Obstetrics and Gynaecology chapters
Postpartum haemorrhage: primary and secondary PPH
Postpartum haemorrhage is the leading cause of maternal death worldwide. This chapter covers definitions, the four causes (tone, tissue, trauma, thrombin), active management of the third stage, the drug ladder from oxytocin to carboprost, surgical steps and secondary PPH.
- Primary PPH is loss of 500 ml or more within 24 hours of birth; secondary PPH is abnormal bleeding from 24 hours to 6 weeks.
- Causes are the 4 Ts: Tone (atony, the commonest), Tissue, Trauma, Thrombin. Active management of the third stage with oxytocin 10 IU IM cuts PPH from about 15% to 5%.
- Management: call for help and resuscitate, rub up the uterus, empty the bladder, then oxytocin, ergometrine (not in hypertension), carboprost (not in asthma), misoprostol, then balloon or compression sutures and early hysterectomy if needed.
On this page
Overview
Postpartum haemorrhage (PPH) is excessive bleeding from the genital tract after the birth of the baby. It is the leading cause of maternal death worldwide and a major cause in Pakistan, where anaemia, home births and delays in reaching care make it more dangerous. Young healthy women compensate well, so serious loss can hide behind a normal blood pressure.
Definitions
| Term | Definition |
|---|---|
| Primary PPH | Loss of 500 ml or more from the genital tract within 24 hours of birth |
| Major obstetric haemorrhage | Loss of 2,500 ml or more, transfusion of 5 or more units of red cells, or the need to treat coagulopathy |
| Secondary PPH | Fresh or abnormal bleeding from 24 hours to 6 weeks after delivery |
Visual estimates of blood loss are usually too low.
Causes: the 4 Ts
| T | Cause | Notes |
|---|---|---|
| Tone | Uterine atony | Commonest cause; uterus soft and "boggy" |
| Tissue | Retained placenta, cotyledon, membranes or clots; placenta accreta | Inspect the placenta after every delivery |
| Trauma | Perineal, vaginal and cervical tears; uterine rupture; uterine inversion; haematoma | Uterus well contracted yet bleeding continues |
| Thrombin | Coagulopathy: DIC (abruption, amniotic fluid embolism, sepsis, pre-eclampsia), inherited disorders (e.g. von Willebrand disease, factor VIII deficiency) | Blood fails to clot |
4 Ts = Tone, Tissue, Trauma, Thrombin. Tone is the big one.
Risk factors for atony
- Overdistended uterus: multiple pregnancy, macrosomia, polyhydramnios.
- Tired uterus: prolonged labour, induction or oxytocin augmentation.
- Grand multiparity.
- APH, especially placental abruption.
- Full bladder (stops the uterus contracting).
Other risk factors for PPH: placenta praevia and accreta, previous caesarean sections, perineal trauma, bleeding disorders, anaemia before delivery.
Prevention
- Treat antenatal anaemia (check and correct haemoglobin before delivery).
- Identify high-risk women; deliver them where blood and theatres are available.
- Active management of the third stage of labour (AMTSL) for every woman:
1. Oxytocin 10 IU IM as the anterior shoulder delivers or straight after the baby. 2. Clamping and cutting the cord (a 1-3 minute delay is now preferred, especially for preterm babies, as the baby receives placental blood). 3. Controlled cord traction once signs of separation appear, with the other hand guarding the uterus above the pubis.
Active management reduces PPH from about 15% to 5%.
Signs that the placenta has separated: the cord seems to get longer, there is a brief gush of blood, and the fundus rises and becomes firm and globular.
The third stage is prolonged after 30 minutes with active management (or 60 minutes with physiological management). A retained placenta needs manual removal under anaesthesia in theatre.
Pulling hard on the cord before separation, without guarding the uterus, can cause uterine inversion.
Recognising haemorrhage
- Symptoms: anxiety, thirst, nausea, feeling cold, dizziness.
- Signs: tachycardia, tachypnoea, narrow pulse pressure, reduced urine output, a rising fundus (blood collecting in the uterus).
- Few signs appear until about 1,000 ml is lost; hypotension is a late sign, usually after about 2,000 ml.
Do not be reassured by a single normal haemoglobin. Treat the patient, not the number.
Management of primary PPH
Work on all fronts at once: call for help, resuscitate, find and treat the cause.
1. Call for help and resuscitate
- Senior obstetrician, anaesthetist, midwives, haematology and blood bank.
- ABC, high-flow oxygen, lie flat.
- Two large-bore IV cannulas; FBC, clotting, cross-match.
- Warm fluids, then blood and blood products early; consider giving products before clotting results worsen.
- Monitor pulse, BP, urine output (catheter).
