Obstetrical hemorrhage, or bleeding within the first few hours of delivery, remains the number one cause of maternal death in the world, accounting for 25 percent of all cases. In developed countries, however, advances in modern techniques to control bleeding have made the risk of death due to postpartum hemorrhage extremely low (one out of one hundred thousand). 4 The true incidence of postpartum hemorrhage is difficult to determine because of a variety of factors, including how we define hemorrhage. In one method, we say that a postpartum hemorrhage is blood loss of more than 500 milliliters, which is equivalent to about one and a half cans of soda. But determining the blood loss at delivery is an estimate. In another approach, doctors identify a postpartum hemorrhage by whether or not a patient feels symptoms of dizziness or weakness or has a drop in her blood count by 10 percent or more.
A NURSE CAN TELL
A registered nurse, Michelle was pregnant with her first child, and it was important to her to make an attempt at a natural, unmedicated childbirth. She carried to term and went into labor spontaneously, but after more than thirty hours of hard labor with no end in sight, she needed a little rest and requested an epidural. Michelle also had a low-lying placenta, where the placenta was near but not covering the cervix. Most women with low-lying placentas are still able to have normal vaginal births, as long as there are no signs of excessive bleeding during labor.
After more than forty hours, Michelle finally pushed out a beautiful baby boy. The new mom was elated but also exhausted from her hours of toil. It’s always normal to have some bleeding during the labor and after the birth. Typically, after the baby and the placenta are delivered, the uterus begins to contract on its own, to help stop the bleeding. Unfortunately, Michelle began to bleed profusely, at a time when the bleeding should have begun slowing. I followed all the steps that we normally take when we encounter excessive bleeding: massaging of the uterus to help promote contraction, IV Pitocin, careful examination of the vagina and cervix to be certain there were no lacerations, inspection of the placenta to be certain there were no fragments left behind, and an injection of methergine, a medication to help the uterus contract. But even after all these steps, Michelle still continued to bleed.
It’s important to maintain a calm, professional atmosphere in the delivery room no matter what the emergency. But Michelle, as a trained nurse, quickly noticed something out of the ordinary was going on. When she heard me ordering a second IV line and urgent lab tests, calling out for her vital signs, and asking the nurse to get two bags of blood ready, she looked up with her baby in her arms and, with a tremor in her voice, asked, "Dr. Park, thank you for being calm, but am I going to be okay?" My response was, "Yes, you will be fine. But I may have to take you to the OR in a minute if your bleeding continues this way."
Finally, Michelle’s tired uterus contracted and stopped her bleeding. Being young and healthy was a huge advantage for her. Despite the fact that she lost a large amount of blood–about two liters–she remained stable throughout the dramatic time as her body was able to compensate. After it was all over, she showed signs of anemia, so she did require a transfusion of blood, but that too went smoothly. Just a few days later, Michelle left the hospital with a beautiful infant son in her arms.
Over the years, we’ve moved away from transfusing moms unless absolutely necessary. Many factors, including maternal health, will influence the need for transfusion. Because Michelle felt quite dizzy, we knew that she would struggle with her anemia at home trying to care for and breastfeed a newborn. The blood transfusion was just what her body needed to help in its recovery from her dramatic birth experience.Alane
The risk factors for postpartum hemorrhage are:
Lacerations of the vagina or cervix,
Blood clotting disorders.
Uterine atony is the most common reason for excessive bleeding. Normally, after the baby and the placenta have been delivered, the uterus contracts to slow down and stop the uterine bleeding, called involution. Atony means the uterus resists contracting, stays soft, and continues to bleed. At term, an enormous amount of blood flows through your uterus every minute, so it does not take long to lose blood to the point where you become anemic. Remember, also, that your uterus has been distended for months, making room for a term infant, placenta, and amniotic fluid. A term uterus that was carrying your seven-pound baby must contract to half its size within minutes. The following conditions put you at risk for having uterine atony:
Any condition that distends your uterus more than the usual, such as twins, a very large baby, or polyhydramnios (excessive amounts of amniotic fluid)
Your uterus working to the point where it is totally overtaxed and exhausted and is unable to contract well anymore because the muscles are so fatigued
Long inductions, which lead to an overtired uterus
Developing an infection in the uterus during your labor
These are simply risk factors, and having any of these conditions does not necessarily mean you’ll have uterine atony. A mother’s body is resilient; you’d be surprised by what it’s able to handle.
Lacerations: Lacerations are spontaneous tears in your vagina or on your cervix that result from the baby coming through the birth canal. Depending on their location and extent, some lacerations can bleed profusely after delivery. In addition, episiotomies (a cut in the perineum made by your doctor) can also be associated with bleeding.
Abnormal placentas: The uterine blood vessels where your placenta implants are large with life-giving blood coursing through them. After the delivery of the placenta, these vessels are supposed to constrict to stop the blood flow. In abnormal placentas, such as placenta previa or accreta, the vessels may have a harder time clamping down, causing you to bleed excessively. In addition, if your placenta does not separate from the wall of the uterus completely and pieces of it are left behind, the uterus may continue to bleed.
Certain medical conditions: Some of these conditions are severe preeclampsia or blood clotting disorders.
If your doctor determines that you are bleeding excessively, you will be given an IV with fluids to help replace what your body has lost and maintain your blood pressure. The medical team will massage your uterus to help it to contract, identify any tears that need to be repaired, and examine the placenta to be sure no small fragments have been left behind.
If fundal massage is not effective, medication to help your uterus contract may be given through the IV, as an injection in your arm or thigh, or as a rectal suppository. The blood bank will be notified in case you need a blood transfusion. If all fails, your doctor may need to take you to surgery to stop the bleeding. In some cases, the large blood vessels that feed your uterus need to be tied off or, in more serious scenarios, your uterus may be removed. Remember that your doctor and nurses have been well trained for this complication, and you have to trust that they are making the right decisions for you.
You will be evaluated for anemia through a blood test. We can determine how well your body is adjusting to the anemia by measuring your vital signs and urine output. You may be able to forego a transfusion if you are healthy, your vital signs are stable, you can walk around without dizziness, and we can see that you’re able to handle your baby well.
A. Jacobs, "Overview of Postpartum Hemorrhage" (September 2010). http://www.uptodate.com/contents/overview-of-postpartum-hemorrhage (accessed February 14, 2011).
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