CCS Case: Postpartum Hemorrhage — Uterine Atony

Case: Postpartum Hemorrhage — Uterine Atony

Clinical Setup

• Presentation: 29-year-old female, 30 minutes post spontaneous vaginal delivery, heavy vaginal bleeding (~800 mL estimated), boggy uterus on palpation, BP 92/58, HR 118, pale.
• Location: Labor and Delivery / Postpartum Unit.

Optimal Order Pathway

1. Immediate Orders (Minute 0–1):
   • Continuous monitoring, pulse oximetry, BP q5–15min.
   • 2 large-bore IVs, Normal saline or Lactated Ringer’s wide open; strict I/O with Foley.
   • Fundal massage stat; call OB attending + anesthesia + blood bank (activate hemorrhage protocol).
2. Focused Exam (Minute 1–2):
   • Uterine tone and fundal height, perineal/vaginal laceration check, estimate ongoing blood loss, placenta completeness check.
3. Diagnostics (Minute 2–5):
   • CBC, Type and Crossmatch (4+ units), PT/INR, PTT, fibrinogen.
   • Bedside ultrasound (retained products of conception).
4. Therapeutics (Minute 5–15):
   • Oxytocin IV infusion FIRST-LINE stat; if atony persists add Methylergonovine IM (avoid if hypertensive) then Carboprost IM (avoid if asthmatic).
   • Transfuse PRBCs for ongoing bleeding/instability; give tranexamic acid (TXA) within 3 hours of birth per protocol.
   • Empty bladder (Foley); inspect and repair lacerations; manual removal if retained placenta.
   • Refractory bleeding: Bakri balloon tamponade, then IR uterine artery embolization, then surgical (B-Lynch suture, hysterectomy as last resort).
   • Advance clock in 5–15 min increments; track cumulative blood loss and vitals.
5. Disposition (Minute 15–20):
   • Transfer to OB ICU/stepdown if massive transfusion or instability; otherwise postpartum floor with close monitoring.
   • Monitor for DIC, Sheehan syndrome signs, and re-bleed.
6. Final 2 Minutes:
   • Counsel on anemia recovery (iron supplementation), warning signs of late PPH, contraception planning.
   • Schedule OB follow-up within 1–2 weeks; arrange lactation support and depression screening.