Management of Obstetric Haemorrhage (Amalgamated With PPH) : Aternity Uidelines
Management of Obstetric Haemorrhage (Amalgamated With PPH) : Aternity Uidelines
Management of Obstetric Haemorrhage (Amalgamated With PPH) : Aternity Uidelines
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Contents
Antepartum Haemorrhage (APH) is defined as bleeding from the genital tract, occurring from
24 weeks of pregnancy and prior to the birth of the baby. Any bleeding prior to this gestation
is classed as a threatened miscarriage.
Common causes of APH include placenta praevia, placental abruption and local causes (e.g.
bleeding from the vulva, vagina or cervix). In some clinical cases a cause may not be
identified and may be described as an unexplained APH. Management will depend on the
severity of the bleed and the patient’s condition. A full antenatal check should be performed
and a doctor review undertaken by the appropriate seniority (dependant on clinical
picture/severity). A Kleihauer test should be performed in rhesus D (RhD) negative women to
quantify fetal maternal haemorrhage and determine the dose of anti-D immunoglobulin
required. Women with on-going bleeding, or loss greater than spotting, should remain in
hospital for observation.
All women with a single heavy APH (similar to a period) or lighter recurrent APHs should be
referred for serial growth scans and review in a consultant antenatal clinic.
.
N.B. Postpartum Haemorrhage (PPH) should be anticipated for women who have
experienced an APH in labour and an appropriate management plan put in place.
2. Postnatal Haemorrhage
Secondary PPH
Haemorrhage from the genital tract more than 24 hours after delivering and up to 6 weeks
post delivery
3. Risk Factors
4. Clinical Assessment
5. Management
The aim of management is to replace the circulatory volume with appropriate resuscitation
and arrest bleeding.
CALL FOR HELP-Pull the emergency buzzer and ask the first attendant to call 2222 and
state:
A- Assess the airway, consider 15 litres high flow oxygen via a non-rebreathe mask and
perform oxygen saturations.
B- Assess the respiratory rate.
C- Position the patient flat.
Perform a manual blood pressure and maternal pulse.
Insert two large bore cannulas and obtain:
-Full blood count
-Group and save (Cross match 4 units minimum)
-Coagulation screen, including fibrinogen (Blue top)
-Rotem (Another Blue top (for the anaesthetist to run a ROTEM test)
-Renal and Liver function for baseline
Keep the women warm using appropriate available measures.
Insert a Foley catheter with urometer to monitor urine output.
Infuse 2 litres of warmed isotonic crystalloid (Hartmann’s solution). Further fluid
resuscitation can continue as required.
Monitor pulse, blood pressure, respiratory rate and temperature every 15 minutes recording
of parameters on a modified early obstetric warning score (MEOWS) chart and COMMENCE
OBSTETRIC HAEMORRHAGE PROFORMA (Appendix 2).
Access to blood
2 units of emergency O Rh negative blood are available in the CDS blood fridge. If used
blood bank must be informed so that it can be replaced.
Further blood must be obtained via blood bank. When available it will be placed in the blood
fridge outside blood bank on level 6 (Appendix 1). Porters should be requested to transport
blood to appropriate area. If there is likely to be a delay in the availability of porters other staff
members may be utilised as appropriate, i.e. HCAs, MCAs, theatre staff. In this instance, the
access code for all the blood fridges is 1111.
Portering arrangements:
Office hour’s Maternity porter, bleep 0462
Out-of-hour’s via hospital portering services, ext. 52000
8. Rotem
Give the second blue top blood sample to the anaesthetist. They will run a
ROTEM test. This will provide important information regarding clotting and will
help guide management. They will inform the on call haematology consultant of
the result.
9. Arrest Bleeding
Antepartum Haemorrhage
Prepare for delivery. Be aware of the high risk of postpartum haemorrhage.
Postpartum Haemorrhage
Always consider the 4 T’s:
Tone
Tissue
Tears
Thrombus
If pharmacological measures fail to control the haemorrhage, surgical interventions and the
exclusion of retained products should be initiated sooner rather than later. This will require a
regional or general anaesthetic.
Intrauterine balloon tamponade (Bakri balloon) is an appropriate first line surgical intervention
for most women where uterine atony is the main cause of haemorrhage. A broad spectrum
intravenous antibiotic, such as co-amoxiclav 1.2g, should be given in theatre and continue for
the time the balloon is in place (usually 24 hours). Antibiotics can stop once the balloon has
been removed. However they may be continued at the discretion of the clinician responsible
for insertion and this should be documented in the notes.
Laparotomy to allow B-Lynch or modified B-Lynch (does not require the uterus to be
opened) suture insertion. There is a laminated card in theatre demonstrating the
technique.
Intraoperative cell salvage
Compression of the aorta
Arterial embolisation or insertion of internal iliac balloon catheters by an interventional
radiologist. Contact the on-call consultant radiologist via switchboard. The consultant
obstetrician, consultant anaesthetist and consultant radiologist will make a decision
about where treatment will take place.
Arterial ligation. Consider bilateral uterine artery ligation. Ureters should be identified
prior to ligation. Bilateral internal iliac artery ligation is best done by a vascular
surgeon.
Hysterectomy. Resort to hysterectomy sooner rather than later especially in cases of
accrete or rupture. Ideally a second consultant should be involved in the decision.
Consider transfer to ITU once the bleeding is controlled or the Enhanced Observation Room
on CDS.
12. The management and treatment of women refusing blood and blood
products
There must be a clearly documented plan of management for women who refuse blood and
blood products in the patient records. Jehovah’s Witness Trust paperwork and consent
should be used and treatments that are accepted should be clearly documented.
It is expected that every episode of care be recorded clearly, in chronological order and as
contemporaneously as possible by all healthcare professionals as per Hospital Trust Policy.
This is in keeping with standards set by professional colleges, i.e. NMC and RCOG.
All entries must have the date and time together with signature and printed name.
Record Keeping must include use of the Obstetric Haemorrhage Proforma (Appendix 2)
Management Time
Bakri Balloon Y N :
B-Lynch Suture Y N :
Hysterectomy Y N :
Vaginal Pack Y N :
1 2 3 4 5 6 7 8
Packed Red
Cells
Fresh Frozen
Plasma
Platelets
Cell Salvage Volume Time Volume Time
Type
Type
Type
Cross references
Guidelines can now be found on the network share (drive) ‘G:\DocumentLibrary\UHPT
Clinical Guidelines\Maternity’.
Maternity Hand Held Notes, Hospital Records and Record Keeping
References
RCOG Green-top Guideline No.52. Prevention and Management of postpartum
Haemorrhage. December 2016.
NICE Intrapartum care for healthy women and babies. Clinical guideline (CG190). December
2014. Last update: February 2017.
NICE Intraoperative cell salvage in obstetrics. Interventional procedures guideline (IPG 144)
November 2005.
Work Address Maternity Unit, Derriford Hospital, Plymouth, Devon, PL6 8DH
Version 8
Maternal observations, fibrinogen test
Recombinant activated factor VII removed
Bakri Balloon
Changes Obstetric Haemorrhage Proforma