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Postpartum Hemorrhage: Prevention and Treatment ANN EVENSEN, MD, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin JANICE M

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Postpartum Hemorrhage: Prevention and Treatment ANN EVENSEN, MD, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin JANICE M This is an updated version of the article that appeared in print. Postpartum Hemorrhage: Prevention and Treatment ANN EVENSEN, MD, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin JANICE M. ANDERSON, MD, Forbes Family Medicine Residency Program, Pittsburgh, Pennsylvania PATRICIA FONTAINE, MD, MS, HealthPartners Institute for Education and Research, Bloomington, Minnesota Postpartum hemorrhage is common and can occur in patients without risk factors for hemorrhage. Active man- agement of the third stage of labor should be used routinely to reduce its incidence. Use of oxytocin after delivery of the anterior shoulder is the most important and effective component of this practice. Oxytocin is more effective than misoprostol for prevention and treatment of uterine atony and has fewer adverse effects. Routine episiotomy should be avoided to decrease blood loss and the risk of anal laceration. Appropriate management of postpartum hemorrhage requires prompt diagnosis and treatment. The Four T’s mnemonic can be used to identify and address the four most common causes of postpartum hemorrhage (uterine atony [Tone]; laceration, hematoma, inversion, rupture [Trauma]; retained tissue or invasive placenta [Tissue]; and coagulopathy [Thrombin]). Rapid team-based care minimizes morbidity and mortality associated with postpartum hemorrhage, regardless of cause. Massive trans- fusion protocols allow for rapid and appropriate response to hemorrhages exceeding 1,500 mL of blood loss. The National Partnership for Maternal Safety has developed an obstetric hemorrhage consensus bundle of 13 patient- and systems-level recommendations to reduce morbidity and mortality from postpartum hemorrhage. (Am Fam Physi- cian. 2017;95(7):442-449. Copyright © 2017 American Academy of Family Physicians.) More online pproximately 3% to 5% of obstet- Prevention at http://www. ric patients will experience post- Risk factors for postpartum hemorrhage are aafp.org/afp. partum hemorrhage.1 Annually, listed in Table 2.8 However, 20% of postpar- CME This clinical content these preventable events are tum hemorrhage occurs in women with no conforms to AAFP criteria Athe cause of one-fourth of maternal deaths risk factors, so physicians must be prepared for continuing medical 9 education (CME). See worldwide and 12% of maternal deaths in to manage this condition at every delivery. CME Quiz Questions on the United States.2,3 The American College Strategies for decreasing the morbidity and page 417. of Obstetricians and Gynecologists defines mortality associated with postpartum hem- Author disclosure: No rel- early postpartum hemorrhage as at least orrhage are listed in Table 3, 6,10-14 including evant financial affiliations. 1,000 mL total blood loss or loss of blood the choice to deliver infants in women at coinciding with signs and symptoms of high risk of hemorrhage at facilities with hypovolemia within 24 hours after delivery immediately available surgical, intensive of the fetus or intrapartum loss.4,5 Primary care, and blood bank services. postpartum hemorrhage may occur before The most effective strategy to prevent delivery of the placenta and up to 24 hours postpartum hemorrhage is active manage- after delivery of the fetus. Complications ment of the third stage of labor (AMTSL). Scan the QR code below of postpartum hemorrhage are listed in AMTSL also reduces the risk of a postpar- with your mobile device Table 13,6,7; these range from worsening of tum maternal hemoglobin level lower than for easy access to the common postpartum symptoms such as 9 g per dL (90 g per L) and the need for man- patient information hand- fatigue and depressed mood, to death from ual removal of the placenta.11 Components of out on the AFP mobile site. cardiovascular collapse. this practice include: (1) administering oxy- This review presents evidence-based rec- tocin (Pitocin) with or soon after the deliv- ommendations for the prevention of and ery of the anterior shoulder; (2) controlled appropriate response to postpartum hem- cord traction (Brandt-Andrews maneuver) orrhage and is intended for physicians who to deliver the placenta; and (3) uterine mas- provide antenatal, intrapartum, and post- sage after delivery of the placenta.11 Pla- partum care. cental delivery can be achieved using the 442Downloaded American from the Family American Physician Family Physician website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2017 American Academy of VolumeFamily Physicians. 