Postpartum hemorrhage

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Postpartum hemorrhage is common and can occur in patients without risk factors for hemorrhage. Active man- agement of the third stage of labor should be used routinely to reduce its incidence. Use of oxytocin after delivery of the anterior shoulder is the most important and effective component of this practice. Oxytocin is more effective than misoprostol for prevention and treatment of uterine atony and has fewer adverse effects. Routine episiotomy should be avoided to decrease blood loss and the risk of anal laceration. Appropriate management of postpartum hemorrhage requires prompt diagnosis and treatment. The Four T’s mnemonic can be used to identify and address the four most common causes of postpartum hemorrhage (uterine atony [Tone]; laceration, hematoma, inversion, rupture [Trauma]; retained tissue or invasive placenta [Tissue]; and coagulopathy [Thrombin]). Rapid team-based care minimizes morbidity and mortality associated with postpartum hemorrhage, regardless of cause. Massive trans- fusion protocols allow for rapid and appropriate response to hemorrhages exceeding 1,500 mL of blood loss. The National Partnership for Maternal Safety has developed an obstetric hemorrhage consensus bundle of 13 patient- and systems-level recommendations to reduce morbidity and mortality from postpartum hemorrhage. (Am Fam Physi- cian. 2017;95(7):442-449. Copyright © 2017 American Academy of Family Physicians.)

Postpartum Hemorrhage: Prevention and Treatment ANN EVENSEN, MD, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

JANICE M. ANDERSON, MD, Forbes Family Medicine Residency Program, Pittsburgh, Pennsylvania

PATRICIA FONTAINE, MD, MS, HealthPartners Institute for Education and Research, Bloomington, Minnesota

pproximately 3% to 5% of obstet- ric patients will experience post-

partum hemorrhage.1 Annually, these preventable events are

the cause of one-fourth of maternal deaths worldwide and 12% of maternal deaths in the United States.2,3 The American College of Obstetricians and Gynecologists defines early postpartum hemorrhage as at least 1,000 mL total blood loss or loss of blood coinciding with signs and symptoms of hypovolemia within 24 hours after delivery of the fetus or intrapartum loss.4,5 Primary postpartum hemorrhage may occur before delivery of the placenta and up to 24 hours after delivery of the fetus. Complications of postpartum hemorrhage are listed in Table 13,6,7; these range from worsening of common postpartum symptoms such as fatigue and depressed mood, to death from cardiovascular collapse.

This review presents evidence-based rec- ommendations for the prevention of and appropriate response to postpartum hem- orrhage and is intended for physicians who provide antenatal, intrapartum, and post- partum care.

Prevention Risk factors for postpartum hemorrhage are listed in Table 2.8 However, 20% of postpar- tum hemorrhage occurs in women with no risk factors, so physicians must be prepared to manage this condition at every delivery.9 Strategies for decreasing the morbidity and mortality associated with postpartum hem- orrhage are listed in Table 3,6,10-14 including the choice to deliver infants in women at high risk of hemorrhage at facilities with immediately available surgical, intensive care, and blood bank services.

The most effective strategy to prevent postpartum hemorrhage is active manage- ment of the third stage of labor (AMTSL). AMTSL also reduces the risk of a postpar- tum maternal hemoglobin level lower than 9 g per dL (90 g per L) and the need for man- ual removal of the placenta.11 Components of this practice include: (1) administering oxy- tocin (Pitocin) with or soon after the deliv- ery of the anterior shoulder; (2) controlled cord traction (Brandt-Andrews maneuver) to deliver the placenta; and (3) uterine mas- sage after delivery of the placenta.11 Pla- cental delivery can be achieved using the

CME This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions on page 417.

Author disclosure: No rel- evant financial affiliations.

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Brandt-Andrews maneuver, in which firm traction on the umbilical cord is applied with one hand while the other applies suprapubic counterpressure15 (eFigure A).

The individual components of AMTSL have been evalu- ated and compared. Based on existing evidence, the most important component is administration of a uterotonic drug, preferably oxytocin.12,16 The number needed to treat to prevent one case of hemorrhage 500 mL or greater is 7 for oxytocin administered after delivery of the fetal ante- rior shoulder or after delivery of the neonate compared with placebo.16 The risk of postpartum hemorrhage is also reduced if oxytocin is administered after placental deliv- ery instead of at the time of delivery of the anterior shoul- der.17 Dosing instructions are provided in Table 4.6

An alternative to oxytocin is misoprostol (Cytotec), an inexpensive medication that does not require injection and is more effective than placebo in preventing postpar- tum hemorrhage.12 However, most studies have shown that oxytocin is superior to misoprostol.12,18 Misoprostol also causes more adverse effects than oxytocin—com- monly nausea, diarrhea, and fever within three hours of birth.12,18

The benefits of controlled cord traction and uterine massage in preventing postpartum hemorrhage are less clear, but these strategies may be helpful.15,19,20 Controlled

cord traction does not prevent severe postpartum hem- orrhage, but reduces the incidence of less severe blood loss (500 to 1,000 mL) and reduces the need for manual extraction of the placenta.21

Diagnosis and Management Diagnosis of postpartum hemorrhage begins with rec- ognition of excessive bleeding and targeted examina- tion to determine its cause (Figure 16). Cumulative blood loss should be monitored throughout labor and deliv- ery and postpartum with quantitative measurement, if

Table 2. Risk Factors for Postpartum Hemorrhage

Antepartum hemorrhage

Augmented labor

Chorioamnionitis

Fetal macrosomia

Maternal anemia

Information from reference 8.

