PPH Summary

Definitions

  • Primary PPH: ≥500ml blood loss within 24h of birth
  • Major PPH: >1000ml blood loss
  • Secondary PPH: Bleeding 24h-12 weeks postnatal

Risk Factors

  • Uterine atony (most common)
  • Multiple pregnancy
  • Previous PPH
  • Retained placenta
  • Trauma/episiotomy

4Ts Causes

  • Tone: Uterine atony
  • Tissue: Retained products
  • Trauma: Tears/rupture
  • Thrombin: Coagulopathy

Primary Drugs

  • Oxytocin 5 units IV
  • Ergometrine 500mcg IV/IM
  • Tranexamic acid 1g IV
  • Carboprost 250mcg IM

Resuscitation

  • Call for help
  • 2 large IV access
  • Cross-match 4 units
  • Group O RhD-negative blood
  • Fluid resuscitation

Secondary PPH

  • Antibiotics + uterotonics
  • Assess for retained products
  • Ultrasound if needed
  • Surgical evacuation if severe

Postpartum Haemorrhage (PPH)

Comprehensive guide to classification, risk factors, and management of obstetric haemorrhage

Definitions

Primary Postpartum Haemorrhage

  • Most common form of major obstetric haemorrhage
  • Blood loss ≥500ml from genital tract within 24 hours of birth
  • Minor: 500-1000 ml
  • Major: >1000 ml

Secondary Postpartum Haemorrhage

  • Abnormal or excessive bleeding from birth canal
  • Occurs between 24 hours and 12 weeks postnatally
  • Often due to infection or retained products

Risk Factors

Risk factors for PPH may present antenatally or intrapartum. Women with known risk factors should only be delivered in hospitals with blood bank facilities.

Antepartum Factors

  • Multiple pregnancy
  • Previous PPH
  • Pre-eclampsia
  • Fetal macrosomia
  • Placenta accreta

Intrapartum Factors

  • Failure to progress in second stage
  • Prolonged third stage of labour
  • Retained placenta
  • Episiotomy
  • Perineal laceration
  • General anaesthesia

Most common cause: Uterine atony. Prophylactic uterotonics should be routinely offered in management of third stage of labour.

Immediate Management of Major PPH

Major PPH = blood loss >1000 ml and continuing to bleed OR clinical shock

Visual estimation of blood loss is inaccurate - include clinical signs and symptoms in assessment.

Clinical Signs of Hypovolaemic Shock in Pregnancy

Blood Loss Clinical Signs
1000-1500 ml Tachycardia, tachypnoea, slight fall in systolic BP
>1500 ml Systolic BP <80 mmHg, worsening tachycardia, altered mental state

Resuscitation Protocol

Initial Response

  • Call for help
  • Position patient flat
  • Keep warm
  • High-flow oxygen
  • 2 x large IV access

Investigations

  • FBC, U&Es, LFTs, coagulation screen
  • Cross-match 4 units minimum
  • Baseline observations

Fluid & Blood

  • Transfuse blood ASAP
  • Emergency O RhD-negative blood initially
  • Up to 3.5L warmed fluids initially
  • 2L warmed isotonic crystalloid first

Blood Product Replacement

Product Indication Dose
Fresh Frozen Plasma (FFP) After 4 units RBC if bleeding continues 12-15 ml/kg
Cryoprecipitate Fibrinogen <2 g/l with ongoing haemorrhage 2 pools
Platelets Platelets <75 × 10⁹/l with ongoing haemorrhage 1 pool

Assess Cause - The 4 Ts

TONE

Uterine atony

TISSUE

Retention of placental tissue

TRAUMA

Vaginal/cervical tears, uterine rupture

THROMBIN

Coagulopathies

Stop the Bleeding - Medical Management

Initial Measures
  • Bimanual uterine compression
  • Ensure bladder empty (urinary catheter)
  • Repair perineal/vaginal/cervical tears

Pharmacological Agents

Drug Dose & Route Notes
Oxytocin 5 units slow IV First-line agent
Ergometrine 500 micrograms slow IV/IM Avoid in hypertension
Tranexamic acid 1 g slow IV (give early) Repeat after 30 min if needed
Oxytocin infusion 40 units in 500 ml at 125 ml/hour Maintenance therapy
Carboprost 250 micrograms IM every 15 min (max 8 doses) Prostaglandin F2α
Misoprostol 800 micrograms SL Prostaglandin E1

Continuous Assessment & Escalation

  • Chart observations regularly
  • Continue to assess blood loss
  • Accurate fluid balance
  • Reassess causes of bleeding
  • 2nd dose of tranexamic acid if PPH persists

Surgical intervention: Consider if pharmacological measures fail. Intrauterine balloon tamponade is appropriate first-line surgical intervention for uterine atony.

Secondary Postpartum Haemorrhage

Causes

Endometritis

  • Uterine infection
  • Fever/rigors
  • Lower abdominal pain
  • Foul-smelling lochia

Retained Products

  • Retained products of conception (RPOC)
  • Spotting with occasional gush of fresh blood
  • Uterus may still be high

Other Causes

  • Subinvolution of placental site
  • Coagulation disorders
  • Infected episiotomy

Warning: Approximately 10% of cases present with massive haemorrhage leading quickly to hypovolemic shock.

Management

Initial Assessment
  • Assess haemodynamic status
  • Quantify blood loss
  • Evaluate patient concerns
  • Vaginal microbiology swabs
  • Pelvic ultrasound (though unreliable for RPOC diagnosis)

Medical Treatment

Antibiotics

  • First-line: Ampicillin + Metronidazole
  • Penicillin allergy: Clindamycin + Metronidazole
  • Severe infection: Add Gentamicin

Follow local antimicrobial guidelines

Uterotonics

  • Syntocinon (oxytocin)
  • Syntometrine (oxytocin+ergometrine)
  • Carboprost (PGF2α)
  • Misoprostol (PGE1)

Surgical Management

Indications: Excessive or continuing bleeding irrespective of ultrasound findings.

Risk: Surgical evacuation carries high risk of uterine perforation (softer, thinner postpartum uterus). Always involve senior obstetrician.

Balloon catheter: Insertion into uterus may be effective in continuing haemorrhage before considering surgical evacuation.