Postpartum Hemorrhage

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APGO educational topic number 27
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postpartum hemorrhage hello I am dr. PP
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Hemmings and I will be your guide for
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our journey today into the land of
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postpartum hemorrhage postpartum
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hemorrhage is an obstetric emergency it
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is a major often preventable cause of
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maternal morbidity and mortality it is
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one of the top three causes of maternal
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mortality in both high and low income
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countries the absolute risk of death
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from postpartum hemorrhage approach is
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one in a hundred in low-income countries
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it is estimated that there is one
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maternal death every four minutes
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secondary to postpartum hemorrhage the
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objectives of this video are to list the
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risk factors for postpartum hemorrhage
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construct a differential diagnosis for
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immediate and delayed postpartum
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hemorrhage and finally develop an
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evaluation and management plan for the
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patient with postpartum hemorrhage
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including consideration of various
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resource settings let’s start with some
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basic definitions postpartum hemorrhage
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is generally defined as blood loss
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greater than 500 CCS after a vaginal
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delivery are greater than 1,000 CCS
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following a cesarean delivery primary
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postpartum hemorrhage occurs within the
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first 24 hours after delivery and is
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caused by uterine atony
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80% of cases other causes of primary
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postpartum hemorrhage include retained
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placenta especially placenta accreta
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defects and coagulation uterine
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inversion and lacerations secondary
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postpartum hemorrhage occurs between 24
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hours and 6 to 12 weeks postpartum
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causes include retain products of
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conception infection inherited
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coagulation defects and sub involution
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of the placental site let’s begin by
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discussing risk factors for uterine
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atony
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here is our uterus and the baby has just
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delivered ideally the uterus will clamp
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down and you will feel good tone which
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feels like a rock of hard muscle when
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the uterus does not clamp down we call
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this uterine atony
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what can cause acne anything that over
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descends the uterus so polyhydramnios
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are multiple to stations if a patient
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develops chorioamnionitis during labor
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then the muscle will not work as well
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symbolized here by the little green
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bacteria if she had a prolonged labor
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and/or an augmented labor with oxytocin
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so here is her arm with the IV that has
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éxito sand running into it for a long
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time on the opposite extreme of
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at a fast labor than the uterus can
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sometimes react by acting surprised as
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already all done and does not clamp down
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lastly a history of a postpartum
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hemorrhage or Asian or Hispanic
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ethnicity are also risk factors are
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there actions that we can take to try to
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prevent uterine atony active management
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of the third stage of labor which is the
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time between the delivery of the fetus
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and the placenta can reduce the
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incidence of postpartum hemorrhage
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active management includes fundal
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massage gentle cord traction and IV or
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IM oxytocin let’s move now to evaluation
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and management we’ve discussed risk
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factors in preparation but it’s
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important to note that postpartum
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hemorrhage can often occur without any
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warning as well general measures upon
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recognizing excessive blood loss include
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assessing the patient’s overall status
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including vital signs make sure that you
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have adequate nursing and physician
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support and think right away about
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adequacy of IV access and blood
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availability start the evaluation with a
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bimanual examination if there is uterine
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atony the uterus will feel boggy and
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soft at the time of bimanual exam you
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can assess for retained placental
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fragments and you can assess the uterine
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wall for rupture a careful inspection
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should also be performed of the perineum
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vulva vagina and cervix the next step
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will be the targeted intervention
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depending on the etiology we will start
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by discussing the management of uterine
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atony in more detail here is the big
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boggy atonic uterus we will start by
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draining the bladder it’s difficult for
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a uterus to clamp down if there’s a full
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bladder next we’ll move on to medical
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management there are multiple uterotonic
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medications that can be used
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individually or combined to contract the
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uterus methyl gergõ novan maleate
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tradename methergine is a potent
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uterotonic and is given intramuscularly
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this should not be given to women with
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hypertension 15 methyl prostaglandin F 2
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alpha tradename Hema bate also
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stimulates the myometrium muscles to
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contract and is given intramuscularly
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it should not be given to women with
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asthma for it can theoretically
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constrict the bronchioles oxytocin
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should also be given intravenously and
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misoprostol can be administered buccal E
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or rectally in cases where medical
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management is not sufficient for
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hemostasis the next step is uterine
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tamponade this is achieved by uterine
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packing or by inflating
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Bakri balloon within the uterine cavity
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both of these methods work by applying
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pressure internally to staunch the flow
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of blood if these measures do not
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improve the bleeding then the next step
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will be surgical management one of the
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first steps can be a b-lynch suture a
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stitch is placed on the anterior surface
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of the uterus and then travels
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posteriorly on the posterior aspect of
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the uterus a stitch is placed and in the
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suture travels anteriorly and the suture
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is tied this manually compresses the
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uterus in addition a uterine artery
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ligation can be performed for the
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uterine arteries insert here on the
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uterus at the level of the internal loss
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in interventional radiology can also be
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used to assist with uterine artery
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embolization the patient has to be
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stable however in order to be able to
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transport her to the interventional
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radiology location if all of these
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measures fail hysterectomy is the
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definitive step in managing postpartum
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hemorrhage it is important to note some
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key concepts here about blood
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replacement therapy when a patient is
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experiencing a severe postpartum
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hemorrhage the idea now is to intervene
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earlier to prevent coagulopathy such as
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di C from developing packed red blood
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cells are the mainstay of blood
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replacement therapy when there is a
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severe ongoing hemorrhage of four or
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more units of packed red blood cells
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needed over one hour or ten or more
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units over 12 to 24 hours the current
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recommendation is to transfuse in a 1 to
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1 to 1 ratio which is one unit of packed
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red blood cells to one unit of fresh
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frozen plasma to one unit of platelets
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these interventions thus far have
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described options in high resource
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settings what are the options for low
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resource settings
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remember that 99% of maternal deaths
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occur in developing countries and
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postpartum hemorrhage accounts for one
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half of all postpartum maternal deaths
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active management of the third stage of
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labor is the gold standard
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recommendation at this time the same
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three measures that we discussed earlier
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in this video
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IV or I am oxytocin gentle cord traction
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and fundal massage oxytocin is the
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recommended uterotonic however it is not
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readily available in some settings with
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the highest risk for mortality and
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morbidity from postpartum hemorrhage
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current investigations are looking into
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whether misoprostol could prove to be a
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viable substitute
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settings where oxytocin is not available
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this concludes the aapko video on
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postpartum hemorrhage
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we reviewed key concepts about
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ideologies risk factors and management
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for postpartum hemorrhage in low and
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high resource settings