The Main Event
Your first call of the day: a pregnant female in labor is in need of transport to the hospital. On arrival to the residence, you are met at the door by the “significant other” (sometimes called the husband) and led to a nearby bedroom.
“Hello Ma’am, how often are the contractions?”
“It’s coming!” she says.
“Ma’am?”
“I feel like pushing and this ain’t my first rodeo! You better check!” she replies.
On visual examination, you find about six centimeters of fetal head poking through. You are thankful you gloved up prior to leaving the ambulance, as the patient again informs you the baby is coming (said in a higher pitched voice) while actively pushing the head out of the vagina — leaving you with just enough time for your next move.
You quickly check for an umbilical cord around the neck (there is none) and then suction out the nose and mouth with a bulb suction device, being careful not to touch the posterior throat (pharynx) that could cause a valsalva reflex and slow the baby’s heart rate (not good). Since the head is generally the biggest part of the fetus, the rest of the body follows the head with the next push.
The baby cries vigorously and is pink in color, except for the blue hands and feet (normal acrocyanosis). You place two clamps on the cord and cut between them. Make sure to leave an inch or two of cord attached to the infant; it contains two arteries and a vein that are used for vascular access in the receiving facility if needed. Your partner dries and wraps the baby, making sure to cover the head (a large surface area that loses heat rapidly) and then places the infant next to the warm mother.
Back at the delivery site, you notice a little bleeding from the vagina. You know that the placenta should deliver in about 10 to 20 minutes and can be associated with increased bleeding due to the vascular placenta separating from the vascular uterine wall.
While preparing for transport, you note even more umbilical cord is showing from the vagina and the bleeding is brisker. With a small push, the patient delivers the spongy, bloody placenta, leaving the exposed uterine vessels to bleed heavily; but you know what to do. You firmly massage the top of the uterus (fundus), just like you would knead bread dough. Push up and back as you massage. Do not push downward on the fundus as this may cause a uterine inversion, where the uterus turns inside out (bad). The massage will generally cause the muscular uterus to contract, which will help constrict the bleeding vessels.
This indeed helps slow the patient’s vaginal bleeding, but not enough to ease your level of comfort. You ask the mother if she will be breast feeding (she says yes) and you have her begin. You explain to her that the stimulation of the nipple by the infant sucking will increase release of a hormone called oxytocin, which will help with the bleeding.
Oxytocin is responsible for initiating and maintaining contractions during labor. Once delivery is complete, oxytocin levels drop unless there is nipple stimulation or given in drug form as pitocin. Along with stimulating milk production, you get the same effect as in labor: uterine contractions that now help after delivery to shrink the uterus and decrease excessive bleeding.
Your combination therapy is successful and bleeding is minimal. The remainder of this patient contact is uneventful. However, you are aware that on occasion, the bleeding won’t stop.
When it doesn’t stop
Excessive bleeding can occur while the mother is in labor, during delivery, or after delivery. During labor, hemorrhage may be caused by a placenta praevia that was undetected before the onset of labor, or a placental abruption that occurs during labor.
At delivery, bleeding can occur from injury to the cervix, the vagina or the perineum (area surrounding the vaginal opening). Trauma can occur with any delivery, but is more likely from a large fetus or an abnormal presentation, like a head and an arm trying to exit at the same time. In addition, the use of delivery assist devices, such as forceps or vacumn extractors, increases the risk of injury and bleeding.
After delivery (postpartum), a certain amount of vaginal bleeding is expected during separation and expulsion of the placenta. Excessive bleeding is most often the result of an inability of the uterus to contract and shrink in size, which decreases the diameter of the open uterine blood vessels. Therefore, anything that interferes with the process increases the risk of postpartum hemorrhage. This includes retained placental tissue or blood clots that will prevent the uterus from shrinking even with strong contractions and/or a uterus with weak contractions post-delivery.
Poor postpartum contractions (uterine atony) is the number one cause for postpartum hemorrhage. It can be caused by an overstretched uterus due to a pregnancy with a large fetus or multiple fetuses; from uterine fatigue due to prolonged labor; or exposure to certain medications during labor, such as magnesium — a smooth muscle relaxant used to prevent or treat seizures from pregnancy-induced hypertension.
Initial treatment, regardless of delivery location or level of provider, is uterine massage as noted earlier. Advanced field treatment may include administration of pitocin and intravenous fluid resuscitation as indicated.
If heavy bleeding continues after arrival to a medical facility, other drugs in addition to pitocin are available to help contract the uterus: methylergonovine (Methergine), carboprost (Hemabate), and misoprostol (Cytotec). If a blood bank is available, the patient may need to make a withdrawal. Examination of the perineum, vagina and cervix should be performed to look for bleeding from lacerations, although these are infrequently the cause of the bleeding.
The unresponsive patient
The patient who is unresponsive to the treatment noted so far requires manual exploration of the uterus by an experienced provider to remove any retained tissue or blood clots preventing the uterus from clamping down. If this doesn’t help, or if there is no retained tissue and the medications aren’t helping, there are a couple of options.
Any facility that performs deliveries should have a Bakri balloon. This simple device can be inserted into the bleeding uterus through the cervix and inflated with normal saline, thus compressing the bleeding vessels inside the uterus. Be sure not to fill the balloon with air due to the risk of embolus if it ruptures. There is also a separate tube running through the Bakri balloon that is open on both ends, thus connecting the uterine fundus to the outside so that you can visually determine if the bleeding is controlled. This device can be removed in 12 to 48 hours and most often provides resolution of the abnormal bleeding.
If the balloon fails, the patient will need an operation to tie off or ligate the large arteries that supply the uterus. The uterus will not die off (necrosis) because there are smaller arteries that supply blood to the uterus that do not contribute to the excessive bleeding. If arterial ligation is unsuccessful, surgical removal of the uterus (hysterectomy) will be necessary for hemorrhage control. Larger hospitals may have interventional radiologists who can float an arterial catheter into the large arteries that supply the uterus and shut off the blood supply with a balloon or by injecting a substance that can block the arteries. This may prevent the need for surgery.
Summary
Most episodes of abnormal vaginal bleeding that threaten maternal survival occur after delivery of the infant. When you encounter this patient in the field, your initial efforts will help slow the flow as you transport to the next level of care. Your goal is to keep the main event from becoming the final event.
References
- Barbieri RL. Massive Obstetric Hemorrhage: High- and Low-tech Tools. OBG Management 2005;12:9-10
- Mercier FJ, Van de Velde M. Major Obstetric Hemorrhage. Anesthesiology Clinics 2008;26:53-66
- Anderson JM Etches D. Prevention and Management of Postpartum Hemorrhage. American Family Physician 2007;75:6:875-882.
- Ramanathan G, Arulkumaran S. Postpartum Hemorrhage. Journal of Obstetrics and Gynecology 2006; November: 967-973
