Postpartum hemorrhage is defined as a cumulative blood loss greater than 500 mL, or bleeding associated with signs and symptoms of hypovolemia within the first 24 hours following birth.  It is an obstetric emergency and one of the top five causes of maternal mortality; the loss of blood can be significant, as the uterine artery blood flow at term can be as high as 750 mL/minute and can account for up to 15% of cardiac output.

Causes of postpartum hemorrhage include the “Four Ts”:

• Tone (uterine atony, the most common cause)
• Trauma (to genital structures)
• Tissue (retention of placenta or membranes)
• Thrombin (coagulopathy)

Patients at higher risk of postpartum hemorrhage include women with multiple pregnancies (more than four), a past history of postpartum or antepartum hemorrhage, and a large baby. 

Normally, the fundus will not become firm and contracted until the placenta is delivered.  Avoid fundal massage prior to placental delivery and continue to check for vaginal bleeding while observing vital signs.  In cases of postpartum hemorrhage prior to placental delivery, consider performing fundal massage as increased uterine tone can promote placental separation and potentially decrease postpartum hemorrhage.

• Assess for fundal tone, visible blood loss, and perineal or vaginal lacerations.
• Quantify blood loss: use abdominal pads to collect blood and calculate weight difference on hospital arrival.  With uterine atony, blood loss can be significantly greater than what is observed externally.  Look for signs of hypovolemia closely.
• In an unstable patient, assess vital signs and shock index, and treat as per CPG D01: Shock

• Fundus is firm: provide high-flow oxygen; correct hypvolemia with up to 40 mL/kg normal saline; administer tranexamic acid while en route.  Manage visible lacerations with direct pressure and dressings.
• Fundus is not firm: provide uterine massage (firm pressure in a circular motion with a cupped hand). 
  • Encourage mother to empty bladder if possible; a full bladder will impede and prevent contractions of the uterus, which will prevent uterine emptying, exacerbating blood retention, atony, and hemorrhage
  • Encourage infant to suckle breast
  • The placenta should naturally deliver on its own within 30-60 minutes; manipulation is not authorized
  • Do NOT attempt active delivery of placenta due to risk of uterine inversion

Conveyance to a hospital with obstetrical and surgical facilities is preferred.  Contact CliniCall for additional guidance.

• In most cases, postpartum hemorrhage is a malfunction of one of the body’s mechanisms of uterine bleeding control; these include myometrial contraction causing direct compression of the blood vessels, and local hemostatic factors that promote clotting.
• If bleeding remains uncontrolled despite oxytocin or carboprost/Hemabate and tranexamic acid, surgical intervention is likely to be required.