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Literature Review

Risk Factors, Preventive Measuresand Managing for Primary

Postpartum Hemorrhage.

Reda Mohamed Nabil Aboushady&Amel Dawod Kamel

Department of Maternity and Newborn Health Nursing, Faculty of Nursing, Cairo University

Egypt.

Corresponding author’s email: dawod_m3@yahoo.com

Abstract

One of the millennium development goals set by the United Nations is to reduce maternal

mortality by three quarters by 2015. The achievement of this goal must focus on understanding

the dynamics of them causes of maternal mortality and removing such causes. Postpartum

hemorrhage (PPH) is a major cause of perinatal morbidity and mortality worldwide. This paper

highlights currently risk factors and preventive measure for managing PPH. View their

prevalence of PPH, causes and risk factors, pathophysiology, signs and symptoms, clinical

examination, diagnosis, prognosis, complications and adverse outcomes from PPH. Finally,

management, nursing responsibility for women anticipating PPH and prevention measures of

PPH.

Key words: Primary Postpartum Hemorrhage (PPH), Risk Factors, Preventive Measure.

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List of content

No Items Page

1- Introduction. 4

2- Magnitude of the problem. 4

3- Conceptual framework. 6

4- Definition of postpartum hemorrhage (PPH). 7

5- Prevalence of postpartum hemorrhage (PPH). 9

6- Causes and risk factors.

11

7- Pathophysiology. 17

8- Signs and symptoms. 18

9- Clinical examination of postpartum hemorrhage

(PPH).

19

10- Diagnosis of postpartum hemorrhage (PPH). 20

11- Prognosis of postpartum hemorrhage (PPH). 20

12- Complications and adverse outcomes from PPH. 21

13- Management of postpartum hemorrhage (PPH). 21

14- Nursing Responsibility for Women Anticipating

PPH

32

15- Prevention of postpartum hemorrhage (PPH). 35

16- References. 39

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List of Tables

No Items Page

1- Summary of postpartum hemorrhage definitions. 8

2- Summary of risk factors for PPH 16

List of Figures

No Items Page

1- Recommended treatment algorithm for the

treatment of PPH

24

2- Uterine massage 26

3- Bimanual compression 27

4- Administering PF2α 28

5- Balloon Tamponade 29

6- B-Lynch compression suture 30

7- Uterine artery ligations 31

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Introduction

Gynecologic hemorrhage represents excessive bleeding of the female

reproductive system. Such bleeding could be visible or external, namely bleeding

from the vagina, or it could be internal into the pelvic cavity or form a hematoma.

Hemorrhage associated with a pregnant state or during delivery is an obstetrical

hemorrhage. All women lose some blood as the placenta separates from the uterus

and immediately afterward. Women who have C-sections generally lose more than

those who give birth vaginally. But because the amount of blood in your body

increases by almost 50 percent during your pregnancy, your body is well prepared

to deal with this expected blood loss. Normal just after childbirth is primarily from

open blood vessels in the uterus, where the placenta was attached. As the placenta

begins to separate, these vessels bleed into the uterus. After the placenta is

delivered, the uterus usually continues to contract, closing off these blood vessels

(Fridman & Korst, 2005). Primary postpartum hemorrhage (PPH) remains an

important complication of child birth and contributes significantly to maternal

mortality. PPH is the direct cause of maternal deaths and is a major contributor

factor in a further 5 fatalities. The reported incidence of PPH in UK varies from

4% to 11%. In USA a reasonable consensus of 1% -10% of pregnancies is

complicated by PPH, with the actual number range of 2-4% (Michael & Wainscott,

2006).

Magnitude of the problem

Death as a result of pregnancy remains the main cause of premature mortality

worldwide (Fawcus et al., 1995). Every year, 536,000 women die as a result of

complications during pregnancy, childbirth and /or postpartum period. This

https://en.wikipedia.org/wiki/Female_reproductive_systemhttps://en.wikipedia.org/wiki/Female_reproductive_systemhttps://en.wikipedia.org/wiki/Vaginahttps://en.wikipedia.org/wiki/Hematomahttps://en.wikipedia.org/wiki/Pregnancyhttps://en.wikipedia.org/wiki/Childbirthhttps://en.wikipedia.org/wiki/Obstetrical_hemorrhagehttps://en.wikipedia.org/wiki/Obstetrical_hemorrhage

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amounts to one death every minute with an estimated quarter of these deaths

occurring as a consequence of hemorrhage (World Health Organization{WHO},

2007; Millennium Development Goals Report, 2009). PPH is a major cause of

maternal morbidity and mortality worldwide. The traditional definition of PPH

used in most textbooks is sequence of hemorrhage (WHO, 2012) excessive

bleeding from the genital tract after delivery of a child and it could be primary or

secondary. It is primary when there is a blood loss of 500 ml or more within the

first twenty four hours after child birth and secondary if the excessive loss of blood

occurred at any time after first day to 42 days of puerperium.

The incidence of PPHis about 1 in 5 pregnancies, in the developing world,

several countries have maternal mortality rates in excess of 1000 women per

100,000 live births, and WHO statistics suggest that 25% of maternal deaths are

due to PPH, accounting for more than 100,000 maternal deaths per year

(Abouzahr, 1998). Increasing incidence of PPH over the years, imbalance between

resource-rich and resource-poor areas are probably due to a combination of

increased prevalence of risk factors such as grand multiparty, lack of safe blood

banking, non-routine use of prophylaxis against hemorrhage, and lack of measures

for drug and surgical management of a tony are all rate of 2.8%, again with the

highest rate in Africa (5.1%).Although accountable for only 8% of maternal deaths

in developed countries, postpartum hemorrhage is the second leading single cause

of maternal mortality, ranking behind preeclampsia/ eclampsia.

Globally, postpartum hemorrhage is the leading cause of maternal mortality.

