post-partum haemorrhage (PPH)

introduction

Primary PPH: Genital tract blood loss ≥ 500mL during the third stage of labour and up to 24 hours after birth
- major PPH is defined as loss > 1000mL blood
Secondary PPH: Genital tract blood loss ≥ 500mL after 24 hours and up to 6 weeks after birth
PPH is a major cause of mortality, morbidity and long term disability related to pregnancy and birth

Active management of the third stage of labour
IV access (e.g. consider 2 large bore cannulae )
FBE, group and save or cross match at the onset of labour
consider the need for a postpartum oxytocin infusion
consider the need for a senior obstetrician or anaesthetist to be present at birth or in theatre
consider need for use of cell salvage and / or rapid flow devices

if the placenta is retained, AVOID ergometrine and oxytocin/ergometrine (Syntometrine®)
if major PPH (>1000mL loss), activate massive transfusion protocol, call obstetrician, transfer to theatre, consider bimanual compression

early identification and response improves outcomes
if on ward access the PPH box containing the needed medications and call an obstetric alert if severe PPH
2 large bore iv access and FBE, clotting screen, cross match if not already done
oxygen via face mask
1-2L NSaline stat then blood if indicated
accurate fluid balance chart
5-10 minutely maternal obs
look for the cause - see the 4 T's above

if genital trauma is the cause, apply pressure to bleeding perineal lacerations
RPOC - check placenta and membranes - if incomplete, organise transfer to theatre for EUA
if uterine atony is most likely the cause:
- massage uterus
- expel any clots
- administer uterotonics:
  - oxytocin:
    - if not already given in 3rd stage, give 10U IV over 3-5 minutes or im if no iv access
    - once PPH has been controlled then can start infusion 40U in 40mL NSaline and give at 10mL/hr for 4hrs
  - ergometrine IF placenta has been delived but still atony with PPH:
    - 250mcg im PLUS 250mcg slow iv if no C/I such as hypertension, cardiac disease, HS, retained placenta
    - can repeat dose if needed (max. 1500mcg or 3mL in 24hrs)
  - insert IDC if not already done and monitor urine output
  - carboprost:
    - off-label use in severe PPH but only for warrant holders
    - 250mcg deep im every 15 minutes prn to max. 8 doses but patient should be in theatre if needs 4th dose
    - C/I include acute PID, active cardiac, resp, renal or hepatic disease
- consider bimanual compression of the uterus
consider uterine rupture as a cause
if there is uterine inversion, manually replace the uterus if possible. Do not attempt to remove the placenta even if it is still attached until the uterus is replaced. If efforts to replace the uterus are unsuccessful, transfer to theatre urgently for GA and manual replacement.

activate massive blood transfusion protocol as soon as large volume losses are anticipated
operating theatre at Sunshine now has ROTEM (ROtational Thrombo-ElastoMetry) to allow point-of-care decisions regarding clotting factor replacement in Post-Partum Haemorrhage
engage the assistance of consultant haematologist and anaesthetist