ANTEPARTUM
HAEMORRHAGE
MANAGEMENT
By
Sizwell Phiri
6/19/2022
Sizwell
INTRODUCTION
• Obstetric haemorrhage is one of the leading cause of maternal
mortality in developing countries and in developed countries , it is a
complication of substandard care. A study by the World Health
Organisation (WHO) revealed that 25-30% of maternal death are due
to peripartum haemorrhage.
• Applying conventional definition of haemorrhage to peripartum
haemorrhage may be misleading as blood loss up to 1000mls is not
uncommon during deliveries. Although no consensus exists on the
definition of massive obstetric haemorrhage. Presence of EITHER of
the following has been described
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INTRODUCTION con…
• Sudden blood loss >1500mls (25% of blood volume)
• Blood loss >3000mls in less than 3hours (50% of blood volume)
• Blood loss of 150mls/min in 20minutes (>50% of blood volume)
• Requirements of acute transfusion of >4 units of packed red cells
Hemodynamic collapse occurs only when almost 35-45% of
circuilating volume is lost
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Definition:
• Any bleeding from the genital tract after 24 weeks and
before the onset of labour. All cases are admitted to
hospital.
• This state may place the life of the fetus or the mother
or both at risk
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General Classification
• Placenta Praevia
• Placenta Abruption
• Other causes - show
•
ruptured uterus
•
local causes
•
cause unknown
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ANTEPARTUM HAEMORRHAGE: CAUSES
(1)
UTERUS
Abruption, placenta praevia
Significant APH is always due to placental separation
(2)
CERVIX
(3) IN
LABOUR
(4) CAUSE
UNKNOWN
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Erosion, polyp, carcinoma
Show = blood-stained mucus
Ruptured uterus
50%. Bleeding comes from the uterus
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Management of massive haemorrhage
• SHOUT FOR HELP. Urgently mobilize all available personnel
•A- Assess airway
•B- Breathing
•C- Evaluate the circulation
•Monitor vital signs (pulse, blood pressure, respiration,
temperature).
• E = Eliminate the cause: Think about possible causes
when taking a history and assessing the patient
•Haemorrhage may be concealed
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ANTEPARTUM HAEMORRHAGE: HISTORY
Take an ample history;
Amount
Mucus
Pain
Life
Episodes/ Events surrounding
bleed
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ANTEPARTUM HAEMORRHAGE: HISTORY TAKING
(1) AMOUNT Teaspoon, cupful; Did it go down legs, bed wet?
Pads
Beware of concealed abruption (10 - 20 %)
Clotting = abruption
(2) PAIN
What does this suggest? Especially back and abdo
(3) MUCUS
Mucus with light blood staining = show if in labour.
Bright = previa Dark = abruption Beware of
Concealed abruption
(4) LIFE
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Does she still feel the baby moving? If not moving??
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Management of massive haemorrhage
If before birth,
position mother in
the left lateral
position
(30degrees) to
minimise the
effects of aortocaval compression
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ANTEPARTUM HAEMORRHAGE: EXAMINATION
•GENERAL
If low BP = shock = needs resuscitation
If high BP = ?
•ABDOMINAL Signs of abruption Tenderness and hardness of the
uterus. What other condtions
can present like this?
Rupture
Abdominal preg
Signs of Praevia
Presenting Part ? High suggests PP
Fetal heart
CS scar
Clots suggest PP
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ANTEPARTUM HAEMORRHAGE: INVESTIGATIONS
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•ULTRASOUND
This will locate the placental site and
will show if the fetal heart is present.
•FETAL HEART
TRACING
Looking for signs of fetal distress
Absent FH suggests Abruption
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ANTEPARTUM HAEMORRHAGE: MANAGEMENT
(a) Maternal
condition
(b) Fetal
condition
(c)Gestational
age
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If shocked, need IV fluids fast. Cannulate
with 2x largebore(grey/green)canula .Oxygen
therapy. Put in lateral position, watch urine
(catheter).Collect FBC.grouping and x-match
If distressed, deliver at any
gestation
Under 37 weeks, try to be
conservative if there is no fetal
distress and the bleeding stops.
The aim is to avoid prematurity.
After 37 weeks, usually deliver
as the baby is now mature.
Usually CS if blood loss
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greater
than 500 mls
Rapidly infuse IV fluids (normal saline or Ringer’s
lactate) initially
at the rate of 1 L in 15–20 minutes;
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What are the features about the blood passed
vaginally in Praevia and Abruptions
Praevia
Abruption
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Bright red blood which is clotting
Dark red blood which is nonclotting
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APH: PLACENTA PRAEVIA (MANAGEMENT)
(1) What is the management of patients with placenta
praevia?
