Post Partum Hemorrhage

Understanding Postpartum Hemorrhage: Postpartum hemorrhage, or excessive bleeding after childbirth, is a significant concern, occurring in approximately 1-5% of deliveries. The mortality rate associated with postpartum hemorrhage is around 2%, but this can vary globally. Some countries experience mortality rates as high as 20%. Additionally, there’s a 10-15% risk of recurrence in subsequent pregnancies, emphasizing the importance of understanding and addressing this issue.

Physiological Changes and Risks: Pregnancy induces significant physiological changes, resulting in a high-volume, low-resistance state. The uterus receives ten times the normal blood flow during pregnancy, making postpartum hemorrhage a critical concern. Notably, vital signs might not immediately reflect bleeding, making early detection challenging. Pregnant patients can lose up to two liters of blood without immediate changes in vital signs.

Recognizing Post-Delivery Physiological Changes: Understanding the physiological changes in vital signs during and after pregnancy is crucial for pre-hospital providers. Pregnancy induces peripheral vasodilation, causing a slight drop in blood pressure. The heart rate increases by 10-15 points, and the respiratory system undergoes changes, requiring increased oxygen. Although the heart rate goes up in a pregnancy and the blood pressure goes down normaly, it is important that any abnormal vital signs such as a heart rate above 100 and a blood pressure below 100 systolic be treated as abnormal until proven otherwise. 

Four T’s: Causes of Postpartum Hemorrhage:

1. Tone: Involving inadequate uterine contraction, the most common cause.
2. Trauma: Typically lacerations that result during delivery and can lead to significant bleeding.
3. Tissue: Relates to retained placental tissue.
4. Thrombin: Referring to coagulopathy or difficulty in clotting.

Approach to Postpartum Hemorrhage in the Field: In a pre-hospital setting, managing postpartum hemorrhage involves a systematic approach. Key steps include:

• Administration of TXA: Tranexamic acid, if available, can help reduce bleeding.
• Uterotonic Administration: Oxytocin induces uterine contractions. If not available, can have baby latch which will stimulate the production of moms natural occurring oxytocin. 
• Fundal Massage: Applying firm pressure to the uterus to encourage contraction.
• Addressing Lacerations: Check for lacerations and apply direct pressure to bleeding points if lacerations are visible.
• Transport to Hospital: Prioritize getting the patient to the hospital immediately for further evaluation and intervention.

Secondary Postpartum Hemorrhage: In some cases, bleeding may occur after the initial 24 hours post-delivery, indicating secondary postpartum hemorrhage. Possible causes include retained products, subinvolution of the placental bed, or infection. In such cases, prompt resuscitation aimed at supportive care of abnormal vitals and transport to the hospital are critical.

Summary and Takeaways: Dr. Moreira emphasizes the importance of considering postpartum hemorrhage in every pregnant patient. Pre-hospital providers should be prepared to manage complications by following a systematic algorithm. Early recognition, administration of appropriate medications, fundal message, direct pressure and prompt transportation to the hospital are key components of effective intervention.

In conclusion, being proactive and vigilant in managing postpartum hemorrhage in the field is crucial for ensuring the well-being of both mother and child. Regular training, awareness, and a systematic approach are vital for pre-hospital providers to navigate these critical situations successfully.