The condition is responsible for 25% of delivery-associated deaths, and this figure

is as high as 60% in some countries (Mininoetal., 2007). International initiatives to

improve outcomes have invested in training birth attendants (traditional or

otherwise) and nurse midwives on the active management of the third stage of

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labor (the period immediately after delivering of the infant). Most efforts focus on

uterine a tony, which is the primary cause of PPH. This has included education on

manual techniques to increase uterine contraction-retraction and making

pharmacologic uterotonic agents as (oxytocin and misoprostol) more available

postpartum hemorrhage is a potentially life-threatening complication of both

vaginal and cesarean delivery. Associated morbidity is related to the direct

consequences of blood loss as well as the potential complications of haemostatic

and resuscitative interventions (Miller, Lester &Hensleigh, 2004; USAID, 2008).

1) - Conceptual framework

The theoretical framework for primary postpartum hemorrhage is the

nursing process according to NANDA (North American Nursing Diagnosis

Association, 1982), as it used as clinical judgment to strike a balance of

epistemology between personal interpretation and research evidence in which

critical thinking may play a part to categorize the women issue and course of

action. It encourages nurses with orderly thought, analysis, and planning when

working with women and deciding on what care needs must be met. There are five

steps in the nursing process; Assessment, Diagnosis, Planning, Implementation,

and Evaluation. Nurse’s use critical thinking in each of the steps involved in order

to solve problem, make decisions, and/or collaborate with other disciplinary team

members in providing patient care. Once a nurse has identified the needs of the

patient, the nurse is better equipped to create a nursing care plan that will meet

health goal.

Nursing process is the frame work for providing professional, quality

nursing care; it directs nursing activities for health promotion, health protection

and disease prevention and is used by nurses in every practice setting and

specialty.

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2)–Definition of Postpartum hemorrhage (PPH)

There is no single definition of PPH exists and a number of definitions are

currently in use worldwide. The definition of obstetric hemorrhage varies widely

in the literature. The severity of PPH will be influenced by the rate and the total

volume of blood loss and also the response to treatment.According to the World

Health Organization (WHO) PPHis defined as a blood loss of 500 ml or more

within 24 hours after birth.

Blood loss of more than 500 ml for vaginal delivery and more than 1000 ml

for caesarean section are considered abnormal (Wise& Clark, 2008; Society of

Obstetricians and Gynecologists of Canada (SOGC), 2009). Additional

resources should be mobilized if blood loss exceeds 1500 ml. A practical definition

of major obstetric hemorrhage includes:

(1) An estimated blood loss of 2500 ml or more, (2) Transfusion of five or more

units of blood or

(3) Treatment for coagulopathy. Arias, (2005) found that, the average blood loss

following vaginal delivery and cesarean section was aproximately500-100ml,

respectively. It follows that postpartum hemorrhage should exceed significantly

that number. The problem is that the estimation of blood loss at delivery is

notoriously inaccurate because it is based on the visual observation of obstetrician

rather than on any objective measurement. In a recent study a hematocrit change of

10% or need for red blood cell transfusionwas adopted as a definition of

postpartum bleeding. This definition has multiple advantages and should be

universally accepted.

Williams 23rd

Edition, (2010) “Traditionally, postpartum hemorrhage has been

defined as the loss of 500 mL of blood or more after completion of the third stage

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of labor. This is problematic because half of all women delivered vaginally shed

that amount of blood or more when losses are measured quantitatively”.

According to UK Royal College of Obstetricians and Gynecologists, (2009),

Primary PPH defined as; estimated blood loss of 500-1000 mL in the absence of

clinical signs of shock and Severe PPH defined as, estimated blood loss of >1000

mL or clinical signs of shock or tachycardia with a smaller estimated loss.

According to Rath, (2011)PPH is commonly defined as blood loss exceeding

500 mL following vaginal birth and 1000 mL following cesarean. Definitions vary,

however, and are often based on inaccurate estimates of blood loss. Moreover,

average blood loss at birth frequently exceeds 500 or 1000 mL. PPH is frequently

classified as primary/immediate/early, occurring within 24 hours of birth, and

secondary/delayed/late, occurring more than 24 hours post-birth to up to 12 weeks

postpartum. In addition, PPH may be described as third or fourth stage depending

on whether it occurs before or after delivery of the placenta respectively (Schorn,

2010).

Table (1) Summary of PPH definitions

Clinical Aspects Definitions

Blood loss volume

Traditional definitions of PPH include:

A blood loss in excess of 500 mL (WHO, 2009; SOGC),

2009)after vaginal birth.

A blood loss in excess of 1000 mL (WHO, 2009) after

caesarean section (CS)

Severe PPH is used to describe a blood loss greater than or

equal to 1000mL(Begley et al., 2011).

Very severe(Begley et al., 2011) PPH are used to describe

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a blood loss of greater than 2500 mL

Hemodynamic

compromise

Due to frequent underestimation of blood

loss(Moussa&Alfirevic, 2007).PPH may first be detected

through hemodynamic compromise.

Manifests as increasing tachycardia and hypotension

• A healthy pregnant woman will only show mild signs of

shock after a blood loss of 1000 mL

• Conversely, compromise may occur earlier in women

with (SOGC, 2009): Gestational hypertension with

proteinuria- anemia- dehydration and small stature (Royal

Australian and New Zealand College of Obstetricians and

Gynecologists (RANZCOG), 2011).

Hematocrit

PPH can be retrospectively diagnosed by a 10% decline in

postpartum hematocrit levels(ACOG, 2006).

Blood transfusion

The Australian Council on Healthcare Standards, (2012)

indicator for PPH isblood transfusion required after a

massive blood loss equal to or greater than 1000 mL or in

response to a postpartum hemoglobin (Hb) of less than 80

g/L.

Secondary

Secondary PPHis outside the scope of this guideline as it

refers to excessive bleeding that occurs between 24 hours

post birth and 6 weeks postnatal (RANZCOG, 2011).

3)-Prevalence of postpartum hemorrhage (PPH)

Worldwide the overall prevalence of PPH is estimated to be 6 to 11 percent

(Calvert et al., 2012).Rates vary by data source and country as well as assessment

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method with a prevalence of 10.6 percent when measured by objective appraisal of

blood loss and 7.2 percent when assessed with subjective techniques(Carroli et al.,

2008).A systematic review estimated prevalence of PPH with 500 mL of blood loss

or more at 10.5 percent in Africa, 8.9 percent in Latin America and the Caribbean,

6.3 percent in North America and Europe, and 2.6 percent in Asia(Carroli et al.,

2008).

Another systematic review was higher, with similarly wide regional

variation: 26 percent in Africa, 13 percent in North America and Europe, and 8

percent in Latin America and Asia(Calvert et al., 2012).The prevalence of PPH

with 1000 mL blood loss or more was considerably lower in both reviews with

overall estimates of 1.9 to 2.8 percent(Carroli et al., 2008; Calvert et al., 2012). In

spite of lower estimates for PPH in developed countries compared with developing

countries, several studies have noted an increase in PPH in high-resource regions

(Rossen et al., 2010; Lutomski et al., 2012; Mehrabadi et al., 2012; Mehrabadi et

al., 2013).In the United States, the prevalence of PPH rose from 2.3 percent in

1994 to 2.9 percent in 2006, a 26 percent increase(Callaghan, Kuklina&Berg,

2010). Defining PPH has historically been difficult. Waiting for a patient to meet

PPH criteria, particularly in resource-poor settings or in cases of sudden

hemorrhage, may delay appropriate intervention. Any bleeding that has the

potential to result in hemodynamic instability, if left untreated, should be

considered PPH and managed accordingly. PPH can be divided into 2 types: early

(< 24 hours after delivery) and late (24 hours to 6 weeks after delivery). Most cases

of PPH (>99%) are early.

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4) - Causes and risk factors

According to Royal College of Obstetricians and Gynecologists, (2009)the

most common causes of PPH is uterine atony (impaired uterine contraction after

birth), which occurs in about 80 percent of cases. Atony may be related to over

distention of the uterus, infection, placental abnormalities, or bladder distention.

Though the majority of women who develop PPH have no identifiable risk factors,

clinical factors associated with uterine atony as multiple gestation,

polyhydramnios, high parity, and prolonged labor. Other causes of PPH include

retained placenta or clots, lacerations, uterine rupture or inversion, and inherited or

acquired coagulation abnormalities (McLintock, &James, 2011; Zelop, 2011).

The common causes (etiology) of PPH are referred to as the ‘Four T’s’ and in

order of most to least commonly occurring are (Maame&Yiadom, 2013).

1. Tone (70 %):

Atonic uterus

2. Trauma (20%): o Lacerations of the cervix, vagina and perineum

Extension lacerations at CS

Uterine rupture or inversion

Consider non-genital tract trauma (e.g. subcapsular liver rupture)

3. Tissue (10%):

Retained products, placenta (cotyledon or succenturiate lobe), membranes or

clots, abnormal placenta

4. Thrombin (< 1%):

Coagulation abnormalities

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Uterine a tony

A tony is by far the most common cause of postpartum hemorrhage. Uterine

contraction is essential for appropriate hemostasis, and disruption of this process

can lead to significant bleeding. Uterine atony is the typical cause of postpartum

hemorrhage that occurs in the first 4 hours after delivery.

Risk factors for a tony include the following

Over distended uterus (eg, multiple gestation, fetal macrosomia, polyhydramnios)

Fatigued uterus (eg, augmented or prolonged labor, amnionitis, use of uterine

tocolytics such as magnesium or calcium channel blockers)

Obstructed uterus (eg, retained placenta or fetal parts, placenta accreta, or an

overly distended bladder)

Laceration or hematoma

Trauma to the uterus, cervix, and/or vagina is the second most frequent

cause of PPH. Injury to these tissues during or after delivery can cause significant

bleeding because of their increased vascularity during pregnancy. Vaginal trauma

is most common with surgical or assisted vaginal deliveries. It occurs frequently

with deliveries that involve a large fetus, manual exploration, instrumentation, a

fetal hand presenting with the head, or spontaneously from friction between

mucosal tissue and the fetus during delivery. Cervical lacerations are fewer now

that forceps-assisted deliveries are less common. They are more likely to occur

when delivery assistance is provided before the cervix is fully dilated.

Risk factors for trauma include the following:

Delivery of a large infant

Any instrumentation or intrauterine manipulation (e.g, forceps, vacuum, manual

removal of retained placental fragments)

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Vaginal birth after cesarean section (VBAC)

Episiotomy

Retained placenta

Retained placental tissue is most likely to occur with a placenta that has

an accessory lobe, deliveries that are extremely preterm, or variants of

placenta accrete. Retained or adherent placental tissue prevents adequate

contraction of the uterus allowing for increased blood loss.

Risk factors for retained products of conception include the following:

Prior uterine surgery or procedures

Premature delivery

Difficult or prolonged placental delivery

Multilobed placenta

Signs of placental accrete by antepartum ultrasonography or MRI

Clotting disorder

During the third stage of labor (after delivery of the fetus), hemostasis is

most dependent on contraction and retraction of the myometrium. During this

period, coagulation disorders are not often a contributing factor. However, hours to

days after delivery, the deposition of fibrin (within the vessels in the area where the

placenta adhered to the uterine wall and/or at cesarean delivery incision sites) plays

a more prominent role. In this delayed period, coagulation abnormalities can cause

PPH alone or contribute to bleeding from other causes, most notably trauma. These

abnormalities may be preexistent or acquired during pregnancy, delivery, or the

postpartum period.

http://emedicine.medscape.com/article/272187-overview

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Potential causes include the following:

Platelet dysfunction: Thrombocytopenia may be related to preexisting disease,

such as idiopathic thrombocytopenic purpura (ITP) or, less commonly, functional

platelet abnormalities. Platelet dysfunction can also be acquired secondary to

HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count).

