last authored: Dec 2011, David LaPierre
Mary is a 34 year-old pregnant woman who is admitted to the labour and delivery unit in a rural hospital. She is at 39 wees gestational age and this pregnancy has been uneventful. However, during her first pregnancy, she bleed sufficiently to require a transfusion.
She has been having contractions for the past eight hours, and she thinks her 'water broke' two hours ago. Her cervix is 6 cm dilated.
What is the definition of postpartum hemorrhage?
Postpartum hemorrhage (PPH) is defined as:
What are the causes and risk factors for postpartum hemorrhage?
Causes and risk factors for PPH include the four T's:
decreased Tone, also known as atony, when the uterus fails to appropriately contract after birth:
What may be done to prevent postpartum hemorrhage?
Steps to take to prevent PPH include:
Oxytocin was given during the delivery of the anterior shoulder, but after delivery of the placenta, Mary indeed begins bleeding profusely.
What are your initial managment steps?
PPH can be a life threatening emergency.
Steps to take include:
What investigations, if any, do you perform?
Send bloodwork for:
An ultrasound can be helpful in assessing for retained products in the uterus, especially in late-onset hemorrhage.
You have an IV running with normal saline bolus and oxytocin, and only a minor laceration of the vagina was noted. The uterus remains boggy.
What are your next management steps? What medications do you consider?
Along with oxytocin, other medications that can be used include:
Inspect blood in an unheparinized tube for clotting; if blood remains liquid after x min, consider transfusion of platelets and coagulation factors.
If the uterus remains atonic, prepare for the OR. Surgical interventions can include:
Mary's bleeding settles with administration of misoprostol and ongoing bimanual compression. Her vitals remain stable, and her bloodwork is normal. Her hemoglobin at the time of delivery is 112, but the next morning is 76. After discussion, she receives a unit of packed red blood cells to treat her anemia.
She hs an otherwise uneventful recovery and is discharged two days after her delivery.
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