In this section
haemorrhage continues to be a significant contributor world-wide to the 500,000
maternal pregnancy related deaths each year accounting for 30% of the total
Until recent times, Primary PPH
was defined as a blood loss of > 500 mL from the genital tract in first 24
hours post delivery2. This
definition however, is based on subjective observations and accurate assessment
of excessive blood loss is difficult. Recent research indicates that clinical
estimates of blood loss frequently fall below the actual amount and the
incidence of PPH is being under reported by 30-50%. On the basis of these
findings, more objective assessment parameters have been advocated for the
diagnosis of major PPH (primary postpartum haemorrhage) - viz:
is haemodynamically unstable
has a blood loss of >1000 mL from genital
has a >10% change in her haematocrit
between admission and the postpartum period.3 or
requires a transfusion of red blood cells3
Based on these definitions the incidence of postpartum haemorrhage for a
vaginal delivery has been estimated at 3.9% 4 and 6.4% 5 for a caesarean
Aetiology of Primary Postpartum Haemorrhage (<24 hours post-delivery)
adage that 'an empty intact contracted uterus will not bleed in the presence of
a normal clotting mechanism' helps one remember the important causes.
Retained placental tissue
Lower genital tract laceration
Uterine inversion (rare)
'ALSO' course teaches the mnemonic 'The 4 T's" for the same reason:
High Risk Patients
Over-distended uterus (twins, large fetus, polyhydramnios)
Grande multipara P4 or more
Past history of PPH or retained placenta or MROP
Prolonged labour eg. First stage >12hrs, Second stage >3hrs
Large baby/large placenta
Antepartum haemorrhage including abruption
Management of Primary Postpartum Haemorrhage
management in a woman thought to be at high risk of primary postpartum
Active Management of excessive
postpartum blood loss:
Insert a large IV
line, preferably 14 gauge. Insert 2nd IV line if necessary.
Take blood for full
blood picture, group and hold
screen (fibrinogen, APTT, PT, D-dimer) and cross match blood (at least 2 Units)
Hartmanns solution or Normal Saline
plasma expanders, eg:
blood (packed cells)
7. Insert an indwelling urinary
8. If the placenta is retained and
the woman has a fully functioning epidural or spinal anaesthetic, manual
removal of the placenta can be undertaken in the Delivery Suite; manual removal
may not be attempted without functioning epidural or spinal or general
9. If the placenta is delivered
massage the uterus (may use bimanual compression if necessary), commence an
oxytocin infusion of 40 IU Syntocinon in 1000 mL compound sodium lactate
solution (CSL) at 120 mL/hour. Syntocinon infusions with higher concentrations
or rates of administration are not associated with an improved response to the
drug but substantially increase the side effects from the medication.6
10. If the syntocinon infusion fails
to achieve uterine contraction additional medical treatment should be
instituted rather than increasing the dose or rate of syntocinon:
PR. This agent is the optimum first line agent after syntocinon infusion for
the treatment of primary post partum haemorrhage and its use is associated with
5 fold lesser need for further intervention than syntometrine.7
ampoule intramuscular if not already administered. If ergometrine has already
been administered (as Ergometrine or Syntometrine) a second dose of 250
micrograms may be given but beware of the hypertensive woman who may develop
extreme hypertension following the administration of ergometrine. The total
dose of ergometrine in 24 hours must not exceed 1000 micrograms.
11. Check genital tract thoroughly
for the presence of trauma/lacerations and repair; firm pressure on a bleeding
perineal wound is an important temporary measure.
12. If loss continues to be excessive
despite the above measures, the patient should be promptly taken to theatre for
exploration of the uterus and lower genital tract.
1. Consider bimanual compression while
awaiting commencement of the procedure.
2. Examination under anaesthetic to remove
retained products, repair any tears.
inserting a central
line and/or arterial line
frozen plasma, cryoprecipitate and platelet concentrates
the need for
4. Administer intramyometrial
prostaglandin F2a. 1 mL of Prostaglandin F2a 5mg/mL is diluted in 20 mL normal
saline; 5 mL is administered slowly intramyometrically in 1-2 mL aliquots in
the presence of the Obstetric Consultant and appropriate Anasthetic staff.
NB. The Prostaglandin F2a ampoule
contains 5 times more than the dose needed.
Uterine / Vaginal Tamponade
Insertion of a Foley catheter is useful in repaired
cervical lacerations that continue to bleed or in cervical pregnancies.
For uterine tamponade:
Insert a Bakri double balloon catheter. Fill each balloon with 80 mL
saline. Remove 24hrs later.
Pack the uterus. Tie 3-4 gauze rolls together, soak in an iodine
solution, and pack uterus and vagina. Remove 24 hours later.8
Consider applying aortal
compression at surgery or via pressure through the abdominal wall (This may be
helpful as a temporary measure if the patient is in shock.9
Laparotomy / Surgical
be an option if available.
AbouZahr C. Royston E. Eds. The
global picture: the causes of maternal death. In Maternal mortality: a global
fact-book. 1991; pp. 7-11, Geneva: World Health Organization.
Pritchard JA. Baldwin RM. Dickey
JC. Wiggins KM. Blood volume changes in pregnancy and the puerperium. II. Red
blood cell loss and changes in apparent blood volume during and following
vaginal delivery, cesarean section, and cesarean section plus total
hysterectomy. Am J Obstet Gynecol. 1962; 84: 1271-1282.
American College of Obstetricians
and Gynecologists. Postpartum hemorrhage. ACOG Educational Bulletin 1998;
Number 243. In 2001 Compendium of Selected Publications, Washington DC: ACOG.
Combs CA. Murphy EL, LRJ. Factors
associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991;
Combs CA. Murphy EL. Laros RK Jr.
1991. Factors associated with postpartum hemorrhage in cesarean birth. Obstet
Gynecol 1991; 77: 77-82.
Roberts WE. Emergent obstetric
management of postpartum hemorrhage. Obstet Gynecol Clin North Am. 1995; 22(2):
Lokugamage AU, Sullivan KR,
Niculescu I, Tigere P, Onyangunga F, El Refaey H, Moodley J, Rodeck CH. A
randomized study comparing rectally administered misoprostol versus Syntometrine
combined with an oxytocin infusion for the cessation of primary post partum
hemorrhage. Acta Obstet Gynecol Scand. 2001; 80:835-9.
Druzin ML. Packing of lower
uterine segment for control of post cesarean bleeding in instances of placenta
previa. Surg Gynecol Obstet 1989; 169: 543-45.
Riley DP. Burgess RW. External
abdominal aortic compression: A study of a resuscitation manouver for
postpartum hemorrhage. Obstet Gynecol Surv 1995; 50: 426-7
AbdRabbo SA. Stepwise uterine
devascularization: A novel technique for management of uncontrollable
postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol
1994; 171: 694-700.
B-Lynch C. Coker A. Lawal AH. Abu
J. Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum
haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet
Gynaecol. 1997; 104:3: 372-5.
O'Leary JA, SO. Hemorrhage with
uterine artery ligation. Contemp Ob/Gyn Update Surg 1986; 27: 13-16.
Allahbadia G. Hypogastric artery
ligation: A new perspective. Obstet Gynecol Surv 1993; 48: 613-15.
Stanco LM. Schrimmer DB. Paul RH.
Mishell DR Jr. Emergency peripartum hysterectomy and associated risk factors.
Am J Obstet Gynecol. 1993; 168: 879-883.