Approach to postpartum hemorrhage: Clinical sciences

Postpartum hemorrhage is bleeding after delivery that results in either a cumulative blood loss of at least 1000 mL or blood loss associated with signs and symptoms of hypovolemia, no matter the route of delivery. Immediate, or primary postpartum hemorrhage occurs in the first 24 hours following delivery, while delayed, or secondary postpartum hemorrhage occurs more than 24 hours to 12 weeks following delivery. All postpartum hemorrhages are obstetric emergencies and require timely recognition and management.

All patients presenting with postpartum hemorrhage are considered unstable and need acute management. First, you’ll need to stabilize their airway, breathing, and circulation. Next, monitor their vital signs and obtain IV access, if not already present. Begin a crystalloid infusion or increase the rate if already administered. Then, obtain a blood type and crossmatch to prepare blood products in case a transfusion is necessary. Also, activate the obstetric hemorrhage team or personnel you’ll need to assist you. Lastly, take a moment to review the patient’s clinical course for the most likely cause of their hemorrhage.

Once these steps are done, it’s important to assess time from delivery. If 24 hours or less has passed since delivery, we are talking about immediate postpartum hemorrhage. The first step is to obtain a focused history and physical examination; as well as labs, including a CBC, PT, PTT, INR, and fibrinogen to evaluate for anemia and coagulopathy.

Patients with immediate hemorrhage will have profuse bleeding, sometimes continuous in nature and other times in the form of large intermittent clots. History might also reveal potential risk factors for postpartum hemorrhage, such as high parity, prolonged use of oxytocin, intraamniotic infection, multifetal gestation, or precipitous delivery.

Here’s a clinical pearl! Although the definition of postpartum hemorrhage as 1000 mL of blood loss applies to both vaginal and c-sections, a blood loss greater than 500 mL in a vaginal delivery is still considered abnormal. Be sure to explore possible causes for the high volume of blood loss and watch closely for further bleeding.

The next step is to find the cause of their bleeding. A useful way to remember the most common causes of immediate postpartum hemorrhage is the 4 Ts: tone, trauma, tissue, and thrombin.

Let’s start by assessing the uterine tone. Lack of uterine tone, referred to as uterine atony, is the failure of the myometrium to adequately contract after birth, and it’s the most common cause of postpartum hemorrhage. This is because a well-contracted uterus mechanically compresses bleeding vessels allowing for hemostasis.

To assess uterine tone evaluate the uterus and perform a bimanual exam. This is done by placing one hand in the vagina and pushing against the body of the uterus while the other hand is placed on the abdomen and is used to palpate the fundus from above. A uterus with adequate tone will feel firm and contracted. However, if the uterus is soft and boggy then uterine atony is the cause of hemorrhage.

Here’s a clinical pearl! if you observe or palpate the uterine fundus in the lower uterine segment or within the vagina, it means that it has turned partially or completely inside out with the top collapsed into the endometrial cavity or vagina. In this case, we are talking about uterine inversion. This is a separate obstetrical emergency, and also contributes to postpartum hemorrhage.

The next step is to assess for obstetric trauma. Obstetric trauma most commonly occurs during vaginal delivery. Examine the perineum, vulva, vagina, and cervix. If you see disruption of the vaginal or cervical tissue and bleeding from the vaginal or cervical mucosa, the diagnosis is a vaginal or cervical laceration.

Here are a couple of clinical pearls! Cervical lacerations often bleed more heavily than vaginal lacerations due to increased blood supply and can be harder to repair. In order to assess for a cervical laceration, you can use two ring forceps to “walk” the cervix, meaning you will hold the cervix gently and move the rings in a circular fashion until you have adequate visualization and can see if a defect is present. If you’re unable to see well in the delivery room, move the patient to the operating room for a thorough exam and repair.

Now, if your patient had a c-section, you can assess for trauma by doing a close inspection of the hysterotomy site as well as any other sites of surgical dissection. Make sure to evaluate for a uterine artery laceration, uterine rupture, or broad ligament hematoma.

On the other hand, if you note a collection of blood in the vaginal or vulvar soft tissue and palpate a tense, painful, and compressible mass, the patient has a vaginal or vulvar hematoma.

Alright, now it’s time to assess for retained tissue. Once again, you’ll need to do a bimanual exam and, if possible, have a member of your team perform a bedside ultrasound. If there’s retained tissue, you’ll feel placental membranes or tissue within the endometrium. Additionally, you may see echogenic or heterogeneous material within the endometrial cavity on ultrasound. If these findings are present, the patient’s hemorrhage is caused by retained products of conception.