PPH

 Signs and symptoms may initially include: an increased heart rate, feeling faint upon standing, and an increased breath rate. As more blood is lost the women may feel cold, their blood pressure may drop, and they may become unconscious.

Causes of postpartum hemorrhage
Cause	Incidence
Uterine atony	70%
Trauma	20%
Retained tissue	10%
Coagulopathy	1%

·        .

 

Oxytocin is typically used right after the delivery of the baby to prevent PPH. Misoprostol may be used in areas where oxytocin is not available. Early clamping of the umbilical cord does not decrease risks and may cause anemia in the baby, thus is usually not recommended.

Active management of the third stage is a method of shortening the stage between when the baby is born and when the placenta is delivered. This stage is when the mother is at risk of having a PPH. Active management involves giving a drug which helps the uterus contract before delivering the placenta by a gentle but sustained pull on the umbilical cord whilst exerting upward pressure on the lower abdomen to support the uterus.

Another method of active management which is not recommended now is fundal pressure. A review into this method found no research and advises controlled cord traction because fundal pressure can cause the mother unnecessary pain. Allowing the cord to drain appears to shorten the third stage and reduce blood loss but evidence around this subject is not strong enough to draw solid conclusions.

Nipple stimulation and breastfeeding triggers the release of natural oxytocin in the body, therefore it is thought that encouraging the baby to suckle soon after birth may reduce the risk of PPH for the mother. A review looking into this did not find enough good research to say whether or not nipple stimulation did reduce PPH. More research is needed to answer this question.

Performing a uterine massage

Side view of a uterine massage with underlying anatomy

Uterine massage is a simple first line treatment as it helps the uterus to contract to reduce bleeding. Although the evidence around the effectiveness of uterine massage is inconclusive, it is common practice after the delivery of the placenta.

Intravenous oxytocin is the drug of choice for postpartum hemorrhage. Ergotamine may also be used.

Oxytocin helps the uterus to contract quickly and the contractions to last for longer. It is the first line treatment for PPH when its cause is the uterus not contracting well. A combination of syntocinon and ergometrine is commonly used as part of active management of the third stage of labour. This is called syntometrine. Syntocinon alone lowers the risk of PPH. Based on limited research available it is unclear whether syntocinon or syntometrine is most effective in preventing PPH but adverse effects are worse with syntometrine making syntocinon a more attractive option. Ergometrine also has to be kept cool and in a dark place so that it is safe to use. It does reduce the risk of PPH by improving the tone of the uterus when compared with no treatment however it has to be used with caution due to its effect raising blood pressure and causing worse after pains.

More research would be useful in determining the best doses of ergometrine, and syntocinon.

The difficulty using oxytocin is that it needs to be kept below a certain temperature which requires resources such as fridges which are not always available particularly in low-resourced settings. When oxytocin is not available, misoprostal can be used. Misoprostal does not need to be kept at a certain temperature and research into its effectiveness in reducing blood loss appears promising when compared with a placebo in a setting where it is not appropriate to use oxytocin. Misoprostal can cause unpleasant side effects such as very high temperatures and shivering (hyperpyrexia). Lower doses of misoprostal (400mcg and below) appear to be safer and cause less side effects.

Giving oxytocin in a solution of saline into the umbilical vein is a method of administering the drugs directly to the placental bed and uterus. However quality of evidence around this technique is poor and it is not recommended for routine use in the management of the third stage. More research is needed to ascertain whether this is an effective way of administering uterotonic drugs. As a way of treating a retained placenta, this method is not harmful but has not been shown to be effective.

Carbetocin compared with oxytocin produced a reduction in women who needed uterine massage and further uterotonic drugs for women having caesarean sections. There was no difference in rates of PPH in women having caesarean sections or women having vaginal deliveries when given carbetocin. Carbetocin appears to cause less adverse effects. More research is needed to find the cost effectiveness of using carbetocin.

Tranexamic acid, a medication to promote blood clotting, may also be used to reduce bleeding and blood transfusions in low-risk women, however evidence is not yet strong.

In some countries, such as Japan, methylergometrine and other herbal remedies are given following the delivery of the placenta to prevent severe bleeding more than a day after the birth. However there is not enough evidence to suggest that these methods are effective.

Medical devices[edit]

The World Health Organization recommends the use of a device called the non-pneumatic anti-shock garment (NASG) for use in delivery activities outside of a hospital setting, the aim being to improve shock in a mother with obstetrical bleeding long enough to reach a hospital.

Protocol[edit]

A detailed stepwise management protocol has been introduced by the California Maternity Quality Care Collaborative. It describes 4 stages of obstetrical hemorrhage after childbirth and its application reduces maternal mortality.

·        Stage 0: normal - treated with fundal massage and oxytocin.

·        Stage 1: more than normal bleeding - establish large-bore intravenous access, assemble personnel, increase oxytocin, consider use of methergine, perform fundal massage, prepare 2 units of packed red blood cells.

·        Stage 2: bleeding continues - check coagulation status, assemble response team, move to operating room, place intrauterine balloon, administer additional uterotonics (misoprostol, carboprost tromethamine), consider: uterine artery embolization, dilatation and curettage, and laparotomy with uterine compression stitches or hysterectomy.

·        Stage 3: bleeding continues - activate massive transfusion protocol, mobilize additional personnel, recheck laboratory tests, perform laparotomy, consider hysterectomy.

A Cochrane review suggests that active management (use of uterotonic drugs, cord clamping and controlled cord traction) during the third stage of labour reduces severe bleeding and anemia. However, the review also found that active management increased the mother's blood pressure, nausea, vomiting, and pain. In the active management group more women returned to hospital with bleeding after discharge, and there was also a reduction in birthweight due to infants having a lower blood volume. The effects on the baby of early cord clamping was discussed in another review which found that delayed cord clamping improved iron stores longer term in the infants. Although they were more likely to need phototherapy (light therapy) to treat jaundice, the improved iron stores are expected to be worth increasing the practice of delayed cord clamping in healthy term babies. For preterm babies (babies born before 37 weeks) a review of the research found that delaying cord clamping by 30–45 seconds increased the amount of blood flow to the baby. This is important as increased blood volume in the baby made them less likely to develop some serious complications. Much of the research around this subject is poor quality so further, larger research projects are likely to produce more reliable results