Assessing and managing hypovolemic shock in puerperal women

The major cause of maternal death worldwide is postpartum hemorrhage (PPH). Early identification is the basis for adequate treatment. In addition to the visual estimation of blood loss, clinical signs could offer a more reliable representation of the cardiovascular system of the bleeding woman. However, in postpartum women, recognition of hypovolemic shock through vital signs is impaired owing to physiological cardiovascular changes in pregnancy. The Shock Index [SI] is one composite vital sign that may help in the identification of women with hypovolemic shock. Values of SI ≥ 1 in the first hour postpartum indicate cardiac decompensation, and treatment should be implemented immediately. From the diagnosis of PPH, first-line measures should ensure coordinated care actions including the availability of blood derivatives, the establishment of conditions for volume replacement, oxygen therapy, and identification and timely treatment causes of bleeding. Individualized fluid resuscitation should start with warmed crystalloids and be limited to 3.5 L.     

再谈产后出血患者出血量的计算

产后出血(postpartum hemorrhage)是产科最常见、最凶险的并发症之一,是导致全球孕产妇死亡的主要原因。准确地预估出血量,对临床上选择何种方法预防和治疗产后出血具有重要的指导意义。临床上常用的方法有：目测法、面积法、称重法、血红蛋白测定法以及休克指数等方法,近年又有学者研究发明了一种新型直观、较为精确的容量袋法。     

产后出血的预测和预警

孕产妇死亡率逐年下降，但是产后出血仍是主要原因。产后出血的风险评估包括高危因素的识别和风险评估工具的使用，但现有手段仍有其局限的地方。同时，还需要实时对产后出血进行预警，常用指标包括出血量、失血速度、生命体征、休克指数等，同时基于这些指标构建实用的产后出血预警系统。     

The more you lose the more you miss: accuracy of postpartum blood loss visual estimation. A systematic review of the literature

Midwives and nurses have a key role in monitoring postpartum period. They represent the first line professional figure in quantifying blood loss, initiating early diagnosis of obstetric hemorrhage, and mobilizing a team response, if needed. These actions are crucial in determining maternal outcome in postpartum hemorrhage (PPH). In our review we aimed to: (1) Provide a picture of PPH including its pathophysiology, epidemiology, and associated complications; (2) Discuss diagnosis of this dangerous postpartum event; and, (3) Especially evaluate the efficiency of the employment of visual blood loss estimation as a rapid way to suspect PPH and activate the patient assessment.     

Volume Replacement Following Severe Postpartum Hemorrhage

Severe postpartum hemorrhage (PPH) can be defined as a blood loss of more than 1500 mL to 2500 mL. While rare, severe PPH is a significant contributor to maternal mortality and morbidity in the United States and throughout the world. Due to the maternal hematologic adaptation to pregnancy, the hypovolemia resulting from hemorrhage can be asymptomatic until a large amount of blood is lost. Rapid replacement of lost fluids can mitigate effects of severe hemorrhage. Current evidence on postpartum volume replacement suggests that crystalloid fluids should be used only until the amount of blood loss becomes severe. Once a woman displays signs of hypovolemia, blood products including packed red blood cells, fresh frozen plasma, platelets, and recombinant factor VIIa should be used for volume replacement. Overuse of crystalloid fluids increases the risk for acute coagulopathy and third spacing of fluids. A massive transfusion protocol is one mechanism to provide a rapid, consistent, and evidence‐based team response to this life‐threatening condition.     

Postpartum hemorrhage and transfusion of blood and blood components

Postpartum hemorrhage (PPH) is one of the top 5 causes of maternal mortality in developed and developing countries. The incidence of PPH is 40% after vaginal delivery and 30% after cesarean section. Criteria for PPH are based on the amount of blood loss. In clinical obstetrics, exact measurement of blood loss is often difficult. The most important treatment of PPH is red blood cell (RBC) transfusion. In the past few years, increasing concern has arisen about this treatment. Despite the introduction of several new guidelines, transfusion criteria still vary widely between clinicians. The decision whether to prescribe RBC transfusion is mostly based on postpartum hemoglobin (Hb) values. RBC transfusion should be aimed to reduce morbidity and especially to improve health-related quality of life (HRQoL). In this review, etiology, epidemiology, treatment, and prevention of postpartum hemorrhage are described. Special attention is given to the role of RBC transfusion in the treatment of PPH and the effects of RBC transfusion on HRQoL. TARGET AUDIENCE:: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES.: After completion of this article, the reader should be able to summarize the new guidelines related to transfusion criteria, explain the importance of reducing morbidity related to improving quality of life issues, and list infectious and noninfectious complications of a red blood cell transfusion.     

Postpartum hemorrhage: early identification challenges

Postpartum hemorrhage is the leading cause of maternal morbidity and mortality worldwide. The majority of maternal deaths associated with hemorrhage could be preventable. The accurate assessment of blood loss, identification of risk factors and timely recognition of postpartum hemorrhage remain major challenges in obstetrics. It is important to review available modalities for estimation and quantification of peripartum blood loss, the value of risk assessment tools as well as the challenges in early recognition of clinical signs and symptoms of postpartum hemorrhage.     

Drape estimation vs. visual assessment for estimating postpartum hemorrhage.

OBJECTIVE: To compare (1) visual estimation of postpartum blood loss with estimation using a specifically designed blood collection drape and (2) the drape estimate with a measurement of blood loss by photospectrometry. METHODS: A randomized controlled study was performed with 123 women delivered at the District Hospital, Belgaum, India. The women were randomized to visual or drape estimation of blood loss. A subsample of 10 drape estimates was compared with photospectrometry results. RESULTS: The visual estimate of blood loss was 33% less than the drape estimate. The interclass correlation of the drape estimate to photospectrometry measurement was 0.92. CONCLUSION: Drape estimation of blood loss is more accurate than visual estimation and may have particular utility in the developing world. Prompt detection of postpartum hemorrhage may reduce maternal morbidity and mortality in low-resource settings.     

Postpartum haemorrhage and haematological management

Postpartum haemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide. Recent report of the Centre for Maternal and Child Enquiries (CMACE) in the United Kingdom, which was previously called Confidential Enquiries into Maternal and Child Health (CEMACH), confirmed a reduction in maternal deaths during the last Triennium (2006–2008). This is attributed to improvements in timely diagnosis and prompt and aggressive treatment. PPH is now the sixth most common direct cause of maternal deaths in the U.K. World Health Organization (WHO) estimates that postpartum haemorrhage accounts for 25% of maternal deaths worldwide. Substandard care and ‘too little being done too late’ remain a significant contributor of maternal deaths.Primary PPH refers to a blood loss from the genital tract of 500 ml or more within 24 h of delivery (or >1000 ml during caesarean section). Secondary PPH refers to an excessive blood loss between 24 h and 6 weeks after birth. Massive PPH refers to a blood loss of over 2000 ml (or >30% of blood volume) and is associated with increased maternal morbidity and mortality. A timely, multi-disciplinary and systematic approach to restore the volume, clotting system and the oxygen carrying capacity of blood, whilst steps are taken to arrest bleeding, is essential to save life.Primary postpartum haemorrhage is caused by uterine atony, genital tract trauma, retained placental tissue and membranes after birth or coagulopathy. The latter may not only be a cause of PPH, but also could be an effect of massive haemorrhage due to a ‘washout phenomenon’. Rapid and profuse bleeding results in loss of platelets and clotting factors, that get ‘washed out’. This may lead to a depletion of coagulation factors and resultant bleeding.     

