Management of Postpartum Haemorrhage (PPH)

dr. Manuel Hutapea, SpOG (K). Onk

DEFINITION
A blood loss of 500ml or more during puerperium and severe PPH as a blood loss of 1000ml or more.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Postpartum Haemorrhage (PPH). RANZCOG College Statement. March 2014.

EPIDEMIOLOGY
Postpartum haemorrhage (PPH) remains a major cause of both maternal mortality and morbidity within Australia and New Zealand. Incidence 5 15%

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Postpartum Haemorrhage (PPH). RANZCOG College Statement. March 2014.

CLASSIFICATION
Primary PPH
Within 24 hours of delivery.

Secondary PPH
Between 24 hours and six weeks postpartum.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Postpartum Haemorrhage (PPH). RANZCOG College Statement. March 2014.

PREVENTION
Risk factors
Most cases of PPH have no identifiable risk factor. Women with significant risk factors for PPH should deliver in a unit with rapid access to blood and blood products

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Postpartum Haemorrhage (PPH). RANZCOG College Statement. March 2014.

PREVENTION
Abnormal placentation
Appropriate recognition, preparation and management of women with placenta praevia or suspected morbidly adherent placentation is crucial.

These conditions are associated with increased risk of catastrophic haemorrhage and maternal mortality.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Postpartum Haemorrhage (PPH). RANZCOG College Statement. March 2014.

PREVENTION
Management of the third stage of labour
Active management of the third stage of labour recommended to all pregnant women. Prophylactic oxytocics Vaginal or caesarean birth. Misoprostol is less effective that oxytocin and have a greater incidence of side effects.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Postpartum Haemorrhage (PPH). RANZCOG College Statement. March 2014.

MANAGEMENT
REGOCNITION COMMUNICATION RESUSCITATION MONITORING AND INVESTIGATION DIRECTED TREATMENT
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Postpartum Haemorrhage (PPH). RANZCOG College Statement. March 2014.

MANAGEMENT
RECOGNITION
Assessment of ongoing blood loss Visual estimation of blood loss is notoriously unreliable Accurate measures weighing drapes, pads and swabs Estimated blood loss (EBL) 500ml-1000ml with no clinical shock Greater than 1000ml and continuing bleeding There is clinical signs of shock or tachycardia
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Postpartum Haemorrhage (PPH). RANZCOG College Statement. March 2014.

MANAGEMENT
COMMUNICATION
Requires a multidisciplinary team approach. The clinical team involved, their response to PPH, and ability to escalate this response in the face of severe haemorrhage will vary according to the setting and circumstance of delivery. Communication with the patient and their support person is IMPORTANT.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Postpartum Haemorrhage (PPH). RANZCOG College Statement. March 2014.

MANAGEMENT
RESUSCITATION
Assessment of airway and breathing initially with administration of high flow oxygen. Intravenous access should be established with blood sent for full blood count, coagulation profile and cross-match. Rapid infusion with fluids. Blood transfusion. Keeping the woman warm and positioned flat.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Postpartum Haemorrhage (PPH). RANZCOG College Statement. March 2014.

MANAGEMENT
MONITORING AND INVESTIGATION
Recording of observations at regular intervals, establishing IV access and performing the basic haematological investigations. Ongoing PPH or significant blood loss (>1000ml) measurement of continuous pulse, blood pressure, oxygen saturation and urinary output. The need for transfer should be anticipated and initiated early
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Postpartum Haemorrhage (PPH). RANZCOG College Statement. March 2014.

MANAGEMENT
DIRECTED TREATMENT
Management of PPH invariably involves addressing the causes of bleeding THE FOUR Ts Tone (Uterine Atony)
Uterine massage or bimanual uterine compression; Empty bladder. Syntocinon by slow intravenous injection or infusion. Ergometrine by slow intravenous injection
Misoprostol (1000mcg) rectally Prostaglandin F2 intra-muscularly or intra-myometrially
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Postpartum Haemorrhage (PPH). RANZCOG College Statement. March 2014.

MANAGEMENT
DIRECTED TREATMENT
Trauma
The perineum, vagina and cervix visually inspected Pressure should be applied to bleeding areas and repair attempted, either in the labour ward or the operating theatre if required

Tissue
Retained placenta, cotyledon or membranes Repeat oxytocic dose, empty the bladder and transfer to theatre for manual removal of placenta.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Postpartum Haemorrhage (PPH). RANZCOG College Statement. March 2014.

MANAGEMENT
DIRECTED TREATMENT
Thrombin
Rarely the primary cause of PPH and usually the consequence of massive haemorrhage and as such is addressed briefly above.

Theatre - surgical interventions

Balloon tamponade Haemostatic brace suturing Bilateral ligation of uterine or internal iliac arteries Hysterectomy

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Postpartum Haemorrhage (PPH). RANZCOG College Statement. March 2014.

SECONDARY PPH
Associated with endometritis (with or without retained products of conception). Conventional treatment
Antibiotic therapy and uterotonics In situations of excessive or continued bleeding surgical intervention, particularly the evacuation of retained products, should be considered, irrespective of ultrasound findings
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Postpartum Haemorrhage (PPH). RANZCOG College Statement. March 2014.

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