Katlyn Carter

Practice Guideline Last updated: 10/24/19

Evaluation and Management of Postpartum Hemorrhage (PPH)
Definition: Postpartum hemorrhage is the leading cause of maternal mortality and morbidity in
both developed and developing countries. It causes about 8% of maternal deaths in the United
States and 25% in developing countries (Gruenberg, 2008). PPH can lead to shock, renal failure,
acute respiratory distress syndrome, coagulopathy, and can lead to other system dysfunction or
failures. In addition, it can interfere with the early postpartum period by causing hypotension,
anemia, and exhaustion (Gruenberg, 2008).
Primary/early PPH develops within the first 24 hours of birth. (occurs in 1-3% of women)
Secondary/late PPH occurs 24 hours to 12 weeks postpartum.
60% of those who hemorrhage are high risk. 40% are low risk.

Traditionally defined as blood loss >500mL, but quality of blood should be considered, in
addition to s/s of shock (may be individualized).

“…best defined by the provider who deems blood loss significant enough to warrant
intervention” (Gruenberg, 2008)

Assessment
 Risk Factors
 Obesity
 High parity
 Asian or Hispanic
 Precipitous labor
 Preeclampsia
 Uterine overdistention related to multiple gestation, polyhydramnios, or macrosomia
 Long, difficult labor
 Rapid, intense labor
 Preterm delivery
 Prior PPH
 Previous cesarean delivery
 Increased risk of time between birth of baby and birth of placenta exceeds 30 mins
 May also occur in the ABSENCE OF RISK FACTORS

 Subjective Symptoms
 bleeding exceeding 500ml
 lightheadedness
  vertigo
 syncope
 hypotension
 tachycardia
 oliguria (producing small amounts of urine)

 Objective Symptoms
 Bleeding exceeding 500ml
 Syncope
 Hypotension
 Tachycardia
 Oliguria
 Some people may not show s/s until 25% of blood volume is lost (>1500ml)

 Clinical Test Considerations:

 CBC

Management Plan
 Therapeutic measures to consider:
 Preventative measures
 Controlled birth of head to minimize trauma
 Physiologic management of third stage with no risk factors
 Active management of third stage with risk factors
 Fundal massage after placenta is delivered
 Encourage breastfeeding and skin-to-skin

PPH Prior to the Delivery of the Placenta

 Monitor and encourage delivery of placenta, if indicated
 Watch for separation gush
 Monitor fundal height
 Controlled cord traction (windmill, if indicated)
 If no bleeding/minimal bleeding consider Intraumbilical Injection
 20-60mls saline solution injected into umbilical vein (may add Pitocin (10-30u or
misoprostol 800mcg crushed into solution)
 Remember to deduct that volume from EBL
 Manual exploration and removal may be necessary

PPH With Placenta Delivered

 First thought: Atony Worst thought: Uncontrollable hemorrhage, DIC, shock
Atony (70%), Trauma (20%), Retained products (10%), Coagulation defects (1%)
(Gruenberg, 2008)

 Check placenta for completeness

 Examine tissue (vagina, cervix, perineum) for laceration
 Consider fullness of bladder (urinary catheterization, if indicated)
 Assess maternal vital signs
 Consider uterotonic medications
 Pitocin 10 units IM or 20-40 units in 1000ml normal saline or LR IV fluids
 Misoprostol (Cytotec) 400-1000mcg rectally, sublingually, or buccally
 Methergine 0.2mg IM (indicated for persistant, boggy uterus; avoid in client with
hypertension)
 Start IV therapy (prefer 18-gauge catheter)
 Could consider enema if unable to establish catheter
 Bimanual compression (internal or external) press uterus between hands
 BT-Cath (uterine tamponade catheter for PPH)
 Consider Anti-shock garment
 Consider uterine packing (with Chitosan-covered gauze)

 Complimentary measures to consider:

 Preventatives
 Nettle or alfalfa infusion
 Motherwort tincture
 Treatment of hemorrhage due to atony
 Shepherd’s purse tincture
 Anti-Bleed herbal blend
 Breast stimulation

 Considerations for pregnancy, delivery, and breastfeeding

 PPH may make early postpartum challenging
 Exhaustion
 Shortness of breath
 Malaise
 Delayed milk production

 Client and family education

 Discuss and create transport plan
  If symptomatic, as for help before getting up/toileting/showering/etc.
 Take iron replacement therapy
 Dietary sources
 Supplements
 Blood Builder
 Hemo-Plex
 Floradix
 Yellow dock
 Vitamin C
 Rest
 Adequate nutrition
 Discuss how to recognize s&s
 Review when to call

 Follow-up
 Document findings, treatment, and client response
 Observe
 Persistent bleeding
 Signs of hypovolemia or anemia
 Weakness
 Dyspnea
 Syncope
 CBC/hematocrit and hemoglobin
 Day 1 pp
 Repeat if bleeding continues
 4-6 week check
 Indications for Consult, Collaboration, or Referral
 OB/GYN
 For hemorrhage that does not respond immediately to treatment OR as would be
expected with treatment
 S&S of shock
 For transport
 For suspicion of the following:
 Retained placental products
 Severe lacerations or hematomas
 Uterine rupture
 For anything outside the midwife’s scope of practice
References
Gruenberg, B. U. (2008). Birth Emergency Skills Training: Manual for Out of Hospital
Midwives. Synclitic Press.

King, T. L., Brucker, M. C., Kriebs, J. M., & Fahey, J. O., Gegor, C. L., Varney, H.
(2015). Varney's midwifery. Jones & Bartlett Learning.

Marshall, J. E., Raynor, M. D. (2015). Myles textbook for midwives. Philadelphia, PA: Elsevier
Ltd.

Posner, G. D., Black, A. Y., Jones, G. D., & Dy, J. (2013). Oxorn-Foote human labor and birth,
6th edition. New York: McGraw Hill.

Tharpe, N. L., Farley, C. L., & Jordan, R. G. (2016). Clinical practice guidelines for midwifery
& women's health. Jones & Bartlett Publishers.