Postpartum hemorrhage

Postpartum hemorrhage

  • Blood loss ≥ 1L OR blood loss ➔ hypovolemia OR ssx of hypovolemia

  • Primary PPH (MC): within 24hrs postpartum

  • Secondary PPH: within 24hrs to 12wks postpartum


    • B/l large bore IV access

    • Empty bladder (straight cath or foley)

    • Ensure bleeding is not vaginal or incisional

    • Assess uterine tone, rupture, retained POC tissue

    • Assess for uterine inversion (round mass protruding from cervix) ➔ immediate manual uterine repositioning

  • First: Uterine external compression and bimanual uterine massage

  • First line med: Oxytocin (40 units in 1L NS via IV or 10 units via IM)

    • Continued bleeding:

      • Carboprost tromethamine IM q15mins up to 8 times (CI in asthmatic pts)

      • Methylergonovine IM q2-4hrs (CI in HTN, coronary/cerebral artery dz, Raynaud's)

      • Misopristol (rectal or buccal)

    • Continued bleeding >1.5L: Administer tranexamic acid, massive transfusion protocol

Uterine atony

  • MCC of PPH

  • Uterus fails to contract after placenta delivers ➔ myometrial (spiral arteries) bleeding

  • Risk factors: Muliparity, prolonged delivery, abnormal placental implantation, leiomyomas, chorioamnionitis

Retained placental tissue

  • TX with manual removal of placental tissue, surgery if unsuccessful

Ruptured uterus

  • Risk factors: Previous C-section, macrosomia, multiple gestations, maternal age >35yo, too much oxytocin

  • SSX are severe ABD pain, may palpate fetal parts, fetal distress, loss of fetal station

  • TX is emergency C-section

Perineal lacerations

  • 1st°: Superficial injury to vaginal mucosa ± perineal skin

  • 2nd°: Involves perineal body

  • 3rd°: Involvement of anal sphincter

    • 3rd° A: <50% anal sphincter torn

    • 3rd° B: >50% anal sphincter torn

    • 3rd° C: External and internal anal sphincters torn

  • 4th°: Involvement of rectal mucosa

  • 3rd and 4th° lacerations are obstetric anal sphincter injuries (OASIS)