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Hemorrhage after delivery, or postpartum hemorrhage, is the loss of greater than 500 ml of blood following vaginal delivery, or 1000 ml of blood following cesarean section. It is the most common cause of perinatal maternal death in the developed world and is a major cause of maternal morbidity worldwide.^[1]

Causes

Causes of postpartum hemorrhage are uterine atony, trauma, retained placenta, and coagulopathy, commonly referred to as the "four Ts":^[1]

• Tone: uterine atony is the inability of the uterus to contract and may lead to continuous bleeding. Retained placental tissue and infection may contribute to uterine atony.
• Trauma: trauma from the delivery may tear tissue and vessels leading to significant postpartum bleeding.
• Tissue: retention of tissue from the placenta or fetus may lead to bleeding.
• Thrombin: a bleeding disorder occurs when there a failure of clotting, such as with diseases known as coagulopathies.

Management

Medication

Intravenous oxytocin is the drug of choice for postpartum hemorrhage. Misoprostol may also be effective if oxytocin is not available.^[2]

Protocol

A detailed stepwise management protocol has been introduced by the California Maternity Quality Care Collaborative.^[3] It describes 4 stages of obstetrical hemorrhage after a delivery and its application reduces maternal mortality.^[4]

• Stage 0: normal - treated with fundal massage and oxytocin.
• Stage 1: more than normal bleeding - establish large-bore intravenous access, assemble personnel, increase oxytocin, consider use of methergine, perform fundal massage, prepare 2 units of packed red cells.
• Stage 2: bleeding continues - check coagulation status, assemble response team, move to operating room, place intrauterine balloon, administer additional uterotonics (misoprostol, carboprost tromethamine), consider: uterine artery embolization, dilatation and curettage, and laparotomy with uterine compression stitches or hysterectomy.
• Stage 3: bleeding continues - activate massive transfusion protocol, mobilize additional personnel, recheck laboratory tests, perform laparotomy, consider hysterectomy.

A Cochrane database study^[5] suggests that blood loss and the risk of postpartum bleeding will be reduced in women offered active management of the third stage of labour, rather than expectant management. However, the use of ergometrine for active management was associated with nausea or vomiting and hypertension, and controlled cord traction requires the immediate clamping of the umbilical cord.

See also

• Obstetrical hemorrhage

References