• 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

• 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

• 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