1. Definition:

PPH is defined as excessive vaginal bleeding (more than 500mls) from the genital tract after the birth of the child.

2. Types:

1. Primary (immediate): PPH that occurs within the first 24 hours after delivery.
2. Secondary: PPH occurs after the first 24 hours until 6 weeks after delivery.

PPH accounts for the majority of maternal deaths from hemorrhage and in the Sudan there is a lot of effort that need to be done to reduce the maternal deaths from PPH.

3. Predisposing factors:

1. Excessive uterine distension (twins, poly hydramnios, large baby).
2. Multiparity  (the uterine muscles are week and thin).
3. Prolonged labour.
4. Vaginal delivery.
5. Placenta praevia.
6. Deep anesthesia.
7. Accidental hemorrhage with couvelaire uterus (the uterus will fail to contract).
8. DIC usually associated with concealed placental abruption.

4. Causes:

1. Uterine atony (the uterus fails to contract, this is the commonest).
2. Retained placenta (the placenta fails to separate completely).
3. Uterine rupture.
4. Cervical tear.
5. Vaginal tear.

5. Consequences of PPH:

1. Circulatory failure (shock and death).
2. Puerperal anemia.
3. Maternal morbidity.
4. Acute renal failure.
5. Pituitary necrosis (Sheehan's syndrome).

6. Clinical picture:

• History.
• Examination:
  • If the patient is shocked there are signs of shock.
  • Vaginal bleeding.
  • The placenta, if retained you find the cord, and the uterus at the umbilicus very soft.

7. Prevention:

• This very important, so during booking of the pregnant woman any risk factor (grand multiparity, twins or history of PPH before) should be underlined and advice given.
• Correction of anemia during pregnancy.
• Prolonged labour must be prevented.
• Correct procedure to deliver the placenta should be used (avoid Crede's method).
• Use of syntocinon or ergometrine for management of third stage.

8. Treatment:

The treatment of primary PPH is based on 2 principles:

1. Stop the bleeding.
2. Restore the blood volume.

8.1. Treatment if the placenta not delivered:

• By abdominal examination ascertain  whether uterus is contracted (firm) or not (soft).
• If the uterus is soft (not contracted) you need to stimulate a contraction by rubbing on the fundus (per abdomen).
• Give I.V syntometrine or I.V syntocinon.
• The placenta may be separated but not delivered. Sign of that when you pull on the cord (Brandt-Andrew's method) the cord will lengthen.
• Examination of the placenta.
• If the there is a missed lobe, the woman should taken to theatre for manual removal under anesthesia (general).
• Bimanual compression.
• I.V. line with I.V. syntocinon or I.M.
• If the placenta has not separated and on V/E there are no signs of separation provided I.V. oxytocin been given, manual removal of the placenta should be done.
• If after manual removal bleeding is still going on, either ligation of internal iliac  arteries or hysterectomy may be the resort.

8.2. Treatment if the placenta is delivered:

• Feel the uterus if it is soft stimulate a contraction.
• I.V. syntocinon or ergometrine.
• In case of the uterus being firm (contracted) & bleeding is still there is a possibility of cervical or vaginal laceration or rupture uterus. DIC is a possibility if there is predisposing factor.
• Hysterectomy may be the last resort if the bleeding does not stop with all the measures taken.

9. Post-partum collapse:

• It occurs secondary to post-partum hemorrhage in almost all cases.
• Rarely it can occur due to a medical problem complicating the pregnancy or labour, like cerebral malaria, CVA, diabetic hypoglycemia, etc…
• The clinical picture is very obvious, the patient who delivered just now had a PPH and develop symptoms of collapse.
• History is straight forward.
• Examination: the patient is drowsy or in coma, rapid thready pulse, very low BP, and post-partum bleeding ongoing.

9.1. Treatment:

1. I.V. line or venesection.
2. I.V. fluids.
3. Immediate blood transfusion, or plasma (Rh -ve blood in case of delayed cross- matched).
4. The observation of the patient with the foot of bed raised.
5. DIC: if bleeding persists in spite of all those measures.

10. Primary post-partum hemorrhage from laceration:

• Vagina.
• Cervical tear.
• Ruptured uterus.
• Diagnosis: when the bleeding continues after the placenta has been delivered and the uterus is firmly retracted.
• EUA  and management.

11. Secondary PPH:

Occurs more than 24hrs after delivery-up to 6wks after delivery.

11.1. Causes:

• Usually retention of a piece of placenta.
• Infection.
• Separation of a slough that has formed on a cervical or vaginal tear.

11.2. Diagnosis:

• History.
• Examination.
• USS.

11.3. Treatment:

• EUA and exploration of the uterus with the finger or sponge forceps.
• C/S of cervical swab.
• Antibiotic if there infections.