div class=”ChapterContextInformation”>
36. Postpartum Hemorrhage
36.1 Introduction
An error doesn’t become a mistake until you refuse to learn from it. —Orlando Battista
Hemorrhage, even to this day, is the major killer of pregnant women both in developing and developed countries. Postpartum hemorrhage (PPH) is a dreaded complication of labor and delivery and presents itself not only in women at high risk for the complication but also sometimes in apparently low-risk gravida in the most innocuous and unexpected situations. Global statistics for causes of maternal mortality state that maternal anemia directly or indirectly is responsible in 19.3% of cases, hemorrhage in 23.7%, pregnancy-induced hypertension (PIH) and eclampsia in 13.1%, unsafe abortions in 12.6%, sepsis in 10.6%, obstructed labor in 6.4%, and others in 14.2%. It is obvious that hemorrhage remains the major killer, and healthcare workers need to be alerted and trained to handle this emergency [1].
It is important to understand “why bleeding occurs.” The rule of four Ts (tone, tissue, trauma, thrombin) will quickly take us to the cause. Atony of the uterus is responsible for 75–90% of the cases of PPH. Trauma to the uterus, cervix, vagina and perineum, and tissue (retained placenta and membranes) and coagulopathy will account for the rest.
Though contribution of PPH as a cause of maternal death is 25% globally. In India, PPH contributes to 38% of all maternal deaths, which is considerably high given the Indian Maternal Mortality Ratio (MMR) of 212/100,000, and not merely suboptimal obstetric care was responsible. The newer trend in obstetric morbidity due to rise in cesarean section and comorbidities like obesity, diabetes, human immunodeficiency virus (HIV) infections, and drug abuse is adding to the problems [2].
There is evidence showing that comprehensive emergency obstetric care is responsible for 33% reduction of maternal death.
Research by the Prevention of Maternal Mortality Project has indicated attention to three delays in the Emergency Obstetric Care (EmOC).
Decision to seek EmOC
Reaching healthcare facility
Obtaining treatment at healthcare facility
The third delay is detrimental and not uncommon. Hard fact about mortality from PPH is that it is different from other major obstetric causes of death. If not managed, PPH can cause death in 8–12 h, obstructed labor in 2 days, and sepsis in 6 days, but with severe PPH, if not promptly managed, a woman can die in just 2 h after delivery [2].
36.2 Classification and Definitions
PPH can be primary or secondary, with primary hemorrhage occurring within the first 24 h of delivery and secondary between 24 h and 6–12 weeks postpartum. Primary PPH occurs in 4–6% of pregnancies and is caused by uterine atony in greater than 80% cases.
The classical definition of PPH is blood loss more than 500 mL within 24 h after vaginal delivery or more than 1000 mL after cesarean section. Significant blood loss can be well tolerated by most young healthy women, and an uncomplicated delivery often results in blood loss more than 500 mL without any compromise to the mother’s condition [3].
A decline in hematocrit of greater than 10% has also been used to define PPH. This hematocrit value provides an objective laboratory measure. However, this may not reflect the current hematologic status in acute situations since it can take hours for losses to create laboratory value changes. Hypotension, dizziness, pallor, and oliguria occur when blood loss is substantial.
Any bleeding that results in hemodynamic instability, if left untreated, should be considered PPH and managed accordingly.
In severe PPH if there is a blood loss of more than 1500 mL, decline in hemoglobin of more than 4 g/dL, acute transfusion of at least 4 units of red blood cells (RBCs), or surgical/nonsurgical hemostatic intervention (angiographic embolization, surgical arterial ligation, or hysterectomy), will need to be decided soon.
Blood loss of greater than 150 mL/min (within 20 min causing loss of >50% of blood volume).
Sudden blood loss of greater than 1500–2000 mL (loss of 25–35% of blood volume).
In major PPH if there is blood loss of more than 2500 mL, transfusion of more than 5 units of packed red blood cells (PRBC) or treatment for ensuing coagulopathy will have to be done without delay [4].
36.2.1 Massive Blood Loss
This is defined as the loss of one blood volume in a 24-h period or transfusion of more than ten units of blood within a 24-h period. The rate of blood loss is an important factor. A practical definition is the loss of 50% of blood volume within a 3-h period or loss at a rate of 150 mL/min.
Circulating volume at term is approximately 5 L. For an average built woman between 50 and 70 kg, massive hemorrhage has occurred when the loss is estimated at 1.5–2.0 L.
This situation could be seen within 10–15 min of delivery; appropriate action (according to protocol) must be initiated to restore circulating blood volume and tissue oxygenation while awaiting blood products and laboratory test results to guide the replacement therapy [5].
36.2.1.1 Methods to Estimate Blood Loss
Underestimation of blood loss following delivery can be avoided if all shed blood is measured and sponges, wraps, swabs, etc. are carefully weighed.
Visual estimation: This common method underestimates PPH by 30–50%. This inaccuracy increases as blood loss increases and delays diagnosis and timely action.
Use of the blood collection drape: Funnel-shaped plastic bag hangs from the edge of the delivery table and is calibrated with two lines, alert line of yellow color at the 350 mL mark and a red action line at the 500 mL mark.
Collection of blood in a kidney tray or in a calibrated container.
Clotted blood volume represents half of the blood volume required to form the clots.
