Postpartum Hemorrhage (PPH): What Is It, And How Is It Treated?
Postpartum hemorrhage is one of the leading causes of Maternal Death in the US, so it is a serious topic that needs to be discussed.
It used to be defined as blood loss over 500mL for a vaginal birth and 1000mL for a c-section birth. Recently (2017), ACOG updated their definition to 1000mL regardless of the mode of delivery, along with having signs and symptoms of hypovolemia (extreme blood loss affecting the whole body).
Even though the definition has changed to 1000mL for birth, this does not mean we should be responding differently to hemorrhages. We should still respond in the same way to identify the hemorrhage, determine the cause, and treat it!
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Types of Postpartum Hemorrhage
There are two types of Postpartum hemorrhage (PPH):
- Primary PPH: Within the first 24 hours after birth
- Secondary PPH: Occurs 24 hours to 12 weeks postpartum!
The most commonly known is primary PPH, which occurs within the first 24 hours after delivery. Hospitals usually want to wait until 24 hours postpartum to remove IV access due to this reason.
Secondary hemorrhage occurs after 24 hours up to 12 weeks postpartum! So, being aware of the signs and symptoms to look out for is important!
Risk Factors for Postpartum Hemorrhage
There are risk factors that increase the chance of a PPH occurring. These are usually noted by the medical team to assign a PPH risk category of Low, Moderate, or High. Some risk factors are:
- Infection during labor (Chorioamnionitis)
- Prolonged Labor/Induction
- Especially if on Pitocin for a prolonged period
- Polyhydramnios
- Multiple Babies (Twins, triples, etc.)
- More than four previous deliveries
- Macrosomia (large for gestation baby)
- Large Uterine Fibroids
- High Blood Pressure
- Magnesium Sulfate Use for Severe Pre-Eclampsia management
- Precipitous Birth
- Operative Vaginal Delivery
- Previous PPH
- Previous C-section
- Placental attachment disorders like Placenta Accreta, increta, percreta
Signs and Symptoms of Postpartum Hemorrhage
Routinely primary hemorrhages were identified by visual estimation of blood loss by the healthcare team, typically the providers. Hospitals, Birth Centers, and Home Birth Providers usually are doing drills throughout the year to keep up with the skill of estimating blood loss visually, but it is still not the most reliable method. Studies have shown that we typically underestimate blood loss when this technique is used. So if we are able to quantify the blood loss in real time by weighing the pads, this is proven to be more accurate. Quantification of blood loss is not always realistic depending on the help available at delivery.
Signs and Symptoms of significant blood loss are:
- Elevated Heart rate
- Decreased Blood Pressure
- Elevated RR – shallow breaths
- Pale
- Cool, clammy skin (sweaty)
- Fatigue, weakness
- Dizziness or fainting when doing activity
- Saturating a Menstrual Pad in less than 1-2 hours
- Passing large clots
The Causes of a Postpartum Hemorrhage
The causes of a Postpartum Hemorrhage all fall into one of the four categories known as the 4 Ts: Tone, Trauma, Tissue, and Thrombin.
Tone
Tone refers to the tone of the uterus; after birth, the uterus should be firm. This is the cause of 80% of postpartum hemorrhages.
This is because the uterus usually clamps down and stops blood flow from the placental wound, the wound where the placenta was attached inside the uterus.
If the uterus is not firm, the placental wound is bleeding into the uterine cavity. This is why we do fundal assessments to check the tone of the uterus to ensure it is firm.
If it is firm when we assess, no need to massage.
If it is not firm, also called boggy, we will try to massage the fundus to help encourage it to firm up to ensure no excessive postpartum bleeding.
Some risk factors for the tone to be an issue are:
- Prolonged use of Pitocin, usually because of a long induction;
- Precipitous labor;
- Large baby;
- Polyhydramnios (too much amniotic fluid);
- Multiple babies;
- Prolonged labor;
- Or an infection during labor.
Trauma
Trauma refers to lacerations to the perineum or birth canal, including the cervix. Once the repair of the laceration is completed, the hemorrhage is resolved.
