hemorrhage (PPH) is defined as a blood loss of 500 mL or more after vaginal
delivery, or more than 1000 mL after cesarean delivery that results in symptoms
of hemodynamic instability.
Bleeding during the first 24 hours after delivery is early PPH.
Bleeding between 24 hours and 6 weeks after delivery is late
incidence of PPH for all deliveries is up to 3-6%.
Causes of early PPH:
Causes of late PPH:
Predisposing factors for uterine atony:
Antepartum or early intrapartum assessment of risk factors
for PPH should be performed.
Patients identified as being at risk for PPH should have
blood typed and cross-matched immediately.
management of the third stage of labor. Uterotonic agents should be
administered as soon as the newborn’s anterior shoulder is delivered: oxytocin
10-20 U/L of normal saline by intravenous infusion or 5-10 U I/M.
for typing and cross-maching
I/V infusion system (1 or 2)
of the uterus
compression of the uterus
of maternal vital signs
Fluid and blood replacement
Inspection of the lower
or surgical repositioning of the uterus
for at least 24 hours
exploration of uterine cavity
removal of placenta
currettage (if needed)
(repair or hysterectomy)
bleeding severe and/or continuous -
Embolization of uterine vessels can be considered.
20-80 U/L of crystalloid I/V infusion (continuously if effective).
oxytocine is not effective, one or all drugs:
methylergometrine 0.2 mg I/M, next dose after 15 min.,
then every 4 hours.
PGE1 analogue (misoprostol) 600-1000 μg
0.25 mg I/M, I/V or intramyometrial injection (during laparotomy) every
15-90 min. (max. 2 mg)
Prognosis of PPH depends mostly on the cause, but the underestimation of blood loss, delaying diagnosis and treatment may lead to a life threatening situation.
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