TABLE 1018 Physical Findings Cause and Treatment of Postpartum Hemorrhage

FIG. 101-1. Management plan for postpartum hemorrhage. (From American College of Obstetricians and Gynecologists: Postpartum Hemorrhage. Washington, 1998, with permission.)

The management of postpartum hemorrhage is dependent on stabilization of the patient and diagnosis of the cause of bleeding (see Table 101:8). If bleeding is massive, two large-bore intravenous lines should be started, CBC and clotting studies performed, and the patient typed and crossmatched for blood. A red-top tube should be kept by the bedside, and if a clot has not formed by 7 min, a coagulopathy, either causing the bleeding or resulting from the blood loss, may be present.

Good lighting and suction should be maintained. A speculum examination should be performed to inspect for trauma to the vaginal, vulvar, or cervical tissues. Any lacerations should be repaired after local anesthesia is provided. If a laceration is extensive, the patient should be taken immediately to the operating room.

If a mass is seen in the vaginal vault and the uterus cannot be palpated on the abdominal examination, the possibility of uterine inversion is strong. Emergency obstetric consultation is required.

If blood is seen to be coming from the cervix, the possibility of atony or retained products of conception is high. If atony is present and the uterus is large and doughy, the patient should be treated with oxytocin. It is administered by diluting 20 to 30 U in 1 L of normal saline or lactated Ringer's solution and infusing the fluid at 200 mL/h. Methylergonovine maleate, an alternative agent, can be given at a dose of 0.2 mg intramuscularly, has an onset of action of 7 min, and lasts for 2 h. This agent should not be used if hypertension or preeclampsia is present. Once bleeding is controlled, the patient can be discharged on an oral maintenance dose of 0.2 mg q6h.

If the uterus has good tone, the possibility of retained products of conception is high. An ultrasound study confirms the diagnosis.

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