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COURSE MANUAL
Postpartum
Hemorrhage
Management
with Uterine Balloon Tamponade
Massachusetts General Hospital
In partnership with KMET, JHPIEGO,
Unicef, PATH, University of Nairobi, the
Ministry of Health of Kenya, the Ministry
of Health of the Republic of South Sudan,
AIIT, and Kenya WHO
© Copyright 2013 Massachusetts General Hospital, the Ministry of Health
of Kenya and the Ministry of Health of the Republic of South Sudan
POSTPARTUM HEMORRHAGE
SALINE
OXYTOCIN
© Copyright 2013 Massachusetts General Hospital,
the Ministry of Health of Kenya and the Ministry of
Health of the Republic of South Sudan
Contents
4
Background on PPH
Learning Objectives
5
Definitions
Causes of Postpartum Hemorrhange
6
Uterine Atony
7
Active management of third stage of labor (AMTSL)
Prophylactic use of a uterotonic medication
8
Controlled cord traction for placental delivery
9
Uterine massage
10
Simple Interventions to Treat Postpartum Bleeding
Breastfeeding
Checking for tears
11
Empty the urinary bladder
Fluid resuscitation
12
Removal of retained placenta or blood clots
13
Bimanual compression
14
Uterotonics for PPH treatment
15
Uterine Balloon Placement
16
Balloon Removal
17
Transport Planning
18
Anti-Shock Garment
19
Uterine inversion
20
Surgical treatments
Uterine Compression Sutures
21
Uterine Artery Ligation Procedures
Hysterectomy
22
Conclusion
Background on PPH
Postpartum hemorrhage (PPH) is the most common cause of maternal
death around the world. In 2008, an estimated 358,000 women died from
pregnancy- or childbirth-related causes.1 Twenty-five percent of these deaths
were caused by postpartum hemorrhage. The highest burden of maternal
mortality is in sub-Saharan Africa, where 34% of maternal deaths are caused
by hemorrhage.2
This training will review the management of PPH and help participants master
use of a uterine balloon for tamponade. Uterine Balloon Tamponade (UBT)
is a medical technique used to control postpartum hemorrhage uncontrolled
by primary interventions. UBT uses a balloon to apply pressure to the inside
of the mother’s uterus to stop bleeding after delivery. UBT can be performed
with devices ranging from expensive, high-grade manufactured balloons to
simple balloons made of condoms or rubber gloves. We will discuss the use
of the condom balloon for UBT.
Learning Objectives
• To be able to recognize and diagnose PPH, the most common cause of
maternal death
• To be able to perform a series of maneuvers to treat PPH
• To be able to utilize a uterine balloon for tamponade of PPH
• To be able to stabilize a woman with intractable PPH before transfer
or surgery
Master the following skills:
• Active management of the third stage of labor
• Correct dosing of uterotonics
• Placement of the uterine balloon
To guide us through the steps in the management of PPH, this course utilizes
the checklist or algorithm shown on the inside cover of this booklet.
This checklist should be displayed as a poster in all labor wards. It should
be clearly visible so that providers can see it whenever a mother has PPH.
For additional copies of the checklist, please contact the uterine balloon
tamponade trainer.
4
Definitions
• Postpartum hemorrhage is loss of blood as a result of birth which
exceeds 500ml for a vaginal birth and 1000ml for a cesarean section.
• Primary postpartum hemorrhage occurs within the first 24 hours after
delivery.
• Secondary postpartum hemorrhage occurs after 24 hours from
delivery and within the first 6 weeks.
Causes of Postpartum Hemorrhage
There are several causes of postpartum hemorrhage which can be remembered through the classic English memory mnemonic of the “4 Ts.”3 They are:
• Tone: uterine atony, distended bladder
• Trauma: uterine, cervical, or vaginal injury, uterine inversion
• Tissue: retained placenta or clots
• Thrombin: pre-existing or acquired coagulopathy
Each of these causes should be considered in any patient with PPH. They
are addressed, at least in part, by the steps in the Postpartum Hemorrhage
Checklist using an efficient, evidence-based approach.
