Obstetric Haemorrhages — Study Notes

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1. Magnitude of the Problem

• ~14 million pregnancy-related haemorrhages per year worldwide
• At least 128,000 women bleed to death annually
• Risk of death from PPH:
  • 1:100,000 deliveries in the UK/USA
  • 1:1,000 births in some developing countries (100× higher)

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2. Management Flaws — Why Women Die

1. Underestimation of blood loss
2. Inadequate volume replacement
3. Delayed operative interventions

• Lack of back-up services (blood bank, surgical services)
• Lack of referral system

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3. Definitions of PPH

Most Appropriate Definition (WHO 1998 / Cunningham 2001)

• Early PPH: ≥500 ml after vaginal delivery, or ≥1000 ml after caesarean — occurring within 24 hours
• Late PPH: 24 hours up to 6 weeks after childbirth

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4. Prevention — Active Management of the Third Stage of Labour (AMTSL)

1. Oxytocin 10 IU IM within 1 minute of birth of the baby
2. Controlled cord traction to deliver the placenta
3. Uterine massage until contracted

Uterotonic Options

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5. Principles of Management (SOGC, 2000)

1. Early recognition
2. Initial assessment and treatment
3. Identification of aetiology and direct therapy
4. Replacement of blood loss

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6. Step 1 — Early Recognition

• Check uterine tone (should be hard and round)
  • Every 15 min for the first hour
  • At end of 2nd, 3rd, 4th hour, then every 4 hours
• Estimate blood loss — clinical + quantitative methods

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7. Step 2 — Initial Assessment and Treatment

• Respiration, BP, HR, skin colour, urine output
• Coagulation screen, ABO type & cross-match

• Insert 1–2 large-bore IV lines (size 16 or larger)
• Bolus infusion: 1 litre crystalloid in 15 minutes (ratio 3 ml:1 ml blood loss)

• Tilt head down
• Clear airways
• Oxygen by mask 6–8 L/min

• Explore uterus: atony, retained placental fragments, rupture
• Explore lower genital tract: trauma
• Observe clots

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8. Step 3 — Identification of Aetiology: The 4 "T"s

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Vaginal Bleeding Management by Placental Status

1. Oxytocin 10 IU IM (if not already given)
2. Massage uterus; attempt controlled cord traction if contracted
3. If unsuccessful → vaginal exam; remove from cervix if present
4. If not in vagina/cervix → manual removal
5. If placenta accreta → surgical treatment

• Remove fragments by hand, ovum forceps, or large curette
• If bleeding persists → bedside clotting test (clot failure at 7 min = coagulopathy)
• If fragments cannot be removed (accreta) → surgical treatment

• Check for uterine atony
• Check for trauma

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Bleeding Due to Uterine Atony — Drug Treatment

• Initial: 10 IU IM/IV or 20 IU in 1000 mL saline at 60 drops/min
• Continuing: repeat 10 IU after 20 min if heavy bleeding, or 10 IU in 1000 mL saline at 30 drops/min

• Initial: 0.2 mg IM/IV slowly
• Continuing: 0.2 mg IM every 15 min; up to 5 doses (total 1.0 mg)
• Onset: 2–5 min IM; duration ~3 hours

• Initial: 0.25 mg deep IM or intramyometrial
• Continuing: 0.25 mg every 15 min; up to 8 doses (2 mg total)
• Success rate: 86–96%; majority need only one dose

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Bleeding Due to Trauma

• Uterine rupture → laparotomy
• Vaginal/cervical lacerations → careful complete examination and repair

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9. Refractory Haemorrhage

1. Call for help
2. Inform Blood Bank and ICU
3. Assign roles: one midwife monitors/records; one manages blood preparation; one physician manages transfusion

• Continue IV crystalloids
• Prepare for surgery — BETTER SOONER THAN LATER

• Bimanual compression of the uterus (one fist vaginally, one hand abdominally)
• Compression of the aorta (external pressure above umbilicus)

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10. Surgical Haemostasis — Arresting Bleeding

1. B-Lynch suture (haemostatic compression suture) — first described 1997; >1300 cases reported; prevented hysterectomy in most; no serious complications; fertility preserved
2. Bilateral ligation of uterine arteries — effectiveness 80–96%
3. Bilateral ligation of internal iliac arteries
4. Hysterectomy — incidence 7–13/10,000 births; most common indication now is placenta accreta/percreta (49.6%)

• Subtotal is preferred in most PPH cases
• Total (with cervix) needed when bleeding source is in lower segment/cervix (rupture, placenta praevia, increta)
• Do not delay hysterectomy while attempting less familiar procedures

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11. Step 4 — Replacement of Blood Loss

Crystalloids vs. Colloids

• First-line: Normal saline (crystalloid), ratio 3:1
• Colloids have no survival advantage over crystalloids and are more expensive
  • Albumin: RR mortality 1.02; HES: 1.16; Dextran: 1.24 (Roberts & Alderson, 2004)

Red-Cell Transfusion Indications

• Only when there is decreased oxygen-carrying capacity (clinical hypoxia)
• Transfusion threshold individually determined:
  • Critical Hb level: 70 g/L, but clinical signs of anaemia/hypoxia are equally important
• If blood loss ≥1000 mL and continuing → red cells should be readily available

Fresh-Frozen Plasma (FFP)

• Indicated only for replacement of coagulation factors in clotting disorders
• Give if PT and APTT exceed 1.5× control level in the presence of continued bleeding

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12. Conclusions

• Each facility must have local PPH protocols
• Routine AMTSL reduces PPH risk by 60%
• Ensure availability of equipment, drugs, and trained personnel

• Early recognition and resuscitation are vital
• Oxytocin (up to 40 IU) and prostaglandins effective for uterine atony
• Bimanual compression and aorta compression are recommended for temporary arrest
• Surgical intervention must not be delayed — BETTER SOONER THAN LATER
• Hysterectomy is not always necessary; it need not be total in every case

• Crystalloids are first-line
• Blood transfusion is vital in severe PPH but must be used judiciously
• Strict indications for red-cell and FFP transfusion