DEFINITION

This is excessive bleeding following delivery and is described as primary and secondary. Primary postpartum haemorrhage (PPH) is loss of blood estimated to be >500 ml, from the genital tract, within 24 hours of delivery (the most common obstetric haemorrhage):1 Minor PPH is estimated blood loss of up to 1000 mls. Major PPH is any estimated blood loss over 1000 mls. Secondary PPH is defined as abnormal bleeding from the genital tract, from 24 hours after delivery until 6 weeks postpartum.

Pospartum Haemorrhage

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Primary Postpartum Haemorrhage Aetiology

The most common cause of postpartum haemorrhage (PPH) is uterine atony. Other common causes are: Retained placenta or fragments of placenta Vulvar or vaginal lacerations or haematoma Atony and retained placenta are 80% of all cases; lacerations comprise the bulk of the other 20%. Cervical lacerations, uterine rupture, broad ligament haematoma and extra genital bleeding also need to be excluded.

Epidemiology
Obstetric haemorrhage remains one of the major causes of maternal death in both developed and developing countries. In the 2003-2005 report of the UK Confidential Enquiries into Maternal Deaths, haemorrhage was the third highest direct cause of maternal death; a rate similar to the previous triennium.2

Risk factors
Factors relating to the pregnancy: Antepartum haemorrhage in this pregnancy Placenta praevia (15 x risk)
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Multiple pregnancy (5 x risk) Pre-eclampsia or pregnancy-induced hypertension (4 x risk) Nulliparity (3 x risk) Previous PPH (3 x risk) Asian ethnic origin (2 x risk) Maternal obesity (2 x risk) Factors relating to delivery: Emergency Caesarean section (CS) (9 x risk)5 Elective CS (4 x risk) - especially if >3 repeat procedures6 Retained placenta (5 x risk) Mediolateral episiotomy (5 x risk) Operative vaginal delivery (2x risk) Labour of >12 hours (2 x risk) >4 kg baby (2 x risk) Maternal pyrexia in labour (2 x risk) Pre-existing maternal haemorrhagic conditions: Factor 8 deficiency - Haemophilia A carrier Factor 9 deficiency - Haemophilia B carrier Von Willebrand's disease

Presentation

Symptoms: continuous bleeding, which fails to stop after delivery of the placenta - third stage Signs: loss of >1000 ml may be accompanied by clinically apparent shock, i.e. tachycardia, hypotension

Investigations

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 Thorough examination of the lower genital tract. This may require theatre/anaesthesia. FBC, clotting screen, crossmatch Hourly urine output Continuous pulse/blood pressure or central venous pressure monitoring ECG, pulse oximetry

Management
Ideally one of the emergency drills to be practised by the team on the labour ward.1 Call expert assistance. Secure IV access with 2 x 14-gauge cannulae. If the perceived blood loss is 500-1000 ml and there are no signs of clinical shock, basic measures, (crossmatch 2 units, FBC, clotting screen, IV access and monitoring clinical observations) should suffice. However, loss of greater than 1000 mls or any signs of shock should lead to full alert of the clinical team: experienced midwife, obstetric registrar (alert consultant), anaesthetic registrar (alert consultant), alert haematologist, alert transfusion service, call porters for transport of specimens and blood products. Consider arterial line monitoring transfer to ITU. Oxygen should be given by mask at 8 litres per minute. Transfuse crossmatched blood (6 units initially) as soon as possible. Until then, infuse crystalloid or colloid as required. If 3.5 litres are given and no blood is available, give O NEG, or uncross matched blood of own blood group. Use a warming device and a pressure cuff. Do not use a blood filter. Do not use dextrans. Give up to 1 litre of fresh frozen plasma (FFP) and 10 units of cryoprecipitate if clinically indicated. A new haemostatic agent- recombinant factor VIIa - has had some clinical success, but its efficacy and safety is untested in clinical trials as yet.7,8 Monitor temperature and urine output (catheterise).
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 Stop the bleeding. Ensure bladder empty and bimanually compress the uterus rub up a contraction. A Sengstaken-Blakemore tube has been used to compress the uterus. One series of 17 cases showed a 71% success rate in stopping the haemorrhage.9 Give IV syntocinon 10 units or IV ergometrine 500 micrograms. Commence syntocinon infusion 30 units in 500 ml. Give IM (into uterine wall) carboprost 500 micrograms if still atonic. Try misoprostol 1000 micrograms rectally. Exclude other causes than atony: Tissue (retained products of conception). Trauma (of the genital tract). Thrombin (abnormalities of coagulation). If pharmacological measures fail to control the haemorrhage, resort to surgery early: Bilateral ligation of the uterine arteries or bilateral ligation of the internal iliac (hypogastric) arteries. An alternative to ligation is embolisation with gelatin sponge.10 Amenorrhoea has been reported following this, secondary to necrosis of the uterine wall and obliteration of the cavity.11 Uterine bracing suture, (the B-Lynch suture) to the anterior and posterior uterine walls has been shown to be effective and safe,12 with reports of successful pregnancy following its use.13,14 Hysterectomy should be considered early, especially in cases of placenta accreta or uterine rupture.

Complications
Shock Collapse Disseminated intravascular coagulation

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Prognosis
The Confidential Enquiry into Maternal Deaths for 2000-2002 reported 17 deaths related to obstetric haemorrhage in that triennium.15 This gives a rate of 8.5 per million.

