Atonic Postpartum Hemorrhage: Blood Loss, Risk Factors, and Third Stage Management

Quantification of blood loss for the diagnosis of postpartum hemorrhage: a systematic review and meta-analysis

OBJECTIVE

to compare the effectiveness of different diagnostic methods to estimate postpartum blood volume loss.

METHODS

a systematic review of effectiveness according to PRISMA and JBI Protocol. Searches in PubMed/MEDLINE, LILACS, Scopus, Embase, Web of Science and CINAHL, with descriptor "Postpartum Hemorrhage" associated with keyword "Quantification of Blood Loss". Tabulated extracted data, presented in metasynthesis and meta-analysis was applied to quantitative data. To assess risk of bias, JBI Appraisal Tools were applied.

RESULTS

fourteen studies were included, published between 2006 and 2021. Quantification of loss by any method was superior to visual estimation and is highly recommended, however the studies' high heterogeneity did not allow estimating this association.

CONCLUSION

the studies' high heterogeneity, with a probable margin of error given the uncontrolled factors, indicates the need for further studies, however quantification proved to be effective in relation to visual estimate. PROSPERO registration CRD 42021234486.

The impact of extending the second stage of labor on repeat cesarean section and maternal and neonatal outcome

OBJECTIVE

To evaluate the effects of extending the second stage of labor in women attempting a trial of labor after a cesarean section (TOLAC).

METHOD

A retrospective cohort study comparing maternal and neonatal outcomes following TOLAC over two periods: period I whose prolonged second stage was considered 2 h, and period II whose prolonged second stage was considered 3 h. The primary outcome was repeat cesarean delivery (CD) rate.

RESULTS

Incidence of repeat CD was significantly lower in period II (18.1% vs 29.7%, P < 0.001). Incidence of uterine rupture was significantly higher in period II (P < 0.001). Instrumental delivery rates were significantly higher in period II (26.2% vs 15.6%, odds ratio [OR] 1.67, 95% CI 1.21-3.56, P < 0.001). Rates of third- and fourth-degree perineal lacerations, chorioamnionitis, and length of hospital stay were similar between groups. Incidence of fetal acidemia was significantly higher in period II (1.5% vs 0.7%, OR 2.14, 95% CI 1.32-5.63, P < 0.001), and incidence of neonatal intensive care unit (NICU) admission was significantly higher (2.5% vs 1.6%, P = 0.004).

CONCLUSION

Extension of the second stage of labor is associated with a decrease in repeat CD rate with a concomitant increase in instrumental delivery rates, uterine rupture, fetal acidemia, and NICU admissions. These findings may warrant further consideration of allowing a prolonged second stage in patients attempting TOLAC.

Risk factors of primary postpartum hemorrhage among postnatal mothers in the public hospital of southern Tigray, Ethiopia, 2019: A case-control study

Background

Postpartum hemorrhage is the most common direct cause of maternal mortality and morbidity; among them, primary postpartum hemorrhages are an enormous element. Although it has an incredible impact on maternal lifestyle, this is the most neglected area in Ethiopia and there is a lack of studies achieved within the study area. So this study aimed to identify the risk factors of primary postpartum hemorrhage among postnatal mothers in public hospitals in southern Tigray, Ethiopia, 2019.

Methods

Institution-based unmatched case-control study design was conducted on 318 (106 case and 212 controls) postnatal mothers in public hospitals of Southern Tigray from January to October 2019. We used a pretested, structured interviewer-administered questionnaire and a chart review to collect the data. Bivariate and multivariable logistic regression models were used to identify the risk factors. P-value ≤ 0.05 was considered statically significant for both steps and an odds ratio with a 95% confidence level was used to see the strength of association.

