- Postpartum Hemorrhage in Third World: A Review of Clinical Management StrategiesSadhana Gupta, Mousumi Das Ghosh
- Postpartum Hemorrhage: Se tting Criteria for Clinical AuditV Rajasekharan Nair, P Lekshmi Ammal
- Safety in the Labor WardNuzhat Aziz, Pallavi Chandra
- Clinical Governance: Standard Operating Procedure for Obstetric HemorrhageMuralidhar V Pai
- The Obstetric High-dependency Unit: Need of the HourSanjay Gupte, Girija Wagh
- Obstetric Hemorrhage: Prevention and Management (Golden Hour)MB Bellad
- Assessment of Blood LossBS Susheela Rani
- Massive Obstetric Hemorrhage and Role of Blood Transfusion in Management
INTRODUCTION
Any pregnant woman who will deliver is at risk of postpartum hemorrhage (PPH).1 Worldwide, PPH is the major cause of maternal mortality, contributing to 25% of 300,000 maternal deaths each year.2 The disease burden makes it a global priority. However, women in third world countries have higher morbidity and mortality compared to those in developed world.3,4 The main reason being “too little, too late”, which means patients do not get the right treatment (oxytocics, fluids, and blood) at the appropriate time. The suffering is due to poverty, gender inequality, and limited access to health care. These causes delay in decision to seek treatment, delay in reaching the healthcare facility due to lack of transport, road conditions and delay at the hospital due to poor health infrastructure, incorrect treatment, and excess workload.5 The fifth Millennium Development Goal (MDG-5) by the United Nations failed to achieve reduction of maternal deaths. The maternal mortality ratio (MMR) of India has fallen from 750 in the 60s to 400 in the 90s and 130 in 2014–2016. About 20% of maternal deaths happen in India in spite of having only 16% of world population.5 Most of these deaths occur within first 4 hours of delivery reflecting the importance of third stage of labor.1 To achieve the sustainable development goal by 2030, increased access to quality maternal care before, during, and after childbirth should be targeted.6
POSTPARTUM HEMORRHAGE
It is defined as blood loss more than 500 mL in vaginal birth and 1 L in cesarean section. Clinically, any blood loss that can produce hemodynamic instability should be considered as PPH.7 Primary PPH occurs within first 24 hours of birth and uterine atony is the most common cause. Secondary PPH occurs between 24 hours of birth and 6 weeks postpartum. The causes are retained products of conception, infection, or both.7 The incidence of PPH is less after vaginal birth (2–4%) compared to cesarean section (6%).5
ETIOLOGY7
The causes of PPH are classified as per mnemonic, the four Ts.
- Tone: This can be uterine atony/distended bladder
- Trauma: Uterine, cervical, or vaginal injury
- Tissue: Retained placenta or clots and abnormal placentation
- Thrombin: Pre-existing/acquired coagulopathy.
DIAGNOSIS
Postpartum hemorrhage can happen without warning. Hence, prompt diagnosis by monitoring blood loss after delivery and vitals is the key for successful management. Quantitative methods to assess blood loss are more accurate and preferable compared to visual estimation. This can be done by weighing pads and sponges before and after blood soakage. Use of underbuttock graduated drapes also helps in quantitative assessment.3
Absorbent delivery mats, which can hold 500 mL of blood is being used in many countries.4 The ordinary plastic bag (24 inches × 16 inches) used by shopkeepers can be developed into PPH bag (designed by WHO) which is cheap, easily available, and can be disposed after use.8 Clinical markers (signs and symptoms) depend on amount of blood loss and her pre-existing condition. Symptoms of hypovolemia like giddiness, weakness, palpitations, sweating, restlessness, confusion, and signs like hypotension, tachycardia, oliguria, and falling oxygen saturation should be monitored. Tachycardia is an early sign and shock is a late sign.9 Often mother experiences hypotension only after significant blood loss of more than 1,500 mL. Obstetric shock index (OSI) can be used to identify significant blood loss. This is defined as heart rate divided by systolic blood pressure and ranges between 0.7 and 0.9. Values more than 1 is an indicator for estimating blood loss and need for blood transfusion.
