Overview

• Blood loss >500 mL at vaginal delivery or >1000 mL at caesarean section.
• Primary → occurs within 24 hours of delivery of baby. Affects 5-7% of deliveries.
  • Minor (500-1000 mL and no signs of shock) or major (>1000 mL or signs of shock).
• Secondary → >24 hours to 6 weeks. Typically due to retained placental tissue or endometritis (MOST COMMON).
• Causes (4 T’s)
  • Tone (Uterine Atony) → most common cause. Uterus fails to contract after birth.
  • Trauma → damage to genital structures (eg. perineal tear, lacerations, episiotomy).
  • Tissue → retained placental fragments in the uterine cavity.
  • Thrombin → underlying clotting disorder.
• Risk Factors → previous PPH, prolonged labour, pre-eclampsia, increased maternal age, polyhydramnios (too much amniotic fluid around baby), emergency caesarean section, placenta praevia (placenta attaches low in the uterus), placenta accreta (placenta grows too deeply into wall of uterus), macrosomia (newborn who is larger than average), episiotomy, assisted delivery techniques (forceps).
  • Placenta Accreta → risk factors include past caesarean sections (most important), Asherman syndrome and pelvic inflammatory disease. In many cases, total hysterectomy is the definitive treatment, especially when the patient becomes haemodynamically compromised.

Making Diagnosis

Clinical Features

• Heavy bleeding from vagina.
• Shock → tachycardia + hypotension.
• Nausea, tachypnoea, thirst, cold, pain.
• Dependent on cause
  • Tone → uterus may feel enlarged, soft or boggy.
  • Trauma → visible lacerations or tears on vaginal exam.
  • Tissue → on examination of placenta, the placental tissue or membranes may be incomplete.

Investigations

• Clinical Diagnosis.

Management Plan

• Minimising Risk ⇒ prophylactic uterotonics to all women in 3rd stage of labour to reduce risk.
  • Vaginal Delivery → IM Oxytocin.
  • C-Section → IV Oxytocin.