POSTPARTUM HAEMORRHAGE  (PPH)

• Postpartum haemorrhage (PPH) can be either primary or secondary.
• Primary or early PPH is defined as blood loss of at least 500 mls from the genital tract during the third stage of labour or in the first 24 hrs after delivery. If blood loss is less than 500 mls but is sufficient to cause haemodynamic compromise, then it is classified as PPH.
• Secondary PPH is bleeding from the genital tract greater than expected after 24 hrs and up to 6 weeks postpartum. Secondary PPH is more likely to present in the community when most patient would have been discharged from the hospital.
• At caesarean section, blood loss of over 1,000 mls is considered to be significant.

Primary PPH

• Incidence is about 5% of all deliveries in developed world.

Causes of primary PPH

Remember: 4 T’s – tone, trauma, tissue, thrombin.

• TONE - uterine atony – 70%
• TRAUMA - genital tract trauma -  20%
• TISSUE - retained products of conception -  10%
• THROMBIN - coagulopathy / DIC - 1%

Other – uterine inversion

Risk factors for primary PPH
Antenatal  

• Factors that increase risk of uterine atony - Grand multiparity, Multiple pregnancy, Polyhydraminos
• Factors that increase risk of operative delivery and genital tract trauma - Nulliparity
• Factors that increase risk of coagulopathy - Aantepartum haemorrhage in current pregnancy / Placental abruption, Preeclampsia
• Other factors - Placenta preavia, Previous PPH, Maternal obesity

Intrapartum

• Operative delivery - Emergency caesarean section, Instrumental delivery, Mediolateral episiotomy
• Factors associated with uterine atony - Prolonged labour both 1st & 2nd stage of labour, Obstructed labour
• Retained placenta
• Pyrexia in labour
• Precipitate labour

Pre existing conditions

• Von willibrands disease
• Haemophilia A & B

Prevention of post-partum haemorrhage  
Antenatal

• Ensure adequate Hb levels prior to delivery. Supplement iron if appropriate. Identify risk factors and plan appropriately for delivery.

Intrapartum

• Active management of third stage of labour with routine use of prophylactic oxytocics (oxytocin or oxytocin + ergometrine).
• Others
• Systematic training of healthcare professionals in the identification and treatment of common causes of PPH may help. This includes guidelines, simulated training exercises / drills

Management of primary PPH

• PPH is an obstetric emergency
• Call for help
• Assess airway, breathing, circulation
• Brief explanation of events and need for intervention to the woman / her partner
• Rub-up a contraction – will stop / reduce bleeding in the majority of cases
• Obtain venous access with two wide-bore cannulae
• Blood for FBC, Group & save / cross-match, clotting
• Administer uterotonic agents to induce contraction: Ergometrine plus oxytocin infusion
• Commence iv fluids – options are crystalloid, colloid, O Rh negative blood depending on severity of loss
• History to identify potential causes – any pre-disposing factors, delivery of the placenta and whether it appeared complete
• Examination – P, BP, Temp, uterine size, position, tone; systematic genital tract examination to identify trauma: beginning with the vulva, vagina then cervix. Repair any injury
• If bleeding does not settle obtain informed consent for examination under anaesthesia which will include exploration of the uterine cavity for retained products
• In severe cases, laparotomy and hysterectomy may be necessary. Conservative measures such a balloon tamponade and use of brace sutures may also be used.
• Ensure that the woman and her partner are fully informed of events once bleeding has been controlled

Secondary Post-partum haemorrhage

Main Causes

• Infection – endometritis / PID,
• Retained placental tissue

Other causes

• Trauma – dehiscence of episiotomy, rupture of vulval / vaginal haematoma
• Pre existing uterine disease – e.g. fibroids, polyps
• Side-effects of contraception such as depot-medroxyprogesterone acetate / IUCD

Risk factors for endometritis
Antenatal

• Prolonged rupture of membranes
• Low socio economic status
• Anaemia, diabetes mellitus

Intrapartum

• Caesarean section
• Manual removal of placenta
• Multiple vaginal examinations in labour
• Uterine instrumentation

Management of secondary PPH

• When secondary PPH presents with heavy bleeding, the woman should be asked to dial 999 and request paramedic assistance and transfer to the hospital via ambulance
• When secondary PPH presents with slight – moderate / intermittent bleeding, assessment and initial treatment in the community is appropriate

History

• Amount and frequency of bleeding – presence of clots / tissue
• Duration since delivery
• Change in lochia since delivery including offensive vaginal loss
• Use of contraception
• Intra-partum events – mode of delivery, any difficulties delivering the placenta, primary PPH
• Presence of fever / rigors

Examination

• Pulse, BP, Temperature, respiratory rate
• Abdominal palpation – size of uterus (enlarged uterus with delayed involution is consistent with retained products), uterine tenderness (suggests endometritis)
• Speculum examination to assess blood loss, state of the cervical os and presence of tissue. Any suture lines should also be inspected
• Digital vaginal examination may be necessary to assess uterine tenderness, state of the cervical os and presence of cervical excitation which occurs in pelvic cellulitis

Investigations

• FBC, CRP, group and save / cross match
• Swabs – high vaginal, endocervical and Chlamydia swabs
• Blood cultures if temp > 38 C or history of rigors
• The value of pelvic ultrasound scan is questionable

Treatment

• If  bleeding is light and the woman is systemically well, initial treatment should be undertaken in the community with oral broad-spectrum antibiotics (including anaerobic cover)
• Criteria for referral to hospital include:

1. Heavy bleeding
2. Clinical evidence of sepsis
3. Tissue passed PV
4. Failure to improve after 48-72h treatment with antibiotics
5. Recurrence after initial ‘successful’ treatment   

In hospital, women will be treated with antibiotics for at least 24h +/- evacuation of retained products of conception