Postpartum Haemorrhage
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Direct answer
Postpartum haemorrhage (PPH) is blood loss of 500 mL or more after a vaginal birth (about 1000 mL at caesarean) within 24 hours; bleeding from 24 hours to six weeks is secondary PPH. Uterine atony causes the large majority, so management starts the moment the uterus feels soft — massage, empty the bladder and step up uterotonics (oxytocin, ergometrine barring hypertension, misoprostol, carboprost) alongside resuscitation with two wide-bore cannulae and crossmatched blood. If drugs fail, escalate mechanically — balloon tamponade, B-Lynch compression suture, stepwise uterine artery and internal iliac ligation — with hysterectomy as the life-saving last resort. PPH remains a leading direct cause of maternal death in India, hence universal active management of the third stage.
What you must remember
- Primary PPH: 500 mL or more within 24 hours of vaginal birth (about 1000 mL at caesarean); secondary PPH: excessive bleeding from 24 hours to six weeks, usually retained tissue or sepsis.
- The 4T causes: tone (atony, 70 to 80 per cent), trauma (tears, rupture, inversion), tissue (retained placenta or clots, accreta) and thrombin (coagulopathy).
- Atony risk factors: prolonged labour, overdistended uterus (twins, polyhydramnios), grand multiparity, anaemia, chorioamnionitis and prolonged oxytocin use.
- Uterotonic ladder: oxytocin 10 units IM or 5 units slow IV; ergometrine 0.2 mg IM or IV (avoided in hypertension and heart disease); misoprostol 800 micrograms sublingually; carboprost 250 micrograms IM every 15 minutes to 8 doses (avoided in asthma).
- Surgical ladder: bimanual compression, balloon tamponade (Bakri or Foley), B-Lynch suture, stepwise uterine artery ligation, internal iliac ligation, then hysterectomy.
- Trauma needs direct repair — inspect cervix, vagina and perineum after every instrumental birth; acute inversion is repositioned at once.
- Prevention: active management of the third stage with prophylactic oxytocin, controlled cord traction and massage; high-risk women deliver where blood and surgery exist.
Common confusion
Examiners test cause-directed thinking: a contracted uterus that still bleeds points to trauma (inspect and repair) or retained tissue (evacuate), while a soft boggy uterus is atony (massage and uterotonics). Drug contraindications are a favourite — ergometrine in preeclampsia and carboprost in asthma are the wrong answers. Secondary PPH with fever and foul discharge is retained products with sepsis — antibiotics and evacuation, not repeat uterotonics alone.
Exam-focused takeaway
FMGE PPH items are sequence and contraindication questions: order the uterotonic ladder, identify the 4T from a vignette (soft uterus after twins — atony), and pick balloon tamponade as the first mechanical step after drugs. Know exact doses, the 500 and 1000 mL definitions, and internal iliac ligation before hysterectomy. As a leading killer of Indian mothers, PPH is guaranteed marks — treat it as such.
Frequently asked questions
How is postpartum haemorrhage defined?
Blood loss of 500 mL or more within 24 hours of a vaginal birth (about 1000 mL at caesarean); excessive bleeding from 24 hours to six weeks is secondary PPH.
What is the commonest cause of primary PPH?
Uterine atony, about three-quarters of cases — hence massage, bladder emptying and uterotonics come before rarer causes.
Which uterotonics are used, in what doses?
Oxytocin 10 units IM or 5 units slow IV; ergometrine 0.2 mg; misoprostol 800 micrograms sublingually; carboprost 250 micrograms IM every 15 minutes to a maximum of eight doses.
What is done when drugs fail in atonic bleeding?
Escalate mechanically — balloon tamponade, then B-Lynch compression suture, stepwise uterine artery ligation, internal iliac ligation, and hysterectomy if bleeding continues.
Why is carboprost avoided in asthma?
It is a prostaglandin F2 alpha analogue that bronchoconstricts and can precipitate severe bronchospasm.
What causes secondary postpartum haemorrhage?
Most often retained products with endometritis, sometimes subinvolution — managed with antibiotics and careful evacuation rather than uterotonics alone.