Postpartum Hemorrhage

2. POST- PARTUM HAEMORRHAGE
(PPH)

3. GOALS
1. To appreciate the contribution of PPH
towards MMR.
2. Able to identify and appreciate the severity
of PPH
3. To understand and identify the main causes
of PPH.
4. To be competent in the management of PPH.

4. Major cause of death….
Maternal death attributable to PPH – 35%
reduction from 2006 – 2014
Still an important cause of maternal death
In Sarawak
The incidence of death from PPH – halved
from 12 in 2007 – 2011 to 5 deaths in 2012 -
2016

6. DEFINITION
1° PPH
◦ BLOOD LOSS FROM THE GENITAL TRACT IN EXCESS OF 500 ML
IN THE FIRST 24 HOURS OF DELIVERY
2° PPH
◦ EXCESSIVE BLEEDING FROM THE GENITAL TRACT AFTER THE
FIRST 24 HOURS POST PARTUM UNTIL 6 WEEKS AFTER
DELIVERY.

7. SEVERITY
Severity Amount of blood loss (ml)
Minor 500 – 1000
Major > 1000
Massive > 1500
*RCOG defined severe PPH as blood loss of 2000
ml; however, with the logistic of Sarawak, we would
like to lower the threshold to prevent potential delay
in resuscitation.

8. ANTICIPATION IS CRUCIAL
RISK REDUCING MEASURES:
*ANTENATAL.
*INTRAPARTUM
*POSTPARTUM

10. MANAGEMENT
I. RECOGNITION AND ASSESSMENT
II. COMMUNICATION (RED ALERT)
◦ O & G SPECIALIST
◦ ANAESTHETIST
◦ SISTER ON CALL
◦ BLOOD BANK/HAEMATOLOGIST
III. RESUSCITATION
IV. ARRESTING THE BLEED
V. MONITORING AND INVESTIGATION

11. Assessment for the severity

13. Obstetric shock index
Defined as HR/SBP
Has been used as an early marker of compromise in various
shock in non pregnant population
For pregnant population, normal SI ranges from 0.7- 0.9; SI
 1 predicts adverse clinical outcome

14. CAUSES OF 1°PPH
A. UTERINE ATONY (TONE)
B. RETAINED PLACENTA (TISSUE)
C. TRAUMA
D. COAGULATION DEFECT (THROMBIN)

15. CAUSES OF 2°PPH
A. RETAINED POC
B. ENDOMETRITIS
C. TROPHOBLASTIC DISEASE OR SUB-
INVOLUTION OF UTERUS.

16. RESUSCITATION
*RESTORATION OF INTRAVASCULAR VOLUME
*OPTIMISATION OF OXYGEN CARRYING
CAPACITY

17. RESUSCITATION
DR ABC (IF UNCONSCIOUS, FOLLOW BLS)
ASSESS VITAL SIGNS AND CONSCIOUS LEVEL
2 X 14/16 G CANNULA
TAKE 20 ML OF BLOOD FOR
◦ GXM 4 UNITS PC
◦ FBC
◦ COAGULATION SCREENING
◦ ELECTROLYTES

18. RESUSCITATION
INFUSE FLUIDS (CRYSTALLOID- HM OR N/S)
◦ Ratio of 1 : 3
INFUSE COLLOIDS (GELAGUNDIN)
◦ MAINTAIN CIRCULATORY VOLUME WHILE WAITING FOR BLOOD
◦ Ratio 2: 3
BLOOD
◦ To Increase oxygen delivery
◦ IN DIRE STATES, USE GROUP SPECIFIC BLOOD OR UNMATCHED OR O RH –VE
or RH +VE BLOOD
CBD
OXYGEN

19. RESUSCITATION
GIVE WARM BLOOD
CORRECT MATCH BLOOD
* IN DIRE SITUATION- EMERGENCY
CROSS MATCH, O +VE OR O-VE
BLOOD
CORRECT COAGULATION (DIVC
regime- FFP, cryopercipitate,
platelet)

20. ARRESTING THE BLEED….. SPECIFIC
TREATMENT

21. IV Tranexamic acid in pph
Intravenous Tranexamic acid infusion can be used
in management of PPH
◦ Dose: 1gm (100mg/ml); infuse over 10 minutes (1
ml/min) dose can be repeated if bleeding continues after
30 minutes or rebleeding occurs within 24 hours
◦ It should be given early in PPH (within 3 hours)
◦ It can be given in all causes of bleeding

