PREVENTION AND MANAGEMENT OF PPH
Monitoring and Investigation
**Basic measures for MINOR PPH (blood loss 500-1000 ml, no clinical shock and bleeding ceasing): • Consider venepuncture (20 ml) for: -group and screen -full blood count -coagulation screen including fibrinogen -pulse and blood pressure recording every 15 minutes. **Full Protocol for MAJOR PPH (blood loss greater than 1000ml and continuing to bleed OR clinical shock): • Consider venepuncture (20 ml) for: -crossmatch (4 units minimum) -full blood count -coagulation screen including fibrinogen -renal and liver function for baseline. • Monitor temperature every 15 minutes. • Continuous pulse, blood pressure recording and respiratory rate (using oximeter, electrocardiogram and automated blood pressure recording). • Foley catheter to monitor urine output. • Two peripheral cannulae, 14- or 16-gauge. • Consider arterial line monitoring (once appropriately experienced staff available for insertion). • Consider transfer to intensive therapy unit once the bleeding is controlled or monitoring at high dependency unit on delivery suite, if appropriate. • Recording of parameters on a flow chart such as the modified obstetric early warning system charts. • Documentation of fluid balance, blood, blood products and procedures.
Resuscitation
**Basic measures for MINOR PPH (blood loss 500-1000 ml, no clinical shock): -Intravenous access (14-gauge cannula x 1). -Commence crystalloid infusion. **Full protocol for MAJOR PPH (blood loss > 1000 ml and continuing to bleed OR clinical shock): -Assess airway. -Assess breathing. -Evaluate circulation -Oxygen by mask at 10-15 litres/minute. -Intravenous access (14-gauge cannula x 2, orange cannulae). -Position flat. -Keep the woman warm using appropriate available measures. -Transfuse blood as soon as possible. -Until blood is available, infuse up to 3.5 litres of warmed crystalloid Hartmann's solution (2 litres) and/or colloid (1-2 litres) as rapidly as required. -The best equipment available should be used to achieve RAPID WARMED infusion of fluids. Special blood filters should NOT be used, as they slow infusions. -Recombinant factor VIIa therapy should be based on the results of coagulation.{rFVIIa will not work if there is no fibrinogen and effectiveness may also be suboptimal with severe thrombocytopenia (less than 20 x 109/l).Therefore, fibrinogen should be above 1g/l and platelets greater than 20 x 109/l before rFVIIa is given.} -Fluid therapy and blood product transfusion: ~Crystalloid Up to 2 litres Hartmann's solution ~Colloid up to 1-2 litres colloid until blood arrives ~Blood Crossmatched If crossmatched blood is still unavailable, give uncrossmatched group-specific blood OR give 'O RhD negative' blood ~FFP 4 units for every 6 units of red cells or PT/APTT> 1.5 x normal. ~Platelets concentrates if PLT count < 50 x 109 ~Cryoprecipitate If fibrinogen < 1 g/l {the main therapeutic goals of management of massive blood loss is to maintain: • haemoglobin > 8g/dl • platelet count > 75 x 109/l • prothrombin < 1.5 x mean control • activated prothrombin times < 1.5 x mean control • fibrinogen > 1.0 g/l.}
Risk factors for PPH
1**presenting antenatally and associated with a substantial increase in the incidence of PPH; women with these factors should be advised to deliver in a consultant-led maternity unit: -Suspected or proven placental abruption (Thrombin ) -Known placenta praevia (Tone) -Multiple pregnancy (Tone) -Pre-eclampsia/gestational hypertension (Thrombin) 2**presenting antenatally and associated with a significant (though smaller) increase in the incidence of PPH; these factors should be taken into account when discussing setting for delivery: - Previous PPH (Tone). -Asian ethnicity (Tone) -Obesity (BMI >35) (Tone) -Anaemia (<9 g/dl) 3**becoming apparent during labour and delivery; these factors should prompt extra vigilance among clinical staff: - Delivery by emergency caesarean section (Trauma) -Delivery by elective caesarean section (Trauma) -Induction of labour - -Retained placenta (Tissue) -Mediolateral episiotomy (Trauma) -Operative vaginal delivery (Trauma) -Prolonged labour (> 12 hours) (Tone) . -Big baby (> 4 kg) (Tone/trauma) -Pyrexia in labour (Thrombin) -Age (> 40 years, not multiparous) (Tone)
Risk management
• Annual 'skill drills' should ensure all members of staff, including those operating the blood bank,know exactly what to do, ensuring that appropriate blood products are delivered to the labour ward. • A multidisciplinary approach to treatment should ensure that everyone knows how to work together to ensure prompt and efficient treatment in such an emergency. • A prospective randomised trial in the UK demonstrated that practical,multi-professional training in the management of obstetric emergencies has been shown to increase midwives' and doctors' knowledge. Furthermore, conducting such training locally or in a simulation centre was no different. • Accurate documentation of a delivery with postpartum haemorrhage is essential. • Major obstetric haemorrhage can be traumatic to the woman, her family and the birth attendants; therefore, debriefing is recommended by a senior member of the team who was involved at the time of events at the earliest opportunity. -see APPENDIX II
Communication
• Basic measures for MINOR PPH (blood loss 500-1000 ml, no clinical shock): -Alert the midwife-in-charge. -Alert first-line obstetric and anaesthetic staff trained in PPH. Full protocol for MAJOR PPH (blood loss more than 1000 ml and continuing to bleed OR clinical shock): -Call experienced midwife (in addition to midwife in charge). -Call obstetric middle grade and alert consultant. -Call anaesthetic middle grade and alert consultant. -Alert consultant clinical haematologist on call. -Alert blood transfusion laboratory. -Call porters for delivery of specimens/blood. -Alert one member of the team to record events, fluids, drugs and vital signs.
Arresting the bleeding
• Causes for PPH may be considered to relate 'the four Ts': tone tissue ,trauma and thrombin . •-The most common cause of primary PPH is uterine atony. However, clinical examination must be undertaken to exclude other or additional causes: • retained products (placenta, membranes, clots) • vaginal/cervical lacerations or haematoma • ruptured uterus • broad ligament haematoma • extragenital bleeding (for example, subcapsular liver rupture) • uterine inversion. -When uterine atony is perceived to be a cause of the bleeding, the following mechanical and pharmacological measures should be instituted, in turn, until the bleeding stops: • Bimanual uterine compression (rubbing up the fundus) to stimulate contractions. • Ensure bladder is empty (Foley catheter, leave in place). • Syntocinon 5 units by slow IV (may have repeat dose). • Ergometrine 0.5 mg by slow IV or IM injection (contraindicated in women with hypertension). • Syntocinon infusion (40 units in 500ml Hartmann's solution at 125ml/hour) unless fluid restriction is necessary. • Carboprost 0.25 mg by IM injection repeated at intervals of not less than 15 minutes to a maximum of 8 doses (contraindicated in women with asthma). • Direct intramyometrial injection of carboprost 0.5 mg (contraindicated in women with asthma).. • Misoprostol 1000 micrograms rectally. If pharmacological measures fail to control the haemorrhage, initiate surgical haemostasis sooner rather than later. Intrauterine balloon tamponade is an appropriate firstline 'surgical' intervention for most women where uterine atony is the only or main cause of haemorrhage. If this fails to stop the bleeding, the following conservative surgical interventions may be attempted, depending on clinical circumstances and available expertise: • balloon tamponade • haemostatic brace suturing (such as using procedures described by B-Lynch or modified compression sutures) • bilateral ligation of uterine arteries • bilateral ligation of internal iliac (hypogastric) arteries • selective arterial embolisation. • Resort to hysterectomy SOONER RATHER THAN LATER (especially in cases of placenta accreta or uterine rupture). A second consultant clinician should be involved in the decision for hysterectomy.
