Postpartum Hemorrhage

Jorge Garcia, MD
December, 2001

Goals of talk
Definition
Rapid diagnosis and treatment
Review risks

Case 1.

Healthy 32 yo G2P1.
Augmented vaginal delivery, no tears.
Nurse calls you one hour after delivery
because of heavy bleeding.
What do you do?
What do you order?

Case 2

26 yo G4 now P4.
NSVD, with help from medical student.
You leave the room to answer a page while
waiting for placenta to deliver, but are
called back overhead, stat.
Huge blood clot seen in vagina.
What is this, and what do you do next?

Definition

Mean blood loss with vaginal delivery:

500cc
> 1000cc is hemorrhage
Mean blood loss with C/S: 1000cc
>1500cc is hemorrhage
Seen in ~5% of deliveries.

Early vs. Late

Most authors define early as < 72h.
ALSO defines it as <24h.
Late hemorrhage is more likely due to
infection and retained placental tissue.

Prenatal Risk Factors

Most patients with hemorrhage have none.

Pre-eclampsia (RR 5.0)
Previous postpartum hemorrhage (RR 3.6)
Multiple gestation (RR 3.3)
Previous C/S (RR 1.7)
Multiparity (RR1.5)

Intrapartum Risk Factors

Prolonged 3rd stage (>30 min) (RR7.5)

medio-lateral episiotomy (RR4.7)
midline episiotomy ( RR1.6)
Arrest of descent (RR 2.9)
Lacerations (RR 2.0)
Augmented labor ( RR1.7)
Forceps delivery (RR 1.7)

Easy to miss
Physicians underestimate blood loss by
50%
Slow steady bleeding can be fatal
Most deaths from hemorrhage seen after 5h
Abdominal or pelvic bleeding can be
hidden

Always look for signs of bleeding

Estimate blood loss accurately.
Evaluate all bleeding, including slow
bleeds.
If mother develops hypotension,
tachycardia or painrule out intraabdominal blood loss.

Initial Assessment

Identify possible post partum hemorrhage.

Simultaneous evaluation and treatment.
Remember ABCs.
Use O2 4L/min.
If bleeding does not readily resolve, call for
help.
Start two 16g or 18g IVs.

ALSOs 4 Ts
Tone (Uterine tone)
Tissue (Retained tissue--placenta)
Trauma (Lacerations and uterine rupture)
Thrombin (Bleeding disorders)

Tone: Think of Uterine Atony

Uterine atony causes 70% of hemorrhage
Assess and treat with uterine massage
Use medication early
Consider prophylactic medication...

Bimanual Uterine Exam

Confirms diagnosis of uterine atony.
Massage is often adequate for stimulating
uterine involution.

Medications for Uterine Atony

1. Oxytocin promotes rhythmic

contractions.
Give IM or IU, not IV. (Can cause BP)
40U/L at 250cc/h.

2. Methergine 0.2mg (1 amp) IM

3. Hemabate 0.25mg IM q 15min (max X8).

Medications: Methergine

Causes tetanic uterine contraction.

May trap placenta.
Can cause Hypertension, especially IV.
Contraindicated in hypertensive patients
and those with pre-eclampsia.
Some authors skip Methergine altogether.

Prostaglandin F2 15-methyl

Hemabate 0.25mg IM or IU.

Used to be called Prostin.
Controls hemorrhage in 86% when used
alone, and 95% in combination with above.
Can repeat up to eight times.
Contraindicated in active systemic diseases.
Can cause nausea/vomiting/diarrhea, BP.

Tissue: Retained placenta

Delay of placental delivery > 30 minutes seen

in ~ 6% of deliveries.
Prior retained placenta increases risk.
Risk increased with: prior C/S, curettage ppregnancy, uterine infection, AMA or increased
parity.
Prior C/S scar & previa increases risk (25%)
Most patients have no risk factors.
Occasionally succenturiate lobe left behind.

Abnormal Placental Implantation

Attempt to remove the placenta by usual
methods.
Excess traction on cord may cause cord tear
or uterine inversion.
If placenta retained for >30 minutes, this
may be caused by abnormal placental
implantation.

Abnormal implantation defined.

Caused by missing or defective decidua.

Placenta Accreta: Placenta adherent to
myometrium.
Placenta Increta: myometrial invasion.
Placenta Percreta: penetration of
myometrium to or beyond serosa.
These only bleed when manual removal
attempted.

