The Case of Mary Twale

Mary is a 34 year-old pregnant woman who is admitted to the labour and delivery unit in a rural hospital. She is at 39 wees gestational age and this pregnancy has been uneventful. However, during her first pregnancy, she bleed sufficiently to require a transfusion.

 

She has been having contractions for the past eight hours, and she thinks her 'water broke' two hours ago. Her cervix is 6 cm dilated.

Postpartum hemorrhage (PPH) is defined as:

• blood loss greater than 500 ml for vaginal delivery
• blood loss greater than 1000 ml for Cesarean section

Causes and risk factors for PPH include the four T's:

decreased Tone, also known as atony, when the uterus fails to appropriately contract after birth: prolonged or precipitous labour previous PPH large infant induction or augmentation infection Tissue retained placenta, blood clot fibroids, other uterine anomalies

Trauma spontaneous laceration to the vagina or cervix episiotomy increased risk with instrument delivery uterine rupture Thrombin coagulopathy thrombocytopenia sepsis disseminated intrvascular coagulation anti-coagulant medications

Steps to take to prevent PPH include:

• administration of IM or IV oxytocin with delivery of the anterior shoulder
• massage of the uterus to increase contraction
• active delivery of the placenta, with adequate traction

 

 

 

 

 

Oxytocin was given during the delivery of the anterior shoulder, but after delivery of the placenta, Mary indeed begins bleeding profusely.

PPH can be a life threatening emergency.

Steps to take include:

• ask for help
• provide IV fluids (normal saline or ringer's lactate)
• begin or maintain an oxytocin IV infusion
• remove the placenta if still present
• provide bimanual compression of the uterus, feeling for and removing clots and placental tissue if found
• ask for blood to be maintained in reserve
• assess for, and repair, lacerations
• insert a bladder catheter to assess fluid status and reduce pressure on the uterus

Send bloodwork for:

• CBC
• type and screen
• consider coagulation studies

An ultrasound can be helpful in assessing for retained products in the uterus, especially in late-onset hemorrhage.

 

 

 

You have an IV running with normal saline bolus and oxytocin, and only a minor laceration of the vagina was noted. The uterus remains boggy.

 

 

Along with oxytocin, other medications that can be used include:

• misoprostol
• ergometrine - caution with hypertension
• methylergonovine (Methergine)
• 15-methyl prostaglandin (Hemabate)

Inspect blood in an unheparinized tube for clotting; if blood remains liquid after x min, consider transfusion of platelets and coagulation factors.

If the uterus remains atonic, prepare for the OR. Surgical interventions can include:

• hematoma drainage
• uterine packing
• B-lynch compression sutures following laparotomy
• hysterectomy