Postpartum Haemorrhage

Question 1

What is postpartum haemorrhage?

Answer 1

Bleeding after delivery of baby and placenta, the most common cause of significant obstetric haemorrhage.

Question 2

What is the definition of minor postpartum haemorrhage (PPH)?

Answer 2

Loss of <1000ml blood.

Question 3

What is the definition of major postpartum haemorrhage (PPH)?

Answer 3

Loss of >1000ml blood.

Question 4

What is primary postpartum haemorrhage?

Answer 4

Bleeding that occurs within 24 hours of delivery.

Question 5

What is secondary postpartum haemorrhage?

Answer 5

Bleeding that occurs from 24 hours to 12 weeks postpartum.

Question 6

What are the Four Ts of postpartum haemorrhage aetiology?

Answer 6

• Tone (uterine atony)
• Trauma (e.g. perineal tear)
• Tissue (retained placenta)
• Thrombin (bleeding disorder)

Question 7

List some risk factors for postpartum haemorrhage.

Answer 7

• Previous PPH
• Multiple pregnancy
• Obesity
• Large baby
• Failure to progress in second stage
• Prolonged third stage
• Pre-eclampsia
• Placenta accreta spectrum
• Retained placenta
• Instrumental delivery
• General anaesthesia
• Episiotomy or perineal tear

Question 8

What are some preventive measures for postpartum haemorrhage?

Answer 8

• Treating anaemia (antenatally)
• Giving birth with empty bladder
• Active management of third stage (IM oxytocin)
• IV tranexamic acid in c-section during third stage

Question 9

What does the initial management of postpartum haemorrhage include?

Answer 9

• ABCDE
• Lie woman flat, keep her warm
• Insert 2 large bore cannulas
• Bloods - FBC, U&E, clotting screen
• Group cross match 4 units
• Warmed IV fluids and blood resuscitation
• Oxygen (regardless of sats)

Question 10

What are the mechanical methods for stopping postpartum bleeding?

Answer 10

• Rubbing the uterus (through abdomen)
• Catheterisation (bladder distention to prevent uterine contractions)

Question 11

What are some medical treatments for postpartum haemorrhage?

Answer 11

• Oxytocin (40 units in 500mls)
• Ergometrine (stimulates smooth muscle contraction, CI in hypertension)
• Carboprost (prostaglandin analogue)
• Misoprostol (prostaglandin analogue)
• Tranexamic acid (antifibrinolytic)

Question 12

What are some surgical treatments for postpartum haemorrhage?

Answer 12

• Intrauterine balloon tamponade
• B-lynch suture (suture around uterus)
• Uterine artery ligation
• Hysterectomy (’last resort’)

Question 13

What causes secondary postpartum haemorrhage?

Answer 13

• Retained products of conception (RPOC)
• Infection (e.g. endometritis)

Question 14

What investigations are done for secondary postpartum haemorrhage?

Answer 14

• Ultrasound
• Endocervical and high vaginal swabs

Question 15

What is the management for secondary postpartum haemorrhage?

Answer 15

• Surgical evaluation
• Antibiotics