As per the World health organization, the quantitative definition of post-partum haemorrhage is arbitrary and is related to the amount of blood loss in excess of 500 ml following the birth of the baby. This statement may be useful for statistical purposes, as the effect of the blood loss is more important rather than the amount of blood lost.

The clinical studies state, “any amount of bleeding from or into the genital tract following the delivery of the new-born up to the end of the puerperium, which affects the general condition of the mother evidenced by the increase pulse rate and falling blood pressure is called postpartum haemorrhage”. In this process, many guidelines define the loss of 500 ml blood in 5 minutes is consider as a PPH but if the mother is having anaemia, the 300 ml blood will affect the condition of the mother.

Incidence:

The incidence widely varies mainly because of a lack of uniformity in the criteria used in the definition. The incidence is about 4–6% of all deliveries.

Objective:

By the end of this exercise, the participant will be able to:

• Identify PPH and its probable cause.
• Provide initial management and refer for specialist care.

Equipment needed for simulation: Mamma Natalie, IV arm, drip stand, BP apparatus, Stethoscope, Tourniquet, Catheterization model, IV set, Inj. oxytocin, Tablet Misoprostol, IV fluids, Iodine solution, 0.5% chlorine solution, PPE, Adhesive tape, long gloves, IV cannula, and drip set, kidney tray, PPH Management box with artificial colour etc.

Articles Required for the Management of PPH

S. No.	Articles and Medicine	Quantity Required
1	Cannula 16,18 gauze	2
2	IV set	2
3	RL and NS	2
4	Inj. Oxytocin	24 ampules (should be kept in the refrigerator or in a vaccine carrier at 2-8oc temp.)
5	20, 10 and 5 cc Syringes	2 each
6	Surgical Gloves	6 pieces
7	Inj. Carboprost	8 ampules should be kept in the fridge
8	Tablet Misoprostol (200 micrograms)	4 tablets
9	EDTA Vial for blood sample (Hb and Blood group)	1
10	Plain Vial for blood sampling	1
11	Condom	5
12	Sterile thread	1
13	Folies catheter and Uro bag	3
14	Chromic Catgut no. 1 & 2	2 each
15	Vicryl sutures No. 1	2 each

Steps	Rationale
Shout for help and mobilize all available health care provider.	Shout for help is important in every critical complication to provide immediate appropriate care to the mother.
Reassure the mother.	Ask her name and how she is feeling.
Assess the vital sign of the mother’s BP, Pulse rate, Respiration rate and volume of Bleeding.	Assessing vital signs help you to diagnose the severity of PPH.
Insert two IV cannulas (wide bore,16-18 gauze)	1 IV line for Oxytocin and another one for Fluid as due to blood loss mother may go to shock.
Take blood for assessing Hemoglobin, Blood grouping and cross-matching	Due to blood loss, there may be blood transfusion required.
Check whether oxytocin has been given in AMTSL. If not, give oxytocin 10 IU IM	AMTSL- Active management of 3rd stage of labour.
Start oxytocin 10 IU in 500 ml of RL at 40–60 drops per minute (Repeat the same) and start plain RL in the second IV Line at 40-60 Drops per minute.	Repeat the same after finishing.
Catheterized and emptied the Bladder.	A filled bladder may be the cause of atonic uterus.
Wash hands and wear sterile gloves.
Palpate and massage the uterus to ensure the uterus is well contracted. Look for the cause of the PPH.	Atonicity of the uterus may cause PPH.
If the uterus is not contracted it indicates an atonic uterus. If the atonic uterus is present start continuous uterine massage and administered Tablet Misoprostol 800 microgram per. Discard the used gloves in a red bin and wear a new pair of gloves	Ensure Clockwise and anti-clockwise massage till the uterus is well contracted (you may feel a cricket ball-like structure
Check for soft-tissue trauma/tear. If 1st and 2nd degrees of tear/trauma/ extension of episiotomy repair it.  If a 3rd or 4th-degree tear is present refer to the higher centre (FRU/DH) for further management	If bleeding is from lacerations, compress with swab or piece of gauze for a few seconds until it is controlled.
Check the Completeness of the placenta and membranes. If Complete Placenta is retained refer to the Higher centre with an oxytocin drip for Manual removal.	If a bit of the Placenta or membrane is left inside the uterus it will cause severe bleeding (PPH). Examination of the placenta is mandatory during 3rd stage of labour to prevent PPH.
If the bleeding has not stopped, move to the next management which is Bimanual compression.
If Bleeding is still not controlled perform Aortic Compression, Uterine balloon tamponed under the supervision of a Specialist/ Lady medical officer.	The presence of a Specialist is mandatory at this stage.
At any point once bleeding is under control start observation and massage the uterus every 15 minutes for the first 2 hours.
Monitor vitals closely every 10 minutes for 30 minutes every 15 minutes for the next 30 minutes, and every 30 minutes for the next 3-16 hours or until the condition is stable.	Monitoring is very important as there is a chance that the condition of the mother is worse again.
In case of tear and retained placenta look for sign of the infection and administer antibiotics.	Antibiotics will be Inj. Ampicillin- 1gm IV, Inj. Gentamicin-80 mg IM and Inj. metronidazole 500 ml IV.
Assess urine output every 4 hours until > 30 ml/hour
If bleeding is still not in control- Document all the steps of management in labour room record and prepare referral slip with complete information. Give prior information to the referral facility.	If the patient needs to be referred, a detailed referral note must be prepared about vital signs, medication given, blood group (if known), etc.
Urgently Refer to higher facility with complete referral note. If available apply NASG Garment.	NASG is used to treat shock, resuscitate, stabilize and prevent further bleeding in women during PPH also will help to safely transfer the women in referral facility for emergency obstetrics care.

