Management of Postpartum Hemorrhage
Karin A. Fox
GENERAL PRINCIPLES
Definition
Postpartum hemorrhage (PPH) refers to hemorrhage exceeding normal physiologic blood loss at or shortly after delivery. The World Health Organization (WHO) and Royal College of Obstetricians and Gynaecologists (RCOG, United Kingdom) define PPH as blood loss ≥500 mL within 24 hours after birth (1,2). The American College of Obstetricians and Gynecologists (ACOG) reVITALize project revised the definition in 2014 from >500 mL following vaginal delivery and >1,000 mL blood loss following cesarean delivery to ≥1,000 mL of blood loss or blood loss accompanied by signs or symptoms of hypovolemia, regardless of the mode of delivery (3). Primary or early PPH occurs within the first 24 hours of delivery, and secondary, late, or delayed PPH occurs between 24 hours and 12 weeks postpartum. PPH is a leading cause of maternal morbidity and mortality worldwide, of which many are considered preventable with timely recognition and intervention. Women in low-resource settings and developing countries are faced with a disproportionately high risk of death from PPH (4).
PPH is not a “stand-alone” diagnosis, meaning that recognition or diagnosis of PPH is insufficient. To appropriately treat PPH, one must identify and treat any underlying etiologies. The Alliance for Innovation on Maternal Health (AIM) developed standardized patient safety bundles to address the need for systematic improvements in patient care to improve outcomes using the “4 R’s” to improve outcomes: “ Readiness, Recognition & Prevention, Response, and Reporting & Systems Learning” (5). This system links diagnosis and recognition with the ability and urgency to appropriately act and continuously improve to drive down morbidity and mortality caused by PPH.
PPH may be rapid and acute, as with placenta accreta spectrum involving hypervascularity or placental abruption, or it may result from slow, indolent but continuous bleeding.
Physical Examination
A systematic approach to the physical examination will help ensure all potential sources of bleeding are investigated and repaired. The order of the examination may vary, depending upon whether the delivery was vaginal or by cesarean delivery (perineal to abdominal vs. abdominal to perineal approach, respectively), but all bleeding sources should be considered until the patient is stabilized.
Ensure continuous situational awareness to and recording of ongoing blood loss before, during, and after any delivery.
Monitor the patient’s color, mental status, vital signs, urine output for signs of hypovolemic (hemorrhagic) shock. It is critical to initiate resuscitation and transfusion early, before advanced stages of shock (see Table 5.1.1). Maintaining normothermia is important, as coagulation factor function declines as a patient’s body temperature cools. Fever caused by endometritis warrants antibiotic therapy.
It is reasonable to move to an operating room early, to ensure adequate lighting, patient positioning, equipment, and anesthesia and support personnel are available to control bleeding.
Examine the introitus and vagina for any lacerations that may require repair. These may be superficial and external or deep and high within the vaginal vault. For deep lacerations, retraction of the vaginal walls manually or with retractors (right-angled retractors, sidewall retractors, Breisky-Navratil, or Deaver retractors) may be necessary for adequate exposure and visualization.
Examine the cervix for lacerations. Exposure and retraction of the vagina may be required. The cervix remains dilated and soft immediately after delivery and may be difficult to see in its entirety, without careful examination. Gentle use of long-handled forceps to maneuver the cervix edges may help the provider visualize the entire circumference. Care should be used to avoid tearing this soft tissue with instruments used.
Examine the uterine tone and location. If the uterus is not round, firm, and well contracted when palpated abdominally (or directly at the time of cesarean delivery), uterine atony should be suspected. If an irregular or “heart” shape is noted at the fundus and the patient does not have a known uterus didelphys, uterine inversion should be suspected. The uterine fundus may be well contracted, whereas the lower uterine segment remains relatively relaxed and soft (lower segment atony). This is best palpated with one hand in the posterior fornix of the vagina during bimanual massage. Marked deviation of the fundus to one side of the abdomen may be a sign of hematoma formation within the broad ligament, even after vaginal delivery.
Examine the placenta. If the placenta appears fragmented or incomplete or does not deliver within 20 to 30 minutes, manually explore the intrauterine cavity/upper vagina to assess for uterine inversion, placenta accreta, or retained products of conception. Following vaginal delivery, it requires sufficient cervical dilatation and adequate analgesia to allow the provider to place one hand through the cervix into the uterine cavity via a vaginal approach. Alternatively, portable ultrasound is also useful to assess for retained products of conception.
Following cesarean delivery or at the time of laparotomy, inspect the anterior and posterior surfaces of the uterus, ovaries, and fallopian tubes and parametria for any signs of bleeding or hematoma formation. This may require extending the abdominal incision and/or temporarily packing the bowel and omentum away from the surgical field with moistened laparotomy sponges or towels to allow visualization and exteriorization of the uterus to see posteriorly and along the parametria.
If the uterus has been exteriorized, it is important to inspect any sites of repair once again after the uterus has been returned to the abdominal cavity. Exteriorization places the lower branches of the uterine arteries on stretch, hypothetically reducing perfusion pressure. The hysterotomy or other sites may then bleed once this pressure is released.
Inspect any edges of omentum or adhesions that were transected upon abdominal entry, and ensure they are hemostatic before abdominal closure. Omental vessels do not contract as other systemic vessels do, and venous ooze from them or lysed adhesions, although slow, can accumulate over time. The postpartum abdomen is sufficiently spacious and distensible to permit a large volume of intraperitoneal blood to accumulate.
