8.2 Early postpartum haemorrhage

Early postpartum haemorrhage is defined as bleeding that occurs within 24 hours (usually immediately) after delivery of the placenta. The volume exceeds the normal 500 ml third stage blood loss.

Delay in treatment can lead to coagulation disorders, with a risk of massive, diffuse bleeding. Close delivery room monitoring is crucial for two hours postpartum, in order to rapidly identify and treat haemorrhage.

8.2.1 Possible causes

Uterine atony

The placenta has been expelled, but the uterus fails to retract. The uterus gets larger, extends, and becomes soft. Predisposing factors for uterine atony incude: overstretching, (polyhydramnios, multiple pregnancy, large foetus), prolonged labour, and infection (chorioamniotitis).

Obstetric trauma

Uterine rupture; cervical, vaginal and vulvar lacerations; episiotomy that is bleeding, uterine inversion.

Retained placenta

The entire placenta or a fragment of the placenta remains in the uterus.
In rare cases, it is impossible to remove the placenta manually because there is no cleavage plane between the placenta and the uterine wall (placenta accreta). In this event, refer for hysterectomy.

Coagulation disorders

Coagulation disorders may be the cause or the result of haemorrhage.
For diagnosis, see Chapter 3, Section 3.2.2.

8.2.2 Management during the first 30 minutes

Treatment is always the same, and performed immediately to avoid massive haemorrhage:

– Ask for help.

– Evaluate the heart rate, blood pressure, level of consciousness, oxygen saturation (if available), and blood loss (blood loss is easily underestimated, up to 50%), then monitor regularly.

– Insert two IV lines (catheter 16-18G), rapid fluid resuscitation with Ringer lactate or 0.9% sodium chloride (1 litre over 15 minutes).

– In anticipation of a blood transfusion, determine the patient’s blood type and select potential donors or make sure that blood is available. If transfusion is performed, the blood must have been tested (HIV-1, HIV-2, hepatitis B, hepatitis C and syphilis).

– Measure haemoglobin (HemoCue).

– High-flow oxygen therapy.

– If systolic blood pressure is < 90 mmHg, elevate the legs (keep, or replace, the patient's feet in the delivery table stirrups).

– Perform uterine massage to expel any clots and aid uterine contraction. In case of massive haemorrhage, maintain bimanual compression until uterotonics take effect.

– Make sure the uterus is empty: immediately remove the placenta manually if it has not yet delivered and/or manually explore the uterus.

– Administer routinely a uterotonic to correct uterine atony or ensure uterine retraction:
oxytocin: 5 to 10 IU by slow IV injection, and at the same time, start an IV infusion with 20 IU of oxytocin in 1 litre of Ringer lactate or 0.9% sodium chloride, to be administered over 2 hours (160 drops/minute).

– Insert a Foley catheter: keeping bladder empty facilitates uterine retraction.

– Inspect systematically the birth canal: check for injury to the cervix or vagina using retractors.

– Record in a chart: results of the initial evaluation, monitoring and actions, indicating the times.

8.2.3 Cause-specific management

Uterine atony

– Administer oxytocin: 5 to 10 IU by slow IV injection, and at the same time, start an IV infusion with 20 IU oxytocin in 1 litre of Ringer lactate or 0.9% sodium chloride, administered over 2 hours (160 drops/minute).
– Combine with uterine massage; maintain bimanual compression if bleeding is severe.
– If no effect within 15 minutes:
misoprostol sublingually: 800 micrograms2 and/or methylergometrine IM: 0.2 mg
– If no effect, insert a balloon for uterine tamponade (Appendix 2).

Obstetric trauma

Check routinely.

– Uterine rupture: Chapter 3, Section 3.3.
– Cervical or vaginal tears: Section 8.5.
– An episiotomy can bleed: temporarily stop arterial bleeding with a clamp and suture as quickly as possible.
– Uterine inversion: Section 8.4.

Retained placenta

– Immediate manual removal if the placenta has not yet delivered and/or routine uterine exploration to remove any clots or placental debris (allows good uterine retraction) and to verify that there was no uterine rupture (for vaginal deliveries with a scarred uterus, in particular).
– Perform manual placenta removal and manual uterine exploration under anaesthesia. Do not proceed without anaesthesia unless anaesthesia cannot be performed immediately.
– Give routine antibiotic prophylaxis (cefazolin or ampicillin slow IV1 : 2 g as a single dose).

Coagulation disorders

– Active management of the haemorrhage reduces the risk of secondary coagulation disorders.
– In the event of coagulation disorders, transfuse:
• fresh whole blood (blood freshly collected, for less than 4 hours, and that has not been refrigerated), or
• packed red blood cells or whole blood + fresh frozen plasma.

8.2.4 Management of persistent haemorrhage

– Maintain adequate haemodynamics: Ringer lactate up to 2 litres, then a plasma substitute and blood. The goals are systolic blood pressure ≥ 100 mmHg, oxygen saturation ≥ 95%, urine ouput ≥ 30 ml/hour, and normal level of consciousness.

– Insert a Bakri intrauterine balloon (Appendix 2). If the patient is still in a BEmONC facility, it is imperative to transfer her to a CEmONC facility once the balloon is inserted.

– Transfuse if blood loss is heavy (> 1500 ml), to achieve or maintain a haemoglobin level of at least 7 g/dl and/or if there are coagulation disorders. Blood or blood products must have been screened before transfusion (HIV-1, HIV-2, hepatitis B, hepatitis C and syphilis).

In the event of moderate haemorrhage with no coagulation disorder, transfuse packed red blood cells or whole blood.

In the event of massive haemorrhage and/or coagulation disorders, transfuse fresh whole blood or packed red blood cells or whole blood + fresh frozen plasma.

– Make sure that all procedures (manual placenta removal, uterine exploration, birth canal inspection, oxytocics, and urinary catheterisation) have indeed been performed.

– Additional measures:
• at a minimum, massage the uterus every 15 minutes for 2 hours,
plus, if needed, one of the following procedures:
• apply pressure to the abdominal aorta (just above the umbilicus) until the femoral pulse is no longer palpable, for example, the time it takes to insert a Bakri balloon or start laparotomy (Figure 8.2);
• compress the uterus with both hands through the abdominal wall, if it is still large and atonic;
• compress the uterus between fingers in the vagina and a hand on the abdomen (Figure 8.3);
• compress the uterus between the fist and a hand on the abdomen (Figure 8.4).

Figure 8.2 - Aortic compression

Figure 8.3 - Uterine compression through the vagina

Figure 8.4 - Uterine compression through the vagina

– Arrange transfer to a CEmONC facility for surgery if the situation is not controlled and for those who have required a Bakri balloon.

– Further surgical procedures might be:

• Conservative:
  - Stepwise ligation of the uterine blood supply (round ligaments, utero-ovarian arteries, uterine arteries);
  - Uterine compression suture (B-Lynch or other type suture)2 .

• Radical: hysterectomy with adnexal preservation. Subtotal hysterectomy is preferable, as it limits the operative time.

Note: after the acute episode, administer ferrous sulfate + folic acid PO for 3 months (Chapter 4, Section 4.1).

Ref Notes
1 For patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory problems or oedema): clindamycin IV, 900 mg as a single dose.

For more information on B-Lynch suture, see: A Comprehensive Textbook of Postpartum Hemorrhage 2nd  Edition. Section 9, Chapter 51: Therapy for Non-atonic Bleeding, C. B-Lynch and H. Shah. Conservative Surgical Management.