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Postpartum Hemorrhage


  1. Blood loss of 500 mL (normal delivery) & 1 ltr (LSCS) or more after completion of third stage of labor.
  2. ACOG definition: Bleeding which causes Hct to decrease by 10% or the need of blood transfusion after delivery.

Remember 4Ts =


       T1 = Tone (Poor Uterine contraction)


       T2 = Tissue (Retained products)


       T3 = Trauma (to genital tract)


       T4 = Thrombin (Coagulation abnormalities)

Predisposing Factors and Causes of Immediate Postpartum Hemorrhage


Bleeding from placental implantation site

Hypotonic myometrium-uterine atony (MC)

  1. Hypertensive disorders
  2. Antepartum hemorrhage
  3. Over distended uterus -large fetus, twins, and hydramnios
  4. Following prolonged labor
  5. Following very rapid labor
  6. Following oxytocin-induced or augmented labor
  7. High parity
  8. Uterine atony in previous pregnancy
  9. Chorioamnionitis
  10. Drugs-tocolytic agents, halothane
  11. Retained placental tissue
  12. Avulsed cotyledon and succenturiate lobe
  13. Abnormally adherent-accreta, increta, and percreta

Trauma to the genital tract


Large episiotomy, including extensions Lacerations of perineum, vagina, or cervix Ruptured uterus

Coagulation defects


Intensify all of the above

Important points in management of atonic PPH

  1. Rapid, continuous infusion of dilute IV oxytocin (40-80 U) in 1L NS to be started.
  2. Methergine: 0.2 mg IM repeat every 5 mins as needed up to 5 doses.
  3. The 15-methyl derivative of prostaglandin F2a (carboprost tromethamine) is used for uterine atony. The initial recommended dose is 250 μ (0.25 mg) given intramuscularly, and this is repeated if necessary at 15-90 min intervals up to a maximum of eight doses.
  4. Misoprostol, a synthetic prostaglandin El analog, is also effective for the treatment of uterine atony. WHO recommends that misoprostol (800 μg) be given rectally.
  5. An intravenous bolus of 10 units of oxytocin causes a transient but followed by an abrupt increase in cardiac output.
  6. Oxytocin should not be given intravenously as a large bolus, but rather as a much more dilute solution by continuous intravenous infusion or as an intramuscular injection.
  7. The half-life of intravenously infused oxytocin is approximately 3 minutes. Prolonged oxytocin administration can cause water intoxication due to its antidiuretic action
  8. Shivkar's pack: Condom inflated with saline acts as tamponade.
  9. Internal iliac artery ligation:
    1. Ligation of the internal iliac arteries (anterior division) at times reduces the hemorrhage appreciably.
    2. The most important mechanism of action with internal iliac artery ligation is an 85-percent reduction in pulse pressure in those arteries distal to the ligation.
    3. This converts an arterial pressure system into one with pressures approaching those in the venous circulation and more amenable to hemostasis via simple clot formation. Bilateral ligation of these arteries does not appear to interfere with subsequent reproduction.
  10. Uterine compression sutures:
    1. In 1997, B-Lynch described a surgical technique for severe postpartum hemorrhage in which a pair of vertical brace chromic sutures were secured around the uterus, giving the appearance of suspenders, to compress together the anterior and posterior walls.
    2. Hayman sutures
    3. Cho square sutures
    4. Gunshella sutures
  11. Uterine artery embolization.
  12. Medical management: Atonicity is the most common cause of PPH. Any drug which increases the tone of uterus or the force of contraction is used to control PPH and is called oxytocic. Ref. Dutta Obs. 71e, p416
  13. Commonly used oxytocics in the management of PPH




Dose frequency

Side effects



10-40 units in 1 L of crystalloid solution

First line: IV, second line: IM (10 units)

Continuous IV

Nausea, Water intoxication

Not as IV bolus, otherwise none


0.2 mg

First line IN/IV, second line PO

Every 2-4 hours

Nausea, vomiting, Hypertension

Hypertension, Preeclampsia

15 methyl PGF

0.25 mg

First line IM, second line intrauterine

Every 15-90 min. (8 doses maximum)

Nausea, Vomiting, Diarrhea, Chils

Bronchial asthma, Active cardiac, Renal of hepatic disease

Misoprostol (PGE1)

600-1000 mcg

First line PR, second line PO

Single dose

Fever tachycardia


In case of massive haemorrhage if medical methods fail then either mechanical or surgical methods should be adopted.

Mechanical methods- include

  1. Bimanual compression
  2. Uterine packing under anesthesia
  3. Balloon tamponade with a Sengstaken tube inserted into the uterus.



Details of Surgical method

  1. B lynch Suture (Brace suture) is an alternative to vessel ligation technique in the surgical management of PPH. B lynch suture involves the use of vertical brace sutures, which oppose the anterior and posterior walls of the uterus, which leads to compression of the fundus and the lower uterine segment, thereby controlling the hemorrhage.
  2. The main advantage is that it is very easy to perform and may obviate the need for a hysterectomy.
  3. It is commonly performed at cesarean section but can also be done after vaginal delivery.

Fig: Lynch suture

Application of block sutures (multiple square sutures): The anterior and posterior uterine walls are approximated until no space is left in uterine cavity using block sutures / multiple squares.

  1. Uterine and ovarian artery ligation: It is easier than internal iliac artery ligation and can be tried as the first resort.
  2. Internal iliac artery ligation (anterior division): It should be considered before hysterectomy, especially in nullipara, as the uterus can be preserved.
  3. The artery is ligated about 3 cm from common iliac artery. It will ensure that posterior division is not included in the ligature, as it may lead to loss of lower limb sensation (femoral artery and dorsalis pedis artery are branches of posterior division.
  4. Arterial embolization: Done when patient is hemodynamically stable and good radiological facilities are available.
  5. Under fluoroscopic guidance femoral artery is catheterised, the bleeding vessel identified and embolisation is carried out using gel foam.
  6. Hysterectomy: It is the most definitive method of controlling PPH and should be the last resort.

Extra edge:


In Mechanical methods-Shivkars pack i.e condom inflated with saline can also be used as a tamponade.


Besides B lynch sutures, other sutures which can be applied on the uterus for managing PPH are-

  1. Haymann suture
  2. Cho square suture
  3. Gunshella suture


Fig: Uterine and ovarian artery ligation

Fig: Internal iliac artery ligation

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