What is Postpartum Hemorrhage (PPH)?
Postpartum hemorrhage (PPH) is a significant obstetric emergency characterized by excessive bleeding following childbirth. It remains one of the leading causes of maternal morbidity and mortality worldwide, especially in low-resource settings.
.jpg "Postpartum Hemorrhage (PPH) - Hemorrhage After Childbirth")
Table of Contents
Definition of Postpartum Hemorrhage
PPH is traditionally defined as the loss of 500 mL or more of blood after vaginal delivery or 1000 mL or more after cesarean section within the first 24 hours postpartum. However, some experts advocate using clinical signs of hypovolemia and hemodynamic instability rather than an absolute blood volume because blood loss can be underestimated. PPH is classified into:
🔹 Primary (early) PPH: Occurs within 24 hours of delivery and accounts for most cases. It is typically caused by uterine atony, which is the inability of the uterus to contract after delivery. Uterine atony can be caused by a variety of factors, including prolonged labor, multiple pregnancies, large fetal size, and previous uterine surgery. Other causes of primary PPH include vaginal or cervical lacerations, retained placental tissue, and coagulation disorders.
🔹 Secondary (late) PPH: Occurs between 24 hours and 12 weeks postpartum. It is typically caused by retained placental tissue or infection. Other causes of secondary PPH include uterine subinvolution, cervical or vaginal lacerations, and coagulation disorders.
*PPH can also be defined as any degree of bleeding that places the mother's health or life at risk, regardless of the amount of blood loss.
Additional Articles:
Etiology and Causes of Postpartum Hemorrhage (PPH)
Postpartum hemorrhage (PPH) is caused by a variety of factors that interfere with the normal cessation of bleeding after delivery. The causes are classically summarized by the "Four Ts": Tone, Tissue, Trauma, and Thrombin.
1. Uterine Atony (Tone)
Uterine atony is the most common cause of PPH, responsible for approximately 70-80% of cases. Normally, after the placenta separates, the uterine muscles contract vigorously to compress the blood vessels at the placental site, minimizing bleeding. When the uterus fails to contract adequately—a condition known as uterine atony—these vessels remain open, leading to excessive bleeding.
Risk factors for uterine atony include:
🔹 Overdistension of the uterus: Multiple pregnancies (twins or more), polyhydramnios (excess amniotic fluid), and macrosomia (large babies) stretch the uterus and impair its ability to contract.
🔹 Prolonged labor or rapid labor: Both can exhaust the uterine muscle.
🔹 Use of uterine relaxants: Medications such as magnesium sulfate (used for preeclampsia) or general anesthesia can decrease uterine tone.
🔹 High parity: Women with multiple previous births may have weaker uterine muscles.
🔹 Chorioamnionitis (infection of the fetal membranes): Can impair uterine contractility.
🔹 Retained placenta or parts: Prevents full uterine contraction.
Read more about: Uterine Atony
2. Retained Placenta or Tissue (Tissue)
Failure to expel the entire placenta or fetal membranes after delivery is another important cause of PPH. Retained placental tissue prevents the uterus from contracting fully, keeping blood vessels open and bleeding ongoing.
Types of retained placenta include:
🔹 Placenta accreta spectrum: The placenta abnormally adheres or invades the uterine wall (accreta, increta, percreta), making separation difficult or impossible, causing severe bleeding.
🔹 Trapped placenta: The placenta separates from the uterine wall but is trapped behind a closed cervix.
🔹 Incomplete separation: Only part of the placenta separates, leaving fragments behind.
🔹 Retained tissue is more likely with previous cesarean sections, uterine surgery, or abnormalities of the placenta.
3. Trauma to the Genital Tract (Trauma)
Physical injury to the birth canal—cervix, vagina, vulva, or perineum—can cause significant bleeding postpartum even if the uterus contracts well. Lacerations or tears can result from:
🔹 Instrumental delivery: Use of forceps or vacuum can increase trauma risk.
🔹 Rapid or precipitous labor: Quick delivery increases the chances of tearing.
🔹 Operative vaginal delivery or cesarean section: Surgical incisions or extensions can bleed.
🔹 Episiotomy: Sometimes, extension of the cut can lead to bleeding.
🔹 Large baby or malpresentation: These can cause stretching or tears of soft tissues.
Trauma may be occult and not immediately obvious, so persistent bleeding despite a firm uterus should prompt examination for genital tract injury.
4. Coagulopathy (Thrombin)
Coagulation disorders reduce the blood’s ability to clot properly, causing uncontrolled bleeding even if the uterus contracts and there is no trauma or retained tissue. Coagulopathy may be:
🔹 Pre-existing: Such as hemophilia, von Willebrand disease, or platelet disorders.
