9.1 Postpartum Haemorrhage (PPH): Definition, 4Ts, Bimanual Compression & Medical Protocols

Postpartum Haemorrhage (PPH): Definition, 4Ts, Bimanual Compression & Medical Protocols

Postpartum haemorrhage (PPH) remains one of the leading direct causes of maternal morbidity and mortality worldwide and across the United Kingdom. Rapid recognition, structured multidisciplinary communication, and swift execution of mechanical, pharmacological, and surgical interventions are essential competencies tested in the NMC Midwifery Test of Competence. Practice in the UK is governed by the Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guideline No. 52 (Postpartum Haemorrhage: Prevention and Management).

---

Clinical Definitions & Classification of PPH

Postpartum haemorrhage is categorized by timing (primary versus secondary) and quantified by the estimated volume of blood loss alongside maternal clinical compromise.

Primary Postpartum Haemorrhage

Primary PPH is defined as the loss of ≥500 mL of blood from the genital tract occurring within 24 hours of birth.

In accordance with national UK guidelines, primary PPH is clinically stratified into:

• Minor PPH: Cumulative blood loss of 500 mL to 1,000 mL without clinical signs of shock.
• Major PPH: Cumulative blood loss of >1,000 mL, or any volume of bleeding accompanied by maternal cardiovascular compromise or clinical shock. Major PPH is further subdivided into:
  • Moderate Major PPH: Blood loss of 1,001 mL to 2,000 mL.
  • Severe / Massive Major PPH: Blood loss exceeding 2,000 mL, or bleeding associated with profound haemodynamic instability.

Secondary Postpartum Haemorrhage

Secondary PPH is defined as excessive, abnormal, or prolonged vaginal bleeding occurring between 24 hours and 12 weeks postpartum (RCOG). It is most commonly triggered by endometritis (pelvic infection) or retained placental tissue or membranes, frequently presenting in the community with subinvolution of the uterus, pyrexia, pelvic pain, and offensive lochia.

---

The 4Ts Aetiological Framework

When managing PPH, midwives utilize the mnemonic of the 4Ts to systematically diagnose and treat the underlying source of bleeding:

---

Step-by-Step Emergency Resuscitation Protocol

Management of major PPH requires rapid, simultaneous execution of communication, clinical assessment, resuscitation, and source control.

                    ┌──────────────────────────────────────────────┐
                    │          PRIMARY PPH ESCALATION PROTOCOL     │
                    └──────────────────────┬───────────────────────┘
                                           │
         ┌──────────────────┬──────────────┴─────┬──────────────────┐
         ▼                  ▼                    ▼                  ▼
┌─────────────────┐┌─────────────────┐┌─────────────────┐┌─────────────────┐
│  CALL FOR HELP  ││  ABCDE & AIRWAY ││   CIRCULATION   ││   MECHANICAL    │
│                 ││                 ││                 ││  INTERVENTIONS  │
│ • Emergency bell││ • High-flow O2  ││ • 2x 14G cannula││ • Rub up fundus │
│ • Call 2222     ││   (15 L/min NRB)││ • Bloods to lab ││ • Hamilton      │
│ • MDT alerted   ││ • Target sats   ││ • Warmed fluids ││   compression   │
│   (Obs, Anaesth,││   94–98%        ││ • Group & match ││ • Empty bladder │
│    Blood Bank)  ││                 ││   (4–6 units)   ││   (Foley in)    │
└─────────────────┘└─────────────────┘└─────────────────┘└─────────────────┘

1. Communication & Team Mobilization

• Pull the emergency call bell immediately.
• Dial the hospital emergency number (2222 across UK NHS trusts) and state clearly: "Obstetric Emergency, Major Obstetric Haemorrhage, Delivery Suite / Room Number."
• The obstetric emergency team must be mobilized at once: duty obstetric registrar, consultant obstetrician, duty anaesthetist, operating department practitioner (ODP), senior coordinating midwife, blood transfusion laboratory biomedical scientist, and hospital portering staff.
• Appoint a dedicated scribe to record timestamps, vital signs, administered medications, and cumulative blood loss.

2. Airway, Breathing & Oxygenation

• Assess airway patency and administer high-flow oxygen at 15 L/min via a non-rebreathe mask with reservoir bag, titrating to maintain maternal oxygen saturations between 94% and 98%.

3. Circulation & Intravenous Access

• Establish two wide-bore intravenous cannulae (preferentially 14-gauge orange or 16-gauge grey) into prominent antecubital veins.
• Immediately draw urgent baseline laboratory bloods:
  • Full Blood Count (FBC) (haemoglobin and platelet count);
  • Clotting Screen (Prothrombin Time [PT], Activated Partial Thromboplastin Time [APTT], and Fibrinogen level);
  • Group and Crossmatch 4 to 6 units of packed red blood cells;
  • Urea & Electrolytes (U&Es) and Liver Function Tests (LFTs);
  • Venous or Arterial Blood Gas (VBG/ABG) for bedside assessment of lactate, haemoglobin, base deficit, and ionised calcium.
• Initiate rapid intravenous fluid resuscitation with up to 2,000 mL of warmed isotonic crystalloid (e.g. Hartmann's solution or 0.9% sodium chloride). If bleeding persists and crossmatched blood is not yet available, administer Group O RhD-negative uncrossmatched blood from the satellite emergency fridge without delay.