Maternal obesity

Multifetal gestation

Preeclampsia

Primiparity

Prolonged labor

Table 1. Complications of Postpartum Hemorrhage

Anemia

Anterior pituitary ischemia with delay or failure of lactation (i.e., Sheehan syndrome or postpartum pituitary necrosis)

Blood transfusion

Information from references 3, 6, and 7.

Death

Dilutional coagulopathy

Fatigue

Myocardial ischemia

Orthostatic hypotension

Postpartum depression

Table 3. Strategies to Reduce Morbidity and Mortality from Postpartum Hemorrhage

Readiness by every unit

Have a hemorrhage cart with medications, supplies, checklist, and instruction cards immediately available

Establish a response team and know who to call when help is needed

Establish massive and emergency release transfusion protocols

Institute unit education on protocols and run unit-based drills

Recognition and prevention efforts for every patient

Antenatal assessment

Screen for and treat anemia antenatally

Screen for sickle cell disease and thalassemia in women of African, Southeast Asian, or Mediterranean descent

Obtain sonograms for women at high risk of invasive placenta

Perform delivery in facility with blood bank and in-house surgical services if the patient has a high risk of hemorrhage

Identify Jehovah’s Witnesses and other patients who decline blood products

Intrapartum management

Use active management of the third stage of labor in every delivery

Avoid routine episiotomy

Avoid instrumented deliveries, especially forceps

Use perineal warm compresses

Measure cumulative blood loss and track postpartum vital signs

Response for every hemorrhage

Use an emergency management plan with checklists

Provide support program for patients, families, and staff

Reporting and systems learning for every unit

Establish a culture of huddles and postevent debriefs

Complete a multidisciplinary review for systems issues

Establish a perinatal quality improvement committee

Adapted with permission from Council on Patient Safety in Women’s Health Care. Obstetric hemorrhage patient safety bundle. http:// safehealthcareforeverywoman.org/patient-safety-bundles/obstetric- hemorrhage/ [login required]. Accessed October 16, 2016. Additional information from references 6, and 11 through 14.

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possible.22 Although some important sources of blood loss may occur intrapartum (e.g., episiotomy, uterine rupture), most of the fluid expelled during delivery of the infant is urine or amniotic fluid. Quantitative mea- surement of postpartum bleeding begins immediately after the birth of the infant and entails measuring cumu- lative blood loss with a calibrated underbuttocks drape, or by weighing blood-soaked pads, sponges, and clots; combined use of these methods is also appropriate for obtaining an accurate measurement.22 Healthy pregnant women can typically tolerate 500 to 1,000 mL of blood loss without having signs or symptoms.9 Tachycardia may be the earliest sign of postpartum hemorrhage. Orthostasis, hypotension, nausea, dyspnea, oliguria, and chest pain may indicate hypovolemia from significant hemorrhage. If excess bleeding is diagnosed, the Four T’s mnemonic (uterine atony [Tone]; laceration, hematoma, inversion, rupture [Trauma]; retained tissue or invasive placenta [Tissue]; and coagulopathy [Thrombin]) can be used to identify specific causes (Table 56). Regardless of the cause of bleeding, physicians should immediately

summon additional personnel and begin appropriate emergency hemorrhage protocols.

TONE (UTERINE ATONY)

Uterine atony is the most common cause of postpartum hemorrhage.9 Brisk blood flow after delivery of the pla- centa unresponsive to transabdominal massage should prompt immediate action including bimanual compres- sion of the uterus and use of uterotonic medications (Table 46). Massage is performed by placing one hand in the vagina and pushing against the body of the uterus while the other hand compresses the fundus from above through the abdominal wall (eFigure B).

Uterotonic agents include oxytocin, ergot alkaloids, and prostaglandins. Oxytocin is the most effective treatment for postpartum hemorrhage, even if already used for labor induction or augmentation or as part of AMTSL.8,23,24 The choice of a second-line uterotonic should be based on patient-specific factors such as hyper- tension, asthma, or use of protease inhibitors. Although it is not a uterotonic, tranexamic acid (Cyklokapron)

Table 4. Medications Used for Prevention and Treatment of Postpartum Hemorrhage

Medication Dosage Prevention Treatment Contraindications and cautions Mechanism of action Adverse effects Cost*

First-line agent

Oxytocin (Pitocin) Prevention: 10 IU IM or 5 to 10 IU IV bolus

Treatment: 20 to 40 IU in 1 L normal saline, infuse 500 mL over 10 minutes then 250 mL per hour

+ + Overdose or prolonged use can cause water intoxication

Possible hypotension with IV use following cesarean delivery

Stimulates the upper segment of the myometrium to contract rhythmically, constricting spiral arteries and decreasing blood flow through the uterus

Rare $1 ($13) for 10 units of injectable solution

Second-line agents

Carboprost (Hemabate), a prostaglandin F2-alpha analogue

250 mcg IM or into myometrium, repeated every 15 to 90 minutes for a total dose of 2 mg

