Interdisciplinary team training with realistic simulation should be used to improve perinatal safety. Anterior pituitary ischemia with delay or failure of lactation i. Information from references 3 , 6 , and 7. This review presents evidence-based recommendations for the prevention of and appropriate response to postpartum hemorrhage and is intended for physicians who provide antenatal, intrapartum, and postpartum care.
Risk factors for postpartum hemorrhage are listed in Table 2. Information from reference 8. Have a hemorrhage cart with medications, supplies, checklist, and instruction cards immediately available.
Screen for and treat anemia antenatally. Screen for sickle cell disease and thalassemia in women of African, Southeast Asian, or Mediterranean descent. Obtain sonograms for women at high risk of invasive placenta.
Perform delivery in facility with blood bank and in-house surgical services if the patient has a high risk of hemorrhage. Identify Jehovah's Witnesses and other patients who decline blood products. Use active management of the third stage of labor in every delivery. Avoid routine episiotomy.
Avoid instrumented deliveries, especially forceps. Use perineal warm compresses. Measure cumulative blood loss and track postpartum vital signs. Obstetric hemorrhage patient safety bundle. Accessed October 16, Additional information from references 6 , and 11 through The most effective strategy to prevent postpartum hemorrhage is active management of the third stage of labor AMTSL.
AMTSL also reduces the risk of a postpartum maternal hemoglobin level lower than 9 g per dL 90 g per L and the need for manual removal of the placenta.
Brandt-Andrews maneuver for controlled cord traction. Firm traction is applied to the umbilical cord with one hand while the other hand applies suprapubic counterpressure. Prevention and management of postpartum hemorrhage. Am Fam Physician. Based on existing evidence, the most important component is administration of a uterotonic drug, preferably oxytocin. Overdose or prolonged use can cause water intoxication. Stimulates the upper segment of the myometrium to contract rhythmically, constricting spiral arteries and decreasing blood flow through the uterus.
Possible hypotension with IV use following cesarean delivery. Second-line agents. Avoid in patients with asthma or significant renal, hepatic, or cardiac disease. Improves uterine contractility by increasing the number of oxytocin receptors and causes vasoconstriction. Avoid in hypertensive disorders of pregnancy, including chronic hypertension. Causes vasoconstriction and contracts smooth muscles and upper and lower Segments of the uterus tetanically. Use with caution in patients with human immunodeficiency virus infection who are receiving protease inhibitors.
Prevention: mcg orally Treatment: to 1, mcg rectally or to mcg sublingually or orally. Use with caution in patients with renal impairment and with other clotting factors such as prothrombin complex concentrate.
Generic price listed first; brand price listed in parentheses. Food and Drug Administration for use in prevention or treatment of postpartum hemorrhage. Adapted with permission from Evensen A, Anderson J. Chapter J. Postpartum hemorrhage: third stage pregnancy. Leawood, Kan. An alternative to oxytocin is misoprostol Cytotec , an inexpensive medication that does not require injection and is more effective than placebo in preventing postpartum hemorrhage.
The benefits of controlled cord traction and uterine massage in preventing postpartum hemorrhage are less clear, but these strategies may be helpful. Diagnosis of postpartum hemorrhage begins with recognition of excessive bleeding and targeted examination to determine its cause Figure 1 6.
Cumulative blood loss should be monitored throughout labor and delivery and postpartum with quantitative measurement, if possible. Quantitative measurement of postpartum bleeding begins immediately after the birth of the infant and entails measuring cumulative blood loss with a calibrated underbuttocks drape, or by weighing blood-soaked pads, sponges, and clots; combined use of these methods is also appropriate for obtaining an accurate measurement.
Orthostasis, hypotension, nausea, dyspnea, oliguria, and chest pain may indicate hypovolemia from significant hemorrhage. If excess bleeding is diagnosed, the Four T's mnemonic uterine atony [Tone]; laceration, hematoma, inversion, rupture [Trauma]; retained tissue or invasive placenta [Tissue]; and coagulopathy [Thrombin] can be used to identify specific causes Table 5 6.
Regardless of the cause of bleeding, physicians should immediately summon additional personnel and begin appropriate emergency hemorrhage protocols. Algorithm for the prevention and management of postpartum hemorrhage. Many of the steps involved in diagnosing and treating postpartum hemorrhage must be undertaken simultaneously. Steps in maternal resuscitation may differ based on the actual cause. Uterine atony is the most common cause of postpartum hemorrhage.
Massage is performed by placing one hand in the vagina and pushing against the body of the uterus while the other hand compresses the fundus from above through the abdominal wall eFigure B.
Bimanual uterine compression massage. One hand is placed in the vagina and pushes against the body of the uterus while the other hand compresses the fundus from above through the abdominal wall.
The posterior aspect of the uterus is massaged with the abdominal hand and the anterior aspect with the vaginal hand. Uterotonic agents include oxytocin, ergot alkaloids, and prostaglandins.
Oxytocin is the most effective treatment for postpartum hemorrhage, even if already used for labor induction or augmentation or as part of AMTSL. Although it is not a uterotonic, tranexamic acid Cyklokapron may reduce mortality due to bleeding from postpartum hemorrhage but not overall mortality when given within the first three hours and may be considered as an adjuvant therapy. Lacerations and hematomas due to birth trauma can cause significant blood loss that can be lessened by hemostasis and timely repair.
Episiotomy increases the risk of blood loss and anal sphincter tears; this procedure should be avoided unless urgent delivery is necessary and the perineum is thought to be a limiting factor. Vaginal and vulvar hematomas can present as pain or as a change in vital signs disproportionate to the amount of blood loss. Small hematomas can be managed with ice packs, analgesia, and observation. Patients with persistent signs of volume loss despite fluid replacement, as well as those with large greater than 3 to 4 cm or enlarging hematomas, require incision and evacuation of the clot.
