Post Partum Haemorrhage

Question 1

Postpartum haemorrhage (PPH)

Answer 1

Bleeding after delivery of the baby and placenta

Question 2

Criteria for postpartum haemorrhage

Answer 2

500ml after a vaginal delivery

1000ml after a Caesarean section

Question 3

Classification of postpartum haemorrhage

Answer 3

Minor PPH – under 1000ml blood loss

Major PPH – over 1000ml blood loss

Question 4

Primary PPH

Answer 4

Bleeding within 24 hours of birth

Question 5

Secondary PPH

Answer 5

Bleeding from 24 to 12 weeks after birth

Question 6

Causes of postpartum haemorrhage

Answer 6

T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)

Question 7

Risk factors for PPH

Answer 7

Previous PPH

Multiple pregnancy

Obesity

Macrosomia

Failure to progress in the second stage of labour

Prolonged third stage

Pre-eclampsia

Placenta accreta

Retained placenta

Instrumental delivery

General anaesthesia

Episiotomy or perineal tear

Question 8

Prevention of PPH

Answer 8

Treating anaemia during the antenatal period

Giving birth with an empty bladder (a full bladder reduces uterine contraction)

Active management of the third stage

Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients

Question 9

Management of PPH

Answer 9

Obstetric emergency

1. Resuscitation with an ABCDE approach
2. Get help - senior midwives, obstetricians, anaesthetics, haematologists, blood bank staff and porters.

Activate the major haemorrhage protocol

3. Lie the woman flat, keep her warm and communicate with her and the partner
   Insert two large-bore cannulas
4. 2 grey wide bore cannulas and bloods - FBC, U&E and clotting screen, Group and save and cross match 4 units
5. Warmed IV fluid and blood resuscitation as required - O neg
6. Oxygen (regardless of saturations)

Question 10

When is fresh frozen plasma used

Answer 10

Used where there are clotting abnormalities or after 4 units of blood transfusion

Question 11

Treatment to stop PPH

Answer 11

Mechanical:

• Rub the uterus through the abdomen to stimulates a uterine contraction
• Catheterisation (bladder distention prevents uterus contractions)

Medical options - stimulate uterine contractions

Surgical options

Question 12

Medical treatment of PPH

Answer 12

Oxytocin (slow injection IM followed by continuous infusion)

Ergometrine (intravenous or intramuscular) - contraindicated in hypertension

Carboprost (IM) - caution in asthma

Misoprostol (sublingual)

Tranexamic acid (IV) is an antifibrinolytic that reduces bleeding

Question 13

Intravenous infusion of oxytocin

Answer 13

40 units in 500 mls

Question 14

Surgical treatment options for PPH

Answer 14

Intrauterine balloon tamponade

B-Lynch suture – putting a suture around the uterus to compress it

Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow

Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life

Question 15

Intrauterine balloon tamponade

Answer 15

Inserting an inflatable balloon into the uterus to press against the bleeding

Question 16

Causes of secondary PPH

Answer 16

Retained products of conception (RPOC)

Infection (i.e. endometritis)

Question 17

Investigations of secondary PPH

Answer 17

Ultrasound for retained products of conception

Endocervical and high vaginal swabs for infection

Question 18

Management of PPH

Answer 18

Surgical evaluation of retained products of conception

Antibiotics for infection