Learning Objectives
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Define postpartum hemorrhage.
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Discuss technique for quantification of blood loss.
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Manage postpartum hemorrhage.
Postpartum hemorrhage (PPH) is defined as cumulative blood loss greater than or equal to 1000 mL or excessive blood loss leading to development of symptoms (i.e., lightheaded, vertigo, syncope) and signs of hypovolemia (i.e., hypotension, tachycardia, or oliguria)
Classification of Postpartum Hemorrhage
Postpartum hemorrhage affects 5%–15% of women giving birth. PPH can be categorized into one of two categories:
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Early (primary)
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Occurs within the first 24 hours
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Etiologies (think the “4 T’s”):
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Uterine a t ony (80%–90% of cases)
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T issue—retained products of conception
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T rauma—uterine, cervical or vaginal lacerations
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T hrombin—dilutional or consumptive coagulopathy, coagulation disorders
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Late (secondary)
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Occurs between 24 hours and sixth week postpartum
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Most likely to occur from 6 to 14 days postpartum
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Etiology is usually infection, uterine subinvolution, or retained placental tissue
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Risk Factors
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Overdistended uterus, as caused by polyhydramnios or multiple gestations
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Macrosomia
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Prolonged labor
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Extended third stage of labor
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High parity
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Fibroid uterus or other uterine anomalies
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Placenta previa
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Cesarean delivery
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Episiotomy
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Trauma and lacerations
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Use of forceps or vacuum device
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History of uterine atony or hemorrhage
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Use of general anesthesia
Postpartum Assessment
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Prompt and accurate identification of the signs and symptoms of postpartum hemorrhage is key
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Typical schedule of evaluation:
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Every 15 minutes for 1 hour, then
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Every 30 minutes for 1 hour, then
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Every hour for 4 hours, then
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Every 4 hours for first 24 hours, then
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Every 8 hours until discharge
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Expect a slight increase in lochia with ambulation and breastfeeding
Quantification of Blood Loss
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Quantification of blood loss improves accuracy of estimated blood loss related to PPH
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Accomplished by knowing totaling measurements of blood in collection devices. Commonly used values are shown in Figs. 17.1 and 17.2 .
Fig. 17.1
Examples of blood loss. (A) Soaked 4 × 4 = 5 mL. (B) Fist-sized clot = 60 mL. (C) Soda can-sized clot = 355 mL. (D) Partially soaked peripad = 50 mL. (E) Peripad = 70 mL. (F) Full, dripping Chux = 800 mL. (G) 1/2 saturated lap sponge = 50 mL. (H) Full lap sponge = 75 mL. (I) Full, dripping lap sponge = 100 mL.
Fig. 17.2
Example of quantitative blood loss. The measured blood loss is 75 mL (full lap) + 50 mL (half lap) + 5 mL (4 × 4) + 5 mL (4 × 4). It is therefore recorded as 135 mL.
Management of Postpartum Hemorrhage
Active Management of the Third Stage of Labor
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Begin uterotonic drugs after the delivery of the anterior shoulder
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Ensure uterine contractions after delivery of placenta by fundal palpation and bimanual massage if necessary
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Inspect placenta for completeness
Identify the Etiology of the Hemorrhage
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Palpate the abdomen: assess uterine tone
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Inspect the cervix, vagina, vulva, and perianal area for lacerations, hematomas, or uterine inversion
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Perform manual exploration of uterine cavity to remove clots and retained tissue
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Consider coagulopathy. These may include the following:
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Hemophilia A
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Von Willebrand’s disease
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Liver disease
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Therapeutic anticoagulation
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Thrombocytopenia
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Disseminated intravascular coagulation (from preeclampsia, intrauterine fetal demise, severe infection, placental abruption, or amniotic fluid embolism)
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Approach to Uterine Atony
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Begin with bimanual fundal massage ( Fig. 17.3 )
