While the delivery of a healthy infant is an essential goal of obstetrics and the immediate postpartum period is usually uneventful, significant and serious complications can occur. Management of the third stage of labor (between the delivery of the baby and the delivery of the placenta) and the subsequent few hours require close attention by the medical providers. The most serious complication following delivery of the baby remains postpartum hemorrhage which is a significant cause of maternal morbidity and mortality.
Postpartum hemorrhage is the acute loss of more than 500 cc. of blood that occurs following the delivery of the baby. It complicates approximately 2% to 10% of all deliveries but is severe in only 1% of cases. Postpartum hemorrhage is associated with increased maternal morbidity and mortality. Factors that increase the risk for a postpartum hemorrhage to occur include:
Uterine contraction following the delivery of a baby is responsible for controlling blood loss. Clot formation also plays an important role in limiting the amount of blood lost following delivery and the subsequent days. Changes occurring during the course of a pregnancy helps protect against the complications of postpartum hemorrhage. Maternal blood volume normally increases approximately 50% and protects the mother against postpartum hypotension and anemia. A marked increase in clotting factors and decrease in fibrinolytic activity help in the clot formation and fibrin deposition following delivery of the placenta.
Uterine atony, a condition in which the uterus fails to contract following the delivery of the placenta, accounts for most cases of postpartum hemorrhage. Abnormal labor, an overdistended uterus, the use of Pitocin and the presence of a uterine infection (chorioamnionitis) appear to predispose to uterine atony. Severe postpartum uterine bleeding as a result of failure of the uterus to contract (atony) accounts for more than one third (33%) of postpartum hysterectomies.
Several agents cause the uterus to contract following delivery of the placenta. Oxytocin (Pitocin) that is naturally produced in the posterior pituitary can also be administered intravenously. Prostaglandins, locally produced by the uterus can also be administered by various routes to produce the uterus to contract. Other medications have the opposite effect, mainly uterine relaxation which can lead to dangerous bleeding following delivery. Drugs used around the time of delivery that are associated with uterine relaxation include:
Beta-sympathomimetics (terbutaline, ritodrine)
Nonsteroidal anti-inflammatory (ibuprofen)
Calcium antagonists (Nifedipine)
Anesthesia gases (Inhalation agents)
Controversy still exists concerning the benefit of active management compared with the expectant management of the third stage of labor. Several studies have shown that active management of labor is associated with a decreased occurrence of postpartum hemorrhage. Retained placenta or a portion of the placenta is a common cause of postpartum hemorrhage. Retained placenta is more common following delivery of very premature infants. Complications such as placenta accreta (absence of normal cleavage plane between the placenta and the uterus) or placenta increta when the placenta has grown into the uterine muscle, require at times surgical intervention.
Treatment of a postpartum hemorrhage sequentially consists of medical, interventional and ultimately surgical options.
Oxytocin (Pitocin) infusion
Ergot derivatives (ergonovine, ergometrine)
Prostaglandin F2α (carboprost tromethamine)
Uterine curettage (D & C)
Utero-ovarian artery ligation
Uterine artery ligation (O’Leary method)
Hypogastric artery ligation
Not all postpartum vaginal bleeding originates from the uterus. Injuries to the birth canal such as vaginal and cervical lacerations are a common source of postpartum hemorrhage. Forceps delivery following a prolonged labor and/or performed under emergency circumstances is a frequent cause of lacerations of the birth canal. Failure of the postpartum hemorrhage to respond to uterine massage and/or the administration of uterotonic agents should raise the suspicion that injury to the birth canal is the source of the blood loss.
When the drastic decision to perform an hysterectomy is taken, preservation of the ovaries is essential. Women who have just delivered an infant are generally young and surgical menopause resulting from removal of their ovaries exposes them to the risk of subsequent long term complications. Knowledge of the pelvic anatomy and the experience to deal with a serious complication such as postpartum hemorrhage that requires a surgical intervention are extremely important. Attempts by inexperienced surgeons to surgically treat severe postpartum hemorrhage have been associated with undesirable surgical complications.
Treatment of severe postpartum hemorrhage (with or without shock) requires massive replacement of blood and crystalloid solutions. Electrolyte imbalance (hypokalemia, hypocalcemia) as well as hemodynamic changes require close monitoring and frequent interventions. Successful treatment of severe postpartum hemorrhage requires a multidisciplinary approach with close collaboration among members of the care team (obstetrician, nurses, anesthesiologist and consultants).
Medical providers are responsible for the diagnosis and management of complications that arise during the third stage of labor such as postpartum hemorrhage. If you believe that you, your child or your loved one have been misdiagnosed, are victims of a postpartum hemorrhage or wrongly treated and suspect the postpartum complications may be the result of a medical provider’s error that was diagnosable, avoidable and/or preventable, you may have a valid cause of action. The injury may be the result of a medical provider's mistake in handling your condition and the result of medical negligence. Dr. Borten has over 35 years of experience as an obstetrician and gynecologic surgeon to fully evaluate the merits of your potential case. Allow the Boston area medical malpractice attorneys at Gorovitz & Borten help you assert your rights and get the compensation you deserve.
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