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Key messages

  • Primary postpartum haemorrhage (PPH) is an obstetric emergency - SUMMON HELP IMMEDIATELY.
  • PPH is vaginal bleeding after childbirth in excess of 500 ml or sufficient to compromise the woman.
  • PPH is the leading cause of maternal mortality worldwide.
  • Tone: uterine atony is the most common cause of PPH. Remember there may be more than one cause.

Preparation

Primary PPH management flowchart

Secondary PPH management flowchart

  • All clinicians should:
    • know where to find all equipment for PPH management in their service
    • know their local escalation procedures
    • understand which blood products are available at their service and how to access them
    • know how to activate their local massive transfusion protocol (MTP)
    • attend multidisciplinary obstetric emergency training annually (for example, PROMPT, MSEP).

Prevention

  • Document identified risk factors.
  • Determine placental location at second trimester ultrasound (US).
  • Identify and correct maternal anaemia and iron deficiency.
  • Provide women with information about active and physiological third stage management.
  • Plan for active management of third stage for all women with identified risk factors.
  • If a woman requests physiological third stage management, document a plan for indications for instigation of active management.
  • Act promptly to manage slow progress in labour.
  • Ensure oxytocics, IV fluid and equipment are checked, prepared and readily available.

Active management of third stage

Vaginal birth

  • Oxytocin (Syntocinon) 5-10iu IM/IV.

Caesarean section - emergency and elective

  • Consider the use of Carbetocin (Duratocin) 100 microg (1 ml) IV:
    • administer as a slow bolus, over one minute
    • must be given after delivery of the baby
    • can be given before or after delivery of the placenta.

Risk factors

  • When risk factors are identified, document a plan for ongoing care.
  • Remain alert - many cases of PPH have no identifiable risk factors.

Table 1. Risk factors for PPH

Antenatal Intrapartum
History of PPH Augmentation of labour
BMI >35 Spurious labour - prolonged latent phase of labour
Maternal anaemia (undiagnosed or untreated) Precipitate or incoordinate labour
Maternal iron deficiency Prolonged active first stage >12 hours
Antepartum haemorrhage (APH) Prolonged second stage >3 hours
Previous macrosomic baby ≥ 4500 g Prolonged physiological third stage >1 hour
Polyhydramnios Prolonged active third stage >30 mins
Fibroids Surgical intervention - forceps, vacuum, episiotomy, caesarean
Induction of labour Maternal fatigue or exhaustion
Known coagulopathy Pyrexia in labour
Abnormal placentation Shoulder dystocia
Hypertensive disorders Fetal macrosomia ≥ 4500 g
Placenta praevia Placental abruption
Multiple pregnancy Incomplete third stage

Primary PPH - management

PPH is an obstetric emergency - SUMMON HELP IMMEDIATELY.

Primary PPH management flowchart

Causes

  • Tone (70 per cent), atonic uterus, distended uterus, uterine muscle exhaustion
  • Trauma (19 per cent), cervical, vaginal or perineum
  • Tissue (10 per cent), retained products of conception
  • Thrombin (1 per cent), blood clotting disorders.

Management

Documentation

  • Scribe to contemporaneously document assessments and response to management:
    • record on PPH chart, if available.
  • Commence a Maternity Observation and Response Chart.
  • Commence a Fluid Balance Chart.
  • Document products given on blood administration form and fluid balance chart.
  • Ensure doctors' orders are signed.

Fluid resuscitation

  • Commence with a crystalloid (CSL or NaCl 0.9 per cent) at a ratio of three litres of fluid for every one litres of estimated blood loss.
  • Colloid may be a suitable alternative for the third litre.
  • Prevent hypothermia:
    • warm fluids, if possible
    • warm blankets.
  • Infuse fluids as quickly as possible, aided by a rapid infusion set or hand pump set.

Drugs

Table 2. PPH Drugs

  Drug Dosage Route/s of administration
1st line Oxytocin* (Syntocinon) 10 iu IM or IV
Syntometrine* 1 ml IM
Ergometrine 500 microg
or
250 microg + 250 microg
IM

IM + IV (give IV slowly)
2nd line Tranexamic acid 1 g in 100ml 0.9% NaCl IV (given over 10 mins)
3rd line CarboPROST 250 microg/1 mL IM
After immediate management Misoprostol 600 microg Buccal or PR
Oxytocin infusion 40 iu in 1L CSL IV (given over 4 hours)

* If not given as part of 3rd stage management

  • Avoid giving Syntometrine/Ergometrine to women with a BP ≥140/90:
    • may be given judiciously in context of massive haemorrhage.
  • If blood loss is >1 litre, give Tranexamic Acid 1g IV.
  • Consider administering an antiemetic.
  • Carboprost should be given with caution to women with a history of asthma, as it can induce bronchospasm.
  • Consider Gastrostop or equivalent if giving CarboPROST, to minimise side effect of diarrhoea.

