Initial steps to manage PPH.
More bleeding than usual / than expected, at a delivery
See under specific drugs.
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
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.
If not already done:
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:
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.
Identify uterine rupture.
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.
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
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
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
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
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
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.
Surgical help. More drugs