What is the management for increased postpartum vaginal (PV) bleeding after a cesarean section (C-section)?

Management of Increased Postpartum Vaginal Bleeding After Cesarean Section

For increased postpartum vaginal bleeding after cesarean section, prompt administration of oxytocin (10-40 units in 1000 mL IV fluid) should be initiated as first-line management, followed by additional uterotonic agents if bleeding persists.

Initial Assessment and Management

First-Line Management

• Oxytocin administration:
  • IV infusion: 10-40 units in 1000 mL of non-hydrating solution at a rate necessary to control uterine atony 1
  • IM administration: 10 units after placental delivery can be given 1

Assessment of Bleeding

• Quantify blood loss (postpartum hemorrhage defined as ≥500 mL after vaginal delivery or ≥1000 mL after cesarean delivery) 2
• Monitor vital signs frequently for signs of hemodynamic instability
• Assess uterine tone through abdominal palpation
• Examine for retained placental fragments or lacerations

Escalation of Management for Persistent Bleeding

Second-Line Interventions (if bleeding continues despite oxytocin)

1. Additional uterotonic agents:

   • Carboprost tromethamine (Hemabate): 250 μg IM, can be repeated at 15-90 minute intervals as needed (maximum 8 doses/2 mg total) 3
   • Avoid prostaglandin F2α in women with asthma as it may cause bronchospasm 4
   • Avoid ergometrine in women with respiratory conditions as it may cause bronchospasm 4

2. Mechanical interventions:

   • Uterine massage to stimulate contractions
   • Intrauterine balloon tamponade for refractory cases 5
   • Uterine compression sutures (B-Lynch) if bleeding continues 4

Third-Line Interventions

• Blood product replacement according to massive transfusion protocols 4
• Consider tranexamic acid for hyperfibrinolysis 4
• Surgical interventions:
  • Bilateral uterine artery ligation 4
  • Hysterectomy as last resort for uncontrollable bleeding 5

Special Considerations

Dosing Considerations

• Higher-dose oxytocin regimens (80 units/500 mL over 1-4 hours) have been associated with lower rates of postpartum hemorrhage compared to lower-dose regimens (10-30 units) 2
• However, some studies show that low-dose regimens (10 units over 2-4 hours) are as effective as higher-dose regimens (30 units over 8-12 hours) in preventing PPH after cesarean section 6

Risk Factors to Consider

• History of previous postpartum hemorrhage
• Prolonged labor
• Chorioamnionitis
• Multiple gestation
• Polyhydramnios
• Macrosomia
• Obesity

Monitoring and Follow-up

• Continue to monitor vital signs, uterine tone, and vaginal bleeding
• Serial hemoglobin/hematocrit measurements to assess blood loss
• Consider thromboprophylaxis with LMWH for women at increased risk of VTE, especially with prolonged immobility 4
• Early mobilization for all women after cesarean section to reduce VTE risk 4

Pitfalls and Caveats

• Underestimation of blood loss is common in cesarean sections, occurring in 5-10% of cases 5
• Delayed postpartum hemorrhage (24 hours to 12 weeks post-delivery) is rare but can occur and requires prompt management 7
• Avoid making the diagnosis of amniotic fluid embolism based exclusively on hemorrhage from persistent atony with secondary coagulopathy 4
• Ensure thorough inspection of the cesarean incision, cervix, and vagina to rule out lacerations as the cause of bleeding 4

By following this algorithmic approach to managing increased postpartum vaginal bleeding after cesarean section, clinicians can effectively reduce maternal morbidity and mortality associated with this potentially life-threatening complication.