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BackTable / OBGYN / Article
4 T's of Postpartum Hemorrhage
Taylor Spurgeon-Hess • Updated Jun 26, 2023 • 652 hits
During delivery, one thing on every provider’s mind is the feared complication of postpartum hemorrhage. Causes often include uterine atony, laceration, coagulopathy, or retained tissue. Future technology aims to clue in providers earlier in order to prevent further complications.
This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable OBGYN Brief
• The definition of postpartum hemmorhage, as defined by TheAmerican College of Obstetricians and Gynecologists (ACOG), is a blood loss greater than 1000 ccs.
• Currently, blood loss is often recorded quantitatively based on measurements of the materials holding blood, while in the past it was measured qualitatively by providers’ visual estimates.
• The 4 T's of postpartum hemmorrage refer to the causes, which include: tone (uterine atony), trauma (laceration), tissue (retained placenta), and thrombin (coagulopathies).
• Future technology seeks to identify postpartum hemorrhage earlier with the help of wearable devices capable of monitoring a patient’s hemodynamic state.
Table of Contents
(1) Definition of Postpartum Hemorrhage
(2) 4 T's of Postpartum Hemorrhage
(3) Future Technology to Prevent Postpartum Hemorrhage
Definition of Postpartum Hemorrhage
While postpartum hemorrhage generally refers to excessive bleeding after childbirth, the specifics for diagnosis, set by the American College of Obstetricians and Gynecologists (ACOG), have changed over time. Currently, ACOG defines postpartum hemorrhage as blood loss greater than 1000 ccs. However, monitoring a patient’s hemodynamic state is important for blood loss between 500 and 1000 ccs if patients deliver vaginally. In the past, most practices measured blood loss in a qualitative fashion; they looked around at the blood all around the area during delivery and guessed roughly how much blood was lost. Today, many practices have switched to quantitative measurement as it is believed by many to be more accurate. Any material with blood on it is weighed and the measurements are recorded in order to calculate total blood loss. The timing of the bleeding can clue the physician into the potential causes of the hemorrhage. Bleeding that occurs less than 24 hours after delivery is considered acute postpartum hemorrhage, while any bleeding from 24 hours to 12 weeks following delivery is considered late postpartum hemorrhage.
[Dr. Christopher Beck]
Can we talk about what is postpartum hemorrhage? Roxane, why don't we start with you? Then I'll let you guys kind of guide the conversation after we get some floor information established.
[Dr. Roxane Rampersad]
Recently, ACOG has changed that definition to include blood loss greater than 1,000 ccs. I think that's the number that we're paying attention to. For vaginal delivery though, even though greater than 500 may not change your hemodynamic state, it's still an important number to look at for vaginal delivery. Greater than 500 and less than 1,000 is still an important number to pay attention to if someone has reached that state of blood loss after vaginal delivery.
[Dr. Anthony Shanks]
One thing I want to point out for people that are listening that don't know, ACOG is the American College of Obstetricians and Gynecologists and they set our ground rules for what we do in practice. I feel like many of us get a chance to serve on those committees to interpret the evidence and make these protocols, but we really take them as guidance on what we do. When we trained like when we talk about blood loss, if you remember--
[Dr. Christopher Beck]
When did you guys train? How far back are we talking?
[Dr. Roxane Rampersad]
Oh, Tony. Do you have to keep bringing that up?
[Dr. Roxane Rampersad]
We are not dinosaurs.
[Dr. Anthony Shanks]
We are not dinosaurs. That is true. Why I bring it up is, if you remember an interventional radiologist back when you were doing your clerkships through labor and delivery, the nature of deliveries, there is going to be blood loss at that time. When we do them, we used to qualitatively measure blood. I actually googled these pictures because I remember looking at a lap sponge and then having to make a guess on how much blood there is. Now, there's been this movement where we have to do quantitative blood loss. Dr. Rampersad, you want to tell us what quantitative blood loss is?
[Dr. Roxane Rampersad]
Gosh, quantitative blood loss, I think, is the bane of our practice at our university. You're right.
[Dr. Anthony Shanks]
Why is that?
[Dr. Roxane Rampersad]
Because it was really easy to estimate blood loss. I think we looked at the bag, we looked at the laps, and we looked at the blood all around, and we're like, "You know what? That's 500 ccs. We all learned what our 500 and what our 400 look like. Quantitative blood loss is a little bit more labor-intensive. Our nurses now have to gather everything that has blood on it and they have to weigh it.
They have to know what it weighs prior to the delivery and what it weighs with blood. We also have to take into account amniotic fluid, which is also lost at the time of delivery. It's not an easy thing to do, but it's something that we've switched over because qualitative blood loss is probably not as accurate as quantitative blood loss. I know that's controversial too.
