Postpartum haemorrhage (PPH)

O72.0-3

DESCRIPTION

Primary postpartum haemorrhage (PPH) is blood loss >500 mL that occurs within 24 hours of birth.
Secondary PPH occurs 24 hours to 12 weeks after delivery (late or delayed PPH).
The most common cause is an atonic uterus.

GENERAL MEASURES

  • Massage fundus and expel clots from vagina.
  • Empty the bladder.
  • Two intravenous lines (wide bore if possible).
  • Bimanually compress the uterus to stop the bleeding.
  • If no response to medicine treatment, insert a condom catheter (an open condom slipped over a large Foley’s catheter and secured at its base with string to provide a makeshift balloon catheter) into uterus, inflate with 400-500mL of saline and clamp. Pack vagina with swabs to prevent expulsion and refer urgently.

MEDICINE TREATMENT

Replace fluids:

  • Sodium chloride 0.9%, IV, infused as fast as possible in one IV line.

AND

  • Oxytocin, IV, 20 units in 1 000 mL sodium chloride 0.9% infused at 250 mL/hour in 2nd IV line.

LoEI [39]

If no response:

  • Ergometrine, IM, 0.5 mg.

LoEIII

OR

  • Oxytocin/ergometrine, IM, 5 units/0.5 mg.
    • Avoid ergometrine in hypertensive women and those with heart disease, unless haemorrhage is life threatening (women haemodynamically unstable).
    • Repeat after 10–15 minutes if no response to 1st dose, while arranging referral.

Only in settings where oxytocin is not available:

  • Misoprostol, sublingual/rectal, 600 mcg as a single dose.

LoEI[40]

REFERRAL

All cases.