Primary Postpartum Haemorrhage (PPPH)
 
Status
PPPH (Blood loss >500ml in first 24 hours from birth
   
Assess
• Fundus Tone
• Visible blood loss
• Perineal/vaginal laceration
         
Fundus firm
• Palpable firm, central and compacted Fundus
High flow oxygen therapy
Analgesia as required as per Pain Relief
Manage perfusion as per Hypovolaemia
Manage any visible laceration with a dressing and firm pressure
 
Fundus not firm
• Fundus boggy and not palpable as per Fundus firm
Manage as per Fundus Firm

Massage Fundus until firm and blood loss reduces
 - Use a cupped hand
 - Apply firm pressure in a circular motion
Encourage mother to empty bladder if possible
Encourage baby to suckle breast
   
Fundus remains not firm

Misoprostol 800mcg Oral
Oxytocin 10iu IM
Repeat Oxytocin 10iu IM after 5 minutes if bleeding continues
Stop
DO NOT ATTEMPT delivery of placenta due to risk of uterine inversion
   
  Intractable haemorrhage
 

Perform External Abdominal Aortic Compression:
  - Locate point of compression just above the umbilicus and slightly to the left
  - Apply downward pressure with a closed fist directly through the abdominal wall
  - Effectieness of compression may be assessed by assessing palpable femoral pulse with pressure applied
 
 
 
 
Special Notes
Contact Perinatal Emergency Referral Service (PERS) on 1300 137 650 for advice (via clinician)

• Massaging a Fundus that is firm, central and contracted may interfere with normal placental post birth separation and worsen bleeding. Fundal massage should only be applied when the Fundus is not firm

• The four T's of Primary Post Partum haemorrhage are:
  - Tone (Uterine atony)
  - Trauma (to genital structures)
  - Tissue (retention of placenta or membranes
  - Thrombin (coagulopathy)

The most common cause of PPPH is uterine atony

An empty and contracted uterus does not bleed

• Higher risk patients included multiple pregnancy, more than four pregnancies, past history of PPH, history of APH, large baby

• PPH can occur before or after the birth of the placenta

• Misoprostol is a synthetic prostaglandin which in Australia is licensed for prevention of gastric ulcers. However, because it can induce /augment uterine contractions it is used for inducing labour/ abortion as well as to treat haemorrhage after normal delivery. Its use in post partum haemorrhage is supported by major Victorian Obstetric Hospitals. Misoprostol is widely used in countries where there are no other medications available to control post partum haemorrhage. As its use in these circumstances is non licensed in Victoria, verbal consent must be obtained prior to administration and appropriate notation made.

• There may be some risks/complications and side effects which may include nausea; diarrhoea; or abdominal pain. In rare instances in women who have had a caesarean section the uterine scar may rupture which would require surgery

• Side effects are unlikely for the dosage that will be given