Obstetrics & Gynaecology
Postpartum Haemorrhage (PPH): Blood Loss, HAEMOSTASIS & Uterotonic Doses
Contents
Postpartum haemorrhage in one place: how to estimate the loss, the order of steps to stop the bleeding, and the doses of every uterotonic. Based on the OLSS (Obstetric Life Saving Skills) lecture on bleeding in obstetrics (APH and PPH) at Hospital Sultan Haji Ahmad Shah (HOSHAS), Temerloh.
PPH is the commonest cause of maternal death worldwide, and deaths from haemorrhage are usually avoidable.
Definitions
| Term | Definition |
|---|---|
| PPH | Blood loss >500 mL (or >1,000 mL at caesarean section) |
| Primary PPH | Within the first 24 hours after delivery |
| Secondary PPH | After 24 hours of delivery |
| Major obstetric haemorrhage | Blood loss >1,000 mL: major 1,000-2,000 mL, massive >2,000 mL |
Causes
| Antepartum | Intrapartum | Postpartum |
|---|---|---|
| Abruptio placentae | Ruptured uterus | Primary (4 Ts): tone (uterine atony), tissue (retained placenta / POC), trauma (cervical, perineal or uterine tears), thrombin (coagulation disorder, HELLP) |
| Placenta praevia | Abruptio placentae | Secondary: infection, retained POC, uterine AV malformation, coagulation disorder, rarely GTD |
| Severe chorioamnionitis or sepsis | Vasa praevia | |
| Severe pre-eclampsia (hepatic rupture) | Amniotic fluid embolism | |
| Local causes | Complications of caesarean section | |
| Morbidly adherent placenta |
Remark: POC = products of conception; HELLP = haemolysis, elevated liver enzymes, low platelets; AV = arteriovenous; GTD = gestational trophoblastic disease.
Risk factors
Prolonged, augmented or rapid labour; previous PPH; an over-distended uterus (multiple pregnancy, polyhydramnios, macrosomia); uterine anomalies (fibroids); operative delivery; chorioamnionitis; maternal obesity.
- In most cases there are no risk factors.
- Blood loss is always underestimated.
- Clinical signs are late: hypovolaemia may not show until 35-40% of the circulating volume is lost.
- Always think of concealed haemorrhage in abruptio placentae.
General principles
- Recognition and assessment of severity.
- Communication and call for help.
- Resuscitation.
- Treatment: arrest the bleeding.
- Monitoring and documentation.
Estimating blood loss
Visual estimates from the pictograph used in the lecture:
| Item | Amount soaked or filled | Blood loss |
|---|---|---|
| Sanitary pad | 1/4 · 1/2 · fully | 20 · 50 · 100 mL |
| Kidney dish | 1/4 · 1/2 · completely | 100 · 250 · 500 mL |
| Linen protector | 1/4 · 1/2 · almost fully | 500 · 1,000 · 1,500 mL |
| Sarong | 1/2 · fully | 400 · 700 mL |
| Vaginal pack | Fully | 80 mL |
Signs of shock
| Blood loss (% of blood volume) | MAP (mmHg) | Symptoms and signs |
|---|---|---|
| 10-15% (500 mL) | Normal | Postural hypotension, mild tachycardia (90-100 bpm) |
| 15-30% (1,000-1,500 mL) | Slight fall | Tachycardia (110-120 bpm), thirst, weakness |
| 30-40% (1,500-2,000 mL) | 50-70 | Tachycardia (120-140 bpm), pallor, oliguria (<30 mL/h), confusion, restlessness |
| >40% (>2,000 mL) | <50 | Tachycardia (>140 bpm), anuria, air hunger, coma, death |
| Early shock | Late shock |
|---|---|
| Awake, aware, anxious | Confused or unconscious |
| Slightly fast pulse (≥110/min) | Very fast and weak pulse |
| Slightly fast breathing (≥30/min) | Extremely fast and shallow breathing |
| Pale | Pale and cold |
| Mild low BP (systolic <90 mmHg) | Very low BP |
| Urine output ≥30 mL/h | Urine output <30 mL/h |
Because blood loss is underestimated, look for tachycardia, hypotension, reduced pulse pressure, delayed capillary refill and oliguria.
