How to Eliminate Postpartum Hemorrhage

Three Methods:Managing PPHUsing Medications to Stop PPHPreventing PPH

Postpartum Hemorrhage, or PPH, is medically defined as blood loss greater than 500ml after vaginal delivery, and 1000ml after cesarean delivery. It has been stated than PPH is the leading cause of maternal morbidity and mortality.[1] Hence, it is a serious condition that requires prompt management and optimal treatment.

Note: PPH is serious medical condition which requires professional treatment. Therefore, the steps provided below should only be performed by a licensed physician.

Method 1
Managing PPH

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    Perform a uterine massage. The first step in managing this condition is a technique called bimanual uterine massage which is performed to try to stimulate the uterus to regain its tone.[2] At the same time, administration of uterotonics (like oxytocin) should be carried out.
    • Uterine massage should only be carried out by a physician. It involves elevating the uterus, by pressing on the fundus both internally (with one hand) and externally (with the other).
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    Try bimanual compression if the massage does not work. If uterine massage fails to give the uterus some degree of "tone", bimanual compression should be applied. This is a similar maneuver to the uterine massage, with a more aggressive approach.
    • With bimanual compression, a firm pressure is applied by the physician with both hands (which are in similar positions as in uterine massage) in order to evoke a response from the uterine musculature.
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    Manually explore the uterine cavity if bimanual compression does not produce results. Manual exploration of the uterine cavity is carried out by the physician, to try to find the cause of PPH. Exploration of the uterine cavity should be performed in the operating room, in more sterile conditions, to minimize chances of contracting an infection.
    • The exploration may reveal some defects in the muscular wall of the uterus, as well as hematomas, or even uterine rupture, which can be seen if the patient had previous cesarean delivery or uterine surgery.
    • If any of these disorders are found during the exploration by the physician, operative intervention will be necessary.
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    Remove any fragments found in the uterus. During a manual examination, placental fragments that were retained in the uterus during birth may be discovered.
    • Removal of these fragments is essential in eliminating PPH, since they can be recognized as the source of bleeding.
    • Manual removal of these fragments or curettage are procedures by which these fragments are removed. Curettage comprises surgical "scraping" of these fragments, with the use of a scoop.
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    Use surgical methods to combat the PPH. In such cases, a laparotomy is performed to efficiently control and stop the bleeding, by promptly identifying the source of hemorrhage. Laparotomy is a procedure carried out via a large incision on the abdominal wall, in order to gain direct access into the abdomen and uterus.
    • Depending on the findings, surgical suturing, ligation of blood vessels, and in severe cases, hysterectomy, are procedures that are indicated in PPH.
    • Suturing and ligation include management of the arterial supply to the uterus and the abdominal cavity. Closing these arteries may effectively reduce and eliminate PPH.
    • Hysterectomy is performed only if these surgical procedures fail, and the patient is not hemodynamically stable.
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    Use sutures to repair wounds caused by trauma. Lacerations and hematomas resulting from birth trauma can cause significant blood loss that can be lessened by hemostasis and timely repair. Sutures should be done if direct pressure does not stop the bleeding.
    • Episiotomy increases blood loss and the risk of anal sphincter tears, and this procedure should be avoided unless urgent delivery is necessary and the perineum is thought to be a limiting factor.[3]
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    Treat hematomas. A hematoma is a solid swelling of clotted blood within the tissue. It can present as pain or as a change in vital signs disproportionate to the amount of blood loss. Small hematomas can be managed with close observation.
    • Patients with persistent signs of blood loss despite fluid replacement, as well as those with large or enlarging hematomas, require incision and evacuation of the clot.
    • The involved area should be irrigated and the bleeding vessels ligated.
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    Revert the uterus in case of uterine inversion. Uterine inversion is rare, occurring in 0.05 percent of deliveries. The inverted uterus usually appears as a bluish-gray mass protruding from the vagina.
    • Every attempt should be made to replace the uterus quickly. Once the uterus is reverted, uterotonic agents should be given to promote uterine tone and to prevent recurrence.
    • If initial attempts to replace the uterus fail or a cervical contraction ring develops, administration of magnesium sulfate, terbutaline (Brethine), nitroglycerin, or general anesthesia may allow sufficient uterine relaxation for manipulation.
    • If these methods fail, the uterus will need to be replaced surgically.[4]
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    Consider a cesarean delivery in the case of a uterine rupture. Although rare in an unscarred uterus, clinically significant uterine rupture occurs in 0.6 to 0.7 percent of vaginal births, after a cesarean delivery in women with a low transverse or unknown uterine scar.[5]
    • The risk increases significantly with previous classical incisions or uterine surgeries, and to a lesser extent with shorter intervals between pregnancies or a history of multiple cesarean deliveries, particularly in women with no previous vaginal deliveries.
    • Before delivery, the primary sign of uterine rupture is decrease in fetal heart rate (bradycardia). Vaginal bleeding, abdominal tenderness, maternal tachycardia (increased heart rate in mother), circulatory collapse, or increasing abdominal girth are also signs of uterine rupture. Symptomatic uterine rupture requires surgical repair of the defect or a hysterectomy.
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    Treat tissue retention. Classic signs of placental separation include a small gush of blood with lengthening of the umbilical cord and a slight rise of the uterus in the pelvis. The mean time from delivery until placental expulsion is eight to nine minutes. Longer intervals are associated with an increased risk of postpartum hemorrhage, with rates doubling after 10 minutes.
    • Retained placenta (i.e., failure of the placenta to deliver within 30 minutes after birth) occurs in less than 3 percent of vaginal deliveries. One management option is to inject the umbilical vein with 20 mL of a solution of 0.9 percent saline and 20 units of oxytocin. This significantly reduces the need for manual removal of the placenta compared with injecting saline alone.[6]
    • Alternatively, physicians may proceed directly to manual removal of the placenta, using appropriate analgesia. If the tissue plane between the uterine wall and placenta cannot be developed through blunt dissection with the edge of the gloved hand, invasive placenta should be considered.

Method 2
Using Medications to Stop PPH

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    Consider the use of oxytocin. Oxytocin stimulates the upper segment of the uterine myometrium to contract rhythmically, which constricts spiral arteries and decreases blood flow through the uterus. Oxytocin is an effective first-line treatment for postpartum hemorrhage.
    • 10 international units (IU) should be injected intramuscularly, or 20 IU in 1 L of saline may be infused at a rate of 250 mL per hour.
    • As much as 500 mL can be infused over 10 minutes without complications.
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    Give the mother ergot alkaloids. Methylergonovine (Methergine) and ergometrine are ergot alkaloids that cause generalized smooth muscle contraction in which the upper and lower segments of the uterus contract.
    • However, these ergot alkaloid agents raise blood pressure, hence they are contraindicated in women with hypertension. [7] Other adverse effects include nausea and vomiting.
    • A typical dose of methylergonovine, 0.2 mg administered intramuscularly, may be repeated as required at intervals of two to four hours.
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    Give the mother prostaglandins. Prostaglandins enhance uterine contractility and cause vasoconstriction. The prostaglandin most commonly used is 15-methyl prostaglandin F2a, or carboprost (Hemabate). Misoprostol is another prostaglandin that increases uterine tone and decreases postpartum bleeding.
    • Misoprostol is effective in the treatment of postpartum hemorrhage, but side effects may limit its use.[8]
    • It can be administered sublingually, orally, vaginally, and rectally. Doses range from 200 to 1,000 mcg; the dose recommended by FIGO is 1,000 mcg administered rectally.

Method 3
Preventing PPH

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    Discuss your patient’s medical history. Risk factors for postpartum hemorrhage include a prolonged third stage of labor, multiple delivery, episiotomy, fetal macrosomia (large baby) , and history of postpartum hemorrhage.[9]
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    Actively manage your patient. Active management, which involves administering a uterotonic drug with or soon after the delivery of the first shoulder and using controlled cord traction and uterine massage after delivery of the placenta can decrease the risk of postpartum hemorrhage and shorten the third stage of labor with no significant increase in the risk of retained placenta.[10]
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    Reexamine your patient regularly. Reexamination of the patient's vital signs and vaginal flow before leaving the delivery area may help detect slow, steady bleeding.
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    Consider giving your patient oxytocin to reduce her chances of developing PPH. Prophylactic administration of oxytocin (Pitocin) reduces rates of postpartum hemorrhage by 40 percent. This reduction also occurs if oxytocin is given after placental delivery.[11]


  • As mentioned previously, PPH is the leading cause of maternal morbidity and mortality. Hence, the attending physician should always bear PPH in mind every time when bleeding occurs after labor.
  • Prompt diagnosis and optimal intervention (depending on the cause and source of blood loss) should be implemented immediately to prevent further complications.

Sources and Citations

  2. The Prevention and Management of Postpartum Haemorrhage: Report of Technical Working Group, Geneva 3–6 July 1989. Geneva: World Health Organization, 1990.
  3. Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol. 1991;77:69–76.
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Categories: Pregnancy