Postpartum haemorrhage (PPH) – prevention, assessment and management

• Document identified risk factors.
• Determine placental location at second trimester ultrasound (US).
• Identify and correct maternal anaemia and iron deficiency.
• Plan for active management of third stage for all women with identified risk factors.
• If a woman requests physiological third stage management, document a plan for indications for instigation of active management.
• Act promptly to manage slow progress in labour.
• Ensure oxytocics, IV fluid and equipment are checked, prepared and readily available.

Active management of third stage

Vaginal birth

• Active Management and use of prophylactic uterotonics in the third stage of labour reduces the risk of PPH.1,2,3
• See : third stage of labour in Labour and Birth eHandbook topic
• In settings where multiple uterotonics are available, Oxytocin 10 IU IM/IV is the recommended uterotonic agent for the prevention of PPH for ALL births.4

Note : The use of Carbetocin (100mcg MI/IV) is recommended for all births  (not just caesarean section) in contexts where its cost is comparable to other effective uterotonics.4 

Caesarean section - emergency and elective

• Consider the use of Carbetocin (Duratocin) 100 microg (1 ml) IV:
  • administer as a slow bolus, over one minute
  • must be given after delivery of the baby
  • can be given before or after delivery of the placenta.

• When risk factors are identified, document a plan for ongoing care.
• Most women having a PPH will have no identified risk factors.3 Remain alert.

Table 1. Risk factors for PPH

PPH is an obstetric emergency - SUMMON HELP IMMEDIATELY.

Primary PPH management flowchart

Causes

• Tone (70 per cent), atonic uterus, distended uterus, uterine muscle exhaustion
• Trauma (19 per cent), cervical, vaginal or perineum, pelvic haematoma, uterus
• Tissue (10 per cent), retained products of conception, invasive placenta
• Thrombin (1 per cent), blood clotting disorders, inherited or acquired including Disseminated intravascular coagulation (DIC).

Management

• Effective management of PPH requires the prompt recognition of the situation, escalation, effective communication, resuscitation, monitoring, investigation and direct treatment of the underlying cause. 
• Escalate and involve senior clinical assistance in a timely manner
• Ongoing assessment of blood loss is vital (accumulative total)
• Visual estimates of blood loss have been found to be inaccurate.1,5,6
• Weighing all blood loss is recommended as a good practice point when a PPH occurs (1ml of blood equals 1 gram). Note that weight alone is also subject to error as weighed amount may include liquor.  
• Also consider clinical signs and symptoms of hypovolemia, speed of blood flow, the woman’s prior haemoglobin. 
• Ensure bloods are collected for blood group, cross match and hold.

Documentation

• Assign a scribe to contemporaneously record events, document assessments, vital signs, medications given and response to management:
  • record on PPH chart, if available.
• Commence a Maternity Observation and Response Chart.
• Commence a Fluid Balance Chart.
• Document products given on blood administration form and fluid balance chart.
• Ensure doctors' orders are signed.

Fluid resuscitation

• Commence with a crystalloid (CSL or NaCl 0.9 per cent) at a ratio of three litres of fluid for every one litre of blood loss.
• Colloid may be a suitable alternative for the third litre.
• Prevent hypothermia:
  • warm fluids, if possible
  • warm blankets.
• Infuse fluids as quickly as possible, aided by a rapid infusion set or hand pump set.

Drugs

Table 2. PPH Drugs

* If not given as part of 3rd stage management **Consider transfer to the theatre after 1 dose of carboprost if bleeding has not resolved - Carboprost can be repeated at intervals of not less than 15 minutes to a maximum of 8 doses.

• Avoid giving Syntometrine/Ergometrine to women with a BP ≥140/90:
  • may be given judiciously in context of massive haemorrhage.
• WHO now strongly recommends use of IV tranexamic acid (within 3 hours of birth) in addition to standard care for women with clinically-diagnosed PPH following vaginal birth or caesarean section. Tranexamic acid should be used in all cases of PPH, regardless of whether the bleeding is thought to be due to genital tract trauma or other causes, including uterine atony.7
• Consider administering an antiemetic.
• Carboprost should be given with caution to women with a history of asthma, as it can induce bronchospasm.
• Consider loperamide (Gastrostop or equivalent) if giving CarboPROST, to minimise side effect of diarrhoea.

