On Call Postpartum Hemorrhage management

The other night I was on call overnight and had an amazingly busy, scary, enlightening and highly educational night. I should have known I was up for a crazy call night when during sign out at the beginning of my call I was paged to the floor where a woman who had just recently delivered was hemorrhaging out. I quickly ran to the patient's room to find a panicked nurse and an even more panicked husband to see blood flooding out of the patients vagina. I would have to say that OB is probably one of the more bloody specialties. It seems like I am constantly changing my scrubs as they get drenched in blood . 

I immediately assessed the situation and realized that this had to be postpartum hemorrhage due to uterine atony or a laceration that had re-opened. I decided to go with the bimanual uterine massage because as I examined the patients abdomen I could tell that the uterus was in fact atonic, which means the uterus has failed to retract to its normal size and remains stretched out. This leads to massive hemorrhage and actual can cause maternal demise if not treated quickly.

Uterine atony is a loss of tone in the uterine musculature. Normally, contraction of the uterine muscle compresses the vessels and reduces flow. This increases the likelihood of coagulation and prevents bleeds. Thus, lack of uterine muscle contraction can cause an acute hemorrhage. Clinically, 75-80% of postpartum hemorrhages are due to uterine atony.

I place my whole hand into the vagina until I reached the uterus and squeezed down on it while using my other hand to squeeze the uterus by pushing on the patient's abdomen. You essentially mash the uterus between your hands on the inside and on the outside. This is painful for the patient and has to be performed quickly to reduce the risk of death. This procedure is effective and can dramatically reduce the bleeding and get the uterus to regain its tonicity. 

Fortunately this procedure worked and the massive hemorrhage began to subside as I continued to massage the uterus. I was sweating but remained calm which in turn calmed the family and the patient. I uttered out a few orders for the nurse to hang some medications and lactated ringers in addition to calling for some labs to determine how much blood was lost. These labs helped determine whether we needed to transfuse the patient.

Ultimately the patient did not need a transfusion and following the uterine massage I found a laceration that was up on the vaginal wall that needed further suturing. Most of the bleeding had stopped due to the uterine massage and the medications and I was able to stop the remaining trickle by repairing the laceration.

This was the start of my 24 hour call and I was only 1 hour in to my shift. I knew the night was going to be a blast. I love this job.

More to come….