Postpartum Hemorrhage Study Guide

Postpartum Hemorrhage (PPH)

• PPH is a leading cause of maternal mortality, especially in developing countries.
• Defined as excessive bleeding from the genital tract:

  • 500ml after vaginal delivery

  • 1000ml after cesarean section

  • Any bleeding affecting the mother's condition after delivery, regardless of the amount.

Causes of PPH

• Uterine Atony (80%): The most common cause.
  • Myometrial contraction (occlusion of uterine blood vessels) is impaired.
  • Factors contributing to uterine atony include prolonged labor, excessive uterine distension, weakened uterine musculature (fibroids, anemia, malnutrition, etc.), grand multiparity, full bladder, fear, pain, antepartum hemorrhage, anesthesia or sedatives, and shock.
• Extra-Uterine: Traumatic bleeding (e.g., lacerations).
• Blood Clotting Defects: Hypofibrinogenemia/DIC (associated with obstetric disorders like placental abruption, retained dead fetus, amniotic fluid embolism, severe pre-eclampsia, and sepsis).

Classification of PPH

• Third Stage Hemorrhage: Occurs during or before placental expulsion.
  • Causes: Traumatic (lacerations), or placental issues (partial separation/retained placenta).
    • Partial separation: poor third stage management, uterine inertia, placental anomalies (accreta, succenturiata).
    • Complete retention: poor third stage management, uterine inertia, unconscious patient, membrane adhesions.
  • Diagnosis: Flabby uterus, trickle of blood, soft/hard fundus (depending on cause), boggy suprapubic region (membrane adhesions).
  • Management: Bladder emptying, blood replacement, oxytocin, uterine massage/manual placental removal.
• True Postpartum Hemorrhage: Occurs after placental expulsion within 24 hours.
  • Primary PPH: Within first 24 hours.
  • Secondary PPH: After 24 hours.

Causes of Primary PPH

• Uterine Atony:
• Mechanical Interference: Retained placenta/membranes, placenta succenturiata.
• Trauma: Genital tract lacerations.
• Coagulation Defects: Acquired or congenital.

Clinical picture of PPH (general signs of excessive blood loss):

• Thirst, dyspnea, restlessness, rapid pulse, subnormal temp, low blood pressure, sweating, tachypnea, pallor, sunken eyes, dimness of vision, fainting, or coma.

Complications of PPH

• Hemorrhagic shock
• Puerperal anemia
• Puerperal sepsis
• Venous thrombosis and pulmonary embolism
• Sheehan's syndrome (pituitary damage)
• Recurrence in subsequent pregnancies

Prevention of PPH

• Identify and manage high-risk patients:
  • Anemia, nutritional deficiencies, uterine over-distention, multiparity, fibroids, previous PPH, antepartum hemorrhage, IUFD, PIH, diabetes, etc.
  • Active management of third stage of labor & fourth stage (first 2 hours postpartum). Essential to avoid uterine atony.
• Necessary routine measures: blood grouping/typing, hospital deliveries.
• Proper management of labor stages: avoid prolonged labor, trauma, bladder issues.

Management of PPH (Atonic)

• Resuscitative measures: fluid/plasma replacement, monitoring
• Control bleeding measures:
  • Inspect placenta (completeness), catheterization.
  • Massage uterus.
  • Oxytocics (IV/infusion).
  • Explore genital tract and uterus for lacerations/retained tissue, and remove clots.
  • Bimanual uterine compression.
  • Uterine packing (controversial).
  • Surgical measures (ligation/hysterectomy).

Traumatic PPH

• Predisposing factors: instrumental delivery, malposition/presentation, excessive manipulation, large fetus.
• Sites of trauma: cervix, vagina, vulva.
• Management: stitches/packing based on site.

Secondary PPH

• Bleeding after 24 hours.
• Causes: retained placental parts, subinvolution, inversion, estrogen withdrawal, sloughing tissue, new growths.
• Diagnosis: Variable bleeding, subinvolution, sepsis, speculum/bimanual exam, ultrasound.
• Management: general treatment, removal of retained tissue, ligation if needed, biopsy.

Nursing Management of PPH

• Assessment: risk factors, vital signs, bleeding characteristics, amount, lab work.
• Interventions (atony): inform physician, assess uterine tone, massage uterus, observe mother, administer oxytocics, bladder emptying, placenta examination, reassurance.
• Interventions (trauma): pressure to site, assessment, equipment preparation, intervention (stitches).