Arnold W. Cohen, MD,
Chairman
Department of
Obstetrics &
Gynecology
Albert Einstein Medical
Center
Professor of Ob/Gyn
Jefferson Medical
College
Philadelphia, PA.
Old Problem – Consistent Thoughts
Definition…
 Arbitrary and problematic
 Traditionally: (Baskett, 1999)
 EBL >=500 cc after vaginal delivery
 EBL >=1000 cc after a cesarean section
 Excessive blood loss that makes the patient
symptomatic (ie lightheadedness, vertigo,
syncope) +/-signs of hypovolemia (ie
hypotension, tachycardia, or oliguria)
Incidence…
 Affects 5-15% of women giving birth
 Two categories:
 Early (primary) hemorrhage: occurs within the first 24
hours postpartum
 Late (secondary) hemorrhage: occurs after 24 hours
postpartum
Be Prepared…
 Risk Factors:
 Macrosomia
 Labor induction and augmentation
 Prolonged second stage
 Chorioamnionitis
 Magnesium sulfate use
 Previous PPH
(Jackson, 2001)
Be Prepared…
Risk Factor
OR
CI
Retained placenta
3.5
2.1-5.8
Failure to progress during the second
stage of labor
3.4
2.4-4.7
Placenta accreta
3.3
2.4
2.3
1.9
1.7-6.4
2.0-2.8
1.6-3.4
1.6-2.4
Induction of labor
1.7
1.4
1.2-2.1
1.1-1.7
Augmentation of labor with oxytocin
1.4
1.2-1.7
Lacerations
Instrumental delivery
Large for gestational age (LGA) newborn
Hypertensive disorders
Sheiner et al 2005
Prevention
 Active management of the 3rd stage of labor
 uterotonic administration (preferably oxytocin)
immediately upon delivery of the baby (or shoulders)
 early cord clamping and cutting
 gentle cord traction with uterine countertraction when
the uterus is well contracted (ie, Brandt-Andrews
maneuver).
Benefits of Active Management Vs
Physiological management
Outcome
Ctrl rate
RR
CI
PPH > 500ml
14 %
0.38
0.32-0.46
PPH > 1000ml
2.6%
0.33
0.21-0.51
Hgb < 9 g/dl
6.1%
0.4
0.29-0.55
Blood transfusions
2.3%
0.44
0.22-0.53
Therapeutic
Uteretonics
17%
0.2
0.17-0.25
Prendiville, 2000
Etiologies (4T’s)…
 Tone: uterine atony (80%)
 Tissue: retained placental tissue
 Trauma: uterine, cervical or vaginal lacerations
 Thrombin: dilutional coagulopathy, consumptive
coagulopathy and coagulation disorders
Clinical findings in Ob PPH…
Blood Loss
SBP
Symptoms
and signs
Degree of
shock
500-1000 mL
(10-15%)
Normal
Palpitations,
tachycardia,
dizziness
Compensated
1000-1500 mL
(15-25%)
Slight fall (80100 mm Hg)
Weakness,
tachycardia,
sweating
Mild
1500-2000 mL
(25-35%)
Moderate fall
Restlessness,
(70-80 mm Hg) pallor, oliguria
Moderate
2000-3000 mL
(35-50%)
Marked fall
Collapse, air
(50-70 mm Hg) hunger, anuria
Severe
Two important facts…
1. Caregivers consistently underestimate visible blood loss by
as much as 50%. The volume of any clotted blood
represents half of the blood volume required to form the
clots.
