PPH management steps

1. Postpartum Haemorrhage
(PPH)
By Bernadette Gregory, Senior Lecturer in Midwifery
Updated by Jacqui Williams, Senior Lecturer in Midwifery

2. Definitions
An excessive bleeding from the genital tract
occurring at any time from the birth of the child to
12 weeks postnatal.
PRIMARY
most common refers to the 1st
24 hours
commonest and most dangerous(Mousa & Alfiric, 2007)
Incidence approx. 6% of all deliveries
SECONDARY
occurs after 24 hours up to 12 weeks postnatal
(Alexander et al, 2002).
Incidence 1-3% of all pregnancies

3. Definitions cont’d.
• PPH traditionally over 500 mls. (WHO, 1990;
1989) but may vary between hospitals/countries.
• Smaller losses than this would be treated as
serious later in the puerperium.
• Definitions are of limited value –it is much more
important to assess the effect of blood loss on
the mother.
• “Excessive” in some contexts may be a much
smaller amount which may affect the mother.

4. Blood loss
• Minor 500-1000ml
• Major more than 1000ml
• Moderate 1000-2000ml
• Severe over 2000ml
(RCOG, 2009)

5. Estimating blood loss- how scientific?
• Difficult to measure
• Unreliable
• Underestimation
• Unpredictable
• Unexpected
• Relevant research
Levy & Moore (1985)
Prasertcharoensuk et al (2000)
Buckland & Homer (2007)

6. Causes
• The placental site – the failure of the
uterus to contract and retract adequately-
the myometrium is flaccid or atonic.
• Are there any retained products ?
• Genital tract trauma/ damage – is it
cervical, vaginal or uterine ?

7. Risk factors
• History of previous PPH or retained placenta
and membranes
• multiple pregnancy
• polyhydramnios
• anaemia
• Antepartum haemorrhage (APH)
• prolonged labour
• Pre eclampsia/ Pregnancy induced hypertension
(P.I.H.)
• general anaesthesia
• Fibroids
• Mismanagement of the 3rd
stage of labour

8. Risk factors contd..
• Retained placenta or retained products
• Use of tocolytic drugs
• Induced or augmented labours
• Inversion of the uterus
• Infection eg chorioamnionitis
• More common in grande multiparity
• DIC
• other clotting disorders
• unknown

9. Prevention better than cure
• Preconception: optimal health to begin
pregnancy, correct anaemia ….
• Pregnancy: identify risk factors, diagnosis and
treatment of anaemia
• Labour: policy guidelines, good management 1st
,
2nd
and 3rd
stage of labour – treat uterus with
respect !
• Suggest active management of 3rd
stage (RCOG,
2009)
• After delivery: careful monitoring in 1st
hour after
delivery

10. Good Management
• Assess
• Stop bleeding
• Resuscitation
• Fluid replacement
• Hospitalisation

11. At Home
• Call paramedic team to attend
• Take bloods for X match, full blood count (FBC),
clotting studies and site an Intravenous line –
start fluids
• Record vital signs
• Keep evidence of blood loss
• Inform appropriate person on delivery suite and
give an accurate account of woman’s condition
• Arrange transfer to hospital a.s.a.p.
• During transfer monitor condition, give O2

12. Principles of care
• ascertain the site of the bleeding
• deliver the placenta
• “rub up a contraction”
• give an oxytocic drug: syntometrine &/or
ergometrine
• monitor vital signs frequently
• empty bladder
• prepare for theatre, Intravenous fluids, order
blood,
• manual removal of placenta and membranes

13. After delivery of the placenta and
membranes
• “rub up a contraction”
• give an oxytocic drug
• if necessary empty the bladder
It is essential that these steps are taken asap
if the midwife suspects that the uterus is
failing
• Check placenta and membranes for
completeness
• Arrange theatre for evacuation of retained
products of conception

14. External bimanual compression
• The left hand dips down as far as possible
behind the uterus. The right hand is
pressed flat on the abdominal wall; the
uterus is compressed and pulled upwards
into the abdomen.

15. Internal bimanual compression
• Carried out under general anaesthetic
• Right hand into vagina. Closed to form a fist,
pushed up in direction of the anterior vaginal
fornix. The left hand is placed on the vaginal
wall, dips down behind the uterus, pulls it
forwards and towards the symphysis. The 2
hands are pressed firmly together, thus
compressing the uterus and placental site.
Continue pressure until uterus contracts and
remains retracted

16. Abdominal aortic compression
• short term emergency measure whilst
awaiting emergency assistance. The
midwife places a fist on the mother’s
abdomen, above the fundus and
below the level of the renal arteries
(Lumbar 1/2)