🔹 Acquired: Conditions during pregnancy or delivery can cause acquired coagulopathies, including:
🔹 Disseminated intravascular coagulation (DIC): Triggered by placental abruption, severe preeclampsia/eclampsia, amniotic fluid embolism, or sepsis.
🔹 Massive hemorrhage itself: Large blood loss can consume clotting factors (consumption coagulopathy).
🔹 Severe liver disease: Impaired production of clotting factors.
Recognition of coagulopathy is crucial because it may worsen bleeding and requires correction with blood products.
Other Contributing Factors
🔹 Uterine inversion: A Rare but catastrophic condition where the uterus turns inside out, causing severe bleeding and shock.
🔹 Placental abruption: Premature separation of the placenta before delivery, causing bleeding and consumptive coagulopathy.
🔹 Placenta previa: Placenta implanted low over or near the cervical opening, prone to bleeding before or during delivery.
Risk Factors for Postpartum Hemorrhage (PPH)
Postpartum hemorrhage (PPH) can occur unpredictably, but certain risk factors increase the likelihood of its development. Awareness of these risk factors enables healthcare providers to prepare appropriately and manage deliveries with heightened vigilance to reduce maternal morbidity and mortality. The risk factors for PPH broadly relate to those that affect uterine tone, placental abnormalities, delivery complications, and coagulation status.
1. Uterine Overdistension
Conditions that cause excessive stretching of the uterus impair its ability to contract effectively after delivery, increasing the risk of uterine atony and subsequent PPH. These include:
🔹 Multiple pregnancies (twins, triplets, or more)
🔹 Polyhydramnios (excess amniotic fluid)
🔹 Macrosomia (large fetal size, usually >4 kg)
🔹 Long-standing pregnancies (post-term pregnancies) that may result in an enlarged uterus
2. Prolonged or Rapid Labor
Both abnormally prolonged labor and precipitous (very rapid) labor can predispose to PPH. Prolonged labor fatigues the uterine muscles, reducing their contractile ability. Conversely, rapid labor can cause trauma to the birth canal and reduce effective uterine contraction postpartum.
3. Use of Uterine Relaxants and Anesthesia
Certain medications and anesthetic agents can relax the uterus and impair contraction:
🔹 Magnesium sulfate, commonly used in preeclampsia management
🔹 General anesthesia and volatile agents during cesarean section
🔹 Beta-agonists used for tocolysis or preterm labor
4. Previous History of PPH
Women who have experienced PPH in previous pregnancies are at significantly higher risk of recurrence, making thorough antenatal planning and monitoring essential.
5. Placental Abnormalities
Conditions involving the placenta increase the risk of PPH:
🔹 Placenta previa (placenta covering or close to the cervical os) often causes bleeding during labor or delivery.
🔹 Placenta accreta spectrum disorders (abnormal invasion into the uterine wall) are associated with severe hemorrhage due to difficulty in placental separation.
🔹 Retained placenta or fragments increase bleeding risk by preventing uterine contraction.
6. Operative and Instrumental Delivery
Use of instruments such as forceps or vacuum extraction can cause trauma to the birth canal. Cesarean sections also carry an increased risk of PPH due to surgical incision and potential uterine atony.
7. Coagulation Disorders
Both pre-existing and acquired coagulation disorders increase the risk of uncontrolled bleeding postpartum. Conditions such as:
🔹 Inherited bleeding disorders (e.g., von Willebrand disease, hemophilia carrier status)
🔹 Disseminated intravascular coagulation (DIC) from placental abruption or sepsis
🔹 Severe preeclampsia or HELLP syndrome
8. Maternal Factors
Certain maternal characteristics are linked with increased PPH risk:
🔹 High maternal age (>35 years)
🔹 High parity (more than 4 previous births)
🔹 Anemia during pregnancy, which reduces the physiological reserve to tolerate blood loss
🔹 Obesity, which may complicate delivery and surgical access
9. Other Factors
🔹 Prolonged use of oxytocin for labor induction or augmentation can lead to receptor desensitization and uterine atony.
🔹 Chorioamnionitis or intrauterine infection can impair uterine contractility.
🔹 Manual removal of the placenta, which may cause trauma and bleeding.