Points Should be Remembered:

• PPH is the global leading cause of Maternal death.
• Misuse of Oxytocin during the antenatal and postnatal period must be avoided.
• Active Management of the Third Stage of Labour (AMTSL) is preventing PPH.
• The atonic uterus is the commonest cause of PPH. Studies say’s 70% of PPH cause due to Atonic Uterus.
• Resuscitate patient, catheterize to facilitate uterine contraction, give oxytocin uterine massage to manage atonic PPH.
• MRP must be urgently performed if Atonic PPH occurs with retained placenta
• Traumatic PPH should be surgically repaired under cover of antibiotics
• If the Cervical Tear is less than 0.5 cm dose not required active management until not bleeding excessively.
• Only acute inversion should be managed by manual replacement of uterus. Unnecessarily doing this should be avoided.
• Case of Rupture uterus if not possible to repaired then only move for hysterectomy.

Conclusion:

Reducing postpartum haemorrhage can help lessen the annual number of women who experience severe bleeding associated with pregnancy-related illnesses or deaths. Most of the postpartum haemorrhages that happen can be prevented. Ninety percent of women have no risk factors, while some diseases may make a woman more likely to haemorrhage. As a result, all women must have access to skilled birth attendants (SBAs), who can minimise danger during labour and delivery. Among these is the application of active management of the third stage of labour (AMTSL), which has been linked to a nearly 60% decrease in the incidence of PPH.

References:

• RCOG [Internet]. [cited 2024 Apr 2]. Prevention and Management of Postpartum Haemorrhage (Green-top Guideline No. 52). Available from: https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/prevention-and-management-of-postpartum-haemorrhage-green-top-guideline-no-52/
• Escobar MF, Nassar AH, Theron G, Barnea ER, Nicholson W, Ramasauskaite D, et al. FIGO recommendations on the management of postpartum hemorrhage 2022. International Journal of Gynecology & Obstetrics. 2022;157(S1):3–50.
• Günaydın B. Management of Postpartum Haemorrhage. Turk J Anaesthesiol Reanim. 2022 Dec 1;50(6):396–402.
• Organization WH. WHO Guidelines for the Management of Postpartum Haemorrhage and Retained Placenta. World Health Organization; 2009. 62 p.
• Nadisauskiene RJ, Kliucinskas M, Dobozinskas P, Kacerauskiene J. The impact of postpartum haemorrhage management guidelines implemented in clinical practice: a systematic review of the literature. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2014 Jul 1;178:21–6.
• Rizvi F, Mackey R, Barrett T, McKenna P, Geary M. Successful reduction of massive postpartum haemorrhage by use of guidelines and staff education. BJOG: An International Journal of Obstetrics & Gynaecology. 2004;111(5):495–8.