OBSTETRICS

Management Algorithm for Atonic

Postpartum Haemorrhage
Edwin Chandraharan, MBBS, MS(Obs&Gyn), DFFP(UK), MRCOG;
Sabaratnam Arulkumaran, MBBS, MD, PhD, FRCOG

I
t is estimated that every year, about 600,000 to 800,000 women die during childbirth around
the world. In the developing world, postpartum haemorrhage (PPH) accounts for up to half of
all maternal deaths. Even in developed countries, life-threatening PPH occurs in about 1 in
1,000 deliveries. The latest Confidential Enquiries into Maternal Deaths in the UK has listed PPH
as the third most common direct cause of maternal mortality.1 And we should not forget that many
women survive with severe morbidity. Apart from anaemia, fatigue, depression and the risks of
blood transfusion in the short term, many women require a hysterectomy to save their lives. This
results in the loss of fertility in the prime of their lives, leading to social and psychological conse-
quences. It is also well known that severe PPH can cause necrosis of the anterior pituitary gland,
leading to Sheehans syndrome.
Three delays have been identified as the causes of maternal death: delay in seeking medical
care, delay in reaching healthcare facilities and delay in receiving appropriate care in a healthcare
institution. The former two are seen mainly in developing countries. The latter, however, is common
to both developing and developed countries. The Confidential Enquiries has in fact emphasized that
deaths caused by PPH are due to too little done too late.1
In this article we present an algorithm to manage atonic PPH, a condition that contributes
to significant maternal morbidity and mortality in both the developing and developed world. The
algorithm incorporates measures aimed at timely and appropriate management of atonic PPH to
save lives and to avoid serious morbidity.

DEFINITION

PPH refers to the loss of more than 500 mL of blood from the genital tract after delivery.
A volume of 500 mL is an arbitrary cutoff volume. In an anaemic patient, even less blood loss may
cause morbidity and mortality. During caesarean sections, many obstetricians would consider blood
loss of 1,000 mL as a cutoff point. This provides an allowance for more bleeding that occurs during
a caesarean section as compared with vaginal delivery. Blood loss is often underestimated by
healthcare professionals. It has been estimated that PPH occurs in 2% to 11% of deliveries; if an

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 OBSTETRICS

objective assessment of blood loss is made, the incidence
may rise up to 20%. A practical definition of PPH would be
any bleeding from the genital tract that results in haemo-
dynamic instability, which may endanger the life of the
mother. PPH that occurs within the first 24 hours of deliv-
ery is called primary PPH. Common causes are atonic
uterus, trauma to the genital tract, presence of retained
placenta and membranes, and coagulopathy. An atonic
uterus is the commonest cause of primary PPH, account-
ing for 80% of all cases.2 Bleeding that occurs after 24
hours is called secondary PPH, and is commonly due to
retained tissue and/or infection. In this article, we focus
namic instability. It is always
better to overestimate the
blood loss and be proactive.
Level of consciousness, pulse,
blood pressure and, if facilities
are available, oxygen saturation
should be monitored. At the
time of the insertion of two
large-bore (14G) IV cannulae,
blood should be taken for inves-
tigations. These include full
blood count (FBC), clotting pro-
Figure 1. Management algorithm for
of atonic PPH HAEMOSTASIS.
H Ask for help
A Assess (vital parameters, blood loss) and
resuscitate
E Establish aetiology, ensure availability of
blood, ecbolics (syntometrine, ergometrine,
bolus Syntocinon)
M Massage uterus
O Oxytocin infusion/prostaglandins
IV/per rectal/IM/intramyometrial
S Shift to theatre exclude retained products
and trauma/bimanual compression

our discussion on the management of primary PPH caused file, urea and electrolytes, and T Tamponade balloon/uterine packing

by uterine atony. grouping and crossmatching. A Apply compression sutures

B-Lynch/modified
Rapid fluid infusion with crys-
S Systematic pelvic devascularization
MANAGEMENT OF ATONIC PPH talloids and colloids should be uterine/ovarian/quadruple/internal iliac

carried out until crossmatched I Interventional radiologist if appropriate,

PPH is an obstetric emergency. Overtreatment causes less
harm than inaction. Accurate estimation of blood loss,
appropriate replacement of volume and coagulation fac-
tors and a multidisciplinary approach are essential.
Management should follow a clear and logical sequence
of steps. We have attempted to formulate a management
algorithm for this serious and potentially fatal condition.
(Figure 1) The mnemonic HAEMOSTASIS spells out the
suggested actions that may facilitate the management of
atonic PPH in a logical and stepwise manner.
Ask for HELP
It is prudent to ask for help. The presence and advice
of a senior obstetrician, midwife, anaesthetist and
haematologist are vital. Services of ancillary staff should
be sought to help in the management. A multidisciplinary
approach would optimize the monitoring and manage-
ment of fluids, electrolytes and coagulation parameters as
well as provide input if further measures are necessary.
Assess and Resuscitate
It is important to make an initial assessment regarding the
degree of blood loss and the severity of the haemody-
uterine artery embolization
blood is available. Crystalloids
S Subtotal/total abdominal hysterectomy
(0.9% normal saline or
Hartmanns solution) are pre-
ferred over colloids, as the latter are associated with a
4% increase in the absolute risk of maternal mortality
compared with crystalloids.3 The maximum recommended
dosage of colloids is 1,500 mL in 24 hours.
Establish Aetiology, Ensure
Availability of Blood and Ecbolics
Establish Aetiology
It is vital to try to identify a cause while resuscitation is
being carried out to save valuable time. For the purpose of
this article we confine our discussion to atonic PPH. The
uterus should be examined for contraction and retraction;
it may also be worthwhile to check for free fluid in the
abdomen, if the history suggests trauma (previous cae-
sarean section, difficult instrumental delivery) or if the
patients condition is poor compared with what is expect-
ed based on the estimated blood loss. It is important to
ask about the completeness of the placenta and mem-
branes. If there is doubt, the patient should be prepared
for examination under anaesthesia. It is important to

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 OBSTETRICS
exclude any trauma to the genital tract. During caesarean
section, the uterine cavity may be explored to remove
remnants of placenta and membranes, if present. A mor-
bidly adherent placenta may pose a problem during both
vaginal delivery and caesarean section. Aggressive,
appropriate and timely management is essential to reduce
morbidity and mortality. If difficulty is experienced during
the removal of the placenta or if the placenta is deemed
incomplete, the uterine cavity should be explored to
exclude retained products. Following vaginal delivery, a
uterine tamponade can be attempted prior to laparotomy
to arrest haemorrhage in cases of placenta accreta. If
haemorrhage due to a morbidly adherent placenta occurs
during a caesarean section, haemostatic sutures, sys-
temic pelvic devascularization and uterine artery
embolization may be tried. A placenta increta or percreta
may be encountered during caesarean section, especially
in the presence of a previous uterine scar.
Ecbolics
Once atonic uterus has been identified as the cause of
PPH, measures should be taken to ensure uterine
contraction and retraction. Syntometrine (or, if not avail-
able, ergometrine) can be repeated. Syntocinon (10 units)
can be administered as a slow IV bolus.
Ensure Availability of Blood and
Blood Products
Replacement of the circulating blood volume with
crystalloids and colloids should be followed by restoration
of the oxygen-carrying capacity of the blood and correc-
tion of any derangements in coagulation. This involves
transfusion of blood and blood products. In special cir-
cumstances, autotransfusion may be considered,
although during a caesarean section this carries a theo-
retical risk of amniotic fluid embolism and infection.
Autotransfusion involves collection of maternal blood and
the use of a cell-saver device to wash and filter the blood
to remove the leukocytes and reinfuse the red cells.4
However, autotransfusion and other blood products may
JPOG MAY/JUN 2005 108
not be acceptable to some patients. Hence, anaesthetists
and haematologists should be involved very early to
ensure optimum fluid management. In the case of mas-
sive PPH, where more than 30% of blood volume is lost,
blood transfusion should be considered very early, espe-
cially in the presence of continued bleeding. Until
crossmatched blood is available, O negative or uncrossed-
matched group-specific blood may be transfused if there
were no abnormal antibodies in the recipients blood.
Massage the Uterus
It is important to massage the uterus to stimulate uterine
contraction and retraction and this should be commenced
very early. It may act synergistically with the uterotonic
drugs.
Oxytocin Infusion/Prostaglandins
Syntocinon 40 units can be added to 500 mL of normal
saline and infused at a rate of 125 mL/hour. It is important
to avoid fluid overload, as fatal pulmonary and cerebral
oedema with convulsions due to dilutional hyponatraemia
has been reported. This is caused by the antidiuretic hor-
mone (ADH)-like effect of oxytocin. Hence, careful
monitoring of fluid input and output is essential if oxytocin
is infused in large amounts.
Prostaglandins are invaluable in the management of
atonic PPH, although they are not recommended as pro-
phylaxis of PPH due to their adverse gastrointestinal side
effects. Hemabate (15-methyl prostaglandin 2 alpha)
250 g can be administered intramuscularly. The dose can
be repeated every 15 minutes for a maximum of eight
doses (2 mg).5 However, it is advisable to move the patient
to the theatre if profuse bleeding persists after three
doses of Hemabate. Intramyometrial injection of
Hemabate has been tried,6,7 but recent studies have ques-
tioned its effectiveness. One should be aware that serious
complications, including severe hypotension and cardiac
arrest, have been reported with systemic prostaglandin
administration. If the PPH is unresponsive to ergometrine
or oxytocin, rectal misoprostol (8001,000 g) may be

tried.8,9 This is a valuable option in developing countries
due to its low cost and relatively easier storage.
Apart from IV crystalloids, colloids, blood and oxy-
tocin, infusion of blood products needs to be considered.
In massive obstetric blood loss, rapid infusion of fresh
frozen plasma (FFP) may be required to replace clotting
factors other than platelets. It is recommended that with
every 6 units of blood transfusion, 1 L of FFP should be
administered (15 mL/Kg). Hence, four to five bags of FFP
are required, as each bag contains about 200 to 250 mL of
FFP. It is important to maintain the platelet count above
50,000 by infusing platelet concentrates when indicated.
Cryoprecipitate may also be needed if the patient devel-
ops disseminated intravascular coagulation (DIC) and her
fibrinogen drops to less than 1 g/dL (10 g/L).
Shift to Theatre
If the patient continues to bleed despite initial manage-
ment, it is best to transfer her to the theatre. Examination
should be carried out to exclude any retained placental
tissue or membranes. If retained products are suspected,
manual removal and uterine curettage should be
carried out. A bimanual compression can be carried out
at this stage to squeeze the uterus between the abdom-
inal and vaginal hands.
Tamponade or Uterine Packing
In the presence of intractable PPH despite initial manage-
ment, it is important to consider the onset of coagulopathy
being superimposed on refractory atony. The use of uter-
ine tamponade may help in arresting haemorrhage. It also
allows adequate time to correct the coagulopathy if pres-
ent. It is advisable to involve senior members of the
obstetric team at this point, if this has not been done ear-
lier. Involvement of a haematologist is mandatory and the
intensive care unit should be alerted. Special protocols
should be in place for the management of massive obstet-
ric haemorrhage. The first step should be to alert all
members of the team (including the haematologist and
the hospital porter) in case of an emergency through the
OBSTETRICS
hospital switchboard (e.g. Code Blue). A tamponade
test, which has a positive predictive value of 87% for the
successful management of PPH, using a Sengstaken tube
was described.10 If the tamponade arrests the bleeding
(i.e. positive), the chances of the patient requiring any fur-
ther surgical intervention is remote. However, if this fails
to control the haemorrhage, the patient needs a surgical
intervention.
Uterine tamponade with a balloon is easy to insert
and takes only a few minutes. It arrests the bleeding and
may prevent coagulopathy due to massive blood loss and
the need for further surgical procedures. It should be con-
sidered in all patients not responding to medical therapy.
Although a Sengstaken-Blakemore oesophageal catheter
(SBOC) is most commonly used, the Rusch urological
hydrostatic balloon11 and the Bakri SOS balloon12 may
also be used. Usually a volume of about 300 to 400 mL
may be required to exert the desired counter pressure to
stop bleeding from the uterine sinuses. In developing
countries, if these catheters are not freely available, uter-
ine packing could be tried with sterile gauze. A
tamponade in time is likely to reduce the need for blood
transfusion, laparotomy and hysterectomy and thus may
help preserve fertility. Figure 2 shows a tamponade bal-
loon with a pressure-reading device that helps to infuse
the volume needed to achieve a pressure close to the sys-
tolic pressure to stop the bleeding. These special devices
are currently undergoing clinical trials after the success
with SBOC balloons.
Apply Compression Sutures
Failure of the tamponade test to arrest haemorrhage war-
rants laparotomy. The decision to perform a laparotomy
must be made early in these circumstances. Consent for
examination under anaesthesia, tamponade, laparotomy
and hysterectomy should have been obtained as the
patient is being moved to the theatre. This may not
always be feasible due to the patients condition or her
level of consciousness. In such cases, it may be advisable
to inform her next-of-kin of the possibility of laparotomy
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 OBSTETRICS

