Guideline

Postpartum Haemorrhage

Immediate Actions
 Call for help and escalate as necessary
 Initiate fundal massage
 Focus on maternal resuscitation and identifying cause of bleeding
 Determine if placenta still insitu
 Tailor pharmacological management to causation and maternal condition (see orange box).
 Complete a SAS form when using carboprost.

Pharmacological regimen (see flow sheet summary)

 Administer third stage medicines if not already done so.
 Administer ergometrine 0.25mg both IM and slow IV (contraindicated in hypertension)
If cause is uterine atony- administer carboprost 250 micrograms (1mL) by deep intramuscular injection
 Administer loperamide 4mg PO to minimise the side-effect of diarrhoea
 Administer antiemetic Ondansetron 4mg IV, if not already given
If cause is cervical, vaginal or perineal trauma- administer Tranexamic acid- 1G IV in 10mL via syringe driver
set at 1mL/minute administered over 10 minutes OR as a slow push over 10 mins.
Once bleeding is controlled, administer misoprostol 600microg buccal and initiate an infusion of oxytocin 40U
in 1L Hartmann’s at a rate of 250mL/hr for 4 hours.

1. Purpose
This document outlines the guideline details for managing primary postpartum haemorrhage at the Women’s.
Where processes differ between campuses, those that refer to the Sandringham campus are differentiated by
pink text or have the heading Sandringham campus.
For guidance on postnatal observations and care after a major PPH, please refer to the procedure ‘Postpartum
Haemorrhage - Immediate and On-going Postnatal Care after Major PPH

2. Definitions
Primary postpartum haemorrhage (PPH) is traditionally defined as blood loss greater than or equal to 500
mL, within 24 hours of the birth of a baby (1).
Secondary PPH is defined as a blood loss of more than 500mL after 24 hours and up to 12 weeks postnatally
(1).
A major PPH is defined as such when there is continued bleeding and failure to respond to first-line
management and cases where blood loss is approaching or exceeding 1000mL (1).
DIC- Disseminated intravascular coagulation.

3. Responsibilities
Obstetric and midwifery staff are responsible for recognising and promptly managing postpartum
haemorrhage, for collaborating with other clinicians necessary for the woman’s care, escalating to senior
clinicians in cases of major PPH.
Senior medical staff (on-call Obstetric Consultant) are responsible for attending all cases of major PPH or
on request.

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Anaesthetic staff are responsible for providing and advising on clinical care in cases of major PPH when
intensive monitoring and resuscitation are required.
The Haematology Consultant should be consulted early to co-ordinate the provision of blood products and
provide advice regarding transfusion support and management of coagulopathy.
Other available specialists such as Gynae/ Oncology Consultant should be consulted early when bleeding is
intractable, where hysterectomy or ligation/ embolisation of uterine arteries are being considered.
Sandringham - Blood product support for bleeding patients is provided by the Alfred Pathology Service.
Consider notifying major PPH to the Alfred Hospital Blood Bank and the Laboratory Haematologist on call (03
9076 3100).

4. Guideline
4.1 Principles of care
PPH is recognised early and prompt treatment initiated in order to reduce the associated morbidities and
mortality.
Effective teamwork and communication is essential with resuscitation, monitoring, investigation and directed
treatment conducted simultaneously .
Management includes addressing the 4 causes of PPH; uterine atony, retained tissue, genital tract trauma and
clotting disorders. These are commonly known as the ‘4 T’s’; tone, tissue, trauma and thrombin.
Active management of third stage is recommended to all women as this reduces the risk of PPH and the need
for blood transfusion .
4.2 Assessment
Assessment includes effective team management, recognition, communication, resuscitation, monitoring and
investigation as well as directed management. Whilst uterine atony is the leading cause of PPH, all causes of
should be considered: tone, trauma, tissue and thrombin.
Recognition: visual estimation of blood loss has been recognised as unreliable. Where possible blood loss
should be estimated by weighing linen, drapes, pads and swabs. It is important to remember that the clinical
signs of haemorrhagic shock are delayed in the newly parturient woman due to the increased blood volume of
pregnancy.
Communication: includes communication between all members of the multidisciplinary team with timely
escalation to senior obstetric and midwifery staff, the involvement of haematologists and anaesthetists in clinical
care. The woman and her support people must be included in the communication.
Resuscitation: initial resuscitation is based on the ABC approach with advanced resuscitation guided by the
clinical situation.
An increasing trend in the incidence of PPH has been noted and all maternity clinicians should remain alert to
the possibility of PPH 4.
Minimum observations include vital signs at regular intervals, measuring on-going blood loss and awareness
of total blood loss volume, oxygen saturation and establishing IV access. A designated ‘PPH Box’ is considered
a good risk management approach as all necessary equipment is gathered in one area and quickly available.
For suggested contents, see Appendix 2.
Investigations: include basic haematological investigations. Further investigations are guided by the clinical
situation.
4.3 Management of women at risk for PPH (2)
Planned vaginal birth
 Confirm labour management plan when the woman is diagnosed in labour
 Establish intravenous access (16 gauge cannula)

