Management of Postpartum Hemorrhage - Essay Example

? Postpartum hemorrhage (PPH) is a leading cause of death and morbidity relating to pregnancy (WHO, 2004). Uterine atony is said to be the major cause of postpartum hemorrhage, and trauma is reported to increase the risk for postpartum hemorrhage. Women with Postpartum hemorrhage in a pregnancy are at increased risk of PPH in a subsequent pregnancy. With this knowledge, caregivers and pregnant mothers in pre-hospital setting are able to anticipate and prevent uterine atony, as well as avoid unnecessary episiotomies, cesareans, and other genital tract trauma that have the ability to reduce to a large extend, the mortality and morbidity that result from postpartum hemorrhage. The epidemiology, clinical examination and management of postpartum hemorrhage in pre-hospital setting, including causes, management protocol, clinical approach and risk factors associated with it are presented here. Management of Postpartum Hemorrhage in the Pre-hospital Setting Introduction Elbourne et al. (2001) defined postpartum hemorrhage as the loss of more than 500 ml of blood after delivery that occurs in up to 18 percent of births. It is the most common maternal morbidity in developed countries and a major cause of death worldwide (Elbourne et al., 2001). In severe cases, blood loss exceeding 1,000 ml is considered physiologically significant and can result in hemodynamic instability (Bais et al., 2004). According to World Health Organization (WHO) report, Postpartum hemorrhage (PPH) is considered the leading cause of pregnancy related deaths worldwide (WHO, 2004) with an estimated 140,000 women dying annually from this complication (AbouZahr, 2003). Magann, Evans and Hutchinson (2005), in a study of PPH from the King Edward Memorial Hospital in Perth, Australia, found the following to be risk factors for Postpartum hemorrhage: prior postpartum hemorrhage, Asian race, antepartum hemorrhage, genital tract lacerations, macrosomia, labor induction, stillbirth, age, prolonged labor, chorioamnionitis, history of retained placenta, epidural anesthesia, and forceps after a failed vacuum (Magann Evans & Hutchinson, 2005). In a prospective cohort study, where PPH was defined as blood loss of 1000 ml or greater, Magann et al. (2005) found that the risk of PPH increased with the length of the third stage of labor. These investigators found that after 30minutes, the odds of PPH were 6 times higher than less than 30 minutes. There was an increased risk of PPH at 10 minutes (Magann et al., 2005). Clinical examination and management. The aim of postpartum hemorrhage management is to secure the life of the mother and that of the new born. Clinical examination is done to identify the causes and therefore offer correct treatment. A physical examination that includes making quick and vigilant assessment on the amount of blood lost and monitoring of vital signs that include temperature, blood pressure breathing, and pulse until breathing is controlled is done by the paramedic. As part of clinical examination, questions in regards to pregnancy, labour, and delivery experiences could be asked to assess risk factors. While bleeding is managed, other key examinations need to be performed to identify the cause and control hemorrhage. These include: examination of the uterine size, examination of the placenta for completeness and examination of birth canal for trauma. For secondary survey, perform focused physical examination. It is also prudent to examine the cervical for any tear because cervical tear causes postpartum hemorrhage that results from forceful second stage of labour before the cervix fully dilates. Ideally the cervix is supposed to dilate at a rate of one centimeter par hour failure of the same leads to complications such as prolonged labour. FAST (Focused Abdominal Sorography for Trauma) is done to look for intra-abdominal fluid and pelvic ultrasound to conclude physical examination. The best preventive strategy is active management of the third stage of labor that calls for administration of uterotonic drug (Prendiville, Elbourne, & McDonald, 2000). Postpartum hemorrhage is an obstetric emergency and, therefore, we begin by initiating care. Emergency care in this case focuses on arresting bleeding and could also imply recovery of lost blood by administering blood transfusion. In UK, midwives for home delivery are advised to put an intravenous drip in at home as they wait for an ambulance. A paramedic ambulance is called for help packed with medical kit. The paramedic massages the uterus to stimulate it for contraction in order to arrest bleeding. It is important to measure estimated blood loss as soon as possible. Monitoring of