Uterine massage is a simple first line treatment as it helps the uterus to contract to reduce bleeding. Although the evidence around the effectiveness of uterine massage is inconclusive, it is common practice after the delivery of the placenta.
Ergotamine may also be used. Combination of
misoprostol plus oxytocin probably reduces the need for additional uterotonics and the need for blood transfusion, while carbetocin probably makes little difference to blood transfusion. It is the first line treatment for PPH when its cause is the uterus not contracting well. A combination of syntocinon and
ergometrine is commonly used as part of active management of the third stage of labour. This is called syntometrine. Syntocinon alone lowers the risk of PPH. Based on limited research available it is unclear whether syntocinon or syntometrine is most effective in preventing PPH but adverse effects are worse with syntometrine making syntocinon a more attractive option. It may reduce the risk of PPH by improving the tone of the uterus when compared with no treatment, however it must be used with caution due to its effects of raising blood pressure and worsening pain. Misoprostol can cause unpleasant side effects such as very high body temperatures and shivering. Giving oxytocin in a solution of saline into the umbilical vein is a method of administering the drug directly to the placental bed and uterus. As a way of treating a retained placenta, this method is not harmful and has shown low certainty evidence of effectiveness.
Carbetocin compared with oxytocin produced a reduction in women who needed uterine massage and further uterotonic drugs for women having caesarean sections.
Tranexamic acid, a clot stabilizing medication, makes little to no difference to blood loss, the risk of severe morbidity or additional surgical interventions. A 2017 trial found that it decreased the risk of death from bleeding from 1.9% to 1.5% in women with postpartum bleeding.
Surgery Surgery may be used if medical management fails or in case of cervical lacerations, tears in the uterine wall or a uterine rupture. Methods used may include uterine artery ligation, ovarian artery ligation, internal iliac artery ligation, selective arterial embolization, B-lynch suture, and
hysterectomy. Bleeding caused by traumatic causes should be managed by surgical repair. When there is bleeding due to uterine rupture a repair can be performed but most of the time a hysterectomy is needed. There is currently no reliable evidence from randomised clinical trials about the effectiveness or risks of mechanical and surgical methods of treating postpartum bleeding. In those with
placenta accreta (in which the placenta invades into the muscular layer of the uterus) planned caesarian delivery is recommended due to the very high risk of PPH although the optimal time for planned delivery is not well established with the
American College of Obstetricians and Gynecologists recommending planned caesarian at delivery between 34 weeks and 35 weeks and 6 days gestation and the
Royal College of Obstetricians and Gynaecologists recommending it between 35 and 36 weeks and 6 days.
Medical devices The
World Health Organization recommends the use of a device called the
non-pneumatic anti-shock garment (NASG) for use in delivery activities outside of a hospital setting, the aim being to improve shock in a mother with
obstetrical bleeding long enough to reach a hospital. External aortic compression devices (EACD) may also be used.
Uterine balloon tamponade (UBT) can improve postpartum bleeding. Inflating a
Sengstaken–Blakemore tube in the uterus successfully treats atonic postpartum hemorrhage refractory to medical management in approximately 80% of cases. Such procedure is relatively simple, inexpensive and has low surgical morbidity. While effective, commercially available devices may be expensive for settings in which postpartum hemorrhage is most common. Low-cost devices, such as the ESM-UBT, have been shown to be effective without the need for operative intervention. Uterine balloon tamponade devices may be left in place for up to 24 hours in the treatment of PPH. A detailed stepwise management protocol has been introduced by the California Maternity Quality Care Collaborative. It describes four stages of obstetrical hemorrhage after childbirth and its application reduces maternal mortality. • Stage 0: normal - treated with fundal massage and
oxytocin. • Stage 1: more than normal bleeding - establish large-bore intravenous access, assemble personnel, increase oxytocin, consider use of
methergine, perform fundal massage, prepare 2 units of
packed red blood cells. • Stage 2: bleeding continues - check coagulation status, assemble response team, move to
operating room, place
intrauterine balloon, administer additional
uterotonics (misoprostol,
carboprost tromethamine), consider:
uterine artery embolization,
dilatation and curettage, and
laparotomy with uterine compression stitches or hysterectomy. • Stage 3: bleeding continues - activate
massive transfusion protocol, mobilize additional personnel, recheck laboratory tests, perform laparotomy, consider hysterectomy. A
Cochrane review suggests that active management (use of uterotonic drugs, cord clamping and controlled cord traction) during the third stage of labour may reduce severe bleeding and
anemia. However, the review also found that active management increased the patient's blood pressure, nausea, vomiting, and pain. In the active management group more patients returned to hospital with bleeding after discharge, and there was also a reduction in birthweight due to infants having a lower blood volume. The effects on the baby of early cord clamping was discussed in another review which found that delayed cord clamping improved iron stores longer term in the infants. Although they were more likely to need phototherapy (light therapy) to treat jaundice, the improved iron stores are expected to be worth increasing the practice of delayed cord clamping in healthy term babies. Another Cochrane review looking at the timing of the giving
oxytocin as part of the active management found similar benefits with giving it before or after the expulsion of the placenta. There is no good quality evidence on how best to treat a secondary PPH (PPH occurring 24 hrs or more after the birth). ==Epidemiology==