– + Avoid in patients with asthma or significant renal, hepatic, or cardiac disease

Improves uterine contractility by increasing the number of oxytocin receptors and causes vasoconstriction

Nausea, vomiting, and diarrhea

NA ($270) for 250 mcg of injectable solution

Methylergonovine (Methergine)

0.2 mg IM, repeat every two to four hours

– + Avoid in hypertensive disorders of pregnancy, including chronic hypertension

Use with caution in patients with human immunodeficiency virus infection who are receiving protease inhibitors

Causes vasoconstriction and contracts smooth muscles and upper and lower segments of the uterus tetanically

Nausea, vomiting, and increased blood pressure

$9 (NA) for 0.2 mg of injectable solution

Misoprostol (Cytotec),† a prostaglandin E1 analogue

Prevention: 600 mcg orally

Treatment: 800 to 1,000 mcg rectally or 600 to 800 mcg sublingually or orally

Use only when oxytocin is not available

+ Use with caution in patients with cardiovascular disease

Causes generalized smooth muscle contraction

Nausea, vomiting, diarrhea, pyrexia, and shivering

$1 ($5) per 200-mcg tablet

Tranexamic acid (Cyklokapron)†

1 g intravenously over 10 minutes, may be repeated after 30 minutes

- + Use within three hours of onset of bleeding

Use with caution in patients with renal impairment and with other clotting factors such as prothrombin complex concentrate

Inhibits breakdown of fibrin and fibrinogen by plasmin

May increase risk of thrombosis and cause visual defects

$24 ($50)

IM = intramuscularly; IV = intravenous; NA = not available.

*—Estimated retail price based on information obtained at http://online.lexi.com/action/home (login required; accessed June 10, 2016). Generic price listed first; brand price listed in parentheses. †—Misoprostol and tranexamic acid are not approved by the U.S. Food and Drug Administration for use in prevention or treatment of postpartum hemorrhage.

Adapted with permission from Evensen A, Anderson J. Chapter J. Postpartum hemorrhage: third stage pregnancy. In: Leeman L, Quinlan J, Dresang LT, eds. Advanced Life Support in Obstetrics: Provider Syllabus. 5th ed. Leawood, Kan.: American Academy of Family Physicians; 2014:11.

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may reduce mortality due to bleeding from postpar- tum hemorrhage (but not overall mortality) when given within the first three hours and may be considered as an adjuvant therapy.25 Table 4 outlines dosages, cautions, contraindications, and common adverse effects of utero- tonic medications and tranexamic acid.6

TRAUMA

Lacerations and hematomas due to birth trauma can cause significant blood loss that can be lessened by hemostasis and timely repair. Episiotomy increases the risk of blood loss and anal sphincter tears; this procedure should be avoided unless urgent delivery is necessary and the perineum is thought to be a limiting factor.26

Vaginal and vulvar hematomas can present as pain or as a change in vital signs disproportionate to the amount of blood loss. Small hematomas can be managed with ice packs, analgesia, and observation. Patients with per- sistent signs of volume loss despite fluid replacement, as well as those with large (greater than 3 to 4 cm) or enlarging hematomas, require incision and evacuation

of the clot.27 The involved area should be irrigated and hemostasis achieved by ligat- ing bleeding vessels, placing figure-of-eight sutures, and creating a layered closure, or by using any of these methods alone.

Uterine inversion is rare, occurring in only 0.04% of deliveries, and is a potential cause of postpartum hemorrhage.27 AMTSL does not appear to increase the incidence of uter- ine inversion, but invasive placenta does.27,28 The contributions of other conditions such as fundal implantation of the placenta, fundal pressure, and undue cord traction are unclear.27 The inverted uterus usually appears as a bluish-gray mass protruding from the vagina. Patients with uterine inver- sion may have signs of shock without excess blood loss. If the placenta is attached, it should be left in place until after reduction to limit hemorrhage.27 Every attempt should be made to quickly replace the uterus. The John- son method of reduction begins with grasp- ing the protruding fundus with the palm of the hand, directing the fingers toward the posterior fornix.27 The uterus is returned to position by lifting it up through the pelvis and into the abdomen (eFigure C). Once the uterus is reverted, uterotonic agents can pro- mote uterine tone and prevent recurrence. If initial attempts to replace the uterus fail or

contraction of the lower uterine segment (contraction ring) develops, the use of magnesium sulfate, terbutaline, nitroglycerin, or general anesthesia may allow sufficient uterine relaxation for manipulation.28

Uterine rupture can cause intrapartum and post- partum hemorrhage.29 Although rare in an unscarred uterus, clinically significant uterine rupture occurs in 0.8% of vaginal births after cesarean delivery via low transverse uterine incision.30 Induction and augmenta- tion increase the risk of uterine rupture, especially for patients with prior cesarean delivery.31 Before delivery, the primary sign of uterine rupture is fetal bradycar- dia.31,32 Other signs and symptoms of uterine rupture are listed in eTable A.

