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 Signs and Symptoms

Introduction

  • 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

Postpartum Hemorrhage

  • PPH is the most common obstetrical complication of childbirth
    • Defined 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 
  • 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

Etiology

  • 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
  • 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, factor XI deficiency)
  • May be acquired during pregnancy [eg idiopathic thrombocytopenic purpura (ITP), thrombocytopenia with preeclampsia, disseminated intravascular coagulopathy (DIC)] or from therapeutic anticoagulation (eg history of thromboembolic disease)

Risk Factors

  • 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
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