Postpartum Hemorrhage

Aka: Postpartum Hemorrhage, Post-partum Bleeding

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II. Definitions

  1. Postpartum Hemorrhage (2014 definition)
    1. Blood loss >1000 ml OR
    2. Signs and symptoms of Hypovolemia
    3. Previously diagnosed as blood loss >500 cc, need for pRBC transfusion or >10% drop in Hematocrit
  2. Primary Postpartum Hemorrhage (Early Postpartum Hemorrhage)
    1. Blood loss within 24 hours
  3. Secondary Postpartum Hemorrhage (Late Postpartum Hemorrhage)
    1. Blood loss after 24 hours and before 6 weeks
    2. Due to placental eschar slouphing, Retained Placenta

III. Epidemiology

  1. Incidence: 3-5% of all deliveries
  2. Responsible for 25% of worldwide maternal deaths and 14% of U.S. maternal deaths

IV. Risk Factors

  1. No risk factor in 20% of Postpartum Hemorrhage cases
  2. Prolonged labor
    1. Prolonged third stage >18 minutes
    2. Proloned third stage >30 minutes (RR 6)
  3. Maternal conditions
    1. Prior history Postpartum Hemorrhage (RR 2-3)
    2. Grand Multipara
    3. Primipara
    4. Chorioamnionitis
    5. Multiple Gestation
    6. Preeclampsia
    7. Antepartum Hemorrhage
    8. Maternal Anemia
    9. Maternal Obesity
  4. Fetal Conditions
    1. Fetal Macrosomia
  5. Medications and procedures
    1. Magnesium Sulfate infusion
    2. Prolonged Pitocin infusion
    3. Episiotomy

V. Causes: Mnemonic: 4T's

  1. Tone diminished or uterine atony (70 to 80% of cases)
    1. Pathophysiology: Uterus fails to contract despite being empty (and unable to control bleeding at placental site)
    2. Excessive Uterine distension
      1. Twin Gestation
      2. Fetal Macrosomia
      3. Polyhydramnios
    3. Multiparity
      1. Fibrosis in uterine Muscle
    4. Prolonged labor (uterine inertia)
    5. Prolonged Third Stage of Labor (>18 minutes)
    6. Labor augmented with Oxytocin
    7. Chorioamnionitis
    8. General Anesthesia
    9. Placenta Previa
      1. Lower segment does not contract
    10. Abruptio Placentae
      1. "Couvelaire" Uterus may not contract
  2. Trauma (20% of cases)
    1. Uterine Inversion
    2. Uterine Rupture
    3. Cervical Laceration
    4. Vaginal Hematoma
  3. Tissue (10% of cases)
    1. Retained Placenta
    2. Placenta accreta (or other invasive placenta)
  4. Thrombin (1% of cases)
    1. Coagulopathy
    2. Disseminated Intravascular Coagulation

VI. Signs

  1. Inspect Vagina and Cervix for bleeding source
  2. Uterus is soft and boggy in atony
  3. Quantify blood loss
    1. Under-buttocks drape with calibrated catch
    2. Weigh blood soaked pads, clots
  4. Observe for findings of Hemorrhagic Shock
    1. Sinus Tachycardia (may be earliest sign of Postpartum Hemorrhage)
    2. Orthostasis
    3. Hypotension
  5. Observe for end-organ ischemia
    1. Chest Pain
    2. Dyspnea
    3. Nausea or Vomiting
    4. Oliguria

VII. Labs

  1. Complete Blood Count with Platelets
  2. ProTime (PT)
  3. Partial Thromboplastin Time (PTT)
  4. Type and cross for 2-4 units of pRBC
  5. Other Coagulation Disorder labs to consider
    1. Fibrinogen level
    2. Fibrin split products
    3. D-Dimer

VIII. Management: Active Management of the Third Stage of Labor

  1. Oxytocin (10 IU IM or 20 IU/L at 250 ml/h) administered on delivery of newborn's anterior Shoulder
    1. Reduces Incidence from 16.5% to 3.8% of deliveries
    2. See Third Stage of Labor
  2. Controlled cord traction
  3. Limit the third stage to <10 minutes
    1. Delayed placental delivery >10 min doubles bleed risk
  4. Early cord clamping and cutting does not appear to reduce Postpartum Hemorrhage risk
    1. Delayed cord clamping is now recommended for 1-3 minutes to reduce newborn Anemia risk

