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Hello and welcome back to another episode. Today I'm going to talk about postpartum hemorrhage and the definition of postpartum hemorrhage has varied over time. Most recently, the American College of Obstetricians and Gynecologists supports the criteria for postpartum hemorrhage as a cumulative blood loss of 1000 ML or greater or any blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process. And this is regardless of the mode of delivery being vaginal or by cesarean. About 3 to 5% of all deliveries are complicated by postpartum hemorrhage, and this is the leading cause of maternal mortality worldwide. Thankfully, we have access to a large arsenal of interventions both in the United States and throughout the world that can be utilized to prevent and treat hemorrhage and ideally reduce morbidity and mortality. Before we go any further, I wanted to let you know about a new resource that I created for fourth year med students who just matched into OB GYN and are about to start their residencies this July. It's called the OB GYN Residency Starter Pack, a five step guide for incoming interns, and it's free, and I designed it to help you feel more prepared and less overwhelmed as you get ready for day one. Whether you're wondering what to review or what some of the best resources are to help you prepare, the guide will walk you through five essential steps to help you hit the ground running. Like I said, it's completely free and you can download it at subscribepage IO forward slash OB Intern Guide or through the show notes linked to this episode. All right, back to the content. So what is a normal postpartum blood loss? Based on the available objective data, the mean estimated blood loss after a vaginal Delivery is about 500 ML and after a C section, 1000 ML. Because of the physiologic changes of pregnancy, the signs or symptoms of considerable blood loss, such as tachycardia and hypotension, often don't present until there is substantial blood loss, meaning by the time a patient is tachycardic and hypotensive, they've actually already lost 25% of their blood volume, which is approximately one and a half liters. So it's very important to identify an evolving postpartum hemorrhage and intervene before the vital signs even start to deteriorate. Now, there is a long list of risk factors for postpartum hemorrhage and you can review that list in Table 1 of the ACOG Practice Bulletin Number 183 Postpartum hemorrhage linked in the show notes. I will touch on some of them. Firstly, anything that over distends the uterus like a macrosomic baby, polyhydramnios, multifetal gestation and fibroids. Other risk factors include the prolonged use of pitocin, intra amniotic infection, general anesthesia, grand multiparity, and precipitous delivery like I mentioned. To see the list of all the other risk factors, check out that Practice bulletin. Now, it's important for you to understand the two different categories of hemorrhage. We have primary hemorrhage, also called early hemorrhage. Those are hemorrhages that occur within 24 hours of delivery. Then we have secondary or late hemorrhages and Those occur from 24 hours all the way out to 12 weeks postpartum. In this episode, I'm going to focus on primary or early postpartum hemorrhage. So now that we know some of the risk factors, what actually causes the postpartum hemorrhage itself? The number one cause of primary postpartum hemorrhage is uterine atony, which is the inability of the uterine myometrium to effectively contract. So if you remember, in a term pregnancy, blood flow to the uterus is 500 to 700 milliliters per minute. That's a ton of blood flow. So when the placenta comes out, all of those spiral arteries going from the uterine wall and into the placenta are left open. And the only way to immediately control bleeding from those vessels is to clamp down on them. And normally that's what the uterus does. The myometrium contracts and acts as a sort of giant tourniquet to all those spiral arterioles. Other causes of primary hemorrhage include lacerations, retained placental products, and abnormally adherent placenta, such as in placenta accreta spectrum disorders, coagulation defects like disseminated intravascular coagulation and or uterine inversion. So let's say you have a patient that just delivered a nine pound infant vaginally. As soon as that baby comes out, you're already going to be working on the prevention process of postpartum hemorrhage. We prevent postpartum hemorrhage via active management of the third stage of labor, which as a reminder is the period of time between fetal delivery and placental delivery. We do this by administering pitocin at the same time as performing uterine massage and umbilical cord traction to facilitate placental delivery. Those are your preventative measures measures. Now let's say you did all those things. The placenta delivered and appeared to be intact, meaning it didn't come out in pieces. And now you notice brisk bleeding. Where do we start? Before you do anything, just make sure that the postpartum pitocin is actually running because sometimes it just gets forgotten. That's step number one. And then knowing that the number one cause of postpartum hemorrhage is at me. A good place to start is by performing a bimanual exam to palpate the uterus. So you're going to insert one hand through the vagina to feel the cervix and lower uterine segment and place your other hand on the maternal abdomen to palpate the fundus. Both of these should feel firm on palpation, so if they're not, then go ahead and perform a bimanual massage, meaning use one hand to massage the fundus from the outside and the other hand to squeeze and massage that lower uterine segment internally. Sometimes clots get trapped in the lower uterine segment, which prevents it from clamping down, so you should scoop those out if you feel them. Now while you're doing this, you want to be thinking about how long it's been since their bladder was drained. Because a full bladder can inhibit uterine contractility. Oftentimes patients have been pushing for many hours without a Foley or the chance to empty their bladder. So if this is the case, just go ahead and drain the bladder so we can at least eliminate that as a contributing factor. While this is happening, you want to keep an eye out on the amount of blood that is accumulating in the under buttock. Drape if the bleeding is ongoing or rapid, especially if it's approaching around 500cc's you should be notifying the room to activate a postpartum hemorrhage protocol if your institution has one, or at least calling for the following 1 Ensure the patient has adequate IV access, ideally with two IVs. 2 Administer fluid resuscitation. A good place to start is to bolus about 500 cc's to a liter of normal saline or lactated ringers. Three is to call for hemorrhage medications to bedside and four get the patient some blankets to maintain a normal body temperature. You also want to perform an inspection of the vagina, cervix and perineum early on to assess for any lacerations, and obviously if any of those appear to be the source of the bleeding, they should be repaired. If there are no hemorrhaging lacerations and the uterus is still atonic, you should consider performing a uterine sweep. So insert your entire hand in through the cervix to the uterine cavity all the way up to the fundus to palpate for any remaining placental fragments or membranes that could be stuck inside and remove them. You can do this under ultrasound guidance if needed as well. By now you should have a hemorrhage kit at bedside, which would just be a packet of all the hemorrhage meds, ultrasound and other devices that we're going to talk about later. All right, that brings us to the end of the Postpartum Hemorrhage Basics Episode Part 1. Let's do a quick review. Postpartum hemorrhage is defined as a cumulative blood loss of 1 liter or greater or any blood loss accompanied by signs or symptoms of hypovolemia within 24 hours of birth. Hemorrhage that occurs within 24 hours of birth is considered a primary or early postpartum hemorrhage, whereas hemorrhage that occurs 24 hours after birth or greater is considered a secondary or late postpartum hemorrhage. The number one cause of a primary postpartum hemorrhage is uterine atomy, but other causes include lacerations, retained placental products, an abnormally adherent placenta, coagulation defects and or uterine inversion. Postpartum hemorrhage can be prevented through the active management of the third stage of labor, and this includes the administration of pitocin while performing funnel massage and cord traction to help deliver the placenta. If a patient hemorrhages, your first steps involve by manual exam and massage, draining of the bladder, assessing for obstetric lacerations, and confirming that there are no products of conception still remaining within the uterine cavity. Stay tuned for next week's episode where we will review the pharmacologic, mechanical and intraoperative interventions that can be used to manage postpartum hemorrhage. Per usual all the references I mentioned are linked in the episode show notes along with the free OB GYN Residency Starter Pack. See you next week. Free audio post production by alphonic.com.