Post-Partum Haemorrhage

Introduction

Post-partum haemorrhage may be primary or secondary.
Primary postpartum haemorrhage refers to bleeding of more than 500 ml from the genital tract within the first twenty-four hours of delivery or any amount of blood loss that result in haemodynamic compromise of the patient.
It usually occurs during or immediately after the third stage of labour.
Secondary post-partum haemorrhage is defined as excessive vaginal bleeding occurring from twenty-four hours to six weeks after delivery.
The bleeding may occur with the placenta retained or after its expulsion from the uterus.
Postpartum haemorrhage becomes life threatening if the mother is already anaemic.
Blood loss of more than 500 ml may lead to shock.

Causes of post-partum haemorrhage

  1. The following are the causes of post-partum haemorrhage
  2. Uterine atony (70-90% of cases)
  3. Retention of all or part of placental tissue within the uterine cavity
  4. Infection within the uterine cavity (endo-myometritis)
  5. Genital tract trauma
  6. Clotting disorders

Symptoms of post-partum haemorrhage

The symptoms of post-partum haemorrhage are:

  1. Excessive or prolonged vaginal bleeding after delivery
  2. Lower abdominal pains

Signs of post-partum haemorrhage

The following are the signs of post-partum haemorrhage

  1. Active bleeding from the genital tract
  2. Conjunctival pallor
  3. Rapid pulse
  4. Blood pressure may be low or normal
  5. Deterioration of maternal levels of consciousness
  6. Flabby poorly contracted uterus
  7. Obvious tears in birth canal and/or perineum
  8. Obvious retained placenta
  9. Suprapubic tenderness

Investigations

  • FBC, sickling status
  • Bedside clotting test
  • Blood grouping and cross-matching
  • Ultrasound scan (if patient is stable to check for retained placenta tissue)

Treatment for post-partum haemorrhage

Treatment objectives

  1. To identify the cause and stop bleeding as quickly as possible
  2. To correct hypotension
  3. To correct resulting anaemia

Non-pharmacological treatment

Due to uterine atony (70-90% of cases), with no placental retention

  • Massage fundus of uterus to stimulate contraction
  • Encourage woman to empty bladder or pass a urethral catheter to empty the bladder and monitor urine output
  • Bimanual compression of the uterus and balloon tamponade if uterus fails to contract with massage

Due to retained placenta

  • Attempt removal of the placenta by controlled cord traction as soon as a contraction is felt. If not successful await the next contraction and repeat the procedure:
  • If the placenta cannot be expelled in this fashion, manual removal under anaesthesia is indicated
  • If the placenta has been delivered and is incomplete, exploration the uterus and manual removal under anaesthesia is indicated
  • If the facilities for manual removal of placenta under anaesthesia are not immediately available refer to hospital

Bleeding with uterus well contracted and placenta completely delivered

  • Examine the patient in the lithotomy position with adequate analgesia and/or anaesthesia, good lighting to identify and suture perineal, vaginal and cervical tears
  • If the tear(s) extends into the uterine body, effective suturing cannot be performed and repair will involve a laparotomy
  • For ruptured uterus, repair or hysterectomy is required

Bleeding associated with coagulopathy

  • Bedside clotting test – 5 ml of blood placed in a 10 ml round bottomed glass tube should clot in 6 minutes

Pharmacological treatment

A. If the uterus is poorly contracted (Atony)

1st Line Treatment
Evidence Rating: [A]
Oxytocin, IM, 10 units stat..
Then
Oxytocin, IV, infusion, 10-40 units in 500 ml Dextrose saline or 0.9% or Normal saline
Note

Dose not to exceed 40 units
If intravenous oxytocin is unavailable, or if the bleeding does not respond to oxytocin, the following second line drugs are recommended.

2nd Line Treatment
Evidence Rating: [B]
Misoprostol, sublingual, 600 microgram (for PPH prophylaxis within 1 minute of delivery).
Misoprostol, sublingual, 800 microgram stat if patient is conscious (for PPH treatment)

Or

3rd Line Treatment
Evidence Rating: [B]
Ergometrine, IV,

  • 500 microgram stat.

Or

Evidence Rating: [B]
Oxytocin-ergometrine, IM,

  • (Oxytocin 10 units and Ergometrine 500 microgram) stat.

Or

Evidence Rating: [B]
Oxytocin-misoprostol,

  • (Oxytocin, IV, 10 units and Misoprostol, rectal, 600 micrograms) stat.

Note

High rates of adverse effects (nausea, vomiting, and high blood pressure) occur in women treated with ergometrine.
They should not be given to women with hypertension in pregnancy or heart disease.

B. Protracted bleeding uncontrolled by Oxytocin and other Uterotonics or if bleeding is due partly to trauma

Evidence Rating: [B]
Tranexamic Acid, slow IV (not to exceed 100 mg per minute),

  • 1 g stat.

Then

  • 1 g 8 hourly (Maximum 3 g in 24 hours)

C. Hypovolaemia

Sodium Chloride 0.9% or Ringers lactate, IV, and blood transfusion as clinically indicated (See ‘Shock’)

D. Anaesthesia for manual removal of placenta

Morphine, IV,

  • 2.5 – 5 mg stat. as required (if no anaesthetist is available)

Or

Pethidine, IV slowly or IM,

  • 1 mg/kg 6-8 hourly as required (max. 100 mg per dose)

And

Diazepam, slow IV,

  • 5-10 mg 8 hourly as required (NOT more than 2.5 mg per minute)

Note

Do not mix pethidine and diazepam in the same syringe.
Monitor respiratory rate of patient closely.
Stop drugs if respiratory rate is less than 12 per minute.

Or

Ketamine, IM,

  • 5-10 mg/kg stat.

Or

Ketamine, IV,

  • 0.5-2 mg/kg stat.

Note

Ketamine must be used only by trained Medical Officer/anaesthetist.
Provide antibiotics prophylaxis after manual removal of placenta or exploration of uterus or repair of birth canal tears.

E. Secondary Postpartum Haemorrhage

Oxytocin, IV infusion, 20 units in 1 L of Normal Saline

Or

Ergometrine, oral,

  • 500 microgram 8 hourly for 3 days

F. Antibiotic prophylaxis

Amoxycillin, oral,

  • 500 mg 8 hourly for 7 days

And

Metronidazole, oral,

  • 400 mg 8 hourly for 7 days

Referral Criteria

Refer patients who do not respond to the treatments above to a specialist.
Also refer promptly to a hospital with theatre and blood transfusion facilities for examination under anaesthesia and/or laparotomy if these are not immediately available.