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Obstetrics [POST-PARTUM HEMORRHAGE]

Introduction
Pregnant women have an expanded vascular volume so can
tolerate significant blood loss. You see a 1000cc blood loss in a
gangbanger and he's probably going to die. You see a 1000cc in
a delivery and mom will likely be fine. Post-partum hemorrhage,
however, is defined as 500cc for vaginal delivery and 1000cc
for C-section. Finding the cause of and stopping the bleeding is
critical. Surgery is ultimately the option, but there will be more
to do between blood loss and surgery.

1) Uterine Atony
The most common cause of post-partum hemorrhage. After
delivery, the uterus should contract down and the bleeding Most common cause of post-partum bleeding
should stop. But a tired uterus may fail to contract. Either the
oxytocin was on too long, the woman was just contracting for Large boggy uterus
too long, or tocolytics were onboard. If theres bleeding, most
OBs just assume it is atony. The uterus will feel boggy and
Massage uterus --> methylergometrine --> oxytocin
large. The treatment is to get the uterus contracting. It starts with
uterine massage. Medications can also be used to contract the
uterus. Start with methylergometrine (methergine). This is a Surgery is always the ultimate answer to all post-partum
smooth muscle constrictor that mostly acts on the uterus. If there hemorrhage
was oxytocin on board and its now off, turn the oxytocin back
on. Before going to surgery, also try hemabate (though this is
not the answer on the shelf).

2) Uterine Inversion
If theres a post-partum hemorrhage but the uterus cant be felt,
its likely an inversion. Caused by a defect in the myometrium, Post-partum hemorrhage + No palpable uterus
its imperative to keep the uterus in place. The diagnosis can be
made just by looking. Tack the fornices in place, then give
Do a speculum exam
oxytocin to contract the uterus back into the original position.

3) Retained Placenta Tack the fornices and oxytocin


Products of conception can be left behind. The uterus will be
firm and will fail to progress. This might also present as
continued bleeding weeks after delivery. The degree in which
the placenta has embedded defines the name of the disease.
Obviously, the deeper it is the harder it is to get out. Forgive the Normal placenta, blood
analogy, but it helps to make the idea stick. The uterus is a vessels not out to surface
vascular bed, much like an oil well. The placenta goes drilling
for blood. Sometimes it goes wide and sometimes it goes deep.
In a fresh uterus (no pregnancies) the vascular supply is rich and
the placenta does not have to go deep or wide. When the uterus
Comes out Stays in What we see
is used (multiple pregnancies) the placenta will go either wide
(placenta previa) or deep (retained placenta). So risk increases
Blood
with increasing pregnancies. The other way to get this disease vessels to
is if an accessory lobe or fractured placenta embeds deeply. edge
This will present with vessels that run to the edge of the
placenta, which is why we always inspect the placenta after
delivery. The first step is a dilation and curettage to get it out.
Accreta: endometrium
Failure results in a hysterectomy. An ultrasound or beta-
not into myometrium
quant can be used to follow post-delivery regression and as a
guide for treatment.
Percreta: to Serosa Increta: into
myometrium

OnlineMedEd. http://www.onlinemeded.org
Obstetrics [POST-PARTUM HEMORRHAGE]

4) Vaginal Lacerations
Every time theres a vaginal delivery check for lacerations of
both the vagina and cervix. Its especially important to check
during precipitous deliveries or macrosomic babies. The
uterus is normal but there will be obvious and visible
lacerations of the vagina. To fix, apply pressure to start. If they
don't stop bleeding or theyre obviously large (see the OB
operations content on episiotomies) do local anesthesia and
suture them closed. If an episiotomy has been done, youre
going to know to sew it back up.

5) DIC
Placental contents getting into mom's blood can cause an
embolism, but it can also cause DIC. If suspected, get a DIC
panel (platelets, INR, fibrinogen) if bleeding continues.

6) Unexplained Bleeding
Blood loss is a bad thing. If the patient continues to bleed its
necessary to move to operative control after all drugs fail.
Arterial ligation (uterine arteries then hypogastric arteries)
followed ultimately by hysterectomy if everything else fails.
Obviously, while she is losing blood monitor counts and
transfuse as needed (physiology before the number, as acute
blood loss will not be revealed on labs acutely).
Bleeding
>500cc Vaginal
>1000cc C-Section

Uterine Palpation
Boggy Absence Firm Normal Normal

Uterine Atony Uterine Inversion Retained Placenta Vaginal Laceration DIC

Massage Inspect Vagina Inspect Vagina DIC labs


Methergine Sew lacerations Sew lacerations
Oxytocin
Hemabate
Accreta Increta Percreta

Endometrium Myometrium Serosa


Everything
negative and
persistent
bleeding
Unexplained Bleeding
OR
Surgical Ligation
Hemodynamic Hysterectomy
instability

OnlineMedEd. http://www.onlinemeded.org