🩸  Postpartum Hemorrhage (PPH)

Course Overview

Postpartum hemorrhage (PPH) is a life-threatening obstetric emergency defined as excessive vaginal bleeding following delivery:

• Greater than 500 mL after vaginal delivery

• Greater than 1000 mL after cesarean section

• Or any blood loss sufficient to cause or threaten hemodynamic instability

PPH is classified as:

• Primary PPH: occurs within the first 24 hours after delivery

• Secondary PPH: occurs from 24 hours up to 6 weeks postpartum

Prompt recognition and timely, structured management are critical to reduce maternal morbidity and mortality.

Learning Objectives

By the end of this module, learners should be able to:

1. Define postpartum hemorrhage and differentiate primary from secondary PPH.

2. Identify the main causes of PPH using the 4 Ts framework.

3. Recognize the clinical signs and symptoms of PPH and maternal shock.

4. Formulate an organized stepwise management approach.

5. Outline definitive interventions, including surgical procedures, for uncontrolled PPH.

6. Emphasize team coordination and post-event debriefing.

 Causes of PPH (The 4 Ts)

PPH can result from one or multiple contributing factors:

1. Tone (uterine atony) – the most common cause

   • Risk factors: high parity, multiple pregnancy, macrosomia, polyhydramnios, antepartum hemorrhage, full bladder, uterine fibroids

2. Trauma (birth canal injury)

   • Risk factors: instrumental delivery, previous uterine surgery, transverse lie, poor management of second stage of labour, uterotonics (oxytocin, misoprostol, dinoprostone)

3. Tissue (retained products of conception)

   • Risk factors: preterm labor, previous uterine surgery, abnormal placental morphology (e.g., succenturiate lobe), poor third stage management

4. Thrombin (coagulopathy)

   • Causes include DIC, HELLP syndrome, ITP, TTP, and inherited or acquired bleeding disorders

 Clinical Presentation

Signs and symptoms of PPH and maternal compromise include:

• Excessive vaginal bleeding (volume often underestimated)

• Signs of shock:

  • Tachycardia ≥ 100 bpm

  • Hypotension < 90/60 mmHg

  • Tachypnea and air hunger

  • Thirst and fluid requests

  • Restlessness, confusion, or disorientation

  • Cold, clammy sweat

• Pallor on inspection

• Decreased urine output if severe

Early recognition is key to prevent progression to cardiovascular collapse.

 Stepwise Management

Management should follow a structured, escalating approach:

Immediate Actions

1. Call for help – activate the emergency obstetric team and designate a team leader.

2. Establish sterile field.

3. Secure 2 large-bore IV lines (14–18G).

4. Collect blood samples:

   • Full blood count (FBC)

   • Group and crossmatch

   • Bedside clotting time

   • Serum fibrinogen and coagulation profile

   • LFTs, U&E, KFTs

5. Monitor vitals and pallor.

6. Administer uterotonics:

   • Oxytocin 10 IU IM stat

   • Oxytocin 20 IU in 500 mL normal saline at 20 drops/min

   • Misoprostol 800 mcg sublingual/rectal

   • Tranexamic acid 1 g IV stat (within 3 hours of PPH onset)

7. Concurrent uterine massage.

8. Catheterize the bladder.

9. Inspect vulva, vagina, and perineum; repair tears if present.

10. Manual uterine exploration for retained products or wall defects.

Secondary Interventions

• Bimanual uterine compression or aortic compression

• Prepare for cervical assessment/repair if indicated

• Uterine balloon tamponade for persistent bleeding

• Administer broad-spectrum antibiotics and analgesia once hemostasis is achieved

Definitive/Surgical Management

If bleeding persists despite medical and mechanical interventions:

• Obtain consent and prepare for urgent laparotomy

• Procedures may include:

  • Uterine compression sutures (e.g., B-Lynch, Hayman)

  • Uterine artery ligation or stepwise devascularization

  • Pelvic arterial embolization or intra-aortic balloon occlusion

  • Hysterectomy (last resort)

 Post-event Considerations

• Team acknowledgment and documentation

• Post-event debriefing to evaluate response and improve protocols

• Monitor patient for:

  • Hemodynamic stability

  • Signs of infection

  • Ongoing bleeding or coagulopathy

 Key Summary Points

• PPH is defined as blood loss > 500 mL vaginally or >1000 mL cesarean or any bleeding causing hemodynamic compromise.

• Classified as primary (<24h) or secondary (24h–6 weeks).

• Causes follow the 4 Ts: Tone, Trauma, Tissue, Thrombin.

• Early recognition of signs of shock is critical.

• Stepwise management: call for help → IV access → uterotonics → manual measures → balloon tamponade → surgical interventions.

• Team coordination and post-event review are essential for quality care.

Recommended References

• Williams Obstetrics, 27th Edition, Cunningham FG et al.

• WHO Recommendations for the Prevention and Treatment of Postpartum Hemorrhage, 2022.

• American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin No. 183: Postpartum Hemorrhage, 2017.

• Ministry of Health Zambia: National Guidelines for Emergency Obstetric Care.