The most common cause of primary PPH is uterine atony. Atony is the
failure of the uterine muscle to contract sufficiently after delivery, resulting
in continuing blood flow from the placental bed. Secondary PPH is most
commonly due to infection, retained products of conception, or both.
W
HO, UNICEF, UNFPA, World Bank. Trends in Maternal Mortality 1990-2008,
K
han et al. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006 Apr
1;367(9516):1066-74.
3
F IGO Safe Motherhood and Newborn Health Committee. Prevention and treatment of postpartum hemorrhage in low-resource settings. International J Gyn Obstetrics. 2012;117:108–18
1
2
5
Uterine Atony
The blood vessels that feed the endometrium and the placenta during
pregnancy pass between muscle fibers of the uterus. Normally after delivery
of the baby and placenta, the uterine muscles contract tightly, and in so doing,
constrict around these blood vessels and prevent the rapid flow of blood
from these vessels. If the muscle fibers fail to contract, blood continues to
flow through the vessels, resulting in hemorrhage. Approximately 70-80% of
primary PPH cases are due to uterine atony.4
The uterus will often contract in response to direct stimulation, such as
uterine massage, and will usually respond well to uterotonic medications
(discusssed later). Uterine atony is more common in situations where the
uterine muscle has been stretched such as with multiple gestations, multiparous patients, polyhydramnios and macrosomia. It is also more common
in prolonged labor, augmented labor, rapid labor, preeclampsia, operative
delivery, or in the presence of chorioamnionitis.5
Ibid.
4
Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with
5
vaginal birth. Obstet Gynecol 1991; 77:69-76. (Level II-2). And Stones RW, Paterson CM,
Saunders NJ. Risk factors for major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol
1993; 48:15-8.
6
Active management of third stage of labor (AMTSL)
Active management of the third stage of labor refers to steps taken
immediately following the birth of the baby that decrease the risk of severe
postpartum hemorrhage. This involves:
1. Prophylactic use of a uterotonic medication
2. Controlled cord traction for placental delivery
3. Uterine massage
Prophylactic use of a
uterotonic medication
Uterotonics for PPH prophylaxis: given as a single dose within the first
minute after completed delivery of the infant(s)
Oxytocin
10 IU IM/IV
• The first-line uterotonic recommended by the WHO and FIGO for
PPH prevention in health facilities.
• FIGO recommends for IV route use 5 IU slow IV push
• Must be stored between 2-8°C. Can be held at 15-25°C for up to
30 days then discarded. Keep from freezing.
Misoprostol
600μg orally
• Useful in multiple settings. May also be used at the community
level by community midwives and other health workers.
• Store in aluminum blister pack at room temperature in a closed
container.
• Misoprostol can also be given sublingually if patient is unable
to swallow pills or rectally if needed for a patient who is
unresponsive.
• May cause shivering and/or a fever. Occasionally, the fever after
misoprostol can be high and will require cool sponge baths or
paracetamol. Look also for other causes for the fever such as
intrauterine infection
Ergometrine or
Methylergometrine
0.2mg IM
• Contraindicated in women with high blood pressure, cardiac
disease, preeclampsia or eclampsia because these medications
can increase blood pressure. Avoid in unscreened populations.
• Must be stored between 2-8°C and protected from light and
freezing.
7
Controlled Cord Traction (CCT) involves encouraging the delivery of the
placenta through gently pulling on the umbilical cord while supporting the
uterus to prevent inversion.
As long as the newborn does not need immediate resuscitation, wait at least
1-3 minutes after delivery before clamping and cutting the cord. According
to the WHO and FIGO, CCT should only be performed by a skilled birth
attendant as the cord can tear from the placental disk and too much traction
without uterine support can result in uterine inversion.
Steps for CCT (adapted from FIGO guidelines):
1. Clamp the cord close to the perineum and hold the cord and clamp in one
hand.
2. Place the other hand just above the pubic bone to stabilize the uterus and
apply counter-pressure during controlled cord traction
3. With a strong uterine contraction, gently pull downward on the cord to
deliver the placenta while applying counter pressure on the uterus. The
mother may be encouraged to gently bear down during this maneuver.
