Procedure: Postpartum haemorrhage
The Procedure
Hello again from the Emergency Procedures team.
Postpartum haemorrhage (PPH)
Today we step out of our comfort zone and tackle postpartum haemorrhage (PPH). Take a few deep breaths and your own pulse, then dive into the video
Detailed written instructions and explanation are available here and in our Free App (iOS and Android). This video is hot off the press and we want your help improving it. Drop us a line with any suggestions
So, without further ado…here is the video
The rationale…
What’s the main thing I need to remember about complications of childbirth in the ED?
Get help early……….
A deliver in the emergency department is not a normal delivery, it is unexpectedly rapid labour known as a precipitous delivery. Precipitous deliveries have high rates of complications including breech delivery, shoulder dystocia, nuchal cord, and post-partum haemorrhage.
We need to prepare for the worst.
Put out a neonatal and obstetric emergency call for all births occurring in or on the way to the ED.
Remind me of the causes of PPH?
The common causes of PPH are:
- TONE: Reduced uterine tone (70%)
- TRAUMA: laceration, rupture of uterus (20%)
- TISSUE: Retained placenta or blood clots (10%)
- THROMBIN: Coagulopathy (1%)
Post partum haemorrhage may be external, intraabdominal, retroperitoneal, or in the pelvic floor and is not always associated with large vaginal blood loss (>500ml).
What key information do I need to remember for managing PPH?
Resuscitate with a massive transfusion as you would for any trauma.
Compress visible bleeding sources (trauma).
Treat uterine atony mechanical (bi-manual compression) and with uterus constricting medications.
Aim for specialist interventions in theatre if unresolved after 30 mins.
What do I need to remember about the uterotonic (uterus constricting) medications?
We always oxytocin and TXA which should be available in the ED.
You need to remember not to focus on specialist medications (ergometrine, carboprost) too much.
If bleeding does not settle the patient needs to be in the operating room within 30 mins. You can give other uterotonics if available and it does delay progress to theatre
I’ve spotted an improvement that could be made to your video and guide?
Don’t be shy, let us know! Drop us a line
The App
Emergency Procedures
Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist Emergency Medicine, Prince of Wales Hospital. Lead author of Lead author of Emergency Procedures App | Twitter | YouTube |
Dr Amanda Beech FRACP MBBS (Hons) BSc PHED (Hons). Obstetric medicine physician and endocrinologist. Staff Specialist Royal Hospital for Women, Sydney. Director of Simulation training
2 Comments
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Hello all
Thanks for a good go on PPH
The video can be improved by making it more real – examiner with gauze in examination hand (right). The examiner to maintain firm pressure and massaging fundus.(The close the Tap – Toniquet the spiral artery approach)
The SR. MARCH-OT approach like we approach any major haemorrhage. Compression of the bleeding site and uterotonic compression effect – imi uterotonic all given as soon as baby is out – serial use or use combination and early TXA 1g IVI as soon as IVC is in.
Happy to help add & edit on your next version
Reach out [email protected].
We need to add – Massive PPH Haemorrhage & transfusion management-
The SR. MARCH – OT approach and the early TXA, fibrinogen and RoTEM / TEG in tertiary units. The fresh whole blood as the best resuscitation and replacement fluid. No room for crystalloids in massive haemorrhage. The Lethal triage in Massive haemorrhage and the coagulopathy cascade.
Read – The Paradigm shift in severe PPH management (etwell.m a al )
Thanks for the comments. Happy to have your help in a review and update. We have tried to emphasis compression, quick use of avialable medications and theatre rapidly. Keen to hear your ideas. Emailing you privately.