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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

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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.

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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