2. 1
POST PARTUM HAEMORRHAGE
• WHO
• All post partum blood losses over 500ml
• However it is widely recognised that in 1st world countries women
can cope easily with blood loss of this magnitude and 1000mls is a
more appropriate figure
• RCOG:
• Primary PPH involving an estimated blood loss of 500–1000 ml (and
in the absence of clinical signs of shock) should prompt basic
measures
• If a woman with primary PPH is continuing to bleed after an
estimated blood loss of 1000 ml, this should prompt a full protocol
of measures to achieve resuscitation and haemostasis.
3. 2
CAUSES
• Tone (~80%)
• Failure of the uterus to contract will prolong bleeding
• Infection, retained products etc. will contribute
• Trauma (~20%)
• Tissue damage sustained during delivery (vulval or vaginal lac)
• Tissue
• Retention of products (foetus, placenta, membranes)
• Thrombin (a few…)
• Coagulopathies increase the risk and severity of PPH
• 2/3 PPHs have no identifiable cause or risk factors
4. 3
RISKS (SIGNIFICANT ANTENATAL RISKS)
• Serious Risks
• Tone
– Known Placenta Praevia (12x)
– Multiple Pregnancy (5x)
• Thrombin
– Known or Suspected Placental Abruption (13x)
– Pre-Ecclampsia (4x)
– Gestational Diabetes (4x)
• Women with these risks should be managed in CLU
5. 4
RISKS (OTHER ANTENATAL RISKS)
• Moderate Risks
• Tone
– Previous PPH (3x)
– Asian Ethnicity (2x)
– BMI >35 (2x)
• Anaemia (Hb <9g/dL) (2x)
• These women should consider management in CLU when labour
plans are discussed
6. 5
RISKS (LABOUR & DELIVERY)
• Factors arising during labour and delivery
• Tone
– Age – Primagravida >40yo (1.5x)
– Birth Weight >4kg (2x) (also Trauma)
• Trauma
– Mediolateral Episiotomy (5x)
– Emergency C Section (4x)
– Elective C Section (2x)
• Tissue
– Retained Products (5x)
• Thrombin
– Pyrexia in Labour (2x)
• Induction of Labour (2x)
7. 6
PREVENTION
• Active Management of 3rd Stage of Labour
• Administration of syntocin 5-10iu IM reduces risk by ~60%
• Location of Placenta
• Location of placenta should be identified by antenatal USS
• Especially in women with previous C Section
8. 7
MANAGEMENT
• 500-1000 mls
• Alert senior clinical staff (Sister Midwife, Anaesthetics team,
Obstetric team)
• >1000 mls or Clinical Shock
• Request immediate help (2222 Obstetric Emergency)
• Activate Major Haemorrhage Protocol
– Lothian: 2222, Inform MHP, Location and Planned moves,
Products required, Your Contact, Clinical and Patient Info,
– This is why we G&S and 16G Cannulate obstetric patients
9. 8
MANAGEMENT
• Airway & Breathing
• Obtain and maintain airway and provide high flow O2
• Circulation
• Establish good access and take U&Es, FBC, Coag, G&S
• Begin fluids:
– 2L warmed Hartmann‘s
– O-neg or Xmatched blood (FFP 4u : 6u PRC)
– Coagulation aids as necessary from Coag screen
• Aim for Hb > 8g/dl, Plts > 75 x 109/l, PTT < 1.5 APTT < 1.5 fibrinogen >
1.0 g/l.
• Stop the bleeding
10. 9
HAEMOSTASIS
• Consider the four Ts and exclude them
• Trauma
– Vaginal/cervical lacs, haematoma, extragenital bleeding, uterine
inversion, uterine rupture, broad ligament rupture
• Tissue
– Retained products
• Thrombin
– Coag screen
• Tone
– Utilise available and appropriate methods to reverse atony
13. 12
MONITORING
• Continuous obs
• Including CCM and temperature at 15 min intervals
• Catheterise
• Measure fluid balance
• Consider arterial invasive monitors
• Consider ITU transfer or HDU monitoring