---

Mechanical Interventions: Fundal Massage, Bimanual Compression & Catheterisation

Before or simultaneously with pharmacological administration, physical measures must be applied to mechanically compress the myometrial vascular bed:

1. Uterine Fundal Massage: Place a cupped hand firmly onto the maternal fundus and perform continuous circular rubbing motions ("rubbing up a contraction") to stimulate endogenous prostaglandin release and muscular contraction.
2. Bimanual Uterine Compression (Hamilton Manoeuvre):
   • Cleanse the perineum with antiseptic solution and don sterile gloves.
   • Form a firm fist with the dominant gloved hand and introduce it into the vagina, positioning the knuckles against the anterior vaginal fornix, pressing against the anterior uterine wall.
   • Place the other hand externally over the maternal abdominal wall onto the posterior aspect of the uterine fundus.
   • Compress the uterine corpus firmly between the internal vaginal fist and external abdominal hand, forcing the anterior and posterior uterine walls together. This directly compresses the bleeding placental bed vessels against each other, stemming arterial flow while medical therapies take effect.
3. Indwelling Bladder Catheterisation:
   • Insert a Foley catheter with a dedicated urometer.
   • A distended urinary bladder displaces the uterus superiorly and laterally, mechanically obstructing myometrial contraction and atony resolution.
   • Catheterisation empties the bladder immediately and allows strict hourly monitoring of urinary output, serving as an indispensable indicator of renal perfusion and end-organ resuscitation (target ≥0.5 mL/kg/hr or ≥30 mL/hr).

---

Pharmacological Uterotonic Ladder & Tranexamic Acid

When uterine atony is diagnosed or suspected, the midwife and obstetric team must administer uterotonic medications sequentially according to the evidence-based clinical ladder:

---

Intrauterine Balloon Tamponade & Surgical Escalation

If pharmacological uterotonics fail to arrest bleeding, the woman must be transferred immediately to the obstetric operating theatre for surgical interventions:

1. Examination Under Anaesthesia (EUA): Direct visual inspection of the cervix, vagina, and perineum using broad Sims specula under optimal theatre lighting to exclude undetected high vaginal or cervical lacerations, alongside manual uterine exploration to remove any retained cotyledons or succenturiate lobes.
2. Intrauterine Balloon Tamponade (Bakri Balloon):
   • A sterile silicone balloon catheter is inserted through the cervix into the uterine cavity.
   • The balloon is inflated with 300 mL to 500 mL of warmed sterile saline under direct ultrasound visualization until firm contact with the myometrial walls is achieved.
   • A "tamponade test" is considered positive if bleeding via the central drainage lumen ceases. The balloon exerts direct hydrostatic pressure against the endomyometrial venous sinuses. It is maintained under continuous oxytocin infusion coverage for 12 to 24 hours before gradual deflation.
3. Haemostatic Brace Sutures (B-Lynch Suture): Compressive surgical suturing wrapping around the uterine fundus and lower segment, compressing the anterior and posterior walls together.
4. Vascular Ligation & Interventional Radiology: Bilateral uterine artery ligation, internal iliac (hypogastric) artery ligation, or selective percutaneous arterial embolization.
5. Peripartum Emergency Hysterectomy: The definitive, life-saving intervention of last resort for intractable haemorrhage refractory to all conservative surgical measures.

---

Activation of the Major Haemorrhage Protocol (MHP)

When blood loss exceeds 1,000 mL with active uncontrolled bleeding, or when haemodynamic shock ensues, the midwife or team leader activates the hospital Major Haemorrhage Protocol (MHP) by contacting the blood transfusion laboratory:

• Blood Products (RCOG GTG52): Red cells are given first, using O RhD-negative or group-specific blood in an emergency. If bleeding continues after 4 units of red cells and coagulation results are not yet available, 4 units of fresh frozen plasma are given; thereafter FFP and fibrinogen replacement are guided by laboratory or point-of-care tests. Platelets are given if the count falls below 75 × 10⁹/L. Obstetric protocols are therefore test-guided rather than a fixed 1:1:1 trauma ratio.
• Fibrinogen Replacement: Normal pregnancy fibrinogen levels are elevated (4.0–6.0 g/L). A fibrinogen level falling below 2.0 g/L is an ominous predictor of catastrophic coagulopathy and DIC, warranting immediate infusion of Cryoprecipitate (typically two pools of 5 units) or Fibrinogen Concentrate.
• Calcium Maintenance: Massive transfusion with citrated blood products chelates ionized calcium, impairing coagulation and myocardial contractility; 10 mL of 10% Calcium Gluconate IV is administered every 4 units of blood products.
• Point-of-Care Coagulation: Utilization of Rotational Thromboelastometry (ROTEM) or Thromboelastography (TEG) allows rapid, goal-directed guided transfusion within 10–15 minutes.