Causes. Prevention

Causes

Causes of PPH may be conveniently remembered using 4 T’s as a mnemonic:

· Tone(Uterine atony)

· Tissue (retained products)

· Trauma( cervical & genital tract trauma during delivery)

· Thrombosis (coagulation disorder)

Other Risk factors include:-Prolonged labour, multiple pregnancy, polyhydramnios, large baby, obesity, previous uterine atony & coagulopathy.

Prevention

The most significant intervention shown to reduce the incidence of PPH is the active management of the third stage of labour (see below).Other measures to prevent or reduce the impact of MOH include

· Avoidance of prolonged labour

· Minimal trauma during assisted vaginal delivery

· Detection & treatment of anaemia during pregnancy

· Identification of placenta praevia by antenatal ultrasound examination.

· Where facilities exist, magnetic resonance imaging (MRI) may be a useful tool and assist in determining whether the placenta is accreta or percreta. Women with placenta accreta/percreta are at very high risk of major PPH. If placenta accreta or percreta is diagnosed antenatally, there should be consultant-led multidisciplinary planning for delivery ⁹.

Active management of the third stage

This represents a group of interventions including early clamping of the umbilical cord, controlled cord traction for placental delivery & prophylactic administration of uterotonic at delivery (e.g. oxytocin) ¹⁰. Active management of the third stage is associated with a lower incidence of PPH and need for blood transfusion ¹¹. A longer acting oxytocin derivative, carbetocin, is licensed in the UK specifically for the indication of prevention of PPH in context of caesarean delivery. Randomised trials suggest that a single dose (100 mcg) of carbetocin is at least as effective as oxytocin by infusion ^{12, 13}.

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