Uterine inversion is rare, occurring in only 0. Patients with uterine inversion may have signs of shock without excess blood loss. If the placenta is attached, it should be left in place until after reduction to limit hemorrhage.
The Johnson method of reduction begins with grasping the protruding fundus with the palm of the hand, directing the fingers toward the posterior fornix. Once the uterus is reverted, uterotonic agents can promote uterine tone and prevent recurrence. If initial attempts to replace the uterus fail or contraction of the lower uterine segment contraction ring develops, the use of magnesium sulfate, terbutaline, nitroglycerin, or general anesthesia may allow sufficient uterine relaxation for manipulation.
Reduction of uterine inversion Johnson method. A The protruding fundus is grasped with fingers directed toward the posterior fornix. B The uterus is returned to position by pushing it through the pelvis and C into the abdomen with steady pressure toward the umbilicus.
Uterine rupture can cause intrapartum and postpartum hemorrhage. American College of Obstetricians and Gynecologists. ACOG practice bulletin no. Obstet Gynecol. Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section. National Institutes of Health Consensus Development conference statement: vaginal birth after cesarean: new insights March 8—10, Retained tissue i.
Classic signs of placental separation include a small gush of blood, lengthening of the umbilical cord, and a slight rise of the uterus. The mean time from delivery to placental expulsion is eight to nine minutes.
Invasive placenta placenta accreta, increta, or percreta can cause life-threatening postpartum hemorrhage. Coagulation defects can cause a hemorrhage or be the result of one. These defects should be suspected in patients who have not responded to the usual measures to treat postpartum hemorrhage or who are oozing from puncture sites.
A coagulation defect should also be suspected if blood does not clot in bedside receptacles or red-top no additives laboratory collection tubes within five to 10 minutes. Coagulation defects may be congenital or acquired eTable B.
Evaluation should include a platelet count and measurement of prothrombin time, partial thromboplastin time, fibrinogen level, fibrin split products, and quantitative d -dimer assay. Physicians should treat the underlying disease process, if known, and support intravascular volume, serially evaluate coagulation status, and replace appropriate blood components using an emergency release protocol to improve response time and decrease risk of dilutional coagulopathy.
HELLP hemolysis, elevated liver enzyme levels, and low platelet levels syndrome. Evensen A, Anderson J. Significant blood loss from any cause requires immediate resuscitation measures using an interdisciplinary, stage-based team approach. Medical attention is needed very quickly to stop the bleeding. Postpartum haemorrhage is often caused by the uterus womb not contracting as it should after the birth , leading to bleeding from the large blood vessels that supply the placenta.
It can also be caused by an injury to the uterus, cervix, vagina or perineum, or by a problem with the placenta such as placenta praevia , placental abruption, placenta acreta or retained placenta. In most women, there are no known risk factors for postpartum haemorrhage. However, it is more likely if you have:. Most women will receive a dose of medication to help the uterus contract and deliver the placenta. If your doctor or midwife thinks you are at increased risk of postpartum haemorrhage, you will be advised to give birth in a major hospital with blood products ready in case you need to be given a blood transfusion.
You will be given extra medication to help your uterus contract. Postpartum haemorrhage is a medical emergency. To treat it, your medical team will insert an IV needle into a vein and possibly a catheter into your bladder. They will examine you to find the cause of the bleeding and keep a close eye on your blood pressure and pulse to check for signs of shock.
Treatments for postpartum haemorrhage include massaging the uterus to help the placenta to be delivered, giving you medication, or offering you a blood transfusion. Sometimes the only way to stop the bleeding and save your life would be to remove the uterus. Afterwards you will need to be closely monitored in hospital, sometimes in an intensive care unit ICU. You are at increased risk of having another postpartum haemorrhage next time.
Options about who you can contact or talk to include:. Learn more here about the development and quality assurance of healthdirect content. Learn more about labour complications. A retained placenta is when part or all of the placenta is not delivered after the baby is born. It can lead to serious infection or blood loss. It is a medical emergency that requires immediate intervention. Excessive and rapid blood loss can cause a severe drop in the mother's blood pressure and may lead to shock and death if not treated.
The following are the most common symptoms of postpartum hemorrhage. However, each woman may experience symptoms differently. Symptoms may include:. Swelling and pain in tissues in the vaginal and perineal area, if bleeding is due to a hematoma. The symptoms of postpartum hemorrhage may resemble other conditions or medical problems. Always consult your doctor for a diagnosis. In addition to a complete medical history and physical examination, diagnosis is usually based on symptoms, with laboratory tests often helping with the diagnosis.
Tests used to diagnose postpartum hemorrhage may include:. Estimation of blood loss this may be done by counting the number of saturated pads, or by weighing of packs and sponges used to absorb blood; 1 milliliter of blood weighs approximately one gram. The aim of treatment of postpartum hemorrhage is to find and stop the cause of the bleeding as quickly as possible.
Treatment for postpartum hemorrhage may include:. Bakri balloon or a Foley catheter to compress the bleeding inside the uterus. Packing the uterus with sponges and sterile materials may be used if a Bakri balloon or Foley catheter is not available. Replacing lost blood and fluids is important in treating postpartum hemorrhage. Intravenous IV fluids, blood, and blood products may be given rapidly to prevent shock. The mother may also receive oxygen by mask. Postpartum hemorrhage can be quite serious.
However, quickly detecting and treating the cause of bleeding can often lead to a full recovery. Postpartum Hemorrhage. What is postpartum hemorrhage? Conditions that may increase the risk for postpartum hemorrhage include the following: Placental abruption.
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