Inherited coagulopathy: Preexisting abnormalities of the clotting system, as factor

X deficiency or familial hypofibrinogenemia

Use of anticoagulants: This is an iatrogenic coagulopathy from the use of heparin,

enoxaparin, aspirin, or postpartum warfarin.

Disseminated intravascular coagulation (DIC): This can occur, such as from

sepsis, placental abruption, amniotic fluid embolism, HELLP syndrome, or

intrauterine fetal demise.

Dilutional coagulopathy: Large blood loss, or large volume resuscitation with

crystalloid and/or packed red blood cells (PRBCs), can cause a dilutional

coagulopathy and worsen hemorrhage from other causes.

Physiologic factors: These factors may develop during the hemorrhage such as

hypocalcemia, hypothermia, and acidemia.

http://emedicine.medscape.com/article/779545-overviewhttp://emedicine.medscape.com/article/779097-overviewhttp://emedicine.medscape.com/article/252810-overviewhttp://emedicine.medscape.com/article/253068-overview

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Uterine inversion

"Traction": The traditional teaching is that uterine inversion occurs with an

atonic uterus that has not separated well from the placenta as it is being delivered

or from excessive traction on the umbilical cord while placental delivery is being

assisted. Studies have yet to demonstrate the typical mechanism for uterine

inversion. However, clinical vigilance for inversion, secondary to these potential

causes, is generally practiced. Inversion prevents the myometrium from contracting

and retracting, and it is associated with life-threatening blood losses as well as

profound hypotension from vagal activation.

Factors underlying the increase remain unknown; however, studies

investigating changes in maternal age, obesity, mode of delivery, multiple birth,

duration of labor, and placental abnormalities (Ford et al., 2007). A large

proportion of women who develop PPH do not have identifiable risk factors, so all

women must be considered to be at risk. However, antenatal screening is important

to identify women who are at high risk of PPH, so that appropriate management

plans can be developed and implemented.

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Table (2) summary of Risk factors for PPH

Risk factors Etiology

Antenatal

Increased maternal age – more than 35 years Tone

Asian ethnicity. Tone/trauma

Obesity – Body mass index (BMI) of more than 35 kg/m Tone

Grand multiparty – uncertain as mixed findings Tone/tissue

Existing uterine abnormalities (e.g. anatomical anomalies,

fibroids) Tone

Maternal blood disorders:

• Idiopathic thrombocytopenia purpura

• Thrombocytopenia caused by pre-eclampsia/gestational

hypertension

• Disseminating intravascular coagulation (DIC)

Thrombin

History of previous PPH or retained placenta Tone/tissue

Anaemia of less than 9 g/dL at onset of labour. No reserve

Antepartum haemorrhage associated with:

• Suspected or proven placental abruption

• Known placenta praevia

Tissue/Tone/

Thrombin

Over distension of the uterus:

• Multiple pregnancy

• Polyhydramnios

• Macrosomia – greater than 4 kg

Tone

Intrauterine fetal death

Thrombin

Intrapartum

Precipitate labour Trauma/Tone

Prolonged labour – first, second or third stage Tone

Chorioamnionitis, pyrexia in labour (e.g. prolonged membrane

rupture) Tone/Thrombin

Oxytocin use31 – induction of labour Tone

Amniotic fluid emboli (AFE)/DIC Thrombin

Uterine inversion Trauma/Tone

Genital tract trauma (e.g. episiotomy, ruptured uterus) Trauma

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According to Royal Australian and New Zealand College of Obstetricians and

Gynecologists (2010)

5)-Pathophysiology of occurrence PPH

At term, the uterus and placenta receive 500-800 mL of blood per minute

through their low resistance network of vessels. This high flow predisposes a

gravid uterus to significant bleeding if not well physiologically or medically

controlled. By the third trimester, maternal blood volume increases by 50%, which

increases the body's tolerance of blood loss during delivery. Following delivery of

the fetus; the gravid uterus is able to contract down significantly given the

reduction in volume. This allows the placenta to separate from the uterine interface,

exposing maternal blood vessels that interface with the placental surface.

Assisted vaginal birth2 Trauma/Tone

CS – more risk with emergency (e.g. extension or lacerations

from deep engagement or malpresentation.

Trauma/Tone

Postnatal

Retained products (e.g. placenta, cotyledons or succenturiate

lobe, membranes, clots)

Tissue

Drug-induced hypotonia10 (e.g. anaesthetic, magnesium

sulphate)

Tone

Bladder distension preventing uterine contraction (e.g. obstructed

indwelling catheter (IDC), unable to void)

Tone

AFE/DIC Thrombin

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After separation and delivery of the placenta, the uterus initiates a process

of contraction and retraction, shortening its fiber and kinking the supplying blood

vessels, like physiologic sutures or "living ligatures (Bouwmeester, etal., 2003).

If the uterus fails to contract, or the placenta fails to separate or deliver, then

significant hemorrhage may ensue. Uterine atony, or decreasemyometrial

contractility, accounts for 80% of postpartum hemorrhage. The other major causes

include abnormal placental attachment or retained placental tissue, laceration of

tissues or blood vessels in the pelvis and genital tract, and maternal coagulopathies.

An additional, though uncommon, cause is inversion of the uterus during placental

delivery.The traditional pneumonic "4Ts: tone, tissue, trauma, and thrombosis" can

be used to remember the potential causes. Here, a 5th

is added; “T” for uterine

inversion that will be called “traction”(Tintinalli, Kelen&Stapczynski, 2004;

ACOG, 2006).

