Practice Guideline created in collaboration with Lori Hedlund and Amanda Latham

10-04-2019
Evaluation and management of Postpartum Hemorrhage (PPH)
1. Definition or Key Clinical Information:
PPH is defined as bleeding that occurs any time after the birth of the baby; this can be before, during, and/or after the birth of the
placenta. PPH is defined as > 500 ml of blood loss following vaginal birth, severe PPH is defined as blood loss >1,000 ml after
vaginal birth or s/sx of circulating blood volume instability (Fukami, et al., 2019). “Primary postpartum hemorrhage (PPH),
classified as hemorrhage that occurs within 24 hours of delivery, occurs in 4% to 6% of pregnancies. PPH is the single most
significant cause of maternal death worldwide and an important contributor to maternal deaths in the United States (Kacmar,
Mhyre, Scavone, Fuller, & Toledo, 2014).” The most common causes of primary PPH include uterine atony, trauma/lacerations,
retained placenta, and bleeding disorders. Secondary PPH occurs between 24h-12wk after birth. This is often caused by retained
placenta fragments, intrauterine infection, subinvolution of the uterus and placental site, or uterine myoma. According to the
CDC(2019), pregnancy-associated mortality in the United States in 2013 was 17.3 per 100,000 live births, and 11.4% of those
were caused by PPH. In 2013, the pregnancy-associated mortality in the united states was 17.3 per 100,000 live births.
According to the Center for Disease Control (2019), 11.4% of those deaths are caused by PPH. Hematoma formation is also a
possible cause of PPH, although not as obvious. The blood will collect insidiously (up to 1L) in the perineum, lower vagina,
broad ligament or vaginal vault.
2. Assessment
i. Risk Factors

Abnormal placenta placement History of PPH Prolonged second stage

Amniotic fluid embolism Hypotension Prolonged labor
Avulsed cotyledon Increased weight gain Retained blood clots or birth products
Chorioamnioitis Laceration of perineum, vagina, cervix (membranes)
Coagulopathies Multiple gestations Ruptured uterus
Congenital coagulation defections (i.e., Oxytocin-induced or augmented labor Sepsis
Willebrand’s disease) Placenta abruption Severe vaginal or perineal lacerations
Disseminated intravascular coagulation Polyhydramnios Stillbirth
Episiotomy (esp. mediolateral) Precipitous labor/birth Succenturiate lobe placenta
Fetal macrosomia over 4,000g Pregnancy generated by assisted Therapeutic anticoagulation
HELLP syndrome reproductive technology Use of general anesthetics
Hematoma Pregnancy-induced hypertension Uterine abnormalities (i.e., fibroids)
High parity Uterine inversion

