What is the best next step in managing a patient with two wide-bore intravenous (IV) lines and administered intravenous (IV) fluids, likely for postpartum hemorrhage (PPH) or uterine atony?

From the Guidelines

The best next step in management of this patient is administration of uterotonics (option B). When a patient presents with postpartum hemorrhage, the most common cause is uterine atony, which is typically a clinical diagnosis in >75% of patients 1. The initial treatment for uterine atony includes uterine massage and uterotonic drugs such as oxytocin, and the majority of patients respond well to these treatments 1. Key points to consider in the management of postpartum hemorrhage include:

• Uterine atony is the most common cause of early postpartum hemorrhage
• Initial treatment includes uterine massage and uterotonic drugs such as oxytocin
• Manual replacement of the uterus (option D) is critical in cases of uterine inversion, but this is not the most common cause of postpartum hemorrhage
• Administration of uterine relaxants (option A) may be needed in certain situations, but they are not the first step in management
• Emergent laparotomy (option C) and removal of the placenta (option E) may be necessary in certain situations, but they are not the initial steps in management The use of tranexamic acid has also been recommended for the treatment of postpartum hemorrhage, as it has been shown to reduce blood loss and mortality 1. However, the initial step in management should focus on addressing the underlying cause of the hemorrhage, which in most cases is uterine atony, and administering uterotonics such as oxytocin.

From the FDA Drug Label

To control postpartum bleeding, 10 to 40 units of oxytocin may be added to 1,000 mL of a nonhydrating diluent and run at a rate necessary to control uterine atony Prior treatment should include the use of intravenously administered oxytocin, manipulative techniques such as uterine massage and, unless contraindicated, intramuscular ergot preparations Following delivery of the placenta, for routine management of uterine atony, hemorrhage and subinvolution of the uterus.

The best next step in management of this patient is administration of uterotonics, such as oxytocin, to control postpartum bleeding and uterine atony, as indicated in the drug labels of oxytocin 2, carboprost tromethamine 3, and methylergonovine 4. Key considerations include:

• Uterine atony management with oxytocin
• Postpartum hemorrhage treatment with uterotonics
• Intravenous administration of oxytocin for postpartum bleeding control

From the Research

Management of Postpartum Hemorrhage

The best next step in management of this patient involves preventing postpartum hemorrhage, which is a leading cause of maternal morbidity and mortality worldwide.

• Uterine atony is estimated to account for 70% to 80% of postpartum hemorrhage cases, and pharmacotherapy remains the first-line preventative therapy 5.
• The use of uterotonics, such as oxytocin, carbetocin, methylergonovine, ergometrine, misoprostol, and prostaglandin analogs, is recommended to prevent postpartum hemorrhage 5, 6.
• Oxytocin is the first-line uterotonic agent in the United States for prevention of postpartum hemorrhage, and its administration can be in the form of a bolus or infusion 7, 8.
• Combined therapy, rather than oxytocin alone, is advised for preventing postpartum hemorrhage, as it has an additive or synergistic effect and a greater risk reduction for postpartum hemorrhage prevention 5.
• Carbetocin is probably the most effective agent in reducing blood loss and the need for additional uterotonics, although it is not yet available for use in the United States 9.

Options for Management

Considering the options provided:

• Administration of uterotonics (option B) is the best next step in management, as it is the first-line preventative therapy for postpartum hemorrhage.
• Administration of uterine relaxants (option A) is not recommended, as uterine atony is the most common cause of postpartum hemorrhage.
• Emergent laparotomy (option C) may be necessary in cases of severe postpartum hemorrhage, but it is not the best next step in management.
• Manual replacement of the uterus (option D) may be necessary in cases of uterine inversion, but it is not the best next step in management.
• Removal of the placenta (option E) is not relevant to the management of postpartum hemorrhage in this scenario.