Postpartum Haemorrhage (PPH) Management

Clinical assessment

Based on observed or estimated excessive blood loss postpartum, combined with clinical assessment of uterine tone (palpation), inspection for genital tract tears, and checking for retained placenta/products. Assess for signs of shock.

Investigations

• Visual estimation or quantification of blood loss (pad counts, weighing swabs/drapes)
• Abdominal palpation for uterine tone and size
• Speculum examination to inspect cervix and vagina for tears
• Manual exploration of the uterus (if suspect retained products or rupture - requires analgesia/anaesthesia)
• Continuous vital signs monitoring (HR, BP, RR, SpO2)
• Haemoglobin (Hb) / Hematocrit (Hct) - baseline and serial
• Blood group and cross-match (essential - request blood products early)
• Consider coagulation studies (Platelets, PT/INR, aPTT, Fibrinogen) if coagulopathy suspected or massive transfusion

Diagnostic criteria

Blood loss >500 mL (vaginal delivery) or >1000 mL (caesarean section) within 24 hours (Primary PPH), or significant bleeding between 24h and 6 weeks (Secondary PPH).

Non-pharmacological management

• Call for Help! (Mobilize team, notify senior staff/specialist).
• Simultaneous Resuscitation (ABCDE approach) and Identifying/Treating Cause.
• Airway & Breathing: High-flow oxygen.
• Circulation: Secure large-bore IV access (x2 if possible). Commence rapid IV fluid resuscitation (warmed crystalloids - NS 0.9% or RL, e.g., 2L fast, then titrate to response). Monitor vital signs.
• Uterine Massage: Continuous external massage if uterus is atonic.
• Empty Bladder: Insert Foley catheter.
• Identify Cause (4 Ts):
• - Tone: Continue massage, administer uterotonics (see pharmacological).
• - Tissue: Inspect placenta for completeness. If retained, perform manual removal (under analgesia/anaesthesia). Ensure uterus is empty.
• - Trauma: Systematically inspect perineum, vagina, cervix for tears. Repair lacerations.
• - Thrombin: Consider coagulopathy if bleeding persists despite other measures, or known risk factor. Manage with blood products (FFP, platelets, cryoprecipitate) based on lab results/clinical picture (hospital level).
• If bleeding continues despite uterotonics and massage:
• - Bimanual Uterine Compression.
• - Intrauterine Balloon Tamponade (UBT) insertion.
• - Application of Non-pneumatic Anti-shock Garment (NASG) - especially useful during transport.
• Surgical measures (Hospital level): Uterine artery embolization, Compression sutures (e.g., B-Lynch), Hysterectomy (last resort).

Pharmacological treatment

• Uterotonics (for Uterine Atony):
• - Oxytocin: 10 IU IM or slow IV push. Can add 20-40 IU to 1 Litre IV fluids and infuse rapidly (e.g., 500ml over 30 min, then 250ml/hr). FIRST LINE.
• - Ergometrine: 0.2 mg IM or slow IV. Repeat once after 15 min if needed. CONTRAINDICATED in hypertension/pre-eclampsia. (Can be given combined with oxytocin as Syntometrine).
• - Misoprostol: 800 micrograms sublingually (or rectally/orally). Useful if oxytocin unavailable or ineffective.
• - Carbetocin: 100 mcg IV/IM (single dose) - Primarily used for PREVENTION, NOT standard treatment of established PPH per UCG.
• Antifibrinolytic:
• - Tranexamic Acid (TXA): 1 gram slow IV (over 10 minutes) given ASAP within 3 hours of delivery. Repeat 1 gram IV after 30 minutes if bleeding continues.
• Blood Products Transfusion: Based on estimated blood loss, haemodynamic status, Hb levels. Use cross-matched blood when possible. Consider early transfusion in massive PPH.
• Antibiotics: Prophylactic antibiotics (e.g., Ampicillin 2g IV + Metronidazole 500mg IV stat) if manual removal of placenta, significant trauma, or prolonged procedure. Treat vigorously if infection suspected (secondary PPH).
• Follow specific Ugandan treatment algorithms/guidelines for PPH management.

Monitoring

Continuous monitoring of: Vital signs (HR, BP, RR, SpO2), Vaginal bleeding (estimate ongoing loss), Uterine tone and size, Urine output, Level of consciousness. Monitor response to interventions. Keep accurate records.