The Department of OB/GYn of Xinjiang
Postpartum hemorrhage denotes
excessive bleeding (>500mL in
vaginal delivery) following delivery.
Hemorrhage may occur before,
during, or after delivery of the
Actual measured blood loss during
uncomplicated vaginal deliveries has
been shown to average 700mL, and blood
loss may often be underestimated.
Nevertheless, the criterion of a loss of
500mL is acceptable on historical grounds
and because 1 unit (U) of blood also
The parallel has obvious value in
estimating the need for transfusion.
Blood lost during the first 24 hours after
delivery is early postpartum
Blood lost between 24 hours and 6
weeks after delivery is late postpartum
The incidence of excessive blood loss
following vaginal delivery is 5-8%.
Postpartum hemorrhage is the most
common cause of excessive blood loss in
pregnancy, and most transfusions in
pregnant women are performed to
replace blood lost after delivery.
Hemorrhage in the third leading cause of
maternal mortality in the USA and is directly
responsible for about one-sixth of maternal
In less –developed countries, hemorrhage is
among the leading obstetric causes of maternal
Morbidity & Mortality
Although any woman may suffer excessive
blood loss during delivery, women already
compromised by anemia of intercurrent
illness are more likely to demonstrate
serious deterioration of condition, and
anemia and excessive blood loss may
predispose to subsequent puerperal
Major morbidity associated with
transfusion therapy (e.g, hepatitis, human
immunodeficiency virus infection,
transfusion reactions) is infrequent but it is
Moreover, other types of treatment for
anemia may involve some risk.
Postpartum hypotension may lead to
partial or total necrosis of the anterior
pituitary gland and cause postpartum
panhypopituitarism, or Sheehan’s
syndrome, which is characterized breast
size, loss of pubic and axillary hair,
hypothyroidism, and adrenal insufficiency.
The condition is rare (<1 in 10.000
A woman who has been hypotensive
postpartum and who is actively lactating
probably does not have Sheehan’s
Hypotension can also lead to acute renal
failure and other organ system injury.
In extreme hemorrhage, sterility will result
from hysterectomy performed to control
intractable postpartum hemorrhage.
Causes of postpartum hemorrhage
include uterine atony, obstetric
lacertations, retained placental tissue,
and coagulation defects.
A. Uterine Atony
Postpartum bleeding is physiologically
controlled by constriction of interlacing
myometrial fibers that surround the
blood vessels supplying the placental
Uterine atony exists when the
myometrium cannot contract.
Atony is the most common cause of
postpartum hemorrhage (50% of cases).
Predisposing causes include
Excessive manipulation of the uterus,
General anesthesia (particularly with
Uterine overdistention (twins or polyhydramnios),
Operative delivery and intrauterine
Oxytocin induction or augmentation of
Previous hemorrhage in the third stage
Extavasation of blood into the
myometrium (Couvelaire uterus),
And intrinsic myometrial dysfunction.
B. obstetric Lacerations
Excessive bleeding from an
episiotomy, lacerations, or both
cause about 20% of
Lacerations can involve the uterus, cervix,
vagina, or vulva, and they usually result
from precipitate or uncontrolled delivery
or operative delivery of a large infant.
However, they may occur after any
delivery. Laceration of blood vessels
underneath the vaginal or vulvar
epithelium results in hematomas.
Bleeding is concealed and can be
particularly dangerous, since it may go
unrecognized for several hours and only
become apparent when shock occurs.
Episiotomies may cause excessive
bleeding if they involve arteries or large
varicosities, if the episiotomy is large, if
there is a delay between episiotomy and
delivery, or if there is a delay between
delivery and repair of the episiotomy .
Persistent bleeding (especially bright red)
and a well-contracted, firm uterus
suggest bleeding from a laceration or
from the episiotomy.
When cervical or vaginal lacerations are
identified as the source of postpartum
hemorrhage, repair is best performed with
Spontaneous rupture of the uterus is rare.
Risk factors for this complication include
grand multiparity, malpresentation,
previous uterine surgery, and oxytocin
induction of labor.
Rupture of a previous cesarean section
scar after vaginal delivery may be an
increasingly important cause of
C. Retained Placental Tissue
Retained placental tissue and
membranes cause 5-10% of
Retention of placental tissue in the uterine
cavity occurs in placenta accrete, in
manual removal of the placenta, in
mismanagement of the third stage of
labor, and in unrecognized succenturiate
Ultrasound and transvaginal duplex
Doppler imaging are effective in
evaluating these patients.
These noninvasive methods of evaluation
can identify retained blood clots or
If the endometrial cavity appears empty,
unnecessary dilataion and curettage
may be avoided.
