Introduction
During parturition, postpartum blood loss should be measured as accurately as possible. There is no standardly-accepted definition of postpartum haemorrhage. In the Netherlands, postpartum haemorrhage is defined as 1000 ml or more of blood loss. Internationally, this boundary is set at 500 ml.
Causes
The most important causes of postpartum haemorrhage:
- Uterine atony (reduced contractility of the uterus).
- Marked uterine distension (multiple pregnancies, polyhydramnios, macrosomia).
- High parity.
- Prolonged birth.
- Uterine fibroids.
- Congenital uterine anomaly.
- Damage to the soft birth canal.
- Coagulation disorders.
Management
It is important to distinguish between a haemorrhage that occurs prior to the birth of the placenta (third stage of labour) and one that occurs after the birth of the placenta (post placental stage). Any haemorrhage greater than 1000 ml is reason to admit a new mother to hospital. The means of transport depends on a number of factors such as:
- Whether or not the bleeding has stopped.
- Amount of blood lost.
- Clinical condition of the woman.
Procedure
- Determine the height of the fundus and check whether the uterus is well contracted.
- Determine as quickly as possible the origin of the blood loss (from the uterus, episiotomy wound, tears in the cervix, vaginal wall, perineum).
- Empty the bladder.
- Have a drip inserted as soon as possible (if necessary, by ambulance personnel).
If the uterus is well contracted:
- Assess whether the placenta is detached in the lowest uterine segment. Use Küstner’s manoeuvre to determine this.
- If the placenta is detached:
- Stimulate the birth of the placenta by means of Bar’s manoeuvre.
- Check whether the placenta is complete.
- If the blood loss persists, determine its origin once more, administer a uterotonic agent (oxytocin or Methylergometrine) and while waiting for the ambulance, suture the bleeding vessels, tears and/or episiotomy, if necessary.
- Refer the woman for hospital admission.
- If the placenta is not detached, refer the woman immediately for clinical treatment.
If the uterus is not well contracted:
- Administer oxytocin (e.g. 5 IU i.m.).
- Stimulate the uterus to contract by means of gentle fundal massage.
- As soon as the uterus contracts, assess whether the placenta is detached and in the lowest uterine segment. Use Küstner’s manoeuvre to determine this.
- If the placenta is detached:
- Stimulate the placenta to be born using Bar’s manoeuvre.
- Check whether the placenta is complete.
If the placenta is complete:
- Administer Methylergometrine (e.g. 0.2 mg i.m.). Important: Methylergometrine is contraindicated in the case of hypertension and uterine fibroids. While waiting for the ambulance, suture any bleeding vessels, tears and/or episiotomy, as necessary. Refer the woman for hospital admission.
If the placenta is not complete:
- Administer oxytocin i.m. and refer the woman for clinical treatment (evacuation of the uterus).
- If the placenta is not detached, refer the woman immediately for clinical treatment.
‘Controlled Cord Traction’ (Brandt-Andrews Method)
If in the event of heavy blood loss postpartum, the placenta is not born after the administration of oxytocin and the use of the Bar’s manoeuvre; the Brandt-Andrews Method can also be used. For this method, the uterus must be contracted.
Procedure
- Induce the uterus to contract by gently massaging the uterine fundus or wait until the woman has a contraction that can be clearly felt.
- Place the palm of the left hand on the lower abdomen between the pubic symphysis and the fundus at the height of the lowest uterine segment.
- Hold the umbilical cord under light tension with the right hand whilst at the same time exerting upwards counter pressure with the left hand in the direction of the uterus.
- Keep the hands in this position and repeat the manoeuvre during every palpable uterine contraction.
Possible Risks: Severing of the umbilical cord, uterine inversion.