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KEY QUESTIONS
What are the indications for procedural management of postpartum hemorrhage (PPH)?
How does the approach for management differ between vaginal delivery and cesarean section (C-section)?
What are the causes of significant hemorrhage other than atony, and how are they best managed?
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CASE 68-1
The patient is a 32-y.o. G3P2002 with chronic hypertension and poorly controlled A2 gestational diabetes who was admitted in active labor at 38 5/7 weeks gestation. She progressed to complete cervical dilation and 0 station and pushed for 2 hours, but was unable to make descent. She was taken for indicated cesarean delivery for arrest of descent at 0 station. The infant was delivered from the direct occiput posterior position with Apgars 8 and 9, weight 4100 g. No extensions were noted at the time of delivery, and the patient was taken to PACU in stable condition. Quantitative blood loss from surgery was 800 cc.
Then, 30 minutes after arrival to the PACU, the physician was called due to the passage of two large blood clots with uterine massage. A bimanual exam was performed, and another 600 cc of clot were evacuated from the uterus. The patient received carboprost and misoprostol, but she continued to have heavy bleeding, and bimanual massage revealed a persistently atonic uterus. Massive transfusion protocol was enacted, and the decision was made to move forward with procedural management.
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PPH, one of the most common obstetrical emergencies, is also one of the most manageable when acted upon quickly. Favorable outcomes are noted consistently when solid patient safety principles are enacted, as described in Chapter 13. Although it can be a cause of severe maternal morbidity and mortality, if recognized early and managed appropriately, maternal mortality can almost always be avoided. This chapter will focus on technical aspects of procedural management of PPH related to the following procedures: intrauterine tamponade, uterine compression sutures, uterine artery ligation, and peripartum hysterectomy. The overall approach, stages of hemorrhage, medical management, potential integration of procedures such as dilation and curettage or uterine artery embolization, and transfusion principles are discussed in Chapter 41.
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ANATOMY AND PATHOPHYSIOLOGY
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PATHOPHYSIOLOGY OF UTERINE ATONY AND POSTPARTUM HEMORRHAGE
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The most common cause of PPH is uterine atony, accounting for 80% to 85% of cases. Uterine atony results from failure of the myometrium to contract adequately following delivery of the fetus. When the myometrium fails to contract, the spiral arteries remain dilated, and hemorrhage results. Uterotonic medications and bimanual massage are first-line treatments to promote contractility of the myometrium to attempt to constrict the spiral arteries and decrease bleeding. Placement of an intrauterine balloon can result in tamponade of these arteries from within the uterus. A B-Lynch suture compresses the uterus and spiral arteries from the outside. Successful bilateral O’Leary stitches, or uterine artery ligation, will turn the high-pressure arterial system into a low-flow ...