MANAGEMENT
A number of national and international organizations have developed and updated guidelines for the prevention and management of PPH. All healthcare facilities should have protocols based on these with local modifications as necessary.4
Stay Prepared
The strategy is to stay prepared to handle hemorrhagic emergencies. Protocols and algorithms should be available, displayed in labor room and audited from time to time to ensure that the practices are evidence based. The preparedness to face emergencies should be tested periodically through simulation-based team training (PPH drills). Drills identify the weaknesses and strengths and hence improve teamwork and coordination among staff.4 Randomized controlled trials of teamwork training report increase in knowledge, practical skills, communication, and team performance.
Maintenance of obstetric hemorrhage carts or boxes is another strategy to ensure preparedness as all the drugs and surgical instruments are in one place which saves time (Table 1).4
Management of Postpartum Hemorrhage
Management includes a range of medical, mechanical, temporizing, and surgical procedures.4 The critical steps are communicate (for help), resuscitate (assess blood loss and replace with fluids and blood), investigate (cause of bleeding), initiate uterotonics, and ligate the great arteries.10
Medical Management (Uterotonics) (Table 2)
For management of PPH, oxytocin is the first choice. It acts on the smooth muscle of the upper segment of uterus and contracts it rhythmically, constricts blood vessels, and decreases blood flow through the uterus.7 Intravenous (IV) infusion facilitates steady flow and a sustained effect. The effect can be stopped within 1 hour of discontinuing IV infusion.
Ergometrine is the second line of treatment. It acts on the smooth muscle of both upper and lower segment of uterus and contracts tetanically.115
There is increased frequency of retained placenta requiring manual removal. Also maternal adverse effects are higher.
Prostaglandin is the third line of treatment. Misoprostol may also be considered as third-line drug because of low cost, easy storage, and ease of administration compared to prostaglandin.11 There is a quick response with oral and sublingual administration but tapers fast. Vaginal or rectal administration have slower onset but prolonged effect.1 Ministry of Health and Family Welfare (MoHFW), India recommends Misoprostol as second-line treatment after oxytocin.12
A key factor in third world countries is the continued preference for home deliveries, which are often attended by family members or unskilled birth attendants. Therefore, integrated interventions that inform women and the surrounding community on birth preparedness and possible risks, and train providers in high-quality antenatal services ensuring timely detection and management or referral of high-risk obstetrical cases are essential for getting women the care they need in emergency situations.12 The MoHFW, Government of India has taken a policy decision to identify mothers who may have home delivery and distribute Misoprostol tablets in advance by Accredited Social Health Activists (ASHAs).12,15 The woman has to take one tablet of Misoprostol (600 mg) orally just after delivery of the baby and before the placenta comes out.15 ASHA/Auxiliary nurse midwife (ANM) sensitizes the key decision makers of the pregnant household for timely referral through preidentified transport for helping women access the services available as and when required. This takes care of the first two delays that cause maternal death.6
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Storage of uterotonics: Both oxytocin and methylergometrine are stored at 2–8°C. Oxytocin is preferably refrigerated, but it may be stored at room temperature up to 3 months. Misoprostol is packed in aluminum blister and stored at room temperature in a closed container.7
Fluids and blood transfusion: Resuscitation during PPH includes restoring both blood volume and oxygen carrying capacity. Two wide bore intravenous lines should be established and blood sample drawn for diagnostic tests (full blood count, coagulation screen, urea, and electrolytes) and crossmatching minimum of 4 units blood. General practice is to start with IV fluids followed by packed cells and coagulation factors. Warmed fluids reduce the risk of coagulopathy.9 Preferably isotonic crystalloids are used in place of colloids.10,12 Fluid replacement corrects hypovolemia but aggravates dilutional coagulopathy. This leads to academia and hypothermia. Crossmatched blood is the best fluid to replace and early transfusion leads to better outcome. A high concentration of oxygen should be administered.
