Obstetrics 15: Third-stage and Postpartum Emergencies Portal
Introduction
Excessive blood loss occurring during the third stage of labor or in
the postpartum period often places the mother at risk. Frequent causes
include uterine atony, retained placenta, uterine inversion, uterine
rupture, birth trauma, or clotting abnormalities. As with most
emergencies, early recognition, systematic evaluation, and rapid
treatment are essential to successful management.
Incidence and Epidemiology
Both retained placenta and postpartum hemorrhage are relatively common
complications of obstetrics. Of vaginal deliveries, 2% to 6% are
complicated by retained placenta. Postpartum hemorrhage occurs in 5% to
10% of deliveries. Other, rarer complications include uterine inversion
(1 in 2000 deliveries), uterine rupture (1 in 2500 deliveries),
acquired coagulopathy, and birth trauma (1 in 1500 to 4000 deliveries).
Patient Assessment
History. Because retained placenta and
postpartum hemorrhage are common but almost impossible to predict, a
physician must be prepared to manage them at every delivery. Prior
hemorrhage and other maternal conditions have been associated with
postpartum hemorrhage, but accurately predicting significant bleeding
has been difficult.
Retained placenta is defined as the inability to deliver the placenta within 30 minutes after the birth. Consider giving Pitocin after the delivery of the anterior shoulder as this will often prevent retained placenta and associated blood loss. When the placenta becomes unusually adherent, rare events such as placenta accreta (abnormal adherence of the chorionic villi to the myometrium), placenta increta (a form of placenta accreta in which the chorionic villi invade the myometrium), and placenta percreta (a form of placenta accreta in which the chorionic villi have invaded the full thickness of the myometrium all the way to its peritoneal covering) may occur. These may cause significant morbidity and mortality.
Early recognition is essential for successful management of postpartum hemorrhage. Postpartum hemorrhage is defined as more than 500 cc of blood loss in the first 24 hours after completion of the third stage of labor. Unfortunately, most physicians underestimate the amount of blood loss, possibly delaying the diagnosis. Doubling your first estimate of blood loss may be more accurate. Also, realize that slow but steady bleeding can be as dangerous as brisk bleeding. When bleeding occurs into the abdomen creating a large hematoma, significant blood loss may occur. This is difficult to detect and may lead to underestimation of blood loss.
If bleeding continues, direct treatment toward the specific condition. Continue with fluid resuscitation, oxygen, and vital sign monitoring. Summon additional nurses and physicians as needed for additional emergency care. Consider early blood transfusion with type-specific, un-crossmatched whole blood, a central IV line, and PASGs. Prepare for a possible operative emergency procedure when bleeding is severe and the vital signs are unstable
Retained Placenta
Exam. Once retained placenta has been
determined, begin a systematic approach to removal. If the uterus is
well contracted, the placenta is low in the uterine cavity, and the
cervix and lower uterus are contracted around the placenta, the
placenta is trapped. Treatment consists of applying suprapubic pressure
with one hand to hold the uterus in place and using firm traction on
the umbilical cord to attempt to remove the placenta. If this fails,
treat as if the placenta has not separated.
Treatment
- Prepare for the possibility of significant blood loss by placing a large bore IV.
- Notify lab for the possible need of type-specific blood and arrange for adequate anesthesia if manual removal is necessary.
- Oxytocin may be given first because it causes rhythmic uterine contractions and often induces placental detachment. Oxytocin may be given by IM or dilute IV infusion.
- If firm traction or oxytocin is not successful, manual removal is necessary.
- Consider analgesia prior to placental extraction. Morphine Sulfate 10 mg IV at the bedside or spinal analgesia in the operation room should be effective.
- Place a large Bango curette at the bedside or in the OR prior to removing the placenta in case an accreta is encountered after placental extraction.
- If there has been placental separation, try to pull the placenta through the cervix. Relaxing the uterus can help to accomplish this goal. One method of relaxation is to halt any uterine massage. Other methods include general anesthetic (with halothane) or terbutaline SQ.
- Because large amounts of blood may be lost when the uterus is relaxed, relaxing the uterus must be done quickly. Be prepared to reverse the uterine relaxation when the placenta has been removed.
- If the placenta has not separated, identify the cleavage plane between the placenta and the uterus. Slowly advance your hand along this plane. Ideally, you can deliver the placenta intact.
- After removal, examine the uterus to assure complete removal of the entire placenta and membranes. Then massage the uterus, administer oxytocin, and resuscitate the patient as needed.
- If you are unable to identify the cleavage plane or cannot find the cleavage plane along the entire placenta, you may be dealing with a placenta accreta, and a combination of manual and surgical removal is necessary.
- If the bleeding is not controllable with this method, an emergency hysterectomy is the treatment of choice.
- Late sequelae of retained placenta are late postpartum bleeding and infection. For this reason, monitor closely any woman who has had treatment for retained placenta.
Uterine Atony
Exam. Uterine massage not only
helps determine uterine atony as the cause of postpartum bleeding, but
also is the first treatment used to correct the atony and (hopefully)
to resolve the bleeding.
Treatment
- If uterine massage has not been effective, give oxytocin. Start a large bore IV, continue uterine massage, and give oxytocin either IM or by dilute IV infusion.
- Do not give oxytocin as an IV bolus due to possible transient vasodilation and resulting hypotension. If bleeding persists, administer methylergonovine.
- The usual dose of Methergine is 0.2 mg IM. Again, do not give IV.
- Effects from both oxytocin and methylergonovine are usually apparent within 5 to 10 minutes of administration.
- If bleeding from uterine atony persists in spite of massage, oxytocin administration, and methylergonovine administration, a prostaglandin is needed.