There's a lot of people that battle that back and forth. I think even ACOG has changed a little bit on that where I don't think they're pushing, I think, quantitative blood loss. I think a lot of other societies and a lot of what are called perinatal quality collaboratives in each state that follow maternal mortality and follow metrics like these quality improvement metrics still use and are still pushing quantitative blood loss.
[Dr. Anthony Shanks]
It's like 1 gram is equivalent to 1 milliliter. With the new definitions of it being like 1,000 milliliters, whether it's a vaginal delivery or C-section. Now, it's really up to the nurses to help us out. Because when you're in a C-section, certainly, you're focused on the field and you're going to rely on your nurses to measure that. What Roxane was mentioning I find interesting is that there are so many things that we do where we're trying to be objective.
I do think going forward, I definitely feel like even though it's uncomfortable learning this new thing, I feel like it makes sense. We'll get better at measuring things and I think that we'll be able to respond to changes better. You're going to hear us use the term "protocol" a lot. I've shared this analogy with Roxane in the past, but I feel like labor and delivery, sometimes it's a lot like baseball. It's a sporting metaphor here is that there's a lot of times when you're just going to be sitting around.
You'll be waiting for the ball to be hit to you. When you have in your head like if you're in center field and you know if that ball is hit to you, what base you're going to throw to, same with protocols. I know exactly where I'm going to go with what's next. You have to think about that each time because even though we have some predictors that we'll get into, when it happens, you have to be ready in that moment and know where you're throwing.
[Dr. Christopher Beck]
All right, excellent. All right, so we know some quantitative numbers for postpartum hemorrhage. Do you guys make any distinction between early-late postpartum hemorrhage? Can you talk about maybe some of the timing issues regarding hemorrhage? Of course, you're counting laps and you're trying to have an idea of how much blood loss, but then there's also the clinical picture of what's the patient doing on the table or on the field.
[Dr. Roxane Rampersad]
Sure, so acute and late are how we differentiate the blood loss. Acute is within that first 24 hours and late is beyond that 24 hours and really up to 12 weeks is how we differentiate blood loss.
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4 T's of Postpartum Hemorrhage
When time is of the essence and determining the cause of a patient’s postpartum hemorrhage is crucial for proper management, obstetricians utilize the timing of the bleeding and other clues to help them narrow down the differential. The four 4's of postpartum hemmorrage refer to the causes, which include: tone (uterine atony), trauma (laceration), tissue (retained placenta), and thrombin (coagulopathies). For operative deliveries, providers should remain alert to ensure they do not miss a laceration. During a Cesarean section (C-section), uterine atony can be ruled in or out based on the physical exam. Oxytocin is administered at high rates after the delivery of the baby which causes contraction of the uterus in order to decrease blood loss. If blood loss increases to a concerning level, physicians expedite the delivery of the placenta. For ongoing bleeding, an ultrasound may be administered to check for retained products.
[Dr. Anthony Shanks]
I think in terms of the definitions, this early and late, that first 24 hours versus after, they may clue you in on what's happening for the non-OBGYNs that are listening to this. We always talk about the four T's of postpartum hemmorage, which are the causes of it. Now, we know it's going to be 1,000 ccs. Irregardless of delivery, we're going to quantitatively define it.
Those four T's of postpartum hemmorrhage stand for tone, trauma, tissue, and then thrombin is the last one. That's the order. When we say "tone," we think about uterine atony. You've got a uterus that's been working. All of a sudden, it doesn't want to. It doesn't want to clamp down. That's a big cause of that and the most common one. Trauma. If you had a vaginal delivery that needed an operative delivery, maybe you did forceps. You may have a laceration that needs to be addressed. That's the second most common.
The pathways that you do to fix that are going to be different. The third one is tissue. Did you leave something behind? Is this like a placenta accreta or maybe you had an accessory lobe that's still in there? Then the last one, the thrombin is just defects in the coagulation pathways. I think whether it's early or late, thinking about those four T's of postpartum hemmorhage will help triage in your head what you're going to do at that time.
[Dr. Christopher Beck]
You were saying that sometimes the timing drives you in a certain differential, so how does the timing play into whether you think it's either atonic uterus versus trauma?
[Dr. Anthony Shanks]
Well, I think, actually, the clinical scenario that you're doing, I think I'm much more hyper-alert for possible lacerations if it's an operative delivery. If you're doing a vaginal delivery that's complicated for a large baby, you'll be ready for that. When you're in a C-section, you're right there, hands on the uterus. You know right away whether there's issues with tone. The first thing is you work through there. Whether it happens in the first 24 hours or the next 24 hours, I'm still thinking in that same pathway and what I'm going to do.
[Dr. Christopher Beck]
All right, so we can do it a couple of different ways. You can set the scene for a standard patient and how you work through this differential or work through your algorithm, or you can just talk about it either way. Roxane, do you want me to start with you?
[Dr. Roxane Rampersad]
Sure, so I think postpartum hemorrhage is always on every obstetrician's mind after the birth of a child. One of the things that happen is that we start oxytocin after the delivery of that baby. That's to help the uterus contract to allow us to decrease the blood loss.
[Dr. Christopher Beck]
That's regardless, that's all deliveries?
[Dr. Roxane Rampersad]
Really every delivery in the United States who has an IV hooked up. Most patients are on oxytocin already, but oxytocin is usually in the room and it's ready for that birth. After that birth, it's initiated. We initiate it before the delivery of the placenta. We have that going. It's at a really high rate and that is all to have that uterus contract down. At the same time while we're trying to deliver that uterus-- I'm sorry, that placenta-
[Dr. Christopher Beck]
Sure.
[Dr. Roxane Rampersad]
-we're watching, right? We're watching the blood loss. It can pick up. If it starts to pick up and it starts to increase and we're concerned about it, then I think that mobilizes a lot of people in the room that maybe we're starting to have a hemorrhage. We expedite delivery of the placenta. If that bleeding is ongoing, we start to feel that uterus. If it's atonic, meaning it feels soft, it doesn't feel contractile, then we know likely this is an atonic uterus.
Atony is the most common reason why patients have postpartum hemorrhage. At the same time, while you're massaging, trying to firm that uterus up and you're increasing your oxytocin, you're looking around. You're making sure you're not having any lacerations. You're going into your mind, "Am I hitting any of those 4 T's like Tony mentioned? Do I have any lacerations? Do I think I could have retained tissue?"
Often, if that bleeding is ongoing, we're bringing in the ultrasound. We're checking to make sure we don't see any evidence of retained products. We're looking also at the blood. Is it clotting? If we start to see clots, we don't think that patient is in DIC. We don't think the coagulation cascade is affected. What we're feeling and what we're seeing helps to guide that management.
Future Technology to Prevent Postpartum Hemorrhage
Engineers continue to explore technology that could assist in preventing postpartum hemorrhage before it occurs. Current endeavors include the design of wearable technology that could track a patient’s hemodynamic state, allowing doctors to stay ahead of the condition. The ”heads up“ that technology like this provides would allow for preemptive measures, such as expedited delivery, vessel ligation, or transfusion preparation, to be taken before excessive blood loss occurs. Personalized medicine technology with extensive vital tracking capacity has the potential to change the way postpartum hemorrhage is assessed and addressed.
[Dr. Anthony Shanks]
All right, so let's think future state. We've covered, Roxane, what things are like now. What are we working on with Jada and everything? We have the protocols. Specifically, with postpartum hemorrhage, what do you think we need to be cognizant of? Where do you think things are going? What do you think we could potentially do to offset this in the future?
[Dr. Roxane Rampersad]
Gosh, Tony, that's a really good question and blew my mind here. I don't know besides [chuckles] tamponade and what else we can do. You know what? Actually, let me take that back. I think one of the things that's really exciting that potentially could help us are these devices that engineers are looking at that are wearable, that potentially could let us know about the hemodynamic state before we're behind the eight ball because that's the issue, right, is that oftentimes when we recognize it, that patient could be already behind the eight ball and we're trying to catch up.
I think that would be an amazing thing. Patients would come in. They would be laboring or they could be in the operating room. They would wear some sort of optical device that's looking at that volume and hemodynamic states. That could clue us in, "Hey, your patient is going to be in trouble." Start doing these things potentially. Maybe you need to start thinking about transfusion ahead of time, or maybe you need to start thinking about ligating vessels or being more expedient with your surgery. That, I think, could be something in the future that could really help us.
[Dr. Anthony Shanks]
Yes, I love to think about these moonshots. I think that's how you get these big developments, not just in medicine but in anything. It's usually something that's a little bit outside of the box. I love the idea of personalized medicine. That's just one aspect of it. Certainly, in the most acute of settings that you can keep track of that person's vital signs before they get too sick.
I think in terms of the etiology for these postpartum hemorrhages, we've had such a focus on creating a diagnosis and preparation. Boy, I wish there was a way to prevent it. If there was some way, maybe after a delivery that you could apply something on the inside of a non-pregnant uterus that can reestablish a stable wall internally. Again, pie in the sky. That may be something 50 years down the road. Somebody will be able to figure out, but I think that would be cool.
Podcast Contributors
Dr. Roxane Rampersad
Dr. Roxane Rampersad is a professor and practicing OBGYN with Washington University School of Medicine in St. Louis.
Dr. Anthony Shanks
Dr. Anthony Shanks is a professor of clinical obstetrics and gynecology with the Indiana University School of Medicine.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2022, November 15). Ep. 4 – IR/OB Collaboration in Treating Postpartum Hemorrhage [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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