The diagnosis of postpartum haemorrhage begins with
recognition of excessive bleeding and methodic examination to determine its
cause The “Four Ts” mnemonic (Tone, Trauma, Tissue, and Thrombin) can be used
to detect specific causes (Bias, et al.,
2010).
recognition of excessive bleeding and methodic examination to determine its
cause The “Four Ts” mnemonic (Tone, Trauma, Tissue, and Thrombin) can be used
to detect specific causes (Bias, et al.,
2010).
Management of postpartum haemorrhage
Many of the steps involved in diagnosing and treating
postpartum hemorrhage must be undertaken simultaneously. Although the steps in
maternal resuscitation are consistent (bold arrows)
other actions may differ based on the actual cause. (IV = intravenous; IU =
international units; CBC = complete blood count; IM = intramuscularly; RBC =
red blood cells; ICU = intensive care unit)
postpartum hemorrhage must be undertaken simultaneously. Although the steps in
maternal resuscitation are consistent (bold arrows)
other actions may differ based on the actual cause. (IV = intravenous; IU =
international units; CBC = complete blood count; IM = intramuscularly; RBC =
red blood cells; ICU = intensive care unit)
Tone
Uterine atony is the most common cause of postpartum haemorrhage.
Because hemostasis associated with placental separation depends on myometrial
contraction, atony is treated initially by bimanual uterine compression and
massage, followed by drugs that promote uterine contraction.
Because hemostasis associated with placental separation depends on myometrial
contraction, atony is treated initially by bimanual uterine compression and
massage, followed by drugs that promote uterine contraction.
Uterine massage
Brisk blood flow after delivery of the placenta should
alert the physician to perform a bimanual examination of the uterus. If the
uterus is soft, massage is performed by placing one hand in the vagina and
pushing against the body of the uterus while the other hand compresses the
fundus from above through the abdominal wall. The posterior aspect of the
uterus is massaged with the abdominal hand and the anterior aspect with the
vaginal hand (Bias, et al., 2010).
alert the physician to perform a bimanual examination of the uterus. If the
uterus is soft, massage is performed by placing one hand in the vagina and
pushing against the body of the uterus while the other hand compresses the
fundus from above through the abdominal wall. The posterior aspect of the
uterus is massaged with the abdominal hand and the anterior aspect with the
vaginal hand (Bias, et al., 2010).
Uterotonic agents
Uterotonic agents include oxytocin, ergot alkaloids,
and prostaglandins. Oxytocin stimulates the upper segment of the myometrium to
contract rhythmically, which constricts spiral arteries and decreases blood
flow through the uterus.Oxytocin is an effective first-line treatment for
postpartum hemorrhage; 10 international units (IU) should be injected intramuscularly,
or 20 IU in 1 L of saline may be infused at a rate of 250 mL per hour. As much
as 500 ml can be infused over 10 minutes without complications (Bias, et al., 2010).
and prostaglandins. Oxytocin stimulates the upper segment of the myometrium to
contract rhythmically, which constricts spiral arteries and decreases blood
flow through the uterus.Oxytocin is an effective first-line treatment for
postpartum hemorrhage; 10 international units (IU) should be injected intramuscularly,
or 20 IU in 1 L of saline may be infused at a rate of 250 mL per hour. As much
as 500 ml can be infused over 10 minutes without complications (Bias, et al., 2010).
Trauma
Lacerations and hematomas resulting from birth trauma
can cause significant blood loss that can be lessened by hemostasis and timely
repair. Sutures should be placed if direct pressure does not stop the bleeding.
Episiotomy increases blood loss and the risk of anal sphincter tears, and this
procedure should be avoided unless urgent delivery is necessary and the
perineum is thought to be a limiting factor.
can cause significant blood loss that can be lessened by hemostasis and timely
repair. Sutures should be placed if direct pressure does not stop the bleeding.
Episiotomy increases blood loss and the risk of anal sphincter tears, and this
procedure should be avoided unless urgent delivery is necessary and the
perineum is thought to be a limiting factor.
Hematomas can present as pain or as a change in vital
signs disproportionate to the amount of blood loss. Small hematomas can be
managed with close observation. Patients with persistent signs of volume loss
despite fluid replacement, as well as those with large or enlarging hematomas,
require incision and evacuation of the clot. The involved area should be irrigated
and the bleeding vessels ligated. In patients with diffuse oozing, a layered
closure will help to secure hemostasis and eliminate dead space (Bias, et al., 2010).
signs disproportionate to the amount of blood loss. Small hematomas can be
managed with close observation. Patients with persistent signs of volume loss
despite fluid replacement, as well as those with large or enlarging hematomas,
require incision and evacuation of the clot. The involved area should be irrigated
and the bleeding vessels ligated. In patients with diffuse oozing, a layered
closure will help to secure hemostasis and eliminate dead space (Bias, et al., 2010).
Uterine rupture
Although rare in an unscarred uterus, clinically
significant uterine rupture occurs in 0.6 to 0.7 percent of vaginal births
after caesarean delivery in women with a low transverse or unknown uterine
scar. The risk increases significantly with previous classical incisions or
uterine surgeries, and to a lesser extent with shorter intervals between
pregnancies or a history of multiple caesarean deliveries, particularly in
women with no previous vaginal deliveries. Compared with spontaneous labour,
induction or augmentation increases the rate of uterine rupture, more so if
prostaglandins and oxytocin are used sequentially (Bias, et al., 2010).
significant uterine rupture occurs in 0.6 to 0.7 percent of vaginal births
after caesarean delivery in women with a low transverse or unknown uterine
scar. The risk increases significantly with previous classical incisions or
uterine surgeries, and to a lesser extent with shorter intervals between
pregnancies or a history of multiple caesarean deliveries, particularly in
women with no previous vaginal deliveries. Compared with spontaneous labour,
induction or augmentation increases the rate of uterine rupture, more so if
prostaglandins and oxytocin are used sequentially (Bias, et al., 2010).
Tissue
Classic signs of placental separation include a small
gush of blood with lengthening of the umbilical cord and a slight rise of the
uterus in the pelvis. Placental delivery can be achieved by use of the
Brandt-Andrews manoeuvre, which involves applying firm traction on the
umbilical cord with one hand while the other applies suprapubic counter pressure The mean time from delivery until placental
expulsion is eight to nine minutes. Longer intervals are associated with an
increased risk of postpartum hemorrhage, with rates doubling after 10 minutes. Retained
placenta (i.e., failure of the placenta to deliver within 30 minutes after
birth) occurs in less than 3 percent of vaginal deliveries. One management
option is to inject the umbilical vein with 20 ml of a solution of 0.9 percent
saline and 20 units of oxytocin (Magnann, et
al., 2009).
gush of blood with lengthening of the umbilical cord and a slight rise of the
uterus in the pelvis. Placental delivery can be achieved by use of the
Brandt-Andrews manoeuvre, which involves applying firm traction on the
umbilical cord with one hand while the other applies suprapubic counter pressure The mean time from delivery until placental
expulsion is eight to nine minutes. Longer intervals are associated with an
increased risk of postpartum hemorrhage, with rates doubling after 10 minutes. Retained
placenta (i.e., failure of the placenta to deliver within 30 minutes after
birth) occurs in less than 3 percent of vaginal deliveries. One management
option is to inject the umbilical vein with 20 ml of a solution of 0.9 percent
saline and 20 units of oxytocin (Magnann, et
al., 2009).
Thrombin
Coagulation disorders, a rare cause of post-partum
hemorrhage, are unlikely to respond to the measures described above. Most
coagulopathies are identified before delivery, allowing for advance planning to
prevent postpartum hemorrhage. These disorders include idiopathic
thrombocytopenic purpura, thrombotic thrombocytopenic purpura, von Willebrand’s
disease, and hemophilia. Patients also can develop HELLP (hemolysis, elevated
liver enzyme levels, and low platelet levels) syndrome or disseminated
intravascular coagulation. Risk factors for disseminated intravascular coagulation
include severe pre-eclampsia, amniotic fluid embolism, sepsis, placental
abruption, and prolonged retention of fetal demise. Abruption is associated
with cocaine use and hypertensive disorders. Excessive bleeding can deplete
coagulation factors and lead to consumptive coagulation, which promotes further
bleeding. Coagulation defects should be suspected in patients who have not
responded to the usual measures to treat post-partum hemorrhage, and in those
who are not forming blood clots or are oozing from puncture sites.
hemorrhage, are unlikely to respond to the measures described above. Most
coagulopathies are identified before delivery, allowing for advance planning to
prevent postpartum hemorrhage. These disorders include idiopathic
thrombocytopenic purpura, thrombotic thrombocytopenic purpura, von Willebrand’s
disease, and hemophilia. Patients also can develop HELLP (hemolysis, elevated
liver enzyme levels, and low platelet levels) syndrome or disseminated
intravascular coagulation. Risk factors for disseminated intravascular coagulation
include severe pre-eclampsia, amniotic fluid embolism, sepsis, placental
abruption, and prolonged retention of fetal demise. Abruption is associated
with cocaine use and hypertensive disorders. Excessive bleeding can deplete
coagulation factors and lead to consumptive coagulation, which promotes further
bleeding. Coagulation defects should be suspected in patients who have not
responded to the usual measures to treat post-partum hemorrhage, and in those
who are not forming blood clots or are oozing from puncture sites.
Management consists of treating the underlying disease
process, supporting intravascular volume, serially evaluating coagulation
status, and replacing appropriate blood components. Administration of
recombinant factor VIIa or clot-promoting medications (e.g., tranexamic acid
[Cyklokapron]) may be considered (Magnann, et
al., 2009).
process, supporting intravascular volume, serially evaluating coagulation
status, and replacing appropriate blood components. Administration of
recombinant factor VIIa or clot-promoting medications (e.g., tranexamic acid
[Cyklokapron]) may be considered (Magnann, et
al., 2009).
References
Bias, J. M., Eskes, M.,
Bonsel, G.J. & Bleker, O. P. (2010). Postpartum haemorrhage in nulliparous women:
incidence and risk factors in low andhigh risk women. A Dutch population-based cohort
study on standard (>or =500ml) and severe (> or = 1000ml) postpartum haemorrhage.
Eur J Obstet Gynecol Reprod Biol 115:166-72.
Bonsel, G.J. & Bleker, O. P. (2010). Postpartum haemorrhage in nulliparous women:
incidence and risk factors in low andhigh risk women. A Dutch population-based cohort
study on standard (>or =500ml) and severe (> or = 1000ml) postpartum haemorrhage.
Eur J Obstet Gynecol Reprod Biol 115:166-72.
Magnann, E. F., Evans, S.,
Chauhan, S. P., Lanneau, G., Fisk, A.D. & Morrison, J.C. (2009). The length
of third stage of labor and the risk of postpartum haemorrhage. Obstet Gynecol 105:2903.
Chauhan, S. P., Lanneau, G., Fisk, A.D. & Morrison, J.C. (2009). The length
of third stage of labor and the risk of postpartum haemorrhage. Obstet Gynecol 105:2903.