2. Treat atony (the drug ladder)
| Step | Measure | Key caution |
|---|---|---|
| 1 | Uterine massage (rub up a contraction); empty the bladder | First action for a boggy uterus |
| 2 | Oxytocin 5-10 IU IV or IM, then an oxytocin infusion | Safe in most women |
| 3 | Ergometrine 500 micrograms IM or slow IV, or Syntometrine (ergometrine 500 micrograms with oxytocin 5 IU) | Contraindicated in hypertension and pre-eclampsia |
| 4 | Carboprost 0.25 mg IM, repeated at intervals of at least 15 minutes, maximum 8 doses | Avoid in asthma (bronchospasm) |
| 5 | Misoprostol 800-1,000 micrograms rectally | Useful where storage and injections are limited |
| Adjunct | Tranexamic acid (antifibrinolytic) | Reduces bleeding; give early |
Ergometrine raises blood pressure; carboprost constricts bronchi. These two contraindications are among the most tested PPH facts.
3. Bimanual compression
One fist in the anterior fornix, the other hand on the abdomen pressing the uterus against it. It buys time while drugs act or theatre is prepared.
4. Find and fix other causes
- Tissue: examine the placenta; if incomplete or retained, manual removal or evacuation in theatre.
- Trauma: inspect and repair tears under good light and analgesia.
- Thrombin: correct clotting with blood products.
5. Surgery and radiology (if bleeding continues)
- Intrauterine balloon tamponade.
- Compression sutures such as the B-Lynch suture.
- Interventional radiology (arterial embolisation) where available.
- Arterial ligation.
- Hysterectomy: do not leave it too late; early hysterectomy saves lives when simpler steps fail.
Uterine inversion and rupture
| Event | Clues | Management |
|---|---|---|
| Uterine inversion | Shock out of proportion to bleeding, fundus not felt abdominally, mass in the vagina; risk from cord traction without separation | Immediate manual replacement; if that fails, replace under anaesthesia or by hydrostatic method (2-3 litres of warm saline into the vagina); then oxytocin |
| Uterine rupture | Previous caesarean, oxytocin, sudden severe pain, shock, fetal distress or loss of the fetal heart, presenting part no longer felt | Urgent laparotomy, deliver the baby, repair or hysterectomy |
Secondary PPH
- Bleeding from 24 hours to 6 weeks; commonest between days 7 and 14.
- Main causes: endometritis and retained placental tissue (often hard to tell apart).
| Feature | Endometritis | Retained products |
|---|---|---|
| Pain | Constant low abdominal pain | Crampy pain |
| Uterus | Tender | Larger than expected |
| Cervical os | Closed | Open |
| History | Fever, offensive lochia | Prolonged third stage, passage of tissue |
- Management: resuscitate if needed, broad-spectrum antibiotics, uterotonics (e.g. ergometrine), and evacuation of retained products if present (usually after antibiotic cover).
- Ultrasound helps only if it shows an empty uterus; clots and debris are normal after birth.
- Rarer causes: hormonal contraception, bleeding disorders and choriocarcinoma.
Complications of massive PPH
- Hypovolaemic shock, acute kidney injury, DIC, transfusion reactions, loss of fertility after hysterectomy, death.
- Sheehan syndrome: necrosis of the anterior pituitary after severe hypotension. Prolactin fails, so the woman cannot breastfeed, and over weeks to months she develops amenorrhoea and other features of hypopituitarism.
Expect: the 500 ml and 24-hour definition of primary PPH and the 24 hours to 6 weeks window for secondary PPH; uterine atony as the commonest cause and its risk factors (twins, macrosomia, polyhydramnios, prolonged or induced labour, grand multiparity, APH); active management of the third stage with oxytocin 10 IU IM; uterine massage and bladder emptying as first steps; ergometrine contraindicated in hypertension; carboprost avoided in asthma; misoprostol dose; B-Lynch suture and hysterectomy; inversion after cord traction; secondary PPH from endometritis or retained products; Sheehan syndrome.
Quick revision
- Primary PPH: 500 ml or more within 24 hours; major: 2,500 ml or more.
- 4 Ts: tone (commonest), tissue, trauma, thrombin.
- AMTSL: oxytocin 10 IU IM, cord clamping, controlled cord traction; PPH 15% to 5%.
- Order: massage and catheter, oxytocin, ergometrine or Syntometrine, carboprost, misoprostol.
- No ergometrine in hypertension; no carboprost in asthma.
- Then bimanual compression, balloon, B-Lynch, radiology, hysterectomy.
- Hypotension appears late (around 2,000 ml).
- Secondary PPH: days 7-14 peak; endometritis or retained tissue; antibiotics and evacuation.
Written by The House Job from standard references (Obstetrics by Ten Teachers; Basic and Clinical Pharmacology by Katzung).
FAQ
Why is uterine atony the commonest cause of PPH?
After delivery, bleeding from the placental bed is controlled mainly by contraction of the interlacing muscle fibres; if the uterus does not contract, the vessels stay open.
Why must the bladder be emptied in PPH?
A full bladder sits against the lower uterus and stops it contracting properly, so a catheter can help the uterus firm up.
Why is ergometrine avoided in pre-eclampsia?
It causes vasoconstriction and can sharply raise blood pressure, risking a stroke in a woman whose pressure is already high.
What is the commonest time and cause of secondary PPH?
It is most common in the second week after birth and is usually due to endometritis or retained placental tissue.