8. Postpartum haemorrhage:

See also MCQ 11, question 45.

PPH is genital tract bleeding in excess of 500 ml. from the delivery of the baby until six weeks later.

Primary is within the first twenty four hours.

The condition is usually due to uterine atony.

The uterine wall is a lattice of muscle fibres arranged in different directions.

The spiral arteries running to the placental site traverse the interstices of the lattice.

If the uterus retracts well after delivery, i.e. the muscle fibres shorten and stay shortened.

The interstices shrink and the muscle fibres act as a "living ligature" to "garrotte" the spiral arteries and effect haemostasis.

To demonstrate this, I open the fingers of my left hand.

I then spread them apart as far as they will go.

I do the same with my right hand.

I lay the fingers of my right hand over the fingers of my left hand, but at right angles to them.

The gaps between the fingers represent the interstices of the lattice.

One can imagine the spiral arteries running through them.

Then I close the fingers of both hands to represent shortening of the muscle fibres.

This gives a good idea of how the spiral arteries get "garotted". 

Next on the list are retained products and local trauma.

Coagulation defects are well down the list.

It does tend to recur and a previous third stage problem would be grounds for advising delivery in a consultant unit.

The condition may not be revealed, as in broad ligament or para-vaginal haematoma.

An OSCE station might ask for a definition and then the steps to be taken immediately and after X minutes if the bleeding has not subsided.

You could also be asked what non-medical interventions might be appropriate.

Immediate management means applying the unit protocol – make sure that you have read the local version.

This means calling for help.

First measures are to rapidly assess the patient and try to effect uterine contraction by “rubbing up a contraction” and administering syntocinon, syntometrine or ergometrine, usually IV.

Has the placenta been delivered and does it appear complete?

An IV infusion should be established promptly via a large cannula.

Bloods must be sent for a full blood count and cross match.

A clotting screen may be helpful as a baseline, though it is unlikely to be abnormal at this stage.

A midwife should be given the task of keeping a tally of blood loss and fluid replacement.

If you don’t, after half an hour or so you will have no idea of where you are up to, with a risk of over or under transfusion.

If the uterus is not empty, it has to be emptied promptly.

If the bleeding persists, particularly if the uterus is well contracted, genital tract trauma has to be sought.

Most often this will be perineal or vaginal, but cervical tears, broad ligament haematomas and uterine rupture can occur.

In the latter cases, the external loss may be deceptively small and the possibility of severe bleeding arises because of signs of shock or severe pain rather than PPH.

The examination should be done in theatre under appropriate anaesthesia, either general or regional.

If the uterus continues to relax, despite syntocinon and ergometrine, prostaglandins may be helpful.

Non medical interventions include:

    hysterectomy,

    ligation of the internal iliac arteries,

    the alternative being embolisation, if you have an interventional radiologist,

    and the B-Lynch suture, which swaddles the uterus in the hope of forcing compression of the spiral arteries.