                    \"\"<\/p>\n
                    \"\"<\/p>\n
                    MANAGEMENT<\/h2>\n
                      \n
                    1. It is a dire obstetric emergency and needs to be managed as such.<\/li>\n
                    2. Rapid, Aggressive, Timely, collaborative<\/u> and Skilled interventions are critical for survival.<\/li>\n
                    3. \u201cGolden hour\u201d<\/li>\n
                    4. Call for help<\/li>\n
                    5. Multidiciplinary<\/li>\n<\/ol>\n
                        \n
                      • Obstetrician<\/li>\n
                      • Anaesthetist<\/li>\n
                      • Haematologist\/Lab scientists<\/li>\n
                      • Midwives\/nurses<\/li>\n
                      • **Interventional radiologists<\/i><\/li>\n
                      • Other support staff<\/li>\n<\/ul>\n
                        \"\"<\/p>\n
                        \"\"<\/p>\n
                        Ensure ABC of resuscitation for pts in shock.<\/p>\n
                        Establish two IV access (wide bore cannula)<\/p>\n
                        Obtain investigations (FBC, PCV, Electrolytes, Grouping and cross matching, Clotting profile)<\/p>\n
                        IV fluids, preferably, warm crystalloids<\/p>\n
                        Catheterize patient<\/p>\n
                        Rub for contraction<\/p>\n
                        Quickly Inspect placenta\/ Genital Exploration<\/p>\n
                        Uterotonic agents<\/p>\n
                          \n
                        • Oxytocin<\/li>\n
                        • Ergometrine( NOT TO BE USED IN PTS WITH HYPERTENSION)<\/li>\n
                        • Misoprostol<\/li>\n
                        • Syntometrine<\/li>\n
                        • Carbetocin<\/li>\n
                        • Carboprost (Prostaglandin F2 alpha)<\/li>\n<\/ul>\n
                          Tranexamic acid<\/p>\n
                          Blood and blood products<\/p>\n
                            \n
                          • Fresh whole blood(Oneg)<\/li>\n
                          • Fresh frozen plasma<\/li>\n
                          • Cryoprecipitate<\/li>\n
                          • Platelet concentrate<\/li>\n<\/ul>\n
                            MANAGEMENT OF ATONY<\/h2>\n
                              \n
                            1. Ensure bladder is empty;<\/li>\n
                            2. Massage uterus for contraction;<\/li>\n
                            3. Administer oxytocin 10 IU bolus\/other uterotonics and relevant medication<\/li>\n
                            4. Commence oxytocin infusion<\/li>\n
                            5. Do manual compression of the uterus if not well contracted;<\/li>\n
                            6. External aortic compression<\/li>\n<\/ol>\n
                              \"\"<\/p>\n
                              EXTERNAL AORTIC COMPRESSION<\/h2>\n
                              \"\"<\/p>\n
                              TAMPONADE<\/h2>\n
                              Tamponade with specialized catheters<\/p>\n
                                \n
                              • Bakri<\/li>\n
                              • Rusch<\/li>\n
                              • Sengstaken blake more<\/li>\n
                              • Improvised condom\/foleys catheter (resource poor settings)<\/li>\n<\/ul>\n
                                Commercially Available Balloon Tamponades in Use<\/h2>\n
                                \"\"<\/p>\n
                                THE CONDOM \/FOLEY’S CATHETER TAMPONADE<\/h2>\n
                                \"\"<\/p>\n
                                \"\"<\/p>\n
                                SURGICAL APPROACH<\/h2>\n
                                Uterine compression sutures; B- Lynch<\/p>\n
                                Ligation of vessels : Systematic Pelvic Devascularization; (Uterine artery ligation, Ovarian artery ligation, Internal iliac artery ligation)<\/p>\n
                                Arterial embolization<\/i><\/p>\n
                                Hysterectomy<\/p>\n
                                  \n
                                • Early recourse to hysterectomy<\/li>\n<\/ul>\n
                                  \"\"<\/p>\n
                                  \"\"<\/p>\n
                                  \"\"<\/p>\n
                                  MANAGEMENT OF TISSUE<\/h2>\n
                                    \n
                                  • Deliver the placenta and membranes by controlled cord traction or manual removal if retained;<\/li>\n
                                  • If membranes are retained do manual vacuum aspiration.<\/li>\n
                                  • If it\u2019s morbidly adherent placenta either: administer methotrexate or hysterectomy.<\/li>\n
                                  • Give broad spectrum antibiotics.<\/li>\n
                                  • Transfuse as appropriate<\/li>\n<\/ul>\n
                                    MANAGEMENT OF TRAUMA<\/h2>\n