Monitoring pulse rate, blood pressure, oxygen saturation, and urine output is the cornerstone of management. Record chart of fluid balance, blood, blood products, and procedures helps in management. Delivery of any drug to the uterus, especially intramuscular (IM) will be compromised by poor circulation, therefore fluid resuscitation should be effective.9 Ratio of fresh frozen plasma (FFP) and red blood cells (RBCs) at 1:1 or 1:2 improves survival.4 Fibrinogen levels should be maintained between 100 mg/dL and 200 mg/dL and the fall seen in severe PPH is corrected with cryoprecipitate transfusion.4
Massive postpartum hemorrhage: This is defined as the loss of more than 2,500 mL of blood and is associated with massive blood transfusion, need for obstetric hysterectomy, and critical care. This leads to increased morbidity and mortality. Main therapeutic goal is to maintain hemoglobin > 8 g/dL, platelet count > 75,000/mL, prothrombin < 1.5 × mean control, activated prothrombin time < 1.5 × mean control, and fibrinogen > 1.0 g/L.14
Role of Tranexamic acid: The World Maternal Antifibrinolytic trial (WOMAN trial) was a 7randomized, double-blind, and placebo-controlled study with a clinical diagnosis of PPH, recruiting over 20,000 women (regardless of mode of birth). The trial authors concluded that early use (within 3 hours) of IV Tranexamic acid reduces maternal death due to PPH, and that early treatment has more favorable outcome.16,17
Mechanical and Temporizing Methods
If uterotonics fail to arrest bleeding, mechanical methods need to be considered.7 Although atonicity is the major cause of PPH, other causes (three of four Ts) must be ruled out.
They include:
- Bimanual compression of the uterus (external or internal)
- Aortic compression
- Hydrostatic intrauterine balloon tamponade
- Uterine packing
- Use of an antishock garment for the treatment of shock or transfer to another level of care, or while waiting for laparotomy
- Compression sutures.
Uterine massage: Uterine massage is recommended by the WHO and International Federation of Gynecology and Obstetrics (FIGO) for treatment of PPH based on “low cost and safety”.18
Bimanual compression: In bimanual compression, one hand is inserted deep into the vagina and rotated either clockwise or counterclockwise against the cervix and uterus that is being firmly grasped by the abdominal hand. The advantage of this technique is that it can be applied by midwives also and training requirements are minimal.19
Aortic compression: Aortic compression is a simple technique which does not prevent or delay any other steps. Blood pressure is kept higher, blood is prevented from reaching the bleeding area in the pelvis, and volume is conserved.7
Uterine packing: Gauze soaked with 5,000 units of thrombin in 5 mL of saline inserted from one cornu to the other with ring forceps serves as tamponade to control bleeding.13 Careful count is documented and checked during removal and antibiotic coverage is useful. This is not recommended by WHO due to the potential risks.
Balloon tamponade: The various types of balloons used are Foley's catheter, Rusch balloon, Bakri balloon, Sengstaken-Blackmore esophageal catheter, and sterile glove and condom. If bleeding is controlled after tamponade, it is a positive test and a negative test indicates that bleeding is persisting despite tamponade and may be coming from a genital tract trauma. Cases with negative balloon tamponade test need immediate surgical interventions.14
One can use Foley's balloon catheters filled to 75 cc or 100 cc in each instance. Despite being designed for a 30 mL capacity, larger volumes up to 150 mL can be reached before the catheter bursts.19 In the absence of urinary catheters, a condom can be inserted into the uterus on a straight catheter, inflated with 200–500 mL of normal saline according to need and tied off with silk so as to facilitate retention into the uterus. A balloon tamponade alone is successful in 77.5–88.8% or more cases, thus avoiding further surgical treatment.7
Nonpneumatic antishock garment: The non-pneumatic antishock garment (NASG) is a first-aid compression garment device used in obstetric hemorrhage and shock. It looks like the bottom half of a wetsuit, cut into segments. This helps in transportation of a patient to a hospital or overcoming delay in obtaining blood and definitive treatment. The unique garment permits perineal access so that operative procedures can be accomplished.19 It acts by decreasing blood flow to the pelvis and maintaining circulation of the core organs—heart, lungs, and brain.8
WHO and FIGO recommend use of NASG.4 It is easy to use and a short training is enough for nonmedical personnel.
