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

Postpartum%20hemorrhage Diagnosis

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 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
Editor's Recommendations
Special Reports