Postpartum hemorrhage (PPH) is a potentially life-threatening complication of both vaginal and cesarean delivery. Traditionally, PPH was defined as blood loss greater than 500 mL in a vaginal delivery and greater than 1,000 mL in a cesarean delivery. However, studies have revealed that an uncomplicated delivery often results in blood loss of more than 500 mL without any compromise of the mother's condition. These findings resulted in adoption of a broader definition for PPH. Any bleeding that results in signs and symptoms of hemodynamic instability, or bleeding that could result in hemodynamic instability if untreated, is considered PPH. Blood loss of greater than 1,000 mL with an vaginal delivery or a decrease in postpartum hematocrit level greater than 10% of the prenatal value also can be considered PPH. Some study findings suggest that the incidence of PPH Asian and Hispanic women is increased compared with that of other women.
This is excessive bleeding following delivery and is described as primary and secondary.
The WHO definitions:
- Primary post-partum haemorrhage is loss of blood estimated to be >500ml, from the genital tract, within 24 hours of delivery (commonest obstetric haemorrhage).
- Secondary PPH is defined as abnormal bleeding from the genital tract, from 24 hours after delivery until 6 weeks post-partum.
The commonest cause of PPH is uterine atony (failure of the uterus to contract effectively).
Other common causes are:
- Retained placenta or fragments of placenta
- Vulvar or vaginal lacerations or haematoma
Atony and retained placenta are 80% of all cases, lacerations comprise the bulk of the other 20%.
Cervical lacerations, uterine rupture, broad ligament haematoma and extra genital bleeding also need to be excluded.
- The most frequent cause of PPH is uterine atony, a condition in which the uterine corpus does not constrict properly, allowing continued blood loss from the placental site. Risk factors for atony include the following:
- Factors relating to the pregnancy:
- Antepartum haemorrhage in this pregnancy
- Placenta praevia (15x risk)
- Multiple pregnancy (5x risk)
- Pre-eclampsia or pregnancy induced hypertension (4x risk)
- Nulliparity (3x risk)
- Previous PPH (3x risk)
- Asian ethnic origin (2x risk)
- Maternal obesity (2x risk)
- Factors relating to delivery:
- Emergency Caesarean section (9x risk)0502
- Elective CS (4x risk) - especially if >3 repeat procedures
- Retained placenta (5x risk)
- Mediolateral episiotomy (5x risk)
- Operative vaginal delivery (2x risk)
- Labour of >12 hours (2x risk)
- >4kg baby (2x risk)
- Maternal pyrexia in labour (2x risk)
- Uterine inversion may be associated with hemorrhage of approximately 2 L. No definitive study findings have demonstrated the relationship between traction on the umbilical cord and uterine inversion, although many clinicians indicate that a correlation may exist.
- Uterine rupture may be associated with little vaginal bleeding, but it should be considered in the presence of severe abdominal pain and unstable hemodynamic findings.
- Pre-existing maternal haemorrhagic conditions:
- Factor 8 deficiency - Haemophilia A carrier
- Factor 9 deficiency - Haemophilia B carrier
- Von Willebrands disease
- Symptoms: Continuous bleeding, which fails to stop after delivery of placenta - third stage
- Signs: Loss of >1000ml may be accompanied by clinically apparent shock i.e. tachycardia, hypotension
- Thorough examination of the lower genital tract. This may require theatre/anaesthesia.
- FBC, Clotting screen, Cross match
- Hourly urine output
- Continuous pulse/BP or CVP monitoring
- ECG, pulse oximetry
HELLP (Haemolysis, Elevated Liver enzymes and Low platelets)
In a woman with excessive postpartum bleeding, simultaneously perform the physical examination and resuscitation. Focus the examination on determining the cause of the bleeding. The patient may not have the typical hemodynamic changes of shock early in the course of the haemorrhage due to physiologic maternal hypervolemia. Occult PPH always is an important consideration when unstable haemodynamic findings are present without evidence of excessive blood loss.
- Bimanual palpation of the uterus may reveal bogginess, atony, or uterine enlargement, with a large amount of accumulated blood. Palpation may also reveal hematomas in the perineum or pelvis.
- During suctioning, careful visual inspection of the cervix and vagina under good light may reveal the presence and extent of lacerations.
- Examine the placenta for missing portions, which suggest the possibility of retained placental tissue.
- Check for oozing from skin puncture sites or intravenous sites in patients with excessive bleeding as this could indicate a coagulopathy.
- Ideally one of the emergency drills to be practised by the team on labour ward.
- Calling and alerting expert assistance. If the perceived blood loss is 500-1000ml and there are no signs of clinical shock, basic measures, (cross match 2 units, FBC, Clotting screen, IV access and monitoring clinical observations ) should suffice.
- However loss of greater than 1000mls or any signs of shock should lead to full alert of the clinical team.
