Primary post-partum haemorrhage is the loss of >500 ml of blood per-vagina within 24 hours of

delivery. It can be classified into two main types:

 Minor PPH – 500-1000ml of blood loss

 Major PPH – >1000ml of blood loss

It is a major cause of obstetric morbidity and mortality worldwide.

In this article, we shall examine the risk factors, clinical features and management of a primary post-
partum haemorrhage.

Aetiology and Risk Factors:

The causes for primary post-partum haemorrhage can be broadly categorised by the 4 T’s – tone, tissue,
trauma and thrombin.

Tone

‘Tone’ refers to uterine atony, which is the most common cause of primary post-partum haemorrhage.
This is where the uterus fails to contract adequately following delivery, due to a lack of tone in the
uterine muscle.

The risk factors for uterine atony include:

 Maternal profile: Age >40, BMI > 35, Asian ethnicity.

 Uterine over-distension – multiple pregnancy, polyhydramnios, fetal macrosomia.
 Labour – induction, prolonged (>12 hours).
 Placental problems – placenta praevia, placental abruption, previous PPH.

Tissue

‘Tissue’ refers to retention of placental tissue – which prevents the uterus from contracting. It is the
second most common cause of 1° PPH

Trauma

This refers to damage sustained to the reproductive tract during delivery (e.g. vaginal tears, cervical
tears). Risk factors include:

 Instrumental vaginal deliveries (forceps or ventouse)

 Episiotomy
 C-section

Thrombin

‘Thrombin’ refers to coagulopathies and vascular abnormalities which increase the risk of primary post-
partum haemorrhage:

 Vascular – Placental abruption, hypertension, pre-eclampsia.

 Coagulopathies – von Willebrand’s disease, haemophilia A/B, ITP or acquired coagulopathy i.e.
DIC, HELLP.

By OpenStax College [CC BY 3.0], via Wikimedia Commons

Fig 1 – Placenta praevia, where the placenta is inserted into the lower uterine segment. It is an
important risk factor for post-partum haemorrhage.

Clinical Features
The main feature of a post-partum haemorrhage is bleeding from the vagina.

If there is substantial blood loss, the patient may complain of dizziness, palpitations, and shortness of
breath.

On Examination:

 General examination may reveal haemodynamic instability with tachypnoea, prolonged

capillary refill time, tachycardia, and hypotension.
 Abdominal examination may show signs of uterine rupture i.e. palpation of fetal parts as it
moves into the abdomen from the uterus.
 Speculum examination may reveal sites of local trauma causing bleeding.
 Examine the placenta to ensure that the placenta is complete (a missing cotyledon or ragged
membranes could both cause a PPH).

By ‫ דולה‬- ‫[ תמרה דהן‬CC BY-SA 3.0], via Wikimedia Commons

Fig 2 – A complete placenta. In the assessment of post-partum haemorrhage, the placenta should be
examined.

Investigations
The initial laboratory tests in primary post-partum haemorrhage include:

 Full blood count

 Cross match 4-6 units of blood
 Coagulation profile
 Urea and Electrolytes
 Liver function tests

Management
The management of primary post-partum haemorrhage should include the simultaneous delivery of
TRIM:

 Teamwork (Immediate Management)

 Resuscitation (Immediate Management)
 Investigations and Monitoring (Immediate Management)
 Measures to arrest bleeding (Definitive Management)

Immediate Management
 Teamwork – Involve appropriate colleagues for minor and major PPH, including the midwife in
charge and midwives, obstetricians, anaesthetists, blood bank, clinical haematologist and
porters. Communication between the team, and diligent documentation is vital.
 Investigations and Monitoring – Investigations as above. Monitoring should include RR, O2 sats,
HR, BP, temperature every 15 mins. Consider catheterisation and insertion of a central venous
line.

Resuscitation
Resuscitate the patient via an A-E approach:
  Airway
o Protect airway (may lose it with reduced levels of consciousness).
 Breathing
o 15L of 100% oxygen through non-rebreathe mask.
 Circulation:
o Assess circulatory compromise (Cap refill, HR, BP, ECG)
o Insert two large bore (14G) cannulas and take blood samples (see below)
 Start circulatory resuscitation. Give cross-matched blood as soon as it is
available, until then give up to 2L of warmed crystalloid and 1-2L of warmed
colloids, then transfuse O negative or uncross matched group specific blood.
o Additional blood productions i.e. factor VIIa in Haemophilia A, and if major haemorrhage
protocol activated may need to supplement fresh frozen plasma, platelets, fibrinogen.
(Discussion with blood bank)
 Disability
o Monitor patient’s Glasgow coma score (GCS).
 Exposure
o Expose patient to identify bleeding sources.

Definitive Management
The definitive treatment for primary post-partum haemorrhage is largely dependent on the underlying
cause:

Uterine Atony

 Bimanual compression to stimulate uterine contraction – insert a gloved hand into the vagina,
then form a fist insider the anterior fornix to compress the anterior uterine wall and the other
hand applies pressure on the abdomen at the posterior aspect of the uterus (ensure the bladder
is emptied by catheterisation).
 Pharmacological measures (Table 1) – act to increase uterine myometrial contraction.
 Surgical measures – intrauterine balloon tamponade, haemostatic suture around uterus (e.g. B-
lynch), bilateral uterine or internal iliac artery ligation, hysterectomy (as a last resort).

By Christopher Balogun-Lynch and Tahira Aziz Javaid [CC BY 3.0]

Fig 3 – Management of PPH; (a) Bimanual compression, (b) Balloon tamponade.

Trauma

Primary repair of laceration, if uterine rupture: laparotomy and repair or hysterectomy.

Tissue

Administer IV Oxytocin, manual removal of placenta with regional or general anaesthetic, and
prophylactic antibiotics in theatre. Start IV Oxytocin infusion after removal.

Thrombin

Correct any coagulation abnormalities with blood products under the advice of the haematology team.

Table 1 – Drugs used in Primary Post-Partum Haemorrhage

Drug Mechanism of Action Side Effects Contraindications
Synthetic oxytocin, act Nausea, vomiting,
Hypertonic uterus,
Syntocinon on oxytocin receptors in headache, rapid infusion à
severe CVS disease
the myometrium hypotension
Hypertension,
Multiple receptor sites Hypertension, nausea,
Ergometrine eclampsia, vascular
action bradycardia
disease
Cardiac disease,
Bronchospasm,
pulmonary disease i.e.
Carboprost Prostaglandin analogue pulmonary oedema, HTN,
asthma, untreated
cardiovascular collapse
PID
 Misoprostol Prostaglandin analogue Diarrhoea
Prevention
Active management of the 3rd stage of labour routinely reduces PPH risk by 60%:

 Women delivering vaginally should be administered 5-10 units of IM Oxytocin prophylactically.

 Women delivering via C-section should be administered 5 units of IV Oxytocin

Shoulder dystocia refers to a situation where, after delivery of the head, the anterior shoulder of the
fetus becomes impacted on the maternal pubic symphysis, or (less commonly) the posterior shoulder
becomes impacted on the sacral promontory.

It is an obstetric emergency, with an incidence of approximately 0.6-0.7% in all deliveries.

In this article, we shall look at the risk factors, clinical features and management of shoulder dystocia.

Pathophysiology
In normal labour, the fetal head is delivered via extension out of the pelvic outlet. This is followed by
restitution of the fetal head, so it lies in a neutral position in relation to its spine. This means the fetal
shoulders now lie in an anterior-posterior position.

Shoulder dystocia occurs when there is impaction of the anterior fetal shoulder behind the maternal
pubic symphysis, or impaction of the posterior shoulder on the sacral promontory. A delay in delivery of
the fetal shoulders leads to hypoxia in the fetus, proportional to the time delay to complete delivery.

Applying traction on the fetal head can result in fetal brachial plexus injury, and is major cause for
litigation in obstetrics.

Adapted from work by OpenStax College [CC BY 3.0], via Wikimedia Commons
Fig 1 – The stages of normal childbirth. Shoulder dystocia commonly occurs at stage 2, where the
anterior shoulder becomes impacted on the maternal pubic symphysis.

Risk Factors
The risk factors for shoulder dystocia can be divided into pre-labour and intrapartum factors:

Pre-Labour Intrapartum
 Previous shoulder dystocia – increases
 Prolonged 1st stage of labour
recurrence risk by x10
 Secondary arrest (when there is initially
 Macrosomia – fetal weight above >4.5kg.
good progress in labour and then
However 48% happen in babies weighing
progress stops, usually due to
<4kg.
malposition of the baby)
 Diabetes – increases risk by x2-4 (due to
 Prolonged second stage of labour (time
increased risk of macrosomia – baby’s
whilst fully dilated and pushing)
weight distribution is disproportionately
 Augmentation of labour with oxytocin
bigger in abdomen compared to head)
 Assisted vaginal delivery (e.g forceps or
 Maternal BMI > 30
ventouse)
 Induction of labour
Clinical Features
Shoulder dystocia is defined by a delay in delivery of the shoulders following the head during a vaginal
delivery with the next contraction after using normal traction.

On examination, signs that may occur to aid the diagnosis are:

 Difficulty in delivery of the fetal head or chin.

 Failure of restitution – the fetal remains in the occipital-anterior position after delivery by
extension and therefore does not ‘turn to look to the side’.
 ‘Turtle Neck‘ sign – the fetal head retracts slightly back into the pelvis, so that the neck is no
longer visible, akin to a turtle retreated into its shell.

Management
REMEMBER – If managed appropriately the risk of permanent brachial plexus injury can be almost
eliminated.

The immediate steps in the management of shoulder dystocia include:

 Call for help – shoulder dystocia is an obstetric emergency (will need senior obstetrician, senior
midwife and paediatrician in attendance).
 Advise the mother to stop pushing – this can worsen the impaction.
 Avoid downwards traction on the fetal head (increases risk of brachial plexus injury) – only use
“routine” axial traction (i.e. keep the head in line with the baby’s spine), and do not apply fundal
pressure (increases the risk of uterine rupture).
 Consider episiotomy – this will not relieve obstruction but can make access for manoeuvres
easier.

First Line Manoeuvres

 McRoberts manoeuvre – hyperflex maternal hips (knees to chest position) and tell the patient
to stop pushing. This widens the pelvic outlet by flattening the sacral promontory and increasing
the lumbosacral angle. This single manoeuvre has a success rate of about 90% and is even higher
when combined with ‘suprapubic pressure’, (see below).
 Suprapubic pressure is applied in either a sustained or rocking fashion to apply pressure behind
the anterior shoulder to disimpact it from underneath the maternal symphysis.

By Alison Martin [CC BY-NC-SA-2.5], via SharingInHealth

Fig 2 – The McRoberts manoeuvre – hyperflexion of the legs to increase the AP diameter of the pelvis.

Second Line (‘Internal’) Manoeuvres

 Posterior arm – insert hand posteriorly into sacral hollow and grasp posterior arm to deliver.
 Internal rotation (“corkscrew manoeuvre”) – apply pressure simultaneously in front of one
shoulder and behind the other to move baby 180 degrees or into an oblique position.

If the above manoeuvres fail then roll patient onto all fours and repeat (this may widen the pelvic outlet
as the legs are abducted and flexed).

Further Manoeuvers
These are only to be considered when the above measures have been unsuccessful, and are very rarely
used in the UK:

 Cleidotomy – fracturing the fetal clavicle.

 Symphysiotomy – cutting the pubic symphysis.
 Zavenelli – returning the fetal head to the pelvis for delivery of the baby via caesarean section.

Post-Delivery
After delivery of the fetus, active management of the 3rd stage of labour is recommended (due to
increased risk of PPH). A PR examination should be performed to exclude a 3rd degree tear.

Shoulder dystocia can be a traumatic experience, particularly if the women does not have regional
anaesthesia. Debrief the mother and birth partner(s), and advise them of the risk of recurrence with any
subsequent delivery.

Consider a physiotherapist review before discharge, as women are at increased risk of pelvic floor
weakness/3rd degree tear, musculoskeletal pain and temporary nerve damage.

Additionally, a paediatric review is recommended before discharge to assess for brachial plexus injury,
humeral fracture or hypoxic brain injury.

Complications
The complications of shoulder dystocia can be divided into maternal and fetal:
  Maternal – 3rd or 4th degree tears (3-4%), post-partum haemorrhage (11%).
 Fetal – humerus or clavicle fracture, brachial plexus injury (2-16%), hypoxic brain injury.

Summary
 Shoulder dystocia is an obstetric emergency that can lead to lasting injury to the baby.
 It is usually unpredictable, but there are risk factors that make it more likely, especially having
had a previous baby with a shoulder dystocia and diabetes.
 Prompt management in a multi-disciplinary team will lead to the best outcomes and training in
skills drills is essential.
 The majority of shoulder dystocias are delivered by McRoberts manoeuvre.