Postpartum Hemorrhage

DR.ARINI FIRMANSYAH, SP.OG,M.KES

Classic Definition
Early
◦ Occurs when blood loss is greater than
500 ml in the first 24 hours after a vaginal delivery or greater than 1000 ml
after a cesarean birth
*Normal blood loss is about 300 - 500 ml.)

Late
◦ Hemorrhage that occurs after the first 24 hours
 Examples of definitions for postpartum
hemorrhage
Organization Definition of PPH
•Blood loss ≥500 mL within 24 hours after birth.
[1]
World Health Organization •Severe PPH: Blood loss ≥1000 mL within the same time
frame.
•Cumulative blood loss ≥1000 mL or blood loss
[2] accompanied by signs or symptoms of hypovolemia within
American College of Obstetricians and Gynecologists
24 hours after the birth process (includes intrapartum loss)
regardless of route of delivery.
•Minor PPH (500 to 1000 mL) and major PPH (>1000 mL).
[3]
Royal College of Obstetricians and Gynaecologists Subdivisions of major PPH include moderate (1001 to 2000
mL) or severe (>2000 mL).
•Active bleeding >1000 mL within the 24 hours following
[4]
International expert panel birth that continues despite the use of initial measures,
including first-line uterotonic agents and uterine massage.
[5] •Any amount of bleeding that threatens the patient's
Society of Obstetricians and Gynaecologists of Canada
hemodynamic stability.
References: World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva: World Health Organization; 2012.
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin Number 183, October 2017: Postpartum hemorrhage. Obstet Gynecol 2017; 130:e168.
Prevention and management of postpartum haemorrhage: Green-top guideline No. 52. BJOG 2017; 124:e106.
Abdul-Kadir R, McLintock C, Ducloy AS, et al. Evaluation and management of postpartum hemorrhage: Cnsensus from an international expert panel. Transfusion 2014; 54:1756.
Leduc D, Senikas V, Lalonde AB, et al. Active management of the third stage of labour: Pevention and treatment of postpartum hemorrhage. J Obstet Gynaecol Can 2009; 31:980.
Hemostatis upon
placental separation

Mechanical hemostasis :
contraction of the
myometrium
Clotting : local decidual
hemostatic factors
 Risk Factor
• Retained placenta (OR 3.5, 95% CI 2.1-5.8)
• Failure to progress during the second stage of labor (OR 3.4, 95% CI 2.4-4.7)
• Placenta accreta (OR 3.3, 95% CI 1.7-6.4)
• Lacerations (OR 2.4, 95% CI 2.0-2.8)
• Instrumental delivery (OR 2.3, 95% CI 1.6-3.4)
• Large-for-gestational-age (LGA) newborn (OR 1.9, 95% CI 1.6-2.4)
• Hypertensive disorders (OR 1.7, 95%CI 1.2-2.1)
• Induction of labor (OR 1.4, 95%CI 1.1-1.7)
• Augmentation of labor with oxytocin (OR 1.4, 95% CI 1.2-1.7).

Sheiner E, Sarid L, Levy A, Seidman DS, Hallak M. Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage:
a population-based study. J Matern Fetal Neonatal Med. 2005 Sep. 18(3):149-54.
Other risk fx
• Personal or family history of previous PPH • Leiomyoma
• Obesity • Couvelaire uterus
• High parity • Bleeding diathesis, acquired bleeding
diathesis
• Asian or Hispanic race
• Anemia
• Precipitous labor
• Drugs
• Uterine overdistention
• Chorioamnionitis
• Uterine inversion
 Cause of hemorrhage

Tonus Tissue Trauma Thrombin

The “Four Ts” Mnemonic Device for
Causes of Postpartum Hemorrhage

APPROXIMATE INCIDENCE
FOUR TS CAUSE (%)
Tone Atonic uterus 70
Trauma Lacerations, hematomas, 20
inversion, rupture
Tissue Retained tissue, invasive 10
placenta
Thrombin Coagulopathies 1
Symptoms related to blood loss with
postpartum hemorrhage
Blood loss, % (mL) Blood pressure, mmHg Signs and symptoms
Palpitations, lightheadedness, mild
10 to 15 (500 to 1000) Normal
increase in heart rate
Weakness, sweating, tachycardia
15 to 25 (1000 to 1500) Slightly low
(100 to 120 beats/minute)
Restlessness, confusion, pallor,
25 to 35 (1500 to 2000) 70 to 80 oliguria, tachycardia (120 to
140 beats/minute)
Lethargy, air hunger, anuria,
35 to 45 (2000 to 3000) 50 to 70 collapse, tachycardia (>140
beats/minute)

Adapted from: Bonnar J. Massive obstetric haemorrhage. Baillieres Best Pract Res Clin Obstet Gynaecol
2000; 14:1.
Management
• Resuscitation and management of obstetric hemorrhage and, possibly, hypovolemic shock
• Identification and management of the underlying cause(s)
Acute medical management of PPH
 Prevention

Prevention
Prevention

Prevention
Antenatal and intrapartum risk fx for PPH
Risk assessment tool
Prevention Oxytocin administration
(IM/IV, 10 IU))

WHO, ACOG, AAFP,

AWHONN
Active management recommend
of the third stage of administering
Uterine massage uterotonics (usually
labor oxytocin) after all
births

Umbilical cord traction

Case
Mrs. Blynch is a 30y/o P5A0 who just delivered a 4210 gram male infant by spontaneous vaginal
delivery. The placenta delivered spontaneously but your nurse is concerned with the amount of
bleeding she is seeing. The patient did not have an episiotomy and she does have an IV in place
with oxytocin running at this time. The estimated blood loss at the time of delivery was 350cc.

1. Risk Factors?
2. Assessment?
Thank You