Postpartum Hemorrhage

Classification of Postpartum Hemorrhage

Postpartum hemorrhage affects 5%–15% of women giving birth. PPH can be categorized into one of two categories:

• Early (primary)

  • Occurs within the first 24 hours

  • Etiologies (think the “4 T's”):

    • Uterine a t ony (80%–90% of cases)

    • T issue—retained products of conception

    • T rauma—uterine, cervical or vaginal lacerations

    • T hrombin—dilutional or consumptive coagulopathy, coagulation disorders

• Late (secondary)

  • Occurs between 24 hours and sixth week postpartum

  • Most likely to occur from 6 to 14 days postpartum

  • Etiology is usually infection, uterine subinvolution, or retained placental tissue

Risk Factors

• Overdistended uterus, as caused by polyhydramnios or multiple gestations

• Macrosomia

• Prolonged labor

• Extended third stage of labor

• High parity

• Fibroid uterus or other uterine anomalies

• Placenta previa

• Cesarean delivery

• Episiotomy

• Trauma and lacerations

• Use of forceps or vacuum device

• History of uterine atony or hemorrhage

• Use of general anesthesia

Postpartum Assessment

• Prompt and accurate identification of the signs and symptoms of postpartum hemorrhage is key

• Typical schedule of evaluation:

  • Every 15 minutes for 1 hour, then

  • Every 30 minutes for 1 hour, then

  • Every hour for 4 hours, then

  • Every 4 hours for first 24 hours, then

  • Every 8 hours until discharge

• Expect a slight increase in lochia with ambulation and breastfeeding