It has been a busy day in your emergency department. The precipitous delivery that occurred at triage was complicated by shoulder dystocia. Luckily you had some help, and one of your colleagues is managing the neonatal resuscitation. Nurses are starting to congratulate mom and pat you on the back, when a senior nurse points out that the patient looks pretty pale. You glance at the monitor and notice a heart rate of 145 and only then do you notice that she is bleeding… a lot. We need an approach to postpartum hemorrhage.
This approach to postpartum hemorrhage was originally published in 2015. It has been on my list to update ever since the publication of the WOMAN trial (although I am not sure my recommendations changed at all after WOMAN.) Recently, I received a message from a Dr. Nancy Kerr with a few suggestions and a wonderful list of references to help optimize my recommendations. It is important to note that prevention is a big part of the management of postpartum hemorrhage. Active management of the third stage of labour includes prophylactic oxytocin and uterine massage, started soon after delivery of the anterior shoulder. (ACOG 2017) This post focuses on hemorrhage that has already begun.
Call for help: Obstetrics should be involved ASAP.
Get good vascular access and activate your massive transfusion protocol.
Palpate the uterus to assess for atony. Perform uterine fundal massage. If no response, apply bimanual compression with one hand below the uterus in the vagina and the other compressing from above through the lower abdominal wall. (ACOG 2017; WHO 2012) If pain control or sedation is required, I approach it like trauma, with small titrated doses of ketamine or fentanyl.
Start medications to address uterine tone
- 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)
- Other agents can be added as needed: (ACOG 2017; Anderson 2007)
- Misoprostol 800 mcg orally (can also be given rectally or sublingually if needed) (Tunçalp 2012)
- Methylergonovine 0.2 mg IM
- Carboprost 250 mcg IM (can repeat q 15 min to a max of 8 doses)
- There is no evidence to indicate which agents are most effective. Most guidelines would recommend using all four options, unless there was a contraindication (see notes below). (ACOG 2017)
Address potential coagulopathy. Send bloodwork to assess for coagulopathies and DIC, but start resuscitating empirically. Medications that should be considered are:
- FFP and platelets as part of massive transfusion.
- DDAVP for von Willebrand disease.
- Factor replacement for hereditary hemophilia.
- Cryoprecipitate for DIC.
Consider tranexamic acid. The initial post recommended giving 1 gram of TXA intravenously. However, the WOMAN study has since been published, and showed no benefit from TXA. (WOMAN 2017) Considering the possibility that WOMAN overlooked a benefit in the sickest patients, the limited harms of TXA, and the fact that not giving TXA goes against the guidelines, I would probably give TXA to the sickest PPH patients.
Examine the genital tract for retained products and trauma. If there are retained products in the uterus, remove them using blunt dissection with a finger. If the placenta cannot be removed, placenta accreta is likely, and the patient will require urgent transfer to the operating room. Suture any lacerations. (Anderson 2007; ACOG 2017)
If there is ongoing bleeding, you can attempt to tamponade the bleeding. (Hopefully obstetrics is involved at this point, and can help expedite transfer to the OR for definitive management.) There are a number of options for tamponade, depending on what is available in your department: (Anderson 2007; WHO 2012)
- A foley catheter is the mostly widely available option, but is small compared to the uterine cavity – you will probably need to use more than one.
- The Rusch or Bakri balloons are specifically designed for this purpose, but unlikely to be available in an emergency department.
- A Blakemore tube is another option (fold the distal tip backwards and inflate the esophageal portion of the tube).
Another temporizing option is to attempt external aortic compression. (WHO 2012) Note: Dr. Kerr wanted me to emphasize aortic compression. In her expert opinion, it works quite well.
Transfer the patient for definitive management. (ACOG 2017)
- Transfer the patient to the operating room for hysterectomy or uterine artery ligation (probably the most readily available option).
- Another option is to transfer to interventional radiology for uterine artery embolization. This options is generally only for stable patients, with persistent slow bleeding, as an attempt to maintain fertility.
The primary causes of postpartum hemorrhage are often referred to as the “4 Ts”:
Special Case: Uterine Inversion
Luckily rare, inversion of the uterus can result in life threatening hemorrhage, and requires a slightly different approach:
Like before, start fluid resuscitation and massive transfusion protocol.
You need to reduce the uterus to stop the bleeding. This is extremely painful and may require the operating room and general anesthesia to accomplish.
Do not remove the placenta until the uterus has been reduced.
To facilitate reduction, stop the oxytocin infusion. Medications may be required to relax the uterus:
- Nitroglycerine 50mcg IV q2-3min
- Terbutaline IV infusion of 5mcg/min to start, can titrate up to 25mcg/min
- Magnesium 1-4 grams IV
- Inhaled anesthetics
Using one hand, push the fundus of the uterus directly back along the line of the vagina. The most commonly described technique involves placing the fundus of the uterus in the palm of your hand with your fingers facing forward into the vagina to add circumferential pressure. Another technique is to push with a closed fist. If this fails, the patient needs to be transferred immediately to the operating room. (ACOG 2017; Anderson 2007)
After replacement, restart the oxytocin drip (40 units in 1L NS at 200ml/hr).
Maintain firm pressure on uterus, through the introitus, until the uterus is firm.
Other emergency obstetrics plans
Secondary postpartum hemorrhage occurs more than 24 hours after delivery, and can occur as long as 12 weeks postpartum. The approach is generally the same, but infection and retained products are the major causes, and so antibiotics should be added early. (ACOG 2017)
The uterotonic medications:
|Oxytocin||10-40 units per L IV or 10 units IM|
|Methylergonovine||0.2 mg IM||Hypertension, preeclampsia, cardiovascular disease|
|Carboprost||250 mcg IM q 15 minutes to max of 8 doses||Asthma|
|Misoprostol||800 mcg PO (or sublingual or rectal)|
|From ACOG 2017|
Primary differential of postpartum hemorrhage: (ACOG 2017)
- Uterine Atony
- Retained uterine products / placenta accreta
- Genital tract trauma
- Uterine inversion (rare)
- Uterine rupture (rare)
What changed from the original post?
The original version of this post recommended vaginal packing with gauze as an option. That is specifically recommended against by the world health organization (but not other organizations such as ACOG). (WHO 2012; ACOG 2017) I used to recommend misoprostol be given rectally, as that is the most common recommendation in textbooks. However, it can be given orally and most of the evidence is actually for oral or sublingual dosing, so there is no need to use the rectal route, and the rectal route may actually work slower. (ACOG 2017; Tunçalp 2017) The TXA section was also updated to reflect the results of the WOMAN trial. The original post did not mention prevention at all. Finally, I attempted to add inline citations to make the source of the recommendations more obvious.
Before you go, I would love it if you liked Fist10EM on facebookTitle image by Csutkaa on Visualhunt.com / CC BY-NC-SA
Bakri balloon image used with permission from the amazing medical illustrator Lisa Clark: http://clark-illustration.com/
Other FOAMed Resources for Postpartum Hemorrhage
ACOG. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstetrics and gynecology. 2017; 130(4):e168-e186. [pubmed]
Desai S and Henderson SO. Chapter 181. Labor and Delivery and Their Complications. In: Marx JA et al. eds. Rosen’s Emergency Medicine, 8e. Philadelphia: Elsevier Saunders; 2014.
Ducloy-Bouthors AS, Jude B, Duhamel A, et al. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care. 2011;15:(2)R117. [pubmed]
Echevarria MA, Kuhn GJ. Chapter 104. Emergencies after 20 Weeks of Pregnancy and the Postpartum Period. In: Tintinalli JE et al. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381573
Pope, Jennifer V. and Tibbles, Carrie D. (2012). The difficult emergency delivery. In: Winters, M.E. (Ed). Emergency Department Resuscitations of the Critically Ill. Dallas, Tx: ACEP.
Tunçalp Ö, Hofmeyr GJ, Gülmezoglu AM. Prostaglandins for preventing postpartum haemorrhage. The Cochrane database of systematic reviews. 2012; [pubmed]
WOMAN trial collaborators . Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet (London, England). 2017; PMID: 28456509 [free full text]
WHO recommendations for the prevention and treatment of postpartum haemorrhage. 2012. Available at: http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf