SDMS ID: P2010/0496-001 2.

9/09WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Purpose: Postpartum haemorrhage (PPH) remains one of the main causes of maternal morbidity. Early recognition of PPH, followed by systematic evaluation and treatment and prompt fluid resuscitation are essential to minimise morbidity and mortality. Definition: Primary PPH is defined as blood loss of 500ml or more during and in the first 24 hours after childbirth: severe PPH is defined as blood loss of 1000ml or more OR Any amount of blood loss postpartum that causes haemodynamic compromise. Prevention Active management of the third stage of labour is recommended for all women. The risk of PPH can be reduced by 50% with routine administration of oxytocic drugs as part of active third stage management. All women should be fully informed of the current evidence regarding benefits and harms of active and physiological management of the third stage of labour. This includes the recommended use of oxytocics for the prevention of PPH and associated side effects and risks. Risk factors for PPH Abnormalities of uterine contraction (Tone) 70% Genital tract trauma (Trauma) 20% Retained products of conception (Tissue) 10% Abnormalities of coagulation (Thrombin) 1% See appendix 1 antenatal and intrapartum risk factors Preventative management in woman identified at risk includes: Insert large bore (16FG or larger) IV cannula at the onset of labour or when risk factor identified Take blood for FBC and group and hold Active management of third stage with Syntometrine (as per general orders) in the absence of hypertension Prophylactic Syntocinon infusion post partum Management of Postpartum Haemorrhage Management of Postpartum Haemorrhage WACSClinProc2.9/06 Management of Post Partum Haemorrhage Midwifery and Medical Staff, Queen Victoria Maternity Unit PPH, haemorrhage

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Clinical assessment of blood loss Degree of Shock

Compensation Blood loss Blood pressure changes (systolic pressure) Signs and symptoms 500-1000 ml 10-15% None Mild Shock 1000-1500ml 15-25% Slight fall (80-100 mmHg) Weakness Sweating Tachycardia Moderate Shock 1500-2000ml 25-35% Marked fall (70-80 mmHg) Restlessness Pallor Oliguria Severe Shock 2000-300ml 35-45% Profound fall (50-70 mmHg) Collapse Anuria

Palpitation Dizziness Tachycardia

Management of PPH Call for help call Code Obstetric Explain nature of the emergency to woman and her support people Deliver the placenta Massage the fundus Insert two large bore IV cannulas Commence IV fluids Hartmanns or Normal Saline, infuse rapidly Give or repeat o Oxytocin (Syntocinon) 10 units IMI as per general orders o or Ergometrine and oxytocin (Syntometrine) 1ml IMI (only if not hypertensive) as per general orders o or Ergometrine maleate (Ergot) 500 micrograms IMI or 250 micrograms IV(only if not hypertensive) as per general orders Commence IV Oxytocin (Syntocinon) 40 units in 1000L Normal Saline at a rate of 250ml/hr via pump. If no IV access and/or blood loss > 1000ml give Misoprostol (Cytotec) 1000 micrograms rectally (as per standing orders) can be initiated by midwifery staff. Consider ABC - Facial oxygen Monitor BP, pulse, respiration Consider IDC and commence fluid balance monitoring Bimanual compression Check placenta complete Check for trauma/lacerations apply pressure Consider thrombin is the blood clotting? Consider clotting screen Measure all blood loss Prepare for transfer to operating theatre If blood loss is extreme consider aortic compression with a fist in the epigastrium Consider Dinoprost (Prostaglandin F2 alpha) woman must have IV access and cardiac monitoring with resuscitation equipment and an anaesthetist on standby. Other drug therapy that maybe used in consultation with a haematologist o Carboprost (Haemabate) stored in pharmacy o Recombinant Factor VII Interventional radiology Arterial embolization

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Surgical Management Intrauterine tamponade and packing Suturing of lower genital tract trauma Laparotomy o Consider rupture of uterus (especially if previous caesarean section) o B Lynch suture o Uterine artery ligation o Internal iliac artery ligation o Hysterectomy Postnatal Considerations Debriefing for woman and her support people Increased risk of infection Delayed lactation Iron deficiency anaemia Exposure to blood products Haemorrhagic shock, Coagulopathy Renal necrosis Surgical intervention Attachments
Attachment 1 Attachment 2 Attachment 3 Attachment 4 Attachment 5 Attachment 6

Antenatal and Intrapartum Risk Factors for PPH A stepwise approach to the management of PPH Drug therapy for management of PPH B-Lynch Suture Technique References Additional Reading

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years. Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Developed By: Stakeholders:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Date: 3 August 2009

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APPENDIX 1 Antenatal and Intrapartum Risk Factors for PPH Cause Aetiology Process
Abnormalities of uterine contraction (Tone) atonic uterus over distended uterus

Clinical Risk Factors

physiological management of third stage rd prolonged 3 stage (more than 30 minutes) polyhydramnios multiple gestation macrosomia rapid or incoordinate labour st nd prolonged labour (1 or 2 stage) labour dystocia high parity labour augmented with Syntocinon pyrexia prolonged ROM (more than 24 hours) magnesium sulphate, nifedipine, salbutamol, general anaesthetic fibroid uterus uterine anomalies labour induced labour augmented with Syntocinon labour dystocia malposition precipitous delivery operative delivery (vacuum or forceps) malposition deep engagement previous uterine surgery rd strong cord traction in 3 stage, especially with fundal placenta short umbilical cord high parity relaxed uterus, lower segment & cervix placenta accreta, especially fundal congenital uterine weakness or anomalies antepartum use of magnesium sulphate or oxytocin incomplete placenta at delivery placenta accreta or percreta previous caesarean or other uterine surgery high parity abnormal placenta on USS atonic uterus bruising elevated BP, HELLP fetal death pyrexia, CBC antepartum haemorrhage (current or previous) sudden collapse

70%
uterine muscle exhaustion

intra amniotic infection drug induced hypotonia functional or anatomic distortion of the uterus episiotomy or lacerations (cervix, vagina or perineum)

Genital tract trauma (Trauma)

20%
extensions, lacerations at caesarean section uterine rupture uterine inversion

Retained products of conception (Tissue)

retained placenta abnormal placenta retained cotyledon or succenturiate lobe retained blood clots coagulation disorders acquired in pregnancy Idiopathic Thrombocytopenic Purpura (ITP) Von Willebrands disease Haemophilia carrier Disseminated Intravascular Coagulopathy (DIC) pre-eclampsia dead fetus in utero severe infection abruption amniotic fluid embolus therapeutic anti-coagulation

10%
Abnormalities of coagulation (Thrombin)

1%

history of blood clot

NSW Department of Health Policy Directive 2005 Postpartum haemorrhage (PPH) Framework for prevention, early recognition & management Management of Post Partum Haemorrhage May-11 4 WACS Clinproc2.9

APPENDIX 2 A stepwise approach to the management of PPH

Step 1 Initial Assessment and Treatment Early recognition, prompt resuscitation, identify cause of bleeding, baseline lab tests Resuscitation Assess Aetiology Laboratory Tests CALL FOR HELP abdominal assessment of FBC uterus (tone, tissue) two large bore IV (16g) coagulation screen explore lower genital tract oxygen by mask ABO group and cross match (trauma) monitor BP, pulse, respiration, review history (thrombin) urine output, other symptoms (eg pain) observe clots +/- catheter +/- oxygen saturation Step 2 Directed Therapy Treat cause, massage/compress uterus, oxytocic for atony, evacuate clots or retained products, repair trauma, reverse coagulation defects Tone Tissue Trauma Thrombin uterine massage manual removal correct inversion reverse anticoagulation bi-manual curettage repair laceration compression replace factors identify rupture oxytocic drugs haematoma Misoprostol (rectally) Step 3 Intractable PPH Multidisciplinary team, compression / packing / vasopressin / angiographic embolization, fluid & blood components to maintain haemodynamic & coagulation status Individualised management according to situation, medical experience, and the facilities and personnel available. Ongoing monitoring, replacement of blood & clotting factors Get Help Local Control BP and Coagulation nd 2 obstetrician/gynae bi-manual compression crystalloid surgeon experienced in the +/- pack uterus / vaginal to blood products management of massive, allow adequate replacement intractable PPH of volume, blood & clotting In consultation with haematologist: factors prior to definitive anaesthetist Carboprost (15-methyl PGF2) surgery coagulation team (Haemabate) +/- embolism OT, lab and ICU staff Recombinant Factor VII Dinoprost (Prostaglandin F2 Alpha) Step 4 Surgery An experienced gynaecological surgeon to locate the source and stem bleeding / peripartum hysterectomy Examination under An experienced Hysterectomy. This may be anaesthetic gynaecological surgeon will the safest option for a less carry out the most appropriate experienced surgeon or when Repair lacerations procedure to reduce blood vascular ligation fails supply to the uterus Step 5 Post Hysterectomy Bleeding If consumptive coagulopathy present with continued widespread bleeding Abdominal Packing Angiographic embolization as available Senior obstetrician gynaecologist to liaise with Dr Marcus Mykytowycz 0409 994201

