Postpartum hemorrhage and uterine changes

Postpartum hemorrhage

excessive blood loss in a woman after childbirth

Primary postpartum hemorrhage

within the first 24 hours after childbirth

Secondary/delayed postpartum hemorrhage

occurs between 24hrs to 6 weeks after childbirth

Vaginal delivery mean blood loss

500cc

Vaginal delivery blood loss with hemorrhage

more than 1000cc

C-section mean blood loss

1000cc

C-section blood loss with hermorrhage 

more than 1500cc

Prenatal risk factors 

• history of previous pp hemorrhage 

• pre-eclampsia

• problems with the placenta

• obesity 

• null/multiparity 

• previous c-section

• multiple gestation, may create highamniotic fluid levels 

Intrapartum risk factors

• interventions: augmented labor, forceps or vacuum delivery, episiotomy, c-section

• prolonged labor

• large fetus

• chorioamnionitis

• stillbirth

Augmented labor

methods that stimulate or speed the progression of labor when it is delayed or stopped

Chorioamnionitis

a bacteria infection of the membranes and fluid surrounding the fetus 

What are the 4 Ts to evaluate for the causes of postpartum?

• Tone (Uterine tone)

• Tissue (Retained tissue, placenta)

• Trauma (Lacerations and uterine rupture)

• Thrombin (Bleeding disorders)

Tone

• think of uterine atony, causes 70% of hemorrhage, MC cause of postpartum hemorrhage

• uterus is not responding to oxytocin

  • or lower level oxytocin

Tissue

• retained placenta, delay of placental delivery

• prior C/S

• most patients have no risk

• traction on umbilical cord

Traction on umbilical cord

• tear and inversion of uterus

• retained for >30 minutes, this may be caused by abnormal placental implantation

Trauma

• episiotomy

• hematoma

• uterus (uterine inversion and uterine rupture)

Thrombin

• coagulopathies

• work up with platelets

Diagnosis

physical exam, blood tests, blood clotting tests, clot observation tests, angiography, ultrasound (look for retained placental tissue)

Treatment 

based on the severity of bleeding: medications, trauma/surgical repair, bimanual uterine massage, fluids, oxygen, and/or resuscitationcitation

Prevention

some evidence supports use of oxytocin after delivery of anterior shoulder

Involution of uterus (after contraction/birth)

immediately after placental expulsion it is at umbilicus

Involution of uterus (within 1 week)

descend into the cavity of the pelvis 

Involution of uterus (within about 9 days)

regain previous non pregnant size

What can speed up the process of involution of the uterus?

if the mother is nursing 

What is the rate of involution of uterus?

descend about 1cm/day until it reaches its non-pregnant size 

When does pain after delivery normally become mild?

the 3rd postpartum day

what causes pain after delivery?

• puerperal uterus remains tonically contracted

• uterine contraction (when infant suckles oxytocin releases)

Lochia

early in puerperium, sloughin go decidul tissue → vaginal discharge of variable quantity

Lochia rubra

first few days after delivery, blood in lochia

Lochia serosa

after 4 days, becomes progressively pale in color 

Lochia alba

after 10th day, white or yellow-white color

What is the duration of lochia?

2-4 weeks after delivery

Return of menstruation without nursing

6-8 weeks

Return of menstruation with constant nursing 

• prolaction levels prevents ovulation 

• menstruation will return after nursing