Strictly Clinical

Secondary postpartum hemorrhage: Risk factors, assessment, and intervention

Jayne Kennedy, a 35-year-old, gravida 2, para 2, is admitted to the emergency department with heavy vaginal bleeding. Two weeks earlier, she’d delivered an infant by a repeat Cesarean section. Nursing assessment reveals a temperature of 102° F (38.8° C); heart rate, 140 beats/minute; and blood pressure, 88/42 mm Hg. Her only notable medical history is dietary-controlled gestational diabetes mellitus (GDM), which occurred during both pregnancies. She’s now presenting with a secondary postpartum hemorrhage.

Scenarios like this happen more often than you might think. Also called late or delayed hemorrhage, secondary postpartum hemorrhage occurs between 24 hours and 6 weeks postpartum. Typically occurring after discharge, it’s the leading cause of readmission in postpartum patients. In contrast, primary (early) postpartum hemorrhage occurs within the first 24 hours after delivery.

Most postpartum patients aren’t aware of the potentially life-threatening complications that can occur if bleeding goes untreated. In fact, postpartum hemorrhage (primary and secondary combined) is the leading cause of maternal morbidity in low-income countries and accounts for about 25% of maternal deaths globally. Fortunately, with appropriate diagnosis and management, catastrophic consequences can be prevented.

Defining postpartum hemorrhage

Postpartum hemorrhage refers to an estimated blood loss of 500 mL or more after delivery.Some experts add a hematocrit decrease of 10% or more to the definition.

Secondary postpartum hemorrhage can be hard to identify. A patient who’s hemorrhaging may assume she’s just having heavy—but normal—postpartum bleeding.

Causes

Infection and retained products of conception are the leading causes of secondary postpartum hemorrhage. Pelvic ultrasound may be done to detect retained placental fragments. Clinicians should suspect retained fragments in a patient with delayed lactogenesis.


Retained products of conception can lead to uterine atony—failure of effective uterine contraction after delivery. This condition accounts for 75% to 80% of postpartum hemorrhage cases. Risk factors include:

  • an overly distended uterus caused by polyhydramnios, multiple gestation, or macrosomia
  • uterine muscle exhaustion caused by rapid labor, prolonged labor, or high parity
  • intraamniotic infection caused by fever or prolonged labor
  • anatomic abnormalities, such as fibroids or placenta previa.

Uterine atony can be localized or affect the whole musculature.

Predelivery risk factors

The first step in preventing primary and secondary postpartum hemorrhage is to identify at-risk patients before delivery. Risk factors include:

  • personal or family history of postpartum hemorrhage
  • abnormal placentation
  • placental abruption
  • preeclampsia
  • multiple gestation
  • multiple parity
  • precipitous labor
  • chorioamnionitis
  • polyhydramnios
  • macrosomia
  • uterine infection
  • uterine inversion
  • sickle cell anemia
  • gestational diabetes
  • obesity
  • Asian or Hispanic ethnicity
  • coagulation disorders. (See Role of coagulation disorders in postpartum hemorrhage).

In our opening scenario, patient Jayne Kennedy is at increased risk for postpartum hemorrhage because of her multiple parity and history of gestational diabetes.

Delivery and postdelivery risk factors

Identifying blood loss during and after delivery is crucial. Distinguishing secondary hemorrhage and heavy postpartum bleeding can be challenging. What’s more, visual or estimated assessment of blood loss can be inaccurate.One study found healthcare providers underestimated postpartum blood loss during delivery by 21% to 28%. Implementing objective quantitative measurement of blood loss can lead to more accurate estimates.

During labor and delivery, trauma (including uterine, cervical, and vaginal laceration) increases postpartum hemorrhage risk and is a leading cause of secondary hemorrhage. Trauma can be spontaneous or induced by an intervention (for instance, vaginal delivery using an instrument such as a forceps or a vacuum). It also can stem from a uterine incision that’s too low or not curved appropriately.

Some vaginal hematomas may not occur until several days after delivery. Vaginal hematomas or lacerations not diagnosed immediately after delivery are a major cause of secondary hemorrhage. Cesarean wound dehiscence or nonunion of the incision site that’s not evident immediately may lead to hemorrhage weeks after delivery.

Uterine pseudoaneurysm is a less common but underdiagnosed cause of secondary hemorrhage. It causes bleeding episodes that are hard to control and irritated by curettage. Vessel thrombi and their partial occlusion can disrupt natural uterine subinvolution. Pseudoaneurysm may lead to unnecessary hysterectomy; clinicians should consider this condition in postpartum patients with heavy bleeding.

Assessment

Careful assessment of pregnant patients helps identify postpartum hemorrhage risk. Assessment should include a complete history and evaluation of the delivery for potential risk factors. A boggy uterus (indicating poor uterine tone) is a red flag, because uterine atony is the leading cause of postpartum hemorrhage.Be sure to assess uterine tone to detect atony early.A boggy, dilated uterus may signal a large amount of blood.

