Prevention and Management of Postpartum

Haemorrhage

Executive summary of recommendations

GTG 2016

Prediction and prevention of PPH

• Risk factors for PPH may present antenatally or intrapartum; care plans must be modified as and when risk factors arise.
• Clinicians must be aware of risk factors for PPH and should take these into account when counselling women about place of delivery.
• Women with known risk factors for PPH should only be delivered in a hospital with a blood bank on site.
• Antenatal anaemia should be investigated and treated appropriately as this may reduce the morbidity associated with PPH. [New 2016] D
• Uterine massage is of no benefit in the prophylaxis of PPH. [New 2016] A
• Prophylactic uterotonics should be routinely offered in the management of the third stage of labour in all women as they reduce the risk of PPH.
• For women without risk factors for PPH delivering vaginally, oxytocin (10 iu by intramuscular injection) is the agent of choice for prophylaxis in the third stage of labour.
• A higher dose of oxytocin is unlikely to be beneficial. A
• For women delivering by caesarean section, oxytocin (5 iu by slow intravenous injection) should be used to encourage contraction of the uterus and to decrease blood loss. B
• Ergometrine–oxytocin may be used in the absence of hypertension in women at increased risk of haemorrhage as it reduces the risk of minor PPH (500–1000 ml). C
• For women at increased risk of haemorrhage, it is possible that a combination of preventative measures might be superior to syntocinon alone to prevent PPH. [New 2016]
• Clinicians should consider the use of intravenous tranexamic acid (0.5–1.0 g), in addition to oxytocin, at caesarean section to reduce blood loss in women at increased risk of PPH. [New 2016
• How should PPH be managed?

Identification of the severity of haemorrhage

Clinicians should be aware that the visual estimation of peripartum blood loss is inaccurate and

that clinical signs and symptoms should be included in the assessment of PPH. [New 2016] C

Communication and multidisciplinary care

• Communication with the patient and her birthing partner is important, and clear information of what is happening should be given from the outset. [New 2016]
• Relevant staff with an appropriate level of expertise should be alerted of PPH. [New 2016]
• The midwife in charge and the first-line obstetric and anaesthetic staff should be alerted when women present with minor PPH (blood loss 500–1000 ml) without clinical shock.
• A multidisciplinary team involving senior members of staff should be summoned to attend to women with major PPH (blood loss of more than 1000 ml) and ongoing bleeding or clinical shock.

Resuscitation

Measures for minor PPH

Measures for minor PPH (blood loss 500–1000 ml) without clinical shock:

intravenous access (one 14-gauge cannula)

_ urgent venepuncture (20 ml) for:

– group and screen

– full blood count

– coagulation screen, including fibrinogen

_ pulse, respiratory rate and blood pressure recording every 15 minutes

_ commence warmed crystalloid infusion.

Measures for major PPH

Full protocol for major PPH (blood loss greater than 1000 ml) and continuing to bleed or

clinical shock (see Appendix III):

_ A and B – assess airway and breathing

_ C – evaluate circulation

_ position the patient flat

_ keep the woman warm using appropriate available measures

_ transfuse blood as soon as possible, if clinically required

_ until blood is available, infuse up to 3.5 l of warmed clear fluids, initially 2 l of warmed

isotonic crystalloid.

-Further fluid resuscitation can continue with additional isotonic

crystalloid or colloid (succinylated gelatin). Hydroxyethyl starch should not be used.

_ the best equipment available should be used to achieve rapid warmed infusion of fluids

_ special blood filters should not be used, as they slow infusions.