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 Send sample for Blood Group and Antibody screen.

NOTE: women who have a red cell antibody should have a group and hold when she presents in labour or prior
as blood provision takes longer in this circumstance. All women birthing at Sandringham have a full blood
count and ‘group and hold’ on admission.
 Active management of the third stage with IM syntometrine ® 1mL, unless contraindicated
 This may include having 40 units oxytocin infusion available to commence when needed.
Planned caesarean section8
 May be associated with placenta praevia or other cases with a high risk of haemorrhage
 An experienced obstetrician should be physically present in theatre
 An experienced consultant anaesthetist should provide anaesthesia
 A valid blood group and antibody screen result should be available (within 72 hours of collection)
NOTE: women who have a red cell antibody should have a group and hold when she presents in labour or prior
as blood provision takes longer in this circumstance
 Insert two large bore cannulae (at least 16 gauge)
 Intravenous fluids should be warmed (use temperature controlled fluid warming device e.g. blood warmer)
to avoid hypothermia
 Ensure that devices to infuse fluid under pressure are in theatre
 Consider warming of the woman e.g. using a forced air warmer.
Suspected abnormal adherence of placenta
 Arrange the back-up of another experienced obstetrician, gynaecologist, urologist or vascular surgeon
 Preoperative consultation with an interventional radiologist to determine the availability and feasibility of
embolisation should the need arise. Note – not available at Sandringham.
 Perioperative notification to the Women’s blood bank must occur
4.5 With rapid PPH> 1500 mL (1, 3)
Sandringham – Activate Massive Transfusion Guideline and communicate with Haematology/ Anaesthesia.
Call for help – midwifery, obstetric and anaesthetic (MET call/ Pink Alert).
Ensure the ‘massive transfusion’ box is brought to the room.
Stop the bleeding – e.g. vaginal examination to exclude causes other than atony, remove any clots present,
apply pressure to minimise bleeding.
Administer oxygen at 8-12 litres via re-breathing mask.
Intravenous access x 2 using 16 gauge cannulae.
Arrange urgent pathology testing for Blood Group and Antibody Screen, Full Blood Count (FBC), Coagulation
Screen (INR, APTT, fibrinogen).
If emergency transfusion is required (before pre-transfusion testing is complete), emergency O Negative red
cells should be requested by telephone from the blood bank.
In the case of massive blood loss, the senior obstetrician / anaesthetist should liaise with the haematologist to
arrange further appropriate blood product support.
Lower head of bed, position woman flat (may remain with legs bent or in lithotomy).

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Resuscitate with appropriate intravenous fluid, e.g. sodium chloride 0.9 %, Hartmann’s solution (crystalloid) or
colloid volume expander (Albumin 4% or 20%). When using crystalloid, the ratio of resuscitative intravenous
fluid required to blood lost is 3:1.
To resuscitate more quickly, administer intravenous fluids using a pressure infusion device.
Transfuse blood as soon as possible if clinically required. The decision to transfuse is based on both clinical and
haematological assessment (1).
Until blood is available infuse up to 3.5L of warmed clear fluids. Initially 2L of warmed isotonic crystalloid.
Further fluid resuscitation can continue with additional isotonic crystalloid or colloid.
Hypothermia increases the risk of disseminated intravascular coagulation and other complications. This may be
prevented by pre-warming resuscitation fluids, e.g. use temperature controlled blood warmers and warm air
blankets.
Avoid hypotension by adequate fluid replacement in relation to ongoing measured blood loss.
Administer second bolus dose of oxytocin 10 units intravenously.
Prepare woman for theatre for manual removal of placenta with anaesthesia after adequate pre-operative
resuscitation.
Monitor maternal observations for clinical signs of shock (e.g. tachycardia, tachypnoea, decreased blood
pressure, weakness, sweating, restless, nausea) and resuscitate if present.
Monitor oxygen saturation with pulse oximeter.
Consider prophylactic antibiotics in theatre.
Consider the possibility of an abnormally adherent placenta.
If at any time bleeding is rapid or the woman is haemodynamically unstable:
 Delegate two people (e.g. anaesthetist plus midwife or theatre nurse) to
continue with resuscitative measures
 Bimanually compress the uterus by placing a fist in the anterior fornix of
the vagina and the other hand rubbing up the uterine fundus (see
diagram)
 If unsuccessful, perform aorto-caval compression.
Diagram - Illustrating internal bimanual compression of the uterus

