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Postpartum Hemorrhage

By

Julie S. Moldenhauer

, MD, Children's Hospital of Philadelphia

Last full review/revision Jul 2021| Content last modified Jul 2021
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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 of the hemorrhage.

Causes

The most common cause of postpartum hemorrhage is

  • Uterine atony

Risk factors for uterine atony include

Other causes of postpartum hemorrhage include

Diagnosis

  • Clinical evaluation

Diagnosis of postpartum hemorrhage is clinical (eg, noting the amount of blood lost, monitoring vital signs).

Diagnosis references

Treatment

  • Fluid resuscitation and sometimes transfusion

  • Uterine massage

  • 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.

Treatment of Postpartum Hemorrhage

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.

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.

Treatment reference

  • 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

Prevention

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.

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).

  • 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
METHERGINE
CYKLOKAPRON
CYTOTEC
PITOCIN
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Operative Vaginal Delivery
In order to facilitate delivery, operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the 2nd stage of labor. Which of the following is NOT considered an indication for operative vaginal delivery?
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