The bleeding can make it difficult to repair quickly because it can obscure the tissue’s view, so they will likely apply pressure to the lacerations in between sutures to help minimize blood loss.
Tissue
Tissue refers to any retained placental fragments, including a retained placenta. If the placenta is still inside, it can be harder for the uterus to fully contract down and stop bleeding.
If the cause is retained tissue, manual removal of the placenta or placental fragments is recommended. This is NOT comfortable, and pain control should be considered, especially if an epidural is not in place.
If the manual removal is unsuccessful, moving to a D&C can be the next step.
Sometimes retained placental fragments are not identified at delivery and can be found weeks later due to prolonged heavy bleeding. In this case, a D&C is recommended as the treatment choice to get the fragments out, and the heavy bleeding then resolves shortly after.
Thrombin
Thrombin refers to the coagulation status of the person.
This can be due to blood clotting factor levels being abnormal, which could lead to our body not being able to clot off even small wounds.
This can be due to a genetic condition or something that developed during pregnancy.
Two common reasons for thrombin being caused are placental abruption or amniotic fluid embolism.
These both disrupt the clotting factor levels so much that someone can develop a condition called DIC where they have depleted their clotting factors by creating small clots throughout the body and then they can begin bleeding uncontrollably, even from small wounds.
Management of Postpartum Hemorrhage
A common practice in hospitals now is to do more of an active management of the third stage of labor (placenta delivery) to try to prevent postpartum hemorrhage.
Active Management includes:
- Giving IV Pitocin to all at either delivery of the baby or the placenta,
- Fundal massage to keep the uterus firm,
- And cord traction to encourage the placenta to deliver quicker.
You always have the right to decline any of these procedures.
Treatment of Postpartum Hemorrhage
Treatment options when PPH may depend on the reason for the hemorrhage and the birthing location.
More intervention options will be available at hospitals, but out-of-hospital births (OOH) have many capabilities to respond to PPH. I would recommend asking your specific midwife what options they will have to respond to PPH if delivering OOH at home or at a free-standing birth center.
Usually the treatment starts with:
- Uterine massage (external and internal)
- Available at all birthing location options: Hospital and OOH
- Medications such as pitocin, cytotec, hemabate, methergine, and TXA. Pitocin, cytotec, hemabate, and methergine are called uterotonics. Uterotonics are medicines that cause the uterus to contract down in hopes of stopping the bleeding. If possible it could be beneficial at this time to have an additional IV line placed or if at a home birth or birth center possibly having one line placed.
- Pitocin: IV or IM. This is synthetic oxytocin that is given through the IV or given as a shot into the muscle (IM). This is the first line medications and in most cases just using pitocin is enough to stop the hemorrhage. This is routinely used in a lot of hospital as soon as the baby or placenta is delivery as a way to prevent postpartum hemorrhage.
- Cytotec: pill that can be given orally, vaginally, or rectally. Can cause temperature to rise as a side effect.
- Hemabate: IM (intramuscluar shot) Contraindicated if someone has asthma. Usually the last medication used because it can cause extreme diarrhea.
- Methergine: IM, Contraindicated if someone has hypertension.
- TXA: IV. This is an antifibrinolytic agent, which just means it prevents the breakdown of blood clots. It should be used within 3 hours of birth for it to be effective.
- These medications should be available at all hospitals, but not all home and birth centers may have these medications other than pitocin. So it could be a good question to ask during prenatal appointments.
- Emptying the bladder if it has been a while, because a full bladder can prevent the uterus from being able to contract down as well.
- Not all home and birth center will have foley catheters to use, so could be a question to ask if they will have a foley to empty the bladder during an hemorrhage.
- If placental fragments are noted when doing the internal massage, a manual removal of the fragments is done to hopefully allow the uterus to contract down.
- Can be done in all birthing locations, but pain management in hospital and OOH would be different.
- Bakri balloon: A large balloon tool that is placed inside the uterus and then inflated with fluid to place pressure on the wound inside the uterus to stop the bleeding. The blood is then collected in a bag and monitored for the next 24 hours. When the bleeding is low enough or has stopped, they slowly start to deflate the bakri till they are able to remove it. While deflating it, they monitor the bleeding closely to ensure it does not pick up.
