Diagnosis and Management of Postpartum Hemorrhage:

A Review
*Fitra Rizia

* Department of Obstetrics and Gynecology, Faculty of Medicine Syiah Kuala University

Abstract
One of the Millennium Development Goals set by the United Nations in 2000 is to reduce
maternal mortality by three-quarters by 2015. If this is to be achieved, maternal deaths related
to postpartum haemorrhage (PPH) must be significantly reduced. PPH is generally defined as
blood loss greater than or equal to 500 ml within 24 hours after birth, while severe PPH is
blood loss greater than or equal to 1000 ml within 24 hours. Excessive bleeding affects
approximately 5 to 15 percent of women after giving birth. The etiologies of early PPH are
most easily understood as abnormalities of one or more of four basic processes. Bleeding
will occur if for some reason the uterus is not able to contract well enough to arrest the
bleeding at the placental site. Retained products of conception or blood clots, or genital tract
trauma may cause large blood losses postpartum, especially if not promptly identified.
Coagulation abnormalities can cause excessive blood loss alone or when combined with one
of the other processes. As a memory aid these processes can be thought of as the four Ts;
Tone, Tissue, Trauma and Thrombin. Effective team management of PPH involves
recognition, communication, resuscitation, monitoring and investigation and directed
treatment. Once a PPH has been recognised these components should be conducted
simultaneously for optimal patient care.