6)-Signs and symptoms

The following are the most common signs and symptoms of PPH. However, each

woman may experience symptoms differently(Carrolietal., 2008).

decreased blood pressure

increased and pain in tissues in the vaginal and perennial area

Uncontrolled bleedingheart rate

decrease in the red blood cell count (hematocrit)

swelling

The abnormal blood loss will be picked up by the midwifery staff or

obstetrician caring for you. However, if the excessive blood loss is occurs

following the first 24 hours after delivery (secondary postpartum hemorrhage)

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yourself may notice the increased blood loss as increased need for sanitary

napkin changes and/or increased loss into the toilet/shower.

Depending on the amount of blood loss, you may experience some of the

symptoms of anemia including tiredness and lethargy. The amount of blood loss

may be severe that you may require a blood transfusion. You may even need to

undergo other treatments including surgery to prevent further blood loss.You

may experience difficulty breastfeeding your baby if your pituitary gland has

been affected by the blood loss as well as other symptoms of Sheehan’s

syndrome inPPH, massive blood loss can diminish the supply of blood to

the gland and cause cell death. If greater than 10% of the gland is affected, then

the woman can are affected symptoms of anterior pituitary insufficiency

including:

Failure to lactate (breastfeed);

Weakness;

Lethargy;

Hypersensitivity to cold;

Decreased sweating;

Atrophy (shrinking) of the external genitalia;

Amenorrhea (loss of periods) or oligomenorrhea (reduced periods);

Hair loss; and

Absences of menopausal symptoms (KEMH, 2009).

7)-Clinical examination of postpartum hemorrhage (PPH)

Magann and his college (2005) mentionedthat the doctors need to carefully

but quickly make an assessment on the amount of blood lost and to monitor vital

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signs including temperature, pulse, breathing and blood pressure until the bleeding

is controlled. Questions regarding the pregnancy, labor and delivery may be asked

to assess for risk factors which may help to identify the cause of bleeding.

Key examinations need to be performed in an attempt to identify the

cause and control the hemorrhage. These include:

Examination of uterine size;

Examination of the placenta for completeness; and

Examination of the birth canal for trauma.

8)-Diagnoses of Postpartum Hemorrhage (PPH)

PPH is diagnosed clinically when significant blood loss (>500mL) is

observed. The clinical history should begin with consideration of signs and

symptoms that are most crucial in managing potential circulatory collapse,

identifying the cause of PPH, and selecting therapies, as follows.

Is the placenta delivered?

What has been the duration of the third stage of labor?

How long has the bleeding been heavy?

Was initial post-delivery bleeding light, medium, or heavy?

Are symptoms of hypovolemia present?

In delayed PPH, what is the bleeding pattern since delivery

9)-Prognosis of Postpartum Hemorrhage (PPH)

The consequences of postpartum hemorrhage vary depending on several factors

including:

Amount of blood loss;

Health of the mother prior to the event; and

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Treatment availability including blood transfusions.

Significant postpartum hemorrhage may be associated with the development

of Sheehan’s syndrome, severe anemia and maternal mortality(CEMACH, 2004).

10)-Complication and adverse outcomes from PPH

According toWorld Health Organization,(2012)PPH is one of the leading

causes of maternal mortality and morbidity worldwide and accounts for nearly one-

quarter of all maternal deaths. Several studies have suggested that deaths

associated with PPH could be prevented with prompt recognition and more timely

and adequate treatment (Torre et al., 2011; Kilpatrick et al., 2012).Sever PPH

can be associated with organ failureas; shock, edema, compartment syndrome,

transfusion complications, thrombosis, acute respiratory distress syndrome, sepsis,

anemia, intensive care, and prolonged hospitalization, hypovolaemic shock,

disseminated intravascular coagulation, acute kidney injury, liver failure, acute

(adult) respiratory distress syndrome, death(McLintock& James , 2011; Zelop,

2011).

11)-Management of PPH

Early assessment and aggressive treatment of PPH are important for reducing

morbidity and mortality rates. A critical first step in managing persistent PPH is

rapid recognition that clinically significant bleeding (unresponsive to initial

measures) has occurred, with effective communication of the situation to the

appropriate team members, both clinical and laboratory staff. Subsequent measures

include immediate resuscitation with definitive action to arrest the bleeding

(obstetric, surgical, and/or hematologic) and ongoing assessment and monitoring of

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the response to treatment.10 Persistent severe PPH requires early involvement of

the most experienced members of the team.

Assessment of PPH severity: estimation of blood loss and clinical

assessment

The accurate assessment of blood loss during PPH facilitates timely transfusion

and reduces the severity of hemorrhagic shock.

Measurement of blood loss

Training regarding the measurement or estimation of blood loss is given to anyone

undertaking midwifery or obstetric practice. Accurate monitoring of blood loss

volume is recommended using widely available pictorial guidelines (Bose et al.,

2010) or physical collection where possible

Clinical assessments of the severity of PPH

In otherwise fit and healthy women, development of tachycardia and

hypotension are relatively late events in PPH, only occurring after loss of

significant blood volume. Regular clinical assessment (every 30 min) of pulse,

blood pressure, and respiratory rate can provide an indication of clinical

compromise especially if recorded on a modified obstetric early warning

chart(Singh et al., 2012).

Treatment of PPH

The immediate resuscitation of women with PPH includes assessment of the

airway and breathing and the administration of oxygen by mask at 10 to 15 L/min.

The woman should be kept flat and kept warm using appropriate available

measures. Intravenous (IV) access with two 14-gauge cannulas should be obtained

and an infusion of warmed crystalloid should be commenced until blood is

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available. The maximum volume of infused clear fluids should, ideally, not exceed

a total of 3.5 L (up to 2 L of warmed crystalloid solution as rapidly as possible,

followed by up to an additional 1.5 L if blood is still not available) while awaiting

compatible blood.

