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

2. 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

3. 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

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

5. 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

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

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

9. 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

10. 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

11. 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

12. Continuous Cord Traction

13. 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

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

16. 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

17. 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

18. 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!

19. 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

20. 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

21. 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