OCTOBER 8, 2009

First day of our duty in Angono General Hospital our area is OB ward
Postpartum hemorrhage before placental delivery is called third-stage hemorrhage. Whether
bleeding begins before or after placental delivery, or at both times, there may be no sudden
massive hemorrhage but rather steady bleeding that at any given instant appears to be moderate,
but persists until serious hypovolemia develops. Especially with hemorrhage after placental
delivery, the constant seepage may lead to enormous blood loss. The effects of hemorrhage
depend to a considerable degree upon the non-pregnant blood volume, magnitude of pregnancy
induced hypervolemia, and degree of anemia at the time of delivery. A treacherous feature of
postpartum hemorrhage is the failure of the pulse and blood pressure to undergo more than
moderate alterations until large amounts of blood have been lost. Sometimes the hypovolemia
may not be recognized until very late. When excessive hemorrhage is even suspected in the
woman with severe pregnancy-induced hypertension, efforts should be made immediately to
identify those clinical and laboratory findings that would prompt vigorous crystalloid and blood
replacement.

The differentiation between bleeding from uterine atony and from lacerations is tentatively made
on the condition of the uterus. If bleeding persists despite a firm, well-contracted uterus, the
cause of the hemorrhage most probably is from lacerations. Bright red blood also suggests
lacerations. To ascertain the role of lacerations as a cause of bleeding, careful inspection of the
vagina, cervix and uterus is essential. Sometimes bleeding may be caused by both atony and
trauma, especially after major operative delivery. Anesthesia should be adequate to prevent
discomfort during such an examination.

Management of Third-Stage Bleeding:

Some bleeding is inevitable during the third-stage as the result of transient partial separation of
the placenta. If the signs of placental separation have appeared, expression of the placenta
should be attempted by manual fundal pressure. Descent of placenta is indicated by the cord
becoming slack. If bleeding continues, manual removal of the placenta is mandatory.

Technique of Manual Removal: adequate analgesia and anesthesia is mandatory. Aseptic

surgical technique should be employed. After grasping the fundus through the abdominal wall
with one hand, the other hand is introduced into the vagina and passed into the uterus, along the
umbilical cord. As soon as the placenta is reached, its margin is located and the ulnar border of
the hand insinuated between it and the uterine wall. Then with the back of the hand in contact
with the uterus, the placenta is peeled off its uterine attachment by a motion similar to that
employed in separating the leaves of a book. After its complete separation, the placenta should
be grasped with the entire hand, which is then gradually withdrawn. Membranes are removed at
the same time by carefully teasing them from the deciduas, using ring forceps to grasp them as
necessary. Some clinicians prefer to wipe out the uterine cavity with a sponge. If this is done, it is
imperative that the sponge not be left in the uterus or vagina. (Source-21st edition William's
Obstetrics)

Management After Delivery of Placenta:

The fundus should always be palpated following placental delivery to make certain that the uterus
is well contracted. If not firm vigorous fundal massage is indicated. Most often 20 U of oxytocin in
1000 ml of lactated Ringer or normal saline proves effective when administered intravenously at
approximately 10 ml/minute (200 mU of oxytocin per minute) simultaneously with effective uterine
massage. Oxytocin should never be given as an undiluted bolus dose as serious hypotension or
cardiac arrhythmias may follow.

Bleeding Unresponsive to Oxytocics: continued bleeding after multiple oxytocic administrations

may be from unrecognized genital tract lacerations, including in some cases of uterine rupture.
The following management is suggested to be initiated immediately:
1. Employ bimanual uterine compression. The technique consists simply of massage of the
posterior aspect of the uterus with the abdominal hand and massage through the vagina
of the anterior uterine aspect with the other fist. This procedure will control most
hemorrhage.
2. Obtain help!
3. Blood transfusions (if needed). The rate of blood transfusion during cesarean section
ranges from 1% to 14%. Intraoperative blood salvage (IBS) is an alternative to
homologous blood transfusion and its attendant risks of infection and transfusion
reaction. But the use of cell saver technology during cesarean section, intraoperative
erythrocyte salvage and autotransfusion, has been limited by theoretical concerns about
amniotic fluid embolism and infection. IBS may be lifesaving in remote regions with
limited blood banking services. Women at risk for intraoperative hemorrhage (previa,
known accreta, preoperative anemia) who object to homologous blood transfusion may
benefit from IBS technology. Blood is collected, after the delivery of infant and removal of
all fetal products and amniotic fluid, with a large bore suction device. The cell saver
device with leukocyte depletion filter, then washes and filters the suctioned fluid and
collected red cells can be transfused. This process can be set up in a single, continuous
circuit so that patients with religious objections (e.g. Jehovah's Witnesses) may accept
therapy with this device.
4. Explore the uterine cavity manually for retained placental fragments or lacerations. If a
portion of placenta is missing, the uterus should be explored and the fragment is
removed either manually or by curettage.
5. Thoroughly inspect the cervix and vagina after adequate exposure. If any laceration is
seen, it should be sutured to control the bleeding.
6. Prostaglandins: the 15-methyl derivatives of prostaglandin F2alpha was approved in the
mid 1980s by the Food and Drug Administration for treatment of uterine atony. The initial
recommended dose is 250 micro-g (0.25 mg) given intramuscularly, and this is repeated
if necessary at 15 to 90 minute intervals up to a maximum of eight doses. Prostaglandin
E1 analogue, misoprostol is best known for the labor induction and medical abortion is
quite effective to treat uterine atony. Rectally or orally doses of 400 to 1000 micro-g is
given and it is rapidly absorbed. It is also safe for preeclamptic and hypertensive patients,
having no effect on blood pressure. Misoprostol is not associated with MI and
bronchospasm and therefore it is safe for asthmatic patients. The drug's other significant
advantages are its heat-stable preparation (it requires no refrigeration) and its low cost.
7. Uterine packing: concerns of concealed hemorrhage and uterine over distension has
made the use of this procedure very rare. In recent years, however, several modifications
of this procedure have allayed these concerns. Balloon tamponade using either a Foley
catheter (30 ml balloon) or a Sengstaken-Blakemore tube has been shown to effectively
control postpartum bleeding, and may be useful in several settings: uterine atony,
retained placental tissue and placenta accreta. The Foley catheter or Sengstaken-
Blakemore tube should be guided through the cervix into the uterus and the balloon can
then be inflated to achieve the desired tamponade and can be removed in 12 to 24 hours.
8. Surgical management: if retained placental fragments are suspected, curettage is done to
control the bleeding. In cases of uterine rupture patient might need repair of laceration or
hysterectomy. The most common cause of uterine rupture is separation of a previous
cesarean scar. Uterine atony if not under control by any procedure might sometimes
need hysterectomy or internal iliac artery ligation.
9. Angiographic embolization: this technique has become popular for the management of
intractable puerperal hematomas. In can be used primarily or usually when hemostasis is
not obtained by surgical methods.
 SIGNS AND SYMPTOMS