TISSUE

Retained tissue (i.e., placenta, placental fragments, or blood clots) prevents the uterus from contracting enough to achieve optimal tone. Classic signs of placental sepa- ration include a small gush of blood, lengthening of the umbilical cord, and a slight rise of the uterus. The

Table 4. Medications Used for Prevention and Treatment of Postpartum Hemorrhage

Medication Dosage Prevention Treatment Contraindications and cautions Mechanism of action Adverse effects Cost*

First-line agent

Oxytocin (Pitocin) Prevention: 10 IU IM or 5 to 10 IU IV bolus

Treatment: 20 to 40 IU in 1 L normal saline, infuse 500 mL over 10 minutes then 250 mL per hour

+ + Overdose or prolonged use can cause water intoxication

Possible hypotension with IV use following cesarean delivery

Stimulates the upper segment of the myometrium to contract rhythmically, constricting spiral arteries and decreasing blood flow through the uterus

Rare $1 ($13) for 10 units of injectable solution

Second-line agents

Carboprost (Hemabate), a prostaglandin F2-alpha analogue

250 mcg IM or into myometrium, repeated every 15 to 90 minutes for a total dose of 2 mg

– + Avoid in patients with asthma or significant renal, hepatic, or cardiac disease

Improves uterine contractility by increasing the number of oxytocin receptors and causes vasoconstriction

Nausea, vomiting, and diarrhea

NA ($270) for 250 mcg of injectable solution

Methylergonovine (Methergine)

0.2 mg IM, repeat every two to four hours

– + Avoid in hypertensive disorders of pregnancy, including chronic hypertension

Use with caution in patients with human immunodeficiency virus infection who are receiving protease inhibitors

Causes vasoconstriction and contracts smooth muscles and upper and lower segments of the uterus tetanically

Nausea, vomiting, and increased blood pressure

$9 (NA) for 0.2 mg of injectable solution

Misoprostol (Cytotec),† a prostaglandin E1 analogue

Prevention: 600 mcg orally

Treatment: 800 to 1,000 mcg rectally or 600 to 800 mcg sublingually or orally

Use only when oxytocin is not available

+ Use with caution in patients with cardiovascular disease

Causes generalized smooth muscle contraction

Nausea, vomiting, diarrhea, pyrexia, and shivering

$1 ($5) per 200-mcg tablet

Tranexamic acid (Cyklokapron)†

1 g intravenously over 10 minutes, may be repeated after 30 minutes

- + Use within three hours of onset of bleeding

Use with caution in patients with renal impairment and with other clotting factors such as prothrombin complex concentrate

Inhibits breakdown of fibrin and fibrinogen by plasmin

May increase risk of thrombosis and cause visual defects

$24 ($50)

IM = intramuscularly; IV = intravenous; NA = not available.

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mean time from delivery to placental expulsion is eight to nine minutes.33 Longer intervals are associated with an increased risk of postpartum hemorrhage, with rates doubling after 10 minutes.33 Retained placenta (i.e., fail-

ure of the placenta to deliver within 30 minutes) occurs in less than 3% of vaginal deliveries.34,35 If the placenta is retained, consider manual removal using appropriate analgesia.35 Injecting the umbilical vein with saline and

Prevention and Management of Postpartum Hemorrhage

Figure 1. Algorithm for the prevention and management of postpartum hemorrhage. Many of the steps involved in diagnosing and treating postpartum hemorrhage must be undertaken simultaneously. Steps in maternal resuscitation may differ based on the actual cause. (IM = intramuscularly; PPH = postpartum hemorrhage.)

Active management of the third stage of labor

Oxytocin (Pitocin) 10 IU IM or 5 to 10 IU intravenously no earlier than delivery of anterior shoulder, controlled cord traction, uterine massage after placenta

If, despite active management, there is estimated blood loss ≥ 500 mL,* brisk bleeding, pulse rising, blood pressure falling, or maternal symptoms of hypotension, then initiate resuscitation, investigation of and treatment for postpartum hemorrhage, and quantitative measurement of ongoing blood loss

Resuscitation

Call for help

Perform bimanual uterine massage

Institute labor unit hemorrhage protocol

Deliver oxytocin 20 IU in 1 L normal saline, infuse 500 mL over 10 minutes then 250 mL per hour

Use two large-bore intravenous needles

Provide oxygen by mask

Monitor blood pressure, pulse, and urine output

Consider laboratory testing such as type and crossmatch, complete blood count

Determine cause and treat using the Four T’s mnemonic

Severe postpartum hemorrhage

Transfuse red blood cells, platelets, and clotting factors using massive transfusion or emergency release protocol

Consult anesthesia, surgery, and an intensivist

Support blood pressure with vasopressors

Consider uterine packing, balloon tamponade, vessel embolization or ligation, compression sutures, and hysterectomy

Aftercare

Monitor for ongoing blood loss (preferably quantitative measurement) and vital signs

Assess for signs of anemia (fatigue, shortness of breath, chest pain, lactation problems)

Debrief with and listen to patients and staff regarding their experience with the emergency

Soft, boggy uterus

TONE

Laceration or uterine inversion

TRAUMA

Retained placenta or clot

TISSUE

Blood not clotting

THROMBIN

Suture lacerations

Drain expanding hematoma

Replace inverted uterus

Inspect placenta

Explore uterus

Manual removal of placenta

Curettage

Observe clotting

Check coagulation studies

Replace clotting factors, platelets

Supply fresh frozen plasma

Oxytocin†: 20 to 40 IU in 1 L normal saline, infuse 500 mL over 10 minutes then 250 mL per hour

Carboprost (Hemabate): 250 mcg IM or into the myometrium every 15 to 90 minutes (2 mg total)

Methylergonovine (Methergine): 0.2 mg IM every two to four hours

Misoprostol (Cytotec): 800 to 1,000 mcg rectally or 600 to 800 mcg sublingually or orally

*—The American College of Obstetricians and Gynecologists defines early postpartum hemorrhage as blood loss of 1,000 mL or more accompanied by signs and symptoms of hypovolemia; cumulative blood loss of 500 to 999 mL alone should trigger increased supervision and potential interven- tions as clinically indicated. †—Oxytocin should be used as a first-line agent, with other agents added only if needed to control hemorrhage.

