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Intraoperative Management of Postpartum Hemorrhage
Module

Simulation

Intraoperative Management of Postpartum Hemorrhage

Module

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Objectives

By the end of this lesson, you should be able to do the following:

Recognize the morbidity and mortality of obstetrical hemorrhage
Estimate blood loss amount during an obstetrical hemorrhage
Initiate early and aggressive treatment for postpartum hemorrhage
Practice techniques to manage various causes of hemorrhage

Background

Obstetrical hemorrhage is the leading cause of maternal morbidity and mortality
Postpartum hemorrhage causes 11% of maternal deaths and is the leading cause of death on the day of delivery.
Failure to recognize excessive blood loss is a major contributing factor
Lack of early recognition and intervention

Key Elements
- Recognition and prevention
  - Risk assessment
  - Active management placental delivery
- Readiness
  - Massive transfusion protocol
  - Medication dose
- Definition
  - EBL > 1000 with signs or symptoms of hypovolemia
  - Primary postpartum hemorrhage- within 24 hours of birth
  - Delayed postpartum hemorrhage- more than 24 hours after birth up to 12 weeks
- Early postpartum hemorrhage – Cumulative blood loss of >/= 1000mL
OR
- Blood loss is accompanied by signs or symptoms of hypovolemia within 24 hours of delivery
- Cumulative blood loss of 500-999mL should trigger increased supervision and potential interventions, as clinically indicated
Medium Risk
- Prior CS, uterine surgery, multiple gestations
- Grand multiparity
- Prior hemorrhage
- Large fibroids
- BMI > 40
High Risk (2 or more factors)
- Abnormal placentation, abruption
- Hct < 30
- Platelet < 70,000
- Coagulopathy
Medium Risk
- Chorioamnionitis
- Prolong oxytocin > 24 hours
- Prolong second stage
- Magnesium sulfate
- Operative delivery
- Overdistended uterus
High Risk
- New active bleeding
- Two or more medium risk factors
The 4 Ts:
- Tone Uterine atony 95%
- Tissue Retain tissue/clots
- Trauma Laceration, rupture, inversions
- Thrombin Coagulopathy
Etiology of Postpartum Hemorrhage*
- Primary
  - Uterine atony
  - Retained placenta--especially placenta accreta
  - Defects in coagulation
  - Uterine inversion
- Secondary
  - Subinvolution of placental site
  - Retained products of conception
  - Infection
  - Inherited coagulation defects
Risk Factors of Postpartum Hemorrhage**
- Prolonged labor
- Augmented labor
- Rapid labor
- History of postpartum hemorrhage
- Episiotomy, especially mediolateral
- Preeclampsia
- Overdistended uterus (macrosomia, twins, hydramnios)
- Operative delivery
- Asian or Hispanic ethnicity
- Chorioamnionitis
*Adapted from Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap L 3rd, Wenstrom KD. Obstetic hemorrhage. In: Williams obstetrics. 22nd ed. New York (NY): McGraw-Hill; 2005. p. 809-54 and Alexander J, Thomas P, Sanghera J. Treatments for secondary postpartum haemorrhage. The Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD002867. DOI: 10.1002/14651858.CD002867.

**Data from Stones RW, Paterson CM, Saunders NJ. Risk factors for major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol 1993;48:15-8 and Combs CA, Murphy EL, Laros RK. Factors associated with hemorrhage in cesarean deliveries. Obstet Gynecol 1991;77:77-82.

Symptoms Related to Blood Loss with Postpartum Hemorrhage

Blood Loss Percent (mL)	Blood Pressure (mm Hg)	Signs and Symptoms
10 to 15 (500 to 1000)	Normal	Palpitations, lightheadedness, mild increase in heart rate
15 to 25 (1000 to 1500)	Slightly low	Weakness, sweating, tachycardia (100 to 120 beats/minute)
25 to 35 (1500 to 2000)	70 to 80	Restlessness, confusion, pallor, oliguria, tachycardia (120 to 140 beats/minute)
35 to 45 (2000 to 3000)	50 to 70	Lethargy, air hunger, anuria, collapse, tachycardia (> 140 beats/minute)

Adapted from: Bonnar J. Baillierres Best Pract Res Clin Obstet Gynaecol 2000; 14:1.

- Imprecise estimation is the main factor leading to delays in treatment of hemorrhage
- Quantification of blood loss with graduated drapes, weight based measurements all provide an improved measure of actual blood loss
- The evidence that this leads to improved outcomes has not been established
- Obstetric hemorrhage bundles, of which quantitative blood loss measurements are part of, have been shown to improve clinical outcomes

Initial Management

Early recognition
Supportive care
Treat the etiology
Stop the bleeding
Unit standard, stage-based obstetrical emergency response plan
Perform bimanual uterine massage
Place 2 large IV bores
Monitor vitals/clinical signs
Administer crystalloid 3:1 replacement rate
Ensure bladder is empty
Initiate OB hemorrhage protocol
Notify anesthesia and nursing
Obtain stat labs CBC, coag, fibrinogen, T&C
Assess 4 Ts

Bimanual Compression for Uterine Atony

Medication Therapy

	Adverse Effect
Oxytocin (Pitocin) 10-40 international units/liter IV or 10 units IM (no IV access)	Causes water intoxication
Prostaglandin F2 alpha (Carboprost, Hemabate) 0.25 mg IM q 15 min x 8 doses (maximum)	Avoid with asthma
Prostaglandin E1 (Misoprostol, Cytotec) 1000mcg rectally	Fevers, Diarrhea
Prostaglandin E2 (Dinoprostone, Prostin E2) 20mg per rectum q 2 hours	Avoid with hypotension
Methylergonovine (Methergine) 0.2 milligrams/milliliters every 4 hours for 6 doses	Avoid with hypertension

Uterine Vessels, Ureter, Uterus After Cesarean Delivery

Uterine vessels, ureter, uterus after cesarean delivery.

O’ Leary Stitch (Bilateral Uterine Artery Ligation)

No. 1 chromic
Place the suture anterior to posterior in uterine myometrium
2-3 cm medial to uterine vessels
Find avascular space in broad ligament lateral to uterine artery/vein and tied
Suture is usually placed at level of cervical internal os.

O'Leary Stitch for bilateral uterine artery ligation.

Uterine Artery Ligation

B-Lynch (Brace Suture)

Number 2 chromic / 0 vicryl suture on CTX(B) needle
Rules of 3s:
- 3cm from right lateral border
- Go through 3 cm above and 3cm from lateral border
- Compresses uterine fundus 3-4 cm from right corneal border
- 3 cm anteriorly and below the lower incision margin on left side

B-Lynch brace suture.

B-Lynch Suture in Place

A large Mayo needle with #2 chromic catgut is used to enter and exit the uterine cavity at A and B. The suture is looped over the fundus and then reenters the uterine cavity posteriorly at C, which is directly below B. The suture should be pulled very tight at this point. It then enters the posterior wall of the uterine cavity at D, is lopped back over the fundus, and anchored by entering the anterior lateral lower uterine segment at E and crossing through the uterine cavity to exit at F. The free ends at A and F are tied down securely to compress the uterus.

Adapted from Obstetrics & Gynecology Case Reports & Reviews, Vol. 95, Num 6, June 2000.

Surgical Management

Uterine curettage
Placental bed suture
Uterine artery ligation
Utero-ovarian ligation
Repair uterine rupture
B-Lynch suture, multiple square sutures
Hysterectomy

B-Lynch suture in place. — B-Lynch suture

Objectives Review

You should now be able to do the following:

Recognize the morbidity and mortality of obstetrical hemorrhage
Estimate blood loss amount during an obstetrical hemorrhage
Initiate early and aggressive treatment for postpartum hemorrhage
Practice techniques to manage various causes of hemorrhage

Contributing Authors

Erika Banks, MD, FACOG Professor, Vice Chair, Residency Program Director Department of Obstetrics & Gynecology and Women’s Health Albert Einstein College of Medicine – Montefiore Medical Center
Meleen Chuang, MD, FACOG Assistant Professor Department of Obstetrics & Gynecology and Women’s Health Albert Einstein College of Medicine – Montefiore Medical Center
Veronica Lerner, MD, FACOG Associate Professor Department of Obstetrics & Gynecology and Women's Health Albert Einstein College of Medicine – Montefiore Medical Center
Heena Purswani, MD Resident University of Southern California