INTRODUCTION
Postpartum hemorrhage (PPH) is defined as cumulative blood loss of greater than or equal to 1000 ml within 24 hours after birth, regardless of route of delivery. It is the leading cause of maternal death worldwide (1). Hemorrhage requiring blood transfusion is the leading cause of severe maternal morbidity, including respiratory failure, shock, inability to clot, kidney failure, loss of fertility, and necrosis of the pituitary gland. A postpartum hemorrhage expert witness may be needed in litigation involving maternal deaths
Interestingly, the rate of PPH has increased over time, even though maternal death rates have fallen (2). This decrease in mortality is associated with improvements in blood product transfusion protocols and the use of hysterectomy in patients with hemorrhage refractory to all other measures. Still, in the United States, many cases of severe morbidity and death due to hemorrhage can be prevented or mitigated. A postpartum hemorrhage expert witness can help determine if a woman who suffered PPH was resuscitated appropriately.
The implementation of standardized bundles of care by obstetric providers and hospitals has improved care (3). Patients with PPH who are treated without care algorithms generally have poorer outcomes.
Patients can exhibit several risk factors for PPH that allow providers to plan the management and even prevention of PPH. Failure to recognize PPH and act in a timely manner can lead to catastrophic consequences including lifetime morbidity, disability, and death.
In patients who have suffered PPH with severe morbidity or death, review of the record will often identify a series of interventions that were provided either too late, in an illogical or random order, or not at all. Subtle or gross deviations from the standard of care, or causation of PPH, may be determined with the help of a postpartum hemorrhage expert witness.
RISK FACTORS FOR PPH
Several well-established risk factors for PPH exist (4). Chorioamnionitis (infection of the placenta and surrounding membranes, usually occurring during labor), and protracted labor are examples of common risk factors. Multiple gestation, uterine fibroids, and high parity (having experienced six or more births) are other characteristics commonly found in women who have an increased risk of PPH. Additional risk factors include retained placenta or placental membranes, lacerations of the cervix, vagina, or vulva, and an abnormally adherent placenta. Finally, a history of PPH is itself a risk factor for PPH.
Risk assessment tools exist (5) that correctly identify more than 80% of patients who will experience PPH. However, many women who have no risk factors also experience PPH, emphasizing the importance of anticipating the possibility of PPH in all recently delivered women (6).
Anecdotally, one of the most common causes of PPH is a cervical laceration. Women who experience a cervical laceration resulting in PPH often are “grand multiparous,” having delivered 6 or more babies previously. Frequently, their labors are “precipitous,” with expulsion of the baby occurring very rapidly, even before the cervix is fully dilated. As tremendous uterine forces thrust the baby through the birth canal, the incompletely dilated cervix necessarily tears in order to accommodate the baby and propel it through the birth canal. The lacerated cervix, bleeding briskly, often cannot be visualized separately from normal uterine bleeding. A thorough exam, sometimes requiring anesthesia and a skilled assistant, can identify this type of laceration, facilitating repair. A postpartum hemorrhage expert witness can help determine whether an exam was indicated.
PREVENTING PPH
With vaginal deliveries, the third stage of labor is defined as the time between delivery of the infant and delivery of the placenta. Standard of care is the “active management” of the third stage of labor, which includes 3 components: a) administration of oxytocin, b) uterine massage, and c) traction on the umbilical cord (7). Intravenous oxytocin remains the most effective medication to prevent PPH, with the fewest side effects (8).
Patients’ outcomes are improved with performance of all components of the active 3rd stage of labor management. If the patient has suffered a laceration that is bleeding, pressure can be applied to it until placental delivery.
RECOGNIZING PPH
Visual estimations of blood loss after both vaginal delivery and cesarean delivery are inaccurate. Historically, providers underestimate blood loss (9). Quantitative blood loss (QBL) is more accurate than estimated blood loss (EBL) and can be determined by subtracting amniotic fluid volume from the amount of blood in a canister or bag, and adding the weight of laparotomy sponges and gauze pads.
Once postpartum bleeding exceeds expected volumes (500 ml for vaginal delivery and 1000 ml for cesarean delivery), an immediate and thorough evaluation is performed. The most common causes for excess blood loss are: a) uterine atony (poor tone of the uterine muscle), b) lacerations of the birth canal, and c) incomplete delivery of the placenta (retained placenta) (3).
During recovery after vaginal or cesarean delivery, assessment of bleeding is made frequently and thoroughly. Typically, once the baby and placenta are delivered, and any lacerations are repaired, the patient is “tucked in” with her baby and breastfeeding can commence if appropriate. A large obstetric perineal pad is placed so that postpartum blood loss can be assessed, and hemorrhage can be recognized. Oxytocin is infused and vital signs are taken frequently. The uterine fundus is massaged frequently and the perineal pad checked for excess blood or clots.
MANAGING PPH
Management of PPH depends upon the etiology. To determine the etiology, a thorough physical exam is performed. It is important to note that healthy pregnant (or recently pregnant) women can silently lose 1 – 2 liters of blood, even with no symptoms of blood loss and no changes in vital signs. A postpartum hemorrhage expert witness will review the medical records to understand the etiology.
Uterine atony is by far the most common cause of PPH (10). Several uterotonic medications are available to treat the boggy uterus. Most will work better when the bladder is first drained. A postpartum hemorrhage expert witness can assess the suitability and timing of administration of these medications.
