GENERAL MANAGEMENT OF PATIENTS WITH POSTPARTUM HEMORRHAGE
Postpartum hemorrhage is an unequivocal emergency; all available resources should be mobilized immediately upon its recognition.
A general approach to management is outlined in Box 12.2. Because most cases of PPH are caused by uterine atony, the uterus should be palpated abdominally, seeking the soft, “boggy” consistency of the relaxed uterus. If this find-ing is confirmed, oxytocin infusion should be increased and either methylergonovine maleate or prostaglandins administered if excessive bleeding continues.
Other questions that may help direct assessment include:
· Was expulsion of the placenta spontaneous and appar-ently complete?
· Were forceps or other instrumentation used in delivery?
· Was the baby large or the delivery difficult or precipitous?
· Were the cervix and vagina inspected for lacerations?
· Is the blood clotting?
While the cause of the hemorrhage is being identified, gen-eral supportive measures should be initiated (see Box 12.2). Such measures include large-bore intravenous access; rapid crystalloid infusions; type, cross match, and admin-istration of blood or blood components as needed; peri-odic assessment of hematocrit and coagulation profile; and monitoring of urinary output. The judicious use of blood component therapy is key to management. The mainstay of blood replacement therapy is packed red blood cells, with other components used as indicated for various dis-orders of the clotting cascade. See Table 12.1 for an out-line of blood products and their effects.
The management of PPH is greatly facilitated if patients at high risk are identified and preliminary preparations are made before the bleeding episode. Box 12.3 reviews such pre-liminary, precautionary measures.