Primary PPH

Treatment

• Abnormal vaginal bleeding within 24 hours of delivery
• Set up an IV line and empty bladder
• Replace blood loss with IV fluids (isotonic crystalloids) and blood when available
• Identify and treat the cause
• If uterine atony:
• Rub up a contraction
• Give 10 units Oxytocin IV stat then 40 units in 1 litre N/S, infuse over 4 hours
• If oxytocin not available, give Misoprostol 800mcg rectally or sublingually stat
• Tranexamic acid (1g IV over 10 minutes) is recommended if oxytocin does not rapidly stop the bleeding, to be used within 3 hours of delivery.
• Use of non-pneumatic anti-shock garment as temporizing measure
• Refer to hospital with nurse accompaniment if at the health centre
• If bleeding does not stop despite uterine massage and uterotonics then consider:
• Bimanual uterine compression or external aortic compression
• Additional uterotonics such as ergometrine if available
• Intrauterine balloon tamponade
• A second dose of Tranexamic acid IV, 1g over 10 minutes can be given 30 minutes after the 1st dose
• Examination under anesthesia: repair any genital tract trauma and proceeding to exploratory laparotomy, and surgical management including B-Lynch suture or hysterectomy if bleeding continues.
• If retained placenta, attempt manual removal or evacuation in theatre
• If ruptured uterus suspected, proceed to laparotomy and assess need / possibility for repair versus hysterectomy.