Postpartum Hemorrhage
last authored: July 2010, David LaPierre
last reviewed: Sept 2010, Lauren Brodie
Introduction
"If you lose your father, it's bad luck; if you lose your mother, you're an orphan."
Dr. Jean Chamberlain Froese, Canadian obstetrician living in Uganda
Postpartum hemorrhage (PPH), or excessive bleeding after birth, is the most common, and preventable, causes of maternal mortality worldwide (UN 2010). It affects 14 million women yearly, leading to death in 140,000 and severe, long-lasting anemia in 1.6 million (AbouZhar, 2003). Hemorrhage is the third leading cause of maternal death in the US (after embolism and hypertension). PPH has an incidence of 2-8%, with a recurrence rate of 20-25%.
PPH is defined as more than 500mL blood loss within the first 24 hours after normal vaginal delivery, or more than 1000mL after cesarean section. However, actual measured blood loss following uncomplicated vaginal delivery is 700 mL, and we frequently underestimate blood loss (Poggi, 2007). Hemorrhage of this magnitude is common without being an imminently life-threatening situation.
Primary PPH occurs within the first day, while the much rarer secondary PPH may occur after the first 24hours. PPH can occur without warning, and health care providers should be prepared and equipped for its possibility.
The Case of Jill M.
Jill is a 34 year-old woman who arrives at the labour and delivery unit in labour with her fifth child. Her last delivery was complicated by a post-partum hemorrhage, and she (and the doctor and nurses) are concerned it may happen again.
- what are the risk factors for PPH?
- how can it be prevented?
- what are the treatments that may be considered if PPH does occur?
Causes and Risk Factors
A mnemonic to remember causes of PPH is the four T's: tone, tissue, trauma, thrombin.
Tone: uterine atony (50-80% of cases) Bleeding is normally controlled by contriction of the myometrium around the vasculature supplying the placenta. Atony occurs when these muscles do not contract.
Maternal factors
Uterine factors
Placental factors
Labour
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Tissue: factors that prevent sufficient uterine contraction
Trauma:
Thrombin: coagulopathy
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Prevention
Prevention is the most desirable strategy for managing PPH, and all patients should be evaluated regarding their potential risk.
Women who suffer from anemia, malnutrition, or otherwise poor health are more likely to experience mobidity or mortality with excessive blood loss. Health should be optimized as best as is possible before delivery.
Patients at increased risk may have blood typed and cross-matched immediately if possible, with blood stored for 24 hours. IV access should be maintained.
PPH may be prevented by actively managing the third stage of labour and by giving oxytocin IM, or slow IV infusion as the anterior shoulder delivers. This has been shown to result in significant reduction in blood loss >500mL and in the need for therapeutic oxytocin (Poggi, 2007). Following delivery, the uterus should be massaged in a circular or back-and-forth motion to encourage contraction.
The placenta typically separates and delivers soon after the infant. Signs of placental separation include the uterus becoming round and firm, a rising of the uterus, a sudden gush of blood, and cord lengthening. Traction of the cord, along with abdominal fundual pressure towards the head, will faciliate placental delivery after separation. Inspect the placenta for completeness immediately after delivery.
Assessment
Recognition of the amount and location of hemorrhage is critical. Ensure adequate lighting, assistance, pain control, and retractors.
Bleeding may be hidden in the uterus or as a vaginal or vulvar hematoma. The OR may be needed to definitively identify source of bleeding.
- history
- physical exam
History
Interview the patient for signs and symptoms of hypotension. These include:
- oliguria
- headache
- pre-syncope
Physical Exam
Assess fundus for firmness, or lack thereof (bogginess). Perform prompt and firm uterine massage, removing clots by bimanual exam. Lacerations of the perineum, vagina, and cervix may be identified visually or on exam.
If the placenta is undelivered, remove manually.
Observe the patient for signs of hypotension, which include:
- decreased blood pressure
- pallor
- diaphoresis
- confusion
- lab investigations
- imaging
Lab Investigations
If hemorrhage occurs, send bloodwork for:
- CBC
- platelets
- type and X-match 4 units
- consider coagulation studies
Imaging
Ultrasound may be used to assess for retained POC. This is especially important for hemorrhage occurring a few hours after delivery.
