2. What causes PPH?
OBG Management: Why does PPH occur?
Dr. Brown: The leading cause is uterine atony, a failure of the uterus to contract and undergo resolution following delivery of an infant. Approximately 80% of cases of early PPH are related to uterine atony.
There are other causes of PPH:
- lacerations of the genital tract (perineum, vagina, cervix, or uterus)
- retained fragments of placental tissue
- uterine rupture
- blood clotting abnormalities
- uterine inversion.
3. Is it possible to prepare for PPH?
OBG Management: What is the starting point for management of PPH?
Dr. Brown: Prevention of, and preparation for, hemorrhage begin well before delivery. During the prenatal period, for example, it is important to assess the woman’s level of risk for PPH. Among the variables that increase her risk:
- any situation that leads to overstretching of the uterus, including multiple gestation, whether delivery is vaginal or cesarean
- a history of PPH.
It is important that women with these characteristics maintain adequate hemoglobin and hematocrit levels by taking vitamin and iron supplements in the antepartum period.
In addition, women who have abnormal placental implantation, such as placenta previa, are at risk for bleeding during the antepartum period and during cesarean delivery. They should maintain a hematocrit in the mid-30s because of expected blood loss during delivery.
OBG Management: What preparatory steps should be taken at the time of hospital admission if a woman has an elevated risk of bleeding?
Dr. Brown: When the patient is hospitalized in anticipation of delivery—whether vaginal or cesarean—the team should assess her hemoglobin and hematocrit levels and type and screen for possible transfusion. The patient should also be apprised of her risk and the potential for transfusion.
Last, the anesthesia team should be alerted to her risk factors for postpartum bleeding.
4. What intrapartum variables signal an increased risk of PPH?
OBG Management: During labor and delivery, what variables signal an elevated risk of bleeding?
Dr. Brown: Risk factors for hemorrhage become more apparent during this period. They include prolonged or rapid labor, prolonged use of oxytocin, operative delivery, infections such as chorioamnionitis, and vaginal birth after cesarean delivery (VBAC).
Bleeding with VBAC merits special attention because it could signal uterine rupture. Women who have a low transverse uterine scar and who undergo VBAC have a risk of uterine scar separation during labor of 0.5% to 1%.
OBG Management: What about retained placenta or a placenta that requires manual removal?
Dr. Brown: These intrapartum variables are not as easy to anticipate. They may suggest a condition such as placenta accreta, especially if the patient is undergoing VBAC.
Uterine inversion can also lead to hemorrhage and is a medical emergency.
OBG Management: What steps should be taken at the time of labor to ensure a safe outcome?
Dr. Brown: A type and screen should be available for all women on labor and delivery, and the team should anticipate the need to cross-match for blood if there is a high potential for transfusion. For example, a woman known to have anemia (hematocrit <30%) should have a cross-match performed so that blood can be prepared for transfusion.
In addition, women who are undergoing planned delivery for placental implantation disorders should have blood in the operating room ready for transfusion when cesarean is performed. These women are at great risk of hemorrhage and peripartum hysterectomy.
5. What first-line strategies do you recommend?
OBG Management: Do you recommend oxytocin administration and fundal massage for every patient after delivery of the infant?
Dr. Brown: Yes. These strategies lessen the risk of uterine atony and excessive bleeding after vaginal delivery. At the time of cesarean delivery, expression of the placenta and uterine massage, along with oxytocin administration, reduce the risk of excessive blood loss.
If bleeding continues even after the uterus begins to contract, look for other causes of the bleeding, such as uterine laceration or retained placental fragments.
OBG Management: What uterotonic agents do you use besides oxytocin, and when?
Dr. Brown: Oxytocin is the first-line agent for control of hemorrhage. I give a dosage of 10 to 40 U/L of normal saline or lactated Ringer solution, infused continuously. Alternatively, 10 U can be given intramuscularly (IM). Second-line drugs and their dosages are listed in the TABLE.
Uterotonic agents and how to administer them
| Drug | Dosage and route | Considerations |
|---|---|---|
| FIRST-LINE | ||
| Oxytocin | 10–40 U/L of saline or lactated ringer solution, infused continuously, Or 10 U IM | The preferred drug—often the only one needed |
| SECOND-LINE | ||
| Misoprostol (Cytotec, Prostaglandin e1) | 800–1,000 μg can be given rectally | Often, the second-line drug that is given just after oxytocin because it is easy to administer |
| Methylergonovine (Methergine) | 0.2 mg IM every 2–4 hr | Contraindicated in hypertension |
| Carboprost tromethamine (Hemabate) | 0.25 mg IM every 15–90 minutes (maximum of 8 doses) | Avoid in patients who have asthma. Contra-indicated in hepatic, renal, and cardiac disease |
| Dinoprostone (Prostin e2) | 20 mg suppository can be given vaginally or rectally every 2 hours | Avoid in hypotension |