Post Partum Haemorrhage

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Post Partum Haemorrhage (PPH) is 500mLs or above
Major PPH - 1000mLs
Massive PPH - 1500mLs

Primary PPH is a blood loss of 500mLs or more within 24 hours of delivery.
Secondary PPH is a blood loss of 500mLs between 24 hours and 6 weeks post delivery.

Remember that haemorrhage is a continuum

READINESS – knowing your 'at risk' women

ALL WOMEN SHOULD HAVE A RECENT HAEMOGLOBIN RESULT AVAILABLE (WITHIN 4 WEEKS Of ADMISSION) IF NOT THEN CHECK ON ADMISSION.

Antenatal Risk Factors:
  • Substantial:
    • Suspected or proven placental abruption
    • Known placenta praevia
    • Multiple pregnancy
    • Preclampsia/pregnancy-induced hypertension
  • Significant (though smaller)
    • Previous PPH
    • Asian ethnicity
    • Obesity: BMI greater than 35
    • Anaemia: Hb less than 90grams/litre
    • Grand multiparity (5 births or more)
    • Aged over 40, not multiparous (more than one child)

Intrapartum Risk Factors:

  • Operative delivery
  • Induction of labour
  • Retained placenta
  • Episiotomy
  • Prolonged labour
  • Big baby birth weight greater than 4kgs
  • Pyrexia in labour

All women who have had a previous caesarean section must have had a placental site determined by ultra sound.

COMPLETE PPH RISK SCORE ASSESSMENT SHEET at booking of elective section, admission in labour, for IOL or augmentation of labour. Complete prior to second stage and following delivery

On admission, women in above categories must be considered for:

  • IV: one venflon (size 14G)
  • Full blood count and Group & Save
  • Active Management of Third Stage
  • Familiarise care givers with PPH protocol

Recognition

Generous estimation of blood loss

Pregnancy induced cardiovascular changes protect against the effects of haemorrhage.

By term

  • Cardiac output has increased by 50%
  • Blood volume from 70mL/kg to 100mL/kg (5 to 7 litres/kg)

Tachycardia may be the only sign of haemorrhage until 30 to 40% of the circulating volume has been lost.

Complete PPH risk assessment score with management pathway chart for ALL women at booking of elective section, admission in labour, for IOL or augmentation of labour. Complete prior to second stage and following delivery

Commence National MEWS chart

Table 1: Clinical features of shock in pregnancy related to blood loss

Blood loss

Clinical features

Level of shock

500mL to 1000mL

Normal blood pressure

Tachycardia

Palpitations , dizziness

 

Stage 0:  15% blood loss or less

Compensated

1000mL to 1500mL

Hypotension systolic 90 to 80mmHg

Tachycardia

Tachypnoea (21 to 30 breaths/min)

Delayed capillary refill time

Pallor, sweating        

Weakness, faintness, thirst

 

Stage 1: 15 to 30% blood loss

Mild

1500mL or more

Hypotension 80 to 60mmHg

Rapid, weak pulse greater than 110bpm

Tachypnoea greater than 30

Pallor, cold clammy skin

Poor urinary output less than 30mL/hr

Restless, anxiety , confusion

Moderate

2000mL or more

Severe hypotension less than 50mmHg

Pallor, cold clammy skin, peripheral cyanosis

Air hunger

Anuria, confusion or unconsciousness, collapse

 

Stage 3: 30% blood loss or higher and ongoing clinical concerns

Severe

Maternity & Child Quality Improvement Collaborative (SPSP) 

Recommends quantitative assessment of blood loss.

All women who deliver, regardless of method of delivery, should be assessed for blood loss. More accurate methods, such as graduated drapes and weighing of pads, should be used for women with an estimated blood loss of a 1,000mL and above.

Response

This is an obstetric emergency. Early recognition and co-ordinated, multidisciplinary team work will improve outcome.

Once PPH has been identified, management involves four components, all of which must be undertaken SIMULTANEOUSLY:

  • communication
  • resuscitation
  • monitoring and investigation
  • arresting the bleeding

Where Primary PPH occurs in a woman delivering in a different setting other than that of a consultant led unit the role of professionals on site is to institute first aid measures whilst arranging transport to a consultant led unit by the most expeditious means.

Management

Documentation – assign a scribe to keep contemporaneous notes of all events and interventions, whatever the setting

Table 2: Management of PPH

IN CONSULTANT LED HOSPITAL

PPH 500mL or above

OUT OF HOSPITAL CMU AND COMMUNITY

PPH 500mL or above
  • Communication:
  • Summon most experienced midwifery and obstetric staff available
  • Alert theatre staff and anaesthetist
  • Assign scribe
  • Weigh swabs and inco pads  
  • Communication:
  • Summon available staff –midwife, GP
  • Contact ambulance service via 999 to arrange transfer
  • Inform on call obstetricians at Raigmore/Caithness
  • Resuscitation
  • Remember ABCDE
  • Airway – oxygen via face mask (10 to 15 litres/min), regardless of woman’s SpO2
  • Early anaesthetic review if impaired conscious level/suspected airway compromise
  • IV access with one 14 G cannula – take FBC, coagulation screen, group and save, U&Es
  • Commence crystalloid infusion
  • Resuscitation:
  • Remember ABCDE
  • Airway – oxygen via face mask (10 to 15 litres/min), regardless of woman’s SpO2
  • Airway management
  • IV access - take FBC, coagulation screen, group and save, U&Es.
  • Commence crystalloid infusion
  • Monitor and Investigations
  • Blood investigations as above
  • Observations every 15 minutes recorded on MEWS including pulse oximetry
  • Monitor and Investigations
  • Blood investigations as above
  • Observations every 15 minutes recorded on MEWS including pulse oximetry
  • Arrest the Bleeding
  • Rub up a contraction
  • Empty bladder
  • Put baby to breast
  • Check placenta is complete
  • Bi manual compression

Drug regimen see below
  • Arrest the Bleeding
  • Rub up a contraction
  • Empty bladder
  • Put baby to breast
  • Check placenta is complete
  • Bi manual compression - this might be considered earlier out of hospital

Drug regimen see below

Table 3 – Management of Major Obstetric Haemorrhage

Major Obstetric

Haemorrhage

Blood loss greater than 1000mL and continuing to bleed or clinical shock.

Simultaneously – communicate, resuscitate, monitor and investigate and arrest the bleeding.

Communicate

  • Experienced midwife in addition to the senior charge midwife
  • 2222 call - for obstetric FY2, middle grader and obstetric anaesthetists.
  • On call Obstetric Consultant should be contacted urgently and should attend.
  • Call BTS technician and confirm availability of group specific blood, requesting 4 units.
  • Ensure clarity regarding degree of urgency
  • Clarify timing of availability of cross-matched or group-specific blood.
  • If unable to wait for group-specific blood (15min) – use O negative blood
  • Arrange delivery of blood samples by porter or runner
  • Alert haematologist on call
  • Assign scribe, record events, fluids, drugs and vital signs.

In CMU:

  • Emergency buzzer – medical & nursing colleagues, anaesthetist vital, lab staff (may need to call in if OOH’s)
  • Early contact with Raigmore Consultant, support from senior labour ward staff.

In Community:

  • Call 999 indicate obstetric emergency. GP to attend if possible
  • Contact Raigmore ensure ready to receive, senior staff available

CMU’s & Community Hospitals – may need to consider use of Emergency Medical Retrieval Service (EMRS) to ensure safe transfer

Resuscitate

  • Utilise fast action response trolley
  • Remember your ABCDE
  • Assess airway
  • Assess breathing
  • Evaluate circulation
  • Apply Oxygen at 10 to 15L
  • IV access – 2 x 14G cannula
  • Position flat
  • Keep warm
  • Transfuse as soon as possible
  • Fluid Therapy and blood product transfusion:
  • Ensure fluids are warmed
  • Crystalloid – up to 2L of Hartmann’s
  • Colloid – up to 1.5L until blood arrives
  • Blood – cross matched. If cross matched unavailable, give uncross matched group-specific blood, or give O RhD negative blood.
  • Blood Fridge location
  • Fresh Frozen Plasma – order and prescribe 4 units FFP, thereafter liaise with haematologist for guidance / will depend on coagulation results and clinical situation
  • Platelets concentrates – order and prescribe 1 unit, thereafter if PLT count less than 75 x 109/L
  • Cryoprecipitate – order and prescribe 2 bags if fibrinogen less than 2 g/L
  • Consider the use of FVIIa; liaise with haematologist

Total volume of clear fluids 2L before transfusion of blood.

