Ep 123: Postpartum Hemorrhage


Today’s episode is an important one about postpartum hemorrhage. Postpartum hemorrhage is a leading cause of maternal morbidity and mortality. We’ve gotten better over the past several years but it still happens.

Postpartum hemorrhage can be scary because you’re entirely dependent on the hospital staff to promptly recognize and treat the situation. Depending on how severe it is you may have trouble advocating for yourself. It’s important to know how serious this can be and have an idea of what you should expect if you have increased bleeding after birth. We can prevent bad things from happening so long as hemorrhage is recognized early and treated swiftly. Today you’re going to learn about the signs, symptoms, and treatment so you can help keep yourself safe.

In this Episode, You’ll Learn About:

  • What is primary postpartum hemorrhage
  • How common is postpartum hemorrhage
  • What symptoms you and your medical care providers should be on the lookout for
  • How severe PPH is and how important it is to recognize and treat it quickly
  • What are the causes and risk factors associated with PPH
  • How to treat and prevent postpartum hemorrhage
  • What secondary postpartum hemorrhage is and how to recognize and treat it

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Ep 123: Postpartum Hemorrhage

Nicole: In today's episode, you're going to learn about postpartum hemorrhage.

Nicole.: Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Nicole: Hello there. Welcome to another episode of the podcast. This is episode number 123. Thank you for being here with me today. So today's episode is an important one about postpartum hemorrhage. Postpartum hemorrhage is a leading cause of maternal morbidity and mortality. We've gotten better over the past several years, but it still happens. So in this episode, you are going to learn what is postpartum hemorrhage? What the amount is that qualifies as hemorrhage. You'll learn about primary postpartum hemorrhage, which is within 24 hours postpartum. And you'll learn the causes, how it's recognized, how it's treated as well as some things that can be done to prevent it. You'll also learn about secondary postpartum hemorrhage, which is hemorrhage between 24 hours and 12 weeks postpartum, the causes, how we recognize and treat that. And then finally, the recurrence risk of postpartum hemorrhage. If you had it happen before. Now, postpartum hemorrhage can be scary because the reality is you're entirely dependent on the hospital staff to promptly recognize and treat postpartum hemorrhage.

Nicole: And depending on how severe it is, you may not feel well enough to advocate for yourself. And actually even having someone with you who can advocate for you on your behalf may not necessarily guarantee anything. If you're not familiar with the story of Kira Johnson, she was a woman who in 2016, died after a second cesarean birth because of unrecognized or untreated postpartum hemorrhage after her cesarean. And this was despite her family members pleading for help. Um, her husband actually has turned this into a movement to help improve the treatment of postpartum hemorrhage. Again, her name is Kira Johnson. You can look up her story. If you're interested. The website is for Kira for moms, the number four, then K I R a, the number four again, M O M s.com. Now, with that being said, it's important to know how serious postpartum hemorrhage can be, and that you have an idea of what you should expect.

Nicole: If you have increased bleeding after birth, the most important part of postpartum hemorrhage is early recognition and treatment. We can prevent bad things from happening as long as we recognize it early and treat it early. So through this episode, you're going to know what that looks like, what early recognition and treatment looks like. All right, before we get into the episode, a listener, shout out. This is from Dee Pippin and the title of the review is just three emoji claps. Love it, love it, love it. And the review says this podcast is reducing my anxiety about preparing for my baby's delivery by the minute. So grateful. Well, thank you, Dee Pippin. I'm so grateful that you find the podcast helpful, and that is reducing your anxiety about preparing for your baby's birth. The other thing that can reduce your anxiety or anyone's anxiety about preparing for birth is good childbirth education and this podcast and my online childbirth education class, the Birth Preparation Course, go hand in hand. To get you ready for birth in the Birth Preparation Course, I take you through my five step beautiful birth prep process to get you calm, confident, and empowered for your birth. You'll understand how to prepare your mind, what to expect in your body and how to have the support that you need both during labor and the postpartum period. This course is extremely affordable. You're not going to find anything with this much value. It's under $200 and that's intentional because I don't want it to be super expensive for you. You got lots of other stuff to pay for. So do check out all the details of the course at drnicolerankins.com/enroll. Okay, so let's talk about postpartum hemorrhage. First, we're going to start off with primary postpartum hemorrhage. Primary postpartum hemorrhage is defined as a cumulative cumulative blood loss. So when we add up all of the blood loss, it is greater than or equal to 1000 milliliters.

