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.

PATHOPHYSIOLOGY OF UTERINE ATONY AND POSTPARTUM HEMORRHAGE

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 venous system, decreasing blood flow through the spiral arteries and allowing coagulation. Cesarean hysterectomy provides definitive management of any uterine source of bleeding.

Other causes of PPH (see Table 68-1) include trauma to the reproductive organs and coagulation disorders of the mother. Cervical and vaginal trauma may result from vaginal delivery and may result in significant blood loss if not repaired quickly. Uterine trauma may result from uterine rupture or from extensions into the uterine or cervical arteries during cesarean delivery.

For hemorrhage related to atony, uterotonic agents should always be used as the first-line therapy, whether the delivery is vaginal or via C-section. However, the obstetrician should not hesitate to move forward with procedural management in a patient who has not responded quickly to medical management. The threshold for moving to procedural management will depend on several factors (listed in Box 68-1), including the patient’s hemodynamic status, rate of blood loss, starting hemoglobin concentration, medical comorbidities, partial versus intermittent or absent response to medical therapy, and the level of suspicion for complicating factors, such as focal placenta accreta. If prolonged delay occurs between medical management and initiation of procedural management, the patient becomes at risk for development of life-threatening coagulopathy, which may make the conservative procedures less effective and necessitate more aggressive surgical management. Procedural management should always be performed in conjunction with appropriate resuscitation of the patient, including activation of the massive transfusion protocol when indicated. If the physician is moving forward with procedural management of hemorrhage, anesthesia and nursing staff should always be notified promptly, and appropriate backup called if needed.

PPH, regardless of route of delivery, is defined by the American College of Obstetricians and Gynecologists (ACOG) as cumulative blood loss of ≥1000 mL or blood loss accompanied by signs or symptoms of hypovolemia. However, providers should not wait until that definition has been met before intervening if abnormally brisk bleeding is noted after delivery. After vaginal delivery, if medical management and uterine massage have failed to stop the bleeding, careful inspection (or reinspection) of the vagina and cervix should be performed to exclude lacerations as a source of the bleeding.

Depending on the severity of the bleeding, adequacy of anesthesia, stability of the patient, and the immediate availability of necessary resources, the initial steps in evaluation and procedural management of refractory PPH may be appropriately performed at the bedside or may need to be undertaken in the operating room. Bimanual examination should always be performed to evaluate for retained products of conception.

If careful examination does not elucidate a cause of bleeding other than generalized atony, intrauterine balloon placement should be the first-line treatment of hemorrhage after vaginal delivery. If the intrauterine balloon fails to control the hemorrhage adequately, the patient then needs to be taken emergently to the operating room for exploratory laparotomy. Then the uterus should be evaluated and, if possible, attempts should be made to control the bleeding with uterine compression sutures or uterine artery ligation. Peripartum hysterectomy generally should be used as a last resort, given the high morbidity of the procedure and its impact on future fertility.

For hemorrhages related to trauma, the first-line therapy should be tailored to the specific cause of hemorrhage. As mentioned previously, common causes of trauma-related hemorrhage are surgical extensions into the uterine vessels, uterine rupture, and cervical and vaginal lacerations.

The definition of PPH and the threshold to begin intervention at the time of cesarean delivery are the same as for vaginal delivery. Although atony is the most common cause of blood loss at time of C-section, the uterus should be inspected carefully for other causes. Extensions into the uterine vessels and broad ligament can cause significant blood loss and should be identified and repaired quickly. These are usually best repaired by uterine artery ligation, and uterine compression sutures are unlikely to be effective in these cases.

For hemorrhage related to atony and refractory to medication, uterine compression sutures should be performed first, given the lower incidence of complications compared to uterine artery ligation. If uterine compression sutures, intrauterine balloon placement, or both have failed, then uterine artery ligation is an appropriate next step, as it may allow resuscitation to catch up to the patient’s blood loss, although it will not improve uterine tone. If all other options have been exhausted and hemorrhage continues, cesarean hysterectomy is indicated.

Although the atmosphere during PPH can often be chaotic, it is always important to pause and discuss what is happening with the patient and her family (Box 68-2). Prior to moving the patient to the operating room, in the event that medical management has failed, all possible procedures should be explained and consent obtained. If the patient is unstable or unconscious, discussion may be had with the family instead. It is most important to stress to the patient the uncertainty that exists about which procedures may be required, and to always address the possibility of a hysterectomy should more conservative measures fail. In addition, the risk for a return to the operating room and the possible need for uterine artery embolization should bleeding continue ideally will be addressed prior to the first trip to the operating room.

As discussed in Chapter 13, the importance of effective communication among team members is paramount to ensure optimal patient outcomes during any obstetric emergency. As soon as PPH is recognized and it is noted that medical management may not be effective, the team should start preparing for all possible next steps. The hemorrhage cart should be called for if it has not already been brought to the bedside. The hemorrhage cart should contain an intrauterine balloon, a large (60 mL) syringe to facilitate balloon inflation, and 1 L of sterile saline. An ultrasound should be brought to the bedside. If not previously activated, the massive transfusion protocol should be activated and a complete blood count (CBC), fibrinogen, and prothrombin time/international normalized ratio (PT/INR) and aPTT should be drawn. The operating room staff should be alerted for the possible need of an exploratory laparotomy, and the operating room should be set up with a laparotomy tray, hysterectomy tray, and a vaginal tray in case vaginal trauma is identified. If not already in place, a Foley catheter should be placed in the bladder for the monitoring of urine output. Backup should be identified and called in if necessary. Interventional radiology may also be alerted at this time. Box 68-3 gives the preprocedure checklist.