Review
Post-partum haemorrhage
Soma Mukherjee
Sabaratnam Arulkumaran
Abstract
Obstetric haemorrhage accounts for 25% of maternal deaths in develop-
ing countries and post-partum haemorrhage (PPH) is the most common
type. It accounts for 10.6% of all direct maternal deaths in the UK and,
according to the recent Confidential Enquiries into Maternal and Child
Health report, it is the third most common cause of maternal mortality.
The enquiry concluded that a number of these deaths were avoidable
and highlighted ‘doing too little too late’.
Failure to assess the clinical picture, underestimating blood loss,
­delayed treatment, lack of multidisciplinary team work and failure to
seek timely senior help are some of the issues highlighted. Clinicians
should be aware of appropriate surgical measures and the timing of
­interventions. Effective team work, pooling of resources and the pres-
ence of a ‘rapid PPH response teams’ can improve outcome.
Keywords balloon tamponade; blood transfusion; haemostasis;
­postpartum haemorrhage; surgery; uterotonics
Introduction
Post-partum haemorrhage (PPH) refers to an estimated blood
loss in excess of 500 ml following a vaginal birth and a loss
greater than 1000 ml during a Caesarean section. Major haemor-
rhage is defined as an estimated blood loss of more than 2500 ml
or the transfusion of 5 or more units of blood or treatment of
­coagulopathy.
These values are arbitrary as visual estimation of blood loss is
not reliable. Patients with a low body mass index have a lower
blood volume of 70 ml/kg and anaemic women have fewer
reserves to withstand blood loss and hence will decompensate
sooner. Thus, a useful definition takes into account any blood
loss that causes a major physiological change like a fall in blood
pressure, as the risk of dying from PPH depends on the amount
and rate of blood loss and the woman’s health.
PPH is classified as primary and secondary. Primary PPH
occurs within 24 hours of delivery and secondary PPH after
24 hours and within 6–12 weeks post-partum.
Soma Mukherjee MBBS MRCOG is a Lecturer in the Department of
Obstetrics and Gynaecology, St Georges Hospital, University of
London, London, UK.
Sabaratnam Arulkumaran MBBS MD PhD FRCOG is a Professor at the
Department of Obstetrics and Gynaecology, St Georges Hospital,
University of London, London, UK.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:5
Causes and risk factors
PPH is commonly due to one or a combination of four processes
referred to in the ‘4Ts’ mnemonic:
• tone (post-delivery poor uterine contraction)
• tissue (blood clots and/or retained products of conception)
• trauma (genital tract)
• thrombin (coagulation abnormalities).
Common risk factors for PPH are an over-distended uterus due
to fetal macrosomia, multiple pregnancy and polyhydramnios.
Antepartum haemorrhage, chorio-amnionitis, coagulation dis­
orders, fibroid uterus, induction of labour, instrumental delivery,
obesity, pre-eclampsia, previous Caesarean section delivery, pre-
vious history of PPH, primigravidity, prolonged rupture of mem-
branes and/or labour are also considered to be risk factors.
There is a trend in the UK towards delaying child-bearing.
Increased maternal age, Caesarean and instrumental deliveries
and placenta praevia increase the incidence of PPH. An increas-
ing number of multiple pregnancies due to assisted reproduction
can also result in an increased incidence of PPH.
PPH can occur in women without identifiable risk factors. In
absolute numbers, more women without risk factors have atonic
PPH as compared with those with risk factors.
Pathophysiology
The blood vessels supplying the placental bed pass through an
interlacing network of muscle fibres of the myometrium. Myo-
metrial contraction causes placental separation and causes blood
vessels to constrict. This haemostatic mechanism or ‘living liga-
tures’ control the bleeding from the placental bed when the pla-
centa separates. Uterine atony results in a failure of these ‘living
ligatures’ to stop the bleeding. The active management of the
third stage of labour is associated with a reduction in the risk of
PPH and less need for blood transfusion by enhancing the above
physiological process.
Mild shock occurs when 20% of the blood volume is lost,
resulting in decreased perfusion of non-vital organs and tissues
(i.e. bone, fat, skeletal muscle) with pale and cool skin. When
20–40% of the blood volume is lost, moderate shock occurs with
decreased perfusion of vital organs (i.e. gut, kidneys, liver), oli-
guria and/or anuria, a drop in blood pressure, and mottling of
the skin in the legs. When 40% or more of the blood volume is
