Title of Guideline (must include the word “Guideline” (not
protocol, policy, procedure etc)
Guideline for The Management of
Postpartum Haemorrhage
Contact Name and Job Title (author)
Ghada El Senoun, Consultant obstetrician
Directorate & Speciality
Family Health, Obstetrics
Implementation date
February 2014
Version
Five
Supersedes
Original Guideline produced in 1999 and
updated 2005 by Dr Ramsay, Consultant in
Feto-maternal medicine, 2010 by Ghada El
Senoun,Sr city hospital
February 2014
Date of submission
Date on which guideline must be reviewed (this should be one to
three years)
Explicit definition of patient group to which it applies (e.g.
inclusion and exclusion criteria, diagnosis)
February 2019
Abstract
This guideline describes the management of
postpartum haemorrhage both medical and
surgical techniques
Key Words
PPH, obstetric
haemorrhage,factorVII,’Syntocinon’, ‘carboprost’,
‘oxytocics’,’uterotonics’,’B-lynch suture’,’uterine
artery embolism’ ,’bilateral ligation’, balloon,
Rusch,
Statement of the evidence base of the guideline – has the
guideline been peer reviewed by colleagues?
Yes
Obstetric postpartum haemorrhage.
Evidence base: (1-5)
1a
meta analysis of randomised controlled trials
1b
at least one randomised controlled trial
2a
at least one well-designed controlled study without
randomisation
2b
at least one other type of well-designed quasiexperimental study
3
well –designed non-experimental descriptive studies
(ie comparative / correlation and case studies)
4
expert committee reports or opinions and / or clinical
experiences of respected authorities
5
recommended best practise based on the clinical
experience of the guideline developer
Consultation Process
NUH Maternity Guideline Development Group
Target audience
Midwives, Obstetricians, Amaesthetists
Meta analysis of randomised controlled
trials,
Cochrane review 2007,2014.
Expert committee reports or opinions and/or
clinical experience of respected authorities
(RCOG green top guideline 52)
This guideline has been registered with the trust. However,
clinical guidelines are guidelines only. The interpretation
and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a
senior colleague or expert. Caution is advised when using
guidelines after the review date.
Page 2 of 36
Contents
1. Background:
2. Definition and risk factors
2.1 Signs and symptoms of obstetric haemorrhage
2.2 Key signs of massive obstetric haemorrhage
3. Management
3.1 Communication
3.2 Resuscitation
3.3 Fluid therapy and blood product transfusion
3.4 Monitoring and Investigation:
3.5 Identification of the cause and arrest of bleeding
3.5.1 Uterine atony – first line treatment
3.5.2 If first line utero-tonics are not efficient consider second line
group
3.5.3 Suspected or actual retained products
3.5.4 Suspected surgical cause
3.5.5 Failure of second line uterotonics
3.6 Surgical measures to control the bleeding
3.6.1 Uterine tamponade:
3.6.2 Uterine haemostatic sutures:
3.6.3 Internal iliac artery ligation:
3.7 Tranexamic acid
3.8 Recombinant factor VIIa:
3.9 Failure of the above measures?
3.9.1 Selective arterial occlusion or embolisation by
interventional radiology:
3.9.2 Hysterectomy
4. Care following the control of haemorrhage
5. Risk management
5.1 Documentation:
5.2 Debriefing:
6. Risk factors for primary postpartum haemorrhage (PPH).
Table 1: Risk factors presenting antenatally
Table 2: Risk factors becoming apparent during labour /delivery
Monitoring Plan
References
Page 3 of 36
Appendices
Appendix 1
Interventional Radiology
Appendix 2
A pictorial guide to aid estimation of estimated blood loss in major
obstetric haemorrhage
Appendix 3. (Summary)
A flow chart of the different steps for the management of major
postpartum haemorrhage .
Appendix 4
Haemostatic uterine sutures
Appendix 5.
Protocol for use of Recombinant Coagulation Factor VIIa
Appendix 6
Rational for protocol for rVIIa
Appendix 7
Background and rationale for the protocol
Appendix 8
Obstetric haemorrhage flow chart
Appendix 9
Communication
Appendix 10
Risk factors for primary postpartum haemorrhage(PPH)
Page 4 of 36
MANAGEMENT OF PRIMARY POST PARTUM HAEMORRHAGE
1. Background
Obstetric haemorrhage is one of the major causes of maternal
morbidity and mortality in both developed and developing countries.
In the 2006–2008 report of the UK Confidential Enquiries into
Maternal Deaths, haemorrhage was the sixth highest direct cause of
maternal death (3.9 deaths/million maternities) (CMACE; 2011).
Substandard care was identified in 66% of cases, with 6 out of 9
cases in the 2006–2008 triennium judged to have received ‘major
substandard care’. For four women it was considered that different
treatment may have altered the outcome.
2. Definition and risk factors
Primary post partum haemorrhage (PPH) is defined as bleeding from
the genital tract in excess of 500 mls within 24 hours of the birth of a
baby (Cochrane Database Syst Rev 2007). The Royal College of
Obstetricians and Gynaecologists defines primary PPH as minor
(500–1000 ml) or moderate (1000 - 2000 ml) or severe ( more than
2000ml) in its Green Top Guideline (RCOG Green-top Guideline No.
