A 34-year-old woman just delivered a 4100-g boy after a 15-hour labor, including a 21/2-hour second stage. During the repair of a midline episiotomy, there is a marked increase in the amount of vaginal bleeding.
Which of the following is the best immediate management of the probable cause of this postpartum hemorrhage?
- massage and compression of the uterine fundus
- intravenous administration of 20 units of oxytocin
- abdominal hysterectomy
- uterine artery embolization
- hypogastric artery ligation
Answer(s): A
Explanation:
Immediate management is bimanual massage and compression of the uterine fundus by placing one fist into the anterior vaginal fornix and the other hand abdominally posterior to the uterus. The uterine massage is often enough to cause myometrial contractions and slowing of the bleeding. Oxytocin or an ergot alkaloid (e.g., methylergonovine) should then be administered if bimanual massage of the uterus is ineffective.
Insertion of a gauze pack is never indicated because it is rarely effective. It may actually worsen the bleeding by preventing contraction of the myometrium. Persistent bleeding from the uterus despite these measures may indicate uterine rupture, retained placental fragments, or placenta accreta. If a careful curettage of the uterine lining fails to remove any placental fragments and decrease uterine bleeding, hypogastric artery ligation or a hysterectomy must be considered.