Postpartum hemorrhage is currently defined as a cumulative blood loss of 1000 cc within 24 hours of delivery for all delivery types (as opposed to the prior definition of 500 cc for vaginal delivery and 1000 cc for Cesarean delivery). It can also be defined as blood loss accompanied by signs and symptoms of hypovolemia within 24 hours of delivery.

Tranexamic acid (TXA) is now another treatment option.

– Dr. Hughey

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APGO educational topic number 27
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postpartum hemorrhage hello I am dr. PP
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Hemmings and I will be your guide for
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our journey today into the land of
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postpartum hemorrhage postpartum
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hemorrhage is an obstetric emergency it
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is a major often preventable cause of
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maternal morbidity and mortality it is
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one of the top three causes of maternal
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mortality in both high and low income
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countries the absolute risk of death
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from postpartum hemorrhage approach is
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one in a hundred in low-income countries
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it is estimated that there is one
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maternal death every four minutes
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secondary to postpartum hemorrhage the
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objectives of this video are to list the
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risk factors for postpartum hemorrhage
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construct a differential diagnosis for
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immediate and delayed postpartum
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hemorrhage and finally develop an
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evaluation and management plan for the
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patient with postpartum hemorrhage
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including consideration of various
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resource settings let’s start with some
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basic definitions postpartum hemorrhage
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is generally defined as blood loss
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greater than 500 CCS after a vaginal
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delivery are greater than 1,000 CCS
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following a cesarean delivery primary
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postpartum hemorrhage occurs within the
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first 24 hours after delivery and is
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caused by uterine atony
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80% of cases other causes of primary
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postpartum hemorrhage include retained
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placenta especially placenta accreta
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defects and coagulation uterine
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inversion and lacerations secondary
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postpartum hemorrhage occurs between 24
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hours and 6 to 12 weeks postpartum
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causes include retain products of
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conception infection inherited
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coagulation defects and sub involution
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of the placental site let’s begin by
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discussing risk factors for uterine
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atony
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here is our uterus and the baby has just
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delivered ideally the uterus will clamp
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down and you will feel good tone which
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feels like a rock of hard muscle when
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the uterus does not clamp down we call
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this uterine atony
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what can cause acne anything that over
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descends the uterus so polyhydramnios
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are multiple to stations if a patient
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develops chorioamnionitis during labor
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then the muscle will not work as well
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symbolized here by the little green
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bacteria if she had a prolonged labor
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and/or an augmented labor with oxytocin
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so here is her arm with the IV that has
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éxito sand running into it for a long
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time on the opposite extreme of
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at a fast labor than the uterus can
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sometimes react by acting surprised as
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already all done and does not clamp down
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lastly a history of a postpartum
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hemorrhage or Asian or Hispanic
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ethnicity are also risk factors are
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there actions that we can take to try to
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prevent uterine atony active management
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of the third stage of labor which is the
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time between the delivery of the fetus
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and the placenta can reduce the
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incidence of postpartum hemorrhage
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active management includes fundal
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massage gentle cord traction and IV or
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IM oxytocin let’s move now to evaluation
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and management we’ve discussed risk
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factors in preparation but it’s
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important to note that postpartum
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hemorrhage can often occur without any
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warning as well general measures upon
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recognizing excessive blood loss include
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assessing the patient’s overall status
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including vital signs make sure that you
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have adequate nursing and physician
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support and think right away about
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adequacy of IV access and blood
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availability start the evaluation with a
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bimanual examination if there is uterine
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atony the uterus will feel boggy and
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soft at the time of bimanual exam you
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can assess for retained placental
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fragments and you can assess the uterine
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wall for rupture a careful inspection
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should also be performed of the perineum
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vulva vagina and cervix the next step
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will be the targeted intervention
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depending on the etiology we will start
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by discussing the management of uterine
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atony in more detail here is the big
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boggy atonic uterus we will start by
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draining the bladder it’s difficult for
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a uterus to clamp down if there’s a full
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bladder next we’ll move on to medical
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management there are multiple uterotonic
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medications that can be used
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individually or combined to contract the
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uterus methyl gergõ novan maleate
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tradename methergine is a potent
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uterotonic and is given intramuscularly
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this should not be given to women with
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hypertension 15 methyl prostaglandin F 2
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alpha tradename Hema bate also
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stimulates the myometrium muscles to
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contract and is given intramuscularly
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it should not be given to women with
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asthma for it can theoretically
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constrict the bronchioles oxytocin
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should also be given intravenously and
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misoprostol can be administered buccal E
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or rectally in cases where medical
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management is not sufficient for
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hemostasis the next step is uterine
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tamponade this is achieved by uterine
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packing or by inflating
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Bakri balloon within the uterine cavity
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both of these methods work by applying
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pressure internally to staunch the flow
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of blood if these measures do not
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improve the bleeding then the next step
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will be surgical management one of the
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first steps can be a b-lynch suture a
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stitch is placed on the anterior surface
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of the uterus and then travels
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posteriorly on the posterior aspect of
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the uterus a stitch is placed and in the
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suture travels anteriorly and the suture
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is tied this manually compresses the
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uterus in addition a uterine artery
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ligation can be performed for the
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uterine arteries insert here on the
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uterus at the level of the internal loss
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in interventional radiology can also be
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used to assist with uterine artery
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embolization the patient has to be
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stable however in order to be able to
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transport her to the interventional
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radiology location if all of these
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measures fail hysterectomy is the
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definitive step in managing postpartum
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hemorrhage it is important to note some
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key concepts here about blood
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replacement therapy when a patient is
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experiencing a severe postpartum
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hemorrhage the idea now is to intervene
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earlier to prevent coagulopathy such as
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di C from developing packed red blood
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cells are the mainstay of blood
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replacement therapy when there is a
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severe ongoing hemorrhage of four or
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more units of packed red blood cells
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needed over one hour or ten or more
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units over 12 to 24 hours the current
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recommendation is to transfuse in a 1 to
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1 to 1 ratio which is one unit of packed
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red blood cells to one unit of fresh
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frozen plasma to one unit of platelets
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these interventions thus far have
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described options in high resource
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settings what are the options for low
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resource settings
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remember that 99% of maternal deaths
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occur in developing countries and
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postpartum hemorrhage accounts for one
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half of all postpartum maternal deaths
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active management of the third stage of
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labor is the gold standard
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recommendation at this time the same
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three measures that we discussed earlier
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in this video
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IV or I am oxytocin gentle cord traction
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and fundal massage oxytocin is the
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recommended uterotonic however it is not
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readily available in some settings with
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the highest risk for mortality and
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morbidity from postpartum hemorrhage
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current investigations are looking into
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whether misoprostol could prove to be a
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viable substitute
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settings where oxytocin is not available
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this concludes the aapko video on
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postpartum hemorrhage
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we reviewed key concepts about
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ideologies risk factors and management
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for postpartum hemorrhage in low and
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high resource settings