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You have just assisted with a relatively uneventful spontaneous vaginal delivery of a 38-week newborn to a 29-year-old G1P0001 mother. During your immediate, postpartum maternal assessment, you notice a large amount of vaginal bleeding persisting.

Questions

1. What is the most common cause of this condition?
2. What are the two most important steps in managing this?
3. What are some of the other etiologies to think about?

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Answers

• The most common cause of post-partum hemorrhage is uterine atony and is responsible for up to 75% cases. The amount of bleeding can also be much greater than what is visible due to the flaccid and dilated uterus.
• The two most important steps in managing uterine atony are:
  • Performing bi-manual uterine massage to stimulate contraction
  • Administration of uterotonics
    • ALL women get oxytocin either:
      • 15 units in 250mL of LR
      • 10 units IM
    • If still bleeding after oxytocin:
      • Carboprost tromethamine (Hemabate) 0.25mg IM every 15min up to a max dose of 8mg
      • Methergine 0.2mg IM every 2-4 hours
      • Misprostol 400mcg (SL/buccal/rectal)

• Uterine atony is the most common cause of post-partum hemorrhage, but is responsive to uterotonics in most instances, so it is not the most common cause of massive transfusion. Other etiologies to think about are:
  • Retained placenta/membranes
  • Lacerations or rupture
  • HELLP syndrome
  • Abnormal placentation

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References

1. Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesthesia and analgesia. 2010; 110(5):1368-73. [pubmed]