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Simulation

Intraoperative Management of Postpartum Hemorrhage

Module

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Objectives

By the end of this lesson, you should be able to do the following:

  • Recognize the morbidity and mortality of obstetrical hemorrhage
  • Estimate blood loss amount during an obstetrical hemorrhage
  • Initiate early and aggressive treatment for postpartum hemorrhage
  • Practice techniques to manage various causes of hemorrhage

Background

  • In 2010, 3,999,386 infants were born in the United States
  • 4-6% of births in the United States result in postpartum hemorrhage
  • Obstetrical hemorrhage is the leading cause of maternal morbidity and mortality
  • Failure to recognize excessive blood loss is a major contributing factor
  • Lack of early recognition and intervention

Initial Management

  • Early recognition
  • Supportive care
  • Treat the etiology
  • Stop the bleeding
  • Unit standard, stage-based obstetrical emergency response plan
  • Perform bimanual uterine massage
  • Place 2 large IV bores
  • Monitor vitals/clinical signs
  • Administer crystalloid 3:1 replacement rate
  • Ensure bladder is empty
  • Initiate OB hemorrhage protocol
  • Notify anesthesia and nursing
  • Obtain stat labs CBC, coag, fibrinogen, T&C
  • Assess 4 Ts

Bimanual Compression for Uterine Atony

Bimanual compression for uterine atony. 
Bimanual compression for uterine atony. The uterus is positioned with the fist of one hand in the anterior fornix pushing against the anterior wall, which is held in place by the other hand on the abdomen. The abdominal hand is also used for uterine massage.

Medication Therapy

Adverse Effect
Oxytocin (Pitocin) 10-40 international units/liter IV or 10 units IM (no IV access) Causes water intoxication
Prostaglandin F2 alpha (Carboprost, Hemabate) 0.25 mg IM q 15 min x 8 doses (maximum) Avoid with asthma
Prostaglandin E1 (Misoprostol, Cytotec) 1000mcg rectally Fevers, Diarrhea
Prostaglandin E2 (Dinoprostone, Prostin E2) 20mg per rectum q 2 hours Avoid with hypotension
Methylergonovine (Methergine) 0.2 milligrams/milliliters every 4 hours for 6 doses Avoid with hypertension

Uterine Vessels, Ureter, Uterus After Cesarean Delivery

Uterine vessels, ureter, uterus after cesarean delivery.

O’ Leary Stitch (Bilateral Uterine Artery Ligation)

  • No. 1 chromic
  • Place the suture anterior to posterior in uterine myometrium
  • 2-3 cm medial to uterine vessels
  • Find avascular space in broad ligament lateral to uterine artery/vein and tied
  • Suture is usually placed at level of cervical internal os.

O'Leary Stitch for bilateral uterine artery ligation.

Uterine Artery Ligation

Uterine artery ligation. 
Uterine artery ligation. The suture goes through the lateral uterine wall anteriorly, curves around posteriorly, then reenters anteriorly. When tied, it encompasses the uterine artery.

B-Lynch (Brace Suture)

  • Number 2 chromic / 0 vicryl suture on CTX(B) needle
  • Rules of 3s:
    • 3cm from right lateral border
    • Go through 3 cm above and 3cm from lateral border
    • Compresses uterine fundus 3-4 cm from right corneal border
    • 3 cm anteriorly and below the lower incision margin on left side

B-Lynch brace suture.

B-Lynch brace suture.

B-Lynch brace suture.

B-Lynch Suture in Place

B-Lynch brace suture. 
Anterior uterine wall with a B-Lynch suture in place.
B-Lynch brace suture. 
An enlarged drawing of lower uterine segment with B-Lynch suture in place.

A large Mayo needle with #2 chromic catgut is used to enter and exit the uterine cavity at A and B. The suture is looped over the fundus and then reenters the uterine cavity posteriorly at C, which is directly below B. The suture should be pulled very tight at this point. It then enters the posterior wall of the uterine cavity at D, is lopped back over the fundus, and anchored by entering the anterior lateral lower uterine segment at E and crossing through the uterine cavity to exit at F. The free ends at A and F are tied down securely to compress the uterus.

Adapted from Obstetrics & Gynecology Case Reports & Reviews, Vol. 95, Num 6, June 2000.

Surgical Management

  • Uterine curettage
  • Placental bed suture
  • Uterine artery ligation
  • Utero-ovarian ligation
  • Repair uterine rupture
  • B-Lynch suture, multiple square sutures
  • Hysterectomy
B-Lynch suture in place. 
B-Lynch suture
B-Lynch suture in place. 
B-Lynch suture
B-Lynch suture in place. 
Hayman uterine compression suture
B-Lynch suture in place. 
Surgical ligation locations of uterine blood supply

Objectives Review

You should now be able to do the following:

  • Recognize the morbidity and mortality of obstetrical hemorrhage
  • Estimate blood loss amount during an obstetrical hemorrhage
  • Initiate early and aggressive treatment for postpartum hemorrhage
  • Practice techniques to manage various causes of hemorrhage

Contributing Authors

  • Erika Banks, MD, FACOG Professor, Vice Chair, Residency Program Director Department of Obstetrics & Gynecology and Women’s Health Albert Einstein College of Medicine – Montefiore Medical Center
  • Meleen Chuang, MD, FACOG Assistant Professor Department of Obstetrics & Gynecology and Women’s Health Albert Einstein College of Medicine – Montefiore Medical Center
  • Veronica Lerner, MD, FACOG Associate Professor Department of Obstetrics & Gynecology and Women's Health Albert Einstein College of Medicine – Montefiore Medical Center
  • Heena Purswani, MD Resident University of Southern California