D. Coagulation Defects
Coagulopathies in pregnancy may be
acquired coagulation defects seen in
association with several obstetric
disorders, including abruption placentae,
excess thromboplastin from a retained
dead fetus, amniotic fluid embolism,
severe preeclampsia, eclampsia, and
These coagulopathies may present as
and disseminated intravascular
Transfusion of more than 8 IU of blood
may in itself induce a dilutional
Von Willebrand’s disease, autoimmune
thrombocytopenia, and leukemia may
also occur in pregnant women.
Prevention of hemorrhage is
preferable to even the best treatment.
All patients in labor should be
evaluated for risk of postpartum
Risk factors include:
coagulopathy, hemorrhage, or blood
transfusion during a previous
anemia during labor;
oxytocin induction or augmentation of
rapid or tumultuous labor;
severe preeclampsia or eclampsia;
vaginal delivery after previous cesarean
general anesthesia for delivery;
and midforceps delivery.
A. Predelivery Preparation:
All obstetric patients should have blood
typed and screened on admission.
Patients identified as being at risk for
postpartum hemorrhage should have
their blood typed and cross-matched
The blood should be reserved in the blood
band for 24 hours after delivery.
A large-bore intravenous catheter should
be securely taped into place after insertion.
Delivery room personnel should be
alerted to the risk of hemorrhage.
Severely anemic patients should be
transfused as soon as cross-matched
blood is ready.
With increasing concerns associated with
blood transfusion, autologous blood
domation in obstetric patients at risk for
postpartum hemorrhage has been
Following delivery of the infant,
the uterus is massaged in a circular
or back-and –forth motion until the
myometrium becomes firm and well
Excessive and vigorous massage of the
uterus before, during, or after delivery of
the placenta may interfere with normal
contraction of the myometrium and
instead of hastening contraction may
lead to excessive postpartum blood loss.
C. Third Stage of Labor Normal
The placenta typically separates from the
uterus and is delivered within 5 minutes of
delivery of the infant.
Attempts to speed separation are of no
benefit and may cause harm.
Spontaneous placental separation is
impending if the uterus becomes round
and firm, a sudden gush of blood comes
from the vagina, the uterus seems to rise
in the abdomen, and the umbilical cord
moves down out of the vagina.
The placenta can then be removed from
the vagina by gentle traction on the
Prior to placental separation, gentle
steady traction on the cord combined
with upward pressure on the lower uterine
segment (Brandt-Andrews maneuver)
ensures that the placenta can be
removed as soon as separation occurs
and provides a means of monitoring the
consistency of the uterus.
Adherent membranes can be
removed by gentle traction with
The placenta is inspected for
completeness immediately after
Manual Removal of the Placenta
Opinion is divided about the timing of
manual removal of the placenta.
In the presence of hemorrhage, it is
obviously unreasonable to wait for
spontaneous separation, and manual
removal of the placenta should be
undertaken without delay.
Efforts to promote routine manual removal
of the placenta were often made in the
The rationale includes shortening the third
stage of labor, decreasing blood loss,
developing experience in placenta accrete,
and providing a way to simultaneously
explore the uterus.
These real or potential benefits must be
weighed against the discomfort caused
to the patient, the risk of infection, and
the risk of causing more bleeding by
interfering with normal mechanisms of
The uterus is stabilized by grasping the
fundus with a hand placed over the
The other hand traces the course of the
umbilical cord through the vagina and
cervix into the uterus to palpate the edge
of the placenta.
The membranes at the placental margin
are perforated, and the hand is inserted
between the placenta and the uterine wall,
palmar side toward the placenta.
The hand is then gently swept from side
to side and up and sown to peel the
placenta from its attachments to the
When the placenta has been completely
separated from the uterus it is grasped
and pulled from the uterus.
The fetal and maternal sides of the
placenta should be inspected to ensure
that it has been removed in its entirety.
On the fetal surface, incomplete
placental removal is manifested as
interruption of the vessels on the chorionic
plate, usually shown by hemorrhage.
On the maternal surface, it is possible to
see where cotyledons have been
If there is evidence of incomplete
removal, the uterus must be re-explored
and any small pieces of adherent
The uterus should be massaged until a
firm myometrial tone is achieved.
Immediate Postpartum Period
Uterotonic agents may be administered
as soon as the infant’s anterior shoulders
is delivered, but this risks entrapment of
the placenta or of an undiagnosed
second twin inside a tightly contracted
Routine administration of oxytocics
during the third stage reduces the
blood loss of delivery and decreases
the chances of postpartum
hemorrhage by 40% (Elbourne et al,
Oxytocin, 10-20U/L of isotonic saline, or
other intravenous solution by slow
intravenous infusion, or 10U
intramuscularly, can be used in every
patient after delivery of the infant.
