Diagnosis and Management of Shock in Postpartum Haemorrhage

Postpartum haemorrhage (PPH) is a serious complication that can occur after childbirth, posing a significant risk to maternal health. In some cases, PPH can lead to shock, a life-threatening condition requiring immediate attention and intervention. 

In this blog, we will delve into the diagnosis and management of shock in postpartum haemorrhage, shedding light on the crucial steps healthcare professionals take to save lives.

Table of Contents

• What is Postpartum Haemorrhage? 

• What are the causes and risk factors of PPH?

• What is the diagnosis of shock in PPH?

• What is the Immediate management of PPH shock?

• What is the treatment of PPH shock? 

• Is Shock Index a predictor of PPH? 

• FAQs

What is Postpartum Haemorrhage (PPH)?

Postpartum haemorrhage, or PPH, is a condition characterised by excessive bleeding that occurs within 24 hours after childbirth.* It can strike unexpectedly, making it essential to understand its causes, risk factors, and, most importantly, how to address it promptly.

PPH is a global concern, with thousands of maternal deaths occurring due to this condition each year. To grasp the importance of managing shock in PPH, it's vital to first comprehend what PPH entails.

What are the Causes and Risk Factors of PPH?

PPH can result from various factors, including uterine atony (inadequate uterine contractions), lacerations, placental abnormalities, and coagulation disorders. Several risk factors increase the likelihood of PPH, such as multiple pregnancies, large babies, a history of previous PPH, and certain underlying medical conditions.

Diagnosing PPH and identifying its underlying causes are critical steps in preventing shock. 

Let's explore the most common causes and risk factors of postpartum haemorrhage to understand in depth:

• Blood clotting condition (thrombin): If you suffer from a pregnancy condition such as eclampsia or coagulation disorder, it can interfere with the clotting ability of the body. As a result, even a tiny bleed becomes uncontrollable. 

• Retained placental tissue: It happens when the entire placenta does not separate from the uterine wall. The condition of the placenta causes the condition and affects the ability of the uterus to contract after delivery. 

• Uterine Trauma: Any damage to the area between your anus and genitals known as perineum, uterus, cervix or vagina can cause bleeding. Use of vacuum extractions or forceps or similar instruments during delivery can increase the probability of uterine trauma. Further, a collection of blood known as hematoma can form in a concealed causing bleeding for hours or days after delivery. 

• Uterine atony: The steady loss of blood after delivery when uterine muscles do not contract enough to shut the placenta blood vessels lead to uterine atony. It also refers to a weak or soft uterus after delivery. 

Who is at risk for Postpartum Haemorrhage? 

Women with placental problems including retained placenta, placental abruption, placenta previa, and placenta accreta are at high risk of PPH. 

If the uterus is overenlarged, it can also increase the risk for PPH. If the uterus is strained or overextended from: 

• Excessive amniotic fluid

• Giving birth to a baby weighing 9 or more pounds

• Having twins, triplets or more

• Multiple pregnancies

PPH risk factors can happen during labour of delivery: 

• You have experienced PPH in prior deliveries

• Tearing or perineal lacerations during vaginal delivery

• Infection during labour

• Prolonged labour

• Given tocolytics to stop labour

• Given oxytocin to induce labour

• Given general anaesthesia

• C-section

Other PPH risk factors that should be considered are:

• Advanced maternal age

• Obesity

• History of five or more deliveries

• Anaemia

• Intrahepatic cholestasis of pregnancy (ICP)

• Blood clotting disorders

• Infection

• Preeclampsia or high blood pressure

Diagnosis of Shock in Postpartum Haemorrhage

Recognising shock in PPH is imperative for timely intervention. Clinical symptoms to watch for include excessive bleeding and altered vital signs like blood pressure and heart rate. Early diagnosis ensures that shock can be addressed effectively, potentially saving the mother's life.

The most common shock symptoms in PPH is excessive, persistent bleeding after delivery. 