Escalation

• Ensure escalation of care to the senior clinical team when a woman has a PPH.
• Activate massive transfusion protocol (MTP) if:
  • the woman is receiving four units of packed red cells in less than four hours and is haemodynamically unstable
  • there are clinical or laboratory signs of coagulopathy.
• Access emergency O negative blood if required.
• Advise pathology department of likely blood requirements as soon as possible.
• If the woman's condition deteriorates, facilitate transfer to theatre:
  • for ongoing bleeding due to atonic uterus, bimanual compression may be required
  • for ongoing bleeding due to perineal trauma, apply pressure during transfer.
• In the event of transfer, consult with Senior Registrar or Consultant Obstetrician at the supporting hospital to inform them of the woman's condition, management and reason for transfer.
• Obtain verbal orders.
• Remember PIPER is always available to provide support and advice in PPH management:
  • phone 1300 137 650.

Observations

• Until blood loss is under control or woman is transferred to theatre:
  • five-minutely vital signs - conscious state, heart rate, blood pressure, respiratory rate, O2 saturation
  • uterine tone and blood loss
  • 15-minutely temperature.
• Document a running total of blood loss (accumulated).
• Record conscious state.
• Record urine output.

Ongoing management

• Repeat pathology half to one hourly until PPH has stabilised:
  • FBE
  • coagulation profile
  • venous gases.
• Advise laboratory of MTP stand down.
• Lack of routine observations in the postpartum period, failure to appreciate bleeding was occurring, lack of post operative measurements of pulse and blood pressure or recognition of vital signs such as oxygen saturation and respiratory rate, even when it was known that the mother sustained a large bleed have been shown to have contributed to maternal deaths.8

Management for specific causes of PPH

Table 3. Management for specific causes of PPH

• Antibiotics should be given while the balloon is in situ.
• Monitor for signs of increased loss in the catheter bag.
• Maximum indwell time (as per manufacturer instructions) is 24 hours.
• Return to theatre is not required for balloon removal.
• Balloon removal can be undertaken by trainee medical or midwifery staff under direction of senior obstetric staff.
• At the time of removal ensure any vaginal packs are also removed and this is documented in the inpatient progress notes.

Are you in ED? Notify the obstetric team as soon as possible.

Secondary PPH management flowchart

Definition

• Secondary PPH is defined as a blood loss of >500 ml after 24 hours and up to six weeks postpartum.
• The majority of secondary PPH are the result of sub-involution of the uterus secondary to uterine infection and/or retained products of conception.
• Other causes include:
  • pre-existing uterine disease (fibroids, cervical polyps)
  • trauma
  • coagulopathies.

Assessment

• Escalate and involve senior clinical assistance in a timely manner
• Initiate resuscitation if required.
• Assess blood loss (accumulative)
• If haemodynamically compromised, treat as for primary PPH.
• Consider IV antibiotics.
• Document:
  • obstetric history - review the health record for completeness of placenta and membranes 
  • vital signs - heart rate, blood pressure, respiratory rate, O2 saturation, temperature
  • uterine size and tenderness
  • pain/cramping
  • vaginal loss.

Investigations

• Consider:
  • group and hold (X-match if indicated)
  • FBE
  • CRP
  • serum BhCG
  • clotting profile
  • MSU if there are signs of infection
  • blood cultures if maternal temperature is >38 degrees
  • speculum examination with low vaginal swabs and high vaginal swabs
  • ultrasound/Doppler studies.