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oxytocin does not clearly reduce the need for manual removal.35-37 If blunt dissection with the edge of the gloved hand does not reveal the tissue plane between the uterine wall and placenta, invasive placenta should be considered.

Invasive placenta (placenta accreta, increta, or percreta) can cause life-threatening postpartum hemorrhage.13,34,35 The incidence has increased with time, mirroring the increase in cesarean deliveries.13,34 In addition to prior cesarean delivery, other risk factors for invasive placenta include placenta previa, advanced maternal age, high parity, and previous invasive placenta.13,34 Treatment of invasive placenta can require hysterectomy or, in select cases, conservative management (i.e., leaving the pla- centa in place or giving weekly oral methotrexate).13

THROMBIN (COAGULATION DEFECTS)

Coagulation defects can cause a hemorrhage or be the result of one. These defects should be suspected in patients who have not responded to the usual measures to treat postpartum hemorrhage or who are oozing from puncture sites. A coagulation defect should also be sus- pected if blood does not clot in bedside receptacles or red- top (no additives) laboratory collection tubes within five to 10 minutes. Coagulation defects may be congenital or acquired (eTable B). Evaluation should include a platelet count and measurement of prothrombin time, partial thromboplastin time, fibrinogen level, fibrin split prod- ucts, and quantitative d-dimer assay. Physicians should treat the underlying disease process, if known, and sup- port intravascular volume, serially evaluate coagulation status, and replace appropriate blood components using an emergency release protocol to improve response time and decrease risk of dilutional coagulopathy.7,38,39

Ongoing or Severe Hemorrhage Significant blood loss from any cause requires immedi- ate resuscitation measures using an interdisciplinary, stage-based team approach. Physicians should perform

a primary maternal survey and institute care based on American Heart Association standards and an assess- ment of blood loss.14,40 Patients should be given oxygen, ventilated as needed, and provided intravenous fluid and blood replacement with normal saline or other crystal- loid fluids administered through two large-bore intrave- nous needles. Fluid replacement volume should initially be given as a bolus infusion and subsequently adjusted based on frequent reevaluation of the patient’s vital signs and symptoms. The use of O negative blood may be needed while waiting for type-specific blood.

Elevating the patient’s legs will improve venous return. Draining the bladder with a Foley catheter may improve uterine atony and will allow monitoring of urine output. Massive transfusion protocols to decrease the risk of dilutional coagulopathy and other postpartum hemor- rhage complications have been established. These proto- cols typically recommend the use of four units of fresh frozen plasma and one unit of platelets for every four to six units of packed red blood cells used.7,39

Uterus-conserving treatments include uterine packing (plain gauze or gauze soaked with vasopressin, chitosan, or carboprost [Hemabate]), artery ligation, uterine artery embolization, B-lynch compression sutures, and balloon tamponade.7,41-43 Balloon tamponade (in which direct pressure is applied to potential bleeding sites via a balloon that is inserted through the vagina and cervix and inflated with sterile water or saline), uterine packing, aortic com- pression, and nonpneumatic antishock garments may be used to limit bleeding while definitive treatment or trans- port is arranged.7,41,44 Hysterectomy is the definitive treat- ment in women with severe, intractable hemorrhage.

Follow-up of postpartum hemorrhage includes moni- toring for ongoing blood loss and vital signs, assess- ing for signs of anemia (fatigue, shortness of breath, chest pain, or lactation problems), and debriefing with patients and staff. Many patients experience acute and posttraumatic stress disorders after a traumatic deliv- ery. Individual, trauma-focused cognitive behavior therapy can be offered to reduce acute traumatic stress symptoms.45 Debriefing with staff may identify neces- sary systems-level changes (Table 3).6,10-14

Systems Approach to Prevention and Treatment Complications of postpartum hemorrhage are com- mon, even in high-resource countries and well-staffed delivery suites. Based on an analysis of systems errors identified in The Joint Commission’s 2010 Sentinel Event Alert, the commission recommended that hospi- tals establish protocols to enable an optimal response to changes in maternal vital signs and clinical condi-

Table 5. Four T’s Mnemonic for the Specific Causes of Postpartum Hemorrhage

Pathology Specific cause Approximate incidence (%)

Tone Atonic uterus 70

Trauma Lacerations, hematomas, inversion, rupture

Tissue Retained tissue, invasive placenta 10

Thrombin Coagulopathies 1

Adapted with permission from Evensen A, Anderson J. Chapter J. Postpartum hemorrhage: third stage pregnancy. In: Leeman L, Quin- lan J, Dresang LT, eds. Advanced Life Support in Obstetrics: Provider Syllabus. 5th ed. Leawood, Kan.: American Academy of Family Physi- cians; 2014:4.

