Postpartum Haemorrhage (PPH)

Introduction

Postpartum haemorrhage (PPH) is defined as a blood loss of 500ml or more following childbirth.¹

PPH can be categorised according to the volume of blood loss and timing of the haemorrhage:

• Minor PPH: 500-1000ml blood loss without clinical signs of shock.
• Major PPH: >1000ml blood loss, or <1000ml visible blood loss with clinical signs of shock.
• Primary PPH: PPH occurring within 24 hours of delivery.
• Secondary PPH: PPH occurring from 24 hours up to 12 weeks post-delivery.

Postpartum haemorrhage is one of the leading direct causes of maternal mortality in the UK.²

It is important to understand the causes of PPH and have an approach to clinical assessment and management of this common obstetric emergency.

Aetiology

The causes of primary PPH are often referred to as the “four T’s”:^1,3

• Tone: an atonic (not well contracted) uterus accounts for up to 80% of cases of primary PPH.
• Trauma: injury as a result of childbirth, most commonly perineal tears, lacerations and/or episiotomy.
• Tissue: retained products of conception (e.g. retained placenta).
• Thrombin: underlying disorders of clotting (e.g. haemophilia or use of low molecular weight heparin).

Secondary PPH is usually due to one of two causes:³

• Endometritis: infection of the endometrium.
• Retained products of conception.

Risk factors

Risk factors for PPH include:^1,4

• Previous PPH (particularly when the cause was atony)
• Grand multiparity
• Overdistension of the uterus (polyhydramnios/macrosomia/multiple pregnancy)
• Clotting disorders
• Antepartum haemorrhage
• Placenta praevia
• Prolonged labour
• Operative birth or caesarean section
• Induction of labour

Clinical features

The main clinical feature of PPH is heavy bleeding from the vagina (or directly from the uterus at caesarean section).

There may also be signs of haemodynamic instability, such as tachycardia, hypotension, prolonged capillary refill time or cool peripheries.

Other clinical features are dependent on the underlying cause of the haemorrhage.

Primary PPH

Tone: the uterus may feel enlarged, soft or “boggy”.

Trauma: there may be visible lacerations or tears on vaginal examination.

Tissue: on examination of the placenta, the placental tissue or membranes may be incomplete.

Secondary PPH

The most common cause of secondary PPH is endometritis, which may present with the following clinical features:

• Signs of sepsis: tachycardia, hypotension and pyrexia.
• The uterus may be tender or bulky on palpation.
• On speculum examination, the cervical os may be open and foul-smelling discharge may be present.

Investigations

PPH is a clinical diagnosis based on signs and symptoms.

Bedside investigations

All patients with PPH should have their vital signs taken as part of their clinical assessment and management.¹

Laboratory investigations

The following blood tests should be taken as part of the management of primary PPH:¹

• Full blood count: to assess for anaemia.
• Coagulation screen: heavy bleeding can lead to disordered clotting.
• Group & save and crossmatch: to enable transfusion of cross-matched blood.
• Urea & electrolytes and liver function tests: to assess baseline function.

The management of secondary PPH includes screening for sepsis as this may develop secondary to endometritis.

Sepsis screening involves the following additional investigations:³

• Blood cultures: to establish if there is bacteraemia.
• Blood tests: lactate and CRP.
• High vaginal swabs: to send for culture to inform later antibiotic choice.
• Pelvic ultrasound scan: to look for evidence of retained products of conception.

Management

Minimising risk

Anaemia¹

All pregnant women should have a full blood count carried out at booking and at 28 weeks gestation. Antenatal anaemia (if microcytic or normocytic) should be treated with iron supplementation and monitored for improvement.

Active management of the third stage of labour⁴

The third stage of labour refers to the time after the baby is delivered until delivery of the placenta and membranes.

This stage can be managed “passively” or “actively” depending on maternal preference.

However, it is important that women are informed of the increased risk of postpartum haemorrhage if they opt for passive management.

Table 1. An overview of active and passive management of the third stage of labour.

For women who already have risk factors for PPH, active management is strongly recommended.

All women should be offered prophylactic uterotonics as part of the routine management of the third stage to reduce the risk of PPH.

Management of PPH¹

Postpartum haemorrhage is an obstetric emergency which should be managed by a senior obstetrician with support from anaesthetic and midwifery teams.

An ABCDE approach should be adopted when managing patients with PPH.

Airway: consider airway adjuncts and call for anaesthetic support if there is an airway problem.

Breathing: assess respiratory rate and oxygen saturations as well as performing auscultation of the chest. Consider supplemental oxygen.

Circulation:

• Assess for signs of haemodynamic instability: heart rate, blood pressure, central capillary refill time.
• Estimate blood loss and assess for ongoing bleeding.
• Establish intravenous access with two wide bore cannulas and take bloods.
• Consider using point of care testing to estimate haemoglobin level (e.g. HemoCue).
• Administer warmed crystalloid solution until blood products are available.
• Insert a urinary catheter to monitor urine output and to prepare for possible further intervention (e.g. C-section).

Estimating blood loss from PPH can be challenging. Weighing swabs can help with assessing the volume of blood loss. 

Most hospitals will have a major obstetric haemorrhage protocol which should be activated if there is >1000ml blood loss with ongoing bleeding. The purpose of the protocol is to minimise delays in accessing blood products.

Further treatment depends on the suspected underlying cause of PPH.

Tone

Atony is the most common cause of PPH.

Management options for PPH secondary to atony include:

• Pharmacological: uterotonic drugs (oxytocin, syntometrine, carboprost, misoprostol).
• Mechanical: rub the uterine fundus to stimulate contractions and/or bi-manual compression (one hand in the vagina with the other hand compressing the uterine fundus).
• Surgical: common measures include intra-uterine balloon tamponade and haemostatic sutures. Hysterectomy is rare but should be considered in life-threatening haemorrhage where other measures have failed.

Trauma

Any perineal tears should be repaired by an experienced obstetrician or midwife.

Tissue

If the placenta is retained and there is ongoing bleeding, it may be necessary to go to theatre for manual removal of the placenta/retained tissues.

Thrombin

Consider administration of tranexamic acid.

Consider agents such as vitamin K in discussion with haematology if appropriate.

Liaise with haematology with regards to blood products. As a guide, prior to blood results being available, it is reasonable to assume that fresh frozen plasma will need to be given after every 4 units of red blood cells.

Secondary PPH³

Secondary PPH is usually caused by endometritis and/or retained products of conception. Therefore, management is similar to that of any infection/sepsis.

See the GeekyMedics article here for more information on the acute management of sepsis.

Consider a pelvic ultrasound scan if retained products are suspected. Surgical evacuation of retained products of conception may be necessary.

A blood transfusion should be considered if haemoglobin is below 80g/L and the patient is symptomatic of anaemia.

Care following PPH¹

Consider the best place for care following a PPH, which may be critical care if invasive monitoring is required.

Postpartum haemorrhage can be incredibly traumatic for the woman and her birthing partner, so it is important to debrief, explaining what happened and discussing any implications for future pregnancies.

Ensure that documentation is clear, with accurate timings of each step taken.

Complications

Complications of PPH include:^1,3

• Anaemia possibly requiring blood transfusion
• Hypovolaemic shock leading to organ dysfunction such as acute kidney injury
• Post-traumatic stress disorder
• Hysterectomy
• Disseminated intravascular coagulation
• Sheehan’s syndrome (postpartum pituitary gland necrosis)
• Death

Key points

• Postpartum haemorrhage is defined as blood loss of over 500ml following childbirth and is one of the leading direct causes of maternal mortality in the UK.
• The causes of primary PPH can be remembered by the four T’s: tone, trauma, tissue and thrombin. 
• The most common cause of secondary PPH is endometritis and/or retained products of conception.
• Active management of the third stage of labour reduces the risk of PPH.
• Patients with PPH should be managed using an ABCDE approach with senior input from the obstetric team.
• Assess patients with PPH for signs of haemodynamic instability and ensure adequate intravenous access.
• Management of atony can involve pharmacological (uterotonic drugs), mechanical (uterine stimulation or bi-manual compression) or surgical (e.g. balloon tamponade) options.
• PPH can be a traumatic experience for patients and debriefing may be required.

Reviewer

Dr Jill Sturt

Consultant Obstetrician and Gynaecologist

Editor

Dr Chris Jefferies

References

1. Royal College of Obstetricians and Gynaecologists. Postpartum Haemorrhage, Prevention and Management. Published in 2016. Available from: [LINK]
2. MBRRACE-UK. Saving Lives, Improving Mothers’ Care 2015-2017. Published in 2019. Available from: [LINK]
3. Patient.info. Postpartum Haemorrhage. Published in 2015. Available from: [LINK]
4. NICE. Intrapartum care for healthy women and babies. Published 2014, updated 2017. Available from: [LINK]