ii. Subjective/objective Symptoms

● Uncontrolled bleeding
● Decrease in blood pressure and/or other signs of shock
○ Blurred vision, clammy skin, rapid and/or weak pulse, confusion, dizziness, ringing ears, weakness, fainting
or client feeling faint
● Maternal collapse
● Enlarged uterus; boggy uterus, there may be little-to-no visible blood-loss.
● Pale skin
● Nausea
● Hematoma; involution/lochia are WNL, but maternal pain will become increasingly severe.
iv. Clinical Test Considerations
Since PPH manifests with such a rapid onset that diagnostic procedures are almost entirely limited to a physical examination and
immediate management. It is important to estimate blood loss as accurately as possible, this may include using a basin to collect
blood or weighing chux pads noting the presence of other fluids and subtracting the weight of the pads.
No test are indicated in the immediate management of PPH, but the following test can be useful once the bleeding had been
controlled if indicated:
● CBC
○ Onset of care and repeated at 28 weeks to determine blood type/Rh factor, platelet count, and Hgb/Hct levels;
iron-deficiency anemia can be treated in an effort to minimize the impact of PPH
○ Initially, the postpartum hemoglobin (Hgb) value does not reflect the amount of blood loss.
● Baseline coagulation
○ Initial coagulation study findings are typically WNL; but abnormalities may be noted, particularly when PPH
is preceded by abruptio placenta, HELLP syndrome, fatty liver of pregnancy, intrauterine fetal demise,
embolic events, or septicemia.
● U/S to detect presence of retained placenta fragments or membranes.
● Use gentle cord traction to assess for placenta detachment
3. Management plan
Determine the source of bleeding using the four T’s mnemonic steps as presented by Advanced Life Support in Obstetrics (NM
Midwives Assoc., 2019).
● Tone: uterine
● Trauma: laceration
● Tissue: retained placenta
● Thrombin: clotting defect
i. Therapeutic measures to consider
● Anti-hemorrhagic medicine
○ Oxytocin: 10 units IM or 20-40 units in 1L of fluid via IV drip. (CA allows IV oxytocin; Community
standards for CA is 2 doses IM, q15 min)
○ Cytotec: prophylaxis; 600mg PO or rectally within one minute of delivery or treatment; 800mg PO or
rectally.
○ Methergine: 0.5 mg IM or 0.125 or 0.25 mg intravenously
● IV prophylactically for clients with PPH risk factors or for treatment of PPH.
● Bladder catheterization, if indicated
ii. Complementary measures to consider
● Facilitate birth of the placenta
● If placenta is delivered, express clots, and apply fundal massage until uterus is firm and contracted
● Apply direct pressure to any bleeding lacerations
● Assess placenta for completeness; manually remove fragments as indicated
● Herbs can be used as a first line of action if the PPH is mild enough; Hem Halt Placenta Release tinctures, Yarrow,
Angelica, Cottonroot.
● Essential oils; leg/foot massage with diluted Cypress oil
● Iron supplementation should begin in the first or third trimester depending on Hgb levels.
● PP tea given to all clients containing Shepherd’s Purse and Cinnamon Bark.
● If placenta is born, a piece of the placenta can be used to manage PPH by placing a piece bucally.
● Consider internal or external bi-manual compression to manually contract the uterus until bleeding slows.
● Monitor maternal vital signs
iii. Considerations for pregnancy, delivery and lactation Discuss with clients who present with risk factors the benefits of
active management of third stage and the negative implications associated with PPH, such as infection, prolonged healing,
fatigue, weakness, depression, inadequate milk supply, etc. Discuss the management plan in the event of PPH. Tolerance of blood
loss is contingent upon many factors; some people will be symptomatic with higher Hgb levels than others. Discuss the
possibility of blood transfusions and assess the client’s level of compliance; transfusion is indicated when Hgb falls below 6g/dL
and may be indicated at higher levels for some clients.
iv. Client and family education Having a PPH increases your risk for subsequent PPH. Education and support should be
provided regarding replenishing their blood volume and obtaining adequate rest to promote healing. Monitoring the client’s Hgb
levels in the postpartum period may also be indicated. Blood draw is preferred to be done 24h after birth to allow client’s body to
equilibrate after the blood loss.
v. Follow-up Monitor Hgb levels with a hemoglobinometer or CBC to ensure levels are rising and not in danger zone.
4. Indications for Consult, Collaboration or Referral
● If retained birth products are unable to be expelled
● If PPH is not well-controlled after all measures within midwife’s scope are utilized
● Client request
5.References
Center for Disease Control. (2019, June 4). Pregnancy Mortality Surveillance System | Maternal
and Infant Health | CDC. Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-survei
llance-system.htm?CDC_AA_refVal=https://www.cdc.gov/reproductivehealth/maternali
nfanthealth/pmss.html.
Fukami, T., Koga, H., Goto, M., Ando, M., Matsuoka, S., Tohyama, A., … Tsujioka, H. (2019).
Incidence and risk factors for postpartum hemorrhage among transvaginal deliveries at a
tertiary perinatal medical facility in Japan. Plos One, 14(1). doi:
10.1371/journal.pone.0208873
Kacmar, R. M., Mhyre, J. M., Scavone, B. M., Fuller, A. J., & Toledo, P. (2014). The Use of
Postpartum Hemorrhage Protocols in United States Academic Obstetric Anesthesia Units.
Anesthesia & Analgesia, 119(4), 906–910. doi: 10.1213/ane.0000000000000399
King, T. L., Brucker, M. C., Fahey, J., Kriebs, J. M., & Gegor, C. L.,Varney, H. (2014). Management of immediate
postpartum hemorrhage. Varney’s Midwifery, (5), 1065-1066.
March of Dimes. (2019). Postpartum hemorrhage. Retrieved from
https://www.marchofdimes.org/pregnancy/postpartum-hemorrhage.aspx.
Marshall, J. & Raynor, M. (2014). Physiology and care during the third stage of labor. Myle’s Textbook for
Midwives, (16), 406-414.
NM Midwives. (2019). Practice guidelines. New Mexico Midwives Association: Practice Guidelines. Retrieved
from: https://nmhealth.org/publication/view/guide/1725/
Posner, G., Dy, J., Black, A. & Jones, G. (2013). Postpartum hemorrhage. Oxorne-Foot Human Labor & Birth, (6),
368-388.