17. Traumatic PPH
• Approx 20% of cases of PPH arise from a
laceration of some part of the genital tract
(Llewellyn Jones 1999)
Treatment may be :
• direct pressure
• application of sponge forceps
• sutured under GA or regional anaesthetic
• if there is a tear on the uterus may need a
hysterectomy
• vulval haematoma may occur

18. Maternal effects
• anaemia
• blood coagulation disorders incl.
• disseminated intravascular coagulation
• widespread tissue damage –
• renal, leading to oliguria or anuria
• cardiac failure , respiratory failure,
• liver damage – jaundice
• convulsions and coma from brain damage
• pituitary gland involvement – Sheehan’s
syndrome
• maternal mortality and morbidity

19. Major obstetric haemorrhage
(MOH) Confidential Enquiries
Recurrent themes
• Failure to recognise problems
• Failure to take action
• Failure to refer
• Inappropriate delegation
• Lack of team work
Potentially avoidable
• 50% of maternal deaths
• 75% of intra partum related deaths

20. Maternal deaths 2000-2002
Substandard clinical care
• Failure to recognise and act on common signs of
critical illness
• Lack of follow up of non attenders
• Failure to communicate relevant medical history
• Poor communication and team working in MDT
• Failure to call early for senior help
• Wrong diagnosis or treatment

21. Recommendations
• skills drills to improve management of
massive obstetric haemorrhage (MOH)
• multi professional approach
• teamwork training
• Protocols for MOH involving blood bank
Saving Mothers’ Lives (2003- 2005)
Annual multi professional training for all staff
NHS Litigation Authority CNST LEVEL 2 (2010)

22. Non- surgical & surgical approaches to
massive obstetric haemorrage
• The B- Lynch (Brace) suture is a surgical
technique for the control of MOH as an
alternative to hysterectomy (BJOG 1997)
• Bilateral internal artery ligation
• Embolisation
• Cell savers – blood lost at operation is
centrifuged and washed then returned to pt as
concentrated RBC so transfused with own blood
not someone else’s

23. What are the advantages of cell
salvage ?
• Avoidance of hazards of blood transfusion
SHOT reports 1996- 2001deaths
due to blood transfusion 62 (12.4 per year) and major
morbidity 165.
• 3 cases of probable V CJD transmission
• Availability- blood is a finite resource
• Cost – one blood bank blood is £120
• Acceptable to Jehovah’s witnesses
• However does not replace platelets or clotting factors
• May become contaminated with fetal red cells (Rh)
• Amniotic fluid embolism

24. Haematological aspects of Massive Obstetric
Haemorrhage
• Blood count, group and cross match , coagulation screen, u+ e
(Patient ID so important as only need 30 mls. of wrong blood needed to
have ABO incompatability which can be fatal)
• Volume replacement –(crystalloid/ colloid)
• Emergency group O Neg blood available
• Platelets are not stored in blood bank they are requested from
Regional blood transfusion centre so need to anticipate situation
• FFP and Cryoprecipitate – takes 30 mins to thaw so again anticipate
• FACTOR vii a – NOVOSEVEN given as an IV bolus dose – currently
only licensed for haemophillia – costly product and danger of
indiscriminate clot –last ditch attempt in MOH

25. References
Buckland, S.S. ; Homer, C.S.E. (2007) Estimating blood loss after birth using simulated clinical
examples Journal of the Australian College of Midwives vol 20, no 2 June pp85-88
Centre for Maternal and Child Enquiries (CMACE) (2007) Saving Mothers’ Lives 2003-2005 London,
CMACE.
Levy, V. and Moore. J. (1985) The midwife’s management of the third stage of labour Nursing Times
vol 81, no 39 25 September pp 47-50
Mousa, H.A. Alfirevic,Z. (2007) Treatment for primary postpartum haemorrhage. Cochrane Database
Systematic Review; (1):CD003249.DOI:10.1002?14651858.CD003249.pub2
NHS Legal Authority (NHLSA) (2010) CNST Maternity Standards 2010/11 www.nhlsa.com (accessed
22 November 2010)
Prasertcharoensuk, W. Swanpanich, H. Lumbiganon, P. (2000) Accuracy of the blood loss estimation
in the third stage of labor International Journal of Obstetrics and Gynecological Obstetrics 71:9-
70
Royal College of Obstetricians and Gynaecologists (RCOG) (2009) Prevention and management of
postpartum haemorrhage Green-top guideline no 52 November
Royston, E., Armstrong, S. (Eds) (1989) Preventing Maternal Deaths. Geneva, World Health
Organisation (WHO)
World Health Organisation (WHO) (1990) The Prevention and Management of Postpartum
Haemorrhage Report of A Technical Working Group. Geneva: WHO.

26. Sources
Fraser, D. and Cooper, M A (Ed) (2009)
Myles Textbook for Midwives 15th
Edition
Edinburgh, Elsevier Churchill Livingstone

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the HEA in 2011. For further information see:
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