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Primary postpartum haemorrhage - PERS - Perinatal Emergency Referral Service

Primary Postpartum Haemorrhage



Overview
Postpartum haemorrhage continues to be a significant contributor world-wide to the 500,000 maternal pregnancy related deaths each year accounting for 30% of the total number.1

Definition
Until recent times, Primary PPH was defined as a blood loss of > 500 mL from the genital tract in first 24 hours post delivery2. This definition however, is based on subjective observations - making accurate assessment of excessive blood loss is difficult. Recent research indicates that clinical estimates of blood loss frequently fall below the actual amount and the incidence of PPH is being under reported by 30-50%. On the basis of these findings, more objective assessment parameters have been advocated for the diagnosis of major PPH - viz:

The patient:
  • is haemodynamically unstable
  • has a blood loss of >1000ml from genital tract
  • has a >10% change in her haematocrit between admission and the post partum period.3 or
  • requires a transfusion of red blood cells3

Based on these definitions the incidence of postpartum haemorrhage for a vaginal delivery has been estimated at 3.9% 4 and 6.4% 5 for a caesarean delivery.

Aetiology of Primary Postpartum Haemorrhage (<24 hours post delivery)
The adage that 'an empty intact contracted uterus will not bleed in the presence of a normal clotting mechanism' helps one remember the important causes.

  • Uterine atony
  • Retained placental tissue
  • Lower genital tract laceration
  • Uterine rupture
  • Uterine inversion (rare)
  • Placenta accreta
  • Hereditary coagulopathy

The 'ALSO' course teaches the mnemonic 'The 4 T's" for the same reason:

  • Tone - atonic uterus;
  • Trauma - cervical, vaginal & perineal lacerations, pelvic haematomas, uterine inversion, ruptured uterus;
  • Tissue - retained tissue, invasive placenta;
  • Thrombin - coagulopathies.

High Risk Patients
  • Over-distended uterus (twins, large fetus, polyhydramnios)
  • Grande multipara P4 or more
  • Past history of PPH or retained placenta or MROP
  • Anaemia
  • Prolonged labour eg. First stage &gt;12hrs, Second stage &gt;3hrs
  • Operative delivery
  • Large baby/large placenta
  • Antepartum haemorrhage including abruption
  • Chorioamnionitis

Management of Primary Postpartum Haemorrhage

Preventive management in a woman thought to be at high risk of primary postpartum haemorrhage:



1. Insert an IV line (preferably 14g cannula)
2. Take blood for group and hold, full blood picture and consider cross-matching blood
3. Active management of third stage, including Syntometrine one ampoule intramuscularly (if Ergometrine is contra-indicated by hypertension or heart disease give Syntocinon 10IU) and controlled cord traction once the uterus is well contracted.

Active Management of excessive postpartum blood loss:



Initiate Emergency Care
1. Call for help once blood loss exceeds an estimated 500mL.
2. Massage the uterine fundus and measure blood loss.
3. Check vital signs.
4. Check that Syntometrine one ampoule or Ergometrine 0.25mg or Syntocinon 10IU has been administered; if not, do so.
5. Implement local emergency procedures
  • Insert a large IV line, preferably 14 gauge. Insert 2nd IV line if necessary.
  • Take blood for full blood picture, group and hold
  • Consider clotting screen (fibrinogen, APTT, PT, D-dimer) and cross match blood (at least 2 Units)
6. Infuse
  • crystalloids, eg: Hartmanns solution or Normal Saline
  • plasma expanders, eg: gelofusine, haemaccel
  • blood (packed cells)
7. Insert an indwelling urinary catheter
8. If the placenta is retained and the woman has a fully functioning epidural or spinal anaesthetic, manual removal of the placenta can be undertaken in the Delivery Suite; manual removal may not be attempted without functioning epidural or spinal or general anaesthesia.
9. If the placenta is delivered massage the uterus (may use bimanual compression if necessary), commence an oxytocin infusion of 40 IU Syntocinon in 1000 ml compound sodium lactate solution (CSL) at 120 ml/hour. Syntocinon infusions with higher concentrations or rates of administration are not associated with an improved response to the drug but substantially increase the side effects from the medication.6
10. If the syntocinon infusion fails to achieve uterine contraction additional medical treatment should be instituted rather than increasing the dose or rate of syntocinon:
  • Misoprostol 800mcg PR. This agent is the optimum first line agent after syntocinon infusion for the treatment of primary post partum haemorrhage and its use is associated with 5 fold lesser need for further intervention than syntometrine.7
  • Syntometrine one ampoule intramuscular if not already administered. If ergometrine has already been administered (as Ergometrine or Syntometrine) a second dose of 250 micrograms may be given but beware of the hypertensive woman who may develop extreme hypertension following the administration of ergometrine. The total dose of ergometrine in 24 hours must not exceed 1000 micrograms.
11. Check genital tract thoroughly for the presence of trauma/lacerations and repair; firm pressure on a bleeding perineal wound is an important temporary measure.
12. If loss continues to be excessive despite the above measures, the patient should be promptly taken to theatre for exploration of the uterus and lower genital tract.

