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1. Postpartum Hemorrhage
Jorge Garcia, MD
December, 2001

2. Goals of talk
 Definition
 Rapid diagnosis and treatment
 Review risks

3. Case 1.
 Healthy 32 yo G2P1.
 Augmented vaginal delivery, no tears.
 Nurse calls you one hour after delivery
because of heavy bleeding.
 What do you do?
 What do you order?

4. Case 2
 26 yo G4 now P4.
 NSVD, with help from medical student.
 You leave the room to answer a page while
waiting for placenta to deliver, but are
called back overhead, stat.
 Huge blood clot seen in vagina.
 What is this, and what do you do next?

5. Definition
 Mean blood loss with vaginal delivery:
500cc
 > 1000cc is “hemorrhage”
 Mean blood loss with C/S: 1000cc
 >1500cc is “hemorrhage”
 Seen in ~5% of deliveries.

6. Early vs. Late
 Most authors define early as < 72h.
 ALSO defines it as <24h.
 Late hemorrhage is more likely due to
infection and retained placental tissue.

7. Prenatal Risk Factors
 Most patients with hemorrhage have none.
 Pre-eclampsia (RR 5.0)
 Previous postpartum hemorrhage (RR 3.6)
 Multiple gestation (RR 3.3)
 Previous C/S (RR 1.7)
 Multiparity (RR1.5)

8. Intrapartum Risk Factors
 Prolonged 3rd stage (>30 min) (RR7.5)
 medio-lateral episiotomy (RR4.7)
 midline episiotomy ( RR1.6)
 Arrest of descent (RR 2.9)
 Lacerations (RR 2.0)
 Augmented labor ( RR1.7)
 Forceps delivery (RR 1.7)

9. Easy to miss
 Physicians underestimate blood loss by
50%
 Slow steady bleeding can be fatal
 Most deaths from hemorrhage seen after 5h
 Abdominal or pelvic bleeding can be
hidden

10. Always look for signs of bleeding
 Estimate blood loss accurately.
 Evaluate all bleeding, including slow
bleeds.
 If mother develops hypotension,
tachycardia or pain…rule out intra-
abdominal blood loss.

11. Initial Assessment
 Identify possible post partum hemorrhage.
 Simultaneous evaluation and treatment.
 Remember ABCs.
 Use O2 4L/min.
 If bleeding does not readily resolve, call for
help.
 Start two 16g or 18g IVs.

12. ALSO’s 4 Ts
 Tone (Uterine tone)
 Tissue (Retained tissue--placenta)
 Trauma (Lacerations and uterine rupture)
 Thrombin (Bleeding disorders)

13. “Tone: Think of Uterine Atony”
 Uterine atony causes 70% of hemorrhage
 Assess and treat with uterine massage
 Use medication early
 Consider prophylactic medication...

14. Bimanual Uterine Exam
 Confirms diagnosis of uterine atony.
 Massage is often adequate for stimulating
uterine involution.

15. Medications for Uterine Atony
 1. Oxytocin promotes rhythmic
contractions.
 Give IM or IU, not IV. (Can cause ↓ BP)
 40U/L at 250cc/h.
 2. Methergine 0.2mg (1 amp) IM
 3. Hemabate 0.25mg IM q 15min (max
X8).

16. Medications: Methergine
 Causes tetanic uterine contraction.
 May trap placenta.
 Can cause Hypertension, especially IV.
 Contraindicated in hypertensive patients
and those with pre-eclampsia.
 Some authors skip Methergine altogether.

17. Prostaglandin F2 15-methyl
 Hemabate 0.25mg IM or IU.
 Used to be called Prostin.
 Controls hemorrhage in 86% when used
alone, and 95% in combination with above.
 Can repeat up to eight times.
 Contraindicated in active systemic diseases.
 Can cause nausea/vomiting/diarrhea, ↑ BP.

18. Tissue: Retained placenta
 Delay of placental delivery > 30 minutes
seen in ~ 6% of deliveries.
 Prior retained placenta increases risk.
 Risk increased with: prior C/S, curettage p-
pregnancy, uterine infection, AMA or
increased parity.
 Prior C/S scar & previa increases risk
(25%)
 Most patients have no risk factors.
 Occasionally succenturiate lobe left behind.

19. Abnormal Placental Implantation
 Attempt to remove the placenta by usual
methods.
 Excess traction on cord may cause cord tear
or uterine inversion.
 If placenta retained for >30 minutes, this
may be caused by abnormal placental
implantation.

20. Abnormal implantation defined.
 Caused by missing or defective decidua.
 Placenta Accreta: Placenta adherent to
myometrium.
 Placenta Increta: myometrial invasion.
 Placenta Percreta: penetration of
myometrium to or beyond serosa.
 These only bleed when manual removal
attempted.