Prevention
The active management of the third stage of labour; prophylactic oxytocics should be routinely used in the third stage of labour as they decrease the risk of postpartum haemorrhage (PPH) by 60%.16,1 For most women syntometrine (ergometrine 0.5 mg with 5 IU oxytocin) is the drug of choice. By some clinicians, oxytocin alone (10 IU) is preferred in women with hypertension.

Secondary Postpartum Haemorrhage

This commonly presents in primary care as prolonged or excessive bleeding once the woman has returned home after delivery.

Aetiology
The two most common causes are:

Infection - endometritis. This occurs in 1-3% after spontaneous vaginal delivery. It is the most common cause of postnatal morbidity between day 2 and day 10. Risk factors: Caesarean section, prolonged rupture of membranes, severe meconium staining in liquor,17 long labour with multiple examinations, manual removal of placenta,18 mother's age at extremes of reproductive span, low socioeconomic status, maternal anaemia, prolonged surgery, internal fetal monitoring and general anaesthetic.
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Pospartum Haemorrhage

 Retained products of conception (RPOC)

Assessment
History: as above; also extended labour, difficult 3rd stage, ragged placenta, primary postpartum haemorrhage (PPH). Examination: systemic illness, fever, rigors, tachycardia, tissue visible within loss. Suprapubic area may be tender, with elevated fundus that feels boggy in RPOC.

Investigation
FBC Blood cultures are positive in 10-30% Check MSU High vaginal swab; also gonorrhoea/chlamydia Ultrasound - may be used if RPOC are suspected, although there may be difficulty distinguishing between clot and products. RPOC are unlikely if a normal endometrial stripe is seen

Management
Speculum examination will allow visualisation of the cervix and lower genital tract to exclude lacerations. If a clot is visible within the cervical os, it may be removed with tissue forceps (although few GPs regularly carry these), allowing the cervix to close. When antibiotics are clinically indicated, a combination of ampicillin (clindamycin if penicillin-allergic) and metronidazole is appropriate. In cases of endomyometritis (tender uterus) or overt sepsis, then the addition of gentamicin is recommended.19,1 The patient may need to be referred if too unwell to tolerate oral medication; IV clindamycin and gentamicin tds until
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afebrile for greater than 24 hours.20 Oral follow-up treatment is not required. Use doxycyline if chlamydia is suspected. If retained products of conception are suspected, elective curettage with antibiotic cover may be required. Surgical measures should be undertaken if there is excessive or continuing bleeding, irrespective of ultrasound findings. A senior obstetrician should be involved in decisions and performance of any evacuation of RCOP, as these women are carrying a high risk of uterine perforation. The patient may require iron supplementation if Hb has fallen. Warn of the risk of constipation.

1st Day at Ward @ 13/12/2011

New case from L&D accompanied with Staff Nurse and JM. Patient just back from OT for Manual removal of placenta ( MRP ). On arrival, general condition of patient comfortable. Vital sign checked. Blood pressure: 140/60 mmHg. Afebrile. Pain score: 3/10. On Pitocin over 6 hour continue from OT. CBD insitu with clear urine. Post op plan care carried out. To remove tampon at 9pm. Keep CBD at least for 1day.

At 2000 H Patient comfortable. Vital sign checked and recorded. Afebrile. IV flagyl 500mg and IV unasyn 1.5gm for first dose given. At 2100
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During take over report, patient rest in bed. No complaint active. Patient was complete blood transfusion at 2030H ( third pint ) for FBC 6 hour post transfusion required.

At 0000
General condition of patient stable and vital sign taken. Blood pressure: 103/69 mmHg, pulse rate: 90/min. afebrile. Uterus well contracted. Pad chart staining with normal lochia. Patient taken diet well. KIV to allow home if hemoglobin normal. Antibiotic served as ordered.

2nd Day at Ward @ 14/12/2011 At 1654 H

Post 2h Past Manual Removal Of Retained Placenta. Para1 at EDD post SVD complicated by primary Postpartum haemorrhage. Delivered baby boy at 1325 hour. Total EBL: 600ml+400ml ( during MRP ), Hemoglobin pre operation: 8.9 g/dl Problem: Admitted at Itensive Care Unit ( ICU ) at 37 weeks for urosepsis 1 month ago for 10 days. Intubated, completed abx ciprofloxacin in Hospital Kota Bharu. Procedure: Manual Removal Of Retained Placenta. Time: 1420-1515 hour.

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Findings: Placenta bulk in fundus. Manual Removal Of Placenta ( MRP ) done. Episiotomy tear sutured. Extended tear over clitoris and right labia- bleeding secured. Sweeling over episiotomy site, not increasing in size. EBL: 400ml Hemoglobin pre Operation: 8.9 g/dl

Currently: Slightly drowsy Mild headache resolving No palpitation. Minimal tolerable abdominal pain. Plan: Continue post operation plan. Vital sign monitoring. To inform if develop sign and symptom of anemia, tachycardia, blood pressure falls. Strict pad chart. To remove tampon today at 9pm. Repeat FBC at 9pm

At 2100 H
Progress:
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Pain tolerable, denies sign and symptom of anemia, taking orally well. Plan: To put in tampon soaked in flavin. Start mist carminative. Tablet papase. Off CBD coming morning. If hemoglobin < 8, to transfuse blood coming morning. Hemoglobin: 5.8, plan: to transfuse 2 pint packed cell coming morning.

3rd Day at Ward @ 15/11/2011 At 0722 H

Para1 at EDD post SVD complicated by primary postpartum haemorrhage. Progress: Ongoing packed cell transfusion first pint. Otherwise, no active complaint.

Pospartum Haemorrhage

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