4.6 Management of PPH

Sandringham – If bleeding persists, early transfer to theatre and proactive communication. Refer to the
guideline Transfer to Tertiary - W@S, as necessary.
If the placenta is in-situ and cannot be delivered and there is no bleeding, management as for retained
placenta.
If there is bleeding, management is the same regardless of whether the placenta is in or out.
Ensure the uterus is contracted.
If the uterus is not contracted:
 Continue uterine massage to stimulate a contraction and expel any clots present. If the uterine fundus feels
bulky and uterine massage does not expel clots, put on sterile gloves and perform vaginal examination to
remove clots.
 Insert indwelling catheter.
 Administer bolus ergometrine 250 micrograms intravenously and/or 250 micrograms intramuscularly.
Alternatively repeat bolus oxytocin 10 units intravenous and/or 10 units intramuscular (if concerned about
maternal hypertension).

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Postpartum Haemorrhage

 Administer antiemetic Ondansetron 4mg IV.

 Check that the placenta is complete.
Determine the principle cause if the bleeding.

If cause is TONE (uterine atony): Carboprost (Hembate®) 250 micrograms (1mL) by deep intramuscular injection
repeated at intervals of no less than 15 minutes to a maximum of 8 doses (2mg).
 Administer loperamide 4mg orally to minimise the side-effect of diarrhoea
 Administer antiemetic Ondansetron 4mg IV, if not already given
 If more than one dose of Carboprost is required, the woman must be transferred to theatre for further management
and the duty consultant must attend.

If cause is TRAUMA (to cervix, vagina, perineum): Tranexamic acid- 1G IV in 10mL via syringe driver set at
1mL/minute administered over 10 minutes OR given as a SLOW IV push.
Once bleeding controlled, administer misoprostol 600micrograms buccal and initiate an infusion of 40 units of
oxytocin in 1L 0/9% NaCl at a rate of 250mL/hr over 4 hours as postnatal prophylaxis.

If bleeding continues despite a well contracted uterus look for other causes and escalate to the obstetric
consultant before blood loss reaches 1L.
 Position the woman in lithotomy with adequate anaesthesia / analgesia
 Ensure adequate lighting, assistance and instruments to provide adequate exposure
 It may be necessary to take the woman to theatre to examine under anaesthesia
 Inspect vulva, vagina, cervix and perineum for trauma. Consider uterine rupture.
 Suture and repair as indicated
 Consider coagulation abnormalities
 In addition to full blood count, check D-dimer, coagulation studies including INR, APTT, fibrinogen
 Treat coagulation abnormalities with appropriate components which may include fresh frozen plasma (FFP),
platelets and cryoprecipitate
 Consider underlying cause if disseminated intravascular coagulation (DIC) present
 Consult with haematologist regarding appropriate blood products supports
 If DIC is secondary to sepsis, also consult with microbiologist.

If bleeding persists despite treatment:

 Contact the theatre and anaesthetist if not already done
 Ensure adequate consultant obstetric / specialist support available
 Consider repeating ergometrine
 Transfer woman to theatre.

In theatre management:

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 Consider Carboprost 500 micrograms (2mL) by direct intramyometrial injection (consider contraindications
which include known cardiac, pulmonary, renal or hepatic disease) (1, 4, 5).

Note: The manufacturer does not recommend intramyometrial use. Therefore this method of administration
is the responsibility of the administering clinician - in consultation with a consultant obstetrician. See
procedure Postpartum Haemorrhage - Carboprost (Hemabate®)
 Consider exploration of uterine cavity under anaesthesia
 Consider uterine tamponade with the Bakri balloon
 Consider packing the uterus and vagina
 Bimanually compress the uterus by placing a fist in the anterior fornix of the vagina and the other hand
rubbing up the uterine fundus
 If this controls the bleeding, maintain this compression for at least 30 minutes
 If uterotonics and mechanical compression techniques are unsuccessful, decide whether to perform
o B-lynch brace suture
o Hysterectomy
o Angiography and embolisation
o Ligation of the internal iliac vessels.
 Management of rapid PPH is as section 4.5

4.7 Documentation
Complete mandatory documentation including:
 Mandatory observations
 Date/time of Bakri balloon/uterine pack insertion
 Proposed date/time of Bakri balloon/uterine pack removal.
 Parkville campus- use of the PPH form within the Maternity Clinical Information System is encouraged to
ensure contemporaneous documentation.
Sandringham Campus
Ensure contemporaneous documentation in Progress Notes MR/94.

4.8 Further Information

Incidence
The incidence of PPH within Australia and New Zealand is between 5-15% (6)
Risks
The table below outlines some common risk factors for PPH. These risks should be identified both antenatally
and during labour. Other risk factors to consider are a previous history of PPH and any previous uterine surgery,
including but not limited to caesarean birth, myomectomy, STOP, dilatation and curettage (D and C). However
two thirds of women who have a PPH have no known risk factors (2).
Table 1 - Common Risk Factors for PPH (1)

Tone Trauma Tissue Coagulopathy

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Postpartum Haemorrhage

Prolonged labour Operative delivery Retained placental Pre-eclampsia

tissue
Precipitate labour Cervical / vaginal HELLP Syndrome
lacerations
Abnormal placentation
Dysfunctional labour Placental abruption

Morbidly adherent FDIU>4/52

Grand Multiparity
placenta
Amniotic Fluid Embolism
Multiple pregnancy
Sepsis
Polyhydramnios
Bleeding disorders
Macrosomia
Drugs (aspirin / heparin)
Abnormalities: fibroids

Intrauterine infection

Uterine relaxing agents such

as Magnesium sulphate /
general anaesthetic/
tocolytics (terbutaline)

Whilst major PPH is no longer the leading cause of maternal death in Australia, suboptimal care is persistently
identified as a major factor for those who die. For every maternal death, it is estimated that there are around 80
instances of ‘near-miss’ where women experience a life-threatening complication, sometimes with continuing
morbidity1. Whilst most women with postpartum blood loss less than 1000mL suffer no significant morbidity, the
percentage of women who suffer a major PPH at the Women’s is comparable with local and international figures
of 1-2%. Long term morbidity includes renal impairment, Sheehan Syndrome and the risk of blood-borne
infections from blood transfusions (7).
It is recommended that all maternity staff should have a recognised procedure for managing PPH which is
rehearsed on a regular basis (8). Training should be provided to all maternity care staff regarding assessment of
blood loss (9).
Factors which contribute to maternal death have been reported (10); lack of routine observation in the
postpartum period, failure to appreciate that bleeding was occurring, lack of optimal post-operative
measurement of pulse and blood pressure or recognition of abnormal vital signs such as oxygen saturation and
respiratory rate, even when it was known the mother had sustained a large bleed. Other factors that contribute
to suboptimal care include (9):
 Lack of awareness of the signs and symptoms that could signal deterioration, and the role of vigilant
monitoring in early detection
 Vital signs not monitored consistently, or not monitored at all
 Changes in vital signs not detected
 Lack of recognition of the implications of changes in vital signs
 Uncertainty about when to trigger assistance, resulting in delays in notifying medical staff of signs of
deterioration
 Delays by medical staff in responding to notification, or provision of an inappropriate response
 Inconsistent skills of ward medical and nursing staff on how to manage the deteriorating patients
 A delay or not seeking supervision or advice in a timely manner
 Ineffective communication and handover of critically ill patients.

Expanded definitions

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Postpartum Haemorrhage

 Bakri balloon is a balloon tamponade indicated for women not responding to uterotonics and uterine
massage. It is used to control haemorrhage due to uterine atony in the upper segment of the uterus and
to control bleeding in the lower uterine segment secondary to placental implantation in the lower uterine
segment. Please see procedure ‘Postpartum Haemorrhage - Bakri Balloon Tamponade’ for more
information.
 Hypovolaemic shock is a life-threatening condition in which reduced circulatory volume results in
inadequate tissue perfusion. In the early phases of haemorrhage, the body compensates for blood loss
by raising systemic vascular resistance in order to maintain blood pressure and perfusion to vital organs.
Clinically, this corresponds to a narrowing of the pulse pressure. As bleeding continues, however, further
vasoconstriction is impossible, resulting in decreased blood pressure, cardiac output, and end-organ
perfusion. Compensatory homoeostatic mechanisms are activated, including vasoconstriction, increased
cardiac activity, reduced fluid excretion and increased platelet numbers. Blood flow to the heart, brain and
adrenal glands is optimized at the expense of other organs. When persistent, irreversible cell damage
occurs, and falling myocardial perfusion leads to a vicious cycle of myocardial failure and death. The
clinical signs are delayed in newly parturient women due to the increased blood volume of pregnancy. By
the time these vital signs are abnormal the woman will have lost at least 1500mL.
 B-Lynch suture: uterine compression sutures running through the full thickness of both uterine walls
(posterior as well as anterior) for surgical management of atonic PPH. The B-Lynch suturing technique
(brace suture) is useful because of its simplicity of application, life-saving potential, relative safety and
capacity for preserving the uterus and subsequent fertility. The adequacy of haemostasis can be
assessed both before and immediately after application of the suture. This technique is an alternative to
major surgical procedures for controlling pelvic arterial pulse pressure or hysterectomy. It has been
shown, when applied correctly, to be successful with no problems and no apparent complications. Only if
it fails, need other more radical surgical methods be considered.

Misoprostol is a heat-stable prostaglandin analogue that can be administered orally, sublingually,
vaginally and rectally.

Shivering and pyrexia (> 40°C) are typical side effects and their severity is dose-related.
These are generally transient (16).

Misoprostol can cause gastrointestinal effects such as diarrhoea, abdominal pain, nausea and vomiting,
which may occur and resolve within 2 to 6 hours (14).

Route of Onset of action Time to reach peak Duration of action

administration concentration (Tmax)

oral (swallowed) 8 minutes 7.5 to 30minutes (mean = ~ 2hours

14.2 minutes)

buccal 41.2 minutes 30 minutes ~ 5 hours

sublingual 11 minutes 26 +/- 11.5 minutes ~ 3hours

rectal 100 minutes 45 to120 minutes (mean = ~ 4 hours

71.7 minutes)

vaginal 20 minutes 45 to 120 minutes (mean ~ 4 hours

= 65 minutes)

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5. Evaluation, monitoring and reporting of compliance to this guideline

Compliance to this guideline will be monitored, evaluated and reported through the notification of clinical
incidents on VHIMS and by monthly clinical audit of PPHs greater than 1500mLs.