IX. Management: Resuscitation

  1. Indications
    1. Brisk bleeding
    2. Hypotension and Tachycardia
  2. Initial General Management
    1. See ABC Management
    2. Emergent Obstetrician Consultation
    3. Bimanual uterine massage
      1. See description below
      2. Single most important corrective measure
    4. Nursing
      1. Large Bore (14-16 gauge) Intravenous Access (2 sites)
      2. Isotonic crystalloid bolus (NS, LR)
      3. Supplemental Oxygen
      4. Type and cross for 4 units pRBC
      5. Empty Bladder with Foley Catheter (may improve uterine tone)
      6. Patient in Trendelenburg or with legs elevated
      7. Close hemodynamic monitoring with frequent Vital Signs
        1. Shock Index >0.9 to 1.0 predicts higher mortality and need for pRBC transfusion
        2. Targets during Resuscitation: 80-90 mmHg systolic Blood Pressure (50 to 60 mmHg MAP)
    5. Medications
      1. Oxytocin (10 IU IM or 20 IU/L at 250 ml/h), and continue for first 24 hours
      2. Tranexamic Acid (TXA) 1 gram over 10 minutes (and repeat dose in 30 min if bleeding continues)
        1. Reduces mortality if given within 3 hours of delivery in Hemorrhage >500 ml after NSVD (1000 ml after c/s)
      3. Methylergonovine (Methergine) 0.2 mg IM now and may be repeated every 2 to 4 hours
      4. Misoprostol: 600 mcg sublingual or 1000 mcg rectally once
  3. Next measures for refractory bleeding
    1. Assess 4 Ts (Tone, Trauma, Tissue, Thrombin) below
    2. Hemabate (Carboprost Tromethamine, 15-methyl-Prostaglandin F2 alpha)
      1. See precautions below (expect severe Diarrhea in 20% of patients, bronchoconstriction in Asthma)
      2. Dose: 0.25 mg IM or intromyometrium every 15 minutes to maximum of 2 mg
  4. Massive Hemorrhage Management
    1. Transfuse pRBC, Platelets, Cryoprecipitate, factors as indicated
      1. See Massive Transfusion Protocol (for 4 or more units pRBC In 24 hours)
      2. May require O negative Blood Transfusion until typed blood is available
      3. Shock Index >0.9 to 1.0
      4. Rule of 30 (blood loss of at least 30%)
        1. Hemoglobin or Hematocrit drop 30% OR
        2. Systolic Blood Pressure drop of 30 mmHg OR
        3. Heart Rate increase 30 bpm
    2. Balloon tamponade (temporizing measure)
      1. Bakri Balloon or BT Cath Balloon (either is preferred)
        1. Bakri Balloon is filled with 500 cc saline
        2. Bakri Balloon is large enough to stabilize bleeding via tamponade within Uterus
      2. Foley Catheter inserted into Cervix and balloon inflated with sterile saline or sterile water
        1. Foley Catheter is unlikely to expand enough to provide meaningfull intrauterine pressure
        2. Consider a Condom on end of the Foley Catheter tip, which could be expanded to 500 cc
      3. Other alternative balloon options
        1. Sengstaken-Blakemore Tube
    3. Compressive Uterine packing (temporizing measure)
      1. Foley Catheter placed first to decompress Bladder
      2. Use gauze in a continuous roll such as Kerlix
        1. Consider gauze soaked in Thrombin, Vasopressin, chitosan or Hemabate (Carboprost)
      3. Maximize visualization with large speculum and good lighting
      4. Insert continuous gauze in layers with a ring forceps
        1. Start with gauze inserted from fundus to vaginal canal and then layer the gauze back and forth
        2. Attempt to place as many layers as possible
      5. Prevent infection with packing
        1. Remove packing within 12 to 24 hours
        2. Administer broad spectrum IV Antibiotics
      6. References
        1. Warrington (2019) Crit Dec Emerg Med 33(6):18
    4. Nonpneumatic Antishock Garment (MAST Trousers)
      1. May stabilize central perfusion until definitive management
    5. Surgical interventions (definitive management)
      1. Vessel embolization (Intervention Radiology)
        1. Efficacy 90%
        2. Often preserves fertility
      2. Uterine compression Sutures
        1. Efficacy: 92%
        2. Least complex of surgical measures
      3. Temporary Ligation of Uterine and Hypogastric arteries
        1. Efficacy: 40%
      4. Peripartum Hysterectomy
        1. Associated with high morbidity

