19/07/2025
📌 Topic: What is PPH? Why does it occur, and what are its causes? How should a nurse manage a patient with Postpartum Hemorrhage (PPH)? Learn below 👇
🔴 PPH (Postpartum Hemorrhage) is excessive bleeding after childbirth. It primarily occurs due to lack of uterine contraction or failure of the uterus to clamp down after delivery. As a result, blood vessels remain open, leading to continued bleeding. Retained placenta, birth-related trauma, or blood clotting disorders can also contribute.
Generally, if blood loss exceeds 500 mL after va**nal delivery or 1000 mL after cesarean section within 24 hours, it is termed as PPH.
✅ Causes of PPH (The 4 Ts):
PPH typically results from four major causes, known as the 4 Ts:
1. Tone (Uterine Atony or Failure of Uterine Contraction):
When the uterus does not contract properly, bleeding does not stop.
🔹 Causes:
Overdistended uterus (e.g., twin pregnancy, large baby, polyhydramnios)
Prolonged or rapid labor
Uterine exhaustion
Abnormal uterine structure or defects
Prior uterine surgery or trauma
2. Tissue (Retained Placenta):
If any part of the placenta remains inside the uterus, it can cause bleeding.
🔹 Causes:
Placenta Accreta (deeply attached placenta)
Partial or complete retention of the placenta
Retained placental membranes
3. Trauma (Ge***al Tract Injury):
Injuries to the va**na, cervix, or uterus during delivery can lead to bleeding.
🔹 Causes:
Vaginal tears during delivery
Cervical or deep va**nal lacerations
Injuries from cesarean section or surgical procedures
Trauma from forceps or vacuum extraction
4. Thrombin (Coagulopathy or Blood Clotting Disorders):
When the body cannot form clots properly, PPH may occur :
🔹 Causes:
Pre-existing bleeding disorders (e.g., Von Willebrand Disease)
Hemorrhagic shock during pregnancy or delivery
Amniotic fluid embolism
Infection-related sepsis
5. Other Contributing Factors:
Uterine anomalies
Uterine fibroids
Multiple pregnancies
Prolonged labor
✅ Risk Factors for PPH:
✔️Certain conditions increase the risk of PPH:
1. Maternal History:
Previous PPH
History of uterine surgery
2. Pregnancy Complications:
Twin pregnancy
Placental abnormalities (placenta previa, placental abruption)
Polyhydramnios
3. During Labor:
Prolonged labor
Emergency cesarean section
Overuse of oxytocin
Use of instruments (forceps or vacuum)
✅ Nursing Management of Postpartum Hemorrhage (PPH):
👉 1. Initial Assessment and Stabilization:
Assess the patient’s condition and ensure life-saving interventions.
🔹 Assess Vital Signs:
Evaluate ABC (Airway, Breathing, Circulation)
Place the patient in a flat position
Monitor vital signs closely
Look for signs of hypovolemic shock (e.g., rapid pulse, low blood pressure, pale skin)
🔹 Check Blood Loss:
Estimate bleeding by weighing soaked pads or measuring suction device contents
🔹 Monitor Uterus:
Palpate to determine if the uterus is firm or boggy (soft) — a soft uterus indicates poor contraction
👉 2. Immediate Interventions:
A. Manage Uterine Atony (Most Common Cause):
i. Uterine Massage:
Perform firm fundal massage to stimulate uterine contraction
This is the most effective initial measure for atonic bleeding
ii. Uterotonic Drugs:
Oxytocin: 10 IU IM or 20 IU in 1L IV fluid
Misoprostol: 800–1000 mcg rectally
Ergometrine: 0.2 mg IM (contraindicated in hypertension or preeclampsia)
Carboprost: 250 mcg IM every 15–90 minutes (up to 8 doses)
iii. Empty the Bladder:
Insert catheter to prevent full bladder from interfering with uterine contraction
B. Treat Retained Products (Tissue):
Assist the doctor in manual removal of retained placenta or membranes
C. Manage Trauma:
Examine the cervix, va**na, and perineum for injuries and assist in repair or suturing
D. Manage Coagulopathy (Thrombin):
If clotting disorders are suspected, administer appropriate blood products (e.g., FFP, platelets)
👉 3. Fluid Resuscitation and Blood Replacement:
i. Establish IV Lines:
Insert two large-bore IV cannulas
ii. Administer Fluids:
Use isotonic solutions (e.g., Ringer’s lactate, Normal saline) to restore circulating volume
iii. Blood Transfusion:
Crossmatch blood and keep ready for transfusion if needed
iv. Monitoring and Documentation:
🔹 Continuous Monitoring:
Observe vital signs, uterine tone, and ongoing bleeding
Monitor urine output (should be at least 30 mL/hour)
🔹 Documentation:
Record all treatments, medications, patient responses, and amount of blood loss
👉 4. Emotional Support:
Reassure the patient and her family about the care being provided
Provide emotional and psychological support to reduce stress
👉 5. Collaboration with the Healthcare Team:
If initial measures fail, immediately notify the obstetrician
Assist with advanced interventions such as:
✓ Uterine tamponade (e.g., Bakri balloon)
✓ Surgical procedures (e.g., uterine artery ligation, hysterectomy)
👉 6. Preventive Measures:
🔹 Active Management of the Third Stage of Labor (AMTSL):
Administer uterotonics immediately after delivery
Use controlled cord traction for placental delivery
Massage the uterus after delivery
🔹 Identify Risk Factors:
Monitor patients with multiple pregnancies, prolonged labor, or prior history of PPH
