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10 practical, evidence-based recommendations for the management of severe postpartum hemorrhage

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From planning ahead to calling in a multidisciplinary team in special cases, here is advice on handling this obstetric emergency


Dr. Sibai reports no financial relationships relevant to this article.

By the time a pregnancy reaches term, approximately 500 to 800 mL of blood are circulating through the uterus and placenta every minute, thanks to the intricate network of blood vessels permeating these organs. So it is not surprising that postpartum hemorrhage complicates as many as one in every 20 deliveries, both vaginal and cesarean. Usually, hemorrhage is the result of uterine atony, but other entities may also cause or contribute to acute bleeding.

Severe postpartum hemorrhage, defined as a loss of more than 1,500 mL of blood, complicates approximately 1% of all deliveries and is a leading cause of maternal death. Severe PPH poses serious and often unpredictable challenges to obstetric providers, from the need to make an early diagnosis and establish and treat the cause to the ability to manage hemorrhagic shock.

In this article, I sort through data on the management of this potentially catastrophic event and summarize 10 evidence-based recommendations that can help reduce acute and long-term maternal complications.

1. Plan and rehearse a step-by-step approach

Wise A, Clark V. Challenges of major obstetric haemorrhage. Best Pract Res Clin Obstet Gynaecol. 2010;24(3):353–365.

It is important to anticipate and prepare for the possibility of PPH so that you can respond quickly and effectively when it occurs. Evaluation and management should be simultaneous and should not be hindered by confusion or chaos. Successful management requires early recognition; identification of the cause; the securing of help; continuous monitoring of vital signs and blood loss; prompt resuscitation with fluids, blood, and blood products; and medical or surgical treatment.

2. Know the signs and symptoms of severe hemorrhage

Moore J, Chandraharn E. Management of massive postpartum haemorrhage and coagulopathy. Obstet Gynaecol Reprod Med. 2010;20(6):174–180.

Persistent vaginal bleeding is the first sign of PPH. The bleeding may be continuous oozing or it may be profuse. In addition to bleeding, the patient will exhibit several of the signs and symptoms listed in the TABLE.

Signs and symptoms of postpartum hemorrhage

Systolic pressure, ≤90 mm HgAnxiety
Pulse, ≥110 beats per minuteTachypnea
Narrow pulse pressureDizziness
Hunger for air
Coldness and clamminessConfusion
Pale appearance
Oliguria or anuria

3. Call for help within 10 minutes after making
the diagnosis of PPH

Driessen M, Bouvier-Colle MH, Dupont C, et al. Postpartum hemorrhage resulting from uterine atony after vaginal delivery. Factors associated with severity. Obstet Gynecol. 2011;117(1):21–31.

In the early stages of uterine atony, delaying care beyond 10 minutes increases the risk of severe PPH.

4. Identify patients at very high risk of hysterectomy
and end-organ dysfunction

O’Brien D, Babiker E, O’Sullivan O, et al. Prediction of peripartum hysterectomy and end organ dysfunction in major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol. 2010;153(2):165–169.

Rossi AC, Lee RH, Chmait RH. Emergency postpartum hysterectomy for uncontrolled postpartum bleeding: a systematic review. Obstet Gynecol. 2010;115(3):637–644.

In a study of 117 cases of severe obstetric hemorrhage, several independent risk factors for peripartum hysterectomy and end-organ dysfunction were identified:

  • number of previous cesarean deliveries (odds ratio [OR], 3.28; 95% confidence interval [CI], 1.95–5.5)
  • placenta previa (OR, 13.5; 95% CI, 7.7–184)
  • placenta accreta (OR, 37.7; 95% CI, 7.7–184)
  • uterine rupture (OR, 7.25; 95% CI, 1.25–42)
  • number of units of red blood cells (RBCs) transfused (OR, 1.31; 95% CI, 1.13–1.5).

5. Perform uterine-compression sutures within 1 hour
after delivery

Kayem G, Kurinczuik JJ, Alfirevic Z, Spark P, Brocklehurst P, Knight M; UK Obstetric Surveillance System (UKOSS). Uterine compression sutures for the management of severe postpartum hemorrhage. Obstet Gynecol. 2011;117(1):14–20.

Balloon tamponade of the uterine cavity and uterine-compression sutures are crucial in the management of PPH. In a series of 211 women who were treated with a uterine-compression suture to control PPH, the rate of hysterectomy was 16% if the procedure was performed within an hour of delivery, but it rose to 42% with a delay of 2 to 6 hours.

6. When you suspect placenta previa or placenta accreta,
plan delivery by a multidisciplinary team

Eller AG, Bennett MA, Sharshiner M, et al. Maternal morbidity in cases of placenta accreta managed by multidisciplinary care team compared with standard obstetric care. Obstet Gynecol. 2011;117(2 Pt 1):331–337.

Placenta previa and placenta accreta are frequently associated with severe intrapartum and postpartum hemorrhage. In a retrospective cohort study of 141 cases of placenta accreta that were managed by a multidisciplinary care team (n=79) or received standard obstetric care (n=62), women managed by the multidisciplinary team were less likely (43% vs 61%) to require a large volume of transfusion. They were also less likely to require reoperation within 7 days of delivery for bleeding complications (3% vs 36%) and less likely to experience composite maternal morbidity (47% vs 75%).


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