Life–saving management of massive primary postpartum hemorrhage with emergency total peripartum hysterectomy
Chandrika C G1*, Shalini H S2, Vijayakumari. D3
1Nursing Incharge, Kauvery Hospital, Electronic City, Bangalore
2Chief Nursing Officer, Kauvery Hospital, Electronic City, Bangalore
3Nurse Educator, Kauvery Hospital, Electronic City, Bangalore
*Correspondence
Abstract
Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality worldwide, nearly one-quarter of all maternal deaths, necessitating prompt and effective management strategies. The overall prevalence of PPH worldwide is estimated to be 6 to 11 percent. This review provides a comprehensive overview of the current approaches to PPH management. The etiology of PPH is categorized into the “4 Ts”: tone, trauma, tissue, and thrombin, which guide diagnosis and intervention.
The initial approach to managing PPH involves recognizing the condition, identifying its cause, and initiating suitable interventions tailored to the underlying etiology. Treatment typically follows a stepwise progression from minimally invasive methods to more invasive options, including compression techniques, pharmacologic agents, procedural interventions, and surgical treatments. For refractory cases, second-line interventions include balloon tamponade, uterine compression sutures, arterial embolization. Internal iliac artery ligation or peripartum hysterectomy is employed to achieve definitive hemostasis. While these techniques are lifesaving, they require specialized expertise and resources, underscoring the need for well-equipped healthcare systems and trained personnel.
Key words: Postpartum hemorrhage (PPH); World Health Organization (WHO).
Introduction
Postpartum haemorrhage (PPH) represents a critical challenge in maternal healthcare, particularly in low- and middle-income countries like India. This life-threatening condition is a significant contributor to maternal morbidity and mortality, demanding comprehensive understanding and strategic interventions. The global burden of PPH is profound, accounting for 27% of direct maternal deaths worldwide. In 2017, PPH was responsible for 127,000 maternal deaths despite being largely preventable. In the Indian context, postpartum haemorrhage presents a particularly acute healthcare challenge. PPH accounts for 19.9% of maternal mortality in India. Rural areas experience alarmingly high PPH rates, with approximately 12% of deliveries affected, escalating to 15% in subsequent pregnancies. This prevalence substantially exceeds the global average of 1-10% across healthcare settings according to the World Health Organization (WHO).
Definition
Postpartum haemorrhage is defined as blood loss exceeding 500 ml following vaginal birth, with severe PPH characterized by a blood loss of more than 1000 ml. In cases of cesarean delivery, PPH is defined as blood loss exceeding 1000 ml. The Ministry of Health and Family Welfare (MoHFW) of India defines primary PPH as a blood loss of 500 ml or more from the genital tract within 24 hours of delivery or as a smaller amount of blood loss that results in hemodynamic instability for the woman. Severe PPH is identified as blood loss greater than 1000 ml within the same 24 hours.
Case Overview
A case of S/P LSCS at 12:01AM on 02.04.2026 at outside hospital was referred to our hospital in view of continuous vaginal bleeding post LSCS (PPH). During vaginal toileting, continuous bleeding observed and Inj.Methargin and Carboprost, PPH and Carbetocin given from outside hospital and referred to our hospital for further management.
Obstetric & Menstrual History
- Obstetric formula – G1P1L1
- Antenatal history of GDM on diet / Hypothyroidism.
- Blood Group – B’ Positive
Past History: Known case of Hypothyroidism on Thyronorm 75 Mcg
Clinical Examination
On arrival
32 years / Female, average built.
| Heart Rate | 122 Beats/Min |
| Blood Pressure | 67/45 mm of Hg |
| Respiratory Rate | 20 Breaths/ Min |
| Temperature | 97.6 |
| SPO2 | 92% on RA |
| Respiratory Assessment | Bilateral normal vesicular breath sounds present |
| Cardiovascular Assessment | S1 S2 + |
| Central Nervous System | NFND |
| P/A | Soft |
| P/V | Active Bleeding + |
Case Presentation
32-Year-old female presented to ER with the above-mentioned history. On arrival at ER, active bleeding present, GCS: E2V5M6, saturation 92% on room air, she was connected to oxygen support via face mask (4L/min). ABG showed pH 7.14, pCO2 41, HCO3 19, Lac 7.9. D Dimer sent. Patients’ attenders were counseled regarding the need for surgery. After obtaining informed and written consent and PAC clearance, she was shifted to OT, intubated and connected to ventilator support (FiO2 40%, PEEP 5, RR18, TV 430). She underwent Exploratory Laparotomy + Total peripartum Hysterectomy under general anesthesia on 02.04.2026. 5 PRBC, 6 FFP and 1 SDP transfused and shifted to MICU for further management.
Procedure: Exploratory Laparotomy + Total Peripartum Hysterectomy done under General Anaesthesia on 02.04.2026.
Findings
- Hemoperitoneum 2.5liters.
- Uterus: Atonic, no hematomas, bleeding from uterus. Spontaneous ozing +, rectus abdominal muscle, skin, rectus sheath+.
Procedure
- Under all aseptic precautions, under general anesthesia, in supine position, parts painted and draped.