Management of massive postpartum haemorrhage and coagulopathy

Postpartum haemorrhage (PPH) continues to remain the leading cause of maternal morbidity and mortality worldwide. Whilst this is especially true in resource limited countries, it also remains a significant problem in developed countries. The traditional definition of primary PPH is blood loss from the genital tract of 500 ml or more within 24 h of delivery (or >1000 ml during caesarean section). Secondary PPH refers to an excessive blood loss between 24 h and 6 weeks, postnatally. Massive PPH refers to a blood loss of over 2000 ml (or >30% of blood volume) and hence, is an obstetric emergency that requires a systematic, multi-disciplinary approach to restore the volume, clotting system and the oxygen carrying capacity of blood, whilst steps are taken to arrest bleeding as quickly as possible.The last confidential enquiry into maternal deaths (CEMACH, 2003–2005) in the UK cited ‘haemorrhage’ as the third highest cause of direct maternal deaths with 6.6 deaths per million maternities. This report found that 58% of these deaths may have been preventable and ‘too little being done, too late’ (failure to appreciate clinical picture, delay in instituting appropriate treatment, delay is summoning senior help and system failures) continues to contribute to maternal morbidity and mortality, even in the developed world.Massive obstetric haemorrhage may occur in the antepartum (placenta praevia, placental abruption and placenta accreta) or postpartum period. It is has been observed that the incidence of massive PPH is likely to be increasing due to the increased incidence of risk factors such as morbidly adherent placenta secondary to previous caesarean sections and maternal obesity. However, massive obstetric haemorrhage and the resultant coagulopathy can occur in women deemed to be at ‘low risk’ and hence, all clinicians managing women during pregnancy and labour need to possess knowledge and skills to recognize symptoms, signs and complications of massive obstetric haemorrhage. This may ensure institution of timely and appropriate treatment that could save lives.     

Massive postpartum haemorrhage and management of coagulopathy

Postpartum haemorrhage (PPH) is a leading cause of maternal morbidity and mortality in both the developed and developing world. By definition, PPH refers to a blood loss of>500 ml (or>1000 ml during a caesarean section) after the delivery of the fetus. However, this is an arbitrary value as women who are ‘small made’ (low blood volume) or anaemic may not tolerate even a blood loss of 500 ml. Massive PPH refers to the loss of 30–40% (generally>2 L) of the patient's blood volume, resulting in changes in the haemodynamic parameters which lead to moderate or severe shock. Consequences of such massive blood loss include sudden and rapid cardiovascular decompensation and coagulopathy, as well as iatrogenic complications of fluid replacement and multiple blood transfusions (pulmonary oedema, transfusion reactions and adult respiratory distress syndrome).     

产后出血的研究进展

产后出血（PPH）是导致孕产妇患病及死亡的常见原因之一,目前多数定义为阴道分娩后24 h累计失血量≥500 mL,剖宫产术后累计失血量≥1 000 mL。但PPH的诊断不仅要以失血量为依据,也要重视血流动力学的改变。缩宫素作为预防和治疗PPH的一线药物已成为共识,卡贝缩宫素、卡前列素氨丁三醇和米索前列醇等亦可应用。具有PPH高危因素的孕妇,剖宫产术中除预防使用缩宫素之外,还可考虑静脉使用氨甲环酸以减少出血。尚无证据表明哪一种手术治疗方式更佳,常需根据实际情况进行选择。发生PPH时,凝血功能异常是大量输血和子宫切除的预测指标,当出血难以控制时,早期输注纤维蛋白原是安全和有效的。早期识别,综合处理,建立团队,总结和模拟演练都是PPH处置不可或缺的环节。     

Obstetric hemorrhage and coagulation: an update. Thromboelastography, thromboelastometry, and conventional coagulation tests in the diagnosis and prediction of postpartum hemorrhage