36.2.1.2 Initial Response Management
The golden hour refers to the first 60 min from the time of recognition of PPH. It is the time in which resuscitation must begin to achieve maximum survival. As more delay is there to start the resuscitation, the percentage of surviving patients decreases. Too little, too late is the cause of mortality: too little IV fluids, blood, and clotting factors and too late resuscitation, blood replacement, and surgical measures to arrest bleeding [6].
Call for and mobilize help.
Communicate the problem to the woman, family members present, and multidisciplinary team members with timely escalation to senior obstetric and midwifery staff and involvement of hematologist, blood bank, and anesthetists. The lead clinician should delegate tasks during maternity emergency.
Significant blood loss due to any cause requires standard maternal resuscitation measures.
- 1.
Airway, breathing, circulation.
- 2.
Two large-bore intravenous (IV) access—Gray (No. 16) and green (No. 18); IV set, blood set, and three-way stopcock.
- 3.
Oxygen by face mask at the rate of 6–8 L/min.
- 4.
Infusion of crystalloids (normal saline (NS)/Ringer’s lactate (RL)) three times in volume to the blood lost.
- 5.
36.2.2 Stage 1
Stage 1 is initiated when the estimated blood loss (EBL) is more than 500 mL after vaginal delivery or more than 1000 mL after cesarean section, or vital signs show more than 15% change from baseline (heart rate >100 bpm, blood pressure 85/45 mmHg, O2 saturation <95%).
Successful management of PPH requires that both components should be simultaneously and systematically addressed. Resuscitative measures, diagnosis, and treatment of the underlying cause must occur quickly before sequelae of severe hypovolemia develop.
36.2.2.1 Resuscitation
The goal of initial resuscitation is to achieve sufficient circulating blood volume to enable transfer of the patient to a site where effective treatment can occur. The degree of initial volume resuscitation will depend on the level of care that can be offered at the facility. If necessary, the patient must be accompanied by an experienced member of staff to a higher level of care.
Initial resuscitation is based on the airway, breathing, circulation (ABC) approach with advanced resuscitation guided by the clinical situation.
36.2.2.2 Assessment
Monitor the conscious state and vital signs at regular intervals, oxygen saturation (by pulse oximeter), uterine tone, and urine output. Maintain record of EBL. It is important to recognize the clinical signs of varying degrees of blood loss.
Emergency response measures should be initiated and steps taken to assure fluid resuscitation and core perfusion maintained via lower extremity elevation and in some cases anti-shock compression wrap.
A designated “PPH box” is a good risk management approach as all necessary equipment is quickly available in it.
If no pulse, start cardiopulmonary resuscitation (CPR).
Position the woman to maximize venous return. Lower head of bed. Raising the legs improves venous return and is consistent with the positioning used to diagnose and treat the underlying causes of bleeding.
Intravenous access—insert at least two (14 or 16 gauge) cannulae.
Full blood count (FBC), clotting screen [fibrinogen, activated partial thromboplastin time (APTT), prothrombin time (PT), D-dimer], collect blood for crossmatch.
Insert indwelling urinary catheter—urine output monitored at 15-min intervals.
Avoid hypotension by adequate fluid replacement in relation to ongoing measured blood loss.
Avoid hypothermia, as this increases the risk of disseminated intravascular coagulation (DIC). Prewarm resuscitation fluids and use warm air blankets.
Commence bimanual massage. Bimanual massage results in a decrease in bleeding even if the uterus remains relatively atonic, thus allowing resuscitation a chance to begin to catch up with blood loss.
Documentation: Scribe assessments and response to management on the observation chart.
Delegate two persons to continue with resuscitative measures.
If unsuccessful, perform aortocaval compression.
36.2.2.3 Identify Cause and Stop the Bleeding
Continue uterine massage to stimulate a contraction and expel any clots present.
If bleeding continues despite a well-contracted uterus, look for other causes (e.g., incomplete placenta, cervicovaginal tears, and hematomas). Use the four Ts mnemonic:
Tone (uterine), 70%
Trauma (uterine rupture/cervical or vaginal lacerations), 20%
Tissue (retained placental tissue), 10%
Thrombin (bleeding disorder), 1%
Bedside clotting test: Take 2 mL of venous blood into a plain glass test tube. Hold the tube in closed fist to keep it warm (+37 °C). After 4 min, tip the tube slowly to see if a clot is forming. Tip it again every minute until the blood clots and the tube can be turned upside down. If a clot does not form after 7 min or a soft clot forms that breaks down easily, it is suggestive of a clotting disorder [9].
36.2.2.4 Fluid Resuscitation
Perform initial resuscitation with large volumes of crystalloid solution: normal saline (NS) 0.9%, compound sodium lactate solution (Hartmann’s solution), or lactated Ringer’s solution as rapid fluid bolus, 2 L over 10 min:
To resuscitate more quickly, administer IV fluids using a pressure infusion device/blood pressure (BP) cuff.
When using crystalloid, the ratio of resuscitative IV fluid required to blood lost is 3:1 because most of the infused fluid shifts from intravascular space to interstitial space. This shift, along with oxytocin use, may result in peripheral edema in the days following PPH.
If large amounts (>10 L) of crystalloids are being infused, Ringer’s lactate (RL) is preferred over NS.
Dextrose-containing solutions (5% dextrose in water or dextrose normal saline [DNS]) have no role in the management of PPH.
PPH of up to 1500 mL in a healthy woman can usually be managed by crystalloid infusion alone if the cause of bleeding is arrested. Blood loss in excess of this usually requires the addition of a PRBC transfusion.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