Removal of Abnormal Placenta

Oxytocin 10U in 20cc of NS placed in

clamped umbilical vein.
If this fails, get OB assistance.
Check Hct, type & cross 2-4 u.
Two large bore IVs.
Anesthesia support.

Removal of Abnormal Placenta

Relax uterus with halothane general

anesthetic and subcutaneous terbutaline.
Bleeding will increase dramatically.
With fingertips, identify cleavage plane
between placenta and uterus.
Keep placenta intact.
Remove all of the placenta.

Removal of Abnormal Placenta

If successful, reverse uterine atony with
oxytocin, Methergine, Hemabate.
Consider surgical set-up prior to separation.
If manual removal not successful, large
blunt curettage or suction catheter, with
high risk of perforation.
Consider prophylactic antibiotics.

Trauma (3rd T)
Episiotomy
Hematoma
Uterine inversion
Uterine rupture

Uterine Inversion

Rare: ~1/2000 deliveries.

Causes include:
Excessive traction on cord.
Fundal pressure.
Uterine atony.

Uterine Inversion
Blue-gray mass protruding from vagina.
Copious bleeding.
Hypotension worsened by vaso-vagal
reaction. Consider atropine 0.5mg IV if
bradycardia is severe.
High morbidity and some mortality seen:
get help and act rapidly.

Uterine Inversion

Push center of uterus with three fingers into

abdominal cavity.
Need to replace the uterus before cervical
contraction ring develops.
Otherwise, will need to use MgSO4,
tocolytics, anesthesia, and treatment of
massive hemorrhage.
When completed, treat uterine atony.

Uterine Rupture

Rare: 0.04% of deliveries.

Risk factors include:
Prior C/S: up to 1.7% of these deliveries.
Prior uterine surgery.
Hyperstimulation with oxytocin.
Trauma.
Parity > 4.

Uterine Rupture

Risk factors include:

Epidural.
Placental abruption.
Forceps delivery (especially mid forceps).
Breech version or extraction.

Uterine Rupture

Sometimes found incidentally.

During routine exam of uterus.
Small dehiscence, less than 2cm.
Not bleeding.
Not painful.
Can be followed expectantly.

Uterine Rupture before delivery

Vaginal bleeding.
Abdominal tenderness.
Maternal tachycardia.
Abnormal fetal heart rate tracing.
Cessation of uterine contractions.

Uterine Rupture after delivery

May be found on routine exam.
Hypotension more than expected with
apparent blood loss.
Increased abdominal girth.

Uterine Rupture
When recognized, get help.
ABCs.
IV fluids.
Surgical correction.

Birth Trauma

Lacerations of birth tract not rare: causes

post partum hemorrhage in 1/1500
deliveries.

Birth Trauma

Risk factors include:

Instrumented deliveries.
Primiparity.
Pre-eclampsia.
Multiple gestation.
Vulvovaginal varicosities.
Prolonged second stage.
Clotting abnormalities.

Birth Trauma
Repair lacerations quickly.
Place initial suture above the apex of
laceration to control retracted arteries.

Repair of cervical laceration

Birth Trauma: Hematomas

Hematomas less than 3cm in diameter can

be observed expectantly.
If larger, incision and evacuation of clot is
necessary.
Irrigate and ligate bleeding vessels.
With diffuse oozing, perform layered
closure to eliminate dead space.
Consider prophylactic antibiotics.

Pelvic Hematoma

Vulvar hematoma

Thrombin (4th T)
Coagulopathies are rare.
Suspect if oozing from puncture sites noted.
Work up with platelets, PT, PTT, fibrinogen
level, fibrin split products, and possibly
antithrombin III.

Prevention?

Some evidence supports use of oxytocin

after delivery of anterior shoulder, in
umbilical vein or IV.

Summary: remember 4 Ts
Tone
Tissue
Trauma
Thrombin

Summary: remember 4 Ts

TONE
Rule out Uterine
Atony

Palpate fundus.
Massage uterus.
Oxytocin 40U/L @
250cc / h.
Methergine one amp
IM (not in
hypertensives)
Hemabate IM q 15min

Summary: remember 4 Ts

Tissue
R/O retained placenta

Inspect placenta for

missing cotyledons.
Explore uterus.
Treat abnormal
implantation.

Summary: remember 4 Ts

TRAUMA
R/o cervical or vaginal
lacerations.

Obtain good exposure.

Inspect cervix and
vagina.
Worry about slow
bleeders.
Treat hematomas.

Summary: remember 4 Ts

THROMBIN

Check labs if
suspicious.