POSTPARTUM HEMORRHAGE (PPH)

Women Health (MFD 3122)

Diploma of Physiotherapy
Universiti Industri Selangor
 Definition
• PPH is defined as an excessive bleeding following
the birth of the baby.
• May occur before or after delivery of the placenta.
• About 4% women with postpartum hemorrhage and
it’s likely with a Cesarean birth.
• Average amount blood loss in vaginal delivery is
500mL
• Average amount blood loss in Cesarean birth is
1000mL
 Epidemiology
• PPH can cause severe mortality and morbidity
• According to CDC data, 17% of maternal mortality
is due to hemorrhage.
• It though to be one third to one half cases
• PPH occur in women childbearing age
 Causes
• PPH can be causes by 4 T’s:
• Tone/uterine atony
- Failure of uterus to contract and retraction
- Over distension of the uterus major risk for atony
- Poor contraction result from fatigue due to
prolonged labor / rapid forceful labor (if
stimulated)
- It also can result from inhibition of contractions by
drugs
 Normal postpartum with Uterine atony allows
contracted uterus preventing hemorrhage to flow into the
from bleeding uterus
Cont.
1. Trauma
- Delivery may tear tissue and vessels to significant
postpartum hemorrhage.
- Cesarean delivery results in twice average blood
loss of vaginal delivery
- It may occur during prolonged labor or vigorous
labor (uterus stimulated by the oxytocin and
prostaglandin)
- It also may occur during remove the retained
placenta manually or instrumentally that lead to
cervix laceration.
 Cont.
1. Thrombosis
- fibrin deposition over placenta site and clots within
supplying vessels play a significant role in hour and days
following delivery and lead to late PPH.
2. Tissue
- Retention of placenta is more common.
- It likely to retained at extreme preterm gestation (<
24weeks) and significant bleeding may occur.
- Failure complete separation of placenta can occur in
placenta accreta
- Placenta implanted over a previous scar tissue especially
if associated with placenta previa
 Pathology
• Over period of pregnancy, maternal blood volume
increase approximately 50%(4L – 6L).
• Plasma volume increase than total RBC volume cause
fall in hemoglobin concentration and hematocrit volume.

• Increase blood volume serves to fulfill the perfusion

demand of low-resistance utero-placenta and provide a
reserve for blood loss that occurs at delivery
• Estimated blood flow to the uterus 500-800mL/min,
which constitutes 10-15% CO. most of this flow
traverses to the low-resistance placental bed
 Cont.
• The uterine blood vessels that supply placental site
traverse a weave of myometril fibers. As these
fibers contract during delivery, retraction occurs.
• Characteristics of retraction is to maintain its
shortened length following each successive
contraction.
• Then the blood vessels is compressed and kinked
by crisscross latticework and normally blood flow is
quickly occluded.
• This arrangement of muscle bundles has been
referred as living ligatures or physiologic sutures.
 Classifications
1. Primary Postpartum Hemorrhage
• Also known as early PPH
• Defined as bleeding from genital tract during the 1st 24 hours
after birth
• May occur before or after the third stage of labor is
completed.
2. Secondary Postpartum Hemorrhage
• Also known as delayed PPH
• Defined as excessive bleeding from the genital tract with a
blood loss of 400mL / more
• Occur after the first 24 hours following delivery until 6th week
puerperium.
Sign and symptoms
• Uncontrolled bleeding (>2pad/30min)
• Decrease BP
• Increase heart rate
• Decrease in the RBC count
• Swelling and pain
• Lightheadedness, nausea and visual disturbance
• Anxiety, pale and clammy skin
• Increase pulse rate and respiratory rate
Risk factor
• Multiple gestation
• Large baby
• Polyhydramnias
• Nulliparity or multiparity (multiple pregnancy)
• Prolonged labor
• Asian or Hispanic women
• Placenta previa
• Placenta accreta
• Previous PPH
• Forcep and vacum delivery
Complications
• Associated with blood transfusion
• Consumptive coagulopathy
• Disseminated intravascular coagulation
• Bleeding disorder
• Shock
• Collapse
• Multiple organ failure associated with circulatory
collapse and decreased organ perfusion
 Diagnosis
• Doctor will do physical examination by checking:
1. Temperature – elevated temperature indicate
endometritis that can lead second postpartum
hemorrhage
2. Pulse rate and blood test – help to determine
presence shock
3. Vaginal examination to determine if opening of the
cervix is open or closed and vaginal discharge is
offensive.
4. Examine genital area to look any lacerations, tears or
episiotomy that may lead to PPH
 Doctor management
• There are 2 doctor management:
1. Non-conservative
2. Conservative
• Non-conservative
• Oxytocin – IM administered where it can stimulate
upper segment of myometrium to contract rhythmically
• Ergometrine and methylergonovine (methergine)
- generalized smooth muscle contraction in
upper and lower segment of the uterus to
contract tetanically. Administered by IM
Cont.
 Prostaglandin - enhances uterus contractility and causing
vasoconstriction. The most common of prostaglandin such
as 15-methyl prostaglandin F, or carboprost (Hemabate).
Administered IM.
 Misoprostol - another type of the prostaglandin that
increases uterine tone and decreases postpartum
bleeding. Administered by orally, vaginally and rectally.
 Syntometrine - combination with oxytocin and ergometrine.
Injection is given just after the birth of the child to stimulate
the womb to contract.
 Cont.
• Conservative
• Uterovaginal packing – packing the uterus with sponges
and sterile materials
• Uterine curettage – also known as dilation and
curettage (D&C). To remove remaining tissue in uterus.
Doctor will use dilator to open cervix and insert hollow
tube through cervix. Then suction performed to
removed retain tissue.
• Laporotomy – an incision to gain access to abdominal
cavity before hysterectomy take place
 Cont.
• Hysterectomy – surgical removal of uterus. Types of
hysterectomy such as radial hysterectomy (complete
removal of the uterus, upper vagina, and parametrium),
subtotal hysterectomy (removal of the fundus of the
uterus, leaving the cervix in situ) and total hysterectomy
(Complete removal of the uterus including the corpus and
cervix)
• Bakri balloon catheter – used for temporary control or
reduction PPH. Used with guidance of ultrasound
• Sengstaken-Blakemore tube - used to tampon the uterus it
reduced need for surgery or embolization in most patients
and was also useful for controlling bleeding while patients
waited for such procedures.
• Foley catheter - type of catheters with a 30 mL
balloon that use to tampon the uterus. It’s inserted
behind the cervical wall and inflated

Foley catheter

Bakri balloon catheter

 Physiotherapy management
• Bimanual Examination / Speculum Examination
• Bimanual / Uterine massage
1. Johnson method
2. Internal bimanual massage
3. External bimanual massage
Cont.
• Breathing / relaxation technique – to control or
slowing down patient’s heart rate.
• Patient education
• breastfeeding. It allow patient to secrete their
own oxytocin to help contract the uterus and
expel the placenta.
• warned patient not to do exercise that can
cause excessive stress to the uterus.
Cont.
• Bimanual or uterine massage technique .

Internal Bimanual massage technique

for the uterine atony
 Cont.

Johnson’s Method 3
Cont.

External bimanual/uterine massage

Cont.
• Exercise for postpartum
• Day 1 – pelvic tilt, abdominal breathing, ankle circles
(where to enhance circulation
• Day 2-7 – leg sliding exercise, arm and upper back
stretch
• After 1st week – straight curl-up, sits-up, diagonal sits-
up, gentle aerobic exercise (walking)
• Patient’s education
1. Lifting and moving
2. Bending
3. Protect posture