4. If the placenta does not descend during the initial attempts at traction,
wait until the uterus feels well contracted again or there are signs of
placental separation. Then repeat. Signs of placental separation:
• Lengthening of the umbilical cord
• Small gush of blood
• Spontaneous elevation of the uterine fundus.
5. As the placenta delivers, hold the placenta in both hands and twist to
encourage the membranes to come out.
6. Look carefully at the placenta to be sure it has no missing parts which
may be retained in the uterus.
8
Uterine (fundal) massage is performed prophylactically after placental
delivery if uterotonics were unavailable or if, upon palpation of the top of the
uterus (fundus), good uterine tone is not appreciated. It is also the first step
in the treatment of postpartum hemorrhage and/or uterine atony.
Massaging the uterus helps it to contract. To massage properly, the fundus of
the uterus should be found within the abdomen and massaged in a circular
motion down towards the vagina. This procedure should be continued until
the bleeding stops. After delivery, the fundus of a well contracted uterus
should be at or near the level of the umbilicus. If the fundus is far above this,
it may also be a sign of a full bladder.
Sometimes the uterus will tighten with the massage and then relax a few
minutes later. If this occurs, resume the massaging. If the bleeding is very
heavy and the uterus feels relaxed or soft, the uterine massage can be
performed with two hands - one hand on the fundus of the uterus and the
other hand above the pubic bone holding the neck of the uterus. If this is
unsuccessful, the second hand can be placed in the vagina (gloved), pushing
on the uterus from inside while uterine massage is performed. Often uterine
massage is all that is required for even heavy bleeding.
9
Simple Interventions to Treat Postpartum Bleeding
Some very natural and early steps to treat postpartum bleeding or hemorrhage include breastfeeding; checking for signs of lacerations in the
perineum, vagina or cervix; and/or emptying the maternal bladder.
Breastfeeding
Putting the baby directly to the breast helps the uterus contract. Stimulation
of the nipples releases oxytocin into the maternal circulation and provides a
natural uterotonic. Therefore, it is important for the baby AND the mother to
start breastfeeding immediately after delivery. If the baby is not able to nurse,
manual stimulation of the maternal nipples may also be helpful, particularly in
the setting where uterotonic medications are limited or unavailable.
Checking for tears
A delivering mother can sustain tears in her cervix and vagina as well as in
her perineum. It is difficult to see tears higher inside, but they can often be
seen by using a speculum or by putting two fingers in the vagina and pushing
down until the vaginal walls and cervix are visible. Vaginal wall tears can
also be felt with an experienced hand. Any tear that is bleeding should have
pressure applied to reduce blood loss and then be appropriately sutured.
If a woman has a very large tear, she may need to be referred to a higher
level health care facility, otherwise she may develop a fistula with life-long
problems, such as leaking urine or stool.
10
Empty the urinary bladder
A full bladder can prevent a postpartum uterus from being able to contract.
Most women will not have a full bladder after pushing to deliver their baby.
However, ensuring the urinary bladder is empty is a simple step which may
prove helpful if there is urine in the bladder. Also, the uterus may be unable
to contract if there are blood clots in the lower part of the uterus. These clots
may come out when the mother squats and bears down to urinate.
Women do not always have normal sensation for needing to urinate just after
they have delivered. They may not be aware their bladder is full. It is often
useful to have the woman try to urinate even if she cannot sense the need
to go. Alternatively, a urinary catheter may be placed to ensure the bladder is
emptied.
While performing each of these steps, remember to continue doing fundal
massage if the uterus is relaxed. Call for additional staff if bleeding is brisk to
help with the massage and other measures.
Fluid resuscitation
SALINE
A woman with postpartum hemorrhage can quickly become hemodynamically
unstable and may develop hypotension, tachycardia, and with continued
bleeding, shock and organ failure. Rehydration and resuscitation should
start early. Even if IV fluids are unavailable, rehydration can begin for an alert
mother with oral rehydration solution (ORS). If bleeding is brisk, 1-2 largebore IV catheters should be placed followed by early blood bank notification
and isotonic crystalloid infusion (normal saline or lactated ringers). Call for
help from physicians, any critical care specialists, and blood bank personnel.
11
Removal of retained placenta or blood clots
PPH can also be caused by parts of the placenta or blood clots that are still
inside the uterus. These can keep the uterus from contracting completely.
Placenta or blood clots can be removed by hand as shown in the picture.
This is the same maneuver that is used to remove a placenta that does not
come out on its own after delivery and CCT. To do this procedure, the provider
puts on sterile gloves and reaches inside the uterus, trying to separate
the placenta from the uterine wall by sliding a hand beneath the placental
disc and peeling the placenta away. Sometimes the placenta will not peel
away completely in one piece and instead will come out in multiple pieces.
Remove as much of the retained placenta and blood clots as possible while
performing fundal massage to decrease the bleeding.
Occasionally, the cervix will begin to contract with the blood clots still inside.
If this is the case, only a couple of fingers will fit through the cervix into the
uterus. Try to remove all the clots by inserting as many fingers as possible
while pushing down on the fundus of the uterus with the other hand.
12
Bimanual compression
Once the placenta and blood clots are removed, heavy bleeding may occur.
Massage the uterus with both hands, one placed in the vagina and the
other hand outside on the fundus of the uterus. This is called bimanual
compression. A fist can also be placed in the vagina against the uterus with
the other hand on the abdomen and the uterus is squeezed between both
hands to provide pressure on the bleeding. This is an appropriate maneuver
to decrease brisk blood flow while uterotonic medications are being administered and allowed to work or while a uterine balloon is being prepared for
placement. This requires teamwork for simultaneous interventions.
13
Uterotonics for PPH treatment:6
Given as soon as possible after PPH is recognized.
6
Oxytocin
IV infusion 20-40
IU/L fluid infusion
at 40-60 drops per
minute
• The first line therapy recommended by the WHO and FIGO
• The WHO recommends IV infusion over IM administration for
treatment of PPH.
• Can be used even when oxytocin has been used for prophylaxis.
• Must be stored between 2-8°C. Can be held at 15-25°C for up to
30 days then discarded. Keep from freezing.
Misoprostol
800 µg sublingual
• Not to be used for treatment if 600 µg was just given for
prophylaxis
• NOTE: Treatment dose is higher than prophylactic dose.
• Misoprostol can also be given rectally if needed for a patient who
is unresponsive.
• May cause shivering and/or a fever. Occasionally, the fever after
misoprostol can be high and will require cool sponge baths or
peracetamol. Look also for other causes for the fever such as
intrauterine infection
• Store in aluminum blister pack in a closed container. Does not
require refrigeration.
Ergometrine or
Methylergometrine
0.2mg IM. Can repeat
every 2-4 hours with a
maximum of 5 doses
(1mg) in 24 hours
• Contraindicated in women with high blood pressure, cardiac
disease, preeclampsia or eclampsia because these medicationsy
can increase blood pressure. Avoid in unscreened populations.
• Must be stored between 2-8°C and protected from light and
freezing.
Syntometrine
(combination of
oxytocin 5 IU and
ergometrine 0.5mg)
Give 1 ampule IM
• Contraindicated in women with high blood pressure, cardiac
disease, preeclampsia or eclampsia because this medication can
increase blood pressure. Avoid in unscreened populations.
• Must be stored between 2-8o C and protected from light and
freezing
Carbetocin
100µg IM or IV
over 1 minute
• Contraindicated in women with high blood pressure, cardiac
disease, preeclampsia or eclampsia because this medication can
increase blood pressure. Avoid in unscreened populations.
• Must be stored between 2-8o C and protected from freezing.
Should be used immediately after opening.
Carboprost
0.25 mg IM
every 15 minutes
(maximum 2mg)
• Contraindicated in women with high blood pressure, cardiac
disease, preeclampsia or eclampsia because this medication can
increase blood pressure. Avoid in unscreened populations.
• Must be stored between 2-8o C and protected from freezing.
FIGO Safe Motherhood and Newborn Health Committee. Prevention and treatment of postpartum hemorrhage in low-resource settings. International J Gyn Obstetrics. 2012;117:108–18
14
Tranexamic acid may be offered as a treatment for PPH if:
• administration of oxytocin followed by second uterotonic has failed to stop
the bleeding, or
• it is thought that the bleeding may be partly due to trauma.
Data on the use of tranexamic acid in obstetric literature is limited.
Administration of antibiotics: In cases where endomyometritis is thought
to be a contributing cause of PPH, including most cases of secondary PPH,
broad spectrum antibiotics should be administered and continued as clinically
indicated.
Uterine Balloon Placement
If a woman is still bleeding after these steps, a uterine balloon can be placed
into her uterus and inflated with water. The balloon presses on the bleeding
vessels inside the uterus allowing the bleeding to be controlled. Patients
with the bleeding stopped in this way can be stabilized and if necessary,
transferred with the balloon in place to an operating room or referral facility
for further observation or treatment.
Before placing the uterine balloon inside the uterus, assemble its various
components. These components consist of a urinary catheter, a condom,
cotton string ties, a large syringe, and a one-way valve. The condom needs to
be rolled completely out and then tied to the end of the foley. The assembled
condom-catheter device is then inserted into the bleeding uterus. Be sure
that it is inserted through the cervical opening and into the uterus and that
it is not just in the vagina. If the balloon is inflated in the vagina, it may not
address bleeding from within the uterus.
15
Once the uterine balloon is in the uterus, it can be filled with clean water.
Begin by inflating the small balloon of the catheter with 15 ml of water. The
small balloon helps secure the catheter inside the uterus. To make it easier,
the red line on the syringe indicates the amount of water needed to fill up the
small balloon and another red mark on the catheter indicates where to put
the 15 ml of water. The other opening (without red mark) is to blow up the
condom with clean water. Fill the condom with water until the bleeding stops.
This usually requires 300-500ml, but it can vary.
When the bleeding stops, the mother is ready for careful observation or
transfer to a referral facility. The uterine balloon should stay in place during
transfer and for at least 6–24 hours. Always try to transfer the newborn with
the mother so that breastfeeding can continue. A single prophylactic dose of
antibiotics is recommended when the uterine balloon is placed. The mother
should be given appropriate IV fluids or blood replacement products until she
is stable and no longer is heavily bleeding.
Balloon Removal
While the woman is being observed, the balloon should then be deflated only
partway and not removed. If significant bleeding resumes, the balloon can be
reinflated. If there is no bleeding after an hour of partial deflation, the balloon
can be completely deflated, removed, and discarded.
16
Transport Planning
Some of the most important life-saving activities of medical facilities are
careful planning for emergencies and good communication. For facilities
without available operating rooms or physicians 24 hours daily, transfer to
another facility will occasionally be required for critically ill patients. Every
effort to plan for safe and efficient transfers from one facility to another
should be made prior to an emergency so critical time is not wasted during
an event. Skilled health personnel should always accompany a critically ill
patient until they are received by appropriate staff at the referral center.
Therefore facilities should be sure there is an available emergency transport
vehicle, fuel for the vehicle, supplies to be used during transfers and enough
available personnel for a transfer at any time. Emergency vehicles should not
be used for other hospital business unless another vehicle remains available
for an emergency.
Communication regarding the patient must occur via phone before or
immediately upon leaving the originating facility so the receiving facility can
begin preparing for the patient’s arrival. Resuscitation should also begin at
the originating facility including placement of IVs, crystalloid administration as
well as blood products (if indicated) and available and appropriate antibiotics
and medications. Upon arrival at the referral facility, the accompanying
provider must be ready to inform the receiving facility of the patient’s medical
history, events leading to the transfer and all treatments and medications
administered before transfer.
17
Anti-Shock Garment
If available, the anti-shock garment may be used as a temporizing measure
to address severe blood loss and hypovolemia while a patient undergoes
transfer to a referral facility for blood transfusion or further treatment.
Research evaluating the potential benefits and harms of anti-shock garments
is ongoing.
