Critical Procedure - Post-partum haemorrhage

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For all procedures, ask yourself, 'does this need to be done 'now vs later'? And should this be done by 'me vs someone else?' Very often the answers will be 'now' and 'me' - so read on!

Post-partum Haemorrhage

 

Description

Initial steps to mangage PPH.

Indications

Early PPH.

Contraindications

See under specific drugs.

Equipment

Preferably a pre-prepared 'PPH tray' with all medications and equipment ready.
Drugs Oxytocin, Carboprost
Hands.
Gloves.
Large bore IV cannulae
N. Saline
Sponge forceps and gauze
Sims speculum

Procedure

Much needs to be done - be organised and delegate when possible.

If severe, consider External Aortic Compression early.


The vast majority of PPH will be controlled by ensuring the placenta is out, uterine massage/bimanual compression and uterotonic drugs (see below) - so don't panic, but act now.

Management is directed at the 4 T's, whilst remembering the ABC’s.

The following should be carried out 'in parallel' ie. at the same time.

Uterine massage / bimanual compression.Bimanual compression of the uterus

Establish large bore vascular access early but do not delay manual procedures for doing this.  Equally, do not delay setting up an Oxytocin IV.   If vascular access is delayed, consider giving  10 Units Oxytocin IM.

Hang 1L N Saline containing Oxytocin 20-40 units/L IV wide open (or  20 to 40 IU in 250 mL of normal saline, infused IV at an hourly rate of 500 to 1000 mL).

Oxygen by mask.

Group and crossmatch, CBC, clotting studies.  Request blood either crossmatched or 'O Rh neg'

Consider urinary catheterisation.


Search for the cause with a careful examination of the patient and the placenta. Look for and correct th 4 T's (see below)


Review the 4T's if haemorrhage is not controlled by the above measures.

 

Tone
Tissue
Trauma
Thrombin
Uterine massage.
Bimanual compression of uterus
(one hand in vagina, the other on
the fundus, compress together).
Drugs (see below).
Tamponade with urinary catheter balloon with 60-80mls of sterile water/saline - or Sengstaken Blakemore oesophageal tube
Delivery of the placenta.
Manual removal of placental tissue or clots.
Manual exploration or curettage of uterine cavity.
Correct uterine inversion.
Repair laceration.
Identify uterine rupture.
Reverse anticoagulation.
Replace factors.



Drugs

All, except TXA, increase uterine tone.  TXA in not first line but can be given following the other drugs.

Oxytocin

Action: Causes myometrial contraction
20-40 units/L IV wide open
10 units IM/IMM (intramuscular or intramyometrial)
5 units IV bolus IV bolus
Side effects: Chest pain, headache, nausea, vomiting
Contraindications: None

Ergonovine/ergometrine/methyl-ergonovine

0.25 mg IM - can repeat in 15 mins. then 2-4 hourly.  Maximum dose 1.25mg (5 doses of 0.25mg)
0.125 mg IV Give every 15 min, if needed, Max 5 doses
Side effects: Peripheral vasospasm, hypertension, nausea & vomiting. Interacts with drugs used to treat HIV
Contra-indication: Hypertension

Carboprost (Hemabate)

0.25 mg IM/IMM Give at maximum of every 15 min as needed. Max 8 doses
Side effects: Flushing, diarrhoea, nausea, vomiting, bronchospasm, flushing, restlessness, oxygen desaturation
Cautions: Asthma, hypertension, hypotension
Contra-indications: Hepatic and renal disease. Active cardiac or pulmonary disease

Misoprostol

400-800 micrograms SL/PO Oral/SL work faster than rectal.
800-1000 micrograms PR
Use: A useful alternative if oxytocin is not available, SL and Oral routes are simpler than parenteral administration required for the other uterotonic drugs.
Side effects: Nausea and vomiting, diarrhoea, abdominal pain,pyrexia
Contra-indications: None

Tranexamic Acid

1g IV over 10 minutes, then 1g IV 30 minutes later NB. Not a uterotonic agent so prioritize the above
Side effects: (Rarely) nausea and vomiting


Potential pitfalls

Not calling for help early.
Not realising the urgency.
Being slow to administer Oxytocin (remember to give it IM if vascular access is delayed).
Inadequate performance of uterine massage or bi-manual compression because of panic and distractions.
Not requesting blood early.

"Plan B"

Surgical help.  More drugs

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Last modified: Sunday, 27 March 2016, 8:30 AM