Postpartum Haemorrhage Nursing Guide

PPH Definition and Classification

Definitions

Type	Definition	Timing
Primary PPH	Blood loss ≥500 mL within 24 hours of vaginal delivery OR ≥1000 mL after caesarean section	Within 24 hours of delivery
Major PPH	>1000 mL (moderate major) or >2000 mL (severe major)	Within 24 hours
Secondary PPH	Abnormal bleeding from 24 hours to 12 weeks postpartum	24 hrs – 12 weeks

PPH is the leading cause of maternal death globally — occurring every 7 seconds somewhere in the world. Early recognition and systematic treatment saves lives.

Risk Factors

Category	Risk Factors
Antenatal	Grand multiparity (≥5), multiple pregnancy, polyhydramnios, placenta praevia, placenta accreta spectrum, pre-eclampsia, antepartum haemorrhage, anaemia, obesity, uterine fibroids, previous PPH or uterine surgery
Intrapartum	Prolonged labour, instrumental delivery (forceps/ventouse), caesarean section, precipitate labour, shoulder dystocia, chorioamnionitis, general anaesthesia
Maternal	Coagulopathy (von Willebrand, thrombocytopenia), anticoagulation therapy, uterine malformations

The 4 Ts Framework

Systematic approach to identifying PPH causes — every PPH should be worked through the 4 Ts methodically.

🅃 Tone (70–80% of PPH)

Uterine atony — the uterus fails to contract after delivery, leaving placental bed blood vessels open.

Assess: uterus feels boggy, soft, poorly contracted on palpation
Signs: heavy continuous bleeding, uterine fundus above umbilicus
Nursing action: bimanual uterine massage, uterotonic drugs, bladder emptying (full bladder prevents uterine contraction)

🅃 Tissue (10%)

Retained products of conception — placenta or membranes not fully delivered, preventing uterus from fully contracting.

Assess: placenta inspection (cotyledons, membranes complete?), ultrasound
Management: manual removal of placenta under anaesthesia, surgical evacuation
Secondary PPH — retained products most common cause

🅃 Trauma (10–20%)

Genital tract lacerations, uterine rupture or inversion.

Inspect: perineum, vagina, cervix systematically under good lighting
Cervical lacerations: caused by rapid descent, instrumental delivery
Uterine rupture: emergency laparotomy
Uterine inversion: do not remove placenta if attached; immediate reduction

🅃 Thrombin (1%)

Coagulopathy — pre-existing (haemophilia, von Willebrand) or acquired (DIC from PPH, abruption, pre-eclampsia, AFE).

Signs: oozing from IV sites, gums, wound; blood not clotting
Investigations: FBC, fibrinogen (target >2 g/L), APTT, PT, thromboelastography (TEG)
Management: FFP, cryoprecipitate (fibrinogen), platelets, TXA, Factor VIIa in refractory cases

PPH Management Protocol

Call for help immediately. PPH is a time-critical obstetric emergency. Activate massive obstetric haemorrhage protocol if blood loss >1000 mL or clinically shocked.

Immediate Actions — ABC + Uterotonic

Call for help: Senior midwife, obstetrician, anaesthetist, haematologist
Airway/Breathing: Oxygen 15 L/min via non-rebreather mask; consider early intubation if compromised
IV access: Two large-bore (14G) cannulas; take bloods (FBC, G&S × 4 units, coag, fibrinogen, U&E)
Fluid resuscitation: Hartmann's/saline; avoid excessive crystalloid (worsens dilutional coagulopathy); prepare blood products
Uterotonic: Oxytocin 10 IU IV slowly (or IM) first line; massage uterus
Catheterise: IDC with hourly measurement; target ≥30 mL/hr
Keep warm: Hypothermia worsens coagulopathy; warm IV fluids, blankets
Tranexamic acid (TXA): 1 g IV over 10 min WITHIN 3 HOURS of delivery — repeat once if bleeding continues

Massive Transfusion Protocol (MTP)

Activate if blood loss >2500 mL or haemodynamically shocked. Target ratio: 1:1:1 (pRBC : FFP : platelets).

Blood Product	Target
Packed red blood cells (pRBC)	Haemoglobin >80 g/L (some centres 70 g/L)
Fresh frozen plasma (FFP)	PT/APTT <1.5× normal
Cryoprecipitate	Fibrinogen >2 g/L (obstetric target)
Platelets	>75 × 10⁹/L (some centres >50)
Calcium (calcium gluconate 10%)	After 4+ units pRBC — citrate in blood products chelates calcium

Surgical Interventions (Escalation)

Uterine balloon tamponade — Bakri balloon or condom catheter; first-line surgical haemostasis
Uterine compression sutures (B-Lynch, Cho)
Internal iliac artery ligation
Interventional radiology — uterine artery embolisation (UAE) — preferred if patient stable and radiology available (GCC major centres)
Hysterectomy — last resort; life-saving in uncontrolled PPH

Uterotonic Drug Guide

Step-Up Uterotonic Protocol

Drug	Dose	Route	Notes / Contraindications
Oxytocin (Syntocinon)	10 IU slow IV push; then 40 IU in 500 mL at 125 mL/hr	IV / IM	First line; causes hypotension if given as rapid IV bolus — give slowly. NOT with hypotension. Infusion for sustained effect
Ergometrine (Syntometrine)	0.5 mg IM or slow IV	IM / IV	Causes vasoconstriction — contraindicated in hypertension, pre-eclampsia, cardiac disease. Very effective for uterine atony
Carboprost (Hemabate)	250 mcg IM every 15 min (max 8 doses = 2 mg)	IM	PGF2α analogue; contraindicated in asthma; causes bronchospasm, flushing, diarrhoea
Misoprostol	800–1000 mcg rectally or 600 mcg sublingually	PR / SL / buccal	Useful if no IV access; thermostable — valuable in resource-limited settings; causes shivering, pyrexia
Tranexamic acid (TXA)	1 g IV over 10 min; repeat once if bleeding continues within 24 hrs	IV	Antifibrinolytic; reduces maternal death by 30% when given within 3 hours of delivery (WOMAN Trial). Give early.

