Post Partum Haemorrhage



Primary PPH

>500 ml, first 24h from delivery.

  • Retained Placenta/Products
  • Atony
  • Ruptured uterus
  • Trauma

Prophylaxis: Syntometrine (500 mcg ergometrine, 5 units syntocinon)

Risk factors

  • over-distension of uterus
  • twins
  • polyhydramnios
  • multiparity
  • antepartum haemorrhage
  • fibroids
  • bleeding tendency
  • pre-eclampsia
  • past history of post-partum haemorrhage

Initial Management

  1. O2
  2. Call for help
  3. Two 16G cannulae
  4. X-match 4 units, ± platelets, Hb, clotting.
  5. IV Hartmanns, Blood replacement.
  6. Check Hx of of incomplete placenta/membranes.
  7. Examine uterus to ensure contracted.
  8. Examine cervix/vagina to exclude tears.
  9. Examine cervix to exclude retained placenta in cervical canal - shock.
  10. Catheterise, hourly urine output.
  11. Inform Obstetric Registrar.

Mx major haemorrhage due to atony:

  1. Rub up a contraction/bimanual compression.
  2. Syntocinon 10 i.u. iv. repeated (V/D).
  3. Syntocinon 40 i.u./500 ml saline over 4 hours.
  4. Ergometrine 0.5 - 1.0 mg (Avoid in hypertension = V/C), causes nausea, vomiting, headache.
  5. If continuing (>1500 ml):
  6. Prostaglandin E2 5 mg in 500 ml saline - 10 mcg/minute for 2 minutes then 20 mcg/min.
  7. Carboprost (Hemabate) 250 mg in 1 ml, deep IM or into myometrium. Repeat every 90 mins (max 12 g = 48 doses). Avoid prostaglandins in asthmatics and cardiac disease
  8. Surgery - EUA, repair rupture, internal iliac A ligation, hysterectomy.

Secondary PPH

Definition

>500ml after 24 h from delivery

Usually minor compared to primary. For review by Obs registrar

  1. Antibiotics (ceph/met)
  2. USS
  3. EUA/ERP

Causes

  • Retained products
  • Trauma
  • Infection

Content drafted by Dr Íomhar O' Sullivan 23/06/2003. Reviewed by Dr ÍOS 02/02/04, 02/02/05, 30/05/2007. Next review 30/05/2008.