and its sequelae. Laparotomy allows for direct visualiza- compression force.14 This technique also alleviates the
tion and access to the uterus as well as to the pelvic need for opening the uterus. Horizontal full thickness com-
vasculature. Direct uterine massaging may be tried. pression sutures have also been tried, especially to
It is very important control bleeding from the placental site in placenta prae-
Figure 2. Tamponade balloon with a to strike the right via at the time of caesarean section.15 These could also be
pressure reading device.
balance between the applied in the lower segment, while taking care not to
Bedside pressure-reading device
(reads 102 mm Hg)
Drainage need to save life and the obliterate the cervical canal. (Figure 3A) The risk of
channel
desire to preserve the damage to the bladder can be prevented by ensuring the
patients fertility. Before bladder reflection is below the level of suture insertion.
trying any conservative Passage of sutures 2 cm medial to the lateral border of the
Tamponade surgical procedures, it uterus is aimed at preventing ureteric injuries.
balloon with
350 mL of is essential to reassess A combination of multiple vertical compression
saline
the situation based on sutures may be needed in some cases. (Figure 3B) Cho et
the amount of blood al16 described a multiple square suturing technique,
3-way tap to fill the
loss, persistence of which approximates anterior and posterior uterine walls
balloon and to take bleeding, haemodynam- at various points, virtually obliterating the uterine cavity.
pressure readings
ic status and the These vertical compression and multiple square sutures
patients parity. It is prudent to discuss with the anaes- are easy to perform, less time-consuming and can be
thetist regarding her ability to withstand possible further applied by less experienced surgeons as they are well
bleeding if conservative measures fail. This is especially within the uterine body and do not involve areas traversed
true in developing countries, where the patient might by uterine vessels or ureters.
have lost a significant amount of blood by the time
she reaches the referral centre, which might have Systematic Pelvic Devascularization
limited amount of blood for transfusion. In such situations, If the compression sutures fail, ligation of blood vessels
it is wiser to consider radical measures, which include supplying the uterus should be tried. These include liga-
total or subtotal hysterectomy to save the patients tion of both uterine arteries, followed by tubal branches of
life albeit at the cost of her fertility. On the other hand, if both ovarian arteries proximal to the ovarian ligament
the patients condition is stable, compression sutures can (called the quadruple ligation). Uterine artery ligation is
be tried. straightforward once the uterovesical fold of peritoneum
Compression sutures were first described by is incised and the bladder is reflected down.17 A window
Christopher B-Lynch and hence they are often called the is made in the broad ligament just lateral to the uterine
B-Lynch sutures.13 Bimanual compression can be vessels and the needle is passed through this opening.
applied to the uterus to determine whether a compression Medially, the needle is passed through the lower uterine
suture is likely to be of value. The anterior and posterior myometrium, about 2 cm from the lateral margin, thus
walls are apposed by vertical brace sutures using getting a good bite and then tie. The same procedure is
a delayed absorbable suture material, resulting in contin- repeated on the other side. If bleeding continues, tubal
uous compression of the uterus. Various modifications branches of both ovarian arteries can be tied medial to
have been made to this original technique. These include the ovarian ligament. The needle should be passed
using two separate vertical compression sutures instead through a clear area of the mesosalpinx on either side
of one to increase the tension applied and hence the of the blood vessels.

