Postpartum%20hemorrhage Signs and Symptoms

• The 3rd stage of labor 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

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

• PPH is the most common obstetrical complication of childbirth with a prevalence of 1.9-8% in Asia
  • Defined traditionally as blood loss of ≥500 mL for vaginal delivery and ≥1000 mL for cesarean delivery, after completion of the 3rd stage of labor
    • Severe PPH is defined as persistent or ongoing blood loss of >1000 mL during the 1st 24 hours after delivery or blood loss which may produce signs and symptoms of hemodynamic instability
    • Life-threatening PPH is refractory blood loss of >2500 mL or hypovolemic shock
  • Another proposed definition is a 10% fall in hematocrit value
    • Limited use because such marker may be delayed and may not reflect present hematologic status 
    • 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
• Whenever possible, blood loss should be measured quantitatively and should be the basis of PPH staging and management 
  • 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
• Early or primary PPH is defined as bleeding of >500 mL within 24 hours of delivery 
  • One of the leading causes of maternal mortality
  • Causes may include uterine atony, pelvic trauma, retained tissue, coagulopathy, uterine inversion and abnormal placentation
• Late, delayed or secondary PPH occurs 24 hours after delivery and up to 6-12 weeks after birth
  • Causes may include endometritis, retained products of conception, coagulopathy, infection, uterine pathology 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

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

Tone (Uterine Atony)

• Failure of contraction and retraction of myometrial muscle fibers after delivery
• Most common cause of PPH at 70% of cases
• Causes of uterine atony include the following:
  • Overly distended uterus: Multiparity, fetal macrosomia, polyhydramnios
  • Fatigued uterus: 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, prolonged rupture of membranes, chorioamnionitis, anemia 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 abnormally adherent 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, factor XI deficiency, idiopathic thrombocytopenic purpura)
• May be acquired during pregnancy [eg thrombocytopenia with preeclampsia, disseminated intravascular coagulopathy (DIC), severe infection, amniotic fluid embolism, fetal death, abruption] or from therapeutic anticoagulation (eg history of thromboembolic disease)

• Previous 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
• Anemia