Postpartum Haemorrhage (PPH)
RCOG Prevention and Management of Postpartum Haemorrhage (Green-top Guideline No. 52). Last reviewed: Dec 2016.
Definition
There are 2 types of PPH:
- Primary PPH: loss of ≥500 mL of blood from the genital tract, within 24 hours of the birth of a baby
- Secondary PPH: abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postnatally
PPH can be classified by blood loss volume:
- Minor PPH: blood loss of 500-1000 mL
- Major PPH: blood loss of >1000 mL
Aetiology
Primary PPH
The causes of PPH can be grouped into four mechanisms, collectively known as the ‘4 Ts’:
| Mechanism | Specific cause | Key risk factors / associations |
|---|---|---|
| Tone (uterine atony) ~70% | Uterine overdistension |
|
| Impaired uterine contraction |
|
|
| Trauma ~20% | Genital tract / uterine injury |
|
| Tissue ~10% | Retained placenta / products |
|
| Thrombin <1% | Coagulopathy |
|
The most common identifiable cause of PPH is uterine atony (tone).
Most cases of PPH actually occur in women with no identifiable risk factors.
Secondary PPH
Key causes include:
- Endometritis
- Retained products of conception
- Subinvolution of placental implantation site
Work-Up
Primary PPH
Investigations in PPH are not cause-specific. Their primary purpose is to assess the severity of haemorrhage, guide resuscitation, and monitor end-organ function.
- Minor PPH (500-1000 mL): FBC, group and save, coagulation screen
- Major PPH (>1000 mL):
- FBC, group and save, coagulation screen
- Cross-match at least 4 units of blood
- U&E, LFTs
- Continuous physiological monitoring (e.g. pulse, BP, RR)
- Catheterisation to monitor urine output
The cause of PPH is almost always identified clinically
- Uterine atony → soft, boggy uterus which may be larger than expected (distended with clot)
- Trauma → direct visualisation on inspection and/or speculum
- Tissue
- Placenta fails to deliver / separate → placenta accreata spectrum
- Ultrasound with echogenic material within the uterine cavity → retained production of conception
- Thrombin → laboratory confirmation
Secondary PPH
The following investigations are recommended:
- High vaginal and endocervical swabs – to test for endometritis
- Pelvic ultrasound – to identify or exclude retained products of conception
Suspect endometritis in those with:
- Secondary PPH (bleeding between 24 hours and 12 weeks postnatally)
- Fever
- Foul-smelling lochia
- Uterine tenderness
- Abdominal pain and/or pelvic pain
Prevention
Preventive strategies are aimed at preventing primary PPH.
Strategies to be offered to ALL women:
- Identify and treat any antenatal anaemia (see the Anaemia in Pregnancy article for more information)
- Offer routine prophylactic uterotonic drugs (usually oxytocin) during 3rd stage of labour
Strategies specific to those at risk of primary PPH:
- Deliver in a hospital with a blood bank on site
- Consider giving tranexamic acid to those who are delivered by Caesarean section
DO NOT offer the following to prevent primary PPH:
- Routine uterine massage
- Early cord clamping
Management
Primary PPH
Routine / Non-Specific Management
Regardless of the underlying cause, the initial focus is always on resuscitation
- Call for help + A-E approach
- Fluid resuscitation and/or RBC transfusion (therapeutic goal is to maintain Hb >80 g/L)
- Consider tranexamic acid to reduce bleeding and the need for transfusions
Atony-Specific Management
As the most common cause of primary PPH (~70% of cases), the management protocol for uterine atony is strongly emphasised and is high-yield for exams.
The following applies when uterine atony is suspected to cause PPH. Measures should be escalated sequentially until the bleeding stops.
| Step | Measure type | Recommended management |
|---|---|---|
| 1 | Mechanical |
|
| 2 | Pharmacological | If mechanical measures fail, administer the following drugs in sequence until the bleeding stops:
|
| 3 | Surgical and radiological | If pharmacological measures fail, attempt and escalate the following in sequence until the bleeding stops:
|
Other Cause-Specific Management
Overview of management directed towards the underlying cause:
| Underlying cause | Management principle |
|---|---|
| Placenta accreta spectrum | Hysterectomy |
| Uterine rupture | Hysterectomy |
| Coagulopathies | Depends on the coagulation profile
|
Secondary PPH
Initial management: resuscitation if necessary
Definitive management depends on the underlying cause:
| Underlying cause | Management |
|---|---|
| Endometritis | Clindamycin + gentamicin |
| Retained placental tissue | Surgical evacuation |