lost, severe shock occurs resulting in decreased perfusion of the
heart and brain, agitation, restlessness, coma, echocardiogram
and electroencephalogram abnormalities, and finally cardiac
arrest.
Prevention of PPH
Only 40% of women who develop PPH have an identifiable risk
factor. Women with risk factors should be delivered in centres
with transfusion and intensive care unit facilities. The Royal
College of Obstetricians and Gynaecologists (RCOG) urges early
or prophylactic interventional radiology for the prevention and
management of PPH in high-risk cases and recommends strate-
gies for the management of unpredicted PPH.
Prevention of PPH includes antenatal risk assessment and
treatment of anaemia or other health problems so that women
121 Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved.
 Review
are healthy enough to withstand PPH, as well as appropriate
intra-partum and post-partum management. The International
Confederation of Midwives and the International Federation of
Gynecology and Obstetrics (FIGO) have together launched a
world-wide programme to promote active management of the
third stage of labour for all women. Active management con-
sists of interventions designed to facilitate placental delivery by
improving uterine contractions and preventing PPH by averting
uterine atony. These measures include administration of utero-
tonic agents, controlled cord traction and uterine massage after
delivery of the placenta, as deemed appropriate. This approach
reduces the risks of PPH, anaemia, requirement for blood transfu-
sion, prolonged third stage of labour and use of therapeutic drugs
for PPH. It is recommended that active management should be
routine for women in maternity hospitals and there is no evi-
dence to suggest that this recommendation should not include
low-risk births at home or in birth centres.
Oxytocin is used routinely in the active management of the
third stage of labour. It is routinely administered for the prevention
and treatment of PPH as a first-line agent as it is effective within
2–3 minutes after injection and, as it has minimal side effects, it
can be used in all women. If oxytocin is unavailable, ergometrine
maleate 0.5 mg intramuscularly, ergometrine with oxytocin 5 IU/ml
(syntometrine) or misoprostol 0.4 mg orally can be used.
Misoprostol – which is a prostaglandin E1 analogue – can be
administered by oral, sublingual and rectal routes. The main side
effects are diarrhoea, nausea and vomiting. Rectal misoprostol
causes less shivering and pyrexia, than oral misoprostol. A recent
Cochrane review on the use of prostaglandins for the prevention
of PPH concluded that neither intramuscular prostaglandins nor
misoprostol are preferred to conventional injectable uterotonics
as part of the management of the third stage of labour especially
for low-risk women.
Carbetocin is a long-acting oxytocin agonist and has been
used for the prevention of PPH. The advantage of intramuscular
carbetocin over intramuscular oxytocin is its longer duration of
action. It induces a prolonged uterine response post-partum, both
in amplitude and frequency of contraction. Carbetocin is associ-
ated with reduced need for other uterotonic agents and uterine
massage, and there are no differences in side effects between
carbetocin and oxytocin.
FIGO recommends that skilled birth attendants should use
physiological (or expectant) management of the third stage if
oxytocin or misoprostol are unavailable.
In 2006, the World Health Organization held a technical con-
sultation on the prevention of post-partum haemorrhage and it
recommends the following.
• Active management of the third stage of labour should ­include:
administration of an uterotonic soon after the birth of the baby;
delayed cord clamping; and delivery of the placenta by controlled
cord traction followed by uterine massage.
• Active management of the third stage of labour should be
­offered by skilled attendants, as potential risks such as uterine
inversion, may result from inappropriate cord traction.
• Oxytocin should be offered for the prevention of PPH in pref-
erence to oral, sublingual or rectal misoprostol.
• In the absence of active management of the third stage of
labour, an uterotonic drug (oxytocin or misoprostol) should be
offered.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:5
Management
A management algorithm – HAEMOSTASIS – has been proposed
to aid stepwise management of atonic PPH. The following section
has been adapted from: Chandraharan E & Arulkumaran S. Man-
agement algorithm for atonic postpartum haemorrhage. J Psycho-
som Obstet Gynaecol June 2005: 106–112 and Doumouchtsis SK,
& Arulkumaran S. Postpartum haemorrhage: changing practices.
In: Recent Advances in Obstetrics and Gynaecology. Vol 24. Dunlop
W, Ledger WL (eds). London: The Royal Society of Medicine
Press Ltd; 2008. pp. 89–104.
HAEMOSTASIS algorithm
General medical management
H Call for help
A Assess (vital signs, blood loss) and resuscitate
E Establish aetiology, ecbolics, ensure availability of blood
Establish aetiology: ‘4Ts’ – tone, tissue, trauma, thrombin
Ecbolics (syntometrine, ergometrine, bolus syntocinon)
Ensure availability of blood and blood products
M Massage the uterus
O Oxytocin infusion, prostaglandins (intravenous, rectal,
­intramuscular, intramyometrial)
Specific surgical management
S Shift to operating theatre – bimanual compression anti-
shock garment, especially if transfer is required
T Tissue and trauma to be excluded and proceed to tampon-
ade with balloon or uterine packing
A Apply compression sutures
S Systematic pelvic devascularisation (uterine, ovarian,
quadruple, internal iliac)
I Interventional radiology, uterine artery embolisation
S Subtotal or total abdominal hysterectomy
H – Call for help
Major PPH must be managed appropriately by a multidisciplinary
team. Consultant obstetricians, anaesthetists, haematologists,
midwives, theatre staff, blood bank, hospital porters and even
the intensive care/high dependency unit staff should be alerted.
A – Assess (vital signs, blood loss) and resuscitate
Early recognition, prompt resuscitation and restoration of the cir-
culating blood volume are the components in the management of
PPH. General resuscitation measures include assessment of the
haemodynamic status by monitoring the patient’s vital param-
eters (level of consciousness, blood pressure, pulse and oxygen
saturation).
Accurate estimation of the blood loss warns of impending
haemorrhagic shock. Different methods of estimation have been
evaluated and guidelines to improve accuracy of the visual esti-
mation of blood loss have been suggested. Two large bore can-
nulae are inserted and blood samples taken for full blood count,
group and save and cross-match, coagulation screen and renal
and liver profile.
Fluid resuscitation in PPH is often conservative because of
underestimation of blood volume and rapid blood loss. It is
important to remember that symptoms of hypovolaemia are
often delayed due to compensatory mechanisms as these women
122 Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved.
 Review
are fit and young. Concerns that fluid overload will lead to pul-
monary oedema and cardiac failure, may be misleading. A loss
of 1 litre of blood requires replacement with 4–5 litres of crystal-
loid (0.9% normal saline or lactated Ringer’s solution) or col-
loids until cross-matched blood is made available, as most of the
intravenous fluid shifts from the intravascular to the interstitial
space.
‘The golden first hour’
Severe haemorrhage leads to cardiovascular failure if not diag-
nosed and treated effectively. As the severity depends on body
weight and metabolism and haemoglobin levels, emergency
measures should be initiated if the estimated blood loss is more
than one-third of the woman’s blood volume (blood volume
[ml] = weight [kg] × 80) or more than 1000 ml or a change in
­haemodynamic status.
As more time passes between the onset of severe shock and
effective resuscitation, the chances of survival decrease because
metabolic acidosis sets in. The ‘golden first hour’ is the time
at which resuscitation must be commenced to ensure the best
chance of survival. The probability of survival decreases sharply
after the first hour if the patient is not effectively resuscitated.
For the general acute management of PPH a ‘rule of 30’ has
been proposed. If the patient’s systolic blood pressure (SBP) falls
by 30 mmHg, heart rate (HR) rises by 30 beats/min, respiratory
rate increases to >30 breaths/min and haemoglobin or haema-
tocrit drop by 30%, and/or her urinary output is <30 ml/hour,
then the patient is most likely to have lost at least 30% of her
blood volume and is in moderate shock leading to severe shock.
The use of the ‘shock index’ (SI) is invaluable in the monitoring
and management of women with PPH. It refers to HR divided by the
SBP. The normal value is 0.5–0.7. With significant haemorrhage,
it increases to 0.9–1.1. The change in SI of an individual patient
appears to correlate better in identifying early acute blood loss than
the HR, SBP or diastolic blood pressure used in ­isolation.
E – Establish aetiology, ecbolics, ensure availability of blood
• Establish aetiology: 4Ts – tone, tissue, trauma, thrombin
• Ecbolics (syntometrine, ergometrine, bolus syntocinon)
• Ensure availability of blood and blood products
