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INTRODUCTION
Haemorrhage is the third commonest cause of direct maternal death (CEMACE 2007). Obstetric haemorrhage can quickly become life-threatening

G Excessive blood loss at or after delivery of fetus (see above for volumes) in first 24 hr. Affects approximately 5% of all deliveries in the UK

Primary postpartum haemorrhage

G Normal blood volume from 13/40 is approximately 100 mL/kg G Acceptable blood loss at vaginal delivery is 500 mL G Acceptable blood loss at caesarean section is 1000 mL

RECOGNITION AND ASSESSMENT

G Excessive blood loss from genital tract >24 hr after birth and within 12 weeks of delivery

Secondary postpartum haemorrhage

Blood Loss
Table 1: Classification of haemorrhage Use as a guide always treat symptomatic women regardless of blood loss Class Volume loss Clinical signs 1 <15% Minimal mild tachycardia G Normal BP unchanged pulse pressure , G Normal respiratory rate G Normal urine output 2 1530% Moderate tachycardia (110130 bpm) G Normal or slightly decreased BP (diastolic pressure , increasing) G Moderate increase in respiratory rate G Decreased urine output G Subtle CNS/mental changes (e.g. anxiety) Significant marked tachycardia (120160 bpm) 3 3040% G Decreased systolic BP G Marked increase in respiratory rate G Marked decrease in urine output G Obvious CNS/mental changes (e.g. drowsiness) G Cold, clammy skin Severe/life-threatening 4 >40% G Marked tachycardia G Systolic BP <80 mmHg G Absent peripheral pulses G Severe oliguria or anuria G Marked increase in respiratory rate G Obvious CNS/mental changes (e.g. confusion or unconsciousness) G Cold, clammy skin

Blood loss >20% must be treated

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PREVENTION
Table 2: Risk factors Antepartum Intrapartum Prolonged third stage Augmented labour Assisted delivery Episiotomy Caesarean section Shoulder dystocia Big baby

G Hypertensive diseases in pregnancy G Multiple pregnancy G Previous PPH G Previous caesarean section G Antepartum haemorrhage G Obesity G Age >40 yr G Anaemia

G G G G G G G

Table 3: Cause of haemorrhage (the four Ts) G Atonic uterus G Cervical, vaginal or perineal lacerations G Pelvic haematoma G Inverted uterus G Uterine rupture C Tissue G Retained tissue G Invasive placenta (accreta) D Thrombin G Coagulopathies A Tone B Trauma 4 Ts Specific cause Relative frequency 70% 20%

10% 1%

G Women at increased risk of bleeding, active management of third stage advised G Give syntometrine (ergometrine and oxytocin) 1 mL IM in third stage G For hypertensive woman or those whose blood pressure has not been checked before delivery, give 5 or 10 units oxytocin IM or slow IV bolus

Prevention is better than cure follow the following principles

G Summon help senior obstetrician, anaesthetist, senior midwife and ancillary staff if necessary G Consider: G A AIRWAY check airway not compromised G B BREATHING oxygenate with 15 L/min O2 via face mask
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IMMEDIATE MANAGEMENT (ALL PPH)

G C CIRCULATION obtain venous access insert large bore 14 or 16 gauge cannula and take bloods for FBC, clotting screen, Group & save and crossmatch if required (see Major haemorrhage below) G Palpate uterus for atony and commence fundal massage. Consider bimanual compression G Empty bladder to assist with uterine contraction G Commence oxytocin infusion use local regimen for postpartum G Monitor pulse and blood pressure every 15 min initially

G Classification 2,3,4 (see table 1) G Simultaneously perform resuscitation, monitoring, arresting bleeding and communication

MAJOR OBSTETRIC HAEMORRHAGE >1500 ML

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In first instance follow management as above
G 15 L/min oxygen via face mask initially, with woman lying flat G Attach non-invasive blood pressure (NIBP) cuff G Monitor and record hourly on HDU chart: G BP G pulse G SpO2 (maintain at >95%) G respiratory rate G urine output G core temperature G Insert with hourly urimeter attached and maintain urine output >0.5 mL/kg/hr G Consultant obstetrician (who will usually attend as soon as possible) G Consultant anaesthetist (expected to attend if woman going to theatre) G Theatre team (even if not immediately going to theatre) G Haematologist (especially if haemorrhage >40 mL/kg or uncontrolled) G Haematology biomedical scientist to allow them to prepare for major haemorrhage G Consider involving surgical colleagues as required G For causes of haemorrhage (4 Ts) including surgery see Tone (uterine atony), Trauma, Tissue and Thrombin below G commonest cause is uterine atony G If surgery to be carried out for major PPH, it is usual to obtain consent for hysterectomy G Involve consultant with greater gynaecological surgical experience in complex cases. Consider contacting interventional radiologist
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Oxygen

G Estimate blood loss by direct observation of overt blood loss AND clinical signs of intra-abdominal blood loss G Summon help: G obstetric registrar G anaesthetist (resident registrar or staff grade) G senior midwives (e.g. midwife coordinator and another experienced midwife) G other personnel (e.g. porter/auxiliary/HCA to run errands etc) G Take blood for: G FBC G APTT G PT (INR) G crossmatch (at least 4 units of packed red cells. Consider requesting type specific blood in a dire emergency. Consider requesting FFP) G U&E, creatinine and Kleihauer and cannulate, (insert two 16 or 14 gauge venous cannulae one in each arm) G Give fluids one litre compound sodium lactate (Hartmanns) solution stat G Follow with blood, colloid or crystalloid as indicated by availability, blood loss and womans haemodynamic state G Do not give more than 3.5 L clear fluids [up to 2 L compound sodium lactate (Hartmanns) solution and 1.5 L colloid] while waiting for blood G Prepare blood/fluid warmer(s) to use as soon as possible especially for blood products. Keep woman warm

Monitoring

Bloods

Urinary catheter

Inform

Fluids

Specific treatment

Blood/fluid warmer

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G FBC G APTT G PT (INR) G Ca2+, Fibrinogen +/- blood gases G State of haemorrhage and womans physiological state after initial resuscitation Table 4: Blood product replacement Blood product Haemoglobin Indication Give fully crossmatched blood if possible. If insufficient time, give type specific and, only as an absolute necessity, give O negative blood Avoid dilutional coagulopathy by early and adequate use of FFP (and other blood products as required) Give when count <50 x 109/L or significant ongoing bleeding with a count of <75 x 109/L or on consultant haematologist advice Give if fibrinogen levels <100 mg/L and on consultant haematologist advice Give only on consultant haematologist advice 90 microgram/kg repeated 2-hrly if necessary If recommended by consultant haematologist

Repeat blood tests

Central venous and arterial lines

G If continuing haemorrhage (or haemorrhage >40 mL/kg) or need to go to theatre for second time, insert CVC and arterial lines (and monitor CVP and BP directly) G Use early if cardiovascular system compromised by disease

Reassess

Fresh frozen plasma (FFP) Platelets

Cryoprecipitate Recombinant factor Vlla Tranexamic acid IV

G Suspect if massive (>10 units blood) transfusion with ongoing hypotension, check Ca2+. Give 1020 mL calcium gluconate 10% by slow IV infusion. Ensure ECG monitoring when administering calcium gluconate

Hypocalcaemia

Post event
G Unless advised to be inappropriate by consultant obstetrician/anaesthetist, thromboprophylaxis is required regardless of mode of delivery once bleeding has settled G These women are at increased risk of thromboembolism, consider antiembolic stockings and other methods of mechanical thromboprophylaxis whilst being nursed in HDU, and give low molecular weight heparin

