Essential equipment

Sterile glovesMedications: Tranexamic acid, Pitocin, Hemabate, Methergine, CytotecAppropriate suturesGauze rollsRing forceps

Steps

  1. Recognize postpartum hemorrhage (PPH) as >500 mL after vaginal delivery or >1000 mL after cesarean section. PPH may occur early (within 24 hours of delivery) or late (24 hours to 6 weeks after delivery).

  2. Consult OB immediately.

  3. Obtain IV access and appropriately resuscitate the patient. Obtain appropriate labs (fibrinogen, CBC, PT/PTT, type and screen, etc.).

  4. Administer tranexamic acid as soon as possible.

  5. Palpate uterus via abdominal exam or bimanual exam.

  6. If the uterus is soft and boggy, the cause of PPH is likely uterine atony.

    • Begin firm manual massage of uterus while administering oxytocic agents (first line: oxytocin; second line: methergine, hemabate, cytotec).

    • If bleeding persists, begin bimanual uterine compression. Use one hand to compress and massage the uterus through the abdominal wall while using the fist of the other hand to gently massage the opposite wall of the uterus through the vagina. This helps compress both walls of the uterus against each other.

    • If bleeding persists, consider uterine tamponade with sterile gauze packing, specialized intrauterine balloon catheter, or placing a Foley catheter into the atonic uterine cavity until surgical intervention or arterial embolization can be performed.

  7. If uterus is firmly contracted, search for additional causes of bleeding

    • Inspect lower genital tract for lacerations.

      1. Control bleeding by direct pressure or by gentle application of ring forceps to bleeding cervical lacerations.

      2. Use absorbable sutures to control bleeding from accessible lacerations.

    • Inspect delivered placenta, and consider retained placental fragments. These may be removed by gentle manual extraction.

      1. This procedure is painful and associated with increased risk of infection, so analgesia and antibiotics should be administered.

      2. Use one hand to follow the path of the umbilical cord and find the maternal placental plane. Use the other hand to steady the uterine fundus through the maternal abdomen.

      3. The plane should feel velvety and irregular and should be gently dissected with side-to-side motion of the fingers until the placenta separates.

    • Consider coagulopathy.

      1. Replace appropriate blood components.

  8. If there is no palpable fundus, PPH may be due to uterine inversion. The diagnosis is made by visualization of palpation of the uterine fundus in the vaginal vault or protruding through the introitus. Immediate reposition of the uterus is required.

    • Procedural sedation or general anesthesia may be necessary.

    • Stop any oxytocic drugs and administer tocolytic agents (terbutaline, magnesium sulfate, nitroglycerine).

    • Insert one hand into the vagina, with the tips of the fingers at the uterocervical junction. Hold the uterine fundus firmly in the palm of the hand.

    • With the opposite hand, gently reposition the uterine fundus cephalad along the long axis of the vagina.

    • After replacement, begin fundal massage and/or bimanual massage/compression and administer oxytocin.