An increasing score suggests a deviation from a normal physiological state and indicates clinical deterioration, which should prompt an escalation in response by clinicians who have the appropriate level of skill to care for the patient. 6,7 These systems assign a score to a range of clinical vital signs to form a total maternity early warning score. The use of maternity early warning scoring to improve early detection of clinically deteriorating patients and escalation of the clinical response is increasing. Careful and repeated clinical assessments and documentation of vital signs, such as pulse rate, BP, temperature, and respiratory rate is essential for identifying a trend indicating physiological decompensation in response to hypovolemia. By the time women have significant hypotension or tachycardia or an increased respiratory rate or become distracted or agitated, they usually have lost in excess of 2000 to 2500 mL. Healthy pregnant women show minimal physiological response to blood loss of 1000 to 1500 mL, perhaps only becoming slightly tachycardic with a minor decline in systolic BP. Risk factors should be reassessed frequently during labor and birth. However, it is critical that all staff caring for women in labor and childbirth be aware that most women who have severe PPH have no identifiable antenatal risk factors and that a high level of awareness be maintained. Women with risk factors identified antenatally should be managed in the appropriate setting with access to skilled staff and a blood bank and with precautionary steps taken during labor and childbirth to minimize the risk of PPH and respond early if it occurs ( Figure 1).
Some women enter pregnancy with risk factors for PPH or develop these risk factors during the course of pregnancy or labor and birth ( Table 1). The differential diagnosis is not wide and includes one or more of the following: uterine atony, retained placenta, and placental malimplantation (previa, accreta, increta, or percreta), and genital tract trauma or coagulopathy, often referred to as the “4 T’s” (tone, tissue, trauma, and thrombin). Postpartum hemorrhage should not be viewed as a diagnosis but rather a clinical manifestation of an underlying condition or conditions that require identification and treatment. The pediatric team was called to review the infant, who had a 3990-g birth weight and some initial floppiness but responded rapidly to basic resuscitation. Immediate postpartum blood loss was estimated at 1200 mL. Active management of the third stage of labor appeared complete, with controlled cord traction, intramuscular oxytocin, and delivery of the placenta. A successful vacuum extraction (ventouse) was performed after episiotomy by the senior resident, with birth of the infant after 80 minutes in the second stage. The first stage of labor was complete at 17 hours, and initial effective pushing occurred in the second stage, with the head on the perineum at 65 minutes with no further advancement. At 11 hours, an epidural was placed after the IV oxytocin was started. She made slow progress in the first stage of labor, requiring augmentation with IV oxytocin. A complete blood count on admission showed hemoglobin (Hb) 10.4 × 10 9/L, platelets 152, white blood cell count 7.8 × 10 9/L. Her admission observations were normal: afebrile, pulse 88 per minute, blood pressure (BP) 110/68 mm Hg, and respiratory rate 14 per minute. The patient had spontaneous onset of labor at 39 +5 weeks’ gestation. Identification of coagulopathy by viscoelastic point-of-care testing or conventional laboratory assays can be helpful in guiding management of PPH and preventing severe maternal outcomes. Coagulopathy can be an early feature in PPH that may be unrecognized, as it can be present before massive transfusion has occurred. The pivotal role of fibrinogen and hyperfibrinolysis in the evolution and as a treatment target for PPH is increasingly recognized.
Common causes include uterine atony, retained placenta, trauma to the genital tract or uterus, and coagulopathy. Therefore, all pregnant women must be considered to be at risk of PPH. Although some women have risk factors for PPH that can be identified during pregnancy or during labor or birth, most women with severe PPH do not have any risk factors. Prevention of excess maternal deaths requires a coordinated approach to prevention, early recognition, and intervention by a multidisciplinary team. Postpartum hemorrhage (PPH) is the leading cause of global maternal mortality and accounts for approximately one-quarter of all maternal deaths worldwide.
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