Published: December 1998

Publications

Management of Postpartum Haemorrhage

Dr Keith Harrison
O&G Consultant
Hastings Memorial Hospital
Hastings

The following article on the management of postpartum haemorrhage was published in Prescriber Update (No.16:4-9) in April 1998.  A number of queries were received about the article.  The authors responded to these queries in Prescriber Update (No.17:7-8) which was published in December 1998.  That article is also included here.

Management of postpartum haemorrhage
Queries raised on the management of postpartum haemorrhage

Active management of the third stage of labour significantly decreases the risk of postpartum haemorrhage. It involves the use of oxytocic medication, immediate cord clamping and delivery of the placenta by controlled cord traction. Practitioners need to be aware of the risk factors for postpartum haemorrhage. Women at risk should deliver in units where specialist assistance, operating facilities, and blood and blood products are available. If haemorrhaging persists, despite treatment with Syntocinon and Syntometrine, specialist assistance should urgently be sought.

Postpartum haemorrhage (PPH) remains an important complication of childbirth and contributes significantly to maternal mortality. In the most recent triennial audit of maternal death in the United Kingdom, PPH was the direct cause of 8 maternal deaths and was a major contributing factor in a further 5 fatalities. Care was adjudged to be substandard in most cases.¹

In addition, the morbidity of puerperal anaemia and the risks associated with blood transfusion make limitation of blood loss at delivery an important objective.

Definitions vary

Primary PPH is classically defined as blood loss from the genital tract, exceeding 500mls within 24 hours of delivery. This definition is of limited practical use as accurate quantification of blood loss is seldom possible, and the average blood loss at delivery is 500 to 600 mls.

Blood loss of >1000mls is a more useful definition of PPH as this corresponds to the 95th centile for blood loss associated with spontaneous vaginal delivery.²

Secondary PPH is defined as excessive blood loss from the genital tract after 24 hours following delivery, until six weeks post delivery.

Incidence varies: 4% - 22%

The reported incidence of PPH in the UK varies from 4% to 11%. National figures for New Zealand are not available. National Women’s Hospital reports a high incidence of PPH with 18% of all women suffering a primary PPH of 500 to 1000mls and 4% suffering a primary blood loss of >1000mls.³

These figures suggest that there is scope for improvement in the management of the third stage of labour amongst New Zealand practitioners.

Aetiology

Uterine Atony

Failure of sustained uterine contraction following partial or complete placental separation may result in massive haemorrhage from the placental vascular bed. Prolonged labour, uterine overdistension, grand multiparity, retained placental tissue or haematometria (abruption) may contribute to inadequate myometrial contraction. Uterine inversion is a rare but dramatic cause of uterine atony and haemorrhage.

Trauma

Haemorrhage may result from vulval, perineal, vaginal or cervical tears. Rupture into the clitoral venous plexus may cause remarkable loss. Occult bleeding into the para vaginal space, ischiorectal fossa and broad ligaments may follow vaginal laceration. Occasionally, uterine rupture presents as a PPH.

Coagulopathy

Clotting dysfunction and disturbance of platelet function are unusual but important causes of PPH. In the majority of cases, the clotting disorder is secondary to pre-eclampsia, abruption or massive blood loss. Almost all maternal mortalities attributable to PPH are associated with coagulopathy and, in most cases, the bleeding dysfunction is recognised late and inadequately treated. Failure to control PPH quickly with standard measures behoves exclusion of coagulopathy and full specialist support.

Risk Factors

Although the risk of severe PPH (>1000mls) is low (<5%), many haemorrhages are predictable.

The following are risk factors:

• previous PPH;
• uterine overdistension (multiple pregnancy/macrosomia/polyhydramnios);
• prolonged labour (especially prolonged second stage);
• instrumental delivery;
• grand multiparity (>5);
• pre-eclampsia; and
• clotting/platelet dysfunction.

To reduce the risk of PPH, aspirin therapy (used in pre-eclampsia) should cease at least 3 days prior to delivery.

The management of the third stage of labour in at-risk women should be active with:

• intravenous access
• cross matched blood available for transfusion
• ecbolic at delivery (Syntocinon 10 IU or Syntometrine 1 ampoule)
• placental extraction (controlled cord traction).

Active vs expectant/physiological management of third stage labour

There are two methods of management of the third stage of labour; either active management or expectant/physiological management. Neither method can be practised in isolation.

Active management of labour is practised routinely in the UK, Australia and New Zealand, although with the emergence of a strong midwifery influence expectant/physiological management is now often used by midwifery practitioners. Expectant or physiological management of the third stage is popular in Northern European countries, in parts of the USA and Canada and is the practice of choice for domiciliary practice in New Zealand.

Active management of the third stage is a package of interventions which reduces the chances of PPH. It involves the administration of an oxytocic drug either intramuscularly or intravenously with, or immediately after, the birth of the baby. The cord is then clamped and cut, and once signs of placental separation have occurred the placenta is delivered by controlled cord traction. The fundus should be contracted and the uterus splinted by suprapubic pressure.

Expectant management is a "leave well alone" approach. No oxytocic drug is given at delivery. The cord is not cut until pulsation ceases and no clamp is applied, other than the umbilical clamp. Controlled cord traction is not used. Once signs of separation have occurred, the placenta will deliver spontaneously either with the aid of gravity or nipple stimulation. Expectant management of the third stage should only be practised where there has been a normal progression through labour and delivery. All aspects of expectant management practice must be employed if this practice is to be successful.⁴

Twofold reduction in PPH risk with active management

Three randomised trials of active versus expectant management of the third stage of labour were reviewed by Prendiville, Elbourne and McDonald in the Pregnancy and Childbirth Module of the Cochrane Database Systematic Reviews.⁵ The outcomes measured were maternal and perinatal complications of the third stage of labour.

Results demonstrated that active management of the third stage of labour is associated with a twofold reduction in the risk of PPH, and a significant reduction in postpartum anaemia and the need for blood transfusions during the puerperium. Women did, however, experience some adverse affects. Nausea, vomiting, headaches and hypertension were more common. One trial in Dublin demonstrated that there were more retained placentas requiring manual removal. However, this was not replicated in the two other trials conducted in Bristol and Brighton.⁵ The reasons for this are not apparent.

No difference in neonatal outcomes

One trial (in Bristol) measured neonatal outcomes. There were no significant differences in Apgar scores, neonatal respiratory problems or breastfeeding rates. There were fewer admissions to the special care baby unit with active management, but these differences were not statistically significant. Mothers and midwives did not strongly favour either method of management.

Active management with informed consent should be routine practice

The implication for both obstetric and midwifery practice is that active management of third stage of labour has positive outcomes for women in terms of a reduction in the amount of blood loss in PPH, the need for blood transfusions and postpartum anaemia. For the woman, postpartum well-being is improved. Offsetting this is the higher risk of experiencing short-term adverse side effects such as nausea, vomiting and headache.

An important consideration for all obstetric and midwifery practitioners is the right of all women to accurate information, so that they can make informed choices about the management of their labour and the birth of their baby. In domiciliary practice where labour and delivery have been straightforward, and with full informed consent, there may be a place for expectant/physiological management of the third stage. However, in most settings, active management of the third stage should be the routine practice. This is especially so when an actively managed approach to labour and birth has taken place.

Management of Postpartum Haemorrhage

Correspondence to Dr Keith Harrison, O&G Consultant, Hastings Memorial Hospital, Hastings phone 06 878 8109, fax 06 878 1318.

References

1. Report on confidential enquiries into maternal deaths in the United Kingdom 1991 - 1993. HMSO 1996.
2. Riggs JW, Blanco JD. Post partum complications in management of labour and delivery. Ed. Creasy RK, Ch.10:223-255. Blackwell 1996.
3. National Women’s Hospital Annual Report. 1996 Inhouse Publication.
4. National Childbirth Trust, 1993.
5. Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management of the third stage of labour. In: Neilson JP, Crowther CA, Hoidnett ED, Hofmeyer GJ, Keirse MJNC (eds). Pregnancy and Childbirth Module of the Cochrane Database of Systematic Reviews, (updated 3 June 1997). Available in the Cochrane Library (database on disk and CDROM). The Cochrane Collaboration, Issue 3. Oxford: Update Software; 1997. Updated quarterly.

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Queries Raised on the Management of Postpartum Haemorrhage

Prescriber Update No. 17, December 1998

Prescriber Update (No. 16, April 1998) contained an article and flow chart on the management of postpartum haemorrhage. Medsafe and the authors received a number of queries and criticisms about the management protocol. The following points of clarification from the authors explain the intent of the original article in respect of the issues raised.

The authors wrote the article on the assumption that the placenta had been delivered and routine initial measures for the management of heavy bleeding post delivery would have occurred, i.e. fundal massage to contract the uterus, the administration of an ecbolic, either Syntometrine or Syntocinon depending on the woman’s blood pressure, and emptying of the bladder.

1. The clinical situation being addressed
   The treatment suggested is for the management of severe rapid onset primary postpartum haemorrhage, i.e. when blood loss is perceived to have exceeded 1000mls. That is implied in the text of the article but not explicitly stated on the flow chart. This management protocol is not suggested for women with minor degrees of postpartum bleeding, or for the routine management of the third stage of labour. The management protocol shown on the flow chart is, therefore, applicable to the management of postpartum haemorrhage of severe and rapid onset.
2. Uterine massage
   There has been considerable criticism that the management protocol suggests that uterine compression be applied after establishment of intravenous access. The authors agree that uterine massage is the first action if deemed appropriate to the situation. All elements of the initial measures and treatment should take place within a short timeframe (5 to 10 minutes), hence it is essential that immediate assistance is obtained. Intravenous access and vigorous replacement of intravascular volume remain the mainstay of treatment for severe acute haemorrhage of any origin.
3. Placental removal and emptying the bladder
   If heavy and persistent bleeding occurs with the placenta in-situ, it is important that an attempt be made to remove the placenta and if unsuccessful to proceed immediately to surgical removal. The authors believe that the process of intravenous access and fluid replacement, use of ecbolics and recourse to obstetric/anaesthetic help, would remain unchanged. An empty bladder is said to aid uterine contraction. Catheterisation with an indwelling cathether will maintain an empty bladder and is useful in assessing fluid balance.
4. Administration of Syntometrine intravenously
   The authors agree that Syntometrine is not routinely used intravenously due to the high incidence of nausea, vomiting and hypertension. However, in cases of severe haemorrhage due to uterine atony, Syntometrine IV rapidly and effectively restores uterine tone in most cases and its use in these circumstances can be justified.