Nicole: And that is about half of a two liter bottle. Okay? Like if you look at a two liter bottle of drink or soda or whatever, about half of that. If it's 1000 milliliters in 24 hours, or it's blood loss that's accompanied by signs and symptoms of what's called hypovolemia hypo is low -valemia is volume. So signs and symptoms of low blob blood volume. Like you don't feel well, you look pale, your heart rate's high. If you have those signs within 24 hours after birth, then that is a primary postpartum hemorrhage. Okay? So one more time, blood loss is greater than or equal to a thousand milliliters or blood loss that's accompanied by signs or symptoms of hypovolemia within 24 hours after birth. Postpartum hemorrhage is estimated to happen in as high as 10% of births. Okay? So it's fairly common that it happens now, as far as some of those symptoms, some of the symptoms that you'll experience, if you have postpartum hemorrhage, uh, are palpitations, lightheadedness, you may have a mild increase in heart rate that's in the beginning. And then as the blood loss increases, the symptoms are going to increase because your body is manifesting that, Hey, I don't have enough blood. So you may feel weakness. You may feel sweating. The heart rate is going to continue to go higher. You may start to breathe faster and your blood pressure may drop. If it gets very serious, you can get confused, pale, restless. You also may stop making urine because as your body, um, loses blood, it tries to shunt blood to the most important parts of the body. So that's going to be to protect, protect the brain and keep the heart pumping. So the kidneys will start to shut down. You also may have cool and clammy skin because again, the blood, the body is pulling away blood from the less vital functions to the most vital organs.

Nicole: Okay. Um, and in the most extreme instances, the blood loss gets really bad, then you can collapse and pass out. Now, keep in mind that we use the same definition of post-partum hemorrhage, whether or not it's a vaginal birth or a cesarean birth. It didn't always used to be that way. As a matter of fact, that's a relatively recent thing where we use the same definition. It used to be a lower definition for vaginal birth ham, but now we use the same definition greater than a thousand milliliters. We do, however, still keep in mind that a blood loss greater than 500 milliliters in a vaginal birth, because that used to be the cutoff for vaginal, that should be considered abnormal. And that should be a reason for us to investigate and make sure that everything is okay. Now I'm going to continue to say this repeatedly throughout the episode, but postpartum hemorrhage is a true, true obstetric emergency.

Nicole: It is one of the top five causes of maternal mortality worldwide. Okay. The risk of death is a lot lower in places like the US, where we have more resources, but it is definitely, um, a problem worldwide. In the US, maternal mortality after postpartum hemorrhage is about 2%. Now, mortality isn't the only thing that can happen as a result of postpartum hemorrhage. There are other important secondary things that can happen from hemorrhage, including respiratory distress syndrome, where your lungs shut down, shock, um, which is when your body literally goes into shock. And you can have something called disseminated intravascular coagulation or DIC where your body doesn't clot properly. Um, acute renal failure. Again, that comes from your body, the shunting blood away from the kidneys. When the kidneys don't get blood flow, your kidneys can fail. It can cause loss of fertility. So these sort of secondary things can happen about 4% of the time.

Nicole: And the reason that postpartum hemorrhage is so serious is because there is a real potential for massive hemorrhage very quickly in the later stages of pregnancy, the blood flow through the uterine arteries. Okay. There are two arteries that supply the blood flow to the uterus. One on each side of the uterus, the blood flow through those arteries in the last stages of pregnancy is between 500 and 700 milliliters per minute. Okay. I need you to hear me say that because that is a lot of blood flow going to the uterus between 500 to 700 milliliters of blood per minute. It accounts for approximately 15% of what your heart is pumping out in the later stages of pregnancy is going completely to your uterus. So thinking about all of the other parts of your body, your brain, your kidneys, your liver, your intestines, um, your heart itself needs to receive blood, all of the blood vessels and things in your arms, your legs, all of that.

