Chapter 135. Postpartum Hemorrhage Management

Postpartum hemorrhage, or excessive blood loss following delivery, is the leading cause of maternal death worldwide. It is traditionally defined as blood loss greater than 500 mL after vaginal delivery and 1000 mL after a cesarean section.1 This is impractical because the normal blood loss is believed to be 300 to 500 mL following a vaginal delivery and 900 to 1200 mL following a cesarean section.2 It has also been defined as blood loss that results in a decrease in the hematocrit of greater than 10 points between admission and the postpartum period, which corresponds to the 97th percentile of vaginal and 92nd percentile of cesarean deliveries.1,2 A clinically useful definition is excessive bleeding that results in signs and/or symptoms of hypovolemia (e.g., tachycardia, hypotension, oliguria, dizziness, palpitations, syncope, and/or shortness of breath), which corresponds to a 10% or more loss in total blood volume.3 Postpartum hemorrhage can occur at sites within or external to the genitourinary tract (Table 135-1).

The incidence of postpartum hemorrhage ranges from 4% to 6% of pregnancies in the United States.3 Primary postpartum hemorrhage accounts for greater than 90% of all cases and occurs within 24 hours of delivery. It is most commonly the result of excessive bleeding from the placental implantation site (uterine atony) or trauma to the genital tract. It can be associated with a considerable drop in hematocrit and significant maternal complications. Secondary postpartum hemorrhage occurs more than 24 hours after delivery and up to 12 weeks postpartum. It is usually the result of excessive bleeding from the placental implantation site or retained products of conception, but can also be caused by an infection or coagulation defects.3,6 This chapter reviews the pathophysiology of early postpartum hemorrhage, discusses the diagnosis and assessment of postpartum hemorrhage, and concludes with strategies for treatment.

The most common causes of postpartum hemorrhage are uterine atony (70% to 90%), genital tract trauma (5% to 8%), retained products of conception (3% to 5%), and hematologic or coagulopathic abnormalities (<2%). Uterine inversion is a rare cause of postpartum hemorrhage. Risk factors for uterine atony include a prolonged third stage of labor, induced or augmented labor, high parity, an overdistended uterus, use of uterine relaxing agents, chorioamnionitis, some types of anesthesia, and previous postpartum hemorrhage.1 Genital tract injuries include vaginal or cervical lacerations, episiotomies, vulvar or vaginal hematomas, and uterine rupture. Retention of all or part of the placenta interferes with uterine contraction, resulting in continued bleeding from the implantation site. Hematologic abnormalities include von Willebrand's disease, disseminated intravascular coagulation, and other less common inherited, congenital, or acquired disorders.

In a normal pregnancy, the plasma volume increases by approximately 40% and the red cell mass by 25% resulting in a hypervolemia of about 1500 to 2000 mL.3,5 This compensates for typical blood losses. Visual estimates of blood loss are inaccurate, especially if blood is mixed with amniotic fluid. Weigh all pads for an accurate assessment (1 g = 1 mL of blood). The signs and symptoms of postpartum hemorrhage include measurable blood loss greater than 500 mL, tachycardia, hypotension, oliguria, syncope, pallor, diaphoresis, palpitations, dizziness, shortness of breath, and fatigue. Concealed hemorrhage from a vaginal hematoma, uterine rupture, or broad ligament hematoma must be suspected if the patient is symptomatic in the absence of obvious blood loss.

Patients at risk for postpartum hemorrhage require blood typed and held on admission. Leading risk factors associated with early postpartum hemorrhage in vaginal birth include prolonged third stage of labor, preeclampsia, mediolateral episiotomy, previous postpartum hemorrhage, multiple gestations, arrest of descent, and soft tissue lacerations.1 Other risk factors are listed in Table 135-2. Surgical deliveries, as compared with vaginal deliveries, are often associated with increased blood loss. Inhalation anesthesia, especially with halogenated agents, increases the risk for postpartum hemorrhage and should be used sparingly in high-risk cases.5,7 Other risk factors for postpartum hemorrhage in cesarean deliveries include chorioamnionitis, preeclampsia, protracted active phase of labor, and arrest of descent.2

All postpartum hemorrhage must be controlled as soon as possible to prevent maternal morbidity and mortality. The two foremost causes of postpartum hemorrhage are uterine atony and lower genital tract lacerations. Such lacerations and injuries are most common with difficult deliveries, especially operative vaginal deliveries, and with the use of an episiotomy. Carefully examine the vagina and cervix for injury immediately following delivery of the infant and placenta. If present, these factors should be noted and the possibility of postpartum hemorrhage anticipated.

