Post-partum haemorrhage (PPH)

Question 1

Define what post-partum haemorrhage is

Answer 1

This is blood loss ≥ 500ml after the birth of the baby

Question 2

Define what Primary PPH is ?

Answer 2

This is PPH occurring within 24hrs after delivery of the baby

Question 3

Define what secondary PPH is

Answer 3

This is PPH occurring > 24hrs and < 12/52 post delivery of the baby

Question 4

How is the severity of PPH classified ?

Answer 4

• Minor = 500-1000ml, without clinical signs of shock
• Major = > 1500ml or signs of shock or on-going bleeding

Question 5

What are the risk factors for PPH?

Answer 5

• Anaemia
• Previous/ or undergoing C-section
• Placenta praevia or accreta
• Previous PPH
• Previous retained placenta
• Multiple pregnancy
• Polyhydramnios
• Obesity - BMI > 35
• Fetal macrosomnia
• Prolonged labour
• Operative delivery

Question 6

What is done to help prevent PPH ?

Answer 6

Active management of the 3rd stage of labour - 1st line = syntococin (oxytocin), 2nd line = syntometerine/ergometrine (think for those at higher risk of PPH)

Question 7

What are the main causes of PPH?

Answer 7

The commonest cause of PPH is uterine atony. However, clinical examination must be undertaken to exclude other causes:

• Retained products (placenta, membranes, clots)
• Vaginal/cervical laceration
• Ruptured uterus
• Broad ligament haematoma
• Extra-genital bleeding

Question 8

Describe the overall management of PPH

Answer 8

Call for help

Then immediate simultaneous management of the following 3 things:

• Assessing the patient
• Stopping the bleeding
• Fluid replacement

Question 9

When assessing a patient with PPH what is done ?

Answer 9

• Vital Signs: Pulse, BP, CRT, Sats every 15min
• Give Oxygen
• Determine Cause of bleeding- 4Ts (tone, tissue, trauma, thrombin)
• Blood Samples: FBC, clotting, fibrinogen, U&E, LFT, Lactate
• Cross-match 6 units RBCs
• May need Major Haemorrhage protocol (if so tranexamic acid 1st line to give)

Question 10

Describe the management of ‘stopping the bleeding’ in someone with a PPH

Answer 10

Uterine massage and bimanual compression and foley catheter to empty bladder

And Drugs:

• 1st line = either IV syntocinon or IM syntometrine (more effective but more side effects and cant be used if HTN, PET, or cardiac disease) (can have a second dose)
• 2nd line = IV infusion of syntocinon in 500ml hartmans
• 3rd line = IM carbaprost (up to 8 doses)
• 4th line = Misoprostol PR

If persistent beyond this point make sure to have called for a consultant and EUA done to determine the cause e.g. vaginal, cervical, perinanal trauma, retained products etc. Repair or surgical measures then used

Question 11

What are the main causes of secondary PPH?

Answer 11

Due to retained placental tissue or endometritis

Question 12

Describe the management of secondary PPH

Answer 12

Exclude retained products of conception (RPOC) with U/S - if so needs surgical evacuation

Infection likely cause so need to do high vaginal & endocervical swabs

Question 13

After PPH has been managed (primary or secondary) what is needed to be done ?

Answer 13

Thromboprophylaxis and management of anaemia so may need to be given IV Fe/ oral