POSTPARTUM HAEMORRHAGE (PPH)

PREVENTING PPH BEFORE LABOUR

RISK FACTORS IDENTIFIABLE DURING PREGNANCY. If a mother has a history of any of these, she is more likely to have a PPH and should deliver in hospital: (1) Grand multiparaarity (>5 children). (2) An antepartum haemorrhage in this pregnancy. (3) A postpartum haemorrhage, or a retained placenta, in a previous pregnancy. (4) Multiple pregnancy or other cause of polyhydramnios. (5) Hypotonic uterine action in a previous pregnancy.

RISK FACTORS IDENTIFIABLE DURING LABOUR. (1) Prolonged labour. (2) General anaesthesia, usually with ether or halothane. (3) A full bladder. (4) ‘Fiddling with the uterus’ during the third stage. (5) Placenta praevia. (6) Placental abruption, mainly because this causes a clotting defect. (7) A clotting defect, especially DIC. (8) Incomplete expulsion of the placenta.

CAUTION! (1) A postpartum haemorrhage may occur without there being any risk factors. (2) When you ‘rub up a uterus’, use the flat of your hand on the fundus. ‘Fiddling’ is all kinds of pushing, pulling, and rubbing, which cause partial separation of the placenta before the uterus has contracted firmly.

PREVENTING PPH DURING LABOUR

Give every mother, especially those with risk factors, an oxytocic drug: (1) Ergometrine with oxytocin 1 ml IV. Or, (2) 5 units of oxytocin IM. Or, (3) ergometrine 0.5mg IM. They will work quicker if you give them IV, but there may be nobody around who can do this routinely. Give a mother one of these, as soon as her baby is born—and you are sure there is no twin in her uterus. Then deliver her placenta by controlled cord traction. If supplies are short, you may only be able to give an oxytocic drug to mothers at risk.

If she has a risk factor for PPH, set up IV dextrose–water before she reaches the second stage. When her baby and her placenta have been delivered, add 20 units of oxytocin IV (500 ml) at 30drops/min for at least 3 hours. Also, use ergometrine as usual.

CONTROLLED CORD TRACTION. As soon as her uterus is contracting firmly from the action of oxytocin or ergometrine, put your left hand on her abdomen, above her pubic symphysis, and turn your palm towards her head. Grasp her uterus. As soon as it feels hard from the effect of the oxytocic, push it upwards towards her umbilicus (deliver the placenta more by pushing her uterus up than by pulling on the cord). Wind two or three loops of cord round your index finger and gently pull on the cord, first downwards and backwards, and then more anteriorly as the cord comes out.

As soon as the placenta is delivered check to make sure that: (1) it is complete and that no lobes of it have been left behind (see below) and, (2) that there are no obvious tears in her birth canal. Keep her in the labour ward, and monitor her for at least 1hr, before returning her to the ward. Check that her uterus is well contracted and note any bleeding.

Ideally, you should never apply controlled cord traction before the uterus has hardened under the effect of an oxytocic drug; so if you don’t have any oxytocics, you should not do it. In practice, little harm results provided there are already signs of placental separation (lengthening of the cord, hardness and mobility of the uterus). Although it is a very valuable procedure, there is a risk, particularly if you do it incorrectly, that you may invert the uterus.

CAUTION! Don’t squeeze her uterus to try to get the placenta out. This is very painful.

RESUSCITATION FOR PPH

As soon as you are called to a patient with a PPH, quickly call an assistant: at least 2 people are needed. Resuscitate the patient vigorously, as you would any other hypovolaemic patient (53.2). What is the state of her peripheral circulation? How much blood has she lost? Is it clotting normally in the receiver used to collect it? It may clot to start with, and then stop clotting later. What has been done so far? Monitor the volume of blood she continues to lose, her peripheries, pulse and blood pressure, and her urine output.

If she is still bleeding: Is her uterus still contracted? Is the placenta out and complete? Does she have any obvious lacerations of her vulva, vagina or perineum?

If she is not still bleeding, is her uterus well contracted?

CAUTION! Put someone in charge of her, and make sure that she is that person’s sole responsibility, until bleeding has stopped, and her condition is stable. Poor supervision is an important cause of death in PPH.