52) and recommends blood loss of more than 1500mls as the trigger
for an incident form (RCOG Clinical Governance Advice Sept 09).
Risk factors may present antenatally or intrapartum. Tables 1 and 2
(see section 6) summarise known risk factors and associated odds
ratios for the risk of primary PPH. Attempts should be made during
pregnancy to identify women at risk of excessive bleeding following
delivery and if there are sufficient risk factors they should be advised
to deliver in a Consultant Led Unit for the wellbeing and safety of both
the mother and the baby.
Uterine atony accounts for 80% of cases of major postpartum
haemorrhage. Other causes include retained or morbidly adherent
placental tissue, uterine and genital tract trauma, surgical
haemorrhage, or coagulopathy secondary to abruption, sepsis, preeclampsia, or amniotic fluid embolus. This is recalled as the ‘four T’s’
– tone, tissue, trauma, thrombin.
Abnormally adherent placenta (placenta accreta and the more severe
Page 5 of 36
forms: increta or percreta) is associated with catastrophic haemorrhage
and carries a high morbidity, surgical interventions and maternal
mortality. Evidence is accumulating suggesting that the incidence of
morbid adhesion of the placenta is rising and it has been linked to the
increase in caesarean section, particularly repeat caesarean section
(You and Zahn, 2006). Several investigators have reported on the
prophylactic use of interventional radiology, including balloon occlusion
or selective pelvic artery embolisation, for the management of cases of
antenatally diagnosed placenta accreta with variable success rates
(Mitty et al, 1993; Dubois et al, 1997; Hansch et al, 1999).
See appendix 1 for details of the indications for interventional
radiology and how to contact the team.
Women who decline blood transfusion should be identified and
managed according to Trust guideline Management of Women
Declining Blood and Blood Products During Pregnancy and Labour.
Their refusal of transfusion and management plan should be clearly
documented in the antenatal record/Medway and transferred in
labour to the intrapartum record. In the event of haemorrhage, there
should be prompt direct involvement of the consultant in each of the
key specialities; obstetrics, anaesthesia and haematology.
2.1 The signs and symptoms of obstetric haemorrhage
In most cases blood loss will be obvious. There is good evidence that
clinical staff underestimate blood loss at delivery by up to 40% and a
chart showing common amounts of blood loss can be used to guide
estimates (Appendix 2 - Pictorial Reference Guide to Aid Visual
Estimation of Blood Loss in Obstetric Haemorrhage). Persistent
‘trickling’ over several hours can result in substantial loss. The
Confidential Enquiry (CMACE; 2011) has also identified delay of
response to early clinical signs of shock as a contributing factor.
Estimation of blood loss should be as accurate as possible
 All women who deliver on delivery suite should have blood loss
quantification. Blood loss should be measured in a measuring
jug or similar, swabs, incontinence pads etc should be weighed
(dry weight of the swab/pad should be subtracted, 1g is
equivalent to 1ml of blood).
 In theatre, the amount of fluid in the suction bottle should be
noted. Liquor should be measured at the time of delivery and
Page 6 of 36
this figure subtracted from the total volume in the suction bottle
to give blood loss. All swabs should be weighed (dry weight of
the swabs subtracted, 1g is equivalent to 1ml of blood). The
total blood loss includes blood in the suction bottle, weighed
from swabs and any clots collected in receivers.
2.2 Key signs of massive obstetric haemorrhage are:
a. Rising pulse rate
b. Pallor
c. Fall in blood pressure
d. Altered conscious level
e. Rising respiratory rate
f. Decreased urine output
g. Deviations from normal on the Early Warning Score
3. Management
The management of major primary PPH requires a multidisciplinary
approach with rapid and good communication between clinical
specialities.
Once primary PPH has been identified, management involves
four components, all of which must be undertaken
simultaneously:
- communication
- resuscitation
- monitoring and investigation
- and arresting the bleeding
An outline for the management of this condition is described in
appendix 3.
3.1 Communication
The key to successful management is prompt involvement of
experienced staff, trained in the management of haemorrhage. The
guidance below is not rigid, and it is the woman’s clinical state, rather
than measured blood loss that should determine actions (remember
estimated blood loss is often an underestimate)
Page 7 of 36
Basic measures for minor PPH
(blood 500 - 1000ml, no clinical shock, bleeding not ongoing):
 Assess placenta is complete, examine for trauma, rub a
contraction, empty bladder, consider Syntocinon
 Alert the delivery suite coordinator/midwife-in-charge of the
clinical area
Basic measures for moderate PPH
(blood 1000 - 2000ml, no clinical shock, blood loss not ongoing):
 Assess placenta is complete, examine for trauma, rub a
contraction, empty bladder, consider Syntometrine or
Syntocinon
 Alert the delivery suite coordinator/midwife-in-charge of the
clinical area
 Bleep the obstetric SHO to assess the woman
 Bleep the obstetric registrar to review the woman
 Early Warning Scores will inform the urgency of the situation
Full protocol for major PPH – potentially life-threatening
(blood loss more than > 2000ml OR clinical shock OR ongoing
blood loss):
In Community
The attending midwife must dial 999 and request the paramedic
ambulance for transfer into maternity unit. If the second midwife is not
already present, he/she must be summoned urgently. The attending
midwife must telephone the Labour Suite Co-ordinator and inform her
of the clinical situation and estimated time of arrival.
