Uterine Examination with Antibiotic Coverage in Postpartum Hemorrhage
Manual uterine examination with prophylactic antibiotic coverage is a fundamental first-line intervention for postpartum hemorrhage to identify and remove retained placental tissue, with antibiotics specifically recommended to prevent infection from the intrauterine manipulation.
Primary Role and Indication
Manual uterine examination serves as an essential diagnostic and therapeutic intervention when PPH occurs, allowing direct identification of retained products of conception (RPOC), which complicates approximately 1% of third-trimester deliveries and represents the second most common cause of PPH after uterine atony 1. The examination enables immediate removal of retained tissue that may be preventing adequate uterine contraction 2.
Antibiotic Prophylaxis Protocol
Antibiotic prophylaxis must be administered at the time of manual uterine examination to prevent endometritis and sepsis from the intrauterine manipulation 2. The recommended regimen includes:
- Ampicillin as the broad-spectrum penicillin component, providing gram-positive and some gram-negative coverage 1
- Gentamicin as the aminoglycoside component, extending coverage to gram-negative organisms 1
This combination mirrors the evidence-based antibiotic regimen used for preterm prelabor rupture of membranes, where ampicillin combined with an aminoglycoside has demonstrated efficacy in preventing infectious complications 1.
Clinical Context and Timing
The examination should occur as part of the initial PPH management algorithm, specifically when:
- Bleeding persists despite uterine massage and first-line uterotonics (oxytocin 5-10 IU) 2
- The uterus remains boggy or fails to contract adequately despite interventions 3
- Clinical suspicion exists for retained placental fragments based on incomplete placental delivery 3
The examination must be performed within the first 30 minutes of PPH recognition, as this timeframe is critical for escalating to second-line agents like sulprostone if bleeding continues 2.
Additional Antibiotic Considerations
If blood loss exceeds 1,500 mL during the examination and management process, prophylactic antibiotics should be re-dosed to maintain adequate tissue levels given the dilutional effect of massive fluid resuscitation 1. This re-dosing prevents infectious complications in the setting of extensive tissue manipulation and potential contamination.
Integration with Comprehensive PPH Management
The uterine examination with antibiotic coverage fits within the broader PPH algorithm:
- Concurrent interventions include careful visual inspection of the lower genital tract for lacerations, continued uterine massage, and maintenance oxytocin infusion not exceeding 40 IU cumulative dose 2
- If RPOC is identified and removed but bleeding persists, proceed to second-line uterotonics (sulprostone) within 30 minutes 2
- If no RPOC is found and bleeding continues despite medical management, consider intrauterine balloon tamponade before surgical or interventional radiology options 2
Critical Pitfalls to Avoid
Do not delay antibiotic administration until after the examination is complete—antibiotics should be given immediately when the decision to perform manual exploration is made 2. The manipulation itself introduces bacteria into the uterine cavity, making prophylaxis rather than treatment the appropriate approach.
Do not assume that removal of visible placental fragments is sufficient—the examination must be thorough and systematic to identify all retained tissue, as incomplete removal will result in continued bleeding 1, 3.