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This is excessive bleeding following delivery and is described as primary and secondary.
- Minor PPH is estimated blood loss of up to 1000 mls.
- Major PPH is any estimated blood loss over 1000 mls.
Shah Jehan built the Taj Mahal in memory of his third wife, Mumtaz Mahal, who died giving birth to her fourteenth child, apparently of a PPH, in 1631.
Primary postpartum haemorrhage
The causes of PPH have been described as the "four T's":
- Tone: uterine atony, distended bladder.
- Trauma: lacerations of the uterus, cervix, or vagina.
- Tissue: retained placenta or clots.
- Thrombin: pre-existing or acquired coagulopathy.
The most common cause of PPH is uterine atony, followed by retained placenta.
Obstetric haemorrhage is no longer a major cause of maternal death in the UK. In the 2006-2008 report of the UK Confidential Enquiry into Maternal Deaths, haemorrhage was the sixth highest direct cause of maternal death; a rate lower than the two previous triennia.
Studies quote an incidence of PPH of around 5-10%[4, 5]. Incidence of severe PPH (blood loss >1000 ml or life-threatening) is quoted as around 0.3-1.86% depending on definition, and with regional variation.
- Antenatal risk factors:
- Antepartum haemorrhage in this pregnancy.
- Placenta praevia (12 x risk).
- Suspected or proven placental abruption.
- Multiple pregnancy (5 x risk). Also other causes of uterine over-distention such as polyhydramnios or macrosomia.
- Pre-eclampsia or pregnancy-induced hypertension (4 x risk).
- Grand multiparity (four or more pregnancies).
- Previous PPH (3 x risk) or previous history of retained placenta.
- Asian ethnic origin (2 x risk).
- Maternal obesity. Body mass index >35 kg/m2(2 x risk).
- Existing uterine abnormalities.
- Maternal age (40 years or older).
- Maternal anaemia. Hb <9 g/dL (2x risk).
- Factors relating to delivery:
- Emergency caesarean section (4 x risk).
- Elective caesarean section (2 x risk) - especially if >3 repeat procedures.
- Retained placenta (5 x risk).
- Mediolateral episiotomy (5 x risk).
- Induction of labour (2 x risk).
- Operative vaginal delivery (2 x risk).
- Labour of >12 hours (2 x risk).
- >4 kg baby (2 x risk).
- Maternal pyrexia in labour (2 x risk).
- Pre-existing maternal haemorrhagic conditions:
- Symptoms: continuous bleeding, which fails to stop after delivery of the placenta - third stage.
- Signs: loss of >1000 ml may be accompanied by clinically apparent shock, ie tachycardia, hypotension.
Haemolysis, Elevated Liver enzymes and Low Platelets (HELLP). See separate article HELLP syndrome for more information.
Ideally one of the emergency drills to be practised by the team on the labour ward.
A woman who will refuse blood products should have a management plan agreed early in the pregnancy, in case of haemorrhage.
Royal College of Obstetricians and Gynaecologists (RCOG) guidelines recommend four components of management to be instigated at the same time, once PPH has been identified. These are:
Alert all relevant professionals. In minor PPH, this is the midwife in charge, and first-line obstetric and anaesthetic staff. For major PPH, this also includes alerting the obstetric, anaesthetic and haematology consultants as well as the blood transfusion laboratory and porters.
IV access with a 14-gauge cannula, and commence crystalloid infusion for minor PPH.
For major PPH:
- Assess airway, breathing, circulation.
- Oxygen by mask at 10-15 litres per minute.
- IV access with 2 x 14-gauge cannulae.
- Keep the woman lying flat and warm.
- Transfuse blood as soon as available. Until available, transfuse up to 2 litres of warmed crystalloid Hartmann's solution and/or 1-2 litres of colloid. Infusions should be warmed and a blood filter not used. In the absence of cross-matched blood, components may be required in line with local hospital guidelines and haematological advice.
- Recombinant factor VIIa (rFVIIa) is increasingly frequently used for arresting bleeding in severe haemorrhage.
3. Monitoring and investigation
For minor PPH, FBC, blood group, coagulation screen. Monitor pulse and blood pressure every 15 minutes.
For major PPH:
- FBC, coagulation screen, baseline U&E, LFT.
- Crossmatch 4 units of blood minimum.
- Continuous monitoring of pulse, blood pressure, respiratory rate and urine output.
- Temperature monitoring every 15 minutes.
- Consider arterial line monitoring and ITU transfer.
