Postpartum haemorrhage

Related Subjects: |Antepartum haemorrhage |Postpartum haemorrhage |Acute Haemorrhage

Compared with expectant management, the active management of the third stage of labour is associated with a substantial reduction in the occurrence of PPH. If the third stage of labour lasts more than 30 minutes, CCT and IV/IM oxytocin (10 IU) should be used to manage the retained placenta.

About

• CCT: Controlled cord traction
• Primary PPH: loss of > 500 mls/blood within first 24 hrs after birth. Minor 500-1000mls Major > 1000 mls.
• Secondary PPH: Excess bleeding between 24 hrs and 12 weeks post natally.

Aetiology the 4 Ts

• Tone: uterine atony is commonest cause
• Trauma: vaginal or cervical lacerations
• Tissue: retained placental tissue
• Thrombin : clotting issues

Risks

• Anticoagulants
• Bleeding disorders

Clinical

• Frank PV bleeding
• Haemorrhagic shock: Hypotension, tachycardia pallor, Delayed capillary return, oliguria

Investigations

• Monitor FBC, U&E, LFT, Clotting
• Group and cross match

Prevention

• Consider Oxytocin to encourage uterine contraction usually 10 IU IV/IM
• Consider misoprostol where oxytocin is unavailable
• Consider IV Tranexamic acid if increased risk
• Early cord clamping not now advised
• If 3rd stage of labour delayed then manual removal of placenta

Management

• Mild: IV access. IV crystalloid fluids. Monitor
• Severe: ABC, IV access, Oxygen. Lie flat.
• Infuse warm clear fluids until blood available
• Consider transfusion O rhesus negative if needed
• After 4 U red cells consider FFP 12-15 ml/Kg until haemostatic tests known
• Cryoprecipitate if low Fibrinogen. < 2g/L
• Platelets if count < 75 x 10⁹/L
• Uterine artery embolisation
• Hysterectomy if bleeding fails to stop

References

• Post Partum haemorrhage at RCOG