PRACTICE GUIDELINES University of Mississippi Medical Center Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine The Wiser

Hospital for Women and Infants Jackson, Mississippi

BLEEDING: POSTPARTUM HEMORRHAGE I. GENERAL A. Definition Postpartum hemorrhage is defined as > 500 mL blood loss for vaginal delivery and 1000 mL after cesarean birth. It complicates more than 10% of all deliveries. B. Symptomatology A more helpful classification is to determine the percentage of blood volume lost as it applies to patient symptomatology.1 Classes of Hemorrhage Based on Patient Symptoms Class I % Blood loss Pulse Systolic BP Mean arterial pressure (MAP) II. 15 Normal Normal 80-90 Class II 20-25 100 Normal 80-90 Class III 30-35 120 70-80 50-70 Class IV 40 140 60 50

DIFFERENTIAL DIAGNOSIS A. Conditions associated with postpartum hemorrhage following vaginal delivery include2 : 1. Uterine atony (MgSO4, oxytocin, overdistended uterus, prolonged/precipitous labor, amnionitis) 2. Genital lacerations 3. Uterine inversion 4. Coagulopathy B. Conditions following cesarean section are usually due to: 1. Uterine atony 2. Uterine rupture 3. Lacerations of vessels in the cardinal ligament 4. Placentation abnormalities (accreta, etc.) C. Others 1. Coagulopathy 2. Retained placenta 3. General anesthesia

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MANAGEMENT (Figures 1, 2) A. Manipulative 1. Re-examine patient and drain bladder 2. Check for cervical and vaginal lacerations 3. Elevate the uterus with vaginal hand and massage using abdominal hand 4. Ultrasound, D & C for retained products 5. Consider use of MAST suit (particularly useful if transport necessary) 6. Aortal compression at surgery or via pressure through the abdominal wall (helpful if patient in shock)3 7. Gel foam/vasopressin embolization via selective arteriography4 (must place lines before surgery in high-risk patients) B. Medical 1. Oxytocin - 40 units in 1000 cc of crystalloid at 200 mL/hour 2. Methylergonovine - 0.2 mg IM (only use if normotensive and NEVER use this drug by the IV route) 3. Prostaglandins a. 15 methyl PGF2" (Hemabate) 0.25 mg intramuscularly (or intramyometrial via the vagina or through the abdomen) - may be repeated every 20 minutes up to 6 doses (DO NOT GIVE IF THE PATIENT HAS A HISTORY OF ASTHMA) b. Prostaglandin E2 suppositories - may be inserted rectally or wrapped in a 4x4 gauze and placed vaginally anterior to the cervix 4. Uterine packing - 3-4 five-yard Kerlex rolls tied together and soaked in betadine remove 6-24 hours (pack uterus and vagina - will need Foley) C. Stepwise Surgical Treatment 1. Foley catheter tamponade (useful in cervical pregnancies or in repaired cervical lacerations that continue to bleed) 2. Uterine artery ligation - O'Leary stitch (Figure 3) 3. Consider B-Lynch suture placement 4. Ovarian artery ligation 5. Hypogastric artery ligation 6. Hysterectomy D. Uterine Inversion (Figures 4,5) - use Huntington or Haultain surgical techniques via laparotomy if manual replacement does not work) SEQUENTIAL ACTION FOR PATIENTS WITH POSTPARTUM HEMORRHAGE A. Identify cause as rapidly as possible (lacerations, retained products, atony, intraabdominal [no visible blood loss], etc.) B. Bimanual exam with cervicovaginal inspection, empty bladder C. Treat hypovolemia dependent on blood loss, liberal crystalloid replacement, monitor output, type/match blood D. Intravenous, high-dose oxytocin E. Methergine if not responsive to oxytocin (normotensive only) F. Methylated prostaglandin (Hemabate) or prostaglandin E2 (Prostin E) - AVOID IN ASTHMATICS G. Cytotec (Misoprostol) Regimen - 400 mg per rectum H. Uterine packing - pack uterus and vagina (will need Foley) I. Inform patient and family J. Re-evaluation of patient's hemodynamic status; give blood according to NIH protocol in Anemia in Pregnancy Guidelines (Figure 6) BLEEDING: POSTPARTUM HEMORRHAGE 5:2

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K. Prepare for surgery and/or arteriography/embolization L. Transfer to tertiary center if stable and unable to give definitive therapy V. CONSULTATION Twenty-four hour consultation concerning this protocol or any other assessment of problems is available by calling the Wiser Hospital for Women and Infants. For those outside Jackson, the number is 1-800-962-2213 (toll free), or for those inside Jackson, 815-7200. Specify if you wish to speak with the faculty physician on call instead of the resident physician. UTILIZATION OUTSIDE UMC These guidelines for care within UMC are prepared primarily for the use of our nursing, medical student, and resident physician personnel. They are available for distribution to any health care provider with the understanding that the concepts and practices stated herein will meritably be modified to some extent to fit the individual patient and the individual institution.

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Revised: October, 2002

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