                                      \n
                                    • Episiotomy repair<\/li>\n
                                    • Perineal\/vaginal tear repair<\/li>\n
                                    • Cervical laceration repair<\/li>\n
                                    • Uterine repair\/Hysterectomy<\/li>\n<\/ul>\n
                                      MANAGEMENT OF THROMBIN<\/h2>\n
                                        \n
                                      • Multidisciplinary<\/li>\n
                                      • Haematologist<\/li>\n
                                      • Anaesthetist\/Intensivist<\/li>\n
                                      • Treat underlying cause<\/li>\n
                                      • Give appropriate blood products<\/li>\n<\/ul>\n
                                        \"\"<\/p>\n
                                        NON PNEUMATIC ANTI-SHOCK GARMENT<\/b><\/h2>\n
                                        \"\"<\/p>\n
                                        \"\"<\/p>\n
                                        TREATMENT OF PPH\u00a0 UTERINE INVERSION<\/b>\"\"<\/h2>\n
                                        Manual replacement <\/b>–<\/p>\n
                                        – Under GA\/Uterine relaxant \u2013 Tocolytics (terbutaline, nitroglycerin, MgSO4)<\/p>\n
                                        – Oxytocin infusion post-replacement<\/p>\n
                                        Placenta adherent, LEAVE IN SITU, attempt to deliver may cause MASSIVE HAEMORRHAGE and\/or shock.<\/p>\n
                                        Prompt manually replace the inverted uterus to its normal position.<\/p>\n
                                        A hand inside the vagina and pushing the fundus along the long axis of the vagina toward the umbilicus (Johnson\u2019s Maneuvers).<\/p>\n
                                          \n
                                        • Hydrostatic<\/b> method<\/b><\/li>\n
                                        • Surgical method <\/b>(delayed procedure) Huntington & Haultain procedures<\/li>\n<\/ul>\n
                                          \"\"<\/p>\n
                                          MANAGEMENT OF SECONDARY PPH<\/h2>\n
                                          FEATURES<\/b><\/p>\n
                                            \n
                                          • Bleeding PV<\/li>\n
                                          • Fever<\/li>\n
                                          • Feeling of unwell<\/li>\n
                                          • Uterine subinvolution<\/li>\n
                                          • Abdominal tenderness<\/li>\n
                                          • Offensive vaginal discharge<\/li>\n<\/ul>\n
                                            EVALUATION<\/b><\/p>\n
                                              \n
                                            • Clinical history<\/li>\n
                                            • Examination<\/li>\n
                                            • Investigation<\/li>\n
                                            • FBC<\/li>\n
                                            • HVS MCS<\/li>\n
                                            • Sepsis screening<\/li>\n
                                            • Imaging studies<\/li>\n<\/ul>\n
                                              TREATMENT (underlying cause)<\/b><\/p>\n
                                                \n
                                              • Resuscitation<\/li>\n
                                              • Uterotonics \/Antifibrinolytic may be beneficial<\/li>\n
                                              • Antibiotic cover<\/li>\n
                                              • Evacuation of retained products (requires expertise due to risk of Asherman\u2019s and perforation) – May be done under USS guidance<\/li>\n
                                              • Blood transfusion\/Blood products\/clotting factor concentrates<\/li>\n
                                              • Chemotherapy<\/li>\n
                                              • Arterial embolization<\/li>\n
                                              • Hysterectomy<\/li>\n<\/ul>\n
                                                COMPLICATIONS OF PPH<\/b><\/h2>\n
                                                Early:<\/p>\n
                                                  \n
                                                1. Anemia<\/li>\n
                                                2. Fatigue<\/li>\n
                                                3. Hypovolemic shock<\/li>\n
                                                4. Blood Transfusion Reaction<\/li>\n
                                                5. Acute kidney injury<\/li>\n
                                                6. Myocardial Ischemia<\/li>\n
                                                7. DIC<\/li>\n
                                                8. Death<\/li>\n
                                                9. Hysterectomy:<\/li>\n<\/ol>\n
                                                  Urinary\/ G.I tract injury, Pelvic hematoma, abscess.<\/p>\n
                                                  Late:<\/p>\n
                                                    \n
                                                  1. Uterine synechae<\/li>\n
                                                  2. Sheehan’s syndrome<\/li>\n
                                                  3. Secondary Amennorhea<\/li>\n
                                                  4. Post Partum depression<\/li>\n
                                                  5. Secondary Infertility<\/li>\n<\/ol>\n
                                                    PPH PREVENTIVE MEASURES<\/b><\/h2>\n
                                                    Regular\u00a0 ANC: Identification of high risk cases<\/p>\n
                                                    Skilled Birth Attendants<\/p>\n
                                                    Antepartum correction of anaemia<\/p>\n
                                                    Delivery in hospital with facility for Emergency Obstetric Care.<\/p>\n
                                                    Availability of functional Ambulances to transfer high risk cases to higher level of care facility<\/p>\n
                                                    Local\/Regional anaesthesia in place of halogenated GA, as appropriate<\/p>\n
                                                    Active management of 3rd stage of labour<\/p>\n
                                                    4th Stage of labour – Observation, Oxytocin infusion postpartum (as indicated)<\/p>\n
                                                    RECOMMENDATION<\/h2>\n
                                                      \n
                                                    • Female Education and Empowerment<\/li>\n
                                                    • Doctors should be drilled periodically on management of PPH<\/li>\n
                                                    • Labour ward nurses should also be trained on the importance of holistic care of immediate post partum patient<\/li>\n
                                                    • Primary health centres should be rejuvenated by the government at several levels.<\/li>\n<\/ul>\n
                                                      CONCLUSION<\/b><\/h2>\n
                                                      Everywoman will experience bleeding after delivery but not all have PPH.<\/p>\n
                                                      Prevention, early recognition, prompt and appropriate intervention are key to minimize the ugly trend of PPH<\/p>\n
                                                      REFRENCES<\/h2>\n
                                                      1.Slide on Management of Post Partum Haemorrhage by Dr Archiving consultant obstetrician )<\/p>\n
                                                      2.Update slide on Trend on Management\u00a0 of post partum haemorrhage\u00a0 by Prof John Mulbah, Dr Kingsley Onaji<\/p>\n
                                                      3.Ben- Charlotte video on thmangeagement of post partum haemorrhage<\/p>\n
                                                      4.Comprehensive\u00a0 Obstetrics\u00a0 In The Tropics Textbook (second edition)<\/p>\n
                                                      5.Basic Steps\u00a0 in Obstetrics & Gynaecological Procedures\u00a0 Textbook\u00a0 by O.L. Lavant et. al; 2017<\/p>\n
                                                      6.OBGYN STEP BY STEP; A Concise guide to cases and procedures in Obstetrics And\u00a0 Gynaecology\u00a0 by O.U.j Umeora et. al.<\/p>\n
                                                      7.https:\/\/www.who.int\/news\/item\/09-05-2023-lifesaving-solution-dramatically-reduces-severe-bleeding-after-childbirth<\/p>\n
                                                      \"\"Causes<\/b> of PPH<\/b><\/p>\n
                                                       <\/p>\n
                                                       <\/p>\n","protected":false},"excerpt":{"rendered":"
                                                      Management Of Postpartum Haemorrhage BY DR AKPAN, UDORIMA INTRODUCTION DEFINITIONS PHYSIOLOGY OF THIRD STAGE OF LABOUR…<\/p>\n","protected":false},"author":2,"featured_media":520,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"nf_dc_page":"","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[38,1],"tags":[],"class_list":["post-527","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-journal","category-uncategorized"],"yoast_head":"\nManagement Of Postpartum Haemorrhage - May Hospital, Shendam<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/mayhospitalshendam.com\/?p=527\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Management Of Postpartum Haemorrhage - 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