Referral transportation—quick initial assessment and referral: A functional referral system with teamwork between referral levels will be effective to achieve goals in third world countries. Initial assessment should be done, assessment of CAB (circulation, airway, and breathing), IV fluids started along with oxytocin infusion, bladder catheterized and uterine massage/bimanual uterine compression/aortic compression and balloon tamponade considered before transferring with ongoing uterotonic infusion.
During transporting a woman who is bleeding, a skilled health worker should accompany her.12 The woman should be kept warm with legs elevated to improve blood circulation to vital organs if NASG is not available. Uterine massage should be continued with bimanual uterine compression.
There should be unified record system and a protocol-based referral.12
Surgical Methods
A fifth T is added along with four Ts of etiology to emphasize the importance of theater and surgery in managing all patients of PPH.20
It is advisable to start with uterotonics, and then gradually step up to invasive procedures. Compression sutures and vascular ligation may be tried. Senior obstetrician should be involved, when available. In cases of massive PPH, early decision for hysterectomy should be taken.7
Vascular ligation: The aim of vascular ligation in atonic uterus is to decrease the pulse pressure and thereby reduce blood supply to the uterus.13 The median success of vascular ligation is 92%.
- Bilateral uterine artery ligation (O'Leary sutures)—first-line approach
- Utero ovarian ligament ligation—second-line approach
- Internal iliac artery ligation requires a retroperitoneal approach.
Knowledge of pelvic anatomy and course of great vessels and ureter is needed. This dampens the pulse pressure and transforms the pelvic arterial system into a venous like system losing the trip hammer effect of arterial pulsations facilitating hemostasis.10
Widely used uterine compression suture is B-Lynch. This is placing a “belt and suspenders” on the body of the uterus, whereby the fundus is compressed and held in a compact position.19 The intervention is ideal after a cesarean section when a hysterotomy wound exists on the anterior uterine surface. Other techniques like Cho multiple square suture and Hayman have been described. All these techniques have equal efficacy, approximately 60–75%.13
Nausicaa compression suture has been recently published to be useful in placenta accreta spectrum (PAS) and other causes of severe PPH.21 This preserves fertility and avoids extensive surgery in cases of PAS without parametrial invasion.
Hysterectomy: Emergency postpartum hysterectomy is the definitive treatment when conservative therapies have failed. It causes permanent loss of reproductive function and postpartum depression. However, when needed, early decision saves lives.
Radiological Methods
This technique is used before surgical intervention in a hemodynamically stable patient with active bleeding.1 Percutaneous transcatheter arterial embolization is performed by interventional radiologists and needs special set up, which is available 9in limited centers. The advantage is that it is fertility preserving. After fluoroscopic identification of bleeding vessels, they are sealed with absorbable gelatin sponges, coils or microparticles.13
Hematoma at catheterization site, technical difficulty in accessing the uterine arteries, infection, uterine ischemia requiring hysterectomy, and radiation hazards are the problems encountered.8
TRAUMATIC POSTPARTUM HEMORRHAGE
Injury to the genital tract is suspected when bleeding persists in spite of a well-contracted uterus. This may be spontaneous or iatrogenic (manipulations used to deliver the baby). Patient has to be shifted to operation theater and trained assistants are needed for adequate exposure and identification of the bleeding points. Good lighting, effective pain relief, and proper positioning is essential.8
There can be vulvar and paravaginal hematomas in lower genital tract and broad ligament and retroperitoneal hematomas adjacent to the uterus.8 Lower genital tract hematomas will need evacuation with layer closure followed by vaginal packing. Upper genital tract injury will need laparotomy and surgical therapy.
SECONDARY POSTPARTUM HEMORRHAGE
This occurs in 1% of pregnancies. Most common cause is retained products of conception with or without infection.13 Diagnosis can be confirmed by ultrasound. Uterine tenderness and low grade fever may be present.
