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

Flowchart 1.3 Management of primary postpartum haemorrhage

Flowchart 1.4 If placenta not delivered within 30 minutes of birth 

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
  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 

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