Postpartum%20hemorrhage Diagnosis

• Clinicians should be knowledgeable on risk assessment of PPH in recognizing stages of hemorrhage and prompt systematic intervention to avoid poor outcomes (eg maternal blood loss, hypotension, hypoxia, acidosis)
  • As visual estimation of blood loss is inaccurate as it is often underestimated, patient’s overall signs and symptoms should always be considered in the clinical assessment 
  • Consider an intra-abdominal cause of bleeding if visible blood loss is less than the observed degree of hemodynamic instability 
  • An obstetric shock index [pulse rate divided by systolic blood pressure (SBP)] of >1 is associated with significant PPH and needs immediate intervention 
• Perform simultaneously with acute treatment
• Prompt assessment to identify source or cause of hemorrhage
  • Exploration of the uterus
  • Careful inspection of the cervix and vagina
• Include complete blood count (CBC), ABO type screen and crossmatch, and coagulation studies 
• All centers involved in the care of pregnant women should have a protocol addressing obstetric hemorrhage

Degrees of Shock

Severe PPH

• Loss of 35-45% (2-3 L) of the total blood volume
• Patient is in profound shock manifesting as lethargy, SBP 50-70 mmHg, rapid and deep breathing and is anuric

Moderate PPH

• Loss of 25-35% (1.5-2 L) of the total blood volume
• Patient is restless with worsening tachycardia and tachypnea, confused with SBP 70-80 mmHg and is oliguric (urinary output is 5-20 mL/hr)

Mild PPH

• Loss of 15-25% (1-1.5 L) of the total blood volume
• Patient is weak, agitated, sweating, tachypneic and tachycardic with cold extremities; there is usually a slight fall in SBP to 80-100 mmHg and urine output is 20-30 mL/hr

Compensated PPH

• Loss of 10-15% (0.5-1 L) of the total blood volume
• Patient experiences palpitations and dizziness, urine output may remain adequate at >30 mL/hr