Postpartum Hemorrhage

Question 1

Uterine atony treatment

Answer 1

Dilute IV oxytocin
Bedside uterine massage and compression
IM prostaglandin F2-alpha (Hemabate) or rectal misoprostol

Question 2

Postpartum hemorrhage definition

Answer 2

Loss of 500mL or more during vaginal delivery

Loss of 1,000mL or more during cesarean

Question 3

Uterine atony

Answer 3

Myometrium has not contracted to cut off the uterine spinal arteries, clinically manifested by boggy uterus

Question 4

When is Methergine used?

Answer 4

Treatment of uterine atony
Ergot alkaloid agent, induces myometrial contraction
Contraindicated in HTN

Question 5

When is Methergine contraindicated?

Answer 5

HTN due to risk of stroke

Question 6

Hemabate

Answer 6

Prostaglandin F2-alpha, stimulates myometrial contraction

Contraindicated in asthmatic patients

Question 7

Hemabate contraindication

Answer 7

Asthma due to risk of bronchoconstriction

Question 8

Risk factors for uterine atony

Answer 8

Magnesium sulfate 
Oxytocin use during labor 
Rapid labor and/or delivery 
Overdistention of the uterus (macrosomia, multifetal pregnancy, and hydramnios) 
Intraamniotic infection (chorio) 
Prolonged labor 
High parity

Question 9

Which artery should be ligated in uncontrolled post partum hemorrhage?

Answer 9

Internal iliac artery ligation

Uterine artery

Question 10

Which stitch can be used intraoperatively for post partum hemorrhage?

Answer 10

B-lynch

Question 11

Postpartum hemorrhage - palpation of the uterine fundus reveals firmness

Answer 11

Consider lacerations (surgical management) or coagulopathy (replace clotting factors)

Question 12

Postpartum hemorrhage - palpation of the uterine fundus reveals bogginess

Answer 12

Bimanual massage and IV dilute oxytocin

Question 13

If after interventions for postpartum hemorrhage, the patient continues to bleed

Answer 13

Two large bore IVs, Foley to empty bladder, call for blood, monitor vitals, move to OR

Question 14

Firm contracted uterus with persistent postpartum bleeding

Answer 14

Consider genital tract laceration
Consider accrete or retained placenta
No lacerations –> consider coagulopathy

Question 15

Secondary (late) postpartum hemorrhage (after first 24 hours)

Answer 15

Subinvolution of the placental site (usually occurs 10-14 days after delivery)

Question 16

Subinvolution of the placental site

Answer 16

Usually occurs 10-14 days after delivery
Treat with PO ergot alkaloid (Methergine)
Other treatment - IV dilute oxytocin, IM prostaglandin F2-alpha compounds (Hemabate)

Question 17

Uterine fundal tenderness, fever, and foul smelling lochia

Answer 17

Suspect endometritis

Question 18

How do you reduce the incidence of PPH?

Answer 18

Active management of the third stage of labor - give oxytocin immediately upon delivery, late cord clamping, and gentle cord traction with uterine countertraction with a well contracted uterus