Postpartum Hemorrhage (PPH) – Causes, Risk Factors, Symptoms, and Management

Postpartum Hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality worldwide. It is defined as excessive bleeding following childbirth and requires immediate recognition and intervention. Although advancements in obstetric care have reduced maternal deaths, PPH continues to be a critical emergency in delivery rooms.

Understanding its definition, risk factors, pathophysiology, clinical presentation, and treatment protocols is vital for nurses, midwives, and physicians to save lives.

Definition of Postpartum Hemorrhage

Vaginal Birth: Loss of more than 500 ml of blood

Cesarean Birth: Loss of more than 1000 ml of blood

Additional Indicator: A 10% drop in hematocrit levels

Even smaller amounts of blood loss can be dangerous in women with anemia or pre-existing conditions, which is why careful monitoring is essential.

Pathophysiology of PPH

The uterus plays a vital role in controlling postpartum bleeding.

• After delivery, the uterus is described as the “living ligature” because it contracts tightly, compressing blood vessels to stop hemorrhage.
• If the uterus fails to contract effectively, bleeding continues.
• This failure to contract is known as uterine atony, the most common cause of PPH.

Full bladder is often the number one reversible cause of uterine atony, as it displaces the uterus and prevents proper contraction.

Signs and Symptoms of Postpartum Hemorrhage

Recognizing PPH early is crucial:

• Hypotonia of the uterus (soft, relaxed)
• Atony or boggy uterus on palpation
• Uterus deviated to the right (due to bladder distension)
• Uncontrolled vaginal bleeding

If untreated, these symptoms can rapidly progress to shock and maternal death.

Risk Factors for Postpartum Hemorrhage

Certain maternal and fetal factors predispose women to PPH:

• Multiple gestations (twins, triplets)
• Polyhydramnios (excess amniotic fluid)
• Macrosomic fetus (> 8 lbs)
• Multifetal gestation
• Prolonged or rapid labor
• Use of uterine relaxants (magnesium sulfate, anesthesia)

Awareness of these risk factors allows for proactive monitoring.

Causes of Postpartum Hemorrhage

The 4 T’s mnemonic helps recall the major causes:

Tone: Uterine atony (most common)

Tissue: Retained placenta or clots

Trauma: Lacerations of the cervix, vagina, or perineum

Thrombin: Coagulopathies interfering with clotting

Drugs for Management of PPH

A systematic drug approach is used, often remembered by the mnemonic “Oh My Hemorrhage” – indicating the order in which medications are administered.

1. Oxytocin (“Pitocin”)

Action: Stimulates contraction of the uterine smooth muscle.

Use: First-line treatment for PPH.

Administration: IV/IM.

2. Methergine (“Methylergonovine”)

Action: Causes vasoconstriction to contract the uterus.

Contraindication: Not to be used in patients with hypertension (increases blood pressure).

3. Hemabate (Carboprost Tromethamine)

Action: Prostaglandin that stimulates uterine contractions and controls bleeding.

Contraindication: Avoid in patients with asthma (bronchospasm risk).

4. Misoprostol

Action: Stimulates uterine contractions.

Administration: Often given rectally for rapid absorption.

Non-Pharmacological Interventions

Fundal massage: Encourages uterine contraction.

Bladder emptying: Prevents displacement of the uterus.

IV fluids and blood transfusion: To manage hypovolemic shock.

Surgical interventions (if uncontrolled):

• Uterine tamponade (Bakri balloon)
• Artery ligation
• Hysterectomy (as a last resort)

Clinical Management Algorithm

1. Assess and call for help (multidisciplinary response).

2. Massage the uterus and ensure bladder is empty.

3. Administer oxytocin (first-line drug).

4. If bleeding persists → Methergine (unless hypertensive).

5. If still uncontrolled → Hemabate (unless asthmatic).

6. Misoprostol as an additional option.

7. If medical management fails → move to surgical options.

Summary Table of Drugs

Drug	Action	Contraindication	Route
Oxytocin	Uterine smooth muscle contraction	None specific	IV/IM
Methergine	Vasoconstriction, uterine contraction	Hypertension	IM/PO
Hemabate	Prostaglandin, uterine contraction	Asthma	IM
Misoprostol	Uterine contraction	None specific	Rectal/Oral

Clinical Importance

• PPH is preventable and treatable when recognized early.
• Nursing staff must monitor fundal tone, lochia, vital signs, and urine output after delivery.
• Education of healthcare workers in active management of the third stage of labor (AMTSL) significantly reduces PPH risk.

FAQs on Postpartum Hemorrhage

Q1. What is the most common cause of postpartum hemorrhage?

Uterine atony – the uterus fails to contract effectively.

Q2. How much blood loss is considered normal after birth?

Up to 500 ml in vaginal birth and 1000 ml in cesarean birth is considered within normal limits. Beyond this, it is PPH.

Q3. Why is methergine contraindicated in hypertension?

Because it causes vasoconstriction, leading to increased blood pressure.

Q4. What is the last resort treatment for uncontrolled PPH?

Hysterectomy may be required if bleeding cannot be controlled by drugs or less invasive procedures.

Q5. Can postpartum hemorrhage be predicted?

Certain risk factors increase likelihood, but it can occur unexpectedly even in low-risk women. Hence, preparedness is essential.