POSTPARTUM HEMORRHAGE Definition Postpartum hemorrhage denotes by liaoqinmei


									Postpartum Hemorrhage

The Department of OB/GYn of Xinjiang
         Medical University
   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
    contains 500Ml.

   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
    not insignificant.

   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
implantation site.
   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
    halogenated compounds),
   Uterine overdistention (twins or polyhydramnios),
   Prolonged labor,
   Grand multiparity,
   Uterine leiomayomas,
Operative delivery and intrauterine
Oxytocin induction or augmentation of
Previous hemorrhage in the third stage
Uterine infection,
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
 postpartum hemorrhages.
   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
    adequate anesthesia.
   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
    postpartum hemorrhage.
C. Retained Placental Tissue

  Retained placental tissue and

  membranes cause 5-10% of

  postpartum hemorrhages
   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
    placental tissue.
   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
hypofibrinogenemia, thrombocytopenia,
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.
Risk Factors

  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;
   grand multiparity;
   multiple gestation;
   large infant;
   polyhydramnios;
   dysfunctional 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
B. Delivery

     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
          Placental Separation

   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
    umbilical cord.
   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
    ring forceps.

   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

    placental separation.

   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
    placenta removed.
   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
    contracted uterus.
   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
    of repair.
   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
    been effective.
   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.
                Evaluation of
             Persistent 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

   Obtain assistance.

   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
cesarean section;

(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
out twins.
   Ensure that all placental parts have been
    delivered and that the uterus is intact.
   This should be done even in the case of a
    well-contracted uterus.
   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
    exploring hand.
   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.

To top