Maternity Unit
The attending midwife must request a 2222 ‘major obstetric
haemorrhage’, which will alert key Obstetric, anaesthetic/theatre
team and midwifery staff, haematology as outlined in Appendix 8.
 The most senior midwife in the clinical area will delegate a
staff member to run samples (Runner) this would normally
be a midwife or midwifery assistant. Porters may be able to
help in extreme situations. The runner will take samples to
the lab and fetch blood products. The automated chute
system should not be used in these circumstances
Page 8 of 36

Someone to record events (Scribe). This would normally be
an attending midwife
 The Obstetrician leading the management of the
haemorrhage or the co-ordinating Midwife will identify a
team member to communicate with the laboratories
The laboratory staff will be informed that it is a “major obstetric
haemorrhage” and they will facilitate appropriate haemoglobin
estimation and blood products.
In situations where there is ongoing haemorrhage Six units crossmatched Blood (electronic, O-neg, type specific - according to
need)are to be requested. Further products as required will be issued
after discussion between leading clinician and blood bank. The
leading clinician is likely to be most senior anaesthetist. Only one
person should communicate with blood bank.
Once the woman and the situation are stable the Haematology team
should be thanked and “stood down”.
- Systematic under estimation of blood loss is a recognized problem.
Where possible use visual algorithm to determine degree of blood loss
and advise the leader of the resuscitation team (senior obstetrics and
anaesthetic staff) (Appendix 2).
- Early involvement of appropriate senior staff and laboratory
specialists is fundamental to the management of PPH.
- The use of the term ‘controlled major obstetric haemorrhage’ or
‘ongoing major obstetric haemorrhage’ may be used to define the
urgency for the need of the team.
- Communication with the woman and her birthing partner is
important and clear information of what is happening should be given,
as this is a very frightening event. Also make sure baby is safe
3.2 Resuscitation
A primary survey of a collapsed or severely bleeding woman should
follow a structured approach of simple ‘ABC’, with resuscitation
Page 9 of 36
taking place as problems are identified; that is, a process of
simultaneous evaluation and resuscitation.











3.3
Assess airway
Assess breathing
Evaluate circulation
Oxygen by mask at 10–15 litres/minute, regardless of maternal
O2 concentration
Intravenous access (14/16gauge cannula x 2)
Position flat (if postpartum) or 30° tilt if baby in utero . Raising
the legs can increase blood flow to the central circulation.
There is no advantage to a ‘head down’ position
Keep the woman warm using appropriate available measures
(patient warming device).
Foley catheter to monitor hourly urine output (with urometer).
Transfuse blood as soon as possible.
Until blood is available, infuse up to 3.5 litres in total of
preferably warmed crystalloid including Hartmann’s solution
(2 litres) and/or colloid (1–2 litres) as rapidly as required.
The best equipment available should be used to achieve
rapid warmed infusion of fluids.
Fluid therapy and blood product transfusion:
In a major obstetric haemorrhage(MOH), when MOH is called,
Blood Bank will do the checking and any member of staff can
then collect the blood . Individuals collecting the blood only
require a hospital swipe card so that they can get into blood
bank and a patient identifier eg a sticker with the patient’s name
on it. The blood does not need to be prescribed before collection
Crystalloid
- Up to 2 litres Hartmann’s solution
Colloid
- Up to 1.5 litres until blood arrives (remember
risk of anaphylaxis)
Page 10 of 36
Blood
- Cross matched
- If unavailable give uncrossmatched group
specific blood OR give ‘O RhD negative’ blood.
- Do not give group O RhD negative blood to
patients known to have anti-c antibodies.
Fresh frozen
- 4 units for every 6 units of red cells
plasma
- or if prothrombin time/activated partial
thromboplastin time > 1.5 x normal (12–15 ml/kg
or total 1 litre).
Platelets
- If platelet count < 50 x 109.
Cryoprecipitate
- If fibrinogen < 2 g/l.
Cell salvage is available on both sites for planned cases. It is usually
available at all times on the Queen’s site for emergency cases, and is
usually available on the City site, though this would need to be
discussed with theatres to ensure a practitioner trained in cell salvage
is available.
The British Committee for Standards in Haematology (Stainsby et
al 2006) summarises the main therapeutic goals of management
of massive blood loss is to maintain:
● haemoglobin > 80g/l
● platelet count > 75 x 109/l
● prothrombin < 1.5 x mean control
● activated prothrombin times < 1.5 x mean control
● fibrinogen > 2.0 g/l
Page 11 of 36
3.4 Monitoring and Investigation:
All women should have observations
done every 15 minutes and recorded
on Obstetric early warning score
chart.
Basic measures for MINOR PPH
blood loss 500-1000ml, no clinical shock and cessation of bleeding:
Consider venepuncture (20ml) for:
- group and save
- full blood count
- coagulation screen and specify fibrinogen
- pulse, blood pressure and respiratory rate recording every 15
minutes.
