Postpartum Hemorrhage: Prevention and Treatment

 

Am Fam Physician. 2017 Apr 1;95(7):442-449.

Author disclosure: No relevant financial affiliations.

Postpartum hemorrhage is common and can occur in patients without risk factors for hemorrhage. Active management 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 transfusion 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.

Approximately 3% to 5% of obstetric patients will experience postpartum hemorrhage.1 Annually, these preventable events are the cause of one-fourth of maternal deaths worldwide and 12% of maternal deaths in the United States.2,3 The American College of Obstetricians and Gynecologists defines early postpartum hemorrhage as at least 1,000 mL total blood loss or loss of blood coinciding with signs and symptoms of hypovolemia within 24 hours after delivery of the fetus or intrapartum loss.4,5  Primary postpartum hemorrhage may occur before delivery of the placenta and up to 24 hours after delivery of the fetus. Complications of postpartum hemorrhage are listed in Table 13,6,7; these range from worsening of common postpartum symptoms such as fatigue and depressed mood, to death from cardiovascular collapse.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Routinely use active management of the third stage of labor, preferably with oxytocin (Pitocin). This practice will decrease the risks of postpartum hemorrhage and a postpartum maternal hemoglobin level lower than 9 g per dL (90 g per L), and reduce the need for manual removal of the placenta.

A

11, 12, 16, 18

Oxytocin is the most effective treatment for postpartum hemorrhage, even if already used for labor induction or augmentation or as part of active management of the third stage of labor.

A

8, 23, 24

Avoid routine episiotomy, which increases the risk of blood loss and anal sphincter tears, unless urgent delivery is necessary and the perineum is thought to be a limiting factor.

A

25

When needed, use massive transfusion protocols to decrease the risk of dilutional coagulopathy and other postpartum hemorrhage complications.

C

7, 38

Interdisciplinary team training with realistic simulation should be used to improve perinatal safety.

C

46, 47


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Routinely use active management of the third stage of labor, preferably with oxytocin (Pitocin). This practice will decrease the risks of postpartum hemorrhage and a postpartum maternal hemoglobin level lower than 9 g per dL (90 g per L), and reduce the need for manual removal of the placenta.

A

11, 12, 16, 18

Oxytocin is the most effective treatment for postpartum hemorrhage, even if already used for labor induction or augmentation or as part of active management of the third stage of labor.

A

8, 23, 24

Avoid routine episiotomy, which increases the risk of blood loss and anal sphincter tears, unless urgent delivery is necessary and the perineum is thought to be a limiting factor.

A

25

When needed, use massive transfusion protocols to decrease the risk of dilutional coagulopathy and other postpartum hemorrhage complications.

C

7, 38

Interdisciplinary team training with realistic simulation should be used to improve perinatal safety.

C

46, 47


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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Table 1.

Complications of Postpartum Hemorrhage

Anemia

Anterior pituitary ischemia with delay or failure of lactation (i.e., Sheehan syndrome or postpartum pituitary necrosis)

Blood transfusion

The Authors

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ANN EVENSEN, MD, is an associate professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health, Madison; and a member of the ALSO India Advisory Board....

JANICE M. ANDERSON, MD, is associate director at Forbes Family Medicine Residency Program, Pittsburgh, Pa.; the medical director of The Midwife Center for Birth and Women's Health, Pittsburgh; and director of Women's Health at the Allegheny County Jail, Pittsburgh.

PATRICIA FONTAINE, MD, MS, is a senior clinical research investigator at the HealthPartners Institute for Education and Research, Bloomington, Minn.

Address correspondence to Ann Evensen, MD, University of Wisconsin School of Medicine and Public Health, 100 North Nine Mound Rd., Verona, WI 53593 (e-mail: ann.evensen@uwmf.wisc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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