Successful treatment of PPH requires rapid response to bleeding and continual planning of the next step to be taken if the current measures are not enough. It also depends on excellent communication amongst the team with a willingness to ask for help early in the process. The approach is not necessarily a linear one. Multiple measures can and should be instituted simultaneously in order to control bleeding and stabilize the patient.
Choosing the appropriate management of PPH depends on 2 primary factors : Estimated blood loss and mode of delivery. A clinician must first estimate the volume of blood loss clinically. From there, decisions regarding which method(s) to use to manage ongoing excess bleeding depends on the mode of delivery and the most likely etiology of the bleeding.
Situational Awareness – Clinical Recognition of PPH
Approach to Management of PPH following Vaginal Delivery. (for more details see MORE Ob, ALARM)
I. Vaginal Delivery with 500-1000mL estimated blood loss
Attempt to first manage with medical management and minimally invasive procedures.
- Call for help-nursing, anesthesia, lab, consider OR availability
- Begin bimanual uterine massage.-(continuous bimanual compression)
- Continue to monitor vital signs and quantify blood loss.
- Ensure intravenous access with a large gauge catheter(s).
- Start oxytocin 40iu in 1L NS (avoid direct intravenous injection of undiluted oxytocin).
- Draw labs +/- cross match
- Examine for lacerations, retained products of conception, uterine inversion, and other causes of bleeding. Consider bedside ultrasound of uterus. Treat as appropriate (eg, repair lacerations, curettage, reposition uterus, etc).
- Foley catheter collapse bladder and monitor urine output
II. Vaginal Delivery with 1000-1500mL blood loss with ongoing excessive bleeding and/or hemodynamic instability.
- Do all of the above.
- Draw blood for baseline labs (complete blood count, coagulation studies, cross match if not already done)
- Move the patient to the operating room
- Consider intrauterine balloon for tamponade.
- Transfuse two units packed red cells and one to two units fresh frozen plasma if available. Activate a massive hemorrhage protocol if more blood likely needed
III. Blood loss >1500mL with ongoing excessive bleeding, and hemodynamic instability despite initial therapy.
If hemorrhage persists in spite of these relatively simple measures, emergency surgical intervention with adequate anesthesia is a must. A second i.v. and arterial line are inserted and hemodynamic support is maintained. Oxygen is administered and a massive hemorrhage protocol is “called.” Re-examination of the lower genital tract is recommended with large retractors and good surgical assistance. Ring forceps are used to “run” the cervix looking for unrecognized lacerations. Curettage and exploration of the endometrial cavity is performed if retained products are suspected. If these measures fail, emergency laparotomy is the next step with preparation for B-Lynch compression sutures and possible subtotal hysterectomy.
- Initiate massive transfusion protocol (transfuse appropriate ratio of red cells, fresh frozen plasma -according to availability and local MHP) (KEY POINT-ensure you have a MHP for PPH in your facility)
- Two large bore I.V.s running
- Administer oxygen: Maintain O2 saturation >95%
- Prepare for emergency surgical intervention, articulate the gravity of the situation to the rest of the team
- Keep patient warm.
- Treat acidosis.
- Check ionized calcium and potassium levels every 15 minutes once a massive transfusion protocol has been initiated and treat hypocalcemia and hyperkalemia aggressively. Continue until the emergency has been contained and the protocol for massive transfusion has been stopped.
- EUA (seek vaginal lacerations with sidewall right angle retractors, palpate the uterine scar, banjo curettage to remove placental fragments, consider uterine packing)
- Laparotomy (B-Lynch,Cho suture, subtotal hysterectomy)
- If conservative surgical interventions are not successful, perform hysterectomy. Hysterectomy should not be delayed in women who require prompt control of uterine hemorrhage to prevent death.
PPH Checklist: https://www.wsha.org/wp-
PEARL: UTERINE RUPTURE
• think about uterine rupture. Palpate lower segment through the dilated cervix. Is the public bone palpable?
• Was the labour long (obstructed)? Was there “intrapartum” hemorrhage?
• Ask about any previous uterine instrumentation or attempted instrumentation.
• Bedside ultrasound: look for intraperitoneal “concealed” bleeding
Approach to Management of PPH following Cesarean Section
I. Cesarean Section Delivery with 1000-1500mL estimated blood loss, with ongoing excessive bleeding and/or mild tachycardia and/or hypotension.
Consider 4 T’s:
- Tone: GA may cause uterine atony ,prolonged labour, chorioamnionitis, polyhydramnios
- Tissue: rule out abnormal placentation
- Trauma: Manual and visual exploration of cavity to check for bleeding site, uterine incision extension, uterine artery laceration etc
- Thrombin: patient history
- Notify the team (anesthesia, lab, nurses, consider calling referral centre/transport)
- Determine likely etiology (tone, tissue, trauma, thrombin)
- Bimanual compression and uterotonics (oxytocin, carboprost, ergometrine, misoprostol, txa, vasopressin)
- Crossmatch, MTP, fluids
- Consider Bakri and uterine packing
- Resort to B-Lynch suture and other compression sutures earlier rather than later
- Check for “concealed” blood loss per vaginum
- Uterine artery ligation, Internal iliac artery ligation less commonly used
- Kerlix gauze, packing forceps
- Goodwin bundle (ring forceps, right angle retractors for the lateral vaginal walls, weighted speculum, chest needle drivers, long scissors)
- Intracavitary (Bakri) balloon
- Suture for B Lynch (eg. #2 Vicryl on a 70mm curved needle)
PEARL: LOWER SEGMENT UTERINE BLEEDING:
- Uterotonics do not help as lower segment is non-contractile
- Bakri (single) balloon may not be enough so vagina needs tamponade in order to compress the lower segment
- Use a device with vaginal balloon,
- Pack the vagina tightly with layers of Kerlex gauze and insert a Foley into the urethra
- Try inflating a blood pressure cuff in a bag in the vagina
II. Cesarean Delivery with >1500mL blood loss, with ongoing excessive bleeding and/or hemodynamic instability.
If previous interventions unsuccessful be ready for peripartum hysterectomy