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

  • Signs of shock
    • Increased RR
    • Pulse weak and fast (more than 100bpm) or difficult to feel
    • Central capillary refill longer than 2 seconds
    • Pale, cool, moist skin
    • Restless, confused, drowsy, occasionally unconscious
    • Low BP for age or relative to person's previously recorded values

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

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