Treatment

• Management will depend largely on the woman's condition and haemodynamic status.
• If unstable:
  • administer uterotonics as for primary PPH
  • balloon tamponade and uterine packing may be indicated for continued haemorrhage.
• Surgical management options include:
  • EUA and curettage (exercise caution especially in suspicion of infection due to increased risk of perforation and Asherman’s syndrome)
  • Selective Pelvic Arterial Embolisation (SPAE)
  • ligation of internal iliac arteries
  • hysterectomy.

• Women exhibiting any signs of infection or retained products require antibiotics.
• Commence antibiotics within the first hour.

IV antibiotics - if febrile/septic

• Ampicillin (or amoxicillin) 2 g IV STAT, then 1 g every six hours

and

• Metronidazole 500 mg IV every 12 hours
• +/- Gentamicin 5 mg/kg IV daily.

Allergy to Penicillin

• Clindamycin or Lincomycin 900 mg IV every eight hours
• +/- Gentamicin 5 mg/kg IV daily.

Oral antibiotics - if afebrile but infection is suspected

• Augmentin Duo Forte (amoxicillin 875 mg/clavulanic acid 125 mg) every 12 hours, for seven days
• Metronidazole 400 mg every eight hours, for seven days.

Allergy to Penicillin

• Ciprofloxacin 500 mg every 12 hours, for seven days
• Metronidazole 400 mg every 12 hours, for seven days.

• When consenting a woman for 'examination under anaesthesia' the consent must include the possibility of hysterectomy in the event of intractable bleeding due to uterine atony.

Consider

• Prophylactic intravenous antibiotics
• Fluid management
• Accurate record of fluid balance
• Appropriate staffed area for stabilisation and recovery: birth suite, theatre recovery room, HDU/ICU, postnatal ward
• Frequency of vital signs and observation
• Appropriate thromboprophylaxis
• Debriefing staff
• Case review

Debriefing the woman, her partner and family is essential.

Audit and performance improvement

All maternity services should have processes in place for:

• auditing clinical practice and outcomes
• providing feedback to clinicians on audit results
• addressing risks, if identified
• implementing change, if indicated.

Auditable standards:

• women with risk factors with a documented management plan
• women with risk factors with appropriate IV access
• appropriate administration of uterotonics
• appropriate correction of maternal anaemia and/or iron deficiency.
• appropriate documentation of management of women who have had a PPH
• proportion of maternity clinicians who have undergone skills drills training in PPH.
   

For further information or assistance with auditing, please contact the Maternity and Newborn Clinical Network: maternityehandbook@safercare.vic.gov.au.

References

1. Mavrides E, Allard S, Chandraharan E, Collins P, Green L, Hunt B J, Riris S, Thomson A J on behalf of Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage. BJOG 2016, Green top guideline No. 52. Retrieved from DOI: .10.1111/1471-0528.14178

2. WHO recommendations for the prevention and treatment of Postpartum Haemorrhage. Geneva : World Health Organization; 2012 {Internet} (cited Oct 2019). 

3. The Royal Australian and New Zealand College of Obstetricians and Gynaecologoists. Management of Postpartum Haemorrhage (PPPH) guideline, C-Obs 43, RANZCOG. Amended February 2016.

4. WHO recommendations : uterotonics for the prevention of postpartum haemorrhage. Genevea: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO.

5.  Hancock A, Weeks A D & Lavender D T, Is accurate and reliable blood loss estimation the ‘crucial step’ in early detection if postpartum haemorrhage : an integrative review of the literature. BMC Pregnancy Childbirth, 15, 2015 
230. 10.1186/s12884-015-0653-6

6. Schorn M, Measurement of Blood Loss : review of the literature Vol 55 No 1, 2010 American College of Nurse-Midwives

7. WHO recommendations on tranexamic acid for the treatment of postpartum haemorrhage. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO {Internet} (Dec 2019)

8. Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, el at. Saving Mothers Lives : reviewing maternal deaths to make motherhood safer: 2006-2008. The eighth report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG. 2011; 118 Suppl 1:1-203. 
 