6. References
1. Prevention and Management of Postpartum Haemorrhage: Green-top Guideline No. 52. BJOG.
2017;124(5):e106-e49.
2. South Australian Perinatal Practice Guidelines - Postpartum haemorrhage. Department of Health,
Government of South Australia; 2013.
3. South Australian Perinatal Practice Guidelines - Prostaglandin Analogues for Major Postpartum
Haemorrhage. Department of Health, Government of South Australia; 2016.
4. Product Information - Hemabate Sterile Solution [Internet]. Pfizer Canada Inc. 2014.
5. Queensland Clinical Guidelines - Primary postpartum haemorrhage. State of Queensland (Queensland
Health) 2018.
6. Management of Postpartum Haemorrhage (PPH). The Royal Australian and New Zealand College of
Obstetricians and Gynaecologists; 2017.
7. Knight M, Callaghan WM, Berg C, Alexander S, Bouvier-Colle MH, Ford JB, et al. Trends in postpartum
hemorrhage in high resource countries: a review and recommendations from the International Postpartum
Hemorrhage Collaborative Group. BMC pregnancy and childbirth. 2009;9:55.
8. Major morbidities associated with childbirth in Victoria. Topic 1: Obstetric haemorrhage and associated
hysterectomy. In: Services DoHH, editor. 2012.
9. Emergencies Around Childbirth: A Handbook for Midwives. Boyle M, editor: CRC Press; 2016.
10. Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, et al. Saving Mothers' Lives:
Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential
Enquiries into Maternal Deaths in the United Kingdom. BJOG. 2011;118 Suppl 1:1-203.
11. Khan RU, El-Refaey H, Sharma S, Sooranna D, Stafford M. Oral, rectal, and vaginal pharmacokinetics of
misoprostol. Obstet Gynecol. 2004;103(5 Pt 1):866-70.
12. Meckstroth KR, Whitaker AK, Bertisch S, Goldberg AB, Darney PD. Misoprostol administered by
epithelial routes: Drug absorption and uterine response. Obstet Gynecol. 2006;108(3 Pt 1):582-90.
13. Schaff EA, DiCenzo R, Fielding SL. Comparison of misoprostol plasma concentrations following buccal
and sublingual administration. Contraception. 2005;71(1):22-5.
14. Tang OS, Gemzell-Danielsson K, Ho PC. Misoprostol: pharmacokinetic profiles, effects on the uterus and
side-effects. Int J Gynaecol Obstet. 2007;99 Suppl 2:S160-7.
15. Tang OS, Schweer H, Seyberth HW, Lee SW, Ho PC. Pharmacokinetics of different routes of
administration of misoprostol. Hum Reprod. 2002;17(2):332-6.
16. Hoj L, Cardoso P, Nielsen BB, Hvidman L, Nielsen J, Aaby P. Effect of sublingual misoprostol on severe
postpartum haemorrhage in a primary health centre in Guinea-Bissau: randomised double blind clinical
trial. BMJ. 2005;331(7519):723.

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7. Appendices
Appendix 1: Postpartum Haemorrhage Flow chart and medicines summary
Appendix 2: Contents of Postpartum Haemorrhage Box
Appendix 3: Postpartum Haemorrhage Medication Guide

Please ensure that you adhere to the below disclaimer:

PGP Disclaimer Statement

The Royal Women's Hospital Clinical Guidelines present statements of 'Best Practice' based on thorough evaluation of
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Whilst appreciable care has been taken in the preparation of clinical guidelines which appear on this web page, the Royal
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representation implied or expressed concerning the efficacy, appropriateness or suitability of any treatment or product is
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In view of the possibility of human error and / or advances in medical knowledge, the Royal Women's Hospital cannot and
does not warrant that the information contained in the guidelines is in every respect accurate or complete. Accordingly, the
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You are encouraged to consult other sources in order to confirm the information contained in any of the guidelines and, in
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NOTE: Care should be taken when printing any clinical guideline from this site. Updates to these guidelines will take place
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 Appendix 1

Postpartum Haemorrhage Flowchart

PPH Management

Standard care Consider and manage other causes

Maintain warmth, lie flat, IDC, fundal
massage, expel clots, administer oxygen Check the placenta and
TISSUE membranes are complete
Insert large bore IV ( 16G) Escalate to senior obstetrician
Remember- DRABC before blood loss reaches 1 L
Observations TRAUMA Repair lacerations

 BP, HR, RR and SaO2 every five

minutes Consider history, consider
THROMBIN
Call for help and  Continuously monitor blood loss until clotting studies Escalate
bleeding under control
simultaneously CONSIDER
 Temp every 15 minutes
initiate:
 Monitor blood loss and hourly urine  Emergency O negative red blood cells
output  Use of rapid infuser/warmer
 Start fluid balance chart  FFP, platelets, cryoprecipitate
 Regular pathology 30 to 60 minutes
Rapid Fluid Replacement

Give 2 L initially, then a ratio of 3 L of fluid

to 1 L of estimated blood loss Do you need an anaesthetist?
(includes crystalloids, plasma expanders
and blood products). Do you need a haematologist?

Do you need to activate the Massive Transfusion protocol?

