Postpartum Haemorrhage

Definitions
Primary PPH blood loss of 500ml or more within 24hours of delivery.

Secondary PPH significant blood loss between 24 hours and 6 weeks after birth.

Why do we care?
Major obstetric haemorrhage more than 1000ml

Very rapidly lead to maternal death

 3rd highest cause of direct maternal death in the UK and Ireland (2003-2005) 58% of these cases care was seriously substandard

Major cause of severe maternal morbidity in near-miss audits

Risk Factors
Most cases have no risk factors Previous PPH Antepartum haemorrhage Grand multiparity Multiple pregnancy Polyhydramnios Fibroids Placenta praevia Prolonged labour (&oxytocin)

Prevention
Be aware of risk factors may present antenatally or intrapartum Treat anaemia antenatally Active management of the 3rd stage Prophylactic oxytocics reduce the risk of PPH by 60% (oxytocin or oxytocin & ergometrine) 5IU IM for vaginal delivery 5IU IV for LSCS Consider oxytocin infusions

4 Ts
Tone Tissue Thrombin Trauma

Causes
Tone
Previous PPH Prolonged labour Age > 40 years Big baby Multiple pregnancy Placenta praevia Obesity Asian ethnicity
Tissue Retained placenta/ membrane/clot

Thrombin Abruption PET Pyrexia Intrauterine death Amniotic fluid embolism

Trauma Caesarean section (emergency > elective) Perineal trauma Operative delivery Vaginal and cervical tears Uterine rupture

DIC

 Blood loss is commonly underestimated Loss may be well-tolerated Beware the trickle and the moderate lochia Minor PPH can easily progress to major PPH.

Management
Has the placenta been delivered and is it complete? Is the uterus well-contracted? Is the bleeding due to trauma?

Resuscitation
A & B 10 -15l/min O2 by facemask C2 14 gauge cannulae
blood for Hb, U&E, LFTs, clotting crossmatch 4 units 2 litres of crystalloid rapidly transfuse as soon as possible consider O ve blood if any delays.

Uterine Contraction-First Line Drugs

Oxytocin 5IU Oxtocin infusion 40IU in 500mls Ergometrine 0.5mg Carboprost (Haemabate) 0.25mg IM every 15 minutes x 8 doses Misoprostol 600 mcg sublingually

Uterine Contraction non-pharm

Empty uterus Foley catheter Rub up a contraction Bimanual compression Balloon tamponade Brace suture Uterine artery ligation Internal iliac artery ligation Interventional radiology

 Hysterectomy before its too late

B-Lynch Suture

Balloon Tamponade

Haematological Management

DIC Transfuse without delay Involve haematology service at an early stage Correct coagulopathy Liase with consultant haematologist re use of recombinant Factor V11 (Novoseven) and Fibrinogen.

 Traumatic for patient, family and staff. Debriefing for patient and staff. Case analysed to ensure care was of good standard and any substandard care can be improved.

Secondary PPH
Infection Retained placenta Trophoblastic disease Antibiotics Evacuation of retained products if bleeding persistent or significant amount of tissue retained.