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The classic definition of an immediate Postpartum Hemorrhage is the loss of 500 cc or more of blood. It is useful to remember that, even in the normal course of an uncomplicated birth with no interference such as medications in labor or assisted birth procedures, the amount of bleeding may be variable. The amount of usual blood loss in the third stage of labor has been documented as little as 50 cc of blood and as much as just under the 500 cc designated as a postpartum hemorrhage. The World Health Organization estimates that worldwide, 585,000 die each year in pregnancy and childbirth. The major reasons listed are hemorrhage, obstructed labor and infection. The incidence of deaths due to hemorrhage is estimated at 24. Of equal concern though, is the incidence of hemorrhage which may not only threaten death, but which also causes delays in maternal recovery, ability to care for an infant, and decreased function due to fatigue. Maternal morbidity was divided into obstetric complications, preexisting medical conditions, and cesarean delivery. Healthy People 2010 contains several new guidelines for reducing maternal morbidity, including an aggregate measure involving reductions in rates of maternal complications during labor and delivery. American Journal of Public Health, April 2003, vol 93, No 4. Specific causes for post partum hemorrhage are not usually given in statistical reports based on international or national data because this level of detail is not available. Therefore, the above data regarding mortality from hemorrhage includes all circumstances in the childbirth period. The morbidity data relates to the prevalence of postpartum hemorrhage after a vaginal birth. Individual research studies may provide data where they have focused on specific causes of hemorrhage in their studies e. The amount of blood loss that an individual may sustain without physiological evidence of stress is also quite variable. A vulnerable woman may have adverse alterations in blood pressure, pulse and general response indicating stress with less than 500 cc of blood loss. Conversely, it is possible for a woman to lose much more than 500 cc of blood without an apparent adverse physiological response. Sally Yeomans, to attend home births with her at Chicago Maternity Center in Chicago, Illinois during spring break in 1961. She was employed there, when not at Yale, to teach the obstetrical residents from Case Western Reserve University School of Medicine, as they attended poor women in their homes for their births. This day, I was the student accompanying her. The expectant mother was a large African American woman of high multiparity. She labored normally and gave birth without incident. As soon as the placenta was out, however, she had a massive flow of blood from her vagina. We later estimated the total at well over 1,000 cc of blood loss. My instructor immediately took over and the problem was brought under control. I monitored her pulse and blood pressure, and was amazed to find that it varied not a bit from her vital signs during labor. Again her vital signs changed not at all. As we discussed the case, it was pointed out that her failure to void prior to the birth, with subsequent pressure of the full bladder, probably inhibited the expected contraction of the uterus as the placenta emerged. Since she was large, and obviously well hydrated, she was able to sustain the blood loss in the short term without adverse response. Needless to say, our follow up care took this into consideration. As indicated in other sections of this tutorial, blood loss during and immediately after the third stage of labor may be due to a number of reasons. The management of all of these circumstances, except uterine atony as a unique reason, has been discussed in the previous sections. This section will focus on the most common reason for excessive immediate bleeding during and after the third stage of labor e. It has been clinically noted that an empty bladder prior to the birth will enable the uterus to contract most effectively when the placenta is being delivered. Therefore, it is highly desirable to enable the woman to empty her bladder during the active phase of first stage labor and shortly before she enters the second stage of labor. A woman in normal labor should be allowed to ambulate freely. Therefore, it is very easy for her to walk frequently to the toilet to void. Women who are confined to bed should be assisted to void in bed. Women who have very mild uterine contractions in the active phase of first stage labor, will probably have the same type of contractions during second and third stage. These may be sufficient to enable birth, especially in a multiparous woman, but often are not sufficient to result in effective contraction at the time the placenta is born. The birth attendant who notes the nature of the uterine contractions in late first stage labor will not be surprised by a uterus that does not contract effectively in t filexlib.
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