1. Postpartum Haemorrhage

2. Definitions Primary PPH – blood loss of 500ml or more within 24hours of delivery. Secondary PPH – significant blood loss between 24 hours and 6 weeks after birth.

3. Why do we care? Major obstetric haemorrhage – more than 1000ml Very rapidly lead to maternal death

4. 3 rd highest cause of direct maternal death in the UK and Ireland (2003-2005) 58% of these cases care was “seriously substandard” Major cause of severe maternal morbidity in “near-miss audits”

5. Risk Factors Most cases have no risk factors Previous PPH Antepartum haemorrhage Grand multiparity Multiple pregnancy Polyhydramnios Fibroids Placenta praevia Prolonged labour (&oxytocin)

6. Prevention Be aware of risk factors – may present antenatally or intrapartum Treat anaemia antenatally Active management of the 3 rd stage Prophylactic oxytocics reduce the risk of PPH by 60% (oxytocin or oxytocin & ergometrine) 5IU IM for vaginal delivery 5IU IV for LSCS Consider oxytocin infusions

7. 4 T’s Tone Tissue Thrombin Trauma

8. Causes Tone Previous PPH Prolonged labour Age > 40 years Big baby Multiple pregnancy Placenta praevia Obesity Asian ethnicity Tissue Retained placenta/ membrane/clot

9. Thrombin Abruption PET Pyrexia Intrauterine death Amniotic fluid embolism DIC Trauma Caesarean section (emergency > elective) Perineal trauma Operative delivery Vaginal and cervical tears Uterine rupture

10. Blood loss is commonly underestimated Loss may be well-tolerated Beware the “trickle” and the “moderate lochia” Minor PPH can easily progress to major PPH.

11. Management Has the placenta been delivered and is it complete? Is the uterus well-contracted? Is the bleeding due to trauma?

12. Resuscitation A & B – 10 -15l/min O2 by facemask C - 2 14 gauge cannulae blood for Hb, U&E, LFTs, clotting crossmatch 4 units 2 litres of crystalloid rapidly transfuse as soon as possible – consider O – ve blood if any delays.

13. Uterine Contraction-First Line Drugs Oxytocin 5IU Oxtocin infusion – 40IU in 500mls Ergometrine 0.5mg Carboprost (Haemabate©) 0.25mg IM every 15 minutes x 8 doses Misoprostol 600 mcg sublingually

14. Uterine Contraction – non-pharm Empty uterus Foley catheter Rub up a contraction Bimanual compression Balloon tamponade Brace suture Uterine artery ligation Internal iliac artery ligation Interventional radiology

15. Hysterectomy – before it’s too late

17. B-Lynch Suture

18. Balloon Tamponade

19. Haematological Management DIC Transfuse without delay Involve haematology service at an early stage Correct coagulopathy Liase with consultant haematologist re use of recombinant Factor V11 (Novoseven©) and Fibrinogen.

20. Traumatic for patient, family and staff. Debriefing for patient and staff. Case analysed to ensure care was of good standard and any substandard care can be improved.

21. Secondary PPH Infection Retained placenta Trophoblastic disease Antibiotics Evacuation of retained products if bleeding persistent or significant amount of tissue retained.