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Postpartum Hemorrhage

Obstetric hemorrhage is one of the three leading causes of maternal mortality. Postpartum hemorrhage has been defined as the loss of more than 500 mL of blood following delivery. However, the average blood loss in an uncomplicated vaginal delivery is about 500 mL, with 5% losing more than 1,000 mL.

Clinical Evaluation of Postpartum Hemorrhage

Causes of Postpartum Hemorrhage. Uterine atony, retained placental fragments, lower genital tract lacerations, uterine inversion, uterine rupture, coagulopathy.

Uterine atony is the most common cause of postpartum hemorrhage. Conditions associated with uterine atony include an overdistended uterus (eg, polyhydramnios, multiple gestation), rapid or prolonged labor, macrosomia, high parity, and chorioamnionitis.

Conditions Associated with Bleeding from Trauma include forceps delivery, macrosomia, precipitous labor and delivery, and episiotomy.

Conditions Associated with Bleeding from Coagulopathy and Thrombocytopenia include abruptio placentae, amniotic fluid embolism, preeclampsia, coagulation disorders, autoimmune thrombocytopenia, and anticoagulants.

Conditions Associated with Uterine Rupture include previous uterine surgery, internal podalic version, breech extraction, multiple gestation, and abnormal fetal presentation. High parity is a risk factor for both uterine atony and rupture.

Uterine Inversion. Incomplete inversion is detected by abdominal vaginal examination, which will reveal a uterus with an unusual shape.


Following delivery of the placenta, the uterus should be palpated to determine whether atony is present. If atony is present, vigorous fundal massage should be administered. If bleeding continues despite uterine massage, it can often be controlled by bimanual uterine compression.

Genital tract lacerations should be suspected in patients who have a firm uterus, but who continue to bleed. The cervix and vagina should be inspected to rule out lacerations. If no laceration is found but bleeding is still profuse, the uterus should be manually examined to exclude rupture.

The placenta and uterus should be examined for retained placental fragments. Placenta accreta is usually manifest by failure of spontaneous separation.

Bleeding from non-genital areas (venous puncture sites) suggests coagulopathy. Laboratory tests that confirm coagulopathy include INR, partial thromboplastin time, platelet count, fibrinogen, fibrin split products, and a clot retraction test.

Medical Treatment