Other PPH symptoms include: 

• Severe pelvic or abdominal pain

• Vomiting or nausea

• Clammy or pale skin

• Decreased red blood cell count

• Increased heart rate

• Feeling dizzy due to drop in blood pressure or blurred vision

Importance of monitoring blood pressure and heart rate

Heart rate and blood pressure monitoring is crucial to assess the condition of the mother in addition to measuring blood loss. The pulse rate and systolic blood pressure shows the important warning signs of PPH for prompt treatment. 

Shock Index, the ratio of heart rate to systolic pressure, used to predict the changes in clinical condition and blood loss. Monitoring blood pressure, heart rate and measuring blood loss, together can help doctors make informed decisions around intravenous fluid delivery. Also, vital signs monitoring is an essential tool for intrapartum and antenatal care.  

Daksh OSI is a shock index monitor that helps doctors to predict Postpartum Haemorrhage. It measures the pulse rate, blood pressure, and oximeter to determine the shock index allowing doctors to detect PPH early on and do the necessary treatment. 

Immediate Management of PPH Shock

When shock sets in, swift action is necessary. Initial measures include ensuring an open airway, administering oxygen, and establishing intravenous access for fluid resuscitation. Additionally, uterotonic medications play a vital role in controlling bleeding. 

For healthcare professionals, these immediate steps are critical in stabilising the patient and preventing further deterioration.

The Initial Steps for Managing PPH Shock are:

1. Assessment and Recognition: The immediate signs of shock may include altered mental status, rapid and weak pulse, hypotension (low blood pressure), and pallor. Recognising shock is crucial for immediate intervention.

2. Airway Management: Ensure that the patient's airway is clear and adequately maintained. If there are any obstructions, reposition the patient's head and neck to establish a patent airway. Doctors may use nasopharyngeal airways if necessary.

3. Oxygen Administration: Administering high-flow oxygen through a non-rebreather mask (at least 15 litres per minute) helps improve oxygenation. Adequate oxygen levels are essential to support tissue perfusion.

4. Positioning: The patient is placed in a left lateral tilt (also known as the "Trendelenburg position") to alleviate pressure on the vena cava and enhance venous return. This can help improve cardiac output.

The Role of Shock Index and Daksh OSI

Assessing the severity of shock in PPH can be aided by tools like the Shock Index (SI) and Daksh Obstetric Shock Index (Daksh OSI). SI, calculated by dividing heart rate by systolic blood pressure, offers insights into the patient's condition. 

Daksh OSI is specifically designed to predict PPH risk by providing obstetric shock index value, helping healthcare professionals make informed decisions.

Conclusion

In the realm of maternal health, the diagnosis and management of shock in postpartum haemorrhage are critical skills for healthcare providers. Prompt recognition, followed by appropriate interventions, can make a significant difference in outcomes. 

By understanding the causes, risk factors, and tools like the Shock Index and Daksh OSI, healthcare professionals can improve their ability to save lives during this challenging obstetric emergency.

Remember that early intervention is the key to a successful outcome when dealing with shock in postpartum haemorrhage.

Frequently Asked Questions

What is Postpartum Haemorrhage?

Postpartum Haemorrhage (PPH) is a condition where excessive bleeding occurs after childbirth, typically within the first 24 hours.

What are the causes of Postpartum Haemorrhage?

PPH can be caused by factors such as uterine atony (the uterus fails to contract properly), trauma during childbirth, placental problems, and coagulation disorders

Can PPH be predicted and prevented?

While PPH cannot always be prevented, early detection and prompt management of risk factors can reduce its occurrence. Dakshi SI helps determine early signs of PPH such that doctors can perform immediate treatment. 

How is Postpartum Haemorrhage diagnosed?

Diagnosis is based on clinical symptoms, physical examination, and sometimes additional tests like ultrasound or blood tests. Daksh SI helps predict PPH by monitoring critical vitals of the mother.

What are the long-term complications of PPH?

Severe PPH can lead to complications like anaemia, organ dysfunction, and, in rare cases, maternal death.

How can I support a loved one experiencing PPH?

Stay calm, call for medical assistance, and offer emotional support. Avoid interventions that could worsen the situation.