Postpartum haemorrhage

• Postpartum haemorrhage (PPH) is defined as a blood loss of 500 ml or more within 24 hours after birth.
• It is classified into two types: primary (occurs within 24 hours of delivery) and secondary (or delayed, occurs from 24 hours to 12 weeks postpartum).

• PPH is a leading cause of maternal mortality worldwide, especially in low- and middle-income countries.
• The incidence varies but is estimated to affect 1% to 5% of deliveries.

PPH primarily results from four ‘T’s:

• Tone: Uterine atony is the most common cause of PPH.
• Tissue: Retained placental tissue or clots.
• Trauma: Trauma to the genital tract, including tears, episiotomy, or uterine rupture.
• Thrombin: Coagulopathies, either pre-existing or acquired during delivery.

• Previous history of PPH.
• Prolonged labour or rapid labour.
• Uterine atony (failure of the uterus to contract after delivery).
• Retained placenta or placental fragments.
• Placenta praevia or accreta.
• Overdistended uterus (e.g., multiple gestation, polyhydramnios).
• Operative delivery (e.g., forceps, vacuum, caesarean section).
• Maternal obesity.
• Uterine infection or chorioamnionitis.

• Excessive bleeding from the vagina.
• Decreased blood pressure and increased heart rate (signs of hypovolaemic shock).
• Pallor.
• Cold, clammy skin.
• Fatigue or loss of consciousness in severe cases.

Primarily clinical based on a blood loss of 500 ml or more within 24 hours after birth (primary) or between 24 hours to 12 weeks postpartum (secondary).

Immediate Management:

• Initial Steps: Ensure two large-bore intravenous (IV) lines are in place, administer IV fluids, and initiate blood transfusion if necessary.
• Uterine Massage: To stimulate contraction.
• Medications: Administer uterotonics (e.g., oxytocin, misoprostol) to encourage uterine contraction.
• Manual Removal of Placenta: If retained placenta is suspected.

Surgical Interventions:

• Uterine Tamponade: Use of a balloon tamponade system to apply internal pressure and stop bleeding.
• Laparotomy: For cases of uncontrollable bleeding or when the source of bleeding needs to be surgically addressed (e.g., uterine rupture repair).
• Uterine Artery Embolisation: In cases where bleeding does not respond to conventional therapies and the patient is haemodynamically stable.
• Hysterectomy: As a last resort when all other measures fail to control bleeding.

• Hypovolaemic shock.
• Sheehan’s syndrome (postpartum pituitary gland necrosis).
• Acute renal failure.
• Coagulopathy.
• Maternal death.

• Active Management of the Third Stage of Labour (AMTSL): Involves the administration of a prophylactic uterotonic, controlled cord traction, and uterine massage after delivery of the placenta to prevent PPH.
• Risk Factor Identification: Early identification and management of risk factors during antenatal care and labour.

• Postpartum haemorrhage (PPH) is a significant cause of maternal morbidity and mortality, demanding prompt recognition and management.
• The primary goal in managing PPH is to quickly identify the cause and implement appropriate interventions to control bleeding and stabilise the patient.
• Understanding the risk factors, pathophysiology, and effective management strategies for PPH is crucial for medical students and healthcare professionals.