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tion. These protocols should be tested in drills, and sys- tems problems that interfere with care should be fixed through their continual refinement.46 In response, The Council on Patient Safety in Women’s Health Care out- lined essential steps that delivery units should take to decrease the incidence and severity of postpartum hem- orrhage14 (Table 36,10-14). The creation of a hemorrhage cart with supplies, and the use of huddles, rapid response teams, and massive transfusion protocols are among the recommendations. Advanced Life Support in Obstet- rics (ALSO) training can be part of a systems approach to improving patient care. The use of interdisciplinary team training with in situ simulation, available through the ALSO program and from TeamSTEPPS (Team Strat- egies and Tools to Enhance Performance and Patient Safety), has been shown to improve perinatal safety.47,48

This article updates previous articles on this topic by Maughan, et al.,49 and by Anderson and Etches.50

Data Sources: A PubMed search was completed in Clinical Queries using the key term postpartum hemorrhage. The search included meta- analyses, randomized controlled trials, clinical trials, and reviews. Also searched were the Cochrane Database of Systematic Reviews, Essential Evidence Plus, National Institute for Health and Care Excellence guide- lines, Agency for Healthcare Research and Quality evidence reports, the Institute for Clinical Systems Improvement, and the National Guideline Clearinghouse. Search dates: October 12, 2015, and January 19, 2016.

This article is one in a series on “Advanced Life Support in Obstetrics (ALSO),” initially established by Mark Deutchman, MD, Denver, Colo. The coordinator of this series is Larry Leeman, MD, MPH, ALSO Managing Editor, Albuquerque, N.M.

The Authors ANN EVENSEN, MD, is an associate professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health, Madison; and a member of the ALSO India Advisory Board.

JANICE M. ANDERSON, MD, is associate director at Forbes Family Medi- cine Residency Program, Pittsburgh, Pa.; the medical director of The

Midwife Center for Birth and Women’s Health, Pittsburgh; and director of Women’s Health at the Allegheny County Jail, Pittsburgh.

PATRICIA FONTAINE, MD, MS, is a senior clinical research investigator at the HealthPartners Institute for Education and Research, Bloomington, Minn.

Address correspondence to Ann Evensen, MD, University of Wiscon- sin School of Medicine and Public Health, 100 North Nine Mound Rd., Verona, WI 53593 (e-mail: [email protected]). Reprints are not available from the authors.

REFERENCES

1. Knight M, Callaghan WM, Berg C, et al. Trends in postpartum hemor- rhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth. 2009;9:55.

2. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323-e333.

3. Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD. Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol. 2008;199(1):36.e1-36.e5.

4. Menard MK, Main EK, Currigan SM. Executive summary of the reVITAL- ize initiative: standardizing obstetric data definitions. Obstet Gynecol. 2014;124(1):150-153.

5. American College of Obstetricians and Gynecologists. Obstetric data definitions (version 1.0). Revitalize. https://www.acog.org/-/media/ Departments/Patient-Safety-and-Quality-Improvement/2014reVITALize ObstetricDataDefinitionsV10.pdf. Accessed October 2, 2016.

6. Evensen A, Anderson J. Chapter J. Postpartum hemorrhage: third stage pregnancy. In: Leeman L, Quinlan J, Dresang LT, eds. Advanced Life Sup- port in Obstetrics: Provider Syllabus. 5th ed. Leawood, Kan.: American Academy of Family Physicians; 2014.

7. Guidelines and Audit Committee of the Royal College of Obstetri- cians and Gynaecologists. Prevention and management of postpartum haemorrhage. https://www.rcog.org.uk/en/guidelines-research- services/guidelines/gtg52/. Accessed March 23, 2017.

8. Mousa HA, Blum J, Abou El Senoun G, Shakur H, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev. 2014;(2):CD003249.

9. Magann EF, Evans S, Hutchinson M, Collins R, Howard BC, Morrison JC. Postpartum hemorrhage after vaginal birth: an analysis of risk factors. South Med J. 2005;98(4):419-422.

10. Council on Patient Safety in Women’s Health Care. Obstetric hemor- rhage patient safety bundle. http://safehealthcareforeverywoman.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Routinely use active management of the third stage of labor, preferably with oxytocin (Pitocin). This practice will decrease the risks of postpartum hemorrhage and a postpartum maternal hemoglobin level lower than 9 g per dL (90 g per L), and reduce the need for manual removal of the placenta.

A 11, 12, 16, 18

Oxytocin is the most effective treatment for postpartum hemorrhage, even if already used for labor induction or augmentation or as part of active management of the third stage of labor.

A 8, 23, 24

In women with postpartum hemorrhage, tranexamic acid (Cyklokapron) given within the first three hours after birth reduces mortality due to bleeding, but not overall mortality.

B 25

Avoid routine episiotomy, which increases the risk of blood loss and anal sphincter tears, unless urgent delivery is necessary and the perineum is thought to be a limiting factor.

A 26

When needed, use massive transfusion protocols to decrease the risk of dilutional coagulopathy and other postpartum hemorrhage complications.

