Notes on PPH for step 2

Primary Postpartum Haemorrhage
Primary postpartum haemorrhage (PPH) is defined as loss of more than 500ml of blood from the genital tract within 24 hours of delivery¹

PPH can be described as minor or major depending upon the level of blood loss;
Minor PPH involves the loss of of anything up to 1000mls of blood
Major PPH involves the loss of more than 1000mls of blood
Causes
Causes of postpartum haemorrhage include uterine atony, trauma, retained placenta, and coagulopathy. These causes are often referred to as the “four Ts” Tone (uterine atony) Trauma (lacerations) Tissue (retained placenta) Thrombin (coagulopathy)2
Uterine atony

Uterine atony is the most common cause of PPH account for around 70% of cases.² It occurs due to the uterus losing its muscle tone. As a result it does not contract after delivery and therefore the uterine vessels are not clamped down on allowing large amounts of bleeding to occur. The uterus can become atonic for a number of reasons such as prolonged labour (the uterus tires out) or multiple birth (the uterus is large & stretched making it less effective at contracting)
Retained placenta

Retained placenta accounts for around 10% of cases of PPH.² It results from either all or part of the placenta been retained within the uterus. This prevents the uterus from contracting fully and therefore the uterine vessels are not occluded & continue to bleed.
Vaginal or Vulval Lacerations

Vulval & vaginal lacerations account for most of the other 20% of PPH cases.² They occur due to the mechanics of birth and can be very severe. They must be monitored for some time afterwards to ensure no infection develops and proper healing occurs.
Coagulopathy

Around 1% of PPH cases occur as a result of coagulapathy.² Common causes of coagulopathy include haemophilia A or B. It’s important to rule out coagulopathy as it can result in the death of a patient if not identified early.
Risk factors
Pregnancy factors³

Placenta praevia (15 x risk)
Multiple pregnancy (5 x risk)
Pre-eclampsia (4 x risk)
Previous PPH (3 x risk)
Nulliparity (first childbirth) (3 x risk)
Placental abruption

Delivery factors³

Emergency caesarian section (9 x risk)
Retained placenta (5 x risk)
Elective caesarian section (4 x risk)
Mediolateral Episiotomy
Prolonged labour (>12 hours)
Big baby (>4kg)

Maternal factors³

Obesity – BMI >35 (2 x risk)
Asian ethnicity
Haemophilia (type A or B)
Anaemia (<9g/dl)
Age > 40 years

Symptoms & Signs
Symptoms³

Prolonged & worsening vaginal bleeding after delivery
Passing many large clots
Lower abdominal pain
Pelvic pain
Light headedness / Fainting
Shortness of breath

Signs

Pale skin
Tachycardia
Tachypnea
Hypotension
Tender abdomen
Fever
Decreased consciousness

Investigations³
Vaginal examination – determine source of bleeding
Abdominal examination – tender abdomen suggests uterine bleeding
FBC – sudden drop in Hb suggests acute blood loss
Clotting – prolonged PT & APTT suggest disseminated intravascular coagulation
Blood pressure – low BP indicates blood loss
Pulse rate – usually tachycardia present due to hypovolaemic shock
Oxygen saturation – may be decreased to decreased red blood cells & Hb
Hourly urine output - if decreased suggests blood volume loss
ECG
Complications
Hypovolaemic Shock
HELLP – Haemolysis, Elevated Liver Enzymes, Low Platelets
Disseminated Intravascular Coagulation – due to consumption of clotting factors
Management ³
Minor PPH

If minor PPH with no clinical signs of shock;
Contact obstetric doctor
Get IV access with two 14 gauge cannula’s
Crystalloid infusion
Crossmatch 2 units of blood
BP, Pulse & Oxygen Saturation
FBC
Clotting
Regular clinical monitoring & observation

Major PPH

Contact senior clinical staff
Call Obstetric registrar & alert Consultant
Call Anaesthetic registrar & alert Consultant
Experienced Midwife
Alert consultant haematologist on call
Alert blood transfusion lab
Call porters to transfer specimens & blood products quick