Postpartum Hemorrhage

 

Definition

Postpartum hemorrhage (PPH) is excessive blood loss at delivery sufficient to affect the general condition of the mother as shown by rising pulse rate, falling blood pressure, and poor peripheral perfusion.

The traditional definition, based on blood loss of 500 ml or more from within the reproductive tract after birth within 24 hours of delivery, is difficult to estimate in clinical practice.

 

There are two types of PPH:

• primary (within the first 24 hours)

• Secondary (through the 42^nd  day)

 

 

Postpartum hemorrhage is the leading cause of maternal mortality

 

Risk Factors

• Increasing maternal age >35 years

• Increasing parity

• Anemia and poor nutritional status

• Uterine overdistension (multiple pregnancy, macrosomia, polyhydramnios)

• Antepartum hemorrhage

• Previous postpartum hemoorhage

• Prolonged labor

• Traumatic delivery with laceration of perineum, cervix, vagina or uterus

• Complications of third stage of labor

• Previous cesarean section

• Certinal general anesthetics (e.g. halothane)

• Uterine fibroid

• Coagulation disorders:

Ø      Acquired

-         Pregnancy induced hyepertension

-         Amniotic fluid embolism

-         Placental abruption

-         Placenta praevia

-         Fetal demise

Ø      Inherited

Causes

 

• Poor uterine contraction (hypotonic or atonic)

• Damage to genital tract (traumatic)

• Coagulation disorders

 

Principal clinical signs

 

• Excessive observed loss of blood

• Falling blood pressure

• Tachycardia

 

NB In patients with hypertension or pre-eclampsia severe blood loss may cause misleading “normal” blood pressure

 

Laboratory Examination

 

• Complete blood count (hemoglobin, hematocrit, differential, platelet count)

• Bleeding time

• Coagulation time

• Blood grouping and Rh type

• Cross match as many units as needed for clinical situation

 

Laboratory Findings

 

• Low hemoglobin or hematocrit

• Increased bleeding time

• Increased coagulation time

• Decreased platelets

• Decreased fibrinogen

• Increased prothrombin time

• Increased partial thromboplastin time

• Fibrin split products positive

 

Management

 

Antenatal period

• Recognize risk factors

• For patients with previous PPH:

Ø      Routine laboratory examinations

Ø      Iron and Folic acid supplementation

Ø      Educate the patient to come to the hospital early in labor, the importance of iron supplementation, and the need to seek immediate medical attention if vaginal bleeding occurs

Ø      Refer to a tertiary level facility for antenatal management

 

Labor and Deliver

 

• Order routine laboratory examinations ( standard admission orders for labor ward)

• Actively manage the third stage of labor. Add oxytocin to IV infusion or inject IM with delivery of anterior shoulder or, if not hypertensive or cardiac patient, use ergometrine (Methergine)

 

Hemorrhage after delivery of baby, before delivery of the placenta:

 

• Determine cause of retained placenta (hour glass contraction vs partial separation)

• Continuous monitoring of pulse, blood pressure, urine output, and blood coagulation

• Establish adequate IV access (If not already in place)

• Empty bladder with Foley catheter

• Massage uterine fundus

• Administer Ergotrate 0.2 mg(1 ampule) M stat followed by controlled cord traction to deliver the placenta (maximum dose should not exceed 1 mg-5 amps) and watch for uterine inversion

• Administer rapid IV saline solution and start 40 IU oxytocin/liter

 

> If bleeding persists without delivery of placenta, rapidly explore the perineum, vagina, and cervix looking for lacerations

Call the anesthesiologist and perform manual removal of the placenta with adequate sedation (e.g. valium, pethidine) or anesthesia

 

      > If bleeding persists after removal of placenta , see below

 

Hemorrhage immediately after delivery of placenta:

 

• Establish adequate IV access (if not already in place)

• Prepare for blood transfusion

• Empty bladder with Foley catheter

• Administer Ergotrate 0.2 mg IV stat

• Administer Oxytocin 10-50 IU in 500 ml of dextrose or mixed IV solution, rapid infusion rate until the uterus contracts and the hemorrhage stops

• Put the baby to the breast to suck or stimulate nipples manually

• Massage uterine fundus

 

 

If bleeding persists, explore the perineum, vagina, and cervix looking for lacerations and repair as needed

 

• Call the anesthesiologist

• Call the senior specialist

• Explore the uterine cavity for retained placental fragments

• If there are retained placental fragments, remove manually or with ring forceps, and if needed curettage (suction curettage) or large blunt curette

 

If bleeding still persists then a blood coagulation disorder must be suspected and investigated

 

• continue bimanual massage

• Give Carboprost 250 micrograms intramyometrial (transabdominal), repeat/5 min until senior specialist and anesthesiologist arrive

• Perform an emergency laparotomy if above fails or ruptured uterus is found

• Laparotomy:

Ø      1^st step: Inspect uterus. If lacerated, repair adequately. If atony give direct massage

Ø      2^nd step: Inject intramyometrial Carboprost

Ø      3^rd step:

• Ligation of uterine arteries

• Consider ligation of hypogastric arteries, if you are trained in this technique

 

Ø      4^th step: subtotal hysterectomy

 

 

Late postpartum hemorrhage (after 24 hours)

Follow the steps above

 

 

Important considerations

 

• Remember that a postpartum patient can lose a large amount of blood in a very short time. You must act promptly and anticipate complications

• Assure adequate team coverage

• A laparotomy for postpartum hemorrhage need not be delayed while awaiting for blood transfusion. This is an extremely urgent situation

• Administer antibiotic prophylais, such as 1 gm ampicillin before and after the procedure

• D not give oxytocin as undiluted IV push since the patient may collapse

 

 

 

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