C 7, 39

Interdisciplinary team training with realistic simulation should be used to improve perinatal safety. C 47, 48

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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org/patient-safety-bundles/obstetric-hemorrhage/ [login required]. Accessed October 16, 2016.

11. Begley CM, Gyte GML, Devane D, McGuire W, Weeks A. Active ver- sus expectant management for women in the third stage of labour. Cochrane Database Syst Rev. 2015;(3):CD007412.

12. Tunçalp Ö, Hofmeyr GJ, Gülmezoglu AM. Prostaglandins for pre- venting postpartum haemorrhage. Cochrane Database Syst Rev. 2012;(8):CD000494.

13. Committee on Obstetric Practice. Committee opinion no. 529: placenta accreta. Obstet Gynecol. 2012;120 (1):207-211.

14. Main EK, Goffman D, Scavone BM, et al.; National Partnership for Maternal Safety; Council on Patient Safety in Women’s Health Care. National partnership for maternal safety: consensus bundle on obstet- ric hemorrhage [published correction appears in Obstet Gynecol. 2015;126(5):1111]. Obstet Gynecol. 2015;126(1):155-162.

15. Deneux-Tharaux C, Sentilhes L, Maillard F, et al. Effect of routine con- trolled cord traction as part of the active management of the third stage of labour on postpartum haemorrhage: multicentre random- ized controlled trial (TRACOR) [published corrections appear in BMJ. 2013;347:f6619 and BMJ. 2013;346:f2542]. BMJ. 2013;346:f1541.

16. Westhoff G, Cotter AM, Tolosa JE. Prophylactic oxytocin for the third stage of labour to prevent postpartum haemorrhage. Cochrane Data- base Syst Rev. 2013;(10):CD001808.

17. Soltani H, Hutchon DR, Poulose TA. Timing of prophylactic uterotonics for the third stage of labour after vaginal birth. Cochrane Database Syst Rev. 2010;(8):CD006173.

18. Bellad MB, Tara D, Ganachari MS, et al. Prevention of postpartum haemor- rhage with sublingual misoprostol or oxytocin: a double-blind randomised controlled trial. BJOG. 2012;119(8):975-982, discussion 982-986.

19. Hofmeyr GJ, Abdel-Aleem H, Abdel-Aleem MA. Uterine massage for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2013;(7):CD006431.

20. Chen M, Chang Q, Duan T, He J, Zhang L, Liu X. Uterine massage to reduce blood loss after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2013;122(2 pt 1):290-295.

21. Hofmeyr GJ, Mshweshwe NT, Gülmezoglu AM. Controlled cord traction for the third stage of labour. Cochrane Database Syst Rev. 2015;(1):CD008020.

22. Quantification of blood loss: AWHONN practice brief number 1. J Obstet Gynecol Neonatal Nurs. 2015;44(1):158-160.

23. American College of Obstetricians and Gynecologists. Postpartum hem- orrhage from vaginal delivery. Patient safety checklist no. 10. Obstet Gynecol. 2013;121:1151-1152.

24. Sosa CG, Althabe F, Belizan JM, Buekens P. Use of oxytocin during early stages of labor and its effect on active management of third stage of labor. Am J Obstet Gynecol. 2011;204(3):238.e1-238.e5.

25. WOMAN Trial Collaborators. Effect of early tranexamic acid admin- istration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an interna- tional, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116.

26. Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev. 2009;(1):CD000081.

27. You WB, Zahn CM. Postpartum hemorrhage: abnormally adherent pla- centa, uterine inversion, and puerperal hematomas. Clin Obstet Gyne- col. 2006;49(1):184-197.

28. Baskett TF. Acute uterine inversion: a review of 40 cases. J Obstet Gyn- aecol Can. 2002;24(12):953-956.

29. Guiliano M, Closset E, Therby D, LeGoueff F, Deruelle P, Subtil D. Signs, symptoms and complications of complete and partial uterine ruptures during pregnancy and delivery. Eur J Obstet Gynecol Reprod Biol. 2014;179:130-134.

30. National Institutes of Health Consensus Development Conference Panel. National Institutes of Health Consensus Development conference

statement: vaginal birth after cesarean: new insights March 8-10, 2010. Obstet Gynecol. 2010;115(6):1279-1295.

31. American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 115: vaginal birth after previous cesarean delivery. Obstet Gynecol. 2010;116(2 pt 1):450-463.

32. Guise JM, McDonagh MS, Osterweil P, Nygren P, Chan BK, Helfand M. Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section. BMJ. 2004;329(7456):19-25.

33. Magann EF, Evans S, Chauhan SP, Lanneau G, Fisk AD, Morrison JC. The length of the third stage of labor and the risk of postpartum hemor- rhage. Obstet Gynecol. 2005;105(2):290-293.

34. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty- year analysis. Am J Obstet Gynecol. 2005;192(5):1458-1461.

35. Weeks AD. The retained placenta. Best Pract Res Clin Obstet Gynaecol. 2008;22(6):1103-1117.

36. Nardin JM, Weeks A, Carroli G. Umbilical vein injection for management of retained placenta. Cochrane Database Syst Rev. 2011;(5):CD001337.