Blood transfusion

• There are no firm criteria for initiating red cell transfusion.
• The decision to provide blood transfusion should be based on both clinical and haematological assessment. [New 2016]

Selection of red cell units for transfusion

• Major obstetric haemorrhage protocols must include the provision of emergency blood with
• immediate issue of group O, rhesus D (RhD)-negative and K-negative units, with a switch to group-specific blood as soon as feasible. [New 2016]D
• If clinically significant red cell antibodies are present, close liaison with the transfusion laboratory is essential to avoid delay in transfusion in life-threatening haemorrhage. [New 2016]
• All delivery units, especially small units without a blood bank on site, should maintain a supply of group O, RhD-negative blood. [New 2016]
• Intraoperative cell salvage should be considered for emergency use in PPH associated with caesarean section and with vaginal delivery. [New 2016] D

Blood components

     Transfusion of fresh frozen plasma (FFP)

• If no haemostatic results are available and bleeding is continuing, then, after 4 units of red blood cells, FFP should be infused at a dose of 12–15 ml/kg until haemostatic test results are known. [New 2016] D
• If no haemostatic tests are available, early FFP should be considered for conditions with a suspected coagulopathy, such as placental abruption or amniotic fluid embolism, or where detection of PPH has been delayed. [New 2016]
• If prothrombin time/activated partial thromboplastin time is more than 1.5 times normal and haemorrhage is ongoing, volumes of FFP in excess of 15 ml/kg are likely to be needed to correct coagulopathy. [New 2016] D
• Clinicians should be aware that these blood components must be ordered as soon as a need for them is anticipated, as there will always be a short delay in supply because of the need for thawing. [New 2016]

Fibrinogen

• A plasma fibrinogen level of greater than 2 g/l should be maintained during ongoing PPH. [New 2016] C
• Cryoprecipitate should be used for fibrinogen replacement. [New 2016] D

Transfusion of platelets

• During PPH, platelets should be transfused when the platelet count is less than 75 X 10⁹/l based on laboratory monitoring. [New 2016] D

Is there a role for antifibrinolytic drugs?

• Consideration should be given to the use of tranexamic acid in the management of PPH. [New 2016]

Is there a role for recombinant factor VIIa (rFVIIa) therapy?

• The routine use of rFVIIa is not recommended in the management of major PPH unless as part of a clinical trial. [New 2016]

Monitoring and investigation in major PPH: what investigations should be performed and how should women be monitored?

Full protocol for monitoring and investigation in major PPH (blood loss greater than 1000 ml) and ongoing haemorrhage or clinical shock:

1.immediate venepuncture (20 ml) for:

• cross-match (4 units minimum)
• full blood count
• coagulation screen, including fibrinogen
• renal and liver function for baseline

2.monitor temperature every 15 minutes

3.continuous pulse, blood pressure recording and respiratory rate (using oximeter,

electrocardiogram and automated blood pressure recording)

4.Foley catheter to monitor urine output

5.two peripheral cannulae, 14 gauge

6.consider arterial line monitoring (once appropriately experienced staff available for insertion)

7.consider transfer to intensive therapy unit once the bleeding is controlled or monitoring at high dependency unit on delivery suite, if appropriate

8.recording of parameters on a modified early obstetric warning score (MEOWS) chart (see Appendix IV)

9.acting and escalating promptly when abnormal scores from a MEOWS chart are observed

10.documentation of fluid balance, blood, blood products and procedures.

What is the role of the anaesthetist in the management of PPH?

• The management of PPH requires a multidisciplinary approach:
  • the anaesthetist plays a crucial role in maintaining haemodynamic stability and, if necessary, in determining and administering the most appropriate method of anaesthesia. [New 2016] D

What methods should be employed to arrest the bleeding?

• Clinicians should be prepared to use a combination of pharmacological, mechanical and surgical methods to arrest PPH.
• These methods should be directed towards the causative factor. [New 2016] D

What pharmacological and mechanical strategies can be used?

• When uterine atony is perceived to be a cause of the bleeding, then a sequence of mechanical and pharmacological measures should be instituted in turn until the bleeding stops.

What surgical treatments can be employed to arrest the bleeding?

• If pharmacological measures fail to control the haemorrhage, surgical interventions should be initiated sooner rather than later. D
• Intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage. C
• Conservative surgical interventions may be attempted as second line, depending on clinical circumstances and available expertise. C
• It is recommended that a laminated diagram of the brace suture technique be kept in theatre.
• Resort to hysterectomy sooner rather than later (especially in cases of placenta accreta or uterine rupture). C
• Ideally and when feasible, a second experienced clinician should be involved in the decision for hysterectomy.

How should secondary PPH be managed?

• In women presenting with secondary PPH, an assessment of vaginal microbiology should be performed (high vaginal and endocervical swabs) and appropriate use of antimicrobial therapy should be initiated when endometritis is suspected. [New 2016] D
• A pelvic ultrasound may help to exclude the presence of retained products of conception, although the diagnosis of retained products is unreliable. [New 2016] C
• Surgical evacuation of retained placental tissue should be undertaken or supervised by an experienced clinician. D

Risk management

• Every maternity unit should have a multidisciplinary protocol for the management of PPH. [New 2016]
• All staff involved in maternity care should receive training in the management of obstetric emergencies, including the management of PPH. B
• Training for PPH should be multiprofessional and include team rehearsals. [New 2016] B
• All cases of PPH involving a blood loss of greater than 1500 ml should be the subject of a formal clinical incident review.

Documentation

• Accurate documentation of a delivery with PPH is essential.

Debriefing

• An opportunity to discuss the events surrounding the obstetric haemorrhage should be offered to the woman (possibly with her birthing partner/s) at a mutually convenient time.

 Introduction

• The traditional definition of primary PPH is the loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby.
• PPH can be minor (500–1000 ml) or major (more than 1000 ml). Major can be further subdivided into
• moderate (1001–2000 ml) and severe (more than 2000 ml).
• Secondary PPH is defined as abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postnatally.
• PPH as related to abnormalities of one or more of four basic processes – ‘the four Ts’: tone, trauma, tissue and thrombin.
• The most common cause of PPH is uterine atony

Risk factor	The four Ts	OR (95% CI)
Multiple pregnancy	Tone	3.30 (1.00–10.60)16 4.70 (2.40–9.10)24
Previous PPH	Tone	3.60 (1.20–10.20)16
Pre-eclampsia	Thrombin	5.00 (3.00–8.50)16 2.20 (1.30–3.70)31
Fetal macrosomia	Tone	2.11 (1.62–2.76)20 2.40 (1.90–2.90)24
Failure to progress in second stage	Tone	3.40 (2.40–4.70)23 1.90 (1.20–2.90)31
Prolonged third stage of labour	Tone	7.60 (4.20–13.50)16 2.61 (1.83–3.72)20
Retained placenta	Tissue	7.83 (3.78–16.22)20 3.50 (2.10–5.80)23 6.00 (3.50–10.40)24
Placenta accrete	Tissue	3.30 (1.70–6.40)23
Episiotomy	Trauma	4.70 (2.60–8.40)16 2.18 (1.68–2.76)20 1.70 (1.20–2.50)24
Perineal laceration	Trauma	1.40 (1.04–1.87)20 2.40 (2.00–2.80)23 1.70 (1.10–2.50)24
General anaesthesia	Tone	2.90 (1.90–4.50)31

• It is recommended that parenteral iron therapy should be considered antenatally for women with iron deficiency anaemia who do not respond to oral iron
• These have established that both active management and the use of prophylactic uterotonics in the third stage of labour reduce the risk of PPH
• However, active management results in a lower birthweight, reflecting a lower blood volume from early cord clamping.
• delaying clamping for at least 2 minutes is beneficial to the newborn and that the benefits extend into infancy.
• delaying clamping for at least 2 minutes is beneficial to the newborn and that the benefits extend into infancy.
• This review indicated that ergometrine–oxytocin (Syntometrine_, Alliance, Chippenham, Wiltshire, UK), oxytocin 5 iu and oxytocin 10 iu have similar efficacy in preventing PPH in excess of 1000 ml.
• Using the definition of PPH as blood loss of at least 500 ml, ergometrine–oxytocin was associated with a small reduction in the risk of PPH (Syntometrine_ versus oxytocin any dose; OR 0.82, 95% CI 0.71–0.95).
• There were major differences between ergometrine–oxytocin and oxytocin alone in the adverse effects of nausea and vomiting, and elevation of blood pressure, with ergometrine–oxytocin carrying a five-fold increased risk.
• An RCT Compared with 10 iu, administering 40 iu or 80 iu of prophylactic oxytocin did not reduce overall PPH treatment when given in 500 ml over 1 hour for vaginal delivery. 1+