2. Most women giving birth are healthy and compensate for
blood loss very well. This, combined with the fact that the
most common birthing position is some variant of
semirecumbent with the legs elevated, means that
symptoms of hypovolemia may not develop until a large
volume of blood has been lost
25 ml peripad
50 ml peripad
100 ml peripad
A saturated 4x4 12-ply sponge =
5 ml
Other methods
of
quantification:
•Weight
•Direct
Measurement
25 ml
100 ml chux
250 ml chux
350 ml chux
500 ml chux
50 ml
75 ml
18x18 laps: 25 ml approx 50%; 50 ml approx 75%;
75 ml entire surface; 100 ml saturated and dripping
100 ml
Treatment…
Two major components:
 Resuscitation and management of
obstetric hemorrhage and, possibly,
hypovolemic shock
 Identification and management of the
underlying cause(s) of the hemorrhage
Philadelphia Delivery Centers
Organize the team…
 Call for help ( Attending, nurse , anesthesiologist)
 Designate a nurse to record vital signs, urine output,
fluids and drugs administered
 Assess the vital signs every 5-10min
Resuscitation…
 Administer 5-7L/min of Oxygen by face mask
 Place 2 large bore IV lines
 Initial Blood work:
 Type and cross match,
 CBC,
PT/PTT/INR,
 Fib, FSP,
 Cr,
 S-8

 Fluid Resusciation with NS or LR to maintain BP at 90
mm/Hg
 Blood transfusion using Massive Transfusion Protocol
 Correct coagulopathy if present
Massive Transfusion Protocol
“1:1:1”
 Consider activation of a MT protocol when patient actively bleeding and
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any of the following:
Systolic blood pressure < 90 mmHg
Ph < 7.1
Base deficit > 6 meq/L
Temperature below 34°C
INR > 2.0
Platelet count < 50,000/mm³
Once activated, the blood bank will send 6 units of PRBC, 6 units of FFP,
6 units of platelets, and 10 units of cryoprecipitate. After this, if the
patient remains bleeding (the protocol has not being inactivated), 6
more units of PRBC and FFP will be prepared along with 20 units of
cryoprecipitate. The latter product is given in order to elevate the
fibrinogen level since the next step of the protocol is to
Recombinant Activated factor VII administer.
At any point, if the patient’s hemorrhage stops, the blood bank should
be notified so that the protocol can be terminated.
If bleeding persists, the sequence is started again.
Blood Products
General considerations
 Keep the platelet count > 50,000. If less than that,
administer 10-12 units initially
 If surgical intervention is necessary, maintain Plt
count > 80-100,000.
 Cryoprecipate may be used along with FFP for
fibrinogen levels <100, give in 6-12 unit doses
Blood Component Therapy
Product
Vol
Contents
Effect
PRBCs
240
RBC, WBC, plasma
Increase hematocrit 3
percentage points,
hemoglobin by 1 g/dL
Platelets
50
Platelets, RBC,
WBC, plasma
Increase platelet count
5,000– 10,000/mm3 per unit
FFP
250
Fibrinogen,
antithrombin III,
factors V and VIII
Increase fibrinogen by 10
mg/dL
Cryoprecipitate
40
Fibrinogen, factors
VIII and XIII, von
Willebrand factor
Increase fibrinogen by 10
mg/dL
Targets after Transfusion…
 Fibrinogen > 100mg/dl
 Hematocrit >21%
 Hemoglobin >7g/dl
 Platelet count >50,000
 PT/PTT <1.5 times control
Response to Resuscitation…
 Pay attention to pt’s level of consciousness
 Monitor BP
 Maintain BP around 90 mm/Hg Systolic
 Monitor RR
 Frequent auscultation of lung fields
 Start Blood if BP cannot be maintained or when
Bleeding is controlled
Work up…
 Exam Patient- DR or in OR
 Uterine Tone
 Genital Lacerations
 Placenta
 Bleeding Sites
 Lab Studies: Type and cross match, CBC,
PT/PTT/INR, Fib, FSP, Cr, S-8
 Imaging Studies: bedside U/S
Initial Management…
 Empty bladder
 Vigorous bimanual Uterine massage
 Manual exploration of uterine cavity. (Use
U/S to r/o retained placenta)
 Uterontonics
 Careful inspection of cervix, vagina, vulva and
perianal area for lacerations and/or
hematomas in OR
 Consider coagulopathy if no other cause
identified
Medical Management…
UTEROTONICS…
 Pitocin: 40 units in 1 liter NS or LR IV rapid
infusion or 10 units IM (Avoid undiluted IV
push)
 Methergine: 0.2mg IM q2-4hr, max 5 doses
(Contraindicated with HTN)
 Hemabate: 0.25mg IM or intramyometrial q 2090min, max 8 doses (Contraindicated with
Asthma)
 Cytotec: 800-1000mcg PR or SL (not per vagina)
Management
 Monitor CBC, Coagulation studies, ABG
 Monitor pulse oximetry
 Monitor Urine output with indwelling catheter
 Correct coagulopathy
 FFP- preferred because of volume
 Cryoprecipitate
If PPH hemorrhage continues after
uterotonics…
 Shift to OR
 Exam under anesthesia: carefully re-inspect the cervix,
vagina, vulva and perianal areas for lacerations and /or
hematomas
 Perform D&E to make sure that there is no retained
placental tissue (“Banjo” curette)
Packing and Tamponade…
If PPH still continues….
 Packing: 4 inch gauze pack into uterus using a
sponge stick. If thrombin available, soak gauze
with 5,000 units thrombin in 5cc sterile saline
 SOS Bakri Tamponade Balloon: Insert balloon,
instill 300-500 cc saline
 Foley catheters: if Bakri balloon unavailable.
Insert one or more bulbs, instilled with 60-80cc
of NSS
SOS BAKRI
TAMPONADE
BALLOON
CATHETER
Illustration by Lisa Clark
The Simple Solution for
Postpartum Hemorrhage
Intractable PPH at
vaginal delivery
Uterine Artery Embolization
No coagulopathy
Hemodynamically stable to go to Radiology suite
Interventional Radiologist available
UAE: special considerations…
If patient is relatively stable, not coagulopathic and an
intervention radiologist is available; consider arterial
embolization before proceeding to exploratory
laprotomy.
Temporizing measures like packing and SOS Bakri
balloon tamponade can be used in the meanwhile.
Intractable PPH at
Vaginal delivery
Laparotomy
 Make midline vertical abdominal incision
 Begin with bilateral uterine art ligation-Figure of
8’s
If unsuccessful, consider…
 B-Lynch suture or square compression suture
 Vicryl 1
 Hpogastric artery ligation
 Hysterctomy (supracervical)
PPH at cesarean delivery
 Aggressive resuscitation
 Direct bimanual compression
 Direct intramyometrial injection of Hemabate may be





undertaken
Retained placenta can be removed under direct
visualization
Compression sutures may be placed
LUS can be packed with end in the vagina for 24-30 hrs
Hypogastric Artery Ligation
Supracervical Hysterectomy
Post Op care…
 Continue resuscitation
 Monitor vital signs and urine output
 Monitor vaginal bleeding
 Repeat labs as indicated
 Disposition: ?ICU
 Monitor for coagulopathy
 Monitor for complications: anemia, ARDS, ATN
being most common
Documentation…
 Infusion type and rate
 Massive Transfusion Protocol (1:1:1)
 Blood
 Platelets
 Fibrinogen
 Medications administered
 Patient response
 Vital signs and urine output
 Nursing and Physician notes
Management of
Post Partum Hemorrhage
Post Partum Hemorrhage Box
Post Partum Hemorrhage Box
Post Partum Hemorrhage Meds
H.A.E.M.O.S.T.A.S.I.S
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M
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S
T
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S
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ask for help
Assess (VS, EBL) and resuscitate
Establish etiology, ensure availability of blood,
ecbolics
Massage uterus
Oxytocin/Methergine/Hemabate/Cytotec
Shift to OR
Tamponade balloon, uterine packing
Apply compression sutures
Systematic pelvis devascularization
Interventional radiologist – UAE
Subtotal/total abdominal Hysterectomy
Thank-you
from the
Chairs of Ob/Gyn in Philadelphia