Escalation

  • Activate massive transfusion protocol (MTP) if:
    • the woman is receiving four units of packed red cells in less than four hours and is haemodynamically unstable
    • there are clinical or laboratory signs of coagulopathy.
  • Access emergency O negative blood if required.
  • Advise pathology department of likely blood requirements as soon as possible.
  • If the woman's condition deteriorates, facilitate transfer to theatre:
    • for ongoing bleeding due to atonic uterus, bimanual compression may be required
    • for ongoing bleeding due to perineal trauma, apply pressure during transfer.
  • In the event of transfer, consult with Senior Registrar or Consultant Obstetrician at the supporting hospital to inform them of the woman's condition, management and reason for transfer.
  • Obtain verbal orders.
  • Remember PIPER is always available to provide support and advice in PPH management:
    • phone 1300 137 650.

Observations

  • Until blood loss is under control or woman is transferred to theatre:
    • five-minutely vital signs - heart rate, blood pressure, respiratory rate, O2 saturation
    • uterine tone and blood loss
    • 15-minutely temperature.
  • Document a running total of blood loss.
  • Record conscious state.
  • Record urine output.

Ongoing management

  • Repeat pathology half to one hourly until PPH has stabilised:
    • FBE
    • coagulation profile
    • venous gases.
  • Advise laboratory of MTP stand down.

Management for specific causes of PPH

Table 3. Management for specific causes of PPH

Tone
  • Massage the atonic uterus to stimulate contraction and expel clots.
  • Administer oxytocics
  • Insert IDC
  • If attempts to deliver the placenta have been unsuccessful, prepare for immediate manual removal under anaesthesia in theatre
  • If heavy bleeding continues, apply bimanual compression until further management decisions are made
  • In the event of intractable bleeding, surgical intervention in theatre may be required, for example, examination under anaesthetic, insertion of a uterine balloon (Bakri), B-Lynch suture, uterine artery ligation, hysterectomy
  • If required, uterine balloon is inserted as per manufacturer's instruction (see Post insertion care for more information)
  • If packing is used, the packs must be tied to the uterine balloon catheter and document presence and plan for removal
Trauma
  • In all cases of primary PPH, check the genital tract thoroughly to exclude bleeding from trauma, for example, lacerations, haematomas
  • In the presence of visible trauma, apply pressure and manage either in birth suite or under anaesthesia in theatre
  • Vaginal or uterine packing may be required to control bleeding
  • Packing the uterus is best undertaken in theatre after an examination under anaesthesia and with a senior obstetrician involved.
  • When packing the uterus:
    • tie 3--4 gauze rolls together, lightly soak gauze in sodium chloride 0.9 per cent and tightly pack the uterus and vagina to ensure an effective tamponade
    • document the number of packs present and a plan for their removal
  • If the placenta is delivered and the uterus contracted, consider other concealed causes of trauma such as ruptured uterus, broad ligament haematoma
Tissue
  • If the placenta is not delivered and bleeding continues, prepare for examination and manual removal under anaesthesia in theatre
  • If the placenta is delivered, check the placenta and membranes for completeness
  • Where tissue is retained, or bleeding continues, prepare for examination under anaesthesia in theatre
  • If anaesthetic or theatre staff are not available, the placenta is retained and bleeding is vigorous, manual removal without anaesthesia is only considered as a lifesaving manoeuvre
  • Alternatively, apply vigorous bimanual compression until further help is available
Thrombin
  • In the presence of a well contracted uterus and where trauma and retained tissue have been excluded, consider investigating for coagulopathies
  • Consider coagulopathy as a consequence of ongoing PPH

 

Post insertion care of uterine balloon tamponade

  • Antibiotics should be given while the balloon is in situ.
  • Monitor for signs of increased loss in the catheter bag.
  • Maximum indwell time (as per manufacturer instructions) is 24 hours.
  • Return to theatre is not required for balloon removal.
  • Balloon removal can be undertaken by trainee medical or midwifery staff under direction of senior obstetric staff.
  • At the time of removal ensure any vaginal packs are also removed and this is documented in the inpatient progress notes.