A systematic assessment to identify the cause of bleeding
is made using the ‘4Ts’ mnemonic. Thorough assessment of
the uterine tone is followed by uterine massage and adminis-
tration of uterotonic agents if the uterus is atonic. Exploration
of the uterine cavity under anaesthesia is essential to exclude
or remove retained placental tissue and membranes. If bleed-
ing persists despite a well-contracted uterus, examination under
anaesthesia must include looking for cervical tears or tears in
the vaginal vault, as these may involve the uterus and/or broad
ligament and may be the cause of retroperitoneal haematomas.
Pressure and/or packing are useful to achieve haemostasis and
to prevent haematoma formation. Suspect a coagulation defect
if retained tissue or trauma is excluded and bleeding continues
despite a well-contracted uterus.
Uterine atony is the most common cause of PPH. Medical
management consists of oxytocin 10 units by slow intravenous
injection, ergometrine 0.5 mg by slow intravenous injection,
methergine 0.2 mg intramuscularly, oxytocin infusion, 15-methyl
PGF2 intramuscularly or intramyometrially, or misoprostol.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:5
If bleeding continues, blood transfusion must be commenced
if the estimated blood loss is over 30% of the blood volume or
if the patient is haemodynamically unstable despite aggressive
resuscitation. Group O, Rhesus-negative blood should be trans-
fused until grouped and cross-matched blood is available.
Coagulopathy may be due to a number of factors: disseminated
intravascular coagulation (DIC); depletion of clotting factors
within blood clots (‘washout phenomenon’); dilution of clotting
factors with crystalloid fluid resuscitation; lack of clotting factors
in stored blood; hypothermia; and acidosis secondary to hypoxia.
Dilutional coagulopathy occurs when about 80% of the original
blood volume has been replaced. One litre of fresh frozen plasma
should be administered (15 ml/kg) with every 6 units of blood
transfused. Platelet concentration should be maintained at more
than 50 × 109 per litre or more than 80–100 × 109 per litre if
surgical intervention is likely. Cryoprecipitate (which provides a
more concentrated form of fibrinogen) and other clotting factors
(VIII, XIII, von Willebrand factor) may be required if there is DIC
or if the fibrinogen level is less than 10 g/l.
M – Massaging the uterus
Bimanual uterine massage (vaginal hand in the anterior fornix
and abdominal hand on the uterine fundus) is a very effective
measure and reduces bleeding even if the uterus remains atonic,
allowing resuscitation to be effective and, thus, reducing further
blood loss.
O – Oxytocin infusion, prostaglandins
Oxytocin, can be given as a slow intravenous bolus (5 units) or as
an infusion (40 units in 500 ml of 0.9% normal saline, infused at
a rate of 100–125 ml/hour) in order to maintain uterine contrac-
tion. There are no absolute contraindications, but an antidiuretic
effect with volume overload can develop with high cumulative
doses. If the uterus remains atonic after initial oxytocic therapy,
syntometrine or ergometrine can be repeated.
Ergometrine is an ergot alkaloid and hypertension and cardiac
disease are contraindications due to the possible development of
severe hypertension and myocardial ischaemia.
Carboprost is a prostaglandin F2 analogue administered
intramuscularly or intramyometrially. It is a second-line agent
for uterine atony (0.25 mg repeated every 15–20 minutes to a
maximum dose of 2 mg). It is known to be 80–90% effective in
decreasing blood loss due to PPH in cases that are refractory to
oxytocin and ergometrine. It is contraindicated in asthma as it
is bronchoconstrictive and other side effects include diarrhoea,
vomiting, fever, headache and flushing.
Misoprostol is a synthetic prostaglandin E1 analogue and has
been used in the management of PPH. Placebo-controlled ran-
domised trials compared misoprostol with placebo and showed
that misoprostol use was not associated with any significant
reduction of maternal mortality, hysterectomy, additional use of
uterotonics, blood transfusion, or evacuation of retained prod-
ucts. Misoprostol was associated with a significant increase of
maternal pyrexia and shivering. However, an unblinded trial
showed better clinical response to rectal misoprostol than a
combination of syntometrine and oxytocin. A recent Cochrane
review concluded that the addition of misoprostol with oxy-
tocin is superior to the combination of oxytocin and ergomet-
rine alone for the treatment of primary PPH. As the peak serum
123 Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved.
 Review

c­ oncentration of oxytocin is much smaller than oral misopro-
stol, which reaches its serum peak concentration at 20 min, a
combination of these two agents can provide a sustained utero-
tonic effect.
A number of case reports of empirical ‘off-label’ use of recom-
binant activated factor VII show that it may be an alternative
haemostatic agent when the standard treatment is ineffective.
The Scottish Confidential Audit of Severe Maternal Morbidity
recommends that, if conservative measures fail to control haem-
orrhage, surgical haemostasis should be commenced ‘sooner
rather than later’. Other reports from the RCOG recommend that
obstetricians must consider all available interventions to stop
haemorrhage including B-Lynch suture, uterine artery embolisa-
tion or even radical surgery.
Recommendations have been made that all hospitals with
delivery units should aim to provide an emergency interventional
radiology service as these have the potential to save the lives of
patients with massive PPH.
The American College of Obstetricians and Gynecologists
suggests that uterine tamponade can be effective in decreasing
haemorrhage secondary to uterine atony, and procedures such as
uterine artery ligation or B-Lynch suture may be used instead of
the need for hysterectomy. In patients with stable vital signs but
persistent bleeding, arterial embolisation is suitable, especially if
the rate of blood loss is not excessive.
S – Shift to operating theatre (anti-shock garment, especially if
transfer is required and bimanual compression)
In home births and midwifery-led units, transfer to a centre with
greater facilities is indicated at this stage. A new type of non-
pneumatic anti-shock garment (NASG) can reverse the effect
of shock on the body’s blood distribution by applying external
counter pressure to the legs and abdomen and returning blood
to the vital organs, thus keeping the woman stabilised until she
reaches a hospital.
A pilot study showed that in women in whom the NASG
was used, compared with women in a control group, bleeding
decreased by 50% in those experiencing various forms of obstet-
ric haemorrhage (e.g. post-abortion complications, PPH or rup-
tured ectopic pregnancy). The use of this device could be critical
in reducing maternal mortality in low-risk areas where reaching
a health facility could take time.
that uterine packing is a safe, quick and effective procedure for
controlling PPH.
Successful use of uterine balloon tamponade has been reported
using a number of devices, including a Bakri balloon, a condom,
a Foley’s catheter, the Rusch urological hydrostatic balloon and
the Sengstaken–Blakemore oesophageal catheter (SBOC). The
SBOC has been the most frequently used and reported device.
Overall, the reported success rates vary between 70% and
100%. Uterine tamponade with the SBOC has been described as
a prognostic test in obstetric haemorrhage. The ‘tamponade test’
has had a positive result of >87% for the successful manage-
ment of PPH in these studies.
The ‘tamponade test’ arrests bleeding in most women with
severe PPH and allows the obstetrician to identify women requir-
ing a laparotomy. This method has the advantages that: (i) inser-
tion is easy and rapid with minimal anaesthesia; (ii) it can be
performed by relatively inexperienced personnel; (iii) removal is
painless; and (iv) failed cases can be identified rapidly. The early
use of balloon tamponade results in reduced total blood loss and
haemorrhage-related maternal mortality. No immediate prob-
lems (such as bleeding and sepsis) or long-term complications
(such as menstrual and fertility problems) have been reported in
women who have undergone uterine tamponade.
A – Applying the compression sutures
If the patient is stable and bimanual compression of the uterus
has successfully achieved haemostasis, then compression sutures
may be of value. Various modifications have been reported to the
original B-Lynch suture technique (Figures 1 and 2). The major
advantages are easy application of such sutures and preservation
of fertility. The disadvantage is the need for laparotomy. Recog-
nised complications include erosion through the uterine wall,
pyometra and uterine necrosis.