Prostaglandins

• two Cochrane reviews
• Neither intramuscular prostaglandins (such as carboprost, a 15-methyl prostaglandin F2a analogue) nor misoprostol (a prostaglandin E1 analogue given orally or sublingually) were preferable to conventional injectable uterotonics (oxytocin and/or ergometrine) for routine prophylaxis.
• oxytocin is superior to misoprostol in the prevention of PPH

Carbetocin

• longer-acting oxytocin derivative
• Carbetocin is licensed in the UK specifically for the indication of prevention of PPH in the context of caesarean delivery.
• statistically significant reduction in the need for further uterotonics compared with oxytocin for those undergoing a caesarean.
• statistically significant reduction in the need for further uterotonics compared with oxytocin for those undergoing a caesarean.
•  carbetocin (100 micrograms given as an intravenous bolus over 1 minute) should be used for the prevention of PPH in elective caesarean deliveries.

Tranexamic acid

• Tranexamic acid was effective in decreasing the incidence of blood loss greater than 1000 ml in women who had undergone caesarean section (RR 0.43, 95% CI 0.23–0.78; four studies; 1534 women), but not vaginal birth
• As visual estimation often underestimates blood loss, more accurate methods may be used, such as blood collection drapes for vaginal deliveries and the weighing of swabs.
• the physiological increase in circulating blood volume during pregnancy means that the signs of hypovolaemic shock become less sensitive in pregnancy
• In pregnancy, pulse and blood pressure are usually maintained in the normal range until blood loss exceeds 1000 ml; tachycardia, tachypnoea and a slight recordable fall in systolic blood pressure occur with blood loss of 1000–1500 ml.
• A systolic blood pressure below 80 mmHg, associated with worsening tachycardia, tachypnoea and altered mental state, usually indicates a PPH in excess of 1500 ml.
• A retrospective cohort study concluded
  • that the shock index identifies women at risk of adverse outcomes secondary to PPH
• in major PPH, the following members of staff should be called and summoned to attend:

_ an experienced midwife (in addition to the midwife in charge)

_ the obstetric middle grade

_ the anaesthetic middle grade

_ the on-call clinical haematologist with experience in major haemorrhage

_ porters for delivery of specimens/blood.

• Furthermore, the consultant obstetrician and consultant anaesthetist should be alerted, and the blood transfusion
• laboratory should be informed.

Crystalloid		Up to 2 l isotonic crystalloid.
Colloid		Up to 1.5 l colloid until blood arrives.
Blood		If immediate transfusion is indicated, give emergency group O, rhesus D (RhD)-negative, K-negative red cell units. Switch to group-specific red cells as soon as feasible.
Fresh frozen plasma (FFP)		Administration of FFP should be guided by haemostatic testing and whether haemorrhage is continuing: If prothrombin time (PT) or activated partial thromboplastin time (APTT) are prolonged and haemorrhage is ongoing, administer 12–15 ml/kg of FFP. If haemorrhage continues after 4 units of red blood cells (RBCs) and haemostatic tests are unavailable, administer 4 units of FFP.
Platelet concentrates		Administer 1 pool (300ml) of platelets if haemorrhage is ongoing and platelet count less than 75 9 109/l.
Cryoprecipitate		Administer 2 pools (10 units) of cryoprecipitate if haemorrhage is ongoing and fibrinogen less than 2 g/l.

Crystalloid		Up to 2 l isotonic crystalloid.
Colloid		Up to 1.5 l colloid until blood arrives.
Blood		If immediate transfusion is indicated, give emergency group O, rhesus D (RhD)-negative, K-negative red cell units. Switch to group-specific red cells as soon as feasible.
Fresh frozen plasma (FFP)		Administration of FFP should be guided by haemostatic testing and whether haemorrhage is continuing: If prothrombin time (PT) or activated partial thromboplastin time (APTT) are prolonged and haemorrhage is ongoing, administer 12–15 ml/kg of FFP. If haemorrhage continues after 4 units of red blood cells (RBCs) and haemostatic tests are unavailable, administer 4 units of FFP.
Platelet concentrates		Administer 1 pool (300ml) of platelets if haemorrhage is ongoing and platelet count less than 75 9 109/l.
Cryoprecipitate		Administer 2 pools (10 units) of cryoprecipitate if haemorrhage is ongoing and fibrinogen less than 2 g/l.

