Up to 18% of births can result in postpartum hemorrhage, which is defined as the loss of more than 500 mL of blood after delivery. A physiologically significant blood loss of more than 1,000 mL can lead to hemodynamic instability.
By Muhammad Amjid, Muhammad Sajid and Muhammad Alamgeer
A serious postpartum hemorrhage will occur in about 3% of vaginal deliveries, even with the proper care. It is a leading cause of death globally and the most prevalent maternal morbidity in developed economies. Orthostatic hypotension, anemia, and exhaustion are side effects of postpartum bleeding that may make it more difficult for mothers to care for their newborns. Postpartum anemia increases the risk of postpartum depression. In the most severe cases, hemorrhagic shock may result in anterior pituitary ischemia with delayed or unsuccessful lactation (i.e., postpartum pituitary necrosis), occult cardiac ischemia, dilutional coagulopathy, and death. Blood transfusion may be necessary and involves related hazards. Bleeding after 24 hours as a result of retained placental fragments or delayed postpartum hemorrhage, which happens when the placental eschar sloughs off, is also possible.
A prolonged third stage of labour, multiple deliveries, episiotomies, fetal macrosomia, and a previous postpartum hemorrhage are risk factors for postpartum hemorrhage. However, postpartum hemorrhage can happen to women who have no risk factors, so doctors need to be ready to treat it at every delivery. Prior to delivery, anemia should be identified and treated, the mother’s views on blood transfusions should be taken into consideration, and routine episiotomies should be stopped. Before leaving the delivery room, check the patient’s vital signs and vaginal flow again to see whether any slow, persistent bleeding is present.
The number of cases of postpartum hemorrhage that can be prevented by actively managing the third stage of labour (NNT = 12) is the best preventative strategy. Hospital policies that support this practice have significantly decreased the incidence of severe hemorrhage. Active management reduces the risk of postpartum hemorrhage and shortens the third stage of labour without noticeably raising the risk of retained placenta. This involves giving a uterotonic medication concurrently with or shortly after the delivery of the anterior shoulder, controlled cord traction, and, typically, early cord clamping and cutting. Active treatment reduces the incidence of postpartum hemorrhage by 68 percent as compared to expectant management, which relies solely on gravity or nipple stimulation to help the placenta separate spontaneously.
Uterine massage following placenta delivery has been added to the definition of active management of the third stage of labour in the International Federation of Gynecology and Obstetrics (FIGO)20. Delaying cord clamping for about 60 seconds has the advantage of boosting iron stores and reducing anemia, which is crucial in preterm infants and in low-resource settings. It has not been demonstrated that the delay causes more newborn morbidity or maternal blood loss. Oxytocin (Pitocin) given as a preventative measure lowers postpartum hemorrhage rates by 40%; this reduction also occurs if oxytocin is given after placental delivery. Because it is less likely to cause adverse effects and is at least as effective as ergot alkaloids or prostaglandins at avoiding postpartum hemorrhage, oxytocin is the preferred medication in this situation. The drug misoprostol (Cytotec), which has greater adverse effects but is less expensive, heat- and light-stable, and doesn’t require syringes, plays a part in preventing postpartum hemorrhage (NNT = 18).
Management and Diagnosis
Recognizing heavy bleeding and doing a thorough examination to identify its origin are the first steps in making a postpartum hemorrhage diagnosis. To identify particular causes, use the “Four Ts” mnemonic (Tone, Trauma, Tissue, and Thrombin).
The most frequent reason for postpartum bleeding is uterine atony. Atony is initially treated by bimanual uterine compression and massage, followed by medications that induce uterine contraction, because hemostasis associated with placental separation depends on myometrial contraction.
After the placenta has been delivered, a doctor should undertake a bimanual examination of the uterus if there is a rapid blood flow. When massaging a soft uterus, one hand is placed in the vagina and pressed against the uterine body while the other hand presses the fundus from above via the abdominal wall. The abdominal hand is used to massage the back of the uterus, while the vaginal hand is used to rub the front.
