postpartum hemorrhage is a significant
loss of blood after giving birth and
it's the number one reason for maternal
morbidity and maternal death around the
world specifically it's defined as
losing more than 500 milliliters of
blood after a vaginal delivery or more
than 1,000 milliliters after a caesarean
section delivery of course deliveries
can be messy and it's impossible to
measure the precise amount of blood
that's lost and there's the possibility
of internal bleeding so additional
criteria to consider for postpartum
hemorrhage include a decrease of 10
percent or more in hematocrit from
baseline as well as changes in the
mother's heart rate blood pressure and
oxygen saturations all of which suggest
a significant blood loss significant
bleeding in the first 24 hours after
delivery is called primary postpartum
hemorrhage and after that it's called
secondary or late postpartum hemorrhage
the most common causes of postpartum
hemorrhage can be lumped into four
groups which can easily be remembered as
the forties tone trauma tissue and
thrombin tone refers to the lack of
uterine tone also known as uterine atony
basically a soft spongy boggy uterus and
this is the main cause of postpartum
hemorrhage generally resulting in a slow
and steady loss of blood now the
universe is a muscular organ wrapped by
three layers of smooth muscle called the
myometrium which contracts during labor
to dilate and face the cervix and
ultimately push out the fetus in
placenta after delivery the myometrium
continues to contract and this squeezes
down and the placental arteries at the
point where they're attached to the
uterine wall which clamps them shut and
therefore reduces uterine bleeding and
those contractions continue for a few
weeks after delivery with uterine atony
though the uterus fails to contract
after birth and those placental arteries
don't clamp down which leads to
excessive bleeding in postpartum
hemorrhage
uterine atony can be caused by several
things repeated distension of the uterus
as a result of multiple pregnancies over
stretching from twins or triplets or any
condition that causes too much uterine
stretching can interfere with efficient
uterine contractions and lead to
diminished own in eventual uterine atony
uterine atony can also happen when the
uterine muscles fatigue during the
delivery process because of a prolonged
labor it can also happen when a woman is
unable to empty your bladder since a
full bladder can push against the uterus
and interfere with uterine contractions
finally some commonly used obstetric
medications like anesthetics especially
halothane as well as magnesium sulfate
nifedipine and terbutaline can all
interfere with uterine contractions and
increase the risk of uterine atony
uterine atony can be treated by fundal
massage or massaging the fundus the
upper section of the uterus which is
typically near the umbilicus right after
birth fundal massage causes the smooth
muscle in the uterine wall to contract
in harden if a full bladder seems to be
interfering with contractions then a
woman can urinate or have a catheter
placed if she can't avoid by herself
medication to help firm up the uterus
can also be given and if necessary the
bleeding might be stopped surgically all
right the next T trauma refers to damage
to any of the genital structures the
uterus cervix vagina and perineum this
can include the incision from missus
arian delivery incidental trauma from a
baby coming through the vaginal canal or
trauma from instruments used in delivery
for example the use of forceps vacuum
extraction or an episiotomy a small cut
used to enlarge the vaginal opening
which can also cause unintended bleeding
sometimes at bleeding's in a concealed
location and a hematoma can form which
is a mass or collection of blood and go
unnoticed for hours after delivery a key
to recognizing hematoma is severe pain
and persistent bright red vaginal
bleeding in spite of a firmly contracted
uterus in general any trauma related
bleeding is an emergen
see and the sight of bleeding has to be
repaired right away generally by
applying pressure and stitching
lacerations
next e tissue refers to placental
fragments retained in the uterine cavity
the entire placenta normally separates
from the uterine wall in the third stage
of labor but occasionally a part of the
placenta can stay behind in the uterus
in placenta accreta the placenta invades
the myometrium so it doesn't easily
separate from the uterus plus an accreta
or just too much traction on the
umbilical cord can both cause the
placenta to be retained this in turn
prevents effective uterine contractions
and leads to uterine atony
the goal with this one is to prevent it
from happening in the first place by
making sure that the placenta comes out
completely intact and removing any
tissue that does get retained as soon as
possible
thrombin the final T refers to the
mother having some condition that
prevents blood clots from forming
normally for example a genetic disorder
like von Willebrand disease or an
obstetric condition like eclampsia and
placental abruption which might result
in a clotting disorder and these can
lead to disseminated intravascular
coagulation or di C these are conditions
that prevent a clot from forming
normally when there's a bleed and this
can turn even a tiny bleed into a
serious problem since it doesn't stop
easily the treatment for each of these
is specific to the underlying cause
right so postpartum hemorrhage is an
obstetric emergency and maintaining
adequate circulating volume is a key
priority regardless of the cause
intravenous fluids and blood products
may be used to ensure that the vital
organs are well perfused
all right as a quick recap postpartum
hemorrhage is the most common cause of
maternal morbidity and mortality around
the world and the causes are the forties
tone trauma tissue and thrombin the most
common cause uterine atony can usually
be managed with fundal massage and
medications to help the uterus contract
you