Introduction

Postpartum hemorrhage is a leading cause of maternal morbidity and mortality. Classically defined as blood loss greater than 500 mL after a vaginal delivery and 1000 mL after cesarean delivery, these definitions of postpartum hemorrhage are antiquated. Although this system is easy to remember, visual estimations of blood loss are inaccurate. Clinically useful information is better conveyed if postpartum hemorrhage is classified based on a combination of estimated blood loss, patient symptoms and volume status.

The differential diagnosis of postpartum hemorrhage includes genital lacerations, uterine atony, retained placenta (including accreta), uterine inversion, uterine rupture, scar dehiscence, disseminated intravascular coagulation, consumptive coagulopathy, hematoma, thrombocytopenia, and, rarely, coagulation disorders. There are several risk factors associated with postpartum hemorrhage listed in Box 17.1.

Diagnosis and management

In the setting when there is excessive bleeding, a second large-bore intravenous line should be placed as well as a transurethral catheter to monitor the patient’s fluid status. Crystalloid should be infused at a 3/1 ratio to the amount of blood lost. Colloid (albumin, dextran, hespan) has little added benefit compared to crystalloid in restoring intravascular volume. Furthermore, certain colloids can promote coagulopathy. The blood bank should be notified that an obstetric patient is hemorrhaging and packed red blood cells should be obtained. In the absence of cross-matched blood, O negative blood should be obtained followed by type-specific blood until cross-matched blood is available. It is also important to anticipate the need for fresh-frozen plasma and cryoprecipitate as it may take approximately 30 minutes to an hour to thaw. Replacement of blood products is addressed at the end of this chapter. Oxytocin (20–80 units diluted in 1000 mL of normal saline) should be administered intravenously and run continuously. Directly bolusing oxytocin intravenously is not recommended as this may precipitate significant hypotension. Alternatively, if there is no intravenous access, 10 units of oxytocin can be administered intramuscularly. Concomitantly, attempts should be made to determine the cause of bleeding and proceed with treatment.

Often the clinician must multitask and assess the perineum for lacerations, palpate the uterine fundus for atony, and inspect the placenta to ensure it has delivered intact. Having an assistant push the uterus towards the vagina can facilitate evaluation for cervical lacerations. This also allows evaluation for uterine atony and visualization for any trailing membranes or placental fragments. If the uterus is firm and the bleeding is determined to be from a laceration, appropriate steps should be taken to repair the laceration. In the setting of a cervical laceration, a traction suture can be placed at the external os and the laceration can be repaired, making sure that the suture goes beyond the apex of the laceration. Often the cervix appears as if there are multiple lacerations but only those that are actively bleeding should be repaired.

The diagnosis of uterine atony is established by the combination of postpartum hemorrhage in the presence of a large, relaxed uterine fundus. Bimanual uterine massage should be applied while oxytocin and other uterotonics are administered. Bimanual uterine massage consists of elevating the uterus with one hand in the vagina and a separate hand massaging the fundus abdominally. If massage is not adequately causing the uterus to contract, bimanual compression should be applied where a fist is placed in the anterior vaginal fornix and the opposite hand firmly presses the uterine fundus to tamponade the vascular sinuses in the uterus. Additional uterotonics are given. Methylergonovine 0.2 mg can be administered intramuscularly. The dosage may be repeated every 2–4 hours. This agent is contraindicated in hypertension. An alternative uterotonic agent is 15-methyl prostaglandin F2-α. An initial dose of 0.25 mg may be administered IM following vaginal delivery or directly into the myometrium at cesarean delivery. Dosages may be repeated at intervals of 15–90 minutes as necessary. The total dosage should not exceed eight doses (2 g). This prostaglandin preparation is contraindicated in patients with asthma or glaucoma. Dinoprostone 20 mg vaginally or rectally may also be administered, but caution is advised in patients who are hypotensive. We advise starting with 10 mg and observing for any changes in blood pressure. As a third-line agent, we use misoprostol 800–1000 μg per rectum. Based on available data, the use of misoprostol as a nonsurgical intervention to treat uterine atony seems reasonable as long as the physician is aware of the potential side effects. This medication may be useful in preventing surgical interventions that would require laparotomy or hysterectomy, although further studies are needed to determine optimal route of delivery and dosage.

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