AFJOG

GUIDELINES DEFINITION Primary postpartum haemorrhage (PPH) is the loss of 500ml or more of blood from the genital tract within 24 hrs of the birth of a baby via normal vaginal delivery (NVD) or more than 1000ml following Caesarean Section. Secondary PPH occurs between 24 hours and 6 weeks post-delivery. Accuracy of the amount of PPH can be improved with the use of the MATERNAL WELL TRAY or calibrated drapes and outcomes can be improved with the implementation of the E-MOTIVE bundled approach. E – Early detection and Trigger Criteria M – Massaging of uterus O – Oxytocic drugs T – Tranexamic Acid IV– Intravenous fluids E – Examination of genital tract and escalation of treatment when necessary See algorithm at end of document Antenatal risk factors High risk: • Suspected or proven abruptio placentae • Placenta praevia • Placenta accreta spectrum • Multiple pregnancy • Polyhydramnios Moderate risk: • Previous PPH • Obesity (BMI > 35kg/m2) • Anaemia (Hb < 9g/dL) • Grande multiparity (P5 or more) Intra-partum risk factors • Caesarean delivery (emergency > elective) • Induction of labour • Retained placenta • Operative vaginal delivery • Prolonged labour (> 12hours) • Big baby (> 4kg) • Pyrexia in labour Preventative measures Active management of 3rd stage labour including • Prophylactic uterotonics: Carbetocin or Syntocinon® or Syntometrin (the latter NOT FOR patients with hypertension or cardiac disease) during the 3rd stage labour. Preferably Carbetocin due to its long half-life (10 x that of Syntocinon) as well as its non-sensitivity to temperature and lack of side effects. Syntocinon is heat sensitive and the cold chain must be maintained from manufacturing until usage and has a half-life of only 4 minutes. • Vaginal birth : Carbetocin (PABAL®) 100μg IV bolus OR 10 IU Syntocinon IMI bolus after a second fetus is excluded • Caesarean section: Carbetocin (PABAL® ) 100μg IV bolus OR 5-10 IU Syntocinon IV bolus. • Patients with placenta praevia should be assessed carefully for placenta accreta spectrum antenatally, including MRI if adequate ultrasound examination is unavailable (see PLACENTA ACCRETA SPECTRUM DISORDERS GUIDELINE). • Iron supplementation antenatally for women with iron deficiency anaemia (see Iron Deficiency Anaemia in Pregnancy guideline). Causes (4 T’s) • Tone: Uterine atony • Trauma: Trauma to genital tract, uterine inversion • Tissue: Retained products of conception, abnormal placentation (placenta praevia/accreta/percreta) • Thrombin: Coagulation defects Goals of management • Control haemorrhage • Restore or maintain adequate circulatory volume to prevent hypovolaemic shock (hypoperfusion of vital organs), restore and maintain adequate tissue oxygenation, reverse or prevent coagulopathy. • Treat the obstetric cause of PPH MANAGEMENT OF PPH Resuscitate • Call most senior midwife and notify obstetrician. • Call Emergency Centre Doctor if no Gynaecologist on site, or activate hospital response. • Assess CAB (Circulation, airway and breathing) - Start facemask O2 immediately, if breathing spontaneously OR begin bag-mask-ventilation if not breathing spontaneously. • Get IV access (2 x large bore cannulas). • Send blood for FBC/renal functions/clotting profile incl. fibrinogen/cross-match. • Order 2 units red packed cells and 2 units fresh frozen plasma (FFP) (alert blood bank to possible major transfusion protocol and stress urgency). • Administer Tranexamic acid (Cyklokapron®) 1g (100mg/ml) IVI @ 1ml/min (i.e., 10 mls given over 10 minutes) and second dose after 30 minutes if bleeding continues. • Must be given as soon as possible and not later than within 3 hours in all cases of post- partum haemorrhage, regardless of whether the bleeding is thought to be due to genital tract trauma or for other reasons, including uterine atony. • Tranexamic acid must be given for all “clinically diagnosed PPH” as defined above or any blood loss that is sufficient to compromise haemodynamic stability. • Start transfusion as early as possible, but in meantime infuse warm fluids • 2-3 litres crystalloids (Normal saline, Ringers Lactate) OR BETTER OBS | SASOG Post Partum Haemorrhage 3.0 African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | 33