1. Post-Partum Haemorrhage
250mL per slide

2. Overview Incidence Risk factors Causes Medical Management
Surgical Management
Use of blood products/MTP

3. Post-Partum Haemorrhage
≥500mL vaginal birth
≥1000mL caesarean section
Major cause of maternal morbidity and mortality
5% of births in Australia affected by significant post-partum haemorhage (>1000mL)

4. Antenatal Risks: Screen and Address!
antepartum haemorrhage (especially placental abruption and placenta praevia)
PPH with a previous pregnancy
known abnormal placental adherence (e.g. accreta, increta or percreta)
multiple pregnancy (e.g. twins and higher order multiples)
disorders of haemostasis/inherited bleeding disorders
grand multiparity
pre-eclampsiamacrosomia
maternal obesity
elective or previous caesarean section
Hb <9g/dL
Persons refusing blood products

5. Prevention - Anaemia Decreases ability to cope with PPH Treat anaemia
Hb <10.5 in pregnancy
Increased plasma volume expansion relative to red cell mass, therefore physiological dilution with Hb decrease
2-3x iron requirements during pregnancy
Increased MCV indicates folate deficiency as opposed to iron deficiency anaemia

6. Risks during labour and birth
Use of oxytocics in labour
Prolonged labour
Pyrexia
Instrumental and surgical delivery
Episiotomy
Placental retention
Physiological third stage
Active third stage management reduces PPH risk by 60%

7. Primary PPH
Tone ≈70%
Trauma ≈20%
Tissue ≈10%
Thrombin ≈1%

8. Secondary PPH From 24 hours post birth to 12 weeks
Abnormalities of placentation
Infection
Pre-existing uterine disease
Trauma
Disorders of haemostasis
The majority of cases of secondary postpartum haemorrhage are due to inadequate involution of the uterus caused by uterine infection and/or retained placental tissue

9. Recognition Blood Loss Pulse BP Signs 10-15% Increased Normal
Postural hypotension
15-30%
Increased +
Peripheral vasoconstriction
30-40%
Increased ++
70-80mmHg
Pallor, oligouria, confusion
>40%
Increased +++
<60mmHg
Dyspnoea, collapse, anuria

10. H: Ask for HELP and Hands on the uterus (uterine massage)
HAEMOSTASIS
H: Ask for HELP and Hands on the uterus (uterine massage)
A: Assess and resuscitate (vital signs, IV fluids, blood and blood products)
E: Establish aetiology, ensure availability of blood and ecbolics (oxytocin)
M: Massage uterus
O: Oxytocics – Oxytocin infusion/prostaglandins– IV/per rectal/IM/intramyometrial
S: Shift to theatre – bimanual compression/anti-shock garment
T: Tissue and Trauma (exclude/manage)/proceed to Tamponade balloon/uterine
packing
A: Apply compression sutures – B-Lynch/modified compression sutures (2–5)
S: Systematic pelvic devascularization – uterine/ovarian/quadruple/internal iliac
I: Interventional radiology (and if appropriate, uterine artery embolization)
S: Subtotal/total abdominal hysterectomy
Best Practice & Research Clinical Obstetrics and GynaecologyVol. 22, No. 6, pp. 1089–1102, 2008

11. COPIOUS Call for help O2 Position head down IV access, fluids, bloods
O-Negative blood
Uterine massage, Urinary Catheter
Syntocinon/ergometrine

12. Tone (Atony) Overdistension of the uterus Uterine infection
Pharmacological agents
Uterine inertia after a prolonged or induced labour
Uterine inversion
Fibroids
Full bladder
Retained placenta or retained blood clot
Hypovolaemia and shock

13. Atony Tone Rub up contractions Bimanual compression Medication
Ergometrine 500 microg IV/IM *HTN, headaches, nausea
10 units syntocinon IV
Syntocinon infusion 40 units/4 hours
800microg misoprostol PR
(Carboprost 250microg IM, NEVER IV)
Aortic Compression

14. Trauma Tissue Systematic check of cervix, vaginal vault and perineum
Repair tears
Tissue
Ensure adequate checking of placenta and membranes
Be wary of placenta accreta

15. Thrombin Coagulopathies Preeclampsia/PIH HELLP syndrome
Amniotic fluid embolism
Sepsis
Bleeding disorders
Drugs (aspirin, heparin)
FDIU

16. DIC Occurs earlier in PPH than other massive haemorrhage situations
Widespread activation of clotting cascade leads to thrombosis and consumption of coagulation factors
Results in depletion of coagulation factors and platelets
Highlights the need for Cryoprecipitate in obstetric haemorrhage

17. Fluid Resuscitation & Blood Products
Up to 3L warm crystalloid
Early consideration of blood products
2 units PRCs
2 units PRCs, 2 units FFP
10 units (2.5g) Cryoprecipitate (higher concentration of fibrinogen)
Consider platelets if levels<50
Consider 1g tranexamic acid loading dose the g infusion over 8/24

18. Massive Transfusion Protocol
Consultant to contact blood bank directly
MTP Pack
2 Units PRCs (O-negative from theatre)
2 Units PRCs (crossmatched)
10 Units Cryoprecipitate
4 Unit Platelets (pooled)
Monitor FBE, UEC, CMP Coags, blood gas every hour

19. Surgical Management Intrauterine balloon tamponade B-Lynch Suture
Appropriate first line management in theatre
‘Tamponade Test’ to assess for laparotomy
If tamponade effective, remote need for laparotomy
If ineffective, further surgical management likely
B-Lynch Suture
Uterine artery/Internal iliac ligation
Subtotal/Total Hysterectomy
Embolisation

22. Blood flow to pregnant term uterus 500-800mL min

24. Key Problem Areas (PROMPT)
Failure to make a clear diagnosis of PPH
Delay in commencing fluid resuscitation
Delay in decision to transfer to theatre
Uncertainty in estimating blood loss
Uncertainty in how to access blood products rapidly