I. Look for causes--"4 T's":

  1. TONE, i.e. uterine atony (check with palpation; 70% of cases)
  2. TRAUMA, i.e. vaginal or cervical lacerations (check with inspection, 20% of cases)
  3. TISSUE, i.e. retained placental fragments, inc. placenta accreta; uterine rupture or inversion (check with manual exploration of uterine cavity; 19% of cases)
    1. Note uterine inversion can cause vasovagal response with hypotension and bradycardia
  4. THROMBIN, i.e. clotting disorders (1% of cases)

II. Prevention of postpartum hemorrhage with "Active Management" of Stage 3 of labor--In randomized studies associated with 6-18% less incidence of significant postpartum hemorrhage, need for maternal transfusion, need for use of meds to control maternal bleeding, stat. sig.change in baby's HCT and duration of stage 3 (Am. J. Obs. Gyn 177:770, 1997; Lancet 351:693, 1998; and other studies)

  1. Oxytocin immed. after delivery of baby but before del. of placenta if not twins! (10-20U in 500-1000ml IVF wide open or 10U IM)
  2. Clamp cord <30sec after delivery
  3. "Controlled" traction on cord
  4. NOTE--there is a risk of entrapment of an undiagnosed twin gestation with this approach
  5. Injection of oxytocin in the umbilical vein during third stage of labor (after delivery of baby but before delivery of placenta).

    1. In a study in 449 women at low risk for postpartum hemorrhage randomized to oxytocin 20IU vs. saline placebo via umbilical vein after cord clamping in third stage of labor, women in the oxytocin group had sig. lower mean estimated blood loss (195mL vs. 288mL) and sig. lower incidence of blood loss > 500mL (0.5% vs. 3.9%) (Obs. Gyn. 116:619, 2010-JW)

III. Treatment of postpartum hemorrhage from uterine atony

  1. Mechanical compression/massage of uterus
  2. Oxytocin 20-40U in 1L IVF at 10-15 ml/min (=200-600mu/min)--Can give IM 10U if no IV
  3. Methergine 0.2mg IM ( can repeat Q2-4h)
    1. Don't give if HTN is present
    2. Can cause contraction of lower uterine segment and entrap placenta
  4. Hemabate (15-methyl-PG F2-alpha), 0.25mg IM Q15-90min; max 8 doses
    1. Put on pulse-ox, b/c can cause bronchoconstriction
    2. Can also increase BP
    3. Often caues n/v, diarrhea, flushing, headache
    4. Use with caution if sig. asthma, HTN, or renal disease
  5. Misoprostol (PGE1 analog) per rectum
    1. 14 women requiring emergency management of severe postpartum hemorrhage, unresponsive to uterine massage, oxytocin, and ergometrine (unless contraindicated due to preeclampsia) were treated with 1000mg of misoprostol per rectum. Bleeding was controlled in all cases (Obs. Gynecol. 92:212, 1998--AFP)
    2. Advantages over hemabate: cheaper, doesn't elevate BP, doesn't have as great a propensity to pulmonary edema or exacerbation of asthma
  6. If heavy:
    1. 2nd IV
    2. Type & cross for blood
    3. Supplemental oxygen
    4. Foley to measure urine output
  1. Check labs when time allows (CBC, platelets, PT/PTT, fibrinogen)
  2. Hysterectomy as a last resort

(Sources include 2002 Advanced Life Support in Obstetrics course syllabus; American Academy of Family Physicians)