Also check for large clots or heavy bleeding. Odorous lochia, severe abdominal cramping, uterine tenderness, and increased body temperature also may indicate hemorrhage. Assess the cervix for lacerations or hematomas and check the uterine cavity for clots and retained tissue. Other potential signs of hemorrhage include hypovolemia, as indicated by decreased blood pressure or increased heart rate.

Management

If you suspect postpartum hemorrhage, notify all available staff, including the obstetrician and additional nurses, to address this critical situation. Massive hemorrhage, which occurs in about 10% patients with secondary postpartum hemorrhage, calls for resuscitation with the support of multiple teams. The cause of bleeding should be identified as soon as possible to ensure proper treatment. (See Treatment based on the underlying cause.)

Take the patient’s vital signs. As ordered, insert a large-bore I.V. line and administer oxygen with a nonrebreather face mask. Expect the primary care provider to prescribe fluid resuscitation with isotonic crystalloids. As ordered, draw blood for laboratory analysis, including hemoglobin, hematocrit, and platelets levels, along with a coagulation profile and blood typing and crossmatch to prepare for a blood transfusion.

To promote uterine contraction, the patient may require uterotonic drugs, such as oxytocin, given at a starting dose of 1 millliunit/minute and increased by 1 to 2 milliunits/minute no more often than every 30 to 60 minutes in a controlled situation; alternatively, 10 units of oxytocin can be injected intramuscularly. The patient also may receive misoprostol 800 to 1,000 mcg rectally, methylergonovine maleate 0.2 mg I.M. every 5 minutes for up to five doses, or a prostaglandin F2a analogue (such as carboprost tromethamine) 0.25 mg I.M. every 15 minutes for up to eight doses. During hemorrhage, 20 units in 1 L of saline solution can be infused I.V. (from 250 mL/hour up to 500 mL over 10 minutes). Know that methylergonovine maleate is contraindicated in patients with hypertension and F2a analogues are contraindicated in those with asthma or bronchospasm.

If hemorrhage doesn’t respond to uterotonic agents, expect the physician to try balloon tamponade. Bakri and Rüsch balloons have successfully treated both primary and secondary postpartum hemorrhage.

Prevention

To help prevent postpartum hemorrhage during and after delivery, clinicians should take appropriate steps even before delivery. The World Health Organization recommends giving oxytocin 10 units I.V. or I.M. in all deliveries. Cord traction is an option for placenta removal in cesarean delivery if skilled clinicians are present. Know that early cord clamping is contraindicated unless clinicians suspect the newborn will need immediate resuscitation. Also, fundal massage (manual abdominal massage) can help the uterus contract.

Preparedness and patient teaching

To improve the facility’s success rate in treating postpartum hemorrhage, clinicians should create protocols and policies specific to postpartum hemorrhage. Also, in-service simulations help prepare obstetric and emergency room staff for specific events that may arise.

In most cases, secondary postpartum hemorrhage arises after the patient has been discharged. So before discharge, teach patients about the potentially life-threatening complications of hemorrhage, as well as signs and symptoms. Be sure to discuss bleeding parameters, to help patients distinguish heavy postpartum bleeding from hemorrhage. Instruct them to seek immediate medical help if they saturate a perineal pad with blood in 15 minutes or less or if blood pools under their buttocks. Inform them that suturing a perineal pad in less than 2 hours calls for further assessment. Provide information written at a fifth- or sixth-grade level. Finally, tell patients when to contact their primary care providers.

Lauren Buettel is a staff nurse at Hackensack University Medical Center in Hackensack, New Jersey, and a clinical instructor at Ramapo College of New Jersey in Mahwah.

Selected references

Aiken CEM, Mehasseb MK, Prentice A. Secondary postpartum haemorrhage. Fetal Matern Med Rev. 2012;23(1):1-14.

AWHONN. Special Issue: 2015 Convention Proceedings. J Obstet Gynecol Neonatal Nurs. 2015;44(suppl 1), s1-s86.

Belfort MA. Overview of postpartum hemorrhage. UpToDate. 2016.

Lowdermilk DL, Perry SE, Cashion MC Maternity Nursing: Revised Reprint. 8th ed. St. Louis, Missouri; Mosby; 2013.

Lowdermilk DL, Perry SE, Cashion MC, Alden KR. Maternity and Women’s Health Care. 10th ed. St. Louis, Missouri: Mosby; 2012.

Renee J. Quantitative measurement of blood loss during delivery. AWHONN Practice Brief Number 1. J Obstet Gynecol Neonatal Nurs. 2014;00:1-3.

Schorn MN, Phillippi JC. Volume replacement following severe postpartum hemorrhage. J Midwifery Womens Health. 2014;59(3):336-43.

World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva: Author; 2012.

Zubor P, Kajo K, Dokus K, et al. Recurrent secondary postpartum hemorrhages due to placental site vessel subinvolution and local uterine tissue coagulopathy. BMC Pregnancy Childbirth. 2014;14:80.

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