Additional reading

• Australian Red Cross Blood Service (2013).
• Attilakos et.al. (2010). Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double-blind randomised trial. BJOG, 117: 929–936. DOI: 10.1111/j.1471-0528.2010.02585.x
• Australian Government Department of Health, Therapeutic Goods Administration (2018). Australian Public Assessment Report for Carbetocin
• Bellad et.al. (2012) Prevention of postpartum haemorrhage with sublingual misoprostol or oxytocin: a double-blind randomised controlled trial. BJOG 2012;119:975-986. doi: 10.1111/j.1471-0528.2012.03341.x.
• De Bonis et.al. (2012). Carbetocin versus oxytocin after caesarean section: similar efficacy but reduced pain perception in women with high risk of postpartum haemorrhage. The Journal of Maternal-Fetal & Neonatal Medicine, 25:6, 732-735, DOI: 10.3109/14767058.2011.587920
• Elati, A., & Weeks, A. (2012) Risk of Fever After Misoprostol for the Prevention of Postpartum Hemorrhage: A Meta-Analysis. American College of Obstetricians and Gynecologists, 120(5), 1140-1148.
• Hofmeyr et.al. (2005) Misoprostol to treat postpartum haemorrhage: a systematic review BJOG: an International Journal of Obstetrics and Gynaecology, Vol. 112, 547-553.
• International Federation of Gynecology and Obstetrics (2012) Treatment of Post-Partum Haemorrhage with Misoprostol: FIGO Guideline in Brief.
• King Edward Memorial Hospital Guidelines (2016) Obstetric Emergencies - Post Partum Haemorrhage (PPH) Department of Health Western Australia.
• King Edward Memorial Hospital Guidelines (2016) Obstetric Emergencies - Secondary Post Partum Haemorrhage (PPH) Department of Health Western Australia.
• Larciprete et.al. (2013). Carbetocin versus oxytocin in caesarean section with high risk of post-partum haemorrhage. Journal of Prenatal Medicine, 7:1, 12-18.
• MIMs on line MIMS Class: Agents acting on the uterus, MIMS Australia 2013.
• MIMs on line. Ergometrine maleate Full Product Information. 11/02/2008 accessed 29/10/13.
• Monash Health (2018) Primary Postpartum Haemorrhage Procedure v10.0.
• Morris et.al. (2017) FIGO's updated recommendations for misoprostol used alone.
• in gynecology and obstetrics. Int J Gynecol Obstet; 138: 363-366. doi: 10.1002/ijgo.12181.
• National Blood Authority Australia, Patient Blood Management Guidelines: Module 1 Critical Bleeding/Massive Transfusion.
• Pfizer (2014). Product monograph - Hemabate® Sterile Solution (carboprost tromethamine injection USP).
• Quibel et.al. (2016) Active Management of the Third Stage of Labor With a Combination of Oxytocin and Misoprostol to Prevent Postpartum Hemorrhage: A Randomized Controlled Trial. American College of Obstetricians and Gynecologists, 128(4), 805-811.
• Razali et.al. (2016). Carbetocin compared to oxytocin in emergency cesarean section: a randomized trial. European Journal of Obstetrics & Gynecology and Reproductive Biology, 198, 35-39. DOI: 10.1016/j.ejogrb.2015.12.017
• Royal Women's Hospital (2013) Postpartum haemorrhage.
• South Australian Perinatal Practice Guidelines (2012) Secondary Postpartum haemorrhage.
• Su  LL, Chong  YS, Samuel  M. (2012). Carbetocin for preventing postpartum haemorrhage. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD005457. DOI: 10.1002/14651858.CD005457.pub4.
• The Royal Women’s Hospital (2017). Postpartum Haemorrhage – Carboprost.
• Weeks, A. (2014) The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next? BJOG, 122, 202-212. doi: 10.1111/1471-0528.13098.
• WHO (2012) Prevention and Treatment of PPH. World Health Organization. Geneva: Switzerland.
• WOMAN Trial Collaborators (2017) The effects of early tranexamic acid administration on mortality, hysterectomy and other morbidities in women with PPH (WOMAN). The Lancet.