CLINICAL OBSTETRICS AND GYNECOLOGY

Volume 53, Number 1, 157–164

r 2010, Lippincott Williams & Wilkins

Clinical Evaluation
During Postpartum
Hemorrhage
JOANNE N. QUIÑONES, MD, MSCE,*
JENNIFER B. UXER, DO,w JULIA GOGLE, RNC,w
WILLIAM E. SCORZA, MD,* and
JOHN C. SMULIAN, MD, MPH*
*Division of Maternal Fetal Medicine; and w Department of
Obstetrics and Gynecology, Lehigh Valley Health Network,
Allentown, Pennsylvania

Abstract: Obstetric hemorrhage remains the most 4% to 6% of all deliveries, is defined in

important cause of maternal mortality worldwide, general terms as excessive bleeding that
accounting for 30% of all direct maternal deaths. As
the method of management depends on multiple occurs within the first 24 hours after
concurrent and sequential evaluations of the patient’s delivery.2,3 Nevertheless, the definition
status, it is helpful to have an evaluation strategy of PPH varies by mode of delivery and is
prepared for when a postpartum hemorrhage is estimated as greater than 500 mL after a
encountered to facilitate interventions. This review vaginal delivery and as greater than
describes an etiology-based approach to the clinical
evaluation of postpartum hemorrhage and a sug- 1000 mL after a cesarean delivery.4 The
gested systems process that allows both a timely and World Health Organization has defined
appropriate evaluation of the hemorrhaging mother. PPH blood loss as greater than 500 mL in
Key words: obstetric hemorrhage, maternal mortality, the first 24 hours after delivery.5 Some
etiology, evaluation propose to define PPH as a decrease in
hematocrit levels by at least 10%5 or
blood loss sufficient to cause significant
Introduction symptoms in the mother (lightheaded-
Obstetric hemorrhage remains the most ness, syncope, low blood pressure, tachy-
important cause of maternal mortality cardia, or low urine output). Although
worldwide, accounting for 30% of all not the focus of this article, secondary
direct maternal deaths.1 Primary postpar- PPH occurs between 24 hours and 6 weeks
tum hemorrhage (PPH), which occurs in after delivery, complicates 1% to 3% of
all deliveries and is most commonly owing
Correspondence: Joanne N. Quiñones, MD, MSCE,
to retained placental tissue.6
Division of Maternal Fetal Medicine, Department of Regardless of the definition used, pri-
Obstetrics and Gynecology, Lehigh Valley Health
Network, I-78 and Cedar Crest Boulevard, Allentown, mary PPH is a clinical emergency requir-
PA. E-mail: [email protected] ing urgent evaluations and interventions

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 53 / NUMBER 1 / MARCH 2010

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158 Quiñones et al

that challenge the delivering clinician size are assessed by resting one hand on
(whether obstetrician, family practi- the fundus and palpating the anterior
tioner, or midwife), anesthesia personnel, aspect of the uterus. A bimanual exam-
nursing staff, operating room facilities, ination may facilitate this assessment. If
laboratory, and blood bank. As the meth- the uterus is boggy to palpation, large
od of management depends on multiple in size, and excessive bleeding is noted,
concurrent and sequential evaluations of bleeding is likely explained by uterine
the patient’s status, it is helpful to have an atony. Risk factors for uterine atony in-
evaluation strategy prepared for when a clude prolonged use of oxytocin, rapid or
PPH is encountered to facilitate interven- prolonged labor, overdistension (in cases
tions. This is true whether the hemorrhage such as multiple gestation, polyhydram-
is at a vaginal or cesarean delivery or nios, macrosomia), chorioamnionitis,
whether it is anticipated or unexpected. grand multiparity, and use of uterine re-
However, any evaluation strategy should laxing agents (magnesium sulfate, nitro-
be cognizant of the underlying etiology of glycerin, halogenated anesthetics). With
the hemorrhage. atony, the uterus should be mobilized or
pushed cephalad and massaged as the
most important initial intervention. Uter-
Acute Evaluation of PPH - the ine elevation stretches the uterine arteries,
Obstetrician’s Approach causing compression whereas the myome-
The diagnosis of PPH should immediately trium is stimulated to contract. If tone
prompt addressing the following: (1) the remains poor after several minutes despite
clinical circumstances surrounding the vigorous massaging of the uterus, admin-
delivery, (2) a general assessment of the istration of ecbolics such as oxytocin,
patient, (3) evaluation of vital signs and methylergonovine (in the absence of hy-
(4) detailed physical examination. Impor- pertension), or prostaglandin F2-a (in the
tant questions include: Was the course of absence of significant asthma) is indicated
labor normal? Was labor long and/or was as described in other articles in this issue.
the delivery difficult? Is the patient cold, The bladder should be emptied using
anxi- intermittent or continuous catheteriza-
ous? Is the patient hemodynamically tion for persistent bleeding as a full blad-
stable? der may interfere with contraction of the
PPH is usually caused by 1 of the 4 lower uterine segment, even if the fundus
basic etiologies, defined as the 4 T’s7: appears firm.
(1) Abnormal uterine contractility or atony
Although most authorities suggest that
(tone) the placenta should be promptly exam-
(2) Lacerations or general shock trauma ined to determine if it is intact, it is often
(trauma) difficult for the clinician to divert atten-
(3) Retained products of conception (tissue) tion away from a bleeding mother. In
(4) Abnormalities of coagulation (thrombin) addition, membrane segments or cotyledon
fragments may have detached without
For a patient who delivers vaginally, leaving clues in the main placental mass,
once the placenta is delivered, excessive so uterine exploration with adequate an-
bleeding should prompt careful explora- algesia should be performed as part of an
tion of the uterus, vagina, and cervix. This early initial assessment. Routine postpar-
will usually allow an assessment of the tum uterine manual exploration and/or
first 3 etiologies, but a clinical examina- sponge curettage after all vaginal deliv-
tion may not be able to diagnose a coa- eries for prevention of bleeding is not
gulation abnormality. Uterine tone and suggested.8 Rather we prefer perform-

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 Clinical Evaluation of Postpartum Hemorrhage 159

ing such exploration if bleeding persists If bleeding persists despite a firm, well-
despite adequate tone and massage to contracted uterus, the source of bleeding
ensure there are no retained secundines. is likely from lacerations.9 Careful inspec-
Uterine exploration will also make the tion of the vagina, cervix, and uterus is
diagnosis of placental invasion or uterine therefore essential. Isolated lacerations
rupture, 2 uncommon, but life-threaten- involving the middle or upper third of
ing causes of PPH. If placental fragments the vagina, although less common, may
are noted at the time of uterine explora- extend deep into the underlying tissues
tion, manual extraction will assist in the and thus give rise to significant hemor-
removal of the products. If available, a rhage. Bleeding from these lacerations is
bedside sonogram may be expeditiously controlled by appropriate suturing. Deep
performed to evaluate retained products cervical tears should be suspected in cases
by assessing an endometrial stripe (Fig. 1). of excessive hemorrhage during and after
But in an emergency situation, uterine the third stage of labor, particularly if the
exploration may be more informative uterus is firm and well contracted. Ade-
and time efficient than performing a sono- quate exposure and careful inspection of
gram. Removal of retained products may the cervix are key elements of this evalua-
require intervention in the operating tion. An assistant should use right angle
room for evaluation under optimum anes- retractors or equivalent while the opera-
thesia and possible curettage. A large tor grasps the cervix with a ring forceps
Banjo curette should be used with gentle and evaluates any hemorrhaging lacera-
traction to decrease the risk of uterine tions. Lighting should be optimized and
perforation. Guidance with a transab- the patient may be moved to the operating
dominal sonogram may assist the clini- room if necessary to ensure adequate
cian with the removal of placental anesthesia and/or availability of instru-
fragments. Uterine inversion is a rare ments. The cervix and vagina should also
event, may be complete or incomplete, be examined for the presence of a hema-
and merits both rapid diagnosis and cor- toma that may require drainage. Anesthe-
rection as profuse hemorrhage and shock sia should be consulted as rapid blood loss
may quickly occur. may lead to rapid maternal decompensa-
tion. Intravenous lines should be ade-
quate for access in case crystalloid
volume expansion or transfusion of blood
products become necessary.
If bleeding continues despite uterine
massage, exploration, and administration
of ecbolics (as described elsewhere), mater-
nal hemodynamics should be evaluated.
Although not precise, changes in the vital
signs and clinical examination may provide
information in estimating blood loss. La-
boratory studies that should be obtained
include hemoglobin/hematocrit, platelet
count, coagulation factors (protime, partial
thromboplastin time, International Nor-
malized Ratio), and fibrinogen. The initial
FIGURE 1. Transabdominal view via sono- laboratory results may return normal but
gram of a normal postpartum uterine lining. A will serve as a baseline for the patient who
thin endometrial stripe is noted.
continues to experience excessive bleeding

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160 Quiñones et al

despite all efforts. With significant PPH, a of a vaginal delivery is frequently under-
hemorrhagic bleeding diathesis is common. estimated by 30% to 50%.10 In the setting
The hospital’s blood bank should receive a of PPH, a method of quickly and more
sample of blood for type and cross match. accurately estimating losses is needed
Blood products should be matched for the instead of employing the usual ‘‘guessti-
patient, including packed red blood cells, mate.’’
fresh frozen plasma, and cryoprecipitate. Clinical symptoms can be used to assist
In the meantime, as with any medical in determining the acute blood loss. How-
resuscitation, basic attention to airway, ever, in a PPH which does not result in
breathing, and circulation are crucial to 40% to 50% loss of maternal blood (class
avoid making a controlled effort uncon- 4), changes in clinical status may lag
trolled. This includes: behind blood loss. This can lead to under-
estimation of the blood loss secondary to
 Adequate space to evaluate and manage the time it takes for the body sys-
the patient which may require the operating tems to equilibrate.
room Immediate, more accurate, bedside
 Oxygen and airway support should general estimations of blood loss can be made.
anesthesia be needed Please clarify the Studies have shown a 16% underestima-
phrase ‘‘Access to oxygen and airway sup- tion with small losses and up to a 41%
porty’’ as it seems unclear.
 Several large-bore intravenous catheters underestimation with large losses. One
for fluids and possibly blood products
study showed that using a conical cali-
 Foley catheter placement to monitor urine brated drape to collect blood loss de-
output creased the inaccuracy of all volumes
of blood loss to <15%.11 In the event
Clinical indicators of maternal hemo- calibrated drapes are not available, other
dynamic and coagulation status include methods using equipment typically found
blood pressure, pulse (may be more sensi- in a labor room can be helpful. Blood can
tive indicator of acute hypovolemia), peri- be collected or transferred into a cali-
pheral pulse, cool extremities, hypothermia, brated basin for accurate measurement.
pale conjunctiva/nail beds, and change in 4  4 gauze sponges are typically included
sensoria (Table 1). with delivery sets. These have been shown
Visual estimation of blood loss tends to to have an average carrying capacity of
be imprecise with the degree of inaccuracy 10 ± 2 mL.12 Accounting for maternal
higher with increasing amounts of blood blood in the placenta is also important.
loss. Regardless of a practioner’s experi- Approximately 150 mL resides in the pla-
ence level, estimated blood loss at the time centa itself.10

TABLE 1. Benedetti’s Classification of Hemorrhage10

Hemorrhage Acute Blood Percent
Class Loss (mL) Loss Symptoms
1 900 15 None, palpitations, dizziness, mild tachycardia
2 1200-1500 20-25 Mild tachycardia, tachypnea, diaphoresis, weakness
3 1800-2100 30-35 Overt hypotension, tachycardia (120-160 beats/
min), tachypnea, restlessness, pallor, oliguria,
Cold and clammy extremities
4 2400 40 Hypovolemic shock

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 Clinical Evaluation of Postpartum Hemorrhage 161

A quick, more accurate bedside estima- and visualization are key elements of this
tion of acute blood loss can be made using evaluation.
the following equation: All of these evaluations need to be per-
½Number of soaked 4  40 s  ½10 mL þ formed in an expeditious, efficient man-
ner owing to the quick decompensation of
150 mL maternal blood in the placenta þ women hemorrhaging after delivery. Dur-
ing an acute hemorrhage, performing a
amount of blood in the basins ‘‘workup’’ for possible coagulation disor-
ders such as Von Willebrand disease or
Although it may take some time for the factor XI deficiency is not practical. How-
laboratory to provide results of coagula- ever, for women with previous PPH,
tion studies, a simple bedside test can many authors consider such evaluation
identify low levels of fibrinogen. A vo- necessary between pregnancies.14,15
lume of 5 mL can be placed in an extra-red
top tube (no preservative) and set aside.
Individuals with normal coagulation Acute Evaluation of PPH - a
function should form a stable clot in the Multidisciplinary Approach
tube within 8 to 10 minutes.13 If the fibrino- Owing to the significant morbidity and
gen level is low (<150 mg/dL), the blood potential mortality associated with PPH,
will not clot, or if it does, it will partially or it is of utmost importance to develop
completely dissolve in 30 to 60 minutes. effective evaluation strategies to assist
Coagulation replacement can thus be re- with the management and treatment of
quested from the blood bank as empiric the mother. Because emergency situations
therapy if the blood fails to clot within 8 to create opportunities for errors in care, it is
10 minutes. essential that obstetricians/delivery pro-
After further evaluation, the decision viders and labor and delivery staff work
to move toward more aggressive therapy together to develop systems within their
is usually a judgment call; delays in inter- units to address the coordinated manage-
vention can have catastrophic conse- ment of acute hemorrhage and massive
quences, so we recommend erring on the transfusion for the woman experiencing
side of early comprehensive evaluation PPH. Although specifics of management
and therapy. A basic strategy for evalua- and transfusion care are described in de-
tion during a PPH at vaginal delivery is tail elsewhere in this issue, we present here
outlined in Figure 2. an example of a systems process that
Evaluation of PPH at the time of cesar- allows timely and appropriate evaluation
ean delivery requires the same organized that is reproducible. At our institution,
etiology-based approach as described we refer to this process as a ‘‘Code
above. Interventions to address persistent Crimson.’’16
bleeding despite conservative measures A scheduled Code Crimson is a
include arterial ligation, uterine suturing planned delivery that will potentially in-
techniques (oversewing of a bleeding site, volve a massive transfusion situation,
B-lynch suture placement, and multiple such as placental abruption, placenta pre-
square suturing), packing, and hysterec- via, a suspicion for placenta accreta or
tomy. These techniques will be discussed suspected percreta. An unscheduled Code
elsewhere within this series of reviews. Ex- Crimson is an unexpected hemorrhage event
cessive bleeding arising from cervical and/ requiring the massive transfusion protocol.
or vaginal extensions of the hysterectomy A Code Crimson is activated either by the
requires careful exploration, inspection, attending obstetrician or the attending
and prompt repair via suturing. Exposure anesthesiologist. A designee phones the

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162 Quiñones et al

FIGURE 2. Suggested approach to the patient experiencing postpartum hemorrhage.

page operator and announces ‘‘Activate This initial communication effort is im-
Code Crimson in Labor and Delivery.’’ portant for timely management decisions
Personnel expected to respond immedi- and interventions, but is also critical for
ately to the Code Crimson include the 24 accurate evaluations of the patient through-
hour attending on call for obstetrics, the out the bleeding episode. Each member
attending anesthesiologist, and certified of the team is assigned a role for evalua-
nurse anesthetist covering obstetrics, all tion, either of the patient or the ongoing
resident physicians assigned to the obste- process.
trics service and pastoral care. Personnel After obtaining adequate intravenous
expected to call back immediately include access, the patient is provided an active
the Maternal Fetal Medicine physician on warming device (ie, Bair hugger) and
call, the Nursing Director of Labor and temperature monitoring. Stat labora-
Delivery, Chief of Obstetrics, Interven- tories include type/cross match, complete
tional Radiology physician on call, Gyne- blood count, protime, partial thrombo-
cologic Oncologist on call, the plastin time, fibrinogen, fibrin split pro-
perfusionist on call at the discretion of ducts, and metabolic profile.
Anesthesia, and the nursing supervisor. As an important component of the eva-
Both the Medical Director and manager luation of a hemorrhaging patient is the
of the blood bank are also notified of the laboratory testing, special arrangements
Code Crimson. under a Code Crimson can facilitate

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 Clinical Evaluation of Postpartum Hemorrhage 163

results. Specimens with label, patient including prepackaged laboratory tubes

identification, time, and operating room and requisition slips for blood bank and
phone number are given to the designated blood sampling as well as a surgical he-
Labor and Delivery nurse personnel who morrhage instrument tray.
then sends the specimen to the blood bank Although all of these procedures opti-
and rapid response lab. We have been able mize the evaluation and care of a patient
to refine the process in our unit such that with PPH and facilitate communication, no
results are phoned to the operating room system will prevent all adverse outcomes.
as soon as they are available—15 minutes
for hemoglobin, hematocrit, and platelet
count, 30 minutes for other Code Crim- Summary
son laboratories. Once the initial speci- PPH occurs in a significant number of
mens are sent, the obstetrician and deliveries and can lead to acute decom-
anesthesiologist directing the case deter- pensation of an otherwise healthy mother.
mine the need for subsequent studies and Effective evaluation is critical to allow
decide with blood bank personnel about appropriate therapeutic interventions.
the need for blood transfusion. An evaluation process should be orga-
Staffing by nursing includes a circulator nized around a step-wise approach that
(the patient’s primary care nurse), a scrub is implemented quickly and efficiently to
nurse, an additional coordinating nurse, a allow effective care. A Code Crimson
runner (additional person such as an nurse approach to significant hemorrhage sce-
or a technical partner), and the charge narios assists in organizing the roles of
nurse. The charge nurse (who can also physicians, nurses, and support staff to
activate the Code Crimson) designates staff prioritize medical care and effectively
to the various roles above. The charge nurse manage resources.
also prioritizes patient care needs on the
other units and communicates unit status
as indicated to the unit medical and nurs- References
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