Questionnaire/history:

Passage of clots?

Continuous bleeding that is more than usual lochia?

Breastfeeding?

> 4 weeks post birth?

(Note: consider first period (period will be delayed if breastfeeding, consider if breastfeeding has stopped))

Past medical history?

Manual removal of placenta?

Prolonged rupture of membranes?

Prolonged labour or fever during labour?

(Note: if any of the above consider endometriosis or retained products of conception (RPOC)

(most common causes of pathological secondary PPH)

Current medication?

Known drug allergies?

Examination:

Temperature?

Uterine tenderness of failure of uterine involution?

Offensive discharge (common if RPOC present)?

Management:

Primary postpartum haemorrhage (PPH) (in first 24 hours)

999 admission

Secondary PPH (in 24 hours to 12 weeks, usually 7-14 days postpartum)

> 4 weeks post birth: consider first period (period will be delayed if breastfeeding, consider if breastfeeding has stopped)

HVS and endocervical swabs

Consider pelvic USS for RPOC but they can be unreliable and if RPOC suspected refer to obstetrics & gynaecology(O&G) as surgical evacuation may need to be considered

Admit if unwell or haemodynamically unstable

If endometritis suspected and well enough to be treated in the community use broad-spectrum antibiotics

Reference(s):

RCOG 2016

BMJ 2017