Shock index = heart rate ÷ systolic BP (normal 0.7-0.9). >1 may indicate occult shock. Use the obstetric shock index calculator.
Remark: MAP = mean arterial pressure.
Communication and resuscitation
Communication is crucial: clear roles and responsibilities, a competent team, closed-loop communication, clear messages and mutual respect.
Fluids: crystalloids replace volume 3:1 (1,500 mL for 500 mL lost), colloids 1:1; blood and blood products increase oxygen delivery. End points: urine output >0.5 mL/kg/h, MAP >65 mmHg, CVP >4 mmHg.
Arresting the bleeding
Medical
- IV oxytocin
- IM Syntometrine (do not exceed 2 doses)
- IM carboprost
- Misoprostol
- Tranexamic acid
Mechanical
- Empty the bladder.
- Uterine massage.
- Bimanual compression of the uterus, maintained for 10 minutes:
- Explain to her and give analgesia.
- With a sterile gloved, lubricated hand in the vagina, form a fist in the anterior fornix and press against the anterior wall of the uterus.
- With the other hand on the abdomen, find the fundus and push it deep into the abdomen behind the uterus, pressing on the posterior uterine wall.
- Maintain until the bleeding is controlled and the uterus contracts.
- Aortic compression.
- Intrauterine balloon tamponade (e.g. Bakri balloon).
- Non-pneumatic anti-shock garment.
By cause
| Tone | Trauma | Tissue | |
|---|---|---|---|
| Findings | Uterus relaxed, boggy and soft; fundus may be above the umbilicus if the cavity fills with blood and clots | Bleeding from genital tract trauma; uterine rupture; extended uterine angles; tears at caesarean; extragenital causes (subcapsular liver rupture, ovarian or splenic vessels) | Retained placenta and membranes, found on bimanual examination |
| Investigations | FBC, coagulation profile, urea and electrolytes; abdominal ultrasound if not responding to fluid and blood, to exclude uterine rupture or intraperitoneal bleeding | Inspection at caesarean (by exteriorisation); ultrasound for free fluid in uterine rupture | Examination under anaesthesia |
| Management | Uterotonics (oxytocics, prostaglandins, ergot alkaloids), balloon tamponade, then the haemostasis algorithm | Repair the trauma; pelvic arterial embolisation for broad ligament or supralevator haematoma | Manual removal of the placenta or retained products under regional or general anaesthesia |
Remark: FBC = full blood count.
HAEMOSTASIS algorithm
| Step | |
|---|---|
| H | Ask for help and hands on the uterus (uterine massage) |
| A | Assess and resuscitate |
| E | Establish the aetiology; ensure blood is available |
| M | Massage the uterus |
| O | Oxytocin infusion; prostaglandins (IV, per rectum, IM or intramyometrial) |
| S | Shift to theatre: aortic pressure, anti-shock garment or bimanual compression as appropriate |
| T | Tamponade balloon or uterine packing, after excluding tissue and trauma |
| A | Apply compression sutures: B-Lynch or modified |
| S | Systematic pelvic devascularisation: uterine, ovarian, quadruple or internal iliac ligation |
| I | Interventional radiology and, if appropriate, uterine artery embolisation |
| S | Subtotal or total abdominal hysterectomy |
Surgical management
In escalating order: intrauterine balloon tamponade; compression sutures (B-Lynch, Hayman, or multiple square sutures by Cho et al., with Vicryl 1.0 or liver sutures, per local preference); uterine artery ligation; internal iliac artery ligation; arterial embolisation; hysterectomy.