A high concentration of oxygen (10–15 l/min) via a facemask should be administered, regardless of maternal oxygen concentration.

main therapeutic goals of the management of massive blood loss as maintaining:

_ Hb greater than 80 g/l

_ platelet count greater than 50 9 109/l

_ prothrombin time (PT) less than 1.5 times normal

_ activated partial thromboplastin time (APTT) less than 1.5 times normal

_ fibrinogen greater than 2 g/l.

• Traditionally, a total volume of 3.5 l of clear fluids (up to 2 l of warmed isotonic crystalloid as rapidly as possible, followed by up to a further 1.5 l of warmed colloid if blood is still not available) comprises the maximum that should be infused while awaiting compatible packed red cells.
• Cochrane review concluded that resuscitation with colloids was not associated with an improvement in survival and that the use of one particular colloid, hydroxyethyl starch, might increase mortality.

Blood transfusion

• The aim of antibody screening is to determine the presence of red cell antibodies of likely clinical significance.
  • risk of haemolytic disease of the fetus and newborn
  • risk of haemolytic transfusion reactions.
• In elective transfusion in the antenatal period,
  • CMV-seronegative products should be used to avoid transmission of CMV to the fetus
• In an emergency, such as PPH, standard leucocyte-depleted components should be given to avoid delay, and CMV-negative blood or platelets are not needed for transfusion during delivery or in the postpartum period.
• Intraoperative cell salvage (the process whereby blood shed during an operation is collected, filtered and washed to produce autologous red blood cells [RBCs] for transfusion to the patient) is commonly being used, Several bodies have endorsed cell salvage in obstetric practice.
  • should be considered for emergency use in PPH associated with both caesarean section and vaginal delivery(SALVO study on progress).
• Routine coagulation tests are widely available and have well-regulated quality control.
  • They include PT,APTT, Clauss fibrinogen assay and platelet count.
• However, turnaround times are often too slow to be clinically useful in acute and rapidly evolving bleeds, and inevitably reflect the past haemostatic status of the woman.
• Clauss fibrinogen should always be measured as part of the routine coagulation screen because it falls early and may be reduced to a clinically significant level despite a normal PT/APTT.
• Platelet number should be measured as part of the full blood count. Point of care testing using viscoelastometry, such as thromboelastography  and rotational thromboelastometry
• The main advantage is that results are known sooner than for laboratory tests.
• However,NICE has concluded that there is insufficient evidence to recommend the routine adoption of viscoelastometric point of care testing in the management of PPH.
• If used, a quality control protocol  should be agreed with the haematology laboratory.
• The drawbacks of early FFP are that
  • the majority of women with PPH will have normal coagulation at the time of administration,
  •  it is associated with an increased risk of transfusion-associated circulatory overload (TACO)100 and transfusion-related acute lung injury.
• FFP results in relatively small increments in fibrinogen level, and to increase the level rapidly, cryoprecipitate or fibrinogen concentrate are required
• PT/APTT greater than 1.5 times normal demonstrate that severe and established haemostatic impairment has occurred
• FFP should be infused at a dose of 12–15 ml/kg and 6:4 RBC:FFP transfusion
  • maintained until tests of haemostasis are available
• Fibrinogen below 3 g/l and especially below 2 g/l is associated with progression of bleeding, increased RBC and blood component requirements, and the need for invasive procedures
• Platelets should be transfused at a trigger of 75 X 10⁹/l to maintain a level greater than 50 X 10⁹/l during ongoing PPH.