Secondary PPH - management

Are you in ED? Notify the obstetric team as soon as possible.

Secondary PPH management flowchart

Definition

  • Secondary PPH is defined as a blood loss of >500 ml after 24 hours and up to six weeks postpartum.
  • The majority of secondary PPH are the result of sub-involution of the uterus secondary to uterine infection and/or retained products of conception.
  • Other causes include:
    • pre-existing uterine disease (fibroids, cervical polyps)
    • trauma
    • coagulopathies.

Assessment

  • Initiate resuscitation if required.
  • If haemodynamically compromised, treat as for primary PPH.
  • Consider IV antibiotics.
  • Document:
    • obstetric history
    • vital signs - heart rate, blood pressure, respiratory rate, O2 saturation, temperature
    • uterine size and tenderness
    • pain/cramping
    • vaginal loss.

Investigations

  • Consider:
    • group and hold (X-match if indicated)
    • FBE
    • CRP
    • serum BhCG
    • clotting profile
    • MSU if there are signs of infection
    • blood cultures if maternal temperature is >38 degrees
    • speculum examination with low vaginal swabs and high vaginal swabs
    • ultrasound/Doppler studies.

Treatment

  • Management will depend largely on the woman's condition and haemodynamic status.
  • If unstable:
    • administer uterotonics as for primary PPH
    • balloon tamponade and uterine packing may be indicated for continued haemorrhage.
  • Surgical management options include:
    • EUA and curettage
    • Selective Pelvic Arterial Embolisation (SPAE)
    • ligation of internal iliac arteries
    • hysterectomy.

Antibiotics

  • Women exhibiting any signs of infection or retained products require antibiotics.
  • Commence antibiotics within the first hour.

IV antibiotics - if febrile/septic

  • Ampicillin (or amoxicillin) 2 g IV STAT, then 1 g every six hours

and

  • Metronidazole 500 mg IV every 12 hours
  • +/- Gentamicin 5 mg/kg IV daily.

Allergy to Penicillin

  • Clindamycin or Lincomycin 900 mg IV every eight hours
  • +/- Gentamicin 5 mg/kg IV daily.

Oral antibiotics - if afebrile but infection is suspected

  • Augmentin Duo Forte (amoxicillin 875 mg/clavulanic acid 125 mg) every 12 hours, for seven days
  • Metronidazole 400 mg every eight hours, for seven days.

Allergy to Penicillin

  • Ciprofloxacin 500 mg every 12 hours, for seven days
  • Metronidazole 400 mg every 12 hours, for seven days.
  • When consenting a woman for 'examination under anaesthesia' the consent must include the possibility of hysterectomy in the event of intractable bleeding due to uterine atony.

Post emergency care

Consider

  • Prophylactic intravenous antibiotics
  • Fluid management
  • Accurate record of fluid balance
  • Appropriate staffed area for stabilisation and recovery: birth suite, theatre recovery room, HDU/ICU, postnatal ward
  • Frequency of vital signs and observation
  • Appropriate thromboprophylaxis
  • Debriefing staff
  • Case review

Debriefing the woman, her partner and family is essential.

More information

Audit and performance improvement

All maternity services should have processes in place for:

  • auditing clinical practice and outcomes
  • providing feedback to clinicians on audit results
  • addressing risks, if identified
  • implementing change, if indicated.

Auditable standards:

  • women with risk factors with a documented management plan
  • women with risk factors with appropriate IV access
  • appropriate administration of uterotonics
  • appropriate correction of maternal anaemia and/or iron deficiency.

For further information or assistance with auditing, please contact the Maternity and Newborn Clinical Network: maternityehandbook@safercare.vic.gov.au.