 Consider Hartmann’s infusion
Full protocol for moderate or severe PPH
blood loss greater than 1000ml and continuing to bleed OR clinical
shock
 Take 30 mls of blood as these are needed for:
- full blood count (one purple top)
- coagulation screen and specify including fibrinogen (one
blue top; must be filled to level given)
- crossmatch at least 4 units (2 pink top)
- renal and liver function for baseline (one yellow top).
 Always send blood samples to the labs by a Runner, rather than
the automated chute system
 Monitor temperature every 15 minutes
 Continuous pulse, blood pressure recording and respiratory rate
(using oximeter, electrocardiogram and automated blood pressure
recording)
 Hourly fluid balance
- Including hourly urine output and fluid input (type,
volume, and intravenous site)
 Fundal height and tone
 Blood loss
 Medication administered record on prescription chart
3.5 Identification of the cause and arrest of bleeding
Causes for primary PPH may be related to one or more of ‘the four
Page 12 of 36
Ts’:
 tone (abnormalities of uterine contraction)
 tissue (retained placenta and membranes. Ensure that the
placenta has been examined and is complete)
 trauma (of the genital tract)
 thrombin (abnormalities of coagulation).
3.5.1 Uterine atony (Tone)– first line treatment
- rub up contraction
- ensure that the bladder is empty
- Syntometrine (Syntocinon 5iu/ergometrine 0.5mg) or Syntocinon 5iu
if Syntometrine is contra-indicated should be given by slow IV
injection or intramuscularly
- Syntocinon infusion 40iu in 500mls 0.9% Sodium Chloride to run at
125mls /hr. it is expected that most women with uterine atony will
respond to this management.
3.5.2 If first line utero-tonics are not effective consider second
line group and perform bimanual compression
a. Carboprost 0.25 mg by intramuscular injection repeated at
intervals of not less than 15 minutes to a maximum of 8 doses
(should be used with caution in women with asthma) (RCOG
Clinical Governance Advice Sept 09)
b. Misoprostol 600 micrograms rectally (can be used in women with
asthma). Repeat dosages should not be given within 2 hours.
Shivering fever and diarrhoea are common side effects. Maternal
pyrexia is usually self limiting and responds well to paracetamol (if
these occur, wait 6 hrs before repeating the dose) (RCOG Clinical
Governance Advice Sept 09)
3.5.3 Suspected or actual retained products (Tissue)
If there is retained placenta or placental tissue is suspected
arrangement should be made for transfer to theatre for evacuation of
retained products once the woman is stabilised.
3.5.4 Suspected trauma cause (Trauma)
Adequate inspection of the lower genital tract is required to rule out
surgical causes; use pressure if necessary to initially stop bleeding,
then arrange formal repair.
If known bleeding diathesis discuss with haematology.
Page 13 of 36
3.5.5 Failure of second line management
If pharmacological measures fail to control the haemorrhage, initiate
surgical haemostasis sooner rather than later. Consideration should
be given to examination in theatre where the uterus appears to be
well contracted. Furthermore, evidence of coagulopathy should be
sought.
Options when second line uterotonics fail
 assess uterine tone and continue utero-tonics.
 assess blood loss and its rate
 re-assess initial diagnosis
 bimanual compression of the uterus.
 re-assess level of blood transfusion provision
3.6 Surgical measures to control the bleeding
3.6.1 Uterine tamponade:
- Intrauterine balloon using Bakri balloon (Bakri et al 2001) or Rusch
catheter (Keriakos et al 2006) is an appropriate ‘surgical’ intervention
for most women where uterine atony is the only or main cause of
haemorrhage.
- The balloon can be filled with warm saline with volume that varies
between 400-500mls. However, the use of smaller and bigger
volumes have been described (Keriakos et al 2006).
- Ultrasound scan may be used to guide the process of insertion. It is
advisable to use 50ml syringe for inflation of the balloon.
- It is recommended to observe bleeding and fundal height after
insertion and oxytocin infusion should be continued for 24 hours.
- Consider prophylactic antibiotics: Guideline for Antibiotics in
Obstetrics
3.6.2 Uterine haemostatic sutures:
- Current evidence from published case series and audits suggest
that uterine compression suture can reduce the rate of
hysterectomies in women with major primary PPH.
- They include B-lynch suture (B-Lynch 1997), modified B-lynch or
simple Brace suture (Hayman 2002), and multiple square sutures
(Cho 2000). Appendix 4 describes the technique of each one with a
Page 14 of 36
simple diagram. It is advisable to use 2 vicryl on a straight or large curved
needle.
- The choice of technique should be individualised by the consultant
obstetrician, but a blunt taper point 70mm monocryl or vicryl is suggested
3.6.3 Internal iliac artery ligation:
Current evidence suggests that the success rate of bilateral internal iliac
artery ligation to control major primary PPH is under 50% (RCOG Green-top
Guideline No. 52). Therefore, available balloon tamponade and haemostatic
sutures may be simple and more effective than internal iliac artery ligation.
3.7 Tranexamic acid
Tranexamic acid is an anti-fibrinolytic agent and is well established for
controlling haemorrhage. 1g can be given intravenously three times each
day. Consider early use in appropriate cases.
3.8 Recombinant factor VIIa:
- The use of recombinant factor VIIa (rVIIa) should be considered prior to
the decision to carry out hysterectomy. The rational behind using rVIIa is
summarised in Appendix 5,6,7. It also highlights the exact dose and steps
that should be taken before given the drug.
