Post-Partum Haemorrhage – Emergency Management
Management of Post-Partum Haemorrhage – General
Mnemonic from ALSO (Advanced Life Support in Obstetrics) course:
H – call for Help
A – Address woman and partner
E – Empty bladder/blood results/vital signs
M – Measure
O – Oxytocic
R – Rub up a contraction/remove placenta/baby to breast
R – Rethink causes – Tone, Tissue, Trauma, Thrombin
H – Haemobate (drug given directly into uterus transabdominally)
A – Arrange theatre
G – General anaesthetic
E – Ensure notes complete
HAEMORRHAGE is in an weird order in my opinion – I’d put the EMOR part in a different order. I’d be making sure her bladder was emptied during labour, and certainly would not be putting in a catheter until the placenta was out, the contraction rubbed up and then an oxytocic used, in that order. Sometimes I use the oxytocic as the first thing, and although I can look aand judge while I am doing all this, the actual blood measurement when I weigh and pour is really not on my list of priorities.
If the placenta was still in situ, I would definitely put a catheter in as one of the first things to do. If the bladder is full, it may be what is causing the problem if the uterus cannot contract to expel the placenta.
Tania, I was involved with midwife management of a PPH at a homebirth, and I think the order of actions taken was closer to your suggestions.
Third labour, slow to get going but active for four hours. Woman drinking some fluids but not wishing to pass urine the couple of times it was suggested. BP slightly elevated above normal. No drugs, baby born normally, physiological 3rd stage (except cord cut and clamped before placenta delivered by mother) no tears, very little blood loss. Mother choosing not to breastfeed. Much rejoicing and activity with family members coming into bedroom fairly soon afterwards. Uterus well-contracted.
Then 30 mins later active p.v. (per vagina) bleeding. First midwife rubbed up a contraction and expressed a few large clots. Bleeding stopped. Woman’s observations taken-normal range, uterus w/c (well-contracted).
Debate about syntometrine. One midwife thought it would help and one midwife from her experience thought it may make bleeding worse at that point. Syntometrine given with woman’s permission and about 10 mins later acute uterine afterbirth pains and more active pv bleeding. More clots expressed. BP slightly lower and pulse slightly faster but normal range still. Uterus felt w/c.
Even though woman now having post-sytometrine excruiating after-birth pain/cramping and trickling blood asked her pass urine on toilet very nearby instead of passing catheter. No panicking, she was helped to loo. After passing another largeclot down loo she passed urine. Uterus well contracted. All bleeding and pain stopped. Again BP lower but within normal range but pulse now 90.
Reflective diagnosis was that a large clot was clamped in internal os causing pain and secondary bleeding but it was finally dislodged by mobilising and passing urine in an upright position. It is believed that passing a catheter may not have helped to dislodge this clot and doing an internal to fully investigate would have been too painful for mother. Guestimated blood loss between 800 and 1000mls.
Discussed transfer but woman not wanting to unless further bleeding as she now felt fine and observations okay. HB pre birth-12.1, 3 days post-birth 9.3. One midwife stayed with her for next few hours but no further unusual blood loss. Woman took iron supplement and felt very well after two weeks.
At visits, she often expressed her joy of having had this first homebirth and not bothered by the PPH and very pleased that she did not get transferred to hospital. She has given permission for this account to be told. Successful outcome but I would be interested in comments as this is first PPH I’ve been involved with at a home birth.
I would be grateful for any details you could give me on how severe haemorrhage is handled at home or in hospital? There is some discussion on the homebirth list at the moment on the old “You can’t have a home birth with Hb below 10 g/dll ” line, and my understanding is as follows:
– For most women who end up having a blood transfusion after birth, this is not an emergency along the lines of “Get that blood into her right now or she’ll die!”. How it usually happens is that, a day or two after the birth, if her blood sample still shows a low Hb then she may be offered a transfusion to boost it up. Obviously you would have to go into hospital for this. But an emergency transfer is very unlikely. This is different from the severe PPHs that happen sometimes when the mother’s life is at risk – you know,the ‘bleed to death in four minutes’ scenario that some GPs like to talk about when home birth is mentioned! Sorry to be gory, but if the worry is actually exsanguination then I doubt it would make any difference what your Hb level was to start with!
BUT, with only reading and my own experience to go on, I am aware that I may not be seeing the whole picture. I have heard several times of women who had a PPH at home transferring to hospital for a transfusion, but most cases I’ve heard of have been non-emergency transfers; the bleeding stopped while the woman was at home, but she transferred to have her Hb ‘topped up’ with a transfusion.
In your practices, what is done in the case of severe blood loss, either in hospital or at home? I have read that plasma volume expanders (?) are sometimes used – is this just to keep blood circulating, albeit ‘diluted’ blood, while the haemorrhage is controlled? What resources are available to treat severe PPH in hospital, which are not available at home? The one we all know about is surgical intervention of course…
A woman with a postpartum blood loss of 100mls could be classified as having a haemorrhage if her health status is such that even such a small blood loss has an adverse effect on her!
You’re right in that the majority of blood transfusions are non-urgent, i.e. topping up the woman’s iron level when a full blood count has shown that she is anaemic and when she has symptoms of anaemia – pale, breathless, tired etc etc. However, there are occasions when the bleeding is torrential and will not stop. There can be a number of causes, the most common being the failure of the uterus to contract or a tear in the cervix.
If it is failure of the uterus to contract (atonic uterus) then there is an emergency drill which every midwife knows by heart: rub up a contraction, administer an oxytocic (such as syntocinon or ergometrine), seek medical aid, remove any blood clots that may be stuck in the cervix and empty the bladder. More often than not this is all that is needed, the bleeding is stopped and then, if required, a non-urgent transfer and possible blood transfusion will happen.
Sometimes though, the emergency drill is not enough, the woman continues to bleed and further action is required. Initially a continuous intravenous infusion of tocolytics such as syntocinon or ergometrine will be commenced, together with a plasma expander such as Haemacell or Gelifusine. Occasionally, even this fails and an oxytocic will be injected directly into the uterus through the abdominal wall.
The main problem with such a catastrophic bleed is that DIC can occur (disseminated intravascular coagulation) when this happens the clotting mechanism in the blood ‘goes all to cock’ with little blood clots forming in the capilliaries – this uses up all the clotting factors and, strangely enough, the upshot is even further haemorrhage.
So, it all sounds really frightening doesn’t it? In reality such a worst-case scenario happens very rarely but when it does happen it is very frightening to all concerned – it has happened to two women in my care (both hospital deliveries – is there a message there), thankfully they both survived but all involved were very traumatised (including the midwife!).
I think rather than Hb or even MCV (mean cell volume), the midwife should consider factors that are known to predispose towards post-partum-haemorrhage and if these are present advise the woman accordingly. It is interesting though, that some of the things we do to women in hospital are predisposing factors towards pph anyway!
Remember this is a highly unlikely scenario in a physiological labour, but it can happen and has happened to me.
Depends on when in the third stage it happens. If the placenta is in situ and there is heavy abnormal bleeding the drill should be something along the lines of:
- Get help ie send for a paramedic ambulance. If when it turns up all is well, it can return to base, but have it coming.
- Give an oxytocig drug either Intramuscular Sytometrine or Intravenous ergometrine and attempt controlled cord tractrion IF the fundus has contracted and you feel that the placenta has separated. But if there is resistance do NOT keep pulling on the cord. the oxytocic will contract the uterus, stop the bleeding and if there is any possibility that this is a morbidly adherent placenta the place to deal with it is in an operating theatre.
If the placenta is out and the Mum starts to bleed heavily the drill is much the same
- Send for help
- Rub up a contraction ie massage the top of the uterus to stimulate it to contract
- Give an oxytocic drug. If this does not stop the bleeding, and it usually does, then put up an IV. If transferring, the midwife or paramedic should set up an intravenous infusion prior to transfer so that there is a vein open and ready for easy access if necessary.
- I would use either one of the blood expanders Haemocel or Gelufsen, if the blood loss had caused a deterioration in the Mum’s condition, shown by a rapid thready pulse and a fall in BP. Or something like Hartmanns solution , if she was fine and it was just a precautionary IV. In both cases if you have a cooperative baby get the little darling to suckle
Mary Cronk, midwife
This abstract talks about surgical techniques for controlling PPH while avoiding hysterectomy. It involves five steps – if step 1 doesn’t work you proceed to step 2, and so on to 5. The study covered 103 women with ‘uncontrollable’ PPH and this method worked in all cases; no hysterectomies were needed. Some of the steps (ovarian vessel ligation, for example?) might compromise future fertility, perhaps? But still – this looks like it should be required reading for all obstetricians. Any thoughts?
Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus.
AUTHORS: AbdRabbo SA AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, Shatby Maternity University Hospital, Alexandria, Egypt. SOURCE: Am J Obstet Gynecol 1994 Sep;171(3):694-700 CITATION IDS: PMID: 8092217 UI: 94379110 ABSTRACT: OBJECTIVE: The objective of this study was to test the efficacy of a novel stepwise technique of uterine devascularization for management of uncontrollable postpartum hemorrhage.
STUDY DESIGN: Stepwise uterine devascularization was performed for 103 patients to control intractable postpartum hemorrhage not responding to classic management. This technique entails five successive steps, so if bleeding is not controlled by one step the next step is taken until bleeding stops. The steps were (1) unilateral uterine vessel ligation, (2) bilateral uterine vessel ligation, (3) low uterine vessel ligation, (4) unilateral ovarian vessel ligation and (5) bilateral ovarian vessel ligation.
RESULTS: The procedure was effective in all cases (100%), and hysterectomy was not needed in any case. No complications occurred, and the survival rate was 100%. Among the patients followed up normal menstruation and pregnancy occurred. CONCLUSION: Stepwise uterine devascularization is an effective and safe alternative to hysterectomy for management of uncontrollable postpartum hemorrhage.
I have read this with great interest & also with a few smiles! Someone slap my wrists but …… don’t you think that this “procedure” is just pure common sense – is it just me or did anyone else think this? I’m not being flippant, honest! Said with large grin on face – and a couple of head shakes!! Yes, I completely agree that it SHOULD be compulsory reading for ALL obstetricians ……..
Smilingly, Brenda – Midwife
It sounds like what they’re basically saying is “Tie off the blood vessels supplying the uterus in this order, one by one, rather than just ripping the whole lot out” – is that a plain English translation of “stepwise devascularisation”?
You’ve got it in a nutshell!
AH updated 17 June 2001