Postpartum haemorrhage

Surgical approach (what the obstetric team typically does)

• Call for help early: senior obstetrician, senior anaesthetist, midwife-in-charge, haematology, blood bank; activate major obstetric haemorrhage protocol
• Immediate measures
  • Bimanual uterine massage; empty bladder; assess uterine tone and ongoing loss
  • Exclude retained products: inspect placenta; consider manual uterine exploration; ultrasound if uncertain
  • Inspect/repair genital tract trauma (cervix/vagina/perineum); consider theatre for examination under anaesthesia
• Escalation for uterine atony (stepwise)
  • Uterotonics (oxytocin/ergometrine/carboprost/misoprostol) + tranexamic acid
  • Intrauterine balloon tamponade (e.g., Bakri) ± vaginal packing
  • Surgical haemostasis: compression sutures (e.g., B-Lynch), uterine artery ligation, internal iliac artery ligation (variable success, technically demanding)
  • Interventional radiology: uterine artery embolisation (if haemodynamically stable and available)
  • Peripartum hysterectomy (life-saving; do not delay in refractory bleeding/placenta accreta spectrum)
• If suspected uterine inversion
  • Immediate manual replacement (Johnson manoeuvre) + tocolysis to facilitate reduction (e.g., GTN) then uterotonics after reduction
• If placenta accreta spectrum suspected/confirmed
  • Avoid forcible placental removal; planned approach often includes leaving placenta in situ and proceeding to hysterectomy with senior team

Anaesthetic management (overview for PPH/theatre)

• Type of anaesthesia: often conversion to GA if ongoing major haemorrhage, shock, need for laparotomy/hysterectomy, or inadequate neuraxial block; neuraxial may be continued/extended if stable and surgery limited
• Airway: usually cuffed ETT for major haemorrhage (aspiration risk, need for controlled ventilation, prolonged surgery); SGA only as short-term rescue/bridge in selected stable cases
• Duration: variable; 30–60 min for EUA/repair/balloon; 1–3+ h for laparotomy, embolisation transfer, or hysterectomy
• How painful: high if laparotomy/hysterectomy; moderate for EUA/repair; ensure multimodal analgesia and consider neuraxial/abdominal wall blocks if coagulation allows and time permits
• Immediate anaesthetic priorities
  • Simultaneous resuscitation and haemostasis: two large-bore IV cannulae (14–16G) + rapid infuser/warming; consider arterial line early; central access if poor peripheral access/vasopressors required
  • Activate massive transfusion/obstetric haemorrhage protocol; early TXA; targeted blood component therapy guided by labs/viscoelastic testing
  • Prevent the lethal triad: hypothermia, acidosis, coagulopathy (active warming, warmed fluids/blood, adequate ventilation/perfusion, calcium replacement)
  • Vasopressors: treat vasodilation/anaesthetic-induced hypotension but prioritise volume/blood; noradrenaline infusion often appropriate in ongoing shock after initial volume

Definition and classification

• Primary PPH: bleeding within 24 h of birth; Secondary PPH: 24 h to 6–12 weeks postpartum (definitions vary)
• Quantification: cumulative blood loss ≥500 mL after vaginal birth or ≥1000 mL after caesarean often used; any blood loss causing haemodynamic instability is clinically significant
• Major PPH commonly defined as ≥1000 mL; severe/life-threatening often ≥2000 mL or requiring massive transfusion

Aetiology: the 4 Ts

• Tone (uterine atony) — most common
  • Risk factors: overdistension (multiple pregnancy, polyhydramnios, macrosomia), prolonged/precipitate labour, chorioamnionitis, oxytocin use, uterine fatigue, high parity, uterine fibroids, GA/volatile agents
• Tissue (retained placenta/products; placenta accreta spectrum)
  • Placenta accreta spectrum risk: placenta praevia + previous caesarean, uterine surgery/curettage, Asherman’s
• Trauma (genital tract lacerations, uterine rupture, uterine inversion)
  • Consider if uterus well-contracted but bleeding continues
• Thrombin (coagulopathy: pre-existing or acquired)
  • Causes: placental abruption, severe pre-eclampsia/HELLP, sepsis, amniotic fluid embolism, massive haemorrhage/dilutional coagulopathy, anticoagulants, inherited bleeding disorders

Recognition and initial actions (first minutes)

• PPH is often underestimated: use quantitative blood loss (weigh swabs, measure suction) and clinical signs; remember pregnancy physiology masks shock until late
• Immediate actions: call for help; left uterine displacement if still pregnant (e.g., at CS); high-flow oxygen; keep warm; secure IV access; send bloods
  • Bloods: FBC, coagulation (PT/APTT/fibrinogen), group & screen/crossmatch; consider VBG/ABG with lactate, calcium, base deficit
• Early communication: blood bank for emergency O negative / group-specific blood; consider cell salvage if in theatre and not already set up

Resuscitation principles (anaesthetic focus)

