Obstetric haemorrhage, which includes both antepartum and postpartum haemorrhage, is the leading cause of maternal death worldwide.
Within the UK, maternal death from obstetric haemorrhage is uncommon, but still causes approximately 7 deaths per year. Postpartum haemorrhage (PPH) is a common cause of maternal morbidity and up to 40% of blood loss is considered life-threatening in PPH.
Postpartum haemorrhage (PPH) can be defined as either primary or secondary.
Primary PPH is defined as vaginal bleeding that occurs from delivery of baby to 24 hrs postpartum.
Secondary PPH is defined as vaginal bleeding from 24 hrs postpartum to 12 weeks postpartum.
The extent of blood loss in PPH is often underestimated.
The severity of PPH is dependent on the extent of blood loss and can be divided into minor, moderate or severe.
Risk factors for the development of PPH can be divided into both antenatal and intrapartum factors.
Major antepartum factors include multiple pregnancy, antepartum haemorrhage and previous history of PPH. Below is a list of the main risk factors for PPH.
The main intrapartum factors for PPH include retained placenta, C-section and induction of labour. A list of intrapartum risk factors is shown below.
The aetiology of PPH can be remembered as the 'four T's'.
The four T's include Tone, Trauma, Tissue and Thrombin.
The management of PPH is critical because mother's can lose a significant amount of blood and develop shock.
The specific management of a PPH can be divided into interventions aimed to reduce the risk of developing a PPH or stopping a PPH.
In the event of a major postpartum haemorrhage, the major haemorrhage protocol should be activated throughout switchboard (2222).
Activation of the major haemorrhage protocol means you are alerting blood bank to the need for urgent blood products. Immediate access to O- blood can be found in maternity but this is a limited resource. Once the haemorrhage protocol is activated, a 'runner' needs to send an FBC, crossmatch and coagulation to blood bank. A blood pack is then sent back to the patient via the 'runner' with group specific blood and fresh frozen plasma. Further products can be acquired following communication with blood bank
Uterine atony is the most common cause of PPH and uterotonic drugs are used to prevent it.
These medications work by increasing the force and frequency of smooth muscle contraction within the uterus.
In the event that uterotonic medications are ineffective, or bleeding cannot be stopped, surgical intervention needs to be considered.
Secondary PPH is often associated with endometritis (endometrial infection) or retained products of conception (RPOC).
In cases of secondary PPH, it is important to assess for infection with high vaginal and endocervical swabs. Concurrently, an ultrasound scan be be completed looking for any RPOC or collections. Mothers may needs antibiotics +/- surgical evacuation of retained products of conception (ERPC).
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