WOMAN Trial (2017): TXA 1g IV within 3 hours of delivery → 30% reduction in mortality from PPH. Must be given within 3 hours — after this, no benefit and possible increased risk of thromboembolic events.

GCC-Specific Context

PPH Risk in GCC Populations

Grand multiparity: Higher fertility rates in GCC (especially KSA, Kuwait, Oman) — gravida 6, 7, 8 presentations are more common than in Western practice. Grand multiparity is a major uterine atony risk factor
Placenta praevia/accreta: Higher caesarean section rates in GCC (30–50% in some centres) → increasing placenta accreta spectrum disorder (PAS/MAP) — requires specialist MDT management, interventional radiology, cell salvage availability
Iron deficiency anaemia: Pre-existing anaemia worsens PPH tolerance — GCC programmes screen and treat iron deficiency in pregnancy. Many GCC patients present with Hb 80–90 g/L at delivery
Consanguinity: Higher rates of von Willebrand disease, platelet disorders and hereditary coagulopathies in consanguineous GCC families — pre-pregnancy haematology screening important
Religious considerations: Blood transfusion — Jehovah's Witness patients require advance care planning; cell salvage and pharmacological alternatives should be pre-planned. Most GCC Muslim patients accept blood transfusion as life-saving treatment under Islamic bioethical principles

Exam Tips

PPH definition: ≥500 mL vaginal, ≥1000 mL caesarean
Most common cause: uterine atony (Tone) — 70–80%
First-line uterotonic: oxytocin 10 IU IV/IM
TXA within 3 hours — WOMAN trial; reduces mortality by 30%
Ergometrine contraindicated in hypertension and pre-eclampsia
Carboprost contraindicated in asthma
Secondary PPH: 24 hrs – 12 weeks; most common cause = retained products

Exam MCQs — DHA / SCFHS / QCHP

Q1. A patient has a postpartum haemorrhage after a normal vaginal delivery. The uterus is palpated and feels soft, large and boggy. What is the MOST LIKELY cause and first action?

A) Retained placenta — perform manual placenta removal B) Uterine atony — administer oxytocin and perform uterine massage C) Coagulopathy — administer FFP and cryoprecipitate D) Genital tract laceration — inspect perineum under lighting

✅ B — A soft, boggy uterus indicates uterine atony — the most common PPH cause (70–80%). First actions: uterine massage (bimanual compression), oxytocin 10 IU IV slowly, ensure bladder is empty (full bladder prevents contraction). A contracted, firm uterus suggests other causes.

Q2. A midwife is about to administer ergometrine 0.5 mg IM to a patient with PPH. The patient's BP is 165/105 mmHg. What should the midwife do?

A) Administer as ordered — PPH control is the priority B) Withhold ergometrine — it is contraindicated in hypertension; use an alternative uterotonic C) Halve the dose to 0.25 mg — safer in hypertensive patients D) Administer IV instead of IM to reduce vasoconstriction effect

✅ B — Ergometrine causes vasoconstriction and is CONTRAINDICATED in hypertension, pre-eclampsia and cardiac disease. Use carboprost (if not asthmatic), misoprostol or further oxytocin. Administering ergometrine to a hypertensive patient risks hypertensive crisis, cerebrovascular accident or cardiac ischaemia.

Q3. Tranexamic acid (TXA) is ordered for a patient with PPH 2.5 hours after delivery. Blood loss is 900 mL. What is the CORRECT dose and route?

A) 500 mg orally — oral route is acceptable B) 1 g IV over 10 minutes C) 2 g IV bolus over 1 minute for rapid effect D) TXA is only indicated after 3 hours — withhold at this point

✅ B — TXA 1 g IV over 10 minutes (NOT as a rapid bolus — seizure risk). Must be given within 3 hours of delivery. The WOMAN trial showed 30% reduction in maternal death from bleeding when given early. At 2.5 hours, it is still within the window and should be given promptly.

Q4. A woman presents 10 days after delivery with heavy vaginal bleeding, fever (38.8°C) and uterine tenderness. What is the MOST LIKELY diagnosis?

A) Primary PPH — she should have been treated in hospital B) Secondary PPH with endometritis and/or retained products — requires antibiotic therapy and possible surgical evacuation C) Lochia rubra — normal red discharge at 10 days D) Acute appendicitis mimicking PPH

✅ B — Secondary PPH (24 hours to 12 weeks postpartum) with fever and uterine tenderness = endometritis ± retained products of conception. Management: IV antibiotics (broad spectrum), ultrasound to exclude retained products, surgical evacuation (ERPC) if confirmed. This is a medical emergency — sepsis risk is significant.

🩸 Postpartum Haemorrhage (PPH)