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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 manage PPH.

Indications

More bleeding than usual / than expected, at a delivery

Contraindications

See under specific drugs.

Equipment

Ideally a pre-prepared 'PPH tray' with all medications and equipment is ready.
Drugs: Oxytocin, Ergometrine, Carboprost, Misoprostol, Tranexamic acid
Large bore IV cannulae, IV fluid, blood
Bakri balloon or "Foley, condom and thread"
Sponge forceps and gauze
Sims (weighted) speculum
Good lighting and a stool

Procedure

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

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.

If severe, consider External Aortic Compression early.

Simultaneously / in rapid succession:

***Do not delay manual (hands-on) manoeuvres to get IV access - physical/ manual attempts to stop the bleeding are top priority.

• Call for oxytocin infusion 20-40 units in 1L of NS (saline) - WIDE open.
  
• Placenta in? Try to get it out - continuous cord traction, with your second hand guarding the uterus against inversion.
• Go to bi-manual uterine compression - see image.
  
• Consider early External Aortic Compression (video) if practical - get you some thinking time and time to get organised.
  
• Use Bakri balloon or 'Foley in condom' (video) to try to achieve tamponade of uterine haemorrhage - insert to uterus - fill with 250-500 mL NS (saline) in Bakri balloon or condom whilst holding in place. Ensure is in uterus and not just occluding the vagina and thus hiding bleeding.
  

If not already done:

• Oxygen by mask
• Give blood
• Labwork: Group and cross-match, CBC, clotting studies.
• Empty the bladder.

Vascular access, drawing blood and catheterization should happen in parallel to attempts to find the cause of and stop the bleeding.

Keep searching for the cause/source if bleeding continues. Look for the 4 T's.

The examination is difficult - some tips are:

• be seated comfortably with excellent lighting
• use a Sims (weighted) speculum, or a regular (metal or plastic) speculum, separated into two parts, so you can stretch widely to see. Asking a team member to hold one or more parts while you explore the vagina is helpful++
• have a large supply of gauze squares
• use sponge forceps with gauze loaded, to explore the vagina, pushing on the walls - this enhances the view and might also identify the bleeding site.

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 Bakri balloon / 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, or if other drugs are not available.

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 (**SL/PO 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 realizing 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.
Packing the vagina and hiding ongoing haemorrhage.
Not requesting blood early.

"Plan B"

Surgical help. More drugs

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