X. Management: Four T's (see Above)

  1. Tone (Soft, boggy Uterus)
    1. Empty the Bladder!
    2. Bimanual uterine massage
      1. Bimanual massage between vagina and uterine fundus
      2. One hand in clenched fist within vagina pushes against the Uterus
      3. Other hand compresses fundus through the Abdomen
    3. Uterotonic Medications
      1. Oxytocin 20 IU per Liter NS (first-line, single most-effective agent)
        1. Infuse 250 cc/h (Max: 500 cc/10 min)
      2. Methyl-ergonovine (Methergine) 0.2 mg IM q2-4 hours
        1. Contraindicated in Severe Hypertension
      3. Misoprostol (Cytotec, PGE1)
        1. Misoprostol: 600 mcg sublingual or 1000 mcg rectally once or
        2. Misoprostol 400 mcg per Rectum after placenta delivery and 100 mcg at 4 hours and 8 hours
        3. Prophylaxis (bleeding risk): Misoprostol 600 mcg sublingual or orally within 1 minute of delivery
      4. Hemabate (Carboprost Tromethamine, 15-methyl-Prostaglandin F2 alpha)
        1. Rarely used in U.S. practice due to severe Diarrhea in up to 20% of patients
        2. Risk of bronchoconstriction in Asthma
        3. Dose: Hemabate 0.25 mg IM every 15 minutes to maximum of 2 mg
      5. Dinoprostone (PGE2)
        1. Caliskan (2002) Am J Obstet Gynecol 187:1038-45
  2. Trauma (Genital Laceration, Uterine Inversion)
    1. Avoid episiotomy unless urgent delivery (Fetal Distress, Shoulder Dystocia)
    2. Inspect Vagina and Cervix for bleeding source
      1. Suture Lacerations if present
      2. Drain large vaginal or vulvar Hematomas (>3 cm), irrigate and obtain Hemostasis
      3. Remove retained clot within Cervix
    3. Evaluate Uterus
      1. Consider exploring Uterus
      2. Evaluate for Uterine Rupture (0.8% of low transverse VBACs or Vaginal Births after cesarean)
        1. Higher risk with Oxytocin Induction and augmentation
        2. Most common presenting sign is Fetal Bradycardia
      3. Evaluate for Uterine Inversion (0.04% of deliveries)
        1. Presents as bluish-gray mass protruding from vagina, and shock without excessive blood loss
        2. Immediately replace Uterine Inversion (without removing placenta if still attached)
        3. Emergent Consultation
        4. Life threatening if not replaced
  3. Tissue (Retained Placenta)
    1. Inspect placenta for missing segments
    2. Manually remove Retained Placenta
    3. Consider placenta accreta (invasive placenta) if tissue plane is not easily distinguished on manual placenta removal
    4. Consider curettage and prepare for possible Dilatation and Curettage or surgery
  4. Thrombin (Clotting disorder)
    1. Signs
      1. Refractory Postpartum Hemorrhage
      2. Blood continues to ooze from venous puncture sites
      3. Blood does not clot in Red Top blood tubes (no additives) within 5-10 minutes
    2. Obtain labs as above
      1. Includes Platelet Count, INR, PTT, Fibrinogen level, Fibrin split products, D-Dimer
    3. Replace Coagulation Factors (and Blood Products as below)
      1. Tranexamic Acid (TXA) 1 gram over 10 minutes (low risk, often given early, regardless of labs)
      2. Fresh Frozen Plasma (FFP)
      3. Platelet Transfusion
      4. Factor VIIa

XI. Management: Post-Stabilization

  1. Monitor for ongoing bleeding
    1. Frequent Vital Signs
    2. Symptomatic Anemia (e.g. Fatigue, Shortness of Breath, Chest Pain)
    3. Serial Hemoglobin

XII. Prevention

  1. Consider planning delivery for high risk patients at tertiary centers
    1. Antepartum or chronic Anemia (e.g. Sickle Cell Anemia, Thalassemia)
    2. Coagulopathy history
    3. Invasive placenta risks (e.g. VBAC)
    4. Jehovah's Witness and others refusing Blood Transfusions
  2. Prepare healthcare team and hospital protocols in advance for Postpartum Hemorrhage emergencies
    1. Prepare Postpartum Hemorrhage cart with needed medications, supplies, emergency cards
    2. Nurse and Provider Education (e.g. ALSO)
  3. Active Management of the Third Stage of Labor
  4. Avoid episiotomy

XIII. Complications

  1. Acute Blood Loss Anemia
    1. Hemorrhagic Shock requiring Blood Transfusion
    2. Dilutional Coagulopathy (increased bleeding risk)
      1. Replace 1 unit Platelets and 4 units FFP for every 4-6 units of pRBC in Massive Transfusion
    3. Death
  2. Sheehan Syndrome (postpartum pituitary necrosis)
    1. Anterior pituitary ischemia
    2. Results in delayed or failed Lactation
  3. Myocardial Ischemia

XIV. References

  1. Lively and Clare (2022) Crit Dec Emerg Med 36(5): 4-10
  2. Alamia (1999) Obstet Gynecol Clin North Am 26:385-98 [PubMed]
  3. Anderson (2007) Am Fam Physician 75(6):875-82 [PubMed]
  4. Dresang (2015) Am Fam Physician 92(3): 202-8 [PubMed]
  5. Escobar (2022) Int J Gynaecol Obstet 157(Suppl 1):3-50 +PMID: 35297039 [PubMed]
  6. Evensen (2017) Am Fam Physician 95(7): 442-9 [PubMed]
  7. Lalonde (2006) Int J Gynaecol Obstet 94:243-53 [PubMed]
  8. Magann (2005) Obstet Gynecol Clin North Am 32:323-32 [PubMed]

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