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Postpartum haemorrhage

Introduction, etiology

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Postpartum haemorrhage (PPH) is a loss of 500 ml or more from the genital tract after delivery and includes all occurrences of bleeding within 24 hours after delivery.

Secondary postpartum delivery haemorrhage includes all cases of PPH occurring between 24 hours after delivery of the baby and 6 weeks postpartum.
Retained placenta describes the situation when the placenta has not been delivered within one hour after the birth of the baby.

Atonic bleeding occurs from the placenta site because the uterus is unable to contract adequately and thus the blood vessels are not compressed and bleeding is not controlled. Any condition that interferes with uterine contraction, such as retained placenta, will predispose to atonic bleeding.

Recommended treatments

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Atonic postpartum haemorrhage
oxytocin
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injection, 10 IU in 1-ml ampoule

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For treatment details see references 1 & 2
or
ergometrine
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tablet, 200 micrograms (hydrogen maleate)
injection, 200 micrograms (hydrogen maleate) in 1-ml ampoule

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For treatment details see references 1 & 2
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or, 15-methyl prostaglandin F2α (must not be given intravenously, as it may prove fatal). For treatment details see references 1 & 2

For the treatment of shock
sodium chloride
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injectable solution, 0.9% isotonic (equivalent to Na+ 154 mmol/l, Cl- 154 mmol/l

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For treatment details, please see reference 3
sodium lactate (compound solution)
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injectable solution

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For treatment details, please see reference 3

Post-partum haemorrhage anaemia - (if haemoglobin is below 7 g/dL or haematocrit is below 20% (severe anaemia))
ferrous salt
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tablet, equivalent to 60 mg iron
oral solution equivalent to 25 mg iron (as sulfate)/ml

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For treatment details see reference 1
plus
folic acid
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tablet, 1 mg, 5 mg
injection, 1 mg (as sodium salt) in 1-ml ampoule

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For treatment details see reference 1

In hookworm endemic areas
albendazole
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chewable tablet, 400 mg

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For treatment details see reference 1
or
mebendazole
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chewable tablet, 100 mg, 500 mg

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For treatment details see reference 1
or
pyrantel
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chewable tablet 250 mg (as embonate)
oral suspension, 50 mg (as embonate)/ml

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For treatment details see reference 1

References
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Managing Complications in Pregnancy and Childbirth. A guide for midwives and doctors, 2000, WHO/RHR/00.7. Section 1. Normal Labour and childbirth: Active management of the third stage.
   http://www.who.int/reproductive-health/impac/Clinical_Principles/Normal_labour_C57_C76.html#C73
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Managing Complications in Pregnancy and Childbirth. A guide for midwives and doctors, 2000, WHO/RHR/00.7. Section 2. Vaginal bleeding after childbirth.
   http://www.who.int/reproductive-health/impac/Symptoms/Vaginal_bleeding_after_S25_S34.html
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Managing Complications in Pregnancy and Childbirth. A guide for midwives and doctors, 2000, WHO/RHR/00.7. Section 2. Shock.
   http://www.who.int/reproductive-health/impac/Symptoms/Shock_S1_S5.html
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Postpartum haemorrhage module, Education material for teachers of midwifery, World Health Organization, 1996, WHO/FRH/MSM/96.2
   http://www.who.int/bookorders/anglais/home1.jsp?sesslan=1
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Report of the WHO Informal Consultation on the use of praziquantel during pregnancy/lactation and albendazole/mebendazole in children under 24 months, Geneva, 8-9 April, 2002, WHO/CDS/CPE/PVC/2002.4
   http://www.who.int/wormcontrol/documents/en/pvc_20024full.pdf
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Benzimidazoles: use in children, Essential Medicines, WHO Drug Information, Vol 17, No. 1, 2003
   http://www.who.int/druginformation/vol17num1_2003/vol17-1.pdf

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