- Prostaglandin F2 alpha (Hemabate) at the dose of 0.25 mg IM or intromyometrially is often effective.
- Hemabate may be repeated every 15 minutes up to 8 doses. However, if there is not significant improvement after 2 doses, use another treatment method, such a 400 µg of rectal misoprostel (Cytotec) or surgical intervention.
- To give intramyometrially, hold the uterus up against the abdominal wall and inject directly into the uterus, through the abdominal wall.
- Uterine contractions usually begin in an average of 3 minutes. If bleeding persists in spite of the above treatments, determine a cause other than uterine atony.
Uterine Inversion
Exam. Precipitating factors for uterine
inversion include excessive traction on the umbilical cord, uterine
atony, excessive fundal pressure, placental implantation in the dome of
the uterus, congenital weakness of the uterus, and primigravidity. A
diagnosis of uterine inversion is made by identification of a
bluish-gray mass protruding from the vagina with or without the
placenta attached. Uterine inversion may also present as a vaginal mass.
Treatment
- The importance of prompt recognition and treatment cannot be overemphasized. Uterine inversion is rare but potentially life threatening if not diagnosed and treated appropriately. Significant risk for hemorrhage and shock occur.
- If uterine inversion is diagnosed before the cervix forms a contraction ring around the inverted uterus, attempt to replace the uterus immediately. Several methods are suggested to manually replace the inverted uterus back into the pelvic/abdominal cavity.
- If the initial attempts at reinversion fail or a contraction ring has already formed, general anesthesia and/or tocolytic agents are necessary.
- If able to relax the contraction ring, attempt to replace the uterus. If this is unsuccessful, surgical replacement will be required.
- At whatever point you are able to reinvert the uterus, administer oxytocin, ergonovine, or prostaglandin F2 alphato achieve uterine tone and prevent reinversion.
Uterine Rupture
Exam. Signs of uterine rupture
before delivery include vaginal bleeding, abdominal tenderness,
tachycardia, abnormal FHR, and the cessation of uterine contractions.
If an intrauterine pressure catheter is in place, the pressure will
drop to zero after uterine rupture. Other signs include postpartum
bleeding and excessive signs of circulatory collapse without excessive
external blood loss. A sign late in the process is increasing abdominal
girth.
Uterine rupture may be found on routine exam or during the evaluation of postpartum hemorrhage. A lower uterine segment rupture that is < 2 cm in size and asymptomatic requires only observation. Any other uterine rupture requires close monitoring of the patient's condition. Fluids are given as needed; consider surgical intervention for the patient.
Treatment
- Certain types of uterine rupture may cause life-threatening bleeding and must be managed rapidly. Operative intervention—either hysterectomy or surgical repair of the uterine defect—is the principal treatment.
- The patient's condition will determine the speed at which surgical repair needs to be accomplished.
- Hemodynamic instability--such as tachycardia, hypotension, and poor tissue perfusion--requires temporary measures to control the bleeding. Possible measures are direct aortic compression or anteflexion, elevation and compression of the uterus.
Acquired Coagulapathy
Exam. Most patients with coagulopathy have
been identified prior to delivery, but several obstetrical conditions
may cause a coagulation disorder. These include severe
preeclampsia/eclampsia, placental abruption, intrauterine fetal demise,
amniotic fluid embolism, and sepsis. If treatment directed toward the
more common causes of postpartum hemorrhage is ineffective, and clots
are not being formed, consider a coagulation disorder. Determine the
platelet level, as persons with low platelets are most likely to have
coagulation defects. In addition to the platelet level, initial studies
should include PT, PTT, fibrinogen level, fibrin split products, and
possibly antithrombin III levels.
Treatment
- Treatment consists of managing the underlying mechanism, continually evaluating the coagulation status of the patient, and replacing appropriate fluids.
- Goals are to maintain adequate fibrinogen levels with fresh frozen plasma, to keep the platelet count greater than 50 000, to maintain the hematocrit at 30% with packed RBCs, and to correct a prolonged PT or PTT with fresh frozen plasma.
Birth Trauma to the Mother
Exam. Risk factors include primiparity,
instrumented delivery, preeclampsia, multiple gestation, vulvovaginal
varicosities, prolonged second stage, and clotting abnormalities. Most
lacerations are found during a thorough examination to identify the
source of bleeding that is done after other attempts to control
postpartum hemorrhage have failed. The majority of hematomas present as
pain, vital sign instability, or hemodynamic change out of proportion
to the amount of external blood loss.
Treatment
- Any laceration that is bleeding significantly needs to be repaired quickly. This includes lacerations to the cervix, vagina, or perineum.
- A hematoma < 3 cm in diameter may be observed if the patient is stable.
- Any hematoma > 3 cm or persistent signs of volume depletion in spite of adequate fluid replacement should have the hematoma incised and clots evacuated.
Conclusion
Since emergencies in the third stage of labor or in the
postpartum
period are difficult to predict, practitioners must be ready to handle
a possible emergency of this type at each delivery.
Retained Placenta Algorithm
Postpartum Hemorrhage Algorithm
Perform uterine massage*
Administer oxygen
Insert large bore IV with NS or Lactated Ringer’s
Start Oxytocin 10 units IM or 10 to 40 units/L IV
@ < 250 mL/h
Administer Methergine, 0.2 mg IM
| Is hemorrhage controlled? |  |
Yes |
|
1. Maintain IV access 2. Maintain oxytocin for 24 h 3. Monitor vital signs and bleeding |
No
Proceed to Hemabate below if
hemorrhage continues**
Perform manual
uterine exploration (consider procedural sedation)
Consider the
causes of postpartum hemorrhage
