Post Partum Haemorrhage - Dr Thomas Carins Australian South Asian Healthcare Association (ASHA) Maternal Health Education Program

Post-Partum Haemorrhage (PPH) One of the biggest causes of maternal death Death depends largely on medical care Potentially life-threatening complications: Anaemia, prolonged hospital stay, failure to breastfeed, pituitary infarction, blood products, haemorrhagic shock, coagulopathies, acute tubular necrosis, coma, hysterectomy

Definition PPH Primary PPH Secondary PPH Severe PPH Loss of 500ml or more during childbirth Occurs within 24 hours Secondary PPH Severe PPH Occurs after 24 hours Loss of 1000ml or more, OR any amount that causes haemodynamic compromise

Causes Tone (70%) Trauma (20%) Tissue (10%) Thrombin (1%)

Tone Abnormalities in uterine tone (70%) Atonic Uterus Over-distended uterus Uterine muscle dysfunction Intra-amniotic infection Drug-induced uterine hypotonia Anatomic distortion of uterus

Trauma Genital tract trauma (20%) Episiotomy or lacerations Lacerations of caesarean section Uterine rupture Uterine inversion

Tissue Retained products (10%) Retained placenta Retained membranes Abnormal placenta Retained cotyledon

Thrombin Abnormalities of coagulation (1%) Retained blood clots Coagulation disorders Disseminated intravascular coagulation (DIC) Preeclampsia Retained deceased fetus Severe infection Therapeutic anticoagulation Amniotic fluid embolism

Prevention Two thirds of cases of PPH cannot be predicted Check Hb antenatally Consider the previous risk factors Limit interventions Offer active management of third stage Continuous observations for first hour

Active Management of 3rd Stage 10U Syntocinon IM once anterior shoulder delivered Continuous cord traction Can still perform delayed cord clamping May reduce neonatal anaemia (at least in preterm) Does not increase PPH risk Recommended management of 3rd stage! Has been shown to reduce incidence of PPH

Continuous Cord Traction

Expectant Management of 3rd Stage No interventions are undertaken Placenta delivered by maternal effort Cord is clamped once pulsation ceases MUST Immediate and sustained baby skin-to-skin contact Keep mother and baby warm Woman in upright position No cord traction Safe for women with low risk of PPH Must have constant observations

Management Most women can lose 500 – 1000ml of blood without circulatory compromise. Visual estimation of loss very inaccurate Weigh all packs and swabs.

Management DRS ABCD Immediate fundal massage Apply pressure to any perineal trauma Two large IV cannulas Commence IV fluids Insert urinary catheter Oxygen and Saturation monitor Consider blood transfusion Specific approach based on cause

Management – Tone Syntocinon IM 10 units 40 Units Syntocinon in 1L CSL at 250mls/hr Ergometrine 500microg IM OR 250microg IV And antiemetics!!! Avoid if retained products Avoid in preeclampsia or hypertension Syntometrine (Ergometrine and Oxytocin) 1ml IM followed by further 1ml 2hrs later Prostaglandin F2α 250mcg carboprost IM injection

Management – Tone 1000 mcg Misoprostol (3-4 tabs) rectally Onset of action 100mins Duration of action 4 hours Bi-manual uterine massage One hand into woman’s anterior fornix Other hand compressing uterus against fist Painful if conscious!

Management – Trauma Identify lacerations & apply pressure Particularly cervical tears Vaginal lacerations must be promptly sutured Use sponge forceps to work around cervix to check for tears Uterine inversion Rare but life-threatening Push centre of fundus with fingers until uterus reverts May require sedation/GA if cervix already contracted

Management – Tissue Failure to deliver placenta - 3% of deliveries If contracted uterus, likely low placenta Continuous cord traction and counter-traction If non-contracted uterus, likely non-separated placenta Manual removal of placenta required Under GA

Management – Thrombin Rare! Mostly identified prior to birth Should be considered after exclusion of other causes Should send of coagulation studies Treat the underlying disease Seek Haematology advice