Treatment should be focused on etiology and includes uterotonics and broad antibiotic coverage. Uterine curettage may be needed after diagnosis of retained products. Often small amount of tissue may be removed, but effective enough to control bleeding promptly. These patients may require hysterectomy if uncontrolled bleeding, hence should be counseled before initiating any operative procedure.13
TO DECIDE WHEN TO START TREATMENT
Early and proactive treatment has the best outcome and prevents coagulopathy.2 In Benedetti classification, alert line is when there is blood loss of 500–1,000 mL and no clinical signs of cardiovascular instability. Observation and staying prepared for resuscitation is advised. However, action line which calls for full protocol to resuscitate, monitor, and arrest bleeding is with blood loss more than 1,000 mL or clinical signs of shock.22
AFTER CARE
Continued care of woman over next 24–48 hours is essential. The aim is to maintain systolic blood pressure of at least 100 mm Hg and a stabilizing heart rate (90 beats/min).7
Secondary sequelae from hemorrhage include adult respiratory distress syndrome, shock, disseminated intravascular coagulation, and acute renal failure.13 These women are at risk of anemia. Hence, iron supplements should be given for at least 3 months.7 It can also lead to lactation failure. Late sequelae are infertility and pituitary infarction (Sheehan's syndrome).
Interestingly, there are increased chances of recurrence of PPH in future pregnancies.18 The incidence and volume of blood loss are also proportionate to number of episodes in previous pregnancies.
THE INDIAN SCENARIO
India is emerging as the leading economy in the world and global power, yet we are losing 10mothers to a cause, PPH which is not only preventable but also treatable even in low resource settings.8 Efforts have been made by Government of India to reduce maternal deaths like training of doctors and paramedical staff [Emergency Obstetric Care (EmOC), Basic EmOC (BEmOC), and skilled birth attendant (SBA)] and promotion of institutional deliveries under various schemes (Janani Suraksha Yojana and Janani Shishu Suraksha Karyakram). WHO and FIGO supports community-based Misoprostol distribution by health worker.4 MoHFW, Government of India has introduced home distribution of Misoprostol to pregnant women who may have home deliveries by ANMs and ASHAs.15
Federation of Obstetric and Gynaecological Societies of India (FOGSI) in collaboration with MSD for Mothers and Jhpiego implemented a 3-year program (2013–2016) aimed to increase access to high impact, evidence-based antenatal, intrapartum, and immediate postpartum care to mothers by leveraging the enterprise of private sector providers in Uttar Pradesh and Jharkhand. In the second phase, FOGSI has developed 16 core clinical standards and Manyata is a stamp of quality which ensures the best clinical practices for safer experience of mothers during childbirth. Jhpiego is providing the technical support for this quality improvement implementation.23 After five rounds of assessments, 122 out of 140 participating facilities achieved a 70% score or better, compared to only 3% of facilities at baseline.23
KEY MESSAGES
- Any pregnant woman who will deliver is at risk of PPH. This can be prevented by overcoming the three delays and by preparedness of the center to handle hemorrhagic emergencies.
- The critical steps are Communicate (for help), Resuscitate (assess blood loss and replace with fluids and blood), Investigate (cause of bleeding), Initiate uterotonics, and Ligate the great arteries.
- Conservative measures to be tried first, rapidly moving if these do not work to more invasive procedures. Along with four Ts of etiology, fifth T (Theater) is emphasized in managing patients.
- Early and proactive treatment prevents adverse outcomes and saves lives.
- Postpartum hemorrhage is a preventable and treatable disease, even in low resource settings.
- Will, Skill, and Drill of every health worker and obstetrician will overcome all hurdles.
HAEMOSTASIS is a pneumonic used in the series of sequential steps taken to control postpartum hemorrhage.
H Ask for Help
A Assess vitals, blood loss, and resuscitate
E Establish etiology and treat accordingly
M Massage uterus
O Oxytocin infusion and medical management
S Shock garment and shift to higher center/theater
T Tamponade balloon
A Apply compression sutures—B-Lynch or modified
S Systematic pelvic devascularization (uterine, ovarian, and internal iliac)
I Interventional radiologist—uterine artery embolization
S Subtotal or total hysterectomy.