- The use of rVIIa may be considered as a treatment for life- threatening
post-partum haemorrhage. However, it should not be
considered as a substitute for, nor should it delay the performance of a lifesaving procedure such as embolisation or surgery.
- If body weight is not known it is advisable to give a dose 7.2 mg where
body weight is expected to be less than 90kg and is 9.6mg where body
weight over 90kg.
3.9 Failure of the above measures
3.9.1 Selective arterial occlusion or embolisation by
interventional radiology:
It should be considered if the interventional radiologist is available and the
general condition of the patient allows time for insertion (see appendix 1).
Page 15 of 36
3.9.2 Hysterectomy
- Subtotal hysterectomy may be sufficient in most cases to arrest
haemorrhage.
- Resort to hysterectomy sooner rather than later especially in cases
of placenta accreta. (RCOG Green-top Guideline No. 52)
- Where hysterectomy is being considered the on-call consultant
gynaecologist should attend.
4. Care following the control of haemorrhage
Following massive obstetric haemorrhage women should be
cared for in an area equipped to provide Advanced Obstetric
Care (AOC).
- Documentation should be carried out on an obstetric early warning
score chart (OEWS) chart.
1. This should be at 30 minute intervals for the first hour.
2. Then hourly for 4 hours.
3. Then 4 hourly until 24 hours post procedure.
- uterine contraction should be maintained by an infusion (40 units of
oxytocin in 500ml at 125 ml/hr), keep an eye on uterine tone and
vaginal bleeding
- hourly fluid balance
- repeat blood sampling should be individualized
- postnatal transfusion should rarely be considered where the
haemoglobin is more than 70g/l
- women and their families should be offered an opportunity to
discuss events with a senior member of the clinical team before
discharge from hospital.
-Remove Bakri balloon ,if used, after 24 hours by slow deflation
5. Risk management
5.1 Documentation:
Inadequate documentation in obstetrics can lead to potential
medico-legal consequences.
It is important to document:
• the staff in attendance and the time they arrived
• the sequence of events
• the time of administration of different pharmacological agents
given, their timing and sequence
• the time of surgical intervention, where relevant
Page 16 of 36
• the condition of the mother throughout the different steps
• the timing of the fluid and blood products given.
•
Complete the PPH continuous audit proforma. The proforma must
be photocopied and the photocopy placed in the women’s hospital
notes. The original must be put with the other completed continuous
audit proformas (NB the photocopy is put in the woman’s notes because
audit is unable to scan non-original audit forms).
• Complete the online incident reporting form for all PPH>1500ml.
5.2 Debriefing:
Major obstetric haemorrhage can be traumatic to the woman, her
family and the birth attendants. It is therefore recommended that a
senior member of the team who was involved at the time of events
offers debriefing at the earliest opportunity.
This should include arrangements for follow-up and investigations as
necessary, such as screening for coagulopathies if there are other
indicators and screening for the rare complication of
panhypopituitarism (Sheehan syndrome) secondary to hypotension
6. Risk factors for primary postpartum haemorrhage (PPH)
Table 1: Risk factors presenting antenatally and associated with an
increase in the incidence of PPH:
Risk Factor
Four ‘T’s
Odds ratio for
PPH (99%CI)
● Suspected or proven placental abruption
Thrombin
13 (7.61–12.9)
● Known placenta praevia
Tone
12 (7.17–23)
● Multiple pregnancy
Tone
5 (3–6.6)
Page 17 of 36
● Pre-eclampsia/gestational hypertension
Thrombin
4
● Previous PPH
Tone
3
● Asian ethnicity
Tone
2 (1.48–2.12)
● Obesity (BMI >35)
Tone
2 (1.24–2.17)
● Anaemia(<9g/dl)
-
2 (1.63–3.15)
Table 2: Risk factors becoming apparent during labour/delivery
which should prompt extra vigilance among clinical staff:
Risk Factor
Four ‘T’s
Odds ratio for PPH
(99%CI)
● Emergency Caesarean section
Trauma
4 (3.28–3.95)
● Elective Caesarean section
Trauma
2 (2.18–2.80)
● Induction of labour
-
2 (1.67–2.96)
● Retained placenta
Tissue
5 (3.36–7.87)
● Mediolateral episiotomy
Trauma
5
● Operative vaginal delivery
Trauma
2 (1.56–2.07)
Page 18 of 36
● Prolonged labour (>12 hours)
Tone
2
● Big baby (>4 kg)
Tone/Trauma 2 (1.38–2.60)
● Pyrexia in labour
Thrombin
2
● Age (>40)(not multiparity)
Tone
1.4 (1.16–1.74)
Staff Training
Staff will be provided training on post partum haemorrhage in line
with the Nottingham University Hospitals Maternity Services Training
Needs Analysis (2010).
Monitoring Plan
The Guideline for The Management of Postpartum Haemorrhage will be
monitored in conjunction with the NUH Maternity Services Clinical and
Operational Monitoring Plan.
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Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine
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Guideline No. 52. Prevention and management of postpartum
haemorrhage.