• A–E with parallel haemorrhage control; treat as major trauma physiology
• Airway/breathing: anticipate aspiration; early RSI if deteriorating, ongoing major bleeding, reduced consciousness, or need for laparotomy
• Circulation: permissive hypotension is NOT appropriate in obstetrics (uteroplacental perfusion and maternal end-organ perfusion); aim for adequate MAP and mental status while haemostasis achieved
• IV access and monitoring
  • 2 × large-bore cannulae; pressure bags/rapid infuser; consider arterial line early (beat-to-beat BP, sampling) and urinary catheter for output
  • ECG, SpO2, NIBP (until art line), capnography if intubated, temperature, hourly urine output
• Fluids and blood: avoid large volumes of crystalloid; early balanced blood component therapy; warm everything
• Calcium: citrate toxicity common with massive transfusion; give calcium chloride/gluconate guided by ionised calcium (aim normal iCa)
• Hypothermia prevention: forced-air warming, fluid warmers, warmed blood; target normothermia

Uterotonics and key drugs (doses, cautions)

• Oxytocin
  • First-line: small IV boluses (e.g., 1–3 IU slow IV) then infusion (e.g., 10–40 IU in 500–1000 mL crystalloid at appropriate rate; local protocols vary)
  • Adverse effects: hypotension, tachycardia, myocardial ischaemia (rare), water intoxication with prolonged high-dose infusion
• Ergometrine (or Syntometrine where used)
  • Dose often 0.5 mg IM/slow IV (check local guidance)
  • Contraindications/cautions: hypertension, pre-eclampsia, ischaemic heart disease; causes nausea/vomiting, bronchospasm (rare), coronary vasospasm
• Carboprost (15-methyl PGF2α)
  • Dose often 250 micrograms IM/intramyometrial, repeat every 15–20 min to max 2 mg (protocol dependent)
  • Contraindications/cautions: asthma (bronchospasm), pulmonary hypertension; adverse effects: diarrhoea, vomiting, fever
• Misoprostol (PGE1 analogue)
  • Often 800–1000 micrograms PR (or SL/oral per protocol)
  • Adverse effects: pyrexia, shivering, diarrhoea
• Tranexamic acid (TXA)
  • Give early: 1 g IV as soon as PPH diagnosed; consider second 1 g if bleeding continues after 30 min or restarts within 24 h (per WOMAN trial approach; align with local guideline)
  • Best within 3 hours of birth; avoid delay
• Fibrinogen replacement
  • Fibrinogen falls early in obstetric haemorrhage; low fibrinogen predicts severity; replace with cryoprecipitate or fibrinogen concentrate per protocol/viscoelastic testing

Blood products and haemostatic strategy (exam-ready)

• Activate major haemorrhage protocol early: aim for timely RBC + FFP + platelets in balanced ratios until guided therapy available
• Targets (typical; follow local policy)
  • Hb: pragmatic target often ≥80 g/L during active bleeding (higher if ongoing shock/cardiac disease)
  • Platelets: keep >75 ×10^9/L (many aim >100 ×10^9/L if ongoing massive bleeding)
  • Fibrinogen: keep ≥2.0 g/L (often aim ≥2.0–3.0 g/L in obstetrics due to high baseline)
  • PT/APTT: aim <1.5 × normal
  • Temperature >36°C; ionised Ca2+ normal; pH >7.2
• Viscoelastic testing (TEG/ROTEM) can speed targeted therapy
  • Common pattern: early low fibrinogen (e.g., low FIBTEM A5/A10) → give cryo/fibrinogen concentrate
• Cell salvage
  • Recommended/accepted in obstetrics (including CS) with leucocyte depletion filter per local practice; ensure anti-D prophylaxis for RhD-negative mothers if fetal blood exposure possible
• Recombinant factor VIIa: rescue therapy only after correction of fibrinogen/platelets/pH/temperature/calcium and surgical control attempted; thrombosis risk

Anaesthesia technique considerations

• If neuraxial in situ (epidural/spinal)
  • Assess haemodynamic stability and block adequacy; top-up epidural cautiously if stable and surgery limited
  • Convert to GA early if major haemorrhage, high likelihood of laparotomy/hysterectomy, agitation, or airway/ventilation concerns
• General anaesthesia
  • RSI with cricoid (as per local practice); use haemodynamically stable induction (ketamine/etomidate where appropriate; reduce propofol dose)
  • Volatile agents reduce uterine tone; consider minimising volatile concentration and using adjuncts (opioid, ketamine, TIVA) once baby delivered; balance against need for anaesthesia depth
  • Early invasive monitoring, active warming, frequent blood gases and coagulation checks
• Postoperative care
  • HDU/ICU if massive transfusion, ongoing vasopressors, coagulopathy, hypothermia, acidosis, or after hysterectomy
  • Analgesia: multimodal; consider TAP block/wound infiltration if coagulation acceptable; avoid neuraxial catheter removal until coagulation normal and per ASRA/RA-UK timing guidance
  • Thromboprophylaxis: high VTE risk postpartum and after haemorrhage/surgery; balance against bleeding—start when haemostasis secured

Secondary PPH (late bleeding) — anaesthetic relevance

• Causes: retained products, endometritis, subinvolution of placental site, coagulation disorders
• May present for EUA/ERPC; assess sepsis, anaemia, ongoing bleeding; ensure group & screen, coagulation, IV access; consider aspiration risk still increased early postpartum