Postpartum haemorrhage

Overview

•Primary PPH - blood loss ≥500 ml within 24 hours of delivery
•Secondary PPH - abnormal bleeding from 24 hours to 12 weeks postpartum

Presentation

•Excessive vaginal bleeding - bright red and brisk, or slower with clots
•Boggy, poorly contracted uterus - hallmark of uterine atony on bimanual examination
•Tachycardia - earliest compensatory sign; do not wait for hypotension
•Hypotension - late sign indicating decompensation
•Fresh vaginal bleeding in labour - warrants continuous CTG monitoring (NICE guideline); may indicate placental abruption or praevia
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Tachycardia is the earliest and most reliable haemodynamic indicator of significant blood loss. A postpartum woman with HR >100 bpm must be treated as haemorrhaging until proven otherwise - do not wait for hypotension. Blood loss is consistently underestimated by 30-50%.

Investigations

🥇 First-line

•FBC, coagulation screen (PT, APTT, fibrinogen), group and crossmatch (≥4 units packed red cells), U&E, ABG with lactate

🏆 Gold standard

•Direct inspection of placenta and membranes immediately after delivery
•Secondary PPH: Pelvic/transabdominal ultrasound - identify retained products of conception

Management

Immediate · All primary PPH
  1. 1Call for senior obstetric and anaesthetic help immediately
  2. 2Activate major haemorrhage protocol if loss >1000 ml or haemodynamic compromise
  3. 3Two large-bore IV cannulae, catheterise bladder
  4. 4Send FBC, coagulation, crossmatch
  5. 5Oxytocin 10 IU IV/IM + tranexamic acid IV
  6. 6Bimanual uterine massage for atony
Secondary PPH - retained products
Surgical evacuation (ERPC) under GA or regional anaesthesia
Secondary PPH - endometritis
Broad-spectrum antibiotics (e.g. co-amoxiclav or metronidazole + co-amoxiclav); admit and resuscitate if haemodynamically unstable

Prevention

•Active management of third stage (NICE recommended) - reduces PPH risk by ~60%: oxytocin 10 IU IM after delivery of anterior shoulder, controlled cord traction, uterine massage
•Treat antepartum anaemia - Hb <110 g/L at delivery significantly increases severe PPH morbidity

Complications

Key complications
Hypovolaemic shock
DIC - consumption coagulopathy, worsens bleeding
Acute kidney injury
Sheehan's syndrome - pituitary necrosis; failure to lactate + secondary amenorrhoea
ARDS - massive transfusion
Death - leading cause of maternal death worldwide
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Secondary PPH is most commonly caused by retained products of conception (Tissue). Always exclude retained products with ultrasound before attributing secondary PPH to infection alone.

Causes - The 4 T's

4 T's of PPH
CauseDetailsTiming
ToneUterine atony (~70%) - failed 'living ligature' contractionPrimary (most common)
TraumaLacerations, uterine rupture - instrumental delivery, precipitate labourPrimary
TissueRetained placenta/membranes prevent uterine contractionSecondary (most common cause)
ThrombinCoagulopathy (DIC, inherited disorders) - cause and consequence of massive PPHPrimary or secondary