PPH WITH A RETAINED PLACENTA

Try to make her uterus contract. (1) If you have not given her ergometrine, with or without oxytocin, give it now. (2) If this fails to stimulate a contraction, gently massage her uterus (‘rub up’ a contraction). (3) Remove her placenta by controlled cord traction, as soon as her uterus is contracting firmly. It should deliver immediately.

If controlled cord traction fails to deliver her placenta, remove it manually. Before doing a formal manual removal, you may be wise to do a vaginal examination, and see if it has stuck in her cervix, from which you can remove it quite easily. While preparing to do a manual removal concentrate on: (1) resuscitating her, and (2) keeping her uterus contracted with 20–40 units oxytocin IV. (3) If the oxytocin does not work, gently rub up a contraction.

MANUAL REMOVAL OF THE PLACENTA can either be fairly easy, or rather difficult. It is usually best done in the labour ward (which must be equipped for anaesthetic resuscitation) rather than the theatre, which will cause delay and require moving her. You will need stirrups to maintain a lithotomy position and a good light. Before you start, set up IV saline or Ringer’s lactate, if necessary with 2 IV lines. If she already has oxytocin IV, stop this just before manual removal to allow her cervix to relax, so that you can get your fingers inside the uterus.

Ketamine is safest; do not use sedation in a hypotensive patient. Use sterile procedures.

Hold the cord in your left hand. Put the tips of the fingers of your right hand together, and introduce it into the upper part of her vagina. If her placenta has stuck in her cervix, grasp it and slowly remove it. Now let go of the cord, and place your left hand on her fundus (over the towel). Prevent her fundus from being pushed up, as you gradually work your way into her uterus with your right hand. Feel for the part of the placenta which has already separated, and push your fingers between it and the wall of her uterus. Gently separate her placenta from the wall of her uterus with a slow sawing movement, with the side of your hand.

CAUTION! All this time keep your left hand pressing on her fundus, so as to bring her uterus as close to your right hand, as you can. If you don’t do this there is a danger you may tear it.

As soon as the placenta has separated, grasp it with your right hand, remove it, and ask your assistant to inspect it. While this is being done, and whether it looks complete or not, explore her uterus for any pieces that may have been left behind, and remove them. Only now remove your right hand from her uterus. Finally, give her a further dose of IV ergometrine with or without oxytocin, and wait for her uterus to contract. As it begins to do this, remove your hand. As you do so, check that the lower segment is intact.

Before you finish make sure that there are no other sites of bleeding; so explore her uterus as described below.

Inspect her placenta to see if: (1) a piece of it has been left inside, or (2) a vessel is running off one edge of it. This may lead to an extra lobe which has been left inside. If either of these things have happened, the missing piece of placenta must be removed.

If she continues to bleed, apply BIMANUAL COMPRESSION (23-10A). Put your right hand into her upper vagina. Put your left hand on her abdomen, and use it to push her fundus down onto your right hand. Press for at least 5mins, and then review the situation. Continue IV oxytocin 20 units to 500 ml and infuse it at a rate that will keep her uterus contracted. Continue for at least 12 hours, using more IV fluid and oxytocin as necessary. Monitor her carefully. Treat with antibiotic prophylaxis. Keep her in hospital for at least 5days, because of the increased risk of puerperal sepsis, particularly endometritis. Check the haemoglobin level.

PPH AFTER PLACENTAL EXPULSION

Failure of the uterus to contract is the most important cause, so aim for an empty, well-contracted uterus.

Feel her fundus. It should be hard and round, and below her umbilicus. If it is soft and difficult to feel, it may be relaxing. Rub it up to make it contract. This may expel some blood and clots. If her bladder is full, catheterize it. Treat with ergometrine 0.5 mg with or without oxytocib (if she has not already had it).

Resuscitate her with 2 IV infusions of saline or Ringer’s lactate. To the first add 20 units oxytocin. Infuse in fast, un­til her uterus contracts well. Then slow it to 40 drops/min. Continue this for 2 hours afterwards.

Use the second IV infusion to replace the blood she has lost with a plasma substitute (dextran), or blood. Aim for a blood pressure 100 mm.

Inspect her placenta for missing pieces with great care, if you have not already done so. If a piece is retained it will have to be removed. If there are any obvious perineal tears, suture them.

If bleeding stops, continue to monitor her, to resuscitate her if necessary, and to use IV oxytocin.