Management
All resources and personnel necessary to promptly respond to PPH should be available during delivery.
Again prevention is critical regarding PPH. This includes:
- risk profile assessment, blood typed and cross-matched as deemed necessary.
- oxytocin with delivery of anterior shoulder
- timely (within 10 min) of delivery of placenta, assisted with steady traction on umbilical cord and steady upward traction on the lower uterine segment
Repair of lacerations
Ensure adequacy of lighting and assistants. A pack in the posterior vagina can help keep the field visible. Do not forget to remove it after repair.
As vessels tend to retract from laceration site, it is best to start at the highest extent of the laceration. Gentle traction should be used to bring the laceration site closer to the introitus. Sutures should be placed to obtain hemostasis. Further inspection of the entire birth canal should follow.
Lacerations extending into the broad ligament, or causing large hematoma, require operative assessment and repair.
Ongoing bleeding
If bleeding persists after placental delivery and repair of lacerations, recuscitation may quickly become necessary. Key components include:
- continue monitoring and support of of ABC's
- obtain IV access with two large bore IV's
- notify nursing, anesthesia staff
- inspect cervix and vagina
- manually compress uterus
- obtain blood for typing and cross-match, transfuse as necessary
- observe blood for clotting
- begin fluid replacement
- explore uterine cavity
- bladder catheterization to measure fluids, relieve discomfort, and offload the uterus
Bimanual compression and massage is a key measure in controlling atonic hemorrhage, and may need to be comntinued for up to 30 minutes. One hand is placed on the patient's abdomen to compress the fundus, and the other is placed into the vagina. One finger is placed on either side of the cervix to push it anteriorly and cephalad. Uterine arteries may be palpated.
Medications
First line treatment of postpartum hemorrhage is oxytocin. It may be given as IM or IV drip; run wide open in saline or Ringer's until uterine firmness increases.
Other options include (most contraindicated with hypertension or asthma):
- prostaglandin E1 derivative (misoprostol) PO, sublingual, or PR (may cause significant GI upset)
- ergometrine (caution with hypertension and some HIV medications)
- methylergonovine (Methergine) IM
- 15-methyl prostaglandin (hemabate) IM
- prostaglandin E2 per rectum
Refractory Cases
With uncontrolled bleeding, inform patient of urgency of situation and of potential need for hysterectomy. Discuss all possibilities and obtain consent. Reinspect, including previous surgical repair of lacerations. A tamponade balloon may be very helpful.
Re-evaluate potential role of coagulopathy by placing blood in an unheparinized tube. Transfuse as necessary; consider replacing platelets and cogulation factors.
If uterus remains atonic, prepare for OR and move to surgical interventions. Options include:
- hematoma incision and drainage
- removal of retained POC using curette or forceps
- uterine packing
- vessel ligation or embolization (interventional radiology)
- B-lynch compression sutures via laparotomy
- hysterectomy
Consequences and Course
The most serious consequence of PPH is death, and unfortunately a common one in much of the world. Over 140,000 women die worldwide from PPH yearly (AbouZhar, 2003). Other consequences of PPH include:
- shock
- need for transfusion and its attending complications
- adult respiratory distress syndrome
- renal failure following hypotension
- coagulopathy
- Sheehan syndrome (pituitary necrosis)
- loss of fertility following surgical intervention
Resources and References
AbouZhar C. 2003. Global burden of maternal death and disability. Br Med Bull. 67(1): 1-11.
Anderson JM, Etches D. 2007. "Prevention and management of postpartum hemorrhage". American Family Physician 75 (6): 875–82.
ACOG Practice Bulletin No 76: Postpartum Hemorrhage. Washington DC. Oct 2006.
Poggi SBH. 2007. Chapter: Postpartum Hemorrhage and the Abnormal Puerperium. In Lange, Current Diagnosis and Treatment, Obstetrics and Gynecology, 10th Edition. pp 477-484.
United Nations Millenium Development Goals Report 2010.
Topic Development
authors: David LaPierre (2010)
reviewers:
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