NSW Department of Health Policy Directive 2005 Postpartum haemorrhage (PPH) Framework for prevention, early recognition & management
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APPENDIX 3 Drug therapy for management of PPH Drug

Syntocinon (Synthetic oxytocic) OR IV Syntocinon 5 units bolus x 2 5 minutes apart to avoid hypotension If Syntocinon has been given and the placenta is out insert two large bore IV cannulas (16G) and commence: 40u Syntocinon in 1000ml Hartmanns at 250ml/hr IV Hartmanns or 0.9% Sodium Chloride IM Syntometrine 1ml following expulsion of placenta, or when bleeding occurs Repeat dose of 1ml after no less than two hours if necessary The total dose given in 24 hours should not exceed 2ml.

Dose & Route

IM Syntocinon 10 units

Side Effects
usually none facilitates lactation painful contractions nausea, vomiting (water intoxication) transient vasodilation & hypotension if undiluted IV doses high doses or prolonged administration in electrolyte free fluids can cause water intoxication from antidiuretic effect

Contraindications
hypersensitivity to drug

Syntometrine (Ergometrine maleate 0.5mg: Oxytocin 5IU per ml)

nausea, vomiting uterine hypertonicity & abdominal pain headache, dizziness skin rashes hypertension bradycardia cardiac arrhythmia chest pain anaphylactoid reactions

Ergometrine maleate

Ergometrine 500 micrograms IM OR Ergometrine 250 micrograms IV. This should be injected slowly over one minute or diluted to a volume of 5ml with sodium chloride 0.9% before administration to prevent serious side effects. The total dose given in 24 hours should not exceed 1000 micrograms.

nausea, vomiting abdominal pain headache dizziness rash peripheral vasoconstriction hypertension cardiac arrhythmias chest pain anaphylactoid reactions

any suspicion of retained placenta exclude twin pregnancy hypersensitivity to ergometrine, other ergot alkaloids or any ingredient in the preparation history of hypertension eclampsia pre-eclampsia severe or persistent sepsis heart disease peripheral vascular disease impaired vascular disease impaired hepatic or renal function any suspicion of retained placenta exclude twin pregnancy hypersensitivity to ergometrine, other ergot alkaloids or any ingredient in the preparation history of hypertension eclampsia pre-eclampsia or current diastolic equal or greater than 90mmHg severe or persistent sepsis heart disease peripheral vascular disease impaired hepatic or renal function

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APPENDIX 3 Drug therapy for management of PPH Drug

Carboprost (Haemabate) (15-methyl PGF2)

Dose & Route

Used in consultation with haematologist 250 micrograms by deep IM injection Repeat if necessary at intervals of not less than 15 minutes to a maximum total dose of 2mg Can be given by direct intramyometrial injection 5mg/ml diluted in 9ml normal saline. Inject 0.5mg (1ml) transabdominally into the myometrium on each side of the fundus, or 1mg (2ml of prepared solution) into the uterine fundus. This can be repeated if atonia present at the doctors discretion to a maximum of 3 mg. Transcervical injection at 9 and 23 oclock to help contract the uterine arteries. Ensure IV access, cardiac monitoring and oxygen therapy are in place prior to administration. Resuscitation equipment should be available and an anaesthetist on standby

Side Effects
nausea, vomiting, diarrhoea hypertension dyspnoea bronchospasm pulmonary oedema transient pyrexia

Contraindications
caution in women with asthma, hypertension, renal or hepatic disease

Dinoprost (Prostin F2 alpha)

nausea, vomiting headache, flushing, pyrexia cardiac arrest relative risks include pelvic infections or previous caesarean uterine rupture

caution in women with asthma, hypertension, active cardiac, renal or hepatic disease hypersensitivity

Misoprostol (Cytotec)

1000 micrograms rectally if IV access not available and blood loss approaching 1000ml

Diarrhoea Abdominal pain

Known allergy to prostaglandin caution in women with asthma

NSW Department of Health Policy Directive 2005 Postpartum haemorrhage (PPH) Framework for prevention, early recognition & management.

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ATTACHMENT 4 The B-Lynch Surgical Technique The principle The suture aims to exert continuous vertical compression on the vascular system. In the case of post partum haemorrhage from placenta praevia, a transverse lower segment compression suture is effective. The technique It is assumed the surgeon is right handed and standing on the right-hand side of the patient. A laparotomy is always necessary to exteriorise the uterus. A lower segment transverse incision is made or the recent lower segment Caesarean section suture removed to check the cavity for retained placental fragments and to swab it out. Test for the potential efficacy of the B-Lynch suture before performing the procedure The patient is placed in the Lloyd Davies or semi-lithotomy position. An assistant stands between the patients legs and intermittently swabs the vagina to determine the presence and extent of the bleeding. The uterus is then exteriorized and bimanual compression performed. To do this, the bladder peritoneum is reflected inferiorly to a level below the cervix. The whole uterus is then compressed by placing one hand posteriorly with the ends of the fingers at the level of the cervix and the other hand anteriorly just below the bladder reflection. If the bleeding stops on applying such compression, there is a good chance that application of the B-Lynch suture will work and stop the bleeding. Suture application Given that the test criteria for the B-Lynch suture placement are met, the uterus remains exteriorized until application of the suture is complete. The senior assistant takes over in performing compression and maintains it with two hands during the placement of the suture by the principal surgeon. 1. First stitch relative to the low transverse Caesarean section/hysterotomy wound. With the bladder displaced inferiorly, the first stitch is placed 3 cm below the Caesarean section/hysterotomy incision on the patients left side and threaded through the uterine cavity to emerge 3 cm above the upper incision margin approximately 4 cm from the lateral border of the uterus. The fundus The suture is now carried over the top of the uterus and to the posterior side. Once situated over the fundus, the suture should be more or less vertical and lie about 4 cm from the cornu. It does not tend to slip laterally toward the broad ligament because the uterus has been compressed and the suture milked through, ensuring that proper placement is achieved and maintained. The posterior wall The location on the posterior uterus where the suture is placed through the uterine wall is actually easy to surface mark posteriorly. It is on the horizontal plane at the level of the uterine incision at the insertion of the uterosacral ligament. Role of the assistant As the operation proceeds, the assistant continues to compress the uterus as the suture is fed through the posterior wall into the cavity. This will enable progressive tension to be maintained as the suture begins to surround the uterus. Assistant
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2.

3.

4.

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compression will also help to pull the suture material through to achieve maximum compression, without breaking it, at the end of the procedure. Furthermore, it will prevent suture slipping and uterine trauma. The suture now lies horizontally on the cavity side of the posterior uterine wall. 5. The fundus As the needle pierces the uterus cavity side of the posterior wall, it is placed over the posterior wall, bringing the suture over the top of the fundus and onto the anterior right side of the uterus. The needle re-enters the cavity exactly in the same way as it did on the left side, that is 3 cm above the upper incision and 4 cm from the lateral side of the uterus through the upper incision margin, into the uterine cavity and then out again through 3 cm below the lower incision margin. Later role of the assistant The assistant maintains the compression as the suture material is milked through from its different portals to ensure uniform tension and no slipping. The two ends of the suture are put under tension and a double throw knot is placed for security to maintain tension after the lower segment incision has been closed by either the one- or two-layer method. Relation to the hysterotomy incision The tension on the two ends of the suture material can be maintained while the lower segment incision is closed, or the knot can be tied first, followed by closure of the lower segment. If the latter option is chosen, it is essential that the corners of the hysterotomy incision be identified and stay sutures placed before the knot is tied. This ensures that, when the lower segment is closed, the angles of the incision do not escape it. Either procedure works equally well. It is important to identify the corners of the uterine incision to make sure no bleeding points remain unsecured, particularly when most of these patients are hypotensive with low pulse pressure at the time of the B-Lynch suture. Post-application and hysterotomy closure It is probably that the maximum effect of suture tension lasts for only about 24 48 hours. Because the uterus undergoes its primary involutionary process in the first week after vaginal or caesarean delivery, the suture may have lost some tensile strength, but hemostasis would have been achieved by that time. There is no need for delay in closing the abdomen after the application of the suture. The assistant standing between the patients legs swabs the vagina again and can confirm that the bleeding has been controlled.

6.

8.

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ATTACHMENT 5 REFERENCES American Academy of Family Physicians 2000 Advanced life support in obstetrics (ALSO) course syllabus (4th edn). American Academy of Family Physicians, Kansas B-Lynch C, Keith L, Lalonde A & Karoshi M, A textbook of postpartum haemorrhage: A comprehensive guide to the evaluation, management and surgical intervention 2006 Sapiens Publishing, United Kingdom. Enkin M, Keirse J, Neilsen J et al 2000 A guide to effective care in pregnancy and childbirth. Oxford University Press, London NSW Department of Health Policy Directive Postpartum haemorrhage (PPH) Framework for prevention, early recognition & management. Online: http://www.health.nsw.gov.au/policies/PD/2005/PD2005_264.html Pairman S, Pincombe J, Thorogood C, Tracy S, Midwifery preparation for practice 2006 Elsevier Australia

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