Recognizing these risk factors enables clinicians to stratify risk, plan delivery in an adequately equipped setting, and prepare preventive strategies such as active management of the third stage of labor and availability of uterotonics and blood products. Despite these factors, PPH can still occur unpredictably, so vigilance during the postpartum period is always crucial.(alert-passed)
Clinical Scoring System for Predicting Risk of Postpartum Hemorrhage (PPH)
| Risk Factor | Points |
|---|---|
| Previous history of PPH | 3 |
| Multiple pregnancy | 2 |
| Placenta previa or low-lying placenta | 3 |
| Macrosomia (estimated fetal weight >4 kg) | 2 |
| Prolonged labor (>12 hours) | 1 |
| Rapid labor (<3 hours) | 1 |
| Induction or augmentation with oxytocin | 1 |
| Instrumental delivery (forceps/vacuum) | 2 |
| Cesarean section | 2 |
| Uterine overdistension (polyhydramnios, large baby, multiple gestation) | 2 |
| Maternal anemia (Hb <10 g/dL) | 1 |
| Maternal age >35 years | 1 |
| Coagulopathy or bleeding disorder | 3 |
| Chorioamnionitis/infection | 1 |
Risk Stratification Based on Total Score
| Total Score | Risk Level | Clinical Implication |
|---|---|---|
| 0–2 | Low Risk | Routine care and monitoring |
| 3–5 | Moderate Risk | Increased vigilance, prepare uterotonics, and IV access |
| ≥6 | High Risk | Plan delivery in a well-equipped facility with blood products ready, and consider prophylactic interventions |
Notes for Use
🔹 This scoring system is a guideline and should be adapted to local clinical settings.
🔹 Some risk factors (e.g., placenta previa, history of PPH, coagulopathy) carry more weight due to their strong association with severe PPH.
🔹 Women identified as moderate or high risk may benefit from active management of the third stage of labor, early availability of blood transfusion, and close postpartum monitoring.
Clinical Features of Postpartum Hemorrhage (PPH)
Postpartum hemorrhage (PPH) is characterized primarily by excessive bleeding after childbirth. Recognizing its clinical features early is essential for prompt intervention and to reduce the risk of severe complications, including shock and maternal death. The presentation can range from mild bleeding to life-threatening hemorrhage.
1. Excessive Vaginal Bleeding
The hallmark of PPH is abnormal bleeding from the genital tract after delivery. This may manifest as:
🔹 Profuse vaginal bleeding: Often the most obvious sign, with large amounts of bright red blood loss that saturates pads rapidly.
🔹 Continuous or intermittent bleeding: Bleeding may be ongoing or in spurts.
🔹 Clot passage: Large clots may be passed, which can indicate significant blood loss or retained tissue.
It is important to note that visual estimation of blood loss often underestimates the actual volume lost. Blood soaked into drapes or pooling under the patient should be assessed carefully.
2. Uterine Findings
On abdominal palpation, the uterus may reveal important clues:
🔹 Soft, boggy uterus: Suggests uterine atony, the most common cause of PPH. The uterus fails to contract firmly to compress the blood vessels.
🔹 Firm uterus: May indicate bleeding due to trauma, retained tissue, or coagulopathy rather than atony.
🔹 Enlarged uterus: Could suggest retained placental tissue or clots inside the uterus.
3. Vital Signs and Signs of Hypovolemia
As blood loss progresses, systemic signs of hypovolemia and shock become evident:
🔹 Tachycardia (increased heart rate): An early compensatory response to blood loss.
🔹 Hypotension (low blood pressure): Occurs as blood volume decreases.
🔹 Pallor and cold, clammy skin: Due to peripheral vasoconstriction and poor perfusion.
🔹 Tachypnea (rapid breathing): Compensatory to maintain oxygen delivery.
🔹 Weakness, dizziness, and syncope: Due to decreased cerebral perfusion.
🔹 Decreased urine output: Reflects renal hypoperfusion.
Monitoring vital signs closely during the postpartum period is crucial, as overt signs of shock may only appear after significant blood loss (up to 30-40% of blood volume).
4. Signs Related to Specific Causes
🔹 Trauma: Visible vaginal or cervical lacerations or episiotomy bleeding. Pain and localized swelling may be present.
🔹 Retained Placenta: Continued bleeding despite a firm uterus; may feel bulky uterus or detect tissue on ultrasound.
🔹 Coagulopathy: Diffuse oozing of blood from multiple sites, including venipuncture sites, along with bleeding per vagina. May be associated with bruising or petechiae.
🔹 Uterine inversion: Sudden severe pain, a mass protruding from the vagina, and massive bleeding with signs of shock.
5. Secondary (Late) PPH Features
Late PPH, occurring between 24 hours and 12 weeks postpartum, typically presents with:
🔹 Delayed or prolonged vaginal bleeding or spotting.
🔹 Subinvolution of the uterus: The uterus fails to return to normal size, often due to retained products or infection.
🔹 Signs of infection: Fever, foul-smelling lochia, and uterine tenderness if infection is present.
