Intrapartum and Postpartum Hemorrhage

This chapter deals with intrapartum and postpartum hemorrhage. It provides the background information of the disease, and discusses its prevention, diagnosis, treatment, prognosis, and evidence. Uterine atony is responsible for at least 80% of postpartum hemorrhage. Hemorrhage can be related to trauma, such as lacerations, incisions, or uterine rupture. The best prevention is anticipation/preparation, which may involve interdisciplinary team huddles for high-risk patients and, when indicated, transfer to an appropriate level of care for delivery. Patients at high risk (placenta previa/accreta, thrombocytopenia, active bleeding, coagulopathy, two or more medium risk factors) should have type and cross. Ultrasound evaluation of the uterus may be helpful to look for retained products of conception; for delayed postpartum bleeding, it may also help detect choriocarcinoma. Treatment almost always starts with uterotonics, because atony is the leading cause of postpartum hemorrhage, with prompt escalation to other interventions as needed.