Postpartum Haemorrhage (PPH)

Clinical description

Primary PPH is defined as blood loss ≥ 500 ml within 24 hrs of vaginal delivery, or blood loss ≥ 1,000 ml within 24 hrs of Caesarean delivery, or any amount of blood loss that disturbs maternal hemodynamic status.

Secondary PPH is defined as abnormal bleeding at 24 hrs to 6-12 wks postnatal. Usually from retained products.

Causes of PPH

• Uterine atony (most common), retained placenta/products, vaginal/cervical lacerations, uterine rupture, uterine

inversion, and coagulation disorders (i.e. DIC).

• All patients should be screened for risk factors on admission.

Risk factors for PPH:

• Grand multiparity, multiple gestation, severe pre-eclampsia, abruptio placenta, obesity, large uterine myomas,

macrosomia, fetal macrosomia, polyhydramnios and prolonged labor.

• Patients at risk should have an IV inserted on admission and uterotonic medications should be readily available.

Blood samples should be obtained for group and crossmatch if indicated.

Prevention of PPH is done via routine active management of the third stage of labour (AMTSL).Routine prophylactic oxytocin 20 IU in 1L NS at 30 drops/min for grandmultiparity, patients with APH, multiple gestation, polyhydramnios, macrosomia, and prolonged labour. AMTSL includes the following:

• Oxytocin 10 IU IM immediately after all deliveries, including caesarean deliveries
• Controlled cord traction for delivery of placenta, including caesarean delivery
• Uterine massage
• Regular and frequent assessment of uterine tone by palpation of fundus after delivery of placenta
• Misoprostol 600 μg administered orally can be used for the prevention of PPH if oxytocin is not available1

Diagnosis History/Exam/Investigations PVB, +/- shock. Quantification of blood loss is preferred over visual estimation.

Treatment

Initial management

• STOP BLEEDING AS YOU CALL FOR HELP (i.e. Bimanual compression, aortic compression)
• Call for help and check circulation, airway, breathing (CAB)
• Obtain IV access and start IV fluids. If blood loss is greater than 1000 ml, insert 2 large-bore cannulae (i.e. 16G or

18G).

• Oxygen 10-15 L/min if available
• Insert foley catheter
• Draw blood:
• X-match ≥ 4-6 units PRBC and 4-6 units FFP (at a 1:1 ratio with PRBC)
• Bedside clotting time
• FBC (if unavailable, then Hb)
• Uterine massage to induce contractions
• Place woman in supine position and keep warm

For uterine atony

• Vigorous uterine massage
• Repeat oxytocin 40 IU IV in 1 liter NS @ 125cc/hr
• Misoprostol 800 mcg sublingual or PR or 600 mcg PO.

Note: misoprostol is not as effective as oxytocin and may not further increase uterine tone when used in combination with oxytocin1.

• The use of tranexamic acid 1 g IV STAT (PO if no IV) is recommended for the treatment of PPH if oxytocin and

other uterotonics fail to stop the bleeding.2, 3.

• If bleeding persists, arrange for EUA. Check for cervical lacerations or any missed vaginal lacerations, or possible

retained products

• Consider intrauterine balloon tamponade using a condom catheter (300-500 mL saline)

Clinical description

• If above steps fail, then consider laparotomy for B-Lynch suture, bilateral uterine artery ligation (O’Leary sutures),

or hysterectomy. While awaiting OT, perform bimanual uterine or aortic compression.

For retained products/placenta

• If able to tolerate, give Pethidine 100 mg IM and perform manual removal of placenta at bedside
• If unable to tolerate, then manual removal and/or evacuation with banjo curette in OT under anesthesia
• If morbidly adherent or retained, then consult senior doctor immediately
• A single dose of antibiotics (ampicillin or first-generation cephalosporin) is recommended if manual removal of the

placenta is practised2.

For vaginal/cervical lacerations

• Identify apex before initiation of repair
• Consider repair in OT if difficult to visualize apex at bedside

For coagulopathy

• Evaluate for coagulation abnormality via bedside clotting time. A clotting time greater than six minutes is

considered abnormal.

• Draw blood for platelet count, PT and PTT, and fibrinogen (if available)
• If deranged, then transfuse PRBC, FFP, +/- platelets, +/- whole blood

For uterine inversion

• Consult anesthesia
• Suspect if on bimanual examination, the finding of a firm mass below or near the cervix, coupled with the absence

of identification of the uterine corpus on abdominal examination

• If the inversion occurs before placental separation, detachment or removal of the placenta should not be undertaken
• Place palm of the hand against the fundus as if holding a tennis ball, with the fingertips exerting upward pressure

circumferentially

• Uterine relaxant may be necessary- terbutaline, magnesium sulfate, halogenated general anesthetics, and

nitroglycerin have been used

• If not successful, then laparotomy
• Huntington procedure - progressive upward traction on the inverted corpus using Babcock or Allis forceps
• Haultain procedure - incising the cervical ring posteriorly, allowing for digital repositioning of the inverted

corpus, with subsequent repair of the incision 1FIGO Guidelines: Prevention and treatment of postpartum hemorrhage in low-resource settings. Int J Gynecol Obstet. 117 (2012) 108–118 2WHO recommendations for the prevention and treatment of postpartum haemorrhage, 2012 3Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage. Lancet 2017; 389: 2105–16.