06/06/2026
MANAGEMENT OF POST PARTURM HAEMORRHAGE
Introduction
Post-partum haemorrhage (PPH) is one of the most alarming and serious emergencies a midwife may face and is especially terrifying if it occurs immediately, following a straight forward birth. It is always a frightening experience for the woman and can underrate her confidence, influence her attitude towards future child bearing and delay her recovery. In Zambia PPH is major contributor to maternal mortality( 25%).the midwife is often the first and may be the only professional person present when haemorrhage occurs, so her prompt competent action is crucial in saving women’s lives. If Zambia has to achieve SDG number three (3) which is good health and wellbeing this is an area to pay attention to.
Definition
This is bleeding from the ge***al tract after delivery of the baby amounting to 500mls or more or any amount of bleeding the can cause deterioration in the patient’s condition (Ngoma, 2003).
Types
There two major types; primary and secondary PPH
Primary PPH
This occurs within 24 hours of delivery, which is termed as critical.
This is the most severe and common one of the emergencies in obstetrics.
Secondary PPH
Occurs any time from 24 hours to 6 weeks postpartum.
Primary PPH
The main causes of Primary PPH are ;
• Uterine atony
• Lacerations of the ge***al tract
• Retained placental fragments
• Blood coagulation problems
Uterine atony( the commonest), bleeding from the placental site, due to lack of tone of the uterine muscle es, or any condition interfering with contraction and retraction of the uterine muscles. The major causes of atony are; prolonged labour/difficult labour (an exhausted uterus), polyhydramnios, incomplete placental separation, retained cotyledons, placental fragments or membranes, precipitate labour, placenta praevia, placenta abruptio, general anaesthesia, full bladder, mismanagement of third stage of labour.
Prolonged labour.
In a labour where the active phase lasts for more than 12 hours, uterine inertia may result from muscles exhaustion.
Precipitate labour
When the uterus has contracted vigorously and frequently resulting in duration of a labour that is one hour, then the muscles may have sufficient opportunity to retract.
Polyhydramnios
The myometrium becomes excessively stretched and therefore less efficient.
Placenta praevia
The placental site is partially or wholly in the lower segment, where the thinner muscle layer contains few oblique fibres; this results in a couvelaire uterus.
General anaesthesia
Anaesthetic agents may uterine relaxation, in particular the volatile inhalation agents, for example halothane.
Mismanagement of third stage of labour
Fundus fidgeting or manipulation of the uterus may precipitate arrthymic contraction so that the placenta only partially separates and retraction is less.
A full bladder
If the bladder is full , its proximate to the uterus in the abdomen on completion of the second stage may interfere with uterine contraction.
Incomplete placental separation; if the placenta remains fully attached to the uterine wall, its unlikely to cause bleeding. However, once separation has begun, maternal vessels are torn. If placental tissue remains partially imbedded in the spongy decidua efficient contraction and retraction are interrupted.
Retained cotyledon
These will simply impend efficient muscle action.
TRAUMATIC CAUSES
These are further subdivided into 3
Lacerations of the cervix; may be due to
• Premature bearing down
• Delivery of the after coming head of breech
• Forceps deliveries and especially rotational forceps delivery
• Internal versions (these lacerations can extend up into the body of the uterus causing uterine rupture).
Lacerations of the va**na; may be due to
• Primi gravida
• Delivery of babies with large presenting diameters of the head
• Large, persistent OPP, face or after coming head in a breech presentation
• Contracted pelvis
• Manipulations and forceps delivery
Lacerations of the perineum or v***a (including the l***a and cl****is)
• Bad management of the 2nd stage of labour not delivering the smallest diameter or not performing an episiotomy when one is indicated.
• Too rapid deliveries (precipitate labour, an uncontrolled patient).
• Delivery of large diameters of the head (large babies, persistent OPP etc).
• Manipulations and forceps delivery
• Rigid perineum
• Tears of l***a and cl****is can occur if the midwife tries to preserve the integrity of the perineum at all costs.