Thromboprophylaxis

G Within a reasonably short time period, consultant obstetrician should counsel woman and her family providing explanation and significance of cause of haemorrhage G Ideally midwife should remain with woman and family throughout the emergency situation

Support for woman and family

G Contraindicated for at least 12 hr after haemorrhage has settled and platelet count normal 103

Non steroidal antiinflammatory drugs

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Documentation
G Ensure documentation completed with times, names etc G If bleeding still not controlled, consider uterine cavity balloon tamponade, haemostatic brace suture, hysterectomy, uterine artery ligation/embolisation by an interventional radiologist etc G A consultant obstetrician must be involved G A second consultant opinion before hysterectomy can be helpful but hysterectomy should be performed sooner rather than later

A TONE (UTERINE ATONY) Immediate management

G Fundal massage, empty bladder and consider bimanual uterine massage

G Oxytocin start oxytocin infusion. Use local regimen for postpartum via volumetric pump G Remember to inspect vulva, vagina and cervix for trauma/lacerations G Consider a first or repeat dose of oxytocin 5 or 10 units by slow IV bolus IM, ergometrine 250 microgram IM with an antiemetic [contraindicated in pregnancy induced hypertension (PIH) or other significant cardiovascular disease], misoprostol 1000 microgram PR or 250 microgram carboprost (methyl prostaglandin F2 Hemabate) IM or intramyometrially (may be repeated up to every 15 min to a maximum of 2 mg)

B TRAUMA Inverted uterus

G Degree of haemodynamic shock is often disproportionate to the volume of the haemorrhage

G Replace uterus as soon as possible using manual, hydrostatic or surgical methods G Anticipate massive haemorrhage G Some women may experience a vasovagal episode (hypotension and bradycardia) during uterine replacement

Continuing bleeding
G If above measures fail to prevent ongoing or recurrent bleeding, suspect Trauma, Tissue (e.g. retained products of conception) or Thrombin (e.g. a coagulopathy)

G Run an oxytocin drip 40 units in 500 mL of sodium chloride 0.9% at 125 mL/hr through a pump for at least 4 hr after replacement

Uterine rupture
G See Uterine rupture guideline

G Consider surgical examination under anaesthesia G if woman haemodynamically stable, use pre-existent regional (epidural) anaesthesia G if woman not stable or (dilutional) coagulopathy present, use general anaesthesia

Perineal trauma
G See Third and fourth degree perineal tears guideline

Other
G Broad ligament haematoma G Extra genital bleeding e.g. sub capsular liver rupture

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C TISSUE Retained placenta
G See Retained placenta guideline

Acquired coagulopathies
G Will often represent a form of disseminated intravascular coagulation (DIC) and will usually result in continuing or worsening haemorrhage without blood product replacement therapy G Suspect DIC in abruption, severe PIH, prolonged +/- infected retained fetus/products of conception, amniotic fluid embolism or prolonged/untreated hypovolaemic shock

Risk factors
G Previous retained placenta G Caesarean section G Placenta praevia G D&C

G High parity or maternal age

G Once retained placenta diagnosed, inform anaesthetist

G Give prophylactic antibiotics follow local policy

G FBC, PT, INR, APTT, and APTTR in the first instance in all those conditions where there is a known associated complication of DIC G If platelet count <50 x 109/L or INR >1.6, check fibrinogen and fibrinogen degradation products (FDP) levels G Seek advice of a consultant haematologist about treatment and further investigations

Placenta accreta/increta/percreta
G Once attempts made to separate adherent placenta (surgically/forcibly), expect massive haemorrhage G If expected or happens, follow management plan for major obstetric haemorrhage

G Give platelets, FFP +/- cryoprecipitate as directed by investigations

D THROMBIN Inherited coagulopathies

G Several inherited conditions will give rise to excessive peripartum haemorrhage if incorrectly managed and not detected antenatally. Seek advice from consultant haematologist at earliest opportunity (ideally antenatally) about the investigation and treatment of these varied and uncommon conditions

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