From the Guidelines
Management of postpartum hemorrhage at 5 hours with good uterine tone and bleeding from the os requires prompt investigation for genital tract trauma and possible retained placental fragments. The first step is to perform a thorough examination to identify lacerations of the cervix, vagina, or perineum that may be actively bleeding, as these are common causes of postpartum hemorrhage in the presence of good uterine tone 1. While preparing for examination, it is crucial to establish two large-bore IV lines, send blood samples for complete blood count, coagulation studies, and cross-matching, and begin fluid resuscitation with crystalloids to prevent hypovolemia and ensure adequate blood pressure 1. Monitoring vital signs closely and assessing blood loss are also vital components of management. If bleeding is significant, consideration should be given to transfusion of packed red blood cells, and administration of tranexamic acid 1g IV over 10 minutes (which can be repeated after 30 minutes if bleeding continues) to help stabilize clots, as supported by recent studies on the use of antifibrinolytic therapy in postpartum hemorrhage 1. Additionally, if examination reveals retained placental fragments despite good uterine tone, manual removal or curettage under ultrasound guidance may be necessary, and prophylactic antibiotics should be given if manual exploration or surgical repair is performed to prevent infection. The identification of the bleeding source is paramount since uterine atony has been ruled out by the good uterine tone, making genital tract trauma or retained placental fragments the most likely causes in this timeframe. Imaging modalities such as pelvic ultrasound or contrast-enhanced CT may be useful in diagnosing the cause of hemorrhage, especially if the source is not immediately apparent on physical examination 1. Overall, the management strategy should prioritize the stabilization of the patient, identification of the bleeding source, and appropriate intervention to control the hemorrhage and prevent complications.
From the Research
Management of Postpartum Hemorrhage (PPH)
- The management of PPH at 5 hours postpartum with good uterine tone and bleeding from the os involves identifying the underlying cause, estimating blood loss, and initiating a resuscitation protocol with fluid replacement, blood transfusion, and close monitoring of the woman 2.
- Since the patient has good uterine tone, the cause of bleeding is likely not due to uterine atony, and other causes such as retained placenta or obstetric trauma should be considered.
- The use of uterotonics, such as oxytocin, may not be effective in this scenario since the uterus already has good tone, and other management strategies should be considered.
Uterotonic Agents
- Oxytocin is the first-line uterotonic agent for the prevention of PPH, and its use has been shown to be effective in reducing the risk of PPH 3, 4.
- However, in this scenario, the patient already has good uterine tone, and the use of oxytocin may not be necessary.
- Other uterotonics, such as methylergonovine and carboprost, may be considered as second-line agents, but their use should be based on the underlying cause of the bleeding and the patient's individual needs 5, 6.
Specific Management Strategies
- The patient should be closely monitored for signs of hemorrhage, and fluid replacement and blood transfusion should be initiated as needed 2.
- A spec exam should be performed to identify the source of bleeding, and other diagnostic tests, such as ultrasound, may be considered to rule out retained placenta or other causes of bleeding.
- The patient's vital signs, including blood pressure, heart rate, and oxygen saturation, should be closely monitored, and interventions should be initiated to stabilize the patient as needed.