Operative interventions in the management of major postpartum haemorrhage

Abstract

In many recent studies in the developed world, the incidence of postpartum haemorrhage (PPH) has been rising, though the mortality has come down, suggesting improvement in the management of this condition. Since the publication of the RCOG guidelines in 2009 for management of PPH and the Sheffield guidelines for the use of Rusch balloon along with the initial small case series (Keriakos and Mukhopadhyay 2006), many units have introduced the guidelines into clinical practice. This has led to the reduction of surgical intervention in our unit. Major PPH accounted for 1.6% of the total deliveries in our hospital. Surgical interventions accounted for 7.8% of these cases and only 0.1% of the total deliveries. Risk factors for PPH were identified in 83%. In this paper, we reviewed the management of all patients who had major PPH and failed medical management over a period of about 4 years. All surgical interventions including Rusch balloon, B-Lynch suture, radiological interventions and hysterectomy were described. An update to Rusch balloon guidelines and Sheffield guidelines for management of major PPH are appended.

Keywords::

• B-Lynch sutures
• intrauterine tamponade
• major PPH
• Rusch balloon

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Appendix

Management of Postpartum Haemorrhage

Refer also to Obstetric guideline ‘Women who decline blood products’ (http://nww.sth.nhs.uk/STHcontDocs/STH_CGP/Obstetrics/WomenWhoDeclineBloodProducts.doc) and STH policy ‘Guideline for the management of patients, age 18 years or over who decline treatment using blood products’ (http://nww.sth.nhs.uk/STHcontDocs/STH_Pol/ClinicalGovernance/Patients18plusWhoDeclineProductsOfHumanOrigin.doc)

DEFINITION

Postpartum haemorrhage (PPH) is usually defined as greater than 500 ml estimated blood loss after delivery of the baby.

It may be classified as major or minor depending on estimated blood loss and clinical signs.

Minor PPH Estimated Blood Loss, less than 1,000 ml and no clinical signs of shock.

Major PPH Estimated Blood Loss, more than 1,000 ml and continuing to bleed OR clinical shock.

Total blood volume at term is approximately 100 ml/kg. For a woman of 70 kg a blood loss of more than 40% of her total blood volume (2,800 ml) is generally regarded as life-threatening.

RISK FACTORS

• Past history of postpartum haemorrhage

• Grand multiparity

• Maternal age > 40 years

• Multiple pregnancy

• Polyhydramnios

• Abruptio placenta

• Placenta praevia

• Pre-eclampsia/gestational hypertension

• BMI > 35

• Pre-existing anaemia

• Operative delivery (caesarean section or instrumental)

• Induction of labour

• Retained placenta

• Big baby

• Pyrexia in labour

• Prolonged labour

Blood loss at delivery is oft en underestimated.

Minor PPH can easily progress to major PPH and progress is sometimes unrecognised.

Many cases of PPH have no identifiable risk factors.

The causes of PPH may be considered to relate to one or more of four ‘Ts’

• Tone (abnormalities of uterine contraction)

• Tissue (retained products of conception)

• Trauma (of the genital tract)

• Thrombin (abnormalities of coagulation)

The management of Postpartum Haemorrhage involves 4 components which should be undertaken SIMULTANEOUSLY:

Communication and Documentation

Resuscitation

Monitoring and Investigation

Arrest the bleeding

MINOR POSTPARTUM HAEMORRHGE

Estimated Blood Loss, less than 1,000 ml and no clinical signs of shock.

1. Communication and Documentation

• Alert LW Coordinator/Senior Midwife

• Alert the on-call Obstetric Specialist Trainee Registrar and the on-call Anaesthetic Registrar

• Ensure a member of the team records all fluids and drugs administered, vital signs and any procedure or intervention

2. Resuscitation

• Open Emergency Box for Postpartum Haemorrhage and PPH drug box

• Intravenous access (2 large bore cannulae)

• Commence crystalloid infusion (0.9% Normal saline)

3. Monitoring and Investigation

• Cross-match 2–4 units, FBC, clotting screen, D-dimers

• Record and document MEWS observations and vaginal blood loss every 15 minutes until the woman is stable and no longer bleeding

4. Arrest the Bleeding

The following measures should be instituted in turn until the bleeding ceases.

• Rub up a uterine contraction manually

• Commence an intravenous infusion and administer a solution of 40 units oxytocin in 500 ml normal (0.9%) saline at a rate of 125 ml per hour (10 units an hour)

• Administer 250 micrograms Ergometrine intravenously (except for patients with hypertension, cardiac disease, impaired pulmonary, renal or hepatic function—give these women a bolus of 5 units of intravenous oxytocin SLOWLY). Intravenous oxytocin should be used with great caution in the presence of hypovolaemia. A bolus of intravenous oxytocin may cause profound hypotension, especially in a hypovolaemic woman (Confidential enquiries into Maternal deaths 1997–1999, Pinder et al. 2002)

• Insert a catheter to empty the bladder and measure urine output hourly

• If bleeding continues, alert the Emergency Obstetric Team (2222) and continue management as for Major Postpartum Haemorrhage

MAJOR POSTPARTUM HAEMORRHAGE

Estimated Blood Loss, more than 1,000 ml and continuing to bleed OR clinical shock.

Signs and symptoms of shock include tachycardia, tachypnoea, hypotension (late sign) oliguria, confusion and metabolic acidosis.

1. Communication and Documentation

• Summon the Emergency Obstetric Team (2222), i.e.:

902 midwife bleep holder/Labour ward coordinator

Consultant Obstetrician (between 08.00 hours and 20.00 hours)

Senior trainee Obstetric Registrar

Senior trainee Anaesthetic Registrar

Obstetric theatre ODA

Porters

• Inform Blood Bank and on-call haematologist–State MAJOR OBSTETRIC HAEMORRHAGE–See Blood Transfusion Policy, (http://nww.sth.nhs.uk/STHcontDocs/STH_Pol/ClinicalGovernance/Patients18plusWhoDeclineProductsOfHumanOrigin.doc), page 85, Massive Transfusion Haemorrhage Flowchart

• Alert Obstetric theatre and request Cell Salvage

• Ensure a member of the team records all fluids and drugs administered, vital signs and any procedure or intervention

• Communicate with the woman and her birthing partner and give clear information of what is happening

• Alert the consultant obstetrician if he/she is not on site

2. Resuscitation

• Open Emergency Box for Postpartum Haemorrhage and PPH drug box

• Assess Airway, Breathing and Circulation

• Oxygen by Mask—10–15 litres per minute

• IV access—2 Large bore cannulae

• Position flat

• Keep the woman warm

• Transfuse blood as soon as possible

• Infuse crystalloid—Hartman's solution or normal 0.9% Saline up to 2 litres and then up to 1 litre colloid until blood available

• If blood loss is more than 2 litres infuse O negative blood while waiting for cross-matched blood

• Blood products—fresh frozen plasma, platelet concentrate, cryoprecipitate should be given on advice from on call haematologist

• Consider Recombinant Activated Factor VII (rFVIIa) (NovoSeven®, Novo Nordisk, Denmark)

3. Monitoring and Investigation

• Urgent FBC, cross-match 6 units, U + E, LFTS, clotting screen and D-dimer

• Continuously record and document maternal pulse, blood pressure, respiratory rate, oxygen saturation and temperature

• Document blood loss every 5 minutes

• Catheterise bladder and record urine out put hourly

• Consider arterial line monitoring

• Document fluid balance, blood, blood products and all procedures

4. Arrest the Bleeding

Initial measures as the same as for minor PPH namely:

• Rub up a uterine contraction manually

• If bleeding continues administer oxytocin and ergometrine as indicated below and perform bimanual compression of the uterus

