Birth Emergency Skills Training Postpartum Hemorrhage Written and Illustrated by Bonnie U. Gruenberg, CNM, MSN, CRNP, EMT-P All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or distributed in any form or by any means, electronic or mechanical (including photocopying, recording, and scanning), except as permitted under the 1976 United States Copyright Act, without the prior written permission of the publisher. Postpartum Hemorrhage • Cause of most maternal morbidity and mortality worldwide. • Can lead to shock, renal failure, acute respiratory distress syndrome, coagulopathy, Sheehan's syndrome, or death. Postpartum Hemorrhage Defined variously as • Symptomatic bleeding • EBL 500 ml after vaginal birth or 1,000 ml after cesarean • 10% decline in postpartum hemoglobin levels. In truth, PPH is best defined by clinician who decides blood loss is enough to warrant intervention. Risk Factors for PPH • • • • • • Prior PPH Uterine over-distention Shoulder dystocia Prolonged labor Episiotomy Instrumented delivery Be prepared for PHH at every delivery Hemorrhage? Get on TRAC: What causes hemorrhage? • T TRAUMA (20%) • R RETAINED products (10%) • A ATONY (>70%) • C COAGULATION defects (1%) Expectant Third Stage Management • Wait for placenta to separate. • Leave cord intact until stops pulsing. • Oxytocin or baby to breast after placenta delivers. Active Third Stage Management • Oxytocin with delivery of anterior shoulder or baby (or sometimes after placenta). • Cord clamping early (30 sec) or delayed (45-90 sec). • Controlled cord traction. • Uterine massage after placenta. Active 3rd Stage management encouraged • Recommended by obstetrical and midwifery organizations worldwide. • Shortens third stage, decreases PPH, does not increase retention of placenta. Timing of Cord Clamping • Research now supports delayed cord clamping (45-90 sec). – Decreases anemia in both full and preterm infants. – Decreases brain hemorrhage and respiratory distress syndrome in preterm infants. – Less risk of fetomaternal transfusion. Controlled Cord Traction • • • • • • • • • Clamp cord near introitus. Watch for signs of detachment. Grasp uterus just above the symphysis. With contraction, exert pressure upward and backwards. Encourage mother to push. Apply careful downward and backwards traction to cord. Tension initially light, gradually increased. If the placenta does not deliver after 30–40 seconds, wait for next contraction, repeat. Aggressive cord traction can cause uterine inversion or cord avulsion. Bleeding with placenta undelivered? • Use controlled cord traction and Brandt Andrews maneuver. • May give IV/IM oxytocin before placenta is out– doesn’t cause retained placenta. • May inject umbilical vein with 20 ml of a 0.9% saline containing 20–40 u of oxytocin. Manual Removal of Placenta If placenta not easily delivered or cord is avulsed: – Allow uterus to relax, insert hand. – Control fundus with opposite hand. – Remove placenta if it is in the lower segment. – Seek placental edge. – Use hand as a spatula, insert fingers into cleavage plane between placenta and uterus. – Gather placenta in your palm, remove intact. – If unsuccessful, transport for surgical removal. Uterine Atony • Most PPH due to uterine atony. • Assess tone while massaging uterus through abdominal wall. • Give oxytocin 20–40 units in 1 liter of NS at 10–15 ml/min rapidly, or 10 units IM. • Empty bladder with catheter. • Express clots or manually remove clots from the vagina, cervix, and lower uterine segment. Grasp the uterus through the abdominal wall with your two hands and knead firmly. Bimanual Compression for Uterine Atony • Insert entire hand in the vagina, in the anterior fornix and make a fist. • Grasp fundus with your other hand and bend it onto the fist that is inside vagina. • Compress uterus between your hands to remove clots and stimulate contraction. Bimanual Compression • 10 minutes of compression usually decreases bleeding even if atony persists. • May control bleeding from ruptured uterus. • Alternatively, may grasp uterus with hands through abdomen and compress for 10 minutes. Aortic Compression • Useful if hemorrhage is severe and hospital is distant. • Place fist on maternal abdomen with index finger at umbilicus and knuckles in line with spine. • Compress aorta against spine. You will feel pulse under your fist. • Palpate for femoral pulse with your opposite hand. Compress until the femoral pulse disappears. • If womans’s legs become tingly, release pressure to allow some perfusion, then resume. Medications: Ergot alkaloids • Methylergonovine (Methergine), ergometrine, and ergonovine cause tetanic uterine contraction. • Give 0.2 mg IM, may repeat q 2– 4 h. • May cause nausea and vomiting, hypertension . • Contraindications: Hypertension and preeclampsia . Prostaglandins • IM carboprost (Hemabate) 250 mcg repeat q 15 m to max 8 doses. – Vasoconstricts and stimulates contraction. – Side effects include vomiting, diarrhea. – Use with caution in asthma and hypertension. • Misoprostil – Up to 1,000 mg rectally, 200 mcg orally. For prevention 600 orally postpartum. – Side effects fever, nausea, and diarrhea. Retained Tissue • Inspect the placenta for missing fragments or lobes. • If hemorrhage continues despite compression and uterotonics, enter uterus to remove clots, membrane, and retained tissue. • Try wrapping gauze around one hand and gently sweeping uterus. • Adherent placental fragments may require D&C in hospital. Examine for missing fragments A succenturiate lobe may remain in the uterus after the rest of the placenta delivers, causing hemorrhage. Tissue Trauma • Likely if bleeding persists despite well-contracted uterus. • Inspect genital tract from perineum to cervix. • Palpate uterine cavity for evidence of uterine rupture. • Apply pressure to bleeding laceration - suture the wound if direct pressure does not stop bleeding. Cervical Lacerations – Insert a speculum. – Grasp anterior cervix with ring forceps. – Place a second ring forceps at the 2o'clock position, and systematically place one forceps ahead of the next, proceeding around the circumference. – Suture cervical lacerations only if they are actively bleeding. – If you cannot find apex, place stitch high and sew proximally, using traction on suture line to pull apex into view. Hematomas • May occur with or without laceration. • Causes intense pain and localized, tender swelling, tachycardia and hypotension. • Broad ligament hematomas are palpable as mass adjacent to the uterus. • Expanding hematomas require incision and drainage. Coagulopathy • Continued bleeding but no clotting. • Bruising, petechiae, bleeding from puncture sites, nose, mouth, GI tract, and vagina. • Caused by clotting disorders, HELLP or DIC. Disseminated Intravascular Coagulation (DIC) • Causes simultaneous uncontrolled bleeding and clotting. • May lead to stroke, myocardial infarction, end-organ dysfunction, shock, death. • In hospital treatment includes treating the cause and transfusion of blood products or injection of heparin. DIC Causes. – Severe blood loss. – Amniotic fluid embolism. – Abruption. – Sepsis. – Retained fetal demise. – Trauma. DIC OOH treatment. • Rapid transport with EMS. • Bilateral large-bore IVs of lactated ringers or normal saline. • Minimize skin punctures. • Draw blood. • Oxygen. • Left lateral flat positioning. • Frequent reassessment of vital signs, fetal heart tones, uterine tone, bleeding. Invasive Placenta • Placenta invades beyond normal cleavage plane. – Into uterine wall (placenta accreta). – Into uterine muscle (placenta increta). – Through uterine wall (placenta percreta). • Life-threatening hemorrhage occurs when provider attempts manual removal of placenta. Uterine Inversion • Uterus turns inside out and protrudes. – Through cervical os (incomplete). – Into vagina (complete). – Beyond the vulva (prolapsed). • Very rare, more common in multiparous women. • May result from attendant pulling on cord. • Presents with shock and lifethreatening hemorrhage. Uterine Inversion – Replace uterus without removing the placenta with palm pressing from inside the uterus. – After replacement, give uterotonic medications. – Surgical replacement or hysterectomy may be necessary. Late Postpartum Hemorrhage • Excessive bleeding 24 hr to 12 weeks postpartum. • From subinvolution, retained products, infection, diffuse atony. • Not usually as heavy as that immediate PPH. Postpartum Hemorrhage Priorities • Get help. • • • • • • • • • • • • ABCs. Fundal massage. Trendelenberg positioning. Uterotonics. Treat for shock. Remove retained products. Repair traumatic bleeding. Oxygen 10 liters by nonrebreather mask. Large bore IVs of rapidly infusing crystalloid. Baseline labs—CBC, PT, PTT fibrinogen. Insert Foley. Rapid transport if unstable. PPH – “DAMIT” to dam the flow of blood • D Deliver placenta. • A Aggressively massage uterus. Assess for retained products, coagulopathy and trauma. • M Meds — oxytocin, methylergonovine or prostaglandins. • I IV, shock positioning, oxygen, bimanual compression. • T Transport rapidly. First Thought, Worst Thought: • What is the most likely cause of postpartum hemorrhage? – Atony. • What is the worst it could be? – Uncontrollable hemorrhage, DIC, shock. The advice and strategies presented herein are not intended for use by nonprofessionals, may not be appropriate for every situation, and should not be used outside the applicable protocol or scope of practice. Neither the author nor the publisher shall have any liability to any person or entity with respect to any loss or damage caused or alleged to be caused directly or indirectly by the information presented.