Pathology Consider transfer to theatre
Full blood count, group and crossmatch,
consider clotting screen

Pharmacological
management
1 First line 2a Second line-TONE 2b Second-line- TRAUMA 3 After immediate management
rd
If not already given for 3 stage,
 Oxytocin 10 IU IM/IV (slow over 3-5 mins)
 Tranexamic acid 1 g in 10 mLs over Consider transfer to ICU or
OR
 Carboprost 250microg/1 mL deep IM  Misoprostol 600microg buccal
10 minutes via syringe driver at a Complex Care Unit
 Syntometrine® 1mL IM at no less than 15 mins intervals to a rate of 100mg/minute
(or PR if maternal conditio n
THEN precludes this)
maximum of 2mg (8 doses) OR
 Ergometrine 0.25mg slow IV and IM (First dose may be given in the Birth Centre)  Oxytocin infusion 40 units in 1 L of
Tranexamic acid 1 g in 10 mLs as a slow
and Ondansetron 4mg IV AND 0.9% normal saline, at a rate of
push, over 10 minutes
250ml/hr IV over 4 hours/as Oxytocin
 Ondansetron 4mg IV (if not already given) AND
Administration procedure.
 Loperamide 4mg PO  Ondansetron 4mg IV (if not already given)
(BP 140/90 – Syntometrine and
ergometrine contraindicated)

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 Guideline

Postpartum Haemorrhage : Summary

PPH Management

Pharmacological management- summary

ASK: has third stage mgt been administered?

0  Oxytocin 10 IU IM/IV
OR
 Syntometrine® 1mL IM (unless contraindicated)
If not already given,
(Hypertension – Syntometrine contraindicated)

STEP 1: Immediate management

1  Ergometrine 0.25mg slow IV and IM (unless contraindicated)

 Ondansetron 4mg IV

STEP 2a: Determine the cause TONE?

2a 

Carboprost 250microg/1 mL deep IM
First dose may be given in the Birth Centre
(at no less than 15 min intervals)

 IV ondansetron 4mg (if not already given)

 Loperamide 4mg PO (to minimise side-effects of diarrhoea)

2b STEP 2b OR TRAUMA?
 Tranexamic acid 1 g/10mL IV given over 10 minutes via syringe driver at
100mg/min
OR
 Tranexamic acid 1 g/10mL IV given over 10 minutes as a slow push
 IV ondansetron 4mg (if not already given)

STEP 3 After immediate management

3
 Misoprostol 600microg buccal
(PR if maternal condition precludes this)
 Oxytocin infusion 40 units in 1 L of sodium chloride (or Hartmann's
Solution), IV at a rate of 250mL/hr as per Oxytocin Administration procedure.

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 Appendix 2

PPH Box Contents

The PPH box consists of two components:

1. A tackle box with a bright lid works well as a light-weight, easily recognised and transportable box. It also
precludes over-stocking.
2. A clearly labelled container for refrigerated items
Contents are dependent on the location of the box. Contents are listed within the box for consistent restocking
of items. Boxes are restocked by ward areas.
All areas excluding Birth Centre:
Box 1: Top Shelf
For cannulation: For blood pathology
16G IV cannulae *2 23G 1¼” needles (blue) *2
18G IV cannulae *2 21G 1½” needles (green) *2
Skin prep swabs (for IV cannulation) Blood tubes:
Tegaderm (or similar for securing IV cannulae)  EDTA KE/9mL and 2.7mL
 Serum gel Z/7.5mL
Transpore tape
 Coagulation 9NC/3mL
Luer-lock connectors
Sodium chloride ampoules 10mL *2 Tourniquet
Water for injections ampoule 10mL*2 Alcohol swabs
Additive labels Specimen transport bags
Multi-adapters Pathology request slips
3-way adapter (for IV giving set) 10mL syringe *3

Bottom Shelf

1L sodium chloride 0.9% or Hartmann’s solution Foley catheter 14ch

Gelofusine (plasma expander) Urine drainage bag or Urimeter *1
10mL ampoule water for injections
IV giving sets- standard *2
10mL syringe
IV giving set- Alaris pump *1

Box2: kept in fridge (restocked by ward area after use)

Drugs: Syringes:
Oxytocin 10unit (box of 5 ampoules) 3mL x 3
Ergometrine 500mcg (box of 5 ampoules) 5mL x 3
Ondansetron 4mg (2 ampoules) Needles :
Misoprostol 200mcg x 3 tablets 1G *3
23G *3

IV infusion label x 2

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 Appendix 2

PPH Box Contents

Birth Centre:
Box 1

1L sodium chloride 0.9% 1 x syringe / needle kit containing:

Gelofusine (plasma expander) x 1 5mL syringe x 2
3mL syringe x 2
IV giving sets- standard
10mL syringe x1
IV giving set- Alaris pump 21G needle x 2
Extension line for syringe pump 19G needle x 2
IV infusion labels
3-in-1 extension LS-connector (octopus)