• Commence an intravenous infusion and administer a solution of 40 units oxytocin in 500 ml normal (0.9%) saline at a rate of 125 ml per hour

• Give 250 micrograms Ergometrine intravenously (except for patients with hypertension, cardiac disease, impaired pulmonary, renal or hepatic function—give these women a bolus of 5 units of intravenous oxytocin SLOWLY) Intravenous oxytocin should be used with great caution in the presence of hypovolaemia. A bolus of intravenous oxytocin may cause profound hypotension, especially in a hypovolaemic woman (Confidential Enquiries into Maternal deaths 1997–1999, Pinder et al. 2002)

• If above measures do not arrest the bleeding transfer the woman to theatre and request the presence of the on call obstetric consultant if he/she is not already present. The most common cause of primary PPH is uterine atony. However, clinical examination must be undertaken to exclude other or additional causes:

• retained products (placenta, membranes, clots)

• vaginal/cervical lacerations or haematoma

• ruptured uterus

• broad ligament haematoma

• extragenital bleeding (for example, subcapsular liver rupture)

• uterine inversion.

When uterine atony is perceived to be the cause of the haemorrhage and there has not been an adequate response to bimanual uterine compression, oxytocin and ergometrine the following pharmacological and surgical measures should be instituted. The choice of surgical interventions will depend on the clinical circumstances and available expertise.

Prostaglandins

If bleeding continues and causes other than uterine atony have been excluded, administer carboprost (prostaglandin F2alpha)—250 micrograms by deep intramuscular injection. Carboprost may be repeated up to a maximum of 2 mg. The interval between doses should ideally be 90 minutes but never less than 15 minutes. Carboprost should only be requested by an experienced registrar or consultant. The major side-effects include pyrexia, nausea/vomiting and hypertension. Caution must be exercised in the presence of maternal hypertension, asthma, cardiac disease, impaired pulmonary, renal or hepatic function. Severe bronchospasm may occur even in those without asthma (Harber et al. 2007).

There is limited data on the use of misoprostol (prostaglandin E1) to treat PPH. However, where parenteral prostaglandins are not available or where there are contraindications (usually asthma) to prostaglandin F2alpha, misoprostol may be an appropriate alternative 800–1,000 micrograms rectally.

Rusch Balloon Catheter—See Rusch Balloon Catheter and Postpartum Haemorrhage (http://nww.sth.nhs.uk/STHcontDocs/STH_CGP/Obstetrics/RuschBalloonCatheter.doc)

B-Lynch Suture (brace suture)

The test of potential efficacy of this technique is bimanual compression after exteriorising the uterus. The B-Lynch suture allows conservation of the uterus and fertility.

Pelvic Arterial Embolisation

The Jessop wing does not have on-site interventional vascular radiology. Pelvic arterial embolisation is an option for control of postpartum haemorrhage which has failed to respond to the methods described above. This technique should be considered before embarking on a hysterectomy. If this procedure is being considered, please contact the ‘on-call’ vascular radiologists at the RHH or Northern General hospital.

Resort to hysterectomy SOONER RATHER THAN LATER (especially in cases of placenta accreta or uterine rupture).

A second Consultant Clinician should usually be involved in the decision for hysterectomy.

5. Post Haemorrhage Management

Once bleeding ceases, close monitoring of the maternal condition should continue for at least 12 hours in Obstetric HDU or RHH ITU. Maternal MEWS scoring should be recorded every 15 minutes for the 1st hour and then every 30 minutes for the 2nd hour and then if there is no evidence of bleeding and recordings are stable, every hour for a total of 6 hours. Ensure maternal urine output is measured for the first 12 hours post-haemorrhage and is at least 30 ml each hour.

6. Documentation and Debriefing

Events during and after a postpartum haemorrhage should be accurately documented.

Inadequate documentation in obstetrics can lead to potential medico-legal consequences. It is important to record the:

• staff in attendance

• sequence of events

• time of administration of different pharmacological agents given, their timing and sequence

• time of surgical intervention, where relevant

• condition of the mother throughout the different steps

• timing of the fluid and blood products given.

Major obstetric haemorrhage can be traumatic to the woman, her family and the birth attendants; therefore, debriefing is recommended by a senior member of the team who was involved at the time of events at the earliest opportunity.

This should include arrangements for proper follow-up and investigations as necessary, such as screening for coagulopathies if there are other indicators and screening for the rare complication of panhypopituitarism (Sheehan syndrome) secondary to hypotension.

7. Secondary Postpartum Haemorrhage

Secondary PPH is often associated with endometritis. When antibiotics are clinically indicated, a combination of ampicillin (clindamycin if penicillin allergic) and metronidazole is appropriate. In cases of endomyometritis (tender uterus) or overt sepsis, seek advice from a microbiologist about appropriate antibiotic therapy.

Surgical measures should be undertaken if there is excessive or continuing bleeding, irrespective of ultrasound findings.

Consultant obstetrician should be involved in decisions and performance of any evacuation of retained products of conception as these women are carrying a high risk for uterine perforation.

Monitoring Arrangements

This guideline will be monitored as detailed in the Jessop Wing Maternity Services Clinical and Operational Monitoring Plan.

Author for the guidelines:

Fiona Fairlie

Designation: Consultant Obstetrician

MANAGEMENT OF MAJOR POSTPARTUM HAEMORRHAGE

Estimated Blood Loss, more than 1,000 ml and continuing to bleed OR clinical shock

Women at High Risk of Haemorrhage

The following conditions are associated with a significant risk of maternal haemorrhage either antepartum, intrapartum and/or postpartum:

• Placenta Praevia

• Morbidly Adherent Placenta (Accreta/Increta/Percreta)

• Placental Abruption

• Large or Multiple Uterine Fibroids

• Previous Postpartum Haemorrhage with Complications

• Uterine Inversion

Before Delivery (not applicable to Abruption and Uterine Inversion, complications which cannot be predicted):

• Detect and correct anaemia.

• Consultant obstetrician and anaesthetist should be alerted to the arrival of these women on labour ward.

• Adequate intravenous access (2 large bore cannulae) should be in place before any surgery starts.

• Alert blood bank and haematologist—at least 4 units of blood should be cross-matched and be immediately available.

Once Delivery is Inevitable:

• A consultant obstetrician should be present for any elective or emergency surgery.

• Any anaesthetic should be supervised by a consultant anaesthetist.

See also the following guidelines: Postpartum Haemorrhage, Antepartum Haemorrhage, Women who Decline Blood Products

Author for the guidelines:

Fiona Fairlie

Designation: Consultant Obstetrician

Rusch Balloon Catheter for Major Postpartum Haemorrhage

INTRODUCTION

A Rusch balloon is a latex urological hydrostatic balloon catheter. Its use is one of the recognised techniques for controlling postpartum haemorrhage. The balloon conforms naturally to the contour of the uterus and hence, it applies symmetrical pressure to the entire uterine cavity. Complex uterine packing is not required and the device is easy to remove. The procedure is easy to learn and can be performed by the registrar on-call after discussing the case with the consultant.

INDICATIONS FOR USE

It may be used in any case of postpartum haemorrhage except for those due to trauma of the genital tract or if there is a history of latex allergy.

PREREQUISITES:

• General or regional anaesthesia in the operating theatre

• An assistant to help with equipment handling

• Consent for laparotomy and hysterectomy

• A 50–100 ml syringe, and 1 litre warm fluid

• Two vaginal retractors and 5 sponge holder forceps

• IV antibiotics in theatre and until the catheter is removed

• Oxytocin infusion (at a rate of 2.5 units per hour, i.e. 10 units in 500 ml normal saline at 125 ml per hour over 12–24 hours) to be maintained whilst the balloon is in situ and for 4 hours post-removal

• Moist ribbon gauze vaginal pack.

