- 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).
- 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
- 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.
- 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
|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.
- 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.
- 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.
- 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.
Table 2. PPH Drugs
|Drug||Dosage||Route/s of administration|
|1st line||Oxytocin* (Syntocinon)||10 iu||IM or IV|
250 microg + 250 microg
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.
- 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.
- 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.
- Repeat pathology half to one hourly until PPH has stabilised:
- coagulation profile
- venous gases.
- Advise laboratory of MTP stand down.
Management for specific causes of PPH
Table 3. Management for specific causes of 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 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)
- Initiate resuscitation if required.
- If haemodynamically compromised, treat as for primary PPH.
- Consider IV antibiotics.
- obstetric history
- vital signs - heart rate, blood pressure, respiratory rate, O2 saturation, temperature
- uterine size and tenderness
- vaginal loss.
- group and hold (X-match if indicated)
- 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.
- 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
- 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
- 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
- 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.
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.
- 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: firstname.lastname@example.org.
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First published: November 2018
Last web update: February 2019
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