  • The clinical picture should be the main determinant for the need of blood transfusion and time should not be wasted waiting for laboratory results.
  • Liaise with anaesthetists, haematologists regarding appropriate combination of IV clear fluids, blood and blood products.

Therapeutic goals of management of major blood loss is to maintain:

  • Hb greater than 80g/L
  • Platelet count greater than 75 x 109/L
  • Prothrombin less than 1.5 mean control
  • APTT less than 1.5 mean control
  • Fibrinogen greater than 2.0g/L

In CMU & Community:

Similar may have restriction on fluid availability

Monitor

Blood samples to be sent for:

  • Group and save for cross matching 4 units. In the absence of abnormal antibodies, group-specific blood should be available without delay.
  • Full blood count send as urgent request asking for full blood count, clotting screen and FDPs U&Es and LFTs
  • Observations every 15 minutes and recorded on MEWS , to include pulse oximetry
  • Consider ECG
  • Assign a scribe and use post partum haemorrhage checklist
  • Foleys catheter to monitor urinary output.
  • Monitor hourly urine volumes.
  • Consider insertion of CVP line (anaesthetic registrar/consultant)
  • Consider care setting, HDU ITU

In CMU & Community:

Again similar but may vary depending on location

Causes for PPH may be considered to relate to one or more of the four T’s

  • Tone: abnormalities of uterine contraction
  • Tissue: retained products of conception, retained placenta
  • Trauma: of the genital tract
  • Thrombin: abnormalities of coagulation

The most common cause of primary PPH is uterine atony. However clinical examination must be undertaken to exclude other or additional causes.

  • Retained products (placenta, membranes or clots)
  • Vaginal/Cervical lacerations or haematoma
  • Ruptured uterus
  • Broad ligament haematoma
  • Extra genital bleeding (for example, sub capsular liver rupture)
  • Uterine inversion

Table 4: Strategies for stopping the bleeding

Stop The Bleeding

*taken from SPSP PPH 4 stage approach doc 2018

Max dose of Ergometrine is 500microgram. If Syntometrine (Ergometrine 500microgram/oxytocin 5 units) has already been given, the maximum dose of Ergometrine has been administered.

If uterine atony is perceived to be the cause use these measures initially

  • Ensure bladder is empty
  • Bi manual uterine compression
  • Check placenta to ensure it is complete

Pharmacological

Uterotonics/Tranexamic acid Document time given

Drug

Dose

Time

Additional Drug

Dose

Time

Oxytocin

5 units IV

 

Tranexamic acid

1g IV

 

Ergometrine (contraindicated with PET) 

 with PET)

500microgram IV or IM

 

Tranexamic acid

1g IV

  

Oxytocin infusion

40 units over 4 hours IV

 

 

 

 

Oxytocin

10 units IM (if no IV access)

 

 

 

 

Syntometrine (contraindicated with PET)

with PET)

1mL IM (if no IV access)

 

 

 

 

Misoprostol

800 or 1000microgram PR/SL

 

 

 

 

Carboprost (Hemabate) 250microgram IM up to 8 doses (caution in asthma) Document time of each dose

Notes:

1

5

2

6

3

7

4

8

Non-Pharmacological

The following methods can be considered; they are not listed in any order of preference.

  • Packing of uterus
  • Balloon catheter tamponade
  • Uterine brace suture
  • Ligation of uterine arteries
  • Hysterectomy
  • Arterial embolisation
  • Ligation of internal iliac arteries

The exact method or combination of methods chosen will depend on the circumstances and the skills and experience of the surgeon involved. The main principle is not to wait too long before action is taken. Consultants must be involved early in all such cases.

Packing of the uterus

Insert wide ribbon gauze firmly, making sure it is place initially at the fundus using a sponge holder and then fed systematically in to the uterus. Each layer pressed firmly home before the next layer introduced.

