Obstetrics & Gynecology

Last updated on: September 16th, 2021

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Postpartum Hemorrhage

Clinicals - History


Primary postpartum haemorrhage (PPH) is the excessive bleeding from the genital tract within 24 hours of childbirth, but most cases manifest immediately after birth. It is defined as total blood loss >500 mL after vaginal delivery and >1000 mL after delivery by a Caesarean section. Massive PPH refers to the loss of 30%–40% of the patient’s blood volume. Secondary PPH occurs between 24 hours and 12 weeks post-delivery.


The Four T's mnemonic is used to quickly identify and address the four most common causes of postpartum haemorrhage:

T – Tone for uterine atony;

T- Trauma for laceration, hematoma, inversion, rupture;

T – Tissue for retained tissue or invasive placenta; and

T– Thrombin for congenital or acquired coagulopathy.

Risk factors

Risk factors for PPH include: advanced maternal age, antepartum hemorrhage, augmented or prolonged labor, chorioamnionitis, fetal macrosomia, maternal anemia, multifetal gestation, preeclampsia, placenta praevia, placental abruption, invasive placentation, instrumental delivery, previous PPH or Caesarean section. 20% of PPH occurs in women with no risk factors.

Symptoms of hypovolemia

PPH can occur without obvious signs of external bleeding. It may present only with symptoms of hypovolemia including dizziness, nausea, restlessness, palpitations and excessive thirst. Loss of consciousness or maternal collapse, in the setting of vaginal bleeding after childbirth, indicate severe PPH complicated by hypovolemic shock.


Shortness of breath and air hunger are decompensating features, suggesting significant PPH with more than 40% total blood volume loss.


Excessive or persistent pelvic pain after delivery may indicate hematoma formation. Abdominal pain is a feature of secondary PPH indicating endometritis.

History of clotting dysfunction

Coagulopathy can cause PPH or be the result of one. PPH can be anticipated in women with known congenital or acquired clotting disorders. Clotting defects should be suspected in women who have history of abnormal bleeding and bruising, or present with petechial, subconjunctival and mucosal haemorrhage.

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