Early subtle signs like mild tachycardia or increased bleeding should prompt urgent evaluation to prevent progression to severe hemorrhage and shock. Effective monitoring during the immediate postpartum period is vital to detect and manage PPH timely manner.(alert-passed)
Complications of Postpartum Hemorrhage (PPH)
Postpartum hemorrhage is a serious obstetric emergency that, if not promptly recognized and managed, can lead to a range of immediate and long-term complications affecting maternal health and survival. These complications arise primarily due to massive blood loss, inadequate tissue oxygenation, and the body’s response to shock and trauma.
1. Hypovolemic Shock
One of the most critical complications of PPH is hypovolemic shock, resulting from rapid and severe blood loss. When blood volume decreases significantly, the heart and lungs cannot deliver enough oxygenated blood to vital organs. The body initially compensates by increasing heart rate and constricting blood vessels, but without intervention, these compensatory mechanisms fail. Hypovolemic shock manifests clinically as low blood pressure, rapid pulse, cold and clammy skin, altered mental status, and decreased urine output. If untreated, shock can lead to multi-organ failure and death.
2. Anemia and Its Sequelae
Significant blood loss leads to anemia, reducing the oxygen-carrying capacity of the blood. Even after initial recovery, women may suffer from iron-deficiency anemia due to depletion of iron stores. Anemia contributes to fatigue, delayed wound healing, and reduced physical capacity, impairing the mother’s ability to care for her newborn. Severe anemia may require blood transfusions and prolonged rehabilitation.
3. Disseminated Intravascular Coagulation (DIC)
PPH can trigger disseminated intravascular coagulation, a life-threatening disorder where the blood’s clotting system is abnormally activated. In DIC, widespread clot formation occurs within small blood vessels, consuming clotting factors and platelets, which paradoxically leads to severe bleeding elsewhere. DIC complicates PPH by exacerbating hemorrhage and increasing the risk of organ damage due to microvascular clots. Prompt recognition and treatment with blood products are essential to prevent fatal outcomes.
4. Infection and Sepsis
Women experiencing PPH, especially those undergoing repeated manual uterine exploration or surgical interventions such as dilation and curettage (D&C), are at increased risk of postpartum infection. Retained placental tissue can serve as a nidus for bacterial growth, leading to endometritis (infection of the uterine lining) or pelvic abscess. If untreated, infections can progress to systemic sepsis, which is a major cause of maternal mortality worldwide.
5. Organ Failure
Severe and prolonged hypovolemia from PPH can lead to dysfunction or failure of vital organs:
🔹 Kidney failure: Due to reduced blood flow and acute tubular necrosis, resulting in decreased urine output and electrolyte imbalances.
🔹 Liver failure: Ischemic injury can occur during shock states.
🔹 Respiratory distress: Secondary to fluid overload from aggressive resuscitation or acute lung injury.
🔹 Neurological injury: Resulting from hypotension and hypoxia, leading to confusion, coma, or even irreversible brain damage.
6. Sheehan’s Syndrome (Postpartum Hypopituitarism)
Severe PPH can cause ischemic necrosis of the anterior pituitary gland, a rare but serious late complication known as Sheehan’s syndrome. It results in varying degrees of hypopituitarism — deficient production of pituitary hormones. Women may present months to years later with symptoms such as failure to lactate, amenorrhea, hypothyroidism, adrenal insufficiency, and fatigue.
7. Psychological and Social Impact
The trauma of experiencing a life-threatening hemorrhage can lead to long-lasting psychological effects, including anxiety, depression, and post-traumatic stress disorder (PTSD). The sudden loss of blood, emergency interventions, and prolonged hospital stays may disrupt bonding with the newborn and affect breastfeeding. Socially, women may face economic hardships due to prolonged recovery or inability to return to work promptly.
8. Future Pregnancy Risks
Women who have experienced PPH are at increased risk of recurrent hemorrhage in subsequent pregnancies. Complications such as uterine scarring or Asherman’s syndrome (intrauterine adhesions) after surgical treatment for retained placenta can affect future fertility and pregnancy outcomes.
Postpartum hemorrhage can have severe and wide-ranging complications affecting multiple body systems. Early detection and aggressive management are critical to minimizing these risks. Long-term follow-up and support are equally important to address both physical and psychological sequelae in affected women.(alert-passed)
Diagnosis of Postpartum Hemorrhage (PPH)
The diagnosis of postpartum hemorrhage involves timely recognition of excessive bleeding following childbirth, assessment of hemodynamic status, and identification of the underlying cause. Accurate diagnosis is essential to initiate prompt and appropriate management to reduce maternal morbidity and mortality.