Nicole: So that all of that gets 85%. Whereas just the uterus gets 15%. It's a tremendous amount of blood flow. So because of that, massive hemorrhage can happen very, very quickly. That's why we have to take this extremely seriously. Okay. So what causes postpartum hemorrhage? So normally what happens after birth is that once the baby is delivered, then the uterus shrinks down very quickly. And because of that, it causes the placenta to separate. Okay. And that separation happens because of that shrinkage of the uterus. And when that uterus shrinks, the placenta separates, it compresses the blood vessels that are supplying the placenta, and it literally just cuts off the blood supply to them. Okay. The other thing that happens is that blood clotting factors get activated to cause your blood to clot. Okay. So most cases of postpartum hemorrhage are caused by a disturbance in one of those things.

Nicole: So the uterus doesn't contract down, those blood vessels can't compress, the placenta doesn't separate properly, and that causes bleeding, or there's an issue with the blood clotting factors that doesn't happen very commonly. And then the other most common reason for postpartum hemorrhage is trauma. And where I'm going to talk about that in more detail and by trauma, I mean, tears or blood clots in the vagina. All right. So in a little bit more detail, the most common cause of primary postpartum hemorrhage is something called uterine atony. And that causes 70 to 80% of postpartum hemorrhage. That is when the uterus again, doesn't have good tone, um, right after delivery. Okay. The uterus shrinks down. It's actually pretty remarkable to me. Um, it's like a remarkable thing of nature. Every time I see it, the uterus at a full-term pregnancy is literally like up into like your ribs, right?

Nicole: Like that's how, how high the baby is immediately after birth. Your uterus is going to shrink half its size back down to just under the belly button. Like within moments after birth, it shroop, shrinks down and that helps to cut off those blood vessels. And when it shrinks down and those muscles frim up, okay, just like if you tense your muscles in your arm, for instance, like if you flex your arm, if you fill your biceps, those muscles feel nice and tight. That's what the uterus is supposed to do right after birth to shut off that blood flow and get the blood to stop. So it should feel firm. It should feel hard like a rock almost after birth. All right. So when that doesn't happen, that's what can cause bleeding those blood vessels can't get shut off. And again, it's 70 to 80% of postpartum hemorrhage is caused by this.

Nicole: So this is what we suspect first as the etiology or the cause of postpartum hemorrhage. And I'll talk about what we do in a minute. Now, the second most common thing is lacerations or tears, and they can be in the vagina. They can be in the cervix. Sometimes cervical lacerations happen. Other things that can happen are hematomas, which are blood clots that can happen in the vagina or in the spaces around the vagina. Uterine rupture is a rare cause of postpartum hemorrhage where the uterus literally ruptures or bleeding from the uterine incision and the subsidiary in birth. Okay. Also retained placenta, which is when a piece of the placenta doesn't come out. If that piece of placenta is still there and blood flow is still going through it, that can cause increased bleeding or an abnormally adherent placenta that doesn't come off like it's supposed to, that can cause postpartum hemorrhage.

Nicole: Um, also those defects in what's called coagulation, the ability of the blood to clot can cause things to happen. And these can be inherited things like Von Willebrand's disease is one that can lead to increase the risk of postpartum hemorrhage. Or you can develop coagulation problems or difficulty with your blood clotting from something like placenta abruption, or severe preeclampsia. That doesn't happen very often, less than around 5% of the time or so, but that does happen as well. And then finally, uterine immersion can increase the risk of postpartum hemorrhage. That's literally when the uterus flips inside out there's, there's no other way to really say that. That's a rare, scary thing. I've seen it happen twice in my career that I've had to care for that. Okay. So what are some risk factors for postpartum hemorrhage.

Nicole: In one study that looked at over 150,000 births, these were some of the risk factors for postpartum hemorrhage in order of how they happened. Okay. So the first one was a retained placenta or membranes, um, arrest or making no progress. We say failure to progress. I hate that term failure to progress because I just don't like the way it sounds. But during the second stage of labor, which is when you're pushing, so you get to completely dilated and then, um, can't deliver or the baby doesn't come out vaginally and you need a C-section. So failure to progress during the second stage of labor increases the risk of postpartum hemorrhage, an adherent placenta meaning it just doesn't want to come off the wall of the uterus like it normally should, lacerations, um, instrumental delivery with the vacuum or forceps, bigger babies, hypertensive disorders like preeclampsia or HELLP syndrome, um, induction of labor can increase the risk of postpartum hemorrhage that can be from prolonged use of Pitocin or just from a prolonged labor in general.