Globally, postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality. In the current treatment of severe PPH, first-line therapy includes transfusion of packed cells and fresh-frozen plasma in addition to uterotonic medical management and surgical interventions. In persistent PPH, tranexamic acid, fibrinogen, and coagulation factors are often administered. Secondary coagulopathy due to PPH or its treatment is often underestimated and therefore remains untreated, potentially causing progression to even more severe PPH. In most cases, medical and transfusion therapy is not based on the actual coagulation state because conventional laboratory test results are usually not available for 45 to 60 minutes. Thromboelastography and rotational thromboelastometry are point-of-care coagulation tests. A good correlation has been shown between thromboelastometric and conventional coagulation tests, and the use of these in massive bleeding in nonobstetric patients is widely practiced and it has been proven to be cost-effective. As with conventional laboratory tests, there is an influence of fluid dilution on coagulation test results, which is more pronounced with colloid fluids. Fibrinogen seems to play a major role in the course of PPH and can be an early predictor of the severity of PPH. The FIBTEM values (in thromboelastometry, reagent specific for the fibrin polymerization process) decline even more rapidly than fibrinogen levels and can be useful for early guidance of interventions. Data on thromboelastography and thromboelastometry in pregnant women are limited, particularly during the peripartum period and in women with PPH, so more research in this field is needed.     

Bakri balloon versus condom-loaded Foley’s catheter for treatment of atonic postpartum hemorrhage secondary to vaginal delivery: a randomized controlled trial

Objective: To assess the efficacy and safety of condom-loaded Foley’s catheter versus Bakri Balloon in the management of primary atonic post partum hemorrhage (PPH) secondary to vaginal delivery.

Study design: This study was single blinded randomized controlled trial conducted at Assiut Woman’s Health Hospital, Egypt in the period between October 2014 and December 2015. It Comprised 66 women with primary atonic PPH following vaginal delivery. Eligible participants were randomly assigned to Bakri balloon (group A) or condom-loaded Foley’s catheter (group B). The primary outcome was the success of tamponade to stop the uterine bleeding without additional surgical interventions. Secondary outcomes included time between insertion and stoppage of the bleeding, the amount of blood transfusion and maternal complications.

Results: Both treatment modalities successfully controlled the primary atonic PPH without a statistically significant difference [30/33(91.0%) and 28/33(84.84%), p?=?.199; respectively]. However; Bakri balloon required shorter time to stop the uterine bleeding (9.09?min vs. 11.76?min, p?=?.042; respectively). There was no statistically significant difference between both groups regarding postpartum maternal complications, the vital signs, urine output, hemoglobin and hematocrit levels from before to after tamponade insertion.

Conclusions: Condom-loaded Foley’s catheter is as effective as Bakri balloon in the management of primary atonic PPH following vaginal delivery but requires a significant bit longer time to stop the attack.     

A continuum of care model for postpartum hemorrhage

The leading cause of maternal mortality is hemorrhage, generally occurring in the postpartum period. Current levels of PPH-related morbidity and mortality in low-resource settings result from institutional, environmental, cultural and social barriers to providing skilled care and preventing, diagnosing and treating PPH. Conventional uterotonics to prevent PPH are typically not available or practical for use in low-resource settings. In such deliveries, most often taking place at home or in rural health centers, underestimation of blood loss leads to a delay in diagnosis. Deficiencies in communication and transportation infrastructure impede transfer to a higher level of care. Inability to stabilize a patient who is in hemorrhagic shock rapidly results in death. To address these individual factors, we propose a continuum of care model for PPH, including routine use of prophylactic misoprostol or other appropriate uterotonic, a standardized means of blood loss assessment, availability of a non-pneumatic anti-shock garment, and systemization of communication, transportation, and referral. Such a multifaceted, systematic, contextualized PPH continuum of care approach may have the greatest impact for saving women's lives. This model should be developed and tested to be region-specific.     

Combination of motherwort injection and oxytocin for the prevention of postpartum hemorrhage after cesarean section

Objective: To evaluate the efficacy and safety of motherwort injection combined with oxytocin for preventing postpartum hemorrhage (PPH) after cesarean section (CS).

