– History –
- CC:
- Onset: when? First time? Sudden\gradual? Continuous\intermittent? Increasing\decreasing?
- Characteristics: amount? Color? Clots? Tissue? Smell?
- Associated sx:
- Constitutional: fever, chills, appetite?
- GI: N\V, abdominal pain?
- Anemia: dizziness, syncope, headache, palpitations, SOB?
- Quick important points:
- Antepartum:
- Gravida? Para? Abortions? Living?
- Antenatal US: when? Findings?
- Dx w\ any pregnancy conditions: GDM, anemia, pre-eclampsia
- Peripartum:
- Term\preterm?
- Mode of delivery: vaginal, instrumental, C\S?
- Needed episiotomy?
- Labor: received oxytocin? Prolonged? PPROM?
- Placenta previa, retained placenta?
- Complications: trauma\lacerations
- PMHx:
- HTN, DM, bleeding ds, infections
- Medications: anticoagulants
- Previous surgeries, C\S, trauma, blood transfusion
- Antepartum:
– Physical Exam –
- WIPE, blah blah, chaperone
- Vital signs: pulse, BP, temperature
- General inspection: pallor, confused, skin bruises\petechia
- CVS, CNS, Resp exam: to assess hemodynamic status of the pt
- Abdominal exam:
- Tender: uterine rupture, retained placenta
- Doughy soft uterus: uterine atony
- Pelvic exam:
- Inspect: vaginal lacerations or trauma
- Speculum: cervical lacerations
- Bimanual exam
- Check placenta if it’s complete or missing portions!
– Investigations –
- CBC, blood type, cross match, coagulation profile, chemistry (electrolyte, BUN\Cr), liver enzymes
– Management –
- Resuscitate and stabilize the pt -> ABCs! (focus on circulation)
- Treat underlying cause:
- Uterine atony:
- Continuous bimanual uterine compression
- Uterotonic drugs: Oxytocin -> methylergonovine -> misoprostol -> carbopost tromethamine
- Methylergonovine is contraindicated in hypotension, Raynaud’s, scleroderma
- If failed medical Tx -> tamponade balloon, interventional radiology, surgery
- Trauma:
- Thorough inspection of entire perineum and birth canal
- Analgesia
- Surgical repair
- Tissue:
- Inject umbilical vein with 20 mL NS + 20 U oxytocin
- Analgesia
- Manual removal
- Thrombin:
- Blood products replacement or transfusion (according to CBC and coagulation profile)
- Uterine atony: