Deliveries are relatively rare in the ED, but precipitous deliveries in the ED can evoke fear and anxiety in even the most seasoned EM practitioners. One institution reported that 1 in 160 deliveries occurred in its prehospital or ED settings with a wide variety of maternal and neonatal complications, including PostPartum Hemorrhage (PPH), and with a perinatal mortality rate of 9%.
PPH is the leading cause of maternal morbidity and mortality worldwide with a prevalence of 6% causing approximately 140,000 deaths each year. In the US, PPH is the 5th leading cause of mortality and accounts for ~ 11% of maternal deaths. Serious morbidity such as ARDS, coagulopathy, shock, loss of fertility, and Sheehan syndrome (pituitary necrosis) may also occur as a sequela of PPH. Despite improved obstetrical care, the incidence of PPH is increasing in the US, rising 26% between 1994 and 2006.
A 28-year old, G3P2, 39-week pregnant woman presents to your ED complaining of painful uterine contractions occurring every 5 minutes over the last 4 hours. She denies fluid leakage but reports a small amount of vaginal bleeding. Her pregnancy was uncomplicated although her doctor worried that her baby is large. She denies any past medical or surgical history. Arrival vital signs are: BP 118/72, P 102, R 23, and O2 sat 98%. Amniotic fluid rushes out just as you begin the pelvic exam, and a vigorous male infant delivers without complication. Within 5 minutes of delivery, the placenta delivers spontaneously. Persistent brisk vaginal bleeding is noted with clots. Repeat BP is 92/56 and PR is 118.
Is this normal bleeding or PPH?
It is normal and expected to have some bleeding after vaginal delivery. Postpartum hemorrhage has traditionally been defined as loss of more than 500 mL of blood loss with a vaginal delivery. Estimating blood loss by visualization is unreliable.
Most EDs don’t have calibrated obstetric drapes to collect and measure PPH blood so this is not generally a viable option to quantify the amount of blood loss. Another method that is relatively accurate is the gravimetric method, or measuring by weight. Place chux pads to absorb the blood, then weigh each pad. Every 1 gm = 1 mL of blood. Our patient had a chux weighing 820 gm which approximates 820 mL of blood.
What is the most likely cause of PPH in our patient?
The most common cause, 80%, is uterine atony, and is most likely in our patient. Risk factors for PPH include prolonged or rapid labor, previous history of PPH, preeclampsia, and an over distended uterus (such as from macrosomia, twins, polyhydramnios), and Asian or Hispanic ethnicity.
A helpful mnemonic to remember the four most common causes of PPH is the 4 Ts:
- Tone – atony or loss of uterine tone
- Trauma/Tears – perineal/cervical lacerations
- Tissue – retained products of conception/tissue in the uterus
- Thrombin – coagulopathies
This patient is symptomatic with continuing blood loss of over 800 mL which is clearly PPH. Begin concurrent evaluation and management steps while mobilizing obstetrical consultation. As with other forms of hemorrhagic shock, begin fluid resuscitation, hemodynamic monitoring, and obtain blood for CBC, platelets, type and crossmatch while you identify and treat the underlying causes.
Especially if you are in a rural area or work in a community ED without obstetrical services, consider developing a precipitous delivery kit and/or cart that is regularly checked and readily available. These precipitous delivery carts/kits should contain medications and the dosing information needed to treat PPH (especially oxytocin and misoprostol), gauze rolls, long-arm sterile gloves for vaginal/uterine examination, chux pads and scale, tamponade devices or foley catheters, and appropriate suture material.
The decision to transfuse is based on clinical judgment and should be considered when there is significant ongoing blood loss and in particular if there are unstable vital signs. If the decision is made to transfuse, it is done to replace coagulation factors and red cells for oxygen carrying capacity and not for volume replacement. If transfusion is indicated for ongoing blood loss, massive transfusion protocols are recommended.
Tone: Uterine massage
Palpate the uterine fundus after delivery of the placenta to assess for tone. The uterus should feel firm. In uterine atony it may feel boggy and soft. To restore tonicity, massage using both hands: inserting a gloved hand inside the vagina to massage the lower uterine segment, and apply the other hand to the lower abdomen, in order to compress and massage the uterine fundus between both hands. This maneuver should diminish bleeding, expel blood and clots and be temporizing while other treatment is started.
Uterotonics – for PPH, give oxytocin (Pitocin), 20 units/liter of NS or LR IV as a rapid infusion with 500cc over 10 minutes, and then 250 cc/hr. For precipitous deliveries without PPH, the dose is 10 units IM. Never give oxytocin IV undiluted as it can cause hypotension. If bleeding persists, Methylergonovine (Methergine) 0.2 milligrams IM q 2-4 hours can be given to a maximum of 5 doses, but is contraindicated in cases of hypertension. For continued severe bleeding, consider the addition of a prostaglandin analogue of PGF2α, such as Hemabate or Carboprost 250 micrograms IM q 15-90 minutes to a maximum of 8 doses. Do not give Hemabate or Carboprost in asthmatics. If still bleeding, or if the above drugs are not available or contraindicated, give Misoprostol (cytotec 800-1000 milligrams PR).
Visual inspection –with ongoing blood loss after uterine massage a visual examination should be done to look for any perineal, vaginal or cervical tears or lacerations and if possible repair them with sutures. If unable to suture, any identified lacerations may be packed with sterile gauze dressings to stop persistent bleeding until definitive repair is done later.
Ultrasound evaluation – if bleeding persists, ultrasound examination can diagnose retained products. A normal endometrial stripe makes this highly unlikely, but detection of echogenicity in the uterus is concerning. When retained products are suspected and there is ongoing bleeding a gloved hand can be inserted into the uterus to gently remove any retained clots or tissue by bluntly dissecting along the uterine wall.
Consider coagulopathies – rarely, bleeding may result from coagulopathies arising from clinical situations such as HELLP syndrome, abruptio placentae, prolonged intrauterine fetal demise, sepsis or amniotic fluid embolism. If bleeding continues to be severe, obtain baseline clotting studies including PT, aPTT, and fibrinogen. Human recombinant factor VIIa, which acts on the extrinsic clotting pathway, may be given in doses of 50 to 100 micrograms/kg every 2 hours until hemostasis has been achieved in severe life-threatening bleeding if available. Blood products may also be needed to replace clotting factors.
What if the bleeding persists after all the above are unsuccessful? What next?
If you have reached this point, you will have made every effort to get obstetrical assistance, and are either awaiting arrival or are arranging transportation to the closest appropriate facility. Continue your best efforts at resuscitation and stabilization..
If no help is on the way, tamponade of the uterine cavity is the next option.
Most EDs will not have a commercially available balloon device for uterine packing, so gauze rolls, tied together for easy removal, can be placed to tamponade the uterus. Place the gauze in the fundus first to avoid any undetected collections of blood and layer it from side to side until the end extends out of the cervical os. Give broad spectrum antibiotics. Concealed bleeding can still occur with gauze in place, so monitor for persistent bleeding.
The Bakri postpartum balloon and the BT-cath balloon tamponade catheter are both FDA approved devices that can be used if available. These devices are relatively easy to place and allow quick determination of effectiveness by gauging ongoing blood loss through the inner lumen. Place under US guidance , if possible, to confirm proper position and to confirm there are no retained products of conception. Once the catheter is inserted into the uterus inflate the balloon with saline to a maximum of 500 mL and apply gentle traction to the balloon shaft for optimal effect. If these devices are not available, a Foley catheter or Sengstaken-Blakemore tube are alternatives.
Why not use Tranexamic Acid (TXA)?
The rationale for using tranexamic acid is based on its safety and effectiveness in reducing mortality in trauma patients without increasing adverse events. (CRASH-2 trial). There are several promising studies using TXA in PPH with the WOMAN Trial (World Maternal Antifibrinolytic Trial) being the largest (15,000 women) intention to treat RCT currently being conducted. However, TXA has not been FDA approved for this indication and it is not currently recommended by the American College of Obstetrics and Gynecology. The World Health Organization recommends using TXA if oxytocin and other uterotonics fail to stop bleeding or if bleeding may be partly due to trauma. The dose is 1 gram IV.
- Create a precipitous delivery cart/kit that is available at all times with equipment/medications to manage PPH, especially if your facility has no immediate obstetrical backup.
- Use a gravimetric (weight based) method to identify blood loss and diagnose PPH.
- Remember the 4 T’s (Tone, Trauma, Tissue, Thrombin) to help systematically identify and treat the potential causes of PPH.
- EM physicians should be aware of new drugs and devices currently available and specifically designed to treat and manage PPH.
Your Story – Emergency Births
Virgin Birth: It was Christmas Day and an 18-year-old came in with severe lower abdomen pain. Examined her and a baby was crowning. “I can’t be pregnant,” she said, “I’ve never had sex!”
Backseat Baby: Security ran in saying a woman was having a baby in a car. I run out with a nurse and discovered that the baby’s head was delivered but she had not taken off her underwear. The head was pushing hard against the underwear which we couldn’t pull off as her legs were spread. Everything was stuck – the head in the underwear, the underwear on her legs, the woman in the car with legs spread wider than the doors. It took 2-3 minutes for someone to get scissors but it felt like hours. Even with the underwear removed we couldn’t move the woman because her legs were still spread wider than the door. Baby delivered in the car and we came in looking like we lost a serious street fight. It all worked out but was pretty exciting for a few minutes there.