Approach to postpartum hemorrhage: Clinical sciences

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Introduction0:00–0:38

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.

Acute Management 0:38–1:15

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.

Immediate Postpartum Hemorrhage1:15–2:40

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.

Uterine Tone2:40–3:55

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 Trauma3:55–5:26

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.

Retained products of conception (Tissue)5:26–5:57

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. Our last T is for thrombin, meaning you need to assess for coagulopathy as the cause of hemorrhage.

Coagulopathy (Thrombin)5:57–6:52

To make this diagnosis, you must review the laboratory test results sent during your initial evaluation. If you note low platelets, lower than 100,000; low fibrinogen, lower than 300; a prolonged PT with an INR over 1.5; and a prolonged PTT; then coagulopathy is the cause of hemorrhage.
This includes inherited coagulation defects, as well as acquired coagulopathies that may develop from events like an amniotic fluid embolism, placental abruption, or preeclampsia with severe features.Okay, if your exam, ultrasound, and labs are all unremarkable but the patient continues to bleed significantly, repeat the evaluation and monitor the patient’s vital signs closely.
Also be aware that multiple causes can co-exist. Now that the 4Ts that may cause immediate postpartum hemorrhage are covered, let’s go all the way back and talk about delayed postpartum hemorrhage.

Delayed Postpartum Hemorrhage6:52–7:38

Again, this is a hemorrhage that occurs after 24 hours through 12 weeks post-delivery. When assessing these patients start with a focused history and physical examination, and obtain labs like a CBC, PT, PTT, and INR.
All patients with delayed hemorrhage will report abnormal postpartum bleeding patterns, although the exact bleeding profile may differ.
Abnormal bleeding might include the passage of large clots, prolonged or intermittent gushes of heavy bleeding, or saturating more than one pad an hour.
Let’s dive into it! First, let's talk about a patient that is afebrile and does not have uterine tenderness on a physical exam.

Retained products of conception7:38–8:35

Their labs may show anemia secondary to blood loss from delivery, however, coagulation studies are normal. If this is the case, consider retained products of conception as the source of hemorrhage.
Your next step is to obtain a pelvic ultrasound. If you see a thickened, heterogeneous endometrium, with or without a mass in the endometrial cavity, you ’ve confirmed the diagnosis of retained products of conception.
This is more common after a vaginal delivery versus c-section but can occur after either. Here’s a clinical pearl!
In some cases, retained products of conception could be due to an abnormally adherent placenta, such as a focal placenta accreta.
Now moving on to our next scenario. Let’s discuss a patient who reports a fever and on a physical exam has an elevated temperature, uterine tenderness, and a malodorous vaginal discharge.

Endometritis8:35–9:30

Their labs may show anemia as well as leukocytosis with a left shift. This patient has postpartum endometritis.
Note that this condition can occur both with or without retained products of conception, so if the patient doesn’t clinically improve with initial antibiotic therapy, consider an ultrasound like before to evaluate the endometrial cavity.Here’s a high-yield fact!
The most important risk factor for postpartum endometritis is c-section. Other risk factors include long labor or prolonged rupture of membranes, operative vaginal delivery, manual removal of the placenta, and group B streptococcus colonization.
Let’s go back once again. Some patients will have a history of heavy menstrual bleeding or a family history of a bleeding disorder, and no uterine tenderness on physical exam.

Inherited coagulopathy9:30–10:08

Their labs may show anemia and abnormal PT, PTT, and INR. In this patient, consider an inherited coagulopathy.
The next step is to obtain a pelvic ultrasound. If the ultrasound is normal, perform genetic testing for inherited coagulopathy.
If positive, this confirms the diagnosis of an inherited coagulopathy, such as Von Willebrand disease. Let’s go back one last time!

Alternative diagnosis10:08–10:26

After assessing for the most common causes of delayed postpartum hemorrhage, consider alternative diagnoses, such as subinvolution of the placental site, neoplasia, vascular malformation, or hypoestrogenism.Alright, as a quick recap… Postpartum hemorrhage is a life-threatening complication of childbirth that requires timely recognition and management.

Review10:26–11:02

After stabilizing the patient, look for the cause of postpartum hemorrhage.Common causes of immediate postpartum hemorrhage include uterine atony; obstetric trauma, such as vaginal or cervical laceration, or vaginal or vulvar hematoma; retained products of conception; and coagulopathy.
On the other hand, causes of delayed postpartum hemorrhage include retained products of conception, endometritis,