T – Tissue and trauma to be excluded and proceed to tampon-

ade with balloon or uterine packing
Continuous bleeding indicates transfer to and evaluation in the
operating theatre. Examination with appropriate lighting, equip-
ment, analgesia and assistance permits assessment of the uterine
tone and excludes retained tissue and trauma. Bimanual uter-
ine compression helps to control bleeding while monitoring and
resuscitation continues and preparations are made for further
interventions.
Uterine packing has always been considered effective, quick
and safe for controlling PPH. The use of uterine packing in the
management of PPH fell into disrepute in the 1960s following
concerns that it: (i) was potentially traumatic and time-consum-
ing; (ii) might conceal ongoing haemorrhage; (iii) might pre-
dispose to the development of infection; and (iv) represented a Figure 1 The B-Lynch suture. Reproduced with permission from Sapiens
‘non-physiological approach’. More recently, studies concluded Publishing, 2006.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:5 124 Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved.
 Review

Tubal Branch of the ovarian artery

Uterine artery

Figure 3 Quadruple ligation. Reproduced with permission from Elsevier

Publishers, 2008 (Chandraharan E & Arulkumaran S. Surgical aspects of
postpartum haemorrhage. Best Practice & Research Clinical Obstetrics
and Gynaecology, 2008).

the procedure has the potential to preserve fertility. Prophylactic

embolisation has a role in an elective Caesarean section when
the placenta is thought to be morbidly adherent.
Complications include haematoma formation, infection, con-
trast-related side effects and ischaemia, resulting in uterine and

Reproduced with permission from Sapiens Publishing, 2006.

a Cho’s multiple square technique. b Vertical and horizontal
compression sutures. Internal
iliac vein
Figure 2
Ureter

S – Systematic pelvic devascularisation

Pelvic devascularisation requires laparotomy, and progressive,
step-wise devascularisation, whereby the uterine, ovarian and
External
internal iliac arteries are ligated (Figure 3). Internal iliac artery iliac artery
ligation (Figure 4) is effective in arresting bleeding from within
the genital tract, however, it takes time, is technically challeng-
ing and carries the risk of injury to neighbouring structures.
Prerequisites include a haemodynamically stable patient, spe-
cialist surgical expertise and a patient’s desire to preserve her
future fertility. The reported success rates are between 40% and
100%. When arterial ligation fails, hysterectomy follows and has Ligation of anterior division
a higher morbidity compared with those patients undergoing of internal iliac artery
hysterectomy without previous attempts at arterial ligation.
Figure 4 Internal iliac artery ligation: anatomy of the lateral pelvic wall.
I – Interventional radiology and uterine artery embolisation Reproduced with permission from Elsevier Publishers (Chandraharan E
Arterial embolisation under fluoroscopic guidance was first & Arulkumaran S. Surgical aspects of postpartum haemorrhage, Best
described in 1979. The success rate is as high as 70–100% and Practice & Research Clinical Obstetrics and Gynaecology, 2008).