Results

Abnormal third stage of labor [adjusted odds ratio = 5.86, 95% confidence interval (2.55-13.43), P = 000], cesarean section [adjusted odds ratio = 5.61, 95% confidence interval (2.79-11.30), P = 0.000], lack of active management of third-stage labor [adjusted odds ratio = 3.88; 95% confidence interval (1.29-11.60), P = 0.015], absence of labor monitoring by partograph [adjusted odds ratio = 3.82, 95% confidence interval (1.31-11.09), P = 0.014], lack of antenatal care [adjusted odds ratio = 2.76, 95% confidence interval (1.13-6.75), P = 0.026] and complications during pregnancy [adjusted odds ratio = 2.79, 95% confidence interval (1.34-5.83), P = 0.006] were found to be risk factors for primary postpartum hemorrhage.

Conclusion

In this study complications and lack of maternal health interventions in the course of the antepartum and the intrapartum period were found to be risk factors for primary postpartum hemorrhage. A strategy for improving essential maternal health services and detecting and handling complications in a timely manner will help to prevent primary postpartum hemorrhage.

Epidemiology and definition of PPH worldwide

Postpartum/peripartum hemorrhage (PPH) is an obstetric emergency complicating 1-10% of all deliveries and is a leading cause of maternal mortality and morbidity worldwide. However, the incidence of PPH differs widely according to the definition and criteria used, the way of measuring postpartum blood loss, and the population being studied with the highest numbers in developing countries. Despite all the significant progress in healthcare, the incidence of PPH is rising due to an incomplete implementation of guidelines, resulting in treatment delays and suboptimal care. A consensus clinical definition of PPH is needed to enable awareness, early recognition, and initiation of appropriate intensive treatment. Unfortunately, the most used definition of PPH based on blood loss ≥500 ml after delivery suffers from inaccuracies in blood loss quantification and is not clinically relevant in most cases, as the amount of blood loss does not fully reflect the severity of bleeding.

Risk factors and recurrence of cause-specific postpartum hemorrhage: A population-based study

OBJECTIVE

To explore risk profiles of the different types of postpartum hemorrhage (PPH >500ml or severe PPH >1500ml) and their recurrence risks in a subsequent delivery.

METHODS

With data from The Medical Birth Registry of Norway and Statistics Norway we performed a population-based cohort study including all singleton deliveries in Norway from 1967-2017. Multilevel logistic regression was used to calculate odds ratio (OR), with 95% confidence interval (CI), with different PPH types (PPH >500ml or PPH >1500ml (severe PPH) combined with retained placenta, uterine atony, obstetric trauma, dystocia, or undefined cause) as outcomes.

RESULT

We identified 277 746 PPH cases of a total of 3 003 025 births (9.3%) from 1967 to 2017. Retained placenta (and/or membranes) was most often registered as severe PPH (29.3%). Maternal, fetal, and obstetric characteristics showed different associations with the PPH types. Male sex of the neonate was associated with reduced risk of PPH. This effect was strongest on PPH due to retained placenta (adjusted OR, (aOR): 0.80, 95% CI 0.78-0.82), atony (aOR 0.92, 95% CI: 0.90-0.93) and PPH with undefined cause (aOR 0.96, 95% CI: 0.95-0.97). Previous cesarean section showed a strong association with PPH due to dystocia (aOR of 13.2, 95% CI: 12.5-13.9). Recurrence risks were highest for the same type: PPH associated with dystocia (aOR: 6.8, 95% CI: 6.3-7.4), retained placenta and/or membranes (aOR: 5.9, 95% CI: 5.5-6.4), atony (aOR: 4.0, 95% CI: 3.8-4.2), obstetric trauma (aOR: 3.9, 95% CI: 3.5-4.3) and PPH of undefined cause (aOR: 2.2, 95% CI: 2.1-2.3).

CONCLUSION

Maternal, fetal and obstetric characteristics had differential effects on types of PPH. Recurrence differed considerably between PPH types. Retained placenta was most frequently registered with severe PPH, and showed strongest effect of sex; delivery of a boy was associated with lower risk of PPH. Previous cesarean increased the risk of PPH due to dystocia.

The relation between cigarette smoking with delivery outcomes. An evaluation of a database of more than nine million deliveries

OBJECTIVES

Smoking in pregnancy is associated with an increased risk of preterm birth (PTB), intrauterine growth restriction, placental abruption and perinatal death. The association between smoking and other delivery outcomes, such as chorioamnionitis, mode of delivery or postpartum hemorrhage (PPH), however, is insufficient as only few studies addressed these issues. The aim of the study was to evaluate the association between prenatal smoking and delivery outcomes in a large database, while controlling for confounding effects.

METHODS

A retrospective population-based study using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS). A dataset of all deliveries between 2004 and 2014 (inclusively) was created. Our control group included all pregnant women who did not smoke during pregnancy, which was compared to pregnant women who smoked. A multivariate logistic analysis was conducted, adjusting for any statistically significant confounding effects.

RESULTS

Our study identified 9,096,788 births between 2004 and 2014. Of which, 443,590 (4.8%) had a documented diagnosis of smoking. A significantly higher risk was found for PTB (odds ratio 1.39, CI 1.35-1.43), preterm premature rupture of membranes (odds ratio 1.52, CI 1.43-1.62) and small for gestational age (SGA) neonates (odds ratio 2.27, CI 2.19-2.35). The risks of preeclampsia (odds ratio 0.82, CI 0.78-0.85), chorioamnionitis (odds ratio 0.88, CI 0.83-0.4), PPH (odds ratio 0.94 CI 0.9-0.98) and operative vaginal delivery (odds ratio 0.9, CI 0.87-0.94) were lower among smokers.

CONCLUSIONS

This large database confirms the findings of previous smaller studies, according to which smoking decreases the risk of preeclampsia while increasing the risk of PTB and SGA neonates. The current study also revealed a decreased risk for PPH as well as for chorioamnionitis among pregnant smokers.

Anesthesia technique and postpartum hemorrhage: a prospective cohort study

Background and objective

During the past few years, an increased number of postpartum hemorrhages have been noticed, even in high-income countries. It has been suggested that this escalation could be associated with increased obstetric interventions. Among such interventions, anesthesia is one of the most prevalent. The present study aimed to investigate the influence of peripartum anesthesia on total blood loss during the 24 hours after delivery.

Methods

We performed a complementary analysis from a prospective cohort study that evaluated postpartum bleeding within 24 hours after birth. The study was performed between February 1^st, 2015 and March 31^st, 2016 at the Women’s Hospital at the Universidade Estadual de Campinas, Brazil. Postpartum bleeding was measured using a calibrated drape and summing the blood contained in the compresses and pads used for 24 hours. We calculated means, percentages, and standard deviation and performed Mann-Whitney analysis for the relation of anesthesia with Postpartum Hemorrhage (PPH) and logistic regression for drugs used in the anesthesia with PPH, using SAS 9.4 software.

Results

We included 270 women in the study; of these, 168 received anesthesia for delivery and almost 50% of them had spinal and epidural anesthesia. The mean blood loss within 24 hours after delivery did not show differences between those who did and those who did not receive obstetrical anesthesia (579.0 ± 361.6 vs. 556.6 ± 360.6; p = 0.57). Logistic regression showed that anesthesia, the type of anesthesia, and the drug used did not influence the PPH above 500 mL and above 1000 mL within 2 hours (p > 0.05).

Conclusion

Anesthesia did not influence postpartum bleeding after vaginal delivery.

Literature Review: Physiological Management for Preventing Postpartum Hemorrhage

The aim of this paper was to summarize the existing literature regarding postpartum hemorrhage (PPH) and its physiological management (i.e., skin-to-skin contact and breastfeeding). The background surrounding PPH and the role of skin-to-skin contact (SSC) and breastfeeding (BF) in PPH are identified, and these interventions are supported as a crucial means of preventing or minimizing the incidence of PPH. Despite its importance, to the best of my knowledge, an evaluation of this relationship has not yet been undertaken. The narrative literature review approach was used to summarize topic related researches. The search included three databases: CINAHL, PubMed, and Google Scholar. All articles related to the role of SSC and BF in PPH were chosen from the different databases. The findings demonstrate that SSC and BF are cost-effective methods that could be considered practices for the prevention of PPH. Immediate Skin-to-skin contact (SSC) and breastfeeding (BF) are central mediators of the psychophysiological process during the first hour after delivery (the third and fourth stages of labor).

The Role of Skin-to-Skin Contact and Breastfeeding on Atonic Postpartum Hemorrhage

Objectives: were to (a) determine incidence of postpartum hemorrhage (PPH) in all women delivering between 2009 and 2015, and (b) determine the amount of Estimated Blood Loss (EBL) and duration of the third stage of labor in each subgroup for women with or without PPH, and (c) compare EBL and duration of 3rd stage of labor between subgroups in groups of women with or without PPH. Design: A retrospective chart review conducted using codes for atonic PPH. Setting: Records from a University based tertiary setting, 264 charts were reviewed and data from 154 charts were analyzed. One-way ANOVAs followed with post-hocs and a 2-way ANOVA were conducted. Results: PPH rate increased by 47.50% from 2009–2015. For women with PPH, EBL was lower in skin to skin contact (SSC) + Breastfeeding (BF) subgroup. For women without PPH, EBL was lower in SSC only subgroup. Third stage of labor duration was longer in women with PPH. Conclusions: Study confirmed the increasing trends of PPH due to uterine atony and proposed role of SSC and BF in decreasing EBL and shorten the duration of the 3rd stage of labor for PPH women, usefulness of SSC and BF as physiologic practices merit further study.

Incidences of Atonic Postpartum Hemorrhage and Related Risk Factors at a Tertiary Hospital in Saudi Arabia

Background: In 2017, there were 295,000 maternal deaths worldwide from preventable causes related to birth. The leading cause of maternal mortality is obstetric hemorrhage. In Saudi Arabia, a paucity of evidence about incidences of atonic Postpartum Hemorrhage (PPH) and related risk factors exists. Therefore, aims were to (a) identify incidences of atonic PPH from 2015 to 2018 (b) determine risk factors of atonic PPH in vaginal birth. Methods: Retrospective chart review with purposive sampling conducted revealed 386 charts, 220 (57%) vaginal birth and 166 (43%) caesarian section (CS). Logistic regression analysis was used. Results: Incidences of atonic PPH were 2.5% from 2015 to 2017, with the rate increasing by 12% from 2017 to 2018. In vaginal birth, significant associations between the severity of blood loss with epidural (F = 6.314, df = 1, p = 0.013), episiotomy (F = 4.38, df = 1, p = 0.038), induction of labor (IOL) (F = 1.224, df = 1, p = 0.004), and Interaction between IOL, AUG, and epidural (F = 7.24, df = 1, p = 0.041) found. Discussion: Increasing rate of atonic PPH confirmed. Epidural, episiotomy, induction of labor, and induction with augmentation are factors associated with severe atonic PPH in vaginal birth.

Early Prediction of Blood Loss and Postpartum Hemorrhage after Vaginal Delivery by Ultrasound Measurement of Intrauterine Content

The ability of ultrasound to predict postpartum hemorrhage remains poorly described. The aim of this study was to evaluate whether ultrasound measurement of intrauterine content can predict blood loss and postpartum hemorrhage after vaginal delivery. We used a preliminary prospective monocentric study of 201 women who delivered vaginally after 34 wk of gestation. Measurements were performed 30-45 min after normal vaginal delivery according to strict ultrasonographic criteria. Analysis of the relationship between ultrasound measurements and hemoglobin loss showed a strong linear correlation (R² = 0.59 and R² = 0.4 for isthmic and fundal measurements). The maximal value between the fundal and isthmic measurements seems to provide the best accuracy to predict loss of hemoglobin higher than 3 g/dL (area under the curve [AUC] of the receiver operating characteristic curve, 0.9; 95% confidence interval [CI], [0.76-0.97]) and post-partum hemorrhage (AUC, 0.99; 95%CI, [0.984-0.99]). In case of intrauterine content >2 cm (135/201), the risks of loss of hemoglobin higher than 3 g/dL (5/135 vs. 0/66) and post-partum hemorrhage (11/135 vs. 0/66) were increased, all the more if the intrauterine content was >4 cm (4/16 and 11/16, respectively). Considering the maximal measurement, the most optimal cut-off value for clinical practice could be 2.4 cm (sensibility 100%, specificity 57%) and 4.1 cm (sensibility 100%, specificity 97%) for loss of hemoglobin higher than 3 g/dL and post-partum hemorrhage, respectively.

Bimanual examination for clot evacuation: a retrospective cohort study of women with postpartum haemorrhage after vaginal delivery

BACKGROUND

Bimanual clot evacuation (BCE) is a simple clinical manoeuvre that may reduce need for surgical intervention in the management of severe postpartum haemorrhage (PPH). We sought to determine whether performing BCE in cases of severe PPH after vaginal birth reduces the need for surgical intervention.

METHODS

A retrospective chart review of women who delivered vaginally with a severe PPH between January 1, 2011 and December 31, 2014 in a single tertiary women's hospital in Sydney, Australia was conducted. Severe PPH was classified as a blood loss ≥1000mls. The need for surgical management (including operating theatre uterine exploration or evacuation, intrauterine balloon tamponade, repair of significant trauma, uterine or internal iliac artery ligation, B-Lynch suture insertion or hysterectomy) was the primary outcome measure, as expressed by need for operating theatre utilisation.

RESULTS

From a cohort of 438, 149 women (34.0%) had BCE, of whom 29 (19.5%) required surgical management compared to 103 of 289 women with no BCE (35.6%); an odds ratio (OR) of 0.38 for BCE (confidence interval 0.20-0.72; p = 0.003). Early BCE (< 1 h of delivery) was associated with a further reduction in surgery (OR 0.24; confidence interval 0.08-0.70; p = 0.009) compared to late BCE (> 1 h of delivery). There was no reduction in estimated blood loss (p = 0.86) or blood transfusion (p = 0.71) with BCE.

CONCLUSION

Our study suggests BCE reduces theatre utilisation in the context of severe PPH following vaginal delivery. Prospective trials are needed to determine whether BCE should be endorsed as a treatment modality for PPH post-vaginal delivery.

Maternal complications in twin pregnancies in Finland during 1987-2014: a retrospective study

BACKGROUND

To investigate the trends and changes in the incidence and overall outcome of twin pregnancies in Finland, a retrospective study was conducted with emphasis on maternal complications, covering a 28-year study period.

METHODS

All 23,498 twin pregnancies with 46,363 live born and 633 stillborn children in Finland during 1987-2014 were included in the study. Data were collected from the national Medical Birth Register and the Care Register on Hospital Care (Finnish Institute for Health and Welfare, Finland) regarding the parturients' characteristics and incidences of several pregnancy and childbirth complications. The incidences of twin pregnancies and maternal complications during pregnancy and childbirth are the main outcome measures of the study. The results are expressed in percentages, means, medians, ranges and standard deviations (SD), when appropriate.

RESULTS

Twins comprised 1.4% of all births in Finland in 1987-2014. Parturients' mean age has remained stable, but the share of over 35 year-old parturients is increasing. The incidences of pre-eclampsia, intrahepatic cholestasis of pregnancy, gestational diabetes and postpartum haemorrhage have risen during the study period. Almost half (44.9%) of twins were born preterm, almost half via Caesarean section (47.1%), and 27.7% of twin labours were induced.

CONCLUSIONS

Several pregnancy complications increased during the study period. Advanced maternal age among twin parturients has risen, enhancing the risks for developing complications in a pregnancy already of a high-risk category, and predisposing to preterm delivery. National and international guidelines are necessary to improve the overall outcome of twin pregnancies.