Postpartum Bleeding

In the U.S., postpartum bleeding is the second most common cause of pregnancy- associated death, accounting for approximately 14 percent of pregnancy associated deaths. Globally, postpartum hemorrhage is the leading cause of maternal mortality, responsible for about 25 to 30 percent of all maternal deaths, or somewhere between 46,000 and 70,000 deaths annually, or one woman from post every seven minutes. The burden is disproportionately large in low-and middle-income countries, particularly in sub-Saharan Africa and South Asia, largely due to a lack of access to blood transfusions, medications, and skilled care.

The most common cause of pregnancy-associated bleeding is postpartum uterine atony (a boggy/floppy uterus). Post-partum bleeding is preventable. I have managed postpartum bleeding thousands of times. None of my patients have died from any pregnancy associated illness, including postpartum hemorrhage.

There are several ways to treat postpartum uterine bleeding. The most common method is intravenous (IV) pitocin. Another very old treatment is methergine given IM (in the muscle). Today we have revisited packing the uterus. Today we use something like a balloon, but I think it is only slightly more effective than the packing of yesteryear. Another approach is to give prostaglandin IM.

And finally, there is fundal massage. It is always my first choice for increasing uterine tone and decreasing uterine bleeding. There remains some confusion about the definition of fundal massage. Some people think that it means pushing on the top of the uterus (the fundus) to expel the blood from the uterus and vagina, and to assess the amount of bleeding which has occurred since delivery. But fundal message really means to make a small circle about 2 inches from side to side through the umbilicus (belly button) with minimal pressure. This procedure actually is the best technique for inducing uterine tone and for me it has always been my primary treatment to prevent postpartum hemorrhage. I once massaged a patient’s uterus for eight hours, but the patient did well and did not have to have a blood transfusion.

We have many options to prevent death from bleeding. Fundal massage, as I have described it above works very well. You can use it anywhere and all you need is two fingers to perform it so you don’t need a lot of medication or fancy machinery or exceptional skills, but you do need to understand how fundal massage works as described above.