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Postpartum HemorrhageAka: Active Management of the Third Stage of Labor

Definition
1. Primary Postpartum Hemorrhage
  1. Blood loss >500 cc within 24 hours
2. Secondary Postpartum Hemorrhage
  1. Blood loss >500 cc after 24 hours
  2. Due to placental eschar slouphing, Retained Placenta
Epidemiology
1. Incidence: 5% of all deliveries
2. Increased risk if prior history Postpartum Hemorrhage
  1. Relative risk increases 2-3 fold
Causes: Mnemonic: 4T's
1. Tone diminished
  1. Uterine Atony represents 70% Postpartum hemorrhage
2. Tissue
  1. Retained Placenta
  2. Placenta accreta
3. Trauma
  1. Uterine Inversion
  2. Uterine Rupture
  3. Cervical Laceration
  4. Vaginal hematoma
4. Thrombin
  1. Coagulopathy
Pathophysiology: Uterine Atony
1. Uterus fails to contract despite being empty
  1. Unable to control bleeding at placental site
2. Predisposing Causes
  1. Excessive Uterine distension
    1. Twin Gestation
    2. Fetal Macrosomia
    3. Polyhydramnios
  2. Multiparity
    1. Fibrosis in uterine muscle
  3. Prolonged labor (uterine inertia)
  4. Labor augmented with Oxytocin
  5. General Anesthesia
  6. Placenta Previa
    1. Lower segment does not contract
  7. Abruptio Placentae
    1. "Couvelaire" Uterus may not contract
Risk Factors
1. Grand Multipara
2. Prolonged labor (especially prolonged third stage)
3. Chorioamnionitis
4. Multiple Gestation
5. Magnesium Sulfate infusion
6. Prolonged Pitocin infusion
7. Episiotomy
8. Fetal Macrosomia
Examination
1. Inspect Vagina and Cervix for bleeding source
Labs
1. Complete Blood Count with platelets
2. ProTime (PT)
3. Partial Thromboplastin Time (PTT)
4. Type and cross for 2-4 units of pRBC
Management: Active Management of the Third Stage of Labor
1. Pitocin administered on delivery of anterior shoulder
  1. Reduces Incidence from 16.5% to 3.8% of deliveries
  2. See Third Stage of Labor
2. Controlled cord traction
3. Limit the third stage to <10 minutes
  1. Delayed placental delivery >10 min doubles bleed risk
4. Early cord clamping and cutting
  1. Initially recommended due to lower hemorrhage risk
  2. Consider 60 second wait to reduce newborn Anemia
Management: Four T's (see Above)
1. Tone (Soft, boggy uterus)
  1. Bimanual uterine massage
    1. Bimanual massage between vagina and uterine fundus
    2. Empty the bladder!
  2. Uterotonic Medications
    1. Oxytocin 20 IU per Liter NS
      1. Infuse 250 cc/h (Max: 500 cc/10 min)
    2. Methergine 0.2 mg IM q2-4 hours
      1. Contraindicated in Hypertension
    3. Hemabate 0.25 mg IM q15 min to maximum 2 mg
    4. Misoprostol 1000 mcg PR
2. Trauma (Genital Laceration, Uterine Inversion)
  1. Inspect Vagina and Cervix for bleeding source
    1. Suture Lacerations if present
    2. Drain large hematomas (>3 cm)
  2. Evaluate uterus
    1. Consider exploring uterus
    2. Replace Uterine Inversion
3. Tissue (Retained Placenta)
  1. Inspect placenta for missing segments
  2. Manually remove Retained Placenta
  3. Consider curettage
4. Thrombin (Clotting disorder)
  1. Obtain labs as above
  2. Replace Coagulation Factors
    1. Fresh frozen plasma
    2. Platelet transfusion
    3. Factor VIIa
Management: Resuscitation
1. Indications
  1. Brisk bleeding
  2. Hypotension and tachycardia
2. Initial Management
  1. Large Bore (16 gauge) Intravenous Access (2 sites)
  2. Close hemodynamic monitoring
  3. Supplemental Oxygen
  4. Patient in Trendelenburg
3. Massive hemorrhage management
  1. Transfuse pRBC, platelets, factors as indicated
  2. Uterine packing and tamponade
  3. Surgical interventions
    1. Vessel embolization
    2. Ligation of Uterine and Hypogastric arteries
    3. Hysterectomy
References

Obstetrics Book

Antepartum Disorders

Perinatal Disorders

Pathology and Laboratory Medicine Chapter related topics

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Postpartum HemorrhageAka: Active Management of the Third Stage of Labor

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