PP bleed is almost never fatal so keep the mother in hospital until
37-38 weeks. Do a CS then. The aim is to deliver the baby when it
is mature
(2) When would you need to deliver her before 37
weeks?
If heavy bleeding occurs which does not stop.
steroids
Remember
(3) What causes bleeding from Placenta
•
Praevia?
Contractions
Vaginal examination
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Abruption Aetiology
•
•
•
•
•
•
•
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Folic/ascorbic acid deficiency
ECV
Sudden release of polyhydramnios
Short cord
Muliparity
Anaemia
PET
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APH: PLACENTAL ABRUPTIONS (DIAGNOSIS)
What is the usual
history?
• Bleeding in 90% (other 10%
=?)
• Pain
What are the main
features on
examination?
• Tenderness and tenseness of uterus
• The fetal heart is absent in most
•Remember revealed/concealed
•
Ultrasound
=
may
show
the
What investigations
abruption and rule out
will help in confirming
praevia and will confirm
the diagnosis?
absent FH.
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APH: PLACENTAL ABRUPTIONS (MANAGEMENT)
(1) RESUSCITATE
(2) TRANSFUSE
•ABC O2/IV access/urinary output
• IV FLUIDS AND BLOOD: How do you
know you are giving enough?
• BP > 100 and pulse < 100
(3) CHECK FH
• Conjunctiva pink and urine flowing
Baby alive and < 6cms = do CS
(4) DELIVER
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Baby dead = deliver vaginally by
AROM and oxytocin i.e. induce
labour. Caution with multips. If
breech may need IPV with weight on
head Sizwell
THE SMALL APH and APH CAUSE UNKNOWN
(1) Do an ultrasound to exclude placenta praevia.
(2) Check the FH to exclude an abruption.
(3) Do a speculum examination to exclude local cause in the
cervix.
Management: Keep the patient in hospital for 48 hours after
bleeding has stopped. Danger of preterm labour!!!!
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Postpartum Haemorrhage (PPH)
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INTRODUCTION
• More than half of all maternal deaths occur within 24
hours of childbirth, mostly due to severe bleeding.
• PPH accounts for about 25% of maternal deaths world
wide.
• Rapid action is critical for survival.
• Incidence varies from 2 to 8% among hospitals
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Definition:
Any blood loss from the birth channel exceeding 500 ml
or more
- Primary PPH within 24 h
- Secundary PPH after 24 h
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PREDISPOSING FACTORS
• Prolonged or obstructed labour may result in uterine
inertia due to muscle exhaustion
• Polyhydramnious (overstretched uterus)
• Multiple pregnancy (overstretched uterus and large
placental site)
• Anaemia
and
malnutrition
(lack
of
oxygen/glucose/other essential nutrients
• Grand multiparity (tired and fibrosed uterus)
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Cont…
• Induction of labour and augmentation of labour for
hypotonic uterine action
• Placenta praevia (the lower segment is unable to
control bleeding effectively because the thinner muscle
layer contains few oblique fibres)
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Cont…
• Precipitate labour with large baby when the uterus has
contracted vigorously during the first and second stage of labour
then the muscles have insufficient opportunity to retract.
• General anaesthetic agents such as halothane cause uterine
relaxation
• Mismanagement of third stage such as fiddling with the fundus
or manipulation of the uterus may precipitate arrhythmic
contractions resulting in only partial separation of the placenta
• Previous history of PPH –there is a risk of recurrence in
subsequent pregnancies.
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Cont…
• Fibroids –THESE INTERFERE WITH UTERINE
CONTRACTION
• High parity-lax abdominal muscles
• Full or over distended bladder
• Retained products of conception
• Anaemia not able to withstand haemorrhage so any
small loss may alter condition of woman.