Repair of Lacerations
If bleeding is excessive before
placental separation, manual removal
of the placental is indicated.
Otherwise, excessive manipulation of
the uterus should be avoided.
The vagina and cervix should be
carefully inspected immediately after
delivery of the placenta, with adequate
lighting and assistants available.
The episiotomy is quickly repaired after
massage has produced a firm, tightly
A pack placed in the vagina above the
episiotomy helps to keep the field dry;
attaching the free end of the pack to the
adjacent drapes reminds the operator to
remove it after the repair is completed.
The tendency of bleeding vessels to
retract from the laceration site is the
reason for one of the cardinal principles
Begin the repair above the highest extent
of the laceration.
The highest suture is also used to provide
gentle traction to bring the laceration site
closer to the introitus.
Hemostatic ligatures are then placed in
the usual manner, and the entire birth
canal is carefully inspected to make sure
that there are no additional bleeding sites.
Extensive inspection also provides time to
confirm that prior hemostatic efforts have
A cervical or vaginal laceration
extending into the broad ligament should
not be repaired vaginally.
Laparotomy with evacuation of the
resultant hematoma and hemostatic
repair or hysterectomy is required.
Large or expanding hematomas of the
vaginal walls require operative
management for proper control.
The vaginal wall is first exposed by an
If a laceration accompanies the
hematoma, the laceration is extended
so that the hematoma can be
completely evacuated and explored.
When the bleeding site is identified, a
large himostatic ligature can be placed
well above the site.
This ensures hemostasis in the vessel,
which is likely to retract when lacerated.
The hematoma cavity should be left open
to allow drainage of blood and ensure
that bleeding will not be concealed if
hemostasis cannot be achieved.
If there is no laceration in the vaginal side
wall when a hematoma is identified, then
an incision must be made over the
hematoma to allow treatment to proceed
as outlined above.
Following delivery, recovery room
attendants should frequently massage the
uterus and check for vaginal bleeding.
If vaginal bleeding persists after delivery
of the placenta, aggressive treatment
should be initiated.
It is not sufficient to perform perfunctory
uterine massage, for instance, without
searching for the cause of the bleeding
and initiating definitive treatment.
The following steps should be
undertaken without delay:
Manually compress the uterus
If not already done, obtain blood for
typing and cross-matching.
Observe blood for clotting to rule out
Begin fluid or blood replacement.
Carefully explore the uterine cavity.
Completely inspect the cervix and vagina.
Insert a second intravenous catheter for
administration of blood or fluids.
Measures to Control Bleeding
Manual exploration of the uterus
The uterus should be explored
immediately in women with postpartum
Manual exploration should also be
considered after delivery of the placenta
in the following circumstances:
(1) when vaginal delivery follows previous
(2) when intrauterine manipulation, eg,
version and extraction, has been
(3) when malpresentation has occurred
during labor and delivery;
(4) when a premature infant has been
(5) when an abnormal uterine contour
has been noted prior to delivery; and
(6) when there is a possibility of
undiagnosed multiple pregnancy-to rule
Ensure that all placental parts have been
delivered and that the uterus is intact.
This should be done even in the case of a
Exploration performed for reasons other
than the evaluation of hemorrhage should
also confirm that the uterine wall is intact
and should attempt to identify any
possible intrauterine structural
Place a fresh glove over the glove on the
Form the hand into a cone and gently
introduce it by firm pressure through the
cervix while the fundus is stabilized with
the other hand.
Sweep the backs of the first and second
fingers across the entire surface of the
uterus, beginning at the fundus.
In the lower uterine segment, palpate
the walls with the palmar surface of one
Uterine lacerations will be felt as an
obvious anatomic defect.
All exploration should be gentle, since the
postpartum uterus is easily perforated.
Uterine rupture detected by manual
exploration in the presence of postpartum
hemorrhage requires immediate
A decision to repair the defect or
proceed with hysterectomy is made on
the basis of the extent of the rupture, the
patient’s desire for future childbearing,
and the degree of the patient’s clinical
Bimanual compression and massage
The most important step in controlling
atonic postpartum hemorrhage is
immediate bimanual uterine compression,
which may have to be continued for 20-
30 minutes or more.
Fluid replacement should begin as soon
as a secure intravenous line is in place.
Typed and cross-matched blood is given
when it is available.
Manual compression of the uterus will
control virtually all cases of hemorrhage
due to uterine atony, retained products
of hemorrhage due to uterine atony,
retained products of conception, and
coagulopathies, and it may even control
bleeding from a lacerated cervix.