REFERENCES
- Leduc D, Senikas V, Lalonde AB, et al. Active management of the third stage of labour: Prevention and Treatment of postpartum haemorrhage. J Obstet Gynaecol Can. 2009; 31(10):980–93.
- Kerr RS, Weeks AD. Postpartum haemorrhage: a single definition is no longer enough. BJOG. 2017;124(5):723–6.
- Lockhart E. Post partum hemorrhage: a continuing challenge. Hematology Am Soc Hematol Educ Program. 2015;2015:132–7.
- Devi K, Singh L, Singh M, et al. Postpartum hemorrhage and maternal deaths in North East India. Open J Obstet Gynecol. 2015;5:635–8.
- World Health Organization. (2017). World Health Statistics 2017: Monitoring health for the SDGs. [online] Available from https://www.who.int/gho/publications/world_health_statistics/2017/en/ [Last accessed July, 2019].
- FIGO Guidelines. Prevention and treatment of postpartum haemorrhage in low resource settings. Int J Gynaecol Obstet. 2012;117:108–18.
- Pankaj Desai, Atul Munshi. FOGSI Focus, 2007.
- PPH Prevention and Management. Clinical Practice, Auckland Guideline, 2015.
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- World Health Organization. (2009). WHO guidelines for the management of postpartum haemorrhage and retained placenta. [online] Available from https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241598514/en/ [Last accessed July, 2019].
- Ministry of Health and Family Welfare. Guidance note on prevention and management of postpartum hemorrhage. Maternal Health Division, Ministry of Health and Family Welfare; 2015.
- Shields LE, Goffman D, Caughey A. ACOG practice bulletin: Clinical management guidelines for obstetrician-gynecologists. Obstet Gynecol. 2017;130(4):e168–86.
- Reddi Rani P, Begum J. Recent advances in the management of major postpartum haemorrhage–A review. J Clin Diagn Res. 2017; 11(2):QE01–QE05.
- NRHM. (2013). Operational guidelines and reference manual for advance distribution of misoprostol to prevent postpartum haemorrhage during home births. [online] Available from http://www.nrhmorissa.gov.in/writereaddata/Upload/Documents/Operational%20Guidelines%20and%20Reference%20Manual%20for%20Misoprostol%20for%20PPH-Nov.%207,%202013-final.pdf [Last accessed July, 2019].
- FOGSI. (2014). Consensus statement for prevention of PPH. [online] Available from https://www.fogsi.org/wp-content/uploads/2015/11/pph.pdf [Last accessed July, 2019].
- The Lancet. WOMAN: reducing maternal deaths with tranexamic acid. Lancet. 2017;389(10084):2081.
- Association of Ontario Midwives. (2016). Postpartum hemorrhage: Clinical Practice Guideline No. 17. [online] Available from https://www.ontariomidwives.ca/sites/default/files/CPG%20full%20guidelines/CPG-Postpartum-hemorrhage-PUB.pdf [Last accessed July, 2019].
- Louis K, Mahantesh K, Christopher B-L. Postpartum hemorrhage: prevention and treatment. J Obstet Gynecol India. 2008; 58(5): 392–8.
- RANZCOG. (2017). Management of Postpartum Haemorrhage (PPH). [online] Available from https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Management-of-Postpartum-Haemorrhage-(C-Obs-43)-Review-July-2017.pdf?ext=.pdf [Last accessed July, 2019].
- Shih JC, Liu KL, Kang J, et al. ‘Nausicaa’ compression suture: a simple and effective alternative to hysterectomy in placenta accreta spectrum and other causes of severe postpartum haemorrhage. BJOG. 2019;126(3): 412–7.
- Coker A, Oliver R. Definitions and classification. In: B-Lynch C, Keith L, Lalonde A, Karoshi M (Eds). A Comprehensive Textbook of Postpartum Hemorrhage, 2nd edition. Duncow: Sapiens Publishing; 2006.
- MSD for Mothers, JHPIEGO, FOGSI. Lessons learned from a quality improvement program for private maternity care facilities in India. [online] Available from https://www.merckformothers.com/docs/White_Paper_Merck_for_Mothers.pdf [Last accessed July, 2019].