- Written by: Dr. Kyla Freeman (Family Medicine Resident, PGY1)
- Expert reviewed by: Dr. Nicole Ebert (OSS trained rural Family Doctor)
- Hosts: Kyla Freeman, Patricia Massel, Caitlin Blewett
The goal of this episode is to review the key risk factors and management steps for postpartum hemorrhage. We will cover the basics that all maternity care providers should know as well as discuss some topics which may or may not be within the scope of a low-risk family doctor, but are helpful to know so you can be thinking ahead to those next steps and counselling patients on what might come next.
**New PPH Guidelines were released by the SOGC December 2022**
Key Medications & Maneuvers
- Oxytocin 10 units IM as routine PPH prophylaxis11
- Oxytocin 20-40 units in 1L normal saline; Side effects are GI, hypotension9,11
- Misoprostol 400mcg SL ; Side effects are fever9,11
- Ergonovine 0.2-0.25mg IM or IV Q2H ; Side effects GI, hypertension ; Contraindications are hypertension9,11
- Carboprost 250mcg IM or IMM Q15 minutes to max of 8 doses; Side effects GI, bronchospasm, headache; Caution with asthma & major cardiovascular, renal or hepatic dysfunction9,11
- Tranexamic acid 1g IV over 10 minutes11
- Bimanual massage9,11
- Manual clot and/or placenta removal9,11
- Balloon tamponade9,11
- External aortic compression9,11
- Radiology – uterine artery embolization9,11
- Surgical – vessel ligation, compression sutures, hysterectomy9,11
California Maternal Quality Care Collaborative
Explore website for excellent PPH resources and handouts
OB Hemorrhage Toolkit 2.0. California Maternal Quality Care Collaborative. https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit. Accessed April 10. 2021.
- 1. Belfort MA. Overview of postpartum hemorrhage. In Lockwood CJ, Barss VA, eds. UpToDate website. https://www.uptodate.com/contents/overview-of-postpartum-hemorrhage?search=postpartum%20hemorrhage&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Updated June 24, 2021. Accessed July 3, 2021.
- 2. Belfort MA. Secondary (late) postpartum hemorrhage. In Simpson LL, Levine D, Barss VA, eds. UpToDate website. https://www.uptodate.com/contents/secondary-late-postpartum-hemorrhage?search=postpartum%20hemorrhage&topicRef=6710&source=see_link. Updated May 11, 2020. Accessed April 6, 2021.
- 3. Carroll M, Daly D, Begley CM. The prevalence of women’s emotional and physical health problems following a postpartum haemorrhage: a systematic review. BMC Pregnancy Childbirth. 2016; 16(1), 261. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5011962/. Published September, 2016. Accessed March 29, 2021
- 4. Demers C, Derzko C, David M, Douglad J. No. 163 – Gynecological and obstetric management of women with inherited bleeding disorders. JOGC. 2018; 40(2), e91-e103. https://doi.org/10.1016/j.jogc.2017.11.036. Reaffirmed February 2018. Accessed March 28, 2021.
- 5. Dunning T, Harris JM, Sandall J. Women and their birth partners’ experiences following a primary postpartum haemorrhage: a qualitative study. BMC Pregnancy Childbirth. 2016; 16(80). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4835830/. Published April 2016. Accessed March 29, 2021.
- 6. Leduc D, Senikas V, Lalonde AB. No. 235-Active management of the third stage of labour: Prevention and treatment of postpartum hemorrhage. JOGC. 2018; 40(12), e841-855. https://doi.org/10.1016/j.jogc.2018.09.02. Reaffirmed December 2018. Accessed March 28, 2021.
- 7. Main KM, Goffman D, Scavone BM, et al. National Partnership for Maternal Safety consensus bundle on obstetric hemorrhage. Obstet Gynecol. 2015; 126(1): 155-162. DOI: 10.1097/AOG.0000000000000869.
- 8. Mavrides E, Allard S, Chandraharan E, Collins P, Gree L, Hunt BJ, Riris S, Thomson AJ on behalf of the Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum hemorrhage. BJOG. 2016; 124: e106 – e149. https://doi.org/10.1111/1471-0528.14178. Accessed March 31, 2021.
- 9. OB Hemorrhage Toolkit 2.0. California Maternal Quality Care Collaborative. https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit. Accessed April 10. 2021.
- 10. Society of Obstetricians and Gynecologists of Canada [SOGC]. Course manual: Advances in labour and risk management. 27th ed. Canada. SOGC; 2020-2021.
- 11. Society of Obstetricians and Gynecologists of Canada [SOGC]. Postpartum Hemorrhage. In: Course manual: Advances in labour and risk management. 27th ed. Canada. SOGC; 2020-2021: 336-382.
- 12. Society of Obstetricians and Gynecologists of Canada [SOGC]. Antepartum and Intrapartum Hemorrhage. In: Course manual: Advances in labour and risk management. 27th ed. Canada. SOGC; 2020-2021: 462-489.
- 13. Thurn L, Wikman A, Lindqvist PG. Postpartum blood transfusion and hemorrhage as independent risk factors for venous thromboembolism. Thromb Res. 2018; 165, 54-60. https://doi.org/10.1016/j.thromres.2018.03.002. Published March, 2018. Accessed April 7, 2021.