Postpartum%20hemorrhage Diagnosis
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
- Defined as blood loss of 500 mL or more, for vaginal delivery, after completion of the 3rd stage of labor
- 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