If she continues to bleed with an empty uterus (5% chance), note the following and take the appropriate action:

(A) Is her uterus still poorly contracted, despite the oxytocin? If so, increase the rate of infusion. If this fails, she may have a piece of placenta remaining inside, or, much less commonly, a ruptured uterus. So explore her uterus if you have not already done so.

(B) Does the blood coming from her uterus clot normally? If it fails to clot, she probably has a clotting defect.

(C) Does her uterus remain well contracted, but she bleeds in spite of it? If so, explore her genital tract for tears, from her fundus to her clitoris. If you find tears, suture them. If you don’t find any tears (and her blood clots), pack her uterus and vagina. If it does not clot, see below.

EXPLORATION OF THE CERVIX

INDICATIONS. (1) As a normal part of any manual removal (see above). (2) A mother who continues to bleed with the placenta out. Also see below on the indications for packing.

METHOD. Use sterile precautions. Catheterize her. Use ketamine. Put her into the lithotomy position, get a good light, and find a Sims’ speculum, and an assistant to help hold it. Wipe out the blood in her vagina with cotton wool swabs. Look at its walls. Check that her vaginal wall, and her perineal and vulval skin are intact. To inspect her cervix, use two swab- holding forceps. Grasp the front lip of her cervix with one of them. Pull her cervix gently down, and look for lacerations on it. If there are no lacerations in that bit of cervix, use the second forceps to pull down the next bit of cervix, and look at that. Go right round her cervix in this way, looking at every part (23-11). Then put your hand into her uterus and carefully feel its front, sides, back, and fundus. Feel for a rupture of her uterus (22.18), and for any pieces of adherent placenta.

If she has lacerations of her perineum, vagina, or cervix, suture them. Only suture a cervical tear, if it is causing arterial bleeding. A venous ooze is not a sufficient indication for suturing.

If she is bleeding from multiple small tears rather than one large one which you can easily suture, or there is a steady ooze, pack her uterus and vagina.

If a piece of placenta remains inside, scrape it off with your fingers. If you cannot get it all off, she has an abnormally adherent placenta, leave it.

If you find a rupture in her uterus, apply bimanual compression (if the bleeding is severe), until you can get the theatre organized for a laparotomy (22.18).

PACKING THE UTERUS AND VAGINA

INDICATIONS. (1) Continued bleeding, when there is no clotting defect, and no tear in the upper vagina, cervix, or uterus, which is large enough to repair surgically, and when other methods to control bleeding, particularly the adequate use of oxytocic drugs, have failed. (2) Continued bleeding after a clotting defect has been corrected, or when you are unable to correct it.

METHOD. Use sterile precautions. Put her into the lithotomy position. Pack her uterus and vagina with a wide roll of sterile gauze, or laparotomy pads, or failing these, maternity pads, which are less satisfactory, because they may get lost inside. Start by packing her fundus and work downwards. Use ring forceps to push lengths of gauze through her vagina into her uterus, until both are firmly packed down to her perineum. Pack tightly to press on her cervix from below. The pack should fill her uterus. However, if both her cervix and her uterus are well contracted, you may not be able to pack her uterus completely. If so, a well packed vagina may press adequately on a bleeding cervix.

CAUTION! (1) Be sure to pack her whole genital tract, from her fundus to her introitus if you possibly can, for which you will need large quantities of gauze. (2) Don’t only pack her vagina, because she will bleed above the pack and her uterus will fill with blood, the only sign of which may be increasing shock. (3) If you use maternity pads or separate pieces of gauze, you must tie them together, or they will get lost.

When you have packed her uterus, she will have difficulty in passing urine, so catheterize her. Continue to monitor her and to infuse IV fluid or blood as necessary. Remove the pack after 24–48 hours, preferably at 24 hours.

DIFFICULTIES WITH PPH

IF A PATIENT IS BLEEDING SEVERELY AND THERE IS GOING TO BE SOME DELAY, compress her aorta. Stand on her left and feel for her left femoral pulse with your left hand. Clench your right fist and with your index finger level with her umbilicus and your knuckles in the line of her spine, press gently and firmly through her abdominal wall so as to compress her aorta against her spine. You will feel it pulsating. Press so that you no longer feel any pulsations and obliterate her femoral pulse. If necessary, this method can be kept up for hours, while she is referred or while preparations for surgery are being made, changing hands and workers as required. If her legs become numb, allow a little blood to flow through them.

