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Postpartum hemorrhage is the most common cause of maternal mortality worldwide and
remains among the top three causes of maternal mortality in the U.S. and industrial nations,
after thromboembolism and hypertension.44 There are 1.4 deaths per 100,000 live births due
to hemorrhage. The risk of hemorrhage and death is much higher in black women and other
nonwhite women than in white women.45
Postpartum hemorrhage usually occurs within the first 24 hours of delivery and is referred to
as primary postpartum hemorrhage. Secondary postpartum hemorrhage occurs after the first
24 hours and up to 6 weeks postpartum. The main causes of primary postpartum hemorrhage
are uterine atony, retained placental fragments, lower genital tract lacerations, uterine rupture,
uterine inversion, and hereditary coagulopathy.
Excessive blood loss in the postpartum period is defined as a 10% drop in the hematocrit, a
need for transfusion of packed red blood cells, or volume loss that causes symptoms of
hypovolemia. Normally, plasma volume increases by 40% and red blood cell volume by 25%
at the end of the third trimester. The hematologic changes of pregnancy can mask the typical
symptoms of hemorrhage. A high clinical suspicion for postpartum hemorrhage is important
to avoid significant morbidity. Patients may initially present with only a mild increase in
pulse rate. Up to a 30% loss in total blood volume may be required before a significant
change in blood pressure occurs.
Initial treatment of postpartum hemorrhage should focus on aggressive fluid resuscitation and
identification and treatment of the underlying cause. Severe hemorrhage may require
transfusion of blood products. The clinician should examine the state of contractility of the
uterus and apply bimanual compression, if needed. A thorough examination looking for signs
of laceration or retained products or any other cause requiring specific treatment should be
performed. US is important to identify retained products. Genital tract lesions should be
repaired. Pharmacologic treatment of postpartum hemorrhage focuses on promoting
uterine contraction and correcting coagulopathies and is outlined in Table 104-11.
Drug
Comments
Prostaglandin
Drug
Comments
Side effects: nausea, vomiting, diarrhea
Prostaglandin
Side effects: nausea, vomiting, diarrhea, hypertension,
bronchospasm
Avoid in patients with hypertension or asthma
A trial of recombinant activated factor VII may be considered if other pharmacologic therapy
fails. Recombinant activated factor VII has been successfully used to control hemorrhage in
both hemophiliacs and non hemophiliacs, presumably by increasing the levels of thrombin
and therefore aid in hemostasis. Currently, recombinant activated Factor VII is used on a
case-by-case basis, and further studies are necessary to determine its role in managing
postpartum hemorrhage.46
Other Considerations in Postpartum Hemorrhage
Uterine atony can occur from overdistention of the uterus due to fetal macrosomia,
polyhydramnios, or multifetal gestation. Patients may require large doses of oxytocin and
fluid resuscitation. Uterine inversion, which occurs in 1 in 2000 deliveries due to overzealous
attempts to remove the placenta, requires immediate manual replacement of the placenta.
This is a very painful and difficult procedure that may require general anesthesia and uterine
relaxation agents. Retention of placental fragments and abnormal placental implantation may
also lead to severe hemorrhage and may require emergency peripartum hysterectomy.47
e. If the placenta is out but bleeding continues, explore the uterus for retained placenta
fragments (premedicate if time allows) and perform bimanual compression.
(1) Order 10 to 20 units Pitocin to current IV if not already given.
(2) If not improving, see Fourth Stage Hemorrhage Management guidelines below.
f. If signs and symptoms of shock develop:
(1) Infuse Ringer's lactate solution (RL) rapidly.
(2) Place patient flat with legs slightly elevated.
(3) Give oxygen per mask.
(4) Keep patient warm, cover with warm blankets.
(5) Continue monitoring vital signs.
II. Fourth Stage Hemorrhage
A. Definition. Fourth stage hemorrhage is defined as blood loss of 500 ml (some references
use 650 ml) or more between the time the placenta is delivered and 24 hours after.
B. Etiology
1. Uterine atony due to:
a. Primary atony
b. Overdistended uterus
(1) Multiple gestation
(2) Large baby
(3) Polyhydramnios
c. Exhaustion of uterine muscle
(1) Multiparity
(2) Prolonged labor
(3) Use of oxytocin in labor
d. Inability of the uterus to contract properly:
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(1) Precipitous labor, delivery, or both
(2) Uterine myomas
(3) Full bladder
2. Trauma and lacerations
a. Episiotomy. Blood loss can reach 200 cc normally. When arterioles or large veins are cut or
torn, the amount of blood loss can be considerably more.
b. Lacerations of the vulva, vagina, or cervix
c. Ruptured uterus, possibly from a previous cesarean scar
d. Uterine inversion
e. Puerperal hematomas
3. Retained placental fragments or clots
C. Management
1. Preventive techniques
a. Clamp bleeding vessels immediately to conserve blood.
b. Avoid an episiotomy if possible. If an episiotomy is necessary, avoid a prolonged interval
between performance of episiotomy and delivery of the baby.
c. Avoid undue delay from birth of the baby to repair of episiotomy or lacerations.
d. Routinely inspect upper vaginal vault and cervix.
e. Start repair above apex to avoid failure to secure a bleeding vessel there.
f. Routinely inspect placenta for missing parts and broken vessels. Be aware of trailing
membranes at time of delivery of the placenta. Remove them slowly.
g. If there is reason to believe placental fragments are retained, medicate as necessary,
manually explore uterus, inform physician as necessary.
(d) If still bleeding administer Hemabate one amp IM every five minutes three times. Give
first dose 10 minutes post Prostin.
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(4) Send someone to call physician.
(5) Continue bimanual compression.
(6) Have assistant monitor vital signs and watch for signs of shock.
c. If bleeding is not under control, have assistant get type and cross if not already done.
d. If uterus is well-contracted and bleeding continues, look for lacerations.
(1) If first or second degree lacerations of vagina or perineum, repair.
(2) If lacerations of cervix or third or fourth degree lacerations of vagina or perineum:
(a) Clamp any bleeders and wait for physician.
(b) If physician still has not arrived and hemostasis is not attained, repair as necessary to
attain hemostasis.
e. If signs of shock develop:
(1) Infuse LR rapidly.
(2) Place patient flat with legs slightly elevated.
(3) Give oxygen per mask.
(4) Keep patient warm, cover with blankets.
(5) Have assistant monitor vital signs.
f. In extreme cases, consider the following:
(1) Injection of oxytocin directly into the uterus with Iowa trumpet
(2) Aortic compression
(3) Alert OR in case a D&C or hysterectomy are necessary
3. Follow-up management
a. Obtain hematocrit:
(1) Twelve hours after delivery
(2) Twenty-four hours after delivery
b. Consider ordering supplemental iron