Management of Postpartum Hemorrhage with a Firm Uterus
When treating postpartum hemorrhage in a patient with a firm uterus, placing uterine compression sutures is not necessary and should be avoided as this intervention is specifically indicated for uterine atony, not for a firm uterus.
Understanding Postpartum Hemorrhage with a Firm Uterus
When the uterus is firm during postpartum hemorrhage, this indicates that uterine atony (the most common cause of PPH) is not the primary issue. Instead, the bleeding is likely due to one of the following causes:
- Lacerations of the genital tract
- Retained placental fragments
- Coagulopathy
- Hematomas (bladder flap, subfascial, or perivaginal)
Appropriate Management Steps
Explore the lower genital tract - This is essential as traumatic bleeding from vaginal tears or lacerations is the most likely cause when the uterus is firm 1. A thorough examination of the vagina, cervix, and perineum is necessary to identify and repair any lacerations.
Ensure adequate analgesia - Proper pain control is crucial to allow for thorough examination and repair of any identified lacerations 1, 2. Without adequate analgesia, patient discomfort may limit the ability to perform a complete examination.
Ensure good lighting and exposure - Proper visualization is critical for identifying the source of bleeding, especially when examining the lower genital tract for lacerations 1, 2. Inadequate lighting or exposure can result in missed lacerations and continued bleeding.
Why Uterine Compression Sutures Are Not Indicated
Uterine compression sutures (such as B-Lynch sutures) are specifically designed to treat uterine atony by mechanically compressing the uterus when it fails to contract adequately 1. When the uterus is already firm, this indicates that it has contracted appropriately, and therefore:
- Compression sutures would not address the underlying cause of bleeding
- They would subject the patient to unnecessary surgical intervention
- They could potentially cause uterine ischemia or synechiae when not indicated
Additional Management Considerations
For a patient with PPH and a firm uterus:
- Rule out retained placental fragments - Even with a firm uterus, retained placental tissue may be present and causing bleeding
- Assess for coagulopathy - Laboratory testing including complete blood count, prothrombin time, partial thromboplastin time, and fibrinogen levels should be performed 1
- Consider imaging - If the source of bleeding is not identified on examination, imaging studies such as ultrasound or CT may be helpful to identify hematomas or other causes 1
Common Pitfalls to Avoid
- Focusing only on uterine atony - Remember that 25% of PPH cases are not due to atony 1, 3
- Delaying exploration of the genital tract - Prompt identification and repair of lacerations is essential
- Inadequate lighting or exposure - This can lead to missed lacerations and continued bleeding
- Performing unnecessary interventions - Such as placing compression sutures when the uterus is already firm
By following these guidelines and avoiding unnecessary interventions like uterine compression sutures in patients with a firm uterus, clinicians can provide appropriate and targeted management for postpartum hemorrhage, reducing maternal morbidity and mortality.