The most common cause of postpartum hemorrhage is
Risk factors for uterine atony include
Uterine overdistention (caused by multifetal pregnancy Multifetal Pregnancy Multifetal pregnancy is presence of > 1 fetus in the uterus. Multifetal (multiple) pregnancy occurs in up to 1 of 30 deliveries. Risk factors for multiple pregnancy include Ovarian stimulation... read more , polyhydramnios Polyhydramnios Polyhydramnios is excessive amniotic fluid; it is associated with maternal and fetal complications. Diagnosis is by ultrasonographic measurement of amniotic fluid volume. Management is by treating... read more , fetal anomaly, or an abnormally large fetus Large-for-Gestational-Age (LGA) Infant Infants whose weight is > the 90th percentile for gestational age are classified as large for gestational age. Macrosomia is birthweight > 4000 g in a term infant. The predominant cause is... read more )
Grand multiparity (delivery of ≥ 5 viable fetuses)
Other causes of postpartum hemorrhage include
Lacerations of the genital tract
Retained placental tissues
Subinvolution (incomplete involution) of the placental site (which usually occurs early but may occur as late as 1 month after delivery)
Uterine fibroids Uterine Fibroids Uterine fibroids are benign uterine tumors of smooth muscle origin. Fibroids frequently cause abnormal uterine bleeding, pelvic pain and pressure, urinary and intestinal symptoms, and pregnancy... read more may contribute to postpartum hemorrhage. A history of postpartum hemorrhage may indicate increased risk.
Diagnosis of postpartum hemorrhage is clinical (eg, noting the amount of blood lost, monitoring vital signs).
There are various assessment tools (eg, checklists) to help obstetric practitioners and health care facilities develop ways to rapidly recognize and manage postpartum hemorrhage (1 Diagnosis references Postpartum hemorrhage is blood loss of > 1000 mL or blood loss accompanied by symptoms or signs of hypovolemia within 24 hours of birth. Diagnosis is clinical. Treatment depends on etiology... read more , 2 Diagnosis references Postpartum hemorrhage is blood loss of > 1000 mL or blood loss accompanied by symptoms or signs of hypovolemia within 24 hours of birth. Diagnosis is clinical. Treatment depends on etiology... read more ). These tools are widely available and can be adjusted to suit the needs of the specific patient population.
1. California Maternal Quality Care Collaborative Hemorrhage Task Force: OB hemorrhage toolkit V 2.0. Accessed 7/3/21.
2. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics: Practice Bulletin No. 183: Postpartum hemorrhage. Obstet Gynecol 130:e168–186, 2017.
Fluid resuscitation and sometimes transfusion
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. A dilute oxytocin IV infusion (10 or 20 [up to 80] units/1000mL of IV fluid) at 125 to 200 mL/hour is given immediately after delivery of the placenta. The drug is continued until the uterus is firm; then it is decreased or stopped. Oxytocin should not be given as an IV bolus because severe hypotension may occur.
In addition, 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 F2-alpha 250 mcg IM every 15 to 90 minutes up to 8 doses or methylergonovine 0.2 mg IM every 2 to 4 hours (which may be followed by 0.2 mg orally 3 to 4 times a day for 1 week) 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. If oxytocin is not available, heat-stable carbetocin can be given IM instead. 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.
An intrauterine vacuum-induced hemorrhage-control device is now available. It applies low-level suction to induce uterine contractions, causing the uterus to collapse on itself; as a result, blood vessels in the myometrium constrict and hemorrhage is rapidly stopped (1 Treatment reference Postpartum hemorrhage is blood loss of > 1000 mL or blood loss accompanied by symptoms or signs of hypovolemia within 24 hours of birth. Diagnosis is clinical. Treatment depends on etiology... read more ). The device consists of an intrauterine loop, an expandable seal that is filled with sterile fluid and blocks the cervix to maintain the vacuum, and a vacuum connector attached to a tube that connects with a vacuum source. Suction is applied for 1 hour after bleeding is controlled.
A uterine balloon tamponade is a simple device made from common, low-cost materials that can stop post-partum hemorrhage due to a relaxed uterus. It’s inserted inside the uterus, filled with fluid and works by compressing the bleeding vessels. This video will show how to use a uterine balloon tamponade for postpartum hemorrhage.
This woman is bleeding heavily. Her uterus is not contracting even though you have massaged it, given her medicine to contract her uterus, and done bimanual compression. Tell the woman what you need to do and why. Ask for her consent. Then place a urinary catheter into her bladder. Do aortic compression as you prepare and insert a uterine balloon tamponade.
Have your supplies ready in a kit: a urinary catheter, sterile gloves, a condom, sterile string, a 60 milliliter syringe, an IV giving set, and a 500 milliliter bag of IV fluid. You will also need a ring forceps, and a sims speculum. Wash your hands and put on sterile gloves. Place the condom over the catheter. Then tie a string tightly around the end of the condom.
Let’s see that again close up: unroll the condom over the catheter until the condom is completely unrolled. Then, with a length of sterile string, securely tie the end of the condom. Place the speculum to visualize the cervix. Then insert the catheter with the condom through the cervix and high into the uterus. Some birth attendants use 2 condoms for extra security.
Connect the catheter to the IV giving set and run in 300 to 500 milliliters of IV fluid. As the condom fills with water it presses against the inside of the uterus where the bleeding is coming from. The pressure stops the bleeding. Inflate the condom until it is visible at the cervix. Now ‒ fold the catheter and clamp it to keep the fluid inside. Record how much fluid you have used, and the insertion time.
Mark the level of the uterine fundus. Monitor if the fundus rises beyond the mark. This is a sign of hidden bleeding. If bleeding is not controlled 15 minutes after inserting the balloon tamponade, keep the device in place and transport the woman for surgical care immediately. If bleeding is controlled, give oxytocin 20 units in 1 liter of IV fluid at 60 drops per minute. Also give the woman a single dose of antibiotics to prevent infection ‒ either 2 grams of ampicillin IV OR 1 gram of cefazolin IV.
Closely monitor the woman’s bleeding, her fundal height, and vital signs. After 6 hours and up to 24 hours, if the woman is stable – with no vaginal bleeding and her fundal height is at the same level – start to slowly remove the fluid from the balloon. Remove 200 milliliters every hour. If her bleeding starts again, refill the balloon. If there is no further vaginal bleeding 30 minutes after the balloon is flat, remove the balloon. Continue to monitor the woman for the next 6 hours.
Remember, have your supplies ready in a balloon tamponade kit. As the condom fills with water, it presses against the inside of the uterus and stops the bleeding. After 6 hours and up to 24 hours, if the woman is stable, begin to slowly remove the fluid.
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Blood products are transfused as necessary, depending on the degree of blood loss and clinical evidence of shock. Massive transfusion Complications of massive transfusion The most common complications of transfusion are Febrile nonhemolytic reactions Chill-rigor reactions The most serious complications, which have very high mortality rates, are Acute hemolytic... read more of packed red blood cells, fresh frozen plasma, and platelets in a 1:1:1 ratio can be considered after consultation with expert hematologists and the blood bank (2 Treatment reference Postpartum hemorrhage is blood loss of > 1000 mL or blood loss accompanied by symptoms or signs of hypovolemia within 24 hours of birth. Diagnosis is clinical. Treatment depends on etiology... read more ). Medical centers should develop protocols for massive transfusion.
Tranexamic acid can also be used if initial medical management is ineffective.
1. D’Alton ME, Rood KM, Smid M C, et al: Intrauterine vacuum-induced hemorrhage-control device for rapid treatment of postpartum hemorrhage. Obstet Gynecol 136 (5):1–10, 2020. doi: 10.1097/AOG.0000000000004138
Predisposing conditions (eg, uterine fibroids Uterine Fibroids Uterine fibroids are benign uterine tumors of smooth muscle origin. Fibroids frequently cause abnormal uterine bleeding, pelvic pain and pressure, urinary and intestinal symptoms, and pregnancy... read more , polyhydramnios Polyhydramnios Polyhydramnios is excessive amniotic fluid; it is associated with maternal and fetal complications. Diagnosis is by ultrasonographic measurement of amniotic fluid volume. Management is by treating... read more , multifetal pregnancy Multifetal Pregnancy Multifetal pregnancy is presence of > 1 fetus in the uterus. Multifetal (multiple) pregnancy occurs in up to 1 of 30 deliveries. Risk factors for multiple pregnancy include Ovarian stimulation... read more , a maternal bleeding disorder Excessive Bleeding Unusual or excessive bleeding may be indicated by several different signs and symptoms. Patients may present with unexplained nosebleeds (epistaxis), excessive or prolonged menstrual blood flow... read more , history of puerperal hemorrhage or postpartum 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/hour for 1 to 2 hours) 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 hour after completion of the 3rd stage of labor.
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).
Postpartum hemorrhage assessment tools are widely available and can be adjusted for the specific patient population.
Replenish intravascular volume, repair genital lacerations, and remove retained placental tissues.
Massage the uterus and, if necessary, use uterotonics (eg, oxytocin, prostaglandins, methylergonovine).
If hemorrhage persists, consider use of an intrauterine vacuum device, intrauterine balloon tamponade, 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|
|Recothrom, Thrombi-Gel , Thrombin-JMI, Thrombin-JMI Epistaxis, Thrombi-Pad, Thrombogen|
|Adalat, Adalat CC, Afeditab CR, Nifediac CC, Nifedical XL, Procardia, Procardia XL|