Postpartum haemorrhage (PPH) is a complication, which can occur
with both vaginal and caesarean
delivery. Since studies have revealed
that even in an uncomplicated delivery there might be blood loss of
more than 500 mL without any threat to the mother's condition, the
traditional definition that PPH was blood loss greater than 500 mL in a
vaginal delivery and greater than 1,000 mL in a caesarean delivery was
modified into a broader definition. It is now defined as any
bleeding that results in signs and symptoms of hemodynamic instability,
or bleeding that could result in hemodynamic instability if untreated.PPH
may also be considered as blood loss greater than 1,000 mL in a vaginal
delivery or a decrease in postpartum hematocrit level greater than 10%
of the prenatal value. PPH can be divided into early PPH,
occurring within 24 hours after delivery, and late PPH occurring 24
hours to 6 weeks after delivery.Causes 1.
Uterine atony is the most frequent cause of PPH.2. Lacerations of the cervix and/or vagina are the second most frequent causes.3. Placental retention (complete or partial). 4. Coagulation disorders and thrombocytopenia (pre-existing or occurring during the second or third
stage of labour).5. Trauma during delivery resulting in haematomas in the perineum or pelvis. 6. Uterine inversion.7.
Uterine rupture. This may be associated with slight vaginal bleeding,
but is considered in the presence of severe abdominal pain and unstable
hemodynamic findings. The risk factors for PPH include the
following: prolonged third stage of labour, preeclampsia, mediolateral
episiotomy, previous history of PPH, multiple gestation, arrest of
descent, maternal hypotension, coagulation abnormalities, Asian or
Hispanic ethnicity, forceps or vacuum delivery, augmented labour,
nulliparity, multiparity, and polyhydramnios. Treatment:Resuscitative
measures:These include administration of 100% oxygen, placing several
intravenous lines with large-bore catheters and infusion of crystalloid
solutions (isotonic sodium chloride or Ringer lactate solution warmed,
if possible) and monitoring cardiac function, blood pressure, pulse,
and pulse oximetry. Typing and cross matching of packed red blood cells
for transfusion is done. Type-specific blood may be needed if the
patient is in a critical condition. Blood warmers permitting rapid
infusion are preferred in unstable patients.
Active Management of the Third Stage of Labor:Most
cases of PPH occur during the third stage of labor, wherein the uterine
muscles contract and the placenta begins to separate from the uterine
wall. The third stage typically lasts between 5-15 minutes. The third
stage of labor is considered to be prolonged if it continues for more
after 30 minutes. Uterine atony causes inadequate constriction of the
blood vessels at the placental site resulting in severe bleeding.
Active management of the third stage of labor involves methods to speed
the delivery of the placenta by increasing uterine contractions and to
prevent PPH by averting uterine atony. These comprise:1. Use of
oxytocic agents, including oxytocin, ergonovine, methylergonovine, and
prostaglandin, to stimulate uterine contraction and control haemorrhage
a. Oxytocin (Pitocin) is given at a dose of 10-40 units IV in 1000 mL of IV fluid at a rate high enough
to control uterine atony. Syntometrine (ergometrine combined with
oxytocin) appears to be even more effective than oxytocin alone b. Ergonovine (Ergotrate Maleate) is given at a dose of 0.2 mg IM/IV; repeat q2-4h prn. c. Methylergonovine (Methergine) is given at a dose of 0.2 mg IM/I; repeat q2-4h if required.d. Prostaglandins also are effective in controlling bleeding, but are generally more expensive and have many side effects.Carboprost (Hemabate) – is a prostaglandin given at a dose of 250 mcg IM q15-90 min. Misoprostol
(Cytotec) is a synthetic analog of prostaglandin E. Several studies
have suggested that 400 to 600 mcg ofmisoprostol may be as effective
in reducing postpartum hemorrhage as oxytocin or syntometrine. 2.
Clamping and cutting the umbilical
cord soon after delivery- in active
management of the third stage of labor, the umbilical cord is
immediately clamped and cut following delivery to allow other active
management interventions. 3. Controlled cord tension- this
involves gentle pulling of the cord downwards during a uterine
contraction, and simultaneously putting pressure on the
uterus by
pushing on the abdomen just above the pubic bone. This aids in
placental separation from the uterus and in its delivery. 4.
Other measures: direct pressure over lacerations in the perineum,
cervix, vagina, or uterus may help control bleeding. In extreme cases,
the uterus can be packed with gauze, although it is not usually
recommended. Sometimes, despite all measures, the bleeding might
continue. Checking the placenta might reveal missing placental tissue,
which may still be adherent to the uterine wall causing excessive
bleeding. This may be removed by gently sweeping the inner wall of the
uterus with gauze wrapped around the hand or with the use of an
instrument. If uterine inversion occurs, the uterus can be gently
pushed back into position. Fresh frozen plasma or a platelet
transfusion may be considered if the patient has coagulopathy or
thrombocytopenia, respectively. An emergency laparotomy may be required
in case of uterine rupture. Conclusion: PPH can be
considered as a potentially life threatening emergency. The most common
cause of PPH is uterine atony. The management includes immediate
resuscitative measures and active management of the third stage of
labour like use of oxytocic agents, cord clamping and cutting,
controlled cord tension, and other measures like transfusion, removal
of retained placenta etc.
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