Balloon catheter (Bakri balloon catheter) tamponade

For atonic haemorrhage; probably equivalent to packing. Requires no surgery. Has drain channel to allow blood out of uterus.

Sterile, single use catheters are kept in theatre. Pass through cervical os and attach provided giving set and inflate with around 300mL (up to 500mL) sterile sodium chloride 0.9% using the 50mL syringe provided.

Have several large Sim’s speculae available for access to the cervix, and sponge holders may be helpful to ‘guide’ the balloon in to the uterus.

If the cervix is dilated, sometimes insufficient resistance in lower uterus for balloon to be retained – consider cervical cerclage (Mersilene or prolene), tightened to diameter of 3cm.

Balloons can also be used for tamponade in the vagina when there is bleeding from vaginal lacerations.

Uterine brace suture

  • Test potential success – if bimanual compression is effective, this suture should be also.
  • The suture is inserted as below.
  • Suggested material coated 1 vicryl on large hand-held needles

(Suture W9391 available in theatres).

  • If no caesarean section, then incise uterus as if for caesarean section, with lower uterine segment transverse incision.
  • Assistant needs to compress uterus to enable suture to be tensioned and tied.
  • If major placenta praevia – additional figure of 8 sutures may be necessary
  • Check suture is clear of bowel, ureters, bladder and major vessels, and cornu of uterus.

If suture slips laterally off fundus, consider taking bite at fundus to prevent slippage.

Arterial embolisation / internal artery ligation

  • May be most useful for recurrent bleeds perhaps after initial surgery where the loss can be replaced in the short term, and where further surgery should be avoided if possible. The patient needs to be transferred to the X-ray department and therefore must be stable enough for this to be done safely.
  • Pre-operative placement may be considered in high risk cases (eg suspected placenta accreta)
  • Temporary intra-arterial tamponading balloons may be inserted in obstetric theatre without X-ray equipment to stop bleeding prior to transfer to x-ray for embolisation??
  • There may or may not be an on-call consultant radiologist for this procedure; they can be contacted in X-Ray Theatre during the day or via switchboard out of hours.
  • If radiology is not available a vascular surgeon should be called to assist with internal iliac ligation if required.

Please see 'B-Lynch suture' section for visual example

Report

Debrief

The woman and family should be debriefed and this should be documented in the medical records.

The multidisciplinary team should be debriefed regarding the case and encouraged to attend maternal morbidity meetings.

Clinical Quality Assurance Trigger

A trigger form should be completed. This is so the case can be taken to the clinical risk forum for discussion.

Birth Register

Clear documentation of amount of total blood loss recorded in the birth register. This will in turn initiate completion of in house SCASMM form and monthly maternity SPSP data if over 2500mL.

Post natal Consultant Review

For major haemorrhage; notes must go to consultant for discharge letter and follow up.

All staff involved in maternity care should receive mandatory annual training in the management of obstetric emergencies including the management of post partum haemorrhage.

Training for post partum haemorrhage should be multidisciplinary and include team drills.

B-Lynch suture

PPH post event checklist

For PPH post event checklist click here

PPH risk assessement

For PPH risk assessment click here

References

  1. ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS, Post Partum Haemorrhage Guideline 52. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg52/
  2. SPSP McQIC and Healthcare Improvement Scotland PPH 4 stage approach recommendations 2018

Abbreviations

Abbreviation Meaning
PPH Post partum haemorrhage
HB Haemoglobin
BMI Body mass index
IV Intravenous
IOL Induction of labour
FBC Full blood count
U&Es Urea & Electrolytes
FFP Fresh frozen plasma
PLT Platelet
APTT Activated partial thromboplastin time
ECG Electrocardiogram
FDPs Fibrin degradation products
LFTs Liver function test
CVP Central venous pressure

Last reviewed: 06 February 2020

Next review: 28 February 2023

Author(s): Maternity and Obstetrics working group

Version: 2

Approved By: TAM subgroup of ADTC

Reviewer Name(s): Obstetric Consultant and Labour Suite lead

Document Id: TAM439