Postpartum Hemorrhage

I thought this is an emergency medicine website…. It is but… information and reminders like this may save a patient that delivers in the ED or when no Doc is covering the floors late at night. These general concepts can also be applied to hemorrhage after spontaneous/incomplete abortion.

General causes:

• Uterine atony/failure of contraction
• Retention of a portion of the placenta, clots or retained products in uterus or os
• Damage to the genital tract (cervix laceration, vaginal wall lacerations)
• Coagulopathy (HELLP, underlying bleeding disorder)

Management (in a general order):

• Fluids, blood products and good resuscitation
• Fix coagulopathy
• Deliver the fetus and placenta (inspect the placenta to make sure it is all there)
• Bimanual massage -  one hand on the fundus and the other in the anterior fornix with compression between the two hands with a rocking motion (this also helps expel any clots in the uterus)
• Consider exploring and empty the uterine cavity manually if concern for retained products
• Visualize the cervix and vagina,  if significant bleeding…stitch the bleeders
• If uterine atony persists despite bimanual massage, then use medications to decrease the amount of bleeding: oxytocin (1st line, IV),  ergonovine (2nd line, IV), carboprost (2nd line, IM) (Note: 1000 mcg of misoprostol given rectally is likely effective for refractory bleeding after giving oxytocin, ergonovine, or both)
• Consider uterine packing (plain gauze, gauze soaked with 5000 U thrombin and 5 mL saline or a catheter placed and inflated)
• Always remember to have good lighting and large suction catheters
• Get help… OB, surgery, interventional radiology, or transfer if stable

Postpartum Hemorrhage. http://emedicine.medscape.com/article/275038-overview

Rajan PV, Wing DA. Postpartum hemorrhage: evidence-based medical interventions for prevention and treatment. Clin Obstet Gynecol. 2010 Mar;53(1):165-81.