Nicole: And then outside of induction, if you have a prolonged first or second stage of labor, first stage is from zero to 10 centimeters, second is 10 to delivery of baby. And then other risk factors are, um, a history of previous postpartum hemorrhage, either in yourself or in your family, uh, obesity, high parity. If you've had lots of children before, usually four or more than essentially the uterus just gets a little lazy for lack of a better word, or it's a harder for it to remember to clamp down like it's supposed to, Asian or Hispanic race, having a fast labor can increase your risk of postpartum hemorrhage, a big uterus that's, um, that's distended either from something like having lots of extra fluid or having twins or multiples can increase the risk, chorioamnionitis, which is infection during labor that can do it as well. Sometimes fibroids can do it because fibroids can interfere with the ability of the uterus to clamp down nicely.

Nicole: Um, also a later gestational age, like between 41 and 42 weeks as well. So there are lots of things that are risk factors potentially for postpartum hemorrhage. Really we need to look at it that anybody who has a baby is at risk potentially for postpartum hemorrhage and we need to be prepared for that accordingly. Now, where are some things we can do to prevent postpartum hemorrhage? Um, one of the things that are is recommended is what's called active management of the third stage of labor. The third stage of labor is delivery of the placenta. And one of the things that works in active management, well, there are three components to active management. And let me tell you all three, the first one we know works very well for sure. Okay. And that is oxytocin administration after birth, and it's given at varying times. Sometimes it's like right after delivery of the baby's shoulder.

Nicole: Sometimes it's a delivery after the baby is completely out. Sometimes it's delivery after the placenta. I usually do it after the placenta is out. There's no well-established protocol for each and oxytocin is the brand name for it is Pitocin. So it's given what's called prophylactically to help prevent bleeding. And it's given through an IV or it can be given through an injection in the muscle. This remains the most effective medication that we know of to prevent postpartum hemorrhage. And it's actually recommended by the World Health Organization, ACOG, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians and the Association of Women's Health, Obstetric, and Neonatal nurses all recommend giving oxytocin after birth in order to prevent postpartum hemorrhage. The other things that we do that are part of the active management of that third stage of labor are uterine massage, which is massaging the uterus massage helps it to firm up.

Nicole: Okay. It helps the muscles to farm up and then umbilical cord traction, which is gently pulling traction on the umbilical cord to help coax the placenta out. Gentle traction is the key. Now another important piece of prevention is identifying and preparing for folks who are at risk. Okay. And you may be at risk if we know that you have something called a placenta previa or accreta when the placenta is either an, um, covering the cervix or accreta is when it goes into the muscle wall of the uterus. If you have a known bleeding disorder that puts you at risk. If for some reason you refuse blood transfusion, like Jehovah's witnesses, um, refuse blood transfusion. Um, if you have a severe anemia, then we need to try to address those things ahead of time. So for example, if you have a severe anemia, then we want to get you iron during pregnancy, sometimes IV iron infusions during pregnancy, in order to get your blood count up so that if you have postpartum hemorrhage, you're not in bad shape.

Nicole: After, after any blood loss, we also can quantify folks based on whether they're low risk, medium risk or high risk, and not all hospitals do this in a formalized way, but we certainly should look in the, the prenatal period as well as when you're admitted to the hospital to see where you fall in that spectrum, and then prepare things accordingly. Sometimes that involves getting blood ready just in case to be ready to use quickly in the event of an emergency. Now you're going to be low risk if you have a Singleton pregnancy, meaning it's just one baby in there, if you've had fewer than four vaginal deliveries, no previous uterine surgery, no history of postpartum hemorrhage, no known disorder, you're going to be low risk. We're not going to need to do a lot to get prepared for your birth. Your risk of postpartum hemorrhage is going to be low.

Nicole: If you fall in the medium miss risk category, you've had prior uterine surgery, for example, cesarean births. If you've had more than four vaginal deliveries, if you have multiples like twins, if you have really large fibroids, if you have a history of postpartum hemorrhage, if you have, um, chorioamnionitis during pregnancy or during your labor, rather then that can increase your risk, puts you in that medium risk category. We're definitely going to be ready to get blood available quickly if needed, not necessarily have it already ready, but get it ready quickly if needed. And if you have anemia, be sure that we're actively treating that anemia during your pregnancy. And then things that put you at high risk are things like placenta previa, where the placenta covers the opening of the cervix, your hermatocrit, which is a measure of your blood count is less than 30.

