Practice Guideline for Postpartum Hemorrhage

Contributing factors:

Rapid or prolonged labor, uterine over distention, use of tocolytic or anesthetic agents in labor, operative birth, high parity, uterine infection, prior uterine atony, retained placental fragments, lower genital tract lacerations, uterine rupture, uterine inversion, placenta accreta, hereditary coagulopathy

Infection, placental site subinvolution, retained placental fragments, hereditary coagulopathy

Intervention

As interventions are initiated, consider all causes and potential sites of bleeding including cervical or vaginal lacerations.

  • Manually examine the internal lower uterine segment and the uterine cavity.
  • Consider pain medication needs of the woman.

Notify anesthesia.

 

Obtain blood type and screen, if not already done.

Rationale

Considerable blood loss may occur with vaginal or cervical lacerations. Manual examination can detect a pelvic hematoma. Retained blood clots can impair uterine contractility.

 

Early notification of personnel will facilitate readiness for emergency procedures, if needed. Timing of notification of personnel depends on local resources.

Perform uterine massage

  • Stabilize uterus with 1 hand over the symphysis pubis and press fingers into lower abdomen below fundus.
  • Massage top of fundus using other hand.

This method prevents uterus from being pushed out into the pelvis during massage. Massage is much less effective if the fundus is compressed in the pelvis.

   

Begin documenting frequent VS, flow, I&O

 

Establish IV access with large bore needle

  • For continued hemorrhage, a second IV line will be needed.

Provide intravascular crystalloid volume expander (LR or NS )

 

Prevent hypotension and shock.

 

The order of interventions below will vary, determined by the clinical judgements of the health care team:

Check patient for full bladder & insert foley if indicated

Full bladder may prevent uterus from contracting. Urine output is an indicator of intravascular volume and renal perfusion

   

Hang IV with oxytocin 20 40 U / 1000mL NS or LR

  • If patient does not have IV line give 10 units oxytocin IM

Onset of action IV is 1 minute. A solution of 20-40u/1000mL running @ a rate of 300mL/hr will deliver 100-200mu/min. Do not give IV bolus of undiluted oxytocin as hypotension and cardiac arrhythmia may occur.

Onset of action IM is 3-7 minutes.

Administer supplemental O2

Always provide oxygen to patients with hemorrhage or shock to maximize oxygenation of organs

Cover unexposed body with warm blankets

 

Consider the following pharmacologic options:

 
  • Methergine 0.2 mg IM

As a smooth muscle stimulant, it may cause venospasm or arteriospasm. Do not give to patient with hypertension or symptomatic heart disease

  • Misoprostol 600-1000micrograms per rectum or

Misoprostol 600micrograms orally

Both oral and rectal administration of misoprostol have been studied and shown to be effective in stabilizing patients with postpartum hemorrhage. Misoprostol is inexpensive and can be easily stored on maternity units for emergent availability.

  • Hemabate 250micrograms IM or directly into the uterine muscle (fundus). May be repeated q 15 minutes up to 8 doses

Stimulates rapid, sustained uterine contractions, onset of action in minutes. This medication can cause bronchospasm. It is contraindicated in women with a history of asthma.

Perform manual compression of the uterus

  • Consider pain medication
  • Continue to massage the fundus
  • Insert other hand into the vagina and form a fist and push up against the body of the uterus
  • Compress the uterus against the hand in the vagina
  • Continue to massage the fundus

Bimanual uterine compression compresses the uterine vessels and stimulates uterine contractions

Consider blood replacement

Prepare patient for operating room.

  • Notify the OR that equipment for curretage and laporatomy should be prepared
  • Initiate second &/or third IV line, if not previously done.
  • Request at least 4 units of packed red blood cells
  • Draw blood for CBC, platelet count, PT, PTT,

Draw blood for FDP, FSP, or D-dimer

  • Continue to hold uterus out of pelvis and massage
  • Continue pharmocologic means to control bleeding
  • Reconsider other causes of bleeding than uterine atony.

 

Laparatomy for arterial ligation or hysterectomy

The timing of notification of operating room personnel will depend on local resources.

 

 

 

 

Bleeding may be controlled by manual or pharmacologic means prior to beginning a laparotomy.

An examination under anesthesia may reveal a repairable laceration or retained placental fragments that can be surgically repaired without laparotomy.

If severe bleeding continues after above interventions, laparatomy for arterial ligation or hysterectomy is likely to be needed.

References:

Developed and Reviewed by:

 

This guideline has been developed by Dartmouth-Hitchcock Medical Center. DHMC is not responsible for its use or misuse by other parties or in other clinical settings. Qualified personnel should make an independent assessment of the appropriateness of this material before it is used in other clinical settings or for other purposes.