Postpartum haemorrhage (PPH)

Postpartum haemorrhage (PPH)

Postpartum haemorrhage (PPH) is abnormal uterine bleeding following delivery up to 6 weeks (42 days) postpartum. It is classified into primary and secondary PPH.

Primary postpartum haemorrhage

Primary PPH is typically defined as blood loss of more than 500 mL after vaginal delivery or more than 1000 mL after caesarean section within the first 24 hours after delivery. It may also be defined as any amount of blood loss after delivery that results in haemodynamic instability.

Management of postpartum haemorrhage at the dispensary and health centre

• Insert two large-bore IV cannulas and start rapid infusion of compound sodium lactate or 0.9% sodium chloride

• Start oxytocin (IV) 20 IU in 500 mL normal saline at a rate of 20 drops per minute

• Ensure there are no retained placental tissues

• Clamp or ligate any bleeding perineal tears

• Massage the uterus

• Insert a urethral catheter

Referral

• If bleeding continues, immediately refer the patient to a hospital with an escort by a skilled health attendant

• Maintain IV fluid infusion during transfer

Management of postpartum haemorrhage at the hospital

• Call for help and mobilize resources

• Obtain blood samples for haemoglobin level, blood grouping, and cross-matching

• Insert two large-bore IV cannulas and rapidly infuse compound sodium lactate or 0.9% sodium chloride

• Give blood transfusion depending on the amount of blood loss

• Start oxytocin (IV) 20 IU in 500 mL compound sodium lactate or 0.9% sodium chloride and titrate at 20 drops per minute

OR

• Misoprostol (PO) 1000 mcg or per rectum

• Perform additional interventions as indicated, including:

  • Balloon tamponade

  • Total abdominal hysterectomy (TAH)

  • Internal iliac artery ligation

  • B-Lynch suture

  • Other surgical interventions depending on patient condition and available expertise

Prevention of postpartum haemorrhage: Active management of the third stage of labour (AMTSL)

• Ensure there is no remaining second twin

Give one of the following uterotonics:

• Oxytocin (IM) 10 IU

OR

• Misoprostol (PO) 600 mcg

• Controlled cord traction (CCT) is recommended for vaginal births

• Sustained uterine massage is not recommended for prevention of PPH in women who have received prophylactic oxytocin

Prevention of postpartum haemorrhage during caesarean section

• Oxytocin (IV/IM) 10 IU is the recommended uterotonic for prevention of PPH during caesarean section

• Cord traction is the recommended method for removal of the placenta during caesarean section.