Obstetric Hemorrhage

PPH Basics - Code Red Causes

• Primary PPH: Blood loss >500 mL (vaginal) / >1000 mL (CS) within 24 hrs.
• Severe PPH: >1000 mL (any delivery) or signs of shock.
• Massive PPH: >2000 mL loss / >5 units PRBC / hemodynamic instability.
• Code Red: Protocol for life-threatening PPH.
• Causes (📌 4 T's):
  • Tone (Atony): 70-80%; e.g., uterine overdistension, prolonged labor.
  • Trauma: Lacerations (cervical, vaginal, perineal), uterine rupture, inversion.
  • Tissue: Retained placenta/membranes/clots.
  • Thrombin: Coagulopathy (e.g., DIC, HELLP, AFE, anticoagulants).

⭐ Uterine atony is the most common cause of PPH, responsible for 70-80% of cases.

Risk & Prevention - Flood Watch Duty

• Identify High-Risk:
  • Previous PPH (recurrence risk 20-25%)
  • Uterine overdistension (twins, polyhydramnios, macrosomia)
  • Placental issues (previa, accreta spectrum)
  • Grand multiparity (≥5 births)
  • Severe anemia (Hb <7 g/dL)
• Proactive Measures:
  • Antenatal: Correct anemia (target Hb >11 g/dL), blood availability, high-risk referral.
  • Intrapartum: Skilled birth attendant.
  • Active Management of Third Stage of Labor (AMTSL):

    ⭐ AMTSL is key, reducing PPH incidence by >60%. Includes: uterotonic (Oxytocin 10 IU IM/IV), controlled cord traction, uterine massage.

  • PPH preparedness: Drills, PPH cart, multidisciplinary team communication.

PPH Management - Damage Control Drill

• Immediate Actions:
  • Call for HELP (Activate PPH Protocol/Code Red).
  • ABC: High-flow O₂, 2 large-bore IVs (14-16G).
  • Blood products: O neg/type-specific; activate Massive Hemorrhage Protocol (MHP).
  • Tranexamic acid (TXA): 1g IV over 10 min (repeat 1g IV if bleeding continues after 30 min or restarts within 24h).
• Uterine Atony Management (Sequential):
  • Bimanual uterine massage.
  • Oxytocin: 5 IU IV slow, then 20-40 IU in 500ml infusion.
  • Ergometrine: 0.25-0.5mg IM/IV (C/I: Hypertension, cardiac disease).
  • Carboprost (PGF2α): 0.25mg IM (q15min, max 8 doses / 2mg) (C/I: Asthma).
  • Misoprostol: 800-1000mcg PR/SL.
• Escalation if Bleeding Persists:
  • Intrauterine balloon tamponade (e.g., Bakri balloon).
  • Surgical hemostasis:
    • Compression sutures (e.g., B-Lynch).
    • Stepwise devascularization (uterine, ovarian, internal iliac artery ligation).
  • Interventional Radiology: Uterine Artery Embolization (UAE) if patient stable for transfer.
  • Hysterectomy: Definitive, life-saving measure.

⭐ Tranexamic acid (TXA) 1g IV should be administered as soon as possible, ideally within 3 hours of bleeding onset in PPH, to reduce mortality from hemorrhage.

Anesthesia & Advanced Care - Lifeline Logistics

• Anesthesia:
  • General Anesthesia (GA) with Rapid Sequence Intubation (RSI) for airway & hemodynamic control.
  • Induction: Ketamine (0.5-1 mg/kg IV) if unstable.
  • Maintain: Low MAC volatiles, opioids.
• Access & Monitoring:
  • ≥2 large-bore IVs (14-16G).
  • Arterial line (continuous BP, ABGs).
  • Central line (CVP, vasopressors).
• Massive Transfusion Protocol (MTP):
  • Early activation; Ratio PRBC:FFP:Platelets often 1:1:1.
  • Targets: Hb >7-8 g/dL, Platelets >50,000/µL, INR <1.5, Fibrinogen >1.5-2 g/L.
• Key Medications:

  ⭐ Tranexamic acid (TXA): 1g IV over 10 min within 3 hours of bleeding onset, may repeat 1g IV over 8 hours if ongoing.

  • Vasopressors (e.g., Noradrenaline).
  • Calcium gluconate/chloride (for MTP-induced hypocalcemia).
  • Recombinant Factor VIIa (rFVIIa): 90 µg/kg (rescue therapy).
• Definitive Care:
  • Interventional Radiology: Uterine Artery Embolization (UAE).
  • Surgical: Tamponade (Bakri), compression sutures (B-Lynch), vessel ligation, hysterectomy.
• Supportive: Warm all fluids/blood; monitor core temp, UO, coagulation (TEG/ROTEM).

High‑Yield Points - ⚡ Biggest Takeaways

• Uterine atony is the most common cause of Postpartum Hemorrhage (PPH).
• Active Management of Third Stage of Labor (AMTSL) significantly reduces PPH incidence.
• Administer Tranexamic Acid (TXA) within 3 hours of birth in PPH.
• Key uterotonics: Oxytocin (first-line), Ergometrine, Misoprostol, Carboprost.
• For refractory atony, consider Bakri balloon or surgical interventions like B-Lynch suture.
• Early recognition and multidisciplinary approach are vital for management.
• Remember the Four Ts for PPH causes: Tone, Trauma, Tissue, Thrombin.