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Obstetric
Haemorrhage
Aims
To recognise Obstetric Haemorrhage
To practise the skills needed to respond to
a woman who is bleeding
To achieve competence in those skills
Haemorrhage is common
Most common cause of maternal death
worldwide
Accounts for ~30% of maternal deaths
Deaths from haemorrhage could often be
avoided. (In SA, over 80% haemorrhage deaths are
avoidable)
SAVING MOTHERS REPORT FOR
SOUTH AFRICA, 2005 – 2007
OBSTETRIC HAEMORRHAGE
• Accounted for 491 maternal deaths in South Africa
during 2005 – 2007. (12.4% of total deaths and the third most
common cause of maternal death)
• Most common causes of haemorrhage deaths were:
APH: Abruptio placentae
PPH: uterine atony (prolonged labour)
retained placenta
ruptured uterus
bleeding associated with caesarean section
Haemorrhage is often not
recognized
 Blood loss is underestimated because in pregnancy
signs of hypovolaemia do not show until the losses are
large
 This is because mother compensates for blood loss by
shutting off the blood supply to the fetoplacental unit
 Mother can lose up to 35% of circulating blood volume
(2000 mls) before showing signs of hypovolaemia
Haemorrhage – signs
Pale
Confused
Increased HR, reduced BP
FH abnormalities
Reduced urine output
Obvious or hidden bleeding
WHEN SIGNS ARE THERE THEY ARE
SIGNIFICANT, HAVE HIGH SUSPICION
AND ACT QUICKLY!
Haemorrhage - management
Have an accessible protocol (poster form)
ABCs
C replace the volume and stop the
bleeding
Haemorrhage
ABCs
Circulation
IV access by 2 large bore cannulae
Send off blood samples
Give iv fluids and blood if available
Be aware of potential coagulation disorders
NB: Establish the CAUSE of the
Haemorrhage
 Pregnancy
 Abortion, ectopic, abruptio, praevia
 Labour
 Abruption, praevia, ruptured uterus
 After delivery (4Ts)
 uterine aTony,
 Trauma (cervical or perineal, or ruptured uterus)
 reTained placenta
 reTained products
 Post Caesarean bleeding
 Atony, trauma, placental site bleeding
 Any of the above +/- coagulation disorder
Haemorrhage – stop the bleeding
• Good history and systematic examination to
determine cause
• CALL for help: Resuscitation and diagnosis of
cause of bleeding plus treatment must occur
concurrently.
• How to stop bleeding for most causes will be
covered in breakout sessions
• Stepwise approach in case of uterine atony
Suspected Uterine Atony
 Empty bladder
 Give Oxytocics (oxytocin,ergometrine,prostaglandin)
 Massage uterus / bimanual compression
 Aortic compression
 Ongoing bleeding -- look for other cause
 Ongoing bleeding– Uterine balloon tamponade
 Ongoing bleeding - EUA
- laparotomy
Oxytocic agents for treating uterine atony
Drug
Dose
Max dose
Further
doses
Cautions
oxytocin
IM; 10 units
IV; slowly
IV; infusion
20-40iu/
IV bolus
2.5units
Litre
Avoid >3
litres of fluid
containing
oxytocin
ergometrine
IM: 0.5mgms Repeat dose Total 1.0mg
IV: 0.2mgms after 15
minutes
Hypertension,
pre-eclampsia,
heart disease
misoprostol
400600mcgms
sublingual or
rectal
pyrexia
PGF2alpha
Intramyometri
al; 5mgms in
10 mls saline.
Give 1ml
Repeat dose Total 2.0
after 10
mgms (4
mins.
doses)
Asthma, do not
give IV
Treatment of PPH from other causes
• Retained placenta…. Manual removal. (Efficacy of
Intraumbilical cord oxytocin injection not proven)
• Suspected retained placental products….
uterine evacuation under anaesthesia
• Cervical and vaginal trauma…..Repair with good
light/ understanding of the anatomy.
• Ruptured uterus ….Laparotomy
• Unknown cause…Early recourse to Examination
under Anaesthesia and possible laparotomy
Haemorrhage - Laparotomy
Compression of the aorta
Uterine compression suture (eg B-lynch)
 Uterine vessel ligation
Hysterectomy
Prevention of PPH
 Routine iron supplementation in pregnancy
 Anticipate / Be prepared
 Detect at risk women to deliver at referral hospital
 Available supplies - IV fluids, cannulae, oxytocics,
misoprostol, blood transfusion services
 Prevent prolonged labour
 Active management of third stage of labour
 Routine postpartum and post caesarean section
monitoring of vital signs and bleeding
?
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RECAP
Recognising Obstetric Haemorrhage
Causes
Management
 Protocol
 ABC
 Blood replacement
 Diagnosis of cause of bleeding
Methods to arrest haemorrhage