Post Partum Haemorrhage - A Summary of Management

1. Post Partum Haemorrhage Adam Collins

2. Post Partum Haemorrhage WHO All post partum blood losses over 500ml However it is widely recognised that in 1 st world countries women can cope easily with blood loss of this magnitude and 1000mls is a more appropriate figure RCOG: Primary PPH involving an estimated blood loss of 500–1000 ml (and in the absence of clinical signs of shock ) should prompt basic measures If a woman with primary PPH is continuing to bleed after an estimated blood loss of 1000 ml, this should prompt a full protocol of measures to achieve resuscitation and haemostasis .

3. Causes Tone (~80%) Failure of the uterus to contract will prolong bleeding Infection, retained products etc. will contribute Trauma (~20%) Tissue damage sustained during delivery (vulval or vaginal lac) Tissue Retention of products (foetus, placenta, membranes) Thrombin (a few…) Coagulopathies increase the risk and severity of PPH 2/3 PPHs have no identifiable cause or risk factors

4. Risks (Significant Antenatal Risks) Serious Risks Tone Known Placenta Praevia (12x) Multiple Pregnancy ( 5x ) Thrombin Known or Suspected Placental Abruption (13x) Pre- Ecclampsia (4x) Gestational Diabetes (4x) Women with these risks should be managed in CLU

5. Risks (Other Antenatal Risks) Moderate Risks Tone Previous PPH (3x) Asian Ethnicity (2x) BMI >35 (2x) Anaemia ( Hb <9g/ dL ) (2x) These women should consider management in CLU when labour plans are discussed

6. Risks (Labour & Delivery) Factors arising during labour and delivery Tone Age – Primagravida >40yo (1.5x ) Birth Weight >4kg (2x) (also Trauma) Trauma Mediolateral Episiotomy (5x) Emergency C Section (4x) Elective C Section (2x ) Tissue Retained Products (5x ) Thrombin Pyrexia in Labour (2x ) Induction of Labour (2x )

7. Prevention Active Management of 3 rd Stage of Labour Administration of syntocin 5-10iu IM reduces risk by ~60% Location of Placenta Location of placenta should be identified by antenatal USS Especially in women with previous C Section

8. Management 500-1000 mls Alert senior clinical staff (Sister Midwife, Anaesthetics team, Obstetric team) >1000 mls or Clinical Shock Request immediate help (2222 Obstetric Emergency) Activate Major Haemorrhage Protocol Lothian: 2222, Inform MHP, Location and Planned moves, Products required, Your Contact, Clinical and Patient Info, This is why we G&S and 16G Cannulate obstetric patients

9. Management A irway & B reathing Obtain and maintain airway and provide high flow O 2 C irculation Establish good access and take U&Es, FBC, Coag, G&S B egin fluids: 2L warmed Hartmann‘s O- neg or Xmatched blood (FFP 4u : 6u PRC) Coagulation aids as necessary from Coag screen Aim for Hb > 8g/dl, Plts > 75 x 10 9 /l, PTT < 1.5 APTT < 1.5 fibrinogen > 1.0 g/l . Stop the bleeding

10. Haemostasis Consider the four Ts and exclude them Trauma Vaginal/cervical lacs , haematoma, extragenital bleeding, uterine inversion, uterine rupture, broad ligament rupture Tissue Retained products Thrombin Coag screen Tone Utilise available and appropriate methods to reverse atony

11. Uterine Atony Physical Methods Bimanual uterine massage Empty bladder (catheterise) Drugs Syntocin or other uterotonics Ergometrine, Carboprost, Misoprostol PR 1000mg Surgical interventions Balloon tamponade Haemostatic brace suturing Ligation of uterine arteries Ligation of internal iliac ateries Arterial embolisation

12. Uterine Atony

13. Monitoring Continuous obs Including CCM and temperature at 15 min intervals Catheterise Measure fluid balance Consider arterial invasive monitors Consider ITU transfer or HDU monitoring