Postpartum hemorrhage is implicated in approximately 28 percent of pregnancy-related deaths. Since most postpartum hemorrhages occur in the first 24 h postdelivery, unless the delivery takes place at home or in a freestanding birthing center, such patients are unlikely to present to the emergency department. However, delayed hemorrhage may be seen days to weeks postpartum.
The differential diagnosis of hemorrhage in the period immediately following delivery includes uterine atony, uterine rupture, laceration of the lower genital tract, retained placental tissue, uterine inversion, and coagulopathy. After 24 h, retained products may cause bleeding. Other causes include uterine polyps or a coagulopathy, most commonly von Willebrand disease.
A history as to length and amount of bleeding should be obtained because physiologic bleeding takes place in the postpartum period and may be of variable duration, not uncommonly extending for periods of up to 5 weeks after delivery. The patient should be questioned about difficulty delivering the placenta. Manual delivery of the placenta increases risk of postpartum hemorrhage.
A careful history and physical examination should elicit the diagnosis in the majority of cases ( Table 10.1:8). The commonest cause of bleeding within the first 24 h is uterine atony. Normally, after delivery the uterus is firm, globular in shape, and palpable at or below the umbilicus. When uterine atony occurs, the uterine fundus is "doughy" in consistency and possibly palpable above the umbilicus. The best way to diagnose this is by abdominal palpation and bimanual examination. If the tone of the uterus is good but blood is seen to be coming from the cervical os, the possibility of retained products of conception or uterine rupture must be considered. Uterine rupture is more common after prior cesarean section as a result of separation of the scar. Prior uterine surgery and multiparity can also predispose to this complication. Very rarely, rupture occurs in the face of no prior risk factors. Another cause of bleeding is inversion of the uterus, which occurs most commonly after strong traction is placed on the umbilical cord in an effort to deliver the placenta. Replacement of the fundus is emergent and may require anesthesia. Diagnosis of the cause will allow proper treatment (Fig 101:1).
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