Obstetric Emergencies
Postpartum hemorrhage (PPH) is defined as excessive bleeding after childbirth. It accounts for ~25% of maternal deaths globally and can occur unpredictably. Every minute counts — hence the obstetric golden rule: “Never underestimate postpartum bleeding.”
Definition & Types
Traditional vs. clinical definitions.
Traditional
- Vaginal: ≥500 mL
- Cesarean: ≥1000 mL
Clinical
- Any loss causing instability
| Type | Timing | Description |
|---|---|---|
| Primary (Early) | Within 24h | Most common, life-threatening |
| Secondary (Late) | 24h–6 weeks | Retained tissue, infection |
Etiology: The 4 T’s
Mnemonic: Tone, Tissue, Trauma, Thrombin
| Cause | Description | Examples |
|---|---|---|
| Tone | Uterine atony | ~70–80% of cases |
| Tissue | Retained placenta/clots | Prevents contraction |
| Trauma | Lacerations, hematomas | Cervix, vagina, rupture |
| Thrombin | Coagulation defects | DIC, preeclampsia |
Risk Factors
~50% occur without risk factors — vigilance for all.
Pregnancy
- Multiple pregnancy
- Polyhydramnios
- Grand multiparity
- Placenta previa
Labour
- Prolonged/rapid
- Induction
- Instrumental
After Delivery
- Retained placenta
- Uterine inversion
Clinical Presentation & Assessment
Excessive bleeding, boggy uterus, shock signs.
- ABC assessment
- Estimate blood loss
- Check uterine tone
- Inspect placenta
- FBC, coagulation, cross-match
Management: Stepwise Approach
Resuscitate, identify cause, treat simultaneously.
| Drug | Dose / Route | Comments |
|---|---|---|
| Oxytocin | 10 IU IM + 20 IU in 1L IV | First-line |
| Ergometrine | 0.2 mg IM/IV | Avoid in HTN |
| Carboprost | 250 µg IM q15–20min | Avoid in asthma |
| Misoprostol | 800–1000 µg PR/SL | Alternative |
Advanced: Balloon tamponade → B-Lynch → hysterectomy
Prevention: AMTSL
- Oxytocin 10 IU IM
- Controlled cord traction
- Uterine massage
Key Takeaways
- PPH: ≥500 mL or instability
- Atony = 70–80%
- 4 T’s mnemonic
- Oxytocin + massage first
- AMTSL prevents
- Act fast — delay kills
Conclusion
PPH is a preventable yet deadly emergency. Rapid recognition, resuscitation, and systematic management save lives.
PPH demands speed and skill — every second counts.