NOTE: THE RECOMMENDATION FOR OXYTOCIN INFUSION RATE IS LESS THAN THAT RECOMMENDED FOR MANAGEMENT OF POSTPARTUM HAEMORRHAGE

DESCRIPTION OF THE PROCEDURE:

1. The woman should be placed in the Lloyd Davies position.

2. The bladder is then catheterised.

3. Hold the cervix with 4 sponge holders if the patient had vaginal delivery. One sponge holder is placed on the anterior lip of the cervix, one on the posterior lip. The other two forceps are used to reduce the cervical opening by placing them laterally on both sides, holding the anterior and posterior lips at the same time.

4. The Rusch catheter is inserted into the uterine cavity using sponge holder forceps.

5. Using a 50–100 ml bladder syringe, the catheter is inflated via the drainage port, not the valve port, with 300–800 ml of either warm saline, 5% dextrose or distilled water. Infusion should continue until bleeding ceases or when the resistance equivalent to that used when inflating a Foley catheter balloon is achieved.

6. The amount of fluid inserted into the balloon should be documented in the case records.

NB: If a vaginal pack is not required—see Note 7: the balloon may be inflated to a maximum of 1,000 ml. If a pack is required, the balloon pressure increases and may lead to balloon rupture, hence the requirement to restrict inflation to 800 ml in these cases.

7. The vagina is then packed using moist ribbon gauze to keep the balloon in place especially when the cervix is fully dilated following vaginal delivery. The pack is placed as follows: start packing the posterior fornix, then remove the sponge holder from the posterior lip, then pass the gauze over the cervix and pack the anterior fornix after removing the sponge holder from the anterior cervical lip, then pack both lateral fornices and remove both sponge holders.

8. A vaginal pack may not be needed if the woman has had an elective caesarean section or an emergency caesarean section at less than 5 cm dilatation.

POST-PROCEDURE

1. Effective pain relief is required preferably opiate analgesia (e.g. subcutaneous morphine).

2. The woman should be transferred to HDU and the catheter and the pack remain in situ for 12–24 hours.

3. Oxytocin infusion (at a rate of 2.5 units per hour, i.e. 10 units in 500 ml normal saline at 125 ml per hour over 12–24 hours) should be administered to maintain the uterine tone.

NOTE: THE RECOMMENDATION FOR OXYTOCIN INFUSION RATE IS LESS THAN THAT RECOMMENDED FOR MANAGEMENT OF POSTPARTUM HAEMORRHAGE

REMOVAL OF THE BALLOON AND/OR VAGINAL PACK

The balloon should be removed between 9am–3pm when the senior help is immediately available.

Before removal of the balloon, the woman should be fasted for 6 hours and obstetric theatre alerted.

The balloon should be removed in obstetric HDU.

When asking midwifery staff to remove the balloon, detailed instructions should be provided.

After 12–36 hours the fluid from the catheter is withdrawn gradually at a rate of 100 ml every 15 minutes and the last 200 ml can be withdrawn in one go.

The vaginal pack then is removed. The time of this should be documented in the case notes.

Oxytocin infusion at a rate of 40 units in 500 ml normal saline over 4 hours should be administered to maintain the uterine tone.

Antibiotic cover is advised in the first 12–24 hours.

DOCUMENTATION

It is essential that the documentation is accurate with comprehensive details of postoperative care.

POTENTIAL PROBLEMS

If you are faced with difficulty removing the fluid from the balloon then the most likely cause is kinking of the catheter and hence you need to remove part or all the vaginal pack.

The balloon can rupture (rare). If that happened remove the pack and the balloon and watch for bleeding. In most cases if the balloon was in place for 4 hours or more, the woman will not bleed and you do not need to replace it. If it happens very soon after insertion it could be replaced.

Author for the guidelines, updated March 2011:

Remon Keriakos

Designation: Consultant Obstetrician