19.10 Postpartum haemorrhage (PPH)

Postpartum haemorrhage (PPH) is caused by: (1) Bleeding from the placental site because the uterus has failed to contract—much the most important cause. (2) Tears of the genital tract—rupture of the uterus, cervical tears, tears of the upper vagina, and vulval tears, especially near the urethra and clitoris. (3) Occasionally by a clotting defect, especially disseminated intravascular coagulation (DIC), which produces a fibrinogen deficiency.

Aim to resuscitate the patient, to stop the bleeding, and to monitor her carefully. Bleeding most often occurs from the placental site, so your first objective must be an empty well-contracted uterus with the placenta out.

When you pack the uterus, do so on the correct indications, and after all proper steps have been taken. Packing is messy and time-consuming, and needs large quantities of sterile dressings. If there is a steady ooze, blood is scarce, and HIV common, packing may save a mother’s life. In theory, packing is undesirable; in practice it is very useful as a near last resort, before tying her uterine or her iliac arteries, or removing her uterus. It is much less effective in controlling bleeding from her uterus, than from her cervix. Much the best way to do this is to give her oxytocics to make her uterus contract, if it will.

DIC is probably the commonest cause of a massive PPH, when the uterus is empty, and is satisfactorily contracted. It is the commonest clotting defect, and is an important and preventable cause of maternal death. It is uncommon after a normal delivery, and is more common after abruption (20.11), an obstructed labour (22.4), or an intrauterine death (20.3). Try to keep two bottles of fibrinogen (one gram) in the refrigerator of your maternity unit. This is the only clotting factor which it is practicable for you to stock. If you cannot get it, or any fresh frozen plasma, you will have to give her fresh blood. To do this, you will find it helpful if all your permanent medical and nursing staff know their blood groups, and can be called upon in an emergency.