COAGULATION DISODERS
Conditions interfering with maternal blood clotting, mechanism. These including;
• DIC hypofibrogenemia.
• Conge***al blood clotting defects (lack of clotting factors).
• Other conditions interfering with maternal blood clotting, such heparinization of the mother.
Clinical features
These will depend on the cause
a) Atonic uterus; this will feel large soft and high up in the abdomen (the fundus of the uterus will be felt near the level of the umbilical; cord or above and also displaced to the right or left.).
b) Vaginal bleeding; this could be gushes ( when the uterus is rubbed up or massaged)
c) Traumatic
• The uterus will feel contracted
• Bleeding; the bleeding from any part of birth canal will ape ravenous bleeding, a steady stream of dark red blood.
• Arterial bleeding spurts of bright red blood, corresponding to the patients pulse.
• Combined .
d)Coagulation failure
• Prolonged clotting time (normal 6- 8 minutes).
• Evidence of generalised bleeding (haematuria, nasal bleeding, bleeding from the veins- punctured sites).
• Unless this condition has been recognised and corrected before delivery, bleeding will continue despite all attempts to control it.
HYPOVOLAEMIC SHOCK
In any of these types of haemorrhage, signs of shock may not appear immediately, as the cardiovascular system may compensate at first. However, shortly after this, the patient may suddenly collapse and if adequate treatment is not commenced immediately, the shock will become irreversible and death becomes inevitable.
MANAGEMENT OF PPH
Aims
• Treat the cause
• Control bleeding]
• Prevent complications
Immediate management
The three basic principles of care should be applied immediately upon observing that there is excessive bleeding;
• Call for medical aid
• Stop the bleeding
• Resuscitate the mother
Call for medical aid
This is an important initial step so that help is on the way whatever transpires if bleeding is brought under control before the doctor arrives then no action by the doctor will be needed. However, the woman’s condition can deteriorate very rapidly, in which case medical assistance will be required urgently. If the mother is at home or a midwife led unit, the emergency department of the closet obstetric unit should be contacted and depending on the policy of the department, the team may be summoned or ambulance transfer arranged. Mean while, check the vital signs, if in shock, manage immediately; start an Intravenous line ringer’s lactate, apply NASG if allowed.
Non-Pneumatic Anti-Shock Garment (NASG)
• NASG is a simple device that counteracts shock and decreases blood loss by applying direct counter pressure to the lower parts of the body.
• Developed by NASA 20+ yrs. ago
• Useful as a first aid tool that
• Keeps woman alive during prolonged transportation to reach help.
• Physiology – shunts blood to vital organs (anti-shock)
• During delays, provides up to 48hrs stability
• Neoprene and Velcro
• In 2008 growing clinical evidence for PPH use (UCSF)
• Ongoing demonstrations in India and Nigeria (Pathfinder)
• Expensive, poor quality controls
• It can very easily and quickly be applied. Application requires about 2 minutes
• Can be used by persons with minimal training
• Within 2-5 minutes of application most patients with severe shock regain consciousness and vital signs begin to stabilize
• The Non Pneumatic Garment is less expensive and simpler than predecessors
• It also has less danger of excessive pressures due to over-inflation
Stop the bleeding
If the placenta is inside the uterus
The patient’s bladder should be empty. If this has been attended to earlier, then a catheter should be inserted without delay. In order to control bleeding, first priority is to stimulate the uterus to contract and second to get the placenta out of the uterus. The uterine muscles can then remain contracted and retracted. With this in mind, the midwife can then proceed as follows;
Rub up a contraction
Give oxytocin 10 units start/ repeated. Alternatively ergometrine 0.25- 0.5 mg may be injected IV which will be affected within 45 seconds. If possible put the baby to the breast to start sucking, so that more oxytocin will be produced.
Rub up a contraction again
Apply CCT if separation has taken place with the next contraction but if bleeding continues and is over and above 500mls, send for MO and transfer patient to hospital immediately.
