• Clinical science

Postpartum hemorrhage (Puerperal hemorrhage)


Postpartum hemorrhage (PPH) is an obstetric emergency and is defined as a blood loss > 500 mL following vaginal birth. The onset may be early, within 24 hours, or late, from 24 hours to 12 weeks postpartum. The most significant causes of postpartum hemorrhage are uterine atony, maternal birth trauma, abnormal placental separation, and coagulation disorders. Mothers present with features of anemia (e.g., lightheadedness, pallor) or hypovolemic shock (e.g., hypotension, tachycardia). Treatment depends on the underlying condition and may include suturing of bleeding lacerations, manual maneuvers to aid in placental separation, and uterotonic agents for uterine atony. A hysterectomy is often considered as a last resort in uncontrolled postpartum hemorrhage.


The 4 Ts of Postpartum Hemorrhage: Tone, Trauma, Tissue, Thrombin


Uterine atony

  • Definition: failure of the uterus to effectively contract and retract after complete or incomplete delivery of the placenta, which can lead to severe postpartum bleeding from the myometrial vessels
  • Epidemiology: responsible for ∼ 80% of PPH cases
  • Risk factors: overdistention of the uterus
  • Clinical findings
    • Abnormal vaginal bleeding
    • Soft, enlarged (increased fundal height), boggy ascending uterus
  • Diagnosis: clinical diagnosis
  • Treatment
    1. General measures
    2. Uterine massage and external compression
      • Bimanual uterine massage
        • A clenched fist is inserted into the anterior vaginal fornix and exerts pressure on the anterior wall of the uterus.
        • The other hand is positioned externally and presses against the inner fist, located in the uterine body.
      • Credé's maneuver
        • The cranial part of the uterus is held with four fingers positioned at the posterior side of the uterus and the thumb at the anterior surface.
        • The pressure compresses the uterine vessels and aids in the expulsion of the placenta.
      • Fritsch's maneuver
        • One hand grasps the labia majora and presses it firmly into the vulva.
        • Simultaneously, the second hand is positioned at the posterior side of the uterus (as in Credé's maneuver) and is pushed distally against the other hand.
        • One hand grasps the labia majora and presses it firmly into the vulva.
        • Simultaneously, the second hand is positioned at the posterior side of the uterus (as in Credé's maneuver) and is pushed distally against the other hand.
        • Manual removal of the placental remains
        • Fundal massage
    3. Tranexamic acid: give ASAP to stop fibrinolysis and to reduce mortality
    4. Uterotonic agents as needed :
      1. IV oxytocin (diluted in saline)
      2. IM carboprost tromethamine (if the patient does not suffer from asthma)
      3. IM methylergonovine (if no hypertension or arterial disease is present)
      4. Prostaglandins such as misoprostol (useful when injectable uterotonic agents are unavailable or contraindicated)
    5. Speculum examination of the vagina and cervix to evaluate possible sources of extrauterine bleeding (e.g., vaginal injury caused during birth)
    6. Intracavitary application of prostaglandin
    7. Exclude coagulation disorders (e.g., disseminated intravascular coagulation or hyperfibrinolysis): blood coagulation should be tested (alternatively a thrombelastogram performed) and treatment is based on the results, e.g., substitution of deficient coagulation factors (such as FFP or prothrombin complex concentrate) or administration of tranexamic acid (in hyperfibrinolysis)
    8. In severe hemorrhage: blood transfusions; (whole blood or red blood cell concentrates) and/or platelet transfusions
    9. Last resort: hysterectomy


Uterine inversion


Abnormal placental separation


Abnormal placental attachment

Retained placenta

Clinical features


If the placenta does not separate within 30 minutes after birth or there is evidence of postpartum hemorrhage, the following measures are to be taken:

  1. General measures
  2. Brandt-Andrews maneuver
    • One hand is placed on the abdomen, securing the uterine fundus and preventing uterine inversion.
    • The other hand applies steady downward traction on the umbilical cord.
  3. Uterotonic agents
  4. If only partial removal of placenta is suspected: postpartum inspection of the placenta and fetal membranes → sonography to locate the succenturiate placenta
  5. Manual palpation, followed by dilation and curettage (D&C) or vacuum removal of RPOC under anesthesia/regional anesthesia and high-dose IV administration of uterotonic agents
  6. Last resort: hysterectomy in failed attempts for placental detachment, persistent bleeding, and prostaglandin resistance

Uterine-preserving measures are relatively contraindicated in placental implantation disorders (placenta increta/percreta)!


Birth trauma

  • Etiology: spontaneous or iatrogenic injury (i.e., during instrumental delivery or cesarean section)
  • Clinical features
  • Treatment
    • Following vaginal delivery
      • Supportive measures (fundal massage, fluid therapy, uterotonic agents)
      • Immediate repair of obvious bleeding lacerations
      • Consider arterial embolization if the patient is hemodynamically stable or immediate laparotomy if hemodynamically unstable.
    • Following cesarean section
      • Supportive measures
      • Uterine artery ligation
      • Uterine compression suture technique (e.g., B-Lynch suture which compresses the uterus), if the above techniques fail
  • Hysterectomy as a last resort


Velamentous cord insertion

  • Definition: abnormal cord insertion into chorioamniotic membranes, resulting in exposed vessels only surrounded by fetal membranes, in the absence of protective Wharton's jelly
  • Etiology: unknown
  • Clinical findings
    • Features of fetal hypoxia, especially following rupture of membranes (ROM)
    • Besides abnormal vaginal bleeding, the mother's condition is unaffected as blood loss occurs only in the fetus.
  • Diagnosis
  • Treatment
    • Normal delivery of the fetus (consider elective cesarean section if the first stage is not complete and the cord is in the lower segment of the uterus)
    • Regular fetal assessment (e.g., fetal growth and heart rate tracing)
    • Deliver ≤ 40 weeks gestation
  • Complications