Manage Postpartum Hemorrhage
Don’t fail to recognize PPH – even the most subtle ongoing bleeding post-delivery can qualify - A Pickens
image by: HWN
HWN Suggests
3 Thoughts
As a veteran of many a PPH, I’d just add in a couple of thoughts: – If the patient is not bleeding much, don’t worry too much about delivering the placenta immediately. It can take a few minutes (or sometimes half an hour or more) for “separation” to occur, after which time the placenta comes away pretty easily on it’s own. If you’re pulling on the cord before then (even gently) there is an increased risk of uterine inversion or retained products...
When in doubt – the highest yield intervention is bimanual compression. You don’t have to remember any drug doses and can do that for as long as it takes to have help arrive to start thinking about all the drugs.
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Management of postpartum hemorrhage
All patients get oxytocin: Either 10 units IM or 40 units in 1L of normal saline, run open until the uterus is firm, then at 200ml/hr (ACOG 2017; Anderson 2007; WHO 2012).
Post Partum Hemorrhage in the ED
Post partum hemorrhage (PPH) is a common and dangerous complication of child birth. According to CDC estimates, hemorrhage is the most common cause of maternal death in both developed and developing countries.
The 4 T’s of Postpartum Hemorrhage
PPH is a rare entity in the ED, but a systematic approach is vital to managing this life-threatening complication of delivery.
Articles of Interest
Approach to Postpartum Hemorrhage
The majority of PPH etiologies can be remembered by the 4T’s: Tone, Trauma, Tissue, and Thrombin.
OBJECTIVE 4: Managing Postpartum Hemorrhage
Remember the “4 T’s” as possible underlying causes of PPH with uterine atony, by far, being the most common. Try to fix uterine tone first by utilizing the typical sequence of bladder decompression, uterine massage and uterotonic agents.
Precipitous Delivery and Postpartum Hemorrhage in the Emergency Department
Most PPH will respond to first line atony treatments.
Sim Corner: Post Partum Hemorrhage
Most common etiologies: uterine atony > trauma/lacerations> retained products> coagulopathy. Have a step-wise process to evaluate for the above causes...
TXA in Post-Partum Hemorrhage
The WOMAN study demonstrated that TXA confers a small but significant decrease in death from bleeding in patients with PPH without an increase in thromboembolic events. It is reasonable to consider using TXA, an inexpensive medication, in the treatment of this life-threatening disorder.
California decided it was tired of women bleeding to death in childbirth
The maternal mortality rate in the state is a third of the American average. Here's why.
Resources
First10EM
All patients get oxytocin: Either 10 units IM or 40 units in 1L of normal saline, run open until the uterus is firm, then at 200ml/hr (ACOG 2017; Anderson 2007; WHO 2012).
RebelEM
Blood loss > 500 ml after a delivery (or > 250 ml after an abortion). The management of post-abortion hemorrhage is similar to that of post-partum hemorrhage (PPH).
