Lacerations should be surgically repaired. Unless the patient has undergone a vaginal birth after cesarean (VBAC) or the bleeding is observed to originate in the uterus, it is not necessary initially to inspect the uterine cavity manually.
Retained placenta
After delivery, inspection of the placenta helps to determine if all cotyledons have been expelled intact. Be aware, however, that portions may remain behind even when the delivered placenta appears to be complete. When the uterus is firm and careful inspection of the lower genital tract reveals no bleeding sites, uterine exploration is necessary.
Manually explore the uterine cavity and remove any retained placenta that is encountered. Adequate anesthesia—even, at times, general anesthesia—is crucial under these circumstances. In some cases, postpartum curettage performed with a specially designed curet may help. Complete removal of all portions of the placenta generally leads to the prompt cessation of bleeding.
When the preceding methods fail to resolve bleeding due to retained placenta, prompt exploratory laparotomy is mandatory. On occasion, broad-ligament hematomas may be detected, the laceration corrected, and hysterectomy avoided. In other instances, hysterectomy is performed as a lifesaving measure without exact knowledge of the source of the bleeding. This is often followed by the pathologic diagnosis of placenta accreta.
When the uterus is firm and careful inspection of the lower genital tract reveals no bleeding sites, uterine exploration is necessary.
Other surgical approaches. Ligation of the uterine or internal iliac arteries is more likely to be effective in cases of uterine rupture. The classic approach to treating placenta accreta is hysterectomy. While a theoretical benefit exists for hypogastric artery ligation in some cases, the rarity of indications for this procedure means that very few recently trained obstetricians will be proficient enough to perform it under emergent conditions. A lack of such knowledge does not indicate inadequate training or technique. Rather, internal artery ligation has limited clinical value and is never required by the standard of care. With an experienced operator, however, the technique may occasionally make uterine conservation possible.
Coagulopathy
There are only 2 causes of acute consumptive coagulopathy in obstetrics: massive placental abruption and amniotic fluid embolism. Most chronic coagulation defects are uncovered long before pregnancy, usually during a workup for menorrhagia. Thus, in most cases of acute disseminated intravascular coagulopathy (DIC), such clotting abnormalities will be readily apparent.
In the bleeding patient with DIC, rapidly infuse platelets and/or fresh frozen plasma, depending on laboratory values. In general, fresh frozen plasma should be administered when a bleeding patient has a fibrinogen level below 100 mg/dL. Platelets are reserved for the bleeding patient with a platelet count below 30,000 per cubic centimeter.
If large amounts of lost blood are replaced only with crystalloid solution and packed red blood cells, the patient may develop a dilutional coagulopathy that resembles DIC in many ways. Treatment is the same. If shock intervenes, elements of both dilutional and consumptive coagulopathy may be present.
Other considerations
In managing postpartum hemorrhage, a number of other nuances or options may be relevant.
Placenta accreta. The prevalence of placenta accreta is on the rise—some experts have even described it as epidemic.7 The principal predisposing factors are placenta previa and 1 or more prior cesarean deliveries: In a patient with placenta previa and 1 prior cesarean, the risk of placenta accreta approaches 25%; in the presence of 2 or more cesareans, this risk exceeds 50%.7 Thus, the increased prevalence of placenta accreta is not surprising, considering the rise in cesarean sections over the past decade.
A number of diagnostic techniques, including color-flow ultrasound, power Doppler, and magnetic resonance imaging (MRI), may be helpful in the antenatal diagnosis of placenta accreta. In fact, in certain centers, these techniques appear to have a high degree of sensitivity and reasonable positive predictive value.8,9 Still, no diagnostic test is so sensitive that the clinician can perform a repeat cesarean in a patient with placenta previa without being prepared for cesarean hysterectomy. Prior to delivery, these patients should be informed of their high risk of requiring hysterectomy. In addition, blood generally should be prepared as type and cross rather than type and screen, and the OR should have the instrumentation and personnel necessary to perform an emergent hysterectomy.
One of the most important variables is the decision to perform hysterectomy. If the placenta does not readily shell out when manual removal is attempted, the operator should not attempt to pull it out in fragments. Rather, he or she should proceed immediately to hysterectomy.
No diagnostic test is so sensitive that the clinician can perform a repeat cesarean in a patient with placenta previa without being prepared for cesarean hysterectomy.