- Not usually available in OOH locations.
- The last resort is an emergency Hysterectomy, but this is usually a decision that is made after all other interventions have been used and were not successful at stopping the bleeding.
- Not an option in OOH locations, hopefully one is able to be transferred quickly to get to a hospital for this to be done if it is needed.
- Blood Transfusion should be considered during this process as well. Its recommended that some sort of plan like a massive transfusion protocol be established in hospitals to be able to respond to PPH. If blood is being considered, having two IV lines is recommended.
- Not an option in OOH locations, will need to be transferred.
Post PPH care
Post PPH care depends on the person and what interventions are used to treat the PPH. Usually, all that is needed is closer monitoring of the bleeding with more frequent vital signs and fundal assessments. This is to ensure another hemorrhage does not occur. Education of signs and symptoms to look out for includes monitoring postpartum bleeding before being discharged home. If more interventions were used, this might lead to being moved to a higher level of care, such as an ICU is necessary.
A debrief should occur after a PPH has occurred. This includes one done with the family to go over what occurred, what interventions were used, why they were done, and as a medical team. The debrief alone could be so helpful in processing the trauma caused by the PPH for both the family and medical care team. As a medical team, we strive to improve the response in future PPH by giving feedback on the team’s response and communication during the PPH. The feedback can be both positive and negative!
Post PPH care
Post PPH care depends on the person and what interventions are used to treat the PPH. Usually, all that is needed is closer monitoring of the bleeding with more frequent vital signs and fundal assessments. This is to ensure another hemorrhage does not occur. Education of signs and symptoms to look out for includes monitoring postpartum bleeding before being discharged home. If more interventions were used, this might lead to being moved to a higher level of care, such as an ICU is necessary.
A debrief should occur after a PPH has occurred. This includes one done with the family to go over what occurred, what interventions were used, why they were done, and as a medical team. The debrief alone could be so helpful in processing the trauma caused by the PPH for both the family and medical care team. As a medical team, we strive to improve the response in future PPH by giving feedback on the team’s response and communication during the PPH. The feedback can be both positive and negative!
FAQs About Postpartum Hemorrhage (PPH):
What is the main cause of postpartum hemorrhage?
The main cause of postpartum hemorrhage is the inability of the uterus to properly contract after childbirth, which leads to excessive bleeding.
What is one of the first signs of postpartum hemorrhage?
One of the first signs of postpartum hemorrhage is excessive bleeding, which may be accompanied by large blood clots or a sudden increase in bleeding.
Who is at risk for postpartum hemorrhage?
Women who have had multiple pregnancies, a previous history of postpartum hemorrhage, a prolonged or difficult labor, a cesarean delivery, or certain medical conditions such as preeclampsia or placenta previa are at a higher risk for postpartum hemorrhage.
What are 2 common sources of postpartum hemorrhage?
Two common sources of postpartum hemorrhage are the uterus and the birth canal, which can both experience excessive bleeding after childbirth.
Will postpartum hemorrhage go away?
Postpartum hemorrhage requires immediate medical attention to prevent serious complications, and will not go away on its own.
What are red flags of postpartum hemorrhage?
Red flags of postpartum hemorrhage include excessive bleeding that is not controlled by basic measures such as massage or medication, feeling dizzy or faint, rapid heart rate, low blood pressure, and passing clots larger than a golf ball.
How can I prevent postpartum hemorrhage?
To prevent postpartum hemorrhage, it is important to receive adequate prenatal care, have a skilled healthcare provider present during labor and delivery, and receive appropriate treatment for any underlying medical conditions.
How do you stop postpartum hemorrhage?
To stop postpartum hemorrhage, healthcare providers may use a variety of interventions including uterine massage, medication, or surgical procedures such as uterine artery ligation or a hysterectomy.
When should I be worried about postpartum bleeding?
It is important to seek medical attention immediately if you experience heavy bleeding after childbirth that is not slowing down or stopping, or if you pass large blood clots or tissue.