DEFINITION Postpartum hemorrhage, defined as the loss of more than 500 mL of blood

after delivery, occurs in up to 18 percent of births.1,2 Blood loss exceeding 1,000 mL is considered physiologically significant and can result in hemodynamic instability.3 Even with appropriate management, approximately 3 percent of vaginal deliveries will result in severe post-partum hemorrhage.4 It is the most common maternal morbidity in developed countries and a major cause of death worldwide.

INTRO

What is Postpartum hemorrhage?

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Postpartum hemorrhage: Excessive bleeding after childbirth delivery. Postpartum hemorrhage: The presence of abnormal uterine bleeding immediately after LABOR, OBSTETRIC or childbirth.

Postpartum Haemorrhage!!!
This is excessive bleeding following delivery and is described as primary and secondary.

Primary postpartum haemorrhage (PPH) is loss of blood estimated to be >500 ml, from the genital tract, within 24 hours of delivery (the most common obstetric haemorrhage):1
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Minor PPH is estimated blood loss of up to 1000 mls. Major PPH is any estimated blood loss over 1000 mls.

Secondary PPH is defined as abnormal bleeding from the genital tract, from 24 hours after delivery until 6 weeks postpartum.

Postpartum hemorrhage: Types list.

The list of types of Postpartum hemorrhage mentioned in various sources includes:
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Primary postpartum hemorrhage - bleeding immediately after delivery. Secondary postpartum hemorrhage - delayed bleeding occurring within 2 weeks of delivery .

Symptoms of Postpartum hemorrhage

The list of signs and symptoms mentioned in various sources for Postpartum hemorrhage includes the 6 symptoms listed below:
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Heavy vaginal bleeding after childbirth - may be mild or life-threatening Loss of blood - may be mild or life-threatening Reduced blood pressure Increased heart rate Reduced blood cell count Swelling of vaginal tissue

Complications list for Postpartum hemorrhage

The list of complications that have been mentioned in various sources for Postpartum hemorrhage includes:
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Blood loss Shock Death Septicemia Death due to blood loss

Causes of Postpartum hemorrhage

The most common cause of postpartum hemorrhage is caused by failure of the uterus to contract following delivery of the baby. Another cause is failure of the placenta to separate from the uterus and maternal problems with coagulation.

Pathophysiology
Over the course of a pregnancy, maternal blood volume increases by approximately 50% (from 4 L to 6 L). The plasma volume increases somewhat more than the total RBC volume, leading to a fall in the hemoglobin concentration and hematocrit value. The increase in blood volume serves to fulfill the perfusion demands of the low-resistance uteroplacental unit and to provide a reserve for the blood loss that occurs at delivery.[5] At term, the estimated blood flow to the uterus is 500-800 mL/min, which constitutes 10-15% of cardiac output. Most of this flow traverses the lowresistance placental bed. The uterine blood vessels that supply the placental site traverse a weave of myometrial fibers. As these fibers contract following delivery, myometrial retraction occurs. Retraction is the unique characteristic of the uterine muscle to maintain its shortened length following each successive contraction. The blood vessels are compressed and kinked by this crisscross latticework, and, normally, blood flow is quickly occluded. This arrangement of muscle bundles has been referred to as the "living ligatures" or "physiologic sutures" of the uterus.[4] Uterine atony is a failure of the uterine myometrial fibers to contract and retract. This is the most important cause of PPH and usually occurs immediately following delivery of the baby, up to 4 hours after the delivery. Trauma to the genital tract (ie, uterus, uterine cervix, vagina, labia, clitoris) in pregnancy results in significantly more bleeding than would occur in the nonpregnant state because of increased blood supply to these tissues. The trauma specifically related to the delivery of the baby, either vaginally in a spontaneous or assisted manner or by cesarean delivery, can also be substantial and can lead to significant disruption of soft tissue and tearing of blood vessels.

Prevention
Risk factors for postpartum hemorrhage include a prolonged third stage of labor, multiple delivery, episiotomy, fetal macrosomia, and history of postpartum hemorrhage.3,4,11,12 However, postpartum hemorrhage also occurs in women with no risk factors, so physicians must be prepared to manage this condition at every delivery.13 Strategies for minimizing the effects of postpartum hemorrhage include identifying and correcting anemia before delivery, being aware of the mother's beliefs about blood transfusions, and eliminating routine episiotomy.14 16 Reexamination of the patient's vital signs and vaginal flow before leaving the delivery area may help detect slow, steady bleeding. The best preventive strategy is active management of the third stage of labor (number needed to treat [NNT] to prevent one case of postpartum hemorrhage = 12).17,18 Hospital guidelines encouraging this practice have resulted in significant reductions in the incidence of massive hemorrhage.19 Active management, which involves administering a uterotonic drug with or soon after the delivery of the anterior shoulder, controlled cord traction, and, usually, early cord clamping and cutting, decreases the risk of postpartum hemorrhage and shortens the third stage of labor with no significant increase in the risk of retained placenta.17,18 Compared with expectant management, in which the placenta is allowed to separate spontaneously aided only by gravity or nipple stimulation, active management decreases the incidence of postpartum hemorrhage by 68 percent.17 Early cord clamping is no longer included in the International Federation of Gynecology and Obstetrics (FIGO) definition of active management of the third stage of labor, and uterine massage after delivery of the placenta has been added.20 Delaying cord clamping for about 60 seconds has the benefit of increasing iron stores and decreasing anemia, which is especially important in preterm infants and in low-resource settings.16,2123 The delay has not been shown to increase neonatal morbidity or maternal blood loss.16,21,23 Prophylactic administration of oxytocin (Pitocin) reduces rates of postpartum hemorrhage by 40 percent24; this reduction also occurs if oxytocin is given after placental delivery.2,18 Oxytocin is the drug of choice for preventing postpartum hemorrhage because it is at least as effective as ergot alkaloids or prostaglandins and has fewer side effects.2,25,26 Misoprostol (Cytotec) has a role in the

prevention of postpartum hemorrhage (NNT = 18)16; this agent has more side effects but is inexpensive, heat- and light-stable, and requires no syringes.