Traumatic Postpartum Haemorrhage

Traumatic postpartum haemorrhage is bleeding after birth from injury to the genital tract, including tears of the cervix, vagina and perineum, vulval and vaginal haematomas, episiotomy extension, uterine rupture and uterine inversion. It causes 15 to 20 percent of postpartum haemorrhage. It is suspected when bleeding continues with a firm, well contracted uterus.

• Risk factors: instrumental delivery, precipitate labour, macrosomia, shoulder dystocia, episiotomy, previous scar, internal version, obstructed labour.
• Bleeding can be concealed in a haematoma or the broad ligament.
• Early inspection of the tract finds most injuries.

Women have bright red steady bleeding after birth with a hard, well contracted uterus, perineal or pelvic pain, a bulging vaginal or vulval mass, or shock out of proportion to visible bleeding.

• Continuous trickle despite a firm uterus.
• Rising fundus or flank pain with concealed bleeding.
• Differential diagnosis: uterine atony, retained placenta, coagulopathy, uterine rupture, uterine inversion, broad ligament haematoma.
• Complications: shock, coagulopathy, infection, wound breakdown, fistula, anal sphincter injury, hysterectomy, maternal death.

The approach is systematic examination of the genital tract with good light, analgesia and an assistant.

• Inspect vulva, perineum, vagina and cervix; rectal examination for sphincter and mucosa injury; palpate the uterus for tone, and for a defect or inversion.
• Pulse, blood pressure, fundal height and urine for blood.
• Haemoglobin, platelets, fibrinogen, clotting screen, group and cross-match 2 to 4 units.
• Ultrasound or CT for suspected haematoma or free fluid.

The principle is to find the source, repair it, and resuscitate, with laparotomy for rupture or deep bleeding.

• Supportive: call for senior help; two large-bore cannulae; Ringer's lactate 1 to 2 litres rapidly; lithotomy in theatre with light and retractors; bladder catheter; analgesia; blood transfusion for shock.
• Pharmacological: lignocaine 1 percent 10 to 20 mL infiltration (maximum 3 mg/kg, absolute maximum 200 mg; with adrenaline 7 mg/kg, absolute maximum 500 mg) or spinal or epidural for large repairs; oxytocin 10 IU IM after birth and infusion of 20 IU in 1 litre Ringer's lactate at 125 mL per hour for 4 hours; tranexamic acid 1 g IV over 10 minutes (repeat once after 30 minutes if bleeding continues); cefazolin 2 g IV plus metronidazole 500 mg IV once at repair, then amoxicillin-clavulanate 625 mg oral 8-hourly for 5 days for deep or sphincter tears; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); fresh frozen plasma 15 mL/kg and cryoprecipitate 10 units for fibrinogen below 2 g/L.
• Procedures: repair of cervical tears from the apex with size 0 polyglactin; repair of vaginal and perineal tears in layers; drainage of haematomas with ligation of bleeding vessels; vaginal packing for 12 to 24 hours for oozing; laparotomy for uterine rupture or tears extending into the broad ligament, with repair or hysterectomy; uterine replacement for inversion; embolisation where available.
• Special groups: women with a previous scar and heavy bleeding with pain are assessed for scar rupture; women who decline transfusion have cell salvage.
• Red flags: bleeding with a contracted uterus, expanding mass, rising fundus, shock, sudden loss of contractions, haematuria.
• Follow-up: pulse, blood pressure and bleeding every 15 minutes for 2 hours then 4-hourly for 24 hours; haemoglobin at 24 hours; wound review at 1 week; review at 6 weeks; ferrous sulphate 200 mg oral 8-hourly for 3 months.