Postpartum Hemorrhage

Preventative measures

• oxytocin

• fundal massages

Postpartum hemorrhage

excessive bleeding after childbirth; pad becomes saturated within one hour

What amount of blood loss from a vaginal delivery is considered a postpartum hemorrhage?

> 500 mL blood loss

What amount of blood loss from a cesarean delivery is considered a postpartum hemorrhage?

> 1,000 mL blood loss

Primary causes

• uterine atony: failure of uterus to contract after delivery

• trauma: lacerations or tears of the birth canal

• retained placenta or fragments of it left in uterus

• coagulation disorders (e.g. disseminated intravascular coagulation – DIC)

Uterine atony tx

• give oxytocin + fundal massage q15min for at least an hour

• is bladder full? empty it with straight cath

Retained placenta tx

• examine if whole or calcified

• notify MD —> will go in and manually sweep it

Risk factors for PPH

• multiple pregnancies (twins, triplets)

• previous hx of PPH

• overdistention of uterus (large baby, polyhydramnios (excessive amount of amniotic fluid during pregnancy)

• prolonged labor/use of forceps —> assisted delivery

• high BP or preeclampsia

  • pre-existing HTN

  • gestational HTN

• placental factors:

  • placenta previa: low implantation of placenta in uterus that causes it to cover cervix and get pushed out as baby grows —> bleeding

  • placenta abruption: placenta detaching from uterine wall

Clinical manifestations

• heavy bleeding (soaking through pads in less than an hour)

• rapid HR (tachycardia)

• low BP (hypotension)

• pale or cool skin

• weakness or dizziness

• clammy or sweaty skin

Management of PPH: Immediate

• fundal massage to stimulate uterine contractions (tone uterus) and reduce bleeding (from uterine atony)

• IV fluids and blood transfusions: stabilize mother’s blood volume

• Medications:

  • oxytocin (first-line tx for uterine atony)

  • Misoprostol (rectal), ergometrine, carboprost (other uterogenic agents) if bleeding persists

Management of PPH second line

• surgical intervention:

  • repair of lacerations or tears

  • manual removal of placenta w/ abx after

  • uterine artery ligation or hysterectomy

Prevention strategies

• active management of third stage of labor:

  • early clamping and cutting of umbilical cord

  • administering oxytocin after delivery of baby to promote uterine contraction

• careful monitoring during and after delivery:

  • routine uterine massage (fundals)

  • prevention of overdistention of uterus (managing multiple pregnancies)

Complications of PPH for mother

• shock (blood loss)

• organ failure (liver, kidney)

• DIC (disseminated intravascular coagulation —> overactive blood clotting system leading to widespread formation of blood clots that block blood vessels and cause organ damage)

• anemia + need for blood transfusion

• infection from retained placenta or uterine trauma

Complications of PPH for baby

• prematurity (if PPH leads to early delivery)

• neonatal anemia