Nicole: Um, if you have a known bleeding disorder, if your platelet count platelets help your blood clot, if they're very low, those are situations. Also, if you've had multiple cesareans, these are situations where we may, what's called cross-match blood. So get blood ready for you to have it, to be able to give quickly if need be. Now, one of the key things, if you identify particularly prenatally as high risk for postpartum hemorrhage, then you really want to be in a facility that has the appropriate level of care for your needs. And some of those things that are really necessary for people who are at higher risk of postpartum hemorrhage are having adequate personnel obstetricians in house all the time or in the hospital, rather all the time, um, anesthesiologist available, sometimes more advanced surgeons available if need be, having all of the medications available, having, um, adequate IV access, having all of the blood products available and adequate blood bank.

Nicole: So you want to be sure that you have a facility that has all of those things available if needed. And the reality is that there are many hospitals, especially in smaller communities or in rural areas that don't have that higher level of service available 24 7. Okay. And this is why recognition is so important, proper condition and treatment because if you're in a rural area or a smaller area hospital, and we don't know exactly who's going to have postpartum hemorrhage, it can develop quickly in anybody. Then we need to have a very good plan in place. The hospital needs to have a plan in place to identify it early and then get you transferred to a facility that can care for you if need be. Okay. So it's really, really important to recognize early. So people can get treatment including transfer to a higher level of care if need be.

Nicole: I have seen it happen where a small hospital doesn't have blood available. The blood bank runs out of blood for instance, in the setting of an obstetric emergency. So you don't want to get behind in that regard. Now I'm not saying that you have to deliver in a hospital that has a higher level of care, um, because that's not, that's not feasible, feasible or practical, but it's really important that your hospital has things in place that if something happens, you can be transferred quickly and they have those relationships available. Okay. So how do we evaluate for postpartum hemorrhage? All right. So one of the things that's really important is to recognize that signs and symptoms of considerable blood loss often don't happen until blood loss is really high. All right. So what I mean by that is that you could have lost 25% of your blood, 25% like a liter and a half of your blood before you start to see outward signs, like your heart rate going up or your blood pressure starting to stop.

Nicole: All right. So it's really, really important that we know that when you have already gotten to that point where we're seeing some changes in, what's called your vital signs, your heart rate, your blood pressure, you've already probably lost a lot of blood. All right. So, um, it's really important to recognize those things early, because that is what is critical for preventing death. Now, some of the things that can happen is that your hospital, or that should be in place rather that your hospital should have is something that's called an obstetrical emergency response team. And our hospital, we call it a code Oberg where the nurse can call it, the anesthesiologist can call it. And basically what a code Ober does is it brings everybody to the room quickly. So it brings an obstetrician to the room, anesthesiologist to the room, L and D nurse to the room.

Nicole: It can bring, um, an ICU nurse to the room, depending on the team. It can bring a medicine hospitalist or an internal medicine doctor who, who specializes in in ICU medicine to the room. So code Ober brings everybody together quickly. This is one of the benefits of having a hospitalist program, like what I do, because there's going to be an OB doctor in the hospital, 24 7, that's one of the big benefits of, of hospitalist programs or having an OB doctor in the hospital 24 7 is to deal with the emergencies. Like that's the point of having, of having someone there is that it helps to decrease or helps treat these emergencies faster. Um, other things that need to happen is that your hospital should have postpartum hemorrhage kits, which are kits that are assembled that have all of the medications and things together.

Nicole: We have a little box that has like all of our medicines. You just, boom, grab that postpartum hemorrhage kit. All of the medicines are right there. So they're readily available when needed to give you don't have to go get them out of the other storage medications or anything. They're just really, really easily available. Another important piece of evaluation is accurately quantifying the blood loss. We used to do something called an estimated blood loss, and we still do to some degree where we look at the blood loss and we say, it looks like it's about 500 CCS. It looks like it's about 700 CCS. Study after study after study has shown that we underestimate blood loss by estimated blood loss. So blood loss needs to be accurately quantified and that's done by weighing. So when the blood is on the pads, when the blood is on the sponges that we use, those things are weighed.

