eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Pregnancy, Postpartum Hemorrhage: Follow-up

Author: Maame Yaa A B Yiadom, MPH, MD, Staff Physician, Department of Emergency Medicine, Brigham and Women's Hospital and Massachusetts General Hospital
Coauthor(s): Daniela Carusi, MSc, MD, Instructor, Obstetrics and Gynecology and Reproductive Biology, Harvard Medical School; Consulting Physician, Department of Obstetrics and Gynecology, Medical Director, Department of General Ambulatory Gynecology, Brigham and Women's Hospital
Contributor Information and Disclosures

Updated: Oct 21, 2009

Follow-up

Transfer

If a patient is brought to a hospital without obstetric services, the EM providers should initiate resuscitation and transfer the patient as quickly as possible to a hospital with obstetric services for definitive care. Discuss an en route resuscitation plan with the EMS transport team, and make the receiving hospital aware of what the patient's status was upon departure from the ED so that the appropriate resources are mobilized before her arrival. Be sure to adhere to patient transfer laws set by the transferring facility, city, EMS transport organization, and state.

Deterrence/Prevention

The active management of the third stage of labor has been shown to decrease the incidence and severity of postpartum hemorrhage (PPH). This includes the administration of oxytocin or misoprostol, uterine massage, gentle traction on the umbilical cord, and prompt placental delivery. Women with a known uterine scar or suspected placental abnormalities should be delivered and managed in a hospital setting, and instrumentation should be avoided, when possible, during vaginal delivery.

For further information, see the World Health Organizations recommendations on the prevention of postpartum hemorrhage.15

Complications

Consequences include the sequelae of hemorrhage; aggressive fluid resuscitation; blood-product exposure; and procedures done to control uterine, cervical, vaginal, or peritoneal hemorrhage. See Mortality/Morbidity for more detail.

Prognosis

The prognosis depends on the cause of the PPH, its duration, the amount of blood loss, comorbid conditions, and the effectiveness of treatment. Prompt diagnosis and treatment are essential to achieving the best outcome for any given patient. Most reproductive-age women will do well if managed promptly in a setting with operative and blood-product resources available.

Patient Education

Postpartum hemorrhage can be a frightening experience for patients. It is important to provide reassurance and communicate through each step of emergency care. Make patients aware of what to anticipate through their clinical course including expected procedures; transport; and the indication, risks, and benefits of interventions. 

Miscellaneous

Medicolegal Pitfalls

To avoid common medicolegal pitfalls consider the following:

  • Active management of the third stage of labor is key to reducing the incidence and severity of postpartum hemorrhage (PPH). Be sure to perform early uterine massage and administer oxytocic agents.
  • Contact an OB/GYN consultant before or upon initiating the evaluation of the patient.
  • Some typical vaginal deliveries are associated with blood loss of more than 500 mL. However, emergency department personnel should assume that any patient with blood loss greater than 500 mL and ongoing bleeding has postpartum hemorrhage. Resuscitation should be started while evaluating the patient for the cause of postpartum hemorrhage.
  • Always suspect occult hemorrhage (eg, hematoma, intra-abdominal) in postpartum patients who have unstable vital signs with little or no external bleeding. Consider atypical signs of hemorrhage, such as restlessness, dyspnea, and back and abdominal pain, which may be the first signs of hemorrhage in a hemodynamically stable patient. 
  • Early recognition of a coagulopathy and prompt administration of coagulation factors may be life saving. This may entail immediate transfusion based on clinical suspicion, rather than waiting for laboratory results to return.
  • When a patient is delivered to a facility without obstetrical services, adequate resuscitation should be achieved before the patient is transferred. An en route resuscitation plan should be communicated to the transporting EMS team, and the patient's condition upon departure should be reported to the receiving providers. All institutional, state, and national regulations for patient transfer should be followed.

Special Concerns

  • With early postpartum hemorrhage occurring right after delivery, remember that 2 patients—the mother and the newborn—require evaluation and intervention.
  • Because of the hemodynamic changes in pregnancy (increased blood volume and physiologic anemia), the signs and symptoms of hypovolemia may not be apparent until the hemorrhage is severe.
 
Acknowledgments

Special thanks to Dr. Donnie Bell for his assistance with the "Imaging" section for this topic.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Michael P Wainscott, MD, to the development and writing of this article.



More on Pregnancy, Postpartum Hemorrhage

Overview: Pregnancy, Postpartum Hemorrhage
Differential Diagnoses & Workup: Pregnancy, Postpartum Hemorrhage
Treatment & Medication: Pregnancy, Postpartum Hemorrhage
Follow-up: Pregnancy, Postpartum Hemorrhage
References
Further Reading
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References

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Further Reading

Postpartum Hemorrhage (PPH). Shahid M. Ahmad, Atif Farid, Demitra del Silva, Harish Kodi.

New Technologies to Save Mothers Lives from PPH. PATH/USAID.

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Keywords

postpartum hemorrhage, postpartum bleeding, PPH, bleeding after delivery, vaginal delivery, cesarean delivery, birth, giving birth, blood loss after birth, blood loss after delivery, maternal death, 4 T's, 4 Ts, tone, tissue, thrombosis, uterine atony, uterine prolapse, oxytocin, hemorrhage, coagulopathy, living ligatures, physiologic sutures, DIC, uterine inversion, maternal mortality, uterotonic, oxytocin, Pitocin, misoprostol, Cytotec, ergotamine, methylergotamine, carboprost, Hemabate, recombinant factor VIIa, retained products of conception, retained placenta, obstetrics, pelvic ultrasound, bedside ultrasound, third stage of labor, 3rd stage of labor

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Contributor Information and Disclosures

Author

Maame Yaa A B Yiadom, MPH, MD, Staff Physician, Department of Emergency Medicine, Brigham and Women's Hospital and Massachusetts General Hospital
Maame Yaa A B Yiadom, MPH, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, National Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Daniela Carusi, MSc, MD, Instructor, Obstetrics and Gynecology and Reproductive Biology, Harvard Medical School; Consulting Physician, Department of Obstetrics and Gynecology, Medical Director, Department of General Ambulatory Gynecology, Brigham and Women's Hospital
Daniela Carusi, MSc, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Reproductive Health Professionals, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Assaad J Sayah, MD, Chief, Department of Emergency Medicine, Cambridge Health Alliance
Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Medicines Company Consulting fee Consulting; Pfizer Salary Employment

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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