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					                                     WOMEN'S HEALTH PROGRAM

                                  GUIDELINES AND PROTOCOLS

                                                                                    Revised - October 2005

The incidence of excessive bleeding following birth ranges from 5-15% of deliveries. In Alberta in 1999-
2000, 16.5% of hospital deliveries were recorded as having postpartum hemorrhage (>500 ml blood loss
in the first 24 hours for vaginal deliveries and >1000 cc blood loss for caesarean section1.) Postpartum
hemorrhage (PPH) is a cause of direct maternal mortality and may account for at least 10-15% of direct
maternal deaths2.

Active management of the 3rd stage of labour involving prophylactic oxytocin given within 2 minutes of the
baby's birth and controlled cord traction significantly lowers the incidence of postpartum hemorrhage
versus expectant management (6.8% vs 16.5%, p <0.0001)3.

Policy for Prevention of Postpartum Hemorrhage

1. Oxytocin 5 units IV or 10 units IM after delivery of the shoulder to be given routinely.

2. In patients at risk for PPH (past history of PPH or risk factors - See Appendix A), a large bore IV (#18)
   access with Ringer's Lactate or Normal Saline should be established prior to delivery and blood
   obtained for CBC and type and screen.


Blood loss of >500 mL for vaginal delivery or >1000 mL for caesarean section in the first 24 hours.
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Women's Health Program Guidelines and Protocols

Nursing Protocol

1. Get help. Notify physician/midwife.

2. Initiate IV with large bore (#18) and Ringer's Lactate or Normal Saline and infuse a bolus.

3. Control bleeding by:

         • uterine massage
         • emptying uterus with fundal pressure
         • emptying the bladder

4. Assess and record vital signs.

5. Assess amount of bleeding by weighing and counting number of pads.

6. Administer medications and further fluid volume replacement as per order of physician.

Medical Protocol

    Medical Therapy

    The following therapy is to be done in order while simultaneously assessing etiology and applying
    directed treatment as appropriate.

         •   Oxytocin (Syntocinon) 40-60 units/1000 mL in Ringer's Lactate or Normal Saline at no greater
             at 125 mL/hour. This should be added as an additional or "piggy back" line to the main
             intravenous line of Normal Saline or Ringer's Lactate which can then be used as necessary
             for fluid resuscitation.

         •   Ergometrine:         0.25 mg IV slow push by physician
                                  0.125 mg IV and 0.125 mg IM
                                  0.25 mg IM.

         •   Carboprost (Hemabate) 250 mcg IM or intramyometrially (repeated at intervals of not less
             than 15 minutes to a maximum of 5 doses). Add antidiarrheal agent as per drug monograph.

         •   If carboprost contraindicated (asthma, MI) or ergonovine contraindicated (gestational
             hypertension) or unavailable, give misoprostol 800 mcg rectally.

    Medical Assessment and Treatment:

    1. Assess volume of blood loss. Order CBC and coagulation screen if indicated (PTT, INR,
Prevention and Treatment of Postpartum Hemorrhage                                                        3
Women's Health Program Guidelines and Protocols

    2. Replace blood loss by:

             • Crystalloid (Ringer's Lactate or Normal Saline)

             • Blood
                         Red blood cell transfusion is advised where blood loss is in excess of 40% of
                         women's blood volume (2L) or if ongoing hemorrhage is occurring.

             • Blood Factors
                      One litre (4-5 bags) of plasma is recommended for every 6 units of blood.
                      Platelet transfusion to maintain platelets at 50 x 109
                      Cryoprecipitate if fibrinogen falls to less than 1 g/L

             • Other volume expanders as appropriate

    3. Assess etiology:

             • explore uterus (tone, tissue)
             • explore lower genital tract (trauma)
             • review history (thrombin)

    4. Directed therapy

             • Tone:          massage
                              uterotonic agents

             • Tissue:       manual removal

             • Trauma:       correct inversion
                             repair laceration
                             identify rupture

             • Thrombin: reverse anticoagulants and replace factors

      5. Intractable PPH

             (1)    Get help. [another obstetrician, anesthetist, (possibly ICU, radiology)].