Nicole: And then we accurately measure the blood loss to know exactly where we're coming from. So those are the important pieces of evaluation to start with are to notice it quickly, have an emergency response team in place to respond quickly. Again, that's one of the benefits of 24 7 obstetricians have postpartum hemorrhage kits where we have all the medicines together and then accurately quantify those blood loss accurately quantified the blood loss. Okay. That's just the beginning. That's just to start now. The next step is once the obstetrician gets to the bedside, or it could be a midwife, um, you need to identify the source of the bleeding. So is it from the uterus. Most often is going to be uterine atony or which is that uterus not firming up right like it's supposed to, but it could be cervical lacerations, vaginal lacerations. And I'll talk about in just a moment, how we treat those.

Nicole: It could be, um, uh, hematomas or blood clots in the vagina. This can typically be done with a quick and careful physical exam. So just looking, seeing what's what, feeling the uterus. Sometimes we have to feel inside to feel if there's some blood clots that are there that need to come out, if there's placenta there, all of those things. And then once we identify what the reason is, then we, it, and sometimes we treat kind of more than one, one thing at once. If it's not easily identifiable what it is. Um, so we start with kind of a step-wise approach and we do the least invasive things to the most invasive things. Now, as I said, multiple times, the primary reason is usually usually uterine atony. So we start with uterine massage, just rubbing the uterus that helps to get it to firm up. And then at the same time, we administer medicines, something called utero tonics, which are utero, is uterus.

Nicole: Tonics makes it get tone. All right. And they help to clamp the uterus. I'm not going to go through all of the different medications that are used, but they're typically given a shots in your arm. There's some that are given IV in order to some that are given rectally in order to help the uterus clamp down. So we start, start with those and it's very common to use many. So we may use two or three or even four uterine tonic agents to help get the uterus to clamp down. If that doesn't work, then we're going to go to something called tamponading the uterus, where we put something inside of the uterus. And essentially it helps to apply pressure to the walls of the uterus where those blood vessels are to help prevent them from bleeding. And that can be done with the intrauterine balloon, or it can be done with packing, which is where literally we, we shove a tremendous amount of gauze up in, in your side, your uterus, and that helps to pack it and, and cut off those blood vessels.

Nicole: And we leave that packing there for 12 to 24 hours. And there are some surgical techniques that can happen as the next step. Something called a B Lynch suture, which is essentially a big stitch around the uterus to squeeze it down, that can happen in a cesarean birth, that doesn't happen very commonly after vaginal birth, but typically at a cesarean birth is when we would use a B Lynch. Also sometimes embolization of the pelvic arteries is an option for uterine atony. Um, that is something that's done by the interventional radiologist. So you need to be in a hospital that has that available, and essentially it is cutting off blood supply to the, the pelvic arteries, which is going to cut off blood supply to the uterus. And then a final step is a life saving measure is hysterectomy to remove the uterus in order to prevent bleeding.

Nicole: And that happens in roughly 2% of cases. Now after uterine atony, then the other thing is going to be lacerations and we need to identify and repair those lacerations. Sometimes that involves going to the or. In the op in the labor and delivery room, the lighting is not always the best. Sometimes you may not be as comfortable, um, the bed, we can't get you in a great position to see. So if there's still continued bleeding, then we may need to move to the OR in order to properly see and assess things and get things taken care of quickly. Retained placenta is another thing that we need to be mindful of and look out for. And the, the, the first thing for that, that is to once the placenta comes out, is looking at it to make sure it looks okay. All right. So in every single note, you know, placenta came out and looks intact.