References

  • Australian Red Cross Blood Service (2013).
  • Attilakos et.al. (2010). Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double-blind randomised trial. BJOG, 117: 929–936. DOI: 10.1111/j.1471-0528.2010.02585.x
  • Australian Government Department of Health, Therapeutic Goods Administration (2018). Australian Public Assessment Report for Carbetocin
  • Bellad et.al. (2012) Prevention of postpartum haemorrhage with sublingual misoprostol or oxytocin: a double-blind randomised controlled trial. BJOG 2012;119:975-986. doi: 10.1111/j.1471-0528.2012.03341.x.
  • De Bonis et.al. (2012). Carbetocin versus oxytocin after caesarean section: similar efficacy but reduced pain perception in women with high risk of postpartum haemorrhage. The Journal of Maternal-Fetal & Neonatal Medicine, 25:6, 732-735, DOI: 10.3109/14767058.2011.587920
  • Elati, A., & Weeks, A. (2012) Risk of Fever After Misoprostol for the Prevention of Postpartum Hemorrhage: A Meta-Analysis. American College of Obstetricians and Gynecologists, 120(5), 1140-1148.
  • Groom, K. M., & Jacobson, T. Z. (2006). The management of secondary postpartum hemorrhage. Textbook of postpartum hemorrhage A comprehensive guide to evaluation, management and surgical intervention. Duncow: Sapiens Publishing, 316-24.
  • Hofmeyr et.al. (2005) Misoprostol to treat postpartum haemorrhage: a systematic review BJOG: an International Journal of Obstetrics and Gynaecology, Vol. 112, 547-553.
  • International Federation of Gynecology and Obstetrics (2012) Treatment of Post-Partum Haemorrhage with Misoprostol: FIGO Guideline in Brief.
  • King Edward Memorial Hospital Guidelines (2016) Obstetric Emergencies - Post Partum Haemorrhage (PPH) Department of Health Western Australia.
  • King Edward Memorial Hospital Guidelines (2016) Obstetric Emergencies - Secondary Post Partum Haemorrhage (PPH) Department of Health Western Australia.
  • Larciprete et.al. (2013). Carbetocin versus oxytocin in caesarean section with high risk of post-partum haemorrhage. Journal of Prenatal Medicine, 7:1, 12-18.
  • MIMs on line MIMS Class: Agents acting on the uterus, MIMS Australia 2013.
  • MIMs on line. Ergometrine maleate Full Product Information. 11/02/2008 accessed 29/10/13.
  • Monash Health (2018) Primary Postpartum Haemorrhage Procedure v10.0.
  • Morris et.al. (2017) FIGO's updated recommendations for misoprostol used alone.
  • in gynecology and obstetrics. Int J Gynecol Obstet; 138: 363-366. doi: 10.1002/ijgo.12181.
  • National Blood Authority Australia, Patient Blood Management Guidelines: Module 1 Critical Bleeding/Massive Transfusion.
  • Pfizer (2014). Product monograph - Hemabate® Sterile Solution (carboprost tromethamine injection USP).
  • Quibel et.al. (2016) Active Management of the Third Stage of Labor With a Combination of Oxytocin and Misoprostol to Prevent Postpartum Hemorrhage: A Randomized Controlled Trial. American College of Obstetricians and Gynecologists, 128(4), 805-811.
  • Razali et.al. (2016). Carbetocin compared to oxytocin in emergency cesarean section: a randomized trial. European Journal of Obstetrics & Gynecology and Reproductive Biology, 198, 35-39. DOI: 10.1016/j.ejogrb.2015.12.017
  • Royal College of Obstetricians & Gynaecologists (2016) Prevention and Management of Postpartum Haemorrhage: Green-top guideline no.52.
  • Royal Women's Hospital (2013) Postpartum haemorrhage.
  • South Australian Perinatal Practice Guidelines (2012) Secondary Postpartum haemorrhage.
  • Su  LL, Chong  YS, Samuel  M. (2012). Carbetocin for preventing postpartum haemorrhage. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD005457. DOI: 10.1002/14651858.CD005457.pub4.
  • The Royal Women’s Hospital (2017). Postpartum Haemorrhage – Carboprost.
  • Weeks, A. (2014) The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next? BJOG, 122, 202-212. doi: 10.1111/1471-0528.13098.
  • WHO (2012) Prevention and Treatment of PPH. World Health Organization. Geneva: Switzerland.
  • WOMAN Trial Collaborators (2017) The effects of early tranexamic acid administration on mortality, hysterectomy and other morbidities in women with PPH (WOMAN). The Lancet.

Get in touch

Maternity and Newborn Clinical Network
Safer Care Victoria

Version history

First published: November 2018

Last web update: February 2019

Review by: November 2020

Uncontrolled when downloaded

Page last updated: 25 Feb 2019

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