There are no absolute contraindications to the management of postpartum hemorrhage. Therapies for postpartum hemorrhage, specifically drug therapy for uterine atony, may have significant side effects. Avoid undiluted rapid IV infusions of oxytocin which can cause hypotension. Ergots, such as methylergonovine, are potent vasoconstrictors and should be given intramuscularly. They are contraindicated in the presence of cardiac disorders, coronary artery disease, hypertensive disorders, preeclampsia, scleroderma, and Raynaud's phenomenon. Prostaglandin F (PGF) is contraindicated in patients with active asthma as it can incite severe bronchospasm in sensitive individuals.4 It may also result in vasoconstriction of the pulmonary bed.4 The side effects include diarrhea, fever, and tachycardia. PGE2 (Prostin) should be avoided in hypotensive patients. Human recombinant factor VIIa is a new, expensive treatment for life-threatening hemorrhage but can cause subsequent thromboembolism.8

• Sterile gown and gloves
• Face mask with eye shield or goggles
• Cap
• Povidone iodine or chlorhexidine solution
• Foley catheter
• Gauze sponges
• Sponge-tipped applicators (large)
• Sterile delivery drapes
• Alcohol swabs
• 16 to 18 gauge needle
• 10 mL syringe
• 22 to 25 gauge epidural needle for injection
• Weighted vaginal speculum or Sims retractor
• Two right angle (Heaney) retractors
• Four ring forceps
• Straight Mayo scissors or sterile scalpel
• 2-0 or 3-0 suture: polyglactin (Vicryl) or chromic gut
• SOS Bakri tamponade balloon
• Sengstaken–Blakemore tube
• Three 30 mL bulb Foley catheters
• Packing forceps

Medications

• Local anesthetic solution (lidocaine, bupivacaine, or mepivacaine)
• Oxytocin (Pitocin)
• Methylergonovine maleate (Methergine)
• 15-methyl PGF2α (Hemabate, Carboprost)
• Misoprostol or PGE1 (Cytotec)
• Dinoprostone or PGE2 (Prostin)
• Factor VIIa (NovoSeven)
• 4-inch gauze soaked with 5000 U of thrombin in 5 mL of saline

The initial management must be aimed at stabilizing the mother and identifying the bleeding source. Apply bimanual compression (Figure 135-1), which will control most hemorrhage, and obtain help. Establish intravenous access at two sites with 16 to 18 gauge angiocatheters. Type and cross match the patient for any required blood components if not done previously. Place a Foley catheter to monitor urine output and to allow the uterus to contract. Regulate fluid intake carefully.

Identification of the origin or site of bleeding is critical. Uterine hypotonia is the most frequent source of hemorrhage. Therefore, uterotonics are usually administered concurrently with a complete examination of the uterus. Palpation will often exhibit a boggy, soft, and spongy uterus that may be increasing in size due to the accumulation of clots and blood within the endometrial cavity. These must be cleared to allow for adequate uterine contractions. Continued bleeding from the endometrial cavity through the cervical os is always present. A well-contracted uterus does not bleed significantly in the absence of a severe coagulopathy. Examination of the uterus is performed by palpation of the fundus with the nondominant hand and manual exploration of the uterine cavity with the other. Ultrasound may be used to ascertain the presence of placental tissue or clots that may require manual removal and/or curettage.

Continued hemorrhage with a firm uterus indicates bleeding from another source such as the lower uterine segment, the cervix, or the vagina. Examine all areas carefully, even after hemorrhage is noted at one site, as there may be more than one source of hemorrhage. Begin at the most distal aspects of the genital tract and work proximally.

Uterine Atony

Oxytocin and fundal (transabdominal) massage should be initiated just after delivery of the placenta, which usually results in a firm, contracted (rock-like) fundus. However, the uterus may never become firm or may relax again.

Uterine atony is identified by palpating a soft and boggy uterus. Begin transabdominal uterine massage to promote uterine muscle contractions. Use one or two hands to palpate the uterus through the abdominal wall and rhythmically press downward in a circular motion. Massage in a firm but gentle manner, without pushing the uterus through the birth canal (inversion). Avoid overly vigorous massage, as this can injure the vasculature of the broad ligament.5

Initiate an oxytocin infusion at the same time as fundal massage. Inject 40 units of oxytocin into 1 L of intravenous sterile normal saline. Allow this solution to infuse over 10 minutes. Alternatively, administer 10 U of oxytocin intramuscularly. Repeat the oxytocin dose if atony persists.

Continued bleeding requires the initiation of bimanual uterine compression. Massage the posterior aspect of the uterus with the abdominal hand and the anterior aspect of the uterus through the vagina with the other hand clenched into a fist (Figure 135-1).5 Use the intravaginal hand to massage the uterus against the external pressure applied by the abdominal hand. This allows for more effective uterine massage. Perform manual uterine exploration if the massage fails to control the hemorrhage. Manual uterine exploration can localize and extract any placental fragments remaining within the uterus.

Begin second-line medications to contract the uterus if bimanual massage is ineffective. Consult an Obstetrician prior to administering any of these medications. In the nonhypertensive patient, administer 0.2 mg of methylergonovine (Methergine) intramuscularly. This is an ergot derivative that causes uterine contraction. The dose may be repeated every 2 to 4 hours. Prostaglandin F-2 (Hemabate) is a potent stimulator of uterine contraction.9 Administer 250 μg intramuscularly or transabdominally into the uterine musculature every 15 to 90 minutes to a maximum total dose of 2 mg. Misoprostol (Cytotec) has been widely used and is inexpensive, safe to use in patients with hypertension, and safe to use in patients with asthma. Administer 800 to 1000 μg (in 100 μg tablets) rectally. This dose may be repeated every 4 to 6 hours. Monitor the patient's temperature frequently as pyrexia can occur. Dinoprostone (Prostin) 20 mg rectal suppository is preferred over the intravaginal route as continued bleeding may expel the suppository. This may be repeated every 2 hours. Consider using 16.7 to 200 μg/kg of factor VIIa concentrate (NovoSeven) intravenously. This agent has the potential to cause intravascular clot formation with subsequent end organ damage.

Sustained bleeding requires an Obstetrician for curettage or other operative management. A discussion of these techniques is beyond the scope of this chapter. Tamponade the uterus while waiting as described below. Alternatively, consult an Interventional Radiologist, if available, to consider uterine artery embolization.

Balloon Tamponade

The SOS Bakri balloon was designed to tamponade the uterus for postpartum bleeding.10 Gently grasp the balloon with a ringed forceps. Insert it into the uterus transcervically. Hold the tubing in place at the cervical os to ensure the balloon remains above the cervix. Instill 300 to 500 mL of sterile saline to inflate the balloon. Clamp the tubing. Apply gentle traction. Secure the tube to the patient's thigh or attach a 500 mL saline bag to the tubing as a weight. Blood will drain from sites proximal to the tube. If bleeding is excessive, tamponade has failed.

If a Bakri balloon is not available, use a Sengstaken–Blakemore tube. These are often available in the Emergency Department. Insert the Sengstaken–Blakemore tube into the uterine cavity. Inflate the gastric balloon with 250 mL of sterile saline. Apply slight traction and secure the tube as described above. Flush the lumen of the Sengstaken–Blakemore tube with 10 mL of sterile saline to clear any clots or blood collected behind the balloon.

If neither of these devices is available, use Foley catheters with a 30 mL balloon. Gently grasp the distal end of the Foley catheter with ring forceps. Insert it completely into the uterus. Securely hold the catheter in place. Instruct an assistant to instill 50 to 60 mL of sterile saline into the balloon and clamp the tubing. Repeat this procedure with up to two more Foley catheters to completely fill the endometrial cavity and tamponade the hemorrhage.

Uterine Packing

If none of the previously mentioned devices are available or if they fail, consider packing the uterus. Tightly pack the uterus, starting at the fundus and working outwards, with 4-inch wide gauze roll (e.g., Kerlix) soaked in 5 mL sterile saline and 5000 units of thrombin. Administer intravenous broad spectrum antibiotics if the uterus is packed with gauze to prevent a subsequent toxic shock syndrome. Carefully monitor hematocrit, urine output, and uterine size. Blood may collect behind in the uterus with all forms of tamponade.

Retained Placenta

Postpartum hemorrhage, whether primary or secondary, may be caused by retained placental tissue within the uterine cavity. The retained placental tissue may be completely attached, partially separated, or completely separated from the uterine wall. Placental fragments completely attached to the uterine wall may not be removable manually and may require a curettage or laparotomy. Completely or partially separated placental fragments may remain due to a closed cervix entrapping them or inadequate uterine contractions. Manual extraction will remove the retained placental fragments. Administer adequate anesthesia. A uterine relaxant may be utilized to relax the lower uterine segment in the absence of uterine atony. This must be performed using strict aseptic technique.

Insert a sterile gloved hand through the open cervix and into the uterine cavity (Figure 135-2). Place the other hand on the abdominal wall and over the fundus of the uterus. Gently and carefully sweep the fingers around the circumference of the uterus to determine if any fragments of placenta remain. Identify the edge of the fragment if it has not separated from the uterine wall. Gently place the fingertips under the edge of the fragment. Gently remove any placental fragments from the uterus by alternating abducting, adducting, and advancing the fingers in a scissors-like motion until the entire fragment is separated from the uterus.8 Grasp and gently remove the placental fragments when separated from the uterine wall. Ensure that the entire placenta is removed. Reinsert a hand into the uterine cavity and palpate for any remaining placental fragments. Examine the placenta carefully to make sure that no cotyledons are missing.

Determine if any placental membranes are retained. Reinsert the gloved hand covered with a gauze sponge (Figure 135-3). Wipe the uterine walls with the sponge to collect any retained membranes. Remove the gauze sponge with any adherent membranes.

Identify the edge of the placenta if it has not separated from the uterine wall. Gently place the fingertips under the edge of the placenta, forming a line of cleavage between the uterine wall and the placenta. Alternately abduct, adduct, and advance the fingers in a scissors-like motion until the entire placenta is separated from the fundus (Figure 135-2).8 Gently remove the placenta from the uterine cavity. Make sure that the entire placenta is removed. Reinsert a hand into the uterine cavity and palpate for any remaining placental fragments. Examine the placenta carefully to make sure that no cotyledons are missing. Initiate intravenous oxytocin following removal of the placenta.

The placenta is likely embedded into the wall of the uterus if it does not manually separate. This is known as placenta accreta, percreta, or increta depending on the degree of myometrial penetration. Consult an Obstetrician as a laparotomy, hysterotomy, and possibly a hysterectomy will be required.

Genital Tract Abnormalities

Bleeding from the lower uterine segment, cervix, or upper vagina is difficult to diagnose and manage. The anatomic locations are awkward and difficult to visualize. Excessive bleeding makes visualization even more problematic. It may be almost impossible to see a small laceration or an individual bleeding vessel. Do not attempt to repair a laceration that cannot be completely visualized as this could result in damage to other structures. The uterotonic medications, such as oxytocin and the prostaglandins, are less effective due to the relative paucity of contractile muscle in these tissues. Consider packing the uterus with gauze or a vaginal pack if available. Management of excessive bleeding from this area may require a laparotomy with uterine artery embolization or a hysterectomy. Discussion of these techniques is beyond the scope of this chapter.

Laceration Repair

All lacerations must be repaired. Always make sure there is adequate exposure and visualization of the laceration. Insert a Foley catheter if the laceration is in proximity to the urethra. This ensures urethral patency and helps preclude inclusion when placing sutures. Scrub the perineum with povidone iodine or chlorhexidine solution. Apply sterile drapes beneath the patient's buttocks, on the legs, and on the abdomen to prevent contamination from nonsterile areas. Provide anesthesia with the injection of local anesthetic solution directly into the laceration or with a nerve block. Refer to Chapter 132 for details regarding perineal nerve blocks.

Thorough knowledge of the anatomy and awareness of where sutures are being placed is necessary to avoid perforation of any proximate viscera. Always use absorbable suture. Refer to Chapter 132 for complete details regarding the repair of an episiotomy. A brief description of the repair procedure is provided below.

First-Degree Lacerations

First-degree lacerations involve the fourchette, the perineal skin, and/or the vaginal mucous membrane. They spare the underlying fascia and muscle. If the lacerations are small and hemostatic, they do not need to be repaired. Use continuous (running) 2-0 or 3-0 polyglactin (Vicryl) suture to close the vaginal mucosa and submucosa. Chromic gut suture is an alternative but causes more postprocedural pain until it is absorbed. Interrupted sutures may better approximate the laceration if it is very irregular. Approximate the cut margins of the hymenal ring with a stitch. Repair skin lacerations with subcuticular 3-0 sutures as they cause less perineal pain.5 An alternative is to place interrupted 3-0 sutures.5

Second-Degree Lacerations

Second-degree lacerations involve the perineal skin, vaginal mucous membrane, subcutaneous tissue, fascia, and muscles of the perineum but not the anal sphincter muscle. Repair is essentially the same as for an episiotomy but complicated by the irregularity of the laceration. Begin as in a first-degree laceration by repairing the vaginal mucosa and submucosa. Do not place the sutures too deep as to avoid injuring the ureters above the vaginal fornices. Approximate the hymenal ring. Place interrupted 2-0 or 3-0 Vicryl or chromic gut sutures to close the fascia and muscles of the lacerated perineum. Carry a continuous (running) suture downward to unite the superficial fascia and then upward to close the subcutaneous tissue. Close the skin with a running subcuticular stitch. Alternatively, the subcutaneous tissue and skin may be closed together with interrupted 3-0 chromic sutures to minimize the amount of buried suture in the superficial perineal layers.5

Third-Degree Lacerations

Third-degree lacerations involve a second-degree laceration that extends into the anal sphincter but not the rectal mucosa. Isolate, approximate, and suture together the cut ends of the anal sphincter muscle with interrupted 2-0 Vicryl sutures. The remainder of the repair is the same as that for second-degree lacerations.5

Fourth-Degree Lacerations

Fourth-degree lacerations extend through the rectal mucosa to expose the rectal lumen. Approximate the torn rectal mucosa with running or interrupted 3-0 or 4-0 chromic gut sutures placed approximately 0.5 cm apart. Cover this muscular layer with a layer of fascia. Proceed as with the repair of third-degree lacerations.5

Cervical Lacerations

Gently grasp each side of the cervical laceration with ringed forceps. Start at the apex of the laceration using 2-0 chromic gut suture and close the laceration in a running pattern. Do not suture closed the endocervical canal. If the apex cannot be visualized, start at the highest point that can be visualized and place the first stitch as a single interrupted stitch. Use the suture to apply gentle traction to identify the upper part of the laceration. Place interrupted 2-0 chromic gut sutures to close the apex. Use a running stitch to close the lower part of the laceration.

Thoroughly examine the patient to ensure the cessation of bleeding. Any additional bleeding sites must be found and repaired. Carefully monitor the patient's vital signs and urinary output. Manage any hypotension with fluid boluses and packed red blood cells as indicated. Follow serial complete blood counts if the patient has lost a significant amount of blood. Persistent hypotension, tachycardia, or a hematocrit less than 21% may require a transfusion. Hemodynamically stable patients may be expectantly managed.

The aftercare for postpartum hemorrhage is targeted toward the etiology of the bleeding episode. Warm sitz baths alternated with ice packs applied to the perineum three to four times a day will decrease inflammation and the risk of infection in patients with lacerations or episiotomies. Stool softeners will decrease the pain of defecation and the risk of wound dehiscence, especially with third- or fourth-degree lacerations. A high-fiber, low-residue diet may be helpful. Prescribe oral analgesics for pain relief. Nonsteroidal anti-inflammatory drugs or acetaminophen provide adequate analgesia for most patients. Narcotic analgesics such as hydrocodone or acetaminophen with codeine may be necessary initially. Avoid formulations that increase constipation in patients with third- or fourth-degree lacerations.

Follow complete blood count values until the patient is asymptomatic and stable. Consider a transfusion if the patient's hematocrit is less than 25, the patient is symptomatic from anemia, or is hemodynamically unstable. Prescribe 325 mg of iron sulfate orally twice daily.

Follow-up therapy for uterine atony often includes the use of oxytocin (20 to 40 U/L of intravenous fluid) for 12 to 24 hours. An alternative is oral Methergine. Initiate therapy after consultation with an Obstetrician.

Maternal complications resulting from postpartum hemorrhage include shock, acute renal failure, acute respiratory distress syndrome, the need for blood transfusion, a consumptive or dilutional coagulopathy, the need for surgical intervention (dilatation and curettage or laparotomy) and its associated complications, extreme fatigue, postpartum endometritis, and Sheehan's syndrome. Complications associated with pharmacologic therapy can be avoided by carefully selecting the appropriate patient for each agent (see “Contraindications,” above).

Postpartum hemorrhage is a serious and potentially lethal condition. Early identification of risk factors and a prompt response to the early signs and symptoms of postpartum bleeding will decrease the morbidity and mortality of this situation. Always consult an Obstetrician immediately if the patient experiences postpartum hemorrhage.