Secondary postpartum haemorrhage

Abnormal vaginal bleeding between 24 hours and 6 weeks after birth

Causes

• Retained products (part of placenta or membranes left inside uterus)
• Endometritis (infection in uterus)
• Other — cervical polyps, cancer, blood clotting disorders
• May be more than 1 cause

Do not

• Do not let woman eat or drink anything — may need operation — consider IV fluids

Check first

Do first — if emergency

If vaginal blood loss of 500mL or more OR any bleeding that causes signs of shock

• Medical consult
• Give oxygen to
• Target O₂ sats 94–98%
• OR if moderate/severe COPD — 88–92%
• Put in IV cannula — largest possible
• Give normal saline — 1L straight away
• If you can't get IV cannula in — put in intraosseous needle
• Put in indwelling urinary catheter
  
• Do hourly measures — aim for 0.5mL/kg/hr
• Give oxytocin IM — 10 international units, single dose
• Feel uterus. If soft/boggy — see Rubbing up a contraction
• Prepare oxytocin infusion (40 international units in 1L normal saline)
• If directed to by doctor — give misoprostol rectal — 800microgram, single dose

Look — in file notes

• Date and details of birth — type of birth (more common after lower uterine caesarean section and if there was chorioamnionitis during labour) — estimated blood loss, were placenta and membranes thought to be complete, any perineal tears or episiotomy, any complications, eg infections during or after birth
• Last Hb and vaginal swab results
• Contraception used since birth — especially Depo-Provera or ENG-implant. Could it be causing bleeding
• Medical history, allergies, medicines

Ask

• Bleeding — how much, what colour, bad smell, any clots, has it stopped since birth
• When did bleeding become heavy
• Did bleeding start after sex
• Could this be first period
• Did anything cause bleeding to start (eg injury)
• Pain — where, when did it start
• Any other symptoms — fever, chills, nausea, vomiting

Check

• Urine for U/A, send for MC&S
• Blood loss
  
• Check woman's clothing
• Is blood coming from vulva, vagina or rectum
• Colour — bright, dark
• Clots — how big, any smell
• Measure and record blood loss
• Get a pad and weigh it. Put pad between woman’s legs. Change pad each time you check
• Save and weigh all used pads — 1g increase=1mL loss
• 1 soaked pad holds about 100mL
• Head-to-toe exam — with attention to
• Abdomen — feel for tenderness, rebound, guarding
• Uterus — tender, painful, hard or soft. If soft/boggy — see Rubbing up a contraction
• Speculum exam if skilled
• Look at vulva and perineum for sores, bleeding, infected tears
• Try to see where bleeding coming from — may need to swab out vagina
• Is cervix open or closed. If open — remove any tissue caught in cervix using sponge forceps. Save all clots and tissue
• High vaginal swab for MC&S and endocervical swabs for MC&S, gonorrhoea, chlamydia and trichomonas NAAT
• Look for infected tears of vagina or cervix
• Bimanual exam, if skilled
• Tenderness, masses, size of uterus, is cervix painful when moved

Do

• POC test — Hb
• Take blood for serum beta hCG, blood cultures before giving antibiotics
• If well, no signs of infection, only small amount of blood loss (less than 500mL) — medical consult about treating in community
• See — Childbirth postpartum infections

Send to hospital if

• Heavy bleeding and/or shock
• Unwell and/or temp more than 38°C
• Severe abdominal pain
• Possible retained products
• Diagnosis uncertain

Medical consult about antibiotics

• Give amoxicillin OR ampicillin IV — adult 2g, single dose AND metronidazole IV — adult 500mg, single dose AND gentamicin IV — doses — single dose
• THEN amoxicillin OR ampicillin IV — adult 1g, every 6 hours (qid) AND metronidazole IV — adult 500mg, every 12 hours (bd)
• If delay in sending to hospital of more than 24 hours — give gentamicin once a day — doses if directed by doctor
• If allergy to penicillin — medical consult

While waiting for evacuation

• Explain to woman what is happening and why
• Consider appropriate escort for baby, who will go with mother
• Continue management as directed by doctor