Postpartum Haemorrhage
Definitions
• Primary PPH –
blood loss of 500ml or more
within 24hours of delivery.
• Secondary PPH – significant blood loss
between 24 hours and 6
weeks after birth.
Why do we care?
Major obstetric haemorrhage – more than
1000ml
Very rapidly lead to maternal death
• 3rd highest cause of direct maternal death in
the UK and Ireland (2003-2005)
• 58% of these cases care was “seriously
substandard”
• Major cause of severe maternal morbidity in
“near-miss audits”
Risk Factors
Most cases have no risk factors
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Previous PPH
Antepartum haemorrhage
Grand multiparity
Multiple pregnancy
Polyhydramnios
Fibroids
Placenta praevia
Prolonged labour (&oxytocin)
Prevention
• Be aware of risk factors – may present antenatally
or intrapartum
• Treat anaemia antenatally
• Active management of the 3rd stage
• Prophylactic oxytocics reduce the risk of PPH by
60% (oxytocin or oxytocin & ergometrine)
• 5IU IM for vaginal delivery
• 5IU IV for LSCS
• Consider oxytocin infusions
4 T’s
Tone
Tissue
Thrombin
Trauma
Causes
Tone
Previous PPH
Prolonged labour
Age > 40 years
Big baby
Multiple pregnancy
Placenta praevia
Obesity
Asian ethnicity
Tissue
Retained placenta/
membrane/clot
Thrombin
Abruption
PET
Pyrexia
Intrauterine death
Amniotic fluid embolism
DIC
Trauma
Caesarean section
(emergency > elective)
Perineal trauma
Operative delivery
Vaginal and cervical tears
Uterine rupture
• Blood loss is commonly underestimated
• Loss may be well-tolerated
• Beware the “trickle” and the “moderate
lochia”
• Minor PPH can easily progress to major PPH.
Management
• Has the placenta been delivered and is it
complete?
• Is the uterus well-contracted?
• Is the bleeding due to trauma?
Resuscitation
A & B – 10 -15l/min O2 by facemask
C2 14 gauge cannulae
blood for Hb, U&E, LFTs, clotting
crossmatch 4 units
2 litres of crystalloid rapidly
transfuse as soon as possible – consider O –
ve blood if any delays.
Uterine Contraction-First Line Drugs
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Oxytocin 5IU
Oxtocin infusion – 40IU in 500mls
Ergometrine 0.5mg
Carboprost (Haemabate©) 0.25mg IM every
15 minutes x 8 doses
• Misoprostol 600 mcg sublingually
Uterine Contraction – non-pharm
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Empty uterus
Foley catheter
Rub up a contraction
Bimanual compression
Balloon tamponade
Brace suture
Uterine artery ligation
Internal iliac artery ligation
Interventional radiology
• Hysterectomy – before it’s too late
B-Lynch Suture
Balloon Tamponade
Haematological Management
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DIC
Transfuse without delay
Involve haematology service at an early stage
Correct coagulopathy
Liase with consultant haematologist re use of
recombinant Factor V11 (Novoseven©) and
Fibrinogen.
• Traumatic for patient, family and staff.
• Debriefing for patient and staff.
• Case analysed to ensure care was of good
standard and any substandard care can be
improved.
Secondary PPH
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Infection
Retained placenta
Trophoblastic disease
Antibiotics
Evacuation of retained products if bleeding
persistent or significant amount of tissue
retained.