How to Eliminate Postpartum Hemorrhage
Perform a uterine massage., Try bimanual compression if the massage does not work., Manually explore the uterine cavity if bimanual compression does not produce results., Remove any fragments found in the uterus., Use surgical methods to combat the...
Step-by-Step Guide
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Step 1: Perform a uterine massage.
The first step in managing this condition is a technique called bimanual uterine massage which is performed to try to stimulate the uterus to regain its tone.At the same time, administration of uterotonics (like oxytocin) should be carried out.
Uterine massage should only be carried out by a physician.
It involves elevating the uterus, by pressing on the fundus both internally (with one hand) and externally (with the other). -
Step 2: Try bimanual compression if the massage does not work.
If uterine massage fails to give the uterus some degree of "tone"
bimanual compression should be applied.
This is a similar maneuver to the uterine massage, with a more aggressive approach.
With bimanual compression, a firm pressure is applied by the physician with both hands (which are in similar positions as in uterine massage) in order to evoke a response from the uterine musculature. , Manual exploration of the uterine cavity is carried out by the physician, to try to find the cause of PPH.
Exploration of the uterine cavity should be performed in the operating room, in more sterile conditions, to minimize chances of contracting an infection.
The exploration may reveal some defects in the muscular wall of the uterus, as well as hematomas, or even uterine rupture, which can be seen if the patient had previous cesarean delivery or uterine surgery.
If any of these disorders are found during the exploration by the physician, operative intervention will be necessary. , During a manual examination, placental fragments that were retained in the uterus during birth may be discovered.
Removal of these fragments is essential in eliminating PPH, since they can be recognized as the source of bleeding.
Manual removal of these fragments or curettage are procedures by which these fragments are removed.
Curettage comprises surgical "scraping" of these fragments, with the use of a scoop. , In such cases, a laparotomy is performed to efficiently control and stop the bleeding, by promptly identifying the source of hemorrhage.
Laparotomy is a procedure carried out via a large incision on the abdominal wall, in order to gain direct access into the abdomen and uterus.
Depending on the findings, surgical suturing, ligation of blood vessels, and in severe cases, hysterectomy, are procedures that are indicated in PPH.
Suturing and ligation include management of the arterial supply to the uterus and the abdominal cavity.
Closing these arteries may effectively reduce and eliminate PPH.
Hysterectomy is performed only if these surgical procedures fail, and the patient is not hemodynamically stable. , Lacerations and hematomas resulting from birth trauma can cause significant blood loss that can be lessened by hemostasis and timely repair.
Sutures should be done if direct pressure does not stop the bleeding.
Episiotomy increases blood loss and the risk of anal sphincter tears, and this procedure should be avoided unless urgent delivery is necessary and the perineum is thought to be a limiting factor., A hematoma is a solid swelling of clotted blood within the tissue.
It can present as pain or as a change in vital signs disproportionate to the amount of blood loss.
Small hematomas can be managed with close observation.
Patients with persistent signs of blood loss despite fluid replacement, as well as those with large or enlarging hematomas, require incision and evacuation of the clot.
The involved area should be irrigated and the bleeding vessels ligated. , Uterine inversion is rare, occurring in
0.05 percent of deliveries.
The inverted uterus usually appears as a bluish-gray mass protruding from the vagina.
Every attempt should be made to replace the uterus quickly.
Once the uterus is reverted, uterotonic agents should be given to promote uterine tone and to prevent recurrence.
If initial attempts to replace the uterus fail or a cervical contraction ring develops, administration of magnesium sulfate, terbutaline (Brethine), nitroglycerin, or general anesthesia may allow sufficient uterine relaxation for manipulation.
If these methods fail, the uterus will need to be replaced surgically., Although rare in an unscarred uterus, clinically significant uterine rupture occurs in
0.6 to
0.7 percent of vaginal births, after a cesarean delivery in women with a low transverse or unknown uterine scar.The risk increases significantly with previous classical incisions or uterine surgeries, and to a lesser extent with shorter intervals between pregnancies or a history of multiple cesarean deliveries, particularly in women with no previous vaginal deliveries.
Before delivery, the primary sign of uterine rupture is decrease in fetal heart rate (bradycardia).
Vaginal bleeding, abdominal tenderness, maternal tachycardia (increased heart rate in mother), circulatory collapse, or increasing abdominal girth are also signs of uterine rupture.
Symptomatic uterine rupture requires surgical repair of the defect or a hysterectomy. , Classic signs of placental separation include a small gush of blood with lengthening of the umbilical cord and a slight rise of the uterus in the pelvis.
The mean time from delivery until placental expulsion is eight to nine minutes.
Longer intervals are associated with an increased risk of postpartum hemorrhage, with rates doubling after 10 minutes.
Retained placenta (i.e., failure of the placenta to deliver within 30 minutes after birth) occurs in less than 3 percent of vaginal deliveries.
One management option is to inject the umbilical vein with 20 mL of a solution of
0.9 percent saline and 20 units of oxytocin.
This significantly reduces the need for manual removal of the placenta compared with injecting saline alone.Alternatively, physicians may proceed directly to manual removal of the placenta, using appropriate analgesia.
If the tissue plane between the uterine wall and placenta cannot be developed through blunt dissection with the edge of the gloved hand, invasive placenta should be considered. -
Step 3: Manually explore the uterine cavity if bimanual compression does not produce results.