18
Uterine inversion
A rare postpartum complication that can lead to severe and intractable postpartum hemorrhage is uterine inversion. This can occur at the time of delivery
of the placenta. In uterine inversion, the fundus of the uterus descends down
through the dilated cervix so that the uterus is effectively turned inside out.
The provider will feel a fleshy mass upon examination of the vagina. Bleeding
is often brisk and severe.
To return the uterus to its normal anatomical position, the provider must, using
sterile gloves, cup a hand up around the fundus and begin to push from
inside at the base as pictured. Pushing directly on the fundus may lead to
additional contraction of the uterine muscle and difficulty replacing the uterus.
If the placenta is attached to the uterine fundus while the inversion takes
place, it should not be removed as this also may cause heavier bleeding as
well as contraction in the uterine muscle and make replacement extremely
difficult.
After the uterus is returned to the anatomic position, a prophylactic dose
of antibiotics should be administered. Recommended regimens include:
Ampicillin 2g IV plus Metronidazole 500mg IV or Cefazolin 1g IV plus Metronidazole 500mg IV.
19
Surgical treatments
When all else fails, surgery may be required to treat postpartum hemorrhage and some women cannot survive postpartum hemorrhage without
it. The following are the main surgical techniques used to treat postpartum
hemorrhage.
1. Uterine Compression Sutures
In this technique, the surgeon tries to compress the uterine muscles mechanically since the fibers themselves would not contract to constrict the bleeding
vessels. The B-Lynch suture procedure places a large, long stitch through the
anterior and posterior uterine muscle walls and across the uterine fundus so
that the suture forms what looks like a set of suspenders. When tightened
it cinches down the body of the uterus into a tight ball. This mechanical
external compression of the uterine wall provides compression of the internal
vessels.
20
2. Uterine Artery Ligation Procedures
Ligation procedures target the known major blood vessels that bring blood
flow to the uterus. Most of the blood flow in the uterus comes through the
uterine artery which arises from major arteries in the pelvis and courses up
along the uterus. There is also additional blood flow which may come through
the ovarian arteries closer to the fundus of the uterus. These blood vessels
can be identified, isolated, and tied off to diminish blood flow to the uterus.
3. Hysterectomy
When these simpler surgical procedures fail, as a last resort, the uterus is
removed to stop the continuing hemorrhage. Removal of the uterus, also
known as a hysterectomy, prevents any future childbearing. The ovaries can
be left still within the mother as they continue to release normal female
hormones.
21
Conclusion:
Postpartum hemorrhage remains a significant cause of maternal deaths
worldwide. However, with appropriate use of available techniques -- including
the use of uterine balloon tamponade and appropriate access to resuscitation
and surgical facilities-- most cases of death from postpartum hemorrhage
can and should be prevented. Use of the uterine balloon for postpartum
hemorrhage represents a significant advance in non-surgical treatment of
PPH and should be a part of the equipment and methods available for treatment of PPH when it is uncontrolled by normal maneuvers and uterotonics.
The majority of this PPH review booklet is based on contents from
the following:
• FIGO Safe Motherhood and Newborn Health Committee. Prevention and
treatment of postpartum hemorrhage in low-resource settings. International
J Gyn Obstetrics. 2012;117:108–18.
• WHO recommendations for the prevention and treatment of postpartum
haemorrhage. 2012.
• Postpartum haemorrhage. ACOG Practice Bulletin No. 76. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2006;
108:1039-47.
• National Guidelines for Quality Obstetrics and Perinatal Care. Republic
of Kenya Ministry of Public Health and Sanitation and Ministry of Medical
Services, 2012.
• National Orientation Package for Targeted Postnatal Care. Republic of
Kenya Ministry of Public Health and Sanitation, April 2011.
22
The contents of Postpartum Hemorrhage Management with Uterine Balloon
Tamponade was written and edited by Dr. Melody Eckardt, Dr. Brett Nelson,
Dr. Roy Ahn, Hannah Harp and Dr. Thomas Burke from Massachusetts
General Hospital, Dr. Kuria Ndiritu, Dr. Pamela Godia, and Judith Maua from
the Division of Reproductive Health of the Kenya MOH, and Dr. Monica
Oguttu and Lidi Dulo from KMET.
24