vital signs is done and this includes; temperature, blood pressure, pulse and breathing. Alerting senior obstetric and anesthetist becomes a necessity in case of adverse events. Resuscitation measures should then be started. Primary survey includes ABC; Airway assessment is done to evaluate for patency. Perform the breathing adequacy as needed provide 100% oxygen supplementation. There is need to assess the status of circulation by considering peripheral pulse to examine the source of bleeding, perineal examination, heart rate and blood pressure. Support circulation to vital organs by putting the patient into trendelenburg position. Place at least large-bore IV’s, while stating crystalloid infusion though both IV’s. Monitoring of vital signs is then established to guide continued management. A drip is set up in the ambulance en-route. It is also advisable to obtain sample for lab testing. One should consider blood culture in case the patient is malodorous as inflammation of lining of the uterus could complicate. On reaching a resourced healthcare centre or hospital, the paramedic gives a detailed report of intervention strategies employed during pre-hospital management of the situation and waits for signal from medics before living. The paramedic should not manually remove if possible; the placenta because invasive placenta is life threatening and may need specialized care. Literature review Obstetric ambulance services in pre-hospital setting. Obstetric ambulance service provider is composed of a midwife, obstetrician, anesthetist and other healthcare personnel called to attend to mothers experiencing obstetric complications occurring in community setting. The anesthetic equipment consists of intravenous infusion equipment, intravenous fluids and blood group. According to Liang (1963), Professor Farquhar was the brain behind obstetric flying squad with his injunction that “instead of rushing a shocked and collapsed patient to hospital for nursing and specialist aid the specialist and the nurse should be rushed to the scene.” In UK, in 1930s, majority of births took place at home (Liang, 1963) and there was need for emergency backup to general practitioners. The most common problems dealt with included postpartum hemorrhage, while other cases included retained placenta, as well as obstructed labour. In developed countries, most birth now occurs in hospitals and the ambulance services are well developed. Today, less than 1% of the total births in United Kingdom occur at home and the paramedics have prioritized rapid transport of distressed mothers to a hospital after managing obstetric complication on site as the primary objective. Management Protocol of postpartum hemorrhage Barbieri (2009) reported that “California Maternity Quality Care Collaborative” (CMQCC) introduced a detailed step by step management protocol for postpartum hemorrhage. Four stages of obstetrical hemorrhage are applied after a delivery to reduce maternal mortality (Barbieri, 2009). The four stages include: Stage 0: normal delivery- treated with gentle massage and oxytocin Stage 1: more than normal bleeding- establish large-bore intervention access, assemble personnel, increase oxitocin, consider the use of methergine, perform fundal massage and prepare two units of packed red cells. Stage 2: bleeding continues- check coagulation status, assemble response team, move to the operating room, place intrauterine balloon and administer additional uterotonics. One should consider dilation and curettage, uterine artery embolization and laporotomy or hysterectomy. Stage 3: bleeding continues - activate massive transfusion protocol, because more than ten units of packed red blood cells could be needed. Mobilize additional personnel, recheck laboratory tests, perform laparotomy, while consider hysterectomy. Misoprostol is an alternative drug and could be used if oxytocin is not available. The protocol is a strategy for minimizing chances of postpartum hemorrhage. It aims at identifying and correcting loss of blood before delivery. Active management After examining Cochrane review, Begley et al. (2011) suggested that even though active management significantly reduces severe maternal bleeding and anemia compared to expectant management; it was found to increase the mother’s blood pressure, use of drugs for pain relief, after pains, nausea, and vomiting (Begley et al., 2011). This study also pointed out that active management group returned to hospital to treat bleeding after discharge, and there was also reported cases of reduced birth weight because infants had a lower blood volume. The same study indicated that timing administration of oxytocin before the expulsion of placenta as part of the