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Obstetrics

Postpartum Haemorrhage (PPH)

Excessive vaginal bleeding after childbirth, defined as >500ml after vaginal delivery or >1000ml after Caesarean section. Primary PPH occurs within 24 hours, Secondary PPH occurs from 24 hours to 6 weeks postpartum. A leading cause of maternal mortality.

Also known as: PPH, Bleeding After Delivery

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Referral and warning signs

When to refer

IMMEDIATE EMERGENCY REFERRAL/TRANSFER to higher level (H/RR) for PPH unresponsive to initial measures, retained tissue, major trauma, rupture, or need for blood/surgery. Transfer with IVs, fluids, potentially UBT/NASG.

Red flags

  • Persistent heavy bleeding
  • Signs of shock
  • Boggy uterus
  • Suspected retained placenta/tear/rupture
  • Unresponsive patient

Signs and symptoms

  • Excessive vaginal bleeding.
  • Signs of shock (tachycardia, hypotension, pallor, confusion).
  • Uterus soft/boggy (Atony).
  • Uterus firm but bleeding persists (Trauma).
  • Retained/incomplete placenta (Tissue).
  • Signs of coagulopathy (rare initially).

Risk factors

  • Atony: Prolonged/augmented/precipitate labour, Multiple pregnancy, Polyhydramnios, Macrosomia, Grand multiparity, Chorioamnionitis, Fibroids, History PPH.
  • Tissue: Retained placenta/fragments.
  • Trauma: Tears, Episiotomy extension, Uterine rupture/inversion.
  • Thrombin: Coagulopathy (Abruption, PET/HELLP, Sepsis, AFE).

Diagnosis

Clinical assessment

Recognize excessive bleeding, assess haemodynamics (ABC). Systematically assess '4 Ts': Tone (palpate uterus), Tissue (examine placenta, explore uterus), Trauma (inspect birth canal), Thrombin (consider if others excluded). Estimate blood loss. Monitor vitals.

Investigations

  • Clinical assessment primary.
  • Hb (baseline/post).
  • Blood Group & Cross-match URGENT.
  • Coagulation screen (if suspected).

Diagnostic criteria

EBL >500ml (vaginal) or >1000ml (C/S) OR any bleeding causing instability.

Management

Non-pharmacological management

  • IMMEDIATE ACTIONS (Simultaneous): Call HELP. ABC Resuscitation (Oxygen, 2 large IVs). Uterine Massage. Empty Bladder. Identify Cause (4 Ts). Keep Warm.
  • If Atony: Continue massage, give uterotonics.
  • If Tissue: Manual removal.
  • If Trauma: Repair tears.
  • If Rupture: Laparotomy.
  • If Inversion: Replace immediately.
  • If Bleeding Persists (despite uterotonics): Bimanual Compression, Aortic Compression, Uterine Tamponade (UBT/Packing), NASG.
  • Surgical Measures (Hospital): Compression sutures, Arterial ligation, Hysterectomy.

Pharmacological treatment

  • Fluid Resuscitation: Rapid IV Crystalloids (NS/RL - 2L fast).
  • Blood Transfusion: Early transfusion (WB/PRBCs).
  • Uterotonics (For Atony): Oxytocin (10 IU IM or 20-40 IU in IV fluid), Misoprostol (800-1000 mcg PR/SL), Ergometrine (0.2-0.25mg IM/IV - NOT if HTN). Carboprost (specialist). Carbetocin (PREVENTION only).
  • Antifibrinolytic: Tranexamic Acid (TXA) 1g IV slowly (<3h delivery), repeat 1g if needed.
  • Antibiotics: Prophylactic if MRP/trauma etc.

Monitoring

Continuous Vitals, Blood loss, Uterine tone, Consciousness, Urine output. Monitor Hb, coagulation.

Complications

  • Shock.
  • Anaemia.
  • AKI.
  • Sheehan's Syndrome.
  • DIC.
  • Hysterectomy/Infertility.
  • Psychological trauma.
  • Death.

Prevention

  • Active Management of Third Stage (AMTSL).
  • Antenatal anaemia correction.
  • Manage HRP.
  • Skilled birth attendance.
  • Avoid unnecessary interventions.

Patient education

  • (Post-event): Explanation, treatments received. Rest/iron importance. Signs secondary PPH/infection. Contraception. Emotional support.

Uganda-specific notes

Leading cause of maternal death. AMTSL critical. Misoprostol key alternative. TXA recommended. Access to blood/theatre/UBT/NASG varies. Teamwork vital.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 16, Section 16.4.6

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