Postpartum hemorrhage
USMLE Step 2 CKDifficulty: easyLast updated:
A 33-year-old woman, gravida 4 para 4, has a vaginal delivery of a 4,300-g infant after a 22-hour labor. The placenta delivers spontaneously and appears complete. Over the next 20 minutes, she has an estimated blood loss of 1,100 mL. Pulse is 112/min and blood pressure is 102/64 mm Hg. The uterine fundus is soft and boggy above the umbilicus. Inspection shows no cervical or vaginal lacerations. Two large-bore IV lines are in place and crystalloid is running.
Which of the following is the most appropriate next step in management?
Answer and explanation
Correct answer: A. Bimanual uterine massage and an intravenous oxytocin infusion
A soft, boggy uterus with heavy bleeding after delivery, with a complete placenta and no lacerations, indicates uterine atony. This is the most common cause of postpartum hemorrhage, and this patient has several risk factors: a large infant causing overdistention, prolonged labor, and multiparity. The source states that hemostasis is attempted by bimanual uterine massage and IV oxytocin infusion, alongside fluid resuscitation and transfusion if needed. A dilute oxytocin infusion is used. The source warns that oxytocin should not be given as an IV bolus because severe hypotension may occur. Other uterotonics such as prostaglandins and methylergonovine, and surgical or interventional procedures, are used if first-line measures fail.
Each option explained
- A. Bimanual uterine massage and an intravenous oxytocin infusionCorrect. For uterine atony, bimanual massage plus IV oxytocin infusion is the first-line hemostatic measure.
- B. Rapid intravenous bolus of 10 units of oxytocinIncorrect. Oxytocin should not be given as an IV bolus because it can cause severe hypotension.
- C. Emergency hysterectomyIncorrect. Hysterectomy is a last resort after medical and less invasive measures fail.
- D. Uterine artery embolizationIncorrect. Embolization is considered for persistent bleeding after first-line uterotonic therapy.
- E. Expectant management with serial hemoglobin measurementIncorrect. Ongoing hemorrhage of more than 1 L with tachycardia requires active treatment.
Key point
Postpartum hemorrhage from uterine atony: bimanual uterine massage plus IV oxytocin infusion (never an IV bolus) with resuscitation.
From the source
“Hemostasis is attempted by bimanual uterine massage and IV oxytocin infusion.”