- Records of all parameters on flow chart - for example, the modified obstetric early warning system (MEOWS) charts.
4. Measures to arrest the bleeding
- Examination to establish cause, and exclude other causes than uterine atony (the most common cause).
- If the cause is established to be uterine atony, the following measures are taken in turn:
- Bimanual uterine compression to stimulate contraction.
- Ensure the bladder is empty.
- Oxytocin 5 units by slow IV infusion. May require repeat. The latest Cochrane review supports the use of oxytocin as first-line treatment.
- Ergometrine 0.5 mg slow IV or IM unless there is a history of hypertension.
- Oxytocin infusion unless fluid restriction is necessary.
- Carboprost 0.25 mg IM repeated to a maximum of 8 doses unless there is a history of asthma. It is licensed only for bleeding after a caesarean section in Europe. It is also sometimes used off licence as an intramyometrial injection.
- Misoprostol 1000 micrograms rectally. The Cochrane review determined misoprostol is not as effective as oxytocin, but may be helpful in low resource settings, as it does not need refrigeration or infusion.
- If these physical and pharmacological methods are not succeeding, surgical options as follows:
- Balloon tamponade.
- Haemostatic brace suturing - eg, the B-Lynch compression suture.
- Bilateral ligation of the uterine arteries.
- Bilateral ligation of the internal iliac arteries.
- Selective arterial embolisation.
- Hysterectomy should be considered early, especially in cases of placenta accreta or uterine rupture. If possible, a second consultant should be involved in this decision.
- Hypovolaemic shock.
- Disseminated intravascular coagulation.
- Acute kidney injury.
- Liver failure.
- Acute (adult) respiratory distress syndrome.
The Confidential Enquiry into Maternal Deaths for 2006-2008 reported nine deaths related to obstetric haemorrhage in that triennium.
In the UK the risk of death from PPH has been estimated as 1 in 100,000 deliveries.
The active management of the third stage of labour significantly reduces the risk of PPH. Prophylactic oxytocics should be routinely used in the third stage of labour, as they decrease the risk of PPH by 60%[1, 2]. For most women delivering vaginally, oxytocin 5 or 10 IU IM is the prophylactic agent of choice. It is used as an infusion for women having caesarean sections. Syntometrine® (oxytocin plus ergometrine) may also be used in the absence of hypertension. Although oxytocin is the management of choice, in low resource settings misoprostol is an alternative[13, 14]. Its advantages are that it can be given orally. One study found it was more effective when given sublingually.
Women at risk of PPH should be identified, and the place of their delivery planned accordingly.
Secondary postpartum haemorrhage
This commonly presents in primary care as prolonged or excessive bleeding once the woman has returned home after delivery.
The two most common causes are:
- Infection - endometritis. This occurs in 1-3% after spontaneous vaginal delivery. It is the most common cause of postnatal morbidity between day 2 and day 10. Risk factors are:
- Caesarean section, prolonged rupture of membranes, severe meconium staining in liquor, long labour with multiple examinations, manual removal of placenta, mother's age at extremes of the reproductive span, low socio-economic status, maternal anaemia, prolonged surgery, internal fetal monitoring and general anaesthetic.
- Retained products of conception (RPOC).
Symptoms vary but may include:
- Abdominal pain.
- Offensive smelling lochia.
- Abnormal vaginal bleeding - postpartum haemorrhage.
- Abnormal vaginal discharge.
- General malaise.
Look for history of extended labour, difficult third stage, ragged placenta, PPH.
There may be:
- Tenderness of the suprapubic area and adnexae.
- Elevated fundus which feels boggy in RPOC.
- Blood cultures.
- Check MSU.
- High vaginal swab; also gonorrhoea/chlamydia.
- Ultrasound - may be used if RPOC are suspected, although there may be difficulty distinguishing between clot and products. RPOC are unlikely if a normal endometrial stripe is seen. Ultrasound is not helpful in endometritis.
- If sepsis is suspected in the community, urgent referral to hospital is indicated where 'red flag' signs and symptoms are present. If the woman appears seriously unwell, by emergency ambulance:
- Pyrexia >38 degrees C.
- Sustained tachycardia (more than 90 bpm).
- Breathlessness (respiratory rate > 20 breaths per minute - a serious symptom).
- Abdominal or chest pain.
- Diarrhoea and/or vomiting.
- Uterine or renal angle pain and tenderness.
- Woman is generally unwell or seems unduly anxious/distressed.
- Speculum examination will allow visualisation of the cervix and lower genital tract to exclude lacerations. If a clot is visible within the cervical os, it may be removed with tissue forceps (although few GPs regularly carry these), allowing the cervix to close.
