00:02
Now we'll talk about
postpartum hemorrhage.
00:06
So postpartum hemorrhage can
be divided into primary
versus secondary.
00:10
Primary postpartum hemorrhage
occurs within the first 24 hours
after delivery.
00:16
Secondary postpartum hemorrhage
anywhere from 24 hours up to
12 weeks after delivery.
00:21
It is important to know
the difference
because the causes
are different.
00:25
Postpartum hemorrhage is now defined as cumulative
blood loss of greater than 1000 milliliters
or blood loss accompanied by signs
or symptoms of hypovolemia
within 24 hours
after birth, regardless of the mode of delivery.
00:39
So when we think of primary
postpartum hemorrhage
and our causes we think
of the 4 T's.
00:44
That's Tone, Tissue, Trauma
and Thrombin Disorders.
00:48
We're going talk about each
of these in a little detail.
00:51
Tone is important because this
accounts for 80 percent
of the causes of postpartum
hemorrhage.
00:57
So there are some risk factors
for you uterine atony.
01:00
First is the extension
of the uterus.
01:02
Anything that distends
the uterus such as multifetal
gestation or polyhydramnios
can cause the uterus to have
difficulty contracting leading
to uterine atony
and being a cause of postpartum
hemorrhage.
01:14
Also uterine infection such as
in the case of chorioamnionitis.
01:18
Rapid or prolong labor.
01:20
Fibroids or Grand multiparous.
01:21
Again anything that's going to
interfere with the ability
of uterus to contract can
lead to uterine atony.
01:27
And that can lead to
postpartum hemorrhage.
01:31
Moving on to tissue.
01:32
This refers to retain
products of conception.
01:35
We can see this when there's
an extra lobe of the placenta
that may be missing.
01:40
Or if we have an abnormal
placentation such as placenta
acreta, placenta increta
or placenta percreta.
01:48
Trauma refers to any lacerations
to the cervix, the vagina,
the perineum.
01:53
This can also include hematomas.
01:56
And then thrombin disorder
is that anything that will
prevent clotting to take place.
02:00
Such as DIC or in HELLP syndrome.
02:06
Now when we look at our causes
of late postpartum hemorrhage
or secondary postpartum hemorrhage,
that's infection
such as metritis.
02:12
Retain products of conception.
02:15
So again if we have a lobe
that's left behind.
02:18
Subinvolution
or coagulation defects.
02:23
So when we talk about our
treatment for postpartum
hemorrhage.
02:26
The treatment is directed
to the cause.
02:28
But remember no matter what
the cause is, the initial step
in management will always
be destabilize the patient.
02:37
So when we think about our
management, we first want
to call for help.
02:42
We want to make sure that we
have whoever we need to help us
in this situation including another
obstetrician,
nurses and the help of our
anesthesia colleagues.
02:51
You want to begin resuscitation.
02:52
If someone is bleeding,
the first thing you want to do
is start two large bore
IV needles.
02:57
Remember as they continue to
bleed, it's going to be very
difficult to get IV access if
you not already establish that.
03:03
You also want to give IV fluids
and you want to start calling
for blood.
03:08
You want to check lab.
03:09
You can to see where
you're starting.
03:11
So these labs will include
a CBC, a type-in screen, PT,
PTT, INR, and Fibrinogen.
03:19
Now I don't know how quickly
you get your labs
back in your hospital.
03:24
But sometimes when we need
our lab results back quicker
than we can get them
from the lab.
03:29
So there's a quick way you can
check to see if someone
is going in DIC.
03:32
It's called the Red Top
Tube Test.
03:34
You take a red test
tube that has a red top.
03:39
Put 2 to 3 cc of mom's blood
into that test tube
and you leave it alone for
about 6 minutes.
03:45
You'll expect her blood to clot
and stay clotted
for 6 to 10 minutes.
03:50
If the blood does not clot
it that time,
then you can suspect that patient
is going into DIC.
03:56
Next you want to consider
the etiology.
03:59
Remember we're going to direct
our therapy
to whatever the cause
of postpartum hemorrhage is.