If you CANNOT GET YOUR WHOLE HAND THROUGH HER CERVIX TO DO A MANUAL REMOVAL (not uncommon if she has been given a lot of ergometrine shortly before the manual removal is done, or there has been a long delay), you are in difficulty. Avoid this problem, if you can, by using IV oxytocin, rather than ergometrine, and by discontinuing it just before manual removal. Try to get one or two fingers through her cervix, and push her fundus well down with your other hand. Usually, her cervix relaxes gradually so that, if you are slow and gentle, you can put your whole hand into her uterus.

If her placenta seems abnormally adherent to her uterus (PLACENTA ACCRETA), remove what you safely can piecemeal, without perforating her uterus, and leave the rest. If her uterus does not contract well, she will not bleed from these areas, but only from the separated ones. The placenta which you have to leave will be slowly absorbed. She is at serious risk from sepsis and secondary postpartum haemorrhage. Continue IV oxytocin for 48 hours, then stop if she is satisfactory. Treat with prophylactic chloramphenicol and metronidazole. Monitor her carefully, and keep her in hospital.

If YOU PUT YOUR FINGERS THROUGH HER UTERINE WALL as you remove the placenta (easily done, but this should be rare if you do the procedure properly), do a laparotomy and inspect the tear. If it is a minor one, you may be able to repair it. If it is a large tear, repair it, and if bleeding is not controlled, tie her uterine or her internal iliac arteries. If you don’t think it is safe for her to labour again, and her relatives agree, tie her tubes. A hysterectomy is seldom necessary.

If her blood FAILS TO CLOT in the receiver as it comes from her vagina, she probably has DIC (Disseminated Intravascular Coagulation). If necessary, you can confirm this with a bedside clotting test (20.11), but don’t let this delay you; control is urgent. Infuse 2g fibrinogen rapidly IV. Transfuse whole blood with 10 ml 10% calcium gluconate after the third bottle. Infuse another 1G fibrinogen 15–30 minutes later, if necessary. If her problem is DIC causing afibrinogenaemia, this should be enough. If you don’t have fibrinogen, transfuse fresh whole blood. Her clotting defect will probably correct itself within 12 hours of delivery of the placenta, so if you can only keep her alive during this period, she will probably live.

If she CONTINUES TO BLEED FROM AN EMPTY UTERUS, DESPITE ALL THE ABOVE MEASURES, try oxytocin 40 units to 500 ml of fluid in a fast running IV and repeated doses of ergometrine 0.5 mg IV. Try prostaglandins if you have them. If this fails, resort to hysterectomy (24.16). She may have a small rupture of her uterus, which you can only diagnose at laparotomy.

If her uterus TURNS INSIDE OUT as her placenta is delivered (rare), she has INVERSION OF HER UTERUS. This may happen spontaneously, or as a complication of controlled cord traction, particularly in elderly multiparas. Untreated, she can easily die. Immediately push it back. If you can return it immediately, it should go back easily. If there is any delay, she may become shocked, and replacing it will be much more difficult. Wash her prolapsed uterus with warm fluid, treat with chloramphenicol, resuscitate her, administer a general anaesthesia, and put her into the lithotomy position. There are two methods. (1) Use an enema nozzle and a douche can of warm saline suspended 1m above her. Wash out her vagina with fluid, insert the nozzle, and close her vagina with you left forearm. The hydrostatic pressure of saline will slowly return her fundus over 15–30 minutes. Replace it slowly and manipulate it as little as possible. Check that reduction is adequate. (2) Slowly and gently replace it manually, her fundus last.

If she presents after several weeks with CHRONIC INVERSION, do a laparotomy. You will probably find that, whereas her uterus is protruding a considerable distance from her vulva, internally it seems to be inverted from her lower segment, which is much congested. Her tubes may enter pits on either side of her evaginated uterus and be attached at their bottoms. Isolate her bladder from the lower part of her uterus and divide its rolled-over rim where it is inverted and constricted. Alternatively, pull it up with a volsellum and incise the posterior rim of the depression in her uterus through both thicknesses of its inverted wall (Haultain’s operation, 23-12). This should allow you to withdraw her fundus from inside, aided if necessary by a finger passed through the incision into her vagina. Repair the wound you have made in her uterus in 2 layers.

CAUTION! (1) Inversion of the uterus is much less common than prolapse of the swollen cervix through the vulva. You can easily push this back and it seldom recurs. (2) See also prolapsed fibroids (24.7).