Postpartum hemorrhage – causes, symptoms, treatment, pathology

Postpartum hemorrhage – causes, symptoms, treatment, pathology

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 500ml of blood after a vaginal delivery or more than 1000ml after a cesarean section
delivery. Of course, deliveries can be messy and it’s
impossible to measure the precise amount of blood that’s lost. In addition, there’s the possibility of
internal bleeding. So additional criteria to consider for postpartum
hemorrhage include a decrease of 10% or more in hematocrit from baseline, and changes in
a 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 “4 Ts”: Tone, Trauma,
Tissue, and Thrombin. Tone refers to a lack of uterine tone or 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. The uterus is a muscular organ wrapped by
three layers of smooth muscle called the myometrium, which contracts during labor to dilate and
efface the cervix and ultimately push out the fetus and placenta. After delivery, the myometrium continues to
contract and this squeezes down on the placental arteries at the point where they are attached
to the uterine wall, clamping them shut, thereby reducing uterine bleeding. The contractions continue for a few weeks
after the delivery. With uterine atony, though, the uterus fails
to contract after birth, and those placental arteries don’t clamp down, leading to excessive
bleeding. Uterine atony can be caused by several things,
repeated distention of the uterus as a result of multiple pregnancies, overstretching from
twins or triplets, or any condition that causes too much uterine stretching can interfere
with efficient uterine contractions and lead to diminished tone and eventual uterine atony. Uterine atony can also occur when the uterine
muscles fatigue during the delivery process because of prolonged labor. It can also occur when a woman is unable to
empty her bladder, since a full bladder can push against the uterus and interfere with
uterine contractions. Finally, some commonly used obstetric medications
such as anesthetics (especially halothane), 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,
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 wall uterine wall to contract and harden. If a full bladder seems to be interfering
with contractions, a woman can urinate or have a catheter placed if she’s unable to
void by herself. Medications to help firm up the uterus can
also be given, and if necessary, the bleeding may be stopped surgically. Alright the next ‘T’, trauma, refers to
damage to any of the genital structures – the uterus, cervix, vagina, or perineum. This can include the incision from a cesarean
delivery, incidental trauma from a baby coming through the vaginal canal, or trauma from
instruments used in the delivery. For example, the use of forceps, vacuum extraction,
or an episiotomy, a small cut used to enlarge the vaginal opening, can all cause unintended
bleeding. Sometimes the bleeding is in a concealed location
and a hematoma can form and go unnoticed for hours after delivery. A key to recognizing a 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 emergency and the site of bleeding has to be repaired right away – generally by applying
pressure and stitching lacerations. 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 remains
behind in the uterus. In placenta accreta, the placenta invades
the myometrium so it doesn’t easily separate from the uterus. Placenta accreta or simply 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 here is to prevent this 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 may result in a clotting disorder, the most dangerous of which
is disseminated intravascular coagulation or DIC. These are conditions that prevent a clot from
forming normally when there’s a bleed, and this can make even a tiny bleed into a serious
problem since it won’t easily stop. The treatment for each of these is specific
to the specific underlying cause. 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. As a quick recap, postpartum hemorrhage is
the most common cause of maternal morbidity and mortality around the world, and the causes
are the 4 T’s: Tone (atony), Trauma, Tissue, and Thrombus (coagulopathy). The most common cause – uterine atony – can
usually be managed with fundal massage and medications to help the uterus contract.

75 Replies to “Postpartum hemorrhage – causes, symptoms, treatment, pathology”

  1. 1st i had to say i love ur videos clear concept in seconds thank u for that….which didi u studied for medicine ?

  2. U are a great help for medicos , i am really very thankful to u , u cleared lots of my concepts perfectly ! Keep it up & i was just abt to tell u to make videos on obs gyn & here u are , i will also recommend surgery videos , & thanx for the help , keep uploading , i have recommeded ur channel to all my frnds !!great work 👍🏻

  3. just a suggestion for a correction, in DIC there isn't prevention of clot formation, it's actually the opposite. "Coagulation" obviously refers to clot formation, and it's usually multiple small clots in the micro-vasculature. The reason why mothers are at risk of DIC postpartum is because the body shifts from a blood viscosity lower than normal, seen during and throughout pregnancy, to a state of hypercoagulability as a physiological response used to prevent postpartum haemorrhage.