JPOG MAY/JUN 2005 110


Internal iliac artery ligation is an option if bleeding
persists. This requires an experienced surgeon who is
familiar with the anatomy of the lateral pelvic wall.
Routine identification of the internal iliac vessels and the
ureters during elective hysterectomies may help obstetri-
cians to build up confidence when faced with an
emergency. The parietal peritoneum may be picked up
divided at the lateral pelvic wall at the level of the pelvic
brim after identifying the ureter as it crosses the common
iliac vessels. It may be then reflected medially along with
the medial leaf of the broad ligament and the ureter be
held away from the internal iliac vessels by a loop. The
internal iliac artery should then be traced from above
downwards until it divides into the anterior and posterior
divisions. The anterior division should be ligated with
black silk or linen (permanent suture material). The pro-
cedure should be repeated on the other side.
Alternatively, the broad ligament may be opened
by clamping, cutting and ligating the round ligaments
and the lateral pelvic wall approached through this
route. Some obstetricians prefer this route as they
are familiar with the same procedure during routine
hysterectomy.
Bilateral internal iliac artery ligation has been found
to reduce the pulse pressure by up to 85% in arteries
distal to the ligation. This translates to an acute reduction
in the blood flow by about 50% in the distal vessels.18
The reported success rate of this procedure has
been between 40% and 75%19 and is invaluable for
avoiding a hysterectomy. Potential complications include
haematoma formation in the lateral pelvic wall, injury to
the ureters, laceration of the iliac vein and accidental
ligation of the external iliac artery. Ligation of the main
trunk of the internal iliac artery may result in intermittent
claudication of the gluteal muscles due to ischaemia.
Fortunately, these complications are rare. Examining
the femoral pulse prior to tightening the ligature, proper
identification of anatomical structures and ligating
the anterior division of the internal iliac artery may help
to prevent these complications.
OBSTETRICS
Interventional Radiologist
Figure 3. B-Lynch sutures.
In women who are not acutely
compromised or bleeding severely, A
interventional radiology can be Vertical
compression
considered. This procedure is usually sutures
performed under fluoroscopic guidance
by an interventional radiologist. The
target vessel (internal iliac, uterine or
ovarian) is reached by passing a Uterus
catheter via the femoral artery. Various
materials are used to occlude the ves-
sels. These include gelatin sponge, Horizontal
sutures after
polyurethane foam or polyvinyl alcohol reflecting
the bladder
particles, and are usually resorbed down
within 10 days. The success rates may
20
B
be as high as 85% to 95% and the
Multiple vertical compression sutures
entire procedure may take about
1 hour.21,22 Uterine artery embolization
helps to avoid radical procedures and
preserve fertility. Menstruation typically
returns within 3 months and subse-
quent pregnancies have been
reported.23 This technique is also useful
in the presence of coagulopathy. In
cases where PPH is anticipated (pres-
ence of placenta accreta or increta),
embolization catheters can be placed (A) Technique of separate vertical and
horizontal compression sutures; (B) multiple
prophylactically prior to a planned vertical compression sutures.
caesarean section, as this may help
appropriate management without compromising future
fertility. Complications include vessel perforation,
haematoma, infection and tissue necrosis.24 Uterine
necrosis has also been reported and hence the need
to inform the patient regarding this uncommon
complication. This procedure should be carried out by
radiologists with expertise in interventional radiology.
Subtotal or Total Abdominal
Hysterectomy
Hysterectomy should be total or subtotal depending on
JPOG MAY/JUN 2005 111
 OBSTETRICS

the clinical situation. If the bleeding is predominantly from
the lower segment (as in PPH following a major degree
placenta praevia), a total abdominal hysterectomy is war-
ranted. A subtotal hysterectomy may be performed if the
bleeding is mainly from the upper segment and the cause
is unresponsive uterine atony. Subtotal hysterectomy
has lower morbidity and mortality rates and requires less
time to perform. Hysterectomy is the last resort in the
management of atonic PPH. However, one may have to
resort to hysterectomy much earlier if the haemodynamic
condition is unstable and if there is uncontrollable bleed-
ing despite other medical and surgical measures. Due to
the anatomical changes of pregnancy, it is important to
exercise utmost care to prevent visceral trauma, especial-
ly of the bladder and ureters. It is also important to clamp
the ovarian ligament medially to avoid non-intentional or
inadvertent oophorectomy. The 15-year experience of
obstetric hysterectomy from a tertiary centre in Nigeria
revealed a maternal mortality rate of 12.5% and urinary
tract injury rate of 7.5% after this procedure.25 This
emphasizes the need to seek senior help and early inter-
vention when necessary.
POSTOPERATIVE INTENSIVE CARE
It is important to remember that the management of
PPH does not stop with the arrest of bleeding. Often,
these patients have received multiple fluid and blood
transfusion and may have undergone surgical procedures.
Hence, it is prudent to manage them, with a multidiscipli-
nary input, in a high-dependency unit (HDU) or intensive
care unit (ICU) to ensure continuity of optimum care.
CONCLUSIONS
The algorithm we have proposed (HAEMOSTASIS)
aims to help in the management of atonic PPH following
vaginal delivery in a logical and systematic manner, to
avoid maternal morbidity and mortality. PPH is an impor-
tant cause of pregnancy-related deaths in both
developing and developed countries. Atonic PPH during
caesarean section can be managed by direct uterine mas-
sage, intramyometrial injection of prostaglandins as well
as oxytocin infusion. Further measures include uterine
compression sutures, systemic pelvic devascularization
and hysterectomy. Although several case reports exist,
more prospective studies are needed to study the effec-
tiveness of tamponade balloon test and vertical and
horizontal compression sutures. Optimum management
of atonic PPH may help to reduce maternal morbidity and
save many lives.
About the Authors
Dr Chandraharan is Senior Lecturer and Dr Arulkumaran is Professor
and Head at the Division of Obstetrics and Gynaecology, St. Georges
Hospital Medical School, London, United Kingdom.
E-mail: echandra@sghms.ac.uk, sarulkum@sghms.ac.uk

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