Jorge Garcia, MD
Healthy 32 yo G2P1+0.
Previous C/S 2 years back
Augmented vaginal delivery with vacuum extraction, with episiotomy On admission uterus will contracted. Lochia normal
Second day Patient complaining of continues sever pain prescribed as pressure on the rectum side which was not relieved by analgesia. Lochia was minimal, episiotomy site is clear.
Glycerin Suppository inserted
Patient called she started bleeding per vagina.
Upon fundal palpation; Atony in left lateral position
Speculum used to examine vagina, bleeding increase. Clots noted Tachycardiac, BP maintained. Syntocine 40 units plus Methergine injection given.
Patient fainted, crush call announced. IV fluids started sent to OT for laboratory
Postpartum Hemorrhage Definition
Mean blood loss with vaginal delivery:
> 1000cc is “hemorrhage”
Mean blood loss with C/S: 1000cc
>1500cc is “hemorrhage”
Seen in ~5% of deliveries.
Early vs. Late
Most authors define early as < 72h.
ALSO defines it as
Most patients with hemorrhage have none.
Pre-eclampsia (RR 5.0)
Previous postpartum hemorrhage (RR 3.6)
Multiple gestation (RR 3.3)
Previous C/S (RR 1.7)
Intrapartum Risk Factors
Prolonged 3rd stage (>30 min) (RR7.5)
medio-lateral episiotomy (RR4.7)
midline episiotomy ( RR1.6)
Arrest of descent (RR 2.9)
Lacerations (RR 2.0)
Augmented labor ( RR1.7)
Forceps delivery (RR 1.7)
Easy to miss
Physicians underestimate blood loss by
Slow steady bleeding can be fatal
Most deaths from hemorrhage seen after 5h
Abdominal or pelvic bleeding can be
Always look for signs of bleeding
Estimate blood loss accurately.
Evaluate all bleeding, including slow bleeds.
Vital sign Changes (Tachycardia, hypotension,
Abdominal Signs ( pain, flabby uterus, higher
fundal height, distended abdomen)
Pale, weakness, anxiety
Identify possible post partum hemorrhage.
Simultaneous evaluation and treatment.
Use O2 4L/min.
If bleeding does not readily resolve, call for
Start two 16g or 18g IVs.
ALSO’s 4 Ts
Tone (Uterine tone)
Tissue (Retained tissue--placenta)
Trauma (Lacerations and uterine rupture)
Thrombin (Bleeding disorders)
“Tone: Think of Uterine Atony”
Uterine atony causes 70% of hemorrhage
Assess and treat with uterine massage
Use medication early
Consider prophylactic medication...
Bimanual Uterine Exam
Confirms diagnosis of uterine atony.
Massage is often adequate for stimulating
Medications for Uterine Atony
1. Oxytocin promotes rhythmic
Give IM or IU, not IV. (Can cause BP)
40U/L at 250cc/h.
2. Methergine 0.2mg (1 amp) IM
3. Hemabate 0.25mg IM q 15min (max
Causes tetanic uterine contraction.
May trap placenta.
Can cause Hypertension, especially IV.
Contraindicated in hypertensive patients
and those with pre-eclampsia.
Prostaglandin F2 15-methyl
Hemabate 0.25mg IM or IU.
Used to be called Prostin.
Controls hemorrhage in 86% when used
alone, and 95% in combination with above.
Can repeat up to eight times.
Contraindicated in active systemic diseases.
Can cause nausea/vomiting/diarrhea, BP.
Results from a tear in the rectovaginal septum (which is normally a tough, fibrous, sheet-like divider between the rectum and vagina). Rectal tissue bulges through this tear and into the vagina as a hernia....
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