Ob.gyns. and hospitals should have an organized and systematic treatment plan for postpartum hemorrhage, according to an updated practice bulletin from the American College of Obstetricians and Gynecologists (ACOG).

ACOG is recommending that obstetric care facilities post guidelines regarding the diagnosis methods and management techniques of postpartum hemorrhage. If postpartum hemorrhage is suspected, a physical exam should be performed to quickly inspect the uterus, cervix, vulva, and perineum to identify the source of bleeding. Once the cause has been identified, a treatment plan specific to the etiology of the bleeding can be implemented (Obstet Gynecol. 2017;130:e168-86).

“Less invasive methods should always be used first,” Aaron Caughey, MD, PhD, one of the coauthors of the practice bulletin, said in a statement. “If those methods fail, then more aggressive interventions must be considered to preserve the life of the mother.”

The ACOG reVITALize program defines postpartum hemorrhage “as cumulative blood loss greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process,” which differs from more traditional definitions of postpartum hemorrhage that puts the blood loss at more than 500 mL after vaginal birth and more than 1,000 mL after cesarean delivery.

The unpredictable nature of postpartum hemorrhage and its potential for severe morbidity and mortality make identifying its risk factors a priority. Risk assessment tools have been shown to identify 60%-85% of patients who will experience a serious hemorrhagic event. Risk factors for postpartum hemorrhage can be made into a simple table that categorizes different factors into low, medium, or high risk categories and posted in obstetric care facilities.

“The important thing is for providers to be able to recognize the signs and symptoms of excessive blood loss earlier and to have the resources at hand for the prompt escalation to more aggressive interventions if other therapies fail,” said Dr. Caughey, professor and chair of obstetrics and gynecology at Oregon Health and Science University, Portland.

Prevention is one of the key strategies outlined for combating postpartum hemorrhage. Many clinicians and organizations advise active management of the third stage of labor to decrease the likelihood of women experiencing postpartum hemorrhage. This can be done by administering oxytocin, massaging the uterus, and traction of the umbilical cord. Oxytocin can be administered both intravenously and intramuscularly and presents the lowest risk of adverse affects.

“By implementing standard protocols, we can improve outcomes,” Dr. Caughey said. “And this is even more critical for rural hospitals that often do not have the ability to treat a woman who may need a massive blood transfusion. They need to have a response plan in place for these obstetric emergencies, which includes triage and transferring patients to higher-level facilities, if necessary.”