Prostaglandins, oxytocin, and ergot alkaloids are examples of uterotonic substances. The top segment of the myometrium is stimulated by oxytocin to contract rhythmically, which narrows spiral arteries and reduces blood flow through the uterus. Ten international units (IU) of oxytocin should be injected intramuscularly or 20 IU in 1 L of saline may be given at a rate of 250 mL per hour as a first-line treatment for postpartum hemorrhage. It is safe to inject up to 500 mL over the course of ten minutes.1 The ergot alkaloids methylergonovine (Methergine) and ergometrine (not available in the US) elicit widespread smooth muscle contraction, which causes the upper and lower parts of the uterus to contract titanically. Methylergonovine is typically injected intramuscularly in doses of 0.2 mg, which may be repeated as needed every two to four hours. Ergot alkaloid medications are not advised for use in pregnant or hypertensive women since they increase blood pressure. Vomiting and nauseousness are other negative effects. Vasoconstriction and increased uterine contractility are both caused by prostaglandins. The prostaglandin 15-methyl prostaglandin F2a, often known as carboprost, is the most widely utilised one (Hemabate). A 0.25 mg dose of carboprost can be injected intramuscularly or intravenously, and it can be repeated once every 15 minutes for a total dose of 2 mg. Up to 87 percent of patients have had bleeding successfully controlled with carboprost. Chorioamnionitis or other bleeding risk factors are frequently present when it is ineffective. The only absolute contraindication to carboprost is hypersensitivity, but it should be taken with caution in individuals who have asthma or high blood pressure. Nausea, vomiting, diarrhoea, hypertension, headaches, flushing, and pyrexia are a few of the side effects. Misoprostol is a prostaglandin that decreases postpartum bleeding and raises uterine tone. It is an effective treatment for postpartum hemorrhage, but adverse effects may prevent its widespread usage. Sublingually, orally, vaginally, and rectally are all ways to deliver it. The dosage ranges from 200 to 1,000 mcg; FIGO suggests using 1,000 mcg intravenously. Shivering, pyrexia, and diarrhoea are just a few of the negative effects that are linked to higher peak levels and greater doses. Misoprostol is frequently used to treat postpartum hemorrhage, although it is not recognized in the United States. for this indication, the Food and Drug Administration.
Blood loss from birth trauma-related lacerations and hematomas can be significantly reduced by hemostasis and prompt repair. If applying pressure to the wound does not stop the bleeding, sutures should be used. Unless an urgent delivery is required and the perineum is believed to be a limiting factor, episiotomy increases blood loss and the possibility of anal sphincter tears. Pain or a change in vital signs that is disproportional to the amount of blood loss can be symptoms of hematomas. Close monitoring can be used to treat small hematomas. Patients who have growing or big hematomas or who continue to show volume loss despite fluid replacement need to be cut open and have the clot removed. The bleeding vessels need to be tied off, and the affected area should be irrigated. A multilayer closure will aid to ensure hemostasis and remove dead space in patients with diffuse oozing.
In 0.05 percent of births, uterine inversion occurs. Uterine inversion may be less common if the third stage of labour is actively managed. The placenta’s implantation at the fundal region may cause inversion; the effects of fundal pressure and excessive cord traction are unknown. Usually a bluish-gray lump projecting from the vagina, the inverted uterus is seen. Another red flag could be vasovagal reactions that cause vital sign changes that are out of proportion to the quantity of bleeding. The placenta should be left in situ until after reduction since it frequently remains attached. Every effort should be taken to promptly replace the uterus. The projecting fundus is first grasped using the Johnson reduction technique, with the fingers pointing toward the posterior fornix. By being raised through the pelvis and into the abdomen, the uterus is put back in its proper place. After the uterus has been reversed, uterotonic medications should be used to support uterine tone and stop recurrence. If the first attempts to replace the uterus are unsuccessful or a cervical contraction ring forms, magnesium sulphate, terbutaline (Bertine), nitroglycerin, or general anesthesia may be used to help the uterus relax enough to be moved. The uterus will need to be surgically replaced if none of these approaches work. Tear in the uterus.
Clinically severe uterine rupture happens in 0.6 to 0.7 percent of vaginal births following caesarean delivery in women with low transverse or unexplained uterine scars, despite being uncommon in uteruses without scars. Shorter intervals between pregnancies or a history of multiple caesarean births have a smaller impact on risk, which is especially true for women who have never given birth vaginally. The risk also rises dramatically with prior classical incisions or uterine procedures. If prostaglandins and oxytocin are administered in succession, the rate of uterine rupture during induction or augmentation is higher than during spontaneous labour. However, there are relatively few ruptures (i.e., 1 to 2.4 percent). When trying a vaginal birth after a previous caesarean delivery, misoprostol shouldn’t be used for cervical ripening or induction. Before delivery, the primary sign of uterine rupture is fetal bradycardia. As well as vaginal bleeding, abdominal discomfort, maternal tachycardia, circulatory collapse, or growing abdominal girth, tachycardia or late decelerations might also signal a uterine rupture.