Vessels within the rectus muscles (inferior epigastric artery and vein) or smaller vessels can lead to significant bleeding if inadvertently transected.
Ensure adequate hemostasis of the subcutaneous layer before skin closure.
Table 5.1.1 Classification of Hemorrhagic Shock
Class I
Class II
Class III
Class IV
Blood volume%
Up to 15%
15%-30%
30%-40%
>40%
HR (bpm)
<100
>100
>120
>140
BP
Normal or increased
Normal (+ till)
Decreased (MAP <60)
Decreased
PP
Normal
Decreased
Decreased
Decreased
Cap refill
Normal
May be delayed
Usually delayed
Always delayed
RR
Normal
Mildly increased
Moderate to marked tachypnea
Marked tachypnea/respiratory collapse
UOP (mL/h)
Over 30
20-30
5-15
Essentially anuric
Mental status
Normal or anxious
Anxious
Confused
Lethargic obtunded
BP, blood pressure; bpm, beats per minute; Cap, Capillary; HR, heart rate; PP, pulse pressure; RR, respiratory rate; UOP, urine output.
Classes III and IV shock are advanced stages of shock and indicate loss of physiologic compensatory mechanisms and must be treated emergently. (Adapted from Subcommittee on Advanced Trauma Life Support (ATLS) of the American College of Surgeons (ACS), Committee on Trauma. Advanced Trauma Life Support Course for Physicians. 10th ed. Committee on Trauma, American College of Surgeons; 2018:43.)
If vital sign changes are encountered that are consistent with hemorrhage (tachycardia, hypotension), vaginal bleeding may be ongoing. Ask an assistant to inspect between the patient’s legs. For patients with significant risk for hemorrhage, consider positioning the patient in low lithotomy position for the surgery (in “yellowfin” stirrups) to facilitate checking for vaginal bleeding or accessing the vagina in case adjunctive measures are required.
Differential Diagnosis
Primary PPH
Uterine atony (associated with uterine distension from polyhydramnios or multiple gestations, prolonged labor induction, chorioamnionitis)
Lacerations of the reproductive tract (uterine, parametrial, cervical, vaginal/sulcal, labial) or vascular supply to the reproductive tract. Lacerations may occur with spontaneous vaginal delivery and are more common following forceps or vacuum-assisted delivery.
Retained placenta
Placenta accreta spectrum (invasive placenta)
Uterine inversion
Placental abruption
Coagulopathy (von Willebrand disease, coagulation factor deficiency, supratherapeutic anticoagulation, or consumptive or dilutional disseminated intravascular coagulopathy)
Secondary or delayed PPH
Retained placenta
Subinvolution of the placental bed (failure of superficial maternal spiral arteries to close or slough, allowing ongoing oozing to occur)
Coagulopathy
Nonoperative Management
Uterotonic medications should be used as part of active management of the third stage of labor, to reduce the risk of PPH, and as a treatment for uterine atony (see Table 5.1.2).
Antifibrinolytic medication such as tranexamic acid is now widely used. It has shown a decreased risk of death owing to hemorrhage if given within the first 3 hours after delivery.
Prompt treatment of chorioamnionitis/endometritis with antibiotics reduces the risk of uterine atony and puerperal infection.
Transfusion of blood or blood products in a timely manner (before the onset of any coagulopathy) is highly recommended. The use of a 1:1:1 ratio of red blood cells (RBCs) to fresh frozen plasma (FFP) and platelets (PLT) should be considered, especially when massive hemorrhage ensues (see Chapter 6.4). Large volumes (3-4 L) of crystalloid for intravenous resuscitation may exacerbate coagulopathy through dilutional effects.
Use of intravaginal or intrauterine tamponade with an intrauterine balloon or packing has been shown to reduce the need for hysterectomy in over 80% of cases in a large meta-analysis (6). Tamponade is often combined with surgical interventions such as described below, and hysterectomy may still be required if bleeding continues despite tamponade.
Arterial embolization or intra-arterial occlusion by interventional radiology specialists has gained interest and is being more widely used. It should be noted that this is considered an adjunctive method for hemorrhagic control. Arterial occlusion may not address slow oozing from venous sources. If a patient is briskly bleeding and not already in a hybrid interventional radiology/operating room suite, the time required to move the patient for embolization may prove unsafe; however, the risks versus benefits of the degree and location of bleeding must be carefully considered.
IMAGING AND OTHER DIAGNOSTICS
Peripartum hemorrhage is often easily recognizable when vaginal or intraoperative bleeding occurs. Occult bleeding, such as in cases of intra-abdominal hemorrhage or formation of a retroperitoneal or perineal hematoma, although not as readily seen can be diagnosed by careful evaluation of the patient’s physical examination, vital signs, and diagnostic imaging.
The decision to proceed with surgical exploration vs. diagnostic imaging must be individualized to the patient’s clinical status and the available local resources. When active bleeding is ongoing, any undue delay may lead to further deterioration. For example, in a patient who has recently delivered via cesarean delivery with an extension of the hysterotomy into the uterine artery requiring uterine artery ligation, deviation of the uterus to the side contralateral to the ligated artery combined with signs and symptoms of hemorrhagic shock, especially without an appropriate response to transfusion, is sufficient to warrant exploratory laparotomy without imaging.
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