If CCT is successful and placenta is out, expel the clots as well. If CCT is unsuccessful and bleeding continues, a second attempt of CCT must be tried, if it fails and patient is still bleeding. Do manual removal of the placenta. It means that it has failed to separate, and this is a retained placenta this is diagnosed when the placenta remains in situ 30 minutes to one hour after delivery of the baby. The management is usually manual removal. (Refer to the procedure manual p. 73).
Management ;where the placenta and membranes are already delivered.
If the uterus is atonic following delivery of the placenta, light fundal pressure may be used to expel residual clots whilst a contraction is stimulated.
Empty the bladder and give oxytocin 10 IU IM start
If an effective contraction is not maintained, 40 IU in oxytocin in a litre of IV fluids should be commenced. The placenta and membranes must be examined for completeness because retained fragments are often responsible for uterine atony.
Bimanual compression
If the bleeding continues, bimanual compression of the uterus may necessary in order to apply pressure to the placental site. It is desirable for intravenous infusion to be in progress. The fingers of one hand are inserted into the va**na like a cone, the hand is formed into a fist and placed into the anterior va**na fornix, the elbow resting on the bed. The other hand is placed behind the uterus abdominally, the fingers pointing towards the cervix. The uterus is brought forwards and compressed between the palm of the hand positioned abdominally and the fist in the va**na. If bleeding persists, a clotting disorder must be excluded. Perform a bedside clotting test (if the clot does not clot within 7 minutes or a clot that down easily suggest a coagulopathy).
If still bleeding continues, hysterectomy is done
Management in traumatic post-partum haemorrhage
If bleeding occurs despite a well contracted uterus, it almost certainly the consequence of trauma to the uterus, va**na, perineum, l***a or a combination of these.
In order to identify the source of bleeding the mother is placed in the lithotomy position under a good directed light. An episiotomy wound or tears to the anterior l***a, cl****is and perineum often bleed freely. These external injuries are easily identified and torn vessels may be clamped with artery forceps prior to ligation. Internal trauma to the va**na, cervix or uterus commonly occurs following instrumental or manipulative delivery.
A speculum is inserted to enable the cervix and va**na to be clearly visualised and examined. Tissue or artery forceps may be used to apply pressure prior to suturing under G.A . If bleeding persist when the uterus is well contracted and no evidence of trauma can be found, uterine rupture must be suspected. Following a lap, this is repaired, but if bleeding remains uncontrolled, an hysterectomy may be inevitable.
Management due to coagulation failure
This can occur following severe pre Eclampsia, antepartum haemorrhage , amniotic fluid embolism, IUD or sepsis. Fresh blood is usually the best treatment as this will contain platelets and the coagulation factors V and VII. Sometimes only fresh frozen plasma and fibrinogen are given.
Resuscitation of the mother
The aims of resuscitation are to restore circulation and assess and correct the postnatal Hb level.
An intravenous infusion should be commenced while peripheral veins are easily negotiated. This will provide a route for oxytocin infusion or fluid replacement. As an emergency measure, the mother’s legs may be lifted in order to allow blood to drain from them into the central circulation. However, the foot of the bed should not be raised as this encourages pooling of blood in the uterus contracting.
It is usually expedient to catheterise the bladder in order to minimise trauma should an operative procedure be necessary and exclude a full bladder as the cause of further bleeding
On no account should a woman in a collapsed state be moved prior to resuscitation and stabilisation, if measure are successful in controlling the any further loss, administration of oxytocin 40 IU in a litre of ringers lactate infused slowly over 8- 12 hours will ensure continued uterine contraction. This will help to minimise the risk of recurrence. Before this collect blood for HB and x- match.
Subsequent care
Once bleeding is controlled the total volume lost must be estimated as accurately as possible. Large amounts appear less than they are in reality.
Maternal pulse and BP are recorded every quarter hourly and temperature every 4 hours.
The uterus should be palpated frequently to ensure that it remains well contracted and lochia must be observed. IV therapy must be carefully observed to avoid circulatory overload.
Fluid intake and urinary output are recorded as indicators of renal function. The output should be carefully measured on an hourly basis by the use of self retaining catheter. The woman remains in labour ward until her condition is stable. All records should be meticulasouly completed and signed as soon as possible. Continued vigilance will be important for 24 – 48 hours. As soon as woman will need a quiet period for recuperation, a single room may be offered and visitors restricted only to close relatives. Discharge can only be considered after 2- 3 days.
Complications
Severe haemorrhage leading to;
Tubular nephrosis and anuria
Liver, lung, brain and retinal damage
Sheehan’s syndrome
Maternal death
puerperal sepsis due to;
retained products
Anaemia
Infections introduced by high rate of interference in the cause and treatment of primary PPH
SECONDARY POSTPARTUM HAEMORRHAGE
The main causes are;
Retained products of conception
Presence of large uterine clot
Signs and symptoms
Lochia is heavier than normal and has a bright red colour, it may be offensive if there is infection
Fever
Tachycardia
sub involution
Management
Call for the Doctor
Reassure the woman and her support person.
Rub up a contraction by massaging the uterus if its still palpable.
Expel any clots
Encourage the woman to empty the bladder
Give uretonic drugs such as ergometrine IV
Keep all pads and linen to assess the blood loss.
If bleeding persist discuss other range of management, prepare her for theatre.
Careful assessment is usually undertaken prior to the uterus being explored under G.A. Normally ultra sound is used. If the products of conception cannot be seen on a scan, the woman is treated conservatively with antibiotics and oral ergometrine. HB should be estimated prior to discharge. If below 9 gm commence the woman on iron therapy.
Subsequent care
Lactation may be compromised, reassure that the woman it will be resumed soon.
Control the haemoglobin levels/ control anaemia
Start the patient on broad spectrum antibiotics in high doses ( amoxicillin 500mg tds, gentamycin 160mg tds and metrodinadazole 400mg).
Prevention of PPH
The use of uterotonics for the prevention of PPH during the third stage of labour is recommended for all births, Oxytocin (10 IU, IV/IM) is the recommended uterotonic drug for the prevention of PPH. In settings where oxytocin is unavailable, the use of other injectable uterotonics (if appropriate ergometrine/methylergometrine or the fixed drug combination of oxytocin and ergometrine) or oral misoprostol (600 μg) is recommended. In settings where skilled birth attendants are not present and oxytocin is unavailable, the administration of misoprostol (600 μg PO) by community health care workers and lay health workers is recommended for the prevention of PPH.
In settings where skilled birth attendants are available, CCT is recommended for va**nal births if the care provider and the parturient woman regard a small reduction in blood loss and a small reduction in the duration of the third stage of labour as important In settings where skilled birth attendants are unavailable, CCT is not recommended.
Late cord clamping (performed after 1 to 3 minutes after birth) is recommended for all births while initiating simultaneous essential new-born care.
Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women.BoRecommendations for the treatment of PPH
Intravenous oxytocin alone is the recommended uterotonic drug for the treatment of PPH.
If intravenous oxytocin is unavailable, or if the bleeding does not respond to oxytocin, the use of intravenous ergometrine, oxytocin-ergometrine fixed dose, or a prostaglandin drug (including sublingual misoprostol, 800 μg) is recommended.
Managing all antenatal conditions that might lead to PPH in the antenatal period
Keeping the bladder empty throughout all stages of labourBox C: Organization of care
The use of formal protocols by health facilities for the prevention and treatment of PPH is recommended
The midwife should anticipate for hypofibrogenemia in cases of abruption- placentae and prolonged retention of a dead fetus.
Conclusion
Zambia is headed to achieving the MDGs particularly, no. 5 (reducing maternal mortality by ¾ by 2015). PPH is the major contributor to MMR. Rapid, Aggressive, Timely and Skilled interventions actions are critical for survival and reduce the MMR to the expected figures. PPH however, sometimes may led to serious complications that have life time consequences. It’s therefore imperative that this is avoided.
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PARTUM HAEMORRHAGE
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