Prevention and Management of Postpartum Haemorrhage

Definitions

Primary PPH: blood loss from the genital tract of 500ml or more within 24 hours of delivery
Minor PPH: 500-1000ml
Major PPH: >1000ml (moderate 1000-2000ml, severe >2000ml)
Massive PPH: >2000ml or rate of loss >150ml/min or >50% blood volume lost
Secondary PPH: abnormal bleeding from the genital tract between 24 hours and 12 weeks postpartum

Risk Factors

Antenatal: previous PPH, multiple pregnancy, polyhydramnios, high parity, fibroids, placenta praevia, placenta accreta spectrum, BMI >35, maternal age >40, pre-eclampsia, anaemia
Intrapartum: prolonged labour, augmented labour, precipitate labour, operative vaginal delivery, caesarean section, general anaesthesia, episiotomy/perineal tears, chorioamnionitis, retained placenta

Four T's of PPH

Tone (70%): uterine atony — most common cause
Trauma (20%): genital tract lacerations, uterine rupture, uterine inversion
Tissue (10%): retained placenta or placental fragments, placenta accreta
Thrombin (<1%): coagulopathy — DIC, pre-existing bleeding disorder, anticoagulant therapy

Prevention

Active management of the third stage reduces PPH risk by 60%
Components: prophylactic uterotonic, controlled cord traction, early cord clamping (if PPH risk high)
First-line prophylactic uterotonic: oxytocin 10 IU IM or 5 IU slow IV
For caesarean section: oxytocin 5 IU slow IV
Higher-risk women: consider carbetocin 100mcg IV or oxytocin + ergometrine (Syntometrine)

Stepwise Management Algorithm

Call for help — multidisciplinary team, senior obstetrician, anaesthetist, haematologist
ABC assessment — two large-bore IV cannulae (14G), bloods (FBC, coag, crossmatch 4 units), fluid resuscitation
Identify and treat cause (4 T's)
Bimanual uterine compression (rubbing up the fundus)
Pharmacological management (see below)
Intrauterine balloon tamponade (Bakri balloon)
Surgical interventions if pharmacological measures fail
Interventional radiology (uterine artery embolisation) if available
Hysterectomy as last resort

Pharmacological Interventions

Drug	Dose	Route	Notes
Oxytocin	5 IU slow IV or 40 IU in 500ml infusion	IV	First-line
Ergometrine	500mcg	IM or slow IV	Contraindicated in hypertension, pre-eclampsia
Carboprost (Hemabate)	250mcg, repeat every 15min (max 8 doses)	IM (intramyometrial)	Contraindicated in asthma
Misoprostol	800-1000mcg	Sublingual/rectal	Useful when IV access unavailable
Tranexamic acid	1g IV over 10min	IV	Give within 3 hours of onset (WOMAN trial)

Surgical Interventions

B-Lynch suture (uterine compression suture)
Internal iliac artery ligation
Uterine artery ligation
Selective arterial embolisation (interventional radiology)
Subtotal or total hysterectomy — definitive treatment when all else fails

Massive Transfusion

Activate massive transfusion protocol early
Target ratio: 1 unit FFP per 1 unit packed red cells
Consider cryoprecipitate if fibrinogen <2g/L
Point-of-care coagulation testing (TEG/ROTEM) guides targeted replacement
Cell salvage may be used in obstetric haemorrhage

Important Facts for MRCOG

Uterine atony is the most common cause of primary PPH (70%)
Active management of the third stage is recommended for all women
Tranexamic acid should be given within 3 hours (WOMAN trial evidence)
Carboprost is contraindicated in asthma
Ergometrine is contraindicated in hypertension/pre-eclampsia
B-Lynch suture is a fertility-preserving surgical option
PPH is the leading direct cause of maternal death globally

Source: RCOG Green-top Guideline No. 52 (2016 (updated 2022))

Read the original on rcog.org.uk

Clinically reviewed by NHS obstetricians and gynaecologists · Source last updated 2016 (updated 2022)

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