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In this article, Cliodhna Grady, Clinical Risk Advisor, sets out risk management advice on the management of postpartum haemorrhage.

Obstetric haemorrhage remains one of the major causes of maternal mortality in both developed and developing countries.

Primary postpartum haemorrhage (PPH) is the most common form of major obstetric haemorrhage. The definition of a primary PPH is the loss of 500mls or more of blood from the genital tract within 24 hours of the birth of a baby. Uterine atony accounts for 70% of PPH; other causes include trauma to the genital tract, retained products (placental tissue, membranes or clots) and coagulopathies.

Risk Factors for PPH

Antenatal risk factors

  • Previous retained products of conception / PPH
  • Hb <8.5g/dl
  • BMI > 35
  • Grand multiparity
  • Antepartum haemorrhage
  • Overdistention of the uterus (multiple pregnancy,
    polyhydramnios, macrosomia)
  • Existing uterine abnormalities
  • Low lying placenta
  • Maternal age > 35

Intrapartum risk factors

  • Induction of labour
  • Prolonged first, second or third stage
  • Oxytocin use
  • Precipitate labour
  • Operative deliver
  • Caesarean section

All maternity units should have a multi-disciplinary protocol for the management of PPH, with regular skill drills to practice and enhance a coordinated response to this obstetric emergency.

1. Be aware of risk factors

All health professionals involved in the care of women in labour should be aware of the risk factors for PPH (see table). If risk factors for PPH are identified, these should be highlighted in the woman’s healthcare record and be included at clinical handovers.
A care plan covering the third stage of labour should be discussed with the woman and documented in the healthcare record. That said, most cases of PPH have no identifiable risk factors, therefore vigilance and early recognition of haemorrhage is required in all settings.

2. Be vigilant for early signs of haemorrhage

It is important to be aware of the physiological increase in circulating blood volume during pregnancy meaning that the signs of hypovolemic shock may be less sensitive in pregnancy. Continuous monitoring of the woman’s clinical condition, observations, uterine tone and vaginal blood loss in the immediate postpartum period is essential.

3. Focus on timely management

When PPH occurs, timely management is crucial, in addition to effective communication and teamwork. Visual estimation often underestimates blood loss and other methods of measuring of blood loss should be employed. Therapeutic interventions should be directed towards the causative factor, endeavouring to identify the source of bleeding and arrest it.

4. Communicate clearly and effectively

Communication with the woman and her birth partner is essential. Clear information of what is happening should be provided from the outset of the PPH event. Debriefing the woman (and her birth partner) is important, allowing time to discuss the events surrounding the haemorrhage, and should be offered to the woman and her birthing partner following a PPH.

The Major Obstetrics Haemorrhage Project

According to the National Women and Infants Health Programme (NWIHP), for every woman who dies of pregnancy-related causes, twenty or thirty others experience morbidity, potentially causing permanent damage to their normal functioning.

NWIHP notes that major obstetric haemorrhage (MOH) and, specifically, the incidence of postpartum haemorrhage is increasing in Irish maternity units and there is a need to reduce this increasing trend.

NWIHP further notes that a MOH audit in 2011-2013 showed good practices being followed in Irish maternity units, however, standardising these practices and sharing learning would be beneficial.

In this context, a joint venture between NWIHP and the National Perinatal Epidemiology Centre – the Major Obstetrics Haemorrhage Project - has commenced.

The aim of this initiative is to lower the incidence of MOH in maternity units by developing a standardised approach to measurement, audit, policies and procedures and training modules.

References for this article are available on request.

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