Nicole: When I say every single note, I mean, every single delivery note always make a note that I have looked at the placenta and the placenta looks intact. Now, even when the placenta looks like it's all there, sometimes there may be accessory lobes of the placenta that when that's an extra lobe, that wouldn't have necessarily you can't see for sure. So that's a possibility. Typically what happens after that, if we suspect a retained placenta is to manually remove that piece of placenta and manual removal is, is what it sounds like. We have to reach inside your uterus and use our hands to sweep and get that placenta out. All right, when you have an epidural, it is pretty, not uncomfortable, I should say, you shouldn't feel a ton. You may feel some, feel some pressure. If you don't have an epidural, I'm not going to lie, it's going to be uncomfortable as it you may think it to, to reach your hand and have someone reach their hand in there and remove a piece of the placenta. But sometimes it just needs to be done and needs to be done quickly in order to control that bleeding. We can give you pain medicine through your IV to take the edge off, but it will be uncomfortable. Okay? Other things that we look for are blood clots, something called hematomas, and they can be on the labia. They can be in the vagina. They can be in the spaces surrounding the vagina. Those are often harder to diagnose because you can't necessarily see them. You may feel them, or you may have a suspicion based on pain or, um, vital signs where the heart rate changes or the blood pressure goes low. So blood clots typically they don't need surgery.

Nicole: We just have to keep an eye on those. They tend to wall themselves off eventually, but we do have to, to keep an eye on those. And then finally, if you have issues like coagulopathy where suddenly your blood isn't clotting, that can happen from placenta abruption, that can happen from amniotic fluid embolism, which is a very, very, very rare thing that happens when amniotic fluid gets into the circulation. Um, it's a rare, unpredictable, very devastating event. Um, so that can cause your blood not to clot properly. And we have to catch up with giving you blood products until your body kind of kicks into clotting on its own. Okay. Now, throughout the process, while we're looking at all these things, again, the uterine atony, lacerations, retained placenta, hematomas, all of those things throughout the process, we are monitoring your vital signs. Okay. We are checking your blood count in order to make sure your blood count isn't too low.

Nicole: All right, we are monitoring your bleeding and continuously weighing it in the initial stages. You want to see a lot of people looking in available to make sure that this bleeding is okay. All right. You want to see a lot of people around. It can be scary because it's like, why are all these people here? But all of those people are there because they need to be there to make sure that this bleeding doesn't get serious. And as the bleeding slows down, then people kind of filter out of the room, but you want to see a prompt and thorough response to postpartum hemorrhage. Because again, that is how we make sure it doesn't get serious. Other things that we're going to be doing are given IV fluids, we're going to place a second IV if you don't already have, um, if you have one IV, we're going to place the second one.

Nicole: If you don't have to IVs, we're going to place two IVs so we can have easy access to get you IV fluids, to help get your blood count, blood volume up. Sometimes you need a blood transfusion to help get your blood count up roughly 15% or so folks will need a blood transfusion afterwards for postpartum hemorrhage. All right. And then the last thing I'll say about primary postpartum hemorrhage, there is something called a, uh, inter-operative cell Savage, where it's also known as autologous blood transfusion. And the way I can describe it is that essentially it's used sometimes during a cesarean birth, especially for someone who doesn't want to receive a blood transfusion, where we collect blood, that, um, we get, we recollect your blood that happens during blood loss of the surgery, and we filter it and essentially give it back to you. Okay. Now the issue with cell Savage is that it is not widely available.

Nicole: It requires special staff. It requires some time to set up. So even though theoretically, it sounds like it is a great option in practicality because postpartum hemorrhage is largely unpredictable. It's usually not available, um, very quickly. So it's rarely available or used. Okay. So that's it for primary postpartum hemorrhage. Quickly for secondary postpartum hemorrhage that is blood, uh, blood loss that occurs between 24 hours and 12 weeks postpartum, some definitions say 48 hours and six weeks, but roughly, um, in the later stages of the postpartum period, it doesn't happen very often. It occurs anywhere from 0.2% to 2.5% of postpartum women. Most of the time, if it happens, it's going to be within the first one to two weeks postpartum, the most common causes are retained products of conception. So pieces of placenta that are left, I have seen that happen before where a piece of placenta just kept causing continued bleeding. Something called subinvolution of the placenta bed, which is where the spot where the placenta was inside the uterus just doesn't quite clamp down nicely like we wanted to. And then infection. There are some rare causes like vascular malformations, choriocarcinoma, which is cancer of a placenta, um, cervical cancer. Those are rare things that happen. Sometimes we can't determine the cause of what caused the secondary postpartum hemorrhage. Some risk factors for secondary postpartum hemorrhage are having a primary postpartum hemorrhage. That's probably the most significant, not probably that is the most significant risk factor. Also having a previous history of postpartum hemorrhage can increase your risk. And the most common clinical presentation is that you're just going to have vaginal bleeding that's more than what is expected. Okay. Sometimes there may be pain. There may be fever. There may be tenderness in the uterus, but it's going to start of course, with more vaginal bleeding. And that can be tricky because you're, you're, you, you're going to have bleeding after birth, right?