1. Clinical Diagnosis: Estimation of Blood Loss
PPH is primarily a clinical diagnosis based on the amount of blood lost after delivery. Traditionally, PPH is defined as blood loss exceeding:
500 mL after vaginal delivery
1000 mL after cesarean section
However, visual estimation of blood loss is notoriously inaccurate and often underestimated. Blood may be lost internally or pool under the patient, making assessment difficult. Therefore, clinical signs and symptoms of blood loss are critical adjuncts to quantify severity.
2. Assessment of Vital Signs and Hemodynamic Stability
Since quantifying blood loss is challenging, the patient’s vital signs and overall clinical status provide vital clues to the extent and impact of hemorrhage.
🔹 Tachycardia and hypotension indicate significant blood loss.
🔹 Altered mental status, pallor, and diaphoresis suggest progressing shock.
🔹 Decreased urine output signals poor renal perfusion and severe hypovolemia.
Serial monitoring of vital signs is essential during the immediate postpartum period, especially for high-risk women.
3. Physical Examination
A thorough physical examination focuses on the following:
🔹 Uterine tone and size: Palpation of the abdomen to determine if the uterus is firm and contracted (normal) or soft and boggy (suggestive of uterine atony).
🔹 Inspection of the vagina and perineum: To identify any lacerations, hematomas, or retained placental fragments causing bleeding.
🔹 Evaluation for uterine inversion: Check for a visible or palpable mass protruding from the vagina, which may cause sudden hemorrhage.
4. Laboratory Investigations
Laboratory tests help assess the severity of blood loss, guide transfusion decisions, and identify coagulopathy:
🔹 Complete blood count (CBC): To determine hemoglobin and hematocrit levels, though early after bleeding, these may not immediately reflect the true loss due to hemoconcentration.
🔹 Coagulation profile: Prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen levels, and platelet counts to detect disseminated intravascular coagulation (DIC) or other bleeding disorders.
🔹 Blood typing and crossmatching: Essential to prepare for a possible blood transfusion.
5. Imaging Studies
Ultrasound plays an important role in diagnosing retained products of conception or identifying uterine abnormalities:
🔹 Pelvic ultrasound (transabdominal or transvaginal): Can detect retained placental tissue, intrauterine clots, or uterine anomalies contributing to bleeding.
🔹 Doppler studies: Occasionally used to evaluate uterine blood flow in complicated cases.
6. Differential Diagnosis and Identification of the Cause
Identifying the cause of PPH is critical for targeted management. The “4 Ts” mnemonic guides clinicians:
🔹 Tone: Uterine atony, the most common cause, is diagnosed by a soft, poorly contracted uterus.
🔹 Tissue: Retained placenta or clots are suspected if bleeding continues despite a firm uterus.
🔹 Trauma: Vaginal, cervical, or uterine lacerations identified by visual inspection and palpation.
🔹 Thrombin: Coagulopathies are diagnosed via lab tests and clinical suspicion.
Diagnosis of postpartum hemorrhage relies on clinical vigilance, careful monitoring, and a systematic approach to identify severity and etiology. Because visual blood loss estimation is often unreliable, combining clinical signs, physical examination, laboratory data, and imaging ensures timely diagnosis and effective treatment planning.(alert-passed)
Management of Postpartum Hemorrhage
The management of postpartum hemorrhage is a time-sensitive emergency that requires rapid assessment, stabilization, and targeted treatment to control bleeding, prevent complications, and save the mother’s life. The approach involves simultaneous resuscitation and identification of the underlying cause to guide specific interventions.
A. Emergency Care: ABCD Approach
The ABCs of postpartum management are a set of guidelines that are used to prioritize and manage maternal health in the immediate postpartum period. The ABCs stand for:
A - Airway: Ensure that the mother's airway is open and clear to allow adequate oxygenation. If the mother is unconscious, she may need to have her airway opened and supported with a breathing tube or oxygen mask.
B - Breathing: Check the mother's breathing and ensure that she is adequately ventilated. If the mother is having difficulty breathing or has respiratory distress, she may need supplemental oxygen or mechanical ventilation.
C - Circulation: Check the mother's pulse and blood pressure to ensure that she has adequate circulation. If the mother has signs of shock or is hypotensive, fluid replacement and blood transfusion may be necessary to maintain blood pressure.
D - Disposition: Once the mother's airway, breathing, and circulation have been stabilized, her disposition should be determined. If the mother is stable, she may be transferred to the postpartum unit for further monitoring. If the mother is unstable, she may need to be transferred to the intensive care unit (ICU) for further management.
E - Evaluation: The mother should be continuously evaluated for signs of bleeding, infection, or other complications. Vital signs, urine output, and hemoglobin levels should be monitored regularly to ensure that she is stable and recovering well.
In postpartum hemorrhage, the mother may experience hypovolemic shock due to excessive blood loss, which can compromise the airway, breathing, and circulation. The ABC approach ensures that these critical components are assessed and managed in a timely and effective manner, which can reduce the risk of complications and improve maternal morbidity and mortality.