First-line management

First-line measures should be directed to the treatment of atony, which is the

most common cause of PPH: primarily, uterine massage to stimulate uterine

muscle contractions and a trial of therapy with uterotonic agent. The choice and

dosing of uterotonic agents as a first-line therapy should be administered according

to local guidelines. The bladder should be emptied and an indwelling catheter

should be inserted. An obstetric review to identify and manage other causes for

PPH that is, retained placenta or genital tract trauma, should be performed.

Second-line management

If initial measures fail to stop bleeding and uterine a tony persists, other

pharmacologic (uterotonics and hemostatic agents) and mechanical or surgical

measures should be instituted. Progression to secondary measures should ideally

trigger the initiation of a predefined management algorithm for the aggressive

treatment of persistent PPH. Escalation of mechanical or conservative surgical

interventions in cases of ongoing uterine a tony will depend on the availability of

expertise. Options include intrauterine balloon tamponade or hemostatic brace

sutures (such as B-Lynch or modified B-Lynch suture) surgical ligation of the

uterine arteries and radiologic uterine artery embolization (Fig. 1).

24

Fig. 1.Recommended treatment algorithm for the treatment of PPH. *Declaration of PPH. The loss of more than a normal volume

of blood in the immediate postpartum period should lead to prompt response to control the bleeding. †Uterotonics used may vary

between institutions and should be patient specific; typical uterotonic administration will include IV infusion of Syntocinon, intramuscular

Syntometrine, or prostaglandin analogs, for example, misoprostol, carboprost, or sulprostone. ‡Surgical and obstetric

measures used to manage PPH will depend initially on the mode of delivery. Early recourse to B-Lynch or other compression

suture may be more appropriate after cesarean section than after vaginal delivery. §The use of rFVIIa is off-label and must be considered

carefully. Published case series have reported efficacy in this setting with some authors suggesting that in selected cases it

may be appropriate to consider before hysterectomy. Hysterectomy should be a last resort. aPTT = activated partial thromboplastin

time; CBC = complete blood count; PT = prothrombin time; ROTEM = rotational thromboelastometry; TEG = thrombelastography

25

Third line of management

Surgical therapies: Surgical interventions should be performed by the most

experienced obstetrician available.

B-lynch suture – this method aims to exert continuous vertical compression

by way of a suture that runs the full thickness of both the anterior and posterior

uterine walls.

Uterine artery ligation – the uterine arteries are the major source of blood

to the uterus and hence the ligation (tying off) of these arteries is a method of

controlling PPH. The uterus remains viable due to blood feeding into it from

smaller vessels. Subsequent menstruation and pregnancies are unaffected by this

procedure.

Internal iliac artery ligation – this can also be performed in an attempt to

control PPH or in any situation associated with uncontrolled pelvic bleeding. Care

must be taken to positively identify both the external and internal branches of the

iliac artery as ligation of the external iliac artery may result in loss of the lower

limb. Care must also be taken to avoid theureter, which lies close by.

Hysterectomy – is an effective and often lifesaving procedure where the

bleeding cannot be controlled by other methods. However, deaths do occur

following and during hysterectomy in cases of massive haemorrhage and where the

procedure is delayed until the patient is nearly moribund (B-Lynch et al., 1997;

Elhassan etal., 2010).

Guidelines for the prevention of PPH, such as the joint statement of the

International Confederation of Midwives and the International Federation of

Gynecology and Obstetrics (2004), recommend routine massage of the uterus after

delivery of the placenta. Massage is thought to stimulate uterine contraction,

possibly through stimulation of local prostaglandin release, and thus reduce

hemorrhage. Procedure of uterine massage as following; 1) Explain the procedure

http://www.myvmc.com/medical-dictionary/b-lynch-suture/http://www.myvmc.com/medical-dictionary/uterine-artery-ligation/http://www.myvmc.com/medical-dictionary/internal-iliac-ligation/http://www.myvmc.com/medical-dictionary/ureter/http://www.myvmc.com/medical-dictionary/hysterectomy/

26

and its purpose to the mother; 2) Prepare equipment’s and take to bed side ;3)

Screen the mother’s bed to keep privacy; 4) Close the windows ,if open

anddrafty;5)Wash hands to prevent infection; 6) Ask the mother to empty her

bladder if she has not voided recently to obtain accurate information’s;7) Place the

mother in a spine position with her knee slightly flexed to tolerate abdominal

muscles; 8) Put on the clean gloves and lower the perineal pad to observe amount

of saturation and characteristics of lochia) Place the non-dominant and above the

symphysis pubis; 10) Use the flat part of the fingers “not the fingers tip” for

palpation; 11) begin palpation at the umbilicus and palpate gently until the funds is

located; 12)Note the firmness and location of the funds “the funds should be firm

in mid line” and approximately at the level of umbilicus; 13) If the funds is

difficult to locate or is soft or “boggy” atomic ,keep the non-dominant round above

the symphysis pubis and massage the funds with the dominant hand until the funds

is firm; 14) Observe the vulva for passage of the blood clots and for development

of hematoma or bleeding from lacerations; 15) Remove bloody pads ,clean

perineum and apply sterile perineal pad; 16) Help the client to find a comfortable –

position; 17)Record consistency and of the funds, bleeding and perineum; 18)

Report a funds that does not stay firm and 19) Wash hands after care away of

equipment.

Figure2 .Uterine massage

27

Figure 3.Bimanual compression

If women conscious, inform her of procedure and provide analgesia, then:

-Using non-dominant hand:

Keeping fingers straight and thumb tucked in palmar side of index

finger insert hand into vagina with palm facing the woman’s thigh

Once fingers meet resistance roll the hand so that palm is upward and

curl fingers into a fist placing thumb on top of index finger

Place the fist into the anterior fornix of the vagina and apply upward

pressure.

-Using other (dominant) hand:

Identify the uterine fundus

Deeply palpate to situate fingers behind the fundus

Cupping the fundus compress it firmly around the intravaginal fist

Maintain compression and evaluate effec

28

Figure 4.Administering PF2α

If conscious, inform woman of procedure and provide analgesia, then:

• Situate non-dominant hand using same techniques as above

• The dominant hand is used to administer intramyometrial

PGF2α via an injection in multiple sites of the uterine funds.

