Define and describe the types, causes and management of atonic PPH of postpartum Haemorrhage.

Definition

Postpartum haemorrhage (PPH) is blood loss of 500 mL or more from the genital tract after a vaginal birth (or ≥ 1000 mL after caesarean section), or any amount of blood loss that adversely affects the mother's haemodynamic state. It is a leading cause of maternal death worldwide.

Causes of PPH - the 4 T'S

Types

• Primary PPH — occurs within the first 24 hours of delivery. It includes third-stage haemorrhage (before expulsion of the placenta) and true PPH (after expulsion).
• Secondary PPH — abnormal bleeding between 24 hours and 6 weeks postpartum, usually from retained products or endometritis.

Causes — the "four T'S"

• Tone — atonic uterus (≈ 80%): failure of the uterus to contract. Causes include over-distension (twins, polyhydramnios, big baby), prolonged or precipitate labour, grand multiparity, antepartum haemorrhage, prolonged oxytocin use, general anaesthesia, retained placenta and a full bladder.
• Trauma: lacerations of the cervix, vagina or perineum, episiotomy, uterine rupture or inversion.
• Tissue: retained placenta, placental fragments or a morbidly adherent placenta (accreta).
• Thrombin: coagulation disorders — DIC (abruption, sepsis, amniotic-fluid embolism), HELLP, or inherited bleeding disorders.

Management of Atonic PPH

Atonic PPH is managed by simultaneous resuscitation and arrest of bleeding, calling for senior help early ("call for help").

1. Resuscitation

• Two large-bore IV cannulae; send blood for grouping/cross-match and clotting; start rapid crystalloids and blood transfusion; give oxygen, keep the patient warm, catheterise the bladder and monitor vitals and urine output.

2. Mechanical measures

• Rub up a contraction by firm uterine massage; ensure the bladder is empty.
• Bimanual compression of the uterus while drugs take effect.

3. Uterotonic drugs

• Oxytocin — 10 IU IM or 20 IU in 500 mL infusion (first line).
• Ergometrine / methylergometrine 0.2 mg IM/slow IV — contraindicated in hypertension and cardiac disease.
• Carboprost (15-methyl PGF₂α) 250 µg IM, repeated every 15 minutes (max 8 doses) — avoid in asthma.
• Misoprostol 800 µg per rectum/sublingual.
• Tranexamic acid 1 g IV (give early) reduces death from bleeding.

4. If bleeding continues

• Uterine tamponade — intrauterine balloon (e.g. Bakri/condom catheter) or uterine packing.
• Examine for and repair genital-tract trauma; explore the uterus and remove retained tissue.
• Non-pneumatic anti-shock garment as a temporising measure during transfer.

5. Surgical measures (if conservative measures fail)

• B-Lynch (brace) suture.
• Stepwise uterine devascularisation — bilateral uterine and ovarian artery ligation, then internal iliac (hypogastric) artery ligation.
• Uterine artery embolisation where available and the patient is stable.
• Peripartum hysterectomy — the life-saving last resort.

Postpartum haemorrhage is caused by one of the '4 Ts': Tone (uterine atony — by far the commonest, giving a soft, boggy uterus), Trauma (genital tract tears — bleeding despite a firm uterus), Tissue (retained placenta) and Thrombin (coagulopathy). Management resuscitates and treats the cause simultaneously, escalating from uterotonics through tamponade and compression sutures to hysterectomy; active management of the third stage prevents about 60% of cases.

WHY the '4 TS' Are the Key to Managing PPH

The value of the '4 Ts' — Tone, Trauma, Tissue, Thrombin — is that they convert a terrifying emergency into a systematic drill. In a woman bleeding torrentially, the temptation is to give one uterotonic after another; but if the cause is a cervical tear or a retained placenta, no amount of oxytocin will stop the bleeding, and the delay is fatal. The 4 Ts force the accoucheur to identify the cause while resuscitating. The single most useful bedside sign is the state of the uterus: if it is soft and boggy, the cause is atony (Tone — by far the commonest, ~70%), and massage and uterotonics are the answer; if the uterus is firmly contracted yet the woman is still bleeding, the cause cannot be atony — it must be Trauma (a tear of the cervix, vagina or perineum, or uterine rupture), and the genital tract must be inspected and repaired. If the placenta was incomplete, suspect Tissue; if the blood simply will not clot anywhere, suspect Thrombin (DIC). Understanding that a contracted-or-boggy uterus immediately separates the two commonest causes explains why the 4 Ts are the framework of every PPH protocol.

WHY Prevention Beats Treatment

Understanding why active management of the third stage is the most valuable single intervention in obstetrics for maternal survival explains its universal adoption. PPH is the leading direct cause of maternal death worldwide, and it kills quickly — a woman with an atonic uterus can lose her entire blood volume within minutes, often where blood and surgery are not immediately available. Treating established PPH therefore depends on resources many women do not have. Prevention, by contrast, is cheap, simple and applicable to every delivery: a prophylactic uterotonic (oxytocin 10 IU IM) with delivery of the anterior shoulder, controlled cord traction, and uterine massage — together reducing the incidence of PPH by around 60%. The physiology is straightforward: the placental bed bleeds until the interlacing 'living ligature' fibres of the myometrium contract and occlude the spiral arteries; giving a uterotonic ensures this happens promptly and completely rather than leaving it to chance. Recognising that PPH is best defeated before it starts explains why AMTSL is recommended for every birth, and why oxytocin is the essential drug of every labour room.

• PPH = blood loss >500 mL (vaginal) or >1000 mL (caesarean), or any loss causing haemodynamic compromise; primary (<24 h) or secondary (24 h–12 wk).
• Causes — the 4 Ts: Tone (atony, ~70%), Trauma (tears/rupture), Tissue (retained products), Thrombin (coagulopathy).
• A soft, boggy uterus = atony; bleeding despite a firm uterus = trauma → inspect the genital tract.
• Stepwise: massage/bimanual compression → oxytocin → ergometrine → carboprost → misoprostol → tranexamic acid → balloon tamponade → B-Lynch/devascularisation → hysterectomy.
• Prevention: active management of the third stage (oxytocin 10 IU IM) reduces PPH by ~60%.