Royal College of Obstetricians and Gynaecologists Clinical
Governance Advice Sept 09: Improving Patient Safety – Risk
Management for Maternity and Gynaecology
Page 20 of 36
Stainsby D, MacLennan S, Thomas D, Isaac J, Hamilton PJ.
Guidelines on the management of massive blood loss. Br J Haematol
2006;135:634–41.
You WB, Zahn CM. Postpartum haemorrhage: abnormally adherent
placenta, uterine inversion, and puerperal haematomas. Clin Obstet
Gynecol
2006;49:184–97.
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APPENDIX 1
INTERVENTIONAL RADIOLOGY
Vascular Interventional Guidelines for Post Partum
Haemorrhage
There are two patient groups who may benefit from Vascular
Interventional Radiology support in management of major obstetric
haemorrhage.
1) Predicted high risk patients
2) Unpredicted post partum haemorrhage
Contact:
There are currently 5 vascular interventional radiologists who can
provide vascular obstetric services. Drs O’Neill, Whitaker, Ramjas,
Habib and Travis. There is a daytime (0800-1800 Monday to Friday)
duty consultant at QMC who can be contacted via the secretaries
(Exts 70487 and 70488), or via the angiography suite (Ext 67142).
There is an interventional radiology on call service across the trust.
Referral to this service must be made at Consultant to Consultant
level.
1) Predicted high risk patients
These to include:
a)
Previous major obstetric haemorrhage
b)
Previous placenta accreta or percreta
c)
US or MRI evidence of current accreta or percreta
d)
Uterine vascular malformation
For identified high risk patients placement of internal iliac balloons /
catheters should be considered. This is to facilitate balloon occlusion
of the anterior division of the internal iliac artery following delivery
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with the option to embolise the anterior division of the internal iliac
artery.
There is currently little evidence in the published literature for this
excepting short case series. These series present conflicting views.
Whilst the inflation of balloons may not significantly alter the course of
haemorrhage the ability to embolise via those balloons is probably of
benefit.
As soon as a high risk patient is identified the consultant obstetrician
should contact a consultant interventional radiologist (as listed above)
to discuss if intervention is appropriate. If intervention is agreed upon a
date for elective caesarean should be decided with booking of the
angiographic suite and C-arm theatre fluoroscopy for 0900 hours.
Technique
Pre procedure:
Informed consent should be obtained by a consultant
radiologist prior to the procedure.
In addition to preparation on the ward the patient should have a urinary
catheter and epidural catheter (if required) placed prior
to attendance in the angiographic suite.
Procedure in Angiographic Suite:
Midwifery and anaesthetic staff should be in attendance. Bilateral
common femoral artery 6 french sheaths connected to pressure bags.
Placement of crossing, bilateral Co-rail conformable balloons, or
alternate, within the anterior division of the internal iliac arteries.
If the anterior division cannot be successfully cannulated then the
main internal iliac trunk can be used.
Wires should be left in the balloon shafts to avoid kinking.
Pressure bags to be connected to the lumens.
Test inflations should be undertaken to establish volume required to
occlude. 1ml medallion syringes to be connected via flow switches
to balloons.
All sheaths and catheters should be fixed in place and patient to be
transferred to obstetric theatre.
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Procedure in Obstetric Theatre:
Initial check of catheter position with portable C-arm. Subsequent
to delivery and clamping of cord balloons to be inflated blind and
time recorded.
If blood loss >3000ml or at request of consultant obstetrician blind
embolisation with gelfoam slurry should be considered. When
surgical intervention has finished discussion as to whether to
remove arterial access should be undertaken. Ideally a closure
device such as angioseal should be used.
If there is continued haemorrhage transfer to the angiographic suite
should be considered for targeted embolisation if surgical methods of
control have failed.
2)
Unpredicted post partum haemorrhage
If interventional radiology is considered for post partum haemorrhage
uncontrolled by medical and surgical manoeuvres then the current lack
of an on-call rota should not deter a consultant interventional
radiologist from being contacted. It would reasonable to ask for
attendance to enable discussion as to the merits of embolisation.
Undertaking embolisation in obstetric theatre would be exceptionally
challenging with portable equipment and thus those patients most
likely to benefit from embolisation are those who can be stabilised
and transferred to the angiographic suite. It takes approximately 30
minutes to have the angiographic suite staffed and ready for a patient
to undergo embolisation.
Decisions should be taken between all consultant staff present as to
the most appropriate management pathway.
The method of embolisation will depend on the findings at
angiography and the interventional radiology consultant will decided
on the method used. Patients transferred to the angiographic suite
will need to be accompanied by anaesthetic and obstetric staff. If
embolisation is initially successful further embolisation can be
considered if re-bleeding occurs.
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Appendix 2
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Summary
Appendix 3. A flow chart of the different steps for the management of
major postpartum haemorrhage. Resuscitation, monitoring, investigation
and treatment should occur simultaneously.