- For endometritis: IV antibiotics if there are signs of severe sepsis. If less systemically unwell, oral treatment may be sufficient. Antibiotic choice should be guided by type and likely source of infection, as well as by local prescribing guidelines. The RCOG guideline for sepsis following pregnancy recommends IV piperacillin/tazobactim. For severe sepsis, carbapenem plus clindamycin. Other options, for less severe infections include co-amoxiclav, metronidazole and gentamicin. However, it stresses guidelines based on local resistance should be followed
- If RPOC are suspected, elective curettage with antibiotic cover may be required. Surgical measures should be undertaken if there is excessive or continuing bleeding, irrespective of ultrasound findings. A senior obstetrician should be involved in decisions and performance of any evacuation of RCOP, as these women are carrying a high risk of uterine perforation.
- The patient may require iron supplementation if Hb has fallen. Warn of the risk of constipation.
90% of cases of postpartum endometritis treated with antibiotics improve within 48-72 hours. If this is not the case, the patient should be re-evaluated.
Further reading and references
A practical guideline for the haematological management of major haemorrhage; British Committee for Standards in Haematology (Jul 2015)
FIGO Guidelines: Prevention and treatment of postpartum hemorrhage in low-resource settings; International Journal of Gynecology and Obstetrics 117 (2012) 108–118
Saving Mothers' Lives. Reviewing maternal deaths to make motherhood safer: 2006-2008; Centre for Maternal and Child Enquiries (CMACE), BJOG, Mar 2011
Fullerton G, Danielian PJ, Bhattacharya S; Outcomes of pregnancy following postpartum haemorrhage. BJOG. 2013 Apr120(5):621-7. doi: 10.1111/1471-0528.12120. Epub 2013 Jan 23.
Carroli G, Cuesta C, Abalos E, et al; Epidemiology of postpartum haemorrhage: a systematic review. Best Pract Res Clin Obstet Gynaecol. 2008 Dec22(6):999-1012. doi: 10.1016/j.bpobgyn.2008.08.004. Epub 2008 Sep 25.
Intrapartum care: care of healthy women and their babies during childbirth; NICE Clinical Guideline (Dec 2014)
Silver RM, Landon MB, Rouse DJ, et al; Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006 Jun107(6):1226-32.
Magon N, Babu K; Recombinant Factor VIIa in Post-partum Hemorrhage: A New Weapon in Obstetrician's Armamentarium. N Am J Med Sci. 2012 Apr4(4):157-62. doi: 10.4103/1947-2714.94938.
Singh S, McGlennan A, England A, et al; A validation study of the CEMACH recommended modified early obstetric warning system (MEOWS). Anaesthesia. 2012 Jan67(1):12-8. doi: 10.1111/j.1365-2044.2011.06896.x. Epub 2011 Nov 9.
Mousa HA, Blum J, Abou El Senoun G, et al; Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev. 2014 Feb 132:CD003249.
Price N, B-Lynch C; Technical description of the B-Lynch brace suture for treatment of massive postpartum hemorrhage and review of published cases. Int J Fertil Womens Med. 2005 Jul-Aug50(4):148-63.
Cantwell R, Clutton-Brock T, Cooper G, et al; Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG. 2011 Mar118 Suppl 1:1-203. doi: 10.1111/j.1471-0528.2010.02847.x.
Prata N, Bell S, Weidert K; Prevention of postpartum hemorrhage in low-resource settings: current perspectives. Int J Womens Health. 2013 Nov 135:737-52. doi: 10.2147/IJWH.S51661. eCollection 2013.
Hundley VA, Avan BI, Sullivan CJ, et al; Should oral misoprostol be used to prevent postpartum haemorrhage in home-birth settings in low-resource countries? A systematic review of the evidence. BJOG. 2013 Feb120(3):277-85
Bellad MB, Tara D, Ganachari MS, et al; Prevention of postpartum haemorrhage with sublingual misoprostol or oxytocin: a double-blind randomised controlled trial. BJOG. 2012 Jul119(8):975-82
French LM, Smaill FM; Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. 2004 Oct 18(4):CD001067.
Mulic-Lutvica A, Axelsson O; Postpartum ultrasound in women with postpartum endometritis, after cesarean section and after manual evacuation of the placenta. Acta Obstet Gynecol Scand. 200786(2):210-7.
Bacterial Sepsis following Pregnancy; Royal College of Obstetricians and Gynaecologists (April 2012)