It has been a busy day in your emergency department. The precipitous delivery that occurred at triage was complicated by shoulder dystocia. Luckily you had some help, and one of your colleagues is managing the neonatal resuscitation. Nurses are starting to congratulate mom and pat you on the back, when a senior nurse points out that the patient looks pretty pale. You glance at the monitor and notice a heart rate of 145 and only then do you notice that she is bleeding… a lot…
Call for help: Obstetrics should be involved ASAP.
Activate your massive transfusion protocol.
Palpate the uterus to assess for atony. Perform uterine fundal massage. If no response, apply bimanual compression with one hand below the uterus in the vagina and the other compressing from above through the lower abdominal wall.
Start medications to address uterine tone
- All patients get oxytocin: Either 10 units IM or 40 units in 1L NS, run open until the uterus is firm, then at 200ml/hr
- Other agents added as needed:
- Misoprostol 800mcg rectally (can also be given orally or sublingually)
- Methylergonovine 0.2mg IM
- Carboprost 250mcg IM (can repeat q15min to a max of 8 doses)
Start medications to address any potential coagulopathy. Until we see the results of the WOMAN trial, I would suggest starting tranexamic acid 1 gram IV on any woman who does not respond to oxytocin. Other medications that should be considered are:
- FFP and platelets as part of massive transfusion
- DDAVP for potential von Willebrand disease
- Factor replacement for hereditary hemophilia
- Cryoprecipitate for DIC
Examine the genital tract for retained products and trauma. If there are retained products in the uterus, remove them using blunt dissection with a finger. Suture any lacerations.
If there is ongoing bleeding, you are going to need to tamponade the bleeding. There are a number of options, depending on what is available in your department:
- A foley catheter is the mostly widely available option, but is small compared to the uterine cavity – you will probably need to use more than one
- Manually pack with 12-20 yards of 4 inch gauze
- A Rusch balloon filled with approximately 500ml of saline
- A Blakemore tube (fold the distal tip backwards and inflate the esophageal portion of the tube)
If you are unsuccessful at stopping the bleeding using a tamponade method, there are three advanced techniques that can be considered, depending on your resources:
- Transfer to interventional radiology for uterine artery embolization
- Transfer the patient to the OR for hysterectomy or uterine artery ligation (probably the most readily available option)
- Temporize with aortic compression or REBOA
Special Case: Uterine Inversion
Luckily rare, inversion of the uterus can result in life threatening hemorrhage, and requires a slightly different approach:
Like before, start fluid resuscitation and massive transfusion protocol.
You need to reduce the uterus to stop the bleeding. This is extremely painful and may require the OR and general anesthesia to accomplish.
Do not remove the placenta until the uterus has been reduced.
To facilitate reduction, stop the oxytocin infusion. Medications may be required to relax the uterus:
- Nitroglycerine 50mcg IV q2-3min
- Terbutaline IV infusion of 5mcg/min to start, can titrate up to 25mcg/min
- Magnesium 1-4 grams IV
Using one hand, push the fundus of the uterus directly back along the line of the vagina.
After replacement, restart the oxytocin drip (40 units in 1L NS at 200ml/hr)
Maintain firm pressure on uterus, through the introitus, until the uterus is firm
Primary differential of postpartum hemorrhage:
- Uterine Atony
- Retained uterine products
- Uterine inversion
- Genital tract trauma
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Other FOAMed Resources
Pope, Jennifer V. and Tibbles, Carrie D. (2012). The difficult emergency delivery. In: Winters, M.E. (Ed). Emergency Department Resuscitations of the Critically Ill. Dallas, Tx: ACEP.
Echevarria MA, Kuhn GJ. Chapter 104. Emergencies after 20 Weeks of Pregnancy and the Postpartum Period. In: Tintinalli JE et al. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381573
Desai S and Henderson SO. Chapter 181. Labor and Delivery and Their Complications. In: Marx JA et al. eds. Rosen’s Emergency Medicine, 8e. Philadelphia: Elsevier Saunders; 2014.
Ducloy-Bouthors AS, Jude B, Duhamel A, et al. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care. 2011;15:(2)R117. [pubmed]
WHO recommendations for the prevention and treatment of postpartum haemorrhage. 2012. Available at: http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf
ACOG “Management of Obstetric Hemorrhage” protocol available: https://www.acog.org/~/media/Districts/District%20II/PDFs/Final_Hemorrhage_Web.pdf