Call for help
If at home dial 999 request paramedic ambulance,(midwife must escort women in ambulance)
Senior midwife/Obs & Anaes
Initiate the Major Obstetric Haemorrhage protocol(dial 2222)
Alert Consultant Obstetrician on call
Resuscitation Airway Breathing
Circulation
Oxygen mask (15L)
Fluid balance (2L Hartmann's, 1.5L colloid) Blood transfusion
(ORhD neg or group specific blood) Blood products (FFP,
PLT, cryoprecipitate)
Keep patient warm
Monitoring and investigations
Medical treatment
- 14/16g cannulae x2
- FBC, coagulation including fibrinogen, U&Es,
LFTs
- X-Match (4U, FFP, PLT, cryoprecipitate)
- ECG, oximeter
- O2 mask
- Foley catheter
- Blood products
- Commence record chart
- Weigh all swabs and estimate blood loss
- Rub A contraction
- Empty bladder
- Oxytocin 5iu x2 (slow IV)
- Ergometrine 500 μg (slow IV)
- Oxytocin infusion (40 u in 500ml)
If bleeding persist
- Carboprost 250 μg IM every 15mns up to 8 times
(contraindicated in asthmatics)
- Misoprostol 600 μg rectally (can be used in
asthmatics)
-Bimanual uterine compression
Theatre
- Is the uterus contracted?
- Examination under anaesthetic
- Has any clotting abnormality been corrected?
- Bimanual compression.
- Intrauterine balloon tamponade.
- Laparotomy bimanual compression.
- Haemostatic uterine sutures.
- Bilateral internal iliac artery ligation.
- Recombinant factor VIIa
- Consider HDU (high dependency
ITU.
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- Hysterectomy (gynae consultant)
- Uterine Artery embolosation
unit). Or
Appendix 4
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Appendix 5
Guideline for use of Recombinant Coagulation Factor VIIa
(NovoSeven ®) in uncontrolled haemorrhage
It is recommended that blood product replacement and use of rVIIa is discussed with the on-call
haematologist.
Massive uncontrolled haemorrhage defined as:
1.Consider after 6 units of blood have been given
2. Definite after 8 units of blood have been
No
rVIIa not indicated
Yes
All accepted and available surgical measures to
control bleeding attempted, or surgical measures
impossible/inappropriate.
No
rVIIa not indicated
unless/until surgical
control attempted.
Yes
Appropriate haemostatic replacement
therapy given?
1. FFP 10-15ml/kg (2 standard units for
adults). Aim for PT and APTT < 1.5x control
2. Cryoprecipitate 1-1.5 packs / 10kg. Aim for
fibrinogen > 0.5g/L, ideally >1g/L
3. Platelets 1-2 adult doses. Aim for platelet
9
count > 50 x 10 / L
4. Tranexamic acid 1g 3 times a day by slow IV
injection (adult dose)
Haemostatic replacement
therapy should be given and
situation reassessed.
There may be a role for
unlicensed use of
QuickClot®
No
Yes
pH  7.2
Fibrinogen > 0.5g/L (ideally > 1g/L) Platelets
9
> 50 x 10 / L
.
Aim Core Temperature > 35 oC
No
Correct pH and give appropriate
haemostatic replacement therapy
Reassess bleeding and
need for rVIIa.
Yes
Consultant responsible for patient
authorises uses of rVIIa.
If use of rVIIa is approved:
1. Telephone request to Blood Bank
2. Give patient details, weight and name of
authorising consultant and fill in Blood Bank
request form.
3. rVIIa should be collected from Blood
Bank (will only be issued following receipt of
appropriately completed request form.)
Dose by IV bolus
< 55kg = 5mg (1x 5mg vial)
55 - 75kg = 7mg (1x 2mg vial + 1x 5mg vial)
76 – 100kg = 9mg (1x 5 mg + 2 x 2mg vials)
101 -120kg = 11mg (2x 5mg vials + 1x 1mg vial)
>120kg = 11mg (2x 5mg vials + 1x 1mg vial)
( >120kg dose based on lean body mass)
Reassess bleeding after 20 min. Check coagulation screen and fibrinogen. If
bleeding uncontrolled, it is recommended that repeat doses are discussed with
on-call haematologist.
Page
29 of Recent
35
caution:
thrombosis or high risk (eg PE, MI, thrombotic stroke in last
6months; prosthetic heart valve
Appendix 6
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Appendix 7 Background and rationale for the guideline for rVIIa
Recombinant activated factor VIIa (rFVIIa) is licensed for the treatment
of haemophilia with inhibitors, FVII deficiency and Glanzmann’s
thrombasthenia with platelet refractoriness.
It’s off label use as a haemostatic agent in massive uncontrolled
bleeding in a wide range of clinical scenarios is rapidly expanding, but
no evidence-based guidelines are available.
Uncontrolled massive bleeding after trauma or complicated surgical
procedures is frequently a combination of surgical and coagulopathic
bleeding. Treatment of coagulopathic bleeding centres on
replacement therapy with appropriate blood products, but may be
unsuccessful in some cases of massive blood loss, predicting a poor
outcome.
Mechanism of action of rVIIa
rVIIa is identical to the human plasma protein with only minor
difference in post-translational carboxylation, hydroxylation and
glycosylation. Its half-life is short: 2-3 hours in haemophiliacs with
inhibitors, and less in children and bleeding individuals.
Coagulation models suggest that rVIIa enhances haemostasis at the
site of injury without a systemic hypercoagulable effect. This is
thought to explain the good safety profile of rVIIa with respect to
thrombosis.