How should PPH be managed?
• Once PPH has been identified,management involves four components, all of which must be undertaken SIMULTANEOUSLY: communication, resuscitation,monitoring and investigation, arresting the bleeding.
Definition of postpartum haemorrhage
• Primary PPH involving an estimated blood loss of 500-1000 ml (and in the absence of clinical signs of shock) should prompt BASIC measures (close monitoring, intravenous access, full blood count, group and screen) to facilitate resuscitation should it become necessary. • If a woman with primary PPH is continuing to bleed after an estimated blood loss of 1000 ml (or has clinical signs of shock or tachycardia associated with a smaller estimated loss), this should prompt a FULL protocol of measures to achieve resuscitation and haemostasis.
Introduction
• Primary postpartum haemorrhage (PPH) is the most common form of major obstetric haemorrhage. • The traditional definition of primary PPH is the loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby. •PPH can be minor (500-1000 ml) or major (more than 1000 ml).Major could be divided to moderate (1000-2000 ml) or severe (more than 2000 ml) . •Secondary PPH is defined as abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postnatally. •In the 2003-2005 report of the UK Confidential Enquiries into Maternal Deaths, haemorrhage was the third highest direct cause of maternal death (6.6 deaths/million maternities)
Prediction and prevention of postpartum haemorrhage
• Risk factors may present antenatally or intrapartum; care plans must be modified when risk factors present. Most cases of PPH have no identifiable risk factors. • Active management of the third stage of labour lowers maternal blood loss and reduces the risk of PPH. Prophylactic oxytocics should be offered routinely in the management of the third stage of labour in all women as they reduce the risk of PPH by about 60%. • For women without risk factors for PPH delivering vaginally, oxytocin (5 iu or 10 iu by intramuscular injection) is the agent of choice for prophylaxis in the third stage of labour. •For women delivering by CS, oxytocin (5 iu by slowintravenous injection) should be used to encourage contraction of the uterus and to decrease blood loss. A bolus dose of oxytocin may possibly be inappropriate in some women, such as those with major cardiovascular disorders, suggesting that a low-dose infusion might be a safer alternative. • Syntometrine may be used in the absence of hypertension (for instance, antenatal low haemoglobin) as it reduces the risk of minor PPH (500 - 1000 ml) but increases vomiting. • Misoprostol is not as effective as oxytocin but it may be used when the latter is not available, such as the home-birth setting. • All women who have had a previous caesarean section must have their placental site determined by ultrasound.Where facilities exist,magnetic resonance imaging (MRI)may be a useful tool and assist in determining whether the placenta is accreta or percreta. Women with placenta accreta/percreta are at very high risk ofmajor PPH. • If placenta accreta or percreta is diagnosed antenatally, there should be consultant-led multidisciplinary planning for delivery. Consultant obstetric and anaesthetic staff should be present, prompt availability of blood, FFP and platelets be confirmed and the timing and location for delivery chosen to facilitate consultant presence and access to intensive care. • Available evidence on prophylactic occlusion or embolisation of pelvic arteries in the management of women with placenta accreta is equivocal.
How should secondary PPH be treated?
• Secondary PPH is often associated with endometritis. When antibiotics are clinically indicated, a combination of ampicillin (clindamycin if penicillin allergic) and metronidazole is appropriate. In cases of endomyometritis (tender uterus) or overt sepsis, then the addition of gentamicin is recommended. • Surgical measures should be undertaken if there is excessive or continuing bleeding, irrespective of ultrasound findings. A senior obstetrician should be involved in decisions and performance of any evacuation of retained products of conception as these women are carrying a high risk for uterine perforation. {Investigations of secondary PPH should include high and low vaginal swabs,blood cultures if pyrexial, full blood count,C-reactive protein. A pelvic ultrasound may help to exclude the presence of retained products of conception, although the appearance of the immediate postpartum uterus may be unreliable}