Management of post-partum haemorrhage

Abstract

The most recent Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) confidential enquiry into maternal deaths 2012–2014 states that for women in the United Kingdom, giving birth remains as safe as ever, with a maternal mortality rate of <9 per 100,000. The maternal mortality rate continues to fall. However, according to the Confidential Enquiry into Maternal and Child Heath (CEMACH) report 2011–13, obstetric haemorrhage was one of the leading causes of direct maternal death and was in fact, ranked second.According to the Green Top Guidelines on Postpartum Haemorrhage on the ‘prevention and management of postpartum haemorrhage’ (2016), produced by the Royal College of Obstetricians and Gynaecologists (RCOG), primary postpartum haemorrhage (PPH) is the most common form of major obstetric haemorrhage and is defined as the loss of 500 ml or more blood from the genital tract within 24 hours of birth of a baby. PPH can be minor (500–1000 ml) or major (>1000 ml). Major can be further subdivided into moderate (1001–2000 ml) and severe (>2000 ml).Secondary PPH is defined as any abnormal bleeding or excessive bleeding from the birth canal between 24 hours and 12 weeks after delivery. Although, in some cases, massive obstetric haemorrhage can be anticipated, enabling steps to be taken for prevention and timely and effective management, it most often occurs in women who are classified as ‘low risk’, with no identified antenatal or intrapartum risk factors. A timely, systematic and multidisciplinary approach to restore the blood volume and clotting system whilst arresting bleeding, at the same time, should be the key cornerstones in the management of PPH. Such an approach would help further reduce maternal morbidity and mortality. Hence, all clinicians involved in antepartum and intrapartum care should have the necessary knowledge and skills to identify risk factors, signs and symptoms of massive PPH and should have adequate training in not only activating potentially life-saving emergency protocols but also in taking immediate steps to arrest ongoing bleeding.