recombinant factor VIIa (rFVIIa) therapy

• reduces blood loss through enhancement of tissue factor-dependent coagulation.
  •  Its effectiveness is markedly diminished by hypothermia, acidosis and low platelets, so effective resuscitation towards normal physiology is a prerequisite of its use
  • It is also important that once the bleeding is arrested and any coagulopathy is corrected, chemical thromboprophylaxis is administered, as there is a high risk of thrombosis.
  •  Alternatively, anti-embolism stockings, foot impulse devices or intermittent pneumatic compression devices can be used if chemical thromboprophylaxis is contraindicated, for example, in cases of thrombocytopenia

pharmacological and mechanical strategies

• _ palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)
  • _ ensure that the bladder is empty (Foley catheter, leave in place)
  • _ oxytocin 5 iu by slow intravenous injection (may have repeat dose)
  • _ ergometrine 0.5 mg by slow intravenous or intramuscular injection (contraindicated in women with hypertension)
  • _ oxytocin infusion (40 iu in 500 ml isotonic crystalloids at 125 ml/hour) unless fluid restriction is necessary
  • _ carboprost 0.25 mg by intramuscular injection repeated at intervals of not less than 15 minutes to a maximum of eight doses (use with caution in women with asthma)
  • _ misoprostol 800 micrograms sublingually.
• If bleeding occurs at the time of caesarean section, intramyometrial injection of
  • carboprost may be used (although not licensed). It is also possible to inject intramyometrial carboprost through the abdominal wall in the absence of laparotomy.
  •  The recommended dose is 250 micrograms intramuscularly.
  • This may be repeated every 15 minutes to a total dose of 2 mg (eight doses). However,
  •  if significant atonic haemorrhage continues after a third dose of carboprost, without significant improvement (i.e. 30 minutes or more after the first dose was given), the team should consider transfer to the operating theatre for examination under anaesthesia.
  • International Federation of Gynecology and Obstetrics recommend that in the management of PPH, misoprostol is administered sublingually.
  • Compression of the aorta may be a temporary but effective measure to allow time for resuscitation to catch up with the volume replacement and the appropriate surgical support to arrive

Uterine balloon tamponade

• Tamponade using various types of hydrostatic balloon catheter has superseded uterine packing for the control of atonic PPH.
  •  Case series have used a Foley catheter, Bakri balloon, Sengstaken– Blakemore oesophageal catheter and a condom catheter.
  • The urological Rusch balloon has been described as preferable by virtue of larger capacity, ease of use and low cost
  • A Scottish study-balloon tamponade was employed, successfully avoiding hysterectomy in 75 (91%) women.
  • This success rate is of the same order as that reported in other case series

Haemostatic suturing

• Double vertical compression sutures have proved effective in treating PPH due to atony and placenta praevia.
  • This may have a dual action of reducing uterine blood flow and compressing the bleeding surface.
  • the overall failure rate of sutures leading to hysterectomy was 25%.
  •  There was no difference in failure rate among B-Lynch, modified B-Lynch and other suture techniques.
  • A systematic review has concluded that compression sutures are associated with a low complication rate.
  • A higher risk of uterine ischaemia appeared to be caused when the procedure was combined with vessel ligation.
  •  No negative impact on fertility has been reported.
  • Case series have reported the combined use of haemostatic suturing and balloon tamponade in the management of PPH
• Stepwise uterine devascularisation and internal iliac artery ligation
  • Stepwise uterine devascularisation describes the successive ligation of
    •  (i) one uterine artery,
    • (ii) both uterine arteries,
    • (iii) low uterine arteries,
    •  (iv) one ovarian artery and
    •  (v) both ovarian arteries, in the
      • management of PPH.
  • this technique requires a high degree of surgical skill and training, and may be associated with ureteric injury
  • following internal iliac artery ligation suggests that subsequent fertility and pregnancy outcomes are not impaired (EVI 3)
• Selective arterial occlusion or embolisation by interventional radiology
• Hysterectomy
  • The decision for hysterectomy should be made by an experienced consultant clinician and the decision
  • preferably discussed with a second experienced clinician when feasible.29 Early recourse to hysterectomy is recommended, especially where bleeding is associated with placenta accreta or uterine rupture.
  • Hysterectomy should not be delayed until the woman is in extremis or while less definitive procedures  with which the surgeon has little experience are attempted.

