Management Of Primary Postpartum Haemorrhage

Management of Primary Postpartum Haemorrhage By Dr Dambo Obstetrics & Gynaecology Dept

Introduction • Postpartum haemorrhage (PPH) remains an important complication of childbirth and contributes significantly to maternal mortality. • All women who carry a pregnancy beyond 28 weeks’ gestation are at risk for PPH and its sequelae. • Maternal mortality rates have declined greatly in the developed world, PPH remains a leading cause of maternal mortality in developing countries

Management • Involves History taking Clinical examination Investigations Treatment But all are done simultaneously

Components of Management • Once PPH has been identified, management may be considered to involve four components - all of which must be undertaken simultaneously: • Communication • Resuscitation • Monitoring and Investigation • Arresting the Bleeding

Communication • BASIC MEASURES (minor PPH, blood loss 500 - 1000ml, no clinical shock) – Alert senior midwife – Alert first-line medical staff • FULL PROTOCOL (major PPH, blood loss >1000ml OR clinical shock) • Call experienced midwife • Call Obstetric Registrar and alert Consultant • Call Anaesthetic Registrar and alert Consultant • Alert haematologist on call • Alert blood transfusion service • Call porters for delivery of specimens/blood

Resuscitation • BASIC MEASURES (minor PPH, blood loss 500 - 1000ml, no clinical shock) • IV access (14 G cannula x 1) • Commence crystalloid (eg Hartmann’s or Normal Saline) infusion

Resuscitation cont • • • • •

FULL (major PROTOCOL PPH, blood loss >1000ml OR clinical shock) IV access (14 G cannula x 2) head down tilt oxygen by mask at 8 litres / min Transfuse blood – Until blood available, infuse in turn (as rapidly as required): • crystalloid (eg Hartmann’s) maximum 2 litres • colloid (eg Gelofusine, Haemaccel, human albumin 4.5%) maximum 1.5 litres – If X-matched blood still unavailable once 3.5 litres of crystalloid/colloid infused: • GIVE ‘O’ NEG BLOOD OR • GIVE Un X-matched, own group blood as available • If bleeding is unrelenting and results of coagulation studies are still unavailable: – Give 1 litre Fresh Frozen Plasma – Give 10 units cryoprecipitate empirically • Use the best equipment available to achieve RAPID WARMED infusion of fluids • Do not use special blood filters: they slow infusions • Dextrans are hazardous and should not be used in obstetric practice.

Monitoring and Investigation • BASIC MEASURES (minor PPH, blood loss 500 - 1000ml, no clinical shock) • Venepuncture (20ml) for: – X-match (2 units) – Full blood count – Clotting screen

• Frequent pulse and blood pressure recording • Foley catheter to monitor urine output

Monitoring and Investigation contd • FULL PROTOCOL (major PPH, blood loss >1000ml OR clinical shock) • Venepuncture (20ml) for: – X-match (6 units) – Full blood count – Clotting screen

• Continuous pulse and blood pressure recording (using oximeter, ECG and automated BP recording) • Foley catheter to monitor urine output • Central venous pressure monitoring (once appropriately experienced staff available for insertion) • Consider transfer to intensive therapy unit

Arresting the Bleeding • The commonest cause of primary PPH is uterine atony. However, clinical examination must be undertaken to exclude other causes: • Retained products (placenta, membranes, clots) • Vaginal/cervical lacerations or haematoma • Ruptured uterus • Broad ligament haematoma • Extragenital bleeding

Arresting the Bleeding contd • When uterine atony is perceived to be the cause of the bleeding, the following measures should be instituted, in turn, until the bleeding stops: – – – – – –

"Rub up the fundus" to stimulate contractions Ensure bladder is empty (Foley catheter, leave in-situ) Syntocinon 10 units by slow IV injection Ergometrine 0.5mg by slow IV injection Syntocinon infusion (30 units in 500ml Hartmann’s at 125ml/hr) Carboprost (Haemabate) 0.25mg IM (repeated at intervals of not less than 15 minutes to a – maximum of 5 doses)

• Examine placenta for completeness – if not explore the uterus to remove fragments • Bimanual compression is a temporary measure

Arresting the Bleeding contd • Uterine packing – with gauze or balloon tamponade – Sengstaken Blakemore tube or foleys catheter. • Prostaglandin options: i.m or into the uterine muscle – 15-Methyl PGF2a (0.5-1.0mg) (Haemabate, Carboprost). Misoprostol tabs. • If bleeding from cervical, vaginal lacerations or episotomy wound :repair. • Arterial embolization – if units have the resources or experience • Application of a military antishock trousers (MAST) Suit.

Arresting the Bleeding contd • If conservative measures fail to control haemorrhage, initiate surgical haemostasis SOONER RATHER THAN LATER – At laparotomy, direct intramyometrial injection of Carboprost (Haemabate) 0.5mg – B-Lynch brace suture. – Bilateral ligation of uterine arteries – Bilateral ligation of internal iliac (hypogastric arteries) – Hysterectomy – Resort to hysterectomy SOONER RATHER THAN LATER (especially in cases of placenta accreta or uterine rupture)

Complications • • • • • • • • •

Anaemia Hypovolaemic shock Adult respiratory distress syndrome Pulmonary oedema Acute Renal Failure Hypopituitarism (sheehan`s syndrome) Uterine synechiae Sepsis. Death

Prevention Management for women at risk • Intravenous access •

Save serum for rapid cross-match if needed or actually cross-match 2 units

• Active management of the 3rd stage of labour - uterotonic administration (preferably oxytocin) immediately upon delivery of the anterior shoulder of the baby - early cord clamping and cutting - gentle cord traction with uterine countertraction when the uterus is well contracted (ie, Brandt-Andrews maneuver).

Conclusion • PPH is a common complication of childbirth and a leading cause of maternal morbidity and mortality. Clinicians should identify risk factors before and during labor so that care may be optimized for high-risk women. However, significant life-threatening bleeding can occur in the absence of risk factors and without warning. All caregivers and facilities involved in maternity care must have a clear plan for the prevention and management of PPH. This includes sound resuscitation skills and familiarity with all medical and surgical therapies available.