A Synopsis or AFP's "Prevention and Management of Postpartum Hemorrhage"

Prevention and Management of Postpartum Hemorrhage
JANICE M. ANDERSON, M.D., Forbes Family Medicine Residency Program, Western Pennsylvania Hospital Forbes Regional Campus, Monroeville, Pennsylvania DUNCAN ETCHES, M.D., M.CL.SC., University of British Columbia Faculty of Medicine, Vancouver, British Columbia
Am Fam Physician. 2007 Mar 15;75(6):875-882.
http://www.aafp.org/afp/2007/0315/p875.pdf

     Postpartum hemorrhage is considered when more than 500 ml of blood are lost after delivery. Complications include orthostatic hypotension, anemia, and fatigue. In severe cases, such as when blood loss exceeds 1000 ml, hemorrhagic shock, anterior pituitary ischemia and posterior pituitary necrosis may occur. Risk factors include a prolonged third stage of labor, episiotomy, fetal macrosomia, and multiple deliveries.
     Active management of the third stage of labor is the strategy that is used to minimize the occurrence or postpartum hemorrhage. The parts of active management are;
-administration of oxytocin (or misoprostol) after delivery of the shoulder,
-cord traction, and
-uterine massage after delivery.
Early cord clamping and cutting is no longer part of active management. Delaying clamping has been shown to increase fetal iron stores as well as lowering the risk of anemia. Active management will shorten the third stage of labor. In expectant management, the placenta will separate on its own, but it may take longer, this increasing the risk of third stage complications.
     The four common causes of postpartum hemorrhage are "tone, trauma, tissue, and thrombin". Tone, or uterine atony, is the most common cause of postpartum hemorrhage. Treatment consists of bimanual uterine massage and oxytocin, ergot alkaloids, or prostaglandins. These medications stimulate uterine contraction and vasoconstriction.
     Trauma is referring to laceration, hematomas, uterine inversion and rupture. Episiotomies are discouraged unless absolutely necessary. Lacerations can be sutured.  Hematomas are treated through irrigation and ligation. Uterine inversion is rare but may be related to placental implantation. It looks like blue-gray tissue coming out of the vagina. Treatment consists of grasping the protruding part and pushing it up into the pelvis and abdomen to revert it. If the attempt fails, medications to promote uterine relaxation can be given (magnesium sulfate, terbutaline, nitroglycerin, or anesthesia). Surgery is another option. Once the uterus is properly reverted, medications can be given to increase uterine tone. Rupture of the uterus can occur in women who have a previous history of uterine scarring, previous uterine surgery, multiple cesarean sections, and short intervals between deliveries. Induction and augmentation of labor (prostaglandins, oxytocin, and misoprostol) also increases the risk or rupture. Signs of rupture include tachycardia, late decelerations, abdominal tenderness, circulatory collapse, and increasing abdominal girth.
     Tissue refers to retained tissue or placenta in the uterus. Placental delivery can be spontaneous or accelerated through active management. Oxytocin can also be injected into the umbilical vein. Retained product may need to be removed manually. The placenta can also be invaded into the uterus. "Placenta accreta adheres to the myometrium, placenta increta invades the myometrium, and placenta percreta penetrates the myometrium" (that was stolen straight from the article). Risk factors include older age, high parity, placenta previa, and previous CS. Common treatment includes hysterectomy or methotrexate.
     Thrombin refers to coagulation disorders. Most of these have been discovered before the woman become pregnant. Patients who have pre-eclampsia or placental abruption may develop HELLP or DIC. Excessive bleeding should be evaluate by ordering platelet counts, PT/PTT, fibrinogen and FSPs. These coagulopathies can be treated accordingly.