How should secondary PPH be managed

• The causes of secondary PPH are numerous and include endometritis, RPOC and subinvolution of the placental implantation site
  • This review concluded that a combination of clindamycin and gentamicin is appropriate,and that once uncomplicated endometritis has clinically improved with intravenous therapy, there is no additional benefit from further oral therapy

It is important to record:

• _ the staff in attendance and the time they arrived
  • _ the sequence of events
  • _ the administration of different pharmacological agents, their timing and sequence
  • _ the time of surgical intervention, where relevant
  • _ the condition of the mother throughout the different steps
  • _ the timing of the fluid and blood products given.

The four Ts	Risk factors/notes
Tone: abnormalities of uterine contraction Overdistension of uterus	Polyhydramnios, multiple gestation, macrosomia
Intra-amniotic infection	Fever, prolonged rupture of membranes
Functional/anatomic distortion of uterus	Rapid labour, prolonged labour, fibroids, placenta praevia, uterine anomalies
Uterine relaxants, e.g. magnesium and nifedipine	Terbutaline, halogenated anaesthetics, glyceryl trinitrate
Bladder distension	May prevent uterine contraction
Tissue: retained products of conception Retained cotyledon or succenturiate lobe Retained blood clots Trauma: genital tract injury Lacerations of the cervix, vagina or perineum	Precipitous delivery, operative delivery
Extensions, lacerations at caesarean section	Malposition, deep engagement
Uterine rupture	Previous uterine surgery
Uterine inversion	High parity with excessive cord traction
Thrombin: abnormalities of coagulation Pre-existing states Haemophilia A	History of hereditary coagulopathies or liver disease
Idiopathic thrombocytopenic purpura	Bruising
von Willebrand’s disease History of previous PPH Acquired in pregnancy Gestational thrombocytopenic	Bruising
Pre-eclampsia with thrombocytopenia e.g. HELLP	Elevated blood pressure
Disseminated intravascular coagulation a) Gestational hypertensive disorder of pregnancy with adverse conditions	Coagulopathy
b) in utero fetal demise	Fetal demise
c) severe infection	Fever, neutrophilia/neutropenia
d) abruption	Antepartum haemorrhage
e) amniotic fluid embolus	Sudden collapse
Therapeutic anticoagulation	History of thromboembolic disease

The four Ts	Risk factors/notes
Tone: abnormalities of uterine contraction Overdistension of uterus	Polyhydramnios, multiple gestation, macrosomia
Intra-amniotic infection	Fever, prolonged rupture of membranes
Functional/anatomic distortion of uterus	Rapid labour, prolonged labour, fibroids, placenta praevia, uterine anomalies
Uterine relaxants, e.g. magnesium and nifedipine	Terbutaline, halogenated anaesthetics, glyceryl trinitrate
Bladder distension	May prevent uterine contraction
Tissue: retained products of conception Retained cotyledon or succenturiate lobe Retained blood clots Trauma: genital tract injury Lacerations of the cervix, vagina or perineum	Precipitous delivery, operative delivery
Extensions, lacerations at caesarean section	Malposition, deep engagement
Uterine rupture	Previous uterine surgery
Uterine inversion	High parity with excessive cord traction
Thrombin: abnormalities of coagulation Pre-existing states Haemophilia A	History of hereditary coagulopathies or liver disease
Idiopathic thrombocytopenic purpura	Bruising
von Willebrand’s disease History of previous PPH Acquired in pregnancy Gestational thrombocytopenic	Bruising
Pre-eclampsia with thrombocytopenia e.g. HELLP	Elevated blood pressure
Disseminated intravascular coagulation a) Gestational hypertensive disorder of pregnancy with adverse conditions	Coagulopathy
b) in utero fetal demise	Fetal demise
c) severe infection	Fever, neutrophilia/neutropenia
d) abruption	Antepartum haemorrhage
e) amniotic fluid embolus	Sudden collapse
Therapeutic anticoagulation	History of thromboembolic disease

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