A modest bloody gush, a lengthening of the umbilical cord, and a slight elevation of the uterus in the pelvis are all traditional indicators of placental separation. The Brandt-Andrews procedure, which involves using one hand to put firm traction on the umbilical cord and the other to administer suprapubic counterpressure, can be used to deliver the placenta. Eight to nine minutes pass on average from delivery until placental ejection. The risk of postpartum hemorrhage increases with longer intervals, with rates doubling after 10 minutes. Less than 3% of vaginal births result in retained placentas, or the placenta that doesn’t deliver within 30 minutes after birth. One treatment approach is to inject 20 mL of a 0.9 percent saline and 20 units of oxytocin solution into the umbilical vein. Compared to injecting saline alone, this greatly lowers the requirement for physical removal of the placenta. As an alternative, doctors may perform the manual placenta removal right away while administering the proper analgesics. Invasive placenta should be considered if the tissue plane between the uterine wall and placenta cannot be formed with blunt dissection with the edge of the gloved hand. An invasive placenta may seem dangerous. Since the 1950s, there has been an increase in the incidence of caesarean sections, which has gone from 0.003 percent to 0.04 percent of deliveries.
Placenta accreta binds to the myometrium, placenta increta invades the myometrium, and placenta percreta penetrates the myometrium to or beyond the serosa. This term is based on the depth of invasion and is easily remembered by alliteration. Older maternal age, high parity, past caesarean or invasive placenta deliveries, and placenta previa are risk factors (especially in combination with previous caesarean delivery, increasing to 67 percent with four or more). Hysterectomy is the most widely used treatment for invasive placenta. Conservative management, on the other hand, can occasionally be effective (for example, keeping the placenta in place or administering oral methotrexate once a week until the b human chorionic gonadotropin levels are 0). Women who have had a retained placenta treated need to be on the lookout for any late consequences, such as infection and late postpartum bleeding.
A rare cause of postpartum bleeding known as coagulation abnormalities is unlikely to react to the above-mentioned treatments. The majority of coagulopathies are discovered prior to delivery, enabling proactive planning to avoid postpartum hemorrhage. These illnesses include hemophilia, von Willebrand’s disease, thrombotic thrombocytopenic purpura, and idiopathic thrombocytopenic purpura. Patients may also experience disseminated intravascular coagulation or the HELLP syndrome (hemolysis, elevated liver enzyme levels, and low platelet levels). Severe preeclampsia, amniotic fluid embolism, sepsis, placental abruption, and prolonged retention of fetal demise are risk factors for disseminated intravascular coagulation. Cocaine use and hypertensive conditions are linked to disruption. Excessive bleeding can deplete coagulation factors and lead to consumptive coagulation, which promotes further bleeding. Coagulation defects should be suspected in patients who have not responded to the usual measures to treat postpartum hemorrhage, and in those who are not forming blood clots or are oozing from puncture sites. Evaluation should include a platelet count and measurement of prothrombin time, partial thromboplastin time, fibrinogen level, and fibrin split products (i.e., dimer). Management consists of treating the underlying disease process, supporting intravascular volume, serially evaluating coagulation status, and replacing appropriate blood components. Administration of recombinant factor VIIa or clot-promoting medications (e.g., tranexamic acid (Cyklokapron) may be considered.
Standard maternal resuscitation techniques are required for significant blood loss from any cause. More than 1,000 mL of blood lost necessitates immediate action and an interdisciplinary team strategy.
A hysterectomy or surgical correction of the abnormality is necessary for symptomatic uterine rupture. A minor, asymptomatic lower uterine segment defect or bloodless dehiscence might be monitored expectantly if it is found during the postpartum period. Hysterectomy is the only option for women who have severe, uncontrollable bleeding. Uterine packing or tamponade procedures, B-lynch uterine compression sutures, artery ligation, and uterine artery embolization are examples of uterus-conserving treatments for patients who want to become pregnant in the future.