Priority Topic: Pregnancy

Key Feature 10a: In the patient presenting with clinical evidence of a postpartum complication (ex: delayed or immediate bleeding, infection): Diagnose the problem (ex: unrecognized retained placenta, endometritis, cervical laceration).
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation, Diagnosis

Key Feature 10b: In the patient presenting with clinical evidence of a postpartum complication (ex: delayed or immediate bleeding, infection): Manage the problem appropriately.
Skill: Clinical Reasoning, Selectivity
Phase: Treatment

Postpartum Hemorrhage
Postpartum hemorrhage is classified as blood loss greater than an estimated 500 mL after vaginal delivery or 1000 mL after Cesarean delivery, or after any amount of blood loss that compromises maternal hemodynamics. Although postpartum hemorrhage commonly occurs immediately or shortly after delivering the infant, significant bleeding after delivery is recognised as postpartum bleeding until 6 weeks postpartum. The etiologies for postpartum hemorrhage are remembered as the 4 Ts: Tone (uterine atony), trauma (uterine, cervical, or vaginal injury), tissue (retained placenta or clots), and thrombin (coagulopathy). It is standard of care to give women a dose of oxytocin immediately upon delivery of the infant to promote increased uterine tone after delivery and thereby decrease the risk of postpartum hemorrhage. However, uterine atony is still the most common cause of immediate postpartum hemorrhage. 

In the setting of active postpartum hemorrhage, the first thing the clinician needs to do is focus on getting the placenta out if still intrauterine, along with considering the ABCs. This will involve an immediate call for help and starting at least one large bore IV proceeded by fluid replacement as indicated. Blood will need to be collected for CBC, electrolytes including ionized calcium, creatinine, urea, liver function tests, type and crossmatch if blood transfusion may be needed, and coagulation studies in the setting of a suspected coagulopathy. Monitor maternal vital signs frequently, and transfuse red blood cells and fresh frozen plasma empirically if indicated, using O- blood if the type and crossmatch is not readily available. In the setting of a massive bleed, standard practice, at least in the large institutions I've worked in, is to have a massive transfusion protocol that can be activated.

If the uterus feels boggy rather than firm, uterine massage and giving more oxytocin is warranted. Additional uterotonics, such as ergotamine, may also be indicated, and UpToDate has a new recommendation to use tranexamic acid early as an adjunct in the medical management of PPH. The uterus can also be manually compressed by the clinician’s two hands to control bleeding while obstetrical help is on the way. Consider exploring the uterus for retained products if analgesia allows for this. Catheterizing the bladder is indicated to empty the bladder, which can promote uterine tone, but also to assist in monitoring volume status in the setting of an active bleed. Balloon catheter tamponade is a method of attenuating a severe bleed if operative management is not urgently available.

If the uterus is instead firm on palpation, the cause of the postpartum hemorrhage is less likely to be due to insufficient uterine tone (it is muscular uterine  tone that clamps down on bleeding vessels after placental separation). Commonly, lacerations of the vagina and sometimes the cervix are the major source of bleeding, and if so, will need to be repaired. Low-risk obstetricians are trained to repair first and second degree perineal repairs, but usually the third and fourth degree tear repairs fall under the purview of the obstetrician. It is important to anesthetize the area prior to suturing, ideally with epinephrine for its vasoconstricting properties. Packing may help to provide pressure to bleeding vessels and temporize the amount of blood loss while obstetrical help is on the way. If perineal repairs have taken care of any obvious sort of haemorrhaging lacerations but bleeding persists, manually exploring the uterus for retained tissue or clots and removing any that are found is needed, ideally in the OR. If there is a coagulopathy, then it will need to be corrected by way of administering platelets and cryoprecipitate, as indicated.

Endometritis
If a woman develops a fever greater than 24 hours but no longer than 10 days postpartum, she may have endometritis, which is an infection of the internal uterine lining that has the potential to spread systemically. The greatest risk factor for acquiring endometritis is having had a Cesarean section. Women typically present with fever and uterine tenderness, and they may also have a foul-smelling vaginal discharge or abnormal uterine bleeding. Trending a white blood cell count may be helpful to look for a rising neutrophil count as a sign of infection, but endometrial cultures are not indicated because rates of contamination on sample selection are just so high. Treatment is by way of broad-spectrum antibiotics to target the typical polymicrobial infection abrewing. Ongoing monitoring is important to ensure appropriate response to antibiotics, which are to be continued until the patient has had symptom resolution for 2-3 days.