-
Step 4: Remove any fragments found in the uterus.
-
Step 5: Use surgical methods to combat the PPH.
-
Step 6: Use sutures to repair wounds caused by trauma.
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Step 7: Treat hematomas.
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Step 8: Revert the uterus in case of uterine inversion.
-
Step 9: Consider a cesarean delivery in the case of a uterine rupture.
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Step 10: Treat tissue retention.
Detailed Guide
The first step in managing this condition is a technique called bimanual uterine massage which is performed to try to stimulate the uterus to regain its tone.At the same time, administration of uterotonics (like oxytocin) should be carried out.
Uterine massage should only be carried out by a physician.
It involves elevating the uterus, by pressing on the fundus both internally (with one hand) and externally (with the other).
If uterine massage fails to give the uterus some degree of "tone"
bimanual compression should be applied.
This is a similar maneuver to the uterine massage, with a more aggressive approach.
With bimanual compression, a firm pressure is applied by the physician with both hands (which are in similar positions as in uterine massage) in order to evoke a response from the uterine musculature. , Manual exploration of the uterine cavity is carried out by the physician, to try to find the cause of PPH.
Exploration of the uterine cavity should be performed in the operating room, in more sterile conditions, to minimize chances of contracting an infection.
The exploration may reveal some defects in the muscular wall of the uterus, as well as hematomas, or even uterine rupture, which can be seen if the patient had previous cesarean delivery or uterine surgery.
If any of these disorders are found during the exploration by the physician, operative intervention will be necessary. , During a manual examination, placental fragments that were retained in the uterus during birth may be discovered.
Removal of these fragments is essential in eliminating PPH, since they can be recognized as the source of bleeding.
Manual removal of these fragments or curettage are procedures by which these fragments are removed.
Curettage comprises surgical "scraping" of these fragments, with the use of a scoop. , In such cases, a laparotomy is performed to efficiently control and stop the bleeding, by promptly identifying the source of hemorrhage.
Laparotomy is a procedure carried out via a large incision on the abdominal wall, in order to gain direct access into the abdomen and uterus.
Depending on the findings, surgical suturing, ligation of blood vessels, and in severe cases, hysterectomy, are procedures that are indicated in PPH.
Suturing and ligation include management of the arterial supply to the uterus and the abdominal cavity.
Closing these arteries may effectively reduce and eliminate PPH.
Hysterectomy is performed only if these surgical procedures fail, and the patient is not hemodynamically stable. , Lacerations and hematomas resulting from birth trauma can cause significant blood loss that can be lessened by hemostasis and timely repair.
Sutures should be done if direct pressure does not stop the bleeding.
Episiotomy increases blood loss and the risk of anal sphincter tears, and this procedure should be avoided unless urgent delivery is necessary and the perineum is thought to be a limiting factor., A hematoma is a solid swelling of clotted blood within the tissue.
It can present as pain or as a change in vital signs disproportionate to the amount of blood loss.
Small hematomas can be managed with close observation.
Patients with persistent signs of blood loss despite fluid replacement, as well as those with large or enlarging hematomas, require incision and evacuation of the clot.
The involved area should be irrigated and the bleeding vessels ligated. , Uterine inversion is rare, occurring in
0.05 percent of deliveries.
The inverted uterus usually appears as a bluish-gray mass protruding from the vagina.
Every attempt should be made to replace the uterus quickly.
Once the uterus is reverted, uterotonic agents should be given to promote uterine tone and to prevent recurrence.
If initial attempts to replace the uterus fail or a cervical contraction ring develops, administration of magnesium sulfate, terbutaline (Brethine), nitroglycerin, or general anesthesia may allow sufficient uterine relaxation for manipulation.
If these methods fail, the uterus will need to be replaced surgically., Although rare in an unscarred uterus, clinically significant uterine rupture occurs in
0.6 to
0.7 percent of vaginal births, after a cesarean delivery in women with a low transverse or unknown uterine scar.The risk increases significantly with previous classical incisions or uterine surgeries, and to a lesser extent with shorter intervals between pregnancies or a history of multiple cesarean deliveries, particularly in women with no previous vaginal deliveries.
Before delivery, the primary sign of uterine rupture is decrease in fetal heart rate (bradycardia).
Vaginal bleeding, abdominal tenderness, maternal tachycardia (increased heart rate in mother), circulatory collapse, or increasing abdominal girth are also signs of uterine rupture.
Symptomatic uterine rupture requires surgical repair of the defect or a hysterectomy. , Classic signs of placental separation include a small gush of blood with lengthening of the umbilical cord and a slight rise of the uterus in the pelvis.
The mean time from delivery until placental expulsion is eight to nine minutes.
Longer intervals are associated with an increased risk of postpartum hemorrhage, with rates doubling after 10 minutes.
Retained placenta (i.e., failure of the placenta to deliver within 30 minutes after birth) occurs in less than 3 percent of vaginal deliveries.
One management option is to inject the umbilical vein with 20 mL of a solution of
0.9 percent saline and 20 units of oxytocin.
This significantly reduces the need for manual removal of the placenta compared with injecting saline alone.Alternatively, physicians may proceed directly to manual removal of the placenta, using appropriate analgesia.
If the tissue plane between the uterine wall and placenta cannot be developed through blunt dissection with the edge of the gloved hand, invasive placenta should be considered.
About the Author
Susan Kelly
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