POSTPARTUM HAEMORRHAGE

Vaginal bleeding of more than 500 mL after vaginal delivery or >1000 mL after caesarean section.

  • Primary PPH occurs in the first 24 hours after delivery
  • Secondary PPH occurs between 24 hours and six weeks after delivery

PPH is an EMERGENCY. It can occur in any woman and needs prompt recognition and treatment.

Causes

  • Tone: failure of uterus to contract, precipitated labour
  • Tissues: such as retained placenta (in part or whole) or membranes which may lead to atony as well as infection in the uterus
  • Tears (e.g. damage to/rupture of the perineum, vagina, cervix or uterus)
  • Thrombotic disorders which may be due to DIC following abruptio placenta or severe APH

High risk patients

  • History of previous PPH, multiple previous C/S, multiple pregnancy
  • Placenta praevia, abruptio placenta
  • Precipitated labour, prolonged labour, large baby
  • Patients with hypertensive disorders

Clinical features

  • Bleeding from the genital tract which may be a gush of blood or a small but persistent trickle of blood (>1 pad
    soaked in five minutes)
  • The uterus may still be large, soft, and not contracted especially in primary PPH
    • If uterus is well contracted, look for tears on the perineum,vagina, cervix, or uterus
  • Signs of shock may be present: tachycardia, low BP, cold and clammy skin
  • In secondary PPH, there may be signs of infection, e.g., fever, abdominal tenderness

Investigations

  • Hb and blood group should have been already done and recorded during ANC; if not, do them urgently
  • Women at high risk of PPH should have blood cross matched and at least 2 units booked
  • If time allows (e.g. in secondary PPH), check blood for Hb, clotting

MANAGEMENT

The principles of management include two major components:

  1. Resuscitation and management of obstetric haemorrhage and possibly hypovolemic shock
  2. Identification and management of underlying causes

First aid

  • Check uterus to see if contracted
  • Massage uterus (to expel clots)
  • Give oxytocin 10 IU IM or IV slowly
  • Empty the bladder
  • Start IV fluids (normal saline), give according to patient BP
  • If oxytocin not available, give misoprostol 800  micrograms sublingually or rectally (only one
    dose)

Check if placenta has been expelled, and is complete

  • If yes, expel any clots in the birth canal
  • If not, perform manual removal or refer
  • Prophylatic antibiotic: ampicillin 2 g IV stat plus metronidazole 500 mg IV
  • If signs of infection, give antibiotics as in puerperal fever

If uterus contracted and placenta expelled

  • Check for local causes if bleeding continues
    • Inspect carefully the lower genital tract for perineal lacerations, haematomas, vaginal and
      cervical tears

If bleeding not responding,

  • Repeat oxytocin 10 IU IV/IM after 20 minutes
  • Give misoprostol sublingual or rectally 800 micrograms (if not given before)
  • Restore blood volume with IV fluids
  • Refer for further management and blood transfusion if necessary
  • Check for coagulation problems
Caution
  • Even if bleeding persists, never give repeat misoprostol

Prevention

  • Ensure active management of 3rd stage of labour for all women in labour, and delivery by skilled staff
  • Give oxytocin 10 IU IM within 1 minute of delivery of the baby, after ruling out presence of another baby
  • Clamping and cutting the cord after cessation of cord pulsations (approx. 1-3 minutes after delivery of the baby
    whichever comes first)
  • Controlled cord traction during a contraction with counter-traction to deliver the placenta
  • Massage the uterus immediately after delivery of the placenta to ensure the uterus is contracted
  • Identify mothers at risk and manage accordingly
  • Give 5 days’ prophylactic antibiotics in prolonged or obstructed labour, or in presence of other risk factors,
    e.g. rupture of membranes, birth before arrival at health facility, instrument delivery: