1. Postpartum Hemorrhage Anuradha Perera (B.Sc.N)special

2. Goals of talk w Definition w Rapid diagnosis and treatment w Review risks

3. Definition w Mean blood loss with vaginal delivery: 500ml w Seen in ~5% of deliveries.

4. Early vs. Late w Most authors define early as < 72h. w ALSO defines it as <24h. w Late hemorrhage is more likely due to infection and retained placental tissue.

5. Prenatal Risk Factors w Pre-eclampsia,PIH w Previous postpartum hemorrhage w Multiple gestation w Previous C/S w Multiparity w Polyhydroamniosis

6. Intrapartum Risk Factors w Prolonged 3rd stage (>30 min) w medio-lateral episiotomy w midline episiotomy w Arrest of descent w Lacerations w Augmented labor w Forceps delivery

7. Easy to miss w Physicians underestimate blood loss by 50% w Slow steady bleeding can be fatal w Most deaths from hemorrhage seen after 5h w Abdominal or pelvic bleeding can be hidden

8. Always look for signs of bleeding w Estimate blood loss accurately. w Evaluate all bleeding, including slow bleeds. w If mother develops hypotension, tachycardia or pain…rule out intra-abdominal blood loss.

9. Initial Assessment w Identify possible post partum hemorrhage. w Simultaneous evaluation and treatment. w Remember ABCs. w Use O2 4L/min. w If bleeding does not readily resolve, call for help. w Start two 16g or 18g IVs.

10. ALSO’s 4 Ts w Tone (Uterine tone) w Tissue (Retained tissue--placenta) w Trauma (Lacerations and uterine rupture) w Thrombin (Bleeding disorders)

11. “Tone: Think of Uterine Atony” w Uterine atony causes 70% of hemorrhage w Assess and treat with uterine massage w Use medication early w Consider prophylactic medication...

12. Bimanual Uterine Exam w Confirms diagnosis of uterine atony. w Massage is often adequate for stimulating uterine involution.

13. Medications for Uterine Atony w 1. Oxytocin promotes rhythmic contractions. w 2 Urgometrine

14. Tissue: Retained placenta w Delay of placental delivery > 30 minutes seen in ~ 6% of deliveries. w Prior retained placenta increases risk. w Risk increased with: prior C/S, curettage p- pregnancy, uterine infection, or increased parity. w Prior C/S scar & previa increases risk (25%) w Most patients have no risk factors. w Occasionally succenturiate lobe left behind.

15. Abnormal Placental Implantation w Attempt to remove the placenta by usual methods. w Excess traction on cord may cause cord tear or uterine inversion. w If placenta retained for >30 minutes, this may be caused by abnormal placental implantation.

16. Abnormal implantation defined. w Caused by missing or defective decidua. w Placenta Accreta: Placenta adherent to myometrium. w Placenta Increta: myometrial invasion. w Placenta Percreta: penetration of myometrium to or beyond serosa. w These only bleed when manual removal attempted.

18. Removal of Abnormal Placenta w Oxytocin 10U in 20cc of NS placed in clamped umbilical vein. w If this fails, get OB assistance. w Check Hct, type & cross 2-4 u. w Two large bore IVs. w Anesthesia support.

19. Removal of Abnormal Placenta w Relax uterus with halothane general anesthetic and subcutaneous terbutaline. w Bleeding will increase dramatically. w With fingertips, identify cleavage plane between placenta and uterus. w Keep placenta intact. w Remove all of the placenta.

21. Removal of Abnormal Placenta w If successful, reverse uterine atony with oxytocin, Methergine, Hemabate. w Consider surgical set-up prior to separation. w If manual removal not successful, large blunt curettage or suction catheter, with high risk of perforation. w Consider prophylactic antibiotics.

22. Trauma (3rd “T”) w Episiotomy w Hematoma w Uterine inversion w Uterine rupture

23. Uterine Inversion w Rare: ~1/2000 deliveries. w Causes include: w Excessive traction on cord. w Fundal pressure. w Uterine atony.

24. Uterine Inversion w Blue-gray mass protruding from vagina. w Copious bleeding. w Hypotension worsened by vaso-vagal reaction. Consider atropine 0.5mg IV if bradycardia is severe. w High morbidity and some mortality seen: get help and act rapidly.

25. Uterine Inversion w Push center of uterus with three fingers into abdominal cavity. w Need to replace the uterus before cervical contraction ring develops. w Otherwise, will need to use MgSO4, tocolytics, anesthesia, and treatment of massive hemorrhage. w When completed, treat uterine atony.

27. Uterine Rupture w Rare: 0.04% of deliveries. w Risk factors include: w Prior C/S: up to 1.7% of these deliveries. w Prior uterine surgery. w Hyperstimulation with oxytocin. w Trauma. w Parity > 4.

28. Uterine Rupture w Risk factors include: w Epidural. w Placental abruption. w Forceps delivery (especially mid forceps). w Breech version or extraction.

29. Uterine Rupture w Sometimes found incidentally. w During routine exam of uterus. w Small dehiscence, less than 2cm. w Not bleeding. w Not painful. w Can be followed expectantly.

30. Uterine Rupture before delivery w Vaginal bleeding. w Abdominal tenderness. w Maternal tachycardia. w Abnormal fetal heart rate tracing. w Cessation of uterine contractions.

31. Uterine Rupture after delivery w May be found on routine exam. w Hypotension more than expected with apparent blood loss. w Increased abdominal girth.

32. Uterine Rupture w When recognized, get help. w ABCs. w IV fluids. w Surgical correction.

33. Birth Trauma w Lacerations of birth tract not rare: causes post partum hemorrhage in 1/1500 deliveries.

34. Birth Trauma w Risk factors include: w Instrumented deliveries. w Primiparity. w Pre-eclampsia. w Multiple gestation. w Vulvovaginal varicosities. w Prolonged second stage. w Clotting abnormalities.

35. Birth Trauma w Repair lacerations quickly. w Place initial suture above the apex of laceration to control retracted arteries.

36. Repair of cervical laceration

37. Birth Trauma: Hematomas w Hematomas less than 3cm in diameter can be observed expectantly. w If larger, incision and evacuation of clot is necessary. w Irrigate and ligate bleeding vessels. w With diffuse oozing, perform layered closure to eliminate dead space. w Consider prophylactic antibiotics.

38. Pelvic Hematoma

39. Vulvar hematoma

40. Thrombin (4th “T”) w Coagulopathies are rare. w Suspect if oozing from puncture sites noted. w Work up with platelets, PT, PTT, fibrinogen level, fibrin split products, and possibly antithrombin III.

41. Prevention? w Some evidence supports use of oxytocin after delivery of anterior shoulder, in umbilical vein or IV.

42. Summary: remember 4 Ts w Tone w Tissue w Trauma w Thrombin

43. Summary: remember 4 Ts w “TONE” w Rule out Uterine Atony w Palpate fundus. w Massage uterus. w Medications

44. Summary: remember 4 Ts w “Tissue” w retained placenta w Inspect placenta for missing cotyledons. w Explore uterus. w Treat abnormal implantation.

45. Summary: remember 4 Ts w “TRAUMA” w cervical or vaginal lacerations. w Obtain good exposure. w Inspect cervix and vagina. w Worry about slow bleeders. w Treat hematomas.

46. Summary: remember 4 Ts w “THROMBIN” w Check labs if suspicious.

47. Case 1. w Healthy 32 yo G2P1. w Augmented vaginal delivery, no tears. w Nurse calls you one hour after delivery because of heavy bleeding. w What do you do? w What do you order?

48. Case 2 w 26 yo G4 now P4. w NSVD, with help from medical student. w You leave the room to answer a page while waiting for placenta to deliver, but are called back overhead, stat. w Huge blood clot seen in vagina. w What is this, and what do you do next?