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  • Nathan Riley, MD

Beloved Holistics Radio Episode 78 - Postpartum Hemorrhage

Updated: Aug 3

“I live on Earth at present, and I don’t know what I am. I know that I am not a category. I am not a thing — a noun. I seem to be a verb, an evolutionary process – an integral function of the universe.” ― R. Buckminster Fuller




PB #183, Published October 2017


Five Pearls

1. PPH is defined as 1000 mL for either vaginal or cesarean birth.

2. Go with your gut in diagnosing PPH, and do it fast! You can't rely on vital signs or lab work to make the call to action in the acute setting.

3. Uterine atony is the most common cause of PPH. Manage through uterine massage, uterotonics, tamponade, and UAE. Opening up her abdomen to place compression sutures, ligate the uterine vessels, or perform hysterectomy are last resort!

4. Remember the triad of the amniotic fluid embolism: respiratory decompensation, hemodynamic instability, and DIC.

5. As soon as you feel that she's lost too much blood activate your institution's transfusion protocol. Remember that you can never get pre-screened blood fast enough when you actually need it.


Definition of postpartum hemorrhage (PPH)

- 1000 mL estimated blood loss (EBL) in childbirth (regardless of vaginal or cesarean mode of birth)

- contrast this with prior definition of 500 mL after vaginal, 1000 mL cesarean

- alternatively, a drop in Hct by ≥10% is also diagnostic, but not useful in the setting of acute hemorrhage (it takes time to run labs!)

- you also can't rely on vital signs in the acute setting: healthy young people will maintain hemodynamically stability until they have lost a TON of blood

- eyeballing is a pretty decent weigh to estimate blood loss


Lots of things can cause excessive bleeding in childbirth

- primary causes: within 24 hrs of birth

- secondary causes: >24 hrs of birth up to 10 weeks postpartum

- think of the four Ts when you're in the heat of the moment: tone, trauma, tissue, and thrombin

- most common: uterine atony, genital tract lacerations, and retained placenta

- less common: placental abruption, coagulopathy (acquired or inherited), amniotic fluid embolism, placenta accreta, or uterine inversion

- running through simulations is a fine way to get comfortable with assessing for any of these things in a matter of minutes


Risk factors

- pretty unpredictable, unfortunately

- long labor and chorio are risk factors

- if you've had them on pitocin for 9 years at 30 munits/min or mag sulfate then you should expect heavy bleeding

- there are a bunch of risk stratification tools but none of them work very well (tell me I'm wrong...)



Many women don't want active management of the the 3rd stage

- and this is totally fine! another great opportunity to have a conversation about risks/benefits

- active management reduces the risk of postpartum atony (most common cause of excessive bleeding in childbirth)

- it includes: administration of oxytocin (10 units IV or IM) immediately after birth (even before placenta delivers itself), cord traction to usher along placental delivery, and uterine massage (belly rub)

- Cochrane found no difference in PPH risk with cord traction, uterine massage, or nipple stim/breastfeeding

- addition of methylergonovine or misoprostol provides no benefit as prophylaxis (these meds come into play when hemorrhage happens, though!)

- administration of prophylactic oxytocin after delayed cord clamping hasn't been found to predispose patients to PPH


Ok...she's bleeding heavily...now what?

- breathe...stay calm

- ask her how's she's feeling, find out as much info as possible from her nurse, doula, midwife, nurse, etc.

- how much blood is there? is it more than usual?

- think about the etiologies throughout and act accordingly

- spend 10 seconds consenting her to a vulvovaginal exam and possibly a bimanual exam


Note: If you feel like you could "take care of things" by reaching up into her uterus with your gloved hand, then this should be a separate conversation. An additional 10 seconds isn't going to be the difference between life and death.


- if uterus is firm, move on to an examination of the vulva, vagina, and perineum; any bleeding lacs?

- while this is all happening, you may start calling for supplies (bakri balloon, sutures, and medications)

- if she's bled sufficiently heavy, you should also consider transport to the operating room if you're already in the hospital (or transfer from home to hospital if she gave birth outside)

- good lighting and exposure with reactors or surgical assistance can be critical in identifying lacerations related to the cervix or deep in the vagina

- access to blood products is a good thing to have on your mind, too


Uterine atony

- uterus remains squishy after birth, so all of the blood vessels and sinuses in the region where the placenta was previously attached blood like stink

- anything you can do to help that uterine muscle to contract will stop this bleeding: massage, compression, medications, or tamponade should be on your mind

- first, drain the bladder! (a full bladder can cause atony)


Uterine massage

- one hand in the vagina; one hand on the abdomen

- remove any clots or tissues that you fee in the cervix

- squeeze the uterus between your hands

- very uncomfortable for mom and invasive, so obtain consent first (risks versus benefits as I described earlier)

- even if fundus is firm, the lower uterine segment may be squishy or "boggy", thus uterotonic might still be warranted


Uterotonics

- oxytocin is usually offered prophylactically in the hospital setting (10 units IM or IV)

