postpartum%20hemorrhage
POSTPARTUM HEMORRHAGE
Postpartum hemorrhage is defined as blood loss of ≥500 mL for vaginal delivery or 1000 mL for abdominal (Caesarean) delivery after completion of the 3rd stage of labor.
Another proposed definition is a 10% fall in hematocrit value.
Since the clinical estimation of the amount of blood loss is typically inaccurate, the diagnosis of postpartum hemorrhage remains a subjective clinical assessment of the amount of blood loss that jeopardizes a woman's hemodynamic stability.
Postpartum hemorrhage may produce hemodynamic instability during the 1st 24 hours after delivery.

Introduction

  • Begins immediately after delivery of the fetus and ends with the delivery of the placenta and fetal membranes
    • Most cases of postpartum hemorrhage (PPH) occur during this stage; the amount of blood lost depends on how quickly the 3rd stage occurs
    • Typically lasts for 5-15 minutes; after 30 minutes, it is considered prolonged and may indicate a potential complication

Management of 3rd Stage of Labor

Expectant Management

  • Best described as “hands off” approach, often termed as physiologic method
  • Placental separation without intervention
    • Either delivered spontaneously or aided by gravity
  • The cord is not clamped or cut until it has stopped pulsating
  • Change in shape of the uterine fundus

Active Management

  • Clinical trials show that actively-managed 3rd stage of labor has lower incidence of PPH, retained placenta and lower need for additional uterotonic drugs
  • The International Federation of Gynecology and Obstetrics (FIGO) and the International Confederation of Midwives jointly stated that active management of the 3rd stage of labor should be offered to women since it is proven to reduce the incidence of PPH, the quantity of blood loss and the use of blood transfusion
  • The World Health Organization (WHO) Reproductive Health Library and Cochrane database confirmed that active management is associated with reduced maternal blood loss, postpartum anemia and decreased need for blood transfusion
  • Active management of the 3rd stage of labor is practiced in many countries, but in others it may be reserved for women at high risk for PPH

Etiology

  • Early postpartum hemorrhage (PPH) is typically caused by at least one of following:Tone, tissue, trauma, thrombin

Tone (Uterine Atony)

  • Is the failure of contraction and retraction of myometrial muscle fibers after delivery
  • This is the most common cause of PPH
  • Causes of uterine atony include the following:
    • Overly distended uterus: Multiparity, fetal macrosomia, polyhydramnios
    • Fatigued uterus: Amnionitis, prolonged labor or rapid forceful labor, use of tocolytics, high parity
    • Obstructed uterus: Retained placenta or fetal parts, placenta accreta, overly distended bladder, anatomic/ functional distortion of uterus
    • Other causes include previous PPH or use of general anesthesia

Tissue (Retained Products of Conception)

  • Bleeding may occur from retained products, blood clots, cotyledon or succenturiate lobe or from an abnormal placenta

Trauma (Genital Tract Trauma)

  • Genital tract damage may occur spontaneously or through manipulations used to deliver the baby, eg episiotomy
  • Lacerations may be present in the cervix, vagina or perineum
  • Extensions or lacerations at cesarean section
  • Uterine rupture or uterine inversion

Thrombin (Coagulopathy)

  • Can be caused by preexisting disorders (eg hemophilia A, von Willebrand’s Disease)
  • May be acquired during pregnancy [eg idiopathic thrombocytopenic purpura (ITP), thrombocytopenia with preeclampsia, disseminated intravascular coagulopathy] or therapeutic anticoagulation (eg history of thromboembolic disease)

Signs and Symptoms

Signs of Placental Separation

  • Lengthening of the umbilical cord
  • Gush of blood from vagina
  • Change in shape of the uterine fundus
    • Discoid to globular form with elevation of fundal height

Risk Factors

  • Previous postpartum hemorrhage (PPH)
  • Preeclampsia
  • Multiple gestation
  • Obesity
  • Episiotomy
  • Cesarean section
  • Retained placenta or placenta accreta
  • Large for gestational age newborn
  • General anesthesia
  • Failure to progress in 2nd stage 
  • Prolonged 3rd stage of labor
  • High parity
  • Overly distended uterus
  • Genital tract trauma or perineal laceration
  • History of coagulopathy
  • Augmented labor
  • Instrumental delivery
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS JPOG - Malaysia digital copy today!
DOWNLOAD
Editor's Recommendations
Most Read Articles
27 Nov 2017
Transdermal oestradiol added to progesterone reduces menopause-related depression, researchers reported at the annual meeting of The North American Menopause Society in Philadelphia, US.
5 days ago
Intravenous (IV) iron is less toxic and more effective compared to oral iron, making it a potential frontline therapy for neonatal iron deficiency anaemia, suggests a recent study.
Tracy TC Kwan, BSc (Nursing), MPH; Hextan YS Ngan, MBBS, FHKAM (O&G), MD (HK), FRCOG, 01 Aug 2013

Human papillomavirus (HPV) infection is a prevalent disease worldwide. Consequences of HPV infection vary, depending on the infected individuals and the HPV genotype involved. Life-threatening consequences are not uncommon, and cervical cancer is a clear demonstration of the virus’s potency. While the incidence of cervical cancer is heavily concentrated on developing countries,1 the impact of HPV-related diseases on developed countries has not ceased. In the United States alone, HPV infections are the most common sexually transmitted disease with an estimated 5 million new cases being diagnosed in 2000 among young adults, incurring nearly US$3 billion in terms of direct medical costs.2 A multinational study involving 18,498 women showed that cervical HPV prevalence varied greatly geographically, ranging from the low of 1.6% in North Vietnam to the high of 27% in Nigeria. In general, HPV prevalence peaked among young, sexually active women and declined with age. In selected countries, however, a second peak was noted in women older than 55 years.3 The high prevalence of HPV-related diseases incurs a heavy burden on the healthcare systems of developed and developing countries alike, which renders HPV research and prevention a global public health imperative. On an individual level, the afflictions caused by HPV-related diseases go beyond that of physical suffering to affecting the psychological well-being of the infected. This is the focus of our paper.

27 Nov 2017
Chronic hepatitis B virus (HBV) infection is a global problem. Chronic HBV infection is probably the most common maternal infection encountered in Hong Kong, China, and Southeast Asia. In Hong Kong, which is one of the endemic areas, immunisation against HBV was first provided in 1983 to infants born to mothers who were screened positive for hepatitis B surface antigen (HBsAg). Immunisation became widespread since November 1988, but HBsAg-positive mothers are still encountered frequently.1