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Postpartum Hemorrhage

by Julie S. Moldenhauer, MD

Postpartum hemorrhage is blood loss of > 500 mL during or immediately after the 3rd stage of labor in a vaginal delivery or > 1000 mL in a cesarean delivery. Diagnosis is clinical. Treatment depends on etiology of the hemorrhage.

Causes of postpartum hemorrhage include

  • Uterine atony (the most common)

  • Lacerations of the genital tract

  • Extension of an episiotomy

  • Uterine rupture

  • Bleeding disorders

  • Retained placental tissues

  • Hematoma

  • Uterine inversion

  • Chorioamnionitis

  • Subinvolution (incomplete involution) of the placental site (which usually occurs early but may occur as late as 1 mo after delivery)

Risk factors for uterine atony include uterine overdistention (caused by multifetal pregnancy, polyhydramnios, or an abnormally large fetus), prolonged or dysfunctional labor, grand multiparity (delivery of 5 viable fetuses), relaxant anesthetics, rapid labor, and chorioamnionitis.

Uterine fibroids may contribute to postpartum hemorrhage. A history of prior postpartum hemorrhage may indicate increased risk.

Treatment

  • Removal of retained placental tissues and repair of genital lacerations

  • Uterotonics (eg, oxytocin, prostaglandins, methylergonovine)

  • Sometimes surgical procedures

Intravascular volume is replenished with 0.9% saline up to 2 L IV; blood transfusion is used if this volume of saline is inadequate. Hemostasis is attempted by bimanual uterine massage and IV oxytocin infusion, and the uterus is explored for lacerations and retained placental tissues. The cervix and vagina are also examined; lacerations are repaired. Bladder drainage via catheter can sometimes reduce uterine atony.

15-Methyl prostaglandin F 2 α 250 mcg IM q 15 to 90 min up to 8 doses or methylergonovine 0.2 mg IM q 2 to 4 h (which may be followed by 0.2 mg po tid to qid for 1 wk) should be tried if excessive bleeding continues during oxytocin infusion; during cesarean delivery, these drugs may be injected directly into the myometrium. Oxytocin 10 units can also be directly injected into the myometrium. Prostaglandins should be avoided in women with asthma; methylergonovine should be avoided in women with hypertension. Sometimes misoprostol 800 to 1000 mcg rectally can be used to increase uterine tone.

Uterine packing or placement of a Bakri balloon can sometimes provide tamponade. This silicone balloon can hold up to 500 mL and withstand internal and external pressures of up to 300 mm Hg. If hemostasis cannot be achieved, surgical placement of a B-Lynch suture (a suture used to compress the lower uterine segment via multiple insertions), hypogastric artery ligation, or hysterectomy may be required. Uterine rupture requires surgical repair.

Blood products are transfused as necessary, depending on the degree of blood loss and clinical evidence of shock. Infusion of factor VIIa (50 to 100 mcg/kg, as a slow IV bolus over 2 to 5 min) can produce hemostasis in women with severe life-threatening hemorrhage. The dose is given q 2 to 3 h until hemostasis occurs.

Prevention

Predisposing conditions (eg, uterine fibroids, polyhydramnios, multifetal pregnancy, a maternal bleeding disorder, history of puerperal hemorrhage) are identified antepartum and, when possible, corrected. If women have an unusual blood type, that blood type is made available ahead of time. Careful, unhurried delivery with a minimum of intervention is always wise.

After placental separation, oxytocin 10 units IM or dilute oxytocin infusion (10 or 20 units in 1000 mL of an IV solution at 125 to 200 mL/h for 1 to 2 h) usually ensures uterine contraction and reduces blood loss. After the placenta is delivered, it is thoroughly examined for completeness; if it is incomplete, the uterus is manually explored and retained fragments are removed. Rarely, curettage is required. Uterine contraction and amount of vaginal bleeding must be observed for 1 h after completion of the 3rd stage of labor.

Key Points

  • Before delivery, assess risk of postpartum hemorrhage, including identification of antenatal risk factors (eg, bleeding disorders, multifetal pregnancy, polyhydramnios, an abnormally large fetus, grand multiparity).

  • Replenish intravascular volume, repair genital lacerations, and remove retained placental tissues.

  • Massage the uterus and use uterotonics (eg, oxytocin, prostaglandins, methylergonovine) if necessary.

  • If hemorrhage persists, consider packing, surgical procedures, and transfusion of blood products.

  • For women at risk, deliver slowly and without unnecessary interventions.

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • PITOCIN
  • METHERGINE
  • CYTOTEC

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