postpartum%20hemorrhage
POSTPARTUM HEMORRHAGE
Postpartum hemorrhage is defined as blood loss of ≥500 mL for vaginal delivery after completion of the 3rd stage of labor while for cesarean delivery, the cut-off is 1000 mL.
It may present as either early (primary) or late (secondary) postpartum hemorrhage.
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

  • Placenta and fetal membranes are delivered after uterine massage, controlled cord traction and use of uterotonic drugs
  • 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 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, factor XI deficiency)
  • 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 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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