Keywords: postpartum hemorrhage, management

I. Introduction mortality ratio to less than 70 per 100 000

Since 1990 reducing deaths from
complications of pregnancy and childbirth
has been high on the international agenda,
spearheaded through Millennium
Development Goal 5 which had the aim of
reducing maternal mortality by 3 quarters
by 2015. While the global number of
maternal deaths was reduced by 43%
during this period, some countries made
little progress and the overall number of
maternal death remains unacceptably
high1. With the introduction of the
Sustainable Development Agenda which
will cover the period 2016-2030, the
international community has been set a
new target - to reduce the global maternal
live births.1
PPH is generally defined as blood
loss greater than or equal to 500 ml within
24 hours after birth, while severe PPH is
blood loss greater than or equal to 1000 ml
within 24 hours. PPH is the most common
cause of maternal death worldwide. Most
cases of morbidity and mortality due to
PPH occur in the first 24 hours following
delivery and these are regarded as primary
PPH whereas any abnormal or excessive
bleeding from the birth canal occurring
between 24 hours and 12 weeks
postnatally is regarded as secondary
PPH..1
 PPH may result from failure of the
uterus to contract adequately (atony),
genital tract trauma (i.e. vaginal or cervical
lacerations), uterine rupture, retained
placental tissue, or maternal bleeding
disorders. Uterine atony is the most
common cause and consequently the
leading cause of maternal mortality
worldwide. In practice, blood loss after
delivery is seldom measured and it is not
clear whether measuring blood loss
improves the care and outcome for the
women. In addition, some women may
require interventions to manage PPH with
less blood loss than others if they are
anaemic.1,2
Risk factors for PPH include grand
multiparity and multiple gestation.
However, PPH may occur in women
without identifiable clinical or historical
risk factors. It is therefore recommended
that active management of the third stage
of labour be offered to all women during
childbirth, whenever a skilled provider is
assisting with the delivery (1). Active
management should include: (i)
administration of a uterotonic soon after
the birth of the baby; (ii) clamping of the
cord following the observation of uterine
contraction (at around 3 minutes); and (iii)
delivery of the placenta by controlled cord
traction, followed by uterine massage.3,4
Even with these efforts to prevent
PPH, some women will still require
treatment for excessive bleeding. Multiple
interventions (medical, mechanical,
invasive non-surgical and surgical
procedures), requiring different levels of
skill and technical expertise, may be
attempted to control bleeding. Effective
treatment of PPH often requires
simultaneous multidisciplinary
interventions. The health care provider
needs to begin resuscitative efforts
quickly, establish the cause of the
haemorrhage, and possibly obtain the
assistance of other care providers, such as
an obstetrician, anaesthetist or radiologist.
Avoiding delays in diagnosis and
treatment will have a significant impact on
sequelae and chance of survival. These
guidelines therefore include care
pathways (or algorithms) for management
of PPH, as a practical guide for clinicians.
2,4
This article is a review from several
guidelines and another recent study related
PPH management.
II. Definition
During a WHO informal meeting
of experts in 1989, PPH was dened as
the loss of 500mls or more of blood from
the genital tract after delivery of the
baby.2 This denition has been widely
cited, and has been relatively unchallenged
until recently, despite the meetings report
acknowledging 500 ml as an arbitrary
gure and not always of great clinical
signicance. In recent years, professional
societies have developed definitions with
more clinical signicance. The Royal
College of Obstetricians and
Gynaecologists (RCOG) in 2011 endorsed
the 500 ml threshold in their denition of
Minor PPH, although it stated that 1000
ml (or a lesser volume with clinical shock),
should be classed as Major PPH. They
recommend readiness for resuscitation in
response to blood loss 5001000 ml, but a
full protocol of measures when the blood
loss reaches 1000 ml or there are clinical
signs of shock.5
The American College of
Obstetricians and Gynecologists (ACOG)
held a modied Delphi vote of its
members in 2014 to reach a consensus on a
PPH denition. They dismissed the 500 ml
cutoff, endorsing in its place a denition of
greater or equal to 1000 ml or blood loss
with signs or symptoms of hypovolemia.4
The WHO avoided a specic
recommendation in their 2012 guidelines,
instead commenting that PPH is
commonly dened as blood loss 500 ml or
more.5 The most recent WHOendorsed
denition was instead for Severe PPH,
dened by the WHO Working Group on
Maternal Mortality and Morbidity
Classications as genital bleeding after
delivery, with at least one of the following:
perceived abnormal bleeding (1000 ml or
more) or any bleeding with hypotension or
blood transfusion.5
III. Etiology
Excessive bleeding affects
approximately 5 to 15 percent of women
after giving birth.7,11,13,14 The etiologies
of early PPH are most easily understood as
abnormalities of one or more of four basic
processes. Bleeding will occur if for some
reason the uterus is not able to contract
well enough to arrest the bleeding at the
placental site. Retained products of
conception or blood clots, or genital tract
trauma may cause large blood losses
postpartum, especially if not promptly
identified. Coagulation abnormalities can
cause excessive blood loss alone or when
combined with one of the other processes.
As a memory aid these processes can be
thought of as the four Ts; Tone, Tissue,
Trauma and Thrombin.5,6
In the population-based studies,
the incidence of PPH is around 5% of
deliveries in the absence of a precise
measurement of blood loss and around
10% when it is quantified. The incidence
of severe PPH is around 2%. Uterine atony
is the principal cause of PPH. Lacerations
of the genital tract are responsible for
approximately 1 of every 5 cases of PPH
and for a still higher rate of severe PPHs.
Maternal mortality due to obstetric
hemorrhage has fallen in France (currently
1.6 deaths/100,000 live births), but it
remains the leading cause of maternal
death (16%) and the most avoidable
(80%). In developed countries, PPH is the
principal cause of severe maternal
morbidity. Beyond the direct consequences
of acute hypovolemia, it exposes women
to the complications of transfusion,
resuscitation, and to infertility if
hysterectomy is required..6,7
IV. Management of PPH
Effective team management of
PPH involves recognition, communication,
resuscitation, monitoring and investigation
and directed treatment. Once a PPH has
been recognised these components should
be conducted simultaneously for optimal
patient care.1 Some guidelines invoke
basic measures for estimated blood loss
(EBL) of 500ml-1000ml with no clinical
shock and a full protocol of measures for
EBL greater than 1000ml and continuing
bleeding, or where there is evidence of
clinical shock. It is important to consider
both the patients prior haemoglobin and
her total blood volume when assessing the
severity of PPH. Total blood volume at
term is approximately 100ml/kg (i.e.
7000ml for a 70 kg woman, but only
5000ml for a 50kg woman).8,9
The principal risk factors of PPH
are those for uterine atony, but they are
globally not predictive. The risk of
recurrence during a subsequent delivery is
multiplied by 3 and increases still more
with each PPH. Particular attention must
be paid to the risk factors related to aspects
of the management of labor or delivery,
because these may be modifiable
(professional consensus). In particular, a
dose-dependent association has been
reported between PPH and oxytocin
administration during labor (LE3)
1. Recognition
Assessment of ongoing blood loss is an
essential aspect of post-partum care.
Visual estimation of blood loss is
notoriously unreliable and often
underestimates true blood loss. More
accurate measures such as weighing
drapes, pads and swabs can also be used.
Clinical signs of shock or tachycardia
should prompt a thorough assessment of
the mother including an accurate appraisal
of blood loss, both concealed and
revealed.8
2. Communication
The successful management of PPH
requires a multidisciplinary team
approach. The clinical team involved, their
response to PPH, and ability to escalate
this response in the face of severe
haemorrhage will vary according to the
setting and circumstance of delivery. All
centres providing obstetric care should
implement and regularly review a clear
plan of communication, resuscitation and
directed treatment to respond to PPH The
successful management of PPH requires a
multidisciplinary team approach. The
clinical team involved, their response to
PPH, and ability to escalate this response
in the face of severe haemorrhage will
vary according to the setting and
circumstance of delivery. All centres
providing obstetric care should implement
and regularly review a clear plan of
communication, resuscitation and directed
treatment to respond to PPH.8
3. Resuscitation
The cornerstone of resuscitation is
restoration of blood volume and oxygen-
carrying capacity. A simple ABC
approach is often used initially but clinical
judgement should be used to guide
resuscitation in each situation.
Immediately call for help
Rapidly assess for danger to self and
others
Assessment of airway and breathing
initially with administration of high flow
oxygen is recommended
Wide-bore intravenous access should be
established with blood sent for full blood
count, coagulation profile and cross-match.
Rapid infusion with fluids, ideally
warmed, should be begun once intravenous
access is achieved.
The use of group specific or group O
RhD-negative blood should be considered
early to restore oxygen carrying capacity.
It is critical that facilities providing
obstetric care have, and adhere to, a
massive transfusion protocol with which
all staff are familiar.8,9
4. Monitoring and investigation
Appropriate monitoring and investigation
should be guided by clinical judgement,
but in all cases of PPH, should, at a
minimum, include the recording of
observations at regular intervals, (not
monitoring and already done by now) and
repeating, as indicated, in an appropriate
time frame the haematological
investigations. Pulse rate, blood pressure,
oxygen saturation and urinary output
measurement should be instigated for any
significant (>1000ml) or ongoing PPH,
and invasive monitoring of arterial blood
 TABEL 1 Temuan Klinis PPH
Derajat Syok