Methods: From March 2011 and February 2013, a randomized study was conducted on 165 primipara undergoing CS. 83 and 82 cases were placed into the combination of oxytocin and motherwort group and oxytocin group, respectively. Blood loss was calculated and measured during three periods: from placental delivery to the end of CS, from the end of CS to 2?h postpartum and from 2?h postpartum to 24?h postpartum. Vital signs were also measured.

Results: Blood loss in the period from placental delivery to the end of CS was similar (P?=?0.58) in these two arms. The quantity of total blood loss from the end of CS to 2?h postpartum (P?=?0.03) and from 2?h postpartum to 24?h postpartum (P?=?0.01) were significantly reduced in the combination of oxytocin and motherwort group. No significant abnormal vital signs were observed. Mild, transient side effects occurred more often in the combination of oxytocin and motherwort group.

Conclusions: It is efficacious and safe that combination use of motherwort injection and oxytocin could reduce blood loss and prevent PPH after CS.     

A Comparison Between Visual Estimation and Laboratory Detennination of Blood Loss During the Third Stage of Labour

Summary: A prospective study was conducted to compare the accuracy of visual estimation of blood loss (EBL) at delivery with laboratory determination of measured blood loss (MBL). It showed that EBL tends to be clouded by the conventional teaching that blood loss at delivery is usually between 200 to 300 mL. Women with MBL up to 150 mL were overestimated and the best correlation was in women with MBL between 150 to 300 mL. There was a tendency to underestimate blood loss when the MBL was between 301 to 500 mL. Of the 9 women with a primary postpartum haemorrhage, only one was correctly diagnosed as such and 3 women were estimated to have blood losses of at least 500 mL but the measured blood losses were all lower. It was concluded that visual estimation of blood loss is inaccurate, especially at the extremes of MBL and that primary postpartum haemorrhage is not detected by visual estimation of blood loss, unless there are associated signs of haemodynamic instability.     

Effect of Quantification of Blood Loss on Activation of a Postpartum Hemorrhage Protocol and Use of Resources

ObjectiveTo determine if quantification of blood loss (QBL) would result in fewer activations of postpartum hemorrhage (PPH) protocols than visual estimation of blood loss (EBL) after cesarean birth and to track the use of related resources.DesignProspective observational trial.SettingA tertiary academic medical center in the midwestern United States.ParticipantsA total of 42 cases of cesarean birth.MethodsWe visually estimated blood loss during cesarean birth and quantified blood loss with colorimetric testing after the surgery. We compared EBL to QBL in four categories, from no hemorrhage to severe PPH, and documented resources used for women placed on the institutional PPH protocol by EBL who did not meet criteria for PPH by QBL.ResultsThe median EBL was 1,275 ml (interquartile range = 1,100–1,510 ml), and the median QBL was 948 ml (interquartile range = 700–1,267 ml, p < .001). Twenty-four (57%) instances of PPH based on visual EBL would not have been classified as such based on QBL. The most frequently used resources in these cases included laboratory testing and administration of uterotonics.ConclusionUse of QBL during cesarean births would have reduced the number of identified PPHs by more than 50% over visual EBL and may have reduced the resources used as part of care.     

POSTPARTUM HEMORRHAGE

Severe hemorrhage occurs in less than 1% of all pregnancies; however, it remains one of the important causes of maternal morbidity and mortality. Although the importance of hemorrhage has been recognized in obstetric circles for years, in the last decade or so, research has been conducted that has disproven long-held beliefs, Nurse-midwives must be knowledgeable about the etiology, management, and treatment of postpartum hemorrhage. This article presents an overview of postpartum hemorrhage and its pharmacologic and nurse-midwifery management. The overview includes definitions of postpartum hemorrhage, identifies risk factors for hemorrhage, and addresses problems associated with estimation of blood loss. The mechanisms of action of ergots, oxytocin, and prostaglandins are described, and criteria for selecting a medication are presented. Herbal remedies for hemorrhage are discussed briefly. Also discussed are the optimal time for drawing the hematocrit and what this laboratory value can tell the nurse-midwife.