Visual summary

Postpartum haemorrhage
A suggested approach to management based on possible causes*

Primary postpartum haemorrhage

Poor uterine tone Tears or trauma Retained tissue

Clinical findings Clinical findings Clinical findings
Abdominal Uterine fundus Bleeding Retained placenta and membranes
palpation
May be felt above the from areas of trauma within genital tract Identified during bimanual examination
Uterus feels relaxed, umbilicus if uterine
boggy, and soft cavity is filled with
blood and clots Uterine rupture Extension of Investigations
uterine angles
Examination under anaesthesia
Investigations If patient is not Tears during caesarean section
responsive to fluid and
Full blood count blood replacement: Management
Extragenital causes
Coagulation profile Abdominal Manual removal
ultrasound Such as subcapsular live rupture or rupture
of ovarian or splenic vessels of placenta or retained products of conception
Urea and To exclude uterine under regional or general anaesthetic
electrolytes rupture or intra-
peritoneal bleeding
Investigations
Inspection during Ultrasound Coagulopathy
Management caesarean section
May help identify free Clincal findings
Uterotonic agents HAEMOSTASIS
By exteriorisation fluid in patients with
algorithm
uterine rupture Continuing bleeding, contracted uterus
Oxytocics
See main article
Prostaglandins for recommended,
Management Investigations Full blood count
stepwise, surgical
Ergot alkaloids measures when Urea and
medical treatment Repair of identified genital tract trauma electrolytes Coagulation profile
fails
Uterine balloon
tamponade Pelvic arterial embolisation
Management
May be required in cases of broad ligament
or supralevator haemoatoma Medical Surgical
Immediate Only with trauma or
replacement of blood atonic haemorrhage
and coagulation unresponsive to
factors and platelets medical treatment

Secondary postpartum haemorrhage 24 hours to 12 weeks after delivery

Endometritis Pseudo-aneurysm, uterine artery Retained tissue

Clinical findings Clinical findings Clinical findings Fever
Guarding and
Uterine tenderness rebound tenderness Profuse bleeding Shock Foul smelling or offensive Uterine
May be noted if there vaginal discharge tenderness
on clinical examination
is peritonitis More than 24 hours after childbirth
Investigations Ultrasound
Investigations Investigations
To confirm retained products of conception
Ultrasound to exclude: Doppler ultrasound MRI
High To exclude pelvic abscess
Retained products of conception vaginal Pelvic angiography
swabs
Pelvic abscess Management
Surgical
Management
Medical
Evacuation of
Management Medical Surgical
Oral antibiotics retained products
Uterine artery of conception
Oral Admit to hospital Antibiotics if Admit for intrave-
antibiotics coexisting infection embolisation
nous antibiotics if Consider expectant
for intravenous antibiotics
Correction of blood unwell or haemody- management in
if patient is unwell or
volume namically unstable mild cases
haemodynamically unstable

*Adapted from RCOG Green-top Guideline on postpartum haemorrhage5

© 2017 BMJ Publishing group Ltd.

Read the full http://bit.ly/BMJpphG Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations,
article online conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of
treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own
risk. For the full disclaimer wording see BMJ's terms and conditions: http://www.bmj.com/company/legal-information/