Kompensasi Ringan Sedang Berat

Perdarahan 500-1000 ml 1000-1500 ml 1500-2000 ml 2000-3000 ml

10-15% 15-25% 25-35% 35-45%

Perubahan Tidak ada slight fall marked fall (70- profound fall
Tekanan darah (80-100 mmH g) 80 mmH g) (50-70 mmH g)
(Tekanan Sistole)

Gejala dan Tanda palpitations weakness restlessness collapse air

dizziness sweating pallor oliguria hunger
tachycardia tachycardia anuria

Tabel 1. Derajat syok

TABEL 2 FAKTOR RISIKO PPH

EtiologI Faktor risiko klinis

Abnormalitas kontraksi uterus - over distended uterus - polyhydramnios

(Tone) - multiple gestation
- macrosomia

- kelelahan otot uterus - rapid labour

- prolonged labour
- high parity

- i n f e k s i intra amniotic - fever

- prolonged RO M

- k e l a i n a n fungsional/anatomi uterus - fibroid uterus

- placenta previa
- uterine anomalies

Retensi produk uterus - Retensio jaringan - incomplete placenta at

(Tissue) - abnormal placenta delivery
- retaensio cotyledon atau l o b u s - previous uterine surgery
succinturiate - high parity
- abnormal placenta on U/S

- retained blood clots - atonic uterus

Trauma jalan lahir - lacerasi cervix, - precipitous delivery

(Trauma) vagina or perineum - operative delivery

- extensions, laserasi - malposition

saat SC - deep engagement

- rupture uterus - previous uterine surgery

- inversion uterus - high parity

- fundal placenta
Gangguan Pembekuan - penyakit sebelumnya - hx of hereditary
(Thrombin) - hemophilia A coagulopathies
- von W illebrands D isease - hx of liver disease