22. Removal of Abnormal Placenta
 Oxytocin 10U in 20cc of NS placed in
clamped umbilical vein.
 If this fails, get OB assistance.
 Check Hct, type & cross 2-4 u.
 Two large bore IVs.
 Anesthesia support.

23. Removal of Abnormal Placenta
 Relax uterus with halothane general
anesthetic and subcutaneous terbutaline.
 Bleeding will increase dramatically.
 With fingertips, identify cleavage plane
between placenta and uterus.
 Keep placenta intact.
 Remove all of the placenta.

25. Removal of Abnormal Placenta
 If successful, reverse uterine atony with
oxytocin, Methergine, Hemabate.
 Consider surgical set-up prior to separation.
 If manual removal not successful, large
blunt curettage or suction catheter, with
high risk of perforation.
 Consider prophylactic antibiotics.

26. Trauma (3rd “T”)
 Episiotomy
 Hematoma
 Uterine inversion
 Uterine rupture

27. Uterine Inversion
 Rare: ~1/2000 deliveries.
 Causes include:
 Excessive traction on cord.
 Fundal pressure.
 Uterine atony.

28. Uterine Inversion
 Blue-gray mass protruding from vagina.
 Copious bleeding.
 Hypotension worsened by vaso-vagal
reaction. Consider atropine 0.5mg IV if
bradycardia is severe.
 High morbidity and some mortality seen:
get help and act rapidly.

29. Uterine Inversion
 Push center of uterus with three fingers into
abdominal cavity.
 Need to replace the uterus before cervical
contraction ring develops.
 Otherwise, will need to use MgSO4,
tocolytics, anesthesia, and treatment of
massive hemorrhage.
 When completed, treat uterine atony.

31. Uterine Rupture
 Rare: 0.04% of deliveries.
 Risk factors include:
 Prior C/S: up to 1.7% of these deliveries.
 Prior uterine surgery.
 Hyperstimulation with oxytocin.
 Trauma.
 Parity > 4.

32. Uterine Rupture
 Risk factors include:
 Epidural.
 Placental abruption.
 Forceps delivery (especially mid forceps).
 Breech version or extraction.

33. Uterine Rupture
 Sometimes found incidentally.
 During routine exam of uterus.
 Small dehiscence, less than 2cm.
 Not bleeding.
 Not painful.
 Can be followed expectantly.

34. Uterine Rupture before delivery
 Vaginal bleeding.
 Abdominal tenderness.
 Maternal tachycardia.
 Abnormal fetal heart rate tracing.
 Cessation of uterine contractions.

35. Uterine Rupture after delivery
 May be found on routine exam.
 Hypotension more than expected with
apparent blood loss.
 Increased abdominal girth.

36. Uterine Rupture
 When recognized, get help.
 ABCs.
 IV fluids.
 Surgical correction.

37. Birth Trauma
 Lacerations of birth tract not rare: causes
post partum hemorrhage in 1/1500
deliveries.

38. Birth Trauma
 Risk factors include:
 Instrumented deliveries.
 Primiparity.
 Pre-eclampsia.
 Multiple gestation.
 Vulvovaginal varicosities.
 Prolonged second stage.
 Clotting abnormalities.

39. Birth Trauma
 Repair lacerations quickly.
 Place initial suture above the apex of
laceration to control retracted arteries.

40. Repair of cervical laceration

41. Birth Trauma: Hematomas
 Hematomas less than 3cm in diameter can
be observed expectantly.
 If larger, incision and evacuation of clot is
necessary.
 Irrigate and ligate bleeding vessels.
 With diffuse oozing, perform layered
closure to eliminate dead space.
 Consider prophylactic antibiotics.

42. Pelvic Hematoma

43. Vulvar hematoma

44. Thrombin (4th “T”)
 Coagulopathies are rare.
 Suspect if oozing from puncture sites noted.
 Work up with platelets, PT, PTT, fibrinogen
level, fibrin split products, and possibly
antithrombin III.

45. Prevention?
 Some evidence supports use of oxytocin
after delivery of anterior shoulder, in
umbilical vein or IV.

46. Summary: remember 4 Ts
 Tone
 Tissue
 Trauma
 Thrombin

47. Summary: remember 4 Ts
 “TONE”  Palpate fundus.
 Rule out Uterine  Massage uterus.
Atony  Oxytocin 40U/L @
250cc / h.
 Methergine one amp
IM (not in
hypertensives)
 Hemabate IM q 15min

48. Summary: remember 4 Ts
 “Tissue”  Inspect placenta for
 R/O retained placenta missing cotyledons.
 Explore uterus.
 Treat abnormal
implantation.

49. Summary: remember 4 Ts
 “TRAUMA”  Obtain good exposure.
 R/o cervical or vaginal  Inspect cervix and
lacerations. vagina.
 Worry about slow
bleeders.
 Treat hematomas.

50. Summary: remember 4 Ts
 “THROMBIN”  Check labs if
suspicious.