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CAUSES:
Primary PPH
Tone
Tissue
Trauma
Thrombosis
TTTT
Secundary PPH:
Subinvolutio uteri, infection
Retention
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Assessment and mgt
• Assessment should be coupled with resuscitative
measures
• It should be focused at finding the cause
• Look for occult bleeding were vaginal bleeding is less
compared to haemodynamic changes
• Bimanual palpation may reveal atonic uterus and
hematomas
• Look for vaginal and cervical lacerations
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Cont…
•Re-examine placenta
•Look for other bleeding sites
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CONT…
Have protocol in labour ward
1. Call for help
2. Perform Rapid Evaluation (Vital Signs & cause
BP, pulse, RR, Pallor)
3. Massage Uterus
4. If shock is present/suspected, start Immediate
Resuscitation
Start IV Infusion 1 litre/15 min
Give Oxytocin 10Units IM ff 40iu in 1litre NS
Take Blood for X-Match and coagulation studies
Give Oxygen
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Cont…
• Catheterize to monitor urine output (>30ml/hr)normal while
<30ml/hr not normal
• Check Placenta for completeness
• Examine birth canal for tears
• Monitor closely for further bleeding
• When client is stabilized Check HB
• If low, treat anaemia
• In massive haemorrhage order a minimum of 6 units whole
blood
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ATONIC UTERUS!
FIRST ACTION IS MASSAGE UTERUS
DRUG
DOSE &
ROUTE
CONT.
DOSE
OXYTOCIN IM 10 IU
IV 40 Iu in
1000ml at
IV 20 IU in 40 drps
1000 ml NS /min
at
60drp/min
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MAX
DOSE
PRECAU&
CI
NOT more DO NOT
than 3 litres Give IV
of IV fluids Bolus
containing
Oxytocin
ATONIC UTERUS cont
DRUG
DOSE &
ROUTE
MISOPROSTOL ORAL/SL
(CYTOTEC)
INTRAVAG
RECTAL
200800mcg
(600mcg)
CONT.
DOSE
MAX
DOSE
CAUTIONS
& CI
200mcg
Every 4
hours
2000mg
Asthma
Heart
Disease
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ATONIC UTERUS
OTHER MEASURES
• Bimanual compression
• Uterine artery ligation
• Hysterectomy
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MANAGING RETAINED PLACENTA
•
•
•
•
Ensure bladder is empty
Apply Controlled Cord Traction: If it fails,
Repeat Oxytocin 10u IM: If not successful in 30 min
Attempt Manual Removal of Placenta
• Give Pethidine and diazepam
• Give antibiotics: (Ampicillin 2g + Metronidazole 500mg)
• Perform procedure and examine placenta for
completeness
• Give Oxytocin 40 iU/1000 mls NS or RL at 40 dpm
• Monitor BP, Pulse, Pad and Urine output closely
• Add Ergot or Prostaglandin if bleeding continues
• Transfuse PRN and treat for anaemia
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SPECIFIC NURSING CARE IN THE PUERPERIUM
• As primary postpartum haemorrhage predisposes to secondary
postpartum haemorrhage and puerperal sepsis, this patient
must be carefully monitored.
SPECIFIC NURSING CARE
• Pulse, respiration and blood pressure are taken quarterly-for the
first hour, hourly for the next 4 hours and then four hourly.
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Cont…
• The uterus is checked at least quarter-hourly for the first hour,
hourly for the next 4 hours and then 4 hourly for the first 24
hours. It is then checked twice daily and measured daily for any
sign of sub-involution.
• The lochia is checked at the same time as the uterus and any
abnormally heavy red lochia, clots, pieces of placenta and/or
membrane passed, are reported to the doctor.
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Cont…
• Where traumatic postpartum haemorrhage has taken place, the
midwife must inspect the site of haemorrhage regularly for
further haemorrhage and for the possible formation of a
haematoma.
• The intravenous infusion is usually continued for at least 24
hours.
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Cont…
• It is essential to ensure that the patient empties her bladder
when she micturates.
• The patient is encouraged to take extra fluids and the fluid
balance is monitored until normal.
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Cont…
• Blood is taken for haemoglobin estimation and if between 911g/dl, patient is usually treated with oral iron tablets.
• Haemoglobin levels of less than 7 g/dl may require blood
transfusion.
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Cont…
• If there are signs of infection that is fever or foul smelling
vaginal discharge, give triple antibiotic therapy Ampicillin 2g iv
6hrly, gentamicin 80mg 8 hourly Metronidaaazole 500mg iv
8hrly.
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PREVENTION OF PPH
• Ensuring that no woman goes in labour with anaemia.
• Prompt management of conditions that can predispose to PPH
• Active management of third stage.
• Proper use of the partogram to prevent prolonged labour
• Ensure that the bladder is empty before second stage of labour.
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COMPLICATIONS
• DIC
• Anaemia
• Shock
• Puerperal infection
• Sheehan’s syndrome
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Massive obstetric haemorrhage
•Can occur
•Antepartum: APH
•Postpartum: PPH
•REMEMBER: sometimes it is the APH
that weakens and the PPH that kills
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