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 refers to vaginal bleeding up to 12 weeks following delivery. Prompt recognition and management is key to good outcomes. It should be remembered that earlier antepartum haemorrhage can reduce a patient’s physiological reserve and ability to compensate for bleeding in the postpartum period.
Postpartum haemorrhage (PPH) can be classified as either primary or secondary.
PPH can be graded as minor, moderate and severe.
The severity of PPH is dependent on the extent of blood loss and can be divided into minor, moderate or severe. The extent of blood loss in PPH is often underestimated.
Risk factors for the development of PPH can be divided into both antepartum 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 and refer in particular to primary PPH:
Secondary PPH most commonly occurs secondary to retained products of conception and endometritis.
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.
NOTE: synthetic oxytocin can be used to stimulate contraction of the uterus. Remember a 'baggy' atonic uterus is a cause of 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. A MOH call activates a team of obstetricians, midwives, anaesthetists, theatre, porters, blood bank and haematologists. Immediate access to O- blood can be found on the maternity unit but this is a limited resource.
Once the haemorrhage protocol is activated, a 'runner' needs to send an FBC, crossmatch and coagulation screen 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 the 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 should be completed looking for any RPOC or collections. Mothers may need antibiotics +/- surgical evacuation of retained products of conception (ERPC).
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