Prehospital Management Of Postpartum Haemorrhage

Postpartum haemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality worldwide, and its prompt recognition and management are crucial in the management of postpartum haemorrhage. 

Both primary and secondary postpartum haemorrhage demand immediate intervention, often in time-critical situations. This article outlines the key aspects of  prehospital management of postpartum haemorrhage, focusing on the practical steps that paramedics can take to stabilise patients while enroute to the hospital.

Postpartum Haemorrhage Classifications

PPH is typically classified into two categories:

• Primary PPH: Defined as blood loss of 500 mL or more within 24 hours following childbirth. However, any blood loss that results in clinical signs of hypovolaemic shock, regardless of the volume, should also be considered PPH.
• Secondary PPH: Occurs between 24 hours and 6 weeks postpartum. In the prehospital environment, it’s crucial to be aware of clinical signs like a maternity sanitary pad soaking within 30 minutes, which can signal significant blood loss.

Regardless of the type of PPH, the prehospital management of postpartum haemorrhage is the same. It is essential to ensure all steps are completed to provide effective care.

Postpartum Haemorrhage Severity

Postpartum haemorrhage severity can vary, and recognising the degree of blood loss is critical:

• Minor PPH: 500–1000 mL blood loss
• Moderate PPH: 1000–2000 mL blood loss.
• Severe PPH: >2000 mL blood loss, often requiring immediate, aggressive intervention.

Estimating blood loss in the field can be challenging, and it’s frequently underestimated. Clinicians must rely not only on visible blood loss but also on the clinical signs of hypovolaemic shock such as tachycardia, hypotension, and altered mental state.

Pathophysiology Of Postpartum Haemorrhage 

The underlying causes of PPH can be remembered as the Four T’s, however the cause of PHH does not change the prehospital management of postpartum haemorrhage.

Tone (Uterine Atony): This is the most common cause of PPH, accounting for around 70% of cases. A loss of uterine muscle tone leads to continued bleeding from the placental bed. Risk factors include prolonged labour, multiple pregnancies, and a ‘baggy’ uterus.

Trauma: Genital tract tears, uterine rupture, and episiotomy are common trauma-related causes.

Tissue: Retained placenta, placenta accreta, and blood clots can prevent the uterus from contracting effectively.

Thrombin: Coagulopathies, either pre-existing or resulting from severe haemorrhage, impair the body’s ability to form clots and stop bleeding.

Postpartum Haemorrhage Risk Factors

Several factors predispose a patient to PPH, and these can be divided into antepartum (period before childbirth) and intrapartum (period during labour) causes: 

Prehospital Management of Postpartum Haemorrhage – Immediate Actions 

As soon as PPH is suspected, follow prehospital management of postpartum haemorrhage local guidelines to call for senior obstetric, midwifery, and anaesthetic support. Early intervention by a multidisciplinary team improves maternal outcomes.

Airway/Breathing – Administer high-flow oxygen to maintain tissue oxygenation.

Circulation  – Large-bore IV cannulation (14G or 16G) should be used

Prehospital Management of Postpartum Haemorrhage – Specific Actions 

This is the first step in prehospital management of postpartum haemorrhage is managing uterine atony (failure of the uterus to contract) is manual uterine massage which may stop the postpartum haemorrhage.

How To Perform Uterine Message

1. Palpate the Abdomen: Gently feel for the top of the uterus (the fundus).
2. Assess Uterine Size/Height: If the uterus is below the level of the umbilicus, the tone is likely to be good.
3. Assess Uterine Tone: The uterus should feel firm, similar to a cricket ball. If a firm, central structure cannot be felt at or below the umbilicus, assume poor tone and begin uterine massage.
4. Commence Uterine Massage: Use a cupped hand to gently massage the uterus in a circular motion.

During massage, the uterus should become firm. Provide pain relief as needed. Initially, some PV bleeding or clots may be observed as the uterus contracts. Continue massaging while monitoring PV blood loss, which should reduce over time.

Where uterine tone is poor or bleeding occurs, it is ideal for one clinician to be dedicated to performing the massage. Keep your hand in place to detect any relaxation in tone, and resume massage if poor tone or bleeding persists.

Note: If there is any specific reason to suspect another fetus is in the uterus, do not administer any uterotonics or perform uterine massage in prehospital management of postpartum haemorrhage.

‘Uterotonics’ are essential in controlling uterine bleeding by inducing contractions. Commonly used drugs include:

Syntometrine: A combination of oxytocin and ergometrine.

Misoprostol: A prostaglandin analogue that can be administered rectally if intravenous access is not feasible.

Carbetocin: Used in some ambulance services as an alternative to Syntometrine.

It’s vital to administer uterotonics one at a time in the prehospital management of postpartum haemorrhage if multiple are available, monitoring the response before moving on to the next drug. If the haemorrhage is catastrophic, rapid administration of multiple uterotonics can be given in quick succession.

Note: If there is any specific reason to suspect another fetus is in the uterus, do not administer any uterotonics or perform uterine massage in prehospital management of postpartum haemorrhage.

Tranexamic acid, an antifibrinolytic agent, should be administered as soon as possible and within three hours of the onset of PPH to reduce blood loss.

Administer TXA intravenously if possible. However, intramuscular administration can be considered if IV access cannot be obtained for the prehospital management of postpartum haemorrhage

TXA administration should not delay transportation to the hospital, and it can be given while enroute.

Hypovolaemic shock is a significant risk in PPH. Maintaining systolic blood pressure at 90 mmHg with fluid replacement is crucial to prevent shock and organ damage. Large-bore IV cannulation (14G or 16G) should be used to ensure rapid fluid administration, but if access is difficult, prioritise transportation to definitive care.

The above prehospital management of postpartum haemorrhage can be used regardless of whether the placenta has delivered or not.

If the baby is well, leave the cord intact until it has turned white or for at least 60 seconds after birth. However, in the event of a PPH, the cord may be clamped and cut earlier if needed to facilitate the management of the haemorrhage.

Avoid pulling on the cord or placenta before it has naturally delivered. If the placenta does deliver, place it in an appropriate clinical waste bag and transport it to the hospital.

Do not delay on scene waiting for the placenta to deliver if a PPH is occurring. Instead, initiate a time-critical transfer to the hospital following local guidelines, with an early pre-alert.

Once the initial interventions are in place, undergo a time critical conveyance to hospital and provide a pre-alert starting ‘postpartum haemorrhage’.

Continuously monitor vital signs, assessing for hypovolaemia and providing further interventions as required. Continue to estimate blood loss.

If there is an external tear, apply direct pressure with swabs to control bleeding.

Transport the patient in a supine position, ensuring constant monitoring of uterine tone and continued uterine massage if necessary.

Provide emotional support to the patient and the family, as PPH is a highly distressing event.

Bimanual Compression

In cases of catastrophic haemorrhage where uterine massage and uterotonics fail, bimanual compression may be indicated. This is an internal manoeuvre typically performed by trained paramedics or medical staff and is reserved for severe cases. Always follow local guidelines regarding the performance of this technique.

JRCALC Flowchart

Conclusion

Effective prehospital management of postpartum haemorrhage is vital for improving maternal outcomes. Early recognition, uterine massage, timely administration of uterotonics and TXA, and fluid resuscitation can significantly reduce the severity of haemorrhage. In all cases, it is important to seek senior clinical support and transport the patient promptly to a facility capable of managing this life-threatening condition.

Key Points

Bibliography

Chandraharan, E. and Krishna, A. (2017). Diagnosis and management of postpartum haemorrhage. BMJ https://doi.org/10.1136/bmj.j3875