Box 2: Kept in fridge (restocked by ward area after use)

Drugs: Syringes:
Oxytocin 10unit (box of 5 ampoules) 3mL x 3
Ergometrine 500mcg (box of 5 ampoules) 5mL x 3
Ondansetron 4mg(2 ampoules) Needles :
Misoprostol 200mcg x 3 tablets 21G x 3
23G x 3
25 G Spinal needles x2 (for IMM carboprost)

IV infusion label x 2

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 Appendix 3

Postpartum Haemorrhage Medicines Guide

Medicine Dose Route Side effects Contraindication Comments

Ergometrine 250 microgram, repeat as IV or IM Tonic uterine contraction, Severe hypertension and + ondansetron 4mg IV
needed to max of 4 doses nausea, vomiting and raised cardiac disease
BP Hypersensitivity to
ergometrine
Ergometrine/ 1mL, repeat if necessary IM Nausea, vomiting and raised Severe hypertension and Alternative first line medicine unless
oxytocin to max of 3mL total BP cardiac disease contraindicated
(Syntometrine®) Hypersensitivity to
(1mL = ergometrine 0.5mg medicine
& oxytocin 5 units)
Carboprost After vaginal birth: 250 IM bronchospasm, pulmonary Hypersensitivity to any Second line medicine for PPH caused by uterine
(Hemabate ®) micrograms in 1mL oedema, hypoxia, acute component of the atony unresponsive to first and second line
ampoules by deep IM hypertension (usually preparation: carboprost, treatmentergometrine.
injection or transient and requiring no tromethamine, sodium Intramyometrial injection is not recommended by
intramyometrially, at treatment), acute chloride, benzyl alcohol the manufacturer however off-label use is
intervals of no less than hypotension, cardiac Patients with known supported by evidence- see PPH- Carboprost
15minutes to a maximum arrhythmia,flushing, syncope active cardiac, procedure.
of 2mg (8 doses) OR 2mL and palpitations, pulmonary, renal or
into each cornu to abdominal cramps, hepatic disease
maximum 2mg diarrhoea and vomiting, an Acute pelvic
Laparotomy: as above- increase in temperature inflammatory disease
500micrograms greater than 1.1°C,
intramyometrially to a max convulsions (rarely),
of 2mg flushing, shivering, uterine
rupture, headache (usually
mild and transient)
Tranexamic acid 1 g in 10mL ampoule of IV Nausea, vomiting, diarrhoea, Hypersensitivity to Second-line management of PPH when bleeding
tranexamic acid allergic dermititis. tranexamic acid or any of unresponsive to 40U oxytocin infusion and IV/IM
intravenously via syringe its excipients ergometrine.when bleeding is caused by trauma.
pump at a rate of 1mL per Patients with a history or Consider when there is likelihood of delay in
min administered over 10 risk of thrombosis should accessing an operating theatre e.g. out of hours.
minutes OR 1g in 10mL not be given tranexamic This may reduce the overall blood loss whilst
given over 10 minutes by acid, unless at the same waiting.
slow IV push. time it is possible to give
treatment with
anticoagulants.
Active thromboembolic
disease such as deep

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 Appendix 3

Postpartum Haemorrhage Medicines Guide

vein thrombosis (DVT),

pulmonary embolism and
cerebral thrombosis.

Oxytocin 10 units, repeat bolus IV or IM Painful contraction, nausea Hypersensitivity to In place of ergometrine if blood pressure elevated
or vomiting, water oxytocin
intoxication, hypotension
40 units in 1L sodium IV infusion
chloride 0.9% at rate of
250mL/h if placenta is out
Misoprostol 400 600 microgram Oral/sublingualBuccal Nausea, vomiting, diarrhoea, Hypersensitivity to Oral/sublingualBuccal administration has a
(2 3 tablets) abdominal pain, pyrexia misoprostol quicker onset with a peak plasma
concentration around 15-30 minutes falling
steeply within 60 minutes4
Misoprostol 600 microgram Rectal Nausea, vomiting, diarrhoea, Hypersensitivity to Third line management after ergometrine and
(3 tablets) abdominal pain, pyrexia misoprostol carboprost. Rectal administration has a slower
onset (around 45-120 minutes) and the fall is
gradual (over 240 minutes)

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