Its haemostatic effects are mediated by the thrombin it generates by
both tissue factor (TF) dependent and independent mechanisms. The
TF independent mechanism requires platelets for the direct activation
of Factor X on their surface by rVIIa. It is likely that in the presence of
TF, the more efficient TF-dependent mechanism predominates.
It is probable that the action of rVIIa requires the presence of
adequate substrate for the reactions involved in securing adequate
haemostasis. The minimum levels of other coagulation factors
required are not known, but some authors have suggested minimum
levels of fibrinogen required for an adequate response. Although
there are case reports of the successful use of rVIIa in severe
thrombocytopenia, the only randomised controlled trial in
thrombocytopenic individuals suggested that a low platelet count is
likely to predict a poor response to rVIIa therapy.
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Both clinical and experimental data suggest that acidosis inhibits
response to rVIIa treatment. Significant acidosis is very likely in
severely ill bleeding patients, and may predict a poor response to
rVIIa. There is currently no evidence that correction of acidosis prior
to treatment improves the response to rVIIa.
Clinical studies of rVIIa treatment
Currently there is little evidence that the use of rVIIa in uncontrolled
haemorrhage as a result of trauma or surgery reduces mortality. The
limited randomised controlled trial data available showed a reduction
in the transfusion of red blood cell units was observed with rV11a
(estimated reduction of 2.0 RBC units per patient treated, p=0.07).
The need for transfusions of 20 units of RBC was significantly
reduced (14% vs. 33% of patients, p=0.03). There was also a nonsignificant reduction in mortality and trend toward fewer critical
complications. Preliminary data suggests that relative to placebo
rV11a may be a cost effective therapy.
Clinical decision making in these situations remains very difficult and
should involve senior medical staff.
References:
Boffard KD et al. Recombinant factor V11a as adjunctive therapy for
bleeding control in severely injured trauma patients: two parallel
randomised placebo-controlled double-blind clinical trials. J Trauma
2005; 59: 8-18
Spahn D et al. Management of bleeding following major trauma: a
European guidance. Critical Care 2007; 11: R17
Vincent JL. Recommendations on the use of recombinant activated
factor V11 as an adjunctive treatment for massive bleeding- a
European perspective. Critical Care 2006; 10: R120
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Appendix 8 - Communication
Maternity Unit Communication in a
Major Obstetric Haemorrhage – day time
“major obstetric
haemorrhage”
“
attending midwife or theatre staff to ask for
2222 obstetric haemorrhage
state delivery suite room number or
obstetric theatre or ward
this calls
obstetric consultant
obstetric registrar
obstetric SHO
on-call obstetric
anaesthetist
Labour Suite Co-ordinator
Haematology/blood bank
}
}
to
attend
} the
patient
} immediately
}
}
and the delivery suite co-ordinator
who will identify a person to liaise with
haematology and blood bank.
Once the situation and the woman are
stable thank and “stand down” the
haematology service
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Maternity Unit Communication in a
Major Obstetric Haemorrhage – night time
“major obstetric haemorrhage”
“
attending midwife or theatre staff to ask for
2222 obstetric haemorrhage
state delivery suite room number or obstetric
theatre or ward
this calls
obstetric registrar
obstetric SHO
on-call obstetric
}
} to attend
the
} patient
anaesthetist
} immediately
Labour Suite Co-ordinator }
and the delivery suite co-ordinator
who will identify a person to liaise with
Haematology/blood bank
Once the situation and the woman are
stable thank and “stand down” the
haematology
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Community Communication in a
Major Obstetric Haemorrhage
Call 999 paramedic
ambulance
Contact labour suite at the
appropriate maternity unit
QMC: 8754672
City: 9627710
Inform on call
Supervisor of
Midwives following
transfer in
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Appendix 10
6. Risk factors for primary postpartum haemorrhage (PPH)
Table 1: Risk factors presenting antenatally and associated with an
increase in the incidence of PPH:
Risk Factor
Four ‘T’s
Odds ratio for
PPH (99%CI)
● Suspected or proven placental abruption
Thrombin
13 (7.61–12.9)
● Known placenta praevia
Tone
12 (7.17–23)
● Multiple pregnancy
Tone
5 (3–6.6)
● Pre-eclampsia/gestational hypertension
Thrombin
4
● Previous PPH
Tone
3
● Asian ethnicity
Tone
2 (1.48–2.12)
● Obesity (BMI >35)
Tone
2 (1.24–2.17)
● Anaemia(<9g/dl)
-
2 (1.63–3.15)
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Table 2: Risk factors becoming apparent during labour/delivery
which should prompt extra vigilance among clinical staff:
Risk Factor
Four ‘T’s
Odds ratio for PPH
(99%CI)
● Emergency Caesarean section
Trauma
4 (3.28–3.95)
● Elective Caesarean section
Trauma
2 (2.18–2.80)
● Induction of labour
-
2 (1.67–2.96)
● Retained placenta
Tissue
5 (3.36–7.87)
● Mediolateral episiotomy
Trauma
5
● Operative vaginal delivery
Trauma
2 (1.56–2.07)
● Prolonged labour (>12 hours)
Tone
2
● Big baby (>4 kg)
Tone/Trauma 2 (1.38–2.60)
● Pyrexia in labour
Thrombin
2
● Age (>40)(not multiparity)
Tone
1.4 (1.16–1.74)
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