- methylergonovine, 15 methyl prostaglandin F2α, or misoprostol


Bakri balloon

Homeopathic and herbal tinctures

TINCTURES

Shepard’s Purse

CottonRoot Bark

Blue Cohosh

Motherwort

Dong Quai

Yarrow


HOMEOPATHICS

Arnica

Kali Carb

Pulsatilla

Ipecacuanha


Uterine balloon tamponade

- Bakri balloons or even a large foley (or hell, lubricated gauze!) can tamponade bleeding coming from inside the uterus

- can be used in conjunction with massage and uterotonics

- you can leave it in for many hours, and it will definitely decrease blood loss

- you can even think of it as a temporizing measure until you can get your patient to the hospital (or the IR suite)

- 75% effective



Uterine artery embolization

- last resort because it can negatively impact future fertility (though not necessarily)

- patient is sedated, a catheter is inserted in through her femoral artery and under fluroscopic guidance the radiologist will find their way to the uterine artery before embolizing the vessel with microparticles or coils (done on both sides)

- 80% success rate

- also small risk of uterine necrosis, DVT, or peripheral neuropathy (<5% composite risk)


Compression sutures

- various techniques exist, but the B-lynch technique is probably the favorite

- Hayman is another technique

- obviously these are much easier to do if she had a c-section; if it was a vaginal birth, she may prefer UAE rather than an abdominal incision (risks...benefits...alternatives...again and again and again)

- use size 1 chromic suture (rapidly absorbing) to prevent bowel entrapment

- 60-75% effective


Lacerations

- vulvar, vaginal, and perineal lacerations can be repaired within minutes with adequate control of bleeding

- techniques for suturing non-cervical lacerations is covered in PB# 198

- remember good lighting, anesthesia, and retraction with surgical assistance when necessary to do the job

- cervical lacerations can bleed very briskly making it super hard to repair without help

- if they extend through the cervicovaginal junction, the uterine artery may be transected, in which case you can get retroperitoneal or intraperitoneal bleeding (monitor closely!)

- cervical lacs might be higher on your differential if labor was rapid or if she began pushing before the cervix is fully dilated

Repair of cervical laceration

- if the following day after a birth your patient is complaining of otherwise unexplained vaginal or rectal pressure, you may need to consider the likelihood of a genital tract hematoma

- hematomas can occasionally collect so much blood that vital signs may become unstable or H/H can drop dramatically

- manage conservatively! (packing the vagina or rectum with lubricated gauze can help to decompress a hematoma)

- incision and drainage should be reserved for only the most severe cases (can lead to more bleeding!)


Note: If you you see no blood, but your patient is hemodynamically unstable or blood work continues to reflect blood is disappearing, rush her down for a CT to ascertain an occult hematoma. IR may be able to identify the bleed and stop embolize it emergently!


Succenturiate lobe is a little buddy to the main placenta

Retained placenta/POCs

- check the placenta after it delivers to ensure that it's intact

- even if it's intact, you can't be sure that a succenturiate lobe was left inside

- ultrasound really isn't always helpful in diagnosing this right after birth, but heck, if you take a look and see a big honking echogenic chunk of something in the cavity, there's a good chance that it would only help to remove it

- consent after risks/benefits is, AS ALWAYS, critical

- you can sometimes clean the cavity with a gloved hand (very uncomfortable without adequate anesthesia!)

- curettage can also be helpful if manual exam and US are insufficient

- be careful when performing curettage, as that soft boggy uterus can be easily perforated

- if the placenta piece isn't coming out (or if the placenta hasn't delivered after an hour or longer!), you may want to consider the likelihood of placenta accreta (more on this later...)



Coagulopathy

- placental abruption or amniotic fluid embolism can lead to massive, rapid blood loss

- if suspected, you may need to active your massive transfusion protocol (more on this later)


Placental abruption

- in abruption, the characteristic labor pattern is frequent contractions, vaginal bleeding, and very commonly changes to the FHR tracing

- the placenta and any blood collected behind it are usually delivered and all is well once the uterus firms up

- on occasion, however, blood can extravasate into the myometrium ("Couvelaire uterus") and cause a severe uterine atony

- disseminated intravascular coagulation (DIC) and hypofibrinogenemia may result --> bad news


Note: In DIC, blood clot forms all over the body as a chain reaction, leaving few clotting factors floating around to stop bleeding from other sites: uterus, lacerations, IV sites, etc.


Amniotic fluid embolism

- rare, unpredictable, unpreventable, and devastating emergency

- characterized by hemodynamic and respiratory compromise in addition to DIC (nasty triad that you should remember!)



