Postpartum Haemorrhage
Postpartum haemorrhage occurs more frequently in the first 2 h after delivery and is classified as early or primary postpartum haemorrhage (i.e. occurring in the first 24 h after birth). Late or secondary postpartum haemorrhage (appearing after the first
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Postpartum Haemorrhage
6.1
Definition, Incidence and Main Risk Factors
Postpartum haemorrhage occurs more frequently in the first 2 h after delivery and is classified as early or primary postpartum haemorrhage (i.e. occurring in the first 24 h after birth). Late or secondary postpartum haemorrhage (appearing after the first 24 h) is outside the aim of this chapter. There is no worldwide agreement on the definitions of postpartum haemorrhage and major postpartum haemorrhage. Some define postpartum haemorrhage as blood loss exceeding 500 ml and major postpartum haemorrhage as blood loss exceeding 1000 ml. Others define postpartum haemorrhage as blood loss exceeding 500 ml in vaginal deliveries and exceeding 1000 ml at caesarean section. The limitation of all these definitions is the difficulty in quantifying blood loss accurately, particularly in vaginal deliveries. Collector bags can be used for this purpose, but blood frequently falls outside; amniotic fluid and urine may be collected and both will affect quantification. Weighing of swabs is routinely performed in some centres, but the practice is time-consuming and not widely disseminated, and similar inaccuracies to those referred for collector bags may occur. The most widely used alternative is visual estimation of blood loss, but this has well-known limitations, although improved accuracy may be achieved with visual aids, where the appearance of different blood quantity losses is depicted on photographs/drawings (Fig. 6.1). An additional problem arises from the fact that small women and those with pre-existing anaemia may decompensate with lesser quantities of blood loss. Another definition of postpartum haemorrhage is a reduction in the haematocrit exceeding 10 %, but routine blood analysis before and after birth is rarely practised in low-risk labours, where the majority of complications occur. The need for blood transfusion is an alternative criterion, but it is used mainly in research settings, it leaves out less severe cases of haemorrhage, and transfusion criteria may vary between centres.
© Springer International Publishing Switzerland 2017 D. Ayres-de-Campos, Obstetric Emergencies, DOI 10.1007/978-3-319-41656-4_6
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Postpartum Haemorrhage
Fig. 6.1 Quantification of blood loss based on drawings
From a clinical point of view, the most important factor to define postpartum haemorrhage is the one that should trigger a response from the healthcare team. In the majority of situations, this occurs because profuse and/or persistent genital bleeding is witnessed to occur spontaneously after birth or when uterine massage is performed. Bleeding may be mild and rapidly reversible, so it is important to separate the concept of major postpartum haemorrhage, where more complex interventions need to be considered. Blood loss exceeding 1000 ml or a heart rate approaching the systolic blood pressure is probably the most useful criteria, from a clinical point of view. The “shock index”, defined as the heart rate divided by systolic blood pressure, is used
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