Complication of 3rd stage of labor - Primary postpartum haemorrhage

1 Introduction
1.1 Definition
Primary postpartum haemorrhage (PPH) is defined as excessive bleeding in the first 24 hours post birth. There is no single definition for PPH [refer to Table 1]. Diagnosing PPH in an emergent situation most commonly occurs through estimation of volume of blood loss and changes in the haemodynamic state.

Blood loss volume
• Traditional definitions of PPH include:
o A blood loss in excess of 500 mL9,10 after vaginal birth
o A blood loss in excess of 1000 mL10-12 after caesarean section (CS)
• Severe PPH is used to describe a blood loss greater than or equal to 1000mL13
• Very severe13 or major14 PPH are used to describe a blood loss of greater than 2500 mL
Haemodynamic compromise
• Due to frequent underestimation of blood loss15, PPH may first be detected through haemodynamic compromise10 [refer to Table 6]:
o Manifests as increasing tachycardia and hypotension
• A healthy pregnant woman will only show mild signs of shock after a blood loss of 1000 mL16,17
• Conversely, compromise may occur earlier in women with10:
o Gestational hypertension with proteinuria
o Anaemia
o Dehydration
o Small stature16,18
Haematocrit
PPH can be retrospectively diagnosed by a 10% decline in postpartum haematocrit levels12
Blood transfusion
The Australian Council on Healthcare Standards indicator for PPH is19:
• Blood transfusion required after a massive blood loss equal to or greater than 1000 mL or in response to a postpartum haemoglobin (Hb) of less than 80 g/L
Secondary
Secondary postpartum haemorrhage is outside the scope of this guideline as it refers to excessive bleeding that occurs between 24 hours post birth and 6 weeks postnatally18
The World Health Organisation’s International Classification of Diseases (ICD-10) defines postpartum haemorrhage as ‘haemorrhage after delivery of fetus or infant’ and includes sub-classifications of20:
• Third stage: haemorrhage associated with retained, trapped or adherent placenta
• Other immediate: haemorrhage following delivery of placenta, postpartum haemorrhage (atonic)
• Delayed and secondary: haemorrhage associated with retained portions of placenta or membranes
• Postpartum coagulation defects: postpartum afibrinogenaemia or fibrinolysis
1.2 Incidence
PPH is the most common form of obstetric haemorrhage and is a leading cause of maternal morbidity and mortality.21 In 2010, 5.9% of birthing women in Queensland suffered a PPH.

Emergency systems
To optimise clinical response to major PPH ensure staff familiarity with the following:
• Activating a multidisciplinary response
• Duties and responsibilities when a massive transfusion protocol (MTP) is activated, including contacting:
o Or calling-in medical and/or theatre staff in an emergency
o Or calling-in local laboratory/blood bank staff for the urgent supply of blood products and processing of blood samples
o A haematologist/transfusion specialist for clinical or laboratory advice
o Retrieval Services Queensland (RSQ) to discuss/facilitate maternal transfer
o Laboratory/blood bank when there is a decision to cease MTP
• If applicable for the facility, the duties/responsibilities for:
o Activation of the emergency donor panel (EDP)
o Contacting the EDP co-ordinator – at least 2 contacts for 24 hour coverage

Common causes
The common causes (aetiology) of PPH are referred to as the ‘Four T’s’ and in order of most to least commonly occurring are3,21:
1. Tone (70 %):
o Atonic uterus
2. Trauma (20%):
o Lacerations of the cervix, vagina and perineum
o Extension lacerations at CS
o Uterine rupture or inversion
o Consider non-genital tract trauma (e.g. subcapsular liver rupture)
3. Tissue (10%):
o Retained products, placenta (cotyledon or succenturiate lobe), membranes or clots, abnormal placenta
4. Thrombin (< 1%):
o Coagulation abnormalities

