Post-Partum Haemorrhage

Question 1

What is PPH?

Answer 1

Loss of 500ml or more within 24 hours of giving birth

Minor blood loss 500-1000ml
Major blood loss >1000ml

In UK, 18% of births suffer a PPH.
Major PPH complicates 1.3% of births.

Question 2

Secondary PPH

Answer 2

Abnormal or excessive bleeding from the birth canal between 24 hours - 12 weeks postnatally

Question 3

4 causes of PPH

Answer 3

• Tone
• Tissue
• Trauma
• Thrombin

Question 4

Tone

Answer 4

Uterine atony / poor uterine tone cause 70-90% PPH
If uterus does not contract after birth and occlude the spinal arteries that supply placenta, PPH occurs.

Hence, utertonic works!

Question 5

Tissue

Answer 5

If any tissue left after birth, such as placenta or membrane, uterus will continue bleeding to remove them (10% PPH).

Retained products may be inadvertently expelled during fundal massage, causing clots & tissue to be expelled from vagina

Question 6

Trauma

Answer 6

Trauma to genital tract occurs in 85% of births

Clotting problems are rare (1% PPH). Coagulopathy is rare in these cases.

Question 7

Treatment

Answer 7

• Fundal Massage
• Oxytocin
• Direct Pressure
• IV drugs

Question 8

Fundal Massage

Answer 8

Most common is uterine atony.

only do this if placenta has delivered

Fundal massage : place left hand just above umbilicus and move behind and downwards towards symphysis. Contracted hard uterus felt? Good

Soft and boggy uterus? ‘rubbing up’ a contraction should happen, massage the fundus in a circular motion to stmiulate a contraction (can cause pain)

Question 9

Oxytocin

Answer 9

Produced during immediate bonding / skin to skin & breast feeding; contracts uterus to reduce bleeding.

Question 10

Direct Pressure

Answer 10

Trauma to genital tract may require external pressure with a maternity pad or gauze; definitive tx is suturing perineum.

Question 11

Tissue

Answer 11

Remaining placental tissue can cause bleeding

Question 12

PPH diagram

Answer 12

Question 13

IF PLACENTS HAS BEEN EXPELLED…

Answer 13

• Wide bore cannula.
• Carbetocin if BP allows.
• Continue fundal message.
• 800mcg misoprostol sublingually if not worked after 15 minutes.
• Consider TXA.

Question 14

IF PLACENTA IS IN SITU…

Answer 14

Do not do fundal massage as it may cause placenta to partially separate from uterine wall, causing further haemorrhage

Carbetocin / Misoprostol as above

Rapid conveyance, consider TXA