- acquired in
pregnancy - bruising
- ITP - elevated BP
- thrombocytopenia dengan pre- - fetal demise
eclampsia
- fever, W BC
- D IC
- antepartum haemorrhage
- pre-eclampsia
- sudden collapse
- dead fetus in utero
- severe infection
- abruption
- amniotic fluid embolus

- therapeutic anti-coagulation - hx of blood clot

The following agents are useful in the

pressure or central venous pressure may be
necessary depending upon the clinical
situation. Consideration must be given to
the most appropriate place of care in
women with severe PPH; this may be a
high dependency care or intensive care
unit in some instances. Where patients
need to be transferred to a more highly
equipped facility for management of PPH,
the need for transfer should be anticipated
and initiated early. In the meantime,
aggressive resuscitation should continue
and regular communication with the
receiving unit is essential.9
a. Tone - uterine atony is the most
common cause of primary PPH but clinical
assessment should be used to exclude
other causes. The following interventions
have all been used to stop the bleeding,
generally in the stepwise progression as
presented here.
i. Mechanical
Uterine massage or bimanual
uterine compression
Empty bladder
ii. Pharmacological:
management of PPH. They are commonly
given in combination and, in the absence
of individual contraindications, a patient
may be given all four in the event of
severe ongoing atonic bleeding. Because
of the difficulties in undertaking clinical
trials in the circumstances of unexpected
PPH, the outcomes of the uterotonics in
varying combinations to manage PPH have
not been assessed by sufficiently-powered
randomised controlled trials. However,
their use is strongly recommended if the
atonic haemorrhage is continuing 7,8
Oxytocin
- 5 units by slow intravenous injection (if
already administered for 3rd stage
management, a repeat dose may be
given).
- 40 units in 500ml Hartmanns solution
at 125ml/hr (unless fluid restriction is
necessary
Ergometrine 0.25 mg by slow
intravenous or intramuscular injection,
repeated if necessary 5 minutely up to a
maximum of 1.0 mg; in the absence of
contraindications
 Management of PPH a er Vaginal Delivery

Call obstetric and

anesthesiology teams
Collec on bag
INITIAL 30
Obstetric team Anesthesiology team
MANAGEMENT min
OF PPH
Manual removal of placentaif Monitor
not yet delivered Communica on Assess and maintain hemodynamics:
Manual uterine explora on if plasma expansion by
placenta already delivered
Urinary catheterizati on crystalloids
Visual assessment of the lower
genital tract Sutures Uterine Anesthesia for manual explora on of the
massage uterus
Oxytocin 5-10 IU slow IV or IM (Max: 40 IU)
An bio c therapy
Failure of ini al management
Preven on of hypothermia, oxygen therapy
Hemocue

Verify
- 2nd peripheral blood
venous linegroup
16 gand IAS validity
30 SULPROSTONE
- Ini al lab work: CBC, platelets, PT, AC, Fibrinogen +/- Hemocue
min* In-dwelling urinary catheteriza on - Order reserva on of units of packed red blood cells

Failure of - Fluid resuscita on

Sulprostone
+/-
(crystalloids/colloids)
intra-uterine
balloon
-Transfusion of packed
tamponnade
Hemodinamically unstable red blood cells
SEVERE OR -Hypothermia preven on
Hemodinamically stable
and/or -+/- laboratory results
PERSISTENT Massive hemorrhage and +/- Tranexamic acid
POST PARTUM
HEMORRHAGE and/or Emboliza on rapidly available +/- Fresh frozen plasma
Emboliza on unavailable
CONSERVATIVE SURGERY
EMBOLIZATION +/- Fibrinogen
+/- Arterial catheter
Arterial liga on
(BLUA or BLIIA) +/- Platelets
+/- Central venous catheter
and/or
+/- Noradrenaline
Failure
Uterine compression suture Failure

