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### ~~**Sri Lanka Journal of Obstetrics and Gynaecology**~~
## **SLCOG**
### **Guideline No: 03** **June 2022**

_**Please cite this paper as: de Silva PHP, Lanerolle S, Dodampahala HS, Silva R, Mathota C, on behalf of the**_
_**Sri Lankan College of Obstetricians and Gynaecologists. Management of Primary Postpartum**_
_**Haemorrhage.**_
### ~~Sri Lanka College of Obstetricians and Gynaecologists~~

#### SLCOG G u id e li ne


## **Management of primary postpartum haemorrhage**

**P H P de Silva** [a] **, Sanath Lanerolle** [b] **, H S Dodampahala** [c] **, Ruwan Silva** [d] **, C Mathota** [e ] _**on behalf of the Sri**_

_**Lanka College of Obstetricians and Gynaecologists**_

Correspondence: Sri Lanka College of Obstetricians and Gynaecologists, No. 112, Model Farm Road, Colombo 08.
E-mail: [email protected]

#### **1. Introduction**

The aim of this guideline is to provide evidence-based
recommendations in the management of primary
postpartum haemorrhage (PPH). This is the commonest direct cause of maternal death globally and in
Sri Lanka. The objective of this guideline is to ensure
anticipation, prevention, early detection and timely and
appropriate management of PPH.
#### **2. Definition**

For the purpose of this guideline PPH is defined as
blood loss of 500 ml or more from the genital tract
within 24 hours of the birth of a baby. Blood loss of
over 1000 ml is defined as major PPH. Major can be
further sub-divided into moderate (1001-2000 ml) and

severe >2000 ml.

In a woman with lower body mass (e.g. <60 Kg) a
lower level of loss of blood volume may be clinically
significant.

Since blood volume differs between persons,

blood loss must be individualized.

The loss of 40% or more of the blood volume is life

threatening and will be defined as a massive
obstetric haemorrhage. Blood volume = 100ml/Kg


Irrespective of the loss of blood volume, appearance
of cardiovascular instability (i.e. tachypnea, altered
mental status, tachycardia and hypotension) signifies
possibility of major obstetric hemorrhage.
#### **3. Prevention of Postpartum** **Haemorrhage**

Active management of the third stage of labour is the
cornerstone of prevention of primary PPH.

Postpartum care observations should be recorded on
a MEOWS chart for early detection of patients needing
further care.

_**Minimizing risk:**_

  - Anemia in pregnancy should be corrected during
antenatal period. Patients who are decided for
delivery advise to have minimum level of
haemoglobin of 10 g/dL.

  - Maintain adequate hydration during labor in
order to have physiological maximum
circulatory volume.

PPH occurs most often in women without risk

factors. Therefore, the blood group and level of
haemoglobin of every woman who goes into labor must
be known.


_Sri Lanka Journal of Obstetrics and Gynaecology_ 2022; **44:** 127-132

DOI: http://doi.org/10.4038/sljog.v44i2.8056

a _Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka_

b _Consultant Obstetrician and Gynaecologist, Castle Street Hospital for Women, Colombo 8, Sri Lanka_

c _Professor in Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, University of Colombo,_
_Sri Lanka_

d _Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka_

e _Consultant Obstetrician and Gynaecologist, Colombo North Teaching Hospital, Ragama, Sri Lanka_

_Vol. 44, No. 2, June 2022_ **127**

#### SLCOG Guideline

Women with known risk factors associated with PPH,

as listed in Box 1. Should be advised to deliver in a

specialist obstetric unit under extra vigilance. Of these,
Abruptio placenta, Placenta praevia and Morbidly
adherent placentae are especially at higher risk.


**Good practices:**

  - All women under-going labor preferably should
have a large bore cannula.

  - Any woman with at least one risk factor should
have intravenous access established with either

a 16 or Gray cannula and a sample of blood
taken and preserved for grouping and DT and

or save.

  - Attempt to estimate and record blood loss in all
deliveries.

  - Check the state of the uterine fundus as a routine

post-delivery observation practice.
#### **4. Management of Primary PPH**

In Sri Lanka usual practice has been to commence
treatment when there is continuing bleeding despite
uterine massage irrespective of the amount of blood
lost.

_**It is recommended that this practice be continued.**_


4.1. **Identification of severity of haemorrhage**

Clinicians should be aware that the visual estimation

of post partum blood loss is inaccurate and that clinical
signs and symptoms should be included in the
assessment of PPH.

Shock index (SI)- (Heart rate/Systolic Blood Pressure)
as an effective predictor for PPH SI <0.9 provides
reassurance, whereas SI ≥1.7 indicates a need for
urgent attention in haemorrhage. (BJOG. 2015; 122(2):
268-75. doi: 10.1111/1471-0528.13206.)

Call for help:

Who should be informed when the woman presents
with PPH?

  - **Early involvement of appropriate senior**
**staff is fundamental to the management of**

**PPH.**

**•** **Any significant postpartum bleeding should**
**be informed to the highest level of obstetric**
**team. This should be done by the attending**

**Medical Officer.**

**•** **However, in the absence of a MO any staff**

**member could inform.**

**•** **Even the situation is manageable by middle**
**grade medical staff information to the**
**highest level is essential.**

**•** **In minor PPH, the first line staff should be**

**alerted.**

**•** **In major PPH, the following members**

**should be alerted at the same time with**

**effective communication.**

a. The obstetric middle grade,

b. The anesthetic middle grade; Where available,
the early involvement of the anesthetic team,
even while the patient is still in the labor room

is recommended.

c. Inform theatre

d. Alert MO blood bank

e. Alert Consultant Obstetrician

f. Alert Consultant Anaesthetist

g. Transfusion medicine specialist /
Haematologist

h. Alert the head of the institution


**128** _Sri Lanka Journal of Obstetrics and Gynaecology_

In a hospital clear instruction to telephone operator
how to convey such message should be given by the
administration to alert the stipulated staff as stated
above. The telephone operator should document the
list of staff informed and submit it to the ward to be

attached to the Bed Head Ticket.

**Communication with the mother**

Maintain a calm atmosphere.

Keep the mother (and labor companion/family)
informed and reassure the mother regularly where

feasible.

4.2. **Documentation: It is important to record:**
**to be done later once the mother is stable**

  - The staff attended and the time the sequence of

events.

  - The details of interventions, administration of
pharmacological agents, fluid and blood products
given, surgical interventions.

  - The condition of the mother throughout the
different steps.

  - It is recommended that one member of staff is

delegated specifically for this task and to
coordinate with other relevant disciplines.

4.2.1. **Measures for minor PPH: Blood loss**

**500-1000ml without clinical shock**

  - Assess, monitor and record: general condition,
estimated blood loss, pulse, blood pressure and
respiratory rate (every 15 minutes)

  - Ensure there is intravenous access with a wide

(14-16 G) bore cannulae.

  - Send blood for cross matching and baseline full

blood count.

  - Start Ringer’s lactate (Hartmann’s)/ Normal

saline.

  - Identify the cause of bleeding.

  - Keep the woman warm.

  - Pay attention to the temperature of labor room,
operating theatre, intravenous fluids, blood,
blood products and fluids used for lavage.
Hypothermia is known to promote coagulopathy.

  - Maintain MEOWS chart.

#### SLCOG Guideline

4.2.2. **PPH of more than blood loss 1000ml/**

**active bleeding/ signs of shock**

  - Recognize this as a life-threatening emergency.

Quick action without delay saves life.

  - Major PPH once suspected should be managed

in adequately equipped operating theatre with

all resuscitation facilities.

  - Early involvement of appropriate senior staff is

fundamental for the management of major PPH.

Following members of staff should be called

and summoned to attend. Theatre in charge

Nursing officer, Consultant Obstetrician,

Consultant Anaesthetist, Consultant Transfusion

specialist, Consultant Haematologist, Overseer

of minor staff.

  - Team work, Resuscitation, Monitoring,

Controlling bleeding pharmacologically and

surgically, taking general measures, all should

go hand in hand because all are equally

important.

  - Attempts must be made to prevent or minimize

dilutional coagulopathy, hypothermia, and

metabolic acidosis from the beginning of

resuscitation protocol.
#### **Resuscitation**

  - ABCDE approach.

  - Clear airway. High flow oxygen to keep SPO2>

95%, attach oximeter probe.

  - Intubate, ventilate – if abnormal breathing,

unconscious, unresponsive.

  - Insert two 14-16 g cannulae, draw 20 ml blood

for grouping, DT, FBC, BU, Electrolytes,

APTT, PT/INR, ROTEM, S. Fibrinogen.

  - Request 6 U blood, Cryoprecipitate 20 U, FFP

4 U, platelets 1 adult dose.

  - Inform blood bank to activate massive haemor
rhage protocol.

  - Monitor BP, ECG, AVPU, CBS, UOP, CVP

  - Transfuse blood as soon as possible. Minimise

crystalloid, replace blood loss with blood. In

emergency use on the availability of specific


_Vol. 44, No. 2, June 2022_ **129**

#### SLCOG Guideline

blood. O-ve O+ve group-specific uncross

matched cross-matched.

  - Warm patient with forced air warmer, Warm
fluids/blood using rapid warmer infuser. Or

normal blood warmer.

  - Control bleeding- medical/ physical manoeuvres
and surgical.



- Get ROTEM result within 5-10 min. Replace as
indicated by ROTEM.

- If ROTEM not available start giving shock
packs – 4:4: I adult dose of platelets.

- Due consideration must be given to keeping
transport facilities available to obtain blood and
blood products from another institution.


**130** _Sri Lanka Journal of Obstetrics and Gynaecology_

4.5.1. **Establish a cause for the bleeding – Four**
**T’s, Tone, Tissue, Trauma, Thrombin**

4.5.3.1. **Management of Atonic Haemorrhage**

  - Start uterine massage by ‘rubbing up the fundus’.

  - Clear the cervical canal and vagina of blood clots
by vaginal examination.

  - Hypothermia is a particular risk in the theatre

environment. Measures must be taken to

minimize the loss of heat from the woman.

  - Cochrane review 25 [th] April 2018 conclude
Ergometrine plus Oxytocin combination,
misoprostol plus oxytocin combination is more
effective in preventing PPH [500ml than using
current standard of Oxytocin alone.

  - Administer either Ergometrine maleate 0.5 mg
slow IV or methyl Ergometrine 0.2 mg slow IV
or oxytocin 5 IU IV and start an infusion of 40
IU of Oxytocin in 500 ml of Hartmann’s /
Normal Saline solution at 125 ml per hour via
an infusion pump.

  - Ergometrine can be repeated in every 2 hours
up to 3 doses.

  - Start bimanual compression of uterus.

  - If the bleeding fails to abate completely in 5-10
minutes administer/repeat Ergometrine 0.5mg
IV. (Level IV – SLCOG consensus) (WHO 2000
publication Managing Complications in
Pregnancy and Child Birth Page 5-28, Table 1,
Can repeat Ergometrine for the first time in 15
Minutes up to four doses thereafter in four hours
apart.).

  - At the same time, administer Tranexamic acid

1 g by slow IV over 10 minutes. Maximum
benefit is achieved if given within 30 minutes.
This dose may be repeated after 30 minutes if
necessary and later if bleeding recommences.

  - If the bleeding fails to abate completely in a
further 10 minutes administer misoprostol
1000mic per rectally or sublingually.

  - If the bleeding fails to abate completely for
above measures proceed to uterine balloon
tamponade. Compression of Aorta just above
the bifurcation helps to minimize the loss until
other measures are readily available.

#### SLCOG Guideline

  - For details of the method of balloon tamponade.

Bakri Catheter.

  - Any institution undertaking delivery of pregnant

women should have members trained for

insertion of tamponade catheter.

**Before transferring the patient it’s important**
**to do the following;**

   - Large bore cannula inserted and IV
Crystalloids (NS/RL) or blood running

   - Oxygen 10-15L/ min to keep SpO2 > 95%

   - IV Tranexamic acid 1g given

   - Temporizing measures such as manual
aortic compression and sand bags to
compress the uterus are recommended
while the patient is in transit

   - Inform the receiving institution/Ward / ICU

  - After the balloon is inserted and the vagina
packed (to keep the balloon in the uterus), the
woman’s vital parameters and the level of the
fundus must be monitored carefully. Where
these indicate the woman is continuing to bleed.

  - Prior to laparotomy the woman must be examined under anesthesia for tears in the genital

tract.

  - The surgical measures would depend on the

woman's condition. “Too little too late” is the

main contributor to mortality in PPH. First hour
known as the golden hour in decision making.
Surgical measures include brace (compression)
sutures, uterine de-vascularization, Haemostatic

mattress sutures to bleeding sinusoids, Box
sutures to include the bleeding lower segment
in Placenta Previa, internal iliac ligation and
Hysterectomy.

  - The “sandwich technique” involves inserting a
balloon tamponade after the application of brace

sutures.

**Resort to hysterectomy without delay if other**
**measures appear to be failing.**


_Vol. 44, No. 2, June 2022_ **131**

#### SLCOG Guideline

4.5.3.2. **Management of Traumatic PPH**

**Manage only in theatre under suitable anaes-**
**thesia and exposure**

1. Exclude high vaginal and cervical tears before
suturing episiotomy.

2. Examine for paravaginal and broad ligament
haematomata with a combined per vaginal and
per rectal examination.

3. Early use of USS recommended for identification of internal bleeding.

4. Paravaginal hematomas of more than 5 cm
diameter will usually require surgical evacuation.
A bleeding point is usually present and must
be looked for. In cases where it is difficult to

control bleeding, a Foley catheter with its
balloon inflated may be left in the cavity. Packing
of the vagina may also be useful.

5. Cervical tears must be identified by systematic
inspection of the cervix using Green- Armytage
forceps and sutured.

6. In case of multiple tears with venous oozing, it
may be better to insert a balloon catheter into
the vagina or to pack the vagina with moistened
vaginal packs than to try to suture all the tears.

7. Vasopressin soaked pack (1 vial: 200ml diluted
saline).

**Rupture of the uterus**

  - Rupture of the uterus must be suspected when
the general condition is deteriorating out of
proportion to the visible blood loss and there is
continuing bleeding in the presence of a

contracted uterus.

  - This is particularly so in a woman with a scarred

uterus.

4.5.3.3. **Coagulopathy causing PPH**

  - This could be due to coagulopathy following


Death in utero, Abruptio placentae, severe PreEclampsia, HELLP syndrome, Sepsis, Amniotic
fluid embolism, Acute fatty liver, primary
immune Thrombocytopenia, Von Willebrand’s

disease etc.

  - It could also be due to suboptimal management

of the PPH.

  - Early summoning of a Haematologist and
Transfusion medicine specialist for management
will be important in this situation.

  - Where available, Thromboelastometry should be

used.

**Special Situations**

  - Tranexamic acid 1 g IV can be given for high
risk mothers who undergo caesarean section in
addition to Syntocinon.

  - When there is placenta praevia after a previous

caesarean section, it is advisable to look for

specific USS features of accreta /percreta.

  - The timing and location for delivery should be
chosen to facilitate consultant presence and
access to intensive care and other supportive
care. Eg Rapid transfusion facilities, availability
of blood and blood products.

  - It is important to educate the relatives about the
risks and the need for critical care post operatively and consent obtained.

4.5.4. **Debriefing**

  - It is possible that a major PPH could result in
significant psychological morbidity.

  - This could be minimized by timely debriefing
of the patient and her family, preferably by the

Consultant.

  - This should be done immediately after the event,
before discharge or at the postnatal visit or at
any time as requested by her or the family.


**132** _Sri Lanka Journal of Obstetrics and Gynaecology_