Procedure: Postpartum haemorrhage

Procedure, instructions and discussion

Postpartum haemorrhage (PPH)

Detailed written instructions and explanation are available 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

Instructions

Indications

• Bleeding after birth (>500ml)

Or

• Bleeding after birth with signs/symptoms of hypovolemia

Contraindications (ABSOLUTE/relative)

• None

Alternatives

• None

Consent

NOT REQUIRED – IF LACKS CAPACITY

• Emergency procedure to prevent serious injury or death
• Brief verbal explanation of the procedure is still recommended

Potential complications

• Pain
• Failure (to control bleeding)
• Medication side effects

Infection control

• Standard precautions
• PPE: apron, surgical mask, protective eyewear, gown, Sterile gloves

Area

• Resuscitation bay

Staff

• Procedural clinician
• Assistant (bimanual uterine compression)
• Resuscitation team
• Obstetric emergency team
• Scribe

Equipment

• Lubricating jelly
• Gauze
• Towel or sheet
• Absorbent pads

Positioning

• Lay patient flat
• Empty bladder prior to procedure bimanual compression
• Draw patients heels up towards her bottom and put ankles together
• Relaxing the legs outwards (hips and knees flexed, hips abducted, knees dropped to sides)

Medication

EMERGENCY DEPARTMENT MEDICATIONS

• Oxytocin 10 Units IM (normal dose after birth)

plus

• Tranexamic acid IV 1 g in 10 ml over 10 mins

plus

• Oxytocin infusion – 40 Units in 1 litres NaCl 0.9% over 4 hours

FOR GI SIDE EFFECTS OF UTERUS CONTRACTING (UTEROTONIC) MEDICATIONS

• Ondansetron 4 mg IV
• Loperamide 4 mg PO

PAIN RELIEF

• Morphine IV 5-10 mg (titrated)

ADDITIONAL UTEROTIC MEDICATIONS IF AVAILABLE)

• Ergometrine 250 mcg IM & IV
• Carboprost 250 mcg deep IM

INITIATE OXYTOCINE & TRANSEXAMIC ACID PROMPTY IN THE EMERGENCY DEPARTMENT

INITIATE OTHER UTERINE CONTRACTING MEDICATIONS IF AVAILABLE

IF BLEEDING IS NOT SETTLING WITHIN 30 MINUTES INVASIVE INTERVENTION IS USUALLY REQUIRED

Sequence (PPH management)

• Fundal massage (treating the most likely cause during assessment)
• Activate massive transfusion protocol, crossmatch and send coagulation samples
• Confirm obstetric emergency team called
• Confirm oxytocin 10 Units IM given after birth, if not, give now.
• Start oxytocin infusion 40 Units in 1 litres sodium chloride 0.9% over 4 hours
• Perform a genital exam looking for the source of the bleeding (perineal or vaginal)
• If perineal or vaginal trauma, apply point pressure to bleeding area
• If no trauma identified prepare to perform bimanual uterine compression
• Decompress the bladder rapidly by inserting a catheter (making uterine compression more effective)
• Place your hand inside the vaginal removing any palpable clot in vagina or cervix.
• The apply pressure up against the cervix with your fist while squeezing and massaging the fundus abdominally
• Administer additional drug options
• Continue massive transfusion and transfer to the operating theatre

Post-procedure care

FURTHER CARE

• Send placenta and products of conception for histopathology
• Document the procedure and findings
• Offer to contact support (partner, family, friends, social work)

MONITORING FOR FURTHER BLEEDING

• Continuous cardiorespiratory monitoring
• Pad checks every 30-60 minutes
• Refer for urgent invasive intervention if further heavy bleeding

Tips

• Resuscitate (MTP), examine and compressed, start oxytocin + TXA
• Aim for specialist interventions in theatre if unresolved after 30 mins
• Do not worry about specialist uterotonic medication if unavailable

Discussion

Post partum haemorrhage may be external, intraabdominal, retroperitoneal, or in the pelvic floor and is not always associated with large vaginal blood loss (>500ml).

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%)

As the most common cause if uterine atony we focus on treating this cause mechanically and with medications immediately available in the emergency department (oxytocin and tranexamic acid). Addition uterine constricting (uterotonic) medications can be given if available, but the focus should be on resuscitation and transfer for specialist treatment in theatre if bleeding is not settling in 30 minutes (rather than obtaining rare medication if unavailable).

You should immediately request obstetric support and be aware of the high risk of deterioration requiring surgical intervention. If your hospital has an obstetric emergency number, you should activate it as soon as possible both to prepare for the possibility of theatre and get experience help to the patient.

References

• Belfort MA. Postpartum hemorrhage: Medical and minimally invasive management. In: UpToDate. Waltham (MA): UpToDate. Viewed March 2024.
• Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.
• Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.
• Wheaton N, Al-Abdullah A, Haertlein T. Postdelivery Emergencies. Emerg Med Clin North Am. 2019 May;37(2):287-300. doi: 10.1016/j.emc.2019.01.014. Erratum in: Emerg Med Clin North Am. 2020 Nov;38(4):xiii.
• Giouleka S, Tsakiridis I, Kalogiannidis I, Mamopoulos A, Tentas I, Athanasiadis A, Dagklis T. Postpartum Hemorrhage: A Comprehensive Review of Guidelines. Obstet Gynecol Surv. 2022 Nov;77(11):665-682.
• WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017 May 27;389(10084):2105-2116.
• WHO Recommendation on Tranexamic Acid for the Treatment of Postpartum Haemorrhage. Geneva: World Health Organization; 2017.

The App