B. General Management of Postpartum Hemorrhage (PPH)
After the ABC management of postpartum hemorrhage (PPH), the next steps for managing PPH will depend on the cause and severity of the bleeding. The following are steps for managing PPH:
1. Identify the cause of bleeding
The first step in managing PPH is to identify the cause of bleeding. The most common causes of PPH include uterine atony, retained placenta or placental fragments, genital tract trauma, and coagulopathy. Once the cause of bleeding is identified, appropriate interventions can be implemented to control the bleeding.
2. Uterine Massage
Uterine massage involves applying firm, gentle pressure on the uterus through the abdomen to stimulate contractions and promote uterine tone. It is usually the first-line non-invasive intervention after delivery to prevent or treat uterine atony. This procedure may cause mild discomfort or cramping but should not be painful. Internal manual removal of retained placental tissue is a separate procedure and should only be performed if indicated by clinical assessment.
3. Bimanual Compression
Bimanual compression is another technique used to manage PPH. This method involves manually compressing the uterus with one hand from the outside while the other hand is inserted into the vagina to compress the bleeding vessels. The goal of bimanual compression is to control bleeding and stimulate uterine contractions.
Bimanual compression is typically done by a healthcare provider and may be done in conjunction with uterine massage or other interventions. The procedure may cause some discomfort or pain but is generally well-tolerated.
Bimanual compression is usually reserved for cases where uterine massage alone is not effective in controlling bleeding or in cases where the uterus is atonic (unable to contract). If bleeding continues despite bimanual compression, more aggressive interventions may be necessary, such as medication or surgery.
4. Medical Management
Medical management is the first-line treatment for PPH and involves the use of medications to control bleeding. The medications used for PPH include:
🔹 Oxytocin: Oxytocin is a hormone that stimulates uterine contractions and is the first-line medication for PPH. It is usually given as an intravenous (IV) infusion or injection. Oxytocin is effective in reducing bleeding and preventing uterine atony, which is the most common cause of PPH.
🔹 Methylergonovine: Methylergonovine is an ergot alkaloid that causes strong uterine contractions. It is used as a second-line medication for PPH when oxytocin fails to control bleeding. Methylergonovine should be used with caution in women with hypertension, as it can cause a rapid increase in blood pressure.
🔹 Carboprost: Carboprost is a prostaglandin analog that is used when other medications fail to control bleeding. It causes strong uterine contractions and is administered as an intramuscular injection.
🔹 Tranexamic acid: Tranexamic acid is an antifibrinolytic medication that helps to stabilize blood clots and prevent further bleeding. It is most effective when administered within three hours of bleeding onset.
5. Fluid Replacement
If the mother has lost a significant amount of blood, fluid replacement may be necessary to maintain blood pressure and prevent shock. Intravenous fluids, blood transfusions, or both may be given depending on the severity of the blood loss.
6. Surgical Intervention
If conservative measures fail to control bleeding, surgical interventions may be necessary. Some of the surgical options include:
🔹 Uterine Artery Embolization: This involves injecting a substance into the uterine artery to block blood flow to the uterus and stop bleeding.
🔹 Uterine Compression Sutures: This involves placing sutures in the uterus to compress bleeding vessels and control bleeding.
🔹 Uterine Balloon Tamponade: This involves placing a balloon inside the uterus and inflating it to compress bleeding vessels and control bleeding.
🔹 Hysterectomy: This is the last resort and involves removing the uterus if bleeding cannot be controlled by other methods.
7. Follow-up
The mother should be monitored closely after the bleeding has been controlled. She may need to stay in the hospital for a few days to ensure that she is stable and to manage any complications that may arise.
C. Specific Management for Postpartum Hemorrhage (PPH)
Specific management will depend on the cause of the hemorrhage.
1. Tone (Uterine Atony)
The management of uterine atony involves a stepwise approach, starting with conservative measures such as bimanual uterine massage, administration of uterotonic medications, and fluid resuscitation. If these measures fail, more invasive interventions such as intrauterine balloon tamponade or uterine artery embolization may be considered. In severe cases, a hysterectomy may be necessary.
Read more: Uterine Atony
2. Trauma (Genital Tract Injury)
Trauma to the genital tract during delivery is another important cause of postpartum hemorrhage. Tears or lacerations can occur in the cervix, vagina, vulva, or perineum, especially after instrumental deliveries, rapid labor, or large babies. Additionally, hematomas—collections of blood within soft tissues—may form due to vessel injury.