37. Güngördük K, Asicioglu O, Besimoglu B, et al. Using intraumbilical vein injection of oxytocin in routine practice with active management of the third stage of labor: a randomized controlled trial. Obstet Gynecol. 2010;116(3):619-624.

38. Cunningham FG, Nelson DB. Disseminated intravascular coagulation syndromes in obstetrics. Obstet Gynecol. 2015;126(5):999-1011.

39. Lyndon A, Lagrew D, Shields LE, Main E, Cape V. Improving health care response to obstetric hemorrhage. (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care). Developed under contract #11-10006 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; Published by the Cali- fornia Maternal Quality Care Collaborative, 3/17/15.

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41. World Health Organization. WHO guidelines for the management of postpartum haemorrhage and retained placenta. http://apps.who.int/ iris/bitstream/10665/44171/1/9789241598514_eng.pdf. Accessed Sep- tember 29, 2016.

42. Grönvall M, Tikkanen M, Tallberg E, Paavonen J, Stefanovic V. Use of Bakri balloon tamponade in the treatment of postpartum hemorrhage: a series of 50 cases from a tertiary teaching hospital. Acta Obstet Gyne- col Scand. 2013;92(4):433-438.

43. American College of Obstetricians and Gynecologists. ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 76, October 2006: postpartum hemorrhage. Obstet Gynecol. 2006;108(4):1039-1047.

44. Miller S, Martin HB, Morris JL. Anti-shock garment in postpartum haem- orrhage. Best Pract Res Clin Obstet Gynaecol. 2008;22(6):1057-1074.

45. Roberts NP, Kitchiner NJ, Kenardy J, Bisson JI. Early psychological inter- ventions to treat acute traumatic stress symptoms. Cochrane Database Syst Rev. 2010;(3):CD007944.

46. Preventing maternal death. Jt Comm Perspect. 2010;30 (3):7-9.

47. Riley W, Davis S, Miller K, Hansen H, Sainfort F, Sweet R. Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. Jt Comm J Qual Patient Saf. 2011;37(8):357-364.

48. American College of Obstetricians and Gynecologists Committee on Patient Safety and Quality Improvement. Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol. 2014;123(3):722-725.

49. Maughan K, Heim SW, Galazka SS. Preventing postpartum hemor- rhage: managing the third stage of labor. Am Fam Physician. 2006; 73(6):1025-1028.

50. Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007;75(6):875-882.

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eTable B. Causes of Disordered Coagulation

Acquired

Amniotic fluid embolism

Consumptive coagulation secondary to excessive bleeding of any origin

Disseminated intravascular coagulation secondary to abruption

Fetal demise

HELLP (hemolysis, elevated liver enzyme levels, and low platelet levels) syndrome

Placental abruption

Preeclampsia with severe features

Sepsis

Use of anticoagulants such as aspirin or heparin

Chronic or congenital

Hemophilia

Idiopathic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura

Von Willebrand disease

Information from: Evensen A, Anderson J. Chapter J. Postpartum hemorrhage: third stage pregnancy. In: Leeman L, Quinlan J, Dresang LT, eds. Advanced Life Support in Obstetrics: Provider Syllabus. 5th ed. Leawood, Kan.: American Academy of Family Physicians; 2014.

eTable A. Signs and Symptoms of Uterine Rupture

Abdominal tenderness

Circulatory collapse

Elevation of presenting fetal part

Fetal bradycardia*

Increasing abdominal girth

Loss of uterine contractions

Maternal tachycardia

Vaginal bleeding

*—Most common initial presenting sign.

Information from: American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 115: vaginal birth after previous cesarean delivery. Obstet Gynecol. 2010;116(2 Pt 1):450-463.

Guise JM, McDonagh MS, Osterweil P, Nygren P, Chan BK, Hel- fand M. Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section. BMJ. 2004;329(7456):19-25.

National Institutes of Health Consensus Development Conference Panel. National Institutes of Health Consensus Development confer- ence statement: vaginal birth after cesarean: new insights March 8-10, 2010. Obstet Gynecol. 2010;115(6):1279-1295.

Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2017 American Academy of Family Physicians. For the private, non- commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.

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eFigure C. Reduction of uterine inversion (Johnson method). (A) The protruding fundus is grasped with fin- gers directed toward the posterior fornix. (B) The uterus is returned to position by pushing it through the pelvis and (C) into the abdomen with steady pressure toward the umbilicus.

Reprinted with permission from Anderson JM, Etches D. Prevention and man- agement of postpartum hemorrhage. Am Fam Physician. 2007;75(6):879.

eFigure A. Brandt-Andrews maneuver for controlled cord traction. Firm traction is applied to the umbilical cord with one hand while the other hand applies suprapubic counterpressure.

Reprinted with permission from Anderson JM, Etches D. Prevention and man- agement of postpartum hemorrhage. Am Fam Physician. 2007;75(6):880.

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eFigure B. Bimanual uterine compression massage. One hand is placed in the vagina and pushes against the body of the uterus while the other hand compresses the fun- dus from above through the abdominal wall. The poste- rior aspect of the uterus is massaged with the abdominal hand and the anterior aspect with the vaginal hand.

Reprinted with permission from Anderson JM, Etches D. Prevention and man- agement of postpartum hemorrhage. Am Fam Physician. 2007;75(6):878.

BONUS DIGITAL CONTENT