- Incision opened along the suture.
- Hemoperitoneum 2.5L found.
- Suction done. Active bleeding is found from upper abdomen.
- Surgeon was called and incision extended up to xiphisternum.
- Exploration done. collected bleeding found, no organ injury noted. In view of bleeding from uterus not controlled with Bi-manual compression.
- Proceeded to hysterectomy, cornual structures clamped and cut.
- UV fold found to be dissected already
- Bilateral uterine pedicles clamped and cut.
- Bilateral mackendot’s ligament clamped and cut.
- Vault opened.
- Specimen sent for HPE.
- Vault closure done. Wash given
- Abdomen closed in layers.
In MICU, Inj. Calcium gluconate stat dose given and started on Inj. Fentanyl infusion, IV antibiotics, IV Tranexamic acid, IV fluid and other supportive measures. Grave risk and poor prognosis explained to the patient attenders. Lab investigation showed Hb 6.1g/dL, PCV 20.4%, TLC 35080cells/cumm. 1 pint of PRBC, 2 pints of RDP and 4 pints of Cryo were transfused. Repeat Hb showed 8.7g/dL, 1pint of PRBC transfused. Patients remained clinically stable, strict monitoring was done. She was weaned off ventilator support and extubated. She was shifted to the ward and continued medications. Chest physiotherapy initiated. Patient complaints of fever, loose stools and cough which was managed with antipyretics, probiotics, nebulization and other supportive measures. Blood culture and urine culture sent (report awaited). Serial vital monitoring was done in ward. She remained hemodynamically and clinically stable, maintaining saturation on room air, P/A: soft, wound healthy, no discharge, dressing dry. no fresh complaints hence being discharged with the following advice.
Discussion
This case highlights the importance of early recognition and prompt management of PPH, a life-threatening emergency. Massive blood loss can rapidly progress to hemorrhagic shock, metabolic acidosis and multi organ dysfunction if not treated immediately. Successful management requires rapid assessment, aggressive fluid resuscitation, timely blood and blood component transfusion, administration of uterotonic agents when indicated and early surgical intervention when conservative measures fail. In this patient, emergency exploratory laparotomy with total peripartum hysterectomy was performed as a lifesaving procedure after massive hemorrhage. Post Operative intensive care including ventilator support and hemodynamic monitoring ensured stabilization and recovery.
Preventive strategies for postpartum hemorrhage
- Antenatal care plays a vital role in minimizing the risk of postpartum hemorrhage (PPH).
- Addressing anemia early in pregnancy, ensuring hemoglobin levels are at least 10 g/dL at delivery, and maintaining adequate hydration and nutrition during labour.
- Identifying high-risk pregnancies through detailed clinical history, ultrasonography, and, where required, advanced imaging techniques like MRI is essential for those with conditions such as placenta previa, uterine over distension, or coagulation disorders.
- Management of the Third Stage of Labor (AMTSL) The active management of the third stage of labour (AMTSL) is a cornerstone in preventing PPH.
The primary steps
- Administering a uterotonic agent,
- Controlled cord traction, and
- Uterine massage immediately after delivery of the baby.
- Methylergonovine, a second-line treatment
- Misoprostol, a prostaglandin E1 analogue,
- Carboprost,
- Tranexamic acid
In cases where pharmacological measures fail to control bleeding, non-surgical & surgical options are balloon tamponade, uterine compression sutures, artery ligations, or hysterectomy.
Compression Techniques: Bi manual uterine compression is performed by manually compressing the uterus externally and internally to stimulate contractions and reduce bleeding. Combining UBT with uterine compression sutures, such as the B-Lynch technique, can enhance hemostatic outcomes.
Image Source: Primary Post-Partum Haemorrhage; Nandhaa Pazhaniappan
Non-Pneumatic Anti-Shock Garment (NASG): The NASG is a cost-effective, first-aid compression device used to stabilize women with hypovolemic shock caused by PPH Applying circumferential pressure to the lower body improves blood flow to critical organs (heart, lungs, and brain) and reduces bleeding from the uterus and pelvic region. NASG is reusable, adjustable for various body types, and proven to reduce maternal mortality and the need for advanced surgical interventions.
Image Source: Medisave Health & Lifestyle Private Limited
Uterine Balloon Tamponade (UBT): UBT involves inserting a balloon into the uterus and inflating it with sterile fluid to apply pressure and stop bleeding. Available devices include fixed-volume balloons (Bakri balloon, ESM-UBT) and free-flow balloons (Ellavi UBT Zukovsky balloon) . UBT effectively prevents hysterectomy and controls PPH, with success rates between 83% and 95%.
