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

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 Ts
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

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

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 its too late

B-Lynch Suture

Balloon Tamponade

Haematological
Management

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

Infection
Retained placenta
Trophoblastic disease
Antibiotics
Evacuation of retained products if
bleeding persistent or significant
amount of tissue retained.