  4. Ur guys are so good n really helping in my clinical studies since im in 5th year..I really understand well after my lecture classes…thank u so much….Please keep on doing in medicine and surgery and gynae& obs…u guys are making the topic simple n easily understandable…thank u so much. .I really love it…really appreciate u guys hardwork for helping medical students like me..keep up the good work

  5. brilliant!! I love this lecture, it helped me prepare one for my OBGYN rotation where I lectured my colleagues. Also referred them here to watch!!

  6. By 'Multiple pregnancies' I guess you mean Multiparity. (As multiple pregnancy = twins or more)

  7. I would suggest that you add atleast a little bit about the steps of management of atonic post partum haemorrhage like the use of uterotonic drugs ,tamponade ,artery ligation , embolization, compression sutures etc etc.

  8. Just right after I had my 2nd child naturally, I noticed the doctors and nurses had worried looks on their faces. They were all talking and I heard the word "blood", in their conversation. They were massaging my belly for a while. They were also examining my birth canal with their hands. I can surely say, it was sooooo painful because I just had my baby 10 minutes before. Then they gave me pitocin, and a shot of something to my right thigh. I was scared and my tears were coming out. At one point, I asked them, "am I bleeding?!" A nurse said no but I believe she didn't want to frighten even more. They paged my doctor who delivered my baby. One doctor told me they didn't know what was going on and it would be too painful for me to have them examine me more right there. He wanted to take me to the O.R. to see what was happening. He gave me a form to sign (my hands were shaking). Basically, if they couldn't stop the bleeding, they were to perform a hysterectomy. Luckily, my doctor came back, continued massaging my belly, and I didn't need to go to the O.R. When they helped me to sit on the wheelchair to go to the recovery floor, I looked at the bed where I had given birth. So much blood. Even on the floor. I felt dizzy looking at that. My doctor later told me I had uterine atony and not to have any more kids. It was an extremely scary experience.

  9. Very good video.. thumbs up. Can u plis upload more video regarding o&g.. its very useful for me.. do u hv video for uterine rupture?

  10. This is a really great video, however, isn't placenta INcreta the type that "invades" the myometrium? Placenta Accreta is the abnormal attachment to the myometrium but doesn't go as deeply as "increta"

  11. Sir/Mam,
    heartly thanking you for such valuable videos
    plzz can you tell more about
    and its various types in details

  12. Risk factors for postpartum hemorrhage include a prolonged third stage of labor, multiple delivery, episiotomy, fetal macrosomia, and history of postpartum hemorrhage. However, postpartum hemorrhage also occurs in women with no risk factors. So physicians from Bio tex clinic told me that doctors must be prepared to manage this condition at every delivery. Strategies for minimizing the effects of postpartum hemorrhage include identifying and correcting anemia before delivery. Being aware of the mother's beliefs about blood transfusions, and eliminating routine episiotomy. Reexamination of the patient's vital signs and vaginal flow before leaving the delivery area may help detect slow, steady bleeding. The best preventive strategy is active management of the third stage of labor to prevent one case of postpartum hemorrhage. Hospital guidelines encouraging this practice have resulted in significant reductions in the incidence of massive hemorrhage. Active management, which involves administering an uterotonic drug with or soon after the delivery of the anterior shoulder, controlled cord traction, and, usually, early cord clamping and cutting. Decreases the risk of postpartum hemorrhage and shortens the third stage of labor with no significant increase in the risk of retained placenta. Compared with expectant management, in which the placenta is allowed to separate spontaneously aided only by gravity or nipple stimulation. Active management decreases the incidence of postpartum hemorrhage by 68 percent.

  13. This is what happened to me after I gave birth to my son almost 3 yrs ago. Lost 2.1Ltrs of blood. Grateful for both of us being alive after this ordeal. Thanks for giving me for more information on this. Much love!!

  14. I suffered blood loss of 1.7l during suction D&C for a missed miscarriage at 12 weeks and was given blood transfusion. The doctor said it was because of uterine atony but don’t know what caused it. So many unanswered questions 😔

Leave a Reply

Your email address will not be published. Required fields are marked *