Epidemiology and Definition:
- 3-5% of deliveries
- Cause of 1/4 of obstetrical deaths worldwide, and 12% in the US.
- ACOG definition: 1000mL of blood loss (or blood loss + hypovolemic symptoms) from prior to placenta delivery up to 24 hours after delivery.
- 20% occur in women with NO risk factors.
- Unit prep: PPH carts, massive transfusion protocols, drills
- Pre-delivery: screen for anemia, screen for thalassemia and sickle cell if applicable, U/S in women at risk for invasive placentas, identify JWs.
- Delivery: active management of third stage, avoid episiotomy and instruments, measure blood loss and monitor VS
- PPH: use a checklist, manage the family
- Post-event: debriefs, reviews, QI
Active Management of the Third Stage of Labor (AMTSL):
- Oxytocin with or soon after delivery of the anterior shoulder (NNT = 7 to prevent one PPH of 500+mL)
- Prevention: 10 U IM or 5-10 U IV
- Treatment: 20-40 U in 1L NS, 500mL over 10 min, then 250mL/hr.
- Controlled cord traction with suprapubic counterpressure
- Uterine massage after placenta delivery
Misoprostol also an alternative to oxytocin, though most studies suggest oxytocin superior. (Misoprostol –> N, D, fever)
- 600 mcg PO for prevention
- 800 – 1000 mcg PR or 600-800 mcg PO/SL for treatment
- Tachycardia may be earliest symptom
- THE FOUR Ts:
- TONE: uterine atony (70% of PPH)
- TRAUMA: laceration, inversion, hematoma, rupture (20%)
- TISSUE: retained or invasive placenta (10%)
- THROMBIN: coagulopathy (1% or less)
Immediate response to uterine atony with PPH: bimanual massage! (Vigorous, consider pain control if possible.)
Signs of hypovolemia or shock disproportionate to visible blood loss: think hematoma.
- If > 3-4 cm or expanding, I&D hematoma with hemostasis of bleeding vessels, irrigation.
Uterine inversion: Around 4/10,000. May cause shock sxs without much visible blood loss. AMTSL does not increase rate, but invasive placenta does. Looks like a blue/gray mass protruding from the vagina. REPLACE IMMEDIATELY WITH OPEN HAND –> FIST MANEUVER. If placenta still attached, do NOT remove (to limit bleeding).
- If Johnson maneuver (above) fails, use MgSO4, terbutaline, nitroglycerin or general anesthesia.
Uterine rupture: about 8/1000 deliveries with hx of LTCS, risk increased with induction or augmentation.
Retained placenta: Mean time from delivery to expulsion is 8-9 mins. Risk of PPH increases after 10 mins. Retained if 30+ mins.
- Consider invasive placenta if no tissue plane obvious with attempt to separate with gloved hand.
- Invasive placenta may need surgery (hyst), but can sometimes be conservatively managed (e.g., weekly PO MTX).
Thrombin: consider coagulopathy if blood is not clotting in containers or in red top tube in 5-10 minutes, or if oozing from puncture sites.
- Eval: PT, aPTT, platelets, FSPs, fibrinogen, D-dimer.
- Don’t forget other causes: amniotic fluid embolism, consumptive coagulopathy/DIC, sepsis, HELLP, fetal demise…
Treat it like a trauma:
- Two large-bore IVs
- Bolus LR or NS
- O negative blood if needed while awaiting type-specific
- Support oxygenation, ventilation
- Massive transfusion protocols:
- 4 U FFP + 1 U platelets per 4-6 units of pRBCs given
- Foley cath
Advanced uterine-saving measures:
- Uterine packing
- Uterine artery ligation
- Balloon tamponade devices
- B-Lynch procedure