Other management options for PPH


Tranexamic acid

- administered as 1g bolus IV

- antifibrinolytic agent

- might help, data is mixed

- doesn't appear to increase risk of VTE


Vascular ligation

- generally reserved for instances in which even UAE fails

- you'll need to do an ex-lap (preferably by vertical incision for better visualization)

- O'Leary stitches can be placed bilaterally to completely ligate the uterine vessels as they ascend the sides of the uterine isthmus

- the uterine vessels can also be ligated as the pass through the utero-ovarian ligaments

- hypogastric artery ligation has fallen out of favor as it's more technically difficult and less successful

- >90% effective

Source: presentation by Dr. Douglas Montgomery, MFM, Kaiser Riverside

Hysterectomy

- ok, I've tried everything, and the uterus is still feels like a sack of worms

- you're likely already inside the abdomen because you've tried ligation

- postpartum hysterectomy is your last resort because the giant vessels and distorted anatomy make for a very challenging surgery (plus most women would prefer to keep their uterus)

- 6-12% risk of bladder injury

- 0.5-40% risk of ureteral injuries

- go for supracervical if you need to in order to as fast, safe, and efficient as possible


Placenta accreta

- placenta grows into the wall of the uterus (can even grow through the uterus and attached to adjacent organs

- high mortality rate

- if you try to detach the placenta, it will sheer off a part of the uterus and the patient will exsanguinate

- can be diagnosed prior to birth but sometimes it's missed (and placenta won't come out after birth!)

- associated with placenta previa in setting of prior c-section:

  • after 1st c-section 3% risk of accreta

  • 2nd: 10%

  • 3rd: 40%

  • 4th: 60%

  • 5th: 67%

- even if no previa, risk of accreta is increased w/ history of c-section:

  • after 1st: 0.2% risk of accreta

  • 2nd: 0.3%

  • 3rd: 0.6%

  • 4th: 2.1%

  • 5th: 2.3%

  • 6th: 6.7%

- ultrasound can be suggestive, then MRI can confirm

- cesarean hysterectomy is recommended for management of accreta

- have a pre-operative meeting if possible in order to plan for anethesia needs, DIC/transfusion needs, etc.

- preserving the uterus may be an option for focal accreta (tiny bit of attachment), but when this approach has been studied, 40% of women ultimately required emergent hysterectomy

- of those who preserve their uterus, there's a 20% chance of abnormally adherent placenta in subsequent pregnancy


What if you suspect PPH is due to uterine rupture?

- hard to predict uterine rupture

- but if you noticed a loss of station, change in FHR tracing, and sudden worsening of labor pain at time of birth, and then bleeding is ongoing or she develops hemodynamic instability, you may need to take her to the OR for ex-lap and repair of rupture (or hysterectomy if repair is impossible)


How do you manage uterine inversion?

- this is when the uterus pops itself inside out --> you'll be able to see or feel the inside of the uterine fundus vaginally!

- the fundus can also invert during a c-section

- while inverted, all of the fresh, juicy blood vessels are decompressed and can bleed horrifically

- incidence is far <0.1%

- only risk factor is history of inversion in prior pregnancy

- you replace the inversion by literally pushing on it circumferentially until it pops back in

- tocolytic agents (e.g. terbutaline, mag sulfate, and nitroglycerin) haven't been found to be effective, but, hey, why not call for it?

- still not working?

  • Huntington procedure: push up with Babock or Allis forceps

  • Haultain procedure: incise posterior cervix to facilitate reversion

- worst case scenario is to go to ex-lap for surgical exploration/correction

- in rare instances, the inversion can recur, so there has been some success with placement of compression sutures to prevent this from happening


Special considerations for secondary postpartum hemorrhage

- incidence: 1% of pregnancies

- defined as: >24 hrs up to 12 weeks PPH

- uterine atony due to retained POC can present long after birth

- endometritis can present as hemorrhage (check for uterine tenderness, fever)

- von Willebrand Disease is a classic board question answer for PPH

- get an US right off the back, and consider curettage if appropriate

- consent for hysterectomy before performing any procedure



Darker birth tub water = greater EBL


To transfuse or not to transfuse

- if you see a ton of blood, just activate your transfusion protocol

- they'll probably send up O negative, pre-screened blood

- if you end up not needing it, no sweat...send it back :-)

- collect CBC, INR/PT, PTT, and fibrinogen as soon as you realize she's lost a lot of blood

- this is especially true if EBL >1500 mL or if you see hemodynamic changes


Note: In hypovolemia due to blood loss, HR increases before you see any changes to BP


- in truly hemorrhagic bleeding, you need to transfuse fresh frozen plasma (FFP) and platelets in addition to red blood cells (RBCs)

- use a 1:1:1 ratio of these three products

- if you suspect DIC (e.g. hypofibrinogenemia, increased INR/PT, increased PTT), call for cryoprecipiate

- fibrinogen concentrates and recombinant factor VII haven't been fully studied in PPH and they're expensive, so they're a last resort

- after bleeding has stabilized, your patient may still benefit from transfusion if her Hgb remains <7 g/dL, especially if symptomatic or hemodynamically unstable


Don't be overzealous with transfusion of blood products

- this can lead to hyperkalemia, citrate toxicity (acidemia), and hypocalcemia

- all of these things can actually worsen coagulopathy

- transfusion reactions occur at an incidence of 0.8 per 1000 units transfused


**If you attend home births, it may be useful to keep an anti-shock garment to help keep your patient alive while awaiting an ambulance if you begin to see hemodynamic changes!

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