- Experienced midwife, obstetric registrar, (alert consultant), anaesthetic registrar (alert consultant), alert haematologist, alert transfusion service, call porters for transport of specimens and blood products.
- Nurse patient with head down tilt.
- Oxygen should be given by mask at 8 litres per minute.
- Transfuse cross matched blood (6 units initially) a.s. A. P.
- Until then infuse crystalloid or colloid as required.
- If 3.5 litres given and no blood available, give O NEG, or uncross matched blood of own blood group.
- Use a warming device and a pressure cuff.
- Do not use a blood filter.
- Do not use dextrans.
- Give up to 1 litre of FFP and 10 units of cryoprecipitate if clinically indicated.
- There is evidence that nitroglycerine may help with retained placenta.0801
A new haemostatic agent- recombinant Factor VII a - has had some clinical success, but its efficacy and safety is untested in clinical trials as yet.
- Secure IV access with 2 x14 gauge cannulae.
- Stop the bleeding.
- Exclude other causes than atony.
- Ensure bladder empty and bi-manually compress the uterus and rub up a contraction.
- Give IV syntocinon 10 units or IV ergometrine 500 mcg.
- Commence syntocinon infusion 30 units in 500ml.
- IM Carboprost 500mcg.
- Resort to surgery early. At laparotomy inject carboprost directly into the myometrium.
- Bilateral ligation of the uterine arteries or bilateral ligation of the internal iliac (hypogastric) arteries.
- An alternative to ligation is embolisation with gelatine sponge.9802 One case of amenorrhoea has been reported following this, secondary to necrosis of the uterine wall and obliteration of the cavity.0602
- Uterine Bracing suture, (the B-Lynch suture9701) to anterior and posterior uterine walls has been shown to be effective and safe,0503, 0701 with reports of successful pregnancy following its use.0504,0603
- Hysterectomy should be considered early, especially in cases of placenta accreta or uterine rupture.
For each woman who dies in the UK following peripartum hysterectomy, more than 150 survive. The most commonly reported causes of haemorrhage were uterine atony (53%) and morbidly adherent placenta (39%). Women were not universally managed with uterotonic therapies. Fifty women were unsuccessfully managed with B-Lynch or other brace suture prior to hysterectomy, 28 with activated factor VII and 9 with arterial embolisation. 0702
- Disseminated Intravascular Coagulation
The Confidential Enquiry into Maternal Deaths for 2000-2002 reported 17 deaths related to obstetric haemorrhage in that triennium. This gives a rate of 8.5 per million.
The Active Management of the Third stage of Labour; prophylactic oxytocics should be routinely used in the third stage of labour as they decrease the risk of PPH by 60%.9601 For most women syntometrine ( ergometrine 0.5mg with 5i.u oxytocin) is the drug of choice. Oxytocin alone (10i.u) is preferred by some clinicians in women with hypertension.
This commonly presents in primary care as prolonged or excessive bleeding once the woman has returned home after delivery.
The two commonest causes are:
- Infection- endometritis. Occurs in 1-3% after spontaneous vaginal delivery. It is the most common cause of postnatal morbidity between day 2 and day 10.
- Retained products of conception (RPOC)
Endometritis risk factors
Caesarean section, prolonged rupture of membranes, severe meconium staining in liquor,15 long labour with multiple examinations, manual removal of placenta,16 mothers age at extremes of reproductive span, low socio-economic status, maternal anaemia, prolonged surgery, internal fetal monitoring and general anaesthetic.
History: As above, also extended labour, difficult 3rd stage, ragged placenta, primary PPH.
Examination: Systemic illness, fever, rigors, tachycardia, tissue visible within loss. Suprapubic area may be tender, with elevated fundus that feels boggy in RPOC.
- Blood cultures are positive in 10-30%
- Check MSU
- High vaginal swab, also gonorrhoea/chlamydia
- Ultrasound; may be used if RPOC suspected, although there may be difficulty distinguishing between clot and products. RPOC are unlikely if a normal endometrial stripe is seen.
- Speculum examination will allow visualisation of cervix and lower genital tract to exclude lacerations. If clot is visible within the cervical os, it may be removed with tissue forceps (though few GP regularly carry these), allowing the cervix to close.
- If infection suspected, combinations of broad spectrum e.g. amoxicillin, gentamicin and metronidazole, can be given.0301 Patient may need to be referred if too unwell to tolerate oral medication; IV clindamycin and gentamicin tds until afebrile for greater than 24 hours.0401 Oral follow up treatment is not required. Use doxycyline if chlamydia is suspected.
- If retained products of conception are suspected elective curettage with antibiotic cover may be required.
- Patient may require iron supplementation if Hb has fallen. Warn of the risk of constipation.
90% of cases treated with antibiotics improve within 48-72 hours. If this is not the case, the patient should be re-evaluated.
Maternal Mortality Rates
Maternal Mortality From Haemorrhage.