Postpartum Hemorrhage

1. Postpartum Hemorrhage Ms. Nirmala (B.Sc.N)special

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

3. Definition • Mean blood loss with vaginal delivery: 500ml • Seen in ~5% of deliveries.

4. 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.

5. Prenatal Risk Factors • Pre-eclampsia ,PIH • Previous postpartum hemorrhage • Multiple gestation • Previous C/S • Multiparity • Polyhydroamniosis

6. Intrapartum Risk Factors • Prolonged 3rd stage (>30 min) • medio-lateral episiotomy • midline episiotomy • Arrest of descent • Lacerations • Augmented labor • Forceps delivery

7. 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

8. 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.

9. 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.

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

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

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

13. Medications for Uterine Atony • 1. Oxytocin promotes rhythmic contractions. • 2 Urgometrine

14. 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, or increased parity. • Prior C/S scar & previa increases risk (25%) • Most patients have no risk factors. • Occasionally succenturiate lobe left behind.

15. 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.

16. 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.

18. 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.

19. 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.

21. 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.

22. Trauma (3rd “T”) • Episiotomy • Hematoma • Uterine inversion • Uterine rupture

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

24. 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.

25. 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.

27. 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.

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

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

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

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

32. Uterine Rupture • When recognized, get help. • ABCs. • IV fluids. • Surgical correction.

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

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

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

36. Repair of cervical laceration

37. 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.

38. Pelvic Hematoma

39. Vulvar hematoma

40. 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.

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

42. Summary: remember 4 Ts • Tone • Tissue • Trauma • Thrombin

43. “TONE” Rule out Uterine Atony Palpate fundus. Massage uterus. Medications Summary: remember 4 Ts

44. “Tissue” retained placenta Inspect placenta for missing cotyledons. Explore uterus. Treat abnormal implantation. Summary: remember 4 Ts

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

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

47. 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?

48. 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?