Post Partum Haemorrhage

Question 1

What

Answer 1

Postpartum haemorrhage (PPH) refers to bleeding after delivery of the baby and placenta. It is the most common cause of significant obstetric haemorrhage, and a potential cause of maternal death. To be classified as postpartum haemorrhage, there needs to be a loss of:

500ml after a vaginal delivery
1000ml after a caesarean section

It can be classified as:

Minor PPH – under 1000ml blood loss
Major PPH – over 1000ml blood loss

Major PPH can be further sub-classified as:

Moderate PPH – 1000 – 2000ml blood loss
Severe PPH – over 2000ml blood loss

It can also be categorised as:

Primary PPH: bleeding within 24 hours of birth
Secondary PPH: from 24 hours to 12 weeks after birth

Question 2

Causes

Answer 2

There are four causes of postpartum haemorrhage, remembered using the “Four Ts” mnemonic:

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

Question 3

Risks

Answer 3

Previous PPH
Multiple pregnancy
Obesity
Large baby
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 4

Treat

Answer 4

Preventative Measures
Several measures can reduce the risk and consequences of postpartum haemorrhage:

Treating anaemia during the antenatal period
Giving birth with an empty bladder (a full bladder reduces uterine contraction)
Active management of the third stage (with intramuscular oxytocin in the third stage)
Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients

Management
Postpartum haemorrhage is an obstetric emergency and needs to be managed by an experienced team, including senior midwives, obstetricians, anaesthetics, haematologists, blood bank staff and porters.

Management to stabilise the patient involves:

Resuscitation with an ABCDE approach
Lie the woman flat, keep her warm and communicate with her and the partner
Insert two large-bore cannulas
Bloods for FBC, U&E and clotting screen
Group and cross match 4 units
Warmed IV fluid and blood resuscitation as required
Oxygen (regardless of saturations)
Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion

In severe cases, activate the major haemorrhage protocol. Each hospital will have a major haemorrhage protocol, which gives rapid access to 4 units of crossmatched or O negative blood.

Question 5

Treatment to Stop Bleeding

Answer 5

Treatment to Stop the Bleeding
The treatment options for stopping the bleeding can be categorised as:

Mechanical
Medical
Surgical

Mechanical treatment options involve:

Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”)
Catheterisation (bladder distention prevents uterus contractions)

Medical treatment options involve:

Oxytocin (slow injection followed by continuous infusion)
Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension)
Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)
Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction
Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding

TOM TIP: The intravenous infusion of oxytocin is given as 40 units in 500 mls. You may hear midwives or obstetricians referring only to “40 units” without specifying the drug. They are referring to an oxytocin infusion for PPH.

Surgical treatment options involve:

Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding
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 6

Secondary Postpartum Haemorrhage

Answer 6

Secondary postpartum haemorrhage is where bleeding occurs from 24 hours to 12 weeks postpartum. This is more likely to be due to retained products of conception (RPOC) or infection (i.e. endometritis).

Investigations involve:

Ultrasound for retained products of conception
Endocervical and high vaginal swabs for infection

Management depends on the cause:

Surgical evaluation of retained products of conception
Antibiotics for infection