Advanced Life Support In Obstetrics (ALSO) – Postpartum Hemorrhage: Third Stage Pregnancy

All that follows is from The Advanced Life Support in Obstetrics (ALSO) Course Manual, Chapter J, published January 2013:

“Postpartum hemorrhage (PPH) can be classified as primary, within 24 hours of delivery, or secondary, which occurs 24 hours to 12 weeks postpartum. Primary PPH is more common than secondary PPH.”

“Even with appropriate management, approximately five percent of obstetric patients will experience PPH, and one percent of vaginal deliveries will result in severe PPH. PPH is the number one cause of maternal mortality in the developing world and is the cause of 25% of maternal death worldwide. It is the most common cause of maternal morbidity in high resource countries and is trending upward.”

“Risk factors include antepartum and intrapartum conditions as listed in Table 2. However, 20 percent of patients who develop postpartum hemorrhage have no risk factors, so providers must be prepared to treat it at every delivery.”

Table 2. Risk Factors for Postpartum Hemorrhage

“The best preventive strategy [for postpartum hemorrhage  prevention] is active management of the third stage of labor (AMTSL). This includes 1) administering oxytocin with, or soon after, the delivery of the anterior shoulder and 2) cutting the cord after a delay of one to three minutes, 3) controlled cord traction to deliver the placenta and 4) uterine massage after delivery of the placenta. To perform controlled cord traction, grasp the cord with one hand and gently apply traction while simultaneously applying suprapubic (NOT fundal pressure with the other hand [called the “Brandt manuever]).

 “Early definitions of AMTSL did not include transabdominal uterine massage after placental delivery, but it is a reasonable approach and is now included in some AMTSL.”

“Administration of a uterotonic drug is the most important step in reducing PPH. Oxytocin (IM or IV) is the preferred uterotonic agent for preventing PPH because it is at least as effective and has fewer side effects than the ergot alkaloids and prostaglandins.”

“Antenatally, patients who are at high risk for invasive placenta (such as prior uterine surgery, placenta previa, or coagulopathy) should have a sonogram. Women found to have invasive placenta and others at high risk of PPH should be delivered at a facility with blood bank, anesthesia, and surgical capabilities.”

“The diagnosis of PPH begins with recognition of excessive bleeding and methodical examination for its cause.”

Table 3. Mnemonic for the Specific Causes of PPH – The Four T

TONE

“Uterine atony is the most common cause of PPH. Because hemostasis following placental separation depends on myometrial contraction, transabdominal massage is recommended following every delivery. Atony unresponsive to transabdominal massage is treated initially by bimanual uterine massage while awaiting drugs that promote contraction of the uterus.”

TRAUMA 

“Lacerations and hematomas resulting from birth trauma can cause significant blood loss that can be lessened by hemostasis and timely repair. Sutures are placed if direct pressure does not stop the bleeding. Episiotomy increases blood loss as well as the risk of anal sphincter tears and should be avoided unless urgent delivery is necessary and the perineum is felt to be the limiting factor in achieving delivery.”

“Hematomas can present as pain or as a change in vital signs out of proportion to the amount of blood loss observed. Patients with persistent signs of volume loss despite fluid replacement, or with large or enlarging hematomas, require incision and evacuation of the clot. The involved area should be irrigated and the bleeding vessels ligated. Often a specific vessel cannot be identified and hemostatic figure of eight sutures are placed. Where there is diffuse oozing, a layered closure will help to secure hemostasis and eliminate dead space. Small, nonexpanding vaginal or vulvar hematomas (typically less than 5 cm) can be managed conservatively with ice packs, analgesia and continued observation.”

Uterine Inversion

“Uterine inversion is rare, occurring in about one in 2,500 deliveries. Active management of the third stage, including the Brandt maneuver, described above, does not appear to increase the incidence of uterine inversion. . . . The patient may show signs of shock (pallor, hypotension) without excess blood loss. Upon inspection, the inverted uterus may be in the vaginal vault or may protrude from the vagina, appearing as a bluish-gray mass that may not be readily identifiable as an inverted uterus. Roughly half the time, the uterus is still attatched and it should be left in place until reduction to limit hemorrhage. If oxytocin is running it should be stopped, and an attempt should be made to replace the uterus quickly. There are several methods for reduction. . . . [See YouTube videos at the end of this post.] Once the uterus is reverted, uterotonic agents should be given to promote uterine tone and prevent recurrence. If initial attemps to repllace the uterus have failed or a cervical contraction  ring develops, terbutaline, nitroglycerine, or general anesthesia may allow sufficient uterine relaxation for manipulation.”

Uterine Rupture

“Although rare in an unscarred uterus, clinically significant uterine rupture complicates approximately 0.8 percent of trials of labor after cesarean at term (TOLAC) at term. The risk is significantly increased in a women with previous classical uterine incisions or a myomectomy that goes completely through the uterine wall: these women should not have a trial of labor and should be delivered by elective cesarean at 37 to 38 weeks. . . . Compared to spontaneous labor, induction of a patient with a uterine scar increases the risk of uterine rupture to 1.0 to  1.5%. The use of prostaglandins for cervical ripening appears to be associated with an increased risk of uterine rupture. . . .”

“During labor, the first sign of uterine rupture is usually fetal heart rate changes such as fetal bradycardia. Other signs or symptoms include vaginal bleeding, abdominal tenderness, increasing abdominal girth, loss of uterine contractions, elevation of the presenting part, maternal tachycardia or circulatory collapse.”

“Uterine rupture can cause harm to both fetus and mother. Uterine rupture may require surgical repair of the defect, blood transfusion, or hysterectomy. Small asymptomatic lower uterine segment defects incidentally noted on postpartum uterine exploration can be followed expectantly. An Agency for Healthcare Research and Quality (AHRQ) -sponsored summary about trial of labor (TOL) found no maternal deaths from uterine rupture among patients with term pregnancies.”

“Although maternal morality is reduced by choosing TOLAC over ERCD, this choice is associated with increased fetal morality.”

TISSUE

Retained tissue (placenta, placental fragments, and blood clots) prevents the uterus from contracting enough to achieve optimal tone.

Retained Placenta

“A small gush of blood with lengthening of the cord and a slight rise of the uterus in the pelvis are classic signs of placental separation. Firm traction on the umbilical cord with one hand while the other applies suprapubic counter pressure (Brandt maneuver) typically achieves placental delivery. The mean time from delivery to placental expulsion is eight to nine minutes. A longer interval is associated with an increased risk of PPH, doubling after 10 minutes. Retained placenta, defined as the failure of the placenta to deliver within 30 minutes after birth, occurs in less than three percent of vaginal deliveries. Injecting the umbilical vein with saline and oxytocin (UVI) does not reduce the risk of retained placenta.” 

“If the placenta does not deliver after 30 minutes, manual removal of the placenta is necessary. If the patient is stable, taking time to establish adequate analgesia is strongly recommended. This will make the procedure easier to perform and will make the procedure easier to perform and will reduce the patient’s emotional and physical distress.”[See text, p. 14, for the procedure to remove the placenta]

“Invasive placenta can be life threatening. The incidence has increased to at least 0.04 percent of deliveries, likely related to the increase in cesarean section rates. Other risk factors include: prior invasive placenta, placenta previa (especially in combination with prior cesarean sections, increasing to 67 percent with four or more prior cesareans), advanced maternal age, and high parity.”

“Classification is based on the depth of invasion. Placenta acreta adheres to the myometrium, placenta increta invades the myometrium, and placenta percreta penetrates the myometrium to or beyond the serosa. The usual treatment for invasive placenta is hysterectomy.”

THROMBIN

“Coagulation disorders, a rare cause of PPH, are unlikely to respond to uterine massage, utertonics, and repair of lacerations. Coagulation defects may be the cause and/or the result of a hemorrhage and should be suspected in those patients who have not responded to the usual measures to treat PPH, are not forming blood clots, or are oozing from puncture sites.”

“Evaluation should include a platelet count, prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen level, and fibrin split products (d-dimer).”