POST PARTUM HAEMORRHAGE SIMPLIFIED

 Primary post-partum haemorrhage is the loss of >500 ml of blood per-vagina within 24 hours of delivery. It can be classified into two main types:

• Minor PPH – 500-1000ml of blood loss
• Major PPH – >1000ml of blood loss

It is a major cause of obstetric morbidity and mortality worldwide.

Aetiology and Risk Factors:

The causes for primary post-partum haemorrhage can be broadly categorised by the 4 T’s – tone, tissue, trauma and thrombin.

Tone

‘Tone’ refers to uterine atony, which is the most common cause of primary post-partum haemorrhage. This is where the uterus fails to contract adequately following delivery, due to a lack of tone in the uterine muscle.

The risk factors for uterine atony include:

• Maternal profile: Age >40, BMI > 35, Asian ethnicity.
• Uterine over-distension – multiple pregnancy, polyhydramnios, fetal macrosomia.
• Labour – induction, prolonged (>12 hours).
• Placental problems – placenta praevia, placental abruption, previous PPH.

Tissue

‘Tissue’ refers to retention of placental tissue – which prevents the uterus from contracting. It is the second most common cause of 1° PPH

Trauma

This refers to damage sustained to the reproductive tract during delivery (e.g. vaginal tears, cervical tears). Risk factors include:

• Instrumental vaginal deliveries (forceps or ventouse)
• Episiotomy
• C-section

Thrombin

‘Thrombin’ refers to coagulopathies and vascular abnormalities which increase the risk of primary post-partum haemorrhage:

• Vascular – Placental abruption, hypertension, pre-eclampsia.
• Coagulopathies – von Willebrand’s disease, haemophilia A/B, ITP or acquired coagulopathy i.e. DIC, HELLP.

Resuscitation

Resuscitate the patient via an A-E approach:

• Airway
  • Protect airway (may lose it with reduced levels of consciousness).

• Breathing
  • 15L of 100% oxygen through non-rebreathe mask. 

• Circulation:
  • Assess circulatory compromise (Cap refill, HR, BP, ECG)
  • Insert two large bore (14G) cannulas and take blood samples (see below)
    • Start circulatory resuscitation. Give cross-matched blood as soon as it is available, until then give up to 2L of warmed crystalloid and 1-2L of warmed colloids, then transfuse O negative or uncross matched group specific blood.
  • Additional blood productions i.e. factor VIII in Haemophilia A, and if major haemorrhage protocol activated may need to supplement fresh frozen plasma, platelets, fibrinogen. (Discussion with blood bank)

• Disability
  • Monitor patient’s Glasgow coma score (GCS).

• Exposure
• Expose patient to identify bleeding sources.

Clinical Features

The main feature of a post-partum haemorrhage is bleeding from the vagina.

If there is substantial blood loss, the patient may complain of dizziness, palpitations, and shortness of breath.

On Examination:

• General examination may reveal haemodynamic instability with tachypnoea, prolonged capillary refill time, tachycardia, and hypotension.
• Abdominal examination may show signs of uterine rupture i.e. palpation of fetal parts as it moves into the abdomen from the uterus.
• Speculum examination may reveal sites of local trauma causing bleeding.
• Examine the placenta to ensure that the placenta is complete (a missing cotyledon or ragged membranes could both cause a PPH).

Investigations

• The initial laboratory tests in primary post-partum haemorrhage include:

  • Full blood count
  • Cross match 4-6 units of blood
  • Coagulation profile
  • Urea and Electrolytes
  • Liver function tests

Management

• • The management of primary post-partum haemorrhage should include the simultaneous delivery of TRIM:

    • Teamwork (Immediate Management)
    • Resuscitation (Immediate Management)
    • Investigations and Monitoring (Immediate Management)
    • Measures to arrest bleeding (Definitive Management)

Immediate Management

• • • Teamwork – Involve appropriate colleagues for minor and major PPH, including the midwife in charge and midwives, obstetricians, anaesthetists, blood bank, clinical haematologist and porters. Communication between the team, and diligent documentation is vital.
    • Investigations and Monitoring – Investigations as above. Monitoring should include RR, O2 sats, HR, BP, temperature every 15 mins. Consider catheterisation and insertion of a central venous line.

Resuscitation

• • • Resuscitate the patient via an A-E approach:

      • Airway
        • Protect airway (may lose it with reduced levels of consciousness).
      • Breathing
        • 15L of 100% oxygen through non-rebreathe mask. 
      • Circulation:
        • Assess circulatory compromise (Cap refill, HR, BP, ECG)
        • Insert two large bore (14G) cannulas and take blood samples (see below)
          • Start circulatory resuscitation. Give cross-matched blood as soon as it is available, until then give up to 2L of warmed crystalloid and 1-2L of warmed colloids, then transfuse O negative or uncross matched group specific blood.
        • Additional blood productions i.e. factor VIII in Haemophilia A, and if major haemorrhage protocol activated may need to supplement fresh frozen plasma, platelets, fibrinogen. (Discussion with blood bank)
      • Disability
        • Monitor patient’s Glasgow coma score (GCS).
      • Exposure
        • Expose patient to identify bleeding sources.

Definitive Management

• • The definitive treatment for primary post-partum haemorrhage is largely dependent on the underlying cause:

    Uterine Atony

  • Bimanual compression to stimulate uterine contraction – insert a gloved hand into the vagina, then form a fist insider the anterior fornix to compress the anterior uterine wall and the other hand applies pressure on the abdomen at the posterior aspect of the uterus (ensure the bladder is emptied by catheterisation).
  • Pharmacological measures (Table 1) – act to increase uterine myometrial contraction.
  • Surgical measures – intrauterine balloon tamponade, haemostatic suture around uterus (e.g. B-lynch), bilateral uterine or internal iliac artery ligation, hysterectomy (as a last resort).

  • Trauma

    Primary repair of laceration, if uterine rupture: laparotomy and repair or hysterectomy.

    Tissue

    Administer IV Oxytocin, manual removal of placenta with regional or general anaesthetic, and prophylactic antibiotics in theatre. Start IV Oxytocin infusion after removal.

    Thrombin

    Correct any coagulation abnormalities with blood products under the advice of the haematology team.

Mind Map: Postpartum Haemorrhage (PPH)

• • Central Concept: POSTPARTUM HAEMORRHAGE (PPH)

    Excessive bleeding after childbirth that can be life‑threatening if not promptly managed.

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1️⃣ Definition

• • • Blood loss ≥500 mL after vaginal delivery

    • Blood loss ≥1000 mL after caesarean section

    • Any blood loss causing hemodynamic instability

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2️⃣ Classification

A. Primary (Early) PPH

• • • Occurs within 24 hours after delivery

B. Secondary (Late) PPH

• • • Occurs 24 hours – 6 weeks postpartum

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3️⃣ Causes – The 4 Ts

🔴 Tone (Most common)

• • • Uterine atony

    • Over‑distended uterus (multiple pregnancy, polyhydramnios)

🔴 Tissue

• • • Retained placental fragments

    • Placenta accreta

🔴 Trauma

• • • Cervical, vaginal, or perineal tears

    • Uterine rupture or inversion

🔴 Thrombin

• • • Coagulation disorders

    • Severe pre‑eclampsia, DIC

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4️⃣ Risk Factors

• • • Prolonged or obstructed labour

    • Grand multiparity

    • Previous history of PPH

    • Induction or augmentation of labour

    • Instrumental or caesarean delivery

    • Anemia

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5️⃣ Clinical Features

• • • Excessive vaginal bleeding

    • Boggy or enlarged uterus

    • Hypotension

    • Tachycardia

    • Pallor, cold clammy skin

    • Reduced urine output

    • Restlessness or confusion

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6️⃣ Nursing Assessment

• • • Assess amount and type of bleeding

    • Palpate uterine tone and size

    • Monitor vital signs

    • Check perineum for trauma

    • Monitor urine output (≥30 ml/hr)

    • Review delivery history

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7️⃣ Nursing Management

Immediate Actions (Emergency Care)

• • • Call for help / activate emergency protocol

    • Perform uterine massage

    • Ensure empty bladder

    • Administer prescribed uterotonics

    • Establish IV access (large bore)

    • Start IV fluids (crystalloids)

Medications

• • • Oxytocin

    • Misoprostol

    • Ergometrine (if not contraindicated)

    • Tranexamic acid (as prescribed)

Ongoing Care

• • • Monitor bleeding and uterine tone

    • Record intake and output

    • Prepare for blood transfusion

    • Assist in surgical interventions if needed

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8️⃣ Prevention

• • • Active management of third stage of labour (AMTSL)

    • Early identification of risk factors

    • Proper uterine tone assessment post‑delivery

    • Prompt breastfeeding to enhance uterine contraction

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9️⃣ Complications

• • • Hypovolemic shock

    • Severe anemia

    • Acute renal failure

    • Maternal death

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🔟 Health Education

• • • Teach mother to recognize excessive bleeding

    • Importance of early postnatal visits

    • Encourage adequate nutrition and iron intake

    • Advise immediate hospital return if danger signs occur

 Key Nursing Role

• • Early recognition + Rapid intervention = Lives saved

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    Tip for Exams & Practice:
    👉 Always remember PPH = 4 Ts + Emergency Management