Immediate Postpartum Hemorrhage

■ Postpartum hemorrhage denotes excessive bleeding (> 500 mL in vaginal delivery; > 1,000 for C-section) following delivery.

■ Blood loss during first 24 hours: "Early" postpartum hemorrhage

■ Blood loss between 24 hours and 6 weeks after delivery: "Late" postpar-tum hemorrhage

Causes

■ Coagulation defects

■ Uterine atony (myometrium cannot contract postpartum)

■ Ruptured uterus

■ Degrees of retained placental tissue

■ Bleeding from the placental implantation site

■ Trauma to the genital tract and adjacent structures

Most common cause is uterine atony. Normally the uterus contracts, compressing blood vessels and preventing bleeding.

Risk Factors

■ Blood transfusion/hemorrhage during a previous pregnancy

■ Coagulopathy

■ Vaginal birth after cesarean (VBAC)

■ Midforceps delivery

Management

1. Manually compress and massage the uterus—controls virtually all cases of hemorrhage due to atony.

2. Obtain assistance.

3. Give oxytocin (20 units in 1 L of lactated Ringer's) or mether-gonovine or prostaglandins if oxytocin is ineffective.

4. If not previously done, obtain blood for typing and crossmatching/be-gin fluid or blood replacement.

5. Carefully explore the uterine cavity to ensure that all placental parts have been delivered and that the uterus is intact.

6. Inspect the cervix and vagina.

7. Place Foley and monitor urine output.

If all this fails:

■ Hysterectomy or

■ Radiographic embolization of pelvic vessels or

■ Uterine artery ligation or hypogastric artery ligation

One unit of blood contains 500 mL.

Incidence of excessive blood loss following vaginal delivery is 5 to 8%.

CARPIT (pronounced "carpet")

Coagulation defect

Atony

Rupture

Placenta retained Implantation site Trauma w

The cause of the postpartum bleeding should be sought out and treated immediately.

Oxytocin should never be given as undiluted bolus because serious hypotension can result.

Increta = Invades Percreta = Penetrates

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