Risk factors
Table 3. Risk factors for PPH
Risk factors
Aetiology
Antenatal
Increased maternal age – more than 35 years6,21
Tone
Asian ethnicity6,21
Tone/trauma
Obesity – Body mass index (BMI) of more than 35 kg/m2 6
Tone
Grand multiparity – uncertain as mixed findings6,10,15,28,29
Tone/Tissue
Existing uterine abnormalities6 (e.g. anatomical anomalies, fibroids10)
Tone
Maternal blood disorders6,10:
• Von Willebrand disease
• Idiopathic thrombocytopenia purpura
• Thrombocytopenia caused by pre-eclampsia/gestational hypertension
• Disseminating intravascular coagulation (DIC)
Thrombin
History of previous PPH6,21 or retained placenta6
Tone/tissue
Anaemia of less than 9 g/dL at onset of labour30
No reserve
Antepartum haemorrhage associated with21:6
• Suspected or proven placental abruption
• Known placenta praevia
Tissue/Tone/ Thrombin
Over distension of the uterus10:
• Multiple pregnancy
• Polyhydramnios
• Macrosomia – greater than 4 kg10,21
Tone
Intrauterine fetal death10
Thrombin
Intrapartum
Precipitate labour6,10
Trauma/Tone
Prolonged labour – first, second or third stage6,10
Tone/Tissue
Chorioamnionitis6, pyrexia in labour21 (e.g. prolonged membrane rupture10)
Tone/Thrombin
Oxytocin use31 – induction of labour6,21
Tone
Amniotic fluid emboli (AFE)/DIC10
Thrombin
Uterine inversion10
Trauma/Tone
Genital tract trauma10 (e.g. episiotomy, ruptured uterus)
Trauma
Assisted vaginal birth21
Trauma/Tone
CS – more risk with emergency (e.g. extension or lacerations from deep engagement or malpresentation10
Trauma/Tone
Postnatal
Retained products21 (e.g. placenta, cotyledons or succenturiate lobe, membranes, clots10)
Tissue
AFE/DIC10
Thrombin
Drug-induced hypotonia10 (e.g. anaesthetic, magnesium sulphate)
Tone
Bladder distension preventing uterine contraction10 (e.g. obstructed indwelling catheter (IDC), unable to void)
Tone

Third and fourth stages of labour
The care provided during the 3rd and 4th stages of labour may assist in the prevention or earlier detection and treatment of PPH.
3.1 Management of the third stage of labour
Table 4 compares outcomes of active management of the third stage versus physiological management for women with mixed risk of bleeding. Refer to Guideline: Normal birth32 for further evidence considerations for physiological and active management in the low risk woman.
Table 4. Mixed risk: active versus physiological third stage management
Active management considerations*
Reduces13
• Severe PPH
o Effect not evident in women at low risk of bleeding
• Postpartum haemoglobin less than 9 g/dL at 24-72 hours following birth
o Effect not evident in women at low risk of bleeding
• Use of therapeutic uterotonics during the third stage of labour or in the first 24 hours after birth
• Need for blood transfusion
Increases13
• Incidence of maternal diastolic BP greater than 90 mmHg
• Vomiting after birth
• After pain and use of analgesia from birth up to discharge from birth suite
• Above three findings thought to be related to the use of Ergot compounds
• Return to hospital as an in- or out-patient because of bleeding
• Postnatal maternal haemoglobin
Technique
• Administer prophylactic oxytocic soon after birth
o Insufficient evidence to identify optimal timing13
• Commence controlled cord traction– with a strong uterine contraction33 and after signs of placental separation [refer to Guideline: Normal birth32]
• Massage uterine fundus after birth of the placenta, as appropriate33
Recommendations:
• Discuss with all women antenatally:
o The risks and benefits of active and physiological management of third stage of labour13
o In active management the ability to minimise hypertensive effects and interference of placental transfusion by13:
§ Omitting the ergot component of the prophylactic uterotonic
§ Oxytocin 10 IU IM is the prophylactic uterotonic drug of choice9,10
§ Delaying cord clamping (for 2-3 minutes34)
• For women at low risk of bleeding who choose physiological management, ensure option of uterotonic as a treatment is available if:
o Excessive bleeding occurs13
o Delay in placental birth greater than 1 hour6
o Woman requests to shorten third stage