Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality worldwide. Epidemiologic studies show an increasing frequency and severity of PPH in the past decade, due to an increase in uterine atony and placenta accreta, percreta, and increta. Management of PPH requires prompt and efficient multidisciplinary intervention to improve uterine tone; provide adequate fluid and hemodynamic resuscitation, administer blood products, and decide whether additional procedures such as interventional radiology or surgery are needed. Optimal management of PPH requires adequate communication between all team players (nurses, midwives, obstetricians, anesthesiologists, hematologists/blood bank, surgeons, interventional radiologists, and intensive care unit staff). Teamwork is facilitated when protocols are in place to allow human allocation and tasks to be well defined along with adequate record keeping. Algorithms for the use of blood products, fibrinogen, recombinant activated factor VII (rFVIIa), tranexamic acid, blood cell salvage devices, and other conservative maneuvers (Bakri balloon, B-Lynch procedure, interventional radiology) should be in place to reduce the need for hysterectomy and massive transfusion. Adequate documentation, debriefing after clinical care, and audits should facilitate monitoring of the success of such protocols. Practice guidelines and recommendations established by national societies and organizations have flourished in the literature over the past 5 to 8 years to assist clinicians in the prevention and management of PPH, of which the practice bulletin of the American College of Obstetrics and Gynecology (ACOG) in 2006,1 the International Confederation of Midwives, the International Federation of Gynecology and Obstetrics (FIGO) initiative in 2006,2 the clinical practice guideline of the Society of Obstetricians and Gynaecologists of Canada (SOGC) in 2009,3 the California Maternal Quality Care Collaborative (CMQCC) guide in 2010,4 the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines in 2011,5 and the most updated World Health Organization (WHO) recommendations in 20126 are just a few examples.
The goal of this chapter is to present a practical and updated overview on current modalities and recommendations that are available, to improve the management of planned and unplanned obstetric hemorrhages, and to prevent fatal outcomes for both mothers and their infants.
DEFINITIONS AND TAXONOMY OF POSTPARTUM AND MAJOR OBSTETRIC HEMORRHAGES
The clinical estimation of blood loss during delivery is frequently inaccurate, in general underestimated, and the presence of amniotic fluid may be a confounding factor. It is important to bear in mind that healthy women will not become symptomatic before a significant amount of blood loss has occurred. In other words, by the time significant obstetric hemorrhage has been observed, women may already have lost 10% to 15% of their circulating blood volume. Nonetheless, whereas symptoms, hemodynamic parameters, a hematocrit value or the need for blood products would appear valuable to determine whether a hemorrhage is significant or not, the diagnosis is usually based solely on the estimated blood loss (Table 20-1).
Table 20-1.Definitions and Taxonomy of ...