Nicole: So you're going to have bleeding. So it can be tricky to know like, Hey, is this too much? So if you're ever in doubt, if you ever have concerns and obviously go in to be seen to check about the amount, but typically it's going to be like either I'm continually bleeding or it's, I'm going through more than a pad in a couple of hours for bleeding. When we're trying to figure out what's causing secondary postpartum hemorrhage. One of the most important things is to learn what happened after birth or at the birth, were there are some risk factors for retained placenta. Like did you have to have a manual extraction where you had the placenta removed? Did you have any tears? Um, secondary postpartum hemorrhage is more common after a vaginal births than cesarean, but it does happen after cesarean as well.

Nicole: Usually we start with an ultrasound examination that can help us see if there is a piece of placenta there that can help see some vascular abnormalities sometimes. So that can be very helpful. And then the management depends on what the issue is. For retained placenta, you may need a DNC. If there's a vascular problem, you may need individual radiology. Sometimes we have to give medicines to help the uterus clamp down anymore. If there's infection then there needs to be antibiotics, sometimes the DNC works. Even if we can't identify anything on ultrasound or any other, cause for some reason, just cleaning out the uterus can help with that secondary postpartum hemorrhage. All right, now finding final thing, what's the recurrence risk of postpartum hemorrhage. The biggest risk and that's for most anything is if you had something before. So if you had a prior postpartum hemorrhage, that's going to increase your risk.

Nicole: And if you have one, you have roughly an 18% risk of it happening again in a subsequent pregnancy. It depends to some degree on what the reason was for the postpartum hemorrhage. But you can expect, let's say roughly 20% recurrence risk in the next pregnancy. Its definitely something that you want to point out to your doctor that, Hey, I had a postpartum hemorrhage with my last birth so that we can be prepared just in case. All right. So just to recap, primary postpartum hemorrhage is blood loss greater than a thousand CCS in 24 hours. Prompt recognition and treatment is key. When we do that, then we save lives and people don't have bad outcomes, plain and simple. Most often post-partum hemorrhage is from uterine atony, but there are other causes like vaginal or cervical lacerations, retained placenta, problems with blood clotting. We routinely prevent it with oxytocin, given at birth, either through an IV or in your muscle, also uterine massage and that gentle umbilical cord blood traction also to prevent it.

Nicole: It's really important to identify if you're a high risk for postpartum hemorrhage and then make sure resources are available to care for you if need be. That secondary postpartum hemorrhage is rare, but it does happen. That's within 24 hours to 12 weeks postpartum. Now postpartum hemorrhage is one common complication that can happen after birth, but there are several other things that you should want to know about as well. Things like meconium, shoulder dystocia, chorioamnionitis. In the Birth Preparation Course, you will learn an overview of all of these things and so much more. So do check out the Birth Preparation Course. That's drnicolerankins.com/enroll. So there you have it. Be sure to subscribe to the podcast in Apple Podcast or wherever you're listening to me right now. And if you feel so inclined, I would love it if you leave an honest review in Apple Podcast it helps other women find the show. And I love to hear what you have to say about the show. Plus I do shoutouts from those reviews as well. Do come check me out on Instagram gon come follow me over there. I provide lots of additional information, um, with posts, with videos, I'm even doing a reel, something that I never thought I would do so you can check me out and follow me on Instagram @drnicolerankins. So that is it for this episode, do come on back next week. And until then, I wish you a beautiful pregnancy and birth.

Nicole.: Thanks so much for listening to this episode of the All About Pregnancy & Birth podcast, head to my website, drnicolerankins.com to get even more great information including free downloadable resources on how to manage pain in labor and warning signs to look out for after birth. You'll also find information on my free online class on How To Make A Birth Plan That Works as well as everything you need to know about my signature online childbirth education class, the Birth Preparation Course. Again, that's drnicolerankins.com and I will see you next week.

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