95, Number For the 7 private,◆ April noncom 1, 2017- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Postpartum Hemorrhage Brandt-Andrews maneuver, in which firm traction on cord traction does not prevent severe postpartum hem- the umbilical cord is applied with one hand while the orrhage, but reduces the incidence of less severe blood other applies suprapubic counterpressure15 (eFigure A). loss (500 to 1,000 mL) and reduces the need for manual The individual components of AMTSL have been evalu- extraction of the placenta.21 ated and compared. Based on existing evidence, the most important component is administration of a uterotonic Diagnosis and Management drug, preferably oxytocin.12,16 The number needed to treat Diagnosis of postpartum hemorrhage begins with rec- to prevent one case of hemorrhage 500 mL or greater is 7 ognition of excessive bleeding and targeted examina- for oxytocin administered after delivery of the fetal ante- tion to determine its cause (Figure 16). Cumulative blood rior shoulder or after delivery of the neonate compared loss should be monitored throughout labor and deliv- with placebo.16 The risk of postpartum hemorrhage is also ery and postpartum with quantitative measurement, if reduced if oxytocin is administered after placental deliv- ery instead of at the time of delivery of the anterior shoul- 17 6 der. Dosing instructions are provided in Table 4. Table 3. Strategies to Reduce Morbidity and An alternative to oxytocin is misoprostol (Cytotec), an Mortality from Postpartum Hemorrhage inexpensive medication that does not require injection and is more effective than placebo in preventing postpar- Readiness by every unit 12 tum hemorrhage. However, most studies have shown Have a hemorrhage cart with medications, supplies, checklist, that oxytocin is superior to misoprostol.12,18 Misoprostol and instruction cards immediately available also causes more adverse effects than oxytocin—com- Establish a response team and know who to call when help is monly nausea, diarrhea, and fever within three hours of needed birth.12,18 Establish massive and emergency release transfusion protocols The benefits of controlled cord traction and uterine Institute unit education on protocols and run unit-based drills massage in preventing postpartum hemorrhage are less Recognition and prevention efforts for every patient clear, but these strategies may be helpful.15,19,20 Controlled Antenatal assessment Screen for and treat anemia antenatally Screen for sickle cell disease and thalassemia in women of African, Southeast Asian, or Mediterranean descent Table 1. Complications of Postpartum Obtain sonograms for women at high risk of invasive placenta Hemorrhage Perform delivery in facility with blood bank and in-house surgical services if the patient has a high risk of hemorrhage Anemia Death Identify Jehovah’s Witnesses and other patients who decline Anterior pituitary ischemia Dilutional coagulopathy blood products with delay or failure of Fatigue Intrapartum management lactation (i.e., Sheehan Myocardial ischemia Use active management of the third stage of labor in every syndrome or postpartum delivery pituitary necrosis) Orthostatic hypotension Avoid routine episiotomy Blood transfusion Postpartum depression Avoid instrumented deliveries, especially forceps Information from references 3, 6, and 7. Use perineal warm compresses Measure cumulative blood loss and track postpartum vital signs Response for every hemorrhage Use an emergency management plan with checklists Table 2. Risk Factors for Postpartum Provide support program for patients, families, and staff Hemorrhage Reporting and systems learning for every unit Establish a culture of huddles and postevent debriefs Antepartum hemorrhage Maternal obesity Complete a multidisciplinary review for systems issues Augmented labor Multifetal gestation Establish a perinatal quality improvement committee Chorioamnionitis Preeclampsia Adapted with permission from Council on Patient Safety in Women’s Fetal macrosomia Primiparity Health Care. Obstetric hemorrhage patient safety bundle. http:// Maternal anemia Prolonged labor safehealthcareforeverywoman.org/patient-safety-bundles/obstetric- hemorrhage/ [login required]. Accessed October 16, 2016. Additional Information from reference 8. information from references 6, and 11 through 14. April 1, 2017 ◆ Volume 95, Number 7 www.aafp.org/afp American Family Physician 443 Postpartum Hemorrhage Table 4. Medications Used for Prevention and Treatment of Postpartum Hemorrhage Medication Dosage Prevention Treatment Contraindications and cautions Mechanism of action Adverse effects Cost* First-line agent Oxytocin (Pitocin) Prevention: 10 IU IM or 5 to + + Overdose or prolonged use can cause water Stimulates the upper segment of the Rare $1 ($13) for 10 IU IV bolus intoxication myometrium to contract rhythmically, 10 units of Treatment: 20 to 40 IU in 1 L Possible hypotension with IV use following
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