Lacerations of the genital tract are also common sources of bleeding. These occur more often after operative vaginal deliveries (vacuum and forceps assisted deliveries). They are often arterial in nature, and rapid blood loss can occur in minutes. Visualization of the upper vagina and cervix for purposes of repair may prove extremely difficult without adequate anesthesia. Rapid transfer of the patient to a setting where she can be examined thoroughly and comfortably is periodically necessary. A postpartum hemorrhage expert witness can help determine if the patient received this optimal care.
In the patient who is exhibiting symptoms of blood loss with deteriorating vital signs, but in whom obvious bleeding is not present, a concealed hemorrhage or hematoma (a collection of blood in an organ or body space) must be considered (3). Hematomas may not be recognized for hours after delivery and if suspected, aggressive resuscitation measures should be initiated immediately, even before imaging has been performed to confirm the diagnosis. The obstetric provider considers surgical planning to drain or pack the hematoma, along with interventional radiology (if available) for possible embolization, or plugging, of the bleeding vessel. The operating room is prepared and the blood bank is instructed to urgently obtain several units of cross-matched blood. General surgery is consulted. Interventional radiology and the necessary support staff are informed of services potentially required and the imaging suite is opened. A postpartum hemorrhage expert witness can help determine whether this multidisciplinary approach was utilized.
After delivery, placental remnants or portions of the amniotic sac can remain in the uterine cavity and are well known to cause excess bleeding. Even when the placenta is visually intact, suspicion for retained products of conception should be high if there is no other source of bleeding. A manual exploration of the uterus can be performed. Placenta accreta, a condition in which the placenta becomes abnormally adherent to the uterine wall, is often diagnosed at this time. During an exam, the lack of a palpable plane between placental and uterine tissues is a sign that the placenta may not be completely removable, and placenta accreta is suspected.
An example of retained placenta that is difficult to diagnose is that of the succenturiate (accessory) lobe of the placenta (3). Succenturiate placentas have a small island of placental tissue that is attached to the outer rim of the “main” placenta by only a tenuous membrane. With delivery of the largest placental mass, the extra lobe can easily separate from the larger mass and remain behind. Bedside ultrasound can often provide imaging that suggests a retained accessory lobe. A postpartum hemorrhage expert witness can help determine if retained placenta played a role in the patient’s blood loss.
Further management options for PPH include medications (uterotonics), tamponade (pressure) techniques, vessel embolization (occlusion), and surgical options including hysterectomy. Subtleties of management are dictated by unique patient characteristics and resources available at the hospital. For example, women with high blood pressure may need an alternative approach, as they cannot safely receive certain uterotonics without causing worsening of their blood pressure. Again, a postpartum hemorrhage expert witness can assist in determining if the patient received standard of care.
CONCLUSION
The obstetric provider must be aware of the unique large physiologic reserve women have in the peripartum time period. A pregnant person’s cardiopulmonary system is able to maintain normal blood pressure and heart rate despite enormous blood loss. Women can remain symptom free while maintaining their normal vital signs (11). They have normal cognition and can converse without difficulty. Consequently, they may not appear to need resuscitation, even though blood loss is far beyond what is expected. Using a standardized protocol to evaluate and treat the PPH patient is associated with earlier intervention and ultimate resolution of PPH, with few or no long-term consequences.
REFERENCES
- Say L, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014;2:e323-33.
- Callaghan WM, et al.Identification of severe maternal morbidity during delivery hospitalizations, United States, 1991 – 2003. Am J Obstet Gynecol 2008:199:133.e1-8
- ACOG Practice Bulletin. Postpartum Hemorrhage. Number 183, October 2017.
- New South Wales Ministry of Health. Maternity – prevention, early recognition and management of postpartum hemorrhage. Policy Directive. July 2017.
- Lyndon A, et al. Improving health care response to obstetric hemorrhage version 2.0. A California quality improvement toolkit. Stamford, CA: California Maternal Quality Care Collaborative; Sacramento, CA: California Department of Public Health; 2015.
- Wetta LA et al. Risk factors for uterine atony/postpartum hemorrhage requiring treatment after vaginal delivery. Am J Obstet Gynecol 2013;209:51.e1,51-6.
- Guidelines for oxytocin administration after birth. AWHONN Practice Brief Number 2. J Obstet Gynecol Neonatal Nurs 2015;44:161-3.
- Westhoff G et al. Prophylactic oxytocin for the third stage of labour to prevent postpartum haemorrhage. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.:CD001808.
- Dildy GA, et al. Estimating blood loss: can teaching significantly improve visual estimation? Obstet Gynecol 2004;104:601-6.
- Joseph KS, et al. Investigation of an increase in postpartum haemorrhage in Canada. Maternal Health Study Group of the Canadian Perinatal Surveillance System. BJOG 2007;114:751-9.
- Pacagnella RC, et al. A systematic review of the relationship between blood loss and clinical signs. PLoS One 2013;8:e57594.
About the author
Dr. Madland has won several awards for patient-centered care. He is a full time OB/GYN and has been in active practice for 21 years. He is the OB/GYN Department Clinic Medical Director for an academic metropolitan medical center. He has delivered over 4000 babies and performed over 250 robotic gynecologic surgeries. He is a fellow of the American College of Obstetricians and Gynecologists and is on Mayo Clinic (Rochester) Community Staff. As faculty with the University of Minnesota Medical School, he has extensive teaching experience and has won the Resident Teaching Award.
Contact Information:
701-818-8956, mobile phone
