Primary postpartum haemorrhage

>/= 500ml blood loss within 24 hours after birth 

Routine administration of IM Oxytocin during 3rd stage of labour reduces PPH risk by 60%:

• Vaginal delivery: 5-10 units

• C-section: 5 units

Causes: The 4 T's:

• TONE (atonic uterus (uterus fails to contract following delivery)- 70% of cases)

• TRAUMA (to genital tract or perineum - 20% of cases)

• TISSUE (retained products of conception which prevents uterus from contracting - placental/membrane tissue)

• THROMBIN (coagulation disorders)

Presentation

• Signs of haemodynamic instability

  • • Tachypnoea

    • Prolonged cap refill time

    • Tachycardia

    • Hypotension

• Signs of uterine rupture i.e. palpation of fetal parts as it moves out of the uterus into the abdomen 

• Signs of local trauma to vagina/perineum 

• Ensure that the placenta is complete 

Investigations 

• FBC

• Cross match 4-6 units of blood

• Coagulation profile

• U&E's

• LFTs

Management:

• ABCDE  

• Fluid resuscitation 

• Definitive management of underlying cause 

1. Uterine atony

• Bimanual compression to stimulate uterine contraction 

  • • Ensure the bladder is emptied by catheterisation

    • Insert a gloved hand into the vagina and form a fist inside the anterior fornix to compress the anterior uterine wall

    • The other hand applies pressure on the abdomen at the posterior aspect of the uterus 

• Pharmalogical measures: 

  • • IV syntocinon (oxytocin) 10 units or/followed by IV ergometrine 500 micrograms (contraindicated in hypertension)

    • IM carboprost (contraindicated in asthma)

    • Rectal misoprostol

• If medical options failure to control the bleeding then surgical options will need to be urgently considered

  • • The RCOG state that the intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage

    • Other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries

    • If severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

2. Trauma

• Primary repair of laceration

  • • 1st degree = tear within vaginal mucosa only

    • 2nd degree = tear into subcutaneous tissue

    • 3rd degree = laceration extends into external anal sphincter

    • 4th degree = laceration extends through external anal sphincter into rectal mucosa

• If uterine rupture: laparotomy and repair or hysterectomy

3. Tissue 

• Administer IV Oxytocin

• Removal of placenta with regional or general anaesthetic

• Prophylactic antibiotics in theatre

• Start IV Oxytocin infusion after removal

4. Thrombin 

Haematologist input - treat underlying coagulopathy