22. ASSESSMENT AND MANAGEMENT
CAUSES ASSESSMENT MANAGEMENT
TONE Uterine massage
Assessment of
uterine size
Uterine massage
IV Tranexamic acid 1 g stat
Oxytocics – oxytocin or syntometrine
• Oxytocin (Pitocin) – IM Pitocin bolus 10 units/IV Pitocin bolus 5
units (can be repeated to a total of 10 units IV Pitocin bolus)
• Syntometrine – IM 1 ampule stat (5 units oxytocin and 0.5 mg
ergometrine)
• IV Oxytocin infusion 40 units in 1 pint normal saline for 4 hours
(125 mls/H)
Carboprost (Haemabate)
• IM 250 g stat; can repeat up to maximum of 8 doses at 15 min
interval
• HOWEVER, IF THE BLEEDING CONTINUES AFTER 3 DOSES,
CONSIDER OTHER METHODS TO STOP BLEEDING

23. CAUSES ASSESSMENT MANAGEMENT
TONE Uterine massage
Assessment of
uterine size
Uterine tamponade
• Bakri Balloon insertion
• Bimanual compression – temporary measure, while
transporting or awaiting for OT
Surgical intervention – examination under anaesthesia
• B-lynch
• Internal iliac artery ligation
• Uterine artery ligation
• Hysterectomy
ASSESSMENT AND MANAGEMENT

25. CAUSES ASSESSMENT MANAGEMENT
TRAUMA Systematic
examination of
perineum
Repair immediately if feasible
Examination under anaesthesia in case of difficult
assessment
If repair is not feasible, control bleeding temporary with
vaginal packing during transfer
TISSUE Examination of
placenta and
membrane
Exploration of
uterus
MRP
Examination under anaesthesia
Digital evacuation of uterus in OT
THROMBIN Trace FBC and
coagulation screen
Correction of coagulopathy
ASSESSMENT AND MANAGEMENT

27. MONITORING AND INVESTIGATIONS

28. MONITORING AND INVESTIGATIONS
BP, PR.
RR, SpO2.
Temperature: Avoid hypothermia.
Pain score.
Fluid balance: Monitor urine output.
Take blood for FBC, coagulation profile, ABG.
◦ Optimise Hb, correct coagulopathy and acidosis
Vasopressor or inotropic drugs may be required in massive
PPH

29. MONITORING AND INVESTIGATIONS
Monitoring in HDU at least or ICU with co-management
with intensivist in cases of massive PPH with DIVC
Record parameters into SOS chart
OBSTETRIC SHOCK INDEX should be one of the monitoring
parameter

30. 1 GOLDEN
HOUR

31. DOCUMENTATION…

32. Postpartum Haemorrhage Checklist
Patient’s name:
IC No: RN:
Time of call for help for PPH: Called by: Date:
Team Member Name Time arrived
On-call O&G Specialist
On-call O&G Registrar
On-call O&G MO
On-call Anaesthetic MO
On-call Anaesthetist
Observations Fluids
Time Pulse BP Type Volume Time
Blood sent Time
FBC
GXM units
PT/PTT
Placenta delivered Yes No
Urinary catheter
Drug Dose TIme
Syntometrine IM 1 ampule
Ergometrine IM/IV 500mcg/ 1 amp (if normal BP)
Oxytocin 40 units in 500ml N/S at 125ml/H
Haemabate (Carboprost) IM 250 mcg/ 1amp
Haemabate (Carboprost) IM 250 mcg/ 1amp
Haemabate (Carboprost) IM 250 mcg/ 1amp
Haemabate (Carboprost) IM 250 mcg/ 1amp
Haemabate (Carboprost) IM 250 mcg/ 1amp
Haemabate (Carboprost) IM 250 mcg/ 1amp
Haemabate (Carboprost) IM 250 mcg/ 1amp
Haemabate (Carboprost) IM 250 mcg/ 1amp
Form filled by: Signature:
Initial Management Time
Oxygen given
Head bed down
Brannula No. 1
Brannula No. 2

33. SECONDARY PPH…

34. SECONDARY PPH
Usually presents in the 2nd - 3rd week post partum
Initial management similar to primary PPH
Refer to hospital for further Ix and Mx
Hospital setting
◦ HVS for culture
◦ Start antibiotics
◦ Difficult to differentiate POC and blood clot by U/S
especially in the first 2 weeks postpartum
◦ If retained POC, need evacuation (ERPOC) after 24 hours
of antibiotics