Hysterectomy without +/-

salpingectomy/oophorectomy rFVIIa

Gambar 1. Manajemen PPH dengan persalinan normal7

Misoprostol (1000mcg) per rectal. bronchospasm (therefore

In the hospital setting there is evidence contraindicate ed where there is a
to suggest that misoprostol is clinically significant history of asthma).
equivalent to further oxytocin in women Carboprost
who have already received prophylactic 500mcg administered intra-muscularly
oxytocin when used for excessive post- or intra-myometrially in repeated doses
partum bleeding due to suspected as required, up to a maximum total
uterine atony. cumulative dose of 3.0 mg (ie up to 6
Prostaglandin F2 (dinoprost) doses).7
Pemberian its analogues are the most b. Trauma of the genital tract. Thorough
potent of the uterotonics but also have assessment of the entire genital tract is
the most serious adverse effect profile essential. The perineum, vagina and cervix
which includes severe hypertension and should all be visually inspected for
bleeding sources. Pressure should be
applied to bleeding areas and repair
attempted, either in the labour ward or the
operating theatre if required. If the patient
is shocked and the amount of vaginal
bleeding is normal, consider intra-
abdominal sources such as ruptured uterus,
broad ligament haematoma, subcapsular
liver rupture, ruptured spleen, and ruptured
aneurysm
c. Tissue (retained products of conception)
- usually due to retained placenta,
cotyledon or membranes. If the placenta
has been delivered assess for obvious
missing tissue. Examine the mother
vaginally to assess the adherence of the
Gambar 2.Manajemn PPH saat SC
placenta and if adherent repeat oxytocic
dose, empty the bladder and transfer to
theatre for manual removal of placenta.
d. Thrombin (abnormalities of
coagulation) - rarely the primary cause of
PPH and usually the consequence of
massive haemorrhage and as such is
addressed briefly above. Specific
discussion is beyond the scope of this
guideline.
e. Theatre - surgical interventions should
be initiated sooner rather than later,
especially hysterectomy in cases of uterine
rupture, placenta accreta or uncontrolled
massive haemorrhage. The following is a
list of some available procedures.
This should not necessarily be a step-wise
progression and both order and utilisation
will depend on the services/ clinical
experience available and the individual
clinical circumstances.
i. Balloon tamponade. Several case series
have been published reporting the results
of using a Foley catheter, Bakri balloon,
Rusch balloon or Sengstaken-Blackmore
oesophageal catheter with good results
where the uterus is empty and contracting.
ii. Haemostatic brace suturing (such as the
B-Lynch suture).
Referensi
1. World Health Organizations. WHO
guidelines for the management of
postpartum haemorrhage and retained
placenta. WHO Library Cataloguing-in-
Publication Data; 2009.
2. Schuurmans N, Catherin MK, Lane C.
Prevention and Management of
Postpartum Haemorrhage. SOGC Clinical
Practice Guideline : April 2000.
3. Goffman D, Nathan L, Chazotte C.
Obstetric Haemorrhage : A global review.
Elsevier; 2015.
4. Sentilhes L, Goffinet F, Vaysierre C.
Comparison of postpartum haemorrhage
guidelines : discrepancies underline our
lack of knowledge. BJOG: 2016.
5. Kerr RS, Weeks AD. Postpartum
haemorrhage : a single definition is no
longer. BJOG: 2016
.
iii. Bilateral ligation of uterine arteries
iv. Bilateral ligation of internal iliac
arteries by an experienced operator.
v. Selective arterial embolisation. This
intervention can only be achieved in
institutions with timely access to both
radiological expertise and equipment. It is
important to note that time delays in
accessing embolisation can occur and
should not preclude alternate surgical
treatment
vi. Hysterectomy
6. RCOG. Prevention and Management of
Postpartum Haemorrahge. Green-top
Guideline: agustus 2009.
7. RANZCOG. Management of
postpartum haemorrhage. C-obs: 2016.
8. Reddy A, Peregrine E, Velinor A.
Guideline for the management of
Postpartum haemorrhage and massive
obstetric haemorrhage. NHS Foundation;
2011.
9. Sentilhes L, Vasyirre C, Catherine DT,
et al. Postpartum hemorrhage : guidelines
for clinical practice from the French
Collage of Gynaecologists and
Obstetricians. Elsevier: 2016; 12-21.
10. FIGO. Management of Postpartum
Hemorrhage findings from a survey 69
FIGO member association. FIGO; 2012