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  • How do we predict and prevent postpartum hemorrhage (PPH)?

  • What nonsurgical strategies are available for the management of PPH?

  • How do you recognize and manage uterine inversion?

CASE 41-1

A 31-y.o. G4 P4004 with a history of one cesarean delivery and successful VBAC has just delivered a 3.5-kg infant and is in the third stage of labor. You start oxytocin infusion immediately after the delivery of the infant and are actively managing the delivery of the placenta with gentle cord traction. Suddenly, the placenta delivers, and there is a larger-than-usual gush of blood, which continues at a brisk pace. You place your hand inside the vagina to begin bimanual massage and you feel a hard, round mass with a smooth surface. What is your next step?


The ability to anticipate, recognize, and manage PPH is a cornerstone of inpatient obstetric practice. It is not only critical that the obstetrician be well versed in its management but that facilities have the personnel, supplies, and equipment readily available to manage this obstetric emergency.

PPH continues to be one of the top causes of maternal mortality worldwide, responsible for up to a third of pregnancy-related deaths. In the developed world, hemorrhage is the most common reason for maternal admission to the intensive care unit (ICU), while in low-resource settings, obstetric hemorrhage is responsible for up to half of the postpartum deaths that occur.1,2 The incidence of PPH is dependent upon the definition used, but it is generally estimated to be 1% to 5% of deliveries.3,4 An analysis of temporal trends and risk factors for severe PPH reviewed 8.5 million deliveries in the United States A nationwide inpatient sample from 1999 to 2008 showed a rate of 2.8% for PPH, while 0.3% were complicated by severe PPH.4

Perhaps the most relevant fact is that obstetric hemorrhage is the most preventable cause of maternal mortality.5 Factors that contribute to mortality from hemorrhage are lack of obstetrical and anesthesia services and the availability of blood products. Recently, there have been state and national efforts to implement comprehensive hemorrhage protocols and patient safety bundles on obstetric hemorrhage. The common theme reiterated in contemporary hemorrhage management plans is the avoidance of “delay and denial”, as well as the active aggressive treatment of hemorrhage in earlier stages. Implementation of quality initiatives aimed at reducing morbidity and mortality from PPH has shown significant reductions in morbidity and has been proven successful in decreasing the rates of transfusion and hysterectomy.6,7


The definition of PPH is not standard in the literature, which makes it difficult to determine its true incidence. Historically, PPH has been defined by the volume of blood loss, either from estimated blood loss or through quantitative measurement. Typically, >500 ...

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