postpartum%20hemorrhage
POSTPARTUM HEMORRHAGE
Postpartum hemorrhage is defined as blood loss of ≥500 mL for vaginal delivery after completion of the 3rd stage of labor while for cesarean delivery, the cut-off is 1000 mL.
It may present as either early (primary) or late (secondary) postpartum hemorrhage.
Postpartum hemorrhage may produce hemodynamic instability during the 1st 24 hours after delivery.

Patient Observation

  • Inspection of both the placenta and the lower genital tract
    • The placenta should be inspected for completeness
    • The lower genital tract thoroughly examined for lacerations
  • Ensure continued uterine contraction by fundal palpation and rub or massage as necessary
    • Uterus should be massaged immediately then every 15 minutes thereafter, repeated as needed during the first 2 hours
    • Ensure that the uterus does not relax after massage is stopped
  • Monitor patient for any sign of excessive bleeding

Evaluation

  • Postpartum hemorrhage (PPH) may produce hemodynamic instability during the 1st 24 hours after delivery
    • Defined as blood loss of 500 mL or more, for vaginal delivery, after completion of the 3rd stage of labor
      • For abdominal (cesarean) delivery, the cut-off is 1000 mL
    • Another proposed definition is a 10% fall in hematocrit value
      • Some women may become compromised with relatively small blood loss (eg anemic women, women with gestational hypertension with proteinuria, dehydration)
      • Morbidity associated with PPH may be reduced with evaluation and treatment of antenatal anemia 
  • Since the clinical estimation of the amount of blood loss is typically inaccurate, the diagnosis of PPH remains a subjective clinical assessment of the amount of blood loss that jeopardizes a woman’s hemodynamic stability
  • Bleeding of this amount within 24 hours of delivery is termed early or primary
    • One of the leading causes of maternal mortality
  • Late or secondary PPH occurs 24 hours after delivery and up to 6-12 weeks after birth
    • Causes may include endometritis, retained products of conception and subinvolution of the placental implantation site 
    • Consider endometritis or retained products of conception if patient has a prior history of prolonged rupture of membranes or manual placenta removal, prolonged labor, or fever during labor 
    • An ultrasound scan can help rule out retained products of conception 
  • Women with bleeding disorders have an increased risk of both early and late PPH

Assessment

  • 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 BP) of >1 is associated with significant PPH and needs immediate intervention 
  • 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, systolic blood pressure (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; urine output is 20-30 mL/hr and there is usually a slight fall in SBP to 80-100 mmHg

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
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