Image Source: Primary Post-Partum Haemorrhage; Nandhaa Pazhaniappan
SR Cannula: The SR cannula is a minimally invasive tool for managing PPH. It enables rapid evacuation of blood and clots from the uterus. It enhances haemorrhage control and visualization for interventions, offering quick bedside deployment without surgery and making it ideal for emergencies. Preventing postpartum haemorrhage (PPH) involves adopting evidence-based practices, including active management of the third stage of labour with timely administration of uterotonic agents like oxytocin. Ensuring adequate antenatal care, correcting maternal anemia, and identifying high-risk cases, such as those with uterine over-distension or abnormal placentation, are essential. Routine monitoring of vital signs and early recognition of excessive blood loss are critical. Proper hydration during labour and maintaining a prepared team with access to uterotonics, resuscitation equipment, and surgical intervention facilities further reduce PPH risks. Structured protocols and training also play a vital role in prevention
Image Source: Paul Medical Systems
External aortic compression : External aortic compression is advised for the management of postpartum hemorrhage resulting from uterine atony following vaginal delivery. Administer compression adjacent to the umbilicus on the left side, while monitoring the pulsation of the femoral vein. Compression is efficacious when the femoral pulse is absent.
Surgical Management of Postpartum Hemorrhage (PPH)
Uterine Compression Sutures
Uterine compression sutures are surgical techniques employed to manage postpartum hemorrhage (PPH) caused by uterine atony when other measures fail. Introduced in 1997 with the B-Lynch suture, various modifications, including the Hayman, Transverse Isthmic Cervical Apposition Suture Ouahba (Four Transverse Sutures) sutures and Cho sutures have since been developed. These sutures compress the uterus to achieve hemostasis while preserving fertility, offering a less invasive alternative to procedures like hysterectomy. Each technique has unique benefits and potential complications, such as uterine necrosis or synechiae. Their effectiveness, typically high, is best ensured when applied promptly in cases of severe PPH. They are effective, with success rates ranging from 76% to 100%, and can be combined with balloon tamponades for better outcomes
Image Source: Wikipedia; Artery of round ligament of uterus
Unilateral Ovarian Vessel Ligation: One ovarian artery is ligated to further control bleeding.
Bilateral Ovarian Vessel Ligation: Both ovarian arteries are ligated as a last resort. This approach has shown high efficacy (100% success in the cited study) and avoids hysterectomy, allowing future fertility. The technique is straightforward, quick, and minimizes complications such as blood loss
Image Source: Jaypee Brothers Medical Publishers
Internal Iliac Artery Litigation: This procedure can be lifesaving when conventional measures fail to control bleeding. The reported success rate of internal iliac artery ligation (IIAL) ranges from 40% to 100%. By transforming the arterial flow into a venous-like system, it facilitates stable clot formation and achieves hemostasis. The main indications for internal iliac artery ligation include atonic or traumatic postpartum hemorrhage, adherent placenta, placental abruption, uterine rupture and placenta previa
Uterine artery embolization: Uterine artery embolization (UAE) is a non-surgical intervention for controlling persistent postpartum haemorrhage (PPH), with success rates exceeding 90%. It avoids laparotomy and is often preferred over uterine artery ligation. UAE involves inserting a catheter through the femoral arteries to block uterine blood flow, promoting clot formation and tissue necrosis. It is considered a safe option for preserving fertility and resuming menstruation post-procedure. However, complications include low-grade fever, pelvic infection, hematomas, transient ischemia, and rare arterial injury
Image Source: Uterine Artery Embolization: Procedure, Success Rate, Recovery & Cost; PACE Hospitals
Hysterectomy: Peripartum hysterectomy is the last resort for uncontrolled PPH when all other methods fail. It is often indicated in placenta accreta, uterine rupture, or severe bleeding and is associated with significant morbidity and mortality. There are two types of Subtotal hysterectomy and Total hysterectomy These surgical methods are life-saving interventions for refractory PPH, tailored to the clinical situation and available expertise Steps for Peripartum hysterectomy
Postoperative Monitoring
Transfer the patient to an intensive care unit for close monitoring of hemodynamic status, coagulation parameters, and organ function. Management for Traumatic PPH begins with careful exploration and cervicovaginal inspection to identify bleeding sources, such as perineal, vaginal, or cervical tears. Hemostatic sutures are applied to control bleeding from these injuries effectively. If uterine rupture is suspected, immediate action is required through an emergency laparotomy to assess and repair the rupture. In cases where bleeding persists despite these measures or the trauma is extensive, a subtotal or total hysterectomy may be necessary as a life-saving intervention. This structured approach ensures prompt identification and control of bleeding to stabilize the patient and prevent further complications.
Conclusion
Post Partum Hemorrhage remains one of the leading causes of preventable maternal mortality worldwide. This case demonstrates that early diagnosis, prompt resuscitation, timely blood component therapy and decisive surgical intervention are crucial in managing severe PPH. A well-coordinated multidisciplinary approach and adherence to standardized management protocols significantly improve maternal survival & Clinical Outcomes.
References
- Konar H, editor. DC Dutta’s Textbook of Obstetrics: Including Perinatology and Contraception. 10th ed. New Delhi: Jaypee Brothers Medical Publishers; 2023. Chapter on Postpartum Haemorrhage
- Ministry of Health and Family Welfare, Government of India. Guidance Note on Prevention and Management of Postpartum Haemorrhage. New Delhi: Maternal Health Division, Ministry of Health and Family Welfare; 2015
