Postpartum Hemorrhage at Vaginal Delivery

Definition:  Estimated blood loss ≥ 500 ml after vaginal delivery or ≥ 1000 ml after cesarean delivery.

Differential Diagnosis: 
 • Atony
 • Lacerations
 • Retained products of conception
 • Uterine inversion
 • Uterine rupture
 • Coagulopathy

Treatment:
 1. Fundal massage.  Be sure bladder is empied.

 2. 2 large bore I.V.’s

 3. Laboratory tests: CBC, CMP, PT, PTT, fibrinogen, type and crossmatch

4.Uterotonic drugs 

• Oxytocin 20-40 units in one liter of normal saline intravenously at rate sufficient to control atony or 10 units IM (including directly into the myometrium)
• Methylergonovine (Methergine) 0.2 milligrams IM  (Contraindication – hypertension)
• 15  methyl – PGF2alpha (Hemabate) 250 micrograms IM q 15 minutes up to 8 doses/24 hours    (Contraindication – asthma)
• Misoprostol (PGE1) 1000 micrograms per rectum or oral
• Dinoprostone (PGE2) 20 milligrams vaginal or rectal suppository, can repeat q 2 hrs.  (Contraindication – hypotension)

 5. Fluid resuscitation and transfusion 

• Vital signs, urine output, and oxygen saturation. 
• Crystalloid to keep systolic BP > 90 mHg.  Crystalloid to blood loss ratio 3:1, i.e., 3 liters of crystalloid for every one liter of blood loss 
• Maintain Hct ≥ 30%
• Maintain urine output ≥ 30 ml/hr
• Maintain serum fribrinogen > 100 mg % and platelets > 50,000/ml3
• No consensus on optimal ratio of blood product replacement.  In general, 1 unit of FFP for 1-2 units of PRBC’s.  Stanford University Medical Center massive transfusion protocol utilizes an initial package consisting of the following:
  6 units PRBC’s
  4 units FFP
  1 apheresis unit of platelets
• Massive transfusion = 10 or more units of PRBC’s in 24 hours
• Massive transfusion Blood Bank phone number ext. 3-9895

 
6. Secondary Interventions

• Adequate anesthesia – choice depends on hemodynamic status and planned interventions
• Inspect cervix and vagina for lacerations
• Exclude uterine rupture
  Palpation of uterine cavity
  Ultrasound of the abdomen
• Remove retained POC — banjo curette or 16 mm suction catheter

 
7. Uterine tamponade

• Balloons – Bakri, BT- Cath
• Uterine Pack (Kerlex gauze)

 8. Arterial embolization

• Interventional radiologist – call radiology front desk  24/7 at 455-4536
• Hemodynamically stable

 9. Recombinant activated factor 7

• Intractable hemorrhage and coagulopathy
• Not much experience in obstetrics
• Increased risk of thromboembolism
• Hematology consult
• Dose 16.7 to 120 micrograms/kg as a single bolus over a few minutes every 2 hours until hemostasis is achieved
• Expensive (about $1 per microgram)

 
10. Laparotomy

• Midline vertical incision is usually preferred
• Aortic compression — temporary measure
• Uterine vessel ligation (O’Leary stitch)
• Uterine compression sutures (B-Lynch)
• Balloon tamponade
• Hypogastric artery ligation
• Hysterectomy
• Intraoperative blood salvage (only for "bring – back” bleeding, not primary c-section with amniotic fluid present) Call main OR 455-3232 to get technician for cell saver.
• Pelvic packing

 11. Delayed postpartum hemorrhage (24 hrs – 12 weeks postpartum)

• Von Willebrand’s disease 
• Uterine atony with retained POC with / without infection
• Subinvolution of the placental site 
• Uterine fibroids 
• Treatment is usually uterotonic agents, antibiotics, and curettage
• Choriocarcinoma of the uterus or vagina