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Postpartum Haemorrhage and Prehospital Management

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Published: 19 May 2018

Somewhere in the world, a woman dies every 4 minutes from postpartum haemorrhage (Sebghati & Chandraharan 2017).

As well as being a terrifying experience for the mother, postpartum haemorrhage can also be one of the most serious and alarming emergencies that a midwife has to manage.

So, can the risks of postpartum haemorrhage occurring be accurately assessed?

What is Postpartum Haemorrhage?

postpartum haemorrhage diagram

Postpartum haemorrhage (PPH) is a potentially serious obstetric complication wherein a patient bleeds excessively after giving birth (RANZCOG 2017).

Some level of postpartum bleeding is normal. However, heavy bleeding is a potentially life-threatening event and requires immediate intervention (Pregnancy, Birth and Baby 2019).

About 5 to 15% of births in Australia and New Zealand result in PPH. While most of these cases are minor, PPH is associated with almost one-quarter of maternal deaths globally and is a leading cause of maternal mortality in Australia and New Zealand (RANZCOG 2017; WHO 2017).

Primary PPH is excessive bleeding within the first 24 hours of birth. It is defined as either:

  • The loss of more than 500 mL of blood following vaginal birth
    • Minor: 500 mL to 1 litre
    • Major: More than 1 litre
  • The loss of more than 1 litre of blood following a caesarean section, or
  • Enough blood loss to cause the mother’s condition to deteriorate.

(QAS 2020; RANZCOG 2017)

Note: The definition of PPH may vary. Always refer to your organisation's policy.

Secondary PPH is defined as a loss of more than 500 mL of blood between 24 hours postpartum and 12 weeks postpartum (RWH 2019).

Risk Factors for Postpartum Haemorrhage

PPH is common and difficult to predict, so all women giving birth should be considered at risk of this complication (RANZCOG 2017). While two-thirds of PPH incidents have no identifiable risk factors (SA DoH 2013), the following factors may play a role in PPH:

  • Weakened uterine muscles (e.g. due to previous births)
  • Having a long labour
  • Fever during labour
  • Having an operative delivery
  • Having an episiotomy
  • The use of oxytocics during labour
  • Giving birth to a large baby
  • A stretched uterus (e.g. due to a multiple pregnancy)
  • Having a bleeding disorder
  • Previous history of PPH
  • Having a caesarean section
  • Antepartum haemorrhage
  • Placenta accreta
  • Having a coagulopathy disorder
  • Being anaemic
  • Being nulliparous
  • Pre-eclampsia
  • Being obese
  • Placental retention.

(Pregnancy, Birth and Baby 2019; SA DoH 2013)

Causes of Postpartum Haemorrhage

The most common cause of PPH is uterine atony (SCV 2019), wherein the uterine muscles do not contract properly post-birth. Usually, the uterus will contract to deliver the placenta and then compress the blood vessels that were attached to it. However, if these contractions are too weak, the blood vessels are able to bleed freely, potentially leading to haemorrhage (Cafasso 2016; Stanford Children’s Health 2016).

The use of inhaled anaesthetics can also promote uterine atony (Cafasso 2016).

Uterine atony is associated with about 70% of PPH incidences. Referred to as ‘tone’, it comprises one of the ‘Four T’s’, which are the most common causes of PPH (QLD DoH 2020).

As well as ‘tone’, the Four T’s also include:

  • Trauma (20% of PPH incidents), which includes:
    • Lacerations of the cervix, vagina or perineum
    • Extension lacerations during caesarean section
    • Uterine rupture or inversion
    • Non-genital tract trauma
  • Tissue (10% of PPH incidents), which includes:
    • Retained products, placenta, membranes or clots
    • An abnormal placenta
  • Thrombin (less than 1% of PPH incidents), which is caused by issues with coagulation.

(QLD DoH 2020)

Clinical Signs and Symptoms of Postpartum Haemorrhage

It is important to note that a patient may not display symptoms of PPH until the blood loss has exceeded 1 litre, as the physiological changes of pregnancy may obscure the signs of haemodynamic instability (QAS 2020).

However, estimates of blood loss at delivery can be subjective and often inaccurate, with a tendency for healthcare staff to underestimate blood loss. Large volumes of blood can soak into bed linen and solidified clots may only represent about half of the actual blood that has been lost (Smith 2018).

It has been found that a visual assessment may underestimate blood loss by over 50% (QAS 2020).

