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A clinical review of Postpartum Hemorrhage (PPH). Explore the etiology, including the 4 Ts, risk assessment, and current protocols for management and prevention.
Initiate vigorous bimanual uterine compression upon identifying blood loss exceeding 500 mL following a vaginal delivery or 1000 mL after a cesarean section. Concurrently, administer a first-line uterotonic agent. A standard protocol is 10 IU of oxytocin via intramuscular injection or as a component of a slow intravenous infusion. This direct physical and pharmacological intervention is the primary response to control profuse bleeding after delivery.
The principal reason for this acute event, representing nearly 80% of incidents, is uterine atony. This state signifies the failure of the myometrium to contract adequately after placental separation. This absence of muscular tone leaves the spiral arteries at the placental implantation site open and uncompressed, permitting rapid and significant depletion of blood volume. Identifying a soft, boggy uterus on palpation confirms this diagnosis.
While uterine atony is the most frequent cause, a methodical assessment must exclude other origins of severe bleeding. These include genital tract trauma, such as deep cervical or high vaginal lacerations; retained placental fragments that prevent full uterine contraction; and underlying coagulation defects. If initial management with massage and oxytocin proves insufficient, prepare for second-line agents like tranexamic acid and escalate to procedures such as balloon tamponade or surgical intervention.
Activate the institutional massive transfusion protocol for any estimated blood loss exceeding 1,500 mL or in the presence of clinical signs of shock. The primary management goal is to identify and treat the specific cause of excessive after-birth bleeding.
Initial simultaneous actions include:
A systematic evaluation of the four main causes (the "4 Ts") must be performed immediately.
If uterotonic medications fail to control uterine bleeding, escalate to mechanical or surgical interventions.
Initiate bimanual uterine compression immediately upon identifying excessive postpartum blood loss. Place a gloved hand inside the vagina, forming a fist against the anterior fornix. Use the other hand to apply firm pressure on the abdomen over the uterine fundus, compressing the uterus between both hands. This action provides direct mechanical tamponade to bleeding vessels and stimulates myometrial contraction. Maintain this pressure until the uterus becomes firm.
If uterine bleeding after delivery persists, apply external aortic compression. Locate the abdominal aorta just superior to the umbilicus and slightly to the left. Apply downward pressure with a closed fist, aiming to compress the vessel against the vertebral column. This technique reduces arterial inflow to the pelvis, serving as a temporary measure while other interventions are prepared.
Concurrently, position the patient with her feet elevated (Trendelenburg position) to augment central circulation. Administer high-flow oxygen at 10 to 15 liters per minute via a non-rebreather mask. Secure two large-bore intravenous lines, 14 or 16 gauge, and begin a rapid infusion of warmed crystalloid solution, replacing estimated volume loss at a 3:1 ratio.
Continuously track vital signs, including blood pressure, pulse, and oxygen saturation, at five-minute intervals. Insert an indwelling urinary catheter to monitor renal perfusion; target an output of at least 30 milliliters per hour. A soft, boggy uterus on abdominal palpation confirms atony, while a firm uterus suggests another source for the severe postnatal bleeding, such as a cervical or vaginal wall tear requiring direct inspection.
Initiate treatment with Oxytocin as the first-line uterotonic agent to manage uterine atony after delivery. Administer 10 to 40 units in 500 mL to 1000 mL of a crystalloid solution, such as Normal Saline or Lactated Ringer's, as a continuous intravenous (IV) infusion. Adjust the rate to achieve and maintain adequate uterine tone. An alternative is 10 units administered intramuscularly (IM).
If uterine tone is not restored and excessive bleeding continues, proceed to a second-line agent. Administer Methylergonovine 0.2 mg IM. This dose can be repeated in 2-4 hours if needed. Do not administer to https://bet-at-homecasino.de with hypertension or preeclampsia due to its vasoconstrictive effects.
An alternative or subsequent second-line agent is Carboprost Tromethamine (15-methyl prostaglandin F2a). Administer 250 mcg IM. Repeat doses are permissible every 15-90 minutes, up to a maximum total dose of 2 mg (8 doses). Avoid use in patients with active asthma because of its bronchoconstrictive properties. Pre-treatment with an antiemetic and an antidiarrheal agent can mitigate common side effects.
For refractory cases of uterine atony, consider Misoprostol (prostaglandin E1 analogue). The recommended dosage is 600-1000 mcg administered as a single dose. Routes of administration include sublingual, buccal, or rectal. The rectal route provides a sustained effect and may produce fewer systemic side effects like shivering and pyrexia compared to other routes.
Preparation: Position the patient in dorsal lithotomy. Insert an indwelling urinary catheter to completely empty the bladder. Inspect the tamponade device for integrity and confirm the valve functions correctly. Prepare 500 mL of sterile saline and a large-volume syringe, typically 60 mL.
Catheter Insertion: Grasp the anterior cervical lip with ring forceps to stabilize the uterus. Manually guide the catheter tip through the cervix and into the uterine cavity. Advance the device until its tip reaches the uterine fundus. Abdominal ultrasound can be used to verify correct fundal placement before inflation.
Balloon Inflation: Begin filling the balloon with sterile saline. Instill the fluid in increments, observing for any continued heavy bleeding from the vagina. The target inflation volume is typically between 300 and 500 mL. Stop inflation if you meet firm resistance or if the patient expresses intense pain, as this may signal uterine rupture or overdistension.
Positioning and Tamponade: After inflation, apply gentle downward traction on the catheter shaft. This action pulls the balloon down to sit snugly against the internal cervical os, applying direct pressure to the lower uterine segment blood vessels. The drainage port must remain external to the vagina to allow for monitoring of ongoing blood loss.
Confirmation and Monitoring: A significant reduction or stop in blood flow from the drainage port and vagina indicates successful tamponade. Secure the catheter to the patient's thigh with tape, maintaining light tension. Connect the drainage port to a calibrated collection bag to accurately measure any subsequent blood accumulation. Regularly palpate the uterine fundus to assess for firmness and monitor the patient's hemodynamic status.
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