• Stabilization of the funds can be achieved by having an assistant

situate their fingers behind the funds.

29

Figure 5.Balloon Tamponade

Somerset D.The emergency management of catastrophic obstetric

haemorrhage.Obstetrics and Gynaecology. 2006; 8(4):18-23.

The process for using the intra-uterine balloon is as follows:

• Empty uterine cavity of clots

• Insert the end of the balloon through the cervix into the uterine cavity, ensuring

the balloon is completely inside the uterus

• Inflate the balloon with sufficient volume of warm sterile saline (approx 250-500

mL); the uterus should now be firm with minimal blood loss

• Assess blood loss through drainage portal for tamponade effect. If bleeding

continues tamponade ineffective and surgical intervention required

• Commence broad spectrum antibiotic cover

• Continue or commence oxytocic infusion.

30

Figure 6.B-Lynch compression suture

The technique is performed at laparotomy or CS:

Test: bleeding controlled by bimanual compression •Technique: #2 chromic on a

75 mm heavy round bodied needle

• (Re) open the abdomen and (re) open the uterus

• Check the uterine cavity for bleeding sites that might be oversewn

• Test for homeostasis before using the B-Lynch suture using bimanual

compression and swabbing the vagina – if bleeding is controlled temporarily in this

fashion the B-Lynch suture is likely to be effective

• Placement of the suture, as demonstrated, requires surgical expertise

Adopted from: B-Lynch C, Coker A, Lawal A, et al. The B-Lynch surgical technique for the

control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported.

BJOG 1997; 104:372–37

31

Figure 7.Uterine artery ligations

This technique is performed at laparotomy or CS:

• The goal of arterial ligation is to decrease uterine profusion and subsequent

bleeding

• It is considered less technically challenging and time consuming than ligation of

other arteries e.g. internal iliac

Adopted from: Francois K, Foley M. Chapter 19: Antepartum and postpartum

hemorrhage. In: Gabbe S, Niebyl J, Simpson J, Landon M, Galan H, Jauniaux E, et

al., editors. Obstetrics: normal and problem pregnancies. 6th ed. Philadelphia:

Saunders, Elseiver; 2012.

32

12-Nursing Responsibility for Women Anticipating PPH

According to the American Journal of Maternal / Child Nursing, (2003),

nursing care during postpartum period is multifaceted requiring knowledge of

normal physiologic process as well as potential risks. Anticipatory guidance during

postpartum period can have a significant impact on postnatal outcomes. So, the

nurse must work toward providing care and education that facilitate holistic family

wellness. As well as complete assessment and obstetric history are very important,

this might include: 1) medical history as; history of medical disease, routine

medications and allergies. 2) Obstetric history as; gravid, parity, history of

postpartum hemorrhage, history of complications during pregnancy, time and

mode of delivery, presence of tears or lacerations during delivery, and anesthesia

or medications, 3) infant status as ; breast or bottle feeding.

Lynna, and Joan (2005) stated that, to outline the nursing care and management

of the postpartum mother who hemorrhages, all patients will receive rapid

interventions to prevent developing symptoms of potential, impending shock as it

can progress rapidly. Therefore, Lynna, and Joan listed what the nurse must assess

for the woman carefully and thoroughly as, immediate, and ongoing physical

assessment of the mother is guided by her unique history and situation. It includes

an assessment of ; vital signs; uterine tone; lochia ; fundal height; condition of

perineum; bladder function; bowel function, and physical comfort.

Finding of this assessment should be documented and reported immediately. also

mother`s history should be reviewed for factors that would predispose to PPH, as

prior history before the present pregnancy or related to the present of pregnancy

and delivery.

33

Pilliteri (2006), reported that, nurses have crucial roles in giving immediate

care for women experiencing postpartum hemorrhage which includes; notify the on

duty physician immediately, keep patient with nothing per month; keep patient on

bed rest in a flat position with head on bed slightly elevated. The nurse should

assess fundal height, firmness, position and lochia for color, odor, amount, and

clots with blood pressure, pulse and respirations every 5-10minutes until stable,

then every30 minutes for 2hrs, then 60 minutes for 4hrs, followed by 2hrsfor 6 hrs.

Monitoring temperature every 4hours with vital signs are also nurse`s duties.

According to John and Barbara (2004) if the uterus is soft and boggy massaging

the Findus firmly while supporting the lower uterine segment until being firm is

recommended.

The nurses also have role in assessing episiotomy through REEDA (redness,

edema, ecchymosis, discharge, and approximation of edges of episiotomy)

method as a possible cause of hemorrhage. Nurses should carefully inspect the

surrounding area of the episiotomy sutures and assess general perineal healing at

least three times daily. Pain, a gaping suture line, and a reddened, edematous

episiotomy (Bobak et al , 2009). Pillitteri (2006) added that, when the nurse turns

the mother to inspect her perineum, she has to be sure to check under her buttocks

to avoid missing any bleeding that may be pooling below her. If uterus remains a

tonic with moderate or excessive flow the nurse has to massage the uterus to

express clots and make it hard as follows; the fundus is first gently felt with the

fingers- tips to assess its consistency. If it is soft and relaxed the fundus is

massaged with a smooth circular motion, applying no undue pressure. When

contraction occurs the hand is held still, the nurse should start IV infusion and

oxytocin drips.

34

The Egyptian Nursing Faculties (2001) stated that, breast feeding is a method

which helps the uterus to contract. If the mother is unable to control breast feeding,

manual stimulation of the nipples is effective. They also added that encouraging

the mother to evacuate the bladder, and if the mother is unable to void or bladder is

distended inserting a Nelton catheter for evacuation is a nurse`s responsibility

because distended bladder my prevent uterus to contract effectively. The uterine

consistency and tony that a firmly contracted fundus rules out uterine a tony and

suggest an unrepaired cervical laceration as the cause of bleeding.

