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Reproductive · Clinical Topics
Postpartum Haemorrhage
Postpartum Haemorrhage (PPH) is defined as significant blood loss after childbirth, a leading cause of maternal mortality. UK definitions are >500ml after vaginal birth or >1000ml after C-section. Management is an emergency, guided by the '4 Ts' mnemonic (Tone, Tissue, Trauma, Thrombin), with uterine atony being the most common cause.
📌 Learning Objectives
- Define primary and secondary postpartum haemorrhage (PPH) and state their diagnostic criteria.
- Identify the four main causes of PPH using the '4 Ts' mnemonic.
- Outline the immediate resuscitation and management steps for acute primary PPH.
- Describe the pharmacological and non-pharmacological interventions for uterine atony.
- Recognise the signs of hypovolaemic shock in a postpartum woman and initiate appropriate management.
- Explain the importance of active management of the third stage of labour in PPH prevention.
📋 Overview
PPH is a critical obstetric emergency. It's classified as Primary PPH (within 24 hours of delivery) or Secondary PPH (24 hours to 12 weeks postpartum). Minor PPH is 500-1000ml; Major PPH is >1000ml. Rapid, multidisciplinary management is essential, involving midwives, obstetricians, anaesthetists, and haematologists. The most frequent cause is uterine atony (70-80%), where the uterus fails to contract and compress placental spiral arteries. Other causes are categorised by the '4 Ts': Tone (atony), Tissue (retained products), Trauma (lacerations/rupture), and Thrombin (coagulopathy). Risk factors include uterine overdistension (e.g., multiple pregnancy, polyhydramnios), prolonged labour, previous PPH, and instrumental delivery. Resuscitation (ABCDE) must occur concurrently with identifying and treating the cause. For massive haemorrhage, activate the 'Major Haemorrhage Protocol' immediately for blood product access.
🔬 Basic Science
After placental delivery, the uterus must contract powerfully to constrict the spiral arteries, preventing haemorrhage – this is 'physiological ligaturing'. Uterine atony is the failure of this mechanism, leading to rapid arterial bleeding. Causes of atony include uterine overdistension (e.g., polyhydramnios, multiple pregnancy), muscle fatigue from prolonged labour, or effects of some anaesthetics. Retained placental tissue prevents effective uterine contraction. Trauma (e.g., cervical tears, uterine rupture) causes direct vascular injury. Coagulopathy (Thrombin) can be pre-existing (e.g., von Willebrand disease) or acquired during massive haemorrhage due to consumption of clotting factors (DIC).
🏥 Clinical Relevance
The cardinal sign is heavy vaginal bleeding post-delivery. Be aware that bleeding can be concealed (e.g., large vaginal haematoma, uterine rupture with internal bleeding). Monitor for signs of hypovolaemic shock: tachycardia is an early sign, followed by tachypnoea, delayed capillary refill, and later, hypotension and altered mental status. Fundal palpation is key: a 'boggy', poorly contracted uterus suggests atony. Secondary PPH often presents with persistent or recurrent bleeding, sometimes with foul-smelling lochia or fever, indicating endometritis or retained products of conception (RPOC). Long-term complications can include Sheehan's syndrome (pituitary necrosis), renal failure, and significant psychological impact.
🧪 Investigations
Bedside: Frequent vital sign monitoring (BP, HR, RR, SpO2, urine output). Fundal palpation to assess uterine tone and height. Inspect placenta for completeness. Thorough inspection of perineum, vagina, and cervix for lacerations. Bloods: Immediate Group and Save, Cross-match (4 units minimum, activate Major Haemorrhage Protocol if severe). Full Blood Count (baseline Hb), Coagulation screen (PT, APTT, Fibrinogen), U&Es, Lactate (indicates tissue hypoperfusion). Imaging: Bedside ultrasound may be used to assess for retained products in stable patients, but clinical management takes precedence in acute PPH.
💊 Management
Acute Primary PPH (Emergency):
1. Resuscitation: ABCDE approach. Large bore IV access (x2), IV fluids (crystalloids), oxygen. Activate Major Haemorrhage Protocol.
2. Identify cause (4 Ts).
3. Tone (Atony):
- Rub up the fundus (vigorous uterine massage).
- Catheterise bladder (full bladder inhibits contraction).
- Medical: IV Oxytocin (10 units bolus, then 40 units in 500ml over 4 hours). IM Ergometrine (500mcg, avoid in hypertension/cardiac disease). IM Carboprost (250mcg, avoid in asthma). Sublingual Misoprostol (800mcg).
- IV Tranexamic Acid 1g over 10 minutes (repeat after 30 mins if bleeding continues).
- Mechanical: Bimanual uterine compression. Intrauterine balloon tamponade (e.g., Bakri balloon).
- Surgical: B-Lynch suture, uterine artery embolisation, internal iliac artery ligation, hysterectomy (life-saving last resort).
4. Tissue: Manual removal of placenta/products (under anaesthesia if necessary).
5. Trauma: Surgical repair of lacerations (cervical, vaginal, perineal) or uterine rupture.
6. Thrombin: Correct coagulopathy (e.g., FFP, cryoprecipitate, platelets as per MHP).
Secondary PPH: Investigate for infection (high vaginal swabs, blood cultures) and retained products (ultrasound). Treat with broad-spectrum antibiotics (e.g., co-amoxiclav or clindamycin + gentamicin) and surgical evacuation of retained products (ERPC) if indicated.
1. Resuscitation: ABCDE approach. Large bore IV access (x2), IV fluids (crystalloids), oxygen. Activate Major Haemorrhage Protocol.
2. Identify cause (4 Ts).
3. Tone (Atony):
- Rub up the fundus (vigorous uterine massage).
- Catheterise bladder (full bladder inhibits contraction).
- Medical: IV Oxytocin (10 units bolus, then 40 units in 500ml over 4 hours). IM Ergometrine (500mcg, avoid in hypertension/cardiac disease). IM Carboprost (250mcg, avoid in asthma). Sublingual Misoprostol (800mcg).
- IV Tranexamic Acid 1g over 10 minutes (repeat after 30 mins if bleeding continues).
- Mechanical: Bimanual uterine compression. Intrauterine balloon tamponade (e.g., Bakri balloon).
- Surgical: B-Lynch suture, uterine artery embolisation, internal iliac artery ligation, hysterectomy (life-saving last resort).
4. Tissue: Manual removal of placenta/products (under anaesthesia if necessary).
5. Trauma: Surgical repair of lacerations (cervical, vaginal, perineal) or uterine rupture.
6. Thrombin: Correct coagulopathy (e.g., FFP, cryoprecipitate, platelets as per MHP).
Secondary PPH: Investigate for infection (high vaginal swabs, blood cultures) and retained products (ultrasound). Treat with broad-spectrum antibiotics (e.g., co-amoxiclav or clindamycin + gentamicin) and surgical evacuation of retained products (ERPC) if indicated.
Revision Resources – expand the sections below for high-yield notes, exam pearls, key facts and further reading.
MLA High-Yield Notes & Quick Revision ⌄
SBA trap: Hypotension is a LATE sign of shock in pregnant women due to physiological adaptations (increased blood volume). Tachycardia is the earliest and most reliable indicator. Always remember the '4 Ts' for diagnosis and management. For OSCEs, be prepared to demonstrate uterine massage and explain the steps of PPH management. Know the contraindications for uterotonics (Ergometrine: hypertension; Carboprost: asthma). Viva question: 'What is active management of the third stage and why is it important?' (Answer: Administration of a uterotonic, controlled cord traction, uterine massage to prevent PPH).
Obstetric emergencies
Maternal mortality
Resuscitation in critical care
Pharmacology of uterotonics
Blood product transfusion guidelines
Management of hypovolaemic shock
- PPH is significant blood loss post-childbirth, a major cause of maternal mortality.
- Primary PPH: within 24 hours; Secondary PPH: 24 hours to 12 weeks.
- Most common cause: Uterine Atony (Tone).
- Management guided by the '4 Ts': Tone, Tissue, Trauma, Thrombin.
- Resuscitation (ABCDE) and identifying the cause occur simultaneously.
- First-line uterotonic for atony is IV Oxytocin.
Exam Pearls ⌄
⭐ High Yield
Primary PPH is >500ml (vaginal) or >1000ml (C-section) within 24 hours; Secondary PPH is 24 hours to 12 weeks postpartum.
The '4 Ts' (Tone, Tissue, Trauma, Thrombin) are the mnemonic for PPH causes, with uterine atony (Tone) being the most common (70-80%).
Tachycardia is the earliest and most reliable sign of hypovolaemic shock in postpartum women; hypotension is a late sign.
First-line uterotonic for atony is IV Oxytocin; Tranexamic acid (TXA) 1g IV should be given early in all PPH cases.
Contraindications for uterotonics: Ergometrine (hypertension/cardiac disease), Carboprost (asthma).
Active management of the third stage of labour (uterotonics, controlled cord traction) significantly reduces PPH risk.
Fundal massage and bladder catheterisation are crucial initial non-pharmacological steps for atonic PPH.
Major Haemorrhage Protocol activation is essential for severe PPH to ensure rapid blood product access.
💡 Clinical Pearl
Hypovolaemic Shock: PPH is a leading cause of hypovolaemic shock in obstetrics. Early recognition of tachycardia and prompt fluid resuscitation are critical.
Disseminated Intravascular Coagulation (DIC): Massive PPH can lead to acquired coagulopathy (Thrombin) due to consumption of clotting factors, potentially progressing to DIC.
Sheehan's Syndrome: Severe PPH with massive blood loss can cause pituitary ischaemia and necrosis, leading to Sheehan's syndrome (hypopituitarism).
Endometritis: Retained products of conception or infection can cause Secondary PPH, often presenting with fever and foul-smelling lochia.
Uterine Rupture: A rare but severe cause of PPH (Trauma), often associated with previous C-sections or uterine surgery, requiring immediate surgical intervention.
⚠️ Exam Tip — Common Mistakes
Underestimating blood loss, as visual estimation is often inaccurate.
Delaying activation of the Major Haemorrhage Protocol in severe cases.
Failing to consider all '4 Ts' when investigating the cause of PPH.
Not recognising tachycardia as an early sign of shock, waiting for hypotension.
Forgetting contraindications for specific uterotonics (e.g., Ergometrine in hypertension).
Inadequate uterine massage or bladder emptying in atonic PPH.
Key Facts ⌄
Primary PPH: >500ml (vaginal) / >1000ml (CS) within 24 hours of delivery.
Secondary PPH: Excessive bleeding 24 hours to 12 weeks postpartum.
Most common cause (70-80%): Uterine atony (Tone).
Management Mnemonic: The 4 Ts (Tone, Tissue, Trauma, Thrombin).
Active management of the third stage (IM oxytocin) is crucial for PPH prevention.
First-line uterotonic: IV Oxytocin (bolus then infusion).
Other uterotonics: Ergometrine, Carboprost, Misoprostol.
Tranexamic acid (TXA) 1g IV should be given early in all cases of PPH.
Related Topics ⌄
References ⌄
- RCOG Green-top Guideline 52 - Postpartum Haemorrhage
- BNF
- Oxford Handbook of Obstetrics and Gynaecology
Further Resources
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