             (2)    Local control:
                       • Manual compression
                       • Vasopressin to placental bed ( 5 units/50 mL)
                       • Uterine tamponade - Sengstaken-Blakemore tube.
                       • B-Lynch suture

             (3)    Surgical options
                       • B-Lynch suture
                       • Uterine artery ligation
                       • Ovarian artery ligation
                       • Internal iliac artery ligation
                       • Hysterectomy

             (4) Radiology Option
                      • Uterine artery/internal iliac embolization
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Women's Health Program Guidelines and Protocols


1. Alberta Health and Wellness. Alberta Reproductive Health: Pregnancies and Births 2000. Alberta.

2. Lewis G, Editor. Why mothers die, 1997-1999. The fifth report of the confidential enquiries into
   maternal deaths in the United Kingdom. On behalf of the National Institute for Clinical Excellence, the
   Scottish Executive Health Department, and the Department of Health, Social Services and Public
   Safety: Northern Ireland. London: RCOG Press; 2001.

3. Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D. Active versus expectant
   management of third stage of labour: the Hinchingbrooke randomised controlled trial. Lancet

4. Schuurmans N, MacKinnon C, Lane C, Etches D. Prevention and management of postpartum
   haemorrhage. SOGC Clinical Practice Guidelines, No. 88, April 2000. J Obstet Gynaecol Can

5. Condous G, Arulkumaran S. Medical and conservative surgical management of postpartum
   hemorrhage. J Obstet Gynaecol Can 2003;25(11);931-935.
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Women's Health Program Guidelines and Protocols

                                                    APPENDIX A

                                            RISK FACTORS IN PPH*
                                               ETIOLOGY PROCESS                     CLINICAL RISK FACTORS
Abnormalities of uterine contraction    • over distended uterus               •   polyhydramnios
(Tone)                                                                        •   multiple gestation
                                                                              •   macrosomia
                                        • uterine muscle exhaustion           •   rapid labour
                                                                              •   prolonged labour
                                                                              •   high parity
                                        • intra amniotic infection            •   fever
                                                                              •   prolonged ROM
                                        • functional/anatomic distortion of   •   fibroid uterus
                                          the uterus                          •   placenta previa
                                                                              •   uterine anomalies
Retained Products of conception         • retained products                   •   incomplete placenta at delivery
(Tissue)                                • abnormal placenta                   •   previous uterine surgery
                                        • retained cotyledon or               •   high parity
                                          succinturiate lobe                  •   abnormal placenta on U/S
                                        • retained blood clots                •   atonic uterus
Genital Tract Trauma                    • lacerations of the cervix, vagina   •   precipitous delivery
(Trauma)                                  or perineum                         •   operative delivery
                                        • extensions, lacerations at          •   malposition
                                          caesarean section                   •   deep engagement
                                        • uterine rupture                     •   previous uterine surgery
                                        • uterine inversion                   •   high parity
                                                                              •   fundal placenta
Abnormalities of Coagulation            • pre-existing states                 •   hx of hereditary coagulopathies
(Thrombin)                                ♦ hemophilia A                      •   hx of liver disease
                                          ♦ von Willebrand's Disease
                                        • acquired in pregnancy
                                          ♦ ITP                               •   bruising
                                          ♦ thrombocytopenia with pre-        •   elevated BP
                                              eclampsia                       •   fetal demise
                                          ♦ DIC                               •   fever, WBC
                                                 pre-eclampsia                •   antepartum haemorrhage
                                                 dead fetus in utero          •   sudden collapse
                                                 severe infection
                                                 amniotic fluid embolus
                                        • therapeutic anti-coagulation        • hx of blood clot

* Table Source: SOGC Clinical Practice Guidelines. Prevention and Management of Postpartum Haemorrhage.
  Table 2. 4