Primary postpartum haemorrhage

Related protocols — Bimanual and aortic compression  and Labour and birth- rubbing up a contraction

• Urgent problem — heavy bleeding after birth is an emergency — woman can die from blood loss
• Empty contracted uterus does not bleed heavily
• Heavy bleeding can have more than one cause
• Women with anaemia are at greater risk

• Vaginal blood loss of 500mL or more within first 24 hours after birth OR any bleeding that causes signs of shock. 1 soaked pad is equal to approximately 100mL of blood
• Continuous slow bleeding can result in a large blood loss over time
• Blood loss is often underestimated — woman can lose 1,200–1,500mL of blood before showing any signs of shock

Causes

Common causes can be grouped under the "4 Ts"

• Tone
• Atonic uterus (uterus not contracted) — most common cause. Can be due to oxytocin not given after birth or full bladder stopping uterus from contracting properly
• Trauma
  
• Tears of the birth canal — perineum, vagina, cervix, uterus
• Rupture of uterus
• Broad ligament haematoma (bleeding into tissues next to the uterus from tears in the cervix, upper vagina or uterus)
• Uterine inversion
• Tissue
  
• Placenta not delivered
• Retained products (placenta delivered but placental tissue, membrane or clots still inside uterus) 
• Thrombin
  
• Woman has a disorder that prevents blood from clotting normally. Can develop because of massive blood loss or can be pre-existing

Do first

• Make sure there is only 1 baby by feeling fundus (top of uterus) — should be no higher than umbilicus.
• If second baby — medical/specialist consult

Check

• Uterus has contracted, pulse, BP, vaginal blood loss — every 5 minutes while bleeding THEN every 15 minutes
• Put pad between woman’s legs. Change pad at each check. Save and weigh all pads — 1g increase = 1mL loss

Do

• POC Test — Hb
• Apply non-pneumatic anti-shock garment if available
• Medical consult about further management and sending to hospital
• Examine cervix, vagina, perineum for tears. Manage what you find — see Tears of the birth canal

While waiting for evacuation

• Keep baby with mother and encourage to breastfeed to stimulate contractions
• Make sure clinic staff member stays with woman all the time
• If placenta delivered — send with woman
• Make sure it is labelled
• Double bag then put in pathology transport container with ice brick
• If bleeding settles and uterus stays contracted
• Check vaginal blood loss, fundus, pulse, BP ​every 15 minutes
• Continue oxytocin infusion (40 international units in 1L normal saline) at 250mL/hr ​
• If no infusion pump —​ monitor carefully
• If evacuation delayed — medical consult about how long to continue
• Give IV fluids as directed by doctor
• Do not let woman eat or drink anything — may need operation
• Work out blood loss ​— weigh pads — 1g increase = 1mL loss
• Continue immediate postnatal care for mother and baby
• Continue observations until evacuated