Uterotonics and other drugs
| Order | Drug | Dose and route | Main cautions |
|---|---|---|---|
| 1 | Oxytocin (Pitocin, Syntocinon) | 5 IU IV slowly over 1-2 min; after 5 min repeat as required to a maximum total of 10 IU (IM also possible). Infusion 5-10 IU/hour (125-250 mL/h): 40 IU in 500 mL-1 L of crystalloid / 0.9% NaCl | Use in place of Syntometrine if the BP is raised. Overdose or prolonged use causes water intoxication; IV push can cause hypotension |
| 2 | Syntometrine (oxytocin 5 IU + ergometrine 0.5 mg per 1 mL) | 1 ampoule (1 mL) IM. IV can cause hypotension. Repeat 1 mL no sooner than 2 hours if necessary; no more than 3 mL in 24 hours | Avoid in retained placenta, severe hypertension, hepatic, renal or cardiac disease, sepsis. Give an antiemetic (e.g. metoclopramide 10 mg IV). Ergometrine 0.5 mg alone (IV or IM) is not recommended first line because of its side effects |
| 3 | Carbetocin (Duratocin) | 100 µg IV bolus over 1 minute. Single dose: do not repeat; if the uterus is still not contracting, use other uterotonics | Long-acting, so its contractions cannot be stopped: never before delivery of the fetus. Licensed for elective caesarean under regional anaesthesia |
| 4 | Carboprost (Hemabate) | 250 µg IM, repeated every 15-90 min as required, maximum 2 mg (8 doses). Intramyometrial use is at the clinician's responsibility | Contraindicated in cardiac, pulmonary, renal or hepatic disease. Caution in asthma, anaemia, diabetes, epilepsy, hyper- or hypotension, jaundice, uterine surgery |
| 5 | Misoprostol (Cytotec) | 800-1,000 µg (4-5 tablets) per rectum. Slow onset: give early | Off-label. Use when oxytocin and ergometrine fail or aren't available |
| 6 | Tranexamic acid | Loading 1 g IV over 10 min (in 100 mL 0.9% NaCl); a further 1 g 30 min later if required. Maintenance: 1 g in 100 mL 0.9% NaCl over 8 hours | Avoid in active thromboembolism. Caution in renal impairment and DIC |
| 7 | Recombinant factor VIIa | 90 µg/kg IV over 3-5 min, after consulting a haematologist; 2nd dose after 20-30 min, maximum 2 doses | Optimise platelets, fibrinogen, pH and temperature first. Raises the VTE risk |
Remark: IU = international units; IM = intramuscular; DIC = disseminated intravascular coagulation; VTE = venous thromboembolism. Doses from the PPH drug table in the lecture (OGSM Handbook of Obstetric Emergencies).
Blood component therapy
| Product | Volume (mL) | Effect per unit |
|---|---|---|
| Packed red cells | 240 | Raises Hb by about 1 g/dL (HCT by 3 percentage points) |
| Platelets | 50 | Raises the platelet count by 5,000-10,000/mm³ |
| Fresh frozen plasma | 250 | Contains fibrinogen, antithrombin III, factors V and VIII |
| Cryoprecipitate | 40 | Raises fibrinogen by about 10 mg/dL |
Complications
Hypovolaemic shock, DIC, respiratory distress syndrome, renal failure, hepatic failure, loss of fertility, pituitary necrosis (Sheehan syndrome) and maternal death.
Don'ts
- Don't delay arresting the haemorrhage.
- Don't use special blood filters.
- Don't forget to check the placenta is complete.
- Don't overlook genital tract trauma.
- Umbilical vein injection for retained placenta isn't needed.
Referral and transfer
- Communication is vital: do not delay referral. But a hasty transfer of an unstable patient may cause more harm.
- Refer early and appropriately; speak directly to the most senior person (specialist, medical officer, matron or sister).
- PPH referrals are either from home, a health clinic or a private clinic to the nearest hospital, or from a hospital without a specialist to one with a specialist.
Sources
- Obstetric Life Saving Skills (OLSS) lecture: Bleeding in Obstetrics: APH and PPH. Hospital Sultan Haji Ahmad Shah (HOSHAS), Temerloh, 2026.
- Obstetrical and Gynaecological Society of Malaysia (OGSM). Handbook of Obstetric Emergencies (ICOE 2018): blood loss pictograph, shock tables, PPH drug table and management figures, as reproduced in the lecture.