Postpartum hemorrhage and its prevention

Almost 500 ml blood loss within 24 hours of child delivery is the clinical condition and termed
as postpartum hemorrhage. In severe cases, the amount of blood loss exceeding 1000ml, which
requires immediate medical attention. The untreated condition may cause maternal death. The
multiple complications of postpartum hemorrhage include long-term disability, shock, and
organ dysfunction. These conditions require long term hospitalization.
The common underlying cause of postpartum hemorrhage is uterine atony, whereas other
physiological alterations during pregnancy and labor, such as uterine rupture, vaginal or cervical
lacerations, blood coagulation disorder can also cause postpartum hemorrhage. Following are
some preventive measures recommended by the World Health Organization (WHO) to prevent
postpartum hemorrhage:

  • In every childbirth, WHO recommended commencing of uterotonics at the initial phase
    of the third stage of labor to prevent postpartum hemorrhage.
  • The recommended uterotonic drug is oxytocin, which is administered either through
    intravenous or intramuscular injection with a dose of 10 IU has a preventive effect
    against postpartum hemorrhage.
  • In case of unavailability of oxytocin in a hospital setting, then some other uterotonics
    like methylergometrine or ergometrine can be injected through the appropriate dose.
    Sometimes a fixed combination of ergometrine and oxytocin also recommended as an
    injectable drug. Misoprostol with 600 µg oral dose is also used as preventive therapy for
    postpartum hemorrhage.
  • Misoprostol with 600 µg oral dose is specifically recommended in the absence of expert
    obstetrician or birth attendants along with the unavailability of oxytocin. This drug is
    often a preventive measure of postpartum hemorrhage in community health care
    centers.
  • Expert obstetrician or experienced birth attendants recommended controlled cord
    traction (CCT) method in properly equipped health care set up. This method is
    specifically recommended for vaginal births.
  • CCT is never recommended in the absence of expert obstetrician or experienced birth
    attendants.
  • Another strong recommendation to prevent postpartum hemorrhage is late cord
    clamping method. This is performed with 1 to 3 minutes of the childbirth. This is applied
    when the initiation of simultaneous essential newborn care is required.
  • In the case of neonate has suffered from air deprivation (asphyxiate) and need to move
    immediately for reviving the condition, then early cord clamping method recommended
    to apply within one minute after the childbirth to prevent postpartum hemorrhage.
  • Patients who have received oxytocin for prophylactic purposes for them sustained
    uterine massage is not recommended as an intervention to prevent postpartum
    hemorrhage.
  • Abdominal uterine tonus assessment is recommended for all pregnant women immediately after childbirth to identify the uterine atony, which is considered as a major cause of postpartum hemorrhage. Early identification can help to prevent postpartum hemorrhage by offering early treatment measure.
  • Intravenous or intramuscular injection of oxytocin is recommended for a cesarean section to prevent postpartum hemorrhage.

In the cesarean section, control cord traction is recommended to remove the placenta. Apart from the above mentioned preventive measures, the WHO also recommended some treatment measure for postpartum hemorrhage. These are as follows:

  • Patients with PPH can be treated by intravenous administering of isotonic crystalloids along with IV fluid to revive the patient condition.
  • In case of oxytocin or other uterotonics fail to stop postpartum hemorrhage, then tranexamic acid is recommended to overcome the condition.
  • Uterine massage has a therapeutic role to treat postpartum hemorrhage.
  • Intrauterine balloon tamponade recommended if patient not responding in treatment with any uterotonics.
  • In a proper infrastructure, artery embolization is recommended to treat uterine atony, when other treatment measures have failed.
  • Bimanual uterine compression is recommended for the temporary measure to control postpartum hemorrhage until proper treatment arrangement not available.
  • In case of vaginal birth, external aortic compression is recommended for the temporary measure to regulate postpartum hemorrhage occurs due to uterine atony until proper treatment arrangement not available.
  • Non-pneumatic anti-shock garments is another temporary measure recommended until appropriate care is available.
  • It is recommended the IV or IM administration of oxytocin with 10 IU dosing in combination with controlled cord traction in case of spontaneous expulsion of the placenta does not occur.
  • A single dose of antibiotic is recommended in case of manual expulsion of the placenta.

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