The list of signs and symptoms mentioned in various sources for Postpartum
haemorrhage includes the 7 symptoms listed below:

• 1. Ongoing blood loss

• 2. Shock
• 3. Hypotension
• 4. Tachycardia
• 5. Decreased urine output
• 6. Tachypnoea
• 7. Poor capillary refill
•
• Diagnostic Procedures

The list of diagnostic tests mentioned in various sources as used in the diagnosis
of Postpartum hemorrhage includes:

Physical examination
1.Temperature - elevated temperature may indicate endometritis (infection of the
lining of the uterus) which may cause secondarypostpartum hemorrhage.
2. Blood pressure and Pulse rate to help determine presence of shock
3. Feel abdomen to determine how much the uterus has contracted down into the
pelvis and establish if the uterus is tender
4. Vaginal examination to determine if opening of the cervix is open or closed and to
determine if vaginal discharge is offensive
5. Examine the genital area to look for any lacerations, tears or episiotomy wounds
which may contribute to postpartum hemorrhage
6. Blood test
• Full blood count
• Coagulation profile including INR, PT, APTT
• More sophisticated bleeding disorder tests depending on suspicion - e.g.
Hemophilia screening, von Willebrand's disease, platelet function studies,
platelet antibodies.
7. Swab of vaginal discharge - for microscopy and culture.
8. Radiological investigations
9. Pelvic ultrasound scan to exclude retained products and clots in the uterus

Misdiagnosis and postpartum hemorrhage

Anemia undiagnosed in pregnancy: The onset of anemia (low red blood cells)
in pregnancy is sometimes overlooked, despite it being a well-known
complication of pregnancy. The problem may be that the main symptom, i.e.
fatigue, is also a typical symptom of pregnancy itself. Furthermore, diagnosis of
anemia requires a blood test to determine the level of red blood cells. Failure to
diagnose anemia is dangerous to the health of the mother near the end of
pregnancy, and increases the risk of severe maternal hemorrhage and blood loss
during birth (possibly even leading to maternal death). Anemia treatment varies
by severity ranging from diet changes, iron tablets, or even iron injections; see
treatment of anemia.

Treatments for postpartum hemorrhage

The following treatments are listed for Postpartum hemorrhage in our knowledge
base:

1. Emergency treatment 11. Gentle uterine fundus massage

2. Blood transfusions 12. Suture visible perineal lacerations
3. Other treatments for shock 13. Oxytocins
• Medications 14. Pitocin
4. Removal of placental remnants 15. Methergine
5. Treatment of secondary postpartum 16. Methylergonovine
hemorrhage: 17. Carboprost
• Antibiotics 18. Hemabate
• Removal of placental remnants 19. Misoprostol
• Curettage 20. Cytotec
6. Call emergency services 21. Ergonovine
7. Oxygen therapy 22. Recombinant factor 7a
8. Intubation if necessary
9. Intravenous fluids
10. Normal saline
Medical Management of Postpartum Hemorrhage (Source: ACOG Practice
Bulletin No. 76, October 2006)

Drug Dose/Route Frequency Comment

Oxytocin (Pitocin) IV: 10-40 units in 1 Continuous Avoid undiluted rapid
liter normal saline IV infusion, which
or lactated Ringer's causes hypotension.
solution.
IM: 10 units
Methylergonovine IM: 0.2 mg Every 2-4 hour Avoid if patient is
(Methergine) hypertensive.
15-methyl PGF 2α IM: 0.25 mg Every 15-90 min, Avoid in asthmatic
(Carboprost) patients; relative
(Hemabate) 8 doses contraindication if
maximum hepatic, renal and
cardiac disease.
Diarrhea, fever,
tachycardia can occur.
Dinoprostone Suppository: Every 2 hour Avoid if patient is
(Prostin E )
2 vaginal or rectal; hypotensive. Fever is
20 mg common. Stored
frozen, it must be
thawed to room
temperature.
Misoprostol 800-1,000 mcg Can cause nausea and
(Cytotec, PGE ) 1 rectally vomiting.

Abbreviations: IV, intravenously; IM, intramuscularly; PG, prostaglandin.

Reference:

http://www.womenshealthsection.com/content/print.php3?
title=obs008&cat=2&lng=english
http://www.wrongdiagnosis.com/sym/postpartum_hemorrhage.htm