WEEK 7 PRESENTATION

POST-PARTUM
HAEMORRHAGE
Jeremy Yang

Case

Mrs Jones rang the Labour Ward as

advised by her general practitioner
because she had noted a small amount of
vaginal bleeding. It was one week before
her due date.

What advice would you give her?

a)

b)

No action, its normal to bleed this

advanced in pregnancy. Its probably a
bloody show, anyway. Come in when
active labour begins
Advise her to visit PAC so a proper Hx,
Ex and Ix can be undertaken. Any

Causes of bleeding in 3rd

trimester

Serious and not to be missed

Placental abruption
Placenta praevia
Vasa praevia

Physiological

Bloody show of labour

Other
PCB/contact bleeding
Cervical polyps

Take a history
Perform
examination
Do
investigations

What are the functions of the midwife,

medical staff and support persons in
achieving a normal delivery?
Midwife (mid = with, wif = woman)
A professional who works in partnership
with pregnant women, giving necessary
support, care and advice throughout
pregnancy, labour and early postpartum

The roles of the Midwife

Regular community antenatal checks throughout

pregnancy and up to ?4/52 postpartum
Education and counselling

Lifestyle advice
Breastfeeding
Parenthood
Sexual/gynaecological health

Guides the woman to appropriate medical care or

assistance if complications detected during
pregnancy
Many midwives are also RNs perform nursing
duties in hospital

Low-risk pregnancies can be followed in its full

course by midwives only. But if there are
complications/ increased risks

Doctors - Seen if the pregnancy is

considered higher risk than normal, e.g.

Increased risk on early pregnancy screening

Complications of pregnancy
Significant POHx
etOH and drugs
Complex social cases
Mental health issues (maternal)
Other medical conditions (maternal and fetal)

Where?

EPAS or PAC, clinics (ANC, HRANC, DAPS/CC,

PIMHS, PDCAT), hospital

Role of the support person (e.g. partner,

family, friend)

To provide emotional and physical

support to the woman during labour (but
also throughout pregnancy)

Changing the kitty litter, doing the housework

Giving massage, helping shower, pain
management techniques
Helping pack for, and transport to hospital
Taking her mind off labour in early stage,
distractions
Getting food/drink and ensuring regular eating
and emptying bladder
Assisting midwives with positioning during
contractions etc.
Giving words of comfort and encouragement
Being by her side at all times

Mrs Jones has just delivered a 4500g

infant after 3hrs labour. She is
bleeding heavily.

Post-partum blood loss whats

normal and whats not?

NORMAL: < 500mL in 1st hour NVD,

<750mL after C/S
ABNORMAL (i.e. 1o PPH): >500mL in 1st
hour NVD

>1000mL in 1st hour OR causes

haemodynamic compromise severe PPH
obstetric emergency

How would you manage this patient?

Simultaneously, not sequentially:
IV access
Monitoring + investigation
Arresting haemorrhage
Resuscitation

How would you manage this patient?

Simultaneously, not sequentially:
IV access

14 or 16 gauge cannula (or x2)

Monitoring + investigation
Appearance, BP, HR, +/- urine output
(catheter)
X-match, FBC, coagulation studies

Arresting haemorrhage
Resuscitation

How would you manage this patient?

Simultaneously, not sequentially:
IV access
Monitoring + investigation
Arresting haemorrhage
Uterine massage
Bimanual compression
Balloon tamponade
1st line Medical: Repeat dose 5-10IU
syntocinon, or orgometrine, syntometrine
2nd line Medical: Misoprostol (off-label)
Surgical: Radiological uterine artery
embolisation

Resuscitation

How would you manage this patient?

Simultaneously, not sequentially:
IV access
Monitoring + investigation
Arresting haemorrhage
Resuscitation
Restore blood volume and O2 carrying
capacity
Fluids (Hartmanns & colloid up to 3500mL)
O2 by mask 10-15mL/min
Keep pt warm, and warm fluids if possible
RBC transfusion ASAP, O- if critically needed
(and FFP, cryoprecipitate if coags deranged)
After 2U blood, add 1U FFP with every additional

unit of blood

Discuss the causes of postpartum

haemorrhage

TONE uterine atony (most common,

70% PPH cases)
TRAUMA
vulval/perineal/vaginal/cervical/C-section
(20% of cases of PPH)
TISSUE retained placental tissue
(10% of cases of PPH)
THROMBIN (coagulopathy) DIC,
ongoing therapeutic anticoagulation,
maternal bleeding disorder (rarely the
primary cause of PPH)

Risk factors for PPH

Associated with a substantial increase in risk of PPH
antepartum haemorrhage (especially placental abruption and
placenta praevia)
PPH with a previous pregnancy
known abnormal placental adherence (e.g. accreta, increta or
percreta)
multiple pregnancy (e.g. twins and higher order multiples)
disorders of haemostasis
inherited bleeding disorders
Associated with a significant though smaller increase in
risk:
grand multiparity (more than five previous births)
pre-eclampsia
macrosomia
maternal obesity
elective or previous LUSCS

Risk factors for PPH

During labour and birth

need for, and use of, oxytocics in labour

prolonged labour (especially prolonged second

and/or third stage)

pyrexia

instrumental and surgical delivery

episiotomy

placental retention

Discuss the differences between primary and

secondary PPH

2o PPH: Excessive uterine bleeding >24hr

and <6/52 postpartum, most commonly 714 days postpartum
Main causes

Retained placental tissue

+/- infection (e.g. endometritis)