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:5 125 Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved.
 Review
bladder necrosis. Specialised equipment and an interventional
radiologist with a great degree of expertise are prerequisites for
this procedure.
A recent systematic review failed to demonstrate that any
one method for the conservative management of severe PPH
was superior to another. The review recommended that uter-
ine balloon tamponade should be considered as the first step in
the management of intractable PPH, which is not due to genital
trauma or retained tissue, and which does not respond to medi-
cal treatment. The choice of measures employed depends on the
available facilities and the degree of ongoing bleeding, the esti-
mated blood loss and the haemodynamic state of the woman.
S – Subtotal or total abdominal hysterectomy
Subtotal or total abdominal hysterectomy is usually a last resort
in the management of PPH and must not be delayed if the conser-
vative measures have failed to control it. Subtotal hysterectomy
may not be effective when the source of the bleeding is in the
lower segment, cervix or vaginal fornices. Hysterectomy is asso-
ciated with numerous postoperative complications (e.g. bowel
injury, fistula formation, pelvic haematoma, sepsis, urinary tract
injury, vascular injury). The resultant loss of child-bearing and
its psychological consequences must not be underestimated.
All these surgical techniques (uterine tamponade, devasculari-
sation, compression sutures and hysterectomy) require the ready
availability of specific instruments and equipment. For this, an
obstetric haemorrhage equipment tray on labour ward facilitates
prompt surgical management of severe obstetric haemorrhage,
and reduces the need for blood transfusion and hysterectomy.
Conclusions
PPH is a major cause of maternal morbidity and mortality. Iden-
tification of risk factors antenatally and intra-partum is useful
in the prevention and treatment of PPH. Catastrophic and life-
­threatening haemorrhage is often unpredictable. Prompt resusci-
tation of the patient with effective restoration of the circulating
blood volume and identification of the cause of bleeding should
be performed in a multidisciplinary team setting. Rapid and
prompt treatment measures should be instituted in a step-wise
manner using the algorithm ‘HAEMOSTASIS’ and assessment
tools such as the ‘rule of 30’ and the ‘shock index’. Protocols for
the prevention and management of PPH should be constantly
updated in every maternity unit. The training of all members of
staff in the management of this common obstetric emergency
should include regular ‘fire drills’. ◆
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:5
Further reading
ACOG Practice Bulletin. Clinical management guidelines for obstetrician-
gynecologists. Number 76. October 2006: postpartum hemorrhage.
Obstet Gynecol 2006; 108: 1039–1047.
Chandraharan E, Arulkumaran S. Management algorithm for atonic
postpartum haemorrhage. J Paediatr Obstet Gynaecol 2005; 31:
106–112.
Chandraharan E, Arulkumaran S. Surgical aspects of postpartum
haemorrhage. Best Pract Res Clin Obstet Gynecol 2008;
22: 1089–1102. Epub 2008 Sep 14.
Dildy 3rd GA. Postpartum hemorrhage: new management options.
Clin Obstet Gynecol 2002; 45: 330–344.
Doumouchtsis SK, Arulkumaran S. Postpartum haemorrhage: changing
practices. In: Dunlop W, Ledger WL, eds. Recent Advances in
Obstetrics and Gynaecology; vol 24. London: The Royal Society of
Medicine Press Ltd, 2008, pp. 89–104.
Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review
of conservative management of postpartum hemorrhage: what to do
when medical treatment fails. Obstet Gynecol Surv 2007;
62: 540–547.
Mousa HA, Alfirevic Z. Treatment for primary postpartum haemorrhage.
Cochrane Database Syst Rev 2007; (1): CD003249.
Penney G, Kernaghan D, Adamson L. Scottish confidential audit of severe
maternal morbidity. 3rd annual report 2005. Edinburgh: Scottish
Programme for Clinical Effectiveness in Reproductive Health, 2005.
Ramanathan G, Arulkumaran S. Postpartum hemorrhage. J Obstet
Gynaecol Can 2006; 28: 967–973.
Saving Mother’s Lives. Reviewing maternal deaths to make motherhood
safer. 2003–2005. The seventh report of the confidential enquiries
into maternal deaths in the United Kingdom. London: CEMACH, 2007.
Practice points
• Specific management of controlling PPH should go hand in
hand with fluid, blood and clotting factor resuscitation
• Every unit should have a protocol to manage PPH in a
stepwise manner
• Medical management should precede surgical management
• Simple surgical management (tamponade, brace sutures) is
less time-consuming, can be done with minimal training and
is effective in more than 80% of cases
126 Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved.