Primary Postpartum Haemorrhage

Primary postpartum haemorrhage is bleeding of 500 mL or more from the genital tract within 24 hours of birth (severe at 1000 mL or more, massive at 2000 mL or more or with instability). The four causes are tone (uterine atony), tissue (retained placenta or fragments), trauma (tears, rupture, inversion) and thrombin (coagulopathy). It is a leading cause of maternal death in Kenya, and rapid stepwise treatment saves lives.

• Risk factors: previous postpartum haemorrhage, prolonged labour, oxytocin use, large baby, twins, polyhydramnios, grand multiparity, anaemia, placenta praevia, abruption, chorioamnionitis, instrumental delivery, general anaesthesia.
• About 40 percent have no risk factor.
• Active management of the third stage lowers the risk by about 60 percent.

Women have heavy vaginal bleeding after birth, a soft boggy uterus (atony) or a firm uterus with continuing bleeding (tears), pallor, tachycardia, falling blood pressure, dizziness and in late shock, confusion and oliguria.

• Blood collecting in a pooled drape or on the bed and clots.
• Rising fundus on palpation in concealed bleeding.
• Differential diagnosis: uterine atony, retained placenta or tissue, cervical or vaginal tear, uterine rupture, uterine inversion, coagulopathy, vulval or vaginal haematoma.
• Complications: hypovolaemic shock, coagulopathy, acute kidney injury, Sheehan syndrome, hysterectomy, transfusion reactions, infertility, maternal death.

The approach is quantified blood loss, rapid examination for the four causes and early tests.

• Measure blood loss (weigh drapes, calibrated bag); pulse, blood pressure, respiratory rate, urine output, shock index (pulse divided by systolic pressure; above 0.9 is concerning).
• Palpate uterine tone and size; inspect cervix, vagina and perineum with light; check the placenta and membranes for completeness.
• Haemoglobin, platelets, fibrinogen (below 2 g/L signals severe haemorrhage), prothrombin time, activated partial thromboplastin time, group and cross-match 4 units; bedside clotting test (no clot in 7 to 10 minutes).
• Ultrasound for retained tissue and free fluid.

The principle is to call for help, resuscitate, find and treat the cause at once, and escalate through uterotonics, mechanical and surgical steps.

• Supportive: call senior obstetric, anaesthetic and blood bank help; two large-bore cannulae; Ringer's lactate 1 to 2 litres rapidly; oxygen 10 to 15 L/minute; lie flat with legs raised; urinary catheter with hourly output; keep warm; massage the uterus; empty the bladder; bimanual compression for atony; blood transfusion for shock.
• Pharmacological: prevention: oxytocin 10 IU IM within 1 minute of birth; treatment: oxytocin 10 IU IM or 5 IU slow IV then infusion of 40 IU in 1 litre Ringer's lactate at 250 mL per hour; ergometrine 0.2 mg IM (repeat after 15 minutes, maximum 1 mg in 24 hours); misoprostol 800 micrograms sublingual once; carboprost 250 micrograms IM every 15 minutes (maximum 8 doses); tranexamic acid 1 g IV over 10 minutes within 3 hours of birth, repeated once after 30 minutes if bleeding continues; cefazolin 2 g IV once for procedures; fresh frozen plasma 15 mL/kg and cryoprecipitate 10 units for fibrinogen below 2 g/L; platelets one adult dose below 50 x 10^9/L; calcium gluconate 1 g IV after every 4 units of blood.
• Procedures: repair of tears; manual removal of retained placenta; uterine balloon tamponade (Foley or condom catheter filled with 300 to 500 mL sodium chloride 0.9 percent, removed after 12 to 24 hours); compression sutures (B-Lynch); uterine and internal iliac artery ligation; embolisation where available; hysterectomy for uncontrolled bleeding; aortic compression with a closed fist above the umbilicus while preparing for surgery.
• Special groups: hypertension, preeclampsia or heart disease avoids ergometrine; asthma avoids carboprost; women who decline transfusion have cell salvage, iron and tranexamic acid.
• Red flags: blood loss above 1000 mL, systolic blood pressure below 90 mmHg, pulse above 120 per minute, fibrinogen below 2 g/L, oliguria below 30 mL per hour.
• Follow-up: pulse, blood pressure and bleeding every 15 minutes for 2 hours then hourly for 4 hours; haemoglobin at 6 and 24 hours; ferrous sulphate 200 mg oral 8-hourly for 3 months; review at 1 week and 6 weeks; plan birth in a facility with blood next time.