Post Partum Haemorrhage
Post Partum Haemorrhage (PPH) is defined broadly as any amount of blood loss that threatens the hemodynamic stability of the woman. More specifically defined as blood loss of more than 500mL following vaginal delivery or more than 1000mL following cesarean delivery. PPH is considered "late" or "secondary" if it occurs >24 hours post partum.
PPH is the leading cause of maternal mortality. All women who carry a pregnancy beyond 20 weeks’ gestation are at risk for PPH and its sequelae. Estimates of blood loss at delivery are subjective and generally inaccurate. Studies have suggested that caregivers consistently underestimate actual blood loss. Women differing capacities to cope with blood loss from PPH, a healthy woman has a 30-50% increase in blood volume in a normal singleton pregnancy and is much more tolerant of blood loss than a woman who has preexisting anemia, an underlying cardiac condition, dehydration or pre eclampsia.
Good detailed summary has been produced by the World Health Organisation (2009) and can be accessed here.
The most common is uterine atony and birth weight, labor induction and augmentation, chorioamnionitis, magnesium sulfate use, and previous PPH were all positively associated with increased risk of PPH.
Classified by the 4 Ts - Tone, Tissue, Trauma, Thrombosis - more detail is available here.
Management principlesPostpartum Haemorrhage (PPH)
Active management of the third stage of labor reduces the incidence and severity of PPH. This is the combination of:
uterotonic administration (preferably oxytocin) immediately upon delivery of the baby
early cord clamping and cutting, and
gentle cord traction with uterine countertraction when the uterus is well contracted (ie, Brandt-Andrews maneuver).
Failing this and using your criteria or those above, the diagnosis of of PPH is made and you must be prepared for some worst case scenarios. Each institution should have a set of guidelines and checklists. The management of severe PPH is a team approach and requires practice to work well.
The Royal Australia and New Zealand College of Obstetricians and Gynaecologists has a wealth of information and resources on their website including a discussion on PPH here.
The Americian College of Obsetricians and Gynaecologists has published some guidelines on obsetric emergencies which may be a useful resource here.
For a good outcome it takes a lot of staff. Its messy and there a number of competing priorities.
As with any resuscitation a team is required. Along with critical physicians familiar with resuscitation other evident members will be the Obstetrician for fundal management, paeditrician for baby, interventional radiology for embolisation if indicated, social work for managing family issues in an emotionally charged environment and "runners" for blood products for them to arrive in a timely fashion and to keep track of what has been ordered and got.
Blood- FBC and coagulation studies should be sent early, amniotic fluid embolism (although rare) can present as DIC and PPH for example
If coagulopathy is suspected then a D dimer and fibrinogen should be taken. Fibrinogen is raised in pregnancy so normal level may be low.
PPH usually manifests with such rapidity that diagnostic procedures are almost entirely limited to a physical examination of the involved structures.
Notify blood bank possible need for
PCs, FFP then cryoprecipitate/platelets as per tests
Up to 1500mLs NS tolerated
Monitor vital signs and urine output
Call for help:
Blood bank, resuscitation team, Obstetrics and Paediatrics
Put the OT standby
Put reliable clinician in charge of driving blood products and monitoring tests
If antepartum, deliver
If postpartum and uterine atony suspected use uterotonics (see below), apply bimanual pressure and empty the bladder
Explore and empty the uterine cavity, and consider uterine packing
Examine the cervix and vagina, ligate any bleeding vessels, and
Ligate the uterine blood supply (ie, uterine, ovarian, and/or internal iliac arteries).
Consider arterial embolization.
Caveat - shocked patient will have less perfusion of muscle therefore IM may be a less reliable route and you may need to use IV doses initially.
Oxytocin 5-10U IM or 5 U IV slowly
Ergometrine 500mcg IM or 50mcg IV slowly. Can be repeated up to a total dose of 500mcg. Avoid if any contraindications present e.g. pre-existing hypertension as can worsen pulmonary hypertension and eclampsia.
'Syntometrine' is a combination drug given IM. 1mL = 5U oxytocin and 500 mcg ergometrine.
Prostaglandin F2 alpha - consult O&G prior to use. Dose = 250U IM every 15 minutes up to a maximum of 8 doses.
Misoprostol not routine. NO additional benefit when added to an oxytocin and ergometrine combination in trials. Dose = 1000mcg PR.
Patients at high risk of ongoing PPH require an oxytocin infusion:
Standard infusion - Oxytocin 40U in 1L of normal saline - 250mL/hr
Pre-eclampsia - 40U in 40mL of normal saline at 10mL/hr. (Lower volume avoids these patients going into fluid overload).
Further References and Resources
- NSW Health Guideline - GL2021_010 - Postpartum Haemorrhage (PPH)
- Appendix list
- 1. Risk Factors for Primary PPH
- 2. NSW Health Primary PPH Quick Reference Guide
- a. Detect and Respond
- b. Management
- 3. Medication Management
- Appendix list
National Blood Authority (NBA) - Guidelines for Obstetrics and Maternity