In the midst of a PPH, the patient typically has signs of acute blood loss, including tachycardia, hypotension, pallor, altered mental status, and decreased urine output.

Ongoing vaginal bleeding is usually present but can be concealed in the setting of a closed cervix after cesarean delivery. In this scenario, a large hematometra develops.

The uterus itself is often atonic, which can be appreciated directly in the setting of an open abdomen at time of cesarean delivery or can be ascertained through an abdominal examination after vaginal birth with the fundus palpated well above the umbilicus.

In rare cases, the uterus may have ruptured into the broad ligament or into one of the other retroperitoneal spaces, and the blood loss may be initially concealed.

The differential diagnosis for PPH includes uterine atony, retained products of conception, coagulopathy, uterine rupture and abnormal placentation; in addition to vulvar and vaginal hematoma, which are discussed elsewhere. Abnormal placentation includes placenta previa and placenta accreta spectrum.

The leading cause of peripartum hysterectomy is abnormal placentation, with uterine atony following closely behind (2).

PPH is first treated with uterine massage and evacuation of the uterus, as well as drainage of the urinary bladder if a catheter is not already in place.

Next, uterotonics are used, typically first with oxytocin, followed by carboprost, methylergometrine, and misoprostol.

Tranexamic acid (TXA) should be administered soon after diagnosis of PPH in addition to uterine massage and uterotonics. TXA has been shown to decrease the likelihood of death from bleeding in the setting of PPH, although its use may not decrease the chance of peripartum hysterectomy (3). Intrauterine balloon tamponade is often used in the setting of PPH; this has been shown to decrease the need for blood transfusion, peripartum hysterectomy, and intensive care unit (ICU) admission (4).

Uterine artery embolization can also be used to assist in the treatment of PPH in a hemodynamically stable patient.

Packed red blood cells and other blood products are often needed in the setting of PPH, particularly as coagulopathy prevents adequate treatment of uterine atony. The transfusion of blood along with appropriate blood products is preferred over large-volume crystalloid transfusion which may exacerbate dilutional coagulopathy. Blood and blood products accomplish both missions of addressing hypovolemic and anemic shock and reestablishing normal or maintaining functional coagulation.

Conservative operative techniques, such as curettage to remove products of conception, compressive sutures such as B-lynch and Cho stitches, and uterine artery ligature (e.g., O’Leary stitch) are often attempted prior to proceeding with hysterectomy.

Typically, the patient is positioned in the supine position because the procedure often immediately follows cesarean delivery.

Low lithotomy position (Figure 4.7.1) can be helpful to access the cervix if needed, to evaluate ongoing vaginal bleeding during the surgery, to delineate posterior and anterior vaginal fornix anatomy using vaginally placed instruments (i.e., end-to-end anastomosis [EEA] sizer), and to facilitate pre-/postoperative cystourethroscopy when indicated. A further advantage is that an assistant can be placed between the patient’s legs.

Peripartum hysterectomy may be performed as a planned procedure or as an emergent procedure. It may also be performed either after vaginal birth or after cesarean delivery.

In the setting of an unplanned hysterectomy, the delivery has often already occurred and most typically an incision on the abdomen has already been made. The most common type of abdominal incision for cesarean delivery is the Pfannenstiel incision, although a vertical midline incision may also have been made (Figure 4.7.2). A peripartum hysterectomy can be accomplished through either incision.

If a hysterectomy is planned, this is often owing to preoperative concern for placenta accreta spectrum. In this scenario, a vertical midline incision is often recommended. Surgical management of placenta accreta spectrum is discussed in Chapter 4.9.

Adequate visualization is best accomplished through the use of a self-retaining retractor such as a Bookwalter device (Figure 4.7.3) or Balfour retractor.