Overview/procedure description
Postpartum
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
number.1
Related Policy
Nil
Definition of Terms
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:
The patient:
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
delivery
Procedure details
Aetiology of Primary Postpartum Haemorrhage (<24 hours post-delivery)
The
adage that 'an empty intact contracted uterus will not bleed in the presence of
a normal clotting mechanism' helps one remember the important causes.
The
'ALSO' course teaches the mnemonic 'The 4 T's" for the same reason:
- Tone - atonic uterus;
- Trauma - cervical, vaginal
and perineal lacerations, pelvic haematomas, uterine inversion, ruptured
uterus;
- Tissue - retained tissue,
invasive placenta;
- Thrombin - coagulopathies.
High Risk Patients
Over-distended uterus (twins, large fetus, polyhydramnios)
Grande multipara P4 or more
Past history of PPH or retained placenta or MROP
Anaemia
Prolonged labour eg. First stage >12hrs, Second stage >3hrs
Operative delivery
Large baby/large placenta
Antepartum haemorrhage including abruption
Chorioamnionitis
Management of Primary Postpartum Haemorrhage
Preventive
management in a woman thought to be at high risk of primary postpartum
haemorrhage:
- Insert an IV line (preferably 14g
cannula).
- Take blood for group and hold,
full blood picture and consider cross-matching blood.
- Active management of third stage,
including Syntometrine one ampoule intramuscularly (if Ergometrine is contra-indicated
by hypertension or heart disease give Syntocinon 10 IU) and controlled cord
traction once the uterus is well contracted.
Active Management of excessive
postpartum blood loss:
Initiate
Emergency Care
- Call for help once blood loss
exceeds an estimated 500 mL.
- Massage the uterine fundus and
measure blood loss.
- Check vital signs.
- Check that Syntometrine one
ampoule or Ergometrine 0.25mg or Syntocinon 10 IU has been administered; if
not, do so.
- Implement local emergency
procedures
Insert a large IV
line, preferably 14 gauge. Insert 2nd IV line if necessary.
Take blood for full
blood picture, group and hold
Consider clotting
screen (fibrinogen, APTT, PT, D-dimer) and cross match blood (at least 2 Units)
6. Infuse
crystalloids, eg:
Hartmanns solution or Normal Saline
plasma expanders, eg:
gelofusine, haemaccel
blood (packed cells)
7. Insert an indwelling urinary
catheter
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
anaesthesia.
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:
Misoprostol 800mcg
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
Syntometrine one
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.
In Theatre:
1. Consider bimanual compression while
awaiting commencement of the procedure.
2. Examination under anaesthetic to remove
retained products, repair any tears.
3. Consider:
inserting a central
line and/or arterial line
administering fresh
frozen plasma, cryoprecipitate and platelet concentrates
the need for
antibiotic cover
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
Therapy10
- B-Lynch stitch11 (see B-Lynch
Diagrams)
- Uterine artery ligation (O'Leary
stitch)12
- Bilateral internal iliac artery ligation13
- Ovarian artery ligation.
3. Hysterectomy14
Arterial embolization
May
be an option if available.
Reference
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