active management of the third stage of labour, did not help the incidence of postpartum hemorrhage if compared to administering the same drug after the expulsion of the placenta. It is apparent that these studies contradict studies by Prendiville (2000) that indicate that administration of the oxitocin before expulsion of the placenta had a significant influence. Clinical Approach Alamia and Meyer (1999) declared that loss of a lot of blood from any cause needed standard maternal resuscitation measures. According to him, blood loss of more than 1,000 ml requires quick action and an interdisciplinary team approach. Hysterectomy is the definitive treatment in women with severe, intractable hemorrhage. In patients who desire future fertility, uterus-conserving treatments include uterine packing B-lynch uterine compression sutures, artery ligation, and uterine artery embolization (Alamia & Meyer, 1999). Emergency setting for adverse events aims to minimize damage and bleeding. Interdisciplinary team approach is rich and effective in its task since there is clear division of duty. Causes of postpartum hemorrhage Uterine atony Oyelese and Ananth (2010) said that by far the most common cause of PPH is failure of adequate uterine contraction or uterine atony. It has been estimated that this is the cause of over 70% of cases of PPH. Uterine atony has always been anticipated if one is aware of risk factors associated with her conditions. Uterine over distension, such as that caused by polyhydramnios, multi fetal gestations, or fetal macrosomia may lead to uterine atony, and consequently PPH (Oyelese & Ananth, 2010). Vary rapid labor which is prolonged leads to uterine atony. It is thought that rapid labor is said to be associated with associated with vigorous rhythmic contractions that wares out the uterus, while prolonged labor usually lead to exhaustion of the uterine, or inadequate contractions of the uterine, that augmented labor also results in atony these contributes to postpartum hemorrhage. Cervical tear causes postpartum hemorrhage that results from forceful second stage of labour before the cervix fully dilates. Precipitate labour leads to cervical tear that is caused by excessive uterine contractions which leads to expulsion of the foetus within a short period of time. Cervical distortion ideally causes cervical tear because of improper functioning of the cervix. The cervix is supposed to dilate at a rate of one centimeter par hour failure of the same leads to complications such as prolonged labour. Genital Tract Trauma Generally, if PPH is not due to uterine atony, genital tract trauma is likely the cause of excessive bleeding. Trauma may result from lacerations of the perineum or cervix, episiotomy, or from uterine rupture. Causes of Postpartum Hemorrhage Uterine atony labor-related as outlined by Oyelese and Ananth (2010): Induction of labor, Oxytocin use, Precipitous labor, Prolonged labor, Chorioamnionitis, Uterine over distension, Multiple pregnancies, Placental abruption with large intrauterine clot, Fetal macrosomia, General anesthesia with inhaled agents, Genital tract trauma, Iatrogenic Cesarean delivery, Forceps delivery, Vacuum delivery Episiotomy, Spontaneous Genital tract lacerations, Uterine rupture, Retained placenta and clots Coagulation disorders, Disseminated intravascular coagulopathy, Placental abruption, Liver dysfunction, Anticoagulant therapy, Uterine inversion, Implantation of the placenta into the lower uterine segment, Placenta previa and Placenta accreta (Oyelese &Ananth 2010). All these increase occurrence of PPH. In this case, we have both iatrogenic trauma and spontaneous trauma. Another cause of postpartum hemorrhage is Cesarean delivery because it increases blood loss during delivery. Instrumental delivery using vacuum or forceps will also increase the risk of postpartum hemorrhage. Retained placenta and clots Fragments of Retained placental prevent adequate contraction of uterine and therefore lead to uterine atony and PPH. Retained placenta or placental fragments leads to loss of uterine muscle action and this then leads to improper contraction and retraction of uterine muscles hence postpartum hemorrhage. Inherited or acquired coagulation defects Disseminated intravascular coagulopathy, such as that associated with placental abruption, intrauterine fetal demise with prolonged retention of a dead fetus, massive blood loss or massive transfusion, amniotic fluid embolism, and sepsis, may lead to PPH. Other disorders of coagulation such as von Willebrand disease, thrombocytopenia, and anticoagulant therapy also are associated with excessive blood loss postpartum (Oyelese & Ananth, 2010). Uterine inversion This is a rare but