With every delivery one thing is guaranteed - a bleeding event will occur. The bleeding may even continue for 4-6 weeks after delivery. However, some physiologic changes have been underway for some time. The mother in fact has been preparing for this for the last 40 weeks. Her circulating blood has significantly increased, and her liver has been making and sequestering extra clotting factors and other various proteins for when baby arrives in this world. Normal blood loss associated with childbirth is usually around 500 ml, and in some cases, it can approach 1 Liter, especially with a cesarian section. However, when precipitous blood loss in the acute setting exceeds one liter, clinicians may have to investigate the cause and origin a little more as this can be a life-threatening condition. This is classic postpartum hemorrhage (PPH). In some cases, the definitive treatment could be a hysterectomy which would save her life, but as a consequence make mom infertile. What could make this abnormal and excessive bleeding take a dramatic turn?? Think about the 4 T's as a good reference point -- they are listed below:
Loss of Tone - think uterine atony, this is the most common problem faced - where the uterus remains weak and soft after childbirth, it loses its ability to contract and therefore bleeding continues even in the presence of oxytocin. Remember, uterine contraction promotes hemostasis, but in this case, it is either never achieved or severely delayed. This is common with prolonged labors, first time moms or multi-gravid moms. Treatment is aimed at tamponade techniques in a hospital setting. Uterine packing or the use of a Bakri balloon are commonplace under physician guidance. These are NOT pre-hospital measures.
Bakri balloon insertion
Tissue problems - think placental abruption and/or placenta previa, or uterine rupture (extremely high mortality rate). As part of your initial OBGYN studies, you learned extensively about these 3rd trimester complications. Early recognition is key and remember the blood may be hidden or occult - invisible to the naked eye, but extremely apparent on abdominal ultrasound. Treat for shock according to your local protocols as some of the products of conception could be retained in the uterus still.
Trauma - consider problems with the vaginal vault or the uterus. This could be physical tears in the vagina, genital tract, perineum or the uterus itself.
Thrombin (clotting) - consider clotting abnormalities also known as coagulopathies. Mom could have an amniotic fluid embolism which would manifest itself as sudden onset dyspnea, following by a rapid consumption of her platelets AND clotting proteins, like fibrinogen. This will likely lead to fulminate DIC and subsequent multi organ dysfunction syndromes. All of this just promotes more deadly hemorrhaging. Mom will end up being transfused with multiple blood products (pRBC's, FFP, platelets, and/or whole blood)
Regardless of the cause - remember the basics to reduce maternal mortality - taking baby to breast can help mom release oxytocin and promote better uterine tone. Fundal massage is still a viable non-invasive option that can be deployed by EMS. Fluid resuscitation could also be clinically indicated but be on the lookout for complications causes directly by this intervention (dilutional thrombocytopenia etc..) Use of TXA in this scenario is still poorly defined, and more research is needed on this front. Additionally, keep in mind that PPH can occur up to 12 weeks after delivery.
The incidence of home-births is increasing, and competence in PPH assessment and management is essential in prehospital personnel. Be prepared and know which area hospitals in your jurisdiction are best suited to treat these patients.
January 15, 2024
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC.