Management of Primary

Postpartum Haemorrhage
By
Dr Dambo
Obstetrics & Gynaecology Dept
 Introduction
• Postpartum haemorrhage (PPH) remains an
important complication of childbirth and
contributes significantly to maternal mortality.
• All women who carry a pregnancy beyond 28
weeks’ gestation are at risk for PPH and its
sequelae.
• Maternal mortality rates have declined greatly in
the developed world, PPH remains a leading
cause of maternal mortality in developing
countries
 Management
• Involves
History taking
Clinical examination
Investigations
Treatment
But all are done simultaneously
Components of Management
• Once PPH has been identified,
management may be considered to
involve four components - all of which
must be undertaken simultaneously:
• Communication
• Resuscitation
• Monitoring and Investigation
• Arresting the Bleeding
 Communication
• BASIC MEASURES
(minor PPH, blood loss 500 - 1000ml, no clinical shock)
– Alert senior midwife
– Alert first-line medical staff
• FULL PROTOCOL
(major PPH, blood loss >1000ml OR clinical shock)
• Call experienced midwife
• Call Obstetric Registrar and alert Consultant
• Call Anaesthetic Registrar and alert Consultant
• Alert haematologist on call
• Alert blood transfusion service
• Call porters for delivery of specimens/blood
 Resuscitation
• BASIC MEASURES
(minor PPH, blood loss 500 - 1000ml, no
clinical shock)
• IV access (14 G cannula x 1)
• Commence crystalloid (eg Hartmann’s or
Normal Saline) infusion
 Resuscitation cont
• FULL (major PROTOCOL
PPH, blood loss >1000ml OR clinical shock)
• IV access (14 G cannula x 2)
• head down tilt
• oxygen by mask at 8 litres / min
• Transfuse blood
– Until blood available, infuse in turn (as rapidly as required):
• crystalloid (eg Hartmann’s) maximum 2 litres
• colloid (eg Gelofusine, Haemaccel, human albumin 4.5%) maximum 1.5
litres
– If X-matched blood still unavailable once 3.5 litres of crystalloid/colloid
infused:
• GIVE ‘O’ NEG BLOOD OR
• GIVE Un X-matched, own group blood as available
• If bleeding is unrelenting and results of coagulation studies are still
unavailable:
– Give 1 litre Fresh Frozen Plasma
– Give 10 units cryoprecipitate empirically
• Use the best equipment available to achieve RAPID WARMED infusion
of fluids
• Do not use special blood filters: they slow infusions
• Dextrans are hazardous and should not be used in obstetric practice.
Monitoring and Investigation
• BASIC MEASURES
(minor PPH, blood loss 500 - 1000ml, no clinical
shock)
• Venepuncture (20ml) for:
– X-match (2 units)
– Full blood count
– Clotting screen
• Frequent pulse and blood pressure recording
• Foley catheter to monitor urine output
 Monitoring and Investigation contd
• FULL PROTOCOL
(major PPH, blood loss >1000ml OR clinical shock)
• Venepuncture (20ml) for:
– X-match (6 units)
– Full blood count
– Clotting screen
• Continuous pulse and blood pressure recording
(using oximeter, ECG and automated BP recording)
• Foley catheter to monitor urine output
• Central venous pressure monitoring (once
appropriately experienced staff available for
insertion)
• Consider transfer to intensive therapy unit
 Arresting the Bleeding
• The commonest cause of primary PPH is uterine
atony. However, clinical examination must be
undertaken to exclude other causes:
• Retained products (placenta, membranes, clots)
• Vaginal/cervical lacerations or haematoma
• Ruptured uterus
• Broad ligament haematoma
• Extragenital bleeding
Arresting the Bleeding contd
• When uterine atony is perceived to be the cause of
the bleeding, the following measures should be
instituted, in turn, until the bleeding stops:
– "Rub up the fundus" to stimulate contractions
– Ensure bladder is empty (Foley catheter, leave in-situ)
– Syntocinon 10 units by slow IV injection
– Ergometrine 0.5mg by slow IV injection
– Syntocinon infusion (30 units in 500ml Hartmann’s at 125ml/hr)
– Carboprost (Haemabate) 0.25mg IM
(repeated at intervals of not less than 15 minutes to a
– maximum of 5 doses)
• Examine placenta for completeness – if not explore the
uterus to remove fragments
• Bimanual compression is a temporary measure
 Arresting the Bleeding contd
• Uterine packing – with gauze or balloon tamponade –
Sengstaken Blakemore tube or foleys catheter.
• Prostaglandin options: i.m or into the uterine muscle –
15-Methyl PGF2a (0.5-1.0mg) (Haemabate, Carboprost).
Misoprostol tabs.
• If bleeding from cervical, vaginal lacerations or
episotomy wound :repair.
• Arterial embolization – if units have the resources or
experience
• Application of a military antishock trousers (MAST) Suit.
 Arresting the Bleeding contd
• If conservative measures fail to control
haemorrhage, initiate surgical haemostasis SOONER
RATHER THAN LATER
– At laparotomy, direct intramyometrial injection of
Carboprost (Haemabate) 0.5mg
– B-Lynch brace suture.
– Bilateral ligation of uterine arteries
– Bilateral ligation of internal iliac (hypogastric arteries)
– Hysterectomy
– Resort to hysterectomy SOONER RATHER THAN LATER
(especially in cases of placenta accreta or uterine rupture)
 Complications
• Anaemia
• Hypovolaemic shock
• Adult respiratory distress syndrome
• Pulmonary oedema
• Acute Renal Failure
• Hypopituitarism (sheehan`s syndrome)
• Uterine synechiae
• Sepsis.
• Death
 Prevention
Management for women at risk
• Intravenous access
• Save serum for rapid cross-match if needed or actually cross-match
2 units
• Active management of the 3rd stage of labour
- uterotonic administration (preferably oxytocin)
immediately upon delivery of the anterior shoulder of the
baby
- early cord clamping and cutting
- gentle cord traction with uterine countertraction when
the uterus is well contracted (ie, Brandt-Andrews
maneuver).
 Conclusion
• PPH is a common complication of childbirth and
a leading cause of maternal morbidity and
mortality. Clinicians should identify risk factors
before and during labor so that care may be
optimized for high-risk women. However,
significant life-threatening bleeding can occur in
the absence of risk factors and without warning.
All caregivers and facilities involved in maternity
care must have a clear plan for the prevention
and management of PPH. This includes sound
resuscitation skills and familiarity with all medical
and surgical therapies available.