However, Gabbe et al. (2002), highlighted that if symptoms and signs of

shock has occurred; the nurse should elevate woman`s legs 20-30 degrees, provide

oxygen by facemask at liters per minute, keep the mother warm which help her to

recover from shock more quick, obtain access with 0.9% normal saline via Y –

tubing in case blood transfusion is necessary, monitor blood work as ordered, the

nurse should also monitor intake and output, urine output should exceed 30mL/

hour. She should watch for symptoms and signs of pulmonary edema (dyspnea,

cough, or increased anxiety). Finally the nurse must document all observations,

findings, and interventions.

35

13)-Prevention of Postpartum Hemorrhage

1. The use of uterotonics for the prevention of PPH during the third stage of labor

is recommended for all births. (Strong recommendation, moderate-quality

evidence).

2. Oxytocin (10 IU), administered intramuscularly, is the preferred medication and

route for the prevention of PPH in low-risk vaginal deliveries. Care providers

should administer this medication after delivery of the anterior shoulder. (I-A)

3. Intravenous infusion of oxytocin (20 to 40 IU in 1000 mL, 150 mL per hour) is

an acceptable alternative for AMTSL. (I-B)

4. An IV bolus of oxytocin, 5 to 10 IU (given over 1 to 2 minutes), can be used for

PPH prevention after vaginal birth but is not recommended at this time with

elective Caesarean section. (II-B)

5. Ergonovine can be used for prevention of PPH but may be considered second

choice to oxytocin owing to the greater risk of maternal adverse effects and of the

need for manual removal of a retained placenta. Ergonovine is contraindicated in

patients with hypertension. (I-A)

6. Carbetocin, 100 _g given as an IV bolus over 1 minute, should be used instead

of continuous oxytocin infusion in elective Caesarean section for the prevention of

PPH and to decrease the need for therapeutic uterotonics. (I-B)

7. For women delivering vaginally with risk factor for PPH, carbetocin 100 _g IM

decreases the need for uterine massage to prevent PPH when compared with

continuous infusion of oxytocin. (I-B)

8. Ergonovine, 0.2 mg IM, and misoprostol, 600 to 800 _g given by the oral,

sublingual, or rectal route, may be offered as alternatives in vaginal deliveries

when oxytocin is not available. (II-1B)

9. Whenever possible, delaying cord clamping by at least 60 seconds is preferred to

clamping earlier in premature newborns (< 37 weeks’ gestation) since there is less

36

intraventricular hemorrhage and less need for transfusion in those with late

clamping. (I-A)

10. For term newborns, the possible increased risk of neonatal jaundice requiring

phototherapy mustbe weighed against the physiological benefit of greater

hemoglobin and iron levels up to 6 months of age conferred by delayed cord

clamping. (I-C)

11. There is no evidence that, in an uncomplicated delivery without bleeding,

interventions to accelerate delivery of the placenta before the traditional 30 to 45

minutes will reduce the risk of PPH. (II-2C)

12.Late cord clamping (performed after 1 to 3 minutes after birth) is recommended

for all births while initiating simultaneous essential newborn care. (Strong

recommendation, moderate quality evidence)

13. Early cord clamping (

37

Also, a Cochrane review suggests that active management (use of uterotonic

drugs, cord clamping and controlled cord traction) during the third stage of labor

reduces severe bleeding and anemia(Begley, 2011).However, the review also

found that active management increased the mother's blood pressure, nausea,

vomiting, and pain. In the active management group more women returned to

hospital with bleeding after discharge, and there was also a reduction in birth

weight due to infants having a lower blood volume. Another Cochrane review

looking at the timing of the giving oxytocin as part of the active management

found similar benefits with giving it before or after the expulsion of the placenta

(Soltani, 2010).

13- PPH 10 Most Common Mistakes According to Stevens et al., (2015)

1. Treating “Postpartum Hemorrhage” as a diagnosis (as opposed to a sign) and not

identifying underlying cause(s)

2. Underestimating blood loss

3. Inattention to vital sign trends

4. Delay in laboratory assessment for developing anemia and coagulopathy

5. Delay in instituting blood component therapy

6. Delay in surgical intervention

7. Not making the mental shift from “normal delivery” to “life-threatening

emergency”

8. Poor perioperative communication between the Obstetrician and

Anesthesiologist regarding who will primarily manage blood loss estimation,

laboratory assessment, and blood component therapy.

9. Poor postpartum communication between nurse and obstetrician regarding

estimated blood loss, patient vital signs and other clinical indicators

10.Lack of preoperative preparation for massive hemorrhage (e.g. placenta previa

with prior cesareans and suspected placenta accreta).

https://en.wikipedia.org/wiki/Cochrane_reviewhttps://en.wikipedia.org/wiki/Anemiahttps://en.wikipedia.org/wiki/Oxytocin

38

14. Preventing Maternal Death According to Clark & Hankins (2012)

In the postpartum patient who is bleeding or who recently has stopped

bleeding and is oliguric, furosamide is not the answer.

Any woman with placental previa and one or more cesarean deliveries

should be evaluated and delivered in a tertiary care medical center.

If your labor and delivery unit does not have a recently updated massive

transfusion protocol based on established trauma protocols, get one today.

15. Postpartum Hemorrhage Conclusions

Significant maternal morbidity and mortality

Usually secondary to uterine atony

Blood loss is inaccurately (under)estimated

Early lab assessment and blood component Rx

There are new diagnostic & therapeutic options

Acknowledgment

Our appreciation and gratitude to Dr. Tawheda Mohamed Khalefa El-

saidy,Lecturer of Community Health Nursing, Faculty of Nursing, Menoufia

University for her valuable advices and guidance.

39

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