In Theatre:



1. Continue bimanual compression
2. Examination under anaesthetic to remove retained products, repair any tears.
3. Consider:
  • inserting a central line and/or arterial line
  • administering fresh frozen plasma, cryoprecipitate and platelet concentrates
  • the need for antibiotic cover

4. Administer intramyometrial prostaglandin F2a. 1ml of Prostaglandin F2a 5/mg/ml is diluted in 20ml normal saline; 5ml is administered slowly intramyometrically in 1-2mL aliquotas in the presence of the Obstetric Consultant and appropriate Anasthetic staff.
NB. The Prostaglandin F2a ampoule contains 5 times more than the dose needed.

Uterine / Vaginal Tamponade:



Insertion of a Foley catheter is useful in repaired cervical lacerations that continue to bleed or in cervical pregnancies

1. Insert an ARD double balloon catheter. Fill each balloon with 80mL saline. Remove 24hrs later
2. Pack the uterus. Tie 3-4 gauze rolls together, soak in an iodine solution, and pack uterus and vagina. Remove 24 hours later.8

Consider applying aortal compression at surgery or via pressure through the abdominal wall (This may be helpful as a temporary measure if the patient is in shock.9

Laparotomy / Surgical Therapy

10
1. B-Lynch stitch11 (see B-Lynch Diagrams)
2. Uterine artery ligation (O'Leary stitch)12
  • Bilateral internal iliac artery ligation13
  • Ovarian artery ligation

3. Hysterectomy14

Arterial embolisation



References
1. AbouZahr C. Royston E. Eds. The global picture: the causes of maternal death. In Maternal mortality: a global fact-book. 1991; pp. 7-11, Geneva:: World Health Organization.
2. Pritchard JA. Baldwin RM. Dickey JC. Wiggins KM. Blood volume changes in pregnancy and the puerperium. II. Red blood cell loss and changes in apparent blood volume during and following vaginal delivery, cesarean section, and cesarean section plus total hysterectomy. Am J Obstet Gynecol. 1962; 84: 1271-1282.
3. American College of Obstetricians and Gynecologists. Postpartum hemorrhage. ACOG Educational Bulletin 1998; Number 243. In 2001 Compendium of Selected Publications, Washington DC: ACOG.
4. Combs CA. Murphy EL, LRJ. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991; 77: 69-76
5. Combs CA. Murphy EL. Laros RK Jr. 1991. Factors associated with postpartum hemorrhage in cesarean birth. Obstet Gynecol 1991; 77: 77-82.
6. Roberts WE. Emergent obstetric management of postpartum hemorrhage. Obstet Gynecol Clin North Am. 1995; 22(2): 283-302.
7. Lokugamage AU, Sullivan KR, Niculescu I, Tigere P, Onyangunga F, El Refaey H, Moodley J, Rodeck CH. A randomized study comparing rectally administered misoprostol versus Syntometrine combined with an oxytocin infusion for the cessation of primary post partum hemorrhage. Acta Obstet Gynecol Scand. 2001; 80:835-9.
8. Druzin ML. Packing of lower uterine segment for control of post cesarean bleeding in instances of placenta previa. Surg Gynecol Obstet 1989; 169: 543-45.
9. Riley DP. Burgess RW. External abdominal aortic compression: A study of a resuscitation manouver for postpartum hemorrhage. Obstet Gynecol Surv 1995; 50: 426-7
10. AbdRabbo SA. Stepwise uterine devascularization: A novel technique for management of uncontrollable postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol 1994; 171: 694-700.
11. B-Lynch C. Coker A. Lawal AH. Abu J. Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol. 1997; 104:3: 372-5.
12. O'Leary JA, SO. Hemorrhage with uterine artery ligation. Contemp Ob/Gyn Update Surg 1986; 27: 13-16.
13. Allahbadia G. Hypogastric artery ligation: A new perspective. Obstet Gynecol Surv 1993; 48: 613-15.
14. Stanco LM. Schrimmer DB. Paul RH. Mishell DR Jr. Emergency peripartum hysterectomy and associated risk factors. Am J Obstet Gynecol. 1993; 168: 879-883.




Original B-Lynch stitch B-Lynch C et al. BJOG, 1997; 104: 372-375




Modified B-Lynch stitch*


General anaesthesia and patient in Lloyd Davies position.
(Re) Open the abdomen and (Re) Open the uterus.
Check the cavity for bleeding sites which might be oversewn.
Test before using the B-Lynch suture - bimanual compression and swab the vagina - if bleeding is controlled temporarily in this fashion the B-Lynch stitch is likely to be effective.

* Modified by Dr Craig Pennell and colleagues at King Edward Memorial Hospital, Subiaco, Western Australia.


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