A thorough and systematic inspection of the birth canal is essential after delivery to identify any such injuries. The healthcare provider should carefully examine the cervix, vaginal walls, and perineal area, often using adequate lighting and a speculum when needed. Failure to detect and repair lacerations can result in ongoing bleeding and hemodynamic instability.
Once identified, genital tract injuries should be repaired surgically with appropriate suturing techniques to control bleeding and promote healing. Large or expanding hematomas may require incision and evacuation to prevent pressure necrosis and severe blood loss. Prompt surgical intervention minimizes morbidity and reduces the risk of infection and prolonged hospital stays.
3. Tissue (Retained Placenta or Clots)
A critical step in preventing and managing postpartum hemorrhage is ensuring that the placenta is completely delivered after childbirth. Retained placental tissue or clots inside the uterus can prevent proper uterine contraction, leading to continued bleeding. Immediately after delivery, the placenta should be carefully inspected to confirm that it is intact and all parts have been expelled. Missing fragments can remain attached to the uterine wall, causing persistent bleeding.
If retained placenta is suspected—indicated by ongoing heavy bleeding, an enlarged and soft uterus, or failure of the uterus to contract adequately—manual removal may be necessary. This procedure involves the clinician inserting a hand into the uterus to gently separate and remove any remaining placental tissue. It requires appropriate analgesia or anesthesia and strict aseptic technique to prevent infection.
Ultrasound examination can be a valuable tool to identify retained placental fragments or large blood clots. It helps in assessing the uterine cavity and guiding further management. In some cases, if manual removal is incomplete or not feasible, surgical evacuation such as dilation and curettage (D&C) may be required. This procedure scrapes the uterine lining under anesthesia to remove residual tissue and control bleeding.
4. Thrombin (Coagulopathy)
Coagulopathy refers to abnormalities in the blood’s ability to clot and can be a primary or secondary cause of postpartum hemorrhage. Underlying bleeding disorders, such as inherited clotting factor deficiencies, or acquired conditions like disseminated intravascular coagulation (DIC), liver disease, or severe preeclampsia, can impair normal clot formation and exacerbate bleeding.
Identifying coagulopathy involves clinical suspicion when bleeding is disproportionate to the apparent cause or if bleeding continues despite correction of other causes. Laboratory tests such as coagulation profiles, platelet counts, fibrinogen levels, and blood smear evaluations are essential for diagnosis.
Management includes treating the underlying disorder and supporting clotting function. Blood products such as fresh frozen plasma, platelets, or cryoprecipitate are administered to replace deficient clotting factors and improve hemostasis. Additionally, correcting associated conditions like hypothermia, acidosis, and electrolyte imbalances is crucial, as these worsen coagulopathy and impede clotting. Early involvement of hematology specialists and a multidisciplinary team enhances management outcomes.
The management of postpartum hemorrhage requires coordinated, multidisciplinary efforts focusing on rapid resuscitation, identification of the bleeding cause, medical and surgical control of hemorrhage, and supportive care. Early intervention greatly improves outcomes and reduces maternal morbidity and mortality.(alert-passed)
Prevention of Postpartum Hemorrhage (PPH)
Preventing postpartum hemorrhage is a key goal in obstetric care to reduce maternal morbidity and mortality. Prevention strategies focus on identifying at-risk women, implementing evidence-based interventions during labor and delivery, and ensuring preparedness for prompt management if bleeding occurs.
1. Antenatal Identification of Risk Factors
Prevention begins during the antenatal period by assessing each pregnant woman for risk factors that increase the likelihood of PPH. These include a history of previous PPH, multiple pregnancies, anemia, prolonged labor, uterine fibroids, or coagulation disorders. Identifying such risk factors enables healthcare providers to plan delivery in settings equipped to handle emergencies, including access to blood transfusion and surgical care. Women with known risks may require closer monitoring and specific interventions during labor.
2. Active Management of the Third Stage of Labor (AMTSL)
AMTSL is the cornerstone of PPH prevention and involves a set of standardized steps performed immediately after the baby’s delivery:
🔹 Administration of uterotonic agents: The World Health Organization recommends giving oxytocin (10 IU intramuscularly) within one minute of delivery to stimulate uterine contractions and reduce bleeding.
🔹 Controlled cord traction: Gentle traction on the umbilical cord helps deliver the placenta more efficiently, reducing the chance of retained placental tissue.
🔹 Uterine massage: After placenta delivery, massage of the uterus encourages contraction and prevents uterine atony.
AMTSL has been shown to significantly reduce the incidence and severity of PPH.
3. Optimizing Maternal Health and Nutrition
Good maternal health before and during pregnancy can reduce the risk of PPH:
🔹 Correction of anemia: Ensuring adequate iron and folate supplementation during pregnancy improves hemoglobin levels, increasing the mother’s tolerance to blood loss.
🔹 Management of underlying conditions: Control of hypertension, diabetes, and infections can improve overall outcomes.
🔹 Adequate antenatal care visits: Regular check-ups allow early detection and management of potential problems.
4. Skilled Birth Attendance and Facility Preparedness
Delivery should ideally take place in a healthcare facility staffed by trained birth attendants who can recognize early signs of PPH and provide timely interventions. Facilities must be equipped with:
🔹 Adequate supply of uterotonics and intravenous fluids.
🔹 Access to blood transfusion services.
🔹 Emergency surgical capabilities for management of severe PPH cases.
🔹 Protocols and checklists to guide rapid response.
Community education about seeking skilled care is also vital to reduce home births without adequate support.
5. Minimizing Trauma During Delivery
Preventive measures to avoid birth canal trauma include:
🔹 Controlled delivery of the fetal head to reduce perineal tears.
🔹 Appropriate episiotomy only when indicated.
🔹 Careful repair of any lacerations immediately.
Reducing trauma helps decrease bleeding due to soft tissue injury.
6. Use of Prophylactic Measures in High-Risk Cases
In women identified as high risk for PPH:
🔹 Prophylactic administration of uterotonics is essential.
🔹 Consider early active management strategies tailored to the patient.
🔹 Close monitoring postpartum for early detection of bleeding.
Some centers also explore tranexamic acid use prophylactically, but its routine use for prevention is still under research.
Preventing postpartum hemorrhage involves a comprehensive approach that spans the antenatal, intrapartum, and postpartum periods. Active management of the third stage of labor combined with skilled birth attendance and facility readiness has the greatest impact. Early identification of risk factors and optimization of maternal health further reduces PPH incidence and improves maternal outcomes.(alert-passed)
Prognosis of Postpartum Hemorrhage (PPH)
The prognosis of postpartum hemorrhage depends on multiple factors, including the severity of blood loss, promptness and effectiveness of management, underlying maternal health, and availability of healthcare resources. Early recognition and intervention significantly improve outcomes, while delays or inadequate care increase the risk of severe complications and mortality.
1. Factors Influencing Prognosis
Several key factors determine the overall prognosis of PPH:
🔹 Volume and rate of blood loss: Rapid and massive hemorrhage poses a higher risk of hypovolemic shock and death compared to slower or minor bleeding.
🔹 Cause of hemorrhage: Uterine atony generally responds well to medical treatment if caught early, whereas trauma, retained placenta, or coagulopathies may require more complex interventions.
🔹 Maternal health status: Pre-existing anemia, cardiovascular disease, or coagulation disorders worsen the prognosis by reducing the body’s ability to compensate for blood loss.
🔹 Timeliness and quality of care: Facilities with skilled providers, blood transfusion capabilities, and surgical support have better outcomes. In low-resource settings, delayed care increases mortality risk.
2. Short-Term Outcomes
With prompt and adequate management, most women with PPH recover fully without lasting effects. Short-term complications that may arise include:
🔹 Hypovolemic shock: If treated swiftly, shock is reversible. However, prolonged shock can lead to multi-organ failure.
🔹 Need for blood transfusions: Transfusion reactions and infections are potential risks but generally manageable.
🔹 Surgical complications: Procedures such as hysterectomy carry risks including infection, anesthesia-related issues, and longer recovery.
3. Long-Term Outcomes
In survivors, the long-term prognosis may be influenced by the extent of complications encountered during the hemorrhage:
🔹 Anemia and fatigue: Recovery from blood loss may take weeks to months, with some women experiencing prolonged weakness.
🔹 Psychological impact: PPH is associated with increased rates of postpartum depression, anxiety, and post-traumatic stress disorder (PTSD), which may affect maternal-infant bonding and family dynamics.
🔹 Fertility and future pregnancies: Surgical interventions like a hysterectomy result in loss of fertility. Even without a hysterectomy, uterine scarring or Asherman’s syndrome after instrumentation can impair future pregnancies. Women with prior PPH are at higher risk of recurrence.
4. Mortality and Global Perspective
Postpartum hemorrhage remains one of the leading causes of maternal mortality worldwide, particularly in low- and middle-income countries. The World Health Organization estimates that PPH accounts for about 25% of maternal deaths globally. Mortality rates vary widely depending on access to emergency obstetric care, with near-zero mortality in well-resourced settings compared to high rates in under-resourced areas.
The prognosis of postpartum hemorrhage varies from full recovery to severe morbidity and death depending on multiple factors. Early diagnosis, effective management, and access to comprehensive obstetric care are critical to improving outcomes. Attention to long-term physical and psychological support is essential to help survivors resume normal life and maintain reproductive health.(alert-passed)
