Postpartum Hemorrhage with a Firm Uterus After Forceps Delivery
A 34-year-old G3P2 is one hour after a forceps-assisted vaginal delivery of a 4.1-kg infant at 39 weeks. The placenta delivered intact and she received oxytocin 10 units intramuscularly. Her uterus is firm at the umbilicus, but there is a continuous trickle of dark blood from the vagina. Estimated blood loss is 700 mL, and the collection drape now contains an additional 350 mL. Blood pressure is 98/58 mm Hg, heart rate 122 beats/min, respiratory rate 22 breaths/min, and oxygen saturation 98% on room air. She is pale and anxious. An 18-gauge IV is in place. She has a history of asthma and no hypertension. The episiotomy is intact on visual inspection.
1. What is your differential diagnosis and immediate assessment?
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The differential includes genital tract laceration, especially after forceps; retained placental fragments; uterine atony despite a firm fundus; and coagulopathy. A firm uterus does not exclude bleeding from a cervical or vaginal laceration, and forceps increase that risk. Immediately quantify cumulative blood loss, assess vital signs and mentation, and start a second large-bore IV. Perform a systematic exam: inspect the vulva, vagina, and cervix with good lighting and retractors; perform a bimanual exam to assess uterine tone and retained tissue; consider bedside ultrasound. Check CBC, coagulation studies, fibrinogen, type and screen or crossmatch, and renal function. Keep the patient warm and monitor urine output.
2. Outline your pharmacologic and laboratory management.
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Start or continue an oxytocin infusion, such as 10 to 40 units in 1,000 mL over 4 to 8 hours, and give methylergonovine 0.2 mg IM if there is no hypertension; repeat every 2 to 4 hours as needed. Because she has asthma, avoid carboprost unless the benefit clearly outweighs bronchospasm risk. Misoprostol 800 mcg sublingual or buccal can be used. Give tranexamic acid 1 g IV within 3 hours of birth if not already given. Transfuse based on clinical instability and laboratory results; a fibrinogen below 200 mg/dL suggests coagulopathy. If bleeding exceeds 1,000 to 1,500 mL or she becomes unstable, activate the massive transfusion protocol and move to the operating room.
3. Bleeding continues despite oxytocin and methylergonovine. What are the next steps?
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Exclude retained products and laceration definitively, then escalate mechanically. Perform manual exploration or sharp curettage for retained fragments and repair any laceration. Insert an intrauterine balloon tamponade (Bakri) or pack the uterus. Give misoprostol if not yet given. Call for anesthesia and the obstetrician and prepare for laparotomy. Surgical options include uterine artery ligation, B-Lynch suture, and, as a last resort, hysterectomy. Continue tranexamic acid and blood products. Document the sequence and times.