important cause of PPH to strong traction on the cord before placental separation. The bleeding is probably because the uterus obviously cannot contract and compress the blood vessels. Shock is often disproportionate to the observed amount of blood loss. Nonetheless, his cause of PPH, if not recognized and treated appropriately, can become life-threatening (Oyelese & Ananth, 2010). Placenta previa and placenta accreta In cases of implantation of the placenta into the lower uterine segment, PPH is more likely. This is because the lower uterine segment is only weakly contractile, And, hence, the primary mechanism of preventing blood loss from the placental implantation site (uterine contraction) is largely ineffective. In cases of placenta accreta, the placenta actually invades the myometrium. There is no plane of cleavage at which the placenta can be separated. Thus, attempts at placental separation lead to tearing of the placenta. The remaining placental fragments and open sinuses typically lead to heavy hemorrhage (Oyelese & Ananth, 2010). Conclusion and Recommendations Postpartum hemorrhage is a condition that can be prevented by use of trained qualified personnel such as midwifes paramedics and doctors during delivery. Increase in the number of hospitals and health care centers, availability of doctors, increase in literacy level and dramatic development in telecommunication and transportation has played a key role in managing postpartum hemorrhage in pre-hospital setting. It is faster to provide care at home and transport patient to the hospital by ambulance. Individuals living far from medical services may receive specialist obstetric and anesthetic care with blood transfusion facilities at home through ambulance services in critical situation. I recommend that each district in united kingdom regularly perform a critical review of management of postpartum and justify the provision of patients’ quick access to using ambulance services. Increase to assess of basic equipment for saving life is a necessity. Decreased delay in reaching site of emergency and referral. Members of the public and family should be taught such techniques as fundal massage and need to respond to emergency. References Alamia, V. Jr., & Meyer, B. A. (1999). Peripartum hemorrhage. Obstet Gynecol Clin North Am. 26:385–98. AbouZahr, C. (2003). Global burden of maternal death and disability. Br Med Bull. 67:1– 11. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2931261/ Barbieri, R. L. (2009). “Planning reduces the risk of maternal death. This tool helps.” OBG Management 21 (8):8-10. Retrieved from http://www.jfponline.com/pages.asp?aid=7779 Bais,  J. M, Eskes  M., Pel,  M., Bonsel,  G. J, & Bleker,  O. P. (2004). Postpartum haemorrhage innulliparous women: incidence and risk factors in low and high risk women. A Dutch population-based cohort study on standard (> or = 500 ml) and severe (> or = 1000 ml) postpartum haemorrhage.  Eur J Obstet Gynecol Reprod Biol.,115:166–72. Retrieved from doi:  10.1097/AOG.0b013e3181a66b05 Begley, C., Gyte, G., Devane, D., McGuire, W., & Weeks, A. (2011). Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews (11). Retrieved from doi: 10.1002/14651858.CD007412.pub3. Elbourne, D. R., Prendiville,  W. J., Carroli,  G., Wood,  J., McDonald,  S. (2001). Prophylactic use of oxytocin in the third stage of labour. Cochrane Database Syst Rev., (4):CD001808. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11687123 Magann, E. F., Evans, S., Hutchinson, M., et al. (2005). Postpartum hemorrhage after vaginal birth: an analysis of risk factors. South Med J., 98:419–422. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2895792/ Magann, E. F., Evans, S., Chauhan, S. P., Lanneau, G., Fisk, A. D., Morrison, J. C. (2005). The length of the third stage of labor and the risk of postpartum hemorrhage.  Obstet Gynecol., 105:290–3. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15684154 Oyelese, & Ananth. (2010). Postpartum Hemorrhage: Epidemiology, Risk Factors, and Causes. Clinical obstetrics and gynecology 53, (1), 147–156 Retrieved from www.clinicalobgyn.co Prendiville, W. J., Elbourne, D., McDonald, S. (2000). Active versus expectant management in the third stage of labour. Cochrane Database Syst Rev.;(3): CD000007. Retrieved from http://www.aafp.org/afp/2006/0315/p1025.html Liang, D. Y. S. (1963). The emergency obstetric service, Belshill Maternity Hospital: 1933-61. J Obstet Gynecol Br Commonwealth, 70:83-93. World Health Organization. (2004). Maternal mortality in 2000: estimates developed by WHO, UNICEF, and UNFPA. Geneva: WHO. Retrieved from http://www.cabdirect.org/abstracts/20043210432.html;jsessionid=E49DC2A3A558085A 0AC8788003BD6160 Read More