Smith (2018) suggests that another consideration in assessing the risks of PPH is the differing capacities of individual women to cope with blood loss. A healthy woman has a 30 to 50% increase in blood volume in a normal singleton pregnancy and is much more tolerant of blood loss than a woman who has pre-existing anaemia, an underlying cardiac condition or a condition secondary to dehydration or preeclampsia.

Women with a low body mass index also have a lower blood volume and tend to have fewer reserves to withstand significant blood loss and so, are likely to experience adverse physiological effects sooner. For these reasons, it’s suggested that PPH should be diagnosed when any amount of blood loss, however small, threatens the hemodynamic stability of the woman.

Symptoms to look out for include:

  • Tachycardia
  • Hypotension
  • Vaginal bleeding, possibly torrential and uncontrolled
  • Signs of shock
  • Restlessness
  • Abnormally large and soft-feeling uterus.

(QAS 2020)

When treating a patient with PPH, a fundal massage should only be performed if the uterus is soft. A uterus that is firm, central and contracting properly does not require massaging; this may worsen bleeding or disrupt the normal placental separation post-birth (QAS 2020).

The Role of Fundal Massage

fundal massage being performed
'Side View of Postpartum Uterine Massage with Internal Anatomy' by Valerie Henry is licensed under CC BY-SA 4.0. Image has been cropped.

Fundal massage, also known as uterine massage, is a technique used to encourage the uterus to contract properly after delivery of the placenta. It involves applying repetitive massaging or squeezing motions to the woman’s abdomen in order to stimulate the uterus (Hofmeyr, Abdel-Aleem & Abdel-Aleem 2013).

Australian clinical guidelines indicate the conditional use of fundal massage if the PPH is caused by uterine atony or a tissue problem (retained products or abnormal placenta) (QAS 2020; RANZCOG 2017; RWH 2019).

When treating a patient with PPH, a fundal massage should only be performed if the uterus is soft. A uterus that is firm, central and contracting properly does not require massaging; this may worsen bleeding or disrupt the normal placental separation post-birth (QAS 2020).

Management of Postpartum Haemorrhage in a Prehospital Setting

When a patient is experiencing a PPH in a prehospital environment, you should first assess whether there is an obvious external tear. If this is the case, apply a direct pressure dressing, administer pain relief and transport the patient to hospital (QAS 2020).

If there is no obvious external tear, check whether the placenta has been delivered (QAS 2020).

If the placenta has been delivered, go to step 5.

placenta after delivery

If the placenta has NOT been delivered:

  1. Initiate Active Management of the third stage of labour (to birth the placenta).
  2. Reassure and calm mother.
  3. Administer oxytocin.
  4. Guard uterus and apply gentle controlled and steady cord traction

If the placenta has been successfully delivered, go to step 5.

If the placenta has NOT yet been successfully delivered, go to step 9.

  1. Massage fundus until firm and central.
  2. Encourage mother to empty bladder.
  3. Consider oxytocin.
  4. If the haemorrhage has been controlled, monitor Per Vaginal loss and fundus for firmness every 5 minutes.
  5. If the haemorrhage is not controlled, consider:
    • Pain relief
    • Breastfeeding (in order to promote the release of oxytocin)
    • Emptying bladder (as the pressure of the bladder on the uterus can case additional atony)
    • Intravenous fluid
    • High flow oxygen
    • Packed red blood cells
    • External aortic compression
    • Bimanual compression.
    Transport to hospital. Pre-notify as appropriate.

(CC: Queensland Ambulance Service, Primary post-partum haemorrhage flowchart 2020)

Consider administering tranexamic acid (TXA) early (within three hours of PPH onset) (QLD DoH 2020).

Note that applying pressure to the perineum will cause significant pain for the patient (QAS 2020).

Can Anything be Done to Prevent PPH?

Whilst identification of risk factors antenatally and intrapartum can be useful in the management of PPH, it is often unpredictable (Pregnancy, Birth and Baby 2019).

Those with identified risk factors may be administered medicine to help induce uterine contraction and delivery of the placenta (Pregnancy, Birth and Baby 2019).

Ultimately, it is only with anticipation, comprehensive policies on the management of obstetric emergencies and prompt mobilisation of resources that lives can be saved.

Note: This article is intended as a refresher and should not replace best-practice care. Always refer to your organisation's policy on fundal massage and management of PPH.

Additional Resources


References

Author

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Anne Watkins
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